Michigan Breast and Cervical Cancer Control Program Billing Manual Fiscal Year 2010

Transcription

1 Michigan Breast and Cervical Cancer Control Program Billing Manual Fiscal Year 2010 Table of Contents 12/14/2009

2 Intentionally left blank

3 Table of Contents History and Overview 1 Residency Requirement..1 Age Requirement...2 Income Level Requirement.2 Insurance Requirement-uninsured.. 2 Insurance Requirement-underinsured.2 Women enrolled in the following are not eligible for the program 3 Services available-screening..3 Services available-diagnostic.3 Cancer Treatment 3 Medicaid Eligibility....3 Illegal Aliens...4 MI BCCCP Goal.4 Provider information...5 Contracting with Local Coordinating Agency 5 Client Enrollment 6 Client Services 7 Claim Submission...8 Adjudication Process..9 Non-reimbursable Procedures 10 Providing Screening and/or Diagnostic Services...10 Billing BCCCP...10 Clients with Insurance 11 Clients with No Insurance..11 Claims will be paid if.12 Why are claims Pended..13 Why would my claims be rejected.13 Who should I contact if I have a question about my claim 13 What information is required to check the status of a claim..13 Health Insurance Portability and Accountability Act (HIPAA).14 Electronic Billing (EDI).14 BCCCP Web Site...17 Billing/Clinical Algorithms 18 Pap Billing Date..27 Claim Forms 28 BCCCP must be placed on all claim forms.28 Provider Payment Report 31 Check..32 Billing Information.33 Claims will be reject if...34 Hold codes..35 BCCCP and County Health Plan (CHP).41 Facility Charges and Fees...41 Common Billing Issues...41 Claim Return Letters...44

4 Fiscal Year End Information..51 Frequently Asked Questions...52 Paper and EDI claim submission Information 52 What is needed for a claim to be PAID..52 What happens if a client does not have a SSN...52 Who can a provider contact regarding CLAIM issues...52 Where can a provider go online for BCCCP information..52 Why do claims pend (for up to 30 days).53 Contact Information 54

5 Figures Figure 1 - MI BCCCP Goal....4 Figure 2 - Client Enrollment...6 Figure 3 Client Services...7 Figure 4 Claim Submission..8 Figure 5 Adjudication Process...9 Figure 6 Explanation of Benefits Payment Example..11 Figure 7 Data entry and Billing Authorization of File 12 Figure 8 Data Entry and Billing No Authorization on file..13 Figure 9 UB Figure 10 HCFA Figure 11 Health Advantage Provider Payment Report..31 Figure 12 BCCCP Check.32 Figure 13 Example of Unit billing...33 Figure 14 How claims are authorized..37 Figure 14 Example of Unit Billing..38 Figure 15 Provider Payment Report 40 Figure 16 BCCCP Logo...40 Figure 17 HCFA-1500 example...41 Figure 18 UB-04 example 42 Figure 19 Example of a missing ICD-9 code...43 Figure 20 Example of a claim being sent to Nationwide..43 Figure 21 Claim does not indicate number of units..44 Figure 22 Not billed with BCCCP min the correct location.45 Figure 23 Claim not on file...46 Figure 24 Invalid CPT Code.47 Figure 25 Claim billed to Nationwide Health plan...48 Figure 26 Social Security Number does not match member file..49 Figure 27 Invalid Anesthesia CPT code(s) and/or Modifier(s) 50

6 Appendixes Appendix A-BCCCP Documents BCCCP Unit Cost Reimbursement Rate Schedule Family Planning Unit Cost Reimbursement Rate Schedule BCCCP Approved ICD-9 Codes BCCCP Approved Revenue Code List BCCCP Approve Place of Service Codes Hold Codes BCCCP Procedure Code Reference Chart Appendix B-WISEWOMAN Documents WISEWOMAN Unit Cost Reimbursement Rate Schedule WISEWOMAN Approved ICD-9 Codes WISEWOMAN Approved Revenue Code List WISEWOMAN Approve Place of Service Codes Hold Codes WISEWOMAN Procedure Code Reference Chart Appendix C-CRC Documents CRC Unit Cost Reimbursement Rate Schedule CRC Approved ICD-9 Codes CRC Approved Revenue Code List CRC Approve Place of Service Codes Hold Codes CRC Procedure Code Reference Chart

7 2010 Billing Manual History and Overview Congress passed the Breast and Cervical Cancer Mortality Prevention Act in Centers for Disease Control and Preventation (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides access to breast and cervical cancer screening services to underserved women in all 50 states, the District of Columbia, five U.S. territories, and 12 tribes. Since 1991, the Michigan Department of Community Health (MDCH) has implemented a comprehensive Breast and Cervical Cancer Control Program (BCCCP) through a multiyear grant from the CDC. With these funds, low income women can receive access to life-saving cancer screening services and follow-up care, including cancer treatment if that should be needed. BCCCP services are coordinated through 21 Local Coordinating Agencies (LCA). These agencies partner with physicians, hospitals, and other health care organizations in their communities to provide all necessary follow-up services. LCAs are required to provide or arrange for basic screening services. This includes clinical breast exams (CBE), screening mammograms, pelvic exams, Pap smears, and patient education. To be enrolled in the BCCC Program, women must meet the following criteria: Residency Requirement Age Requirement Income Level Requirement Insurance Requirement Uninsured, or Underinsured Residency Requirement: 1. Michigan resident with a verifiable current address (e.g. driver s license, voter ID, etc.) 2. EXCEPTIONS: Migrant workers - is a worker moving from one region of the country to another to find employment. Migrant workers are used extensively for crop harvesting. This requires that they follow the harvest seasons. Women living near the border of a neighboring state (Indiana, Ohio, and Wisconsin) who plan to receive all screening and diagnostic services in Michigan. 1

8 2010 Billing Manual Age Requirement: 1. Age are eligible to receive: Breast and/or cervical cancer screening, and/or Diagnostic services; or 2. Age 18-39: Must be referred to BCCCP from a Family Planning (FP) program provider. ONLY eligible to receive cervical diagnostic services for follow-up of a cervical abnormality. Income Level Requirement: 1. Determining Income Level: The woman s income level must be < 250% of the current year s federal poverty level (FPL). 2. Poverty level is determined based on a woman s verbal responses to the following two questions. (No written verification or review of tax documents is required.) What is your yearly household family income? How many people live in your family? (Family consists of married persons or a single individual with or without dependent children) 3. The following link is to Poverty Guidelines, Research, and Measurement Insurance Requirement - uninsured: At the discretion of the LCA, women with insurance are eligible for the program if: 1. Her insurance plans will not reimburse nurse practitioner services because a physician may not be on site when the service(s) were performed, these women are considered uninsured and are eligible to enroll in BCCCP. Information regarding non-coverage of nurse practitioner services MUST be documented in the client s chart. Insurance Requirement underinsured: 1. BCCCP funds must pay for partial or all of a breast or cervical cancer screening and/or diagnostic service for the woman to meet the eligibility requirements for the program. 2. A large deductible (determine by the LCA) must be paid prior to the woman receiving program covered services. Inability to pay the deductible would be considered a financial hardship for the woman and would prevent her from receiving breast/cervical cancer screening and/or diagnostic services. 3. The woman s insurance plan does not reimburse OR only partially reimburses for breast and/or cervical cancer screening and/or diagnostic services. 4. Prior authorization to determine eligibility of underinsured women is NOT required by MDCH staff. 5. The woman must be notified at the time of enrollment (informed consent) that IF it is discovered she either has insurance or inaccurately reported her deductible she will be responsible for the costs incurred in providing BCCCP screening and/or diagnostic services. 2

9 2010 Billing Manual Women enrolled in the following are not eligible for the program: Managed Care Program Health Maintenance Organization (HMO) Medicare Part B Services Available Screening, women aged can receive screening services such as: Clinical Breast Exams Pap smears Pelvic exams Screening mammograms Services Available Diagnostic: If a breast and/or cervical abnormality are identified from the screening test/exam, the woman will be referred to community providers for follow-up. Over 70 diagnostic services are provided free of cost through the BCCCP. Some of these include: Diagnostic mammograms Ultrasounds Breast Biopsy Colposcopy services Colposcopy-directed biopsy services Selected anesthesia services (19120 & 19125) Family Planning women enrolled in the BCCCP are ONLY eligible to receive cervical diagnostic services. Cancer Treatment: In the event of a diagnosis of breast and/or cervical cancer through the BCCCP, a woman may be eligible for Medicaid coverage. If eligible, Medicaid will pay for all of her medical expenses for as long as she is being treated for the cancer. Once treatment is no longer needed, the woman is then potentially eligible (once again, based upon age and income) for continued annual screening services through the BCCC Program. A woman remains eligible for Medicaid until: Her health professional deems the woman is free from cancer and will not require continued cancer therapy, OR She no longer meets the eligibility criteria for this program: Obtained creditable insurance coverage, Reached the age of 65 and has Medicare Part B, or An income that exceeds 250 percent of the federal poverty level. 3

10 2010 Billing Manual Illegal aliens: Note: Women, who are illegal aliens, although eligible for BCCCP services, cannot receive Medicaid coverage. Federal law limits Medicaid coverage to citizens and legal aliens. MI BCCCP Goal: Provide timely/appropriate, cost effective, care to eligible Michigan women: Timely/appropriate care Care provided according to BCCCP Medical Protocol Cost Effective Care Provision of care within BCCCP budget constraints: Balancing quality of care delivery with cost Evaluation of Data Quality Documentation of care according to CDC requirements Figure 1 MI BCCCP Goal diagram Timely/Appropriate Clinical Care Reimbursement for Care/Cost of Care Data Quality Evaluation 4

11 2010 Billing Manual Provider Information Contracting with Local Coordinating Agencies: Sign a contract or letter of agreement with the LCA agreeing to provide screening and/or diagnostic services for BCCCP women according to program requirements and rates. Send the following information to the LCA to enroll as a provider in the BCCC Program: Provider s Federal Tax ID Number and NPI Number Provider s Mailing Address Billing Agency s Name, Federal Tax ID Number, and NPI Number (if different from the provider) Billing Agency s address to receive payments (Payment will be sent to the Provider s mailing address if no billing agency is specified.) Any change in provider or billing information must be communicated to the LCA as soon as possible to avoid delays in provider reimbursement. NOTE: Providers cannot be paid until enrollment information is received by the LCA and forwarded to the State. 5

12 2010 Billing Manual Client Enrollment: A client can fill out enrollment paperwork at either her provider s office or the LCA.. If she enrolled at a provider s office, they must fax the paperwork immediately to the LCA. The paperwork will then have to be entered into the BCCCP database. Fail to send enrollment paperwork to the LCA can cause your claim(s) to be rejected. In other words, your claim(s) reach Health Advantage (HA) before the client has been enrolled into the program resulting in a rejection. Figure 2 Client Enrollment Client Client fills out Enrollment Paperwork at LCA Enrollment Paperwork Client fills out Enrollment Paperwork at Provider and sends to LCA Enrollment information entered into database LCA Local Coordinating Agency BCCCP Database 6

13 2010 Billing Manual Client Services: Client screening service(s) can be preformed at either the LCA or provider s office. Screening paperwork is then sent to the LCA if services were performed at a provider s office. This information must be data entered into the BCCCP database and authorized in order for the service(s) to be paid. Figure 3 Client Services Client goes to LCA and Provider for screening service Local Agency (screening services) Screening Paperwork Provider (screening services) Screening Service information entered into database BCCCP Database 7

14 2010 Billing Manual Claim Submission: Providers/LCAs will submit their claims to HA for processing. Paper claims are mailed to Lansing and electronic claims are submitted via Netwerkes or one of its affiliated clearinghouses. A file will be sent to MDCH for claims adjudication (payment or rejection) nightly by HA. Figure 4 Claim Submission Loacal Agencies/ Providers Paper Claims Electronic Claims Paper claims received at MDCH and then sent to HA Electronic claims received at Clearinghouse and then sent to HA HA receives claims All Claims MDCH receives claims via electronic file 8

15 2010 Billing Manual Adjudication Process: Every evening, MDCH receives a claim file from HA and adjudicates these claims nightly. Weekly a file is sent to HA of all adjudicated claims to be processed for payment. Weekly HA send MDCH an invoice. Weekly MDCH reimburses HA and the provider checks are released. Figure 5 Adjudication Process MDCH Receives claims file from Health Advantage (HA) MDCH approves invoice and send payment to HA Adjudication Program HA receives funds and pays providers Adjudication process BCCCP Database Providers HA Receives final claims file and send invoice to MDCH 9

16 2010 Billing Manual Non-reimbursable Procedures: CDC does not allow reimbursement of the following procedures: CAD (Computer Assisted Device) MRI (Magnetic Resonance Imaging) Screening Ultrasound: Not reimbursed as a screening examination for either normal or high risk women. Providing Screening and/or Diagnostic Services: If authorized by the LCA, enroll the client in the BCCC Program. The BCCCP Client Enrollment form must be faxed or mailed to the LCA within 72 HOURS TO AVOID DELAY IN REIMBURSEMENT. Provide the appropriate screening and/or diagnostic services to BCCCP women or refer for appropriate services. Review the screening and/or diagnostic services results. Contact the LCA to arrange for further follow-up care if needed. Send breast and/or cervical screening results and diagnostic service information to the LCA as soon as services are completed. The LCA must receive this information prior to approving payment for services rendered. Billing BCCCP: Providers must bill BCCCP on an HCFA 1500 or UB-04 form at their USUAL AND CUSTOMARY RATE, not the BCCCP/FP reimbursement rate. Paper claims should be mailed to: BCCCP Claims 109 Michigan Ave WSB 5th Floor Lansing, MI Electronic billing is possible using a HIPAA-required format through Netwerkes. Payer ID #: BCCCP Only CPT codes listed on the current fiscal year BCCCP/FP Reimbursement Rate Schedules will be reimbursed. A BCCCP/FP approved ICD-9 code is required. An approved Revenue codes (UB-04) is required. ecodes.pdf 10

17 2010 Billing Manual All other codes will be rejected. See Appendices in the back of the manual for all billing/reimbursement documents. Providers cannot bill clients for any BCCCP/FP - approved procedures. For clients WITH insurance: Bill all applicable insurance companies for approved services provided prior to submitting claims to BCCCP. Obtain the Explanation of Benefits (EOB) from the insurance company. In all cases of insurance billing, the EOB form must accompany the claim to BCCCP or it will be rejected. For insurance payments AT OR ABOVE the BCCCP/FP rate - the provider will send results of the screening and/or diagnostic services provided to the LCA and WILL NOT BILL BCCCP or the client. For insurance payments that are denied or LESS THAN the BCCCP rate - the provider may bill BCCCP for the difference between the insurance payment and the BCCCP/FP approved rate. Figure 6 Example of an Explanation of Benefits Payment For clients with NO insurance: Providers must bill for BCCCP/FP - approved services for uninsured clients directly to BCCCP at their usual and customary rate. Reimbursement will be paid for the BCCCP/FP approved CPT codes at the rates for that fiscal year. 11

18 2010 Billing Manual Claims will be paid by BCCCP if: All required claim information for the BCCCP client is submitted on either the HCFA 1500 or UB-04 form. The claim contains approved BCCCP/FP CPT, ICD-9, Revenue and Place of Service codes. All screening exam results and/or diagnostic service information has been sent to the LCA to be entered into the BCCCP data system Figure 7 Data entry and Billing Authorization on file Data Entry & Billing Authorization on file: Claim is received at Health Advantage (HA) Claim is sent through BCCCP database to check validity of ICD-9/CPT codes and AUTHORIZATION (Auth) Claim has been fully adjudicated $$$ is processed and checks are issued to the provider If Auth IS present the claim is sent back to HA 12

19 2010 Billing Manual Why would my claims be pended? Provider/Billing Entity not enrolled in BCCCP database. Client screening and/or diagnostic data not sent to the LCA. The LCA will approve payment of the claim once data is received. Claims will be rejected after 30 days if data is not received during that time period. Claims will then need to be resubmitted for payment. Figure 8 Data Entry and Billing No Authorization on file Data Entry & Billing No Authorization on file: Claim is received at Health Advantage (HA) Claim is sent through MBCIS to check validity of ICD-9/CPT codes and AUTHORIZATION Claim rejects PB - and an EOP is sent to the provider After 30 days the claim is sent back to HA If Auth IS NOT present the claim continues on a nightly cycle to check for Auth Why would my claim be rejected? Information needed for processing the claim is missing from HCFA1500 / UB-04. Claim does not contain approved BCCCP/FP CPT, ICD-9, Revenue codes or Place of Service codes. Client is not enrolled in the BCCCP. An EOB does not accompany the claim of an insured client. Who should I contact if I have a question about my claim? All inquiries related to claims processing should be directed to the BCCCP Claims Hotline at Inquiries related to patient care or results of clinical services should be directed to the LCA. What information is required to check the status of a claim? Client MBCIS # / Social Security Number (SSN) Procedure code (CPT code) Date of Service (DOS) Provider Federal ID CLAIMS WILL NOT BE STATUSED WITHOUT THIS INFORMATION!! 13

20 2010 Billing Manual Health Insurance Portability and Accountability Act (HIPAA): We receive a very large number of claims that the envelopes are barely sealed or not sealed at all. These will be sent back to you to correct. DO NOT client sensitive data (SS#, Name, DOB) Before sending claims to MDCH, ask yourself this question - Is this how I would like my medical claims/records handled/mailed? Electronic Billing (EDI): BILLING PROVIDER - 85 Billing Provider Name Individual Providers Enter each part of name in separate fields: Use format: LASTNAME FIRSTNAME MIDDLEINITIAL (not required) Title (not recommended) - so the provider name is not all in the last name field. No punctuation Example EDI: NM1*85*1*SMITH*JOHN*A** -If your software does not allow name separation, please contact HA Provider Services to discuss options. Companies/Groups Enter as much of full name as possible in last name field Use format: GROUPNAME No punctuation Example EDI: NM1*85*2*SMITH RADIOLOGY GR**** Billing Provider Street Address All Providers 999 S ANYWHERE ST or PO BOX 999 No punctuation. N, E, S, W, NE, SW, etc. Standard USPO street-type abbreviations. No additional address information required or processed for street. Billing Provider City, State, Zip Full city name as space allows and standard USPS 2-digit state abbreviation. Important: 5-digit Zip Code Each in a separate field. Member Group Number must be filled. (BCCCP) MEMBER IL (same for QC dependent as applicable) Member Name Enter each part of name in separate fields: 14

21 2010 Billing Manual Use format: LASTNAME FIRSTNAME MIDDLEINITIAL NOTE: Incorrect spelling of name can cause rejection. Member Identification # - MI - All must be exactly 7-digits or will be REJECTED Member Street, City, State, Zip All Members S ANYWHERE ST or PO BOX 999 No punctuation. N, E, S, W, NE, SW etc. Standard USPO street-type abbreviations. No additional address information required or processed for street. Member Date of Birth (and any other date) CCYYMMDD no punctuation Example: CLAIMS DETAIL Units Units value cannot be 0. ALTERNATE PROVIDERS INFO Alternate Provider Name Individual Providers Enter each part of name in separate fields: Use format: LASTNAME FIRSTNAME MIDDLEINITIAL (not required) Title (not recommended) - so the provider name is not all in the last name field. No punctuation Companies/Groups Enter as much of full name as possible in last name field Alternate Provider Street Address where applicable All Providers 999 S ANYWHERE ST or PO BOX 999 No punctuation. N, E, S, W, NE, SW, etc. Standard USPO street-type abbreviations. No additional address information required or processed for street. Alternate Provider City, State, and Zip where applicable Full city name as space allows and standard USPS 2-digit state abbreviation. Important: 5-digit Zip Code Each in a separate field 15

22 2010 Billing Manual PLEASE NOTE: BCCCP is not able to track electronic claims. We have no access to the claims until they have been received by Health Advantage, Inc. Claims must be billed correctly ( BCCCP in the proper loop) in order to be uploaded to BCCCP s daily file. If you have questions about the status of an electronic claim submission, contact: Netwerkes Customer Service (888)

23 2010 Billing Manual BCCCP Web Site: This site contains useful information for providers to access at any time, 17

24 2010 Billing Manual Billing/Clinical Algorithms: The next 8 pages depict different clinical scenarios and what the BCCCP program can pay. As a reminder, this is a federally funded program which dictates what procedures we are allowed to pay for and the amount that is paid out. 18

25 2010 Billing Manual BREAST Immediate Follow-up: Abnormal Clinical Breast Finding BCCCP Decision Making Algorithms Clinical Data Documentation/Reimbursement Guidelines CLINICAL FINDING Abnormal Clinical Breast Exam (Includes nipple discharge, lump/mass, asymmetrical thickening, nodularity or skin changes regardless of normal mammogram result) BCCCP $ Full Office visit (CBE/Pelvic performed) Partial Office Visit (CBE only) CLINICAL FINDING Refer for diagnostic follow-up (IN ADDITION TO THE DIAGNOSTIC MAMMOGRAM). Follow-up may include any/all of the following: BCCCP $ Breast consult, Ultrasound, Breast biopsy, (anesthesia for excisional biopsies), pathology, immediate post biopsy mammogram, 6 month f/u mammogram/us post biopsy NOTE: BCCCP CANNOT reimburse for Breast MRI, MRI Guided Biopsy or Ductogram Continued F/U Post Diagnosis BCCCP $ - 6 month f/u mammogram and/or US - Post bx consult/office visit Note: additional consults > 3 months require MDCH approval If Cancer Diagnosed: Contact BCCCP Coordinator to enroll in MTA 19

26 2010 Billing Manual Breast Immediate Follow-up: Abnormal Mammogram/Ultrasound Results ACR 4 - Suspicious Abnormality, ACR 5 - Highly Suggestive of Malignancy BCCCP Decision Making Algorithms Clinical Data Documentation/Reimbursement Guidelines CLINICAL FINDING: Abnormal Mammogram/Ultrasound ACR 4 -Suspicious Abnormality, ACR 5- Highly Suggestive of Malignancy BCCCP $ Mammogram, Ultrasound CLINICAL FINDING Refer for diagnostic follow-up (May include any/all of the following) BCCCP $ Breast consult (pre/post biopsy, if applicable) Ultrasound, Breast biopsy, (anesthesia for excisional biopsies), pathology, immediate post biopsy mammogram, 6 month f/u mammogram/us post biopsy Continued F/U Post Diagnosis BCCCP $ - 6 month f/u mammogram and/or US - Post bx consult/office visit NOTE: BCCCP CANNOT reimburse for Breast MRI, MRI guided biopsy or Ductogram Note: additional consults > 3 months require MDCH approval If Cancer Diagnosed: Contact BCCCP Coordinator to enroll in MTA 20

27 2010 Billing Manual BREAST Immediate Follow-up: Abnormal Mammogram Result - ACR 0 - Assessment is Incomplete BCCCP Decision Making Algorithms Clinical Data Documentation/Reimbursement Guidelines ACR 0 - Assessment is Incomplete 2 Options CLINICAL FINDING OPTION # 1 Radiologist requests previous mammogram films for comparison NO BCCCP $ for review of comparison films) CLINICAL FINDING Radiologist reviews Comparison films - final result reported on addendum to first mammogram report ACR 1 or ACR 2 Resume annual screening ACR 3 6 month followup mammogram ACR 4 OR 5 CLINICAL FINDING OPTION # 2 Radiologist recommends additional diagnostic follow-up BCCCP $: Ultrasound, Breast consult (pre/post biopsy), FNA s, Breast biopsy(s), Anesthesia (for excisional biopsies), specimen pathology(s) Continued F/U Post Diagnosis BCCCP $ - 6 month f/u mammogram and/or US - If biopsy performed, post bx consult/ office visit Note: additional consults > 3 months require MDCH approval If Cancer Diagnosed: Contact BCCCP Coordinator to enroll in MTA 21

28 2010 Billing Manual CERVICAL Immediate/Short-term Follow-up: PAP TEST RESULT: ASC-US BCCCP Decision Making Algorithms Clinical Data Documentation/Reimbursement Guidelines CLINICAL FINDING: Abnormal Pap Test Result: ASC-US 3 Diagnostic Follow-up Options BCCCP $ Full Office visit (CBE/Pelvic performed) ; Partial Office Visit (Pelvic only), Pap Test OPTION # 1 Repeat Pap test at 6 and 12 months BCCCP $ Both Paps OR OPTION # 2 Refer for: Colposcopy/Biopsy, ECC, HPV BCCCP $ Colposcopy/Biopsy, ECC, HPV OR OPTION # 3 HPV Test (BCCCP ONLY) BCCCP $ HPV Test No BCCCP $ for pre/post-colposcopy consults (unless cancer diagnosed from biopsy) Continued F/U Post Diagnosis Pap@ 6 mos and 12 mos BCCCP $ Both Pap tests NO CIN 2, 3 Colp/Bx Results CIN 2, 3 CLINICAL FINDING HPV Positive CLINICAL FINDING HPV NEGATIVE Both Tests negative Resume screening per BCCCP gls) > ASC on either result Enroll in MTA per BCCCP policy BCCCP $ Pap test at 12 months Continued F/U Post Diagnosis HPV Positive BCCCP $ Pap at 6 and 12 months OR HPV ONLY at 12 months HPV Unknown BCCCP $ Pap at 12 months > ASC or HPV + BCCCP $ Repeat Colposcopy Negative Pap test Resume screening per BCCCP gls) 22

29 2010 Billing Manual CERVICAL Immediate Follow-up: PAP TEST RESULTS: ASC-H, LSIL BCCCP Decision Making Algorithms Clinical Data Documentation/Reimbursement Guidelines CLINICAL FINDING: Abnormal Pap Test Result: ASC-H OR LSIL BCCCP $ Full Office visit (CBE/Pelvic performed) ; Partial Office Visit (Pelvic only), Pap Test (Conventional or LBC) CLINICAL FINDING Refer for diagnostic follow-up BCCCP $ Colposcopy/Biopsy, ECC No BCCCP $ for pre/post-colposcopy consults (unless cancer diagnosed from biopsy) Continued F/U Post Diagnosis BCCCP $ 6 and 12 mos OR HR HPV at 12 mos >/= ASC or HPV + Negative NO CIN 2, 3 CIN 2, 3 Enroll in MTA as per BCCCP policy Refer for Colposcopy/Bx BCCCP $ Routine Screening as per BCCCP Pap Guidelines BCCCP $ Screening Pap tests per guidelines 23

30 2010 Billing Manual CERVICAL Immediate Follow-up: PAP TEST RESULT: HSIL BCCCP Decision Making Algorithms Clinical Data Documentation/Reimbursement Guidelines CLINICAL FINDING: Abnormal Pap Test of HSIL (2 Diagnostic Follow-up Options BCCCP $ Full Office visit (CBE/Pelvic performed) ; Partial Office Visit (Pelvic only), Pap Test (Conventional or LBC) DATA Work-Up Plan = IMMEDIATE (Follow-up within 60 days) OPTION # 1 Immediate LEEP MDCH Pre-approval required (case by case basis) OR OPTION # 2 - Refer for Colp/biopsy, ECC BCCCP $ Colposcopy/Biopsy, ECC No BCCCP $ for pre/post-colposcopy consults (unless cancer diagnosed from biopsy) NO CIN 2, 3 CIN 2, 3 CLINICAL FINDING Unsatisfactory Colp BCCCP $ Colposcopy/Biopsy OR CLINICAL FINDING Satisfactory Colp BCCCP $ Colposcopy/Biopsy Enroll in MTA as per BCCCP policy Diagnostic LEEP or CONE MDCH pre-approval required 2 acceptable approaches Continued F/U Post Diagnosis 6 mos and 12 mos BCCCP $ Pap/Colp 24

31 2010 Billing Manual CERVICAL Immediate Follow-up: PAP TEST RESULT: AGC BCCCP Decision Making Algorithms Clinical Data Documentation/Reimbursement Guidelines CLINICAL FINDING: AGC BCCCP $ Full Office visit (CBE/Pelvic) Partial Office Visit (Pelvic only), Pap Test Refer for Colposcopy/Biopsy, ECC, HR-HPV Test, AND Endometrial Biopsy BCCCP $ (all above) EMB, HR-HPV Test (MDCH pre-approval) NO CIN and NO Endometrial Cancer > CIN 2 but NO Endometrial Cancer NO CIN but Endometrial Cancer Continued F/U Post Diagnosis Enroll in MTA as per BCCCP policy HPV Status Unknown Repeat Pap Test q 6 months X 4 HPV (+) Repeat Pap test AND HR 6 months HPV (-) Repeat Pap test AND HR 12 months NOT eligible for BCCCP MTA Contact MDCH Nurse Consultants for treatment resources BCCCP $ All F/U Pap tests BCCCP $ Pap test/hpv test BCCCP $ Pap test/hpv test CLINICAL FINDING Results: > ASC or HPV +: Refer Colposcopy/Bx BCCCP $ Colposcopy/Biopsy OR CLINICAL FINDING Results: BOTH tests (-) Routine screening - 1 year post date of last Pap test 25

32 2010 Billing Manual BREAST Short-term Follow-up: Mammogram RESULT: ACR 3 - Probably Benign Finding BCCCP Decision Making Algorithms Clinical Data Documentation/Reimbursement Guidelines CLINICAL FINDING Mammogram Result: ACR 3 - Probably Benign Finding Schedule for Short-term follow-up per radiologist s recommendations BCCCP $ Mammogram, Ultrasound (per provider, radiologist recommendation) Short-term Follow-up Monitoring BCCCP $ - 6 month f/u mammogram and/or f/u US post screening MDCH pre-approval for > 2 mammograms/ultrasounds within 12 month time period 26

33 2010 Billing Manual Pap Billing Date: Remember when submitting claims that the general rule is that the date of service is the date the specimen is collected. Where a specimen is collected over a period that spans two calendar days, the date of service is the date the collection period ended. To read this article in full, please go to: 27

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35 2010 Billing Manual Claim Forms BCCCP must be placed on all claim forms: Paper Claims: HCFA 1500 in Box 11 (Group Number) UB-04 in Box 62 (Group Number) Electronic claims: HCFA 1500 (professional) x098a1 Loop 2000B, SBR03 (Insured Group Number) UB-04 (institutional) x096a1 Loop 2000B, SBR03 (Insured Group Number) Figure 9: UB-04 notice the high-lighted areas which are required fields Figure 10: HCFA 1500 notice the high-lighted areas which are required fields 28

36 2010 Billing Manual Figure 9 UB-04 29

37 2010 Billing Manual Figure 10 HCFA

38 2010 Billing Manual Provider Payment Report The BCCCP logo must be present on the Provider Payment Report, if it is not then the program did not pay for any services on that particular report. The BCCCP Hotline is on the Provider Payment Report. This phone line is staffed by BCCCP employees. Payee details who received the check, check date, check number, and check amount. Also present is detailed information for each client that services were paid and/or rejected. Figure 11 Health Advantage Provider Payment Report 31

39 2010 Billing Manual Check The BCCCP logo must be present on the check. If it is not, then the services were not paid for my BCCCP. Figure 12 BCCCP Check 32

40 2010 Billing Manual Billing Information Bill all applicable insurance companies for approved services BEFORE billing BCCCP. The BCCC Program is the payer of last resort. Claims will be reject if: The client is not enrolled in BCCCP. Information required for processing the claims is missing on the HCFA 1500 or UB-04 claim forms. Claims contain non-approved BCCCP CPT, ICD-9, POS, and/or Revenue codes. An EOB does not accompany the claim if the client has a primary insurance. If when billing for multiple services with the same CPT code for the DOS the claim need to be billed as UNITS not listed separately out on the claim form. Figure 13 Example of Unit billing 33

41 2010 Billing Manual Hold codes A hold code is an explanation for how the claim was processed. 1) I9 ICD-9 code not in contract Claim will reject Problem: ICD-9 code used is not a program approved code. Solution: Re-submit claim with program approved ICD-9 code. 2) IC Insurance Payment Claim will reject Problem: Primary Insurance paid more than the BCCCP rate. Solution: Claim is considered paid in full and the client can not be balance billed the remainder. 3) IP Insurance Partial Payment Claim will pay Problem: Primary Insurance paid less than the BCCCP rate. Solution: BCCCP will pay the difference between the insurance payment and the BCCCP approved rate. The client can not be balanced billed the remainder. 4) JL Revenue code not in contract Claim will reject Problem: Revenue code billed is not a program approved code. Solution: Re-submit claim with program approved revenue code. 34

42 5) JM CPT code not in contract Claim will reject 2010 Billing Manual Problem: CPT code billed is not a program approved code. Solution: Re-submit claim with program approved revenue code. 6) JU No related service on file Claim will reject Problem: Example, anesthesia billed before the surgeon billed. Solution: Re-submit claim payment. **Anesthesia cannot be paid until the surgeon bills** 7) N5 - Prior Fiscal Year Claim will reject Problem: CPT code billed is not a program approved code. Solution: Re-submit claim with program approved revenue code. **Fiscal year runs October 1 st 20XX to September 30 th 20XX** 8) N8 - Provider not enrolled Claim will reject Problem: Provider not enrolled in the program. Solution: The provider needs to contact the LCA in their area about becoming a BCCCP Provider. OR visit If you are an approved provider, contract the LCA you have a contract with 35

43 2010 Billing Manual 9) N9 - Service Partially/Fully done by another Provider Claim will reject Problem: Two providers have billed for the same CPT on the same DOS for the same client. Solution: Contact the BCCCP Hotline ( ) for additional help. 10) ND Duplicate claim Claim will reject Problem: This is a duplicate claim that has already been adjudicated under a different claim number. Solution: Call the BCCCP Claims Hotline to request a manual over-ride. You cannot simply keep rebilling because the system will view the historical line as paid and keep rejecting your claim. 11) NE Place of Service not covered Claim will reject Problem: BCCCP does not cover the Place of Service code used Solution: Re-submit claim with a program approved POS code. 12) PB Authorization required Claim will reject after 30 days Problem: The service has not been authorized by the LCA Solution: Service information needs to be sent to the LCA immediately; and/or the service information needs to be entered into the BCCCP database. Follow up with the LCA. **If the service is not entered and authorized with in 30 days of the claim getting into the system, it will then reject.** See figure 14 36

44 Figure 14 How claims are authorized 2010 Billing Manual 13) UN Number of units Mismatch Claim will reject Problem: (1) The provider has billed for multiple units and only 1 unit has been authorized by the LCA. (2) The provider billed multiple services with the same CPT code and date of service each on a separate line instead of all on 1 line with the number of units indicated on the claim form. Solution: (1) Contact the LCA, as there will need to be additional data entry performed. (2) Re-bill utilizing units See Figure 14 37

45 Figure 14 Example of Unit Billing 2010 Billing Manual 14) WC Client is not a WISEWOMAN Claim will reject Problem: (1) Client is not a WISEWOMAN client; (2) Provider is billing for a BCCCP service using a WW ICD-9 code. Solution: (1) Call the LCA you have a contract with and verify whether or not the client is in the WISEWOMAN Program; (2) Re-bill the claim with the appropriate ICD-9 code. 15) XA Denied claim paid Claim will be paid Problem: Claim was denied in error Solution: Payment will be manually processed by BCCCP employees 16) XB Payment error Payment will be taken back or provider will need to refund the Program Problem: Claim paid in error Solution: (1) Tack back/recovery has been requested for the billing service and will appear as a negative amount on future remittance (2) Provider can send a check back directly to Health Advantage 38

46 2010 Billing Manual Send check to: Make check out to: Health Advantage BCCCP Claims G3245 Beecher Road, Ste 200 Flint, MI Attn: Vicky Laney Health Advantage 17) E2 Primary carrier s EOB not included with claim: Claim will reject Problem: Client has insurance and an EOB is necessary to complete the processing of the claim. Solution: (1) Re-submit claim with EOB; OR (2) If the client does not have insurance, contact the agency you work with 18) N9 Service fully/partially paid by another provider Claim will reject Problem: If a Radiologist receives a rejection for N9, the hospital may have been paid in error and that payment will need to be reversed and re-processed for payment to the radiologist. Solution: Contact the BCCCP hotline ( ) 19) ZMM Claims rejected by an entity other than BCCCP BCCCP has NO record of this claim Problem: The client is new to BCCCP and there may have been a time lag from the time the provider billed services to the time the client s enrollment was entered into the BCCCP database; OR The clients social security number, date of birth, or spelling of the name entered into the BCCCP database is different than what the providers are billing with. Solution: Please contact you agency you work with and verify that all the information is correct both in the BCCCP database and on the claim form. Then you will need to RE-BILL. See figure 15 39

47 Figure 15 Provider Payment Report 2010 Billing Manual Claims paid by entities other than BCCCP When the provider receives an Explanation of Payment (EOP) and a check for services billed, please ensure that both the EOP and the check have our BCCCP logo on them. Figure 16 BCCCP Logo If there is any other logo or name, please DO NOT cash the check(s). These check(s) came from an incorrect funding source. Please return the check(s), along with the EOP to the address indicated on the statement with a note saying: Incorrect payment issued. Claims submitted are to be paid by MI BCCCP. Reminder: You will then need to re-bill all claims to BCCCP with BCCCP in the correct box on the claim form(s). 40

48 2010 Billing Manual BCCCP and County Health Plan (CHP): BCCCP and the various CHPs of Michigan serve many of the same women. BCCCP is the primary for CHP for reimbursement of services provided by both BCCCP and CHP. If a provider receives payment for a service that can be paid by BCCCP please refund the County Health Plan (CHP) and bill the services to BCCCP. Facility Charges and Fees: These charges ARE NOT PAYABLE by the BCCC Program! What are facility fees? Hospital charges associated with Biopsies, Fine Needle Aspirations (FNA) Who charges for facility fees? Hospitals and Ambulatory Surgical Care centers Common Billing Issues: 1. BCCCP not on the claim No BCCCP in box 11 on professional claim forms (HCFA1500) No BCCCP in box 62 on hospital claim forms (UB04) BCCP on claim rather than BCCCP Title XV on claim rather than BCCCP BCCCP in box 11c, rather than box 11 (HCFA1500) BCCCP in box 61, rather than box 62 (UB04) Figure 17 HCFA-1500 example Figure 10 UB-04 example 41

49 2010 Billing Manual Figure 18 UB-04 example 2. Client ID should be the clients social security number Client ID field is empty Client ID is BCCCP Client ID is Client ID is 5555 Client ID is Client ID is HPMS# Client ID does not match what is entered in BCCCP database 3. CPT/HCPCS Codes not reimbursed by BCCCP G0123 / G /77051 Drugs and other supplies (bandages) used during Breast Bx FACILITY fees 4. Client not on file Claims billed prior to client enrollment at LCA Claims billed for MEN Claims billed for clients that are inactive in our system 5. Not Unit Billing 6. Claim for DOS in prior fiscal year 42

50 2010 Billing Manual 7. Claim is missing an ICD-9 code Figure 19 Example of a missing ICD-9 code 8. Claims still being sent to Nationwide (former Third Party Administrator) Figure Example of a claim being sent to Nationwide and BCCCP missing 43

51 2010 Billing Manual Claim return letters The letter will tell you exactly why the claim was returned. In this case, claims have not entered the adjudication process. If a claim is returned, you must correct the problem and re-bill. Figure 21 - Claim does not indicate number of units 44

52 2010 Billing Manual Figure 22 Not billed with BCCCP min the correct location 45

53 Figure 23 Claim not on file 2010 Billing Manual 46

54 Figure 24 Invalid CPT Code 2010 Billing Manual 47

55 2010 Billing Manual Figure 25 Claim billed to Nationwide Health plan 48

56 2010 Billing Manual Figure 26 Social Security Number does not match member file 49

57 2010 Billing Manual Figure 27 Invalid Anesthesia CPT code(s) and/or Modifier(s) 50

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59 2010 Billing Manual Fiscal Year End Information Fiscal year ends September 30th of every year (FY XX runs 10/1/20XX to 9/30/20XX.) Original fiscal year claims MUST be received by Health Advantage by December 31st of any fiscal year. For example, fiscal year 09 ends on September 30, 2009 and fiscal year 10 starts on October 10, All original claims for fiscal year 2009 must be received no later that December 31, Any original fiscal year 09 claim received by Health Advantage after 12/31/2009 WILL BE rejected with N5 prior fiscal year. Original claims include claims waiting for EOBs. Corrections for fiscal year 09 must be received by Health Advantage by close of business middle of March each year. A couple items to note. Some of the end of year dates change annually, the agency you work with will provide an end of year timeline to you each year. Claims submitted late WILL NOT be paid. 51

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61 2010 Billing Manual Frequently Asked Questions Paper and EDI claim submission Information. 1. PAPER Claims MI BCCCP ~ Attn: Claims 109 Michigan Ave ~ WSB - 5th Floor Lansing, MI EDI Claims Netwerkes ONLY Payer ID is BCCCP What is needed for a claim to be PAID? Provider must have a contract with a BCCCP LCA and Provider Enrollment form must be on file All required info for the Client s service(s) has been submitted to the LCA for data entry into MBCIS (State database) The claim contains all approved codes (CPT, ICD-9, Place of Service, and Revenue) All screening results and/or diagnostic svc info has been entered into BCCCP database and the Pay Box has been checked What happens if a client does not have a SSN? Contact the LCA with whom you have a contract to see if one is on file OR call the BCCCP Claim Hotline State staff will assign a number to be used for billing purposes Who can a provider contact regarding CLAIM issues? BCCCP Claims Hotline phone fax The BCCCP Claims Hotline will be answered by BCCCP Employees Where can a provider go (online) to obtain information regarding the BCCCP? 52

62 2010 Billing Manual Why do claims pend (for up to 30 days)? The Provider/Billing entity is not enrolled (No Federal Tax ID or NPI Number on file) LCA must fill out a provider enrollment form and fax it to BCCCP State staff at The LCA has not authorized payment because the screening and/or diagnostic data has NOT been sent to the LCA Information needs to be sent to the LCA for data entry into MBCIS (State of MI database) Anesthesia bills before the surgeon 53

63 BCCCP Claim Hotline: phone fax 2010 Billing Manual Contact Information This line will be answered by BCCCP staff not Health Advantage Address and Web Site MI BCCCP 109 Michigan Ave WSB 5th Floor Lansing, MI Tory Phelps Program Technical Analyst phone toll-free fax Sam Burke Program Technical Analyst phone toll-free fax Any questions regarding this manual please contact: Cathy Blaze Reimbursement Coordinator 54

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65 APPENDIX A BCCCP Documents

66 FY2010 BCCCP Unit Cost Reimbursement Rate Schedule BCCCP Approved Services 1. Screening Mammogram (Bilateral) a. Global b. Technical/Facility Only TC c. Professional Only Diagnostic Mammogram (Unilateral) a. Global b. Technical/Facility Only TC c. Professional Only Diagnostic Mammogram (Bilateral) a. Global b. Technical/Facility Only TC c. Professional Only Digital Screening Mammogram (Bilateral) a. Global G0202 b. Technical/Facility Only G TC c. Professional Only G Digital Diagnostic Mammogram (Unilateral) a. Global G0206 b. Technical/Facility Only G TC c. Professional Only G Digital Diagnostic Mammogram (Bilateral) a. Global G0204 b. Technical/Facility Only G TC c. Professional Only G * Surgical Procedure Only - payable as a PROFESSIONAL fee. No payments to Hospitals for facility fees * FY2010 Rate Pap Test, Lab Component (in Bethesda System) - Read by Technician Pap Test Re-screening, Lab Component (in Bethesda System) - Read by Technician Pap Test, Lab Component - Read by Pathologist Pap Test, Automated Thin Layer Preparation (Thin Prep) Manual Screening Pap Test Re-screening, Automated Thin Layer Preparation (Thin Prep) Manual Screening Pap Test, Automated Thin Layer Preparation (Thin Prep) Automated Screening BCCCP 6/25/2009 Page 1 of 6

67 FY2010 BCCCP Unit Cost Reimbursement Rate Schedule BCCCP Approved Services FY2010 Rate 13. Pap Test Re-screening, Automated Thin Layer Preparation (Thin Prep) Automated Screening with Manual Re-screening HPV Typing Office Visit, New Patient Full Exam Office Visit, New Patient Partial Exam Office Visit, Established Patient Full Exam Office Visit, Established Patient Partial Exam Breast or Cervical Consultation Colposcopy ** Cannot be billed with pathology 88305/88307/88325** * Colposcopy with Biopsy of the Cervix and Endocervical Curettage (Colp Bx & ECC) ** Cannot be billed in conjunction with 57505** *57454 ** Cannot be billed with Level V pathology 88307** 22. Colposcopy with Biopsy of the Cervix (Colp w/ Bx) ** Cannot be billed in conjunction with 57505** *57455 ** Cannot be billed with Level V pathology 88307** 23. Colposcopy with Endocervical Curettage (Colp w/ ECC) ** Cannot be billed in conjunction with 57505** *57456 ** Cannot be billed with Level V pathology 88307** Endocervical Curettage (not part of D&C) * Fine Needle Aspiration of Superficial Breast Tissue, Not Using Imaging Guidance * * Surgical Procedure Only - payable as a PROFESSIONAL fee. No payments to Hospitals for facility fees * BCCCP 6/25/2009 Page 2 of 6

68 FY2010 BCCCP Unit Cost Reimbursement Rate Schedule BCCCP Approved Services FY2010 Rate 26. Fine Needle Aspiration of Superficial Breast Tissue, Using Imaging Guidance * Fine Needle Aspiration (FNA), Breast Cyst * Fine Needle Aspiration (FNA), Each Additional Cyst * Breast Biopsy, Needle Core, Not Using Imaging Guidance * Breast Biopsy, Incisional * Breast Biopsy, Excisional, Needle Core, Using Imaging Guidance * Breast Biopsy, Excisional, Automated Vacuum Assisted or Rotating Biopsy Device, Using Imaging Guidance * Breast Biopsy, Excisional *19120 a. Anesthesia services performed personally by anesthesiologist b. Medical supervision by a physician: more than four concurrent anesthesia procedures c. Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals d. CRNA service: with medical direction by a physician AA AD QK QX e. Anesthesiologist medically directs one CRNA QY f. CRNA service: (supervised) without medical direction by a physician QZ * Surgical Procedure Only - payable as a PROFESSIONAL fee. No payments to Hospitals for facility fees * BCCCP 6/25/2009 Page 3 of 6

69 FY2010 BCCCP Unit Cost Reimbursement Rate Schedule BCCCP Approved Services 34. Breast Biopsy, Excision of Single Lesion Identified by Radiological Marker *19125 a. Anesthesia services performed personally by anesthesiologist b. Medical supervision by a physician: more than four concurrent anesthesia procedures c. Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals d. CRNA service: with medical direction by a physician AA AD QK QX e. Anesthesiologist medically directs one CRNA QY f. CRNA service: (supervised) without medical direction by a physician QZ FY2010 Rate Breast Biopsy, Excision of Each Additional Lesion * Pre-op Placement, Needle Localization Wire * Pre-op Placement, Needle Localization Wire, Each Additional Lesion * Image Guided Placement of Metallic Localization Clip, During Breast Biopsy * Stereotactic Localization of Breast Biopsy Radiologic Supervision/Interpretation a. Global b. Technical Component TC c. Professional Component Needle Localization, Radiologic Supervision Interpretation a. Global b. Technical Component TC c. Professional Component Radiological Examination, Surgical Specimen a. Global b. Technical Component TC c. Professional Component * Surgical Procedure Only - payable as a PROFESSIONAL fee. No payments to Hospitals for facility fees * BCCCP 6/25/2009 Page 4 of 6

70 FY2010 BCCCP Unit Cost Reimbursement Rate Schedule BCCCP Approved Services 42. Magnetic Resonance Guidance for Needle Placement, Radiologic Supervision Interpretation a. Global b. Technical Component TC c. Professional Component Breast Ultrasound, Radiologic Supervision Interpretation a. Global b. Technical Component TC c. Professional Component Ultrasonic Guidance/Breast Needle Biopsy, Radiologic Supervision/Interpretation a. Global b. Technical Component TC c. Professional Component Surgical Pathology, Breast or Cervical Biopsy - Level IV a. Global b. Technical/Facility Only TC c. Professional Only **Cannot bill in conjunction with 88307** 46. Surgical Pathology, Breast or Cervical Biopsy - Level V a. Global b. Technical/Facility Only TC c. Professional Only **Cannot bill in conjunction with 88305** 47. Cytopathology, Evaluation of Fine Needle Aspirate to determine Specimen Adequacy a. Global b. Technical Component TC c. Professional Component Cytopathology, Interpretation and Report a. Global b. Technical Component TC c. Professional Component FY2010 Rate * Surgical Procedure Only - payable as a PROFESSIONAL fee. No payments to Hospitals for facility fees * BCCCP 6/25/2009 Page 5 of 6

71 FY2010 BCCCP Unit Cost Reimbursement Rate Schedule BCCCP Approved Services 49. Cytopathology, Selective Cellular Enhancement Technique with Interpretation (e.g., Liquid Based Slide Preparation Method), except Cervical or Vaginal a. Global b. Technical Component TC c. Professional Component **Cannot bill in conjunction with 88173** FY2010 Rate Case Management Anesthesia Required Modifiers and Payment Calculation (Each claim line billing for anesthesia services must include one of the following modifiers. The modifier used will generate a calculated fee screen as described under Payment Rate ) Payment Rate AA - (3 ABUs + 2 Time Units) X $ % AD - (3 ABUs) X $20.88 Flat rate of 3 ABUs, no time units QK - (3 ABUs + 2 Time Units) X $ % QX - (3 ABUs + 2 Time Units) X $ % QY - (3 ABUs + 2 Time Units) X $ % QZ - (3 ABUs + 2 Time Units) X $ % *2009 Medicare Conversion Factor = $20.88 * Surgical Procedure Only - payable as a PROFESSIONAL fee. No payments to Hospitals for facility fees * BCCCP 6/25/2009 Page 6 of 6

72 FY2010 BCCCP Unit Cost Reimbursement Rate Schedule Codes Requiring Nurse Consultant Approval CPT Description FY2010 Rate *57520 *57522 Cone - Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser **Cannot bill in conjunction with Cone - Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser; loop electrode excision **Cannot bill in conjunction with $ $ *58100 *58110 EMB - Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method **Cannot bill in conjunction with EMB - Endometrial sampling (biopsy) performed in conjunction with a colposcopy (List separately in addition to code for primary procedure ~ (Colposcopy 57452, 57454, 57455, 57456)) **Cannot bill in conjunction with $ $49.07 *57460 *57461 LEEP - Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix **Cannot bill in conjunction with LEEP - Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix **Cannot bill in conjunction with $ $ * Surgical Procedure Only - payable as a PROFESSIONAL fee. No payments to Hospitals for facility fees * BCCCP 6/25/2009 Page 1 of 1

73 FY 2010 Family Planning/BCCCP Joint Project Unit Cost Reimbursement Rate Schedule for Services Eligible to Family Planning Clients Under Age 40 with Abnormal Cervical Screenings Abnormal Cervical Screening Follow-up Services FY2010 Rate 1. Pap Test, Lab Component (in Bethesda System) - Read by Technician Pap Test Re-screening, Lab Component (in Bethesda System) - Read by Technician Pap Test, Lab Component - Read by Pathologist Pap Test, Automated Thin Layer Preparation (Thin Prep) Manual Screening Pap Test Re-screening, Automated Thin Layer Preparation (Thin Prep) Manual Screening Pap Test, Automated Thin Layer Preparation (Thin Prep) Automated Screening Pap Test Re-screening, Automated Thin Layer Preparation (Thin Prep) Automated Screening with Manual Re-screening HPV Typing Office Visit, New Patient Partial Exam Office Visit, Established Patient Partial Exam Breast or Cervical Consultation Colposcopy ** Cannot be billed with pathology 88305/88307** * Colposcopy with Biopsy of the Cervix and Endocervical Curettage (Colp Bx & ECC) ** Cannot be billed in conjunction with 57505** *57454 ** Cannot be billed with Level V pathology 88307** 14. Colposcopy with Biopsy of the Cervix (Colp w/ Bx) ** Cannot be billed in conjunction with 57505** *57455 ** Cannot be billed with Level V pathology 88307** * Surgical Procedure Only - payable as a PROFESSIONAL fee. No payments to Hospitals for facility fees * BCCCP 6/25/2009 Page 1 of 2

74 FY 2010 Family Planning/BCCCP Joint Project Unit Cost Reimbursement Rate Schedule for Services Eligible to Family Planning Clients Under Age 40 with Abnormal Cervical Screenings Abnormal Cervical Screening Follow-up Services 15. Colposcopy with Endocervical Curettage (Colp w/ ECC) ** Cannot be billed in conjunction with 57505** *57456 ** Cannot be billed with Level V pathology 88307** FY2010 Rate ECC - Endocervical Curettage (not part of D&C) * Surgical Pathology, Breast or Cervical Biopsy - Level IV a. Global b. Technical/Facility Only TC c. Professional Only **Cannot bill in conjunction with 88307** Surgical Pathology, Breast or Cervical Biopsy - Level V a. Global b. Technical/Facility Only TC c. Professional Only **Cannot bill in conjunction with 88305** Case Management * Surgical Procedure Only - payable as a PROFESSIONAL fee. No payments to Hospitals for facility fees * BCCCP 6/25/2009 Page 2 of 2

75 BCCCP Approved ICD-9 Code List Fiscal Year 2010 ICD9 Diagnosis Code Description Code Malignant neoplasm of female breast; Nipple and areola Malignant neoplasm of female breast; Central portion Malignant neoplasm of female breast; Upper-inner quadrant Malignant neoplasm of female breast; Lower-inner quadrant Malignant neoplasm of female breast; Upper-outer quadrant Malignant neoplasm of female breast; Lower-outer quadrant Malignant neoplasm of female breast; Axillary tail Malignant neoplasm of female breast; Other specified sites of female breast Malignant neoplasm of female breast; Breast (female), unspecified Malignant neoplasm of cervix uteri; Endocervix Malignant neoplasm of cervix uteri; Exocervix Malignant neoplasm of cervix uteri; Other specified sites of cervix Malignant neoplasm of cervix uteri; Cervix uteri, unspecified Malignant neoplasm of body of uterus; Corpus uteri, except isthmus Malignant neoplasm without specification of site; Other Benign neoplasm of skin; skin of trunk, (includes breast and chest wall) 217 Benign neoplasm of breast Benign neoplasm of other female genital organs; Other specified sites of female genital organs Benign neoplasm of other female genital organs; Female genital organ, site unspecified Benign neoplasm of other and unspecified sites; lymph nodes Carcinoma in situ of breast and genitourinary system; Breast Carcinoma in situ of breast and genitourinary system; Cervix uteri Carcinoma in situ of breast and genitourinary system; Other and unspecified female genital organs Neoplasm of uncertain behavior of genitourinary organs; Other and unspecified female genital organs 1 7/2009

76 BCCCP Approved ICD-9 Code List Fiscal Year 2010 ICD9 Diagnosis Code Description Code Neoplasm of uncertain behavior of other and unspecified sites and tissues; Breast Neoplasm of unspecified nature; Breast Benign mammary dysplasias; Solitary cyst of breast Benign mammary dysplasias; Diffuse cystic mastopathy Benign mammary dysplasias; Fibroadenosis of breast Benign mammary dysplasias; Fibrosclerosis of breast Benign mammary dysplasias; Mammary duct ectasia Benign mammary dysplasias; Other specified benign mammary dysplasias Benign mammary dysplasias; Benign mammary dysplasias, unspecified Other disorders of breast; Inflammatory disease of breast Other disorders of breast; Hypertrophy of breast Other disorders of breast; Fat necrosis of breast Other disorders of breast; Galactorrhea not associated with childbirth Other disorders of breast; Signs and symptoms in breast; Mastodynia Other disorders of breast; Signs and symptoms in breast; Lump or mass in breast Other disorders of breast; Signs and symptoms in breast; Other Other disorders of breast; Other specified disorders of breast Other disorders of breast; Unspecified breast disorder Inflammatory disease of cervix, vagina, and vulva; Cervicitis and endocervicitis Inflammatory disease of cervix, vagina, and vulva; Vaginitis and vulvovaginitis; Vaginitis and vulvovaginitis, unspecified Inflammatory disease of cervix, vagina, and vulva; Cyst of Bartholin's gland Inflammatory disease of cervix, vagina, and vulva; Ulceration of vulva; Ulceration of vulva in diseases classified elsewhere Other inflammatory disease of cervix, vagina, and vulva Noninflammatory disorders of cervix; Erosion and ectropion of cervix 2 7/2009

77 BCCCP Approved ICD-9 Code List Fiscal Year 2010 ICD9 Diagnosis Code Description Code Noninflammatory disorders of cervix; Dysplasia of cervix (uteri); Dysplasia of cervix, unspecified Noninflammatory disorders of cervix; Dysplasia of cervix (uteri); Mild dysplasia of cervix Noninflammatory disorders of cervix; Dysplasia of cervix (uteri); Moderate dysplasia of cervix Noninflammatory disorders of cervix; Leukoplakia of cervix (uteri) Noninflammatory disorders of cervix; Stricture and stenosis of cervix Noninflammatory disorders of cervix; Hypertrophic elongation of cervix Noninflammatory disorders of cervix; Mucous polyp of cervix Noninflammatory disorders of cervix; Other specified noninflammatory disorders of cervix Noninflammatory disorders of cervix; Unspecified noninflammatory disorder of cervix Pain and other symptoms associated with female genital organs; Other specified symptoms associated with female genital organs Pain and other symptoms associated with female genital organs; Unspecified symptom associated with female genital organs Disorders of menstruation and other abnormal bleeding from female genital tract; Excessive or frequent menstruation Disorders of menstruation and other abnormal bleeding from female genital tract; Metrorrhagia Disorders of menstruation and other abnormal bleeding from female genital tract; Postcoital bleeding Menopausal and postmenopausal disorders; Postmenopausal bleeding Congenital anomalies of genital organs; Anomalies of cervix, vagina, and external female genitalia; Other anomalies of cervix, vagina, and external female genitalia Nonspecific abnormal findings on radiological and other examination of body structure; Breast; Abnormal mammogram, unspecified Nonspecific abnormal findings on radiological and other examination of body structure; Breast; Mammographic microcalcification Inconculsive mammogram Other (abnormal) findings on radiological examination of breast Other and nonspecific abnormal cytological, histological, immunological and DNA test findings; Abnormal Papanicolaou smear of cervix and cervical HPV; Abnormal glandular Papanicolaou smear of cervix 3 7/2009

78 BCCCP Approved ICD-9 Code List Fiscal Year 2010 ICD9 Diagnosis Code Description Code Other and nonspecific abnormal cytological, histological, immunological and DNA test findings; Abnormal Papanicolaou smear of cervix and cervical HPV; Papanicolaou smear of cervix with atypical squamous cells of undetermined significance (ASC-US) Other and nonspecific abnormal cytological, histological, immunological and DNA test findings; Abnormal Papanicolaou smear of cervix and cervical HPV; Papanicolaou smear of cervix with atypical sqamous cells cannot exclude high grade squamous intraepithel Other and nonspecific abnormal cytological, histological, immunological and DNA test findings; Abnormal Papanicolaou smear of cervix and cervical HPV; Papanicolaou smear of cervix with low grade squamous intraepithelial lesion (LGSIL) Other and nonspecific abnormal cytological, histological, immunological and DNA test findings; Abnormal Papanicolaou smear of cervix and cervical HPV; Papanicolaou smear of cervix with high grade lesion (HGSIL) Other and nonspecific abnormal cytological, histological, immunological and DNA test findings; Abnormal Papanicolaou smear of cervix and cervical HPV; Cervical high risk human papillomavirus (HPV) DNA test positive Other and nonspecific abnormal cytological, histological, immunological and DNA test findings; Abnormal Papanicolaou smear of cervix and cervical HPV; Unsatisfactory smear Other and nonspecific abnormal cytological, histological, immunological and DNA test findings; Abnormal Papanicolaou smear of cervix and cervical HPV; Other abnormal Papanicolaou smear of cervix and cervical HPV Other and nonspecific abnormal cytological, histological, immunological an DNA test findings; Nonspecific abnormal Papanicolaou smear of other site Contusion of trunk; Breast V10.3 Personal history of malignant neoplasm; Breast V10.41 Personal history of malignant neoplasm; Genital organs; Cervix uteri V10.42 Personal history of malignant neoplasm; Genital organs; Other parts of uterus V10.43 Personal history of malignant neoplasm; Genital organs; Ovary V10.44 Personal history of malignant neoplasm; Genital organs; Other female genital organs V13.22 Other genital system and obstetric disorders; Personal history of cervical dysplasia V15.89 Other personal history presenting hazards to health; Other specified personal history presenting hazards to health; Other V16.3 Family history of malignant neoplasm; Breast V45.71 Acquired absence of organ; Acquired absence of breast 4 7/2009

79 BCCCP Approved ICD-9 Code List Fiscal Year 2010 ICD9 Diagnosis Code Description Code V67.00 Follow-up examination; Following surgery; Following surgery, unspecified V67.01 Follow-up examination; Following surgery; Follow-up vaginal pap smear V67.09 Follow-up examination; Following surgery; Following other surgery V69.2 Problems related to lifestyle; High-risk sexual behavior V71.1 Observation and evaluation for suspected conditions not found; Observation for suspected malignant neoplasm V72.31 Special investigations and examinations; Gynecological examination; Routine gynecological examination V72.32 Special investigations and examinations; Gynecological examination; Encounter for Papanicolaou cervical smear to confirm findings of recent normal smear following initial abnormal smear V72.5 Special investigations and examinations; Radiological examination, not elsewhere classified V72.84 Special investigations and examinations;pre-operative examination, unspecified V76.10 Special screening for malignant neoplasms; Breast; Breast screening, unspecified V76.11 Special screening for malignant neoplasms; Breast; Screening mammogram for high-risk patient V76.12 Special screening for malignant neoplasms; Breast; Other screening mammogram V76.19 Special screening for malignant neoplasms; Breast; Other screening breast examination V76.2 Special screening for malignant neoplasms; Cervix V87.43 Personal history of estrogen therapy V87.45 Personal history of systemic steriod therapy V87.46 Personal history of immunosuppressive therapy 7/2009 5

80 Revenue Code Description 0001 Total charge BCCCP Approved Revenue Code List Fiscal Year General classification laboratory or lab 0301 Chemistry lab 0306 Immunology lab 0309 Other laboratory 0310 General classification pathology lab 0311 Cytology pathology 0312 Histology pathology 0314 Biopsy pathology 0319 Other pathology 0320 General classification diagnostic x-ray 0370 General classification anesthesia 0372 Anesthesia incident to other diagnostic services 0379 Other anesthesia 0400 General classification imaging service 0401 Diagnostic mammography 0402 Ultrasound 0403 Screening mammography 0409 Other imaging services 0510 General classification clinic 0514 OB-GYN clinic 0517 Family practice clinic 0519 Other clinic 0520 General classification free-standing clinic 0521 Rural health clinic 0523 Family practice clinic 0529 Other free-standing clinic 0920 General classification - other diagnostic services 0923 Pap smear 1 7/2009

81 FY 10 Approved PLACE OF SERVICE for the BCCCP, WISEWOMAN and MCRCSP Programs Code Place of Service Name Place of Service Description 05 Indian Health Service Free Standing Facility A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require 06 Indian Health Service Provider Based Facility 07 Tribal 638 Free Standing Facility 08 Tribal 638 Provider Based Facility hospitalization. A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients. A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members who do not require hospitalization. A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to tribal members admitted as inpatients or outpatients. 11 Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on a ambulatory basis. 15 Mobile Unit A facility/unit that moves from place-to-place equipped to provide preventative, screening, diagnostic, and/or treatment services. 21 Inpatient Hospital A facility, other than a psychiatric, which primarily provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services by, or under, the supervision of a physician to patients admitted for a variety of medical conditions. 22 Outpatient Hospital A portion of the hospital which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. 24 Ambulatory Surgical Center A freestanding facility, other than a physician s office, where surgical and diagnostic services are provided on an ambulatory basis. 49 Independent Clinic A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventative, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. 50 Federally Qualified Health Center A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary care under the general direction of a physician. 71 Public Health Clinic A facility maintained by either State of local health departments that provides ambulatory primary medical care under the general direction of a physician. 72 Rural Health Clinic A certified clinic which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician. 81 Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician s office. 99 Other Place of Service Other Place of Service not identified above. 1 11/2009

82 Hold Code FY10 BCCCP, WISEWOMAN and MCRCSP ~ Hold Codes 11/2009 Hold Code Descriptor as it appears on Health Advantage's Explanation of Payments (EOP) BCCCP, WISEWOMAN and MCRCSP Hold Code Description Status AB Benefit not covered for age Services inappropriate for age of client REJECT CH Charge less than zero Amount charged for service is less than zero REJECT E2 Requesting Primary Carrier's EOB Primary insurance EOB missing. Must accompany a paper claim for clients with primary insurance. REJECT I9 ICD-9 Code Not In Contract Non-Program ICD-9 code REJECT IC Insurance Payment Primary insurance paid more than the BCCCP rate - claim paid in full REJECT IP Insurance Partial Payment Primary insurance is less than the BCCCP rate PAID IV Code No longer valid No longer a valid CPT/HCPCS or ICD-9 code REJECT JL Revenue Code Not In Contract Non-Program Revenue Code REJECT JM CPT/HCPCS Code Not In Contract Non-Program CPT/HCPCS code REJECT JU No Related Service On File Claim line rejected for no related service (e.g. anesthesia billed, with no related surgery) REJECT N5 Prior fiscal year Service date for prior fiscal year REJECT N6 State Override State (Nurse consultant) approved payment PAID N8 Provider not enrolled Provider/Billing Agency not enrolled in MBCIS. Contact your Local Coordinating Agency (LCA), or visit for additional information REJECT on becoming a program provider N9 Service Partially / Fully Done By Another Provider Service performed and paid to another provider REJECT ND Duplicate Claim Duplicate claim. Claim has already been paid or is currently processing for payment. REJECT NE Place of Service not covered Inappropriate site for care given REJECT PB Authorization Required Claim requires authorization by LCA REJECT RC Client is not a COLORECTAL client Not a COLORECTAL Client (Possible BCCCP claim being billed w/ incorrect ICD-9 code) REJECT RE Refund Provider sent a refund check to Health Advantage (-) Pay TB Take Backs (recovery of funds) BCCCP has requested funds back from a provider (-) Pay UN Number of Units Mismatch Number of units on claim does not match MBCIS units REJECT VR Void & Replace New claim number issued (for various reasons) REJECT WC Client is not a WISEWOMAN client Not a WISEWOMAN Client (Possible BCCCP claim being billed w/ incorrect ICD-9 code) REJECT XA Denied Claim Paid Claim denied in error. Denied claim now paid PAID XB Payment Error Claim paid in error. TPA reversed payment made in error. (Take Back or recovery) REJECT ZMM Client not found - billing error. (EOP will be from McLaren Health Plan/Health Advantage, rather than BCCCP) Claim rejected for various reasons. PLEASE FAX EOP AND CLAIMS TO TORY OR SAM FOR RE-PROCESSING Fax # (517) REJECT

83 FY10 BCCCP Procedure Code Reference Chart CPT / HCPCS Code TC TC TC -26 G0202 -TC -26 G0206 -TC -26 G0204 -TC -26 Procedure Code Description Screening mammography, bilateral (two view film study of each breast) Technical/Facility Component Professional Component Mammography; unilateral Technical/Facility Component Professional Component Mammography; bilateral Technical/Facility Component Professional Component Screening mammography producing direct digital image, bilateral, all views Technical/Facility Component Professional Component Diagnostic mammography, producing direct digital image, unilateral, all views Technical/Facility Component Professional Component Diagnostic mammography, producing direct digital image, bilateral, all views Technical/Facility Component Professional Component Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician (List separately in addition to code for technical service) BCCCP Service Billable with CPT / HCPCS Code (BCCCP Definition) Screening mammogram Two views of each breast Performed on an asymptomatic woman Diagnostic mammogram Two or more views of one breast Performed on a symptomatic woman Diagnostic mammogram Two or more views of each breast Performed on a symptomatic woman Digital screening mammogram Two views of each breast Performed on an asymptomatic woman Digital diagnostic mammogram Two or more views of one breast Performed on a symptomatic woman Digital diagnostic mammogram Two or more views of each breast Performed on a symptomatic woman Conventional Pap test Laboratory technical services Professional component indicated by when physician interpretation required Conventional Pap test Rescreening Laboratory technical services Professional component indicated by when physician interpretation required Pap test Laboratory professional services Use in conjunction with codes 88142, 88143, 88164, when physician interpretation of Pap test is required 1 7/2009

84 FY10 BCCCP Procedure Code Reference Chart CPT / Procedure Code Description HCPCS Code Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening under physician supervision Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening, under physician supervision Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually the presenting problem(s) are of moderate severity. Providers typically spend 30 minutes face-to-face with the patient and/or family. BCCCP Service Billable with CPT / HCPCS Code (BCCCP Definition) Thin Prep Pap test Laboratory technical services Manual screening Professional component indicated by when physician interpretation required Thin Prep Pap test - Rescreening Laboratory technical services Manual screening Professional component indicted by when physician interpretation required Thin Prep Pap test Laboratory technical services Automated screening Thin Prep Pap test - Rescreening Laboratory technical services Automated screening with manual rescreening Full annual clinical exam CBE AND pelvic/pap (if due for Pap test) Symptomatic or diagnosed new patient 2 7/2009

85 FY10 BCCCP Procedure Code Reference Chart CPT / Procedure Code Description HCPCS Code Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually the presenting problem(s) are of moderate to high severity. Providers typically spend 45 minutes face-to-face with the patient and/or family Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations(s), laboratory/diagnostic procedures, new patient; years Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations(s), laboratory/diagnostic procedures, new patient; 65 years and over Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; and straight forward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problems are self limited or minor. Providers typically spend 10 minutes face-to-face with the patient and/or family. BCCCP Service Billable with CPT / HCPCS Code (BCCCP Definition) Full annual clinical exam CBE AND pelvic/pap (if due for Pap test) Symptomatic or diagnosed new patient Full annual clinical exam CBE AND pelvic/pap (if due for Pap test) Asymptomatic new patient between the ages of 40 and 64 Full annual clinical exam CBE AND pelvic/pap (if due for Pap test) Asymptomatic new patient age 65 and older Partial annual clinical exam Either CBE only OR pelvic/pap only Symptomatic or diagnosed new patient 3 7/2009

86 FY10 BCCCP Procedure Code Reference Chart CPT / Procedure Code Description HCPCS Code Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straight forward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of low to moderate severity. Providers typically spend 20 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of low to moderate severity. Providers typically spend 15 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually the presenting problem(s) are of moderate to high severity. Providers typically spend 25 minutes face-to-face with the patient and/or family. BCCCP Service Billable with CPT / HCPCS Code (BCCCP Definition) Partial annual clinical exam Either CBE only OR pelvic/pap only Symptomatic or diagnosed new patient OR colposcopy office visit Full annual clinical exam CBE AND pelvic/pap (if due for Pap test) Symptomatic or diagnosed established patient Full annual clinical exam CBE AND pelvic/pap (if due for Pap test) Symptomatic or diagnosed established patient 4 7/2009

87 FY10 BCCCP Procedure Code Reference Chart CPT / Procedure Code Description HCPCS Code Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; 65 years and over Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: a problem focused history; a problem focused examination; straight forward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are self limited or minor. Providers typically spend 10 minutes face-to-face with the patient and/or family. BCCCP Service Billable with CPT / HCPCS Code (BCCCP Definition) Full annual clinical exam CBE AND pelvic/pap (if due for Pap test) Asymptomatic established patient between the ages of 40 and 64 Full annual clinical exam CBE AND pelvic/pap(if due for Pap test) Asymptomatic established patient age 65 and older Partial annual clinical exam Either CBE only OR pelvic/pap only (including repeat Paps) Partial annual clinical exam Either CBE only OR pelvic/pap only (includes repeat Paps) 5 7/2009

88 FY10 BCCCP Procedure Code Reference Chart CPT / Procedure Code Description HCPCS Code Office consultation for a new or established patient, which requires these three key components: a problem focused history; a problem focused examination; and straight forward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are self limited or minor. Providers typically spend 15 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straight forward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of low severity. Providers typically spend 30 minutes face-to-face with the patient and/or family Office consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of moderate severity. Providers typically spend 40 minutes face-to-face with the patient and/or family. BCCCP Service Billable with CPT / HCPCS Code (BCCCP Definition) Breast or cervical consultation Referral for follow-up problem(s) identified during screening New or established patient Breast or cervical consultation Referral for follow-up of problem(s) identified during screening New or established patient Breast or cervical consultation Referral for follow-up of problem(s) identified during screening New or established patient 6 7/2009

89 FY10 BCCCP Procedure Code Reference Chart CPT / Procedure Code Description HCPCS Code Office consultation for a new or established patient, which requires these three key component: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of moderate to high severity. Providers typically spend 60 minutes face-to-face with the patient and/or family Colposcopy of the cervix including upper/adjacent vagina; Service includes surgical procedure only Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage; Service includes surgical procedure only Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, amplified probe technique Level IV Surgical pathology, gross and microscopic examination; Breast, biopsy, not requiring microscopic evaluation of surgical margins; Cervix, biopsy -TC Technical/Facility Component -26 Professional Component BCCCP Service Billable with CPT / HCPCS Code (BCCCP Definition) Breast or cervical consultation Referral for follow-up of problem(s) identified during screening New or established patient Colposcopy Surgical procedure only Office visit billed separately Colposcopy with biopsy of the cervix and endocervical curettage Surgical procedure only Office visit billed separately Colposcopy with biopsy of the cervix Office visit billed separately Colposcopy with endocervical curettage Office visit billed separately HPV typing of high-risk strain Breast or cervical biopsy, laboratory evaluation of tissue sample Level IV 7 7/2009

90 FY10 BCCCP Procedure Code Reference Chart CPT / HCPCS Code Procedure Code Description Level V Surgical pathology; gross and microscopic examination; Breast, excision of lesion, requiring microscopic evaluation of surgical margins; Cervix, conization Technical/Facility Component Professional Component BCCCP Service Billable with CPT / HCPCS Code (BCCCP Definition) Breast or cervical biopsy, laboratory evaluation of tissue sample Level V -TC Fine needle aspiration; without imaging guidance Fine needle aspiration of superficial breast tissue Not using imaging guidance Fine needle aspiration; with imaging guidance Fine needle aspiration of superficial breast tissue Using imaging guidance Puncture aspiration of cyst of breast; Service includes surgical procedure only Puncture aspiration, breast cyst Surgical procedure only Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for primary procedure); (Use in conjunction with code 19000) Biopsy of breast; percutaneous, needle core, not using imaging guidance separate procedure); Service includes surgical procedure only Puncture aspiration, breast cyst Each additional cyst Breast biopsy, needle core Not using imaging guidance Surgical procedure only Biopsy of breast; open, incisional Breast biopsy, incisional Biopsy of breast; percutaneous, needle core, using imaging guidance Breast biopsy, excisional Needle core Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion, open, male or female, one or more lesions Using imaging guidance Breast biopsy, excisional Automated vacuum assisted or rotating biopsy device Using imaging guidance Breast biopsy, excisional 8 7/2009

91 FY10 BCCCP Procedure Code Reference Chart CPT / HCPCS Code AA -AD -QK -QX -QY -QZ Procedure Code Description Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified Anesthesia service performed personally by anesthesiologist Medical supervision by a physician: more than four concurrent anesthesia procedures Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals CRNA service: with medical direction by a physician Anesthesiologist medically directs one CRNA CRNA service: (supervised) without medical direction by a physician Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified -AA -AD -QK -QX -QY -QZ Anesthesia service performed personally by anesthesiologist Medical supervision by a physician: more than four concurrent anesthesia procedures Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals CRNA service: with medical direction by a physician Anesthesiologist medically directs one CRNA CRNA service: (supervised) without medical direction by a physician Excision of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker (List separately in addition to code for primary procedure); (Use in conjunction with code 19125) BCCCP Service Billable with CPT / HCPCS Code (BCCCP Definition) Anesthesia CPT code used when billing for Breast biopsy, excisional (19120) Anesthesia service performed personally by anesthesiologist Medical supervision by a physician: more than four concurrent anesthesia procedures Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals CRNA service: with medical direction by a physician Anesthesiologist medically directs one CRNA CRNA service: (supervised) without medical direction by a physician Breast biopsy, excision of single lesion identified by radiological marker Anesthesia CPT code used when billing for Breast biopsy, excision of single lesion identified by radiological marker (19125) Anesthesia service performed personally by anesthesiologist Medical supervision by a physician: more than four concurrent anesthesia procedures Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals CRNA service: with medical direction by a physician Anesthesiologist medically directs one CRNA CRNA service: (supervised) without medical direction by a physician Breast biopsy, excision of lesion identified by radiological marker Each additional lesion Preoperative placement of needle localization wire, breast Preoperative placement of needle localization wire 9 7/2009

92 FY10 BCCCP Procedure Code Reference Chart CPT / Procedure Code Description HCPCS Code Preoperative placement of needle localization wire, breast; each additional lesion (List separately in addition to code for primary procedure); (Use in conjunction with code 19290) Image guided placement, metallic localization clip, percutaneous, during breast biopsy (List separately in addition to code for primary procedure); (Use in conjunction with codes 19102, 19103) -TC BCCCP Service Billable with CPT / HCPCS Code (BCCCP Definition) Preoperative placement of needle localization wire Each additional lesion Image guided placement of metallic localization clip during breast biopsy Endocervical curettage (not done as part of a dilation and curettage) ECC Endocervical curettage Not part of D & C Sterotactic localization guidance for breast biopsy or needle placement (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation Technical/Facility Component Professional Component -TC TC TC TC -26 Mammographic guidance for needle placement, breast (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation Technical/Facility Component Professional Component Radiological examination, surgical specimen Technical/Facility Component Professional Component Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation Technical/Facility Component Professional Component Ultrasound, breast(s) (unilateral or bilateral), B-scan and/or real time with image documentation Technical Component Professional Component Stereotactic localization guidance for breast biopsy or needle placement Radiological supervision/interpretation Mammographic guidance for needle placement, breast Each lesion Radiological supervision/interpretation Radiological examination, surgical specimen Magnetic resonance guidance for needle placement Radiological supervision/interpretation Breast ultrasound Radiological supervision/interpretation 10 7/2009

93 FY10 BCCCP Procedure Code Reference Chart CPT / HCPCS Code TC Procedure Code Description Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation Technical/Facility Component Professional Component Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s) Technical/Facility Component Professional Component Cytopathology, evaluation of fine needle aspirate; interpretation and report Technical/Facility Component Professional Component -TC TC Cytopathology, Selective Cellular Enhancement Technique with Interpretation (e.g., Liquid Based Slide Preparation Method), except Cervical or Vaginal **Cannot bill in conjunction with 88173** Unlisted evaluation and management Case Management BCCCP Service Billable with CPT / HCPCS Code (BCCCP Definition) Ultrasonic guidance of breast needle placement Imaging supervision and interpretation Cytopathology, evaluation of fine needle aspirate to determine specimen adequacy Cytopathology, evaluation of fine needle aspirate Interpretation and report Cytopathology, Selective Cellular Enhancement Technique with Interpretation Interpretation and reports 11 7/2009

94 Intentionally left blank

95 APPENDIX B WISEWOMAN Documents

96 FY 2010 WISEWOMAN Unit Cost Reimbursement Rate Schedule WISEWOMAN Screening Services FY 2010 Rate 1. Office Visit, New Patient Full Exam Office Visit, New Patient Partial Exam Office Visit, Established Patient Full Exam Office Visit, Established Patient Partial Exam Cholesterol, Serum or Whole Blood, Total 82465, QW High Density Cholesterol (HDL) 83718, QW Lipid Panel (TC, HDL, triglycerides) 80061, QW Venipuncture Plasma Glucose (Fasting or Casual) 82947, QW Oral Glucose Tolerance Test (OGTT) Hemoglobin A1C (HbA1c) 83036, QW Preventative medicine counseling, individual (15 minutes, face-to-face or telephone) Preventative medicine counseling, individual (30 minutes, face-to-face or telephone) Preventative medicine counseling, individual (45 minutes, face-to-face or telephone) Preventative medicine counseling, individual (60 minutes, face-to-face or telephone) Preventative medicine counseling (30 minutes, face-to-face, in group setting) Preventative medicine counseling (60 minutes, face-to-face, in group setting) Administration and interpretation of health risk assessment instrument Medical Care Case Management QW = Test Performed with Cholestech 1 WISEWOMAN 06/25/2009

97 FY 2010 WISEWOMAN Approved ICD-9 Code List ICD-9 Code 243 Congenital hypothyroidism Thyroiditis; Acute thyroiditis Thyroiditis; Subacute thyroiditis Diagnosis Code Description Thyroiditis; Chronic lymphocytic thyroiditis Thyroiditis; Chronic fibrous thyroiditis Thyroiditis; Iatrogenic thyroiditis Thyroiditis; Other and unspecified chronic thyroiditis Thyroiditis; Thryroiditis, unspecified Diabetes mellitus; Diabetes mellitus without mention of complication; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes mellitus without mention of complication; Type I; (juvenile type), not stated as uncontrolled Diabetes mellitus; Diabetes mellitus without mention of complication; Type II or unspecified type, uncontrolled Diabetes mellitus; Diabetes mellitus without mention of complication; Type I (juvenile type), uncontrolled Diabetes mellitus; Diabetes with ketoacidosis; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes with ketoacidosis; Type I; (juvenile type), not stated as t ll d Diabetes mellitus; Diabetes with ketoacidosis; Type II or unspecified type, Diabetes t ll mellitus; d Diabetes with ketoacidosis; Type I (juvenile type), uncontrolled Diabetes mellitus; Diabetes with hyperosmolarity; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes with hyperosmolarity; Type I; (juvenile type), not stated as uncontrolled Diabetes mellitus; Diabetes with hyperosmolarity; Type II or unspecified type, Diabetes ll mellitus; d Diabetes with hyperosmolarity; Type I (juvenile type), uncontrolled Diabetes mellitus; Diabetes with other coma; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes with other coma; Type I; (juvenile type), not stated as t ll d Diabetes mellitus; Diabetes with other coma; Type II or unspecified type, uncontrolled Diabetes mellitus; Diabetes with other coma; Type I (juvenile type), uncontrolled Diabetes mellitus; Diabetes with renal manifestations; Type II or unspecified type, not stated as uncontrolled 12/18/2009 Page 1 of 6

98 FY 2010 WISEWOMAN Approved ICD-9 Code List ICD-9 Code Diagnosis Code Description Diabetes mellitus; Diabetes with renal manifestations; Type I; (juvenile type), not stated as uncontrolled Diabetes mellitus; Diabetes with renal manifestations; Type II or unspecified type, uncontrolled Diabetes mellitus; Diabetes with renal manifestations; Type I (juvenile type), t ll d Diabetes mellitus; Diabetes with ophthalmic manifestations; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes with ophthalmic manifestations; Type I; (juvenile type), not stated as uncontrolled Diabetes mellitus; Diabetes with ophthalmic manifestations; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes with ophthalmic manifestations; Type I; (juvenile type), not stated as uncontrolled Diabetes mellitus; Diabetes with neurological manifestations; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes with neurological manifestations; Type I; (juvenile type), not stated as uncontrolled Diabetes mellitus; Diabetes with neurological manifestations; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes with neurological manifestations; Type I; (juvenile type), not stated as uncontrolled Diabetes mellitus; Diabetes with peripheral circulatory disorders; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes with peripheral circulatory disorders; Type I; (juvenile type), not stated as uncontrolled Diabetes mellitus; Diabetes with peripheral circulatory disorders; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes with peripheral circulatory disorders; Type I; (juvenile type), not stated as uncontrolled Diabetes mellitus; Diabetes with other specified manifestations; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes with other specified manifestations; Type I; (juvenile type), not stated as uncontrolled Diabetes mellitus; Diabetes with other specified manifestations; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes with other specified manifestations; Type I; (juvenile type), not stated as uncontrolled Diabetes mellitus; Diabetes with unspecified complication; Type II or unspecified type, not stated as uncontrolled 12/18/2009 Page 2 of 6

99 FY 2010 WISEWOMAN Approved ICD-9 Code List ICD-9 Code Diagnosis Code Description Diabetes mellitus; Diabetes with unspecified complication; Type I; (juvenile type), not stated as uncontrolled Diabetes mellitus; Diabetes with unspecified complication; Type II or unspecified type, not stated as uncontrolled Diabetes mellitus; Diabetes with unspecified complication; Type I; (juvenile type), not stated as uncontrolled Disorders of carbohydrate transport and metabolism; Intestinal disaccharidase deficiencies and disaccharide malabsorption Disorders of lipoid metabolism; Pure hypercholesterolemia Disorders of lipoid metabolism; Pure hyperglyceridemia Disorders of lipoid metabolism; Mixed hyperlipidemia Disorders of lipoid metabolism; Hyperchylomicronemia Disorders of lipoid metabolism; Other and unspecified hyperlipidemia Disorders of lipoid metabolism; Lipoprotein deficiencies Disorders of lipoid metabolism; Lipodystrophy Disorders of lipoid metabolism; Lipidoses Disorders of lipoid metabolism; Other disorders of lipoid metabolism Disorders of lipoid metabolism; Unspecified disorder of lipoid metabolism Obesity and other hyperalimentation; Obesity; Obesity, unspecified Obesity and other hyperalimentation; Obesity; Morbid Obesity Overweight Localized adiposity Essential hypertension; Malignant Essential hypertension; Benign Essential hypertension; Unspecified Hypertensive heart disease; Malignant; Without heart failure Hypertensive heart disease; Malignant; With heart failure Hypertensive heart disease; Benign; Without heart failure Hypertensive heart disease; Benign; With heart failure Hypertensive heart disease; Unspecified; Without heart failure 12/18/2009 Page 3 of 6

100 FY 2010 WISEWOMAN Approved ICD-9 Code List ICD-9 Code Diagnosis Code Description Hypertensive heart disease; Unspecified; With heart failure Hypertensive kidney disease; Malignant; Without chronic kidney disease Hypertensive kidney disease; Malignant; With chronic kidney disease Hypertensive kidney disease; Benign; Without chronic kidney disease Hypertensive kidney disease; Benign; With chronic kidney disease Hypertensive kidney disease; Unspecified; Without chronic kidney disease Hypertensive kidney disease; Unspecified; With chronic kidney disease Hypertensive heart and kidney disease; Malignant; Without heart failure or chronic kidney disease Hypertensive heart and kidney disease; Malignant; With heart failure Hypertensive heart and kidney disease; Malignant; With chronic kidney disease Hypertensive heart and kidney disease; Malignant; With heart failure and chronic kidney disease Hypertensive heart and kidney disease; Benign; Without heart failure or chronic kidney disease Hypertensive heart and kidney disease; Benign; With heart failure Hypertensive heart and kidney disease; Benign; With chronic kidney disease Hypertensive heart and kidney disease; Benign; With heart failure and chronic kidney di Hypertensive heart and kidney disease; Unspecified; Without heart failure or chronic kidney disease Hypertensive heart and kidney disease; Unspecified; With heart failure Hypertensive heart and kidney disease; Unspecified; With chronic kidney disease Hypertensive heart and kidney disease; Unspecified; With heart failure and chronic kidney disease Secondary hypertension; Malignant; Renovascular Secondary hypertension; Malignant; Other Secondary hypertension; Benign; Renovascular Secondary hypertension; Benign; Other Secondary hypertension; Unspecified; Renovascular Secondary hypertension; Unspecified; Other 412 Old myocardial infarction 12/18/2009 Page 4 of 6

101 FY 2010 WISEWOMAN Approved ICD-9 Code List ICD-9 Code Diagnosis Code Description 413 Angina pectoris; Angina decubitus Angina pectoris; Prinzmetal angina Angina pectoris; Other and unspecified angina pectoris Other forms of chronic ischemic heart disease; Coronary atherosclerosis; Of unspecified type of vessel, native or graft Other forms of chronic ischemic heart disease; Coronary atherosclerosis; Of native coronary artery Other forms of chronic ischemic heart disease; Coronary atherosclerosis; Of autologous vein bypass graft Other forms of chronic ischemic heart disease; Coronary atherosclerosis; Of nonautologous biological bypass graft Alcoholic cardiomyopathy (Heart disease as a result of excess alcohol consumption) Heart failure; Congestive heart failure; Unspecified Heart failure; Left heart failure Ill-defined descriptions and complications of heart disease; Cardiovascular disease, unspecified Atherosclerosis; Of aorta Atherosclerosis; Of renal artery Atherosclerosis; Of native arteries of the extremities; Atherosclerosis of the extremities, unspecified Atherosclerosis; Of native arteries of the extremities; Atherosclerosis of the extremities with intermittent claudication Atherosclerosis; Of native arteries of the extremities; Atherosclerosis of the extremities with rest pain Atherosclerosis; Of native arteries of the extremities; Atherosclerosis of the extremities with ulceration Atherosclerosis; Of native arteries of the extremities; Atherosclerosis of the extremities with gangrene Atherosclerosis; Of native arteries of the extremities; Other Atherosclerosis; Of other specified arteries Atherosclerosis; Generalized and unspecified and unspecified atherosclerosis Symptoms involving cardiovascular system; Enlargement of lymph nodes Abnormal Glucose Impaired fasting glucose 12/18/2009 Page 5 of 6

102 FY 2010 WISEWOMAN Approved ICD-9 Code List ICD-9 Code Diagnosis Code Description Impaired fasting glucose test (oral) Other abnormal glucose Other specific abnormal findings; Elevated blood pressure reading without diagnosis of hypertension V12.50 Personal history of certain other diseases; Diseases of circulatory system; Unspecified circulatory disease V12.59 Personal history of certain other diseases; Diseases of circulatory system; Other V15.82 Other personal history presenting hazards to health; Other specified personal history presenting hazards to health; History of tobacco use V17.1 Family history of certain chronic disabling diseases; Stroke (cerebrovascular) V17.3 Family history of certain chronic disabling diseases; Ischemic heart disease V17.4 Family history of certain chronic disabling diseases; Other cardiovascular diseases V18.0 Family history of certain other specific conditions; Diabetes mellitus V65.40 Other persons seeking consultation without complaint or sickness; Counseling NOS V67.59 Follow-up examination; Following other treatment; Other V69.0 Problems related to lifestyle; Lack of physical exercise V69.1 Problems related to lifestyle; Inappropriate diet and eating habits V70.0 General medical examination; Routine general medical examination at a health care V71.7 f ilit Observation and evaluation for suspected conditions not found; Observation for suspected cardiovascular disease V72.60 Laboratory examination, unspecified V72.62 Laboratory examination ordered as part of a routine general medical examination V77.1 Screening for Diabetes Mellitus V77.8 Special screening for endocrine, nutritional, metabolic, and immunity disorders; Obesity V77.91 Other and unspecified endocrine, nutritional, metabolic, and immunity disorders; Screening for lipoid disorders V81.1 Special screening for cardiovascular, respiratory, and genitourinary diseases; Hypertension V81.2 Special screening for cardiovascular, respiratory, and genitourinary diseases; Other and unspecified cardiovascular conditions 12/18/2009 Page 6 of 6

103 Revenue Code Description 0001 Total charge BCCCP Approved Revenue Code List Fiscal Year General classification laboratory or lab 0301 Chemistry lab 0306 Immunology lab 0309 Other laboratory 0310 General classification pathology lab 0311 Cytology pathology 0312 Histology pathology 0314 Biopsy pathology 0319 Other pathology 0320 General classification diagnostic x-ray 0370 General classification anesthesia 0372 Anesthesia incident to other diagnostic services 0379 Other anesthesia 0400 General classification imaging service 0401 Diagnostic mammography 0402 Ultrasound 0403 Screening mammography 0409 Other imaging services 0510 General classification clinic 0514 OB-GYN clinic 0517 Family practice clinic 0519 Other clinic 0520 General classification free-standing clinic 0521 Rural health clinic 0523 Family practice clinic 0529 Other free-standing clinic 0920 General classification - other diagnostic services 0923 Pap smear 1 7/2009

104 FY 10 Approved PLACE OF SERVICE for the BCCCP, WISEWOMAN and MCRCSP Programs Code Place of Service Name Place of Service Description 05 Indian Health Service Free Standing Facility A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require 06 Indian Health Service Provider Based Facility 07 Tribal 638 Free Standing Facility 08 Tribal 638 Provider Based Facility hospitalization. A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients. A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members who do not require hospitalization. A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to tribal members admitted as inpatients or outpatients. 11 Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on a ambulatory basis. 15 Mobile Unit A facility/unit that moves from place-to-place equipped to provide preventative, screening, diagnostic, and/or treatment services. 21 Inpatient Hospital A facility, other than a psychiatric, which primarily provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services by, or under, the supervision of a physician to patients admitted for a variety of medical conditions. 22 Outpatient Hospital A portion of the hospital which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. 24 Ambulatory Surgical Center A freestanding facility, other than a physician s office, where surgical and diagnostic services are provided on an ambulatory basis. 49 Independent Clinic A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventative, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. 50 Federally Qualified Health Center A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary care under the general direction of a physician. 71 Public Health Clinic A facility maintained by either State of local health departments that provides ambulatory primary medical care under the general direction of a physician. 72 Rural Health Clinic A certified clinic which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician. 81 Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician s office. 99 Other Place of Service Other Place of Service not identified above. 1 11/2009

105 Hold Code FY10 BCCCP, WISEWOMAN and MCRCSP ~ Hold Codes 11/2009 Hold Code Descriptor as it appears on Health Advantage's Explanation of Payments (EOP) BCCCP, WISEWOMAN and MCRCSP Hold Code Description Status AB Benefit not covered for age Services inappropriate for age of client REJECT CH Charge less than zero Amount charged for service is less than zero REJECT E2 Requesting Primary Carrier's EOB Primary insurance EOB missing. Must accompany a paper claim for clients with primary insurance. REJECT I9 ICD-9 Code Not In Contract Non-Program ICD-9 code REJECT IC Insurance Payment Primary insurance paid more than the BCCCP rate - claim paid in full REJECT IP Insurance Partial Payment Primary insurance is less than the BCCCP rate PAID IV Code No longer valid No longer a valid CPT/HCPCS or ICD-9 code REJECT JL Revenue Code Not In Contract Non-Program Revenue Code REJECT JM CPT/HCPCS Code Not In Contract Non-Program CPT/HCPCS code REJECT JU No Related Service On File Claim line rejected for no related service (e.g. anesthesia billed, with no related surgery) REJECT N5 Prior fiscal year Service date for prior fiscal year REJECT N6 State Override State (Nurse consultant) approved payment PAID N8 Provider not enrolled Provider/Billing Agency not enrolled in MBCIS. Contact your Local Coordinating Agency (LCA), or visit for additional information REJECT on becoming a program provider N9 Service Partially / Fully Done By Another Provider Service performed and paid to another provider REJECT ND Duplicate Claim Duplicate claim. Claim has already been paid or is currently processing for payment. REJECT NE Place of Service not covered Inappropriate site for care given REJECT PB Authorization Required Claim requires authorization by LCA REJECT RC Client is not a COLORECTAL client Not a COLORECTAL Client (Possible BCCCP claim being billed w/ incorrect ICD-9 code) REJECT RE Refund Provider sent a refund check to Health Advantage (-) Pay TB Take Backs (recovery of funds) BCCCP has requested funds back from a provider (-) Pay UN Number of Units Mismatch Number of units on claim does not match MBCIS units REJECT VR Void & Replace New claim number issued (for various reasons) REJECT WC Client is not a WISEWOMAN client Not a WISEWOMAN Client (Possible BCCCP claim being billed w/ incorrect ICD-9 code) REJECT XA Denied Claim Paid Claim denied in error. Denied claim now paid PAID XB Payment Error Claim paid in error. TPA reversed payment made in error. (Take Back or recovery) REJECT ZMM Client not found - billing error. (EOP will be from McLaren Health Plan/Health Advantage, rather than BCCCP) Claim rejected for various reasons. PLEASE FAX EOP AND CLAIMS TO TORY OR SAM FOR RE-PROCESSING Fax # (517) REJECT

106 FY10 WISEWOMAN Procedure Code Reference Chart August 2009 CPT Code Procedure Description WISEWOMAN Service Billable with CPT Code (WISEWOMAN Definition) Office or other outpatient visit for the evaluation and management of a new Full clinical exam patient, which requires these three key components: Patient is new to clinician a detailed history; Straightforward problem of moderate severity a detailed examination; and Detailed history and P/E needed medical decision making of low complexity. Example: Referred to provider for evaluation Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. and treatment of high cholesterol/low HDL, high glucose, or high blood pressure ( Alert or Emergency values) Usually the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations(s), laboratory/diagnostic procedures, new patient; years Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations(s), laboratory/diagnostic procedures, new patient; 65 years and over Full clinical exam Patient is new to clinician Complex problem of moderate to high severity Comprehensive history and P/E needed Example: Referred to provider for evaluation and treatment of high cholesterol/low HDL, high glucose, and high blood pressure Full clinical exam New patient between the ages of 40 and 64 Health maintenance exam, anticipatory guidance Full clinical exam New patient age 65 and older Health maintenance exam, anticipatory guidance 1

107 FY10 WISEWOMAN Procedure Code Reference Chart August 2009 CPT Code Procedure Description WISEWOMAN Service Billable with CPT Code (WISEWOMAN Definition) Office or other outpatient visit for the evaluation and management of a new Partial clinical exam patient, which requires these three key components: Patient is new to clinician a problem focused history; Minor problem a problem focused examination; and Problem-focused history and P/E needed straightforward medical decision-making. Example: Referred to provider for evaluation Counseling and/or coordination of care with other providers or agencies are and treatment of borderline cholesterol. provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problems are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision-making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. Partial clinical exam Patient is new to clinician Straightforward problem of low/moderate severity Problem focused history and P/E needed Example: Referred to provider for evaluation and treatment of high cholesterol/low HDL, high glucose, or high blood pressure (not Alert values) Full clinical exam Patient is known to clinician Straightforward problem of low/moderate severity Problem focused history and P/E needed Example: Referred to provider for evaluation and treatment of high cholesterol/low HDL, high glucose, or high blood pressure 2

108 FY10 WISEWOMAN Procedure Code Reference Chart August 2009 CPT Code Procedure Description WISEWOMAN Service Billable with CPT Code (WISEWOMAN Definition) Office or other outpatient visit for the evaluation and management of an Full clinical exam established patient, which requires at least two of these three key Patient is known to clinician components: Complex problem of moderate to high severity a detailed history; Comprehensive history and P/E needed a detailed examination; Example: Referred to provider for evaluation medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are and treatment of high cholesterol/low HDL, high glucose, and high blood pressure provided consistent with the nature of the problem(s) and the patient s and/or family s needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; 65 years and over Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. Full clinical exam Established patient between the ages of 40 and 64 Health maintenance exam, anticipatory guidance Full clinical exam Established patient age 65 and older Health maintenance exam, anticipatory guidance Partial clinical exam Patient is known to clinician Example: Referred to provider for evaluation and treatment of borderline cholesterol. 3

109 FY10 WISEWOMAN Procedure Code Reference Chart August 2009 CPT Code Procedure Description WISEWOMAN Service Billable with CPT Code (WISEWOMAN Definition) Office or other outpatient visit for the evaluation and management of an Partial clinical exam established patient, which requires at least two of these three components: Patient is known to clinician a problem focused history; Minor problem a problem focused examination; Example: Referred to provider for evaluation straightforward medical decision-making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient s and/or and treatment of high cholesterol/low HDL, high glucose, or high blood pressure (not Alert values) family s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family Cholesterol, serum or whole blood, total Cholesterol, serum or whole blood, total Test performed by venipuncture QW Cholesterol, serum or whole blood, total (CLIA waived) Cholesterol, serum or whole blood, total Test performed with Cholestech Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) High density cholesterol (HDL) Test performed by venipuncture QW Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) High density cholesterol (HDL) (CLIA waived) Test performed with Cholestech Lipid panel. This panel must include the following: Cholesterol, serum, total Lipoprotein, direct measurement, high density cholesterol (HDL Cholesterol) Triglycerides QW Lipid panel. This panel must include the following: Cholesterol, serum, total Lipoprotein, direct measurement, high density cholesterol (HDL Cholesterol) Triglycerides (CLIA waived) Lipid panel (TC, HDL, triglycerides) Test performed by venipuncture Lipid panel (TC, HDL, triglycerides) Test performed with Cholestech Collection of venous blood by venipuncture Venipuncture Glucose; quantitative, blood (except reagent strip) Plasma Glucose Test performed by venipuncture 4

110 FY10 WISEWOMAN Procedure Code Reference Chart August 2009 CPT Code Procedure Description WISEWOMAN Service Billable with CPT Code (WISEWOMAN Definition) QW Glucose; quantitative, blood (except reagent strip) (CLIA waived) Plasma Glucose Test performed with Cholestech Glucose; tolerance test (GTT), three specimens (includes glucose) Oral Glucose Tolerance Test Performed in provider s office Hemoglobin; glycosylated (A1C) Hemoglobin A1C Test performed by venipuncture QW Hemoglobin; glycosylated (A1C) (CLIA waived) Hemoglobin A1C Performed with DCA or Cholestech GDX Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes Preventive medicine counseling Individual Face-to-face OR telephone 15 minutes Preventive medicine counseling Individual Face-to-face OR telephone 30 minutes Preventive medicine counseling Individual Face-to-face OR telephone 45 minutes Preventive medicine counseling Individual Face-to-face OR telephone 60 minutes Preventive medicine counseling In group setting Face-to-face 30 minutes Example: Nutrition education session 5

111 FY10 WISEWOMAN Procedure Code Reference Chart August 2009 CPT Code Procedure Description WISEWOMAN Service Billable with CPT Code (WISEWOMAN Definition) Preventive medicine counseling and/or risk factor reduction intervention(s) Preventive medicine counseling provided to individuals in a group setting (separate procedure); In group setting approximately 60 minutes Face-to-face 60 minutes Administration and interpretation of health risk assessment instrument (e.g., health hazard appraisal) Example: Nutrition education session Administration of WISEWOMAN Health History and Healthy Lifestyle Assessment form. Clients may receive this service once (1) per year Unlisted preventive and medicine service Medical care case management 6

112 WISEWOMAN Program Billing and Reimbursement Policy Only Current Procedural Terminology (CPT) Codes included in the Current Fiscal Year WISEWOMAN Unit Cost Reimbursement Rate Schedule are eligible for reimbursement. The most current Rate Schedule information is available online at: WISEWOMAN Organizations/ Providers can bill for the following services for each program participant during each one-year cycle: 1. Administration and Interpretation of Health Risk Assessment Instrument. 2. One Total Cholesterol Screening. 3. One High Density Lipoprotein Cholesterol Screening. 4. A second Total Cholesterol Screening if the first measurement is >400. Note that two units should be billed if a second measurement is necessary. 5. One Glucose Screening for participants who have not previously been diagnosed with diabetes. 6. One Glycated Hemoglobin (HbA1c) Test for participants who have previously been diagnosed with diabetes. 7. One Diagnostic Exam if screening results for blood pressure, cholesterol, and/or glucose warrant a referral. Note: In the past, a second Diagnostic Exam was eligible for reimbursement under certain circumstances. There are now no circumstances under which MDCH will reimburse for a second diagnostic exam. 8. One fasting lipoprotein panel (lipid panel) if cholesterol screening results warrant a referral. Lab results must be entered into the MBCIS WISEWOMAN module. 9. One follow-up fasting plasma glucose (FPG) and/or one oral glucose tolerance test (OGTT) if glucose screening results warrant a referral. Lab results must be entered into the MBCIS WISEWOMAN module. (If participant requires both a fasting lipoprotein panel and a fasting plasma glucose, both tests should be conducted at the same time.) 10. One venipuncture charge for the blood draw associated with the fasting lipoprotein panel (lipid panel) and/or the fasting plasma glucose (FPG) when the lipid panel and/or FPG is NOT performed on the Cholestech Machine. 11. One 30, 45 or 60 minute face-to-face Preventative Medicine Counseling contact for development of goals using the Healthy Lifestyle Goals form for Intervention Level 3 program participants. (See Lifestyle Counseling Protocols for description of intervention levels and Healthy Lifestyle Goals development.) 12. Up to four Preventative Medicine Counseling contacts for Intervention Level 3 program participants. (See Lifestyle Counseling Protocols for description of intervention levels and Lifestyle Counseling Contacts.) NOTE: WISEWOMAN funds may not be used to reimburse for smoking cessation classes or for diabetes self-management training. 13. Up to two Preventative Medicine Counseling contacts for Intervention Level 2 program participants. (See Lifestyle Counseling Protocols for description of intervention levels 10/2008

113 Billing and Reimbursement Page 2 and Lifestyle Counseling Contacts.) NOTE: WISEWOMAN funds may not be used to reimburse for smoking cessation classes or for diabetes self-management training. 14. Medical Care Case Management for all program participants with Alert values for Blood Pressure or Cholesterol (one time per participant per annual cycle). When billing for Medical Care Case Management, the date of service should be the same as the screening date. MDCH will enter the data and authorization related to Medical Care Case Management. 10/2008

114 Third Party Administrator Procedures for WISEWOMAN Program Services Responsibilities of Provider Provider of Diagnostic Examination Complete the bottom half of the Referral for Diagnostic Exam Form including the date of the diagnostic exam and the plan of care. On the bottom of the Referral for Diagnostic Exam Form, check the box of the Office Visit CPT Code for which you plan to bill. Submit the completed Referral for Diagnostic Exam Form to the referring agency. Bill the Third Party Administrator (TPA) for the Office Visit CPT Code at the Usual And Customary Rate on a HCFA 1500 or UB-92 claim form. Billing should follow the same procedures as for BCCCP. (See BCCCP website for most current billing manual: ) o It is important that the service date and CPT code on the claim match the date of diagnostic exam and Office Visit CPT code checked on the Referral for Diagnostic Exam Form. Provider of Laboratory Services Submit the results of the Lipid Panel, Fasting Plasma Glucose, or Hemoglobin A1C to the referring agency. Bill the TPA for all reimbursable lab services provided at the Usual and Customary Rate on a HCFA 1500 or UB-92 claim form. (See the current fiscal year WISEWOMAN Unit Cost Reimbursement Rate Schedule for a list of allowable CPT codes.) Billing should follow the same procedures as for BCCCP. (See Section II of the Third Party Administrator Provider Manual 2005.) o It is important that the service date on the claim matches the service date on the Laboratory Results submitted to MDCH. MDCH will use the date collected as the authorization date for all laboratory procedures. Responsibilities of WISEWOMAN Program Implementation Site Enter WISEWOMAN data into the WISEWOMAN module of the Michigan Breast and Cervical Cancer Information System (MBCIS). o Failure to enter data in a timely manner will delay payment to the agency or service provider. Bill the TPA for all WISEWOMAN services at the Usual And Customary Rate on a HCFA 1500 claim form. Billing should follow the same procedures as for BCCCP. (See BCCCP website for most current billing manual: See the current fiscal year WISEWOMAN Unit Cost Reimbursement Rate Schedule for a list of allowable CPT Codes and reimbursement rates for the WISEWOMAN program. When billing for Case Management, CPT Code 99429, the service date on the claim must match the Screening Date. 10/2008

115 Third Party Administrator Procedure Page 4 Note: The TPA matches claims to authorizations based on the participant MBCIS number, service date and CPT code. In order to avoid delays in payment, it is important that the participant information, service date and CPT code on the claim match the paperwork submitted to MDCH. 10/2008

116 Intentionally left blank

117 APPENDIX C Colorectal Cancer Documents

118 FY 2010 MI Colorectal Cancer Screening Program Unit Cost Reimbursement Rate Schedule MCRCSP Screening Services 1. Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression SG FY 2010 Rate Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple SG Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding, any method SG Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique SG Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery SG Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique SG Evaluation of surgical specimens: Gross and Microscopic Anatomy; Level IV surgical pathology, gross and microscopic examination; polyp: colorectal a. Global b. Technical/Facility Only TC c. Professional Only Revenue Code 0750 = General classification gastro-intestinal services - $ = A discontinued procedure due to extenuating circumstances or those that threaten the well being of the patient. Not to report elective cancellation. -SG = Ambulatory surgical center (ASC) facility service MCRCSP 11/2009

119 MCRCSP Approved ICD-9 Code List Fiscal Year 2010 ICD9 Code Diagnosis Code Description 153 Malignant neoplasm of colon Malignant neoplasm of colon; Hepatic flexure Malignant neoplasm of colon; Transverse colon Malignant neoplasm of colon; Decending colon Malignant neoplasm of colon; Sigmoid colon Malignant neoplasm of colon; Cecum Malignant neoplasm of colon; Appendix Malignant neoplasm of colon; Ascending colon Malignant neoplasm of colon; Splenic flexure Malignant neoplasm of colon; Other specified sites of large intestine Malignant neoplasm of colon; Colon, unspecified 154 Malignant neoplasm of rectum, rectosigmoid junction, and anus Malignant neoplasm of rectum, rectosigmoid junction, and anus; Rectum Malignant neoplasm of rectum, rectosigmoid junction, and anus; Other Secondary malignant neoplasm of respiratory and digestive systems; Large intestine and Malignant carcinoid tumors of the appendix, large intestine, and rectum Malignant carcinoid tumors of the appendix, large intestine, and rectum; Appendix Malignant carcinoid tumors of the appendix, large intestine, and rectum; Cecum Malignant carcinoid tumors of the appendix, large intestine, and rectum; Ascending colon Malignant carcinoid tumors of the appendix, large intestine, and rectum; Transverse colon Malignant carcinoid tumors of the appendix, large intestine, and rectum; Descending colon Malignant carcinoid tumors of the appendix, large intestine, and rectum; Sigmoid colon Malignant carcinoid tumors of the appendix, large intestine, and rectum; Rectum Benign carcinoid tumors of the large intestine, unspecified portion Benign carcinoid tumors of the large intestine, Appendix Benign carcinoid tumors of the large intestine, Cecum Benign carcinoid tumors of the large intestine, Ascending colon Benign carcinoid tumors of the large intestine, Transverse colon Benign carcinoid tumors of the large intestine, Descending colon Benign carcinoid tumors of the large intestine, Sigmoid colon Benign carcinoid tumors of the large intestine, Rectum Benign neoplasm of other parts of the digestive system; Stomach Benign neoplasm of other parts of the digestive system; Colon Benign neoplasm of other parts of the digestive system; Rectum and anal canal Carcinoma in-situ of digestive organs; Colon Carcinoma in situ of digestive organs; Rectum Neoplasm of uncertain behavior of digestive and respiratory systems; Stomach, intestines, and rectum Neoplasm of unspecified nature; Digestive system Hemorrhoids; Internal hemorrhoids without mention of complication 1 11/2009

120 MCRCSP Approved ICD-9 Code List Fiscal Year 2010 ICD9 Code Diagnosis Code Description Hemorrhoids; External hemorrhoids without mention of complication 538 Gastointestinal mucositis (ulerative) Regional enteritis: Unspecified site (Crohn's Disease) Ulcerative colitis; Ulcerative (chronic) proctitis Ulcerative colitis; Left sided ulcerative (chronic) colitis Ulcerative colitis; Universal ulcerative (chronic) colitis Ulcerative colitis; Ulcerative colitis, unspecified Vascular insufficiency of intestine; Acute vascular insufficiency of the intestine Vascular insufficiency of intestine; Chronic vascular insufficiency of intestine Vascular insufficiency of intestine; Unspecified vascular insufficiency of intestine Other and unspecified noninfectious gastroenteritis and colitis; Eosinophilic gastroenteritis and colitis Other and unspecified noninfectious gastroenteritis and colitis; Eosinophilic gastroenteritis and colitis; Eosinophilic colitis Other and unspecified noninfectious gastroenteritis and colitis; Other and unspecified noninfectious gastroenteritis and colitis Intestinal obstruction without mention of hernia; Volvulus Intestinal obstruction without mention of hernia; Impaction of intestine; Other Intestinal obstruction without mention of hernia; Other specified intestinal obstruction; Other Intestinal obstruction without mention of hernia; Unspecified intestinal obstruction Diverticula of intestine; Colon; Diverticulosis of colon (without mention of hemorrhage) Diverticula of intestine; Colon; Diverticulitis of colon (without mention of hemorrhage) Functional digestive disorders, not elsewhere classified; Constipation Functional digestive disorders, not elsewhere classified; Irritable bowel syndrome Functional digestive disorders, not elsewhere classified; Functional diarrhea Functional digestive disorders, not elsewhere classified; Other functional disorders of the intestine Anal fissure and fistula; Anal fissure 566 Abcess of anal and rectal regions Other disorders of peritoneum; Peritoneal adhesions (postoperative) (postinfection) Other disorders of intestine; Anal and rectal polyp Other disorders of intestine; Stenosis of rectum and anus Other disorders of intestine; Hemorrhage of rectum and anus Other disorders of intestine; Other specified disorders of rectum and anus; Anal or rectal pain Other disorders of intestine; Other specified disorders of rectum and anus; Other Other disorders of intestine; Other specified disorders of intestine; Angiodysplasia of intestine (without mention of hemorrhage) Other disorders of intestine; Other specified disorders of intestine; Angiodysplasia of intestine with hemorrhage Gastrointestinal hemorrhage; Hematemesis 2 11/2009

121 MCRCSP Approved ICD-9 Code List Fiscal Year 2010 ICD9 Code Diagnosis Code Description Gastrointestinal hemorrhage; Blood in stool (hematochezia) Gastrointestinal hemorrhage; Homorrhage of gastrointestinal tract, unspecified Intestinal malabsorption; Unspecified intestinal malabsorption Pruritus and related conditions; Pruritus ani Symptoms involving digestive system; Dysphagia Symptoms involving digestive system; Flatulence, eructation, and gas pain Symptoms involving digestive system; Other symptoms involving digestive system Symptoms involving digestive system; Other symptoms involving digestive system; Diarrhea Symptoms involving digestive system; Other symptoms involving digestive system; Other Other symptoms involving abdomen and pelvis; Hepatomegaly Other symptoms involving abdomen and pelvis; Ascites Nonspecific abnormal findings in other body substances; Stool contents 936 Foreign body in intestine and colon 937 Foreign body in anus and rectum V76.51 Special screening for malignant neoplasms; Intestine; Colon 3 11/2009

122 MCRCSP Approved REVENUE Code List Fiscal Year 2010 REVENUE Code Description 0001 Total charge 0310 General classification pathology lab 0312 Histology pathology 0314 Biopsy pathology 0319 Other pathology 0750 General classification - gastro-intestinal services 0920 General classification - other diagnostic services 1 11/2009

123 FY 10 Approved PLACE OF SERVICE for the BCCCP, WISEWOMAN and MCRCSP Programs Code Place of Service Name Place of Service Description 05 Indian Health Service Free Standing Facility A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require 06 Indian Health Service Provider Based Facility 07 Tribal 638 Free Standing Facility 08 Tribal 638 Provider Based Facility hospitalization. A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients. A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to tribal members who do not require hospitalization. A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to tribal members admitted as inpatients or outpatients. 11 Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on a ambulatory basis. 15 Mobile Unit A facility/unit that moves from place-to-place equipped to provide preventative, screening, diagnostic, and/or treatment services. 21 Inpatient Hospital A facility, other than a psychiatric, which primarily provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services by, or under, the supervision of a physician to patients admitted for a variety of medical conditions. 22 Outpatient Hospital A portion of the hospital which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. 24 Ambulatory Surgical Center A freestanding facility, other than a physician s office, where surgical and diagnostic services are provided on an ambulatory basis. 49 Independent Clinic A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventative, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. 50 Federally Qualified Health Center A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary care under the general direction of a physician. 71 Public Health Clinic A facility maintained by either State of local health departments that provides ambulatory primary medical care under the general direction of a physician. 72 Rural Health Clinic A certified clinic which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician. 81 Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician s office. 99 Other Place of Service Other Place of Service not identified above. 1 11/2009

124 Hold Code FY10 BCCCP, WISEWOMAN and MCRCSP ~ Hold Codes 11/2009 Hold Code Descriptor as it appears on Health Advantage's Explanation of Payments (EOP) BCCCP, WISEWOMAN and MCRCSP Hold Code Description Status AB Benefit not covered for age Services inappropriate for age of client REJECT CH Charge less than zero Amount charged for service is less than zero REJECT E2 Requesting Primary Carrier's EOB Primary insurance EOB missing. Must accompany a paper claim for clients with primary insurance. REJECT I9 ICD-9 Code Not In Contract Non-Program ICD-9 code REJECT IC Insurance Payment Primary insurance paid more than the BCCCP rate - claim paid in full REJECT IP Insurance Partial Payment Primary insurance is less than the BCCCP rate PAID IV Code No longer valid No longer a valid CPT/HCPCS or ICD-9 code REJECT JL Revenue Code Not In Contract Non-Program Revenue Code REJECT JM CPT/HCPCS Code Not In Contract Non-Program CPT/HCPCS code REJECT JU No Related Service On File Claim line rejected for no related service (e.g. anesthesia billed, with no related surgery) REJECT N5 Prior fiscal year Service date for prior fiscal year REJECT N6 State Override State (Nurse consultant) approved payment PAID N8 Provider not enrolled Provider/Billing Agency not enrolled in MBCIS. Contact your Local Coordinating Agency (LCA), or visit for additional information REJECT on becoming a program provider N9 Service Partially / Fully Done By Another Provider Service performed and paid to another provider REJECT ND Duplicate Claim Duplicate claim. Claim has already been paid or is currently processing for payment. REJECT NE Place of Service not covered Inappropriate site for care given REJECT PB Authorization Required Claim requires authorization by LCA REJECT RC Client is not a COLORECTAL client Not a COLORECTAL Client (Possible BCCCP claim being billed w/ incorrect ICD-9 code) REJECT RE Refund Provider sent a refund check to Health Advantage (-) Pay TB Take Backs (recovery of funds) BCCCP has requested funds back from a provider (-) Pay UN Number of Units Mismatch Number of units on claim does not match MBCIS units REJECT VR Void & Replace New claim number issued (for various reasons) REJECT WC Client is not a WISEWOMAN client Not a WISEWOMAN Client (Possible BCCCP claim being billed w/ incorrect ICD-9 code) REJECT XA Denied Claim Paid Claim denied in error. Denied claim now paid PAID XB Payment Error Claim paid in error. TPA reversed payment made in error. (Take Back or recovery) REJECT ZMM Client not found - billing error. (EOP will be from McLaren Health Plan/Health Advantage, rather than BCCCP) Claim rejected for various reasons. PLEASE FAX EOP AND CLAIMS TO TORY OR SAM FOR RE-PROCESSING Fax # (517) REJECT

125 FY 2010 MI Colorectal Cancer Screening Program Unit Cost Reimbursement Rate Schedule Procedure Code Reference Chart CPT Code SG -SG -SG -SG -SG -SG -TC -26 Procedure Description Flexible and Rigid Colonoscopy Procedures; Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) A discontinued procedure due to extenuating circumstances or those that threaten the well being of the patient. Ambulatory surgical center (ACS) facility fee Flexible and Rigid Colonoscopy Procedures; with biopsy, single or multiple Ambulatory surgical center (ACS) facility fee Flexible and Rigid Colonoscopy Procedures; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Ambulatory surgical center (ACS) facility fee Flexible and Rigid Colonoscopy Procedures; with ablation of tumor(s), polyp(s), or other lesion(s) not amendable to removal by hot biopsy forceps, bipolar cautery or snare technique Ambulatory surgical center (ACS) facility fee Flexible and Rigid Colonoscopy Procedures; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery. Ambulatory surgical center (ACS) facility fee Flexible and Rigid Colonoscopy Procedures; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Ambulatory surgical center (ACS) facility fee Evaluation of surgical specimens: Gross and Microscopic Anatomy; Level IV surgical pathology, gross and microscopic examination; polyp: colorectal Technical/Facility Component Professional Component CRC Service Billable with CPT Code (CRC Definition) Flexible and Rigid Colonoscopy Procedures Colonoscopy, flexible, proximal to splenic flexure; Diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) Flexible and Rigid Colonoscopy Procedures With biopsy, single or multiple Flexible and Rigid Colonoscopy Procedures With control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Flexible and Rigid Colonoscopy Procedures With ablation of tumor(s), polyp(s), or other lesion(s) not amendable to removal by hot biopsy forceps, bipolar cautery or snare technique Flexible and Rigid Colonoscopy Procedures With removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery. Flexible and Rigid Colonoscopy Procedures With removal of tumor(s), polyp(s), or other lesion(s) by snare technique Evaluation of surgical specimens: Gross and Microscopic Anatomy Level IV surgical pathology, gross and microscopic examination polyp: colorectal

126 Updated on October 10, Modifier 53 Fact Sheet Definition: Indicates the physician elected to terminate a surgical or diagnostic procedure due to the patient s well-being. Appropriate Usage: A discontinued procedure after induction of anesthesia Report modifier 53 in the first modifier field when appended to procedure code 45378, G0105 and G0121 Bill modifier 53 with the CPT code for the service furnished Inappropriate Usage: On an Evaluation and Management Procedure Code Discontinued surgeries prior to the anesthesia being induced When appended to an E/M procedure code Do not use on time-based procedure codes (i.e. critical care and psychotherapy) Facts: Procedure codes , G , and G have their own fee schedule amounts. All other services billed with 53 are subject to carrier medical review and priced by individual consideration. Supporting documentation should: be available upon request state the procedure was started why the procedure was discontinued state the percentage of the procedure was performed 1

127 Updated on October 10, Example: The physician is reporting that this is a discontinued colonoscopy. Additional documentation available upon request Do not report an E/M code with Modifier 53 Additional Information available upon request