reglab/statecodes huggingface dataset:
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 210 - Ambulatory Surgical Centers › Chapter 1 - General › Rule 23-210-1.6 - Reimbursement

Current through June 25, 2024
A. Mississippi Medicaid Ambulatory Surgical
				Care (ASC) rates are updated October 1 of each year based on eighty percent
				(80%) of the Medicare ASC Payment System rate in effect July 1 of that year set
				by the Center for Medicare and Medicaid Services (CMS).
B. Reimbursement is in accordance with the
				Medicaid ASC Procedure Schedule or the provider's usual and customary charges,
				whichever is less.
C. The Division
				of Medicaid reimburses for multiple procedures as outlined in Miss. Admin. Code
				Part 203, Chapter 4.
D. Surgical or
				other procedures canceled due to scheduling conflicts of the operating suite or
				physician, beneficiary request, or other reason not related to medical
				necessity, cannot be billed and no payment will be made for the procedure.
				Services provided prior to the procedure may be billed and are subject to
				coverage rules for those services.
E. For surgical or other procedures canceled
				or terminated before completion due to changes in the beneficiary's medical
				condition that threaten his/her well-being, only the services that were
				actually performed may be billed are subject to coverage rules for those
				services. Clear documentation regarding the medical necessity for cancellation
				or termination of the procedure must be provided.
F. ASC providers must bill the procedure code
				that accurately reflects the dental services rendered as follows:
1. Dental procedures performed by a
				Mississippi licensed dentist must be billed with a Code on Dental Procedures
				and Nomenclature (CDT).
2. Dental
				procedures performed by a Mississippi licensed dentist who is also a
				Mississippi licensed physician can bill either a CDT code or a Current
				Procedural Terminology (CPT) code.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 210 - Ambulatory Surgical Centers › Chapter 1 - General › Rule 23-210-1.7 - Documentation Requirements

Current through June 25, 2024
The physician and ASC must maintain auditable records that
				  will substantiate the services provided. The ASC must maintain a medical record
				  for each patient. Medical records must include at least the following:
A. Patient identification,
B. Significant medical history and results of
				physical examination,
C.
				Pre-operative diagnostic studies, entered before surgery, if
				performed,
D. Findings and
				techniques of the operation, including a pathologist's report on all tissues
				removed during surgery, except those exempted by the governing body,
E. Any allergies and abnormal drug
				reactions,
F. Entries related to
				anesthesia administration,
G.
				Documentation of properly executed informed patient consent, and
H. Discharge diagnosis and
				instructions.
Miss. Code Ann. §
										43-13-121;
				  42 CFR § 416
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 210 - Ambulatory Surgical Centers › Chapter 1 - General › Rule 23-210-1.8 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Current through June 25, 2024
The Division of Medicaid pays for all medically necessary
				  services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title
				  23, without regard to service limitations and with prior
				  authorization.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 211 - Federally Qualified Health Centers › Chapter 1 - General › Rule 23-211-1.1 - Definitions

Current through June 25, 2024
The Division of Medicaid defines:
A. A Federally Qualified Health Center (FQHC)
				encounter as a face-to-face visit for the provision of services provided by
				physicians, physician assistants, nurse practitioners, nurse midwives,
				dentists, optometrists, clinical psychologists, Licensed Clinical Social
				Workers (LCSWs), Licensed Professional Counselors (LPCs), Licensed Marriage and
				Family Therapists (LMFTs), and Board Certified Behavioral Analysts
				(BCBAs).
B. An encounter rate as a
				prospective payment system (PPS) rate per encounter.
C. Clinician Administered Drugs and
				Implantable Drug System Devices (CADD) as certain physician-administered drugs,
				with limited distribution or limited access for beneficiaries and administered
				in an appropriate clinical setting, which may be reimbursed under the pharmacy
				benefit to the extent the CADDs were not included in the calculation of the
				FQHC's PPS rate, as determined by the Division of Medicaid.
D. Change in the scope of service as a change
				in the type, intensity, duration and/or amount of services.
1. A change in the scope of services occurs
				if:
a) The FQHC has added or has dropped any
				services that meet the definition of an FQHC service as provided in federal
				regulations.
b) The service is
				included as a covered Medicaid service under the Mississippi Medicaid State
				Plan.
c) A change in the intensity
				is a change in the amount of health care services provided by the FQHC during
				an average encounter.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 211 - Federally Qualified Health Centers › Chapter 1 - General › Rule 23-211-1.2 - Provider Requirements

Current through June 25, 2024
A. To participate
				as a Federally Qualified Health Center (FQHC) in the Medicaid program, an
				organization must be approved by the Department of Health and Human Services,
				Centers for Medicare and Medicaid Services (CMS) as an FQHC.
B. FQHC providers must comply with the
				requirements set forth in Miss. Admin. Code Part 200, Rule 4.8 for all
				providers in addition to the specific provider type requirements outlined
				below:
1. National Provider Identifier (NPI),
				verification from the National Plan and Provider Enumeration System
				(NPPES),
2. A copy of the interim
				rate notice or current rate letter from CMS,
3. Copy of the nurse practitioner's protocol
				and license to practice. If the nurse practitioner is not enrolled with the
				Division of Medicaid as a provider, the nurse practitioner must complete a
				provider application and obtain an individual provider number, and
4. Clinical Laboratory Improvement Amendments
				(CLIA) Information form and current CLIA certificate, if applicable.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 211 - Federally Qualified Health Centers › Chapter 1 - General › Rule 23-211-1.3 - Covered Services

Current through June 25, 2024
A. The Division of
				Medicaid limits reimbursement to a Federally Qualified Health Center (FQHC) to
				no more than four (4) encounters per beneficiary per day, provided that each
				encounter represents a different type of visit, as the Division of Medicaid
				only reimburses for one (1) medically necessary encounter per beneficiary per
				day for each of the following visit:
1.
				Medical,
2. Mental
				health,
3. Dental, or
4. Vision.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 211 - Federally Qualified Health Centers › Chapter 1 - General › Rule 23-211-1.4 - Non-Covered Services

Current through June 25, 2024
A. The Division of
				Medicaid does not reimburse an FQHC for services when performed in an inpatient
				or outpatient hospital setting. If a physician is employed by an FQHC and
				provides services in a hospital setting, the FQHC is prohibited from billing
				for these services. The physician must bill under the physician's individual
				Medicaid provider number or group physician Medicaid provider number.
B. The Division of Medicaid does not consider
				the following as an encounter:
1. Vaccine
				administration, and/or
2. Diabetes
				Self-Management Training (DSMT).
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 211 - Federally Qualified Health Centers › Chapter 1 - General › Rule 23-211-1.6 - Documentation Requirements

Current through June 25, 2024
The Division of Medicaid requires Federally Qualified Health
				  Centers (FQHCs) to maintain auditable records that substantiate the services
				  provided in accordance with Miss. Admin. Code Title 23, Part 200, Rule
				  1.3. At a minimum, the records must
				  contain the following on each beneficiary:
A. Date of service,
B. Beneficiary's presenting
				complaint,
C. Provider's
				findings,
D. Treatment rendered,
				and
E. Provider's
				signature.
42 C.F.R. Part
				  491; Miss. Code Ann. §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 212 - Rural Health Clinics › Chapter 1 - General › Rule 23-212-1.1 - Definitions

Current through June 25, 2024
The Division of Medicaid defines:
A. Rural Health Clinic as a provider that has
				been designated a Rural Health Clinic by the Centers for Medicare and Medicaid
				Services (CMS) and for purposes of this policy includes both provider-based
				rural health clinics and freestanding rural health clinics.
1. Free Standing Rural Health Clinic as an
				independent clinic owned by a provider or a provider entity that does not
				qualify for, or have not sought, provider-based status, as designated by
				CMS.
2. Provider-Based Rural Health
				Clinic as a rural health clinic that is owned and operated as an essential part
				of a hospital, nursing home, or home health agency, as designated by
				CMS.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 212 - Rural Health Clinics › Chapter 1 - General › Rule 23-212-1.2 - Provider Requirements

Current through June 25, 2024
A. To participate
				as a Rural Health Clinic (RHC) in the Medicaid program, an organization must be
				approved by the Department of Health and Human Services, Centers for Medicare
				and Medicaid Services (CMS) as an RHC.
B. RHC providers must comply with the
				requirements set forth in Miss. Admin. Code Part 200, Rule 4.8 for all
				providers in addition to the specific provider type requirements outlined
				below:
1. National Provider Identifier (NPI),
				verification from the National Plan and Provider Enumeration System
				(NPPES),
2. A copy of the interim
				rate notice or current rate letter from CMS,
3. Copy of the nurse practitioner's protocol
				and license to practice. If the nurse practitioner is not enrolled with the
				Division of Medicaid as a provider, the nurse practitioner must complete a
				provider application and obtain an individual provider number, and
4. Clinical Laboratory Improvement Amendments
				(CLIA) Information form and current CLIA certificate, if applicable.
a) If the RHC performs only the six (6) tests
				listed in Miss. Admin. Code Part 212, Rule
				1.3.D., a waiver certificate from the
				regional Clinical Laboratory Improvement Amendments (CLIA) office must be
				obtained.
b) If the RHC provides
				other laboratory tests on site, the RHC must comply with all CLIA requirements
				for the laboratory services actually provided.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 212 - Rural Health Clinics › Chapter 1 - General › Rule 23-212-1.3 - Covered Services

Current through June 25, 2024
A. The Division of
				Medicaid limits reimbursement to a Rural Health Clinic (RHC) to no more than
				four (4) encounters per beneficiary per day, provided that each encounter
				represents a different type of visit, as the Division of Medicaid only
				reimburses for one (1) medically necessary encounter per beneficiary per day
				for each of the following visit:
1.
				Medical,
2. Mental health,
3. Dental, or
4. Vision.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 212 - Rural Health Clinics › Chapter 1 - General › Rule 23-212-1.4 - Non-Covered Services

Current through June 25, 2024
A. The Division of
				Medicaid does not reimburse an RHC for services when performed in an inpatient
				or outpatient hospital setting. If a physician is employed by an RHC and
				provides services in a hospital setting, the RHC is prohibited from billing for
				these services. The physician must bill under the physician's individual
				Medicaid provider number or group physician Medicaid provider number.
B. The Division of Medicaid does not consider
				the following as an encounter:
1. Vaccine
				administration, and/or
2. Diabetes
				Self-Management Training (DSMT).
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 212 - Rural Health Clinics › Chapter 1 - General › Rule 23-212-1.6 - Documentation Requirements

Current through June 25, 2024
The Division of Medicaid requires Rural Health Clinics (RHCs)
				  to maintain auditable records that will substantiate the services provided in
				  accordance with Miss. Admin. Code Title 23, Part 200, Rule
				  1.3. At a minimum, the records must
				  contain the following on each patient:
A. Date of service,
B. Beneficiary's presenting
				complaint,
C. Provider's
				findings,
D. Treatment rendered,
				and
E. Provider's
				signature.
42
				  C.F.R. §
											440.20; Miss. Code Ann.
				  §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 212 - Rural Health Clinics › Chapter 1 - General › Rule 23-212-1.7 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Current through June 25, 2024
The Division of Medicaid pays for all medically necessary
				  services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title
				  23, without regard to service limitations and with prior
				  authorization.
Miss. Code
				  Ann. §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 1 - Physical Therapy › Rule 23-213-1.1 - Provider Enrollment Requirements for Physical Therapist

Current through June 25, 2024
Providers of physical therapy must comply with the
				  requirements set forth in Part 200, Chapter 4, Rule 4.8 in addition to the
				  provider specific requirements outlined below:
A. National Provider Identifier (NPI),
				verification from National Plan and Provider Enumeration System
				(NPPES),
B. Copy of licensure card
				or letter from the appropriate board stating current certification and must be
				from state of servicing location, and
C. Verification of social security number
				using a social security card, driver's license if it notes the social security
				number, military ID or a notarized statement signed by the provider noting the
				social security number. The name noted on verification must match the name
				noted on the W-9.
Miss. Code Ann. §
										43-13-121;
				  42 CFR 455, Subpart E
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 1 - Physical Therapy › Rule 23-213-1.2 - Definitions

Current through June 25, 2024
A. Medicaid defines physical therapy services
				as medically prescribed services designed to develop, improve or restore
				neuro-muscular or sensory-motor function, relieve pain, or control postural
				deviations. Services are concerned with the prevention of disability, and
				rehabilitation for congenital or acquired disabilities, resulting from or
				secondary to injury or disease.
B.
				Medicaid defines a physical therapist as an individual who meets the state and
				federal licensing and/or certification requirements to perform physical therapy
				services.
C. Medicaid defines a
				physical therapy assistant as an individual who meets state and federal
				licensing and/or certification requirements to assist in the practice of
				physical therapy services under the supervision of a licensed physical
				therapist.
D. Medicaid defines a
				physical therapy aide as an individual who assists the physical therapist and
				the physical therapist assist in the practice of physical therapy. The physical
				therapy aide performs services under the supervision of the licensed physical
				therapist or licensed physical therapist assistant.
Miss. Code Ann. §
										43-13-121;
				  42
				  CFR 440.110
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 1 - Physical Therapy › Rule 23-213-1.3 - Covered Physical Therapy Services

Current through June 25, 2024
A. The Division of
				Medicaid covers physical therapy services in the outpatient setting when
				medically necessary, ordered by a physician, physician assistant or nurse
				practitioner, and prior authorized by a Utilization Management/Quality
				Improvement Organization (UM/QIO), the Division of Medicaid or a designated
				entity to treat a beneficiary's illness, condition, or injury and the following
				requirements are met:
1. The services require
				the knowledge, skill and judgment of a state-licensed physical therapist.
2. The Certificate of Medical
				Necessity (CMN) for the initial referral/order is completed by the prescribing
				provider prior to the physical therapy evaluation.
3. The plan of care (POC) is developed by a
				state-licensed physical therapist.
4. The prescribing provider approves the
				initial/revised POC with a signature and date:
a) Before the initiation of treatment or
				change in treatment, or
b) Within
				thirty (30) calendar days of the verbal order for the initial treatment plan or
				change in treatment.
5.
				The services are rendered as individualized therapy consistent with the
				symptomatology/diagnosis and do not exceed the beneficiary's needs.
6. The services do not duplicate another
				provider's services including those services provided in a school-based
				setting.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 1 - Physical Therapy › Rule 23-213-1.4 - Non-Covered Physical Therapy Services

Current through June 25, 2024
The Division of Medicaid does not cover or reimburse for
				  physical therapy services in the outpatient setting when:
A. Services are not certified/ordered by a
				physician, physician assistant, or nurse practitioner,
B. The plan of care (POC) has not been
				approved, signed, and dated by the physician, physician assistant, or nurse
				practitioner within established timeframes [Refer to Miss. Admin. Code Part
				213, Rule I.3.A.4.],
C. Services
				do not meet medical necessity criteria,
D. Services do not require the knowledge,
				skill, and judgment of a state-licensed physical therapist,
E. Documentation supports that the
				beneficiary has attained the physical therapy goals or has reached the point
				where no further significant improvement can be expected,
F. Documentation supports that the
				beneficiary has not reached physical therapy goals and is unable to participate
				and/or benefit from skilled intervention, refuses to participate, or is
				otherwise noncompliant with the physical therapy regimen,
G. The beneficiary can perform services
				independently or with the assistance of unskilled personnel or family members,
H. Services duplicate other
				concurrent therapy,
I. Services
				are for maintenance and/or palliative therapy which maintains function and
				generally does not involve complex procedures or the professional skill,
				judgment, or supervision of a state-licensed physical therapist,
J. Conditions could be reasonably expected to
				improve spontaneously without therapy,
K. Services are ordered daily or multiple
				times per day from the initiation of therapy through discharge,
L. Services are normally considered part of
				nursing care,
M. Services are
				provided through a Comprehensive Outpatient Rehabilitation Facility (CORF),
N. Services are billed as separate
				fees for self-care/home-management training,
O. Services are related solely to employment
				opportunities or the purpose is vocationally based,
P. Services are for general wellness,
				exercise, and/or recreational programs,
Q. Services are provided by physical therapy
				aides,
R. Services are delivered
				in a group therapy or co-therapy session,
S. Services are investigational or
				experimental,
T. Services consist
				of acupuncture or biofeedback,
U.
				Services are outside the scope/and or authority of the state-licensed physical
				therapist's specialty and/or area of practice,
V. The provider has not met the prior
				authorization/pre-certification requirements,
W. Services are provided in the home setting, or
X. Services are not specifically listed as
				covered by the Division of Medicaid.
42 CFR § 410.60;
				  Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 1 - Physical Therapy › Rule 23-213-1.6 - Prior Authorization/Precertification

Current through June 25, 2024
A. Medicaid
				requires prior authorization/precertification for certain outpatient therapy
				services.
1. Prior
				authorization/precertification for therapy services is conducted through the
				Utilization Management and Quality Improvement Organization (UM/QIO).
2. Failure to obtain prior
				authorization/precertification will result in denial of payment to the
				providers billing for services.
3.
				The UM/QIO must determine medical necessity for the types of therapy services
				and the number of units reasonably necessary to treat the beneficiary's
				condition. The frequency of visits provided by the therapist must match the
				Plan of Care signed by the physician.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 1 - Physical Therapy › Rule 23-213-1.7 - Prescribing Provider Orders and Responsibilities

Current through June 25, 2024
Medicaid covers therapy services that are medically
				  necessary, as certified by the prescribing provider.
A. The prescribing provider must complete a
				Certificate of Medical Necessity for Initial Referral/Orders and submit it to
				the therapist prior to the therapy evaluation. Medicaid defines prescribing
				provider as a state-licensed physician, nurse practitioner, or physician
				assistant who refers the beneficiary for therapy services.
B. Therapy services must be furnished
				according to a written plan of care (POC).
1.
				The POC must be approved by the prescribing provider before treatment is begun.
a) An approved POC does not mean that the
				prescribing provider has signed the POC prior to implementation, but only has
				agreed to it.
b) Medicaid covers
				for the review to be done in person, by telephone, or facsimile.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 1 - Physical Therapy › Rule 23-213-1.8 - Evaluation and Re-Evaluation

Current through June 25, 2024
A. Medicaid
				requires a Certificate of Medical Necessity for Initial Referral/Orders
				completed by the prescribing provider, and it must be received by the therapist
				prior to performing the initial evaluation. The evaluation does not require
				prior authorization.
B. Medicaid
				requires a comprehensive evaluation of the beneficiary's medical condition,
				disability, and level of functioning before therapy is initiated. A
				comprehensive evaluation must be performed to determine the need for treatment
				and, when treatment is indicated, to develop the treatment plan.
1. Medicaid requires the evaluation must be
				written and must demonstrate the beneficiary's need for skilled therapy based
				on functional diagnosis, prognosis, and positive prognostic
				indicators.
2. The evaluation must
				form the basis for therapy treatment goals, and the therapist must have an
				expectation that the patient can achieve the established goals.
3. Initial evaluations should, at a minimum
				contain, the following information:
a)
				Beneficiary demographic information,
b) Name of the prescribing
				provider,
c) Date of the
				evaluation,
d) Diagnosis/functional
				condition or limitation being treated and onset date,
e) Applicable medical history including
				mechanism of injury, diagnostic imaging/testing, recent hospitalizations
				including dates, medications, comorbidities, either complicating or
				precautionary information,
f) Prior
				therapy history for same diagnosis/condition and response to therapy,
g) Level of function, prior and currenth)
				Clinical status including cognitive function, sensation/proprioception, edema,
				vision/hearing, posture, active and passive range of motion, strength, pain,
				coordination, bed mobility, balance by sitting and standing, transfer ability,
				ambulation on level and elevated surfaces, gait analysis, assistive/adaptive
				devices which are currently in use or required, activity tolerance, presence of
				wounds including description and incision status, assessment of the
				beneficiary's ability to perform activities of daily living and potential for
				rehabilitation, age appropriate information on all children such as
				chronological age/corrected age, motivation for treatment, other significant
				physical or mental disabilities/deficiencies that may affect therapy,
i) Special/standardized tests including the
				name, scores/results, and dates administered,
j) Social history including effects of the
				disability on the beneficiary and the family, architectural/safety
				considerations present in the living environment, identification of the primary
				caregiver, caregiver's ability/inability to assist with therapy,
k) Discharge plan including requirements to
				return to home, school, and/or job,
l) Impression/interpretation of findings,
				and
m) Physical therapist's
				signature, including name, title, and date of service.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 1 - Physical Therapy › Rule 23-213-1.9 - Beneficiary Non-Compliance

Current through June 25, 2024
Medicaid does not cover therapy services when documentation
				  supports that the beneficiary:
A. Has
				not reached therapy goals and is unable to participate and/or benefit from
				skilled intervention,
B. Refuses to
				participate, or
C. Is otherwise
				noncompliant with the therapy regimen. Medicaid defines noncompliance as
				failure to follow therapeutic recommendations which may include any or all of
				the following:
1. Failure to attend scheduled
				therapy sessions, which is defined by Medicaid as cancellation or no show' to
				three (3) consecutive therapy sessions and/or missing half or more of the
				scheduled visits without documentation of valid reasons such as personal
				illness/hospitalization or illness/death in the family,
2. Failure to perform home exercise program
				as instructed by the therapist,
3.
				Failure to fully participate in therapy sessions,
4. Failure of the parent/caregiver to attend
				therapy sessions with beneficiary who is incapable of carrying out the home
				program without assistance,
5.
				Failure to properly use special equipment or adaptive devices, or
6. Failure of parent/caregiver/beneficiary to
				otherwise comply with therapy regimen as documented in the medical
				record.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 1 - Physical Therapy › Rule 23-213-1.10 - Maintenance Therapy

Current through June 25, 2024
Medicaid defines maintenance therapy as activities that
				  preserve the patient's present level of function and prevent regression of that
				  function. Maintenance programs do not require the professional skills of a
				  licensed therapy provider, are not considered medically necessary, and are not
				  covered by Medicaid. Such services include but are not limited to the
				  following:
A. Services related to the
				general welfare of the beneficiary such as exercises to promote fitness and
				flexibility, training or conditioning, and holistic treatments,
B. Repetitive services that are performed to
				maintain function, maintain gait, maintain strength and endurance that do not
				require the professional skills of a licensed therapy provider,
C. Therapy after the beneficiary has achieved
				goals outlined in the Plan of Care or where there is no meaningful progress,
				or
D. Exercises and range of motion
				exercises not related to the restoration of a specific loss of
				function.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 1 - Physical Therapy › Rule 23-213-1.12 - Dual Eligibles

Current through June 25, 2024
A. Medicaid covers
				therapy services not covered by Medicare if the reason for the Medicare denial
				is other than for medical necessity. The therapy services must be pre-certified
				through the UM/QIO.
B.
				Beneficiaries cannot receive services under both programs
				simultaneously.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 1 - Physical Therapy › Rule 23-213-1.13 - Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

Current through June 25, 2024
The Division of Medicaid pays for all medically necessary
				  services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title
				  23, without regard to service limitations and with prior
				  authorization.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 2 - Occupational Therapy › Rule 23-213-2.1 - Provider Enrollment Requirements for Occupational Therapist

Current through June 25, 2024
Providers of occupational therapy must comply with the
				  requirements set forth in Part 200, Chapter 4, Rule 4.8 in addition to the
				  provider specific requirements outlined below:
A. National Provider Identifier (NPI),
				verification from National Plan and Provider Enumeration System
				(NPPES),
B. Copy of licensure card
				or letter from the appropriate board stating current certification and must be
				from state of servicing location, and
C. Verification of social security number
				using a social security card, driver's license if it notes the social security
				number, military ID or a notarized statement signed by the provider noting the
				social security number. The name noted on verification must match the name
				noted on the W-9.
Miss. Code Ann. §
										43-13-121;
				  42 CFR 455, Subpart E
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 2 - Occupational Therapy › Rule 23-213-2.2 - Definitions

Current through June 25, 2024
A. Medicaid defines occupational therapy
				services as medically prescribed services that address developmental and/or
				functional needs related to the performance of self-help skills, adaptive
				behavior, and/or sensory, motor and postural development. Services include
				therapeutic goal-directed activities and/or exercises used to improve mobility
				and Activities of Daily Living (ADL) functions when such functions have been
				impaired due to congenital and/or developmental abnormalities, illness or
				injury.
B. Medicaid defines an
				occupational therapist as an individual who meets the state and federal
				licensing and/or certification requirements to perform occupational therapy
				services.
C. Medicaid defines an
				occupational therapy assistant as an individual who meets the state and federal
				licensing and/or certification requirements to assist in the practice of
				occupational therapy services under the supervision of a licensed occupational
				therapist.
D. Medicaid defines an
				occupational therapy aide as an unlicensed individual who assists the
				occupational therapist and the occupational therapy assistant in the practice
				of occupational therapy. The occupational therapy aide performs services under
				the supervision of the licensed occupational therapist or licensed occupational
				therapy assistant.
E. Medicaid
				defines direct supervision as a state licensed therapist physically being on
				the premises where services are rendered and is available for immediate
				assistance during the entire time services are rendered. The licensed therapist
				may not supervise more than two (2) assistants at a time. Medicaid does not
				cover contacts by telephone, pager, video conferencing, etc. as any type of or
				substitution for direct supervision.
F. Medicaid defines prescribing provider as a
				state licensed physician, nurse practitioner, or physician assistant who refers
				a beneficiary for therapy services.
G. Medicaid defines maintenance therapy as
				activities that preserve the patient's present level of function and prevent
				regression of that function.
Miss. Code Ann. §
										43-13-121;
				  42
				  CFR 440.110;
				  410.59
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 2 - Occupational Therapy › Rule 23-213-2.3 - Covered Occupational Therapy Services

Current through June 25, 2024
A. The Division of
				Medicaid covers occupational therapy services in the outpatient setting when
				medically necessary, ordered by a physician, physician assistant or nurse
				practitioner, and prior authorized by a Utilization Management/Quality
				Improvement Organization (UM/QIO), the Division of Medicaid or a designated
				entity to treat a beneficiary's illness, condition, or injury and the following
				requirements are met:
1. The services require
				the knowledge, skill and judgment of a state-licensed occupational therapist.
2. The Certificate of Medical
				Necessity (CMN) for initial referral/order is completed by the prescribing
				provider prior to the occupational therapy evaluation.
3. The plan of care (POC) is developed by a
				state-licensed occupational therapist.
4. The prescribing provider approves the
				initial/revised POC with a signature and date:
a) Before the initiation of treatment or
				change in treatment, or
b) Within
				thirty (30) calendar days of the verbal order for the initial treatment plan or
				change in treatment.
5.
				The services are rendered as individualized therapy, consistent with the
				symptomatology/diagnosis and do not exceed the beneficiary's needs.
6. The services do not duplicate another
				provider's services including those services provided in a school-based
				setting.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 2 - Occupational Therapy › Rule 23-213-2.4 - Non-Covered Occupational Therapy Services

Current through June 25, 2024
The Division of Medicaid does not cover or reimburse for
				  occupational therapy services in the outpatient setting when:
A. Services are not certified/ordered by a
				physician, physician assistant, or nurse practitioner,
B. The plan of care (POC) has not been
				approved, signed, and dated by the physician, physician assistant, or nurse
				practitioner within established timeframes [Refer to Miss. Admin. Code Part
				213, Rule
				2.3.A.4],
C. Services do not meet medical necessity
				criteria,
D. Services do not
				require the knowledge, skills, and judgment of a state-licensed occupational
				therapist,
E. Documentation
				supports that the beneficiary has attained the occupational therapy goals or
				has reached the point where no further significant improvement can be expected,
F. Documentation supports that the
				beneficiary has not reached occupational therapy goals and is unable to
				participate and/or benefit from skilled intervention, refuses to participate,
				or is otherwise noncompliant with the occupational therapy regimen,
G. The beneficiary can perform services
				independently or with the assistance of unskilled personnel or family members,
H. Services duplicate other
				concurrent therapy,
I. Services
				are for maintenance and/or palliative therapy which maintains function and
				generally does not involve complex procedures or the professional skill,
				judgment, or supervision of a state-licensed occupational therapist,
J. Conditions could be reasonably expected to
				improve spontaneously without therapy,
K. Services are ordered daily or multiple
				times per day from the initiation of therapy through discharge,
L. Services are normally considered part of
				nursing care,
M. Services are
				provided through a Comprehensive Outpatient Rehabilitation Facility (CORF),
N. Services are billed as separate
				fees for self-care/home-management training,
O. Services are related solely to employment
				opportunities or the purpose is vocationally based,
P. Services are for general wellness,
				exercise, and/or recreational programs,
Q. Services are provided by occupational
				therapy aides,
R. Services are
				delivered in a group therapy or co-therapy session,
S. Services are investigational or
				experimental,
T. Services consist
				of acupuncture or biofeedback,
U.
				Services are outside the scope/and or authority of the state-licensed
				occupational therapist's specialty and/or area of practice,
V. The provider has not met the prior
				authorization/pre-certification requirements,
W. Services are provided in the home setting,
				or
X. Services are not
				specifically listed as covered by the Division of Medicaid.
42 CFR § 410.59;
				  Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 2 - Occupational Therapy › Rule 23-213-2.5 - Prior Authorization/ Precertification

Current through June 25, 2024
A. The UM/QIO
				will determine medical necessity, the types of therapy services, and the number
				of units reasonably necessary to treat the beneficiary's condition. The
				frequency of visits provided by the therapist must match the Plan of Care
				signed by the prescribing provider.
B. Prior Authorization/Pre-certification for
				outpatient therapy services is only required for certain procedure codes when
				the services fall into one (1) of the following categories:
1. Therapy services provided to
				beneficiaries, adult and/or children in individual therapist offices or in
				therapy clinics,
2. Therapy
				services provided to beneficiaries, adult and/or children, in the outpatient
				department of hospitals,
3. Therapy
				services provided to beneficiaries, adult and/or children, in physician
				offices/clinics,
4. Therapy
				services provided to beneficiaries in nursing facilities,
5. Therapy services covered under regular
				State Plan benefits and provided to beneficiaries also enrolled in a Home and
				Community-Based Services (HCBS) waiver program, and
6. Therapy services provided to beneficiaries
				covered under both Medicare and Medicaid if Medicare benefits have been
				exhausted.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 2 - Occupational Therapy › Rule 23-213-2.6 - Prescribing Provider Orders/Responsibilities

Current through June 25, 2024
A. Medicaid
				provides benefits for therapy services that are medically necessary, as
				certified by the prescribing provider.
B. The prescribing provider must complete a
				Certificate of Medical Necessity for Initial Referral/Orders form and submit it
				to the therapist prior to therapy evaluation.
C. Therapy services must be furnished
				according to a written plan of care (POC). The plan of care must be approved by
				the prescribing provider before treatment is begun. Medicaid defines approval
				as the prescribing provider has reviewed and agreed with the therapy plan. The
				review can be done in person, by telephone, or facsimile. An approved plan does
				not mean that the prescribing provider has signed the plan prior to
				implementation, only that he/she hasagreed to it. The plan of care must be
				developed by a therapist in the discipline. A separate plan of care is required
				for each type of therapy ordered by the prescribing provider. The plan must, at
				a minimum, include the following:
1.
				Beneficiary demographic information,
2. Name of the prescribing
				provider,
3. Dates of
				service,
4.
				Diagnosis/symptomatology/conditions and related diagnosis codes,
5. Reason for referral,
6. Specific diagnostic and treatment
				procedures/modalities and related procedure codes,
7. Frequency of therapeutic
				encounters,
8. Duration of
				therapy,
9. Precautions, if
				applicable,
10. Short and long term
				goals that are specific, measurable, and age appropriate,
11. Plan for the home program,
12. Discharge plan, and
13. Therapist's signature, name and title,
				and date.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 2 - Occupational Therapy › Rule 23-213-2.7 - Evaluation/Re-Evaluation

Current through June 25, 2024
A. A Certificate of Medical Necessity for
				Initial Referral/Orders must be completed by the prescribing provider, and it
				must be received by the therapist prior to performing the initial evaluation.
				The evaluation does not require prior authorization.
B. Before therapy is initiated, a
				comprehensive evaluation of the beneficiary's medical condition, disability,
				and level of functioning must be performed to determine the need for treatment
				and, when treatment is indicated, to develop the treatment plan. The initial
				evaluation must be completed by a state-licensed therapist. The evaluation must
				be written and must demonstrate the beneficiary's need for skilled therapy
				based on functional diagnosis, prognosis, and positive prognostic indicators.
				The evaluation must form the basis for therapy treatment goals, and the
				therapist must have an expectation that the patient can achieve the established
				goals.
C. Initial evaluations
				should, at a minimum, contain the following information:
1. Beneficiary demographic
				information,
2. Name of the
				prescribing provider,
3. Date of
				the evaluation,
4.
				Diagnosis/functional condition or limitation being treated and onset
				date,
5. Applicable medical
				history: mechanism of injury, diagnostic imaging/testing, recent
				hospitalizations including dates, medications, co-morbidities, with
				complicating or precautionary information,
6. Prior therapy history for same
				diagnosis/condition and response to therapy,
7. Level of function, prior and
				current,
8. Clinical status
				including cognitive function, sensation/proprioception, edema, vision/hearing,
				posture, active and passive range of motion, strength, pain, coordination, bed
				mobility, balance, while sitting and standing, transfer ability, ambulation at
				level and elevated surfaces, gait analysis, assistive/adaptive devices either
				currently in use or required, activity tolerance, presence of wounds including
				description and incision status, assessment of the beneficiary's ability to
				perform activities of daily living and potential for rehabilitation, age
				appropriate information on all children by chronological age/corrected age,
				motivation for treatment, other significant physical or mental
				disabilities/deficiencies that may affect therapy,
9. Special/standardized tests including the
				name, scores/results, and dates administered,
10. Social history including effects of the
				disability on the beneficiary and the family, architectural/safety
				considerations present in the living environment, identification of the primary
				caregiver, caregiver's ability/inability to assist with therapy,
11. Discharge plan including requirements to
				return to home, school, and/or job,
12. Impression/interpretation of findings,
				and
13. Occupational therapist's
				signature, with name and title and date.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 2 - Occupational Therapy › Rule 23-213-2.8 - Maintenance Therapy

Current through June 25, 2024
A. Maintenance
				programs do not require the professional skills of a licensed therapy provider,
				are not considered medically necessary, and are not covered by
				Medicaid.
B. Maintenance programs
				must be planned and taught before the end of active therapy treatment so that
				the beneficiary, family members, or other unskilled caregivers can carry out
				the program. If the maintenance program is not established until after the
				rehabilitative program has been completed, the skills of a therapist for
				development of a maintenance program are not considered medically necessary and
				are covered.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 2 - Occupational Therapy › Rule 23-213-2.9 - Documentation

Current through June 25, 2024
A. Occupational therapy providers must
				document and maintain records in accordance with the requirements set forth in
				Part 200, Chapter 1, Rule
				1.3.
B. Required documentation by an occupational
				therapy servicing provider includes, but is not limited to, the following:
1. Beneficiary demographic information,
2. A copy of the Certificate of
				Medical Necessity for Initial Referral/Orders completed by the prescribing
				provider,
3. Signed consent for
				treatment,
4. Original copies of
				all Outpatient Therapy Evaluation/Re-Evaluation forms specific to the therapy
				ordered,
5. Original copies of all
				Outpatient Therapy Plan of Care forms specific to the therapy ordered,
6. Original copies of all tests
				performed or a list of all tests performed, test results, and the written
				evaluation reports,
7. Treatment
				log if treatment times are not documented in the progress notes including all
				requirements of timed codes as follows:
a)
				The Division of Medicaid defines timed codes as procedure codes that reference
				a time per unit.
b) The Division
				of Medicaid covers units of timed codes based upon the total time actually
				spent in the delivery of the service.
c) The Division of Medicaid considers the
				following activities as not part of the total treatment time:
1) Pre and post-delivery of services,
2) Time the beneficiary spends not
				being treated, and
3) Time waiting
				for equipment or for treatment to begin.
d) The Division of Medicaid defines untimed
				codes as procedure codes that are not defined by a specific time frame.
e) The Division of Medicaid does
				not require documentation of the treatment time for untimed codes.
f) The Division of Medicaid only covers one
				(1) unit for untimed codes regardless of the amount of time taken to complete
				the service.
8.
				Progress notes:
a) Must be documented at
				least weekly.
b) Must include:
1) Date/time of service,
2) Specific treatment modalities/procedures
				performed,
3) Beneficiary's
				response to treatment, functional progress,
4) Problems interfering with progress,
5) Education/teaching activities
				and results,
6) Conferences,
7) Progress toward discharge
				goals/home program activities, and
8) The signature and title of the therapist
				providing the service(s).
c) If treatment times are documented in the
				progress notes in lieu of a treatment log, all requirements for timed codes
				must be met, Refer to timed and untimed codes in this Part.
9. Discharge Summary, if
				applicable, and
10. A copy of the
				completed prior approval form with prior approval authorization, if applicable.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 2 - Occupational Therapy › Rule 23-213-2.10 - Dual Eligibles

Current through June 25, 2024
A. Medicaid covers
				therapy services not covered by Medicare if the reason for the Medicare denial
				is other than for medical necessity. The therapy services must be prior
				authorized/ precertified through the UM/QIO.
B. Beneficiaries may not receive services
				under both programs simultaneously.
Miss. Code Ann. §
										43-13-121