Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 18 - PHYSICIANS' SERVICES › Section 471-18-007 - BILLING FOR PHYSICIAN SERVICES

Current through June 17, 2024
007.01
GENERAL BILLING
  REQUIREMENTS.
Providers must comply with all applicable billing
  requirements codified in 471 NAC 3. In the event individual billing
  requirements in 471 NAC 3 conflict with billing requirements outlined in this
  chapter, the individual billing requirements in this chapter will
  govern.
007.02
SPECIFIC
  BILLING REQUIREMENTS.
Physicians' services must be billed on Form
  CMS-1500 or the standard electronic Health Care Claim: Professional transaction
  (ASC X12N 837). Physicians' services must not be billed by a hospital. The
  physician or the physician's authorized agent must approve and date each paper
  claim. Approval of paper claims is indicated by the handwritten signature,
  signature stamp, or computer-generated signature of the physician or authorized
  agent. When a computer-encoded document or electronic transaction is used, the
  Department may request the provider's source input documentation from the
  provider for input verification and signature requirements. The physician or
  the physician's authorized agent must enter the physician's usual and customary
  charge for each procedure code on the claim.
007.02(A)
PROCEDURE
  CODES.
Physicians must use Healthcare Common Procedure Coding
  System (HCPCS) procedure codes when submitting claims to the Department for
  Medicaid services. Healthcare Common Procedure Coding System (HCPCS) and
  Current Procedural Terminology (CPT) procedure codes used by the Department are
  listed in the Nebraska Medicaid Practitioner Fee Schedule.
007.02(B)
PORTABLE X-RAY
  SERVICES.
Claims for portable x-ray services must contain the name
  of the physician who ordered the service and a diagnosis of medical
  necessity.
007.02(C)
SECOND SURGICAL OPINION.
The second physician must
  bill Nebraska Medicaid with a Healthcare Common Procedure Coding System (HCPCS)
  consultation procedure code indicating the level of the consultation and
  identifying the service as a second surgical opinion.
007.02(D)
PRENATAL, DELIVERY AND
  POSTPARTUM CARE.
When billing Nebraska Medicaid for prenatal,
  delivery, and postpartum care, the provider must submit a claim at the time of
  delivery. When the primary physician does not participate in the total
  obstetrical care, the partial care may be billed separately from the delivery
  using the appropriate procedure codes. An explanation for the partial care must
  be submitted. Providers must use one procedure code but must provide individual
  dates of service on the claim. One charge is submitted covering all:
(i) Routine prenatal care, vaginal delivery,
  and postpartum care; or
(ii)
  Routine prenatal care, cesarean delivery, and postpartum care.
007.02(E)
FRACTURE
  CARE.
Providers may claim subsequent replacement of cast or
  traction devices used during or after the period of follow-up care as an
  independent service using the appropriate Healthcare Common Procedure Coding
  System (HCPCS) procedure code.
007.02(F)
PRACTITIONER
  ADMINISTERED MEDICATIONS.
When billing for medications
  administered during the course of a clinic visit, the physician must use the
  appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code
  for the medication, the correct number of units per the Healthcare Common
  Procedure Coding System (HCPCS) description, the National Drug Code (NDC) of
  the drug administered, the National Drug Code (NDC) unit of measure and the
  National Drug Code (NDC) number of units. A Current Procedural Terminology
  (CPT) code for the administration must also be submitted. When billing for
  medication which does not have a specific Level I or II code, the physician
  must use a miscellaneous Healthcare Common Procedure Coding System (HCPCS) code
  with the name and National Drug Code (NDC) number identifying the drug and
  include the dosage given. If this information is not with the claim, the
  Department may return the claim to the physician for completion or pay the
  claim at the lowest dosage manufactured for the specific drug.
007.02(F)(i)
CHEMOTHERAPY.
Providers must bill for chemotherapy
  using Healthcare Common Procedure Coding System (HCPCS) procedure codes for
  chemotherapy administration. The drug used must be identified and claimed
  separately on the claim using the appropriate Healthcare Common Procedure
  Coding System (HCPCS) procedure code, the number of units per the Healthcare
  Common Procedure Coding System (HCPCS) description, the National Drug Code
  (NDC) of the drug administered, the National Drug Code (NDC) unit of measure,
  and the number of National Drug Code (NDC) units. For drugs which do not have a
  specific Healthcare Common Procedure Coding System (HCPCS) code, the provider
  must use a miscellaneous chemotherapy code. The provider must indicate on or in
  the claim the name of medication, the dosage administered, and the National
  Drug Code (NDC) number, 'unit of measure', and number of units.
007.02(F)(ii)
IMMUNIZATIONS.
When using Vaccine for Children (VFC)
  vaccines, only the administration is billed to Nebraska Medicaid by adding the
  appropriate modifier to the vaccine code. The billed charge for the
  administration must not exceed the Vaccine for Children (VFC) federally
  determined state maximum for Nebraska. It is not necessary to submit a National
  Drug Code (NDC) when billing for vaccines.
007.02(G)
PHYSICIAN'S OFFICE
  LABORATORY.
If the services are provided in a physician's or group
  of physician's private office, payment may be claimed for the medically
  necessary services provided or supervised by the physician, using the
  appropriate Healthcare Common Procedure Coding System (HCPCS) procedure
  code.
007.02(H)
LICENSED AND CERTIFIED INDEPENDENT CLINICAL
  LABORATORY.
The physician must indicate on or with the appropriate
  claim form or electronic format the fee for obtaining the specimen by
  venipuncture or catheterization is for tests performed outside his or her
  office and submit the name of the facility performing the tests on the
  claim.
007.02(I)
BILLING FOR THE PROFESSIONAL AND TECHNICAL COMPONENTS OF HOSPITAL
  INPATIENT AND OUTPATIENT DIAGNOSTIC AND THERAPEUTIC SERVICES.
The
  professional component of hospital diagnostic and therapeutic services must be
  billed as previously described except for facilities paid under an
  all-inclusive rate. The technical component of hospital diagnostic and
  therapeutic services must be billed by the hospital. A hospital may act as the
  billing agent for the physician's professional component. The Department
  requires a separate Medicaid provider number for each specialty for the
  hospital professional component. A separate provider agreement is required for
  each separate provider number. The professional component must be billed on the
  claim, using the appropriate provider number for the professional component of
  the appropriate specialty. Only one specialty, one provider number, may be
  billed on each claim.
007.02(J)
ANESTHESIOLOGY.
The professional component must be
  claimed and must indicate actual time in one-minute increments. The physician's
  medical direction of four or fewer concurrent anesthesia procedures is
  considered a professional component.
007.02(J)(i)
STANDBY
  ANESTHESIA.
The professional component must be billed
  appropriately.
007.02(J)(ii)
CLAIMS FOR PAYMENT.
When a physician bills for
  anesthesia services, the physician must certify with the claim, as appropriate,
  that:
(1) The services were personally
  provided by the physician to the individual; or
(2) When the physician provided medical
  direction for certified registered nurse anesthetist (CRNA) services, the
  number of concurrent services directed is indicated by the appropriate
  modifier.
007.02(J)(iii)
STERILIZATION OR HYSTERECTOMY.
To make payment for
  anesthesia services for sterilizations, a completed copy of Form MMS-100:
  "Sterilization Consent Form" must be on file with the Department. For a
  hysterectomy, a completed copy of Form MMS-101: Informed Consent for
  Hysterectomy, signed and dated by the individual stating she was made aware
  before the surgery that the surgery would result in sterility, must be on file
  with the Department before payment can be made. Claims for these services must
  indicate actual time in one-minute increments.
007.02(J)(iv)
CLAIMS FOR
  CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA) SERVICES.
Claims for
  certified registered nurse anesthetist (CRNA) services must be billed
  accordingly, except rural hospitals which have been exempted by their Medicare
  fiscal intermediary for certified registered nurse anesthetist (CRNA) billing
  must follow the Medicare billing requirements. The Department does not make
  additional reimbursement for emergency and risk factors. When multiple surgical
  procedures are performed at the same time, the certified registered nurse
  anesthetist (CRNA) must bill only for the major procedure. Medicaid does not
  make payment for certified registered nurse anesthetist (CRNA) services for
  secondary procedures.
007.02(K)
LABORATORY AND
  PATHOLOGY.
007.02(K)(i)
INPATIENT HOSPITAL ANATOMICAL PATHOLOGY SERVICES.
Payment for the technical component of anatomical pathology is included in the
  hospital's payment in accordance with 471 NAC 10. The pathologist must claim
  the professional component of anatomical pathology using the appropriate
  Healthcare Common Procedure Coding System (HCPCS) procedure code and modifier.
  Payment is made according to the Nebraska Medicaid Practitioner Fee Schedule.
007.02(K)(ii)(1)
EXCEPTION.
If an anatomical pathology specimen is
  obtained from a hospital inpatient but is referred to an independent laboratory
  or the pathologist of a second hospital's laboratory, the independent lab
  oratory or the pathologist of the second hospital's laboratory to which the
  specimen has been referred may claim payment for the total service. Payment is
  made according to the Nebraska Medicaid Practitioner Fee
  Schedule.
007.02(K)(ii)
OUTPATIENT HOSPITAL ANATOMICAL PATHOLOGY SERVICES.
The
  hospital must claim the technical component according to 471 NAC 10. The
  pathologist must claim the professional component. Payment is made according to
  the Nebraska Medicaid Practitioner Fee Schedule.
007.02(K)(ii)(1)
EXCEPTION.
If an anatomical pathology specimen is
  obtained from a hospital outpatient and is referred to an independent lab
  oratory or the pathologist of a second hospital's laboratory, the independent
  lab oratory or the pathologist of a second hospital's laboratory to which the
  specimen was referred may claim payment for the total service. Payment is made
  according to the Nebraska Medicaid Practitioner Fee Schedule.
007.02(K)(iii)
NON-PATIENT ANATOMICAL PATHOLOGY SERVICES.
A
  non-patient is an individual receiving services who is neither an inpatient nor
  an outpatient. For specimens from non-patients referred to the hospital, the
  hospital must bill the total service. Payment is made according to 471 NAC
  10.
007.02(K)(iv)
LEASED DEPARTMENTS.
If the pathology department is
  leased and an anatomical pathology service is provided to a hospital
  non-patient, the pathologist must claim the total service. Payment is made
  according to the Nebraska Medicaid Practitioner Fee Schedule. Leased department
  status has no bearing on billing for or payment of inpatient or outpatient
  anatomical pathology services.
007.02(K)(v)
CLINICAL LABORATORY
  SERVICES.
The professional and technical components of clinical
  lab oratory services are not separately identified for billing and
  payment.
007.02(K)(vi)
PHYSICIAN'S OFFICE OR INDEPENDENT LABORATORY.
Clinical
  lab oratory services performed in a physician's office or independent lab
  oratory must be billed appropriately.
007.02(K)(vi)(1)
CLINICAL
  LABORATORY CONSULTATION.
The physician must claim a clinical lab
  oratory consultation using the appropriate Healthcare Common Procedure Coding
  System (HCPCS) procedure codes.
007.02(L)
RADIOLOGY.
The professional component must be billed appropriately.
007.02(L)(i)
INPATIENT RADIOLOGY
  SERVICES.
Payment for the technical component of inpatient
  radiology services is included in the hospital's payment in accordance with 471
  NAC 10. Physicians must bill the professional component of inpatient radiology
  services appropriately. Payment for the professional component is made
  according to the Nebraska Medicaid Practitioner Fee Schedule.
007.02(L)(ii)
OUTPATIENT
  RADIOLOGY SERVICES.
The hospital must claim the technical
  component of outpatient radiology services on the appropriate claim form or
  electronic format. Payment is made according to 471 NAC 10. The physician must
  bill the professional component using the appropriate Healthcare Common
  Procedure Coding System (HCPCS) procedure code with the modifier. Payment for
  the professional component is made according to the Nebraska Medicaid
  Practitioner Fee Schedule.
007.02(L)(iii)
NON-PATIENT
  RADIOLOGY SERVICES.
A non-patient is an individual receiving
  services who is neither an inpatient nor an outpatient. If a radiology
  procedure is performed for a non-patient, the hospital must claim the technical
  component. Payment is made according to 471 NAC 10. If the radiology department
  is leased and the service is provided to a non-patient, the radiologist must
  claim the total service. Payment is made is made according to the Nebraska
  Medicaid Practitioner Fee Schedule.
007.02(M)
SERVICES PROVIDED BY
  PHYSICIAN ASSISTANTS.
Claims for services provided by physician
  assistants must be submitted on Form CMS-1500: Health Insurance Claim or the
  standard electronic Health Care Claim: Professional transaction (ASC X12N 837)
  under the physician assistant's provider group number.
007.02(N)
PHYSICIAN SERVICES IN
  SKILLED NURSING FACILITY (SNF), INTERMEDIATE CARE FACILITY (ICF), AND
  INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES
  (ICF/DD).
The physician may bill the Department for an annual
  nursing home physical exam service, regardless of the extent of the exam.
  Additionally, the physician may bill the Department for the recertification
  service. Payment is made according to the Nebraska Medicaid Practitioner Fee
  Schedule.
007.02(N)(i)
ANNUAL
  PHYSICAL EXAMINATION.
If the annual physical examination is
  performed solely to meet the requirement of the Department, the physician must
  submit the claim to the Department on Form CMS-1500: Health Insurance Claim or
  the standard electronic Health Care Claim: Professional transaction (ASC X12N
  837). The Department limits reimbursement for this service to the amount
  allowed under the Nebraska Medicaid Practitioner Fee Schedule.
007.02(N)(ii)
MEDICARE
  COVERAGE.
If a physical examination is performed for diagnosis or
  treatment of a specific symptom, illness, or injury and the individual has
  Medicare coverage, the physician must submit the claim through the usual
  Medicare process. This applies to all physicians' visits in a long-term care
  facility.
007.02(N)(iii)
PHYSICIANS' VISITS TO SKILLED NURSING FACILITY (SNF)
  RESIDENTS.
When billing for a physician's visit, the physician
  must use the appropriate Healthcare Common Procedure Coding System (HCPCS)
  procedure code for a nursing home visit.
007.02(N)(iv)
ON-SITE
  RECERTIFICATION.
The physician is paid according to the Nebraska
  Medicaid Practitioner Fee Schedule. The physician must use the appropriate
  Healthcare Common Procedure Coding System (HCPCS) procedure code for nursing
  home visits when billing Nebraska Medicaid for this service.
007.02(N)(v)
PHYSICIANS' VISITS
  TO INTERMEDIATE CARE FACILITY (ICF) AND INTERMEDIATE CARE FACILITY FOR
  INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) RESIDENTS.
When billing for a physician's visit, the physician must use the appropriate
  Healthcare Common Procedure Coding System (HCPCS) procedure code. The physician
  must submit following statements on or with the claim: "60-day (or alternate
  schedule) intermediate examination."
007.02(O)
TRANSPLANT
  SERVICES.
Physician services must be billed accordingly.
007.02(O)(i)
BILLING FOR
  TRANSPLANT SERVICES PROVIDED TO A MEDICAID-INELLIGIBLE DONOR.
Claims for services provided to a Nebraska Medicaid-ineligible donor must be
  submitted under the Nebraska Medicaid-eligible individual's case number. There
  must be a notation with the claim indicating these services were provided to
  the Nebraska Medicaid-ineligible donor on the individual's behalf.
007.02(P)
ITINERANT
  PHYSICIAN VISITS.
The hospital room charge must be billed on the
  appropriate claim form or electronic format. The physician's service must be
  coded as an office visit and billed on the appropriate claim form or electronic
  format.
007.02(Q)
NURSE
  MIDWIFE OR NURSE PRACTITIONER SERVICES.
Claims for nurse midwife
  services and nurse practitioner services must be submitted on Form CMS-1500:
  Health Insurance Claim according to instructions or on the appropriate
  electronic transaction.
007.02(R)
FEEDING AND SWALLOWING CLINIC SERVICES.
The
  interdisciplinary team (IDT) services must be billed under the physician's
  provider number accordingly. Payment is made according to the Nebraska Medicaid
  Practitioner Fee Schedule. The physician services are billed under appropriate
  Current Procedural Terminology (CPT) codes.
007.02(S)
COMPREHENSIVE
  INTERDISCIPLINARY TREATMENT FOR A SEVERE FEEDING DISORDER.
Claims
  must be submitted accordingly.