Alabama Hospital Association



ALABAMA HOSPITAL ASSOCIATIONRIC/RAC 2019 SPRING MEETINGMEDICAIDFACILITATORS: WESLEY ASHMOREKAREN NORTHCUTTMEDICAID:SOLOMON WILLIAMSSUSAN WATKINSCALLIE JOHNSONTORI NIXPROCEEDINGS held at the Wynlakes Golf & Country Club, 7900 Wynlakes Boulevard, Montgomery, Alabama, on March 18th, 2019, commencing at approximately 1:30 p.m.; and reported by Sara Wilson, Certified Court Reporter and Commissioner for the State ofAlabama at Large.MR. ASHMORE: I'd like to thank Solomon Williams, Callie Johnson, Susan Watkins, and Tori Nix from Medicaid for being here today with us. Thank you. If y'all are ready, we can go ahead and dive into the first question. MR. WILLIAMS: We're ready. MR. ASHMORE: The first question is a follow-up to a prior RIC/RAC meeting. Since providers are receiving medical necessity denials, they need the rationale from the LCD in order for them to research and respond to the denials. We need Medicaid to publish the LCD guidelines. F/U # 1 to New Q1Since providers are receiving Medical Necessity denials, they need the rationale from the LCD in order for them to research and respond to the denial. We need Medicaid to publish the LCD guidelines.Response: Medicaid no longer publishes a list of local determination codes. Please forward specific questions regarding denied claims to Callie Johnson callie.johnson@medicaid.. Additional Discussion:MR. WILLIAMS: We no longer publish LCD guidelines, but if you are experiencing denials for specific claim issues, please forward those claims to us. Callie Johnson is the new contact for the hospital claims, outpatient/inpatient claims, so she should be able to -- she will be able to research those for you. AUDIENCE: Who is that, Solomon? MR. WILLIAMS: Callie Johnson. AUDIENCE: Callie? MR. SOLOMON: Yes. And by the way, Callie is the new nurse for the hospital program. As most of you probably remember Jan Sticka, she's Jan Sticka's replacement. So she's your new contact for claims issues for the hospital program. MR. ASHMORE: Okay. And it looks like her email address is here, so everybody should have a copy of that in your packet; correct? Okay. All right. Do we have any follow-up questions? All right. Moving on to our new questions. This will be our first new question. Would it be possible for Medicaid to provide hospitals with a list of diagnosis codes from the diagnosis group types used for payment on certain drugs? For example, HCPCS code J0897, we've been told that we need a primary diagnosis code from the group 4045, and secondary from group 4046; or primary dx code from group 4047, and secondary from group 4048. Or primary code 4049. What are these different groups, and is there a complete list of drugs and approved diagnosis codes required for payment? Q1-Would it be possible for Medicaid to provide hospitals with the list of diagnosis codes from the “diagnosis group types” used for payment of certain drugs? For example, for HCPCS code J0897 (denosumab injection, 1mg) we have been told that we need a primary dx code from group 4045 and secondary from group 4046; or primary dx code from group 4047 and secondary from 4048; or primary code from 4049. What are these different groups and is there a complete list of drugs and the group diagnosis code(s) required for payment?Response: No. There is no list at this time. Providers should contact their DXC provider representative at 1-855-523-9170 or the DXC claims help desk at 1-800-456-1242 for assistance with specific questions.Additional Discussion:MR. WILLIAMS: Unfortunately, there's not a list at this time, and we kind of addressed this question. We've had this specific question or a question similar to this one previously. At this time, we do not have a list; but if you're having specific issues or questions, please feel free to reach out to your provider rep, or you can call the agency directly. You can call our pharmacy department, and that number is 334-242-5050, and there will be someone there to answer your specific questions. AUDIENCE: Solomon, quickly, it's a very difficult position the hospitals are in here, because you have coverage requirements or guidelines that Medicaid applies after the claim has been filed. You know, kind of the reason why we need this information is so at the front end we know if this patient comes in they have X, Medicaid is not going to cover that. It's kind of -- It's difficult to be in that position, if we can't tell the patient up front, well, you know, Medicaid doesn't cover this or your condition. So we can go through either like a charity policy or maybe the patient wants to pay out of pocket. We can't have those conversations if we don't know until after the claim has been denied what Medicaid actually covers. Does that make sense? So this is definitely information that we need. And, you know, other providers give us this information, and so I don't understand why this is something that can be published. MR. WILLIAMS: Okay. Previously, when ICD 9, I guess, was in effect, you know, there was a list. And I think at that time, the maintenance of that list was kind of difficult. And with ICD 10, what I've been told it's just a little more difficult for the pharmacy team to manage. And all I can do is take your concerns back. I mean, generally speaking or asking, are all of you having the same issues, multiple hospitals or facilities, or it's just isolated? AUDIENCE: Yes. MR. WILLIAMS: Okay. I can take your concerns back and, you know, try and get it addressed for you. But at this time, I just don't have anything, other than, you know, if you're having specific issues on multiple diagnoses, just please call in to the agency and we will do what we can to assist you. AUDIENCE: The only thing I would add, is that if these edits are already built in the claims processing system, it seems like you could just dump that into a table and update it periodically and say, here's what the current codes are. I mean, that certainly would give us a starting place. And it's one thing to say that pneumonia is covered, and so we know that all these other codes are related they're going to be covered, too. But right now, we only have a starting point to kind of understand or to go from that. MR. WILLIAMS: Okay. And I certainly understand. I mean, this is a little beyond my expertise, this is sounding like it's in a total different area than my area, but I will take your concerns back and certainly see if I can get your concerns addressed. AUDIENCE: Thanks. AUDIENCE: Solomon, it's not just the drugs. It's also -- It could be numerous amounts of different things where they'll come back and they'll deny your claim saying this diagnosis isn't covered for this group. Well, you don't know what diagnosis are in that group. So, I mean, it's not just drugs. It's a lot of different things. MR. WILLIAMS: Okay, Fran. Thanks. AUDIENCE: And what we're experiencing is when you do call the help desk or you've reached one of the provider reps, they are not able to give us the information. MR. WILLIAMS: Okay. Until we get a list or until we're able to do something for you, I would just suggest you call directly in to the agency, and the number that I read out earlier, I'll give it toyou once again. It's 334-242-5050. And should be able to help you. AUDIENCE: Will you repeat that number? MR. WILLIAMS: It's 334-242-5050. MR. ASHMORE: All right. Any other? MR. WILLIAMS: Yeah. I was just going to add, certainly if you don't get help or don't get your issues resolved, you know, feel free to reach out to me, which most of you do. MR. ASHMORE: All right. Moving to question number 2. Does Medicaid cover car seat testing codes 94780 and 94781? Q2-Does Medicaid cover car seat testing codes 94780 and 94781? Response: This is not a covered service.Additional Discussion:MR. WILLIAMS: No. It's not a covered service at this time. MR. ASHMORE: Okay. I'm not seeing any follow-up questions. We'll move on to question number 3. Does Medicaid cover the services of a lactation specialist? If so, what CPT codes would be utilized to bill these services? Q3-Does Medicaid cover the services of a lactation specialist? If so what CPT codes would be utilized to bill these services?Response: This is not a covered service.Additional Discussion:MR. WILLIAMS: And again, that's not a covered service either. MR. ASHMORE: Moving to question number 4. Please review when it is appropriate to bill inpatient rehabilitation with an acute care revenue code. Q4-Please review when it is appropriate to bill inpatient rehabilitation with an acute care revenue code.Response: Inpatient rehabilitation services that are provided as part of a recipient’s plan of care during a medically necessary acute care hospital inpatient stay that meet Medicaid’s Adult and Pediatric (SI/IS) inpatient care criteria are covered under the facility’s all-inclusive daily per diem rate and can be billed with an acute care revenue code (eg. 110 or 120). Inpatient rehabilitation services, when billed appropriately under revenue code 128 and provided to a recipient admitted to a lower than acute care rehab subpart unit, are not covered and should be submitted for crossover claims processing only.Additional Discussion: MR. WILLIAMS: Just generally speaking, inpatient rehab services are provided as part of the recipient's plan of care during medically necessary stay that meet our, or Medicaid's, development patient. Pediatric inpatient care criteria are covered under the facilities all-inclusive per diem rate. You know, in the situation where you have rehab services are being provided, and the recipient is no longer in acute care phase of the stay and they can step down to a lower-than-acute-care unit, then we only cover those services for crossover claim billing only. MR. ASHMORE: Any questions from the floor? All right. Moving to our final question here, question number 5. Please provide guidance on how to bill for an incomplete colonoscopy that is repeated due to poor prep or other extenuating circumstance. For example, the physician performs a colonoscopy and the scope is advanced into the cecum. However, due to poor prep that colon cannot be fully visualized. The colonoscopy is repeated on another day with no issues. So for Medicare the hospital would like to verify that we should use from the processing manual on Chapter 18, which states use modifier -73 or -74. So could you provide your instructions? Q5-Please provide guidance on how to bill for an incomplete colonoscopy that is repeated due to poor prep or other extenuating circumstance. For example, the physician performs a colonoscopy and the scope is advanced to the cecum. However, due to poor prep the colon cannot be fully visualized. The colonoscopy is repeated on another day with no issues. For Medicare we would like to verify that we should follow the instruction in the Medicare Claims Processing manual chapter 18 which states to use modifier -73 or -74. For the other payors, please provide instruction that will allow payment for both colonoscopies.Response: For the example above, modifier -73 or -74 would be appropriate for the facility. Additional request - Ask Medicaid for latest updates.Response: Please visit the Alabama Medicaid Newsroom @ medicaid.news.aspx for the latest updates.Additional Discussion:MR. WILLIAMS: For the example, I mean, our feeling would be the same, to use modifier -73 or -74. MR. ASHMORE: Any final questions? Because I know I think our last question here is, is there any updates that Medicaid would like to amend to the group? MR. WILLIAMS: No specific updates, but just a reminder that you can always go to our website or newsroom link, and I placed the link there for you if you would like to take a look at any updates. MR. ASHMORE: Anything else before we conclude the Medicaid portion? AUDIENCE: Mr. Williams, will you be available after this session for a one-on-one question? MR. WILLIAMS: Absolutely. Just for you. MR. ASHMORE: All right. AUDIENCE: Just this week, we had something kind of unusual come up, and it may have been happening and I just didn't realize it. My patient was in the ER saying tonight, but the inpatient order was not written until tomorrow morning like at two a.m. When the claim went in, it went in with a, you know, the ER services, along with it with the dates on the inpatient, the dates of service were, say, the 21st through the 25th, but the admit date was, say, the 22nd. I called customer service. I was told I should split that out. MR. WILLIAMS: Split it out meaning that you should? AUDIENCE: Bill the ER for one day, and then the rest of it. I thought it should have all gone in on one bill. MR. WILLIAMS: Yeah. You should be able to roll all that into the inpatient stay. AUDIENCE: Okay. Claim denied. That's the way we did it, and the claim denied. MR. WILLIAMS: Okay. Do this for me, could you email that specific claim example to me, and we can take a look and contact you individually? AUDIENCE: Okay. Thank you. MS. WATKINS: You want to give her your email address? MR. WILLIAMS: It's Solomon.Williams@Medicaid.. Or you can call me 334-353-3206. MR. ASHMORE: Any more questions? AUDIENCE: I do. I have one quick one. If somebody had just told me this the other day and I didn't know. I guess I didn't know this. Does Medicaid follow or have an inpatient only list, or do they follow Medicare? MR. WILLIAMS: We follow Medicare. It's an E, addendum E, yes. AUDIENCE: Okay. So all right. I just wanted to make sure that inpatient list that Medicaid follows as well. AUDIENCE: Yes. I have a question. Mine was similar to hers. Mine was an outpatient and for observation, and he was admitted the next day. I submitted the claim. And the observation claim denied according to N69 edit. I tried to send in the review to void it to get payment for the inpatient. Would I be able to get paid for the inpatient? MR. WILLIAMS: Again, we'll have to look at claim specifics, and you can send that claim or example in to me, or send it to Callie, and we'll take a look at it for you. AUDIENCE: Okay. Do you have a card that I can get after? MR. WILLIAMS: Absolutely, I do. AUDIENCE: Okay. Thank you. MR. ASHMORE: All right. Anything else before we conclude Medicaid? If not, I'd like to thank Solomon and the Medicaid team for being here today. Thank you. ................
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