Proper Billing Practices, per the Medi-Cal Guidelines
| Date: | October 12, 2016 |
| To: | Health Plan of San Joaquin (HPSJ) Providers |
| From: | HPSJ Provider Services Department |
| Subject: | Proper Billing Practices, per the Medi-Cal Guidelines |
| Business: | Medi-Cal, MCAP (Medi-Cal Access Program, previously known as AIM) |
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Health Plan of San Joaquin (HPSJ) strives to maintain, update and educate on proper billing practices consistent with the guidelines set forth by Medi-Cal. With the implementation and execution of our Claims Editing System, HPSJ finds it necessary to keep you informed of potential improper billing practices.
As provided under Medi-Cal Billing Guidelines, practices can refer to the following from the Medi-Cal website for appropriate billings. The following sections are provided from the Medi-Cal website – http://www.medi-cal.ca.gov/ – for your convenience.
Frequency Restrictions
Certain services have frequency restrictions and should be researched prior to rendering to the member. A prime example of this would be for Pregnancy Related Diagnostic Services, particularly Ultrasounds. CPT codes 76801, 76805, 76811, 76802,
76810, 76812, 76815, 76816, 76817, 76820, 76821, 76825, 76827, 76826, 76828 all have a frequency restriction of once every 180 days. Additional claims may be reimbursed if medical necessity is justified and may be subject to a reduction in reimbursement. Reference the Medi-Cal Guidelines at: http://www.medi-cal.ca.gov/ (See Pregnancy: Early Care and Diagnostic Services (preg early)).
This also applies to certain Cardiology services such as Interrogation Device Evaluations. Please reference the Medi-Cal Guidelines at: http://www.medi-cal.ca.gov/ (See Cardiology (cardio) ).
Multiple Surgery Submissions
Medi-Cal has very specific guidelines regarding Multiple Surgery Submissions. All surgical procedure codes require a modifier. Failure to submit a modifier with a surgical procedure code will result in the claim being denied and returned to the provider for correction. The primary surgeon is required to use modifier AG on the only or highest valued surgical procedure code. When multiple procedures are performed at the same operative session, providers are required to identify the major procedure with modifier AG and each secondary, additional or lesser procedures by adding modifier 51. While Add-On codes and Modifier 51 Exempt codes are exempt from the multiple surgery reimbursement reduction, providers are still required to attach modifier 51 to each additional surgical procedure. Reference the Medi-Cal Guidelines at: http://www.medi-cal.ca.gov/ (See Surgery: Billing With Modifiers (surg bil mod))
Bilateral Procedures
Medi-Cal has very specific guidelines on the use of Modifier 50 and submission requirements. For bilateral procedures requiring a separate incision during the same operative session, providers should bill the first procedure on the first claim line with modifier AG and the second procedure on the next billing line with modifier 50. Example: to bill for a bilateral inguinal hernia surgery in a child under 5 years of age, the provider would bill CPT 49500 with Modifier AG on the first claim line, then enter CPT
49500 Modifier 50 on the second claim line. This will ensure proper reimbursement of 150%. Reference the Medi-Cal Guidelines at: http://www.medi-cal.ca.gov/ (See Surgery: Billing With Modifiers (surg bil mod)).
Anesthesia
To bill anesthesia time units, enter the number of 15-minute increments of anesthesia time in the Units box on the CMS 1500 claim form. Each 15-minute increment equals one time unit. Start & Stop times should be documented in Box 19 of the CMS 1500 claim form. HPSJ requires only time units to be submitted as base units are calculated on the back end. NOTE: Providers who bill electronically are required to submit time in minutes, as units are no longer accepted in the 837 transaction. In addition, Start & Stop times are no longer required for electronic submissions.
Claims billing for more than 40 units of time (10 hours) require that an anesthesia report be attached to the claim with start, stop and total time documented. For CPT 01967, all claims of 20 units or more require an anesthesia report be attached to the claim. Reference the Medi-Cal Guidelines at: http://www.medi-cal.ca.gov/ (See Anesthesia (anest)).
If you feel that you or your billing department can benefit from Medi-Cal billing refresher training you can visit the Medi-Cal website at https://learn.medi-cal.ca.gov/Training/TrainingCalendar.aspx and sign up for one of the many seminars and/or e-learning courses available.
If you have questions, please contact our Provider Services Department at 209-942-6340.