Current through Register Vol. 49, No. 9, September, 2024
6.
d. Other Practitioner's Services
(5) Psychologist Services Refer to Attachment
4.19-B, Item 4.b. (17).
(a) Additional
Reimbursement for Psychologists Services Associated with UAMS - Refer to
Attachment 4.19-B, item 5.
(6) Obstetric-Gynecologic and Gerontological
Nurse Practitioner Services Reimbursement is the lower of the amount billed or
the Title XIX maximum allowable.
The Title XIX maximum is based on 80% of the physician fee
schedule except EPSDT procedure codes. Medicaid maximum allowables are the same
for all EPSDT providers. Immunizations and Rhogam RhoD Immune Globulin are
reimbursed at the same rate as the physician rate since the cost and
administration of the drug does not vary between the nurse practitioner and
physician.
Refer to Attachment 4.19-B, Item 27, for a list of the nurse
practitioner pediatric and obstetrical procedure codes.
(7) Advanced Practice Nurses Services
Associated with UAMS - For additional reimbursement refer to Attachment 4.19-B,
item 5.
(8) Licensed Clinical
Social Workers' Services Associated with UAMS - For additional reimbursement
refer to Attachment 4.19-B, item 5.
(9) Physicians' Assistant Services Associated
with UAMS - For additional reimbursement refer to Attachment 4.19-B, item
5.
7. Home
Health Services
a. Intermittent or part-time
nursing services furnished by a home health agency or a registered nurse when
no home health agency exists in the area;
b. Home health aide services provided by a
home health agency; and
c.
Physical therapy
Reimbursement on basis of amount billed not to exceed the Title
XIX (Medicaid) maximum.
The initial computation (effective July 1, 1994) or the
Medicaid maximum for home health reimbursement was calculated using audited
1990 Medicare cost reports for three high volume Medicaid providers, Medical
Personnel Pool, Arkansas Home Health, W. M. and the Visiting Nurses
Association. For each provider, the cost per visit for each home health service
listed above in items 7.a., b. and c. was established by dividing
total allowable costs by total visits. This figure was then inflated by the
Home Health Market Basket Index in Federal Register #129, Vol. 58 dated July 8,
1993- inflation factors: 1991 - 105.7%, 1992 - 104.1%, 1993 - 104.8%. The
inflated cost per visit was then weighted by the total visits per providers'
fiscal year (i.e., the visits reported on the 1990 Medicare cost reports) to
arrive at a weighted average visit cost.
The physical therapy reimbursement rate calculated under
this method will be submitted to the United States District Court for the
Eastern District of Arkansas (case of Arkansas Medical Society v Reynolds) for
its approval.
For registered nurses (RN) and licensed practical nurses (LPN)
the Full Time Equivalent Employees (FTEs) listed on cost report worksheet S-1,
Part II, were used to allocate nursing costs and units of service (visits). It
was necessary to make these allocations because home health agencies are not
required by Medicare to separate their registered nurses and licensed practical
nurse costs or visits on the annual cost report.
RN and LPN salaries and fringes were separated using an Office
of Personnel Management Survey, which indicated that RNs, on an average, are
paid 36% more than licensed practical nurses. Conversely, if RNs are paid 36%
more than LPNs, then LPNs are paid, on an average, 73.5% of what RNs earn. Cost
report salaries and fringes were allocated based on 100% of RN FTEs and 73.5%
of LPN FTEs. Other costs and service units (visits) were allocated based on
100% of RN FTEs and 100% of LPN FTEs. RN and LPN unit service (visit) costs
were then inflated and weighted as outlined above.
Since home health reimbursement is based on audited costs, the
home health rates will be adjusted annually by the Home Health Market Basket
Index. This adjustment will occur at the beginning of the State Fiscal Year,
July 1. Every third year, the cost per visit will be rebased utilizing the most
current audited cost report from the same three providers and using the same
formula described above to arrive at a cost per visit inflated through the
rebasing year. (The first rebasing will occur in 1996 to be effective July 1,
1997.)
c. Medical Supplies,
Equipment and Appliances Suitable for Use in the Home
(1) Medical Supplies
Effective for dates of service on or after October 1, 1994,
medical supplies, for use by patient in their own home - Reimbursement is based
on 100% of the Medicare maximum for medical supplies reflected in the 1993
Arkansas Medicare Pricing File not to exceed the Title XIX coverage limitations
as specified in Attachment 3.l-A and Attachment 3.l-B, Item l2.c.7.
TO: Arkansas Medicaid Health Care Providers - Home
Health
DATE: November 1, 2006
SUBJECT: Provider Manual Update Transmittal
#82
|
REMOVE
|
INSERT
|
|
Section
|
Date
|
Section
|
Date
|
|
211.200
|
10-13-03
|
211.200
|
11-1-06
|
|
212.000
|
10-13-03
|
212.000
|
11-1-06
|
|
212.301
|
6-1-04
|
212.301
|
11-1-06
|
|
212.302
|
6-1-04
|
212.302
|
11-1-06
|
|
212.310
|
6-1-04
|
212.310
|
11-1-06
|
|
212.311
|
6-1-04
|
212.311
|
11-1-06
|
|
212.330
|
6-1-04
|
212.330
|
11-1-06
|
|
212.340
|
11-1-05
|
212.340
|
11-1-06
|
|
212.342
|
11-1-05
|
212.342
|
11-1-06
|
|
212.343
|
11-1-05
|
212.343
|
11-1-06
|
|
213.200
|
6-1-04
|
213.200
|
11-1-06
|
|
231.100
|
10-13-03
|
213.100
|
11-1-06
|
|
241.020
|
12-1-05
|
241.020
|
12-1-05
|
|
242.130
|
10-13-03
|
242.130
|
11-1-06
|
The primary purpose of this update transmittal is to restore
Home Health physical therapy reimbursement methodology from Medicaid fee
schedule per-unit (one unit equals 15 minutes) compensation to fee-schedule
per visit remuneration, because visit-based costs and charges
are integral to the Arkansas Title XIX State Plan's reimbursement methodology
for all other Home Health professional skilled services. Other revisions in
this transmittal are to correct minor errors, clarify regulations, replace
outdated terminology and to delete obsolete and redundant text.
Section II
Home Health
211.200
Program Criteria for Home Health Services
A. A Medicaid beneficiary is eligible for
home health services only if he or she has had a comprehensive physical
examination and a medical history or history update by his or her PCP or
authorized attending physician within the twelve months preceding the beginning
date of a new plan of care, the first date of service in an extended benefit
period or the beginning date of service in a revised or renewed plan of
care.
B. The appropriateness of
home health services is determined by the beneficiary's PCP or authorized
attending physician.
1. An individual's PCP or
authorized attending physician determines whether the patient needs home health
services, the scope and frequency of those services and the duration of the
services.
2. The PCP or authorized
attending physician is responsible for coordination of the patient's care, both
in-home and outside the home.
C. An individual may be eligible for home
health services when all three of the following conditions exist.
1. The individual is unable to leave home
unattended or without supportive devices or assistance.
a. The individual's inability to leave home
unattended or without supportive devices or assistance makes it impossible or
extremely difficult to treat the individual through outpatient
services.
b. Lack of transportation
does not constitute inability to leave home unattended or without supportive
devices or assistance.
2. The part-time and intermittent services or
the part-time, short-term services provided by a home health agency can meet
the beneficiary's medical needs that would be met through outpatient services
if it were possible for the individual to leave home unattended or without
supportive devices or assistance.
3. The only available alternatives to home
health services are inpatient admission to a hospital or admission to a nursing
facility.
D. Some
examples of individuals for whom home health services may be suitable are those
who need:
1. Specialized nursing procedures
with regard to catheters or feeding tubes,
2. Detailed instructions regarding self-care
or diet or
3. Rehabilitative
services administered by a physical therapist.
E. Some beneficiaries may require home health
services of very short duration while they or their caregiver receive training
enabling them to provide for particular medical needs with little or no
assistance from the home health agency.
F. Some individuals may need only
intermittent monitoring or skilled care. When an individual's skilled care is
so infrequent that more than 62 days elapse between services, that individual
requires a new assessment and a new plan of care for each episode of care,
unless the physician documents that the interval without such care is no
detriment and appropriate to the treatment of the beneficiary's illness or
injury.
212.000
Coverage
Home health in the Arkansas Medicaid Program, when authorized
by the client's PCP or authorized attending physician in accordance with the
regulations set forth in this manual,
comprises skilled nursing services (including home IV therapy),
home health aide services, physical therapy, certain injections, disposable
medical supplies and diapers and underpads.
A. Skilled nursing services of Arkansas
state-licensed, registered professional nurses and licensed practical nurses,
as defined in the State Nurse Practice Act and this provider manual, are
covered.
1. Home IV Therapy is a skilled
service, included in the coverage of LPN or RN home health visits.
a. The necessary supplies for home IV therapy
may be furnished by the home health agency or by a Medicaid Prosthetics Program
provider.
b. Drugs and biologicals
are obtained through the Medicaid Pharmacy Program.
2. Administration of Epogen is a skilled
service that is covered separately from the nursing services included in a home
visit.
B. Home health
aide services under the supervision of a registered professional nurse are
covered. Aides must have current Title XVIII (Medicare) certification, whether
the aide is an employee of a home health agency or is working under an
arrangement with a home health agency.
C. Physical therapy furnished by or under the
supervision of a qualified, certified physical therapist is covered. Physical
therapy assistants must meet or exceed Title XVIII (Medicare) requirements for
physical therapy assistants employed by or working under an arrangement with a
home health agency.
D. Disposable
medical supplies suitable for use in the home are covered.
E. Diapers and underpads for incontinence
attributable to conditions other than infancy are covered.
212.300
Physical Therapy in the Home
Health Program
212.301
A Qualified Physical Therapist in the Home Health Program
A. A qualified physical therapist must be a
graduate of a program of physical therapy approved by both the Committee on
Allied Health Education and Accreditation of the American Medical Association
and the American Physical Therapy Association, as required by federal
regulations [
42
CFR §
440.110(a)(2)(i)
].
B. A qualified physical
therapist must be licensed to practice as a physical therapist in Arkansas [
42
CFR §
440.110(a)(2)(ii), with
proof of the qualified physical therapist's current Arkansas licensure on file
with the home health agency.
212.302
A Qualified Physical Therapy
Assistant in the Home Health Program
A. A qualified physical therapy assistant
must have at least a bachelor's degree or college-level associate degree in
physical therapy approved by the American Physical Therapy
Association.
B. A qualified
physical therapy assistant must be licensed by the Arkansas State Board of
Physical Therapy, with proof of the qualified physical therapist assistant's
current state license on file with the home health agency.
C. A qualified physical therapy assistant
must be under the supervision (as defined by the Arkansas State Board of
Physical Therapy and in section
212.320 of this manual) of a
qualified physical therapist.
212.310
Home Health Physical Therapy
Coverage
Medically necessary physical therapy is covered in the Home
Health Program for all ages under the following conditions.
A. There must be a reasonable expectation
that the intervention will result in clinically discernible functional gain(s)
or will prevent a worsening of the condition.
B. The physical therapy treatment plan must
be Included in a home health plan of care.
C. The therapy must be performed by a
qualified physical therapist or by a qualified physical therapist assistant
under the supervision of a qualified physical therapist.
212.311
Physical Therapy as the Sole
Home Health Service
When the PCP or authorized attending physician prescribes
medically necessary home health physical therapy and no other home health
service, the following guidelines apply.
A. The physical therapy treatment plan serves
as the home health plan of care.
B.
The qualified physical therapist (but not a qualified physical therapist
assistant) may make the required initial and subsequent patient assessments and
perform the duties that would otherwise be those of the registered
nurse.
C. The PCP or authorized
attending physician must authorize the treatment plan before physical therapy
may begin. See section
216.500 for conditions under
which services may begin upon the physician's oral authorization.
D. The PCP or authorized attending physician
must review the treatment plan at the intervals required for home health plans
of care.
E. A comprehensive
physical examination, with a complete history or history update, by the PCP or
authorized attending physician is required within the twelve months preceding
the start date of a new, renewed or revised physical therapy treatment
plan.
212.330
Qualified Physical Therapist Direction of Unlicensed Physical Therapy
Students
Physical therapy services carried out by an unlicensed therapy
student may be covered only when the following requirements are met.
A. Physical therapy carried out by an
unlicensed student must be under the direction of a qualified physical
therapist, and the direction must be such that the qualified therapist is
considered to be providing the physical therapy.
B. To qualify as the performing provider, the
qualified therapist must be present and engaged in observing and supervising
the student during the entire physical therapy encounter.
212.340
Frequency, Intensity and
Duration of Physical Therapy Services for Beneficiaries Under the Age of
21
A. Frequency, intensity and
duration of physical therapy services must be medically necessary and
appropriate to the age of the patient and the severity of the deficit or
disorder.
B. Therapy may be
indicated if there is a reasonable expectation that the intervention will
result in clinically measurable functional gain(s) or will prevent a worsening
of the condition.
212.342
Maintenance Therapy
A. Services that are performed primarily to
maintain range of motion or to provide positioning services for the patient do
not qualify as physical therapy services.
B. Such maintenance services can be provided
to the child as part of a home program administered by the child's caregivers
and do not require the skilled services of a physical therapist in order to be
performed safely and effectively.
212.343
Duration of Services
A. Therapy services should be provided as
long as objectively measured progress is made toward established
goals.
B. If reasonable functional
progress cannot be expected with continued therapy, services should be
discontinued and monitoring or establishment of a caregiver-administered home
program should be implemented.
213.200
Physical Therapy Benefit Limit
Home health physical therapy is limited to one visit per day
for beneficiaries of all ages, but there is no weekly, monthly or annual limit
on the number of prescribed, medically necessary home health physical therapy
visits that a beneficiary aged 21 or older may receive.
A. Home health physical therapy must be
prescribed by the beneficiary's PCP or authorized attending physician and
established on a current home health plan of care.
B. Home health physical therapy for
beneficiaries under the age of 21 is subject to additional
requirements.
231.000
Method of Reimbursement A.
Medicaid reimbursement for home health services is by fee schedule, at the
lesser of the amount billed or the Title XIX (Medicaid) maximum fee.
B. The Arkansas Medicaid Program reimburses
providers for administration of covered injections by fee schedule, at the
lesser of the amount billed or the Title XIX (Medicaid) maximum fee.
C. The Arkansas Medicaid Program reimburses
providers by the visit for nursing services, aide services and physical
therapy.
D. The Arkansas Medicaid
Program reimburses providers by fee schedule, at the lesser of the amount
billed or the Title XIX (Medicaid) maximum fee per covered item, for disposable
medical supplies, diapers and underpads.
242.120
Home Health Physical Therapy
|
Procedure Code
|
Modifier
|
Description
|
|
S9131
|
Home Health Physical Therapy by a Qualified Licensed
Physical Therapist
|
|
S9131
|
UB
|
Home Health Physical Therapy by a Qualified Physical
Therapy Assistant
|
242.130
Specimen Collection
|
Procedure
|
Codes
|
|
36415
|
P9612
|
A. Venipuncture
(drawing blood to obtain a blood sample) and catheterization to collect urine
specimens are excluded from the eligibility criteria for intermittent skilled
nursing services under the home health benefit.
B. When venipuncture to obtain a blood sample
or catheterization to collect a urine specimen is the only skilled service that
is needed by the patient, that individual does not qualify for skilled
services.
