• Ambulance
o Must be billed on a CMS 1500
o Land ambulance transportation should be billed in 42 o For ITA transports enter “SCI=I” in Field 19
o Multiple units valid only on mileage and waiting time code. All other codes enter
a “1”
• Ambulatory Surgery Center (ASC)
o Ambulatory surgery centers must submit charges using the CMS 1500 claim form o Must be billed in place of service 24
• Anesthesia – bill total number of minutes in Block 24G of the CMS 1500 Claim Form
o Failure to bill total number of minutes may result in incorrect reimbursement or
claim denial
o Anesthesiologist must bill modifiers listed below for all ASA codes:
AA‐ Anesthesia service performed personally by anesthesiologist ; or
QX ‐ CRNA/AA service with medical direction by a physician
QK ‐ Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals.
CRNA’s must bill with one of the modifiers listed below for all ASA codes:
QX – CRNA service with medical direction by a physician should be used when under the supervision of a physician
QY – CRNA and anesthesiologist are involved in a single procedure and the physician is performing the medical direction
QZ ‐ CRNA service without medical direction by a physician
• DME/Supplies/Prosthetics and Orthotics
o Purchase only services must be billed with modifier NU
o Please refer to the state DME manuals for appropriate billing of modifiers o When billing for a weekly or monthly rental, a date span can be billed but should
be entered as 1 unit. Also future dates cannot be billed
• Mom/Newborn Billing
o Coordinated Care recommends holding the claims until the newborn receives
their own individual ID.
o When billing a newborn claim under the mother’s Medicaid ID# continue to
follow state requirements around field 19(HCFA)/box 80 (UB)
o In addition, please place an “A” prior to the Medicaid ID # number on the
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• EPSDT/HCY
o Populate 24h with appropriate indicator “Y” if the service is an EPSDT/HCY
screening
o Bill modifier TJ for EPSDT screenings for foster care members
• Home Health
o Must be billed on a UB 04 o Bill type must be 3XX o Must be billed in location 12 o Acceptable modifiers GN, GO, GP
• Community Mental Health Agencies (CMHC)
o For Community Mental Health Agencies contracted as facilities, billing should be
submitted F o r Coordinated Care/Cenpatico, placing the rendering provider’s NPI in box 24J of the 1500 claim form (or its electronic equivalent) may cause claims denials or delays. Place the billing provider’s NPI in this field for accurate claims processing.
o Professional services billed with CPT codes should be billed with the following modifiers
when the rendering practitioner holds one of the identified licensures:
Psychologist – bill with modifier AH or HP
Social Worker – bill with modifier AJ
Master’s Level clinician (e.g. LPC, LMFT) – bill with modifier HO
o HCPCs codes that already have modifiers identified on the state fee schedule should
be billed with the modifiers indicated on the state fee schedule.
• OB Visits
o Providers should bill using the complete OB global care if he/she is providing all of the
maternity care including, prenatal, delivery and postpartum care. One of the following codes should be used:
GlobalOBcare(CPTcodes59400,59510,59610,or59618)includesallthefollowing:
• Routine antepartum care in any trimester;
• Delivery; and
• Postpartum care.
o Use HCPCS code 0500F along with the appropriate billing code on the first prenatal visit.
The Agency is tracking the date a client begins receiving obstetrical care (date the OB record is initiated). Please note this date by entering HCPCS code 0500F with ICD‐9‐CM diagnosis codes V22.0‐V22.2 on the claim.
CodingforAntepartumCareOnly
• If it is necessary to unbundle the OB package and bill separately for antepartum care, bill as follows:
• If the client had a total of one to three antepartum visits, bill the appropriate level of E&M service with modifier TH for each visit, with the date of service the visit occurred and the appropriate diagnosis.
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ModifierTH:Obstetricaltreatment/service,prenatalorpostpartum
• If the client had a total of four to six antepartum visits, bill using CPT code 59425 with a "1" in the unit box. Bill the Agency using the date of the last antepartum visit in the “to and from” fields.
• If the client had a total of seven or more visits, bill using CPT code 59426 with a "1" in the units box. Bill the Agency using the date of the last antepartum visit in the “to and from” fields.
• If the client has one to three visits only for maternity related services by the provider, use CPT codes 99201‐99215 with modifier TH.
• For more information regarding appropriate billing procedures for Obstetrical Services, you can refer to Maternity Related Services in the physician billing manual, pages G12‐ G23
• Notification of Pregnancy
o Use HCPCS code 0500F along with the appropriate billing code on the first prenatal visit.
Coordinated Care is tracking the date a client begins receiving obstetrical care (date the OB record is initiated). Please note this date by entering HCPCS code 0500F with ICD‐9‐CM diagnosis codes V22.0‐V22.2 on the claim.
• Modifiers
o Appropriate Use of – 25, 26, TC, 50, GN, GO, GP
25 Modifier ‐ should be used when a significant and separately identifiable
E&M service is performed by the same physician on the same day of another procedure e.g. 99381 and 99211‐25 Well‐Child and sick visit performed on the same day by the same physician *NOTE:25modifier is not appendedto nonE&Mprocedurecodes,e.g.lab
o 26 Modifier – should never be appended to an office visit CPT code
Use 26 modifier to indicate that the professional component of a test or study is
performed using the 70000 (radiology) or 80000 (pathology) series of CPT codes
Inappropriate use may results in a claim denial/rejection
o TC Modifier – used to indicate the technical component of a test or study is performed
o 50 Modifier – indicates a procedure performed on a bilateral anatomical site
Procedure must be billed on a single claim line with the 50 modifier and quantity of one (1). RT and LT modifiers or quantities greater than one should not be billed when using modifier 50
o GN, GO, GP Modifiers – therapy modifiers required for speech, occupational and physical
therapy. ALL provider types must bill the appropriate modifier to ensure correct payment and avoid claim denial.
• Multi page claims
o The page leading up to the last page of a multi‐page claim should contain the word
“continued” or “cont.” Totaling each page will result in separate claims that may incorrectly reimburse.
• When reporting line item services on multiple page claims, only the diagnosis code(s) reported on the first page may be used and must be repeated on subsequent pages. If more than 12 diagnoses are required to report the line services, the claim must be split and the services related to the additional diagnoses must be billed as a separate claim.
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• Present on Admission (POA) Indicator is required on all inpatient facility claims. Failure to include the PAO may result in a claim denial/rejection
Billing for Immunizations
Immunizations covered under the EPSDT program are listed in the EPSDT Fee Schedule on the states web site (http://www.hca.wa.gov/medicaid/billing/pages/epsdt.aspx) . For vaccines that are available at no cost from the Department of Health (DOH) through the Universal Vaccine Distribution program and the Federal Vaccines for Children program for children 18 years of age and under, Coordinated Care pays only for the administration of the vaccine and not for the vaccines themselves. These vaccines are identified in the Comments column of the Fee Schedule as “free from DOH.”
If an immunization is the only service provided, bill only for the administration of the vaccine and the vaccine itself (if appropriate). Do not bill an E/M code unless a significant and separately identifiable condition exists and is reflected by the diagnosis. In this case, bill the E/M code with modifier 25. If the E/M code is billed without modifier 25 on the same date of service as a vaccine administration, the agency will deny the E/M code. Exception: The E/M code 99211 cannot be billed with a vaccine or the vaccine administration code.
You must bill for the administration of the vaccine and for the cost of the vaccine itself as explained in this section.
• Clients 18 years of Age and Younger – “Free from DOH”
o These vaccines are available at no cost from DOH. Therefore, Coordinated Care will
only reimburse the administration of the vaccine.
o Bill for the administration by reporting the procedure code for the vaccine with
modifier SL (e.g. 90707 SL). Coordinated Care will reimburse the HCA allowed
amount for the administration of vaccines that are free from DOH and are billed with modifier SL (e.g., 90707 SL).
o DO NOT bill CPT codes 90471‐90472 for the administration.
Clients 19 Years of age and older– All Vaccines
o Bill for the cost of the vaccine itself by reporting the procedure code for the vaccine
given. DO NOT use modifier SL with any of the vaccines for client’s 19 years of age and over.
o Coordinated Care pays for the vaccine using the state’s maximum allowable fee schedule. o View the HCA fee schedule to verify if the vaccine is covered.
o Bill for the administration using CPT codes 90471 (one vaccine) and 90472 (each
additional vaccine). Payment is limited to one unit of 90471 and one unit of 90472 (maximum of two vaccines).
o Providers must bill 90471 and 90472 on the same claim as the procedure code for
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