ICD-10 AND THE ADULT DAY CARE WAIVER PROGRAM

December 11, 2015

ICD-10, or The International Classification of Diseases, 10th Revision, went into effect October 1, 2015. It is a revision of the ICD-9-CM system which physicians and other providers have used to code all diagnoses, symptoms, and procedures recorded in hospitals and physician practices.

 

More information about ICD-10 can be located at https://www.cms.gov/medicare/coding/icd10/index.html As well, the MO HealthNet Division (MHD) has information available at their website (click to link to the most recent bulletin).

 

The change to ICD-10 does not affect the Current Procedural Terminology (CPT) and Health Care Procedural Coding System (HCPCS) coding for outpatient procedures. An example of a CPT/HCPCS code is S5100, used to bill Medicaid for Adult Day Care Services.

 

The Missouri Medicaid Audit and Compliance Unit (MMAC) has received questions from Adult Day Care providers regarding ICD-10. Providers want to know if MMAC auditors review ICD-10 codes as part of their audit processes. To determine proper billing, MMAC auditors will ensure Medicaid participants are authorized for the services billed, that the services billed were actually performed, and are properly documented. This involves a review of the billing codes, such as S5100. MMAC auditors do not routinely review ICD-10 codes as part of the Adult Day Care Waiver Program audit process. If an ICD-10 code appears incorrect, an auditor will bring this to the attention of the provider and the Department of Health and Senior Services, but it does not affect the billing process and would not result in an error during an audit.

 

Please contact MMAC at mmac.providerreview@dss.mo.gov if you have any questions.

PRIVATE DUTY NURSING UPDATE

December 11, 2015

Some MO HealthNet-enrolled Private Duty Nursing (PDN) agencies are also enrolled to provide other types of services.  For instance, a PDN agency may also be a provider of in-home services.  Different program rules apply to PDN than to other programs.

 

In July, 2015, in-home services and consumer-directed services providers became required to use “telephony” to track the in and out times of services provided.  This rule does not apply to PDN.  However, some  providers may choose to use their telephony systems for their PDN services as well.  This may cause improper billing if the systems accrue units of service for PDN.

 

While the in-home and consumer-directed programs allow for accrual of units, the PDN program does not.  Click here to read the PDN regulation (13 CSR 70-95).  Click here to read the rules regarding accruing units in in-home or consumer-directed programs (13 CSR 70-91).

 

As well, the PDN program does not allow for rounding of units.  Neither do the other programs.  The PDN regulation states, “A unit of service is fifteen (15) minutes.”  Rounding up is not allowed, as this can cause over-billing.  The Missouri Medicaid Audit and Compliance Unit (MMAC) encourages all providers who use telephony systems to review their systems for compliance across their programs.  The MMAC website has a link to a list of “Questions to Ask Potential Telephony (EVV) Vendors” that offers helpful guidance.  This tool was prepared by members of the MO Alliance for Home Care’s CDS and State Programs Task Force.

 

If you have any questions, please contact MMAC at mmac.providerreview@dss.mo.gov