RELATES TO:
KRS
205.560,
205.565,
210.370-210.485,
311.840,
42 C.F.R.
400.203, Part
414,
415.110,
438.2,
440.50,
447.10,
447.200-447.205,
447.325,
42 U.S.C.
1395m,
1395w-4,
1395x(t)(1),
1396a,
1396b,
1396c,
1396d,
1396s
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(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed, or opportunity presented, by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the method of
reimbursement for physicians' services by the Medicaid program.
Section 1. Definitions.
(1) "Add-on code" or "add-on service" means a
service designated by a specific CPT code that may be used in conjunction with
another CPT code to denote that an adjunctive service has been
performed.
(2) "Anesthesia under
medical direction" means a service that is:
(a) Directed by an
anesthesiologist;
(b) Delivered by
an appropriate and qualified anesthesia provider, including a certified
registered nurse anesthetist; and
(c) Provided concurrently to no more than
four (4) patients by the anesthesiologist.
(3) "Assistant surgeon" means a physician who
attends and acts as an auxiliary to a physician performing a surgical
procedure.
(4) "Community mental
health center" means a facility that meets the community mental health center
requirements established in
902 KAR 20:091.
(5) "CPT code" means a code used for
reporting procedures and services performed by physicians and published
annually by the American Medical Association in Current Procedural
Terminology.
(6) "Department" means
the Department for Medicaid Services or its designee.
(7) "Direct physician contact" means that the
billing physician is physically present with and evaluates, examines, treats,
or diagnoses the recipient.
(8)
"Drug" means the definition of "drugs" pursuant to
42 U.S.C.
1395x(t)(1).
(9) "Federal financial participation" is
defined by 42 C.F.R.
400.203.
(10) "Global period" means the period of time
in which related preoperative, intraoperative, and postoperative services and
follow-up care for a surgical procedure are customarily provided.
(11) "Healthcare common procedure coding
system" means a collection of codes acknowledged by the Centers for Medicare
and Medicaid Services (CMS) that represents procedures or items.
(12) "Incidental" means that a medical
procedure:
(a) Is performed at the same time
as a primary procedure; and
(b)
1. Requires little additional resources;
or
2. Is clinically integral to the
performance of the primary procedure.
(13) "Integral" means that a medical
procedure represents a component of a more complex procedure performed at the
same time.
(14) "Locum tenens
physician" means a substitute physician:
(a)
Who temporarily assumes responsibility for the professional practice of a
physician participating in the Kentucky Medicaid program; and
(b) Whose services are paid under the
participating physician's provider number.
(15) "Major surgery" means a surgical
procedure assigned a ninety (90) day global period.
(16) "Managed care organization" means an
entity for which the department has contracted to serve as a managed care
organization as defined by 42 C.F.R.
438.2.
(17) "Medicaid Physician Fee Schedule" means
a list, located at
https://chfs.ky.gov/agencies/dms/Pages/feesrates.aspx,
that:
(a) Contains the current reimbursement
rates for physician services established by the department in accordance with
this administrative regulation; and
(b) Is updated at least quarterly to coincide
with the quarterly updates made by the Centers for Medicare and Medicaid
Services as required by 42
U.S.C.
1395m and
1395w-4 and
42 C.F.R. Part
414.
(18) "Minor surgery" means a surgical
procedure assigned a ten (10) day global period.
(19) "Modifier" means a reporting indicator
used in conjunction with a CPT code to denote that a medical service or
procedure that has been performed has been altered by a specific circumstance
while remaining unchanged in its definition or CPT code.
(20) "Mutually exclusive" means that two (2)
procedures:
(a) Are not reasonably performed
in conjunction with each other 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.
(21) "Pediatric teaching hospital" is defined
by KRS
205.565(1).
(22) "Physician administered drug" or "PAD"
means any rebateable covered outpatient drug that is:
(a) Provided or administered to a Medicaid
recipient;
(b) Billed by a provider
other than a pharmacy provider through the medical benefit, including a
provider that is a physician office or another outpatient clinical setting;
and
(c) An injectable or
non-injectable drug furnished incident to provider services that are billed
separately to Medicaid.
(23) "Physician assistant" is defined by
KRS
311.840(3).
(24) "Professional component" means the
physician service component of a service or procedure that has both a physician
service component and a technical component.
(25) "Provider group" means a group of at
least two (2) individually licensed physicians who:
(a) Are enrolled with the Medicaid program
individually and as a group; and
(b) Share the same Medicaid provider
number.
(26) "Relative
value unit" or "RVU" means the Medicare-established value assigned to a CPT
code that takes into consideration the physician's work, practice expense, and
liability insurance.
(27)
"Resource-based relative value scale" or "RBRVS" means the product of the
relative value unit (RVU) and a resource-based dollar conversion
factor.
(28) "State university
teaching hospital" means:
(a) A hospital that
is owned or operated by a Kentucky state-supported university with a medical
school; or
(b) A hospital:
1. In which three (3) or more departments or
major divisions of the University of Kentucky or University of Louisville
medical school are physically located and that are used as the primary (greater
than fifty (50) percent) medical teaching facility for the medical students at
the University of Kentucky or the University of Louisville; and
2. That does not possess only a residency
program or rotation agreement.
(29) "Technical component" means the part of
a medical procedure performed by a technician, inclusive of all equipment,
supplies, and drugs used to perform the procedure.
(30) "Usual and customary charge" means the
uniform amount that a physician charges the general public in the majority of
cases for a specific medical procedure or service.
Section 2. Standard Reimbursement.
(1) Reimbursement for a covered service shall
be made to:
(a) The individual participating
physician who provided the covered service; or
(b) The physician:
1. In a provider group enrolled in the
Kentucky Medicaid program; and
2.
Who provided the covered service.
(2) Except as provided in subsection (3) of
this section and Sections 3 through 11 of this administrative regulation,
reimbursement for a covered service shall be the lesser of:
(a) The physician's usual and customary
charge; or
(b) The amount specified
in the Medicaid Physician Fee Schedule established in accordance with this
administrative regulation.
(3) If there is not an established fee for a
listed service in the Medicaid Physician Fee Schedule, the reimbursement shall
be forty-five (45) percent of the usual and customary billed charge.
Section 3. Rates Established Using
a Relative Value Unit and a Dollar Conversion Factor.
(1) Except for a service specified in
Sections 4 through 10 of this administrative regulation:
(a) The rate for a non-anesthesia related
covered service shall be established by multiplying RVU by a dollar conversion
factor to obtain the RBRVS maximum amount specified in the Medicaid Physician
Fee Schedule; and
(b) The rate for
a covered anesthesia service shall be established by multiplying the dollar
conversion factor (designated as X) by the sum of each specific procedure code
RVU (designated as Y) plus the number of units spent on that specific procedure
(designated as Z). A unit shall equal a fifteen (15) minute increment of
time.
(2) The dollar
conversion factor shall be:
(a) Fifteen (15)
dollars and twenty (20) cents for a nondelivery related anesthesia service;
or
(b) Twenty-nine (29) dollars and
sixty-seven (67) cents for all non-anesthesia related services.
Section 4. Medicare
Part B Covered Services. Reimbursement for a service covered under Medicare
Part B shall be made in accordance with
907 KAR 1:006, Section
3.
Section 5. Services with a
Modifier. Reimbursement for a service denoted by a modifier used in conjunction
with a CPT code shall be as established in this section.
(1) A service reported with a two (2) digit
modifier of "51" shall be reimbursed at fifty (50) percent of the fee listed on
the Medicaid Physician Fee Schedule for the service.
(2) A professional component of a service
reported by the addition of the two (2) digit modifier "26" shall be reimbursed
at the product of:
(a) The Medicare value
assigned to the physician's work; and
(b) The dollar conversion factor specified in
Section 3(2) of this administrative regulation.
(3) A technical component of a service
reported by the addition of the two (2) letter modifier "TC" shall be
reimbursed at the product of:
(a) The Medicare
value assigned to the practice expense involved in the performance of the
procedure; and
(b) The dollar
conversion factor specified in Section 3(2) of this administrative
regulation.
(4) A
bilateral procedure reported by the addition of the two (2) digit modifier "50"
shall be reimbursed at 150 percent of the amount assigned to the CPT
code.
(5) An assistant surgeon
procedure reported by the addition of the two (2) digit modifier "80" shall be
reimbursed at sixteen (16) percent of the allowable fee for the primary
surgeon.
(6) A procedure performed
by a physician acting as a locum tenens physician for a Medicaid-participating
physician reported by the addition of the two (2) character modifier "Q6" shall
be reimbursed at the Medicaid Physician Fee Schedule amount for the applicable
CPT code.
(7) An evaluation and
management telehealth consultation service provided by a telehealth provider or
telehealth practitioner in accordance with
907 KAR 3:170 and reported by the
appropriate letter modifier, as applicable, shall be reimbursed at the Medicaid
Physician Fee Schedule amount for the applicable evaluation and management CPT
code.
(8) A level II national
healthcare common procedure coding system modifier designating a location on
the body shall be reimbursed at the Medicaid Physician Fee Schedule amount for
the applicable code.
Section
6. Laboratory, Venipuncture, and Catheter.
(1) Except for a service specified in
paragraph (a) or (b) of this subsection, a physician laboratory service shall
be reimbursed in accordance with
907 KAR 1:028.
(a) Charges for a laboratory test performed
by dipstick or reagent strip or tablet in a physician's office shall be
included in the office visit charge.
(b) A routine venipuncture procedure shall
not be separately reimbursed if submitted with a charge for an office,
hospital, or emergency room visit or in addition to a laboratory
test.
(2) Reimbursement
for placement of a central venous, arterial, or subclavian catheter shall be:
(a) Included in the fee for the anesthesia if
performed by the anesthesiologist;
(b) Included in the fee for the surgery if
performed by the surgeon; or
(c)
Included in the fee for an office, hospital, or emergency room visit if
performed by the same provider.
(3) A laboratory test performed with
microscopy shall be reimbursed separately from an evaluation and management CPT
code.
Section 7.
Delivery-Related Anesthesia, Anesthesia Add-On Services, and Oral
Surgery-Related Anesthesia.
(1) The department
shall reimburse as follows for the following delivery-related anesthesia
services:
(a) For a vaginal delivery, the
lesser of:
1. $215; or
2. The actual billed charge;
(b) For a cesarean section, the
lesser of:
1. $335; or
2. The actual billed charge;
(c) For neuroxial labor anesthesia
for a vaginal delivery or cesarean section, the lesser of:
1. $350; or
2. The actual billed charge;
(d) For an additional anesthesia
for cesarean delivery following neuroxial labor anesthesia for vaginal
delivery, the lesser of:
1. Twenty-five (25)
dollars; or
2. The actual billed
charge; or
(e) For an
additional anesthesia for cesarean hysterectomy following neuroxial labor
anesthesia, the lesser of:
1. Twenty-five (25)
dollars; or
2. The actual billed
charge.
(2)
For an anesthesia add-on service provided to a recipient under the age of one
(1) year or over the age of seventy (70) years, the department shall reimburse
the lesser of:
(a) Twenty-five (25) dollars;
or
(b) The actual billed
charge.
(3) For deep
sedation or general anesthesia relating to oral surgery performed by an oral
surgeon, the department shall reimburse the lesser of:
(a) $150; or
(b) The actual billed charge.
Section 8. Medical
Direction of Anesthesia and Anesthesia Under Medical Direction Services.
(1) A provider or facility performing medical
direction shall comply with all Medicare requirements to perform medical
direction services located in
42 C.F.R.
415.110 and as found in the Medicare Claims
Processing Manual, Chapter 12, Section 50, Paragraph C, as those Medicare
requirements existed at the time of the applicable claim submission. This is a
link to the Medicare Claims Processing Manual, Chapter 12, as it existed in
July 2021:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf.
(2) A reimbursement shall not be made for an
anesthesiologist assistant or a student registered nurse anesthetist unless
those provider types are:
(a) Otherwise
eligible for licensure or certification;
(b) Appropriately enrolled with the
department; and
(c) If applicable,
a managed care organization.
Section 9. Vaccines.
(1) The department shall reimburse
administration of a:
(a) Pediatric vaccine to
a recipient under the age of nineteen (19) years; or
(b) Flu vaccine to a recipient of any
age.
(2)
(a) The department shall reimburse for the
cost of a vaccine administered to a recipient under nineteen (19) years of age,
in addition to administration of the vaccine, for a vaccine that isadministered
to a recipient by a provider.
(b)
For those providers who are enrolled in the Vaccines for Children Program, the
department shall not reimburse for the cost of a vaccine if the vaccine is
readily available at the provider's facility and free through the Vaccines for
Children Program in accordance with
42 U.S.C.
1396s, and
907 KAR 1:680.
Section 10. Physician
Assistant. Reimbursement for a service provided by a physician assistant shall
be seventy-five (75) percent of the amount reimbursable to a physician in
accordance with this administrative regulation.
Section 11. Reimbursement Limits and Related
Requirements.
(1) Reimbursement for an
anesthesia service shall include:
(a)
Preoperative and postoperative visits;
(b) Administration of the
anesthetic;
(c) Administration of
fluids and blood incidental to the anesthesia or surgery;
(d) Postoperative pain management until
discharge from the recovery area;
(e) Preoperative, intraoperative, and
postoperative monitoring services; and
(f) Insertion of arterial and venous
catheters.
(2) With the
exception of an anesthetic, contrast, or neurolytic solution, administration of
a substance to a recipient by epidural or spinal injection for the control of
chronic pain shall be limited to three (3):
(a) Injections per date of service;
and
(b) Dates of service per six
(6) month period.
(3) If
related to the surgery and provided by the physician who performs the surgery,
reimbursement for a surgical procedure shall include the following:
(a) A preoperative service;
(b) An intraoperative service; and
(c) A postoperative service and follow-up
care within:
1. Ninety (90) calendar days
following the date of major surgery; or
2. Ten (10) calendar days following the date
of minor surgery.
(4) Reimbursement for the application of a
cast or splint shall be in accordance with
907 KAR 1:104, Section
3(4).
(5) Multiple surgical
procedures performed by a physician during the same operative session shall be
reimbursed as follows:
(a) The major
procedure, an add-on code, and other CPT codes approved by the department for
billing with units shall be reimbursed in accordance with Section 3(1)(a) or
(2)(b) of this administrative regulation; and
(b) The additional surgical procedure shall
be reimbursed at fifty (50) percent of the amount determined in accordance with
Section 3(1)(a) or (2)(b) of this administrative regulation.
(6) 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.
(7) The
department shall not reimburse for an evaluation and management CPT code
unless:
(a) Direct physician contact occurred
during the visit; or
(b) Direct
physician contact is not required in accordance with
907 KAR 3:005, Section
3(2).
Section
12. Other Provider Preventable Conditions. In accordance with
907 KAR 14:005, the department
shall not reimburse for other provider preventable conditions.
Section 13. Supplemental Payments.
(1) In addition to a reimbursement made
pursuant to Sections 2 through 11 of this administrative regulation, the
department shall make a supplemental payment to a medical school faculty
physician:
(a) Who:
1. Is licensed to practice medicine or
osteopathy in Kentucky;
2. Is
enrolled in the Kentucky Medicaid program in accordance with
907 KAR 1:672;
3. Is participating in the Kentucky Medicaid
program in accordance with
907 KAR 1:671;
4. Is employed by a state university teaching
hospital, a pediatric teaching hospital, or a state university school of
medicine that is part of a university health care system; and
5. Agrees to assign his or her Medicaid
reimbursement, in accordance with
42 C.F.R.
447.10, to the state university entity with
whom the physician is employed; and
(b) For services provided:
1. Directly by the medical school faculty
physician; or
2. By a resident
working under the supervision of the medical school faculty
physician.
(2) A supplemental payment plus other
reimbursements made in accordance with this administrative regulation shall:
(a) Not exceed the physician's charge for the
service provided; and
(b) Be paid
directly or indirectly to the medical school.
(3) A supplemental payment made in accordance
with this section shall be:
(a) Based on the
funding made available through an intergovernmental transfer of funds for this
purpose by a state-supported school of medicine meeting the criteria
established in subsection (1) of this section;
(b) Consistent with the requirements of
42 C.F.R.
447.325; and
(c) Made on an annual basis.
Section 14. The
department shall reimburse for physician administered drugs in accordance with
907 KAR 23:020.
Section 15. Not Applicable to Managed Care
Organizations.
(1) A managed care
organization may elect to reimburse the same amount for physician services as
the department does.
(2) A managed
care organization shall not be required to reimburse the same amount as
established in this administrative regulation for a physician service
reimbursed by the department via this administrative regulation.
Section 16. Federal Financial
Participation. The department's reimbursement for services pursuant to this
administrative regulation shall be contingent upon:
(1) Receipt of federal financial
participation for the reimbursement; and
(2) Centers for Medicare and Medicaid
Services approval for the reimbursement.
Section 17. Appeal Rights.
(1) 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.
(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.