State Medicaid Payment for Caries Prevention Services by Non-Dental Professionals Last Updated June 2013

Transcription

1 Payment Caries Prevention Services by Non-Dental Professionals This table presents the results of a survey conducted by the American Academy of Pediatrics in which the programs in the 50 states and the District of Columbia were asked to provide inmation on coverage caries prevention services provided by non-dental professionals. (e.g.,, MA). Yes (RA, AG, DH & FV) from the? Alabama MD, NP OE/AG $18.00 CDT OE LPN, 6-36 months 3/yr; between Single Medical 2009 No FV $15.00 CDT FV (moderate 6-35 months high risk) Alaska MD, DO OE $57.72 CDT OE No <3 yrs (OE) 2/yr (OE) Yes Medical 7/1/2010 No FV $28.50 CDT FV None (FV) 4/yr (FV) & CHIP dollar NP, PA OE $49.06 CDT OE FV $24.23 CDT FV Arizona None Reimbursement policy approved but not yet funded due to state s budget situation Arkansas None In 2011, Arkansas passed legislation to allow physicians and registered nurses to apply fluoride varnish to children s teeth. Calinia MD, NP FV FFS - $18.00 MCO- $0.00- $27.00 Colorado MD, DO, NP, PA CDT FV CMA, LPN, FV $14.96 CDT FV Any OE $28.41 CDT OE personnel OE $14.85 CDT UNSP Connecticut MD, NP, PA FV $20.00 CDT FV CMA, LPN, OE $25.00 CDT OE Delaware None DC place holder <6 yrs 3 No, but encouraged <5 3 Yes First 40 months (3 rd birthday well-child visit) With each well-child visit (per HEDIS) Continuing ED CME course developed by Dental School Did not previously CDT Code on Dental and Nomenclature (CDT ) UNSP Use unspecified CDT code unspecified diagnostic procedure DH = Recommendation dental home by age 1 **Though the task may be delegated, the assumption is that billing the procedure will be under the responsible provider s name (MD, NP, PA) For specific coding questions contact aapcodinghotline@aap.org 1 Multiple Medical 2006 No No changes Dental 2009 Entailed fiscal note Medical 2007 No The program was launched in 2005 but it was difficult to get buyin from providers until the program became better known.

2 Payment Caries Prevention Services by Non-Dental Professionals Florida Georgia Hawaii place holder Idaho MD, PA, AP MD, NP, DDS Did not previously MD, PA, FNP, NP FV/AG $ with modifier SC (e.g.,, MA). CAN, LPN, A, FV $17.59 CDT FV Yes, MD can delegate to staff but must bill under MD FV $13.58 CDT FV CMA, LPN, NP, PA FV $ months 4 not required. UF Gator Kids Healthy Smiles Program provides if requested by provider. 6 months to 13 years eleven months Twice per year None required 0-21 yrs 2 Yes, Public Health District Dental Program PAHP - Fee service from the? Medical 2008 No Both Depending on Provider rendering service 2009 No Medical 2003 NO No changes since must receive the District Health Dept. to be paid this. CDT Code on Dental and Nomenclature (CDT ) UNSP Use unspecified CDT code unspecified diagnostic procedure DH = Recommendation dental home by age 1 **Though the task may be delegated, the assumption is that billing the procedure will be under the responsible provider s name (MD, NP, PA) For specific coding questions contact aapcodinghotline@aap.org 2

3 Payment Caries Prevention Services by Non-Dental Professionals (e.g.,, MA). from the? Illinois Indiana None MD, APN, FQHC, Out- Patient Hospital Clinic FV $26.00 CDT FV Yes:, LPN, CMA & MA Under age 3 with 4 erupted teeth 3 Coordinated by Illinois Chapter AAP (ICAAP) & Pediatric dentists train pediatricians. Upon completion providers send certificate to state & then can submit claims. Medical 2006 No, but administrative rule had to be changed Began as a pilot program only in Cook County, metro counties & FQHCs. The program is being expanded statewide. requirements still in effect. Iowa MD, NP, PA FV $13.82 CDT FV CMA, LPN, Kansas 0-36 months 3 by I- Smile (Oral Health Bureau) as a physician cost 2001 No Application of fluoride varnish is within the scope of practice Iowa physicians. Although not required, we chose to use our rules making process to allow public comment No dheks.gov/o hi/download/ Memo_profe ssional.pdf MD, NP, PA, FV $17.00 CDT FV CMA, LPN, Under 21 3 (MD) + 3 No, though Title 19 FFS is (DDS) (total Bureau of Oral 6/yr) Health will assistance, T21 is provide CHIP funds to any practitioner who requests it. Online also CDT Code on Dental and Nomenclature (CDT ) available. UNSP Use unspecified CDT code unspecified diagnostic procedure DH = Recommendation dental home by age 1 **Though the task may be delegated, the assumption is that billing the procedure will be under the responsible provider s name (MD, NP, PA) For specific coding questions contact aapcodinghotline@aap.org 3

4 Payment Caries Prevention Services by Non-Dental Professionals (e.g.,, MA). Kentucky MD FV $15.00 CDT FV CMA, LPN, Louisiana MD, NP, PA,, LPN FV $24.87 CDT FV MD, NP, PA,, LPN Maine MD, NP, PA FV $12.00 CDT FV &, MD MD, NP, PA RA $20.00 CDT FV LPN, CMA &, MD Maryland MD, NP FV $24.92 CDT FV LPN,, PA, CMA anyone allowed to give an immunization 1 5 yrs Once every 90 days (maximum of 2 times in a 12-month period) 6 months Every 6 from the? On-line Multiple Not specified 2008 No STFM online 5 yrs months <21 yrs 2 Not required but is made available & practices targeted based on volume of children seen <3 yrs Consistent with what is required by coding specification 9 mo-3 yrs 4 the child can also receive 2 FV applications from a dentist Yes by Office of Oral Health and MCO Medical 12/1/2011 No & CHIP September No 2008 & CHIP September 2010 dental budget No 2009 No regulatory change only Expectation that providers will not bill this service if the child has a dental home. can verify this through the MMIS claims portal to determine if D codes have been billed the child by an oral health provider within the last year. Risk assessment must be documented in record. Expectation that providers will not bill this service if the child has a dental home. The program has worked very well more than 50,000 claims FV CDT Code on Dental and Nomenclature (CDT ) UNSP Use unspecified CDT code unspecified diagnostic procedure DH = Recommendation dental home by age 1 **Though the task may be delegated, the assumption is that billing the procedure will be under the responsible provider s name (MD, NP, PA) For specific coding questions contact aapcodinghotline@aap.org 4

5 Payment Caries Prevention Services by Non-Dental Professionals (e.g.,, MA). Mass. MD, NP FV $26.00 CDT FV PA,, MA Michigan MD, NP FV $9.00 CDT FV LPN, PA, Minnesota MD, NP, PA, FV FFS: $14.00 MCO: variable ($ $20.00) CDT FV CMA, LPN, < 21 but recommend ed under age 3 No limit; recommended not to exceed one application every 180 days Online; group or office visit Multiple <3 yrs 4 times/y Online Both fee service & managed 0-20 yrs 3-6 months Protecting All Children s Teeth (PACT): A Pediatric Oral Health Program (including oral health videos) from the Payments are made through the side if the claims are billed by the side Payment is from the physician () & budgets? FFS & MCO funds 2003 No 2008 No Through the EPSDT Periodicity Schedule, a dental assessment & referral screening are completed including exam, guidance, risk assessment & recommendation to seek dental. All other columns address fluoride varnish only NO We are in the process of updating the to the Smiles Life curriculum. This is in the public comment phase policy review. A bulletin to announce the proposed change will be thcoming with the effective date. 4/12 CDT Code on Dental and Nomenclature (CDT ) UNSP Use unspecified CDT code unspecified diagnostic procedure DH = Recommendation dental home by age 1 **Though the task may be delegated, the assumption is that billing the procedure will be under the responsible provider s name (MD, NP, PA) For specific coding questions contact aapcodinghotline@aap.org 5

6 Payment Caries Prevention Services by Non-Dental Professionals (e.g.,, MA). Mississippi MD, NP, PA FV OE $22.42 $33.04 CDT FV CDT OE Yes regular physician & nurse practice standards apply Missouri MD, NP FV $13.56 CDT FV None <6 yrs 2 times/rolling year <3 yrs 2/fiscal year Online recommended Department of Health & Senior Services, Division of Community & Public Health from the? Medical 2010 No Montana MD FV $18.76 CDT FV NP, PA 0-20 Up to 6 Preferred Dental 2009 Nebraska MD FV $ $11.00 Nevada New Hampshire MD, NP, PA, OE $21.89 CDT OE DDS only FV $53.30 CDT FV LPN PA CDT FV 12 years & younger 3 times in a 12 month period 0-20 yrs One unit per six months MCO* Medical 2008 No *Program is identical MCOs except that the dollar amount payable is specified in the contract between the provider and the health plan. aidprovider. hhs.mt.gov/ pdf/dentist pdf Medical April 20, 2009 FFS, MCO, SCHIP None In 2010, the NH legislature passed a statute requiring DHHS to request funding non-dentists to perm oral health services. The MCO contract terms include an OHscreening, risk assessment, anticipatory guidance, varnish when appropriate, CDT Code on Dental and Nomenclature (CDT ) UNSP Use unspecified CDT code unspecified diagnostic and procedure referral to a dentist, 2x year, 6-36 months of age. MCO contracts are not final. DH = Recommendation dental home by age 1 **Though the task may be delegated, the assumption is that billing the procedure will be under the responsible provider s name (MD, NP, PA) For specific coding questions contact aapcodinghotline@aap.org 6 No Has to have DX V07.31 Payment is $9.00 D1203 & $11 D1206 Dental 2008 Provider must operate within their scope of practice under state law (Nevada Revised Statues)

7 Payment Caries Prevention Services by Non-Dental Professionals New Jersey MD, DO & NP FV, OE,AG, RA, FQHE & DH Rate to be determined CPT code DA Diagnosis code V07.31 (e.g.,, MA). NP, PA Consistent with NJ Board of Medicine Through age 5 Linked to wellbaby visits New Mexico MD FV $15.00 CDT FV Yes 0-3 yrs 6 treatments total up to age 3 New York MD, NP FV $30.00 CDT FV Yes. Claims must be submitted through the MD, NP or DDS Yes, CE class state board approved; Some basic No, but it is recommended 0-7 yrs 4 Recommended but not required N. Carolina MD, NP, PA FV OE $15.61 $35.38 CDT FV CDT OE LPN, 41 months Allowed every 60 days (Max 6 bee age 42 months) Into the Mouths of Babes MCOs: Horizon NJ Health, United Health Community Plan, AMERI- GROUP & HealthFirst MCO from the Comes from MCO dollars The fee service (non-managed program) does not cover this service. Theree, MCOs may cover FV by PCPs as a value-added service.? CY 2012 No MCOs were advised to set a rate less than or equal to that of dentists. NJ Smiles Directory of dentists seeing young children is referral source dentists seeing children beginning at age 1yo. Over 98% of children in MCOs, not in FFS. August 2009 No Both Dental 2009 No Medical 2000 No CDT Code on Dental and Nomenclature (CDT ) UNSP Use unspecified CDT code unspecified diagnostic procedure DH = Recommendation dental home by age 1 **Though the task may be delegated, the assumption is that billing the procedure will be under the responsible provider s name (MD, NP, PA) For specific coding questions contact aapcodinghotline@aap.org 7

8 Payment Caries Prevention Services by Non-Dental Professionals N. Dakota MD, NP, PA, (e.g.,, MA). FV $22.50 CDT FV CMA, LPN, 0-21 yrs 2 approved by Board of Dental Examiners Ohio MD, NP, PA FV $15.00 CDT FV LPN, < 3 yrs Once every 180 days On-line Oklahoma MD, NP, PA FV PA, 6-42 months 2 Yes AAP website Oregon MD, NP, PA FV $12.97 CDT FV Yes, as allowed by scope of practice 6 yrs. & younger 2 times every 12 months, but up to 4 high-risk conditions or oral health factors from the? Dental 2007 Yes Medical 2006 A new Administrative code rule was created authorizing this coverage Medical 2011 No Oklahoma Permanent Rules & Executive Orders include physicians, advanced practice nurses, physician assistants, PG-2 level residents and higher, and IHS/FQHCs as primary providers. nline/viewcode.aspx No Medical 2000 No CDT Code on Dental and Nomenclature (CDT ) UNSP Use unspecified CDT code unspecified diagnostic procedure DH = Recommendation dental home by age 1 **Though the task may be delegated, the assumption is that billing the procedure will be under the responsible provider s name (MD, NP, PA) For specific coding questions contact aapcodinghotline@aap.org 8

9 Payment Caries Prevention Services by Non-Dental Professionals Pennsylvania MD, CP FV $18.00 CDT FV Yes; CP, PA,. 4 yrs & younger 4 Yes: Smiles Life: A National Oral Health Curriculum; Course 6 module: Fluoride Varnish oralhealth.org Medical (Physician & Dentist professional services are both paid from Outpatient Allocation funds.) 2010 No CDT Code on Dental and Nomenclature (CDT ) UNSP Use unspecified CDT code unspecified diagnostic procedure DH = Recommendation dental home by age 1 **Though the task may be delegated, the assumption is that billing the procedure will be under the responsible provider s name (MD, NP, PA) For specific coding questions contact aapcodinghotline@aap.org 9

10 Payment Caries Prevention Services by Non-Dental Professionals Rhode Island South Carolina MD FV MCOs $ $33.00 MD, DO FV $15.89 CDT FV FQHC/RHC* (e.g.,, MA). CDT FV Yes Varies based on MCO, LPN, CAN, CMA, MA or any other office staff member 0-3 yrs 2 per year as part of EPSDT examination 2 Varies based on MCO Yes, online CE certificate in provider s file Three RIte managed & MCO from the? Medical 2009 No Dental 2007 No *FQHC = Reimbursement to be included in the all-inclusive HCPCS (T1015) encounter code T1015 paid to the FQHC. RHC = Claims submitted fee--service ment in addition to the HCPCS (T1015) on CMS1500 m. S. Dakota MD, NP, PA, FV $18.00 CDT FV V20.2 Max. age 5 3 No Both, depends upon child s 2006 or bee No Tennessee MD, PA, NP, Texas MD, NP, PA FV, OE, AG $34.16 (less 2%) FV OE $20.00 $12.00 CDT FV CDT OE Physician supervisor must be contracted provider with Tenn MCO (OE) Yes. CMA, billed with LPN, U5 modifier along with ICD-9 EPSDT codes 99381, 99382, 99391, yrs 2 Yes Online through DBM 6-35 months 6 over age range In person & online Texas course CDT Code on Dental and Nomenclature (CDT ) UNSP Use unspecified CDT code unspecified diagnostic procedure DH = Recommendation dental home by age 1 **Though the task may be delegated, the assumption is that billing the procedure will be under the responsible provider s name (MD, NP, PA) For specific coding questions contact aapcodinghotline@aap.org 10 eligibility Dental 2011 No A dental screening must be permed in order providers to be d FV Medical 9/2008 No. The program began as a strategic initiative that secured Executive and Legislative Budget Board approval. These services are no longer an initiative but are now part of the standard benefit package the age group.

11 Payment Caries Prevention Services by Non-Dental Professionals Utah MD, NP, PA FV $15.00 EP modifier added to ageappropriate ICD-9 EPSDT code (e.g.,, MA). CMA, LPN,, Vermont MD AG, OE, RA $39.00 CDT OE D-0145-No 2 yrs. old & younger FV $15.00 CDT FV D-1206-No Age 0-5 (under 6) Virginia MD, NP, Washington MD, DO, AP, PA, FV $20.79 CDT FV Physicians, Nurse Practitioners, Health Departments, CHIP of Roanoke, & Rural Health Clinics are set up to bill this service. FV $13.25 CDT FV CMA, LPN, OE $29.46 CDT OE FOHE $27.58 CDT MISC 0-4 yrs At each wellchild exam AAP course online 640 On line (AAP course) or 200 hands-on (one-hour) Under 3 yrs. 2 Yes is done by the Virginia Health Department <5 yrs (FOHE & OE) <20 yrs (FV) 2 times in 12 month period age 6 to 20 Course from the? Medical 2007 No All MCOs included by 1/1/09 D-0145 in January, 2008 & all managed ( & Washington Dental Service/Delta Dental) Medical & CHIP Dental No 2006 No 1998 FV 2008 other 2 services No CDT Code on Dental and Nomenclature (CDT ) UNSP Use unspecified CDT code unspecified diagnostic procedure DH = Recommendation dental home by age 1 **Though the task may be delegated, the assumption is that billing the procedure will be under the responsible provider s name (MD, NP, PA) For specific coding questions contact aapcodinghotline@aap.org 11

12 Payment Caries Prevention Services by Non-Dental Professionals West Virginia Pediatrician, GP, FP, APN. PA in FQHC setting only (e.g.,, MA). OE, FV $20.00 T-1503 AP PA in FQHC setting only $25.00 T-1503 DA 6 months to 3 years 4 (2 dental and 2 ) Yes Certification from the WV budget does not distinguish between and dental dollars.? 2012 No WV pays an oral exam (OE) if fluoride varnish (FV) is done in conjunction with a sick visit. is in the process of changing from T to D codes. Wisconsin MD, NP, PA FV - Also, oral assessment plus referral to a dentist beginning at 1 year of age covered as part of comprehensive EPSDT screening. $12.89 CDT FV Two per 12- month period, per provider. Up to four per 12-month period, per provider, cases of demonstrated high need, or permanently disabled members. Wyoming MD FV $35.00 CDT FV CMA, LPN, materials available through Forward Health Portal at wardhealth.wi. gov 0-3 yrs 3 Wyoming Health Department staff dentist FFS most of state; managed the Milwaukee area Dental 2/26/2004 Unknown Dental 2007 No CDT Code on Dental and Nomenclature (CDT ) UNSP Use unspecified CDT code unspecified diagnostic procedure DH = Recommendation dental home by age 1 **Though the task may be delegated, the assumption is that billing the procedure will be under the responsible provider s name (MD, NP, PA) For specific coding questions contact aapcodinghotline@aap.org 12