Billing for Outpatient Anesthesia Services

Transcription

1 HMSA s for particpating healthcare facilities November 009 Billing for Outpatient Anesthesia Services A review of recently processed outpatient anesthesia claims identified an inconsistency in the amounts providers are being reimbursed. The system is being corrected. For outpatient anesthesia codes that do not have established fees, the eligible charge (EC) will be a percentage of the covered items billed. This change will apply to dates of service beginning with January 1, 010 and after. Outpatient anesthesia codes with established fees will continue to process according to their EC. Outpatient anesthesia services are reimbursed separately from other hospital oupatient services. EC for outpatient anesthesia services may be subject to the coinsurance or copayments outlined in HMSA members Guide to Benefits. Facilities are encouraged to review each patient s medical plan benefits to confirm coverage. Billed items must meet HMSA s Payment Determination Criteria and have the proper documentation on file. HMSA reserves the right to request and review medical record documentation for billed services. Facilities should indicate type of bill (TOB) 1x and include one of the following revenue codes: 70, 71, 7, or 79. Facility Reimbursement Changes Affects facility transfers and readmissions Effective 010, HMSA s Diagnosis-Related Group (DRG) reimbursement will change for admissions related to acute facility transfers and readmissions for all private lines of business except HMSA s 65C Plus and QUEST. Transfers Based on Medicare guidelines, for cases where it is medically necessary to transfer a patient from one acute facility to another, the transferring facility (billed with patient status code 0 ) will be reimbursed based on the hospital-specific per diem relating to each DRG; HMSA will pay the facility twice the per diem on the first day plus the per diem for each additional day of inpatient care, up to the full DRG amount. The full DRG payment amounts are reached when the length of stay (LOS) is one day less than the geometric mean LOS for each DRG. The receiving facility will be paid the full DRG. This represents a simplified prorating allocation of the DRG based on the number of days for an inpatient stay. There will be no change to computation of hospital inpatient Base Rate, Relative Weights, DRG rate or outlier thresholds. (continue on next page) PS Hawaii Medical Service Association 818 Keeaumoku St. P.O. Box 860 Honolulu, HI Phone: (808) Branch offi ces located on Hawaii, Kauai and Maui Internet address: Provider Resource Center: hhin.hmsa.com

2 Provider Update Facilities November 009 Facility Reimbursement Changes (continued from previous page) Receiving facilities should not transfer back a patient to the initial facility for continuation of care or patient convenience reasons. Such transfers do not meet medical necessity criteria and will not be reimbursed by HMSA. Readmissions Reimbursement for readmissions, with the same or related condition, within hours to the same facility will be combined and recalculated into a single DRG. Facilities may combine claims or claims will be combined by HMSA upon receipt. Reimbursement for an admission with a related, planned readmission to the same facility (e.g., surgery scheduling issues, surgical team unavailability in which the patient does not require acute care between admissions) will be paid as a single DRG. Facilities will need to utilize the Leave of Absence indicator on the UB-0 hospital claim. As a reminder, there is no reimbursement for readmission resulting from a premature discharge at the same facility; these readmissions present quality of care concerns and should be avoided, or the readmission will be subject to retrospective review and recovery. You may call HMSA s Medical Management Department at or send in a payment determination request prior to a transfer if you need assistance or clarification on the medical appropriateness of the transfer. HMSA s MAC Fee Changes Seasonal Flu Vaccines The maximum allowable charges (MAC) for the following influenza vaccines will decrease as of 010, due to the reduction in the cost of flu vaccines. Code Description (Truncated) Influenza virus vaccine, split virus, preservative free, ages 6 to 5 months, IM New MAC $ FP (Federal Plan Only) $ age years & above, IM $ FP (Federal Plan Only) $ Influenza virus vaccine, split virus, ages 6-5 months of age, $5.61 IM age years & above, IM $ Influenza virus vaccine, live, for intranasal vaccine $ FP (Federal Plan Only) $.69 Seasonal Flu Payment Reminders Payment for the intranasal flu vaccine (90660) and two preservative-free vaccine codes (90655 and 90656) will be made based on the same MAC that HMSA pays for the standard flu vaccine codes (90657 and 90658). The intranasal vaccine and preservativefree vaccines will also be subject to balance billing to members for the difference between HMSA s payment and the provider s charge, with the member s agreement. HMSA will reimburse the full MAC vaccines for members of the Federal Plan (coverage code 87).

3 Provider Update Facilities November 009 Influenza A (H1N1) When billing HMSA s private business plans for administration of the H1N1 vaccine for members, please use 9070, swine fl u administration. For HMSA s 65C Plus plan members, please use G911, Infl uenza A (H1N1) immunization administration for the H1N1 vaccine administration. For the ICD-9- CM diagnosis code, please use V0.81, prophylactic vaccination and inoculation, infl uenza, on all H1N1 vaccine administration claims. If the H1N1 vaccination is administered on the same day as any other immunization, the claim should be submitted with one line for the H1N1 administration and on Update Code Listing Effective 010, the following codes will be added to the Procedure Related Grouping () List as noted I & D of abscess; complicated or multiple Dermal autograft, trunk, arms, legs; first 100 sq cm, (1% body area, infants/children) Muscle, myocutaneous/ fasciocutaneous flap; head & neck 1960 Excision of chest wall tumor including ribs 1996 Placement of radiotherapy afterloading balloon catheter into the breast following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy 110 Genioplasty; augmentation 1555 Excision tumor, neck/thorax, SQ 1 70 Arthroplasty, glenohumeral joint; hemiarthroplasty 550 Open treatment of acromioclavicular dislocation, acute or chronic 5 a separate line bill the appropriate additional vaccine administration code. H1N1 vaccine material, needles, syringes, alcohol swabs and sharps containers are covered by the federal government and are distributed without cost. As a result, HMSA will not pay for vaccine material or any supplies. Providers who submit claims for vaccine and/or supplies will not be paid for the vaccine material and/or supplies with fascial graft (includes obtaining graft) Arthrodesis, wrist; limited, without bone graft 697 Transfer of tendon to restore intrinsic function; ring/small finger 699 Correction claw finger, other methods 77 Excision, tumor, thigh or knee area; SQ 1 71 Autologous chondrocyte implantation, knee 7618 Excision, tumor, leg/ankle; SQ Repair of nonunion or malunion, tibia; without graft Open treatment of medial malleolus fracture, includes internal fixation Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation Excision, tumor, foot; subcutaneous tissue (continued on next page) 1

4 Provider Update Facilities November 009 Update Code Listing (continued from previous page) 9805 Athroscopy, shoulder, diagnostic 065 Repair nasal vestibular stenosis 155 Laryngoscopy w/operating microscope 8 Implantation cardiac recorder 8760 Inguinofemoral lymphadenectomy 111 Excision, tongue lesion UGI w/transendoscopic ultrasound 5190 Destruction, rectal tumor 51 Sigmoidoscopy w/ultrasound exam 78 Ablation, tumors, percutaneous Biopsy, prostate Destruction, vaginal lesion Myomectomy, abdominal approach 6505 Injection, anesthetic Incision for implantation of neurostimulator 6600 Destruction by neurolytic agent Nerve graft, cm Radial keratotomy Fistulization, sclera, for glaucoma 6690 Removal, lens material 6791 Correction, lagophthalmos w/ implantation Biopsy, lacrimal gland 1 Never Events and Future Suspension Dates The table below indicates the type of Never Event and the date claims will suspend for review for the applicable line of business. Never Event HMSA Private Business October 1, HMSA QUEST November 1, 009 FEP 010 Surgery performed on the wrong body part Surgery performed on the wrong patient Wrong surgical procedure performed on a patient Unintended retention of a foreign object in a patient after surgery or other procedure Patient death or serious disability associated with a hemolytic reaction due to administration of ABO/HLA incompatible blood or blood products (continued on next page)

5 5 Provider Update Facilities November 009 Never Events and Future Suspension Dates (continued from previous page) Never Event HMSA Private Business October 1, HMSA QUEST November 1, 009 FEP 010 Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility Stage or pressure ulcers acquired after admission to a healthcare facility Catheter-associated urinary tract infection Vascular catheter-associated infection Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG) Falls and trauma (fracture, dislocation, intracranial injury, crushing injury, burn, electric shock) Surgical site infections following certain orthopedic procedures (spine, neck, shoulder, elbow) Surgical site infections following bariatric surgery for obesity Patient death or serious disability associated with hypoglycemia, the onset of which occurred while the patient is being cared for in a healthcare facility Deep vein thrombosis and pulmonary embolism following certain orthopedic procedures