Magnolia Health Plan

Magnolia Prepay Review of Modifiers

mfoster — Fri, 03 May 2013 18:15:59 +0000

Section 6507 of the Affordable Care Act (ACA) requires all Medicaid/Medicaid Managed Care Organizations to implement the National Correct Coding Initiative (NCCI) edits into their claim processing system. Centers for Medicare and Medicaid Services (CMS) developed the NCCI to help promote correct coding. NCCI’s consists of two main components:

Procedure to Procedure validation:

NCCI defines a list of codes that cannot be billed together.

Medically Unlikely Edits:

Some codes have unit limitations.
When more than the defined numbers of units are billed, it’s considered Medically unlikely. For example, more than one hysterectomy or the removal of more than one appendix, would be considered Medical Unlikely.

Magnolia recently reviewed their claims editing process with the Mississippi Division of Medicaid (DOM). Magnolia uses the NCCI guidelines, the CMS Processing Manual, The American Medical Association (AMA) and various coding societies to ensure correct payment is made and potential fraudulent, wasteful and/or abusive payments are avoided. During our review with the DOM, it was identified that Magnolia and DOM differ in the way payments are made when modifiers are used (explained below). Magnolia is reviewing for the correct use of modifiers prior to payment, whereas DOM reviews modifier usage retrospectively. Below is a brief explanation of the Modifiers and how Magnolia reviews for correct usage and coding.

Modifiers are two digits, alpha-numeric characters appended to CPT/HCPCS codes. A provider uses modifiers to indicate that a procedure or service was altered in some way. Modifiers may be used for informational purposes or they may be used to justify additional payment. Modifiers do not affect the actual service or procedure performed, but instead indicates special circumstances that affect the service.

CMS publishes the NCCI code pair edits. CMS defines which HCPCS/CPT codes are not separately reimbursable when billed together. CMS reports these codes as “column 1/column2” whereby the column 2 code is the code that is denied and considered a component of the “column 1” code. NCCI edits are applied only to services that are billed for the same provider, for the same member, for the same date of service.

However, it may be clinically appropriate for the provider to bill and be reimbursed for both codes. In this case, the provider must bill the appropriate NCCI modifier. Please note the use of the modifier must be clinically appropriate. The provider may not bill NCCI modifiers simply to override the edit. The patient’s medical record documentation and claims history must support their use

Two of the most commonly billed NCCI modifiers, are modifiers -25 and -59.

Modifier -25 is used to indicate that the physician performed a separate evaluation and management service that was above and beyond other services performed on the same date of service.

For example, included in the reimbursement for each CPT/HCPCS code, is an evaluation and management component for professional services related to the procedure being performed – this is not separately reimbursable. However, if during the course of that visit, the patient was seen and treated for an acute condition –that service would be considered for separate reimbursement. It is important to note, that services necessary to perform the procedure are not separately reimbursable.

Examples:

An established patient presents to the podiatrist, complaints of an ingrown toenail. The foot was assessed with the decision to remove the ingrown nail. An E/M service should not be reported.
An established patient presents to the family physician with a new complaint of an uncontrolled bloody nose. An E/M service would be appropriate to report as the physician would have had to do a significant and separate evaluation in addition to controlling the nasal hemorrhage (30901).

Modifier -59 is used to indicate that services which not normally reported together are distinct and therefore unrelated.

For example, modifier -59 is used to report that a service was performed on separate anatomical sites, during a different encounter on the same date of service or a different session, separate lesion or a separate injury. However, modifier -59 should only be used when there is not another appropriate modifier to use (i.e., LT, RT, E1-E4, F1-F9).

ATTN: OB Providers

mfoster — Fri, 12 Apr 2013 18:30:35 +0000

Please click on the link below to access information that will be most important as we move forward in caring for Magnolia members.

ATTENTION OB PROVIDERS

Provider Workshops

mfoster — Fri, 05 Apr 2013 20:30:30 +0000

Magnolia Health Plan cordially invites you to attend a Provider Relations Workshop about Magnolia Health Plan and the MississippiCAN Program. If you are currently a Medicaid Provider and would be interested in becoming a Magnolia Provider, we encourage you to attend. Or, if you are currently a Magnolia provider and would like a refresher course on MississippiCAN, please join us. A presentation and open discussion will include Billing, Claims, Authorizations and Credentialing.

Locations:

Greenville, MS

Delta Regional Medical Center/Pavilion Learning Center/Large Conference Room

1693 Fairgrounds Road

April 24, 2013

10:00 AM – 12:00 Noon & 1:00 PM – 3:00 PM

(Refreshments will be served at both meetings)

RSVP to Tina Lawrence at johallen@centene.com

Ridgeland, MS

Hyatt Place – Jackson/Ridgeland

1016 Highland Colony Parkway

May 8, 2013

10:00 AM – 12:00 Noon & 1:00 PM – 3:00 PM

(Refreshments will be served at both meetings)

Please RSVP to bdonahue@centene.com

McComb, MS

Hampton Inn – Magnolia Room

109 Manisha Drive

May 15, 2013

10:00 AM – 12:00 Noon & 1:00 PM – 3:00 PM

(Refreshments will be served at both meetings)

RSVP to Tina Lawrence at tlawrence@centene.com

Tupelo, MS

North Mississippi Medical Center/Education Center Auditorium

830 S. Gloster Street

May 22, 2013

10:00 AM – 12:00 Noon & 1:00 PM – 3:00 PM

(Refreshments will be served at both meetings)

Please RSVP to johallen@centene.com

UPCOMING WORKSHOPS:

Forrest County – June 2013

Jackson County – July 2013

iPASS SUMMIT

mfoster — Thu, 04 Apr 2013 18:58:49 +0000

Gain direct access to major healthcare payers. Learn tips to get paid more efficiently. Meet provider representatives to resolve individual claims issues. Hear presentations on new programs, policy changes, and claims submittal tips. All of this and more at the iPASS Summit, coming in April and May to Hattiesburg, Oxford, and Metro Jackson.

Hosted By:

SUMMIT DATES and LOCATIONS

Hattiesburg: Friday, April 26

Oxford: Friday, May 3

Metro Jackson: Friday, May 10

OPEN TO ALL PHYSICIANS AND OFFICE MANAGERS!

Click here to register and learn more.

ChoosingWisely®

mfoster — Mon, 18 Mar 2013 15:34:40 +0000

An initiative of the ABIM Foundation

ChoosingWisely® is an initiative of the ABIM Foundation to help physicians and patients engage in conversations about the overuse of tests and procedures and support physician efforts to help patients make smart and effective care choices.

For more information on ChoosingWisely® , please click here.

To improve care and eliminate unnecessary tests and procedures, more than 500,000 physicians developed lists of “Five Things Physicians and Patients Should Question”. Click on the links below to view the lists Magnolia would like to showcase this week.

American Academy of Family Physicians

American Academy of Pediatrics

American College of Obstetricians and Gynecologists

American College of Physicians

New Provider Orientation

mfoster — Mon, 18 Mar 2013 15:31:11 +0000

Magnolia will be conducting new provider orientations over the next few weeks. Please note our upcoming orientation below. Please be sure to include number of attendees when you RSVP. Lunch will be provided!

Date:

3/20/2013

Location:

Holiday Inn/Gulfport Airport

9515 Hwy 49

Gulfport, MS 39503

1st Session:

10:00 AM – 12:00 Noon

2nd Session:

1:00 PM – 3:00 PM

RSVP to Walter Pawlak at wpawlak@centene.com

Modifiers for Therapy CPT Codes

mfoster — Mon, 18 Feb 2013 19:04:31 +0000

These codes are always therapy services, regardless of who performs them. They always require therapy modifiers.

GP for PT

GO for OT

GN for SLP

CPT Codes: 92506, 92507, 92508, 92526, 92597, 92605, 92606, 92607, 92608, 92609, 96125, 97001, 97002, 97003, 97004, 97010, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97762, 97799

Medical Record Review

mfoster — Mon, 18 Feb 2013 18:58:59 +0000

Magnolia Health Plan is in our first year of Medical Record Review (MRR) for Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS is a standardized set of performance measurements developed by the National Committee for Quality Assurance (NCQA) to evaluate consumer health care.

How this will affect you:

RecordFlow is the contracted MRR for Magnolia Health Plan.
RecordFlow is in the process of sending out a fax packet to your office for medical record retrieval.
For any questions, your office should call RecordFlow at (800) 698-1690 or Lynn Mitchell, QI Manager for Magnolia Health Plan, at (866) 912-6285 ext. 66834.
If you need to fax medical records, RecordFlow’s fax number is (855) 757-3630.
Timeframe for MRR retrieval is February through May 2013.

What is HEDIS?

Designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks.
One component of NCQA’s accreditation process.
Measures are related to many significant public health issues, such as diabetes, asthma, cancer and heart disease, as well as preventive services.
Data collection pertains to any enrolled Magnolia member. Medicaid guidelines require completion of HEDIS data collection annually to meet contract requirements.

New Provider Orientations

mfoster — Fri, 15 Feb 2013 15:01:34 +0000

Magnolia will be conducting new provider orientations over the next few weeks. Please review the chart below for locations and times.

To register for an orientation:

Email Johnnie Allen (johallen@centene.com) if you will be attending the Tupelo orientation
Email Brandy Donahue (bdonahue@centene.com) if you will be attending the Jackson orientation

Be sure to include number of attendees.

Date:	Location:	Address:	Time:
2/22/2013	North MS Medical Center	830 S. Gloster Street	1st Session: 10AM – 11:30AM
	Education Center Auditorium	Tupelo, MS 38801	2nd Session: 1PM – 3PM

3/13/2013	Jackson Medical Mall	350 W. Woodrow Wilson	1st Session: 10AM – 11:30AM
	Community Meeting Room	Jackson, MS 39213	2nd Session: 1PM – 3PM

How to Correctly Bill for Evaluation and Management/Preventive Medicine Services

mfoster — Fri, 08 Feb 2013 19:41:24 +0000

The placement of the 25 modifier on the Evaluation and Management/Preventive Medicine procedure codes 99381-99395 will allow payment of the visit and the immunization administration service. However, the 25 modifier should only be reported on a claim when there is identifiably a significant, separately EM/Preventive Medicine Service performed by the professional healthcare provider on the same day of the procedure or other service, as substantiated by documentation in the patient’s medical record.

Claims submitted beginning with dates of service January 1, 2013 which resulted in a denial for NCCI Contra Edit 6562 may be voided by the provider and resubmitted using the 25 modifier with strict adherence to the description cited in the most current American Medical Association CPT codebook.