471 NAC 18-007. BILLING FOR PHYSICIAN SERVICES

007. BILLING FOR PHYSICIAN SERVICES. 007.01 SPECIFIC BILLING REQUIREMENTS. Physicians’ services must be billed on the appropriate Nebraska Medicaid approved claim form or the standard electronic transaction form . 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 provider’s source input documentation may be requested 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. 007.01(A) PROCEDURE CODES. Physicians must use Healthcare Common Procedure Coding System (HCPCS) procedure codes when submitting claims to Nebraska Medicaid . 007.01(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. 007.01(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. 007.01(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. 007.01(D)(i) EXCEPTION. Prenatal Plus Program (PPP) services outside of routine prenatal visits can be billed as they occur and are not submitted as a claim at the time of delivery. 007.01(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. 007.01(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 claim may be returned to the physician for completion or pay the claim at the lowest dosage manufactured for the specific drug. 007.01(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. 007.01(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. 007.01(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. 007.01(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. 007.01(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. A separate Nebraska Medicaid provider number is required 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 and one provider number, may be billed on each claim. 007.01(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. 007.01(J)(i) 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 beneficiary; 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. 007.01(J)(ii) STERILIZATION OR HYSTERECTOMY. To make payment for anesthesia services for sterilizations, a completed copy of the appropriate Nebraska Medicaid approved consent form must be on file with Nebraska Medicaid . For a hysterectomy, a completed copy of the appropriate Nebraska Medicaid approved consent form , signed and dated by the beneficiary stating she was made aware before the surgery that the surgery would result in sterility, must be on file with Nebraska Medicaid before payment can be made. Claims for these services must indicate actual time in one-minute increments. 007.01(J)(iii) 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. Additional reimbursement is not provided 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. Payment is not made for certified registered nurse anesthetist (CRNA) services for secondary procedures. 007.01(K) LABORATORY AND PATHOLOGY. 007.01(K)(i) INPATIENT HOSPITAL ANATOMICAL PATHOLOGY SERVICES. Payment for the technical component of anatomical pathology is included in the hospital’s payment . The pathologist must claim the professional component of anatomical pathology using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code and modifier. 007.01(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 laboratory, or the pathologist of the second hospital's laboratory to which the specimen has been referred may claim payment for the total service. 007.01(K)(ii) OUTPATIENT HOSPITAL ANATOMICAL PATHOLOGY SERVICES. The hospital must claim the technical component according to this title . The pathologist must claim the professional component. 007.01(K)(ii)(1) EXCEPTION. If an anatomical pathology specimen is obtained from a hospital outpatient and is referred to an independent laboratory or the pathologist of a second hospital's laboratory, the independent laboratory, or the pathologist of a second hospital's laboratory to which the specimen was referred may claim payment for the total service. 007.01(K)(iii) NON-PATIENT ANATOMICAL PATHOLOGY SERVICES. A non-patient is a beneficiary 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. 007.01(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. Leased department status has no bearing on billing for or payment of inpatient or outpatient anatomical pathology services. 007.01(K)(v) CLINICAL LABORATORY SERVICES. The professional and technical components of clinical laboratory services are not separately identified for billing and payment. 007.01(K)(vi) PHYSICIAN’S OFFICE OR INDEPENDENT LABORATORY. Clinical laboratory services performed in a physician's office or independent laboratory must be billed appropriately. 007.01(K)(vi)(1) CLINICAL LABORATORY CONSULTATION. The physician must claim a clinical laboratory consultation using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure codes. 007.01(L) RADIOLOGY. The professional component must be billed appropriately. 007.01(L)(i) INPATIENT RADIOLOGY SERVICES. Payment for the technical component of inpatient radiology services is included in the hospital's payment . Physicians must bill the professional component of inpatient radiology services appropriately. 007.01(L)(ii) OUTPATIENT RADIOLOGY SERVICES. The hospital must claim the technical component of outpatient radiology services on the appropriate Nebraska Medicaid approved claim form or electronic format. The physician must bill the professional component using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code with the modifier. 007.01(M) SERVICES PROVIDED BY PHYSICIAN ASSISTANTS (PA). Claims for services provided by physician assistants (PA) must be submitted on the appropriate Nebraska Medicaid approved claim form or the standard electronic : transaction form under the physician assistant’s (PA) provider group number. 007.01(N) PHYSICIAN SERVICES IN NURSING FACILITY (NF), INTERMEDIATE CARE FACILITY (ICF), AND INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). The physician may bill Nebraska Medicaid for an annual nursing facility (NF) physical exam service, regardless of the extent of the exam. Additionally, the physician may bill Nebraska Medicaid for the certification service. 007.01(N)(i) ANNUAL PHYSICAL EXAMINATION. If the annual physical examination is performed solely to meet the requirement of Nebraska Medicaid , the physician must submit the claim to Nebraska Medicaid on the appropriate Nebraska Medicaid approved claim form or the standard electronic transaction format . . 007.01(N)(ii) MEDICARE COVERAGE. If a physical examination is performed for diagnosis or treatment of a specific symptom, illness, or injury and the beneficiary 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 (LTC) facility. 007.01(N)(iii) PHYSICIANS’ VISITS TO NURSING FACILITY (NF) 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 facility (NF) visit. 007.01(N)(iv) ON-SITE RECERTIFICATION. The physician must use the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code for nursing facility (NF) visits when billing Nebraska Medicaid for this service. 007.01(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 the following statements on or with the claim: 60-day or alternate schedule intermediate examination. 007.01(O) TRANSPLANT SERVICES. Physician services must be billed accordingly. 007.01(O)(i) BILLING FOR TRANSPLANT SERVICES PROVIDED TO A MEDICAID-INELIGIBLE DONOR. Claims for services provided to a Nebraska Medicaid-ineligible donor must be submitted under the Nebraska Medicaid-eligible beneficiary’s case number. There must be a notation with the claim indicating these services were provided to the Nebraska Medicaid-ineligible donor on the beneficiary’s behalf. 007.01(P) ITINERANT PHYSICIAN VISITS. The hospital room charge must be billed on the appropriate Nebraska Medicaid approved claim form or electronic format. The physician's service must be coded as an office visit and billed on the appropriate Nebraska Medicaid approved claim form or electronic format. 007.01(Q) CERTIFIED NURSE MIDWIFE (CNM) OR NURSE PRACTITIONER (NP) SERVICES. Claims for certified nurse midwife (CNM) services and nurse practitioner (NP) services must be submitted on the appropriate Nebraska Medicaid approved claim form according to instructions or on the appropriate electronic format transaction. 007.01(R) FEEDING AND SWALLOWING CLINIC SERVICES. The interdisciplinary team (IDT) services must be billed under the physician's provider number accordingly. The physician services are billed under appropriate Current Procedural Terminology (CPT) codes.