Author Topic: S0280/S0281 Electronic Claim Requirements? (Minnesota)  (Read 2111 times)

shanbull

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S0280/S0281 Electronic Claim Requirements? (Minnesota)
« on: June 13, 2013, 09:01:23 AM »
This is a very specific question, it's been difficult for me to find the answers I'm looking for. Our clinic was just certified as a Health Home Demonstrator for the MAPCP program by Medicare. We are in Minnesota, which has slightly different rules about this than the rest of the states with the program. We are brand new to the coding requirements for this. Our clinic does not have a coder. The doctors do their own coding and if there's a problem it comes to me or the other lady in billing. So we're the ones who need to know this. Hopefully someone can help me with this! Here are my questions:

- Do the chronic conditions for patients need to be listed in every claim submitted to qualify for the tier level on the claim? I know about the modifiers for mental illness and non-English speakers, I'm more curious about if the chronic conditions need to be listed in the ICD section.

- I am putting the “P4” reference ID qualifier in the paperwork loop (pathology report) with document ID type “AA”; and the “58” demonstration code in box 19 of the HCFA (“reserved for local use”) – is this correct? I've had a rough time getting information on this.

- Is there any other field that must be filled out in the header or data info for the claim that I haven't already mentioned?

- Is the “place of service” still considered the office for phone calls to patients for care management?

Thanks so much to anyone who can help me out with this! Google was a bust, the Medicare people were unhelpful, and I even called the support center for our claims software and they were able to help me but they're not very familiar with this specific set of coding requirements. I just need to find someone who does this regularly I think.

Michele

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Re: S0280/S0281 Electronic Claim Requirements? (Minnesota)
« Reply #1 on: June 20, 2013, 01:32:38 PM »
Minnesota billing can be quite different than other states.  Sorry, not currently doing any Minnesota billing!  :(
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shanbull

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Re: S0280/S0281 Electronic Claim Requirements? (Minnesota)
« Reply #2 on: June 25, 2013, 08:51:45 AM »
Thanks for responding, and no worries- my question has even stumped our software company! They have two people working on it. I just have to sit and twiddle my thumbs on this one  :P

shanbull

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Re: S0280/S0281 Electronic Claim Requirements? (Minnesota)
« Reply #3 on: July 17, 2013, 01:28:19 PM »
I finally found out the answers to my questions, I'm posting the answers in case anyone else runs into this mess in the future:

Quote
- Do the chronic conditions for patients need to be listed in every claim submitted to qualify for the tier level on the claim? I know about the modifiers for mental illness and non-English speakers, I'm more curious about if the chronic conditions need to be listed in the ICD section.
No they do not. The doctor uses the website for this program to determine a patient's tier level and the listed chronic conditions do not relate to payment

Quote
- I am putting the “P4” reference ID qualifier in the paperwork loop (pathology report) with document ID type “AA”; and the “58” demonstration code in box 19 of the HCFA (“reserved for local use”) – is this correct? I've had a rough time getting information on this.
Yes, this is correct. We have had claims paid now with this coding.

Quote
- Is there any other field that must be filled out in the header or data info for the claim that I haven't already mentioned?
No.

Quote
- Is the “place of service” still considered the office for phone calls to patients for care management?
Yes.

The most important thing to know about this program is that almost every insurance company has a special process you need to go through to prove your clinic is credentialed. The letter from the DHS takes months to arrive (We were credentialed as of June 1st and we still have not received the letter). Being very familiar with the tier levels and modifiers and how they affect what you charge is also important.

shanbull

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Re: S0280/S0281 Electronic Claim Requirements? (Minnesota)
« Reply #4 on: February 14, 2014, 11:44:13 AM »
Sorry to pull up my old thread again, but I wanted to clarify for anyone searching this topic in the future because this process was a 6 month nightmare and I don't want anyone to be misled because of me: my previous post was wrong again. As it turns out, our software had no way to correctly transmit this information and we needed to have a patch created for us just for this situation. The "58" indicator goes in the new box they made, it does NOT appear anywhere on a CMS-1500, nor does it go in any of the numbered boxes that electronically represent the CMS-1500. And what they initially told us about the PWK segment coding going in the documentation data field was just flat out wrong. THERE IS NO SPECIAL HEADER OR DATA SECTION INFO REQUIRED.
« Last Edit: February 14, 2014, 02:27:08 PM by shanbull »

Merry

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Re: S0280/S0281 Electronic Claim Requirements? (Minnesota)
« Reply #5 on: February 14, 2014, 01:53:29 PM »
Always good to have the most accurate information. Thanks for bringing it up. You contribute so much to this forum.

Merry