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HIPAA: FQHC/RHC/IHS-MOA Code Conversion

Health Insurance Portability and Accountability Act (HIPAA) mandated changes to billing requirements for Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) and Indian Health Services – Memorandum of Agreement (IHS-MOA) 638, Clinic providers will become effective on October 1, 2017. These changes include the use of Healthcare Common Procedure Coding System (HCPCS) Level I and Level II national codes. The following Frequently Asked Questions (FAQs) will provide an overview of this transition and point to resources for additional information.

  1. What does the transition from the HCPCS Level III local per visit codes to HIPAA-compliant billing code sets mean?

    Transition from the HCPCS Level III local per visit codes to HIPAA-compliant billing code sets means that FQHC/RHC/IHS-MOA providers who currently submit HCPCS Level III local per visit codes when billing for their services will be required to submit claims using specified HIPAA-compliant Common Procedural Terminology – 4th Edition (CPT-4) Level I and HCPCS Level II code sets, effective for dates of service on or after October 1, 2017.

    For dates of service on or after October 1, 2017, claims submitted with local per visit codes, with the exception of local per visit code 03 (dental services), will be denied. Local per visit code 03, which is used when billing dental services, is not affected by the transition to HIPAA-compliant billing code sets.

  2. Who is affected by the transition to the HIPAA-compliant billing code sets?

    All FQHC/RHC/IHS-MOA providers submitting claims for services rendered on or after October 1, 2017, will be required to use the HIPAA-compliant billing code sets identified in the FQHC/RHC and IHS-MOA code conversion crosswalks in the FQHC/RHC/IHS-MOA section of the HIPAA: Code Conversions page

  3. What is HIPAA and how does it relate to CPT-4 Level I and HCPCS Level II codes?

    HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was passed by Congress in 1996. In addition to eliminating the use of Level III local codes, HIPAA does the following:

    • Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs;
    • Reduces health care fraud and abuse;
    • Mandates industry-wide standards for health care information on electronic billing and other processes; and
    • Requires the protection and confidential handling of protected health information.
  4. Why is the transition to CPT-4 Level I and HCPCS Level II codes happening?

    California has historically used many thousands of HCPCS Level III or local codes (also known as interim codes) for billing and reimbursement of services and supplies. National codes, such as CPT-4 Level I and HCPCS Level II codes, typically are more general in nature compared to local codes. Using CPT-4 Level I and HCPCS Level II code sets will:

    • Simplify the processes and decrease the costs associated with payment for health care services;
    • Improve the efficiency and effectiveness of the health care system and decrease administrative burdens on providers (for example, medical practices, hospitals and health care plans);
    • Provide standardization and consistency in medical service coding; and
    • Characterize a general administrative situation, rather than a medical condition or service, by using non-clinical or non-medical code sets.
  5. When will this transition take place?

    The effective date for this transition to the HIPAA-compliant billing code sets will take place for services rendered on or after October 1, 2017.

  6. What is a HIPAA-compliant billing code set and why does the conversion require use of a revenue code, or revenue code with procedure code and sometimes a modifier?

    A HIPAA-compliant billing code set is a unique combination of service codes used to identify the face-to-face (one-on-one) encounter between the FQHC/RHC/IHS-MOA patient and the FQHC/RHC/IHS-MOA provider, during which time one or more services are furnished. The code set may consist of one of the following:

    • Revenue code;
    • Revenue code and CPT-4 Level I or HCPCS Level II code; or
    • Revenue code and CPT-4 Level I or HCPCS Level II code with a modifier.

    The use of a HIPAA-compliant billing code set is required to bill for the global visit with the patient, and the accompanying informational lines will detail the specific services provided during the global visit.

    Billing local per visit code 03 for dental services is not affected by the transition to HIPAA-compliant billing code sets. Claims for dental services submitted with local per visit code 03 may be submitted on the same claim form as other services billed with HIPAA-compliant billing code sets and informational lines.

    Other than the transition from local codes to the HIPAA-compliant billing code sets, no other policy for FQHC/RHC/IHS-MOA providers is affected.

  7. What is a revenue code and why is it used?

    Revenue codes are published by the National Uniform Billing Committee (NUBC) and used by facilities to identify specific accommodation, ancillary services, unique billing calculations or arrangements. HIPAA mandates that payers, including Medi-Cal, accept revenue codes and utilize them in claim adjudication.

    Revenue codes will be used by FQHC/RHC/IHS-MOA providers to bill for services rendered, which includes use of the facility. Each service should be assigned a revenue code, but not every revenue code will utilize an accompanying procedure code or a modifier to define the global billing code set for the face-to-face encounter.

    Submitting claims with a service code combination that does not match the HIPAA-compliant billing code set for the services rendered may result in underpayments, overpayments or claim denials.

  8. What happens if a revenue code is not included on the claim for a date of service on or after October 1, 2017?

    Claims submitted by FQHC/RHC/IHS-MOA providers without a revenue code for dates of service on or after October 1, 2017, will be denied. Providers have three options for countering a denied claim:

    • Submit a new claim with corrected information if the dates of service are within the six month billing limit;
    • Submit an appeal within 90 days of the date on a Remittance Advice Details (RAD) form showing the claim denial;
    • Submit a Claims Inquiry Form (CIF) within six months of the date on the RAD form showing the claim denial.

    For more information, providers should refer to the Claim Submission and Timeliness Overview (claim sub) section of the Part 1 provider manual and the Appeal Form Completion (appeal form) and CIF Completion (cif co) sections of the appropriate Part 2 provider manual.

  9. What is an "informational line" and why should I include this when billing for services?

    An informational line is an associated line item or line items listed immediately following the HIPAA-compliant global billing code set used to bill the face-to-face encounter with the patient. Informational lines contain only the specific CPT-4 Level I or HCPCS Level II code(s) which identifies the actual service(s) provided, and are not separately reimbursed. When submitting informational lines providers should remember:

    • The Revenue Code field (Box 42) on the information claim detail line must always be blank;
    • The Service Units field (Box 46) on the information claim detail line must always be zeroes; and
    • The Total Charges field (Box 47) for each information claim detail line must always be zeroes.

    Example of billing a HIPAA-compliant billing code set with informational lines:

      42
    Rev.CD
    43
    Description
    44
    HCPCS/RATE/
    HIPPS Code
    45
    Serv.Date
    46
    Serv.
    Units
    47
    Total Charges
    48
    Non-covered charges
    1 0520 Clinic Visit T1015 110117 01 10000 <- payable line
    2     80018 110117 00 000 <- informational
    3     99213 110117 00 000 <- informational
    4 0520 Optometry 92004 111517 01 20000 <- payable line
    5     92002 111517 00 000 <- informational

    Note:

    Computer Media Claims (CMC) submitted with an informational line on the first detail line of the claim will be rejected. CMC claim detail line 01 must include only HIPAA-compliant billing code sets.

    Informational line examples will publish in a future Medi-Cal Update and in the provider manual. Providers are encouraged to routinely check the Medi-Cal website for updates regarding this issue.

  10. How many services can I bill on one claim?

    A single paper claim cannot be billed with more than 22 claim lines. When billing an electronic (CMC) claim, if the addition of informational lines causes the claim to exceed 22 lines, the claim must be split and services billed on separate claims. Electronic claims that exceed 22 claim lines with informational lines will be denied in their entirety.

  11. How will the HCPCS Level III code transition impact my SARs October 1, 2017?

    Effective for dates of service on or after October 1, 2017, FQHC/RHC providers may no longer submit Service Authorization Requests (SARs) with HCPCS Level III local per visit codes. All SARs submitted for FQHC/RHC Service Code Group (SCG) 08 must be submitted with the appropriate HIPAA-compliant billing code set. The only exception is for local per visit code 03 for dental services.

    All SARs with HCPCS Level III local per visit codes, except for local per visit code 03, regardless of status (approved, retroactive or deferred), will be end-dated for dates of service on or after October 1, 2017. Providers are encouraged to submit new SARs with the appropriate CPT-4 Level I or HCPCS Level II codes prior to October 1, 2017, for services that will be provided on or after October 1, 2017.

  12. How will the HCPCS Level III local per visit code transition impact claims billed with dates of service on or after October 1, 2017?

    Effective for dates of service on or after October 1, 2017, claims billed with HCPCS Level III local per visit codes, except for local per visit code 03 for dental services, will no longer be eligible for reimbursement and will be denied.

    Providers have three options for following up a denied claim:

    • Submit a new claim with corrected information if the dates of service are within the six month billing limit;
    • Submit an appeal within 90 days of the date on a RAD form showing the claim denial;
    • Submit a CIF within six months of the date on the RAD form showing the claim denial.
  13. How do I use modifier codes?

    Specific HIPAA-compliant billing code sets require the use of a modifier to identify the type of face-to-face encounter. The specific code sets requiring the use of a specific modifier are listed in the code conversion crosswalks located in the FQHC/RHC/IHS-MOA section of the HIPAA: Code Conversions page.

  14. Do I need to use modifier 99 to indicate multiple modifiers?

    No. Claims using modifier 99 will be denied. HIPAA-compliant billing code sets that do not require a modifier should not be billed with modifier 99 or any other modifier.

  15. What changes should I expect to see with the HIPAA-compliant billing code sets on or after October 1, 2017?

    For dates of service on or after October 1, 2017, FQHC/RHC/IHS-MOA billing policy will be updated to accommodate one of the following:

    • Revenue code;
    • Revenue code and CPT-4 Level I or HCPCS Level II code; or
    • Revenue code and CPT-4 Level I or HCPCS Level II code with a modifier.

    The billing policy update will also allow each claim to be submitted with one of the
    HIPAA-compliant billing code sets followed by one or more informational claim lines.

    A complete listing of the new HIPAA-compliant billing code sets is available in the FQHC/RHC/IHS-MOA section of the HIPAA: Code Conversions page.

  16. Will the FQHC/RHC/IHS-MOA claims transition from HCPCS Level III local per visit codes to HIPAA-compliant billing code sets impact current rates and change how my claims are reimbursed?

    The change to the use of the HIPAA-compliant billing code sets is intended to be budget-neutral and rates will not change as a result of this code conversion. The rates used to reimburse the HCPCS Level III local per visit codes will also be reimbursed for the crosswalked HIPAA-compliant billing code sets.

  17. Where can I find additional information related to the FQHC/RHC/IHS-MOA claims transition from HCPCS Level III local per visit codes to HIPAA-compliant billing code sets?

    Providers may request additional onsite or telephone support via the Telephone Service Center (TSC) at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday. Providers calling from outside of California can contact TSC at 1-916-636-1200.

    For additional information, providers may:

    Providers who would like to receive monthly email notification for newly published Medi-Cal Update bulletins should complete the MCSS Subscriber Form.

    Questions may also be submitted via email to CAMMISCodeConversion@conduent.com.