471 NAC 18-008. PAYMENT

008. PAYMENT. 008.01 GENERAL PAYMENT REQUIREMENTS. The provider will be reimbursed for services rendered in accordance with the applicable Nebraska regulations . 008.02 REIMBURSEMENT. Covered physician services, except clinical laboratory services, are paid at the lower of the provider’s submitted charge or the allowable amount for the procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for the date of service. 008.02(A) EXCEPTION. An out-of-state provider may enter into an agreement for a rate which exceeds the rate according to the Nebraska Medicaid Practitioner Fee Schedule only when Nebraska Medicaid has determined the beneficiary requires specialized services which are not available in Nebraska and no other source of the specialized service can be found. 008.03 SITE OF SERVICE ADJUSTMENT. A site of service differential is applied which reduces the fee schedule amount for specific Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes when the service is provided in a facility setting. Based on the Medicare differential, specific Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) codes will be reimbursed with adjusted rates based on the site of service. 008.04 NON-PAYMENT OF OTHER PROVIDER PREVENTABLE CONDITIONS (OPPC). For physician and non-physician provider claims, payment will be denied for the following other provider preventable conditions (OPPCs): (i) Wrong surgical or other invasive procedure performed on a beneficiary; (ii) Wrong surgical or other invasive procedure performed on the wrong body part; and (iii) Wrong surgical or other invasive procedure performed on the wrong beneficiary. 008.05 SURGERY. The surgical procedure, including 14 days post-operative care, is reimbursed under a Healthcare Common Procedure Coding System (HCPCS) surgery procedure code. When multiple surgical procedures are done at one time, Nebraska Medicaid reimburses the primary procedure according to the Nebraska Medicaid Practitioner Fee Schedule. Any secondary procedures which add significant time and complexity to patient care is reimbursed at one-half of the amount which would be paid if the procedure were the primary procedure. 008.052(A) ASSISTANT SURGEON. When an assistant surgeon is required, reimbursement is made according to the Nebraska Medicaid Practitioner Fee Schedule. Medicare’s assistant surgery policy designation is followed. 008.06 PRACTITIONER ADMINISTERED MEDICATIONS. Practitioner administered injectable medications are reimbursed at 100 percent of the Medicare Drug Fee Schedule plus an administration fee as listed. Injectable medications approved by Nebraska Medicaid but not included on the Medicare Drug Fee Schedule will be reimbursed at the wholesale acquisition cost (WAC) plus 6.8 percent. 008.062(A) ALLERGY INJECTIONS. When the cost of the medication is not listed in either the Drug Topics Red Book or The Blue Book, allergy injections are paid at the provider's submitted charge up to the maximum allowable dollar amount under the Nebraska Medicaid Practitioner Fee Schedule per injection which includes medication and injection fee. If the allergy medication is not prepared in the office of the physician administering the allergen and the administering physician incurs no expense for the supply or the supplier bills Nebraska Medicaid separately, the administering physician is reimbursed according to the Nebraska Medicaid Practitioner Fee Schedule for the injection fee. If the administering physician purchases the supply for administration in the office, the administering physician must not bill Nebraska Medicaid for more than the cost of the supply. The maximum allowable dollar amount under the Nebraska Medicaid Practitioner Fee Schedule must not be exceeded in reimbursement per allergy injection, which includes the cost of the medication and the injection fee. 008.06(B) IMMUNIZATIONS. Reimbursement is available for the provider’s private stock vaccine and the administration fee for immunizations of adolescents age 19 and 20. 008.07 LABORATORY AND PATHOLOGY. 008.07(A) PHYSICIAN’S OFFICE OR INDEPENDENT LABORATORY. Payment is based on the Nebraska Medicaid fee schedule for clinical laboratory services to cover the total service, both professional and technical components. 008.07(A)(i) PHYSICIAN’S OFFICE LABORATORY. Payment for tests obtained in the physician's office but sent to an independent clinical laboratory or hospital for processing must be claimed by the facility performing the tests, using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code. The private physician's office may be reimbursed for the collection by venipuncture or catheterization for these procedures by using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code at the providers' submitted charge up to 100 percent of the Medicare clinical laboratory fee schedule. The private physician is not reimbursed for processing or interpreting tests performed outside their office. 008.07(B) CLINICAL LABORATORY SERVICES. Payment for clinical laboratory services including collection of laboratory specimens by venipuncture or catheterization is made at the amount allowed for each procedure code in the national fee schedule for clinical laboratory services as established by Medicare. 008.07(B)(i) LICENSED AND CERTIFIED INDEPENDENT CLINICAL LABORATORY. When a physician's private office sends the specimen to an independent clinical laboratory for processing, the procedure is paid directly to the independent clinical laboratory. The laboratory is not reimbursed for collecting, handling, or drawing the specimen sent in by a physician's office. Specimens collected by venipuncture or catheterization obtained by the hospital or independent laboratory for hospital or independent laboratory patients are paid for. The private physician is not reimbursed for processing or interpreting tests performed outside their office. Reimbursement is not allowed for collection of specimens in a nursing facility (NF) or long-term care (LTC) facility. If a physician performs some tests on a specimen and then sends the same specimen to an outside facility for additional procedures, the private physician may be reimbursed for the medically necessary procedures performed in their office plus a fee for drawing the specimen by venipuncture or obtaining urine by catheterization sent to a hospital or independent laboratory. 008.07(B)(ii) HOSPITAL CLINICAL LABORATORY SERVICES. There is no separate payment made to the pathologist for routine clinical laboratory services. To be paid, the pathologist must negotiate with the hospital to arrange a salary or compensation agreement. (a) INPATIENT SERVICES. Payment is included in the hospital’s prospective payment rate ; (b) OUTPATIENT SERVICES. Payment is made according to the fee schedule determined by Nebraska Medicaid; and (c) NON-PATIENT SERVICES. Payment is made according to the fee schedule determined by Nebraska Medicaid. 008.08 PROFESSIONAL COMPONENT OF HOSPITAL DIAGNOSTIC AND THERAPEUTIC SERVICES. The professional component of a physician's hospital diagnostic or therapeutic service is paid . In the absence of available payment data the professional component is paid for at a percentage of the allowable fee for the total procedure. The percentage is established by Nebraska Medicaid . 008.09 ANESTHESIOLOGY SERVICES. Covered anesthesiology services are paid for in accordance with the reimbursement rates previously described. Additional reimbursement is not made for emergency and risk factors. 008.10 PAYMENT FOR SERVICES PROVIDED BY PHYSICIAN ASSISTANTS (PA). Payment to physician assistants (PA) is made to the physician provider group number with whom the physician assistant (PA) is enrolled. When payment is made to the physician group, the physician is responsible for payment to the physician assistant (PA). Payments will not be made to physician’s assistants (PA) who are employed by a hospital. 008.11 PAYMENT FOR TRANSPLANT SERVICES. The provider must submit, at the request of Nebraska Medicaid, any medical documentation from the beneficiary’s record to support and substantiate claims submitted to Nebraska Medicaid for payment. 008.11(A) TRANSPLANT SURGEON SERVICES. This fee will include two weeks' routine post-operative care by the designated primary surgeon. Payment for routine post-operative care will not be made to other members of the surgical team. Services provided after the two-week post-operative period may be billed on a fee-for-service basis. 008.12 ITINERANT PHYSICIAN VISITS. The physician will be paid at the rate for the appropriate level of office visit. 008.13 CERTIFIED NURSE MIDWIFE (CNM) SERVICES . Payment for certified nurse midwife (CNM) services is made to the certified nurse midwife (CNM) or the physician group with whom the certified nursemidwife (CNM) has a practice agreement. 008.14 COMPREHENSIVE INTERDISCIPLINARY TREATMENT FOR A SEVERE FEEDING DISORDER. 008.14(A) PEDIATRIC FEEDING DISORDER CLINIC INTENSIVE DAY TREATMENT. Reimbursement for pediatric feeding disorder clinic intensive day treatment for medically necessary services will be a bundled rate based on the sum of the fee scheduled amounts for covered services provided by Nebraska Medicaid enrolled licensed practitioners. 008.14(B) PEDIATRIC FEEDING DISORDER CLINIC OUTPATIENT TREATMENT. Pediatric feeding disorder clinic outpatient treatment for medically necessary services is reimbursed at the appropriate fee schedule amount for a physician consultation for covered services provided by Nebraska Medicaid enrolled licensed practitioners.