Important Contacts . viii Other Important Numbers . xi HRSA Billing Instructions . xii Definitions.1 INTRODUCTION
Section A: Procedure Codes/Dx Codes/Noncovered Services/ Managed Report/Conversion
Grace Period for Discontinued Codes . A.2
HRSA’s Managed Care Organizations . A.3
Codes for Unlisted Procedures (CPT codes xxx99) . A.4
National Correct Coding Initiative . A.5
Services by Substitute Physician-How to Bill . A.6
PROGRAMS (Guidelines and Limitations)
Section B: Office/Outpatient/Children’s Health/Inpatient/ Observation Care/Detoxification/ER/ESRD/Critical Care/Physician Standby/Osteopathic Manipulation/Newborn Care/NICU/PICU/ Oversight/Domiciliary/Rest Home/Custodial Care/Telehealth
Office and Other Outpatient Services . B.1
Hospital Inpatient and Observation Care Services . B.3
Table of Contents # Memo 09-40 Changes are highlighted Physician-Related Services Table of Contents (cont.) Section B: Continued…
Smoking
Emergency Physician-Related Services . B.12
Neonatal Intensive Care Unit (NICU)/Pediatric Intensive Care
Physicians Providing Service to Hospice Clients . B.22
Domiciliary, Rest Home, or Custodial Care Services . B.23
Section C: EPSDT/Immunizations/Immune Globulins/Injections
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) . C.1
Therapeutic or Diagnostic Injections . C.17
Section D: Vision Care Services
Section E: Allergen Immunotherapy/Psychiatric Services/ Podiatric/Radiology/Pathology
Covered Services for Psychiatrists Using ICD-9-CM Diagnosis
Noncovered Services for Psychiatrists Using ICD-9-CM Diagnosis
Limitations for Inpatient and Outpatient Psychiatric Services . E.4
Expanded Mental Health Services for Children . E.5
Section F: Chemotherapy/Surgical/Anesthesia/Major Trauma
Table of Contents # Memo 09-40 Changes are highlighted Physician-Related Services Table of Contents (cont.)
Section G: Continued…
Outpatient
Genetic Counseling and Genetic Testing . G.16
Section H: Reproductive Health Services
How does HRSA define reproductive health services? . H.1
Physician Services Provided to Clients on the Family Planning Only Program
What is the purpose of the Family Planning Only program? . H.6
What drugs and supplies are paid under the Family Planning Only program? . H.8
Maternity Care and Delivery
Prenatal Assessments are not Covered . H.11
Global (Total) Obstetrical (OB) Care . H.11
Additional Monitoring for High-Risk Conditions . H.15
General Obstetrical Payment Policies and Limitations . H.18
Smoking Cessation for Pregnant Women . H.21
Table of Contents # Memo 09-40 Changes are highlighted Physician-Related Services Table of Contents (cont.)
Section H: Continued…
Sterilization
What are HRSA’s payment requirements for sterilizations? . H.24
Additional Requirements for Sterilization of Mentally Incompetent or
When does HRSA waive the 30-day waiting period? . H.25
When does HRSA not accept a signed Sterilization Consent Form? . H.26
Why do I need a DSHS-approved Sterilization Consent Form? . H.26
Who completes the Sterilization Consent Form? . H.27
Frequently Asked Questions on Billing Sterilizations . H.28
How to complete the Sterilization Consent Form? . H.29
How to complete the Sterilization Consent Form for a Client Age 18-20 . H.31
Sample Sterilization Consent Form . H.32
Sample Sterilization Consent Form for a client age 18-20 . H.33
Abortion Center Contracts (Facility Fees) . H.36
PRIOR AUTHORIZATION
Section I: Prior Authorization
“Write or Fax” Prior Authorization (PA) . I.2
Expedited Prior Authorization (EPA) . I.4
Washington State EPA Criteria Coding List . I.6
HRSA-Approved Centers of Excellence (COE) . I.12
HRSA-Approved Organ Transplant COE . I.13
HRSA-Approved Sleep Study Centers . I.15
HRSA-Approved Bariatric Hospitals and Their Associated Clinics . I.19
Table of Contents # Memo 09-40 Changes are highlighted Physician-Related Services Table of Contents (cont.)
Section J: Site of Service (SOS) Payment Differential
How are fees established for professional services performed in facility
How does the SOS payment policy affect provider payments? . J.1
Does HRSA pay providers differently for services performed in
When are professional services paid at the facility setting maximum
When are professional services paid at the non-facility setting
Which professional services have a SOS payment differential? . J.4
Section K: Medical Supplies and Equipment/Injectable Drug Codes
Supplies Included In Office Call (Bundled Supplies) . K.2
Supplies Paid Separately When Dispensed from Provider’s
Section L: Modifiers CPT/HCPCS
BILLING/CLAIM FORM INFORMATION
Section M: Billing and Claim Forms
What Are the General Billing Requirements? . M.1
How Do I Bill for Multiple Services? . M.1
Instructions Specific to Physicians . M.2
How Do I Submit Professional Services on a CMS-1500 Claim Form
Table of Contents # Memo 09-40 Changes are highlighted Physician-Related Services Physician Care Plan Oversight (CPT codes 99375, 99378, and 99380) [Refer to WAC 388-531-1150]
DSHS covers:
•
Physician care plan oversight services once per client, per month.
A plan of care must be established by the home health agency, hospice, or nursing facility.
The provider must perform 30 or more minutes of oversight services for the client each calendar month.
DSHS does not cover: •
Physician care plan oversight services of less than 30 minutes per calendar month (CPT codes 99374, 99377, and 99379).
Physician care plan oversight services provided by more than one provider during the global surgery payment period, unless the care plan oversight is unrelated to the surgery.
Physicians Providing Service to Hospice Clients
DSHS pays for hospice care for eligible clients. To be eligible, clients must be certified by a physician as terminally ill with a life expectancy of six months or less. Contact your local hospice agency and they will evaluate the client. Hospice will cover all services required for treatment of the terminal illness. These services must be provided by or through the hospice agency. DSHS pays providers who are attending physicians and not employed by the hospice agency: •
For direct physician care services provided to a hospice client;
When the provided services are not related to the terminal illness; and
When the client’s provider, including the hospice provider, coordinates the health care provided.
When billing, primary physicians must put their provider number in field 33 of the CMS-1500 Claim Form. When billing, the consulting physician, other than the primary physician, must put the following on the CMS-1500 Claim Form: •
The primary physician name or clinic name and provider number in field 17 and 17a; and
The consulting physician’s performing provider number (PIN#) and group number (GRP#) in field 33.
When billing electronically, enter “Not related to hospice care” in the Comments field.
CPT® codes and descriptions only are copyright 2008 American Medical Association.
- B.21 - Programs (Guidelines/Limitations) # Memo 09-40 Changes are highlighted Physician-Related Services Domiciliary, Rest Home, or Custodial Care Services
CPT codes 99304-99318 are not appropriate E&M codes for use in place of service 13 (Assisted Living) or 14 (Group Home). Providers must use CPT codes 99324-99328 or 99334-99337 for E&M services provided to clients in these settings. Home Evaluation and Management
DSHS pays for Home Evaluation and Management (CPT codes 99341-99350) only when services are provided in place of service 12 (home). Telehealth
What is telehealth?
Telehealth is when a health care practitioner uses interactive real-time audio and video telecommunications to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located. Using telehealth when it is medically necessary enables the health care practitioner and the client to interact in real-time communication as if they were having a face-to-face session. Telehealth allows DSHS clients, particularly those in medically underserved areas of the state, improved access to essential health care services that may not otherwise be available without traveling long distances. The following services are not covered as telehealth: •
Email, telephone, and facsimile transmissions;
Installation or maintenance of any telecommunication devices or systems;
“Store and forward” telecommunication based services. (Store and forward is the asynchronous transmission of medical information to be reviewed at a later time by the physician or practitioner at the distant site).
Who is eligible for telehealth?
Fee-for-service clients are eligible for medically necessary covered health care services delivered via telehealth. The referring provider is responsible for determining and documenting that telehealth is medically necessary. As a condition of payment, the client must be present and participating in the telehealth visit.
CPT® codes and descriptions only are copyright 2008 American Medical Association.
- B.22 - Programs (Guidelines/Limitations) # Memo 09-40 Changes are highlighted Physician-Related Services
DSHS will not pay separately for telehealth services for clients enrolled in a managed care plan. Clients enrolled in a DSHS managed care plan will have a plan indicator in the HMO column on their DSHS Medical ID Card. Managed care enrollees must have all services arranged and provided by their primary care providers (PCP). Contact the managed care plan regarding whether or not the plan will authorize telehealth coverage. It is not mandatory that the plan pay for telehealth. When does DSHS cover telehealth?
DSHS covers telehealth through the fee-for-service program when it is used to substitute for a face-to-face, “hands on” encounter for only those services specifically listed on page B.19. Originating Site (Location of Client)
What is an “originating site”?
An originating site is the physical location of the eligible DSHS client at the time the professional service is provided by a physician or practitioner through telehealth. Approved originating sites are: •
The office of a physician or practitioner;
A federally qualified health center (FQHC).
Is the originating site paid for telehealth?
Yes. The originating site is paid a facility fee per completed transmission. How does the originating site bill DSHS for the facility fee?
• Hospital Outpatient: When the originating site is a hospital outpatient department, payment for the originating site facility fee will be paid according to the maximum allowable fee schedule. To receive payment for the facility fee, outpatient hospital providers must bill revenue code 0789 on the same line as HCPCS code Q3014.
Hospital Inpatient: When the originating site is an inpatient hospital, there is no payment to the originating site for the facility fee.
Critical Access Hospitals: When the originating site is a critical access hospital outpatient department, payment is separate from the cost-based payment methodology. To receive payment for the facility fee, critical access hospitals must bill revenue code 0789 on the same line as HCPCS code Q3014.
CPT® codes and descriptions only are copyright 2008 American Medical Association.
- B.23 - Programs (Guidelines/Limitations) # Memo 09-40 Changes are highlighted Physician-Related Services FQHCs and RHCs: When the originating site is an FQHC or RHC, bill for the facility fee using HCPCS code Q3014. This is not considered an FQHC or RHC service and is not paid as an encounter, and is not reconciled in the monthly gross adjustment process.
Physicians’ Offices: When the originating site is a physician’s office, bill for the facility fee using HCPCS code Q3014.
If a provider from the originating site performs a separately identifiable service for the client on the same day as telehealth, documentation for both services must be clearly and separately identified in the client’s medical record. Distant Site (Location of Consultant)
What is a “distant site”?
A distant site is the physical location of the physician or practitioner providing the professional service to an eligible DSHS client through telehealth. Who is eligible to be paid for telehealth services at a distant site?
DSHS pays the following provider types for telehealth services provided within their scope of practice to eligible DSHS clients: •
Physicians (including Psychiatrists); and
Advanced Registered Nurse Practitioners (ARNPs).
What services are covered using telehealth?
Only the following services are covered using telehealth: •
Consultations (CPT codes 99241–99245 and 99251-99255);
Office or other outpatient visits (CPT 99201-99215);
Psychiatric intake and assessment (CPT code 90801);
Individual psychotherapy (CPT codes 90804-90809); and
Pharmacologic management (CPT codes 90862).
Note: Refer to other sections of these billing instructions for specific policies and limitation on these CPT codes.
How does the distant site bill DSHS for the services delivered through telehealth?
The payment amount for the professional service provided through telehealth by the provider at the distant site is equal to the current fee schedule amount for the service provided. Use the appropriate CPT codes with modifier GT (via interactive audio and video telecommunications system) when submitting claims to DSHS for payment.
CPT® codes and descriptions only are copyright 2008 American Medical Association.
- B.24 - Programs (Guidelines/Limitations) # Memo 09-40 Changes are highlighted
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