Table of Contents 1. Section Modifications... 1 2. Allopathic and Osteopathic Physician... 7 2.1 General Policy... 7 2.2 Reimbursement... 7 2.2.1 Site of Service Differential... 7 2.3 Referrals... 8 2.4 Physician Service Policy... 8 2.4.1 Overview... 8 2.4.2 Physician Employees... 8 2.4.3 Misrepresentation of Services... 8 2.4.4 Health Acquired Conditions (HAC)... 8 2.4.5 Out-of-State Care... 9 2.4.6 Locum Tenens and Reciprocal Billing Arrangements... 9 2.5 Allergy Injections... 10 2.6 Anesthesiology... 10 2.6.1 Overview... 10 2.7 Outpatient Cardiac Rehabilitation (CR)... 10 2.7.1 Qualifying Cardiac Events... 10 2.7.2 Covered Diagnoses... 11 2.7.3 Components of Cardiac Rehabilitation... 11 2.7.4 Limitations for Coverage... 11 2.7.5 Conditions Not Covered... 11 2.8 Consultations... 11 2.9 Emergency Department... 12 2.10 Critical Care Services... 12 2.10.1 Other Procedures... 12 2.11 Prolonged Services... 13 2.12 Diabetes Education and Training... 13 2.12.1 Participant Qualifications for Diabetes Education... 13 2.13 Examinations - Wellness... 14 2.13.1 Instrument-Based Ocular Screening... 14 2.14 Excluded Services... 14 2.15 Immunization... 14 2.15.1 State-Supplied Free Vaccines... 14 2.16 Laboratory Coverage... 16 2.16.1 Physician Office Laboratories... 16 2.16.2 Independent Laboratories... 16 2.16.3 Pathology Laboratory Procedures... 16 2.16.4 Special Services... 16 2.16.5 Blood Lead Screening for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)... 16 2.16.6 PKU Testing... 17 2.16.7 Controlled Substance and Drug Testing... 17 2.17 Obstetrics and Gynecology... 18 November 16, 2017 Page i
2.17.1 Obstetrics Overview... 18 2.17.2 Family Planning... 21 2.17.3 Abortions... 22 2.17.4 Hysterectomy Overview... 23 2.18 Sterilization Procedures Overview... 23 2.18.1 Participant Consent... 24 2.18.2 Waiting Time Exceptions... 24 2.18.3 Interpreter s Statement... 24 2.18.4 When Not to Obtain Consent... 25 2.18.5 Signature Requirements... 25 2.18.6 Statement of Person Obtaining Consent... 25 2.18.7 Physician s Statement... 25 2.18.8 Sterilizations Incidental to Medical Procedure... 25 2.19 Ophthalmologist... 26 2.19.1 Overview... 26 2.19.2 Vision Supplies... 26 2.20 Oral Treatments... 26 2.21 Oral and Maxillofacial Surgery... 27 2.22 Physician-Administered Drugs (PAD)... 27 2.22.1 Reporting National Drug Code (NDC) for Drugs Billed with HCPCS Codes... 27 2.22.2 Compound Drugs... 27 2.23 Psychiatric Care... 28 2.23.1 Outpatient Psychiatric Care... 28 2.23.2 Inpatient Psychiatric Care... 28 2.24 Radiology... 28 2.24.1 Overview... 28 2.24.2 Technical Component... 29 2.24.3 Professional Component... 29 2.24.4 Place-of-Service (POS) Codes... 29 2.24.5 Place-Of-Service (POS) Office... 29 2.24.6 Diagnosis Codes... 29 2.25 Surgery... 30 2.25.1 Global Fee Concept... 30 2.25.2 Complications... 30 2.25.3 Modifiers... 30 2.25.4 Hospital Admissions... 31 2.25.5 Abdominoplasty or Panniculectomy... 31 2.25.6 Bariatric Surgery for Weight Loss... 31 2.25.7 Circumcisions... 32 2.26 Telehealth... 32 2.27 Tobacco Cessation... 32 2.28 Transplants... 33 2.28.1 Overview... 33 2.28.2 Coverage Limitations... 33 2.28.3 Re-Transplants... 33 2.28.4 Multi-Organ Transplants... 33 November 16, 2017 Page ii
2.28.5 Transplant Authorization... 34 2.28.6 Non-Covered Transplants... 34 2.28.7 Follow-Up Care... 34 2.29 QIO Prior Authorization and Medical/Surgical Review... 34 2.29.1 Overview... 34 2.29.2 Penalties... 34 2.29.3 Prior Authorization (PA)... 35 2.29.4 Third Party Recovery (TPR)... 36 November 16, 2017 Page iii
1. Section Modifications Version Section/ Column Modification Description Date SME 38.0 All Published version 11/16/2017 TQD 37.20 2.29.3.3 PA by the Medicaid Medical Care Unit Updated resources 11/16/2017 W 37.19 2.29.1 Overview Removed ICD-9 codes 11/16/2017 W 37.18 2.25.3 Modifiers Added information for anatomical modifiers 11/16/2017 W 37.17 2.24.6 Diagnosis Codes Removed ICD-9 codes 11/16/2017 W 37.16 2.21 Oral and Maxillofacial Surgery Corrected Idaho Smiles phone number 37.15 2.20 Oral Treatments Replaced reference to D1206 and D1208 with new CPT code 37.14 2.18.8 Sterilizations Incidental to Medical Procedure 11/16/2017 W 11/16/2017 W New section 11/16/2017 W 37.13 2.17.2.5 Diaphragm Removed note about morningafter pill 37.12 2.17.2.2 Intrauterine Device (IUD) Removed information about Liletta and Mirena sharing J code 37.11 2.16.7 Controlled Substance and Drug Testing 37.10 2.14.1.1 Acupuncture 2.14.1.2 Biofeedback Therapy 2.14.1.3 Complications 2.14.1.4 Cosmetic Surgery 2.14.1.5 Fertility Related Services 2.14.1.6 Investigational/Unproven/Experimental Procedures 2.14.1.7 Laetrile Therapy 2.14.1.8 Naturopathic Services 11/16/2017 W 11/16/2017 W New Section 11/16/2017 W Removed sections (content contained within General Provider and Participant Information) 37.9 2.14 Excluded Services Added reference to General Provider and Participant Information 37.8 2.13.1 Wellness Exams for Children Up to the Age of 21 2.13.2 Wellness Physicals for Adults 21 Years and Over Removed sections (content contained within General Provider and Participant Information) 11/16/2017 W 11/16/2017 W 11/16/2017 W 37.7 2.13 Examinations Wellness Updated for clarity 11/16/2017 W 37.6 2.9 Emergency Department Removed reference to visit limits for non-hc participants 37.5 2.6.1.1 Billing Anesthesia Added information about base units 11/16/2017 W 11/16/2017 W November 16, 2017 Page 1 of 36
Version Section/ Column 37.4 2.4.6.2 Reciprocal Billing Arrangements Modification Description Date SME Updated section title and all content 37.3 2.4.6.1 Locum Tenens Arrangements Updated section title and all content 37.2 2.4.6 Locum Tenens and Reciprocal Billing Arrangements Updated section title and all content 37.1 2.2 Reimbursement Updated verbiage regarding participant billing 11/16/2017 W 11/16/2017 W 11/16/2017 W 11/16/2017 W 37.0 All Published version 9/7/2017 TQD 36.1 2.22 Physician-Administered Drugs (PAD) Removed reference to PAD list and added reference to Fee 9/7/2017 E Garibovic Schedule 36.0 All Published version 6/5/2017 TQD 35.1 2.23.2 Inpatient Psychiatric Care Added statement regarding authorization for clarity only, no policy change 6/5/2017 W E Garibovic 35.0 All Published version 3/29/2017 TQD 34.1 2.21 Oral and Maxillofacial Surgery Updated dental vendor information 3/29/2017 C Loveless 34.0 All Published version 3/23/2017 TQD 33.1 2.18 Sterilization Procedures Overview 2.18.2 Waiting Time Exceptions Moved reference to sterilization consent form from 2.18.2 to 2.18 3/23/2017 E Garibovic 33.0 All Published version 12/30/2016 TQD 32.1 2.18.3 Interpreter s Statement Removed consent form information and added link to policy 12/30/2016 C Brock E Garibovic 32.0 All Published version 8/31/2016 TQD 31.1 2.17.1 Obstetrics Overview 2.17.4 Hysterectomy Overview 2.18 Sterilization Procedures Overview 2.23.2 Inpatient Psychiatric Care 2.25.5 Abdominoplasty or Panniculectomy 2.25.6 Bariatric Surgery for Weight Loss 2.28.1 Overview [Transplants] 2.29 QIO Prior Authorization and Medical/Surgical Review 2.29.1 Overview (QIO PA) 2.29.3.1 Prior Authorization (PA) Notification 2.29.3.2 Quality Improvement Organization (QIO) PA 2.29.3.3 PA by the Medicaid Medical Care Unit 2.29.4 Third Party Recovery (TPR) Updated QIO information due to vendor change 8/31/2016 D Boyle 31.0 All Published version 6/2/2016 TQD 30.1 2.17.1.5 Billing Ultrasounds and Stress Tests for Multiple Pregnancies Removed table; added information for modifiers 51 and 59 6/2/2016 T Lombard November 16, 2017 Page 2 of 36
Version Section/ Column Modification Description Date SME 30.0 All Published version 5/19/2016 TQD 29.2 2.28.1 Overview (Transplants) Removed Lung transplants are not covered for participants age 5/19/2016 R Natal 21 and older 29.1 2.13.2 Wellness Physicals for Adults 21 Years and Over New section 5/19/2016 C Brock 29.0 All Published version 1/22/2016 TQD 28.1 2.23.1 Outpatient Psychiatric Care 2.26 Telehealth Deleted invalid Telehealth information, added Telehealth section 1/22/2016 C Loveless C Brock 28.0 All Published version 12/1/15 TQD 27.2 2.28.4 TPR Updated per December 2015 COB changes 12/1/15 C Coyle 27.1 2.2 Reimbursement Updated per December 2015 COB changes 12/1/15 C Coyle 27.0 All Published version 10/15/15 TQD 26.3 2.19.2 Vision Supplies Added section by separating contact info from 2.19.1; updated contact information 26.2 2.19.1 Overview Added statement regarding instrument-based ocular screening 10/15/15 A Coppinger 10/15/15 A Coppinger 26.1 2.13.2 Instrument-Based Ocular Screening Added section 10/15/15 A Coppinger 26.0 All Published version 9/25/15 TQD 25.2 2.16.5 Blood Lead Screening for EPSDT Added information about IDAPA rule for lead poisoning screening 9/25/15 C Brock 25.1 2.17.1.5 Billing Ultrasounds and Stress Updated for ICD-10 9/25/15 Tests for Multiple Pregnancies 2.18.1 Participant Consent 2.24.6 Diagnosis Codes 2.28.3.3 PA by the Medicaid Medical Care Unit 25.0 All Published version 8/14/15 TQD 24.2 2.17.2.2 Intrauterine Device (IUD) Added information regarding Liletta and Mirena; indicated when IUDs can be billed for inpatient hospital 8/14/15 J Siroky 24.1 2.17.2 Family Planning Added for Medicaid 8/14/15 J Siroky 24.0 All Published version 6/4/15 TQD 23.1 2.6.1.1 Billing Anesthesia Added information regarding dates 6/4/15 K McNeal C Taylor 23.0 All Published version 3/30/15 TQD 22.2 2.25.6 Bariatric Surgery for Weight Loss Updated bullet about national medical standards 3/30/15 A Coppinger C Taylor 22.1 2.7 Outpatient Cardiac Rehabilitation, and subsections 2.7.1-2.7.5 Added sections 3/30/15 A Coppinger C Taylor 22.0 All Published version 3/12/15 TQD 21.1 2.24.6 Bariatric Surgery for Weight Loss Updates to requirements 3/12/15 A Coppinger C Taylor 21.0 All Published version 1/29/15 TQD November 16, 2017 Page 3 of 36
Version Section/ Column 20.1 2.12.1 Wellness Exams for Children Up to the Age of 21 Modification Description Date SME Updated physical exam information 1/29/15 C Brock C Taylor 20.0 All Published version 1/15/15 TQD 19.1 2.2.1 Site of Service Differential Added list of places of service that receive site of service differential 1/15/15 A Coppinger C Taylor 19.0 All Published version 9/25/14 TQD 18.1 2.17.2 Waiting Time Exceptions Removed statement about 9/25/14 C Taylor paper forms 18.0 All Published version 09/02/14 TQD 17.1 2.2.1 Site of Service Differential In the last sentence, updated 09/02/14 C Taylor link to Site of Service Reduction Codes and changed Reference to Links. 17.0 All Published version 08/15/14 TQD 16.1 2.24.6 Bariatric Surgery Removed Medicare reference and added link to Surgical Review Corporation 08/15/14 M Wimmer C Taylor 16.0 All Published version 08/08/14 TQD 15.1 2.27.3.1 PA Notification Added or adjusted in first 08/08/14 C Taylor sentence 15.0 All Published version 07/07/14 TQD 14.1 2.21. Physician-Administered Drugs (PAD) Clarified information and location of the PAD list 07/07/14 J Siroky C Taylor 14.0 All Published version 07/01/14 TQD 13.2 2.4.4 Health Acquired Conditions Removed date 07/01/14 R Sosin C Taylor 13.1 2.17.2 Waiting Time Exceptions; 2.17.3 Interpreter s Statement; 2.17.6 Statement of Person Obtaining Removed statements that Medicaid will not accept corrected or altered consent 07/01/14 C VZile C Taylor Consent forms. 13.0 All Published version 4/25/14 TQD 12.5 2.19 Oral Treatments Added section 4/25/14 A Coppinger C Taylor 12.4 2.16.1.5 Billing Ultrasounds and Stress Tests for Multiple Pregnancies Added to use ICD-10 diagnosis code 4/25/14 C Taylor 12.3 2.16.1.1 Total Obstetric (OB) Care Clarified using date of delivery as the to and from date. 12.2 2.27.3.1 Prior Authorization (PA) Notification Added new requirement and information for adding PA number to claim 4/25/14 A Coppinger C Taylor 4/25/14 C Taylor 12.1 2.4.4 Health Acquired Conditions Added new section 4/25/14 A Coppinger C Taylor 12.0 All Published version 03/07/14 TQD 11.1 2.16.4 Hysterectomy Overview Added that the sterilization form 03/07/14 C Taylor can also be used and the A required information that needs Coppinger to be included 11.0 All Published version 01/24/14 TQD 10.1 2.24 Tobacco Cessation New section 01/24/14 A Coppinger 10.0 All Published version 12/20/13 TQD 9.2 2.16.3 Removed procedure codes 12/20/13 C Taylor November 16, 2017 Page 4 of 36
Version Section/ Column Modification Description Date SME 9.1 2.25.3.3 Reordered paragraphs for clarity 12/20/13 A Coppinger 9.0 All Published version 09/20/13 TQD 8.1 2.16.1.5 Billing Ultrasounds and Stress Tests for Multiple Pregnancies 2.16.3.1 Participant Consent New section (2.16.1.5); updated 2.16.3.1 for clarity 09/20/13 A Coppinger C Taylor 8.0 All Published version 08/30/13 TQD 7.1 2.20.1-2 Added new information to align 08/30/13 C Burt with current policy 7.0 All Published version 05/31/13 C Taylor 6.1 All Removed outdated information and added updated information for current policies 05/31/13 J Siroky A Farmer A Coppinger 6.0 All Published version 10/02/12 TQD 5.10 2.21.7 Follow-Up Care Removed last procedure code 10/02/12 C Taylor table. This table is available under the Reference Section of the Handbook, Qualis Health Pre-Authorization List 5.9 2.20.3 Modifiers Updated for clarity 10/02/12 C Taylor 5.8 2.20.2 Complications Updated for clarity 10/02/12 C Taylor 5.7 2.19.3 Professional Component Updated with modifier 10/02/12 C Taylor information. 5.6 2.18.3.3 PA by the Medicaid MCU Added outpatient. Updated phys 10/02/12 C Taylor therapy, speech & lang, & occupational therapy. Updated procedure code table 5.5 2.18.3.1 PA Notification Updated to indicate to not 10/02/12 C Taylor include PA number on claim 5.4 2.14.3.2 Waiting Time Exceptions Added additional information 10/02/12 about sterilization forms 5.3 2.14.1.6 Billing for Twin Deliveries Added modifier 59 and clarified 10/02/12 C Taylor this is for multiple deliveries 5.2 2.14.1.4 Billing for Incomplete Clarified information on split 10/02/12 C Taylor Antepartum Care billing 5.1 2.9.1.3 Individual Diabetic Counseling Clarified CDEs services are to 10/02/12 C Taylor augment not substitute 5.0 All Published version 05/23/12 TQD 4.1 2.14.5 Hysterectomies Overview Deleted part of sentence and the PA number entered on the claim from in field 23 of the CMS-1500 claim from, or field 63 of the UB-04 claim form. From the last paragraph 05/23/12 A Coppinger 4.0 All Published version 01/18/12 TQD 3.1 2.1.3 Procedure Codes Removed section; Information 01/18/12 C Taylor is found in General Billing Instructions 3.0 All Published version 11/23/11 TQD 2.22 2.1.3 Procedure Codes Added section 11/23/11 L Stiles 2.21 2.21 Transplants New Section 11/23/11 J Siroky 2.20 2.20 Surgery New subsections added, other sections updated for clarity 2.19 2.19 Radiology New subsections added, other sections updated for clarity 11/23/11 J Siroky 11/23/11 J Siroky November 16, 2017 Page 5 of 36
Version Section/ Column Modification Description Date SME 2.18 2.18 Prior Authorization and Medical / New section 11/23/11 J Siroky Surgical Review 2.17 2.17 Physician-Administered Drugs New section 11/23/11 J Siroky A Farmer 2.16 2.16 Oral and Maxillofacial Surgery Updated for Clarity 11/23/11 J Siroky 2.15 2.15 Ophthalmologist Updated for Clarity 11/23/11 J Siroky 2.14 2.14 Obstetrics and Gynecology New subsections added, other sections updated for clarity 11/23/11 J Siroky A Farmer 2.13 2.13 Laboratory Coverage New section 11/23/11 J Siroky 2.12 2.12 Immunization New section 11/23/11 J Siroky 2.11 2.11 Excluded Services New section 11/23/11 J Siroky 2.10 2.10 Examinations - Wellness New section 11/23/11 J Siroky 2.9 2.9 Diabetes Education and Training New section 11/23/11 2.8 2.8 Prolonged Services New section 11/23/11 J Siroky 2.7 2.7 Critical Care Services New section 11/23/11 J Siroky 2.6 2.6 Emergency Department/Critical Care Services New section 11/23/11 J Siroky 2.5 2.5 Consultations New section 11/23/11 J Siroky 2.4 2.4 Anesthesiology Updated for clarity 11/23/11 J Siroky A Farmer 2.3 2.3 Allergy Injections New section 11/23/11 J Siroky A Farmer 2.2 2.2 Physician Service Policy Updated for clarity 11/23/11 J Siroky A Farmer 2.1 2.1 Introduction New subsections added, other sections updated for clarity 11/23/11 J Siroky A Farmer 2.0 All Published version 08/27/10 TQD 1.2 All Replaced member with 08/27/10 TQD participant 1.1 All Updated numbering for sections 08/27/10 TQD to accommodate Section Modifications 1.0 All Initial document published version 5/7/2010 TQD November 16, 2017 Page 6 of 36
2. Allopathic and Osteopathic Physician 2.1 General Policy This section covers Medicaid services provided by all physician specialties. It addresses the following: Idaho Medicaid s general physician policy Service limitations Medical/surgical review process Specific medical services Prior authorization (PA) 2.2 Reimbursement Idaho Medicaid reimburses physician services on a fee-for-service basis. Participants may be dually eligible for Medicare and Medicaid. The provider must first bill Medicare for rendered services. A copy of the Medicare Remittance Notice (MRN) must be included with the Medicaid claim. If billing electronically, the information from Medicare must be entered on the appropriate screens. QMB Only: Participants who are covered by QMB only are only eligible for Medicare covered services. Medicaid s payment for services will be calculated according to the Member Responsibility methodology. Crossover Claims: These claims may require rebilling to Medicaid with appropriate Medicaid-approved coding for consideration for example, FQHC/RHC/IHC, LTC. See the General Billing Instructions, Coordination of Benefits (COB) regarding Medicaid policy on billing all other third party resources before submitting claims to Medicaid. Participants cannot be billed for any non-reimbursed amount. Providers may only bill noncovered services and items to the participant if the provider has notified the participant of their responsibility to pay in writing prior to rendering services. Notices must specify the non-covered service or item, and be signed by the participant. 2.2.1 Site of Service Differential Idaho Medicaid reduces physician reimbursement when certain procedures are provided in a facility setting. For these procedure codes there is a 30 percent reduction of the Idaho Medicaid fee schedule in the following places of service (POS). 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room - Hospital 24 Ambulatory Surgical Center 25 Birthing Center 31 Skilled Nursing Facility 51 Inpatient Psychiatric Facility 52 Psychiatric Facility - partial hospitalization 61 Comprehensive Inpatient Rehabilitation Facility If the space and supplies are provided by the hospital, and are included in the hospital's cost settlement, the physician can bill for POS 22 under his own provider number on the 1500 form, and there is a site of service deduction. The facility fees are billed by the November 16, 2017 Page 7 of 36
hospital on their UB-04 form under the hospital provider number. Site of service differential pricing also applies to POS 23 and 24. If the physician office space is rented from the hospital and the physician provides his own supplies, the physician should bill on a CMS-1500 claim form, use POS 11 (office), and use his own (or group's own) physician provider number. There is no site of service reduction. The hospital cannot use the same space, etc. to bill for services under their hospital provider number. Refer to Site of Service Reduction Codes, in the Links section of the Provider Handbook. 2.3 Referrals Check eligibility to see if the participant is enrolled in Healthy Connections (HC), Idaho s primary care case management (PCCM) model of managed care, or in Idaho Medicaid Health Home (IMHH), Idaho s enhanced primary care case management system. If a participant is enrolled in one of these programs, a referral may be required from the participant s primary care physician (PCP) prior to rendering services. Prior Authorization may be required in addition to obtaining a referral. 2.4 Physician Service Policy 2.4.1 Overview Physicians in any state are eligible to participate in the Idaho Medicaid Program. They must be licensed in the state where the services are performed, and enroll as an Idaho Medicaid provider with Idaho Medicaid prior to submitting claims for services. See General Provider and Participant Information for more information on enrolling as an Idaho Medicaid provider. 2.4.2 Physician Employees Services provided by employees of a physician may not be billed directly to Idaho Medicaid. However, psychological testing services provided by a licensed psychologist or social worker who are employees of the physician, may be billed under the physician s provider number. This exception applies to testing only. Therapy services that are provided by a physician may be billed with that physician s provider number. If services are provided by a licensed therapist employed by the physician, the therapist must apply for a separate Medicaid provider number and the services billed with that number. 2.4.3 Misrepresentation of Services Any representation that a service provided by a nurse practitioner, nurse midwife, physical therapist, physician assistant, psychologist, social worker, or other non-physician professional was rendered as a physician service is prohibited. 2.4.4 Health Acquired Conditions (HAC) An edit in the claims processing system will look at CMS-1500 claims for HAC and will deny all claims with the modifiers of PA, PB, or PC. November 16, 2017 Page 8 of 36
When submitting a claim to indicate a HAC, one of the following modifiers is required. Modifier PA PB PC Description Surgical or other invasive procedure on wrong body part Surgical or other invasive procedure on wrong patient Wrong surgery or other invasive procedure on patient 2.4.5 Out-of-State Care Out-of-state providers who are enrolled in the Idaho Medicaid Program and have an active Idaho Medicaid provider number may render services to Idaho Medicaid participants without receiving out-of-state prior approval. All medical care provided outside the state of Idaho is subject to the same utilization review, coverage requirements, and restrictions as medical care provided within Idaho. 2.4.6 Locum Tenens and Reciprocal Billing Arrangements Idaho Medicaid allows for physicians to bill for locum tenens and reciprocal billing arrangements. Arrangements may be made with one or more substitute physicians, and do not have to be in writing. The absent physician continues to bill and receive payment for the substitute physician s services as though they were performed by the absent physician. Locum tenens and reciprocal billing arrangements are allowed when: The regular physician is unavailable to provide the services. The Medicaid participant has arranged or seeks to receive services from their regular physician. The regular physician identifies the services provided by a substitute physician by appending the appropriate modifier to the procedure code on claims. The regular physician maintains a record of each service provided by the substitute physician and their National Provider Identifier (NPI). Records must be available to DHW upon request. Services are not reported separately as substitute services for an operation and/or post-operative care covered by a global fee. 2.4.6.1 Locum Tenens Arrangements Locum tenens arrangements occur when the substitute physician covers the regular physician during absences for illness, pregnancy, vacation, or continuing education. The regular physician pays the substitute physician for their services on a per diem, or similar fee-for-time basis. Locum tenens arrangements cannot exceed a period of 90 continuous days. The regular physician must use the Q6 modifier on claims for services provided by the substitute physician in a locum tenens arrangement. 2.4.6.2 Reciprocal Billing Arrangements Reciprocal billing arrangements occur when the substitute physician covers the regular physician during occasional absences such as on-call coverage. The absent physician agrees to cover the substitute physician at a later time in exchange for their services. Arrangements are not to exceed a period of 14 continuous days. The regular physician must use the Q5 modifier on claims for services provided by the substitute physician in a reciprocal billing arrangement. November 16, 2017 Page 9 of 36
2.5 Allergy Injections Reimbursement for office visits is included in the reimbursement for allergy injections. Office visits may only be billed if there is a separately identifiable service, such as treatment for an ear infection. 2.6 Anesthesiology 2.6.1 Overview Medicaid accepts anesthesia codes from the anesthesia section of the Current Procedural Terminology (CPT) Manual. Anesthesia claims must include the CPT anesthesia code that relates to the surgical procedure performed. Anesthesia time begins when the anesthesiologist physically starts to prepare the participant for the induction of anesthesia in the operating room and ends when the anesthesiologist is no longer in constant attendance. A second separate anesthesia session may be reimbursed when a patient is returned to surgery after spending time in another unit of the hospital. In these cases, Medicaid will reimburse both CPT anesthesia codes plus the total time for both sessions, with adequate documentation. Medicaid does not pay for supervision of anesthesia services. The provider who administers the anesthesia, either a physician or Certified Registered Nurse Anesthetist (CRNA), is paid 100 percent of the allowed amount for the procedure. 2.6.1.1 Billing Anesthesia Enter the CPT anesthesia code for the surgical procedure that was performed on the participant, total amount of time in one (1) minute increments, and any necessary modifiers. Base units will be added by the system automatically and should not be billed separately. Idaho Medicaid limits reimbursement for anesthesia procedures to once per day. The anesthesia start date is the only date that should be used. Do not date span. A repeat anesthesia procedure on the same day that is billed with the CPT modifier 76 or 77 will be paid at $0.00. Medicaid considers that a second separate session of anesthesia has occurred when a patient is returned to surgery after spending time in another unit of the hospital. In these cases, Medicaid will reimburse both CPT anesthesia codes plus the total time for both sessions, with adequate documentation. 2.7 Outpatient Cardiac Rehabilitation (CR) Effective for dates of service starting April 1, 2015, outpatient cardiac rehabilitation (CR) is aligned with Medicare s policy. CR in the outpatient setting is a medically supervised program with the goal of preventing future cardiac events. CR can be provided in either a physician s office or an outpatient hospital setting, and must have a physician immediately available and accessible for medical consultations and emergencies at all times. 2.7.1 Qualifying Cardiac Events Participants who have experienced one or more of the following cardiac events are eligible for CR: November 16, 2017 Page 10 of 36
An acute myocardial infarction (MI- heart attack) within the preceding 12 months A coronary artery bypass graft (CABG) surgery Current stable angina pectoris Heart valve repair or replacement Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting A heart or heart-lung transplant Stable chronic heart failure Note: A heart assist device (V43.21) is no longer a qualifying event as of 4/1/2015. 2.7.2 Covered Diagnoses The list of diagnoses that are covered is available under Resources in the Policy document on the Medical Care Unit s website. 2.7.3 Components of Cardiac Rehabilitation Components of cardiac rehabilitation program must include all of the following: Physician-prescribed exercise each day that cardiac rehabilitation items and services are furnished. Cardiac risk factor modification, including education, counseling, and behavioral intervention, tailored to the patient s individual needs. Psychosocial assessment. Outcomes assessment. An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed and signed by a physician every 30 days. 2.7.4 Limitations for Coverage Cardiac rehabilitation program sessions are limited to a maximum of two, one-hour sessions per day for up to 36 sessions, over a period of 36 weeks with the option for an additional 36 sessions over an extended period with prior approval. Place of service (POS) that is covered when CR is done is a physician s office or hospital outpatient setting. 2.7.5 Conditions Not Covered Physical and/or occupational therapy are not medically necessary in conjunction with cardiac rehabilitation unless performed for an unrelated diagnosis. Participation in another outpatient cardiac rehabilitation program in the absence of another qualifying cardiac event is considered investigational. Programs that only offer supervised exercise training are not considered to be cardiac rehabilitation. 2.8 Consultations Idaho Medicaid does not recognize or reimburse for the Current Procedural Terminology (CPT) codes for consultation services (CPT codes 99241 99245 and 99251 99255). For office or outpatient visits, Medicaid will not recognize CPT codes 99241 99245 but will instead require providers to bill these services as new (99201 99205) or established (99211 99215) office/outpatient visits. For inpatient visits, providers should bill initial inpatient patient visits (99221 99223). November 16, 2017 Page 11 of 36
2.9 Emergency Department Emergency departments are defined as organized hospital-based facilities for the provision of unscheduled temporary services to participants who come in for immediate medical attention. The facilities must be available 24 hours a day. Use codes 99281-99285 to report evaluation and management services provided in the emergency department. No distinction is made between new and established participants in the emergency department. 2.10 Critical Care Services Critical care includes the care of critically ill participants, in a variety of medical emergencies that requires the constant attention of the physician. Critical care is usually, but not always, given in a critical care area, such as the Coronary Care Unit, Intensive Care Unit, Respiratory Care Unit, or the Emergency Department. The following services are included in the global reporting and billing of critical care when performed during the critical period by the physician providing critical care: Interpretation of cardiac output measurements. Interpretation of chest x-rays. Pulse oximetry. Blood gases and information data stored in computers (e.g., electrocardiogram [ECG]), blood pressure, hematologic data. Gastric intubation. Temporary transcutaneous pacing. Ventilator management. Vascular access procedures. The critical care codes are used to report the total duration of time spent by a physician providing constant attention to a critically ill participant. Use code 99291 for critical care, including the diagnostic and therapeutic services and direction of care of the critically ill or multiple injuries or comatose participant, requiring the prolonged presence of the physician. This code is used to report the first 30-74 minutes of critical care on a given day. Code 99291 is only billed as one unit. It should be used only once per day even if the time spent by the physician is not continuous on that day. Code 99291 is paid to a physician once per day. Use code 99292 to bill each additional 30 minutes of critical care. This code is used to report each additional 30 minutes beyond the first 74 minutes. Bill 99292 in 30 minute units. 2.10.1 Other Procedures Other procedures that are not directly connected to critical care management (the suturing of laceration, setting of fractures, reduction of joint dislocations, lumbar puncture, peritoneal lavage, bladder tap, etc.) are not included in the critical care and should be reported separately. November 16, 2017 Page 12 of 36
2.11 Prolonged Services Use codes 99354-99357 when a physician provides prolonged service involving direct (faceto-face) participant contact that is beyond the usual service in an inpatient or outpatient setting. Use code 99354 or 99356 to report the first hour of prolonged service on a given date, depending on the place of service. Prolonged service lasting less than 30 minutes on a given date is not separately reported, because the work involved is included in the evaluation and management codes. Use code 99355 or 99357 to report each additional 30 minutes beyond the first hour, depending on the place of service. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately. 2.12 Diabetes Education and Training Medicaid covers individual and group counseling for diabetes education and training. The physician is responsible to furnish basic diabetic care and instruction to the participant and may not use the formally structured program, or a Certified Diabetes Educator, as a substitute. Physician responsibility includes the disease process and pathophysiology of diabetes mellitus, and dosage administration of agents for glycemic management. 2.12.1 Participant Qualifications for Diabetes Education The participant has a recent diagnosis of diabetes (within 90 days) and has not had prior diabetes education. The participant has uncontrolled diabetes manifested by two or more fasting blood sugar levels of greater than one hundred forty milligrams per decaliter (140 mg/dal), hemoglobin A1c greater than eight percent (8%), or random blood sugar levels greater than one hundred, eighty milligrams per decaliter (180 mg/dal), in addition to the manifestations. The participant has recent manifestations resulting from poor diabetes control including neuropathy, retinopathy, recurrent hypoglycemia, repeated infections, or non-healing wounds. 2.12.1.1 Provider Qualifications for Diabetes Education Providers must operate an American Diabetes Association (ADA) Recognized Diabetes Education Program to provide group diabetes counseling/training. Only Certified Diabetes Educators (CDE) may provide individual counseling through a recognized program, a physician s office, or outpatient hospital counseling. The billing provider must submit and maintain proof of the CDE s current diabetic counseling certification with Molina provider enrollment. Counseling services must be billed under the provider number of their employer (e.g., the hospital, or physician s clinic provider number). More information can be found in IDAPA 16.03.09.640-645 Medicaid Basic Plan Benefits. 2.12.1.2 Individual Diabetic Counseling To bill these services, use procedure code G0108, and bill in 30 minute increments to comply with standard coding requirements. Individual counseling services must be face-to- November 16, 2017 Page 13 of 36
face services between a CDE and the participant. The CDE s services are to augment, not substitute, for the services a physician is expected to provide to diabetic participants. Medicaid allows 12 hours, per participant every five years for individual diabetic counseling. 2.12.1.3 Group Diabetic Counseling Group counseling is billed with procedure code G0109 and is billed in 30 minute increments to comply with standard coding requirements. Only hospitals operating an ADA recognized program may bill for group counseling. Medicaid allows 24 hours, per participant, every five years for group diabetic counseling. 2.13 Examinations - Wellness For information regarding wellness exams for both children and adults, please see the Wellness section in the General Provider and Participant Information for more information. 2.13.1 Instrument-Based Ocular Screening Medicaid covers instrument-based ocular screening (e.g. photo screening, automatedrefraction) for all children three years of age and for children ages four to five years, who are unable to cooperate with routine acuity screening (e.g. intellectual disability, developmental delay and sever behavioral disorders). Ocular screening is only covered when completed by a physician or mid-level provider (advanced practice professional nurse or physician assistant). 2.14 Excluded Services For information regarding non-covered procedures, please see the Excluded Services section in the General Provider and Participant Information portion of the handbook. 2.15 Immunization Vaccine administration should conform to the Advisory Committee on Immunization Practices (ACIP) guidelines for vaccine use. 2.15.1 State-Supplied Free Vaccines The Vaccine for Children (VFC) program offers a free-vaccine program for children who have not reached their 19 th birthday. When a free vaccine(s) is administered, the Medicaid claim must include the following information: The CPT code for the vaccine with modifier SL billed at a zero dollar amount ($0.00). The CPT code that accurately reflects the administration of the vaccine(s). 2.15.1.1 Administration of State-Supplied Free Vaccine with Evaluation and Management (E/M) Visit If there is a significant, separately identifiable service performed at the time of the vaccine administration, an E/M visit may also be billed, and the Medicaid claim must include the following information. The CPT code for the vaccine with modifier SL billed at a zero dollar amount ($0.00). The CPT code that accurately reflects the administration of the vaccine(s). The CPT code for the E/M visit with modifier 25. Note: In order to bill the E/M code, documentation in the participant s record must reflect that additional services were rendered at the time the vaccine was given. November 16, 2017 Page 14 of 36
2.15.1.2 Administration of a Provider Purchased Childhood Vaccine With or Without an Evaluation and Management (E/M) Visit This should only occur when a free vaccine is not available. Services provided should be billed at the usual and customary rate. When a provider-purchased childhood vaccine is administered to a child less than 19 years old, the Medicaid claim must include the following information: The CPT or HCPCS code for the injectable vaccine. The CPT code that accurately reflects the administration of the vaccine(s). If there is a significant, separately identifiable service performed at the time of the vaccine administration, an appropriate E/M code may also be billed with modifier 25. Note: In order to bill the E/M code, documentation in the participant s record must reflect that a significant, separately identifiable service was rendered at the time the vaccine was given. See General Provider and Participant Information, Periodicity Schedule for the complete schedule of age-appropriate health history and health screening services. 2.15.1.3 Administration of a Provider Purchased Adult Vaccine With or Without an Evaluation and Management (E/M) Visit When an injection or adult vaccine is administered, the Medicaid claim must include the following information: The CPT code for the vaccine(s) without a modifier. The CPT code that accurately reflects the administration of the vaccine. If applicable, the appropriate CPT code for the E/M visit with modifier 25. Note: In order to bill the E/M code, documentation in the participant s record must reflect that a significant, separately identifiable service was rendered at the time the vaccine was given. 2.15.1.4 Administration of an Injection that is Part of a Procedure When an injection is administered that is part of a procedure (i.e., allergy injections, therapeutic, and diagnostic radiology, etc.), Medicaid will not pay the administration fee(s). 2.15.1.5 Administration Only of an Injectable Vaccine to a Participant with Medicare or Other Primary Payer and Medicaid When billing for a participant who has either Medicare or private insurance in addition to Medicaid, bill Medicare/private insurance first using its billing instructions. If Medicare or the other primary payer combines payment for the administration with the cost of the injectable, a separate administration fee may not be charged. November 16, 2017 Page 15 of 36
2.16 Laboratory Coverage 2.16.1 Physician Office Laboratories Physician office or group practice office laboratories must hold a current Clinical Laboratory Improvement Amendments (CLIA) certificate on file with Molina before Medicaid will reimburse for testing performed in the laboratory. Payments will be denied to any laboratory submitting claims for services not covered by their CLIA certificate. Claims for services rendered outside the effective dates of their CLIA certificate will be denied or may be recouped. Physicians can bill Medicaid for clinical diagnostic laboratory services they personally performed or supervised. Those services are reimbursed at the rate established by Medicaid. Physician-owned laboratories may not bill for tests sent to independent laboratories or pathology laboratories. Medicaid only pays the actual provider of service. An office visit cannot be billed when a participant comes in for a blood draw by a lab technician and does not see the doctor. The lab technician s cost is included in the lab procedure payment. 2.16.2 Independent Laboratories Independent laboratories are not affiliated with a specific physician s office and have a separate provider number. They are able to do testing for multiple groups of physicians. Independent laboratories must bill Idaho Medicaid directly for the services they render. 2.16.3 Pathology Laboratory Procedures Certain pathology lab codes can be broken out into professional and technical components. When billed with place of service 21 (Inpatient), 22 (Outpatient), or 23 (Emergency), a 26 modifier is required, unless the procedure code says, Supervision and Interpretation Only. The hospital will bill for the technical component on its UB-04 claim form. If a pathologist has their own office and equipment, they may bill and be paid for the complete test including those that cannot be broken out into the professional and technical components. 2.16.4 Special Services Handling and conveyance of specimens for transfer from the participant to a place other than a physician s office/place of service 12 (Residence) or 32 (Nursing Home) to a laboratory is covered by Medicaid when billed with procedure code 99001. 2.16.5 Blood Lead Screening for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Federal regulation requires that a screening for lead poisoning be a component of an EPSDT screen. Current Centers for Medicare and Medicaid Services (CMS) policy requires a screening blood lead test for all Medicaid eligible children at 12 months and 24 months of age. In addition, children over the age of 24 months, up to 21 years of age, should receive a screening blood lead test if there is no record of a previous test. November 16, 2017 Page 16 of 36
Providers are required to report lead Poisoning in accordance with IDAPA 16.02.10.380, which states: 01. Reporting Requirements. Each case of lead poisoning must be reported to the Department or Health District within three (3) working days of the identification of the case when determined by symptoms or a blood level of: (4/11/15) a. Ten (10) micrograms or more per deciliter (10 ug/dl) of blood in adults eighteen (18) years and older; or (4/11/15) b. Five (5) micrograms or more per deciliter (5 ug/dl) of blood in children under eighteen (18) years of age. (4/11/15) 02. Investigation. Each reported case of lead poisoning or excess lead exposure may be investigated to confirm blood lead levels, determine the source, and whether actions need to be taken to prevent additional cases. (4/11/15) The Department of Health and Welfare (DHW) reimburses providers for lead testing (CPT 83655) performed by a venous blood draw or by capillary test (CPT 36416). DHW will provide a LeadCare Analyzer machine to providers at no cost. This machine tests for lead by a simple capillary test (finger prick). The results are available immediately. Please contact the Medical Care Unit at 1 (208) 364-1835, or see www.medunit.dhw.idaho.gov, for more information on lead screening. 2.16.6 PKU Testing Newborn screening kits (PKU) are a covered benefit of the Idaho Medicaid Program. Use HCPCS procedure code S3620. Test kits are ordered through the Idaho Newborn Screening Program and must be purchased in advance from this program provider: Idaho Newborn Screening Program 450 West State Street, 4 th floor PO Box 83720 Boise, ID 83720-0036 1(208) 334-4927 in the Boise calling area Note: Follow-up PKU testing for participants diagnosed with PKU can be done in a laboratory. Nutritional services are available for children and pregnant women on the PW Program and are limited to two nutritional services visits per calendar year or per pregnancy. The services must meet the following criteria: Determined to be medically necessary. Ordered by a licensed physician, physician assistant, or nurse practitioner. Performed by a registered dietician or an individual who has a baccalaureate degree from a U.S. regionally accredited college or university, and who has met the academic and professional requirements in dietetics as approved by the American Dietetic Association. 2.16.7 Controlled Substance and Drug Testing Testing for the presence of controlled substances and drugs is only covered when medically necessary for the treatment of a substance use disorder. The physician must be providing or coordinating treatment to order testing. Medical necessity is established with criteria set by CMS and their Idaho regional Medicare contractor, Noridian. Testing is not covered when November 16, 2017 Page 17 of 36
court ordered, or as a condition of employment or probation unless incidental to established medical necessity. 2.17 Obstetrics and Gynecology 2.17.1 Obstetrics Overview Obstetric (OB) care must be billed as a global charge unless the attending physician (or another physician working in the same practice) did not render all components of the care. Antepartum and postpartum care may be billed separately from the delivery only when the services were rendered by a different physician or group. High risk pregnancy case management services are now available to support providers in caring for Idaho Medicaid participants. Pregnant women who are at risk for premature labor or congenital issues of the fetus may be referred to a QIO Case Manager, who will telephonically assist with the coordination of in-home and community support services. To make a referral, contact Telligen at 1 (866) 538-9510 and request Case Management Services. A nurse case manager will send a packet of information to the participant with information about the voluntary, no-cost service. If the participant wishes to participate, they will return the signed form to Telligen. 2.17.1.1 Total Obstetric (OB) Care Total OB care includes cesarean section or vaginal delivery, with or without episiotomy, with or without forceps, or breech delivery. Charges for total OB care must be billed after the delivery using the date of delivery as the to and from date. The initial office examination for diagnosis of a pregnancy may be billed separate from the total OB charges if that is the provider s standard practice for all OB participants. If the participant is new to the office, a new patient office visit code should be used. The initial examination must be identified as such and billed with the appropriate Evaluation and Management (E/M) CPT code. Prenatal diagnostic laboratory charges, such as a complete urinalysis, should be billed as separate charges using appropriate CPT codes. If an outside laboratory, not the clinic, did services, the lab must bill Medicaid directly. Resuscitation of the newborn infant is covered separately if billed under the child s name and Medicaid identification (MID) number. 2.17.1.2 Place-of-Service (POS) Code The POS code for total OB care is normally 21 (Inpatient), and must be in field 24B on the CMS-1500 claim form, or in the appropriate field of the electronic claim. 2.17.1.3 Antepartum Care Antepartum care includes the following usual prenatal services: Recording weight, blood pressure, and fetal heart tones. Routine dipstick urinalyses. Maternity counseling. November 16, 2017 Page 18 of 36
2.17.1.4 Billing for Incomplete Antepartum Care If the physician sees the participant for part of the prenatal care but does not deliver, submit charges only for the services rendered. When billing for the initial physical examination and the second or third follow up visit, use the appropriate E/M CPT code. Any laboratory services not previously submitted can be billed using the appropriate CPT code. Do not bill for lab charges sent to an outside laboratory. Bill only for the services rendered. When billing for four to six prenatal visits, use CPT code 59425 with the total charge for all visits on one line. Do not split out each visit. Enter the first date the participant was seen in both the from and to date fields on the CMS-1500 claim form. If billing a paper CMS-1500 claim form, note the date for each additional visit in field 19. When billing for seven or more prenatal visits with or without an initial visit, use CPT code 59426 with the total charge and the description, Antepartum Care Only, on one line with one charge. Do not split out each visit. Enter the first date the participant was seen in both the from and to date fields on the CMS-1500 claim form. If billing a paper CMS-1500 claim form, note the date for each additional visit in field. 2.17.1.5 Billing Ultrasounds and Stress Tests for Multiple Pregnancies Use the following guidelines to bill for each occurrence of a Primary Code Always document a multiple pregnancy with an appropriate ICD-9-CM/ICD-10-CM diagnosis code Effective 07/01/2015, modifier 51 is no longer a valid modifier for use with the following service codes: 59020, 59025, 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76818, 76819 Modifier 59 may be used for the Primary Codes, if all of the following requirements are met: o Patient s record includes documentation of medical necessity for a repeat primary procedure on the same day and at least 15 minutes apart o The two services are not ordinarily provided on the same day o No other modifier better describes the circumstances Note: Modifier 59 is not subject to CCI edits and should be used appropriately according to national standards. 2.17.1.6 Postpartum Care Postpartum care includes hospital and office visits in the 45 days following vaginal or cesarean section delivery. Postpartum care also includes contraceptive counseling. 2.17.1.7 Billing for Multiple Deliveries Delivery of the first baby should be billed with the appropriate CPT code (59400 or 59510), one (1) unit, and only the charges for the first delivery. Delivery of any additional babies should be billed with a delivery code (59409, 59514, 59612, or 59620), modifier 51 and 59, one (1) unit. All antepartum or postpartum care should be included in the delivery code for the first baby. November 16, 2017 Page 19 of 36