Medicaid / Provider Workgroup meets in Atlanta - October 28, 2009

A group of GAMES / GRTC providers met with representatives of DCH earlier this week to resolve some of the ongoing billing and procedural issues resulting from the recent changes to the Medicaid fee schedule & policies.
 
During the over 90 minute meeting, we simply were not able to address all of the issues raised by GAMES / GRTC members, however, we made some good progress.  More detailed notes are being prepared by Chip Fiske, GRTC Chair.  In the meantime, here are some important highlights.
 
PA’s are currently taking up to 30 days to be approved
While it is not their preferred standard, GMCF is in compliance. They have up to 30 business days to approve / deny. GMCF offered that the additional codes are requiring more detailed review and therefore extending the review time. They are aware of the concerns and are working through the learning curve.
    
Providers request consideration for pushing back the reprocessing (recoupment) date from November 1, 2009
Medicaid representatives agreed to present this request to Financial Services and to Jerry Dubberly, Medicaid Director for consideration. A decision is expected by COB Oct. 29. (Nothing yet at press time.)
 
Batteries – Denying for no PA
There is currently a conflict regarding requiring a PA or not requiring a PA. Medicaid and GMCF representatives will review and get back to us. These should not be denying.
 
E1340 U1 being denied for PA, when is under $200
While modifier U2 does not require a PA for repair services under $200; the U1 modifier used to bill for labor requires a PA always. 
 
Repairs for deleted codes K0010, K0012 under $200 and over $200 –need clarification on the procedure for changing the WC code without impacting payments made prior to 07/01/09
When billing the wheel chair base codes (K0010 and K0012) with the repair/labor code E1340, provider must update the PA with the new CPT Code K0800-K0813, and K013-K0865.
 
K0108 approved list:
(1) The list is incomplete. What is the process for adding items not currently on the list?
For wheelchair assessor services not already on Appendix E, providers will identify directly on the PA request—advising of request for consideration for service to be added to Appendix E. GMCF will determine medical necessity of the item being requested and make recommendation for coverage to DCH. If medically necessary, DCH will then approve and add to Appendix E (K0108 approval list); and post at next manual update. Providers need to make sure they note on MSRP invoice submitted with PA that this item is a K0108, and whether or not it is on the approved K0108 List.
 
(2) Some approved products are manufacturer specific product names where the same product will be called a different name by another manufacturer.
For wheelchair accessory supply/services already on Appendix E under a specific name, the provider will advise (in the narrative section) of the standard name/crosswalk. (For example: a Foot Positioner, Shoe Holder, or Shoe Sandal – all are different manufacturer’s description for the same item, which is on page E-3 of Appendix E as Foot Positioners, Large 9-12.) GMCF will approve accordingly, if the item is found to be medically necessary/appropriate.
 
Nebulizers & Wellcare
CMO’s were given DCH rates on Sept. 29.  They have 45 days to implement changes, so the new pricing should be in effect Nov. 2. 

DCH to hold DME Training Workshop
CLICK HERE for details.

August 31 - Question from Ms. Weesie Walker, NSM, GAMES / GRTC. Response from Ms. Margie Preston, GA DCH

From Weesie:
That still leaves the question about billing the accessories for standers. Standers are configured for the individual.

I have contacted three manufacturers, Altimate, Prime Engineering and Snug Seat. I will forward their comments to you as I receive them.

From Ms. Preston:
Yes, that was my understanding of our discussion. Since standers are not considered wheelchair accessories, billing them using K0108 was incorrect. As stated, during the telephone conference, we are open to considering reasonable suggestions for appropriate alternate codes.  Keep in mind, in accordance with established DCH policies and procedures, unlisted, unspecified, or not otherwise specified (NOS) HCPCS codes may not be considered.  
 
We look forward to hearing from you on this matter. 

August 28 - Question from Ms. Weesie Walker, NSM, GAMES / GRTC. Response from Ms. Margie Preston, GA DCH

From Weesie:
Your answer says
MP: Providers should continue to submit HCPCS codes E0637, E0638, E800[Margie Preston] 00, E0801, and E0802.  According to the HCPCS code description, E0800-E0802 Gait trainer, includes all accessories and components and are not eligible for additional accessories or modifications.

Can you share the link to this description for Codes E0800, E0637, E0638, etc.?

From Ms. Preston:
Ms. Walker,

I apologize for the typos on the codes E8000 codes.  Correction, the gait trainer and stander codes you referred to during our telephone discussion were E0637 and E0368, and E8000-E80002 (not E0800-E0802).  The HCPCS descriptions are as follows; I’ve also scanned and attached an excerpt from the 2009 Professional HCPCS Book

HCPCS Code

Description

E0637

Combination sit to stand system, any size including pediatric, with seat lift feature, with or without wheels

E0638

Standing frame system, one position (e.g. upright, supine or prone stander), any size including pediatric, with or without wheels

E8000

Gait trainer, pediatric size, posterior support, includes all accessories and components

E8001

Gait trainer, pediatric size, upright support, includes all accessories and components

E8002

Gait trainer, pediatric size, anterior support, includes all accessories and components

Statement should read: MP: Providers should continue to submit HCPCS codes E0637, E0638, E8000, E8001, and E8002.  According to the HCPCS code description, E8000-E8002 Gait trainer, includes all accessories and components and are not eligible for additional accessories or modifications. 

As stated according to the HCPCS description, E8000-E80002, include all accessories and components, seemingly negating billing additional components.

August 26, 2009 - The following questions were discussed in a phone conversation between Ms. Weesie Walker, NSM, GAMES / GRTC, Ms. Margie Preston, GA DCH and Ms. Lindsay Ryan, GA DCH. The answers are written in red.

Questions From GA Providers Regarding Reprocessing & PA Updates

1. When will reprocessing begin?
Reprocessing will begin within 60 days of the codes becoming available.
This puts the date at November 1, 2009.

2. What is the payment methodology for K0108?
The payment methodology for approved wheelchair accessory services without a unique HCPCS code remains the same:  100% of Manufacturer’s quote up to the established cap rate in system—unless and until otherwise notified (MP).

3. What is the exact method for recoupment?
Recoupment will be through deduction from Remittance. Claims will be automatically pulled back through for reprocessing on or after November 1, 2009. Providers will see the payment changes on RA.

4. Are providers responsible for recoding claims?
In some cases, codes are no longer valid s, i.e., K0010 and K0011, will just show denied on the RA after reprocessing.
Providers will be required to modify the PA to include the replacement code (K0008*, K0009*, etc) and resubmit with correct codes. Some examples, K0010 and K0011.
(*Correction per Weesie: K0011 replacement codes will be K0848 - K0886. K0010 replacment codes will be K0820 - K0843.)
On E1161, providers will have to modify PA’s to add additional codes for accessories and then resubmit the updated claim.

5. In the case of E1161, reprocessing would include adding additional codes for accessories. How will these resubmittals be handled? 
     On E1161, providers will have to modify PA’s to add additional codes for Accessories and then resubmit the updated claim

6. Reprocessing paid claims is a duplicate process of submitting for prior approval.
How will DCH and GMCF handle the huge increase in submittals? Currently, NSM has 49 claims with date of service on or after July 1. And, we have 28 orders that have not yet been delivered and 58 claims in for prior approval. This is total of 135 claims from just one provider. The total number must be close to 3,000.
DCH estimates that the number of claims to be reprocessed is much lower. GMCF is aware of the additional work load due to all the resubmittals and requests for PA modification. DCH suggests that providers could begin PA modification requests as soon as the system is updates (September 1), prior to November 1.  PA’s or claims updated with the unique HCPCS code and rate, prior to the automatic system reprocessing, will result in a net $0 effect.

7. How does reprocessing work when Medicaid is secondary? Will 20% co-pays be recouped?    
Yes. Any claim submitted to Medicaid whether it is primary or secondary is subject to reprocessing.
LR: It is unknown what the recouped amounts will be. The amount paid by Medicaid (or coinsurance) will be determined by the allowed amount by Medicare in conjunction with Medicaid (which pays the lesser of); therefore, the reimbursement may increase, decrease, or see no change.          

8. Have maximum units for accessories provided as pairs been corrected? Currently  the maximum amount is 1 each.   Now, there are many accessories that would be billed as 2 ea. Or 1 pair. 
MP: Codes specifying bilateral or units greater than one, have been updated in the system. Additional considerations may be given to those codes that may require units greater than 2.
LR: Codes of concern include E0956, E0957, and E1028.

9. Any  K0108 processed against a claim payment is not subject to reprocessing. Please explain. 
      K0108 codes that were already processed and paid, does not require PA modification.

10. What code should providers use to bill for stander and gait trainer accessories? We were using E1399 in the past?
MP: Providers should continue to submit HCPCS codes E0637, E0638, E0800, E0801, and E0802.  According to the HCPCS code description, E0800-E0802 Gait trainer, includes all accessories and components and are not eligible for additional accessories or modifications. 
MP: Regarding billing additional accessories with E0637 and E0638, the Department is open to discussing reasonable recommendations. 
GRTC will contact manufacturers of these products for input on codes for accessories. At this time, there are no codes available from Medicaid
DCH and ACS are planning provider training workshops to be located in three different regions. They hope to have the first one scheduled by the end of next week.
These workshops will go over the process of requesting PA modifications and resubmittal of claims. This will be a hands on workshop.
Representatives from DCH will be present to answer questions.
 

August 21 - Question from Ed Cockman, Family Health Care and Answer from Lindsay Ryan, GA DCH

Lindsey,
We got the attached message when inputting K0040NU into a new PA.  It is listed as a valid code in the SMAP-DME.  Any suggestions?

Mr. Cockman,
Code K0040 is included in the list of “new” codes which won’t be available in the system until September 1, 2009. Please refer to previous provider communications.

Regards,
Lindsay Ryan
Program Specialist II
Medical Policy
lryan@dch.ga.gov

August 20, 2009 - Questions from Weesie Walker, GRTC, GAMES and Answers from Lindsay Ryan, GA DCH

How will the money be recouped?  What is the exact process?
A Mass Adjustment Form will be completed internally and submitted to ACS. Claims are reprocessed by voiding a previously paid claim then reprocessing that same claim to get the result intended for the reprocessing. This will adjust the reimbursement to reflect 80% of the 2007 CMS rate. 

How long will the resubmittal process take?
Once the process is initiated, the systematic resubmittal process occurs immediately following the void and takes seconds per claim. No intervention is required from the provider. 

If providers are submitting for new/different codes, are these PA’s subject to be denied? (I am speaking specifically about claims that have been paid) 
No, a request to update an EXISTING PA using new/different code is not subject to denial, provided the new/different code is for approved services. 

In the case of E1161, providers will be submitting for new codes on services already provided. Will DCH require updated documentation from therapists and physicians as well?
The process requires updating EXISTING PA and should have been documented at the time of the original PA request.  All E1161 PA’s that initially paid the global rate, requires the provider to update the EXISTING PA by: 
a)                   including separate codes for the wheelchair (E1161) and ALL applicable unique modification and component codes
b)                   updating the claim using the same PA number (with the updated information) and separate codes for the wheelchair (E1161) and ALL applicable unique modification and component codes
c)                   voiding and resubmitting the updated claim

Is the department adding staff to handle this huge load of reprocessing? No. The process is systematic and not additional staff is needed.   

It may be more beneficial to schedule a face to face meeting with GAMES, GMCF and DCH to fully discuss our concerns. Providers need to know what the process will be, how long it will take and how this money is to be recouped. 

No direct provider intervention is required prior to or during the systematic claim reprocessing event. Provider intervention is limited to updating outstanding K0108 PA’s and E1161 PA’s and reprocessed claims, as indicated above. 

The amount of monies to be recouped or repaid will is not known until the actual process has occurred.

August 18, 2009 - questions from Ed Cockman, Family Health Care, and answers from Margie Preston, GA DCH regarding reprocessing of claims filed / paid after July 1, 2009

  1. Will all codes billed since 7/1/09 be reprocessed?  [Margie Preston] Yes For instance, will E1390 which paid $198.00 in July 2009 be reprocessed to the new rate of $158.72, recouping 39.28? [Margie Preston] yes (calculations not validated) If so, this would involve hundreds of claims for each and every provider in the state that would have to be recouped and adjusted, resulting in an accounting nightmare.[Margie Preston]  Claim reprocessing to implement new rate changes and to correct over and/or under payment is an established business practice that occurs following all rate changes for all providers. For instance, in 2005, a legislative order rate change was implemented and impacted over 5,000 professional service codes, billed by physicians.   
  1. Will a nebulizer, E0570NU, which was billed and paid as a purchase ($108.00) be reprocessed as a rental, since there is no corresponding E0570 NU in the new codes. No it shouldn’t.  Or would the E0570NU need a new retroactive PA, because it is included in Appendix D?[Margie Preston]  A new PA will only be required for services after September 1, 2009.  Will double check with Lindsay to validate 
  1. Will the enteral codes such as B4150 – B4155, which have valid CMS codes and established 2007 rates, be open for use after Sept. 1, since they are not included in either SMAP DME or Appendix D?  Will claims for those codes be reprocessed for July and August?[Margie Preston]  No.  enternal codes were not considered at this time.  The only new codes considered/added for this period were complex rehab codes used to replace K0108 and unique codes to report already approved services.  We are happy to consider codes for additional services. But can we get through this process first? 
  1. Codes for enteral supplies, such as B4034, B4035, and B4036, which are valid CMS codes are not in SMAP DME or Appendix D, but they are valid CMS HCPCS codes.  Will they be open Sept. 1?  These codes did not require a PA in the past, what about now? 
  1. The old Medicaid manual included rental of an enteral pump in the code B4035.  Under the CMS HCPCS codes, the allowable for B4035 does not include the pump; there is a separate code for enteral pump, B9002.  If this code is valid after Sept 1, will it require a PA?  If the B4035 code is reprocessed for July and August, can we bill for B9002 for July and August, and would that require a retroactive PA? 
  1. What about the whole issue of capped rentals and modifiers KH, KI, and KJ.  Will capped rentals cap after 13 months as per CMS policy, or 10 months as specified in the old Medicaid manual?[Margie Preston]  You’re going to forward information indicating the 13 months rentals? 
  1. Will codes not specifically listed in the GA Medicaid DME Manual be non-covered items? 
  1. How will codes like E0241 – E0246 be priced?  As listed in the new manual, they are BR, requiring a PA with quote.  My understanding now is that a PA is not required.  These items do not have CMS 2007 rates. 
  1. Will an updated manual be published to reflect, for instance, those items that now do not require a PA, or will the July 2009 manual remain as the latest manual published.

     

August 17, 2009 - Correspondence between Weesie Walker, GAMES Director, GRTC member, and Margie Preston, GA DCH

Weesie's request:
 

The reprocessing has not been clearly laid out. Providers are not sure how this will take place.
 
Can you give us the step by step details?
 
Again, GAMES and GRTC feel that this is putting an unnecessary burden on providers to void claims and resubmit. It appears that providers will be submitting twice for every claim paid on or after July 1.  We would like to know what your expectation is for the reprocessing. How long will it take? Is the department prepared to handle the thousands of claims in addition to normal amount?
How will the department recoup money?
How long will modification of the PA take?
 
 
As I talk to more and more providers from around the state, I realize that there is much confusion and misunderstanding. Any information you can provide would help to provide a better understanding.

Ms. Preston's response:

Ms. Walker,
So as not to further complicate the process, we conferred with our claims resolution subject matter expert, who offered that “claims are reprocessed by voiding a previously paid claim then reprocessing that same claim to get the result intended for the reprocessing.” The intended result is to make accurate reimbursement in accordance with the defined methodology and to correct previous claims over and/or underpayments. 
 
  1. For instance, E1161 had previously reimbursed at $3,855.53 prior to July 1, 2009.
  2. The correct reimbursement for this code is $ 1,892.87; which is 80% of CMS 2007 DME rate. 
  3. The reprocessing effort will void the $3,855.53 payment; then reprocess the claim and pay the correct $1,892.97 rate for a net difference of -$1962.66.
  4. The reprocessed transaction claim number (TCN) is preceded by the number 4 on the claim remittance advise (RA).
 
I hope this helps,
 
Thanks,
Margie:-)

 

 

Questions and answers in response to the May 14, 2009 Public Notice of new Medicaid maximum allowables for DME

Q:      Will the 2007 Medicare fees replace the current Medicaid fees even in the cases where the 2007 schedule would result in higher fees and would increase the Medicaid fee schedule. 
A:      yes
 
Q:      If there are codes in the 2007 Medicare fee schedule but they are not currently on the Medicaid list, will they be added or opened?
A:      This will be a case by case basis. 
 
Additional information:  if the code was not added until after the 2007 schedule, it will be allowed at 80% of the fee from the year it was added. For example if a code was added in the 2008 Medicare fee schedule it would be added at 80% of that years fee, or if it was added in the 2009 Medicare fee schedule it would be added at that years fee.  
 
Q:      How does this effect co-pays? 

A:      Coming soon
Q:      How should a provider submit comments? 
A:      Citizens wishing to comment in writing on any of the proposed changes should do so on or before June 4, 2009, to the Board of Community Health, Post Office Box 1966, Atlanta, Georgia 30303.
Also there is opportunity to submit written comments electronically to dbevelle@dch.ga.gov (attn: Deborah Bevelle for Board of Community Health Public Hearing) or fax 404 651 6880.
 
Q:     Whom should we notify if we want to offer public comment on May 26, 2009, 1:00 p.m., at the Department of Community Health (2 Peachtree Street, N.W., Atlanta, Georgia 30303) in the Fifth Floor Board Room?
 A.     No prior notification is required. Citizens wishing to comment should attend the meeting and sign in at the door. There will be two sign in sheets - one is for attendees and the other is a sign-up to speak. If you wish to speak, you need to sign both. The proceeding attorney for the hearing will allow each person on the speaking list a certain time (5-10 minutes) to make comments.