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March 2024

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Welcome to the Kids Health First's Billing & Coding Connection newsletter- an all-in-one resource dedicated for all things billing and coding.


Do you have billing topics, best practices, claim questions, or good news to share? Email KHF at Payorconcerns@khfirst.com.


To add billing staff members to the distribution list, please also email us at Payorconcerns@khfirst.com

CURRENT TRENDS

The Payor Issue Database is found in the Members section of the KHF Intranet under the Financial menu. If you need access to the KHF Intranet, please email PayorConcerns@khfirst.com.

 

The Payor Issue Database contains a current list of payor and claim issues KHF is tracking on behalf of the practices. The issues were identified by your KHF network peers and escalated to KHF for research. In the Payor Issue Database, you will find:

  • key dates (issue identified, most recent update, resolution date)
  • claim issue descriptions
  • current action
  • resolution (when received)
  • practices impacted


When you identify a claim issue during your EOB review, check the Payor Issue Database for known issues and their status. This may decrease your research time and offer next steps. Please encourage all billing staff to reference this helpful resource!

 

Is your issue not found on the Payor Issue Database? Let us know! You can add your practice to an existing issue or submit a new issue for research by emailing PayorConcerns@khfirst.com


Reminder! Please submit your PHI and claims examples securely. KHF can provide a secure email for you if needed.

Ransomware attack on Change HealthCare and Optum-Claims Clearinghouse

What you Need to Know Now!

  • This attack occurred on 2/21/24 and may affect your ability to file claims and to receive payments
  • The attack affects many payors beyond United HealthCare
  • Change Healthcare group is a subsidiary of United Health Group and Optum


The ransomware attack can affect you on three main fronts:

  1. This may be your practice’s claims clearinghouse; or
  2. Change HealthCare may be the electronic claims payment clearinghouse that a payor or TPA utilizes to make their payments to you by connecting with your clearing house; and
  3. This disruption can interfere with your ability to gather information for enrollment verification and prior authorizations; and 
  • While your clearinghouse may be Waystar, Availity or Payerpath (Veridigm), they may use Change Healthcare for certain functions, and
  • The above companies have already removed their connection to Change Healthcare.


The first question to ask: Is Change Healthcare your primary clearinghouse? 


If Change Healthcare is your primary clearinghouse, you will need another option to file your claims:

  • Choose another clearinghouse (the three listed are the most common)
  • Availity offers options for providers who use Change Healthcare as their clearinghouse and are also registered within Availity Essentials™
  • Direct connections to the Availity network via Availity Essentials will be offered at no-cost for the time being.
  • Register here: Availity Lifeline
  • File the claims directly on the payor portal
  • Determine if the payor will accept mailed-in claims


If Availity, Payerpath or Waystar is your primary clearinghouse, continue to monitor notices on their website for advice and the workarounds they have created.

  • Some electronic payments from many payors are processed via Change Healthcare


If Change Healthcare is not your clearinghouse,

  • Your clearinghouse portal may list the affected payor payments
  • Looks for patterns of non-payment by payor
  • If you can, contact the specific payor contact number (on the back of a patient’s cards), and ask if receiving paper checks is acceptable
  • Optum, a health services company that is also owned by UnitedHealth, said it has established a temporary assistance program to extend cash to organizations whose payment systems have been affected. This involves short-term loans that would need to be repaid once Change Healthcare is back up and running
  • To determine eligibility and funding amount, you must register for the program. An Optum Pay account is required to complete registration, to receive funds, and to repay funds. Use your existing Optum Pay account or sign-up for Optum Pay to log-in.
  • Once you enroll, you can see the potential temporary funding assistance
  • Temporary Funding Assistance (optum.com)


Additional Information

United Health Group provides regular website updates regarding the Change Healthcare status here: Information on the Change Healthcare Cyber Response - UnitedHealth Group

 

Additionally, according to an HHS press release from yesterday, CMS strongly encourages Medicaid and CHIP managed care plans to expedite the new iEDI enrollment and adopt strategies for removing or relaxing prior authorization and utilization management requirements, and consider offering advance funding to providers, on behalf of Medicaid and CHIP managed care enrollees to the extent permitted by the State.

 

In addition, the AAP is connecting with the CDC related to VFC implications, particularly borrowing across VFC and private vaccine stock.

 

Stay tuned for additional updates as we learn more about the ransomware attack and its impact on our practices. 


PAYOR UPDATES

Aetna


The Childrens Care Network (TCCN) is pleased to announce the signature of a new value-based program contract with Aetna. The value-based program includes all TCCN members. The agreement will have an effective date retroactive to January 1, 2024. More details will be forthcoming as TCCN implements this new agreement.

 

Aetna Premier Care Network Plus program is now multi-tiered

OfficeLink Updates (aetna.com)

Effective January 1, 2024, the new Aetna Premier Care Network Plus is a multi-tier program. This program is a new national performance network offering.  See pages 28-29 in the above link for details, including example ID card

Medicaid


Found in GAMMIS Provider Messages on 2/19/24: Health Check Reimbursement for RSV Vaccine Administration


Reimbursement for Respiratory Syncytial Virus (RSV) Vaccine Administration

To address provider concerns related to the increased number of RSV cases and maternal RSV vaccination, the Department of Community Health (DCH) is allowing reimbursement for the administration of RSV vaccines. RSV vaccines protect infants and babies from becoming sicker from the virus. The two RSV vaccines, BeyfortusTM and Abrysvo, are available to Health Check providers via the Vaccines For Children (VFC) program. Reimbursement is also allowed on claims submitted for members 19 through 20 years of age.


Beyfortus

DCH allows reimbursement for new RSV vaccine administration codes 96380 and 96381 under the Health Check Program (COS 600). These new vaccine administration codes are covered for the administration of BeyfortusTM RSV monoclonal antibody vaccine and replaces the previously instructed generic CPT code 96372. For claims beginning with date of service March 1, 2024, Health Check providers should no longer report 96372 for the administration of BeyfortusTM. Providers should report the new vaccine administration codes (96380 or 96381) with the EP modifier, along with the BeyfortusTM vaccine product codes (90380 or 90381) with the EP modifier.  


Abrysvo

DCH allows reimbursement for the administration of the Abrysvo vaccine under the Health Check Program (COS 600). For claims beginning with date of service January 1, 2024, Health Check providers should code the Abrysvo product (CPT code 90678) with the EP modifier. Additionally, the Abrysvo product should be reported with the appropriate vaccine administration code (90460, 90471, 90472) with the EP modifier.


Health Check Reimbursement for E&M Codes and Preventative Visits

Provider Messages (georgia.gov)

Effective 01/01/2024, Health Check Providers may report E/M codes 99202-99205, 99213-99215, in addition to E/M codes 99211 and 99212, when also reporting a preventive visit for Medicaid-eligible and PeachCare for Kids® (PCK)-eligible children. Health Check Providers should report the preventive visit with CPT codes 99381-99385, 99391-99395. If an abnormality is encountered or a preexisting problem is addressed during the preventive visit, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99202-99205, 99211-99215 should also be reported.  


Save the Date for the Spring Medicaid Fair

March 21, 2024 - Macon Marriot City Center in Macon, GA.

  • The Spring Medicaid fair is the same day as the KHF Practice Administrator meeting with a speaker presenting. If possible, practices may want to send a billing representative to the Medicaid meeting to allow the PA to attend the KHF PA meeting.

Peach State Health Plans


Letter regarding an adjudication/repricing project for Peach State Medicaid and Ambetter patients not included in claims process for Coordination of Benefits. 

  • Please note, KHF is not contracted for Ambetter.

United Healthcare


Reminder: Balance billing is not permitted

Reminder: Balance billing is not permitted | UHCprovider.com


Information on the restrictions of balance billing is outlined on page 141 in the 2024 UnitedHealthcare Care Provider Administrative Guide. Search “balance billing” in the guide for examples of prohibited payment requests. Members are responsible for paying copays, deductibles and coinsurance amounts for covered services. A bill or payment should not be collected, or lien imposed on a member, for any amount outside of such responsibility. Members who receive a bill or lien from a participating provider for covered services outside of their required cost share, may file a complaint with UnitedHealthcare and/or their state representatives.

BEST PRACTICES & QUICK TIPS

New Add-on Code


New add-on CPT code 99459 (pelvic examination) was introduced effective January 1, 2024. When completing a female pelvic exam in the office, CPT 99459 can be used to for additional payment as E&M codes do not account for extra expenses associated with the procedure.

https://www.aapc.com/codes/coding-newsletters/my-ob-gyn-coding-alert/cpt-2024-update-federal-register-clarifies-pelvic-exam-add-on-code-176774-article

 

Check Your Coding!


Hearing Screening

Hearing screening information as found in the CPT Coding Manual:

The audiometric tests listed below require the use of calibrated electronic equipment, recording of results, and a report with interpretation. Hearing tests (such as whispered voice, tuning fork) that are otorhinolaryngologic evaluation and management services are not reported separately. All services include testing of both ears. Use modifier 52 if a test is applied to one ear instead of two ears.

 

CPT 92551 Screening test, pure tone, air only

  • Code 92551 is used when the patient wears earphones and is asked to respond to tones of different pitches and intensities. This is a limited study.



CPT 92552 Pure tone audiometry(threshold); air only

  • Code 92551 is used when the patient wears earphones and is asked to respond to tones of different pitches and intensities. The threshold (lowest intensity of the tone heard by the patient 50% of the time) is recorded for multiple frequencies. 

 

We Want To Hear From You!


Do you have billing topics, best practices, claim questions, or good news to share? Email KHF at PayorConcerns@khfirst.com.

RESOURCES

Kids Health First Intranet Page