• Like
  • Save

Loading…

Flash Player 9 (or above) is needed to view presentations.
We have detected that you do not have it on your computer. To install it, go here.

Like this presentation? Why not share!

Qualis Health Care Management Services for South Carolina ...

on

  • 706 views

 

Statistics

Views

Total Views
706
Views on SlideShare
706
Embed Views
0

Actions

Likes
0
Downloads
0
Comments
0

0 Embeds 0

No embeds

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment
  • This bulletin does not apply to state agency authorized placements such as PRTFs. This policy applies to acute care inpatient facilities.
  • Mastectomy Procedure Codes along with Repair and Reconstruction Codes.
  • Mastectomy Procedure Codes along with Repair and Reconstruction Codes.
  • Mastectomy Procedure Codes along with Repair and Reconstruction Codes.
  • Spine Codes
  • Spine Codes, Fusion Codes and Fixation Codes
  • Laminectomy and decompression codes
  • Decompression, spinal disk codes
  • Final laminectomy codes

Qualis Health Care Management Services for South Carolina ... Qualis Health Care Management Services for South Carolina ... Presentation Transcript

  • Qualis Health Care Management Services for South Carolina Medicaid Barbara Excell, RN, MSHA, CPHQ, CPUR, PMC Director Medicaid Services Central/East
  • Goals and Objectives
    • Provide a brief overview/background of Qualis Health
    • including the mission, vision and values
    • New additions to the Prior Authorization list effective
    • April 1, 2009
    • February 1, 2009 Prior Authorization changes and
    • timeframe
    • requirements for submission of retro charts
    • What these changes mean for providers
    • Prior authorization review form
    • Care Management Services and timeframes
    • Contact Information
  • Qualis Health Background
    • Qualis Health, headquartered in Seattle, WA, is a private, nonprofit health care quality improvement and care management organization (QIO).
    • Qualis Health has offices in Cayce, SC; Anchorage, AK; Boise, ID; Tustin, CA and Lincoln, NE.
    • Qualis Health has 30 years of experience providing health care utilization/case management and quality assessment/improvement services to public and private sector customers.
  • Care Management Is Our Core Business Vision: To be recognized for leadership, innovation and excellence in improving the health of individuals and populations Mission: To generate, apply and disseminate knowledge to improve the quality of healthcare delivery and health outcomes Values: Integrity, professionalism, collaboration and stewardship
  • Qualis Health South Carolina Staff includes:
    • Director Medicaid Services
    • Registered Nurses
    • RHIA
    • Professional Intake and Administrative Staff
    • Medical Director
    • Associate Medical Director
    • Physician Specialty Consultants
  • Qualis Health SC Medicaid Services
    • Care Management
      • Utilization Review and Quality of Care Reviews
        • Retrospective reviews
        • DRG Analysis
        • Pre-authorization reviews
        • Support Documentation reviews
        • Sterilization reviews
        • Quality of care reviews utilizing CMS guidelines
        • HINN reviews
        • Therapeutic Foster Care onsite reviews
        • PRTF precert reviews
        • PRTF postcert reviews
        • PRTF annual reviews
        • ICF/MR reviews
        • IMD/RTF QOC reviews
  •  
  • Qualis Health Supports the additional codes SC DHHS is implementing for Prior Authorization Effective Beginning April 1, 2009 The changes include additions to the Prior Authorization (PA) list. These codes are in addition to all other codes requiring prior authorization. The following slides will assist providers in determining the best method for updating daily operations/processes to comply with these new changes. Please refer to the SC DHHS provider manual to reference all changes at: http://www.dhhs.state.sc.us/dhhsnew/index.asp
  • Effective April 1, 2009 Additional ICD-9 Codes requiring Prior Authorization where the primary admission diagnosis is one of the following: Oppositional defiant disorder 313.81 Unspecified disturbance of conduct 312.9 Other specified disturbances of conduct, not elsewhere classified 312.8 Mixed disturbance of conduct and emotions 312.4 Disorders of impulse control, not elsewhere classified 312.3 Socialized conduct disorder 312.2 Undersocialized conduct disorder 312.1 Undersocialized conduct disorder, aggressive type 312.0
  • Qualis Health Supports the additional codes SC DHHS implemented for Prior Authorization on February 1, 2009 The changes included additions to the Prior Authorization (PA) list. These codes are in addition to all other codes requiring prior authorization. The following slides will assist providers in determining the best method for updating daily operations/processes to comply with these new changes. Please refer to the SC DHHS provider manual to reference all changes at: http://www.dhhs.state.sc.us/dhhsnew/index.asp
  • These codes required Prior Authorization effective February 1, 2009   Skin Tissue Rearrangement 86.89 85.99 Design Custom Breast Implant 19396 85.21 Removal of Breast Capsule 19371 85 Surgery of Breast Capsule 19370 85.94 Removal of Implant Material 19330 85.43 Mastectomy, Modified Radical 19307 85.47 Mastectomy, Radical, Urban Type 19306 85.45 Mastectomy, Radical 19305 85.34 Mastectomy, SQ 19304 85.41 Mastectomy, Simple Complete 19303 85.22 P-Mastectomy W/LN Removal 19302 85.22 Partial Mastectomy 19301
  • Prior Authorization Update Medicaid Bulletin The policy for Mastectomy and Reconstructive Breast Surgery did not change. Reimbursement is allowed for reconstructive breast surgery following a mastectomy when performed for the removal of cancer or for prompt repair of an accidental injury. Breast reconstruction done for cosmetic reasons is non-covered. Breast Augmentation is non-covered under all circumstances. Program information can be found in the provider and hospital manuals located at www.scdhhs.gov .
  • 81.62 Spine Fusion, Extra Segment 22632 81.08 Lumbar Spine Fusion 22630 81.62 Spine Fusion, Extra Segment 22614 81.08 Lumbar Spine Fusion 22612 81.05 Thorax Spine Fusion 22610 81.03 Neck Spine Fusion 22600 81.01 Neck Spinal Fusion 22595 81.01 Spine & Skull Spinal Fusion 22590 81.62 Additional Spinal Fusion 22585 81.06 Lumbar Spine Fusion 22558 81.04 Thorax Spine Fusion 22556 81.01 Neck Spine Fusion 22554 81.01 Neck Spine Fusion 22548 78.41 Neck/Chest Surgery Procedure 21899
  • 78.49 Spine Surgery Procedure 22899 84.51 Apply Spine Prosth Device 22851 81.30 Reinsert Spinal Fixation 22849   Insert Pelvic Fixation Device 22848   Insert Spine Fixation Device[8 or more segments] 22847   Insert Spine Fixation Device[4-7 segments] 22846   Insert Spine Fixation Device[anterior with segments] 22845   Insert Spine Fixation Device[13 or more segments] 22844   Insert Spine Fixation Device[segments 7-12] 22843   Insert Spine Fixation Device[posterior segmental] 22842   Insert Spine Fixation Device[internal spinal fixation] 22841   Insert Spine Fixation Device[posterior non-segmental] 22840 03.02 Exploration of Spinal Fusion 22830 81.04 Fusion of Spine[8 or more vertebral segments] 22812 81.04 Fusion of Spine[4-7 vertebral segments] 22810 81.04 Fusion of Spine[arthrodesis, anterior] 22808 81.05 Fusion of Spine[13 or more vertebral segments] 22804 81.05 Fusion of Spine[7-12 vertebral segments] 22802 81.05 Fusion of Spine[arthrodesis, posterior] 22800
  • 03.09 Decompress Spinal Cord 63055 78.49 C-Laminoplasty With Graft/Plate 63051 03.09 Cervical Laminoplasty 63050 03.09 Remove Spinal Lamina Add On[each additional segment] 63048 03.09 Removal of Spinal Lamina[lumbar] 63047 03.09 Removal of Spinal Lamina[thoracic] 63046 03.09 Removal of Spinal Lamina[laminectomy, facetectomy and foraminotomy] 63045 03.02 Laminotomy, Additional Lumbar 63044 03.02 Laminotomy, Additional Cervical 63043 03.02 Laminotomy, Single Lumbar 63042 03.02 Laminotomy, Single Cervical 63040 80.51 Spinal Disk Surgery Add On[each additional interspace] 63035 80.51 Low Back Disk Surgery[one interspace] 63030 80.51 Neck Spine Disk Surgery[laminotomy] 63020 03.09 Removal of Spinal Lamina[lumbar] 63017 03.09 Removal of Spinal Lamina[thoracic] 63016 03.09 Removal of Spinal Lamina[laminectomy with decompression and/or exploration] 63015 03.09 Removal of Spinal Lamina[laminectomy with removal of abnormal facets] 63012 03.09 Removal of Spinal Lamina[sacral] 63011 03.09 Removal of Spinal Lamina[lumbar] 63005 03.09 Removal of Spinal Lamina[thoracic] 63003 03.09 Removal of Spinal Lamina[laminectomy with exploration] 63001
  • 80.49 Revise Spinal Cord Ligaments[mre than 2 segments] 63182 80.49 Revise Spinal Cord Ligaments[laminectomy and section of dentate ligaments, w/wo graft segment] 63180 03.09 Drainage of Spinal Cyst[to peritoneal or pleural space] 63173 03.09 Drainage of Spinal Cyst[laminectomy with drainage of intramedullary cyst to subarachnoid space] 63172 03.29 Incise Spinal Cord Tract(s) [laminectomy with myelotomy] 63170 80.99 Removal of Vertebral Body Add On[each additional segment] 63091 80.99 Removal of Vertebral Body[transperitoneal or retroperitoneal approach] 63090 80.99 Removal of Vertebral Body Add On[each additional segment] 63088 80.99 Removal of Vertebral Body[vertebral] 63087 80.99 Removal of Vertebral Body Add On[thoracic] 63086 80.99 Removal of Vertebral Body[vertebral-partial] 63085 80.99 Removal of Vertebral Body Add On[cervical] 63082 80.99 Vertebral corpectomy 63081 80.51 Spine Disk Surgery, Thorax 63078 80.51 Spine Disk Surgery, Thorax 63077 80.51 Neck Spine Disk Surgery[cervical] 63076 80.51 Neck Spine Disk Surgery[discectomy, anterior] 63075 03.09 Decompress Spinal Cord Add On[each additional segment] 63066 03.09 Decompress Spinal Cord[costovertrebral approach with decompression] 63064 03.09 Decompress Spinal Cord Add On[each additional segment] 63057 03.09 Decompress Spinal Cord[lumbar] 63056
  • 03.1 Incise Spinal Column/Nerves [laminectomy with rhizotomy, 1 or 2 segments] 63185 03.1 Incise Spinal Column/Nerves [more than 2 segments] 63190 03.29 Incise Spinal Column & Cord [laminectomy with release of tethered spinal cord, lumbar] 63200 03.29 Incise Spinal Column & Cord [thoracic] 63199 03.29 Incise Spinal Column & Cord [laminectomy with cordotomy, both tracts two stages cervical] 63198 03.29 Incise Spinal Column & Cord [thoracic] 63197 03.29 Incise Spinal Column & Cord [laminectomy with cordotomy, both tracts one stage cervical] 63196 03.29 Incise Spinal Column & Cord [thoracic] 63195 03.29 Incise Spinal Column & Cord [laminectomy with cordotomy] 63194 04.03 Incise Spinal Column/Nerves [laminectomy with section of spinal accessory nerve] 63191
  • Also Effective February 1, 2009 Record receipt timeframe change per the SC DHHS bulletin South Carolina Department of Health and Human Services will no longer grant the additional 60 days in which providers may submit medical records to Qualis Health for retrospective reviews. Once Qualis Health has issued a technical denial for records that have not been received within 30 days of the request, that decision stands as final. To be sure that Qualis Health has the correct information, please contact us at (877) 717-8592 to confirm the correct mailing address and correct hospital contact in order to ensure notifications are received and records are submitted within the 30-day time period. Qualis Health encourages all providers to submit medical records on CDs.
  • Qualis Health SC Medicaid Services Timeframes
        • Retrospective: Qualis Health’s goal is to provide a decision to the provider within 30 days from receipt of all requested information. Effective February 1, 2009, providers now have 30 days to provide the retrospective records to Qualis Health.
        • Pre-authorization: Qualis Health’s goal is to provide a decision to the provider within 15 days from receipt of all requested information.
  • SC Medicaid Preauthorization Review Process
    • Review Request Received
      • Facsimile
      • Mail
      • Telephone
      • iEXCHANGE ®
    Review completed by qualified reviewers Meets Criteria? Notification to all parties Approval # given to providers telephonically To physician reviewer with option of peer-to-peer discussion offered when not approved Notification to facility, provider and SC Medicaid via letter with reconsideration rights included Yes No
  • Qualis Health Supports the SC Medicaid Review Process
    • Through formal training sessions
    • Working consistently with SC DHHS
    • During the utilization review process
    • With outreach to local provider associations
    • Through the local Qualis Health office. You may call us anytime at (877) 717-8592.
    • As we continue to provide these QIO services, we’d like to hear from you regarding:
      • How the review process works for you
      • Any issues or concerns that may arise
      • Additional ways Qualis Health can assist you with education on UM
      • Process improvement opportunities
      • Educational opportunities
  • Contact Information (803) 739-2766 (803) 739-2767 (877) 717-8594 Fax: (803) 739-2755 (877) 717-8592 Phone: Qualis Health 440 Knox Abbott Drive, Suite 220 Cayce, SC 29033 Address:
  • Contact Information Barbara Excell, RN, MHSA, CPHQ, CPUR, PMC Director Medicaid Services Central/East, Qualis Health (803) 739-2758 [email_address] SC DHHS Hospital Services (803)-898-2665 Physician Services (803)-898-2660 http://www.dhhs.state.sc.us/dhhsnew/index.asp
  • Questions?