Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 1 - Medicaid Services › Section 907 KAR 1:360 - Preventive and remedial public health services

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				205.520,
				205.560,
				42
				C.F.R. 431.615,
				42
				U.S.C. 1320d to
				1320d-8,
				45 C.F.R. Parts 160, 164
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health
				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 preventive and remedial public health
				services provided through the Department for Public Health and the method of
				reimbursement for these services by the Kentucky Medicaid Program.
Section 1. Definitions.
(1) "Add-on code" means a designated CPT code
			 which may be used in conjunction with another CPT code to denote that an
			 adjunctive service has been performed.
(2) "CPT code" means a code used for
			 reporting procedures and services performed by physicians or other licensed
			 medical professionals, including a provider type twenty (20), which is
			 published annually by the American Medical Association in Current Procedural
			 Terminology.
(3) "Department" means
			 the Department for Medicaid Services or its designated agent.
(4) "Incidental" means that a medical
			 procedure:
(a) Is performed at the same time
			 as a more complex primary procedure; and
(b)
1.
			 Requires few additional physician resources; or
2. Is clinically integral to the performance
			 of the primary procedure.
(5) "Integral" means that a medical procedure
			 represents a component of a more complex procedure performed at the same
			 time.
(6) "Medically necessary" or
			 "Medical necessity" means a covered benefit is determined to be needed in
			 accordance with
			 907
			 KAR 3:130.
(7) "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.
(8) "Provider type twenty (20)" means an
			 enrolled preventive services provider who conducts covered services via the
			 Department for Public Health to Medicaid recipients. A number shall be assigned
			 by the department to these providers, and the first two (2) digits shall be
			 twenty (20).
(9) "Relative value
			 unit" or "RVU" means the Medicare-established value assigned to a CPT code
			 which takes into consideration the physician's work, practice expense, and
			 liability insurance.
(10)
			 "Screening" means the evaluation of a recipient by a physician or other
			 approved public health provider to determine:
(a) The presence of a disease or medical
			 condition; and
(b) The necessity of
			 further evaluation, diagnostic tests or treatment.