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Provider Notice issued 10/31/14
Modifiers – Modifiers are to be billed according to national coding guidelines.
Two Outpatient Visits Same Day – As per existing APL policy, all outpatient services provided on a given day are to be billed on one outpatient claim form. If multiple claims are submitted, the later ones will be rejected as duplicates.
Service Dates on Series Claims – Form Locator 45 Service Date is required for all outpatient claims.
Newborn Claims and Children’s Hospital NPI - Under the APR-DRG grouper, “normal newborn” DRGs are 626 and 640. Claims grouping to these DRGs need to be billed under the adult facility NPI. If a hospital does inappropriately bill under the children’s hospital NPI, the claim will receive error code P59 – Care Not Appropriate for Children’s Hospital.
Birth Weight Required for Newborns – The April 14, 2014 Informational Notice stated Value Code 54 is required for newborns who are 14 days of age or less on the date of admission. The 3M APR-DRG grouper is actually set to newborns who are 28 days of age or less on the date of admission; therefore, hospitals must utilize Value Code 54 for newborns who are 28 days of age or less on the date of admission.
Psychiatric Clinic Type B Services to be Differentiated by Revenue Code – To better enable the department to identify and track the level and intensity of outpatient psychiatric services, the department will require immediately that intensive outpatient program (IOP) claims be coded with Revenue Code 0913, and partial hospitalization program (PHP) claims be coded with Revenue Code 0912. Claims must still be billed using the specified procedure code of S9480. The final page of the Ambulatory Procedures Listing has been updated to reflect this billing requirement.
Hospital Rate Reform – Outpatient Claim Processing Implementation and Miscellaneous Issues
| To: | Enrolled Hospitals: Chief Executive Officers, Chief Financial Officers, and Patient Accounts Managers; and Ambulatory Surgical Treatment Centers (ASTCs) |
| Date: | October 31, 2014 |
| Re: | Hospital Rate Reform – Outpatient Claim Processing Implementation and Miscellaneous Issues |
As noted in previous informational notices to providers, the department has held outpatient claims pending internal testing of the Enhanced Ambulatory Patient Groups (EAPG) payment system. This testing has been completed, and the department will begin releasing outpatient claims for processing on November 1, 2014.
Due to this delay in the release of outpatient claims, the department is extending its timely filing parameters for outpatient claims with dates of service July 1, 2014, through October 31, 2014. Providers will be able to submit claims with dates of service in this range through April 30, 2015. No manual claim override for the G55 error code will be needed, and these claims may be submitted electronically if applicable. For outpatient dates of service beginning November 1, 2014, claims will be held to the usual 180-day submission timeframe.
Notices Related to Hospital Rate Reform
The department has previously conveyed specific policy and billing instructions in the following notices regarding the hospital rate reform initiative:
Informational Notice Dated October 2, 2014
Informational Notice Dated September 19, 2014
Informational Notice Dated September 16, 2014
Informational Notice Dated August 8, 2014
Informational Notice Dated June 26, 2014
Informational Notice Dated June 19, 2014
Informational Notice Dated April 14, 2014
Informational Notice Dated October 4, 2013
Informational Notice Dated September 10, 2012
It is imperative that hospitals and ASTCs be familiar with these notices and prepare their claims accordingly.
Ongoing Billing Questions:
Some repeated provider issues that have been fielded from HFS staff include:
New Billing Issues and Guidance
Per the Handbook for Providers of Hospital Services, Psychiatric Clinic Type B services must be given at least four hours per day at a minimum of three half-days of active treatment per week. The duration of an individual patient’s participation in this treatment program is limited to six months in any 12-month period.
3M New Illinois-Specific Software
The department and 3M became aware of different data settings between the version of the Illinois-specific 3M EAPG software that HFS has been using for shadow pricing and all versions distributed by 3M in their initial release. HFS wants to ensure that providers who have the Illinois-specific 3M software now have the update released by 3M on October 14, 2014, which resolves the differences. Any current licensee of the Illinois-specific EAPG software may contact 3M at the toll-free phone number (1-800-435-7776) with any specific questions regarding the release of the updated software.
Any questions regarding this notice may be directed to the Bureau of Hospital and Provider Services at 1-877-782-5565.
Theresa A. Eagleson, Administrator
Division of Medical Programs