PHYSICIANS SERVICES PROVIDER MANUAL AUGUST 1, 2021 South Carolina Department of Health and Human Services PHYSICIANS SERVICES PROVIDER MANUAL SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES CONTENTS 1. Program Overview ........................................................................................................................... 1 2. Eligible Providers ............................................................................................................................. 2 • Provider Qualifications ............................................................................................................... 2 • Provider Enrollment and Licensing ............................................................................................ 8 3. Covered Services and Definitions .................................................................................................12 • Primary Care Services .............................................................................................................12 • Physician Services ...................................................................................................................12 • Office/Outpatient Exams Definitions ........................................................................................13 • Ambulatory Care Visit Guidelines ............................................................................................13 • Evaluation and Management Services ....................................................................................15 • Non-Covered Services ...........................................................................................................157 4. Utilization Management ...............................................................................................................165 • Prior Authorization .................................................................................................................165 • Other Service Limitations .......................................................................................................177 5. Reporting/Documentation ............................................................................................................191 • Co-Signatures ........................................................................................................................191 • Evaluation and Management Services Records and Documentation Requirements...........191 • Documentation of the Teaching Physician ............................................................................192 • Convenient Care Clinics ........................................................................................................192 • Telemedicine ..........................................................................................................................192 i PHYSICIANS SERVICES PROVIDER MANUAL SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES • Obstetrics and Gynecology ....................................................................................................192 • Psychiatric and Counseling Services ....................................................................................195 • Tuberculosis (TB) Policy ........................................................................................................197 • Breast Cancer Susceptibility Gene 1 and 2 (BRCA) .............................................................197 • Chiropractic Services .............................................................................................................198 • Pain Management Services ...................................................................................................201 6. Billing Guidance ...........................................................................................................................202 • Services Outside of the Country ............................................................................................202 • Direct Physician Supervision .................................................................................................202 • Physician’s Office within an Institution ..................................................................................202 • Physician Administered Drugs ...............................................................................................202 • Teaching Physician Policy Billing Requirements ..................................................................203 • Reciprocal Billing and Locum Tenens Arrangements ...........................................................204 • Evaluation and Management Services ..................................................................................205 • Immunizations ........................................................................................................................219 • Pediatrics and Neonatology ...................................................................................................219 • Tobacco Cessation ................................................................................................................230 • Obstetrics and Gynecology ....................................................................................................230 • Psychiatric and Counseling Services ....................................................................................237 • Nephrology and End Stage Renal Disease Services ............................................................237 • Part II — Diagnostic Ophthalmology Services ......................................................................239 • Hyperbaric Oxygen Therapy ..................................................................................................243 ii PHYSICIANS SERVICES PROVIDER MANUAL SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES • General Surgery Guidelines ..................................................................................................244 • Surgical Guidelines for Specific Systems ..............................................................................250 • Anesthesia Services ..............................................................................................................251 • Pain Management Services ...................................................................................................253 • Pathology and Laboratory Services.......................................................................................254 • Radiology and Nuclear Medicine ...........................................................................................259 • Federally Qualified Health Center Services ..........................................................................260 • Clinic-Based Physician Policy................................................................................................262 • Rural Health Clinic .................................................................................................................263 • Wrap-Around Payment Methodology ....................................................................................266 iii PHYSICIANS SERVICES PROVIDER MANUAL SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES 1 PROGRAM OVERVIEW The State of South Carolina (South Carolina or State) Medicaid program recognizes professional medical services that are medically necessary, unless limitations are noted within the Other Service Limitations section of this manual. Information in this manual includes South Carolina Medicaid policies for general medical care, such as, office exams. These services are predominantly billed to Medicaid by Primary Care Physicians (PCPs), such as family physicians, internists, general practitioners, obstetricians/gynecologists (OB/GYN) and pediatricians. However, the guidelines are written for all providers rendering services to South Carolina citizens who are Medicaid beneficiaries. Note: References to supporting documents and information are included throughout the manual. This information is found at the following locations: • Provider Administrative and Billing Guide • Forms • Procedure Codes 1 PHYSICIANS SERVICES PROVIDER MANUAL SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES 2 ELIGIBLE PROVIDERS PROVIDER QUALIFICATIONS Physician For Medicaid billing purposes, the term “physician” includes doctors of medicine and osteopathy who are currently licensed in the state in which they are rendering services by that state’s Board of Medical Examiners. Hospital-Based Physician A hospital-based physician is defined as a physician licensed to practice medicine or osteopathy who is employed by a hospital, and whose payment for services is claimed by the hospital as an allowable cost under the Medicaid program and billed by the contracted hospital. Physician’s Assistant A physician assistant (PA) may provide medically necessary covered services as long as the services provided are allowed by State Law and consistent with the agreement between the PA and the PA’s supervising physician. PAs providing services to Healthy Connections beneficiaries must be enrolled as South Carolina Medicaid providers. Services rendered and billed under the PA’s individual National Provider Identifier (NPI) number are reimbursed at 80% of the current Medicaid Family and General Practitioners physician’s fee schedule for professional services. Certified Nurse Midwife A certified nurse midwife (CNM) must be licensed to practice as a Registered Nurse and as a CNM in the state in which he