Denials for CPT Codes 75572 – 75574

CPT codes 75572 – 75574 have been opened for reimbursement effective 1/1/2010.  Claims billed with these codes which denied for Edit 0439 – PROCEDURE NOT A BENEFIT FOR DATE OF SERVICE will be reprocessed for dates of service 1/1/2010 – 8/11/2011.  The mass adjustments will begin the week of 02/13/2012.  If you have any questions, please contact your provider representative or the Division of Medicaid.

Prior Authorizations for Plastic Surgeons

Office visits/consults (including follow-up after procedures) with plastic surgeons do not require prior authorization for par providers.  Surgery would still require prior authorization as with all other outpatient surgical procedures.

Vaccines for Children Update

The Division of Medicaid (DOM) claims processing procedures were recently modified to be in compliance with the 2009 Code Update AMA change in regards to the billing rules for immunization codes 90471 and 90473.  The AMA ruling indicated only one or the other code can be billed on a single date of service.  The recent NCCI mutually exclusive ruling also mandates certain codes cannot be billed together by the same physician on the same beneficiary on the same date of service.

DOM claims processing system will evaluate all claims by the same physician on the same beneficiary on the same date of service.  If a claim is found which indicates one of the codes has been paid, the current claim will be denied.

DOM claims processing procedures were also modified to become in compliance with the 2011 Code Update AMA change in regards to the billing rules for immunization codes 90460 and 90461 on the same date.  Both codes can now be billed on a single date of service.

Hospice Prior Authorization Medical Necessity Changes:

Effective August 15, 2011, the required documentation to support medical necessity for hospice admissions will change.  Our current guidelines only require the physician certification signed by the attending physician and the hospice medical director to be submitted for prior authorization.  Effective August 15, 2011, Magnolia Health Plan will require in addition to the physician certification, a patient election form, a history and physical by the attending physician with the terminal diagnosis listed.  All hospice prior authorizations will be evaluated for medical necessity using the medical necessity criteria developed by the Louisiana Mississippi Hospice and Palliative Care Organization.

Prior Authorizations and Filing Claims Effective 4/1/11

Magnolia Network Providers: Submitting Claims for Payment

CHCs: Submitting Claims with Correct Place of Service Code