Medicare Advantage Outreach and Education Bulletin

Transcription

1 Medicare Advantage Outreach and Education Bulletin Anthem Blue Cross Medicare Advantage Reimbursement Policy Changes: Second Communication Update Anthem Medicare Advantage published Medicare Advantage Reimbursement Policy Changes in your September/October provider newsletter and posted the information under Important Medicare Advantage Updates in August. These policy changes take effect January 1, 2015 and apply to participating providers who serve Individual Anthem Medicare Advantage business. That information has been updated and expanded below to help address any questions you may have. To review the initial provider update, please visit Important Medicare Advantage Updates. System Migration Starting January 1, 2015 Anthem Medicare Advantage will move Individual (non-group) Medicare Advantage members to a new claims processing system to better align with existing Centers for Medicare & Medicaid (CMS) payment Codes not recognized by Original Medicare will be considered by Anthem Medicare Advantage as not reimbursable unless otherwise noted. Reimbursement Policy Changes The initial provider communication included a table that highlighted some of the changes to the policies, also listed below. Providers are reminded to first refer to their provider contracts for Reimbursement policies provide general criteria which may differ for individual providers based on their contract information. It is important to note that these policies may be superseded by mandates in provider contracts, federal or CMS contracts and/or requirements. The following table is a supplemental tool to highlight changes of most impact to our providers. It does not contain all the Anthem Medicare Advantage policies, nor does it contain all the elements for the policies listed. For additional information regarding the policies listed below, as well as the complete set of policies, please review the Medicare Advantage policies portal. Policy Name* Prior to January 1, 2015 Afterhours Services provided in the office during regularly scheduled evening, weekend, or holiday office hours are eligible for separate in addition to the basic covered service. As of January 1, 2015 Anthem Medicare Advantage will align closer to CMS Please refer to the CMS manual or fee schedule for guidance. Description Unless provider contract language stipulates otherwise, Code is no longer considered a covered code by CMS. Code can be reimbursed with preventive services as

2 Allergy Treatment: Immunotherapy Assistant at Surgery (Modifiers 80/81/82/AS) Cancer Treatment and Care Coordination Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed in addition to the basic covered service are not eligible for separate when reported with a preventive service. Assistant Surgeon services reported with Modifier AS will be eligible for at 16 percent of the maximum allowance under the applicable physician extender fee schedule. If there is no applicable physician extender fee schedule, the Assistant Surgeon services will be eligible for under the applicable physician fee schedule at 14 percent of the maximum allowance for the primary procedure. For cancer treatment planning and care coordination, Reimbursement is allowed for allergy immunotherapy. Assistant Surgeon services reported with Modifier AS will be eligible for according to CMS provider manual for details concerning Cancer Treatment and Care part of Anthem Medicare Advantage s ER diversion program. policy policy The details of the Cancer Care Quality Program will now be outlined in the provider

3 Claims Timely Filing: Participating and Non- Participating Consultations Diagnoses Used in DRG Computation separate is available to Anthem participating providers as approved under an Anthem program such as the Cancer Care Quality Program; additional Anthem programs may also be developed to support local healthcare initiatives or state mandates. Consultation service codes may be recognized for some contracted providers, which are divided into two sections based on place of service: office or other outpatient consultations and inpatient consultations. Coordination and the Cancer Care Quality Program. Claims for covered services for covered members using appropriate claims timely filing requirements are reimbursable. The claims timely filing standard is 12 months for participating and non-participating providers and facilities. Office, outpatient or initial inpatient consultation codes are not recognized. The diagnosis and procedure codes that generate the Diagnosis Related Groups (DRG), and therefore the hospital invoice, are accurate, valid and sequenced in accordance with national manual. policy Unless provider contract language stipulates otherwise, the claims timely filing standard is 12 months. policy Unless provider contract language stipulates otherwise, office, outpatient or initial inpatient consultation codes are not recognized. policy We previously

4 Documentation Standards for Episodes of Care coding standards and specified DRG audits are performed to determine that the diagnostic and procedural information that led to the DRG assignment is substantiated by the medical record. Upon request for clinical documentation to support claims payment for services, the provided information should identify the member, be legible, and reflect all aspects of care. This policy outlines the minimum elements needed in order for documentation for episodes of care to be considered complete, and instructs providers to refer to the standard data elements to be included for specific episodes of care as established by The Joint Commission (TJC). conducted DRG validations; this policy is a clarification in support of a process already in place. policy Other documentation not directly related to the member, but relevant to support clinical practice, may be used to support documentation regarding episodes of care; examples are listed within the policy. Providers may be requested to submit additional documentation to support their claims. If documentation is not provided following the request or notification or does not support the services billed for the episode of care, Anthem Medicare Advantage may deny the claim and recover and/or recoup monies previously paid on the claim. Drug and Reimbursement will be

5 Injectable Limits Inpatient Facility Transfers Inpatient Readmissions considered up to the Clinical Unit Limits (CUL) allowed for the prescribed/administered drug. We use the CMS Medically Unlikely Unit (MUE) value. When there is no MUE assigned by CMS, identified codes will have a CUL assigned or calculated based on the prescribing information, The Food and Drug Administration, and established reference compendia. Claims that exceed the CUL will be reviewed for documentation to support the additional units. If the documentation does not support the additional units billed, the additional units will be denied. Payment for services rendered by both the sending and the receiving facility are allowed when a patient is admitted to one acute care facility and subsequently transferred to another acute care facility for same episode of care. Transferring facilities will receive a calculated per diem rate based on length of stay not to exceed the amount that would have been paid if the patient had been discharged to another setting, and receiving facilities will receive full DRG payment. This policy only affects those facilities reimbursed for inpatient services by a DRG methodology. Inpatient readmissions occurring within 24 hours will be considered a single claim for processing. Readmissions occurring within 2 30 days will be policy policy The description of the policy was updated to reflect the policy s adherence to federal guidelines for inpatient facility transfers. The October 9 th, 2013 Inpatient Readmissions Outreach and Education Bulletin described

6 Laboratory and Venipuncture Services General health panel is part of the inclusive list that comprises an entire blood panel. subject to clinical reviews. If the clinical review indicates that the second admission is for the same or similar diagnosis, it may be considered an extension of the initial admission for the purposes of. If substantiated, this may result in a request to refund the payment for the second admission. Anthem Medicare Advantage will align closer to CMS Please refer to the CMS manual or fee schedule for guidance. guidelines for Inpatient Readmissions. The guidelines are detailed in this policy. Unless provider contract language stipulates otherwise, Code is no longer considered a covered code by CMS. Maternity Services Certain obstetric services are included in the global for obstetric services and some services are eligible for separate. Global obstetrical codes billed once per period of a pregnancy (defined as 279 days) are reimbursable when submitted by a single provider or provider group reporting under the same federal Tax Identification Number (TIN). Reimbursement is based on the global obstetric care package (i.e. antepartum, delivery and postpartum) being provided by the provider or provider group. If a provider or provider group does not provide all antepartum, delivery and postpartum services, global obstetrical codes may not be used and providers are to submit only the elements of the obstetric package that were actually provided. Anthem Medicare Advantage will not reimburse for duplicate or otherwise overlapping services during the course of the same pregnancy. The policy outlines services included and not included in the global package. policy

7 Medical Recalls Modifier 62: Co-Surgeons Modifier 66: Surgical Teams Modifier 76: Repeat Procedure by the Same Physician Modifier 77: Repeat Procedure by Another Physician Modifier LT/RT 63 percent of the maximum allowance is reimbursed for each of the two operating surgeons with the appended 62 modifier. Surgical Team services are identified by appending the Modifier 66 to the designated CPT code(s). A claim may be reviewed to determine the eligibility for separate for the repeated procedure code. A claim may be reviewed to determine the eligibility for separate for the repeated procedure code. Claims billed with Modifier LT or RT will not be denied if Anthem Medicare Advantage does not allow for repair or replacement of items due to a medical recall. Please note, Anthem Medicare Advantage will allow of medically necessary procedures to remove and replace recalled or replaced devices. Reimbursement to each surgeon is based on 62.5 percent of the applicable fee schedule or contracted/negotiated rate. Each physician participating in the surgical team must bill the applicable procedure code(s) for their individual services with Modifier 66. If any or all physicians participating in the surgery fail to use the modifier appropriately, claims may be denied or pended for duplicate or suspected duplicate services, respectively. Providers must submit supporting documentation for the use of Modifier 76 with the claim. If a claim is submitted with Modifier 76 without supporting documentation, the claim will be denied. Providers must submit supporting documentation for the use of Modifier 77 with the claim. If a claim is submitted with Modifier 77 without supporting documentation, the claim will be denied. Modifier LT and/or RT should not be billed with Modifier 50. policy policy policy policy policy policy

8 Multiple Radiology Payment Reduction Other Provider Preventable Conditions (OPPC) Preadmission Services for Inpatient Stays also billed with Modifier 50. Primary imaging procedure will be eligible for 100 percent of the maximum allowance for that procedure. For subsequent imaging procedures with an MPI of 4 rendered on that date of service that are reported globally, the professional component will remain at 100 percent. Hospitals shall not bill Anthem, employers, other payers or covered individuals for OPPCs performed in either the inpatient or outpatient setting. Multiple Radiology Payment Reductions are applied as indicated in the policy and to the Professional Component (identified by adding Modifier 26) of certain diagnostic imaging procedures. Reimbursement is based on 100 percent for the physician fee schedule or negotiated amount for the service with the highest Professional Component payment and 75 percent for the Professional Component of subsequent services furnished by the same physician or physicians in the same group practice to the same patient in same session on the same day. OPPCs must be reflected on a Type of Bill 0110 (nopay claim). Appropriate modifiers, condition codes, and surgical codes should be used. Applicable services for a covered member prior to admission to an inpatient hospital are reimbursable. For admitting hospitals, applicable preadmission services are included in the inpatient for the three days prior to and including the day of the member s admission, and therefore are not separately reimbursable expenses. For other hospitals or units (e.g. children s hospitals, psychiatric hospitals), policy policy policy CMS language was added to the policy during biennial review. CMS now indicates: Applicable preadmission services consist of all diagnostic outpatient services and clinically

9 Portable/Mobile /Handheld Radiology Services applicable preadmission services are included in the inpatient within one day prior to and including the day of the member s admission and, therefore, are not separately reimbursable expenses. Portable/mobile radiology services are reimbursable when furnished in a residence used as the patient s home if ordered by a physician and performed by qualified portable radiology suppliers. Portable/mobile radiology studies should not be performed for reasons of convenience. Preventive screenings performed by portable/mobile radiology studies for routine purposes are allowed. related nondiagnostic services that are related to the inpatient stay and are included in the inpatient. A hospital may attest to specific nondiagnostic services as being unrelated by adding a condition code 51 to the outpatient nondiagnostic service to be billed separately. The outpatient diagnostic services of Critical Access Hospitals (CAH) and included in the rural health clinic or federally qualified health center allinclusive rate are not subject to the three or one day payment window. CAH outpatient diagnostic services are separately reimbursable expenses from inpatient stay. policy Reimbursement is based on the applicable fee schedule

10 or contracted/negotiated rate for the radiological service, and transportation and setup components with the use of applicable modifiers; transportation and setup component guidelines are outlined within the policy. The policy also addresses for the use of handheld radiology instruments. Professional Anesthesia Services When Modifier AD is appended to a claim, the percentage is based on the 3 base units. This rate is determined by the Conversion Factor x 3 regardless of the procedure base units reported. When Modifier AD is appended to a claim, is based on 100 percent of the applicable fee schedule or contracted/negotiated rate for up to three base units for anesthesiologists who supervise three or more concurrent or overlapping procedures. policy Additional is allowed for services reported with physical status modifiers P3, P4, and P5. Physical status modifiers or qualifying circumstances codes denoting additional complexity levels are not reimbursable. Prosthetic and Orthotic Devices The replacement of a DME item may be necessary through normal wear and tear. Reimbursement is allowed for prosthetic and orthotic devices, and this policy outlines the methodology. For example, is allowed for replacement of prosthetic and orthotic devices due to irreparable wear in consideration of the reasonable useful lifetime of the device of not less than 5 years based on when the policy In instances of theft, a police report is required for consideration of replacements.

11 equipment is delivered to the member, among other criteria listed in the policy. Reimbursement for Reduced and Discontinued Services Scope of Practice Split-Care Surgical Modifiers Modifier 56 will be calculated at 10 percent of the applicable surgical maximum allowance. Professional providers and facilities can be reimbursed for reduced or discontinued services when they are appended by the appropriate modifier. When Modifier 73 is appended, is reduced to 50 percent of the applicable fee schedule or contracted/negotiated rate. When Modifier 74 is appended, is 100 percent of the applicable fee schedule or contracted/negotiated rate. Services that are within the provider s scope of practice are reimbursable under state law in accordance with CMS The provider shall be licensed in or hold a license recognized in the jurisdiction where the patient encounter occurs. Modifier 56 is not a separately reimbursable modifier. policy As a reminder, Modifier 73 and 74 apply to facility billing and are not applicable for professional provider billing. policy policy Transportation Services: Ambulance and Non-Emergent Transport Reimbursement is allowed for transport to and from covered services or other services mandated by policy Reimbursement is not allowed for mileage when the transport service has been denied or is not covered. Separate is not allowed for additional medical personnel,

12 Unlisted or Miscellaneous Codes Unlisted or miscellaneous codes (a.k.a. Not Otherwise Classified (NOC) codes) are reimbursable. Unlisted or miscellaneous codes should only be used when an established code does not exist to describe the service, procedure, or item rendered. Claims submitted with unlisted or miscellaneous codes must contain the following information and/or documentation for consideration during review: a written description, office notes, or operative report describing the procedure or service performed; an invoice and written description of items and supplies; and/or the corresponding National Drug Code (NDC) number for an unlisted drug code. unusual waiting time, and disposable/first aid supplies. policy *Provider contracts already executed will supersede our policies and/or criteria. Y0071_14_22921_I_12/23/14 Anthem Blue Cross is the trade name of Blue Cross of California: Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross names and symbols are registered marks of the Blue Cross Association.