View
1
Download
0
Category
Preview:
Citation preview
Rules 16 & 18 UpdatesEffective 1/1/2020
Payer’s Presentation
RULE 16
CERTIFIED MEDICAL INTERPRETER
Rule 16-2:
Certified by the Certification Commission for Healthcare Interpreters or the National Board of Certification for Medical Interpreters.
CCHI CERTIFICATION REQUIREMENTS
4
To apply for certification, a candidate must:
● Have a high school diploma;● Demonstrate dual language proficiency; ● Complete 40 hours of training;
Core CHITM written exam (available starting November 14, 2019);
CHITM oral exam (available throughout December 2019 for Spanish, Arabic and Mandarin).
USE OF AN INTERPRETERRule 18-7(H)
Qualified interpreter must be provided on-site or via video or audio remote service:
• Complex medical treatment
• Behavioral health
• Otherwise requested by the injured worker
USE OF AN INTERPRETERRule 18-7(H)
Qualified interpreter:
• A Certified Medical Interpreter, if available for the language; or• Fluent in English and the target language, knows medical and legal
terminology, and health care interpreting ethics and standards of practice.
• No family members or friends, especially minor children, except in an emergency.
USE OF AN INTERPRETERRule 18-7(H)
Qualified interpreter:
• Rates and terms shall be negotiated;
• Prior authorization required, except for emergency treatment;
• Interpreter bills DOWC Z0722
REFERRALS
Rule 16-3(A)(4)(b):
All non-physician providers must have a referral from a physician provider managing the claim or NP/PA working under that physician provider.
REFERRALS
Rule 16-3(A)(4)(a):
A payer or employer shall not redirect or alter the scope of an ATP’s referral to another provider for treatment or evaluation of a compensable injury.
NP/PA UPDATES
10
• Defer to the Colorado Medical Practice Act and the Colorado Nurse Practice Act regarding any required supervision. Only work restrictions and time off information require physician signature.
• Just as PAs, NPs now can become Level I accredited (HB 1105) and be paid 100% of the fee schedule (Rule 18-5(A)).
16-4 Recommendation for Treatment or Modality
Example above is from Low Back Pain MTG, Exhibit Page 42.
16-9(A)(5) Required Billing Forms, Codes, and Procedures
Injured Worker mileage: ○ 120 days to file (unless good cause exists)○ 30 days to reimburse
Injured workers and Interpreters may submit invoices
18-4(A) Maximum Allowances
▪ Negotiate a provider’s travel expenses to a rural area to serve an injured worker NOT addressed in the fee schedule
▪ This reimbursement is in addition to the maximum allowance for medical treatment.
18-4(A)(1) Conversion Factors
Anesthesia $46.50/RVU
Evaluation & Management (E&M) $56.00/RVU
Surgery / Radiology / Pathology / Medicine$70.00/RVU
Physical Medicine and Rehabilitation $47.00/RVU(Includes Medical Nutrition Therapy and Acupuncture)
18-4(E) Radiology
Z9999ALL MRI, CTs, and Nuclear Medicine
Reimburse at:
18-4(B) E&MExhibit #7
▪ Improved language for clarity and time based E&M’s
▪ Qualitative vs Quantitative Documentation
Review of Systems▪ Bullet Counting / Totalling Removed▪ Document those pertinent to the
Injury▪ Added
▫ “Gait” and “Station” to Assessments
▫ “Less than anticipated or worsening” under diagnosis
▪ Overall MDM Highest 2 out of 3 categories
16
18-4(B) E&MExhibit #7 Auditing Form
Level of Service based on
Time Key Components
18-4(F) Pathology
MANUAL THERAPYRule 18-4(G)(4)(b)
▪ Osteopathic Manipulative Treatment and Chiropractic Manipulative Treatment includes manual therapy, unless the provider performs manual therapy in a separate region.
▪ The new language is consistent with CPT® Assistant.
19
8-Minute Rule
8-22 Minutes 1 Unit
23-37 minutes 2 Units
38-52 minutes 3 Units
53-67 minutes 4 Units
68-82 minutes 5 Units
83 minutes 6 Units
8-Minute Rule Example
Example 1 Time Units Rule of 8
97712 Neuromuscular Reeducation
24 2 2
97110 Therapeutic Exercise 23 2 1
Total 47 4 3
Example 2 Time Units Rule of 8
97712 Neuromuscular Reeducation
20 1 2
97110 Therapeutic Exercise 20 1 1
Total 40 2 3
18-4(G)(5) Psychiatric / Psychological Services
•Incorporated 2019 CPT ® Codes for psychological and neuropsychological services
•RVU values in Rule 18
Intraoperative Neurophysiology Monitoring
Rule 18-4(G)(8)(c):
Fee schedule value for CPT® 95941 is equal to fee schedule value for CPT® 95940.
18-4(H)(10) - Gym Memberships
18-4(I) Telemedicine
Providers can use:
Appendix P
Division Z-Codes (when appropriate)
G0459, G0508, and G0509
Additional services may be provided via telemedicine WITH prior authorization (beyond Appendix P)
Medicare Long Term Care Hospitals (MLTCHs)
Rule 18-5(A)(2)(c):
• Reimbursed $3,350 per day, not to exceed 75% of total billed charges.
• If total billed charges exceed $300,000, reimbursement is 75% of billed charges.
• Total length of stay = count the date of admission, not the date of discharge.
Medicare Long Term Care Hospitals (MLTCHs)
Rule 18-5(A)(2)(c):
All charges shall be submitted on a final bill, unless the parties agree on interim billing. The rate in effect on the last date of service covered by an interim or a final bill shall determine payment.
Outpatient Billing
#1 Highest Valued APC = 100% of Exhibit #4 Rate#2 Next APC - 50% of Exhibit #4 Rate#3 Next APC - 50% of Exhibit #4 Rate#4 Next APC - 50% of Exhibit #4 Rate
Separately payable per 18-5(B)(5):Pass through drugs and biologicals (codes with status indicators G, H,or K) Brachytherapy (codes with status indicator U)ED visits or Consultations (codes with status indicator V)
28
18-5(A) Inpatient Hospital Facility Fees
▪ Outlier’s “Difference”: If > $26,994
18-6(A) DMEPOS Reimbursement
Take home supplies under $50 w/o InvoiceUse A9300
18-6(B) Home Care Services
Travel - Z0773
✔ Typically included in the fees listed
✔ Travel time > 1 hour shall be reimbursed (one-way)
✔ Fee shall be agreed upon at the time of prior authorization and shall not exceed $34.68 per hour.
Mileage - Z0772✔ Agree upon travel
allowances ✔ Mileage rate
should not exceed $0.53 per mile, portal to portal.
18-6(C) Drugs and Medications
Opioids / Scheduled controlled substances that are prescribed for treatment lasting longer than 3 days shall be provided through a pharmacy.
18-6(C) Use of CMS-1500 Physician Dispensed Medications
Field 19 03DY = 3 days supply Field 24G 12UN = 12 tablets
33
18-9(A) Opioid Management
▪ Risk & misuse evaluations
▪ Ordering drug tests▪ Checking PDMP results▪ Codes and maximum fees are payable to the
prescribing ATP for a written report
18-7(G) Physician’s Report of WC Injury (WC 164)
MFS Workbooks
▪ Found on the Fee Schedule Pagehttps://www.colorado.gov/pacific/cdle/workers-compensation-proposed-and-adopted-rules
▪ MFS Workbook Review: ▫ Code Look Up▫ Exhibits▫ Division Codes / Adjusted RVUs (Formerly
Exhibit #9)
16-9(E) Proof of Timely Filing
37
❖ EOR states bill was not received within a 120 days and a denial for timely filing was received:➢ Proof of receipt➢ EDI (Electronic submission
of bill) requires confirmation of acceptance from payer.
➢ Certificate of Mailing ➢ Fax requires a
confirmation of receipt➢ Certified Mail
16-9(E) Proof of Timely Filing
Timely filing issues will be considered final 10 months from the date of service, unless extenuating circumstances exist.
Appealing Billed / Service Denials
● Corrected Claim versus an Appeal
● Medical Reasons: requires a physician review
● Non-Medical Reasons: does not involve reviewing medical records
● Clear & Persuasive
Medical Dispute Resolution (MDR) Process
Who’s Who?Rule 16-11(A)(1)(i)
▪ EOBs - “Missing” Information: ▫ Who to contact if disputed?▫ Who is the “real” Carrier (Payer), even if
being processed by a TPA.▫ If a carrier switches TPAs, how would the
Division know or be notified?
▪ Example Direct claim disputes to XXXX, at the following; XXXX, Phone: XXX-XXX-XXXX
41
Interest Required$(amount due) x .08 x (days late) divided by 365 = $(interest) rounded to the nearest penny
Interest Not Required
Notification vs Prior Auth
Treatment is divided into two categories:
44
Notification
45
Within means: 5 days to respond
Prior Authorization
Outside means: 7 days to respond
46
Q&A
Medical Policy Fee Schedule Team
● Medical Billing Dispute Resolution Process Specialist
● colleena.blakeman@state.co.us
● 303-318-8765
3 Colleena Blakeman
● Medical Billing Dispute Resolution Process Specialist
● nina.fresquez@state.co.us
● 303-318-8766
4 Nina Fresquez
● Manager, Medical Services
● christy.culkin@state.co.us
● 303-318-8668
1 Christy Culkin, CPC
2 ● Policy and Regulatory Specialist
● mariya.cassin@state.co.us
● 303-318-8762
Mariya Cassin, JD, CPC-A
Recommended