october 2009 presented by eds provider field consultants home health billing and common denials

October 2009

Presented by

EDS Provider Field Consultants

Home Health Billing and Common Denials

Home Health Billing and Common Denials2 / October 2009

Agenda

•Session Objectives

•Home Health Coverage

•Prior Authorization

•Billing Procedures

•Multiple Visit Billing

•Hospital Discharge

•Common Denials


Objectives

At the end of this session, providers will understand:

•What types of services are covered by Home Health

•Billing procedures

•How to bill multiple visits

•How to bill for hospital discharge

•Common claim denials and how to resolve


Home Health Coverage

•Home health services are available to the Indiana Health Coverage Programs (IHCP) members medically confined to the home

– When services are ordered in writing from a physician and performed in accordance with the written plan of care

•Unlike Medicare, Medicaid members that are confined to the home may:

– Work

– Attend school outside the home

– Leave the home with assistance of another person or an assistive device, such as a wheelchair or walker


Prior Authorization

•Home Health Services require prior authorization

• If the member is Traditional Medicaid or ADVANTAGE Care Select, prior authorization request is faxed to:

– ADVANTAGE Health Solutions • 1-800-784-3981

• If the member is MDwise Care Select, prior authorization request is faxed to:

– MDwise Care Select• 1-866-440-2449


Billing Procedures

•Home health services must be ordered in writing by a physician and require prior authorization (PA)

•Claims are billed on a UB-04 claim form with revenue codes and Healthcare Common Procedure Coding System (HCPCS) codes

•Each day is billed as a separate detail line item

•Level of services, such as a registered nurse (RN) or licensed practical nurse (LPN), provided on the same date of service are billed as separate line items


Billing Procedures

•Billing units of home health visits for therapists, home health aides (HHAs), licensed practical nurses (LPNs) and registered nurses (RNs) should be rounded as follows:

– For therapy visits, if in the home one to seven minutes, units cannot be rounded and are not billable. Services consisting of eight to 15 minutes can be billed as one 15-minute unit of service.

•For HHA, LPN, and RN visits, the claim should be billed as follows:

- If in the home less than 29 minutes, the entire first hour can be billed only when a service was provided

- Example: The nurse walks in and has to call 911 right away for the patient

• If a member refuses service, the provider cannot bill any units of service


Billing Procedures

•Bill visits using code 99600

– LPNs use modifier TE

– RNs use modifier TD

– HHAs use no modifier

•When PA is granted for 99600 TD, the PA covers RN, LPN, and HHA services


Billing Procedures

•As of July 1, 2008, only one overhead is allowed per provider, per member, per day

•An overhead rate is provided to cover administrative costs and reimbursed in addition to a staffing reimbursement component

•Only one overhead is billed per day even if there are one or more encounters, which occurs when an RN, LPN, HHA, or therapist:– Enters the home– Provides service to one or more members– Leaves the home

•Overheads must be reported using occurrence codes 61 and occurrence date or occurrence spans in Fields 35a-36b on the UB-04 claim form

•Occurrence codes are also reported in all electronic claim formats


Example of Billing Occurrence Code

•Provider goes to member’s home and bills for procedure 99600 TD; later that day provider goes back to member’s home and bills 99600 TE

•This is considered two different procedures and needs to be billed on two separate detail lines

•Even though there were two visits, providers must add the overhead to only one of the detail lines


Billing Procedures - MCO

• If a member is enrolled in risk-based managed care (RBMC), providers must contact the appropriate managed care organization (MCO) to obtain prior authorization and billing information:

– Anthem• 1-866-406-2803

– MDwise• 1-800-356-1204

– Managed Health Services• 1-877-647-4848


Multiple Visit Billing

•Billing for multiple visits for the same PA to a member in one day

– Should be billed on the same claim form

– One detail with the total number of units of service provided

– If these services are billed on separate claim forms or on separate claim details, the IHCP denies one or more of the services with edit 5001 – exact duplicate


Hospital Discharge

Services that may be performed without PA:

•An IHCP member discharge from an inpatient stay

•Therapy services ordered by a physician can not continue beyond 30 units in 30 calendar days without PA

•RN, LPN, or HHA-performed services that do not exceed 120 units within 30 calendar days from the inpatient discharge

– Physician must order services in writing prior to the patient’s hospital discharge

– Patient must be homebound


Hospital Discharge

•Services must be within the limits specified in 405 IAC 5-16-3

•Providers are required to bill using occurrence code 50 with the corresponding date of discharge in the occurrence code and occurrence date fields 31-34, a-b on the UB-04 claim form

• If claims are submitted without occurrence code 50 and there is an existing PA, the units of the PA will be decremented


Common Denials

Edit 3001 – Dates of service not on PA database

•Cause – No prior authorization was obtained

•Resolution – PA needs to be obtained or, if this is a hospital discharge, occurrence code 50 with date of discharge should be billed

Edit 558 – Coinsurance and deductible amount missing

•Cause – Coinsurance and deductible were not submitted on claim

•Resolution – Coordination of benefit screen would need to be completed, or if paper UB-04 claim form then box 39 would need to be completed with value codes A1 Medicare deductible or A2 Medicare coinsurance


Common Denials

Edit 593 – Medicare denied detail

•Cause – Claim crossed over from Medicare with a denied Medicare detail

•Resolution – Medicare denied details are submitted to Medicaid as a straight Medicaid claim with the Medicare explanation of benefit

Edit 516 – Occurrence code date does not match claim detail

•Cause – Occurrence date does not match the claim detail

•Resolution – Each occurrence code date entered on the header of the claim must match a service date or service dates in the detail lines on the claim form


Common Denials

Edit 4021 – Procedure code vs. program indicator

•Cause – Procedure code billed is not valid for the service being billed

•Resolution – Procedure code billed is restricted to a specific program; check the claim to make sure the appropriate HCPCS are being billed for home health


Resources

• IHCP Web site at www.indianamedicaid.com

•FSSA Web site at www.in.gov/fssa • IHCP Provider Manual (Web, CD-ROM, or

paper)•Customer Assistance

– 1-800-577-1278, or

– (317) 655-3240 in the Indianapolis local area

•Written Correspondence

– P.O. Box 7263Indianapolis, IN 46207-7263

•Provider Relations field consultant


Questions

October 2009

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october 2009 presented by eds provider field consultants home health billing and common denials

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