Medicaid ICD-10 Implementation Project September 2013 Update

Please share this information with Clinical, Coding, Billing, and IT Staff

The United States Department of Health and Human Services requires that all HIPAA covered entities use the International Classification of Diseases, 10th Revision (ICD-10) codes beginning October 1, 2014. This bulletin provides information regarding the Nebraska Medicaid ICD-10 Implementation Project.

ICD-10 Readiness

One of the frequently heard comments from Medicaid providers when asked if they will be ready to implement ICD-10 on October 1, 2014, is “depends on our software upgrade” or “waiting for our clearinghouse to tell us.” While the software upgrades and clearinghouse readiness are extremely important to the successful submission of ICD-10 codes, clinical documentation and diagnosis coding are just as critical.

Each provider is responsible for the needed changes to their clinical documentation and diagnosis coding. Additionally, reimbursements will be impacted if ICD-10 is not implemented timely and accurately by providers.

According to the CMS website at CMS ICD-10 Planning Check List, critical steps for providers to follow are:

Assess staff training needs. Identify the staff in your office who code, or have a need to know the new codes. There are a wide variety of training opportunities and materials available through professional associations, online courses, webinars, and onsite training. Coding professionals recommend that training take place approximately six months prior to the ICD-10 compliance deadline.

Identify potential changes to work flow and business processes.

Consider changes to existing processes including clinical documentation, encounter forms, and quality and public health reporting.

Identify your current systems and work processes that use ICD-9 codes.

This could include your clinical documentation, encounter forms/superbills, practice management system, electronic health record system, contracts, and public health and quality reporting protocols. It is likely that wherever ICD-9 codes now appear, ICD-10 codes will take their place.  Please review the remaining planning steps, which include:

Talk with your practice management system vendor about accommodations for ICD-10 codes. 

Discuss implementation plans with all your clearinghouses, billing services, and payers to ensure a smooth transition.

Talk with your payers about how ICD-10 implementation might affect your contracts.

Budget for time and costs related to ICD-10 implementation, including expenses for system changes, resource materials, training, and potential slowdown of reimbursement if claims cannot be submitted or processed timely.

Conduct test transactions using ICD-10 codes with your payers and clearinghouses. To assist providers in a successful transition to ICD-10 by October 1, 2014, Nebraska Medicaid will continue to publish monthly Provider Bulletins with helpful information and links to resources.


Check out the Nebraska Health Information Management Association website at: for some training opportunities in Nebraska.

The Nebraska Medicaid ICD-10 Project website also has a number of Frequently Asked Questions at .

The Centers for Medicare & Medicaid Services (CMS) has resources to help prepare for a smooth transition. Visit to find out more.


Please submit questions about this bulletin or about ICD-10 to


Consumer Protection from Fraud in the Health Insurance Marketplace

Steps have been initiated to prevent and respond to individuals attempting to take advantage of the public during health care implementation.  These measures include:

  • Reporting fraud mechanism: A new feature of the Marketplace Call Center (1-800-318-2596, TTY 1-855-889-4325) will now enable individuals to report fraud simply by calling the 1800 number. Call Center operators have been trained to take a fraud complaint, and refer them to FTC’s Consumer Sentinel Network.
  • Creating new pathways: offers easy access to connect consumers to FTC’s Complaint Assistant.
  • Establishing a routing system for complaints through a centralized database: Routing complaints through FTC’s Consumer Sentinel Network will ensure federal, state and local law enforcement have access to consumer complaints and can analyze and refer those complaints as appropriate.
  • Protecting personal data: Building on the certification of the Health Insurance Marketplace’s data hub on Sept. 6, 2013 as in compliance with the stringent security, privacy and data flow standards developed by the National Institute of Standards and Technology – the gold standard for information and independent security controls assessment – the interagency officials have also established a rapid response mechanism that will be employed in the unlikely event of a data security breach.
  • Empowering consumers with information: Building on a proactive effort to inform consumers about potential fraud and privacy threats, the federal government is releasing new educational materials to empower consumers and assisters who are helping consumers navigate the Marketplaces.  They include online tip sheets like Protect Yourself from Fraud in the Health Insurance Marketplace and Tips for Assisters to Help Consumers Navigate the Marketplace. The materials remind consumers that there is assistance, at no cost to them, available to navigate the Marketplace and that they should be suspicious of persons who ask for a fee before providing assistance.  The tip sheets are included under Fraud Protection Fact Sheets on the Outreach & Enrollment webpage of the HCAN website.

Collection of media coverage from the statewide press conferences on Health Insurance Marketplace Open Enrollment

CMS Proposes a Medicare PPS for FQHCs

CMS Proposes a Medicare Prospective Payment System for Federally Qualified Health Centers

Health Centers will Transition to a New Medicare Payment System and Higher Medicare Reimbursements

Later today, the Centers for Medicare & Medicaid Services (CMS) will issue a proposed rule to establish a Medicare prospective payment system (PPS) for Federally Qualified Health Centers (FQHCs), as outlined in the Affordable Care Act.  The proposed, updated payment system, which is scheduled to begin October 1, 2014, would increase Medicare payments to these health centers by approximately 30 percent for services furnished to Medicare beneficiaries in medically underserved areas.

Federally Qualified Health Centers, which are generally required to treat all patients regardless of their ability to pay, provide vital primary and preventive care services to more than 21 million people nationwide. Medicare currently pays them based on reasonable costs and subject to established payment limits for covered services furnished to people with Medicare. The Affordable Care Act requires that the new Medicare PPS account for a number of factors, including the type, intensity, and duration of services provided in this setting, without payment limits that exist under the current system, and be implemented beginning on October 1, 2014. Federally Qualified Health Centers will be transitioned to the new payment system throughout Fiscal Year 2015.

“The new payment system will help even more patients get care in federally-supported health centers,” said CMS Administrator Marilyn Tavenner. “The services provided by these centers help ensure patients get important primary and preventive care that lowers costs and improves health outcomes.”

Under the new PPS, Medicare proposes to pay Federally Qualified Health Centers a single encounter rate per beneficiary per day for all services provided.  The rate would be adjusted for geographic variation in costs and for the higher costs associated with furnishing care to a patient that is new to the health center or is receiving a comprehensive initial Medicare visit (that is, an initial preventive physical examination or an initial annual wellness visit). There is no change to the Federally Qualified Health Center covered services for beneficiaries. The same services that have been paid for by Medicare in the past will continue to be covered under the new system.

CMS developed the proposed rule in close collaboration with the Health Resources and Services Administration (HRSA), which administers the Health Center Program.

Additionally, last week HRSA announced awards of approximately $67 million to these health centers as part of the administration’s ongoing commitment to increase access to quality health care, including $19 million in Affordable Care Act funding to establish 32 new health service delivery sites that will increase access to preventive and primary health care to more than 130,000 additional people.

“These health centers serve some of our most vulnerable populations,” said HRSA Administrator, Dr. Mary Wakefield. “We are excited about our collaboration with CMS to create a payment system that enables these vital health centers to keep doing such important work.”

The proposed rule will be published in the September 23 Federal Register.  CMS will accept comments on the proposed rule until November 18, 2013, and will respond to them in a final rule to be issued in 2014.

For more information, see:


Seasonal Influenza Vaccine 2013/2014 Update


Routine annual influenza vaccination is recommended for all persons aged 6 months or older by the Advisory Committee on Immunization Practices (ACIP) 2013-14 recommendations.

It is expected the adult influenza immunizations will be given with the most cost effective, standard vaccine. However, preservative free and nasal vaccines may be given to adults who have a medical need for one of these preparations versus the injectable preparation containing a preservative. Prior authorization will not be required.

Payment for influenza vaccine for Nebraska Medicaid clients is available pursuant to the pharmaceutical care agreement, or a written order.

Clients eligible under the Vaccine for Children (VFC) Program:

Pregnant women age 18 and younger

Infants/children 6 months thru 18 years of age.

Additional information may be found at:

Medicaid is unable to reimburse providers for private stock vaccine when it is available free of charge through the VFC program.


For VFC vaccines:

1. Medicaid pays only for the administration of vaccines available to providers through the VFC program.

2. Use the vaccine CPT code with an SL modifier for administration.

For Provider Stock Vaccines:

1. Use only for clients over the age of 18.

2. Use an appropriate, applicable ICD-9 diagnosis code.

3. Claims must be billed in a manner consistent with good coding practices and

4. The National Correct Coding Initiative.

5. Use CPT code 90654 for the intradermal form of influenza vaccine.

6. As with any other service, Medicaid is the payer of last resort. Medicare or other

7. Third party payers must be billed first and the EOB from that payer is to be attached to a Medicaid claim form.

Pharmacies can bill the point of sale vendor for eligible clients 19 and over who are not Medicare eligible.

Influenza vaccine may also be administered to adult patients at pharmacies following their protocol if the Pharmacist is willing to do so.

1. All program policies and procedures outlined in this bulletin still apply when flu vaccine is administered at a pharmacy.  Influenza vaccine may be administered by home health care providers during the course of a scheduled Home Health service visit which is authorized through Qualis Health.

Nebraska Medicaid does not pay for: 

Medicare eligible;

Children/infants 6 months thru 18 years of age;

For questions about this information, contact Elaine Bachel, RN Program Specialist, at

For home health questions, contact Gaylene Jeffries, RN Program Specialist, at



Enhanced Payments to Primary Care Providers

Eligible primary care providers will begin to receive enhanced payments in October.

Providers with an attestation form accepted by Nebraska Medicaid prior to June 1, 2013 will receive a one-time payment in October for the increased amount on all eligible services provided and claims adjudicated between January 1, 2013 and September 22, 2013. The October payment will include adjustments to each qualifying claim to pay at the Enhanced Primary Care (EPC) rate and will be reflected on the remittance advice.

For new eligible services where claims are adjudicated September 23, 2013 and after, providers will be paid at the enhanced rate.

As stated in Provider Bulletin 12-63, effective January 1, 2013, attested physicians who provide eligible primary care services to Medicaid clients will be reimbursed at the Medicare rates in effect for calendar years 2013 and 2014. The enhanced rate is available for providers who are fee for service providers with Nebraska Medicaid as well as eligible providers who are enrolled in the Nebraska physical health managed care program.

Providers may still submit Attestation Forms to the Division to qualify for enhanced primary care provider payments. For providers who send in their forms after June 1, 2013, the Division will issue an acceptance date of when the Division receives and accepts the completed form. Only claims with dates of service on or after the provider’s acceptance date will be paid at the enhanced rate.

The attestation form is available on the MLTC website at:

Eligible providers must complete the Attestation Form and submit the original to the following address:

DHHS- Medicaid and Long-Term Care
Enhanced PCP Rates
P.O. Box 95026
Lincoln, NE 68509-5026

A fee schedule for the primary care physician enhanced payments is available on the MLTC website at: and included in Appendix 471-000-522.

A listing of all providers who have submitted attestation forms that have been accepted are listed and updated weekly on the MLTC website at:

Please refer to the previous Provider Bulletins for additional information: 12-63, 13-03, and 13-10, 13-21, and 13-30.

Please direct all questions to the following email address:



OneWorld Medicaid Database Training

The OneWorld Medicaid Database Training has been tentatively scheduled to take place in late October.  Details TBA.

O & E Reporting Categories for Health Centers

  • TRAINING: Number of health center O/E workers trained as certified application counselors (CACs) and have successfully completed all required federal and state training.

–        This includes all O/E assistance workers (staff, contractors, volunteers) who will be providing O/E assistance as CACs.


  • ASSISTANCE: Number of individuals assisted in any part of the enrollment process by a CAC, e.g., individuals or families assisted to set up a profile in the portal, helped to file affordability assistance information, received an eligibility determination, and/or facilitated enrollment into affordable health insurance.

–        Outreach or education can only be counted for interactions that occur face-to-face, in person, with a trained CAC.  These can take place in small group settings which are small enough to allow for customizable interactions to address specific questions.


  • ELIGIBILITY: Number of individuals assisted who receive an eligibility determination regardless of the outcome of the determination.


  • ENROLLMENT: Number of individuals who enroll (e.g., select a qualified health plan or Medicaid/CHIP) with the assistance of a trained health center CAC.

NACHC TeleForum Call next Thursday, Sept. 26 at 1pm CDT

All health center advocates are invited to join NACHC Federal Affairs staff for a free TeleForum call on Sept. 26 to learn what to expect from Congress this fall and how you can help to advance NACHC’s advocacy strategy. To sign up to receive the call, click here.

Nebraska Medicaid Enhanced Primary Care Payments

1-1-2013 to 12-31-2014

****CMS has approved Nebraska Medicaid’s State Plan Amendment regarding paying primary care physicians an enhanced fee.***** See new Frequently Asked Questions

Attestation Form (updated 06-04-13)

Enhanced Primary Care Provider fee schedule

Information about the Enhanced Primary Care Payments

Effective January 1, 2013, certain physicians who provide eligible primary care services to Medicaid clients are eligible to be paid the Medicare rates in effect in calendar years (CY) 2013 and 2014 instead of their usual state-established Medicaid rates.  The enhanced rate is available for providers who are fee for service providers with Nebraska Medicaid as well as eligible providers who are enrolled in the Nebraska physical health managed care program.  This enhanced rate will only be available for the limited periods of the calendar years 2013 and 2014.  At the end of this period, the enhanced federal funding for this program sunsets and the enhanced rate for Medicaid services will end.

The increased payments will pertain to primary care services delivered by a physician (MD or DO) with a specialty designation of family medicine, general internal medicine, or pediatrics.  Physician Assistants (PA) who are supervised by a physician that is eligible for the enhanced rate are also eligible to receive the enhanced rate. The increase will apply to a specific set of services and procedures that Centers for Medicare & Medicaid Services (CMS) designates as “primary care services.”

In order to qualify for the enhanced rates, eligible enrolled Nebraska Medicaid providers must attest to being a primary care physician by one of the following:

  1. Have furnished evaluation & management (E&M) and vaccines services (codes specified by federal regulation)  that equal at least 60% of the Medicaid codes billed during the most recently completed fiscal year.

Eligible providers who may qualify for the enhanced rate must complete an Attestation Form to be submitted with the identified documentation to the Medicaid central office.  The attestation form is listed above.

Providers can immediately begin sending forms and documentation to the following address:

DHHS- Medicaid and Long-Term Care
Enhanced PCP Rates
P.O. Box 95026
Lincoln, NE  68509-5026

Nebraska Medicaid is currently undergoing programming changes to the Medicaid Management Information System (MMIS) to implement these enhanced payments to primary care providers.  Payments will not begin until after January 1, 2013.  Implementation is contingent on completing the necessary system changes and approval by CMS of Nebraska Medicaid’s State Plan Amendment.  Additional details regarding this initiative and its implementation will be provided in future bulletins.

This enhanced rate will only be available for the limited periods of the calendar years 2013 and 2014.  At the end of this period, the enhanced federal funding for this program sunsets and the enhanced rate for Medicaid services will end.

To assist in delivery of information, a dedicated email address has been created for questions and answers specific to this program change.  We will gather the questions and responses and place them on our website.  The email address is:


  1. When will the Enhanced Primary Care Payments Fee Schedule be published? The Enhanced Primary Care Fee Schedule for attested providers will be published prior to when payments are ready to be made.
  2. When will we begin receiving payments? We are currently working with our IT staff to configure our MMIS system to make payments to attested providers on the enhanced primary care codes and adjust claims previously submitted which would qualify for the enhanced rate. Nebraska is anticipating the system will be ready by October 1, 2013.
  3. Are APRN’s eligible for the enhanced primary care payments? CMS clarified with the following information: “The final rule specifies that services must be delivered under the Medicaid physician services benefit. This means that higher payment also will be made for primary care services rendered by practitioners working under the personal supervision of a qualifying physician.  The rule makes clear that, while deferring to state requirements regarding supervision, the expectation is that the physician assumes professional responsibility for the services provided under his or her supervision.  This normally means that the physician is legally liable for the quality of the services provided by individuals he is supervising.  If this is not the case, the practitioner would be viewed as practicing independently and would not be eligible for higher payment.”

We have confirmed with the DHHS Licensure unit that the scope of practice for APRN’s is not in a supervising role nor does the physician assume professional responsibility or liability.  Therefore, APRN’s  do not qualify for the enhanced payments.

Acknowledgement of Attested Providers

Attested Providers (updated 08-28-13)

Board Certification Lists

Medicaid Managed Care Contractors for Physical Health

Adam Steffen 402-507-5885

Provider Relations Representatives:

Rick Helms Phone:(800) 471-0240 ext. 7227 or (402) 995-7227 Email:

Debby Synowicki Phone:  (800) 471-0240 ext. 7243 or (402) 995-7243 Email:

Tonya Yale Phone:  (800) 471-0240 ext. 7247 or (402) 995-7247 Email:

Brenda Wozniak Phone: (800) 471-0240 ext. 7274 or (402) 995-7274 Email:

Marcey Rauert Phone:  (800) 471-0240 ext. 7055 or (402) 995-7055 Email:

Provider Service line for information about general questions about the PCP reimbursement Phone:  1-866-331-2243

UnitedHealthcare Provider Service line for more specific contracting questions Phone:  1-800-284-0626

CMS Final Rule:

Correction to final rule:

Q and A on Increased Medicaid Payments for PCPs

Q and A on Set II INcreased Payments for PCPs

Q and A on Increased Medicaid Payments for managed care