reglab/statecodes huggingface dataset:
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 5 - Hospital Procedures › Rule 23-202-5.1 - Hyperbaric Oxygen Therapy

Current through June 25, 2024
A. The Division of
				Medicaid defines Hyperbaric Oxygen Therapy (HBOT) as a modality in which the
				beneficiary's entire body is placed into the hyperbaric chamber and exposed to
				oxygen under increased atmospheric pressure.
1. The beneficiary is entirely enclosed in a
				pressure chamber breathing 100% oxygen (O 2) at greater
				than one atmosphere pressure.
2.
				Either a mono-place chamber pressurized with pure O 2 or
				a larger multi-place chamber pressurized with compressed air where the
				beneficiary receives pure O 2 by mask, head tent, or
				endotracheal tube may be used.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 5 - Hospital Procedures › Rule 23-202-5.2 - Chelation Therapy

Current through June 25, 2024
A. The Division of
				Medicaid covers only Food and Drug Administration (FDA)-approved chelation in
				an inpatient or outpatient hospital setting in accordance with current
				standards of medical practice.
B.
				Conditions which may be treated with chelation include:
1. Lead poisoning,
2. Iron overload,
3. Metallic mercury poisoning,
4. Copper poisoning,
5. Arsenic poisoning,
6. Gold poisoning,
7. Cystinuria,
8. Wilson's disease, and
9. Severe, active rheumatoid arthritis that
				has failed to respond to an adequate trial of conventional therapy.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 5 - Hospital Procedures › Rule 23-202-5.3 - Sterilization

Current through June 25, 2024
A. The Division of Medicaid covers
				sterilization procedures in an inpatient or outpatient hospital setting in
				accordance with current standards of medical practice for beneficiaries who:
1. Are male or female,
2. Are non-institutionalized,
3. Are twenty-one (21) years of age or older
				at the time of consent, and
4. Are
				mentally competent, able to understand the nature and consequences of the
				procedure, knowingly and voluntarily request the procedure, and give informed
				consent to be sterilized.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 5 - Hospital Procedures › Rule 23-202-5.4 - Abortions

Current through June 25, 2024
A. Notwithstanding any other provision of law
				to the contrary, no public funds that are made available to any institution,
				board, commission, department, agency, official, or employee of the State of
				Mississippi, or of any local political subdivision of the state, whether those
				funds are made available by the government of the United States, the State of
				Mississippi, or a local governmental subdivision, or from any other public
				source, shall be used in any way for, to assist in, or to provide facilities
				for abortion, except:
1. When the abortion is
				medically necessary to prevent the death of the mother, or
2. When the abortion is being sought to
				terminate a pregnancy resulting from an alleged act of rape or incest, or
3. When there is a fetal
				malformation that is incompatible with the baby being born alive.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 5 - Hospital Procedures › Rule 23-202-5.5 - Trauma Team Activation/Response

Current through June 25, 2024
Trauma team activation/response payments are covered under
				  the Mississippi Medicaid Program in an outpatient hospital setting in
				  accordance with current standards of medical practice according to the
				  following criteria:
A. The billing
				hospital must have a complete designation as a Level I, II, III, or IV trauma
				center through the Mississippi State Board of Health, Office of Emergency
				Planning and Response; or if out of state, through the responsible governing
				body of the state in which the beneficiary received services.
B. Payment will be made in accordance with
				the reimbursement methodology of the Division of Medicaid's inpatient or
				outpatient hospital services.
C.
				Trauma activation fees for beneficiaries who are "drive by," or arrive by
				private vehicle without notification from pre-hospital caregivers, are not
				covered. The patient must arrive by ambulance and the hospital must be
				pre-notified by pre-hospital caregivers.
D. Documentation must be maintained in the
				patient's medical record that supports provision of an organized trauma team
				response that meets the criteria for the Level I, II, III, or IV service. A
				facility must not bill and cannot be paid for a level of care above the one (1)
				which they have been designated by the Mississippi State Department of
				Health.
E. All patients must have a
				primary diagnosis that falls within the appropriate International
				Classification Of Disease (ICD) diagnosis code range plus documentation in the
				medical record of one (1) of the following situations:
1. Transfer between acute care facilities, in
				or out,
2. Admission to critical
				care unit, no minimum,
3.
				Hospitalization for three (3) or more calendar days,
4. Death after receiving any evaluation or
				treatment,
5. Admission directly
				from Emergency Department to Operating Room for major procedure, excluding
				plastics or orthopedics procedures on patients that do not meet the three day
				hospitalization criteria,
6.
				Triaged, in accordance with regional trauma protocols, to a trauma hospital by
				pre-hospital care regardless of severity, or
7. Treated in the Emergency Department by the
				trauma team regardless of severity of injury.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 5 - Hospital Procedures › Rule 23-202-5.6 - Hysterectomy

Current through June 25, 2024
A. The Division of Medicaid defines a
				hysterectomy as the surgical removal of the uterus.
B. The Division of Medicaid covers a
				hysterectomy when medically necessary in an inpatient or outpatient setting in
				accordance with current standards of medical practice and when:
1. Prior to the hysterectomy:
a) The person who secured authorization to
				perform the hysterectomy has informed the beneficiary and guardian/legal
				representative, if any, orally and in writing that the hysterectomy will make
				the beneficiary permanently incapable of reproducing, and
b) The beneficiary or guardian/legal
				representative, the person that secured authorization for the hysterectomy, and
				the physician who performs the hysterectomy have completed and signed the
				appropriate section(s) of the Hysterectomy Acknowledgement Form;
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 202 - Hospital Services › Chapter 5 - Hospital Procedures › Rule 23-202-5.7 - Dental Services Provided in a Hospital Setting

Current through June 25, 2024
A.
				The Division of Medicaid covers medically necessary dental treatment in the
				outpatient hospital setting when all the following are met:
1. Quality, safe, and effective treatment
				cannot be provided in an office setting,
2. Inpatient hospitalization is not medically
				necessary [Refer to Miss. Admin. Code Part 204, Rule
				1.11.B.], and
3. Certain dental procedures have been prior
				authorized by the Division of Medicaid or designee.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 1 - General › Rule 23-203-1.1 - Provider Enrollment Requirements for Physicians, Osteopaths, Chiropractors, Podiatrists

Current through June 25, 2024
Physician providers may participate in the Medicaid program
				  upon compliance with provider enrollment requirements outlined in Part 200,
				  Chapter 4, Rule 4.8 in addition to the specific provider type requirements
				  listed below. Physicians, osteopaths, chiropractors and podiatrists must also
				  meet the specific requirements as follow:
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.
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.
D. CLIA
				certificate and completed Certification form, if applicable
E. Copy of specialty certificate(s), if
				applicable
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 1 - General › Rule 23-203-1.2 - Physician Fees

Current through June 25, 2024
Effective for dates of services on and after July 1, 2022,
				  physicians' services are reimbursed at ninety percent (90%) of the Medicare
				  Physician Fee Schedule.
Miss. Code
				  Ann. §§
										43-13-117,
				  43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 1 - General › Rule 23-203-1.3 - Medical Visit Editing

Current through June 25, 2024
Medicaid does not provide separate reimbursement for most
				  Evaluation and Management (E&M) services when a substantial diagnostic or
				  therapeutic procedure is performed.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 1 - General › Rule 23-203-1.4 - Physician Office Visits

Current through June 25, 2024
A. The Division of
				Medicaid covers a combined total of sixteen (16) non-psychiatric physician
				office and hospital outpatient department visits per state fiscal year whether
				occurring during or after office hours or provider established office hours.
				[Refer to Miss. Admin. Code, Part 200, Rule
				9.5 for psychiatric physician office
				and hospital outpatient department visits.]
B. The Division of Medicaid:
1. Defines regularly scheduled office hours
				as the hours between 8:00 a.m. and 5:00 p.m., Monday through Friday, excluding
				Saturday, Sunday and federal and state holidays, referred to in Rule 1.4 as
				"office hours".
2. Permits
				providers to set regularly scheduled office hours outside of the Division of
				Medicaid's definition of office hours, referred to in Rule 1.4 as "provider
				established office hours".
3.
				Requires providers to maintain records indicating the provider's established
				office hours and any changes including:
a) The
				date of the change,
b) The provider
				established office hours prior to the change, and
c) The new provider established office
				hours.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 1 - General › Rule 23-203-1.5 - Hospital Inpatient Visits/Consultations

Current through June 25, 2024
A. An initial
				hospital visit for the beneficiary's attending physician is covered. A
				subsequent hospital visit is not covered on the same day as the initial
				visit.
B. Following the date of
				admission, only one subsequent hospital visit per day is allowed to the
				attending physician. An exception is made when the patient is in an Intensive
				Care Unit (ICU) or Coronary Care Unit (CCU) where the limit is two (2) visits
				per day.
C. An initial inpatient
				consultation is covered for each consultant of a different specialty if the
				patient's condition justifies the medical necessity for multiple consultations.
				Only one (1) initial consultation is allowed per beneficiary, per consultant,
				per admission.
D. Following the
				date of the initial inpatient consultation, one (1) subsequent hospital visit
				per day is allowed to only one (1) consulting physician if the patient's
				condition justifies the medical necessity for the services of more than one (1)
				physician of a specialty different from the attending physician.
E. A subsequent hospital visit and a hospital
				discharge visit on the same date of service are not both covered; only the
				hospital discharge visit is a covered service.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 1 - General › Rule 23-203-1.6 - Locum Tenens/Reciprocal Billing Arrangements

Current through June 25, 2024
A. Locum
				Tenens: For purposes of this rule a "locum tenens" arrangement is defined when
				the regular physician retains a substitute physician to take over the practice
				during an absence. A regular physician is the physician that is normally
				scheduled to see a patient. The regular physician usually pays the substitute
				physician a fixed amount per diem, with the substitute physician being an
				independent contractor rather than an employee.
B. Reimbursement shall be made to the
				patient's regular physician for covered services of a locum tenens physician
				who is not an employee of the regular physician and whose services for patients
				of the regular physician are not restricted to the regular physician's offices
				when all the following criteria are met:
1.
				The regular physician is unavailable to provide the services,
2. The regular physician pays the locum
				tenens for the services on a per diem or similar fee-for-time basis,
3. The Medicaid beneficiary has arranged or
				sought to receive services from the regular physician,
4. The substitute physician does not provide
				the services to the Medicaid beneficiary over a continuous period of longer
				than sixty (60) days,
5. The locum
				tenens physician is an enrolled Mississippi Medicaid provider with a valid
				Mississippi Medicaid provider number,
6. The regular physician identifies the
				services as substitute physician services,
7. The claim is billed with the National
				Provider Identifier (NPI) of the regular physician,
8. The regular physician keeps on file a
				record of each service provided by the substitute physician, and
9. The regular physician ensures that the
				locum tenens physician is properly licensed to practice medicine in the state
				of Mississippi; or, if the regular physician practices in another state, the
				state in which the regular physician is licensed to practice.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 1 - General › Rule 23-203-1.7 - Teaching Facilities' Billing for Resident Services

Current through June 25, 2024
A.
				Medicaid does not apply Medicare policy related to billing for services
				performed by residents in a teaching facility. Medicaid does not cover services
				provided under the direction of the teaching physician.
B. Medicaid covers teaching physicians, who
				are supervising residents, but requires the teaching physician to physically be
				present in the room with the beneficiary and requires documentation in the
				teaching physician medical record that they were physically present in the room
				with the beneficiary when services were rendered by the resident.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 1 - General › Rule 23-203-1.8 - Casting, Splinting, or Strapping in Office Setting

Current through June 25, 2024
A.
				Physicians, physician assistants, or nurse practitioners must bill the
				appropriate procedure evaluation and management code, fracture or dislocation
				codes, or application of casts and strapping code to be reimbursed professional
				fees for application of casts, splints, or strapping performed in the office
				setting. Providers must follow the procedure coding guidelines for selection of
				the appropriate code.
B. For
				casting, splinting, or strapping supplies provided by a physician, physician
				assistant, or nurse practitioner in the office setting, the provider must bill
				the procedure codes for the cost of the supplies.
C. The coding criteria listed above apply to
				replacement casts, splints, or strapping.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 1 - General › Rule 23-203-1.9 - Removal of Impacted Cerumen

Current through June 25, 2024
A. Medicaid covers
				the removal of impacted cerumen only for symptoms directly related to the
				presence of impacted cerumen. Symptoms include, but are not limited to, the
				following:
1. Earache,
2. Itching of the ear,
3. Feeling that the ear is plugged,
4. Partial hearing loss,
5. Ringing in the ear, or
6. Otorrhea
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 1 - General › Rule 23-203-1.10 - 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 203 - Physician Services › Chapter 1 - General › Rule 23-203-1.11 - Global Package

Current through June 25, 2024
A. The Division of
				Medicaid defines a Global Package as a single payment for necessary services
				and products normally furnished during the pre-operative, intra-operative and
				postoperative periods by the "same physician" which is defined as physicians
				and/or other qualified health care professionals:
1. Of the same group,
2. Of the same specialty,
3. Reporting the same federal tax
				identification number, and
4.
				Reimbursed on a fee-for-service basis.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 2 - Physician-Administered Drugs and Implantable Drug System Devices › Rule 23-203-2.1 - Covered Services

Current through June 25, 2024
A. The Division of
				Medicaid covers medically necessary physician-administered drugs and
				implantable drug system devices defined as a drug other than vaccines,
				diagnostic or therapeutic radio pharmaceutical, contrast imaging agent,
				biological or implantable drug system device covered under the Social Security
				Act § 1927(k)(2) that:
1. Are
				administered by a medical professional in a physician's office or other
				outpatient clinical setting,
2.
				Are incident to physician services that are separately billed to the Division
				of Medicaid,
3. Qualifies for
				rebate in accordance with
				42 USC §
											1396r-8,
4. Are Food and Drug Administration (FDA)
				approved or follows medically accepted indications and dosing limits supported
				by one (1) or more of the official compendia as designated by the Centers for
				Medicare and Medicaid Services (CMS), and
5. Are not considered cosmetic,
				investigational, experimental or unproven.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 2 - Physician-Administered Drugs and Implantable Drug System Devices › Rule 23-203-2.2 - Drug Rebates

Current through June 25, 2024
A. In accordance
				with federal regulations, the Division of Medicaid collects Medicaid drug
				rebates from manufacturers on physician-administered drugs per the following:
1. Effective for all drugs administered on
				and after January 1, 2008, providers must submit the National Drug Code (NDC)
				of the drug administered in addition to the appropriate drug code for
				physician-administered drugs on claims.
a) An
				NDC is not required for vaccines or other drugs as specified by CMS.
b) The NDC of the drug administered must
				contain eleven (11) digits in the five (5) four (4) two (2) grouping and, if
				applicable, include "leading zeros (0)" to constitute an eleven (11) digit NDC
				code.
c) The NDC of the drug
				administered must be matched against a database to ensure its validity.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 2 - Physician-Administered Drugs and Implantable Drug System Devices › Rule 23-203-2.3 - Transferred

Current through June 25, 2024
Refer to Miss. Admin. Code Part 203, Rule
				  2.1
Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 2 - Physician-Administered Drugs and Implantable Drug System Devices › Rule 23-203-2.4 - Transferred

Current through June 25, 2024
Refer to Miss. Admin. Code Part 203, Rule
				  2.1
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 2 - Physician-Administered Drugs and Implantable Drug System Devices › Rule 23-203-2.5 - Transferred

Current through June 25, 2024
Refer to Miss. Admin. Code Part 203, Rule
				  2.1
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 2 - Physician-Administered Drugs and Implantable Drug System Devices › Rule 23-203-2.6 - Transferred

Current through June 25, 2024
Refer to Miss. Admin. Code Part 203, Rule
				  2.1
42 CFR
				  §§435.116, 440.210; Miss. Code Ann. §
										43-13-121.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 2 - Physician-Administered Drugs and Implantable Drug System Devices › Rule 23-203-2.7 - 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. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 3 - Anesthesia › Rule 23-203-3.1 - Provider Enrollment

Current through June 25, 2024
A. Providers of
				anesthesia services must comply with all requirements set forth in Part 200,
				Chapter 4, Rule 4.8 for all providers in addition to the specific provider type
				requirement below:
1. Obtain National
				Provider Identifier (NPI) with verification from National Plan and Provider
				Enumeration System (NPPES),
2. Copy
				of current licensure card,
3.
				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.
4. Copy of approved protocol and practice
				setting, if applicable, and
5. Copy
				of specialty certificate(s), if applicable.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 3 - Anesthesia › Rule 23-203-3.2 - Covered Services

Current through June 25, 2024
A. Medicaid covers
				anesthesia services provided by an anesthesiologist/certified registered nurse
				anesthetists (CRNA).
B. Medicaid
				covers CRNAs for anesthesia services for surgical procedures using the
				appropriate anesthesia codes.
C.
				Medicaid covers administration of anesthesia by a CRNA, without medical
				direction, at ninety percent (90%) of the calculated payment for
				anesthesiologists. The appropriate modifier must be used when billing for
				services that are not medically directed.
D. Medicaid covers medically directed CRNA
				services at fifty percent (50%) of the allowance for the anesthesiologist. The
				appropriate modifier should be used when billing for services that are
				medically directed.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 3 - Anesthesia › Rule 23-203-3.3 - Criteria for Medical Direction of Resident

Current through June 25, 2024
A. Medicaid covers
				an anesthesiologist who assumes full responsibility for a patient while the
				anesthesia is being administered by a resident in a teaching facility.
1. Medicaid only covers one anesthesiologist
				for the professional services.
2.
				Medicaid covers the appropriate modifier indicating that the anesthesiologist
				has assumed full responsibility for the patient while the anesthesia is being
				administered by a resident in a teaching facility.
3. The medical direction of residents is
				covered only in a teaching facility.
4. Medicaid covers the anesthesiologist to
				supervise no more than four (4) residents at any one time.
5. Medicaid does not cover medical direction
				by CRNAs.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 3 - Anesthesia › Rule 23-203-3.4 - Billing for Procedures

Current through June 25, 2024
A. Medicaid defines
				one (1) anesthesia time unit as one (1) minute.
B. Medicaid defines anesthesia time as when
				the anesthesiologist begins to prepare the patient for anesthesia care in the
				operating room or in an equivalent area, and ends when the anesthesiologist is
				no longer in personal attendance, that is, when the patient may be safely
				placed under post-operative supervision.
C. Medicaid does not cover additional
				modifying units for physical status, extreme age, utilization of total body
				hypothermia or controlled hypotension, or emergency conditions.
D. Medicaid covers additional coverage for
				the insertion of an arterial line, CVP line, or the insertion/placement of a
				flow directed catheter such as a Swan-Ganz when the procedures are personally
				performed by the anesthesiologist/CRNA in conjunction with anesthesia services
				for a surgical procedure.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 3 - Anesthesia › Rule 23-203-3.5 - 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 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.1 - Definitions

Current through June 25, 2024
A. For purposes of this chapter Medicaid
				defines the following terms related to surgery as follows:
1. Add-on codes are procedures performed in
				addition to the primary service/procedure and are never reported as a
				stand-alone code.
a) Add-on codes describe
				additional intra-service work associated with the primary procedure.
b) Add-on codes are exempt from multiple
				surgery rules.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.2 - Assistant Surgeon

Current through June 25, 2024
A. Medicaid covers
				an assistant surgeon during major surgery, including all surgical cases
				performed under spinal or regional anesthesia if the nature of the surgery
				requires the assistance of a second physician or surgeon. Medicaid covers only
				one (1) assistant surgeon for any case.
B. Medicaid does not cover interns,
				residents, fellows, physician assistants, and nurses, including nurse
				practitioners, as an assistant surgeon.
C. Medicaid covers the services of an
				assistant surgeon when the following criteria are met:
1. The operation must be a covered surgical
				procedure, and
2. The operation
				must be of sufficient difficulty and complexity to require an assistant
				surgeon, and
3. The assistant
				surgeon must actively assist in the surgery.
a) Medicaid defines actively assist as the
				assistant surgeon must assist in the actual performance of the surgical
				procedure, and
b) The assistant
				surgeon, in the event the surgeon is unable to continue, must be able to
				complete the surgery.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.3 - Co-Surgeons

Current through June 25, 2024
A. Medicaid covers the individual skills of
				two (2) or more surgeons when required to perform surgery on the same patient
				during the same operative session. This may be required because of the complex
				nature of the procedure(s) and/or the patient's condition. In these cases, the
				additional physicians are not acting as assistants-at-surgery.
B. Medicaid covers co-surgeons at sixty two
				and one half percent (62.5%) of the Medicaid coverage for co-surgeon
				procedures.
C. Medicaid covers the
				services of two (2) surgeons of the same specialty without regard to the two
				(2) specialty requirement when the services are justified by medical
				documentation.
D. Medicaid covers
				the services of two (2) surgeons in different specialties when performing a
				specific procedure.
1. This is also applicable
				when the different procedures are performed through the same
				incision.
2. Each surgeon must
				report the procedure he/she performed.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.4 - Team Surgeons

Current through June 25, 2024
A. Medicaid covers
				two (2) or more surgeons to perform surgery on the same patient during the same
				operative session.
B. Medicaid
				covers the surgeons of different specialties performing a different procedure,
				even if the procedures are performed through the same incision.
C. The appropriate modifier in conjunction
				with the procedure code for services rendered is required to identify a
				co-surgeon's services.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.5 - Multiple Surgeries

Current through June 25, 2024
A. Part 203,
				Chapter 4 Rule 4.5.A, B is applicable for assistant surgeon, team surgeon, or
				cosurgeon services.
B. Medicaid
				reimburses for the primary procedure at the highest reimbursement rate from the
				Medicaid Physician Fee Schedule. The primary surgical procedure must be billed
				first and other procedures must be billed on subsequent lines on the
				claim.
C. Medicaid covers multiple
				surgical procedures performed by the same surgeon on the same patient and on
				the same date of service. The surgical procedures must be billed together on
				the same claim unless one (1) claim does not accommodate all of the
				procedures.
D. For multiple
				surgeries performed on the same day, Medicaid covers the following:
1. Multiple surgical procedures performed at
				the same operative setting through a single opening are reimbursable at the
				Medicaid rate for the procedure with the greatest reimbursement. The additional
				surgeries through this same opening are not reimbursable unless a second
				surgical procedure adds significant time, risk, or complexity to patient care
				which Medicaid will reimburse as follows:
a)
				The surgery with the greater Medicaid allowed amount will be reimbursed at the
				full amount.
b) The second surgery
				will be reimbursed at one half the Medicaid allowance.
c) The secondary procedure must be billed
				with the appropriate modifier.
d)
				No additional benefits are paid toward incidental, mutually exclusive, or
				unbundled procedures.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.6 - Bilateral Procedures

Current through June 25, 2024
A. Medicaid covers
				bilateral procedures performed during an operative setting, when reported with
				the appropriate procedure code and modifier. One (1) procedure will be paid at
				one hundred percent (100%) of the Medicaid allowable and the second procedure
				will be paid at fifty percent (50%) of the Medicaid allowable.
B. If the bilateral procedures are both
				secondary procedures to a primary procedure, the bilateral secondary procedures
				will each be paid at fifty percent (50%) of the Medicaid allowable.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.7 - Surgical Modifiers

Current through June 25, 2024
A. The applicable
				modifiers for bilateral procedures, multiple procedures, co-surgeons, surgical
				teams, and assistant surgeons must be utilized on claims for surgery.
B. Medicaid reimburses for surgical care only
				at eighty-five percent (85%) of the Medicaid allowable. The applicable modifier
				for this service must be reported with the appropriate surgery procedure
				codes.
C. Medicaid reimburses for
				postoperative management only at fifteen percent (15%) of the Medicaid
				allowable. The applicable modifier for this service must be reported with the
				appropriate surgery procedure codes.
1.
				Medicaid requires a documented agreement for the transfer of care when one (1)
				physician performs a patient's surgical service and another provides the
				postoperative management.
2. The
				agreement must be in the form of a letter, discharge summary, chart notation,
				or other written documentation and be retained in each physician' beneficiary's
				medical record.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.8 - Endoscopic Procedures

Current through June 25, 2024
A. Medicaid
				considers the following incidental and not covered:
1. A diagnostic scope and a surgical scope in
				the same setting,
2. A diagnostic
				scope with biopsy and a surgical scope,
3. A diagnostic scope with or without biopsy
				done with an endoscope and an open surgical procedure in the same anatomic
				area, or
4. A diagnostic scope and
				diagnostic scope with biopsy unless the verbiage distinguishes the procedure as
				"with biopsy" versus "without biopsy".
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.9 - Post-Operative Pain Management

Current through June 25, 2024
A. The surgeon is
				responsible for daily post-operative pain management services except under
				extraordinary circumstances.
B.
				Medicaid covers post-operative pain management provided by several means,
				including, but not limited to:
1. Oral and
				parenteral administration,
2.
				Patient controlled analgesia (PCA), and
3. Epidural.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.10 - Abdominal Panniculectomy

Current through June 25, 2024
A. Medicaid covers
				abdominal panniculectomy (abdominoplasty, abdominodermatolipectomy) only when
				there is medical documentation that demonstrates the procedure is:
1. Medically necessary,
2. Reconstructive,
3. Performed to alleviate the patient's
				symptomatology, and
4. Performed to
				improve function.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.11 - Blepharoplasty

Current through June 25, 2024
A. Medicaid covers a surgical blepharoplasty
				when performed by a general surgeon, plastic surgeon or ophthalmologist in the
				physician's office, inpatient or outpatient facility or an ambulatory surgical
				center.
B. Medicaid defines:
1. Blepharoplasty as any surgery of the
				eyelid performed to improve abnormal functions or reconstruct
				deformities.
2. Cosmetic
				blepharoplasty as surgery performed to reshape normal structures of, or
				surrounding, the eye solely for the purpose of improving the patient's
				appearance or self-esteem.
3.
				Reconstructive blepharoplasty as surgery performed to correct visual impairment
				and/or restore normalcy to a structure that has been altered by trauma,
				infection, inflammation, degeneration, neoplasia or developmental
				errors.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.12 - Circumcisions

Current through June 25, 2024
A. Medicaid does not cover circumcisions
				unless medical necessity is documented in the medical record according to the
				criteria listed below.
1. A diagnosis which
				justifies the medical necessity for circumcision including, but not limited to,
				recurrent balanoposthitis or recurrent urinary tract infections; the diagnosis
				of phimosis alone is not sufficient documentation of medical
				necessity,
2. Failure of the
				patient to respond to conservative treatment; documentation of conservative
				treatment must include, but not limited to, teaching about appropriate hygiene
				and listing of appropriate drug therapy used to treat the condition,
				and
3. The recurrent nature of the
				medical condition.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.15 - Keloids

Current through June 25, 2024
A. Medicaid covers the initial evaluation
				consultation to diagnose the condition and/or develop a plan of
				treatment.
B. Medicaid covers
				treatment only when there is medical documentation that demonstrates any of the
				following signs and symptoms:
1.
				Pain,
2. Persistent itching and/or
				burning sensation,
3. Ulceration
				and bleeding,
4. Limitation of
				movement of the head or a digit or extremity,
5. Obstruction of a bodily orifice,
6. Infection, or
7. Fast growth.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.16 - Male Gynecomastia

Current through June 25, 2024
A. Medicaid covers
				mastectomy, including reconstruction if necessary, for gynecomastia when
				considered medically necessary when the following criteria are met:
1. The tissue removed is glandular breast
				tissue and not the result of obesity, adolescence, or reversible effects of a
				drug treatment which can be discontinued (this would include drug-induced
				gynecomastia remaining unresolved six (6) months after cessation of the
				causative drug therapy),
2.
				Appropriate diagnostic evaluation has been done for possible underlying
				etiology,
3. Pain or tenderness
				directly related to the breast tissue has been refractory to a trial of
				analgesics, anti-inflammatory agents, etc., for a time period adequate to
				assess therapeutic effects,
4. The
				excessive breast tissue development is not caused by non-covered therapies or
				illicit drug usage such as marijuana, anabolic steroids, etc.,
5. The beneficiary has a physician documented
				history of two (2) years or more of gynecomastia that has been refractory to
				conservative treatments,
6.
				Unclothed preoperative photographs from the chin to the waist, including
				standing frontal and side views with arms straight down at sides, and
7. The beneficiary is over eighteen (18)
				years of age, or eighteen (18) months after the end of puberty.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.17 - Otoplasty

Current through June 25, 2024
A. Medicaid covers otoplasty for the
				correction of ears that protrude more than twenty (20) millimeters (mm) and at
				an angle greater than thirty five (35) degrees from the occipital scalp when
				the following criteria is meet:
1. For the
				correction of an external ear deformity associated with an abnormality of the
				external ear canal such as stenosis.
2. When the procedure is intended to improve
				a hearing impairment.
3. When
				performed as part of a staged reconstruction for an absent or inadequate
				external ear.
4. When the
				reconstruction involves a cochlear implant and the procedure is required for
				proper functioning of the device.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.18 - Reduction Mammoplasty

Current through June 25, 2024
A. The Division of
				Medicaid covers reduction mammoplasty only when there is medical documentation
				that demonstrates the procedure is:
1.
				Medically necessary,
2.
				Reconstructive, and
3. Performed
				as a last means of attempting to alleviate a beneficiary's symptomatology and
				dysfunction due to the excessive breast size.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.19 - Skin Tag Removal

Current through June 25, 2024
A. Medicaid does
				not cover removal of benign skin tags that do not pose a threat to health or
				function.
B. Medicaid covers the
				removal of skin tags when there is medical documentation that one or more of
				the following conditions exist:
1. The skin
				tag has one or more of the following characteristics: bleeding, itching,
				pain,
2. The skin tag has physical
				evidence of inflammation such as purulence, oozing, edema, erythema,
3. The skin tag obstructs an
				orifice,
4. The skin tag clinically
				restricts vision,
5. There is
				clinical uncertainty as to the likely diagnosis, particularly where malignancy
				is a realistic consideration based on the skin tag appearance, or
6. A prior biopsy suggests or is indicative
				of malignancy.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.20 - Uvulopalatopharyngoplasty (UPPP/UP3)

Current through June 25, 2024
Medicaid covers uvulopalatopharyngoplasty for the treatment
				  of obstructive sleep apnea syndrome if all of the following are present:
A. Documented obstructed sleep apnea (OSA)
				with apnea hypopnea index (AHI) or respiratory disturbance index (RDI) which
				meets the following parameters in a) or b) below:
1. UPPP/UP3 as sole procedure: with AHI/RDI
				greater than fifteen (15) and less than forty (40), or AHI/RDI ten (10) to
				fifteen (15) with one (1) or more of the conditions listed below:
a) Hypertension,
b) Cardiac arrhythmias predominately during
				sleep,
c) Pulmonary hypertension,
d) Documented ischemic heart
				disease,
e) Impaired cognition or
				mood disorders,
f) History of
				stroke, or
g) Excessive daytime
				sleepiness, as documented by either a score of greater than ten (10) on the
				Epworth Sleepiness Scale or inappropriate daytime napping such as during
				driving, conversation, or eating, or sleepiness that interferes with daily
				activities.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.21 - Ventricular Assist Devices (VAD)

Current through June 25, 2024
A. Medicaid covers
				medically necessary procedures for the insertion or removal of FDA-approved
				ventricular assist devices (VAD) in accordance with its FDA approved uses as
				follows:
1. Post-cardiotomy procedures for
				insertion/removal of a VAD performed during the period following open-heart
				surgery.
2. Bridge-to-transplant
				procedures for insertion/removal of a VAD performed during the period prior to
				heart transplant when the patient is at imminent risk of dying before donor
				heart procurement.
3. Destination
				therapy procedures for insertion/removal of a VAD performed as a permanent
				mechanical cardiac support for individuals with severe New York Heart
				Association (NYHA) Class IV heart failure, and who are not eligible for heart
				transplantation.
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.22 - 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 203 - Physician Services › Chapter 4 - Surgery › Rule 23-203-4.23 - Gastric Electrical Stimulation (GES)

Current through June 25, 2024
A. The Division of
				Medicaid covers Gastric Electrical Stimulation (GES) when used for the
				treatment of chronic intractable (drug-refractory) nausea and vomiting
				secondary to gastroparesis of diabetic or idiopathic etiology. The Food and
				Drug Administration has approved the GES device through a humanitarian
				exemption.
B. The beneficiary's
				medical record must contain documentation that the implanting facility's
				institutional review board (IRB) or equivalent governing body has approved the
				implantation of the GES for the specific indications listed in Rule 4.23
				A.
C. GES is considered medically
				necessary if a beneficiary has a diagnosis of gastroparesis and meets all of
				the following criteria:
1. Is refractory or
				intolerant of two (2) out of three (3) classes of prokinetic medications and
				two (2) out of three (3) antiemetic medications,
2. Has significantly delayed gastric emptying
				as documented by standard scintigraphic imaging of solid food,
3. Has a poor nutritional status and enteral
				feedings or total parental nutrition (TPN) is medically necessary,
				and
4. Is age eighteen (18) through
				seventy (70).
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 5 - Chiropractor › Rule 23-203-5.1 - Covered Services

Current through June 25, 2024
A. Medicaid covers
				chiropractic services for manual manipulation of the spine to correct a
				subluxation.
B. An x-ray must
				demonstrate that a subluxation exists and if the subluxation has resulted in a
				neuromusculoskeletal condition for which manipulation is appropriate
				treatment.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 5 - Chiropractor › Rule 23-203-5.2 - Reimbursement

Current through June 25, 2024
The fee for chiropractic manipulation shall be reimbursed per
				  the fee schedule and shall not exceed seven hundred dollars ($700) per fiscal
				  year (July 1 - June 30) per beneficiary.
Miss. Code Ann. §
										43-13-121
Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 203 - Physician Services › Chapter 5 - Chiropractor › Rule 23-203-5.3 - Coverage Criteria

Current through June 25, 2024
A. A chiropractor
				must use the appropriate procedure code for manual manipulation of the spine to
				correct subluxation. Medicaid coverage will be provided for one (1) procedure
				code that encompasses the entire treatment for any given day.
B. Necessity of treatment must be documented
				by use of the appropriate diagnosis code to report all of the following:
1. Treatment area as denoted by the
				appropriate primary diagnosis code.
2. Symptoms associated with subluxation as
				denoted by the appropriate second diagnosis code.
3. Complicating factors as denoted by the
				appropriate third diagnosis code.