For Participating Rehabilitation Therapists May 2006 Updating coding resources A recent event illustrates the need to keep coding references updated. The 2006 ICD-9-CM code book published by a particular publishing company was noted to have new diagnosis codes, which were proposed for 2006 but had not been finalized by the National Center for Health Statistics (NCHS) and should have been deleted before publication. It was a highly unusual error, but providers and their staff would have been aware of this error if they periodically checked the pertinent Web sites for publishing errors and changes to the various codes used to bill for providers services. Keeping up-to-date with coding changes increases coding accuracy in billing and positively affects provider reimbursement by decreasing the number of claim denials, reducing delays in claims processing and increasing timely reimbursement. Here are some Web sites that you can use to check periodically for updates: The American Medical Association (AMA) maintains and publishes the CPT codes and periodically issues errata to the codes during the year. In addition, codes may be added in July. Go to the AMA Web site: www.ama-assn.org/, or directly to the CPT page: www.amaassn.org/ama/pub/category/3113.html. Some ICD-9-CM information is also posted on the Web site. HCPCS codes are maintained by the Centers for Medicare & Medicaid Services (CMS). The Web site that lists HCPCS code files and information is: www.cms.hhs.gov /02_HCPCS_LEVEL_II_CODES.asp# TopOfPage. The HCPCS is updated quarterly, and the changes are published at this Web site. ICD-9-CM codes are reviewed by NCHS. The ICD-9-CM guidelines, conversion table and addenda are located at: www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm#guidelines. Two resources that give in-depth coding analysis for specific services that may be difficult to code are the CPT Assistant, located at the AMA Web site, and the American Hospital Association (AHA) Coding Clinic for ICD-9-CM coding guidelines, located at www.aha.org. A subscription fee is charged for access to these resources. Inside this Issue Member Privacy...2 65C Plus Update...2 HHIN Corner...5 Reminder...6 For all CPT codes used in this Provider Update: CPT only 2005, American Medical Association. All rights reserved. PS06-049
Member Privacy BlueCard member ID cards do not include Social Security numbers Blue Cross and Blue Shield plans are sensitive to member concerns about identity theft and support legislative efforts toward protecting members privacy. As of January 1, 2006, nearly all Blue Cross and Blue Shield plans have successfully replaced Social Security numbers with alternate unique member identifiers. Members who participate in the BlueCard program receive ID cards with a three-character alpha prefix that identifies the member s home plan. Inclusion of the alpha prefix when using the member ID number is critical for accurate eligibility/benefits verification and claims processing. Helpful Tips To ensure proper claims filing, use these tips to make sure you have accurate BlueCard member information. First, make copies of the front and back of the member s ID card. Next, enter the identification number in the patient s record exactly as it appears on the member s card including the three-character alpha prefix and pass on this key information to your billing staff. Member IDs always include the alpha prefix in the first three positions if the Blue Cross and Blue Shield member participates in the BlueCard program. Following the three-character alpha prefix, BlueCard member ID numbers may be any combination of alpha/numeric characters; the resulting member ID number will contain a maximum of 17 characters. Remember: Do not assume the member s ID number is his or her Social Security number. If you have any questions, please call a BlueCard Teleservice Representative at 948-6280 on Oahu or 1 (800) 648-3190 from the Neighbor Islands. 65C Plus Update Physical, speech and occupational therapy caps Because 65C Plus is a Medicare-based plan, effective January 1, 2006, outpatient therapy services covered under 65C Plus are subject to the following financial limitations (therapy caps): Physical therapy includes outpatient speech-language pathology. These services have a combined annual limit of $1,740 for 2006. Occupational therapy which has an annual limit of $1,740 for 2006. Services performed in all settings, except the outpatient hospital (place of service code 22) and hospital emergency room (place of service code 23), are subject to therapy caps. 2
Exceptions to the therapy cap Once the therapy cap has been met, 65C Plus members can be excepted from the therapy cap if continued therapy services are medically necessary. Types of therapy cap exceptions Exceptions fall into the following categories: Automatically excepted services. Certain evaluation services are excepted from therapy caps. Evaluation services performed to determine if the 65C Plus member s current status requires therapy services fall under the automatic exception. The following evaluation procedures are automatically excepted after therapy caps are reached: 92506, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 97001, 97002, 97003, 97004. In addition to evaluation services that are automatically excepted, CMS has established a list of CONDITIONS and COMPLEXITIES identified by ICD-9-CM codes that are automatically excepted from therapy caps. When the excepted ICD-9-CM code is a CONDITION, the condition must be related to the therapy goals and must directly and significantly impact the rate of recovery before it would be appropriate to exceed the therapy caps. When the excepted ICD-9-CM code is a COMPLEXITY that is in combination with other conditions not on the excepted list, the combination must show that the exception will directly and significantly impact the rate of recovery for the condition being treated. The ICD-9-CM list of conditions and complexities is published in Change Request 4364, Transmittal 855, for publication 100-04, the Medicare Claims Processing Manual. Under an automatic exception, the provider is not required to submit a request for exception or supporting documentation. However, the provider must maintain documentation in the member s clinical records. This documentation must be submitted in response to any subsequent claim review. Request for therapy cap exception. When a 65C Plus member does not qualify for an automatic therapy cap exception, the ordering physician may submit a request for a therapy cap exception to HMSA s Medical Management Department. Providers requesting a therapy cap exception may write to HMSA s Medical Management Department at the following address: Medical Management Department, 6MM Hawaii Medical Service Association P.O. Box 2001 Honolulu, HI 96805 Therapy cap exception requests can also be faxed to (808) 944-5611. This fax line accepts faxes 24 hours a day. The request must include a specific number of additional treatment days needed, not to exceed 15. Documentation must accompany the request and should include the current evaluation or reevaluation, current plan of care, treatment encounter notes and interval progress reports sufficient to explain the 65C Plus member s current functional status and need for continued therapy. An exception request should be submitted as soon as the ordering physician determines that the member may need services beyond the cap limits. Failure to submit requests for cap exceptions prior to the date the cap is surpassed will put the 65C Plus member at risk of incurring the cost of treatment if the request is denied. 3
Reviewing therapy cap exceptions HMSA has 14 calendar days to respond to standard requests and 72 hours for expedited requests. When the request is approved, payment will be made for medically necessary services provided within the number of approved treatment days regardless of whether those services were provided before or after receipt of the request. If the request is denied, the denial letter will include the reason for the denial. Billing with modifier KX When a 65C Plus member qualifies for a therapy cap exception, the practitioner must add a KX modifier to the code for the therapy, subject to the cap limits. By attaching the KX modifier, the provider is attesting that the services billed: Qualify for the cap exception either automatically or by approval of an exception request, Are reasonable and necessary services that require the skills of a therapist, and Are justified by appropriate documentation in the medical record. Modifiers GN, GO and GP are still required and should be used along with the KX modifier, where appropriate. When services not covered by 65C Plus are billed to obtain a denial so the services can be billed to other insurers, use modifier GY. Appealing a denial of a request for therapy cap exception Denial of a request for therapy cap exception is not considered an initial claim determination and is not subject to the administrative appeals process. However, if a 65C Plus member elects to receive services that exceed the cap limitation, even though the services were not approved, the determination made on a claim submitted for such services would be subject to the administrative appeals process. Notification of 65C Plus members exceeding therapy limits Claims received for outpatient therapy services that exceed the therapy cap for which the automatic exception did not apply or request for exception was denied will be reported on the Report to Member and Report to Provider. To review the therapy cap exception process in more detail, please refer to the following documents posted on the CMS Web site: Medlearn Matters 4364 (Change Request 4364): www.cms.hhs.gov/ MedlearnMattersArticles/downloads/ MM4364.pdf. This provides a summary of the therapy cap policy. Transmittals that contain changes to the following Medicare manuals: o o o Medicare Benefit Policy Manual: www.cms.hhs.gov/transmittals/ downloads/r47bp.pdf Medicare Claims Processing Manual: www.cms.hhs.gov/transmittals/ downloads/r855cp.pdf Medicare Program Integrity Manual: www.cms.hhs.gov/transmittals/ downloads/r140pi.pdf 4
HHIN Corner Eligibility for BlueCard members now available through HHIN There are two ways you can verify out-ofstate BlueCard member eligibility: by phone or through the Hawaii Healthcare Information Network (HHIN). These services allow providers to obtain information about covered benefits, plan deductible amounts, copayments and more. By phone By telephone, call 1 (800) 676-BLUE (2583), Monday through Friday. The network is available from 1:30 a.m. until 2 p.m. Hawaii Standard Time when the Mainland is on daylight-saving time or 2:30 a.m. until 3 p.m. Hawaii Standard Time when the Mainland is on standard time. When you call, be sure to have the member s ID card available; you will need the three-character alpha prefix to be connected to the member s home plan. Once you are connected with a representative from the member s home plan, you can verify information such as effective dates of coverage, what deductible or copayment amounts the member is responsible for paying, and other benefits coverage details. For complete instructions on how to contact the member s home plan through the BlueCard 800# Network, follow the directions listed under BlueCard Program in the Provider E-Library. Through HHIN HHIN is an alternative way for providers to verify eligibility for out-of-area BlueCard members. HHIN is advantageous to providers because: It is available for eligibility verification from 2 a.m. until 8 p.m. (Hawaii Standard Time when the Mainland is on standard time) or from 1 a.m. until 7 p.m. (when the Mainland is on daylight-saving time); these hours of availability extend for several hours later than the BlueCard 800# Network. It allows providers to obtain basic details about an out-of-area member s benefits coverage quickly; electronic submissions often receive a response in less than 60 seconds. To check BlueCard eligibility through HHIN, click the BLUE ELIGIBILITY button on the left side of the screen. Enter the member s information in the fields that display (they all are required), and click the SUBMIT button. Please only click the SUBMIT button once; multiple submissions will cause a delay in processing your request. If your search returns no matches, either the information you entered is incorrect or the information is correct, but the HHIN system is currently unavailable. You may re-enter the member s information, or you can verify member eligibility over the phone if it is during the regular business hours outlined above. If your search is successful, member information will be displayed. Ensure the member s personal information in section one (e.g., name, address) matches the information on his or her member ID card. Then, review the following sections to verify member eligibility: 5
Section two Eligibility Begin Date or Eligibility Date Range: Ensure the member s coverage dates include the requested date of service. Section five Benefits Coverage Information: Review basic benefit information such as the type of plan, coverage and benefit. Click each individual line to display more information about the benefits coverage provided. Note: Member information will display in HHIN only if the member s home plan provides these details for availability on HHIN. The information that displays will be only a very basic overview of the member s plan benefits. More specific information about the member s benefits coverage can be obtained by contacting the member s home plan through the BlueCard 800# Network; however, keep in mind the phone network s hours of availability are more limited than HHIN s. For more information about HHIN, call the HHIN Help Desk at 948-6446 on Oahu or 1 (800) 760-4672 from the Neighbor Islands. HHIN frame relay service to be discontinued Effective June 1, 2006, HHIN will no longer be accessible through frame relay connections. HMSA s HHIN Support Staff have been contacting affected providers to coordinate and schedule the conversion from frame relay to Internet connection to HHIN. If you have questions about this conversion, please contact the HHIN Help Desk at 948-6446 on Oahu or 1 (800) 760-4672 from the Neighbor Islands. Reminder Submission of corrected FEP claims If you receive a turnaround document (TAD) for the Federal Employee Program (FEP), please resubmit a corrected claim form. Corrections written directly on the TAD cannot be accepted by FEP for processing. This policy does not apply to HMSA s private business plans (PPO, HMO). For claims filed under these lines of business, corrections should be made directly to the TAD, which should then be mailed to HMSA according to the instructions outlined in the TAD. If you have questions about information in this Provider Update, please call a Provider Teleservice Representative at 948-6330 on Oahu or 1 (800) 790-4672 from the Neighbor Islands. 6