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Medicare/Medicaid Coaltion Report
September 18, 2009


Medicare Medicaid

Flu vaccine
Please note the reimbursement for 90658 has been changed to $11.37 effective Oct. 1, 2009.

For educational resources, visit the government flu information site.

Medicare Administrative Contractor
There is no update for the Indiana Medicare Administrative Contractor (MAC), Jurisdiction 8.

Preparing for the flu season
Medicare covers flu, pneumococcal and administration. For a good source of information, please visit here.

For diagnosis of seasonal influenza or H1N1, use V04.81.

Vaccine codes
Here is pricing effective Oct. 1, 2009:

90655

$15.45

90656

$12.54

90657

$5.68

90658

$11.37

90660

$22/32

Prices can change quarterly. Also note that the new H1N1 vaccine code, G9142, is not payable because the vaccine is furnished at no cost to physicians.

Administration and pricing

Seasonal flu

G0008

$23.04

New H1N1

G9141

$23.04 (same rate as G0008)

Remember there is no deductible or co-insurance for the patient and pricing can change at the beginning of the year.

Pneumococcal Diagnosis: V03.82 

Vaccine:

90669

$95.48

 

90732

$37.61

Administration:

G0009

$23.04

If providing the flu and pneumococcal together:

Diagnosis: V06.6

Administration:

 

G0008 - influenza virus

$23.04

G0009 - pneumococcal

$23.04

Roster billing

For details on roster billing, please visit here.

Reminders from CMS
The Centers for Medicare & Medicaid Services (CMS) issued a reminder that if you have applied for Medicare billing privileges or already provide services to Medicare patients, you are subject to unannounced site visits to confirm your operating location.

Read more about these site visits on the ISMA Web site.

In a MLN Matters bulletin, CMS also reminded physicians recently that your billing privileges will be deactivated if mail is returned as undeliverable and National Government Services (NGS), the Medicare carrier, does not already have a change of address enrollment application pending from you.

See the full MLN Matters article on this topic here.

  

EDS
Phase-out of paper
As of Sept. 1, 2009, EDS no longer prints and mails:

  • Paper Remittance Advices
  • Banner pages
  • Bulletins
  • Newsletters
  • Claim Correction Forms (CCFs)
  • Paper communications
If you are not enrolled to receive payments via electronic funds transfer (EFT), you will continue to receive paper checks by mail.

Notification of hospital services
Effective Oct. 1, 2009, providers who serve Care Select patients in a hospital should notify the patients’ care management organization (CMO) so appropriate care coordination can occur.

Hospital staff is responsible for checking member eligibility upon treatment or admittance. Physicians who use Web interChange to check eligibility will see a button called “Care Select Notification” for Care Select members only. Click the button and enter – within 48 hours:
  • Date of treatment
  • Type of treatment
  • Presenting signs, symptoms and/or diagnoses
Visit here for additional information.

Presumptive eligibility, NOP
To improve birth outcomes for Indiana, presumptive eligibility (PE) and notice of pregnancy (NOP) programs are in full implementation. Here is an overview of how they work.

If you are a qualified provider (QP) facilitating completion of a PE application for a pregnant woman, you must provide a telephone for the applicant to contact the enrollment broker, MAXIMUS, to choose her primary medical provider (PMP) and managed care organization (MCO). The applicant must make these selections the same day she applies for PE. You cannot influence the selection process in any way. MAXIMUS will explain the selection process and identify women who are exempt from choosing PMPs and MCOs.
Once selection of the PMP and MCO is made, the member has the right to change her selection at any time during her PE period by contacting MAXIMUS. You will be paid for the services provided the day of the application, even if the member chooses a different doctor as her PMP.
However, ensure all the following steps are completed the same day a PE applicant is in your office:
  • Verify pregnancy via a professionally administered pregnancy test.
  • Verify eligibility using Web interChange.
  • Access the PE member application via Web interChange.
  • Complete and submit the PE member application.
  • Give applicant the PE determination letter.
  • If the applicant is approved for PE, she must contact the enrollment broker to choose her PMP and MCO. Her selections must be written on the PE determination letter.
  • Have the PE applicant verify all information on the Hoosier Healthwise application, sign the application and fax it to the appropriate Division of Family Resources office or the Documentation Center for Modernized Counties. Include a statement of pregnancy.
These steps must be completed on the same day the member is in your office. Failure to complete the PE application and have the member contact the enrollment broker will result in termination of PE for the member and no reimbursement for your services.

The NOP form is a comprehensive risk assessment used by all three Medicaid MCOs. Prenatal care providers who complete and electronically submit the NOP using Web interChange may be eligible for a $60 incentive.

To be eligible for reimbursement:
  • Pregnant woman must be enrolled with an MCO.
  • Woman’s pregnancy must be less than 30 weeks gestation.
  • NOP must be submitted via Web interChange no more than five calendar days from date risk assessment was completed.
  • Providers must bill the MCO using code 99354 with modifier TH.
  • Date of service on the NOP claim should be date you completed the risk assessment with the pregnant woman.
Only one NOP per member, per pregnancy is eligible for reimbursement. NOPs may be submitted for PE pregnant women.

Present on admission
The Centers for Medicare & Medicaid Services (CMS) has authorized no additional payment to hospitals for cases in which one of the following hospital-acquired conditions was not present on admission (POA):
  • Pressure ulcer stages III and IV
  • Falls and trauma
  • Surgical site infections after bariatric surgery for obesity, certain orthopedic procedures and bypass surgery (mediastinitis)
  • Vascular catheter-associated infection
  • Catheter-associated urinary tract infection
  • Administration of incompatible blood
  • Air embolism
  • Foreign object unintentionally retained after surgery
  • Manifestations of poor glycemic control
  • Deep vein thrombosis/pulmonary embolism
Effective Oct. 1, 2009, hospitals will be required to begin reporting for discharges whether the diagnoses for these selected conditions were POA.

The POA indicator is defined as “present” at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation or outpatient surgery, are considered POA.

A POA indicator must be assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes.

The CMS does not require a POA indicator for external cause of injury code unless it is being reported as an “other diagnosis.” The provider must resolve issues relating to inconsistent, missing, conflicting or unclear documentation.

Phase Three NPI
Stage Three of National Provider Identifier (NPI) will complete implementation about September 2009. Stage Three will change the current logic in the system to eliminate use of Legacy Provider Identifiers (LPIs) for typical health care providers.

Several technical processes involving paper claims, financial and electronic data interchange will be updated to fully implement Stage Three.

Claim form options
You are encouraged to submit claims electronically via Web interChange or on the standard red-ink claim form to expedite claim processing and improve accuracy of data entry. Please refer to the IHCP Newsletter or your field consultant for additional options and information.

MRT outreach
In accordance with 405 IAC 5-20-8 Outpatient Mental Health, the following highlights the plan to reach out to psychiatrists, licensed physicians and health service providers in psychology.

The role of the Medical Review Team (MRT), physicians and consultants who specialize in Medicaid disability eligibility determinations, is to determine an applicant’s categorical eligibility for Medicaid under the disability category. These professionals determine whether new applicants meet the criteria for disability and initiate medical reviews for current Medicaid members. The MRT issues decisions based on medical evidence that supports whether the applicant has a significant impairment.

Early, periodic screening, diagnosis and treatment
The Indiana HealthWatch Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is for members under age 21 to introduce young IHCP members to early and complete evaluations to detect abnormalities before they become chronic or debilitating.

EPSDT periodic medical screenings are conducted at regular intervals during the years of a child’s life, up to the 21st birthday for Medicaid-eligible children and up to the 19th birthday for children in Package C.
If the member is in a Hoosier Healthwise risk-based managed care network, the member’s MCO can provide information. Refer to the HealthWatch/EPSDT Provider Manual for further information.

Healthy Indiana Plan
The Healthy Indiana Plan (HIP) is sponsored by the state of Indiana. It provides more affordable health care choices to thousands of otherwise uninsured individuals throughout Indiana. It covers uninsured adult Hoosiers between the ages of 19 and 64 whose income is up to 200 percent of the federal poverty level and who are not otherwise eligible for Medicaid.

Unlike many other government-sponsored programs, parents and childless adults can participate. Funding for HIP allows coverage of a limited number of childless adults. However, this cap has been met. Low income adults with minor children may still be eligible for coverage. Childless adults who meet all other eligibility requirements are added to a waiting list. Anyone interested in applying for HIP is encouraged to submit an application for review.

Eligible participants must be uninsured for at least six months and cannot have access to employer-sponsored health insurance. Participants will be required to make minimal contributions toward coverage.

Plan administrators include MDwise, Anthem Blue Cross and Blue Shield and Indiana Comprehensive Health Insurance Association/Affiliated Computer Services (ACS) – Enhanced Service Plan (ESP).
Find more here.

Providers do not sign any contracts with the HIP insurers to accept HIP ESP patients. Therefore, all IHCP-enrolled providers are included in the “network” for ESP members and are encouraged to accept new patients.

Mail claims for ESP members to:

ACS 
Attention ESP Claims Processing
P.O. Box 33077
Indianapolis, IN 46203-0077

Find additional information on the HIP in provider bulletins here and here.

ISMA Web site
A new feature on the ISMA Web site Onesource page offers a place for members to submit questions for any MCO. Please submit questions 30 days prior to the next coalition meeting. Or, send questions to Gloria Kirkham, CPC, COBGC.

Answers will be available at the next coalition meeting. See the Medicare/Medicaid Coaltion page for a schedule of meetings. Hope to see you there!

 

 

 

 

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