RELATES TO:
KRS
205.520,
205.560,
42
C.F.R. 431.615,
42
U.S.C. 1320d to
1320d-8,
45 C.F.R. Parts 160, 164
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health
Services, Department for Medicaid Services, has responsibility to administer
the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any 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 preventive and remedial public health
services provided through the Department for Public Health and the method of
reimbursement for these services by the Kentucky Medicaid Program.
Section 1. Definitions.
(1) "Add-on code" means a designated CPT code
which may be used in conjunction with another CPT code to denote that an
adjunctive service has been performed.
(2) "CPT code" means a code used for
reporting procedures and services performed by physicians or other licensed
medical professionals, including a provider type twenty (20), which is
published annually by the American Medical Association in Current Procedural
Terminology.
(3) "Department" means
the Department for Medicaid Services or its designated agent.
(4) "Incidental" means that a medical
procedure:
(a) Is performed at the same time
as a more complex primary procedure; and
(b)
1.
Requires few additional physician resources; or
2. Is clinically integral to the performance
of the primary procedure.
(5) "Integral" means that a medical procedure
represents a component of a more complex procedure performed at the same
time.
(6) "Medically necessary" or
"Medical necessity" means a covered benefit is determined to be needed in
accordance with
907
KAR 3:130.
(7) "Mutually exclusive" means that two (2)
procedures:
(a) Are not reasonably performed
in conjunction with one another during the same patient encounter on the same
date of service;
(b) Represent two
(2) methods of performing the same procedure;
(c) Represent medically impossible or
improbable use of CPT codes; or
(d)
Are described in current procedural terminology as inappropriate coding of
procedure combinations.
(8) "Provider type twenty (20)" means an
enrolled preventive services provider who conducts covered services via the
Department for Public Health to Medicaid recipients. A number shall be assigned
by the department to these providers, and the first two (2) digits shall be
twenty (20).
(9) "Relative value
unit" or "RVU" means the Medicare-established value assigned to a CPT code
which takes into consideration the physician's work, practice expense, and
liability insurance.
(10)
"Screening" means the evaluation of a recipient by a physician or other
approved public health provider to determine:
(a) The presence of a disease or medical
condition; and
(b) The necessity of
further evaluation, diagnostic tests or treatment.
Section 2. Participation
Requirements.
(1) The Department for Public
Health shall comply with the terms and conditions established in the following
administrative regulations:
(b)
907
KAR 1:671, Conditions of Medicaid provider
participation; withholding overpayments, administrative appeal process, and
sanctions; and
(c)
907
KAR 1:672, Provider enrollment, disclosure, and
documentation for Medicaid participation.
(2) The Department for Public Health shall
comply with the requirements regarding the confidentiality of personal medical
records as mandated by
42
U.S.C.
1320d to
1320d-8
and 45 C.F.R. Parts
160 and
164.
Section 3. Covered Services. The following
medically-necessary preventive, screening, diagnostic, rehabilitative, and
remedial services provided by the Department for Public Health directly or
indirectly through its subcontractors shall be covered:
(1) Preventive medicine counseling;
(2) Genetic testing for diagnostic
purposes;
(3)
Immunizations;
(4) A chronic
disease service;
(5) A communicable
disease service;
(6) An early and
periodic screening, diagnosis, and treatment (EPSDT) service;
(7) A family planning service;
(8) A maternity service; or
(9) A pediatric service.
Section 4. Service Limitations.
(1) A laboratory procedure shall be limited
to a procedure for which the provider has been certified in accordance with 42
C.F.R. Part
493 .
(2) A service
allowed in accordance with 42 C.F.R.
441, Subpart E or Subpart F shall be
covered within the scope and limitations of these federal
regulations.
(3) Coverage for a
fetal diagnostic ultrasound procedure shall be limited to two (2) per nine (9)
month period per recipient unless the diagnosis code justifies the medical
necessity of an additional procedure.
Section 5. Reimbursement Pursuant to the
Preventive Health Fee Schedule.
(1) Payment
for a preventive health service specified in Section 3(1) through (9) of this
administrative regulation shall be calculated by multiplying the current
Medicare conversion factor for Kentucky by the nonfacility relative value unit
weight for the procedure code.
(2)
For a service covered under Medicare Part B, reimbursement shall be in
accordance with
907
KAR 1:006.
(3) If a copayment is required in accordance
with
907 KAR
1:604, reimbursement shall be reduced by the amount of
the copayment.
(4) If performed
concurrently, separate reimbursement shall not be made for a procedure that has
been determined by the department to be incidental, integral, or mutually
exclusive to another procedure.
(5)
Except for an applicable add-on code, reimbursement for an anesthesia service
shall be limited to one (1) CPT code and one (1) unit of anesthesia per
operative session.
(6)
Reimbursement for a surgical procedure shall include the following:
(a) A preoperative service;
(b) An intraoperative service;
(c) A postoperative service and follow-up
care:
1. Within ninety (90) days following the
date of major surgery; or
2. Within
ten (10) days following the date of minor surgery; and
(d) A preoperative consultation performed
within two (2) days of the date of the surgery.
(7) A dental service performed pursuant to
this administrative regulation shall be reimbursed pursuant to the DMS Dental
Fee Schedule established pursuant to
907
KAR 1:026.
Section 6. Audits.
(1) The Department for Public Health or
subcontracting local health departments shall provide to the Department for
Medicaid Services or a representative of an agency or office listed in
subsection (2) of this section, upon request:
(a) Information maintained by the provider to
document the service provided;
(b)
Information regarding a payment claimed by the provider for furnishing a
service; or
(c) Information
documenting the cost of the service.
(2) Access to provider or subcontractor
records relating to a service provided shall be required for:
(a) A representative of the United States
Department of Health and Human Services;
(b) The United States Centers for Medicare
and Medicaid Services;
(c) The
United States Attorney General's Office;
(d) The state Attorney General's
Office;
(e) The state Auditor's
office;
(f) The Office of the
Inspector General; or
(g) An agent
or representative as may be designated by the Secretary of the Cabinet for
Health Services.
Section
7. Appeal Rights.
(1) 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.
(2) An appeal of a department decision
regarding a Medicaid recipient based upon an application of this administrative
regulation shall be in accordance with
907
KAR 1:563.
(3) An appeal of a department decision
regarding Medicaid eligibility of an individual shall be in accordance with
907
KAR 1:560.