907 KAR 1:360. Preventive and remedial public health services

Link to law: http://www.lrc.ky.gov/kar/907/001/360.htm
Published: 2015

      907 KAR 1:360. Preventive and remedial

public health services.

 

      RELATES TO: KRS 205.520, 205.560, 42

C.F.R. 431.615

      STATUTORY AUTHORITY: KRS 194A.030(2),

194A.050(1), 205.520(3), 42 U.S.C. 1396a, b, c, d

      NECESSITY, FUNCTION, AND CONFORMITY: The

Cabinet for Health Services, Department for Medicaid Services, has

responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes

the cabinet, by administrative regulation, to comply with any requirement that

may be imposed or opportunity presented by federal law for the provision of

medical assistance to Kentucky's indigent citizenry. This administrative

regulation establishes the provisions relating to preventive and remedial

public health services provided through the Department for Public Health and

the method of reimbursement for these services by the Kentucky Medicaid Program.

 

      Section 1. Definitions. (1) "Add-on

code" means a designated CPT code which may be used in conjunction with

another CPT code to denote that an adjunctive service has been performed.

      (2) "CPT code" means a code

used for reporting procedures and services performed by physicians or other

licensed medical professionals which is published annually by the American

Medical Association in Current Procedural Terminology.

      (3) "Department" means the

Department for Medicaid Services or its designated agent.

      (4) "Incidental" means that a

medical procedure:

      (a) Is performed at the same time as a

more complex primary procedure; and

      (b)1. Requires few additional physician resources;

or

      2. Is clinically integral to the

performance of the primary procedure.

      (5) "Integral" means that a

medical procedure represents a component of a more complex procedure performed

at the same time.

      (6) "KenPAC" means the Kentucky

Patient Access and Care System.

      (7) "KenPAC PCP" means a

Medicaid provider who is enrolled as a primary care provider in the Kentucky

Patient Access and Care System.

      (8) "Medically necessary" or

"Medical necessity" means a covered benefit is determined to be

needed in accordance with 907 KAR 3:130.

      (9) "Mutually exclusive" means

that two (2) procedures:

      (a) Are not reasonably performed in

conjunction with one (1) another during the same patient encounter on the same

date of service;

      (b) Represent two (2) methods of performing

the same procedure;

      (c) Represent medically impossible or

improbable use of CPT codes; or

      (d) Are described in current procedural

terminology as inappropriate coding of procedure combinations.

      (10) "Relative value unit" or

"RVU" means the Medicare-established value assigned to a CPT code

which takes into consideration the physician's work, practice expense, and

liability insurance.

      (11) "Screening" means the

evaluation of a recipient by a physician to determine:

      (a) The presence of a disease or medical

condition; and

      (b) The necessity of further evaluation,

diagnostic tests or treatment.

 

      Section 2. Participation Requirements.

(1) The Department for Public Health shall comply with the terms and conditions

established in the following administrative regulations:

      (a) 907 KAR 1:005, Nonduplication of

payments;

      (b) 907 KAR 1:671, Conditions of Medicaid

provider participation; withholding overpayments, administrative appeal

process, and sanctions; and

      (c) 907 KAR 1:672, Provider enrollment,

disclosure, and documentation for Medicaid participation.

      (2) The Department for Public Health

shall comply with the requirements regarding the confidentiality of personal

medical records as mandated by 42 U.S.C. 1320d to 1320d-8 and 45 C.F.R. Parts

160 and 164.

 

      Section 3. Covered Services. The

following medically-necessary preventive, screening, diagnostic, rehabilitative

and remedial services provided by the Department for Public Health directly or

indirectly through its subcontractors shall be covered:

      (1) A chronic disease service;

      (2) A communicable disease service;

      (3) An early and periodic screening,

diagnosis, and treatment (EPSDT) service;

      (4) A family planning service;

      (5) A maternity service; or

      (6) A pediatric service.

 

      Section 4. Service Limitations. (1) A

laboratory procedure shall be limited to a procedure for which the provider has

been certified in accordance with 42 C.F.R. Part 493.

      (2) A service allowed in accordance with

42 C.F.R. 441, Subpart E or Subpart F shall be covered within the scope and

limitations of these federal regulations.

      (3) Coverage for a fetal diagnostic

ultrasound procedure shall be limited to two (2) per nine (9) month period per

recipient unless the diagnosis code justifies the medical necessity of an

additional procedure.

      (4) Except for a service specified in 907

KAR 1:320, Section 10(3)(a) through (q), a referral from the KenPAC PCP shall

be required for a recipient enrolled in the KenPAC Program.

 

      Section 5. Reimbursement. (1) Payment for

a preventive health service specified in Section 3(1) through (6) of this

administrative regulation shall be calculated by multiplying the current

Medicare conversion factor for Kentucky by the nonfacility relative value unit

weight for the procedure code.

      (2) For a service covered under Medicare

Part B, reimbursement shall be in accordance with 907 KAR 1:006.

      (3) If a copayment is required in

accordance with 907 KAR 1:604, reimbursement shall be reduced by the amount of

the copayment.

      (4) If performed concurrently, separate

reimbursement shall not be made for a procedure that has been determined by the

department to be incidental, integral, or mutually exclusive to another procedure.

      (5) Except for an applicable add-on code,

reimbursement for an anesthesia service shall be limited to one (1) CPT code

and one (1) unit of anesthesia per operative session.

      (6) Reimbursement for a surgical

procedure shall include the following:

      (a) A preoperative service;

      (b) An intraoperative service;

      (c) A postoperative service and follow-up

care:

      1. Within ninety (90) days following the

date of major surgery; or

      2. Within ten (10) days following the

date of minor surgery; and

      (d) A preoperative consultation performed

within two (2) days of the date of the surgery.

 

      Section 6. Audits. (1) The Department for

Public Health or subcontracting local health departments shall provide to the

Department for Medicaid Services or a representative of an agency or office

listed in subsection (2) of this section, upon request:

      (a) Information maintained by the

provider to document the service provided;

      (b) Information regarding a payment

claimed by the provider for furnishing a service; or

      (c) Information documenting the cost of

the service.

      (2) Access to provider or subcontractor

records relating to a service provided shall be required for:

      (a) A representative of the United States

Department of Health and Human Services;

      (b) The United States Centers for

Medicare and Medicaid Services;

      (c) The United States Attorney General’s

Office;

      (d) The state Attorney General’s Office;

      (e) The state Auditor’s office;

      (f) The Office of the Inspector General;

or

      (g) An agent or representative as may be

designated by the Secretary of the Cabinet for Health Services.

 

      Section 7. Appeal Rights. (1) An appeal

of a department decision regarding a Medicaid provider based upon an

application of this administrative regulation shall be in accordance with 907

KAR 1:671.

      (2) An appeal of a department decision

regarding a Medicaid recipient based upon an application of this administrative

regulation shall be in accordance with 907 KAR 1:563.

      (3) An appeal of a department decision

regarding Medicaid eligibility of an individual shall be in accordance with 907

KAR 1:560. (15 Ky.R. 768; eff. 10-21-88; Am. 25 Ky.R. 1257; 1662; eff. 1-19-99;

28 Ky.R. 961; eff. 12-19-2001; 29 Ky.R. 1140; 1656; eff. 12-18-02; 30 Ky.R.

463; 887; eff. 10-31-03; 31 Ky.R. 2052; 32 Ky.R. 272; eff. 8-25-05.)
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