ACS & HIPAA: PROVIDER ACS & HIPAA: PROVIDER BILLING CHANGESBILLING CHANGES
ShereeSheree Howell and Sara WalkHowell and Sara WalkACS Field RepresentativesACS Field Representatives
July 28July 28th,th, 2929thth, and 30, and 30thth, 2003, 2003
What’s NewWhat’s New
! ACS will have thirtydays to key a claim,
rather than the current four days.
! Nursing Homes and DD waiver providers
are required to bill electronically
EqualityCare WebsiteEqualityCare Website
! Effective 09/29/03,you will not be able to access your RA’s from the EqualityCare Website.
Fee SchedulesFee Schedules
! There will be two fee schedules available to providers containing CPT codes and HCPCS codes. This is so ACS will be able to update the EqualityCare Website more timely.
Accepted Claim FormsAccepted Claim Forms
! CMS 1500- Professional (previously called HCFA 1500)
! UB02- Institutional (previously called UB92)
! ADA 2002 (dental)! Universal pharmacy claim
form
NotNot Accepted Claim FormsAccepted Claim Forms
! ACS will no longer accept the waiver claim forms, the transportation claim form, the LTC Screening claim form, or the Nursing Home TAD form, after September 28, 2003.
What Forms to Use For What What Forms to Use For What ServicesServices
! Nursing Facilities- will bill on the UB02
! For LT101, screening or evaluation of PASARR Level II- will bill on the CMS 1500
! Federally Qualified Healthcare Centers- will bill on the UB02
What Forms to Use For What What Forms to Use For What ServicesServices
! Rural Health Clinics- will bill on the UB02
! Waiver and Transportation providers- will bill on the CMS 1500
! Indian Health Services-will bill on the UB02
Attachments to ClaimsAttachments to Claims
! Providers will be able to submit electronic claims with paper attachments. ACS will institute a process to match electronic claims with the appropriate paper attachment. Please see next slide.
W yom ing EqualityC are Program
A ttac hm ent C o ntro l N um be r – F or O ff ic e Use O nly
P rovider Nam e _______________________________________________________________ P ay-to -P rovider N um ber R ecipient N am e __ __ __________ __ __ ________ _______ __ __________ __ __ ___ __ __________ __ __ R ecipient State ID N um ber D ate o f Service (M M D DY Y ) T ype o f D ocum ent – One m ust be checked
" A – A m bu la nc e T rip R e po rt " C – C o nsent F orm (A bo rt ion, H yste rec to my, S te riliza tio n) " H – H o spice P ha rm ac y W a iv er " I – Inv o ice " M – M e dica re EO M B " P – P rio r A utho riza tio n F o rm a nd/o r D oc um e nta tio n " R – M e dica l R eports (Su rg ery , ER , A nesthe sia , e tc .) " S – S w ing B ed Exem ptio n L e tte r " T – Th ird P arty L ia b ility D oc um e nta tion (E OB ’s, D e nia l L etters, Le tte rs a ttem pting to co llec t)
Claim Attachment Control Document
Please use this form when submitting a claim electronically which requires an attachment. The attachment can besubmitted on paper along with this form. If this form is not attached to your documentation, your request CANNOT beprocessed.
RETURN THIS DOCUMENT WITH ATTACHMENTS TO: ACS State Healthcare
P.O. Box 547 Cheyenne, WY 82003
DD/LTC Waiver InformationDD/LTC Waiver Information! LTC and DD Waiver
Providers: After September 29, 2003, the Prior Authorizations will contain HCPCS codes, rather than local codes.
! DD Providers: The PA’s will be terminated as of August 31, 2003, and new PA’s will begin on September 1, 2003.
! The new PA’s will be mailed in the middle of September.
Medicare CrossoversMedicare Crossovers
! ACS will receive Medicare crossover claims in X12 837 directly from Medicare contractors. This includes part A and B claims. ACS will receive paid and denied claims as Medicare crossovers.
TPLTPL! Providers need not make any changes to
current practices on claims where Medicaid is a secondary payer behind Blue Cross Blue Shield, Worker’s Compensation or another third party payer (other than Medicare). Providers will continue to be responsible for submitting claims to other payers.
AdjustmentsAdjustments
! If the claim was billed on paper, the adjustment will be done on paper.
! If the claim was sent electronically, the adjustment will be done electronically in the X12 837 format.
Remittance AdvicesRemittance Advices! Providers will continue to receive paper
Remittance Advices with the specific explanation of benefit (EOB) codes. These will not change.
! Providers will be able to to receive electronic Remittance Advices in the X12 835 format. These will show the standard claim adjustment reason and payment remark codes. Providers will be required to enroll in order to receive an 835 transaction
Prior AuthorizationPrior Authorization! Paper process- provider can request PA by mail,
fax, or receive a pending PA by phone. Provider will receive pending, denied, or approved PA on paper.
! Electronic- X12 278 format- provider can request PA electronically, they will receive response electronically in X12 278 format.
! Web Portal- providers will be able to transmit PA requests via the Internet. More details will be available at a later date.
Provider ManualsProvider Manuals
! Providers will receive new billing manuals in August. They will also be available on our website, wyequalitycare.acs-inc.com.
DD/LTC Waiver InformationDD/LTC Waiver Information! After September 12,
2003, DD and LTC waiver providers will not be allowed to bill through ACE$.
! ACE$ will not be able to process any waiver claims after September 12, 2003.
Who and When to CallWho and When to Call
Contact ACS Provider Relations for :* Claim status* Check status* Recipient eligibility
Cheyenne- (307) 772-8401Outside Cheyenne-1-800-251-1268Monday through Friday, 9am
to 5 pm MST
Who and When to CallWho and When to CallContact Florida EDI
for:! ACS EDI Support Unit-
WINASAP 2003/Enrollment:1-800-672-4959
! Technical Support for Vendors, Billing Agents, Clearing House.1-850-201-11718 am to 5 pm MST
Who and When to CallWho and When to CallContact Florida EDI
for: Registering to receive
electronicresponses such as RA’s, PA’s, Eligibility, and Claims Status.
ModifiersModifiers
! ACS will be able to accept four modifiers on claims, rather than the current two modifiers.
New ModifiersNew Modifiers
Medicaid Level of Care 3 (Case Management By Substance Abuse)U3
Medicaid Level of Care 5 (Community Mental Health Substance Abuse)U5
Medicaid Level of Care 4 (Free Standing Substance Abuse)U4
Intermediate level of careTF
Clinical social workerAJ
Clinical psychologistAHMandated services (this replaces RE modifier)32
Part of Medicaid EPSDT program ( Related to EPSDT)EP
Medicaid Level of Care 2 (Case Management By Community Mental Health)U2Group settingHQ
Medicaid Level of Care 1 (Community Mental Health)U1
Program group, child and/or adolescentTJ
DescriptionModifier
New ModifiersNew Modifiers
State and/or federally-funded programs/servicesSE
Specialized mental health programs for high-risk populationsHK
Follow-up serviceTS
Multi-disciplinary teamHIDoctoral levelHP
Outpatient physical therapy plan of careGPOutpatient speech language pathology plan of careGN
Outpatient occupational therapy plan of careGO
Employee assistance programHJNew equipmentNU
Child/adolescent programHAAdult program, not geriatricHB
Complex/high tech level of careTGDescriptionModifier
! The following slides will show the new CPT, HCPCS, and revenue codes that will replace the current Local Codes for various services beginning September 29, 2003, unless otherwise advised.
Crosswalks: Local Codes Vs. Crosswalks: Local Codes Vs. CPT/HCPCS CodesCPT/HCPCS Codes
Children’s Special HealthChildren’s Special Health
Est. Ped. Follow-up- Complex Dis. 10/min.TJ99212X5911
Init. Comp. Ped. Cons. Complex DisorderTJ99245X5910
Init. Comp. Ped. Cons. Complex DisorderTJ99244X5909
Init. Comp. Ped. Cons. Complex DisorderTJ99243X5908
Init. Comp. Ped. Cons. Complex DisorderTJ99242X5907
DescriptionDescriptionModifierModifierCPT CPT CodeCode
Local Local CodeCode
Children’s Special HealthChildren’s Special Health
Genetic Clinic Initial ExamTJ99244X5915
Est. Ped. Follow-up- Complex Dis. 30/min.TJ99215X5914
Est. Ped. Follow-up- Complex Dis. 30/min.TJ99214X5913
Est. Ped. Follow-up- Complex Dis. 20/min.TJ99213X5912
DescriptionDescriptionModifierModifierCPT CPT CodeCode
Local Local CodeCode
Community Mental Health & Community Mental Health & Substance AbuseSubstance Abuse
Per 15 min
Per 15 min
Per 15 min
Per 15 min
Per 15 min
Per 15 min
Per 15 min
Unit Type
Intensive Ind. Rehab ServiceHK, U1H2014X2896
Individual Rehab ServiceU1H2014X2893
Family PreservationU1, U4, U5H2021X2892
Group TherapyU1, HQ, U4, U5H2019X2853
Comp. Medication ServiceU1, U4, U5H0034
Individual Therapy (Agency based)
U1, U4, U5H2019X2841
Clinical AssessmentU1, U4, U5H0031X2801
DescriptionModifier(s)CPT CodeLocal Code
Community Mental Health & Community Mental Health & Substance AbuseSubstance Abuse
Med. Case Management /ExpandedDELETEDX3127
Adult Case ManagementU2, U3Per 15 minT1017X2912
Ongoing Case ManagementEP, U2, U3Per 15 minT1017X2905
Trans. Case ManagementEP, U2G9012X2903
Inten. Child Treatment ServiceEP, U1Per dayS5145X2901
Inten. Sub Abuse OP Prog. (NEW)U4, U5T1008NEW
Day TreatmentU1, U4, U5Per 15 minH2017X2899
DescriptionModifier(s)Unit TypeCPT CodeLocal Code
Developmental CentersDevelopmental Centers
Therapeutic activities, direct (1 to 1) patient contact by provider/per 15 min.
97530X3130
Therapeutic procedure(s), group/per 15 min.97150X3129
Treatment – speech, language, voice comm., and/or auditory process. Disorder; group/per 15 min.
92508X3128
Treatment – speech, language, voice comm., and/or auditory process. Disorder; individual per 15 min.
92507X3126
Evaluation - speech, language, voice, comm., and/or audio process. Disorder;/individual per 15 min.
92506X3125X3131
Use individual Therapy evaluation CodesDELETED
X3100
DescriptionCPT Code
Local Code
Developmental CentersDevelopmental CentersDescriptionCPT CodeLocal
Code
DELETEDDELETEDX3138
Therapeutic proc.(s), group/per 15 min.97150X3137
Therapeutic proc./per 15 min.97110X3136
PT re-evaluation per 15 min.97002X3135
PT evaluation per 15 min.97001X3134
Occupational Therapy re-evaluation per 15 min.97004X3133
Occupational Therapy evaluation per 15 min.97003X3132
Health Check Health Check ––You must use diagnosis code V20.2, and bill with the You must use diagnosis code V20.2, and bill with the
appropriate CPT code and Modifier below. Payment includes appropriate CPT code and Modifier below. Payment includes incentive payment amount:incentive payment amount:
Est. Pt. 18-20 yrs3299395
Est. Pt. 12-17 yrs3299394
Est. Pt. 5-11 yrs3299393
Est. Pt. 1-4 yrs3299392
Est. Pt. Under 1 year3299391
New Pt. 18-20yrs3299385
New Pt. 12-17yrs3299384
New Pt. 5-11yrs3299383New Pt. 1-4 yrs3299382
New Pt. Under 1 year3299381Preventive Medicine ServicesModifierCPT-4 Codes
Office & Outpatient ServicesOffice & Outpatient Services
Group counseling, per 15 min.
AH (Clinical Psychologist)AJ (Clinical social worker/master’s level counselor) Use of modifiers will pay at
75% of fee
9085790853
X3003
Ind. Or family counseling, per 15
min.
AH (Clinical Psychologist)AJ (Clinical social worker/master’s level counselor) Use of modifiers will pay at
75% of fee
90804908159084690847
X3001
E&M code for new pt.E&M code for est. pt.
99205 OR 99215
X5878
E&M code for new pt.E&M code for est. pt.
99204 OR 99215
X5874
E&M code for new pt.E&M code for est. pt.
99202 OR 99214
X5870DescriptionModifiersCPT CodeLocal Code
Hearing ServicesHearing Services
Advanced Hearing Aid InsuranceX5613X5613
Standard Hearing Aid InsuranceX5612X5612
Hearing aid rentalDELETEX5608
DescriptionProcedure CodeLocal Code
Dental ServicesDental Services
Dental Extraction/Restorative, Hospital Outpatient
D7111-D7250X5846
Dental Extraction/RestorationD7111-D7250X5840
DescriptionProcedure CodeLocal Code
LTC Waiver ServicesLTC Waiver Services
HCBS- Respite care in facilityDELETEDW6006
Per meal
Per 15 min.
Per 15 min.
Per 15 min.
Per day
Unit Type Modifier
HCBS-Home deliver. MealsS5170W6007
HCBS-Respite care in home-HRS5150W6005
HCBS-Personal Care Attend.-HRT1019W6003
Self help assist.T2041W6002
HCBS - Case managementT2024W6001
DescriptionHCPCS Code
Local Code
LTC Waiver ServicesLTC Waiver Services
HCBS-adult day care-HRPer 15 min.S5100W6013
Care coordinatorTFPer dayT2024W6012
HCBS-Non-med. Trans. MonthlyPer trip (one way)
T2003W6011
HCBS-lifeline month.Per monthS5161W6010
HCBS-lifeline install.Per installationS5160W6009
HCBS-skilled nursingPer hourS9123W6008
DescriptionModifierUnit TypeHCPCS Code
Local Code
Assisted Living Facility Assisted Living Facility ServicesServices
Per day
Per day
Per day
Per day
Unit Type
HCBS-ALF-CASE MANAGEMENT
T2024W6099
HCBS-LEVEL IIITGT2031W6098
HCBS-LEVEL IITFT2031W6097
HCBS-LEVEL IT2031W6096
DescriptionModifier(s)HCPCS CodeLocal Code
DD Waiver Services DD Waiver Services –– Targeted Targeted Case ManagementCase Management
Targeted Case management Non waiver DD adult assessment
DELETEDW8002-W8005
Per month
Per month
Unit Type
Targeted Case management Non waiver DD child assessment
HAT2023W8001
Targeted Case management non waiver DD adult assessment
HBT2023W8000
DescriptionModifierHCPCS Code
Local Code
DD Child Waiver ServicesDD Child Waiver ServicesDescriptionModifierUnit TypeHCPCS CodeLocal Code
Special family hab. Home
w/trans.
Per dayT2033W2111
Residential habilitation
Per dayT2016W2107
Respite carePer 15 min.T1005W2105
HomemakerPer 15 min.S5130W2103
Case management subsequent
assess.
TSPer timeT2024W2102
Case management
Init. Assessment
Per timeT2024W2101
Case management
Per monthT2022W2100
DD Child Waiver ServicesDD Child Waiver Services
Environ. Mods. (new)
NUPer timeS5165W2115
Resident. Hab. Trainer w/o trans.
Per hourT2013W2114
Skilled nurs.Per 15 min.T1002W2119
Environ. Mods (exist.)
Per timeS5165W2117
Environ. Mods. (new)
NUPer timeS5165W2115
Resident. Hab. Trainer w/o trans.
Per hourT2013W2114DescriptionModifierUnit TypeHCPCS CodeLocal Code
DD Child Waiver ServicesDD Child Waiver Services
Per 15 min.
Per visit
Per 15 min.
Per 15 min.
Per time
Per time
Per 15 min.
Unit Type
Personal care servicesT1019W2132
Dietician servicesS9470W2129
Psychological H0004W2127
Respiratory therapyG0238W2125
Special. Equip. & supplies (repair)
T2029W2123
Special. Equip. & supplies (new)
NUT2029W2121
Complex skilled nursing T1000W2120
DescriptionModifierHCPCS CodeLocal Code
DD Adult Waiver ServicesDD Adult Waiver Services
Case ManagementPer MonthT2022W3001
Case Management Initial AssessmentPer TimeT2024W3003
Case Management Subsequent AssessmentTSPer TimeT2024W3005
Habilitation/ResidentialPer DayT2016W3011
Habilitation DayPer DayT2020W3015
Habilitation Prevocational Per DayT2014W3017
Per diem
Unit Type
Habilitation support. Employ.T2018W3019
DescriptionModifierHCPCS CodeLocal Code
DD Adult Waiver ServicesDD Adult Waiver Services
Occupational ther.Per 15 min.
G0152W3051
Home modifications (repair)Per timeS5165W3030
Home modifications (new)NUPer timeS5165W3029
Adapt. EquipPer timeT2029W3028
Adapt. Equip. (new)NUPer timeT2029W3027
Personal carePer 15 min.
T1019W3023
Habilitation in home supp.Per hourT2025W3021DescriptionModifierUnit TypeHCPCS CodeLocal Code
DD Adult Waiver ServicesDD Adult Waiver Services
Respiratory therapy servicesPer 15 min.
G0238W3061
Complex Skilled NursingPer 15 min.
T1000W3060
Physical therapy servicesPer 15 min.
G0151W3063
Respite carePer 15 min.
T1005W3071
Skilled nursing ServicesPer 15 min.
T1002W3059
PsychologicalPer 15 min.
H0004W3057
Dietician servicesPer visitS9470W3055
Speech therapyPer 15 min.
G0153W3053DescriptionModifierUnit TypeHCPCS CodeLocal Code
Acquired Brain Injury ServicesAcquired Brain Injury Services
Per diem
Per day
Per time
Per time
Per month
Per hour
Unit Type
ABI day habilitationT2020W3115
ABI Residential habilitationT2016W3111
ABI subsequent Assess.TST2024W3105
ABI initial assess.T2024W3103
ABI case mngmt.T2022W3101
ABI cognitive retrainingT2013W3100
DescriptionModifierHCPCS Code
Local Code
Acquired Brain Injury ServicesAcquired Brain Injury Services
ABI Special. Med. Equip (Subsequent)Per timeT2029W3128
ABI Special. Med. Equip (initial)NUPer timeT2029W3127
ABI Personal Care ServicesPer 15 min.T1019W3123
ABI Habilitation- Support. Employ. ServicesPer diemT2018W3119
ABI Habilitation- Prevocational ServicesPer diemT2014W3117
DescriptionModifier(s)Unit TypeHCPCS Code
Local Code
Acquired Brain Injury ServicesAcquired Brain Injury Services
ABI Psychology Services.Per 15 min.
H0004W3157
ABI Dietician servicesPer visitS9470W3155
ABI Skilled Nursing ServicesPer 15 min.
T1002W3159
ABI Speech, Hearing & Lang. ServicesPer 15 min.
G0153W3153
ABI Occupational TherapyPer 15 min.
G0152W3151
ABI Home Modifications (subsequent)Per timeS5165W3130
ABI Home Modifications (initial)NUPer timeS5165W3129
DescriptionModifier(s)Unit TypeHCPCS Code
Local Code
Acquired Brain Injury ServicesAcquired Brain Injury Services
ABI Complex Skilled NursingDELETEDW3160
Per 15 min.
Per 15 min.
Per 15 min.
Per 15 min.
Unit Type
ABI Respiratory Therapy ServicesG0238W3161
ABI Respite Care ServicesT1005W3171
ABI PT Services. DELETEDW3168
ABI PT Services G0151W3163
ABI Skilled Nursing ServicesT1002W3159
DescriptionModifierHCPCS CodeLocal Code
Traumatic Brain Injury/Spinal Traumatic Brain Injury/Spinal Cord DysfunctionCord Dysfunction
Spinal cord dys- children w/out vents123X0008
Spinal cord dys- children w/ vents123X0007
TBI- Children w/out vents123X0006
TBI- Children w/ vents123X0005
Spinal cord Dys- Adults w/out vents128X0004
Spinal cord Dys-Adults w/ vents128X0003
TBI- ADULTS without Vents128X0002
TBI- ADULTS with Vents128X0001
DescriptionRevenue CodeLocal Code
Indian Health ServicesIndian Health Services
VFC administration771NEW
Hospital Physical Visit987NEW
Multi-specialty encounter (within I.H.S. clinic)
DELETEX5865
Physician services (not within I.H.S. clinic)DELETEX5864
Pharmaceutical encounter (within I.H.S. clinic)
259X5863
Optometric encounter (within I.H.S. clinic)519X5862
Dental encounter (within I.H.S. clinic)512X5681
Medical encounter (within I.H.S. clinic)500X5860
Comp. Health screen. Ref.779X5504RE
Comp. Health screen.779X5504DescriptionRevenue CodeLocal Code
General HealthGeneral Health
Nuwave Pain Management SystemDELETEX5018
Barbara Davis CenterPer visitT1015X5009
Environ. Investigation of primary residence to determine
T1029X5008
Environ. Investigation for Lead ToxicityTST1029X5007
Health visit- elevated blood lead levelsS5190X5006
Wheelchair evaluation.E1340 & 97001X5005
DescriptionModifierUnit TypeProcedure CodeLocal Code
TransportationTransportation
Private vehicle per mile- adultA0090NEW
Private vehicle per mile- childSEA0090NEW
Lodging/per diem escort for childA0200NEW
Lodging/per diemA0180X5966
AirplaneA0140X5965
BusA0110X5964
TaxiA0100X5963
Public transitDELETEX5960DescriptionModifierProcedure CodeLocal Code
Inpatient Hospital ServicesInpatient Hospital Services
NH Room and Board658659
Negotiated Heavy Care rate101672
W9105 Negotiated Heavy Care rate
101671
W9100 Negotiated Heavy Care rate
101670
Nursing home billed leave days18XContracted rehab services128682
Inpatient regional treatment center services JCAHO and
non-JCAHO
919681Inpatient maintenance psych124680
Negotiated extraordinary care, monthly rate
101678
Nursery-Neonatal ICU170-174175DescriptionRevenue Code(s)Deleted Local Revenue Codes
Critical Access Hospital Critical Access Hospital ServicesServices
Critical Access Hospital Outpatient pricing revenue
code
970-986683
DescriptionRevenue Code(s)Deleted Local Revenue Code
Federally Qualified Health Federally Qualified Health Care CentersCare Centers
FQHC’s will bill on a UB02 instead of the CMS 1500 form.
T1015
99381
Procedure Code
X5855
X5515
Local Code
FQHC520
FQHC Health Check520
DescriptionRevenue Code
Rural Health ClinicsRural Health ClinicsRural Health Clinics will bill on a UB02 instead of
the CMS 1500 form.
DELETE
T1015
99381
Procedure Code
X5580
X5850
X5514
Local Code
Medicare CrossoverDELETE
RHC Encounter521
RHC Health Check521
DescriptionRevenue Code
Extraordinary Heavy CareExtraordinary Heavy Care
These recipients require skilled nursing facility extraordinary care because they have an MDS Activities of Daily Living Sum score of ten
(10) or more and require special care or clinically complex care as recognized under the Medicare RUG-III classification system for those conditions which have received PA from the Departments.
101678
Extraordinary Care Revenue Code after 9/29/03
Current Extraordinary Care Revenue Code
LT101 and PASARR Level IILT101 and PASARR Level IIThe following services for LT101 and PASARR The following services for LT101 and PASARR
level II Screenings will be billed on the CMS 1500 level II Screenings will be billed on the CMS 1500 form.form.
PASARR Level II-social summaryDELETEW7207
PASARR Level II- psychologistHIPer visitT2011W7205
Per visit
Unit Type
W7201
W7103
W7101
Local Code
PASARR Level II-committee consultDELETE
LT101 by phoneDELETE
LT101T1023
DescriptionModifierProcedure Code
LT101 and PASARR Level IILT101 and PASARR Level IIThe following services for LT101 and PASARR The following services for LT101 and PASARR
level II Screenings will be billed on the CMS 1500 level II Screenings will be billed on the CMS 1500 form.form.
PASARR Level II- CMHC Eval.Per visitT2011W7302
PASARR Level II- psychiatristHPPer visitT2011W7301
PASARR Level II- audio. examDELETEW7215
PASARR Level II- IT/APPDELETEW7213
PASARR Level II- ICAPDELETEW7211
DescriptionModifierUnit TypeProcedure Code
Local Code
TheTheEndEnd