The September 2003 Health Insurance Portability and Accountability Act (HIPAA) implementation resulted in the following changes in the Medi-Cal provider manuals. All changes are effective for dates of service on or after September 22, 2003.

Important:

New HIPAA In Review

A handy HIPAA In Review guide has been included in this bulletin for you to insert in your provider manual at the end of the HCFA 1500 Completion section. This guide summarizes important HCFA-1500-related changes that resulted from the September 2003 phase of HIPAA implementation.

Place of Service Codes

Place of Service Field (Box 24B)

Local Medi-Cal Place of Service codes are being replaced with national Place of Service codes, which are entered in the same box (24B) as previously entered.

Place of Service codes are defined by the Centers for Medicare and Medicaid Services (CMS).

Manual Changes

• Medi-Cal Place of Service code values are changed to national Place of Service code values.
• A Code Correlation Guide showing the relationship between Medi-Cal Place of Service and national Place of Service codes is added at the end of the HCFA 1500 Completion section to help you understand how local Place of Service codes are being converted to national Place of Service codes.

Billing Limit Exception to Delay Reason Codes

COB Field (Box 24J)

Local Medi-Cal billing limit exception codes are being replaced with national delay reason codes. Delay reason codes are entered in Box 24J, the same box where billing limit exception codes were entered.

Use of national delay reason codes is mandated by HIPAA.

Manual Changes

• A Code Correlation Guide showing the relationship between billing limit exception and delay reason codes is added at the end of the HCFA 1500 Completion section to help you understand how Medi-Cal billing limit exception codes have been converted to national delay reason codes.

Modifiers

Procedures, Services, or Supplies Field (Box 24D)

Up to four modifiers may be entered on HCFA 1500 claims. All modifiers (-26, -47, -60 and -62 in the preceding example) must be billed immediately following the procedure code, with no spaces, in the Procedures, Services or Supplies/Modifier field (Box 24D).

Manual Changes

• The HCFA 1500 Completion section is updated to include instructions for billing with up to four modifiers.
• When billing for services rendered to recipients who are patients in subacute care facilities, you must enter the Place of Service code “99” in the Place of Service field (Box 24B) and modifier -HA (pediatric) or -HB (adult) in the last-used modifier field.

“From-Through” Billing

Date(s) of Service Field (Box 24A)

“From-through” services with a “from” date of service on or after September 22, 2003 are billed with national codes. “From-through” services with a “from” date prior to September 22, 2003 are billed with local Medi-Cal codes. (Please note, the “through” date is “to” on the HCFA 1500.)

Guidelines

Changes for the September 2003 phase of HIPAA implementation established the following guidelines:

• Claims with dates of service on or after September 22, 2003 must be submitted with national Place of Service and delay reason codes.
• Claims for services prior to September 22, 2003 must be billed with local Medi-Cal Place of Service and billing limit exception codes.
• Claims for services rendered on dates of service that include both pre- and post-September 22, 2003 dates must be billed on separate claims (split billed) with national codes on one claim and local Medi-Cal codes on another.

“From-Through” Exemption

Claims for services that require “from-through” billing (identified in policy sections) do not require the split billing. They are billed as indicated in the italicized text under the preceding diagram.

Manual Changes

• The HCFA 1500 Special Billing Instructions section is updated to include the preceding “from-through” information.