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APIPA
Provider Newsletter
An important message to health care professionals and facilities
Fall 2010
Articles of Importance to Read:
AHCCCS Benefit and Co-payment Changes
Effective October 1, 2010, AHCCCS will implement a TMA
(Transitional Medical Assistance) Co-Pay and changes to the
Medicaid adult benefit package. The key Co-Pay and adult changes
are listed below. You may access detailed information regarding
these changes in APIPA Provider Manual at www.myapipa.com or
visit the AHCCCS website at:
www.azahcccs.gov/reporting/legislation/2010/benefitchanges.aspx
for more information.
2010 AHCCCS ADULT BENEFIT CHANGES
The following medical services that will no longer be covered for
eligible Medicaid adults (21 years of age and older):
• Most dental care
• Bone anchored hearing aids and cochlear implants
• Insulin pumps
• Percussive vests
• Orthotics
• Visits to a podiatrist (visit www.myapipa.com for further
information)
• Pancreas transplants (except when pancreas transplant and a
kidney transplant are done at the same time)
• Lung transplants
• Allogeneic unrelated hematopoietic cell transplants
• Heart transplants for non-ischemic cardiomyopathy
Page 1
• AHCCCS Benefit and Co-payment
Changes
Page 3
• Reimbursement Policy
Changes/Updates
Page 7
• Quality Improvement Program
Page 8
• Topical Fluoride Treatments in the
PCP Setting
• Electronic Claim Submission Tips
Page 10
• Provider Satisfaction Survey
• The Medical Technology Assessment
Committee
• Important Reminders:
Page 11
• When the Patient’s Request Can Lead
to Fraud, Waste or Abuse
Page 12
• Text4Baby
• Acute Care Behavioral Health
Assignment Changes
Page 13
• Atrial Fibrillation Information
Page 14
• Vaccines for Children (VFC)
Page 15
• Office for Children with Special
Health Care Needs (OCSHCN)
Cultural Competence Training
Includes Disability Issues
Page 16
• AmeriChoice Utilizes HEDIS Reporting
To Measure Our Health Care
Performance
• New ID Cards in Yuma County
Page 17
• Appointment Availability Standards
Page 18
• Healthy First Steps
• Baby Arizona Program
Page 19
• AHCCCS Provider’s Responsibility
Page 20
• TIPS
Page 21
• Children's Rehabilitative Services
(CRS)
• AskMe3 Approach
Page 22
• Claims Clues
Page 23
• “DOC TALK”
APIPA Provider Newsletter
• Liver transplants for persons with hepatitis C
• Visits to the doctor without a specific
complaint and not being treated for any
symptoms (well exams)
• Microprocessor-controlled lower limbs and
joints for lower limbs
• Outpatient Physical Therapy Limit of 15
visits per contract year (10/1 through 9/30)
Traditional (Nominal / Low) Co-payments
for Some AHCCCS Programs
Co-payment may be charged, but services
cannot be refused for nonpayment of co-pay.
Prescriptions ...............................................$2.30
Non-emergency use of an
emergency room ........................................$3.40
Office Visit...................................................$2.30
TMA (Transitional Medical Assistance CoPayment changes:
Out-patient services for physical,
occupational and speech therapy.............$2.30
The following members and services are
exempt from co-payments:
Other out-patient services .........................$2.30
• Children under age 19
Members with Required Co-payments
(Mandatory)
• People determined to be Seriously Mentally
Ill (SMI) by the Arizona Department of
Health Services
Co-payment may be charged and services can
be refused for nonpayment of co-pay.
• Individuals up through age 20 eligible to
receive services from the Children’s
Rehabilitative Service Program
• People who are in nursing homes,
residential facilities such as Assisted Living
Home or who receive Home and
Community Based Services such as
attendant care or a visiting nurse
TMA (Transitional Medical Assistance)
program
Prescriptions ...............................................$2.30
Office Visit...................................................$4.00
Out-patient services for physical,
occupational and speech therapy.............$3.00
Non-emergency or voluntary
surgical procedures....................................$3.00
• People who receive hospice care
• Hospitalizations and services received while
in a hospital
• Emergency use of an emergency room
• Family Planning services and supplies
• Pregnancy related health care or any
medical condition which may complicate
the pregnancy (including tobacco cessation
treatment for pregnant women)
page 2
TWG/ MED (Title XIX Waiver Group/
Medical Expense Deduction) program
Prescriptions - Generic ..............................$4.00
Prescriptions - Brand ...............................$10.00
Non-emergency use of an
emergency room ......................................$30.00
Office Visit...................................................$5.00
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
For more information, please visit
www.myapipa.com or the AHCCCS website at:
www.azahcccs.gov/reporting/legislation/2010/
benefitchanges.aspx.
APIPA policies may be view in their entirety
by visiting www.myapipa.com or
www.AmeriChoice.com and selecting
Physician>Tools>Reimbursement Policies.
New Policies
Reimbursement Policy
Changes/Updates
Note Regarding Reimbursement Policies
APIPA periodically reviews and updates its
reimbursement policies as well as develops
new reimbursement policies. Meeting the
terms of a particular reimbursement policy is
not a guarantee of payment. Likewise,
retirement of a reimbursement policy affects
only those system edits associated with the
specific policy being retired. Retirement of a
reimbursement policy is not a guarantee of
payment. Other applicable reimbursement
policies, medical policies and claims edits will
continue to apply.
In the event of an inconsistency or conflict
between the information provided in the
Provider Newsletter and the posted policy, the
provisions of the posted reimbursement
policy will prevail.
Note: Unless otherwise noted above, these
reimbursement policies apply to services
reported using the 1500 Health Insurance
Claim Form (CMS-1500) or its electronic
equivalent or its successor form. AmeriChoice
reimbursement policies do not address all
issues related to reimbursement for services
rendered to AmeriChoice members, such as
the member’s benefit plan, AmeriChoice
medical policies and the Provider
Administrative Guide.
page 3
Clinical Lab Edits
Based on the CMS National Coverage
Determination (NCD) coding policy manual,
services that are excluded from coverage
include routine physical examinations and
services that are not reasonable and
necessary for the diagnosis or treatment of an
illness or injury. CMS interprets these
provisions to prohibit coverage of screening
services, including laboratory tests furnished
in the absence of signs, symptoms, or
personal history of disease or injury. A
national coverage policy for diagnostic
laboratory test(s) is a document stating CMS’s
policy with respect to the circumstances
under which the test(s) will be considered
reasonable and necessary, and not screening,
for Medicare purposes.
Because many of the AmeriChoice markets
follow CMS guidelines for reimbursement,
AmeriChoice has made the decision to create
a suite of edits for Clinical Diagnostic Lab
Services. These edits will ultimately contain
many of the services outlined in the CMS
National Coverage Determination (NCD)
coding policy manual.
AmeriChoice will be implementing two edits
effective November 15 beginning with the two
outlined here.
1. CPT code 82378 Carcinoembryonic antigen
(CEA) will be allowed when billed with a
diagnosis on the allowed “diagnosis codes
for CPT 82378” diagnosis list. If the CPT
code 82378 is submitted with a diagnosis
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
that is not on the allowed “diagnosis codes
for CPT 82378” diagnosis list, the claim will
deny with ACA/FCA remark codes (TBD).
2. Claims submitted with CPT code 82105
Alpha-fetoprotein; serum will be allowed
when billed with a diagnosis on the
allowed “diagnosis codes for CPT 82105”
diagnosis list. If the CPT code 82105 is
submitted with a diagnosis that is not on
the allowed “diagnosis codes for CPT
82105” diagnosis list, the claim will deny
with ACA/FCA remark codes (TBD).
Additional edits will be added in the future
and will be announced prior to the
implementation.
Payment for L3000 Orthotic Inserts
AmeriChoice will allow a maximum frequency
of 2 inserts billed as L3000 per foot per year.
AmeriChoice will also require a prescription
(Rx) for DME providers and other
documentation for podiatrists/orthopedists.
AmeriChoice will no longer reimburse for
reimburse for inserts in states where the
codes are not covered. For Medicare
members, in alignment with CMS, the inserts
will no longer be reimbursed.
This policy will take effect for dates of service
of November 1, 2010 or later.
Observation Care Evaluation and
Management Services
AmeriChoice will publish a new
reimbursement policy that will address
appropriate coding and documentation for
Observation Care Evaluation and
Management services billed on a 1500 Health
Insurance Claim Form (a/k/a CMS-1500) or its
electronic equivalent or its successor form.
page 4
This policy does not apply to claims billed on
a UB-04 form. Observation care CPT® codes
99217-99220 as quoted from the CPT manual
are used to report evaluation and
management services provided to new or
established patients designated or admitted
as “observation status” in a hospital. The
policy will reinforce the correct coding
guidelines as published by the American
Medical Association Current Procedural
Terminology manual in addition to CMS
guidelines as outlined below. CMS guidelines
for reporting Observation Care states:
• The medical record must contain;
– dated and timed
• physician’s admitting orders regarding
patient care in observation status
• nursing notes
• physician progress and discharge
notes
– Be in addition to any record prepared as
a result of an emergency department or
outpatient clinic encounter
– Identify the physician was present,
personally performed the services and
the admission to and discharge from
notes were written by the billing
physician
– Satisfy E/M documentation guidelines
for admission to and discharge from
observation care
• 99218-99220 involve less than eight hours
on the same calendar date
• 99234-99236, Observation or Inpatient Care
Services for patients admitted and
discharged on same date of service,
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
involves a minimum of eight hours, but
less than 24 hours on the same calendar
date
• An outpatient code, 99211-99215, shall be
reported for a visit in those rare instances
when a patient is held in observation care
status for more than two calendar dates
• Other physicians must bill codes 9920199215 when providing services to a patient
in observation status
Pursuant to the AmeriChoice “Global Days"
policy, the global surgical fee includes
payment for hospital observation services
(99217-99220, 99234-99236) unless the criteria
for modifiers 24, 25, 57 are met. Refer to the
AmeriChoice "Global Days" policy for
guidelines on reporting services during a
global period.
Policy Updates
Anesthesia Policy
Preoperative and Postoperative Visits
AmeriChoice Anesthesia Policy currently
follows the American Society of
Anesthesiologists (ASA) guidelines which
indicate the usual preoperative and
postoperative visits are not separately
reimbursable with anesthesia management
services (CPT® codes 00100-01999 excluding
01996 and 01953).
To more closely align with the Centers for
Medicaid & Medicare Services (CMS)
guidelines, the following revisions will
be made:
• Evaluation and Management (E/M) codes
will be considered as usual preoperative
and postoperative visits only when
reported on the same date of service as the
anesthesia management services.
page 5
• Critical care CPT codes (99291-99292) will
be removed from the list of E/M CPT codes
(99201-99499, 92002 92004, 92012-92014
G0396-G0397, S0273 –S0274 99201-99499)
that are considered as preoperative and
postoperative visits, and will be separately
reimbursed when reported with anesthesia
management services.
• Since the critical care CPT codes will now
be separately reimbursed when reported
with anesthesia management services, the
requirement to report a modifier 25
(significant, separately identifiable
evaluation and management service by the
same physician on the same day of the
procedure or other service) is no longer
necessary and will be removed from the
policy.
Anesthesia Teaching Guidelines
Based on CMS guidelines, the following
revisions will be made to the anesthesia
teaching guidelines for reporting anesthesia
services:
• A teaching anesthesiologist (M.D.) training
one Student Registered Nurse Anesthetist
(SRNA) would report the modifier AA
(Anesthesia services performed personally
by anesthesiologist) to be reimbursed at
100% of the fee allowance. The case is not
concurrent to any other anesthesia cases.
• When a teaching anesthesiologist (M.D.)
and a Certified Registered Nurse
Anesthetist (CRNA) are jointly training two
SRNAs in concurrent cases, then the CRNA
should report medical direction by use of
the modifier QX (CRNA service with
medical direction by a physician) for each
case. However, the time reported for the
CRNA is limited to actual time spent with
each case.
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
Modifier 47
The 2010 CPT Manual states: “Regional or
general anesthesia provided by the surgeon
may be reported by adding the modifier '47'
to the basic service (this does not include
local anesthesia).
Note: modifier 47 should not be used as a
modifier for anesthesia procedures.”
Effective November 15, 2010, AmeriChoice
will revise the Anesthesia Policy to not
reimburse for anesthesia management
services (CPT® codes 00100-01999 excluding
01996) when a modifier 47 is appended.
Moderate Sedation Policy
According to the American Medical
Association (AMA), anesthesia services (CPT
codes 00100-01999) should not be reported by
the same physician reporting diagnostic or
therapeutic procedures cited in Appendix G of
the 2010 CPT® Manual.
Effective November 15, 2010 AmeriChoice will
not separately reimburse for anesthesia
management services (CPT codes 0010001999 excluding 01996) when reported on the
same date of service by the same individual
physician or health care professional also
reporting a diagnostic or therapeutic
procedure cited in Appendix G of the 2010
CPT® Book and not addressed in the
Anesthesia Reimbursement Policy.
Therapeutic and Diagnostic Injection
Policy – Revisions and Name Change
Revisions to deny Health Care Common
Procedure Coding System (HCPCS)
Supply Codes when billed with CPT codes
96360-96549
Currently, the Therapeutic and Diagnostic
Injection Policy only addresses
page 6
reimbursement when E/M services are
reported in combination with CPT codes
96372-96379. According to CPT® instructions,
physician work related to hydration, injection
and infusion services predominantly involves
affirmation of treatment plan and direct
supervision of staff. If a significant, separately
identifiable E/M is performed, the appropriate
E/M service code should be reported using
modifier 25 in addition to 96360-96549. CPT
codes 96372-96379, which are addressed in
the Therapeutic and Diagnostic Injection
policy, are part of a larger section of CPT®
entitled “Hydration, Therapeutic, Prophylactic,
Diagnostic Injections and Infusions and
Chemotherapy and Other Highly Complex
Drug or Highly Complex Biologic Agent
Administration,” which spans codes 9636096549.The instructions in this section of
Current Procedural Terminology®, 2010
American Medical Association state: “If
performed to facilitate the infusion or
injection, the following services are included
and are not reported separately:
a. Use of local anesthesia
b. IV start
c. Access to indwelling IV, subcutaneous
catheter or port
d. Flush at conclusion of infusion
e. Standard tubing, syringes, and supplies.”
CMS also follows the CPT guidelines for
inclusive services.
AmeriChoice will update the Therapeutic and
Diagnostic Injection Policy to deny HCPCS
medical and surgical supply codes
(reproduced in the appendix) identified by
description as standard tubing, syringes and
supplies, when reported with CPT codes
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
96360-96549 on the same date of service, by
the same physician or health care
professional.
Documentation will be reviewed for
appropriate coding, existence of a more
appropriate code, coverage and
reimbursement allowance.
Examples:
• A4206 - Syringe with needle, sterile, 1 cc or
less, each
• A4216 - Sterile water, saline and/or
dextrose, diluent/flush, 10 ml
With the adoption of the aforementioned
revisions, the policy name will also be
changed to the Injections and Infusion
Services Policy.
The revised policy will be effective for dates
of claims processing on or after November 15,
2010.
Unlisted Codes-clarification of protocol
AmeriChoice is increasing the requirements
around claims submitted with unlisted codes.
AmeriChoice continues to encourage
providers to provide bill with the most
accurate and specific CPT or HCPCS code. If
an unlisted code is used, AmeriChoice is
clarifying the following requirements:
Documentation is required for all unlisted
codes submitted for reimbursement.
Documentation is to include, but is not
limited to:
• Complete description of what the unlisted
code is being used for
• Procedure report for unlisted
surgical/procedure codes
• Invoice for unlisted DME/supply codes
• NDC #, dose and route of administration for
unlisted drug codes
page 7
Claims submitted with unlisted codes that do
not have documentation with them will be
denied.
Quality Improvement Program
The AmeriChoice Quality Improvement
Program strives to continuously improve the
care and services provided to members.
Each year AmeriChoice Health Plans utilize
HEDIS reporting to measure our health care
performance. Healthcare Effectiveness Data
and Information Set (HEDIS) is a set of
standardized performance measures that are
related to many significant public health
issues. Some of these include well-child
visits, immunization rates, lead screening
rates, prenatal care visits, cancer screenings
and diabetes care.
In 2009, 100% of AmeriChoice Plans saw an
improvement in the number of children who
were completely immunized by age 2 as well
as the number of babies who received the
recommended number of well-baby visits by
age 15 months. In 2010, two of AmeriChoice’s
goals are a continued increase in the number
of babies who receive their recommended
well visits and an increase in the number of
women who receive a post-partum visit 21-56
days after delivery.
If you would like further information about
our Quality Improvement Program, our
annual goals or our progress towards
meeting our goals, please call: 800-445-1638
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
Topical Fluoride Treatments in
the PCP Setting
Starting immediately, physicians and certified
registered nurse practitioners in the Unison
MedPLUS and Arizona Physicians IPA
Medicaid networks may provide topical
fluoride treatments for children within the
PCP setting. All providers offering these
services must be appropriately certified for
topical fluoride treatments and complete a
one-time online training module (“Oral Health
Risk Assessment: Training for Pediatricians
and Other Child Health Professionals”).
When billing these services, please use
procedure code D1206. Please call Provider
Services at 1.800.600.9007 for online training
module instructions or more information.
Electronic Claim
Submission Tips
Listed below are some tips to help with
Electronic Claim Submission
• Include your tax identification number (TIN)
along with your NPI number to help
promote timely and accurate payments
Carrier Tables and Payer ID Set-Up
• Set your computer system payer tables to
generate electronic claims instead of paper
claims
• Make sure that Payer spelling and setup are
consistent. Set them as electronic vs. paper
• Confirm that new patient records and
additional payer listings created by front
desk staff are set to be sent electronically
• Contact your software vendor or
clearinghouse with any questions you may
have concerning the placement of
information on your computer/practice
management system
Managing Your Clearinghouse Reports
• Be sure you are working your reports!
Reports show if a claim has been received
by the clearinghouse and sent to the
payer’s system
• You should receive two sets of reports for
every claim batch transmitted: Clearinghouse acknowledgement - claims
accepted and/or rejected by the
clearinghouse - Payer acknowledgementclaims accepted and/or rejected by the
payer
• Member ID Numbers are required
• The Payer ID number indicates where
clearinghouses should direct their claims. Arizona Physicians IPA Payer ID is: 03432
• For additional assistance with electronic
claim submission please contact Arizona
Physicians IPA EDI Support services at:
1-800-210-8315 or email us at HYPERLINK
"mailto:[email protected]"
[email protected]
page 8
• Rejected claims must be corrected and retransmitted electronically. Do not resubmit
these claims via paper. Claims will only be
rejected if there is something incorrect on
the claim. Resubmitting a claim via paper
will not correct the issue and may delay
processing time.
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
How to Avoid Rejections
Electronic Funds Transfer (EFT)
• The majority of rejected claims are the
result of an eligibility issue such as: Subscriber/Subscriber ID not found Coverage has been cancelled
Receive Payment for claims electronically
(EFT)
• Conducting an eligibility check on the
patient helps avoid most rejections.
• Some Claims might be rejected due to a
provider mismatch. To ensure correct
matching of the provider, ensure that you
are submitting with the Tax ID number as
well as the NPI number. If you are
submitting the claim with the Arizona
Physicians IPA Provider ID number (not
required) you must ensure that the number
is exact including the locator code. Should
you submit the claim with the Arizona
Physicians IPA Provider ID number, the
system will by pass the NPI and match
based upon the AmeriChoice Provider ID
submitted.
• Rejected claims must be corrected and retransmitted electronically. Do not resubmit
these claims via paper. Claims will only be
rejected if there is something incorrect on
the claim. Resubmitting a claim via paper
will not correct the issue and may delay
processing time.
Effectively Manage Re-Bills
• Make sure you set your re-submissions/rebills to be sent electronically. Most systems
have automatic claim re-bill capabilities
that resend claims every 30-60 days if
payment has not been posted.
EFT (Electronic Funds transfer) is the method
of transferring money from one bank account
directly to another without any paper money
or checks actually changing hands. One of
the most common EFT programs used is
Direct Deposit for payroll. EFT is safe,
secure, efficient, and more cost effective than
paper claim payments
Claims that may require supporting
information for initial claim review:
A Note about Claim Attachments - Insurance
Payers prefer to receive your claims
electronically. In fact, many insurance
companies have eliminated or significantly
reduced the need for paper attachments for
referrals/notifications, progress notes, ER
visits, and more. Payers will request
additional information when it is needed.
Denial letters from primary carriers are not
sufficient as proof of Coordination of Benefits.
You can find the EFT enrollment form and
FAQ online at HYPERLINK
"http://www.americhoice.com"
www.americhoice.com , or contact our EDI
Support Services Team directly; we can assist
you with the enrollment process. EDI Support
Services: 1-800-210-8315 or email us at
HYPERLINK "mailto:[email protected]"
[email protected].
• Do not send paper claim backup for claims
that have already been sent electronically
page 9
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
Provider Satisfation Survey
Tell Us What You Think
AmeriChoice is committed to making sure
that our services support the ability of your
practice to provide the safest and highest
possible quality of health care to your patients
who are our members. We value and seek
administrative simplicity that takes the
hassles out of clinical practice and reduces
inefficiency and waste. For this reason, we
periodically offer our network physicians the
opportunity to comment on our services. In
the near future you may be receiving a survey
to evaluate the services AmeriChoice provides
to you and our members Your opinions are
important to us and will help us assess the
level of satisfaction with our health plan as
well as identify opportunities for
improvements so that we may better meet the
needs of you practice.
We appreciate your time and cooperation.
The Medical Technology
Assessment Committee
The Committee meets at least 10 times per
year. Reports from the MTAC are reviewed by
the NMCMC (National Medical Care
Management Committee). Recommendations
are forwarded to NQMOC (National Quality
Management Oversight Committee) and then
disseminated to the health plans.
MTAC is responsible for the development and
management of:
• Evidence-based position statements on
selected medical technologies
• Evaluation of new usage of existing
technologies
• Maintenance of externally licensed
guidelines.
• The consideration and incorporation of
nationally accepted consensus statements,
clinical guidelines and expert opinions into
the establishment of national standards for
UnitedHealth Group.
• Ensuring that clinical decisions about the
safety and efficacy of medical care are
consistent across all products and
businesses.
Important Reminders:
Provider Billing Alert-Coordination of
Benefits Claims
Reminder: UnitedHealthcare does not accept
denial letters from primary carriers in place of
an Explanation of Benefits. Coordination of
Benefit claims that are received without
information regarding the primary payers
reimbursement cannot be processed.
Should you have any questions, please
feel free to contact Provider Services at
1-800-345-3627.
Important Claims Mailing Address
Information
Some time ago, we had changed our claims
mailing address and are still receiving mail
addressed to the old address. As of October
1, 2010 all claims mailed to the old address
will continue to be forwarded. As of October
1, 2011, anything received at the old address
will be returned to the sender.
• Assessments of the evidence supporting
new and emerging technologies
page 10
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
Submitting electronic claims can save you
time and money. If you are interested in
submitting claims electronically or signing up
for Electronic Remits or Electronic Funds
Transfer, please visit us at
www.americhoice.com or call EDI Support
Services at 1-800-210-8315 to get started.
The correct claims mailing address is:
APIPA - Arizona Physicians IPA
PO Box 5290
Kingston, NY 12402-5290
Thank you for providing valued services to
our members.
When the Patient’s Request Can
Lead to Fraud, Waste or Abuse
Healthcare providers familiar with recent
news stories should be aware that fraud,
waste and abuse against insurance programs
are a high priority at both the state and
federal level. Most healthcare providers run
an honest practice dedicated to the health and
wellbeing of their patients. However, the
practices of some providers can create an
environment that can impact the entire group.
This can include patients asking their doctors
to take actions that they say are done by other
physicians. These actions, such as waiving copays, charging a greater amount or billing a
higher code, or adding a diagnosis to cover a
service are often rationalized as attempts to
help the patient. For example, listing a
diagnosis of diabetes on a prescription to
allow a patient to obtain equipment such as
shoes may seem to be helping the patient.
However, in addition to insurance fraud, this
diagnosis could impact the future eligibility of
the patient for other insurance products.
Another scenario is a patient asking for a
certification or prescription for durable
page 11
medical equipment the provider does not
believe the patient requires. What do you do
when the patient tells you that another doctor
is prescribing this item for patients they
know? The best practice is to stick with the
facts. Is writing this order within the scope of
your practice or specialty? Are you treating
the patient for a condition that requires the
item or prescription? If no, deny the request,
and explain your decision to the patient.
Always keep in mind that as the prescribing
physician, you would be held responsible for
the validity of the orders.
Combating fraud, waste and abuse is the
responsibility of members, healthcare
providers and insurers alike. It is your
responsibility to report members or other
providers you suspect are committing fraud
and abuse. If you notice a trend of patients
requesting a particular product or service
you do not feel is necessary, you should reach
out to your provider representative to notify
them of the issue. You can also call the
Special Investigations Unit Fraud Hotline
at 877-401-9430.
AHCCCS has recently published to its website
an e-learning seminar -- "Fraud Awareness for
Providers" that discusses provider and
member fraud. We encourage you as
APIPA/AHCCCS providers to have your staff
review / listen to this seminar.
http://www.azahcccs.gov/commercial/default.a
spx. Please contact APIPA Provider Services
(800-445-1638) if you have any questions.
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
Text4baby
Patient’s Get No-Cost Health Information
on Their Cell Phone
Did you know that members can get
information about their baby’s health and
development on their cell phone? It is a new
service called Text4Baby. Pregnant women
and new moms who sign up get three text
messages a week. The messages come from
the National Healthy Mothers, Healthy Babies
Coalition. Thanks to support from mobile
phone companies, the messages are at
no charge.
The text messages use the member’s due
date or baby’s birthday to give them timely
tips. These messages can help member’s
learn about topics such as:
• Prenatal care
Acute Care Behavioral Health
Assignment Changes
Effective October 1, 2010, AHCCCS will
automatically assign all Acute Care enrolled
members into a Regional Behavioral Health
Authority (RBHA) or Tribal RBHA (TRBHA).
Members will be assigned based on the zip
code in which they reside; the T/RBHA will be
identified on the member’s AHCCCS ID card,
the web and 270/271 transactions.
Changes for Acute Care Contractors include:
• No longer responsible for providing up to
72 hours inpatient emergency behavioral
health services to members with
psychiatric or substance abuse diagnoses.
• No longer responsible for covering
behavioral health services during the prior
period.
• Immunizations
• Mental Health
• Your baby’s checkups
• Preventing Birth Defects
• Safe Sleep
• A Healthy Pregnancy
• Nutrition
• Local Resources
PREGNANT? Have a new baby? Join
Text4Baby. To get messages in English, text
BABY to 511411. To get messages in Spanish,
text BEBE to 511411. Or, register at
www.text4baby.org
Acute Care Contractors will:
• Continue to be responsible for all
emergency medical services including
triage, physician assessment and
diagnostic tests.
• Continue to be responsible for
transportation to the initial T/RBHA’s
scheduled appointment.
Changes for T/RBHAs include:
• Now responsible for inpatient behavioral
health services to Acute Care members
with psychiatric or substance abuse
diagnoses in the first 72 hours of
enrollment.
• Now responsible for providing behavioral
health services to Acute Care members
during the Prior Period.
page 12
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
The T/RBHA will:
• Continue to be responsible for medically
necessary psychiatric consultations
provided to Acute Care members in
emergency room settings.
TRIBAL REGIONAL BEHAVIORAL HEALTH
AUTHORITY (TRBHA)
If you have any questions, please contact
Stacey Hochstadter, LCSW, APIPA Behavioral
Health Coordinator, at 602-664-5384 or
[email protected].
Crisis Line:
Coordinator: Cheryl Cayler
RBHA LISTINGS AND COORDINATORS
Member Services:
Coordinator: Dr. Darwin West
Gila, La Paz, Pinal
and Yuma Counties
Cenpatico
Member Services:
Fax:
Crisis Line:
Coordinator: Mary Beardsley
866
800
866
866
495-6738
398-6182
495-6735
495-6738
#26104
Gila River
Member Services:
Cochise, Graham, Greenlee,
Pima, and Santa Cruz Counties
Member Services:
Fax:
Crisis Line:
Coordinator: Stefanie Lockery
Magellan
800
866
800
602
564-5465
892-5023
631-1314
797-8335
Apache, Coconino, Mohave,
Navajo, Yavapai Counties
Member Services:
Fax:
Crisis Line:
Coordinator: Veronica Wilson
page 13
771-9889
443-0365
796-6762
901-6809
Maricopa County
Customer Services:
Fax:
Crisis Line:
Coordinator: Steven Scott
NARBHA
800
800
800
520
928
928
800
928
774-7128
214-1166
640-2123
774-7128
#2168
528-7140
562-7140
259-3449
528-7136
White Mountain Apache
520 879-6060
928 338-4811
Pascua Yaqui
Member Services:
Crisis Line
Coordinator: Theresa Ybanez
520 879-6060
520 591-7206
520 879-6085
Navajo Nation
Member Services:
CPSA
602
or 540
800
602
928 729-4349
Colorado River Indian Tribe
Member Services
928 669-3256
Atrial Fibrillation Information
• The prevalence of atrial fibrillation
increases with age, reaching 8.8% for
individuals between 80 and 89 years
of age.1
• The median age of patients with atrial
fibrillation is approximately 75 years, with
about 70% between the ages of 65 and 85
years.2
• It is estimated that 2.2 million people in the
United States have paroxysmal or
persistent atrial fibrillation.2
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
• According to the American College of
Cardiology, atrial fibrillation is the most
common form of arrhythmia in clinical
practice and accounts for 33% of hospital
admissions for cardiac rhythm
disturbances.2
Facts about Atrial Fibrillation and the Elderly
• Every year between three and eight percent
of people in their 80’s with atrial fibrillation
will suffer a stroke.2
• Atrial fibrillation frequently occurs in the
elderly in association with other conditions,
such as hypertension (about 50%) and
carotid stenosis (about 12%).2
• With persistent atrial fibrillation elderly
individuals may also suffer from related
cognitive impairment.3
• Age > 75 years is one of several risk factors
for stroke in patients with atrial fibrillation
and anticoagulation with warfarin is
strongly advised unless clear
contraindications are present.3
Coding Pearls
• Code atrial fibrillation using a five digit
level of specificity 427.31
• If present and documented, code separately
for other conditions, e.g. hypertension,
heart failure and diabetes mellitus.
• If treatment of atrial fibrillation includes
chronic use of anticoagulants (except
aspirin), code also V58.61 (Long-term
(current) use of anticoagulants).
page 14
Did You Know?2
Symptoms of atrial fibrillation may include:
•
Palpitations
•
Fatigue
•
Shortness of breath
•
Chest pain
•
Lightheadedness or syncope
•
Polyuria
1. English, K. “Managing Atrial Fibrillation in Elderly
People.” BMJ 1999;318:1088-1089.
2. ACC /AHA /ESC “2006 Guidelines for the Management
of Patients with Atrial Fibrillation.” American College of
Cardiology. <www.acc.org>.
3. Falk, RH. Medical Progress, “Atrial fibrillation.” New
England Journal of Medicine 2001;344:1067-1078.
Vaccines for Children (VFC)
The Vaccines for Children (VFC) is a
government program that supplies vaccines
to providers free of charge to provide to
children until they are 19 years old. Since the
vaccines themselves are State-Supplied at no
charge to the provider they require the “SL”
modifier in the primary modifier field. If the
“SL” modifier is not billed in the primary
modifier position then you may see your
claims denied for invalid/missing modifier.
Reimbursement for the VFC services is made
for the administration of the vaccine.
Depending on your contract you may see this
payment on the vaccine itself with the
administration code (G0008-G0010, 9047190474) denied or reimbursement split across
both the admin and vaccine codes.
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
The VFC program is not covered under all
lines of business with APIPA. This is a noncovered benefit for both the Personal Care
Plus (Medicare) and Children’s Rehabilitation
Services (CRS) program. Please submit the
claim for VFC services to the member’s acute
care health plan for reimbursement of these
services.
Current vaccines (by CPT) that are part of the
VFC program in Arizona include:
• 90371
• 90633, only valid for members 1-21 years
old
• 90647, only valid for members 0-6 years old
• 90648, only valid for members 0-6 years old
• 90649, only valid for members 9-27 years
old
• 90650 (added 4/1/2010), only valid for
female members 9-27 years old
• 90655, only valid for members 6-36 months
old
• 90656, only valid for members 3 years or
older
• 90657, only valid for members 6-36 months
old
• 90658, only valid for members 3 years or
older
• 90660, only valid for members 2-49 years
old
• 90669, only valid for members 0-6 years old
• 90670 (added 3/18/2010)
• 90680, only valid for members 1-8 months
old
• 90681, only valid for members 0-8 months
old
• 90696, only valid for members 4-7 years old
• 90698, only valid for members 6-260 weeks
old (up to age 5)
• 90700, only valid for members 0-7 years old
• 90702, only valid for members 0-7 years old
• 90707
page 15
• 90710,
old
• 90713
• 90714,
older
• 90715,
older
• 90716
• 90723
• 90732,
older
• 90734,
old
• 90743,
old
• 90744,
old
• 90748,
only valid for members 1-13 years
only valid for members 7 years or
only valid for members 7 years or
only valid for members 2 years or
only valid for members 11-65 years
only valid for members 0-21 years
only valid for members 0-21 years
only valid for members 0-6 years old
Office for Children with Special
Health Care Needs (OCSHCN)
Cultural Competence Training
Includes Disability Issues
Do you ever feel uncomfortable around a
person with a disability because you are not
sure about proper etiquette? Should you
open that door? Do you worry about saying
the wrong thing, or that your children will ask
an insensitive question? When talking to
someone who uses an interpreter, do you
wonder who to look at? Most of us want to
be respectful, but are not always sure what
behavior is appropriate. During a recent
OCSHCN cultural competence training
discussion, staff asked for resources to learn
more about proper etiquette when interacting
with individuals with disabilities. The Arizona
Bridge to Independent Living (ABIL) website is
a great resource worth sharing with all of you.
It offers etiquette tips depending on the
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
disability at: http://www.abil.org/disabilityetiquette-tips. You may contact Marta Urbina,
[email protected] for more information
regarding OCSHCN’s Family Centered Cultural
Competency Committee.
AmeriChoice Utilizes HEDIS
Reporting To Measure Our
Health Care Performance
The AmeriChoice Quality Improvement
Program strives to continuously improve the
care and services provided to members.
Each year AmeriChoice Health Plans utilize
HEDIS reporting to measure our health care
performance. Healthcare Effectiveness Data
and Information Set (HEDIS) is a set of
standardized performance measures that are
related to many significant public health
issues. Some of these include well-child
visits, immunization rates, lead screening
rates, prenatal care visits, cancer screenings
and diabetes care.
In 2009, 100% of AmeriChoice Plans saw an
improvement in the number of children who
were completely immunized by age 2 as well
as the number of babies who received the
recommended number of well-baby visits by
age 15 months. In 2010, two of AmeriChoice’s
goals are a continued increase in the number
of babies who receive their recommended
well visits and an increase in the number of
women who receive a post-partum visit 21-56
days after delivery.
If you would like further information about
our Quality Improvement Program, our
annual goals or our progress towards
meeting our goals, please call the Provider
Service Center at: 800-445-1638.
page 16
New ID Cards in Yuma County
Arizona Physicians IPA by Untied Healthcare
is partnering with AHCCCS on a pilot program
to issue new ID cards that will help direct the
member to the proper places for medical care.
The new card has the member’s PCP name,
address and phone number on the front of
the card. In addition, the card features the
name, address and hours of operation for the
five urgent care clinics in Yuma County.
The new ID card has been issued to APIPA’s
members in Yuma County only. Physicians
outside of the county may encounter the new
card if the member seeks treatment outside of
the county.
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
The goal of the pilot program is to drive
members to their PCP first for care. They are
instructed to seek medical care at an urgent
care facility if they are in need of medical care
outside of their PCP’s hours of operation or
need medical attention right away in a non
life-threatening situation. Members are
persuaded to only go to a hospital emergency
room in the case of a true emergency.
While the pilot program is currently for
APIPA’s members in Yuma County only,
providers in La Paz, Maricopa and Pima
counties should encounter the new ID cards in
their areas in 2011.
Appointment Availability
Standards
All providers contracted with Arizona
Physicians IPA (APIPA) must ensure that
member appointments and wait times are
compliant with AHCCCS access and
availability standards. A member’s waiting
time for a scheduled appointment at their
PCP’s office should be no more than 45
minutes, except when the PCP is unavailable
due to an emergency.
Primary Care appointments:
a. Emergency appointments - same day of
request
b. Urgent care appointments - within 2 days
of request
b. Urgent care appointments - within 3 days
of referral
c. Routine care appointments - within 45 days
of referral
Dental appointments:
a. Emergency appointments - within 24 hours
of request
b. Urgent care appointments - within 3 days
of request
c. Routine care appointments - within 45 days
of request
Maternity care: initial prenatal care
appointments for enrolled pregnant members
as follows:
a. First trimester - within 14 days of request
b. Second trimester - within 7 days of request
c. Third trimester - within 3 days of request
d. High risk pregnancies - within 3 days of
identification of high risk by the Contractor
or maternity care provider, or immediately
if an emergency exists
Non-emergency transportation services: the
Contractor shall be able to provide the
following standard of service:
• The member shall arrive on time, but no
more than one hour before the
appointment
Specialty referrals appointments:
• The member does not have to wait more
than one hour after calling for
transportation after the conclusion of an
appointment
a. Emergency appointments - within 24 hours
of referral
• The member should not be picked up prior
to the completion of treatment
c. Routine care appointments - within 21
days of request
page 17
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
DEFINITIONS
• Urgent appointment – an acute, but not
necessarily life-threatening condition
which, if not attended to, could endanger
the patient’s health.
• Emergency appointment – When a medical
condition manifests itself by acute
symptoms of sufficient severity (including
severe pain) such that a prudent lay person
who possesses an average knowledge of
health and medicine could reasonably
expect the absence of immediate medical
attention to result in placing the member’s
health or for pregnant women the health of
the women and her unborn child in serious
jeopardy, serious impairment to bodily
functions, or serious dysfunction of any
bodily organ or part.
management services through working with
pregnant members and their maternity care
providers. Services include: encouraging early
initiation of prenatal care, conducting ongoing
pregnancy and clinical assessments, creating
individual care plans and promoting
compliance with regular care and treatment.
You may refer your patients to Healthy First
Steps by faxing the patient’s OB clinical
record or ACOG form to 1-866-702-0771.
Any OB Risk Assessment or OB Notification
form suffices. This form should be faxed upon
completion of the patient’s first prenatal
office visit. Receipt of clinical information will
enable us to more accurately identify risk
factors. Once the risk level is determined,
your patient will receive program information
and the opportunity to enroll in Healthy
First Steps.
Baby Arizona Program
Baby Arizona is a program to help pregnant
women begin the important prenatal care
they need while waiting for the AHCCCS
eligibility process.
APIPA's prenatal case management program,
Healthy First Steps, promotes healthy
pregnancies and quality birth outcomes for
expectant mothers. This is accomplished
through close monitoring of low-risk
pregnancies and early identification of highrisk pregnancies, in order to ensure that
members receive appropriate interventions
and the opportunity to participate in obstetric
case management.
One of our primary goals is to identify
members potentially at-risk for premature
birth or other difficulties. Healthy First Steps
provides maternity care coordination and case
page 18
The key to the success of the Baby Arizona
program is you the provider.
With your help, more Arizona women will
have access to prenatal care quicker, receive
assistance with the AHCCCS application, and
increase the chances of a healthy pregnancy
and a healthy baby.
Providers of all types, clinics, doctors, and
Community Health Centers play an important
role in making Baby Arizona a success. Baby
Arizona providers participate in Baby Arizona
by assisting with the streamlined AHCCCS
health insurance application process. The
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
application process should begin during the
pregnant woman’s first prenatal visit. Prenatal
care should begin and continue during this
application process.
When a pregnant women begins the Baby
Arizona process she is provided with a
physician's name, practice address and phone
number. Usually, this referral will occur by the
Arizona Department of Health Services
Pregnancy & Breast Feeding Hotline or other
participating referral systems.
When contacted by a referred patient or the
hotline, the office will schedule an
appointment and assist in the eligibility
process. The office will perform the same
clinical services for a referred patient on the
initial visit that the office provides for patients
referred from other sources. If a patient is
subsequently determined not to be eligible,
the office will continue to render care upon a
reasonable payment schedule developed
between the office and the patient.
If a patient who is determined eligible opts to
receive care from another provider, the office
will transfer her records to that provider
within ten working days of receiving release
from the patient.
The process to become a Baby Arizona
provider is easy. To begin the process of
becoming a Baby Arizona provider, each
provider must complete a Provider
Agreement. The Provider Agreement was
created by the Arizona Medical Association
(ArMA). Before participating in Baby Arizona,
the medical provider must sign the form. The
form can be found at:
http://www.azahcccs.gov/Publications/Forms/P
lansProviders/BabyAZ-agreement.pdf.
page 19
Return the form to:
Maternal Child Health Coordinator
701 E. Jefferson, MD 6700
Phoenix, AZ, 85034;
or by fax at (602) 417-4162
Remember: Baby Arizona providers must be
registered as an AHCCCS provider.
With your help, more Arizona women will
have access to prenatal care quicker, receive
assistance with the AHCCCS application, and
increase the chances of a healthy pregnancy
and a healthy baby.
AHCCCS Provider’s
Responsibility
As a registered provider with the AHCCCS
Administration, (Arizona’s Medicaid Program,
you have certain obligations and
responsibilities required of you when
providing services to an AHCCCS member.
For more information, visit the AHCCCS
website at: http://www.azahcccs.gov.
• “As a registered provider with the AHCCCS
Administration, (Arizona's Medicaid
Program), you are obligated under 42 C.F.R.
§1001.1901(b), to screen all employees,
contractors, and/or subcontractors to
determine whether any of them have been
excluded from participation in Federal health
care programs. You can search the HHSOIG website, at no cost, by the names of any
individuals or entities. The database is
called LEIE, and can be accessed at
http://www.oig.hhs.gov/fraud/exclusions.asp "
• If a member is in hospice, and you are a
non-hospice provider, you must bill
Medicare for all services that are unrelated
to the terminal illness, with the exception
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
of the supplemental UnitedHealthcare
Medicare benefits, e.g., eyeglasses, dental,
prescription) etc., which will continue to be
directed, provided and paid for by
UnitedHealthcare.
When billing CMS, providers should follow
CMS guidelines, using the appropriate
modifiers. When the non-hospice
providers receive payment from CMS,
these providers should then send the claim
to UnitedHealthcare, along with the CMS
explanation of benefits (EOB) for secondary
payment.
• APIPA Denial Code Explanations: Reason
Code 151 “Payment Denied/Reduced Info
Does Not Support” is used to identify that
the claim/service submitted has exceeded
the maximum daily frequency allowed for
that procedure. If services exceed the
guidelines for maximum daily frequency
please submit medical records justifying
the medical appropriateness of the
additional units. If you have any questions
about the maximum daily frequency of a
CPT/HCPCS please contact the Provider
Service Center (1-800- 445-1638).
• Pharmacy Updates are available at
www.americhoice.com. The pharmacy
hotline is 1-866-651-2217.
• Medical Record Criteria
– All medical records are to be stored
securely.
– Only authorized personnel have access
to records.
– Staff receives periodic training in
member information confidentiality.
page 20
– Medical Records are organized and
stored in a manner that allows easy
retrieval.
– Medical Records are stored in a secure
manner that allows access by authorized
personnel only.
– Medical Records must include: History
& physical; allergies and Adverse
Reactions; Problem List; Medications;
Preventative Services/Screening;
Documentation of clinical findings for
each visit.
• Provider Billing Alert-Coordination of
Benefits Claims
Generally, Coordination of Benefit claims
which are billed to APIPA must have an
Explanation of Benefits attached to the
claim. An Explanation of Benefits cannot be
accepted as an electronic attachment at this
time. Coordination of Benefit claims that
are received without an Explanation of
Benefits may be denied. APIPA will not
accept denial letters from primary carriers
in place of an Explanation of Benefit.
Should you have any questions, please
feel free to contact Provider Services at
1-800-345-3627.
TIPS
For Successful Claims Resolution
• If you cannot verify that a claim is on file,
contact the Provider Service Center (1-800445-1638).
• Providers should not resubmit claims that
have been validated as on file unless
submitting a corrected claim.
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
• File claim disputes within the timely
requirements.
Emergency Services in Hospital
Prior authorization is not required; however,
hospitals must provide notification to APIPA
within the established timelines if the
member is admitted.
Delayed Admission of Elective Stay
Re-authorization is required for elective
admissions/surgeries that are delayed and do
not take place within 60 days of the initial
date authorized.
Change in Observation Status
Prior Auth is required when a member is
changed from observation status to inpatient
status.
Children's Rehabilitative
Services (CRS)
CRS provides family-centered medical
treatment, rehabilitation, and related support
services for children under age 21 with
qualifying chronic and disabling conditions.
Last year over 23,000 children and young
adults received health care and related
support services from the CRS program.
CRS members receive care for their eligible
conditions in multi-specialty interdisciplinary
clinics, but do not receive general primary
care services from the program. The majority
of CRS members are also enrolled in an
AHCCCS Health Plan, where they have a
primary care physician who manages their
care that is not related to their CRS-eligible
condition. Arizona Department of Health
Services provides CRS services through a
contract with APIPA-CRS.
page 21
More information regarding CRS is available
on the ADHS website:
http://www.azdhs.gov/phs/ocshcn/index.htm
CRSA Clinical Practice Guidelines
CRS providers are required to adhere to the
CRS Clinical Practice Guidelines developed by
or with Arizona Department of Health
Services (ADHS).
New Clinical Practice Guidelines recently
posted on the CRSA website include:
• Bone Anchored Hearing Aid (BAHA)
• Deep Brain Stimulation (DBS) for Dystonia
• Metabolic Disease
The complete CRSA Clinical Practice
Guidelines Manual is available on the CRSA
web site:
http://www.azdhs.gov/phs/ocshcn/crs/pdf/Clini
calPracticeGuidelinesManual.pdf.
New guidelines are posted to the APIPA CRS
provider link at: http://myapipacrs.com.
AskMe3 Approach
Arizona Physicians, IPA has joined the
Partnership for Clear Communications and
encourages you to encourage your patients to
use the Ask Me 3 approach. Below is an
excerpt from the AskMe3 website at
www.AskMe3.org
What Can Providers do?
Health literacy is now known to be vital to
good patient care and positive health
outcomes.
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
1. Answer 3
Along with encouraging your patients to use
the Ask Me 3 approach, simple techniques
can increase your patients' comfort level with
asking questions, as well as compliance with
your instructions after they leave
appointments.
• Create a safe environment where patients
feel comfortable talking openly with you
• Use plain language instead of technical
language or medical jargon
• Sit down (instead of standing) to achieve
eye level with your patient
• Use visual models to illustrate a procedure
or condition
• Ask patients to "teach back" the care
instructions you give to them
2. Learn more about low health literacy
This site has fact sheets on the issue of low
health literacy, a white paper detailing the
scope and impact of the problem, and
communication tools to help you in your
practice. Download available materials here
3. Incorporate new knowledge into your
practice
Broadening your knowledge of the low health
literacy issue and associated concerns will
help you to better treat your patients.
page 22
Myth vs. Reality
Myth: Encouraging my patients to ask more
questions will increase the length of their
visit. I simply can't afford to spend more time
with each patient.
Reality: Fearing lengthy appointments, most
doctors allow patients to talk for an average
of 22 seconds before taking the lead.
Research shows, however, that if allowed to
speak freely, the average patient would
initially speak for less than two minutes.
Encouraging questions during the initial visit
may require a short-term time investment;
however, the long-term payoff may include
more accurate compliance, fewer follow-up
visits, and shorter, more focused interactions
as the patient proceeds through his/her
condition.
Claims Clues
A Publication of the AHCCCS Claims
Department
AUGUST 2010
IMPORTANT INFORMATION ABOUT ADULT
RECIPIENT BENEFIT CHANGESIn response to
significant fiscal challenges facing the State
and substantial recent
growth in the Medicaid population, AHCCCS
will implement several changes to the adult
benefit package. Benefit changes will be
effective October 1, 2010. Please use the
following link to view the most current
information available.
http://www.azahcccs.gov/reporting/legislation/
sessions/2010/BenefitChanges.aspx
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
“DOC TALK”
A Message from the AHCCCS Chief Medical
Officer”
Dr. Marc Leib
Proper Use of the 59 Modifier1
Background
The National Correct Coding Initiative (NCCI)
edits define pairs of Current Procedural
Terminology (CPT) or Healthcare Common
Procedure Coding System (HCPCS) codes that
may not be reported together except under
special circumstances. When those
circumstances exist, the two codes may both
be reported and modifier-59 attached to the
normally bundled code to indicate that in that
particular case, the service was distinct and
independent from other services performed
on the same day. The Centers for Medicare
and Medicaid Services (CMS) has published
information regarding the proper use of
modifier-59 with regards to Medicare claims.1
AHCCCS policies regarding the use of this
modifier conform to this guidance.
General Use of the -59 Modifier
According to CMS, appropriate uses of
modifier-59 include situations when the
service normally bundled into the other
service was performed during a different
patient encounter on the same day, on a
different anatomic site or organ system, on a
separate lesion, through a separate incision or
excision, or due to a separate injury. For
purposes of the NCCI edits, the definition of
“different anatomic site” includes a different
organ (even if in the same general anatomic
region) or different lesions in the same organ,
but it does not include treatment of
contiguous structures in the same organ.
Anatomically contiguous areas are not
page 23
considered different anatomic sites for the
purpose of using modifier-59. For example,
repairing an injury to the nail, nail bed and
the surrounding structures on the same digit
cannot be billed using separate CPT codes
and modifier-59. Repair of a nail bed on one
digit and the tissues surrounding the nail bed
on another digit may be billed using modifier59 to indicate that the second procedure was
performed on a separate anatomic area. As a
further example, the posterior structures in
the eye constitute a single anatomic site, even
if treatment included procedures on several
posterior segment structures.
Another source of confusion regarding the
use of modifier-59 may be that it is
sometimes used to describe a “different
procedure or surgery.” By definition, different
CPT/HCPCS codes describe different
procedures or surgeries. If two codes are
listed among the code pairs on the NCCI
edits, bundling cannot be negated by the use
of the modifier-59 if the services were
performed at the same anatomic site during
the same patient encounter. When the
services are performed on a different
anatomic site or during a different patient
encounter on the same day, the normally
bundled code may be billed separately with
modifier-59.
In addition to listing bundled code pairs, the
NCCI indicates whether the two codes may
ever be listed with modifier-59. An indicator of
“0” means that there are no circumstances
that would allow the two codes to be listed
together, even with modifier-59. An indicator
of “1” means that under the proper
circumstances the two codes may both be
listed and modifier-59 used. An indicator of
“1” does not mean that modifier-59 can be
Provider Service Center: 1-800-445-1638
APIPA Provider Newsletter
attached whenever the two codes appear on a
single claim. If the two services were not
provided during a separate patient encounter
or performed on a different anatomic site,
modifier-59 may not be used and payment
will only be made for one of the codes.
Documentation supporting the separate
patient encounter or different anatomic site
may be required to support the use of the -59
modifier.
1 CMS MLN Matters, Number SE0715, Proper Use of
Modifier “-59”
Newsletter articles provide general guidance.
Always consult your contract or call the
Provider Service Center (800-445-1638) with
any questions.
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The APIPA Provider Newsletter is a periodic publication for physicians and other health care
professionals and facilities in the APIPA network.
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