MCO Encounter Error SolutionsGeneral Acute Care and Children’s Hospital Billing Guidelines (P59/P60)

Presented 1/26/2017Updated 1/31/2017

General Acute Care and Children’s Hospital Billing Guidelines (P59/P60)

The Illinois Department of Healthcare and Family Services (HFS) requiresmanaged care organizations (MCO) to meet specific claims data submissionstandards requiring exact data elements on claims submitted from hospitals.

To facilitate the appropriate application of these rules, MCOs are collectivelyrelaying information in an effort to reiterate and provide transparency onhospital billing guidelines for services rendered in general acute care andchildren’s institutional settings.

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• MEMO TO ALL PROVIDERS FROM IAMHP– http://iamhp.net/resources/Documents/IAMHP%20Memo%20to%20All%20Health

%20Plans.pdf

• APPENDIX CHART– http://iamhp.net/resources/Documents/Appendix%20A%20General%20Acute%20

Care%20and%20Children%e2%80%99s%20Billing%20Guidelines%20110116.pdf

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• http://www.molinahealthcare.com/providers/il/PDF/Medicaid/General-Acute-Care-Childrens-Hospital-Billing-Guidelines.pdf

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General Acute Care and Children’s Hospital Billing Guidelines (P59/P60)

Documentation usage - Molina– Supply to Hospital billing teams for clear definitions of proper allowable Category of Service

(COS) codes, labor and delivery DRG codes, taxonomy codes, and NPI numbers which allowsproviders to choose age appropriate information at the point of claim entry. (See examples onupcoming slides)

– Appendix A grid is a go-to resource/quick reference guide for customer service, UM, providerrelations and other internal health plan teams

– Molina posts the documentation on its website– Billing Guidelines and Provider Sample Letters have been sent to higher volume P59 and P60

submitters for provider education. (See example letter on next slide)– Quick reference grid assists business analysts with review of claim data elements for proper

“root cause” recommendations for correction(s), and is shared with provider relations teamfor additional provider education

– Molina identified 683 P59 Children standalone hospital claims with services for members over18 years of age, that did not have the correct specialty affiliations through IMPACT/HFS. Afterupdating with IMPACT/HFS these were resubmitted back to HFS as part of EUM metrics andreporting for the measurement period, using the HFS void and replace process

– Providers that have a Children’s NPI but did not have correct “Children’s” hospital taxonomycodes were corrected in Molina systems, which reduced P59 errors.

– Providers that did not have a Children’s NPI and did not have correct “Adult” hospitaltaxonomy codes were corrected in Molina systems, which reduced P60 errors

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Sample Provider Letter

General Acute Care and Children’s Hospital Billing Guidelines (P59/P60)

Documentation contains all of the following:

– General guidance relating to HFS UB-04/837I submissions– List of HFS-registered Children’s hospitals (See next slide)– Allowable inpatient and outpatient categories of services (COS) for

institutional NPI billing– Children’s Hospital allowable inpatient and outpatient categories of services

(COS)– Labor and delivery DRG usage/guidance– Inpatient Psych and Rehab COS definition– Proper taxonomy usage– Billing for Physical Therapy using Professional NPI– Appendix A grid – All inclusive billing guidelines/Quick reference document

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HFS Registered Children’s Hospitals

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General Acute Care and Children Hospital Billing Guidelines (P59/P60)

Both General Acute Care and Children’s hospitals are required to register their NationalProvider Identifier (NPI) numbers as a Provider Type 030 – General Hospital.

Psychiatric hospitals are required to register their National Provider Identifier (NPI)numbers as a Provider Type 031, and must use appropriate taxonomy code for the type ofservice (and bill type) being billed. (For example: Inpatient Psych Services with bill type of111, at a registered Psychiatric Hospital must bill with the Psychiatric hospital taxonomycode of 283Q00000X on the UB-04 form or 837I format).

Rehabilitation hospitals are required to register their National Provider Identifier (NPI)numbers as a Provider Type 032, and must use appropriate taxonomy code for the type ofservice (and bill type) being billed. (For example: Inpatient Physical rehabilitation with billtype of 111, must bill with the Rehabilitation Hospital taxonomy code of 283X00000X for anadult, and taxonomy code of 283XC2000X for a child, on the UB-04 form or 837I format).

Documentation assists billing departments by providing clear rules when HFS billingguidelines are not met, which precipitates the following errors:

A38 - Missing/Invalid Taxonomy CodeP59 - Care Not Appropriate For Children’s HospitalP60 - Care Not Appropriate For Adult Hospital

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030 General HospitalsAllowable Categories of Service (COS)

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─ 001 Physicians Services─ 011 Physical Therapy Services─ 012 Occupational Therapy Services─ 013 Speech Therapy/Pathology Services─ 014 Audiology Services─ 017 Anesthesia Services─ 020 Inpatient Hospital Services (General)─ 021 Inpatient Hospital Services (Psychiatric)─ 022 Inpatient Hospital Services (Physical

Rehabilitation)─ 023 Inpatient Hospital Services (ESRD)─ 024 Outpatient Services (General)─ 025 Outpatient Services (ESRD)─ 026 General Clinic Services─ 027 Psychiatric Clinic Services (Type 'A')─ 028 Psychiatric Clinic Services (Type 'B')─ 029 Clinic Services (Physical Rehabilitation)─ 030 Healthy Kids Services

─ 035 Alcohol and Substance Abuse Rehab.Services

─ 037 Skilled Care Hospital Residing─ 038 Exceptional Care─ 039 DD/MI Non Acute Care Hospital Residing─ 040 Pharmacy Services (Drug and OTC)─ 041 Medical Equipment/Prosthetic Devices─ 048 Medical Supplies─ 050 Emergency Ambulance Transportation─ 051 Non-Emergency Ambulance Transportation─ 052 Medicar Transportation─ 054 Service Car─ 067 Maternal & Child Health Application─ 068 Mental Health Targeted Case Mgt. Services

for E/I─ 069 Subacute Care Program─ 098 MPE Certification─ 102 Fluoride Varnish for Children under 36

Months─ 105 Hospital Presumptive Eligibility

031 Psychiatric HospitalsAllowable Categories of Service (COS)

– 001 Physicians Services– 010 Nursing Services– 012 Occupational Therapy Services– 013 Speech Therapy/Pathology Services– 014 Audiology Services– 017 Anesthesia Services– 021 Inpatient Hospital Services (Psychiatric)– 024 Outpatient Services (General)– 027 Psychiatric Clinic Services (Type 'A')– 028 Psychiatric Clinic Services (Type 'B')– 035 Alcohol and Substance Abuse Rehab. Services– 037 Skilled Care Hospital Residing– 038 Exceptional Care– 039 DD/MI Non Acute Care Hospital Residing– 040 Pharmacy Services (Drug and OTC)– 041 Medical Equipment/Prosthetic Devices– 048 Medical Supplies– 050 Emergency Ambulance Transportation– 051 Non Emergency Ambulance Transportation– 052 Medicar Transportation– 054 Service Car– 067 Maternal & Child Health Application

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032 Rehabilitation HospitalsAllowable Categories of Service (COS)

– 001 Physicians Services– 010 Nursing Services– 012 Occupational Therapy Services– 013 Speech Therapy/Pathology Services– 014 Audiology Services– 017 Anesthesia Services– 021 Inpatient Hospital Services (Psychiatric)– 024 Outpatient Services (General)– 035 Alcohol and Substance Abuse Rehab. Services– 037 Skilled Care Hospital Residing– 038 Exceptional Care– 039 DD/MI Non Acute Care Hospital Residing– 040 Pharmacy Services (Drug and OTC)– 041 Medical Equipment/Prosthetic Devices– 048 Medical Supplies– 050 Emergency Ambulance Transportation– 051 Non Emergency Ambulance Transportation– 052 Medicar Transportation– 054 Service Car– 067 Maternal & Child Health Application

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Multiple Unique Institutional NPIs / Shared Single Professional NPIGeneral Acute and Childrens Hospitals

Example of hospitals enrolled in the HFS MAP with Multiple Unique Institutional NPIs and a Single SharedProfessional NPI:

• ABC Hospital and ABC Children’s Hospital

Unique General Acute Institutional NPI correlates to Unique Institutional Medicaid ID

• All claims for beneficiaries over the age of 18 must be billed using this NPI regardless of services

• Labor and delivery (DRG REV 626 or 640) claims must be billed using this NPI and the correct taxonomy

• Must select the correct NPI when billing for Inpatient Psych Per Diem Reimbursment

Unique Childrens Acute Institutional NPI correlates to Unique Institutional Medicaid ID• General Inpatient Hospital Claims (except Labor and Delivery DRG REV 626 and 640) for children under the

age of 18 must be billed using this NPI. Provider must be registered with this specialty in the IMPACTsystem

Shared Professional NPI correlates to Shared Single Professional Medicaid ID

Institutional claims billed on UB-04 Professional claims billed on CMS-1500 Physical Therapy billed on CMS-1500 using the Hospital’s Professional Medicaid ID registered for COS 011. Since the Professional NPI is shared between both General Acute and Childrens Acute, Provider is able to use

the shared NPI to bill Physical Therapy for both adults and children hospitals

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Billing Scenario # 1 (Unique Registered NPIs)

10 year old patient presents at ED of general acute hospital and is admitted forInpatient Psychiatric Services.

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Facility has a registered unique general acute NPI and Medicaid ID and a unique Childrens hospital NPI and Medicaid ID.

Children’s Hospital Institutional NPIs must always be used for Members younger than the age of 18 years on the date ofadmission (with the exception of Labor and Delivery claims) for the following COS, unless otherwise registered forspecific psych and rehab COS:

o 020 Inpatient Hospital Services (General) o 025 Outpatient Services (ESRD)o 023 Inpatient Hospital Services (ESRD) o 026 General Clinic Serviceso 024 Outpatient Services (General)

Claims may not be submitted using the Children’s Hospital Institutional NPIs for the following Categories of Servicesunless the provider’s Children’s Hospital Institutional NPI is specifically registered for the allowable Categories ofServices.

o 021 Inpatient Hospital Services (Psychiatric) o 027 Psychiatric Clinic Services (Type 'A')o 022 Inpatient Hospital Services (Physical Rehabilitation) o 028 Psychiatric Clinic Services (Type 'B')

o 029 Clinic Services (Physical Rehabilitation)

Since the Provider in the ABC Children's Hospital example is not registered for 021 Inpatient Hospital Services(Psychiatric) with the Children’s Institutional NPI (1345678921), the provider would bill using the General AcuteInstitutional NPI (1234567891) with the qualifying General Acute Care Hospital taxonomies. Provider will receive theGeneral Acute applicable MHVA, MPA, Psych and Safety Net add-ons and would not be eligible for the Children’s hospitalAdd-ons.

Billing Scenario # 2 (Under 18 - Labor and Delivery)

Facility has a unique registered general acute NPI and Medicaid ID and a unique Children’s hospitalNPI and Medicaid ID.

Labor and Delivery Claims (APR-DRG 626 or 640) for members less than the age of 18 years on thedate of admission must be billed using the General Acute Care Institutional NPI

Claims are submitted with 282NC2000X (General Acute Care Hospital - Children), 281PC2000X(Chronic Disease Hospital - Children), 282N00000X (General Acute Care Hospital), or 282NR1301X(General Acute Care Hospital - Rural), womens, and general taxonomies. Children’s hospitals billingfor these services will receive the General Acute Care Per Diem and applicable MHVA/MPA Add-ons

The Children’s NPI and standard delivery DRGs (540, 541, 542, or 560) should not be billed usingChildren’s Institutional NPI unless it is one of the stand alone Children’s Hospital facilities

Since the Provider in the ABC Children’sHospital is not a stand alone facility, the provider woulduse the General Acute Institutional NPI for individuals under the age of 18 for labor and deliveryservices.

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17 year old patient is admitted and discharged for labor and delivery.

Unique Institutional NPIGeneral Acute Hospitals

Example of hospital enrolled in the HFS MAP with a Unique Institutional NPI:

• Jane Smith Hospital

Unique General Acute Institutional NPI correlates to Unique Institutional Medicaid ID

• All claims for beneficiaries over the age of 18 must be billed using this NPI regardless of services

• Only qualifies for Inpatient Rehabilitation Per Diem rates and not the Psychiatric Per Diem rates

Shared Professional NPI correlates to Shared Single Professional Medicaid ID

Institutional claims billed on UB-04 Professional claims billed on CMS-1500

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Billing Scenario # 3 (Shared Registered NPIs)

22 year old patient presents at ED of general acute hospital and isadmitted for psych services.

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Facility has a single general acute NPI and Medicaid ID and is not registered for psych services.

If the General Acute Care Institutional Hospitals’ NPI is not registered for Category of Service 21 (Psychiatric), theprovider may submit a claim for emergency psychiatric care which is reimbursable under a 3 day DRG using the282N00000X (General Acute Care Hospital) taxonomy.

If the General Acute Care Institutional Hospitals’ NPI is not registered for one of the following Category ofServices, then the provider may not submit a claim for reimbursement for the following Categories of Services:

o 021 Inpatient Hospital Services (Psychiatric)o 022 Inpatient Hospital Services (Physical Rehabilitation)o 027 Psychiatric Clinic Services (Type ’A’)o 028 Psychiatric Clinic Services (Type ’B’)o 029 Clinic Services (Physical Rehabilitation)

Since the Provider in the Jane Smith Hospital example is not registered for 021 Inpatient Hospital Services(Psychiatric), the provider only qualifies for the 3 day emergency DRG psychiatric admission using the GeneralAcute Institutional NPI (1234567891) using the qualifying General Acute Care Hospital taxonomies. Since theGeneral Acute Institutional NPI is registered with the COS 022 (Rehab), the provider would bill with the GeneralAcute Institutional NPI and taxonomy and will receive its Per Diem and applicable MHVA, MPA, and Rehab Add-ons.

General Acute Care and Children’s Hospital Billing Guidelines (P59/P60)

Questions???

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