††††† 907 KAR 3:005. Physicians' services.

 

††††† RELATES TO: KRS 205.520, 205.560, 42 C.F.R. 415.152, 415.174, 415.184, 440.50, 45 C.F.R. 160, 164, 42 U.S.C. 1320-1320d-8

††††† STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 205.560(1)

††††† NECESSITY, FUNCTION, AND CONFORMITY: 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 provisions relating to physicians' services for which payment shall be made by the Medicaid Program on behalf of both the categorically needy and the medically needy.

 

††††† Section 1. Definitions. (1) "Biological" means the definition of "biologicals" pursuant to 42 U.S.C. 1395x(t)(1).

††††† (2) "Common practice" means a contractual partnership in which a physician assistant administers health care services under the employment and supervision of a physician.

††††† (3) "Comprehensive choices" means a benefit plan for an individual who:

††††† (a) Meets the nursing facility patient status criteria established in 907 KAR 1:022;

††††† (b) Receives services through either:

††††† 1. A nursing facility in accordance with 907 KAR 1:022;

††††† 2. The Acquired Brain Injury Waiver Program in accordance with 907 KAR 3:090;

††††† 3. The Home and Community Based Waiver Program in accordance with 907 KAR 1:160; or

††††† 4. The Model Waiver II Program in accordance with 907 KAR 1:595; and

††††† (c) Has a designated package code of F, G, H, I, J, K, L, M, O, P, Q, or R.

††††† (4) "CPT code" means a code used for reporting procedures and services performed by physicians and published annually by the American Medical Association in Current Procedural Terminology.

††††† (5) "Department" means the Department for Medicaid Services or its designee.

††††† (6) "Direct physician contact" means that the billing physician is physically present with and evaluates, examines, treats, or diagnoses the recipient.

††††† (7) "Drug" means the definition of "drugs" pursuant to 42 U.S.C. 1395x(t)(1).

††††† (8) "Emergency care" means:

††††† (a) Covered inpatient and outpatient services furnished by a qualified provider that are needed to evaluate or stabilize an emergency medical condition that is found to exist using the prudent layperson standard; or

††††† (b) Emergency ambulance transport.

††††† (9) "EPSDT" means early and periodic screening, diagnosis, and treatment.

††††† (10) "Family choices" means a benefit plan for an individual who is covered pursuant to:

††††† (a) 42 U.S.C. 1396a(a)(10)(A)(i)(I) and 1396u-1;

††††† (b) 42 U.S.C. 1396a(a)(52) and 1396r-6 (excluding children eligible under Part A or E of Title IV, codified as 42 U.S.C. 601 to 619 and 670 to 679b);

††††† c. 42 U.S.C. 1396a(a)(10)(A)(i)(IV) as described in 42 U.S.C. 1396a(l)(1)(B);

††††† c. 42 U.S.C. 1396a(a)(10)(A)(i)(VI) as described in 42 U.S.C. 1396a(l)(1)(C);

††††† d. 42 U.S.C. 1396a(a)(10)(A)(i)(VII) as described in 42 U.S.C. 1396a(l)(1)(D); or

††††† e. Has a designated package code of 2, 3, 4, or 5.

††††† (11) "Global period" means occurring during the period of time in which related preoperative, intraoperative, and postoperative services and follow-up care for a surgical procedure are customarily provided.

††††† (12) "Global choices" means the department's default benefit plan, consisting of individuals designated with a package code of A, B, C, D, or E and who are included in one (1) of the following populations:

††††† (a) Caretaker relatives who:

††††† 1. Receive Kentucky Transitional Assistance Program (K-TAP) benefits and are deprived due to death, incapacity, or absence;

††††† 2. Do not receive K-TAP benefits and are deprived due to death, incapacity, or absence; or

††††† 3. Do not receive K-TAP benefits and are deprived due to unemployment;

††††† (b) Individuals aged sixty-five (65) and over who receive supplemental security income (SSI) benefits and:

††††† 1. Do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022; or

††††† 2. Receive state supplementations program (SSP) benefits and do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022;

††††† (c) Blind individuals who receive SSI benefits and:

††††† 1. Do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022; or

††††† 2. SSP benefits, and do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022;

††††† (d) Disabled individuals who receive SSI benefits and:

††††† 1. Do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022, including children; or

††††† 2. SSP benefits, and do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022;

††††† (e) Individuals aged sixty-five (65) and over who have lost SSI or SSP benefits, are eligible for "pass through" Medicaid benefits, and do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022;

††††† (f) Blind individuals who have lost SSI or SSP benefits, are eligible for "pass through" Medicaid benefits, and do not meet nursing facility patient status in accordance with 907 KAR 1:022;

††††† (g) Disabled individuals who have lost SSI or SSP benefits, are eligible for "pass through" Medicaid benefits, and do not meet nursing facility patient status in accordance with 907 KAR 1:022; or

††††† (h) Pregnant women.

††††† (13) "Graduate medical education program" or "GME Program" means one (1) of the following:

††††† (a) A residency program approved by:

††††† 1. The Accreditation Council for Graduate Medical Education of the American Medical Association;

††††† 2. The Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association;

††††† 3. The Commission on Dental Accreditation of the American Dental Association; or

††††† 4. The Council on Podiatric Medicine Education of the American Podiatric Medical Association; or

††††† (b) An approved medical residency program as defined in 42 C.F.R. 413.75(b).

††††† (14) "Incidental" means that a medical procedure is performed at the same time as a primary procedure and:

††††† (a) Requires little additional resources; or

††††† (b) Is clinically integral to the performance of the primary procedure.

††††† (15) "Integral" means that a medical procedure represents a component of a more complex procedure performed at the same time.

††††† (16) "KenPAC" means the Kentucky Patient Access and Care System.

††††† (17) "KenPAC PCP" means a Medicaid provider who is enrolled as a primary care provider in the Kentucky Patient Access and Care System.

††††† (18) "Locum tenens" means a substitute physician:

††††† (a) Who temporarily assumes responsibility for the professional practice of a physician participating in the Kentucky Medicaid Program; and

††††† (b) Whose services are paid under the participating physicianís provider number.

††††† (19) "Medical necessity" or "medically necessary" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

††††† (20) "Medical resident" means one (1) of the following:

††††† (a) An individual who participates in an approved graduate medical education (GME) program in medicine or osteopathy; or

††††† (b) A physician who is not in an approved GME program, but who is authorized to practice only in a hospital, including:

††††† 1. An individual with a:

††††† a. Temporary license;

††††† b. Resident training license; or

††††† c. Restricted license; or

††††† 2. An unlicensed graduate of a foreign medical school.

††††† (21) "Mutually exclusive" means that two (2) procedures:

††††† (a) Are not reasonably performed in conjunction with one another during the same patient encounter on the same date of service;

††††† (b) Represent two (2) methods of performing the same procedure;

††††† (c) Represent medically impossible or improbable use of CPT codes; or

††††† (d) Are described in Current Procedural Terminology as inappropriate coding of procedure combinations.

††††† (22) "Optimum choices" means a benefit plan for an individual who:

††††† (a) Meets the intermediate care facility for individuals with an intellectual disability patient status criteria established in 907 KAR 1:022;

††††† (b) Receives services through either:

††††† 1. An intermediate care facility for individuals with an intellectual disability in accordance with 907 KAR 1:022; or

††††† 2. The Supports for Community Living Waiver Program in accordance with 907 KAR 1:145; and

††††† (c) Has a designated package code of S, T, U, V, W, X, Z, 0, or 1.

††††† (23) "Other licensed medical professional" means a health care provider other than a physician, physician assistant, advanced registered nurse practitioner, certified registered nurse anesthetist, nurse midwife, or registered nurse who has been approved to practice a medical specialty by the appropriate licensure board.

††††† (24) "Physician assistant" is defined in KRS 311.840(3).

††††† (25) "Screening" means the evaluation of a recipient by a physician to determine the presence of a disease or medical condition and if further evaluation, diagnostic testing or treatment is needed.

††††† (26) "Special handling, storage, shipping, dosing or administration" means one (1) or more of the following requirements as described in the dosing and administration section of a medicationís package insert:

††††† (a) Refrigeration of the medication;

††††† (b) Protection from light until time of use;

††††† (c) Overnight delivery;

††††† (d) Avoidance of shaking or freezing; or

††††† (e) Other protective measures not required for most orally-administered medications.

††††† (27) "Supervising physician" is defined in KRS 311.840(4).

††††† (28) "Supervision" is defined in KRS 311.840(6).

††††† (29) "Timely filing" means receipt of a claim by Medicaid:

††††† (a) Within twelve (12) months of the date the service was provided;

††††† (b) Within twelve (12) months of the date retroactive eligibility was established; or

††††† (c) Within six (6) months of the Medicare adjudication date if the service was billed to Medicare.

††††† (30) "Unlisted procedure or service" means a procedure for which there is not a specific CPT code and which is billed using a CPT code designated for reporting unlisted procedures or services.

 

††††† Section 2. Conditions of Participation. (1) A participating physician shall be licensed as a physician in the state in which the medical practice is located.

††††† (2) A participating physician shall comply with the terms and conditions established in the following administrative regulations:

††††† (a) 907 KAR 1:005, Nonduplication of payments;

††††† (b) 907 KAR 1:671, Conditions of Medicaid provider participation; withholding overpayments, administrative appeal process, and sanctions; and

††††† (c) 907 KAR 1:672, Provider enrollment, disclosure, and documentation for Medicaid participation.

††††† (3) A participating physician shall comply with the requirements regarding the confidentiality of personal records pursuant to 42 U.S.C. 1320d to 1320d-8 and 45 C.F.R. Parts 160 and 164.

††††† (4) A participating physician shall have the freedom to choose whether to accept an eligible Medicaid recipient and shall notify the recipient of that decision prior to the delivery of service. If the provider accepts the recipient, the provider:

††††† (a) Shall bill Medicaid rather than the recipient for a covered service;

††††† (b) May bill the recipient for a service not covered by Medicaid if the physician informed the recipient of noncoverage prior to providing the service; and

††††† (c) Shall not bill the recipient for a service that is denied by the department on the basis of:

††††† 1. The service being incidental, integral, or mutually exclusive to a covered service or within the global period for a covered service;

††††† 2. Incorrect billing procedures, including incorrect bundling of services;

††††† 3. Failure to obtain prior authorization for the service; or

††††† 4. Failure to meet timely filing requirements.

 

††††† Section 3. Covered Services. (1) To be covered by the department, a service shall be:

††††† (a) Medically necessary;

††††† (b) Clinically appropriate pursuant to the criteria established in 907 KAR 3:130;

††††† (c) Except as provided in subsection (2) of this section, furnished to a recipient through direct physician contact; and

††††† (d) Eligible for reimbursement as a physician service.

††††† (2) Direct physician contact between the billing physician and recipient shall not be required for:

††††† (a) A service provided by a medical resident if provided under the direction of a program participating teaching physician in accordance with 42 C.F.R. 415.174 and 415.184;

††††† (b) A service provided by a locum tenens physician who provides direct physician contact;

††††† (c) A radiology service, imaging service, pathology service, ultrasound study, echographic study, electrocardiogram, electromyogram, electroencephalogram, vascular study, or other service that is usually and customarily performed without direct physician contact;

††††† (d) The telephone analysis of emergency medical systems or a cardiac pacemaker if provided under physician direction;

††††† (e) A preauthorized sleep disorder service if provided in a physician operated and supervised sleep disorder diagnostic center;

††††† (f) A telehealth consultation provided by a consulting medical specialist in accordance with 907 KAR 3:170; or

††††† (g) A service provided by a physician assistant in accordance with Section 7 of this administrative regulation.

††††† (3) A service provided by an individual who meets the definition of other licensed medical professional shall be covered if:

††††† (a) The individual is employed by the supervising physician;

††††† (b) The individual is licensed in the state of practice; and

††††† (c) The supervising physician has direct physician contact with the recipient.

 

††††† Section 4. Service Limitations. (1) A covered service provided to a recipient placed in "lock-in" status in accordance with 907 KAR 1:677 shall be limited to a service provided by the lock-in provider unless:

††††† (a) The service represents emergency care; or

††††† (b) The recipient has been referred by the "lock-in" provider.

††††† (2) An EPSDT screening service shall be covered in accordance with 907 KAR 11:034, Sections 3 through 5.

††††† (3) A laboratory procedure performed in a physicianís office shall be limited to a procedure for which the physician has been certified in accordance with 42 C.F.R. Part 493.

††††† (4) Except for the following, a drug administered in the physicianís office shall not be covered as a separate reimbursable service through the physician program:

††††† (a) Rho (D) immune globulin injection;

††††† (b) An injectable antineoplastic drug;

††††† (c) Medroxyprogesterone acetate for contraceptive use, 150 mg;

††††† (d) Penicillin G benzathine injection;

††††† (e) Ceftriaxone sodium injection;

††††† (f) Intravenous immune globulin injection;

††††† (g) Sodium hyaluronate or hylan G-F for intra-articular injection;

††††† (h) An intrauterine contraceptive device; or

††††† (i) An implantable contraceptive device.

††††† (j) Long acting injectable risperidone; or

††††† (k) An injectable, infused or inhaled drug or biological that:

††††† 1. Is not typically self-administered;

††††† 2. Is not excluded as a noncovered immunization or vaccine; and

††††† 3. Requires special handling, storage, shipping, dosing or administration.

††††† (5) A service allowed in accordance with 42 C.F.R. 441, Subpart E or Subpart F, shall be covered within the scope and limitations of the federal regulations.

††††† (6) Coverage for a service designated as a psychiatry service CPT code and provided by a physician other than a board certified or board eligible psychiatrist shall be limited to four (4) services, per physician, per recipient, per twelve (12) months.

††††† (7)(a) Coverage for an evaluation and management service shall be limited to one (1) per physician, per recipient, per date of service.

††††† (b) Coverage for an evaluation and management service with a corresponding CPT code of 99214 or 99215 shall be limited to two (2) per recipient per year, per physician.

††††† (8) Coverage for a fetal diagnostic ultrasound procedure shall be limited to two (2) per nine (9) month period per recipient unless the diagnosis code justifies the medical necessity of an additional procedure.

††††† (9)(a) An anesthesia service shall be covered if administered by an anesthesiologist who remains in attendance throughout the procedure.

††††† (b) Except for an anesthesia service provided by an oral surgeon, an anesthesia service, including conscious sedation, provided by a physician performing the surgery shall not be covered.

††††† (10) The following services shall not be covered:

††††† (a) An acupuncture service;

††††† (b) Allergy immunotherapy for a recipient age twenty-one (21) years or older;

††††† (c) An autopsy;

††††† (d) A cast or splint application in excess of the limits established in 907 KAR 3:010, Section 4(5) and (6);

††††† (e) Except for therapeutic bandage lenses, contact lenses;

††††† (f) A hysterectomy performed for the purpose of sterilization;

††††† (g) Lasik surgery;

††††† (h) Paternity testing;

††††† (i) A procedure performed for cosmetic purposes only;

††††† (j) A procedure performed to promote or improve fertility;

††††† (k) Radial keratotomy;

††††† (l) A thermogram;

††††† (m) An experimental service which is not in accordance with current standards of medical practice; or

††††† (n) A service which does not meet the requirements established in Section 3(1) of this administrative regulation.

 

††††† Section 5. Prior Authorization Requirements and KenPAC Referral Requirements. (1) The following procedures shall require prior authorization by the department:

††††† (a) Magnetic resonance imaging (MRI);

††††† (b) Magnetic resonance angiogram (MRA);

††††† (c) Magnetic resonance spectroscopy;

††††† (d) Positron emission tomography (PET);

††††† (e) Cineradiography or video radiography;

††††† (f) Xeroradiography;

††††† (g) Ultrasound subsequent to second obstetric ultrasound;

††††† (h) Myocardial imaging;

††††† (i) Cardiac blood pool imaging;

††††† (j) Radiopharmaceutical procedures;

††††† (k) Gastric restrictive surgery or gastric bypass surgery;

††††† (l) A procedure that is commonly performed for cosmetic purposes;

††††† (m) A surgical procedure that requires completion of a federal consent form; or

††††† (n) An unlisted procedure or service.

††††† (2)(a) Prior authorization by the department shall not be a guarantee of recipient eligibility.

††††† (b) Eligibility verification shall be the responsibility of the provider.

††††† (3) The prior authorization requirements established in subsection (1) of this section shall not apply to:

††††† (a) An emergency service; or

††††† (b) A radiology procedure if the recipient has a cancer or transplant diagnosis code.

††††† (4) A referring physician, a physician who wishes to provide a given service, or an advanced registered nurse practitioner may request prior authorization from the department.

††††† (5) A referring physician, a physician who wishes to provide a given service, or an advanced registered nurse practitioner shall request prior authorization by mailing or faxing:

††††† (a) A written request to the department with sufficient information to demonstrate that the service meets the requirements established in Section 3(1) of this administrative regulation; and

††††† (b) If applicable, any required federal consent forms.

††††† (6) Except for a service specified in 907 KAR 1:320, Section 10(3)(a) through (q), a referral from the KenPAC PCP shall be required for a recipient enrolled in the KenPAC Program.

 

††††† Section 6. Therapy Limits. (1) Speech therapy shall be limited to:

††††† (a) Ten (10) visits per twelve (12) months for a recipient of the Global Choices benefit plan;

††††† (b) Thirty (30) visits per twelve (12) months for a recipient of the:

††††† 1. Comprehensive Choices benefit plan; or

††††† 2. Optimum Choices benefit plan.

††††† (2) Physical therapy shall be limited to:

††††† (a) Fifteen (15) visits per twelve (12) months for a recipient of the Global Choices benefit plan; or

††††† (b) Thirty (30) visits per twelve (12) months for a recipient of the:

††††† 1. Comprehensive Choices benefit plan; or

††††† 2. Optimum Choices benefit plan.

††††† (3) Occupational therapy shall be limited to:

††††† (a) Fifteen (15) visits per twelve (12) months for a recipient of the Global Choices benefit plan; or

††††† (b) Thirty (30) visits per twelve (12) months for a recipient of the:

††††† 1. Comprehensive Choices benefit plan; or

††††† 2. Optimum Choices benefit plan.

††††† (4) The therapy limits established in subsection (1) through (3) of this section shall be over-ridden if the department determines that additional visits beyond the limit are medically necessary.

††††† (5)(a) To request an override:

††††† 1. The provider shall telephone or fax the request to the department; and

††††† 2. The department shall review the request in accordance with the provisions of 907 KAR 3:130 and notify the provider of its decision.

††††† (b) An appeal of a denial regarding a requested override shall be in accordance with 907 KAR 1:563.

††††† (6) The limits established in subsections (1), (2), and (3) of this section shall not apply to a recipient under twenty-one (21) years of age. Except for recipients under age twenty-one (21), prior authorization shall be required for each visit that exceeds the limit established in subsection (1) through (3) of this section.

 

††††† Section 7. Physician Assistant Services. (1) With the exception of a service limitation specified in subsections (2) or (3) of this section, a service provided by a physician assistant in common practice with a Medicaid-enrolled physician shall be covered if:

††††† (a) The service meets the requirements established in Section 3(1) of this administrative regulation;

††††† (b) The service is within the legal scope of certification of the physician assistant;

††††† (c) The service is billed under the physician's individual provider number with the physician assistant's number included; and

††††† (d) The physician assistant complies with:

††††† 1. KRS 311.840 to 311.862; and

††††† 2. Sections 2(2) and (3) of this administrative regulation.

††††† (2) A same service performed by a physician assistant and a physician on the same day within a common practice shall be considered as one (1) covered service.

††††† (3) The following physician assistant services shall not be covered:

††††† (a) A physician noncovered service specified in Section 4(10) of this administrative regulation;

††††† (b) An anesthesia service;

††††† (c) An obstetrical delivery service; or

††††† (d) A service provided in assistance of surgery.

 

††††† Section 8. Appeal Rights. (1) An appeal of a department decision regarding a Medicaid recipient based upon an application of this administrative regulation shall be in accordance with 907 KAR 1:563.

††††† (2) An appeal of a department decision regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.

††††† (3) An appeal of a department decision regarding a Medicaid provider based upon an application of this administrative regulation shall be in accordance with 907 KAR 1:671. (23 Ky.R. 1308; eff. 9-18-96; Am. 25 Ky.R. 1737; 2574; eff. 5-19-99; 30 Ky.R. 747; 1541; eff. 1-5-2004; 33 Ky.R. 617; 1405; 1585; eff. 1-5-07; 34 Ky.R. 451; 1474; eff. 1-4-2008; TAm 4-28-2011; TAm 7-16-2013.)