Tag: #skillednursing

Posted in #aetna, #Medicareadvantage, #reimbursement, NY Providers, Prior Authorization Insurance Carrier Updates, Training

Aetna Medicare Advantage: reminder- certain post acute, skilled nursing and home health require pre- approval

Posted on by KR2Medical Billing

This change applies to the providers located in the following states:

NJ, NY, PA, VW

The pre-apporoval applies to some post-acute , skilled nursing, and home health services.

The following HCPCS are affected:

  • G0151: Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
  • G0153: Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.
  • G0155: Services of a clinical social worker in home health or hospice settings, each 15 minutes. 
  • All the codes until G0162

As well as the following codes:

G0299- Direct skilled nursing services of a Registered Nurse (RN) in the home health or hospice setting, each 15 minutes.

G0300-Direct skilled nursing services of a Licensed Practical Nurse (LPN) in the home health or hospice setting, each 15 minutes.

G0463- Skilled services by a Registered Nurse (RN) for observing and assessing a patient’s condition.

G0496- Skilled services by a Licensed Practical Nurse (LPN) for training or educating a patient or family member.

Inpatient Revenue code:

128- daily medical management, skilled rehab services, and regular physician (MD/NP/PA) oversight for intensive rehab patients

Skilled Nursing levels: 1,2,3,4.

Pre-auth process:

1. Go to EviCore.

2.Call 1-888-622-7329 during normal business hours.

3.Fax a request form to 866-705-3574 (Aetna Home Health), 855-633-8631 (AETNA PAC Initial) or 877- 502-0810 (AETNA PAC Concurrent)

For any urgent requess, when  member requires services in less than 48 hours, please call eviCore.

Find this information useful? Follow my blog for more information about current medical billing, coding and reimbursement policies.

Posted in #Medicareadvantage, #unitedhealthcare, Training, Updates

UHC: Payment for COVID-19 testing coverage, outpatient SNF

Posted on by KR2Medical Billing

Previously, UHC would not reimburse for COVID-19 testing when done outside of a skilled inpatient stay at a SNF.

However, during the PHE, starting Jan 27,2020 and then renewed on April 21,2021, subject to further extension, UHC is going to pay for the COVID-19 testing that is done outside of the skilled inpatient stay at a SNF.

This change applies to the following Medicare Advantage Plans:

  • Medicare Advantage Plans
  • Dual Eligible Special Needs Plans (DSNP)
  • Chronic Special Needs Plans (CSNP)
  • UnitedHealthcare Assisted Living Plans (IE-SNP)
  • FIDE/MMP Plans

Plans that this change DOES NOT APPLY TO:

  • UnitedHealthcare Nursing Home Plans (ISNP)
  • UnitedHealthcare commercial plans
  • UnitedHealthcare Community Plans (Medicaid Only Plans)

UHC will re-process the claims, there is no further action needed.

UHC will reprocess claims previously paid at $0 to be reimbursed at 100% of the Medicare fee schedule. No action is required from affected SNFs for these adjustments.

The following codes are going be reimbursed at 100% of Medicare Fee Schedule:

Reminder!

COVID-19 testing performed during an approved skilled stay are subject to Centers for Medicare and Medicaid Services (CMS) consolidated billing rules and are not separately reimbursable, except for the UnitedHealthcare Nursing Home Plan (ISNP). New applicable CMS covered COVID-19 testing codes may be added periodically. We may add or remove codes from the following list, in accordance with CMS coverage guidelines.

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In a meantime, check out my latest posts below:

Posted in Updates

Billing for Multiple Home Health Visits -UHC update, September 2020

Posted on by KR2Medical Billing

According to UHC, in order to prevent payment issues for multiple skilled nursing visits on the same day, providers need to bill in the following manner:

a. Bill each visit on its own line

b. Bill each visit with its RVU and  HCPCS/CPT codes

c. The subsequent visits should be billed with a qualifying modifier (ex. XE)

Adding the appropriate modifier will ensure that the additional visit will be identified and processed for payment correctly, at expected rate.

For more information, please click here, for UHC Medicare Advantage Guidelines/Definitions. .