Tuesday, August 16, 2016

Billing provider name in ASC form - 24j NPI only

Ambulatory surgical  center billing with physician’s name 


 When submitting a claim for an ambulatory surgical center (ASC), please make sure to follow the Centers for Medicare & Medicaid Services (CMS) billing guidelines. The correct placement for a provider name and the CMS national provider identifier (NPI) is below.

Ambulatory surgical centers billing on CMS 1500s should list the NPI for the ASC in box 24J.

ONLY list the surgeon’s name and NPI in box 17 and 17b.

Inaccurate information in the claim fields may cause us to deny a claim or to pay incorrect amounts.


National provider identifier (NPI) 

Previously, we have tried to research an incorrect NPI number submitted on claims. Without clarification to the correct NPI number, we have found there could be downstream impacts. This would include the physician quality reporting initiative (PQRI) or ensuring the correct servicing provider is paid accurately.

To be more efficient in our claims processing, we are changing how we research the incorrectly submitted NPI numbers.


Effective June 18, 2010, we will close the claim and request that the servicing provider submit the correct NPI number. We will communicate this information in a Further Information letter, which may have one of the following statements:
Professional claims

The NPI submitted with this claim does not match the servicing provider name as billed on this claim. Please resubmit with matching NPI and provider name.

The NPI submitted with this claim matches the billing provider name. However it does not match the servicing provider name, which is required. Please resubmit with the appropriate NPI and matching provider name.

The NPI submitted does not reflect the provider specialty per the National Plan and Provider Enumeration System (NPPES) that reflects the services billed. Please resubmit with the appropriate NPI for the servicing provider.

Facility claims

The NPI submitted per NPPES does not match the name billed on the claim. Please resubmit with appropriate and matching NPI and provider.

The NPI submitted per NPPES does not reflect the facility type for the services billed. Please resubmit with the appropriate NPI that reflects the facility type for services provided.

Thursday, August 11, 2016

What is LBOD and what are the situation We could do late filing

Late Bill Override Date 

For electronic claims, a delay reason code must be selected and a date must be noted in the “Claim Notes/LBOD” field.

Valid Delay Reason Codes

1 Proof of Eligibility Unknown or Unavailable

3 Authorization Delays

7 Third Party Processing Delay

8 Delay in Eligibility Determination

9 Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules

11 Other

The Late Bill Override Date (LBOD) allows providers to document compliance with timely filing requirements when the initial timely filing period has expired. Colorado Medical Assistance Program providers have 120 days from the date of service to submit their claim. For information on the 60-day resubmission rule for denied/rejected claims, please see the General Provider Information manual in the Provider Services Billing Manuals section.

Making false statements about timely filing compliance is a misrepresentation and falsification that, upon conviction, makes the individual who prepares the claim and the enrolled provider subject to fine and imprisonment under state and/or federal law.


Billing Instruction Detail Instructions 

LBOD Completion Requirements

· Electronic claim formats provide specific fields for documenting the LBOD.
· Supporting documentation must be kept on file for 6 years.
· For paper claims, follow the instructions appropriate for the claim form you are using.
 UB-04: Occurrence code 53 and the date are required in FL 31-34.
 CMS 1500: Indicate “LBOD” and the date in box 19 – Additional Claim Informaion.
 2006 ADA Dental: Indicate “LBOD” and the date in box 35 - Remarks

Adjusting Paid Claims If the initial timely filing period has expired and a previously submitted claim that was filed within the original Colorado Medical Assistance Program timely filing period or the allowed 60 day follow-up period was paid and now needs to be adjusted, resulting in additional payment to the provider.

Adjust the claim within 60 days of the claim payment. Retain all documents that prove compliance with timely filing requirements.

Note: There is no time limit for providers to adjust paid claims that would result in repayment to the Colorado Medical Assistance Program.

LBOD = the run date of the Colorado Medical Assistance Program Provider Claim Report showing the payment.

Denied Paper Claims If the initial timely filing period has expired and a previously submitted paper claim that was filed within the original Colorado Medical Assistance Program timely filing period or the allowed 60 day follow-up period was denied.

Correct the claim errors and refile within 60 days of the claim denial or rejection. Retain all documents that prove compliance with timely filing requirements.

LBOD = the run date of the Colorado Medical Assistance Program Provider Claim Report showing the denial.


Returned Paper Claims A previously submitted paper claim that was filed within the original Colorado Medical Assistance Program timely filing period or the allowed 60 day follow-up period was returned for additional information.

Correct the claim errors and re-file within 60 days of the date stamped on the returned claim. Retain a copy of the returned claim that shows the receipt or return date stamped by the fiscal agent.
LBOD = the stamped fiscal agent date on the returned claim.


Rejected Electronic Claims An electronic claim that was previously entered within the original Colorado Medical Assistance Program timely filing period or the allowed 60 day follow-up period was rejected and information needed to submit the claim was not available to refile at the time of the rejection.


Correct claim errors and refile within 60 days of the rejection. Maintain a printed copy of the rejection notice that identifies the claim and date of rejection.

LBOD = the date shown on the claim rejection report.



Denied/Rejected Due to Member Eligibility An electronic eligibility verification response processed during the original Colorado Medical Assistance Program timely filing period states that the individual was not eligible but you were subsequently able to verify eligibility. Read also instructions for retroactive eligibility.


File the claim within 60 days of the date of the rejected eligibility verification response. Retain a printed copy of the rejection notice that identifies the member and date of eligibility rejection.
LBOD = the date shown on the eligibility rejection report.


Retroactive Member Eligibility The claim is for services provided to an individual whose Colorado Medical Assistance Program eligibility was backdated or made retroactive.

File the claim within 120 days of the date that the individual’s eligibility information appeared on state eligibility files. Obtain and maintain a letter or form from the county departments of social services that:

· Identifies the patient by name
· States that eligibility was backdated or retroactive
· Identifies the date that eligibility was added to the state eligibility system.

LBOD = the date shown on the county letter that eligibility was added to or first appeared on the state eligibility system.


Delayed Notification of Eligibility The provider was unable to determine that the patient had Colorado Medical Assistance Program coverage until after the timely filing period expired.
File the claim within 60 days of the date of notification that the individual had Colorado Medical Assistance Program coverage. Retain correspondence, phone logs, or a signed Delayed Eligibility Certification form (see Certification & Request for Timely Filing Extension in the Provider Services Forms section) that identifies the member, indicates the effort made to identify eligibility, and shows the date of eligibility notification.

· Claims must be filed within 365 days of the date of service. No exceptions are allowed.
· This extension is available only if the provider had no way of knowing that the individual had Colorado Medical Assistance Program coverage.

· Providers who render services in a hospital or nursing facility are expected to get benefit coverage information from the institution.

· The extension does not give additional time to obtain Colorado Medical Assistance Program billing information.

· If the provider has previously submitted claims for the member, it is improper to claim that eligibility notification was delayed.


LBOD = the date the provider was advised the individual had Colorado Medical Assistance Program benefits.


Electronic Medicare Crossover Claims An electronic claim is being submitted for Medicare crossover benefits within 120 days of the date of Medicare processing/ payment. (Note: On the paper claim form (only), the Medicare SPR/ERA date field documents crossover timely filing and completion of the LBOD is not required.)

File the claim within 120 days of the Medicare processing/ payment date shown on the Standard Paper Remit (SPR) or Electronic Remittance Advice (ERA). Maintain a copy of the SPR/ERA on file.

LBOD = the Medicare processing date shown on the SPR /ERA.



Medicare Denied Services The claim is for Medicare denied services (Medicare non-benefit services, benefits exhausted services, or the member does not have Medicare coverage) being submitted within 60 days of the date of Medicare processing/denial.
Note: This becomes a regular Colorado Medical Assistance Program claim, not a Medicare crossover claim.

File the claim within 60 days of the Medicare processing date shown on the Standard Paper Remit (SPR) or Electronic Remittance Advice (ERA). Attach a copy of the SPR/ERA if submitting a paper claim and maintain the original SPR/ERA on file.

LBOD = the Medicare processing date shown on the SPR/ERA.


Commercial Insurance Processing The claim has been paid or denied by commercial insurance.
File the claim within 60 days of the insurance payment or denial. Retain the commercial insurance payment or denial notice that identifies the patient, rendered services, and shows the payment or denial date.

Claims must be filed within 365 days of the date of service. No exceptions are allowed. If the claim is nearing the 365-day limit and the commercial insurance company has not completed processing, file the claim, receive a denial or rejection, and continue filing in compliance with the 60-day rule until insurance processing information is available.

LBOD = the date commercial insurance paid or denied.



Correspondence LBOD Authorization The claim is being submitted in accordance with instructions (authorization) from the Colorado Medical Assistance Program for a 60 day filing extension for a specific member, claim, services, or circumstances.

File the claim within 60 days of the date on the authorization letter. Retain the authorization letter.
LBOD = the date on the authorization letter.

Member Changes Providers during Obstetrical Care The claim is for obstetrical care where the patient transferred to another provider for continuation of OB care. The prenatal visits must be billed using individual visit codes but the service dates are outside the initial timely filing period.
File the claim within 60 days of the last OB visit. Maintain information in the medical record showing the date of the last prenatal visit and a notation that the patient transferred to another provider for continuation of OB care.

LBOD = the last date of OB care by the billing provider.

Saturday, August 6, 2016

Billing Guide for Hysterectomies and abortions - 59840 - 59847 - CPT codes

Hysterectomies 

Hysterectomy is a benefit of the Colorado Medical Assistance Program when performed solely for medical reasons. Hysterectomy is not a benefit of the Colorado Medical Assistance Program if the procedure is performed solely for the purpose of sterilization, or if there was more than one purpose for the procedure and it would not have been performed but for the purpose of sterilization.
The following conditions must be met for payment of hysterectomy claims under the Colorado Medical Assistance Program. These claims must be filed on paper.

† Prior to the surgery, the person who secures the consent to perform the hysterectomy must inform the member and/or member’s representative verbally and in writing that the hysterectomy will render the member permanently incapable of bearing children.

† The member and/or member’s representative must sign a written acknowledgment that the member has been informed that the hysterectomy will render the member permanently incapable of reproducing. The written acknowledgment may be any form created by the provider that states specifically that, “I acknowledge that prior to surgery, I was advised that a hysterectomy is a procedure that will render me permanently incapable of having children.” The acknowledgment must be signed and dated by the member.

A written acknowledgment from the member is not required if:
† The member is already sterile at the time of the hysterectomy, or
† The hysterectomy is performed because of a life-threatening emergency in which the practitioner determines that prior acknowledgment is not possible.

If the member’s acknowledgment is not required because of the one of the above noted exceptions, the practitioner who performs the hysterectomy must certify in writing, as applicable, one of the following:

† A signed and dated statement certifying that the member was already sterile at the time of hysterectomy and stating the cause of sterility;

† A signed and dated statement certifying that the member required hysterectomy under a life-threatening, emergency situation in which the practitioner determined that prior acknowledgment by the member was not possible. The statement must describe the nature of the emergency.


A copy of the member’s written acknowledgment or the practitioner’s certification as described above must be attached to all claims submitted for hysterectomy services. A suggested form on which to report the required information is the Acknowledgment/Certification Statement for a Hysterectomy form located on the Department’s Web site. Providers may copy this form, as needed, for attachment
to claim(s). Providers may substitute any form that includes the required information. The submitted form or case summary documentation must be signed and dated by the practitioner performing the hysterectomy.


The surgeon is responsible for providing copies of the appropriate acknowledgment or certification to the hospital, anesthesiologist, and assistant surgeon for billing purposes. Claims will be denied if a copy of the written acknowledgment or practitioner’s statement is not attached.


Abortions

Induced Abortions

Therapeutic legally induced abortions are a benefit of the Colorado Medical Assistance Program when performed to save the life of the mother. The Colorado Medical Assistance Program also reimburses legally induced abortions for pregnancies that are the result of sexual assault (rape) or incest.

A copy of the appropriate certification statement must be attached to all claims for legally induced abortions performed for the above reasons. Because of the attachment requirement, claims for legally induced abortions must be submitted on paper and must not be electronically transmitted. Claims for spontaneous abortions (miscarriages), ectopic, or molar pregnancies are not affected by these
regulations.\

The following procedure codes are appropriate for identifying induced abortions:
59840 59841 59851 59852
59850 59855 59856 59857

Diagnosis code ranges:
635.00-635.92
637.00-637.92

Surgical diagnosis codes
69.01 69.51 69.93 74.91 75.0



Wednesday, August 3, 2016

Billing Instruction for Sterilizations, Premature delivery

Voluntary Sterilizations 

Sterilization for the purpose of family planning is a benefit of the Colorado Medical Assistance Program in accordance with the following procedures:

General Requirements 
The following requirements must be followed precisely or payment will be denied. These claims must be filed on paper. A copy of the sterilization consent form (MED-178) must be attached to each related claim for service including the hospital, anesthesiologist, surgeon, and assistant surgeon.

† The individual must be at least 21 years of age at the time the consent is obtained.

† The individual must be mentally competent. An individual who has been declared mentally incompetent by a federal, state, or local court of competent jurisdiction for any purpose cannot consent to sterilization. The individual can consent if she has been declared competent for purposes that include the ability to consent to sterilization.

† The individual must voluntarily give "informed" consent as documented on the MED-178 consent form (see illustration) and specified in the "Informed Consent Requirements" described in these instructions.

† At least 30 days but not more than 180 days must pass between the date of informed consent and the date of sterilization with the following exceptions:

Emergency Abdominal Surgery: An individual may consent to sterilization at the time of emergency abdominal surgery if at least 72 hours have passed since the member gave informed consent for the sterilization.

Premature Delivery: A member may consent to sterilization at the time of a premature delivery if at least 72 hours have passed since she gave informed consent for the sterilization and the consent was obtained at least 30 days prior to the expected date of delivery.

The person may not be an "institutionalized individual".


Institutionalized includes:

† Involuntarily confinement or detention, under a civil or criminal statute, in a correctional or rehabilitative facility including a mental hospital or other facility for the care and treatment of mental illness.

† Confinement under a voluntary commitment in a mental hospital or other facility for the care and treatment of mental illness.

If any of the above requirements are not met, the claim will be denied. Unpaid or denied charges resulting from clerical errors such as the provider's failure to follow the required procedures in obtaining informed consent or failure to submit required documentation with the claim may not be billed to the member.

Informed consent requirements

The person obtaining informed consent must be a professional staff member who is qualified to address all the consenting member’s questions concerning medical, surgical, and anesthesia issues.
Informed consent is considered to have been given when the person who obtained consent for the sterilization procedure meets all of the following criteria:

† Has offered to answer any questions that the member who is to be sterilized may have concerning the procedure.

† Has provided a copy of the consent form to the member.

† Has verbally provided all of the following information or advice to the member who is to be sterilized:

** Advice that the member is free to withhold or withdraw consent at any time before the sterilization is done without affecting the right to any future care or treatment and without loss or withdrawal of any federally funded program benefits to which the member might be otherwise entitled.

** A description of available alternative methods of family planning and birth control.

** Advice that the sterilization procedure is considered to be irreversible.

** A thorough explanation of the specific sterilization procedure to be performed.

** A full description of the discomforts and risks that may accompany or follow the performing of the procedure including an explanation of the type and possible effects of any anesthetic to be used.

** A full description of the benefits or advantages that may be expected as a result of the
sterilization.

** Advice that the sterilization will not be performed for at least 30 days except in the case of premature delivery or emergency abdominal surgery.

** Suitable arrangements have been made to ensure that the preceding information was effectively communicated to a member who is blind, deaf, or otherwise handicapped.

** The individual to be sterilized was permitted to have a witness of his or her choice present when consent was obtained.

· The consent form requirements (noted below) were met.

· Any additional requirement of the state or local law for obtaining consent was followed.


** Informed consent may not be obtained while the individual to be sterilized is:


 In labor or childbirth;
 Seeking to obtain or is obtaining an abortion; and/or
 Under the influence of alcohol or other substances that may affect the individual's sense of awareness.




Friday, July 29, 2016

Filling Up BOX 31 -33 in CMS 1500 FORM FOR ASC billing

Box 31 Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

A holographic signature stamp may be used if authorization for the stamp is on file with the fiscal agent.
An authorized agent or representative may sign the claim for the enrolled provider if the name and signature of the agent is on file with the fiscal agent.
Each claim must have the date the enrolled provider or registed authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.
Unacceptable signature alternatives:
Claim preparation personnel may not sign the enrolled provider’s name.
Initials are not acceptable as a signature.
Typed or computer printed names are not acceptable as a signature.

“Signature on file” notation is not acceptable in place of an authorized signature.

32 32- Service Facility Location Information 

32a- NPI Number

32b- Other ID # Not Required


33
33- Billing Provider Info & Phone #
33a- NPI Number
33b- Other ID #

Required
Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line
Name
2nd Line
Address
3rd Line
City, State and ZIP Code
33a- NPI Number
Enter the NPI of the billing provider
33b- Other ID #

Tuesday, July 26, 2016

ASC Basic Billing Information

Billing Information 


The ASC is responsible for obtaining required billing information from the surgeon. ASC providers are required to verify Medicaid eligibility before services are rendered. If eligibility is not verified, payment may be denied.

ICD-9-CM diagnosis: The diagnosis field(s) must be completed with an appropriate ICD-9-CM diagnosis code(s).

Place of service: Complete the Place Of Service (POS) field with a "24" for ASC facility charges.

Note: Electronic billers should consult the software instructions to assure that POS coding is submitted properly.

Rendering provider: Complete with the eight digit Colorado Medical Assistance Program provider number assigned to the operating surgeon.


Referring provider: If the member is enrolled in the Primary Care Physician (PCP) program and the operating surgeon is not the PCP, the PCP's Colorado Medical Assistance Program provider number must be entered in this field. PCP-enrolled members must obtain PCP referral if surgical services are performed by a physician other than the PCP. If the member does not have an assigned PCP, this field may be left blank.

Sterilization procedures: All sterilization claims must have an attached copy of a properly completed MED-178 sterilization consent form. The surgeon is responsible for providing a copy of the MED-178 to the ASC. Claims without a properly completed MED-178 are denied. Refer to the Ambulatory Surgical Centers provider manual for complete billing requirements.

Hysterectomy procedures: Hysterectomy procedures are a benefit of Colorado Medicaid when performed solely for medical reasons. Hysterectomy is not a benefit if the procedure is performed solely for the purpose of sterilization, or if there was more than one purpose for the procedure and it would not have been performed but for the purpose of sterilization. Refer to the Ambulatory Surgical Centers provider manual for complete billing requirements.

Medicare crossover claims: Medicaid pays the Medicare deductible and coinsurance or the Medicaid-allowed benefit minus the Medicare payment, whichever is less. If Medicare’s payment equals or is more than the Medicaid allowed benefit, crossover claims are paid at zero.

Most Medicare crossover claims are transmitted electronically from Medicare to Medicaid. If a Medicare claim does not cross automatically, the provider is responsible for submitting a "hardcopy crossover" claim on the CMS 1500 paper claim form. Refer to the end of the manual for an example of a completed paper crossover claim.

Saturday, July 23, 2016

Implantable prosthetics CPT code L8600 - L8689

Implantable prosthetics: The following implantable prosthetic HCPCS codes are approved for billing by the ASC or the surgeon as an 837P transaction or on the CMS 1500 paper claim form:

CPT code    Description

L8600 Implantable breast prosthesis, silicone or equal

L8603 Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies

L8606 Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies

L8610 Ocular implant

L8612 Aqueous shunt

L8613 Ossicular implant

L8614 Cochlear device / system

L8619 Cochlear implant external speech processor, replacement

L8630 Metacarpophalangeal joint implant

L8631 Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel or
cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes entire system)


L8641 Metatarsal joint implant

L8642 Hallux implant

L8658 Interphalangeal joint spacer, silicone or equal, each

L8659 Interphalangeal finger joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size

L8670 Vascular graft material, synthetic, implant

L8689   External recharging system for battery (internal) for use with implantable neurostimulator


V2785 Processing, preserving and transporting corneal tissue

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