KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL. Podiatry
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1 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL Podiatry
2 PART II Introduction Section BILLING INSTRUCTIONS Page 7000 Podiatry Billing Instructions Submission of Claim Podiatry Specific Billing Information BENEFITS AND LIMITATIONS 8100 Copayment Benefit Plans Medicaid 8-3 Forms Section
3 PART II This is the provider specific section of the manual. This section (Part II) was designed to provide information and instructions specific to podiatry providers. It is divided into two subsections: Billing Instructions and Benefits and Limitations. The Billing Instructions subsection gives an example of the billing form applicable to podiatry services. The form is followed by directions for completing and submitting it. The Benefits and Limitations subsection defines specific aspects of the scope of podiatry services allowed within the Kansas Medical Assistance Program. HIPAA Compliance As a participant in the Kansas Medical Assistance program, providers are required to comply with compliance reviews and complaint investigations conducted by the Secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. The provider is required to provide the same forms of access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider shall not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.
4 PODIATRY BILLING INSTRUCTIONS Introduction to the HCFA-1500 CMS-1500 Claim Form Updated 05/07 Podiatry providers must use the HCFA-1500 CMS-1500 claim form (unless submitting electronically) when requesting payment for medical services and supplies provided under the Kansas Medical Assistance Program (KMAP). An example of the HCFA-1500 CMS-1500 claim form is in the Forms section at the end of this manual. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the HCFA-1500 CMS-1500 claim form to providers. Refer to Section 1100 of the General Introduction Provider Manual. Complete, line by line instructions for completion of the HCFA 1500 CMS-1500 are available in the General Billing Provider Manual., pages 5-14 through SUBMISSION OF CLAIM: Send completed first page of each claim and any necessary attachments to: Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas BILLING INSTRUCTIONS 7-1
5 7010. PODIATRY SPECIFIC BILLING INFORMATION Updated 11/03 Office Visits: Use evaluation and management (E&M) procedure code BILLING INSTRUCTIONS 7-2
6 BENEFITS AND LIMITATIONS COPAYMENT Updated 11/03 Podiatry services require a copayment of $1.00 per office visit (99213). (Refer to Section 3000 for exceptions.) Bill all services occurring on the same date on the same claim form. Do not reduce charges or balance due by the copayment amount. This reduction will be made automatically by EDS. If multiple claims are submitted for the same date(s) of service, the copayment requirement will be deducted for each claim submitted. BENEFITS & LIMITATIONS 8-1
7 8300. Benefit Plan Updated 08/08 BENEFITS AND LIMITATIONS KMAP beneficiaries will be assigned to one or more Medical Assistance benefit plans. The assigned plan or plans will be listed on the beneficiary ID card. These benefit plans entitle the beneficiary to certain services. From the provider's perspective, these benefit plans are very similar to the type of coverage assignment in the previous MMIS. If there are questions about service coverage for a given benefit plan, refer to Section 2000 of the General Benefits Provider Manual for information on the plastic State of Kansas Medical Card and eligibility verification contact the Customer Service Center at or (785) BENEFITS & LIMITATIONS 8-2
8 BENEFITS AND LIMITATIONS MEDICAID Updated 04/08 PODIATRY SERVICES ARE COVERED FOR KAN BE HEALTHY (KBH) BENEFICIARIES ONLY. Adult Care Home: Podiatry services are not allowed in an adult care home (ACH), except for those services rendered to a KBH beneficiary. ACH Visits: One routine visit per month is covered. No other ACH visits are covered on the same day as an ACH history and physical. Consultations: Only one initial consultation is covered within a 60-day period for the same consumer by the same provider. Only one inpatient follow-up consultation is covered within a 10-day period for the same consumer by the same provider. Only one outpatient follow-up consultation is covered within a 60 day period for the same consumer by the same provider. Documentation: To verify services provided in the course of a postpayment review, documentation in the consumer's medical record must support the service billed. Hospital Visits: One inpatient hospital visit per day is covered. Only one physician will be reimbursed for a patient with a single diagnosis except for consultation. When a patient has two or more diagnoses involving two or more systems where the special skill of two or more physicians are essential in rendering quality medical care, concurrent care is covered for the days when such care is medically necessary and a medical necessity form (Section 4100) is attached. Office Visits: One comprehensive office visit is covered per calendar year, per consumer. Evaluation and management (E&M) office visit procedure codes may be used for any new patient or any patient who has not been seen by the provider within the past three years. BENEFITS & LIMITATIONS 8-3
9 8400. Updated 11/03 Surgery: Ambulatory/Outpatient Surgery: Only one ambulatory/outpatient surgical procedure is reimbursed per day, per consumer. Content of Service: IVs, medications, supplies and injections performed on the same day as an ambulatory outpatient surgery procedure are considered content of service of the surgery and may not be billed separately. Anesthesia, equipment and supplies, drugs, surgical supplies, etc., are considered content of service of the ambulatory/ outpatient surgical procedure. Procedures performed in conjunction with an emergency room visit (sutures, minor surgeries, etc.) are considered content of service of the emergency room visit and may not be billed separately. When reimbursement for the procedure is preferred, the CPT code for the procedure performed shall be billed in lieu of the ER visit. Cosmetic Surgery: Surgeries that are cosmetic in nature (and related complications) are not covered. Any medically necessary procedure which could ever be considered cosmetic in nature must be prior authorized. (Refer to Section 4300.) Elective Surgery: The Medicaid Program will not reimburse for elective surgery unless the procedure is medically necessary and the consumer is a KAN Be Healthy participant. (Refer to Section 2020 for details.) Minor Surgery: All office visits, hospital visits and non-emergency outpatient visits for a period of 21 days after minor surgeries are content of service of the surgery. All office visits and non-emergency outpatient visits rendered on the same day as surgery are content of service of the surgery. BENEFITS & LIMITATIONS 8-4
10 FORMS SECTION CMS-1500
11
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