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OREGON HEALTH AUTHORITY, DIVISION OF MEDICAL ASSISTANCE PROGRAMS




 

DIVISION 130
MEDICAL-SURGICAL SERVICES 

410-130-0000
Foreword
(1) The Division of Medical
Assistance Programs (Division) Medical-Surgical Services rules are designed to assist
medical-surgical providers to deliver medical services and prepare health claims
for clients with Medical Assistance Program coverage. Providers must follow the
Division rules in effect on the date of service.
(2) The Division enrolls only
the following types of providers as performing providers under the Medical-Surgical
program:
(a) Doctors of medicine, osteopathy
and naturopathy;
(b) Podiatrists;
(c) Acupuncturists;
(d) Licensed Physician assistants;
(e) Nurse practitioners;
(f) Laboratories;
(g) Family planning clinics;
(h) Social workers (for specified
services only);
(i) Licensed Direct entry midwives;
(j) Portable x-ray providers;
(k) Ambulatory surgical centers;
(l) Chiropractors;
(m) Licensed Dieticians (for
specified service only);
(n) Registered Nurse First Assistants;
(o) Certified Nurse Anesthetists;
(p) Clinical Pharmacists;
(q) Birthing Centers.
(3) For clients enrolled in
a managed care plan, contact the client's plan for coverage and billing information.
(4) The Medical-Surgical Services
rules contain information on policy, special programs, prior authorization, and
criteria for some procedures. All DMAP rules are intended to be used in conjunction
with the General Rules for Oregon Medical Assistance Programs (OAR 410 division
120) and the Oregon Health Plan (OHP) Administrative Rules (OAR 410 division 141).
(5) The Health Services Commission's
Prioritized List of Health Services is found on their website at: www.oregon.gov/oha/herc/Pages/PrioritizedList.aspx.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: PWC 868, f. 12-30-77,
ef. 2-1-78; AFS 36-1981, f. 6-29-81, ef. 7-1-81; AFS 27-1982, f. 4-22-82 & AFS
51-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas
covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn,
McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS Branch
offices; AFS 50-1986, f. 6-30-86, ef. 8-1-86; AFS 5-1989(Temp), f. 2-9-89, cert.
ef. 3-1-89; AFS 48-1989, f. & cert. ef. 8-24-89, Renumbered from 461-014-0001;
HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0500; HR 6-1994,
f. & cert. ef. 2-1-94; HR 23-1997, f. & cert. ef. 10-1-97; OMAP 31-2000,
f. 9-29-00, cert. ef. 10-1-00; OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP
13-2004, f. 3-11-04, cert. ef. 4-1-04; DMAP 19-2008, f. 6-13-08, cert. ef. 7-1-08;
DMAP 43-2011, f. 12-21-11, cert. ef. 1-1-12
410-130-0005
Federally
Qualified Primary Care Provider
(1) Section 1202 of the Affordable Care
Act (ACA) amended sections 1902(a)(13), 1902(jj), 1905(dd) and 1932(f) of the Social
Security Act to require increased Medicaid payment for primary care services to
qualified providers for calendar years 2013 and 2014 as specified in these rules.
(2) Federally Qualified Primary
Care Services are designated as:
(a) Evaluation and Management
(E&M) Current Procedural Terminology (CPT) codes 99201 through 99499; and
(b) Vaccine administration
CPT codes 90460, 90461, 90471, 90472, 90473 and 90474, or their successor codes;
and
(c) Administration of vaccines
under Vaccines for Children Program (refer to OAR 410-130-0255).
(3) To qualify for the increased
payment, the individual physician must attest that:
(a) The physician has a primary
practice in family medicine, general internal medicine, or pediatric medicine; and
(b) One or both of the following
are true:
(A) The physician is Board-certified
in a specialty or subspecialty of family medicine, general internal medicine, or
pediatric medicine by one of the following boards:
(i) The American Board of
Medical Specialties (ABMS);
(ii) The American Osteopathic
Association (AOA);
(iii) The American Board
of Physician Specialties (ABPS);
(B) The physician can demonstrate
that at least 60 percent of the procedure codes billed and paid in Medicaid claims
were qualifying primary care codes described in section 2 of this rule.
(i) Over the previous calendar
year, if billings exist for this time period; or
(ii) Over the previous month,
if billings do not exist for the previous calendar year.
(4) To qualify for the increased
payment, a Physician Assistant (PA) or Nurse Practitioner (NP) must attest that
they work under the direct supervision of a Physician who:
(a) Qualifies for increased
primary care payments as described in these rules; and
(b) Assumes professional
responsibility for the services rendered by the PA or NP.
(5) Providers seeking the
reimbursement increase from the Division of Medical Assistance Programs (Division)
must self-attest with the Division. Providers, not enrolled with the Division, seeking
the increase from OHP health plans (MCO or CCO), must self-attest with the applicable
MCO or CCO.
(6) Reimbursement: Effective
for dates of service on or after January 1, 2013, the Division shall reimburse primary
care providers as follows:
(a) Federally qualified
primary care providers as described in this rule at the rate specified in OAR 410-120-1340(6)(C)(ii);
or
(b) Other primary care providers,
including potentially qualified providers who do not self-attest to the Division
as described in part (3) of this rule, at the rate specified in OAR 410-120-1340(6)(C)(iii).
(7) Annual review of qualifying
providers: The Division will review a statistically valid sample of providers to
determine whether they satisfy the criteria described in (3) and (4) of these rules.
Providers reviewed who do not satisfy the criteria will be required to reimburse
the Division for the difference between the rate they should have received according
to OAR 410-120-1340(6)(C)(iii) and enhanced rate in OAR 410-120-1340(6)(C)(ii).
The sample will include the following providers:
(a) Physicians who have self-attested
to qualifying for the increased rate; and
(b) Providers who have self-attested
that they are under the direct supervision of a qualified physician.
(8) Supplemental information
on primary care reimbursement under the Affordable Care Act is available at http://www.oregon.gov/OHA/healthplan/pages/pcp-rates.aspx.
Stat Auth.: ORS 413.042
Stats Implemented: 414.025
& 414.065
Hist.: DMAP 14-2013(Temp),
f. & cert. ef. 3-29-13 thru 9-25-13; DMAP 49-2013, f. & cert. ef. 9-25-13
410-130-0015
Doula Services
(1) The primary purpose of providing
concurrent doula services with the services of a licensed obstetrical practitioner
is to optimize birth outcomes, including reduced Caesarian sections, epidural use,
reduced assisted vaginal deliveries, and reduce the number of neonatal care unit
admissions. These face-to-face services are provided only during the labor and delivery
phase of the client’s pregnancy. The following are expected to benefit most
from doula services:
(a) A woman with a racially
or ethnically diverse background including, Black/African American, Asian, Pacific
Islander, Native American, Latino or multiracial;
(b) A homeless woman;
(c) A woman who speaks limited
to no English;
(d) A woman who has limited
to no family or partner support; or
(e) A woman who is under
the age of 21;
(2) Doula services may be
provided only at the request of the licensed obstetrical practitioner. The doula
and licensed obstetrical practitioner must work concurrently. The licensed obstetrical
practitioner must be a physician or advance practice nurse.
(3) Doulas must be certified
and registered with the Authority pursuant to OAR 410-180-0325 through 0327. Certification
must be effective at the time doula services are provided. Doulas must provide proof
of certification to the practitioner.
(4) Doula services are covered
for any woman whose benefit package covers labor and delivery.
(5) The provision of doula
services during labor and delivery must be documented in the client’s medical
record by the licensed obstetrical practitioner.
(6) Payment for doula’s
services
(a) The licensed obstetrical
practitioner may be eligible for an additional payment, as remuneration for the
attending doula providing the doula services;
(b) Doulas may not receive
direct payment from the Division;
(c) To be considered for
the additional payment, the professional claim for the delivery services must include
the unique Medicaid modifier of U9 appended to the appropriate obstetrical code
billed at the time of delivery;
(d) This modifier may only
be billed once per pregnancy. Multiples (i.e., twins, triplets) are not eligible
for additional payment for the doula’s services;
(e) Only one additional payment
shall be made for doula services regardless of the number of doulas providing the
services;
(f) Only providers with a
provider type designation of 34 or 42 may bill the U9 modifier.
(7) Doula services at the
time of delivery are the only services eligible for payment under this rule. Services
provided during the prenatal and postnatal period are governed by OAR 410-130-0595
(Maternity Case Management).
Stat. Authority: ORS 413.042 and 414.065
Stat. Implemented: ORS 414.065
Hist.: DMAP 73-2013, f. 12-31-13,
cert. ef. 1-1-14
410-130-0160
Codes
(1) ICD-10-CM Diagnosis Codes:
(a) Always use the principal
diagnosis code in the first position to the highest degree of specificity. List
additional diagnosis codes if the claim includes charges for services that relate
to the additional diagnoses. However, it is not necessary to include more than one
diagnosis code per procedure code;
(b) Diagnosis codes are required
on all billings including those from independent laboratories and portable radiology
including nuclear medicine and diagnostic ultrasound providers;
(c) Always supply the ICD-10-CM
diagnosis code to ancillary service providers when prescribing services, equipment,
and supplies.
(2) CPT and HCPCS Codes:
(a) Use only codes from the
current year for Current Procedural Terminology (CPT) and Healthcare Common Procedure
Coding System (HCPCS) codes;
(b) Effective January 1,
2005, HIPAA regulations prohibit the use of a grace period for codes deleted from
CPT or HCPCS. In the past the grace period was from January 1 through March 31;
(c) The division may consider
reimbursement for CPT category III codes included under the following headings:
Adaptive Behavior Assessments, Adaptive Behavior Treatment, and Exposure Adaptive
Behavior Treatment With Protocol Modification. All CPT category II (codes with fifth
character of “F”) and all other category III codes (codes with fifth
character “T”) are not Division of Medical Assistance Programs’
(Division) covered services;
(d) Use the most applicable
CPT or HCPCS code. Do not fragment coding when services can be included in a single
code (see the “Bundled Services” section of this rule). Do not use both
CPT and HCPCS codes for the same procedure. This is considered duplicate billing.
(3) The Medical-Surgical
Service rules list the HCPCS/CPT codes that require authorization or have limitations.
The Health Evidence Review Commission’s Prioritized List of Health Services
(rule 410-141-0520) determines covered services.
(4) For determining the appropriate
level of service code for Evaluation and Management services, read the definitions
in the CPT and HCPCS codebook. Use the definitions to verify level of service, especially
for office visits. Unless otherwise specified in the Medical-Surgical provider rule,
use the guidelines from CPT and HCPCS.
(5) Bundled Services: Reimbursements
for some services are “bundled” into the payment for another service.
The Division does not make separate payment for bundled services and clients may
not be billed for bundled services. The Division’s Not Covered/Bundled Services
rule, OAR 410-130-0220, provides more information regarding bundled services.
[Publications: Publications referenced
are available from the agency.]
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025
& 414.065
Hist.: AFS 5-1989(Temp),
f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. & cert. ef. 8-24-89; HR 10-1990,
f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0610; HR 19-1991, f. 4-12-91,
cert. ef. 5-1-91; HR 2-1992, f. & cert. ef. 1-2-92; HR 8-1992, f, 2-28-92, cert.
ef. 3-1-92; HR 23-1992, f. 7-31-92, cert. ef. 8-1-92; HR 40-1992, f. 12-31-92, cert.
ef. 2-1-93; HR 6-1994, f. & cert. ef. 2-1-94; HR 42-1994, f. 12-30-94, cert.
ef. 1-1-95; HR 10-1996, f. 5-31-96, cert. ef. 6-1-96; HR 4-1997, f. 1-31-97, cert.
ef. 2-1-97; OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98; OMAP 17-1999, f. & cert.
ef. 4-1-99; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 2-2002, f. 2-15-02,
cert. ef. 4-1-02; OMAP 23-2003, f. 3-26-03 cert. ef. 4-1-03; OMAP 69-2003 f. 9-12-03,
cert. ef. 10-1-03; OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04; OMAP 8-2005, f.
3-9-05, cert. ef. 4-1-05; DMAP 74-2014(Temp), f. 12-9-14, cert. ef. 1-1-15 thru
6-29-15; DMAP 15-2015, f. 3-27-15, cert. ef. 4-1-15; DMAP 51-2015, f. 9-22-15, cert.
ef. 10-1-15
410-130-0180
Drugs
(1) The Division of Medical Assistance
Programs’ (Division) Medical-Surgical Services Program reimburses practitioners
for drugs only when administered by the practitioner in the office, clinic or home
settings. The Division does not reimburse practitioners for drugs that are self-administered
by the client, except for contraceptives such as birth control pills, spermicides
and patches:
(a) Use an appropriate Current
Procedural Terminology (CPT) therapeutic injection code for administration of injectables;
(b) Use an appropriate Healthcare
Common Procedure Coding System (HCPCS) code for the specific drug. Do not bill for
drugs under code 99070; The Division requires both the NDC number and HCPCS codes
on all claim forms.
(c) When there is no specific
HCPCS code for a drug or biological, use an appropriate unlisted code from the list
below and bill at acquisition cost (purchase price plus postage):
(A) J3490;
(B) J3590;
(C) J7599;
(D) J7699;
(E) J7799;
(F) J8499;
(G) J8999;
(H) J9999;
(I) Include the name of the
drug, National Drug Code (NDC) number and dosage.
(2) Do not bill for local
anesthetics; reimbursement is included in the payment for the tray and/or procedure.
(3) For codes requiring prior
authorization and codes that are Not Covered/Bundled, refer to OAR 410-130-0200
Table 130-0200-1 and OAR 410-130-0220 Table 130-0220-1.
(4) Not covered services
and supplies include:
(a) Laetrile;
(b) Home pregnancy kits and
products designed to promote fertility;
(c) Dimethyl sulfoxide (DMSO),
except for instillation into the urinary bladder for symptomatic relief of interstitial
cystitis;
(d) Infertility drugs;
(e) Sodium hyaluronate and
Synvisc.
(5) Follow criteria outlined
in the following:
(a) Billing Requirements
— OAR 410-121-0150;
(b) Brand Name Pharmaceuticals
— OAR 410-121-0155;
(c) Prior Authorization Procedures
— OAR 410-121-0060;
(d) Drugs and Products Requiring
Prior Authorization — OAR 410-121-0040;
(e) Drug Use Review —
OAR 410-121-0100;
(f) Participation in Medicaid’s
Drug Rebate Program — OAR 410-121-0157.
(A) The Division cannot reimburse
providers for a drug unless the drug manufacturer has signed an agreement with the
Centers for Medicare and Medicaid Services (CMS) to participate in the Medicaid
Drug Rebate Program.
(B) To verify that a drug
manufacturer participates in the Medicaid Drug Rebate Program, visit the CMS website
below to verify that the first five digits of the NDC number (labeler code) are
listed as a participating drug company: http://www.cms.hhs.gov/MedicaidDrugRebateProgram/10_DrugComContactInfo.asp
(6) Clozaril/Clozapine therapy:
(a) Clozapine is covered
only for the treatment of clients who have failed therapy with at least two anti-psychotic
medications;
(b) Clozapine supervision
is the management and record keeping of clozapine dispensing as required by the
manufacturer of clozapine. This is part of an evaluation and management service
conducted by the appropriately licensed prescribing medical practitioner;
(c) Pharmacies dispensing
clozapine shall comply with OAR 410-121-0190.
[ED. NOTE: Tables referenced are available
from the agency.]
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025
& 414.065
Hist.: AFS 5-1989(Temp),
f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. & cert. ef. 8-24-89; HR 10-1990,
f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0620; HR 19-1991, f. 4-12-91,
cert. ef. 5-1-91; HR 43-1991, f. & cert. ef. 10-1-91; HR 6-1994, f. & cert.
ef. 2-1-94; HR 42-1994, f. 12-30-94, cert. ef. 1-1-95; HR 10-1996, f. 5-31-96, cert.
ef. 6-1-96; HR 4-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 3-1998, f. 1-30-98, cert.
ef. 2-1-98; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 13-2001, f. 3-30-01,
cert. ef. 4-1-01; OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 2-2002, f. 2-15-02,
cert. ef. 4-1-02; OMAP 33-2002, f. & cert. ef. 8-1-02; OMAP 39-2002, f. 9-13-02,
cert. ef. 9-15-02; OMAP 52-2002, f. & cert. ef. 10-1-02; OMAP 23-2003, f. 3-26-03
cert. ef. 4-1-03; OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03; OMAP 13-2004, f. 3-11-04,
cert. ef. 4-1-04; OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05; OMAP 26-2006, f. 6-14-06,
cert. ef. 7-1-06; DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07; DMAP 20-2008, f. 6-13-08,
cert. ef. 7-1-08; DMAP 34-2008, f. 11-26-08, cert. ef. 12-1-08; DMAP 18-2009, f.
6-12-09, cert. ef. 7-1-09; DMAP 58-2012(Temp), f. 12-27-12, cert. ef. 12-28-12 thru
6-25-13; DMAP 27-2013, f. & cert. ef. 6-25-13
410-130-0190
Tobacco Cessation
(1) Tobacco treatment interventions
may include one or more of these services: basic, intensive, and telephone calls.
(2) Basic tobacco cessation
treatment includes the following services:
(a) Ask — systematically
identify all tobacco users — usually done at each visit;
(b) Advise — strongly
urge all tobacco users to quit using;
(c) Assess — the tobacco
user’s willingness to attempt to quit using tobacco within 30 days;
(d) Assist — with brief
behavioral counseling, treatment materials and the recommendation/prescription of
tobacco cessation therapy products (e.g., nicotine patches, oral medications intended
for tobacco cessation treatment and gum);
(e) Arrange — follow-up
support and/or referral to more intensive treatments, if needed.
(3) When providing basic
treatment, include a brief discussion to address client concerns and provide the
support, encouragement, and counseling needed to assist with tobacco cessation efforts.
These brief interventions, less than 6 minutes, generally are provided during a
visit for other conditions, and additional billing is not appropriate.
(4) Intensive tobacco cessation
treatment is on the Health Services Commission's Prioritized List of Health Services
and is covered if a documented quit date has been established. This treatment is
limited to ten sessions every three months. Treatment is reserved for those clients
who are not able to quit using tobacco with the basic intervention measures.
(5) Intensive tobacco cessation
treatment includes the following services:
(a) Multiple treatment encounters
(up to ten in a 3 month period);
(b) Behavioral and tobacco
cessation therapy products (e.g., nicotine patches, oral medications intended for
tobacco cessation treatment and gum);
(c) Individual or group counseling,
six minutes or greater.
(6) Telephone calls: the
Division may reimburse a telephone call intended as a replacement for face-to-face
contact with clients who are in intensive treatment as it is considered a reasonable
adjunct to, or replacement for, scheduled counseling sessions:
(a) The call must last six
to ten minutes and provides support and follow-up counseling;
(b) The call must be conducted
by the provider or other trained staff under the direction or supervision of the
provider;
(c) Enter proper documentation
of the service in the client's chart.
(7) Diagnosis Code ICD-10-CM
(F17.200-F17.299; Nicotine Dependence):
(a) Use as the principal
diagnosis code when the client is enrolled in a tobacco cessation program or if
the primary purpose of the visit is for tobacco cessation services;
(b) Use as a secondary diagnosis
code when the primary purpose of this visit is not for tobacco cessation or when
the tobacco use is confirmed during the visit.
(8) Billing Information:
Coordinated care organizations and managed care plans may have tobacco cessation
services and programs. This rule does not limit or prescribe services a Prepaid
Health Plan provides to clients receiving OHP benefits.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025
& 414.065
Hist.: HR 36-1992, f. &
cert. ef. 12-1-92; OMAP 15-1998, f. & cert. ef. 5-1-98; OMAP 17-1999, f. &
cert. ef. 4-1-99; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 13-2001, f.
3-30-01, cert. ef. 4-1-01; OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 69-2003
f. 9-12-03, cert. ef. 10-1-03; OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP
20-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
410-130-0200
Prior Authorization
(1) For fee-for-service (FFS) clients,
prior authorization (PA) is required for all procedure codes listed in Table 130-0200-1
regardless of the setting in which they are performed. For details on where to obtain
PA, download a copy of the Medical-Surgical Services Supplemental Information booklet
at: http://www.oregon.gov/oha/healthplan/Pages/medical-surgical.aspx.
(2) For clients enrolled
in a prepaid health plan (PHP), providers must obtain PA from the client’s
PHP.
(3) The Division shall authorize
for the level of care or type of service that meets the client’s medical need
consistent with the Health Evidence Review Commission’s (HERC) Prioritized
List of Health Services (Prioritized List) and guideline notes, as referenced in
OAR 410-141-0520.
(4) Codes for which medical
need has not been specified by the HERC shall be authorized based on medical appropriateness
as the term is defined in OAR 410-120-0000.
(5) For bariatric surgery,
PA is required in two steps from:
(a) The OHP primary care
provider prior to referral to a bariatric surgery center, and
(b) The bariatric surgery
center prior to surgery.
(6) PA is not required:
(a) For clients with both
Medicare and Medical Assistance Program coverage, and the service is covered by
Medicare. However, PA is still required for bariatric surgeries and evaluations
and most transplants, even if they are covered by Medicare;
(b) For kidney and cornea
transplants unless they are performed out-of-state;
(c) For emergent or urgent
procedures or services;
(d) For hospital admissions
unless the procedure requires PA.
(7) A second opinion may
be requested by the Division or the contractor before PA is given for a surgery.
(8) Treating and performing
practitioners are responsible for obtaining PA.
(9) Refer to Table 130-0200-1
for all services and procedures requiring PA.
(10) Table 130-0200-1.
[ED. NOTE: Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025
& 414.065
Hist.: AFS 868, f. 12-30-77,
ef. 2-1-78; AFS 65-1980, f. 9-23-80, ef. 10-1-80; AFS 27-1982, f. 4-22-82 &
AFS 51-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas
covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn,
McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch
offices; AFS 23-1986, f. 3-19-86, ef. 5-1-86; AFS 38-1986, f. 4-29-86, ef. 6-1-86;
AFS 50-1986, f. 6-30-86, ef. 8-1-86; AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89;
AFS 48-1989, f. & cert. ef. 8-24-89, Renumbered from 461-014-0045; HR 10-1990,
f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0630; HR 25-1990(Temp), f.
8-31-90, cert. ef. 9-1-90; HR 44-1990, f. & cert. ef. 11-30-90; HR 17-1991(Temp),
f. 4-12-91, cert. ef. 5-1-91; HR 24-1991, f. & cert. ef. 6-18-91; HR 40-1992,
f. 12-31-92, cert. ef. 2-1-93; HR 6-1994, f. & cert. ef. 2-1-94; HR 42-1994,
f. 12-30-94, cert. ef. 1-1-95; HR 4-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 3-1998,
f. 1-30-98, cert. ef. 2-1-98; OMAP 17-1999, f. & cert. ef. 4-1-99; OMAP 31-2000,
f. 9-29-00, cert. ef. 10-1-00; OMAP 23-2003, f. 3-26-03 cert. ef. 4-1-03; OMAP 69-2003
f. 9-12-03, cert. ef. 10-1-03; OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP
58-2004, f. 9-10-04, cert. ef. 10-1-04; OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05;
OMAP 50-2005, f. 9-30-05, cert. ef. 10-1-05; OMAP 26-2006, f. 6-14-06, cert. ef.
7-1-06; DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07; DMAP 27-2007(Temp), f. &
cert. ef. 12-20-07 thru 5-15-08; DMAP 12-2008, f. 4-29-08, cert. ef. 5-1-08; DMAP
20-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 18-2009, f. 6-12-09, cert. ef. 7-1-09;
DMAP 15-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 34-2010, f. 12-15-10, cert. ef.
1-1-11; DMAP 43-2011, f. 12-21-11, cert. ef. 1-1-12; DMAP 43-2014, f. & cert.
ef. 7-8-14; DMAP 55-2014(Temp), f. 9-26-14, cert. ef. 10-1-14 thru 3-30-15; DMAP
13-2015, f. & cert. ef. 3-10-15
410-130-0220
Not Covered/Bundled Services/Not Valid
(1) Refer to the Oregon Health Plan
administrative rules (chapter 410, division 141) and General Rules (chapter 410,
division 120) for coverage of services. Refer to Table 130-0220-1 in this rule for
additional information regarding not covered services, for services that the Division
of Medical Assistance Programs (Division) considers to be bundled in other services,
and for codes the Division considers not valid for claims processing.
(2) For additional information,
see General Rules OAR 410-120-1200, Medical Assistance Benefits: Excluded Services
and Limitations.
(3) Table 130-0220-1.
[ED. NOTE: Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025
& 414.065
Hist.: AFS 5-1989(Temp),
f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. & cert. ef. 8-24-89; HR 10-1990,
f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0640; HR 14-1991(Temp), f.
& cert. ef. 3-7-91; HR 21-1991, f. 4-16-91, cert. ef. 5-1-91; HR 42-1994, f.
12-30-94, cert. ef. 1-1-95; HR 4-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 3-1998,
f. 1-30-98, cert. ef. 2-1-98; OMAP 16-1998(Temp), f. & cert. ef. 5-1-98 thru
9-1-98; OMAP 30-1998, f. & cert. ef. 9-1-98; OMAP 17-1999, f. & cert. ef.
4-1-99; OMAP 37-1999, f. & cert. ef. 10-1-99; OMAP 31-2000, f. 9-29-00, cert.
ef. 10-1-00; OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 69-2003 f. 9-12-03,
cert. ef. 10-1-03; OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 58-2004, f.
9-10-04, cert. ef. 10-1-04; OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05; OMAP 45-2005,
f. 9-9-05, cert. ef. 10-1-05; OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 5-2007,
f. 6-14-07, cert. ef. 7-1-07; DMAP 20-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 18-2009,
f. 6-12-09, cert. ef. 7-1-09; DMAP 15-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 43-2011,
f. 12-21-11, cert. ef. 1-1-12; DMAP 55-2014(Temp), f. 9-26-14, cert. ef. 10-1-14
thru 3-30-15; DMAP 84-2014(Temp), .f & cert. ef. 12-24-14 thru 3-30-15; DMAP
13-2015, f. & cert. ef. 3-10-15; DMAP 30-2015(Temp), f. & cert. ef. 5-29-15
thru 11-24-15; DMAP 63-2015, f. 10-29-15, cert. ef. 11-1-15
410-130-0225
Teaching Physicians
(1) Supervising faculty physicians in a teaching hospital may not bill the Division of Medical Assistance Programs (Division) on a CMS-1500 or 837P when serving as an employee of the hospital during the time the service was provided or when the hospital reports the service as a direct medical education cost on the Medicare and Division cost report.
(2) For requirements for the provision of services, including documentation requirements, follow Medicare guidelines for Teaching Physician Services.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065

Hist.: HR 40-1992, f. 12-31-92, cert. ef. 2-1-93; HR 6-1994, f. & cert. ef. 2-1-94; OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; Renumbered from 410-130-0370, OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03; OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
410-130-0230
Administrative Medical Examinations and Reports
(1) This rule does not apply to Managed Health Care plans.
(2) These services are covered only when requested by an CAF, APD, AMH, OYA, Child Welfare branch office or approved by the Division of Medical Assistance Programs (Division). The branch office may request an administrative medical examination or a medical report (DMAP 729) to establish client eligibility for an assistance program or casework planning.
(3) See the Administrative Examination and Report Billing rule for complete billing instructions.
[Publications: Publications referenced are available from the agency.]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065

Hist.: HR 36-1992, f. & cert. ef. 12-1-92; HR 6-1994, f. & cert. ef. 2-1-94; HR 10-1996, f. 5-31-96, cert. ef. 6-1-96; HR 4-1997, f. 1-31-97, cert. ef. 2-1-97 OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98; OMAP 17-1999, f. & cert. ef. 4-1-99; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; Renumbered from 410-130-0900, OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03
410-130-0240
Medical Services
(1) Coverage of medical and surgical
services is subject to the Health Evidence Review Commission’s (HERC) Prioritized
List of Health Services (Prioritized List). Medical and surgical services requiring
prior authorization (PA) are listed in Oregon administrative rule (OAR or rule)
410-130-0200, PA Table 130-0200-1, and medical and surgical services that are Not
Covered/Bundled services are listed in OAR 410-130-0220, Table 130-0220-1.
(2) Coverage for acupuncture
services by an enrolled acupuncture provider are subject to the HERC Prioritized
List and the client’s benefit plan.
(3) Coverage for medically
appropriate chiropractic services provided by an enrolled chiropractor is subject
to the HERC Prioritized List and benefit plan for:
(a) Diagnostic visits including
evaluation and management services;
(b) Chiropractic care including
manipulative treatment;
(c) Laboratory and radiology
services.
(4) Maternity care and delivery:
(a) The Division may consider
payment for delivery within a hospital, clinic, birthing center, or home setting;
(b) For out-of-hospital births,
the Division may only consider payment for labor and delivery care of women experiencing
low risk pregnancy. The Division will determine whether a pregnancy can be considered
low risk and an out-of-hospital birth is eligible for payment;
(c) The Division adopts Table
I from OAR 333-076-0650 to outline the absolute risk factors that, if present, would
preclude payment for initiation or continuation of any out-of-hospital labor and
delivery care. For a planned out-of-hospital birth, the Division requires that a
contingency for an in-hospital birth be included in the medical record. The division
considers all conditions listed in Table I of OAR 333-076-0650 to necessitate an
in-hospital birth if present or anticipated to be present at the onset of labor.
The Division may deny payment for labor and delivery services in an out-of-hospital
setting if it determines that an in-hospital birth was necessary and appropriate
steps to facilitate an in-hospital birth were not pursued. When an in-hospital birth
becomes necessary for a client that was seeking a planned out-of-hospital birth
and care is transferred from one provider to another, the Division will consider
payment for both providers for the portion of care provided. Bill using appropriate
CPT and HCPCS codes.
(d) When a provider is practicing
within the authorization of his or her license, the division may consider payment
for administration of drugs and devices that are used in pregnancy, birth, postpartum
care, newborn care, or resuscitation and that are deemed integral to providing safe
care.
(e) For out-of-hospital births,
drugs authorized in subsection (d) or this section are limited:
(A) For out-of-hospital births,
the Division will make no payment for general, spinal, caudal, or epidural anesthesia
administered for care associated with labor and delivery;
(B) For out-of-hospital births,
the Division will make no payment for inducing, stimulating, or using chemical agents
to augment labor during the first or second stages of labor;
(C) For out-of-hospital births,
the Division will consider payment for chemical agents administered to inhibit labor
only as a temporary measure until referral or transfer of the client to a higher
level of care is complete.
(f) Within the home setting,
the Division may consider payment for appropriate supplies in addition to delivery
payment. The additional payment for supplies includes all supplies, equipment, staff
assistance, and newborn screening cards;
(g) During labor in an out-of-hospital
setting, should any of the risk factors outlined in Table II of OAR 333-076-0650
develop, the Division requires that the client will be transferred to a hospital,
and the Division may deny payment for labor and delivery services if it determines
that appropriate steps to facilitate the transfer were not pursued. Appropriate
transfer of care must be in accordance with the practitioner’s licensure requirements.
When labor management does not result in a delivery, and the client is appropriately
transferred to a higher level of care, the provider shall code for labor management
only. Bill code 59899 and attach appropriate clinical documentation of services
performed with respect to labor management;
(h) For births in an out-of-hospital
setting, should any of the risk factors outlined in Table III of OAR 333-076-0650
develop during the postpartum period in the mother or infant, the Division requires
that the client will be transferred to a hospital, and the Division may deny payment
for labor and delivery services if it determines that appropriate steps to facilitate
the transfer were not pursued. Appropriate transfer of care must be in accordance
with the practitioner’s licensure requirements. The Division will consider
payment for both providers for the portion of care provided when appropriate;
(i) For multiple vaginal
births, use the appropriate CPT code for the first delivery. Use the delivery-only
code for the subsequent deliveries. The Division will reimburse the first delivery
at 100 percent and the subsequent deliveries at 50 percent of the delivery-only
code's maximum allowance. For multiple babies delivered via cesarean section, the
Division pays for the cesarean section only once.
(5) Neonatal Intensive Care
Unit (NICU) procedures:
(a) Are reimbursed only to
neonatologists and pediatric intensivists for services provided to infants when
admitted to a Neonatal or Pediatric Intensive Care Unit (NICU/PICU). All other pediatricians
must use other CPT codes when billing for services provided to neonates and infants;
(b) Neonatal intensive care
codes are not payable for infants on Extracorporeal Membrane Oxygenation (ECMO).
Use appropriate CPT ECMO codes.
(6) Neurology or Neuromuscular
payment for polysomnograms and multiple sleep latency tests (MSLT) are each limited
to two in a 12-month period.
(7) Oral health services
provided by medical practitioners may include an oral assessment and application
of topical fluoride varnish during a medical visit for children. Refer to OAR 410-123-1260
Dental Services program rule.
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025
& 414.065
Hist.: PWC 839(Temp), f.
& ef. 4-28-77; PWC 849, f. 7-15-77, ef. 8-1-77; PWC 868, f. 12-30-77, ef. 2-1-78;
AFS 14-1978(Temp), f. 4-14-78, ef. 4-15-78; AFS 31-1978, f. & ef. 8-1-78; AFS
26-1980, f. 5-21-80, ef. 6-1-80, AFS 56-1980(Temp), f. 8-29-80, ef. 9-1-80; AFS
2-1981, f. 1-9-81, ef. 2-1-81; AFS 36-1981, f. 6-29-81, ef. 7-1-81; AFS 27-1982,
f. 4-22-82 & AFS 51-1982, f. 5-28-82, ef. 5-1-82 for providers located in the
geographical areas covered by the AFS branch offices located in North Salem, South
Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82
for remaining AFS branch offices; AFS 38-1983, f. & ef. 8-1-83; AFS 57-1983,
f. 11-29-83, ef. 1-1-84; AFS 48-1984(Temp), f. 11-30-84, ef. 12-1-84; AFS 29-1985,
f. 5-22-85, ef. 5-29-85; AFS 50-1986, f. 6-30-86, ef. 8-1-86; AFS 56-1987, f. 10-29-87,
ef. 11-1-87; AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. &
cert. ef. 8-24-89; AFS 48-1989, f. & cert. ef. 8-24-89, Renumbered from 461-014-0021
& 461-014-0056; HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0650,
461-014-0690 & 461-014-0700; HR 14-1991(Temp), f. & cert. ef. 3-7-91; HR
18-1991(Temp), f. 4-12-91, cert. ef. 4-15-91; HR 19-1991, f. 4-12-91, cert. ef.
5-1-91; HR 24-1991, f. & cert. ef. 6-18-91; HR 2-1992, f. & cert. ef. 1-2-92;
HR 8-1992, f. 2-28-92, cert. ef. 3-1-92; HR 18-1992, f. & cert. ef. 7-1-92;
HR 36-1992, f. & cert. ef. 12-1-92; HR 40-1992, f. 12-31-92, cert. ef. 2-1-93;
HR 16-1993, f. & cert. ef. 7-2-93; HR 6-1994, f. & cert. ef. 2-1-94, Renumbered
from 410-130-0320, 410-130-0340, 410-130-0360 & 410-130-0740; HR 42-1994, f.
12-30-94, cert. ef. 1-1-95; HR 10-1996, f. 5-31-96, cert. ef. 6-1-96; HR 4-1997,
f. 1-31-97, cert. ef. 2-1-97; OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98; OMAP 17-1999,
f. & cert. ef. 4-1-99; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 13-2001,
f. 3-30-01, cert. ef. 4-1-01; OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP
23-2003, f. 3-26-03 cert. ef. 4-1-03; OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03;
OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 58-2004, f. 9-10-04, cert. ef.
10-1-04; OMAP 88-2004, f. 11-24-04, cert. ef. 12-1-04; OMAP 8-2005, f. 3-9-05, cert.
ef. 4-1-05; OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 18-2009, f. 6-12-09,
cert. ef. 7-1-09; DMAP 58-2012(Temp), f. 12-27-12, cert. ef. 12-28-12 thru 6-25-13;
DMAP 27-2013, f. & cert. ef. 6-25-13; DMAP 75-2013(Temp), f. 12-31-13, cert.
ef. 1-1-14 thru 6-30-14; DMAP 23-2014, f. & cert. ef. 4-4-14; DMAP 73-2014,
f. 12-9-14, cert. ef. 1-1-15
410-130-0245
Early and Periodic Screening, Diagnostic and Treatment Program
(1) The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program, formerly called Medicheck, offers "well-child" medical exams with referral for medically appropriate comprehensive diagnosis and treatment for all children (birth through age 20) covered by the Oregon Health Plan (OHP) Plus benefit package.
(2) Screening Exams:
(a) Physicians (MD or DO), nurse practitioners, licensed physician assistants and other licensed health professionals may provide EPSDT services. Screening services are based on the definition of "Preventive Services" in Oregon Health Plan OAR 410-141-0000, Definitions;
(b) Periodic EPSDT screening exams must include:
(A) A comprehensive health and developmental history including assessment of both physical and mental health development;
(B) Assessment of nutritional status;
(C) Comprehensive unclothed physical exam including inspection of teeth and gums;
(D) Appropriate immunizations;
(E) Lead testing for children under age 6 as required. See the "Blood Lead Screening" section of this rule;
(F) Other appropriate laboratory tests (such as anemia test, sickle cell test, and others) based on age and client risk;
(G) Health education including anticipatory guidance;
(H) Appropriate hearing and vision screening.
(c) The provider may bill for both lab and non-lab services using the appropriate Current Procedural Terminology (CPT) and Health care Common Procedure Coding System (HCPCS) codes. Immunizations must be billed according to the guidelines listed in OAR 410-130-0255;
(d) Inter-periodic EPSDT screening exams are any medically appropriate encounters with a physician (MD or DO), nurse practitioner, licensed physician assistant, or other licensed health professional within their scope of practice.
(3) Referrals:
(a) If, during the screening process (periodic or inter-periodic), a medical, mental health, substance abuse, or dental condition is discovered, the client may be referred to medical providers, Addictions and Mental Health Division (AMH), or dental providers for further diagnosis and/or treatment;
(b) The screening provider shall explain the need for the referral to the client, client's parent, or guardian;
(c) If the client, client's parent, or guardian agrees to the referral, assistance in finding an appropriate referral provider and making an appointment should be offered;
(d) The caseworker or local branch will assist in making other necessary arrangements.
(4) Blood Lead Screening: All children ages 12 months to 72 months are considered at risk for lead poisoning. Children ages 12 months to 72 months with Medical Assistance Program coverage must be screened for possible exposure to lead poisoning. Because the prevalence of lead poisoning peaks at age two, children screened or tested at age one should be re-screened or re-tested at age two. Screening consists of a Lead Risk Assessment Questionnaire (Division form 9033) and/or blood lead tests as indicated.
(5) Lead Risk Assessment Questionnaire: Complete the Lead Risk Assessment Questionnaire (Division form 9033) found in the Medical-Surgical Services Supplemental Information. Beginning at 1 year of age, the questionnaire must be used at each EPSDT exam to assess the potential for lead exposure. Retain this questionnaire in the client's medical record. Do not attach the Division 9033 form to the claim for reimbursement. The Division does not stock this form; photocopy the form and the instructions from the Medical-Surgical Services Supplement Information.
(6) Blood Lead Testing: Any "yes" or "don't know" answer in Part B, questions 1-8 on the Lead Risk Assessment Questionnaire (Division 9033) means that the child should receive a screening blood lead test. An elevated blood lead level is defined as greater than or equal to 10 μg/dL. Children with an elevated blood lead screening test should have a confirmatory blood lead test performed according to the schedule described in Table 130-0245-1 of this rule. If the confirmatory blood lead test is elevated, follow-up blood lead tests should be performed approximately every three months until two consecutive test results are less than 10 μg/dL. Comprehensive follow-up services based on the results of the confirmatory blood lead test are described in Table 130-0245-2 and section (7) of this rule.
(7) Children with a confirmatory blood lead level test of greater than or equal to 10 μg/dL are eligible for a one-time comprehensive environmental lead investigation, not including laboratory analysis, of the child’s home. The child may also receive follow-up case management services.
(a) The investigation of the child’s home and follow-up case management services must be provided by a Division-enrolled medical-surgical provider who has received Oregon Public Health Division training to perform these services. Refer to Medical-Surgical Services rule 410-130-0000 for a list of the medical-surgical providers Division enrolls.
(b) To bill for these services, use HCPCS code T1029. Payment for code T1029 includes the home investigation and any follow-up case management services provided after the home investigation is completed. The Division limits reimbursement of T1029 to one time per dwelling. For clients enrolled in managed care plans, the service is payable by the Division; do not bill the managed care plan.
(8) Method of Blood Collection: Either venipuncture or capillary draw is acceptable for the screening blood lead test. All confirmatory blood lead tests must be obtained by venipuncture. Erythrocyte protoporphyrin (EP) testing is not a substitute for either a screening or a confirmation blood lead test.
(9) Additional Lead-Related Services: Families should be provided anticipatory guidance and lead education prenatally and at each well-child visit, as described in Tables 130-0245-3 and 130-0245-4 of this rule.
(10) Table 130-0245-1
(11) Table 130-0245-2
(12) Table 130-0245-3
(13) Table 130-0245-4
(14) Table 130-0245-5
[Publications: Publications referenced are available from the agency.]

[ED. NOTE: Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.065

Hist.: HR 10-1990, f. 3-30-90, cert. ef. 4-1-90; HR 19-1991, f. 4-12-91, cert. ef. 5-1-91; HR 43-1991, f. & cert. ef. 10-1-91; HR 16-1993, f. & cert. ef. 7-2-93; HR 42-1994, f. 12-30-94, cert. ef. 1-1-95; HR 4-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98; OMAP 17-1999, f. & cert. ef. 4-1-99; OMAP 37-1999, f. & cert. ef. 10-1-99; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; Renumbered from 410-130-0080, OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03; OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04; DMAP 15-2010, f. 6-10-10, cert. ef. 7-1-10
410-130-0255
Immunizations, Vaccines for Children, and
Immune Globulins
(1) The Division of Medical Assistance
Programs (Division) covers immunizations as recommended by the Advisory Committee
on Immunization Practices (ACIP) and approved by the Oregon Immunization Program.
The approved ACIP recommendations are found in Guideline Note 106 of the Health
Evidence Review Commission’s Prioritized List of Health Services as referenced
in OAR 410-141-0520, http://www.oregon.gov/oha/herc/Pages/PrioritizedList.aspx.
(2) Providers shall follow
the (ACIP) guidelines for immunization schedules. Exceptions include:
(a) On a case-by-case basis,
provider may use clinical judgment in accordance with accepted medical practice
to provide immunizations on a modified schedule, and;
(b) On a case-by-case basis,
provider may modify immunization schedule in compliance with the laws of the State
of Oregon, including laws relating to medical and non-medical exemptions for immunizations.
(3) Providers are encouraged
to administer combination vaccines when medically appropriate and cost effective.
(4) Providers must use standard
billing procedures for adults and for any vaccines that are not part of the Vaccines
for Children (VFC) Program.
(5) Vaccines for Children
(VFC) is a federal program that provides vaccine serums at no cost to providers
for clients ages 0 through 18. All vaccines for this age group and for conditions
covered by the VFC program must be obtained through the VFC program. The Division
will not reimburse providers for the administration or purchase of privately purchased
vaccines if the vaccine could have been obtained through the VFC program. For information
about the VFC program or to enroll as a VFC provider, contact the Public Health
Immunization Program. The Oregon VFC program website can be located at http://public.health.oregon.gov/PreventionWellness/VaccinesImmunization/ImmunizationProviderResources/vfc/Pages/index.aspx
(6) The Division will only
reimburse for the administration, not the serum, of vaccines available for free
through the VFC Program. Refer to the 12/24/2013 Current Oregon Immunization Program
State-Supplied Vaccine Billing Codes table available at http://bit.ly/1c3T6zy for
a list of vaccines provided through the VFC Program.
(7) To receive reimbursement
for vaccine administration, VFC program providers must bill the Division:
(a) With the appropriate
vaccine common procedural terminology (CPT) code included;
(b) Including the appropriate
modifier -SL or -26; and
(c) Reporting the vaccine
administration in addition to an Evaluation and Management service (e.g., well-child
visit) if provided on the same date of service;
(8) For clients with private
insurance, providers may bill the Division or the client’s managed care or
coordinated care organization (MCO/CCO) directly for the administration of VFC vaccines.
Medicaid and CHIP are not considered the “payer of last resort” for
administration of VFC vaccines.
(9) In compliance with Section
1202 of the Affordable Care Act ,VFC providers who qualify for the federal primary
care rate increase as specified under 42 Code of Federal Regulation (CFR) 447 Subpart
G (see also OAR 410-130-0005) are eligible for reimbursement for the administration
of VFC vaccines at the Regional Maximum amount:
(a) Effective 1/1/2013 the
Regional Maximum amount is $21.96.
(b) For providers that have
met the federal primary care definition, MCO and CCOs are required to reimburse
the lessor of:
(A) The Regional Maximum
administration fee, or
(B) Medicare 2014 RVU and
2009 conversion factor amount.
(c) MCO and CCOs are not
required to reimburse the Regional Maximum amount to providers that have not met
the federal primary care definition but may at their option.
(d) For all fee for service
providers, the Division reimburses the Regional Maximum amount for the administration
of VFC vaccines.
(10) The Division covers
immune globulins based on the Prioritized List of Health Services. Synagis (palivizumab-rsv-igm)
is covered with prior authorization only for high-risk infants and children. Refer
to Guideline Note 69 of the Health Evidence Review Commission’s List of Prioritized
Services as referenced in OAR 410-141-0520, http://www.oregon.gov/oha/herc/Pages/PrioritizedList.aspx
and Oregon Medicaid Fee-For-Service Prior Authorization Approval Criteria as referenced
in 410-121-0040, www.oregon.gov/OHA/healthplan/pages/medical-surgical.aspx.
[ED. NOTE: Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025
& 414.065
Hist.: HR 4-1997, f. 1-31-97,
cert. ef. 2-1-97; OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98; OMAP 17-1999, f. &
cert. ef. 4-1-99; OMAP 4-2000, f. 3-31-00, cert. ef. 4-1-00; OMAP 31-2000, f. 9-29-00,
cert. ef. 10-1-00; OMAP 13-2001, f. 3-30-01, cert. ef. 4-1-01; OMAP 40-2001, f.
9-24-01, cert. ef. 10-1-01; OMAP 2-2002, f. 2-15-02, cert. ef. 4-1-02; OMAP 51-2002,
f. & cert. ef. 10-1-02; OMAP 23-2003, f. 3-26-03 cert. ef. 4-1-03; Renumbered
from 410-130-0800, OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03; OMAP 13-2004, f.
3-11-04, cert. ef. 4-1-04; OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04; OMAP 45-2005,
f. 9-9-05, cert. ef. 10-1-05; OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 5-2007,
f. 6-14-07, cert. ef. 7-1-07; DMAP 20-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 18-2009,
f. 6-12-09, cert. ef. 7-1-09; DMAP 15-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 34-2010,
f. 12-15-10, cert. ef. 1-1-11; DMAP 43-2011, f. 12-21-11, cert. ef. 1-1-12; DMAP
14-2013(Temp), f. & cert. ef. 3-29-13 thru 9-25-13; DMAP 49-2013, f. & cert.
ef. 9-25-13; DMAP 12-2014, f. & cert. ef. 3-13-14
410-130-0365
Ambulatory Surgical Center and Birthing Center Services
(1) Ambulatory Surgical Centers (ASC) and Birthing Centers (BC) must be licensed by the Oregon Health Division. ASC and BC services are items and services furnished by an ASC or BC in connection with a covered surgical procedure as specified in the Medical-Surgical Services rule or in the Dental Services rule. Reimbursement is made at all-inclusive global rates based on the surgical procedure codes billed.
(2) If the client has Medicare in addition to Medicaid and Medicare covers a surgery, but not in an ASC setting, then the surgery may not be performed in an ASC.
(3) Global rates include:
(a) Nursing services, services of technical personnel, and other related services;
(b) Any support services provided by personnel employed by the ASC or BC facility;
(c) The client’s use of the ASC's or BC's facilities including the operating room and recovery room;
(d) Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment related to the provision of the surgical procedure(s);
(e) Diagnostic or therapeutic items and services related to the surgical procedure;
(f) Administrative, record-keeping, and housekeeping items and services;
(g) Blood, blood plasma, platelets;
(h) Materials for anesthesia;
(i) Items not separately identified in section (4) of this rule.
(4) Items and services not included in ASC or BC Global Rate:
(a) Practitioner services such as those performed by physicians, licensed physician assistants, nurse practitioners, certified registered nurse anesthetists, dentists, podiatrists and Licensed Direct Entry Midwives (for birthing centers only);
(b) The sale, lease, or rental of durable medical equipment to ASC or BC clients for use in their homes;
(c) Prosthetic and orthotic devices;
(d) Ambulance services;
(e) Leg, arm, back and neck brace, or other orthopedic appliances;
(f) Artificial legs, arms, and eyes;
(g) Services furnished by a certified independent laboratory.
(5) ASCs and BCs will not be reimbursed for services that are normally provided in an office setting unless the practitioner has justified the medical appropriateness of using an ASC or BC through documentation submitted with the claim. Practitioner's justification is subject to review by the Division of Medical Assistance Programs (Division). If payment has been made and the practitioner fails to justify the medical appropriateness for using an ASC or BC facility, the amount paid is subject to recovery by Division.
(6) Procedure coding for non-Birthing Centers:
(a) Bill the same procedure codes billed by the surgeon;
(b) For reduced or discontinued procedures, use Common Procedural Terminology (CPT) instructions and add appropriate modifiers;
(c) Attach a report to the claim when billing an unlisted code;
(d) For billing instructions regarding multiple procedures, see rule 410-130-0380.
(7) Procedure coding for Birthing Centers:
(a) Bill code 59409 only once for a single vaginal delivery regardless of the total days that the client was in the facility for labor management, delivery and immediate postpartum care;
(b) For delivery of twins:
(A) Bill the delivery of the first twin with 59409; and
(B) Bill the delivery of the second twin with code 59409 on a separate line;
(c) When labor was managed in the BC but a delivery did not result, bill S4005 (Interim labor facility global) and attach a report documenting the circumstances.
(8) Prior authorization is required for all services listed in Table 130-0200-1. Refer to Rule 410-130-0200.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065

Hist.: OMAP 13-2001, f. 3-30-01, cert. ef. 4-1-01; OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 23-2003, f. 3-26-03 cert. ef. 4-1-03; Renumbered from 410-130-0940, OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03; DMAP 18-2009, f. 6-12-09, cert.ef. 7-1-09
410-130-0368
Anesthesia Services
(1) Anesthesia is not covered
for procedures that are below the funding line on the Health Services Commission’s
Prioritized List of Health Services (see OAR 410-141-0520).
(2) Effective January 1, 2012
all anesthesia claims submitted must be billed in minutes only. This includes;
(a) Claims for services provided
prior to 1/1/12 that are submitted for the first time in 2012;
(b) Resubmitted unpaid claims
for services provided prior to 1/1/12; and
(c) Adjustments made to claims
for services performed prior to 1/1/12. Units must be converted by the provider
from units to minutes.
(3) Qualifier MJ (indicating
minutes) must be added to all claims;
(a) Claims with qualifier UN
(indicating units) will be denied; and
(b) Claims without a qualifier
will be denied.
(4) Reimbursement is based on
the base units assigned to each anesthesia code listed in the current American Society
of Anesthesiology Relative Value Guide plus one unit per each 15 minutes of anesthesia
time, except for anesthesia for neuraxial labor analgesia/anesthesia/anesthesia
(code 01967). See (5) below for reimbursement of neuraxial labor analgesia/anesthesia.
(a) The Division of Medical
Assistance Programs (Division) will automatically calculate payment by adding the
base units of the billed anesthesia code plus a unit per each 15 minutes of anesthesia
time;
(b) Reimbursement will be made
at a fraction of a unit for the last 1-14 minutes of anesthesia time;
(c) Do not add base units in addition to minutes.
(5) Anesthesia for neuraxial labor analgesia/anesthesia
(code 01967) will be paid at a flat rate regardless of the units billed.
(6) Reimbursement for qualifying
circumstances codes 99100-99140 and modifiers P1-P6 is bundled in the payment for
codes 00100-01999. Do not add charges for 99100-99140 and modifiers P1-P6 in charges
for 00100-01999.
(7) A valid consent form is
required for all hysterectomies and sterilizations.
(8) If prior authorization (PA)
was not obtained for a procedure that requires PA, then the anesthesia services
may not be paid. Refer to OAR 410-130-0200 PA Table 130-0200-1.
(9) Anesthesia services are
not payable to the provider performing the surgical procedure except for moderate
(conscious) sedation.
(10) Moderate (conscious) sedation
must be billed with codes 99143-99150.
[ED. NOTE: Tables referenced
are available from the agency.]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: OMAP 8-2005, f. 3-9-05,
cert. ef. 4-1-05; DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07; DMAP 43-2011, f. 12-21-11,
cert. ef. 1-1-12
410-130-0380
Surgery Guidelines
(1) The Division of Medical Assistance Programs (Division) reimburses all covered surgical procedures as global packages. Global payments do not include initial consultation or evaluation of the problem by the surgeon to determine the need for surgery.
(2) Surgical procedures listed in the Medical-Surgical Services administrative rules with prior authorization (PA) indicated require authorization unless they are emergent.
(3) Global payment for major surgery includes:
(a) Surgery;
(b) Pre-operative visits within 15 days of the surgery (except the initial consultation);
(c) Initial admission history and physical;
(d) Related follow-up visits within 90 days after the surgery;
(e) Treatment of complications not requiring a return trip to the operating room;
(f) Hospital discharge.
(4) Global payment for minor surgery includes:
(a) Surgery;
(b) Pre-operative visits within 15 days of the surgery;
(c) Initial admission history and physical;
(d) Related follow-up visits for 10 days after the surgery;
(e) Hospital discharge.
(5) Global payment for endoscopy includes:
(a) Surgery;
(b) Related visit on the same day as the endoscopy procedure;
(c) No follow-up days for this procedure;
(d) Pre-operative and post-operative care provided by the surgeon’s associate(s) or by another physician “on call” for the surgeon are considered included in the reimbursement to the surgeon and will not be paid in addition to the payment to the surgeon;
(e) Do not bill separately for procedures which are considered to be bundled in another procedure. Payment for bundled services is included in the primary surgery payment.
(6) Co-surgeons — Two or more surgeons/same or different specialties/separate functions/one major or complex surgery:
(a) Add modifier -62 to procedure code(s);
(b) Payment will be determined by medical review.
(7) Team Surgeons — Two or more surgeons/different specialties performing/separate surgeries/same operative session:
(a) Add modifier -66 to procedure code(s);
(b) Payment will be determined by medical review.
(8) Multiple Surgical Procedures performed during the same operative session:
(a) Primary Procedure paid at 100% of the Division maximum fee for that procedure;
(b) Second and third procedure paid at 50% of the Division maximum fee;
(c) Fourth, fifth, etc. paid at 25% or less as determined by the Division;
(d) Endoscopic procedures paid at 100% of the Division maximum fee for the primary level procedure. The Division fee for insertion will be deducted from the maximum allowable for each additional procedure performed at the same site;
(e) Bill each procedure on separate lines (even multiples of the same procedure) unless the code description specifies “each additional”;
(f) Bilateral procedures must be billed on two lines unless a single code identifies a bilateral procedure. Use modifier -50 only on the second line;
(g) Reimbursement for laparotomy is included in the surgical procedure and should not be billed separately or in addition to the surgical procedure;
(h) For Integumentary System codes 10000 thru 17999, bill multiples of the same procedure on the same line with the appropriate quantity unless the code indicates the first in a series (i.e., code 11100) or the code is for multiple procedures (i.e., code 11900).
(9) Surgical Assistance — Payment is restricted to physicians, naturopaths, podiatrists, dentists, nurse practitioners, licensed physician assistants, and registered nurse first assistants:
(a) The assistance must be medically appropriate;
(b) No payment will be made for surgical assistant for minor surgical or diagnostic procedures, e.g., “scoping” procedures;
(c) Only one surgical assistant may receive payment (except when the need is clinically documented);
(d) Use an appropriate modifier to indicate assistance.
[Publications: Publications referenced are available from the agency.]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065

Hist.: PWC 868, f. 12-30-77, ef. 2-1-78; AFS 32-1978, f. & ef. 8-1-78; AFS 26-1980, f. 5-21-80, ef. 6-1-80; AFS 27-1982, f. 4-22-82 & AFS 51-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 2-1983, f. 1-31-83; AFS 57-1983, f. 11-29-83, ef. 1-1-84; AFS 4-1984, f. & ef. 2-1-84; AFS 30-1984, f. 7-26-84, ef. 8-1-84; AFS 48-1984(Temp), f. 11-30-84, ef. 12-1-1984; AFS 29-1985, f. 5-22-85, ef. 5-29-85; AFS 38-1986, f. 4-29-86, ef. 6-1-86; AFS 50-1986, f. 6-30-86, ef. 8-1-86; AFS 30-1987, f. 7-15-87, ef. 8-1-87; AFS 56-1987, f. 10-29-87, ef. 11-1-87; AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. & cert. ef. 8-24-89, Renumbered from 461-014-0048, 461-014-0049, 461-014-0053, 461-014-0055 & 461-014-0056; HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0710; HR 19-1991, f. 4-12-91, cert. ef. 5-1-91; HR 8-1992, f. 2-28-92, cert. ef. 3-1-92; HR 23-1992, f. 7-31-92, cert. ef. 8-1-92; HR 40-1992, f. 12-31-92, cert. ef. 2-1-93; HR 6-1994, f. & cert. ef. 2-1-94; HR 42-1994, f. 12-30-94, cert. ef. 1-1-95; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 51-2002, f. & cert. ef. 10-1-02
410-130-0562
Abortion
For medically induced abortions by oral
ingestion of medication use S0199 for all visits, counseling, lab tests, ultrasounds,
and supplies. S0199 is a global package except for medication:
(1) Bill medications with codes
S0190-S0191 and appropriate HCPCS codes.
(2) For surgical abortions use
CPT codes 59840 through 59857:
(3) For services related to
surgical abortion such as lab, ultrasound and pathology bill separately. Add modifier
U4 (a Division of Medical Assistance Programs (Division) modifier) for surgical
abortion related services.
(4) Use the most appropriate
ICD-10 diagnosis code.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025
& 414.065

Hist.: HR 19-1991, f. 4-12-91,
cert. ef. 5-1-91; HR 43-1991, f. & cert. ef. 10-1-91; HR 8-1992, f. 2-28-92,
cert. ef. 3-1-92; HR 23-1992, f. 7-31-92, cert. ef. 8-1-92; HR 6-1994, f. &
cert. ef. 2-1-94; HR 42-1994, f. 12-30-94, cert. ef. 1-1-95; HR 10-1996, f. 5-31-96,
cert. ef. 6-1-96; HR 4-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 3-1998, f. 1-30-98,
cert. ef. 2-1-98; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 2-2002, f. 2-15-02,
cert. ef. 4-1-02; OMAP 23-2003, f. 3-26-03 cert. ef. 4-1-03; OMAP 69-2003 f. 9-12-03,
cert. ef. 10-1-03; DMAP 51-2015, f. 9-22-15, cert. ef. 10-1-15
410-130-0580
Hysterectomies and Sterilization
(1) Refer to OAR 410-130-0200 Prior Authorization, Table 130-0200-1 and 410-130-0220 Not Covered/Bundled Services, Table 130-0220-1.
(2) Hysterectomies performed for the sole purpose of sterilization are not covered.
(3) All hysterectomies, except radical hysterectomies, require prior authorization (PA).
(4) A properly completed Hysterectomy Consent form (DMAP 741) or a statement signed by the performing physician, depending upon the following circumstances, is required for all hysterectomies:
(a) When a woman is capable of bearing children:
(A) Prior to the surgery, the person securing authorization to perform the hysterectomy must inform the woman and her representative, if any, orally and in writing, that the hysterectomy will render her permanently incapable of reproducing;
(B) The woman or her representative, if any, must sign the consent form to acknowledge she received that information.
(b) When a woman is sterile prior to the hysterectomy, the physician who performs the hysterectomy must certify in writing that the woman was already sterile prior to the hysterectomy and state the cause of the sterility;
(c) When there is a life-threatening emergency situation that requires a hysterectomy in which the physician determines that prior acknowledgment is not possible, the physician performing the hysterectomy must certify in writing that the hysterectomy was performed under a life-threatening emergency situation in which he or she determined prior acknowledgment was not possible and describe the nature of the emergency.
(5) In cases of retroactive eligibility:
The physician who performs the hysterectomy must certify in writing one of the following:
(a) The woman was informed before the operation that the hysterectomy would make her permanently incapable of reproducing;
(b) The woman was previously sterile and states the cause of the sterility;
(c) The hysterectomy was performed because of a life-threatening emergency situation in which prior acknowledgment was not possible and describes the nature of the emergency.
(6) Do not use the Consent to Sterilization form (DMAP 742A or B) for hysterectomies.
(7) Submit a copy of the Hysterectomy consent form with the claim.
(8) Sterilization Male & Female: A copy of a properly completed Consent to Sterilization form (DMAP 742 A or B), the consent form in the federal brochure DHHS Publication No. (05) 79-50062 (Male), DHHS Publication No. (05) 79-50061 (Female) or another federally approved form must be submitted to the Division for all sterilizations. The original consent form must be retained in the clinical records. Prior authorization is not required.
(9) Voluntary Sterilization:
(a) Consent for sterilization must be an informed choice. The consent is not valid if signed when the client is:
(A) In labor;
(B) Seeking or obtaining an abortion; or
(C) Under the influence of alcohol or drugs.
(b) Ages 15 years or older who are mentally competent to give informed consent:
(A) At least 30 days, but not more than 180 days, must have passed between the date of the informed written consent (date of signature) and the date of the sterilization except:
(i) In the case of premature delivery by vaginal or cesarean section the consent form must have been signed at least 72 hours before the sterilization is performed and more than 30 days before the expected date of confinement;
(ii) In cases of emergency abdominal surgery (other than cesarean section), the consent form must have been signed at least 72 hours before the sterilization was performed.
(B) The client must sign and date the consent form before it is signed and dated by the person obtaining the consent. The date of signature must meet the above criteria. The person obtaining the consent must sign the consent form anytime after the client has signed but before the sterilization is performed. If an interpreter is provided to assist the individual being sterilized, the interpreter must also sign the consent form on the same date as the client;
(C) The client must be legally competent to give informed consent. The physician performing the procedure, and the person obtaining the consent, if other than the physician, must review with the client the detailed information appearing on the Consent to Sterilization form regarding effects and permanence of the procedure, alternative birth control methods, and explain that withdrawal of consent at any time prior to the surgery will not result in any loss of other program benefits.
(10) Involuntary Sterilization — Clients who lack the ability to give informed consent and are 18 years of age or older:
(a) Only the Circuit Court of the county in which the client resides can determine that the client is unable to give informed consent;
(b) The Circuit Court must determine that the client requires sterilization;
(c) When the court orders sterilization, it issues a Sterilization Order. The order must be attached to the billing invoice. No waiting period or additional documentation is required.
(11) Submit the Consent to Sterilization Form (DMAP 742 A or B) along with the claim. The Consent to Sterilization form must be completed in full:
(a) Consent forms submitted to the Division without signatures and/or dates of signature by the client or the person obtaining consent are invalid;
(b) The client and the person obtaining consent may not sign or date the consent retroactively;
(c) The performing physician must sign the consent form. The date of signature must be either the date the sterilization was performed or a date following the sterilization.
[ED. NOTE: Forms referenced are available from the agency.]

[Publications: Publications referenced are available from the agency.]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065

Hist.: PWC 803(Temp), f. & ef. 7-1-76; PWC 813, f. & ef. 10-1-76; PWC 834, f. 3-31-77, ef. 5-1-77; PWC 868, f. 12-30-77, ef. 2-1-78; AFS 4-1979(Temp), f. & ef. 3-8-79; AFS 11-1979, f. 6-18-79, ef. 7-1-79; AFS 50-1981(Temp), f. & ef. 8-5-81; AFS 79-1981, f. 11-24-81, ef. 12-1-81; AFS 27-1982, f. 4-22-82 & AFS 51-1982, f. 5-28-82, ef. 5-1-82 for providers located in the geographical areas covered by the AFS branch offices located in North Salem, South Salem, Dallas, Woodburn, McMinnville, Lebanon, Albany and Corvallis, ef. 6-30-82 for remaining AFS branch offices; AFS 42-1985, f. & ef. 7-1-85; AFS 50-1986, f. 6-30-86, ef. 8-1-86; Renumbered from 461-014-0030, AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. & cert. ef. 8-24-89; HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0840; HR 43-1991, f. & cert. ef. 10-1-91; HR 23-1992, f. 7-31-92, cert. ef. 8-1-92; HR 6-1994, f. & cert. ef. 2-1-94; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 23-2003, f. 3-26-03 cert. ef. 4-1-03; OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03; OMAP 58-2004, f. 9-10-04, cert. ef. 10-1-04; OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07; DMAP 27-2007(Temp), f. & cert. ef. 12-20-07 thru 5-15-08; DMAP 12-2008, f. 4-29-08, cert. ef. 5-1-08; DMAP 34-2010, f. 12-15-10, cert. ef. 1-1-11
410-130-0585
Family Planning Services
(1) Family planning services are those
intended to prevent or delay pregnancy, or otherwise control family size.
(2) The Division of Medical
Assistance Programs (Division) covers family planning services for clients of childbearing
age (including minors who are considered to be sexually active).
(3) Family Planning services
include:
(a) Annual exams;
(b) Contraceptive education
and counseling to address reproductive health issues;
(c) Laboratory tests;
(d) Radiology services;
(e) Medical and surgical
procedures, including tubal ligations and vasectomies;
(f) Pharmaceutical supplies
and devices.
(4) Clients may seek family
planning services from any provider enrolled with the Division, even if the client
is enrolled in a Prepaid Health Plan (PHP). Reimbursement for family planning services
is made either by the client’s PHP or the Division. If the provider is:
(a) A participating provider
with the client’s PHP, bill the PHP;
(b) An enrolled Division
provider, but is not a participating provider with the client’s PHP, bill
the Division and add modifier –FP to the billed code.
(5) Family planning methods
include natural family planning, abstinence, intrauterine device, cervical cap,
prescriptions, sub-dermal implants, condoms, and diaphragms.
(6) Bill all family planning
services with the most appropriate ICD-10-CM diagnosis code the most appropriate
CPT or HCPCS code and add modifier –FP.
(7) For annual family planning
visits use the appropriate CPT code in the Preventative Medicine series (9938X-9939X)
and add modifier -FP. These codes include comprehensive contraceptive counseling.
(8) When comprehensive contraceptive
counseling is the only service provided at the encounter, use a CPT code from the
Preventative Medicine, Individual Counseling series (99401-99404) and add modifier
-FP.
(9) Bill contraceptive supplies
with the most appropriate HCPCS codes.
(10) Where there are no specific
CPT or HCPCS codes, use an appropriate unlisted code and add modifier -FP. Bill
supplies at acquisition cost.
[ED. NOTE: Forms referenced are available
from the agency.]
Stat. Auth.: ORS 413.042
Stats. Implemented: ORS 414.025,
414.065 & 414.152
Hist.: HR 19-1991, f. 4-12-91,
cert. ef. 5-1-91; HR 43-1991, f. & cert. ef. 10-1-91; HR 8-1992, f. 2-28-92,
cert. ef. 3-1-92; HR 40-1992, f. 12-31-92, cert. ef. 2-1-93; HR 6-1994, f. &
cert. ef. 2-1-94; HR 42-1994, f. 12-30-94, cert. ef. 1-1-95; HR 10-1996, f. 5-31-96,
cert. ef. 6-1-96; HR 4-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 3-1998, f. 1-30-98,
cert. ef. 2-1-98; OMAP 17-1999, f. & cert. ef. 4-1-99; OMAP 31-2000, f. 9-29-00,
cert. ef. 10-1-00; OMAP 13-2001, f. 3-30-01, cert. ef. 4-1-01; OMAP 2-2002, f. 2-15-02,
cert. ef. 4-1-02; OMAP 51-2002, f. & cert. ef. 10-1-02; OMAP 23-2003, f. 3-26-03
cert. ef. 4-1-03; OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03; OMAP 13-2004, f. 3-11-04,
cert. ef. 4-1-04; OMAP 45-2005, f. 9-9-05, cert. ef. 10-1-05; OMAP 26-2006, f. 6-14-06,
cert. ef. 7-1-06; DMAP 34-2010, f. 12-15-10, cert. ef. 1-1-11; DMAP 51-2015, f.
9-22-15, cert. ef. 10-1-15
410-130-0587
Family Planning Clinic Services
(1) This rule pertains only to Family Planning Clinics.
(2) To enroll with the Division of Medical Assistance Programs (Division) as a family planning clinic, a provider must also be enrolled with the Office of Family Health as an Oregon Contraceptive Care (CCare) provider.
(3) Family planning clinics must follow all applicable CCare and the Division rules.
(4) The Division will reimburse family planning clinics an encounter rate only when the primary purpose of the visit is for family planning.
(5) Bill HCPCS code T1015 “Clinic visit/encounter, all-inclusive; family planning” for all encounters where the primary purpose of the visit is contraceptive in nature:
(a) This encounter code includes the visit and any procedure or service performed during that visit including:
(A) Annual family planning exams;
(B) Family planning counseling;
(C) Insertions and removals of implants and IUDs;
(D) Diaphragm fittings;
(E) Dispensing of contraceptive supplies and contraceptive medications;
(F) Contraceptive injections.
(b) Do not bill procedures, such as IUD insertions, diaphragm fittings or injections, with CPT or HCPCS codes;
(c) Bill only one encounter per date of service;
(d) Reimbursement for educational materials is included in T1015. Educational materials are not billable separately.
(6) Reimbursement for T1015 does not include payment for family planning (FP) supplies and medications:
(a) Bill contraceptive supplies and contraceptive medications separately using HCPCS codes. Where there are no specific HCPCS codes, use an appropriate unspecified HCPCS code:
(A) Bill spermicide code A4269 per tube;
(B) Bill contraceptive pills code S4993 per monthly packet;
(C) Bill emergency contraception with code S4993 and bill per packet.
(b) Bill all contraceptive supplies and contraceptive medications at acquisition cost;
(c) Add modifier -FP after all codes for contraceptive services, supplies and medications;
(d) Non-contraceptive medications are not billable under this program.
(7) Reimbursement for T1015 does not include payment for laboratory tests:
(a) Clinics and providers who perform lab tests in their clinics and are CLIA certified to perform those tests may bill CPT and HCPCS lab codes in addition to T1015;
(b) Add modifier -FP after lab codes to indicate that the lab was performed during an FP encounter;
(c) Labs sent to outside laboratories, such as PAP smears, can be billed only by the performing laboratory.
(8) Encounters where the primary purpose of the visit is not contraceptive in nature, use appropriate CPT codes and do not add modifier -FP.
(9) When billing providers who are not participants in a Prepaid Health Plan (PHP) for services provided to clients enrolled in a PHP, add modifier –FP to the billed code.
[ED. NOTE: Forms referenced are available from the agency.]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025, 414.065 & 414.152

Hist.: OMAP 78-2003, f. & cert. ef. 10-1-03; OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05; OMAP 45-2005, f. 9-9-05, cert. ef. 10-1-05; OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 34-2010, f. 12-15-10, cert. ef. 1-1-11
410-130-0595
Maternity
Case Management
(1) The primary purpose of the
Maternity Case Management (MCM) program is to optimize pregnancy outcomes, including
reducing the incidence of low birth weight babies. MCM services are tailored to
the individual client needs. These services are provided face-to-face throughout
the client’s pregnancy, unless specifically indicated in this rule.
(2) This program:
(a) Is available to all pregnant
clients receiving Medical Assistance Program coverage;
(b) Expands perinatal services
to include management of health, economic, social and nutritional factors through
the end of pregnancy and a two-month postpartum period;
(c) Must be initiated during
the pregnancy and before delivery;
(d) Is an additional set of
services over and above medical management of pregnant clients;
(e) Allows billing of intensive
nutritional counseling services.
(3) Any time there is a significant
change in the health, economic, social, or nutritional factors of the client, the
prenatal care provider must be notified.
(4) Only one provider at a time
may provide MCM services to the client. The provider must coordinate care to ensure
that duplicate claims for MCM services are not submitted to the Division.
(5) Definitions:
(a) Case Management —
An ongoing process to assist and support an individual pregnant client in accessing
necessary health, social, economic, nutritional, and other services to meet the
goals defined in the Client Service Plan (CSP)(defined below);
(b) Case Management Visit —
A face-to-face encounter between a Maternity Case Manager and the client that must
include two or more specific training and education topics, address the CSP and
provide an on-going relationship development between the client and the visiting
provider.
(c) Client Service Plan (CSP)
— A written systematic, client coordinated plan of care which lists goals
and actions required to meet the needs of the client as identified in the Initial
Assessment (defined below) and includes a client discharge plan/summary;
(d) High Risk Case Management
— Intensive level of services provided to a client identified and documented
by the Maternity Case Manager or prenatal care provider as being high risk;
(e) High Risk Client —
A client who has a current (within the last year) documented alcohol, tobacco or
other drug (ATOD) abuse history, or who is 17 or under, or has other conditions
identified by the case manager anytime during the course of service delivery;
(f) Home/Environmental Assessment
— A visit to the client's primary place of residence to assess the health
and safety of the client's living conditions;
(g) Initial Assessment —
Documented, systematic collection of data with planned interventions as outlined
in a CSP to determine current status and identify needs and strengths in physical,
psychosocial, behavioral, developmental, educational, mobility, environmental, nutritional,
and emotional areas;
(h) Nutritional Counseling —
Intensive nutritional counseling for clients who have at least one of the conditions
listed under Nutritional Counseling (12)(a)(A-I) in this rule;
(i) Prenatal/Perinatal care
provider — The physician, licensed physician assistant, nurse practitioner,
certified nurse midwife, or licensed direct entry midwife providing prenatal or
perinatal (including labor and delivery) and/or postnatal services to the client;
(j) Case Management Visit Outside
the Home — An encounter outside the client’s home between a Maternity
Case Manager and the client where identical services of a Case Management Home Visit
(G9012) are provided.
(6) Maternity case manager qualifications:
(a) Maternity case managers
must be currently licensed as a:
(A) Physician;
(B) Physician assistant;
(C) Nurse practitioner;
(D) Certified nurse midwife;
(E) Direct entry midwife;
(F) Social worker; or
(G) Registered nurse;
(b) The maternity case manager
must be a Division enrolled provider or deliver services under an appropriate Division
enrolled provider. See provider qualifications in the Division’s General
Rule 410-120-1260.
(c) All of the above must have
a minimum of two years of related and relevant work experience;
(d) Other paraprofessionals
may provide specific services with the exclusion of the Initial Assessment (G9001)
while working under the supervision of one of the practitioners listed above in
this section;
(e) The maternity case manager
must sign off on all services delivered by a paraprofessional;
(f) Specific services not within
the recognized scope of practice of the provider of MCM services must be referred
to an appropriate discipline.
(7) Nutritional counselor qualifications
— nutritional counselors must be:
(a) A licensed dietician (LD)
licensed by the Oregon Board of Examiners of Licensed Dieticians; and
(b) A registered dietician (RD)
credentialed by the Commission on Dietetic Registration of the American Dietetic
Association (ADA).
(8) Documentation requirements:
(a) Documentation is required
for all MCM services in accordance with Division General Rule 410-120-1360; and
(b) A correctly completed Division
form 2470, 2471, 2472 and 2473 or their equivalents meet minimum documentation requirements
for MCM services.
(9) G9001 — Initial Assessment
must be performed by a licensed maternity case manager as defined under (6)(a)(A-G)
in this rule:
(a) Services include:
(A) Client assessment as outlined
in the "Definitions" section of this rule;
(B) Development of a CSP that
addresses identified needs;
(C) Making and assisting with
referrals as needed to:
(i) A prenatal care provider;
(ii) A dental health provider;
(D) Forwarding the Initial Assessment
and the CSP to the prenatal care provider;
(E)
Communicating pertinent information to the prenatal care provider and others participating
in the client's medical and social care;
(b) Data sources relied upon may include:
(A) Initial Assessment;
(B) Client interviews;
(C) Available records;
(D) Contacts with collateral
providers;
(E) Other professionals; and
(F) Other parties on behalf
of the client;
(c) The client's record must
reflect the date and to whom the Initial Assessment was sent;
(d) The Initial Assessment (G9001)
is billable once per pregnancy per provider and must be performed before providing
any other MCM services. Only a Home/Environmental Assessment (G9006) and a Case
Management Home Visit (G9012) or Case Management Visit Outside the Home (G9011)
may be performed and billed on the same day as an Initial Assessment.
(10) G9002 — Case Management
includes:
(a) Face-to-face client contacts;
(b) Implementation and monitoring
of a CSP:
(A) The client's records must
include a CSP and written updates to the plan;
(B) The CSP includes determining
the client's strengths and needs, setting specific goals and utilizing appropriate
resources in a cooperative effort between the client and the maternity case manager;
(c) Care coordination as follows:
(A) Contact with Department
of Human Services (Department) case worker, if assigned;
(B) Maintain contact with prenatal
care provider to ensure service delivery, share information, and assist with coordination;
(C) Contact with other community
resources/agencies to address needs;
(d) Linkage to client services
indicated in the CSP:
(A) Make linkages, provide information
and assist the client in self-referral;
(B) Provide linkage to labor
and delivery services;
(C) Provide linkage to family
planning services as needed;
(e) Ongoing nutritional evaluation
with basic counseling and referrals to nutritional counseling, as indicated;
(f) Utilization and documentation
of the “5 A’s” brief intervention protocol for addressing tobacco
use (US Public Health Service Clinical Practice Guideline for Treating Tobacco Use
and Dependence, 2008). Routinely:
(A) Ask all clients about smoking
status;
(B) Advise all smoking clients
to quit;
(C) Assess for readiness to
try to quit;
(D) Assist all those wanting
to quit by referring them to the Quitline and/or other appropriate tobacco cessation
counseling and provide motivational information for those not ready to quit;
(E) Arrange follow-up for interventions;
(g) Provide training and education
on all mandatory topics - Refer to Table 130-0595-2 in this rule;
(h) Provide client advocacy
as necessary to facilitate access to benefits or services;
(i) Assist client in achieving
the goals in the CSP;
(j) G9002 is billable when three
months or more of services were provided. Services must be initiated during the
prenatal period and carried through the date of delivery;
(k) G9002 is billable once per
pregnancy.
(11) G9005 — High Risk Case Management:
(a) Enhanced level of services
that are more intensive and are provided in addition to G9002;
(b) A client can be identified
as high risk at any time when case management services are provided, therefore G9005
can be billed after 3 months of case management services.
(c) G9005 is billable only once
per pregnancy per provider.
(d) G9002 can not be billed
in addition to G9005.
(12) S9470 — Nutritional
counseling:
(a) Is available for clients
who have at least one of the following conditions:
(A) Chronic disease such as
diabetes or renal disease;
(B) Hematocrit (Hct) less than
34 or hemoglobin (Hb) less than 11 during the first trimester, or Hct less than
32 or Hb less than 10 during the second or third trimester;
(C) Pre-gravida weight under
100 pounds or over 200 pounds;
(D) Pregnancy weight gain outside
the appropriate Women, Infants and Children (WIC) guidelines;
(E) Eating disorder;
(F) Gestational diabetes;
(G) Hyperemesis;
(H) Pregnancy induced hypertension
(pre-eclampsia); or
(I) Other identified conditions;
(b) Documentation must include
all of the following:
(A) Nutritional assessment;
(B) Nutritional care plan;
(C) Regular client follow-up;
(c) Can be billed in addition
to other MCM services;
(d) S9470 is billable only once
per pregnancy.
(13) G9006 — Home/Environmental
Assessment:
(a) Includes an assessment of
the health and safety of the client's living conditions with training and education
of all topics as indicated in Table 130-0595-1 in this rule;
(b) G9006 may be billed only
once per pregnancy, except an additional Home/Environmental Assessments may be billed
with documentation of problems which necessitate follow-up assessments or when a
client moves. Documentation must be submitted with the claim to support the additional
Home/Environment Assessment.
(14) G9011 — Case Management
Visit Outside the Home:
(a) A face-to-face encounter
between a maternity case manager and the client in a place other than the home which
meets all requirements of a Case Management Home Visit (G9012) or a telephone encounter
when a face-to-face Case Management Visit is not possible or practical;
(b) G9011 is billable in lieu
of a Case Management Home Visit and counted towards the total number of Case Management
Home Visits (see G9012 for limitations).
(15) G9012 – Case Management
Home Visit:
(a) Each Case Management Home
Visit must be performed in the client’s home and must include:
(A) An evaluation and/or revision
of objectives and activities addressed in the CSP: and
(B) At least two training and
education topics listed in Table 130-0595-2 in this rule;
(b) Four Case Management Home
Visits (G9012) may be billed per pregnancy. Case Management Visits Outside the Home
(G9011) are included in this limitation;
(c) Six additional Case Management
Home Visits may be billed if the client is identified as high risk and services
were provided for three months or longer;
(d) These additional six visits
may only be billed with or after High Risk Case Management (G9005) has been billed.
Case Management Visits Outside the Home (G9011) are included in this limitation.
(16) Table 130-0595-1
(17) Table 130-0595-2
[ED. NOTE:
Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 413.042 &
414.065

Stats. Implemented: ORS 414.065

Hist.: AFS 57-1987, f. 10-29-87,
ef. 11-1-87; AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. &
cert. ef. 8-24-89, Renumbered from 461-014-0200 & 461-014-0201; AFS 54-1989(Temp),
f. 9-28-89, cert. ef. 10-1-89; AFS 71-1989, f. & cert. ef. 12-1-89; HR 10-1990,
f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0580; HR 19-1991, f. 4-12-91,
cert. ef. 5-1-91; HR 43-1991, f. & cert. ef. 10-1-91; HR 42-1994, f. 12-30-94,
cert. ef. 1-1-95; HR 4-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 34-1998, f. &
cert. ef. 10-1-98; OMAP 17-1999, f. & cert. ef. 4-1-99; OMAP 31-2000, f. 9-29-00,
cert. ef. 10-1-00; OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 51-2002, f.
& cert. ef. 10-1-02; OMAP 23-2003, f. 3-26-03 cert. ef. 4-1-03; Renumbered from
410-130-0100, OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03; OMAP 58-2004, f. 9-10-04,
cert. ef. 10-1-04; OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 5-2007, f. 6-14-07, cert. ef. 7-1-07; DMAP 18-2009, f.
6-12-09, cert. ef. 7-1-09; DMAP 8-2010(Temp), f. 4-13-10, cert. ef. 4-15-10 thru
10-1-10; DMAP 24-2010, f. & cert. ef. 9-1-10; DMAP 22-2011(Temp), f. 7-29-11,
cert. ef. 8-1-11 thru 1-25-12; DMAP 43-2011, f. 12-21-11, cert. ef. 1-1-12
410-130-0610
Telemedicine
(1) For the purposes of this rule, telemedicine is defined as the use of telephonic or electronic communications to medical information from one site to another to improve a patient’s health status.
(2) Unless authorized in OAR 410-120-1200 Exclusions, other types of telecommunications are not covered, such as telephone calls, images transmitted via facsimile machines and electronic mail:
(a) When those types are not being used in lieu of videoconferencing, due to limited videoconferencing equipment access, or
(b) When those types and specific services are not specifically allowed in this rule per the Oregon Health Services Commission’s Prioritized List of Health Services and Practice Guideline.
(3) Provider Requirements:
(a) The referring and evaluating practitioner must be licensed to practice medicine within the state of Oregon or within the contiguous area of Oregon and must be enrolled as a Division of Medical Assistance Programs (Division) provider.
(b) For Addiction and Mental Health Division (AMH) providers, in addition to being enrolled as a Division provider under (3)(a). AMH providers must have an AMH agency letter of approval, certification of Approval or license issued by AMH. Individuals must also be providing covered services and be authorized to submit claims for covered telemedicine services under this rule.
(c) Providers billing for covered telemedicine services are responsible for the following:
(A) Complying with Health Insurance Portability and Accountability Act (HIPAA) and Authority Confidentiality and Privacy Rules and security protections for the patient in connection with the telemedicine communication and related records. Examples of applicable Authority rules are Confidentiality and Privacy Rules: OAR 943 Division 14 and 407-014-0300 to 407-014-0320 (Access Control); OAR 943-120-0170, 410-120-1360, and 410-120-1380. Examples of federal and state privacy and security laws that may apply include, if applicable, HIPAA (45 CFR Parts 160, 162, and 164), and 42 CFR Part 2, and ORS 646A.600 to 646A.628 (Oregon Consumer Identity Theft Protection Act);
(B) Obtaining and maintaining technology used in the telemedicine communication that is compliant with privacy and security standards in HIPAA and Department Privacy and Confidentiality Rules described in subsection (3)(A);
(C) Ensuring policies and procedures are in place to prevent a breach in privacy or exposure of patient health information or records (whether oral or recorded in any form or medium) to unauthorized persons;
(D) Complying with the relevant Health Evidence Review Commission (HERC) practice guideline for telephone and email consultation. Refer to the current prioritized list and practice guidelines at www.oregon.gov/oha/herc/Pages/PrioritizedList.aspx;
(E) Maintaining clinical and financial documentation related to telemedicine services as required in OAR 410-120-1360.
(4) Coverage for telemedicine services:
(a) The telemedicine definition encompasses different types of programs, services and delivery mechanisms for medically appropriate covered services within the patient’s benefit package;
(b) Patient consultations using telephone and online or electronic mail (e-mail) are covered when billed services comply with the practice guidelines set forth by the Health Service Commission (HSC) and the applicable HSC-approved code requirements, delivered consistent with the HSC practice guideline;
(c) Patient consultations using videoconferencing, a synchronous (live two-way interactive) video transmission resulting in real time communication between a medical practitioner located in a distant site and the client being evaluated and located in an originating site, is covered when billed services comply with the billing requirements stated in below;
(d) Telephonic codes may be used in lieu of videoconferencing codes, if videoconferencing equipment is not available.
(5) Telephone and E-mail billing requirements: Use the Evaluation and Management (E/M) code authorized in the HSC practice guideline, unless otherwise authorized in OAR 410-120-1200.
(6) Videoconferencing billing requirements:
(a) Only the transmission site (where the patient is located) may bill for the transmission:
(A) Bill the transmission with code Q3014;
(B) The referring practitioner may bill an E/M code only if a separately identifiable visit is performed. The visit must meet all of the criteria of the E/M code billed;
(C) The referring provider is not required to be present with the client at the originating site.
(b) The evaluating practitioner at the distant site may bill for the evaluation, but not for the transmission (code Q3014):
(A) Bill the most appropriate E/M code for the evaluation;
(B) Add modifier GT to the E/M code to designate that the evaluation was made by a synchronous (live and interactive) transmission.
(c) In addition, for AMH services specifically identified as allowable for telephonic delivery when appropriate, refer to the procedure code and reimbursement rates published by AMH.
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065

Hist.: OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05; DMAP 10-2008(Temp), f. & cert. ef. 4-1-08 thru 9-15-08; DMAP 20-2008, f. 6-13-08, cert. ef. 7-1-08
410-130-0670
Death With Dignity
(1) All Death with Dignity services must be billed directly to the Division of Medical Assistance Programs (Division), even if the client is in a managed care plan.
(2) Death with Dignity is a covered service, incorporated in the "comfort care" condition/treatment line on the Health Services Commission's Prioritized List of Health Services.
(3) The following physician visits and medical encounters are billable when performed by a licensed physician or psychologist:
(a) The medical confirmation of the terminal condition;
(b) The two visits in which the client makes the oral request;
(c) The visit in which the written request is made;
(d) The visit in which the prescription is written;
(e) Counseling consultation(s); and
(f) Medication and dispensing.
(4) More than one of the services listed in sections (3)(a) through (3)(f) may be provided during the same visit. Additional visits for discussion or counseling are also covered for payment.
(5) Billing:
(a) All claims for Death with Dignity services must be made on a paper CMS-1500 billing form;
(b) Do not submit a claim for Death with Dignity services electronically or on an 837P;
(c) Claims must be submitted using appropriate CPT or HCPCS codes;
(d) The Division unique diagnosis code PAD-00 must be entered in Field 21 of the CMS-1500 billing form. Do not list any additional diagnosis codes in this field;
(e) Claims must be submitted only on paper to: Division, PO Box 992, Salem, Oregon 97308-0992;
(f) Prescriptions must be billed only with the Division unique code 8888-PAID-00. This code must be entered in Field 24D of the CMS-1500. In addition, the actual NDC number of the drug dispensed and the dosage must be listed below the prescription code;
(g) the Division may be billed for prescription services only when the pharmacy has been properly notified by the physician in accordance with OAR 847-015-0035. This OAR requires the physician to have the client's written consent to contact and inform the pharmacist of the purpose of the prescription.
[ED. NOTE: Forms referenced available from the agency.]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065

Hist.: OMAP 46-1998, f. & cert. ef.12-1-98; OMAP 17-1999, f. & cert. ef. 4-1-99; OMAP 2-2000, f. 3-31-00, cert. ef. 4-1-00; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06
410-130-0680
Laboratory and Radiology
(1) The following tables list the medical and surgical services that:
(a) Require prior authorization (PA) — OAR 410-130-0200 Table 130-0200-1 (PET scans require PA and are included in the table), and;
(b) Are not covered/bundled — OAR 410-130-0220 Table 130-0220-1.
(2) Newborn screening (NBS) kits and collection and handling for newborn screening (NBS) tests performed by the Oregon State Public Health Laboratory (OSPHL) are considered bundled into the delivery fee and, therefore, must not be billed separately. Replacement of lost NBS kits may be billed with code S3620 with modifier –TC. The loss must be documented in the client's medical record. NBS confirmation tests performed by reference laboratories at the request of the OSPHL will be reimbursed only to the OSPHL.
(3) The Division of Medical Assistance Programs (Division) covers lab tests performed in relation to a transplant only if the transplant is covered and if the transplant has been authorized. See the Division Transplant Services administrative rules (chapter 410, division 124).
(4) All lab tests must be specifically ordered by, or at the direction of a licensed medical practitioner within the scope of their license.
(5) If a lab sends a specimen to a reference lab for additional testing, the reference lab may not bill for the same tests performed by the referring lab.
(6) When billing for lab tests, use the date that the specimen was collected as the date of service (DOS) even if the tests were not performed on that date.
(7) Reimbursement for drawing/collecting or handling samples:
(a) The Division will reimburse providers once per day regardless of the frequency performed for drawing/collecting the following samples:
(A) Blood — by venipuncture or capillary puncture, and;
(B) Urine — only by catheterization.
(b) The Division will not reimburse for the collection and/or handling of other specimens, such as PAP or other smears, voided urine samples, or stool specimens. Reimbursement is bundled in the reimbursement for the exam and/or lab procedures and is not payable in addition to the laboratory test.
(8) Pass-along charges from the performing laboratory to another laboratory, medical practitioner, or specialized clinic are not covered for payment and are not to be billed to the Division.
(9) Only the provider who performs the test(s) may bill the Division.
(10) Clinical Laboratory Improvement Amendments (CLIA) Certification:
(a) The Division will only reimburse laboratory services to providers who are CLIA certified by the Centers for Medicare and Medicaid Services (CMS);
(b) CLIA requires all entities that perform even one test, including waived tests on... "materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of, human beings" to meet certain Federal requirements. If an entity performs tests for these purposes, it is considered under CLIA to be a laboratory;
(c) Providers must notify the Division of the assigned ten-digit CLIA number;
(d) Payment is limited to the level of testing authorized by the CLIA certificate at the time the test is performed.
(11) Organ Panels:
(a) The Division will only reimburse panels as defined by the CPT codes for the year the laboratory service was provided. Tests within a panel may not be billed individually even when ordered separately. The same panel may be billed only once per day per client;
(b) The Division will pay at the panel maximum allowable rate if two or more tests within the panel are billed separately and the total reimbursement rate of the combined codes exceeds the panel rate, even if all the tests listed in the panel are not ordered or performed.
(12) Radiology:
(a) Provision of diagnostic and therapeutic radionuclide(s), HCPCS A9500-A9699, are payable only when given in conjunction with radiation oncology and nuclear medicine codes 77401-79999;
(b) HCPCS codes R0070 through R0076 are covered.
(13) Reimbursement of contrast and diagnostic-imaging agents is bundled in the radiology procedure except for low osmolar contrast materials (LOCM).
(14) Supply of LOCM may be billed in addition to the radiology procedure only when the following criteria are met:
(a) Prior adverse reaction to contrast material, with the exception of a sensation of heat, flushing or a single episode of nausea or vomiting;
(b) History of asthma or significant allergies;
(c) Significant cardiac dysfunction including recent or imminent cardiac decompensation, severe arrhythmia, unstable angina pectoris, recent myocardial infarction or pulmonary hypertension;
(d) Decrease in renal function;
(e) Diabetes;
(f) Dysproteinemia;
(g) Severe dehydration;
(h) Altered blood brain barrier (i.e., brain tumor, subarachnoid hemorrhage);
(i) Sickle cell disease, or;
(j) Generalized severe debilitation.
(15) X-ray and EKG interpretations in the emergency room:
(a) The Division reimburses only for one interpretation of an emergency room patient’s x-ray or EKG. The interpretation and report must have directly contributed to the diagnosis and treatment of the patient;
(b) The Division considers a second interpretation of an x-ray or EKG to be for quality control purposes only and will not be reimbursed;
(c) Payment may be made for a second interpretation only under unusual circumstances, such as a questionable finding for which the physician performing the initial interpretation believes another physician’s expertise is needed.
[ED. NOTE: Tables referenced are available from the agency.]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065

Hist.: AFS 57-1983, f. 11-29-83, ef. 1-1-84; AFS 48-1984(Temp), f. 11-30-84, ef. 12-1-84; AFS 29-1985, f. 5-22-85, ef. 5-29-85; AFS 50-1986, f. 6-30-86, ef. 8-1-86; AFS 56-1987, f. 10-29-87, ef. 11-1-87; Renumbered from 461-014-0056, AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. & cert. ef. 8-24-89; HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0800; HR 19-1991, f. 4-12-91, cert. ef. 5-1-91; HR 43-1991, f. & cert. ef. 10-1-91; HR 8-1992, f. 2-28-92, cert. ef. 3-1-92; HR 27-1992(Temp), f. & cert. ef. 9-1-92; HR 33-1992, f. 10-30-92, cert. ef. 11-1-92; HR 40-1992, f. 12-31-92, cert. ef. 2-1-93; HR 6-1994, f. & cert. ef. 2-1-94; HR 42-1994, f. 12-30-94, cert. ef. 1-1-95; HR 10-1996, f. 5-31-96, cert. ef. 6-1-96; HR 4-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98; OMAP 15-1998, f. & cert. ef. 5-1-98; OMAP 17-1999, f. & cert. ef. 4-1-99; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 51-2002, f. & cert. ef. 10-1-02; OMAP 23-2003, f. 3-26-03 cert. ef. 4-1-03; OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03; OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05; OMAP 50-2005, f. 9-30-05, cert. ef. 10-1-05; OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06; DMAP 20-2008, f. 6-13-08, cert. ef. 7-1-08
410-130-0700
HCPCS Supplies and DME
(1) Use appropriate HCPCS codes to bill all supplies and DME.
(2) For items that do not have specific HCPCS codes:
(a) Use unlisted HCPCS code;
(b) Bill at acquisition cost, purchase price plus postage.
(3) CPT code 99070 is no longer billable for supplies and materials. Use HCPCS codes.
(4) Use S3620 with modifier TC for lost newborn screening (NBS) kits.
(5) The Division of Medical Assistance Programs (Division) bundles reimbursement for office surgical suites and office equipment in the reimbursement of surgical procedures.
(6) Contraceptive Supplies — Refer to OAR 410-130-0585.
(7) A4000-A9999:
(a) All “A” codes listed in Table 130-0700-1 are covered under this program;
(b) All “A” codes not listed in Table 130-0700-1 must be referred to a Durable Medical Equipment (DME) provider;
(c) Do not use A4570, A4580 and A4590 for splint and cast materials. Use codes Q4001-Q4051;
(d) A9150-A9999 (administrative, investigational, and miscellaneous) are not covered, except for A9500-A9699. Refer to OAR 410-130-0680.
(8) B4000-B9999:
(a) HCPCS codes B4034-B4036 and B4150-B9999 are not covered for medical-surgical providers;
(b) Refer these services to home enteral/parenteral providers.
(9) C1000-C9999 are not covered.
(10) E0100-E1799: Division covers only the following DME HCPCS codes for medical-surgical providers when provided in an office setting:
(a) E0100-E0116;
(b) E0602;
(c) E0191;
(d) E1399;
(e) Refer all other items with "E" series HCPCS codes to DME providers.
(11) J0000-J9999 HCPCS codes — Refer to OAR 410-130-0180 for coverage of drugs.
(12) K0000-K9999 HCPCS codes — Refer all items with "K" series to DME providers.
(13) L0000-L9999:
(a) Refer to the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies program Administrative rules for coverage criteria for orthotics and prosthetics;
(b) Refer to Table 130-0220-1 for a list of “L” codes that are not covered;
(c) Reimbursement for orthotics is a global package, which includes:
(A) Measurements;
(B) Moldings;
(C) Orthotic items;
(D) Adjustments;
(E) Fittings;
(F) Casting and impression materials.
(d) Evaluation and Management codes are covered only for the diagnostic visit where the medical appropriateness for the orthotic is determined and for follow-up visits unrelated to the fitting of the orthotic.
(14) Refer to Table 130-0700-1 for supplies and DME covered in the office setting.
[ED. NOTE: Tables referenced are available from the agency.]
Stat. Auth.: ORS 413.042

Stats. Implemented: ORS 414.025 & 414.065

Hist.: AFS 57-1983, f. 11-29-83, ef. 1-1-84; AFS 48-1984(Temp), f. 11-3084, ef. 12-1-84; AFS 29-1985, f. 5-22-85, ef. 5-29-85; AFS 50-1986, f. 6-30-86, ef. 8-1-86; AFS 56-1987, f. 10-29-87, ef. 11-1-87; Renumbered from 461-014-0056, AFS 5-1989(Temp), f. 2-9-89, cert. ef. 3-1-89; AFS 48-1989, f. & cert. ef. 8-24-89; HR 10-1990, f. 3-30-90, cert. ef. 4-1-90, Renumbered from 461-014-0810; HR 19-1991, f. 4-12-91, cert. ef. 5-1-91; HR 40-1992, f. 12-31-92, cert. ef. 2-1-93; HR 6-1994, f. & cert. ef. 2-1-94; HR 42-1994, f. 12-30-94, cert. ef. 1-1-95; HR 4-1997, f. 1-31-97, cert. ef. 2-1-97; OMAP 3-1998, f. 1-30-98, cert. ef. 2-1-98; OMAP 17-1999, f. & cert. ef. 4-1-99; OMAP 4-2000, f. 3-31-00, cert. ef. 4-1-00; OMAP 31-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 13-2001, f. 3-30-01, cert. ef. 4-1-01; OMAP 40-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 2-2002, f. 2-15-02, cert. ef. 4-1-02; OMAP 51-2002, f. & cert. ef. 10-1-02; OMAP 23-2003, f. 3-26-03 cert. ef. 4-1-03; OMAP 69-2003 f. 9-12-03, cert. ef. 10-1-03; OMAP 13-2004, f. 3-11-04, cert. ef. 4-1-04; OMAP 8-2005, f. 3-9-05, cert. ef. 4-1-05; OMAP 26-2006, f. 6-14-06, cert. ef. 7-1-06

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