medicare a changes effective 1/1/11 advanced edi set up … does the change around prev med... ·...

Medicare A Changes effective 1/1/11&&

Advanced EDI Set Up

LeeAnn Pavlick

AgendaProcedure Fee Schedules

� Carrier Specific Requirements

� Date of Service effective

� Fee Increases

Procedure Code Fee Schedule Setup

� Carrier Specific Functionality

� Updating Fee Schedules with active reports

Provider Fee Schedule Assignment

� Insurance Carrier / Insurance Group

� Effective Dates

Approval Plug-in Settings

� Carrier Specific Settings/Functionality

Insurance Carrier Plug-in Settings

� Institutional –UB04/Professional-CMS1500/Dental-ADA

New Claim Medicare A Claim Examples

Electronic Remittance & Electronic Secondary Claims

Void & Adjustment Claims

Multiple Procedure Fee Schedules

Medicare FQHC

� CPT

� Revenue Codes

� Allowed Amounts

Medicare Replacement

State Carrier Specific

Dental Authorizations

Sliding Fee� Allowed Amounts

� Contract Type Codes

� Alternate Payer

Medicaid FQHC

� Allowed Amounts

� Contract Type Codes

� Alternate Payer

Sliding Fee

� Allowed Amounts

Capitated Plans

� Allowed Amounts

Standard

� Allowed Amounts

Procedure Fee Schedules

Allowed Amounts

� $0.00

•Sliding Fee•Sliding Fee

•Medicaid when paid as Encounter

•Capitated Procedures

•Preventative Medicine Services

� 20% of Fee

•Medicare FQHC amount to collect from 2nd

Carrier or Patient

Procedure Fee Schedules

Revenue Codes

� Carrier Specific� Carrier Specific

� Medicare FQHC – applicable revenue code

� Medicaid FQHC – specific revenue code

� Medicare RHC

•0521 – all services except preventative

•0771 – preventative services

Procedure Fee SchedulesContract Type Codes

� Adds Encounter Rate Code to Visit

•QO, QP, QD, QF, QS, Q1-Q6, PO•QO, QP, QD, QF, QS, Q1-Q6, PO

� Preventative

•PM, PO

� Provider Based Split Billing

•PS, SP, ST, UB, DE

� Miscellaneous

•NF, NC, PB, FFS

Miscellaneous Contract Type Codes

NFNFNFNF=Procedure will not be filed to current carrier If CYSFQHCApproval Plug-in is set to run on visit for this carrier, the procedure will be unchecked and not sent

SPSPSPSP=Split Claim during File Creation

PSPSPSPS=Provider Based Billing /Split claims

STSTSTST=Provider Based Billing/Split procedures

UBUBUBUB=Provider Based Billing/UB only unchecked and not sent electronically or printed on HCFA

PMPMPMPM=Preventative Medicine Procedures

PBPBPBPB=Prior Authorization for Dental Claims. If set on Fee Schedule specific for Dental Pre Auth, will send claim as Electronic Pre-Authorization rather than a billable claim.

FFSFFSFFSFFS=Fee For Service on state specific claims, encounter and FFS procedures must appear on same claim

UBUBUBUB=Provider Based Billing/UB only procedures

DEDEDEDE=Provider Based Billing/DME only procedure

NCNCNCNC=Non-Covered Procedures that amount must be reported in specific segment(s) / Institutional

New Contract Type Codes

“PMPMPMPM” & “POPOPOPO” for Preventative Medicine procedures� The “PO” contract type code is used on Preventative Medicine procedures when no other face-to-face service is provided to add the Encounter Rate to the visit. If you have occurrences when it would be used both with an Office Visit or another face to face service as well as by its Office Visit or another face to face service as well as by its self, you will need to set the procedure code up a second time with the other Contract Type Code.

� The “PM” contract type code is used on Preventative Medicine procedures such as the pneumonia and flu vaccines.

Be sure to leave the ANSI Code field blankBe sure to leave the ANSI Code field blankBe sure to leave the ANSI Code field blankBe sure to leave the ANSI Code field blank� CPS06, CPS 9.0, CPS 9.5 and CPS 10.0

• Administration � Claims � EDI � Contract Type Code

� CPOPM04• Administration �General/Administration � Contract Type Code

Contract Type Codes

Contract Type Code Setup – used in Approval Settings

and in Procedure Fee

Schedules

Encounter Code and Rate added to Ticket on Approval

Multiple Fee Schedules

Allowed normally set to 20% of Fee on Medicare A Fee Schedule – 20 % expected from secondary carrier or patient

CPT Code

Medicare FQHC Fee Schedule

patient

Revenue Code to be reported to Medicare A

Contract Type determines Encounter Code/Rate added to ticket

Medicare FQHC–Alternate Payer-Lab

Allowed = Fee on Alternate

Laboratory – will send CLIA # loaded in Facility table

on Alternate Payer Services

Auto-completes Referring on Diagnostic Testing

Procedure will split to new ticket with FFS carrier

Medicare FQHC–Alternate Payer–Hospital

Procedure will split to new ticket with FFS carrier

Standard Fee Schedule/Medicare FQHC Secondary

Allowed normally set to 100 % of Fee

Revenue Code to be reported to Medicare A

Contract Type determines Encounter Code/Rate added to ticket

Medicaid FQHC Fee Schedule

0.00 Allowed on procedures considered procedures considered part of Encounter

Contract Code determines Encounter Rate Code added to Visit

CPT Code sent to Carrier

Revenue Code sent to Carrier

Medicaid FQHC–Alternate Payer–FFS Procedures

Checked to split procedure to FFS carrier

Allowed amount equal to Fee – FFS Carrier

Sliding Fee - Fee Schedule

Allowed amount set to 0.00 on Sliding Fee – Fee Schedule – actual amount due from patient Schedule – actual amount due from patient calculated by Allocation Sets

Update New Procedure Fee Schedule(s)

Reports Component �CHC Folder � “Update Procedures Fee Schedule”

Report will have been added to your system automatically if you loaded the 2010 UDS reports.

This is an Active Report and will update your database with the requested information.

Fee Schedule & Revenue Code Field Options

Double-click in the Select Fee Schedule field, search and locate the New Fee Schedule you created.locate the New Fee Schedule you created.Specify the Appropriate Revenue Code to be assigned to procedures listed in the FQHC Procedures field.CMS is suggesting in their documentation that the appropriate Revenue Code for each procedure is now required and sites should NOT be using the 0521 on every procedure as was previously used. (FQHC)

Procedures to be assigned Revenue Code 0521

Double-click in the FQHC Procedures field and select the procedure codes to be updated with the specified Revenue Code and Contract Type Code. Example: all Evaluation and Management Codes. Do not Do not Do not Do not Evaluation and Management Codes. Do not Do not Do not Do not include the FQHC/RHC encounter rollinclude the FQHC/RHC encounter rollinclude the FQHC/RHC encounter rollinclude the FQHC/RHC encounter roll----up up up up codes such as 520, 521, 900 and other codes such as 520, 521, 900 and other codes such as 520, 521, 900 and other codes such as 520, 521, 900 and other 052x052x052x052x.Populate the Allowed as Percent of Fee. Normally this amount is .20 for twenty percent / the amount you are expecting to receive from either the secondary payer or the patient. The Preventative Codes that were listed by CMS should have a 0 % allowed as the patient or their secondary carrier is NOT responsible for the 20% on these procedures. See list of Preventative codes from CMS Transmittal 2122 /Change Request 7208 (Waiver of Coinsurance and Deductible for Preventative Services)

Contract Type Codes Assigned

Click the setting “Pull CPT from Procedure” to update the new Fee Schedule with the actual CPT codes rather than the previously entered 99212. Populate the appropriate Contract Type Populate the appropriate Contract Type Codes to be assigned “Change to Contract Type” to these procedures.Normally “QO” is utilized for Medical Procedures, “QP” for Psychiatric/Behavioral Health Procedures or the new “PM” for Preventative Medicine procedures that should now be reported. If a Preventative Procedure would be performed without any other Face-to-Face Procedure/Encounter Code, use the Contract Type Code of “PO”. Any procedures that should not be reported in the electronic file or UB04 should be updated with a “NF” (no filing) Contract Type Code. This will uncheck the “File to Insurance” box on the specific procedures.

Updating the Database

With the fields populated properly, populated properly, click on the Preview (binocular) icon.

Updating the Database• Closing the Preview window will

display the following question “Would you like to update the “Would you like to update the “Would you like to update the “Would you like to update the database?”database?”database?”database?”. A “Yes”“Yes”“Yes”“Yes” response will copy the information entered to the Fee Schedule selected.The above steps MUST be repeated The above steps MUST be repeated for each different Revenue Code, Contract Type Code and/or percent responsibility from the patient or the secondary carrier.Providers must now also report any Preventative Medicine Procedures as separate line items on the claims (see MLN Matters documents MM7028 & MM7038). To accomplish this use the above active report and assign the newly created Contract Type codes of “PM” and “PO” to these specific procedure(s).

Assign & Copy Fee Schedule to ProvidersAssign the New Fee Schedule(s) to a Provider with appropriate effective date(s)

Old Fee Schedules will have to be manually expired on each provider separately expired on each provider separately

� CPS06 and CPS 9.0

•Administration � Edit � Responsible Providers

� CPOPM04

•Administration �Edit�Doctors

Assignment of New Fee ScheduleExpiration of Old Fee Schedule

Copy New Fee Schedule(s)

Copy New Fee Schedule(s) to allallallall appropriate providersReports Component �CHC Folder � “Copy Fee CHC Folder � “Copy Fee Schedule to Doctors” Report will have been added to your system automatically if you loaded the 2010 UDS reports.This is an Active Report and will update your database with the requested information.

Selecting Source & Destination Providers

Double-click in the Source Doctor Field and select the provider name that you updated with the New Fee updated with the New Fee Schedule(s).

Double-click in the Destination Doctor(s) field and select ALL the appropriate Providers/Doctors you would like to update with the New 2011 Fee Schedule(s), exceptexceptexceptexceptthe Provider/Doctor selected as the Source Doctor.

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Selecting Fee Schedule to be added to Providers

Double-click in the Fee Schedule field and select the New 2011 Medicare Fee Schedule (if you created more than one new fee more than one new fee schedule you need to repeat the above process for each)Provider will NOT be updated if the specific Fee Schedule already exists in the Provider Fee Schedule Tab.With the above fields populated properly, click on the Preview (binocular) icon.

Updating the Database

• Closing the Preview window will display the following question “Would you like to update the database?”. A update the database?”. A “yes” response will copy the above named Fee Schedule to each of the listed providers/doctors.

Primary Approval Plug-in Settings

If Value Code need to be added to Visit

Encounter Rate and amount added to visit based on Contract Type when Carrier is Primary

be added to Visit

New RHC Setting for Medicare A claims

2nd Approval Plug-in Settings

If Value Code needs to be

added to Visit – Filing Tab added to Visit – Filing Tab

(2) – Institutional Claims

Only

Encounter Rate and amount added to visit based on Contract Type when Primary Carrier Type is FQHC, Commercial, etc.

Other Approval Plug-in Settings

Will adjust balance due based on Allowed Amount in Procedure Fee Schedule

If Patient is always insured –Approval setting on carrier will automatically set. Example Medicare & Medicaid patient is always insured

If Carrier is Managed Care /Capitated Carrier and 2nd

BBA /Wrap around needs to be filed

Provider Based Billing Settings – split claim to Professional and Technical Service as well as DME services. Uses PS Contract Type Code

Insurance Carrier Settings - Filing MethodsSpecify the filing method for all FQHC Carriers (any carrier that adds an Encounter Rate to the visit)Administration � Edit �Insurance Carriers � Search for your Medicare A carrier(s) EDI Insurance Carriers � Search for your Medicare A carrier(s)� EDI tab � Edit/Modify � Filing MethodSpecify the appropriate Filing Method (UB92/UB04 or HCFA/CMS1500 or ADA) (requiredrequiredrequiredrequired)If you also check Eligibility on your FQHC carrier(s), you will need to create a newnewnewnew “all” row Filing Method to be utilized just for the Eligibility.

Institutional/UB04/837I SettingsDo not send patient payment amount in 2300 AMT segment� If amount paid is reported, many times

carriers will make payment to patient.

Send Other Payer Address in Loop 2330 N3 and N4 Segments2330 N3 and N4 Segments

Do Not Send “Legacy numbers when NPI is sent in NM109

Receiver ID – Payer ID

Files To /Uses� Centricity EDI

� Riverbend

� CyClaims

� Palmetto

� Anthem/NGS

Suppress Revenue Code Roll Up

Provider Based Billing� Overrides /Defaults

Professional/CMS1500/837P

Send Insurance Carrier Address in Loop 2010BB N3 and N4 Segments� If claim is going to be dropped to paper

at Clearinghouse

Send Service Authorization Send Service Authorization Exception Code in Loop 2300 REF Segment� Carrier specific requirement (NY)

Do Not Sent Patient Amount Paid in Loop 2300 AMT Segment� If amount paid is reported, many times



Create 2310B Rendering Provider when Filing as Individual

Suppress 2310B Rendering Provider Information when Filing as Group

� FQHC Carrier Specific

Include Procedures with Zero Dollar Fee

� Not all carriers will accept $0.00 amounts

Do Not Send “Legacy” numbers when NPI is sent in Do Not Send “Legacy” numbers when NPI is sent in NM109

Send PRV Segment with Taxonomy Code in 2000A

� Use “BI Provider Code in PRV01

� Override 2310B PRV03 with company Taxonomy code

Do Not send 2310B REF EI

� Carrier Specific

Rollup Loop 2400 to a single line for FQHC visit

� When FQHC Carrier only wants to see FQHC Code w/Total Charge of visit excluding Encounter Rate

List all service lines at $0.00

� Only available as option if Roll-up to single FQHC Code is selected.


Include FQHC Codes

Uses Centricity EDIUses Centricity EDI

Uses CyClaims

Dental/ADA/837D Settings

Send Insurance Carrier Address in Loop 2010BB N3 and N4 Segments� If claim is going to be dropped to paper

at Clearinghouse

Send Service Authorization Exception Code in Loop 2300 REF Exception Code in Loop 2300 REF Segment� Carrier specific requirement (NY)

Do Not Sent Patient Amount Paid in Loop 2300 AMT Segment� If amount paid is reported, many times


Dental/ADA/837D SettingsCreate 2310B Rendering Provider when Filing as Individual

Suppress 2310B Rendering Provider Information when Filing as Group


Include Procedures with Zero Dollar Fee

� Not all carriers will accept $0.00 amounts� Not all carriers will accept $0.00 amounts

Do Not Send “Legacy” numbers when NPI is sent in NM109

Send PRV Segment with Taxonomy Code in 2000A

� Use “BI Provider Code in PRV01

� Override 2310B PRV03 with company Taxonomy code

Do Not send 2310B REF EI

� Carrier Specific

Use Facility Address in 2010AA

Do not populate Co-ordination of Benefits Code

Dental/ADA/837D Settings

Include FQHC Codes


Uses Centricity EDI

� Filing to Centricity ClearinghouseClearinghouse

Uses CyClaims

� Filing Claim Remedi

Dental Pre-Auths

� Creating a Prior Authorization Claim

• No Dates of Service Sent

• Special setup required

– Fee Schedule

– Additional Company

Claim Filing ExamplesClaim in Centricity Practice Management� 0521 99213(E&M) $100.00� 0636 J0540(Injection) 55.00 � 0271 11000(Debridement) 125.00� 0521 GXXXA(WellnessExam) 175.00

FQHC Claim in 837 File� CLM-total chgs 635.00

Claim in Centricity Practice Management� 0636 J0540(Injection) 55.00 � 0271 11000(Debridement) 125.00

FQHC Claim in 837 File� CLM-total chgs 360.00� SV2 (1) 0521/99212/180.00� SV2 (2) 0636/J0540/55.00� CLM-total chgs 635.00

� SV2 (1) 0521/99213/280.00� SV2 (2) 0636/J0540/55.00� SV2 (3) 0271/11000/125.00� SV2 (4) 0521/GXXXA/175.00

RHC Claim in 837 File� CLM-total chgs 455.00� SV2 (1) 0521/noCPT/280.00� SV2 (2) 0521/GXXXA/175.00

Co-Insurance Amount - $56.00

� SV2 (2) 0636/J0540/55.00� SV2(3) 0271/11000/125.00

RHC Claim in 837 File� CLM-total chgs 180.00� SV2 (1) 0521/noCPT/180.00


Claim Filing Examples

Claim in Centricity Practice Management

� 0521 GXXXA(WellnessExam) $175.00

FQHC Claim in 837 File

� CLM-total chgs 175.00

Claim in Centricity Practice Management

� 0521 99213(E&M) $100.00

� 0636 90669(Pneumo ) 75.00

� 0771 G0009(Admin) 10.00

FQHC Claim in 837 File� CLM-total chgs 175.00

� SV2 (1) 0521/GXXXA/175.00

RHC Claim in 837 File


� SV2 (1) 0521/GXXXA/175.00


FQHC Claim in 837 File


� SV2 (1) 0521/99213/100.00

� SV2(2) 0636/90669/75.00

� SV2(3) 0771/G0009/10.00

RHC Claim in 837 File


� SV2 (1) 0521/noCPT/100.00


QUICK REFERENCE INFORMATION:MEDICARE IMMUNIZATION BILLING

(Seasonal Influenza Virus, Pneumococcal, and Hepatitis B)

MLN Matters® Number: SE1039 MLN Matters® Number: SE1039 MLN Matters® Number: SE1039 MLN Matters® Number: SE1039

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Electronic Remittance & Electronic Secondary Claims

Setup of Payer Literals

Response Processor Setup� Claim Adjustment/Reason Codes

Transaction Column SetsTransaction Column Sets� Actual Allowed

� Line Info

� Co-Insurance

� Deductible

� Residual

� Payment Types

� Contractual Adjustment

Payer Literal

Payer Literal from 835/N1 Segment

ISA*00* *00* *28*9000000450 *ZZ*J03141 ISA*00* *00* *28*9000000450 *ZZ*J03141 *061113*0927*U*00401*000943362*0*P*:~

GS*HP*9000000450*J03141*20061113*09270299*943361*X*004010X091A1~

ST*835*943363~

BPR*I*271.11*C*CHK******1391946735*00450 *****20061113~

TRN*1*0002861075*1391946735*00450~

DTM*405*20061110~

N1*PR*NATIONALNITED GOVERNMENT SERVICESNATIONALNITED GOVERNMENT SERVICESNATIONALNITED GOVERNMENT SERVICESNATIONALNITED GOVERNMENT SERVICES~

N3*6775 WEST WASHINGTON STREET~

N4*MILWAUKEE*WI*532145644~

Response Processor

Claim Adjustment/Reason Codes

Only claim level sent on 2nd MSP claimOnly claim level sent on 2nd MSP claim

Transaction Column Set

Void & Adjustment Claims

Frequency Code

� 1 - Original Claim

� 7 – Adjustment

• Visit paid incorrectly/Originally reported to carrier with incorrect data

� 8 – Void

• Removes claim from patients record at carrier /Carrier will take funds back

Professional/CMS1500

� Filing 1 – Resubmission Code

Institutional/UB04

� Filing 1 – Last digit of Type of Bill

Required

� ICN (Internal Control Number/Document Control Number

CMS Contact InformationPrePrePrePre----Implementation Contact(s): Implementation Contact(s): Implementation Contact(s): Implementation Contact(s): Tracey Mackey (claims processing) 410-786-5736 or Corinne Axelrod (policy) 410-786-5620

Mackey, Tracey Y. (CMS/CMM) Mackey, Tracey Y. (CMS/CMM) [mailto:[email protected]]Division of Institutional Claims ProcessingProvider Billing Group - CMCenters for Medicare & Medicaid ServicesU.S. Department of Health and Human Services7500 Security Blvd, Woodlawn MD 21244Mail Stop C4-10-07410-786-5736

Questions?Questions?

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