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Message for Remittance Advices Dated May 15th, 2014


TO: Family Practice, OB/GYN, Nurse Practitioner, FQHC Providers            
RE: New CPT Code for BreastCare

CPT Code 81025 (Urine Pregnancy Test) is payable with an effective date of 01/01/13.  This procedure is only payable if billed in conjunction with one of the following biopsy codes (57420, 57421, 57452, 57454, 57455, 57460, 57461, 57500, 57505, 57520 or 57522) for the same date of service and for the same performing provider.  It is not payable when billed alone.

Changes Made to BreastCare Online System

You may have noticed some recent changes as you have enrolled or reassessed patients in the BreastCare Online System. Several changes have been made to improve data quality and address issues users have experienced. These changes include:

  • Existing patients can only be assessed for eligibility in the month their current plan/card expires.
  • Assess BC Eligibility button is only visible for open plans in the month the plan is set to end
  • Adding a Plan History link on the patient management page to track changed made to the plan
  • Adding an Appointment History link on the patient management page to track appointment status changes
  • Moving the referral source question from the cycle page to Patient Management page to be collected at initial enrollments and reenrollments
  • Moving the emergency contact name and number to the Patient Management page
  • Automatically updating the appointment status to kept if the same date is entered as the performed date on CBE
  • Adding a Plan “I” to represent patients with open or closed plans who are determined to be ineligible when assessed (This is not an actual plan but rather a way to count ineligible patients.)
  • Users can print an ineligible letter
  • Adding current provider to Patient Medical History page
  • When adding a procedure to a cycle, a result is required if a performed date is entered.
  • A special needs question has been added to the Patient Management page. This is a required question that is asked when:
    • a new patient is enrolled
    • an existing patient is reassessed
    • the Update Other information button is selected and the answer is blank

      After the question is answered, you do not have to answer it again unless you need to change the answer.
  • The BreastCare card/letter has been updated to include funding information on the various plans. The card/letter also now opens in a new window allowing all providers to print it directly from the system

As other changes are made, we will continue to provide updates to keep you informed.

Taxonomy Code

BreastCare Providers have had several claims denied due to taxonomy code. For more information on how and when to use the taxonomy code click here or visit the Frequently Asked Questions.

Help your Patient Understand

June 10, 2013 - Health literacy toolkits created by the American Medical Association (AMA) Foundation are available to BreastCare Providers at no cost. The health literacy kit includes an instructional video on DVD and CD-ROM, an in-depth manual for clinicians, and additional resources for education and involvement. Email Lisa.Buckner@arkansas.gov to request your copy. Limited availability.

Provider Remittance Advice (RA) via WebRA

Arkansas BreastCare no longer prints and mails paper Remittance Advice (RAs). RAs are now provided in a PDF format, which can be viewed and downloaded from a secure website. The new RA, referred to as a WebRA, looks exactly like the paper RA, while offering the advantage of electronic search functionality.

Providers must register to have access to their WebRAs. WebRA link is available in the left-hand menu after logging in to the Arkansas Medicaid provider portal. Follow the instructions to register each of your provider’s BreastCare and National Provider Identification numbers. Providers will not have access to their WebRAs until registration is complete.

The WebRA is available for download on the Monday prior to the check being mailed. This is a week earlier than the paper RA. With WebRA, providers may share access to their RAs with other parties, which include other providers such as their affiliated group(s) or non-providers like their corporate office or accountant. Providers control security access to their information via two administrative screens that manage invitations and document access.

WebRAs will be maintained for 35 days to provide a rolling five weeks of PDF RAs online. Providers are encouraged to download and save an electronic copy to their hard drive. After the 35 days, PDF RAs will no longer be available. If you require a copy of an RA that is no longer available in PDF, call the Provider Assistance Center to obtain a paper copy. Standard fees of $.25 per page apply. Providers who currently receive an 835 Electronic Remittance Advice will continue to do so.

Providers who have extenuating circumstances, such as limited or no internet access, may opt out of WebRA by completing a Hardship Waiver application and returning it ADH BreastCare .

If you have questions regarding this notice, please contact the HP Enterprise Services Billing Call Center at -855-661-7830, or locally and Out-of-State at (501) 372-0225.

Clarification on Exam Type

Be sure and use the correct exam type in the On-Line system.

BreastCare On-line System Exam Type selection Office Visit
Procedure Code for claims
Explanation
Initial Exam 99203 Use this for BreastCare Patient first office visits
Annual Exam
99213 Use this for patient annual office visits
Follow Up Exam 99212 Use this for office visit when patient returns for repeat PAP or CBE follow up

Plan D Slots

Attention Providers, you may have noticed a Plan D has been added on your Patient Information page in the BreastCare Online System. This plan creates additional slots to serve women 50-64. No action is needed on your part, the system will assign patients to the correct funding plans. If you have questions or need assistance, please contact BreastCare at 661-2942. Thank you for enrolling and providing BreastCare services for the underserved women of Arkansas.

Claim Denial for Missing Data

Effective September 24, 2012, all PCP claims submitted for a BreastCare patient office visit will be denied unless the patient visit and procedure results (CBE, Pap test, if applicable and/or mammogram) have been entered into the ADH BreastCare system. The denial reason will be “CLAIM DATA MUST MATCH OFFICE VISIT PROCEDURE RESULTS IN ADH SYSTEM: CLIENT ID, PERFORMING PROVIDER NPI AND TAXONOMY, PROCEDURE CODE, AND DATE OF SERVICE”. If your claim is denied, enter the patient visit, procedures and all results into the BreastCare on-line system and then re-file the claim. Please refer to Attachment A of Public Health Agreement, Section V, Page 3,  for further clarification if needed or call 1.855.661.7830.

Plan KA Slots

BreastCare Primary Care Providers, you may see that a new Plan type is shown on the BreastCare Patient Information page. This new KA Plan Type helps us target specific counties in the state for screening women age 40-49 years. The Arkansas Affiliate of the Komen Race for the Cure is funding these screening slots in 63 counties. You may or may not see this Plan Type, depending on your county location. Either way, there is nothing different that you need to do-just continue enrolling BreastCare clients as you have been doing. The system will add the women to the appropriate Plan Type. If you have questions or need assistance, please contact BreastCare at 661-2942. Thank you for enrolling and providing BreastCare services for the underserved women of Arkansas.

CPT Codes

Effective July 9, 2012, BreastCare will cover the following procedure codes: 99204, 99205, 99214, and 99215. These codes will become payable with a date of service starting July 9, 2011.

99204 and 99205, new patient office visit, reimbursable at $96.46 for the professional component and $70.43 for the facility charge.

99214 and 99215, established patient office visit reimbursable at $65.06 for the professional component and $46.87 for the facility charge.

Keep in mind if you choose to provide services at these levels and accept the reimbursement rate above, no other charge may be made against the client for these services per Section IX D, BreastCare Contract.

Effective March 5, 2012, BreastCare will cover CPT Codes:

  • CPT 38500 (biospy or excision of lymph node(s), open, superficial) reimbursed at:
    • $292.95 for the professional component and
    • $919.40 for outpatient surgery.
  • CPT 38525 (biopsy or Excision of lymph node(s), open, deep axillary nodes) reimbursed at:
    • $386.06 for the professional component and
    • $919.40 for outpatient surgery
    • Codes are limited to 2 per DOS, 4 per year.
  • CPT 01610 (anesthesia for excision of lymph nodes(s)) reimbursed at:
    • $441.61 for the professional component, limited to 2 per year. Payment is limited to certain diagnosis codes.

BreastCare Order for Mammograms and Ultrasounds

Effective August 2011, mammogram facilities will be receiving an order for mammograms and ultrasounds signed by the ordering clinician, an APN or physician, with their NPI number listed. Medicare payment policy no longer permits the use of rubber stamps. Therefore; Arkansas BreastCare is discontinuing the use of rubber signature stamps.

Patient Search Problem Has Been Fixed.

Please be aware of new information recently provided to BreastCare providers regarding testing, covered procedures and codes.

Downloads
Frequently Asked Questions

Online BreastCare Enrollment and Reporting

A new online data entry system will go live July 1, 2011, for Community Health Centers, AHECS, and Primary Care Providers. Client enrollment will be decentralized to increase access to enrollment by allowing women to assess eligibility or by contacting a local participating BreastCare Primary Care Provider (PCP). Eligible women will make an appointment with a local provider for a clinical breast exam and Pap test if needed. When the patient is seen, the PCP will enroll her and enter her screening information and mammogram appointment electronically into the BreastCare database via the internet. All test results and recommendations must be entered electronically before claims are submitted. All claims for office visits will be rejected if CBE, Pap test and mammogram results are not in the system when the claim is received. Confidential reports will be made available to each participating provider to help improve their tracking system. The new system will increase the program’s ability to screen more women and provide additional clinical services while improving client and provider satisfaction.

Provider Contract Online

The Public Health Service Agreement for FY 11 will be completed electronically via the internet at https://health.arkansas.gov/breastcareonline. The agreement must be printed, signed, and mailed to Arkansas Department of Health, Shiela Couch, 4815 W. Markham, Slot 11, Little Rock, AR 72205. New agreements or renewal must be completed and submitted to the Arkansas Department of Health by July 1, 2011 for BreastCare services to be reimbursable.

Treatment Benefit Limits

Effective July 1, 2011, the procedure for referring patients diagnosed with breast or cervical cancer, CIN II, or CIN III for treatment is changing. The physician’s office must call the BreastCare program at 501-661-2513 to refer the patients and verify their diagnosis. The patient will then be contacted by the BreastCare Case Manager to complete the Medicaid application. Women cannot be enrolled for Medicaid until the physician has called.

Treatment covered by BreastCare is limited to patients who are eligible for Breast and Cervical Cancer Medicaid category 07. State funds do not cover treatment services for breast or cervical cancer or precancerous cervical conditions. All claims for a BreastCare enrollee diagnosed with breast or cervical cancer and who is also a Medicaid recipient are billed to Medicaid and covered according to Medicaid’s guidelines. BreastCare does not pay claims for treatment.

Eligibility Criteria Changed

Women with comprehensive health insurance which covers inpatient, outpatient, and physician services can no longer receive BreastCare services even if they have a high deductible and/or co-payment.. Plan A and Plan C remain for women who are uninsured or have non-comprehensive insurance such as a cancer policy or hospitalization only policy. 

Effective March 5, 2012, BreastCare will cover CPT Codes:

  • CPT 38500 (biospy or excision of lymph node(s), open, superficial) reimbursed at:
    • $292.95 for the professional component and
    • $919.40 for outpatient surgery.
  • CPT 38525 (biopsy or Excision of lymph node(s), open, deep axillary nodes) reimbursed at:
    • $386.06 for the professional component and
    • $919.40 for outpatient surgery
    • Codes are limited to 2 per DOS, 4 per year.
  • CPT 01610 (anesthesia for excision of lymph nodes(s)) reimbursed at:
    • $441.61 for the professional component, limited to 2 per year. Payment is limited to certain diagnosis codes.

Effective January 1, 2012, Arkansas BreastCare will convert to HIPAA X12 version 5010 for electronic transactions including eligibility (270/271), claims (837P) and claims status (276/277).

Effective December 5, 2009, BreastCare coverage for women will no longer be retroactive 30 days preceding the enrollment date. Thus, we ask providers to be sure you see the patient’s current enrollment card or that you call the enrollment center at 1-877-670-2273 to be sure the patient is enrolled before providing any service. Any service provided prior to the patient’s enrollment date will not be covered including, but not limited to, mammograms and office visits.

Surgical Follow-Up

BreastCare patients may receive follow-up after a mammographic abnormality or benign biopsy for one year. After one year patients go back into annual screening with their Primary Care Providers (PCP). The cycle starts over with another mammogram. Any time that the mammogram is abnormal the patient may receive a biopsy or be referred back to the surgeon if appropriate. An annual visit to the PCP is important. In addition to breast screening, patients receive a Pap test every two (2) years per BreastCare policy.

Category 0 – Need additional imaging evaluation and/or prior mammograms for comparison

BreastCare is now required by CDC to track mammograms with Category 0 that need additional imaging separately from mammograms with Category 0 that require prior films for comparison. BreastCare is responsible for reporting if the comparison with prior films was made and the final imaging outcome. Please help by clearly indicating on the mammogram report if prior films have been requested for comparison.

Physician Orders for Diagnostic Mammograms

BreastCare clients are required to have Physician Orders for diagnostic mammograms. When a client arrives at the mammography facility for her appointment without a Physician Order, the facility will call the provider to request an order. Please fax the order ASAP. The patient will be waiting and may not understand why she has to wait so long or even why her mammogram cannot be performed at all. Please remember to fax the order when a mammogram is scheduled. This will save time and prevent conflict between the provider and the patient.

Revised BreastCare Physician Order

Both ultrasound and diagnostic mammogram are required and should be ordered when a patient is referred for a palpable mass. The BreastCare Physician Order has been revised to include orders for breast ultrasound and diagnostic mammogram in the presence of a palpable mass. These procedures should be done on the same day for the convenience of the patients and to decrease delay in diagnosis. If the ultrasound is not performed when ordered, the patient will be sent back to the facility for the procedure. You may call (501) 661-2636 to obtain a copy of the BreastCare Physician Order.

Effective July 1, 2009, digital mammograms are reimbursed by BreastCare. Please indicate on the mammogram report what type of mammogram is performed.

Effective January 1, 2009, BreastCare will now cover CPT codes 19110 (nipple excision) and 76998 (ultrasound guided localization, intraoperative guidance).

Effective January 1, 2009, BreastCare will now cover CPT code 57420 (colposcopy for entire vagina and cervix, if present). A result and recommendation code is required and payment is limited to certain diagnosis. Please see billing manual for billing criteria.

Effective January 1, 2009, BreastCare will now cover CPT codes 19110 (nipple excision) and 76998 (ultrasound guided localization, intraoperative guidance).

Effective January 1, 2009, BreastCare will now cover CPT code 57420 (colposcopy for entire vagina and cervix, if present). A result and recommendation code is required and payment is limited to certain diagnosis. Please see billing manual for billing criteria.

How are we doing? BreastCare Establishes Quality Indicators BreastCare has established new quality of care indicators for breast and cervical cancer screening. The 41 new breast cancer indicators and 29 new cervical cancer indicators were established after members of a workgroup spent more than a year defining indicators and establishing goals for indicator achievement.

  • Breast Cancer Indicators
  • Cervical Cancer Indicators

Effective June 30, 2008, reimbursement rates for office visits have decreased per the CDC policy dated December 11, 2007. This is for plans B and C only. The procedure codes effected are 99204, 92205, 99214 and 99215.

Effective May 19, 2008, BreastCare will only accept the NPI on claims and eligibility requests. All claims will require an NPI including those submitted on the Internet, Provider Electronic Solutions software and paper. BreastCare Provider Numbers will no longer be accepted on claims. Billing providers, performing providers and referring providers will need to be identified on a claim using NPIs. Any claims received with a BreastCare Provider Number after this date will not be paid.

We encourage you to begin using your NPI immediately for billing. If you need assistance using your NPI for billing, please call the EDS BreastCare Call Center (1-877-670-2273 or local 501-372-0225).

If you need to link an NPI to your BreastCare Provider Number, we encourage you to use our Web-based application. Go to Medicaid and select the Provider section. Enter your BreastCare Provider Number and password to access the NPI reporting tool. You may also need your taxonomy code (if applicable) to link your NPI. If you need assistance linking your NPI or using the Web site, call the EDS BreastCare Call Center at 1-877-670-2273 or local 501-372-0225.

Effective April 14, 2008, laboratory providers (provider types 22 and 69) will be required to submit the referring provider information on all claims starting on this date. If the referring provider information is not completed, you will receive a rejection up front stating: 2330, a referring provider number missing or not on file. This will be used for quality assurance purposes. When Pap tests are done on women who have had hysterectomies for benign conditions, medical necessity will be investigated.

Effective January 1, 2008, BreastCare will now cover CPT Code 57510: cauterization of the cervix, for those patients requiring treatment and do not qualify for BreastCare medicaid.

Effective January 1, 2008, BreastCare will now cover CPT Code 57105: vaginal biopsy and Code 88321: slide consult for all plans. Reimbursement for 57105 is limited to certain diagnosis codes.

Provider Reporting Form for Primary Care Providers

A new form has been developed for primary care providers to report the CBE result, Pap information and mammogram appointments for BreastCare clients. This form must be completed and faxed to 501-661-2264 within five days after a BreastCare visit. BreastCare must have this information to budget appropriately, to refill slots for missed appointments and to be able to assist women when they call for help. Please begin using the enclosed form immediately (See Provider Reporting Form under “Forms”). This form replaces the BCCCP-2 form used by AHECs and CHCs. All primary care providers are to use this form now.

Mammography Facilities Will See Change – Ultrasound Required for Palpable Mass

Providers will be scheduling breast ultrasounds when a palpable mass is found on clinical breast exam. A diagnostic mammogram and breast ultrasound should be done on the same day for the patient’s convenience and to ensure adequate follow-up. Per BreastCare policy, if a simple cyst or benign abnormality is revealed on ultrasound, a surgical consult is not required.

Screening Mammogram Results

Probably Benign BIRADS 3 requires a full imaging work-up. This result should not be reported for a screening mammogram unless additional diagnostic procedures have been performed.

CBE Not Required within 60 days of Mammogram

Patients will receive an annual clinical breast exam, but an exam is no longer required to be within 60 days before the mammogram.
Scheduling Mammograms

Mammograms may be scheduled in the same month as performed in the previous year. It is no longer required to be 365 days from the date of the last mammogram.

Timeline for Receiving Pap Results

Results should be received within 21 calendar days from date of Pap. The cytology lab should report results to the Provider within 3 calendar days after receiving the Pap specimen. Utilization of a Pap Log is necessary to track receipt of Pap test results.

Referrals to Regional Care Coordinators

A Pap test result of Atypical Squamous Cells of Undetermined Significance (ASC-US) now requires that an HPV High Risk DNA test be performed. If the HPV test is positive, colposcopy is required. If the HPV test is negative, a follow-up Pap test is required within six to 12 months. All Pap or HPV tests requiring colposcopy should be referred to the Regional Care Coordinator to assure timely follow-up.

Liquid-Based Pap Test (LBT) versus Conventional Pap Smears

Liquid-based Pap tests are now available to BreastCare clients. LBT are reimbursable according to professional standards every two years. BreastCare clients should receive LBT which is the standard of care over conventional Pap tests. Conventional Pap smears should not be substituted just so a Pap can be performed every year. The patient will be seen by the primary care provider yearly for a CBE regardless of eligibility for Pap.

Surgical Consult Requirements

Mammography films must be taken to all surgical appointments. When surgical consultations are scheduled, patients should be instructed to take films to the appointment. The surgeon must be able to review the films to make an adequate evaluation.

Providers Change of Status

Providers sometimes move, retire or just choose to stop participating in BreastCare. Any changes in your address, phone number, bank account or tax ID should be reported in writing to Shiela Couch by faxing the information to 501-661-2009 or mailing it to 4815 W. Markham, Slot 11, Little Rock, AR 72205. Your provider file will be updated. Call 501-661-2836 with questions.

Endocervical Cells

Absence of endocervical cells is normal in a post-menopausal woman. A Pap test should not be repeated in this situation.

Quality Assurance Reviews for Community Health Centers

Quality Assurance Audits will be conducted on-site at Community Health Centers across the state beginning in Fiscal Year 09. An audit tool has been developed and will be used by the BreastCare Quality Assurance Specialist. More details will be provided as this process is developed.

BreastCare Patients Should Not Receive Bills for Mammograms!

All annual exams for CBE, Pap and mammograms must be scheduled by the BreastCare Phone Center. Primary Care Providers must make sure that a woman is currently enrolled in BreastCare before providing these services for a BreastCare client.

Mammography facilities must make sure she is currently enrolled before performing a mammogram. Check her BreastCare Identification Card to make sure that her eligibility date is current. If she cannot present her card, call 1-877-670-2273 to verify her eligibility. Reimbursement for the office visit and mammogram will be denied if the woman is not currently enrolled in the BreastCare program. Please help prevent this from happening.

Shortage of Primary Care Providers in Northwest Arkansas and Garland County

Based on the number of women needing BreastCare exams, the program needs more providers in certain counties in Northwest Arkansas and Garland County. Currently there are three providers in Springdale, one in Fayetteville and one in Bentonville. This makes it difficult to schedule patients for CBEs and Paps in a timely manner. It may be three to four weeks before a woman can receive an appointment. In addition, obtaining appointments for symptomatic women has become a problem. There is also a shortage of colposcopy providers in Southeast Arkansas.

If you know of any providers in these counties that would be willing to participate in the BreastCare program, please contact Becky Kossover, Contract and Accounts Manager, 501–280-4097.

Pap Requisition When the Pap Specimen is Mailed

The BreastCare ID number must be entered on the Cytology Requisition. The cytology lab cannot bill without the patient’s ID number. If a patient enrolls in BreastCare after she has seen the Provider and received a Pap test, the lab still must have the BreastCare ID number. The best thing to do is allow the patient to use a clinic phone to enroll before she leaves and obtain her BreastCare ID number so it can be entered on the Cytology Requisition and mailed with the Pap specimen.

What Providers Should Know …. About Breast and Cervical Cancer Medicaid

Breast and Cervical Cancer patients and patients with precancerous cervical conditions (CIN II, III, CIS) are enrolled in Breast and Cervical Cancer Medicaid (Plan description “07”) for treatment. BreastCare is not their insurance for treatment, but is being overwhelmed with questions about Medicaid. At the time of enrollment in Medicaid, patients receive extensive counseling regarding Medicaid coverage, a detailed Medicaid brochure, a fact sheet about Medicaid coverage with resource information and contact phone numbers. Please refer these patients to those documents given to them or to Medicaid client assistance at 1-800-482-5431. The following issues cause patients to receive bills:

  • The cancer diagnosis was not entered as the primary diagnosis on the claim. Medicaid category 07 will not pay for diagnosis of “history of malignancy”.
  • The patient has not understood she must have a Medicaid PCP. She considers either her family physician or the specialist she has seen as her PCP. These physicians are not always Medicaid PCPs.
  • The patient has no benefit limit (with the exception of consults) when the services pertain to treatment for cancer and a cancer diagnosis code is entered on claim.