Physician Assistant Handbook

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Physician Assistant Handbook

  1. 1. Florida Medicaid Physician Assistant Coverage and Limitations Handbook Agency for Health Care Administration
  2. 2. UPDATE LOG PHYSICIAN ASSISTANT SERVICES COVERAGE AND LIMITATIONS HANDBOOK How to Use the Update Log Introduction Changes to the handbook will be sent out as handbook updates. An update can be a change, addition, or correction to policy. It may be either a pen and ink change to the existing handbook pages or replacement pages. It is very important that the provider read the updated material and file it in the handbook, as it is the provider’s responsibility to follow correct policy to obtain Medicaid reimbursement. Explanation of the The provider can use the update log to determine if all the updates to the Update Log handbook have been received. Update No. is the month and year that the update was issued. Effective Date is the date that the update is effective. Instructions 1. Make the pen and ink changes and file new or replacement pages. 2. File the cover page and pen and ink instructions from the update in numerical order after the log. If an update is missed, write or call the Medicaid fiscal agent at the address given in Appendix C of the Florida Medicaid Provider General Handbook. UPDATE NO. EFFECTIVE DATE Jul1999—Replacement Pages January 1999 Jan2000—Revised Fee Schedule January 2000 Jan2000—Revised Handbook January 2000 Jan2001—Revised Handbook January 2001 02-1—Replacement Pages January 2002 02-2—Replacement Pages April 2002 03-1—Replacement Pages March 2003 Jan2004—Revised Handbook January 2004 Jan2005—Remove Appendices D and E January 2005
  3. 3. PHYSICIAN ASSISTANT SERVICES COVERAGE AND LIMITATIONS HANDBOOK Table of Contents Chapter/Topic Page Introduction Handbook Use and Format........................................................................................ii Characteristics of the Handbook................................................................................iii Handbook Updates ....................................................................................................iii Chapter 1 – Provider Qualifications and Enrollment Purpose and Definition...............................................................................................1-1 Provider Qualifications ...............................................................................................1-2 Provider Enrollment ...................................................................................................1-3 Provider Requirements ..............................................................................................1-4 Mobile Physician Assistant Units ...............................................................................1-6 Chapter 2 - Covered Services, Limitations, and Exclusions General Services Requirements, Limitations and Exclusions ...................................2-1 Adult Health Screening Services ...............................................................................2-4 Chemotherapy Services.............................................................................................2-7 Custodial Care Facility Services ................................................................................2-9 Family Planning Services...........................................................................................2-10 Family Planning Waiver Services ..............................................................................2-15 Immunization Services ...............................................................................................2-16 Injectable Medication Services ..................................................................................2-19 Newborn Hearing Screenings ....................................................................................2-21 Nursing Facility Services............................................................................................2-24 Obstetrical Care Services ..........................................................................................2-25 Orthopedic Services...................................................................................................2-31 Pathology Services ....................................................................................................2-32 Physician Assistant Evaluation and Management Services ......................................2-34 Psychiatric Services ...................................................................................................2-39 Surgery Services........................................................................................................2-41 Chapter 3 - Procedure Codes and Special Situation Codes Reimbursement Information.......................................................................................3-1 How to Read the Physician Assistant Fee Schedule.................................................3-3 Modifiers and Their Descriptions ...............................................................................3-6 Pricing Modifiers.........................................................................................................3-8 Procedures Limited to Specific Diagnosis Codes ......................................................3-13 Appendix A: Mammography Diagnosis Codes ..........................................................A-1 Appendix B: Outpatient Hysterectomy Diagnosis Codes ..........................................B-1 Appendix C: Diagnosis Code Lists for MRIs and CT Scans......................................C-1 Appendix D: Reserved ..............................................................................................D-1 Appendix E: Reserved ..............................................................................................E-1
  4. 4. Physician Assistant Services Coverage and Limitations Handbook INTRODUCTION TO THE HANDBOOK Overview Introduction This chapter introduces the format used for the Florida Medicaid handbooks and tells the reader how to use the handbooks. Background There are three types of Florida Medicaid handbooks: • Provider General Handbook describes the Florida Medicaid Program. • Coverage and Limitations Handbooks explain covered services, their limits, who is eligible to receive them, and the fee schedules. • Reimbursement Handbooks describe how to complete and file claims for reimbursement from Medicaid. Exceptions: For Prescribed Drugs and Transportation Services, the coverage and limitations handbook and the reimbursement handbook are combined into one. Legal Authority The following federal and state laws govern Florida Medicaid: • Title XIX of the Social Security Act, • Title 42 of the Code of Federal Regulations, • Chapter 409, Florida Statutes, and • Chapter 59G, Florida Administrative Code. The specific Federal Regulations, Florida Statutes, and the Florida Administrative Code, for each Medicaid service are cited for reference in each specific coverage and limitations handbook. In This Chapter This chapter contains: TOPIC PAGE Handbook Use and Format ii Characteristics of the Handbook iii Handbook Updates iii January 2004 i
  5. 5. Physician Assistant Services Coverage and Limitations Handbook Handbook Use and Format Purpose The purpose of the Medicaid handbooks is to furnish the Medicaid provider with the policies and procedures needed to receive reimbursement for covered services provided to eligible Florida Medicaid recipients. The handbooks provide descriptions and instructions on how and when to complete forms, letters or other documentation. Provider The term “provider” is used to describe any entity, facility, person or group who is enrolled in the Medicaid program and renders services to Medicaid recipients and bills Medicaid for services. Recipient The term “recipient” is used to describe an individual who is eligible for Medicaid. General Handbook General information for providers regarding the Florida Medicaid Program, recipient eligibility, provider enrollment, fraud and abuse policy, and important resources is included in the Florida Medicaid Provider General Handbook. This general handbook is distributed to all enrolled Medicaid providers and is updated as needed. Coverage and Each coverage and limitations handbook is named for the service it describes. Limitations A provider who furnishes more than one type of service will have more than one Handbook coverage and limitations handbook. Reimbursement Each reimbursement handbook is named for the claim form that it describes. Handbook Chapter Numbers The chapter number appears as the first digit before the page number at the bottom of each page. Page Numbers Pages are numbered consecutively throughout the handbook. Page numbers follow the chapter number at the bottom of each page. White Space The "white space" found throughout a handbook enhances readability and allows space for writing notes. ii January 2004
  6. 6. Physician Assistant Services Coverage and Limitations Handbook Characteristics of the Handbook Format The format styles used in the handbooks represent a concise and consistent way of displaying complex, technical material. Information Block Information blocks replace the traditional paragraph and may consist of one or more paragraphs about a portion of the subject. Blocks are separated by horizontal lines. Each block is identified or named with a label. Label Labels or names are located in the left margin of each information block. They identify the content of the block in order to facilitate scanning and locating information quickly. Note Note is used most frequently to refer the user to pertinent material located elsewhere in the handbook. Note also refers the user to other documents or policies contained in other handbooks. Topic Roster Each chapter contains a topic roster on the first page, which serves as a table of contents for the chapter, listing the subjects and the page number where the subject can be found. Handbook Updates Update Log The first page of each handbook will contain the update log. Every update will contain a new updated log page with the most recent update information added to the log. The provider can use the update log to determine if all updates to the current handbook have been received. Each update will be designated by an “Update No.” and the “Effective Date”. January 2004 iii
  7. 7. Physician Assistant Services Coverage and Limitations Handbook Handbook Updates, continued How Changes Are The Medicaid handbooks will be updated as needed. Changes may consist of Updated any one of the following: 1. Pen and ink updates—Brief changes will be sent as pen and ink updates. The changes will be incorporated on replacement pages the next time replacement pages are produced. 2. Replacement pages—Lengthy changes or multiple changes that occur at the same time will be sent on replacement pages. Replacement pages will contain an effective date that corresponds to the effective date of the update. 3. Revised handbook—Major changes will result in the entire handbook being replaced with a new effective date throughout. Numbering Update Replacement pages will have the same number as the page they are replacing. Pages If additional pages are required, the new pages will carry the same number as the preceding replacement page with a numeric character in ascending order. (For example: page 1-3 may be followed by page 1-3.1 to avoid reprinting the entire chapter.) Effective Date of The month and year that the new material is effective will appear in the inner New Material corner of each page. The provider can check this date to ensure that the material being used is the most current and up to date. If an information block has an effective date that is different from the effective date on the bottom of the page, the effective date will be included in the label. Identifying New New material will be indicated by vertical lines. The following information blocks Information give examples of how new labels, new information blocks, and new or changed material within an information block will be indicated. New Label A new label for an existing information block will be indicated by a vertical line to the left and right of the label only. New Label and A new label and a new information block will be identified by a vertical line to the New Information left of the label and to the right of the information block. Block New Material in New or changed material within an existing information block will be indicated an Existing by a vertical line to the left and right of the information block. Information Block New or Changed A paragraph within an information block that has new or changed material will Paragraph be indicated by a vertical line to the left and right of the paragraph. Paragraph with new material. iv January 2004
  8. 8. Physician Assistant Services Coverage and Limitations Handbook CHAPTER 1 PHYSICIAN ASSISTANT SERVICES PROVIDER QUALIFICATIONS AND ENROLLMENT Overview Introduction This chapter defines who is an eligible physician assistant and describes the provider qualifications, enrollment requirements, and general program requirements. Background The federal authority governing the provisions, requirements, benefits, and service payment of the Physician Assistant Program is Part 440.60 in Title 42, Code of Federal Regulations (C.F.R.). The state authority for the licensing of PA providers is Chapters 458 and 459, Florida Statutes (F.S.). The Florida Medicaid Physician Assistant Services Program is authorized by Chapter 409, F.S., and Chapter 59G, Florida Administrative Code (F.A.C.). In This Chapter This chapter contains TOPIC PAGE Purpose and Definition 1-1 Provider Qualifications 1-2 Provider Enrollment 1-3 Provider Requirements 1-4 Mobile Physician Assistant Units 1-6 Purpose and Definition Purpose Medicaid reimburses Medicaid-enrolled physician assistants (PAs) for the services listed in Chapter 2 of this handbook that are provided to Medicaid-eligible recipients. January 2004 1-1
  9. 9. Physician Assistant Services Coverage and Limitations Handbook Purpose and Definition, continued Purpose of This This handbook is intended for use by PAs who provide services to Medicaid Handbook recipients. It must be used in conjunction with the Florida Medicaid Provider Reimbursement Handbook, CMS-1500, which contains specific procedures for submitting claims for payment, and the Florida Medicaid Provider General Handbook, which describes the Florida Medicaid Program. Physician A PA is a health care professional who is certified to provide diagnostic and Assistant therapeutic patient care. Definition Provider Qualifications Physician To enroll as a Medicaid provider, a PA must be fully licensed as a physician Assistant assistant as defined in Chapter 458 or Chapter 459, Florida Statutes. Qualifications Collaborative To enroll as a Medicaid provider, a PA must submit a collaborative agreement Agreement form signed by the PA and a Florida licensed practitioner that documents the professional relationship between the PA and the practitioner. If a PA refers a recipient to the collaborating physician, and the collaborating physician is not a Medicaid provider, the PA must advise the recipient that the provider is not enrolled in Medicaid and that the recipient may be billed for the services that the physician renders. The PA must have available a list of Medicaid-enrolled providers from the area Medicaid office for referral to Medicaid- enrolled physicians. The PA may request a list of enrolled practitioners from the area Medicaid office. Collaborative agreement forms are available from the Medicaid fiscal agent by calling 800-289-7799 or from its website at http://floridamedicaid.acs-inc.com. Note: The area Medicaid office telephone numbers and addresses are in Appendix C of the Florida Medicaid Provider General Handbook. Qualified at the PAs must meet all the provider requirements and qualifications and their Time of practices must be fully operational before they can be enrolled as Medicaid Enrollment providers. 1-2 January 2004
  10. 10. Physician Assistant Services Coverage and Limitations Handbook Provider Enrollment General PAs must meet the general Medicaid provider enrollment requirements that are Enrollment contained in Chapter 2 of the Florida Medicaid Provider General Handbook. In Requirements addition, PAs must follow the specific enrollment requirements that are listed in this section. Group Providers Two or more Medicaid-enrolled providers whose practice is incorporated under the same tax identification number must enroll as a Medicaid provider group. In order to receive payment from Medicaid, each member of the group must also enroll as an individual treating provider within the group. The group must have a unique location code for each location in which a group member practices as described below. Multiple Both individual and group providers who have practices at more than one Locations location, i.e., satellite offices, must have a separate location code for each practice location. A location code is a physical location identifier that corresponds to the last two digits of the provider’s Medicaid number. Providers must use the location code assigned to the practice location when billing for services provided at that location. The provider must notify the Medicaid fiscal agent of additional practice locations. Notification must be made in writing on an Application for a New Location Code and must include an effective date for the new location. Applications for New Location Codes can be obtained from the Medicaid fiscal agent by calling 800-289-7799 or from its website at http://floridamedicaid.acs- inc.com. Any closure of a practice location must also be reported to the Medicaid fiscal agent, in writing on office letterhead stationery, along with the effective date of the closure. PA in a Physician If a PA is employed by or contracts with a physician who can enroll as a Group Medicaid provider, the physician must enroll as a group provider and the PA must enroll as a treating provider within the group. If the PA owns the group practice, then the PA must enroll as the group provider, and the other members of the group, including physicians, must enroll as individual treating providers belonging to the group. If the services rendered by the PA are billed with the PA as the treating provider, the services must be provided in accordance with the policies and limitations contained in this handbook. January 2004 1-3
  11. 11. Physician Assistant Services Coverage and Limitations Handbook Provider Enrollment, continued Individual It is the responsibility of the individual treating provider to notify the Medicaid Provider fiscal agent of all group practices for which they are affiliated. Responsibility Within a Group Any individual treating provider who is terminating a relationship with a group Practice practice must notify the Medicaid fiscal agent in writing of the termination in order to update the group’s provider file. Child Health To be reimbursed for Child Health Check-Up screenings, the PA must enroll to Check-Up provide Child Health Check-Up screenings as an additional category of service. Providers This is category of service code 55. The PA must provide the screenings in accordance with the policies in the Florida Medicaid Child Health Check-Up Coverage and Limitations Handbook. Provider Requirements General In addition to the general provider requirements and responsibilities that are Requirements contained in Chapter 2 of the Florida Medicaid Provider General Handbook, PA providers are also responsible for complying with the provisions contained in this section. Provider Florida Medicaid has implemented all of the requirements contained in the Responsibility federal legislation known as the Health Insurance Portability and Accountability Act (HIPAA). As trading partners with Florida Medicaid, all Medicaid providers, including their staff, contracted staff, and volunteers, must comply with HIPAA privacy requirements effective April 14, 2003. Providers who meet the definition of a covered entity, according to HIPAA, must comply with HIPAA Electronic Data Interchange (EDI) requirements effective with the implementation of HIPAA. This coverage and limitation handbook contains information regarding changes in procedure codes mandated by HIPAA. The Medicaid Provider Reimbursement Handbooks contain the claims processing requirements for Florida Medicaid, including the changes necessary to comply with HIPAA. Note: For more information regarding HIPAA privacy in Florida Medicaid, see Chapter 2 in the Florida Medicaid Provider General Handbook. Note: For more information regarding claims processing changes in Florida Medicaid because of HIPAA, see the Florida Medicaid Provider Reimbursement Handbook, CMS-1500. Note: For information regarding changes in EDI requirements for Florida Medicaid because of HIPAA, contact the Medicaid fiscal agent EDI help desk at 800-820-0218. 1-4 January 2004
  12. 12. Physician Assistant Services Coverage and Limitations Handbook Provider Requirements, continued Physician A PA must adhere to physician supervision guidelines set forth in Chapters 458 Supervision and 459, F.S. and Chapters 64B8-30 and 64B15-6, F.A.C. Services provided by a PA must be within the specialty of the supervising physician. A physician may supervise up to a maximum of four PAs per Chapters 458 and 459, F.S. Direct Physician Services provided by a PA under the direct supervision of a physician may be Supervision billed using the physician’s provider number instead of the PA’s provider number. Direct physician supervision means the physician: • Is on the premises when the services are rendered, and • Reviews, signs and dates the medical record An exception is Child Health Check-Up screenings. The PA must directly render Child Health Check-Up screenings and bill using his or her Medicaid ID number. Medicaid will not reimburse the physician and the physician assistant for the same service to the same recipient on the same day. Note: See the Florida Medicaid Child Health Check-Up Services Coverage and Limitations Handbook for a complete description of Child Health Check-Up services. Rural Health Physician assistants who are enrolled as rural health clinic providers must bill for Clinics services in accordance with the policies in the Florida Medicaid Rural Health Clinic Coverage and Limitations Handbook. PAs Employed by A PA who is salaried by a facility that is reimbursed by Medicaid on a cost- Facilities related basis may not be reimbursed on a fee-for-service basis if the cost for the PA’s salary is included in the facility’s cost report. January 2004 1-5
  13. 13. Physician Assistant Services Coverage and Limitations Handbook Mobile Physician Assistant Units Description A mobile physician assistant (PA) unit is a fully operational vehicle, unit, or trailer that travels to different locations for the provision of PA services and is not a stationary PA unit. Limitations and Mobile unit providers must contract with only County Health Departments (CHDs) Exceptions or Federally Qualified Health Centers (FQHCs). Rural Health Clinic (RHC) mobile units must be certified by Medicare as mobile RHCs in accordance with the Code of Federal Regulations, Title 42. Medicaid will reimburse CHDs, FQHCs, and RHCs for mobile unit PA services. Mobile unit services must be provided and billed in compliance with this handbook and the applicable CHD, FQHC or RHC Coverage and Limitations Handbook. 1-6 January 2004
  14. 14. Physician Assistant Services Coverage and Limitations Handbook CHAPTER 2 PHYSICIAN ASSISTANT SERVICES COVERED SERVICES, LIMITATIONS, AND EXCLUSIONS Overview Introduction This chapter describes the services covered under the Florida Physician Assistant Services Program. It also describes limited or excluded services. Topic Roster This chapter contains: TOPIC PAGE General Services Requirements, Limitations and Exclusions 2-1 Adult Health Screening Services 2-4 Chemotherapy Services 2-7 Custodial Care Facility Services 2-9 Family Planning Services 2-10 Family Planning Waiver Services 2-15 Immunization Services 2-16 Injectable Medication Services 2-19 Newborn Hearing Screenings 2-21 Nursing Facility Services 2-24 Obstetrical Care Services 2-25 Orthopedic Services 2-31 Pathology Services 2-32 Physician Assistant Evaluation and Management Services 2-34 Psychiatric Services 2-39 Surgery Services 2-41 General Services Requirements, Limitations and Exclusions Covered Only those services designated in this chapter and listed on the Physician Services Assistant Procedure Codes and Fee Schedule in Appendix D may be reimbursed by Medicaid to a physician assistant (PA). Limitations Certain services are designated with limitations by diagnosis or other limitations in Appendixes A, B, and C. Other limitations specified in this handbook also apply. January 2004 2-1
  15. 15. Physician Assistant Services Coverage and Limitations Handbook General Services Requirements, Limitations and Exclusions, continued Medically Medicaid reimburses for services that are determined medically necessary and Necessary do not duplicate another provider’s service. In addition, the services must meet the following criteria: • Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain; • Be individualized, specific, consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the recipient’s needs; • Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational; • Reflect the level of services that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; and • Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient’s caretaker, or the provider. The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a covered service. Note: See the Glossary in the Florida Medicaid Provider General Handbook for the definition of medically necessary. Duplicate Medicaid will not reimburse a PA and the following provider types for the same Services procedure, same recipient, and same date of service: • Advanced registered nurse practitioner • Chiropractor • County health department • Federally qualified health center • Licensed midwife • Physician • Podiatrist • Registered nurse first assistant • Rural health clinic • Schools 2-2 January 2004
  16. 16. Physician Assistant Services Coverage and Limitations Handbook General Services Requirements, Limitations and Exclusions, continued Service Limitations Medicaid will reimburse only one visit per PA or PA and physician group, per recipient, per day, except for emergency services. Certain procedure codes have service frequency limitations based on utilization control measures. Routine Physicals Payment for routine physicals for recipients 21 and older is limited to the adult health screening service. For recipients under age 21, it is limited to the Child Health Check-Up program. To be reimbursed for Child Health Check-Up screenings, the PA must enroll to provide Child Health Check-Up screenings as an additional category of service. The Child Health Check-Up category of service code is 55. The PA must provide the screenings in accordance with the policies in the Florida Medicaid Child Health Check-Up Coverage and Limitations Handbook and bill for the screenings on the CMS-1500 claim form. Recipients Out of the Medicaid does not reimburse for services furnished to recipients when they are Country out of the country. Maximum Fee The maximum fee is intended to pay the PA for performing the complete procedure including both the technical and professional components. It can be billed only when the same provider performs all components. January 2004 2-3
  17. 17. Physician Assistant Services Coverage and Limitations Handbook Adult Health Screening Services Description An adult health screening is performed by a PA to assess the health status of a Medicaid recipient age 21 and older. It is used to detect and prevent disease, disability and other health conditions or monitor their progressions. This service is not reimbursed for recipients residing in an ICF/DD as these services are covered by the per diem. This is an all-inclusive service. No separate billing for required or recommended components is allowed. Adult Health Medicaid reimburses adult health screening services for recipients age 21 and Screening older with the following procedure codes and no modifier: Procedure Codes • 99385 for new patient age 21-39; • 99386 for new patient age 40-64; • 99387 for new patient age 65 years and older; • 99395 for established patient age 21-39; • 99396 for established patient age 40-64; and • 99397 for established patient age 65 years and older. Screening Medicaid will reimburse for one adult health screening every 365 days. Schedule Adult health screenings are recommended: • For age 21 through 39, one screening every five years, • Age 40 and over, one screening every two years. Required Service A PA who provides adult health screenings must be able to provide or refer and Components coordinate the provision of all required screening components. The required components must be documented in the recipient’s medical record. Required components include the following: • Health history, including any pertinent psychiatric history, • Physical examination, including mental status exam, • Visual acuity testing, • Hearing screen, • Laboratory procedures, and • Referral for or provision of treatment when health problems or deficiencies are diagnosed. Descriptions of these components are provided the following pages. 2-4 January 2004
  18. 18. Physician Assistant Services Coverage and Limitations Handbook Adult Health Screening Services, continued Health History At a minimum, the following items must be documented in the recipient’s medical record: • Present history, • Past history, • Family history, • List of all known risk factors, and • Nutritional assessment. Physical At a minimum, the following items must be documented in the recipient’s Examination medical record: • Measurements of height, weight, blood pressure and pulse; and • Physical inspection to include assessment of general appearance, skin, eyes, ears, nose, throat, teeth, thyroid, heart, lungs, abdomen, breasts, extremities; and performance of pelvic, testicular, rectal, and prostate exam as appropriate per recipient gender. Visual Acuity At a minimum, visual acuity testing must document a recipient’s ability to see at Testing 20 feet. Hearing Screen At a minimum, a hearing screen must document a recipient’s ability to hear by air conduction. Required At a minimum, the following laboratory procedures are required and are included Laboratory in the reimbursement of an adult health screening: Procedures • Urinalysis dipstick for blood, sugar, and acetone; and • Hemoglobin or hematocrit. Urinalysis, Manual or automated urine, hemoglobin and hematocrit tests performed as part Hemoglobin and of an adult health screening are not reimbursed in addition to the adult health Hematocrit screening. The provider may not bill for them as separate procedures. Recommended The following screening components are recommended: Service Components • Mammography screening referral, and • Laboratory procedures. Descriptions of these recommended components follow. January 2004 2-5
  19. 19. Physician Assistant Services Coverage and Limitations Handbook Adult Health Screening Services, continued Recommended Referral for routine screening mammography is recommended by the American Mammography Cancer Society for all females age 35 and older. Screening Referral Mammography screening guidelines are as follows: • Age 35 to 39, one screening baseline mammogram and • Age 40 and over, one screening mammogram every year. A screening mammogram is limited to one a year. A diagnostic mammogram that is used to evaluate or monitor an abnormal finding is allowed more than once a year. Mammograms performed by a mobile x-ray provider are not reimbursable. Note: See Appendix A in this handbook for the list of diagnosis codes required for reimbursing screening mammograms. Recommended The following laboratory procedures are recommended when indicated: Laboratory Procedures • Stool for occult blood; • Tuberculin skin test; • Collection of cervical pap smear for sexually active females and females 18 years old and older; • Collection of prostatic surface antigen (PSA) for males 50 years old and older; and • Collection of specimens for sexually transmitted diseases. The tuberculin skin test can be reimbursed in addition to the adult health screening. Medicaid does not reimburse providers for venipuncture, collection, handling, or transportation of specimens. This is considered part of the evaluation and management service or global fee-for-services. Note: See Pathology Services in this chapter for additional information on laboratory procedures. Procedure Codes See Appendix D in this handbook for a list and description of procedure codes and Fees and fees. 2-6 January 2004
  20. 20. Physician Assistant Services Coverage and Limitations Handbook Chemotherapy Services Description Chemotherapy services are provided to control the growth of malignant cells or provide immunosuppression. Service Coverage Chemotherapy administration, refilling and maintenance of either portable or implantable pump, chemotherapy injection and provision of chemotherapy agent are covered services. Drugs Chemotherapy drugs administered in the office are reimbursed using the appropriate J code. If no specific J code is available bill procedure code J9999. Code J9999 requires that the provider submit medical documentation indicating the drug, dosage, and route of administration given to the recipient. Without all of these components, the claim will be denied. If a J code is not available for non-chemotherapy drugs, bill procedure code J3490. Reimbursement will be the average wholesale price less 13.25 percent. Visits and Procedure codes for chemotherapy services are reimbursed in addition to a Chemotherapy recipient office visit. Either may occur independently on any date of service, or they may occur sequentially on the same day. Agent Chemotherapy agent preparation is included in the service for administration of Preparation the agent. Regional and Regional chemotherapy perfusion is reimbursed using codes for arterial infusion. Parenteral Separate codes for each parenteral method of administration employed may be reimbursed when chemotherapy is administered by different techniques. Placement of an intra-arterial catheter must be billed using the appropriate code from the cardiovascular surgery section of the CPT. January 2004 2-7
  21. 21. Physician Assistant Services Coverage and Limitations Handbook Chemotherapy Services, continued Administration The provider must bill separate codes for each method of administration employed when chemotherapy is administered by different techniques. Service Medicaid does not reimburse for off-label use or investigational drugs. Off-label Limitations use, for the purpose of Medicaid reimbursement, shall be defined as the use of a drug, whether an FDA approved drug or not, when that drug is prescribed for any purpose, treatment or indication which is not specifically set forth in the most current FDA guide for that drug. Investigational use, for the purposes of Medicaid reimbursement, shall be defined as the use of a drug, whether an FDA approved drug or not, when that drug is used as an approved product in the context of a clinical study protocol. Procedure Codes See Appendix D in this handbook for a list and description of procedure codes and Fees and fees. 2-8 January 2004
  22. 22. Physician Assistant Services Coverage and Limitations Handbook Custodial Care Facility Services Description Custodial care facility services are evaluation and management services that are provided to a recipient in a facility that provides room, board, and other personal assistance services, generally on a long-term basis. It includes domiciliary, rest home, or custodial care facilities such as: • Assisted Living Facilities (ALF), • Adult Foster Homes (AFH), • Extended Congregate Care Facilities (ECC), and • Continuing Care Retirement Communities (CCRC). Service Visits for chronic care management are limited to one per month, per recipient, Frequency per PA or another PA, ARNP, or physician of the same specialty who belongs to the same provider group. Acute Care Events Episodic care visits to manage acute events can be reimbursed when the claim is submitted with a 22 modifier and a report is submitted documenting the care provided. Claims will be reviewed by the Medicaid medical consultant for medical necessity. Facility Visit A custodial care facility visit is not reimbursed in addition to another evaluation and management visit on the same day, same provider, same recipient. Excluded Consultation services rendered in a custodial care facility cannot be reimbursed. Services Services provided in an office or room located in a custodial care facility are not reimbursable as PA office visit. Psychiatric services, including pharmacologic management, rendered in a custodial care facility cannot be reimbursed. Procedure Codes See Appendix D in this handbook for a list and description of procedure codes and Fees and fees. January 2004 2-9
  23. 23. Physician Assistant Services Coverage and Limitations Handbook Family Planning Services Description Family planning services can be provided to Medicaid-eligible persons of childbearing age who desire family planning services and supplies. The services are for the purpose of spacing children or preventing pregnancies. Note: For sterilization procedures, see Surgery Services in this chapter. Family Planning Services specific to family planning are reimbursed with CPT procedure codes for Procedure Codes preventive medicine and require the use of the modifier FP. Effective for dates Description Procedure Code Modifier of service on or New Patient Family Planning Visit 99384-99386 FP after October 16, 2003. Established Patient Family Planning Visit 99394-99396 FP Family Planning Counseling Visit 99403 FP Family Planning Supply Visit 99211 FP These services are not reimbursable when billed using any other evaluation and management procedure code. Services for Medicaid does not reimburse for family planning services for a minor (under age Minors 18) unless the minor: • Has his or her parent’s or legal guardian’s consent; • Is married; • Is a parent; • Is pregnant; or • Will suffer from probable health hazards if such services are not provided as determined by the physician, ARNP, or PA based on sexual activity or other medical reasons. The provider must document the reason for providing family planning services to the minor in the recipient’s medical record. Initial Visit Only one initial family planning visit, per recipient, per provider or provider group Components can be reimbursed. The following minimum components must be provided and documented in the recipient’s medical record: • Health history; • Pre-examination education session; • Physical examination; • Required laboratory tests; • Selection of contraceptive method, provision of supplies; and • Post-examination interview. 2-10 January 2004
  24. 24. Physician Assistant Services Coverage and Limitations Handbook Family Planning Services, continued Annual Visit The following minimum components must be provided during an annual family Components planning visit and documented in the recipient’s medical record: • Updating the original data in the patient record; • Physical examination; • Cervical Pap Smear, if not performed within the past three months and results available in the medical record; • Addressing renewal needs of contraceptive method, and • Post-examination interview. Annual visit reimbursements are limited to one every 365 days. Required A cervical pap smear is required for initial or annual family planning visits. Laboratory Tests If a cervical pap smear was performed within the past three months, and the results are available, the test does not need to be repeated. The cervical pap smear is billed by the pathologist. No billing is allowed for the collection, handling, or transportation of laboratory specimens. Recommended The following laboratory tests are recommended for an initial or annual family Laboratory Tests planning visit, when indicated: • Hemoglobin/hemotocrit; • Urinalysis; • Screening for sexually transmitted diseases; • Rubella titer; and Tuberculin skin test. The tuberculin skin test may be reimbursed separately in addition to the family planning service. The rubella and sexually transmitted disease screens are billed by the pathologist or independent laboratory provider providing the service. January 2004 2-11
  25. 25. Physician Assistant Services Coverage and Limitations Handbook Family Planning Services, continued Counseling Visit Counseling visits are rendered to discuss the family planning method chosen or to discuss other available methods. Counseling visits should include information on natural family planning methods. The following components must be provided and documented in the recipient’s medical record: • All information necessary to increase the recipient’s understanding of and motivation for family planning; • Provision of supplies for the contraceptive method, if indicated; and • Identification of any problems with current birth control method. A counseling visit and supply visit are not reimbursable for same date of service, same recipient, to a PA or another PA, ARNP, or physician of the same specialty who belongs to the same provider group. HIV Counseling HIV counseling is reimbursable using procedure codes 99401 or 99402 when HIV testing is indicated. Medicaid will reimburse for a counseling session performed prior to obtaining the specimen for HIV screening and again when blood screening test results are available. HIV counseling must clearly relate to a family planning visit on the same date of service or within the previous 12 months. A family planning ICD-9-CM diagnosis code (V25.01 through V25.9) must be entered on the claims submitted for procedure codes 99401 and 99402. HIV counseling sessions may be billed in addition to a family planning visit or an evaluation and management visit when all components of either visit are performed. HIV counseling sessions are limited to four per year, per recipient acknowledging HIV risks. They are limited to two per lifetime, per recipient for preventive counseling. HIV Medical records documentation must identify risk factors as appropriate or state, Documentation “no acknowledged risk.” Documentation for post-test HIV counseling sessions must minimally contain referrals as appropriate to programs such as the Department of Health’s Partner Elicitation/Notification Program and community mental health agencies. 2-12 January 2004
  26. 26. Physician Assistant Services Coverage and Limitations Handbook Family Planning Services, continued Supply Visit Supply visits are rendered to assess the recipient and to provide family planning supplies such as birth control pills or condoms. The following minimum components must be provided and documented in the recipient’s medical record: • Check of weight and blood pressure; • Check for any side effect of medications; and • Provision of supplies or prescriptions for the contraceptive method. Supply visit reimbursements are limited to once per month. All prescriptions for family planning supplies are reimbursed through the Medicaid Pharmacy program. Natural Methods Training on use of natural family planning methods is not reimbursable. Norplant Norplant services include provision of the Norplant kit and insertion or removal of the capsules. The Norplant System Kit is billed with procedure code A4260. Insertion or removal of Norplant is reimbursable in addition to a family planning initial or annual visit or an evaluation and management visit if all components of an evaluation and management visit are met and documented in addition to the Norplant services. Intrauterine Insertion of an IUD is reimbursable in addition to a family planning initial or Device (IUD) annual visit or an evaluation and management visit if all components of an evaluation and management visit are met and documented in addition to the IUD service. Reimbursement for the IUD device is covered using the appropriate J code or HCPCS procedure code. Procedure code 99070 is not an appropriate code and cannot be reimbursed for an IUD. Removal of an IUD is reimbursable when performed as a separate procedure. No visits can be reimbursed on the same day to the same provider. January 2004 2-13
  27. 27. Physician Assistant Services Coverage and Limitations Handbook Family Planning Services, continued Diaphragms and Provision of diaphragms and cervical caps is by prescription and reimbursed Cervical Caps through the Medicaid Pharmacy Program. The diaphragm or cervical cap fitting can be reimbursed to the PA DepoProvera and Services associated with the decision to use DepoProvera or Lunelle as a Lunelle contraceptive method are covered using the appropriate family planning code. Reimbursement for the medication is covered using the appropriate J code. Pregnancy A pregnancy test may be indicated prior to the use of a particular contraceptive Testing method. Pregnancy testing may be reimbursed if all components of the service are provided. Specimens for pregnancy testing sent to an independent lab may be reimbursed to the laboratory. The provider may not bill for the collection of the specimen. Urinalysis, Manual or automated urine, hemoglobin and hematocrit tests performed as part Hemoglobin and of a family planning visit are not reimbursed in addition to the family planning Hematocrit visit. Providers may not bill for them as separate procedures. Service Limits Family planning procedure codes are not reimbursable on the same date of and Exclusions service to the same recipient with any evaluation and management procedure codes. Procedure Codes See Appendix D in this handbook for a list and description of procedure codes and Fees and fees. 2-14 January 2004
  28. 28. Physician Assistant Services Coverage and Limitations Handbook Family Planning Waiver Services Eligibility The family planning waiver extends eligibility for family planning services for 24 months to postpartum women who have had a Medicaid-financed delivery or pregnancy-related service within two years prior to the date of losing Medicaid eligibility. Note: See Chapter 3 in the Florida Medicaid Provider General Handbook for additional information on Family Planning Waiver Services. Covered Services Recipients are eligible for all the Medicaid-covered family planning services listed under the “Family Planning Services” topic, family-planning related pharmacy services, antibiotics and vaginal antifungals and anti-infectives to treat sexually- transmitted diseases (STDs), sterilization, colposcopy, and transportation to family planning services. Transportation to family planning services is billed by the Medicaid transportation provider. Pharmaceutical services to family planning waiver recipients are billed by the pharmacy dispensing the prescription. Evaluation and Evaluation and management procedure codes 99201 and 99211 are Management reimbursable when the recipient either returns for STD counseling and treatment Codes or has been referred to the RHC for this service. Documentation in the recipient’s medical record must include all components of the evaluation and management service and the status of the recipient related to either the initial or established visit. If initial visit (99201) is billed, the provider must state that the recipient was referred and include the name of referring provider in the recipient’s medical record. The provider must enter diagnosis code 099.9 (venereal disease, unspecified) on the claim form. January 2004 2-15
  29. 29. Physician Assistant Services Coverage and Limitations Handbook Family Planning Waiver Services, continued Service All other Medicaid services are excluded. Exclusions Service Claims for extended family planning services must be submitted with the Requirements following diagnosis codes: E&M codes 99201 and 99211 099.9 Family planning V25.01-V25.9 Colposcopy 622.1, 795.0, or 795.1 * Lab procedure for sexually- 634.0-634.9, 054.0-054.9, 078.0- transmitted diseases 078.19,079.88, 079.98, 090.3-099.9, 112.0-112.9, 131.0-131.9, or V25.09 *Place the appropriate diagnosis code on the order for the tests. Prescriptions Prescriptions to treat sexually transmitted diseases must have “FP” written on them. Immunization Services Description Immunization services provide vaccines to induce a state of being immune to or being protected from a disease. Medicaid reimburses for these services for recipients birth through 20 years of age. Eligible Medicaid eligible recipients from birth through 18 years of age are eligible to Recipients receive free vaccines through the federal Vaccine For Children (VFC) program. The provider may be reimbursed only for the administration of the vaccine. The vaccine is free to the provider through the Vaccine For Children (VFC) program. Medicaid eligible recipients 19 through 20 years of age may receive vaccines through their health care provider. These vaccines are not free to the provider and are reimbursed by Medicaid. Reimbursement includes the administration fee. Medicaid does not reimburse immunization services for recipients who are 21 years of age and older. 2-16 January 2004
  30. 30. Physician Assistant Services Coverage and Limitations Handbook Immunization Services, continued Vaccine for Information regarding the Vaccine for Children (VFC) Program is available by Children Program calling 800-4-VFC-KID or 800-483-2543. (VFC) Vaccines for For eligible recipients from birth through 18 years of age, vaccines and Recipients combination vaccines providing protection against the following diseases are Birth through 18 available free to the provider through the VFC program: Years • Diptheria • Hemophilus influenza type B (HIB) • Hepatitis A • Hepatitis B • Influenza • Measles • Mumps • Pertussis • Poliomyelitis • Pneumococcal • Rubella • Tetanus • Varicella Vaccines for For eligible recipients ages 19 through 20 years, vaccines and combination Recipients 19 vaccines providing protection against the following diseases are reimbursable: Through 20 Years • Diphtheria • Hepatitis A • Hepatitis B • Influenza • Measles • Mumps • Pneumococcal • Rubella • Tetanus • Varicella January 2004 2-17
  31. 31. Physician Assistant Services Coverage and Limitations Handbook Immunization Services, continued Meningococcal Medicaid reimburses the cost of the vaccine and an administration fee for all Vaccine recipients 2-20 years of age who receive the vaccine. Administration Medicaid reimburses an administration fee to physicians, ARNPs and PAs Fee providing free vaccine through the VFC Program to Medicaid-eligible recipients Reimbursement from birth through 18 years of age. Vaccine Medicaid reimbursement for providing vaccines to Medicaid-eligible recipients 19 Reimbursement through 20 years of age includes the cost of the vaccine and an administration fee. The provider must bill with the assigned HCPCS code assigned to the vaccine. Effective with dates of service on or after October 16, 2003, the provider must bill with the appropriate HCPCS procedure code assigned to the vaccine and a modifier HA. Child Health A Child Health Check-Up screening is reimbursable in addition to the Check-Up reimbursement fee for immunizations. Evaluation and Evaluation and management (E&M) services are reimbursable in addition to the Management administration fee for vaccines, provided the visit is for a separate and identifiable Services service and the services are documented in the medical record. Immunization Providers should use the current Recommended Childhood Immunization Schedule Schedule that was developed and endorsed by the Advisory Committee on Immunization Practices, the Committee on Infectious Diseases of the American Academy of Pediatrics, and Infectious Diseases of the American Academy of Family Physicians. The most recent schedule is available on the Centers for Disease Control website at www.cdc.gov/nip. Procedure Codes See Appendix D in this handbook for a list and description of procedure codes and Fees and fees. 2-18 January 2004
  32. 32. Physician Assistant Services Coverage and Limitations Handbook Injectable Medication Services Description Injectable medication services provide for injection of medication into the body. Procedure Code Injectable medications are reimbursed by billing the appropriate A, J, Q, S or HCPCS code when a provider purchases and administers the medication in the office. Non-FDA Medicaid does not reimburse for non-FDA approved medications. Approved Medications Medicaid does not reimburse for procedures that are experimental or when non- FDA approved medications are included in the procedures. Evaluation and The cost of the injectable medication, if it is covered under Florida Medicaid, is Management reimbursable in addition to an evaluation and management (E&M) service. E&M Services services are reimbursable in addition to the administration of an injectable medication, provided the visit is for a separate and identifiable service and the services are documented in the medical record. Reimbursement Medicaid reimburses for injectable medications based on the average wholesale Rate price (AWP) less 13.25 percent. See Appendix D in this handbook for a list and description of procedure codes. Unclassified Procedure code J3490 (unclassified drugs, non-chemotherapy) or J9999 Drugs (chemotherapy) is utilized for any injectable medication without an established A, J, Q, S or HCPCS procedure code, when medication is purchased and administered in the PA’s office. Medical documentation identifying the drug, dosage, and route of administration and initials of the health care professional administering the drug are required for reimbursement of the medication. Without all of these components, the claim will be denied. Reimbursement for J3490 and J9999 is the average wholesale price less 13.25 percent. January 2004 2-19
  33. 33. Physician Assistant Services Coverage and Limitations Handbook Injectable Medication Services, continued Service Medicaid does not reimburse for off-label use or investigational drugs. Limitations Off-label use, for the purpose of Medicaid reimbursement, shall be defined as the use of a drug, whether a Food and Drug Administration (FDA) approved drug or not, when that drug is prescribed for any purpose, treatment or indication which is not specifically set forth in the most current FDA guide for that drug. Investigational use, for the purposes of Medicaid reimbursement, shall be defined as the use of a drug, whether an FDA approved drug or not, when that drug is used as an approved product in the context of a clinical study protocol. 2-20 January 2004
  34. 34. Physician Assistant Services Coverage and Limitations Handbook Newborn Hearing Screenings Description The newborn hearing screening is for the purpose of testing all Medicaid-eligible newborns for hearing impairment to alleviate the adverse effects of hearing loss on speech and language development, academic performance, and cognitive development. The screening is a test or battery of tests administered to determine the need for an in-depth hearing diagnostic evaluation. Newborns are required to either have the screening prior to discharge from the hospital or birthing center or a referral must be made for the screening. Who Can All newborn and infant hearing screenings must be conducted by an audiologist Perform the licensed under Chapter 468, F.S.; a physician licensed under Chapter 458 or 459, Screenings F.S.; or an individual who has completed documented training specifically for newborn hearing screenings and who is directly supervised by a licensed physician or licensed audiologist. Direct supervision means the licensed physician or licensed audiologist: • Is on the premises when the services are rendered, and • Reviews, signs, and dates the medical record. Indirect supervision means the licensed physician or licensed audiologist: • Is available, so as to be physically present to provide consultation or direction in a timely fashion as required for appropriate care of the patient; and • Reviews, signs, and dates the medical record. Eligible Medicaid reimburses for newborn hearing screenings for all eligible recipients from Recipients birth through 12 months of age. Any testing services performed on recipients who are over 12 months old must be performed based on medical necessity and prescribed by and documented by the physician. Required Service The required service components for infant hearing screening include at a Components minimum: • Recipient’s name, • Screening outcome for each ear, and • Any auditory risk factors. January 2004 2-21
  35. 35. Physician Assistant Services Coverage and Limitations Handbook Newborn Hearing Screenings, continued Required All newborn hearing screening claims must include a diagnosis of V72.1 on the Diagnosis Code CMS-1500 claim form for reimbursement. Allowable Non-hospital based hearing services providers who perform screenings in a Reimbursements facility using their own equipment or equipment they lease may bill for a complete procedure. This includes both the technical and professional components of the service, and the provider may receive the maximum allowed reimbursement. Providers who perform screenings in a facility using facility-owned equipment may bill only the professional component, using the appropriate modifier. Note: For additional information, see Pricing Modifiers for the professional component and How to Read the PA Fee Schedule in Chapter 3 of this handbook. Required Any child who is diagnosed as having a permanent hearing impairment must be Referrals referred to the primary care physician for medical management, treatment, and follow-up services. In addition, in accordance with the Infants and Toddlers Program and the Individuals with Disabilities Education Act (Public Law 105-17), any child from birth to 36 months of age who is diagnosed as having a hearing impairment that requires ongoing special hearing services must be referred to the Children’s Medical Services, Early Intervention Program serving the geographical area in which the child resides within two calendar days of identification. Refusal of Service If the newborn’s parent or legal guardian objects to a screening, the screening must not be completed. The provider must maintain a record that the hearing screening was not performed and attach a written objection that is signed by the parent or guardian. Prior There are no prior authorization requirements for newborn hearing screenings. Authorization Medicaid-eligible children who are enrolled in MediPass, HMOs, or Provider Requirements Service Networks do not require pre-authorization. Providers may bill Medicaid for screening services and receive the Medicaid rate of reimbursement. 2-22 January 2004
  36. 36. Physician Assistant Services Coverage and Limitations Handbook Newborn Hearing Screenings, continued Requirements for Appropriate written documentation of service must be placed in the recipient’s Medical Records medical record within 24 hours after the provider completes the screening procedure or within 24 hours of the parent’s or guardians signed refusal of screening. The documentation must include: • Referrals • Screening completion • Results • Interpretation • Recommendations • Follow-up referrals for treatment, if applicable; and • Parent’s or guardian’s refusal of screening, if applicable. Service Medicaid reimburses a maximum of two newborn hearing screenings per eligible Limitations newborn using auditory brainstem response, evoked otoacoustic emissions, or appropriate technology as approved by the United States Food and Drug Administration. If a re-try or noise outcome is received, then the screening must be performed until a pass or fail outcome is received. The process to obtain a pass or fail outcome will result in only one screening reimbursement regardless of the number of screenings performed to obtain the pass or fail outcome. Medicaid reimburses the second screening only if the child does not pass the initial hearing screening test in each ear. Any additional testing required must include a signed statement from the physician placed in the medical record and must be based solely on medical necessity. January 2004 2-23
  37. 37. Physician Assistant Services Coverage and Limitations Handbook Nursing Facility Services Description Nursing facility evaluation and management services are reimbursable when provided to recipients in skilled nursing facilities. Service The provider must bill the nursing facility evaluation and management procedure Requirements codes when providing services to a recipient at a nursing facility. The recipient’s record must contain documentation demonstrating that the visit is medically necessary. Every Medicaid recipient in a nursing facility must have an annual evaluation and management visit (procedure code 99301) performed by the recipient’s primary care provider. Procedure code 99301 may not be billed in addition to other nursing facility codes for chronic care. Service Visits for chronic care management are limited to one per month, per recipient, Limitations by a PA or another PA, ARNP, or physician of the same specialty who belongs to the same provider group. Subsequent ventilator management visits can be reimbursed up to four times per month. Acute Care Events Episodic care visits to manage acute events can be reimbursed if the attending physician is required to visit the patient to make an alteration in the treatment plan of the patient. The procedure must be billed with a 22 modifier. A report documenting the care provided must be submitted with the claim. Claims are reviewed by the Medicaid medical consultant for medical necessity. Facility Visit A nursing facility evaluation and management visit cannot be reimbursed in addition to any other evaluation and management visit on the same date, for the same recipient, for the same PA or another PA, ARNP, or physician of the same specialty who belongs to the same provider group. Excluded Services Services provided in an office or room located in a nursing facility cannot be reimbursed as an office evaluation and management visit. Psychiatric services, including pharmacologic management, rendered in a nursing facility cannot be reimbursed. Procedure Codes See Appendix D in this handbook for a list and description of procedure codes and Fees and fees. 2-24 January 2004
  38. 38. Physician Assistant Services Coverage and Limitations Handbook Obstetrical Care Services Description Obstetrical care services include antepartum, delivery, and postpartum care for the low-medical risk pregnant Medicaid recipient. Note: For information on sterilization, see Surgery Services in this chapter. Direct Supervision All delivery services must be done by or under the direct supervision of the physician. Direct supervision means the supervising physician must: • Be on the premises when the services are rendered; and • Review, sign and date the medical record. Reimbursement Reimbursement for delivery services is made to the physician who directly for Delivery provided the delivery service or to the physician who directly supervised the PA Services who provided the delivery service. On-Call Services When a delivery is performed by a provider who is on-call for another provider, the delivery is billed by the on-call provider who provided the service. Required Prenatal The following components must be provided at each prenatal visit and Services documented in the recipient’s medical record: • Physical examination; • Recording of weight and blood pressure; • Recording of fetal heart tones when clinically appropriate; • Urinalysis and collection of specimens for the laboratory once per pregnancy and at subsequent visits if appropriate; • Hemoglobin or hematocrit once per pregnancy and at subsequent visits if appropriate; • Recipient education, if appropriate; and • Plan of treatment. January 2004 2-25
  39. 39. Physician Assistant Services Coverage and Limitations Handbook Obstetrical Care Services, continued Laboratory The following are included in the reimbursement for any type of prenatal visit: Specimens • Venipuncture, collection, handling, and transportation of specimens sent to an outside laboratory; • Urinalysis; and • Hemoglobin and hematocrit. Other Prenatal The following components must be provided at some point during the pregnancy Services and documented in the recipient’s medical record: • Initial and subsequent history; • Florida’s Healthy Start Prenatal Risk Screening or documentation of refusal; • Offer of HIV counseling and testing; and • Screening of all pregnant women for tobacco use with provision of smoking cessation counseling and appropriate treatment as needed. Prenatal Visit Prenatal visits are limited to a maximum of 10 for low-medical risk recipients. Frequency Prenatal care is prorated, based on an average standard of 10 visits for a low- medical risk. Effective with dates of service on or after October 16, 2003, the procedure code is H1000. Payment for prenatal care is based on a total amount for complete care. Reimbursement for the 10 is the maximum reimbursement for the full course of prenatal care. If additional visits are provided, payment is considered already made in full. The provider may not bill the additional visits to Medicaid or the recipient. To prevent claims denying inappropriately, the provider should bill prenatal visits as they occur. Conditions related to the prenatal period must be billed as prenatal visits. Services provided during the pregnancy that are not related to the pregnancy may be billed as evaluation and management visits with the appropriate non- pregnancy diagnosis code. Prenatal Hospital Prenatal hospital visits in the obstetrical unit for a length of stay less than 24 Visits hours are billed with the appropriate evaluation and management observation codes. 2-26 January 2004
  40. 40. Physician Assistant Services Coverage and Limitations Handbook Obstetrical Care Services, continued Florida’s Healthy The Healthy Start Prenatal Risk Screening should be offered at the first prenatal Start Prenatal Risk visit. The prenatal visit that includes completion of the Healthy Start Prenatal Risk Screening Screening is reimbursed once per pregnancy by billing procedure code H1001. Effective with dates If the Healthy Start Prenatal Risk Screening is completed during the first trimester, of services on or procedure code H1001 with modifier TG should be billed. after October 16, 2003. H1001 is included in the 10 prenatal visit limit for a low-medical risk pregnancy. Florida’s Healthy The provider must retain a copy of the Healthy Start Prenatal Risk Screening form Start Prenatal Risk in the recipient’s medical record to indicate that the screening was completed. Screening Form Do not submit the Healthy Start Prenatal Risk Screening form with the CMS-1500 claim form. (Follow the instructions on the form for the distribution of copies.) If the recipient declines the Healthy Start Prenatal Risk Screening, the provider must document the refusal in the recipient’s medical record, and bill for a prenatal visit (procedure code H1000) instead of a prenatal visit plus Healthy Start Prenatal Risk Screening. Healthy Start Prenatal Risk Screening forms may be obtained from the local county health department. Note: See Chapter 2 in the Florida Medicaid Provider Reimbursement Handbook, CMS-1500, for a copy of Florida’s Healthy Start Prenatal Risk Screening form. Delivery Services Delivery care services include: • Routine hospital admission; • Labor management; • Fetal monitoring; • Intravenous infusion; • Caudal or pudendal block; • Delivery of neonate, vaginal; • Delivery of placenta; • Episiotomy or vaginal repair; • Hospital visits subsequent to delivery; and • Family planning counseling. January 2004 2-27
  41. 41. Physician Assistant Services Coverage and Limitations Handbook Obstetrical Care Services, continued Delivery Services Delivery procedure codes 59410, 59515 and 59614 include immediate that Include postpartum services within the delivery hospitalization. Postpartum Services Postpartum The following components of a postpartum office visit must be provided and Services documented in the recipient’s medical record: • Subsequent history and physical exam; • Urinalysis, hemoglobin, hematocrit, and collection of specimens for the laboratory as indicated; • Counseling regarding family relationships; • Education regarding breast self-exam; • Referrals and counseling as indicated; and • Provision of family planning method chosen by recipient. Postpartum Visit Two postpartum visits within 90 days following delivery may be reimbursed per Frequency pregnancy when medically necessary. Abortions Federal regulations allow payment for abortions only for specific reasons and require the physician to certify the reason for the abortion. Medicaid reimburses for abortions for one of the following reasons: • The woman suffers from a physical disorder, physical injury, or physical illness, including a life endangering physical condition caused or arising from the pregnancy itself, that would place the woman in danger of death unless an abortion is performed; • When the pregnancy is the result of rape as defined in Section 794.011, F.S.; or • When the pregnancy is the result of incest as defined in Section 826.04, F.S. Abortion procedures are reimbursed only for the following diagnoses: 635.00 through 635.92. These diagnosis codes require a fifth digit for reimbursement. An Abortion Certification Form must be completed and signed by the physician who performed the abortion. The form must be submitted with the CMS-1500 claim. The physician must record the reason for the abortion in his medical records for the recipient. Note: See Chapter 2 in the Florida Medicaid Provider Reimbursement Handbook, CMS-1500, for a copy of the Abortion Certification Form and the instructions for completing the form. 2-28 January 2004

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