June 2009    Volume 25, Number 7  

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Dear Medicaid Provider,

Welcome to the June 2009 edition of the Medicaid Update, a monthly publication that delivers the latest Medicaid policy and billing guidance for you and your staff. Our cover story this month clarifies Medicaid's documentation requirements for Evaluation and Management (E&M) services provided by supervising/teaching physicians in Article 28 facilities. This month's newsletter also features important policy billing guidelines and pharmacy updates.

The Medicaid Update is published by the Office of Health Insurance Programs of the New York State Department of Health. We welcome your ideas and suggestions for future issues. Please contact us at (518)486-6829 or via e-mail at medicaidupdate@health.state.ny.us.

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In this issue....

POLICY AND BILLING GUIDANCE

Supervising/teaching physician documentation in the clinic setting
Notice concerning the Americans with Disabilities Act (ADA) Amendments Act Of 2008
Hospitals and birthing facilities are required to report births
Inpatient Directly Observed Therapy for Tuberculosis For Enrollees in Medicaid Managed Care
Behavioral Health Services for HIV+ Individuals Enrolled in Medicaid Managed Care in New York City
EMedNY Combination Edits Personal Emergency Response Services (PERS)

PHARMACY PROVIDERS

Preferred Drug Program Update

ALL PROVIDERS

Easy tips to reduce cancellations and no-show appointments.
Adjusting previously paid claims with multiple claim lines
Smoking cessation advertisement
CSC offers Medicaid provider seminars
Provider Services

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Check out the "What's New" section on the eMedNY Website

The "What's New" page features recent Provider Manual updates and bulletins. For updates and bulletins older than four months, please refer to the archive section and select the desired year. Find out What's New at http://www.emedny.org/new/index.html. Please call the eMedNY Call Center at (800) 343-9000 with any questions.

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SUPERVISING/TEACHING PHYSICIANS IN ARTICLE 28 FACILITIES

The following information clarifies Medicaid's documentation requirements for Evaluation and Management (E&M) services provided by supervising/teaching physicians in Article 28 facilities. These documentation requirements apply to supervisors of residents and interns. Residents and interns (even if licensed) do not function independently. They should only provide medical care under appropriate supervision.

MEDICAID FEE-FOR-SERVICE

1. Professional Component Billed/Paid Under the Physician Fee Schedule

If the supervising/teaching physician is billing Medicaid and being paid under the Physician Fee Schedule for services provided in a clinic setting by a resident/intern, the supervising/teaching physician is required to document at least the following:

• That the supervising/teaching physician performed the service or was physically present during the key or critical portions of the service, when performed by the resident/intern, and;
• The extent of the supervising/teaching physician's participation in the management of the patient.

PLEASE NOTE: Although supervising/teaching physicians need not repeat documentation already provided by a resident/intern, their documentation should reference the resident/intern notes.

E/M Service	Examples of Minimally Acceptable Documentation by Supervising/Teaching Physicians
Initial Visit	"I performed a history and physical examination of the patient and discussed his management with the resident/intern. I reviewed the residents/interns notes and agree with the documented findings and plan of care." (Accompanied by countersignature)
Follow-up Visits	"I saw the patient and evaluated his progress. I agree with the findings and plan of care documented in the residents/interns notes." (Accompanied by countersignature) -OR- "See residents/interns notes for details. I saw and evaluated the patient and agree with the residents/interns findings and plans as written." (Accompanied by countersignature) -OR- "I saw the patient with the resident/intern and agree with his/her findings and care plan." (Accompanied by countersignature)

Exception for Evaluation and Management Services Furnished in Certain Primary Care Centers Affiliated with Graduate Medical Education (GME) Programs -

If a teaching physician in an approved GME Program meets Medicare's criteria for a Primary Care Exception, the teaching physician may bill Medicaid for lower and mid-level E/M services performed by a resident, when the teaching physician is not physically present. Medicare's Primary Care Exception criteria require that the following conditions are met:

• The service must be furnished in a primary care center located in the outpatient department of a hospital or other ambulatory care entity affiliated with an approved GME program.
• The resident, who furnished the billable patient care without the physical presence of the teaching physician, must have completed more than 6 months of an approved residency program.

The supervising/teaching physician, who submits claims under the exception, must:

• Supervise no more than four residents/interns at a time;
• Be immediately available and have no other responsibilities at the time the patient is being seen;
• Assume management responsibility for the patient and ensure that the services rendered are reasonable and necessary;
• Review with the resident/intern, during or immediately following each visit, the key elements of the services provided;
• Document the extent of their participation in the review and direction of services.

For more information on meeting Medicare's Primary Care Exception requirements, see the Centers for Medicare and Medicaid Services (CMS) Guidelines for Teaching Physicians, Interns and Residents at: http://www.cms.hhs.gov/MLNProducts/downloads/gdelinesteachgresfctsht.pdf

2. Professional Component Included in the Facility's Cost Report:

If the cost of the professional component is included in the facility's cost report and the physician is not billing Medicaid fee-for-service, the supervising/teaching physician does not have to be present so long as the three criteria below are met.

The supervising/teaching physician must:

• Be onsite and available to answer questions and provide supervision/guidance, as needed;
• Review, on day of visit, the documentation including the patient's medical history, the resident/intern findings on physical examination, the patient's diagnosis and the prescribed treatment plan;
• Document the extent of his/her participation in the review and direction of services;

Supervision and consultation guidelines are set forth by the NYS Department of Health's Minimum Standards for Hospitals, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Accreditation Council for Graduate Medical Education (ACGME). When the supervising/teaching physician is not salaried by the Article 28 facility and is not billing Medicaid (i.e., medical school faculty), the guidelines set forth by these organizations apply.

MEDICAID MANAGED CARE

If the supervising/teaching physician is providing care through a Medicaid Managed Care Plan, please refer to Appendix I of the Medicaid Managed Care contract for supervision requirements available online at: http://www.health.state.ny.us/health_care/managed_care/docs/medicaid_managed_care_and_family_health_plus_model_contract.pdf

The Department of Health continues to evaluate standards of care and billing requirements in teaching facilities to ensure that high quality, continuous care is provided to Medicaid beneficiaries in compliance with State regulations and national accreditation standards, regardless of billing methodology.

Questions about the Article 28 facility clinic rate structure? Please contact the Bureau of Primary and Acute Care Reimbursement at (518) 474-3267.

Questions about documentation requirements? Please contact the Bureau of Policy Development and Coverage at (518) 473-2160.

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Important Bulletins

 

On September 25, 2008, the President signed into law the Americans with Disabilities Act Amendments Act of 2008 (ADA Amendments Act). It became effective on January 1, 2009. The Act makes important changes to the definition of the term "disability" by overruling several Supreme Court decisions and portions of the Equal Employment Opportunity Commission's (EEOC) ADA regulations. The Act retains the ADA's basic definition of "disability" as an impairment that substantially limits one or more major life activities, a record of such an impairment, or being regarded as having such an impairment. However, it changes the way that these statutory terms should be interpreted in several ways. Full details on these changes are available at: http://www.eeoc.gov/ada/amendments_notice.html

Hospitals and birthing facilities are required to report births for women who receive Medicaid within five (5) business days of the birth to the New York State Department of Health or to the New York City Department of Health and Mental Hygiene for births occurring in NYC. This took effect on July 1, 2000. Hospitals and birthing facilities must report the birth using the State Perinatal Data System (SPDS). Failure to fulfill the reporting requirements or submitting an incorrect Medicaid Client Identification Number (CIN) for the birth mother may result in the hospital or birthing facilities receiving a Notice of Deficiency and/ora $3500 fine per occurrence if the hospital or birthing facility is found to be non-compliant. The mother's CIN associates the newborn with the birth mother. If the mother's CIN is unknown, the field should be left blank. If you are unsure of the SSN, it is preferable to leave the area blank to ensure a system automated match. Providers should not use a sequence such as 123456789 if the CIN is unknown. Please contact the Bureau of Medicaid/Family Health Plus Enrollment at (518) 474-8887 with any questions. NOTE: Newborns of mother's enrolled in a Medicaid managed care plan are automatically enrolled in the mother's health plan unless the newborn appears to meet the criteria for SSI eligibility. This rule also applies to mother's enrolled in Family Health Plus (FHPlus) unless the newborn appears to meet the criteria for SSI eligibility OR the mother's plan does not participate in Medicaid managed care.

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Medicaid Managed Care Reminders:

When ordered by a local health commissioner, Tuberculosis Directly Observed Therapy (TB/DOT) related inpatient stays for Medicaid managed care enrollees are NOT the responsibility of the managed care plan and are payable on a fee-for-service basis. When a person with TB is admitted to the hospital under a local health commissioner's order for non-compliance with a prescribed TB treatment plan, and is enrolled in a health plan, the hospital should contact the Office of Health Insurance Programs, Division of Managed Care (DMC), at (518) 473-0122. A copy of the detention order from the local public health agency will be requested. When the enrollee is discharged, the hospital must submit the claim to eMedNY to obtain a denial with reason code 01172. Once denied, the hospital should contact the DMC for assistance processing the claim using the special edit process.

Individuals living with HIV/AIDS may enroll in either a regular (mainstream) Medicaid managed care plan or an HIV Special Needs Plan (HIV SNP). Mental health services and chemical dependence inpatient rehabilitation services for SSI enrollees in an HIV SNP are covered by the HIV SNP. These services when provided to an SSI member enrolled in a mainstream Managed Care plan are billable to Medicaid fee-for-service. Additional HIV SNP benefit package information is available within Appendix K of the SNP Model Contract at: http://www.health.state.ny.us/diseases/aids/resources/snps/contract.htm. Questions? Please e-mail us at omcmail@health.state.ny.us

This article serves as clarification of an eMedNY payment edit that was implemented on January 9, 2009 to prevent duplicative payments during the same month for Home Health Aide and Personal Care Services (PERS) prior authorized by the local department of social services (LDSS) and PERS when provided as a waiver service under the Long Term Home Health Care Program (LTHHCP). The following rate codes are effected:

Home Health Aide and Personal Care Services

2514     PERS Monthly Service Charge

Long Term Home Health Care Program

3858    PERS Monthly Rate (COS 0388 - Nursing Home Based)

2818    PERS Monthly Rate (COS 0284 - Hospital Based)

2616    PERS Monthly Rate (COS 0260 - Freestanding)

3831    PERS Second Unit Monthly Rate (COS 0388 - Nursing Home Based)

9981    PERS Second Unit Monthly Rate (COS 0260 - Freestanding)

Duplicative claims typically occur when an individual changes the program from which PERS are authorized and both providers bill for PERS for the same month(s) during the transition. Attention to coordination between the LDSS and the LTHHCP of the end date of Home Health Aide and Personal Care Services PERS and the start date of LTHHCP PERS (or vice versa) is required to prevent duplicative claims for the monthly PERS rate. When the Home Health Aide and Personal Care Services PERS will be discontinued, the LDSS is responsible to end-date the LDSS prior approval to reflect the end of PERS through that provider. A claim for any of the monthly PERS rates will be denied payment if another PERS rate code appears in history as paid for that same month. For example, when a Certified Home Health Agency (CHHA) has billed for the PERS (rate code 2514) for the month beginning May 1, 2009, a LTHHCP provider will be denied payment for LTHHCP PERS (rate code 3858) if it is billed within 28 days of the claim for CHHA PERS. Rate codes for PERS installation are NOT subject to these edits.

Questions regarding PERS should be directed to the Office of Long Term Care, Division of Home and Community Based Services at (518) 474-5271.

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The New York State Medicaid Pharmacy and Therapeutics (P&T) Committee recently expanded the Preferred Drug Program to include eight new drug classes. Prescriptions written on or after June 10, 2009 for non-preferred drugs in the following classes will require prior authorization:

• Antibiotics - Topical
• Antihistamines - Intranasal
• Anti-Virals - Topical
• Direct Renin Inhibitors
• Non-Ergot Dopamine Receptor Agonists
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) - Prescription
• Psoriasis Agents - Topical
• Skeletal Muscle Relaxants

To obtain prior authorization for non-preferred drugs, please contact the Call Center at (877) 309-9493 and follow the appropriate prompts.

The most current Preferred Drug List (PDL), with a full listing of preferred and non-preferred drugs for each of the drug classes currently subject to the PDP can be viewed at:

https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf

Additional information, such as a "Quick List" of only preferred drugs and updated prior authorization forms, is available at each of the following Websites:

http://www.nyhealth.gov

http://www.eMedNY.org

https://newyork.fhsc.com

Remember: Preferred drugs do not require prior authorization!

For clinical concerns or preferred drug program questions, please contact (877) 309-9493. For billing questions, contact (800) 343-9000. For Medicaid pharmacy policy and operations questions, contact (518) 486-3209.

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All Providers

Has your practice experienced a decrease in productivity because patients are not keeping their appointments? When patients miss appointments, they interrupt the flow of patient care and impede practice efficiency. When patients miss appointments, they interrupt the flow of patient care and impede practice efficiency. Cancellations and no-shows are an ongoing challenge for many practice environments. The strategies outlined below are not new, however, research suggests that implementing a few simple strategies within your facility can enhance your scheduling process and encourage patients to keep their appointments.

PLEASE NOTE: MEDICAID CANNOT BE BILLED FOR NO-SHOW APPOINTMENTS

TIPS TO REDUCE CANCELLATIONS AND NO-SHOW RATES

• GIVE PATIENTS A REASON TO RETURN: At the end of every appointment it is important to stress the significance of the next appointment (especially to patients with chronic conditions). Medical experts have established that physicians have the best opportunities to impact behavioral change in no-show patients.
• DON'T KEEP PATIENTS WAITING: Patients become frustrated if they need to spend time waiting for their appointment. Respect the patients' time and keep them informed of delays.
• THANK YOUR PATIENTS: Remind scheduling and receptionist staff to thank patients for keeping their appointments and for arriving on time. By personalizing the interaction it reinforces the patient's commitment and provides a positive customer service experience.
• MAKE REMINDER CALLS: Perform automated telephone appointment reminder calls using appropriate technology two days prior to appointment.
• MAKE FOLLOW-UP CALLS: If patients are reminded but still miss their appointments, make follow-up calls to inform them that they were missed and show concern for the missed appointment. Stress the importance of their need to reschedule in the future.

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Document level processing bundles multiple lines submitted on a claim and pays at the claim level assigning the same transaction control number (TCN) to each line. When the TCN is used to submit an adjusted claim, all lines that were assigned that TCN will be impacted by the transaction. Document level processing impacts both electronic and paper claims submitted with multiple claim lines by fee-for-service providers as well as rate-based home health and clinic providers. To adjust (replace) a previously paid claim, providers must know what lines were originally paid under the TCN. Providers are responsible for resubmitting claims that are voided as a result of improperly adjusting previously paid claims.

It is important to follow these instructions

• If an adjustment is submitted without one or more of the lines paid from the previous claim, those omitted lines will be voided and the money taken from the check issued for the weekly payment cycle in which the void is processed.
• If the amount of the voided claims exceeds the total paid claims for that cycle, a negative balance is placed on the provider's file and the payment for any subsequent claims will be used to reduce the negative balance to zero before any further checks will be issued.
• Submitting multiple adjustments without understanding document-level processing can result in unintended voided claims that may create a negative balance for the provider.
  
  Suggestions: Fee-for-service providers are urged to review the instructions and examples in the Billing Guidelines section of their provider manual before submitting claim adjustments. Providers with large numbers of adjustments to submit may want to initially submit one claim to ensure the adjustment processes as the provider intended. Please visit http://www.emedny.org/providermanuals/index.html to review your provider manual. Questions? Please call the eMedNY Call Center at (800) 343-9000.

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• Do you have billing questions?
• Are you new to Medicaid billing?
• Would you like to learn more about ePACES?

If you answered YES to any of these questions, you should consider registering for a Medicaid seminar. Computer Sciences Corporation (CSC) offers various types of seminars to providers and their billing staff. Many of the seminars planned for the upcoming months offer detailed information and instruction about Medicaid's Web-based billing and transaction program - ePACES.

ePACES is the electronic Provider Assisted Claim Entry System which allows enrolled providers to submit the following type of transactions:

• Claims
• Eligibility Verifications
• Utilization Threshold Service Authorizations
• Claim Status Requests
• Prior Approval Requests

Physicians, nurse practitioners and private duty nurses can even submit claims in "REAL-TIME" via ePACES. Real-time means that the claim is processed within seconds and professional providers can get the status of a real-time claim, including the paid amount without waiting for the remittance advice.

Fast and easy seminar registration, locations, and dates are available on the eMedNY Website at: http://www.emedny.org/training/index.aspx

Please review the seminar descriptions carefully to identify the seminar appropriate for your training requirements. Registration confirmation will instantly be sent to your e-mail address. If you are unable to access the Internet to register, you may also request a list of seminars and registration information to be faxed to you through CSC-s Fax on Demand at (800) 370-5809.

Please request document 1002 for July - September seminar dates and 1003 for October - December seminar dates.

CSC Regional Representatives look forward to meeting with you at upcoming seminars!

Questions about registration? Please contact the eMedNY Call Center at (800) 343-9000.

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Your Patients Are Listening
Return to Table of Contents

By providing counseling, pharmacotherapy, and referrals, you can double your patients' chances of successfully quitting. For more information, please visit www.talktoyourpatients.org or call the NY State Smokers' Quitline at 1-866-NY-QUITS (1-866-697-8487).

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Quick Reference Guide
Return to Table of Contents

Office of the Medicaid Inspector General:
http://www.omig.state.ny.us or call (518) 473-3782 with general inquiries or 1-877-87FRAUD with suspected fraud complaints or allegations.

Questions about an Article?
Each article contains a contact number for further information, questions or comments.

Questions about billing and performing EMEVS transactions?
Please contact eMedNY Call Center at: (800) 343-9000.

Provider Training
To sign up for a provider seminar in your area, please enroll online at:
http://www.emedny.org/training/index.aspx

For individual training requests, call (800) 343-9000 or email: emednyproviderrelations@csc.com

Enrollee Eligibility
Call the Touchtone Telephone Verification System at any of the numbers below:

(800) 997-1111    (800) 225-3040      (800) 394-1234.

Address Change?
Questions should be directed to the eMedNY Call Center at: (800) 343-9000.

Fee-for-Service Providers
A change of address form is available at: http://www.emedny.org/info/ProviderEnrollment/index.html

Rate-Based/Institutional Providers
A change of address form is available at: http://www.emedny.org/info/ProviderEnrollment/index.html

Comments and Suggestions Regarding This Publication?
Please contact the editor, Kelli Kudlack, at: medicaidupdate@health.state.ny.us

Medicaid Update is a monthly publication of the New York State Department of Health containing information regarding the care of those enrolled in the Medicaid Program.