Jennifer A. Robinson, CNP, CNM, MS Andrea M. Andersen, MPH

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2 Jennifer A. Rbinsn, CNP, CNM, MS Andrea M. Andersen, MPH 2

3 Describe hw the unbundling f Medicaid LARC reimbursement and ther plicies will influence clinical practices arund reprductive health Identify ptins fr stcking LARCs Describe best practice cding and billing fr LARC services in New Mexic 3

4 Nw everyne, including FQHC prviders can get paid fr LARC devices Unbundling nly applies t FQHCs HSD inf supplement- reimbursement t bill separately makes it mre financially feasible fr prviders 4

5 15 year ld walk in fr birth cntrl ptins First steps Cnfidential visit? Check in/registratin 5

6 Medicaid EOBs will be suppressed fr cnfidential services frm SBHCs N current private insurance EOB suppressin 6

7 Have patient cmplete all registratin frms, including prviding insurance Make cpies f insurance cards Cllect cpy & balances n accunt Verify patients eligibility and benefits fr every patient visit New patients will need t be verified n the fly Established patients can be dne electrnically, by phne r internet RT Welter & Assciates 7

8 Prviders can see mre patients and generate mre revenue if Medical Assistants (MAs) are utilized fr patient flw rming patients, getting prblem lists and histries preparing rms, bld draws, basic tests, set up f prcedures, discharging patients Patient educatin MAs r health educatrs RT Welter & Assciates 8

9 LARC First cntraceptive cunseling training vides and resurces: Bedsider handuts, psters, patient resurces: 9

10 Medicaid MCO cverage fr cntraceptive cunseling, implant, dep, IUD verified at check in Vitals, initial histry, urine pregnancy test dne by MA Health educatin dne with MA r health educatr Ana decides she wants a subdermal cntraceptive implant 10

11 ACOG (Oct 2012), CDC (April 2014), & Title X agree! 11

12 Pregnancy test Sterile 4x4 and 2x2 gauze Alchl prep pads Idine swab r ChlraPrep swab Band aid Cban Lidcaine 3mL Syringe, blunt needle, needle Cnsent frm Patient educatin handut 12

13 Pregnancy test Sterile IUD instrument insertin kit (tenaculum, scissrs, uterine sund, ring frceps) Texas swabs Idine swabs Lubricating jelly Speculum Speculum light Sanitary pad Cnsent frm Patient educatin handut 13

14 Prvider buys the LARC methd directly frm the manufacturer r a designated pharmacy r specialty distributr. Prvider bills the patient s insurance carrier fr the LARC methd and insertin prcedure. Cmmnly described as buy and bill. 14

15 Discunted pricing fr FQHCs Unbundling f billing fr LARCs frm FQHCs makes reimbursement fr 340B-purchased devices pssible as f Sept 2016 in NM! 15

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18 Implant Currently the nly implant available is manufactured by Merck (Nexplann ), which ffers tw buy and bill ptins via CuraScript and CVS Caremark t help prviders stck the implant in advance f patient request. Bth specialty distributrs prvide 90-day net terms, credit card payments r lines f credit, and a 2% discunt fr rders paid with a credit card r within 90 days if inviced. Neither distributr ffers vlume discunts fr the implant. Prviders may request assistance with determining which distributr t use and be directly cnnected t bth distributrs by calling Merck at frm 8:00 a.m. t 8:00 p.m. ET, Mnday thrugh Friday. Bth distributrs require that any prviders purchasing implants must first cmplete the required Merck training prgram. T rder frm CuraScript, yu must first establish an accunt. Call and the Nexplann team will help yu apply fr an accunt. A prvider will need an address, DEA number, federal tax ID number, a clinician s state license number, and a student ID number frm the Nexplann training certificate t cmplete the applicatin. Bank references are als required if a prvider is seeking a line f credit. T get access t 340B pricing, prviders must supply their active 340B number. Curascript will cnfirm yur access t 340B prices, which may take 5 t 15 days. Once an applicatin is cmplete, an accunt is usually set up within 48 hurs. T place an rder using a CuraScript accunt, prviders shuld call r rder nline. Orders received by 6:00 p.m. ET are prcessed that day and shipped secnd-day delivery. Overnight shipping is als available upn request. T rder frm CVS Caremark, prviders shuld cntact a custmer service representative at and request a Buy and Bill Order Frm. Fr whlesale purchases, a prvider will need t cmplete a whlesale agreement and a letter f affiliatin fr each clinician in the practice. T make either an individual r whlesale purchase, a prvider will need an address, NPI number, a clinician s state license number, and a student ID number frm the Nexplann training certificate. Orders received by 4:00 pm ET are prcessed that day and shipped secnd-day delivery. Overnight shipping is als available upn request. 18

19 A pharmacy r specialty distributr bills the patient s insurance carrier directly fr the LARC methd. A prvider bills the patient s insurance carrier fr related prcedures and services. May make stcking the methds ahead f time challenging. It can take up t seven days t receive prducts rdered via the varius specialty pharmacy prgrams (SPPs). 19

20 LNG-IUS All three distributrs f the Bayer LNG-IUS methds CVS Caremark, Prime Therapeutics, and Walgreens ffer an SPP ptin. Prviders shuld cmplete the Specialty Pharmacy Prescriptin Request frm and include patient authrizatin when sending the cmpleted frm t the chsen pharmacy distributr. The Mirena website includes detailed instructins fr cmpleting these frms. The Medicines360 LNG-IUS is available thrugh Accred Specialty Pharmacy. Call 877- ACCREDO t place an rder. Each rder requires a cpy f the patient s insurance card, basic patient demgraphics, and a prescriptin. If yur patient plans t use the Liletta Patient Savings Prgram (see the sectin n patients with cmmercial cverage), supply the Liletta card number alng with the rder. It may take up t 7 days t verify a referral; nce cmplete, the prduct is sent t the practice by vernight mail. Cpper IUD Wmen s Health Access Slutins is the SPP fr the cpper IUD. A prvider must cmplete the Patient Referral and Patient Authrizatin frms. In rder t have the cpper IUD delivered directly, a prvider shuld select Prescriber ffice will use Specialty Pharmacy under the frm sectin Hw d yu intend t btain ParaGard? Implant Prescriptin rders may be placed fr individual patients using the same distributrs as fr whlesale. Send the prescriptin using the CuraScript Benefit Verificatin Frm ( ) r the CVS Caremark Service Request Frm ( ). 20

21 Medical benefit implant in stck n site Infrmed cnsent prcess Insertin cmpleted Fllw up plans made Nw fr the fun part BILLING!... 21

22 3 different cde sets used fr reprting diagnsis cding, prcedure cding, and supplies/ther services: ICD-10-CM (why) CPT (what) HCPCS (device, J) 22

23 ICD-9 cdes nt fully cnverted t ICD-10 in cmmnly used templates Navigating the EMR t find apprpriate ICD-10 cdes (the lkup isn t always the best tl) Lts f unspecified cdes being used! Cding errrs with active cnditins vs. persnal histry f cnditin RT Welter & Assciates 23

24 ICD-10 = diagnsis, WHAT was dne Nexplann insertin/encunter fr initial prescriptin f Nexplann: Z Prvider template has t supprt cding used Example f EHR dcumentatin template is: 24

25 Mst IUD services will be linked t the Z30 series in ICD-10-CM: Z Encunter fr initial prescriptin f intrauterine cntraceptive device Z Encunter fr insertin f intrauterine cntraceptive device Z Encunter fr rutine checking f intrauterine cntraceptive device Z Encunter fr remval f intrauterine cntraceptive device Z Encunter fr remval and reinsertin f intrauterine cntraceptive device Z97.5 Presence f intrauterine cntraceptive device Suttn, K. (2016). The Essential Guide t LARC Cding. Presentatin, ACOG LARC Prgram. 25

26 Defines WHAT services were furnished t the patient 5 digit cde that can describe anything frm an ffice visit t knee surgery Cde selectin shuld be based n the dcumentatin requirements fr each prcedural service see Nexplann insertin prcedure nte example n past slide Example: Patient presents fr a Nexplann remval Remval, nn-bidegradable drug delivery implant RT Welter & Assciates 26

27 Scpe f this talk will nt discuss hw t determine which Outpatient E/M Cdes t use New Patient Cdes: Established Patient Cdes: Preventive Medicine Cdes: Prcedure cdes fr LARC insertin & remval are in additin t utpatient E/M cdes RT Welter & Assciates 27

28 Visit cde fr new patient: Insertin, nn-bidegradable drug delivery implant: T bill fr bth prcedure and device n the same day Add 25 mdifier t the E/M cde fr Nexplann 28

29 58300 Intrauterine cntraceptive device insert Intrauterine cntraceptive device insert FAILED (append mdifier 53) Intrauterine cntraceptive device remval Suttn, K. (2016). The Essential Guide t LARC Cding. Presentatin, ACOG LARC Prgram. 29

30 Healthcare Cmmn Prcedure Cding System Used mstly fr supplies Need t bill in additin t diagnsis and prcedure cdes t get reimbursed fr implant and IUD devices Frm HSD Sept 2016 supplement n unbundling: State f New Mexic Medical Assistance Prgram Manual Supplement 30

31 J7297 Levnrgestrel-releasing intrauterine cntraceptive system, 52 mg, 3 year duratin J7298 Levnrgestrel-releasing intrauterine cntraceptive system, 52 mg, 5 year duratin J7300 Intrauterine cpper cntraceptive J7301 Levnrgestrel-releasing intrauterine cntraceptive system, 13.5 mg Suttn, K. (2016). The Essential Guide t LARC Cding. Presentatin, ACOG LARC Prgram. 31

32 J7307-Etngestrel (cntraceptive) implant system, including implant and supplies ****Nte that the HCPCS cde n the NM HSD Sept 2016 supplement was incrrect, abve is the crrect cde*** Snja Miera- New Mexic Human Services Department 32

33 Must cntain: Revenue cde NDC Cde HCPCS 340B Price NDC Cde 0636 N HCPCS J B Price

34 Required minimal infrmatin fields: The qualifier that precedes the NDC cde- N4 indicates that there will be an NDC that fllws The NDC The crrect reprting f units fr the HCPCS r CPT cde **Fr LARC this will always be 1 unit** State f New Mexic Medical Assistance Prgram Manual Supplement 34

35 0636 Drugs requiring specific identificatin & detailed cding State f New Mexic Medical Assistance Prgram Manual Supplement 35

36 Universal number t ID a drug Several different NDC cdes per LARC Fund n LARC label- 11 digits Claim must cntain NDC cde in additin t revenue and prcedure cde n UB frm r in the 837 electrnic transactin Instructins fr billing LARC items administered in FQHCs, RHCs and HB-RHCS NDC cde requires use f bth upper and lwer rws n a claim line Make sure t line up infrmatin accurately Characters fall within the prper bx and rw State f New Mexic Medical Assistance Prgram Manual Supplement 36

37 Examples Sequence Cde n Package Zer added? Reprted as: N Yes-leading Yes- 2 nd segment Yes- 3 rd segment State f New Mexic Medical Assistance Prgram Manual Supplement 37

38 Devices purchased with 340B pricing are nt being reimbursed by Medicaid? 38

39 340B pricing- requires the additin f acquisitin cst n the NDC cde line Fee fr Service Institutinal Cmpanin Guide 39

40 Page 25, item 452 Reimbursement frm Medicaid fr devices purchased with 340B pricing is guaranteed if the billing prcess is cmpleted as defined in the supplement Include the unit price paid fr 340B device (LIN03 n electrnic frm, Bx 47 n UB frm) Enter the quantity r actual units administered Every 340B device cst varies based n site, s there is n fee schedule fr 340B pricing Devices purchased with 340B pricing are reimbursed based n the list price yu paid Devices purchased withut 340B pricing will be reimbursed based n current fee schedule Current Medicaid reimbursement fr a nn-340b purchased Nexplann is $ This was increased in Jan 2017 frm $ Snja Miera- New Mexic Human Services Department 40

41 Questins abut hw t bill fr LARC? Cntact: Snya Miera r Snya.Miera@state.nm.us 41

42 Cnfidential services fr children in New Mexic. (2007) (1st ed.). Retrieved frm RT Welter and Assciates. (2016, June). Clinic Efficiencies Fr Same Day Insertins Presentatin at the Clrad LARC Sympsium, Denver CO. American Academy f Pediatrics Cmmittee n Adlescence. (Oct 2014). Cntraceptin fr Adlescents. Pediatrics, 134(4). Cmmittee Opinin N (2012). Obstetrics & Gyneclgy, 120(4), di: /ag.0b013e b7d Suttn, K. (2016). The Essential Guide t LARC Cding. Presentatin, ACOG LARC Prgram. 42

43 Interuterine Devices & Implants: A Guide t Reimbursement: State f New Mexic Medical Assistance Prgram Manual Supplement: 0Rules%20and%20Billing/Supplements%20fr%20MAD%20NMAC%20Prgram%20Rules/Supplement% pdf Intrauterine Devices & Implants: A Guide t Reimbursement: EHR Recrd Template: Prgestin Implant Insertin: New Mexic Medicaid Cmpanin Guide: tins%20cmpanin%20guides/fee%20fr%20service/nmffs_%20837i_5010_ pdf Health insurance claim frm UB: Health insurance claim frm 1500: Frms/Dwnlads/CMS1500.pdf 43

44 Envisin New Mexic QI Staff Directry Telephne Jane McGrath, MD, FAAP Prgram Directr Kris Carrill, LISW Prgram Operatins Directr Andrea Andersen, MPH QI Specialist Dan Rifkin, MD Child and Adlescent Psychiatrist Brandn Bell QI Specialist Kirsten Bennett, PhD, RD, LD QI Training, Cnsultatin and Outreach Adrienne McCnnell, MS QI Specialist Carle Cnley, LMSW Prgram Manager Kristine Lucer, MA Accuntant II Terri Chauvet Administrative Assistant III Mary Rams, MD Principal Investigatr-Hiltn Grant Assistant Prfessr Daisy Rser Prgram Manager-Hiltn Grant Eleana Shair Sr. Statistician Curtney McKinney Prgram Manager Janette Schluter Prgram Data Specialist Jeanene Sisk Administrative Assistant II Kevin Werling Systems Analyst lli Michelle Widener Telehealth Prgram Crdinatr 44

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