Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:028 - Independent laboratory and radiological service coverage and reimbursement

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				205.520,
				205.560,
				333.090,
				42 C.F.R.
				440.30, Part 493,
				42 U.S.C.
				1395l(h)(1)(A),
				1396a(a)(9),
				1396b(i)(7),
				1396d
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 authorizes the cabinet, by
				administrative regulation, to comply with a 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 the coverage of and reimbursement for independent
				laboratory and radiological services.
Section
			 1. Definitions.
(1) "CLIA" means
			 the Clinical Laboratory Improvement Amendments, 42 C.F.R. Part 493 .
(2) "CMS" means the Centers for Medicare and
			 Medicaid Services.
(3) "Covered
			 benefit" or "covered service" means an independent laboratory or radiological
			 service for which the department shall reimburse.
(4) "CPT" means the current procedural
			 terminology coding system.
(5)
			 "Department" means the Department for Medicaid Services or its
			 designee.
(6) "Incidental" means a
			 medical procedure or service which:
(a)
1. Is performed at the same time as a more
			 complex primary procedure or service; and
2. Requires little additional resources;
			 or
(b) Is clinically
			 integral to the performance of the primary procedure or service.
(7) "Independent laboratory" means
			 a laboratory which:
(a) Is certified by CMS
			 under the CLIA to perform laboratory services;
(b) Is independent of an institutional
			 setting;
(c) Is a
			 Medicare-participating facility;
(d) Meets the requirements established in 42
			 C.F.R. Part 493 regarding laboratory certification, registration, or other
			 accreditation as appropriate; and
(e) Is a Medicaid-enrolled
			 provider.
(8) "Laboratory
			 director" means an individual meeting the director of laboratory qualifications
			 established in
			 KRS
			 333.090(1), (2), or
			 (3).
(9) "Medicaid-enrolled provider" means a
			 provider participating in the Kentucky Medicaid Program in accordance with
			 907
			 KAR 1:671 and
			 907
			 KAR 1:672.
(10) "Medically necessary" or "medical
			 necessity" means a covered benefit determined to be needed in accordance with
			 907
			 KAR 3:130.
(11) "Medicare-participating" means certified
			 by CMS and accepting reimbursement from Medicare.
(12) "Mutually exclusive" means two (2)
			 laboratory or radiological services:
(a) Not
			 reasonably provided in conjunction with one (1) another during the same patient
			 encounter on the same date of service; or
(b) Representing:
1. Duplicate or very similar items;
			 or
2. Medically inappropriate use
			 of CPT codes.
(13) "Prescriber" means a physician,
			 podiatrist, optometrist, dentist, oral surgeon, advanced registered nurse
			 practitioner, or physician's assistant who:
(a) Is acting within the legal scope of
			 clinical practice under the licensing laws of the state in which the health
			 care provider's medical practice is located;
(b) Is in good standing with:
1.The licensure board of jurisdiction for the
			 provider's practice; and
2.
			 CMS;
(c) Has the legal
			 authority to write an order for a medically necessary service for the
			 recipient; and
(d) If enrolled as a
			 Kentucky Medicaid provider, is in compliance with all requirements of
			 907
			 KAR 1:671 and
			 907
			 KAR 1:672.
(14) "Radiological service" means a service
			 in which X-rays or rays from radioactive substances are used for diagnostic or
			 therapeutic purposes.
(15)
			 "Recipient" is defined in
			 KRS
			 205.8451(9).
(16) "Usual and customary" means the uniform
			 amount which a provider charges the general public for a specific procedure or
			 service.