Michelle Carello, ASTAT Medical Billing
Cindy Cote, RN, Medical Review Nurse( BCBSRI)
Carol DeMelo, Professional Relations Representative (BCBSRI)
Ron Fedele, Certified Ambulance Group
Linda Geoghegan, R.N., Compliance, University Medicine Foundation
Deann Monti, ASTAT Medical Billing
Elaine Narducci, University Med. Foundation
Michele Paolino, University Medicine Foundation
Julie Sylvestre, Comprehensive Practice Management
Andrea Zito, RN, Medical Review Nurse (BCBSRI)

Merle Francis, Professional Services, Arkansas BCBS
Bobbie Yotter, Medical Review, Arkansas BCBS

1. Introductions:

   Carol introduced a new member to the group, Ron Fedele of Certified Ambulance Group and two guests, Merle Francis and Bobbie Yotter from Arkansas Blue Cross and Blue Shield.
    

2. Review of 8/7/03 Meeting minutes and old business

   The explanation of Remark Codes for Crossovers were posted on the Website and in our Winter Newsletter scheduled to be released in December.

   Carol asked the group if they had a chance to review and make comments on existing reason and remarks codes on the provider remittance advice. No one had any comments.

   Michelle from A Stat Billing reported that the ambulance milege code A0425 continued to be denied on a covered trip. Michele also said that when she contacted the Customer Service reps they were told these claims had to be appealed.

   Carol explained that this was contrary to what she had discussed with the Customer Service Coordinator, who stated they were aware of the problem and would adjust on a phone call until the issue was corrected.

   Carol stated she will readdress this issue with the claims manager.
    

3. Workload Transition/Merle Francis, Professional Services

   Merle Francis, Manager of Professional Services at Arkansas BCBS, gave the group a background of Arkansas Blue Cross Blue Shield which currently processes Part B claims for 5 states and Part A claims for the state of Arkansas.

   Merle informed the group that there will continue to be an office in RI, and Arkansas has offered jobs to many of the existing RI Medicare staff..

   It was noted that some functions such as provider enrollment would be handled in Arkansas.

   Merle informed the group that Arkansas BCBS, RI BCBS, and CMS are actively involved in the transition process.

   Merle informed the group that electronic funds transfer would be available to RI providers sometime in March .

   Merle discussed the upcoming EDI and Transition Workload Workshops, scheduled in December and January, for Part A & B providers, that will address any changes that will take place as of 2/1/04. She also informed the group about the Arkansas Medicare web-site, http://www.arkmedicare.com, and web-based training that is available via the web site.

   Providers should be receiving monthly newsletters with updates.
    

4. Transition Workload/Bobbie Yotter, Manager of Post-Pay Medical Review and Data Analysis for Arkansas BCBS.

   Bobbie discussed her role as manager for Arkansas post-pay medical review and data analysis. She elaborated that the results of data analysis aid in the determination of the areas that require provider education. The data analysis team in Arkansas includes statisticians and nurses that do the actual data analysis. Arkansas BCBS will be taking over the RI Data Analysis functions. The results of the data analysis will be communicated to the RI Medical Review Unit and Professional Relations Representatives. Post- Pay Medical Review will also be performed in Arkansas. If the results of data analysis is performed in Arkansas for RI warrants, a post-pay medical review, this task will be performed in Arkansas. If education is needed, RI will be responsible for educating the provider community.

   Bobbie also stated that current RI LMRPs will remain in effect in their present format for at least 6 months. Any new LMRPs will go through the normal procedures and be presented to the CAC (Carrier Advisory Committee).
    

5. Out-Patient Rehabilitation Advisory

   Cindy presented the Out-Patient Rehabilitation Advisory that she had written and had put on the RI Medicare web-site. She stated that recent medical review of out-patient rehabilitation medical records have resulted in claim denials due to incomplete documentation, unclear documentation in the medical records, improper use of CPT codes, or medical necessity issues. She elaborated on this by stating that the documentation must support the type of therapy (CPT code) and the number of units billed. Documentation is considered incomplete, in many instances, because the treatment time is not recorded. Treatment time for time based therapy codes must be recorded in minutes by the therapist.

   The Advisory also includes CMS guidelines related to obtaining certifications and recertifications for out-patient rehabilitation services. The physician must certify at least every 30 days, that they have reviewed the plan and that there is a continuing need for rehabilitation services. Another issue included in the Advisory is instances of improper coding with 97110.

   One of the members of the PCOM stated that someone had informed her that the therapy caps for had been removed. Cindy and other members of the PCOM stated they had not heard of or read anything regarding this at this point in time. (However, according to change request 3005 dated December 8, 2003, this CR removes therapy caps on December 8, 2003 and extends the moratorium through CY 2005.)
    

6. Open Discussion
    
7. Next Scheduled meeting
   Wednesday February 11, 2004
   RI Medical Society