Provider Policy & Procedure Manual E m

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Employer Provider Network, Inc (EPNI)

Provider Policy & Procedure Manual

CPT codes copyright 2014 American Medical Association. All Rights Reserved. CPT is a trademark of the AMA.

Summary of Changes (2014) Chapter 1 – At Your Service Date

4/22/14

Page(s)

1-5 to 1-8

Summary of Change

Care Management Contact Information table was updated with current phone and fax numbers.

Chapter 2 – Provider Agreements Date

Page(s)

Summary of Change

Chapter 3 – Health Care Improvement Date

Page(s)

Summary of Change

Chapter 4 – Care Management Date

4/22/14

5/12/14

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4-33

Summary of Change

Plan-of-Care Review Procedure topic:  Removed reference to MCS and made it more generic.

all

Updated manual to reflect changes made in Blue Cross Manual. Updated UM information.

4-14, 19, 20, 22, 25, 26, 27, 30, 31, 32, 45

References to the Pre-Authorization Request Form updated and CCStpa hyperlinks added throughout chapter.

Chapter 5 – TRICARE Date

Page(s)

Summary of Change

Chapter 6 – Claims Filing Date

Page(s)

EPNI Manual (05/12/14)

Summary of Change

1

Summary of Changes (2014)

Chapter 7 – Reimbursement Reconciliation Date

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Summary of Change

Chapter 8 –Appeals Date

Page(s)

Summary of Change

Chapter 9 – Coding Policies and Guidelines Date

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Summary of Change

Chapter 10 – Template Policies and Procedures Date

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Summary of Change

EPNI Manual (05/12/14)

Chapter 1

At Your Service Table of Contents Introduction................................................................................................................................ 1-2 Provider Policy and Procedure Manual ................................................................................. 1-2 EPNI Overview...................................................................................................................... 1-2 CPT Copyright..................................................................................................................... 1-2 How to Contact Us ..................................................................................................................... 1-3 Provider Services ................................................................................................................... 1-3 Provider Inquiry / Appeal Form............................................................................................. 1-4 General Address..................................................................................................................... 1-4 Claims Address ...................................................................................................................... 1-5 Care Management Numbers and Addresses .......................................................................... 1-5 Other Numbers and Addresses............................................................................................... 1-8 ID Cards...................................................................................................................................... 1-9 Introduction............................................................................................................................ 1-9 ID Cards ................................................................................................................................. 1-9 Helpful Tips ......................................................................................................................... 1-10 Electronic Commerce .............................................................................................................. 1-11 Overview.............................................................................................................................. 1-11 Electronic Transactions........................................................................................................ 1-11 Electronic Data Interchange (EDI) Guidelines .................................................................... 1-11 Provider Communications ...................................................................................................... 1-12

EPNI Provider Policy and Procedure Manual (04/22/14)

1-1

At Your Service

Introduction Provider Policy and Procedure Manual

Employer Provider Network, Inc. (EPNI) developed the Provider Policy and Procedure Manual for participating health care providers and your business office staff. The manual provides information about our claims filing procedures, payment, provider agreements, managed care requirements, communications, and other topics that affect patient accounts and patient relations. As our policies and procedures change, we will keep you updated through Provider Bulletins, Quick Points, and the Provider Press, found on our website at www.ccstpa.com. Information in this manual is a general outline but is part of your provider contract. Provider and member contracts determine benefits.

EPNI Overview

EPNI is a general business corporation which contracts with health care providers to establish open access and managed care networks for third party administrators, such as Comprehensive Care Services, Inc. (CCStpa).

CPT Copyright

CPT codes copyright 2010 American Medical Association. All Rights Reserved. CPT is a trademark of the AMA. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

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EPNI Provider Policy and Procedure Manual (04/22/14)

At Your Service

How to Contact Us Provider Services

A conversation with one of our service representatives often can solve a problem immediately or give you an answer to a claims question. The representatives answering the provider services numbers are available to assist you: 

Monday – Thursday ..........8:00 a.m. – 5:00 p.m. CT

 Friday ................................9:00 a.m. – 5:00 p.m. CT In an industry that is constantly changing, ongoing education of our provider services representatives is necessary. To meet this challenge, we conduct staff training every Friday morning from 8:00 - 9:00 a.m. Please have your provider number and if applicable, the member’s identification number, account number, and claim number ready when you call. The provider services telephone numbers listed are for the provider’s use only. Please refer members to the customer service telephone number on the back of their member ID card. The general provider services phone numbers are: (651) 662-5940 (Twin Cities area) and 1-800-365-2735 (toll-free). Listen for the current phone options when you call. The general provider services fax number is (651) 662-1533.

EPNI Provider Policy and Procedure Manual (04/22/14)

1-3

At Your Service

Provider Inquiry / Appeal Form

The Provider Inquiry and the AUC Appeal forms are designed for providers to fax or mail inquiries and appeals to EPNI. Fax the form to the number listed on the form or mail it to the general EPNI address. All the fields are required to be completed, if applicable. Make sure to clearly state the contact name, phone number, and fax number on all correspondence. 

Inquiries The inquiries can be an adjustment request or claim status request. The form will not be returned to you unless we need clarification on your request. All adjustments that are completed will be found on a future Remittance Advice.



Appeals You will receive written notification if your request is denied. All adjustments that are completed will be found on a future Remittance Advice. A sample of the Provider Inquiry form can be found at: ccstpa.com. The AUC Appeal form can be found at: www.health.state.mn.us/auc/index.html

General Address

The general address is: Employer Provider Network, Inc. P.O. Box 64560 St. Paul, MN 55164-0560 Inquiries and appeals should be mailed to this address.

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EPNI Provider Policy and Procedure Manual (04/22/14)

At Your Service

Claims Address

Submit claims electronically whenever possible. All participating providers are required to electronically submit all claims. Paper claims submitted by the provider will be rejected and will need to be resubmitted electronically. EPNI will not consider such paper claims to have been received until resubmitted electronically. If mailing a scannable claim form, please use the address listed below: Employer Provider Network, Inc. Claims P.O. Box 64338 St. Paul, MN 55164-0338

Care Management Numbers and Addresses

The phone numbers, fax numbers and addresses for care management programs and services are listed below. The most current pre-authorization/pre-certification list and current medical policies are located ccstpa.com under “For Providers”. Additional review guidelines are also found in chapter four of this manual, Care Management. Providers can also contact Provider Services at (651) 662-5940 (Twin Cities area) or 1-800-365-2735 (toll-free). for assistance. Area

Phone/Fax Numbers and Addresses

Case Management

1-866-489-6947

Disease Management

1-866-489-6947

Prenatal Support

1-866-938-9743

Preadmission Notification (PAN) PANs should be submitted on Provider self-service

Provider self-service: www.availity.com

General inquiries:

Phone: 1-866-938-9741 Fax: 1-866-938-9754

Behavioral Health Review (Outpatient)

Fax: (651) 662-0854 Mail: Integrated Health Management Behavioral Health, R472 P.O. Box 64265 St. Paul, MN 55164-0265

Behavioral Health Review (Inpatient) EPNI Provider Policy and Procedure Manual (04/22/14)

Phone: 1-866-938-9741 Fax:

1-866-938-9754 1-5

At Your Service

Area

Phone/Fax Numbers and Addresses

Chiropractic Review

Fax: (651) 662-7816 Mail to: Integrated Health Management Allied Team, R472 P.O. Box 64265 St. Paul, MN 55164-0265

Medical Dental Review

Fax: (651) 662-2810

Pre-service requests can be mailed or faxed

Mail: Integrated Health Management Utilization Management, R472 P.O. Box 64265 St. Paul, MN 55164-0265

Durable Medical Equipment Review

Fax: (651) 662-2810

Pre-service requests can be mailed or faxed

Home Care Review  Home Health Services  Home Infusion Services  Hospice Care Pre-service requests can be mailed or faxed Inpatient Admission Pre-Certification Review

Mail: Integrated Health Management Utilization Management, R472 P.O. Box 64265 St. Paul, MN 55164-0265 Fax: (651) 662-1004 Mail: Integrated Health Management Allied Team, R472 P.O. Box 64265 St. Paul, MN 55164-0265 Phone: 1-866-938-9741 Fax: 1-866-938-9754

For medical and behavioral health related inpatient admissions Pre-certification requests can be submitted via fax or phone

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EPNI Provider Policy and Procedure Manual (04/22/14)

At Your Service

Phone/Fax Numbers and Addresses

Area

Care Management Numbers and Addresses (continued)

Outpatient Therapy Review (PT, OT, SLP) 

Pre-service requests can be mailed or faxed

Fax: (651) 662-7816 Mail: Integrated Health Management Allied Team, R472 P.O. Box 64265 St. Paul, MN 55164-0265

Skilled Nursing Facility Admission Review

Fax: (651) 662-1004

Transplant Review

Fax: (651) 662-1624

Pre-service requests can be mailed or faxed

Mail: Integrated Health Management Transplant Team, R472 P.O. Box 64265 St. Paul, MN 55164-0265

All Other Medical Procedure Review

Fax: (651) 662-2810

Pre-service requests can be mailed or faxed

EPNI Provider Policy and Procedure Manual (04/22/14)

Mail: Integrated Health Management Utilization Management, R472 P.O. Box 64265 St. Paul, MN 55164-0265

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At Your Service

Other Numbers and Addresses

These phone numbers, fax numbers and addresses may be helpful to you.

Company

Phone Number

Address

Delta Dental of Minnesota

(651) 406-5900 or 1-800-328-1188 Fax: (651) 406-5934

Delta Dental 3560 Delta Dental Drive Eagan, MN 55122

USAble Life

(651) 662-5065 1-800-859-2144

USAble Life 3535 Blue Cross Road P.O. Box 64193 St. Paul, MN 55164-9828

Prime Therapeutics, LLC.

(651) 286-4000 or 1-800-858-0723

Prime Therapeutics 1020 Discovery Rd. Eagan, MN 55121

Customer Service

Refer the member to their customer service number printed on the back of their ID card. They may also call (651) 662-5425 or 1-866-356-2425 (toll-free).

Fraud Hot Line

(651) 662-8363 or 1-800-382-2000 ext. 28363

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EPNI Provider Policy and Procedure Manual (04/22/14)

At Your Service

ID Cards Introduction

ID Cards

Your patient’s ID card contains information that is essential for claims processing. We recommend that you look at the patient’s ID card at every visit and have a current copy of the front and back of the card on file. Some of the following information is found on the ID card: 

Name of the plan



Member’s ID number including alpha prefix



Member’s name and group number



Primary care clinic (PCC) name - for managed care plans only



EPNI plan code



Prescription coverage



Copay for prescription drugs



Copay for office visits



Dependent-coverage indicator



Claims submission information

Note: Workers’ Compensation - The Minnesota Department of Labor and Industry requires the use of Social Security numbers for anyone who has ever filed a work comp claim.

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At Your Service

Helpful Tips

1-10

EPNI plans have the option of creating identifiers with any combination of up to 14 letters or digits following the three digit alpha prefix. 

Verify the identity of EPNI cardholders by asking for additional picture identification. If you suspect fraudulent use of an ID card, please call our fraud hot line at (651) 662-8363. You may remain anonymous.



Ask members for their current ID card and regularly obtain new photocopies (front and back). Having the current card will enable you to submit claims with the appropriate member information and avoid unnecessary claims payment delays.



Check eligibility and benefits by calling (651) 662-5940 or 1-800-365-2735.



If the member presents a debit card be sure to verify the copayment amount before processing payments.



Do not use the card to process full payment up front. If you have questions about the debit card processing instructions or payment issues, please contact the toll-free debit card administrator’s number on the back of the card.

EPNI Provider Policy and Procedure Manual (04/22/14)

At Your Service

Electronic Commerce Overview

An important part of EPNI’s cost containment strategy is automating the electronic exchange of information.

Electronic Transactions

Electronic transactions option includes the submission of the following HIPAA compliant transactions: 

Healthcare Electronic claim submission (837 P and I)



Healthcare Electronic remittance advice (835)



Healthcare Benefit request and response (270/271)



Healthcare Claims status request and response (276/277)



Healthcare Service review- Request for review and response (278) EPNI uses Availity for exchanging HIPAA mandated EDI transactions. You can get information on how to register and conduct electronic transactions through Availity by going to availity.com. Electronic Data Interchange (EDI) Guidelines



Minnesota Statute 62J.536 requires all Minnesota providers to submit claims electronically to Minnesota group purchasers. In addition, participating out-of-state providers are required by contract to submit all claims electronically.



All nonparticipating, out-of-state providers who do not have electronic claim submission capabilities must submit claims on an optical character recognition scannable claim form.



EPNI reserve the right to modify these guidelines with advance written notice.



Providers are encouraged to obtain or develop EDI transaction software from the many sources available.

EPNI Provider Policy and Procedure Manual (04/22/14)

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At Your Service

Provider Communications Provider Communications

1-12

EPNI publishes the following communications for providers. Title

Description

Provider Bulletins

EPNI communicates immediate policy and procedure changes through Provider Bulletins. The Provider Bulletins are contractually binding. Portions of this manual will also be updated periodically to reflect policy and procedure changes.

Provider Information Quick Points

This is a communication tool that we are using to get helpful information to you.

Medical Policy Update

This update is included as part of the Provider Press on a quarterly basis. The update contains a summary of medical technologies that have been reviewed, revised, or are new to EPNI’s investigative list. Prior Authorization Request requirements are also indicated in this publication.

EPNI Provider Policy and Procedure Manual (04/22/14)

Chapter 2

Provider Service Agreements Table of Contents Participation and Responsibilities ............................................................................................ 2-2 Advantages of Participation................................................................................................... 2-2 Responsibilities of Participating Providers............................................................................ 2-2 Requirements of Minnesota Law ........................................................................................... 2-5 EPNI’s Responsibilities ......................................................................................................... 2-5 Written Notification and Provider Liability........................................................................... 2-6 Credentialing .............................................................................................................................. 2-7 Overview................................................................................................................................ 2-7 Provider Numbers .................................................................................................................. 2-7 National Provider Identifier (NPI) ......................................................................................... 2-7 Overview................................................................................................................................ 2-8 Credentialing Requirements and Processes ........................................................................... 2-8 Provider Questions and Answers ......................................................................................... 2-10 Accounting for Disclosure Request ........................................................................................ 2-25 Guidelines for the Accounting Disclosure Request ............................................................. 2-25 When to Use the Form ......................................................................................................... 2-25 Disclosures Related to Provider’s Status as a Business Associate ...................................... 2-26 Carrier Replacement Law....................................................................................................... 2-27 Carrier Replacement ............................................................................................................ 2-27 How Carrier Replacement Works........................................................................................ 2-27 Continuous Stay ................................................................................................................... 2-27 Self-Funded Groups ............................................................................................................. 2-27 Governmental and Compliance Required Provisions .......................................................... 2-28 Overview.............................................................................................................................. 2-28 Governmental Required Definitions .................................................................................... 2-28 Compliance with Laws ........................................................................................................ 2-29 HIPAA Requirements .......................................................................................................... 2-31 Non-Interference .................................................................................................................. 2-35 Network Access Agreements............................................................................................... 2-36 Termination of Provider Service Agreements....................................................................... 2-37 Required Notification........................................................................................................... 2-37

EPNI Provider Policy and Procedure Manual (05/10/13)

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Provider Service Agreements

Participation and Responsibilities Advantages of Participation

Responsibilities of Participating Providers

2-2

Advantages of being an Employer Provider Network, Inc. (EPNI) participating provider include: •

Direct payment from EPNI reduces administrative expense and improves cash flow



EPNI Subscribers have financial incentives to use participating providers



Participating providers’ names are included in directories that EPNI publishes for its Subscribers



EPNI Provider Service Agreements do not contain exclusivity clauses that prohibit providers from participating with other health plans



Participating providers receive a Statement of Provider Claims Paid or electronic 835 remittance explaining how claims are processed



Opportunity to attend provider seminars offered free of charge by EPNI



Dedicated service staff available to assist participating providers



Electronic options such as provider web self-service to obtain information

Responsibilities of being a participating provider include: •

Participating providers are required to electronically submit all claims. Paper claims will be rejected and will need to be submitted electronically. EPNI will not consider such paper claims to have been received until resubmitted electronically.



Participating in the EPNI credentialing process.



Participating in EPNI managed care programs.

EPNI Provider Policy and Procedure Manual (05/10/13)

Provider Service Agreements

Responsibilities of Participating Providers (continued)



Submitting preadmission notifications (PANs) or prior authorizations or Pre-certifications when required. PANs may be submitted through provider web self-service or faxed to 1866-938-9754.



Referring Subscribers to other participating EPNI providers and facilities.



Accepting payment provisions outlined in the Provider Service Agreement. If EPNI determines that Health Services are experimental, investigative, or not Medically Necessary, providers may not bill the Subscriber unless the provider gives the Subscriber written notification of non-coverage immediately before the Health Services are performed.



Notifying EPNI of new programs prior to implementation (i.e., technology, new procedures being performed).



Maintaining confidentiality of EPNI's contractual and financial arrangements. Health Services rendered by all providers must be within the scope of the provider’s registration, license, and training and consistent with community standards for quality and utilization. •

Agreeing not to bill EPNI for any professional services provided by Health Care Professionals to themselves, their immediate family members or those living in the same household. Immediate family members include the Health Care Professional's spouse, children, parents or siblings.



Agreeing not to bill Subscribers for missed scheduled appointments except for missing a scheduled behavioral health appointment, provided the provider has notified the Subscriber in writing in advance that this is the provider's policy.

EPNI Provider Policy and Procedure Manual (05/10/13)

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Provider Service Agreements

Responsibilities of Participating Providers (continued)

2-4



Promptly furnishing at the provider’s own expense any additional information that EPNI or the Plan Sponsor shall reasonably request as necessary to respond to claims, utilization review, coordination of benefits, quality improvement and care management review, and medical abstract reports. The provider shall be responsible for obtaining any authorization required to release such information to EPNI or the Plan Sponsor.



Collecting appropriate copayment amounts and not waive these amounts, in accordance with applicable law.



Billing the Subscribers for services listed as exclusions in the Subscriber Contract.



Participating providers may not collect any difference between the amount billed and EPNI’s allowance for covered Health Services, except for Subscriber liabilities such as deductibles and copayment amounts.



Charging the general public the same amounts as EPNI Subscribers (individual hardship cases are an exception).



Billing only for Health Services personally performed by Provider's medical staff or other Health Care Professionals employed by Provider or a facility that meet the eligibility criteria defined by EPNI.

EPNI Provider Policy and Procedure Manual (05/10/13)

Provider Service Agreements

Requirements of Minnesota Law

EPNI’s Responsibilities

Minnesota law requires participating providers to look to EPNI for payment of Health Services covered by the Subscriber Contract. Following are requirements: •

Except for copayments, deductibles and coinsurance amounts, providers may not bill Subscribers for Health Services covered by their EPNI health plan until EPNI has completed processing of the claim or adjustment.



Providers may not refer a Subscriber's account to collection for nonpayment of Health Services covered by the EPNI health plan. Copayments, coinsurance and deductibles can be coordinated through Provider's normal billing, and if applicable, its collections process.



Interest on Health Services covered by EPNI may not be applied to a Subscriber's account.



Effective August 1, 2010, Minnesota Statute [62Q.751] allows: •

Providers may collect deductibles and coinsurance from Subscribers at or prior to the time of service.



Providers may not withhold a service to a Subscriber based on a Subscriber's failure to pay a deductible or coinsurance at or prior to the time of service.



Overpayments by Subscribers to providers must be returned to the Subscriber by the provider by check or electronic payment within 30 days of the date in which the claim adjudication is received by the provider.

EPNI’s responsibilities include the following: •

Make payment directly to participating providers for covered Health Services, respond to inquiries and resolve claims in a timely manner



Maintaining confidentiality of a provider’s charge data in accordance with the terms of the Provider Service Agreement



Establishing a peer-review process to make decisions about Medical Necessity



Keeping Subscribers informed of participating providers through publication of directories



Keeping providers informed of changes which are contractually binding through Provider Bulletins or other communications (e.g. Provider Policy & Procedure Manual)

EPNI Provider Policy and Procedure Manual (05/10/13)

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Provider Service Agreements

Written Notification and Provider Liability

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If it is necessary to recommend that a Subscriber see a nonparticipating provider, the participating provider must give the Subscriber advance, written notification that the recommendation is to a nonparticipating provider. Once notice is given, the Subscriber is responsible for any increased liability if he or she decides to schedule the service. If a Subscriber is not properly informed, the provider making the recommendation to a nonparticipating provider will be liable for increased costs that a Subscriber incurs. Please refer to Waivers in Chapter 4.

EPNI Provider Policy and Procedure Manual (05/10/13)

Provider Service Agreements

Credentialing Overview

EPNI works with many different types of providers through its Provider Service Agreements to establish networks of participating providers.

Provider Numbers

Contracting provider numbers are assigned to providers for contracting purposes. Atypical providers must use this number for billing as well. Other providers will use their NPI for billing. In addition, individual provider numbers are assigned to atypical practitioners to identify which individual performed specific services. All other providers will use their NPI for billing. Each practitioner’s service must be within the scope of their registration, license, training and consistent with community standards for quality and utilization.

National Provider Identifier (NPI)

The Health Insurance Portability and Accounting ActAdministrative Simplification (HIPAA-AS) is the result of legislation passed by the U.S. Congress. The legislation mandates standards for business to business electronic data interchange and code sets, establishes uniform heath care identifiers and seeks protection for the privacy and security of patient data. As it pertains to uniform health care identifiers, the Department of Health and Human Services (DHHS) published the final ruling for the implementation of the National Provider Identifier (NPI) on January 23, 2004. The NPI is a unique all numeric 10 digit number that is assigned by the Centers for Medicare & Medicaid Services (CMS). The NPI replaces all payer assigned providers identifiers, individual and facility, and will be the single provider identifier with which you do business. The purpose of implementing the NPI is to improve the efficiency and effectiveness of the health care system by reducing the number of identifiers associated with any specific provider or provider facility. Implementation will simplify provider identification and billing processes across multiple third party payers (including government programs) and prevent fraud and abuse. Providers who are covered entities (as defined by HIPAA) began applying for NPIs on May 23, 2005, the effective date of the final rule. NPIs must be used solely by providers, clearinghouses and payers as a means to identify provider covered entities. To register on-line or to find the NPI paper application form, access the CMS website at http://nppes.cms.hhs.gov. It is a provider's responsibility to report its NPI to payers.

EPNI Provider Policy and Procedure Manual (05/10/13)

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Provider Service Agreements

Overview

EPNI uses a credentialing process to provide Subscribers with a selection of Providers and Health Care Professionals which have demonstrated backgrounds consistent with the delivery of high quality, cost-effective health care. The credentialing criteria that EPNI has established serve as the foundation for determining eligibility in all EPNI networks. Providers and Health Care Professionals are expected to remain in compliance with credentialing criteria at all times.

Credentialing Requirements and Processes

To learn more about credentialing requirements and processes, please reference the Credentialing and Recredentialing Policy Manual, available at CCStpa.com. Credentialing requirements include, but are not limited to the following:

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EPNI may require credentialing no less than every three years. Recredentialing may occur as often as EPNI determines necessary. Providers may appeal adverse credentialing or recredentialing decisions through EPNI's established appeal process as specified in the Credentialing and Recredentialing Policy Manual.



In the event one or more of Provider’s Health Care Professionals are excluded from participation with EPNI, because he or she has not met the credentialing standards of EPNI or because EPNI has terminated or suspended the Health Care Professional as provided for in the Provider Service Agreement, that Health Care Professional will be treated as a nonparticipating provider by EPNI. Provider agrees to provide prior written notice to any Subscriber receiving treatment from such Health Care Professional that he or she is nonparticipating. If such notice is not provided, neither Provider nor Provider’s nonparticipating Health Care Professional may collect from the Subscriber more than the amount allowed by EPNI. Provider further agrees to be responsible for any applicable nonparticipating penalty payments required in Subscriber Contracts and to hold Subscriber harmless for these payments in such circumstances. Either the affected Health Care Professional or the Provider, on behalf of the affected Health Care Professional, may appeal a suspension or for cause termination as specified in the Credentialing and Recredentialing Policy Manual. This provision shall survive termination of this Agreement.

EPNI Provider Policy and Procedure Manual (05/10/13)

Provider Service Agreements

Credentialing Requirements and Processes (continued)



Some participating Health Care Professionals are exempt from EPNI's credentialing and recredentialing process unless a potential quality of care issue arises, at which time EPNI will undertake a standard credentialing or recredentialing process. In all cases, Provider is responsible for verification that Health Care Professionals hold and maintain (a) a current and unrestricted license, registration, or certification appropriate to their practice; and (b) minimum malpractice coverage appropriate to their scope of practice (not less than $1 million per incident) except to the extent the health care professional is covered by a state or federal Tort Claim Liability statute. The Credentialing and Recredentialing Policy Manual contains a listing of health care professional specialties for which credentialing is required.

Sanctions, Reprimands or Investigations EPNI reserves the right to terminate the Provider Service Agreement upon 30 days' prior written notice to Provider with respect to any Provider or Health Care Professional of a Provider which fails to complete the credentialing or recredentialing process or is sanctioned or reprimanded by any review organization, including but not limited to, any other health insurer or health plan, peer review organization, hospital medical staff or any state licensing board. Providers must immediately notify EPNI in writing of any such sanction or reprimand or any investigation of any Provider or Health Care Professional of which Provider is aware. If the sanction or reprimand is limited to a single Health Care Professional, then the termination shall be effective only to that Health Care Professional.

EPNI Provider Policy and Procedure Manual (05/10/13)

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Provider Service Agreements

Provider Questions and Answers

1. Why is EPNI recredentialing providers? EPNI believes that the credentialing and recredentialing of Health Care Practitioners is an essential step in ensuring that highly qualified Health Care Practitioners treat its Subscribers. This is an important risk management process for EPNI. EPNI feels that the regular monitoring of Health Care Practitioners through the initial and periodic recredentialing process will allow it to ensure that practitioners in its networks are qualified to provide safe and effective care. 2. What do I need to do to be recredentialed? EPNI will send forms that need to be completed about four months in advance of the month that the process must be completed. If Provider has additional questions, call provider services at (651) 662-5200 or toll free at 1-800-262-0820. 3. What forms must I complete? EPNI will send the Health Care Professional a pre-populated credentialing application form that the Health Care Professional will be able to update and fill in missing information. If EPNI is unable to provide the Health Care Professional with a pre-populated credentialing application, the Health Care Professional will be instructed to download the Minnesota Uniform Credentialing Application form that is available by calling provider services. Completed forms may be mailed or faxed. Fax: (651) 662-2905 Mail: EPNI Credentialing Department, R3-11 P.O. Box 64560 St. Paul, MN 55164-0560

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EPNI Provider Policy and Procedure Manual (05/10/13)

Provider Service Agreements

Provider Questions and Answers (continued)

4. How long does the credentialing process take and how will I be notified? It currently takes an average of 45 days to complete the credentialing process. If an application is either incomplete or requires additional research it will take longer. It is critical that all required information is provided on the application, as this will aid in processing time. If the Health Care Professional does not provide all required information, the application will be returned to the Health Care Professional with the missing information highlighted. The application will not be processed until a completed application is returned to EPNI. If EPNI is unable to obtain all required information to complete the credentialing process, it may result in the loss of the Health Care Professional's network participation status. EPNI only notifies Health Care Practitioners when recredentialing is complete if there is an adverse outcome from the recredentialing process. In this situation, the Health Care Professional will be notified in writing within 60 days of the Credentialing Committee’s decision.

EPNI Provider Policy and Procedure Manual (05/10/13)

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Provider Service Agreements

Provider Questions and Answers (continued)

5. What can I do to ensure that my credentialing application is processed in a timely manner? When completing the Minnesota Uniform Credentialing Application form, the following information is often overlooked: •

Minnesota Medicaid ID Number



Explanation of all time gaps in Employment / Practice History greater than three months



Full Employment/Practice History since completion of post graduate training



Complete all fields pertaining to Medical/Graduate/ Professional Education



Complete all fields pertaining to Primary and Other Hospital Affiliations



Date and sign the Authorization and Release



Include a copy of current malpractice liability insurance documentation



Answer all Disclosure Questions, sign, and explain any affirmative responses



Include a legible copy of the Health Care Professional's current DEA registration



Return the completed application promptly. The information is time sensitive

6. What happens if I do not meet your credentialing requirements? As noted, the Health Care Professional will be notified in writing if there is an adverse outcome to the recredentialing process. Included with this notification is an explanation of the Health Care Professional's right to reconsideration of the Credentialing Committee’s decision. If a Credentialing Committee decision is unchanged as a result of the reconsideration process, Health Care Professionals are then notified of their appeal rights, if applicable. Appeal hearing decisions are final.

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EPNI Provider Policy and Procedure Manual (05/10/13)

Provider Service Agreements

Provider Questions and Answers (continued)

7. Who does EPNI credential? EPNI credentials certain Health Care Professionals and provider types: •



Medical Providers: •

Hospitals



Home Health Care



Skilled Nursing Facilities



Ambulatory Surgical Centers (free standing)

Behavior Providers: •







Behavioral Health Institutions (Inpatient, residential or ambulatory settings)

Doctors: •

Physician (M.D., D.O.)



Podiatrist (D.P.M.)



Dentists (D.D.S., D.M.D.)



Chiropractors (D.C.)

Social Workers: •

Licensed Certified Social Worker (L.C.S.W.)



Licensed Clinical Social Worker (L.C.S.W.)



Licensed Independent Clinical Social Worker (L.I.C.S.W.)



Licensed Independent Social Worker (L.I.S.W.)

Counselors: •

Licensed Mental Health Counselor (L.M.H.C.)



Licensed Professional Clinical Counselor (L.P.C.C.)



Licensed Professional Counselor (L.P.C.)

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Provider Service Agreements

Provider Questions and Answers (continued)



Therapists: •





Licensed Marriage and Family Therapist (L.M.F.T.)

Advanced Practice Registered Nurses: •

Certified Nurse Midwife (C.N.M.)



Registered Nurse Clinical Specialist (R.N.C.S., C.N.S.)



Registered Nurse Practitioner (N.P.)

Other Practitioner Types: •

Physician Assistants (P.A.)



Optometrists



Psychologists (M.A., Ph.D., Psy.D.)

• Licensed Acupuncturist (LAc) Note: Health Care Professional titles and abbreviations vary from state to state. Check with appropriate state licensing agencies for specific titles. 8. How often are practitioners routinely recredentialed? Health Care Professionals are recredentialed every three years. They may be recredentialed more frequently as a condition of participation. 9. Are there other situations that result in recredentialing? Yes, credentialing or recredentialing may occur whenever EPNI deems appropriate (e.g., when there are quality of care concerns or when reasonable information has been identified by EPNI that a Subscriber may be endangered by potentially unsafe or unethical care or treatment).

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Provider Questions and Answers (continued)

10. Are there circumstances when practitioners are not credentialed or recredentialed? Yes, the following are examples of situations when credentialing is not required: •

A Health Care Practitioner is currently in approved residency training



A Health Care Practitioner making a first request to take a locum tenens position for 3 months or less



A Health Care Practitioner who provides services that are not covered by EPNI



A Health Care Practitioner not eligible for an EPNI Provider Service Agreement is consequently not credentialed

Health Care Professionals EPNI does not typically credential: •

Audiologist



Certified registered nurse anesthetist (C.R.N.A.)



Licensed Assoc. Counselor (L.A.C.)



Licensed Assoc. Marriage & Family Therapist (L.A.M.F.T.)



Licensed Psychological Practitioner (L.P.P.)



Occupational Therapist (O.T.)



Physical Therapist (P.T.)



Registered Nurse (R.N.)



Registered Nurse First Assistant (R.N.F.A.)



Resident



Social Worker (Levels: L.G.S.W., L.S.W., L.M.S.W., C.S.W., C.I.S.W., C.A.S.W.)



Speech and Language Therapist

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Provider Service Agreements

Provider Questions and Answers (continued)

11. Does EPNI credential hospital-based practitioners? No, hospital-based Health Care Practitioners include pathologists, radiologists, anesthesiologists, (unless practicing pain management) and emergency room physicians. They do not have an independent relationship with EPNI. They work exclusively in the patient setting and provide care only as a result of Subscribers being directed to the inpatient setting for Health Services by the health plan. Exception: All hospital-based behavioral Health Care Professionals listed under the Q&A, “Who do we credential?” are credentialed. 12. Who makes credentialing decisions? Credentialing decisions are made by the Credentialing Committee, which consists of six physicians (including at least one D.O. whenever possible) who also participate in at least one EPNI network. At least one Health Care Practitioner is board-certified in family practice. Two Health Care Practitioner are board-certified in psychiatry, with subspecialties in one of the following areas: child or adolescent psychiatry, or addiction psychiatry. One Health Care Practitioner is board-certified in a surgical specialty. One Health Care Practitioner is board certified in obstetrics and gynecology. Additional voting members of the committee are two nonphysician Health Care Practitioner who are participating in at least one EPNI network and who are licensed or registered to practice a healing art, dentistry or podiatry under Minnesota statutes. Two additional voting members of the committee are EPNI staff.

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Provider Questions and Answers (continued)

13. What are the conditioned actions taken related to adverse practitioner, provider, or delegated credentialing decisions? Actions may reflect an increasing level of severity. Note: These are examples only. •

Increased frequency of recredentialing, site visits, or delegation of a file review



Requirement of a work plan to describe steps to comply with credentialing standards, or if applicable, the terms of a delegation agreement



Continuing education requirements or education by EPNI Staff



Increased frequency of medical record or coding audits by EPNI



Counseling by a peer practitioner, approved by a EPNI medical director or designated provider services director



Formal supervision by a peer



Evaluation by an external peer organization i.e. Health Professionals Services Program (HPSP) or Colorado Personalized Education for Physicians (CPEP)



Participation condition or limitation i.e. practice site, type (group vs. solo), scope of practice



Non-participation



Termination of Provider Contract or delegation agreement

14. When does the Credentialing Committee meet? Meetings occur monthly. Health Care Professional Practitioners' application materials are distributed to committee members one week in advance of the meeting. The medical director reviews complete credentialing applications that do not require additional information on a weekly basis. 15. What are the decision options available to the Credentialing Committee? •

Approve participation (initial credentialing)



Approve continuing participation



Participation with a condition or limitation



Non-participation



Terminate the contract

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Provider Service Agreements

Provider Questions and Answers (continued)

16. How is a practitioner or provider notified about the Credentialing Committee decision? All new practitioners and providers are notified in writing of initial participation decisions. Providers and individual Health Care Practitioners are routinely notified in writing of conditional participation status decisions, including a description of the conditions and reconsideration appeal rights. All Health Care Practitioners /Providers are notified in writing by credentialing staff of any denied credentialing participation decision and appeal rights. Clinic administrators are also notified and are required to facilitate Subscriber transition and proper billing procedures for non-participation status. EPNI staff shall make reasonable efforts to notify the Health Care Practitioner before notifying clinic administrative staff.

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Provider Questions and Answers (continued)

17. What if I do not agree with the Credentialing Committee decision? Health Care Professionals and Providers have the right to request a Reconsideration Appeal according to established policy. To request a Reconsideration Appeal, Health Care Practitioners and Providers must provide EPNI written notice postmarked within 30 days from the date of the conditional, non-participation or termination decision notification letter. The request typically outlines why the appealing Health Care Practitioner or Provider disagrees with the decision and includes new additional information or highlights specific points for reconsideration. Upon receipt of the Health Care Practitioner’s request notice, a Credentialing Committee reconsideration is initiated. The Health Care Practitioner may submit new or additional written information at an upcoming Credentialing Committee meeting. Health Care Professionals are not required to appear in person. Health Care Professionals or Providers may choose to waive individual rights to a Reconsideration Appeal, in which case the appellant may immediately request a hearing before a panel of independent Health Care Practitioners or Providers by requesting such hearing within 30 days of the date of the decision notice letter. If the Health Care Practitioner or Provider chooses to request a Reconsideration Appeal and the Committee upholds its original determination, the Health Care Practitioner also has the right to a hearing before a panel of independent Health Care Practitioners or Providers. The Health Care Practitioner or Provider will be sent a notice regarding the time, date and place of the hearing. At the hearing the Health Care Practitioner or Provider have the following rights: •

A right to representation by an attorney or other person of the Health Care Practitioner's or Provider's choice



To have a record made of the proceedings



To call, examine and cross-examine witnesses



To present relevant evidence determined to be relevant by the appeal panel, regardless of its admissibility in a court of law



To submit a written statement at the close of the hearing

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Provider Service Agreements

Provider Questions and Answers (continued)

17. The Health Care Practitioner or Provider's participation status in the EPNI network may continue pending the outcome of the appeal and hearing process. This is determined on a case-bycase basis by the Credentialing Committee at the time of the decision. If the Health Care Practitioner or Provider chooses not to request a formal appeal of this decision, participating status will end on the date specified in the original notice or if applicable, the conditions will remain. After that date, the Health Care Practitioner will be regarded as non-participating. Details regarding non-participation are conveyed directly to the Health Care Practitioner and clinic administrator. 18. Who are the Appeal Hearing members? Membership consists of two voting external participating Health Care Practitioners or Providers, including one Health Care Practitioner or Provider representing the same or similar specialty area of the appellant, and one EPNI medical director. Each voting member has one vote. The Appeal Hearing’s decision is reached by majority vote. 19. What are the clinic site visit requirements? Prior to contracting with a new EPNI primary care practitioner, OB/GYN, or a potential high-volume behavioral health practitioner, staff conducts a site visit. The site visit includes evaluation of medical record-keeping practices, physical environment, quality improvement structure, access and availability and written clinic policies. Staff evaluates the finding against established criteria and thresholds for compliance and makes a recommendation that is presented to the Credentialing Committee or medical director for review and decision.

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Provider Questions and Answers (continued)

20. What are the site visit requirements for potential highvolume behavioral health practitioners? The criteria for determining a potential high-volume behavioral health practitioner is: •

A psychiatrist or behavioral health professional at the masters level or above who is licensed to practice independently, e.g., a psychologist, social worker or a practitioner who intends to work full-time at a primary practice location with at least two other such practitioners, in any combination. When this criterion is met, the primary practice location must pass the initial site visit. The site visit includes an assessment of access and availability, quality improvement, policies, physical environment and treatment recordkeeping practices.

21. Who do I call if I have questions about credentialing or recredentialing? Call provider services at (651) 662-5200 or 1-800-262-0820. 22. Why did EPNI enact a policy requiring Board Certification? Requiring physicians to be board-certified is consistent with the EPNI purpose to seek partnerships with qualified Health Care Practitioners and Providers committed to delivering quality health care and services to its Subscribers. EPNI Subscribers' expectation is to have consistently trained and educated providers across Minnesota.

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Provider Service Agreements

Provider Questions and Answers (continued)

23. What is the Board Certification policy and when did it go into effect? A Health Care Practitioner's education and training is appropriate, relevant to and consistent with their current scope of practice as demonstrated by completing a residency, fellowship, obtaining board certification or obtaining a Certificate of Added Qualification (CAQ) from a EPNI approved board. a. Physicians requesting network participation after March 15, 2005, must be board-certified or have boards in process. b. Physicians participating in an EPNI network (without any restrictions or conditions on their participation) on March 15, 2005, are deemed to be compliant with this requirement. c. An EPNI -approved board refers to the American Board of Medical Specialties (ABMS) http://www.abms.org/, the American Osteopathic Association http://www.osteopathic.org/index.cfm or the Royal College of Physicians and Surgeons. d. Physicians with specialties that require recertification must comply with the board’s recertification requirements. e. Physicians who have the status of boards in progress must become board certified within six (6) years from the completion date (month/year) of an approved residency program. f. The Credentialing Committee makes the final decision on a case-by-case basis. 24. How will EPNI keep track of board certifications and recertifications? EPNI is fortunate to have sophisticated software capable of tracking credentialing activity. It has the capacity to monitor certification beginning and end dates. In addition, EPNI can review recertification and track the progress toward board certification.

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Provider Service Agreements

Provider Questions and Answers (continued)

25. Will M.D.s and D.O.s who are actively pursuing board certification be allowed to continue to participate with EPNI if the certification process takes longer than six (6) years? Yes, practitioners who are actively pursuing their board certification will be considered on a case-by-case basis by the Credentialing Committee for continued participation if the board certification process takes longer than six years. 26. In some cases foreign-trained physicians may not be eligible for board-certification; will EPNI make exceptions to this policy in these cases? Yes. There may be physicians, trained in foreign countries, who are not eligible for board certification programs through the ABMS or AOA, who will seek participation with EPNI. EPNI does not wish to discourage qualified physicians from joining; therefore, foreign trained physicians who are not eligible for the ABMS or AOA board certification programs will be considered by the Credentialing Committee on a caseby-case basis. The final decision will rest with the EPNI Credentialing Committee. 27. Are there criteria that EPNI considers equivalent to board certification? Yes. In some cases, international graduate physicians who meet the following state licensing eligibility requirements would be exempt from the board certification requirement: Other criteria that EPNI considers equivalent to board certification are the following. •

International graduate physicians licensed in the state of Minnesota and admitted as a permanent immigrant to the United States as a person of exceptional ability in sciences pursuant to the rules of the U.S. Department of Labor.



International graduate physicians licensed in the state of Minnesota and issued a permanent immigrant visa as a person of extraordinary ability pursuant to the rules of the U.S. Department of Labor.



An outstanding professor or researcher and who has a valid license in another country.

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Provider Service Agreements

Provider Questions and Answers (continued)

28. Board certification is time limited. Will EPNI also require proof of periodic recertification? Yes, proof of recertification will be required. Since board certifications do expire, physicians who participate with EPNI will be expected to obtain periodic recertification. EPNI will confirm the certification status of all physicians during the initial and recredentialing process. 29. What happens when the board certification lapses for a physician who is currently board certified at the time this new policy takes effect (3/15/2005) or meets the board certification requirement subsequent to the policy effective date? In some situations, it may be acceptable for a physician’s board certification to lapse. For example, if a physician is boardcertified in family practice, he/she may obtain certification in a family practice subspecialty such as geriatric medicine. In cases where EPNI confirms that a physician obtains certification in an approved subspecialty the primary specialty certification may be allowed to lapse. If a physician’s specialty or subspecialty board certification lapses and the physician is not actively pursuing recertification or fails to recertify, EPNI retains the right to terminate the physician’s participation in networks. 30. Do I need an Individual Provider Number for a locum tenens? A practitioner making a first request to be a locum tenens for three months or less does not need to be credentialed. The clinic needs to submit a practitioner add form to get a provider number for the locum tenens to bill with, and we set the number up to be valid for 90 days. 31. When is credentialing required for a locum tenens?

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If a locum tenens will be staying longer than 90 days they will need to be credentialed. The credentialing process should be started as soon as this is known. Providers do not have to wait until the 90 days is over to begin the credentialing process.



If the practitioner has ever been a locum tenens in our network at any time, they do not qualify for locum tenens status and would need to be credentialed.



The provider number for the locum tenens will become invalid after 90 days.

EPNI Provider Policy and Procedure Manual (05/10/13)

Provider Service Agreements

Accounting for Disclosure Request Guidelines for the Accounting Disclosure Request

EPNI Subscribers have the right to an accounting of certain disclosures that are made of their protected health information (PHI) within six years prior to their request. EPNI will fulfill these requests with a Subscriber disclosure summary. Providers are requested to follow the guidelines listed below and forward required disclosures to: EPNI Attention: Compliance and Regulatory Affairs P.O. Box 64560 St. Paul, MN 55164-0560

When to Use the Form

If a disclosure is subject to an accounting, Providers must use the enclosed form to record the disclosure information. This form can be found at CCStpa.com. Disclosures which require an accounting include disclosures which are made: 1. pursuant to applicable law; 2. for cadaveric organ donation purposes; 3. to avert a serious threat to health or safety; 4. for certain marketing or fundraising exceptions; and 5. to the Secretary of Health and Human Services. The attached form provides a more detailed list of those disclosures that must be accounted for. Not all disclosures of an individual’s PHI are subject to an accounting. Providers are not required to account for disclosures they make: •

before the privacy rules compliance date (April 14, 2003)



to the individual



to or for notification of persons involved in an individual’s care



for treatment, payment, or health care operations



for national security or intelligence purposes



to correctional institutions or law enforcement officials regarding inmates



for research if it involves at least 50 records and we provide individuals with a list of all the research protocols and the researcher’s name and contact information



using de-identified health information

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Provider Service Agreements

Disclosures Related to Provider’s Status as a Business Associate

The Provider Service Agreement requires Provider to account for only those disclosures of records that it holds in its capacity as a business associate. Provider is EPNI's business associate because the Provider Service Agreement requires you Provider to perform certain activities on EPNI's behalf. These business associate activities are: •

Compliance with and implementation of quality improvement/managed care requirements such as providing specific patient records for a quality study; and

• Receiving and resolving Subscriber complaints. Thus, for example, if Provider reports a complaint to EPNI as required by the Provider Service Agreement, Provider is gathering that information and forwarding it to EPNI as its business associate. Provider does not have to report the disclosure to EPNI because it is part of health care operations. If, however, a regulator were to audit EPNI's compliance with handling Subscriber complaints and Provider must release correspondence or records to the regulator, it is a disclosure Provider must account for. Another example would be records that Provider provided to EPNI for Child and Teen Checkups. If the Department of Health were to decide to monitor managed care plans for child and teen checkups, they may ask for all the information Provider provided to EPNI as part of the on-site audits. The disclosure is permitted to the Department of Health without authorization as a public health activity, but it must be accounted for. Provider does not have to account for disclosure of records that it has in its capacity as a provider. For example, as discussed above, Provider might have medical records from providing a teen with a checkup. Subsequently, the teen is involved in a crime and the medical records are necessary for identification purposes. Provider may disclose the medical record to law enforcement authorities and must account to the teen for that disclosure. Provider does not, however, have to account to EPNI for that disclosure.

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Carrier Replacement Law Carrier Replacement

The Law The Minnesota Carrier Replacement Law applies when a Subscriber group terminates its fully insured coverage with one carrier and replaces it with another fully insured group contract. EPNI may apply this law to self-insured groups to determine liability for charges incurred by a Subscriber whose inpatient treatment occurred during this change in coverage.

How Carrier Replacement Works

Continuous Stay



The carrier whose coverage is in effect when a Subscriber is admitted to a facility is liable for all institutional charges incurred by the Subscriber whose inpatient treatment spans the change in coverage.



The carrier in effect at the time of admission is liable for all professional charges incurred up to the termination date of the coverage.



The new carrier is liable for all professional charges incurred beginning on the effective date of the new coverage.



The definition of “discharge” is the date the Subscriber is formally released from the inpatient facility with discharge papers completed.

Continuous stay occurs when the patient is sent to another facility for services unavailable at the current facility and no discharge or admission papers are processed upon transfer. •

In the case of a patient who is discharged and transferred to another facility, both the transportation and charges incurred at the new facility will become the liability of the new carrier.

If…

then…

a new Subscriber was hospitalized prior to the effective date of EPNI coverage

EPNI pays the hospital claim on a pro rata basis beginning on the date coverage becomes effective.

a new Subscriber remains hospitalized on and after the first date of coverage the new Subscriber's other carrier stops paying for the hospitalization or there is no other carrier Self-Funded Groups

Carrier Replacement law does not apply to self-insured business unless otherwise documented in the group agreement.

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Provider Service Agreements

Governmental and Compliance Required Provisions Overview

Federal and state governmental agencies require health plans, such as EPNI, to inform providers of certain information. Additional requirements are also necessary for accreditation and other quality compliance.

Governmental Required Definitions



"Managing Employee" means an individual (including a general manager, business manager, administrator or director) who exercises operational or managerial control over the entity or any part thereof, or who directly or indirectly conducts the day-to-day operations of the entity or any part thereof, as defined in 42 C.F.R. Section 455.101.



"Medicare Advantage" means Medicare Advantage programs as defined by Centers for Medicare and Medicaid (CMS), where EPNI is the payor for health services provided to Medicare Subscribers.



"Medicare Advantage Special Needs Plan" means a Medicare Advantage program as defined by CMS under which EPNI is the payor for health services provided to Medicare Subscribers with special needs. An example of such a plan is Minnesota Senior Health Options (MSHO).



"Minnesota Senior Health Options" (MSHO) means the Minnesota prepaid managed care program, pursuant to Minnesota Statutes, Section 256B.69, subd. 23, that provides integrated Medicare and Medicaid services for Medicaid eligible seniors, age sixty-five (65) and over. MSHO includes Elderly Waiver services for enrollees who qualify, and one hundred eighty (180) days of nursing facility care.



"Person with an Ownership or Control Interest" means a person or corporation that (1) has an ownership interest, directly or indirectly, totaling five percent or more in EPNI or a disclosing entity; (2) has a combination of direct and indirect ownership interests equal to five percent or more in EPNI or a disclosing entity; (3) owns an interest of five percent or more in any mortgage, deed of trust, note or other obligation secured by EPNI or a disclosing entity, if that interest equals at least five percent of the value of the property or assets of EPNI or a disclosing entity; or (4) is an officer or director of EPNI or a disclosing entity (if it is organized as a corporation) or is a partner in EPNI or a disclosing entity (if it is organized as a partnership).

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Compliance with Laws

In order to have a Provider Service Agreement with EPNI, Providers and EPNI are required to abide by all applicable state and federal laws, rules, regulations, orders and requirements that are related to providing health care and billing for health care. •

Cooperation with EPNI. In addition to complying with all state and federal laws, rules, regulations, orders and requirements, Provider further agrees to cooperate with EPNI in its efforts to comply with any and all obligations imposed by state and federal laws, rules, regulations, orders and requirements. This includes 1) promptly notifying EPNI in the event the Provider transfers "substantial financial risk" (as defined in 42 C.F.R. Section 422.208) to any of the health care professionals in its employment; and 2) notifying EPNI within 20 days of entering into any private contract with a Medicare beneficiary pursuant to Section 1802 of the Social Security Act (such notice to include a copy of the private contract and any other information reasonably requested by EPNI).

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Provider Service Agreements

Compliance with Laws (continued)





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Minnesota Department of Human Services Disclosure Requirements. •

Disclosure of Agreements. Provider must ensure that no agreements exist between itself and an excluded entity or individual for the provision of items or health services under a Provider Service Agreement. Provider shall search the Medicare Exclusion Database (MED) or the Office of Inspector General (OIG) List of Excluded Individuals/Entities (LEIE) databases on a monthly basis to insure that no providers, agents, Persons with an Ownership or Control Interest and Managing Employees are (a) excluded from participation in Medicaid under Sections 1128 or 1128A of the Social Security Act, or (b) have been convicted of a criminal offense related to involvement in any program established under Medicare, Medicaid or the Title XX services program. Provider shall notify EPNI within five days of identifying any subcontracting individuals or entities listed in (a) or (b) of this paragraph.



Disclosure of Ownership Information. To assure compliance with 42 C.F.R. Section 438.610, Provider shall report the following information to EPNI prior to the effective date of the Agreement: (a) the name and address of each Person with an Ownership or Control Interest in a disclosing entity or in any subcontractor in which a disclosing entity has direct or indirect ownership of five percent or more; and (b) a statement as to whether any Person with Ownership or Control Interest is related to any other Person with an Ownership or Control Interest



as spouse, parent, child or sibling; and (c) the name of any other organization in which a Person with an Ownership or Control Interest in a disclosing entity also has Ownership or Control Interest.

Advance Directives. Provider must make information available to Subscribers to aid them in completing advance directives, including but not limited to helping them to understand medical terminology, medical care options and referring them to appropriate resources such as the Minnesota Department of Health Website. Upon a Subscriber's request, Provider must maintain a copy of a Subscriber's advance directive in the medical record maintained by Provider.

EPNI Provider Policy and Procedure Manual (05/10/13)

Provider Service Agreements

HIPAA Requirements

HIPAA Compliance. Pursuant to the federal Health Insurance Portability and Accountability Act (HIPAA), and the requirements of the Health Information Technology for Economic and Clinical Health Act, as incorporated in the American Recovery and Reinvestment Act of 2009 (the "HITECH Act") that are applicable to business associates, Provider agrees that it shall: •

Not use or further disclose Protected Health Information (PHI) other than as permitted or required by the Provider Service Agreement between EPNI and Provider, and further agrees that it shall not use or further disclose PHI in a manner that would violate requirements of HIPAA and its implementing regulations (45 C.F.R. parts 160-64) ("HIPAA Regulations") or the HITECH Act;



Report to EPNI any use or disclosure of PHI not provided for by the Provider Service Agreement of which it becomes aware, within five (5) days after such discovery, and ensure that any agents, including any subcontractors, to whom it provides to or receives from PHI, agree to the same restrictions and conditions that apply to Provider with respect to such information;



Upon any termination of the Provider Service Agreement, extend the protections of this Section to any PHI in the possession of Provider, and limit any further use and disclosure of such PHI to those purposes set forth in the Provider Service Agreement;



Develop, implement, maintain and use appropriate administrative, technical and physical safeguards, in compliance with Social Security Act Sec. 1173(d) (42 U.S.C. Sec. 1320d-2(d)), 45 C.F.R. Sec. 164.530(c)) and any other implementing regulations issued by the U.S. Department of Health and Human Services;



Upon receipt of notice from EPNI, promptly amend or permit EPNI access to amend any portion of the PHI which the provider created or received from EPNI so that EPNI may meet its amendment obligations under 45 C.F.R. Sec. 164.526;

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Provider Service Agreements

HIPAA Requirements (continued)





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With the exception of disclosures of PHI made for the purposes specified in 45 C.F.R 164.528(a)(1)(i)-(ix), document and report each disclosure, if any, the provider makes of any PHI Provider has created for EPNI or received from EPNI within five (5) days of the discovery of the disclosure. The provider shall cooperate with EPNI in investigating the disclosure and in meeting EPNI'S obligations under the HIPAA regulations and HITECH Act. In the event of any such disclosure, the provider shall: •

Identify the nature of the non-permitted access, use or disclosure, including the date of the breach and the date of discovery of the breach;



Identify the PHI accessed, used or disclosed as part of the breach (e.g. full name, social security number, date of birth etc.);



Identify who made the non-permitted access, use or disclosure and who received the non-permitted disclosure;



Identify what corrective action the provider took or will take to prevent further non-permitted access, uses or disclosures;



Identify what the provider did or will do to mitigate any deleterious effect of the non-permitted access, use or disclosure; and



Provide such other information, including a written report, as EPNI may reasonably request.

Provider acknowledges and agrees that in the event the Provider breaches this HIPAA requirements, EPNI may terminate the Provider Service Agreement upon written notice to the Provider and/or report such breach by the Provider to the United States Department of Health and Human Services.

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Provider Service Agreements

HIPAA Requirements (continued)

HIPAA Security. The Provider agrees to the following: •

The Provider shall implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of the electronic Protected Health Information ("e-PHI") that it creates, receives, maintains or transmits on behalf of EPNI, as required by 45 C.F.R. Part 164 (the "Security Rules").



To ensure that any agent, including a subcontractor to whom it provides e-PHI agrees to implement reasonable and appropriate safeguards to protect it, and



To report to EPNI any security incident involving e-PHI of which it becomes aware. The Security Rules define a "Security Incident" as an attempted or successful unauthorized access, use, disclosure, modification or destruction of information or interference with system operations in an information system, involving e-PHI that is created, received, maintained or transmitted by or on behalf of Provider or EPNI. Since the Security Rules include attempted unauthorized access, use, disclosure, modification or destruction of information, EPNI needs to have notification of attempts to bypass electronic security mechanisms. Provider and EPNI recognize and agree that the significant number of meaningless attempts to, without authorization, access use, disclose, modify or destroy e-PHI will make a real-time reporting requirement formidable for Provider. Therefore, Provider and EPNI agree to the following reporting procedures: Security Incidents that result in unauthorized access, use, disclosure, modifications or destruction of information or interference with system operations ("Successful Security Incidents") and for Security Incidents that do not so result ("Unsuccessful Security Incidents").

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Provider Service Agreements

HIPAA Requirements (continued)





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For Unsuccessful Security Incidents, Provider and EPNI agree that this paragraph constitutes notice of such Unsuccessful Security Incidents. By way of example, Provider and EPNI consider the following to be illustrative of Unsuccessful Security Incidents when they do not result in actual unauthorized access, use disclosure, modification or destruction of e-PHI or interference with an information system: •

Pings on the Provider's firewall.



Port scans.



Attempts to log onto a system or enter a database with an invalid password or username.



Denial-of-service attacks that do not result in a server being taken off-line.



Malware (worms, viruses, etc.).

For Successful Security Incidents, the Provider shall give notice to EPNI not more than five (5) business days after learning of the Successful Security Incident.

EPNI Provider Policy and Procedure Manual (05/10/13)

Provider Service Agreements

Non-Interference

Provider agrees not to interfere in the business relationships of EPNI with its group purchasers, Subscribers, Plan Sponsors or other providers by discouraging or attempting to discourage group purchasers, Subscribers, Plan Sponsors, or other providers from initiating or maintaining their business relationship with EPNI. This provision does not prohibit normal business activities such as participation in other health plans. This provision prohibits Provider activity such as disclosing proprietary information such as specific financial or other terms of the Provider Service Agreement (as well as specific financial information relating to any other agreement between a provider and EPNI) unless otherwise expressly authorized by EPNI in writing signed by an officer of EPNI or required by law. This provision also prohibits the Provider from defaming EPNI for financial or participation purposes, including but not limited to suggesting other providers, group purchasers, Subscribers or Plan Sponsors terminate their relationships with EPNI. This provision is not intended to interfere with the provider-patient relationship and this provision is not intended to prohibit the Provider from communicating with Subscribers as provided by Minnesota Statutes Section 62J.71. EPNI encourages and permits open communication between the Provider and the patient regarding treatment options available to them regardless of benefit coverage limitations. Benefit coverage is always governed by the terms of the Subscriber Contract. EPNI similarly agrees not to interfere in the business relationships of the Provider with its group purchasers, or other providers by discouraging or attempting to discourage group purchasers or other providers from initiating or maintaining their business relationship with Provider.

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Provider Service Agreements

Network Access Agreements

In addition to providing Health Services to Subscribers enrolled in health benefit plans underwritten or administered by EPNI, the Provider Service Agreement applies to health services provided in the following instances: •

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Health Services provided to Subscribers for whom EPNI or its Affiliates provides access to an EPNI participating provider network, where no administrative or claims payment services are provided and neither EPNI nor its affiliates assume any financial risk or obligation with respect to claims. In all such network access arrangements, EPNI shall ensure that (a) Subscribers are directed to receive Health Services from a provider through benefit differentials outlined in the Subscriber Contract, (b) Subscribers are required to produce a membership card that identifies him/her as a Subscriber who is entitled to use the participating provider network, (c) the application of the EPNI fee schedule is clearly listed on the explanation of benefits furnished to the Subscriber, and (d) that the entity which has contracted with EPNI for access to the participating provider network agrees to comply with the prompt payment/prompt response provisions of the Provider Service Agreement. EPNI shall notify Provider of such network access arrangements and furnish information regarding any special requirements for the applicable Subscriber's contract.

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Termination of Provider Service Agreements Required Notification

A Provider Service Agreement may be terminated according to any one or more of the following provisions: •

Without cause by either Party upon prior written notice to the other Party with termination to become effective 130 days after receipt of written notice.



By a Party upon prior written notice to the other Party in the event of a material breach of the Provider Service Agreement by such other Party and which breach remains uncured 30 days after written notice reasonably specifying the nature of the breach is given to the breaching Party, with termination to become effective on the 30th day after receipt of such written notice.



Immediately upon written notice by EPNI to Provider in the event that EPNI acquires evidence of the potential for significant patient harm or of fraudulent or illegal conduct on the part of Provider or any of Provider's Health Care Professionals with regard to the practice of medicine, claim submission, health care professional eligibility, the delivery of care under the Provider Service Agreement, or in the event of any sanction by CMS under the Medicare program.



By EPNI upon 30 days' prior written notice to Provider with respect to any Provider or Health Care Professional of Provider which fails to complete the credentialing or recredentialing process or is sanctioned or reprimanded by any review organization, including but not limited to, any other health insurer or health plan, peer review organization, hospital medical staff or any state licensing board. The Provider agrees to immediately notify EPNI in writing of any such sanction or reprimand or any investigation of any Provider or Health Care Professional of which Provider is aware. If the sanction or reprimand is limited to a single Health Care Professional, then the termination shall be effective as to that Health Care Professional only.

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Provider Service Agreements

Required Notification (continued)

2-38



By EPNI of Provider's participation in benefit plans (including but not limited to the Minnesota Comprehensive Health Association, the Minnesota Advantage Health Plan, political subdivisions, and Workers' Compensation) if Provider is determined by DHS to be out of compliance with Minnesota Statutes, Section 256B.0644 (requiring providers to accept medical assistance patients) or any other applicable laws. Provider shall notify EPNI immediately in event of such noncompliance. The termination shall be effective as of the first date of such non-compliance.



By EPNI upon 130 days' prior written notice to Provider if Provider's practice moves outside the contracting service area served by this Agreement. Provider shall immediately notify EPNI of any change to its address.

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Chapter 3

Health Care Improvement Table of Contents Introduction to Health Care Improvement ............................................................................. 3-2 General Overview .................................................................................................................. 3-2 Basic Elements of an HCI Program ....................................................................................... 3-2 Leadership.............................................................................................................................. 3-3 Formalized Mechanism for Customer Feedback ................................................................... 3-3 Health Care Improvement Projects....................................................................................... 3-4 Cooperation with EPNI HCI Program ................................................................................... 3-5 Telephone Care: During Office Hours................................................................................... 3-5 Telephone Care: In-coming calls ........................................................................................... 3-5 Telephone Care: After Hours................................................................................................. 3-6 Complaint Review System..................................................................................................... 3-7 Access & Availability ........................................................................................................... 3-7 Written Policies...................................................................................................................... 3-8 Continuity and Coordination of Care................................................................................... 3-12 Medical Record Keeping Practices...................................................................................... 3-13 Medical Record Documentation .......................................................................................... 3-14 Health Care Improvement for Behavioral Health Providers .............................................. 3-16 General Overview ................................................................................................................ 3-16 Cooperation with EPNI HCI Program ................................................................................. 3-16 Additional Requirements for Select Network Providers ..................................................... 3-16 Cooperation with EPNI HCI Program ................................................................................. 3-17 Complaint Review System................................................................................................... 3-17 Additional requirements for Select Network Providers....................................................... 3-17 Access and Availability ....................................................................................................... 3-18 Physical Facility................................................................................................................... 3-19 Written Policies.................................................................................................................... 3-19 Treatment Record Documentation....................................................................................... 3-20 Provider Specific Health Care Data....................................................................................... 3-25 Release of Provider Data by EPNI....................................................................................... 3-25

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Health Care Improvement

Introduction to Health Care Improvement General Overview

This chapter contains detailed information about the EPNI Health Care Improvement (HCI) program, formerly Quality Improvement. The material explains what is expected from participating providers regarding their quality programs and defines provider requirements including medical record keeping practices. The information provided in this chapter is intended for all Open Access providers, however; some requirements may not apply in every facility. Additionally, some requirements for behavioral health providers are different than those described below. Requirements that are different or more stringent for behavioral health providers are detailed.

Basic Elements of an HCI Program

Rationale: EPNI subscribes to the philosophy of Health Care Improvement (HCI) and the multifaceted benefits it offers. All providers associated with EPNI networks must include health care improvement activities in their facilities. Striving to meet or exceed customer expectations should be a driver for a successful program. A well-established program enables Provider to discover root causes, use data to increase production, and maximize available resources. A successful program has three basic elements: it must be customer-focused, data-driven, and processoriented. EPNI supports the six aims for improvement identified in the Institute of Medicine’s Crossing the Quality Chasm. These six aims are that care should be safe, effective, patient-centered, timely, efficient, and equitable. All EPNI providers are expected to incorporate these aims into their health care improvement programs. Some models are available to guide and direct HCI project efforts. Requirements: •

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Provide annual HCI program report upon request to EPNI.

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Leadership

Rationale: Leadership within an organization must support and embrace the philosophy of health care improvement for it to succeed. Advising, supporting, and actively participating in the development and implementation of process improvement is a vital function of leadership. Improving processes within an organization promotes better care and services to customers, creating a marketplace advantage. Requirement: •

Formalized Mechanism for Customer Feedback

Designated HCI Medical Director, who is a practicing physician and is either a MD or DO

Rationale: Patient feedback is an excellent resource that provides innovative and practical ideas for improving care or service. Analyzing feedback for the purpose of improving processes provides opportunities essential to maintaining customer loyalty. Patient feedback is collected in a variety of ways. Surveys provide needed information about particular areas; comment cards capture a patient’s thoughts at the time of a visit; focus groups facilitate discussion; and external surveys provide comparative statistics. Requirements: Collection and analysis of customer feedback. •

Action on collected feedback through the use of a multidisciplinary team where appropriate to initiate system change.

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Health Care Improvement

Health Care Improvement Projects

Rationale: Good business practices consist of effective and efficient work processes. Addressing problems or opportunities within Provider's facility using the HCI process offers distinct advantages. Health Care Improvement projects employ systematic analysis of current practices to reveal refined approaches to everyday operations. Using a defined model means that changes can be tested and adopted effectively. Requirements and changes regarding HCI reporting are distributed annually in the first quarter to all main site primary care providers. EPNI does not routinely collect project information from providers. Requirements listed below should be followed if Provider's facility chooses to implement improvement activities. Suggested project categories may include clinical guideline implementation or improvement, administrative or processoriented improvements, or improvements based on customer feedback. Often providers choose to do one project that is clinical and one that is service-related. EPNI encourages Provider to conduct a survey or focus group of customers as it develops system changes. Requirements:

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Provide HCI program description, contact information, or project reports upon request.



Clinical projects must be based on approved and established guidelines [i.e., Institute for Clinical Systems Improvement (ICSI)].



Projects have completed a full PDCA Cycle or Seven-Step process. Refer to the PDCA or Seven-Step Process information.

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Cooperation with EPNI HCI Program

Rationale: Collaborative efforts need to mutually service EPNI's Subscribers with excellent care and services. Requirements:

Telephone Care: During Office Hours



Consultation and cooperation to resolve individual patient complaints.



Provide medical records for HCI purposes upon request.



Collaborate on corrective action plan when EPNI quality thresholds are not met. The EPNI Quality Council determines thresholds.

Rationale: Patients need telephone access to medical care with a response time based on the urgency of their symptoms. Requirements: During office hours, Subscribers calling a provider will be assessed according to patient care needs by a physician or designee:

Telephone Care: In-coming calls



Immediately for emergencies, 100% of the time



Within 30 minutes for urgent issues, 85% of the time



Within 4 hours for all other call types, 85% of the time

Rationale: A timely response to incoming phone calls promotes patient satisfaction. Requirements: •

Calls answered in six rings



On hold two minutes or less

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Health Care Improvement

Telephone Care: After Hours

Rationale: When Subscribers call Provider's facility, it is important to provide them with information they need, regardless of the time. The best method is having a person answer the phone when the facility is closed, such as an answering service or triage line. To achieve this, providers must have a telephone number that is answered 24 hours a day by either a live person, or an answering system that will provide patients information as outlined below. •

The provider’s name



What to do if the patient feels this is an emergency (i.e. hang up and call 911)



What to do if it is not an emergency, but the patient still needs medical advice



Give the name of the person or location the patient should call, and phone number(s), including the area code



Speak slowly and clearly. State numbers one at a time, such as “six zero five zero” instead of “sixty fifty”

Additional tips: •

Make sure it is quiet in the background when recording the message



If the patient is being asked to call another location, make sure that location has a message or someone answering the phone who can help the patient



EPNI recommends Provider audit its message outside of normal business hours according to these guidelines to make certain it is in compliance with the requirements.

Requirements: •

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Provide 24 hours/day, 7 days/week telephone answer with a triage process to determine call back appropriate for the situation

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Health Care Improvement

Complaint Review System

Rationale: Patient complaints and concerns reflect their perceptions and expectations. Feedback, whether solicited or unsolicited, presents an opportunity to identify issues and implement systematic processes to improve care or service. Providers and EPNI share a joint commitment to Subscriber satisfaction and to the improvement of care and Health Services delivered to EPNI Subscribers. Requirements: All providers will have a policy and procedure in place detailing the following:

Access & Availability



Process to receive written and verbal complaints for EPNI Subscribers



Designate an individual to be the primary contact for complaint management, including the tracking of such complaints



Document the substance of the complaint, the investigation, and any actions taken



Notify Subscribers of the right to complain and appeal to their health plan



Track complaints by categories and report at least annually to an in-house committee

Rationale: Subscribers' concept of the quality of care they receive often begins when they make an appointment. EPNI also wants to insure that Subscribers are able to schedule appointments within a timely manner, relative to the services they seek. Requirements: Satisfaction – Primary Care Providers Only •

Routine Care: 85% of Subscribers will usually or always be satisfied with when they get a routine care appointment (routine care is that which the Subscriber does not need to see a practitioner right away.)*



Urgent Care: 85% of Subscribers will usually or always be satisfied with when they get an urgent care appointment (urgent care is that which is needed right away for an illness, injury or condition.)* * EPNI conducts semi-annual Subscriber satisfaction surveys.

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Health Care Improvement

Access & Availability (continued)

Written Policies

Wait Times •

Preventive Care – within 30 days 85% of the time for well child exam, annual physical exam, etc.



Routine Primary Care – within 7 days 85% of the time for nonurgent symptomatic conditions



Urgent Care – Same day 85% of the time for Medically Necessary care which does not meet the definition of emergency care



Emergency Care – Immediate 100% of the time for immediately life threatening illnesses, injuries and conditions

Rationale: To protect the safety and privacy of all Subscribers, and for the protection of Provider, EPNI requires all providers to develop and implement written policies and procedures applicable to the Health Services they provide. Providers are encouraged to have policies that are facility specific, signed, dated and reviewed annually. Requirement: Each provider will have policies and procedures in place for the following topics that apply to the services provided in the facility. Policy Required

Recommended Risk Management Elements

Advance Directives



Information made available



Discussion is documented in medical record



Copies retained



Hospitals notified upon admission



Eligibility defined (birth through age 20, children)



Forms for documentation addressed



Age-appropriate services defined



Documentation in medical record



Correct coding

Child and Teen Check-ups

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Health Care Improvement

Written Policies (continued)

Policy Required

Recommended Risk Management Elements

Communicable Disease Reporting



Requirement to report communicable diseases by State Health Department



Reporting timeframe (within one day)



Responsibility of reporting defined



Forms, completion and submittal addressed

Complaint Management



See Complaint Review System Section

Confidentiality



Training, including how soon initial training occurs, when or how often refresher training occurs, verified by signatures of trainer and individual being trained, and on file for six years



Accountability, including how control is maintained (i.e., who has keys, who is allowed into the facility and when)



Personal health information (PHI) disposal



Security of both paper and electronic PHI, follow HIPAA guidelines



Reviewed annually

Confidentiality and Security of Medical Records



Refer to the Medical Records section

Foreign Language Translation and Hearing Impaired Services



Assistance provided for both situations



Interpreter available for phone calls and face-to-face interactions



Patients/family are notified that interpreter is provided



Resources are identified

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Health Care Improvement

Written Policies (continued)

Policy Required

Recommended Risk Management Elements

Hazardous Materials and Waste Management



Written plan in place and maintained



Hazardous material and waste defined



Mechanism in place for responding to a spill



MSDS (material safety data sheets) available



Hazardous materials and waste are identified and inventoried



Mechanism defined for responding to a spill/breach of containment



Chemical and regulated medical waste addressed



Hazardous gas and vapors addressed



Orientation and education of staff outlined



Basic overview of infection control and how it relates to controlling disease



Hand washing outlined, when and how



Universal precautions addressed, including glove use



Personal protection equipment addressed



Screening employees for TB



Vaccinating employees for Hepatitis B



Steps taken when employee is exposed to breach of infection control or exposure, how to report to OSHA



Mechanism in place for responding



Medical emergency code is identified



Identify who directs activities



Identify who determines if 911 is called

Infection Control

Medical Emergency

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Health Care Improvement

Written Policies (continued)

Policy Required

Recommended Risk Management Elements

Medication Management



Mechanism in place for procuring, storing, controlling and distributing medications



Narcotics addressed, even if to say they are not kept at the facility



Recalls addressed



Emergency and sample drugs addressed



Sign-out log covered



Prescription pad accessibility addressed

Non-Medical Emergency Policy



Mechanism in place for responding



Include power outages, weather emergencies, bomb threats, and both fire and fire drills

Treating Unaccompanied Minors Policy



Minor defined, exceptions covered



Scheduling appointments addressed



Mechanism in place to respond when an unaccompanied minor calls/arrives asking to be seen



Sample of authorization to consent to treatment of a minor is provided

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Health Care Improvement

Continuity and Coordination of Care

Rationale: Patient continuity and coordination of care (COC) across settings such as inpatient and ambulatory care and transition from specialty to primary care, is critical in ensuring the best care for EPNI's Subscribers and Provider's patients. All providers share a joint responsibility to ensure continuity and coordination of care. Guidelines: Health Records: •

Establish a consistent location(s) for external communications from facilities and/or consultants including but not limited to discharge summaries or notes, consult letters, progress notes, and test or lab results.

Referrals: •

Communicate with specialists/consultants to share the rational for the referral and establish expectations for follow-up and future communications.

Specialty Care and Consultants: •

Provider written communication to the patients’ primary care provider including, but not limited to progress notes, consultation letters and test or lab results.

Inpatient: •

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Request that all discharge summaries and discharge notes be copied to the primary care provider in the dictation process.

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Health Care Improvement

Medical Record Keeping Practices

Rationale: EPNI requires Provider to have a policy and procedure for confidentiality of health information and medical records that meets state and federal requirements. EPNI expects strict adherence to state and federal laws with regards to maintaining Subscribers' medical information and records in a confidential manner. EPNI requires medical records to be maintained in a manner that is current, detailed and organized. Providers must have a tracking process in place for ease of retrieval. Requirements: Each element required 100% of the time. •

A written policy and procedure of medical record keeping practices, which includes the confidentiality and security of medical records, and release of information, is available.



Medical records are kept in a secure location.



Review of the confidentiality policy and procedure is performed at least annually with staff.



A tracking system for medical records is in place.



The medical record forms are available for release.

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Health Care Improvement

Medical Record Documentation

Rationale: The patient medical record is a vehicle for documenting services provided and evaluating continuity and coordination of care. It also serves as legal protection for the patient and practitioner. EPNI, per contractual agreement with both the subscriber and Provider, has access to the Subscriber's medical record for examination and evaluation. EPNI’s corporate confidentiality policy requires that the personal and health information of its Subscribers be maintained as confidential information. All employees are required to attest to their knowledge of this policy and their intent to comply with it. Medical record review is an essential component of a comprehensive health care improvement program. The EPNI Quality Council, which includes practicing physicians, establishes minimum patient medical record documentation standards. Requirements: Each element required 100% of the time. Format

3-14



The content and format of the medical record is organized and includes patient’s address and home and work phone numbers.



Each page in the medical record contains the patient’s name or identification number.



All entries in the medical records contain the author’s identification. Author identification may be a handwritten signature, a unique electronic identifier, or a stamped signature verified with initials.



Medical records are legible to someone unfamiliar with the author’s handwriting.



All encounters/entries are dated.



Immunization status information for all ages is recorded on a single page location.



A summary of preventive services screening is documented in a consistent place.

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Health Care Improvement

Medical Record Documentation (continued)

Content •

Medication allergies and adverse reactions are prominently noted in the record. If the patient has no known allergies or history of adverse reactions, this is appropriately noted in the record.



Significant illnesses and medical conditions are indicated on a problem list.



Past medical history (for patients seen three or more times) is easily identified and includes, as appropriate, significant family history, serious accidents, operations and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations and childhood illnesses.



For patients 10 years and older, there is an appropriate notation concerning the use of tobacco, alcohol and substances.



The history and physical exam identifies appropriate subjective and objective information pertinent to the patient’s presenting complaints and includes medications.

Assessment and Plan •

Laboratory and other studies are ordered, as appropriate



Assessment of each encounter reflects patient’s chief complaint



Treatment plans are consistent with diagnoses

Follow-up •

Encounter forms or notes have a notation, when indicated, regarding follow-up care calls or visits. The specific time of return is noted in weeks, months or as needed.



Unresolved problems from previous office visits are addressed in subsequent visits.



If a consultation is requested, there is a note concerning this visit in the record.



Consultation, lab and imaging reports filed in the chart are reviewed by the primary care physician.



Clinically significant abnormal consultation results, lab or imaging study results have an explicit notation in the follow-up plans.

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Health Care Improvement

Health Care Improvement for Behavioral Health Providers General Overview

This section contains detailed information about the EPNI Health Care Improvement (HCI) program that is specific to behavioral health providers. The information in this section is in addition to or more specific than the requirements in the greater chapter. The material explains what is expected from participating providers regarding their quality programs and defines Provider requirements.

Cooperation with EPNI HCI Program

Rationale:

Additional Requirements for Select Network Providers

Requirements:

Collaborative efforts need to mutually serve EPNI Subscribers and Provider's patients with excellent care and services.

Actively participate in the following EPNI HCI activities. Follow-up after hospitalization for mental illness •

Offer appointments to new and returning patients within seven days of mental health hospitalization discharge. Appointments should be provided within the timeframe commensurate with patient clinical need. EPNI recommends that behavioral health providers develop an appointment scheduling strategy to accommodate newly discharged patients, if they have not already done so. Standardized substance abuse screening in assessment

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Routinely utilize standardized substance abuse screening questionnaires, e.g. CAGEAID, in mental health assessments for new patients age 12 and older. (Routine substance use assessment of 10 and 11 year-old children is also recommended.)



Recommend or complete a comprehensive substance abuse assessment based on the standardized screening results and corroborating clinical information when results indicate the likelihood of substance abuse.

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Health Care Improvement

Cooperation with EPNI HCI Program

Exchange of information with primary care physicians •

Routinely ask all new patients to authorize exchange of information with primary care/treating physicians.



Establish a distinct section in the treatment record, if one does not exist, dedicated to case management activities. The section should contain: •

Documentation of patient authorization or refusal to exchange information with the physician



When authorized, documentation of communication the physician, e.g. report, letter, telephone or email communication



When authorized, the treating psychiatrist should provide the current diagnosis(es), initial medication management information, and general treatment plan to the physician



When recommending the patient seek psychopharmacologic treatment from their physician or if the physician recommended mental health assessment and/or treatment, provide the physician with the current behavioral health diagnosis(es), and general treatment plan if applicable

Complaint Review System

Rationale:

Additional requirements for Select Network Providers

Requirements:

The practice of managing patient complaints in behavioral health clinics is consistent with practices in primary care clinics. Please review page 3-7 for additional information on maintaining a complaint review system.

All providers will have a policy and procedure in place detailing the following: •

Process to receive written and verbal complaints for EPNI Subscribers



Designate an individual to be the primary contact for complaint management, including the tracking of such complaints



Document the substance of the complaint, the investigation, and any actions taken



Notify Subscribers of the right to complain and appeal to their health plan



Track complaints by categories and report at least annually to an in-house committee

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Health Care Improvement

Access and Availability

Rationale: Subscribers' concept of the quality of care they receive often begins when they make an appointment. EPNI wants to ensure that Subscribers are able to schedule appointments in a timely manner; commensurate with the level of care they need. Requirements: Routine initial appointments: 90% of requests within 10 business days. Routine care is defined as a circumstance in which the individual does not present either emergent or urgent conditions and requests clinical services. Follow-up appointment: 90% of requests within 10 business days of the initial appointment. Urgent appointment: 100% of requests within 24 hours. Urgent care is defined as a circumstance in which the individual presents no emergency or immediate danger to self or others; however, the individual, clinician, or concerned party believes that the individual’s level of distress and/or functioning warrants assessment as soon as possible. An urgent condition is a situation that has the potential to become an emergency in the absence of prompt treatment. Non-life-threatening emergency appointment: 100% of requests within 6 hours. A non-life-threatening emergency is defined as a circumstance in which the individual is experiencing a severe disturbance in mood, behavior, thought, or judgment. There may be evidence of uncontrolled behavior and/or deterioration in ability to function independently that could potentially require intense observation, restraint, or isolation. Emergency care: 100% of Subscriber requests immediately. An emergency is defined as a circumstance in which there is imminent risk of danger to the physical integrity of the individual; the individual cannot be maintained safely in his or her typical daily environment.

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Health Care Improvement

Physical Facility

Rationale: EPNI requires behavioral health clinics to provide a safe environment, which protects patient privacy and ensures handicap accessibility for disabled patients. EPNI will monitor and review physical environment to evaluate conformity with regulatory, plan, and accreditation standards. Requirements:

Written Policies



Provider open reasonable working hours



Provide 24 hour/7 day on-call coverage



Accessibility to handicapped Subscribers as defined by the Americans with Disabilities Act, 1990



Controlled substances are secure in a locked cabinet or space and dispensation is logged



A system is in place to ensure that all medications are within the expiration date

Rationale: To protect the safety and privacy of all patients, and for the protection of the clinic, EPNI requires all behavioral health clinics to develop and implement written policies and procedures. Providers are encouraged to have policies that are specific to the clinic and are signed, dated and reviewed annually. Requirement: Each clinic will have policies and procedures in place for the following topic in addition to the policies listed previously in this chapter. •

Behavioral Health Accessibility Standards

Policy Required

Behavioral Health Accessibility Standards

EPNI Provider Policy and Procedure Manual (05/10/13)

Recommended Risk Management Elements



Access to behavioral health appointments commensurate with clinical need



Access to follow-up appointments commensurate with clinical need



Crisis access to clinician 24 hours a day/7 days a week

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Health Care Improvement

Treatment Record Documentation

Rationale: The patient behavioral health treatment record is a vehicle for documenting services and evaluating continuity and coordination of care. It also serves as legal protection for the patient and practitioner. EPNI, per contractual agreement with both the Subscriber and Provider, has access to the Subscriber's record for examination and evaluation. EPNI corporate confidentiality policy requires that the personal and health information of its Subscribers be maintained as confidential information. All employees are required to attest to their knowledge of this policy and their intent to comply with it. Treatment record review is an essential component of a comprehensive Health Care Improvement program. The EPNI Quality Council establishes minimum record documentation standards. Annually, EPNI audits a random sample of patient records from the EPNI population. The records are reviewed in accordance with the required documentation elements. If potential deficiencies are identified at a given site, a more intensive review may occur. Aggregate audit results are disseminated to the Select Network and clinic-specific results are disseminated to each audited clinic. Requirements for Treatment Record Format and Content Record Organization

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The format of the treatment record must be logical and organized.



All forms used in the treatment process must be standardized and consistent for all records.



The treatment record must contain the patient’s current address, employer or school, home and work phone numbers, marital or legal status, appropriate consent forms, and guardianship status information.



Special status situations, such as imminent risk of harm, suicidal or homicidal ideation, or elopement potential, must be prominently documented and updated.

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Health Care Improvement

Treatment Record Documentation (continued)



There must be a signed patient authorization for all external persons with whom treatment information is exchanged. No treatment information can be exchanged without patient authorization or court order.



Each page in the record must contain the patient’s name or identifying number.



All entries must be dated and contain the author’s name, professional degree/designation, and relevant identification number if applicable. If a non-degreed professional completes the entry, the title of the author must accompany the signature, e.g. Family Skills Worker. Author identification may be a handwritten signature or unique electronic identifier. Initials alone are not an acceptable form of identification. Initials may be used in conjunction with a typed signature block that clearly identifies the author.



Errors in documentation must be corrected with a single line drawn through the error with the author’s initials. Initial Assessment •

Presenting problem(s), as well as relevant psychological or social conditions affecting the patient's medical or psychiatric status, must be documented.



Presenting symptoms that are consistent with DSM-IV-TR criteria must be clearly identified and documented, including the onset, duration, and intensity of symptoms.



A psychiatric history must be documented. The psychiatric history should include, if applicable, previous treatment dates, identification of former treating practitioner(s), therapeutic interventions and responses, relevant family psychiatric history, lab test results, and consultation reports.



A medical history must be documented which includes current and/or past major or chronic medical conditions and a current list of medications. Medication allergies and adverse reactions must be prominently noted. If the patient has no known allergies or history of adverse reactions, this must be noted.



For children and adolescents through age 17, a comprehensive developmental history must be documented that includes prenatal and perinatal events, achievement of developmental milestones, and psychological, social, intellectual, and academic history.

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Health Care Improvement

Treatment Record Documentation (continued)



For individuals ten years and older, a substance use history must be documented. The history must include past and present use of tobacco, alcohol, illicit drugs and any misuse of prescription or over-the-counter drugs. Additionally, negative consequences of use and history of assessment and/or treatment should be documented.



Standardized substance abuse screening questionnaire results should be incorporated into the assessment of all new patients twelve years and older.



A social history must be documented that includes family history, current family status, history of physical, sexual or mental abuse or trauma, current social network, and academic or vocational status.



A mental status examination must be documented which includes, at minimum, information about appearance, speech, affect, mood, thought content, judgment, insight, attention, concentration, memory, and impulse control.



A risk assessment that identifies level of risk for harm, including suicidal, homicidal or elopement risk, must be predominantly documented.



Patient strengths and weaknesses that enable or inhibit the individual’s ability to achieve treatment goals must be documented.



An initial treatment plan must be documented.



All behavioral health care practitioners must attempt consultation and coordination of treatment with the patient’s primary care or treating physician. Patient authorization must be obtained prior to the release of any information. If the patient does not wish to have treatment information exchanged, patient refusal must be documented.

Diagnosis

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A DSM-IV-TR diagnosis must be documented. The diagnosis must be consistent with presenting problems, symptoms, clinical history, mental status exam, and other clinical data.



All fives axes must be documented according to the DSM-IVTR multi-axial diagnostic system. The fifth digit of Axes I and II diagnoses must be listed when applicable.



ICD-9-CM codes must be used when submitting claims for payment.

EPNI Provider Policy and Procedure Manual (05/10/13)

Health Care Improvement

Treatment Record Documentation (continued)

Treatment Plan •

The treatment plan must be comprehensive, current, and consistent with the diagnosis. The formal treatment plan must be completed within the first three visits.



The treatment plan must contain clear, objective, and measurable goals as well as the estimated timeframes for goal attainment or problem resolution. Interventions must be appropriate for the diagnosis and/or presenting problem(s).



The patient must participate in the development of the treatment plan and should sign the initial plan and sign or initial all updates or revisions.

Progress Notes •

All entries must contain the date, actual face-to-face contact time, and current diagnosis.



All entries must document the persons present during the visit without using the names of persons other than the identified patient.



The interventions must be consistent with the diagnosis and correspond with current treatment goals.



Recommendations or referrals for preventive or other external services, e.g., stress management, relapse prevention, or community services, must be documented.



The documentation of each entry must clearly state the chief complaint and current status of symptoms as well as patient strengths and limitations in reaching treatment goals.



There must be a notation in each entry about need for followup care, plans for a return visit, or termination of treatment. The specific date or timeframe of a return visit must be noted.



There must be documentation of patient cancellation or failure to show for a visit.



Evidence of coordination of care with other relevant behavioral health providers and/or medical professionals must be documented.



Unresolved problems from previous visits must be addressed and the outcomes documented.



If safety or risk characteristics are identified, they must be prominently documented and addressed during each visit.



Phone conversations with persons relevant to treatment, e.g. referral sources, physicians, or parents, must be documented.

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Health Care Improvement

Treatment Record Documentation (continued)

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Medication Management •

Significant illnesses, clinical risks, and medical conditions are to be clearly noted and revised periodically.



Current medications prescribed by all prescribing physicians must be listed. Dosages and dates of initial prescription and/or refills must be documented.



Evidence of informed patient consent for the receipt of medication must be documented.



Laboratory orders and results must be documented as well as review of the results by the ordering physician. If abnormalities are found, follow-up plans must be documented.

EPNI Provider Policy and Procedure Manual (05/10/13)

Chapter 4

Integrated Health Management Table of Contents Integrated Health Management................................................................................................ 4-4 Introduction............................................................................................................................ 4-4 Objectives .............................................................................................................................. 4-4 Provider Contractual Obligations – Important Program Points............................................. 4-5 Integrated Health Management Decision Making ................................................................. 4-6 Utilization Management ............................................................................................................ 4-7 Overview................................................................................................................................ 4-7 Goals ...................................................................................................................................... 4-7 Integrated Health Management Medical and Behavioral Health Clinical Staff .................... 4-8 Medical Policy ............................................................................................................................ 4-9 Medical and Behavioral Health Policy Development............................................................ 4-9 Medical Policy and Behavioral Health Policy Manual........................................................ 4-10 Pre-Certification & Pre-Authorization Request Forms........................................................ 4-11 Pre-Certification/Authorization ............................................................................................. 4-12 Overview.............................................................................................................................. 4-12 Learn Scope and Purpose..................................................................................................... 4-13 Decision Making and Notification Time Frames................................................................. 4-13 Definition of Urgent Request............................................................................................... 4-14 Utilization Management Services Requiring Pre-Certification/Authorization.................. 4-15 Overview.............................................................................................................................. 4-15 Pre-Certification Requirements ........................................................................................... 4-15 High Technology Diagnostic Imaging Decision Support...................................................... 4-16 Overview.............................................................................................................................. 4-16 Prior Authorization-Chiropractic .......................................................................................... 4-17 Overview.............................................................................................................................. 4-17 Compliance Audits............................................................................................................... 4-17 Prior Authorization Form Tips............................................................................................. 4-17 Prior Authorization-Durable Medical Equipment (DME) .................................................. 4-19 Overview.............................................................................................................................. 4-19 Requirements ....................................................................................................................... 4-19 Eligible or Non-Covered DME (unless specified in Subscriber Contract).......................... 4-20 Prescriptions or Doctor’s Order ........................................................................................... 4-20 DME and Supplies Reviewed .............................................................................................. 4-20 DME & Medical Supply Pre-Authorization Request Form................................................. 4-20 EPNI Provider Policy and Procedure Manual (05/12/14)

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Integrated Health Management

Prior Authorization-Medical/Dental...................................................................................... 4-21 Medical-Surgical Procedures ............................................................................................... 4-21 Temporomandibular Joint (TMJ) Disorder.......................................................................... 4-22 Address ................................................................................................................................ 4-22 Prior Authorization-Outpatient Mental Health.................................................................... 4-23 Overview.............................................................................................................................. 4-23 Medication Management ..................................................................................................... 4-23 Medical Necessity and Level of Care Guidelines................................................................ 4-24 Compliance Audits............................................................................................................... 4-24 Prior Authorization-Outpatient Chemical Dependency ...................................................... 4-25 Overview.............................................................................................................................. 4-25 Compliance Audits............................................................................................................... 4-25 Medical Necessity and Level of Care Guidelines................................................................ 4-25 Prior Authorization-PT/OT/ST .............................................................................................. 4-26 Overview.............................................................................................................................. 4-26 Prior Authorization Recommendation ................................................................................. 4-26 Compliance Audits............................................................................................................... 4-26 Outpatient Therapy Prior Authorization Form .................................................................... 4-26 Prior Authorization-Organ Transplants ............................................................................... 4-27 Overview.............................................................................................................................. 4-27 Contact ................................................................................................................................. 4-27 Case & Disease Management.................................................................................................. 4-28 Overview.............................................................................................................................. 4-28 Program Goals ..................................................................................................................... 4-28 Referrals to Case Management ............................................................................................ 4-28 Disease Management ........................................................................................................... 4-29 Home Health Care Request Form ........................................................................................ 4-30 Home Infusion Services Prior Authorization....................................................................... 4-31 Inpatient Admission Notification & Pre-Certification Request Form. ................................ 4-32 Hospice Care Prior Authorization........................................................................................ 4-33 Minnesota Pregnancy Assessment....................................................................................... 4-34 Preadmission Notification, Plan-of-Care Review, Continued-Stay Notification ............... 4-35 Overview.............................................................................................................................. 4-35 Information Needed for Preadmission Notification............................................................ 4-36 Preadmission Notification Procedure .................................................................................. 4-36 Admissions Requiring Plan-of-Care Review....................................................................... 4-37 Plan-of-Care Review Procedure .......................................................................................... 4-37 Continued-Stay Notification ................................................................................................ 4-39 Discharge Call Back Process ............................................................................................... 4-39 Inpatient Mental Health and Chemical Dependency Notification....................................... 4-40 Suggestion Outpatient Procedures ....................................................................................... 4-41 PAN Fax Forms ................................................................................................................... 4-45

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EPNI Provider Policy and Procedure Manual (05/12/14)

Integrated Health Management

Focused Utilization Review ..................................................................................................... 4-46 Overview.............................................................................................................................. 4-46 Messages Provider May Receive ......................................................................................... 4-47 Special Investigations .......................................................................................................... 4-48 Documentation in the Medical Record .................................................................................. 4-49 Documentation Requirements.............................................................................................. 4-49 Overview.............................................................................................................................. 4-50 GA Modifier......................................................................................................................... 4-50 Directing Subscribers To Nonparticipating Providers......................................................... 4-51 Upgraded/Deluxe Durable Medical Equipment (DME) ...................................................... 4-51 DME Waiver Requirement .................................................................................................. 4-51 DME Claims Submissions ................................................................................................... 4-51 Sample DME Waiver........................................................................................................... 4-51

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Integrated Health Management

Integrated Health Management Introduction

Per the Employer Provider Network, Inc. (EPNI) Provider Service Agreement, Provider has agreed to comply with care management programs administered by EPNI. These care management programs are designed to ensure that the treatment Subscribers receive is reimbursable according to the Medical Necessity guidelines in their Subscriber Contracts. In addition, EPNI reviews investigative and new procedures/Health Services for coverage determinations. Care management programs also ensure the most cost-effective and appropriate use of the health care delivery system. These programs include: 

Pre-certification/authorization of selected procedures, services, supplies, and drugs



Preadmission notification (PAN), pre-certification and concurrent review for inpatient admissions



Retrospective review of claims and medical records



Case and Disease Management

To make utilization decisions, EPNI uses established utilization review decision criteria based on sound clinical evidence. The criterion used to evaluate an individual case is available, free of charge, upon request for Provider's review. Objectives

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Integrated Health Management programs are designed to: 

Maximize the coordination of care and health outcomes



Ensure appropriate and efficient utilization of health care resources



Promote efficient use of health care resources



Define and agree upon appropriate standards of care



Manage service for Subscribers with complex care coordination needs



Identify gaps in Subscribers' care and navigation of resources



Identification of Subscribers with conditions that will benefit from self-care efforts, care intervention and communication

EPNI Provider Policy and Procedure Manual (05/12/14)

Integrated Health Management

Provider Contractual Obligations – Important Program Points

The following points pertain to all of the care management programs. Any Medical Necessity denial determination may be discussed with a physician reviewer by telephone. 

Any Health Services denied using EPNI’s medical necessity guidelines cannot be billed to the Subscriber unless Provider has specifically notified the Subscriber prior to the Health Service being rendered that it is medically unnecessary and will not be covered, and the Subscriber has agreed in writing to pay for the service. This applies to investigative services as well as some non-covered services for mental health.



The care management process is a review for Medical Necessity only. Payment for Health Services is still subject to all other terms of the Subscriber Contract. Therefore, denials may occur for preexisting conditions, benefit maximums, or riders in the Subscriber's Contract, which supersede Medical Necessity.



EPNI recommend that Provider contact provider services to verify coverage, benefits, contract eligibility and limitations for all Subscribers. Service representatives will also verify which care management procedures apply to a Subscriber's Contract.



Providers will continue to be held financially liable for services that are determined to be not Medically Necessary during a review or an audit process even if preauthorization/certification and/or concurrent review is not recommended.

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Integrated Health Management

Integrated Health Management Decision Making

Integrated Health Management including utilization management (UM) decision-making is based only on appropriateness of care, service and existence of coverage. EPNI does not compensate Providers, Health Care Practitioners or other individuals conducting utilization review decision-making activities for denials of coverage or service. EPNI does not offer incentives to decision-makers to encourage denials of coverage or service that would result in less than appropriate care or underutilization of appropriate care and services. EPNI UM decision-making processes ensure that Subscribers are not discriminated against in the delivery of Health Services consistent with the benefits covered in their Subscriber Contract based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information or source of payment through the use of specific clinical criteria and consideration of the individual needs of each case. This statement exists to inform and remind Providers, their employees, their supervisors, upper management, medical directors, UM directors or managers, licensed UM staff, and other personnel and UM staff employed by Providers who make utilization management decisions of this philosophy and practice. This includes delegates conducting utilization management services on behalf of EPNI.

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EPNI Provider Policy and Procedure Manual (05/12/14)

Integrated Health Management

Utilization Management Overview

The purpose of the Utilization Management (UM) Program is to promote effective, appropriate and efficient use of medical and behavioral health care resources for our members. According to Minnesota statute, “‘Utilization review’ means the evaluation of the necessity, appropriateness, and efficacy of the use of health care services, procedures, and facilities, by a person or entity other than the attending health care professional, for the purpose of determining the medical necessity of the service or admission.” The UM program is a set of continuously improving processes, designed to both meet Subscribers' needs, as well as regulatory and accreditation requirements. The UM program includes processes for: 

Identifying over and under utilization



Identifying members with complex health issues that may benefit from case management



The collection and distribution of UM data

IHM uses the UM program processes, procedures and criteria to review and coordinate Subscribers' benefits to enhance the efficiency, affordability and quality of care. Goals

The UM program purpose of promoting effective, appropriate, and efficient use of health care resources is accomplished by adhering to the UM processes described in this program. The program goals are to: 

Ensure objective and consistent utilization management decision-making



Ensure that Subscribers have access to appropriate and timely medical and behavioral health care across the provider network



Improve service and claims processes to provide optimal handling of pre-service authorization and post-service payment

 Ensure timely resolution of identified problems Continually build and maintain collaborative relationships with medical and behavioral health care providers

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Integrated Health Management

Integrated Health Management Medical and Behavioral Health Clinical Staff

IHM medical and behavioral health clinical staff is responsible for the coordination of utilization management functions for eligible Subscribers. Clinical staff is required to maintain an active unrestricted health license in Minnesota. The IHM medical and behavioral health clinical staff is permitted to approve requested authorizations based on plan documents, policies, procedures, and established medical and behavioral health clinical criteria. Physicians or appropriately licensed peer reviewers make necessary medical necessity denials. Contractual benefits, Medical Necessity, appropriateness, and individual needs are evaluated during the review process to determine coverage of Health Services. All requests for services that do not meet Medical Necessity criteria are reviewed through the physician peer review process. UM decision-making is based only on appropriateness of care and service, and existence of coverage. No financial incentive is awarded to clinical staff for denying requests for service or based on coverage decisions.

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EPNI Provider Policy and Procedure Manual (05/12/14)

Integrated Health Management

Medical Policy Medical and Behavioral Health Policy Development

Medical and behavioral health policies are developed by the EPNI Medical and Behavioral Health Policy Committee, which is comprised of practicing physicians and providers representing a variety of specialties in the local community and one health plan representative. EPNI makes its determination of experimental, investigative or unproven based upon a preponderance of evidence after the examination of the following reliable evidence, none of which shall be determinative in and of itself: 1. Whether there is final approval from the appropriate government regulatory agency, if approval is required; 2. Whether there are consensus opinions and recommendations reported in relevant scientific and medical literature, peerreviewed journals, or the reports of clinical trial committees and other assessment bodies; and 3. Whether there are consensus opinions of national and local health care providers in the applicable specialty or subspecialty that typically manages the condition as determined by a survey or poll of a representative sampling of these providers. The committee considers a number of additional factors when evaluating each of the criteria. These factors include, but are not limited to: quality of the available peer-reviewed medical literature; safety, effectiveness, appropriateness of technology; and the relevant impact and consequences of coverage for the technology (for example, patient, health plan, ethical, societal, legal). A drug, device, medical treatment, diagnostic procedure, technology or procedure for which reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes. EPNI bases its decision upon an examination of the following reliable evidence, none of which is determinative in and of itself. Drugs and devices cannot be lawfully marketed without the approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished.

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Integrated Health Management

Medical and Behavioral Health Policy Development (continued)

The drug, device, diagnostic procedure, technology, or medical treatment or procedure is the subject of ongoing Phase I, II, or III clinical trials: 

Phase I clinical trials determine the safe dosages of medication for Phase II trials and define acute effects on normal tissue.



Phase II clinical trials determine clinical response in a defined patient setting. If significant activity is observed in any disease during Phase II, further clinical trials usually study a comparison of the experimental treatment with the standard treatment in Phase III trials. Phase III trials are typically quite large and require many patients to determine if a treatment improves outcomes in a large population of patients); or

Medically reasonable conclusions establishing its safety, effectiveness or effect on health outcomes have not been established. For purposes of this subparagraph, a drug, device, diagnostic procedure, technology, or medical treatment or procedure shall not be considered investigative if reliable evidence shows that it is safe and effective for the treatment of a particular patient. Medical Policy and Behavioral Health Policy Manual

The EPNI Medical and Behavioral Health Policy Manual ("Policy Manual") contains an overview of the criteria used to determine a policy position based on evaluation by EPNI's Medical and Behavioral Health Medical Policy Committee ("Policy Committee") of a new technology (i.e., drug, device, diagnostic procedure, behavioral health procedure, and medical treatment or procedure).The Policy Manual explains how to locate medical policies on www.ccstpa.com. These policies assist EPNI in making a determination if a Health Service is Medically Necessary and/or investigative and include general coding information and prior authorization instructions. The Provider Policy & Procedure Manual is available at www.ccstpa.com, and is incorporated by reference herein. To view the policies, select "For Providers," then select “Learn More”. Select “Medical Policies”, then select “View Policies”. Read and accept the medical policy statement, and then select “View All Active Policies.” The following are several selections to assist with inquires: 

4-10

The “Upcoming Policies” section lists new or revised policies approved by the Policy Committee; these policies become effective 45 days from the date they were posted to the “Upcoming Policies” section of the Policy Manual.

EPNI Provider Policy and Procedure Manual (05/12/14)

Integrated Health Management

Medical Policy and Behavioral Health Policy Manual (continued)

Pre-Certification & Pre-Authorization Request Forms



The “What’s New” section identifies the latest new or revised policies approved by the Policy Committee at least 90 days earlier. These policies are currently in effect and providers should begin following these policies immediately. These policies also appear in the “Active Policy” section of the Policy Manual.



The “Active Policy” section contains the entire list of policies in effect at the time of Provider's inquiry.



The “Prior Authorization Recommended” sections identify procedures, Health Services, devices and drugs for which prior authorization is recommended or required, as stated in the policy. For Provider's convenience, a link to “Prior Authorization Forms” has also been provided.

Request forms are available at ccstpa.com in the For Providers section under Additional Information – Access Forms.

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Integrated Health Management

Pre-Certification/Authorization Overview

The purpose of Pre-certification/authorization is to review Health Services prior to being rendered to determine if the Health Services are contractually eligible and Medically Necessary. Medical policy criteria and Subscriber Contract language is used to assist in determining if benefits are available for the requested Health Service. Certification/Authorization for a Health Service, device or drug does not in itself guarantee coverage, but notifies Provider that as described, the Health Service, device or drug meets the criteria for medical necessity and appropriateness. Services are only covered only if: • The member is enrolled in the health plan on the date of service • The services or items are covered benefits • The provider is eligible for payment • The provider bills for the services that are approved Payment for services and/or supplies EPNI approves in advance are also subject to the terms of the Subscriber’s coverage including any applicable copays and/or deductibles, preexisting condition limitations, contract exclusions and health plan allowed amounts. The “Pre-certification/authorization” section identifies various Health Services, procedures, prescription drugs, and medical devices that require Pre-certification/pre-authorization. The EPNI clinical reviewer uses local and national medical policy, Medicare guidelines, behavioral health criteria and Subscriber Contract language to assist in determining if benefits are available for the request. Criteria are determined by the type of plan in which the Subscriber is enrolled. Authorization for a Health Service, device, or drug does not in itself guarantee coverage but notifies Provider if the request meets the criteria for Medical Necessity and appropriateness. The provider should always check with customer service to make sure the Subscriber or patient has contract benefits and that the coverage is up to date. EPNI will evaluate Provider's request for Pre-certification and will make a determination once all the necessary medical information is received. Review decisions will be made and communicated within required time frames as defined by state and federal law.

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EPNI Provider Policy and Procedure Manual (05/12/14)

Integrated Health Management

Learn Scope and Purpose

These policies are applicable to all commercial and government program products; medical, surgical, and behavioral health services are included. Benefit plans vary in coverage and some plans may not provide coverage for certain services discussed in the medical policies. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and/or federal law.

Decision Making and Notification Time Frames

To ensure timely processing and assist us in meeting compliance with state and federal guidelines, please submit precertification/authorization requests at least 15 business days prior to any elective services being rendered.

Decision-Making Timeframe for Initial Notification (by Telephone or fax to Practitioner only) Follow-up Notification (Electronic or written notification to Members and Providers) Non-Urgent Pre-certification Requests File Type

Initial and Concurrent Within 10 business days* of receiving request, not to exceed 15 Review: calendar days**. Urgent Pre-certification Requests Initial Review:

Within 72 hours of receiving request or as expeditiously as the member's health condition warrants

Concurrent Review:

Within 24 hours of receiving request.

Post-service Request Retrospective Review

Within 30 calendar days** of receiving the request

*Business day: Day in which EPNI is open for business, does not include weekends or holidays. **Calendar day: Days in sequence on calendar, including weekends and holidays.

EPNI Provider Policy and Procedure Manual (05/12/14)

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Integrated Health Management

Definition of Urgent Request

The federal regulations define an urgent request as: 

Requires immediate action to prevent a serious deterioration of a Subscriber’s health that results from an unforeseen illness or an injury, or



Could jeopardize the ability of the individual to regain maximum function based upon a prudent layperson’s judgment, or



In the opinion of the treating physician, would subject the individual to severe pain that cannot be adequately managed without the treatment being requested. An urgent condition is a situation that has the potential to become an emergency in the absence of treatment. Care that has already been provided is not considered urgent. Requests not meeting the conditions for an urgent request will be considered nonurgent. Both urgent and nonurgent requests will be reviewed and completed within current state and federal timelines. For expedited requests, EPNI adheres to federal and state requirements for decision-making time frames. EPNI uses the following definitions to determine if a request is expedited: Requires immediate action to prevent a serious deterioration of a Subscriber’s health that results from an unforeseen illness or an injury, or Could jeopardize the ability of the individual to regain maximum function based upon a prudent layperson’s judgment, or In the opinion of the treating physician, would subject the individual to severe pain that cannot be adequately managed without the treatment being requested. An urgent condition is a situation that has the potential to become an emergency in the absence of treatment. Requests not meeting the criteria for the urgent definition for an urgent request will be considered non-urgent. Providers submitting the request will be notified by EPNI that the request does not meet urgent criteria and will be managed according to non-urgent criteria. Both urgent and non-urgent requests will be reviewed.

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EPNI Provider Policy and Procedure Manual (05/12/14)

Integrated Health Management

Utilization Management Services Requiring PreCertification/Authorization Overview

Medical and behavioral health policies and the list of services that require pre-authorization are available for Provider's use and review at ccstpa.com.

Pre-Certification Requirements

1. At the bottom of the For Providers column, select “Learn More”. At the bottom of the Medical Policy column, select “View Policies”.

2. Read and accept the EPNI Medical Policy Statement 3. Select “View All Active Policies” at the top of the page 4. The “Pre-Certification/Authorization” links on the left-hand side will direct you to the Pre-authorization requirement list. This list identifies the services, procedures, prescription drugs, and medical devices that require pre-certification/authorization.

EPNI Provider Policy and Procedure Manual (05/12/14)

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Integrated Health Management

High Technology Diagnostic Imaging Decision Support Overview

EPNI recommends seeking authorization of the following high technology diagnostic imaging procedures: 

CT including CTA



MRI including MRA, MRS, MRM



Nuclear Cardiology



PET



fMRI

American Imaging Management (AIM) conducts decision support for these procedures on behalf of EPNI. The decision support process used by AIM uses evidence-based appropriateness criteria to evaluate the requested imaging procedure. Prior to performing these procedures, it is recommended that the ordering or the imaging provider by contacting AIM electronically or by telephone. AIM website www.americanimaging.net www.providerportal.net (available 24/7) AIM Call Center: 1-866-455-8417 Select Option 2 Monday through Friday Central Time 8:00 a.m. – 5:00 p.m.

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EPNI Provider Policy and Procedure Manual (05/12/14)

Integrated Health Management

Prior Authorization-Chiropractic Overview

Providers are encouraged call provider services to obtain Subscriber benefits prior to beginning service. Self-insured groups may require prior authorization and impose visit limits. The Chiropractic Treatment Request Form may be faxed or mailed to EPNI. The form is available at www.ccstpa.com

Compliance Audits

The Provider Service Agreement includes certain quality assurance requirements. Pursuant to the Agreement, EPNI may conduct audits to evaluate Provider’s compliance with Medical Necessity guidelines and standards of practice in the community. Such an audit could include post-service claims review, which may result in Provider liability if the care is determined to be not Medically Necessary or medically inappropriate.

Prior Authorization Form Tips

Below are some tips that Provider may find helpful as it completes the Chiropractic Prior Authorization Form. All information on the form must be completed or authorization may be delayed. 

Pain Severity Scale The Pain Severity Scale should be the patient’s rating of his or her pain. Many forms come in with a 10 rating. Be sure patients understand that a pain rating of 10 indicates severe pain that is incapacitating or intractable.



Exact Views Taken For the Exact Views Taken field, list the specific number of views being requested.



Treatment Goals These treatment goals should be specific and patient oriented. For example: 

Return to recreational activities



Be able to care for children



Restore cervical range of motion for safe driving



Increase time sitting, reading, lifting or performing



Household tasks

EPNI Provider Policy and Procedure Manual (05/12/14)

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Integrated Health Management

Prior Authorization Form Tips (continued)

4-18



Active Care Active Care is instruction to the patient about how to care for himself or herself. Examples are exercise, weight loss, stress reduction, lifestyle modification or changes in the work environment.



Smoker and BP>140/90 Make sure the “Y” or “N” are circled in the area at the top of the form.

EPNI Provider Policy and Procedure Manual (05/12/14)

Integrated Health Management

Prior Authorization-Durable Medical Equipment (DME) Overview

EPNI does not accept prior authorizations for durable medical equipment (DME) from the Subscriber or physician. All requests must be made by the DME Provider. The DME Provider can provide all details required, such as specific features, costs, alternatives, and documentation of Medical Necessity as provided by the physician.

Requirements

DME Providers should use the Pre-Authorization Request Form, whenever submitting a prior authorization. This form is available at www.ccstpa.com. All prior authorizations must include medical documentation. The prior authorization request should include the following information: 

The medical diagnosis related to the need for the equipment



The patient’s functional abilities and deficits related to the need for the equipment



Whether the equipment is to be rented or purchased



A breakdown of the charges, if available



The anticipated length of time the equipment will be needed



All applicable HCPCS codes and narratives

Note: HCPCS code E1399 and other unlisted codes should be used only when there is no other HCPCS code to describe the equipment, such as custom-made equipment. Incomplete information or incorrect use of HCPCS codes may result in delayed review of the prior authorization request or incorrect claim payment. EPNI reserves the right to return to the Provider any prior authorization request or to reject a claim that is submitted with an E1399 and other unlisted HCPCS codes without complete description of the equipment. EPNI will accept all valid HCPCS codes and will reimburse as appropriate.

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Integrated Health Management

Eligible or NonCovered DME (unless specified in Subscriber Contract)

Equipment that is primarily and customarily used for a nonmedical purpose, may not be considered “medical” equipment for which payment can be made. Equipment primarily for independence, self-sufficiency and prevention or reoccurrence of medical conditions, are not generally considered as treatment of existing disease. Examples of ineligible DME include: 

environmental aides



exercise equipment



safety equipment



home modifications



sensory aides



vehicle modifications



transportation aides

Note: In certain circumstances, some equipment, even though not necessarily medical equipment, may be eligible when it is serving a similar function of typically eligible DME. Cases must be considered individually since eligibility depends upon the specific situation. Prescriptions or Doctor’s Order

Please submit a copy of the prescription or doctor’s order for DME. The prescription or doctor’s order for DME provides necessary information to assure appropriate notification of decisions to the attending Health Care Provider.

DME and Supplies Reviewed

Provider can write or fax its Prior Authorization Request Form to Medical Review. Refer to Chapter 1 – At Your Service for the address or fax number. The following is a general list of DME or Supplies that Medical Review evaluates.

DME & Medical Supply Pre-Authorization Request Form

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Communications devices



DME over $1,000 without an assigned HCPCS code



Electrical bone growth stimulator



Implantable infusion pumps



Specialty beds/overlays



Vest percussor for cystic fibrosis



Wheelchair (purchase only) Commercial, only

A sample of the DME and Medical Supply Pre-Authorization Request Form is available at www.ccstpa.com.

EPNI Provider Policy and Procedure Manual (05/12/14)

Integrated Health Management

Prior Authorization-Medical/Dental Medical-Surgical Procedures

Self-insured groups may have different requirements and Provider is encouraged to use provider services to obtain Subscriber benefits prior to beginning service. Many Subscriber Contracts cover specific medical-surgical procedures that dentists perform. The procedures which fall into this category are: 

Treatment of accidental injury to natural teeth, which is not regular dental repair or maintenance. Initial treatment must begin within a time frame specified by the Subscriber's Contract and is only to repair or replace teeth. Biting or chewing does not constitute an accident. Treatment involving dental implants and dentures is specifically excluded.



Surgical and nonsurgical treatment of temporomandibular joint (TMJ) syndrome and craniomandibular disorder.



Treatment of cleft lip and palate for Subscribers who have initiated or scheduled services prior to age 19.



Reconstructive surgery to correct a functional physical defect for dependent children (dependent child is defined by the age limit for a dependent child or student dependent, whichever is later, if applicable, as specified in the Subscriber's Plan.)—this would include orthognathic surgery & surgical treatment of cleft lip and palate. Treatment involving dental implants is specifically excluded.



Anesthesia and inpatient and outpatient hospital charges for dental care provided to a covered person who is a child under age five (5); is severely disabled; or has a medical condition that requires hospitalization or general anesthesia for dental treatment. The actual dental service should be billed to the Subscriber's dental carrier.

Prior Authorization is recommended for Health Services related to surgical TMJ, orthodontia for TMJ and reconstructive surgery. A prior authorization is strongly suggested for accidental injury treatment beyond the emergency visit. A prior authorization is recommended for Subscribers over the age of four for facility and anesthesia charges related to a dental procedure. Please direct these requests to Medical/Dental Review.

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Integrated Health Management

Temporomandibular Joint (TMJ) Disorder

Some Subscriber Contracts offer coverage for TMJ disorders. A prior authorization is recommended for surgical treatment and orthodontia. The following information is recommended to be submitted with all PA requests to justify the diagnosis and to provide evidence that all probable etiologies for the TMJ disorder have been considered and that the proposed treatment is appropriate for the identified condition. Documentation must include a complete treatment plan. A diagnosis of TMJ alone is not sufficient. Sufficient evidence must be provided to show medical necessity. The treatment must be appropriate and based on the most costeffective alternative.

Address

Please direct all correspondence to: Integrated Health Management Utilization Management, R472 P.O. Box 64265 St. Paul, MN 55164-0265 Fax: (651) 662-2810

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Prior Authorization-Outpatient Mental Health Overview

Outpatient mental health services are no longer subject to prior authorization and Medical Necessity determination, unless required by the Subscriber's Contract. Providers are encouraged to call provider services to obtain Subscriber benefits prior to beginning services. Note: Please contact provider services for group exceptions to these general prior authorization rules. To obtain prior authorization for Health Services when required by the Subscriber's Contract, Providers should complete the Minnesota Universal Outpatient Mental Health/Chemical Health Authorization Form. The form is available at www.ccstpa.com. The form may be requested by calling provider services.

Medication Management

Prior Authorization for medication management (code 90862 or M0064) is no longer required for sessions exceeding 12 per calendar year, unless required by the Subscriber's Contract.

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Medical Necessity and Level of Care Guidelines

EPNI Medical Necessity Criteria and Level of Care Guidelines were developed with a national advisory panel. The criteria are based on current scientific evidence and community standards, and are reviewed annually by a multidisciplinary behavioral health advisory panel made up of providers from around the state. Copies of the criteria, as related to a specific request for services are available upon request. Mental health and chemical dependency Medically Necessary services are defined as those which are: 

Intended to identify or treat a diagnosable disorder (using the DSM- IV) that causes pain or suffering, threatens life, results in illness as manifested by impairment in social, occupational, scholastic or role functioning.



Consistent with nationally accepted standards of medical practice.



Individualized, specific and consistent with the individual’s signs, symptoms, history and diagnosis.



Reasonably expected to help restore or maintain the individual’s diagnosable disorder.



Not primarily for the convenience of the individual, provider or another party.



Provided in the least restrictive setting that balances safety, effectiveness and efficiency.

Licensed behavioral health review staff use Medical Necessity and therapeutic appropriateness criteria to determine severity of need and appropriate level of care when determining treatment authorizations for mental health and chemical dependency services provided in inpatient, partial hospitalization, residential, day treatment and outpatient level of care settings. Criteria are reviewed annually for effectiveness, appropriateness and consistent application based on clinical practice advances in the field of behavioral health, review of current scientific literature and input from currently practicing behavioral health care practitioners. Compliance Audits

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The Provider Service Agreement includes certain quality assurance requirements. Pursuant to the Agreement, EPNI may conduct audits to evaluate a Provider’s compliance with Medical Necessity guidelines and standards of practice in the community. Such an audit could include post-service claims review, which may result in Provider liability if the care is determined to be not Medically Necessary or medically inappropriate.

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Prior Authorization-Outpatient Chemical Dependency Overview

Outpatient chemical dependency services are no longer subject to Prior Authorization and Medical Necessity determination, unless required by the Subscriber's Contract when provided by a participating provider. It is recommended that Provider call provider services to verify Subscriber benefits prior to beginning treatment. Please contact provider services for group exceptions to these general prior authorization rules. To obtain Prior Authorization for Health Services when required by the Subscriber's Contract, beyond the first two-hour assessment, Provider should complete the Minnesota Universal Outpatient Mental Health/Chemical Health Authorization Form. The form is available at www.ccstpa.com. EPNI behavioral health staff will determine if the Health Services meet the criteria for Medical Necessity and if services are eligible based on documentation supplied and coverage provided by the Subscriber's Contract.

Compliance Audits

The Provider Service Agreement includes certain quality assurance requirements. Pursuant to the Agreement, EPNI may conduct audits to evaluate Provider’s compliance with Medical Necessity guidelines and standards of practice in the community. Such an audit could include post-service claims review, which may result in Provider liability if the care is determined to be not Medically Necessary or medically inappropriate.

Medical Necessity and Level of Care Guidelines

Please reference the Medical Necessity and Level of Care Guidelines information in the Prior Authorization-Outpatient Mental Health section earlier in this chapter.

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Prior Authorization-PT/OT/ST Overview

Prior authorization for outpatient physical, occupational and speech therapy services is recommended in situations listed below for fully insured groups. Self-insured groups may have different requirements and Providers is encouraged call provider services to verify benefits. Provider may write or fax Chiropractic and Allied Health. Refer to Chapter 1 – At Your Service, for the fax number and address.

Prior Authorization Recommendation

1. Non-participating providers: All outpatient therapy services performed by a provider that does not have a Provider Service Agreement. 2. All Maintenance and Specialized Therapy: A prior authorization is required for all lines of business and all diagnoses.

Compliance Audits

The Provider Service Agreement includes certain quality assurance requirements. Pursuant to the Agreement, EPNI may conduct audits to evaluate Provider’s compliance with Medical Necessity guidelines and standards of practice in the community. Such an audit could include post-service claims review, which may result in Provider liability if the care is determined to be not Medically Necessary or medically inappropriate.

Outpatient Therapy Prior Authorization Form

A sample of the Outpatient Physical, Occupational & Speech Therapy Request Form is available at www.ccstpa.com.

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Prior Authorization-Organ Transplants Overview

Prior Authorization for major organ (excluding kidney or cornea transplants), bone marrow and stem cell transplants must be coordinated through EPNI's transplant unit. Prior Authorization for transplants are submitted by the transplant provider. Kidney and Cornea Transplants:

Contact



Covered on the same basis as any other illness



Not included in the EPNI transplant network



Prior authorization is not recommended

Pre-Service requests can be mailed or faxed using the Transplant Request form. The form is available at www.ccstpa.com. Contact information: Integrated Health Management Utilization Management, R472 P.O. Box 64265 St. Paul, MN 55164-0265 Fax: (651) 662-2810

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Integrated Health Management

Case & Disease Management Overview

Mission Statement Integrated Health Management (IHM) combines historically fragmented Disease and Case Management services to provide a whole person approach to improving Subscriber health, working with Subscribers who are facing chronic, complex, catastrophic injuries, illness or diseases. IHM clinicians work collaboratively with Subscribers, Providers, and the community to promote optimal health, and coordinate access to services across the continuum of care that is holistic, seamless and easily accessible. Clinicians Licensed Nurses/Clinicians, using a collaborative process, advocate, assess, plan, implement, coordinate, monitor and evaluate options and services to meet an individual’s specific health care needs through education and communication of available resources to promote high quality, cost effective outcomes for Subscribers with medical and behavioral conditions that require ongoing or intermittent care. Clinicians are required to maintain an active unrestricted health license in Minnesota.

Program Goals

Referrals to Case Management

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Maximize optimal health and functional outcomes.



Identify gaps in care



Reach out to the Subscribers with the greatest need and educate them about their condition



Support and encourage individual accountability for health and wellness (self-care management)



Help Subscribers coordinate their needs and navigate services in the health care system



Tailor interventions and outreach to promote the appropriate use of health care services



Improve Subscribers satisfaction with the health plan and health care system

A referral can be made by contacting the Nurse Guide Team at 1866-489-6947.

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Disease Management

Disease management is a multidisciplinary, continuum-based approach to health care delivery that proactively identifies populations who have or are at risk for, chronic medical and behavioral health conditions. Disease management supports the practitioner-patient relationship and plan of care, emphasizes the prevention of exacerbation and complications using cost-effective, evidence-based practice guidelines and patient empowerment strategies such as education and self-management. The process of disease management evaluates clinical, social/humanistic and economic outcomes with the goal of improving overall health of the whole person. Subscribers who receive disease management services receive support from a dedicated clinician, who assists in facilitating the health of the whole person, not just their individual condition. *Services are offered to Subscribers, participation is optional. * Subscriber eligibility for disease management is determined by the Subscriber Contract. Disease States 

Asthma



Coronary Artery Diseases (CAD)



Chronic Kidney Disease (CKD)



Chronic Obstructive Pulmonary Disease (COPD)



Depression



Diabetes



Heart Failure



Low Back Pain



Oncology

In addition to the above conditions, EPNI also offers a prenatal support program to eligible Subscribers. Please contact customer service to determine if a Subscriber is eligible. A nurse or clinician may contact Provider's office for assistance with a Subscriber's needs or to verify a Subscriber’s contact information. They may also send a Provider a letter including Subscriber goals and/or gaps in care to inform Provider on what EPNI is working with the Subscriber to advance their health care needs. EPNI looks forward to working with its Subscribers' Health Care Practitioners to improve the health of its Subscribers.

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Home Health Care Request Form

During the prior authorization process, EPNI's purpose is to assure that home health care services are reasonable and necessary for the treatment of the Subscriber's illness or injury. Health Services must be ordered in writing from a physician and performed by a Medicare certified/Joint Commission approved home health agency. Home health care must be skilled rather than non-skilled or custodial and of such a level of complexity and intensity that the services can only be performed by a Medicare certified or Joint Commission approved home health agency. Our review is performed referencing Medicare Criteria. The Home Health Care Request Form is available at www.ccstpa.com. Information requested from Provider over the phone or by fax:

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Caller’s name and phone number



Subscriber's name, CCStpa ID #, and group #



Home health agency name, phone number, and EPNI contracting provider #



Diagnosis



Physician’s name recommending the home health care



Treatment request



Homebound status



Subscriber's support system (available caregivers)



Medical history (onset of conditions, test results, surgeries, complications, previous treatment and response)



Problems and functional limitations (measurements, baseline)



Goals (objective, measurable, functional, time-specific)



Plan of care



Home program (physical, occupational, and speech therapies)



Re-evaluation (response and alterations in plan)

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Home Infusion Services Prior Authorization

During the prior authorization process EPNI's purpose is to assure that home infusion services meet EPNI’s Medical Policy guidelines. Prior Authorization is only required for the following situations: Factor Products and IVIG therapy. Services must be ordered in writing from a physician and performed by a Medicare certified/Joint Commission approved home infusion provider/agency. Information requested from Provider over the phone or by fax: 

Caller’s name and phone number



Subscriber's name, CCStpa ID #, and group #



Home infusion provider name, phone number and EPNI contracting provider #



Ordering physician’s name, phone number, and EPNI contracting provider #



Diagnosis



Medical history (onset of conditions, test results, surgeries, complications, previous treatment and response)



Problems and functional limitations (measurements, baseline)



Goals (objective, measurable, functional, time-specific)



Plan of care (infusion request, parenteral, enteral; caregiver/self potential ability to administer infusion; duration) and frequency of infusion

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Integrated Health Management

Inpatient Admission Notification & PreCertification Request Form.

During the prior authorization process EPNI's purpose is to review extended care (i.e., skilled nursing facility, nursing home, extended care unit, swing bed or transitional care unit) for both the appropriateness of the admission and continued length of stay. EPNI's review is performed referencing Medicare criteria. Extended care must be ordered in writing from a physician and performed by a Medicare certified facility. In order to be eligible for coverage, services must be skilled and provided on a daily basis. Custodial care is not a covered service. The Inpatient Admission Notification & Pre-Certification Request Form is available at www.ccstpa.com. Information requested from the provider over the phone or by fax:

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Caller’s name and phone number



Subscriber's name, CCStpa ID #, and group #



Skilled nursing facility name, phone number, and EPNI contracting provider #



Diagnosis



Physician’s name that is recommending skilled nursing care



Medical history (onset of condition; complications, problems and functional limitations; previous treatment response; recent hospitalizations or surgeries; support system)



Plan of care



Anticipated length of stay (Is the goal to return home or is this a permanent placement?)



Therapies being provided, if applicable (Will the claim be submitted using the extended care or the rehabilitation agency’s provider number?)



Name and number of contact person for concurrent review updates

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Hospice Care Prior Authorization

During the prior authorization process EPNI's purpose is to provide a holistic approach to the recipient’s end of life care needs. EPNI assures that the frequency and type of hospice services are tailored to meet the needs of the recipients and verify that a hospice benefit is available. The hospice provider must be Medicare and/or Joint Commission certified. Information requested from Provider over the phone or by fax: 

Caller’s name and phone number



Subscriber's name, EPNI ID #, and group #



Hospice agency name, phone number, and EPNI contracting provider #



Diagnosis



Ordering physician’s name



Has the physician signed a six-month life expectancy form?



Has the family/Subscriber accepted the “hospice philosophy”?



Subscriber's support system (available caregivers)



Medical history (onset of condition and current status)



Services needed (volunteers, nursing, equipment)



Person to whom we should send the hospice letter



Contact person for updates

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Integrated Health Management

Minnesota Pregnancy Assessment

The Minnesota Council of Health Plans initiated a collaborative effort to design a uniform pregnancy assessment tool. The tool, Minnesota Pregnancy Assessment Form, was designed to enable health plans and the Minnesota Department of Human Services (DHS) to accept the same form for all pregnant women in Minnesota. The Minnesota Pregnancy Assessment Form Training Manual was developed to provide providers with the background concerning the form’s development and to assist providers with using the form as part of providing high quality prenatal care. A copy of this manual may be requested from EPNI Case Management. To obtain forms: The Minnesota Pregnancy Assessment Form, #DHS-3294, can be downloaded off the DHS website: http://www.dhs.state.mn.us/provider/forms/ http://edocs.dhs.state.mn.us/lfserver/legacy/DHS-3294-ENG To assure quality care, EPNI requires Provider to do a risk assessment for all its pregnant EPNI Subscribers. EPNI recommends that the Minnesota Pregnancy Assessment Form be used for all patients. For other health plans insured or administered by EPNI: Complete and mail or fax the assessment and the form at the initial visit and again at 24-28 weeks. Send the form to the EPNI Case Management Department at the address or fax number below. Use Provider's EPNI contracting provider number for these Subscribers. EPNI Case Management Perinatal Unit R4-72 P.O. Box 64560 St. Paul, MN 55164-0560 Fax: (651) 622-1004 Phone: (651) 662-1818 or 1-888-878-0139, x1818 Refer to Chapter 11 – Coding Policies and Guidelines, for coding and reimbursement information related to the assessment and form.

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Preadmission Notification, Plan-of-Care Review, Continued-Stay Notification Overview

Per the Provider Service Agreement, preadmission notification (PAN), plan-of-care review, or continued-stay notification is recommended for inpatient admissions. PAN is the notification to EPNI of an inpatient facility stay. This does not represent an approval or a denial of the admission; it is only a notification of the admission. Listed below are descriptions detailing when each is recommended for EPNI (fee-for-service) plans and EPNI (managed care) plans. EPNI (fee-for-service plan) admissions: 

PAN – all admissions-notification only



Plan-of-care review - admissions listed in Admissions requiring plan-of-care review



EPNI (managed care plan) admissions:



PAN - all admissions-notification only



Plan-of-care review - admissions listed in Admissions requiring plan-of-care review

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Integrated Health Management

Information Needed for Preadmission Notification

The following information is necessary for PAN on inpatient admissions: 

Subscriber identification and group numbers



Subscriber name and address



Patient name, birth date, and sex



Admitting physician’s name and EPNI’s individual provider number



Admitting diagnosis code



ICD-9-CM surgical procedure code and narrative, if applicable



Date of surgery, if applicable

 Date of admission Clinical information supporting the need for inpatient admission (plan-of-care) is only necessary for those admissions requiring a plan-of-care review. Maternity/delivery admissions are exempt from PAN. Most Inpatient Admissions for Mental Health or Chemical Dependency do not require plan-of-care review. Admissions for the Subscribers with the following coverage require a plan-of-care review: VA and CCStpa. Refer to Admission Requiring Plan of Care. Preadmission Notification Procedure

The PAN procedure applies to admissions not requiring plan-ofcare review or continued-stay notification. The provider should contact EPNI as soon as the admission is scheduled, but no later than two working days after the admission occurs. How to contact EPNI: 

Phone – Call provider services and please have the information under Information Needed for Preadmission Notification in the previous section available.



Fax – The fax form may only be used for the following exceptions: 

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non-rehab acute inpatient admissions

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Admissions Requiring Plan-of-Care Review

As a general guide, the plan-of-care review pertains only to the following EPNI acute inpatient admissions: 

Direct admissions to acute rehabilitation units or facilities



Admissions for inpatient pain management programs



Residential admissions (inpatient gambling treatment programs, inpatient smoking cessation programs)



Cases where the Medical/Behavioral Health policy recommends a plan of care review



All admissions to nonparticipating providers



Skilled nursing facilities (EPNI Case Management reviews these admissions). There may be hospital-specific requirements. EPNI recommends that Provider contact provider services to verify coverage, benefits, contract eligibility, and limitations for all Subscribers. Provider services representatives will determine if plan of care is required for that Subscriber's Contract. Plan-of-Care Review Procedure

Outlined below are the steps to obtain a plan-of-care review for required admissions. Provider should call provider services as soon as the admission is scheduled but no later than two working days after the admission occurs. This information is critical to ensure seamless payment of claims, as well as triggering review for inclusion of the patient in the discharge follow-up process. EPNI will complete this process in one working day whenever possible. Provider should assume the admission is approved unless unless EPNI initiates further contact. 1. The admitting physician’s office or hospital representative calls EPNI provider services with the necessary information (refer to Information Required for Preadmission Notification) as well as the clinical information supporting the need for inpatient admission (plan-of-care). The provider services representative documents the information, quotes benefits, and then transfers the caller to a clincian. If Provider does not require benefits to be quoted and know that the admission requires a plan-of-care review, Provider may contact the clinician directly. (Refer to Chapter 1 for phone numbers).

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Plan-of-Care Review Procedure (continued)

2. A clincian uses established criteria to screen the medical necessity of the admission. If the clinician…

Then, the clinician…

can approve the admission

will document the information in their tracking tool and inform the caller of the approval and case number. Provider does not need to go beyond this step.

cannot approve coverage for the admission

contacts a physician reviewer who reviews the case. Continue to Step 3.

3. A physician reviewer will review a case that the clincian cannot approve for medical necessity. If the physician reviewer…

Then, the clinician will contact the provider…

is able to approve the admission

who initiated the review and inform the caller of the approval and the case number. Provider does not need to go beyond this step.

is unable to approve coverage for the admission

by phone and written communication is sent to the Subscriber, physician, and hospital. The admitting physician, hospital, or Subscriber may appeal the denial within 30 days. Continue to Step 4.

4. After additional information is provided to us, the physician reviewer will review the case.

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If the physician reviewer…

Then, the clinician will contact the provider…

approves the admission

who initiated the review and inform of the approval and provide the case number.

is unable to approve the admission and no more information is obtained

by phone and written communication is sent to the Subscriber, physician, and hospital. The admitting physician, hospital, or Subscriber may appeal the denial within 30 days.

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Continued-Stay Notification

The information required is the same as for PAN. It is usually a notification process only. Length-of-stay or continued-stay medical necessity review will be performed on cases outlined in the “Admissions Requiring Planof-Care Review” section. Hospital staff is encouraged to contact Case Management if they have identified a Subscriber who may benefit from case management services (refer to the Case Management section).

Discharge Call Back Process

Subscribers with short hospitalizations may not meet the triggers for case management support. To better address their needs, EPNI initiated a discharge follow-up program in the summer of 2005 to help make sure Subscribers have the resources they need to safely manage their care at home. The purpose of discharge follow-up is to achieve the following: 

Support the physician’s discharge and ongoing treatment plans



Assess the Subscriber's /family member’s understanding of his or her diagnosis, discharge plan, medication and treatment plans, and physician follow-up



Coach Subscribers /family members to a better understanding of their conditions, treatment plans and wellness strategies



Identify Subscribers at risk and refer them to appropriate resources



Identify opportunities for integration or referral to other EPNI programs such as care support, clinician phone line, tobacco cessation, or EAP services.

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Integrated Health Management

Discharge Call Back Process (continued)

How does this all work? Currently, if a Subscriber is hospitalized with a condition related to cardiac, respiratory, or obesity surgery, EPNI care managers will call them within a few days following their discharge from the hospital (assuming EPNI has been made aware of the admission). EPNI also follows up with a letter to the Subscriber which informs them that they can call EPNI if EPNI is unsuccessful in reaching them at home. EPNI conducts this call back process for Subscribers who have experienced a behavioral health admission also. The focus is on the following admissions:

Inpatient Mental Health and Chemical Dependency Notification

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Child/adolescent residential



Mental health inpatient admissions for patients younger than age 16



Mental health inpatient admissions for patients older than 65



Mental health inpatient admissions for patients between 17 and 64 if diagnosed with anxiety or mood disorders

The facility is required to contact EPNI for mental health and/or chemical dependency admissions. This is a notification process only for participating Providers for the following Health Services: Acute Care, Partial Hospital and Residential Treatment. Plan-ofcare notification may be required per Subscriber Contract.

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Suggestion Outpatient Procedures

These procedures are usually done on an outpatient basis. If any of these procedures are done on an inpatient basis, preadmission notification is recommended. Below are suggested outpatient procedures. Please refer to the Prior Authorization section of this chapter for additional surgical review requirements.

Procedure Name(s)

ICD-9-CM Codes

Adenoidectomy with or without tonsillectomy

28.2, 28.3, 28.6

Anal Fistulectomy

49.12

Antral Puncture, Sinus Puncture, other than Antrum Intranasal 22.01, 22.02, 22.2, 22.50 Antrostomy, Antrostomy, Sinusotomy Arteriography

88.40-88.58

Arthrodesis (Metatarsophalangeal) Joint and Interphalangeal Joint

81.16, 81.28

Arthroscopy, Arthrotomy, Capsulotomy, with Exploration Drainage or Removal of Foreign body, (Includes Elbow, Knee & others)

80.20-80.29

Biopsy of Perineum, Vulva, Uterus, with or without Fulguration

49.22, 68.13, 71.11, 70.24

Biopsy of Skin, Soft Tissue, Facial Bone, Muscle

76.11, 83.21, 86.11

Blepharectomy, Blepharoplasty, Reconstruction of Eyelid

08.09, 08.61-08.64, 08.6908.74

Breast Biopsy, Incision and Excision, Biopsy of Breast, Needle Biopsy

85.11, 85.12

Bronchoscopy-Rigid, Flexible Biopsy/No Biopsy/Brush, Biopsy & Washings

33.21-33.25, 98.15

Bunionectomy

77.51-77.59

Bursectomy

82.31, 83.5

Canthotomy, Canthoplasty

08.51, 08.59

Capsulotomy-Cutting or Division of Joint Capsule, Capsulectomy

80.40-80.49, 80.94

Cardiac Catheterization (left, right)

37.21-37.23

Carpal Tunnel Release

04.43

Cataract Extraction

13.19

Chalazion Excision, Incision and Drainage Abscess

08.21

Circumcision, Non-Pediatric and Pediatric

64.0

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Procedure Name(s)

ICD-9-CM Codes

Colostomy Revision, Simple

46.40-46.41, 46.43

Culdoscopy, Culdocentesis

70.0, 70.22, 70.23

Cystometrogram

89.22

D&C with or without Cone, Sturmdorf Repair Cryocautomy, Injection, Endometrial Biopsy

67.2, 67.33, 68.13, 69.02, 69.09, 69.59, 69.95

Dental Procedures (Root Canal, Extraction)

23.01-23.49, 23.70-23.71

Dilatation of Bladder

96.25

Discission Lens, Needling Lens, Secondary Membrane Aspiration of Lens Material for Cataract

13.2, 13.3, 13.64

Ectropion, Entropion Repair

08.41-08.49

Endoscopies with or without Biopsy or Removal of Foreign Body

44.11, 44.13-44.15, 45.1145.15, 45.21-45.27, 50.11, 51.11

Esophogoscopy with or without Biopsy, with Foreign Body Removal

42.22, 42.23, 42.24, 98.02

Examination under Anesthesia

89.39

Excision of Ganglion, Ganglionectomy (usually Wrist) Excision/Incision of Pilonidal Cyst

82.21, 83.39, 86.03, 86.21

Excision of Morton’s Neuroma, Neuroma of Somatic Nerve, Neurectomy

04.07

Excision and Simple Closure-Lesion, Cyst Lipoma, Polyps, Nevus, Ingrown Toenails, Fibroma, including Malignant Lesions, Sebaceous Cyst, Planter’s Wart, Basal Cell Melanoma

82.29, 83.39, 83.45, 86.04, 86.23, 86.3, 86.4, 86.51, 86.59

Excision of Turbinate, Inferior Turbinate Fracture

21.61-21.69

Exostosis Excision

77.60

Eye Muscle Surgery; Resection; Recession, Advancement, etc. Any number of muscles, one or both Eyes a) Initial b) Subsequent

08.33, 08.38, 15.11-15.13, 15.19, 15.21, 15.22, 15.29, 15.3-15.7, 15.9

Ganglionectomy, Excision of Ganglion (usually wrist)

82.21, 83.39

Gastrotomy Tube Removal

97.51

Hallux Valgus, Simple Correction by Exostosectomy and Radical Exostosectomy, Exostosis

77.53, 77.54, 77.59, 77.60

Hammer Toe Operation

81.17, 77.56

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Procedure Name(s)

ICD-9-CM Codes

Hemodialysis

39.95

Hemorrhoidectomy, Excision of Hemorrhoid Tags by Simple Ligature (Rubber Band) or by Cryotherapy, Other Hemorrhoid Procedures

49.44, 49.45, 49.46, 49.47, 49.49, 49.03

Hernia Repair (Inguinal and Umbilical, Simple Ventral)

53.00-53.02, 53.10-53.13, 53.49, 53.59

Hydrocele Excision, Hydroelectomy

61.2, 63.1

Hysterosalpingogram

87.82, 87.83

Insertion of Catheter or Injection Agent into Spinal Canal

03.90-03.92

Incision and Drainage of Bartholin’s Abscess, Excision or other Destruction of Bartholin’s Gland

71.22-71.24

Incision and Drainage, Biopsy, or Excision of Nodes

40.0, 40.11, 40.21-40.24, 40.29

Iridectomy, any type

12.13-12.14

Lacrimal Duct Probing or Reconstruction, Splitting of Lacrimal Papilla, Drainage of Lacrimal Duct

09.0, 09.43, 09.51, 09.44

Laparoscopy

54.21

Laryngoscopy, with insertion of Radioactive Substance, Indirect with Removal of Foreign Body

31.42, 92.27, 98.14

Ligation and Excision of Small Varicosity of Long and Short Saphenous, Occlusion of Leg Veins

38.50, 38.59, 38.80, 38.89

Temporal Artery Ligation

38.82

Lithotripsy (ESWL)

59.95, 98.59

Liver Biopsy, Percutaneous

50.11

Lumbar Puncture

03.31

Myelogram

87.21

Myringoplasty, Type II-V

19.4, 19.52-19.55

Myringotomy, with or without Tube Insertion Unilateral or Bilateral, Tympanoplasty, Tympanotomy, Stapedectomy

19.11-19.19, 20.01, 20.09

Nail, Removal of any number, Fingernail or Toenail Removal

86.23

Nasal Polypectomy

21.31, 21.32

Neurolysis, including Carpal Tunnel Decompression, Tarsal Tunnel Release

04.43, 04.44, 04.49

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Integrated Health Management

Procedure Name(s)

ICD-9-CM Codes

Orchiopexy

62.5

Otoplasty, Unilateral, Bilateral

18.79

Palmar Fasciectomy

82.35

Pelvic Examination under Anesthesia

89.26

Perineal Biopsy

86.11, 71.11

Perineoplasty, Perineorrhaphy, Repair of Vulva Fistula

71.71, 71.72, 71.79

Pilonidal Sinus Excision/Incision

86.03, 86.21

Phalangectomy, Finger and Toe Amputation, Metatarsal Head 77.68, 77.88, 77.89, 77.99 Excision Prostate Biopsy

60.11, 60.12

Proctoscopy

48.23

Pterygium (Excision or Transposition)

11.31-11.39

Reduction of Nasal Fracture

21.71, 21.72

Removal of Foreign Body in Muscles and Skin

82.02, 83.02, 86.05, 98.20

Removal of Screws and/or Wires, Foreign Bodies Simple, Superficial

78.60-78.69, 82.02, 83.02, 97.83

Repair of Inguinal Hernia, Non-Pediatric or Pediatric

53.00-53.02, 53.10-53.13, 53.49

Repair of Umbilical Hernia (Pediatric)

53.49

Revision Vessel to Vessel Cannula

39.27, 39.42, 39.93

Rhinoplasty

21.84, 21.85, 21.87

Sclerotomy

12.89

Septoplasty

21.88

Skin Graft

85.83, 86.60, 86.61, 86.63, 86.69

Temporal Artery Ligation

38.82

Temporal Artery, Ligation or Biopsy

38.21, 38.82

Tendon Repair without/with Graft, Implant or Transfer

82.45, 83.64

Tenotomy Hands, Fingers, Feet or Major Tendon

82.11, 83.11, 83.13

Tenovaginomotomy for DeQuervain’s Disease, Release of

82.01

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EPNI Provider Policy and Procedure Manual (05/12/14)

Integrated Health Management

Procedure Name(s)

ICD-9-CM Codes

Tendon, Sheath for DeQuervain’s Tendonitis Tenosynovectomy, Finger, Toe, Wrist, Flexor or Extensor Tendon Sheath, Synovectomy

80.71-80.74, 80.78, 82.33, 83.41, 83.42

Tissurectomy

49.39

Tongue Biopsy

25.01, 25.02

Tonsillectomy with or without Adenoidectomy

28.2, 28.3, 28.6

Tooth Extraction, Surgical Forceps, Root Canal

23.01-23.49, 23.70-23.71

Trabeculectomy

12.64

Trigger Finger Repair, Release of Trigger Finger, Lysis of Hand Lesions

82.01, 82.91

Tubal Ligation

66.39

Turbinate Excision

21.61-21.62

Ureteroscopy

56.31

Urethral Dilation

58.6

Ureteral Stent Placement

59.8

Vagus Nerve Stimulation (VNS)

02.93, 86.94, 86.95, 86.96, 86.97, 86.89

Vasectomy

63.73

Venous Catheterization (Placement, Removal)

38.93

Wedge Resection of Lip, Excision Lesion of Lip, for Malignant Lesion

27.42, 27.43

PAN Fax Forms

A sample of the PAN fax forms titled Admission Notification and Continued-Stay Notification Fax Form is available at www.ccstpa.com.

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Integrated Health Management

Focused Utilization Review Overview

Focused utilization review programs contribute to EPNI's goals of containing health care costs by assuring that Health Services are Subscriber Contract benefits and appropriate. EPNI systematically monitors Health Services of Providers for patterns of overuse, underuse, misuse and abuse in addition for obsolete or questionable practices. EPNI has data warehousing and software programs that look for patterns outside established norms. The analysts review medical records and work with providers to resolve questions on coding, benefits and medical necessity. On-site audits, using a sample of up to the last three years of claims history may be performed. Prompt response to medical records requests will speed up processing of claims under review. Claims are denied as provider liability if the necessary information is not received within 14 calendar days.

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Integrated Health Management

Messages Provider May Receive

The following message appears on the Statement of Provider Claims Paid to tell Provider that EPNI did not receive the information needed to review the claim: 

We cannot continue processing of this claim because the medical information we requested has not been received. We will reprocess your claim upon receipt of the requested information. During utilization review, claims are screened for Medical Necessity. Peer review agents or consultants deny claims only after careful evaluation. Slightly longer processing time is required for claims that must go through the utilization review process. The following messages appear on the Statement of Provider Claims Paid for utilization review denials: 

This contract does not cover charges for treatment, services, or supplies which do not meet our criteria for medical necessity or are not normally provided for the treatment of this condition as determined by our medical staff and/or an independent health care professional reviewer.



These charges are not covered because this contract does not allow services from a provider performing this type of health care.



This service and related charges are considered investigative and are not covered according to this contract. Our Medical Policy Committee continually reviews medical procedures in order to determine the investigative status of this and other services.



These charges are not allowed because there was no documentation in the medical records to support this level of care. Participating providers agree not to bill the Subscriber for any services EPNI determines to be not Medically Necessary or investigative. Medical Necessity denials can be appealed within 30 days from the date Provider is notified. EPNI requests that Provider submit written appeals outlining the issues and ATTACH supporting documentation such as medical records, operative reports, and any medical information documenting unusual circumstances at the time of the request.

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Integrated Health Management

Special Investigations

EPNI actively investigates possible fraudulent claims submissions from both Subscribers and providers. Fraud and abuse investigations conducted by EPNI's Special Investigations Department are among the most thorough in the industry. Inconsistent charges, forged or altered charges, or services billed but never rendered are just a few examples of inappropriate practices that EPNI may verify when conducting its investigation. EPNI's investigation process may include, but is not limited to, record requests, audits, and survey letters. EPNI often conducts its investigations and criminal proceedings in collaboration with outside agencies such as the State Attorney General’s Office, the FBI, postal inspectors, or local authorities. EPNI's goal is to protect EPNI Subscribers and Providers from losses due to fraudulent acts. Information about any person’s inappropriate use of an EPNI policy, ID card, or questionable billing practices should be reported by calling EPNI's fraud hot line. The phone number is listed in Chapter 1 – At Your Service. Callers may remain anonymous if they wish.

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Integrated Health Management

Documentation in the Medical Record Documentation Requirements

To avoid denials for medical necessity, the patient’s medical record must contain certain pertinent information that may be subject to review by EPNI. The Centers for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association (AMA) has developed guidelines for the medical documentation necessary to support a given level of evaluation and management service. EPNI adopted these guidelines to ensure that its Subscribers receive quality care and that Health Services are consistent with the insurance coverage provided. The general guidelines are listed below: 

The medical record should be complete and legible.



The documentation of each patient encounter should include: 

reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;



plan of care; and



date and legible identity of the observer.



If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.



Past and present diagnoses should be accessible to the treating and/or consulting physician.



Appropriate health risk factors should be identified.



The patient’s progress, response and changes in treatment, and revision of diagnosis should be documented.



The CPT/HCPCS and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. Charge slips, super bills, travel cards, or office ledgers are not considered supporting documentation for services provided to a patient. Use of the term IBID (same as above) and/or the use of quotation marks to replace or repeat previously documented information is not acceptable. All information must be in date-sequence order. Health Services not documented as indicated above are not covered by EPNI. Subscribers are not financially liable for Health Services that are denied for inadequate documentation.

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Integrated Health Management

Overview

Per the Provider Service Agreement, Provider may not bill: 

Any Subscriber for medically unnecessary or investigative services. Provider may bill the Subscriber only if the following conditions are met: 

The Subscriber is notified prior to the Health Service being rendered that it is not a covered benefit.



The Subscriber agrees, by signing a waiver, to pay for the service. In addition, Provider should not direct fee-for-service Subscribers to nonparticipating providers (Refer to Referrals to Nonparticipating Providers). EPNI does not consider blanket (nonspecific) waivers sufficient notice to meet the Subscriber notification requirements in the Provider Service Agreement. The waiver must be dated and must specifically identify the procedure or service. The waiver must also advise the Subscriber that he or she would not be liable for these charges unless the waiver is signed. GA Modifier

Use the -GA modifier in field 24D of the CMS-1500 form to indicate: 

Provider has notified a Subscriber that a specific service has been determined by EPNI to be investigative or not Medically Necessary.



Those Health Services will not be covered under the Subscriber's Contract. After this notice, and prior to receiving the Health Services, the Subscriber must have agreed in writing that charges incurred will be the Subscriber's liability. The use of this modifier will result in allowed amounts related to these Health Services being reported in the patient responsibility column of your Statement of Provider Claims Paid with the following message: 

This contract does not cover services or supplies that are not medically necessary or are investigative in nature. Since the patient was notified in advance and agreed in writing to pay for these services, the charges are the patient’s responsibility. Note: The -GA modifier should not be used routinely on all of Provider's claims submittals. Inappropriate use of the -GA modifier may result in an audit of Provider's files and possible payment adjustments.

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EPNI Provider Policy and Procedure Manual (05/12/14)

Integrated Health Management

Directing Subscribers To Nonparticipating Providers

EPNI Providers are required to direct EPNI Subscribers to other EPNI participating providers. Directories of participating providers are available upon request by contacting provider services. The Subscriber will have reduced benefits and incur higher Subscriber liability when using nonparticipating providers.

Upgraded/Deluxe Durable Medical Equipment (DME)

Participating durable medical equipment (DME) suppliers may bill Subscribers for an equipment upgrade or deluxe charge if a waiver is on file and the DME charges are billed correctly. EPNI will continue to reimburse for Medically Necessary standard DME.

DME Waiver Requirement

Participating DME suppliers must obtain a signed, written waiver from the Subscriber that includes the cost for the deluxe features or upgrade. The waiver must also state the following: 

the standard piece of equipment or least costly alternative offered to the Subscriber,



the Subscriber is aware and agrees that EPNI will only pay the standard allowance, and



the Subscriber will be responsible for the deluxe or upgrade charge in addition to his or her contractual obligation. This waiver must be kept on file at Provider's office. Do not send it to EPNI. EPNI does, however, reserve the right to see it. DME Claims Submissions

Two lines of service must be billed. The first line will include the DME HCPCS code and the standard charge for the equipment. The second line must include the same DME HCPCS code with the GA modifier (waiver of liability statement on file) and the upgrade or deluxe charge. For example: 

E0202 - $550.00 (standard charge that will be subject to standard allowance and reductions)



E0202 GA - $150.00 (deluxe/upgrade charge that will be denied as Subscriber liability) The -GA modifier must be submitted as the first modifier on the second service line. Other applicable modifiers, such as -NU (Purchase), should be submitted on the first service line. Sample DME Waiver

A sample waiver for use in Provider's office is available upon request by calling provider services. The waiver includes the information required in order to hold the Subscriber financially liable for deluxe features or upgrades to a durable medical equipment purchase. The waiver should be incorporated into Provider's usual business forms and customized to include Provider's business letterhead.

EPNI Provider Policy and Procedure Manual (05/12/14)

4-51

Chapter 5

TRICARE Table of Contents Introduction to TRICARE ........................................................................................................ 5-2 Overview................................................................................................................................ 5-2 What is TriWest Healthcare Alliance? .................................................................................. 5-2 What is TRICARE? ............................................................................................................... 5-2 What’s the Difference Between a Contracted and Certified Provider? ................................. 5-2 Who Do I Contact Regarding TRICARE for Life? ............................................................... 5-2 What’s the Difference Between TRICARE’s Standard, Extra, and Prime? .......................... 5-3 Who Processes TRICARE Claims? ....................................................................................... 5-3 How Can I Start Receiving Electronic Remittance Advice (ERA) ....................................... 5-3 How Do I Identify TriWest/TRICARE Beneficiaries?.......................................................... 5-3 Where Can I Obtain Additional Information? ....................................................................... 5-4 What Are Some Common Acronyms? .................................................................................. 5-4

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5-1

Introduction to TRICARE

Introduction to TRICARE Overview

A separate Employer Provider Network, Inc. (EPNI) contract is being used for the contracting efforts for the TRICARE product due to this being a nonbranded product.

What is TriWest Healthcare Alliance?

TriWest Healthcare Alliance is a Phoenix-based U.S. Department of Defense contractor that manages the military’s health care entitlement program, TRICARE, in 21 states. TriWest is not an insurance company. Under TRICARE, TriWest serves members and retirees of the U.S. Armed Forces with civilian health care providers. EPNI works with TriWest to enhance that network of civilian physicians, specialists, hospitals and clinics in Minnesota.

What is TRICARE?

TRICARE is the managed care program of the U.S. Department of Defense. It was previously called CHAMPUS. TRICARE receives its funding as part of the annual defense budget, which is approved by Congress and signed by the President. TRICARE provides for mechanisms to ensure health care benefits and services to active duty and retired members of the uniformed services, their families, and survivors worldwide.

What’s the Difference Between a Contracted and Certified Provider?

A contracted provider, also referred to as a network provider, has a TRICARE contract through EPNI. Their issues are resolved by calling TriWest at 1-888-TriWest or the Network Management Consultants (NMC) or the TRICARE Team at (651) 662-3484.

Who Do I Contact Regarding TRICARE for Life?

Wisconsin Physician Services (WPS) is responsible for all TRICARE for Life questions and claims processing. Their website is www.tricare4u.com and their telephone number is 1-866-773-0404.

5-2

A certified provider, also referred to as a non-network/non-contracted provider, has been certified by TriWest and can provide services to TRICARE beneficiaries. Their issues are resolved by TriWest at 1-888-TriWest. If the non-network provider is participating (meaning they are certified, but not contracted) then they accept assignment and are paid for services at 100 percent of the TRICARE allowable amount (CMAC). If a non-network provider is nonparticipating then they do not accept assignment. The nonparticipating provider may charge up to 115 percent of CMAC allowable, but any payments are sent to the beneficiary. The provider must collect their payment from the beneficiary.

EPNI Provider Policy and Procedure Manual (12/08/10)

Introduction to TRICARE

What’s the Difference Between TRICARE’s Standard, Extra, and Prime?

All eligible beneficiaries are given TRICARE Standard as an entitlement. When a TRICARE Standard beneficiary receives services from a non-contracted provider, out-of-pocket costs are generally 20 percent plus a deductible. When the TRICARE Standard beneficiary receives services from a contracted provider they are then eligible for TRICARE Extra, in this case the beneficiary’s out-of-pocket cost decreases to about 15 percent plus a deductible. TRICARE Prime is available only to those beneficiaries who reside within the Prime Service Area (PSA). The beneficiary must sign up for TRICARE Prime and choose a Primary Care Manager (PCM). When a Prime beneficiary receives their care from a contracted provider, there is generally no outof-pocket cost. Prime beneficiaries may also seek care from noncontracted providers and then their copay can be up to 50 percent of the allowable CMAC charges plus a deductible. The exception to the above is for active duty service members (ADSM): ADSM members have the Prime benefit and must always have a referral for services at a provider other than their Primary Care Manager (PCM).

Who Processes TRICARE Claims?

Wisconsin Physician Services has been contracted by TriWest for this function.

How Can I Start Receiving Electronic Remittance Advice (ERA)

To enroll, please download and complete the Electronic Remittance Advice (PDF) document or the fill and print version located at www.triwest.com, Find a Form tab and return it to: WPS Electronic Data Services PO Box 8128 Madison, WI 53708-8128 When you choose to receive ERAs, your files will be sent to you in the ANSI (American National Standards Institute) X12 835 format, version 4010A1, and can be downloaded from the WPS Bulletin Board System (BBS) or through the secure website at triwest.com/provider. For further information about ERA, refer to the 835 Electronic Remittance Advice Transaction guide located in the EDI/Secure Web area of www.triwest.com/provider.

How Do I Identify TriWest/TRICARE Beneficiaries?

Providers can verify eligibility by contacting TriWest at 1-888-TRIWEST or by checking on the secure provider portal at www.triwest.com. Samples of the Military identification (ID) cards are on pages 5-4 and 5-5.

EPNI Provider Policy and Procedure Manual (12/08/10)

5-3

Introduction to TRICARE

Where Can I Obtain Additional Information?

Most issues can be resolved by contacting TriWest at 1-888TRIWEST, or utilizing their website at www.triwest.com. You will have access to the TRICARE Provider Handbook, which goes into much more detail about TriWest and the TRICARE program. If you register on the TriWest website, you will also be able to obtain additional information regarding patient eligibility, claims submission and status, benefit information and referrals and authorizations relative to your group. Contracted TRICARE providers can work with the TRICARE program coordinator. Certified TRICARE providers can contact Triwest at 1-888-874-9378.

What Are Some Common Acronyms?

Common Acronyms are: •

ADSM - Active Duty Service Military



CMAC-CHAMPUS Maximum Allowable Charge (comparable to Medicare pricing in most cases)



CSP – Corporate Service Provider



DoD – Department of Defense



MTF – Military Treatment Facility



OHI – Other Health Insurance



PSA – Prime Service Area



PCM – Primary Care Manager (this is at the physician level, not clinic level)



TFL – TRICARE For Life



TMA – TRICARE Management Activity



TMOP – TRICARE Mail Order Pharmacy

Sample Military Identification, Enrollment Cards There are several identification (ID) and enrollment cards providers should be familiar with in order to verify a patient’s eligibility for TRICARE. Providers should ensure patients have a valid uniformed services (military) ID card, Common Access Card (CAC), or authorization letter of eligibility. It is both allowable and advisable for providers to copy the beneficiary’s ID card for proof of eligibility and for the purpose of rendering needed services. Beneficiaries under the age of 10 are not routinely issued ID cards, so the parent’s ID card may serve as proof of eligibility.

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EPNI Provider Policy and Procedure Manual (12/08/10)

Introduction to TRICARE

Uniformed Services (Military) ID Card The uniformed services ID card is credit-card sized and incorporates a digital photograph of the bearer, bar codes containing pertinent machine-readable data, and printed identification and entitlement information. The beneficiary category determines the ID card’s color: •

Active duty service members–CAC or DD Form 2ACT (green)



Active duty family members–DD Form 1173 (tan)



Members of the National Guard/Reserve—CAC or DD Form 2RES (green)



Family members of National Guard/Reserve members—DD Form 1173-1 (red)



Retirees–DD Form 2RET (blue)



Retiree family members–DD Form 1173 (tan)



TAMP-eligible members–DD Form 2765 (tan)

Uniformed Services Identification Card Active Duty

Uniformed Services Identification Card Active Duty Family Member

The card has the following information: •

Rank and Pay Grade: Indicates sponsor’s rank and pay grade on the front.



Sponsor Status: Indicates the sponsor’s status (e.g., active duty or retired, “INDEF” for retirees) on the front.



Eligibility: Indicates eligibility for TRICARE on the back. The center section should say, “YES” under the box entitled “CIVILIAN.” If a beneficiary using TRICARE For Life (TFL) has an ID card that says “NO” in this block, they are still eligible to use TFL if they are enrolled in Medicare Part B.



Expiration Date: Indicates the expiration date on the back in the box entitled “EXP DATE.” If expired, the beneficiary will need to update their information in the Defense Enrollment Eligibility Reporting System (DEERS) and get a new card.

Common Access Card HO440002PRAL0206

Common Access Card Most active duty service members and drilling National Guard/Reserve members now carry the CAC. The CAC is replacing the uniformed services ID card. Please honor valid CACs – they are valid uniformed services ID cards. EPNI Provider Policy and Procedure Manual (12/08/10)

5-5

Introduction to TRICARE

TRICARE Prime/Prime Remote Enrollment Card Beneficiaries enrolled in TRICARE Prime, TRICARE Prime Remote (TPR), and TRICARE Prime Remote for Active Duty Family Members (TPRADFM) receive TRICARE Prime enrollment cards. Network providers may require beneficiaries to show the card at the time of service. These cards are not required to obtain care but do contain important information for the beneficiary. Only the uniformed services ID card or new CAC card may be used to verify eligibility for care.

TRICARE Prime Card

TRICARE Prime Remote (TPR) Card

TRICARE Reserve Select Card Beneficiaries enrolled in TRICARE Reserve Select (TRS) receive TRS enrollment cards.

TRICARE Reserve Select Card front

TRICARE Reserve Select Card back

HO440002PRAL0206

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EPNI Provider Policy and Procedure Manual (12/08/10)

Chapter 6

Claims Filing Table of Contents Administrative Simplification................................................................................................... 6-4 Introduction............................................................................................................................ 6-4 Web-based Claim Submission, Eligibility, and Remittance Tool ......................................... 6-4 Pharmacy and Dental Claims................................................................................................. 6-4 Pre-system Edits..................................................................................................................... 6-4 Claims with Attachments....................................................................................................... 6-5 Claims with Attachments: Questions and Answers ............................................................... 6-5 Claims with Coordination of Benefits ................................................................................... 6-7 Medicare/Uniform Companion Guide Coding Alignment .................................................. 6-10 Questions.............................................................................................................................. 6-11 1500 HICF Form ...................................................................................................................... 6-12 Professional Claim Submission ........................................................................................... 6-12 Completing the 1500 HICF Form ........................................................................................ 6-12 Common Submission Errors ................................................................................................ 6-13 Zero Billed Charges ............................................................................................................. 6-14 Optical Scanning.................................................................................................................. 6-14 Year 2000 Date Format........................................................................................................ 6-15 Linking and Sequencing ...................................................................................................... 6-15 Linking and Sequencing Example ....................................................................................... 6-16 Place of Service Codes......................................................................................................... 6-16 Site of Service ...................................................................................................................... 6-22 Freestanding Ambulatory Surgery Center Billing ............................................................... 6-23 K3 Segment Usage Instructions for Condition Codes ......................................................... 6-24 Revised 1500 Health Insurance Claim Form ....................................................................... 6-24 NUCC Transition ................................................................................................................. 6-24 Form Availability................................................................................................................. 6-25 About the NUCC.................................................................................................................. 6-25 UB-04 (CMS 1450) Form......................................................................................................... 6-26 Institutional Claim Submission............................................................................................ 6-26 Completing the UB-04 Form ............................................................................................... 6-26 Common Submission Errors ................................................................................................ 6-27 Situations Requiring Electronic Submission ....................................................................... 6-28 Sample UB-04...................................................................................................................... 6-28 UB-04 Implementation ........................................................................................................ 6-28 About the NUBC.................................................................................................................. 6-28 Reminder.............................................................................................................................. 6-28 EPNI Provider Policy and Procedure Manual (10/11/13)

Claims Filing

Ordering Forms and Manuals ................................................................................................ 6-29 HCPCS, CPT and ICD-9-CM Manuals ............................................................................... 6-29 HIPAA Implementation Guides........................................................................................... 6-29 Minnesota Uniform Companion Guides.............................................................................. 6-29 1500 HICF (CMS-1500) UB-04 (CMS-1450) Forms ........................................................ 6-29 UB-04 Manual ..................................................................................................................... 6-29 1500 HICF Manual .............................................................................................................. 6-29 Institution/Facility Billing ....................................................................................................... 6-30 Claim Format Regulations ................................................................................................... 6-30 Procedure Code Regulations................................................................................................ 6-31 Revenue Codes (FL 42) ....................................................................................................... 6-31 HCPCS/ Accommodation Rates/HIPPS Rate Codes (FL 44).............................................. 6-31 Duplicate Billing.................................................................................................................. 6-31 Treatment Room .................................................................................................................. 6-32 Observation Room ............................................................................................................... 6-32 Clinic Charges...................................................................................................................... 6-32 Transfer Case ....................................................................................................................... 6-32 Zero Billed Charges ............................................................................................................. 6-33 Lactation Education ............................................................................................................. 6-33 0636 Drugs Requiring Prior Auth........................................................................................ 6-33 Present on Admission .......................................................................................................... 6-34 Form Completion Instructions ............................................................................................. 6-34 K3 Segment Usage Instructions for POA ............................................................................ 6-35 Claims Filing............................................................................................................................. 6-36 Timely Filing ....................................................................................................................... 6-36 Claims Crossover for Medicare and Medicare Supplement ................................................ 6-36 Medicare Crossover ............................................................................................................. 6-37 UB-04 (CMS-1450) Crossover Information........................................................................ 6-37 1500 HICF (CMS-1500) Crossover Information................................................................. 6-37 Duplicate Claims.................................................................................................................. 6-38 Submission of Claims .......................................................................................................... 6-39 Cancel/Void and Replacement Claims ................................................................................ 6-40 Section A – General Information......................................................................................... 6-41 Section B – COB Related Scenarios Q & A ........................................................................ 6-44 Release of Medical Records................................................................................................. 6-44 Provider Assistance Requested ............................................................................................ 6-45 Medical Records Management Process Improvement......................................................... 6-45 Verify Subscriber Identity.................................................................................................... 6-45 Verify Subscriber Eligibility................................................................................................ 6-46 Basic Character Set Values in the Electronic Transaction................................................... 6-47 Claim Service Dates Restricted to Same Calendar Month .................................................. 6-48 Reporting MNCare and Sales Tax ....................................................................................... 6-49

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EPNI Provider Policy and Procedure Manual (10/11/13)

Claims Filing

Rural Health Clinics and Federally Qualified Health Centers............................................ 6-50 Billing for Medicare Primary............................................................................................... 6-50 Billing Other Than Medicare Primary ................................................................................. 6-50 Coordination of Benefits (COB) ............................................................................................. 6-51 Overview.............................................................................................................................. 6-51 Primacy Determination ........................................................................................................ 6-51 Workers’ Compensation ...................................................................................................... 6-53 No-fault Auto ....................................................................................................................... 6-53 Subrogation .......................................................................................................................... 6-53 TEFRA................................................................................................................................. 6-54 DEFRA ................................................................................................................................ 6-54 COBRA................................................................................................................................ 6-54 OBRA .................................................................................................................................. 6-54 Non-Physician Health Care Providers ................................................................................... 6-55 Introduction.......................................................................................................................... 6-55 Eligibility Criteria ................................................................................................................ 6-55 Definitions............................................................................................................................ 6-55 Employment......................................................................................................................... 6-56 Incident to ............................................................................................................................ 6-56 Direct Supervision ............................................................................................................... 6-57 General Supervision............................................................................................................. 6-57 Collaboration/ Independent Practice.................................................................................... 6-57 Chiropractic Doctors and Multidisciplinary Clinics ............................................................ 6-57 Surgical Technicians............................................................................................................ 6-58 Mid-level Practitioners......................................................................................................... 6-58 Mid-Level Reduction Exemption ........................................................................................ 6-58

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6-3

Claims Filing

Administrative Simplification Introduction

Minnesota Statute 62J.536, requires health care providers and group purchasers (payers, health plans) to exchange claims electronically using a standard format beginning July 15, 2009. The intent of the law is to reduce costs, simplify and speed up health care transactions and to give providers and health plans one set of rules to follow for electronic transactions. This statute applies to all health care providers that submit claims regardless of participating status.

Web-based Claim Submission, Eligibility, and Remittance Tool

EPNI offers a no-cost, web- based tool through Availity to comply with the Minnesota Statute 62J.536. Availity also provides no-cost solutions for providers to obtain eligibility and benefits as well as viewing remittance information. Availity is a one stop shop that optimizes information exchange between multiple heath care stakeholders through a single secure network. Providers may also take advantage of a range of optional, value-added services for a nominal cost. For more information contact Availity at availity.com to register for their no-cost web based tools.

Pharmacy and Dental Claims

The requirement to submit all claims electronically includes dental and pharmacy formatted claim types. EPNI is completing system changes to accept and properly adjudicate these electronic claim types. Due to the complexity of the changes and need for extensive testing, EPNI can not accept dental formatted or pharmacy formatted electronic claims at this time. Pharmacy and dental providers should continue to submit these claim types on paper until notified by EPNI.

Pre-system Edits

EPNI has upgraded its pre-system edits to align with the rules published in the Uniform Claims Companion Guides found on the Administrative Uniformity Committee website at www.health.state.mn.us/auc.

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EPNI Provider Policy and Procedure Manual (10/11/13)

Claims Filing

Claims with Attachments

EPNI accepts claims with attachments electronically. The claim must adhere to the electronic rules found in the Uniform Companion Guides and include the appropriate populated data as indicated in section 4.2.3.4 of the Guides. The related attachment should be faxed to EPNI at 1-800-793-6928 or mailed to: EPNI P.O. Box 64338 St. Paul, MN 55164-0338. The attachment cover sheet found on the AUC website must be used on each claim attachment. Instructions for completing the attachment cover sheet are also available on the AUC website. EPNI has compiled a list of questions and answers in response to provider inquiries regarding sending attachments on electronic claim transactions.

Claims with Attachments: Questions and Answers

1. My clinic has a policy of covering all documentation with an internal cover sheet to protect PHI. Should I be covering the attachments I am sending with this cover sheet? No. Per the AUC Guidelines the only acceptable cover sheet for attachments is the AUC Uniform Cover Sheet for Health Care Claim Attachments. This form can be modified to put a PHI message on the bottom of the page if you desire, but it is the ONLY acceptable cover sheet when sending attachments. 2. Can I send appeals, adjustment requests, status checks and general correspondence using the AUC Uniform Cover Sheet for Health Care Claim Attachments? No. The AUC Uniform cover sheet for Health Care Claim Attachments is ONLY for use when submitting attachments for claims that have been sent electronically. It is not to be used for appeals, adjustment requests, status checks or general correspondence. There are separate forms for these types of correspondence. Please use the appropriate cover sheet for each type of correspondence. Below is a list of the forms and fax numbers for each type of correspondence: 

AUC Uniform Cover Sheet for Health Care Claim Attachments: 1-800-793-6928 (use for attachment to original claims only)



AUC Appeal Request Form: (651) 662-2745 (use to submit claim appeals) EPNI Provider Status Check: (651) 662-2745 (use to submit to request a status check. The form is located at ccstpa.com.

EPNI Provider Policy and Procedure Manual (10/11/13)

6-5

Claims Filing

Claims with Attachments: Q&A (continued)

For further reference on the submission of attachments, please visit the AUC website: www.health.state.mn.us/auc 3. Can I change or remove the AUC logo on the AUC Uniform Cover Sheet for Health Care Claim Attachments? No. EPNI's automated intake process looks for the AUC logo when preparing to scan the attachment. If the logo is missing or has been changed, the automated process cannot take place. This causes delays in the imaging of documents and ultimately can lead to delays in the processing and payment of claims. This is another reason why Provider must not use an internal cover sheet. Provider must also fax attachments face-up or top of the page first as the recognition software scans the top third of the page for the logo. 4. If I have the other insurance carrier payment information in the 837 electronic claim transaction, do I also have to send the EOB in an attachment or notify EPNI that it is in my office? No. Per the AUC guidelines, why Provider should submit the other insurance carrier payment information within the 837. HIPAA regulations prohibit populating the claim record with other insurance carrier information and sending the same information in an attachment. They further prohibit sending data in an attachment that can be codified within the claim record. 5. Can I send the attachment before I send the 837 claim transaction? Yes, provided Provider completes the PWK segment on the 837 with the appropriate information from the AUC Uniform Cover sheet for Health Care Claim Attachments. The PWK segment must include the Report Type code, Report Transmission Code and the Transaction Control Number (the Attachment Control Number on the AUC Uniform Cover sheet for Health Care Claim Attachments). Failure to include this information on the 837 will cause delays in processing and payment and may result in a denial of a claim.

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Claims with Coordination of Benefits

EPNI accepts electronic claims with previous payer payment information populated per the requirements in the Minnesota Uniform Companion Guides. The claims must contain all previous payer group codes, ANSI Claim Adjustment Reason Codes and Remittance Advice Remark Codes as they were received from the previous payer for proper adjudication. These claims will not require an attachment when populated within the claim record. Refer to the Minnesota Uniform Companion Guides, section 4.2.3.5 for more information. Provider agrees to make a good faith effort to secure information on the sources of third party coverage available to each Subscriber and forward such information to EPNI or the Pan Sponsor. Provider agrees to coordinate benefits with other payers in accordance with EPNI’s or the Plan Sponsor’s procedures, and to submit copies of all applicable claims including the applicable payment information received on previous payers remittances to EPNI or the Plan Sponsor. EPNI or the Plan Sponsor shall use its best efforts to coordinate Health Services due a Subscriber in accordance with the provisions of the Subscriber Contract, and to exercise any subrogation in regard to Health Services provided to Subscriber. Provider shall provide any reasonably requested assistance to this effort. EPNI or the Plan Sponsor will administer coordination of benefits consistent with applicable law. When EPNI or the Plan Sponsor is the secondary payer, EPNI shall make payment according to the terms of the Subscriber Contract, except that payment by EPNI shall not exceed the amount that EPNI would make if it had Primary Coverage Responsibility. If Medicare is primary, EPNI shall coordinate benefits according to the coordination of benefits provisions of the Subscriber Contract. EPNI has compiled a list of questions and answers in response to provider inquiries regarding the electronic submission of Coordination of Benefits (COB) information.

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Claims Filing

Claims with Attachments: Coordination of Benefits Q & A (continued)

1. I understand that there is information on the HIPAA 835 transaction that I have to include on the electronic 837 COB transaction. Can you tell me what I have to include so I can make sure I get paid accurately? It is important to use the Minnesota Uniform Companion Guides along with the HIPAA Implementation Guides to ensure the correct segments and elements are completed. The 2320, 2330A, 2330B, and the 2430 loops carry a good portion of the COB information a payer needs to process a secondary claim. The HIPAA 835 transaction provides most of the necessary information to complete the appropriate segments and elements. The HIPAA 835 transaction from the prior payer(s) should provide the CAS segments (loops 2100 and/or 2110), CLP segment (loop 2100), and the SVC segment (loop 2110) that are used to complete the 837 COB transaction. 2. I understand the CAS segment is important for the correct processing of my COB 837 transaction. Where do I get the CAS segment information? Again, the CAS segment information on the 837 COB transactions should come directly from the prior payer’s HIPAA 835 or Remittance Advice/Explanation of Benefits. This information must never be altered or combined in any manner. 3. Do I need to do any combining of claim adjustment Reason Codes or change them to specific codes a supplemental insurer might want? No, when completing the COB information on the 837 use the information as it was provided on the prior payer(s) HIPAA 835 or Remittance Advice/Explanation of Benefits. Never change or alter any of the prior payer(s) payment information including the Claim Adjustment Reason Codes (CARC), Claim Adjustment Group Codes, and Remittance Advice Remark Codes. Changing codes is a violation of HIPAA and could result in payment errors or processing delays. Per the HIPAA Implementation Guide, “Codes and associated amounts should come from 835s (Remittance Advice) received on the claim.” Payers utilize the codes to adjudicate based on the information sent.

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Claims with Attachments: Coordination of Benefits Q & A (continued)

4. I know there are Medicare primary claims that should have crossed over and Medicare has had some problems lately with not being able to cross claims over to supplemental payers. Should I send all my Medicare primary COB claims just in case? No, “automatic” rebilling often results in duplicate claims, increases administrative costs, and delays processing. Please go to Medicare primary COB claim later in this chapter. If the claim is not showing as crossed over on provider web self-service after 30 days from the date the provider received its Medicare payment, then the provider may submit the claim electronically populating the claim record with the COB information exactly as it was received on the Medicare ERA. 5. I have situations where my Medicare primary claims have been adjusted and Medicare is now paying on claims they have denied. How do I send these COB claims to my supplemental insurer? These claims are COB adjustments to the original claim and should crossover to EPNI directly from Medicare. Again, please go to Medicare primary COB claim later in this chapter. If the adjustment did not crossover as it should have within 30 days after Provider received the updated Medicare ERA, submit an adjustment/replacement claim. 6. I have a claim where Medicare paid first. They have now decided to pay one of the services on my three line claim. Should I just send in the COB claim for that one line for EPNI to pay the coinsurance and deductible? No, never send a partial claim. This would be a violation of the rules in the Minnesota Uniform Companion Guides. Again, this could result in duplicate claims, increased administrative costs and processing delays. If the prior payer has made a change to the original or prior claim processing outcome, the original or prior claim must be adjusted to ensure the secondary payment is correct. A “partial” claim should never be sent regardless of whether it is an original or adjustment. As noted in response to question #3, if the prior payer has adjudicated a claim with three services lines, all three service lines should be sent to the secondary payer. Never alter the charges and critical claim information when sending it to a secondary / tertiary payer for payment consideration.

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Claims Filing

Claims with Attachments: Questions and Answers (continued)

7. I have talked with other providers and they tell me that a COB claim must balance. What must balance? The claim paid amounts must be equal to or greater than the line level paid amounts. The CAS segments must always reflect exactly what the prior payer has indicated on HIPAA 835 transaction or Remittance Advice/Explanation of Benefits. Do not add or combine the CAS information. Typically, the professional claim allowed and paid amounts should not be greater than the billed amounts. More information regarding balancing is available in the HIPAA Implementation Guides available for purchase from Washington Publishing (wpc-edi.com). 8. When the prior payer is Medicare how do I list them as the primary payer? Do I list them by the Medicare office, CMS, Federal Medicare, the name of the Medicare contractor, etc? When Medicare is the prior payer, EPNI suggests listing the prior payer as “Medicare.” 9. I am sending COB in the 837 transaction and also sending the EOB as an attachment with the report type code EB and report transmission code AA. This is to make sure that you get the COB information. This specific issue was addressed in the August 6, 2009, Provider Quick Points (QP18E-09). Specifically, in these situations, the Report of Transmission (PWK02) is AA indicating the EOB is available upon request at the provider’s office. The HIPAA 837 Implementation Guides, Report of Transmission (PWK Segment), states: “The PWK segment is required if there is paper documentation supporting this claim. The PWK segment should not be used if the information related to the claim is being sent within the 837 ST-SE envelope.” Therefore sending the information within the transaction and also sending the PWK would be non-compliant and result in a rejection.

Medicare/Uniform Companion Guide Coding Alignment

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EPNI has made several system modifications to accept claims coded using the rules indicated by either Medicare or the Minnesota Uniform Companion Guides, Appendix A. Some billed charges still may not be covered due to Subscriber benefits or EPNI payment policy. Code claims to meet the specifications set forth in the Minnesota Uniform Companion Guides.

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Claims Filing

Questions

Questions regarding the content of the PA02 electronic reports or Availity payer reports should be directed to provider services at (651) 662-5200 or 1-800-262-0820. Questions regarding the payer’s electronic reports not being received should be directed to Provider's clearinghouse. If Provider's clearinghouse is Availity, please refer to availity.com. For questions regarding the attachment requirements, attachment cover sheet and related instructions, COB or coding requirements, refer to the AUC website at health.state.mn.us/auc.

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Claims Filing

1500 HICF Form Professional Claim Submission

The 1500 Health Insurance Claim Form (HICF) (also referred to as the CMS-1500) and the electronic transaction 837P are the only accepted claim submission formats for professional claims. Note: Effective July 15, 2009, only out of state, nonparticipating providers are allowed to submit paper claim forms per Minnesota Statute 62J.536 and the Provider Service Agreement.

Completing the 1500 HICF Form

All required fields on the 1500 HICF claim form must be completed with correct information. Required fields include the following: 1a .........Insured ID number 2...........Patient’s name 3...........Patient date of birth and sex 4...........Insured name 5……...Patient’s address 6...........Patient relationship to insured 11a……Insured’s date of birth, Sex 21.........Diagnosis or nature of illness or injury 24A......Date(s) of service 24B ......Place of service 24D......Procedures, services, or supplies (includes modifiers) 24E ......Diagnosis code 24F ......$ Charge 24G......Days or units 24I……ID Qualifier 24J……Rendering Provider ID (NPI) 25…….Federal tax ID number 33.........Billing provider info and phone number

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Common Submission Errors

Items commonly missed or incorrectly completed on claim forms include: 

Incorrect insured’s ID. Include all numeric and alpha characters with no spaces. Do not include the Subscriber number, group number, plan code, or anything other than insured’s ID



Patient’s Date of Birth (3) requires eight digits (MMDDCCYY)



Insured’s Date of Birth (11a) requires eight digits (MMDDCCYY)



EMG (24C) - enter “Y” if emergency, leave blank for “No”



ID qualifier (24I –shaded) – enter two character qualifier (1B for EPNI legacy ID, 1G for UPIN)



Rendering Provider ID (24J – shaded) – enter the individual provider’s legacy ID, if applicable



Rendering Provider ID (24J – unshaded) – enter the individual provider’s ten digit NPI, if applicable



Procedure codes billed with incorrect units of service (UOS)



Incorrect linking of box 24E to box 21



Service Facility Location Information (32) – enter name and actual address of facility where services were rendered if other than box 33 or patient’s home. Enter in the following format:







Line 1: name of physician or clinic



Line 2: street address



Line 3: city, state, ZIP code. Do not enter other information like from and to locations.

Billing provider info and phone number (33) – enter in the following format: 

Line 1: name of physician or clinic



Line 2: address



Line 3: city, state, ZIP code

Name and address is required. Phone number is not required. If providing a phone number it must be entered in the area to the right of the box title. The area code is entered in parenthesis; do not use a hyphen or space as a separator.

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Claims Filing

Common Submission Errors (continued)



NPI (33a – unshaded) – enter ten-digit clinic NPI



Other ID (33b – shaded)– enter two-character qualifier (1B for EPNI) and legacy ID failure to submit all surgical procedures for the same date of service on one claim



Patient’s name; submit exactly the way it is on their identification card



Uppercase alpha characters are required

Zero Billed Charges

EPNI will allow zero-billing or no charge submission lines or claims.

Optical Scanning

EPNI uses an optical scanner for the entry of claims into its processing system. Use of the scanner improves accuracy and timeliness of claims processing. The following instructions for completing the 1500 HICF form must be followed: 1. Use only the official Drop-Red-Ink 1500 HICF forms. EPNI cannot accept black-and-white or photocopied forms. 2. Providers who preprint their name and address in box 33 should use a 10 or 12 character pitch. 3. Print requirements: 

Ink should be dark, which may require frequent ribbon changes.



Ink should be dense. Some older dot matrix printers may produce a print that is too “spacey”.



Use UPPERCASE characters only.



Use 10 or 12 font size.



Use a standard font such as Courier.



Do not hand write anything on the claim form.



Do not use slashes, dashes, decimal points, dollar signs or parentheses. 4. Enter all information on the same horizontal line. 5. Left justify all fields and enter all information within the designated field. 6. Do not fold claims. 7. A maximum of six line items is allowed in box 24. Line items must be double-spaced. If an unlisted procedure code is used, a narrative description is required. Enter supplemental information in the shaded section of 24A through 24G above the corresponding service line.

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Year 2000 Date Format

Linking and Sequencing

EPNI follows the 2006 guidelines set forth by the Administrative Uniformity Committee in the Minnesota Standards for the Use of the CMS-1500 Claim Form document. Specifically, EPNI recommends that submitters use: 

eight-digit dates for the birth date fields (3, 9b, and 11a)



six-digit dates for field 24a



six-digit or eight-digit for fields 12, 14, 15, 16, 18, 31

There are two diagnosis boxes, one is box 21 and the other is box 24E. Box 21 has space for four ICD-9-CM diagnosis codes and these codes relate to all the services indicated on the claim detail lines (24). Box 24E specifies what diagnosis or diagnoses relate to that particular line only. It is essential to communicate the primary diagnosis for the service performed, especially if more than one diagnosis is related to a line item. Adjudication is based on the first linked diagnosis. Note: do not key the actual diagnosis. Linking/sequencing rules: 

Sequence numbers relate to the ICD-9-CM diagnosis codes in box 21 and are 1, 2, 3, and 4.



The primary diagnosis is listed first in the sequence if more than one diagnosis is related.



If multiple pages are submitted, the diagnoses must be in the same order on each page in field 21.

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Claims Filing

Linking and Sequencing Example

21.

DIAGNOSIS OR NATURE OF ILLNESS

1.

V72.5

3.

2.

845.01

4.

24.

A DATE(S) OF SERVICE

1. 02 05 10 2. 02 05 10

B POS

C EMG

11 11

V76.2

D PROCEDURES, SERVIES OR SUPPLIES 99212 88150

E DX POINTE R 21 3

Box 21

There are three diagnosis codes indicated.

Box 24

Detail line item 1 indicated the service in box 24D as 99212, E/M office service. The linked diagnoses are 2 and 1, or 845.01 and V72.5. The diagnoses are sequenced as 2 then 1. This indicates the primary diagnosis is 845.01 and V72.5 is secondary. V72.5 is considered a routine diagnosis, but this is not a primarily routine service. Detail line item 2 indicates the service in box 24D as 88150, pap smear. There is only one diagnosis linked to the service. The linked diagnosis is 3, or V76.2.

Place of Service Codes

Only nationally assigned place of service codes are accepted. These codes are also available at http://www.cms.hhs.gov/PlaceofServiceCodes/Downloads/placeofservice.pd f

Following are the current place of service codes as of November 2009. These codes should be used on professional claims to specify the entity where service(s) were rendered. Place of Service Codes

Place of Service Name

Place of Service Description

01

Pharmacy

A facility or location where drugs and other medically related items and services are sold, dispensed or otherwise provided directly to patients.

02

Unassigned

N/A

03

School

A facility whose primary purpose is education.

04

Homeless Shelter

A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters).

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Place of Service Codes

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 hospitalization.

06

Indian Health Service Provider-based Facility

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 and outpatients.

07

Tribal 638 Free-standing A facility or location owned and operated by a federally Facility 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.

08

Tribal 638 Providerbased Facility

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 admitted as inpatients or outpatients.

09

Prison-Correctional Facility

A prison, jail, reformatory, work farm, detention center or any other similar facility maintained by either federal, state or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders.

10

Unassigned

N/A

11

Office

Location other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis and treatment of illness or injury on an ambulatory basis.

12

Home

Location other than a hospital or other facility, where the patient receives care in a private residence.

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Claims Filing

Place of Service Codes

Place of Service Name

Place of Service Description

13

Assisted Living Facility

Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, seven days a week, with the capacity to deliver or arrange for services including some health care and other services.

14

Group Home

A residence with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services (e.g., medication administration).

15

Mobile Unit

A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic and/or treatment services.

16

Temporary Lodging

A short-term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and that is not identified by any other POS code. (Effective 04/01/08.)

17

Walk-in Retail Health Clinic

A walk-in health clinic, other than an office, urgent care facility, pharmacy or independent clinic and not described by any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services. (This code is available for use immediately with a final effective date of May 1, 2010.)

18-19

Unassigned

N/A

20

Urgent Care Facility

Location distinct from a hospital emergency room, an office, or a clinic, where the purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention.

21

Inpatient Hospital

A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

22

Outpatient Hospital

A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

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Place of Service Codes

Place of Service Name

Place of Service Description

23

Emergency RoomHospital

A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

24

Ambulatory Surgical Center

A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.

25

Birthing Center

A facility, other than a hospital’s maternity facilities or a physician’s office, which provides a setting for labor, delivery and immediate postpartum care as well as immediate care of newborn infants.

26

Military Treatment Facility

A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).

27-30

Unassigned

N/A

31

Skilled Nursing Facility

A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing or rehabilitative services, but does not provide the level of care or treatment available in a hospital.

32

Nursing Facility

A facility which primarily provides residents with skilled nursing care and related services for the rehabilitation of injured, disabled or sick persons, or on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.

33

Custodial Care Facility

A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.

34

Hospice

A facility, other than a patient’s home, in which palliative and supportive care for terminally ill patients and their families are provided.

35-40

Unassigned

N/A

41

Ambulance-Land

A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.

42

Ambulance-Air or Water

An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.

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Claims Filing

Place of Service Codes

Place of Service Name

Place of Service Description

43-48

Unassigned

N/A

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 preventive, diagnostic, therapeutic, rehabilitative or palliative services to outpatients only.

50

Federally Qualified Health Center

A facility located in a medically undeserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.

51

Inpatient Psychiatric Facility

A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.

52

Psychiatric FacilityPartial Hospitalization

A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.

53

Community Mental Health Center

A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC’s mental health services area who have been discharged from inpatient treatment at a mental health facility; 24-hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services; screening for patients being considered for admission to state mental health facilities to determine the appropriateness of such admission; and consultation and education services.

54

Intermediate Care Facility/Mentally Retarded

A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.

55

Residential Substance Abuse Treatment Facility

A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing and room and board.

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Place of Service Codes

Place of Service Name

Place of Service Description

56

Psychiatric Residential Treatment Center

A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment.

57

Non-residential Substance Abuse Treatment Facility

A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include: individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.

58-59

Unassigned

N/A

60

Mass Immunization Center

A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims or using the roster billing method. This generally takes place in a mass immunization setting, such as a public health center, pharmacy or mall but may include a physician office setting.

61

Comprehensive Inpatient Rehabilitation Facility

A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include: physical therapy, occupational therapy, speech pathology, social or psychological, orthotics and prosthetics.

62

Comprehensive Outpatient Rehabilitation Facility

A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy and speech pathology services.

63-64

Unassigned

N/A

65

End-Stage Renal Disease Treatment Facility

A facility other than a hospital that provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or homecare basis.

66-70

Unassigned

N/A

71

Public Health Clinic

A facility maintained by either state or local health departments that provides ambulatory primary medical care under the general direction of a physician.

72

Rural Health Clinic

A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.

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Claims Filing

Place of Service Codes

Place of Service Name

Place of Service Description

73-80

Unassigned

N/A

81

Independent Laboratory

A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician’s office.

82-98

Unassigned

N/A

99

Other Place of Service

Other place of service not identified above.

Site of Service

EPNI is specifying, for clarity, the difference between a facility and a non-facility with respect to the place of service where a service was rendered. For billing purposes, professional (1500) billers should use an appropriate place of service code to indicate where services were rendered. Examples of facilities include hospitals and ambulatory surgery centers. Examples of nonfacilities include a provider's office and all places not listed below. The following is a current comprehensive list of facilities, as defined by EPNI:

6-22

Place of service code

Place of service name

21

Inpatient hospital

22

Outpatient hospital

23

Emergency room - hospital

24

Ambulatory surgical center

26

Military treatment facility

31

Skilled nursing facility

34

Hospice

41

Ambulance - land

42

Ambulance - air & water

51

Inpatient psychiatric facility

52

Psychiatric facility - partial

53

Community mental health center

56

Psychiatric residential treatment center EPNI Provider Policy and Procedure Manual (10/11/13)

Claims Filing

Freestanding Ambulatory Surgery Center Billing

In order to streamline its administrative processes and comply with regulatory requirements, EPNI transitioned all freestanding ambulatory surgery center providers to new Provider Service Agreements, which are based on the following guidelines and provisions: 

Use of Professional Claims Submission Formats Freestanding Ambulatory Surgery Center providers submit claims utilizing a CMS 1500 claim form or the HIPAA 837P claims transaction, in compliance with Minnesota Statute 62J.52. Use the national place of service code 24.



Fee Schedule Based Payment Methodology APC weights were used to create fee schedule allowances (Allowance=APC weight x conversion factor) for each procedure code, as appropriate.



Recognition of Multiple Surgeries and Bilateral Procedures For multiple surgeries, the procedure with the highest billed charge is reimbursed at 100% of the allowed amount. Subsequent services are reimbursed at 50% of the allowed amount. Bilateral surgeries are billed on one line with a 50 modifier and reimbursed at 150% of the allowed amount.



Adjudication of Services at the Claim Line Level Payment is calculated at the lesser of the percent of Provider’s Regular Billed Charges as detailed in the Provider Service Agreement or the EPNI fee schedule allowance, implemented at a claim line/service level.

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Claims Filing

Freestanding Ambulatory Surgery Center Billing (continued)

Payment of individual procedures--APC methodology determines which Health Services are included/excluded from separate reimbursement, including implants/devices and tissue. Services excluded from separate reimbursement are listed on the provider fee schedule with a zero allowance. Professional services, including anesthesia, should not be billed under this Provider Service Agreement. Individual provider NPI numbers are not required. Corneal tissue – Claims that contain corneal tissue charges must be submitted with the invoice for that corneal tissue.

K3 Segment Usage Instructions for Condition Codes

Condition Code The NUBC has added condition codes to their code set to identify situations where Workers' Compensation requires duplicate or appeal submissions. The 837P format does not include a standardized way of reporting condition codes. To report applicable condition codes on a professional claim, the K3 segment should be used. BG is the qualifier to indicate this value and should be followed by the appropriate condition code (refer to the NUBC Guide and Code Set available from the National Uniform Billing Committee at http://www.nubc.org). Report at 2300 loop only. K3*BGW2~

Revised 1500 Health Insurance Claim Form

A sample of the new 1500 claim form can be found at ccstpa.com.

NUCC Transition

The National Uniform Claim Committee (NUCC) revised the CMS-1500 claim form in part, to complement the transition from the UB-92 to the UB-04 and ensure its function prior to the May 23, 2007, deadline for reporting the NPI. The revised form, the 1500 Health Insurance claim form (version 08/05) was effective April 1, 2007. Only the revised (08/05) form is to be used. All rebilling of claims should use the revised (08/05) form from this date forward, even though earlier submissions may have been on the current (12/90) 1500 claim form.

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Claims Filing

Form Availability

Documents related to the release of the new version of the form, including the revised form, a new reference instruction manual, a log of changes to the current form and the recommended transition timeline, are available at nucc.org. In addition to revising the 1500 claim form, the NUCC has drafted a reference instruction manual detailing how to complete the form. The purpose of this manual is to help standardize nationally the manner in which the form is being completed. A copy of the instruction manual is available on the NUCC website.

About the NUCC

The National Uniform Claim Committee is a voluntary organization whose members include representatives from major providers, payers, health researchers and other organizations representing billing professionals and electronic standard developers. The NUCC maintains the uniform data set known as the National Uniform Claim Committee Data Set designed for the non-institutional claims. The NUCC is also a signatory to a Memorandum of Understanding with five other organizations designated by the U.S. Department of Health and Human Services to collectively serve as the Designated Standard Maintenance Organizations (DSMO) to the HIPAA Transaction Standard Implementation Guides.

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Claims Filing

UB-04 (CMS 1450) Form Institutional Claim Submission

The UB-04 (also referred to as the CMS-1450) and the electronic transaction 837I are the only accepted claim submission formats for institutional claims. Note: Effective July 15, 2009, only out of state, nonparticipating providers are allowed to submit paper claim forms per Minnesota Statute 62J.536 and the Provider Service Agreement.

Completing the UB-04 Form

Providers must complete all required field locators on the UB-04 claim form. EPNI requires the fields listed below. For a more detailed explanation of each field locator, reference the NUBC UB-04 manual. 1

Provider name

47

Total charges

3a

Patient control number

50a-c

Payer name

4

Type of bill

51a-c

5

Federal tax number

Health plan identification number

6

Statement covers period

52a-c

8b

Patient name/identifier

Release of information certification indicator

53a-c

Assignment of benefits certification indicator

9a-e Patient address

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10

Patient birth date

11

Patient sex

58a-c

Insured’s name

14

Priority (Type) of visit

59a-c

15

Source of referral for admission or visit

Patient’s relationship to insured

60a-c

Insured’s unique identifier

66

Diagnosis and procedure code qualifier (ICD version indicator)

67

Principal diagnosis code and present on admission indicator

17

Patient discharge status

42

Revenue codes

43

Revenue description

46

Units of service

EPNI Provider Policy and Procedure Manual (10/11/13)

Claims Filing

Common Submission Errors

Items commonly missed or incorrectly completed on the UB-04 claim form include: 

Claims must be typed and spaced within guide lines



Uppercase alpha characters are required



FL 1 BILLING PROVIDER ADDRESS – first line must be the name of the facility. Second line must be the street address. Third line must be the city, state, and ZIP code. Fourth line must be the telephone number



FL 3A PAT. CNTL - # must not be blank



FL 4 TYPE OF BILL - must be 4 digits, first digit is a leading zero (for paper claims)



FL 6 STATEMENT COVERS PERIOD – Enter the from and through dates in MMDDYY format



FL 8B PATIENT NAME - needs the name of the patient, must not be blank



FL 10 DATE OF BIRTH - must be in MMDDCCYY format



FL 13 ADMISSION HOUR – required for inpatient claims. Enter the code that corresponds with the time the patient was admitted. Code 99 is invalid and will no longer be accepted



FL 14 ADMISSION TYPE and 15 ADMISSION SOURCE OF REFERRAL - must not be blank



FL 42 Line 23 of the itemization REV CODE 0001 must be listed along with a "CREATION DATE" and a total charge



FL 42 REV CODE - all revenue codes must be 4 digits



FL 45 SERVICE DATE - must be in MMDDYY format



FL 50 PAYER NAME – enter the payer’s name only, do not include the payer’s address



FL 51 HEALTH PLAN ID – until it becomes mandated, enter the (legacy/proprietary) number as assigned by the corresponding payer in FL 50 A, B, C



FL 54 PRIOR PAYMENTS – Enter amount paid by the payer toward payment of bill. If claim was processed and nothing paid, list 0.00. If claim has not been processed, leave blank



FL 56 NATIONAL PROVIDER IDENTIFIER



FL 57 OTHER PROVIDER ID – provider’s legacy number if provider is a Minnesota provider



FL 66 DIAGNOSIS AND PROCEDUREE CODE QUALIFIER - small box below, must be a 9 (ninth revision) at this time

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Claims Filing

Situations Requiring Electronic Submission

EPNI will not accept CMS-1450 HICF paper claims if one of the following fields have been exceeded: 

Line dollar amount is greater than $9,999,999.99



Total dollar charge is greater than $9,999,999.99

Any claims submitted over these limits will be rejected. Adjustments will not be allowed on these claims. A new claim must be submitted using the proper format. Sample UB-04

A sample of the UB-04 (CMS-1450) claim form is at ccstpa.com.

UB-04 Implementation

The UB-04 was approved by the National Uniform Billing Committee (NUBC) as a replacement for the UB-92. The UB-04 contains a number of improvements and enhancements that resulted from nearly four years of research, including better alignment with the electronic HIPAA ASC X12N 837-Institutional transaction standard. On May 23, 2007, the UB-92 was discontinued; only the UB-04 form and data set specifications should be used. All rebilling of claims must use the UB-04 from this date forward, even though earlier submissions may have been on the UB-92.

About the NUBC

Established in 1975, the NUBC is the official data content body responsible for maintaining the data set for institutional health care providers. Representation includes provider, payer, electronic standards development organizations, public health data standards organizations, and others. The NUBC is also one of six Designated Standard Maintenance Organizations (DSMO) responsible for the maintenance and development of HIPAA administrative simplification transaction standards. (Note: Also see http://www.nubc.org/INFORMATION_ON_UB-04.pdf)

Reminder

Providers are encouraged to submit claims electronically whenever possible. If submitting paper claims, the timeline for submission of the correct paper claim form must be followed. A sample of the revised claim form can be found on ccstpa.com.

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Claims Filing

Ordering Forms and Manuals HCPCS, CPT and ICD-9-CM Manuals

HCPCS, CPT and ICD-9-CM manuals can be purchased from major bookstores or publishers, such as the American Medical Association.

HIPAA Implementation Guides

To order national Electronic Data Interchange Transaction Set Implementation guides on paper or electronic versions, contact Washington Publishing Company: 1-800-972-4334 Or visit their website at http://www.wpc-edi.com.

Minnesota Uniform Companion Guides

Minnesota Uniform Companion Guides containing instructions for electronic transactions are available free of charge on the Administrative Uniformity website under “Guides” at www.health.state.mn.us/auc/.

1500 HICF (CMS-1500) UB-04 (CMS-1450) Forms

To order 1500 HICF and UB-04 forms contact: U.S. Government Printing Office (202) 512-0455 or visit the website at http://www.cms.hhs.gov/CMSForms/ Form vendors or publishers, such as the American Medical Association or the American Hospital Association.

UB-04 Manual

To order the UB-04 Manual contact: National Uniform Billing Committee (NUBC) at http://www.nubc.org/become.html for more information and an order form, or call the American Hospital Association at (312) 422-3390 for questions.

1500 HICF Manual

To order a paper copy of the Minnesota standards for the use of the 1500 HICF Claim Form contact: Minnesota’s Bookstore 660 Olive Street St. Paul, MN 55155 or call: (651) 297-3000 or 1-800-657-3757 This manual may also be downloaded from the AUC website at http://www.health.state.mn.us/auc/index.html. The National Uniform Claim Committee 1500 Health Insurance Claim Form Reference Instruction Manual is also available at http://www.nucc.org/.

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Claims Filing

Institution/Facility Billing Claim Format Regulations

HIPAA Administrative Simplification code and transaction regulations dictate the standard claim format and codes for electronically submitted claims. Institutional claims are billed on the 837I electronic format. The paper equivalent is the UB-04 claim form. EPNI considers the following providers as ‘institutional’ and as such, should bill on the institutional claim format (837I or UB-04).

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Category

Definition

Home Health Agency

HHA is a public agency or private organization that is primarily engaged in providing skilled nursing services and other therapeutic services, such as physical therapy, occupational therapy, medical social services and home health aide services. Can be freestanding or hospital attached. Care is rendered in the home and is in lieu of a hospital confinement.

Hospice

Hospice programs provide health care for terminally ill patients. Care may be done in the patient’s home, at special hospice units, or a separate hospice care facility.

Hospital

An institution that provides medical, diagnostic and surgical care. Services can be rendered on an inpatient or outpatient basis.

Nonresidential treatment center

This type of institution is the same as a residential primary treatment center with the exception that services are rendered on an outpatient basis only.

Nursing home

A Skilled Nursing Facility (SNF) provides skilled nursing care and related services for patients who require medical or nursing care; or rehabilitation services for injured, disabled, or sick person.

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Claims Filing

Claim Format Regulations (continued)

Category

Definition

Psychiatric hospital

A psychiatric hospital provides care to emotionally ill patients. These facilities must be licensed by the state in which they are located.

Residential primary treatment center

Residential treatment programs for chemical dependency are planned and purposeful sets of conditions and events for the care of inebriated and drug dependent persons which provides care and treatment for five or more inebriate or drug dependent persons on a 24 hour basis. Excluded for this definition are receiving (detoxification) centers.

(IP chem dep)

Procedure Code Regulations

The medical procedure code set for inpatient services is ICD-9CM procedure codes. Procedure information will be reported on outpatient claims using HCPCS codes.

Revenue Codes (FL 42)

A revenue code identifies a specific accommodation and/or ancillary service or billing calculation. The revenue code is four characters. The first digit is usually a 0 (zero); however, there are codes that begin with other than 0 (100X, 210X, 310X). It is important to report all four digits.

HCPCS/ Accommodation Rates/HIPPS Rate Codes (FL 44)

For inpatient bills, the accommodation rate relating to the room and board revenue code is entered in form locator 44.

Duplicate Billing

EPNI will only reimburse the professional of clinic services when a Subscriber is seen in a clinic setting (POS 11). Facilities that have clinics physically located onsite or next to a hospital frequently bill an additional claim either electronically or on a UB04 with a place of service 22 for the same services that the physician is billing. In some cases, facilities submit revenue code 0361. EPNI considers this practice duplicate billing. Facility overhead is included in the professional reimbursement weighting and conversion factor; therefore, complete and final reimbursement will be made on the professional claim only.

For outpatient bills, report the HCPCS code, if applicable, to indicate the specific outpatient service in form locator 44. Some HCPCS codes or billing situations may require submission of modifiers. Modifiers are reported following the HCPCS code. EPNI accepts modifiers; however, we currently do not adjudicate the claim/service based on modifiers.

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Treatment Room

EPNI considers a treatment room as an overhead expense reimbursed as part of the physician’s professional fee. Therefore, billing facility fees through the 0760, 0761 or 0769 codes duplicates the physician’s professional claim (1500 HICF) and will deny as provider liability. If Medicare is primary, and EPNI is secondary, EPNI will accept the 0760, 0761 or 0769 revenue codes, and process according to Medicare’s guidelines.

Observation Room

Observation Care, billed under revenue code 0762, is allowed for admits of less than 24 hours. Claims for observation services over 24 hours will be processed as an inpatient claim.

Clinic Charges

Clinic charges, billed under revenue code 051X, are considered an overhead expense reimbursed as part of the physician’s professional fee. Therefore, billing facility fees through the 05100519 revenue codes duplicates the physician’s professional claim (1500 HICF) and will deny as provider liability.

Transfer Case

Effective January 1, 2007, a transfer case will be defined as when a patient is discharged from one facility to another. Patient status codes are a required field (Form Locator 17) on the institutional claim (837I or UB-04). This code indicates the patient’s status as of the “Through” date of the billing period. It is important to note that the patient status code indicates a destination and not a level or type of care received. When a patient is transferred/discharged to another facility, patient status may affect reimbursement. All patient status codes are accepted but not all will result in a transfer case classification. The following patient status codes are used by EPNI to classify a transfer case.

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Code

Definition

02

Discharged/transferred to a short-term general hospital for inpatient care

05

Discharged/transferred to another type of healthcare institution not defined elsewhere in this code list

43

Discharged/transferred to a federal health care facility

65

Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital

70

Discharged/transferred to another type of healthcare institution not defined elsewhere in this code list

EPNI Provider Policy and Procedure Manual (10/11/13)

Claims Filing

Zero Billed Charges

EPNI will allow zero-billing or no charge submission lines or claims.

Lactation Education

For billing purposes, lactation services are considered to be part of the mother’s charges and should not be billed on the newborn’s claim. Submit all claims for lactation education on the 837I or UB-04 claim for m using revenue code 0942. These charges must be submitted on the mother’s original maternity/delivery claim and require a narrative description. Claims for lactation services submitted under infant’s name or number will be rejected. If lactation education is necessary after discharge, it can be billed as part of the post-partum visit under the mother’s identification number.

0636 Drugs Requiring Prior Auth

The revenue code 0636, by definition, is for drugs requiring detailed coding. A HCPCS code must always be submitted with 0636. However, some drugs that may be submitted under this revenue code also require prior authorization. The following require prior authorization: 

IVIG



Aminolevulinic Acid



Factor products

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Claims Filing

Present on Admission

The present on admission (POA) indicator is required on all claims for inpatient admissions to general acute care hospitals for Medicare beneficiaries with discharge dates on or after October 1, 2007. General Reporting Requirements

Form Completion Instructions



The POA indicator is required for all claims involving Medicare and commercial inpatient admissions to general acute care hospitals.



The POA indicator is assigned to principal and secondary diagnoses.



Present on admission is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter while in the emergency room, under observation or during outpatient surgery are also considered as present on admission.



If the condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current coding guidelines, then the POA would not be reported.



The POA indicator is not required for the external cause of injury code unless it is being reported as an “other diagnosis”.



Critical access hospitals, Maryland waiver hospitals, long-term care hospitals (LTCH), cancer hospitals and children’s inpatient facilities are exempt from this requirement.

For electronic claims using the 837I, refer to the Minnesota Uniform Companion Guide for the Institutional Electronic Health Care Claim Transaction (ANSI ASC X12 837I). Information on submission of the POA indicator is found in Appendix D of the guide. The guide can be accessed at http://www.health.state.mn.us/auc/mn837i.pdf. POA indicators should only be submitted along with correlating diagnosis codes. On UB-04 (CMS-1450) paper claims, the POA indicator is the eighth digit of Form Locator (FL) 67, Principal Diagnosis and the eighth digit of each of the Other Diagnosis fields FL 67 A-Q. One POA indicator is submitted per diagnosis. POA indicators should only be submitted along with correlating diagnosis codes. Use the POA indicators as Provider would normally submit to Medicare. For more information, refer to http://www.cms.hhs.gov/HospitalAcqCond.

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Claims Filing

K3 Segment Usage Instructions for POA

To send present on admission (POA) indicator(s), send the letters “POA”, followed by a single POA indicator for every diagnosis reported on the claim, except for admitting diagnosis and patient reason for visit diagnosis. The POA indicator for the principal diagnosis should be the first indicator after “POA”. POA indicators for secondary diagnoses would follow next, if applicable. The “Z” is used to indicate the end of POA information for most claims and the “X” indicates the end of POA information for claims that have an exception to processing. The “X” value was added to provide a way to indicate an exception to processing if necessary in the future. For “E” diagnosis codes, put the POA after the “Z” or “X.” Note: The X value indicates there is an exception to how the values are to be used in the processing of the indicators. Report at 2300 loop only. POA indicator values: 

Y=Yes, present at the time of inpatient admission.



N=No, not present at the time of inpatient admission.



U=Unknown, the documentation is insufficient to determine if the condition was present at the time of inpatient admission.



W=Clinically Undetermined; the provider is unable to clinically determine whether the condition was present at the time of inpatient admission or not.



1=Represents a space or blank and means the dx code is exempt from reporting of POA.



Z=Indicates the end of reporting of POA indicators for the other dx codes.



X=Indicates the end of reporting of POA indicators for the other dx for Inpatient Exempt Providers (CR6086).

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Claims Filing

Claims Filing Timely Filing

Most Subscriber Contracts contain a time limit for claims submittal. The limit is usually six months after the date of service, with a few exceptions. The provider is liable for claims not submitted within the timely filing limit. Providers are required to submit claims in accordance with the timely filing provision of the Provider Service Agreement. Provider is liable for claims not submitted within the timely filing limit. For medical care that involves follow-up, such as surgery and routine postoperative care, it is better to bill EPNI after all services have been completed, as long as it is within the time limit. Replacement Claims Effective May 22, 2010, EPNI requirements for timely filing of replacement claims will be as follows: 

The timely filing limit on replacement claims will be six calendar months from the process date of the predecessor claim.



There is no timely filing limit on cancel claims (claim frequency code of 8).

Provider Submitted Appeals

Claims Crossover for Medicare and Medicare Supplement



Effective May 22, 2010, EPNI requirements for timely filing of provider appeals will change as follows:



The timely filing limit on appeals will be 90 days from the remit date of the claim on all provider submitted appeals.



In no event may Provider send a replacement claim with no data changes to the payer in order to extend the 90 days allowed from remittance date of the claim to appeal.

The claims crossover system reduces Provider's paperwork by using the Medicare claim form to process both Medicare and Medicare Supplement benefits. Through the crossover, Medicare generates a second claim automatically for Subscribers who have secondary or supplemental benefits with EPNI. Providers have only one claim form to submit—the 1500 HICF (CMS-1500) for Medicare Part B or the UB-04 (CMS-1450) for Medicare Part A. While EPNI can only accept changes from the Subscriber, it encourages providers who are aware of Heath Insurance Claim Number (HICN) changes to assist their patients in communicating this information to EPNI.

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Claims Filing

Medicare Crossover

EPNI provides COBC a weekly eligibility file of all EPNI Subscribers enrolled for coverage under the Medicare program. When Medicare processes a claim, the Medicare Subscriber's HICN will be compared to the HICNs on the eligibility file sent by EPNI. If found, the date of service on the Medicare claim will be compared to the EPNI coverage effective and cancel dates. If the claim’s date of service falls within those dates, the claim will be crossed over to EPNI electronically.

UB-04 (CMS-1450) Crossover Information

The current message indicating the claim was sent to EPNI will continue to be displayed on the Subscriber's Medicare Summary Notice (MSN) or on the Explanation of Medicare Benefits (EOMB). Medicare will indicate on the Provider’s Remittance Advice (RA) if the claim was sent to the supplemental insurer. On the Intermediary RA, claim status codes of 19, 20, or 21 indicate that the claim was crossed over. If the HICN is not found on the EPNI eligibility file, or if the date of service on the claim is outside the given EPNI coverage effective and cancel dates, the claim will not be forwarded to EPNI electronically.

1500 HICF (CMS-1500) Crossover Information

A note associated with the ANSI remark code indicates which payer will receive the claim information. Providers will continue to see MA18 and the name of the payer on the Medicare RA when the payment information is forwarded to a single payer. However, code N89 will be used when the payment information is forwarded to multiple payers; only one of those payers will be named on the RA even though the payment information is forwarded to multiple payers. Paper claims submitted to EPNI with the Medicare RA attached and the N89 remark code stating the payment information was forwarded to EPNI will be returned to the provider. Adjusted Medicare B claims will not be crossed over to EPNI. If the claim is not forwarded, then: 

The statement or code indicating the claim was forwarded to EPNI will not appear on the MSN, EOMB or RA.



The patient or provider must submit the paper claim to EPNI along with the MSN, EOMB or RA.

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Claims Filing

Duplicate Claims

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Duplicate billing adds millions of dollars each year to health care administrative costs. Many providers operate under the erroneous assumption that frequent rebilling leads to faster payment. Unnecessary rebilling increases overhead costs of providers and EPNI. Below are several ways Provider can help reduce duplicate claims costs: 

When filing the claim, be sure to tell patients not to bill on their own.



Eliminate “automatic” rebillings. Wait 30 calendar days for EPNI to process claims.



Before rebilling, use provider web self-service or call provider services for claims status information.



Don’t submit previously billed claims with new claims “just to be safe.” This only delays payment of all new claims.



Upon receipt of a Medicare RA showing that the claim has electronically been ‘‘crossed over’’ to EPNI, do not submit the paper RA as a claim.



If a claim has been denied, electronically resubmitting the RA will only result in a second denial. Check with provider services before pursuing the matter.

EPNI Provider Policy and Procedure Manual (10/11/13)

Claims Filing

Submission of Claims

EPNI's goal is to pay claims as quickly as possible. By following the above suggestions, Provider can help hold down everyone’s administrative costs. To ensure the proper administration of benefits by EPNI, providers shall submit claims to EPNI even when their claims have been paid in full by other third parties such as Medicare. When submitting claims in these cases, the provider shall submit a copy of the explanation of medical benefits with the claim. Providers shall submit claims to EPNI for all services provided, even in cases when the provider suspects a service will not be covered. This will ensure the proper administration of benefits and take advantage of changes in coverage that providers may not be aware. Provider must submit claims to EPNI electronically in most cases. Upon reasonable advance written notice to Provider, EPNI may refuse to process paper claims, or charge Provider for processing paper claims. Both Provider and EPNI are subject to Minnesota Statute, Section 62J.356 and other applicable laws, regulations or guidance that governs electronic claims submission. EPNI reserves the right to verify the clinical accuracy of claims through its claims systems. All health plan administration including application of benefits and patient eligibility is applied after clinical correctness has been established. Provider must comply with coding and billing requirements based on coding rules of CPT, ICD-9-CM, HCPCS and/or Minnesota Department of Health Uniform Companion Guides, including any updates or changes to such coding rules and/or guides as applicable and as interpreted by EPNI and as set forth in the coding policies and guidelines of the Provider Policy & Procedure Manual. Provider further agrees to submit claims for Health Services to EPNI in the most cost effective manner when more than one billing option exists. Provider is responsible for obtaining any authorization required to release such information to EPNI and/or the Plan Sponsor.

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Claims Filing

Cancel/Void and Replacement Claims

Minnesota statute 62J.536, requires Provider to submit all claims electronically. This requirement includes all cancel and replacement claims as well as original submissions. Cancel claims are claims that should not have been billed or where key claim information such as the billing provider or patient name were submitted incorrectly. Replacement claims are sent when data submitted on the original claim was incorrect or incomplete. Effective on and after May 1, 2010, EPNI will no longer accept adjustment requests via paper or through provider web self-service at providerhub.com. Providers will be required to adhere to the State of Minnesota Uniform Companion Guide requirements and the Administrative Uniformity Committee (AUC) Best Practices for replacement claims. Additionally, as of May 1, 2010, provider services will no longer accept requests to change data elements within a claim as these should be sent electronically as replacement claims. Provider services will still accept requests to adjust claims in situations where the claim processed incorrectly even though correct information was provided on the original submission. Exceptions Exceptions to this electronic replacement claims enforcement are as follows:

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Dental formatted adjustment requests will still be accepted if received on paper.



Pharmacy formatted adjustment requests will still be accepted if received on paper.



Nonparticipating providers that are located in counties that border Minnesota are exempt from the statute; therefore, paper claims will still be accepted from these providers.



Adjustment requests received from the Veterans Administration (VA) and Indian Health Services.

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Claims Filing

Cancel/Void and Replacement Claims (continued)

Additional Information If Provider is unable to send electronic replacement and/or cancel claims, EPNI has secured the services of Availity to provide a free web-based service for provider data entry of claims. To learn more about submitting claims using Availity’s no-cost web-based tool, go to availity.com. EPNI has completed system changes to accept and properly adjudicate electronic cancel and replacement claims. Following are some of the common questions related to proper submission requirements. Section A contains general information, and section B is for specific handling of coordination of benefits (COB) related scenarios.

Section A – General Information

1. What is an example of a replacement claim? I have read the Administrative Uniformity Committee (AUC) description and would like some clarity on these claims. A replacement claim, to paraphrase the Minnesota Uniform Companion Guides for claims, is used to completely replace a previously submitted claim when data within the claim record is added, changed or deleted. An example would be a professional claim sent with all diagnosis pointers set to “1.” On review by the provider after original payment, it is determined the second procedure was done in reference to the third diagnosis on the claim. A replacement claim is sent to correct the diagnosis pointer on line 2. See section 4.2.3.2 of the Minnesota Uniform Companion Guides, version 4.0, dated March 2009, and the related AUC Replacement/Void Claims Best Practice available on the AUC website at health.state.mn.us/auc. 2. Can I send a replacement claim if I have the wrong subscriber ID on the previous submission? No. According to the AUC Replacement/Void Claims Best Practice, “When identifying elements change, a void submission is required to eliminate the previously submitted claim.” Changes to identifying information related to the billing provider, patient, payer, subscriber or statement covers period dates, require that a cancel claim transaction be submitted for the original claim and that a new claim with the corrected information be submitted to the payer. These requirements are similar to the Centers for Medicare and Medicaid Services (CMS) requirements.

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Claims Filing

Section A- General Information (continued)

3. Can I send an attachment on a replacement claim? Yes, if it is relevant to the changes being made on the replacement claim or needed to support a particular coding change. For example, the addition of a 59 modifier to indicate that the service being billed is a distinct procedure or service will require supporting medical documentation to be submitted with the replacement claim. 4. If EPNI denied my claim because the date of injury was required but not submitted in the claim, can I send an AUC Appeal Request Form to have the claim reconsidered and list the requested date of injury in the Reason for Appeal section? No. Provider must submit a replacement claim with the corrected data (injury date) in the 837 transaction. 5. What is an appeal? The Minnesota Uniform Companion Guides, version 4.0, dated March 2009, section 4.2.3.2, describe an appeal as “Provider is requesting a reconsideration of a previously adjudicated claim but there is no additional or corrected data to be submitted.” For example, Provider receives a claim denial because EPNI considered the procedure investigative. Provider's request to reconsider must be submitted on the AUC Appeal Request Form along with supporting documentation following the instructions in the AUC Submission of Appeals Best Practice. Fax the AUC Appeal Request Form and supporting documentation to EPNI at (651) 662-2745. 6. What are some examples of reasons for appeals? The following is a list of reasons to send an appeal, according to the Minnesota Uniform Companion Guide(s) for Claims:

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timely filing denial



payer allowance



incorrect benefit applied



eligibility issues



benefit accumulation errors



medical policy/Medical Necessity

EPNI Provider Policy and Procedure Manual (10/11/13)

Claims Filing

Section A- General Information (continued)

7. All of the claim information was submitted correctly; however, it appears not all claim data I sent was recognized by the system. Is it acceptable for me to call EPNI to simply have my claim adjusted using what was previously submitted or do I need to appeal? It is acceptable for Provider to request the claim be adjusted to recognize the data within the submission through a phone call to provider services. It would also be acceptable for Provider to submit its request using the AUC Appeal Request Form. 8. I am sending documentation in response to a request for additional documentation from EPNI. Do I need to send a replacement claim with the attached medical records? If Provider is responding to an information request letter sent by EPNI, regardless of whether Provider has also received a denial on its remittance, Provider should submit the requested information, along with a copy of the information request letter. Do not send an AUC Appeal Request Form. These same instructions are included on the letter that Provider receives. 9. I am sending documentation in response to a denial on my remittance advice from EPNI. Do I need to send a replacement claim with the supporting information needed? If Provider is sending the additional documentation as a result of a denial on a remittance advice only, and not in response to an information request letter from EPNI, and the claim requires changes to claim data elements (such as date of injury, procedure code changes, diagnosis code changes, etc.), then a replacement claim must be sent which includes any necessary attachments. If Provider is sending the additional documentation as a result of a denial on a remittance advice only and the claim does not require changes to claim data elements Provider also may send a replacement claim. If Provider is are sending additional documentation because Provider believes it did not receive correct payment and this documentation supports its position, Provider must send the AUC Appeal Request Form along with the documentation to support its request.

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Claims Filing

Section B – COB Related Scenarios Q&A

How do I send COB information when it was not included with the previous submission? 

Scenario 1 If Provider has received a HIPAA compliant remittance advice (835) and its system has the capability to populate the information within a secondary claim, or the submission date is after December 15, 2009, Provider must submit a replacement claim with the data appropriately entered within the claim record.



Scenario 2 If Provider has received a HIPAA compliant remittance advice (835) from a prior payer and its system is not capable of populating the information within the HIPAA secondary claim transaction (837) before December 15, 2009, Provider may send a replacement claim with the addition of the PWK segment and send the paper remittance advice from the previous payer as an attachment.



Scenario 3 If Provider has not received a HIPAA compliant remittance advice (835) from the previous payer, Provider may send a replacement claim transaction with the addition of the PWK segment and send the paper remittance advice from the previous payer as an attachment.

Note: After December 15, 2009, all Minnesota group purchasers must provide a HIPAA and State of Minnesota compliant remittance advice. Providers are required by the Minnesota Uniform Companion Guides (section 4.2.3.5) to submit the previous payment information electronically using the proper fields within the claim transactions. Additional Information For additional information on these types of claims, please refer to the Minnesota Uniform Companion Guides and related Best Practice documentation on the Administrative Uniformity website at www.health.state.mn.us/auc/guides.htm. Release of Medical Records

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The Minnesota Statute that states “consent for the release of medical records are valid for only one year,” also provides that consents to release medical records to insurers for purposes of claims payment do not expire after one year. Since there are circumstances where such consents are only valid for one year, providers may wish to update their records on an annual basis.

EPNI Provider Policy and Procedure Manual (10/11/13)

Claims Filing

Provider Assistance Requested

Medical Records Management Process Improvement

Verify Subscriber Identity

Providers are reminded that: 

Provider Service Agreements state “The provider shall promptly furnish any additional information EPNI or the Plan Sponsor shall reasonably request as necessary to respond to claims.”



HIPAA considers release of such records as required for “business operations.”



ARIs are required under Minnesota law.



Providers gather information from patients on an annual basis to facilitate timely processing of claims.

EPNI is improving its medical records management process to better serve providers. 

Reduced requests- Changes to the EPNI internal medical records procedures will eliminate unnecessary medical record requests.



Clearer instructions- A form will accompany all medical record requests to facilitate claims processing.

EPNI has received a number of calls from its Subscribers who have stated that they did not receive certain Health Services that were billed under their Subscriber identification number. Upon comparing consent for treatment forms with signatures on file it appears that such Health Services were provided to an imposter. In order to prevent this occurrence, providers are requested to take appropriate steps to verify Subscribers' identity, such as viewing a government issued identification card and an EPNI member ID card at each encounter. If Provider suspects fraudulent use of a member ID card, please call EPNI's fraud hotline at (651) 662-8363. Callers may remain anonymous.

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Claims Filing

Verify Subscriber Eligibility

Effective January 15, 2009, Minnesota Statute 62J.536 required health care providers and group purchasers (payers, plans) to exchange eligibility electronically using a standard format. The intent of the law is to reduce costs, simplify and speed up health care transactions, and give providers and health plans one set of rules to follow for electronic transactions. This statute applies to all health care providers that request benefit or eligibility information regardless of participating status. Rules for Checking Eligibility and Benefits According to the Minnesota Department of Health, the compliant modes for initial eligibility inquiries and responses are either via provider hub or submission of the Eligibility Inquiry and Response Electronic Transaction (ANSI ASC X12 270/271). If, after an initial compliant exchange (via web or EDI), additional information or review is needed, Provider may place a phone call to a service representative. The Minnesota Administrative Uniformity Committee (AUC) has published a best practice related to checking eligibility and benefits for Subscribers. The best practice covers four major areas: 

When and how to verify



Preferred methods of eligibility inquiry



Sharing eligibility information



Data elements that should be used to update information systems The recommendation of the AUC is that eligibility be checked for each patient once per calendar month since most eligibility changes occur at the beginning of a month. Please refer to the best practice at the following link for other helpful tips. www.health.state.mn.us/auc/bstprac01.pdf. Questions? If Provider wants to register to receive the electronic eligibility (270/271) transaction, contact Availity at availity.com. Provider can also use the provider web self-service site to check eligibility and benefits. To apply, go to the Welcome page on providerhub.com. Click on the link “Want access to this online service for your office?”

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Claims Filing

Basic Character Set The AUC has published a best practice regarding utilization of the Values in the Electronic basic character set values within the transaction data. Transaction

The basic character set includes some punctuation characters and spaces. These values when used unnecessarily can cause issues with matching to the payers’ enrollment for the provider or the Subscriber; or may cause the data to be incorrectly extracted/interpreted within the payers’ applications.

If any of the punctuation characters within the basic character set are used as delimiters then they cannot be used in the transmitted data within a data element. Punctuation and spaces should only be utilized within the elements when they add value to the data. They should not be used when their usage is not essential to the interpretation of the data content. Basic character set: uppercase letters (A-Z), numeric digits (0-9), space ( ), exclamation point (!), double quote (“), single quote (‘), ampersand (&), right parenthesis, left parenthesis, asterisk (*), period (.), plus sign (+), comma (,), hyphen (-), forward slash (/), colon (:), semi-colon (;), question mark (?), and equals sign (=). Even though the “@” character is in the extended character set it is allowed for email addresses within the PER segment. This character must not be used as a delimiter. Examples to illustrate best practice: Description

Incorrect Examples

Correct Example

Name Titles (no period should be used)

JR.

JR

MR.

MR

PhD.

PHD

M.D.

MD

Address – no periods should be used as part of the address

P.O.

PO

AVE.

AVE

Commas and periods should be used at the end of a sentence in a text field to separate from another sentence within the text field.

A PERIOD WITHIN A SENTENCE MAY HAVE VALUE DESCRIPTION OF SERVICE IS ABC

A PERIOD WITHIN A SENTENCE MAY HAVE VALUE. DESCRIPTION OF SERVICE IS ABC.

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Claims Filing

Description Basic Character Set Values in the Electronic Transaction (continued) Hyphens and

apostrophes should not be used within a last name field Leading and trailing spaces within fields should not be used

Claim Service Dates Restricted to Same Calendar Month

Incorrect Examples

Correct Example

SMITH-JONES

SMITHJONES

O’BRIEN

OBRIEN

Rendering practitioner last name = “_JONES” or “JONES_”

Rendering practitioner last name = “JONES”

The AUC has published a best practice regarding claim service dates in the same calendar month. The purpose of this best practice is to avoid split claims and rejections. Most eligibility changes occur at the beginning or end of a calendar month. Some payer systems require claims contain only services that are associated with a particular eligibility period. Current practice is to split these claims at the payer site to push through systems or to reject the claim. On a professional claim, service date spans should only be within the same calendar month. Multiple claims may be submitted for different dates within the same calendar month based on the provider’s billing practices. On an institutional outpatient claim, statement and service date spans should only be within the same calendar month. Observation, extended recovery and emergency department services beginning before and completing after midnight are exceptions to this best practice if performed during the same visit. Procedures beginning on one day and ending on another should be billed together. This best practice does not apply to an institutional inpatient claim. Pharmaceuticals should be billed with the administration/dispensed date rather than a span of dates. Monthly equipment rental should be billed with the start date of the rental period only rather than the span of days. Equipment rented on other than monthly basis needs both from and through dates. Units of service should be reported as one (1) per rental period. These service date spans should only be within the same calendar month. Example would be daily rental of equipment.

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EPNI Provider Policy and Procedure Manual (10/11/13)

Claims Filing

Claim service dates Restricted to Same Calendar Month (continued)

Supplies should be billed with the purchase date rather than the span of days. Refer to Appendix A of the MN Uniform Companion Guides for additional guidance on service date coding. Examples to illustrate best practice: Example 1 (equipment rental single month): Equipment is rented for January 17 through February 16. Service date should be reported as January 17 with no end date. DTP*472*D8*20080117~ Example 2 (equipment rental multiple months): Equipment is rented for March 3 through May 15. Should be submitted as three separate claims, claim one would be reported as March 3 with no end date; claim two would be reported as April 3 with no end date; claim three would be reported as May 3 with no end date. DTP*472*D8*20080303~ DTP*472*D8*20080403~ DTP*472*D8*20080503~

Reporting MNCare and Sales Tax

Instructions for MNCare tax billing only apply if the provider bills the group purchaser for MNCare tax. Some providers do not bill the group purchaser for MNCare tax. This document DOES NOT require them to do so but if they do identify the tax it must be done as follows. Some group purchasers may not reimburse MNCare tax unless it is identified in the AMT. Sales tax instructions for professional claims are as follows: 

MNCare tax must be reported as part of the line item charge and reported in the corresponding AMT tax segment on the lines. Sales tax must be reported using HCPCS code S9999 for the tax and must be billed on the same claim as the related taxable service.

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Claims Filing

Rural Health Clinics and Federally Qualified Health Centers Billing for Medicare Primary

Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) are Medicare provider designations. Medicare requires RHCs and FQHCs to bill services on a UB-04 claim form. Since billing as a RHC or FQHC would be secondary to Medicare, we will only accept these clinic claims on the UB-04 (or 837I). The claim should be submitted following Medicare billing requirements (e.g., TOB 071X and revenue code 0521 for a clinic visit to a RHC).

Billing Other Than Medicare Primary

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If Medicare is not primary, services must be billed as a clinic, not as a RHC/FQHC, under Provider's EPNI clinic provider number or NPI and submitted as a professional claim 837P (1500 HICF, CMS-1500).

EPNI Provider Policy and Procedure Manual (10/11/13)

Claims Filing

Coordination of Benefits (COB) Overview

Third-party payers rely on Coordination of Benefits (COB) to eliminate duplicate payments when a Subscriber has more than one coverage for Health Services. Please complete the information under ‘‘other coverage’’ on claims for EPNI Subscribers. List the names of any other carriers and the Subscriber's ID number, if possible. EPNI determines which carrier is primary payer and ensures that duplicate payments are not made for the same services.

Primacy Determination

EPNI follows the National Association of Insurance Commissioners (NAIC) rules to identify the primary insurance carrier.

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Claims Filing

Coordination of Benefits Types. There are seven types of coordinating benefits that are outlined below. The only way to determine what type of COB a Subscriber has is to contact provider services. All seven types follow these first 3 steps: 1. The primary carrier pays appropriate benefits under its contract. 2. The claim is submitted to the secondary plan's carrier. 3. The secondary plan will never pay more than it would pay in the absence of coordination. COB Type 1 and 2 (Standard Coordination)

COB Type 3 (Benefits less Other Insurance Benefits)

COB Type 4 (only with Medicare)

4. The secondary plan pays the difference between the higher allowed amount and what the primary plan paid.

4. The secondary plan processes up to the secondary plan's allowed amount. The secondary plan subtracts the amount the primary plan paid from the amount it would have paid without coordination.

4. The secondary plan's allowed amount is determined by subtracting Medicare's paid from Medicare's allowed.

5. The combined payment of the primary and secondary plans will not exceed the total incurred expenses.

5. If the primary plan paid less 5. That amount is reduced by than what the secondary plan the any applicable deductibles would have paid without and coinsurance. coordination, the secondary plan pays the difference. 6. If the primary plan paid more than what the secondary plan would have paid without coordination, the secondary plan pays nothing. (Integration)

6. The combined payment of the primary and secondary plans will not exceed the total incurred expenses.

7. The combined payment of the primary and secondary plans will not exceed the total incurred expenses.

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Claims Filing

COB Type 1 and 2 (Standard Coordination)

COB Type 3 (Benefits less Other Insurance Benefits)

COB Type 4 (only with Medicare)

The result:

The result:

The result:

The Subscriber would not be responsible for payment of a portion of his or her eligible medical expenses.

The Subscriber is responsible for any applicable deductible or coinsurance amounts for eligible medical expenses under both plans.

The Subscriber may be responsible for a portion of his or her eligible medical expenses.

Note: When coordinating benefits with Medicare all COB Types coordinate up to Medicare's allowed amount when the provider accepts assignment and the provider is located within the state of Minnesota. The federal Medicare Secondary Payer (MSP) law dictates when Medicare pays secondary. When coordinating benefits with another commercial carrier all COB types coordinate up to the higher allowed amount between the two plans except when integration is involved. Integration will coordinate up to EPNI’s allowed amount. It is important that all charges submitted to the primary payer be submitted to the secondary payer, even though charges were paid in full. Workers’ Compensation

In cases where an illness or injury is employment-related, Workers’ Compensation is primary. If notification is received that the Workers’ Compensation carrier has denied the claim, Provider should submit the claim to EPNI regardless of whether the case is being disputed. It is also helpful to send the other carrier’s denial statement with the claim.

No-fault Auto

The No-fault Automobile Insurance Act calls for automobile insurance coverage to be primary without regard to cause or fault for the accident. The health insurance carrier would be the secondary payer. If notification is received that the no-fault auto carrier has denied the claim, Provider should submit the claim to EPNI regardless of whether the case is being disputed. It is also helpful to send the other carrier’s denial statement with the claim.

Subrogation

Subrogation literally means the substitution of one person for another. It is the right to recover payments for a Subscriber whose personal injuries are caused by the negligence or wrongdoing of another. Minnesota does not have specific statutes or laws that apply to subrogation. Some group health care coverage plans do have subrogation in their certificates or contracts.

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Claims Filing

TEFRA

The 1982 Tax Equity and Fiscal Responsibility Act (TEFRA) applies to employers with 20 or more employees. Under TEFRA, group health coverage becomes the primary payer and Medicare the secondary payer for active employees between ages 65 and 70. TEFRA applies to active employees from the first day of the month of their 65th birthday to the first day of the month following their 70th birthday.

DEFRA

Effective January 1, 1985, the Deficit Reduction Act (DEFRA) expands the TEFRA aged workers’ guidelines to include dependent spouses (ages 65 to 70) of actively employed workers under 70.

COBRA

On April 7, 1986, the Consolidated Omnibus Budget Reconciliation Act (COBRA) amended the Working Aged Provision to eliminate the age 69 limit. Medicare will no longer become primary payer when an employed person turns age 70 or the spouse of an employed person turns 70. The group remains primary payer until the employee retires.

OBRA

The Omnibus Budget Reconciliation Act (OBRA) of 1986 introduces the term ‘‘active individual’’ and defines it as the employee, the employer, or individual associated with the employer in a business or family relationship. Medicare will now be the secondary payer for disabled Medicare beneficiaries who elect to be covered by an employer-based group health plan, either as current employees or family of such employees. The minimum number of employees under this provision is set at 100. The employer’s insurance pays primary.

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Claims Filing

Non-Physician Health Care Providers Introduction

EPNI and its affiliates will pay for reasonable and necessary Health Services performed by certain non-physician Health Care Providers. Eligible Health Services are determined by the Health Care Provider’s scope of practice and the Subscriber's Contract.

Eligibility Criteria

Below is the eligibility criteria for non-physician Health Care Providers:

Definitions



Non-physician Health Care Practitioners must meet applicable state or federal laws or licensing standards.



When collaboration is required, non-physician Health Care Providers in independent practice must work in collaboration with a physician licensed in the state where the Health Services take place.



A non-physician Health Care Provider not eligible as an independent contractor must be an employee of a physician or limited-license practitioner (such as chiropractor or optometrist) licensed in the state where the Health Services took place. The employing provider must be legally and medically responsible for the supervised employee’s services.



Eligible non-physician Health Care Providers must apply for and meet EPNI credentialing criteria.



Credentialed practitioners must use the EPNI individual provider number or NPI when submitting Health Services.



Services rendered by supervised employees who are not issued individual provider numbers must be submitted under the supervising physician’s provider number or NPI. The -U7 modifier should be appended to the HCPCS code to indicate a non-physician Health Care Providers rendered the Health Service.



Health Services rendered must be eligible under the Provider Service Agreement and Subscriber Contract and the Health Care Provider’s scope of practice.



A countersignature of notes and orders by the employing or supervising physician is required if the non-physician Health Care Provider’s licensure and/or scope of practice requires a signature.

Centers for Medicare and Medicaid Services (CMS) guidelines are the basis for the following definitions. For added clarification, EPNI has further defined supervision as either direct or general.

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Claims Filing

Employment

As defined by CMS, the non-physician performing an “incidentto” service may be a part-time, full-time or leased employee of the supervising physician group practice or the legal entity that employs the supervising physician. A leased employee is a nonphysician working under a written employee leasing agreement, which provides that: 

The non-physician, although employed by the leasing company, provides services as the leased employee of the physician or other entity; and



The physician or other entity has control over all actions taken by the leased employee with regard to medical services rendered to the same extent that the physician or other entity would have such control if the leased employee were directly employed by the physician or other entity.

To satisfy the employment requirement, the non-physician must be considered an employee of the supervising physician or other entity under the common law test of an employer/employee relationship. Services provided by auxiliary personnel not employed by the physician, physician group practice, or other legal entity are not covered as incident to a physician’s service. Incident to

“Incident to” physician’s professional services means that the Health Services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment or an injury or illness. 

The Health Care Provider’s service must be furnished as an integral part of the physician’s personal professional service in the course of diagnosis or treatment of an illness or injury.



An employee of the physician must render service under the physician’s direct supervision.



The physician must perform the initial and subsequent service with a frequency that reflects his/her active participation in managing the course of treatment.

Health Care Providers who are issued individual provider numbers are considered incident to the physician when performing services within the same encounter on the same day as the physician. Incident to services are applicable in the office place of service only.

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Direct Supervision

The physician must be present in the office suite and immediately available to assist and direct throughout the performance of the Health Service. Direct personal supervision does not mean that the physician must be present in the same room with the non-physician practitioner. A physician cannot provide direct or personal supervision via telemedicine. Direct Supervision is only applicable in the office place of service.

General Supervision

General supervision refers to Health Services furnished under the physician’s overall direction and supervision. The physician does not have to be physically present in the same office suite. He or she may provide general supervision by periodic review of the non-physician’s practice and availability either in person or through electronic communications (telemedicine, telephone, etc.).

Collaboration/ Independent Practice

Certain Health Care Providers are qualified to set up their own practice. Although these practitioners work independently and do not require physician supervision, they must work with or collaborate with a physician. For example, a physical therapist may perform therapy independently; however, the patient’s physician makes the initial determination that the patient requires or will benefit from physical therapy. The physical therapist works in collaboration with the physician.

Chiropractic Doctors and Multidisciplinary Clinics

Chiropractic doctors must maintain a separate Provider Service Agreement and provider number when practicing in a multidisciplinary clinic setting with medical doctors. EPNI does not allow chiropractors to bill services as “incident to” a physician’s services. Services performed by a chiropractor must bill under the chiropractor’s own provider number. The assignment of a chiropractic provider number is fundamental to the appropriate processing of EPNI Subscriber Contracts and Provider Service Agreements. It allows EPNI to identify the specialty of the individual providing the services. This is especially important to enable EPNI to correctly administer those Subscriber Contracts that have visit limitations, exclusions and other benefit variances. A multidisciplinary clinic with medical and chiropractic doctors must adhere to this requirement that independently licensed chiropractors must maintain a separate Provider Service Agreement with EPNI and bill appropriately. There are no exceptions to this policy. Any deviation from this billing requirement is a violation of the Provider Service Agreement.

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Claims Filing

Surgical Technicians

Surgical technicians are considered to be hospital-based practitioners and as such cannot have an independent relationship with EPNI nor can their services be billed under a supervising physician’s individual provider number. Surgical technicians are members of the operating team that prepare the patient and the operating room for surgery, transport patients, observe vital signs and check charts during surgery.

Mid-level Practitioners

EPNI is clarifying the definition of mid-level practitioners based on practitioner specialties. The practitioner's specialty is established based on their current state license and is appropriately determined during the credentialing process. The following is a comprehensive current list of mid-level practitioners:

Mid-Level Reduction Exemption

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Adult nurse practitioner



Certified nurse midwife



Clinical nurse specialist



Family nurse practitioner



Gerontological nurse practitioner



Licensed practical nurse



Neonatal nurse



OB/GYN nurse practitioner



Optician



Pediatric nurse practitioner



Physician assistant



Public health agency/nurse



Registered nurse first assistant



School nurse practitioner

Retail Health providers and online care providers are exempt from the mid-level reduction as defined in the provider contract.

EPNI Provider Policy and Procedure Manual (10/11/13)

Chapter 7

Reimbursement / Reconciliation Table of Contents Reimbursement .......................................................................................................................... 7-2 Payment Methodology ........................................................................................................... 7-2 Direct Payment....................................................................................................................... 7-3 Electronic Funds Transfer...................................................................................................... 7-3 CPIU Payment Increase ......................................................................................................... 7-4 Inpatient Claims Paid at DRG Rates...................................................................................... 7-4 Complication and Co-Morbidity Defined.............................................................................. 7-5 Serious Preventable Medical Errors....................................................................................... 7-5 Replacement of Medical Devices .......................................................................................... 7-6 Overpayments ........................................................................................................................ 7-6 Remittance Advice ..................................................................................................................... 7-7 Introduction............................................................................................................................ 7-7 Sample Statement of Provider Claims Paid ........................................................................... 7-7 2006 Remittance Advice Change........................................................................................... 7-7 ANSI Codes ........................................................................................................................... 7-7 Questions and Answers.......................................................................................................... 7-8 Remit Balancing Tips .......................................................................................................... 7-12 Provider Remittance Reconciliation Report ......................................................................... 7-13 Introduction.......................................................................................................................... 7-13 Provider Remittance Reconciliation Report ........................................................................ 7-14 Field Description.................................................................................................................. 7-15

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7-1

Reimbursement / Reconciliation

Reimbursement Payment Methodology

Additional information regarding payment methodology is available in the Provider Service Agreement. Fee Schedules A list of applicable fee schedule allowances is available to Provider upon request of Provider, up to twice annually. Employer Provider Network, Inc. (EPNI) will not accept retroactive charge increases from Provider. Payment amounts may be affected by Provider certification or EPNI credentialing criteria, as detailed in the Provider Policy & Procedure Manual. If Provider begins billing for a new Health Service (e.g. newly accepted medical practice, new technology, new services for practice), Provider agrees to give EPNI ninety (90) days' advance written notice prior to submitting claims or billing for any such new Health Service. Changes to Minnesota Health Care Programs Payment In the event that CMS or DHS has published rate or methodology changes, EPNI shall implement such changes within 90 days of the date that such change is effective or by the first day of the following calendar quarter after the changes are released, whichever is later, unless otherwise specified by the state or federal regulatory agency. Provider shall not request adjustments, and EPNI shall not adjust any claims paid prior to the effective date EPNI implements any such changes.

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EPNI Provider Policy and Procedure Manual (05/10/13)

Reimbursement / Reconciliation

Direct Payment

EPNI sends claims payments directly to participating providers. Payments are sent weekly. Effective December 15, 2009, Minnesota Statute 62J.536 requires all providers to accept from group purchasers the health care payment and remittance advice transaction (835). The statute further allows the use of web-based technology for complying with the requirements as long as the data content and rules of the Minnesota Uniform Companion Guides are followed. Beginning second quarter 2011, EPNI will no longer print and mail any paper remittances. Providers will also not be able to obtain a printed copy of the remittance through provider services except for remittances produced before February 2010. Providers must register through Availity to receive the electronic 835 or register for access to the provider portal, provider web self-service (PWSS) to view its remittance information. Providers can register for both options. The full on-line view through the portal via PWSS was available as of September 22, 2010 A nonparticipating provider generally receives neither direct reimbursement from EPNI nor a copy of the statement for any Subscriber that has EPNI coverage. Subscribers cannot assign benefits to providers. EPNI pays the Subscriber directly for nonparticipating providers.

Electronic Funds Transfer

EPNI offers Electronic Funds Transfer (EFT). Instead of weekly checks with remits, Provider can now receive electronic payments directly into its facility’s checking or savings account. The funds are securely transferred via the Automated Clearinghouse (ACH) process. Electronic payment will streamline Provider's reconciliation process, eliminate deposit delays due to check handling, and improve cash flow. If Provider currently receives an 835 electronic remittance advice and registers for EFT, paper remittances will be shut-off 60 business days from the 835 go-live date. The Provider Automatic Payment application is available at ccstpa.com; click on the Provider tab and then Forms.

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7-3

Reimbursement / Reconciliation

CPIU Payment Increase

Consumer Price Index" or "CPIU" means the Minneapolis/Saint Paul Average All Items Consumer Price Index for Urban Consumers as published by the U.S. Department of Labor, Bureau of Labor Statistics.) EPNI reserves the right to conduct an audit to assure that increases to payment have not exceeded the Maximum Increase. In the event that an increase in Provider's Regular Billed Charges exceeds the Maximum Increase, payment to Provider shall be reduced proportionately. Any payments made in excess of the Maximum Increase shall be subject to the over payment provisions herein. The method used in determining if the payment increase from one contract year to the next exceeded the Maximum Increase will be calculated in aggregate, rather than on a claim-byclaim basis, and will include a case mix adjustment as determined by EPNI. That calculation will 1) omit any Health Services provided less than five (5) times during the contract year being reviewed; and 2) include only Health Services that have been performed in both the current contract year and prior contract year.

Inpatient Claims Paid at DRG Rates

EPNI pays inpatient claims at DRG (Diagnosis-related group) rates for most hospitals. Some rural hospitals may continue to be paid at a percentage of charge. About DRGs The DRG reimbursement methodology has over 500 inpatient categories of care, which are updated annually by the Centers for Medicare and Medicaid Services (CMS). DRGs are a way of categorizing inpatient hospital services by diagnosis groups that have similar patterns of hospital resource use and similar lengths of stay. DRG assignment is based on the patient’s principal and secondary diagnoses, principal and secondary procedure codes, age, sex and discharge status. Payments are based on the assigned DRG case weight, multiplied by a base rate (conversion factor) that EPNI negotiates with hospitals. Coding Compliance Coding compliance relates to the accuracy and completeness of the ICD-9-CM diagnosis and procedure codes that are used to assign DRGs and determine payment. EPNI requests that hospitals establish adequate internal procedures to ensure the accuracy of claims submissions. EPNI reserves the right to conduct random chart audits on a sample of records to ensure that diagnoses submitted justify the DRG and adhere to ICD-9-CM coding rules. Coding errors that are determined to represent a fraudulent claim may be subject to penalties.

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Reimbursement / Reconciliation

Complication and Co-Morbidity Defined

According to St. Anthony Publishing, a “complication” is a condition that arises during a hospital stay and prolongs the length of stay by at least one day in approximately 75 percent of the cases. The same source defines “co-morbidity” as a pre-existing condition that, because of its presence with a specific diagnosis, will cause an increase in length of stay by at least one day in approximately 75 percent of cases. The condition must affect the patient’s hospital care by requiring one or more of the following: •

Clinical evaluation



Therapeutic treatment



Diagnostic studies or procedures



Increased length of stay

• Increased nursing care and/or monitoring Although there is a standard list of diagnoses that are considered complications or co-morbidities, if the diagnosis does not require one or more of the above services, it should not be listed as a diagnosis. The physician must verify and document the conditions, based on clinical findings and treatment in the record. Serious Preventable Medical Errors

When the negligence, omission, or error on the part of Provider results in the Subscriber incurring additional medical expenses no payment will be made by EPNI for, nor shall Provider bill either EPNI or the Subscriber for said additional medical expenses. The National Quality Forum has defined certain events as serious preventable medical errors, and these are the situations for which no payment shall be made by EPNI or the subscriber. A listing of these events can be found at www.qualityforum.org. This listing will be updated periodically by the National Quality Forum. Examples of serious preventable errors include: •

Unintended retention of a foreign object in a patient after surgery.



Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration).



Surgery performed on the wrong body part.



Surgery performed on the wrong patient.



Wrong surgical procedure performed on a patient.



Infant discharged to the wrong person.

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Reimbursement / Reconciliation

Replacement of Medical Devices

No payment will be made by EPNI and neither EPNI nor the Subscriber shall be billed for the cost of a replacement device in excess of the actual cost paid by Provider for the replacement device. Provider is obligated to submit to EPNI proof of the actual payment amount made by Provider to the manufacturer or reseller of the replacement device for such replacement device and is likewise obligated to advise EPNI of any rebate, retroactive payment, warranty program payment and/or waiver of payment received from the device manufacturer or reseller. This applies to, but is not limited to, devices subject to warranty replacement programs and/or recalls, whether or not such warranty replacement programs and/or recalls are due to device failures design defects and/or defective materials. If a third party such as a medical device manufacturer or reseller recalls or replaces a device and Provider is either reimbursed for the cost of the device or is not charged for the replacement device, no charge for the device will be billed to EPNI or the Subscriber. Provider shall bill only for the professional services associated with the replacement procedure; provided however, that no payment will be made by EPNI, and Provider shall not bill EPNI or Subscriber for any Health Service in the event that the Subscriber is held harmless by the manufacturer and/or other third party for such Health Services rendered in the removal of a defective device and/or insertion of a replacement device.

Overpayments

In the event EPNI makes a corrective adjustment EPNI may deduct any overpayments from future payments owed to Provider together with an explanation of the credit action taken. EPNI shall be entitled to use a statistically valid sample when determining overpayment amounts. EPNI shall have the right to offset against any amounts due and owing or which become due and owing to Provider under the Provider Service Agreement, any amount (a) due and owing or which become due and owing to EPNI and/or any Affiliate under the Provider Service Agreement and/or (b) that may have been paid by EPNI and/or its Affiliates to Provider in error, including without limitation, payments made to Provider for non-covered Health Services. To the extent EPNI exercises the foregoing right to offset against claims for Health Services otherwise properly payable, such claims to which the offset is applied shall be deemed to be paid by EPNI, and Provider shall not have the right to balance bill Subscriber for such claim amounts.

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EPNI Provider Policy and Procedure Manual (05/10/13)

Reimbursement / Reconciliation

Remittance Advice Introduction

The remittance advice is mailed or transmitted via an 835 electronic transaction every week. The weekly remittance will include claims that are processed or adjusted before the end of the day Friday. Provider will receive a separate remittance for each NPI and each type of claim (i.e. institutional, professional). Remember to always keep remittances to meet HIPAA requirements in a central location for easy retrieval, as they are an essential resource for business.

Sample Statement of Provider Claims Paid

A sample of the PDF version of the provider remittance with field descriptions is available on CCStpa's web site.

2006 Remittance Advice Change

The Health Care Administrative Simplification Act of 1996 allowed Minnesota health care providers and payers the chance to implement administrative standards and simplified procedures throughout the industry. Minnesota Statute 62J.536 further required payers and providers in Minnesota to develop and implement a uniform paper Explanation of Benefits (EOB) and Remittance Advice report (remit). The Minnesota rules prescribe specific data fields that must appear on the EOB and remit.

ANSI Codes

EPNI will adopt all the conventions addressed in the “Minnesota Paper Explanation of Benefits and Uniform Paper Remittance Advice Report” manual developed by the Administrative Uniformity Committee (AUC) in the PDF version of the remittance. A copy of the manual is available on their website at: •

http://www.health.state.mn.us/auc/index.html; or

• Minnesota’s Bookstore at (651) 297-3000 or 1-800-657-3706. The guide sets forth the standard approach to be adopted by payers and providers.

EPNI Provider Policy and Procedure Manual (05/10/13)

7-7

Reimbursement / Reconciliation

Questions and Answers

1. Where will adjusted claims appear? They will appear on the Statement of Provider Claims Paid or 835 remittance as noted in the guide. 2. How can I identify adjustments in the statement? The claim number will be the same as in the original statement, except the last two digits. For example: If the original claim ended in 00 the adjusted claim will end in 01. If it needs to be adjusted again, it will end in 02, etc. On a paper Statement of Provider Claims Paid, if EPNI then makes additional or adjusted payment for that claim, the newly processed claim will be printed above the original claim. 3. How do I use the Accounts Receivable Recoupment Report? This report is sent out under separate cover from the weekly remittance and lists the claims that will be recouped that week. The amount listed on this report will be reflected on the weekly statement. Remember to keep this report in a central location for easy retrieval. 4. Do I have to credit the subscriber’s account based on the Accounts Receivable Recoupment Report? If Provider has already credited the Subscriber’s account based on the remittance that reflected the adjustment, then do not adjust the Subscriber’s account again. This is an internal workflow for Provider's office. Adjusting the Subscriber’s account using both the weekly remittance and the Accounts Receivable Recoupment Report may result in duplication.

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EPNI Provider Policy and Procedure Manual (05/10/13)

Reimbursement / Reconciliation

Questions and Answers (continued)

5. What if there is a claim on my statement for a Subscriber that is not ours? Request an adjustment by contacting provider services. Please do not return EPNI's payment check or send EPNI a refund check unless EPNI requests it. 6. What can I bill the Subscriber and how can I identify it on the statement? The Patient Responsibility field reflects the total Subscriber liability. This is the amount that the Subscriber is responsible to pay. However, Provider may have already billed the Subscriber for copayments or Subscriber liability amounts up front. 7. What do I have to write-off and how can I identify so on the statement? The group code 'CO' signifies a provider contractual obligation. Any amounts associated to the use of this code should be written off. 8. Do Subscribers receive their Explanation of Health Care Benefits (EOB) at the same time as Providers? No, the Subscriber’s EOB is mailed daily and Provider’s remittances are sent or posted weekly. However, EPNI mails Subscribers’ EOBs monthly if there is zero Subscriber liability and payment was made to the Provider. If a Subscriber references a claim that Provider hasn't received notice on yet, it should be on Provider's next remittance.

EPNI Provider Policy and Procedure Manual (05/10/13)

7-9

Reimbursement / Reconciliation

Questions and Answers (continued)

9. What does the claim number represent? The claim number is a sequence of numbers that identifies each claim. Knowing what the claim number consists of may assist Provider in better understanding the claim. The information below describes a claim number. Example: Claim number 0109361034020 0109= Julian date the claim was entered into EPNI's claims processing system (i.e., 109th day of 2010). 361034= the sequence number for claims entered on that date 02= The second position reflects if the claim has been adjusted (i.e., 0= original claim, 1= claim adjusted the first time, 2= claim adjusted the second time, etc.) This also may reflect a claim has been split. If a claim is split, EPNI is unable to process as one claim so EPNI processes it as two. Two main reasons to split a claim are when benefits have changed in the middle of the claim or there are too many lines for EPNI to process it as one claim. 10. How do I request an adjustment or inquiry? An adjustment should be requested when Provider notices the adjudication error. Please remember if data on the claim needs to be changed, Provider must send a complete replacement claim rather than request an adjustment. Provider can request an adjustment by: •

Submitting a request through provider web self-service.



Fax in the Provider Inquiry fax form to: (651) 662-2745.



Mail in a request to: EPNI P.O. Box 64560 St. Paul, MN 55164-0560 For inquiries:

7-10



Provider Web self-service is found at: www.providerhub.com



Call provider service at (651) 662-5940 or 1-800-365-2735. Please wait 30 days before checking the status of a claim or adjustment.

EPNI Provider Policy and Procedure Manual (05/10/13)

Reimbursement / Reconciliation

Questions and Answers (continued)

11. What do I do with interest payments? Interest payments that Provider receives should be posted to a miscellaneous account. This is money that is Provider's and should not be posted to the account of the Subscriber it pertains to. By posting this money to a Subscriber’s account they may end up with a credit. 12. Are there any limits for making adjustments? EPNI may make, and Provider may request, corrective claim adjustments (recoupments or additional payments) to previously processed claims for Health Services within six months of the date a claim is paid or denied unless the adjustment is made for the following circumstances (and thus are not limited to this six month period): •

One or more insurer is involved, whether primary or secondary (i.e., Medicare secondary payer, no-fault automobile coverage, subrogation, coordination of benefits, workers’ compensation, TEFRA, etc.)



The adjustment is required due to provider error (i.e., the provider should not have billed for services, a claim was a duplicate of a claim previously paid, fraud, incorrect billing, etc.)



The adjustment is required pursuant to applicable law, regulation, rule, order or contractual requirement or



The adjustment is required as part of a contractual settlement obligation with the provider. Note: Provider errors or data changes require a replacement claim or cancel claim be submitted within six months of the last adjudication date. •

Corrective adjustment requests must be received within six months from the date the claim was last paid or denied by EPNI.

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7-11

Reimbursement / Reconciliation

Remit Balancing Tips

Amounts reported in the remittance, if present, must balance at three levels: service line, claim and total remittance. Service Line Balancing Although the service payment information is situational, it is required for all professional claims or anytime payment adjustments are related to specific lines from the original submitted claim. When used, the submitted service lines minus the sum of all monetary adjustments must equal the amount paid for the service line. •

Charge – Adjustment Amount = Payment Amount

Claim Balancing Balancing must occur at the claim level so that the submitted charges minus the sum of all monetary adjustments equals the claim paid amount. •

Charge – Adjustment Amount = Claim Payment Amount

Remit Balancing Within the transaction, the sum of all payments minus the sum of all adjustments equals the Payment Amount. •

7-12

Sum of all Payments totaled – the Sum of all Adjustments = Total payment amount of this remittance

EPNI Provider Policy and Procedure Manual (05/10/13)

Chapter 8

Appeals Table of Contents Provider Appeals........................................................................................................................ 8-2 Introduction............................................................................................................................ 8-2 Prior Authorization and Pre-Admission Notification Appeal Process .................................. 8-2 Appeals of Medical Necessity Determination ....................................................................... 8-3 Appeals of Processed Claims................................................................................................. 8-3 Initial Appeal ......................................................................................................................... 8-3 Voluntary Second Appeal ...................................................................................................... 8-4 Coding Appeals...................................................................................................................... 8-5 Supporting Documentation .................................................................................................... 8-6 Urgent / Expedited Appeals ................................................................................................... 8-7 Standard Appeals (Medical record) ....................................................................................... 8-7 Arbitration.................................................................................................................................. 8-8 Timeline to Commence Arbitration ....................................................................................... 8-8 Venue/Applicable Law .......................................................................................................... 8-8 Process to Invoke Arbitration ................................................................................................ 8-9 Arbitration Expenses/Award.................................................................................................. 8-9

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8-1

Appeals

Provider Appeals Introduction

An appeal is a written request for review. Appeals require the provider to include with the request documentation of items such as chart notes, medical records, operative reports and letters of medical necessity. Appeals present detailed information in an attempt to change a previous decision made by EPNI. To ensure a thorough review, appeals submitted without appropriate supporting documentation will be returned to Provider. For information about settlement appeals, refer to the Provider Service Agreement.

Prior Authorization and Pre-Admission Notification Appeal Process

Provider may appeal a prior authorization request denied as medically unnecessary within 30 days of notification. Provider’s request must be in writing and should be addressed to the analyst who signed the denial letter. An appeal reviewer will review the case and make a final decision. Please contact the appeal reviewer who signed the denial letter for any questions about a specific approval or denial. When coverage is denied for prior authorization or preadmission notification based on Medical Necessity, the appeal reviewer notifies Provider by telephone and/or sends letters to the Subscriber, hospital, and physician. The physician, Subscriber or facility may appeal the denial within 30 days of the date of the denial letter. The appeal may be initiated either by telephone or by letter. EPNI’s review is only a Medical Necessity review and is subject to all other limitations in the Subscriber’s Contract. Services may be denied because of exclusions, limitations on preexisting conditions, and Medical Necessity requirements contained in the Subscriber’s Contract. These contract provisions will prevail over a Medical Necessity decision. The decision to continue an inpatient stay or Health Services ultimately rests with the patient and the physician. All available information is provided to a physician reviewer who is board certified in the same or similar general specialty as typically manages the medical condition or treatment and was not involved in the original determination.

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Appeals

Appeals of Medical Necessity Determination

When a Medical Necessity denial is made, the Provider or Subscriber has the right to appeal the case. The exact appeals process will be communicated to Provider in the event of a denial. Provider may call EPNI to discuss the denial decision with the physician reviewer. Provider or the Subscriber may also request a free copy of the guideline that EPNI used to determine Medical Necessity/appropriateness for a specific denial decision.

Appeals of Processed Claims

The EPNI provider appeals process has two levels: Initial appeal and voluntary second appeal. Situations brought to appeal include the following categories: •

benefit administration



claims processing



determinations of allowed amount



provider profiles



services denied due to lack of preadmission notification or prior authorization occurring after claim submission

• timely filing denials This appeal process does not apply to settlement appeals, Medical Necessity, prior authorization and preadmission denials occurring prior to claim submission. Adjustment requests and information return requests are not appeals. As such, they should be sent to the general EPNI address listed in Chapter 1, At Your Service. Initial Appeal

Initial Appeals must be requested within 90 days of the date claim notification is issued. There is no limit on the dollar amount. This appeal review may be conducted by EPNI appeals staff, medical review staff, and/or utilization review staff. Mail initial appeal requests to: EPNI Attn: Appeals Department Route S150 P.O. Box 64668 St. Paul, MN 55164-0668

EPNI Provider Policy and Procedure Manual (05/10/13)

8-3

Appeals

Voluntary Second Appeal

Voluntary second appeals must be filed within 60 days of the initial appeal decision. The amount at issue must be $500 or more. Calculate the amount at issue by subtracting the deductible, coinsurance and paid amount from the billed charge. For example: Billed amount

$ 2,000

- (deductible)

500

- (coinsurance)

200

- (paid amount)

500

Amount at issue

$

800

If the amount at issue is $500.00 or more then this appeal review may be conducted by EPNI appeal staff, medical review staff, utilization review staff, peer review, or a committee comprised of medical and non-medical staff. Claims for the same patient or multiple patients relating to the same category can be aggregated at this level (Provider may combine two or more claims to meet the $500.00 amount-incontroversy requirement). Provider must be able to provide additional information at the voluntary second appeal level than that which was available at the Initial Appeal level. Examples of additional information include RVU studies, and published reports supporting Provider’s position. Mail voluntary second appeal requests to: EPNI Attn: Appeals Department Route W350 P.O. Box 64668 St. Paul, MN 55164-0668

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EPNI Provider Policy and Procedure Manual (05/10/13)

Appeals

Coding Appeals

EPNI’s coding edits are updated at minimum annually to incorporate new codes, code definition changes and edit rule changes. All claims submitted after the implementation date of this update, regardless of service date, will be processed according to the updated version. Where Medicare’s CCI (Correct Coding Initiative) edits are identical, EPNI will consider the appeal with additional documentation; however, the issue may be upheld. Adjustments, and/or request refunds will not be made when processing changes are a result of new code editing rules due to a software version update. Notice of this update will be published in a Provider Bulletin. EPNI has adopted a standard process to review edit appeals and providers have the right to appeal with additional information. Appeals received without additional information will not be reviewed. The denial will be upheld. If Provider has a question or appeal about EPNI’s policy regarding a particular coding combination, provide a written statement of the concern, along with the following and/or documentation normally required for a medical review. •

Written explanation supporting the procedures submitted, i.e., specific references, specialty specific criteria.



Documentation from a recognized authoritative source that supports Provider’s position on the procedure codes submitted. Once received, the inquiry or appeal will be reviewed. The review may result in approval or denial of the claim, based on review of the information submitted. Note: Requests to add modifier -24, -25, or -59 to a denied service must be submitted as an electronic replacement claim with supporting documentation. Appeal requests may be faxed or mailed. Send appeal requests to the following address: EPNI Attn: Appeals Department Route W350 P.O. Box 64668 St. Paul, MN 55164-0668 Fax appeal requests to: (651) 662-2745

EPNI Provider Policy and Procedure Manual (05/10/13)

8-5

Appeals

Supporting Documentation

The two key elements for submitting documentation with appeal requests are the patient’s name and the date of service. Both should be included on each page of the documentation submitted. Additionally, the documentation should correspond with the dates of service at issue. When the provider submits the appealed claim, the responsibility for gathering and submitting documentation that supports the service rests with the provider. EPNI will offer guidance and assistance as necessary, but the responsibility for identifying what is needed and where it is located is the provider’s. The list below includes common types of claim denials/reductions which may be submitted for appeal and the sources of documentation suggested for each type. This information is presented as a guide, and is not a complete listing.

Supporting Documentation (continued)

Type of denial or reduction

Documentation

Surgical Complications

Operative report, chart notes, letter stating rationale for complication

Medical Necessity

Medical records and rationale for service performed

Investigative

Medical records and rationale for service performed

Claim Denied for no PA

Medical records and rationale for services

Cosmetic

Medical records and rationale for services

DRG/Category Code

Rationale for questioning of payment

Private Room

Notes, doctor’s order and letter of Medical Necessity

Allowed Amount for unlisted code

Chart notes or invoice, NDC number and a letter to review allowance for an unlisted code. This is independent from Medical Necessity review process. Note: An invoice is required for DME or supply allowance appeals.

Allowed Amount – for Chart notes, letter and operative report modified CPT/HCPCS when applicable to review allowance. codes. Allowed Amount – excluding unlisted codes. 8-6

Copy of fee schedule or Provider Service Agreement.

EPNI Provider Policy and Procedure Manual (05/10/13)

Appeals

Supporting Documentation (continued)

Urgent / Expedited Appeals

Type of denial or reduction

Documentation

Incompatible Diagnosis

Letter requesting review of codes that are denying as incompatible and related notes

Timely Filing

Documentation supporting submission of a claim after timely filing, such as secondary coverage, patient expired during timely filing period, or DME rental charges that span the timely filing period.

Coding Edit

All supporting documentation for corresponding date of service.

An urgent appeal is done when an initial or continued treatment is dependent on a quick determination. Urgent is defined as medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations: 1. Could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, although it may not rise to the level of being a life threatening circumstance, or 2. In the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Urgent appeals are completed within 72 hours of receipt of the appeal request, or sooner, based on the medical exigencies of the case. Providers should contact the EPNI clinician who signed the denial letter to initiate an Urgent Appeal.

Standard Appeals (Medical record)

A standard or medical record appeal is completed within 60 days of receipt of medical information. The appeal decision is final unless new information is provided.

EPNI Provider Policy and Procedure Manual (05/10/13)

8-7

Appeals

Arbitration Timeline to Commence Arbitration

The Parties agree that any disputes or controversies relating to payment for Health Services shall be commenced no later than two years from the date of the provision of said Health Services by Provider (provided that such time limit shall not apply to those circumstances where claims adjustments are not limited to 12 months, as set forth in the Provider Policy & Procedure Manual). If the source of a dispute or controversy does not in any respect involve a payment for a Health Service, then such action must be commenced within two years of the date on which Provider’s claim arose. Any action not brought within the time limits set forth above shall be barred, without regard to any other limitations period set forth by law or statute.

Venue/Applicable Law

All arbitrations between the Parties shall be venued in Minneapolis, Minnesota and shall be conducted in accordance with Minnesota law and, except to the extent inconsistent with Minnesota law, the Commercial Arbitration Rules of the American Arbitration Association. If any of the Parties are defendants to a claim which is not subject to mandatory arbitration, including, without limitation, claims involving medical malpractice, then that Party may assert indemnity or contribution claims against any other Party within the nonarbitrable action.

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EPNI Provider Policy and Procedure Manual (05/10/13)

Appeals

Process to Invoke Arbitration

A Party may invoke arbitration by serving written notice on the other Party. The notice will include a list of arbitrator candidates. If the Parties agree on one of the arbitrator candidates in the notice, then the arbitrator will serve as the sole arbitrator of the dispute. If the Parties do not agree on an arbitrator within fifteen (15) calendar days after receipt of the notice, the recipient of the notice will select one arbitrator and the Party providing notice will select one arbitrator within ten (10) calendar days thereafter and the two arbitrators so selected will select a third arbitrator within ten (10) calendar days thereafter. The third arbitrator so selected will be the sole arbitrator and will conduct the arbitration. All disputes between the Parties will be separately arbitrated and will not be joined or combined with the arbitration or other resolution of disputes between EPNI and any other person(s) or class of persons, unless expressly agreed to by the Parties in writing. Not withstanding the above, and except for medical necessity reviews as detailed in Minnesota statute 62M, the Parties further agree that any appeals decision involving Medical Necessity or provider credentialing for which arbitration is pursued will be overturned or modified only if the arbitrator determines that the decision of the appeals panel or reviewer was arbitrary and capricious. Nothing in this mandatory arbitration provision shall provide a right of arbitration where such rights have been waived or another review process has been agreed to.

Arbitration Expenses/Award

Each Party will be responsible for payment of its own attorneys or other advisors and for its appointed arbitrator. The expenses and fees of the sole arbitrator and of the arbitration proceeding will be shared equally by each of the Parties. The Parties will abide by and perform any award rendered by the arbitrators and a judgment of the court having jurisdiction in accordance with this Agreement may be entered on the award.

EPNI Provider Policy and Procedure Manual (05/10/13)

8-9

Chapter 9

Coding Policies and Guidelines Table of Contents Coding ......................................................................................................................................... 9-9 Overview................................................................................................................................ 9-9 HCPCS Codes........................................................................................................................ 9-9 CPT® /Level I ....................................................................................................................... 9-10 Level II HCPCS ................................................................................................................... 9-12 ICD-9-CM............................................................................................................................ 9-14 Revenue Codes..................................................................................................................... 9-15 Compatibility ....................................................................................................................... 9-16 General Guides..................................................................................................................... 9-16 Zero-billing .......................................................................................................................... 9-16 Coding Edits ............................................................................................................................. 9-17 Overview.............................................................................................................................. 9-17 Edit Descriptions.................................................................................................................. 9-18 Mutually Exclusive Procedures ........................................................................................... 9-19 Incidental Procedures........................................................................................................... 9-20 Medical Visits on the Same Day as Surgery........................................................................ 9-21 Global Surgical Package - Pre and Post Operative Services ............................................... 9-22 General Claims Processing Information .............................................................................. 9-23 Medical and Surgical Supplies............................................................................................. 9-23 Multiple Surgery Guidelines................................................................................................ 9-23 Patient Billing Impact .......................................................................................................... 9-23 Coding Appeals.................................................................................................................... 9-24 Helpful Coding Tips ............................................................................................................ 9-24 Coding Immunizations and Injections ................................................................................. 9-25 Copays....................................................................................................................................... 9-26 Office Call Copays............................................................................................................... 9-26 Modifiers................................................................................................................................... 9-27 Modifiers.............................................................................................................................. 9-27 Modifier Guidelines ............................................................................................................. 9-28 Anatomical Modifiers .......................................................................................................... 9-36 Modifiers defined by DHS................................................................................................... 9-37 Anesthesia ................................................................................................................................. 9-41 Overview.............................................................................................................................. 9-41 Full-time Anesthesia Services.............................................................................................. 9-41 Part-time (Medically Directed) Anesthesia Services........................................................... 9-42 EPNI Provider Policy and Procedure Manual (11/01/07)

9-1

Coding Policies and Guidelines

Qualifying Circumstances.................................................................................................... 9-42 Physical Status ..................................................................................................................... 9-42 Qualifying Circumstances and Physical Status Submission................................................ 9-43 Electroconvulsive Treatments.............................................................................................. 9-43 Local Anesthesia.................................................................................................................. 9-43 Medical Services and Invasive Procedures.......................................................................... 9-43 Epidural Anesthesia for a Surgical Procedure ..................................................................... 9-43 Epidural Anesthesia for Pain Management.......................................................................... 9-44 Anesthesia for Nerve Blocks ............................................................................................... 9-44 Daily Management of Epidural Drug Administration ......................................................... 9-44 Epidural Anesthesia for Labor and Delivery ....................................................................... 9-45 Moderate (conscious) Sedation............................................................................................ 9-46 Monitored Anesthesia Care.................................................................................................. 9-46 Patient Controlled Analgesia ............................................................................................... 9-46 Standby ................................................................................................................................ 9-46 Documentation..................................................................................................................... 9-46 Time Designation/Submission ............................................................................................. 9-47 Diagnosis Coding................................................................................................................. 9-47 Multiple Surgery .................................................................................................................. 9-47 Add-on Anesthesia Procedures ............................................................................................ 9-47 Behavioral Health Services for CMS-1500 ............................................................................ 9-48 Overview.............................................................................................................................. 9-48 Practitioners who Should be Using this Section .................................................................. 9-48 Units..................................................................................................................................... 9-48 Coding Restrictions.............................................................................................................. 9-49 Psychiatry and Chemical Dependency Assessments ........................................................... 9-49 Family Therapy.................................................................................................................... 9-50 Medication Management ..................................................................................................... 9-50 Behavioral Health Evaluation & Management (E&M) Office Calls................................... 9-51 Nutritional Counseling......................................................................................................... 9-51 Eligibility of Dieticians / Nutritionists................................................................................. 9-51 Psychological Testing .......................................................................................................... 9-52 Practitioner Key ................................................................................................................... 9-55 Policies................................................................................................................................. 9-56 Marital Counseling............................................................................................................... 9-56 Opiod Maintenance Drug Therapy ...................................................................................... 9-56 Tobacco Cessation ............................................................................................................... 9-57 Rule 29 Setting..................................................................................................................... 9-57 Day Treatment ..................................................................................................................... 9-57 Compatibility ....................................................................................................................... 9-58 Health and Behavior Assessment Codes.............................................................................. 9-58 Missed Appointments .......................................................................................................... 9-59 Court Ordered Treatment..................................................................................................... 9-60 Guidelines for Court Ordered Evaluations .......................................................................... 9-61 Parity .................................................................................................................................... 9-64 Behavioral Health Quality Improvement Objectives........................................................... 9-64 Prior Authorization .............................................................................................................. 9-66 Preadmission Notification.................................................................................................... 9-66 9-2

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Groups that Carve Out Behavioral Health Benefits............................................................. 9-66 Where to Bill Claims ........................................................................................................... 9-66 Professional Behavioral Health Coding Grid ...................................................................... 9-67 Behavioral Health Services for UB-92 ................................................................................... 9-92 Overview.............................................................................................................................. 9-92 Practitioners Who Should be Using this Section ................................................................. 9-92 Behavioral Health Evaluation or Testing Coding Guidelines.............................................. 9-92 Units..................................................................................................................................... 9-92 Individual Behavioral Health Therapy................................................................................. 9-92 Family and Group Therapy.................................................................................................. 9-93 Chemical Dependency and Alcohol Rehabilitation............................................................. 9-94 Restricted Codes .................................................................................................................. 9-94 Billing a Behavioral Health Assessment.............................................................................. 9-94 Testing.................................................................................................................................. 9-94 Family Therapy.................................................................................................................... 9-95 Revenue Code 0916 with 90847 .......................................................................................... 9-95 Nutritional Counseling / Dieticians ..................................................................................... 9-95 Detox.................................................................................................................................... 9-95 Health and Behavioral Assessment Codes........................................................................... 9-96 Non-Residential Treatment Centers..................................................................................... 9-96 Compatibility ....................................................................................................................... 9-96 Partial Psych Admissions..................................................................................................... 9-96 Rule 5 – Emotionally Handicapped Facilities ..................................................................... 9-97 Recreational Therapy ........................................................................................................... 9-97 Court Ordered Treatment..................................................................................................... 9-97 Prior Authorizations............................................................................................................. 9-97 Parity .................................................................................................................................... 9-98 Groups that Carve Out Behavioral Health Benefits............................................................. 9-98 Where to File Claims ........................................................................................................... 9-98 Institutional Behavioral Health Coding Grid....................................................................... 9-99 Chiropractic Services............................................................................................................. 9-101 Overview............................................................................................................................ 9-101 Examination Codes ............................................................................................................ 9-101 Chiropractic Manipulation Treatment................................................................................ 9-102 Chiropractic Manipulation with Visit ................................................................................ 9-102 Manual Therapy ................................................................................................................. 9-103 Massage Therapy ............................................................................................................... 9-103 Conjunctive Therapy, Modality: Office, Home or Nursing Home.................................... 9-103 Maintenance or Palliative Care.......................................................................................... 9-103 Source of Condition ........................................................................................................... 9-104 Diagnostic Services............................................................................................................ 9-104 Practicing in Multi-Disciplinary Clinics............................................................................ 9-104 Documentation Guides....................................................................................................... 9-105 Prior Authorization ............................................................................................................ 9-106 Form Required ................................................................................................................... 9-106 Compliance Audits............................................................................................................. 9-106 Dental Services ....................................................................................................................... 9-107 EPNI Provider Policy and Procedure Manual (11/01/07)

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Coding Policies and Guidelines

Medical-Surgical Procedures ............................................................................................. 9-107 Prior Authorization ............................................................................................................ 9-108 Claim Form ........................................................................................................................ 9-108 Coordination Between Dental and Medical Carriers ......................................................... 9-109 TMJ Claims Submission .................................................................................................... 9-109 Diagnostic Studies ............................................................................................................. 9-110 Emergency Room............................................................................................................... 9-110 Dental Procedures and Pre-op / Medical Exams................................................................ 9-110 Durable Medical Equipment and Supplies.......................................................................... 9-111 Durable Medical Equipment (DME) Definition ................................................................ 9-111 Prior Authorization Requirements ..................................................................................... 9-111 Ineligible Items .................................................................................................................. 9-113 DME Rental Guidelines..................................................................................................... 9-114 Waivers and Upgraded/ Deluxe DME ............................................................................... 9-114 Waiver Claim Submission ................................................................................................. 9-115 Sample Waiver Form ......................................................................................................... 9-115 DME Coding...................................................................................................................... 9-116 Sales Tax............................................................................................................................ 9-116 Handling / Conveyance...................................................................................................... 9-116 Claims Filing Requirements .............................................................................................. 9-116 Hearing Aids ...................................................................................................................... 9-116 Oxygen and Oxygen Aiding Equipment (Includes Ventilators)........................................ 9-117 Coding Modifiers ............................................................................................................... 9-117 DME Repairs and Maintenance (Excludes Oxygen Equipment) ...................................... 9-118 Replacement of Purchased Equipment .............................................................................. 9-118 Billing for Supplies ............................................................................................................ 9-119 Rental Unit Submission ..................................................................................................... 9-120 Hospital DME Providers.................................................................................................... 9-120 DME/Supply Internet Purchases........................................................................................ 9-120 Home Health, Home Infusion, and Hospice ........................................................................ 9-121 Definitions.......................................................................................................................... 9-121 Prior Authorization ............................................................................................................ 9-121 Home Health ...................................................................................................................... 9-122 Home Infusion ................................................................................................................... 9-123 Hospice .............................................................................................................................. 9-125 Hospital Care.......................................................................................................................... 9-126 Initial Hospital Care........................................................................................................... 9-126 Subsequent Hospital Visits ................................................................................................ 9-126 Critical Care ....................................................................................................................... 9-126 Hospital Observation Services........................................................................................... 9-127 Observation Care Discharge Day Management................................................................. 9-127 Hospital Discharge............................................................................................................. 9-127 Continuing Intensive Care Services................................................................................... 9-127 Swing Beds ........................................................................................................................ 9-127 Skilled-Nursing Facility Care ............................................................................................ 9-127

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Institutional Care ................................................................................................................... 9-128 Facility Clinic..................................................................................................................... 9-129 UB-92 Manual ................................................................................................................... 9-129 UB-04................................................................................................................................. 9-129 Procedure Code Regulations.............................................................................................. 9-129 Revenue Codes (Form Locator 42).................................................................................... 9-129 HCPCS / Rates (Form Locator 44) .................................................................................... 9-130 Revenue Codes Requiring HCPCS / CPT ......................................................................... 9-130 Outpatient Facility Fee Billing........................................................................................... 9-134 Returned Paper Claims ...................................................................................................... 9-134 Education / Training 0942 and Other Therapeutic Services 0949..................................... 9-134 Lactation Education ........................................................................................................... 9-135 Zero Line and Negative Dollar Charges ............................................................................ 9-135 Diabetic Education............................................................................................................. 9-135 Revenue Code 0636 ........................................................................................................... 9-135 Revenue Codes 0500 and 0509.......................................................................................... 9-135 Behavioral Health Revenue Codes .................................................................................... 9-136 Transfer of Care / Transfer Case........................................................................................ 9-136 Laboratory Services............................................................................................................... 9-137 Overview............................................................................................................................ 9-137 Organ or Disease-Oriented Panels ..................................................................................... 9-137 Lyme Disease Titer ............................................................................................................ 9-137 Office Visits ....................................................................................................................... 9-137 Standing Orders ................................................................................................................. 9-138 Venipunctures and Lab Handling ...................................................................................... 9-138 Papanicolaou Smears ......................................................................................................... 9-139 Pregnancy Tests ................................................................................................................. 9-140 Purchased Services/Outside Lab........................................................................................ 9-140 Stat Lab Charges ................................................................................................................ 9-140 Maternity/Obstetrical Services ............................................................................................. 9-142 Global Obstetrical Care...................................................................................................... 9-142 Antepartum Care................................................................................................................ 9-142 Delivery.............................................................................................................................. 9-142 Subsequent VBACs ........................................................................................................... 9-142 Postpartum Care................................................................................................................. 9-142 Intitial Visit and Itemized Services.................................................................................... 9-142 Submission Options and Coding Alternatives ................................................................... 9-143 Pre-term Birth Prevention Services ................................................................................... 9-144 Two Physicians Involved in Care / Same Tax ID.............................................................. 9-145 New Born Care .................................................................................................................. 9-145 Complications or Unusual Circumstances ......................................................................... 9-145 Exceptions.......................................................................................................................... 9-145 Lactation Education ........................................................................................................... 9-145 Collection of umbilical cord blood .................................................................................... 9-146 Obstetrical Care Coding Alternatives ................................................................................ 9-146

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Coding Policies and Guidelines

Medical Emergency ............................................................................................................... 9-147 Introduction........................................................................................................................ 9-147 Criteria for Medical Emergencies...................................................................................... 9-147 Emergency Department Services....................................................................................... 9-148 Medical Services..................................................................................................................... 9-149 Allergy Testing .................................................................................................................. 9-149 Allergy Immunotherapy..................................................................................................... 9-149 Anticoagulation Clinic – S9401......................................................................................... 9-149 Blood, Occult, Feces Screening ......................................................................................... 9-150 Cardiovascular Stress Test................................................................................................. 9-150 Chemotherapy Administration........................................................................................... 9-151 Chemical Dependency Assessment ................................................................................... 9-151 Office or Other Outpatient and initial Inpatient Consultations.......................................... 9-152 Day Treatment ................................................................................................................... 9-152 Diabetic Education............................................................................................................. 9-152 E-Care Visits...................................................................................................................... 9-153 G0101................................................................................................................................. 9-155 Hospital Discharge............................................................................................................. 9-155 Immunizations.................................................................................................................... 9-156 Injections............................................................................................................................ 9-157 Infusion Therapy................................................................................................................ 9-158 Interpreter Services ............................................................................................................ 9-158 Transfusion – Blood and Blood Products .......................................................................... 9-158 Locum Tenens.................................................................................................................... 9-158 Natural Family Planning .................................................................................................... 9-158 Nicotine Dependence ......................................................................................................... 9-159 Revenue Codes Used by Facilities 0944 or 0945 .............................................................. 9-160 Eligibility to Bill for Specific Procedures.......................................................................... 9-160 Coverage for Tobacco Treatment Medications.................................................................. 9-160 New and Established Patients ............................................................................................ 9-160 Oral Medication ................................................................................................................. 9-161 Non-Physician Healthcare Practitioners ............................................................................ 9-161 Practitioners Credentialed by EPNI with an Individual Provider Number........................ 9-162 Practitioners Not Credentialed by EPNI with an Individual Provider Number................. 9-163 Preventive Medicine .......................................................................................................... 9-164 Couseling and/or Risk Factor Reduction ........................................................................... 9-164 Room or Machine Set-up Charges..................................................................................... 9-164 Supplies in the Office......................................................................................................... 9-164 Adjunct CPT Codes ........................................................................................................... 9-164 Care Plan Oversight Services............................................................................................. 9-165 Prolonged Physician Services ............................................................................................ 9-165 Telephone Calls ................................................................................................................. 9-165 Team Conferences ............................................................................................................. 9-166 Televideo Consultations..................................................................................................... 9-166 Exceptions.......................................................................................................................... 9-167 Urgent Care........................................................................................................................ 9-167 Weight Management Care ................................................................................................. 9-167 9-6

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Optometric/Optical Services ................................................................................................. 9-172 Opthalmological Services .................................................................................................. 9-172 Charges for Lenses and Contact Lens Fitting .................................................................... 9-172 Eyewear Billing and Reimbursement ................................................................................ 9-172 Vision Therapy Services .................................................................................................... 9-173 Claims Filing Requirement ................................................................................................ 9-173 Pharmacy Services ................................................................................................................. 9-174 Claims Filing Requirements .............................................................................................. 9-174 Drug Claims Submission ................................................................................................... 9-174 Prior Authorization ............................................................................................................ 9-174 Injectable Drugs ................................................................................................................. 9-174 Copays / Coinsurance ........................................................................................................ 9-174 Vacation Prescription Requests ......................................................................................... 9-174 Drug Formulary ................................................................................................................. 9-175 Non-Formulary .................................................................................................................. 9-175 Compounded Prescriptions ................................................................................................ 9-176 Prescription Cost Less Than Copay................................................................................... 9-177 Over-the-Counter Drugs .................................................................................................... 9-177 NDC Numbers ................................................................................................................... 9-177 Discounting or Waiving Copays........................................................................................ 9-177 Dispense as Written (DAW) .............................................................................................. 9-177 Prescribing Physician’s DEA............................................................................................. 9-177 Pharmacy Audits................................................................................................................ 9-177 Investigative Drug Use ...................................................................................................... 9-177 Radiology Services ................................................................................................................. 9-178 General Guidelines............................................................................................................. 9-178 Diagnosis............................................................................................................................ 9-178 Modifiers............................................................................................................................ 9-178 Radiation Treatment Management..................................................................................... 9-178 Maternity Ultrasound Compatibility.................................................................................. 9-179 Purchased Services / Outside Lab...................................................................................... 9-179 Diagnostic and Screening Mammogram............................................................................ 9-179 Code 76140 ........................................................................................................................ 9-179 Comparison Xray ............................................................................................................... 9-179 Rehabilitative Services........................................................................................................... 9-181 Physical Therapy Modalities.............................................................................................. 9-181 Physical Therapy Procedures............................................................................................. 9-181 Physical Therapy Evaluation Codes .................................................................................. 9-181 Occupational Therapy........................................................................................................ 9-182 Occupational Therapy Evaluation Codes........................................................................... 9-183 Speech Therapy and Evaluation......................................................................................... 9-183

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Coding Policies and Guidelines

Surgical Services .................................................................................................................... 9-184 General Guidelines............................................................................................................. 9-184 Bilateral Services ............................................................................................................... 9-184 Unlisted Procedures ........................................................................................................... 9-184 Facility Fees for Office Surgery ........................................................................................ 9-184 Global Surgical Package .................................................................................................... 9-185 Fractures............................................................................................................................. 9-185 Incidental Surgery.............................................................................................................. 9-185 Lesions ............................................................................................................................... 9-186 Surgical Trays and Supplies............................................................................................... 9-186 Standby Services................................................................................................................ 9-186 Treatment of Warts ............................................................................................................ 9-186 Assistant Surgeons ............................................................................................................. 9-187 Co-Surgeons....................................................................................................................... 9-188 Multiple Surgeries.............................................................................................................. 9-188

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Coding Policies and Guidelines

Coding Overview

EPNI requires submission of valid codes to report medical services and supplies on both professional and institutional claims. This includes Healthcare Common Procedural Coding System (HCPCS) codes, International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes, and Revenue codes. The Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code Set regulation stipulates submission and acceptance of approved medical code sets. HCPCS and ICD-9-CM codes are among the approved HIPAA medical code sets and must be valid for the actual date of the service. If a HCPCS or ICD-9-CM code is not valid for the date of service, the claim will be returned or denied. Revenue codes are a data element of the institutional claim (837I or UB92) and must be valid for the date of submission. If a Revenue code is not valid on the date submitted, the claim will be returned or denied.

HCPCS Codes

The HCPCS coding system was developed by CMS (Centers for Medicare and Medicaid Services) to standardize coding systems used to process claims for all payers, including Medicare and Medicaid. HCPCS is a two level coding system-Level I, a.k.a., CPT®, and Level II. All nationally developed codes are accepted; however, coverage is not guaranteed and other restrictions may apply. Services may deny for various reasons including a member contract exclusion or service limitation, EPNI corporate or medical policy, or subject to standardized coding edits. HCPCS codes are updated several times throughout the year. The primary update is January of each year. CMS provides updates to Level II codes on a quarterly basis. In addition to January, code updates are done in April, July, and October. CPT codes are generally updated only in January; however, the AMA can release codes early and make codes slated for the next year’s publication available in the prior July.

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Coding Policies and Guidelines

CPT® /Level I

Level I or CPT® (Current Procedural Terminology) codes are developed and maintained by the American Medical Association. Each procedure is identified with a five digit numeric or numeric-alpha code. CPT is a set of codes, descriptions, and guidelines intended to describe procedures and services performed by physicians and other health care providers. Inclusion or exclusion of a procedure does not imply any health insurance coverage or reimbursement policy. There are eight main sections to the CPT manual, including subsections with anatomic, procedural, conditions, or descriptor subheadings. All listings are in numeric order except for Evaluation and Management (E/M) codes. E/M codes are the most frequently used and are listed first in the CPT manual. Section Numbers and Sequences: Anesthesiology

00100 to 01999 99100 to 99140

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Category II Codes

0001F to 4018F

Category III Codes

0003T to 0161T

Evaluation and Management (E/M)

99201 to 99499

Medicine (except Anesthesiology)

90281 to 99602

Pathology and Laboratory

80048 to 89356

Radiology

70010 to 79999

Surgery

10021 to 69990

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Coding Policies and Guidelines

CPT® /Level I (continued)

Modifiers A modifier is used to indicate that the service or procedure that has been performed has been altered by some specific circumstance but has not changed the definition or code. A complete listing of modifiers is found in Appendix A of CPT. Level I codes are not limited to CPT modifiers. HCPCS Level II modifiers may also be used with Level I codes and/or in combination with CPT modifiers. Genetic Testing Code Modifiers are found in Appendix I of CPT. CPT Format CPT codes are five characters in length (either all numeric or numericalpha) and designed as stand-alone descriptions of medical procedures. Some procedures in CPT are not printed in their entirety but refer back to a common portion of the procedure listed in the preceding entry. These are sometimes referred to as indented procedures. For example: 97010: Application of a modality to one or more areas; hot or cold packs 97012: traction, mechanical The common part of the code 97010 is before the semicolon and is also considered part of the code 97012. The full narrative for 97012 is “Application of a modality to one or more areas; traction, mechanical”. Guidelines Guidelines are presented at the beginning of each of the main eight sections. Some section subheadings may contain instructions or information specific to those codes. Code Symbols Certain symbols may precede a code to indicate additional information. New CPT codes will be preceded by a bullet (z) symbol. Revised CPT codes will be preceded by a triangle (▲) symbol. Add-on CPT code will be preceded by a plus (:) symbol. Codes that include conscious sedation will be preceded by a target (~) symbol.

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Coding Policies and Guidelines

Level II HCPCS

Level II HCPCS are developed and maintained by CMS. Level II consists of codes for supplies, materials, injections, and services. Each Level II code is identified with a five digit (alphanumeric) code. Level II codes are generally referred to simply as HCPCS codes to differentiate them from the Level I (CPT) codes. HCPCS codes are generally used because CPT has a limited code selection for these areas. All listings are in alpha category order except for modifiers. Format HCPCS codes are five characters in length, consisting of one alpha and four numeric characters. Level II codes start with alpha characters A through V and relate to these nationally defined categories:

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Code

Description

A0000 - A0999

Transportation Services Including Ambulance

A4000 - A8999

Medical and Surgical Supplies

A9000 - A9999

Administrative, Miscellaneous, and Investigational

B4000 - B9999

Enteral and Parenteral Therapy

C1000 - C9999

Outpatient PPS

D0000 - D9999

Dental Procedures

E0100 - E9999

Durable Medical Equipment

G0000 - G9999

Procedures/Professional Services (Temporary) (including Injections, Laboratory, Medical Services, Supplies)

H0001 - H2037

Alcohol and Drug Abuse Services (includes prenatal care codes)

J0000 - J9999

Drugs Administered Other than Oral Method (J0000-J8999-Injection; J9000-J9999Chemotherapy Drugs)

K0000 - K9999

Temporary Codes (for DMERCS including Durable Medical Equipment, Orthotics & Prosthetics, Supplies)

L0000 - L4999

Orthotics Procedures

L5000 - L9999

Prosthetic Procedures

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Coding Policies and Guidelines

Level II HCPCS (continued)

Code

Description

M0000 - M0301

Medical Services

P0000 - P9999

Pathology and Laboratory (including Blood Products)

Q0000 - Q9999

Q Codes (Temporary) (including Injections, Laboratory, Occupational Therapy, Physical Therapy)

R0000 - R5999

Diagnostic Radiology Services (including Portable X-ray)

S0000 - S9999

Temporary National Codes (Non-Medicare)

T1000 - T9999

National T Codes Established for State Medicaid Agencies

V0000 - V2999

Vision Services

V5000 - V5999

Hearing Services

Modifiers A modifier is used to indicate that the service or supply has been altered by some specific circumstance but has not changed the definition or code. A complete listing of modifiers is found as an appendix to the HCPCS manual. Level II codes are not limited to HCPCS modifiers. CPT modifiers may also be used with Level II codes and/or in combination with HCPCS modifiers. Code Changes New HCPCS codes will be preceded by bullet (z) symbol. Revised HCPCS codes will be preceded by a triangle (σ ) symbol. Reinstated HCPCS codes will be preceded by a circle ({ ) symbol. Reinstated codes were previously deleted codes that have been reactivated.

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Coding Policies and Guidelines

ICD-9-CM

ICD-9-CM is a statistical classification system that arranges diseases, injuries, and procedures into groups. Most ICD-9-CM are numeric and consist of three, four, or five digit numbers and a description. The coding structure is revised approximately every 10 years by the World Health Organization. Annual updates, effective October 1, are published by NCVHS and CMS. Code Changes (not all publishers will include this information) New ICD-9-CM codes will be preceded by a bullet (z) symbol. Revised ICD-9-CM codes will be preceded by a triangle (σ ) symbol. Format ICD-9-CM consists of three volumes: • Volume I - The Tabular List Volume I is a numeric listing of diagnosis codes and descriptions consisting of seventeen chapters that classify diseases and injuries. In addition, two sections of supplementary codes (V and E codes) are included. Most diagnosis codes are four or five digit codes. The base ICD-9-CM diagnosis code consists of three digits which may be further defined or classified by a fourth or fifth digit following a dot (this divides and identifies the base diagnosis). For example: 738.1 is the diagnosis “Other acquired deformity of head.” “Zygomatic hyperplasia” is coded as “738.11”. The addition of “1” specifically defines the acquired deformity. • Volume 2 - The Alphabetical Index Consists of an alphabetic list of terms and codes. • Volume 3 - Procedures: Tabular List and Alphabetic Index Volume 3 is a numeric listing of procedure codes and descriptions consisting of 17 chapters containing codes and descriptions for surgical procedures and miscellaneous diagnostic and therapeutic procedures. Codes from Volume 3 are intended only for use by hospitals. ICD-9-CM procedure codes are two, three or four digit codes. The base ICD-9-CM procedure code consists of two digits that may be further defined or classified by a third or fourth digit following a dot (this divides and identifies the base procedure). For example: 50 is the procedure “Operations on liver”. “Closure of laceration of liver” is coded as “50.61”. The addition of “.61” specifically defines the liver operation. Only valid diagnoses, submitted to their full specificity, are accepted. If a fourth or fifth digit applies to a specific diagnosis code, it must be submitted.

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Coding Policies and Guidelines

ICD-9-CM (continued)

Linking or Sequencing

Revenue Codes

Revenue codes are developed by the National Uniform Billing Committee and are used to identify specific accommodation charges, ancillary service charges, or a type of billing calculation. They are only to be submitted on the uniform bill, or UB-92 (CMS-1450 claim form) or the institutional electronic claim format (837I).

On the CMS-1500 claim form there are two diagnosis boxes, one is box 21 and the other is box 24E. Box 21 has space for four ICD-9-CM diagnosis codes and these codes relate to all the services indicated on the claim detail lines (24). Box 24E specifies what diagnosis or diagnoses relate to that particular line only. The primary diagnosis for the service performed must be appropriately linked to that service, especially if more than one diagnosis relates to a line item. Up to four diagnoses can be linked to a detail service line; however, adjudication is based on the first linked diagnosis.

Format Revenue codes are four digits in length. The first three digits define the category and the fourth digit defines the subcategory. It is important for the subcategory to be properly defined for appropriate payment. For example: 012X is the category for “Room & board-Semi-Private Two Bed (Medical or General)”. While 012X indicates the type of accommodations it does not identify the department or area in the hospital where the patient is staying. However, the code 0122 (OB/2BED) would properly indicate a semi-private room in the OB. The list of revenue code is extensive and can be found in the UB-92 manual under FORM LOCATOR SPECIFICATIONS, form locator 42. HIPAA transaction standards require submission of HCPCS/CPT codes on outpatient facility claims. Guidelines for submission of HCPCS/CPT codes including modifiers can be found in the UB-92 manual under FORM LOCATOR SPECIFICATIONS, form locator 44

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Coding Policies and Guidelines

Compatibility

HCPCS and ICD-9-CM Codes EPNI requires that diagnosis codes and procedures performed be compatible. These conditions are identified separately not only to assure correct coding, but also appropriately apply benefits. A chart of the patient condition and the compatible diagnosis codes is found in the EPNI Provider Policy and Procedure Manual, Chapter 6 and can be used as a general guide for determining compatibility. Revenue Codes Revenue codes must also be compatible with the claim type of bill*. Some revenue codes are very specific to the place where the service was rendered. *The type of bill (TOB) is three digits and indicates the type of facility (1st digit), bill classification (2nd digit), and frequency (3rd digit) of the services indicated on the claim. For example, the TOB 111 indicates hospital inpatient admit through discharge claim.

General Guides

Submit the code that most accurately identifies the service(s) performed. Documentation in the patient’s medical record must support the codes submitted. Do not use multiple codes when services can be represented by a single code, unless otherwise instructed. Fragmented services (reporting several codes when one adequately defines the service) will be subject to our coding software edits and may be denied. Unlisted codes should only be used if no code exists to describe the service or supply. HCPCS codes for unlisted services require a complete narrative description. Submit all services for the same date of service on the same claim. Codes C1000-C9999 are for items classified in new-technology ambulatory payment classifications (APCs) under the outpatient prospective payment systems. These codes are exclusively for use in billing for institutional transitional pass-through payments. “C” HCPCS codes may be submitted on institutional (UB-92) claims only. “C” codes submitted on a professional claim (CMS-1500) will deny as provider liability. If you do not agree with how a claim was processed and wish to appeal, refer to Chapter 8. Chapter 8 defines the appeal process and gives guidelines for filing an appeal.

Zero-billing

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Beginning September 1, 2006, any claim type filed to EPNI with a $0.00 billed charge will be accepted for processing. Providers will no longer need to add a nominal charge, such as $.01 or $1.00 to a service line item for which they intended to bill or indicate as (zero) $0.00.

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Coding Policies and Guidelines

Coding Edits Overview

EPNI uses an automated procedure editing tool. This tool has been adopted and modified by EPNI to assist in a consistent and fair claim review process. The procedure code edits may also reflect EPNI’s Medical Coverage Guidelines, benefit plans, and other EPNI policies. Unbundling, fragmentation, mutually exclusive procedures, duplicate, obsolete, or invalid codes are all identified through the use of this coding edit application. The procedure code edits are based on CPT guidelines, a review of the Center for Medicare and Medicaid Services (CMS) Correct Coding Initiative policies and guidelines, specialty society guidelines, agreed upon industry practices and analysis by an extensive clinical consultant network. This automated review process is designed to apply the same industry criteria consistently across all professional claims.

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Coding Policies and Guidelines

Edit Descriptions

Procedure Code Unbundling/Replacement Procedure code unbundling is the submission of multiple procedure codes for a group of specific procedures that are components of a single comprehensive code. Procedure unbundling may occur in one of two ways: A professional claim could be submitted that has procedure codes for both the individual components, and the procedure code for the comprehensive procedure. EPNI would rebundle the individual component codes into the comprehensive procedure code for payment. Procedure unbundling could also occur when a professional claim is submitted with only the individual components of the comprehensive code. In this situation, the software will recognize the relationship between the comprehensive code and its individual components. Then, it will automatically add the comprehensive code to the claim and rebundle the individual components into that comprehensive code for payment. An example would be billing the following procedure codes together: 33207- Insertion of heart pacemaker, ventricular 33208- Insertion of heart pacemaker, atrial and ventriucular Procedure 33208 is identified as the primary procedure code. CPT 33207 would be rebundled because it is an integral part of procedure 33208. Rather than a line item denial, the procedure and related charge will be summed together and a new allowance for the surviving code will be established based on your contracted fee schedule. Another example would be billing the following procedure codes together: •

82374- Carbon dioxide



82435- Chloride



84132- Potassium

• 84295- Sodium In combination, the four codes above would be rebundled and replaced with the more appropriate procedure 80051-electrolyte panel. Related charges will be summed together and the allowance based on the comprehensive code 80051. When this edit is applicable, the following message will appear on your current remittance advice: This service is a component of a procedure that has already been processed on this or another claim.

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Coding Policies and Guidelines

Mutually Exclusive Procedures

Mutually exclusive procedures exist when a claim is submitted for two or more procedures that are not usually performed on the same patient, on the same date of service. In mutually exclusive relationships, the most clinically intense code is recognized for payment. Clinical intensity is generally based on the total RVU for the procedures submitted. An example would be billing the following procedure codes together: •

58260- Vaginal Hysterectomy

• 58150- Total Abdominal Hysterectomy Since a hysterectomy would not be performed using two different approaches, the vaginal hysterectomy would be denied as mutually exclusive to the abdominal hysterectomy. This edit would result in the line item denial of procedure 58260 and would be the participating network provider’s liability. Another example would be billing the following procedures together: •

27550- Closed treatment of a knee dislocation

• 27556- Open treatment of a knee dislocation The knee would not be reduced by doing both procedures. The open procedure would survive as the one that was more clinically intense. This would result in the line item denial of procedure 27550 and would be the participating network provider’s liability. When this edit is applicable, the following message(s) will appear on your current remittance advice: Payment is included in the allowance of the other procedure. Service is not payable with other service rendered on the same date. These charges are not covered. Less complex procedures with the same outcome and date of service as another procedure are not eligible.

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Coding Policies and Guidelines

Incidental Procedures

Incidental is defined as a procedure carried out at the same time as a primary procedure, but is clinically integral to the performance of the primary procedure, and therefore, should not be reimbursed separately. An example would be billing the following procedure codes together: •

59300- Episiotomy

• 59409- Vaginal delivery An episiotomy performed as part of the overall management of a delivery does not warrant a separate identification. This would result in the line item denial of procedure 59300 and would be the participating network provider’s responsibility. Another example would be billing the following procedure codes together: 44005- Enterolysis (lysis of adhesions, separate procedure) 44140- Partial colectomy with anastomosis Services that are identified by CPT with the term “separate procedure” are commonly carried out as an integral component of a total service. Separate procedures are not reported in addition to the total procedure or service of which it is considered an integral component. This would result in the line item denial of procedure 44005 and would be the participating network provider’s liability. When this edit is applicable, the following message(s) will appear on your current remittance advice:

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This procedure is incidental to another procedure processed on this or another claim.



This procedure is incidental to the primary procedure. Reimbursement is included in the allowance for that primary procedure.

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Coding Policies and Guidelines

Medical Visits on the Same Day as Surgery

In keeping with the CPT surgical “package”, related Evaluation and Management (E/M) services are not reimbursed separately when submitted with a procedure performed on the same day. Modifiers may be used with E/M services that are not considered part of the same day surgical package. Please refer to the current year’s CPT manual for evaluation and management services and surgery guidelines. Some of the related CPT modifiers would include: -24 unrelated E/M service by the same physician during a postoperative period -25 significant, separately identifiable E/M service by the same physician on the day of a procedure The provider should add these modifiers when a patient’s condition requires a significant, separately identifiable service above and beyond the usual care associated with the procedure. Documentation in your files must support the use of modifier –25 with E/M codes as defined in CPT. Use modifier –25 with new-patient and established-patient E/M codes to prevent denial of significant, separately identifiable E/M services performed on the same day as a procedure or other service. Some of these other services are allergy injections, joint injections, chemotherapy administration, brachytherapy services, and dialysis. Modifier –25 is not required by EPNI with consultation and emergency room codes. One of the following messages will appear on your current remittance advice: •

Payment is included in the allowance for another service/procedure



Based on the other services submitted for this service date, reimbursement is not considered for this medical visit.

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Coding Policies and Guidelines

Global Surgical Package - Pre and Post Operative Services

As defined by CPT, the surgical “package” includes the surgical operation, local infiltration, metacarpal/digital block or topical anesthesia when used, and the normal, uncomplicated follow-up care visits. These services, when billed in addition to surgery, are denied as included in the surgical allowance. The surgical package includes all normal and uncomplicated care including pre-and post-operative visits as part of the reimbursement for the surgical procedure. Pre-operative visits are defined as visits by the surgeon or another practitioner in the same practice on the day of a surgery for minor procedures and the day before or day of major surgical procedures. We do not consider new patient codes exceptions to the package. The fact that the patient is new is not reason alone to exclude the visits from the global package. EPNI follows the same post-operative timeframes associated with surgical procedures as Medicare of 10, or 90 days. These can be found in the Federal Register. Routine post-operative medical visits rendered with this timeframe and related to the surgery will not be recognized for separate reimbursement as an unbundled component of the total surgical package. One of the following messages will appear on your current remittance advice: •

This procedure is within the postoperative range for a surgery found on this or another claim.



This procedure is within the preoperative range for a surgery found on this or another claim.



Pre and post-operative care is a covered benefit and these services are included in the allowance Modifiers -55 and -56 For EPNI, modifiers –55 and –56 for pre- and post-operative care are used with E/M codes, not with surgery codes. Modifier –57 Modifier –57 is used to indicate that the E/M service resulted in the initial decision to perform surgery either the day before a major surgery (90 day global) or the day of a major procedure.

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Coding Policies and Guidelines

General Claims Processing Information

Scope Procedures Our coding software makes the following assumptions when determining payment for multiple scope procedures billed on the same date of service: •

A diagnostic scope is always incidental to a surgical scope.



A diagnostic scope with biopsy is always incidental to a surgical scope.



A diagnostic scope with or without biopsy is always incidental to an open surgical procedure in the same area.



A diagnostic scope rebundles to a diagnostic scope with biopsy unless the code description makes the distinction with biopsy vs. without biopsy.



CPT descriptions such as: complete vs. partial, with vs. without, complex vs. simple, etc. means there are two mutually exclusive codes for the procedures.

Medical and Surgical Supplies

Medical and surgical supplies during an outpatient or physician office visit are included as incidental to the evaluation and management service or procedure performed, and will not be separately reimbursed.

Multiple Surgery Guidelines

Multiple surgical procedures performed during the same operative session are processed in accordance with EPNI multiple surgical guidelines. These guidelines state the primary procedure is reimbursed at 100% of the fee schedule or billed amount, whichever is less. Secondary, tertiary procedures, etc., are reimbursed at 50% of the fee schedule or billed amount, whichever is less, regardless of separate site or incision. In addition, procedures noted in CPT as “modifier –51 exempt” are not subject to multiple surgery reductions. Overall, the most clinically intense service coincides with the higher relative value unit (RVU) assigned, although occasionally, this may not be the case. All questionable claims decisions are eligible for inquiry and/or appeal. In these cases, the appeals process should be followed.

Patient Billing Impact

The patient is not responsible and must not be balance billed for any procedures for which payment has been denied or reduced by EPNI as the result of a coding edit. Edit denials are designed to ensure appropriate coding and to assist in processing claims accurately and consistently.

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Coding Policies and Guidelines

Coding Appeals

EPNI’s coding edits are updated at minimum annually, to incorporate new codes, code definition changes and edit rule changes. All claims submitted after the implementation date of this update, regardless of service date, will be processed according to the updated version. Where Medicare’s CCI (Correct Coding Initiative) edits are identical, we will consider the appeal with additional documentation, but the issue may be upheld. No retrospective payment changes, adjustments, and/or request refunds will be made when processing changes are a result of new code editing rules due to a software version update. Notice of this update will be published in a Provider Bulletin, with a ‘Summary of Change’ summarizing new edits. EPNI has adopted a standard process to review edit appeals and providers have the right to appeal with additional information. If you have a question or appeal about our policy regarding a particular coding combination, provide a written statement of the concern, along with the following information and/or documentation normally required for a medical review. Written explanation supporting the procedures submitted, i.e., specific references, specialty specific criteria Documentation from a recognized authoritative source that supports your position on the procedure codes submitted Once received, the inquiry or appeal will be reviewed and if necessary, forwarded to the medical review department for determination. The review may result in approval or denial of the claim, based on review of the information submitted. Send your request for review to the following address: EPNI Attn: Provider Coding Appeals P.O. Box 64560 St. Paul, MN 55164-0560

Helpful Coding Tips

We recognize the challenges you have in staying up-to-date with coding changes. Below are some helpful tips to assist with accurate and effective coding to support correct claim processing and reimbursement. Code using current coding books. Order new CPT and HCPCS manuals every year, as codes are added, deleted, and revised annually. Submitting invalid or deleted codes will result in claim denials. Web links to review for possible updates: http://www.ama-assn.org/ama/pub/category/3884.html http://www.cms.hhs.gov/medicare/hcpcs/default.asp http://www.cms.hhs.gov/medlearn/icd9code.asp

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EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Coding Immunizations and Injections

It is appropriate when administering an immunization or injection to bill administration codes (90465-74, 90772- 90774, G0008-10). Reimbursement for vaccines/toxoids and immunization administration is currently allowed in addition to preventive medicine services (99381-99384, 99391-99394, 99401-99404) and newborn care services (99431, 99432, 99435). Immunizations If only an immunization is administered, bill the CPT code for the vaccine/toxoid administered and the applicable CPT administration code (90465-90474). Example: A 65-year old patient comes to your office just for a flu vaccine. Bill the vaccine code 90658 and vaccine administration code 90471. Immunizations and E/M Visits Evaluation and management codes 99201-05 and 99212-15 are eligible for separate reimbursement when billed on the same date of service as vaccine/toxoid codes 90476-90749 and the immunization administration codes 90465-90474. Example: A one-year-old established patient has a preventive visit and a polio vaccine. Bill the appropriate preventive visit CPT code (i.e., 99392), the polio vaccine (i.e., 90712) and in this case, the oral administration code (90473).

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Coding Policies and Guidelines

Copays Office Call Copays

Following is a listing of procedure codes to which the office call copay may apply when included in the contract benefits. This is not an allinclusive list. Code

Description

90804 - 90815

Psychotherapy

90847, 90853

Family therapy/ Group therapy

92002 - 92014

Ophthalmological services (new or established patient)

9-26

92597

Evaluation for use/fitting of voice prosthetic device

92605, 92607

Evaluation for prescription of speech/ non-speech generating device

97001 - 97004

Physical and occupational evaluations and reevaluations

98925 - 98929

Office or outpatient visit with osteopathic manipulative therapy

98940 - 98943

Chiropractic visit with manipulation/adjustment

99201 - 99215

Office or other outpatient services, new and established patient

99218 - 99220

Initial observation care

99241 - 99245

Consultations (office, outpatient) new or established patient- Based on place of service

99354 - 99357

Prolonged physician services

99381 - 99387

Preventive medicine, new patient

99391 - 99397

Preventive medicine, established patient

99401 - 99404

Preventive medicine individual counseling

99411 - 99412

Preventive medicine group counseling

99420, 99429

Other preventive medicine services

G0245 - G0246

E/M of a diabetic patient

H1000, H1001, H1003

Prenatal risk assessment, high risk antepartum care, nutrition education

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Coding Policies and Guidelines

Modifiers Modifiers

General Guidelines Modifiers are two digit codes that are appended to a service as a means to indicate that the service/procedure is affected or altered by a specific circumstance and to add specificity, but not changed in its definition. Modifiers are found both in both CPT and HCPCS manuals. CPT modifiers can be found in Appendix A. Genetic Testing Code Modifiers are found in Appendix I of CPT. A complete list of HCPCS modifiers is found as an appendix to the HCPCS manual. CPT codes are not limited to CPT modifiers. HCPCS codes are not limited to HCPCS modifiers. HCPCS modifiers may also be used with CPT codes and/or in combination with CPT modifiers. CPT modifiers may also be used with HCPCS codes and/or in combination with HCPCS modifiers. For example, -TC and –76 can be appended to a radiology procedure to indicate the technical component of the services was repeated. Modifiers may be used to indicate that: •

A service or procedure has both a professional and technical component.



A service or procedure was performed by more than one physician and/or in more than one location.



A service or procedure has been increased or reduced.



Only part of a service was performed.



A bilateral procedure was performed.



A service or procedure was provided more than once.



Unusual events occurred.

• A purchased or rented DME item. You may submit more than one modifier per detail line; however, the EPNI claims system cannot always adjudicate the claim based on all modifiers submitted. Submit the modifier affecting payment in the first position. Note: If your claim is denied due to lack of documentation to support the use of a specific modifier, you may submit a claim payment appeal. Your appeal must be in writing and accompanied by the necessary documentation.

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Coding Policies and Guidelines

Modifier (continued)

The information outlined below is a general guideline regarding the use of modifiers. The list is not all-inclusive. Refer to you CPT and HCPCS for a complete list of modifiers. When a specific service/circumstance requires the use of a modifier, the submission criteria is outlined in the applicable specialty section of the Coding Chapter of the EPNI Provider Policy and Procedure Manual.

Modifier Guidelines

The impact to payment statements below are a general guide and not a guarantee of payment

Mod

Description

Submission Guidelines

Impact To Payment

-22

Unusual Procedural Service

Requires submission of an operative report, narrative and/or other relevant documentation that adequately describes what care/service was greater than usually required.

The availability of additional payment will be determined based on review of supporting documentation.

Do not use modifier –22 when there is an existing code to describe the service. -24

Unrelated Evaluation and Management (E/M) Service by the Same Physician During a Postoperative Period. Note: EPNI defines the “same physician” as the same physician, or physicians of the same or similar specialty within the same clinical practice.

9-28

By appending the –24 modifier to an unrelated E/M service you are indicating that the patient’s condition requires a significant, separately identifiable E/M service above and beyond the other service provided, or beyond the usual preoperative and postoperative care associated with the procedure that was performed. Services appended with a –24 modifier must be sufficiently documented in the patient’s medical record that the visit was unrelated to the post operative care of the procedure. An ICD-9-CM that clearly indicates that the reason for the encounter was different and unrelated to the postoperative care may provide sufficient documentation.

Separate payment of the E/M may be allowed.

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Mod

Description

Submission Guidelines

Impact To Payment

-25

Significantly Separately Identifiable Evaluation and Management (E/M) Service by the Same Physician on the Same Day of the Procedure of Other Service

Use the –25 modifier when an E/M service is rendered on the same day as a minor surgical procedure (0 or 10 day global period).

Separate payment of the E/M may be allowed.

Professional Component

Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier ‘26’ to the usual procedure number.

-26

The use of –25 is appropriate only when the E/M service provided is above and beyond the usual pre and post op service associated with a procedure. No documentation needs to be submitted with the initial claim. However, E/M services submitted with a –25 modifier are subject to review. Furthermore, medical documentation, when requested , needs to support the significant, separately identifiable E/M service. Payment is made based on the professional portion of the RVU associated with the service.

The professional component applies to the physician who interprets the procedure and provides a written report. -50

Bilateral Procedure

Surgical procedures performed on bilateral pieces of anatomy should be billed on two lines. The –50 modifier should be appended to one of the submitted lines of service.

Payment is made at 50% of the allowed amount for the secondary procedure.

EPNI adheres to CMS’ published list of bilateral procedures

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Coding Policies and Guidelines

Mod

Description

Submission Guidelines

Impact To Payment

-51

Multiple Procedure

When more than one service is performed during the same operative session, the –51 modifier should be appended to all secondary surgical procedures.

Multiple surgical payment is based on the allowed amount. The lowest valued procedure(s) will have the multiple surgical reduction applied. When covered, payment is made at 50% of the allowed amount for all allowable secondary procedures.

It is not necessary to append the –51 modifier to “add on” or –51 modifier to exempt codes. Applicable code edits will be applied to services submitted.

-52

Reduced Services

Append the –52 modifier to indicate that a service or procedure is partially reduced or eliminated at the physician’s discretion. This provides a means of reporting reduced services without disturbing the identification of the basic service.

The normal full charge billed or a reduced charge for the procedure may be submitted. EPNI will pay the lesser of either 90% of the physician fee schedule allowance for the procedure or the charge submitted.

-53

Discontinued Procedure

Append –53 when the physician elects to terminate the procedure

The normal full charge or reduced charge should be submitted.

-54

Surgical Care Only

Append –54 when one physician performs intraoperative portion of a surgical procedure while another practitioner(s) from a different practice provides preoperative and/or postoperative management.

Payment is made at 90% of the allowed amount.

Surgery should be billed globally (no modifier) if the pre-, intra-, and –post operative services are rendered by the same provider or other practitioners who are employed by the same clinic (same tax ID number).

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Coding Policies and Guidelines

Mod

Description

Submission Guidelines

Impact To Payment

-55

Postoperative Management Only

Append –55 to each post-op visit (E&M) only when post-op is provided by a different clinic than performed the surgery.

Separate payment of the E/M may be allowed.

Do not append –55 to the surgical procedure code

-56

Preoperative Management Only

Append –56 to the pre-op visit (E&M) only when pre-op is provided by a different clinic than performed the surgery Do not append –56 to the surgical procedure code.

-57

Decision for Surgery

The –57 modifier is appended to indicate that the E/M service resulted in the initial decision to perform surgery either the day before or the day of a major surgical procedure (90 day global period).

Services will be denied if the surgical procedure code is submitted with the –55 modifier or billed by a practitioner who is employed by the same clinic (same tax ID number) as the surgeon. Separate payment of the E/M may be allowed. Services will be denied if the surgical procedure code is submitted with the –56 modifier or billed by a practitioner who is employed by the same clinic (same tax ID number) as the surgeon. Separate payment of the E/M may be allowed.

Do not append this modifier when a minor surgical procedure (0, 10 day global period) is performed. The –57 should not be used to report an E/M service that was pre-planned or prescheduled the day before or the day of surgery, as they would be included as part of the global surgical package.

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Coding Policies and Guidelines

Mod

Description

Submission Guidelines

Impact To Payment

-59

Distinct Procedural Service

Modifier –59 may be appended to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. However, when another already established modifier is appropriate it should be used rather than modifier –59. Only if no more descriptive modifier is available, and the use of modifier –59 best explains the circumstances, should be modifier –59 be used. Modifier –59 is always appended to the component procedure code. Documentation supporting the separate and distinct status must be present in the patient’s medical record.

Modifer-59 may not affect edits or payment. However, if applicable, the modifier should be appended to the service. Generally, the –59 modifier is only applicable to those code combinations noted in the Correct Coding Initiative (CCI) code list with a modifier indicator of “1” which specifies the services are distinct and separate and thus allowed. Service denied may be considered on subsequent appeal.

-62

Two Surgeons

The use of this modifier is appropriate to identify the use of two primary surgeons when required during a surgical procedure. Documentation should be submitted to support the use of the –62 modifier.

Payment will be determined based on the Medicare Physician Fee Schedule Database (MPFSDB) indicators 1 or 2 and based on Medical Review of supporting documentation.

-66

Surgical Team

The use of this modifier is appropriate to identify the services of a physician involved as part of a surgical team. Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties) are carried out under the “surgical team” concept.

Payment will be determined based on a case-by-case basis and review of supporting documentation.

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EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Mod

Description

Submission Guidelines

Impact To Payment

-76

Repeat Procedure, Same Physician

The practitioner may need to indicate that Separate payment of a procedure or service was repeated the service may be subsequent to the original procedure or made. service on the same day. This circumstance may be reported by adding modifier –76 to the repeated procedure/service (i.e., 82947 glucose, 82947-76 repeat glucose). Note: In situations warranting the use of both the –26 and –76 modifier (e.g., reading multiple chest x-rays of a patient performed on the same day), submit the – 26 modifier in the first position with the initial procedure and the –76 in the first position for the repeat procedure.

-77

Repeat Procedure, Another Physician

The practitioner may need to indicate that Separate payment of a procedure or service was repeated the service may be subsequent to the original procedure or made. service on the same day. This circumstance may be reported by adding modifier –77 to the repeated procedure/service (i.e., 82947 glucose, 82947-77 repeat glucose). Note: In situations warranting the use of both the –26 and –77 modifier (e.g., reading multiple chest x-rays of a patient performed on the same day), submit the – 26 modifier in the first position with the initial procedure and the –77 in the first position for the repeat procedure.

-79

Unrelated Procedure/Servi ce, same physician during post-op period

Append this modifier to Separate payment of procedures/services performed during the the service may be post operative period of another made. procedure, if the procedure/service is unrelated to the original procedure.

-80

Assistant Surgeon

Append this modifier to surgical assists performed by a physician, nurse practitioner, or RNFA.

Payment is made at 16% of the allowed amount.

EPNI adheres to CMS’ published list of services eligible for surgical assist.

Multiple surgery pricing logic also applies to assistant at surgery services.

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Coding Policies and Guidelines

Mod

Description

Submission Guidelines

Impact To Payment

-90

Reference (outside) Lab

The use of the –90 modifier is appropriate when a lab provider, not the treating physician, performs a laboratory procedure. The –90 modifier should be appended to the procedure code/test that was sent to the lab.

The modifier does not impact payment for the lab test; however, it may be used in determining whether payment will be made for more than one type of specimen collection.

-91

Repeat Clinical Diagnostic Lab Test

Append the modifier to a lab procedure that was repeated during the day.

Separate payment of the service may be made.

-AA

Anesthesia services performed personally by the anesthesiologist

Append the modifier when the anesthesiologist is physically present in the operating room, personally performs the induction and emergence, and directly monitors the patient throughout the entire operative procedure.

Payment is made at the full-time anesthesia conversion rate.

-AD

Medical supervision by a physician; more than four concurrent anesthesia procedures

Append the modifier when the anesthesiologist supervises more than four concurrent anesthesia procedures. The anesthesiologist may perform the induction and emergence but may not be present during the entire operative session.

Payment is made at the part-time anesthesia conversion rate.

-AS

Assistant at Surgery

Append this modifier to surgical assists performed by a physician assistant.

Payment is made at 16% of the allowed amount. Multiple surgery pricing logic also applies to assistant as surgery services.

-QK

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Medical direction (by physician) of two, three or four concurrent procedures by qualified personnel

Append the modifier when the anesthesiologist supervises more than four concurrent anesthesia procedures. The anesthesiologist may perform the induction and emergence but may not be present during the entire operative session.

Payment is made at the part-time anesthesia conversion rate.

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Mod

Description

Submission Guidelines

Impact To Payment

-QS

Monitored anesthesia service

Append the modifier when the anesthesiologist provides specific anesthesia services to a particular patient undergoing a planned procedure including performing a preanesthetic examination, be physically present in the operating suite, monitors the patient’s condition, and is prepared to furnish anesthesia services as necessary.

Payment is made at the part-time anesthesia conversion rate. Only one –QS service per day will be allowed.

-QX

CRNA service with medical direction by a physician

Append the modifier on the CRNA charges when the anesthesiologist supervises the CRNA who performed the anesthesia procedure. The anesthesiologist may perform the induction and emergence but may not be present during the entire operative session.

Payment is made at the part-time anesthesia conversion rate.

-QY

Medical direction of one Certified Registered Nurse Anesthetist by an anesthesiologist

Append the modifier on the anesthesiologist charges when the anesthesiologist supervises the CRNA who performed the anesthesia procedure. The anesthesiologist may perform the induction and emergence but may not be present during the entire operative session.

Payment is made at the part-time anesthesia conversion rate.

-QZ

CRNA service without medical direction by a physician

Append the modifier when the CRNA is physically present in the operating room, personally performs the induction and emergence, and directly monitors the patient throughout the entire operative procedure.

Payment is made at the full-time anesthesia conversion rate.

-TC

Technical component

Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier ‘TC’ to the usual procedure number.

Payment is made based on the technical portion of the RVU associated with the service.

The technical component applies to the actual physical performance of the service, which includes the equipment, supplies and personnel.

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Coding Policies and Guidelines

Anatomical Modifiers

The following modifiers indicate a specific anatomic site. They should be submitted in the first modifier position, if applicable. Appropriate use of these modifiers may assure correct claims adjudication.

Code

Definition

E1

Upper left eyelid

E2

Lower left eyelid

E3

Upper right eyelid

E4

Lower right eyelid

F1

Left hand second digit

F2

Left hand third digit

F3

Left hand fourth digit

F4

Left hand fifth digit

F5

Right hand thumb

F6

Right hand second digit

F7

Right hand third digit

F8

Right hand fourth digit

F9

Right hand fifth digit

FA

Left hand thumb

LC

Left circumflex coronary artery

LD

Left anterior descending coronary artery

LT

Left side (used to identify procedures performed on the left side of the body)

RC

Right coronary artery

RT

Right side (used to identify procedures performed on the right side of the body)

T1

Left foot second digit

T2

Left foot third digit

T3

Left foot fourth digit

T4

Left foot fifth digit

T5

Right foot great toe

T6

Right foot second digit

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Coding Policies and Guidelines

Code

Definition

T7

Right foot third digit

T8

Right foot fourth digit

T9

Right foot fifth digit

TA

Left foot great toe

Modifiers defined by DHS

The national HCPCS Panel developed several modifiers that could be defined by the various state Medicaid agencies. The Minnesota Department of Human Services has defined these as follows. Each modifier has more than one definition dependent on what service it is appended to or the program affected. The modifiers are generally informational only.

Code

Definition

Instruction

U1

Definition 1= Vulnerable Adult Case Management

Append the modifier if directed to in guidelines that may be found elsewhere in this manual.

Definition 2= IEP Physical Therapy (T1018) Definition 3= Added absorbency (A4521-A4554) Definition 4= CDCS- Personal Assistance (T2028) Definition 5= Transitional Services- furniture (T2038) U2

Definition 1= Home Care Case Management Definition 2= IEP Occupational Therapy (T1018) Definition 3= Maximum absorbency (A4521-A4554)

Append the modifier if directed to in guidelines that may be found elsewhere in this manual.

Definition 4= CDCS – Treatment & Training (T2028) Definition 5= Transitional Services- supplies (T2038) U3

Definition 1= CWTCM Definition 2= IEP Speech Therapy (T1018) Definition 3= NET Broker admin fee (A0080, A0090, A0100, A0110, A0120)

Append the modifier if directed to in guidelines that may be found elsewhere in this manual.

Definition 4= CDCS- Environmental Modifications & Provisions (T2028)

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Coding Policies and Guidelines

Code

Definition

Instruction

U4

Definition 1= Case Management via Telephone

Append the modifier if directed to in guidelines that may be found elsewhere in this manual.

Definition 2= IEP Mental Health Services (T1018) Definition 3= NET Taxi or equal, door to door (A0100) Definition 4= CDCS- Self-direction Support Activities (T2028) U5

Definition 1= Partial Day (DT&H) Definition 2= IEP Nursing Services (T1018) Definition 3= NET Taxi or equal, wheelchair, curb to curb (A0100)

Append the modifier if directed to in guidelines that may be found elsewhere in this manual.

Definition 4= End tidal CO2 monitor, monthly rental (E1399) U6

Definition 1= Temporary Service Increase Definition 2= IEP PCA/Paraprofessional Services (T1018)

Append the modifier if directed to in guidelines that may be found elsewhere in this manual.

Definition 3= NET Taxi or equal, wheelchair, door to door (A0100) Definition 4= End tidal CO2 spot check, weekly rental (E1399) U7

Definition 1= Physician Extender (medical services) Definition 2= IEP Assistive Technology Devices (T1018) Definition 3= NET Bus/train, monthly pass (A0110) Definition 4= Oximeter spot check, weekly rental (E0445)

Append this modifier to services by non-credentialed or non-enrolled practitioners when performing incident-to services under the direct supervision. The services would be reported under the directing physician’s provider number. The modifier does not impact payment.

Append the modifier if directed to in guidelines that may be found elsewhere in this manual.

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EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Definition

Instruction

U8

Definition 1= Home Based Mental Health Service

Append the modifier if directed to in guidelines that may be found elsewhere in this manual.

Definition 2= IEP Special Transportation (T1018) Definition 3= NET Level of need assessment (LON) (T1023) Definition 4= CDCS-Flexible case management (T2028)- separately recognized component of selfdirection support devices U9

Definition 1= Therapeutic Support Foster Care Definition 2= Behavioral Programming by Aide (S5135)

Append the modifier if directed in guidelines that may be found elsewhere in this manual.

Definition 3= NET level of need assessment (LON) II (T1023) Definition 4= Corporate settings (S5140, 55141, T2030TG, T2032, T2017, T2016) UA

Definition 1= Children’s Therapeutic Services and Supports Definition 2= Night Supervision (S5135)

Append the modifier if directed to in guidelines that may be found elsewhere in this manual.

Definition 3= NET Broker review (T1023) Definition 4= Supervision (T1019 and T1003) UB

Definition 1= Non-reservation American Indian Chemical Health only Definition 2= 24-Hour Emergency Service (S5135, S5136)

Append the modifier if directed to in guidelines that may be found elsewhere in this manual.

Definition 3= NET Taxi or equal, wheelchair, assisted station to station (A0100) Definition 4= DT&H Pilot Rate C (T2021) Definition 5= Out-of-town Respite (S5150) UC

Definition 1= Specialized Maintenance Therapy Definition 2= Extended Home Care Services Definition 4= Waiver Case Management (T1016)

EPNI Provider Policy and Procedure Manual (11/01/07)

Append the modifier if directed to in guidelines that may be found elsewhere in this manual.

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Coding Policies and Guidelines

Code

Definition

Instruction

UD

Definition 1= Professional service for fitting and evaluation of customized DME/PO (use with K0108)

Append the modifier if directed to in guidelines that may be found elsewhere in this manual.

Definition 2= Transitioning to community living services (90882, H2017) Definition 3= ER Triage (99201, 99211) Definition 4= AC Discretionary Service (T2025)

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EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Anesthesia Overview

EPNI accepts the CPT American Society of Anesthesiologists codes (ASA), 00100-01999, for anesthesia services billed on a CMS-1500 claim form. We do not accept surgical codes submitted with anesthesia modifiers. All services for the same operative session should be submitted on the same claim.

Full-time Anesthesia Services

We define full-time anesthesia as follows: Full-time anesthesia services are provided personally by the anesthesiologist to an individual patient. The anesthesiologist is physically present in the specific operating room, personally performs the induction and emergence, and directly monitors the patient throughout the entire operative procedure. The anesthesiologist may leave the specific operating suite to perform necessary administrative duties. However, the anesthesiologist does not perform other revenuegenerating procedures when billing full-time anesthesia services. This definition includes one-on-one supervision of a certified registered nurse anesthetist (CRNA) present in the same operating suite. Use modifier AA for full-time physician services. EPNI also considers anesthesia services provided by independent CRNA and physician-employed CRNA to be full-time if the above criteria are met and medical direction is not provided by a physician. Modifier QZ would be used for full-time CRNA services. The HCPCS level II modifiers (AA and QZ) should be listed in the first modifier position. The anesthesia modifiers should only be reported with the CPT anesthesia codes 00100-01999. Other services (such as nerve blocks), may be performed by an anesthesiologist or CRNA, but should not be submitted with an anesthesia modifier.

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Coding Policies and Guidelines

Part-time (Medically Directed) Anesthesia Services

Medically directed anesthesia services are provided by the anesthesiologist when he or she is supervising two or more CRNAs. The anesthesiologist may perform the induction and emergence but is not necessarily present during the entire operative session and may be supervising two or more procedures at the same time. Use modifier -AD or -QK for the medical direction provided by a physician (part-time services). Use modifier -QY for part-time medical direction of one CRNA by an anesthesiologist. Use modifier -QX for medically directed CRNA services (part-time). Use modifier -QS for part-time monitored anesthesia care. The HCPCS level II modifiers (AD, QK, QS, QX and QY) should be listed in the first modifier position.

Qualifying Circumstances

Physical Status

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In accordance with CPT, the following circumstances are recognized for submission of risk. The corresponding eligible base units that may be allowed are also listed. Code

Base Units

Description

99100

1

Anesthesia for patient of extreme age; under one year and over 70. (List separately in addition to the code for the primary anesthesia procedure.)

99116

5

Anesthesia complicated by utilization of total body hypothermia. (List separately in addition to the code for the primary anesthesia procedure.)

99135

5

Anesthesia complicated by utilization of controlled hypotension. (List separately in addition to the code for the primary anesthesia procedure.)

99140

2

Anesthesia complicated by emergency conditions (specify). (An emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat of life or body part.) (List separately in addition to the code for the primary anesthesia procedure.)

Six levels are currently recognized for patient physical status that may be used to distinguish various levels of complexity of the anesthesia service provided. Submit these physical status modifiers in the second modifier position, on the same line as the anesthesia service code. The corresponding eligible base units that may be allowed are also listed. EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Qualifying Circumstances and Physical Status Submission

Modifier

Base Units

Description

P1

0

Normal, healthy patient

P2

0

Patient with mild systemic disease

P3

1

Patient with severe systemic disease

P4

2

Patient with severe systemic disease that is a constant threat to life

P5

3

A moribund patient who is not expected to survive without the operation

P6

0

Declared brain-dead patient whose organs are being removed for donor purposes

The example below illustrates a claim that is submitted appropriately. It is for a situation where both qualifying circumstances and physical status may apply.

Procedure Code

Modifier

Description

00862

AA

Anesthesia for extra- peritoneal procedures in lower abdomen, including urinary tract; renal procedures, including upper 1/3 of ureter, or donor nephrectomy; performed by a full-time M.D.; patient with severe systemic disease.

P3

99140

AA

Emergency procedure performed by a full-time MD.

Electroconvulsive Treatments

To bill for anesthesia for electroshock treatments (00104), submit the appropriate anesthesia modifier. Time units and risk are recognized for this service.

Local Anesthesia

Local anesthesia, such as a nerve block, is included in the surgical procedure code. Do not submit a separate charge for this service.

Medical Services and Invasive Procedures

Anesthesia HCPCS modifiers should be submitted with ASA codes only. Do not submit anesthesia modifiers with medical services such as hospital visits, consultations, ventilation management, CPR, daily epidural management, or with invasive procedures such as vascular injections or nerve blocks.

Epidural Anesthesia for a Surgical Procedure

The insertion and administration of an epidural by an anesthesia provider for anesthesia during a surgical procedure should be reported with the appropriate anesthesia code. Codes 62311 or 62319 should not be used.

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Epidural Anesthesia for Pain Management

The insertion of an epidural catheter for pain management services by a qualified provider should be reported with either code 62311 or 62319, as appropriate. Time units are not appropriate for codes 62311 and 62319, and anesthesia modifiers are not required.

Anesthesia for Nerve Blocks

Anesthesia services for diagnostic or therapeutic nerve blocks and injections are submitted under codes 01991 or 01992 only when a different provider performs the block or injection.

Daily Management of Epidural Drug Administration

Daily management of an epidural catheter performed on the same date as the insertion of the catheter is considered to be included in the insertion and should not be reported separately. Subsequent daily management of epidural drug administration in the inpatient setting, including daily visits and removal of the epidural catheter, may be reported using CPT code 01996 (daily management of epidural or subarachnoid drug administration). Do not submit anesthesia modifiers or time for epidural daily management. Removal of the epidural catheter alone does not constitute daily management. If the only service performed is removal of the catheter, code 01996 should not be reported. Subsequent daily management of an epidural catheter performed in a setting other than inpatient hospital should be reported using the appropriate Evaluation and Management code.

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Coding Policies and Guidelines

Epidural Anesthesia for Labor and Delivery

Insertion Only When a provider performs the insertion of an epidural catheter for continuous analgesia, but does not participate in the ongoing management and monitoring of the epidural analgesia for labor and delivery, the claim should be for the insertion service only (code 62319). Time units are not appropriate for code 62319, and anesthesia modifiers are not required. Insertion and Management When a provider inserts the epidural catheter and participates in ongoing management and monitoring of the patient's epidural analgesia, the anesthesia code 01967 (neuraxial labor analgesia/ anesthesia for planned vaginal delivery) or 01968 (anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia) should be reported for the complete service using the appropriate anesthesia modifier, with anesthesia time units for actual face-to-face time. It would not be appropriate to report 62319 for the insertion of the catheter in addition to the epidural management. 99140 It is also not appropriate to bill the emergency qualifying circumstance code (99140) with normal deliveries. Emergency code 99140 applies only to cases where a “delay in treatment would result in an increased risk to life or body part,” according to the ASA Relative Value Guide. Do not confuse inconvenient case with emergencies, such as a surgery that takes place on the weekend or after normal business hours. Management Only In many cases, a physician will insert the epidural catheter, but a CRNA is responsible for the ongoing management and monitoring of the patient’s epidural analgesia. When this is the case, the CRNA should submit the anesthesia code 01967 or 01968 using the appropriate anesthesia modifier, with anesthesia time units for actual face-to-face time.

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Coding Policies and Guidelines

Moderate (conscious) Sedation

The physician who performs a procedure may bill moderate sedation, codes 99143 - 99145, in addition to billing the procedure. The use of these codes requires and includes an independent trained observer. The observer is not eligible to bill for anesthesia. Do not submit an anesthesia modifier with these codes. When a second physician, other than the healthcare professional performing the procedure, provides moderate sedation in the facility setting (e.g., hospital, outpatient hospital/ambulatory surgery center) the second physician reports 99148 - 99150. Codes 99148 - 99150 may not be reported in a non-facility setting (e.g., office). Do not submit 99143 - 99150 with procedures that include conscious sedation as an inherent part of providing the procedure. These procedures are listed in Appendix G of the 2005 CPT manual. The target symbol (~) will precede applicable codes in the main body of the CPT manual.

Monitored Anesthesia Care

Monitored anesthesia care (MAC) refers to instances in which an anesthesiologist has been called on to provide specific anesthesia services to a particular patient undergoing a planned procedure. In this case, the physician performs a preanesthetic examination, is physically present in the operating suite, monitors the patient’s condition, makes medical judgments regarding the patient’s anesthesia needs, and is prepared to furnish anesthesia service as necessary. For those circumstances under which such care is medically necessary and requested by the performing surgeon, EPNI will allow submission for MAC the same as for any other anesthesia service. Use modifier -QS for monitored anesthesia services.

Patient Controlled Analgesia

EPNI recognizes that patient-controlled analgesia (PCA) has demonstrated clear value to the patient. However, we do not recognize a separate charge for this service because postoperative pain control has already been included in the reimbursement of the surgical fee, which was paid to the performing surgeon. Patient controlled analgesia is also given to patients who have not had surgery (such as cancer patients) for pain control. It will be covered in such cases.

Standby

Anesthesia standby occurs when an anesthesiologist or CRNA is present in case his or her services are required for anesthesia, but otherwise performs no medical intervention. EPNI does not cover anesthesia standby. Standby services are considered ineligible and should not be billed to EPNI or the patient.

Documentation

The anesthesia record (either at the facility or the provider’s office) must clearly identify the professional or professionals providing the anesthesia service. For legal reasons, and in order to justify charges, EPNI requests that both the CRNA and anesthesiologist signatures be present for medically directed care.

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Time Designation/Sub mission

Anesthesia time should be indicated on the CMS-1500 claim form in the unit field (24G). Anesthesia time begins when the anesthesiologist or CRNA begins to prepare the patient for the induction of anesthesia in the operating room, or an equivalent area, and ends when they are no longer in personal attendance. Code the anesthesia time as minutes in the units of service field. See the sample CMS-1500 form, fields 24D-24G.

Diagnosis Coding

Use ICD-9-CM diagnosis codes. Select the diagnosis code that best describes the reason for the surgery based on the patient’s medical record. Use code V50.1, plastic surgery for unacceptable cosmetic surgery appearance, when the patient has requested elective surgery and that is the only surgery performed during an operative session.

Multiple Surgery

Code anesthesia services associated with multiple or bilateral surgical procedures performed during the same operative session with the single anesthesia code that has the highest base unit value.

Add-on Anesthesia Procedures

Only one anesthesia code will be accepted and processed. Do not submit “add-on” anesthesia procedures.

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Behavioral Health Services for CMS-1500 Overview

This section of the manual is intended for all mental health (behavioral health) practitioners who bill on the CMS-1500 claim form. This section is not intended for practitioners whose services are billed on the UB-92.

Practitioners who Should be Using this Section

Psychiatrists, PhD level psychologists, masters level psychologist, Licensed Independent Clinical Social Worker, Certified Nurse Specialist in Psychiatry and Licensed Marriage and Family Therapist, and Psychiatric Mental Health Nurse Practitioner. For Rule 29 clinics all other behavioral health practitioners should bill with these codes under the supervising practitioner's individual provider number and with the "U7" modifier.

Units

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One unit should be submitted based on the HCPCS code narrative. If there is no time designation the service is considered ‘per session’ and only one unit should be submitted regardless of actual time spent.

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Coding Restrictions

Psychiatry and Chemical Dependency Assessments

Code

Restriction

90816 90829

Inpatient Therapy codes are not covered based on APA coding guidelines.

90845

Psychoanalysis is generally a member contract exclusion. If covered, must be provided by a MD.

90846

Family Therapy without the patient present is generally not covered if the patient is over the age of 18.

90882

Environmental intervention for medical management purposes is not covered because it is included in the practitioner's basic service.

90885

Psychiatric evaluation of hospital records - not covered because it is included in the practitioner's basic service.

90887

Interpretation or explanation of exam results - not covered because reimbursement is included in the testing code.

90889

Preparation of report- not covered as a contract exclusion.

90899

Unlisted code-narrative and documentation of time must be submitted. Must be provided by a MD.

90801 and 90802 This is a per session code. Bill one unit of service per session regardless of time. Either 90801 or 90802 can be billed with either a chemical dependency diagnosis, or a psychiatric condition diagnosis. If the assessment does not reveal a behavioral health condition, bill with the sign or symptom precipitating the assessment. Rule 25 – Chemical dependency assessors should submit their assessments with a 90801 on a CMS-1500 form.

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Family Therapy

90846 90846 is billed for family therapy when the patient is not present. It is usually only covered until the patient is 18, but there may be specific contract exclusions on some self-insured groups. 90846 should be billed under the specific patient, not the member. Bill one unit per session regardless of total time. 90847 90847 is billed for family therapy when the patient is present. It is usually only covered until the patient is 18, but there may be a specific contract exclusion on some self-insured groups. 90847 should be billed under the specific patient, not the member. Bill one unit per session regardless of total time.

Medication Management

M0064 and 90862 It is not appropriate to bill a medication management code on the same day as an evaluation and management. If both are billed on the same day the medication management service will deny as incidental to the evaluation and management code. Medication management can be billed by a nurse practitioner, physician assistant, M.D. and clinical nurse specialist in psychiatry, and psychiatric mental health nurse practitioner. Medication management is eligible with a psychiatric diagnosis but is not with a chemical dependency diagnosis. This service is eligible when billed in the office or skilled nursing facility. It is not an eligible service when billed with an inpatient place of service. A medication management visit billed on the same day as an inpatient visit will deny as incidental to the inpatient visit. Medication management rendered in the outpatient clinic setting should be billed on a professional claim only (837P or CMS-1500). If billed on a facility claim it will be denied. M0064 includes a component for a brief office visit.

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Behavioral Health Evaluation & Management (E&M) Office Calls

99201 – 99215 Patients who receive an E/M service billed with a behavioral health diagnosis within their designated primary care clinic by a nonbehavioral health practitioner will have services reimbursed according to their behavioral health contract benefit. This E/M service will not be accumulated towards any dollar or visit maximums. A member who receives a behavioral health E/M service by a nonbehavioral health practitioner outside their PCC, but not within the Select Behavioral Health Network will require a referral for their highest level of benefits. Fee for service members who have open access to the EPNI network and receive a behavioral health E/M service by a non-behavioral health practitioner will have services reimbursed according to their behavioral health contract benefit. This E/M service will not be accumulated towards any dollar or visit maximums. Behavioral health E/M services provided outside the EPNI network will be subject to the member’s nonparticipating provider benefit limitations.

Nutritional Counseling

97802 - 97804, S9470

Eligibility of Dieticians / Nutritionists

Eating disorder diagnosis: For eating disorder diagnosis 307.1, 307.50 & 307.51, licensed nutritionists and licensed dieticians can bill independently for procedure codes S9470, 97802, 97803, and 97804. No referral is required for the highest benefit level.

Nutritional counseling is eligible if billed with either a behavioral health diagnosis or a medical diagnosis.

Registered dietician services must be submitted to EPNI by an eligible medical clinic or hospital. The individual provider number of the registered dietician must be submitted on the claim. Registered dieticians can only bill for procedure codes S9470, 97802, 97803, and 97804 with behavioral health diagnoses. All other diagnoses: Licensed nutritionists and licensed/certified dietitians can bill independently for procedure codes S9470, 97802, 97803, and 97804 for any diagnosis. Claims for registered dieticians billing services outside of behavioral health diagnoses will deny unless the services are submitted under the individual provider number of a supervising physician. The modifier U7 should also be submitted. EPNI Provider Policy and Procedure Manual (11/01/07)

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Psychological Testing

96101 - 96103, 96118 - 96120 There are no limits on the number of hours required to complete the testing. Total time will accumulate towards the patient’s benefit maximums. Each test should be associated with medical necessity-not a battery of test for screening purposes. 90887 (explanation of findings) should not be billed, reimbursement for these services is included in the testing reimbursement. The CPT® codes for psychological and neuropsychological testing were effective January 1, 2006. These new codes reflect who does the testing: a psychologist, a technician or a computer. EPNI is providing coverage and billing policies for these codes on the following pages.

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Coding Policies and Guidelines

Code

Narrative

Units

Practitioner

General Policies

96101

Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report.

Report 1unit per hour of face-toface testing, interpretation and preparation of report

MD, LP-PhD, LP-MA

The psychologist or psychiatrist administers and interprets the test(s) and prepares the report.

Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face.

Report 1 unit per hour of face-toface testing

96102

Billed under the MD, LP-PhD, LPMA individual provider number.

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MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, LMFT

A technician under direct supervision, administers the test(s). The supervising qualified licensed practitioner interprets the test(s) and prepares the report. Billed under the supervising licensed practitioner provider number.

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Coding Policies and Guidelines

Code

Narrative

Units

Practitioner

General Policies

96103

Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., (MMPI), administered by a computer, with qualified health care professional interpretation and report.

Report 1 unit per testing session regardless of the number of tests taken

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA

Patient is alone and taking a computerbased test.

Neuropsychological testing (e.g., Halstead-Reitan neuropsychological battery, Wechsler memory scales and Wisconsin card sorting test), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report.

Report 1 unit per hour of face-toface testing, interpretation and preparation of report

96118

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A qualified licensed practitioner interprets the test(s) and prepares the report. Billed under the licensed practitioner provider number.

MD, LP-PhD, LP-MA

The psychologist or psychiatrist administers and interprets the test(s) and prepares the report. Billed under the MD, LP-PhD, LPMA individual provider number.

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Coding Policies and Guidelines

Code

Narrative

Units

Practitioner

General Policies

96119

Neuropsychological testing (e.g., Halstead-Reitan nuropsychological battery, Wechsler memory scales and Wisconsin card sorting test), with qualified health care professional interpretation and report administered by technician, per hour of technician time, face-to-face.

Report 1 unit per hour of

MD, LP-PhD, LP-MA

A technician, under direct supervision, administers the test(s).

Neuropsychological testing (e.g., Wisconsin card sorting test), administered by a computer, with qualified health care professional interpretation and report.

Report 1 unit per testing session regardless of the number of tests taken

96120

The supervising qualified licensed practitioner interprets the test(s) and prepares the report Billed under the supervising licensed practitioner provider number. MD, LP-PhD, LP-MA

Patient is alone and taking a computerbased test. A qualified licensed practitioner interprets the test(s) and prepares the report. Billed under the licensed practitioner provider number

Practitioner Key

CNS-Psych = Clinic Nurse Specialist, Psychiatric specialty; LP-Ph.D. = Licensed Psychologist, Doctorate; LP-MA = Licensed Psychologist, Masters; LICSW = Licensed Clinical Social Worker; MD = Psychiatrist; PMHNP = Psychiatric Mental Health Nurse Practitioner; LMFT = Licensed Marriage and Family Therapist; PA = Physician’s Assistant; NP= Nurse Practitioner

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Policies

Policies applicable to the codes on the previous pages: •

Test result interpretation and report preparation are an inherent part of the testing service and not separately billable. Only one testing code may be billed.



Only a licensed psychologist or other licensed health care professional may bill for the psychological and neuropsychological tests.



The date of service submitted should be the date the test(s) is completed, regardless of when the test and/or report is completed.



Testing, scoring and interpretation done solely by a computer is not a billable service.



There is no specific definition of technician: a technician may be a psychometrist, student or trainee. However, the testing may be reported if the service is rendered under direct supervision of a qualified practitioner. The testing will be billed under the supervising practitioner’s individual provider number.



Direct supervision definition: The physician/qualified practitioner must be present in the office and immediately available to assist and direct throughout the performance of the service.



Direct personal supervision does not mean that the physician/qualified practitioner must be present in the same room with the non-physician/qualified practitioner. A physician/qualified practitioner cannot provide direct or personal supervision via telemedicine. Direct supervision is only applicable in the office place of service.

Marital Counseling

Diagnosis Code V61.10

Opiod Maintenance Drug Therapy

H0020

Generally, marital counseling is a member contract exclusion and will deny as member responsibility when this diagnosis code is used as the primary diagnosis.

Participating freestanding opioid treatment clinic services should be billed on a CMS-1500 using HCPCS code H0020 and the appropriate chemical dependency iagnosis code. H0020 would be used for either Methadone or Buprenorphine administration.11 Members will have services paid at the highest level of benefits within the Select Network. No referral will be required. Services can be billed on one line, 1 unit = 1 day. No individual provider number is required.

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Tobacco Cessation

Diagnosis Codes 305.1 or V15.82 If the intent is counseling and/or visit to obtain a prescription for smoking cessation medication/patches submit diagnosis 305.1 or V15.82. If linked to an E/M service a preventative or general illness benefit will be applied depending on the member’s benefits. Do not use as a primary diagnosis if the member has a primary behavioral health diagnosis that is being treated such a depression but member also uses tobacco. If so, 305.1 or V15.82 should be listed as a secondary diagnosis.

Rule 29 Setting

State licensed Rule 29 clinics will have three provider numbers: •

One for services in the clinic



One for M.D/Psychiatrists to bill for inpatient services

• One for PhD level psychologists to bill for inpatient services Services should be billed under the appropriate provider number. Any inpatient services billed under the Rule 29 clinic provider number will be denied. Rule 29 clinics can only provide outpatient mental health services under this licensure. Some Rule 29 clinics will also be licensed as nonresidential chemical dependency providers. It is important to keep these two entities separate. Chemical dependency assessments (code as 90801) with a chemical dependency diagnosis can be provided under the Rule 29 provider number but no other chemical dependency services. If a patient is being treated for depression secondary to a chemical dependency, the depression diagnosis should be billed as the primary diagnosis under the Rule 29 clinic provider number. Non-licensed practitioners may treat patients, however their services MUST be billed under the supervising practitioner’s individual provider number with the ‘U7’ modifier. Day Treatment

H2012 Day treatment services are provided at a licensed Rule 29 facility. Day treatment is defined by the patient attending a minimum of three hours per day. Bill one line for each day and one unit for each hour the patient attends the program. Services are reimbursed under the patient’s behavioral health benefit.

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Compatibility

This is a very common and frequent cause for claim denials. The diagnosis code and CPT code must be compatible with the practitioner’s licensure. Mental health diagnosis codes are generally only compatible with the psychiatric CPT codes with the exception of 90801 and 90802 which are also compatible with a chemical dependency diagnosis.

Health and Behavior Assessment Codes

96150 - 96155 Codes 96150 - 96155 are eligible to be billed by all behavioral practitioners. However, per CPT, 96150 - 96155 describe services offered to patients who present with established illnesses or symptoms, are not diagnosed with mental illness, and may benefit from evaluations that focus on biopsychological factors related to the patients’ physical health status. The primary diagnosis for the claim line containing the assessment, and intervention codes should be a non-behavioral diagnosis code. An example would be a newly diagnosed cancer patient or a patient struggling with infertility.

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Missed Appointments

EPNI does not pay for missed scheduled appointments. EPNI recommends that your clinic establish a uniform cancellation policy requiring 24-hour advance notification. Your clinic may bill a patient who misses a scheduled behavioral health appointment, provided you have notified the member in writing in advance that this is your policy. A copy of this signed notification should be maintained in your patient’s medical record. Your patient should be billed no more than your contracted rate. Government programs like Medicare prohibit billing for missed appointments. Policy applies to: This policy applies to providers whose scope of practice is Behavioral Health, including Psychiatrists, Licensed Psychologists (LP), Licensed Independent Clinical Social Workers (LICSW), Licensed Marriage and Family Therapists (LMFT), Registered Nurse Clinical Specialist (CNS) and Out-patient Chemical Dependency (OPCD) facilities. This policy change is not intended to apply to medication management provided within the member’s primary care clinic or internist’s office. Guidelines to be followed: EPNI would expect Behavioral Health providers to abide by the following guidelines: Medicare members cannot be charged for missed appointments Establish a reasonable business policy that allows for patients not to be charged for failed appointments due to circumstances outside of their control Abide by guidelines established by the American Medical Association (AMA) and the American Psychological Association (APA), which state it is ethical for providers to charge for missed appointments or for appointments not canceled at least 24 hours in advance, if patients are fully advised of the possibility of such charges

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Court Ordered Treatment

When a court order for treatment is based on evaluation and recommendation by a physician, licensed psychologist, licensed alcohol and drug dependency counselor or a certified chemical dependency assessor (rule 25) we will consider the order medically necessary. EPNI will provide coverage for these court ordered services according to the patient’s contract benefits. For example if the member does not have inpatient chemical dependency benefits and the patient is court ordered into inpatient chemical dependency treatment, there will be no coverage for the services. The evaluation and court order MUST be faxed in to Care Management at (651) 662-0851 as soon as possible so the necessary approval can be entered into the claim system and ensure the claim is paid accurately. If the court order is to a specific non-network provider but the member does not have any benefits for non-network providers, EPNI will cover the services as they would for any other network provider. However, fee-for-service members will be responsible for the difference between the billed amount and EPNI’s allowed amount.

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Guidelines for Court Ordered Evaluations

An appropriately licensed physician or psychologist must perform the mental health assessment. A physician, licensed alcohol and drug dependency counselor, or certified chemical dependency assessor must perform the chemical dependency assessment. The following services are eligible for EPNI coverage (subject to the terms of the member's contract): •

Mental Health evaluations/diagnostic assessments and related testing



Chemical Health evaluations



72 hour holds under the Mental Health Act, Minn. Stat. § 253B.05



24 hour mental health observation beds



Mental Health evaluations to determine the need for civil commitment for treatment The following are EPNI guidelines regarding Mental Health Evaluation components: (From EPNI Behavioral Health Guidelines for Treatment Record Documentation previously sent to providers by EPNI Quality Improvement.) •

The assessment or mental status exam is to identify appropriate subjective and objective information pertinent to the patient's presenting complaint. The presenting symptoms are to be clearly identified with the onset, duration and intensity documented.



The assessment contains the patient's presenting problem(s) as well as relevant psychological or social conditions affecting the patient's medical or psychiatric status. For children and adolescents (18 and under), past medical history and psychiatric history includes prenatal and perinatal events and a complete developmental history (physical, psychological, social, intellectual, and academic).



The mental status exam is to document the patient's affect, speech, mood, thought content, judgment, insight, attention or concentration, memory, impulse control, suicidal ideation and homicidal ideation.



For patients 10 years and older, there is to be an appropriate notation in the assessment concerning past and present use of tobacco, alcohol, as well as illicit, prescribed and over-the-counter substances.



Past medical/behavioral history is easily identifiable in the record and includes, if applicable; previous treatment dates, former provider information, therapeutic interventions and responses, source of clinical data, relevant family information, results of lab test and consultation reports.

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Guidelines for Court Ordered Evaluations (continued)



To determine if a comprehensive substance abuse evaluation is needed, a substance abuse screening is to be incorporated into the assessment of all new patients. This can be accomplished by the use of brief questionnaires such as the CAGAID or the AUDIT.



The provider is to have procedures in place for the re-assessment of patients who return for treatment after having been out of treatment for an extended period of time.



The MH evaluation components of the following assessments are eligible for EPNI coverage (subject to the terms of the member's contract):



Civil Competency evaluations (Evaluation to guide courts in determining whether a person is mentally competent to manage their own affairs)



Competency and Diminished Capacity Evaluations (Evaluation to guide courts in determining whether to award guardianship of an adult) Domestic violence assessments Pre-placement assessments (For evaluation prior to county placement in various settings, which may include foster care, shelter care, residential treatment, corrections, etc.) Sex offender evaluations (does not cover the criminal history review nor risk assessment portions as identified in MN Rule 2955.0100, Subp.7. A, B, C, D, G, and J) Forensic Evaluations: EPNI does not cover forensic evaluations conducted to answer specific legal questions. In contrast to a Mental Health Evaluation, a forensic evaluation is conducted primarily to assist the legal system in making decisions regarding family, civil or criminal matters. In these instances, the summary and conclusions relate directly to the legal issues, and the relationship between psychological factors and the legal issues are described. (For more information go to www.psychologyinfo.com/forensic/index.html, a link provided through the American Psychological Association Web site.) It is our expectation that a MH professional conducting one of the following assessments will use their clinical judgment. In the event the MH professional determines that the member requires a MH evaluation as a component of one of these evaluations for the purpose of identifying and determining treatment needs, EPNI will consider the component eligible for coverage, subject to the terms of the member's contract.

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Guidelines for Court Ordered Evaluations (continued)

The following are examples of forensic evaluations that are not covered by EPNI: •

Adoption home studies (Evaluation to guide courts in decision whether to allow adoption of children by an individual or couple)



Adoption Readiness Evaluations (Evaluation to guide courts in decisions regarding adoption placement planning)



Adult Pre-sentencing Evaluations (Evaluation to guide courts in determining sentencing of adults in criminal matters)



Assessment of Emotional Factors in Sexual Harassment and Discrimination (Evaluation to guide courts decision regarding sexual harassment and/or discrimination)



Child Abuse Evaluations, including sexual abuse evaluations (Investigative evaluation to determine presence and/or extent of child physical and/or sexual abuse)



Child Custody Evaluations (Evaluations to guide the courts decision in determining who should have custody of minor children)



Criminal Competency Evaluations (Evaluation to determine whether a person is competent to stand trial)



Development of Family Reunification Plans (Service to guide courts decisions regarding child placement/return to family setting)



Education classes for DUI offenses (Education classes/program regarding driving under the influence. A CD diagnosis is not required for attendance.)



Evaluating the Credibility of Child Witnesses (Evaluation to guide courts in determining credibility of a child witness)



Evaluations of Juveniles accused of Criminal Acts (Evaluation to guide courts in determining whether a minor should be tried as an adult)



Evaluations to Assess Termination of Parental Rights (Evaluation to guide courts decision regarding termination of parental rights)



Juvenile Pre-sentencing Evaluations (Evaluation to guide courts decision related to sentencing in criminal matters)



Juvenile Probation Evaluations (Evaluation to guide courts decision related to probation terms in criminal matters)



Mediation of Parental Conflicts about Children (Service to provide assistance to parents engaged in a legal dispute over child custody and/or visitation)

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Guidelines for Court Ordered Evaluations (continued)



Parenting Assessments/Parental Competency Evaluation (Evaluation to guide the courts decisions about parental rights, custody and placements)



Personal Injury Evaluations (Evaluation to guide courts decision in awarding damages related to personal injury)



Visitation Risk Assessments (Evaluations to guide the courts decision in determining child visitation rights. May include grandparent visitation.)



Worker's Compensation Evaluations (Evaluation to determine extent of damage related to a worker's compensation claim)

Parity

There are federal laws and state mandates that dictate mental health parity laws which are applicable to all fully insured groups. Self-insured groups are not subject to parity laws and legislation, unless they choose to add this benefit. Parity means that a member’s behavioral health benefits are exactly the same as their medical benefits. For example, if the member has coverage from a non-network provider for illness E&M service then they will have coverage for a non-network provider for a behavioral health service.

Behavioral Health Quality Improvement Objectives

Based upon results of the 2004 quality improvement activities and National Committee for Quality Assurance (NCQA) standards, EPNI requires participation from behavioral health providers in the following activities. Follow-up After Hospitalization for Mental Illness: Offer appointments to new and returning patients within seven days of mental health hospitalization discharge. Appointments should be provided within the timeframe commensurate with patient clinical need. EPNI recommends that behavioral health providers develop an appointment scheduling strategy to accommodate newly discharged patients, if they have not already done so. Standardized Substance Abuse Screenings in Mental Health Assessments: Routinely utilize standardized substance abuse screening questionnaires (e.g., CAGEAID) in mental health assessments for new patient’s age 12 and older. (Routine substance use assessment of 10- and 11-year-old children is also recommended.) Recommend or refer patients for comprehensive substance abuse assessment based on the screening results and corroborating clinical information from the substance use assessment.

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Coding Policies and Guidelines

Behavioral Health Quality Improvement Objectives (continued)

Exchange of Information with Primary Care Physicians Routinely ask all new patients to authorize exchange of information with primary care/specialty physicians. Establish a distinct section in the treatment record, if one does not exist, dedicated to case management activities. This section should contain: Documentation of patient authorization/refusal to exchange information with the physician. When authorized, documentation of communication with the physician (e.g., report, letter, telephone or e-mail communication). When recommending the patient seek psychopharmacologic treatment from their physician or if the physician recommended mental health assessment and/or treatment, provide the physician with the current behavioral health diagnosis(es), diagnostic criteria (i.e., symptoms with onset, duration and severity) and treatment plan, if applicable. When authorized, the treating psychiatrist or clinical nurse specialist should provide the current diagnosis(es) and initial medication management information to the primary care/specialty physician. This requirement is important for patient safety. Appointment Accessibility Provide routine initial appointments within 10 business days of the request. Provide routine follow-up appointments within 10 business days of the initial appointment. Provide urgent appointments within 24 hours of the request. Provide non-life-threatening-emergency appointments within 6 hours of the request. Provide or facilitate life-threatening-emergency care immediately. Questions Questions, comments, or material requests should be directed to: Attn: Mary Rains R4-18 EPNI P.O. Box 64179 St. Paul, MN 55164-0179 Phone: (651) 662-0826 or 1-800-382-2000 ext. 20826 Fax: (651) 662-3625

EPNI Provider Policy and Procedure Manual (11/01/07)

9-65

Coding Policies and Guidelines

Prior Authorization

EPNI does not require prior authorization for outpatient mental health or chemical dependency services. Will be required if the patient is seen out of network and the patient does not have any benefits out of the network. Exception: Some groups still require a prior authorization. Contact Provider Service for the specific group’s requirements.

Preadmission Notification

Call (651) 662-2474 or 1-800-469-1110 or fax form 15715 to (651) 662-0856 to notify EPNI of admissions into day treatment, partial psych or inpatient programs.

Groups that Carve Out Behavioral Health Benefits

There are some self-insured groups that contract with another carrier to handle their behavioral health coverage. This means that any type of behavioral health treatment billed to EPNI will be denied. The claims should be filed to the designated Third Party behavioral health carrier for processing. This information should be obtained from the patient or their family. EPNI may not have access to the carrier’s information. Exception: Behavioral health E/M and medication management services are eligible as stated above, if provided in either the patient’s primary clinic or a fee-for-service eligible non-behavioral health practitioner’s office. If a behavioral health E/M service is denied, EPNI should be contacted for the claim to be reprocessed.

Where to Bill Claims

9-66

All behavioral health claims should be filed to EPNI.

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Professional Behavioral Health Coding Grid Code

Description

Units

Who May Submit

90801

Psychiatric diagnostic interview exam

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90802

Interactive diagnostic interview exam

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90804

Individual psychotherapy, insight oriented, 1 per session office/outpatient, 20-30 min.

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90805

Individual psychotherapy, insight oriented, 1 per session office/outpatient, 20-30 min., w/E/M

MD, CNS-Psych, PMHNP

90806

Individual psychotherapy, insight oriented, 1 per session office/outpatient, 45-50 min.

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90807

Individual psychotherapy, insight oriented, 1 per session office/outpatient, 45-50 min., w/E/M

MD, CNS-Psych, PMHNP

90808

Individual psychotherapy, insight oriented, 1 per session office/outpatient, 75-80 min.

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90809

Individual psychotherapy, insight oriented, 1 per session office/outpatient, 75-80 min., w/E/M

MD, CNS-Psych, PMHNP

90810

Individual psychotherapy, interactive, office/outpatient, 20-30 min.

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90811

Individual psychotherapy, interactive, office/outpatient, 20-30 min., w/E/M

1 per session

MD, CNS-Psych, PMHNP

90812

Individual psychotherapy, interactive, office/outpatient, 45-50 min.

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

EPNI Provider Policy and Procedure Manual (11/01/07)

Misc

9-67

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

90813

Individual psychotherapy, interactive, office/outpatient, 45-50 min., w/E/M

1 per session

MD, CNS-Psych, PMHNP

90814

Individual psychotherapy, interactive, office/outpatient, 75-80 min.

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90815

Individual psychotherapy, interactive, office/outpatient, 75-80 min., w/E/M

1 per session

MD, CNS-Psych, PMHNP

90816

Individual psychotherapy, insight oriented, 1 per session inpatient, 20-30 min.

Not applicable

Not covered – part of inpatient payment based on APA guides

90817

Individual psychotherapy, insight oriented, 1 per session inpatient, 20-30 min., w/E/M

Not applicable

Not covered – part of inpatient payment based on APA guides

90818

Individual psychotherapy, insight oriented, 1 per session inpatient, 45-50 min.

Not applicable

Not covered – part of inpatient payment based on APA guides

90819

Individual psychotherapy, insight oriented, 1 per session inpatient, 45-50 min., w/E/M

Not applicable

Not covered – part of inpatient payment based on APA guides

90821

Individual psychotherapy, insight oriented, 1 per session inpatient, 75-80 min.

Not applicable

Not covered – part of inpatient payment based on APA guides

9-68

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

90822

Individual psychotherapy, insight oriented, 1 per session inpatient, 75-80 min., w/E/M

Not applicable

Not covered – part of inpatient payment based on APA guides

90823

Individual psychotherapy, interactive, inpatient, 20-30 min.

1 per session

Not applicable

Not covered – part of inpatient payment based on APA guides

90824

Individual psychotherapy, interactive, inpatient, 20-30 min., w/E/M

1 per session

Not applicable

Not covered – part of inpatient payment based on APA guides

90826

Individual psychotherapy, interactive, inpatient, 45-50 min.

1 per session

Not applicable

Not covered – part of inpatient payment based on APA guides

90827

Individual psychotherapy, interactive, inpatient, 45-50 min., w/E/M

1 per session

Not applicable

Not covered – part of inpatient payment based on APA guides

90828

Individual psychotherapy, interactive, inpatient, 75-80 min.

1 per session

Not applicable

Not covered – part of inpatient payment based on APA guides

90829

Individual psychotherapy, interactive, inpatient, 75-80 min., w/E/M

1 per session

Not applicable

Not covered – part of inpatient payment based on APA guides

EPNI Provider Policy and Procedure Manual (11/01/07)

9-69

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

90845

Psychoanalysis

1 per session

MD only

Not covered – may be a contract exclusion

90846

Family psychotherapy (without patient present)

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

May be a contract exclusion

90847

Family psychotherapy (with patient present)

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90849

Multiple family group psychotherapy

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90853

Group psychotherapy (other than family)

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90857

Interactive group psychotherapy

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90862

Pharmacologic management w/minimal psychotherapy

1 per session

MD, CNS-Psych, PMHNP, PA, NP

90865

Narcosyntheses

1 per session

MD, CNS-Psych, PMHNP

90870

Electroconvulsive therapy; single seizure

1 per day

MD only

90871

Electroconvulsive therapy; multiple seizures, per day

1 per day

MD only

90875

Individual psychophysiological therapy incorporating biofeedback, 20-30 min.

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90876

Individual psychophysiological therapy incorporating biofeedback, 45-50 min.

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

9-70

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

90880

Hypnotherapy

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

90882

Environmental intervention for medical management purposes

1 per session

MD only

Not covered - incl. in basic service

90885

Psychiatric evaluation of hospital records

1 per day

MD only

Not covered - incl. in basic service

90887

Interpretation or explanation of exam results

1 per day

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

Not covered - incl. in basic service

90889

Preparation of report of patient’s psychiatric status

1 per service

MD only

Not covered contract exclusion

90899

Unlisted psychiatric service or procedure

1 - submit time

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

Submit narrative

90901

Biofeedback training by any modality

1 per session

MD only

Not covered in home POScontract exclusion

90911

Biofeedback training, perineal muscles, anorectoal or urethral sphincter, including EMG and/or manometry

1 per session

MD only

Not covered in home POScontract exclusion

EPNI Provider Policy and Procedure Manual (11/01/07)

9-71

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

96101

Psychological testing, (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report

1 unit per hour of face-to-face testing, interpretation and preparation of report

MD, LP-Ph.D., LP-MA

The psychologist or psychiatrist administers and interprets the test(s) and prepares the report. Billed under the MD, LP-PhD, LP-MA individual provider number.

96102

Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face

Report 1 unit per hour of face-to-face testing

MD, LP-PhD, LP-MA, LICSW, CNSPsych, LMFT

A technician under direct supervision, administers the test(s). The supervising qualified licensed practitioner interprets the test(s) and prepares the report. Billed under the supervising licensed practitioner provider number.

96103

Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI), administered by a computer, with qualified health care professional interpretation and report

Report 1 unit MD, LP-PhD, LP-MA, LICSW, CNSper testing Psych, PMHNP, LMFT, NP, PA session regardless of number of tests

9-72

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

96116

Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, e.g., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report

1 per hour

MD, LP-PhD., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA

96118

Neuropsychological testing (e.g., Halstead-Reitan neuropsychological battery, Wechsler memory scales and Wisconsin card sorting test), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report

Report 1 unit per hour of face-to-face testing, interpretation and preparation of report

MD, LP-Ph.D., LP-MA

EPNI Provider Policy and Procedure Manual (11/01/07)

Misc

The psychologist or psychiatrist administers and interprets the test(s) and prepares the report. Billed under the MD, LP-PhD, LP-MA individual provider number.

9-73

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

96119

Neuropsychological testing (e.g., Halstead-Reitan neuropsychological battery, Wechsler memory scales and Wisconsin card sorting test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-face

Report 1 unit per hour of face-to-face testing

MD, LP-PhD, LP-MA

A technician under direct supervision, administers the test(s). The supervising qualified licensed practitioner interprets the test(s) and prepares the report. Billed under the supervising licensed practitioner provider number.

96120

Neuropsychological testing (e.g., Wisconsin card sorting test), administered by a computer, with qualified health care professional interpretation and report

Report 1 unit MD, LP-PhD, LP-MA per testing session regardless of number of tests

Patient is alone and taking a computerbased test. A qualified licensed practitioner interprets the test(s) and prepares the report. Billed under the licensed practitioner provider number.

9-74

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

96150

Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, healthoriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA

MH/CD diagnosis is NOT primary diagnosis

96151

Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, healthoriented questionnaires), each 15 minutes face-to-face with the patient; reassessment

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA

MH/CD diagnosis is NOT primary diagnosis

96152

Health and behavior intervention, each 15 minutes, face-to-face; individual

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA

MH/CD diagnosis is NOT primary diagnosis

96153

Health and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients)

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA

MH/CD diagnosis is NOT primary diagnosis

96154

Health and behavior intervention, each 15 minutes, face-to-face; family (with the patient present)

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA

MH/CD diagnosis is NOT primary diagnosis

96155

Health and behavior intervention, each 15 minutes, face-to-face; family (without the patient present)

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA

MH/CD diagnosis is NOT primary diagnosis

EPNI Provider Policy and Procedure Manual (11/01/07)

9-75

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

98960

Education and training for patient selfmanagement by a qualified, nonphysician health care professional using a standard curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient

1 per 30 minutes

MD, LP-PhD., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA

98961

Education and training for patient selfmanagement by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 2-4 patients

1 per 30 minutes

MD, LP-PhD., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA

98962

Education and training for patient selfmanagement by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; 5-8 patients

1 per 30 minutes

MD, LP-PhD., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, NP, PA

9920199205

Office or other outpatient E/M – new patient

1 per visit

MD only

9921199215

Office or other outpatient E/M – established patient

1 per visit

MD only

9922199223

Hospital inpatient E/M – initial

1 per visit

MD only

9923199233

Hospital inpatient E/M – subsequent

1 per visit

MD only

9-76

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

99234 – 99236

Observation or inpatient hospital care

1 per day

MD only

99238

Hospital discharge, 30 minutes or less

1 per day

MD only

99239

Hospital discharge, more than 30

1 per day

MD only

9924199245

Office or other outpatient consultation

1 per session

MD only

9925199255

Inpatient consultation, initial

1 per session

MD only

9926199263

Inpatient consultation, follow-up

1 per session

MD only

9928199285

Emergency department E/M

1 per session

MD only

G0175

Scheduled interdisciplinary team conference (minimum of three exclusive of patient care nursing staff) with patient present

1 per session

N/A

Denied. If IP or partial hospital part of hospital rates. If OP – no medically necessary care is provided.

G0176

Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient’s disabling mental health problems, per session (45 minutes or more)

1 per session

N/A

Denied. If IP or partial hospital part of hospital rates. If OP – no medically necessary care is provided.

EPNI Provider Policy and Procedure Manual (11/01/07)

9-77

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

Denied. If IP or partial hospital part of hospital rates. If OP – no medically necessary care is provided.

G0177

Training and educational services related to the care and treatment of patient’s disabling mental health problems per session (45 minutes or more)

1 per session

N/A

H0001

Alcohol and/or drug assessment

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, Rule 25

H0002

Behavioral health screening to determine eligibility for admission to treatment program

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

H0003

Alcohol and/or drug screening; laboratory analysis of specimens for presence of alcohol and/or drugs

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

H0004

Behavioral health counseling and therapy, per 15 minutes

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

H0005

Alcohol and/or drug services; group counseling by a clinician

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

H0006

Alcohol and/or drug services; case management

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

H0007

Alcohol and/or drug services; crisis intervention (outpatient)

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, mobile crisis provider specialty, Rule 29.

H0008

Alcohol and/or drug services; sub-acute detoxification (hospital inpatient)

1 per session

MD

9-78

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

H0009

Alcohol and/or drug services; acute detoxification (hospital inpatient)

1 per session

MD

H0010

Alcohol and/or drug services; sub-acute detoxification (residential addiction program inpatient)

1 per session

MD

H0011

Alcohol and/or drug services; acute detoxification (residential addiction program inpatient)

1 per session

MD

H0012

Alcohol and/or drug services; sub-acute detoxification (residential addiction program outpatient)

1 per session

MD

H0013

Alcohol and/or drug services; acute detoxification (residential addiction program outpatient)

1 per session

MD

H0014

Alcohol and/or drug services; ambulatory detoxification

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

H0015

Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education

1 per session

N/A

H0016

Alcohol and/or drug services; medical/somatic (medical intervention in ambulatory setting)

1 per session

MD, PA, NP, CNS-Medical

EPNI Provider Policy and Procedure Manual (11/01/07)

Misc

Denied – CD treatment part of facility charges.

9-79

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

H0017

Behavioral health; residential (hospital residential treatment program), without room and board, per diem

1 per diem

N/A

Denied – CD treatment part of facility charges.

H0018

Behavioral health; short-term residential (non-hospital residential treatment program), without room and board, per diem

1 per diem

N/A

Denied – CD treatment part of facility charges.

H0019

Behavioral health; long-term residential (non-medical, non-acute care in residential treatment program where stay is typically longer than 30 days), without room and board, per diem

1 per diem

N/A

Denied – CD treatment part of facility charges.

H0020

Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program)

1 per session

Methedone clinic

Covered when provided within a methadone clinic.

H0021

Alcohol and/or drug training service (for staff and personnel not employed by providers)

1 per session

N/A

Not covered

H0022

Alcohol and/or drug intervention service (planned facilitation)

1 per session

N/A

Not covered

9-80

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

H0023

Behavioral health outreach service (planned approach to reach a target population)

1 per session

N/A

Not covered

H0024

Behavioral health prevention information dissemination service (one-way direct or non-direct contact with service audiences to affect knowledge or attitude)

1 per session

N/A

Not covered

H0025

Behavioral health prevention education service (delivery of services with target population to affect knowledge, attitude and/or behavior)

1 per session

N/A

Not covered

H0026

Alcohol and/or drug prevention process service, community-based (delivery of services to develop skills of impactors)

1 per session

N/A

Not covered

H0027

Alcohol and/or drug prevention environmental service (broad range of external activities geared toward modifying systems in order to mainstream prevention through policy and law)

1 per session

N/A

Not covered

H0028

Alcohol and/or drug prevention problem identification and referral service(e.g. student assistance and employee assistance programs), does not include assessment

1 per session

N/A

Not covered

H0029

Alcohol and/or drug prevention alternatives service (services for populations that exclude alcohol and other drug use e.g. alcohol free social events)

1 per session

N/A

Not covered

EPNI Provider Policy and Procedure Manual (11/01/07)

9-81

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

Not covered

H0030

Behavioral health hotline service

1 per session

N/A

H0031

Mental health assessment, by nonphysician

1 per session

LP-Ph.D., LP-MA, LICSW, CNS-Psych, PMHNP, LMFT, NP, PA

H0032

Mental health service plan development by non-physician

1 per session

N/A

H0034

Medication training and support, per 15 minutes

1 per 15 minutes

N/A

H0035

Mental health partial hospitalization, treatment, less than 24 hours

1 per day

Rule 29

H0036

Community psychiatric supportive treatment, face-to-face, per 15 minutes

1 per 15 minutes

N/A

Not covered

H0037

Community psychiatric supportive treatment program, per diem

1 per day

N/A

Not covered

H0038

Self-help/peer services, per 15 minutes

1 per 15 minutes

N/A

Not covered

H0039

Assertive community treatment, face-toface, per 15 minutes

1 per 15 minutes

N/A

Not covered

H0040

Assertive community treatment program, per diem

1 per day

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

H0046

Mental health services, not otherwise specified

1 per 1 minute

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

9-82

Not covered

Not covered

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

H0047

Alcohol and/or other drug abuse services, not otherwise specified

1 – submit time

N/A

Denied – CD treatment part of facility charges.

H0048

Alcohol and/or other drug testing: collection and handling only, specimens other than blood

1 per service

N/A

Denied – CD treatment part of facility charges.

H2001

Rehabilitation program, per ½ day

1 per day

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

Pends for review.

H2010

Comprehensive medication services, per 15 minutes

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

H2011

Crisis intervention service, per 15 minutes

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

Not covered

H2012

Behavioral health day treatment, per hour

1 per hour

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

Not covered with a chemical dependency diagnosis.

H2013

Psychiatric health facility service, per diem

1 per day

N/A

Not covered

H2014

Skills training and development, per 15 minutes

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

Eligible for all programs with autism diagnosis. Not covered for all other diagnoses.

EPNI Provider Policy and Procedure Manual (11/01/07)

9-83

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

H2015

Comprehensive community support services, per 15 minutes

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

Not covered. Submit UA modifier for crisis intervention.

H2016

Comprehensive community support services, per diem

1 per day

N/A

Not covered

H2017

Psychosocial rehabilitation services, per 15 minutes

1 per 15 minutes

N/A

Not covered

H2018

Psychosocial rehabilitation services, per diem

1 per day

N/A

Not covered

H2019

Therapeutic behavioral services, per 15 minutes

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

Not covered

H2020

Therapeutic behavioral services, per diem

1 per day

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

PMAP/MNCare only

H2021

Community based wrap-around services, per 15 minutes

1 per 15 minutes

N/A

Not covered

H2022

Community based wrap-around services, per diem

1 per day

N/A

Not covered

H2023

Supported employment, per 15 minutes

1 per 15 minutes

N/A

Not covered

H2024

Supported employment, per diem

1 per day

N/A

Not covered

H2025

Ongoing support to maintain employment, per 15 minutes

1 per 15 minutes

N/A

Not covered

9-84

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

H2026

Ongoing support to maintain employment, per diem

1 per day

N/A

Not covered

H2027

Psychoeducational service, per 15 minutes

1 per 15 minutes

N/A

Not covered

H2028

Sexual offender treatment, per 15 minutes

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP, Certified Residential Sex Offender Treatment Facility

H2029

Sexual offender treatment, per diem

1 per day

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP, Certified Residential Sex Offender Treatment Facility

H2030

Mental health clubhouse services, per 15 minutes

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

Not covered

H2031

Mental health clubhouse services, per diem

1 per day

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

Not covered

H2032

Activity therapy, per 15 minutes

1 per 15 minutes

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

Not covered – used for Therapeutic Camp

H2033

Multisytemic therapy for juveniles

1 per session

N/A

Not covered

H2034

Alcohol and/or drug abuse halfway house services, per diem

1 per day

N/A

Not covered

H2035

Alcohol and/or other drug treatment program, per hour

1 per hour

N/A

Not covered

EPNI Provider Policy and Procedure Manual (11/01/07)

9-85

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

1 per day

N/A

Not covered Not covered

H2036

Alcohol and/or other drug treatment program, per diem

H2037

Developmental delay prevention activities, 1 per 15 dependent child of client, per 15 minutes minutes

N/A

M0064

Brief office visit for monitoring or changing drug prescriptions

1 per session

MD, CNS-Psych, PMHNP, PA, NP

S3005

Performance measurement, evaluation of patient self assessment, depression

1 per session

N/A

S9475

Ambulatory setting substance abuse treatment or detoxification services, per diem

1 per day

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT

S9480

Intensive outpatient psychiatric services, per diem

1 per day

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

S9482

Family stabilization services, per 15 minutes

1 per 15 minutes

N/A

Not covered

S9484

Crisis intervention mental health services, per hour

1 per hour

Rule 29, Mobile Crisis

Submit –UA modifier for MH professional Child/Adolescent practitioner. Submit –HN modifier for BA level practitioner.

9-86

Not covered

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Units

Who May Submit

Crisis intervention mental health services, per diem

1 per diem

Rule 29, Mobile Crisis

T1006

Alcohol and/or substance abuse services, family/couple counseling

1 per session

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

T1007

Alcohol and/or substance abuse services, treatment plan development and/or modification

1 per session

N/A

T1008

Day treatment for individual alcohol and/or substance abuse services

1 per day

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

T1009

Child sitting services for children of the individual receiving alcohol and/or substance abuse services

1 per session

N/A

Not covered

T1010

Meals for individual receiving alcohol and/or substance abuse services (when meals not included in the program)

1 per day

N/A

Not covered

T1011

Alcohol and/or substance abuse services, not otherwise classified

1 – submit time

MD, LP-Ph.D., LP-MA, LICSW, CNSPsych, PMHNP, LMFT, PA, NP

T1012

Alcohol and/or substance abuse services, skills development

1 per session

N/A

Not covered

T1023

Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol, per encounter

1 per session

N/A

Not covered

S9485

Description

EPNI Provider Policy and Procedure Manual (11/01/07)

Misc

UA modifier for MH professional Child/Adolescent practitioner. HN modifier for BA level practitioner.

Not covered

9-87

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

T1024

Evaluation and treatment by an integrated, specialty team contracted to provide coordinated care to multiple or severely handicapped children, per encounter

1 per session

N/A

Not covered

T1025

Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, mental and psychosocial impairments, per diem

1 per day

N/A

Not covered

T1026

Intensive, extended multidisciplinary services provided in a clinic setting to children with complex medical, physical, medical and psychosocial impairments per hour

1 per hour

N/A

Not covered

T1027

Family training and counseling for child development, per 15 minutes

1 per 15 minutes

N/A

Not covered

T1028

Assessment of home, physical and family environment, to determine suitability to meet patient's medical needs

1 per session

N/A

Not covered

T1029

Comprehensive environmental lead investigation, not including laboratory analysis, per dwelling

1 per session

N/A

Not covered

T2010

Preadmission screening and resident review (PASRR) level I identification screening, per screen

1 per screen

N/A

Not covered

9-88

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

T2011

Preadmission screening and resident review (PASRR) level II evaluation, per evaluation

1 per evaluation

N/A

Not covered

T2012

Habilitation, educational; waiver, per diem

1 per hour

N/A

Not covered

T2013

Habilitation, educational, waiver; per diem

1 per hour

N/A

Not covered

T2014

Habilitation, prevocational, waiver; per diem

1 per day

N/A

Not covered

T2015

Habilitation, prevocational, waiver; per hour

1 per hour

N/A

Not covered

T2016

Habilitation, residential, waiver; per diem

1 per day

N/A

Not covered

T2017

Habilitation, residential, waiver; 15 minutes

1 per 15 minutes

N/A

Not covered

T2018

Habilitation, supported employment, waiver; per diem

1 per day

N/A

Not covered

T2019

Habilitation, supported employment, waiver; per 15 minutes

1 per 15 minutes

N/A

Not covered

T2020

Day habilitation, waiver; per diem

1 per day

N/A

Not covered

T2021

Day habilitation, waiver; per 15 minutes

1 per 15 minutes

N/A

Not covered

T2022

Case management, per month

1 per calendar month

N/A

Not covered

T2023

Targeted case management; per month

1 per calendar month

N/A

Not covered

EPNI Provider Policy and Procedure Manual (11/01/07)

9-89

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

T2024

Service assessment/ plan of care development, waiver

1 per session

N/A

Not covered

T2025

Waiver services; not otherwise specified (NOS)

1 per session

N/A

Not covered

T2026

Specialized childcare, waiver; per diem

1 per day

N/A

Not covered

T2027

Specialized childcare, waiver; per 15 minutes

1 per 15 minutes

N/A

Not covered

T2028

Specialized supply, not otherwise specified, waiver

1 per session

N/A

Not covered

T2029

Specialized medical equipment, not otherwise specified, waiver

1 per session

N/A

Not covered

T2030

Assisted living; waiver, per month

1 per calendar month

N/A

Not covered

T2031

Assisted living; waiver, per diem

1 per day

N/A

Not covered

T2032

Residential care, not otherwise specified (NOS), waiver; per month

1 per calendar month

N/A

Not covered

T2033

Residential care, not otherwise specified (NOS), waive; per diem

1 per day

N/A

Not covered

T2034

Crisis intervention, waiver; per diem

1 per day

N/A

Not covered

T2035

Utility services to support medical equipment and assistive technology/ devices, waiver

1 per session

N/A

Not covered

9-90

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Code

Description

Units

Who May Submit

Misc

T2036

Therapeutic camping, overnight, waiver; each session

1 per session

N/A

Not covered

T2037

Therapeutic camping day, waiver; each session

1 per session

N/A

Not covered

T2038

Community transition, waiver; per service

1 per session

N/A

Not covered

T2039

Vehicle modifications, waiver; per service

1 per session

N/A

Not covered

Continued next page T2040

Financial management, self-directed, waiver; per 15 minutes

1 per 15 minutes

N/A

Not covered

T2041

Supports brokerage, self-directed, waiver; per 15 minutes

1 per 15 minutes

N/A

Not covered

T2048

Behavioral health; long-term care residential (non-acute care in a residential treatment program where stay is typically longer than 30 days), with room and board, per diem

1 per day

N/A

Not covered

EPNI Provider Policy and Procedure Manual (11/01/07)

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Coding Policies and Guidelines

Behavioral Health Services for UB-92 Overview

This section of the manual is intended for all behavioral health practitioners who bill on the CMS-1450 (UB-92) claim form. This section is not intended for practitioners whose services are billed on the CMS-1500.

Practitioners Who Should be Using this Section

Residential treatment centers, non-residential treatment centers, Rule 5 facilities, Rule 8 facilities, hospitals, state hospitals and treatment centers, freestanding detox centers.

Behavioral Health Evaluation or Testing Coding Guidelines

Use the following codes for submitting behavioral health evaluation or testing services on the UB92.

Units

Revenue Code

HCPCS Code

Narrative

Time

Units

0914

90801

Psychiatric diagnostic review

Per session

1 unit

0914

90802

Interactive psychiatric diagnostic interview

Per session

1 unit

0918

96101 – 96102

Psychological testing per hour

60 minutes

1 per hour

0918

96118 – 96119

Neuropsychological testing battery with interpretation or report

60 minutes

1 per hour

One unit should be submitted based on the HCPCS code narrative. If there is no time designation, the service is considered ‘per session’ and only one unit should be submitted regardless of the actual time spent. Unit guidelines are also noted in the appropriate following sections.

Individual Behavioral Health Therapy

9-92

Use the following codes for billing individual behavioral health services.

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Revenue Code

HCPCS Code

0911

Family and Group Therapy

Narrative

Time

Units

Psychiatric/Psychologic al service/rehabilitation. Do not use for CD services

Based on CPT code used

1 unit on CPT code used

0912

H2012

Psychiatric/Psychologic al service/partial hospitalization - less intensive

One line for each day the patient attends the program

1 unit for each hour the patient attends the program

0914

See CPT codes for individu al therapy

Psychiatric/psychologic al service/individual therapy

Based on CPT code

Depend s CPT code used

Use these codes when billing behavioral health family and group therapy services on an UB-92. Revenue Code

HCPCS Code

Narrative

Time

Units

0915

See HCPCS codes for group therapy

Psychiatric/Psychological service/group therapy

Based on CPT code

Based on CPT code

0916

90846 or 90847

Psychiatric/Psychological service/family therapy

Per session

1 unit per session

0917

90875 or 90876

Psychiatric/psychological service/biofeedback

Per session

1 unit per session

0918

96101 96102, 96118 96119

Psychiatric/psychological service/testing

60 minute

1 unit per 60 minutes

EPNI Provider Policy and Procedure Manual (11/01/07)

9-93

Coding Policies and Guidelines

Chemical Dependency and Alcohol Rehabilitation

Restricted Codes

Billing a Behavioral Health Assessment

Use these codes when billing alcohol or chemical dependency rehabilitation services on a UB-92.

Revenue Code

HCPCS Code

0944 Submit code describing service 0945

Narrative

Time

Units

Submit Drug Rehabilitation code individual or group describin g service

Based on CPT code

Based on CPT code

Submit Alcohol Rehabilitation code - individual or group describin g service

Based on CPT code

Based on CPT code

These revenue codes have restrictions on use and/or coverage Revenue Code

Restriction

0911

Can only bill with a mental health diagnosis

0913

EPNI does not recognize

0917

Can only bill with a mental health diagnosis

0919

Contract exclusion and is not covered

0944

Can only bill with a drug dependency diagnosis code

0945

Can only bill with an alcohol dependency diagnosis code

Bill 0912 and 90801/90802 with a mental health, chemical dependency or alcohol diagnosis code Bill 0944 and 90801/90802 with a chemical dependency diagnosis code Bill 0945 and 90801/90802 with an alcohol dependency diagnosis

Testing

0918 with 09101 – 96103, 96118 - 96120 Testing is compatible with all behavioral health diagnosis codes.

9-94

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Family Therapy

0916 with 90846 Revenue code 0916 and CPT 90846 is billed for family therapy when the patient is not present. It is usually only covered until the patient is 18. But there may be a specific contract exclusion on some self-insured groups. 0916 and 90846, should be billed under the specific patient, not the member. Bill one unit per session, regardless of total time.

Revenue Code 0916 with 90847

Revenue 0916 and CPT 90847 is billed for family therapy when the patient is present. This service may be a contract exclusion on all ages or over age 18 on some self-insured groups. 0916 and 90847 should be billed under the specific patient, not the member. Bill one unit per session, regardless of total time.

Nutritional Counseling / Dieticians

0942 with 97802 – 97804 Nutritional counseling is eligible if billed with either a behavioral health diagnosis or a medical diagnosis. Eating disorder diagnosis: For eating disorder diagnosis codes 307.1, 307.50, & 307.51, licensed nutritionists and licensed dietitians can bill independently for procedure codes S9470, 97802, 97803, and 97804. No referral is required for the highest benefit level. Registered dietitians services must be submitted to EPNI by an eligible medical clinic or hospital. The individual provider number of the registered dietitian must be submitted on the claim. Registered dieticians can only bill for procedure codes S9470, 97802, 97803, and 97804 with behavioral health diagnoses.

Detox

0126 Bill one unit of service per night spent in a detox bed. A chemical dependency or an alcohol dependency diagnosis must be submitted. Detox services are eligible when they are provided in a state licensed freestanding detoxification center, a hospital or residential treatment center.

EPNI Provider Policy and Procedure Manual (11/01/07)

9-95

Coding Policies and Guidelines

Health and Behavioral Assessment Codes

96150 - 96155

Non-Residential Treatment Centers

State licensed non-residential treatment centers can only bill outpatient chemical services. No mental health services will be covered in this setting.

CPT 96150 - 96155 describe services offered to patients who present with established illnesses or symptoms and not diagnosed with mental illness. The primary diagnosis should be a non-behavioral diagnosis code. On facility claims 96150-96155 should not be reported with revenue codes 0900-0919. Codes 96150-96155 may be submitted under revenue code 0940.

Some non-residential treatment centers are dually licensed as both a Rule 29 clinic and a residential treatment center. It is important to bill appropriate services under each separate entity. Mixing services and provider specialty will cause a claim to deny. Compatibility

This is a frequent and common cause of claim denials. Revenue code 0944 should only be billed with a chemical dependency diagnosis code. Revenue Code 0945 should only be billed with an alcohol dependency diagnosis code.

Partial Psych Admissions

0120 Partial psych is billed under a facility provider with a K in the fifth position. Example would be 1234KAB. Patients must attend a minimum of six hours per day. Reimbursement is made according to the patient's inpatient mental health benefits. All partial psych program services are combined into one charge and billed under revenue code 0120 using 1 unit of service for each day the patient is in the program. This includes group and individual therapy services. All other services such as lab work or radiology services should be split out and billed on a separate UB92 under the hospital provider number using the appropriate revenue codes. All partial psych program days should be billed on one claim. No interim billing can be accepted. Partial psych services are not eligible with a primary alcohol or chemical dependency diagnosis.

9-96

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Rule 5 – Emotionally Handicapped Facilities

Rule 5 facilities must have state licensure to provide services. Preadmission notification is required. Services are processed under the patient's inpatient medical benefit and are subject to any day or dollar limitations. Some self-insured contracts may deny as a contract exclusion. Benefits will end the day the patient turns 18.

Recreational Therapy

0941

Court Ordered Treatment

When a court order for treatment is based on an evaluation and recommendation by a physician, licensed psychologist, licensed alcohol and drug dependency counselor or a certified chemical dependency assessor (rule 25) we will consider the order for treatment medically necessary.

Recreational therapy may be part of an approved CD outpatient program. It is included under the CD program charges and should not be billed separately under revenue ode 0941.

EPNI will provide coverage for these court ordered services according to the patient's contract benefits. For example, if the member does not have inpatient chemical dependency benefits and the patient is court ordered into inpatient chemical dependency treatment, there will be no coverage for the services. The evaluation and court order MUST be faxed in to Care Management at (651) 662-0851 as soon as possible so the necessary approval can be entered into the claim system and ensure the claim is paid accurately. If the court order is to a specific non-network provider but the member does not have any benefits for non-network providers, EPNI will cover the services as they would any other in-network provider. However, feefor-service members will be responsible for the difference between the billed amount and EPNI’s allowed amount. Prior Authorizations

EPNI does not require prior authorization for outpatient mental health or chemical dependency services provided within the EPNI network. Will be required if the patient is seen out of network and the patient does not have any benefits out of the network. Exception: Some groups still require a prior authorization. Contact Provider Services for the specific group's requirements.

EPNI Provider Policy and Procedure Manual (11/01/07)

9-97

Coding Policies and Guidelines

Parity

There are federal and state mandates that dictate mental health parity laws that are applicable to all fully insured groups. Self-insured groups are not subject to parity laws and legislation. Parity means that a member's behavioral health benefits are exactly the same as their medical benefits. For example, if the member has coverage from a non-network provider for an illness E/M service then they will have coverage for a non-network provider for a behavioral health service.

Groups that Carve Out Behavioral Health Benefits

There are some self-insured groups that contract with another carrier to handle their behavioral health coverage. This means that any type of behavioral health treatment billed to EPNI will be denied. The claims should be filed to the designated Third Party behavioral health carrier for processing. This information should be obtained from the patient or their family. EPNI may not have access to the carrier's information. Exception: Behavioral health E/M and medication management services are eligible as stated above, if provided in either the patient's primary care clinic or a fee-for-service eligible non-behavioral health practitioner's office. If a behavioral health E/M service is denied, EPNI should be contacted for the claim to be reprocessed.

Where to File Claims

9-98

All behavioral health claims should be filed to EPNI.

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Institutional Behavioral Health Coding Grid Code

Description

Units

0900

Behavioral Health Treatments/Services, General Classification

1 unit based on CPT/HCPCS

0901

Behavioral Health Treatments/Services, Electroshock Treatment

1 unit based on CPT/HCPCS

0902

Behavioral Health Treatments/Services, Milieu Therapy

1 unit based on CPT/HCPCS

0903

Behavioral Health Treatments/Services, Play Therapy

1 unit based on CPT/HCPCS

0904

Behavioral Health Treatments/Services, Activity Therapy

1 unit based on CPT/HCPCS

0905

Behavioral Health Treatments/Services, Intensive Outpatient Services – Psychiatric

1 unit based on CPT/HCPCS

0906

Behavioral Health Treatments/Services, Intensive Outpatient Services - Chemical Dependency

1 unit based on CPT/HCPCS

0907

Behavioral Health Treatments/Services, Community Behavioral Health Program (Day Treatment)

1 unit based on CPT/HCPCS

0910

Behavioral Health Treatments/Services, Reserved for National Use

1 unit based on CPT/HCPCS

0911

Behavioral Health Treatments/Services, Rehabilitation

1 unit based on CPT/HCPCS

0912

Behavioral Health Treatments/Services, Partial Hospitalization - Less Intensive

1 unit based on CPT/HCPCS

0913

Behavioral Health Treatments/Services, Partial Hospitalization - Intensive

1 unit based on CPT/HCPCS

0914

Behavioral Health Treatments/Services, Individual Therapy

1 unit based on CPT/HCPCS

0915

Behavioral Health Treatments/Services, Group Therapy

1 unit based on CPT/HCPCS

0916

Behavioral Health Treatments/Services, Family Therapy

1 unit based on CPT/HCPCS

EPNI Provider Policy and Procedure Manual (11/01/07)

Misc

Not valid

9-99

Coding Policies and Guidelines

Code

Description

Units

0917

Behavioral Health Treatments/Services, Bio Feedback

1 unit based on CPT/HCPCS

0918

Behavioral Health Treatments/Services, Testing

1 unit based on CPT/HCPCS

0919

Behavioral Health Treatments/Services, Other Behavioral Health Treatments/Services

1 unit based on CPT/HCPCS

0944

Drug Rehabilitation

1 unit based on CPT/HCPCS

0945

Alcohol Rehabilitation

1 unit based on CPT/HCPCS

1000

Behavioral Health Accommodations, General Classification

1 per day

Room and Board

1001

Behavioral Health Accommodations, Residential Treatment - Psychiatric

1 per day

Room and Board

1002

Behavioral Health Accommodations, Residential Treatment - Chemical Dependency

1 per day

Room and Board

1003

Behavioral Health Accommodations, Supervised Living

1 per day

Room and Board

1004

Behavioral Health Accommodations, Halfway House

1 per day

Room and Board

1005

Behavioral Health Accommodations, Group Home

1 per day

Room and Board

9-100

Misc

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Chiropractic Services Overview

Chiropractors should use CPT codes when billing for services. Providers should submit the code that most accurately identifies the service(s) performed, paying close attention to attended versus unattended procedures (for example, 90732 versus 97014). The fact that a code exists does not guarantee the service is covered for all EPNI members. The member's health coverage contract defines the services that are eligible for payment.

Examination Codes

An examination includes inspection of the patient and review of diagnostic tests to diagnose disease or evaluate progress. Use of the E/M codes must be supported within your medical record. Per CPT, "Chiropractic manipulative treatment codes include a premanipulation patient assessment. Additional E/M services may be reported separately using the modifier -25, if the patient's condition requires a significant, separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure". It would be inappropriate to bill 99214, 99215, 99204 or 99205 along with manipulative treatment codes. These will be rejected as Provider liability. Documentation in the patient’s record, must support the additional E/M service. As noted by the Minnesota Chiropractic Association, an E/M would be appropriate for the following situations: New Patient A new patient is one that has not received any professional services from the chiropractor or another chiropractor in the same group practice within the past three years. Established Patient –New Injury or Exacerbation The E/M is needed to obtain history and fully evaluate the patient's condition for an initial treatment plan or, in the event of an exacerbation, modify a previous treatment plan. Established Patient –Re-examination Periodic examinations are typically performed in order to formally assess the patient's response to treatment, progress, and make necessary changes to the treatment plan. For any of the above circumstances, a -25 modifier must be submitted on the E/M service if there was a significant separately identifiable E/M service.

EPNI Provider Policy and Procedure Manual (11/01/07)

9-101

Coding Policies and Guidelines

Chiropractic Manipulation Treatment

The chiropractic manipulation treatment codes (CMT) include a premanipulation patient assessment, the adjustment, and evaluation of the effect of treatment. The CMT codes 98940 - 98942 are used to indicate the number of spinal areas manipulated. CMT code 98943 is used to report chiropractic manipulation of one or more of the extra-spinal regions (head region; lower extremities; upper extremities; rib cage; abdomen). PRE Service PRE Service work may include a review of: •

the patient’s records



their diagnostic tests



communication with other providers

• the actual preparations for care INTRA Service INTRA Service work would include: •

discussion about the service with the patient



a pertinent evaluation and assessment of the patient



the procedure

POST Service POST Service work includes:

Chiropractic Manipulation with Visit

9-102



an evaluation and discussion with the patient about the effect of treatment



arrangement of additional services or referral to another provider



discussion of the case with other providers



review of literature about the patient’s condition



documenting the service

If an evaluation and management service is done with the manipulation, the E/M will deny unless it is submitted with a -25 modifier, signifying significant, separately identifiable illness or injury.

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Manual Therapy

Code 97140, manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes. The primary difference between 97140 and the CMT codes (98940-98943) is that the CMT codes specify the number of spinal/extra-spinal regions manipulated, and the 97140 specifies one or more regions, per 15 minutes of service. When CMT services (98940-98943) and 97140 are provided to the same body region, it would not be appropriate to separately report both services. The services within 97140 would include a manipulation. When CMT services and 97140 are provided to separate body regions by different techniques, it would be appropriate to bill both. Code 97140 should be submitted with a modifier –59. Documentation must indicate and support the submission of the –59 modifier.

Massage Therapy

An independent massage therapist is an ineligible provider. When a massage therapist is employed and supervised by the chiropractor, the massage therapy must be performed as an adjunct to or in preparation for the chiropractic manipulation. The chiropractor should submit procedure code 97124 with a -U7 modifier. “Relaxation massages” are non-covered services.

Conjunctive Therapy, Modality: Office, Home or Nursing Home

Therapies must be used in conjunction with adjustment or manipulation on the same day for most contracts. If more than one therapy is done per treatment, submit documentation with the claim to support the necessity for the additional therapy.

Maintenance or Palliative Care

Rehabilitation services that would not result in measurable progress relative to established goals are non-covered services. The “AT” modifier distinguishes active/corrective treatment from maintenance therapy. The AT modifier should be appended to all manipulative and therapeutic procedures (such as chiropractic manipulations and physical therapy modalities) performed for active/corrective treatments. The absence of the AT modifier would indicate maintenance or palliative care.

EPNI Provider Policy and Procedure Manual (11/01/07)

9-103

Coding Policies and Guidelines

Source of Condition

Incorrect coding of "source of condition" is the major reason for delay in processing chiropractic claims. Follow the procedures outlined below to eliminate claim delays. Illness Typically an illness diagnosis is found in the 700 range of ICD-9-CM codes. If services are not related to a specific injury, choose a diagnosis code outside of the ranges given below. Injury Injury is defined as bodily harm caused by an accident. The term includes all related conditions and recurrent symptoms. If services are related to a specific injury, choose a diagnosis code in the 800 - 977 and 980 - 994 ranges. Submit the date of injury in field 14 on the CMS-1500 whenever the services are related to a specific injury. An exacerbation is not necessarily the result of an injury, therefore the appropriate illness diagnosis should be submitted.

Diagnostic Services

Use CPT codes to submit laboratory and X-ray services. The number of services on your claim must be the number of procedures performed, not the number of views taken. For example: Code Units 71020 (Chest x-ray, 2 views) 1

Practicing in MultiDisciplinary Clinics

9-104

Chiropractors practicing in multidisciplinary clinics shall maintain a separate contract and billing number.

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Documentation Guides

To avoid denials for medical necessity, the patient’s medical record must contain certain pertinent information that may be subject to our review. The Centers for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association (AMA) has developed guidelines for the medical documentation necessary to support a given level of evaluation and management service. EPNI adopted these guidelines to ensure that our members receive quality care and that the services are consistent with the insurance coverage provided. The general guidelines are listed below: The medical record should be complete and legible. The documentation of each patient encounter should include: •

reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;



plan of care;



If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.



Past and present diagnoses should be accessible to the treating and/or consulting physician.



Appropriate health risk factors should be identified.



The patient’s progress, response and changes in treatment, and revision of diagnosis should be documented. The CPT/HCPCS and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. Charge slips, super bills, travel cards, or office ledgers are not considered supporting documentation for services provided to a patient. Use of the term IBID and/or the use of quotation marks to replace or repeat previously documented information is not acceptable. All information must be in date-sequence order. Services not documented as indicated are not covered by EPNI. Patients are not financially liable for services that are denied for inadequate documentation. In addition, chart documentation should clearly list the name of the practitioner rendering services to the member, including the names and credentials of employees providing care under the supervision of a chiropractor.

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Coding Policies and Guidelines

Prior Authorization

Beginning January 1, 2006 chiropractic services rendered by EPNI Chiropractic Providers are no longer subject to prior authorization for members of EPNI fully insured groups. For EPNI self-insured groups, it is recommended that prior authorization for chiropractic services be done after 20 visits. Benefits are allowable only for services that are medically necessary. Providers are encouraged to use provider web selfservice or contact Provider Services to obtain member benefits prior to beginning services.

Form Required

To obtain prior authorization, providers should complete the EPNI Chiropractic Prior Authorization Request Form, form number X15718.

Compliance Audits

Your provider service agreement includes certain quality assurance requirements. Pursuant to this agreement, EPNI may conduct audits to evaluate a provider’s compliance with medical necessity guidelines and standards of practice in the community. Such an audit could include post-service claims review using provider utilization thresholds established by EPNI, which may result in provider liability if care is determined to be not medically necessary or medically inappropriate. Medical necessary services are directed toward a diagnosis or condition that is supported by documented subjective and objective findings. Medically necessary care means health care services are appropriate, in terms of type, frequency level, setting and duration, to the member’s diagnosis or condition, and diagnostic testing and preventive services. The intensity of treatment must be consistent with the severity or acuity of the patient’s current level of impairment and/or symptomatology. Additionally, there must be documentation of reasonable progress consistent with the intensity of treatment and the severity/acuity of the patient’s condition.

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Coding Policies and Guidelines

Dental Services Medical-Surgical Procedures

Many of our member contracts cover several medical-surgical procedures that dentists perform. The procedures are: •

Treatment (repair or replacement only) of accidental injury to natural teeth, which is not regular dental repair or maintenance.



Surgical and nonsurgical treatment of TMJ and craniomandibular disorder.



Treatment of cleft lip and palate for a dependent child up to age 19, if medically necessary.



Reconstructive surgery to correct a functional physical defect for dependent children — this would include orthognathic surgery. Treatment involving dental implants is specifically excluded.



Removal of cysts/lesion(s)/tumor(s) and the accompanying pathology reports, scans, anesthesia and allowable supplies. Certain dental services may be reported using either a CPT or dental HCPCS code. CPT codes are generally five numeric digits. Dental HCPCS codes, which are developed by the American Dental Association (ADA), start with the letter D and are followed by four numeric digits. It is important to note that pricing will vary between a comparable CPT and dental HCPCS code and that claims will be reimbursed based on the pricing associated with the code submitted. Pricing for CPT codes is based on Resource Based Relative Value System (RBRVS). Pricing for dental HCPCS codes is based on Delta Dental pricing.

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Coding Policies and Guidelines

Prior Authorization

If a service requires prior authorization, make sure the CPT or dental HCPCS procedure code on the claim is the same as on the prior authorization. For example, if a dental HCPCS code is approved on a prior authorization, use the same code on the claim. Prior authorization requests Begin mailing or faxing prior authorization (PA) requests to: Utilization Management Dept. R4-72 EPNI P.O. Box 64265 St. Paul, MN 55164-0265 Fax: (651) 662-7816 Prior authorization recommendations have changed PAs are recommended for the following services:

Claim Form



Surgical TMJ services



Orthognathic/osteotomies



Orthodontics for TMJ and cleft lip/palate



Bone grafts



Bridges for accidental injuries

Use a CMS-1500 claim form when submitting dental-related claims (the ADA claim form is accepted; however, EPNI prefers the CMS-1500). If you are using the ADA form, be sure to include the diagnosis if the treatment is accident related, for cleft lip/palate or TMJ diagnosis or include the narrative. Treatment of accidental injury to natural teeth Initial treatment must begin within 12 months of the accidental injury and completed at 24 months from date of initial treatment. “Injury” does not include bruxism or biting and chewing. Complete the “date of injury” field on the claim. Submit the appropriate accidental injury diagnosis code on the initial and subsequent claims throughout treatment. Include documentation in support of the accidental injury diagnosis or narrative description of the accident with the claim. Note: Prior authorization for anesthesia for children is not required. Benefits are paid in accordance with the contract.

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Coding Policies and Guidelines

Coordination Between Dental and Medical Carriers

If you perform the types of service listed above for your patients, bill EPNI as usual. If the patient has a dental plan in addition to a medicalsurgical policy, the dental plan is the primary payer.

TMJ Claims Submission

The following guidelines should be used when preparing TMJ-related disorder claims for submission:

Note: If you receive payments from both the dental and medical plans for the same services, refund the medical carrier. We will coordinate up to our U&C allowances or billed charges, whichever is less.

Codes

Guideline

ICM-9-CM

The primary diagnosis code should be 524.60temporomandibular joint disorders. All other primary diagnosis codes submitted for TMJ and craniomandibular disorders will be rejected.

HCPCS codes

The HCPCS code for orthotic therapy should be D7880. All other orthotic codes submitted for TMJ and craniomandibular disorders will be rejected. Study casts and/or mounted or unmounted study models are considered an integral part of the splint therapy and should not be billed separately.

CPT codes nonsurgical

Orthotic adjustments and office call visits are considered an integral part of the orthotic therapy and should not be billed separately. Only the initial visit may be billed separately.

CPT codes surgical

The following procedure codes are considered eligible for reimbursement for surgical services of the temporomandibular joint: 21050, 21060, 21070, 21240, 21242, 21243, 29804 (TMJ arthroscopy— surgical only). Please Note: All postoperative office visits are considered an integral part of the surgical fee and should not be billed separately unless there are documented complications.

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Coding Policies and Guidelines

Diagnostic Studies

The following radiographs are considered eligible for TMJ disorders when medically necessary: •

70328



70330



70332



70336



70355



70486



70487

• 70488 Benefits are not provided for cephalometric radiographs for TMJ disorders. Electromyography (EMG), Computerized Mandibular Scanner, Computerized Jaw Tracking/Motion Analysis, Doppler Auscultation, and Sonography/ultrasound are considered investigative and therefore ineligible when used in the diagnosis and treatment of temporomandibular and craniomandibular disorders. Emergency Room

Emergency room services submitted with dental diagnosis will be processed as a medical service.

Dental Procedures and Pre-op / Medical Exams

When a member comes to your clinic for a pre-op exam for a dental related procedure, code the exam as a medical pre-op. The charges will fall under their medical benefits. Providers should only code as a pre-op exam if they know the procedure will be covered.

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Coding Policies and Guidelines

Durable Medical Equipment and Supplies Durable Medical Equipment (DME) Definition

Prior Authorization Requirements

EPNI defines DME as equipment and related health care supplies and services that are: •

able to withstand repeated use; and



used primarily for a medical purpose; and



generally not useful in the absence of illness or injury;



determined to be reasonable and necessary; and



prescribed by a physician; and



represents the most cost-effective alternative

Fax all prior authorization requests using the Prior Authorization Request for DME form (X15717) to (651) 662-2810. EPNI will approve or deny prior authorization requests based on a member's contract benefits and the criteria defined in applicable medical policies. Prior authorizations should be submitted by the durable medical equipment supplier who will be providing the equipment and should include the appropriate HCPCS code(s). For questions about prior authorizations, call (651) 662-5270 or 1-800528-0934 (choose option 2, then option 4). Providers can also fax prior authorization questions to (651) 662-2810. Members should call the number on the back of their ID card for customer service if they have questions. The items listed in the table on the next page have written medical policies associated with them. To determine eligibility for these items see the applicable medical policy and specific contract benefits.

Item

Medical Policy Number

Prior Authorization Required?

Ambulatory blood pressure monitoring

VII-13

Yes

Apnea appliances

IV-7,VII-26

Yes

Beds, specialty, overlays

VII-9

Yes

Coagucheck/Home Prothrombin Time Monitoring

VI-1

Yes

Cochlear implants and accessories

IV-2

Yes

Communication devices

VII-52

Yes

Dorsal column stimulation devices

IV-74

Yes

Electrical bone growth stimulators

VII-17

Yes

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Coding Policies and Guidelines

Item

Medical Policy Number

Prior Authorization Required?

Enteral feedings

II-41

Yes

Gravity lumbar reduction device (e.g. SD, LTX 3000)

VII-43

Yes

Infusion pumps, implantable

IV-34

Yes

Neuromuscular stimulator

VII-25

See Medical Policy

Oral elemental diets

II-48

Yes

Phototherapy lights for SAD

VII-41

Yes

PUVA light therapy

II-15

Yes

Spinal cord stimulators

IV-74

Yes

Pelvic TENS or Pelvic Floor Electrical Stimulation

VII-49

No

Uterine contraction monitors

VII-22

Yes

Vest percussors (e.g. Thairapy vests)

VII-35

Yes

Wheelchairs

VII-4

Yes, purchase only

Wound healing devices

II-45

Yes

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Coding Policies and Guidelines

Ineligible Items

The following list of items is considered ineligible DME. There is no need to submit prior authorization requests for ineligible items. Note: This is not an all-inclusive list. •

Abdominal support belts for pregnant women



Grab bars





Heading pads

Adaptive eating equipment





Home monitors

Air conditioners





Air filters



Back huggers

Incontinence supplies (e.g. diapers, underpants, underpads, Attends)



Balls for therapy



Lifeline medical alert



Bedpans and urinals



Maternity belts



Biofeedback device, purchase



Overbed tables



Blood pressure cuffs and accessories



Positioning aids (e.g. bolsters, wedges)



Car seats



Reachers



Computer software & hardware



Roman chairs



Copes scoliosis brace total recovery program



Scales



StimMaster E4000



Telephone communication device (TTDY)



Thera cane



Tub stool or bench



Croup tent



Cryocuff (icing device)



Drionic devices (sweating devices)



Elevators/stairlifts





Exercise equipment (e.g. bicycles, tricycles, treadmills and ski machines)

Vehicle modifications (hand controls, lifts and car seats)



Vitrectomy, seated support system (special chair for eye surgery patients)



Wheelchair vehicle lift/ramps



Whirlpools/Jacuzzi/hot tubs



Feeding chairs



Floor sitters



Formula, infant

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Coding Policies and Guidelines

DME Rental Guidelines

Most DME can only be rented for 10 months. DME is considered purchased after 10 months of rental payments. Ten months rental for a particular item equals EPNI allowed amount for the purchase price of that item. No additional claims for rental or purchase of the same device should be submitted after the EPNI allowed amount for the purchase price of that item has been met. The following items are rental only:

Waivers and Upgraded/ Deluxe DME



ventilators



negative pressure ventilators



CPM machines



oximeters



large volume air compressors



airway pressure monitors oxygen concentrators



electric breast pumps

The following is EPNI’s policy for provision of upgraded or deluxe equipment. Providers may bill members for an equipment upgrade or deluxe charge if a waiver is on file and the DME charges are billed correctly to EPNI. EPNI will continue to reimburse only for medically necessary standard DME. Providers must ask for a signed, written waiver that includes the cost for the deluxe features or upgrade. (A sample waiver form can be found on the next page.) The waiver must state ALL of the following:

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The standard piece of equipment or least costly alternative was offered to the member; and



The member is aware and agrees that EPNI will only pay the standard allowance; and



The member will be responsible for the deluxe or upgrade charge in addition to his or her contractual obligation



Providers must keep all signed waivers on file. Do not send waiver forms to EPNI. EPNI reserves the right to request waiver forms from a provider's office when necessary.

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Waiver Claim Submission

Two lines of services must be billed. The first line will include the HCPCS code and the charge for the standard (non-deluxe) equipment. This dollar amount will be subject to contract benefits and usual and customary reductions. The second line must include the same HCPCS code with the -GA modifier (waiver of liability statement on file) and the amount charged for the upgrade or deluxe feature. Example: •

E0202 NU $550.00 (standard, charge that will be subject to standard allowance and member contract benefits)



E0202 GA $150.00 (deluxe/upgrade charge that will be denied as member liability) The -GA modifier must be submitted as the first modifier on the second service line. Other applicable modifiers should be submitted on the first service line only. Sample Waiver Form

As a participating provider with Employer Provider Network (EPNI), we are obligated to notify you of services that are medically unnecessary. This notification will allow us to hold you financially responsible for the upgrade to the durable medical equipment that you are purchasing. We have offered you the standard _______________________ (list type of equipment) at the customary price of $________________ . We have informed you of the least costly alternative, which is the charge for the upgrade or deluxe features is $___________ . By signing and dating this waiver, you are acknowledging that: You are aware of and agree that EPNI will allow only standard equipment. Only the allowed amount for the standard equipment will apply to deductible and coinsurance amounts. You will be financially responsible for the deluxe or upgrade charge. The upgrade charge is in addition to any contractual obligations you have such as deductible and coinsurance amounts. Signature ____________________________ Date: _________

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Coding Policies and Guidelines

DME Coding

DME suppliers and others who bill supply items should use HCPCS level II codes. Our research shows that codes E1399 and K0108 are used excessively and incorrectly. These should be used ONLY when there is no code listed in the HCPCS manual for the equipment. Do not use this code for supplies or equipment that can be coded with a specific code or combination of codes. Unlisted codes (such as K0108 or E1399) require submission of a narrative describing the equipment along with the Manufacturers Suggested Retail Price (MSRP).

Sales Tax

Include any tax in your charge for the item. Do not code tax separately. If submitted, S9999 will be denied as provider liability.

Handling / Conveyance

Handling, conveyance, and/or any other service in connection with the implementation of an order involving devices (code 99002) is not separately reimbursable. These charges should be included in charge for the item.

Claims Filing Requirements

Use the CMS-1500 claim form to report your services to EPNI. To obtain forms, please refer to Chapter 6 – Claims Filing in this manual. Submit ICD-9-CM codes to report an appropriate diagnosis for your patient. Use HCPCS level II codes to report your services. The place of service must be a valid CMS two-digit place of service code. Submit units based on narrative description. DME providers and Skilled Nursing Facilities, billing for place of service 31, 32, or 33, are required to submit an Explanation of Medicare Benefits (EOMB) for their services unless the provider has opted out of Medicare. If the provider has opted out then the provider will need to include the Opt Out letter with claims submitted. Any other place of service does require an EOMB. This applies only to Medicare recipients.

Hearing Aids

Hearing aids are generally not covered for any contracts. Binaural Hearing Aid Units Binaural hearing aid codes should be submitted with 1 unit only. The set allowance reflects two hearing aids. When submitting a charge for hearing aid repair, use HCPCS code V5014. Coverage of hearing aids, services and supplies is contractually based.

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Coding Policies and Guidelines

Oxygen and Oxygen Aiding Equipment (Includes Ventilators)

Coding Modifiers

Oxygen and Oxygen aiding equipment are defined as the following items: •

Oxygen



Ventilators



Negative Pressure Ventilators



Oximeters



Large Volume Air Compressors



Airway Pressure Monitors (excluding CPAP)



Oxygen Concentrators



Oxygen Conservers



Oxygen equipment is reimbursed on a rental basis only, as long as the equipment is medically necessary.



Oxygen contents will only be reimbursed separately when the member owns an oxygen system, or rents or owns only a portable oxygen system.

EPNI requires all DME Providers to submit procedure code modifiers to differentiate rental, purchase and repair or replacement of DME. Modifiers include the following: Rental Modifiers: •

BR: The beneficiary has been informed of the purchase and rental options and has elected to rent the item.



LL: Lease/rental (Use the LL modifier when DME rental is to be applied against the purchase price.)



RR: Rental (Use the RR modifier when the DME is to be rented.)



Purchase modifiers:



BP: The beneficiary has been informed of the purchase and rental options and has elected to purchase the item.



NR: New when rented. (Use the NR modifier when DME which was new at the time of rental is subsequently purchased.)



NU: New Equipment



RP: Replacement and repair. RP may be used to indicate replacement of DME, orthotic and prosthetic devices which have been in use for some time. The claim shows the code for the part, followed by the RP modifier and the charge for the part.

Note: Do not use the following modifiers as they will not be recognized in processing: BU and UE.

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Coding Policies and Guidelines

DME Repairs and Maintenance (Excludes Oxygen Equipment)

Repair of rental DME is not covered. Repair may be allowed for purchased DME. To submit repair, report the HCPCS code for the DME being repaired with the –RP modifier. Submit E1340 (repair or non-routine service for DME requiring the skill of a technician, labor component, per 15 minutes) on a separate line. Include the appropriate number of units (one per 15 minutes). The cost of the repair (including parts and loaner fee) should not exceed our allowable for the purchase of the equipment. Charges for maintenance of DME are not covered. Maintenance would be indicated with the –MS modifier.

Replacement of Purchased Equipment

EPNI’s policy is to pay for replacement of DME, due to normal use and wear, every five (5) years, unless unusual circumstances necessitate replacement of an item sooner than 5 years. Replacement of obsolete or inoperable DME equipment which has been purchased is subject to the same Prior Authorization guidelines as the purchase of the original equipment.

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Coding Policies and Guidelines

Billing for Supplies

Supply items should be submitted with the HCPCS Level II code that most appropriately describes the item. Unlisted supply codes should be used if there is no other code that describes the item. A narrative must be submitted with every unlisted code. Supplies are generally allowed separately only in conjunction with approved home health care. Reimbursement for supplies used in the office is included in the overhead component of the professional service (such as an E&M). Office supplies, such as Betadine or alcohol wipes, will be denied. Payment for supplies is based per narrative description (e.g., each, per pair, per 100, etc.). It is necessary to identify the total number of each supply in the “units” block or the 24F block of the 1500 claim form. Disposable gloves can be reported per 100 (a single box) or per pair. Code A4927 reflects billing per 100. HCPCS code A4930 reflects billing per pair. The unit descriptions for each code differ significantly. It is important to submit the units correctly to ensure appropriate reimbursement. Following is the narrative for each glove code along with a coding example: Code: A4927 Narrative: Glove, non-sterile, per 100 Example: One 100 count box of non-sterile gloves, submit 1unit in box 24G (days or units) on CMS-1500 claim form. Code: A4930 Narrative: Gloves, sterile, per pair Example: One 100 count box of sterile gloves, submit 50 units in box 24G on CMS-1500 claim form. Gloves are restricted to home use only (for approved home health, home infusion, or home dialysis services). Eligibility for reimbursement is subject to member benefits. The following quantities of ostomy and urology-related supplies are considered to be reasonable for a monthly (30-day) period. When quantities in excess of these amounts are supplied to the same patient for use during the same month, the claim(s) must contain an explanation of the medical necessity for such quantities. If the documentation is not on the claim, there may be a delay in processing the claim or the claim may be denied.

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Coding Policies and Guidelines

Billing for Supplies (continued)



Indwelling catheters—two per month



Catheter insertion trays—two per month



Sterile irrigation tray/kit—four per month



Irrigation syringe, bulb or piston—four per month



Bottles of irrigation solution—four per month



Bedside drainage bags—four per month



Leg drainage bags—four per month



Bedside drainage bottle, rigid or expendable—one per month



Leg strap, foam or fabric—one per month



Urinary catheters (straight catheter)—31 per month



Ostomy Pouches—70 per month



If a member signs a waiver accepting responsibility for supplies billed in excess of recommended guides. Bill two lines of service. The first line will include the HCPCS supply code and the second line should be submitted with the same HCPCS code with a –GA modifier. See “Waivers and Upgraded/Deluxe DME” for additional waiver sample and submission information.

Rental Unit Submission

Service counts must be submitted on a monthly basis only and generally submitted as one (1) service per month, instead of 30 units or services. Do not submit claims for more than a thirty day supply of any related supplies. Rental is on a monthly basis only.

Hospital DME Providers

Hospital DME providers are required to bill DME on a UB-92 claim form.

DME/Supply Internet Purchases

DME or supplies purchased from Internet auction sites (such as e-Bay) or private parties are generally not covered. If a DME supply company is the actual supplier, that provider’s number will be assigned and the claim will be processed per the member’s benefits. If the provider is not a DME/supply company (e.g., private party, estate sale), the claim will be denied.

E0935 Rental Guides

Continuous passive motion devices are usually only used for a short period of time during a patient’s recovery period. Therefore, the HCPCS code E0935 (passive motion exercise device) is assigned a daily rental allowance and it limited to 21 days of rental. Submit one unit for each day of rental. For example, if the device is rented for 14 days, indicate 14 in the unit field.

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Coding Policies and Guidelines

Home Health, Home Infusion, and Hospice Definitions

Prior Authorization

Service

Definition

Home Health

Home health care is care provided in a patient's home by qualified personnel.

Home Infusion

Home infusion is the administration of medications or nutrition intravenously or through a feeding tube.

Hospice

Hospice care is a concept of care which provides palliative care (rather than curative care) to a terminally ill patient and family.

All home health and hospice services require prior authorization. Prior authorization is required for the following home infusion services: Blood Factor Products •

IVIG



Aldurozyme®



Fabrazyme®



Home health, Blood factor and IVIG prior authorization is performed by: Case Management Route code: R4-72 (651) 662-5520 888-878-0139 ext. 25520 Fax: (651) 662-1004 Address: P.O. Box 64265 St. Paul, MN 55164-0265 Aldurozyme and Fabrazyme prior authorization is performed by: Medical Review R4-72 P.O. Box 64265 St. Paul, MN 55164-0265 Fax: (651) 662-2810 EPNI must be notified of any changes in treatment plans.

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Coding Policies and Guidelines

Home Health

Examples of home care services requiring review include: skilled home nursing visits, home health aid services, home social worker visits, and personal care attendants. Note: Personal care attendants are not eligible for coverage under most health plans, with the exception of Public Programs. Coverage of services is subject to contract benefits and limitations. Services must be skilled versus non-skilled or custodial. Services must be intermittent and of medical nature. Home health care must be ordered in writing by a physician and performed by a Medicare certified/JCAHO approved home health agency. Services must be submitted on a UB-92 claim form. The appropriate revenue code(s) should be submitted for the services supplied. Home Health revenue code categories are: •

055X: Skilled nursing



056X: Medical Social Services



057X: Home Health-Health Aide



058X: Other visits (Home Health)



059X: Home Health - Units of Service

• 060X: Home Health - Oxygen Prior authorization is recommended except for members who we have been notified are eligible for the elderly waiver program. The authorization number provided by EPNI must be entered in form locator 63 on the UB-92 claim form.

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Coding Policies and Guidelines

Home Infusion

Coverage of services is subject to contract benefits and limitations. Home infusion services must be ordered in writing by a physician and performed by a Medicare certified/JCAHO approved home infusion agency. Claim Submission Changes Submit claims using either the electronic ASC ANCI X 12N 837 format, or on a paper CMS-1500 form using CPT and HCPCS codes. Use the Place of Service code 12 (Home) for services provided in the patient’s home, or in an infusion suite located at the home infusion provider’s office. Professional Id numbers are issued with contracts for all participating home infusion providers. Individual provider numbers are not required. As always, reimbursement is subject to the member’s contract benefits. Per Diem Payment The HCPCS “S” codes for home infusion services are based on a “per diem” reimbursement methodology. The per diem includes all supplies, care coordination and professional pharmacy services. The per diem is billed for each day that a patient is on service from date of admission through date of discharge. Nursing services, drug products and enternal formulas are billed separately from the per diem. Drugs Code all drugs with a HCPCS or CPT code. If a specific code is not available you may use J3490, J7799, or J9999. Provide the narrative, NDC number, and dosage/units supplied, in field 24D on the CMS 1500 claim form. These claims will require manual review. Use drug units as described in the HCPCS or CPT description of the code. Nursing Code home nursing visits lasting up to two hours using CPT code 99601. Report each additional hour beyond the initial two with 99602 with the appropriate number of units. When provided in the infusion suite of a home infusion agency, code each nursing visit lasting up to two hours using CPT code 99199, with a narrative description. Report each additional hour beyond the initial two with 99199-52 with the appropriate number of units, in accordance with the NHIA (National Home Infusion Association) recommendations for billing.

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Coding Policies and Guidelines

Home Infusion (continued)

Catheter Care Bill catheter care per diems (S5498, S5501, S5502) when provided as a stand-alone therapy. Insertion by a nurse of a PICC line (S5522) or midline (S5523) is coded separately from the other nursing visit code and per diem. Supplies required from non-routine catheter procedures such as declotting supplies (S5517), repair kits (S5518), PICC insertion supplies (S5520) and midline insertion supplies (S5521) are coded separately. Prior Authorization Prior authorization is recommended when supplying IVIG, Factor products, Aldurazyme, and Fabrazyme, or other drugs not yet identified. A PA can be completed using the standard PA form X15709. Multiple Therapies For multiple therapies in the same category done on the same date of service as primary therapy, append the following modifiers to the “S” code per diem: •

SH- second concurrently administered infusion therapy

• SJ- third or more concurrently administered therapy Notification Recommended Notification is recommended to our Case Management department for obstetrical patients receiving hydration therapy, tocolytic therapy (i.e., Terbutaline) or anti-emetic infusion (i.e., Reglan or Zofran). This serves as notification to EPNI that the patient may need additional support from our staff. This can be done by calling (651) 662-5520.

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Coding Policies and Guidelines

Home Infusion (continued)

Medicare Primary with EPNI Secondary Medicare Supplement policies will only coordinate with the services that Medicare allows: Submit the nursing claims to Medicare Part A. The claim may crossover to EPNI and process with your Home Health provider number. Agencies who are not certified by Medicare A should subcontract the nursing portion of the service to Medicare A certified home care agency. Submit the drugs and supply charges to Medicare Part B. The claim may crossover to EPNI and should process using your DME provider number. Verification of the crossover may be done through our secure provider web self-service. If the claim is not found, attach the Medicare EOMB and cover letter to a paper claim and submit to EPNI. For services that would be denied by Medicare, but may be allowed by EPNI: A Medicare denial is not required. Submit the claim to EPNI and append the -GY modifier to each line of service.

Hospice

Coverage of services is subject to contract benefits and limitations. Hospice care must be ordered in writing by a physician and performed by a Medicare certified/JCAHO approved hospice agency. Services must be submitted on a UB-92 claim form using a hospice contracting provider ID number. The appropriate revenue code(s) should be submitted for the services supplied. Hospice revenue codes are 0650-0659. Prior authorization is recommended. Claims Submission Hospice claims should be submitted on paper for manual processing to the Case Manager listed on the prior authorization letter to: EPNI Case Management R4-72 P.O. Box 64265 St. Paul, MN 55164 All hospice members are case managed.

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Coding Policies and Guidelines

Hospital Care Initial Hospital Care

EPNI patients have coverage for a physician’s daily inpatient care. Submit a separate charge for medical care on the admission day, using codes 99221 - 99223. Always submit this charge as one unit of service.

Subsequent Hospital Visits

Bill all other inpatient visits as subsequent care, using codes 99231 - 99233. If the patient is still hospitalized when you bill, use the last visit as the discharge date on the claim. Subsequent visits may be combined on one line if all services, diagnoses, and charges are identical, provided by the same individual provider and the dates of service are sequential. Each visit counts as one unit of service. The place-of-service code is inpatient hospital.

Critical Care

Coding of Critical Care is based first on the age of the patient. Neonates- birth through the 28th postnatal day would utilize 99295 and 99296. These are inpatient per day codes. Pediatrics- 29 days old through 24 months would utilize 99293 and 99294. These are inpatient per day codes. Over 24 months of age- anyone older than 24 months would utilize 99291 and 99292. These are time- based codes. Use code 99291 for up to 74 minutes of critical care. Submit one unit of service for this code. Time duration beyond 74 minutes should be coded as 99292 with the appropriate number of units. The narrative for 99292 states “each additional 30 minutes.” Code 99292 must always be submitted with 99291. Example: Critical care for a 26 year old of 2 hours duration Code Units of Service

9-126

99291

1

99292

2

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Coding Policies and Guidelines

Hospital Observation Services

EPNI considers hospital stays for 24 hours or more as inpatient. The hospital observation codes 99218 - 99220 should not be submitted if the hospital stay is more than 24 hours. Evaluation and management services on the same date provided in sites that are related to initiating “observation status” should NOT be reported separately. Subsequent visits provided to patients who have been admitted to the hospital for 24 hours or more should be submitted with codes 99231 - 99233. Observation or inpatient care services provided to patients admitted and discharged on the same date of service are reported using codes 99234 - 99236. The place of service can be either inpatient or outpatient.

Observation Care Discharge Day Management

The discharge management code 99217 may be submitted for the day following initial observation care when a physician performs a final exam, discusses the observation period, provides instructions for continued care, and prepares the discharge record.

Hospital Discharge

Hospital discharge day management services, 99238 or 99239, are only billable by the provider who actually discharged the patient on the actual date of discharge. Face to face contact is required on the day of discharge. Discharge summaries prepared before the patient is discharged are not billable.

Continuing Intensive Care Services

The codes 99298 - 99300 are used to report services subsequent to the day of admission provided by a physician directing the continuing intensive care of the low birth weight (LBW), very low birth weight (VLBW) infant, or normal weight newborn who no longer meets the definition of critically ill but continue to require intensive observation, frequent interventions, and other intensive services. These codes are global 24-hour codes and not reported as hourly services.

Swing Beds

If the hospital census reports the patient as inpatient, use inpatient E&M codes with an inpatient place of service. If the patient has been discharged from inpatient status, use the skilled nursing place of service and the corresponding E/M codes 99304-99310.

Skilled-Nursing Facility Care

Follow the same guidelines for skilled-nursing facility care as for inhospital medical care above. Use codes 99304-99306 for medical care on the day of admission to a skilled-nursing facility. For follow-up care, use codes 99307-99310. The place-of-service code is 31. Claims for skilled-nursing care require admit and discharge dates. Discharge day management codes 99315 or 99316 are used to report the total duration of time spent by a physician for the final nursing facility discharge of a patient.

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Coding Policies and Guidelines

Institutional Care Definitions

Category

Definition

Ambulatory Surgical or Surgicenter

An ambulatory surgical or medical center is a facility that provides ambulatory (walk-in) surgical or medical treatment. These centers provide care usually done in an acute care hospital on an outpatient basis.

Claim Format Regulations

HIPAA Administrative Simplification code and transaction regulations dictate the standard claim format and codes for electronically submitted claims. Institutional claims are billed on the 837I electronic format. The paper equivalent is the UB-92 or CMS-1450 claim form. EPNI considers the following providers as ‘institutional’ and as such, should bill on the institutional claim format (837I or UB-92).

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Home Health Agency

HHA is a public agency or private organization that is primarily engaged in providing skilled nursing services and other therapeutic services, such as physical therapy, occupational therapy, medical social services and home health aide services. Can be freestanding or hospital attached. Care is rendered in the home and is in lieu of a hospital confinement.

Hospice

Hospice programs provide health care for terminally ill patients. Care may be done in the patient’s home, at special hospital units, or a separate hospice care facility.

Hospital

An institution that provides medical, diagnostic and surgical care. Services can be rendered on an inpatient or outpatient basis.

Non-residential Treatment Center

This type of institution is the same as a residential primary treatment center with the exception that services are rendered on an outpatient basis only.

Nursing Home

A Skilled Nursing Facility (SNF) provides skilled nursing care and related services for patients who require medical or nursing care; or rehabilitation services for injured, disabled, or sick person.

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Definitions

Category

Definition

Psychiatric Hospital

A psychiatric hospital provides care to emotionally ill patients. These facilities must be licensed by the state in which they are located.

Residential Primary Treatment Center (IP Chemical Dep)

Residential treatment programs for chemical dependency are planned and purposeful sets of conditions and events for the care of inebriated and drug dependent persons which provides care and treatment for five or more inebriate or drug dependent persons on a 24 hour basis. Excluded for this definition are receiving (detoxification) centers.

Facility Clinic

If a hospital operates a clinic in their facility, clinic charges must be billed as if the clinic were free-standing. Submit clinic charges under the assigned EPNI professional provider number on a professional claim form (CMS-1500 or 837P). The clinic place of service code 11 should be submitted.

UB-92 Manual

The Uniform Billing Manual (UB-92) was developed and maintained by the National Uniform Billing Committee. The data element specifications for all institutional claims are found in the UB-92 manual. This data is for use in EDI billing and payment transactions and related business applications as well as paper claim submission. Providers billing institutional claims should have a UB-92 manual readily available. The manual is available from several sources including directly from the NUBC, commercial publishers, or the state specific manual from the Minnesota Hospital Association. Data elements are updated several times throughout the year.

UB-04

The UB-04 is scheduled to replace the UB-92 beginning with bills created on March 1, 2007. Refer to Chapter 6 for additional information.

Procedure Code Regulations

The medical procedure code set for inpatient services is ICD-9 procedure codes. Procedure information will be reported on outpatient claims using HCPCS codes.

Revenue Codes (Form Locator 42)

A revenue code identifies a specific accommodation and/or ancillary service or billing calculation. The revenue code is four characters. The first digit is usually a 0 (zero); however, there are codes that begin with other than 0 (100X, 210X, 310X). It is important to report all four digits.

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Coding Policies and Guidelines

HCPCS / Rates (Form Locator 44)

For inpatient bills, the accommodation rate relating to the room and board revenue code is entered in form locator 44.

Revenue Codes Requiring HCPCS / CPT

To align more closely with the Centers for Medicare & Medicaid Services (CMS) on revenue codes that require HCPCS/CPT codes on Outpatient Institutional claim submissions, EPNI are adding revenue codes to what is currently required within your provider contract.

For outpatient bills, report the HCPCS code, if applicable, to indicate the specific outpatient service in form locator 44. Some HCPCS codes or billing situations may require submission of modifiers. Modifiers are reported following the HCPCS code. EPNI accepts modifiers; however, we currently do not adjudicate the claim/service based on modifiers.

The list of revenue codes requiring submission of a HCPCS/CPT code is below. In addition to the codes listed below, there may be revenue codes that may be subject to additional coding requirements. These codes will be listed elsewhere (such as 0942). Revenue Codes

Descriptions

Revenue Codes

Descriptions

0274

Medical/Surgical Supplies and Devices – Prosthetic / Orthotic Devices

0291

Durable Medical Equipment (Other than Renal) – Rental

0292

Durable Medical Equipment (Other than Renal) – Purchase of New DME

0293

Durable Medical Equipment (Other than Renal) – Purchase of Used DME

0300

Laboratory – General Classification

0301

Laboratory – Chemistry

0302

Laboratory – Immunology

0303

Laboratory – Renal Patient (Home)

0304

Laboratory – Non-Routine Dialysis

0305

Laboratory – Hematology

0306

Laboratory – Bacteriology & Microbiology

0307

Laboratory – Urology

0309

Laboratory – Other Laboratory

0310

Laboratory Pathological – General Classification

0311

Laboratory Pathological – Cytology

0312

Laboratory Pathological – Histology

0314

Laboratory Pathological – Biopsy

0319

Laboratory Pathological – Other/Mantoux

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Coding Policies and Guidelines

Revenue Codes

Descriptions

Revenue Codes

Descriptions

0320

Radiology-Diagnostic – General Classification

0321

Radiology-Diagnostic – Angiocardiography

0322

Radiology-Diagnostic – Arthrography

0323

Radiology-Diagnostic – Arteriography

0324

Radiology-Diagnostic – Chest X-Ray

0329

Radiology-Diagnostic – Other Radiology-Diagnostic

0333

Radiology-Therapeutic and/or Chemotherapy Administration – Radiation Therapy

0340

Nuclear Medicine – General Classification

0341

Nuclear Medicine – Diagnostic Procedures

0342

Nuclear Medicine – Therapeutic Procedures

0343

Nuclear Medicine – Diagnostic Radiopharmaceuticals

0344

Nuclear Medicine – Therapeutic Radiopharmaceuticals

0349

Nuclear Medicine – Other

0350

CT Scan – General Classification

0351

CT Scan – Head Scan

0352

CT Scan – Body Scan

0359

CT Scan – Other CT Scan

0360

Operating Room Service – General Classification

0361

Operating Room Service – Minor Surgery

0362

Operating Room Service – Organ Transplant (other than kidney)

0367

Operating Room Service – Kidney Transplant

0369

Operating Room Service – Other Operating Room Services

0400

Other Imaging Services – General Classification

0401

Other Imaging Services – Diagnostic Mammography

0402

Other Imaging Services – Ultrasound

0403

Other Imaging Services – Screening Mammography

0404

Other Imaging Services – Positron Emission Tomography/PET Scan

0409

Other Imaging Services – Other Imaging Services

0413

Respiratory Services – Hyperbaric Oxygen Therapy

0450

Emergency Room – General Classification

0451

Emergency Room – EMTALA Emergency Medical Screening Service

0452

Emergency Room – ER Beyond EMTALA Screening

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Coding Policies and Guidelines

Revenue Codes

Descriptions

Revenue Codes

Descriptions

0456

Emergency Room – Urgent Care

0459

Emergency Room – Other Emergency Room

0460

Pulmonary Function – General Classification

0469

Pulmonary Function – Other Pulmonary Function

0471

Audiology – Diagnostic

0480

Cardiology – General Classification

0481

Cardiology – Cardiac Cath Lab

0482

Cardiology – Stress Test

0483

Cardiology – Echocardiography

0510

Clinic – General Classification

0511

Clinic – Chronic Pain Center

0512

Clinic – Dental Clinic

0513

Clinic – Psychiatric Clinic

0514

Clinic – OB-GYN Clinic

0515

Clinic – Pediatric Clinic

0516

Clinic – Urgent Care Clinic

0517

Clinic – Family Practice Clinic

0519

Clinic – Other Clinic

0530

Osteopathic Services – General Classification

0610

Magnetic Resonance Technology (MRT) – General Classification

0611

Magnetic Resonance Technology (MRT) – MRI – Brain (Including Brainstem)

0612

Magnetic Resonance Technology (MRT) – MRI – Spinal Cord (Including Spine)

0614

Magnetic Resonance Technology (MRT) – MRI – Other

0615

Magnetic Resonance Technology (MRT) – MRA – Head and Neck

0616

Magnetic Resonance Technology (MRT) – MRA Lower Extremities

0618

Magnetic Resonance Technology (MRT) – MRA – Other

0619

Magnetic Resonance Technology (MRT) – Other MRT

0636

Pharmacy – Extension of 025X – Drugs Requiring Detailed Coding

0730

EKG/ECG (Electrocardiogram) – General Classification

0731

EKG/ECG (Electrocardiogram) – Holter Monitor

0732

EKG/ECG (Electrocardiogram) – Telemetry

0739

EKG/ECG (Electrocardiogram) – Other EKG/ECG

0740

EEG (Electroencephalogram) – General Classification

0749

EEG (Electroencephalogram) – Other EEG

0750

Gastro-Intestinal Services – General Classification

0759

Gastro-Intestinal Services – Other Gastro-Intestinal

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Coding Policies and Guidelines

Revenue Codes

Descriptions

Revenue Codes

Descriptions

0771

Preventive Care Services – Vaccine Administration Miscellaneous Dialysis – Ultrafiltration Miscellaneous Dialysis – Miscellaneous Dialysis - Other

0880

Miscellaneous Dialysis – General Classification Miscellaneous Dialysis – Home Dialysis Aid Visit Behavioral Health Treatment/ Services – General Classification

0901

Behavioral Health Treatment/ Services – Electroshock Treatment

0903

Behavioral Health Treatment/ Services – Play Therapy

0914

Behavioral Health Treatment/ Services – Individual Therapy

0915

Behavioral Health Treatment/ Services – Group Therapy

0916

Behavioral Health Treatment/ Services – Family Therapy

0917

Behavioral Health Treatment/ Services – Biofeedback

0918

Behavioral Health Treatment/ Services – Testing

0920

Other Diagnostic Services – General Classification

0921

Other Diagnostic Services – Peripheral Vascular Lab

0922

Other Diagnostic Services – Electromyelogram

0923

Other Diagnostic Services – Pap Smear

0924

Other Diagnostic Services – Allergy Test

0925

Other Diagnostic Services – Pregnancy Test

0929

Other Diagnostic Services – Other Diagnostic Service

0940

Other Therapeutic Services – General Classification

0943

Other Therapeutic Services – Cardiac Rehabilitation

0881 0889

EPNI Provider Policy and Procedure Manual (11/01/07)

0882 0900

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Coding Policies and Guidelines

Outpatient Facility Fee Billing

Questions are often directed at EPNI regarding reimbursement for specific revenue codes. Codes for treatment and observation rooms (0760, 0761 and 0769) are frequently questioned, as are clinic charge revenue codes (0510-0519). These billing codes are explained below. Treatment Room Facilities should not bill EPNI for a treatment room using UB-92 revenue codes 0760, 0761 and 0769. EPNI considers a treatment room as an overhead expense reimbursed as part of the physician’s professional fee. Therefore, billing facility fees through the 0760, 0761 and 0769 codes duplicates the physician’s professional claim (CMS1500) and will deny as provider liability if submitted on the UB-92 claim. There is one exception to this policy. If Medicare is primary, and EPNI is secondary, we will accept the 0760, 0761 and 0769 revenue codes, and process according to Medicare’s guidelines. Observation Room Observation Care, billed under revenue code 0762, is allowed for admits of less than 24 hours. Claims for observation services for 24 hours or more will be processed as an inpatient claim. Clinic Changes Clinic charges, are considered an overhead expense and are reimbursed as part of the physician’s professional fee. Therefore, billing clinic charges through the 0510-0519, and 0520, 0523, 0526, and 0529 revenue codes duplicate the physician’s professional claim (CMS-1500) and will deny as provider liability if submitted on the UB-92 claim.

Returned Paper Claims

When you submit a paper claim that is missing required information, or the claim does not meet EPNI’s edits, a letter is sent back to you along with a copy of the entire claim. EPNI will send back a copy of only the first page of the claim, along with the letter. Corrections should be made, the claim reprinted on a UB-92 red drop claim form, and returned by mail. If attachments are necessary, they should be submitted with the corrected claim.

Education / Training 0942 and Other Therapeutic Services 0949

Education or training services may be limited by policy or contract, thus we require submission of a HCPCS/CPT or narrative to determine coverage.

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Coding Policies and Guidelines

Lactation Education

For billing purposes, lactation services are considered to be part of the mother’s charges and should not be billed on the newborn’s claim. Submit all claims for lactation education on the 837I or UB-92 claim form using revenue code 0942. These charges must be submitted on the mother’s original maternity/delivery claim and require a narrative description. Claims for lactation services submitted under infant’s name or number will be rejected. If lactation education is necessary after discharge, it can be billed as part of the post-partum visit under the mother’s identification number.

Zero Line and Negative Dollar Charges

Paper claims submitted to EPNI require that all necessary fields be completed with valid data. This includes charges for each line, and the total charge. Claims that contain a $0.00 line charge, a negative (-) total charge will be returned, with the following exceptions: HIPPS revenue codes (Health Insurance Prospective Payment System) 0022, 0023, 0024 Revenue code 018X (Leave of Absence)

Diabetic Education

Diabetic education services should be billed under revenue code 0942. The appropriate HCPCS code must be submitted in FL44. The codes G0108 or G0109 may be submitted only if the program is certified by the National Diabetes Association. Medical Nutrition Therapy may be billed using codes 97802-97804.

Revenue Code 0636

The revenue code 0636, by definition, is for drugs that require detailed coding. Revenue 0636 must always be submitted with a HCPCS code. However, some drugs that would be submitted under this revenue code also require prior authorization. The following drugs require prior authorization. IVIG HCPCS codes J1563, J1564, Q9941, Q9942, Q9943, Q994 Aminolevulinic Acid HCI code J7308 Factor products HCPCS codes J7190, J7191, J7192, J7193, J194, J7195, J7198, J7199, Q0187, Q2022 If a specific HCPCS code is not available, an unlisted code, such as J3490, J7199 or J9999 may be submitted. When using an unlisted code a narrative, NDC and dosage/units supplied are also required in form locator 84.

Revenue Codes 0500 and 0509

The revenue codes 0500 and 0509 are for outpatient services, specifically for charges for services rendered to an outpatient who is admitted as an inpatient before midnight the day following the date of service. It should not be used as a clinic or a room charge.

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Coding Policies and Guidelines

Behavioral Health Revenue Codes

Refer to the Behavioral Health for UB-Billers section of this chapter for guidelines relating to behavioral health services, including mental health and chemical dependency services.

Transfer of Care / Transfer Case

Transfer of care is when a patient is discharged from one physician to another or from one facility to another. Moving a patient in the hospital from one unit to another does not constitute a transfer. Patient status codes are a required field (Form Locator 22) on the institutional claim (837I or UB-92). This code indicates the patient’s status as of the “Through” date of the billing period. It is important to note that the patient status code indicates a destination and not a level or type of care received. When a patient is transferred/discharged to another facility, patient status may affect reimbursement. All patient status codes are accepted but not all will result in a transfer case classification. The following patient status codes are used by EPNI to classify a transfer case.

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Patient Status

Definition

02

Discharged/Transferred to Another Short-Term General Hospital for Inpatient Care in anticipation of covered skilled care

05

Discharged/Transferred to Another Type of Institution not defined elsewhere in this code list

43

Discharged/Transferred to a Federal Hospital

65

Discharged/Transferred to a Psychiatric Hospital or Psychiatric Distinct Part Unit of a Hospital

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Laboratory Services Overview

EPNI does not allow providers to bill the health plan for laboratory services or imaging studies that are not ordered by a physician or other qualified practitioner. It is the belief of EPNI that in addition to receiving lab or radiology results, the patient also needs interpretation of the tests, recommend for future care, and a course of action that only a physician or other qualified practitioner can deliver. In addition, tests must be medically necessary in order to be eligible for coverage, as determined by a medical professional. As a result, we will only issue payment for services that are coordinated by a physician or other qualified practitioner. A qualified practitioner is a practitioner recognized as an eligible provider by EPNI and practices within the scope of his or her licensure. Specific licensing questions should be directed to your specialty’s licensing board. Laboratory and pathology procedures should be submitted using the HCPCS level I or II code that best describes the service. CPT codes 80048 - 89356 encompass level I codes for the majority of laboratory and pathology procedures. The services listed in the pathology and laboratory section of the CPT manual may be provided by the pathologist or alternatively by technologists who are under the supervision of the pathologist or practitioner. The guidelines outlined below should be adhered to when submitting laboratory services to EPNI.

Organ or Disease-Oriented Panels

The tests listed under each panel (80048 - 80076) identify the defined components of that panel and all tests listed must be performed in order to bill for that panel. Tests performed in addition to those specifically indicated for a particular panel can be billed separately in addition to the panel code.

Lyme Disease Titer

Laboratory testing for Lyme disease titer should be submitted using code 86618.

Office Visits

A level-of-service office visit may be submitted in addition to laboratory tests only when additional separately identifiable services are provided. Obtaining a specimen for a streptococcus test, for example, and relaying the results to the patient are included in the reimbursement for the test itself and may not be billed separately. A minimal level of service may be submitted if a brief history and examination is performed in addition to the laboratory test.

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Coding Policies and Guidelines

Standing Orders

Generally, we do not cover laboratory tests performed because of standing orders on file for certain patients. One example of this is a standing order for routine screening tests when the patient has no clinical symptoms or is not taking medications. Laboratory services based on standing orders are covered only if you can show the medical necessity of the services through your medical records or if the patient has routine screening benefits and the tests are coded with an ICD-9CM as routine services.

Venipunctures and Lab Handling

The following codes apply to venipunctures and lab handling: Code

Description

36415

Collection of venous blood by venipuncture

36416

Collection of capillary blood speciman (eg., finger, heel, ear stick)

99000

Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory

Code 36415 is submitted when the provider performs a venipuncture service to collect a blood specimen(s). As opposed to a venipuncture, a finger/heel/ear stick (36416) is performed in order to obtain a small amount of blood for a laboratory test. These codes should be billed only once regardless of the number of tests performed from that specimen. Code 99000 is an adjunct code submitted to indicate handling and/or conveyance of a specimen for transfer from the physician’s office to a laboratory. This code is never used for lab services performed completely within the physician’s office. If the lab is picking up the specimen, there is no handling cost incurred and the clinic should not bill 99000. The test that is being done from the specimen must be indicated on the claim. This can be indicated by submission of the lab test code with the -90 modifier (if you are billing for the test) or narrative indicating the test code and/or name (done if lab will bill for test instead of clinic). If this information is not present on the claim, the charge will be denied if billed in addition to a venipuncture code 36415. For lab tests requiring routine venipuncture and subsequently sent to an outside lab, the physician office may bill either the venipuncture service or the handling charge, but not both (i.e., 36415 or 99000).

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Coding Policies and Guidelines

Papanicolaou Smears

The procedure codes, diagnosis codes, specimen collection codes, and handling fee, which apply to papanicolaou smears are detailed below: Procedure Codes Codes 88142 - 88154, 88164 - 88167, 88174 - 88175, P3000, P3001, G0123 - G0124, and G0141 - G0148 are for cytopathology screening of cervical or vaginal smears. Submit the appropriate code to reflect the service provided. Procedure code 88141 and 88155 are used to report physician interpretation of a cervical or vaginal specimen and should be listed in addition to the screening code chosen when the additional services are provided. Diagnosis Codes Routine cervical papanicolaou smears should be reported with appropriate ICD-9-CM diagnosis codes: Use this code…

In this situation…

V72.32

As part of a general gynecological examination

V76.2

Without a general gynecological examination

Pap smears performed due to illness, specific related symptoms, or relevant personal or family history should be reported with the most specific ICD-9-CM code available. Specimen Collection Codes The specimen collection codes for a pap smear (Q0091) may be billed in addition to the pap smear code. If an E/M is done at the same time, the specimen collection is included in the level of service reported for the examination and evaluation and should not be billed separately. The collection code will be denied as incidental to the E/M if billed. Handling Fee Code 99000 may be submitted for the cost incurred by the clinic for the handling and/or conveyance of the pap smear for transfer from the physician’s office to an outside laboratory. This code is never submitted for cytopathology screening performed within the physician’s office. Modifier -90 (reference outside laboratory) must also be submitted when the screening is performed by a party other than the treating or reporting physician. This modifier would be submitted with the pap smear code (e.g., 88150-90). Narrative indicating the test being done may be submitted in lieu of the procedure code and modifier if the lab will be billing EPNI for the test instead of the clinic.

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Coding Policies and Guidelines

Pregnancy Tests

Pregnancy tests should be coded as follows: Code

Description

84702

Quantitative, serum

84703

Qualitative, serum

81025

Urine

Laboratory records must document the method (quantitative or qualitative) of testing done and the type of specimen used (serum or urine). Purchased Services/Outside Lab

The entity that performs a test should be the one to bill for that test. However, a provider may, under arrangement with another provider, bill a service that is purchased from that other provider. For example, a clinic may bill for a pap smear that is sent to an independent lab for analysis, or for an X-ray that is done at a hospital because the clinic did not have the appropriate equipment. It is important to remember that only one provider may bill for the service. Claims for purchased services should be submitted on the CMS-1500 as follows: •

Item 24B (place of service)–enter the place of service code where the service was done by the performing provider.



Item 24D (procedure/modifier)–enter the procedure code of the test and the modifier 90.



Item 24K (provider number)–enter the EPNI individual provider number of the ordering physician.



Item 32 (where rendered)–enter the name and address of the performing provider. Please see the example that follows on the next page. Stat Lab Charges

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Charges for stat laboratory requests (S3600 and S3601) are not allowed. If submitted, they will deny as provider liability.

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Example 24.

TO MM MM

A DATES OF SERVICE FROM DD DD

YY

B

C

Place of Svc

Type of Svc

YY

D PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER

05

02

00 06

1 1

99212

05

02

00 06

1 1

88150

05

02

00 06

1 1

05

02

00 06

05

02

00 06

25. FEDERAL TAX I.D. NUMBER

E DIAG NOSI S

G DAYS OR UNITS

H EPSDT Family Plan

I EMG

K

J COB

RESERVED FOR LOCAL USE

$CHA RGES

CODE

12

30.00

1

12345AB

2

10.00

1

12345AB

99000

2

10.00

1

12345AB

1 1

80050

1

50.00

1

12345AB

1 1

36415

1

5.00

1

12345AB

SSN EIN

90

26. PATIENT’S ACCOUNT NO.

27. ACCEPT ASSIGNMENT? (For govt claims, see back) Yes

31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) SIGNED

F

No

32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED (If other than home or Office)

28. TOTAL CHARGE

29. AMOUNT PAID

30. BALANCE DUE

$ 105.00 $ $ 33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE & PHONE

XYZ Lab 123 Main St. St. Paul, MN

DATE

EPNI Provider Policy and Procedure Manual (11/01/07)

PIN#

GRP#

54321BA

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Coding Policies and Guidelines

Maternity/Obstetrical Services Global Obstetrical Care

EPNI accepts the global obstetric care codes 59400, 59510, 59610 and 59618, which include antepartum care, delivery, and postpartum care.

Antepartum Care

Antepartum care includes the subsequent history and physical examinations, recording of weight, height, blood pressures, fetal heart tones, chemical urinalysis, maternity counseling, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery. Any other visits or services within this time period should be coded separately. The provider may choose to bill globally, visit-by-visit, or to use codes 59425 or 59426 for antepartum care. The date of service submitted for antepartum care should be the date of delivery. If antepartum care is not performed for the entire period, code each E/M service separately.

Delivery

Delivery includes admission history and physical, management of uncomplicated labor, and delivery (with or without episiotomy or forceps). Vaginal delivery only should be submitted with procedure code 59409 or 59612 (VBAC). Cesarean delivery only should be submitted with code 59514 or 59620 (VBAC). Multiple births are coded as any other single birth delivery.

Subsequent VBACs

Vaginal births after a Cesarean should be coded using CPT codes 59618, 59620, 59622 regardless if the vaginal birth is the first or subsequent following the Cesarean.

Postpartum Care

Postpartum care includes hospital visits and one to two office visits for usual, uncomplicated postpartum follow-up, urinalysis, and hemoglobins. The global codes (59400, 59510, 59610, or 59618) and delivery codes (59410, 59515, 59614, or 59622) include postpartum care. Submit the postpartum care package (separate procedure) code 59430 only when another provider does the delivery. Submit this code one time with one unit of service. The date of service should be the delivery date.

Intitial Visit and Itemized Services

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The initial visit may be billed separately with an appropriate E/M code. An obstetrical profile (80055) and any laboratory procedure codes (other than urinalysis) should also be submitted separately.

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Coding Policies and Guidelines

Submission Options and Coding Alternatives

The following submission options are available: •

The global codes 59400, 59510, 59610, and 59618 may be submitted with one charge. For contracts subject to Minnesota legislative mandated benefits and others that waive deductibles, copays, or coinsurance on antepartum care, EPNI will process these services separately from the delivery and postpartum care. The global maternity charge will be split based on RBRVS (Resource Based Relative Value System) work values. The provider Statement of Provider Claims Paid will report procedure code 59426 with a payment at 100 percent of the allowance and a delivery code 59410, 59515, 59614, or 59622 with a payment determined according to the contract’s benefits. For contracts that are not subject to Minnesota legislative mandated benefits and/or where antepartum care is subject to regular contract benefits, the global codes 59400, 59510, 59610 and 59618 will process with the charge and code as submitted.



Providers may submit the appropriate E&M codes for each antepartum visit individually with the delivery code 59410, 59515, 59614, or 59622 as an alternative to submitting the global maternity codes 59400, 59510, 59610, or 59618.

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Coding Policies and Guidelines

Pre-term Birth Prevention Services

EPNI will reimburse for certain pre-term birth prevention services when the patient’s contract covers these services. Code

Narrative

Billing

H1000

Prenatal Care, at-risk assessment

Done twice for all patients; once at initial OB visit, and once at 24-28 weeks.

[use the Pregnancy Assessment Form, DHS 3294 (1/97) to complete assessment or the American College of Obstetrics and Gynecology (ACOG) pregnancy assessment form] H1001

Prenatal care, at-risk enhanced service; antepartum management

If the patient is identified via the assessment as high risk. This code may be billed once.

H1003

Prenatal care, at-risk enhanced services; education

If the patient is identified via the assessment as high risk. This code may be billed once.

The services represented by the prenatal care at-risk codes H0002, H0004 and H0005 are already included in the provider’s normal prenatal care and not separately reimbursed.

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Coding Policies and Guidelines

Two Physicians Involved in Care / Same Tax ID

New Born Care

There are situations where the primary physician provides prenatal and postnatal care but does not deliver the baby. The most common situation noted is when a surgeon from the same medical group as the primary physician delivers the baby via C-section. Many times the primary physician is also acting as an assistant-at-surgery. In the case where both physicians are in the same practice (same tax ID), EPNI is recommending the following submission guides: •

Same tax-ID – clinic provider number reported for the claim



Surgeon – bills the global C-section (59510); individual provider number of the surgeon reported on the service line



Primary physician – bills the C-section assist (59514-80); individual provider number of the physician reported on the service line



Provider production and disbursement of reimbursement is an internal process. It is the clinic’s responsibility to assure the providers participating in the patient’s care are appropriately paid.

Submit procedure code 99431 or 99433 and diagnosis code V20.1 to bill for routine services in the hospital for well newborns. If the newborn is ill, submit codes 99221 - 99233 for hospital visits. For discharge day management, submit 99238. Pediatric standby should be submitted with code 99436. Standby services are requested by another physician. The physician may not be providing care or services to other patients during this period. Standby, 99436, includes the initial stabilization of the newborn, thus services may be denied as incidental to 99436. When billing a newborn circumcision (54150 or 54160) on the day of discharge, add modifier –25 to code 99238. A diagnosis indicating the circumcision (V50.2) must be linked as the primary diagnosis to the circumcision procedure (54150 or 54160). For neonatal critical care or intensive (non-critical) low birth-weight services see codes 99295-99300.

Complications or Unusual Circumstances

Submit modifier –22 with specific documentation to justify additional reimbursement along with the delivery or operative report for complications during delivery. Unusual circumstances resulting in extensive antepartum or postpartum care should be coded separately. A narrative/operative report should be sent with the claim.

Exceptions

There may be some contracts that do not follow the maternity/obstetrical guidelines. For contracts that require a copayment per visit, EPNI will request the number of antepartum visits if the global maternity codes 59400, 59510, 59610, or 59618 or the antepartum codes 59425 or 59426 are submitted.

Lactation Education

If done as part of the delivery, serivce should be billed on the UB-92, on the mother’s claim. If this is done after discharge, it should be incorporated into the E/M for postpartum care.

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Coding Policies and Guidelines

Collection of umbilical cord blood

Collection of umbilical cord blood may be done at the time of a delivery either for donation to organizations such as the Red Cross or per the patient’s request to bank the blood for possible future need. Regardless of intent, cord blood collection is not a reimbursable service. If billing for the collection per the request of the patient, the patient must be notified that this charge will be their liability. The charge should be submitted using an unlisted procedure code, such as 59899, with a narrative description and will be denied as member liability.

Obstetrical Care Coding Alternatives

Different options are available for billing Obstetrical care. Listed below are some of the variations. Generally, global billing is preferred. Global Billing Global Billing includes the antepartum care, delivery, and post-partum care. •

59400 -Vaginal delivery



59510 - C-Section



59610 - VBAC

• 59618 - C-Section after VBAC Antepartum Care Only •

59425 - 4 to 6 Visits



59426 - 7 Visits

• E/M - Evaluation and Management codes billed for each visit. Delivery Only •

59409 - Vaginal delivery



59514 - C-Section



59612 - VBAC

• 59620 - C-Section after VBAC Delivery and Post-partum Only •

59410 - Vaginal delivery



59514 - C-Section



59612 - VBAC

• 59620 - C-Section after VBAC Post-partum Care Only

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59430



E/M - Evaluation and Management codes billed for each visit

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Coding Policies and Guidelines

Medical Emergency Introduction

Some members have full coverage for an outpatient medical emergency, which we generally define as the sudden and unexpected onset of a condition requiring immediate medical attention. To receive full benefits, the member must seek care within specified time limits, usually within 24 to 72 hours of the onset of acute symptoms. Accidental injury is not included in the medical emergency benefits. Many coverage plans have separate first-aid or accident benefits.

Criteria for Medical Emergencies

Use the guidelines below to determine if you should submit a claim as a medical emergency. Medical emergency charges should be submitted with the date and time the emergency occurred. If the emergency is related to pregnancy, also indicate that the charges were for emergency services. •

Were the symptoms sudden, severe, and life threatening?



Did the condition require immediate medical (not surgical) attention?



Did the patient see a doctor no later than 72 hours after the problem began?



Did the time or date of the visit indicate it was an emergency?



The following situations generally would not indicate a medical emergency: •

scheduled surgeries or diagnostic procedures such as colon or IVP X rays



follow-up visits for further injections, such as antibiotics



suture removal



urgent but non-life threatening situations seen during regular office hours

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Coding Policies and Guidelines

Emergency Department Services

Emergency department services (codes 99281 - 99285) are submitted by the physician assigned to the emergency room. Assignment is defined as a formal relationship between the physician and the hospital whereby the physician is solely responsible for seeing patients in the emergency room during a specified time period. Physicians who specialize in emergency medicine and use the emergency department as their place of business are generally considered assigned to the emergency room. Other physicians who have arrangements with the hospital to be ‘‘on call’’ to see patients in the emergency department during specific hours may also be considered assigned to the emergency department while seeing patients there. In this case, the physician’s primary responsibility is to the emergency department and the arrangement is between the physician and the hospital, as opposed to an agreement between physicians to cover one another’s patients over the weekend, etc. Any physician seeing a patient in the emergency department to which he/she is not assigned must submit level-of-service office calls according to CPT guidelines.

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Coding Policies and Guidelines

Medical Services Allergy Testing

Allergy testing (95004 - 95078) refers to the evaluation of selective cutaneous and mucous membrane tests to assist in the determination of appropriate immunotherapy. Submit the number of services in accordance with the CPT description. Allergy tests and their interpretation are a single entity; do not submit separately. An office visit with the modifier –25 may be submitted in addition to allergy testing only when additional identifiable services are provided.

Allergy Immunotherapy

Code 95115 should be submitted with one unit of service when one injection is given. Code 95117 should be submitted with one unit of service when multiple injections are given (regardless of the number of injections). Codes 95120 - 95180 should be submitted with the number of services in accordance with the CPT description. Codes 95115 and 95117 include professional services necessary for allergen immunotherapy. A level-of-service office visit with modifier –25 may be submitted in addition to an allergy injection only when additional identifiable services are provided.

Anticoagulation Clinic – S9401

EPNI will accept code S9401 for scheduled visits to an anticoagulation clinic (S9401- anticoagulation clinic, inclusive of all services except laboratory tests, per session). This service will be treated and reimbursed the same as the evaluation and management (E/M) code 99211. Code S9401 will be subject to an office call copay. Code S9401 will not be allowed in addition to an E/M, unless the E/M represents a significant separately identifiable service. If so, the E/M should be appended with the –25 modifier and the appropriate diagnosis linked. Additionally, some contracts may not allow the service and/or code. For example, ‘S’ codes are not accepted for our Medicare products.

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Coding Policies and Guidelines

Blood, Occult, Feces Screening

Codes 82270 (blood, occult; feces, consecutive collected specimens with single determination) or G0107 (colorectal cancer screening; fecaloccult test, 1-3 simultaneous determinations) are to be submitted with one unit of service. These screenings typically test three specimens, but units of service should reflect the series, not number of specimens. The date of service submitted should be the date the test card is returned to the clinic. Codes 82271 and 82272 are also limited to one unit of service.

Cardiovascular Stress Test

Code 93015 is the global code for a cardiovascular stress test, which includes both the professional component (interpretation, report, and physician monitoring) and the technical component (tracing). Submit code 93016 for physician supervision only, without interpretation and report. Submit code 93017 for the technical component only. Submit code 93018 for the professional component only, which includes interpretation report and physician monitoring. Submit prolonged services (codes 99354 - 99357) only if acute intervention is required beyond routine physician monitoring during the test. The monitoring of a patient by a physician during a cardiovascular stress test is considered an integral part of the professional component of the test and not reimbursable as a separate service.

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Coding Policies and Guidelines

Chemotherapy Administration

Chemotherapy administration codes are used for services of a physician or qualified assistant employed by and under the supervision of a physician. The preparation of the chemotherapy agent(s) and related supplies are included in the code for administration of the agent(s). Use the CPT codes below: •

Codes 96401 - 96542 and 96549 cover chemotherapy administration. Specific Level II HCPCS codes should be used to identify the chemotherapy drug(s) utilized.



Codes J8999 or J9999 should be submitted only if no HCPCS code exists. Specify the drug, dosage and NDC code. When billing a dosage higher than that listed in the HCPCS Manual, use the units field to indicate a higher dosage. Example: If the common dosage is 200 mg. but 490 mg. was administered, submit three units of service (round up the dosage). Chemotherapy codes may be independent of the patient’s office visit. An office visit with modifier –25 may be submitted in addition to or subsequent to chemotherapy administration only when additional identifiable services are provided. Professional charges and codes for chemotherapy administration should not be submitted when services are administered by hospital or home health agency personnel. Services of an Oncologist during a postoperative period are rarely “routine postoperative care.” To avoid unnecessary denials, we suggest diagnosis code V58.0 for services related to radiotherapy, and code V58.11 for services related to chemotherapy. Chemical Dependency Assessment

Often providers perform chemical dependency assessments when a court of law orders an evaluation or a family member requests one. Under circumstances like these, providers may submit the following diagnosis code: V79.1, screening for alcoholism use when an alcohol or chemical dependency assessment or evaluation reveals no illness, abuse, or dependency. Services billed with a V79.1 code will apply to the member’s chemical dependency benefit limit.

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Coding Policies and Guidelines

Office or Other Outpatient and initial Inpatient Consultations

Consultation codes 99241 - 99255 include a physician’s services requested by another physician or other appropriate source, for further evaluation or management of the patient. They are designated according to place of service and apply to new or established patients. The consultant must document the consult request and the reason for the consult in the patient record and must also appear in the requesting practitioner’s plan of care. The consult request is typically in writing but it may be verbal so long as both the requestor and the consultant document the conversation in the patient medical record. The consultant must provide a written report to the requesting practitioner. A consultation may include the diagnostic tests needed to provide an opinion or advice. If the physician consultant introduces further therapeutic services, documentation must show that the consultant recommended a course of action at the request of the attending physician. Any subsequent services and continuing care rendered by the consultant cease to be a consultation and become established patient care services. Initial or subsequent services rendered by a consultant may make an initial consultation invalid if records show that patient care was immediately assumed as in a referral. A referral is the transfer of total or specific care of a patient from one physician to another and does not constitute a consultation. Initial evaluation and subsequent service for a referral are designated as levelof-service office visits. Second or confirmatory consults are coded as the appropriate E/M for the setting and type of service.

Day Treatment

Submit one unit of service per day for day treatment programs for behavioral health diagnoses (H2012). Include the actual time of therapy on the claim also.

Diabetic Education

G0108 or G0109 may be submitted for diabetic education only if the program is certified by the National Diabetes Association.

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Coding Policies and Guidelines

E-Care Visits

Effective July 1, 2006 coverage will be extended to E-Care visits. Description: E-Care is a term used to describe limited healthcare services provided over the Internet. E-Care may also be referred to as online medical evaluations, online visits, E-visits, E-consultations, or virtual visit. E-Care is a member initiated online evaluation and management (E/M) visit provided remotely to patients via the Internet. This visit is used to address non-urgent medical symptoms including medication and prescription refills or renewals and review of lab and test results. E-Care visits are not normally ‘real-time’. The provider responds to the patient’s issue within a prescribed time limit. Coverage Criteria: Services obtained from the rendering practitioner by means of online email communication via the Internet may be eligible for coverage for non-urgent care when ALL of the following criteria are met: •

The individual initiating the E-Care visit is an established patient of the provider and has previously received face-to-face treatment



In the judgment of the practitioner, the E-Care visit is medically necessary and involved sufficient resource use, time and complexity to warrant separate recognition as a unique event



Written documentation related to the service must be included in the patient’s medical record and should include the following:



Medical information exchange, assessment, and plan of treatment/care (e.g., symptoms, counseling)



Services must be billed under the rendering practitioner’s provider number Qualifying Criteria: •

Qualifying criteria for reimbursement of online services are as follows:



Practitioner responds within on business day AND one or more of the following:



Patient describes new symptoms and is requesting intervention and/or advice from practitioner to treat new symptoms



Patient describes ongoing symptoms from a recent acute problem or chronic health problem and is requesting intervention and/or advice from practitioner to treat ongoing acute problem or chronic health problem

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Coding Policies and Guidelines

E-Care Visits (continued)



Evidence that practitioner is giving substantive medical advice, revising treatment plan, prescribing/revising medication, recommending additional testing, and/or providing self care/ patient education information for new and/or chronic health problem



Evidence that practitioner is making a new diagnosis and is prescribing new treatment



Patient requesting interpretation of lab and/or test results with evidence that practitioner is providing substantive explanation and recommendations to modify treatment plan, revising medications, etc.



Evidence that practitioner is providing extended personal patient counseling that is changing the course of treatment and impacting the potential health outcome Billing/Coding Information: CODING: 0074T- Online evaluation & management service, per encounter, provided by a physician, using the Internet or similar electronic communications network, in response to a patient’s request; established patient CLAIM FORMAT: Billed on the professional claim format- 837P or CMS-1500. UNITS: One (1). Reimbursement for online medical evaluations is limited to one per day. PROVIDER NUMBER: An individual provider number is required. This service is limited to MD, PA, NP, and CNS-Medical practitioners. EDITS: An E-Care visit, 0074T, will not be allowed on the same day as another E/M visit. Code 0074T will deny as mutually exclusive to these other services. An E-Care visit will not be allowed as a routine followup to surgical care. Code 0074T will deny as part of the post-op period in this case. Not Covered: E-Care services are not covered when provided for the following: NOTE: The following is not an all-inclusive list. E-Care visits may be denied for reasons other than noted below.

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Provider initiated email



Appointment scheduling



Refilling or renewing existing prescriptions without substantial change in clinical situation



Scheduling diagnostic tests

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

E-Care Visits (continued)



Reporting normal test results



Updating patient information



Providing educational materials



Brief follow-up of a medical procedure to confirm stability of the patient’s condition without indication of complication or new condition including, but not limited to, routine global surgical follow-up



Brief discussion to confirm stability of the patient’s chronic condition without change in current treatment



When information is exchanged and the patient is subsequently asked to come in for an office visit



A service that would similarly not be charged for in a regular office visit



Reminders of scheduled office visits



Requests for a referral



Consultative message exchanges with an individual who is seen in the provider’s office immediately afterward



Clarification of simple instructions

Program Exceptions: Benefits are determined by the individual member contract language in effect at the time services were rendered. Check for patient benefits before services are rendered. The following groups do not provide for coverage of E-Care visits: •

Medicare Supplements



Some self-insured groups

G0101

G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) is an accepted code. However, G0101 will deny if billed in conjunction with an evaluation and management service.

Hospital Discharge

Hospital discharge services, 99238 or 99239, can only be billed when services are performed on the actual date the patient left the hospital. A discharge is not billable for a patient’s death.

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Coding Policies and Guidelines

Immunizations

Immunizations are injections separately identified in CPT (codes 90476 - 90749). Submit the code which describes the immunization administered. It is inappropriate to code each component of a combination vaccine separately. The administration code(s) 90465 90474 must be reported in addition to the vaccine and toxoid code(s) 90476 - 90749. Serum from Department of Human Services If receiving serum from the Department of Human Services (DHS) for child immunizations, the provider should bill EPNI for the administration charge only. Providers should submit the immunization code with an –SL modifier to indicate the serum was received from DHS. The administration codes 90465 - 90474 must be reported in addition to the vaccine.

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Coding Policies and Guidelines

Injections

Therapeutic or diagnostic injections may be subcutaneous, intramuscular, intra-arterial, or intravenous. These codes do not include injections for allergen immunotherapy or immunizations. Injectable Drugs Submit the HCPCS Level II code that best describes the injection given in terms of the drug and dosage. Codes for injections include the charge for the drug only. When the dosage given is greater than that listed, use the units field to specify the appropriate number of units according to the HCPCS manual. Example: The patient received 7 mg. of haloperiodol. The common dosage for haloperiodol (J1630) is “up to 5 mg;” 2 UOS should be submitted. The dosage is rounded up to the next unit. The administration charge should be submitted separately. Codes 90779 and J3490 are for unlisted therapeutic injections. The drug name and dosage must be included on each claim, as well as the National Drug Code (NDC) number. Report the drug name, dosage and NDC starting in box 24D of the CMS-1500 or narrative file for electronic claims. Administration Choose the appropriate administration code for the route of administration 90765 - 90779. It is inappropriate to bill an intravenous injection in addition to an intravenous infusion on the same date of service when an injection is administered through the same line as the infusion. The provider may submit the infusion or the injection, but not both. Units of service reflect the number of injections given. If an office visit is submitted on the same day of the subcutaneous or intramuscular injection (90772 - 90775), the administration would be included in the E/M and will deny if submitted separately. Surgical Injections Performed as stand-alone procedures, the injections should be submitted with the appropriate CPT code for the administration of the injection. In addition, submit the HCPCS Level II code for the drug. If no specific HCPCS code exists for the drug, submit J3490 with a narrative indicating the drug name, dosage and NDC. When surgical injections are performed as part of a surgical procedure, submit the HCPCS Level II code for the drug. The administration of the injection is considered part of the surgical procedure itself and should not be submitted separately.

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Coding Policies and Guidelines

Infusion Therapy

Infusion therapy as described below excludes chemotherapy. For prolonged intravenous infusions performed in the office or clinic, submit CPT codes 90765 - 90768 for the administration and the appropriate HCPCS Level II code for the drug. The CPT code includes the administration and supplies. Submit code J3490 with a narrative indicating the drug name, dosage and NDC if a specific HCPCS code for the drug does not exist. When billing a higher dosage than listed in the HCPCS Manual, use the units field to indicate the higher dosage. Codes 90765 - 90768 typically require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. Professional charges for infusion therapy should not be submitted when the service is administered by hospital or home health agency personnel. Do not use these codes to indicate intradermal, subcutaneous, intramuscular, routine IV injections, or chemotherapy.

Interpreter Services

Interpreter services are not separately billable or reimbursed for most members. Use provider web self-service or call Provider Services for benefit information.

Transfusion – Blood and Blood Products

Transfusion of blood and/or blood products is submitted with code 36430 when administered by a physician or qualified assistant employed by and under the supervision of a physician. Preparation of blood and blood products is included in the service for administration of the agent. Professional charges/codes for the transfusion of blood or blood products should not be submitted when administered by hospital or home health agency personnel. Bill the blood separately with the appropriate HCPCS code.

Locum Tenens

A substitute physician who takes over another physician’s practice when that regular physician is absent for specific reasons is generally referred to as a “locum tenens” physician. The regular physician may submit the services rendered by the locum tenens physician under the regular physicians’ provider number. The modifier Q6 should be appended to these services.

Natural Family Planning

The natural family planning (NFP) code H1010 is restricted only to those participating non-clinic providers contracted as a NFP provider. Clinics/medical practitioners providing NFP would bill their services using the appropriate evaluation and management code.

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Coding Policies and Guidelines

Nicotine Dependence

EPNI covers services for the treatment of tobacco dependence. However, coverage for these services depends on the type of provider submitting the claim, the procedure and diagnosis codes submitted, and the patient’s contract with EPNI. Due to these many variables, exact payment can not be determined until we receive the claims for processing. Diagnosis Codes If the primary reason for the outpatient visit to the clinician is tobacco use, claims should be submitted with one of the following diagnosis codes: •

305.1 tobacco use disorder

• V15.82 history of tobacco use Procedure Codes Clinicians should submit the HCPCS code that reflects the service furnished. Claims may process differently depending on the code submitted. The difference reflects the application of the member’s contract benefits. Evaluation and Management (E/M) codes 99201 - 99215: Claims submitted using these problem-related visit codes will process according to the illness portion of the patient’s contract. E/M codes 99241 - 99245: Claims submitted using these preventive consultation codes will also process according to the illness portion of the patient’s contract when submitted with a tobacco diagnosis. E/M codes 99401 - 99404: Claims submitted using these counseling visit codes will process according to the illness portion of the patient’s contract. Codes G0375 and G0376: Claims submitted using these preventive counseling visit codes will process according to the illness portion of the patient’s contract. Code S9453 for stop-smoking classes is generally not an eligible service under the patient’s contract. E/M codes 99384 - 99387 and 99394 - 99397: These comprehensive preventive medicine services include counseling/anticipatory guidance/risk factor reduction interventions. Tobacco cessation counseling is part of a comprehensive preventative medicine evaluation. Therefore it is not separately reportable under these codes. Psychiatric codes 90804 - 90862: Claims submitted using these codes will process according to the substance abuse portion of the patient’s contract.

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Coding Policies and Guidelines

Nicotine Dependence (continued)

Group counseling codes 99411 - 99412 will process according to the illness portion of the patient’s contract when submitted with a tobacco diagnosis. For questions regarding “incident to” services please refer to Chapter 6 of this manual.

Revenue Codes Used by Facilities 0944 or 0945

Facilities such as hospitals, skilled nursing facilities, and residential treatment centers, must bill for tobacco use under revenue codes 0944 (drug rehabilitation) or 0945 (alcohol rehabilitation). Claims submitted using these codes will process according to the substance abuse portion of the patient’s contract.

Eligibility to Bill for Specific Procedures

Standard guidelines regarding provider eligibility apply to procedures submitted with a tobacco diagnosis. Provider eligibility depends on the provider’s scope of practice and the type of procedure being billed. For example, consultation codes are generally only allowed when performed by a MD; however, evaluation and management codes may be eligible if billed by a qualified practitioner such as a Nurse Practitioner, or Physician Assistant. Some procedure codes specific to mental health and chemical dependency may have to be performed by a qualified mental health provider.

Coverage for Tobacco Treatment Medications

All fully insured EPNI plans with drug coverage cover stop-smoking medications. The same copayments and deductibles apply. With a physician’s prescription these patients are eligible for Zyban® and/or any FDA-approved nicotine replacement therapy drug (patch, gum, lozenge, inhaler, and nasal spray). Note: In order to trigger this benefit, the patient does need a physician’s prescription even if the medication is available over the counter. Each self-insured group account chooses whether or not if will cover prescription and/or over-the-counter stop-smoking aids. Thus coverage varies greatly among self-insured groups. Your patients who have EPNI coverage through a self-insured group should call the customer service number on the back of their ID card to determine if they have coverage for tobacco treatment medications and what restrictions might apply. If you have questions you may contact EPNI Provider Services.

New and Established Patients

A new patient is one who has not received any professional services from the provider or another provider of the same specialty who belongs to the same group practice within the past three years. An established patient is one who has received services from the provider or another provider of the same specialty who belongs to the same group practice, within the past three years.

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Coding Policies and Guidelines

Oral Medication

When submitting oral drugs for your EPNI patients, use the procedure codes in your HCPCS manual. HCPCS includes many codes for oral medications and injections which are commonly dispensed in physicians’ offices. Use J8499 (prescription drug, oral, nonchemotherapeutic, NOS) only in limited situations such as after-hours emergency visits, house calls, or in rural areas where access to a community pharmacy is limited. Drug name, dosage, and NDC must be included on each claim. Benefits cannot be extended for drug samples provided by pharmaceutical companies.

Non-Physician Healthcare Practitioners

If the service is rendered by a non-physician healthcare practitioner that we credential, and/or verify licensure and are issued individual provider numbers, we expect that practitioner to submit the services under the individual provider number that EPNI issued to him or her. Some practitioners who are not credentialed or issued individual provider number (such as LPN, RN, dietician), work under the supervision of a physician. The services must be submitted under the supervising physician’s provider number. The -U7 modifier must be submitted with the procedure to indicate these services. This includes those clinics with a pharmacist on staff. Services would be billed under the supervising MD with the -U7 modifier.

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Coding Policies and Guidelines

Practitioners Credentialed by EPNI with an Individual Provider Number

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Listed below are practitioners that are credentialed by EPNI and issued an individual provider number: •

Certified Ind. Clinical Social Worker (CICSW)



Certified Marriage and Family Therapist (CMFT)



Certified Nurse Midwife (CNM)



Certified Professional Counselor (CPC)



Chiropractor (DC)



Dentist (DDS, DMD)



Licensed Certified Social Worker (LCSW)



Licensed Ind. Clinical Social Worker (LICSW)



Licensed Ind. Social Worker (LISW)



Licensed Marriage & Family Therapist (LMFT)



Licensed Prof. Clinical Counselor (LPCC)



Optometrist (OD)



Physician Assistant (PA)



Physician (MD, DO)



Podiatrist (DPM)



Psychiatric Mental Health Nurse Practitioner (PMHNP)



Psychologist (PhD., MA, PsyD., MS, EDD)



Registered Nurse Clinical Specialist (CNS)



Registered Nurse Practitioner (NP)

EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Practitioners Not Credentialed by EPNI with an Individual Provider Number

Listed below are practitioners that are NOT credentialed by EPNI but are issued an individual provider number: Note: Although the following practitioner types do not go through the credentialing process, they do require an individual provider number for claims submission. •

Audiologist



Certified Registered Nurse Anesthetist (CRNA)



Licensed Assoc. Counselor (LAC)



Licensed Assoc. Marriage & Family Therapist (LAMFT)



Licensed Psychological Practitioner (LPP)



Occupational Therapist (OT)



Physician Therapist (PT)



Registered Nurse First Assist (RNFA)



Resident



Social Worker (Levels: LISW, LGSW, LSW, LMSW, CSW, LSW, LMSW, CISW, CASW)



Speech and Language Therapist

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Coding Policies and Guidelines

Preventive Medicine

Routine examinations for adults and children should be submitted with CPT codes 99381 - 99397, according to the age of the patient. The routine nature of the examination should also be indicated by the ICD9-CM code submitted (usually a V-code). Illness and injury-related visits, should be submitted with the office or outpatient evaluation and management codes 99201 - 99215 with the appropriate ICD-9-CM code indicating the illness, injury, symptom, or complaint. The ICD-9-CM code indicates the purpose of performing the examination. Examinations performed in the absence of complaints should be billed as preventive medicine to be compatible with the ICD9-CM code submitted. Providers can bill both an E&M code and a preventive medicine code when a patient goes in for a routine exam and an illness is found that is significant enough to require additional work. Providers should bill 99381 - 99397 with a routine diagnosis code and an illness E&M code 99211 - 99213 with a -25 modifier and an illness diagnosis code. The 25 modifier indicates a significant, separately identifiable evaluation and management service by the same physician on the day of a procedure. The appropriate level of E&M should be submitted. Generally, a level 4 or 5 illness E/M (99204, 99205, 99214, 99215) is not allowed in conjunction with a preventive E/M. Because a level 4 or 5 would require significant additional work, it would seldom be appropriate to bill both. Denials can be appealed, but would require documentation to support both E/M services.

Couseling and/or Risk Factor Reduction

Individual preventive medicine counseling (codes 99401 - 99404) are reimbursed per contract benefits. Group preventive medicine counseling (codes 99411 - 99412) is not reimbursed by EPNI and will deny if submitted.

Room or Machine Set-up Charges

Room or machine set up charges are considered to be an integral part of the procedure being done. Do not submit separately for these services.

Supplies in the Office

Supplies in the clinic setting are generally included or part of the procedure or service. Codes 99070, A4649 and A4550 will be denied. Other supplies, such as Betadine or alcohol wipes, will be denied. Generally, supplies are only allowed separately in conjunction with approved home health care.

Adjunct CPT Codes

Adjunct CPT codes 99050 - 99060 are designed for the provider to report special circumstances under which a basic procedure is performed. EPNI does not consider these or provider inconvenience fees as reimbursable services, and as such are denied as a provider liability.

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Care Plan Oversight Services

Care plan oversight services codes 99374 - 99380 are not reimbursed by EPNI as a separate service from the evaluation and management codes and will deny as provider liability.

Prolonged Physician Services

EPNI reimburses face-to-face prolonged physician services codes 99354 - 99357. Codes 99358 - 99359 are not reimbursed (prolonged services without face-to-face patient contact) and will deny as provider liability.

Telephone Calls

Telephone calls, codes 99371 - 99373, are non-covered services. Calls are considered an integral part of other services the patient receives (usually an evaluation and management service) and not separately reimbursable.

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Coding Policies and Guidelines

Team Conferences

Medical conferences without face-to-face patient contact, codes 99361 - 99362, are not reimbursed, and will deny as provider liability.

Televideo Consultations

EPNI provides reimbursement for certain televideo consultations. These consultations are also sometimes referred to as telemedicine or telehealth services. Televideo consultations are interactive audio and video communications, permitting real-time communication between a distant site physician or practitioner and the member, who is present and participating in the televideo visit at a remote facility. Coverage of televideo consultations includes consultations, office visits, psychotherapy, substance use disorders, as well as the codes allowed per Medicare policy. Facilities may be reimbursed for the origination fee. Both the consulting physician and the remote clinic or remote site will submit a claim for their services. The consulting physician will bill the appropriate CPT® evaluation and management, psychotherapy code or ESRD code. The remote provider will bill for the originating site facility fee only. This service is billable on either the professional or institutional claim format.

Coding

Remote Clinic or Remote Site

Consulting Physician/Practitioner

Q301: Telehealth originating site facility fee

99241 – 99255: Consultations

0780:Telemedicine, General Classification

90801: Psychiatric diagnostic interview

0789: Telemedicine, Other Telemedicine

90804 - 90809: Individual psychotherapy

99201 – 99215: Office or other outpatient visits

90862: Pharmacologic management G0308 - G0309, G0311 - G0312, G0314 - G0315, G0317 - G0318: ESRD related services WITH… -GT- Via interactive audio and video telecommunication systems Note: All of the above services must be appended with the –GT modifier. Co-pay

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None

Co-pays would apply

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Televideo Consultations (continued)

Global Period

Remote Clinic or Remote Site

Consulting Physician/Practitioner

Not included in the global surgical period

Global surgical package edits apply

Exceptions

Televideo consultations are subject to the terms of the member’s contract and may not be covered under the member’s health plan. Televideo consultations do not include telephone calls or Internet consultations. Telephone and Internet consultations are contract exclusions and will be denied.

Urgent Care

Clinic-based urgent care services may be billed under the place of service (POS) 20. The POS code 20 will apply office benefits to the services if submitted. DO NOT bill a corresponding facility claim with the revenue code 0456 if already billing for urgent care on the professional claim (CMS-1500). This would be considered duplicate billing. Hospital based emergency room urgent care should be billed on the UB92 only with the revenue code 0456. Codes S9083 (global fee urgent care centers) and S9088 (services provided in an urgent care center) represent where the service was rendered, not the service itself. Thus, they are not separately covered and will be denied as part of the primary service (such as E/M).

Weight Management Care

In general, EPNI covers services for the treatment of obesity, weight management, nutrition, and physical activity counseling. However, coverage for these services depends on the type of provider submitting the claim, the procedure and diagnosis codes submitted, and the patient’s contract with EPNI. We encourage you to request that your patients check on their coverage before extensive services are provided. Due to the many variable, exact payment can not be determined until we receive the claim for processing. The outline reviews the following seven categories as they relate to coverage for services related to obesity, weight management, nutrition, and physical activity counseling. 1. Diagnosis Codes 2. Procedure Codes 3. Eligible Providers 4. Weight Loss Programs 5. Weight Loss Drugs 6. Physical Activity 7. Surgery

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Weight Management Care (continued)

Diagnosis Codes The physician determines if the patient meets the criteria to be classified as obese. If the patient meets those criteria, two specific obesity diagnosis codes may be used: •

278.00 Obesity, Unspecified

• 278.01 Morbid Obesity In addition to the two specific obesity codes, the provider may also bill for obesity or weight management counseling with routine diagnosis codes such as: •

V65.3 Dietary Surveillance and Counseling



V70.0 Routine General Medical Examination at a Health Care Facility. The obesity diagnosis codes of 278.00. 278.01 and code V65.3 will cause claims to pay according to the illness portion of the patient’s contract. All EPNI contracts have benefits for illness-related services. If the claim is submitted with a routine medical exam code of V70.0, it will pay based on the routine benefits, if any, that are provided by the patient’s contract. Some contracts exclude routine benefits. Claims may be submitted for obesity, weight management, nutrition counseling etc. with the diagnosis of the underlying symptom that brought the patient to the provider. For example, the claim may be submitted with a diagnosis of elevated blood cholesterol, shortness of breath, or diabetes. These claims will process according to the medical illness benefit. Procedure Codes No specific procedure codes exist for the counseling of obesity and weight management. Services for obesity/weight management counseling may be billed under evaluation/management (E/M) codes (99201-99215) provided that those services meet the components of an E/M service. These E/M codes are compatible with all causes, illness or routine related, and will pay according to the diagnosis submitted. Claims may also be submitted as preventive counseling (99401-99404). These codes, however, are only compatible with routine diagnosis codes (e.g. V70.0). Claims submitted with these procedure codes and a routine diagnosis code will process according to the patient’s preventive benefit, provided the patient has coverage for preventive services. If CPT codes 99401-99404 were submitted with a diagnosis of obesity (e.g. 278.00) the claim would reject because the service was incompatible with the diagnosis.

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Weight Management Care (continued)

Medical nutritional therapy codes (97802, 97803, S9470) may be billed when counseling patients on obesity or weight management. These codes are compatible with any diagnosis but are most appropriate or intended for illness or disease-related diagnoses such as obesity or diabetes. Note that code 97804 is nutritional therapy in a group setting. Group therapy services are generally only covered when submitted with diagnosis codes for anorexia, bulimia, diabetes, congestive heart failure, and some maternity diagnosis codes. Nutritionist, Dieticians and Other Providers For many lines of business, EPNI pays Minnesota Licensed Nutritionists, Licensed Dieticians, and Registered Dieticians directly for services submitted with an eating disorder code 307.1, 307.50 and 307.51. The provider may submit using procedure codes S9470, 97802, 97803, or 97804 based on the service provided. No referral is necessary for the highest benefit level. Some self-insured plans, however, may exclude coverage by a dietician, so benefits should be verified. Licensed dieticians and licensed nutritionists can bill for procedure codes S9470, 97802, and 97803 for diagnosis codes other than eating disorders. Services provided by licensed dieticians and nutritionists must be submitted to EPNI using the provider number of an eligible medical clinic or hospital. The individual provider number of the licensed dietician or licensed nutritionist must also be submitted on the claim. Registered dieticians billing for services outside of behavioral health diagnosis codes will have those claims denied unless the services are submitted under the individual provider number of a supervising physician. The –U7 modifier should also be submitted. Health Educators and Exercise Physiologists are not recognized as eligible providers and their services will be rejected if received by EPNI.

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Coding Policies and Guidelines

Weight Management Care (continued)

Weight Loss Programs EPNI does not cover commercial weight loss programs (e.g., Nutrasystems, Jenny Craig, LA Weight Loss, Weight Watchers etc.). While we have a medical policy for very low calorie diets, VII-08, most weight loss programs do not qualify under this medical policy and the benefits covered are limited. The program must be based in a clinic or hospital, physician directed, and the provider must obtain a separate provider number for reimbursement. The patient must also meet criteria in order to be eligible to participate, and we highly recommend that the services be prior authorized. Some self-insured groups may exclude coverage for very low calorie diets or may have specific reimbursement provisions. Weight Loss Drugs Xenical and Meridia are on our formulary as approved weight loss drugs. All fully insured groups cover weight loss drugs. However, each self-insured account chooses whether or not to cover weight loss drugs. Note that patients covered by certain State Health Plan products have specific authorization requirements for weight loss drugs. Physical Activity There are no procedure codes specifically for physical activity counseling. Providers typically bill counseling services for physical activity as an E/M service (99201-99215) provided that the counseling meets the components of an E/M service. There is no specific diagnosis code for physical activity counseling. The provider may also submit codes for preventive counseling (9940199404). These codes however, are only compatible with routine diagnosis codes (e.g., V70.0). Claims submitted with these procedure codes and a routine diagnosis code will process according to the patient’s preventative benefit, provided the patient has coverage for preventative services. Services billed by a personal trainer or an exercise physiologist are not covered. Claims for their services will be denied as an ineligible provider, regardless of the procedure code and diagnosis code submitted. Surgery EPNI has a detailed medical policy, IV-19, regarding provider and patient eligibility criteria for obesity surgery. Some groups exclude coverage for obesity surgery in their contracts; however, fully insured groups cover obesity surgery. Prior authorization is highly recommended.

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Weight Management Care (continued)

Disclaimer: The fine print This information is designed for reference purposes only and does not guarantee coverage. EPNI will consider each individual member’s condition and unique circumstances in making coverage determinations and will make each determination on a case-by-case basis and according to the terms and conditions of the member’s contract, certificate of coverage, or summary plan description, as applicable, including provisions relating to exclusions and limitations. If there is a conflict between the information above and the contract or plan documents, the contract or plan documents govern. This information is current as of second quarter 2005. As you know, EPNI reviews its policies and coverage periodically and may make changes in the future. Any providers who have questions about this information are invited to contact EPNI Provider Service. Physician Certification and Supervision Physician certification and supervision codes G0179-G0182 are not reimbursed as a separate service from the E/M service and will be denied as provider liability. These services may be allowed for Medicare members.

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Coding Policies and Guidelines

Optometric/Optical Services Opthalmological Services

EPNI coding policy follows the CPT system of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians and optometrists. Both E/M codes and ophthalmology codes 92002, 92004, 92012, 92014, and 92015, may be appropriate to use by optometrists or ophthalmologists. The level of E/M service or the selection of ophthalmology codes must appropriately reflect the medical condition, the medical necessity, the tests performed, and be documented in the patient record. Selection of either an E/M code or an ophthalmology code may be appropriate for both routine or medical diagnoses, and should be based on the CPT definitions of services provided. Details of the patient encounter, as recorded on the patient record, must meet or exceed the stated CPT requirements to qualify for the code selected. EPNI requires that all medical services be performed by professionals eligible and credentialed to perform the service. The diagnosis and CPT coding must appropriately reflect the medical condition and that the medical record reflect the medical necessity and severity of the condition.

Charges for Lenses and Contact Lens Fitting

Submit charges for any type of lenses using Level II HCPCS codes. Any fee for fitting and prescription of contact lenses may be reported by submitting a CPT code from the contact lens services section in addition to the contact lens supply code. The fee for fitting and prescription of contact lenses may also be included in the contact lens charge.

Eyewear Billing and Reimbursement

Eyewear claims will be paid to the member, not the provider. If you bill eyewear for a member, you should bill the eyewear on a separate claim form from the one used for the eye exam. Use your optician’s contracting provider number when billing for the eyewear. Your optometrist’s contracting provider number should be submitted when billing for the eye exam. EPNI requires that eye exams and eyewear claims not be billed on the same claim form. Participating providers are allowed to collect only the copayment at the time of service. The exception to this rule is for eyewear services. Providers are now allowed to collect a payment from the member for eyewear at the time of purchase because EPNI will reimburse the member.

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Coding Policies and Guidelines

Vision Therapy Services

EPNI will reimburse the initial visit under 92060. Visual therapy instruction by any method that is provided during the first visit is included in this description. Separate billing for CPT code 92065 will not be allowed for the initial visit. Vision therapy services involve nonsurgical orthoptics, medical, or sensory-motor re-education for patients who suffer from conditions such as strabismus, amblyopia, exotropia, and/or esotropia. All subsequent visits for patient evaluation and monitoring of treatment will be billed to EPNI under CPT code 92065. Office calls (9920199215, 92002-92014) and sensorimotor exams (92060) are not eligible for separate billing from the providers of the visual therapy during the course of treatment unless a medical examination is clinically indicated for other reasons.

Claims Filing Requirement

Use CPT codes or HCPCS level II code to bill your services. ICD-9-CM codes should be used to submit an appropriate diagnosis for your patient. Please note the correct code for routine vision care is V72.0 or 367.0-367.9 completed to the appropriate fourth and fifth digits.

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Coding Policies and Guidelines

Pharmacy Services Claims Filing Requirements

The majority of our member contracts contain basic drug coverage. Drug claims are either processed by EPNI or RGS/Propar. To determine if a drug claim should be submitted to EPNI or RGS for processing, check the member’s ID card. If the member has drug processing through RGS/Propar, the medical identification (ID) card will indicate RGS/Propar under processor with the carrier code “PGIGN”. Gold Net will be indicated under coverage to acknowledge that a Gold Net provider must be used. You must include the two digit numeric dependent code, which is indicated before the name on the ID card.

Drug Claims Submission

RGS claims from Gold Net providers must be processed electronically. If the member has RGS coverage, but the RGS information is not printed on the ID card, the member should pay the prescription in full and submit the claim to RGS for direct reimbursement. Submit RGS member drug claims to: EPNI P.O. Box 64338 St. Paul, MN 55164-0338

Prior Authorization

The prescribing physician must obtain prior authorization through EPNI’s Medical Review area for certain drugs. Some examples of medications requiring Prior Authorization include injectable infertility drugs and growth hormones.

Injectable Drugs

Most prescription benefit plans allow injectable processing online. Be sure to use the appropriate NDC and submit your claim electronically to the processor.

Copays / Coinsurance

The drug copay/coinsurance amount varies for each subscriber. Please rely on “claim response” to correctly identify the amount to collect from the member. If a member’s contract contains the formulary amendment, a dual copay may be in effect. Again, rely on “claim response” to determine the correct amount to collect from the member.

Vacation Prescription Requests

Requests for additional drug quantities (beyond the 34-day supply or 100 unit dosage) may be made by the member, physician, or pharmacist. The member would contact the Customer Service number listed on the back of their ID card. The physician or pharmacist would contact Provider Service. Please keep in mind that some medications are controlled substances and may require a new prescription.

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Drug Formulary

EPNI promotes the use of the drug formulary. It was developed to provide a listing of drugs that are safe, effective, high-quality, and economical. A new drug formulary is mailed yearly to each participating pharmacy. Any participating health care provider may request the addition of a drug to the formulary by completing a formal request form and submitting it to EPNI. The form is included at the end of this section and may be obtained by contacting EPNI Provider Service. A new FDA-approved drug is not considered to be on the drug formulary until it has been approved by the Formulary Committee.

Non-Formulary

Physicians may request non-formulary medication by completing the Physician Request for Non-Formulary Exception, form X15786. A sample follows.

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Coding Policies and Guidelines

Compounded Prescriptions

9-176

Compounded prescriptions are considered formulary drugs provided they contain at least one listed formulary drug in the final product. Use of the compound indicator for compounded prescriptions is reserved for prescriptions requiring the pharmacist to combine two or more ingredients. EPNI Provider Policy and Procedure Manual (11/01/07)

Coding Policies and Guidelines

Prescription Cost Less Than Copay

If the cost of the prescription is less than a member’s copay, the member should pay the lesser of the allowed amount as shown on the claims response.

Over-theCounter Drugs

Most plans do not cover over-the-counter drugs; however, insulin and diabetic supplies are covered by most benefit plans. Some contracts will cover Nicotine Replacement products.

NDC Numbers

The NDC numbers submitted on the pharmacy claim must be taken from the container from which the drug was dispensed. The NDC number must match the manufacturer and package size.

Discounting or Waiving Copays

In order to maintain the level of subscriber responsibility specified in EPNI contracts, it is essential that members pay the agreed-upon copay for their formulary and non-formulary drugs. Both member and provider agreements specifically state that the copay must be collected in full. Noncompliance of this provision, through discount or waiver, could result in termination of the provider agreement.

Dispense as Written (DAW)

EPNI provides for the payment of claims coded ‘‘dispense as written’’ (DAW). Consistent with state law, DAW must be in the physician’s own handwriting or when an oral prescription is given, specifically stated. Physicians may use DAW to prevent generic substitution or to override the non-formulary status of a drug when it is medically necessary. However, most contracts only allow for one DAW override. Only a physician may indicate DAW on a prescription. Neither member nor pharmacist may change this status for any reason. A DAW may not always result in a lower copay. This will be dependent on the patient’s benefit plan.

Prescribing Physician’s DEA

The physician’s DEA (Drug Enforcement Agency) number must be entered on all electronic or paper claims submitted for payment. This information is used for drug utilization review aimed at improving the quality of health care delivered to our members. Leaving this data element out or use of a dummy DEA number constitutes an incomplete pharmacy claim. The prescribing number issued for eligible optometrists must be included when appropriate.

Pharmacy Audits

EPNI performs comprehensive pharmacy program integrity audits to ensure compliance with its programs.

Investigative Drug Use

Drugs used investigatively are not eligible for reimbursement.

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Coding Policies and Guidelines

Radiology Services General Guidelines

Codes 70010-79999 are used for reporting radiology procedures. The number of services on your claim must be the number of procedures performed, not the number of views taken. For example: Code

No. of services

71020 (chest X-ray, two views)

1

Diagnosis

A diagnosis code is required for radiology services and should match the services provided. For example, 76805 should have a maternity diagnosis. For a preoperative chest X-ray, use ICD-9 code V72.82.

Modifiers

Use modifier -26 to indicate a physician’s professional component when only the professional component is reported. Likewise, if only the technical component is being reported, modifier -TC should be added to the CPT code. We expect the global procedure to be reported if both components are performed by personnel in the same clinic.

Radiation Treatment Management

The weekly management code is 77427. Radiation treatment management is reported in units of five fractions or treatment sessions, regardless of the actual time period in which the services are furnished. The services need not be furnished on consecutive days. Multiple fractions representing two or more treatment sessions furnished on the same day may be counted separately as long as there has been a distinct break in therapy sessions, and the fractions are of the character usually furnished on different days. Code 77427 is also reported if there are three of four fractions beyond a multiple of five at the end of a course of treatment; one or two fractions beyond a multiple of five at the end of a course of treatment are not reported separately. The professional services furnished during treatment management typically consists of: •

Review of port films;



Review of dosimetry, dose delivery, and treatment parameters;

• Review of patient treatment set-up; Examination of patient for medical evaluation and management (e.g., assessment of the patient’s response to treatment, coordination of care and treatment, review of imaging and/or lab test results.) The code 77431 is meant to be utilized for radiation therapy management that includes the complete course of therapy, consisting of one or two fractions only. This code is not meant to fill in the gaps for the one or two fractions that may be left over at the end of a long course of therapy.

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Maternity Ultrasound Compatibility

The pregnant uterus ultrasound CPT codes 76801 - 76817 are not compatible with routine or non-specific diagnoses. This includes the diagnosis code V72.5 (Radiological examination, not elsewhere classified). If a definitive diagnosis is not available, a sign or symptom necessitating the ultrasound should be submitted.

Purchased Services / Outside Lab

The entity that performs a test should be the one to bill for that test. However, a provider may, under arrangement with another provider, bill a service that is purchased from that other provider. For example, a clinical provider may bill for an x-ray that is done at a hospital because the clinic did not have the appropriate equipment. It is important to remember that only one provider may bill for the service. Claims for purchased services should be submitted on the CMS-1500 as follows: Field

Enter

item 24B (place of service)

enter the place where the service was done by the performing provider

item 24D (procedure/ modifier)

enter the procedure code of the test and the modifier –90

item 24K (provider number)

enter the provider number of the ordering physician

item 32 (where rendered)

enter the name and address of the performing provider

Diagnostic and Screening Mammogram

Generally, screening and diagnostic services done on the same day are considered mutually exclusive and the screening service will be denied. However, if a diagnostic mammogram is followed by a screening mammogram on the same day, both may be allowed. The modifier –GG must be appended to the diagnostic mammogram code 76090.

Code 76140

Code 76140 (consultation on x-ray examination made elsewhere, written report) is considered an over-read is not allowed. (Over-reads are additional interpretations of film and as such, are not billable to the plan or the patient as a separate charge.)

Comparison Xray

Xrays taken for comparison purposes are generally not covered. Rexrays are allowed if performed at different times of day or before and after surgery, such as orthopedic procedures including casting. Add a – 76 modifier to the second or subsequent xrays.

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Coding Policies and Guidelines

An example is illustrated below. 24.

A

D

B

C

DATES OF SERVICE FROM TO MM DD YY MM DD YY

Place of Svc

Type of Svc

09

01

00 06

1 1

99214

09

01

00 06

2 2

71010

25. FEDERAL TAX I.D. NUMBER

SSN EIN

E

PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER

DIAG NOSI S

27. ACCEPT ASSIGNMENT? (For govt claims, see back) Yes

31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.)

SIGNED

No

32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED (If other than home or Office)

DAYS OR UNITS

EPSDT Family Plan

I

J

EMG

COB

RESERVED FOR LOCAL USE

$CHA RGES

40.00

1

12345AB

30.00

1

12345AB

28. TOTAL CHARGE

29. AMOUN T PAID

30. BALANCE DUE

$ $ $ 33. PHYSICIAN’S, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE & PHONE

ABC Radiologists XYZ Hospital 123 Main St. Little, MN

DATE

PIN#

(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE (12/90)

9-180

G

K

CODE

90

26. PATIENT’S ACCOUNT NO.

F

H

GRP#

1A111ZA

FORM CMS-1500

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Coding Policies and Guidelines

Rehabilitative Services Physical Therapy Modalities

Physical Therapy Procedures

The following physical medicine codes require a physician or therapist to be in constant attendance. Submit the following CPT codes for physical therapy services: Code

Units of Service

97010 - 97028, 97039

1 unit for each modality

97032 - 97036

1 unit for each 15 minutes

The following codes should be used for physical therapy procedures: Code

Units of Service

97110 - 97124

1 unit for each modality

Example: Coding for massage, 50 minutes: Code Time Units of service 97124 50 min.

4

Additional physical therapy codes are 97140-97542 and 97597-97606 should be used as outlined in CPT. Physical Therapy Evaluation Codes

Physical therapists evaluation and re-evaluation services should be submitted using CPT codes 97001 and 97002. Code

Category

Units of Service

97001, 97002

Evaluation and re-evaluation

1 unit

If these codes are billed with other services performed on the same day, they will be denied. These codes may be reported separately only if the patient’s condition requires significant separately identifiable services, above and beyond the usual pre-service and post-service work associated with the procedure performed. In these instances, add modifier –25 to the evaluation or re-evaluation.

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Coding Policies and Guidelines

Occupational Therapy

9-182

Listed below are the CPT-4 physical medicine and rehabilitation codes and additional codes that occupational therapists may submit. Code

Category

Units of Service

97010 - 97028

Modalities, supervised

1 unit for each modality

97032 - 97036

Modalities, constant attendance

1 unit for each 15 minutes

97039

Modality, constant attendance, unlisted

1 unit for each modality

97110 - 97140

Therapeutic procedures

1 unit for each 15 minutes

97150

Therapeutic procedure(s), group

1 unit

97530 - 97542

Therapeutic procedures

1 unit for each 15 minutes

97545

Therapeutic procedures

1 unit for 2 hours

97546

Therapeutic procedures

1 unit for each additional 60 minutes

97597 - 97606

Active wound management

Unit per session

97750 - 97755

Test and measurements

1 unit for each 15 minutes

97799

Other procedures

1 unit (designate time)

97760 - 97762

Orthotic and Prosthetic management

1 unit for each 15 minutes

29105 - 29131 and 29505 29515

Splints

1 unit

29240 - 29280

Strapping

1 unit

92526, 92610 92617

Special otorhinolaryngologic services

1 unit

95831 - 95852 and 95999

Neurology and neuromuscular procedures

1 unit

96105 - 96111

Central nervous system assessments/tests

1 unit per hour

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Coding Policies and Guidelines

Occupational Therapy Evaluation Codes

Occupational therapists should submit evaluation and re-evaluation services using the CPT codes 97003 and 97004.

Code

Category

Units of Service

97003 - 97004

Evaluation and re-evaluation

1 unit

If these codes are billed with other services performed on the same day, they will be denied. These codes may be reported in addition to the therapeutic procedures (97010-97546) if a –25 modifier is appended to the evaluation or re-evaluation (97003-97004) codes. Speech Therapy and Evaluation

Speech therapists, physicians, or M.D. clinics should use CPT code 92507 for their speech therapy services and 92506 for speech evaluation. Submit one unit of service per encounter.

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Coding Policies and Guidelines

Surgical Services General Guidelines

Generally, EPNI covers only surgical procedures performed by a physician for the treatment of illness or injury. Follow these procedures to bill surgical charges:

Bilateral Services



Submit each surgical procedure on a separate line. (Do not submit multiple procedures on one line even if identical procedures were performed.)



Submit all surgeries performed on the same date on one claim. List the appropriate procedure code for each one.



Use modifier -51 for secondary procedures

The bilateral modifier –50 is used to indicate cases in which a procedure normally performed on only one side of the body is performed on both sides. The CPT descriptors for some procedures specify that the procedure is bilateral. In such cases, the bilateral modifier should not be used. Some payers such as Medicare require a one-line entry; however, third-party payers may have different requirements. EPNI requires submission of two lines for bilateral procedures. The –50 modifier should be appended to the second line of service. Example: Line 1= 69421 Line 2= 69421-50

Unlisted Procedures

If a code cannot be found for a surgical procedure, submit the unlisted code from the related section of CPT and attach an operative report to the claim.

Facility Fees for Office Surgery

EPNI does not allow a separate reimbursement for approved office surgery suites. No additional reimbursement will be made for fees associated with procedures performed in office surgical suites regardless if the service(s) is modified with the –SU or –SG modifier. This includes additional units of service for the preoperative preparation, anesthesia and surgical trays.

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Coding Policies and Guidelines

Global Surgical Package

Surgical procedures include the operation itself, local infiltration, metacarpal/digital block or topical anesthesia, when used, and normal, uncomplicated follow-up care. This concept is referred to as a ‘‘package’’ for surgical procedures, and typically begins the day before surgery. Do not submit separate, itemized services for uncomplicated surgical follow-up. Surgical Care Only The post-operative period includes all visits by the primary surgeon unless the visit is for a problem unrelated to the diagnosis for which the surgery was performed or is for an added course of treatment other than the follow-up care that is usually associated with the surgical procedure. When billing for the surgery only, submit the surgical procedure code with a -54 modifier and an appropriately reduced charge to reflect that post-operative care was not provided. Reimbursement for allowable intraoperative services will reflect 90% of the physician fee schedule allowance for the procedure. Pre- or Post-Op Management EPNI is unable to accept the -55 and -56 modifiers with the surgical procedure codes. Submit the appropriate evaluation and management code for each visit with the -55 or -56 modifier when pre-operative and/or post-operative care is provided by a different clinic than performed the surgery.

Fractures

Codes for fracture treatment include the application and removal of the first cast. Do not submit separate charges for these services. Submit cast removal codes only if a different physician does the removal. Submit codes 29000-29590 for the application of casts and strapping only when performed as a replacement during the period of follow-up care. Additional visits are reportable only if additional significantly identifiable services are provided at the time of the cast application or strapping. Removal of a second or third cast by the physician who applied it is included in the casting and strapping codes and not billable separately. If cast application or strapping is provided as an initial procedure in which no surgery is performed (e.g., casting of a sprained ankle or knee), use the appropriate level-of-office visit in addition to the appropriate HCPCS code for the supplies. The removal of an initial cast (in which no surgery was performed) should be submitted as an office visit.

Incidental Surgery

EPNI does not cover procedures that are incidental to other major surgery and unrelated to illness, injury, or sterilization. Incidental surgical procedures do not usually warrant separate identification.

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Coding Policies and Guidelines

Lesions

Certain CPT codes for the integumentary system indicate a second or third lesion. Use these codes only with the primary code for the first lesion. Use an office call code for treatment of wounds, punctures, abrasions, and lacerations that do not require sutures or debridement. Codes 11400-11446, for removal of benign lesions such as keratosis, cover a variety of techniques. The excision of benign lesions with a laser is considered a variation of a surgical excision. The dimension and location of the lesion should be recorded in the operative report. Submit the appropriate code from the range listed above.

Surgical Trays and Supplies

No additional reimbursement will be made for surgical trays, surgical or other miscellaneous supply codes A4550, A4649, and 99070. The allowance for these codes is considered bundled into payment for the other services rendered. Supplies/devices implanted as part of the surgical procedure, are considered integral to the procedure and are generally not separately reimbursable.

Standby Services

All standby services except anesthesia standby should be submitted with code 99360 with one unit per 30 minutes. The type of standby (operative, PTCA) and the total number of minutes the service was provided must be indicated in the medical record. The physician may not be providing care or services to other patients during this time. Do not bill for anesthesia standby as it is considered ineligible and will deny as provider liability.

Treatment of Warts

The treatment of warts (verrucae, papillomas) via surgical or laser excision is considered a variation of destruction of a benign lesion. Use the CPT procedure codes 17000-17004. A cluster of warts is considered a single destruction of warts and should be submitted using one unit of service. Paring or curettement or shaving of warts with or without chemical cauterization should be coded using CPT procedure codes 11055-11057. Electrocauterization or ‘‘burning off’’ of warts should be coded using CPT procedure code 17110. This procedure code includes up to 14 lesions. Fifteen or more lesions are coded as 17111. A cluster of warts is considered a single operative procedure and should be coded as such. EPNI does not recognize the use of CPT procedure codes 11420-11446 for the treatment of warts. This range of codes is considered for other types of skin lesions, such as a keratosis, etc.

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Coding Policies and Guidelines

Assistant Surgeons

Almost all EPNI members have coverage for assistant surgeon’s services when the following criteria are met: •

The surgical assistant is a licensed physician, nurse practitioner (NP), registered nurse first assistant (RNFA), or physician assistant (PA).



The surgical assistant’s services are medically necessary. (This is determined by the complexity of the surgery.)



To bill services of an assistant surgeon (MD, NP, or RNFA acting as an assistant at surgery), use the surgical procedure code with modifier -80. To bill the services of a physician assistant acting as an assistant at surgery, use modifier -AS or -80.



If more than one surgical procedure was done during the same session, give the total hours and minutes for all procedures done. List each procedure separately.



Generally, reimbursement for eligible assistant surgeon services are reimbursed at 16% of the surgery allowance. When an assistant surgeon is involved in multiple surgical procedures, the same method used for determining reimbursement for the primary surgeon shall be used in determining reimbursement for the assistant surgeon.



We do not publish a list of surgeries for which an assistant surgeon is allowed. Generally, we follow the list that CMS has furnished to Medicare carriers, for approved codes.

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Coding Policies and Guidelines

Co-Surgeons

Co-surgery services are identified by use of the CPT modifier -62. Cosurgery involves a surgical procedure report with a single procedure code that requires two surgeons of different specialties or a surgical procedure that involves two surgeons performing parts of the procedure simultaneously. The additional surgeon is not acting as an assistant at surgery (modifier –80 or –AS) or as part of a surgical team (modifier – 66). Documentation must support the use of the –62 modifier. An operative report(s) is required and will be requested if not submitted. Claims must be coordinated by the surgeons prior to filing their claims. One operative report may be used, as long as both surgeons’ responsibilities are identified. The following criteria must be met: Co-surgery services should be submitted using the appropriate CPT surgical procedure code and the modifier -62. If more than one modifier is being reported, list -62 first. Both providers billing the -62 modifier should normally be surgeons of different specialties. Examples would include Gynecology/Urology, General Surgery/ENT, etc. It must be medically necessary and an accepted standard of care to have two surgeons of different specialties perform the surgery. Each surgeon must perform a distinct portion of the surgery. EPNI follows Medicare’s guidelines regarding which procedures will be reimbursed for co-surgery services. The MPFSDB indicators are: •

0 = Co-surgeons are not permitted for this procedure.



1 = Co-surgeons may be paid if supporting documentation is supplied to establish medical necessity.

• 2 = Co-surgeons permitted. Allowable co-surgery services will be determined on a case-by-case basis and upon review of supporting documentation. Reimbursement will be 62.5 percent of the global surgery fee schedule amount for allowable cosurgery services. Additionally, global surgery rules will be applied to each of the physicians participating in a co-surgery. Multiple Surgeries

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All multiple surgeries will be reimbursed the same regardless of whether the subsequent surgical procedure was performed through the same or different incisions. The major surgery is reimbursed at 100% of the allowed amount, and any/all additional procedures are reimbursed at 50% of the allowed amount.

EPNI Provider Policy and Procedure Manual (11/01/07)

Chapter 10

Template Policies and Procedures Table of Contents Instructions for Use.................................................................................................................... 10-2 Advance Directives.................................................................................................................... 10-4 Child and Teen Checkups .......................................................................................................... 10-5 Communicable Disease Reporting............................................................................................. 10-6 Complaint Management............................................................................................................. 10-7 Patient Complaint Intake Template ........................................................................................... 10-9 Confidentiality ......................................................................................................................... 10-10 Confidentiality Statement ........................................................................................................ 10-14 Confidentiality and Security of Medical Records.................................................................... 10-15 Authorization for Release of Information................................................................................ 10-19 Foreign Language Translation and Hearing-Impaired Services .............................................. 10-20 Interpreter Resources ............................................................................................................... 10-22 Interpreter Services Billing Information.................................................................................. 10-23 Hazardous Materials Management .......................................................................................... 10-24 Infection Control...................................................................................................................... 10-28 Medical Emergency ................................................................................................................. 10-32 Medication Management ......................................................................................................... 10-33 Non-Medical Emergency Preparedness................................................................................... 10-37 Treating Unaccompanied Minors ............................................................................................ 10-39 Authorization to Consent to Treatment of a Minor ................................................................. 10-41 Consent to Allergy Treatment for Unaccompanied Minor ...................................................... 10-42 Behavioral Health Accessibility Standards.............................................................................. 10-43

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Template Policies and Procedures

Instructions for Use Introduction

EPNI provides these templates of policies and procedures to assist your facility in creating and personalizing your own policy and procedure. Written policies and procedures describing key functions and activities of your facility serve as risk management tools and provide training materials for employees. Policies provide: •

Direction in decision making and promote consistency of interpretation and applications across organizational lines;



Guidance for future policy development



A frame work for revisions; and



A clear understanding of facility operation, thus minimizing the possibility of illegal and/or authorized action.



Policies are established when persons capable of reasonable judgment could logically arrive at a different decision.

Chapter 1 Requirements EPNI requires the following around policies and procedures: •

Policies are personalized with provider information if templates are used. Replace {ALL TEXT IN BRACKETS} with information that is specific to your facility/health system.



Policies are dated and signed by either provider administration or the medical director each time they are reviewed



On an annual basis, review appropriate policies and procedures with all employees and update if necessary

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

Suggestions

Suggestions for Customizing and Adopting a Policy and Procedure We recommend the following steps in customizing and adopting a policy and procedure within your facility system/medical group.

Preparation

Implementation

Maintenance

1. Review the template policy and procedure and customize the template to include information relevant to your facility setting. Consider additional pertinent information.

5.

Educate all appropriate personnel and practitioners about the approved policy and procedure.

10. Establish an annual review process for reviewing and updating policies and procedures.

2. Review with key facility administration for their input (e.g., administrator, medical director).

6.

Maintain a single location for storage of original policies.

11. Consult with your legal counsel and/or liability carrier for advice on record maintenance for retired policies and procedures.

3. Have your legal counsel and/or liability carrier review your policy and procedure.

7.

Provide copies of policies in appropriate patient care areas for reference.

4. Bring the draft policy and procedure to an internal clinic committee for review and approval.

8.

Include review of policies and procedures as part of new employee orientation.

9.

On an annual basis, review appropriate policies and procedures with all employees.

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Template Policies and Procedures

{Health Care Entity Name}

Subject:

Advance Directives

Effective Date: Approved By: Review/Revision Date Signature Policy {HEALTH CARE ENTITY} makes information regarding advance directives, including how to execute advance directives, available to its competent adult patients and their families. Purpose The purpose is to encourage communication between patients and health care practitioners on the issue of advance directives. Procedure 1.

Practitioners will assess and discuss each patient’s desire for Advance Directives.

2.

Upon request, information on advance directives is provided to patients and their families.

3.

The patient’s practitioner discusses advance directives issues with the patient and his/her family.

4.

Discussions about advance directives are documented in the medical record.

5.

Copies of executed advance directives are maintained in the medical record.

6.

Patients and their families desiring additional information or counseling on advance directives are referred to appropriate community resources.

7.

The facility notifies the hospital of advance directives on file at the facility when the patient is admitted to the hospital.

8.

Patients and their families are informed of this practice.

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Subject:

Child and Teen Checkups

Effective Date: Approved By: Review/Revision Date Signature Policy {HEALTH CARE ENTITIY} provides comprehensive health services that facilitate early discovery and treatment of health problems to children from birth through age 20 years. Purpose The purpose is to appropriately perform, record, and bill C&TC services as required for children. Procedure 1. Identify patients from birth through age 20 years. 2. Schedule a sufficient amount of time for the C&TC exam. 3. Attach the appropriate forms to the patient’s medical record when preparing it for the appointment. 4. Perform the appropriate services for the age of the child or teen. 5. Document all completed components and results on the facility or C&TC form in the medical record: 6. Route the C&TC service information to the appropriate person for correct coding and billing for reimbursement. Use the following two-character alpha referral codes: AV – Patient refused referral ST – Referral to another provider for diagnostic or corrective treatment or scheduled for another appointment with screening provider for diagnostic or corrective treatment for at least one health problem identified during an initial or periodic screening service (does not include dental referrals) S2 – Patient is currently under treatment for referred diagnostic or corrective health problem(s) NU – No referral(s) made Document each component abnormality and the plan for follow-up. If unable to provide all appropriate services, document the reason the service(s) was/were not performed. Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Subject:

Communicable Disease Reporting

Effective Date: Approved By: Review/Revision Date Signature Policy The reporting of communicable diseases to the Department of Health is critical to controlling the spread of disease. These diseases are of such major public health importance that surveillance of their occurrence is in the public interest. The Department of Health has a list of communicable diseases that must be reported from the physician/provider. Cases, suspect cases, carriers, and deaths due to the reportable diseases and infectious agents should be reported within one working day Purpose It is the responsibility of the laboratory, nursing and practitioner staff to be knowledgeable of the reportable communicable tests and conditions and the reporting process. Communicable disease reporting helps to reduce the spread of disease and control outbreaks, and to plan public health interventions. Health care providers are an essential part of the disease surveillance process. While laws mandate reporting, the voluntary cooperation of all concerned is needed for the system to function. Procedure 1.

If a communicable disease identified as reportable by the Department of Health is reported out from the laboratory or any of the reference laboratories used by {HEALTH CARE ENTITY}, it will be the responsibility of the laboratory and/or nurse to bring the result to the attention of the doctor or nurse. Vaccine-preventable diseases should be reported at the time they are suspected. Waiting for laboratory confirmation can delay vital public health action that might control the spread.

2.

When a positive reports comes through the laboratory, the lab tech will attach the appropriate form depending on the test done. The nurse should also be familiar with the communicable disease list in case the attachment of forms is missed.

3.

The nurse/doctor will be responsible to complete the forms and send them to the Department of Health within one working day after the reportable communicable disease is discovered.

4.

The reference laboratories do notify the Department of Health of positive reports on communicable diseases, but the {HEALTH CARE ENTITY} must send the appropriate forms with the complete patient history and information within one working day after the reportable communicable disease is discovered/known.

5.

The Department of Health may communicate with the practitioner/nurse if more information is necessary.

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Subject:

Complaint Management

Effective Date: Approved By: Review/Revision Date Signature Policy {HEALTH CARE ENTITY} will receive and respond within 30 calendar days to both oral and written complaints. All complaints should be resolved at the level the issue occurred. Purpose Complaints or concerns received by facility staff reflect patient perceptions and expectations. Feedback, solicited or unsolicited, presents an opportunity to identify issues and implement systematic processes to improve care and/or service. Procedure Both oral and written complaints will be taken and trended. Designated complaint staff will be responsible for receiving complaints. Complaints related to a specific department will be forwarded to the department supervisor. Complaints related to physicians will be forwarded to either Administration or the Medical Director. 1.

Any staff person may receive either verbal or written patient complaints.

2.

The person receiving the complaint will initiate the complaint intake form.

3.

If the complaint can be resolved at this level, staff member receiving the complaint will:



Resolve complaint.



Notify patient of outcome.



Complete complaint intake form including signature and date.



Completed form will be forwarded to the (designated complaint person) for logging.

4.

If the complaint cannot be immediately resolved, the complaint will be forwarded to (designated complaint staff).

5.

Patient is notified of their right to appeal to the health plan.

6.

(DESIGNATED COMPLAINT STAFF) will review and research the complaint.

7.

(DESIGNATED COMPLAINT STAFF) will notify the patient of the outcome.

8.

The complaint form will be completed, signed, and dated.

9.

The complaint will be logged and filed.

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Template Policies and Procedures

Patient Complaint Records/Trends: Complaints will be trended and reported at least quarterly by issue/type to the appropriate internal committee, e.g., the HCI Committee or Risk Management Committee. It may be appropriate to trend and report more frequently as appropriate for your system. Improvement activities will be identified. Action plans will be developed for improvement opportunities to include the person accountable and the projected date for completion. The appropriate internal committee will monitor the action plans. An annual report will be presented to the HCI Committee including improvement made as a result of patient complaint/concerns. The facility’s Board of Directors will review patient complaints at least annually Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Patient Complaint Intake Template EPNI Medica Health Partners Ucare Other

Patient ID: Patient Name: Home Address: Telephone Number: Date of Birth: Primary MD: Date Received: Occurrence Date: Issue:

Received By:

Access Communication/Behavior Coordination of Care Technical Competence & Appropriateness of Service Facility/Environment Concerns Benefit Coverage, Finance, & Contractual Issues/Concerns

Description of Issue:

Summary of Investigation and Resolution:

Date Resolved: Date Patient Notified of Outcome:

Resolved By: Patient Accepting of Resolution?

Yes / No* /NA

*Patient referred to health plan?

Yes / No

Signature:

Date:

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure. EPNI Provider Policies and Procedures Manual (11/01/07)

10-9

Template Policies and Procedures

{Health Care Entity Name}

Subject:

Confidentiality

Effective Date: Approved By: Review/Revision Date Signature Policy {Health Care Entity} assures confidentiality and security of patient information. All sources of patient information containing clinical, social, financial, and other personal or protected information are treated in a confidential manner. All patient information including but not limited to the following, is considered confidential: •

Name



Date of birth and age



Race



Sex



Address



Phone number



E-mail address



Place of employment



Marital status



Sexual preference



Medical history



Current medical conditions



Financial history



Insurance information



Lab tests and radiology results

Purpose 1.

To provide principles and guidelines for the confidentiality and privacy of patient information.

2.

A sound confidentiality program promotes the overall quality of care and service rendered to a patient.

3.

To meet or exceed requirements set forth by HIPAA (Health Insurance Portability and Accountability Act).

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Template Policies and Procedures

Scope 1.

This policy applies to every individual who comprises the workforce at this facility, either in a permanent or temporary capacity, and whether for employment, as a student or as a volunteer. This includes people performing work on a contractual basis.

2.

It is incumbent upon each person to whom this policy applies directly to ensure that persons performing occasional services at this facility, such as salespeople, maintenance, and housekeeping abide by this policy and sign it, or are not allowed access to information.

This policy does not apply to: 1.

Disclosure to or requests by healthcare providers for treatment purposes, if the other provider is within a related health care entity and the disclosure is for current treatment of the patient,

2.

Disclosures to the individual who is the subject of the information,

3.

Uses or disclosures made pursuant to an authorization requested by the individual,

4.

Uses or disclosures required by compliance with the standardized HIPAA transactions,

5.

Disclosures to the Department of Health and Human Services when disclosure of information is required under the rule for enforcement purposes, and

6.

Uses or disclosures required by law.

References Journal of the American Health Information Management Association, “A Reasonable Approach to Physical Security,” Chicago, IL, April 2002. Journal of the American Health Information Management Association, ‘HIPAA Privacy and Security Training,” Chicago, IL, April 2002. Journal of the American Health Information Management Association, “Understanding the Minimum Necessary Standard,” Chicago, IL, January 2002. Procedures 1.

Training A. Every individual described under Scope in paragraph 1 will receive training regarding this facility’s confidentiality policy within {length of time} of his/her start date (1) Training will be documented and verified by signature of the individual and trainer, and maintained on file for six years. (2) Training will include: a. The vulnerabilities of health information in one’s possession, and b. Procedures which must be followed to ensure protection of the information. B. Refresher training will occur every {frequency of time}, and record of the training will be maintained on file for six years.

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Template Policies and Procedures

2.

Physical Security A. Media Controls {List here how you will control confidential information that is in records, faxes, computers, diagnostic films, etc.} (1) Fax transmissions a. Stand alone machines. Medical and personal information will be received only on a designated machine where confidentiality may be protected. People who do not have access to confidential information within the facility will not be permitted access to the designated machine. b. Computer fax capabilities. Only people in the facility who are permitted to handle confidential information will be permitted to receive fax transmissions that contain medical and personal information. (2) File rooms a. Only people whose job duties require them to have access to records will be permitted into file rooms where medical and personal information is maintained, to include paper and film records. b. Files will be physically secured when necessary to insure that unauthorized access does not occur. The individual file cabinets will be locked, or the room(s) in which the records are stored will be locked. (3) Back-up files and copies of data a. All back-up files, to include, but not limited to tapes, disks, and microfilm will be stored in a secured area, separate from the original source of information. Only people whose job duties require them to have access to confidential information will be permitted to enter the secure area. b. If back up files and copies are stored off site, such as in a warehouse, obtain a copy of that facility’s policies regarding confidentiality. B. Accountability (List here how you plan to be able to trace peoples’ routes and actions and remind people of their responsibilities). (1) All areas that are restricted in access will be labeled as such, with permanent signs. Where possible, keep doors locked or visually monitored. (2) Where possible, use sign-in and sign-out sheets, especially for people performing work that would not usually have access to confidential information, such as vendors and contractors. (3) Change combinations and/or locks on doors when employees leave, even when under “good” circumstances. Keep logs of when locks are changed. Keep lists of who has keys. Keep spare keys locked up. Use swipe cards that will track individual movement through entrances and exits. (4) A provider employee will escort each visitor during his/her entire stay. (5) When possible, make arrangements for housekeeping and maintenance to occur during hours of normal business. Otherwise, they should have to sign a confidentiality agreement.

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Template Policies and Procedures

C. Disposal of Confidential Information (Discuss how you will discard of items that contain medical and personal information). (1) All excess paper documents containing identifiable medical or personal information will be shredded when it is no longer needed. (This will consist of the majority of information within a facility, so it might be advisable that all excess paper documents will be shredded.) (2) Think about how you will destroy medical supplies that contain personal medical information, such as IV bags and plastic medicine vials D. Computer Security (1) All computer screens will be arranged in such a way that only those employees permitted to view medical and personal information will be able to see them. (2) Automatic log off will employ (number) of minutes after the last use. (Idea: When automatic log off occurs, use a screen saver with which you can create messages, make messages regarding security reminders, and change the messages occasionally.) (3) All computers will require individual log-on identification and passwords. (4) When switching users on a computer, the first user will log out before the second user logs on. 3.

Personal Confidentiality A. Ensure discussions with patients or about specific patients occur in areas where others will not overhear the discussion. This includes, but is not limited to: (1) (2) (3) (4) (5) (6)

Appointments Reception desk Exam rooms Consultation rooms Waiting areas Dictation areas

B. Sign-in Rosters (1) Whenever possible, avoid using a patient sign-in roster. (2) If it is necessary to use one, keep all information covered, so that the current patient does not have unintended access to the roster. C. Do not leave documents with personal or medical information in places where people other than the authorized user will be able to read them. D. X-ray view boxes (1) Do not use x-ray view boxes in areas traversed by patients or other people not authorized access to personal and medical information. (2) Do not leave diagnostic films on view boxes while they are not in use Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Confidentiality Statement I confirm that I have reviewed the confidentiality policy of {Health Care Entity}, received necessary training in its implementation, and agree to operate within its limitations and requirements. I understand that information I may have access to is protected by {state} and federal law, and that I may not discuss patients or disclose a patient’s personal or medical information to non-provider personnel, without the patient’s expressed consent, or otherwise permitted by law or statute. I understand that unauthorized release of confidential health care information may be grounds for immediate termination of employment and may subject me to penalties under {state} and/or federal law.

Employer’s Name Printed

Employer’s Signature:

Date

{Health Care Entity Name}Manager or Information Security Manager

Date:

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Subject:

Confidentiality and Security of Medical Records

Effective Date: Approved By: Review/Revision Date Signature Policy {HEALTH CARE ENTITY} assures confidentiality and security of patient information. Any patient record containing clinical, social, financial or other data is treated in a confidential manner. Records are reasonably protected from loss, tampering, alteration, destruction and unauthorized or inadvertent disclosure of information. Medical records are the property of {HEALTH CARE ENTITY} and shall not be removed from the facility’s record keeping system, except when required by law. When applicable, the above principles shall hold for any patient information that is stored in an electronic form outside of the permanent paper record. Unauthorized handling of medical records and/or discussion or patient information in nonpatient areas is cause for disciplinary action. {HEALTH CARE ENTITY} upholds patient rights to confidentiality and privacy of patient information. Confidential information is information that is accessible to the patient, but is not public. Medical data, including reports based on examination, treatment, observation, or conversation with the patient are considered confidential. Patients have the right to disclose their confidential and privileged information and only they can exercise that right. Employees sharing in the care of a patient may review records only as necessary in the performance of his/her duties. Other persons who wish to review or obtain copies of patient information (Medical record) must have written permission from the patient. Only information about care rendered by {HEALTH CARE ENTITY} is released. Requests for other outside records are referred to the agency where the patient received the service. Purpose The purpose is to provide principles and guidelines for the confidentiality and security of the medical record and to set standards and guidelines for the release of patient information.

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Template Policies and Procedures

Procedure 1. Confidentiality A. Upon hire and annually thereafter, employees are educated in and agree to abide by patient confidentiality policies. Attestation of this instruction will be documented annually with the signature of the employee. The signed documents will be maintained in the employee’s file. B. The medical record is to be read only by {HEALTH CARE ENTITY} staff for medical, education, business or other institutional purposes. C. Discussions of patient information are conducted only in patient areas and only in the presence of persons authorized to receive the information. 2. Security A. Active medical records are stored in a {SECURE CENTRAL AREA/MEDICAL RECORDS DEPARTMENT} Inactive records (charts three years older than the current year) are stored {LOCATION}. B. Access to records within the {SECURE CENTRAL AREA/MEDICAL RECORDS DEPARTMENT} is restricted to authorized Medical Record personnel. C. Medical records are retrieved in advance of patient appointments. They are placed in a secured area in the registration area each morning prior to the first scheduled appointment. D. Additional medical records are retrieved throughout the day. For these records, a request slip must be completed with the following information: Date of request Patient name Patient date of birth Chart number (if available) Requestor name E. Upon receipt of a medical record request, medical record staff will locate and pull the chart. They place the request slip in an out guide and place the out guide in the space where the chart was located. F. When a chart is moved to a new location in the facility, an updated request slip is completed and forwarded to the Medical Record Department. G. Medical Records are returned to {SECURE CENTRAL AREA/MEDICAL RECORDS DEPARTMENT} at the end of each business day. H. The {SECURE CENTRAL AREA/MEDICAL RECORDS DEPARTMENT} is locked at the end of each day by the Medical Record staff. I. In the event that a medical record is not returned to {SECURE CENTRAL AREA/MEDICAL RECORDS DEPARTMENT} at the end of the day, it must be stored in a locked drawer or file. Medical Records personnel must be notified of the location of the chart. 10-16

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3. Release of Information A. Authorization A valid authorization for release of information may by an original, a photocopy, or a facsimile copy. The authorization contains the following elements:



It is in writing.



It designates the facility to which the request is directed.



It identifies the patient with full name.



It designates the names of each person or organization to which information is to be released.



It includes an authorizing signature of the patient:

(1) If the patient is a minor, the parent or guardian must sign the authorization. In situations where the minor has given his/her consent for care (pregnancy, sexually transmitted diseases, contraception, alcohol or drug abuse), the minor may authorize release of medical and mental health care information. (2) If the patient has a legally appointed guardian, the authorization is to be signed by the guardian. (3) If the patient is unable to sign his/her name but uses some other means to indicate authorization, such marks must be witnessed and notarized. (4) If the patient is deceased, the personal representative of the estate must authorize release of information. If the patient does not have a personal representative, the spouse or a child may authorize release of information. (5) If the validity of the signature is questioned, a notarized signature may be requested. It is dated. NOTE: The authorization is valid for one year from the date of signature. It designates the specific medical condition and dates of treatment and states the

authorization includes information pertaining to drug or alcohol related problem if that type of information is to be released. It states that the patient may revoke the authorization in writing at any time.

B. Release of Information Process (1) (2)

(3) (4)

(5) (6)

Requests for release of information are forwarded to and processed by the {MEDICAL RECORDS DEPARTMENT}. The medical record is pulled and the parts of the record designated in the authorization are photocopied. EXCEPTION: Under very limited circumstances where the information requested is detrimental to the physical or mental health of the patient, the health care practitioner may withhold the information from the patient and provide it instead to an appropriate third party. The third party, however, may then release the information to the patient. Medical records are faxed to other health care agencies, e.g. hospitals, if needed in urgent and emergency situations. Faxing is otherwise discouraged. In case of an emergency, information may be released by telephone to a physician or to a hospital. The requestor is called back to verify their identity prior to releasing the information. Documentation of the release of information, including what information was released and the name of the requestor, is placed in the medical record. Requests to view medical records must be accompanied by a valid, written authorization from the patient. Before the chart is viewed, the sections that contain correspondence and medical reports from other institutions are removed. The records must be viewed on-site in the presence of a medical record staff member.

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C. Subpoenas, Court Orders, and Search Warrants All subpoenas, court orders and search warrants are forwarded to the {MEDICAL RECORDS DEPARTMENT} for processing. {MEDICAL RECORDS DEPARTMENT} immediately notifies the {ADMINISTRATOR} receipt of a subpoena, court order or search warrant. Subpoenas are processed as follows: (1) (2) (3) (4)

Document the date, time and method of delivery of the document. An original subpoena is preferred but a copy of the subpoena is acceptable. Review the document for validity. A valid subpoena contains the following: Name of party being subpoenaed a. Name of the court and title of the action b. Names of the plaintiff and the defendant c. Date, time, place and manner of the requested appearance d. Specific documents being subpoenaed e. Name and telephone number of the attorney issuing the subpoena f. Signature or stamp and seal of the official empowered to issue the subpoena g. Appropriate fee, unless a method for charging has been established

(5) The subpoena must be accompanied by a valid patient authorization or court order to release the records referred to in the subpoena. If an authorization or court order is not present, it must be received prior to release of the information identified in the subpoena. (6) Assure that the record is complete (up to date). Identify the pages requested in the subpoena, number them and photocopy. (7) A certified photocopy of the record is allowed to be entered into evidence at a trial. A certification statement is prepared to accompany the medical record copies. This statement includes: a. Statement that the copy is a true copy of all records described in the subpoena b. Statement that the records were prepared by personnel of the health care provider or designee c. Number of pages being certified d. Notarized signature of the custodian of the records or designee (8) The subpoena and any associated documentation are placed in the patient’s medical record. a. Court orders and search warrants are processed in the same manner as a subpoena. A separate authorization to release medical records is not required. Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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{Health Care Entity Name}

Authorization for Release of Information I,

Last Name

First Name

Date of Birth

Middle Name

Maiden Name

Social Security Number

hereby authorize To furnish information from medical records to The information to be released is: All/any medical information present in any medical record (including treatment for mental health, chemical dependency and HIV status). Selected medical information about The information is needed for the purpose of: Transfer of medical care Insurance Legal Other (please specify) **************************************************************************** I understand that I may revoke this consent at any time except to the extent it has been acted upon and that upon fulfillment of the above stated purpose or one year from this date (whichever occurs first), this consent will automatically expire without my express revocation. I do not authorize re-release of chemical dependency-related information by the party receiving it. I also understand that I am responsible for any charges associated with transfer of this information. Signature

Date Patient (or Parent or Guardian)

Relationship to Patient

Witness

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Subject:

Foreign Language Translation and Hearing-Impaired Services

Effective Date: Approved By: Review/Revision Date Signature Policy {HEALTH CARE ENTITY} provides communication assistance for those patients and families who require foreign language interpretation and for those who are hearing impaired. These services are provided at no cost to the patient. Purpose The purpose is to ensure that patients and families with language and/or hearing barriers are provided with necessary and appropriate communication assistance to assure accurate and thorough communication of all aspects of patient care, including, but not limited to: •

taking patient history



obtaining informed consent or permission for treatment



explanation of medical procedures and medications



explanation of legal rights and financial matters



health education

Procedure 1.

The patient and/or family may request sign language or oral foreign language interpreter services. Practitioners and/or nursing staff may make the determination of need for interpreter services.

2.

The use of family members for interpreter services is discouraged. Utilize family members only as a last resort. If family members are used, be sensitive to cultural issues (e.g. family roles, health conditions that do not translate, etc.)

3.

When a need for interpreter services is identified, contact the appropriate interpreter service based on patient and family need and insurance coverage. Interpreter services resources, including the AT&T Language Line and TDD/TTY Device, are listed on the Attachment. Have the following information available when contacting the interpreter service:



name and address of provider



phone number and contact person at provider



where, when and to whom interpreter is to report the

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• name of the patient 4. Arrange for appropriate interpreter to be available for patient’s appointment. If patient has previously used an interpreter for a provider appointment, attempt to schedule the same interpreter for future appointments. 5.

Notify patient/family that an interpreter has been scheduled for the patient’s visit. Request that patient notify provider of appointment cancellation at least 24 hours prior to the appointment so that the interpreter service may be cancelled also.

6.

Notify the receptionist/front desk of the interpreter services that have been scheduled.

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Interpreter Resources I.

(Foreign Language and Hearing Impaired Services)

Foreign Language Interpreters A. Spanish

1. Interpreter Agency Name Address Telephone Number 2. AT&T Language Line B. Hmong 1. Interpreter Agency Name Address Telephone Number 2. AT&T Language Line C. Add languages as needed for your patient population II.

Hearing Impaired Services A. Sign Language 1. Interpreter Agency Name Address Telephone Number 2. AT&T Language Line B. TDD/TTY Device

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure. {Health Care Entity Name}

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Interpreter Services Billing Information Date of Service Provider of Service

Patient Name Account Number Date of Birth Address

Insurer

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Subject:

Hazardous Materials Management

Effective Date: Approved By: Review/Revision Date Signature Policy {HEALTH CARE ENITY} maintains a hazardous materials and waste management plan to control hazardous materials and waste. A hazardous material is any material in use that is considered to represent a threat to human life or health. A hazardous waste is a material no longer in use that represents such a threat. Once a material is used, contaminated or determined to be in excess of the amount required, it is considered waste. {HEALTH CARE ENITY} has a mechanism in place in the event of a hazardous material or waste spill. The {SAFETY OFFICER} maintains an inventory of hazardous materials. A “Spill Kit” containing the following items is readily available: Absorbents Isolation gowns Vinyl gloves Wet-Vac Plastic bags and containers Goggles Surgical masks Impervious shoe covers In the event of a spill, the MSDS for that material is reviewed and the proper procedures are followed. Purpose The purpose of the hazardous materials and waste management plan is: To identify, evaluate and inventory hazardous materials and waste generated or used consistent with applicable regulations and laws To provide adequate space and equipment for the safe handling and storage of hazardous materials and waste To establish emergency procedures to use during hazardous materials and waste spills or exposures To provide education to personnel on the elements of the Hazardous Materials and Waste Management Plan To address hazardous materials spills in a safe, appropriate and timely manner

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Procedure A. Identifying, evaluating and taking inventory of hazardous materials and waste 1. {DESIGNATED STAFF} are responsible for identifying and labeling hazardous materials and waste. Upon ordering of these materials, the {DESIGNATED STAFF} notifies the {SAFETY OFFICER} that hazardous materials are being ordered. 2. The {SAFETY OFFICER} maintains an inventory of hazardous materials within the organization. 3. A Material Safety Data Sheet (MSDS) is kept on site for every chemical used in the facility and identified as hazardous. B. Management of chemical waste and regulated medical waste (i.e., sharps) 1. Chemical waste is handled using the following procedures: a. The components of each type of chemical waste are clearly labeled. The label indicates that the material is hazardous waste and lists the components, the strength of the waste and type of hazard it represents. b. Chemical containers are picked up in carts and transported in tote boxes. c. Tote boxes are not over filled and the materials in a tote box are chemically compatible. d. Blood and blood product waste is disposed of in red plastic bags labeled as hazardous waste. e. Sharps, including hypodermic needles and syringes, suture needles, knife blades, trocars from drains and opened glass ampules of medication are disposed of in puncture-proof sharps containers. C. Hazardous Gas and Vapors 1. Regular visual inspection of compressed gas cylinders is performed to ensure cylinders are in safe condition. 2. Pressure relief safety devices meet the Compressed Gas Association (CGA) requirements. 3. Oxygen cylinders are stored a minimum of 20 feet from combustible materials. Cylinders are stored in a secure area to prevent access by unauthorized individuals.

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D. Storage and Handling 1.

Hazardous materials are stored in a designated area and are properly labeled.

2.

Materials that ignite easily (flammable) are stored in a cool, dry, well-ventilated area, away from areas of fire hazard. The flammable storage area has “Flammable Material” signs posted and is equipped with a fire extinguisher.

3.

Materials that are toxic or that can decompose into toxic components from contact with heat, moisture, acids or acid fumes are stored in a cool, well-ventilated area out of direct rays of the sun.

4.

Corrosive materials are stored in a cool, well-ventilated area, isolated from other materials.

5.

Personal protective clothing and equipment is used when handling these materials.

E. Hazardous materials or waste spills, exposures, and other incidents 1.

An incident report is completed on hazardous materials, waste spills and exposures.

2.

Major spill a. A spill is considered major under these conditions: •

A life threatening condition exists; the condition requires the assistance of emergency personnel



The condition requires the immediate evacuation of the building



The spill contains quantities greater than 2 liters



The contents of the spilled material are unknown



The spilled material is highly toxic, biohazardous, or flammable



Physical symptoms are present

b. Procedures for a major spill are:

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Determine what was spilled



Avoid inhaling



Evacuate the area; close doors



Notify the supervisor and the {SAFETY OFFICER}. Report the name of the spilled chemical, amount spilled and the location.



Direct clean up



For disposal of hazardous materials, refer to Hazardous Materials and Waste Management Plan

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3.

Minor spills a. A spill is considered minor under these conditions: •

A relatively small area is affected and only a small number of people need to leave the area until the spill is cleaned up

• The spill can be cleaned up without the assistance of emergency personnel b. Procedures for minor spills are: •

Put absorbent from the Spill Kit on the material if the material spilled is in liquid form (and if this can be done safely)



Notify the supervisor and the {SAFETY OFFICER}



Take appropriate action to remove the hazard



Clean up the area

For disposal of hazardous materials refer to Hazardous Materials and Waste Management Plan Emergency procedures •

4.

a. Identify the chemical before attempting to clean up hazardous chemical spill or splash b. Follow established procedures for cleaning up the specific chemical spill or leak c. Notify persons in the immediate area, the supervisor and the {SAFETY OFFICER} d. Evacuate patients and staff from the area; close doors e. Ensure adequate ventilation F. Orientation and education 1. Orientation and job training are provided for persons who manage or handle hazardous materials and waste. 2. Orientation includes information on the following: a. Precautions for selecting, handling, storing, using and disposing of hazardous materials b. Hazard communication procedures c. Location of policies and procedures, MSDS d. Emergency procedures in the event of an exposure or a spill e. Reporting procedures 3. Retraining is done annually and whenever a new hazard is introduced. Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Subject:

Infection Control

Effective Date: Approved By: Review/Revision Date Signature Policy {HEALTH CARE ENTITY} is committed to the prevention of disease transmission. Infection control is an ongoing, integrated process that facilitates effective methods of prevention and control of infection in patients, employees and visitors. The basis for prevention and control of infection is frequent thorough hand washing in conjunction with Universal Precautions. The risk of infection among employees can be lowered through compliance with immunization policies and post-exposure management. {HEALTH CARE ENTITY}’s staff, volunteers, contractors and residents/students use proper hand-washing techniques as part of the infection control program. Handwashing facilities are located throughout the facility near places of exposure and activity. In areas where sinks are unavailable, antimicrobial products that do not require water for use are available. {HEALTH CARE ENTITY} consistently uses blood and body precautions for all patients. All blood and certain body fluids are treated as if known to be infectious for HIV, HBV, HCV or other bloodborne pathogens. {HEALTH CARE ENTITY} provides personal protective equipment for employees who may have actual or potential exposure to blood or other potentially infectious materials within their job duties. Employees are trained in the use of personal protective equipment. Fluids that have been recognized by the Center for Disease Control as directly linked to the transmission of HBV and/or HIV are blood, blood products, semen, vaginal secretions, cerebrospinal fluid, amniotic fluid, concentrated HBV and HIV viruses in saliva in the dental setting, peritoneal and pericardial fluid. These precautions do not apply to feces, urine, sweat, tears, sputum, vomitus or breast milk unless they contain visible blood. However, proper hand washing technique is observed whenever contact is made with body secretions. {HEALTH CARE ENTITY} screens its employees for tuberculosis (Mantoux) upon hire and annually thereafter, using a “two-step” process{HEALTH CARE ENTITY} does not treat active tuberculosis; individuals with active disease are referred to the {STATE} Department of Health Tuberculosis Prevention and Control Program. {HEALTH CARE ENTITY} offers the Hepatitis B vaccination series to employees who reasonably anticipate occupation exposure. {HEALTH CARE ENTITY} provides a systematic response to blood or body fluid exposure. The vaccination series, post-exposure evaluation and follow-up are provided at no cost to the employee. Updates and ongoing education about infection control is communicated through in-services, annual training, newsletters, etc. and provides personal protective equipment 10-28

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Purpose The purpose is to ensure the safety and health of patients and employees by preventing the spread of infectious agents. Procedure Handwashing 1. Hands are washed a. b. c. d. e. f. g. h. i. j. 2.

Before starting work When visibly contaminated Before and after patient contact After removal of gloves and other protective equipment Before leaving clinical areas Before and after eating, drinking, smoking, applying make-up, changing contact lenses, using the lavatory, blowing or wiping the nose, or similar activities Before and after all activities that entail hand contact with mucous membranes or a break in the skin After handling specimen containers or other surfaces that may be contaminated Before performing invasive procedures Before handling medications

Handwashing Steps a. Wet hands thoroughly and apply a small amount of soap b. Keep fingers pointed down to avoid contaminating the arm c. Vigorously rub hands together for at least 15 seconds d. Wash carefully between fingers and at least tow inches above the wrist e. Rinse thoroughly with water in a downward motion

Universal Precautions 1. Employees, volunteers, and residents/students are trained in the use of universal precautions prior to beginning a job assignment. 2.

Health care workers wash hands before and after patient contact in accord with the Hand Washing Policy.

3.

Health care workers use barrier precautions to prevent skin and mucous membrane exposure when in contact with blood or body fluids of patients.

4.

Gloves are worn when: a. Touching blood or body fluids, mucous membranes or non-intact skin b. Handling items or surfaces soiled with body fluids c. Performing venipuncture or other invasive procedure d. Health care worker has cuts, scratches or other breaks in the skin e. Cleaning up spills that may contain body fluids f. Handling specimens g. There is potential for direct contact with blood or body fluids

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5.

Mask, protective eye wear (goggles or face shield), gown or apron are worn during procedures that are likely to generate splashes of blood or body fluids.

6.

Hand and skin surfaces are thoroughly washed with a germicidal agent immediately if contaminated with blood or body fluids.

7.

Blood and body fluid specimens are placed in well-constructed containers with secure lids to prevent leakage.

8.

Work surfaces are cleaned daily and as needed with an EPA registered tuberculocidal disinfectant agent.

9.

To prevent needle stick injuries, needles are never recapped, bent, broken or removed from disposable syringes. After use, needles and other sharp items are placed in a puncture proof container. Sharps containers are never manually opened or reused.

10. Containers for infectious waste are clearly marked with the biohazard symbol. These containers are lined with red leak-proof bags and have tight-fitting lids, with a footoperated mechanism Personal Protective Equipment 1.

2.

Gloves are worn when there is exposure to blood, body fluids or hazardous substances. The appropriate hand protection is selected depending on the task: a. Utility gloves for maintenance and scrubbing work. These are reusable. b. Sterile gloves for procedures involving contact with sterile areas. These are not reused. c. Examination gloves for patient diagnostic procedures not requiring sterile gloves. These are not reused. Masks are worn in conjunction with eye protection in the event of potential contamination through splashing or splattering of blood, body fluids or hazardous materials. Prescription glasses may be worn in lieu of goggles if they furnish adequate protection.

3.

Gowns and head coverings are worn when splashes of blood, body fluids, or hazardous materials are likely to occur. These are changed when they become soiled or wet.

4.

Shoes that cover the entire foot are required in areas where blood or body fluids are processed and in areas where hazardous materials may be spilled.

5.

Wash hands immediately after removal of personal protective equipment. Place used equipment in designated areas or containers.

Tuberculosis 1.

2. 10-30

Employees are screened for tuberculosis: a. Upon hire b. Annually c. When displaying symptoms of tuberculosis d. When there is a skin test conversion e. When exposed to a tuberculosis patient where appropriate precautions were not observed f. At termination of employment Employees who refuse tuberculosis screening sign a refusal statement EPNI Provider Policies and Procedures Manual (11/01/07)

Template Policies and Procedures

3. 4.

When triaging a patient with suspected tuberculosis, mask the patient and all employees who come in contact with the patient. Place the patient in an examination room apart from other patients. Use tuberculocidal disinfectants to clean the room after the patient has left. Conduct a screening test (Mantoux) for the patient. If the test is positive, refer the patient to the {STATE} Department of Health Tuberculosis Program. Alternatively, the provider may decide to immediately refer the patient to the state program.

Hepatitis B (Vaccination and Post Exposure Evaluation) 1. The HBV series is made available to employees who may reasonably anticipate occupational exposure after they have been trained and within ten working days of initial job assignment unless: a. The employee has received the HBV series b. Antibody testing reveals immunity c. Vaccine is contraindicated for medical reasons d. The employee refuses the HBV series 2. Employees who refuse to complete the HBV series sign a refusal statement. 3. If an employee receives a needle stick or other exposure to patient body fluids, she washes the area with germicidal immediately. In the case of eye contact, flush the eyes for five minutes. 4. Isolate the source of the exposure. 5. Report the incident to the {SAFETY OFFICER} immediately. Complete an incident report form. 6. Provide for a confidential medical evaluation for the employee, including baseline HBV, HCV and HIV testing. 7. Obtain consent and test source individual’s blood sample to determine a baseline for the source patient for HBV, HCV and HIV serological status. 8. Provide follow-up for the employee in accordance with current recommendations of the United States Health Service. 9. Provide counseling to the employee regarding precautions to be taken during the period after the exposure incident. The employee is also given information about potential illnesses to be alert for and is asked to report any related experiences. 10. For OSHA 200 record keeping purposes, an occupational bloodborne pathogen exposure incident is classified as an injury. It is recorded if it meets one of the following criteria: a. It is a work-related injury that involves loss of consciousness, transfer to another job, or restrictions of work or motion b. The incident results in the administration of medical treatment beyond first aid c. The incident results in a diagnosis of seroconversion. The serological status of the employee is not recorded on the OSHA 200. Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Subject:

Medical Emergency

Effective Date: Approved By: Review/Revision Date Signature Policy {HEALTH CARE ENTITY} has a mechanism is place to respond to medical emergencies. Full codes are not conducted at this facility. At least one currently certified CPR person is in the office whenever patients are present. The goal of the medical emergency response team is to stabilize the patient and to contact 911 emergency services if needed. Purpose The purpose is to safeguard the health and well being of patients. Procedure 1.

Upon discovery of a medical emergency, page {MEDICAL EMERGENCY} (use code word for your facility) and the location.

2.

Practitioners, nurses and other staff who are assigned to the medical emergency team respond. The practitioner directs assessment procedures. {STAFF PERSON} records the time and actions of the response.

3.

The {designated person} makes the determination if 911 is to be called.

4.

Staff not directly involved in responding to the medical emergency should maintain “business as usual” along with reassuring family members and other patients.

5.

Within 24 hours, evaluate the effectiveness of the response to the medical emergency

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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{Health Care Entity Name}

Subject:

Medication Management

Effective Date: Approved By: Review/Revision Date Signature Policy {HEALTH CARE ENTITY} has a mechanism in place to manage the procuring, storing, controlling and distributing of sample and stock medications. A licensed health care professional with prescription capabilities is present during facility hours. {HEALTH CARE ENTITY} has a mechanism in place to manage narcotics and other controlled substances. Narcotics stored in a manner that precludes unauthorized access; all such items are stored in a double locked cabinet. The Head Nurse or designee carries the keys to the cabinet during facility hours. After hours, they are locked in the security box. Controlled substances are signed out for use only by practitioners or by Registered Nurses. A count of items in the cabinet is completed and signed by two individuals at the beginning and at the end of each shift. Purpose The purpose is to provide guidelines for appropriate storage, use, and management of medications (including controlled substances) to ensure that legal requirements are met and to ensure safe distribution to patients. Procedures Procuring 1.

Stock medications are purchased. a. An assigned nursing staff person coordinates the purchasing process. b. The nursing staff person places the medications in the stock medication storage area.

2.

Drug company representatives provide sample drugs. a. An assigned nursing staff person coordinates the drug representatives’ time. Upon arrival at the facility, drug representatives check in with the front desk. They are given an identification tag if needed. They are escorted to other areas of the facility by the assigned nursing staff. b. Drug representatives, accompanied by the nursing staff person, place the sample drugs in the storage area and log in the sample drugs that they are providing to the provider.

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Storing 1.

Sample drugs and stock medications are stored in a secure area not accessible to patients.

2.

Access to the area is restricted to practitioners and assigned nursing personnel.

3.

Drugs are organized alphabetically within classes.

4.

Medications requiring refrigeration are stored in the medication refrigerator or freezer as appropriate. This refrigerator is used only for the storage of medications; i.e. no food or other items are stored in the medication refrigerator/freezer. Refrigerator and freezer temperatures are monitored daily.

Controlling 1.

The assigned {STAFF PERSON} maintains a stock medication inventory. Log information includes the lot number of the medication. Expiration dates are monitored. Medications are discarded prior to their expiration date.

2.

The assigned {STAFF PERSON} maintains an inventory of sample drugs. The drug representative who provides the sample logs the medication in. Log information includes the lot number of the drug. The drug representatives, in collaboration with the nursing staff person, are responsible for monitoring expiration dates and removing drugs prior to the expiration date.

3.

The Medical Director approves new medications prior to their addition to the inventory.

4.

Prescription pads are kept in a locked area when not with the provider. Needles and syringes are kept in a secure area.

Distributing 1.

Practitioners prescribe and dispense medications. As necessary, they communicate medication orders either verbally or in writing to nursing staff.

2.

The practitioner or the nursing staff person procures the medication, logs the transaction, and gives the medication to the patient.

3.

The practitioner is responsible for verification that the correct medication is given to the patient.

4.

Medications are labeled with the patient’s name, the name of the medication, the strength, dose and frequency, and lot number.

5.

Education about the medication, its effects, its administration and applicable monitoring procedures and follow-up is given to the patient at the time they receive the medication. The practitioner or the nursing staff document the education in the medical record.

Recalls 1.

Upon notification of a drug recall, the assigned {STAFF PERSON} removes the drug from the inventory and returns it to the drug representative or disposes of it according to the manufacturer’s instructions. This action is documented on the log.

2.

The log is checked to identify all patients that have received the drug. These patients are notified and requested to return any unused drugs to the provider and/or are advised of actions recommended by the manufacturer.

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Emergency Drugs 1.

The assigned {STAFF PERSON} maintains a stock emergency drug inventory. All emergency drugs are logged and include the lot number of the medication and the expiration date.

2.

Emergency drugs are kept secure at all times in an emergency drug cabinet with the use of a security lock.

3.

On a daily basis, the {STAFF PERSON} checks the integrity of security lock. This check also includes monitoring for expiration dates of emergency drugs. Documentation of this monitoring is noted on the daily check sheet. This information includes initials of person, date and time.

4.

If the security lock is broken, the assigned {STAFF PERSON} completes an inventory of entire emergency drug cabinet and inspects the emergency drugs against the inventory list. Any emergency drugs used, missing, or expired are immediately replaced.

Controlled Substances Count Procedures 1.

The Head Nurse or designee obtains the keys to the controlled substance cabinet from the security box upon arrival at the facility each morning.

2.

The Head Nurse or designee, in conjunction with another nursing staff person, counts the controlled substances and documents the count. The count information is recorded in the log. This information includes: •

Date and time



Drug counts



Signatures of both individuals doing the count

3.

Prior to the start of evening shift, the controlled substances are counted by the Head Nurse or designee and the evening Lead Nurse.

4.

A final count is conducted at the end of business hours each day. Two individuals conduct this count.

5.

The keys to the controlled substance cabinet are placed in the security lock box at the end of patient care hours each day.

6.

If a discrepancy in the count occurs, the nurses conducting the count are responsible for investigating and correcting discrepancies in the count.

7.

If a discrepancy is unable to be corrected, the outgoing nurse notifies the Manager immediately.

8.

An incident report is completed for all discrepancies in the count.

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Sign-out Procedures 1.

A practitioner’s order is required for the administration of controlled substances. The order may be oral or written. The order must specify the medication, dosage and route of administration.

2.

A Registered Nurse verifies the order prior to removal of the controlled substance from the locked cabinet.

3.

After verification of the order, the Registered Nurse obtains the appropriate medication from the locked cabinet and completes all fields on the sign-out log including:

4.



Patient name



Date



Name of drug



Dosage of drug



Signature, including credentials, of person accessing the box

If the dose is not a unit dose, wasting of the excess medication must be witnessed by two nurses or by a nurse and a practitioner. The amount wasted is documented and both witnesses sign the documentation.

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Subject:

Non-Medical Emergency Preparedness

Effective Date: Approved By: Review/Revision Date Signature Policy {HEALTH CARE ENTITY} has mechanisms in place to respond to emergencies such as power outages, severe weather, and bomb threats. Purpose The purpose is to ensure the safety of patients and employees. Procedure 1.

Power Outage In the case of power outages, flashlights are available in {SPECIFIC LOCATION}. The {SAFETY OFFICER} assesses the extent and duration of the outage and then makes a determination whether or not to close the facility. When it is necessary to close the facility, patients in the facility will be notified and escorted to the door. A notice will be placed on the exterior door. Patients who have appointments scheduled for later in the day are contacted about the closure of the facility. Their appointments are rescheduled.

2.

Weather Emergency In the event of a tornado warning, an announcement is made to advise patients, employees and visitors of the situation. Close doors. Employees, under the direction of the {SAFETY OFFICER}, guide patients and visitors to the lower level of the building. In buildings without a lower level, everyone moves to the center most location in the building. Patients and visitors are assisted in lying flat or crouching if possible, and in keeping their heads down. At the expiration of the tornado warning, the {SAFETY OFFICER} assesses the facility for damage or safety hazards. If the patient care area is safe, an “All Clear” announcement is made and employees, patients and visitors return to their previous activities. If the facility is damaged, an evacuation may be ordered.

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3.

Bomb Threat In the event of a bomb threat telephone call, keep the caller on the line as long as possible. Write down as much information as possible. Be alert to any distinguishing voice characteristics and to any background noises. Ask for the location of the bomb. If possible, notify a co-worker while you are on the telephone. The co-worker notifies the {SAFETY OFFICER} immediately. S/he calls 911. If the caller states that the bomb is going off immediately, call 911 before alerting the {SAFETY OFFICER}. The {SAFETY OFFICER} pages {FIRE ALERT} (use facility’s code for fire). Evacuate the building.

4.

Fire Ongoing Compliance •

Review local fire code regulations for compliance annually.



Post fire evacuation routes in all patient areas including exam rooms.



Fire drills are conducted annually. The {SAFETY COMMITTEE} evaluates the fire drill



In an emergency:



Upon discovery of a fire, rescue any patients in immediate danger.



Page {FIRE ALERT} (use facility’s code for fire) and the location of the fire.



{DESIGNATED EMPLOYEE/POSITION} calls 911.



Confine the fire. Do not endanger yourself or others in this process.

5.

Evacuate all persons from the building. The {DESIGNATED EMPLOYEE/POSITION} is responsible for ensuring that all persons have been evacuated.

6.

Resume usual operations when “All Clear” has been declared.

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Subject:

Treating Unaccompanied Minors

Effective Date: Approved By: Review/Revision Date Signature Policy {HEALTH CARE ENTITY} has a mechanism in place to treat unaccompanied Minors. Minors, particularly teens and pre-teens, frequently arrive for appointments without the accompaniment of a parent or guardian. A signed authorization consent for regular (i.e., noninvasive, non-complex) treatment is preferable to no consent or the minor going without medical care. The following guidelines apply to such situations unless one of the exceptions below is present. Purpose The purpose is to provide a clear guideline for all staff in the occurrence of an unaccompanied minor seeking treatment. Procedure General Rule Minor patients (under age 18) lack the legal capacity of consent to medical or dental treatment and the consent of a parent or legal guardian should be obtained. Step parents (unless legally adoptive), foster parents, other relatives, etc. have no recognized legal standing to consent on behalf of a minor. All parents and/or legal guardians should be encouraged to accompany their minor children to all medical or dental examinations and/or treatment. Exceptions Minors have the status of adults with respect to health care decisions if they fit in one of three categories: 1.

Emancipated minors – living apart from parents and managing own financial affairs (not necessarily financially independent)

2.

Married minors – minor has been or is married

3.

Minor mother – minor who has borne a child may consent on her own and on her child’s behalf

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Minors also may consent on their own behalf for diagnosis and treatment involving one of the following five medical conditions: 1.

Pregnancy and associated conditions (interpreted to include contraception). Exception: Abortions require notification of both parents.

2.

Venereal disease

3.

Alcohol or drug abuse

4.

Hepatitis B vaccination

5.

Emergency treatment

Finally, exceptions may exist based on the mature minor doctrine, i.e., a minor may legally consent to treatment if he/she is capable of understanding the nature and consequences, and can weigh alternatives, of the treatment. However, the legal status of this doctrine is unclear and it should be used only when absolutely necessary. Guidelines 1.

When an appointment is scheduled for a minor, the caller should be informed that, as a rule, minors cannot be evaluated or treated without the consent of a parent or legal guardian. The caller should be encouraged to have a parent or guardian accompany the patient to the appointment unless one of the exceptions mentioned above is applicable. The caller may also be informed of the availability of parental consent forms.

2.

If a minor shows up for an appointment without a parent or guardian, the following factors should be considered in making a determination whether or not to treat the patient: a. Nature of visit: i.e., a provider may choose to treat very minor self-limiting conditions or provide routine follow-up checks. b. Severity of illness/injury: e.g. emergency treatment may be provided without consent. For a less life threatening yet significant illness/injury, parental consent should be obtained if at all possible, or if there is any question that a patient might choose to remain untreated. c. Invasive procedures, unless in a true emergency, require parental consent.

3.

For routine health maintenance visits, an examination may be conducted, but the parent should be contacted to consent to routine treatment such as updating immunizations (except Hepatitis B), etc.

4.

For continuing treatment, where the parent has given consent at the outset of the proposed treatment/therapy program, treatment may be provided as long as it is within the scope of the original treatment plan. Any unforeseen complications, which require a change in the treatment plan, should be discussed with the parent.

5.

With the exception of treatment for pregnancy (including contraception), venereal disease, alcohol or drug abuse, a provider is encouraged to err on the side of obtaining parental consent for treatment of a minor. This may be done via phone contact when feasible. In some circumstances, evaluations or treatment may have to be delayed until consent can be obtained.

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

Attachment A {Health Care Entity Name}

Authorization to Consent to Treatment of a Minor To: Re: Date of Birth:

Medical Record Number:

, a minor

I hereby authorize _________________________________ (related to the above-named minor as his/her __________________________________________) to consent to such regular health care, including immunization procedures and allergy treatments, on the minor’s behalf as is necessary for the minor’s health and best interests. I also authorize the above-named person to act on my behalf in case the minor experiences a reaction to the authorized treatments or is a victim of injury or illness when immediate medical or surgical care is needed, provided diligent effort is made to notify me of the situation and obtain my preferences. If such efforts to contact me are unsuccessful, I authorize the abovenamed person to take such action and give such consent on the minor’s behalf as that person’s reasonable judgement dictates. I understand that this consent will last for one year unless I change my mind and withdraw by consent sooner in writing. If I withdraw consent, it will not affect actions already taken by

Date

Signature of person who is granting authority to consent

Relationship to minor Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

Attachment B {Health Care Entity Name}

Consent to Allergy Treatment for Unaccompanied Minor To: Re: Date of Birth:

Medical Record Number:

, a minor

I hereby authorize the doctors of ____________________________________ and such assistants as the doctors may designate to administer allergy treatments to the above-named minor at such intervals as are necessary for the minor’s health and best interests. The treatments may be administered whether or not such minor is alone or accompanied by another adult or me. In case the minor experiences a reaction to the authorized allergy treatments, I understand that you will make every effort reasonable under the circumstances to notify me of the situation and obtain my preferences. If such efforts to contact me are unsuccessful or if the situation requires action without delay, I authorize the above named _________________________ personnel to take such action as is medically necessary on the minor’s behalf. I understand that this consent will last for one year unless I change my mind and withdraw by consent sooner in writing. If I withdraw consent, it will not affect actions already taken by

Date

Signature of person who is granting authority to consent

Relationship to minor Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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Template Policies and Procedures

{Health Care Entity Name}

Subject:

Behavioral Health Accessibility Standards

Effective Date: Approved By: Review/Revision Date Signature Policy [HEALTH CARE ENTITY] will ensure timely access to mental health and chemical dependency appointments. [HEALTH CARE ENTITY] will monitor performance and take actions to improve performance when performance is below its standards. Purpose Ensure that the clinical need (emergent, urgent, and routine) of the patient is addressed with the appropriate level of care when accessing behavioral health care services. Definitions Life-threatening emergency care

A circumstance in which there is imminent risk of danger to the physical integrity of the individual; the individual cannot be maintained safely in his or her typical daily environment. Standard: 100% of the time seen immediately.

Non-life-threatening emergency care

A circumstance in which the individual is experiencing a severe disturbance in mood, behavior, thought, or judgment. There may be evidence of uncontrolled behavior and/or deterioration in ability to function independently that could potentially require intense observation, restraint, or isolation. Standard: 100% of the time seen within 6 hours.

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Template Policies and Procedures

Urgent care

A circumstance in which the individual presents no emergency or immediate danger to self or others; however, the individual, clinician, or concerned party believes that the individual’s level of distress and/or functioning warrants assessment as soon as possible. An urgent condition is a situation that has the potential to become an emergency in the absence of prompt treatment. Standard: 100% of the time seen within 24 hours.

Routine care

A circumstance in which the individual does not present either emergent or urgent conditions and requests clinical services. Standard: 90% of the time seen within 10 business days.

Follow-up care

A circumstance in which the individual has undergone an assessment and commenced treatment for a non-emergent or non-urgent mental disorder. Standard: 90% of the time seen within 10 business days

24 hours/7 days

A practice site will provide crisis access to a clinician twenty-four hours per day, seven days per week.

per week accessibility Standard: 100% of time practice site accessible 24 hrs/7 days

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Template Policies and Procedures

Procedure 1.

Intake phase [HEALTH CARE ENTITY] administrative staff member receives a telephone call from new/returning patient and documents the following.

Name, date and time of call, person calling and telephone number(s). Request for service type and reason for request. If the caller does not identify an emergent/urgent clinical need, an appointment will be scheduled within ten business days of the call. • If the caller identifies an emergent/urgent service need, the administrative staff person will transfer the call to a clinician for triage. 2. Triage phase • • •

A clinician will complete a triage assessment for emergent/urgent service requests based upon clinic protocols and make a recommendation for level of care. 3.

Scheduling phase

If the caller identifies a life-threatening emergency, the caller is advised to seek care at the Emergency Room of the nearest appropriate hospital. Access to ER care is facilitated by obtaining the agreement of the caller to seek ER treatment and ascertaining his/her ability to be safely transported. The clinician will direct the caller to the identified ER and notify the ER of the recommendation. • If the caller does not agree to the ER recommendation or is not able to be safely transported, emergency assistance will be obtained via 911. The clinician may flag another staff member to call emergency service, while maintaining contact with the caller until emergency service arrives at the caller’s location. • For an assessment that results in a non-life-threatening emergent appointment recommendation, an appointment is scheduled within six hours of the call. • For an assessment that results in an urgent appointment recommendation, an appointment is scheduled within 24 hours of the call. • For an assessment that results in a routine appointment recommendation, an appointment is made within ten business days of the call. • The clinician may request the assistance of administrative staff to schedule the outpatient appointment. • Appointment date and time are confirmed; practitioner’s name and caller instructions are given. • If an appointment is not available within the timeframe standard for non-life-threatening emergency or urgent need, the clinician/ administrative staff member will locate a provider that is able to provide an appointment within the standard or actively facilitate the caller obtaining assistance from the appropriate health plan. 4. Appointment verification •

The clinical/administrative staff member will confirm life-threatening emergency care at the identified ER within an hour of the call. 5.

Appointment accessibility monitoring Activity

Frequency

EPNI Provider Policies and Procedures Manual (11/01/07)

Process

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Template Policies and Procedures

Accessibility Performance Report

Semiannual

Number calls/month Number/percent of appointment types met

Disclaimer EPNI provides these policies and procedures as samples only. EPNI makes no representations or warranties regarding the completeness or accuracy of such policies and procedures; nor, does it represent or warrant that these policies and procedures meet all applicable requirements of any federal or state law, regulation, rule, or order. These policies should not be construed as legal advice, and the provider should consult its own legal counsel and/or liability carrier prior to implementing any new policy or procedure.

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