Current through Register Vol. 43, No. 02, November 27, 2024
(1) Acupuncture: Not covered.
(2) Administration of anesthesia is a covered
service when administered by or directed by a duly licensed physician for a
medical procedure which is a covered service under the Alabama Medicaid
Program. Medical direction by an anesthesiologist of more than four Certified
Registered Nurse Anesthetists (CRNAs) or Anesthesiology Assistants (AAs)
concurrently will not be covered. For billing purposes, anesthesia services
rendered with medical direction for one CRNA or AA is considered a service
performed by the anesthesiologist. In order to bill for medical supervision,
the anesthesiologist must be physically present and available within the
operating suite. "Physically present and available" means the anesthesiologist
would not be available to render direct anesthesia services to other patients.
However, addressing an emergency of short duration or rendering the requisite
CRNA or AA supervision activities (listed below in a. through g.) within the
immediate operating suite is acceptable as long as it does not substantially
diminish the scope of the supervising anesthesiologist's control. If a
situation occurs which necessitates the anesthesiologist's personal continuing
involvement in a particular case, medical supervision ceases to be available in
all other cases. In order for the anesthesiologist to be reimbursed for medical
supervision activities of the CRNA or AA, the anesthesiologist must document
the performance of the following activities:
(a) performs a pre-anesthesia examination and
evaluation;
(b) prescribes the
anesthesia plan;
(c) personally
participates in the most demanding procedures in the anesthesia plan, including
induction as needed, and emergencies;
(d) ensures that any procedures in the
anesthesia plan that he or she does not perform are performed by a qualified
individual;
(e) monitors the course
of anesthesia administration at frequent intervals;
(f) remains physically present and available
for immediate diagnosis and treatment of emergencies; and
(g) provides indicated post-anesthesia care.
Administration of anesthesia by a self-employed Certified
Registered Nurse Anesthetist (CRNA) is a covered service when the CRNA has met
the qualifications and standards set forth in Rule No.
610-X-9-.01 through
610-X-9-.04 of the Alabama Board
of Nursing Administrative Code. The CRNA must enroll and receive a provider
number to bill under the Alabama Medicaid Program. When billing for anesthesia
services, providers shall follow the guidelines set forth in the current
Relative Value Guide published by the American Society of Anesthesiologists for
basic value and time units. No Physical Status Modifiers can be billed.
Administration of anesthesia by a qualified Anesthesiology
Assistant (AA) is a covered service when the AA has met the qualifications and
standards set forth in the Alabama Board of Medical Examiners Administrative
Code. Reimbursement shall be made only when the AA performs the administration
of anesthesia under the direct medical supervision of the
anesthesiologist.
Anesthesia services may include, but are not limited to,
general anesthesia, regional anesthesia, supplementation of local anesthesia,
or other supportive treatment administered to maintain optimal anesthesia care
deemed necessary by the anesthesiologist during the procedure. Anesthesia
services include all customary preoperative and postoperative visits, the
anesthesia care during the procedure, the administration of any fluids deemed
necessary by the attending physician, and any usual monitoring procedures.
Therefore, additional claims for such services should not be submitted.
(h) Local anesthesia is usually
administered by the attending surgeon and is considered to be part of the
surgical procedure being performed. Thus, additional claims for local
anesthesia by the surgeon should not be filed. Any local anesthesia
administered by an attending obstetrician during delivery (i.e. pudendal block
or paracervical block) is considered part of the obstetrical coverage. Thus,
additional claims for local anesthesia administered by an attending
obstetrician during delivery should not be filed.
(i) When regional anesthesia (i.e., nerve
block) is administered by the attending physician during a procedure, the
physician's fee for administration of the anesthesia will be billed at one-half
the established rate for a comparable service when performed by an
anesthesiologist. When regional anesthesia is administered by the attending
obstetrician during delivery (i.e., saddle block or continuous caudal), the
obstetrician's fee for administration of the anesthesia will be billed at
one-half the established rate for a comparable service performed by an
anesthesiologist. When regional anesthesia is administered by an
anesthesiologist during delivery or other procedure, the anesthesiologist's fee
will be covered and should be billed separately.
(j) When a medical procedure is a noncovered
service under the Alabama Medicaid Program, the anesthesia for that procedure
is also considered to be a noncovered service.
(3) Artificial Eyes: Must be prescribed by a
physician.
(4) Autopsies: Not
covered.
(5) Biofeedback: Not
covered.
(6) Blood Tests: Not
covered for marriage licenses.
(7)
CAT Scans, CTA's, MRI's, MRA's and PET scans: See Chapter 34 of this code for
specific details.
(8)
Chiropractors: Not covered, except for QMB recipients and for services referred
directly as a result of an EPSDT screening.
(9) Chromosomal Studies: Chromosomal studies
(amniocentesis) on unborn children being considered for adoption are not
covered. Medicaid can pay for these studies in the case of prospective mothers
in an effort to identify conditions that could result in the birth of an
abnormal child.
(10) Circumcision:
Circumcision of newborns is a covered service. If medically necessary,
non-newborn circumcision is covered.
(11) Diet Instruction: Diet instruction
performed by a physician is considered part of a routine visit.
(12) Drugs:
(a) Non-injectable drugs: See Chapter 16 of
this Code.
(b) Injectable drugs:
Physicians who administer injectable drugs to their patients may bill Medicaid
for the cost of the drug by using the procedure code designated by Medicaid for
this purpose. The injectable administration code may be used only when an
office visit or nursing home visit is not billed.
(13) Examinations: Office visits for
examinations are counted as part of each recipient's annual office visit limit.
See Rule No.
560-X-6-.14 for details about
this limit.
(a) Annual routine physical
examinations are not covered.
(b)
Medical examinations for such reasons as insurance policy qualifications are
not covered.
(c) Physical
examinations for establishment of total and permanent disability status if
considered medically necessary are covered.
(d) Medicaid requires a physician's visit
once each 60 days for patients in a nursing home. Patients in intermediate care
facilities for the intellectually disabled will receive a complete physical
examination at least annually.
(e)
Physical examination, including x-ray and laboratory work, will be payable for
recipients eligible through the EPSDT Program if the physician has signed an
agreement with Medicaid to participate in the screening program.
(14) Experimental Treatment and/or
Surgery: Not covered.
(15) Eyecare:
(a) Eye examinations by physicians are a
Medicaid covered service.
(b)
Office visits for eyecare disease are counted as part of each recipient's
annual office visit limit. See Rule No.
560-X-6-.14 for details about
this quota.
(16) Filing
Fees: Not covered.
(17) Foot
Devices: See Chapter 13 (Supplies, Appliances, and Durable Equipment) for
specific details.
(18) Hearing
Aids: See Hearing Aids Chapter in this Code.
(19) Hypnosis: Not covered.
(20) Immunizations: Payment for immunizations
against communicable diseases will be made if the physician normally charges
his patients for this service.
(a) The
Department of Public Health provides vaccines at no charge to Medicaid
physicians enrolled in the Vaccines For Children (VFC) Program and as
recommended by the Advisory Committee on Immunization.
(b) Effective October 1, 1994, the Alabama
Medicaid Agency will begin reimbursement of administration fees for vaccines
provided free of charge through the Vaccines For Children (VFC)
Program.
(c) Medicaid tracks usage
of the vaccine through billing of the administration fee using the appropriate
CPT-4 codes.
(d) The Omnibus Budget
Reconciliation Act of 1993 mandated that Medicaid can no longer cover a single
antigen vaccine if a combined antigen vaccine is medically appropriate. This
change will become effective January 1, 1994. The single antigen vaccines may
still be billed only if prior approved before given and a medical justification
is given. These vaccines are diphtheria, measles, mumps, and rubella. In order
to request the prior approval for these vaccines, providers should contact the
Alabama Medicaid Agency fiscal agent.
(21) Infant Resuscitation: Newborn
resuscitation (procedure code 99465) is a covered service when the baby's
condition is life threatening and immediate resuscitation is necessary to
restore and maintain life functions. Intubation, endotracheal, emergency
procedure (procedure code 31500) cannot be billed in conjunction with newborn
resuscitation.
(22) Intestinal
Bypass: Not covered for obesity.
(23) Laetrile Therapy: Not covered.
(24) Newborn Claims: The five kinds of
newborn care performed by physicians in the days after the child's birth when
the mother is still in the hospital that may be filed under the mother's name
and number or the baby's name and number are routine newborn care and discharge
codes, circumcision, newborn resuscitation, standby services following a
caesarean section or a high-risk vaginal delivery, and attendance at delivery
(when requested by delivering physician) and initial stabilization of newborn.
Standby services (procedure code 99360) are covered only when the pediatrician,
family practitioner, neonatologist, general practitioner, or OB/ GYN is on
standby in the operating or delivery room during a cesarean section or a
high-risk vaginal delivery. Attendance of the standby physician in the hospital
operating or delivery room must be documented in the operating or delivery
report. When filing claims for these five kinds of care, CPT codes shall be
utilized. All other newborn care (any care other than routine newborn care for
a well-baby), before and after the mother leaves the hospital, must be billed
under the child's name and number.
(25) Obstetrical Services and Related
Services: Office visits for obstetrical care are counted as part of each
recipient's annual office visit limit under certain conditions. See Rule No.
560-X-6-.14 for details about
this quota.
(a) Family Planning: See the
Family Planning Chapter in this Code.
(b) Abortions: See Rule No.
560-X-6-.09
(1).
(c) Hysterectomy: See Rule No.
560-X-6-.09.
(d) Maternity Care and Delivery: The services
normally provided in maternity cases include antepartum care, delivery, and
postpartum care. When a physician provides total obstetrical care, the
procedure code which shall be filed on the claim form is the code for
all-inclusive "global" care. The indicated date of service on "global" claims
should be the date of delivery. If a woman is pregnant at the time she becomes
eligible for Medicaid benefits, only those services provided during the time
she is eligible will be covered. When a physician provides eight (8) or more
prenatal visits, performs the delivery, and provides the postpartum care, the
physician shall use a "global" obstetrical code in billing. If a physician
submits a "global" fee for maternity care and delivery, the visits covered by
these codes are not counted against the recipient's limit of annual office
visits. For purposes of "global" obstetrical billing, services rendered by
members of a group practice are to be considered as services rendered by a
single provider.
1. Antepartum care includes
all usual prenatal services such as initial office visit at which time
pregnancy is diagnosed, initial and subsequent histories, physical
examinations, blood pressure recordings, fetal heart tones, maternity
counseling, etc.; therefore, additional claims for routine services should not
be filed. Antepartum care also includes routine lab work (e.g., hemoglobin,
hematocrit, chemical urinalysis, etc.); therefore, additional claims for
routine lab work should not be filed.
(i) To
justify billing for global antepartum care services, physicians must utilize
the CPT-4 antepartum care global codes (either 4-6 visits, or 7 or more
visits), as appropriate. Claims for antepartum care filed in this manner do not
count against the recipient's annual office visit limit. Physicians who provide
less than four (4) visits for antepartum care must utilize CPT-4 codes under
office medical services when billing for these services. These office visit
codes will be counted against the recipient's annual office visit
limit.
(ii) Billing for antepartum
care services in addition to "global" care is not permissible; however, in
cases of pregnancy complicated by toxemia, cardiac problems, diabetes,
neurological problems or other conditions requiring additional or unusual
services or hospitalization, claims for additional services may be filed. If
the physician bills fragmented services in any case other than high-risk or
complicated pregnancy and then bills a "global" code, the fragmented codes
shall be recouped. Claims for such services involved in complicated or high
risk pregnancies may be filed utilizing CPT codes for Office Medical Services.
Claims for services involving complicated or high risk pregnancies must
indicate a diagnosis other than normal pregnancy and must be for services
provided outside of scheduled antepartum visits. These claims for services
shall be applied against the recipient's annual office visit limit.
2. Delivery and postpartum care:
Delivery shall include vaginal delivery (with or without episiotomy) or
cesarean section delivery and all in-hospital postpartum care. More than one
delivery fee may not be billed for a multiple birth (twins, triplets, etc.)
delivery, regardless of delivery method(s). Delivery fees include all
professional services related to the hospitalization and delivery which are
provided by the physician; therefore, additional claims for physician's
services in the hospital such as hospital admission, may not be filed in
addition to a claim for delivery or a claim for "global" care.
EXCEPTION: When a physician's first and only encounter with the
recipient is for delivery ("walk-in" patient) he may bill for a hospital
admission (history and physical) in addition to delivery charges.
3. Postpartum care includes office
visits following vaginal or cesarean section delivery for routine postpartum
care within sixty-two (62) days post delivery. Additional claims for routine
visits during this time should not be filed.
4. Delivery only: If the physician performs
the delivery only, he must utilize the appropriate CPT-4 delivery only code
(vaginal delivery only or C-section delivery only). More than one delivery fee
may not be billed for a multiple birth (twins, triplets, etc.) delivery,
regardless of the delivery method(s). Delivery fees include all professional
services related to the hospitalization and delivery which are provided by the
physician; therefore, additional claims for physician's services in the
hospital such as hospital admission, may not be filed in addition to a claim
for delivery only.
EXCEPTION: When a physician's first and only encounter with the
recipient is for delivery ("walk-in" patient) he may bill for a hospital
admission (history and physical) in addition to delivery charges.
5. All obstetrical ultrasounds
must be medically necessary with medical diagnosis documented supporting the
benefit of the ultrasound procedure. Generally, ultrasounds are conducted to
detect gestational age, multiple pregnancies, major malformations, detect fetal
growth disorders (intrauterine growth retardation, macrosomia) and anomalies
that would appear later or may have been unrecognizable in the earlier
scan.
(e) Sterilization:
See the Family Planning Chapter in this Code.
(26) Medical Materials and Supplies: Costs
for medical materials and supplies normally utilized during office visits or
surgical procedures are to be considered part of the total fee for procedures
performed by the physician and therefore are not generally a separately
billable service.
(27) Oxygen and
Compressed Gas: A physician's fee for administering oxygen or other compressed
gas is a covered service under the Medicaid program. Oxygen therapy is a
covered service based on medical necessity and requires prior authorization.
Please refer to the Alabama Medicaid Administrative Code, Rule No.
560-X-13-.15 and the Alabama
Medicaid Billing Manual Chapter 14, DME, for more information.
(28) Podiatrist Service: Covered for QMB or
EPSDT referred services only.
(29)
Post Surgical Visits:
(a) Hospital Visits:
Post-surgical hospital visits for conditions directly related to the surgical
procedures are covered by the surgical fee and cannot be billed separately the
day of, or up to 90 days post surgery.
(b) Office Visits: Post-surgical office
visits for procedures directly related to the surgical procedure are covered by
the surgical fee and are not separately covered the day of, or up to 90 days
post surgery, and cannot be billed separately, e.g. suture removal.
(c) Visits by Assistant Surgeon or Surgeons:
Not covered.
(30)
Preventive Medicine: The Medicaid program does not cover preventive medicine
other than EPSDT screening.
(31)
Prosthetic Devices: External prosthetic devices are not a covered benefit under
the Physician's Program. Internal prosthetic devices (i.e., Smith Peterson
Nail, pacemaker, vagus nerve stimulator, etc.) are a covered benefit only when
implanted during an inpatient hospitalization. The cost of the device is
reimbursed through the payment of the inpatient hospital per diem rate and is
not separately reimbursable.
(32)
Psychiatric Services: Office visits for psychiatric services are counted as
part of each recipient's annual office visit limit. See Rule No.
560-X-6-.14 for details about
this quota.
(a) Psychiatric Evaluation or
Testing: Are covered services under the Physicians' Program if services are
rendered by a physician in person and are medically necessary. Psychiatric
evaluations shall be limited to one per calendar year, per provider, per
recipient.
(b) Psychotherapy
Visits: Shall be included in the annual office visit limit. Office visits shall
not be covered when billed in conjunction with psychotherapy codes.
(c) Psychiatric Services: Under the
Physicians' Program shall be confined to use with psychiatric ICD-9-CM
diagnosis codes (dates of service prior and up to September 30, 2015) (range
290-319) or ICD-10-CM diagnosis codes (dates of service October 1, 2015 and
forward) (range F01.50 - F99) and must be performed by a physician.
(d) Hospital Visits: Are not covered when
billed in conjunction with psychiatric therapy on the same day.
(e) Services Rendered by Psychologist: See
Chapter 11 (EPSDT) for specific information.
(f) Psychiatric Day Care: Not a covered
benefit under the Physicians' Program.
(33) Second Opinions: Office visits for
second opinions are counted as part of each recipient's annual office visit
limit. See Rule No.
560-X-6-.14 for details about
this quota.
(a) Optional Surgery: Second
opinions (regarding non-emergency surgery) are highly recommended in the
Medicaid program when the recipients request them. Payment is made in
accordance with the provider's reasonable charge profile allowance for an
initial office visit for the appropriate level of service.
(b) Diagnostic Services: Payment may be made
for covered diagnostic services deemed necessary by the second
physician.
(34)
Self-Inflicted Injury: Covered.
(35) Surgery
(a) Cosmetic: Covered only when prior
approved for medical necessity. Examples of medical necessity include prompt
repair of accidental injuries or improvement of the functioning of a malformed
body member.
(b) Elective: Covered
when medically necessary.
(c)
Multiple:
1. When multiple and/or bilateral
surgical procedures, which add significant time or complexity are performed at
the same operative session, payment may be made for the procedure with the
highest allowed amount and half of the allowed amount for each subsequent
procedure code that is not considered to be an integral part of the covered
service. This also applies to laser surgical procedures. See Medicaid National
Correct Coding Initiatives at
http://www.medicaid.gov. Exceptions are
noted in Rule No.
560-X-6-.14, Limitations on
Services.
2. Certain procedures are
commonly carried out as integral parts of a total service and as such do not
warrant a separate charge. When incidental procedures (e.g. excision of
previous scar or puncture of ovarian cyst) are performed during the same
operative session, the reimbursement will be included in that of the major
procedure only.
3. Laparotomy is
covered when it is the only surgical procedure performed during the operative
session or when performed with an unrelated or incidental surgical
procedure.
4. CPT defined Add On
codes are considered for coverage only when billed with the appropriate primary
procedure code.
5. Appropriate use
of CPT and HCPCs modifiers is required to differentiate between sides and
procedures. For Medical approved modifiers, refer to the Alabama Medicaid
Provider Manual.
(36) Telephone Consultations: Not
covered.
(37) Therapy: Office
visits for therapy are counted as part of each recipient's annual office visit
limit. See Rule No.
560-X-6-.14 for details about
this quota.
(a) Occupational and Recreational
Therapies: Not covered.
(b)
Physical Therapy: Is not covered when provided in a physician's office.
Physical therapy is covered only when prescribed by a physician and provided in
a hospital setting. See Rule No.
560-X-7-.12 for further
requirements of coverage.
(c) Group
Therapy: Shall be a covered service when a psychiatric diagnosis is present and
the therapy is prescribed, performed, and billed by the physician personally.
1. Group Therapy is included in the annual
office visit limit.
2. Group
Therapy is not covered when performed by a case worker, social services worker,
mental health worker, or any counseling professional other than a
physician.
(d) Speech
Therapy: The patient must have a speech related diagnosis, such as stroke (CVA)
or partial laryngectomy. To be a covered benefit speech therapy must be
prescribed by and performed by a physician in his office. Speech therapy
performed in an inpatient or outpatient hospital setting, or in a nursing home
is a covered benefit, but is considered covered as part of the reimbursement
made to the facility and should not be billed by the physician.
(e) Family Therapy: Shall be a covered
service when a psychiatric diagnosis is present and the physician providing the
service supplies documentation which justifies the medical necessity of the
therapy for each family member. Family therapy is not covered unless the
patient is present. Family Therapy is included in the annual office visit
limit. Family Therapy is not covered when performed by a case worker, social
service worker, mental health worker, or any counseling professional other than
a physician.
(38)
Transplants: See Rule No.
560-X-1-.27 for transplant
coverage.
(39) Ventilation Study:
Covered if done in physician's office by the physician or under the physician's
direct supervision. Documentation in the medical record should contain all of
the following:
(b) Total and timed vital capacity;
(c) Maximum breathing capacity;
(d) Always indicate if the studies were
performed with or without a bronchodilator.
(40) Well-Baby Coverage: Covered only on the
initial visit, which must be provided within eight (8) weeks of the
birth.
(41) Work Incentive: A claim
stating physical examination for a child to be put into a day-care center for
mother to work is a covered procedure. (Must state "Work Incentive
Program.")
Author: Michael Williams, Associate Director,
Dental, EPSDT, and Physician Unit
Statutory Authority: Title XIX, Social Security
Act; 42 C.F.R. §§ 405.310(k),
440.50, et
seq.; State Plan.
