KANSAS
MEDICAL
ASSISTANCE
PROGRAM
PROVIDER MANUAL
Professional PART II PROFESSIONAL SERVICES PROVIDER MANUAL
Section Page INTRODUCTION BILLING INSTRUCTIONS 7000 CMS-1500 Billing Instructions ...... 7-1 Submission of Claim Form ...... 7-7 7010 Specific Billing Information ...... 7-8
BENEFITS AND LIMITATIONS 8100 Copayment ...... 8-1 8200 Reserved for Future Use ...... 8-1 8300 Benefit Plans ...... 8-2 8400 Medicaid Program Overview ...... 8-3 Abortion ...... 8-3 ACH Services ...... 8-4 Ambulance ...... 8-5 Apnea Monitors ...... 8-6 Audiology ...... 8-7 Cardiac Rehabilitation...... 8-8 Children and Family Services Contractors ...... 8-9 CMHC ...... 8-9 Consultations ...... 8-9 CPAP ...... 8-9 Dental ...... 8-9 Developmental Testing...... 8-10 Dietitian Services ...... 8-10 Documentation ...... 8-10 DME ...... 8-11 EKGs ...... 8-11 Emergency Services for Aliens ...... 8-12 Family Planning ...... 8-12 Hospice ...... 8-13 Hospital ...... 8-13 Hyperbaric Oxygen Therapy...... 8-21 Immunizations ...... 8-22 Injections ...... 8-22 Intrathecal Baclofen Pump...... 8-22 Laboratory ...... 8-22 LEA Services ...... 8-24 Maternity Center Services ...... 8-24 Mid-Level Practitioners ...... 8-24 Nursing Facility ...... 8-24 OB/Gynecological ...... 8-24 OB Sonograms ...... 8-26 Office Visits ...... 8-26 Oxygen Therapy ...... 8-26 Pain Management ...... 8-27 Patient Demand Cardiac Monitoring ...... 8-30
Section 8400 (cont.) Pharmacy ...... 8-31 Prosthetic and Orthotic Devices ...... 8-34 Psychiatric ...... 8-35 Radiology ...... 8-36 Renal Dialysis/Kidney Transplants ...... 8-40 Sterilizations ...... 8-41 Surgery ...... 8-44 Therapy (Rehabilitative) ...... 8-45 Transplants ...... 8-47 Tuberculosis ...... 8-47 Vagal Nerve Stimulators...... 8-48 Vision ...... 8-48 Vacuum Assisted Wound Closure Therapy ...... 8-48
Section ARNP 8410 Anesthesia ...... 8-49 Case Management ...... 8-49 Pain Management ...... 8-50 TA Children's Waiver ...... 8-53 ARNP Procedure Codes ...... 8-54
Section LOCAL HEALTH DEPARTMENT 8420 Family Planning ...... 8-55 Skilled Nursing Services ...... 8-55 Prenatal Health Promotion and Risk Reduction (PHP/RR) .... 8-55 Prenatal Health Promotion/Risk Reduction High Risk Nutrition Services (PHP/RRHRN) ...... 8-57 Prenatal Health Promotion/Risk Reduction Enhanced Social Work Services (PHP/RRESW) ...... 8-58 Postpartum/Newborn Home Visit (PP/NBHV) ...... 8-59 Dental Services ...... 8-60 Local Health Procedure Codes ...... 8-61
Section KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT 8430 STATE LABORATORY ...... 8-62
Appendices Procedure Codes and Nomenclature ...... Appendix I Minor Surgery/Outpatient Surgery - Procedure Codes and Nomenclature ...... Appendix II
Forms Abortion Necessity Form CMS-1500 Hearing Aid Necessity Home Monitor Information Home Oxygen Information Hysterectomy Consent Form NDC Detail Attachment Form Sterilization Consent Form (English) & Sterilization Consent Form (Spanish) Instructions for the Sterilization Form
PART II PROFESSIONAL SERVICES
Updated 05/07 This is the provider specific section of the manual. Part II was designed to provide information and instructions specific to professional services providers. It is divided into four subsections: Billing Instructions, Benefits and Limitations, Appendices, and Forms.
Billing Instructions contains instructions on completion and submission of the HCFA-1500 CMS-1500 claim for paper billers.
Benefits and Limitations defines specific aspects of the scope of services covered within the Kansas Medical Assistance Program (KMAP).
The Appendix contains information concerning procedure codes. These appendices were developed to make finding and using procedure codes easier for the biller.
Forms contains forms specific to providers of professional services. These forms may be duplicated for your use. Nonspecific forms (e.g., Prior Authorization, Medical Necessity) are located in Part I of this provider manual.
HIPAA Compliance
As a KMAP participant, providers are required to comply with compliance reviews and complaint investigations conducted by the Secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. The provider is required to provide the same forms of access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A. 21-3853 and amendments thereto.
A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider shall not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL INTRODUCTION
BILLING INSTRUCTIONS
7000. Updated 02/08
THE CMS-1500 CLAIM FORM Providers of professional services must use the CMS-1500 red claim form (unless submitting electronically) when requesting payment for medical services and supplies provided under the Kansas Medical Assistance Program. Any CMS-1500 claim form not submitted on the red claim form will be returned to the provider. An example of the CMS-1500 claim form is in the forms section at the end of this manual. Instructions for completing this form are included on the following pages.
Any of the following billing errors may cause a CMS-1500 claim to deny or be sent back to the provider: • The Kansas MMIS uses electronic imaging and optical character recognition (OCR) equipment. Therefore, information is not recognized if not submitted in the correct fields as instructed. Claim information must be submitted in the correct fields as instructed. • Staples on the claim form. • A CMS-1500 claim form carbon copy.
The fiscal agent, EDS, does not furnish the CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual.
Complete the following CMS-1500 Claim Form fields when applicable:
Fields not identified below should be left blank.
Field 1 Program Identification: Check appropriate box(es).
Field 1A Insured's ID Number: Enter the 11-digit beneficiary identification (ID) number from patient's KMAP ID card. If newborn services, use mother's beneficiary ID number if newborn's number is unknown.
Field 2 Patient's Name: Enter patient's last name, first name, and middle initial exactly as it appears on the medical ID card. If patient is a newborn, enter "newborn", "baby boy", or "baby girl", in the first name field and enter the last name.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BILLING INFORMATION
7-1 7000. Updated 09/07
Field 3 Patient's Date of Birth: Enter patient's date of birth as month, day and year - MM/DD/YYYY (For example, October 1, 1957, would be listed as 10/01/1957). If newborn services, enter baby's date of birth (not mother's).
Patient's Sex: Check the appropriate box.
Field 5 Patient's Address: Enter patient's street address including city, state and zip code.
Field 9 Other Insured's Name: If patient has secondary or supplemental insurance complete fields 9 and 9A-D. (Enter the primary insurance information in field 11.)
Field 10 Is Patient's Condition Related To: Check appropriate box when billing for accident related services only. If box is checked: • Enter all available information in field 11. • Check "other" box if related to "child abuse" or a "self inflicted" injury and note "child abuse" or "self inflicted" in field 10D.
Field 11 Insured's Policy Group or FECA Number: This field should be completed if the patient has insurance primary to Medicaid. If yes, complete fields 11 and 11a-d.
Field 14 Date of ...... : Complete field when billing for accident related services only. Enter date of accident in MM/DD/YY format. Otherwise, leave blank.
Field 17A I.D. Number of Referring Physician: Enter either qualifier ‘1D’ and a 10-digit KMAP provider ID (or all nines if the referring physician is not a KMAP provider), or the enter qualifier ‘ZZ’ and a taxonomy code.
Field 17B Provider’s NPI: Enter the provider’s NPI.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BILLING INFORMATION
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7000. Updated 05/07
Field 17a I.D. Number of Referring Physician: Enter the 10-digit provider number of the referring/ordering physician. Enter all nines if the referring physician is not a Medicaid provider.
Field 18 Hospitalization Dates Related to Current Services: Enter dates of admission and discharge.
Field 20 Outside Lab? Check appropriate box: If "no," bill for procedures performed. If "yes," provider who actually performed service must bill.
Field 21 Diagnosis or Nature of Illness or Injury: Enter the appropriate ICD-9-CM code. If more than one diagnosis applies, list the primary on line 1, secondary on line 2, etc.
Field 22A Original Ref. No. If this is a resubmission of a claim, enter the previous ICN.
Field 23 Prior Authorization Number: Enter the assigned Prior Authorization (PA) number from the approval letter, if applicable.
Field 24A Date(s) of Service: Enter date of service in MM/DD/YY format. If multiple services were performed on consecutive dates, give beginning date in "from" and give the last date of service in the "to" field and complete the units field (24G) accordingly.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BILLING INFORMATION
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7000. Updated 05/07
Field 24B Place of Service: Enter appropriate "place of service code" for each service. Not all of the place of service codes may be appropriate for the service provided. Indicate the place of service code that most accurately reflects where the service was provided.
11 – Office 41 – Ambulance - Land 12 – Home 42 – Ambulance-Air or Water 21 – Inpatient Hospital 50 – Federally Qualified Health Center 22 – Outpatient Hospital (FQHC) 23 – Emergency Room - 53 – CMHC Hospital 54 – ICF/MR 24 – Ambulatory Surgical 65 – End Stage Renal Disease Center Treatment Facility 31 – Skilled Nursing Facility 71 – Local Health Department 32 – Nursing Facility 72 – Rural Health Clinic (RHC) 33 – Custodial Care Facility 81 – Independent Laboratory 34 – Hospice 99 – Other Locations
Field 24D Procedures, Services, or Supplies: Enter HCPCS 5-digit base procedure code (add modifier(s) if appropriate). Explain unusual circumstances.
Field 24E Diagnosis Code: Enter the appropriate line number from field 21.
Field 24F Charges: Enter your usual and customary charge for each service.
Field 24G Days or Units: Enter number of visits, days or units of service rendered, as applicable to each detail line. Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) should bill only one encounter per claim detail.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BILLING INFORMATION
7-4 7000. Updated 09/07
Field 24H EPSDT Family Plan:
COB:(EPSDT/KBH referral value) Enter the 2-digit value when an EPSDT (KAN Be Healthy) screen results in a referral. The value choices include: AV – the beneficiary refused the referral S2 – the beneficiary is currently under treatment ST – new services requested
EPSDT / Family Planning: Enter “E” when completing an EPSDT (KAN Be Healthy) screen. Enter “F” when completing a Family Planning visit. Enter “B” when both, an EPSDT (KBH) and Family Planning visit, are completed.
Field 24I ID Qualifier: Enter qualifier ‘ZZ’ if billing with a taxonomy code in the top half of field 24J. Enter qualifier ‘1D’ if billing with a KMAP provider ID in the top half of field 24J.
Field 24J Rendering Provider ID #: Top half should be a 10-digit KMAP provider ID or a taxonomy code. Bottom half should be an NPI.
Field 26 Your Patient's Account Number: OPTIONAL: Any alpha/numeric character entered in this field will be referenced on the Remittance Advice. No unique characters should be indicated, e.g., *, @, -, #, etc.
Field 27 Accept Assignment: Leave blank. All providers of Kansas Medical Assistance Program services must accept assignment in order to receive payment on a Medicare related claim.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BILLING INFORMATION
7-5 7000. Updated 05/07 Field 28 Total Charge: Enter total of all itemized charges on this page of the claim. If filing more than one claim page for the same beneficiary, total each claim page separately. (Do not include co-payment amount, refer to Section 8100.) When more than one claim page is utilized for the same beneficiary, for the same date of service, follow the instructions below: 1) Ensure the claims are sent to Medicaid together by not tearing the claims apart or by paper clipping the claims together. Do not staple together the claims. 2) Do not total the charges in Field 28. 3) Enter “Continued. Page __ of __” in Field 28. For example, when 10 procedures were provided for the same beneficiary on the same date of service enter, “Continued. Page 1 of 2.” 4) Enter the total charge in Field 28 of the last claim form. According to the example above, the total charge would be in Field 28 on page 2.
Field 29 Amount Paid: Enter any amount paid by insurance or other third party sources known at the time the claim is submitted. If the amount shown in this field is the result of other insurance, documentation of the payment must be attached. (Field 11 must identify the other insurance source.) Refer to Sections 3200 and 3300 for more specific information. Do not enter co-payment or spenddown payment amounts. They are deducted automatically. NOTE: Retain proof of other insurance payment in the consumer's file.
Field 30 Balance Due: Subtract block 29 from 28 and enter the balance here.
Field 31 Signature of Physician or Supplier: Read statement on back of claim form, sign and date. • Phrase "signature on file" is acceptable. • Provider’s name typed/stamped is acceptable.
Field 32A Provider’s NPI: Enter the provider’s NPI. Field 32B KMAP Provider ID or Taxonomy Code: Enter either a 10-digit KMAP provider ID or a taxonomy code. Field 32 Name and Address of Facility Where Services Rendered: Enter name and address of facility (if other than patient's home or provider's facility).
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BILLING INFORMATION
7-6 7000. Updated 09/07
Field 33 Billing Provider Info & Ph #: This information regarding the group number corresponds with the provider information provided in fields 33A and 33B
Field 33A Provider’s NPI: Enter the provider’s NPI.
Field 33B KMAP Provider ID or Taxonomy Code: Enter qualifier ‘1D’ and the 10-digit KMAP provider ID or qualifier ‘ZZ’ and a taxonomy code.
Submission of Claims:
Send completed first page of each claim and any necessary attachments to:
Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, KS 66601-3571
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BILLING INFORMATION
7-7 SPECIFIC BILLING INFORMATION
7010. Updated 07/08
Allergy When billing for an allergy evaluation, follow the instructions in the CPT® codebook and utilize Evaluation and Management (E & M) office visit codes.
The number of units in field 24G for allergen immunotherapy should equal either the number of injections or the number of antigens, dependent upon the code billed.
Anesthesia Medicaid claims for anesthesia shall be billed using the American Society of Anesthesiologists (ASA) codes. Medical direction or supervision of anesthesia services by an anesthesiologist cannot be billed in addition to CRNA anesthesia services. Only direct patient time should be billed, not wait time.
In field 24G, indicate the number of minutes anesthesia was administered. Give only whole numbers. Round all decimals upward to the nearest whole number. Example: 13.4 minutes of anesthesia administered should be indicated as "14" in field 24G.
Chemotherapy Chemotherapy injection codes (96400-96450) must be used for chemotherapy administration.
Chemotherapy drugs should be billed with the appropriate injection procedure code. (Refer to Appendix I.)
Children Immunization Administration Please see Immunization Administration in this section.
'E' Diagnosis Codes External causes of injury and poisoning diagnosis ('E') codes are accepted as a secondary diagnosis when billed in conjunction with a covered primary diagnosis code.
End Stage Renal Disease As of August 1, 2008, providers can enroll to perform end-stage renal disease (ESRD) services with KHPA as a provider type and specialty 30/300 (Renal Dialysis Center).
Emergency Room Services The primary diagnosis code must reflect the emergent condition (presenting symptoms). Refer to the CPT® codebook for levels of care definitions when selecting the appropriate procedure to bill.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BILLING INFORMATION
7-8 7010. Updated 07/08
Exempt License Physicians License-exempt physicians (retired), performing services in a clinic setting, can enroll as a Medicaid provider. The clinic is reimbursed for expenses incurred for providing such services. The billing provider should be the clinic, and the performing provider should be the exempt licensed physician. Claims will be reimbursed at 75 percent of the maximum allowable.
Immunization Administration Providers must bill the appropriate administration code in addition to the vaccine/toxoid code for each dose administered. CPT codes for vaccines covered under the Vaccine for Children (VFC) program will be noncovered.
PACS software requires a charge on each line item being submitted. Providers that bill electronically through the PACS system will need to indicate a charge of $.01 on the line for the vaccine/toxoid code. The MMIS system will deny the service even though a charge was submitted.
Injections In field 24D, enter the HCPCS procedure code, strength and dosage. Injection procedure codes are listed in Appendix I.
Injections not listed in Appendix I are not covered. A predetermination request may be submitted if it is felt a specific injection should be covered. Refer to Section 4200.
Laboratory Panels/Profiles Only the provider performing the laboratory analysis can bill.
When ordered laboratory tests make up a panel or profile, the all-inclusive procedure code should be used to bill. Do not bill each component separately.
Locum Tenens Physicians • Locum tenens physicians must not be in place for more than one year. • It is the provider's responsibility to insure a locum tenens physician covering for a KMAP provider is not excluded from participation in governmental programs including Medicaid. • Upon review of claims, payments will be recouped if it is determined that KMAP paid for a service that was provided by a locum tenens physician who was excluded from participation in governmental programs including Medicaid on the date of service.
Mid-Level Practitioners Physician assistants (PAs) and advanced registered nurse practitioners (ARNPs) must be enrolled as Medicaid providers to bill for services. Indicate the clinic’s number as the billing provider and the PA’s or ARNP’s number as the performing provider on the CMS-1500 claim form. ARNPs and PAs are reimbursed at 75 percent of the Medicaid allowed amount for services provided.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BILLING INFORMATION
7-9 7010. Updated 08/08
Missed Appointments Providers should not bill beneficiaries for missed appointments. Missed appointments are not a distinct reimbursable service but are a part of the providers’ overall cost of doing business.
Newborn Services (When the Mother Is NOT in an HMO) When billing for a newborn who does not have a beneficiary ID number, use "Newborn", "Baby Girl", or "Baby Boy" in the first name field and enter the last name. Use the newborn's date of birth and the mother's beneficiary ID number. The claim will suspend in the claims processing system for up to 45 days pending the fiscal agent's receipt of the newborn's beneficiary ID number from the local SRS office. If the newborn's ID number is received within 45 days, the claim will be processed using that number. If the newborn's ID number is not received within 45 days, the claim will complete processing with the mother's ID number.
This process is to be used when billing the following CPT codes:
31520 54000 99431 36450 54150 99432 36510 54160 99440 36660 99295-99297 94652
Newborn Services (When the Mother Is in an HMO) Notify the HMO that the mother is assigned to at the time of birth is on the mother's Medicaid ID card of the birth. The HMO will provide further instructions if the provider is part of that HMO's network. The mother's HMO will notify SRS and the fiscal agent of the birth.
Nonhospital Based Physician Services Nonhospital based physicians are: • Physicians who are called to the emergency room (ER) when one of their patients presents for services • Emergency physician groups who staff ERs but do their own billing
When nonhospital based physicians assigned to the emergency department render services in the ER, the following procedure codes should be utilized for billing: 99281 99284 99282 99285
When nonhospital based physicians not assigned to the emergency department render services in the ER, the following procedure codes should be utilized for billing:
EMERGENT NONEMERGENT 99281 thru 99285 99201 thru 99215 or 99056
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BILLING INFORMATION
7-10 7010. Updated 11/03
Obstetrical and Gynecological: If you have not provided total obstetrical care and delivery, but did provide pre-delivery, or post-delivery visits, refer to Section 8400 for appropriate procedure codes.
Bill prenatal laboratory services using the corresponding procedure code for each test performed, or utilize the OB panel procedure code. (Routine urinalysis is content of service of prenatal care.)
When billing for twins delivered by the same method, both vaginally or both cesarean, use the appropriate procedure code and indicate 1.5 in the units field. If twins were delivered by different methods, one vaginal and one cesarean, use the appropriate procedure code for each and indicate 1 in each of the units field.
Professional/Technical Component Billing:
Components: Professional: In field 24D, enter the HCPCS base code for services rendered, including modifier "26". (Example: 7207026).
Technical: In field 24D, enter the HCPCS base code of the service performed, including modifier "TC". (Example: 72070TC).
Professional and Technical: In field 24D, enter the HCPCS base code of the radiology service performed. (Example: 72070)
The same procedures performed on the same day: • Must be billed on the same claim. • Must clarify in field 24D the reason for billing more than one procedure (e.g., 2 x- rays at two different times; left arm, right arm).
When same procedures are not billed on the same claim, the additional claim(s) will be denied as a duplicate.
To seek reimbursement for additional services when this occurs: Submit an underpayment adjustment using the Internal Control Number (ICN) from the Remittance Advice (RA) of the paid claim, and state on the adjustment request that more than one procedure was performed on the same day. Refer to Section 5600 for details.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BILLING INFORMATION
7-11 7010. Updated 11/03
Related Services Provided During a Psychiatric Hospitalization: The primary care physician's referral is not required when billing for related physician and ancillary services provided during a psychiatric hospitalization approved through the preadmission assessment process. Indicate the admit and discharge date of the hospitalization in field 18.
Surgery: Always break down charges for each procedure.
When billing multiple surgical procedures on the same date of service, bill the comprehensive procedure as the primary procedure as detail 1 on the claim. Bill all surgical procedures on the same claim.
When billing for multiple surgical procedures on the same day, bill your usual and customary charge for all procedures. Medicaid will reduce subsequent procedures for you.
Assistant Surgeon: In field 24D, enter the HCPCS base code for the surgery performed, including modifier "80." (Example: 3369280)
Bilateral Procedures: Procedures performed bilaterally during a single operative session must be identified with the appropriate CPT procedure code. When a procedure is identified in the CPT® codebook as one that should have a '50' modifier added to the base code when performed bilaterally, bill the procedure as a single line item with the '50' modifier. Procedures billed with the '50' modifier shall be billed only once on the claim as one unit. For example, a bilateral tympanostomy shall be billed indicating procedure code 6943650 as one (1) unit.
When a procedure code states 'unilateral or bilateral' in the description, do not add the '50' modifier. In this instance, the base code is billed only once on the claim and the number of units is one (1). For example, procedure code 58900-Biopsy of ovary, unilateral or bilateral = one unit.
Supplies and Accessories: For splints and accessories supplied by the provider over and above those usually included with the office visit or other services rendered, utilize the CPT procedure code that best fits the item. If a specific CPT procedure code cannot be found, utilize procedure code 99070, and list the drugs, trays, supplies or materials provided.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BILLING INFORMATION
7-12 BENEFITS & LIMITATIONS
8100. COPAYMENT Updated 11/03
Ambulatory/OP surgical center services require a copayment of $3.00 per day.
ARNP and local health department services are exempt from copayment requirements.
Dietitian services require a copayment of $2.00 per date of service for KAN Be Healthy participants 18 years of age and older.
FQHC services require a copayment of $3.00 per encounter.
Physician services require a copayment of $2.00 per office visit.
Psychotherapy services require a copayment of $2.00 per date of service when provided in the office.
RHC services require a copayment of $2.00 per encounter.
Bill all services occurring on the same date on the same claim form.
If multiple claims are submitted for the same date(s) of service, the copayment requirement will be deducted for each claim submitted.
Do not reduce charges or balance due by the copayment amount. This reduction is automatically made during claim processing.
8200.
Reserved for future use
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-1 BENEFITS & LIMITATIONS
8300. Benefit Plans Updated 08/08
KMAP beneficiaries will be assigned to one or more Medical Assistance benefit plans. The assigned plan or plans will be listed on the beneficiary ID card. These benefit plans entitle the beneficiary to certain services. From the provider's perspective, these benefit plans are very similar to the type of coverage assignment in the previous MMIS. If there are questions about service coverage for a given benefit plan, refer to Section 2000 of the General Benefits Provider Manual for information on the plastic State of Kansas Medical Card and eligibility verification contact the Medical Assistance Customer Service Center at 1-800-933-6593 or (785) 274-5990.
For more information about benefit plans, refer to the General Benefits Provider Manual. For example, coverage for the MediKan benefit plan is the same as for Medicaid beneficiaries (refer to Section 8400) with the following exceptions:
• Current Medicaid limitations for psychiatric admissions continue to apply.
• Psychotherapy is limited to a maximum of 24 hours per calendar year.
• Inpatient general hospital services are covered for MediKan beneficiaries for the following conditions only:
o Alcohol and drug detoxification o Burns o Mental health o Severe traumatic injuries o Tuberculosis
Physicians should be aware that hospital admissions for MediKan beneficiaries will be reviewed and consideration of payment made based on the nature of the injury indicated by the diagnosis on the claim.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-2 BENEFITS & LIMITATIONS
8400. MEDICAID PROGRAM OVERVIEW Updated 02/07
The following Benefits and Limitations provide an overview of covered Kansas Medical Assistance Program services that can be utilized in the beneficiary’s total treatment of the consumer. The following information is intended to be general in nature and not inclusive of every benefit and limitation.
If more information is desired, call the EDS Provider Assistance Unit. KMAP Customer Service Center. (Refer to Section 1000 of the General Introduction Manual.)
Abortion Abortions are covered only under the following conditions:
• In the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself. • If the pregnancy is the result of an act of rape or incest. Use the G7 modifier. Use the G7 modifier when billing for abortion services if the pregnancy is the result of an act of rape or incest.
The physician must complete the Abortion Necessity Form to certify that the woman's physical health is in danger, or that this pregnancy is a result of rape or incest. A copy of the form can be found in the forms section at the end of this manual The Abortion Necessity Form is located in the Forms section at the end of this manual and on the KMAP Web site under Publications/Forms/Abortion Necessity Form. The form may be photocopied for your use. All fields blanks must be completed, including the patient's complete address. All pertinent information must be retained with the medical record.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-3 8400. Updated 11/03
Adult Care Home Services The Adult Care Home (ACH) Program provides room and board, plus all routine services and supplies required by patients. To place a Kansas Medicaid beneficiary in a long-term care facility, it must first be determined placement is appropriate. The CARE (Client Assessment Referral Evaluation) screening program is designed to identify the community based service needs of the individual and determine whether a Level II PASARR (Preadmission Screening and Annual Resident Review) is required. Providers should contact the local Area Agencies on Aging for non-Medicaid applicants. For Medicaid-eligible applicants contact the local SRS area office.
Requirements for Supervision of ACH Patients Federal regulations set minimum standards with which the state must comply if it is to continue payment to the provider and the adult care home.
I. Admission Evaluations Nursing Facilities: A medical evaluation must be forwarded to the facility which includes diagnoses, a summary of current medical findings, medical history, mental and physical functional capacity and prognosis.
NF/MH: Requirements are the same as for nursing facilities. In addition, appropriate professional personnel must make a psychiatric evaluation which shall be forwarded to the facility upon approval.
ICF/MR: Requirements are the same as for nursing facilities. In addition, appropriate professional personnel must make a psychiatric evaluation and summary of developmental findings which shall be forwarded to the facility upon approval.
Recertification, medication check and/or plan of care review is considered content of service of the ACH visit and is not covered if billed separately. No other ACH visits are covered on the same day as an ACH history and physical.
II. Annual Medical Evaluation By State Health Department regulations, an annual medical evaluation must be completed on each adult care home resident to include a history and physical with updated diagnosis and prognosis. Tests or observations of the resident indicated by his/her medication regimen must be made when appropriate and properly documented.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-4 8400. Updated 11/03
ACH Visits One routine visit per month is covered. If more than one ACH visit is required per resident, per month, medical necessity must be attached to the claim. (Refer to Section 4000.)
Recertification, medication check and/or plan of care review is considered content of service of the ACH visit and is not covered if billed separately.
One ACH history and physical is covered every 330 days per consumer, regardless of provider. No other ACH visits are covered on the same day as an ACH history and physical.
Ambulance Emergency Transportation The use of an ambulance must be medically necessary. (Refer to Section 4100 for Medical Necessity documentation criteria.) The patient's condition must be such that the use of any other method of transportation is not possible without placing the patient's health in serious jeopardy, seriously impairing bodily functions, or results in serious dysfunction of any bodily organ or part. Some examples of "medical necessity" are: • Transporting in an emergency situation (accident, injury, acute illness) • Patient needs to be restrained • Unconscious or in shock • Requires oxygen or other emergency treatment • Immobilizing fracture or possible fracture • Acute stroke or myocardial infarction • Hemorrhaging • Bedridden • Requires a stretcher or gurney
Nonemergent Ambulance Transportation and Medical Necessity All nonemergent transportation requires medical necessity. A medical necessity (MN) form must be attached to the claim at the time of submission. See the examples below: • Routine transportation for nonambulatory patients • Transportation from the patient's home to the hospital (or hospital to the patient's home) • Transfers between hospitals
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Guidelines for Use of Air Ambulance Services Time: If time is a critical factor in the patient’s recovery or survival, or duration of ground transport would be excessive and potentially detrimental, air transport may be indicated. In general, if the ground ambulance can arrive at the destination institution within 20 minutes, it is the preferred mode of transport. Expertise: If the health care institution does not possess the expertise to provide the definitive care required to stabilize the patient (i.e., advanced life support) and the ground ambulance providers in the near vicinity cannot provide assistance in providing that care, air transport may be indicated. Coverage: If ground ambulance utilization leaves the service area without adequate ground coverage and patient outcome will be compromised by arranging other ground transport, air transport may be indicated. Documentation: The above guidelines serve as a guide to documentation which is necessary to determine proper reimbursement and must specify the indication and justification for air transport. If guidelines are not met, or are met but not documented, the billed transportation will be reimbursed at ground ambulance rates or denied altogether.
Apnea Monitors Determination of the medical necessity for a home apnea monitor is based on factors placing the infant at risk for sudden death as well as on the infant's age. The monitoring device must be ordered by a physician. Home monitoring is medically necessary in infants at risk for sudden death for up to six months of (corrected) age, and up to one (1) year of (corrected) age in infants with bronchopulmonary dysplasia requiring home oxygen. Corrected age is defined as the age of the child had he/she been born at full term (i.e., a child born four weeks premature would not become one year of corrected age until one year and four weeks after the delivery date). The prescribing physician must indicate the length of time he/she feels the apnea monitor will be necessary.
An infant with the following factor(s) is considered to be at risk: • One or more apparent life-threatening event(s) requiring adult intervention, such as mouth to mouth resuscitation or "shaken baby syndrome" may occur • Sibling of one or more sudden infant death syndrome victim(s) • A newborn who continues to have apnea when he/she would otherwise be ready for care at home. Gestational age at discharge and frequency and dates of apneic episodes while hospitalized will assist in determining this condition. • Bronchopulmonary dysplasia. Indicate whether or not oxygen is required following hospital discharge. • Tracheostomy • Certain diseases/conditions associated with apnea or impaired ventilation, such as central hypoventilation
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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A risk factor must be demonstrated on each consumer through the accurate completion of the HOME MONITOR INFORMATIONAL FORM, or similar medical necessity form providing the same information. (Refer to the 'Forms' section for an example of an acceptable Home Monitor Form.) The form(s) and valid prescription (dated on or prior to service dates) must be retained in the files of the provider supplying the monitoring device and are to be provided upon request.
If the consumer has utilized an apnea monitor longer than six months, the HOME MONITOR INFORMATIONAL FORM and copy of a valid prescription are required to be attached to the claim when billing for the seventh month. Claims billed for apnea monitor rental for the seventh month and beyond are reviewed for medical necessity, regardless of provider. Documentation supporting continued need for the apnea monitor must accompany the claim. This documentation should include information from the past 6 months regarding any apneic episodes, or conditions that put the child at risk and indicating continued need of the monitor.
Audiology The following audiology services are covered under the Kansas Medical Assistance Program: • Audiological testing, ear examinations, and evaluations • Dispensing and repair of hearing aids • Trial rental of hearing aids • Batteries Limitations on covered services are outlined below and on the following pages.
Batteries Batteries are limited to six per month for monaural hearing aids and 12 per month for binaural hearing aids. Prior authorization (PA) will not override these limitations. Batteries for use with cochlear devices are limited to lithium ion (three per 30 days) and zinc air (six per 30 days). Batteries for cochlear devices are covered for KAN Be Healthy eligible beneficiaries only. Only one type of battery is allowed every 30 days.
Dispensing of Hearing Aids One dispensing fee is covered for binaural and bicros hearing aids.
Fitting of binaural hearing aids are covered, with documentation on the hearing evaluation form, for the following: • Children under the age of 21, KAN Be Healthy is not required. • A legally blind adult with significant bilateral hearing loss. • A previous binaural hearing aid user. • An occupational requirement for binaural listening.
Modifiers Billing for Audiology services now requires the use of left (LT) and right (RT) modifiers on all monaural services. If the services are binaural the use of left and right modifiers is not allowed.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Explanation of Necessity for Hearing Aid Form Providers must submit the "Explanation of Necessity for Hearing Aid" Form with the Prior Authorization request before approval for a replacement hearing aid will be considered. An example of this form is located in the 'Forms' section at the back of this manual.
Repairs Repairs under $15.00 are not covered.
Repairs exceeding $75.00 must be prior authorized (refer to Section 4300). Approval will be given if in the opinion of the consultant, the repairs are not so extensive that good judgment indicates the fitting and dispensing of a new hearing aid.
Repairs must provide a warranty of six months.
Replacements Hearing aids may be replaced every four years when a medical examination confirms the necessity.
Lost, broken, or destroyed hearing aids will be replaced once with PA during a four year period. The dispenser and consumer must sign a statement documenting the loss, breakage, or destruction of the hearing aid and submit it along with the PA request.
Replacement cords for hearing instruments and cochlear implants are covered with medical necessity documentation.
Testing and Examination Consumers are required to have a medical examination by a physician for pathology or disease. This exam must be provided no more than six months prior to the fitting of a hearing aid, and documented on the "Explanation of Necessity for Hearing Aid" Form.
Cardiac Rehabilitation Phase II Cardiac Rehabilitation is covered using procedure code 93798. This procedure is covered when performed in an outpatient or cardiac rehabilitation unit setting, with the following criteria: • Beneficiary must have a recent cardiology consultation within three months of starting the cardiac rehabilitation program. • Beneficiary must have completed Phase I Cardiac Rehabilitation. • Beneficiary must have one or more of the following diagnoses/conditions: o Acute myocardial infarction (410.00 – 410.92, 414.8) within the preceding three months, post inpatient discharge o Coronary bypass (V45.81) surgery within the preceding three months, post inpatient discharge o Stable angina pectoris (413.9 and 413.0) within three months post diagnosis
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Children and Family Services (CFS) Contractors Medicaid reimbursable services will not be paid by child welfare contractors. All services for children assigned to contractors, including behavior management and mental health, must be billed directly to the Kansas Medical Assistance Program and will be reimbursed at the approved Medicaid rate. Prior authorization and other restrictions apply.
Community Mental Health Centers (CMHC) When a physician desires to send a consumer beneficiary to a Community Mental Health Center, he/she should call the center before making this referral. Each center has its own referral requirements, initial appointment procedures, and vary in services provided. Community Mental Health Center services are covered for outpatient treatment and partial hospitalization.
Consultations Only one initial consultation is covered within a sixty (60-day period per consumer beneficiary by the same provider.
CPAP for KBH Participants Continuous positive airway pressure (CPAP) is a covered service for KAN Be Healthy participants. Prior authorization (PA) for medical necessity is required. Criteria for medical necessity is: 1) Infant Respiratory Distress Syndrome in newborns (e.g., Hyaline Membrane Disease) or 2) Morbid obesity with documented sleep apnea. • 30% over average weight for height, sex, and age, • Sleep study with documented arterial oxygen (O2) saturation of 80% or less. A printout of the documented arterial O2 saturation must be supplied by the provider upon request from the fiscal agent and/or the Adult and Medical Services. • Documented participation in a weight reduction program. This documentation must be supplied by the provider upon request from the fiscal agent and/or the Adult and Medical Services.
Dental HCBS Adult Oral Health Services Effective with dates of service on and after April 1, 2007, oral health services are available to adults ages 21 and older who are enrolled in the Home and Community Based Services Mental Retardation/Developmental Disabilities (MR/DD), Traumatic Brain Injury (TBI), and Physically Disabled (PD) waiver programs. Refer to Exhibit D in the Dental Provider Manual for services available for HCBS MR/DD, TBI, and PD adult beneficiaries. For information about covered dental benefits, contact KMAP Dental Services at 1-800-933-6593 # 4 #.
Orthodontia For information about covered orthodontia benefits, contact KMAP Dental Services at 1-800-933-6593 # 4 #. KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Developmental Testing Providers are reimbursed one visit per day up to three visits per beneficiary per year for developmental testing: extended (which includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments), with interpretation and report. The procedure code used for this service is 96111.
Dietitian Services Dietitian services are covered for KAN Be Healthy participants when provided by a registered dietitian licensed through the Kansas Department of Health and Environment.
Dietitian services may only be rendered as the result of a medical or dental screening referral. Other insurance and Medicare are primary and must be billed first.
Individual focused services are limited to two units (30 minutes) of initial evaluation and 11 follow-up visits per consumer, per year. Additional visits may be covered with prior authorization (PA).
Group focused services are limited to an initial evaluation and 11 follow-up visits per consumer, per year. Additional visits may be covered with PA. (Refer to Appendix I for procedure codes.)
Documentation To verify services provided in the course of a postpayment review, documentation in the consumer's medical record must support the service (level of service) billed. Documentation can be requested at any time to verify that services have been provided within program guidelines. Refer to Section 5000 of the General Billing Provider Manual.
Autoauthentication (computerized authentication) of documentation for the medical record is acceptable documentation for the Kansas Medical Assistance Program. Autoauthentication must meet federal guidelines.
Federal regulation 42 CFR 482.24 (c) (1) (i) requires that there must be a method of determining that the physician authenticated the document after transcription. All entries must be legible and complete and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing or evaluating the service furnished. The author of each entry must be identified and must authenticate his or her entry. Authentication may include the author's signature, written initials, or computer entry.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Durable Medical Equipment (DME) Durable medical equipment (DME) items require a written prescription from the physician. In addition, many DME items and medical supplies require prior authorization before they can be dispensed and payment made. Be sure to give the DME provider adequate information and adequate time to secure prior authorization.
Although an item is classified as DME, it may not be covered in every instance. Coverage is based on the fact that it is reasonable and necessary for treatment of an illness or injury, or will improve the physical functioning of the consumer. Medical equipment is primarily used for medical purposes and is not generally useful in the absence of illness or injury.
Electrocardiograms (EKGs) Electrocardiograms (up to 12 leads) are considered medically necessary when the diagnosis and/or condition clearly indicates one or more of the following: • Relevant cardiopulmonary diagnosis • Significant electrolyte imbalance • Drug induced EKG changes (identify the drug) • Progressive renal disease • Unstable thyroid disease • Specific central nervous system (CNS) disorders causing EKG changes • Congenital disorders causing EKG changes • Symptomatic hypothermia • Shortness of breath • Fainting spells • Monitoring the effects of psychotropic drugs for potential cardiac effects (identify the drug)
Preoperative EKGs are medically necessary for patients over age 40, or those patients under 40 with a history of cardiac problems.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Emergency Medical Services for Aliens In addition to inpatient hospital and emergency room hospital, emergency services performed in outpatient facilities and related physician, lab, and x-ray services will be allowed for the following places of service: office, outpatient hospital, Federally Qualified Health Clinics, state or local public health clinics, rural health clinics, ambulance, and lab for SOBRA claims. Inpatient hospital reimbursement will not be limited to 48 hours. Follow-up care will not be allowed once the emergent condition has been stabilized.
Refer to Section 2040 of the General Provider Manual for specific information.
Family Planning Family planning is any medically approved treatment, counseling, drug, supply, or device prescribed or furnished by a provider to individuals of child-bearing age for purposes of enabling such individuals to freely determine the number and spacing of their children.
Supplies used during the insertion or removal of Norplant are content of service of the procedure and cannot be billed separately.
Planned parenthood clinics shall bill family planning services using Evaluation and Management (E&M) CPT procedure codes.
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Hospice In situations where the attending physician is not operating under contractual arrangement with the hospice, the attending physician will be reimbursed at the regular Medicaid rate for all professional services, including those related to the treatment of the terminal illness without prior authorization. These services include procedure codes which contain a professional component identified with a modifier of 26, such as lab and x-ray.
Hospital (Inpatient) All inpatient stays are subject to utilization review (UR) with the exception of stays involving patients who have Medicare Part A (primary payer). Utilization reviews are performed on a postpayment basis for general inpatient hospital stays.
Take-home drugs are limited to the amount a patient needs to allow time to get to a pharmacy.
Hospital Visits One inpatient hospital visit per provider, per consumer, per day is covered.
A hospital visit and chemotherapy administration to the same consumer by the same provider on the same date of service are not covered.
The same provider cannot bill a hospital visit and psychotherapy on the same day for the same consumer.
Only one inpatient follow-up consultation is covered within a ten (10) day period per consumer, by the same provider.
Hospital visits are considered content of service of procedure code 99431 (History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records).
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Substance Abuse Acute detoxification is covered in any general hospital.
Substance abuse treatment is only covered when provided in an intermediate setting.
Substance abuse treatment provided in an intermediate setting (alcohol and drug addiction treatment facility) is limited to three admissions in a consumer's lifetime, regardless of provider. (Acute detoxification and day treatment are not included in this limitation.)
Hospital (Outpatient) Outpatient services are reimbursed on a fee-for-service basis.
The following are examples of covered outpatient services: • emergency room services • laboratory services • diagnostic or therapeutic radiology services • nuclear medicine services • outpatient surgery • restorative physical therapy
These services should be used for minor surgical or medical procedures which would not require an inpatient stay.
Only one outpatient follow-up consultation is covered within a sixty (60) day period per consumer, by the same provider.
The hospital will not be paid for the use of the emergency room when a patient repeatedly abuses emergency room services. Any patient who continually abuses these privileges despite reprimand should be reported to the Health Care Policy, Medical Policy (refer to Section 2400).
When emergency room services have been determined to be non-emergent, the physician’s fee will be reduced to the non-emergency level.
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Emergency Room The consumer's age and time of admission to an emergency room does not determine emergent status. Conditions relating to the emergency room visit, such as stabilization of an injury or condition, may support the emergent need.
Direct physical attendance by the provider (physician, ARNP, or PA) must be documented in the medical record for the visit to be considered emergent.
Phone or standing orders do not support emergency treatment.
Axillary temperatures are not considered accurate and will be disregarded when determining emergent status.
Consumers may go to the emergency room without a referral from their physician based on the definition of an emergency according to a prudent layperson (as defined by the Balanced Budget Act, 1997): What a layperson would consider an emergency in the absence of medical knowledge. Such an emergency could include, but is not limited to: serious impairment to bodily functions; serious dysfunction of any bodily organ or part; severe pain; or an injury/illness that places the health of the individual in serious jeopardy (and in the case of a pregnant woman, her health or that of her unborn child).
Other Examples of Emergencies Are: • Initial treatment for medical emergencies including indications of severe chest pain, dyspnea, gastrointestinal hemorrhage, spontaneous abortion, loss of consciousness, status epilepticus or other conditions considered "life- threatening." Consumers who require transfer to another facility for further emergency treatment or who expire.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Non-Emergent Situations • Intentional non-compliance with previously ordered medications and treatments resulting in continued symptoms of the same condition. • Refusal to comply with currently ordered procedures/treatments such as drawing blood for laboratory work. • Leaving the emergency room against medical advice. • The consumer had previously been in the same or different emergency room or physician's office for the same condition and the condition had not worsened. • Scheduled visits to the emergency room for procedures, examinations or medication administration. Examples include cast changes, suture removal, dressing changes, follow-up examinations and second opinion consultations. • Visits made to receive a "tetanus" injection in the absence of other emergent conditions. • Visits made to obtain medication(s) in the absence of other emergent conditions. • The conditions/symptoms relating to the visit had been experienced longer than 48 hours or are of a chronic nature and emergency medical treatment to stabilize the condition was not required. • A referral is necessary for all non-emergent services when treating a HealthConnect consumer.
The following conditions will not be considered emergent unless the criteria described has been met:
Alcoholism: An acute medical/surgical condition exists (e.g., gastric bleeding, dehydration).
Depression/Anxiety: Documentation must support the consumer to be an immediate danger to self or others.
Fever: Documented fever in the emergency room of 103 Fahrenheit (39.5 Celsius) or above rectally in children and of 102 Fahrenheit (38.9 Celsius) or above orally in adults.
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Insect Bites and Stings/Embedded Ticks: Documentation must support the presence of complications resulting from the bite/sting beyond the expected local reactions such as redness, itching or swelling.
Minor Burns/Sunburns: Documentation must support presence of complications such as severe swelling, infection or the young age of the consumer. Eye and chemical burns are considered emergent.
Otitis Media - not emergent unless: • The tympanic membrane is bulging or ruptured. • There is drainage from the ear(s). • Documented fever in the emergency room of 103o Fahrenheit (39.5o Celsius) or above rectally in children and of 102o Fahrenheit (38.9o Celsius) or above orally in adults. • The consumer is age three (3) or under and is crying inconsolably. • The physician's examination documents the presence of acute otitis media and there is no access to a physician's office due to holiday or weekend or is after office hours.
Removal of Cutaneous Foreign Bodies: Sedation or the use of extensive medical supplies were required for the removal of the foreign body (e.g., splinters, cactus needles).
Seizures - not emergent unless: • The condition was previously undiagnosed and the visit was following or during a seizure. • A secondary disorder/diagnosis exists (e.g., hypoglycemia, infection, etc.). • The consumer is 12 years of age or younger. • The consumer was brought in by the police and the condition was unknown. • The consumer was in status epilepticus. • The consumer is in an epileptic state aggravated by alcohol/drug ingestion.
Skin Rash/Hives: Documentation must support presence of systemic complications beyond the local skin discomforts resulting from the rash. If the rash causes eye complications or the patient has a history of anaphylactic (allergic) reactions, the visit is considered emergent.
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Observation Room Observation is a service which requires monitoring a patient's condition. Examples of the appropriate use of the observation room may include: • monitoring head trauma • drug overdose • cardiac arrhythmias • false labor
A physician, physician assistant (PA), or ARNP must see the patient within two hours prior to admission to the observation room except for obstetrical labor or scheduled administration of IV medication or blood products. The observation room stay must be medically necessary.
There is no time limit restriction for the observation room. The same reimbursement rate applies regardless of the number of hours required for monitoring. Reimbursement is all inclusive of services and supplies. If there is a discharge and readmission to the observation room from midnight to midnight, only one reimbursement rate will be allowed.
The following examples are considered content of service of the observation room and will not be reimbursed separately: • Minor surgery • Recovery room services following inpatient or outpatient surgery • Recovery/observation following scheduled diagnostic tests such as arteriograms, cardiac catherization, etc. • Scheduled and nonscheduled fetal oxytocin stress tests and fetal non-stress tests • ER physician fee
Hospital (Psychiatric) Inpatient psychiatric admissions are covered only after a psychiatric preadmission assessment has been completed and a determination made that the most appropriate treatment setting is the hospital. No payment will be made for the hospital admission or related physician services without the completion of the preadmission assessment and determination that the hospital admission meets criteria. When seeking to admit a Kansas Medical Assistance Program consumer for inpatient treatment call 1-800-466-2222 to arrange for the assessment to be completed. This toll-free number is staffed 24 hours a day by the Mental Health Consortium (MHC).
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After receiving a request for a psychiatric preadmission assessment the MHC will contact the appropriate Community Mental Health Center (CMHC), or other approved provider if the admission is out-of-state, to complete the assessment face-to-face with the Kansas Medical Assistance Program consumer. Following completion of the assessment, the hospital and admitting physician will be notified of the results verbally and via a letter from the MHC. If the admission was approved a prior authorization (PA) number will be included in the letter for the hospital and physician to utilize when billing for the approved admission and related services.
The primary care physician's referral is not required for psychiatric hospital stays or related physician and ancillary services provided during the psychiatric hospitalization approved through the preadmission assessment process.
Emergency Psychiatric Screening for inpatient services following the sudden onset of severe psychiatric symptoms, which could reasonably be expected to make the individual harmful to self or others if not immediately under psychiatric care. The individual is in crisis and not currently in a place of safety. A screening is completed immediately (no later than 3 hours) to determine appropriate placement.
Urgent Psychiatric Screening is initiated if the individual meets one of the four independent criteria and is currently in a place of safety. An observation bed may be used to provide security and “observation” for individuals in imminent danger and to assist in the determination of the need for psychiatric hospitalization. In this instance, the screening must be completed as soon as possible and within two (2) days of the Consortium’s receipt of the request.
Planned Psychiatric Non-crisis in nature, the screening must be completed within two (2) days of the Consortium’s receipt of the request. The admission must occur within two (2) days of the completion of the screening.
Retroactive Psychiatric Individuals whose Medicare or other primary insurance denied payment for treatment, and who were Medicaid eligible at the time of admission. Other retroactive screens may be authorized for denied requests when eligibility is in question. If the individual receives a valid Medicaid card after a hospital admission has been completed, the Consortium requests the admission information, and completes a pre-admission screening within five (5) working days of the receipt of that information.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Group/Individual Psychotherapy Daily individual or group psychotherapy is required for inpatient hospital stays for psychiatric illness; however, group psychotherapy is not covered when provided by psychologists, physicians or CMHCs in a hospital setting. Inpatient group psychotherapy is content of service of the DRG reimbursement to the hospital.
Psychotherapy is not covered on days electroshock is given.
A maximum of 12 inpatient electroshock treatments per month are covered.
Psychiatric Observation Beds Outpatient psychiatric observation beds are covered for up to two consecutive days. During the observation period the patient must receive a physical examination along with a history of psychiatric assessment which contains recommendations for ongoing treatment. An initial nursing assessment must be completed and nursing progress notes written for each shift. A discharge summary must be completed when the patient is discharged.
A physician must admit the patient to an observation bed and discharge the patient at the end of the observation stay. When an admission follows an observation stay, the physical examination report and the psychiatric assessment must be included in the patient's medical record.
The physical examination and preadmission assessment must be billed by the provider of the service.
Crisis Resolution Services Hospitals may be reimbursed when Medicaid patients are admitted to observation/stabilization beds for crisis resolution services in accordance with the following conditions: • The patient is referred by the primary care case manager, agency, or health professional currently providing care (whichever is applicable). • The patient shall have demonstrated an acute change in mood or thought that is reflected in behavior, indicating the need for crisis intervention to stabilize and prevent hospitalization. • The patient must have a diagnosed psychiatric disorder. • The patient must not be in need of acute detoxification or withdrawal symptoms. • The patient must be medically stable. • The following documentation shall be completed: Nursing assessment (including physical review, mental status, and medication), strength assessment, a personal crisis plan, and at least one progress note.
Crisis resolution services are covered up to two consecutive days.
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Hyperbaric Oxygen Therapy Hyperbaric oxygen therapy is covered under KMAP with PA. The following criteria must be met before a PA will be approved. 1. The services must be for one of the following conditions: a. Acute carbon monoxide intoxication b. Decompression illness c. Gas embolism d. Gas gangrene e. Acute traumatic peripheral ischemia f. Compromised skin grafts g. Chronis refractory osteomyelitis h. Osteoradionecrosis i. Soft tissue radionecrosis j. Cyanide poisoning k. Actinomycosis l. Crush injuries and suturing of severed limbs m. Progressive necrotizing infections n. Acute peripheral arterial insufficiency o. Diabetic wounds of lower extremities 2. It must be documented that other treatments have been attempted with no improvement.
Physicians bill for this procedure using 99183 (one unit equals one session up to two hours).
If there are multiple sessions on the same day (more than one unit for physicians), each subsequent session must be billed on a separate line detail with a 76 modifier.
Hysterectomy: Hysterectomies are covered only for medically indicated reasons. One of the following conditions must also be met and documented. 1. Individual or her representative signs a written acknowledgment of receipt of information that the surgery will make her permanently incapable of reproducing. A Sterilization Consent Form is not an acceptable substitute. 2. Physician shall certify in writing, that the individual was already sterile and state the cause of sterility on an attachment to the claim. The signature in field 31 of the claim form will not suffice. 3. For the consent form only, the physician shall certify in writing, that the surgery was performed under a life-threatening situation and individual certification was not possible. Include a description of the nature of the emergency. The signature in field 31 of the claim form will not suffice. Refer to Section 4300.
A copy of the hysterectomy statement must be attached to the surgeon's claim at the time of submission. A copy of the hysterectomy statement is not required to be attached to related claims (anesthesia, assistant surgeon, hospital, or Rural Health Clinic) at the time of submission. However, no related claim will be paid until the hysterectomy statement with the surgeon's claim has been reviewed and determined to be correct, unless the related claim has the correct hysterectomy statement attached.
A copy of the hysterectomy form can be found in the forms section at the end of this manual. The form may be photocopied for use. KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Immunizations/Vaccines Reimbursement for covered immunizations for children is limited to the administration fee. Vaccines are supplied at no cost to the provider through Vaccines for Children, a federal program administered by the Kansas Department of Health and Environment.
Injections of B12 Vitamin B12 injections are covered only when one or more of the following diagnoses are present: Anemia, fish, tapeworm Friedreich's ataxia; post lateral sclerosis Anemia, iron deficiency Hepatic Diseases or Dysfunctions Anemia - Addison's Malignant and benign neoplasms - Biermer's Neuropathies of malnutrition and alcoholism - Macrocytic Renal Disease - Megaloblastic Sprue, Short Gut Syndrome, Short - Pernicious Bowel Syndrome Crohn's Disease, Ileitis - Strictures of Intestines chronic or regional Whipples Disease Chronic Enteritis/Colitis Dumping Syndrome, Jejunal Syndrome
Intrathecal Baclofen Pump Intrathecal baclofen pumps are covered for Medicaid beneficiaries. This includes the initial and all subsequent implantation(s), revision(s), repairs, catheters, batteries, refills, removals, and maintenance of the intrathecal baclofen pumps when indicated. Three services require PA: 62350, 62351, and 62362. The following conditions must be met:
• The beneficiary must have responded favorably to a trial of intrathecal baclofen and include documentation of previously used medication • The beneficiary’s ICD – diagnosis code must be a covered code and the source of the spasticity must be documented • The beneficiary must be over the age of four years or there must be documentation that there is sufficient space within the child’s chest wall for the pump to be implanted. • Contraindications include pregnancy and active infection at time of surgery
Procedure codes 62311, 62319, 62355, 62365, 95900, 95991, and 62368 do not require prior authorization but HCK beneficiaries do need a referral from their PCPs.
Laboratory Only the provider performing the laboratory analysis shall bill.
When ordered laboratory tests make up a panel or profile the all-inclusive procedure code should be used to bill, do not bill each component separately.
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Laboratory continued A drawing or collection fee is considered content of service of an office visit or other procedure and is not covered if billed separately. The beneficiary cannot be billed for the drawing or collection since it is considered content of another service or procedure.
Do not bill Medicaid for laboratory services referred to an outside laboratory. The laboratory will bill Medicaid directly for their services.
Laboratory procedures performed on inpatients are content of service of the DRG reimbursement to the hospital and should not be billed by an independent laboratory.
Pathologists not contracted by a hospital may bill the professional component (modifier 26) on pathology services provided on inpatients.
Reimbursement will only be made for one complete blood count (CBC) per day. KMAP considers three or more multichannel tests to be a SMA/SMAC, or profile, when performed on the same date of service. Medicaid follows the guidelines outlined in the CPT® codebook to identify automated multichannel tests (SMACs, profiles). When billing for a multichannel test use the appropriate CPT procedure code (organ or disease oriented panels).
Cytogenetic (chromosome) studies are covered for pregnant women (when medically necessary) and KAN Be Healthy participants only. A medical necessity form must accompany the claim when billing for a cytogenetic study for a pregnant woman over 21 years of age.
The following HIV testing is limited to four per calendar year, regardless of provider. Refer to the CPT® codebook for complete description of these procedures: 86689, 86701, 86702, 86703, 87390, 87391, 87534, 87535, 87537, 87538, 87539, 87900, 87903, 87904.
HIV-1, viral load, quantitative, HCPCS code 87536 is covered.
HIV-1, infectious agent genotype analysis by nucleic acid (DNA or RNA), reverse transcriptase and protease (87901) is covered. Medical necessity documentation must include information that the patient meets at least one of the following criteria: 1. The patient presents with virologic failure during Highly Active Antiretroviral Therapy (HAART). 2. The patient has suboptimal suppression of viral load after initiation of antiretroviral therapy. Note: For 87901 only, testing is limited to two per calendar year.
Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis C (87902) is also covered.
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Local Education Agency (LEA) Services Providers of LEA services shall have appropriate credentials from the Kansas State Department of Education. Refer to the Local Education Agency Provider Manual for a complete list of covered services.
Maternity Center Services Labor and delivery in a maternity center setting is covered for Medicaid and MediKan beneficiaries. Maternity centers must be licensed by the State of Kansas (or equivalent if located in another state) and enrolled as a provider in the Kansas Medical Assistance Program. Reimbursement is on a fee-for-service basis. Maternity center services are exempt from beneficiary co-payment. Supplies are content of service of labor and delivery charges. The physician is responsible for billing his/her charges for care provided.
Mid-Level Practitioners All services performed by physician assistants (PAs) or ARNPs within the scope of their license are covered with the same limitations that apply to physician services. Specific limitations are defined in the ARNP section of this manual.
Nursing Facility (NF) Bill procedure code 99318 (Evaluation and management of a new or established patient involving an annual nursing facility assessment) when providing a routine annual history and physical examination.
If the ACH resident is seen for medical reasons other than what can be billed under 99318, the appropriate CPT code(s) should be used. If the resident is Medicare eligible, bill Medicare first.
Obstetrical (OB) and Gynecological The following procedures are content of service of total OB care: • Office visits (nine months before and six weeks after delivery) • Urinalysis • Internal fetal monitor
Total OB care generally consists of 13 office visits, delivery (vaginal or cesarean), and postpartum care. The provider of total OB care should bill CPT codes 59400 (Routine obstetric care, including vaginal delivery and postpartum care) or 59510 (Routine obstetric care, including antepartum care, cesarean delivery, and postpartum care); whichever applies. If an ARNP or PA provides part of the prenatal care but does not deliver the baby, the physician may bill the global fee without indicating the PA or ARNP as the performing provider. If the ARNP or PA provides part of the prenatal care and delivers the baby, the services must be broken out and the PA or ARNP indicated as the performing provider. Providers should not bill for OB services until care is completed (for example, the beneficiary delivers, or the beneficiary is no longer a patient).
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Obstetrical and Gynecological continued When a provider does not complete total OB care, and only partial antepartum care has been provided, the following guidelines apply when billing services:
One to three prenatal visits only - bill using Evaluation and Management (E&M) office visit codes.
Four (4) to six (6) prenatal visits only - bill using CPT procedure code 59425 (Antepartum care only; 4-6 visits). This code shall NOT be billed by the same provider in conjunction with one to three office visits; or in conjunction with procedure code 59426 (Antepartum care only; 7 or more visits).
Complete antepartum care without delivery - bill using procedure code 59426 (Antepartum care only; 7 or more visits). Complete antepartum care is limited to one consumer pregnancy per provider.
Delivery only (no antepartum care provided) - bill using procedure code 59409 (vaginal delivery) or 59514 (cesarean delivery).
Delivery and postpartum care only - bill using procedure code 59410 (Vaginal delivery only, including postpartum care or 59515 (Cesarean delivery only, including postpartum care).
Procedure codes 59425 and 59426 may be billed only once per provider, per consumer pregnancy. These codes shall not be billed together by the same provider for the same consumer, during the same pregnancy.
Pregnancy-related (E&M) office visits shall not be billed in conjunction with procedure code 59425 or 59426 by the same provider for the same consumer, during the same pregnancy.
Fetal oxytocin stress testing (initial or subsequent) is not covered in place of service 21 (inpatient).
Fetal non-stress test (electronic, external fetal monitor applied) is not covered in place of service 21 (inpatient).
Procedure 59426 (Antepartum care - 7 or more visits) is limited to one per pregnancy, per provider.
Only one IUD insertion every seven days per consumer is covered.
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Obstetrical Pelvic Sonograms One routine sonogram will be covered per fetus per pregnancy using the diagnoses V220- V222. A routine obstetrical (OB) sonogram will not be covered if the sonogram is performed solely to determine the fetal sex or to provide parents a view and photograph of the fetus.
Primary diagnosis shall support medical necessity for an OB sonogram. Some examples are: indication of vaginal bleeding, multiple birth, diabetes, size/date discrepancy, fetal anomalies, threatened abortion, placental/uterine abnormalities, fetal demise, maternal drug/alcohol/tobacco use or history of previous miscarriage, Cesarean Section, stillbirth, ectopic pregnancy, eclampsia, or intra-uterine growth retardation.
Medical necessity may also be determined based on maternal age, maternal weight, or fetal position. If applicable, this information should be submitted with the claim.
Office Visits One comprehensive office visit per calendar year per consumer is covered.
Evaluation and management (E&M) office visit procedure codes 99201-99205 may be used for any new patient or any patient that has not been seen by the provider within the past three years.
School or employment physicals should be billed using an E&M office visit procedure code.
An office visit billed on the same day as chemotherapy administration, cast application, or an IUD removal by the same provider for the same patient is not covered.
Oxygen Therapy A nonacute arterial blood gas on room air (either by oximetry or an arterial puncture) is required within one month prior to the initiation of home oxygen therapy. After the initial study, either a blood gas or oximetry study is required annually. The prescription and blood gas levels must be dated prior to the service date, retained in the provider's files, and provided upon request.
Oxygen need determination is based on hypoxemia. Hypoxemia is defined as a Pa02 arterial blood gas level of less than 60mm Hg or oximetry saturation of 85 percent or less.
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Patients who cannot be removed from oxygen for laboratory studies and whose hypoxemia is not documented require signed statements from two physicians, preferably one being a pulmonary specialist, documenting the effects of oxygen supply removal on the beneficiary. These statements must be retained in the provider's files and provided upon request.
Neonates with bronchopulmonary dysplasia whose hypoxemia cannot be documented require a signed letter from a physician, preferably a neonatologist, documenting the patient's condition and prognosis. This letter must be retained in the provider's files and available for review by the medical staff upon request.
The HOME OXYGEN INFORMATIONAL FORM may be found in the Forms section of this manual. Photocopies for your use may be made directly from this page.
NOTE: Additional information may be added to the face of your claim if necessary. Tape billers who have had initial billings denied with EOB 548 (Service denied. This claim and all attachments have been reviewed by the medical staff and the medical necessity of the service rendered is not supported by the documentation provided) may resubmit a paper claim with the necessary documentation noted on the face of the claim. If the claim and/or attachments do not support medical necessity, the service will be denied.
Pain Management Providers are encouraged to use the Pain Management Guidelines developed by The Federation of State Medical Boards of the United States, Inc. and adopted by the Adult and Medical Services Commission. The guidelines are the following:
Evaluation of the Patient 1. A complete medical history and physical examination must be conducted and documented in the medical records. 2. The medical records should document the nature and intensity of the pain, evaluate underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse. 3. The medical record should also document the presence of one or more recognized medical indications for the use of a controlled substance.
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Treatment Plan 1. The written treatment plan should state objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function, and should indicate if any further diagnostic evaluations or other treatments are planned. 2. After treatment begins, the physician should adjust drug therapy to the individual medical needs of each patient. Other treatment modalities or rehabilitation program may be necessary depending on the etiology of the pain and the extent to which the pain is associated with physical and psychosocial impairment. Informed Consent and Agreement for Treatment 1. The physician should discuss the risks and benefits of the use of controlled substances with the patient, significant other(s) or guardian. 2. The patient should receive prescriptions from one physician and one pharmacy where possible. 3. If the patient is determined to be at high risk for medication abuse or have a history of substance abuse, the physician may employ the use of a written agreement between physician and patient outlining patient responsibilities including: • urine/serum medication levels screening when requested • number and frequency of all prescription refills, and • reasons for which drug therapy may be discontinued (i.e. violation of agreement) Periodic Review 1. At reasonable intervals based upon the individual circumstance of the patient, the physician should review the course of opioid treatment and any new information about the etiology of the pain. 2. Continuation or modification of opioid therapy should depend on the physician's evaluation of progress toward stated treatment objectives such as improvement in patient's pain intensity and improved physical and/or psychosocial function, such as ability to work, need of health care resources, activities of daily living and quality of social life. 3. If reasonable treatment goals are not being achieved, despite medication adjustments, the physician should re-evaluate the appropriateness of continued opioid treatment. 4. The physician should monitor patient compliance in medication usage and related treatment plans.
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Consultation 1. The physician should be willing to refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. 2. Special attention should be given to those pain patients who are at risk for misusing their medications and those whose living arrangement pose a risk for medication misuse or diversion. 3. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients. Medical Records 1. The physician should keep accurate and complete records to include: a. the medical history and physical examination b. diagnostic, therapeutic and laboratory results c. evaluations and consultations d. treatment objectives e. discussion of risks and benefits f. treatments g. medications (including date, type, dosage, and quantity prescribed) h. instructions and agreements i. periodic reviews 2. Records should remain current and be maintained in an accessible manner and readily available for review.
Compliance with Controlled Substances Law and Regulations 1. To prescribe controlled substances, the physician must be licensed in the State of Kansas, have a valid controlled substances registration and comply with federal and state regulations for issuing controlled substances prescriptions. 2. Physicians are referred to the Physicians Manual of the U.S. Drug Enforcement Administration (and any regulations issued by the State Medical Board) for specific rules governing issuance of controlled substance prescriptions as well as applicable state regulations.
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Definitions For the purposes of the pain management guidelines for Kansas Medicaid, the following terms are defined as follows: Acute Pain - Acute pain is the normal, predicted physiological response to an adverse chemical, thermal, or mechanical stimulus and is associated with surgery, trauma, and acute illness. It is generally time limited and is responsive to opioid therapy, among other therapies. Addiction - Addiction is a neurobehavioral syndrome with genetic and environmental influences that results in psychological dependence on the use of substances for their psychic effects and is characterized by compulsive use despite harm. Addiction may also be referred to by terms such as "drug dependence" and "psychological dependence". Physical dependence and tolerance are normal physiological consequences of extended opioid therapy for pain and should not be considered addiction. Chronic Pain - A pain state that is persistent and in which the cause of the pain cannot be removed or otherwise treated and which, in the generally accepted course of medical practice, no relief or cure of the cause of the pain is possible or none has been found after reasonable efforts. Chronic pain may be associated with a long-term incurable or intractable medical condition or disease. Physical Dependence - Physical dependence is a physiologic state of neuroadaptation to an opioid which is characterized by the emergence of a withdrawal syndrome if the opioid use is stopped or decreased abruptly, or if an antagonist is administered. Withdrawal may be relieved by re-administration of the opioid. Physical dependence appears to be an inevitable result of opioid use. Physical dependence, by itself, does not equate with addiction. Substance Abuse - Substance abuse is the use of any substance(s) for non-therapeutic purposes; or use of medication for purposes other than those for which it is prescribed. Tolerance - Tolerance is a physiologic state resulting from regular use of a drug in which an increased dosage is needed to produce the same effect or a reduced effect is observed with a constant dose. Tolerance occurs to different degrees for various drug effects, including sedation, analgesia and constipation. Analgesic tolerance is the need to increase the dose of opioid to achieve the same level of analgesia. Analgesic tolerance may or may not be evident during opioid treatment and does not equate with addiction.
Patient Demand Cardiac Monitoring Patient Demand Cardiac Monitoring is covered in the following situations: • Patient demand single or multiple event recording with pre-symptom memory loop, 24 hour attended monitoring, per 30 day period of time; includes transmission, physician review and interpretation • Patient demand single or multiple event recording with pre-symptom memory loop, per 30 day period of time; recording includes hook-up, recording, and disconnection • Patient demand single or multiple event recording with pre-symptom memory loop, per 30 day period of time; monitoring, receipt of transmissions and analysis • Patient demand single or multiple event recording with pre-symptom per 30 day period of time; physician review and interpretation only
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Pharmacy
DAW DOCUMENTATION REQUIRED
In order for KMAP to increase patient safety, unnecessary expenditures, and assist in monitoring drug products, if a prescriber specifies Dispense As Written (DAW) on a drug which has a bioequivalent generic substitute available, the prescriber will be required to fill out the FDA MedWatch form 3500. This MedWatch form must be submitted to the dispensing pharmacy AND also to the FDA. The dispensing pharmacy will then submit this to the KMAP Prior Authorization Unit for evaluation and receive approval if medical necessity is met.
Submitting MedWatch documentation for review: The FDA MedWatch forms may be obtained online at: http://www.fda.gov/medwatch/getforms.htm.
1. Prescribers must mail or fax the completed FDA MedWatch forms to the FDA AND to the dispensing pharmacy.
Address MedWatch 5600 Fishers Lane Rockville, MD 20852-9787 Fax 1-800-FDA-0178
2. Pharmacists must mail or fax the completed FDA MedWatch forms to the KMAP Prior Authorization Unit for consideration. Please include the following information when mailing or faxing the FDA MedWatch forms:
Pharmacy Name Pharmacy Phone and Fax Numbers KMAP Provider Number
Address Kansas Medical Assistance Program PO Box 3571 Topeka, KS 66601-3571 3600 SW Topeka Blvd, Suite 204 Attn: Prior Authorization Fax 1-800-913-2229 or 785-274-5956
3. The Prior Authorization Unit will contact the pharmacy to inform them of the status of the DAW request.
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CRITERIA TO MEET MEDICAL NECESSITY FOR A BRAND NAME DRUG WHEN A BIOEQUIVALENT GENERIC SUBSTITUTE IS AVAILABLE
A. Adverse Reaction(s) to the generic: Documentation by prescriber that the adverse reaction caused by the generic meets one of the following criteria: 1. life threatening 2. hospitalization 3. disability 4. required intervention to prevent impairment or damage
OR
B. Allergic Reaction(s) to the generic: Prescriber must document the beneficiary’s experience of an allergic reaction to the generic product of one or more manufacturers. The dates and clinical details with the name of specific companies and the generic versions involved must be included.
OR
C. Therapeutic Failure(s) of the generic: Prescriber must document the clinical failure due to beneficiary’s suboptimal drug plasma concentration while taking the generic drug when compared to published full pharmacokinetic profiles for the brand name drug.
The term “generic drug” means a drug that is “bioequivalent”. Kansas law refers to the Federal Food and Drug Administration’s definition, which says drugs are bioequivalent if:
1) they use the same active ingredient as the original version of the drug 2) the active ingredient is absorbed and available where it is needed in the body at the same rate
Prior Authorization Some medications require prior authorization (PA) before they can be dispensed and payment made to the pharmacy provider. A staff member may contact you for a patient diagnosis or laboratory data to justify the authorization. Approved PAs will have a specified duration, not to exceed one year.
The KMAP PA and PA Criteria Forms can be viewed and downloaded at: http://www.srskansas.org/hcp/medicalpolicy/pharmacy/
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Preferred Drug List The 2002 Legislature passed a law (Kan. Session. L., 200, c.180) permitting Kansas Medicaid to implement a Preferred Drug List (PDL). The Medicaid Department convened an advisory committee of practicing physicians and pharmacists to evaluate drugs in therapeutic drug classes for clinical equivalence, and to make recommendations to the Kansas Department of Social and Rehabilitation Services (SRS), and to the Drug Utilization Review (DUR) Board. Using a PDL will promote clinically appropriate use of drugs in a cost-effective manner. Prescriptions for the non-preferred drugs will require prior authorization. As other therapeutic drug classes are evaluated by the PDL Advisory Committee and the DUR Board, KMAP will publish this information to providers.
The PDL KMAP Coverage List(s) and their corresponding Prior Authorization Request forms can be viewed and downloaded at: http://www.srskansas.org/hcp/medicalpolicy/pharmacy/.
Days Supply A 31-day supply of medication per prescription is the maximum that may be prescribed and dispensed at one time for medications covered by the program. Refills will be covered only for those drugs which are refillable, as indicated by the ordering physician, and per Kansas Pharmacy Law. KMAP will only allow a refill after 80% of the prescription has been used.
Drug Efficacy Study Implementation All drugs classified as Drug Efficacy Study Implementation (DESI), less-than-effective drugs and their Identical, Related, and Similar (IRS) drugs are non-covered by KMAP.
Legend/OTC Drugs Most legend drugs are covered for Medicaid beneficiaries. Some over-the-counter products are covered with a prescription.
Legend prenatal vitamins are covered for pregnant females only and up to three months postpartum for lactating women.
Drug Restrictions To view KMAP drug restrictions, access the KMAP Pharmacy Provider Manual from the KMAP Web site at https://www.kmap-state-ks.us/Public/Provider.asp. Click Manuals and select Pharmacy from the Manual Type list box. Drug limitations are listed under Benefits and Limitations, Section 8400.
Butorphanol Nasal Spray (Stadol® NS) is limited to 12.5 units (five 2.5 ml bottles) per calendar month per beneficiary.
OxyContin® is limited to a maximum dosage of twice daily for all strengths.
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Drug restrictions cont. SMOKING CESSATION DRUGS: Nicotine patches and buproprion SR (Zyban®) are covered for Medicaid beneficiaries. The medication coverage is limited to a maximum of one twelve-week course of therapy (based upon each manufacturer’s recommended dosing) per 365 days. Nicotine gum, nicotine oral and nasal inhalers will not be covered. A combination of behavioral and pharmacologic cessation therapies have been shown to be most efficacious in helping patients quit smoking.
INFLUENZA DRUGS: Prescription drugs claims for neuraminidase inhibitors zanamivir (Relenza®) and oseltamivir (Tamiflu®) will be paid for dates of service during the influenza (flu) season only and will be limited to one course of therapy per beneficiary per flu season. According to the Kansas Department of Health and Environment, the Centers for Disease Control consider the flu season in Kansas to be from mid-October through mid -April. One course of therapy for both Relenza® and Tamiflu® are defined by the company in the package insert as five days of therapy.
Prosthetic and Orthotic Devices The prosthetic or orthotic device must be necessary and appropriate for the treatment of the patient's illness or injury, or replace or improve the functioning of a body part.
Prosthetic devices are covered when: • Ordered by a physician and supplied by a prosthetic and orthotic provider enrolled in the Kansas Medical Assistance Program, and • The device will replace all or part of the external body members.
Repairs or replacements are covered.
Orthotic devices are covered when: • Ordered by a doctor • Serve in the treatment of the patient's illness • Improve the functioning of a body part
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Psychiatric Outpatient psychotherapy (individual, group, family) will not be covered for Kansas Medical Assistance Program consumers when provided by the same provider within the same quarter as partial hospitalization activity and targeted case management services, except for brief therapy for crisis or continuing evaluation purposes. If more than six hours of individual, group, or family therapy are billed in the same quarter a Medical Necessity (MN) form must be completed and attached to the claim. Medical necessity is defined as the individual exhibiting behavior that is dangerous to himself/herself or others, and without additional therapy inpatient hospitalization would be required.
Individual therapy is limited to 32 hours per calendar year for consumers not participating in the KAN Be Healthy Program. Forty (40) hours of individual therapy per calendar year are allowed for KAN Be Healthy participants.
Group therapy or a combination of group and family therapy is limited to 20 hours per calendar year, per consumer, regardless of provider. Forty (40) hours of group or family therapy (or a combination of these) are allowed per calendar year for KAN Be Healthy participants.
KAN Be Healthy participants continue to be eligible for outpatient psychotherapy (individual, group, family), targeted case management, and partial hospitalization services concurrently.
Six electroshock treatments per month are covered. Psychotherapy is not covered on days that electroshock treatment is given.
Mental health services to consumers residing in a Nursing Facility for Mental Health will be non-covered. Exception will be made for up to eight hours of therapy (90806) for individuals in acute trauma and for Targeted Case Management and Community Psychiatric Supportive Treatment during the 120 days just prior to discharge. These exceptions must be approved by the local quality enhancement coordinator. Other exceptions are psychiatric diagnostic interview (90801), and psychiatric pre-admission assessments which require no special approval.
Psychological Testing Psychological evaluation and psychological testing can be ordered by a physician but is not covered when performed by an M.D. (These services shall be performed and billed by a psychologist who is an enrolled provider.)
Special Psychiatric Program for Children This program was developed for children in the KAN Be Healthy Program who require intensive therapy above normal Medicaid limitations. Such therapy programs require prior authorization and are limited to six months duration.
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The process of applications and approval for this special program will follow the guidelines listed below:
Request prior authorization (refer to Section 4300) to initiate a plan of intensive care.
Attach to the PA form a complete summary of psychiatric and medical history, prognosis, and treatment goals.
Progress summaries shall be submitted to the Director of Medical Programs, Health Care Policy / Medical Policy, upon request.
If inpatient psychiatric treatment becomes necessary, the special outpatient treatment program will be suspended. The possible return of the child to the outpatient program after discharge from inpatient services will be re-evaluated by the Adult and Medical Services.
Radiology The primary diagnosis code on the claim must reflect the medical need for the procedure.
Abdominal Plain Films and Ultrasound Abdominal plain films and ultrasound are considered medically necessary when the primary diagnosis clearly indicates: • abdominal pain, nausea/vomiting, • complications associated with ulcers, • intestinal obstruction, • gallbladder disease, • injury to the abdomen or kidneys, or • malignant neoplasm of the abdominal organs.
An abdominal plain film may be warranted in a pregnant patient when the patient is in labor, fetal position is questionable, and obstetrical ultrasound is unavailable. Supporting documentation must be attached to the claim. It may be necessary to contact the ordering physician for medical necessity information.
Chest X-rays Chest X-rays are considered medically necessary for: • History or indication of cardiopulmonary disease, malignancy, cerebrovascular accident (CVA), long bone fracture; or • Recent thoracic surgery; or • Thoracic injury; or • Chronic cough over one month duration • (Specify as chronic in the diagnosis field. If this specification is not supplied, the condition is considered acute and the X-ray denied.)
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Preoperative and routine admission chest X-rays are not covered unless documentation of medical necessity (one or more of the following factors) is noted on the claim: • Sixty years of age or older • Pre-existing or suspected cardiopulmonary disease • Smokers over age forty • Acute medical/surgical conditions such as malignancy or trauma It may be necessary to contact the ordering physician for medical necessity information.
CT Scans - Abdominal A CT scan of the abdomen is considered medically necessary when the primary diagnosis clearly indicates a malignant neoplasm of the intra-abdominal cavity, lung, genital organs, lymphoma, diseases of the spleen, liver abscess, peritonitis, pancreatitis, abdominal trauma, or abdominal mass.
A CT scan of the abdomen may be considered medically necessary for: • Abdominal Pain - Indicate the severity and length of time the pain, presenting symptoms, suspected conditions, or complications have been present. • Abdominal Aneurysms - Indicate the presenting symptoms and suspected complications. • Acute Lymphocytic Leukemia - Indicate the presenting symptoms and a detailed description of area(s) involved. • Malignant Neoplasm not located in the Intra-Abdominal Cavity, Lung, or Genital Organs - Indicate presenting symptoms and if the CT scan was performed as part of staging the disease process. Medical necessity documentation must be attached to the claim. It may be necessary to contact the ordering physician for medical necessity information.
CT Scans - Head or Brain A CT scan of the head or brain is considered medically necessary when the primary diagnosis clearly indicates intracranial masses/tumors, intracranial congenital anomalies, hydrocephalus, brain infarcts, parencephalic cyst formation, open or closed head injury, progressive headache with or without trauma, intracranial bleeding, aneurysms, or the presence of a neurological deficit.
A CT scan of the head or brain may be considered medically necessary for: • Headache - Indicate length of time and any accompanying Central Nervous System (CNS) symptoms. • Epilepsy - Specify if initial or repeat scan. Indicate if suspected injury occurred during seizure. • Syncope (fainting) - Specify if recurrent or single episode. • Dizziness - Specify if recurrent or single episode. • Acute Lymphocytic Leukemia - Indicate any accompanying CNS symptoms. Medical necessity documentation must be attached to the claim. It may be necessary to contact the ordering physician for medical necessity information.
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MRI - Head or Brain An MRI scan of the head or brain is considered medically necessary when the primary diagnosis clearly indicates intracranial injury, intracranial mass/tumor, CNS malignancies, cerebrovascular disorder, cerebral malformations, disorders of the cerebral hemispheres and higher brain functions, demyelinating diseases, extrapyramidal and cerebellar disorders, brain abscesses, encephalitis, tuberculous meningitis, or the presence of a neurological deficit.
An MRI scan of the head or brain may be considered medically necessary for: • Headache - Indicate length of time and accompanying neurologic symptoms. • Seizure Disorders - Specify if initial or repeat scan and if seizures (or convulsions) are of recent onset, frequency of their occurrence, and any accompanying neurologic symptoms. • Syncope (fainting) - Specify if recurrent or single episode and any accompanying neurologic symptoms. • Dizziness - Specify if recurrent or single episode and any accompanying neurologic symptoms. • Non-CNS Malignancies - Indicate any accompanying neurologic symptoms.
Medical necessity documentation must be attached to the claim. It may be necessary to contact the ordering physician for medical necessity information.
MRI - Breast MRI of the breast will be covered with the following indications: • Staging and therapy planning patients with diagnosed breast cancer • Occult primary breast cancer when there are no positive axillary nodes and no known primary tumor • Inconclusive diagnosis after a standard mammography evaluation (for example, when scar tissue from previous surgery, dense breast tissue of breast implants render Mammographic images inconclusive) MRI used for screening for breast cancer is not justified.
Skull X-rays Skull X-rays are considered medically necessary when the primary diagnosis clearly indicates head trauma, primary or metastatic tumors of the skull, or tumors of the pituitary gland.
A skull X-ray may be considered medically necessary when indicated for: • Chronic Sinusitis - Indicate any pertinent specific suspected complications resulting from chronicity. • Trigeminal Neuralgia - Specify type of lesion suspected. • Abnormalities relating to the head - Specify if done as an evaluation film for non- cosmetic reconstructive surgery. Indicate type of surgery being considered. Medical necessity documentation must be attached to the claim. It may be necessary to contact the ordering physician for medical necessity information.
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Sonograms - Nonobstetrical Pelvic Nonobstetrical pelvic sonograms are considered medically necessary when the primary diagnosis clearly indicates pelvic mass or pain, ovarian cyst, pelvic inflammatory disease, endometriosis, possible retained fetal tissue, or question/history of metastatic disease.
Nonobstetrical pelvic sonograms may be considered medically necessary for: • Abnormal vaginal bleeding, or • Irregular menstrual cycles.
It may be necessary to contact the ordering physician for medical necessity information.
UGI Series An upper gastrointestinal (UGI) series, which requires precertification, is considered medically necessary when the primary diagnosis clearly indicates persistent dysphagia, melena, symptoms of UGI tract bleeding or signs and symptoms of ulcers affecting the UGI tract after medication has failed to relieve the symptoms. State guidelines allow one UGI series per day, per beneficiary, regardless of provider.
UGI series may be considered medically necessary when nonspecific diagnoses such as abdominal pain or dyspepsia are used. When these common nonspecific diagnosis codes are used, additional symptoms and/or circumstances that relate to the medical necessity of the procedure must be indicated. For example: • Is the symptom persistent? If so, how long has the symptom persisted: • Is the symptom recurrent? When was the last episode? • Has the symptom or condition increased in severity? • Was medicinal therapy initiated prior to any procedure being performed? If so, indicate the date each therapy was initiated, name(s) of medication (list all GI related medications tried) and the length of time each medication was tried. What was the patient's response to each treatment? • If a chronic condition, has there been a change in symptoms? If so, describe the change(s). • If cancer diagnosis codes are used, what symptoms are present that indicate UGI involvement?
Claims for UGI X-rays are denied reimbursement when the diagnosis code on the claim is either too non-specific or is the result, rather than the reason, for the procedure. Whenever possible, use the symptoms that most clearly describe the reason for the test.
It may be necessary to contact the ordering physician for medical necessity information.
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Renal Dialysis/Kidney Transplants When it has been determined a consumer has a chronic renal disease (CRD) requiring renal dialysis, the consumer or his representative must first apply for Medicare CRD eligibility.
Medicare allows payment of claims for eligible consumers with chronic renal disease and will reimburse for maintenance dialysis the third month after the maintenance dialysis starts. Refer to the Medicare manual for CRD guidelines.
Medicaid will reimburse claims for services related to chronic renal dialysis and/or kidney transplants only after proof has been attached to one claim that the consumer has applied for Medicare and coverage has been approved or denied. (The Medicare CRD eligibility information will be retained in the claims processing system. Therefore, subsequent claims do not need to have proof of Medicare application.)
Examples of acceptable proof of application by Medicare are: • Medicare EOMB/RA. • Beneficiary Health Insurance Card. • Report of Confidential Social Security Benefit Information. • Letter from Medicare or Social Security explaining that the consumer has applied for Medicare and whether or not beneficiary is eligible.
Hospitals Qualifying for Federal Renal Program Univ. of Kansas Med. Center St. Francis Regional Med. Center 39th & Rainbow Boulevard 929 North St. Francis Kansas City, Kansas 66103 Wichita, Kansas 67211
St. Luke's Hospital Research Hospital & Medical Center 44th and Wornall Road Meyer Boulevard & Prospect Kansas City, Missouri 64111 Kansas City, Missouri 64132
St. Francis Hosp. & Health Center * Humana Hospital, Dodge City * 1700 West Seventh Street Topeka, Kansas 66606 The Children's Mercy Hospital 24th at Gillham Road Kansas City Dialysis & Training Center * Kansas City, Missouri 64108 Located at Research Hospital (CAPD Training & Support Services) Meyer Boulevard & Prospect Kansas City, Missouri 64132 FOR VETERANS: Kansas City V.A. Hospital Asbury Hospital 4801 Linwood Boulevard 400 S. Santa Fe Kansas City, Missouri 64128 Salina, Kansas 67406 Wichita V.A. Hospital 5500 East Kellogg Wichita, Kansas 67218 KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Sterilizations Hysterectomy Hysterectomies are covered only for medically indicated reasons. One of the following conditions must also be met and documented. If one of these three options does not apply to the situation for which you have provided service, you may not be reimbursed. The individual or her representative signs the Hysterectomy Consent Form acknowledging receipt of information that the surgery will make her permanently incapable of reproducing. The Sterilization Consent Form is not an acceptable substitute. The physician shall certify in writing, that the individual was already sterile and state the cause or reason for the sterility on an attachment to the claim. The signature in field 31 of the claim form will not suffice. For the Sterilization Consent Form only, the physician shall certify in writing, that the surgery was performed under a life-threatening situation and individual certification was not possible. Include a description of the nature of the emergency. The signature in field 31 of the claim form will not suffice. Refer to Section 4300 of the General Special Requirements Manual.
A copy of the hysterectomy statement must be attached to the surgeon's claim at the time of submission. The Hysterectomy_Consent_Form, located at the end of this manual in the Forms section and on the KMAP Web site under Publication/Forms/Hysterectomy Consent Form, may be photocopied for your use. A copy of the hysterectomy statement is not required to be attached to related claims (anesthesia, assistant surgeon, hospital, or rural health clinic) at the time of submission. However, no related claim will be paid until the hysterectomy statement with the surgeon's claim has been reviewed and determined to be correct, unless the related claim has the correct hysterectomy statement attached.
All Sterilizations
Guidelines The following guidelines must be accurately followed before reimbursement can be made for any sterilization procedure (including, but not limited to hysterectomy, tubal ligation sterilization, vasectomy). If each item is not followed completely, it will result in the denial of your claim. KMAP or other authorized agencies may ask for documentation at any time, either during the claims processing period or after payment of a claim, to verify that services have been provided within program guidelines.
1) The Sterilization Consent Form mandated by federal regulation, located at the end of this manual in the Forms section, and on the KMAP Web site under Publication/Forms/Sterilization Consent Form, must be used. All voluntary sterilization claims submitted without this specific sterilization consent form will be denied.
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2) The Sterilization Consent Form must be signed so that 30 days have passed before the date the sterilization is performed with the following exceptions:
Premature Delivery • The date of the beneficiary’s consent must be at least three (3) calendar days prior to the date the sterilization was performed. • The expected date of delivery must be indicated on the consent form and the date of the beneficiary’s consent must be at least 30 days prior to the expected date of delivery.
Emergency Abdominal Surgery • The date of the beneficiary’s consent must be at least three (3) calendar days prior to the date the sterilization was performed. • The circumstances of the emergency abdominal surgery must be described by the physician sufficiently to substantiate the waiver of the 30 day requirement.
Three (3) calendar days is used in the above exceptions to guarantee compliance with the minimum federal requirement of 72 hours.
3) The Sterilization Consent Form is valid for 180 days from the date it is signed by the beneficiary. Sterilization claims for individuals that reflect dates of service beyond 180 days from the date the consent form was signed will be denied.
4) The individual must be at least 21 years of age or older on the date the consent form is signed, or the sterilization claim will be denied. (This includes those situations in which the individual has misrepresented his or her age on the consent form to the provider.) The birth date information provided by SRS will be used to determine whether the individual meets the age requirement. This information can be obtained through the KMAP Customer Service Center.
5) Sterilizations on mentally incompetent individuals are not covered. "Mentally incompetent individual" is defined as an individual who has been declared mentally incompetent by a federal, state or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes which include the ability to consent to sterilizations (42 CFR 441.251).
6) The sterilization is not covered when consent is obtained from anyone in "labor," under the influence of alcohol or other drugs, or seeking or obtaining an abortion.
7) Interpreters must be provided when there are language barriers, and special arrangements must be made for handicapped individuals.
8) The physician's statement must be signed and dated no more than two (2) days prior to the surgery, the day of the surgery, or any day after sterilization was performed.
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9) The physician statement on the consent form must be signed by the physician who performed the sterilization. No other signatures will be accepted.
When sterilization results from the treatment of a medical condition, a consent form is not required. However, there must be a note on the face of the claim that states the medical condition that caused the sterility. Claims billed involving these situations will be denied for no sterilization consent form when an explanatory notation is not present on the face of the claim.
The form must be legible in its entirety.
Providers may photocopy this form from the manual. Refer to the Forms section at the end of the manual for a copy of the Sterilization Consent Form.
Note: Sterilization Consent Form instructions are listed following the form.
Transcervical Sterilizations Procedure code 58579 is not covered for transcervical sterilization procedures. Procedure code 58565 is to be used. The procedure must meet all sterilization requirements. Prior authorization is required.
The Essure Kit is included in procedure code 58565 and should not be billed separately. The invoice does not need to be attached to the claim.
Procedure code 58340 (SIS/HSG test) is covered as part of the transcervical sterilization process. This code will be paid only if the transcervical sterilization has been paid previously and the sterilization was performed more than three months prior to the date of service. If a beneficiary has had a transcervical hysteroscopy sterilization, a federal sterilization consent form is required. Additionally, three months must have passed before having the catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography (HSG) - procedure code 58340. To indicate proof of sterilization, ICD-9 CM diagnosis code V25.2 must be used. Prior authorization is not required.
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Surgery Ambulatory/Outpatient Surgery Ambulatory surgery centers are allowed reimbursement for the use of operating room, recovery room, and supplies incurred for minor surgical procedures. Ancillary services, (such as physician, anesthesiologist, and assistant surgeon) charges shall be billed by those providers involved.
Ambulatory surgery centers and outpatient hospitals will be reimbursed for multiple unrelated outpatient surgical procedures performed on the same day as follows: 100% of the current Medicaid rate for the highest value procedure; 50% of the current Medicaid rate for the second procedure; and 25% of the current Medicaid rate for all subsequent procedures.
Content of Service IVs, medications, supplies and injections performed on the same day as an ambulatory outpatient surgery procedure are considered content of service of the surgery and shall not be billed separately.
Anesthesia equipment and supplies, drugs, surgical supplies, and other equipment of the operating room and the recovery room are considered content of service of the ambulatory/outpatient surgical procedure.
Exploratory laparotomy and enterolysis of adhesions are considered content of service when performed in conjunction with another major surgery.
Procedures performed in conjunction with an emergency room visit (sutures, minor surgeries, etc.) are considered content of service of the emergency room visit and shall not be billed separately. When reimbursement for the procedure is preferred, the CPT code for the procedure performed shall be billed in lieu of the ER visit.
Surgery - Breast Reconstruction Breast reconstruction is covered when one of the breast reconstruction procedure codes is billed with one or more of the breast cancer diagnoses listed, and the beneficiary had a mastectomy for breast cancer on or after March 1, 2005, using one of the mastectomy codes listed. Refer to Appendix II for a list of covered codes.
Cosmetic Surgery All surgeries cosmetic in nature (and related complications) are not covered. Any medically necessary procedure which could ever be considered cosmetic in nature must be prior authorized. (Refer to Section 4300.)
Diagnostic and Surgical Procedures Performed Outpatient Certain diagnostic and surgical procedures are reimbursed at a higher rate when performed in the physician's office, ambulatory surgical center, or outpatient general hospital unit.
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Elective Surgery The Medicaid Program will not reimburse for elective surgery unless medically necessary for a KAN Be Healthy participant. (Refer to Section 2020 for details.)
Certain procedures are reviewed on a postpayment, random sample basis. Retain all documentation supporting the non-elective nature of the surgery in your files for review. Documentation includes admission notes, history and physical, operative report and pathology report.
If documentation does not support the non-elective surgery, reimbursement for all claims relating to the surgery will be recovered.
Major Surgery All office visits, hospital visits and non-emergency outpatient visits one day prior to the day of surgery up to a period of 42 days after surgery are content of service of the surgery.
Minor Surgery All office visits, hospital visits and non-emergency outpatient visits for a period of 21 days after minor surgeries are content of service of the surgery.
Office visits and non-emergency outpatient visits rendered on the same day as surgery are content of service.
Note: Medicaid only uses Medicare's global indicators to determine what procedures are considered minor and major procedures for pre/post operative editing.
Therapy Therapy treatments are not covered for psychiatric diagnosis.
Habilitative – Therapy is covered for any birth defects/developmental delays only when approved and provided by an Early Childhood Intervention (ECI), Head Start, or Local Education Agency (LEA) program. Therapy treatments performed in the LEA settings may be habilitative or rehabilitative for disabilities due to birth defects or physical trauma/illness. Therapy of this type is covered only for participants age 0 to under the age of 21. Therapy must be medically necessary. The purpose of this therapy is to maintain maximum possible functioning for children.
Rehabilitative - All therapies must be physically rehabilitative. Therapies are covered only when rehabilitative in nature and provided following physical debilitation due to an acute physical trauma or physical illness and prescribed by the attending physician.
Therapy services are limited to 6 months for non-KAN Be Healthy participants (except the provision of therapy under HCBS), per injury, to begin at the discretion of the provider. There is no limitation for KAN Be Healthy participants.
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Therapy codes must be billed as one unit equals one visit unless the description of the code specifies the unit.
Providers of rehabilitative therapy can submit claims with a combination of the following rehabilitation therapy procedure codes and a diagnosis code in the range of V57.0-V57.9 as the primary diagnosis. Providers are required to submit a secondary diagnosis code to describe the origin of the impairment for which rehabilitative therapy is needed when one of these V-codes is billed as a primary diagnosis.
97001 97003 97010 97012 97014 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97110 97112 97113 97116 97124 97140 97150 97530 97535 97750
Occupational Therapy Must be provided by a home health agency, OP hospital department, or Local Education Agency.
Occupational therapy is covered when services are prescribed by a physician and performed by a registered occupational therapist or a certified occupational therapist assistant working under the supervision of a registered occupational therapist. When services are performed by a certified occupational therapy assistant, supervision must be clearly documented. This may include, but is not limited to, the registered occupational therapist initializing each treatment note written by the certified occupational therapy assistant, or the registered occupational therapist writing “Treatment was supervised” followed by their signature.
Physical Therapy Must be provided by a home health agency, physician's office, outpatient hospital department, or a Local Education Agency.
Physical therapy is covered when services are prescribed by a physician and performed by a registered physical therapist or by a certified physical therapy assistant working under the supervision of a registered physical therapist. When services are performed by a certified physical therapy assistant, supervision must be clearly documented. This may include, but is not limited to, the registered physical therapist initializing each treatment note written by the certified physical therapy assistant, or the registered physical therapist writing “Treatment was supervised” followed by their signature.
Speech Therapy Must be provided by a home health agency, OP hospital department, or a Local Education Agency.
Speech therapy is covered when services are prescribed by a physician and performed by a certified speech pathologist. KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Transplants Liver transplants for Medicaid beneficiaries will only be reimbursed at the University of Kansas Medical Center or at a hospital recommended by their staff.
Heart, lung and heart/lung transplants performed in approved in-state or border city hospitals are covered for KAN Be Healthy participants only.
Heart transplants will be allowed at St. Luke's Hospital in Kansas City, Missouri, or Via Christi (St. Francis Campus) in Wichita, Kansas, or at a hospital recommended by either of these facilities.
Bone marrow, cornea, kidney, and pancreas transplants performed in approved in-state or border city hospitals are covered and do not require prior authorization. Pancreas transplants are only covered when performed simultaneously with or following a kidney transplant.
Tuberculosis Inpatient services related to a tuberculosis (TB) diagnosis, including physician and laboratory services is covered for beneficiaries with the TB benefit plan.
Inpatient hospitalization including physicians’ services for diagnostic evaluation of beneficiaries highly suspected of TB is covered for completion of the diagnosis.
Acute problems, which are present on admission or arise during hospitalization, are covered services. Hospitalization for monitoring toxicity of anti-tuberculosis drugs is covered.
Inpatient claims may be billed directly to KMAP.
Coverage and payment of inpatient or outpatient services are subject to compliance with infectious disease reporting requirements as directed by K.A.R. 28-1-2.
Coverage and payment of outpatient services are coordinated between Kansas Department of Health and Environment (KDHE) and Kansas Health Policy Authority (KHPA) KMAP in accordance with the current interagency agreement. Contact KDHE at 785-296-0739 for determination of coverage.
Anti-tuberculosis drugs to treat the beneficiary and family members are provided at no cost by KDHE. Contact your local health department or KDHE at 785-296-2547.
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Vagal Nerve Stimulators Vagal nerve stimulators (VNS) are covered for beneficiaries with epileptic disorders. With the exception of procedure codes 95970 and 95974, all services must be prior authorized.
VNS services must meet the following conditions: • The beneficiary must have an epileptic disorder. VNS will not be covered for individuals with previous epileptic brain surgery, or individuals with progressive disorders. • Mental retardation with epilepsy is not a contraindication for VNS but must be considered with other factors. • The beneficiary must be over the age of 12, with documentation showing that the VNS will improve quality of life. • All other courses of treatment must be documented, such as conventional and anticonvulsant drugs.
Refer to Appendix II for a list of covered codes.
Vision KMAP offers a variety of optical benefits.
Complete eye examination every four years.
Eyeglasses with certain limitations, see the Vision Provider Manual.
Many vision services have specific limitations. For further information a Vision Provider Manual may be requested (refer to Section 1100).
Vacuum Assisted Wound Closure Therapy Vacuum assisted wound closure therapy is covered for specific benefit plans. Prior authorization is required and criteria must be met. Refer to the Durable Medical Equipment Provider Manual for criteria. For questions about service coverage for a given benefit plan, contact the KMAP Customer Service Center at 1-800-933-6593 or 785-274-5990. All prior authorization must be requested in writing by a KMAP DME provider. All medical documentation must be submitted to the KMAP DME provider.
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8410. ARNP Updated 01/08
SERVICES DESCRIBED IN THIS SECTION ARE SPECIFIC TO ARNP PROVIDERS ONLY.
ARNPs may bill for all Kansas Medical Assistance Program services that they are legally allowed to perform. The scope of these services are outlined by the Kansas State Board of Nursing. All services rendered are subject to Kansas Medical Assistance Program limitations that apply to physician services or limitations listed below if the service is not performed by the physician.
ARNPs are reimbursed at 75 percent of the maximum rate set for physicians. Anesthesia services and KAN Be Healthy screens are reimbursed at the same rate as set for physicians.
Anesthesia Anesthesia services may be considered for payment when provided by a certified registered nurse anesthetist (CRNA) enrolled as an ARNP. Anesthesia is the only service reimbursable to CRNAs under the Kansas Medical Assistance Program.
Case Management ACIL Target Case Management (G9012) is limited to 480 units (15 minutes per unit) per calendar year. Case management must be provided by a pediatric ARNP or general ARNP. Prior authorization (PA) is required when a consumer requires more than 480 units per year of Targeted Case Management. PA requests must be directed to the ACIL Program Manager at (785) 296-3561 (see address below).Services require a HealthConnect Kansas referral, other insurance is primary and must be billed first.
Admission to ACIL services shall require Program Manager approval. Approval for admission into the ACIL program shall be obtained in the following manner:
1. Approved ACIL Targeted Case Management (TCM) providers shall evaluate beneficiaries for eligibility for ACIL services.
2. If the ACIL TCM determines the beneficiary meets eligibility criteria, the ACIL TCM shall submit the following documentation to the ACIL Program Manager (see address below):
• Case Management Provider’s Worksheet and • Assessment Instrument
3. The ACIL Program Manager will review the submitted documentation, and will notify the ACIL TCM provider in writing that the beneficiary has been approved or not approved for admission into the ACIL program.
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Case Management cont. Note: Babies born to mother’s assigned to FirstGuard (HealthWave 19) are excluded from ACIL eligibility. FirstGuard provides intensive medical care needed for these babies.
Note: Any services not provided in accordance with these processes are subject to recoupment.
ATTN: ACIL Program Manager Division of Healthcare Policy Docking State Office Building 915 SW Harrison, 10th Floor Topeka, Kansas 66612-1570
Pain Management
Providers are encouraged to use the Pain Management Guidelines developed by The Federation of State Medical Boards of the United States, Inc. and adopted by the Adult and Medical Services Commission. The guidelines are the following:
Evaluation of the Patient
1. A complete medical history and physical examination must be conducted and documented in the medical records.
2. The medical records should document the nature and intensity of the pain, evaluate underlying or coexisting diseases or conditions, the effect of the pain on physical and psychological function, and history of substance abuse.
3. The medical record should also document the presence of one or more recognized medical indications for the use of a controlled substance.
Treatment Plan
1. The written treatment plan should state objectives that will be used to determine treatment success, such as pain relief and improved physical and psychosocial function, and should indicate if any further diagnostic evaluations or other treatments are planned. 2. After treatment begins, the physician should adjust drug therapy to the individual medical needs of each patient. Other treatment modalities or rehabilitation program may be necessary depending on the etiology of the pain and the extent to which the pain is associated with physical and psychosocial impairment.
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Pain Management cont. Informed Consent and Agreement for Treatment 1. The physician should discuss the risks and benefits of the use of controlled substances with the patient, significant other(s) or guardian. 2. The patient should receive prescriptions from one physician and one pharmacy where possible. 3. If the patient is determined to be at high risk for medication abuse or have a history of substance abuse, the physician may employ the use of a written agreement between physician and patient outlining patient responsibilities including: • urine/serum medication levels screening when requested • number and frequency of all prescription refills • reasons for which drug therapy may be discontinued (i.e. violation of agreement)
Periodic Review 1. At reasonable intervals based upon the individual circumstance of the patient, the physician should review the course of opioid treatment and any new information about the etiology of the pain. 2. Continuation or modification of opioid therapy should depend on the physician's evaluation of progress toward stated treatment objectives such as improvement in patient's pain intensity and improved physical and/or psychosocial function, such as ability to work, need of health care resources, activities of daily living and quality of social life. 3. If reasonable treatment goals are not being achieved, despite medication adjustments, the physician should re-evaluate the appropriateness of continued opioid treatment. 4. The physician should monitor patient compliance in medication usage and related treatment plans.
Consultation 1. The physician should be willing to refer the patient as necessary for additional evaluation and treatment in order to achieve treatment objectives. 2. Special attention should be given to those pain patients who are at risk for misusing their medications and those whose living arrangement pose a risk for medication misuse or diversion. 3. The management of pain in patients with a history of substance abuse or with a comorbid psychiatric disorder require extra care, monitoring, documentation and consultation with or referral to an expert in the management of such patients.
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Medical Records 1. The physician should keep accurate and complete records to include: a. the medical history and physical examination b. diagnostic, therapeutic and laboratory results c. evaluations and consultations d. treatment objectives e. discussion of risks and benefits f. treatments g. medications (including date, type, dosage, and quantity prescribed) h. instructions and agreements i. periodic reviews 2. Records should remain current and be maintained in an accessible manner and readily available for review.
Compliance with Controlled Substances Law and Regulations 1. To prescribe controlled substances, the physician must be licensed in the State of Kansas, have a valid controlled substances registration and comply with federal and state regulations for issuing controlled substances prescriptions. 2. Physicians are referred to the Physicians Manual of the U.S. Drug Enforcement Administration (and any regulations issued by the State Medical Board) for specific rules governing issuance of controlled substance prescriptions as well as applicable state regulations.
Definitions For the purposes of the pain management guidelines for Kansas Medicaid, the following terms are defined as follows: Acute Pain - Acute pain is the normal, predicted physiological response to an adverse chemical, thermal, or mechanical stimulus and is associated with surgery, trauma, and acute illness. It is generally time limited and is responsive to opioid therapy, among other therapies. Addiction - Addiction is a neurobehavioral syndrome with genetic and environmental influences that results in psychological dependence on the use of substances for their psychic effects and is characterized by compulsive use despite harm. Addiction may also be referred to by terms such as "drug dependence" and "psychological dependence". Physical dependence and tolerance are normal physiological consequences of extended opioid therapy for pain and should not be considered addiction. Chronic Pain - A pain state that is persistent and in which the cause of the pain cannot be removed or otherwise treated and which, in the generally accepted course of medical practice, no relief or cure of the cause of the pain is possible or none has been found after reasonable efforts. Chronic pain may be associated with a long-term incurable or intractable medical condition or disease.
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Definitions cont Physical Dependence - Physical dependence is a physiologic state of neuroadaptation to an opioid which is characterized by the emergence of a withdrawal syndrome if the opioid use is stopped or decreased abruptly, or if an antagonist is administered. Withdrawal may be relieved by re-administration of the opioid. Physical dependence appears to be an inevitable result of opioid use. Physical dependence, by itself, does not equate with addiction. Substance Abuse - Substance abuse is the use of any substance(s) for non-therapeutic purposes; or use of medication for purposes other than those for which it is prescribed. Tolerance - Tolerance is a physiologic state resulting from regular use of a drug in which an increase dosage is needed to produce the same effect or a reduced effect is observed with a constant dose. Tolerance occurs to different degrees for various drug effects, including sedation, analgesia and constipation. Analgesic tolerance is the need to increase the dose of opioid to achieve the same level of analgesia. Analgesic tolerance may or may not be evident during opioid treatment and does not equate with addiction.
Technology Assisted Children’s Waiver The technology assisted (TA) children’s waiver provides special waivered services for TA children who would, in the absence of home care services, require a hospital level of care.
Medical Case Management Medical case management is defined as the development of an individualized care plan based on a comprehensive assessment, including financial and complex medical case management. The case manager locates, coordinates, and monitors home care and other services for technology assisted children. Case management must be provided by an ARNP who has experience with the health and social needs of the TA child, fiscal case management, and expertise in the development of assessments, plans of care, monitoring, and utilization review for these children. Case management is limited to 120 hours per calendar year per KAN Be Healthy consumer. Prior authorization (PA) may be requested when a KAN Be Healthy participant requires more than 120 hours of medical case management within the calendar year. PA requests should be directed to the Manager of Special Programs at the Health Care Policy Medical Policy telephone 785-296-3981. Procedure T1016 Targeted Case Management must be indicated when billing for this services.
Limitations • Children must be under the age of 18, • Be ventilator dependent, or require total parental nutrition, or similar conditions, • Be KAN Be Healthy participants, • Are approved as waiver eligible by Medical Services of SRS, • Services delivered to the child must be contained in a plan of care approved by Adult and Medical Services.
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ARNP SPECIFIC PROCEDURE CODES AND NOMENCLATURE
COVERAGE INDICATORS
KBH - KAN Be Healthy participation is required.
PROCEDURE COV. CODE NOMENCLATURE
CASE MANAGEMENT KBH G9012 Other specified case management service not elsewhere classified (This code to be used for ACIL) KBH T1016 Targeted Case Management per 15 minutes (This code to be used for TA waiver)
KAN BE HEALTHY SCREENS
Refer to Section 2020.
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8420. LOCAL HEALTH Updated 01/08
SERVICES DESCRIBED IN THIS SECTION ARE SPECIFIC TO LOCAL HEALTH DEPARTMENT PROVIDERS ONLY.
Family Planning
Family planning is any medically approved treatment, counseling, drugs, supplies, or devices which are prescribed or furnished by a provider to individuals of child-bearing age for purposes of enabling such individuals to freely determine the number and spacing of their children.
• Annual gynecological examination; new patient (S0610) is limited to one per consumer per lifetime. This includes complete physical examination, counseling, and follow-up. • The annual gynecological examination, established patient (S0612) includes complete physical examination, counseling and follow-up. • Contraceptive pills for birth control (S4993) must be billed separately. Billing for contraceptive pills is limited to 13 times per 12 calendar months. • For interim family planning visits (recheck of contraceptive method, modification of prescription, clinical problems and counseling) may use T1001 and Evaluation and Management CPT Codes: 99211, 99212, 99213, and 99214 as appropriate.
Skilled Nursing Services
Home health skilled nursing services by a registered nurse (RN), procedure code T1002, can only be provided by Local Health Departments (LHD) when the services of a home health agency are not available in the county where the consumer resides. LHDs must notify the Home Health program manager in writing (Landon State Office Bldg, 900 Southwest Jackson, Room 900, Topeka, Kansas 66612) that the LHD is providing skilled nursing services in the absence of a home health agency in the beneficiary’s county of residence. LHDs must use the current home health procedure code to bill for RN home health skilled nursing services provided to eligible beneficiaries and must bill using their LHD provider number. LHDs will be subject to the same limits and rates as home health agencies for skilled RN services.
Prenatal Health Promotion and Risk Reduction
Prenatal Health Promotion and Risk Reduction (PHP/RR) services are designed to reduce the incidence of poor pregnancy outcomes for the mother and newborn. PHP/RR facilitates the Medicaid beneficiary’s access to nursing, nutrition and psycho-social assessments, interventions and referrals based on identified risks, and health promotion education.
PHP/RR services are exempt from a HealthConnect primary care case management (PCCM) referral. If the consumer is enrolled in a Medicaid HMO, the local agency will need to contract directly with the HMO to seek reimbursement from the HMO.
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Billing Codes PHP/RR may be billed under H1000 for a single visit(s) (with a maximum of three visits) or under code H1005, for a total package of three visits.
Service Periodicity Services ideally occur once a trimester, with the initial assessment ideally taking place during the first trimester and follow-up visits occurring during the second and third trimester. Services, however, may be provided anytime during the pregnancy depending on when contact with the beneficiary is initiated.
Service Components 1. Data Base Collection and Risk Identification 2. Confirmation of participation in or referral to prenatal medical care 3. Notification of prenatal medical care provider of consumer participation in service and risks identified 4. Referral to appropriate support services 5. Follow-up face-to-face contact based on the beneficiary’s risks/needs, to include health promotion education
Assessment Components 1. Obstetrical care provider name & compliance with care 2. Demographic data, e.g. marital status, age, race, emergency contact, other insurance 3. Medical history (family and self) 4. Past obstetrical history 5. Current obstetrical history and pregnancy status 6. Prepregnancy weight status and weight gain/loss 7. Psychosocial/Environmental, e.g. attitude toward pregnancy, support systems, living arrangements, employment, emotional/stress factors 8. Nutrition Screen a. Frequency of meals/snacks, eating pattern, quantity and quality of food selections b. Unusual dietary practices, e.g. faddism, food avoidance, elective nutrient and/or vitamin supplementation c. Nutrition knowledge, e.g. expectation about weight gain/loss, management of morning sickness, constipation, heart burn d. Behavioral risk factors, e.g. alcohol and/or other substance use
Health Promotion Education Education should be based on risks/needs. Coordination with the prenatal medical care provider and other members of the health care team is recommended. Education is to be provided during face-to-face contacts, with documentation by topic presented.
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Topics for health education should include: prenatal care regimen; normal pregnancy, labor/delivery and postpartum course; maternal physiologic, social and emotional changes; risks for, prevention and identification of pre-term labor and other changes of pregnancy status; nutritional needs of pregnancy/lactation; behavioral risks such as substance use, smoking, alcohol consumption; need for dental assessment/care; fetal growth and development; preparation for labor/delivery; importance of and preparation for breastfeeding; parenting and infant care skills; and family planning.
Referrals Referrals should be made to WIC, Healthy Start, public health prenatal services and other health department services and/or other support services based on the beneficiary’s needs/risks. Documentation of referrals should be made in the case record.
Provider of PHP/RR Registered nurse (RN) or primary obstetrical care provider on agency staff or on contract with local agency.
Note: For additional guidance regarding nursing assessments, refer to the Children, Youth and Families Health Services Manual, Volume I, Maternal & Infant/Perinatal, Kansas Department of Health and Environment.
Prenatal Health Promotion Risk Reduction - High Risk Nutrition Services
Prenatal Health Promotion Risk Reduction (PHP/RR) High Risk Nutrition Services facilitate access to nutrition assessments and interventions by a registered/licensed dietitian (RD/LD) based on the initial nutritional screen done by a registered nurse or primary obstetrical care provider.
PHP/RRHRN services are exempt from a HealthConnect primary care case management (PCCM) referral. If the consumer is enrolled in a Medicaid HMO, the local agency will need to contract directly with the HMO to seek reimbursement from the HMO.
Billing Codes PHP/RRHRN visits (S9470) may be billed before H1000 or H1005 are billed. PHP/RRHRN (S9470) must be billed on a separate claim form from other services since only the federal portion (FFP) is reimbursed by Medicaid. Reimbursement for these services may only be made to approved local agencies.
Service Periodicity The frequency and spacing of visits must be determined by RD/LD based on the nutritional necessity indicators and may include both prenatal visits and one postpartum visit.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
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Indications The initial nutritional screen done by the nurse or primary obstetrical care provider shall support nutritional necessity for referral to an RD/LD for high risk nutrition services to be reimbursed.
Indicators of nutritional necessity include current diagnosis of any of the following conditions that jeopardize nutritional status: inappropriate weight gain/loss; existing diabetes or gestational diabetes; anorexia nervosa or bulimia; GI tract disease or conditions (e.g. celiac disease, regional ileitis, ulcers/ ulcerative colitis); genetic disorders (e.g. cystic fibrosis, galactosemia, hyperlipidemia, PKU); HIV/AIDS; vitamin or mineral deficiencies.
Service Components 1. Nutrition Assessment Update, e.g. reassessment of anthropometric, dietary, and hematologic data 2. Development of nutritional care plan based on updated assessment 3. Provision of one-on-one nutritional counseling, in collaboration with the primary obstetrical care provider
Providers of High Risk Nutrition Services RD/LD on agency staff or on contract with approved local agency.
Note: For additional guidance regarding nutrition assessments and interventions, refer to the Children, Youth and Families Health Services Manual, Volume I, Maternal & Infant/Perinatal, Kansas Department of Health and Environment.
Prenatal Health Promotion/Risk Reduction Enhanced Social Work Services
Prenatal Health Promotion/Risk Reduction Social Work Services (PHP/RRESW) are to provide access to professional social work services by licensed social workers for pregnant and postpartum women who are identified by a registered nurse, licensed social worker and/or primary obstetrical care provider that support a psychosocial necessity.
PHP/RRESW services are exempt from a HealthConnect primary care case management (PCCM) referral. If the consumer is enrolled in a Medicaid HMO, the local agency will need to contract directly with the HMO to seek reimbursement from the HMO.
Billing Codes PHP/RRESW (H1002) must be billed on a separate claim form from other services since only the federal portion (FFP) is reimbursed by Medicaid. Reimbursement for these services may only be made to approved local agencies. Services may be billed by increments, e.g. .25 = 15 minutes, .50 = 30 minutes, .75 = 45 minutes.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-58 8420. Updated 01/08
Service Periodicity Frequency and spacing of visits determined by a licensed social worker based on psychosocial necessity indicators. Maximum of 10 hours per calendar year, which may include prenatal and postpartum contacts.
Indications The initial psychosocial screen shall support a necessity for referral for enhanced social worker services to be reimbursed.
Indicators of psychosocial necessity include: situations that compromise the beneficiary’s ability to enter, continue, and/or comply with prenatal care or make behavioral changes that would impact the pregnancy outcome; limited or lack of support systems; assessed to be at risk for abuse for or are in an abusive environment; and/or have concerns about the effect of the pregnancy on their life goals and pregnancy outcome.
Service Components 1. Psychosocial Needs/Risk Assessment Update, e.g. review of initial screen and completion of a professional social work intake 2. Development of social work care plan based on current assessment, e.g. prioritizing needs, setting clients goals, plans for follow-up 3. Provision of one-on-one counseling in collaboration with the primary obstetrical care provider and other team members
Provider of Enhanced Social Work Services Licensed social workers (LASW, LBSW, LMSW, LCSW) on staff or on contract (appropriate to level of licensure) with approved local agencies.
Note: For additional guidance regarding social work assessments, refer to the Children, Youth and Families Health Services Manual, Volume I, Maternal & Infant/Perinatal, Kansas Department of Health and Environment.
Postpartum/Newborn Home Visit
The Postpartum/Newborn Home Visit (PP/NBHV) provides a transition between the in-patient obstetrical newborn services and the mother’s and infant’s entry into postdelivery out-patient care.
PP/NBHV services are exempt from a HealthConnect primary care case management (PCCM) referral. If the beneficiary is enrolled in a Medicaid HMO, the local agency will need to contract directly with the HMO to seek reimbursement from the HMO.
Service Periodicity One home visit/mother-baby unit, provided by a registered nurse, is made within 28 days after the neonate’s date of birth. No risk indicators are required to provide this home visit.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-59 8420. Updated 01/08
Billing Code Postpartum/Newborn Home Visits (99502) may be billed using either the mother’s or newborn’s current Medicaid number. If using the mother’s Medicaid number, the claim form should also include the newborn’s first and last name or if the newborn’s first name has not been determined, state Baby Boy or Baby Girl and then the newborn’s last name.
Assessment Components 1. Maternal - e.g. postpartum physiological, emotional status, and nutritional status; interaction with and care skills for newborn; family planning; follow-up medical care appointment(s); employment/education plans 2. Newborn - e.g. physiological and nutritional status; weight assessment as indicated; appointment(s) for health care follow-up 3. Parenting and Home - e.g. parenting knowledge/skills; awareness of schedule for newborn/child health assessments/immunizations; home environment 4. Support Systems - source for primary health care; other support
Service Components 1. Parenting and Health Promotion Education based on individual needs/risks 2. Provision of information on well-child assessments and immunizations 3. Provision of information on, at a minimum, SIDS prevention, car seat use, and Shaken Baby Syndrome 4. Referral based on individual needs/risks
Provider Registered nurse on staff or on contract with local agency.
Note: For additional guidance regarding postpartum and newborn nursing assessments, refer to the Children, Youth and Families Health Services Manual, Volume I, Maternal & Infant/Perinatal and Volume II, Children and Youth, Kansas Department of Health and Environment.
Dental Services
Local health departments enrolled with Medicaid may bill for dental services provided to Medicaid beneficiaries and must obtain a separate dental provider number to provide dental services through KMAP. Dental services are billed on the American Dental Association (ADA) form. Please contact the EDS Dental Services Team at 800-933-6593 # 4 # for all dental-related questions. Providers may also refer to the Dental Provider Manual on the KMAP Web site at: https://www.kmap-state-ks.us/Public/providermanuals.asp.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-60 8420. Updated 01/08
LOCAL HEALTH PROCEDURE CODES AND NOMENCLATURE
Local health departments who employ or contract with a physician may bill any appropriate CPT procedure code.
PROCEDURE COV. CODE NOMENCLATURE
FAMILY PLANNING* J1055 Medroxyprogesterone Acetate for Contraceptive J7300 Intrauterine Copper Contraceptive J7302 Intrauterine Levonorgestrel Releasing Contraceptive J7303 Contraceptive supply, hormone containing vaginal ring J7304 Contraceptive Supply, Hormone Containing Patch, each J7306 Levonorgestrel (contraceptive) implant system, including implants and supplies S4993 Contraceptive pills for birth control S0610 Annual gynecological examination ; new patient (This includes complete physical examination, counseling and follow-up). S0612 Annual gynecological examination; established patient (This includes complete physical examination, counseling and follow-up) S0613 Annual gynecological examination; clinical breast examination without pelvic examination
NURSING ASSESSMENT / EVALUATION T1001 Nursing assessment/evaluation completed by a Registered Nurse (RN)
PRENATAL HEALTH PROMOTION AND RISK REDUCTION (PHP/RR) H1000 Prenatal care, at risk assessment S9470 Nutritional counseling, dietitian visit H1002 Prenatal care, at risk enhanced service; care coordination H1005 Prenatal care, at risk enhanced service package S0197 Prenatal vitamins, 30 day supply
POSTPARTUM/NEWBORN HOME VISIT 99502 Home visit for newborn care and assessment
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-61 BENEFITS & LIMITATIONS
8430. KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT (KDHE) STATE LABORATORY Updated 01/08
Covered Services KDHE laboratory services are covered for Medicaid beneficiaries. The following laboratory services are covered:
Neonatal Chemistry Virology/Serology Inorganic Chemistry Diagnostic Microbiology
Laboratory services billed by the KDHE Lab shall be reimbursed at Federal Financial Participation (FFP) only.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-62 8430. Updated 01/08
KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT STATE LABORATORY The following procedure codes are specific to KDHE and are billable to KMAP.
PROCEDURE COV. CODE NOMENCLATURE
NEONATAL CHEMISTRY 84030 Phenylalanine (PKU), blood 84437 Thyroxine (T4), total requiring elution 84443 Thyroid stimulating hormone (TSH) 82776 Galactose-1-phosphate uridyl transferase, screen 82760 Galactose 83020 Hemoglobin, electrophorese
VIROLOGY/SEROLOGY 87178 Microbial identification, nucleic acid probes used 86781 Treponema Pallidum, confirmatory test 86592 Syphilis test; qualitative 86603 Adenovirus 86631 Chlamydia 86644 Cytomegalovirus 86694 Herpes simplex, non-specific type test 86710 Influenza virus 86713 Legionella 86735 Mumps 86738 Mycoplasma 86756 Respiratory synctial virus 86762 Rubella 86765 Rubeola 86787 Varicella-zoster 86788 Antibody; West Nile Virus, IGM 86789 Antibody; West Nile Virus 86790 Virus, not elsewhere specified 87110 Culture, chlamydia, any source 87252 Virus isolation; tissue culture inoculation, observation, and presumptive identification by cytopathic effect 87253 Virus isolation; tissue culture, additional studies or definitive identification (e.g., Hemabsorption, neutralization, immunofluoresence stain), each isolate
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-63 8430. Updated 01/08
PROCEDURE COV. CODE NOMENCLATURE
INORGANIC CHEMISTRY 83655 Lead, quantitative 84202 Protoporphyrin, RBC; quantitative
DIAGNOSTIC MICROBIOLOGY 83631 Lactoferrin, fecal; quantitative 83907 Molecular diagnostics; lysis of cells prior to nuclei acid extraction (for example, stool specimens, paraffin embedded tissue) 83913 Molecular diagnostics; RNA stabilization 83993 Calprotectin, fecal 87015 Concentration (any type), for infectious agents 87046 Culture, bacterial; stool, additional pathogens, isolation and preliminary examination (e.g., campylobacter, yersinia, vibro, e. coli 0157), each plate 87071 Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool 87081 Culture, presumptive, pathogenic organisms, screening only 87101 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair or nail 87102 Culture, fungi, other source except blood 87116 Culture, tubercle or other acid-fast bacilli (e.g., TB, AFB, mycobacteria) any source, with isolation and presumptive identification of isolates 87118 Culture, mycobacterial, definitive identification, each isolate 87140 Culture, typing; immunofluorescent method, each antiserum 87147 Culture, typing; immunologic method, other than immunofluoresence (e.g., agglutination grouping), per antiserum 87172 Pinworm exam (e.g., cellophane tape prep) 87177 Ova and parasites, direct smears, concen. 87184 Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents) 87190 Susceptibility studies, antimicrobial agent; mycobacteria, proportion method, each agent 87205 Smear, primary source with interpretation; gram or giemsa stain for bacteria, fungi, or cell types 87206 Smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types 87210 Smear, primary source with interpretation; wet mount for infectious agents (e.g., Saline, India Ink, KOH preps)
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-64 8430. Updated 01/08
PROCEDURE COV. CODE NOMENCLATURE
87470 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, direct probe technique 87471 Bartonella henselae and Bartonella quintana, amplified probe technique 87472 Bartonella henselae and Bartonella quintana, quantification 87475 Borrelia burgdorferi, direct probe technique 87476 Borrelia burgdorferi, amplified probe technique 87477 Borrelia burgdorferi, quantification 87480 Candida species, direct probe technique 87481 Candida species, amplified probe technique 87482 Candida species, quantification 87485 Chlamydia pneumoniae, direct probe technique 87486 Chlamydia pneumoniae, amplified probe technique 87487 Chlamydia pneumoniae, quantification 87490 Chlamydia trachomatis, direct probe technique 87491 Chlamydia trachomatis, amplified probe technique 87492 Chlamydia trachomatis, quantification 87495 cytomegalovirus, direct probe technique 87496 cytomegalovirus, amplified probe technique 87497 cytomegalovirus, quantification 87498 enterovirus, amplified probe technique 87500 Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (e.g. enterococcus species van A, van B), amplified probe technique 87510 Gardnerella vaginalis, direct probe technique 87511 Gardnerella vaginalis, amplified probe technique 87512 Gardnerella vaginalis, quantification 87515 hepatitis B virus, direct probe technique 87516 hepatitis B virus, amplified probe technique 87517 hepatitis B virus, quantification 87520 hepatitis C, direct probe technique 87521 hepatitis C, amplified probe technique 87522 hepatitis C, quantification 87525 hepatitis G, direct probe technique 87526 hepatitis G, amplified probe technique 87527 hepatitis G, quantification 87528 Herpes simplex virus, direct probe technique 87529 Herpes simplex virus, amplified probe technique 87530 Herpes simplex virus, quantification 87531 Herpes virus-6, direct probe technique 87532 Herpes virus-6, amplified probe technique 87533 Herpes virus-6, quantification
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-65 8430. Updated 01/08
PROCEDURE COV. CODE NOMENCLATURE
87534 HIV-1, direct probe technique 87535 HIV-1, amplified probe technique 87536 HIV-1, quantification 87537 HIV-2, direct probe technique 87538 HIV-2, amplified probe technique 87539 HIV-2, quantification 87540 Legionella pneumophila, direct probe technique 87541 Legionella pneumophila, amplified probe technique 87542 Legionella pneumophila, quantification 87550 Mycobacteria species, direct probe technique 87551 Mycobacteria species, amplified probe technique 87552 Mycobacteria species, quantification 87555 Mycobacteria tuberculosis, direct probe technique 87556 Mycobacteria tuberculosis, amplified probe technique 87557 Mycobacteria tuberculosis, quantification 87560 Mycobacteria avium-intracellulare, direct probe technique 87561 Mycobacteria avium-intracellulare, amplified probe technique 87562 Mycobacteria avium-intracellulare, quantification 87580 Mycoplasma pneumoniae, direct probe technique 87581 Mycoplasma pneumoniae, amplified probe technique 87582 Mycoplasma pneumoniae, quantification 87590 Neisseria gonorrhoeae, direct probe technique 87591 Neisseria gonorrhoeae, amplified probe technique 87592 Neisseria gonorrhoeae, quantification 87620 papillomavirus, human, direct probe technique 87621 papillomavirus, human, amplified probe technique 87622 papillomavirus, human, quantification 87640 Staphylococcus aureus, amplified probe technique 87641 Staphylococcus aureus, methicillin resistant, amplified probe technique 87650 Streptococcus, group A, direct probe technique 87651 Streptococcus, group A, amplified probe technique 87652 Streptococcus, group A, quantification 87653 Streptococcus, group B, amplified probe technique 87797 Infectious agent detection by nucleic acid (DNA or RNA); not otherwise specified, direct probe technique, each organism 87798 not otherwise specified, amplified probe technique, each organism 87799 not otherwise specified, quantification, each organism
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-66 8430. Updated 01/08
PROCEDURE COV. CODE NOMENCLATURE
87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87801 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique 87802 Infectious agent antigen detection by immunoassay with direct optical observation; streptococcus, Group B 87803 Infectious agent antigen detection by immunoassay with direct optical observation; clostridium difficile Toxin A 87804 Infectious agent antigen detection by immunoassay with direct optical observation; Influenza 87808 Infectious agent antigen detection by immunoassay with direct optical observation; Thichomonas Vaginalis 87809 Infectious agent antigen detection by immunoassay with direct optical observation; adenovirus 87810 Infectious agent detection by immunoassay with direct optical observation; Chlamydia trachomatis 87850 Neisseria gonorrhoeae 87880 Streptococcus, group A 87901 Infectious agent genotype analysis by nucleic acid (DNA or RNA), HIV 1, reverse transcriptase and protease
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL BENEFITS & LIMITATIONS
8-67 APPENDIX I
HCPCS PROCEDURE CODES Updated 09/07
The Adult and Medical Services Commission at SRS, requires Kansas Medical Assistance Program (KMAP) professional services billers to submit claims using the Health Care Finance Administration Common Procedure Coding System (HCPCS). HCPCS is a combination of codes which includes Current Procedural Terminology (CPT) codes created and controlled by the American Medical Association; Centers for Medicare & Medicaid Services (CMS) codes created and controlled by CMS; and local codes created and controlled by the Regional CMS office.
A modifier code is a two-digit code that identifies a specific type of service, for example anesthesia, or a variation of the service identified by the base code. Certain services require a modifier code be given in addition to the HCPCS base code. The modifier codes listed below are the only modifier codes currently recognized by Medicaid.
Modifier Description 26 Professional Component 50 Bilateral Procedure 80 Assistant Surgery TC Technical Component 59 Distinct Procedural Service
Physician billers should use CPT codes (refer to Section 1300) when available or when specifically instructed to do so; otherwise the CMS or local codes printed in the following pages should be used.
Not all CPT procedure codes are covered. Contact the KMAP Customer Service Center with questions regarding coverage (refer to the General Introduction Provider Manual, Section 1000).
When a CPT, CMS or local code is not available, the service is noncovered by KMAP. NOC (not otherwise classified) codes are noncovered. (Refer to Section 4200.)
All claims must be coded with HCPCS codes. Claims which only describe the service and do not provide the HCPCS code will be denied.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-1 APPENDIX I SPECIAL PROCEDURE CODES AND NOMENCLATURE COVERAGE INDICATORS Updated 8/06
INV - Invoice must accompany claim KBH - Services covered for KAN Be Healthy participants only MN - Medical Necessity documentation required NC - Non-covered service
PROCEDURE COV. CODE NOMENCLATURE
DIETITIAN SERVICES KBH 97802 Medical Nutrition Therapy – Initial Assessment KBH 97803 Medical Nutrition Therapy – Reassessment and Intervention
FAMILY PLANNING A4260 Levonorgestrel implant (Norplant) and insertion J7300 Intrauterine Copper Contraceptive J7302 Intrauterine Levonorgestrel Releasing Contraceptive * Refer to the CPT® codebook for additional family planning procedure codes.
LABORATORY SERVICES BLOOD P9010 Blood (whole), for transfusion, per unit P9012 Cryoprecipitate, each unit P9016 Red blood cells, leukocytes reduced, each unit P9017 Fresh frozen plasma ((single donor), frozen within 8 hours of collection, each unit P9019 Platelet concentrate, each unit P9021 Red blood cells, each unit P9022 Washed red blood cells, each unit P9023 Plasma, pooled multiple donor, solvent/detergent treated, frozen, each unit P9031 Platelets, leukocytes reduced, each unit P9032 Platelets, irradiated, each unit P9033 Platelets, leukocytes reduced, irradiated, each unit P9034 Platelets, pheresis, each unit P9035 Platelets, pheresis, leukocytes reduced, each unit P9036 Platelets, pheresis, irradiated, each unit P9037 Platelets, pheresis, leukocytes reduced, irradiated, each unit P9038 Red blood cells, irradiated, each unit P9039 Red blood cells, deglycerolized, each unit P9040 Red blood cells, leukocytes reduced, irradiated, each unit P9041 Infusion, albumin (human), 5%, 50 ml P9043 Infusion, plasma protein fraction (human), 5%, 50 ml P9044 Plasma, cryoprecipitate reduced, each unit P9045 Infusion, albumin (human), 5%, 250 ml P9046 Infusion, albumin (human), 25%, 20 ml P9047 Infusion, albumin (human), 25%, 50 ml
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-2 Updated 12/07
PROCEDURE COV. CODE NOMENCLATURE
P9048 Infusion, plasma protein fraction (human), 5%, 250ml P9050 Granulocytes, pheresis, each unit P9051 Whole blood or red blood cells, leukocytes reduced CMV-negative, each unit P9052 Platelets, HLA-matched leukocytes reduced, apheresis/pheresis, each unit P9053 Platelets, pheresis, leukocytes reduced,CMV-negative, irradiated each unit P9054 Whole blood or red blood cells, leukocytes reduced, frozen, glycerol, washed, each unit P9055 Platelets, leukocytes reduced, CMV-negative, apheresis/pheresis, each unit P9056 Whole blood, leukocytes reduced, irradiated, each unit P9057 Ted blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit P9058 Red blood cells, leukocytes reduced, CMV-negative, irradiated, each unit P9059 Fresh frozen plasma between 8-24 hours of collection each unit P9060 Fresh frozen plasma, donor retested, each unit
(The above codes include processing and collection for transfusion; IV infusion sets include volume controller cassettes and buretrols). MATERNITY 59409 Vaginal Delivery Only 59425* Antepartum care only, 4-6 visits 59426 Antepartum care only, 7 or more visits * For 1-3 antepartum care visits, see appropriate E&M code(s) in the CPT® codebook.
NURSING HOME VISITS 99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these three key components: a detailed interval history; a comprehensive examination; and medical decision making that is of low to moderate complexity
PRIMARY PSYCHIATRIC SERVICES W1081 NF/MH individual psychiatric visit (30 minutes) W1082 NF/MH group psychiatric visit (limited to one unit per day, regardless of time spent)
SPLINTS AND ACCESSORIES SUPPLIED BY PHYSICIANS 99070 Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies or materials provided)
MUSCULOSKELETAL A4590 Special casting materials (e.g., fiberglass)
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-3 INJECTIONS Updated 12/07
Injection procedure codes listed below are placed in alphabetical order by generic name. Reference this list by using the generic drug name to find the procedure code. Utilize units to designate the dosage administered if there is not a specific injection code for the dosage.
COVERAGE INDICATORS
KBH - Covered for KAN Be Healthy participants (KBH medical screen current) only. MCD - Injection covered for Medicaid recipients only. PA - Prior authorization is required. * Administration only (patient brings own medication). Medication shall not be billed in conjunction with this procedure.
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY 90772* Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 90773 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intra-arterial 90774 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug 90775 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary procedure) 90776 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (list separately in addition to code for primary procedure) PA J0129 Abatacept 10 mg J1120 Acetazolamide Sodium up to 500 mg vial Q0475 Acyclovir, Zovirax up to 500 mg - - -
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-4 Updated 04/08
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J0132 Injection, acetylcysteine 100 mg J0133 Acyclovir 5 mg J0135 Adalimumab 20 mg J0150 Adenosine for therapeutic use, 6 mg (not to be used to report any adenosine phosphate compounds, instead use A9270) J0152 Adenosine for diagnostic use, 30 mg (not to be used to report any adenosine phosphate compounds; instead use A9270) J0170 Adrenalin, Epinephrine up to 1 ml 1 cc J0180 Agalsidase beta 1 mg J0152 Adenosine 30 mg J0170 Adrenalin, Epinephrine up to 1 ml 1 cc J0200 Alatrofloxacin Mesylate 100 mg - - - PA J0215 Alefacept 0.5 mg J9015 Aldesleukin - - - vial MCD J0205 Alglucerase 10 units J0220 Aglucosidase alfa 10 mg J2997 Alteplase Recombinant 1 mg J0207 Amifostine 500 mg - - - J0278 Amikacin Sulfate 100 mg S0017 Aminocaproic 250 mg 1 cc J0280 Aminophyllin up to 250 mg - - - J0282 Amiodarone HCL 30 mg J1320 Amitriptyline HCL up to 20 mg 2 cc J0300 Amobarbital up to 125 mg vial J0285 Amphotericin B 50 mg - - - J0287 Amphotericin B lipid complex 10 mg J0289 Amphotericin B Liposome 10 mg J0290 Ampicillin Sodium 500 mg vial J0295 Ampicillin Sodium/Sulbactam 1.5 gm vial J0348 Anadulafungin 1 mg J0350 Anistreplase 30 units vial J7197 Antithrombin III (Human) - - - 1 unit MCD Z2064 Antivenin Polyvant (crotalide) - - - 1 ml J9020 Asparaginase, Elspar up to 10,000 10 cc units J0128 Arbarelix 10 mg J0400 Aripiprazole, intramuscular 0.25 mg J2910 Aurothioglucose up to 50 mg 1 cc
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-5 Update 12/07
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J7501 Azathioprine (e.g., Imuran)- 100 mg 20 ml parenteral, vial J9025 Azacitidine per 1 mg J0456 Azithromycin 500 mg - - - J3490 Aztreonam 500 mg 15 cc J3490 Bacitracin 50,000 units vial MCD J0475 Baclofen 10 mg - - - (NDC and product name must be provided) J0476 Baclofen, for intrathecal trial 50 mcg J9025 Azacitidine 1 mg J9027 Injection, clofarabine 1 mg J9031 BCG Live (Intravesical) 50 mg vial J9050 BCNU, Bischlorethyl Nitrosourea, 100 mg vial Carmustine J0515 Benztropine 1 mg 1 cc J0702 Betamethasone Acetate 3 mg 1 cc and Betamethasone Sodium Phosphate J0704 Betamethasone Sodium Phosphate 4 mg 1 cc J0520 Bethanechol Chloride, up to 5 mg 1 cc Myotonachol or Urecholine J9035 Bevacizumab 10 mg J0583 Bivalirudin 1 mg J9040 Bleomycin Sulfate 15 units amp J9041 Bortezomib 0.1 mg PA J0585 Botulinum Toxin Type A per unit - - - PA J0587 Botulinum Toxin Type B per 100 units J0595 Butorphanol Tartrate 1 mg J7633 Budesonide Inhalation Solution 0.25 mg administered through DME, concentrated form S0020 Bupivacaine Hydrochloride 0.5 % - - - J0592 Buprenorphine Hydrochloride 0.1 mg J0592 Buprenorphine 0.3 mg 1 cc J0595 Butorphanol Tartrate 1 mg 1 cc J0706 Caffeine Citrate 5 mg
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-6 Updated 12/07
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J0630 Calcitonin Salmon up to 400 units - - - J0636 Calcitriol 0.1mcg J3490 Calcium Chloride 1 gm 10 cc J3490 Calcium Gluceptate standard 5 cc J0610 Calcium Gluconate 10% 10 cc J9045 Carboplatin 50 mg vial J0637 Caspofungin Acetate 5 mg J0690 Cefazolin Sodium 500 mg 10 cc J0692 Cefepime Hydrochloride 500 mg S0021 Cefoperazone, Cefobid up to 1 gm - - - J0698 Cefotaxime Sodium 1 gm vial S0074 Cefotetan Disodium (Cefotan) 1 gm vial J0694 Cefoxitin up to 1 gm 10 cc J0713 Ceftazidime 500 mg J0715 Ceftazidime Sodium 500 mg - - - J0696 Ceftriaxone Sodium 250 mg vial J1890 Cephalothin Sodium up to 1 gm 10 cc J0710 Cephapirin Sodium up to 1 gm vial J9055 Cetuximab 10 mg J0720 Chloramphenicol Sodium up to 1 gm - - - Siccomate J1205 Chlorothiazide Sodium 500 mg 20 cc J3230 Chlorpromazine HCL up to 50 mg - - - 90725 Cholera vaccine for injectable use standard 1 cc J0725 Chorionic Gonadotropin 100 units - - - J0743 Cilastatin Sodium; Imipenem 250 mg vial J0744 Ciprofloxacin for Intravenous Infusion 200 mg J9060 Cisplatin 10 mg vial J9062 Cisplatin 50 mg - - - S0077 Clindamycin up to 300 mg - - - J0745 Codeine Phosphate 30 mg 1 cc J0760 Colchicine up to 2 mg 2 cc J0770 Colistimethate Sodium up to 150 mg 2 cc J0835 Cosyntropin 0.25 mg - - - J9070 Cyclophosphamide 100 mg 10 cc J9080 Cyclophosphamide 200 mg 20 cc J9090 Cyclophosphamide 500 mg 30 cc J9091 Cyclophosphamide 1 gm - - - J9092 Cyclophosphamide 2 gm - - - J9093 Cyclophosphamide, Lyophilized 100 mg - - - J9094 Cyclophosphamide, Lyophilized 200 mg - - - J9095 Cyclophosphamide, Lyophilized 500 mg - - - J9096 Cyclophosphamide, Lyophilized 1.0 gm - - - J9097 Cyclophosphamide, Lyophilized 2.0 gm - - -
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-7 Updated 09/07
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J7516 Cyclosporine (e.g., Sandimmune)-Parentera 250 mg - - - J9098 Cytarabine 10 mg J9100 Cytarabine 100 mg - - - J9110 Cytarabine 500 mg - - - J9130 Dacarbazine 100 mg 10 cc J9140 Dacarbazine 200 mg 10 cc J7513 Daclizumab, parenteral 25 mg J9120 Dactinomycin, Actinomycin D 0.5 mg 3 cc MCD J1645 Dalteparin Sodium 2500 IU - - - J0878 Daptomycin 1 mg J9150 Daunorubicin 10 mg vial J9151 Daunorubicin Citrate 10 mg Liposomal Formulation J0894 Decitabine 1 mg J0895 Deferoxamine Mesylate 500 mg amp J9160 Denileukin Diftitox 300 mcg J1060 Depandrogyn standard 1 cc J1000 Depo-Estradiol Cypionate up to 5 mg 1 cc J1094 Dexamethasone Acetate 1 mg J1100 Dexamethasone Sodium 1 mg 1 cc Phosphate J1100 & J0670 Dexamethasone Acetate .5 cc and standard - - - Mepivacaine Hydrochloride 1% .5 cc J1190 Dexrazoxane HCL 250 mg - - - J0500 Dicyclomine up to 20 mg 2 cc J9165 Diethylstilbestrol Diphosphate 250 mg - - - J1160 Digoxin up to 0.5 mg 1 cc J1110 Dihydroergotamine up to 0.1 mg 1 cc MCD J1240 Dimenhydrinate up to 50 mg - - - J1200 Diphenhydramine HCL up to 50 mg 1 cc 90701 Diphtheria and Tetanus Toxoids - - - .5 cc and Pertussis Vaccine (DTP); Immunization, Active 90720 Diphtheria, Tetanus, and Pertussis standard - - - (DTP) and Hemophilus Influenza B (HIB) Vaccine 90723 Diphtheria, Tetanus Toxoids, Pertussis, Hepatitis B, and Poliovirus, Inactivated (DTAP-HEPB-IPV) for intramuscular use J1245 Dipyridamole 10 mg 2 ml J1250 Dobutamine HCL 250 mg 1 cc J9170 Docetaxel (Taxotere) 20 mg 1 ml J1260 Dolasetron Mesylate 10 mg J1270 Doxercalciferol 1 mcg
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-8 Updated 12/07
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J9000 Doxorubicin HCL 10 mg vial J9001 Doxorubicin HCL, all lipid formulations 10 mg - - - J1810 Droperidol and Fentanyl Citrate (NDC and product name/description must be provided) up to 2 ml amp J1300* Eculizumab 10 mg J3520 Edetate Disodium 150 mg - - - PA J1324 Enfuvirtide 1 mg MCD J1650 Enoxaparin Sodium 30mg 1 ml J0170 Epinephrine Hydrochloride 1:200 mg 0.3 cc J9178 Epirubicin HCL 2 mg MCD J1325 Epoprostenol 0.5 mg - - - J1330 Ergonovine Maleate up to 0.2 mg 1 cc J1335 Ertapenem Sodium 500 mg J1364 Erythromycin Lactobionate 500 mg - - - J0885 Epoetin Alpha 1000 units J1380 Estradiol Valerate up to 10 mg 1 cc J1390 Estradiol Valerate up to 20 mg 1 cc J0970 Estradiol Valerate up to 40 mg 1 cc J1410 Estrogen Conjugated 25 mg - - - J1435 Estrone 1 mg - - - PA J1438 Etanercept 25 mg - - - J3490 Ethacrynic Acid 50 mg 1 cc J1436 Etidronate Disodium 300 mg 6 ml amp J7307 Etonogestrel (contraceptive) implant system, including implant and supplies S0180 Etonogestrel, including implants and supplies J9181 Etoposide 10 mg 2.5 cc J9182 Etoposide 100 mg 5 cc J7190 Factor VIII (Antihemophilic Factor) per i.u. - - - (NDC and product name/description must be provided) J7191 Factor VIII (Antihemophilic Factor per i.u. - - - [Porcine]) J7192 Factor VIII (Antihemophilic Factor per unit - - - [Recombinant]) J7193 Factor IX (Antihemophilic Factor, per i.u. Purified, Non-Recombinant) J7195 Factor IX (Antihemophilic Factor, per i.u. Recombinant) MCD S0028 Famotidine 10 mg/ml 1 ml J3010 Fentanyl Citrate 0.1 mg 2 cc MCD J1440 Filgrastim (G-CSF) 300 mcg - - -
*This code will be placed on medical review until the Drug Utilization Review (DUR) Board meets to set PA criteria. Once PA criteria has been determined, the code will be taken off of medical review. Providers will be notified when the code is removed from medical review.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-9 Updated 12/07
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY MCD J1441 Filgrastim (G-CSF) 480 mcg - - - J9200 Floxuridine 500 mg 5 cc J1450 Fluconazole 200 mg - - - J9185 Fludarabine Phosphate 50 mg 1 ml J9190 Fluorouracil 500 mgm amp J7311 Fluocinolone Acetonide, intravitreal implant per 0.59 mg J2680 Fluphenazine Decanoate up to 25 mg 1 cc J1452 Fomivirsen Sodium, Intraocular 1.65 mg J1652 Fondaparinux Sodium 0.5 mg J1455 Foscarnet Sodium 1000 mg vial J9395 Fulvestrant 25 mg J1940 Furosemide up to 20 mg 2 cc J1458 Galsulfase 1 mg J1460 Gamma Globulin, Intramuscular standard 1 cc J1470 Gamma Globulin, Intramuscular standard 2 cc J1480 Gamma Globulin, Intramuscular standard 3 cc J1490 Gamma Globulin, Intramuscular standard 4 cc J1500 Gamma Globulin, Intramuscular standard 5 cc J1510 Gamma Globulin, Intramuscular standard 6 cc J1520 Gamma Globulin, Intramuscular standard 7 cc J1530 Gamma Globulin, Intramuscular standard 8 cc J1540 Gamma Globulin, Intramuscular standard 9 cc J1550 Gamma Globulin, Intramuscular standard 10 cc J1560 Gamma Globulin, Intramuscular standard 10 cc J1570 Ganciclovir Sodium 500 mg vial J1580 Garamycin, Gentamycin up to 80 mg 2 cc J1590 Gatifloxacin 10 mg J9201 Gemcitabine HCL 200 mg - - - J9300 Gemtuzumab, Ozogamicin 5 mg J1610 Glucagon Hydrochloride 1 mg 1 cc J1600 Gold Sodium Thiomaleate up to 50 mg 1 ml J1620 Gonadorelin Hydrochloride 100 mcg - - - J9202 Goserelin Acetate Implant 3.6 mg 1 MCD J1626 Granisetron Hydrochloride 100 mcg 1 ml J1631 Haloperidol Decanoate 50 mg 1 cc J1642 Heparin Sodium (Heparin 10 units tubex Lock Flush) J1644 Heparin Sodium 1000 units vial J1571 Hepatitis B immune globulin 0.5 ml (Hepagam B), intramuscular J1573 Hepatitis B immune globulin (Hepagam B), intravenous 0.5 ml Q4090 Hepatitus B immune globulin (Hepagam B), intramuscular, 0.5ml J7321 Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-10 Updated 04/08
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J7322 Hyaluronan or derivative, synvisc, for intra-articular injection, per dose J7323 Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose J7324 Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose J3470 Hyaluronidase up to 150 units 1 cc J3473 Hyaluronidase, recombinant 1 usp unit J3471 Injection, Hyaluronidase, ovine, up to 999 usp units Preservative free, per usp unit J3472 Injection, Hyaluronidase, ovine, per 1000 usp units Preservative free J0360 Hydralazine HCL up to 20 mg amp J1700 Hydrocortisone Acetate, up to 25 mg 1 cc J1720 Hydrocortisone Sodium Succinate up to 100 mg 2 cc J1710 Hydrocortisone Sodium Phosphate up to 50 mg 1 cc J1170 Hydromorphone up to 4 mg 1 cc J3410 Hydroxyzine HCL up to 25 mg 1 cc J1740 Ibandronate sodium 1 mg MCD J9211 Idarubicin Hydrochloride 5 mg vial J1743 Idursulfase 1 mg J9208 Ifosfomide per gm 1 gm vial MCD J1785 Imiglucerase - - - unit J1561 Immune globulin (gamunex), 500 mg intravenous, non-lyophilized (e.g. liquid) J1562 Immune globulin (vivaglobin) 100 mg J1568 Immune globulin (octagam), 500 mg intravenous, non-lyophilized (e.g. liquid) J1569 Immune globulin (gammagard 500 mg liquid), intravenous, non-lyophilized (e.g. liquid) J1572 Immune globulin (flebogamma) 500 mg intravenous, non-lyophilized (e.g. liquid) Q4097 Immune globulin (privigen), intravenous, nonlyophilized (e.g. liquid), 500 mg PA J1745 Infliximab (Remicade) 10 mg vial J9213 Interferon, Alfa-2A, Recombinant 3 mill. units vial J9214 Interferon, Alfa-2B, Recombinant 1 mill. units - - - J9215 Interferon, Alfa-N3 (Human 250,000 units - - - Leukocyte Derived) J9212 Interferon, Alfacon-1, Recombinant 1 mcg
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-11 Updated 04/08
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J1825 Interferon Beta-1A 33 mcg MCD J1830 Interferon Beta 1-B 0.25 mg - - - J9216 Interferon, Gamma 1-B 3 mill. units vial J9206 Irinotecan HCI 20 mg/ml 1 ml J1751 Iron Dextran 50 mg J1752 Iron Dextran 50 mg J1756 Iron Sucrose 21 mg J7658 Isoproterenol Hydrochloride per mg conc. form J7659 Isoproterenol Hydrochloride per mg unit dose form (NDC and product name/description must be provided) J1835 Itraconazole 50 mg J1840 Kanamycin Sulfate up to 500 mg 2 cc J1850 Kanamycin Sulfate up to 75 mg 2 cc J1885 Ketorolac Tromethamine (NDC and product name/description must be provided) 15 mg ml J1931 Laronidase 0.1 mg J0640 Leucovorin Calcium 50 mg vial J1950 Leuprolide Acetate (For Depot) 3.75 mg - - - Suspension) J9218 Leuprolide Acetate 1 mg 1 ml J9217 Leuprolide Acetate, For Depot 7.5 mg/ml 1.5 ml Suspension J9219 Leuprolide Acetate Implant 65 mg (NDC and product name/description must be provided) C9238 Levetiracetam 10 mg J1956 Levofloxacin 250 mg - - -
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-12 Updated 07/07
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J2001 Lidocaine HCL (For intravenous infusion) 10 mg J2010 Lincomycin HCL up to 300 mg 1 cc MCD J2001 Lidocaine HCL 1 - 0.0005 per ml (Lidocaine HCL w/epinephrine) PA J2020 Linezolid 200 mg J7511 Lymphocyte Immune Globulin, 25 mg Antihymocyte Globulin, Rabbit, Parenteral J3475 Magnesium Sulfate 500 mg - - - J2150 Mannitol 25% 50 ml J2170 Mecasermin 1mg J9230 Mechlorethamine HCL (Nitrogen 10 mg 20 cc Mustard), HN2 J1051 Medroxyprogesterone Acetate 50 mg J1055 Medroxyprogesterone Acetate 150 mg 1 cc For Contraceptive Use J1056 Medroxyprogesterone Acetate/ Estradiol Cypionate, 5 mg/25 mg J2180 Meperidine and Promethazine HCL up to 50 mg 2 cc J2175 Meperidine 100 mg 1 cc J0670 Mepivacaine 1% 1 cc J2185 Meropenem 100 mg J9209 Mesna 200 mg vial J3490 Mesoridazine Besylate 25 mg 1 cc J7667 Metaproterenol sulfate, inhalation solution, compounded product, concentrated form per 10 mg J7670 Metaproterenol sulfate, inhalation solution, compounded product, unit dose form per 10 mg J0380 Metaraminol up to 10 mg 1 cc J2800 Methocarbamol up to 10 ml 10 cc J9250 Methotrexate 5 mg - - - J9260 Methotrexate Sodium Mix 50 mg 2 cc J2210 Methylergonovine Maleate up to 0.2 mg 1 cc J1020 Methylprednisolone Acetate 20 mg 1 cc J1040 Methylprednisolone Acetate 80 mg 2 cc J2920 Methylprednisolone Sodium up to 40 mg 1 cc Succinate J2930 Methylprednisolone Sodium up to 125 mg 2 cc Succinate J2765 Metoclopramide HCL up to 10 mg 2 cc S0030 Metronidazole up to 500 mg 100 ml J2248 Micafungin sodium 1 mg J2260 Milrinone Lactate 5 mg J9280 Mitomycin 5 mg - - - J9290 Mitomycin 20 mg - - -
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-13 Updated 12/07
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J9291 Mitomycin 40 mg - - - J9293 Mitoxantrone HCL 5 mg 10 ml J2270 Morphine Sulfate up to 10 mg 1 cc J2271 Morphine Sulfate 100 mg - - - MCD J2275 Morphine Sulfate, preservative-free 10 mg ml sterile solution) J2280 Moxifloxacin 100 mg J2300 Nalbuphine HCL 10 mg 2 cc J2310 Naloxone HCL 1 mg 1 cc J2315 Naltrexone, depot form 1 mg J2320 Nandrolone Decanoate up to 50 mg 0.5 cc J2321 Nandrolone Decanoate up to 100 mg 1 cc J2322 Nandrolone Decanoate up to 200 mg 2 cc J9261 Nelarabine 50 mg J2710 Neostigmine Bromide 1:1000 (1 mg) 1 cc J2710 Neostigmine Methylsulfate up to 0.5 mg 1 cc J2353 Octreotride (Depot form) 1 mg J2354 Octreotride (non-depot form) 25 mg J2357 Omalizumab 5 mg MCD J2405 Ondansetron Hydrochloride 1 mg 0.5 ml J2355 Oprelvekin 5 mg J2700 Oxacillin Sodium up to 250 mg vial J9263 Oxaliplatin 0.5 mg J2410 Oxymorphone HCL up to 1 mg 1 cc J2460 Oxytetracycline HCL up to 50 mg 1 ml J2460 Oxytetracycline HCL 500 mg 10 cc J2590 Oxytocin up to 10 units 1 cc J9264 Injection, paclitaxel protein-bound 1 mg particles J9265 Paclitaxel 30 mg 5 ml KBH,PA 90378 Palivizumab (Synagis) up to 50 mg vial J2469 Palonosetron HCL 25 mcg J2430 Pamidronate Dissodium 30 mg vial C9235 Panitumumab 10 mg J9303 Panitumumab 10 mg J2440 Papaverine HCL up to 60 mg 2 cc J2501 Paricalacitol 1 mcg J2505 Pegfilgrastim 6 mg J9305 Pemetrexed 10 mg J0530 Penicillin G Benzathine & Penicillin up to 600,000 1 cc G Procaine units J0540 Penicillin G Benzathine & Penicillin up to 1,200,000 2 cc G Procaine units J0550 Penicillin G Benzathine & Penicillin up to 2,400,000 4 cc G Procaine units KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-14 Updated 12/07
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J0560 Penicillin G Benzathine up to 600,000 1 cc units J0570 Penicillin G Benzathine up to 1,200,000 2 cc units J0580 Penicillin G Benzathine up to 2,400,000 4 cc units J2540 Penicillin G Potassium up to 600,000 1 cc units J2510 Penicillin G Procaine, Aqueous up to 600,000 1 cc J3070 Pentazocine HCL up to 30 mg 1 cc J2515 Pentobarbital Sodium 50 mg 1 cc J3310 Perphenazine up to 5 mg 1 cc units J2560 Phenobarbital Sodium up to 120 mg 2 cc J1165 Phenytoin Sodium 100 mg 2 cc J2543 Piperacillin Sodium/Tazobactum Sodium 1 gm/0.125 gm vial J9270 Plicamycin (Mithramycin) 2.5 mg 90732 Pneumococcal Vaccine, Polysaccharide - - - 0.5cc 23-Valent, adult or immunosuppressed Patient, for subcutaneous or intramuscular use Z2069 Polymyxin B Sulfate 500,000 units vial J9600 Porfimer Sodium 75 mg - - - J3480 Potassium Chloride 2 meq - - - J2650 Prednisolone Acetate up to 1 ml - - - J0743 Primaxin 250 mg - - - J2690 Procainamide HCL up to 1 gm 2 cc J0780 Prochlorperazine up to 10 mg 2 cc J3490 Prolixin Enanthate 25 mg 1 cc J2550 Promethazine HCL up to 50 mg 1 cc J1800 Propranolol HCL up to 1 mg 1 cc J2720 Protamine Sulfate 10 mg - - - J2724 Protein C Concentrate, intravenous , human 10 IU J3415 Pyridoxine 100 mg 90375 Rabies immune globulin (RIG), human, for intramuscular and/or subcutaneous use 90376 Rabies immune globulin, heat-treated (RIG-HT), human, for intramuscular and/or subcutaneous use C9233 Ranibizumab 0.5 mg J2778 * Ranibizumab 0.1 mg J2780 Ranitidine HCL 25 mg
*This code will be placed on medical review until the Drug Utilization Review (DUR) Board meets to set PA criteria. Once PA criteria has been determined, the code will be taken off of medical review. Providers will be notified when the code is removed from medical review
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-15 Updated 12/07
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J2783 Rasburicase 0.5 mg J1565 Resp Sync Vir Immug (Respigam) 50 mg/ml 1 ml 90378 Respiratory syncytial virus immune globulin 50 mg (RSV-IGIM) for intramuscular use, each J2993 Reteplase 18.1 mg (two single use vials) 90384 Rho(D) immune globulin (RHIG), human, full-dose for intramuscular use J2788 Rho(D) immune globulin, human, mini-dose 50 mg 90385 Rho(D) immune globulin (RHIG), human, mini-dose, for intramuscular use 90386 Rho(D) immune globulin (RHIGIV), human, for intravenous use J2791 Rho(D) immune globulin, human 100 IU (rhophylac) , intramuscular or intravenous J2792 Rho(D) immune globulin, human 100 IU solvent detergent Q4089 RHO (D) Immune Globulin, Human, (Rhophylac), intravenous, 100 IU J2794 Risperidone, long acting 0.5 mg J9310 Rituximab 100 mg MCD J2820 Sargramostin (GM-CSF) 50mcg vial J2916 Sodium Ferric Gluconate 12.5 mg PA,KBH J2940 Somatrem 1 mg J2941 Somatropin 1 mg J3320 Spectinomycin Dihydrochloride up to 2 gm 3.2 cc J0697 Sterile Cefuroxime Sodium 750 mg vial S0040 Sterile Ticarcillin Disodium and 3.1 gm vial Clavulanate J2995 Streptokinase 250,000 unit vial J0330 Succinycholine Chloride up to 20 mg vial J3030 Sumatriptan Succinate 6 mg - - - J7525 Tacrolimus, Parenteral 5 mg C9239 Temsirolimus 1 mg J3100 Tenecteplase 50 mg Q2017 Teniposide - - - 1 ml J3105 Terbutaline Sulfate up to 1 mg - - - J3140 Testosterone Suspension up to 50 mg 1 cc J1060 Testosterone Cypionate & up to 1 ml 1 ml Estradiol Cypionate J1070 Testosterone Cypionate up to 100 mg 1 cc J1080 Testosterone Cypionate 200 mg 1 cc
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-16 Updated 04/08
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY J3120 Testosterone Enanthate up to 100 mg .5 cc J3130 Testosterone Enanthate up to 200 mg 1 cc J0900 Testosterone Enanthate and up to 1 cc - - - Estradiol Valerate J3150 Testosterone Propionate up to 100 mg 2 cc 90389 Tetanus Immune Globulin (TIG), Human, For Intramuscular Use J3280 Thiethylperazine Maleate up to 10 mg 2 cc J9340 ThioTepa 15 mgm - - - J3243 Tigecycline 1 mg J1655 Tinzaparin Sodium 1000 IU J3246 Tirofiban HCL 0.25 mg J3260 Tobramycin Sulfate up to 80 mg 2 cc MCD J9350 Topotecan HCL (Hycamtin) 4 mg vial J9355 Trastuzumab (Herceptin) 10 mg J3302 Triamcinolone Diacetate 5 mg/ml 1 ml J3303 Triamcinolone Hexacetonide 5 mg/ml 1 ml J3400 Triflupromazine HCL up to 20 mg 1 cc J3250 Trimethobenzamide HCL up to 200 mg 2 cc J3315 Triptorelin Pamoate 3.75 mg J3364 Urokinase 5000 units 1 ml J9357 Valrubicin, intravesical 200 mg J3370 Vancomycin HCL 500 mg 10 cc J3490 Verapamil Hydrochloride 5 mg/2 ml 2 ml J3396 Verteporfin 0.1 mg J9360 Vinblastine Sulfate 1 mg 1 cc J9370 Vincristine Sulfate 1 mg/ml 1 ml vial J9375 Vincristine Sulfate 2 mg 2 ml vial J9380 Vincristine Sulfate 5 mg 5 ml vial J9390 Vinorelbine Tartrate 10 mg 1 ml J3420 Vitamin B-12 Cyanocobalamin up to 1000 mcg - - - J3430 Vitamin K, Phytonadione, up to 10 mg 1 cc Menadione, Menadiol Sodium Diphosphate Q4096 Von willebrand factor complex, human ristocetin cofactor (not otherwise specified), per I.U. vwf:rco J3486 Zipasidone 10 mg J3487 Zoledronic Acid (Zometa) 1 mg J3488 Zoledronic Acid (Reclast) 1 mg
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-17 Updated 04/08
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY IV INFUSIONS PROCEDURE CODE NOMENCLATURE DOSE J7030 Infusion, normal saline soln. 1000 cc J7040 Infusion, normal saline soln. 500 ml J7042 5% dextrose/normal saline 500 ml J7050 Infusion, normal saline soln. 250 cc J7060 5% dextrose/Water 500 ml = 1 unit J7070 Infusion, D5W 1000 cc MCD J7100 Infusion, Dextran 40 500 ml MCD J7110 Infusion, Dextran 75 500 ml J7120 Ringers lactate infusion up to 1000 cc J7130 Hypertonic saline soln 50 or 100 meq., 20 cc vial
NOT OTHERWISE CLASSIFIED INJECTIONS J3490 Unclassified drugs J7303 Contraceptive supply, hormone containing vaginal ring, each J7599 Immunosuppressive drug, not otherwise classified J8499 Prescription drug, oral, non-chemotherapeutic, not otherwise classified J8999 Prescription drug, oral, chemotherapeutic, not otherwise classified J9999 Antineoplastic drug, not otherwise classified
AEROSOL ADDITIVES J7604 Acetylcysteine, inhalation solution, per gram compounded product, administered through DME, unit dose form J7602 Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per 1 mg (Albuterol) or per 0.5 mg (Levalbuterol) J7603 Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, per 1 mg (Albuterol) or per 0.5 mg (Levalbuterol) J7609 Albuterol, inhalation solution, compounded product, unit dose 1 mg J7610 Albuterol, inhalation solution, compounded product,concentrated form 1 mg J7611 Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 1 mg J7613 Albuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 1 mg J7622 Beclomethasome, inhalation solution per mg administered through DME, unit dose form KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-18 Updated 04/08
PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY AEROSOL ADDITIVES continued J7624 Betamethasome, inhalation solution per mg administered through DME, unit dose form J7626 Budesonide inhalation solution 0.25 mg administered through DME, unit dose form J7634 Budesonide, inhalation solution, per 0.25 mg compounded product, administered through DME, concentrated form J7632 Cromolyn sodium, inhalation solution, 10 mg compounded product, administered through DME, unit dose form J7641 Flunisolide, inhalation solution per mg administered through DME, unit dose form J7645 Ipratropium Bromide, inhalation solution, per mg compounded product administered through DME, unit dose form J7647 Isoetharine HCL, inhalation solution, per mg compounded product, administered through DME, concentrated form J7650 Isoetharine HCL, inhalation solution, per mg compounded product, administered through DME, unit dose form J7657 Isoproterenol HCL, inhalation solution, per mg compounded product, administered through DME, concentrated form J7660 Isoproterenol HCL, inhalation solution, per mg compounded product, administered through DME, unit dose form J7607 Levalbuterol, inhalation solution, compounded product, concentrated form 0.5 mg J7612 Levabuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, 0.5 mg J7614 Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 0.5 mg J7615 Levalbuterol, inhalation solution, compounded product, unit dose 0.5 mg 94642 Pentamidine, aerosol inhalation 300 mg vial J7676 Pentamidine isethoionate, inhalation 300 mg solution compounded product, administered through DME, unit dose form J7685 Tobramycin, inhalation solution, per 300 mg compounded product, administered through DME, unit dose Note: The NDC and drug name must be included on the claim or the claim will deny.
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-19 IMMUNIZATION ADMINISTRATION Updated 12/07 Providers must bill the appropriate administration code in addition to the vaccine and toxoid code for each dose administered. CPT codes for vaccines covered under the VFC program will be noncovered for children 18 years of age and younger.
COVERAGE INDICATORS ADLT Vaccine covered for adults (19 years of age and older). VFC Vaccine covered by VFC (18 years of age and younger)
PROCEDURE COV. CODE NOMENCLATURE
ADMINISTRATION CODES 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) 90472 each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) 90473 Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) 90474 each additional vaccine (single or combination vaccine/toxoid) )List separately in addition to code for primary procedure) 90465 Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (singe or combination vaccine/toxoid), per day 90466 each additional injection (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure) 90467 Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day 90468 each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)
VACCINE CODES VFC 90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP-Hib-IPV), for intramuscular use VFC 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use ADLT 90701 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use VFC 90702 Diphtheria and tetanus toxoids (DT) adsorbed when administered to individuals younger than 7 years, for intramuscular use VFC 90720 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib), for intramuscular use
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-20 Updated 12/07
PROCEDURE COV. CODE NOMENCLATURE
VACCINE CODES (cont.) VFC 90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitus B, and poliovirus vaccine, inactivated (DTaP-HepB-IPV), for intramuscular use ADLT 90632 Hepatitis A vaccine, adult dosage, for intramuscular use VFC 90633 Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use VFC 90634 Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for intramuscular use ADLT 90636 Hepatitis A and Hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use ADLT 90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use VFC 90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use VFC 90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use ADLT 90746 Hepatitis B vaccine, adult dosage, for intramuscular use ADLT 90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use VFC 90748 Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use VFC 90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use VFC 90646 Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use VFC 90647 Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use VFC 90648 Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use VFC, 90649 Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 ADLT (quadrivalent), 3 dose schedule, for intramuscular use VFC 90655 Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use VFC, 90656 Influenza virus vaccine, split virus, preservative free, when administered ADLT to 3 years and older, for intramuscular use VFC 90657 Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use VFC, 90658 Influenza virus vaccine, split virus, when administered to individuals 3 years ADLT of age and older, for intramuscular use VFC, 90660 Influenza virus vaccine, live, for intranasal use ADLT VFC, 90661 Influenza virus vaccine, derived from cell cultures, subunit, preservative ADLT and antibiotic free, for intramuscular use VFC, 90662 Influenza virus vaccine, split virus, preservative free, ADLT enhanced immunogenicity via increased antigen content, for intramuscular use KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-21 Updated 12/07
PROCEDURE COV. CODE NOMENCLATURE
VACCINE CODES (cont.) VFC, 90663 Influenza virus vaccine, pandemic formulation ADLT VFC, 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous ADLT use VFC, 90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for ADLT subcutaneous use VFC 90733 Meningococcal polysaccharide vaccine (any groups[s]), for subcutaneous use VFC, 90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 ADLT (tetravalent), for intramuscular use VFC 90669 Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use VFC, 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or ADLT immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use VFC 90713 Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use 90675 Rabies vaccine, for intramuscular use VFC 90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use VFC 90703 Tetanus toxoid absorbed, for intramuscular use VFC, 90714 Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when ADLT administered to 7 years or older, for intramuscular use VFC, 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when ADLT administered to 7 years or older, for intramuscular use VFC, 90718 Tetanus and diphtheria toxoids (Td) adsorbed, when administered to ADLT individuals 7 years or older, for intramuscular use VFC, 90716 Varicella virus vaccine, live, for subcutaneous use ADLT ADLT 90736 Zoster (shingles) vaccine, live, for subcutaneous injection
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX I
AI-22 APPENDIX II
MINOR SURGERY/OUTPATIENT SURGERY
PROCEDURE CODES AND NOMENCLATURE
Updated 6/05 PROCEDURE COV. CODE NOMENCLATURE
DENTAL 41899 Unlisted Procedure, Dentoalveolar Structures
BREAST RECONSTRUCTION
OUTPATIENT CODES 19342 Delayed Insertion of Breast Prosthesis 19350 Nipple/Areola Reconstruction 19357 Breast Reconstruction with Tissue Expander 19366 Breast Reconstruction with other Technique
PHYSICIAN CODES 19340 Immediate Insertion of Breast Prosthesis Following Mastopexy, Mastectomy, or in Reconstruction 19342 Delayed Insertion of Breast Prosthesis Following Mastopexy, or in Reconstruction 19350 Nipple/Areola Reconstruction 19357 Breast Reconstruction, Immediate or Delayed, With Tissue Expander 19361 Breast Reconstruction with Latisimus Dorsi Flap, With or Without Prosthetic Implant 19364 Breast Reconstruction with Free Flap 19366 Breast Reconstruction with Other Technique 19367 Breast Reconstruction with Transverse Rectus Abdominis Myocutaneous Flap (TRAM), Single Pedicel, Including Closure of Donor Site 19368 Breast Reconstruction with Transverse Rectus Abdominis Myocutaneous Flap (TRAM), Single Pedicel, Including Closure of Donor Site; with Micro Vascular Anastomosis 19369 Breast Reconstruction with Transverse Rectus Abdominis Myocutaneous Flap (TRAM), Double Pedicel, Including Closure of Donor Site
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX II
AII-1 Updated 12/06
PROCEDURE COV. CODE NOMENCLATURE
MASTECTOMY CODES 19160 Mastectomy, Partial (eg Lumpectomy, Tylectomy, Quadrantectomy, Segmentectomy); 19162 Mastectomy, Partial (Quadrectomy or more); with Axillary Lymphadenectomy 19180 Mastectomy, Simple, Complete 19182 Mastectomy, Subcutaneous 19200 Mastectomy, Radical, Including Pectoral Muscles, Axillary Lymph Nodes 19220 Mastectomy, Radical, Including Pectoral Muscles, Axillary and Internal Mammary Lymph Nodes 19240 Mastectomy, Modified Radical, Including Axillary Lymph Nodes, with or without Pectoralis Minor Muscle, but Excluding Pectoralis Major Muscle 19301 Mastectomy; partial 19302 Mastectomy; partial with axillary lymphadenectomy 19303 Mastectomy, simple, complet 19304 Mastectomy, subcutaneous 19305 Mastectomy, radical, including pectoral muscles, axillary lymph nodes 19306 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes 19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle
BREAST CANCER DIAGNOSES 174.0-175.9 Malignant Neoplasm of the Breast 198.2 Secondary Malignant Neoplasm of Skin 217 Benign Neoplasm of Breast 233.0 Carcinoma in situ of Breast 239.3 Neoplasm of Unspecified Nature of Breast
GENERAL SURGERY **NC W3958 Visual laser ablation of prostate
**Refer to the CPT® codebook for replacement procedure codes (52647 and 52648).
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX II
AII-2 Updated 8/06
PROCEDURE COV. CODE NOMENCLATURE
VAGAL NERVE STIMULATOR CODES PA 61885 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array PA 61888 Revision or removal of cranial neurostimulator pulse generator or receiver PA 64573 Incision for implantation of neurostimulator electrodes; cranial nerve PA 64585 Revision or removal of peripheral neurostimulator electrodes PA 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or indicative coupling PA 64595 Revision or removal of peripheral neurostimulator pulse generator or receiver PA 95970 Electronic analysis of implanted neurostimulator pulse generator system (such as rate, pulse, amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling impedance, and patient compliance measures); simple or complex brain, spinal cord, or peripheral (such as neuromuscular) neurostimulator pulse generator/transmitter without programming PA 95974 Complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour PA 95975 Complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour
KANSAS MEDICAL ASSISTANCE PROGRAM PROFESSIONAL SERVICES PROVIDER MANUAL APPENDIX II
AII-3
FORMS
• ABORTION NECESSITY FORM • CMS-1500 • HEARING AID NECESSITY • HOME MONITOR INFORMATION • HOME OXYGEN INFORMATION • HYSTERECTOMY CONSENT FORM • NDC DETAIL ATTACHMENT FORM • STERILIZATION CONSENT FORM (ENGLISH) • STERILIZATION CONSENT FORM (SPANISH) • INSTRUCTIONS FOR THE STERILIZATION FORM
KANSAS HEALTH INSURANCE PROGRAM ABORTION NECESSITY FORM
I, ______(Please print name of physician), certify that on the basis of my professional judgment, the pregnancy of ______(Name of patient) of ______(address),
______1. Is endangering the life of the mother ______2. Is a result of rape (Patient signature line) ______3. Is a result of incest ______(Date of signature)
______(Signature of Physician) (Date) ______(Physician’s Address)
Explanation of Necessity for Hearing Aids
CONSUMER INFORMATION Consumer Name: ______Consumer Medicaid ID #: ______Consumer Address: ______Date of Birth: ____/____/______Age: ______
PROVIDER INFORMATION Provider Name: ______Provider Medicaid ID #: ______Provider Contact Person: ______Phone Number: (_____)______Fax Number: (_____)______
I. MEDICAL EVALUATION
Etiology of Loss: (circle) Patient History: (circle) Cochlear damage R L Family history of hearing loss? Yes No Otitis media R L Voice affected? Yes No Otosclerosis R L Legally blind? Yes No Congenital R L Other______R L Comments:______
I have medically evaluated this consumer’s hearing loss and he/she is a candidate for a hearing aid(s) in the: (Please circle) Right Ear Only Left Ear Only Either Ear Binaural
Physician Signature: ______Date: ____/____/______
II. HEARING EVALUATION Date Tested: ____/____/______Tested by: (circle) ENT Audiologist Haring Aid Specialist Name: ______Type of Loss: (circle) Address: ______Sensorineural R L ______Conductive R L Mixed R L Pure Tone Air Conduction Pure Tone Bone Conduction 250 500 1000 2000 3000 4000 6000 8000 HZ 500 1000 2000 4000 RE______LE______Masking: (circle) Yes No Masking: (circle) Yes No (Hearing Evaluation continued on page 2)
FAILURE TO COMPLETE THIS FORM IN ITS ENTIRETY WILL RESULT IN THE RETURN OF THE PRIOR AUTHORIZATION REQUEST.
(Hearing Evaluation continued from page 1)
SPEECH RECEPTION THRESHOLD: (Check how obtained) MLV_____ Tape Recording _____ Disc Recording _____ Air Conduction: RE _____ LE _____ MCL RE _____ LE _____ Masking: (circle) Yes No UCL RE _____ LE _____
SPECH DISCRIMINATION: (Check how obtained) MLV_____ Tape Recording _____ Disc Recording _____
Word Recognition: RE _____% LE _____% Test(s) used: ______Masking: (circle) Yes No Specialists Signature: ______Date: ____/____/______Provider Medicaid ID #: ______
Comments:______
III. CERTIFICATION FOR DISPENSING OF HEARING AID (Must be signed by the person who performed the hearing evaluation in Section II.)
Verification for fitting: (circle) ENT Audiologist Hearing Aid Specialist
Hearing aid for: (circle) Right Ear Left Ear Binaural
Hearing Aid Evaluation:
Preferred style of hearing aid(s): (circle) ITE BTE Body Aid Cros BiCros Optic
After evaluating this person, I certify the need for the dispensing of a hearing aid(s).
Specialists Signature: ______Date: ____/____/______Provider Medicaid ID #: ______
If fitting binaural aids, test must include the consumer’s speech reception thresholds and speech discrimination ability under: 1) standard listening conditions using earphones; 2) listening with a monaural fitting; and listening with a binaural fitting. Please attach appropriate documentation. (NOTE: If requesting binaural aids for consumers over 21, please note if consumer is legally blind, has occupational requirements for binaural listening or previous use of binaural aids this information must be attached or appear on this form to be considered for prior authorization.)
IV. FINAL FITTING Has consumer used a hearing aid in the past? (circle) Yes No If yes, list brand and model (if known): ______Approximate age of old hearing aid: ______New Hearing Aid Manufacture Name: ______Style/Model: ______Hearing Aid Specification: BTE, Optic or Body type: Gain ______dBOutput ______dB ITE Matrix: ______Dispenser’s Signature: ______Date: ____/____/______
Provider Medicaid ID #______FAILURE TO COMPLETE THIS FORM IN ITS ENTIRETY WILL RESULT IN THE RETURN OF THE PRIOR AUTHORIZATION REQUEST.
CONSUMER INSTRUCTIONS FOR FORM COMPLETION
SECTION I. A physician must complete this section.
SECTION II. An ENT, certified audiologist, or hearing aid specialist, must complete this section.
SECTION III. An ENT, certified audiologist, or hearing aid specialist, must complete this section.
SECTION IV. The provider who dispenses the hearing aid must complete this section.
Completed form should be faxed to 1-800-913-2229. This form will be returned unprocessed if it is not completed in its entirety. If this request is not received within 15 working days, PA will be denied.
HOME MONITOR INFORMATIONAL FORM
The following information is required when billing for home apnea monitors. Please complete the form and attach it to your claim. In addition, a copy of the physician signed Rx for the monitoring device, dated on or prior to the service date is required to be attached to your claim.
BENEFICIARY'S NAME ______
BENEFICIARY'S DATE OF BIRTH ______
BENEFICIARY'S ID NUMBER ______
PRESCRIBING PHYSICIAN ______
DATE HOME MONITORING BEGAN ______
LENGTH OF TIME MONITOR DEVICE WILL BE NECESSARY AS INDICATED BY THE PRESCRIBING PHYSICIAN ______
List diagnoses and/or conditions indicating medical necessity of home apnea monitoring as cited by the prescribing physician.
______
If any of the following apply, please indicate the information requested: ∃ If the term(s) "apnea" and/or "bradycardia" are listed, a description of the initial episode and its length must be included as well as frequency and dates of apneic episodes while hospitalized. ∃ If bronchopulmonary dysplasia is listed, indicate whether or not the beneficiary utilizes home oxygen. ∃ If born prematurely, indicate either by how many weeks he/she was premature, the gestational age at birth, or the mother's expected date of delivery. ______
If the beneficiary's age is over 6 months (or 6 months post-expected date of delivery in premature beneficiaries) and has utilized a home apnea monitor longer than 3 months, please indicate the medical necessity of continued monitoring as cited by the prescribing physician. Include date(s) of any apneic/bradycardic episodes requiring adult intervention.
______
HOME OXYGEN INFORMATIONAL FORM
The following information is required on beneficiaries receiving oxygen therapy. This, or a similar medical necessity form providing the same information, must be retained in the files of the provider supplying the oxygen contents, vessels and concentrators.
BENEFICIARY'S NAME: ______
BENEFICIARY'S ID#: ______
PRESCRIBING PHYSICIAN: ______
DATE 02 THERAPY STARTED: ______
FLOW/MINUTE: ______
METHOD OF ADMINISTRATION (cannula/mask): ______
INTERMITTENT OR CONTINUOUS: ______
Arterial Blood Gases:
Prior to Start Last Current: of Therapy: Arterial - YES____ NO ____
Ear Oximeter - YES____ NO ____
Date ______Date ______
pH ______pH ______
pC02 ______pC02 ______
p02 ______p02 ______
02 Sat. ______02 Sat. ______
On or Off 02 ______On or Off 02 ______
ATTACH A COPY OF THE ORIGINAL AND/OR CURRENT RX TO THIS FORM
Breathing Treatments: YES_____ NO_____ FREQUENCY______
Comments: ______
______
______
Hysterectomy Consent Form
To be completed by the individual receiving the hysterectomy or her representative, if any:______.(Please print name and relation to patient)
Please select one of the following choices and place your initials on the line next to the statement that best describes your situation.
____Prior to surgery, I received, orally and in writing, information stating that the hysterectomy would render me permanently incapable of reproducing. I understand that I will not be able to become pregnant or bear children. ___ I am already sterile and incapable of bearing children. My physician and I have orally discussed my illness and he/she has given me written information on my illness that has led to the decision for this surgery. The illness/disease/symptoms that I have is called: ______.
______(Signature of Patient or Representative) (Date 00/00/00) ______(Signature of Physician ) (Date 00/00/00)
Kansas Medical Assistance Programs P. O. Box 3571 Provider Line: 1-800-933-6593 From the office of the Fiscal Agent Topeka, KS 66601-3571 Consumer Line: 1-800-766-9012
NDC Detail Attachment This form is a required attachment for any Kansas Medicaid paper claim billed using a drug HCPCS code on a CMS-1500 or a UB-92
Provider Name ______Provider Number______Beneficiary Name______Beneficiary ID Number______Date of Service______
LINE NDC DESCRIPTION UNITS BASIS OF MEASUREMENT *UNIT PRICE GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $ GR ML UN F2 $
Please fill in: Legend: • The corresponding line number from the CMS-1500 (HCFA-1500) or the UB-92 GR – Gram • NDC number used ML - Milliliter • The drug description UN - Unit • The actual quantity (units) given to the patient F2 – International Unit • Circle the appropriate basis of measurement * The unit price (If known) Mo-8812 CONSENT FORM NOTICE YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY THE PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.
* CONSENT TO STERILIZATION * * STATEMENT OF PERSON OBTAINING CONSENT *
I have asked for and received information about sterilization from Before ______signed the ______when I first asked for the consent form. I explained to him/her the nature of the sterilization Doctor or Clinic operation ______, the fact that it is intended to be a information I was told the decision to be sterilized is completely final and irreversible procedure and the discomforts, risks, and up to me. I was told that I could decide not to be sterilized. If I benefits associated with it. decide not to be sterilized my decision will not affect my right to I counseled the individual to be sterilized that alternative future care or treatment. I will not lose any help or benefits from methods of birth control are available which are temporary. I programs receiving federal funds such as A.F.D.C. or Medicaid that I explained that sterilization is different because it is permanent. am now getting or for which I may become eligible. I informed the individual to be sterilized that his/her consent can I UNDERSTAND THAT THE STERILIZATION MUST BE be withdrawn at any tine and that he/she will not lose any health CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE services or any benefits provided by Federal funds. DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, To the best of my knowledge and belief the individual to be BEAR CHILDREN OR FATHER CHILDREN. sterilized is at least 21 years old and appears to be mentally I was told about those temporary methods of birth control that competent. He/she knowingly and voluntarily requested to be are available and could be provided to me which will allow me to sterilized and appears to understand the nature and consequences of bear or father children in the future. I have rejected these alternatives the procedure. and chosen to be sterilized. ______I understand that I will be sterilized by an operation known as a signature Date ______. The discomforts, risks, and benefits ______associated with the operation have been explained to me. All my Facility questions have been answered to my satisfaction. ______I understand that the operation will not be done until at least Address thirty days after I sign this form. I understand that I can change my 8 PHYSICIANS STATEMENT 8 mind at any time and that my decision at any time not to be sterilized Shortly before I performed a sterilization operation upon will not result in the withholding of any benefits or medical services ______on ______, provided by federally funded programs. I explained to him/her the nature of the sterilization operation I am at least 21 years of age and was born on ______, the fact that it is intended to be a final and irreversible procedure and the discomforts, I ______hereby consent risks, and benefits associated with it. I counseled the individual to be sterilized that alternative of my own free will to be sterilized by ______methods of birth control are available which are temporary. I explained that sterilization is different because it is permenant. by a method called ______. My consent I informed the individual to be sterilized that his/her consent can expires 180 days from the date of my signature below. be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds. I also consent to the release of this form and other medical To the best of my knowledge and belief the individual to be records about the operation to: sterilized is at least 21 years old and appears to be mentally Representatives of the Department of Health and Human competent. He/she knowingly and voluntarily requested to be Services, or sterilized and appears to understand the nature and consequences of Employees of programs or projects funded by that Department the procedure. but only for determining if Federal laws were observed. (Instructions for use of alternative final paragraphs: Use the first I have received a copy of this form. paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed ______Date______less than 30 days after the date of the individual's signature on the Signature Month Day Year consent form. In those cases, the second paragraph below must be You are requested to give the following information, but it is not used. Cross out the paragraph not used.) required: (1) At least thirty days have passed between the date of the 0 American Indian or 0 Black (not of Hispanic origin) individual's signature on this consent form and the date the Alaska Native 0 Hispanic sterilization was performed. 0 Asian or Pacific Islander 0 White (not of Hispanic origin) (2) This sterilization was performed less than 30 days but not more than 72 hours after the date of the individual's signature on this * INTERPRETER'S STATEMENT * consent form because of the following circumstances (check If an interpreter is provided to assist the individual to be sterilized: applicable box and fill in information requeste) I have translated the information and advice presented orally to the 0 Premature delivery individual to be sterilized b the person obtaining this consent 0 Individual's expected date of delivery: I have also read to him/her the consent form in ______0 Emergency abdominal surgery: language and explained its contents to him/her. To the best of my (describe circumstances): knowledge and belief he/she understood this explanation. ______Physician Interpreter Date ______Date ______Provider Number (Revised 1/79)
Updated 02/07 HOW TO COMPLETE THE STERILIZATION CONSENT FORM
Consent to Sterilization: The consumer beneficiary must sign and date the left portion of the consent form. All dates must include month, day and year.
Field 1 Required. Enter the name of the doctor or clinic from which the beneficiary received sterilization information.
Field 2 Required. Enter the name of the procedure to be performed.
Field 3 Required. Enter the consumer's beneficiary’s date of birth in MM/DD/YYYY format.
Field 4 Required. Enter the name of the consumer beneficiary.
Field 5 Required. Enter the name of the physician who will be performing the sterilization procedure.
Field 6 Required. Enter the name of the procedure to be performed.
Field 7 Federally Mandated Field. The consumer beneficiary must enter his/her signature here. This field cannot be altered or changed.
Field 8 Federally Mandated Field. The consumer beneficiary must enter the date he/she signed the consent form. This field cannot be altered or changed. The date must be entered in MM/DD/YY format. The consumer beneficiary must be 21 years of age on or before this date.
Field 9 Optional. Enter the race and ethnic designation of the consumer beneficiary.
Field 10 Enter if applicable. If the consumer beneficiary is not able to fully understand the description of service in English, then an interpreter must be present to explain the procedure and must sign and date this section.
Field 11 Required. The interpreter must sign and date the form.
Field 12 Required. Enter the beneficiary’s first name, middle initial, and last name.
Field 13 Required. Enter the name of the procedure to be performed.
Field 14 Required. The person obtaining consent must sign and date here (for example, physician or qualified individual who explained the procedure to the consumer beneficiary). The date should be on or after the date the consumer beneficiary signed the consent form.
Completing the Sterilization Consent form cont. Updated 02/07
Field 15 Required. Enter the name of the facility where the sterilization procedure was performed.
Field 16 Required. Enter the address of the facility.
Field 17 Required. Enter the beneficiary’s first name, middle initial, and last name.
Field 18 Required. The date entered here must be at least 30 days after but no more than 180 days from the date the consumer beneficiary signed the consent form. This date and the date on the claim form must match and be in MM/DD/YY format.
Field 19 Required. Enter the name of the procedure to be performed.
Field 20 If applicable. Check appropriate box. Enter the expected date of delivery. This date must be 30 days after the date the consumer beneficiary signed the consent form. This date is required if either block is checked. The date must be in MM/DD/YY format.
Field 21 Required. The physician who performed the sterilization must sign here. This physician must be the same as the performing physician indicated on the claim.
Field 22 Required. Enter the performing physician's 10-digit Kansas Medical Assistance Program provider number.
Field 23 Required. Enter the date the physician signed the consent form.
Distribution of Form: 1 copy to patient
1 copy for physician's file
1 copy should be attached to the surgeon's claim at the time of submission (State Agency copy). A copy is not required to be attached to related claims (anesthesia, assistant surgeon, ambulatory surgical center, hospital, or rural health clinic) at the time of submission. However, no related claims will be paid until the sterilization form with the surgeon's claim has been reviewed and determined to be correct, unless the related claim has the correct sterilization consent form attached.