WORD SCRAMBLE While were all getting settled lets

WORD SCRAMBLE While we’re all getting settled, let’s have a little fun! How many of these topic related words can you unscramble? (two words) (three words) (two words)

WORD SCRAMBLE ANSWERS (two words) preauthorization claim billable activity CPT Code (two words) ICD 9 coaching (three words) (two words) standard of care (three words) denials Affordable Care Act coding billing documentation reimbursement credentialing EI Benefit coverage referral

UNDERSTANDING THE KEYS TO BILLING, CODING, AND DOCUMENTATION FOR REIMBURSEMENT K E L N L O Y V H E IL M B L E , R P T 1 2 , 0 1 3

DOES INSURANCE BILLING MAKE YOU FEEL THIS WAY SOME DAYS?

T E H G E AM N A PL 1. Billing In and Out of network 2. Pre. Authorization 3. Coding 4. Documentation 5. Denials & Appeals

VERIFY BENEFITS – 3 WAYS TO ASK Does the Policy have the Early Intervention or Developmental Delay Benefit ? Check “Exclusionary Benefits” section or contact the Medical Management Dept. of the Insurance Co. Does the Policy cover the Essential Health Benefits List of the Affordable Care Act ? Habilitative services is on the list. Do they have Out-Patient OT, PT and SLP therapy benefits?

KNOW THE DETAILS…. . • Coverage limitations – Number of sessions per year or in an authorized period of time? • Pre-Authorizations/Re-Authorizations • Is my fee negotiable? Usual and customary fee for service – what the insurance pays for 15 min. unit of therapy in your region of the state • Documentation Required – Dr. Referral & Plan of Care (IFSP Outcomes page)

E TH IN G K N I R T T O E G ETW N Provider Credentialing § -NPI (nppes. cms. hhs. gov) § -CAQH (caqh. org) Complete Application Fee Schedule § -Usual and customary

- ? D S EE M N I A U L O C Y L O A I D T Dr. Signature I T IN HA Provider Credentials W § Va. License # § NPI # ICD 9 and CPT Codes Documentation § IFSP

? K R O W T E N F U O O T SUBMIT A CLAIM ANYWAY

PRE-AUTHORIZATIONS Optum Health Care Solutions (UHC and Aetna ) As of January 2013, online submission is required and the submission time has shortened to within 3 -5 business days of the evaluation. Your claim can be denied if you miss this deadline. Therapy services will not be paid until preauthorization has been approved. Claims submitted without this approval can be denied.

Completed by Provider or or Completed by Service Coordinator

ty i s s e C I D O G N t s E i l ab i h s ng M l a ic d e c e N Accepted health care services and supplies provided by health care entities, appropriate to the evaluation and treatment of a disease, condition, illness, or injury and consistent with the applicable standard of care.

ICD - Diagnosis Codes International Classification of Diseases World wide coding system CPT - Treatment Codes Current Procedural Terminology Developed by the AMA DSM 5 Change in ASD diagnosis criteria

ICD-9 CODES • • • Outdated – over 30 years old 3 -5 characters in length 14, 000 in total ICD-10 CODES • More specific and detailed • Codes 3 -7 characters in length • • 68, 000 in total Effective October 1, 2014

WHAT CAN I DO NOW? Softwar e • Compatible with medical billing • Using HIPPA 5010 IT • Support new data: ICD 10 & new 5010 form Coding • Understand basis of diagnosis selection and ordering

1. A Neurological or Musculoskeletal condition? (741. 9 Spina Bifida, Tuberous Sclerosis 759. 5, PVL 779. 7) 2. If not, then what are you addressing? Muscle weakness 728. 87, Hypertonicity 779. 8, Hypotonia 781. 3 3. Other Relevant Diagnosis codes (758. 0 Down’s Syndrome, Drug Withdrawal Syndrome 779. 5, Prematurity 765. 0, Prader-Willi 759. 81)

2 1 M 0 E 2 H r T e AN b m e D t N p A e S A N ive T t E A ffec E No longer cover 781. 3, 315, 317 -319 codes, 783. 42, 784. 61 for children in plans that exclude developmental delay.

, 4. , 7 8 8 2 7 ty i ax e l , m s s ro e n nd k ea Sy w ’s e cl wn s u Do M d , ia an n o ts, t po en y H am lig 7 , 3 . 1 8 7. . 0 X E 8 75 . 8 2 of

EX. 728. 87, 779. 8, 772. 1, 765. 0 Muscle weakness, hypertonicity, Grade III IVH, 28 wk. prematurity

USE ALL DIGITS – “ 0” IS A DIGIT fifth Ex. Epilepsy (345. 0, 345. 1, 345. 4 -345. 9) requires a digit subclassification of : 0 – without mention of intractable epilepsy Ex. Infantile Spasms is 345. 60 Ex. Spina Bifida 741. 9 requires a fifth digit classification specific to lesion level 0 – unspecified 1 – cervical 2 – dorsal (thoracic) 3 – lumbar Ex. Speech Disorder NOS (784. 5) requires a fifth digit subclassification: 1 – Dysarthria 2 - fluency disorder in conditions classified elsewhere 9 – other speech disturbance

Avoid Non-Specific Codes • Unspecified delay in development 315. 9 • Late walker/late talker 783. 42 • Delayed milestones 783. 42 Most Commonly used ICD 9 Code Sections used for the Birth-3 Population: • Congenital Anomalies (740 -759) • Conditions in the Perinatal Period (760779) • Musculoskeletal System & Connective Tissue (710 -739) • Nervous System (320 -359) • Sense Organs (360 -389)

A THERAPIST MUST CHOOSE THE MEDICAL AND/OR TREATMENT DIAGNOSES THAT MOST REFLECT THE REASON FOR THERAPY.

CPT CODES - THINK ABOUT IT! 97530 Dynamic Activities 97112 Balance, Coordination, Posture 97535 Activities of Daily Living 97110 Therapeutic Exercise 92507 & 92526 Speech

N O TI al A dic T EN Me M g U n i C y DO tif s u J ty i s s e c e N Insurers want to see a link between Codes > Plan of Care (Goals/Services) > Your Note

PART C MEDICAL Eligibility Medical Necessity ASP Evaluation Outcomes Plan of Care Primary Provider Licensed Therapist

WHO is Referring INDICATOR STATEMEN TS AS P Supporting OBJECTIVE DATA WHY are they referring

CHILD OUTCOMES = PLAN OF CARE

TO E S EV E I I H G E C T A A R TO T S ES D E TIN L L U I SK RO G AY N I D K N RY S I L VE L E OA G I H G N O C C A

SESSION NOTES What Are You Doing? How Is the Child/Family Responding ? Why Are You Doing It?

FRAMEWORK FOR YOUR NOTE 1. Participants 2. Update (Reflection on last session) 3. Session Activity/Task that was modeled, taught, demonstrated, altered, or modified 4. Child/Family Response in skilled, measurable terms and progress towards goal 5. New Strategies to use in Routines

S L A I N DE S L A D N A A E P P

TECHNICAL DENIAL REASONS ü ü ü Missing signature Not matching time to units billed Inappropriate CPT codes Unsupported ICD 9 diagnoses No Pre-Authorization Missed timelines

CLINICAL DENIALS üLack of medical necessity üCloning üDuplication of Services üIncomplete medical records

HOW TO WIN THE DENIAL TACTIC Know the Claim Process Document all contacts Submit the IFSP with initial claim

RESOURCES kellyh 63@comcast. net 540 -272 -6306 www. ICD 9 data. com – has conversion to ICD 10 https: //catalog. amaassn. org/Catalog/cpt/issue_search. isp Infantva. org/fiscal