Read Claims Data Definition TAG Institutional and Professional Workgroup minutes text version

Title of Meeting: AUC Claims DD TAG I and P Workgroup Date and Time of Meeting ­ 11/19/08 Location of Meeting ­ Minnesota Dept of Health, Red River Room

Minutes By: Shelagh Kalland Agenda Item Status AUC Antitrust Statement Reminder


Action: None

Attendance and Introductions


Approve Minutes from 11/5/08


Shelagh send to MDH to post on the web. Shelagh will send these to MDH to post on the web site. All members to take version 7 back to their organizations and come ready to approve or have specific other suggested changes at the 12/3 meeting.

Update from AUC Operations meeting

2 best practices passed and will be posted on the website. They are hearing aids and misc supplies/products. Park Nicollet brought forward the following concerns: Sleep studies ­ TAG members thought that the first date should be used on the sleep study line.

Service Date Span per Claim (B10)

Also we are having issues with nuclear medicine claims where a patient is given a drug on one day and comes back the following day for the scan. If two claims are submitted to the payer -- then they are denying stating missing the scan or missing the drug...cpt codes are: 636 A9517, 342 79005 on one day of service and then 340 78018 on another day. TAG suggestion is to add wording stating that procedures beginning on one day and ending on another should be billed together. We also have stress tests where the patient is given a drug on one day and returns a few days later for the test. Billing separate claims are not processed by all payers. Same as nuclear medicine fix in best practice.

Agenda Item Status



If the insurance changes over the month end -- then yes -- the claims would need to be split by payer -- but if the insurance is not changing -- then before we could have this rule about splitting claims over month end -- the payers would need to be able to process the claims separately. Kim W to try to find out more information. We also cannot split claims by payer. So if Medicare cannot accept a split claim -- then we would not be able to split for other payers. Kim W to check for examples to see if they are already covered in the new wording of the best practice. I think that for hospitals the rule should be that series accounts such as rehab, lab and radiation therapy be billed monthly -- and allow the other claims to be submitted as they occur. Kim W to check to see if new wording handles this.

For Medicare, Barb H found that the 1500 does require a through date. They will accept future dates. Generally through date will autopopulate the through date to match the first date and the system assumes monthly rental. Medicare does not prorate monthly rental. If you are eligible for any part of the month, then the monthly rental is an eligible covered benefit. Zahrah from Phoenix Rental was present and explained that they always use the first date only and their system autopopulates with the first date of the rental period. They have no issues getting their claims paid this way. Liz did check with Medica and they only get the first date of the rental period. Work Guide Request from HealthPartners (2010BA and 2010CA, NM108 and NM109) B21 ­ Enteral Products Asking for a change to the 837P, 837I, and 837D Companion Guides to add a note these loops/elements For enteral products for Medicare and Medicaid, actual from and through dates are used for billing. Medicaid does not allow span over month end. Commercial payers do not require from and through. DHS Shelagh will send to MDH stating that we approve the change request. All members to take version 5 back to their organizations and come

Agenda Item Status

Discussion should not require a `22' modifier. Discussed whether we should develop a best practice specific to DHS vs. Commercial to save costs for suppliers. Made more generic to accommodate commercial needs too based on contract or policy requirements. See version 5 of this best practice. Carolyn has a couple questions before she can submit to X12. Question needs to go to Dental, professional and institutional. Need to consider P&C unique needs too for duplicate claim submissions.

Action: ready to approve or have specific other suggested changes at the 12/3 meeting.

B22 ­ New best practice related to COB ­ proposed by Mayo B12 ­ Replacement Best Practice (BCBSM Work Request Form) Common Appeal Form

Consistent field names should be used from Attachment cover sheet for the appeal form. Sandy will make the changes. Should the order be consistent with the attachment cover sheet? Yes. Do we really need the provider address? Yes due to multiple provider addresses tied to single billing provider ID number. Change name to address tied to the `requested by'. Payer address: remove. Add email and fax by requester? Agree to add. No need to add appeal control number. Best practice version 3 added code review to the types of appeals. Should we require the `category' of appeal be the first words in remarks on the appeal form? We will add into the documentation information regarding use of this. Overview of 62J.52, 62J.536, Common Companion Guides and SBAR given by Shelagh. Any professional service or incident to service is considered an RHC service and billed as a professional. Freestanding incidental is billed as professional. Hospital based is billed as institutional.

Carolyn to submit question to X12 as an HIR. Shelagh to add replacement/ cancel examples to best practice. Sandy will continue to work on this form.

Business Needs Form (RHC, FQHC, CAH)

Shelagh to schedule all day (8-4) meeting to review this topic and make recommendations.

Agenda Item Status

Discussion Medicaid pays these as an encounter and ancillaries are bundled into the overall payment. They are moving toward FFS type billing on professional claim form to get detailed billing. Provider based clinic ­ hospital owns the clinic billed today on 1500. Basic Understanding of billing today for CMS: FQHC Professional =UB04 Ancillaries = 1500 CAH ­ provider determines method 1 or 2 and may choose by physician/service type ­ provider must declare method 1 or 2 with Medicare Method 2 =UB04 Method 1=1500 RHC - TBD (4th type) Provider based clinic ­ Medicaid = 1500 and UB, non Medicaid = 1500 Receiving a single form for DHS would require significant programming but are open to 1500, dental and pharmacy claims to allow correct pricing under all programs. Should we have an all day meeting to diagram this out and look at variances with different types of programs. Appendix A for the institutional guide specifies that RHC, FQHC and CAH (in inpatient section) coding should follow Medicare. As such it implies that these will be billed as institutional claim formats. If we are to make changes, we need to do this quickly as providers may be making changes to their systems that we might revert back to how they bill today. We need to avoid rework by addressing this quickly. Suggestion for Medical Code TAG to remove reference to Medicare for RHC and FQHC so that we can create a best practice that may be in conflict to it.


Agenda Item Status Companion Guide Work Request on Replacement Claims and Splits SBAR ­ ASCs

Discussion Did not discuss due to time limitations.


We will have to schedule to have the right people in the room to discuss this at another meeting. Did not discuss due to time limitations.

SBAR ­ Joint meeting with Medical Code TAG regarding transplant billing Next Meeting

Wednesday, December 3, 2008 9:00-12:00 Location ­ MDH, Snelling Office Park, Big Fork Room


Claims Data Definition TAG Institutional and Professional Workgroup minutes

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