To: Enrolled Hospitals: Chief Executive Officers, Chief Financial Officers, and Patient Accounts Managers
Re: Notice #2 - Hospital Fee-for-Service Professional Billing Transition to the Outpatient Institutional Claim Format July 1, 2020
This notice further details the Department’s plans to shift hospital professional billing to the outpatient institutional claim format and eliminate the use of the Ambulatory Procedures Listing (APL), effective for outpatient claims with a From Date of service on and after July 1, 2020. This applies to claims for participants covered under both traditional Medicaid coverage and Medicaid managed care plans.
As stated in the initial June 2, 2020 provider notice, effective for outpatient claims with a From Date of service on and after July 1, 2020, the APL is being eliminated. Hospitals must bill all services previously billed as professional (non-hospital) services as outpatient institutional services via an 837I electronic transaction, or for claims requiring an attachment, a UB-04 paper claim form. Hospitals must bill all outpatient services under the NPI assigned for institutional services. Hospitals should not use their professional services NPI for dates of service beginning July 1, 2020.
Below is further guidance regarding current hospital fee-for-service practitioner billing and the conversion to institutional billing.
Hospital Professional Services Transitioning to the Institutional Claim Format
Hospitals have been allowed to bill fee-for-service under their facility name and professional services NPI for the services described in the Handbook for Practitioner Services, Topic A-202.14. Those services are included below. For dates of service beginning July 1, 2020, these services must be billed on an institutional claim.
· Administration of chemotherapy for the treatment of cancer
· Administration and supply of the following medications:
Ø Chemotherapy agents for the treatment of cancer
Ø Non-chemotherapy drugs administered for the side effects that may occur during the administration of a chemotherapy agent. Claims must be submitted with the cancer-related diagnosis
· Reference (outside) laboratory services
· Laboratory services performed on-site
· Radiology services
· Durable Medical Equipment and Supplies – Hospitals will no longer need to get prior approval for DME items or supplies for individuals covered under traditional fee-for-service Medicaid. The items and supplies will price from the EAPG grouper.
· Speech, Physical, and Occupational Therapy – Hospitals will no longer need to get prior approval for therapies for individuals covered under traditional fee-for-service Medicaid. If more than one type of therapy is given on the same service date, all therapy services must be billed on the same claim. All therapy billing, both evaluations and treatment, continue to require the following modifiers:
· Physical Therapy – GP
· Occupational Therapy – GO
· Speech Therapy – GN
· Audiology Services
· OB Triage (CPT 99211 with TH Modifier)
· Electrocardiogram Tracings, Technical Component Only Code
· Telemedicine Originating Site Only – Hospitals must utilize Revenue Code 0780 to denote the originating site.
· Long Acting Reversible Contraceptives (LARCs) in the Inpatient Setting - For inpatient discharges after July 1, 2020, the device charge should be included on the hospital inpatient claim, and it will price as an add-on amount to the APR-DRG payment determined for the inpatient delivery. The current LARC codes that will prompt the add-on amount are J7296, J7297, J7298, J7300, J7301, and J7307.
Additional Billing Clarification
· National Drug Code (NDC) and Actual Acquisition Cost (AAC) for 340B Drugs –
Hospitals continue to be required to identify the NDC on all outpatient drugs billed. Hospitals must identify all 340B-purchased drugs by reporting modifier “UD”, so that the Department will not claim the rebates. Modifier “UD” must be the first modifier listed after the HCPCS drug code.
- Series Billable Services – Claims will no longer be required to contain specified series-billable procedure codes or revenue codes. Multiple days’ services can be billed on one claim; however, providers must bill around inpatient stays or show those days as a non-covered date span on the outpatient claim. The ‘From’ and ‘Through’ dates of service must be the actual beginning and ending service dates for the outpatient services and cannot exceed 31 days.
· Specific Coding for Emergency Department, Observation, and Psychiatric Services
The three outpatient levels of emergency services remain in place, as well as the procedure and revenue codes associated with them. The coding for observation and psychiatric clinic services also remains in place.
Emergency Room Services
99284, 99285, 99291, G0383, or G0384
99282, 99283, G0381, or G0382
99281 or G0380
Both revenue lines above are required on an observation claim.
Psychiatric Clinic Services
90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90870, 90875, 90876, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, and 99215
Psychiatric Clinic Type B intensive outpatient program (IOP) claims must be coded with Revenue code 0913. Partial hospitalization program (PHP) claims must be coded with Revenue Code 0912.
Hospitals must split claims containing multiple service dates that cross July 1, 2020. This excludes emergency department and observation claims.
Hospital outpatient claims (excluding renal dialysis) for dates of service beginning July 1, 2020 may be placed on hold temporarily until all system requirements have been fully tested and approved. The Department has prepared a question and answer document to assist providers in this transition and it will be updated as needed. Questions may be submitted in writing to HFS.Hospitals@illinois.gov.
Interim Medicaid Administrator