Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 3 - Payment and Services › Section 907 KAR 3:005 - Coverage of physicians' services

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				205.510,
				205.520,
				205.560,
				205.622,
				205.8451,
				311.840-311.862,
				314.011,
				369.101-369.120,
				42 C.F.R.
				400.203,
				413.75(b),
				415.174,
				415.184,
				431.17,
				438.2,
				440.40(b),
				440.50,
				441.20,
				441.200-441.208, 441.250-441.259,
				447.26,
				455.410,
				Part 493, 45 C.F.R. Parts 160, 164,
				42 U.S.C.
				1320 -
				1320d-8,
				1396a(a)(19),
				(30),
				1396r-8(a)
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 Medicaid Program
				coverage provisions and requirements relating to physicians' services.
Section 1. Definitions.
(1) "Advanced practice registered nurse" or
			 "APRN" is defined by
			 KRS
			 314.011(7).
(2) "Behavioral health practitioner under
			 supervision" means an individual who is:
(a)
1. A licensed psychological
			 associate;
2. A licensed
			 professional counselor associate;
3. A certified social worker;
4. A marriage and family therapy
			 associate;
5. A licensed
			 professional art therapist associate;
6. A licensed assistant behavior
			 analyst;
7. A licensed clinical
			 alcohol and drug counselor associate;
8. A certified psychologist; or
9. A certified alcohol and drug counselor;
			 and
(b) Employed by or
			 under contract with the same billing provider as the billing
			 supervisor.
(3) "Common
			 practice" means an arrangement through which a physician assistant administers
			 health care services under the supervision of a physician via a supervisory
			 relationship that has been approved by the Kentucky Board of Medical
			 Licensure.
(4) "CPT code" means a
			 code used for reporting procedures and services performed by medical
			 practitioners and published annually by the American Medical Association in
			 Current Procedural Terminology.
(5)
			 "Department" means the Department for Medicaid Services or its
			 designee.
(6) "Designated
			 controlled substance provider" means the provider designated as a lock-in
			 recipient's controlled substance prescriber:
(a) Pursuant to
			 907 KAR
			 1:677, if the recipient is not an enrollee;
			 or
(b) As established by the
			 managed care organization in which the lock-in recipient is enrolled, if the
			 lock-in recipient is an enrollee.
(7) "Designated primary care provider" means
			 the provider designated as a lock-in recipient's primary care provider:
(a) Pursuant to
			 907 KAR
			 1:677, if the recipient is not an enrollee;
			 or
(b) As established by the
			 managed care organization in which the lock-in recipient is enrolled, if the
			 lock-in recipient is an enrollee.
(8) "Direct physician contact" means that the
			 billing physician is physically present with and evaluates, examines, treats,
			 or diagnoses the recipient.
(9)
			 "Early and periodic screening and diagnosis and treatment" or "EPSDT" is
			 defined by
			 42
			 C.F.R. 440.40(b).
(10) "Emergency care" means:
(a) Covered inpatient or 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.
(11)
			 "Enrollee" means a recipient who is enrolled with a managed care
			 organization.
(12) "Federal
			 financial participation" is defined by
			 42 C.F.R.
			 400.203.
(13) "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.
(14) "Graduate medical education program" or
			 "GME program" means:
(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 by
			 42
			 C.F.R.
			 413.75(b).
(15) "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.
(16) "Integral" means that a medical
			 procedure represents a component of a more complex procedure performed at the
			 same time.
(17) "Lock-in recipient"
			 means:
(a) A recipient enrolled in the
			 lock-in program in accordance with
			 907 KAR
			 1:677; or
(b) An enrollee enrolled in a managed care
			 organization's lock-in program pursuant to
			 907
			 KAR 17:020, Section 6.
(18) "Locum tenens APRN" means an APRN:
(a) Who temporarily assumes responsibility
			 for the professional practice of a physician participating in the Kentucky
			 Medicaid Program; and
(b) Whose
			 services are billed under the APRN's provider number.
(19) "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.
(20) "Managed care organization" means an
			 entity for which the Department for Medicaid Services has contracted to serve
			 as a managed care organization as defined by
			 42
			 C.F.R. 438.2.
(21) "Medicaid basis" means a scenario in
			 which:
(a) A provider provides a service to a
			 recipient as a Medicaid-participating provider in accordance with:
1.
											907
			 KAR 1:671; and
2.
											907
			 KAR 1:672;
(b) The Medicaid Program is the payer for the
			 service; and
(c) The recipient is
			 not liable for payment to the provider for the service other than any cost
			 sharing obligation owed by the recipient to the provider.
(22) "Medical necessity" or "medically
			 necessary" means that a covered benefit is determined to be needed in
			 accordance with
			 907
			 KAR 3:130.
(23) "Medical resident" means:
(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.
(24) "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.
(25) "Non-Medicaid basis" means a scenario in
			 which:
(a) A provider provides a service to a
			 recipient;
(b) The Medicaid Program
			 is not the payer for the service; and
(c) The recipient is liable for payment to
			 the provider for the service.
(26) "Other licensed medical professional"
			 means a health care provider:
(a) Other than
			 a physician, physician assistant, advanced practice registered nurse, certified
			 registered nurse anesthetist, nurse midwife, or registered nurse; and
(b) Who has been approved to practice a
			 medical specialty by the appropriate licensure board.
(27) "Other provider preventable condition"
			 is defined by
			 42
			 C.F.R. 447.26(b).
(28) "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.
(29) "Physician assistant" is defined by
			 KRS
			 311.840(3).
(30) "Podiatrist" is defined by
			 KRS
			 205.510(12).
(31) "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 group provider
			 number.
(32) "Rebateable"
			 means a drug for which the drug manufacturer has entered into and has in effect
			 a rebate agreement in accordance with
			 42 U.S.C.
			 1396r-8(a).
(33) "Recipient" is defined by
			 KRS
			 205.8451(9).
(34) "Screening" means the evaluation of a
			 recipient by a physician to determine:
(a) If
			 a disease or medical condition is present; and
(b) If further evaluation, diagnostic
			 testing, or treatment is needed.
(35) "Supervising physician" is defined by
			 KRS
			 311.840(4).
(36) "Supervision" is defined by
			 KRS
			 311.840(6).
(37) "Timely filing" means receipt of a
			 Medicaid claim by the department:
(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.
(38) "Unlisted procedure or service" means a
			 procedure or service:
(a) For which there is
			 not a specific CPT code; and
(b)
			 That is billed using a CPT code designated for reporting unlisted procedures or
			 services.