BILLING FOR STD/HIV/VH PREVENTIVE SERVICES Presented by Beth Platt, BA, MS CFO, Beth Platt and Associates 6-12-15 6/2/15 1 DISCLOSURE Owner and Chief Financial Officer, Beth Platt and Associates, Rochester, NY 6-12-15 6/2/15 2
LEARNING OBJECTIVES: Explain types of billing; Professional/Referred Ambulatory billing versus Institutional/APG billing. Identify codes for potentially billable services related to STD/HIV/VH prevention services. Explain documentation/care requirements for selecting E&M level billing codes. 5-9-15 5/26/15 3 LEARNING OBJECTIVES: Describe governance differences between Medicare, Medicaid, and 3rd party payers. Identify providers who provide billable services.
Understand when and how to bill by time 5-9-15 5/26/15 4 What has changed? The Patient Protection and Affordable Care Act (PPACA) expanded access to health care & lowered cost barriers to preventive services. Requires Medicare & all qualified commercial health plans to cover a list of preventive services graded A & B by the U.S. Preventive Services Task Force (USPSTF) at no cost to the consumer 6-12-15
6/2/15 5 HOWEVER. For preventive services that must be covered, an office visit cost-share may apply to the office visit (a) if the preventive service is billed separately from the office visit, or (b) if the primary purpose of the office visit is other than the delivery of preventive service and the preventive service is not billed separately from the office visit. 6-12-15 6/2/15 6
Copay/Cost Share An office visit cost-share may not be applied to the office visit if (a) the preventive service is not billed separately from the office visit and (b) the primary purpose of the visit is the delivery of the preventive service. 6-12-15 6/2/15 7 What are Grade A and B? A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that
the net benefit is moderate to substantial. 6-12-15 6/2/15 8 Why bill for Preventive Services (PS)? PPACA with Medicaid expansion: Increased # of patients with insurance Increased # /type of PS covered Insurer cannot charge copays/ or an amount to go towards deductible on PS - Use Modifier 33 Grandfathered plan exception time limited Providers barrier of lack of payment for preventive services - no longer exists 6-12-15
6/2/15 9 STD Clinics ARE considered Essential Community Providers with whom ACOs need to contract to reimburse for providing PS and other public health (PH) services Grant and government funding for billable PS likely to decrease = increased need for revenue Billing needed to maintain HD safety net services 6-12-15 6/2/15
10 Website for list of ECPs This website has a list of ECPs and directions on how to be added to the list. http://hab.hrsa.gov/affordablecareact/ ecp.html 6-12-15 6/2/15 11 PS Overview Will not cover Medicaid fee for service Will highlight general information on STD/HIV/VH PS and billing codes Resources for detailed information re: Description of all PS and documentation
required for each Populations eligible to receive PS Billing codes which vary by insurer 6-12-15 6/2/15 12 Qualified Provider For billing purposes: Nurse practitioner, Certified Nurse Midwife Physician MD or DO, PA Some exceptions HIV counseling & testing, immunizations, etc. Registered Nurses can provide PS bill for 99211 E & M Visit 6-12-15
6/2/15 13 USPSTF A and B Recommendations Insurances Must Cover as Preventive Services: Screening for: Chlamydia , Gonorrhea, Syphilis HIV, Hepatitis B and C STI counseling Preventive /Risk Reduction Counseling 6-12-15 6/2/15 14 USPSTF A and B Recommendations
Insurances Must Cover as Preventive Services: Vaccines: HPV , Hepatitis A and B Alcohol /Substance misuse: screening and counseling Intimate partner violence screening: Tobacco use counseling and interventions: Tobacco use interventions: 6-12-15 6/2/15 15 PS Populations are specific Example: STD screening covers women who are pregnant & under 25 AND anyone at Increased Risk = males under age 25, and those with a history of same infection or other STIs, new or multiple sexual partners, inconsistent condom
use, sex work, drug use For each PS Populations, see http ://www.uspreventiveservicestaskforce.org/Page/Na me/uspstf-a-and-b-recommendations 6-12-15 6/2/15 16 PS Billing Codes are specific PPACA requires PS codes to be posted on each insurance web site Each insurer has specific combinations of CPT or HCPCS and ICD-9 codes required to bill for PS must go to PS charts on each web site. CPT: Level I procedure codes HCPCS : Level II procedure codes for which there are no CPT codes
ICD-9: Diagnostic codes ( ICD-10 soon) 6-12-15 6/2/15 17 PS Billing Codes Vary by Insurer Medicare - very user friendly page with navigation buttons describing each PS and the billing code combinations they pay http ://www.cms.gov/Medicare/Prevention/PrevntionGenI nfo/Downloads/MPS_QuickReferenceChart_1.pdf 6-12-15 6/2/15 18
PS Billing Codes Vary by Insurer NYS Medicaid Fee for Service : www.emedny.org go to Medicaid updates and look through index For Medicaid Managed Care or 3rd party - check your regional sites: United Health Care: www.unitedhealthcareonline.com Aetna: www.aetna.com Cigna: www.cigna.com Blue Cross/Blue Shield: https://www.excellusbcbs.com OTHERS 6-12-15 6/2/15 19 PS Billing WITH E & M Visit
PS services are often provided along with an E & M visit IF a separate PS code exists - Bill the Visit code AND the PS Codes along with Modifier 25 indicating it was a discrete service If no code exists, Counseling and Care Coordination can be billed by TIME This is only applicable to E & M codes 99201-99215 Preventive codes 99381-99397 may cause bundling on all PS procedure codes. 6-12-15
6/2/15 20 Billing by Time E/M with Preventive Services may be coded based on Time, ONLY IF provider spent over 50% of the face-to-face part of the visit Counseling and/or on Coordination of care. Must document over 50% of time for counseling and/or coordination of care key points of counseling and/or coordination of care 6-12-15 6/2/15 21
Example An Established Patient presented for CC of vaginal discharge, History, Exam, MDM done - would have been a 99212 problem focused visit ( 10 min) AND provider did 20 minutes of counseling about patient disclosure of intimate partner violence So, total of 30 min spent, half on counseling Bill for 99214 visit 6-12-15 6/2/15 22 Established Patient E & M Coding Two of the key components* must meet or exceed the stated requirements to qualify for a particular level of service
Visit CPT Code Chief Complaint History* Exam* Medical Decision Making* Time (min.) 6-12-15 99211 99212 Problem Focused 99213
New Patient - E & M Coding Three of the key components* must meet or exceed the stated requirements to qualify for a particular level of service 1997 CMS Visit CPT Code 99201 Problem Focused 99202 Expanded Problem Focused 99203 Detailed 99204 Comprehensiv
e Chief Complaint Required Required Required Required 1-3 HPI 1-3 HPI 1 problem pertinent ROS 4 HPI
2-9 ROS 1 pertinent PFSH 4 HPI 10+ ROS 2-3 PFSH 1-5 bulleted elements 6 bulleted elements 12 bulleted elements All bulleted items
Decision Making* Time (min.) 6-12-15 6/2/15 24 PS related ICD-9 Codes Screening for STD/HIV V70.0 Routine medical exam V72.31 Routine GYN exam Screening for: HPV: V73.81 CT: V73.88 HIV: V 73.89 Bacterial STDs - GC, Syphilis: V74.5
6-12-15 6/2/15 25 PS related ICD-9 Codes V69 Problems related to life style V69.2 = High Risk Sexual Behavior V69.8 = High Risk Group V69.9 = Unspecified could be ETOH or substance user, homeless, incarcerated, conditions affecting diagnosis or management 6-12-15 6/2/15 26
PS related ICD-9 Codes Counseling V65.40 = Counseling NOS V65.42 = Counseling on ETOH/SU V65.44 = HIV Counseling V65.49 = Other specified counseling 6-12-15 6/2/15 27 PS related ICD-9 Codes Contact with or Exposure to: V01.6 = Bacterial STDs V01.79 = Other viral HIV, VH, HSV Carrier or Suspected Carrier: V02.61 = Hep B V02.62 = Hep C
V02.7 = GC V02.8 = Other venereal diseases, syphilis 6-12-15 6/2/15 28 PS related HCPCS Procedure Codes G0010=Admin Heb B Vaccine G0443=ELISA Infectious agent antibody detectin G0432 = HIV antibody EIA HIV 1 or 2 screening G0435 = HIV antibody EIA rapid, oral HIV 1 or 2 G0436 = Smoking cessation counseling 10 min G0437= Smoking cessation more than 10 min G0442 = ETOH Screening G0443 = ETOH Brief Intervention 15 min G0444 = Annual Depression Screening G0445 = HIBC sexual risk reduction counseling G0472: Hepatitis C antibody screening for individual at high
risk and other covered indication(s) Medicare and some 3rd party pay G Codes 6-12-15 6/2/15 29 Chlamydia & Gonorrhea Screening CPT Procedure codes
87110 CT culture 87320 CT ELISA 87491 CT NAAT 87081 - GC culture, presumptive, screening 87591 - GC NAAT 87801 CT and GC NAAT G0445 Counseling to prevent-30 min Use Diagnosis: V74.5, V69.8, V22.0, V22.1 or V23.9 6-12-15 6/2/15 30 Syphilis Screening CPT Procedure Codes 86592: Syphilis antibody indirect (VDRL, RPR, ART) 86593: Quantitative if above is positive titer
86789: Syphilis antibody direct EIA, FTA, TP-PA 36415: venipuncture 36416 : blood from lancet/stick G0445-Counseling to prevent 30 minutes Use Diagnosis V73.89, V22.0, V22.1 or V23.9, V69.8 6-12-15 6/2/15 31 Hepatitis B, C Screening Procedure Codes 86707 Hep B Antibody 86803 Hep C Antibody Modifier *92 if rapid kit used 86804: Hep C Confirmatory Test G0472: Hepatitis C antibody screening for individual at
high risk and other covered indication(s) can have yearly, must use V69.8 high risk group 36415 Venipuncture , 36416 Finger stick Use Diagnosis Hep B: V69.8, V73.89,V22.0, V22.1, V23.89 Hep C-Once in a lifetime if born between 1945-1965 Hep C Once yearly if High Risk/continued drug use. V69.8 with 304.91 6-12-15 6/2/15 32 HIV Screening Procedure Codes 86689 Western Blot used to be confirmatory 86701 HIV type 1 antibody * Modifier 92 86702 HIV type 2 antibody 86703 HIV type 1 and 2, single result 87389 4rth Gen HIV antibody and antigen *Modifier 92 87535 HIV NAAT
36415 Venipuncture , 36416 Finger stick G0432 HIV antibody EIA G0433 HIV antibody EIA, rapid , oral G0435-Rapid Use Diagnosis V73.89, V69.8, V22.0, V22.1, V23.9 Annually or if pregnant 3 times during pregnancy. 6-12-15 6/2/15 33 Preventive Medicine Counseling Any Risk Reduction counseling to prevent a health problem - based on the approximate duration of service: 99401- 15 minutes If between 8-15 minutes add modifier U5 If under 8 minutes DO NOT BILL
99402 - 30 minutes 99403 - 45 minutes 99404 - 60 minutes 6-12-15 6/2/15 34 Sexual Risk Reduction Counseling 99401-99404: Preventive medicine counseling and/or risk factor reduction intervention, time-based in 15 min intervals ( Medicaid pays this on an institutional claim) G0445: High Intensity Behavioral Counseling to Prevent STIs - individual, face to face, includes education skills training and guidance on how to change sexual behavior (30 minutes-semi annually) (Medicare/Excellus pay this code) 6-12-15
6/2/15 35 Health Risk Assessment CPT 99420 (Administration and Interpretation of a risk assessment instrument) for any type of health problem ( cardiovascular, depression, sexual risk, etc.) Screening for ETOH/SU and Tobacco have separate CPT codes, but an insurance co may choose to use 99420 for all screening 6-12-15 6/2/15 36
Hep B , A, and HPV Vaccines Separate CPT codes for each type of vaccine For Vaccine Administration: Initial vaccine: CPT 90460 ( any type vaccine 18 yrs. and younger) or 90471 (injectable vaccine for over 18) cannot bill more than one Initial code on the same date of service. Additional vaccines on same day, code 90461 (any type second vaccine 18 or younger ) or 90472 (each injectable vaccine for adults over 18). 6-12-15 6/2/15 37 Alcohol/SU Misuse: Screening and Brief Intervention Screening is usually done using published tools. http://
www.oasas.ny.gov/AdMed/sbirt/index.cfm AUDIT, ASSIST, CRAFFT, DAST-10, POSIT, CAGE Tools must provide information to tailor an intervention to the identified level of ETOH/SU and must include: An in-person interview Quantity/frequency of substance use over a particular time frame (generally 1-12 months) Problems related to use Dependence symptom Injection drug use. 6-12-15 6/2/15 38 Alcohol /SU Screening , Intervention S = Screening BI = Brief Intervention Can do S only
For some insurers: G0442 = ETOH screen 15 min G0443 = ETOH BI 15 min 6-12-15 Procedure code for S = H0049 Use with Diagnosis code for S = V82.9 Procedure code BI = H0050 Use with Diagnosis code BI = V65.2 6/2/15 39
Definition ETOH/SU Brief Intervention NY Medicaid does not endorse a specific model, ex. FRAMES Providers must use effective strategies intended to motivate individuals to decrease or abstain from ETOH/ SU Examples of effective strategies can be found on www. samhsa.gov 6-12-15 6/2/15 40 Smoking Cessation - Intermediate Diagnosis code 305.1 on claim, can be sole reason for visit Up to 6 sessions in a consecutive 12-month
period CPT 99406 smoking cessation counseling for a 3-10 minute individual session 6-12-15 6/2/15 41 Smoking Cessation - Intensive CPT 99407 intensive smoking cessation counseling greater than 10 minutes and may be a group (Use modifier HQ) Claim may contain other CPT codes for HIV counseling and or E&M codes 6-12-15 6/2/15
42 Tobacco use counseling and interventions Medicare uses G0436 for 3-10 minutes and G0437 for greater than 10 minutes. Other insurances may use those codes also, or the 99401-99407 series of codes. 6-12-15 6/2/15 43 Intimate Partner Violence screening This service is usually included in an exam code 99201-99215.
Remember, if counseling is provided for more than 50% of the visit, may bill by Time 6-12-15 6/2/15 44 E & M Visits & PS Document the CC, History, Exam, MDM Bill the appropriate E & M visit CPT/ICD-9 code that reflects the service rendered Add the PS codes IF they were provided as a discrete service in addition to the E & M visit If no codes for the PS provided , consider billing by Time as the controlling factor 6-12-15
6/2/15 45 Nurse Visit E & M 99211 For an Established Patient A nurse can provide a PS Can bill E & M 99211 All Medicaid Managed Care and other 3rd party will pay - but not Medicaid FFS 6-12-15 6/2/15
46 In Conclusion 1. If separate coding PS can be billed on top of the E & M visit CPT code IF they were provided as a discreet separate service 2. IF no separate coding - E & M visits can be billed by Time spent if over 50% of time was spent on PS related counseling 3. NYS Medicaid Managed Care and Private providers pay for 99211 visits for services provided by a nurse. 6-12-15 6/2/15 47 Useful Websites
List of helpful websites: For Essential Community Providers a list is available at: http://hab.hrsa.gov/affordablecareact/ecp.html To obtain an NPI: https://nppes.cms.hhs.gov/NPPES/Welcome.do To obtain Medicare enrollment forms: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/ EnrollmentApplications.html To obtain ETIN Certification forms and enrollment/EFT forms for NY Medicaid: https://www.emedny.org/info/ProviderEnrollment/ To complete the OMIG CCSL: www.omig.ny.gov To complete the CAQH application http://www.caqh.org/access-upd.php To watch the CAQH tutorial http://www.caqh.org/upd-tutorial.php To obtain Model HIPAA notices http//www.hhs.gov/ocr/privacy/hipaa/modelnotices.html
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