Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 18 - PHYSICIANS' SERVICES
Section 471-18-007 - BILLING FOR PHYSICIAN SERVICES

Universal Citation: 471 NE Admin Rules and Regs ch 18 ยง 007

Current through September 17, 2024

007.01 GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event individual billing requirements in 471 NAC 3 conflict with billing requirements outlined in this chapter, the individual billing requirements in this chapter will govern.

007.02 SPECIFIC BILLING REQUIREMENTS. Physicians' services must be billed on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837). Physicians' services must not be billed by a hospital. The physician or the physician's authorized agent must approve and date each paper claim. Approval of paper claims is indicated by the handwritten signature, signature stamp, or computer-generated signature of the physician or authorized agent. When a computer-encoded document or electronic transaction is used, the Department may request the provider's source input documentation from the provider for input verification and signature requirements. The physician or the physician's authorized agent must enter the physician's usual and customary charge for each procedure code on the claim.

007.02(A) PROCEDURE CODES. Physicians must use Healthcare Common Procedure Coding System (HCPCS) procedure codes when submitting claims to the Department for Medicaid services. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes used by the Department are listed in the Nebraska Medicaid Practitioner Fee Schedule.

007.02(B) PORTABLE X-RAY SERVICES. Claims for portable x-ray services must contain the name of the physician who ordered the service and a diagnosis of medical necessity.

007.02(C) SECOND SURGICAL OPINION. The second physician must bill Nebraska Medicaid with a Healthcare Common Procedure Coding System (HCPCS) consultation procedure code indicating the level of the consultation and identifying the service as a second surgical opinion.

007.02(D) PRENATAL, DELIVERY AND POSTPARTUM CARE. When billing Nebraska Medicaid for prenatal, delivery, and postpartum care, the provider must submit a claim at the time of delivery. When the primary physician does not participate in the total obstetrical care, the partial care may be billed separately from the delivery using the appropriate procedure codes. An explanation for the partial care must be submitted. Providers must use one procedure code but must provide individual dates of service on the claim. One charge is submitted covering all:
(i) Routine prenatal care, vaginal delivery, and postpartum care; or

(ii) Routine prenatal care, cesarean delivery, and postpartum care.

007.02(E) FRACTURE CARE. Providers may claim subsequent replacement of cast or traction devices used during or after the period of follow-up care as an independent service using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code.

007.02(F) PRACTITIONER ADMINISTERED MEDICATIONS. When billing for medications administered during the course of a clinic visit, the physician must use the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code for the medication, the correct number of units per the Healthcare Common Procedure Coding System (HCPCS) description, the National Drug Code (NDC) of the drug administered, the National Drug Code (NDC) unit of measure and the National Drug Code (NDC) number of units. A Current Procedural Terminology (CPT) code for the administration must also be submitted. When billing for medication which does not have a specific Level I or II code, the physician must use a miscellaneous Healthcare Common Procedure Coding System (HCPCS) code with the name and National Drug Code (NDC) number identifying the drug and include the dosage given. If this information is not with the claim, the Department may return the claim to the physician for completion or pay the claim at the lowest dosage manufactured for the specific drug.
007.02(F)(i) CHEMOTHERAPY. Providers must bill for chemotherapy using Healthcare Common Procedure Coding System (HCPCS) procedure codes for chemotherapy administration. The drug used must be identified and claimed separately on the claim using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code, the number of units per the Healthcare Common Procedure Coding System (HCPCS) description, the National Drug Code (NDC) of the drug administered, the National Drug Code (NDC) unit of measure, and the number of National Drug Code (NDC) units. For drugs which do not have a specific Healthcare Common Procedure Coding System (HCPCS) code, the provider must use a miscellaneous chemotherapy code. The provider must indicate on or in the claim the name of medication, the dosage administered, and the National Drug Code (NDC) number, unit of measure, and number of units.

007.02(F)(ii) IMMUNIZATIONS. When using Vaccine for Children (VFC) vaccines, only the administration is billed to Nebraska Medicaid by adding the appropriate modifier to the vaccine code. The billed charge for the administration must not exceed the Vaccine for Children (VFC) federally determined state maximum for Nebraska.

007.02(G) PHYSICIAN'S OFFICE LABORATORY. If the services are provided in a physician's or group of physician's private office, payment may be claimed for the medically necessary services provided or supervised by the physician, using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code.

007.02(H) LICENSED AND CERTIFIED INDEPENDENT CLINICAL LABORATORY. The physician must indicate on or with the appropriate claim form or electronic format the fee for obtaining the specimen by venipuncture or catheterization is for tests performed outside his or her office and submit the name of the facility performing the tests on the claim.

007.02(I) BILLING FOR THE PROFESSIONAL AND TECHNICAL COMPONENTS OF HOSPITAL INPATIENT AND OUTPATIENT DIAGNOSTIC AND THERAPEUTIC SERVICES. The professional component of hospital diagnostic and therapeutic services must be billed as previously described except for facilities paid under an all-inclusive rate. The technical component of hospital diagnostic and therapeutic services must be billed by the hospital. A hospital may act as the billing agent for the physician's professional component. The Department requires a separate Medicaid provider number for each specialty for the hospital professional component. A separate provider agreement is required for each separate provider number. The professional component must be billed on the claim, using the appropriate provider number for the professional component of the appropriate specialty. Only one specialty, one provider number, may be billed on each claim.

007.02(J) ANESTHESIOLOGY. The professional component must be claimed and must indicate actual time in one-minute increments. The physician's medical direction of four or fewer concurrent anesthesia procedures is considered a professional component.
007.02(J)(i) STANDBY ANESTHESIA. The professional component must be billed appropriately.

007.02(J)(ii) CLAIMS FOR PAYMENT. When a physician bills for anesthesia services, the physician must certify with the claim, as appropriate, that:
(1) The services were personally provided by the physician to the individual; or

(2) When the physician provided medical direction for certified registered nurse anesthetist (CRNA) services, the number of concurrent services directed is indicated by the appropriate modifier.

007.02(J)(iii) STERILIZATION OR HYSTERECTOMY. To make payment for anesthesia services for sterilizations, a completed copy of Form MMS-100: Sterilization Consent Form must be on file with the Department. For a hysterectomy, a completed copy of Form MMS-101: Informed Consent for Hysterectomy, signed and dated by the individual stating she was made aware before the surgery that the surgery would result in sterility, must be on file with the Department before payment can be made. Claims for these services must indicate actual time in one-minute increments.

007.02(J)(iv) CLAIMS FOR CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA) SERVICES. Claims for certified registered nurse anesthetist (CRNA) services must be billed accordingly, except rural hospitals which have been exempted by their Medicare fiscal intermediary for certified registered nurse anesthetist (CRNA) billing must follow the Medicare billing requirements. The Department does not make additional reimbursement for emergency and risk factors. When multiple surgical procedures are performed at the same time, the certified registered nurse anesthetist (CRNA) must bill only for the major procedure. Medicaid does not make payment for certified registered nurse anesthetist (CRNA) services for secondary procedures.

007.02(K) LABORATORY AND PATHOLOGY.
007.02(K)(i) INPATIENT HOSPITAL ANATOMICAL PATHOLOGY SERVICES. Payment for the technical component of anatomical pathology is included in the hospital's payment in accordance with 471 NAC 10. The pathologist must claim the professional component of anatomical pathology using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code and modifier. Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule.
007.02(K)(ii)(1) EXCEPTION. If an anatomical pathology specimen is obtained from a hospital inpatient but is referred to an independent laboratory or the pathologist of a second hospital's laboratory, the independent laboratory, or the pathologist of the second hospital's laboratory to which the specimen has been referred may claim payment for the total service. Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule.

007.02(K)(ii) OUTPATIENT HOSPITAL ANATOMICAL PATHOLOGY SERVICES. The hospital must claim the technical component according to 471 NAC 10. The pathologist must claim the professional component. Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule.
007.02(K)(ii)(1) EXCEPTION. If an anatomical pathology specimen is obtained from a hospital outpatient and is referred to an independent laboratory or the pathologist of a second hospital's laboratory, the independent laboratory, or the pathologist of a second hospital's laboratory to which the specimen was referred may claim payment for the total service. Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule.

007.02(K)(iii) NON-PATIENT ANATOMICAL PATHOLOGY SERVICES. A non-patient is an individual receiving services who is neither an inpatient nor an outpatient. For specimens from non-patients referred to the hospital, the hospital must bill the total service. Payment is made according to 471 NAC 10.

007.02(K)(iv) LEASED DEPARTMENTS. If the pathology department is leased and an anatomical pathology service is provided to a hospital non-patient, the pathologist must claim the total service. Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule. Leased department status has no bearing on billing for or payment of inpatient or outpatient anatomical pathology services.

007.02(K)(v) CLINICAL LABORATORY SERVICES. The professional and technical components of clinical laboratory services are not separately identified for billing and payment.

007.02(K)(vi) PHYSICIAN'S OFFICE OR INDEPENDENT LABORATORY. Clinical laboratory services performed in a physician's office or independent laboratory must be billed appropriately.
007.02(K)(vi)(1) CLINICAL LABORATORY CONSULTATION. The physician must claim a clinical laboratory consultation using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure codes.

007.02(L) RADIOLOGY. The professional component must be billed appropriately.
007.02(L)(i) INPATIENT RADIOLOGY SERVICES. Payment for the technical component of inpatient radiology services is included in the hospital's payment in accordance with 471 NAC 10. Physicians must bill the professional component of inpatient radiology services appropriately. Payment for the professional component is made according to the Nebraska Medicaid Practitioner Fee Schedule.

007.02(L)(ii) OUTPATIENT RADIOLOGY SERVICES. The hospital must claim the technical component of outpatient radiology services on the appropriate claim form or electronic format. Payment is made according to 471 NAC 10. The physician must bill the professional component using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code with the modifier. Payment for the professional component is made according to the Nebraska Medicaid Practitioner Fee Schedule.

007.02(L)(iii) NON-PATIENT RADIOLOGY SERVICES. A non-patient is an individual receiving services who is neither an inpatient nor an outpatient. If a radiology procedure is performed for a non-patient, the hospital must claim the technical component. Payment is made according to 471 NAC 10. If the radiology department is leased and the service is provided to a non-patient, the radiologist must claim the total service. Payment is made is made according to the Nebraska Medicaid Practitioner Fee Schedule.

007.02(M) SERVICES PROVIDED BY PHYSICIAN ASSISTANTS. Claims for services provided by physician assistants must be submitted on Form CMS-1500: Health Insurance Claim or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837) under the physician assistant's provider group number.

007.02(N) PHYSICIAN SERVICES IN SKILLED NURSING FACILITY (SNF), INTERMEDIATE CARE FACILITY (ICF), AND INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). The physician may bill the Department for an annual nursing home physical exam service, regardless of the extent of the exam. Additionally, the physician may bill the Department for the certification service. Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule.
007.02(N)(i) ANNUAL PHYSICAL EXAMINATION. If the annual physical examination is performed solely to meet the requirement of the Department, the physician must submit the claim to the Department on Form CMS-1500: Health Insurance Claim or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837). The Department limits reimbursement for this service to the amount allowed under the Nebraska Medicaid Practitioner Fee Schedule.

007.02(N)(ii) MEDICARE COVERAGE. If a physical examination is performed for diagnosis or treatment of a specific symptom, illness, or injury and the individual has Medicare coverage, the physician must submit the claim through the usual Medicare process. This applies to all physicians' visits in a long-term care facility.

007.02(N)(iii) PHYSICIANS' VISITS TO SKILLED NURSING FACILITY (SNF) RESIDENTS. When billing for a physician's visit, the physician must use the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code for a nursing home visit.

007.02(N)(iv) ON-SITE RECERTIFICATION. The physician is paid according to the Nebraska Medicaid Practitioner Fee Schedule. The physician must use the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code for nursing home visits when billing Nebraska Medicaid for this service.

007.02(N)(v) PHYSICIANS' VISITS TO INTERMEDIATE CARE FACILITY (ICF) AND INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) RESIDENTS. When billing for a physician's visit, the physician must use the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code. The physician must submit following statements on or with the claim: "60-day (or alternate schedule) intermediate examination."

007.02(O) TRANSPLANT SERVICES. Physician services must be billed accordingly.
007.02(O)(i) BILLING FOR TRANSPLANT SERVICES PROVIDED TO A MEDICAID-INELLIGIBLE DONOR. Claims for services provided to a Nebraska Medicaid-ineligible donor must be submitted under the Nebraska Medicaid-eligible individual's case number. There must be a notation with the claim indicating these services were provided to the Nebraska Medicaid-ineligible donor on the individual's behalf.

007.02(P) ITINERANT PHYSICIAN VISITS. The hospital room charge must be billed on the appropriate claim form or electronic format. The physician's service must be coded as an office visit and billed on the appropriate claim form or electronic format.

007.02(Q) NURSE MIDWIFE OR NURSE PRACTITIONER SERVICES. Claims for nurse midwife services and nurse practitioner services must be submitted on Form CMS-1500: Health Insurance Claim according to instructions or on the appropriate electronic transaction.

007.02(R) FEEDING AND SWALLOWING CLINIC SERVICES. The interdisciplinary team (IDT) services must be billed under the physician's provider number accordingly. Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule. The physician services are billed under appropriate Current Procedural Terminology (CPT) codes.

007.02(S) COMPREHENSIVE INTERDISCIPLINARY TREATMENT FOR A SEVERE FEEDING DISORDER. Claims must be submitted accordingly.

Disclaimer: These regulations may not be the most recent version. Nebraska may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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