2011 Medicaid Provider Updates
- There have been updates regarding the Health Insurance Portability and Accountability Act (HIPAA) X12 Version 5010 Software upgrade. Up-to-date information can be found on the 5010 Information Web page.
- Checkwrite Dates for the beginning of 2012 have been posted. See the Provider Checkwrite page.
- North Dakota Medicaid allows/reimburses debridement CPT codes 97597 and 97598 effective January 1, 2011
North Dakota (ND) Medicaid has determined that effective January 1, 2011, CPT codes 97597 and 97598 will be allowed/reimbursed when the service is performed and documented by physicians (MD/DO), or nurse practitioners (NP), or physician's assistants (PA) or clinical nurse specialist (CNS); when it is within their scope of practice. Providers performing and billing for debridement as described by the CPT codes must submit the claims(s) under their ND Medicaid provider number. Physician ssistants and clinical nurse specialists who perform and bill for these services, using these CPT codes (if within thier scope of practice) must append the appropriate modifier to the debridement CPT codes.
A PA performing debridement would submit 97597-U1
A CNS performing debridement would submit 97597-U2
97597 Debridement (e.g. high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), open would (e.g. fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface are; first 20 sq cm or less
+97598 Debridement (e.g. high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), open wound (e.g. fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure)
According to 42 CFR 447.45, North Dakota medicaid has a one year timely filing limit. All claims submitted for reimbursement to ND Medicaid must be submitted within that one-year timeframe and remain an active claim. If a claim has been denied, ND Medicaid can process a resubmitted claim within one year from the last remittance advice date that contrained the denied claim.
If you have any questions, please contact North Dakota Medicaid at 1.800.755.2604 and ask to speak with a medical coder.
- The DME Fee Schedule has been updated, along with a Provider Memo regarding the added and deleted codes. Please see the Medicaid DME Provider Web page.
- New Version D.0 Phamacy payer sheets regarding Bill-Rebill & Claim Reversal have been posted on the Payer Sheet Web page.
- A new Nursing Facility Payment System booklet (DN 141), effective January 2012, has been posted. It can be viewed on the Medicaid Provider Manuals page under the Nursing Facility Providers heading.
- *5010 Updates* DHS expects to implement the X12 Version 5010 software January 2, 2012. However, we recently found some technical mapping issues which may, if not easily corrected and tested, prohibit our implementation. Processing claims is vital to the Department's mission, and we will process X12 Version 4010 transactions ONLY after the first of the year if we cannot implement the X12 Version 5010. In order to ensure claims from providers can be processed, DHS will continue to support X12 Version 4010 transactions after the Department's X12 Version 5010 solution is implemented. Please look for updates on this page. We will keep you informed of our progress on the X12 Version 5010 implementation. More information can be accessed on the Companion Documents Web page.
- An MDS 3.0 Submission Guideline has been added to the Nursing Facility Providers heading on the Provider Manuals page.
- The next DME Task Force Meeting has been scheduled for February 2012. More information can be found on the DME Provider Meetings page.
- A reimbursement increase for wheelchair cushions has been posted on the DME Provider main page.
- Subsequent Observation Care - 99224, 99225, 99226
Effective on date of service December 1, 2011, ND Medicaid will allow/reimburse subsequent observation care services when submitted with CPT codes 99224,99225, or 99226.
Payment for a subsequent observation care code is for all the care rendered by the attending/admitting physician on the day(s) other than the initial or discharge date. All other physicians who furnish consultations or additional evaluations, or services while the patient is receiving hospital outpatient observation services, must bill the appropriate office and other oupatient service codes. In the rare circumstance when a patient receives observation services for more than two (2) calendar dates, the physician shall bill observation services furnished on day(s) other than the initial or discharge date using subsequent observation care codes.
- 5010 Update - ND Medicaid is asking providers that are able to creat 5010 transactions to contacts us. We are looking for testing partners. For more information, please see the Companion Guide Web page.
- A new Claims Submission Guideline document for Critical Access Hospitals has been added to the Medicaid Billing Information page.
- Changes have been occuring regarding Medicaid's Health Management program. Information regarding these changes is available on the Managed Care page.
- Physician Signatures - Documentation sbumitted to ND medicaid must be signed by the physician performing the service. All medical record entries must be legible and complete, dated and timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided consistent with organizational policy.
Electronic signatures in medical records will be accepted in the following format:
- Chart 'Accepted by' with provider's name
- 'Electronically signed by' with provider's name
- 'Verified by' with provider's name
- 'Reviewed by' with provider's name
- 'Released by' with provider's name
- 'Signed by' with provider's name
- Signed before import by' with provider's name
- 'Signed: Dr. __________' with provider's name
- Digitized Signature, handwritten and scanned into the computer
- 'This is an electronically verified report by Dr. __________'
- 'Authenticated by Dr. __________'
- 'Authorized by Dr. __________'
- 'Digital Signature: Dr. __________'
- 'Confirmed by' with provider's name
- 'Closed by' with provider's name
- 'Finalized by' with provider's name
- 'Electronially approved by' with provider's name
- 'Signature Derived from Controlled Access Password'
Unacceptable Signatures are:
- Dictated but not read
- Signed but not read
- Rubber Stamp Signatures (Source: 7/29/08: MLN Matters SE0829 CMS States: "Stamped signatures are NOT acceptable on any medical record")
If there is no signature appended to medical record documentation, claims will be denied for no signature.
- The General Information for Providers manual has been updated. It can be accessed on the Medicaid Provider Manuals page.
- A fee schedule update regarding Gait Trainers has been posted on the Durable Medical Equipment Provider page.
- DHS is currently working on the following companion guides - 278 Prior Authorization, 820 Premium Payment, 834 Enrollment, 835 Remittance Advice. We will publish these guides to our Web site upon their completion.
We have completed the following guides - 270 Eligibility Request, 271 Response, 276 Status Request, 277 Information Status Notification, 837 Dental, 837 Institutional, and 837 Professional.These guides are available on the Companion Documents Web page. The guides are provided for clarification purposes only and should be used in conjunction with the applicable HIPAA Implementation Guide.
DHS is currently perfomring system and user acceptance testing of the 5010 transactions. Please watch this Web site for further details as they become available.
- ND Medicaid has updated the Hysteroscopic Tubal Occlusion Medical Policy effective February 1, 2011. Please refer to the Medicaid Medical Policy page for details.
- The new IMD Admission/Disacharge Alert form has been created. It can be found on the Provider Manuals page under the "Under 21 Psychiatric Providers" heading.
- Durable Medical Equipment (DME) Task Force meeting minutes from June 29, 2011 have been posted. They can be found on the DME Providers - Meetings page.
- A link to Northland PACE has been added to the Medicaid Managed Care page.
- A new guideline has been posted on the Medicaid Coding Guidelines page regarding Maternal Depression Screening.
- Updated fee schedules effective July 2011 have been posted on the Provider Fee Schedules page.
- Fee Schedule Update - Effective 07/01/11
In accordance with the legislative mandate to update provider rates with a 3.0% inflationary increase the first and second year of the 11-13 biennium, we have increased provider rates effective for 7/1/2011 dates of services and after. Codes which are priced off a fee schedule will be adjusted with the 3% inflationary increase accordingly.
Codes which are priced using the Relative Value Unit (RVU) methodology have had the conversion factor adjusted. The adjustment in the converstion factor takes into account the implementation of the 2011 RVUs for the dates of service on or after July 1, 2011. Based on previous calendar 12 months' claims volume, the new relative value unit adjustements, and no inflationary increase, the resulting conversion factor adjustment is to $47.46. The previous converstion factor was $53.35. Based on the changes to the relative value units, some fees will increase while others may stay the same or decrease. In the aggregate, the providers whose claims are priced off the RVU methodology will see a cost-neutral impact to their fees.
- As a reminder, the Checkwrite that was previously scheduled for August 1st has indeed been moved to August 2nd. This information is updated and current on on Checkwrite Dates page.
- The Nursing Facility Rate Manual has been updated on the Provider Manuals page.
- DHS has revised the 4010 Companion Guides located on the Companion Guide Web page. These guides are provider for clarification purposes only and should be used in conjunction with the applicable HIPAA Implementation Guide. DHS is currently working on the 5010 Companion guides and will publish those as soon as they become available.
- The Medicaid Managed Care page has been updated with some additional relevant information including the 1915(b) Renewal Waiver to CMS, a PACE Fact Sheet, and the November 2009 letter to Nurse Practitioners informing them of the ability to opt-in to the PCCM program.
- A new Web page regarding ND Medicaid Checkwrite Dates has been created.
- The Web File Transfer link has been moved for the Provider Main page for easier access to our Medicaid Providers.
- Updated versions of two Nursing Facility manuals have been posted on the Provider Manuals page. Minor changes were made to the Assigning a Classification manual and the Nursing Facility Payment System booklet.
- Provider Audit has sent us updated files for Provider Report Documents regarding the following facilites: Basic Care, Residential Child Care, Psychiatric Residential Treatment, and Nursing Facilities.
- ASC Payment Groups, Rates, and Codes for 2011 have been added to the Provider Fee Schedules page. More 2011 Fee Schedules will be posted shortly.
- The Final Policy regarding the External Insulin Infusion Pump has been posted to the Durable Medical Equipment Provider page. Also new on this page is a correction to the Added and Deleted Codes notice from 4/1/11.
- NOTICE TO ALL PROVIDERS:
ND Medicaid considers Claim Adjustment Reason Code 50 to be a contractual obligation (provider liable) for the provider to write off. Any claim denial with Reason Code 50 is not patient reponsible and may not be billed to the patient.
- Two new updates pertain to Durable Medical Equipment (DME) providers. The next DME Task Force meeting has been scheduled; more information can be accessed on the DME Providers' Meetings page. Also, ND Medicaid is having a Policy Review and Comment Period regarding insulin pumps. A draft version of this Policy is avaialble on the main DME Provider page. Comments may be submitted through the end of the month.
- The Provider Billing Manuals page has been updated with two new documents that will aid Transportion, Lodging, and/or Meals providers in completing the CMS 1500 claim form.
- An updated list of Assisted Living Facilities has been posted to the Assisted Living page.
- Medicaid Managed Care now has a new mailbox to address provider inquiries: email@example.com. Managed Care includes the programs of Primary Care Case Management (PCCM; formerly PCP), Program of All-Inclusive Care for the Elderly (PACE), and ExperienceHealthND (disease management).
- Our providers may have already received the April 2011 Provider Bulletin in the mail, which was sent out earlier this week. It is now also listed on the main Provider page.
- Please take note that Individual (non-commercial) Transportation Providers are not required to fill out an Ownership/Controlling Interest and Conviction Information form (SFN 1168) when they enroll to be a ND Medicaid provider. More information can be viewed on the Transportation, Meals, and Lodging Provider Enrollment page.
- Swing Bed rates Effective April 1, 2011 have been posted on the Main Provider Page.
- There have been updates to the Durable Medical Equipment (DME) Fee Schedules. The information is available on the DME Provider main page.
- New and updated screening/review forms have been obtained from DDM Ascend. They have been placed on the Provider Manuals Web page, and are listed under both the Nursing Facility Providers and the Under 21 Psychiatric Providers headings.
Reprocessing Claims Affected by the Affordable Care Act and 2010 Medicare Physician Fee Schedule Changes
When providers identify North Dakota Medicaid electronic or paper claims that are affected by the information below, they will need to adjust and attach a corrected copy of the claims and the new Medicare Explanation of Benefits (EOB). If the provider has to bill electronically because North Dakota Medicaid is required to capture the NDC for drugs on the claim, they will need to submit an adjustment, watch for the denial of this adjustment on their Remittance Advice (RA), and then resubmit the corrected electronic claim. If the claim is over one year from the date of service, the provider is asked to indicate on the claim the last Remittance Advice date and Internal Control Number to avoid timely filing denials.
Reprocessing Claims affected by the Affordable Care Act and 2010 Medicare Physician Fee Schedule Changes (The following information was released Tuesday, February 8, 2011 by the Centers for Medicare & Medicaid Services:
This message is for physicians, other practitioners, ambulance suppliers, inpatient/outpatient hospitals, long term care hospitals, inpatient rehabilitation facilities, home health agencies, and any other provider type affected by the post effective date implementation of select provisions of the Affordable Care Act and the 2010 Medicare physician fee schedule.
On March 23, 2010, President Obama signed into law the Affordable Care Act. Various provisions of the new law were effective April 1, 2010, or earlier and, therefore, were implemented some time after their effective date. In addition, corrections to the 2010 Medicare Physician Fee Schedule (MPFS) were implemented at the same time as the Affordable Care Act revisions to the MPFS, with an effective date retroactive to January 1, 2010.
Due to the retroactive effective dates of these provisions and the MPFS corrections, a large volume of Medicare fee-for-service claims will be reprocessed. Given this large workload, the Centers for Medicare & Medicaid Services (CMS) is taking steps to ensure that new claims coming into the Medicare program are processed timely and accurately, even as the retroactive adjustments are being made. CMS will begin to reprocess these claims over the next several weeks. We expect that this reprocessing effort will take some time and will vary depending upon the claim-type, the volume, and each individual Medicare claims administration contractor.
In the majority of cases, you will not have to request adjustments because your Medicare claims administration contractor will automatically reprocess your claims. Please do not resubmit claims because they will be denied as duplicate claims and slow the retroactive adjustment process. However, any claim that contains services with submitted charges lower than the revised 2010 fee schedule amount (MPFS and ambulance fee schedule) cannot be automatically reprocessed at the higher rates. In such cases, you will need to request a manual reopening/adjustment from your Medicare contractor. While there is normally a one-year time limit for physicians and other providers and suppliers to request the reopening of claims, we believe that these circumstances fall under the "good cause" criteria described in the Claims Processing Manual, Publication 100-04, Chapter 34, Section 10.11 (http://www.cms.gov/manuals/downloads/clm104c34.pdf). CMS is, therefore, extending the time period to request adjustment of these claims, as necessary.
Medicare claims administration contractors will follow the normal process for handling any applicable underpayments or overpayments that occur while reprocessing your claims. Underpayments will be included in your next regularly scheduled remittance after the adjustment. Overpayments resulting from institutional provider (e.g., hospitals, inpatient rehabilitation facilities, etc.) claim adjustments will be offset immediately, regardless of the amount, unless there are insufficient funds to make the offset. When these overpayments cannot be offset, the amounts will accumulate until a $25 threshold is reached. At that time, a demand letter will be sent out the institutional provider. When a claim adjustment for a non-institutional provider (e.g., physician, other practitioner, supplier, etc.) results in an overpayment, the Medicare contractor will send a request for repayment. If this overpayment is less than $10, your contractor will not request repayment until the total amount owed accrues to at least $10. See the Financial Management manual, Publication 100-06, Chapter 4, Section 70.16 or Section 90.2 (http://www.cms.gov/manuals/downloads/fin106c04.pdf) for more information.
The CMS wants to remind physicians, practitioners, suppliers, and other providers, impacted by the retroactive increases in payment rates for claims affected by the Affordable Care Act and 2010 MPFS changes, of the Office of Inspector General policy related to waiving beneficiary cost-sharing amounts attributable to retroactive increases in payment rates resulting from the operation of new Federal statutes or regulations. The policy may be found at the following link: http://oig.hhs.gov/fraud/docs/alertsandbulletins/Retroactive_Beneficiary_Cost-Sharing_Liability.pdf
Please contact your Medicare claims administration contractor with any questions about this information.
- The Provider Manual for Optometric and Eyeglass Services has been updated this month. It can be found on the Provider Manuals page under the Optometric Providers heading.
- In addtition to the updated Optometric Manual, the Division has created a new Prior Authorization form for Vision Services. This form will be the only version accepted beginning March 1, 2011. A Provider Memorandum was sent out in early February regarding this change. The form itself is available for download at https://apps.nd.gov/itd/recmgmt/rm/stFrm/eforms/Doc/sfn00292.pdf.
- There is an updated version of the Step by Step Guide to Assigning a Classification manual. It can be viewed under the Nursing Facilitiy Providers heading on the Medicaid Provider Manuals page.
- An updated list of Assisted Living Facilities is now available and can be viewed on our Assisted Living page.