Please refer to the November, 2017 INITIAL HOSPITAL CARE VISIT BULLETIN. The MO HealthNet Division (MHD) limits payment for Current Procedural Terminology (CPT) codes 99221, 99222, and 99223, to one (1) per inpatient stay. These codes are to be used to report the first hospital initial inpatient encounter by the admitting physician, according to The CPT Professional Codebook.
Since July 1, 1991, the MO HealthNet Division (MHD) has been re-pricing Medicare Part A inpatient hospital crossover claims for the possible payment of Medicare deductible and co-insurance amounts. This Hot Tip is a reminder that the re-pricing policy also applies to Medicare Part C/Advantage plans for inpatient hospital services for deductible, co-insurance and co-pay amounts for participants who are QMB eligible.
The submission of a National Drug Code (NDC) is not required for 340B providers on outpatient hospital claims; however, MO HealthNet prefers claims be submitted with a valid Healthcare Common Procedure Coding System (HCPCS) procedure code and a valid NDC. A valid NDC and/or a valid HCPCS procedure code (not a dump code) must be billed for each medication for MO HealthNet to identify drugs dispensed. For drugs without a valid HCPCS procedure code, revenue code 0250 "General Classification: Pharmacy” should be used with the appropriate NDC.
Providers must bill the correct quantities for medications dispensed to participants in the outpatient hospital setting. Section 15.24.E of the Hospital Provider Manual states the quantity to be billed for injectables and other types of medications dispensed to MHD participants must be calculated as follows:
It is important to remember when it is appropriate to bill MO HealthNet an outpatient hospital facility charge. Inappropriate billing of facility charges will result in recoupment of payments. The following information can be found in the MO HealthNet hospital provider manual which is available at http://manuals.momed.com/manuals/. Please refer to sections 13.38, 15.20, 15.21 and 15.23 for more information regarding outpatient facility charges.
Inpatient hospital admissions must be pre-certified as medically necessary by the MO HealthNet Division (MHD) review authority, Xerox Care and Quality Solutions. In addition to precertification of inpatient stays, Xerox's responsibilities include validation reviews described in 13 CSR 70-15.020(9) and in Section 13.29.F(5) of the MO HealthNet hospital provider manual available at: http://manuals.momed.com/manuals/.
As previously stated in our Radiology Bulletin dated January 15, 2016 (Volume 38, Number 25), Diagnostic Site is a standardized medical imaging safety and quality program designed to assess and credential medical imaging equipment, personnel, and policies of facilities that perform diagnostic imaging services.
Effective February 1, 2016, the MO HealthNet Division (MHD) will no longer require precertification for the following echocardiography procedure codes:
As announced in the June 12, 2014, Volume 36, No. 31, Physician Bulletin, effective June 15, 2014, MO HealthNet will pay for elective circumcisions for all newborn infants less than 28 days old using Current Procedural Terminology (CPT) codes 54150 and 54160.
Reconstructive breast surgery is considered a MO HealthNet covered service, if necessary to restore symmetry as recommended by the oncologist or primary care physician for the patient incident to mastectomy, as well as other documented medical necessity deemed appropriate via MO HealthNet physician consultant review.
