907 KAR 1:104. Reimbursement for advanced registered nurse practitioner services.

 

      RELATES TO: KRS 205.520

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 42 U.S.C. 1396a, b, c, d, 42 U.S.C. 447.200, EO 2004-726

      NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services and placed the Department for Medicaid Services and the Medicaid Program under the Cabinet for Health and Family Services. The Cabinet for Health and Family Services, Department for Medicaid Services, has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed, or opportunity presented, by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes the method for determining amounts payable by the cabinet for a service provided by an advanced practice nurse practitioner (APRN).

 

      Section 1. Definitions. (1) "Advanced practice registered nurse" or "APRN" is defined in KRS 314.011(7).

      (2) "Department" means the Department for Medicaid Services or its designated agent.

 

      Section 2. Reimbursement. (1) Except as specified in subsection (2) of this section or Section 3 of this administrative regulation, reimbursement for a procedure shall be based on the lesser of the following:

      (a) The APRN's actual billed charge for the service; or

      (b) Seventy-five (75) percent of the amount reimbursable to a Medicaid participating physician for the same service pursuant to 907 KAR 3:010.

      (2) An APRN employed by a primary care center, federally qualified health center, hospital, or comprehensive care center shall not be reimbursed directly for services provided in that setting while operating as an employee.

 

      Section 3. Reimbursement Limitations. (1) The department shall reimburse an APRN a three (3) dollar and thirty (30) cent fee for each vaccine administered to a Medicaid recipient under the age of twenty-one (21) up to a maximum of three (3) administrations per APRN, per recipient, per date of service.

      (2) The department shall not reimburse an APRN for the cost of a vaccine which is available free through the Vaccines for Children Program in accordance with 42 U.S.C. 1396s.

      (3) Injectable antibiotics, antineoplastic chemotherapy, and contraceptives in accordance with 907 KAR 1:102, Section 3(4), shall be reimbursed for an APRN at the lesser of:

      (a) The actual billed charge; or

      (b) The average wholesale price of the medication supply minus ten (10) percent.

      (4) Reimbursement for an orthopedic service requiring casting or splinting shall be restricted as follows:

      (a) Payment for a cast or splint applied in conjunction with a surgical procedure shall be inclusive in the payment of the surgical procedure;

      (b) Payment shall not be made for a cast or splint application for the same injury or condition within ninety (90) days of the date of the surgical service; and

      (c) A cast or splint applied for a subsequent injury or condition within ninety (90) days of the first cast or splint application shall be reimbursed if accompanied by supporting documentation.

      (5) Reimbursement of an anesthesia service provided during a procedure shall be inclusive of the following elements:

      (a) Preoperative and postoperative visits;

      (b) Administration of the anesthetic;

      (c) Administration of intravenous fluids and blood or blood products incidental to the anesthesia or surgery;

      (d) Postoperative pain management; and

      (e) Monitoring services.

      (6) Reimbursement of a psychiatric service provided by an APRN shall be limited to four (4) psychiatric services per APRN, per recipient, per twelve (12) months.

      (7) Reimbursement for a laboratory service provided in an office setting shall include the fee for collecting and analyzing a specimen.

      (8) A fee for a laboratory test requiring an arterial puncture or a venipuncture shall include the fee for the puncture.

      (9) Reimbursement shall be limited to one (1) of the following evaluation and management services per recipient, per date of service:

      (a) A consultation service;

      (b) A critical care service;

      (c) An emergency department evaluation and management service;

      (d) A home evaluation and management service;

      (e) A hospital inpatient evaluation and management service;

      (f) A nursing facility service;

      (g) An office or other outpatient evaluation and management service;

      (h) A preventive medicine service; or

      (i) A psychiatric or psychotherapy service.

 

      Section 4. Appeal Rights. (1) An appeal of a negative action taken by the department regarding a Medicaid beneficiary shall be in accordance with 907 KAR 1:563.

      (2) An appeal of a negative action taken by the department regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.

      (3) An appeal of a negative action taken by the department regarding a Medicaid provider shall be in accordance with 907 KAR 1:671. (17 Ky.R. 2366; eff. 5-3-1991; Am. 19 Ky.R. 1454; eff. 1-27-1993; 27 Ky.R. 247; 812; eff. 9-11-2000; TAm 4-28-2011.)