Tag: healthcare

Posted in #reimbursement, Education, NY Providers, Payers and CPT reinbursement, Training, Updates

Understanding Nursing Home vs PDN Coding-NYS

Posted on by KR2Medical Billing

In order for us to understand the coding difference between the nursing home visit codes and PDN (private duty nursing) codes, we need to go back to the basics.

Definitions:

Nursing Home services/visits- the necessary intermittent or part-time nursing care provided for a patient in the patient’s home or home substitute on a per visit basis. These services are usually no more than 2 hours per day and are performed by the Certified Home Health Agency.

Private Duty Nursing services/visits- nursing services that are one on one more personal level, for medical fragile members, that are performed on continuous basis. The purpose of Private Duty Nursing is to assist the caregiver/family members to help the member to remain safely at home. There is a separate code set for PDN services and a corresponding fee schedule.

image is via NYS Medicaid website

Reimbursement:

Nursing Home Visits: are reimbursed in the increments of 15 min

PDN services/visits: are reimbursed by hour.

Exception: the following 2 code are reimbursed per diem because they represent the 13-hour shift

T1030- nursing care by RN, per diem, at home- 13 hour shirt

T1031- nursing care by LPN, per diem, at home- 13-hour shift

Coding–

I. Nursing Home Visits/Services:

a. T1002- RN services, up to 15 min

b. T1003- LPN services, up to 15 min

II. PDN services/visits:

a. S9123- RN services, per hour

b. S9124- LPN services, per hour

Please note that when you are billing the T codes you cannot bill them with the “other nursing codes” , listed below, or when the codes listed below better represent the nursing services that are authorized, performed.

Other Nursing Codes:

image via UHC website

Need more information about NYS Medicaid Home and Community LTC codes: please visit here

PDN services fee schedule, here.

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Posted in #aetna, #Medicareadvantage, #reimbursement, Training, Updates

Aetna: Reimbursement for evaluations with G2082 and G2083 codes…

Posted on by KR2Medical Billing

According to Aetna, effective for DOS 3/1/24 and thereafter, evaluation codes 99212-99215, 99415–99417 will no longer be reimbursed separately when billed on the same DOS for the same member by the same provider.

This change will apply to Commercial and Medicare Advantage Plans.

Modifier 25 will not be able to override this claim edit and the payment for the E/M codes will be included in either code G2082 or G2083

G2082-temporary code for 2024- office or outpatient visit for evaluation and management of already established patient that requires physician or other qualified health care professional supervision up to 56 mg of esketamine nasal self- administration, includes 2 hours post-administration observation.

G2083-temporary code for 2024- office or outpatient visit for evaluation and management of already established patient that requires physician or other qualified health care professional supervision greater than 56 mg of esketamine nasal self- administration, includes 2 hours post-administration observation.

CTP codes 99415, 99416 are used to report the total amount of face-to-face time spent with the patient and/or family/caregiver by clinical staff in the office or
other outpatient setting, on a given date of service even if the time is not continuous. The
physician or qualified health care professional is present to provide direct supervision of the
clinical staff. Codes 99415, 99416 should not be used for prolonged services of less than 30
minutes total duration on a given date.

Want to stay current with the up-to date medical billing and coding information? Follow my blog. #medialbilling #medicalcoding #reimbursement

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MVP: Home Health Auth and Concurrent Review Process changes

Posted on by KR2Medical Billing

The change to the prior authorization process and concurrent review process will affect the Medicare Advantage and DualAccess (D-SNP) Members in New York and Vermont.

As of Jan 1 ,2024 the process for Home Health Services and Concurrent Review will be handled by naviHealth, Inc. d/b/a Optum Home and Community Care.

Important things to remember:

  • Start of Care (SOC) visits will not require prior authorization
  • Providers should submit the notice of initiation of start of care for home health services to Optum Home and Community Care within the 5 days after the Start of Care visit: the provider will receive an Authorization Id, AND MVP Authorization ID- for the FIRST 30 days of the services. The MVP Authorization ID will allow the member to receive services without the need for an authorization.
  • Prior to day 30, Provider must request prior authorization for days 31-60, by discipline, and provide documentation to Optum Home and Community Care.
  • For each subsequent 60-day period, Provider must request prior authorization, by discipline, and provide documentation to Optum Home & Community Care during the 56-60-day recertification window.

If you would like more information, please visit mvphealthcare.com/policies and select Provider Policies, Effective October 1, 2023 (PDF) and review the Utilization and Case Management section.

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