Missouri has specific guidelines and laws regarding medical billing, particularly for healthcare providers and facilities. Here are the key points:Missouri Medical Billing Guidelines

• ICD-10-CM Codes: Missouri requires the use of ICD-10-CM codes for diagnoses, including bills for PPD evaluations.
• CPT Codes: CPT codes are used for procedures, and they must be unbundled.
• HCPCS Codes: HCPCS codes are used for supplies, equipment, and drugs. Q3014 is an allowable service for FQHC/CCBHC and CCBHC.

Missouri Medical Billing Laws

• Timely Billing and Reimbursement:
  • Health Care Provider Responsibilities:
    • Submit initial bill within 90 days after the date of service
    • Appeal to DIR within 60 days from EOB/EOR
    • Only reason for later billing: if claim acceptance is delayed beyond 12 months due to claim’s litigation
    • Use current UB-04/CMS 1500 Forms
  • Insurer/TPA Responsibilities:
    • Pay or deny bill within 45 calendar days of receipt

Incorrect Coding

• Insurer Response:
  • Pay/deny payment for portion of bill correctly coded
  • Return bill to health care provider, request additional information/documentation concerning incorrect codes
  • Approve or deny payment within 20 days after receipt by the insurer of resubmitted bill with additional information/documentation

Resolving Billing Disputes

• Healthcare Provider and Insurer Responsibilities:
  • Both parties are responsible for making and documenting timely, good faith efforts to resolve billing disputes
  • Written correspondence/email is more effective than telephone calls
  • Document all efforts - date, time, contact person’s name

Common Mistakes

• Failure to bill using Missouri Specific Codes
• Inappropriate billing of Observation Care
• Using revenue codes
• Failure to bill using CPT codes
• Incorrect coding
• No/minimal attempts to resolve billing issue independently

Telehealth Services

• Missouri Medicaid Coverage: Telehealth services are covered by Missouri Medicaid when deemed medically necessary.
• Eligible Sites: Facilities eligible for encounter reimbursement (e.g., Indian Health (IH) programs, Federally Qualified Health Centers (FQHCs), Rural Health Centers (RHCs)) may bill for an encounter in lieu of an originating site facility fee.
• Originating Site: Use procedure code Q3014. Originating site Telehealth services are not reimbursable as encounters.

Additional Guidelines

• Prior Authorization: Obtain written prior authorization when appropriate.
• Appeal Rights: Give/follow appropriate appeal rights on EOBs and denial letters.
• Contractual Agreements: Be aware of contractual agreements, changes, and discounts.

These guidelines and laws aim to ensure that healthcare providers and facilities follow specific procedures for billing and claims submission, protecting patients from surprise medical bills and ensuring timely and accurate payment for services.