Provider training_2nd _Addendum 41 to DOH Claims & Adjudication Rules (1).pptx

Addendum

1. Addendum 41 to DOH Claims & Adjudication Rules Provider Workshop 01/07/2024 Daman Confidential 1

2. Addendum 41 | Overview (1/2) Effective 1st Feb 2024, Addendum 41 introduced several changes to E&M Adjudication Rules as below : <Data Classification> 01/07/2024 E&M services within 7 days free follow up E&M services are not separately reimbursable if billed for the same patient , for the same specialty at the same facility or the same facility group on the same date -or within the subsequent week- of service 1 Modifier 25 E&M services are not separately reimbursable by the Same Physician or Other Qualified Health Care Professional on the Same Day of the minor Procedure or Other Service. 2 Modifier 24 Unrelated E&M services provided for the same patient, for the same specialty, at the same facility or the same facility group occurring within day 1 to 14 follow up period 4 Modifier 52 Reduced Services : E&M visits occurring between day 8 to 14 of the initial E&M visit will be paid at 50% of the contractual price 3 Modifier 50 Bilateral Procedure : for bilateral surgical procedures to be used with procedures that occur on identical, opposing structures (e.g., eyes, shoulder joints, breasts) where 150 % adjusted reimbursement for bilateral procedures 5

3. Addendum 41 | Overview (2/2) <Data Classification> 01/07/2024 1 7 14 Free Follow Up Period Same Member - Same Specialty - Same Provider Group Free Visit 2 nd Visit _50% Payment Initial Visit 3 rd Visit _0% Payment Reduced Reimbursement Period* Day *Reduced reimbursement not applicable for different clinical condition and referral visit. Providers shall use modifier to indicate such on the claim and permit 100% reimbursement. Unrelated conditions : Provider can utilize modifier for cases with different clinical condition. Eligibility check via OpenJet continues without impacting the patient journey Claims : the reimbursement of the 2 nd visit shall be reduced at 50% and 3 rd visit at 0% (as it is the 2 nd visit within 7 days of the reduced visit).

4. Exemptions & Definitions Pediatric patients under 18 years. Senior patients above 60 years. People of Determination (POD) Visits related or following IFHAS, other preventive screenings, and vaccination services. Psychiatric conditions as performed by Psychiatrist only. Pregnancy and Maternity related conditions. Emergency visits. Same Provider Group: A Healthcare Facility Group is a group of DoH Licensed Healthcare facilities that are under the same ownership(s) or under the same direct management and oversight of a headquarters. Same Specialty : Specialty refers to the “category” column in the DOH published list of Clinician licenses at Dictionary - Shafafiya | Department of Health Abu Dhabi <Data Classification> 01/07/2024 Exemptions from the Extended follow-up (days 8 to 14) Definitions

5. Eligibility changes To support with the latest DOH updates on managing E&M follow-up visits, the use of modifiers as well as the listed exemptions Daman’s Eligibility Check via OpenJet will be enhanced to offer additional guidance on the visit type at the time of actual visit, by tagging the visits with below Visit Order Identifiers (VOI) and messages: Provider is responsible to check Patient EMR (within same Provider Group) or Malaffi for the details of previous visits and should proceed with claims billing accordingly <Data Classification> 01/07/2024 Visit Tag Visit Description within Same Provider Group + Same Specialty Expected Payment 1-14 days Cycle Free follow up A visit tagged as “free follow-up” by the provider after VOI_1 /VOI_D for the same chief complaint. 0% 1 st week  VOI_1 1 st visit occurred in the 14 days cycle for a new chief complaint. 100% NA VOI_D A visit for a different chief complaint that can occur at any day in the 14 days cycle after an initial visit (VOI_1) 100% with modifier 24 VOI_EF_1 1 st visit occurred in the  2 nd week of the cycle for the same chief complaint (Extended Follow-Up) 50% 2 nd week with modifier 52 VOI_EF_2,3… The subsequent visit(s) occurred in the 2 nd week of the cycle for the same chief complaint. 0% 2 nd week VOI_X A visit that can occur at any day in the 2 nd week of the cycle meeting the exemption criteria (other than Maternity or POD) 100% 2 nd week only VOI_XM A visit that can occur at any day in the 2 nd week of the cycle meeting the Maternity exemption criteria 100% 2 nd week only  VOI_XPOD A visit which can happen at any day in the 2 nd week of the cycle if met the POD exemption criteria (People Of Determination) 100% 2 nd week only   

6. Free Follow Up (As is) Eligibility Process| Free Follow up <Data Classification> 01/07/2024 Screen pop up_ Elective Consultation within 7 Days from Initial Visits (As is):

7. Eligibility Process | Visit tag for a visit of different chief complaint = VOI_D: <Data Classification> 01/07/2024

8. Eligibility Process| Initial Visit Tag= VOI_1 <Data Classification> 01/07/2024

9. Eligibility Process| Screen pop up_ after VOI_1 and VOI_D within 7 days <Data Classification> 01/07/2024

10. Eligibility Process| Visit tag for 1 st extended follow-up = VOI_EF_1 (8 to 14 days) <Data Classification> 01/07/2024

11. Eligibility Process| Visit tag for 2nd , 3rd … extended follow-up = VOI_EF_2 (8 to 14 days) <Data Classification> 01/07/2024

12. How to tag people of determination (POD)? Eligibility Process| People of Determination (POD) <Data Classification> 01/07/2024 If pod: yes, then permit number (id) needs to be captured (pod-id)

13. visit tag for people of determination exemption = VOI_XPOD: Eligibility Process| People of Determination (POD) <Data Classification> 01/07/2024

14. Eligibility Process| Visit tags for maternity exemption = VOI_XM: <Data Classification> 01/07/2024

15. Eligibility Process| Visit tag for other exemptions = VOI_X: <Data Classification> 01/07/2024

16. Claims payment Claims payment will follow the Modifier submission in combination with the visit tag from Eligibility Post Payment audit and recovery will be conducted to complete the claims cycle review and to account for various patterns in claims submission sequence between different facilities Modifier submission on E&M claims eligible for 100% or 50% payment within the 14 days cycle is mandatory Claims related to different chief complaint (VOI_D) within the 14 days cycle submitted without the Modifier 24 will be rejected as CLAI-016 – Incorrect Billing Regime Claims related to the 1 st visit within the 8-14 days for same chief complaint (VOI_EF_1) submitted without the Modifier 52 will be rejected as CLAI-016 – Incorrect Billing Regime Provider is responsible to check Patient EMR (within same Provider Group) or Malaffi for the details of previous visits and should proceed with claims billing accordingly <Data Classification> 01/07/2024

17. Key messages Providers are requested to ensure that patients are not being questioned on their care history within the provider group, would such information be required at the time of billing, coders can access the group EMR / HIS and obtain such. Providers should focus on educating the physicians regarding the patients right to receive communication about their care plan and the illness recovery journey, including when they should expect to start seeing progress with their symptoms, which will reduce the need of members seek care with other physicians . Providers are encouraged to support DOH endeavors to enhance the reimbursement system in Abu Dhabi and the introduction of modifiers based on market needs. The establish reduced reimbursement modifier is based on cost to the provider. Reduction is applied due to prior related work been done reducing the cost of the surgery or subsequent visit (assessment done by the 1st clinician). Modifiers used follows the international definition and use with additional alignment to Abu Dhabi unique healthcare setting. <Data Classification> 01/07/2024

18. Appendix <Data Classification> 01/07/2024

19. FAQs (1/5) Does the rule apply on the same clinician visit within 14 days? Answer: the rule applies for the same specialty at the same facility or the same facility group on the same date -or within the subsequent week- of service   Does the rule apply to the consultation done in the emergency room? Answer: Emergency consultation is excluded from the above rule and the provider must tag the service clearly in Open Jet as an emergency in this condition. Non-emergency consultations conducted in Emergency rooms need to be tagged as a new consultation.   Does the rule apply to dental consultation? Answer: No, existing adjudication rules for dental services apply on USCLS dental visit codes.   Does the rule apply to psychiatric consultation? Answer: No, Psychiatric consultation performed by Psychiatrist is excluded.   In case the member is not eligible can he still call Daman to verify and have a referral? Answer: Any clarifications requested by the member needs to address to Thiqa /Daman call center.   Does it require to collect deductible/Co-payment? Answer: Providers/members are required to adhere to the member's Schedule of Benefits (SOBs). Deductible / Co=payment applies as per SOB only to consultations that are not falling under the free-follow-up period.   what are the excluded conditions from this rule: Paediatric patients under 18 years. Senior patients above 60 years. People of Determination. Visits related or following IFHAS, other preventive screenings, and vaccination services. Psychiatric conditions as performed by Psychiatrist only. Pregnancy and Maternity related conditions. Emergency visits.   <Data Classification> 01/07/2024

20. FAQs (2/5) Are there any changes on the claims’ submission process related to those services and shall the provider add the eligibility IDs to the submission schema? Answer: The provider must submit modifier 52 when he submits the claim to get 50% of the contractual price for 2 nd consultation falls in day 8 to 14 days from the initial consultation.   What would happen if the member visited the same specialty within 14 days for different chief complaint? Answer : Modifier 24 may be used for 100% reimbursement of unrelated E&M visits or referral provided for the same patient, for the same specialty, at the same facility or the same facility group occurring within day 1 to 14 follow up period.   Is there any change in the 7 days free follow up period? Answer: The free follow up visit within 7 days will continue to apply, however in accordance with DOH claims adjudication rules addenda 41, it will be extended to visits at the same specialty within the same provider group.   Do the providers allowed to collect the 50% deducted from the second consultation within the 14 days from the members? Answer: Members must not be financially burdened with the implementation of this addendum release. Will the Basic Plan be affected by the changes? Answer: Yes, the changes defined in Addendum 41 to DOH Claims & Adjudication Rules shall apply across all portfolios including Thiqa , Enhanced, Basic and ABMs.   What is the definition of “Same Provider Group” Answer: A Healthcare Facility Group is a group of DoH Licensed Healthcare facilities that are under the same ownership(s) or under the same direct management and oversight of a headquarters.   What is the definition of “Same Specialty” Answer: Specialty refers to the “category” column in the DOH published list of Clinician licenses at Dictionary - Shafafiya | Department of Health Abu Dhabi   <Data Classification> 01/07/2024

21. FAQs (3/5) Under which category Modifier 52 should be applied? Is it for E&M visits or for both E&M code and Service & Procedure CPT codes? Answer: Modifier 52 is intended to be used in Abu Dhabi when billing the E&M CPT codes for the follow up visit occurring between days 8 to 14 (from the initial E&M visit). Is Modifier 24 applicable to E&M visit in the postoperative period only? Answer: Modifier 24 is intended to be used in Abu Dhabi within day 1 to 14 follow up period for subsequent E&M visit that cannot be reasonably related or detected as part of the initial E&M visit, documentation of evidence and justification should be provided to avail 100% reimbursement – please refer to the rules mentioned in Addendum 41. When using Modifier 24, what are the evidence and justification required to be submitted during Claims submission? Answer: Reported conditions and management should not be related to the condition of the previous visit. For referrals, the referral letter should be attached. Is it advisable to add the “Chief Complaints” in the first paragraph as an additional criterion since the physician needs to assess and manage the new or distinct medical condition separately? Answer : Please refer to section 5.4.3 Modifier of addendum 41, bullet number 2. Can we apply the criteria for free visit within the same facility only and not on the same Group level? Answer: The rule of “for the same patient, for the same specialty at the same facility or the same facility group” will be applied. Does the first E&M follow up visit between 8-14 days will be paid as 50% for any related complaints only, or any distinct problem as well? Answer: Kindly refer to both 5.4.2 Modifier (52) & 5.4.3 Modifier (24) for clarity on same or related problem. What is the definition of “reasonably related or detected conditions”? Answer: Please use the same criteria currently applied to identify 7-day follow up visit.   <Data Classification> 01/07/2024

22. FAQs (4/5) Please advise on the definition related to subspecialist consultant, since the clinician license list in ShafAfiya has no separate column for subspecialty. Answer: Provider should use the DOH clinician category, and for clinicians with privileging, updating the clinicians list is under discussion within DOH. In case the patient visits a clinician of different specialty, but with privileges for the specialty of initial E&M visit, this shall be adjudicated as a subsequent E&M visit to a physician of same specialty.   Does the modifier 50 applicable for the services performed in different anatomic sites but billed with same CPT Codes? Does it require separate contract with Daman to bill these services? Answer: Modifier 50 should be billed with the same CPT code for bilateral procedure and separate contracting is not required. Please refer to 5.4.4 Modifier (50), referencing the eligibility of modifier 50 CPTs .   It is difficult to determine if the visit is a related or unrelated condition on registration level, can Daman not use this tag and rather based on the modifier reported on the claim and the type of eligibility taken during Claims processing? Answer: Please apply the same criteria currently used to identify 7-day follow up visit (no change). Daman will use the information available at eligibility as well as that submitted at Claims for final determination.   Can we have more time to implement those changes and to train the concerned staff on how to implement the modifiers? Answer: Providers is expected all health entities to comply on the implementation date of 1st February 2024.   How will the payers identify the claims exempted from the rules of the implementation of the modifiers (e.g. people of determination)? Answer: Daman will depend on the information provided by provider at eligibility.   Is there any change in the follow-up billing logic of Emergency encounters? Answer: The free follow up visit within 7 days will continue the same in accordance with DOH claims adjudication rules.   <Data Classification> 01/07/2024

23. FAQs (4/5) How to bill for a follow up visit happened on 8 to 14 days but for a different primary diagnosis from the first visit? Answer: Modifier 24 states that the subsequent E&M visit that cannot be reasonably related or detected as part of the initial E&M visit, documentation of evidence and justification should be provided to avail reimbursement.   For Basic Plan, there is no modifier on the basic plan price. Answer: Kindly refer to addendum 41 and modifier 52 for details on the applicability of the rule and excluded groups and conditions.   Is the 1st of February 2024 effective date also applicable to the follow up visit where the initial visit happened prior to the said date? Answer: The system will check up to 14 days prior to the date of the current visit.   Where in Open Jet can the visit tag be selected? Answer: Visit tag will be auto populated in Open Jet based on the patient previous history. Refer to the user guide.   If the visit falls under 50% reimbursement, what is the co-pay or deductible to be collected, 100% or 50%? Answer: Full co-pay or deductible as reflected in the SOB should be applied.   Kindly explain is this modifier applicable to Ophthalmic special codes (92002-92014)? Answer: Yes, it is applicable. Is it applicable to Physiotherapy (OP)? Answer: No, it is not applicable. <Data Classification> 01/07/2024

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