907 KAR 1:028 - Independent laboratory and radiological service coverage and reimbursement
RELATES TO: KRS 205.520, 205.560, 333.090, 42 C.F.R. 440.30, Part 493, 42 U.S.C. 1395l(h)(1)(A), 1396a(a)(9), 1396b(i)(7), 1396d
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services, has responsibility to administer the Medicaid Program. KRS 205.520 authorizes the cabinet, by administrative regulation, to comply with a requirement that may be imposed or opportunity presented by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes the provisions relating to the coverage of and reimbursement for independent laboratory and radiological services.
Section
1. Definitions.
(1) "CLIA" means
the Clinical Laboratory Improvement Amendments, 42 C.F.R. Part 493 .
(2) "CMS" means the Centers for Medicare and
Medicaid Services.
(3) "Covered
benefit" or "covered service" means an independent laboratory or radiological
service for which the department shall reimburse.
(4) "CPT" means the current procedural
terminology coding system.
(5)
"Department" means the Department for Medicaid Services or its
designee.
(6) "Incidental" means a
medical procedure or service which:
(a)
1. Is performed at the same time as a more
complex primary procedure or service; and
2. Requires little additional resources;
or
(b) Is clinically
integral to the performance of the primary procedure or service.
(7) "Independent laboratory" means
a laboratory which:
(a) Is certified by CMS
under the CLIA to perform laboratory services;
(b) Is independent of an institutional
setting;
(c) Is a
Medicare-participating facility;
(d) Meets the requirements established in 42
C.F.R. Part 493 regarding laboratory certification, registration, or other
accreditation as appropriate; and
(e) Is a Medicaid-enrolled
provider.
(8) "Laboratory
director" means an individual meeting the director of laboratory qualifications
established in
KRS
333.090(1), (2), or
(3).
(9) "Medicaid-enrolled provider" means a
provider participating in the Kentucky Medicaid Program in accordance with
907
KAR 1:671 and
907
KAR 1:672.
(10) "Medically necessary" or "medical
necessity" means a covered benefit determined to be needed in accordance with
907
KAR 3:130.
(11) "Medicare-participating" means certified
by CMS and accepting reimbursement from Medicare.
(12) "Mutually exclusive" means two (2)
laboratory or radiological services:
(a) Not
reasonably provided in conjunction with one (1) another during the same patient
encounter on the same date of service; or
(b) Representing:
1. Duplicate or very similar items;
or
2. Medically inappropriate use
of CPT codes.
(13) "Prescriber" means a physician,
podiatrist, optometrist, dentist, oral surgeon, advanced registered nurse
practitioner, or physician's assistant who:
(a) Is acting within the legal scope of
clinical practice under the licensing laws of the state in which the health
care provider's medical practice is located;
(b) Is in good standing with:
1.The licensure board of jurisdiction for the
provider's practice; and
2.
CMS;
(c) Has the legal
authority to write an order for a medically necessary service for the
recipient; and
(d) If enrolled as a
Kentucky Medicaid provider, is in compliance with all requirements of
907
KAR 1:671 and
907
KAR 1:672.
(14) "Radiological service" means a service
in which X-rays or rays from radioactive substances are used for diagnostic or
therapeutic purposes.
(15)
"Recipient" is defined in
KRS
205.8451(9).
(16) "Usual and customary" means the uniform
amount which a provider charges the general public for a specific procedure or
service.
Section 2.
Coverage.
(1) The department shall reimburse
for a procedure provided by an independent laboratory if the procedure:
(a) Is one that the laboratory is certified
to provide by Medicare and in accordance with
907
KAR 1:575;
(b) Is a covered service within the CPT code
range of 80047-89356 except as excluded in Section 3 of this administrative
regulation;
(c) Is prescribed in
writing or by electronic request by a physician, podiatrist, dentist, oral
surgeon, advanced registered nurse practitioner, or optometrist; and
(d) Is supervised by a laboratory
director.
(2) The
department shall reimburse for a radiological service if the service:
(a) Is provided by a facility that:
1. Is licensed to provide radiological
services;
2. Meets the requirements
established in
42 C.F.R.
440.30;
3. Is certified by Medicare to provide the
given service;
4. Is a
Medicare-participating facility;
5.
Meets the requirements established in 42 C.F.R. Part 493 regarding laboratory
certification, registration, or other accreditation as appropriate;
and
6. Is a Medicaid-enrolled
provider;
(b) Is
prescribed in writing or by electronic request by a physician, oral surgeon,
dentist, podiatrist, optometrist, advanced registered nurse practitioner, or a
physician's assistant;
(c) Is
provided under the direction or supervision of a licensed physician;
and
(d) Is a covered service within
the CPT code range of 70010-78999.
Section 3. Exclusions. The department shall
not reimburse for an independent laboratory or radiological service under this
administrative regulation for the following services or procedures:
(1) A procedure or service with a CPT code of
88300-88399;
(2) A procedure or
service with a CPT code of 89250-89356;
(3) A service provided to a resident of a
nursing facility or an intermediate care facility for individuals with an
intellectual disability; or
(4) A
court-ordered laboratory or toxicology test.
Section 4. Reimbursement.
(1) The department shall reimburse an
independent laboratory the current Medicare rate established by CMS:
(a) For Kentucky;
(b) For the covered service or procedure;
and
(c) In accordance with
42 U.S.C.
1395l(h)(1)(A).
(2) Reimbursement for a service provided by
an independent laboratory shall not exceed the limit established in
42 U.S.C.
1396b(i)(7).
(3) The department shall reimburse a
Medicaid-enrolled provider licensed to provide radiological services:
(a) The provider's usual and customary charge
for the service; and
(b) Not to
exceed sixty (60) percent of the upper payment limit established for the
procedure in the Medicaid physician fee schedule pursuant to
907 KAR
3:010.
Section 5. Provider Participation Conditions.
(1) To be reimbursed by the department for a
service provided in accordance with this administrative regulation, a provider
of independent laboratory services or radiological services shall:
(a) Be a Medicaid-enrolled
provider;
(c)
Comply with the requirements regarding the confidentiality of personal records
pursuant to
42
U.S.C. 1320d-8 and 45 C.F.R. parts 160 and
164; and
(d) Annually submit
documentation of:
1. Current CLIA
certification to the department if the provider is an independent laboratory;
and
2. A current radiological
license to the department if the provider provides radiological
services.
(2)
A provider may bill a recipient for a service not covered by the department if
the provider informed the recipient of noncoverage prior to providing the
service.
Section 6.
Appeal Rights.
(1) An appeal of a department
decision regarding a recipient based upon an application of this administrative
regulation shall be in accordance with
907
KAR 1:563.
(2) An appeal of a department decision
regarding Medicaid eligibility of an individual shall be in accordance with
907
KAR 1:560.
(3) An appeal of a department decision
regarding a Medicaid provider based upon an application of this administrative
regulation shall be in accordance with
907
KAR 1:671.
Notes
STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.560, 42 C.F.R. 441.17
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