Transcript National-Council-billing-webinar-3-25-15-rev

Howard Zucker, Acting
Commissioner
Arlene González-Sánchez, M.S., L.M.S.W.
Commissioner
Ann Marie T. Sullivan, M.D.,
Commissioner
Reducing Adolescent Substance Abuse
Initiative (RASAI)
Learning Community
Andrew M. Cuomo, Governor
1
Presenters
• Mark Tremblay, M.A., M.P.A. – NYS Department of
Health - Office of Health Insurance Programs
• Gwen Diamond – NYS Office of Mental Health Reimbursement Policy and Implementation
• Katherine Cusano, Broome County Deputy
Commissioner of Mental Health
• Christopher Baron – Lourdes Hospital - Executive
Director Revenue Cycle
• Rita Guido – Computer Sciences Corporation (CSC) Outreach Supervisor
2
Provider Types Eligible to Bill for
Office-based SBIRT Services
Provider Type
Physicians (services may be performed by
another provider type under the
supervision of the physician)
Required OASAS Approved
Training/Certification
4 hours, unless certified by the American
Society of Addiction Medicine (ASAM), the
American Board of Ambulatory Medicine
(ABAM), the American Academy of
Addiction Psychiatry (AAAP)
or the American Academy Osteopathic
Association (AOA)
Nurse Practitioners
4 hours, unless qualified as a Certified
Addictions Registered Nurse (CARN)
Nurse Midwives
4 hours
Psychologists
4 hours
NOTE: Article 31 clinics cannot submit practitioner claims for SBIRT. Only institutional claims
3
can be submitted for SBIRT
Providers Eligible to Deliver SBIRT Services
Under a Licensed Provider/Facility
Provider Type
Required Training/
Certification
Physician Assistants
4 hours
Registered Nurses
4 hours, unless qualified as a
CARN
4 hours
Licensed Practical Nurses
Licensed Master Social Worker (LMSW) or Licensed Clinical 4 hours
Social Worker (LCSW)
Licensed Mental Health Counselors
4 hours
Licensed Marriage and Family Therapist
4 hours
Certified School Counselor
4 hours
Certified Rehabilitation Counselor
4 hours
OASAS-credentialed professionals including CASACs,
4 hours
(CPPs) and Credentialed Problem Gambling Counselors
Health Educators and unlicensed individuals (may only
12 hours
provide SBIRT services under the supervision of a licensed
health care professional, following consistent protocols)
NOTE: Article 31 clinics cannot submit practitioner claims for SBIRT. Only institutional 4claims
can be submitted for SBIRT
SBIRT Billing Guidelines
Practitioner Offices, Hospitals and
Clinics
5
Insurance Codes and Types of
Insurance
• The type of insurance the patient has, and the
length of time spent in service delivery
determines the codes used.
• This will also determine any fee billed to the
insurance company.
SBIRT Billing Codes
Payer
Code
Description
Medicaid
H0049
Alcohol and/or drug screening
Medicaid
H0050
Alcohol and/or drug service, brief
intervention, per 15 min
7
Medicaid FFS Billing
• CPT H0049 (alcohol and/or drug screening) is used for substance
use screening.
• Diagnosis code ICD-9 code V82.9 (unspecified condition) is
REQUIRED on claims with this procedure code.
• CPT H0050 (alcohol and/or drug service, brief intervention) is used
for substance abuse brief intervention services.
• Diagnosis code ICD-9 V65.42 (counseling and substance abuse) is
REQUIRED on claims with this procedure code.
• When Medicaid is secondary
– Providers must code the correct HCPCS codes when submitting claims to
Medicaid. If Medicare or third-party payors require a different code, it
must be replaced with H0049 or H0050 before submitting to Medicaid.
8
Medicaid FFS Billing cont.
• Frequency Limits – Medicaid will cover two screenings
(H0049) and six brief interventions (H0050) per year
• NCCI Edits – Some procedure code combinations will
consolidate due to the Federal National Correct Coding
Initiative.
• Article 31 clinics are exempt from NCCI edits
For more information see:
http://www.health.ny.gov/health_care/medicaid/rates/apg/docs/ncci_edits_applied_apgclaims.pdf
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-CorrectCoding-Initiative.html
9
Billing SBIRT in an Article 31 Clinic
• Providers will bill use the 837i claim form (do not submit a
separate practitioner claim)
• SBIRT claims will use the appropriate OMH clinic rate code
(e.g., 1504, 1516) and appropriate HCPCS code: H0049 and/or
H0050.
– Both codes have an APG weight of .2803
• SBIRT rates for OMH licensed clinics:
Hospital Rate
(Art.31 Clinic)
Rate with QI
Rate without QI
Upstate Downstate
Article 31 Article 31 County
& DTCs
& DTCs Article 31
Upstate Downstate
Article 31 Article 31 County
& DTCs
& DTCs Article 31
$ 38.95
$ 42.34
$ 54.20
$ 37.51
$ 40.78
$ 52.19
Upstate
Hospital
$39.03
Downstate
Hospital
$50.78
10
Billing SBIRT in
Part 822.4 & 822.5 Clinics
Pre-Admission
• Screen – H0049 (Medicaid)
• Brief Intervention – H0050 (Medicaid)
Post Admission
• Brief Treatment – H0004
• A brief treatment may be billed on the same day as other
categories, including, but not limited to individual or group
counseling services
• Providers should code H0004 and NOT H0050 for postadmission Brief Treatment services
11
APG Payments for SBIRT in
Part 822.4 and 822.5 Programs
Medicaid APG
822-4 Clinic
Rate Per Service Upstate
Upon Full
Implementation
of APG Payments
822-4 Clinic
Downstate
822-5 Opioid
Upstate
822-5 Opioid
Downstate
Screening
$41.37
$48.41
$38.13
$44.62
Brief
Intervention/
Brief Treatment
$41.37
$48.41
$38.13
$44.62
Screening is not intended to be provided to all patients or where it is known
that the patient is appropriate for admission (e.g. a court order);
has an assessment from another program; or presents with circumstances
that indicate that a substance use disorder (SUD) problem may be present.
Additionally, screening may not be provided in a group setting.
12
Medicaid Managed Care
• SBIRT services are covered benefits under Medicaid Managed Care and
Family Health Plus (FHPlus)
• MCOs are required to pay government rate for at least 1st 2 years
• Plans are required to cover the same frequency limits as FFS w/out prior
authorization, but may permit additional screenings/brief intervention
visits
• Reimbursement rates for plan members receiving SBIRT services from in
network providers will be established in provider agreements.
• Out-of-network providers will be reimbursed at negotiated rates, except
for out-of-network emergency departments which will be reimbursed
according to the Medicaid FFS methodology
• FHPlus co-payments are not applicable to SBIRT.
13
Requirements for SBIRT
Documentation
• Screening tool completed – CRAFFT
• Score on the CRAFFT
• Copy of the completed screening tool must be retained
in the record.
• Documentation must denote start/stop time or total
face-to-face time with the patient, because the SBIRT
codes are time-based codes
• Although the completed screenings may be in another
section of the chart, there needs to be representation
on the progress note that the screening still took place.
Modifiers
• Used with Diagnostic Codes: Two digit, two character or alphanumeric characters, appended to the end of a Current Procedural
Technology (CPT) or Healthcare Common Procedure Coding System
(HCPCS) code
• Modifies the code description without changing the core meaning
of the Current Procedural Technology and/or Healthcare Common
Procedure Coding System description
• Provides additional information regarding the services or
procedures provided
• Tells the clinical “story” more completely
• Integral part of the Current Procedural Technology and Healthcare
Common Procedure Coding System coding system
• Are designed to provide payers with additional information needed
to process or adjudicate a claim
Modifiers cont.
• When two separate and distinct patient encounters are provided by a
single provider on the same day, a modifier (e.g., 25 Significant, Separately
Identifiable Evaluation and Management Service or 59 Distinct Procedure
Service) should be appended to the additional procedure/service to
indicate that the second code is separate and/or distinct.
• This is especially important when billing for mental hygiene type services.
For instance, NCCI prohibits billing both 90846 (family psychotherapy) and
SBIRT (i.e., H0049 or H0050) for the same session, but will allow payment
for both codes if modifier 59 is appended to the second procedure
(applicable in Article 31 hospital).
• However, please note that modifiers may only be appended to HCPCS/CPT
codes if clinical circumstances justify use of a modifier.
• A modifier should not be appended to a HCPCS/CPT code solely to bypass
an NCCI edit if the clinical circumstances do not justify its use.
16
Real Life Experiences with SBIRT Billing
• Chris Baron - Lourdes Hospital
• Katherine Cusano - Broome County Mental
Health
17
Computer Sciences Corporation (CSC)
 Responsibilities
– Processing Medicaid claims
– Provider Manuals
– Remittance statements and
checks
– Electronic Fund Transfer
– Billing inquiries & guidelines
– Provider training
– Medicaid Eligibility
Verification System (MEVS)
– Issues paper claim forms
(excluding UB-04)
– Electronic Transmitter
Identification Numbers (ETIN)
– ePACES (Electronic Provider
Assisted Claim Entry System)
– Provider Enrollment
Maintenance (Fee-for-Service)
 Contact
– CSC / eMedNY Call Center (800) 343-9000
– Website – www.emedny.org
18
Computer Sciences Corporation (CSC)
eMedNY Call Center
• Support units for Practitioners, Institutions, Professional, Pharmacy,
MOAS, PTAR and MEIPASS
• Provides assistance with questions regarding:
-
claims
billing
electronic and paper remittance
form orders
prior approval
-
new enrollment into the New York
State Medicaid program
-
ePACES enrollment
Electronic Funds Transfer (EFT)
ETIN applications
provider maintenance forms
Explanation of eligibility
responses
Hours of Operation:
non-pharmacy billing or claims, or provider enrollment:
Monday through Friday: 7:30 a.m. - 6:00 p.m., Eastern Time (excluding holidays)
eligibility, DVS, and pharmacy claims:
Monday through Friday: 7:00 a.m. - 10:00 p.m., Eastern Time (excluding holidays)
Weekends and Holidays: 8:30 a.m. - 5:30 p.m., Eastern Time
19
Computer Sciences Corporation (CSC)
Provider Outreach
• Regional Representatives located in 8 regions
– Capital District, North Country/Mohawk Valley, South/Central
NY, Finger Lakes, Western NY, Hudson Valley, NYC and Long
Island
• CSC Regional Representatives are available to offer provider billing
training on a variety of topics through numerous methods including:
– Individual meetings with providers to train and troubleshoot
issues
– Group training seminars and webinars
• Request a meeting with a regional representative at 800-343-9000
or register to attend a seminar or webinar on the eMedNY website
Training page at www.emedny.org
20
Medicaid Billing Questions
• CSC Billing/Claiming Questions: 1-800-343-9000
• NYS DOH - Medicaid Policy Questions:
1-518-473-2160
• APG Mailbox [email protected]
• NYS OMH – Article 31s Billing Questions
518-474-6911
• NYS OASAS - Billing Questions (518) 457-5989 or
[email protected]
21
Questions?
22