Physician Coverage Guidelines

Allergy Testing And Desensitization

Allergen Immunotherapy

All covered allergen immunotherapy codes 95115 thru 95199 are limited to one unit per day

Allergy Testing

All covered allergy testing codes within the 95010 thru 95056 range are limited to a maximum of 75 tests per day.

Code 95060 is limited to two units per day.

Office Visits

Office visits are not allowed in addition to allergen immunotherapy codes.

Anesthesia Services

Anesthesia Billing Assistance

Anesthesia services for the Rhode Island Medical Program must be billed with the CPT surgical codes (10000 - 69999 range) and the “AA” modifier. 

Anesthesia Procedure Codes

In certain circumstances, the anesthesiologist actually performs a procedure rather than simply administers anesthesia for the procedure. In these instances, the anesthesiologist should bill that procedure without the “AA” modifier. The procedure codes that anesthesiologists may bill without the “AA” modifier are listed below

 CodesDescription

31500Intubation, endotracheal(emergency procedure)

36488 thru 36491Placement of a Venous Catheter

62274 thru 62282Injection of Anesthetic Substance

64400 thru 64450Nerve Blocks

Anesthesia Services

Rendering anesthesia during a procedure is an all-inclusive package, including such services as pre-op and post-op visits, anesthesia care during the procedure, administration of fluids and/or blood, and the usual monitoring services (e.g., ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry).

Epidural Management of Pain

Daily management (01996) and spinal/injection (such as 62278 & 62279) are covered within the payment for the anesthesia given for the surgery, therefore these codes are not to be billed on the day of surgery. Listed below are guidelines for billing these services:

• Daily management of epidural or subarachnoid drug administration (01996) is payable only after the day on which the catheter was introduced.
• Codes 62278 and 62279 are not to be billed on the same date of service as 01996.
• Pain management (01996) is not payable to the operating surgeon; it is restricted to provider specialty (005) anesthesiology. It is also restricted to place of service hospital inpatient (21).
• These codes allow only one unit of service per occurrence; - payment is not based on time units.

Certified Registered  Nurse Anesthetists

Certified Registered Nurse Anesthetists (CRNA) are enrolled in the program and can bill for their services.

Anesthesia Reimbursement

Anesthesia services are reimbursed at 25% of the amount allowed to the primary surgeon for that procedure. The amount allowed to the primary surgeon will be subject to a cutback if multiple procedures are billed on the same day. This cutback will apply to the reimbursement for anesthesia services as well.

Local Anesthesia and IV Sedation

IV sedation and local anesthesia not separately billable services. They are included in the reimbursement for the procedure.

Multiple Anesthesia Modifier

When anesthesia is administered for multiple surgical procedures performed on the same day, modifier “51” must be billed in addition to the “AA” modifier for each procedure billed. Anesthesia claims for multiple procedures on the same day must be billed with the primary procedure on the first detail line of the claim, the secondary procedure on the second detail line, etc.

If more than three (3) surgical procedures are performed, there will be no additional reimbursement for the fourth and subsequent procedures.

Biomarker Testing

Indications

Biomarker testing will be covered when the test result will provide information that will be used formulation of a treatment or monitoring strategy that informs a patient's outcome and impacts the clinical decision-making process and the efficacy test is supported by medical and scientific evidence. 

Coverage and Payment Policy

Documentation must include the following:

1. A face-to-face visit with the ordering healthcare physician within the last 30 days of submitting the request,

OR

2. Documentation that testing has been recommended by a Tumor Board or consulting specialist. 

AND

1. The test will confirm or rule out a diagnosis,

OR

   2. The test result is necessary to determine the correct treatment plan for the beneficiary;

OR

   3. The test result is required to prevent, diagnose, monitor, or treat complications resulting from participation in a clinical trial. 

Requests for Biomarker testing that is subject of a clinical trial or experimental protocol will be denied. 

For those tests requiring Prior Authorization, requests must include a completed Rhode Island Medicaid Prior Authorization Form, Certificate of Medical Necessity for Biomarker Testing, and supporting clinical information. 

Click here for an approved PDF version of the Biomarker Testing Policy.

Cardiology

Billing Complete Procedure

All diagnostic cardiovascular procedures performed in the office must be billed as a complete procedure

Billing Components

Component codes, such as tracing only, interpretation only, and report only, of diagnostic procedures (ECGs and stress testing) are not allowed in the office setting.

Claims Billing Guidelines

Instructions for completing the CMS 1500 claim form are located on the Claims Processing page.

Physician services must be billed with CPT, HCPCS or state codes to identify services rendered and ICD-9/ICD-10 coding to note diagnosis or illness (ICD version determined by date of service).

Prior to coding your claim, close examination of CPT, HCPCS and ICD diagnosis code description is imperative. The Rhode Island Medicaid program adheres to all code descriptions, and limitations regarding age, sex, time, inclusive services and all other guidelines outlined in the code introduction or description as noted in the code book. Incorrect or fragmented billing of services may result in denial or recoupment of reimbursement.

Out-of-state physician providers should follow the same instructions for completing the CMS 1500 claim form as in-state providers. Instructions are located on the Claims Processing page.

Out-of-state physician providers must follow the same coding guidelines as instate providers, as noted above.

Co-payment

There is no co-pay required of recipients for physician services.

Covered/ Non-covered Services

Covered services are listed in the physician’s Fee Schedule.

Services of an unproven, experimental or research nature are not covered services. Services in excess of those deemed medically necessary to treat the patient’s condition, or not directly related to the patient’s diagnosis, symptoms or medical history are not covered. Providers will be notified of any coverage changes through publication of the Provider Update newsletter.

See the Physician Services Policy Statements subsection of this document for service-type specific information.

Definitions

Consultation is a service rendered by a physician whose opinion or advice is requested by the patient’s physician or agency in the evaluation and/or treatment of the patient’s illness. The consultant physician may suggest a course of treatment or therapy which can be overseen by the referring physician.

Current Procedural Terminology (CPT) is a listing of descriptive terms and identifying codes for reporting medical services and procedures performed by physicians.

HCFA Common Procedure Coding System (HCPCS) is a coding system developed by the Health Care Financing Administration to provide a common system for referencing health care procedures performed under the Medicare and Medicaid programs.

Internal Classification of Disease, 9th Revision (ICD-9)/ 10th Revision (ICD-10) is an index of diseases and diagnostic terms to report illnesses, injuries, and reasons for encounter with health care providers. Appropriate version is determined by date of service.

Modifiers are two character alpha-numerics placed after the usual procedure code to denote or further identify the circumstances of a medical service or procedure.

Prior Authorization (PA) is authorization for a procedure or course of treatment obtained before services are rendered.

Dialysis

Daily Dialysis

If the recipient starts dialysis in the middle of a month or is hospitalized during the month, the codes for billing individual days should be used. Code 90922 should be used to bill for daily services rendered in any place of service other than the home. Codes 90935 through 90947 should be billed for daily dialysis services rendered in the home.

Monthly Dialysis

Providers rendering services for end-stage renal disease (ESRD) patients must bill CPT codes 90918 through 90921 for all dialysis-related services. These codes represent a full calendar month of services and are broken down by age. To bill these codes, the “from” and “to” dates of service on the detail line must reflect the last day of the month. The number of units billed must be indicated as one (1) since this represents payment for the entire month. These codes apply to all types of dialysis and all places of service.

Limitations

The above listed dialysis treatment codes cannot be billed in conjunction with office or hospital visits rendered on the same date for dialysis-related services.

EPSDT (Early And Periodic Screening , Diagnosis And Treatment)

EPSDT Eligibility

All children eligible for Medicaid services are enrolled in the EPSDT program until their 21st birthday. The primary care physician bills for preventive care visits using the appropriate codes and informational modifiers. It is not necessary for physicians to complete EPSDT program enrollment forms for Medicaid-eligible children.

The following HCPCS codes are used for billing EPSDT visits:

New Patient

Initial evaluation and management of a healthy individual requiring a comprehensive history, a comprehensive examination, the identification of risk factors, and the ordering of appropriate laboratory/diagnostic procedures, new patient;

 CodeDescription

99381infant (age under 1 year).

99382early childhood (age 1 through 4 years)

99383late childhood (age 5 through 11 years)

99384adolescent (age 12 through 17 years)

99385late childhood (age 5 through 11 years)

Established Patient

Periodic reevaluation and management of a healthy individual requiring a comprehensive history, comprehensive examination, the identification of risk factors and the ordering of appropriate laboratory/diagnostic procedures, established patient;

Code  Description

99391infant (age under 1 year)

99392early childhood (age 1 through 4 years)

99393late childhood (age 5 through 11 years)

99394adolescent (age 12 through 17 years)

99395(age 18 through 20 years) -- use EP modifier

Important: When billing for an EPSDT visit under HCPCS codes 99385 and 99395, the modifier “EP” must be used for patients between the ages of 18 and 20.

Immunizations

Reimbursement for immunizations administered during the EPSDT screening are included in the screening visit fee. Vaccinations are provided free from the Rhode Island Health Department.

Rhode Island Medicaid Program policy states that immunizations are considered to be included in the reimbursement for a physician office visit. Immunization codes (90700-90749) are no longer reimbursable through the Rhode Island Medicaid Program. All immunizations are considered to be part of the fee for the office visit at which the immunization was administered. When it is not possible to administer a vaccine as part of the first office visit and the patient must return to the office for a second visit, the office visit may be billed with procedure code 99211. If the immunizations are not administered at the time of the screening visit, they can be administered at a later date and billed using a code in the 90700 - 90749 ( immunization injections) or 90782 - 90799 (therapeutic or diagnostic injections) range. There is a limit of one code per day.

Referral Modifiers

Informational modifiers must be used when billing for EPSDT visits. The EPSDT information modifiers are as follows:

Modifier Description

A IEPSDT - Appointment Initiated

B1EPSDT - Booster, first

B2EPSDT - Booster,second

B3EPSDT - Booster,third

B4EPSDT - Booster,forth

CAEPSDT - Condition Abnormal

CIEPSDT - Care Instituted

IIEPSDT - Initial Immunization

NAEPSDT - Diagnosis and Treatment Not Available

NOEPSDT - No Appointment Made

PREPSDT - Patient Refused Care/Physician to Residence

RFEPSDT - Referred for Treatment

Evaluation And Management (E&M)

Consultations

Multiple consultation visits are allowed on the same day if ordered by the attending physician, performed by different provider specialties and justified as medically necessary through diagnosis review. All consultation requests and reports must be kept on file with the recipient's medical record.

Emergency Room Visits

Multiple emergency room visits are allowed on the same day if multiple physicians of different specialties are necessary for treatment. Claims will be reviewed by attending provider specialty and diagnosis for medical necessity.

Inpatient Hospital Visits

Only one inpatient hospital visit is allowed per day. If physicians other than the attending physician render service to an inpatient recipient, they must bill consultant codes.

Newborn Resuscitation

Newborn resuscitation is a covered service when any newborn infant, whether delivered vaginally or by C-section, requires measures such as intubation, CPR, Ambu bagging, umbilical artery catheterization, administration of IV or intracardiac drugs in the delivery room by the physician. Procedures such as nasotracheal suctioning or brief administration of oxygen for improvement of color are considered routine delivery room procedures and do not constitute resuscitation.

Nursing Home Visits

The number of nursing home visits performed by a physician is limited to six (6) patients per facility per day. Attending physicians of nursing home recipients are required to visit those recipients every 6 months, or more often if necessary, to evaluate the recipients’ need to stay in the facility.

Office/Clinic Visits

There is a limit of one office/clinic visit per day. If multiple visits are billed, they will be reviewed by diagnosis for medical justification.

Physician Standby

Physician standby is covered only when there is required prolonged physician attendance awaiting the birth of a newborn. Physician standby is considered a minimum of 30 minutes total duration of time on a given date. The physician standby procedure code, 99360, is to be billed in 30 minute increments (30 minutes = 1 unit) and must reflect the total duration of time the physician is in attendance, up to a maximum of 6 units (3 hours). Total duration of less than 30 minutes should not be reported separately.

Supplies and Materials

Reimbursement for supplies and materials used during an office visit or procedures performed in the physician's office are considered to be included in that visit or service

X-ray Interpretation

Routine reading of X-rays during visits is non-covered if the film has been previously interpreted

Injections

Administration Fee

Rhode Island Medicaid Program policy states that immunizations are considered to be included in the reimbursement for a physician office visit. Therefore, immunization codes (90700-90749) are no longer reimbursable through the Rhode Island Medicaid Program. All immunizations are considered to be part of the fee for the office visit at which the immunization was administered. When it is not possible to administer a vaccine as part of the first office visit and the patient must return to the office for a second visit, the office visit may be billed with procedure code 99211.

Covered drugs that are administered via injection during the course of an office visit can be billed in addition to the visit using one of the HCPCS “J” codes. A list of covered drugs billable by physicians appears on the fee schedule.

Laboratory And Pathology

Collection and Handling

Specimen collection and handling fees are not covered.

Complete Procedures

Complete procedure of a pathology service is covered only when performed in the office setting.

Component Billing

If a pathology service is rendered in the inpatient or outpatient setting, a professional component must be billed. Modifier “26” must be used in addition to the CPT code.

Panel Tests

Physicians should bill lab tests individually when the combined rate for individual tests is less than the rate for billing an equivalent panel: however, if the rate for a panel is less than the rate for the individual tests billed separately, then a panel should be billed.

In summary, when billing the usual and customary charge for a panel or the tests billed individually, always bill the combination with the lower reimbursement rate.

Limitations/ Special Requirements

Prior Authorization (PA) is required for certain procedure codes and course of treatment plans before services are rendered. Procedure codes requiring PA are listed in Section 600-10 of the Provider Reference Manual. Instructions for obtaining PA are on the Prior Authorization page.

Out-of-state physician services require prior approval, unless the services were rendered within a border community or in an emergency situation. Approval of the prior authorization request will be determined based upon availability of services within Rhode Island. In emergency situations, the provider must contact DHS within two (2) business days with documentation to justify the services as emergency.

Providers must be located and be performing services in Rhode Island (except for border communities).

See the Physician Services Policy Statements subsection of this document for service-type specific information.

Managed Care

Managed Care Program Information

For more information about RIte Care Program information, see RIteCare.

Maternity Care And Delivery

Obstetrical Billing: Inclusive Package

Obstetrical services, if rendered by the same physician or physician group, must be billed as an all-inclusive package using the appropriate CPT code to denote type of delivery. (59400 for vaginal delivery, 59510 for C-section.) The total payment for the pre- and post-part visits and the delivery will be paid to the attending obstetrician who is requesting payment.

Obstetrical Billing: Component Billing

If a recipient has received pre-natal care elsewhere, appropriate component codes (59409, 59410, 59425, 59426, 59430, 59514 or 59515) should be billed by the provider rendering each service. An example of when the all-inclusive package code would not be appropriate is if a recipient receives pre-natal care in her home town and is out of town when she delivers. Delivery would then be performed by a physician other than the physician or physician group that rendered pre-natal care. Component billing would be appropriate in this situation.

Obstetrical Reminder

It should be noted that all eligible recipients requiring obstetrical services should be urged to seek the services of the obstetrician of their choice at the earliest sign of pregnancy.

Medicare/Medicaid

The Medicaid Program reimbursement for crossover Crossover claims is always capped by the established Medicaid allowed amount, regardless of coinsurance or deductible amounts. The standard calculation for crossover payments is as follows: Medicaid will pay the lesser of:

• The difference between the Medicaid allowed amount and the Medicare Payment (Medicaid allowed minus Medicare paid); or
• The Medicare coinsurance and deductible up to the Medicaid Program allowed amount.

Ophthalmology

Billing Guidelines

An initial refraction exam and an opthalmological medical office visit on the same day are not covered. Providers should bill for one or the other of these procedures.

Physician Assistants

Physician Assistants (PA) may be enrolled as performing providers of medical treatment with Licensed Physician supervision and in accordance with all guidelines of the Medicaid Program. Physician Assistants must be registered by the Rhode Island Department of Health and perform services consistent with the regulations set forth by the Rhode Island Department of Health.

The Physician Assistant must submit evidence of a Rhode Island License/registration and a copy of the sponsoring physician’s license for enrollment.

Reimbursement for Physician Assistant services is made only to the licensed (enrolled) Physician or the Physician Assistant’s employer in accordance with the RI Medicaid Physician Fee schedule.

Pre-certification

Pre-certification (pre-admission review) is required for all inpatient hospital admissions. This includes both elective and non-elective admissions.

Requests for pre-admission review are directed to the contracted (Qualidigim). The admitting physician or physician designee must call the contractor, Qualidigim at least seven (7) calendar days prior to a planned admission.

For both elective and non-elective hospitalizations, the responsibility for admission notification rests with the admitting physician or physician designee. The appropriateness of the planned admission, the treatment site, any pre-operative days, and the proposed length of stay will be evaluated by contractor, Qualidigim.

Admission and length of stay approval by contractor, Qualidigim is not an assurance of benefit payments. Reimbursement will only be issued on behalf of patients whose eligibility under the Medicaid Program is verified through DHS. Any admission length of stay approved by contractor, Qualidigim relates solely to the medical necessity of the proposed hospitalization.

Complete procedures for requesting inpatient pre-certification, reviews and appeals are contained in the Hospital Services Provider Reference Manual policy section.

Provider Participation

Providers must be licensed by the Rhode Island Department of Health Guidelines and must be an enrolled Medicare provider in order to provide and be reimbursed for Physician services.

Radiology Services

Billing Guidelines

Radiology services can be billed by the physician as a complete or a professional component. The professional component must be noted through billing the CPT procedure code in conjunction with the modifier “26”. Radiology services for the technical component (modifier “TC”) are paid only to the facility.

Complete Procedure

A complete procedure includes both the professional and the technical components of a radiological procedure and is limited to an office or nursing home setting only. If the provider renders the complete procedure in the nursing home, the provider must supply their own portable equipment.

There is a limit of one complete procedure per code per recipient per day.

Multiple Procedures

Multiple units of radiological procedures are allowed on the same day if:

• billing is for professional component only, and;
• procedures are performed in an inpatient or outpatient setting; and/or the diagnosis medically justifies multiple (like) procedures

Portable X-Ray Procedures

Portable x-ray services must be performed under the general supervision of a physician and conditions of health and safety must be met.

Coverage for portable x-ray includes skeletal films involving arms and legs, pelvis, vertebral column and skull; chest films not involving the use of contrast media (except routine screening procedures and tests in connection with routine physical examination), and abdominal films which do not include the use of contrast media.

Procedures and examinations which are not covered under the portable x-ray provision include procedures involving fluoroscopy, the use of contrast media, requiring the administration of a substance to the patient or injection of a substance into the patient and/or special manipulation of the patient, requiring special medical skill or knowledge possessed by a doctor of medicine or doctor of osteopathy or requiring medical judgment to be exercised requiring special technical competency and/or special equipment or materials, routine screening procedures and procedures which are not of a diagnostic nature.

Portable x-ray tests must be provided on the written order of a physician. Claims for services involving the chest must contain the name of the physician who ordered the service and the reason the x-ray test was required.

An electrocardiogram tracing by an approved supplier of portable x-ray services may be covered as an other diagnostic test. Portable EKG services must be provided on the written order of a physician.

Procedure Codes Affected

R0070 is used to bill for transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility, regardless of the number of patients seen.

R0076 is used to bill for portable EKG to facility or location, per trip, regardless of the number of patients seen. 

Recertification

Providers are periodically recertified by the Rhode Island Department of Health (RIDOH). The license expiration date for physicians is December 31. Providers obtain license renewal through RIDOH and then forward a copy of the renewal documentation to Gainwell Technologies. Gainwell Technologies should receive this information at least five business days prior to the expiration date of the license. Failure to do so will result in suspension from the program.

A provider may appeal to the RIDOH if the facility does not meet the recertification criteria. If the appeal to RIDOH is not successful, the provider may then appeal to the Centers for Medicare and Medicaid (CMS).

Reimbursement Guidelines

The reimbursement rates for physician services are published on the Fee Schedule. This section contains the CPT, HCPCS and local codes providers must use for billing. Services not listed on the fee schedule are considered non-covered services.

Exceptions include the following:

Services to recipients under the age of 21 who require medically necessary treatments not covered in the fee schedule may be authorized by the Department of Human Services. Prior Authorization procedures are explained in Section 200-30 of the Provider Reference Manual.

If providers are unable to determine a code for the service rendered, unlisted “99” procedure codes may be billed. Prior authorization must be obtained for all procedures billed using the unlisted procedure codes. Medical records may be requested to aid in the review of these claims.

Surgery

Assistant Surgeon Billing

Assistant surgeons should bill the same CPT surgical procedure codes as the primary surgeon with either modifier “80” or “82.” Assistant surgeons are reimbursed at a percentage of the allowed amount for primary surgeons.

Assistant Surgeon

The procedures codes listed on the Fee Schedule are the only Coverage services reimbursable to an assistant surgeon.

Bilateral Procedures

Bilateral procedures are considered a single procedure. The procedure code should be billed on one detail with one unit and the modifier “50”. That detail will be reimbursed at a percentage of the allowed amount. If billing for multiple procedures and one is a bilateral procedure, both the “50” and “51” modifier must be billed in conjunction with the surgical procedure code. Multiple cut-back will still apply. (If the bilateral procedure is a secondary procedure, reimbursement will be a percentage of the allowed amount.)

Multiple Procedures

When billing for multiple surgical procedures on the same date of service, modifier “51” must be billed in conjunction with the surgical procedure code. Reimbursement will be given on a decreasing percentage basis. If more than three surgical procedures are performed, there will be no further reimbursement. Claim must be billed with the primary procedure on the first detail, secondary procedure on the second detail, etc. All surgical codes, with the exception of diagnostic procedure codes and codes with “each additional” noted in the description, are subject to the reimbursement cut-back.

Multiple Procedures for Assistant Surgeon

If multiple procedures are billed, the assistant surgeon is subject to the same cutback as the primary surgeon. When billing multiple procedures, the primary procedure must be billed on the first detail line of the claim, the secondary procedure on the second detail line, etc. If more than three (3) surgical procedures are performed, there will be no additional reimbursement.

Outpatient Surgery

There are a number of surgical procedures that the Medicaid program requires be performed on an outpatient basis in order to receive reimbursement. The Fee Schedule contains a list of outpatient surgery codes. If an outpatient procedure results in complications and the recipient is admitted as an inpatient, claims will be reviewed on an individual basis for reimbursement

Pre-operative and Post-operative Days

All CPT codes within the surgical range (10000 thru 69999) cover one (1) pre-operative day and thirty (30) post-operative days. All office visits and subsequent hospital care days within this range of days that are provided by a physician of the same specialty as the surgeon will be denied as included in the post-operative period of days. The post-operative days are counted starting the first day after surgery.

Team Surgeons

Medicaid will reimburse for team surgeons when highly complex procedures require the concomitant services of several physicians of different specialties. Each surgeon that is part of the “surgical team” should bill the appropriate surgical code for the procedure he/she performed. Each procedure provided by different physicians will be reimbursed at the allowed amount for the procedure they performed. If an assistant surgeon is allowed for the procedure performed, (refer to the Assistant Surgeon Billing and Coverage information in this section), Medicaid will allow for payment for that assistant surgeon in addition to the primary surgeons.

Two Surgeons

Medicaid will reimburse for two surgeons billing for the same surgical procedure if the procedure requires the specialized skills of both surgeons. Each surgeon must bill the same procedure code and identify his/her services by billing modifier “62” in conjunction with the surgical procedure code. Separate reimbursement for an assistant surgeon will not be paid in addition to two surgeons billing the same procedure code. The two primary surgeons will both be reimbursed at a percentage of the allowed amount of the procedure code billed.