Immunization Conference Wyoming Medicaid Covered Services & Billing Requirements May 11 & 12, 2016 Presenter s: Melissa Davis & Elisa Mauch, Field Representative s
What is Medicaid? Medicaid helps pay for healthcare services for children, pregnant women, families with children, and individuals who are aged/blind/disabled who qualify based on citizenship, residency, family income, and sometimes resources and healthcare needs. Non- citizens may be eligible for emergency services. 2
CMS 1500 Provider Manual Located on the Medicaid website http://wymedicaid.acs-inc.com Select Provider 3
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CMS 1500 Provider Manual Covered Services Chapter 21 Covered Services - Practitioner Services Section 21.1 Physician and Nurse Practitioner Services Covered services and billing requirements specific to physicians and practitioners 21.7.1 Immunizations WyVIP Private stock Administration Billing examples 21.17 Public Health Services Definition Non-Covered Services 9
21.7.1 Immunizations Billing Procedures (21.7.1) WyVIP supplied vaccines Private Stock - Privately purchased vaccines WyVIP Supplied Provided free of charge to eligible Medicaid clients 18 years and younger Vaccine reimbursement: $0 reimbursement for vaccine (i.e. TDAP, MMR, influenza, etc.) Bill with vaccine procedure code (90477-90748) and SL modifier (indicates WyVIP) Administration reimbursement: reimburses from fee schedule Bill appropriate vaccine administration code 10
21.7.1 Immunizations Private Stock / Privately Purchased Vaccines (21.7.1) WyVIP was out of stock The vaccine was not supplied through the WyVIP Program Vaccine reimbursement: reimburses at cost (invoice) or from fee schedule, dependent on procedure code and client s age Bill appropriate vaccine procedure code Do not bill with the SL modifier Administration reimbursement: reimburses from fee schedule regardless of how the vaccine was acquired Bill appropriate vaccine administration code Bill usual and customary charges 11
21.7.1 Immunizations Private Stock / Privately Purchased Vaccines (continued) Private Stock Payment Methodology Clients 19 yrs and older / Fee Schedule No invoices required Vaccine procedure codes Influenza (90656 - $15.00, 90658 - $20.00, 90660 - $15.00) Tetanus (90703 - $15.00) MMR (90707 - $15.00) TD (90714 - $15.00) TDAP (90715 - $30.00) Clients 18 yrs and under / Invoice Invoices required (Medicaid Fee Schedule) Vaccine procedure codes same as above Invoices required / Invoice All other vaccine codes for any age 12
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Vaccination Administration Codes (18 or younger, with counseling) Administration Codes Ages 0 18 with Face-to-Face Vaccine Counseling CPT Code Description 90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered 90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (list separately in addition to code for primary procedure) For each vaccination given, the first or only component (antigen) is billed using 90460, each additional component/antigen is billed using 90461. Like codes must be combined onto one line with multiple units. 90461 is reimbursed at $0, and is used for tracking purposes only. 18
Administration Code Billing Scenario 1 Eligible client is a 4 year old child which received the influenza vaccine with counseling Administration code billing would look like this: Code Units Billed Charge Reimbursement 90460 1 $21.72 $21.72 Explanation Vaccine Total Components 90460 (first/only component) 90461 (additional components) Influenza 1 1 0 The Influenza vaccine has only 1 component, only 1 unit of 90460 is reported, to indicate the 1 st or only component the client was vaccinated for. 19
Administration Code Billing Scenario 2 Eligible client is a 4 year old child which received an influenza and MMR vaccine with counseling Administration code billing will look like this: Code Units Billed Charge Reimbursement 90460 2 $43.44 $43.44 90461 2 $0.00 $0.00 Explanation The Influenza vaccine has only 1 component, only 1 unit of 90460 is reported, to indicate the 1 st or only component the client was vaccinated for. The MMR vaccine has 3 components, one unit of 90460 is reported to indicate the 1 st component, and 2 units of 90461 are reported to account for the other 2 components of the MMR vaccine. The units are combined on the claim to show 2 units of 90460 (1 st components) and 2 units of 90461 (additional components). 20
Administration Code Billing Scenario 3 Eligible client is a 4 year old child which received an MMR, Varicella, and DTAP-IPV vaccine with counseling Administration code billing will look like this: Code Units Billed Charge Reimbursement 90460 3 $65.16 $65.16 90461 5 $0.00 $0.00 Explanation The MMR vaccine has 3 components, one unit of 90460 is reported to indicate the 1 st component, and 2 units of 90461 are reported to account for the other 2 components of the MMR vaccine. The varicella vaccine has only 1 component, one unit of 90460 is reported to indicate the 1 st /only component. The DTAP-IPV vaccine has 4 components, one unit of 90460 is reported to indicate the 1 st component, and 3 units of 90461 are reported to account for the other 3 components of the DTAP-IPV vaccine. The units are combined on the claim to show 3 units of 90460 (1 st components) and 5 units of 90461 (additional components). 21
Vaccination Administration Codes (19 or older, no counseling provided) Administration Codes Face-to-Face Vaccine Counseling Not Provided CPT Code 90471 90472 90473 90474 Description Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injection); one vaccine (single or combination vaccine/toxoid) Do not report in conjunction with 90473. Each additional vaccine (single or combination vaccine/toxoid). List separately in addition to code for primary procedure (90471 or 90473). Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) Do not report with 90471. Each additional vaccine (single or combination vaccine/toxoid). List separately in addition to code for primary procedure (90471 or 90473). For vaccinations where face-to-face counseling is not provided, 90471 or 90473 is reported for the first vaccine, and 90472 or 90474 (units combined for multiples) for each additional vaccine. 22
Common Claim Denial Reasons Claim submitted on paper As of July 1, 2015 all claims must be submitted electronically. Not submitting attachments two ways to send attachments Electronically attachments can be submitted by using the Secure Web Portal. You do not have to submit claims through the web portal in order to utilize this option. The Attachment Control Number must be filled in and match the attachment control number put on the claim. By Mail- when mailing in your attachments you must include the Attachment Cover Sheet. This can be found on the Medicaid Website under Forms. The Attachment Control Number must be filled in and match the attachment control number put on the claim. Facility or Treating Provider are not enrolled in Wyoming Medicaid. Both facility and treating providers must be actively enrolled with Wyoming Medicaid in order to bill for services rendered. Billing with Medicaid Provider number instead of NPI. Must always bill using your NPI number. 23
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Important Web Resources Wyoming Medicaid http://wymedicaid.acs-inc.com Medicaid provider manuals fee schedule Contact Us IVR Navigation Tips Secured Provider Web Portal Remittance Advice Claims Submission LT101 Inquiry 25
Questions? 26