Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 3 - Payment and Services › Section 907 KAR 3:010 - Reimbursement for physicians' services

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				205.560,
				205.565,
				210.370-210.485,
				311.840,
				42 C.F.R.
				400.203, Part
				414,
				415.110,
				438.2,
				440.50,
				447.10,
				447.200-447.205,
				447.325,
				42 U.S.C.
				1395m,
				1395w-4,
				1395x(t)(1),
				1396a,
				1396b,
				1396c,
				1396d,
				1396s
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 to qualify for federal
				Medicaid funds. This administrative regulation establishes the method of
				reimbursement for physicians' services by the Medicaid program.
Section 1. Definitions.
(1) "Add-on code" or "add-on service" means a
			 service designated by a specific CPT code that may be used in conjunction with
			 another CPT code to denote that an adjunctive service has been
			 performed.
(2) "Anesthesia under
			 medical direction" means a service that is:
(a) Directed by an
			 anesthesiologist;
(b) Delivered by
			 an appropriate and qualified anesthesia provider, including a certified
			 registered nurse anesthetist; and
(c) Provided concurrently to no more than
			 four (4) patients by the anesthesiologist.
(3) "Assistant surgeon" means a physician who
			 attends and acts as an auxiliary to a physician performing a surgical
			 procedure.
(4) "Community mental
			 health center" means a facility that meets the community mental health center
			 requirements established in
			 902 KAR 20:091.
(5) "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.
(6) "Department" means
			 the Department for Medicaid Services or its designee.
(7) "Direct physician contact" means that the
			 billing physician is physically present with and evaluates, examines, treats,
			 or diagnoses the recipient.
(8)
			 "Drug" means the definition of "drugs" pursuant to
			 42 U.S.C.
			 1395x(t)(1).
(9) "Federal financial participation" is
			 defined by 42 C.F.R.
			 400.203.
(10) "Global period" means the period of time
			 in which related preoperative, intraoperative, and postoperative services and
			 follow-up care for a surgical procedure are customarily provided.
(11) "Healthcare common procedure coding
			 system" means a collection of codes acknowledged by the Centers for Medicare
			 and Medicaid Services (CMS) that represents procedures or items.
(12) "Incidental" means that a medical
			 procedure:
(a) Is performed at the same time
			 as a primary procedure; and
(b)
1. Requires little additional resources;
			 or
2. Is clinically integral to the
			 performance of the primary procedure.
(13) "Integral" means that a medical
			 procedure represents a component of a more complex procedure performed at the
			 same time.
(14) "Locum tenens
			 physician" 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 physician's provider number.
(15) "Major surgery" means a surgical
			 procedure assigned a ninety (90) day global period.
(16) "Managed care organization" means an
			 entity for which the department has contracted to serve as a managed care
			 organization as defined by 42 C.F.R. 438.2.
(17) "Medicaid Physician Fee Schedule" means
			 a list, located at
https://chfs.ky.gov/agencies/dms/Pages/feesrates.aspx
,
			 that:
(a) Contains the current reimbursement
			 rates for physician services established by the department in accordance with
			 this administrative regulation; and
(b) Is updated at least quarterly to coincide
			 with the quarterly updates made by the Centers for Medicare and Medicaid
			 Services as required by 42
			 U.S.C. 1395m and
			 1395w-4 and
			 42 C.F.R. Part
			 414.
(18) "Minor surgery" means a surgical
			 procedure assigned a ten (10) day global period.
(19) "Modifier" means a reporting indicator
			 used in conjunction with a CPT code to denote that a medical service or
			 procedure that has been performed has been altered by a specific circumstance
			 while remaining unchanged in its definition or CPT code.
(20) "Mutually exclusive" means that two (2)
			 procedures:
(a) Are not reasonably performed
			 in conjunction with each other 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.
(21) "Pediatric teaching hospital" is defined
			 by KRS
			 205.565(1).
(22) "Physician administered drug" or "PAD"
			 means any rebateable covered outpatient drug that is:
(a) Provided or administered to a Medicaid
			 recipient;
(b) Billed by a provider
			 other than a pharmacy provider through the medical benefit, including a
			 provider that is a physician office or another outpatient clinical setting;
			 and
(c) An injectable or
			 non-injectable drug furnished incident to provider services that are billed
			 separately to Medicaid.
(23) "Physician assistant" is defined by
			 KRS
			 311.840(3).
(24) "Professional component" means the
			 physician service component of a service or procedure that has both a physician
			 service component and a technical component.
(25) "Provider group" means a group of at
			 least two (2) individually licensed physicians who:
(a) Are enrolled with the Medicaid program
			 individually and as a group; and
(b) Share the same Medicaid provider
			 number.
(26) "Relative
			 value unit" or "RVU" means the Medicare-established value assigned to a CPT
			 code that takes into consideration the physician's work, practice expense, and
			 liability insurance.
(27)
			 "Resource-based relative value scale" or "RBRVS" means the product of the
			 relative value unit (RVU) and a resource-based dollar conversion
			 factor.
(28) "State university
			 teaching hospital" means:
(a) A hospital that
			 is owned or operated by a Kentucky state-supported university with a medical
			 school; or
(b) A hospital:
1. In which three (3) or more departments or
			 major divisions of the University of Kentucky or University of Louisville
			 medical school are physically located and that are used as the primary (greater
			 than fifty (50) percent) medical teaching facility for the medical students at
			 the University of Kentucky or the University of Louisville; and
2. That does not possess only a residency
			 program or rotation agreement.
(29) "Technical component" means the part of
			 a medical procedure performed by a technician, inclusive of all equipment,
			 supplies, and drugs used to perform the procedure.
(30) "Usual and customary charge" means the
			 uniform amount that a physician charges the general public in the majority of
			 cases for a specific medical procedure or service.