Current through Register Vol. 43, No. 02, November 27, 2024
(1)
Within each calendar year each recipient is limited to no more than a total of
14 physician office visits in offices, hospital outpatient settings, nursing
homes, or Federally Qualified Health Centers. Visits counted under this quota
will include, but not be limited to, visits for: prenatal care, postnatal care,
family planning, second opinions, consultations, referrals, psychotherapy
(individual, family, or group), for ESRD services not covered by the monthly
capitation payment, and care by ophthalmologists for eye disease. Physician
visits provided in a hospital outpatient setting that have been certified as an
emergency do not count against the annual office visit limit.
(a) If a patient receives ancillary services
in a doctor's office, by the physician or under his/her direct supervision, and
the doctor submits a claim only for the ancillary services but not for the
office visit, then the services provided will not be counted as a
visit.
(b) For further information
regarding outpatient maintenance dialysis and ESRD, refer to
560-X-6-.19 and Chapter
24.
(c) New patient office visit
codes shall not be paid to the same physician or the same physician group
practice for a recipient more than once in a three-year period.
(2) Physician services to hospital
inpatients. In addition to the office visits referred to in paragraph (1)
above, Medicaid covers up to 16 inpatient dates of service per physician, per
recipient, per calendar year. For purposes of this limitation, each specialty
within a group or partnership is considered a single provider.
(a) Physician hospital visits are limited to
one visit per day, per recipient, per provider.
(b) Physician(s) may bill for inpatient
professional interpretation(s) when that interpretation serves as the official
and final report documented in the patient's medical record. Professional
interpretation may be billed in addition to a hospital visit if the rounding
physician also is responsible for the documentation of the final report for the
procedure in the patient's medical record. Professional interpretation may not
be billed in addition to hospital visits if the provider reviews results in the
medical record or unofficially interprets medical, laboratory, or radiology
tests. Review and interpretation of such tests and results are included in the
evaluation and management of the inpatient. Medicaid will cover either one
hospital visit or professional interpretation(s) up to the allowed benefit
limit for most services. Refer to the Alabama Medicaid Provider Manual for
additional guidelines.
(c)
Professional interpretations for lab and x-ray (CPT code 70000 through 80000
services) in the inpatient setting should be billed only by the specialist
responsible for the official medical record report of interpretation.
Professional interpretations performed by physicians of other specialties for
services in this procedure code range are included in the hospital visit
reimbursement.
(d) Professional
interpretations for lab and x-ray services performed in an outpatient setting
are considered part of the evaluation and management service and may not be
billed in addition to the visit. Professional interpretations may be billed
separately only by the specialist responsible for the official medical record
report of interpretation. Only one professional interpretation per x-ray will
be paid. Claims paid in error will be recouped.
(e) Professional interpretations for lab and
x-ray services performed in an office setting are included in the global fee
and should not be billed separately.
(f) A physician hospital visit and hospital
discharge shall not be paid to the same physician on the same day. If both are
billed, only the discharge shall be paid.
(3) Eyecare: Refer to Chapter Seventeen of
this Code.
(4) Orthoptics:
Orthoptics may be prior authorized by the Alabama Medicaid Agency when
medically necessary.
(5)
Telemedicine: Telemedicine services are covered for limited specialties and
under special circumstances. Refer to the Alabama Medicaid Provider Manual,
Chapter 28 for details on coverage.
(6) Telephone consultations: Telephone
consultations are not authorized.
(7) Prior authorized services: These are
subject to all limitations of the Alabama Medicaid Agency Program.
(8) Post surgical benefits: See Rule No.
560-X-6-.13.
(9) Surgery: When multiple and/or bilateral
procedures are billed in conjunction with one another and meet the CPT's
definition of "Format of Terminology" (bundled or subset), and/or
comprehensive/component (bundled) codes, then the procedure with the highest
allowed amount will be paid while the procedure with the lesser allowed amount
will not be considered for payment as the procedure is considered an integral
part of the covered service.
(a) Operating
microscope procedure coverage is limited. For details on coverage, refer to the
Physician Chapter of the Alabama Medicaid Provider Manual.
(b) Mutually exclusive procedures are defined
as those codes that cannot reasonably be performed in the same session and are
considered not separately allowable or reimbursable. An example of this would
be an abdominal and vaginal hysterectomy billed for the same recipient on the
same date of service.
(c)
Incidental procedures are defined as those codes which are commonly carried out
as integral parts of a total service and as such do not warrant a separate
charge. An example of this would be lysis of adhesions during the same session
as an abdominal surgery.
(d)
Casting and strapping codes as defined in the CPT and billed in conjunction
with related surgical procedure codes are considered not separately allowable
or reimbursable as the fracture repair or surgical code is inclusive of these
services.
(e) Laparotomy Codes are
covered when the laparotomy is the only surgical procedure during an operative
session or when performed with an unrelated surgical procedure.
Author: Teresa Thomas, Program Manager,
EPSDT/Related Svcs
Statutory Authority: Title XIX, Social Security
Act; 42 C.F.R. §§
441.56,
441.57, 401,
et
seq.; State Plan.
