General Providers. Occupational Therapists as Independent Providers

Transcription

1 September 2009 Provider Bulletin Number 973 General Providers Occupational Therapists as Independent Providers Effective with dates of service on and after October 1, 2009, qualified occupational therapists may enroll with KHPA Medical Plans as independent practitioners. Occupational therapists in private practice may provide and bill KHPA Medical Plans for services within their scope of practice in the area of physical medicine. Occupational therapists within a group practice must enroll individually, but services must be billed by the group provider. For information on how to become an enrolled provider, contact Provider Enrollment at , 8:00 a.m. to 4:30 p.m., Monday through Friday. New Manual and Manual Updates The new Rehabilitative Therapy Services Provider Manual is now available with information on physical therapy, occupational therapy, and speech/language pathology. The Physical Therapy Provider Manual will be discontinued on September 30, Additionally, references have been updated in the appropriate provider manuals. Information about the KHPA Medical Plans as well as provider manuals and other publications are available at For the changes resulting from this provider bulletin, please view the new Rehabilitative Therapy Services Provider Manual and the following manuals: General Benefits Provider Manual, Section 2710, page 2-56; General Billing Provider Manual, Section 5600, page 5-11; General Third Party Payment Provider Manual, Section 3500, page 3-18; Professional Provider Manual, Section 8400, page 8-14; and RHC/FQHC Provider Manual, Section 8400, page If you have any questions, please contact Customer Service at (in-state providers) or between 7:30 a.m. and 5:30 p.m., Monday through Friday. EDS is the fiscal agent and administrator of the KHPA Medical Plans. Page 1 of 6

2 2710. GENERAL THERAPY GUIDELINES AND REQUIREMENTS Updated 09/09 Therapy services are covered when they are: Prescribed by a physician, as required by your license/certification. Medically necessary. Habilitative - Habilitative therapy is covered only for participants age zero to under the age of 21. Therapy treatments approved and provided by an Early Childhood Intervention (ECI), Head Start or Local Education Agency (LEA) program may be habilitative or rehabilitative for disabilities due to birth defects or physical trauma/illness. The purpose of this therapy is to maintain maximum possible functioning for children. Rehabilitative - All therapies must be physically rehabilitative. Therapies are covered only when rehabilitative in nature and provided following debilitation due to an acute physical trauma or illness. Provided by a licensed physical or occupational registered therapist or a certified therapy assistant, working under the direct supervision of a licensed physical or occupational registered therapist. When services are performed by a certified therapy assistant, supervision must be clearly documented. This may include, but is not limited to, the licensed physical or occupational registered therapist initialing each treatment note written by the certified therapy assistant, or the licensed physical or occupational registered therapist writing treatment was supervised followed by his or her signature. Therapy services are limited to six months for participants over the age of 21 (except the provision of therapy under HCBS) per injury, to begin at the discretion of the provider. There are no time limits for participants age zero to 21. Therapy codes should be billed as one unit equals one visit unless the description of the code specifies the unit. Documentation requirements of therapy services: Pertinent past and present medical history with approximate date of diagnosis Date, time, and description of each service delivered and by whom (name, designation of profession or paraprofession) Identification of expected goals or outcomes and beneficiary s response to therapy Progress towards goals Please refer to your specific provider manual for additional benefits and limitations. GENERAL BENEFITS PROVIDER MANUAL 2-56

3 5600. Requests for Additional Payments cont Updated 09/09 After processing the overpayment or underpayment, results are reported on a subsequent RA. The original claim will appear on the RA with negative dollar amounts. The adjusted claim will be located directly above the original claim. The adjusted claim will have an internal control number (ICN) that begins with a '5.' When there is a need to adjust a claim that has been adjusted before, indicate the adjusted claim's ICN on the Individual Adjustment Form. The original claim's ICN has been voided from the KMAP system. Adjustment Request Minimums Adjustment requests, both overpayments and underpayments, must exceed a minimum amount on a claim for hospital, pharmacy or nursing facility and minimum amount per service on all professional claims (unless it is to correct the history). Below are the minimum amounts for each type: Hospital per claim - Inpatient $12.00 Inpatient Hospital per claim - Outpatient $ 5.00 Outpatient Nursing facility per claim $12.00 Pharmacy per prescription $ 5.00** Professional* per service $ 5.00 *Professional includes: advanced registered nurse practitioners (ARNPs), ambulances, ambulatory surgical centers, Attendant Care for Independent Living (ACIL), audiologists, behavior management, chiropractors, community mental health centers, day treatment, dentists, durable medical equipment suppliers, Federally Qualified Health Centers (FQHCs), Head Start facilities, Home Health Agencies, hospice, ICF/MR dental, Local Education Agencies (LEAs), local health departments, occupational therapists, optometrists, physical therapists, physicians, podiatrists, prosthetics and orthotics, psychologists, qualified Medicare beneficiaries (QMBs) and Rural Health Clinics. **The $5 minimum does not apply to adjusted incentive fees generated by the pharmacy reimbursement for nursing facility returned medications. There are two exceptions to the minimum amount policy. One exception is when "other insurance" makes a payment after a KMAP payment. Payments made by KMAP must be refunded by the provider upon receipt of payment from any other insurance source. The other exception is overpayments identified as the result of a postpayment utilization management review. Adjustments cannot be processed for zero paid claims unless other insurance, Medicare, or patient liability is involved, and you want to adjust any of these items. When all of the details but one on a claim have been paid, submit a new claim for the unpaid detail only. GENERAL BILLING PROVIDER MANUAL 5-11

4 3500. Updated 09/09 Occupational therapy supplies Perceptual therapy Psychotherapy for patients whose only diagnosis is mental retardation Services for the sole purpose of pain management Services provided in cases of developmental delay for purposes of "infant stimulation" Services which are pioneering or experimental, and complications from such services Services of social workers, team or therapy coordinators, occupational therapists, and speech therapists in private practice (unless beneficiary is a qualified Medicare beneficiary) Transcutaneous electrical nerve stimulation treatments Transplant surgery o Cyclosporine (except when prior authorized, following kidney, liver and bone marrow transplants) o All services related solely to noncovered transplant procedures Transplant surgery, in some cases, is a covered service for a KMAP beneficiary. Call Customer Service for a list. Treatment for obesity EXCEPTION: orlistat (Xenical ) and sibutramine (Meridia ) will be covered with prior authorization (PA). Individuals with a body mass index (BMI) greater than 30 or greater than 27 with comorbidity may be eligible to receive orlistat or sibutramine with PA. Vocational therapy, employment counseling, marital counseling/therapy and social services Voluntary sterilizations which do not meet federal requirements Services provided to a MediKan beneficiary in the following program areas: alcohol and drug addiction treatment facility, behavior management, chiropractic, dental, Head Start facility, Local Education Agency, nonemergency and nonambulance medical transportation, podiatry, and vision The private room difference in a hospital setting Special diet in the hospital when ordered per the patient's request Providers are not to charge a KMAP program beneficiary for services denied for payment by KMAP because the provider has failed to meet a program requirement including PA. Laboratory Services The drawing or collection fee is considered content of service of an office visit or other procedure and is not covered if billed separately. The beneficiary cannot be billed for the drawing or collection since it is considered content of another service or procedure. Note: Providers shall not bill beneficiaries for missed appointments. Missed appointments are not a distinct reimbursable service but a part of the providers overall cost of doing business. Kansas Medical Assistance Program General Third Party Payment 3-18

5 8400. Updated 09/09 Hospital (Inpatient) (continued) Hospital Visits One inpatient hospital visit per provider, per beneficiary, per day is covered. A hospital visit and chemotherapy administration to the same beneficiary by the same provider on the same date of service are not covered. The same provider cannot bill a hospital visit and psychotherapy on the same day for the same beneficiary. Only one inpatient follow-up consultation is covered within a 10-day period per beneficiary, by the same provider. Hospital visits are considered content of service for code Substance Abuse Acute detoxification is covered in any general hospital. Substance abuse treatment is only covered when provided in an intermediate setting. Substance abuse treatment provided in an intermediate setting (alcohol and drug addiction treatment facility) is limited to three admissions in a beneficiary's lifetime, regardless of provider. (Acute detoxification and day treatment are not included in this limitation.) Hospital (Outpatient) Outpatient services are reimbursed on a fee-for-service basis. The following are examples of covered outpatient services: Emergency room services Laboratory services Diagnostic or therapeutic radiology services Nuclear medicine services Outpatient surgery Rehabilitative occupational therapy Rehabilitative physical therapy These services should be used for minor surgical or medical procedures which would not require an inpatient stay. Only one outpatient follow-up consultation is covered within a 60-day period per beneficiary, by the same provider. The hospital will not be paid for the use of the emergency room when a patient repeatedly abuses emergency room services. Any patient who continually abuses these privileges despite reprimand should be reported to KHPA (refer to Section 2400 of the General Benefits Provider Manual). When emergency room services have been determined to be nonemergent, the physician s fee will be reduced to the nonemergency level. PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS 8-14

6 8400. Updated 09/09 Quarterly Supplemental Payments: All providers must send copies of the remittance advices received from the MCE after the end of each quarter. Regardless of the payment methodology, the State will compute quarterly alternative amounts by applying the provider s Medicaid PPS or interim rate to covered encounters paid by the MCE. If it is higher than MCE payments, Medicaid will pay the difference to the provider. If it is lower, the provider will refund the overpayment to the agency. Fiscal Year-End Settlement: This applies only if the alternative option, modified CBS, has been elected by the provider for Medicaid reimbursement. At the time of final retroactive cost settlement for Medicaid payments, the State will also make a final settlement on services provided under the MCE contract. A yearly alternative amount will be computed and compared with total MCE payment plus or minus the quarterly supplemental payments. If the yearly alternative amount is higher, Medicaid will pay the difference to the provider. If it is lower, the provider will refund the overpayment to the agency. Other Ambulatory Services Other ambulatory services are those services which do not meet the Medicare definition of core services under RHC and FQHC benefits and preventive services under FQHC benefit but are covered under the Medicaid state plan. Some examples are ambulance, durable medical equipment, prescription drugs, occupational therapy, physical therapy, and technical component of radiology or EKG. The Kansas Medicaid program reimburses for other ambulatory services (excluding dental services for FQHCs) furnished by RHCs and FQHCs using the methodologies utilized in paying for same services in other settings. To receive reimbursement for other ambulatory services, requirements under the state plan must be met, including enrollment under the respective provider type. RHC / FQHC PROVIDER MANUAL BENEFITS & LIMITATIONS 8-15