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MARYLAND MEDICAL ASSISTANCE PROGRAM The Audiology, Physical Therapy and Early Periodic, Screening, Diagnosis, and Treatment (EPSDT) Provider Manual 1
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maryland department of health
Audiology, Physical Therapy, and Early Periodic, Screening, Diagnosis, and Treatment (EPSDT) Provider Manual
Effective July 1, 2018
MARYLANDDEPARTMENTOFHEALTHCOMAR10.09.23.01-1
MEDICALASSISTANCEPROGRAM
Audiology, Physical Therapy, and Early Periodic, Screening, Diagnosis, and Treatment (EPSDT) Provider Manual
EFFECTIVEJULY2018
1
TABLEOFCONTENTS
EPSDTPROVIDERMANUALOVERVIEW...........................................................................4
GENERALINFORMATION……………………………………………………………………..5
PatientEligibility&EligibilityVerificationSystem(EVS)...................................................5
BillingMedicare.........................................................................................................................5
MCOBilling...............................................................................................................................6
FeeforServiceBilling………………………………………………………………………….6
MedicalAssistancePayments....................................................................................................7
TheHealthInsurancePortability&AccountabilityAct(HIPAA).........................................7
NationalProviderIdentifier(NPI)...........................................................................................8
FraudandAbuse........................................................................................................................8
AppealProcedure.......................................................................................................................9
Regulations.................................................................................................................................9
ProviderRequirements.............................................................................................................9
EPSDTACUPUNCTURE,CHIROPRACTIC,SPEECHLANGUAGEPATHOLOGY,OCCUPATIONAL&NUTRITIONTHERAPYSERVICES&PHYSICALTHERAPYSERVICES……………………………………………………………………………………….10
EPSDTOverview....................................................................................................................10
CoveredServices.....................................................................................................................11
EPSDTAcupuncture,Chiropractic,SpeechLanguagePathology,andOccupationalTherapyServices..................................................................................................................11
PhysicalTherapy.................................................................................................................12
EPSDTNutritionServices..................................................................................................13
Preauthorization....................................................................................................................13
ProviderEnrollment..............................................................................................................13
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EPSDTPopulation………………………………………………………………….………..15ProcedureCodesandFeeSchedules..................................................................16
EPSDTAcupunctureServices............................................................................................16
EPSDTChiropracticServices.............................................................................................16
PhysicalTherapy.................................................................................................................17
EPSDTOccupationalTherapy...........................................................................................18
EPSDTSpeechLanguagePathology..................................................................................19
EPSDTNutritionServices..................................................................................................20
AUDIOLOGYSERVICES.........................................................................................................21
Overview...................................................................................................................................21
CoveredServices......................................................................................................................21
Limitations................................................................................................................................22
PreauthorizationRequirements.............................................................................................25
PaymentProcedures................................................................................................................26
AudiologyServicesFeeSchedule...........................................................................................27
AudiologyServices...............................................................................................................27
HearingAid,CochlearImplant,AuditoryOsseointegratedDevicesandAccessories&Supplies.................................................................................................................................29
VISIONCARESERVICES........................................................................................................33
Overview...................................................................................................................................33
CoveredServices......................................................................................................................33
ServiceLimitations..................................................................................................................34
PreauthorizationRequirements.............................................................................................36
ProviderEnrollment................................................................................................................39
PaymentProcedures................................................................................................................39
PreauthorizationRequiredPriorToTreatment..................................................................42
ProfessionalServicesFeeSchedule-ProviderType12(Non-facility&FacilityIncluded)July1,2018…...............................................................................................................................43
ProfessionalServicesFeeSchedule-ProviderType12–(FacilityOnly)July1,2018.........46
ATTACHMENTA:MARYLANDMEDICALASSISTANCEPROGRAMFREQUENTLYREQUESTEDTELEPHONENUMBERS...................................................49
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ATTACHMENTB:MARYLANDDEPARTMENTOFHEALTHANDMENTALHYGIENEPREAUTHORIZATIONREQUESTFORM-AUDIOLOGYSERVICES......49
ATTACMENTC:HEALTHINSURANCECLAIMFORM.................................................52
ATTACHMENTD:MARYLANDDEPARTMENTOFHEALTHANDMENTALHYGIENEPREAUTHORIZATIONREQUESTFORM-VISIONCARESERVICES....54
EPSDTPROVIDERMANUALOVERVIEW
Inthismanual,youwillfindbillingandreimbursementinformationforthefollowingMedicaid services: Acupuncture, Chiropractic, Speech Language Pathology,Occupational Therapy, Nutrition Therapy, Physical Therapy, Audiology, and VisionServices. The information provided is related to services provided to Medicaidparticipants who are 20 years of age or younger, except for audiology and physicaltherapyserviceswhicharecoveredforMedicaidparticipantsofallages.Pleaserefertothetableofcontentstofindinformationspecifictoeachofthecoveredservices.
Occupational therapy, speech language pathology, and physical therapy services are“carved-out” from the HealthChoice Managed Care Organization (MCO) benefitspackageforparticipantswho are 20 years of age and youngerandmustbebilledfee-for- servicedirectlytotheMedicaidProgram.
Acupuncture, chiropractic, nutrition, and vision services are covered by theHealthChoiceManagedCareOrganization(MCO) benefitspackageforparticipantswho are 20 years of age and younger.
EffectiveJuly1,2018,audiologyservicesarecoveredbytheHealthChoiceMCObenefitspackagefor participants of all ages .
EPSDT refers to Early Periodic Screening Diagnosis and Treatment services forparticipantsunderage21.
SomeservicesdescribedinthismanualarebothEPSDTservices(coveredunderage21)andare also covered services for adults. Someservices for adults described in thismanualareonlycoveredincertainsettings. MostMedicalAssistanceparticipantsareenrolled in MCOs. Certain services for children are not part of the MCO benefitpackage;instead,theyarecarvedoutandmustbebilledtoMedicaidFFSasdescribedinthismanual.
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EPSDTservicescoveredbytheMCOaredescribed inCOMAR10.09.67.20. Whenaparticipantunderage21isenrolledinanMCO,contacttheMCOunlesstheserviceiscarvedout.
Whenaparticipantage21andolderisenrolledinanMCO,theservicesdescribedinthismanualthatarecoveredforadultsaretheresponsibilityoftheMCO.Theseservicesaredescribed inCOMAR10.09.67. Providers must contact the MCOfor furtherdetails.
WhenaparticipantisnotenrolledinanMCO,providersmustfollowtheguidanceinthismanual.
GeneralInformation
PatientEligibility &EligibilityVerificationSystem(EVS)
The EVS is a telephone inquiry system that enables health care providers to verifyquickly and efficiently a Medical Assistance participant’s current eligibility status.MedicalAssistanceeligibilityshouldbeverifiedonEACHDATEOFSERVICEprior torenderingservices. AlthoughMedicalAssistanceeligibilityvalidationviatheProgram’sEVSsystem isnotrequired,itistoyouradvantagetodoso toprevent therejectionofclaims for services rendered to a canceled/non-eligible participant. Before renderingaMedicalAssistanceservice,verifytheparticipant’seligibilityon the date of service viatheProgram’sEligibilityVerificationSystem(EVS)1-866-710-1447.
Ifyouneedadditional EVSinformation,pleasecall theProviderRelationsUnitat410-767-5503or800-445-1159. EVSisaninvaluabletoolthatisfastandeasytouse.
ForprovidersenrolledineMedicaid,WebEVS,anewweb-basedeligibilityapplication,isnowavailableatwww.emdhealthchoice.org. TheprovidermustbeenrolledineMedicaidinordertoaccessthewebEVSsystem.Foradditional informationview thewebsiteorcontact410-767-5340forproviderapplicationsupport.
BillingMedicare5
TheProgramwillauthorizepaymentonMedicareclaimsif:
• TheprovideracceptsMedicareassignments;• Medicaremakesdirectpaymenttotheprovider;• Medicarehasdeterminedthatservicesweremedicallyjustified;• TheservicesarecoveredbytheProgram;and• InitialbillingismadedirectlytoMedicareaccordingtoMedicareguidelines.
If the participant has insurance or othercoverage, or if any other personis obligated,eitherlegally orcontractually,topayfor,ortoreimbursetheparticipantfortheservicesin these guidelines, the provider should seek payment from that source first. If aninsurancecarrierrejectstheclaimor payslessthantheamountallowedbytheMedicalAssistanceProgram,theprovidershouldsubmita claim totheProgram.Acopyof theinsurancecarrier’snoticeorremittanceadviceshouldbekepton fileandavailableuponrequestbytheProgram.Inthisinstance,theCMS-1500mustreflectthe letterK(servicesnotcovered)inbox11oftheclaimform.ContactMedicalAssistance’sProvider RelationsOfficeifyouhavequestionsaboutcompletingtheclaimform.
MCOBilling
Claimsforparticipantswhoare21yearsofageorolderandenrolledinanMCO,mustbesubmitted totheMCOfor payment.Contact theMCOforinformationregarding theirbillingand preauthorizationprocedures.
Acupuncture,nutrition,andchiropracticservicesareacoveredbenefitthroughtheMCOsystem for participants who are 20 years old and younger. Contact the MCO forinformationregardingtheir billingandpreauthorizationprocedures.
Fee for Service (FFS) Billing
ProvidersshallbilltheMarylandMedicalAssistanceProgramforreimbursementontheCMS-1500 and attach any requested documentation. Maryland Medical Assistancespecificprocedurecodesarerequiredfor billingpurposes.Pleaserefertotheprocedurecodeandfeeschedulethatisincludedinthis manual.
TheProgramreservestherighttoreturntotheprovider,beforepayment,allinvoicesnotproperly signed,completed,andaccompaniedbyproperlycompletedformsrequiredbytheDepartment.
TheprovidershallchargetheProgramtheirusualandcustomarychargetothegeneralpublicfor similarservices.TheProgramwillpayforcoveredservices,baseduponthelowerofthe following:
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• Theprovider’scustomarychargetothegeneralpublic;or• TheDepartment’sfeeschedule.
TheProvidermaynotbilltheProgramfor:
• Servicesrenderedbymailortelephone;• Completionofformsandreports;• Brokenormissedappointments;or• Serviceswhichareprovidedatnochargetothegeneralpublic.
To ensure payment by the Maryland Medical Assistance Program, check MarylandMedicalAssistance’s Eligibility Verification System (EVS) for every Medical Assistance patient onthedateofservicetoensurepayment byMarylandMedicalAssistance.
UnderMedicalAssistance’sFee-for-Servicesystem,servicesarereimbursedonapervisitbasis under the procedure code that is listed on Maryland Medical Assistance’sestablished procedurecodeand fee schedule. The schedule will indicate themaximumunitsallowedfortheserviceandthefee amountforeachunitofservice.Themaximumunits are the total number of units that can be billed on the same day of service.MarylandMedicalAssistancewillrejectclaimsthatexceedthemaximum unitsofservice.
PLEASENOTE:ProvidersassignedarenderingprovidernumbermustbilltheMedicalAssistance Program with a group provider number. At this time, only therapy group(providertype28) providerscanbillwithoutincludingarenderingprovidernumberontheclaim.
Medical Assistance Payments
You must accept payment from Medical Assistance as payment in full for a coveredservice. You cannot bill a Medical Assistance participant under the followingcircumstances:
• ForacoveredserviceforwhichyouhavebilledMedicalAssistance;• When you bill MedicalAssistancefor a covered serviceandMedicalAssistance
deniesyourclaimsbecauseofbillingerrorsyoumade,suchas:wrongprocedurecodes, lack of preauthorization, invalid consent forms, unattached necessarydocumentation, incorrectly completedforms, filingafterthetime limitations,orotherprovidererrors;
• When Medical Assistance denies your claim because Medicare or another thirdpartyhaspaiduptoorexceededwhatMedicalAssistancewouldhavepaid;
• ForthedifferenceinyourchargesandtheamountMedicalAssistancehaspaid;
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• Fortransferringtheparticipant’smedicalrecordstoanotherhealthcareprovider;and/or
• Whenservicesweredeterminedtonotbemedicallynecessary.
Youcan billtheparticipantunderthefollowingcircumstances:• If theserviceprovided isnot coveredbyMedicalAssistanceand youhavenotified
theparticipantpriortoprovidingtheservicethattheserviceisnotcovered;or• IftheparticipantisnoteligibleforMedicalAssistanceonthedateyouprovidedthe
service.
TheHealthInsurancePortability&AccountabilityAct(HIPAA)
HIPAAof1996 requires that standard electronichealth transactionsbeusedbyhealthplans, including private, commercial, Medical Assistance and Medicare, health careclearinghouses,andhealthcareproviders.
More information on HIPAA may be obtainedfrom:http://dhmh.maryland.gov/hipaa/Pages/Home.aspx.
NationalProviderIdentifier(NPI)
EffectiveJuly30,2007,allhealthcareprovidersthatperformmedicalservicesmusthavea NPI.TheNPIisaunique,10-digit,numericidentifierthatdoesnot expireorchange.NPI’s are assigned to improve the efficiency and effectiveness of the electronictransmissionofhealthinformation.ImplementationoftheNPIimpactsallpractice,office,or institutionalfunctions,includingbilling,reporting,andpayment.
TheNPIisadministeredbytheCentersofMedicareandMedicaidServices(CMS)andisrequired by HIPAA. Providers must use the legacy MA number as well as the NPInumberwhen billingonpaper.
ApplyforanNPIbyusingtheweb-basedapplicationprocessviatheNationalPlanandProvider EnumerationSystem(NPPES)athttps://nppes.cms.hhs.gov/NPPES/Welcome.do.
Fraud and Abuse
Itisillegaltosubmitreimbursementrequestsfor:
• Amountsgreaterthanyourusualandcustomarychargefortheservice.Ifyouhavemore thanonecharge fora service,theamountbilled to theMarylandMedicalAssistance Program shouldbe the lowest amount billed to any person, insurer,healthallianceorother payer;
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• Serviceswhichareeithernotprovidedornotprovidedinthemannerdescribedontherequest forreimbursement. Inotherwords, youmust accuratelydescribetheservice performed, correctly define the time and place where the service wasprovidedand identifytheprofessionalstatusofthepersonprovidingtheservice;
• Anyproceduresotherthantheonesyouactuallyprovide;• Multiple, individuallydescribedor coded procedures if there isa comprehensive
procedurewhichcouldbeusedtodescribethegroupofservicesprovided;• Unnecessary, inappropriate,non-coveredorharmfulservices,whetherornotyou
actuallyprovidedtheservice;or• Servicesforwhichyouhavereceivedfullpaymentbyanotherinsurerorparty.
You are required to refund all overpayments received from the Medical AssistanceProgram within 30 days. Providers must not rely on Department requests for anyrepaymentofsuch overpayments.Retentionofanyoverpaymentsisalsoillegal.
Aproviderwho is suspendedorremoved fromtheMedicalAssistanceProgramorwhovoluntarily withdraws from the Program must inform participants before renderingservices that he/she isno longer aMedical Assistanceprovider and the participant isthereforefinancially responsiblefortheservices.
Appeal Procedure
AppealsrelatedtoMedicalAssistanceareconductedundertheauthorizationofCOMAR10.09.36.09andinaccordancewithCOMAR10.01.03and28.02.01.Toinitiateanappeal,the appealmustbefiledwithin30daysofreceiptofanoticeofadministrativedecisionsinaccordancewithCOMAR10.01.03.06.
Regulations
Visit the following website to review the regulations that pertain to this manual:http://www.dsd.state.md.us/COMAR/ComarHome.html.
Select option #3; choose select by title number; select title number 10 – MarylandDepartment ofHealth; Select Subtitle 09-Medical CarePrograms; toviewindividualregulationsselect:
1) COMAR10.09.23forEPSDT;2) COMAR10.09.23foracupuncture,nutrition, chiropractic, occupational therapy,
orspeechlanguage pathologyservices;3) COMAR10.09.17forphysicaltherapyservices;4) COMAR10.09.51foraudiologyservices;5) COMAR10.09.14forvisionservices;and6) COMAR10.09.36forgeneralMedicalAssistanceproviderparticipationcriteria.
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ProviderRequirements
TheprovidermustmeetrequirementsassetforthinCOMAR10.09.36,GeneralMedicalAssistanceProviderParticipationCriteria,including:
1. Belicensedandlegallyauthorizedtopracticeoptometryinthestateinwhichtheserviceisprovided;
2. VerifyaMedicalAssistanceparticipant’seligibilitypriortorenderingservices;
3. Maintainadequaterecordsforaminimumof6yearsandmakethemavailable,uponrequest,totheDepartmentoritsdesignee;
4. Provide service without regard to race, creed, color, age, sex, national origin,maritalstatus,orphysicalormentalhandicap;
5. NotknowinglyemployanoptometristoropticiantoprovideservicestoMedicalAssistancepatientsafterthatoptometristoropticianhasbeendisqualifiedfromtheProgram,unlesspriorapprovalhasbeenreceivedfromtheDepartment;
6. AcceptpaymentbytheDepartmentaspaymentinfullforservicesrenderedandmake noadditionalchargetoanypersonforcoveredservices;
7. UsefirstqualitymaterialsthatmeetthecriteriaestablishedbytheDepartment;
8. Placenorestrictionsonparticipants’righttoselectprovidersoftheirchoice;
9. AgreethatiftheProgramdeniespaymentorrequestsrepaymentonthebasisthatanotherwisecoveredservicewasnotmedicallynecessary,theprovidermaynotseekpaymentforthatservicefromtheparticipantorfamilymembers;and
10. AgreethatiftheProgramdeniespaymentduetolatebilling,theprovidermayseekpaymentfromtheparticipant.
EPSDTACUPUNCTURE,CHIROPRACTIC,SPEECHLANGUAGEPATHOLOGY,OCCUPATIONAL&NUTRITIONTHERAPYSERVICES&PHYSICALTHERAPYSERVICES
EPSDTOverview
Thissectionofthemanualaddressesoccupationaltherapy,speech languagepathology10
andphysicaltherapyservicesforchildrenwhentheservicesarenotpartofhomehealthservices or an inpatient hospital stay. These services are “carved-out” from theHealthChoice Managed Care Organization (MCO) benefits package for participantswho are 20 years of age and youngerandmustbebilledfee-for-servicedirectlytothe MedicaidProgram.Servicesprovidedby pediatricians,internists,familypractitioners,general practitioners, nurse practitioners, neurologists, and/or other physicians todeterminewhether a child has a need foroccupational therapy, physical therapy orspeech language pathology services are the responsibility of the MCO and must bebilledtotheMCO.Whentherapyservicesareprovidedtoparticipantsunderage21aspartofhomehealthoraninpatienthospitalstaytheybecometheresponsibilityoftheMCO. In addition, MCOsreimburse for community-based rehabilitation, includingphysical and occupational therapy and speech language pathology services for adultenrollees.ContacttheMCOfortheirpreauthorizationandbillingpolicy/proceduresforparticipants21yearsofageandolder.
Acupuncture,chiropractic,andnutritionservicesaddressedinthis manualarelimitedto MarylandMedicalAssistance’s EarlyPeriodicScreening,DiagnosisandTreatment(EPSDT)population (servicesforparticipants whoare20 years of age and younger).Theseservicesarenotgenerallycoveredforadults.Whenaparticipantunderage21isenrolledinHealthChoicetheMCOisresponsibleforcoveringtheseservices.
Thefollowingchartoutlinesthepayerfortheseserviceswhentheparticipantisenrolledinan MCO:
Service BilltheMCO BillFeeforService(FFS)
OccupationalTherapy 21+older 0-20PhysicalTherapy 21+older 0-20SpeechLanguage 21+older 0-20Acupuncture 0-20 ------Chiropractic 0-20 ------Nutrition 0-20 ------HomeHealthTherapy 0-99 ------InpatientTherapy 0-99 ------DME/DMS 0-99 ------Therapyservicesprovidedbyahospital,homehealthagency,inpatientfacility,nursinghome, RTC,localleadagency,schoolorinaccordancewithanIEP/IFSP,modelwaiver,etc.,arenot specificallyaddressedinthismanual.
CoveredServices
EPSDTAcupuncture,OccupationalTherapy,SpeechLanguagePathology&ChiropracticServices
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ForoccupationaltherapyandspeechlanguagepathologyservicesbillFee-for-Service forparticipants under 21 years of age. Contact the MCO for preauthorization forparticipants 21 years of age and older. Acupuncture and chiropractic services forparticipantsunderage21arecoveredthroughtheMCO.
Services arecovered forparticipants who are 20 years of age and younger when theservicesare:
• Necessary to correct or amelioratedefects and physical illnesses andconditions discoveredinthecourseofanEPSDTscreen;
• Provideduponthereferralorderofascreeningprovider;• Rendered in accordance with accepted professional standards and when the
conditionofaparticipantrequiresthejudgment,knowledge,andskillsofalicensedacupuncturist, licensed occupational therapist, licensed speech pathologist orlicensedchiropractor;
• Deliveredinaccordancewiththeplanoftreatment• Limitedtooneinitialevaluationpercondition;and• Deliveredbyalicensedacupuncturist,licensedchiropractor,licensedoccupational
therapist,oralicensedspeechpathologist.
InordertoparticipateasanEPSDT-referredservicesprovider,theprovidershall:
• Gainapprovalbythescreeningprovidereverysix(6)monthsorasauthorizedbythe Department for continued treatment of a participant. Approval must bedocumented by the screening provider and the therapist, acupuncturist, orchiropractorintheparticipant’smedicalrecord;
• Haveexperiencewithrenderingservicestoindividualsfrombirththrough20yearsofage;
• Submitaquarterlyprogressreporttotheparticipant’sprimarycareprovider;and• Maintainmedicaldocumentationforeachvisit.
PLEASENOTE:Services provided ina facility orby a groupwherereimbursement iscovered byanothersegmentoftheMedicalAssistanceProgramare not covered .
PhysicalTherapy
PLEASENOTE:BillFee-for-Serviceforparticipantsunder21yearsofage.ContacttheMCOfor preauthorizationforparticipants21yearsofageandolder.
Medically necessary physicaltherapy services orderedinwriting by a physician, nursepractitioner,physicianassistantor podiatristarecoveredwhen:
• Provided by a licensed physical therapist or by a physical therapist assistantunderdirect supervisionofthelicensedphysicaltherapist;
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• Renderedintheprovider’soffice,theparticipant’shome,oradomiciliarylevelfacility;
• Diagnostic, rehabilitative, or therapeutic and directly related to the writtentreatmentorder;
• Of sufficient complexity and sophistication, or the condition of the patient issuch,thattheservicesofaphysicaltherapistarerequired;
• Renderedpursuanttoawrittentreatmentorderthatissignedanddatedbytheprescriber;
• Treatment order is kept on file by the physical therapist as part of theparticipant’spermanentrecord;
• Not altered in type, amount, frequency, or duration by the therapist unlessmedicallyindicated. The physical therapist shall make necessary changes and sign thetreatment order, advising the prescriber of the change and noting it in thepatient’srecord;
• Limitedtooneinitialevaluationpercondition;and• Reviewed monthly, thereafter, by the prescriber in communication with the
therapist,iftreatmentistoexceed30days,andtheorderis eitherrewrittenoracopyoftheoriginalorderisinitialedanddatedbytheprescriber.A quarterlyprogressreportshouldbesubmittedtotheparticipant’sprimarycarephysician.
Servicesaretoberecordedinthepatient’spermanentrecordwhichshallinclude:• Thetreatmentorderoftheprescriber;• Theinitialevaluationbythetherapistandsignificantpasthistory;• Allpertinentdiagnosesandprognoses;• Contraindications,ifany;and• Progressnotes,atleastonceeverytwoweeks.
Thefollowingphysicaltherapyservicesarenotcovered:
• Servicesprovidedinafacilityorbyagroupwherereimbursementforphysicaltherapyis coveredbyanothersegmentoftheMedicalAssistanceProgram;
• Servicesperformedby licensedphysical therapyassistants whennot underthedirectsupervisionofalicensedphysicaltherapist;
• Servicesperformedbyphysicaltherapyaides;and/or• Morethanoneinitialevaluationpercondition.
EPSDTNutritionServices
(ContacttheMCOforpreauthorization)
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Medicallynecessarynutritionservicesprovidedbyalicenseddieticiannutritionist;
Renderedinaccordancewithacceptedprofessionalstandardsandwhentheconditionofaparticipantrequiresthejudgment,knowledge,andskillsofalicenseddieticiannutritionist.
PLEASENOTE:NutritionservicesarecoveredthroughtheMCO;contact theMCOforpreauthorizationinformationifservinganMCOenrollee.
Preauthorization
Contact the MCO for information regarding their billing and preauthorizationproceduresforacupuncture,chiropractic,nutrition,andtherapyservicesforparticipantswhoareunder21,orwhoarereceivinghomehealthandinpatientservices.
PreauthorizationisnotrequiredundertheFee-for-Servicesystem;however,itisexpectedthataquarterlycareplanbesharedwiththeparticipant'sprimarycareprovider.
ProviderEnrollment
PLEASE NOTE: Under the Maryland Medical Assistance program, acupuncturists,therapists andchiropractors who are part of a physician’s group are not consideredphysician extenders. Services rendered by these providers cannot be billed under thesupervisingphysician’s renderingnumber.Theseprovidersmustcompleteanenrollmentapplication and obtain aMaryland MedicalAssistance provider number that has beenspecifically assignedtothem under their name. The number will beused when billingdirectlytoMarylandMedicalAssistance.
Therapists, acupuncturists, nutrition dieticians, and chiropractors must be licensed topracticetheirspecialtiesinthe jurisdictionswheretheypractice.(Chiropractorsmustbelicensedandenrolledasaphysical therapistinordertobillforphysicaltherapyservices.)
WhenaMarylandMedical AssistanceProgramproviderapplicationhasbeenapprovedforparticipationinthe Programa9digitprovideridentificationnumberwillbeissued.This number will permit the provider to bill the Program’s computerized paymentprocessing system for services that are covered under the fee-for-service system.Applicants enrolling as a renderer in a group practice must be associated with aMarylandMedicalAssistanceexistingornewgrouppractice of the sameprovider type(i.e.aPTcanenrollasarendererinaPTgrouppracticebutnotinaphysician grouppractice).
PLEASE NOTE: At this time, renderers in a therapy group provider type practice(ProviderType28)are not required tobe assigned an individual renderingMarylandMedical Assistance provider number. A listing of therapists and license numbers of
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participatingmembersofthepracticemustbeattachedtothetherapygroupapplicationforin-stateapplicants.Out-of-stateapplicantsmust submitacopyofalllicensesand/orcertificatesofthetherapistsparticipatinginthepractice.
ChangestothepracticemustbebroughttotheattentionoftheProgram.
ProviderType TypeofPractice SpecialtyCodes
AC-Acupuncture 35(group)or30(individualorrendererinagrouppractice)
18-OccupationalTherapist 35(group)or30(individualor rendererinagrouppractice)
EPSDT–OccupationalTherapy(173)
17-SpeechLanguagePathologist
35(group)or30(individualor rendererinagrouppractice)
EPSDT–Speech/LanguagePathology(209)
13-Chiropractor 35(group)or30(individualorrendererinagrouppractice)
EPSDT–Chiropractor(106)
16-PhysicalTherapist 35(group)or30(individualorrendererinagrouppractice)
PhysicalTherapy(189)
28-TherapyGroup 99(other) Mustbecomprisedofatleast twodifferentspecialties:OT (173),PT(189),SP(209)
85-Nutritionist 35(group)or30(individualor rendererinagrouppractice)
EPSDTNutritionCounseling(124)HealthyStartNutrition(141)
EPSDTPopulation
21yearsofageandolder
ThemajorityofMarylandMedicalAssistanceparticipantsareenrolledinanMCO.Itis
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customary for the MCO to refer their enrollees to therapists in their own providernetwork for this age group. If a participant is 21or olderand is enrolled in anMCO,preauthorizationmaybe requiredbytheMCObeforetreatingthepatient. Contact theparticipant’sMCOfortheir authorization/treatmentprocedures.
UnderMedicalAssistance’sfee-for-servicesystem,coverageforcommunity-basedtherapyservicesforthe21andoveragepopulationislimitedtophysicaltherapyservicesunlesscoverableunderadifferent MarylandMedicalAssistanceProgramthatisnotspecificallyaddressedinthismanual(i.e.hospital services,homehealthservices,etc.)
Under21yearsofage–EPSDTPopulation
Speechlanguagepathology,occupationaltherapyandphysicaltherapyservicesprovidedto participants who are 20 years of age or younger are part of Maryland MedicalAssistance’s fee- for-servicesystem when not provided as a home health or inpatientservice.Homehealthand inpatientcarearecoverablebytheMCO.TherapyproviderswhoareenrolledasaMaryland MedicalAssistanceprovidermayrendertheprescribedtherapy services andbill the Program directly on the CMS-1500 form under his/herMarylandMedicalAssistanceassignedprovideridentificationnumber.
Acupuncture,nutrition,andchiropracticservicescontinueasacoveredbenefitundertheMCOsystem; theseservicesmustbebilledtotheMCOforMCOenrollees.ContacttheMCO for preauthorization/treatment procedures for acupuncture, nutrition, andchiropracticservices.
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Procedure Codes and FeeSchedulesEffectiveJuly1,2018
EPSDTAcupunctureServices
ProcedureCode
Description RequiresPre-Auth
MaximumNumberof Units
MaximumPayment
97810 Acupuncture,1ormoreneedles;withoutelectricalstimulation,initial15-minutesofpersonalone-on-onecontactwiththepatient
N 1 $28.37
97811 Acupuncturewithoutelectrical stimulation,eachadditional15-minutesofpersonalone-on-onecontactwiththe patient,withre-insertionofneedle(s)
N 1 $21.11
97813 Acupuncturewithelectricalstimulation, initial15-minutesofpersonalone-on-onecontactwiththepatient
N 1 $30.27
97814 Acupuncturewithelectricalstimulation, initial15-minutesofpersonalone-on-onecontactwiththepatient,withre-insertionofneedle(s)
N 1 $23.86
EPSDTChiropracticServices
ProcedureCode
Description RequiresPre-Auth
MaximumNumberofUnits
MaximumPayment
98940 ChiropracticManipulativeTreatmentSpinal,1to2regions
N 1 $22.00
98941 ChiropracticManipulativeTreatmentSpinal,3to4regions
N 1 $31.51
98942 ChiropracticManipulativeTreatmentSpinal,5regions
N 1 $41.04
98943 ChiropracticManipulativeTreatmentExtraspinal,1ormoreregions
N 1 $21.18
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PhysicalTherapy
ProcedureCode
Description RequiresPre-Auth
MaximumNumberofUnits
MaximumPayment
97161 PhysicalTherapyEvaluation,Lowcomplexity,20minutes
N 1 $69.20
97162 PhysicalTherapyEvaluation,Moderatecomplexity,30minutes
N 1 $69.20
97163 PhysicalTherapyEvaluation,Highcomplexity,45minutes
N 1 $69.20
97164 PhysicalTherapyRe-Evaluation,Establishedplanofcare
N 1 $47.19
97010 Applicationofmodalityto1ormoreAreas;hotorcoldpacks(supervised)
N 10 $4.77
97012 MechanicalTraction(supervised)
N 10 $12.6797014 ElectricalStimulation
(unattended)N 1 $12.52
97016 VasopneumaticDevice N 2 $15.3797018 ParaffinBath N 10 $8.7697022 Whirlpool N 10 $18.8197024 Diathermy(e.g.microwave) N 10 $5.3497026 Infrared N 10 $4.7797028 UltravioletLight N 10 $5.8797032 AttendedElectrical
Stimulation,each15minutesN 4 $14.96
97033 Iontophoresis,each15minutes N 4 $17.48
97034 ContrastBath,each15-minutes N 4 $14.1797035 Ultrasound,each15-minutes N 4 $9.90
97036 HubbardTanks,each15-minutes
N 4 $26.01
97110 TherapeuticProcedure,each15-minutes
N 4 $29.03
97112 NeuromuscularReeducation N 4 $26.58
97113 AquaticTherapy N 4 $33.9897116 GaitTraining N 4 $22.08
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ProcedureCode
Description RequiresPre-Auth
MaximumNumberofUnits
MaximumPayment
97124 TherapeuticMassage N 4 $20.4697140 ManualTherapy
Techniques,each15minutes
N 4 $23.45
97597 SelectiveDebridement(forwounds≤20 sq.cm.)
N 1 $59.82
97598 SelectiveDebridement(foreach additional20sq.cmwound)
N 1 $25.68
97605 Negativepressurewoundtherapy
N 1 $32.38
97606 Totalwoundsurfacearea≥50sq.cm.
N 1 $38.27
97607 Negativepressurewoundtherapy≤50sp.cm
N 1 $37.79
97608 Negativepressurewoundtherapy>50sq.cm.
N 1 $44.97
97750 Physicalperformancetestormeasurement,each15minutes
N 3 $25.72
97755 AssistiveTechnologyAssessmenteach 15minutes
N 2 $27.68
EPSDTOccupationalTherapy
ProcedureCode
Description RequiresPre-Auth
MaximumNumberofUnits
MaximumPayment
97165 OccupationalTherapyEvaluation,Lowcomplexity,30minutes
N 1 $67.01
97166 OccupationalTherapyEvaluation,Moderatecomplexity,45minutes
No 1 $67.01
97167 OccupationalTherapyEvaluation,HighComplexity,60minutes
No 1 $67.01
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ProcedureCode
Description RequiresPre-Auth
MaximumNumberofUnits
MaximumPayment
97168 OccupationalTherapyRe-Evaluation,Establishedplanofcare
N 1 $44.34
97530 TherapeuticActivities,each15minutes
N 4 $30.56
EPSDTSpeechLanguagePathology
ProcedureCode
Description RequiresPre-Auth
MaximumNumberofUnits
MaximumPayment
92507 Individual N 1 $63.9992508 Group N 1 $30.47
92521 Evaluationofspeechfluency N 1 $91.3592522 Evaluationofspeechsound
productionN 1 $74.00
92523 Evaluationofspeechsoundproductionwithevaluationoflanguagecomprehensionandexpression
N 1 $153.97
92524 Behavioralandqualitativeanalysisofvoiceandresonance
N 1 $77.40
92526 Treatmentofswallowingdysfunction and/ororalfunctionforfeeding
N 1 $80.85
92610 Evaluationoforalandpharyngeal swallowingfunction
N 1 $81.43
92626 Evaluationofauditoryrehabilitation status
N 1 $70.21
92627 Evaluationofauditoryrehabilitation
N 3 $17.37
92630 Auditoryrehabilitation;pre-lingualhearingloss N 1 $63.99
92633 Auditoryrehabilitation;post-lingualhearingloss N 1 $63.99
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EPSDTNutritionServices
ProcedureCode
Description RequiresPre-Auth
MaximumNumberofUnits
MaximumPayment
97802 NutritionAssessmentandintervention
N 4 $30.03
97803 NutritionRe-assessmentandintervention
N 4 $26.35
97804 GroupNutritionService
N 1 $13.55
PLEASENOTE:Services arereimburseduptothemaximumunits as indicatedonthisschedule. ProvidersenrolledasaTherapyGroup(ProviderType28)maybillthepervisitcharge for each enrolled discipline participating in the group. Please refer to the feescheduleformaximum reimbursement.
Claims must reflect the above referenced procedure codes for proper reimbursement.These codes are specific to services outlined in the Provider Manual for EPSDTacupuncture, nutrition, chiropractic, speech language pathology, and occupationaltherapies, as well as physical therapy services, and they are specific to the MarylandMedicalAssistanceFee-for-Servicesystemofpayment.
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AUDIOLOGYSERVICES
Overview
AsofJuly1,2018,audiologyservicesfortheEPSDTpopulationwillbeprovidedthroughtheenrollee’s managedcareorganization(MCO). TheseserviceswereplacedbackintotheMCOsystemofpayment.TheparticipantmayhavetoreceiveapreauthorizationorreferralfromtheMCObeforevisitinganaudiologistforevaluationand/ortreatment.MarylandMedicalAssistanceFFSrequirespreauthorizationoncertainservices.Inordertodeterminewhichservicerequirespreauthorization,review theattachedfeescheduleforaudiologyservices.
CoveredServices
AllservicesforwhichreimbursementissoughtmustbeprovidedinaccordancewiththeregulationsforMarylandMedicalAssistanceAudiologyServices(COMAR10.09.51).
A. TheProgramcoversthefollowingmedicallynecessaryaudiologyservices:
1. Audiologyservices,asfollows:
a. Audiologyassessmentsusingproceduresappropriatefortheparticipant’sdevelopmentalageandabilities;and
b. Hearing-aid evaluations and routine follow-up for participants with anidentifiedhearingimpairment,whocurrentlyuseorarebeingconsideredforhearingaids;
2. Hearingamplificationservices,asfollows:
a. Unilateralorbilateralhearingaidswhicharemedicallynecessaryandare:
1. Not used or rebuilt, and which meet the current standards setforthin21CFR§§801.420and801.421,whichareincorporatedbyreference;
2. Recommendedandfittedbyanaudiologist wheninconjunctionwith written medical clearance from a physician who hasperformedamedicalexaminationwithinthepast6months;
3. Soldona30-daytrialbasis;and
4. Fullycoveredbyamanufacturer’swarrantyforaminimumof2
22
yearsatnocosttotheProgram;
b. Hearingaidaccessoriesandservices,aslistedbelow:
1. Earmolds;
2. Batteries;
3. Routinefollow-upsandadjustments;
4. Repairsafterallwarrantieshaveexpired;
5. Replacementofunilateralorbilateralhearingaidsevery5yearswhendeterminedtobemedicallynecessary;and
6. Other hearing aid accessories determined to be medicallynecessary;
c. Cochlearimplantsandrelatedservices,aslistedbelow:
1. Unilateralorbilateralimplantationofcochlearimplantorimplantswhicharemedicallynecessary;
2. Post-operativeevaluationandprogrammingofthecochlearimplantorimplants;
3. Auralrehabilitationservices;and
4. Repair or replacement of cochlear implant device componentssubjecttothelimitationsinCOMAR10.09.51.05;
d. Auditoryosseointegrateddeviceordevicesandrelatedservices, as listedbelow:
1. Unilateral or bilateral implantation of auditory osseointegrateddeviceswhicharemedicallynecessary;
2. Non-implantable or softband device or devices for participantsyoungerthan5yearsold;
3. Evaluationandprogrammingoftheauditoryosseointegrateddeviceordevices;and
4. Repairorreplacement, orbothofauditoryosseointegrateddevicecomponentssubjecttothelimitationsinCOMAR10.09.51.05.
Limit ations
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A. Covered audiology services includinghearingaids, cochlearimplantsandauditoryosseointegrateddevicesarelimitedto:
1. UnlessthetimelimitationiswaivedbytheDepartment,oneaudiologyassessmentperyear;
2. Theinitialcoverageof:
a. Unilateralandbilateralhearingaidsforchildrenyoungerthan21yearsold;
b. Unilateralhearingaidsforparticipants21yearsoldorolderunlessotherwiseapprovedbytheDepartmentoritsdesignee;
c. Bilateralcochlearimplantsforparticipantsyoungerthan21yearsold;
d. Unilateralcochlearimplantsforparticipants21yearsoldorolder;
e. Bilateralauditoryosseointegrateddevicesforparticipantsyoungerthan21yearsold;and
f. Unilateralauditoryosseointegrateddevicesforparticipants21yearsoldorolder;
3. Replacementofunilateralorbilateralhearingaidsonceevery5yearsunlesstheProgramapprovesmorefrequentreplacement;
4. Replacement of hearing aids, cochlear implants and auditory osseointegrateddevicecomponentsthathavebeenlost,stolen,ordamagedbeyondrepair,afterallwarrantiespolicieshaveexpired;
5. Repairs and replacements that take place after all warranties policies haveexpired;
6. Amaximumof76batteriesperparticipantper12monthperiodforaunilateralhearingaidorosseointegrateddevices, or152 batteries perparticipantper12monthperiodforabilateralhearingaidorosseointegrateddevicespurchasedfromtheDepartmentnotmorefrequentlythanevery6months,andinquantitiesof38orfewerfor aunilateral hearingaidorosseointegrated, or76orfewerfor abilateralhearingaidorosseointegrateddevice;
7. Amaximumof 180 disposable batteries for a unilateral cochlear implant perparticipantper12monthperiodor360disposablebatteriesper12monthperiodfor a bilateral cochlear implant purchased not more frequently than every 6months,andinquantitiesof90orfewerforaunilateralcochlearimplant,or180orfewerforabilateralcochlearimplant;
8. Two replacement cochlear implant component rechargeable batteries per 12-
24
monthperiodforbilateralcochlearimplants,andamaximumofonereplacementrechargeablebatteryforaunilateralcochlearimplant;
9. Twocochlear implant replacement transmitter cables per 12-month period forbilateralcochlearimplants,andamaximumofonereplacementtransmittercableforaunilateralcochlearimplant;
10. Two cochlear implant replacement headset cables per 12-month period forbilateralcochlearimplants,andamaximumofonereplacementheadsetcableforaunilateralcochlearimplant;and
11. Two cochlear implant replacement transmitting coils per 12-month period forbilateralcochlearimplants,andamaximumofonereplacementtransmittingcoilforaunilateralcochlearimplant
12. Chargesforroutinefollow-upsandadjustmentswhichoccurmorethan60daysafterthedispensingofanewhearingaid;
13. Amaximumoftwounilateralearmoldsorfourbilateralearmoldsper12monthperiodforparticipantsyoungerthan21yearsold;and
14. Amaximumofoneunilateral earmoldortwobilateralearmoldsper12-monthperiodforparticipants21yearsoldorolder.
B. Serviceswhicharenotcoveredare:
1. Servicesnotmedicallynecessary;
2. Hearingaidsandaccessoriesnotmedicallynecessary;
3. Cochlearimplantservicesandexternalcomponentsnotmedicallynecessary;
4. Cochlearimplantaudiologyservicesandexternalcomponentsprovidedlessthan90daysafterthesurgeryorcoveredthroughinitialreimbursementfortheimplantandthesurgery;
5. Spareorbackupcochlearimplantcomponents;
6. Spareorbackupauditoryosseointegrateddevicecomponents;
7. Replacement of hearing aids, equipment, cochlear implant components, andauditoryosseointegrateddevicecomponentsiftheexistingdevicesarefunctional,repairable,andappropriatelycorrectoramelioratetheproblemorcondition;
8. Spareorbackuphearingaids,equipment,orsupplies;
9. Repairs to spare or backup hearing aids, cochlear implants, auditoryosseointegrateddevices,equipment,orsupplies;
25
10. Investigationalorineffectiveservicesordevices,orboth;
11. Replacementofimproperlyfittedearmoldorearmoldsunlessthe:
a. Replacementserviceisadministeredbysomeoneotherthantheoriginalprovider;and
b. Replacementservicehasnotbeenclaimedbefore;
12. AdditionalprofessionalfeesandoverheadchargesforanewhearingaidwhenadispensingfeeclaimhasbeenmadetotheProgram;and
13. Loanerhearingaids.
PreauthorizationRequirements
A. TheDepartmentrequirespreauthorizationforthefollowingaudiologyservices:
1. Allhearingaids;
2. Certainhearingaidaccessories;
3. All cochlear implant devices and replacement components except microphone,transmittingcablesandtransmittingcoils;
4. Allauditoryosseointegrateddevices;and
5. Repairs for hearing aids, cochlear implants, and auditory osseointegratedcomponentsexceeding$500.
B. Preauthorizationisvalid:
1. For services rendered or initiated within 6 months from the date thepreauthorizationwasissued;and
2. Ifthepatientisaneligibleparticipantatthetimetheserviceisrendered.
C. EffectiveJuly1,2018,Telligenwillberesponsibleforpreauthorizingallhearingaids,certain hearing aid accessories, all cochlear implant devices, all auditoryosseointegrated devices, repairs exceeding $500, and other cochlear implant andauditoryosseointegratedcomponentsexceeding$500.
D. From July 1, 2018 forward, providers are required to submit these requestselectronicallythroughTelligen’sweb-basedproviderportal,Qualitrac.Qualitracisaweb application that allows healthcare providers to submit review requests for
26
consideration.Alloftheaudiologyitemsonthefeeschedulewithanasterisk(*)afterthe reimbursement amount, will require preauthorization. At this time, theDepartmentrequires thatall providerswhowill submitrequests forhearingaids,cochlearimplantdevicesandcomponents,andauditoryosseointegrateddevicesandcomponentscompleteasecurityregistrationforTelligen’sQualitracproviderportal.PleasevisitTelligen’swebsiteat:http://www.telligenmd.qualitrac.com/document-libraryOnceinQualitrac,downloadtheSecurityAdministratorRegistrationFormandviewtheguideforcompletion.AllprovidersmustcompletethesecurityregistrationpriortoJuly1,2018.Sections3,4,and5ofthepacketwillneedtobecompletedandsenttoTelligen forprocessing. Section5needs tobe notarized. If notarizationcannot becompletedinatimeframetomeetthedeadline,theformscanbefaxedtoTelligenandthenotarizedformmaybemailedwithin30days.OncecompleteddocumentationisreceivedbyTelligen,pleaseallow3-5daysforprocessing.Additionally,Telligenwillbeofferingtrainingsonhowtosubmitpreauthorizationrequests.
E. ThefollowingwrittendocumentationshallbesubmittedbytheprovidertoTelligen,theDepartment‘s designeewitheachrequestforpreauthorizationofhearingaids,cochlearimplants,orauditoryosseointegrateddevices;
1. Audiology report documenting medical necessity of the hearing aids, cochlearimplantsorauditoryosseointegrateddevices;
2. Interpretationoftheaudiogram;and
3. Medicalevaluationbyaphysiciansupportingthemedicalnecessityofthehearingaids,cochlearimplantsorauditoryosseointegrateddeviceswithin6monthsofthepreauthorizationrequest.Thismedicalevaluationisonlyrequiredfortheinitialrequestofthehearingaids,cochlearimplants,orauditoryosseointegrateddevice.
4. Invoiceforthecostofservice, minusanydiscounts, forservicesreimbursedatacquisitioncost(A/C).
A preauthorization request for a hearing aids, cochlear implants, and auditoryosseointegrated device components must be submitted on form DHMH 4525. Theprovidermustcomplete,sign(signaturefromtheaudiologistorhearingaiddispenserisrequired) and submittherequestelectronically throughTelligen’sweb-basedproviderportal,Qualitracprior torenderingtheservicetotheparticipanttoensurecoverage.Itisimperative that correct procedure codes be placedon the request form. Incorrect oromittedinformationwillresultinarejectedrequest.
Determinationofauthorization is issuedviaa letter fromTelligen after thereceiptandreviewoftherequest(formDMHM-4525)hasbeencompleted. Acopyofthenotificationletterissenttotheprovideraswellastotheparticipant.
27
PaymentProcedures
A. ToobtaincompensationfromtheDepartmentforcoveredservices,theprovidershallsubmitarequestforpaymentontheformdesignatedbytheDepartment.
B. AudiologyservicesarereimbursedinaccordancewithCOMAR10.09.23.01-1.
C. Theprovidershallbepaidthelesserof:
1. Theprovider’scustomarychargetothegeneralpublic,unlesstheserviceisfreetoindividualsnotcoveredbyMedicaid;or
2. TherateinaccordancewiththeDepartment’sfeeschedule.
D. TheprovidermaynotbilltheDepartmentorparticipantfor:
1. Completionofformsandreports;
2. Brokenormissedappointments;
3. Professionalservicesrenderedbymailortelephone;and
4. Servicesprovidedatnochargetothegeneralpublic.
E. Audiologycenterslicensedasapartofahospitalmaychargeforandbereimbursedaccording to rates approved by the Health Services Cost Review Commission(HSCRC),setforthinCOMAR10.37.03.
F. TheprovidershallrefundtotheDepartmentpaymentforhearingaids,supplies,orboth,thathavebeenreturnedtothemanufacturerwithinthe30-daytrialperiod.
G. The provider shall give the Department the full advantage of any and allmanufacturer'swarrantiesandtrade-insofferedonhearingaids,equipment,orboth.
H. Unless preauthorization has been granted by the Department or its designee, theDepartmentisnotresponsibleforanyreimbursementtoaproviderforanyservicewhichrequirespreauthorization.
I. For audiology services reimbursed at acquisition cost (A/C), the provider mustcompleteandsubmitapreauthorizationrequesttoTelligen,andincludeaninvoicefortheircostfortheservice,minusanydiscountofferedtothem(ifapplicable).
J. TheDepartmentmaynotmakedirectpaymenttoparticipants.
Audiology ProcedureCodes &FeeScheduleEffectiveJuly1,2018
28
AudiologyServicesFeeSchedule
ProcedureCode Description Maximum
Fee
92550 Tympanometryandreflexthresholdmeasurements(donotreport92550inconjunctionwith92567,92568) $35.00
92551 Screeningtest,puretone,aironly $9.72
92552 Puretoneaudiometry(threshold);aironly $25.40
92553 Puretoneaudiometry(threshold);airandbone $30.25
92555 Speechaudiometrythreshold $18.85
92556 Speechaudiometrythreshold;withspeechrecognition $30.53
92557
Comprehensiveaudiometry-puretone,airandbone,andspeechthresholdanddiscrimination-annualaudiologyassessment(annuallimitationmaybewaivedifmedically
necessaryandappropriate)
$46.80
92560 Bekesyaudiometry;screening $5.50
92561 Bekesyaudiometry;diagnostic $31.14
92562 Loudnessbalancetest;alternatebinauralormonaural $37.37
92563 Tonedecaytest $24.83
92564 Shortincrementsensitivityindex(SISI) $21.98
92565 Stengertest,puretone $13.22
92567 Typanometry(impedancetesting)(donotreport92550or92568inadditionto92567) $20.00
92568 Acousticreflextesting;threshold(donotreport92550or92567inadditionto92568) $16.22
92570 Acousticimmittancetesting(includestympanometry,acousticreflexthreshold,andacousticreflexdecaytesting) $50.00
92571 Filteredspeechtest $21.98
92572 Staggeredspondaicwordtest $25.44
92575 Sensorineuralacuityleveltest $47.10
92576 Syntheticsentenceidentificationtest $29.39
92577 Stengertest,speech $15.26
29
ProcedureCode Description Maximum
Fee
92579 Visualreinforcementaudiometry $35.55
92582 Conditioningplayaudiometry $53.94
92583 Selectpictureaudiometry $40.51
92584 Electrocochleography $70.26
92585 Auditoryevokedpotentialsforevokedresponseaudiometry(ABR) com prehensive $140.00
92586Auditoryevokedpotentialsforevokedresponseaudiometry
(ABR)-lim ited $70.00
92587Distortionproductevokedotoacousticemissions; lim ited
evaluation (singlestimuluslevel,eithertransientordistortionproducts)
$50.00
92588Evokedotoacousticemissions;com prehens ive (comparisonoftransientand/ordistortionproductotoacousticemissions
atmultiplelevelsandfrequencies)$75.00
92590 Hearingaidexaminationandselection;monaural $78.00
92591 Hearingaidexaminationandselection;binaural $78.00
92592 Hearingaidcheck;monaural $42.00
92593 Hearingaidcheck;binaural $42.00
92594 Electroacousticevaluationforhearingaid;monaural $11.00
92595 Electroacousticevaluationforhearingaid;binaural $13.00
92596 Earprotectorattenuationmeasurements $33.42
92601 Diagnosticanalysisofcochlearimplant,patientunder7yearsofage;withprogramming $140.40
92602 Subsequentreprogramming(donotreport92602inadditionto92601) $96.30
92603 Diagnosticanalysisofcochlearimplant,age7yearsorolder,withprogramming $118.62
92604 Subsequentreprogramming(donotreport92604 inadditionto92603) $70.49
92620 Evaluationofcentralauditoryfunction,withreport;initial60minutes $73.76
30
ProcedureCode Description Maximum
Fee
92621 Evaluationofcentralauditoryfunction,withreport;eachadditional15minutes $17.33
92626 Evaluationofauditoryrehabilitationstatus;firsthour(canbeusedpre-opandpost-op) $70.21
92627 Evaluationofauditoryrehabilitationstatus;eachadditional15minutes $17.37
92630 Auditoryrehabilitation;pre-lingualhearingloss $63.99
92633 Auditoryrehabilitation;post-lingualhearingloss $63.99
V5299
Hearingservice,miscellaneous(procedurenotlisted;servicenottypicallycovered,requestforconsideration.
Documentationdemonstratingmedicalnecessityrequired–tobesubmittedwithpreauthorizationrequest.)
A/C*
HearingAid,CochlearImplant,AuditoryOsseointegratedDevicesandAccessories&SuppliesFeeSchedule
ProcedureCode Description Maximum
Fee
L8614
Cochleardevice,includesallinternalandexternalcomponents $18,853.31*
L8615Cochlearimplantdeviceheadset/headpiece,replacement
$428.08
L8616 Cochlearimplantdevicemicrophone,replacement $99.71
L8617Cochlearimplantdevicetransmittingcoil,replacement
$87.09
L8618Cochlearimplantorauditoryosseointegrateddevicetransmitter
cable,replacement $24.89
L861
Cochlearimplantexternalspeechprocessorandcontroller,integratedsystem,replacement $8,093.59*
31
ProcedureCode Description Maximum
Fee
L8621Zincairbatteryforusewithcochlearimplantdeviceandauditory
osseointegratedsoundprocessors,replacement,each $0.59
L8622
Alkalinebatteryforusewithcochlearimplantdevice,anysize,replacement,each;maximum180forunilateralor360per12month
periodforbilateral$0.30
L8623Lithiumionbatteryforusewithcochlearimplantdevicespeech
processor,otherthanearlevel,replacement,each $61.39
L8624Lithiumionbatteryforusewithcochlearimplantorauditory
osseointegrateddevicespeechprocessor,earlevel,replacement,each $153.07
L8625Externalrechargingsystemforbatteryforusewithcochlearimplant
orauditoryosseointegrateddevice,replacementonly,each $179.25
L8627Cochlearimplant,externalspeechprocessor,component,
replacement $6,914.53*
L8628Cochlearimplant,externalcontrollercomponent,replacement
$1,179.04*
L8629Transmittingcoilandcable,integrated,forusewithcochlearimplant
device,replacement $169.95
L8690Auditoryosseointegrateddevice,includesallinternalandexternal
components $4,515.27*
L8691Auditoryosseointegrateddevice,externalsoundprocessor,excludes
transducer/actuator,replacementonly,each $1,634.56*
L8692Auditoryosseointegrateddevice,externalsoundprocessor,usedwithoutosseointegration,bodyworn,includesheadbandorother
meansofexternalattachment$2,503.41*
L8693Auditoryosseointegrateddevice,abutment,anylength,replacement
only $1,439.22*
L8694Auditoryosseointegrateddevice,transducer/actuator,replacement
only,each $896.34*
V5160 Dispensingfee,binaural $175.00
V5170 Cros,intheear $1,190.00*
V5180 Cros,BTE(behindtheear) $1,190.00*
32
ProcedureCode Description Maximum
Fee
V5210 Bicros,ITE(intheear) $1,190.00*
V5220 Bicros,BTE(behindtheear) $1,190.00*
V5200 Dispensingfee,cros $106.00
V5240 Dispensingfee,bicros $106.00
V5254 Digital,monaural,CIC $950.00*
V5255 Digital,monaural,ITC $950.00*
V5256 Digital,monaural,ITE $950.00*
V5257 Digital,monaural,BTE $950.00*
V5258 Digital,binaural,CIC $1,900.00*
V5259 Digital,binaural,ITC $1,900.00*
V5260 Digital,binaural,ITE $1,900.00*
V5261 Digital,binaural,BTE $1,900.00*
V5241 Dispensingfee,monaural $106.00
V5264 Earmold,notdisposable,(limitation=upto2permonaural/4perbinauralperyear) $27.00
V5266 Replacementbatteryforuseinhearingdevicemaximum76peryearformonauralmaximum152peryearforbinaural $0.58
V5267
Hearingaidsupplies/accessories(medicallynecessaryandeffectiveservices.Note:prophylacticearprotection-acopyofthesignedprescriptionfromtheprimarycaredoctor,andadocumented
historyoftympanostomytubemustbeonfile.)
A/C*
99002 Handling/conveyanceservicefordevices $15.00
KEY:
* Requirespreauthorizationforallparticipants
A/C Acquisitioncost
33
VISIONCARESERVICES
OverviewVisionscreeningandtreatmentservicesareincluded inthecomprehensiveEarlyandPeriodic Screening, Diagnostic and Treatment (EPSDT) program for children andadolescentsunder21yearsofage.Ataminimum,EPSDTmustincludeage-appropriatevision assessment and services to correct or ameliorate vision problems, includingeyeglasses.
CoveredServices
AllservicesforwhichreimbursementissoughtmustbeprovidedinaccordancewiththeMarylandMedicalAssistanceVisionCareServices(COMAR10.09.14).
TheMedicalAssistanceProgramcoversthefollowingvisioncareservices:
1. Amaximumof one optometric examination to determine the extent of visualimpairmentorthecorrectionrequiredtoimprovevisualacuity, everytwoyearsfor participants 21 years and older, and a maximum of one optometricexamination ayearforparticipantsyoungerthan21yearsold,unlessthetimelimitationsarewaivedbytheProgram,baseduponmedicalnecessity.
2. Amaximumofonepairofeyeglassesayearforparticipantsyoungerthan21yearsold (unless the time limitations are waivedby the Program, basedonmedicalnecessity)whichhavefirstquality,impactresistantlenses(exceptincaseswhereprescriptionrequirementscannotbemetwithimpactresistantlenses)andframeswhicharemadeoffire-resistant,firstqualitymaterial,whenatleastoneofthefollowingconditionsaremet:
a. Theparticipantrequiresadiopterchangeofatleast0.50;
b. Theparticipantrequiresadioptercorrectionoflessthan0.50basedonmedicalnecessityandpreauthorizationhasbeenobtainedfromtheProgram;
c. Theparticipant’spresenteyeglasseshavebeendamagedtotheextentthattheyaffect visual performance and cannot be repaired to effective performancestandards,orarenolongerusableduetoachangeinheadsizeoranatomy;or
d. Theparticipant’spresenteyeglasseshavebeenlostorstolen.
3. Examinationandeyeglassesforaparticipantwithamedicalcondition,otherthannormal physiological change necessitating a change in eyeglasses (before thenormaltime limits havebeenmet) whenapreauthorizationhasbeenobtainedfromtheprogram.
4. Visuallynecessaryoptometriccarerenderedbyanoptometristwhentheseservices
34
are:
a. Providedbytheoptometristorhislicensedemployee;
b. Related to the patient’s health needs as diagnostic, preventative, curative,palliative,orrehabilitativeservices;and
c. Adequatelydescribedinthepatient’srecord.
5. Opticianserviceswhentheyare:
a. Provided by the optician or optometrist, or by an employee under theirsupervisionandcontrol;
b. Adequatelydescribedinthepatient’srecord;and
c. Orderedorprescribedbyanophthalmologistoroptometrist.
Service Limitations
A. TheVisionCareProgramdoesnotcoverthefollowingservices:
1. Servicesnotmedicallynecessary;
2. Investigationalorexperimentaldrugsorprocedures;
3. ServicesprohibitedbytheStateBoardofExaminersinOptometry;
4. ServicesdeniedbyMedicareasnotmedicallyjustified;
5. Eyeglasses, ophthalmic lenses, optical aids, and optician services rendered toparticipants21yearsorolder;
6. Eyeglasses, ophthalmic lenses, optical aids, and optician services rendered toparticipantsyoungerthan21yearsoldwhichwerenotorderedasaresultofafullorpartialEPSDTscreen;
7. Repairs,exceptwhenrepairstoeyeglassesarecosteffectivecomparedtothecostofreplacingwithnewglasses;
8. Repairsforparticipants21orolder;
9. Combinationormetalframesexceptwhenrequiredforproperfit;
10. Costoftravelbytheprovider;
11. AgeneralscreeningoftheMedicalAssistancepopulation;
35
12. Visualtrainingsessionswhichdonotincludeorthoptictreatment;and
13. Routineadjustment.
B. TheoptometristmaynotbilltheProgramnortheparticipantfor:
1. Completionofformsandreports;
2. Brokenormissedappointments;
3. Professionalservicesrenderedbymailortelephone;
Serviceswhichareprovidedatnochargetothegeneralpublic;andprovidingacopyofaparticipant’spatientrecordwhenrequestedbyanotherlicensedprovideronbehalfoftheparticipant.
C. An optometrist certified by the Board as qualified to administer diagnosticpharmaceuticalagentsmayusethefollowingagentsinstrengthsnotgreaterthanthestrengthsindicated:
1. Agentsdirectlyorindirectlyaffectingthepupiloftheeyeincludingthemydriaticsandcycloplegicslistedbelow:
a. Phenylephrinehydrochloride(2.5%);
b. Hydroxyamphetaminehydrobromide(1.0%);
c. Cyclopentolatehydrochloride(0.5-2.0%);
d. Tropicamide(0.5and1.0%);
e. Cyclopentolatehydrochloride(0.2%)withPhenylephrinehydrochloride(1.0%);
f. Dapiprazolehydrochloride(0.5%);
g. Hydroxyamphetaminehydrobromide(1.0%)andTropicamide(0.25%).
2. Agents directly or indirectly affecting thesensitivity of the cornea including thetopicalanestheticslistedbelow:
a. Proparacainehydrochloride(0.5%);and
b. Tetracainehydrochloride(0.5%).
3. Diagnostictopicalanestheticanddyecombinationslistedbelow:
a. Benoxinatehydrochloride(0.4%)-Fluoresceinsodium(0.25%);and
36
b. Proparacainehydrochloride(0.5%)-Fluoresceinsodium(0.25%).
D. AnoptometristcertifiedbytheBoardasqualifiedtoadministerandprescribetopicaltherapeuticpharmaceuticalagentsislimitedto:
1. Ocularantihistamines,decongestants,andcombinationsthereof,excludingsteroids;
2. Ocularantiallergypharmaceuticalagents;
3. Ocular antibiotics and combinations of ocular antibiotics, excluding speciallyformulatedorfortifiedantibiotics;
4. Anti-inflammatoryagents,excludingsteroids;
5. Ocularlubricantsandartificialtears;
6. Tropicamide;
7. Homatropine;
8. Nonprescriptiondrugsthatarecommerciallyavailable;and
9. Primaryopen-angleglaucomamedications,inaccordancewithawrittentreatmentplandevelopedjointlybetweentheoptometristandanophthalmologist.
E. TheProgramwillonlypayforlensestobeusedinframespurchasedbytheProgramortoreplacelensesintheparticipant’sexistingframes,whicharedefinedasthosewhichhavebeenfittedwithlensesandpreviouslywornbytheparticipantforthepurposeofcorrectingthatpatient’svision.
F. Providers maynot sell a frameto a participant as a private patient andbill theProgramforthelensesonly.
G. Providersmaynotbill theProgramfor lenseswhentheparticipantpresents new,unfittedframeswhichwerepurchasedfromanothersource.
H. Providersmaynotbill theProgramforthemaximumallowedfeeforframesandcollect supplemental payment from the participant to enable that participant topurchaseadesiredframethatexceedsProgramlimits.
I. If after the provider has fully explained the extent of Program coverage, theparticipantknowinglyelectstopurchasethedesiredframesandlenses,theprovidermaysellacompletepairofeyeglasses(framesandlenses)toaparticipantasaprivatepatientwithoutbillingtheProgram.
PreauthorizationRequirements
37
A. Thefollowingservicesrequirewrittenpreauthorization:
1. Optometric examinations to determine the extent of visual impairment or thecorrectionrequiredtoimprovevisualacuitybeforeexpirationofthenormaltimelimitations;
2. Replacement of eyeglasses due to medical necessity or because they were lost,stolenordamagedbeforeexpirationofthenormaltimelimitations;
3. Contactlenses;
4. Subnormalvisionaidexaminationandfitting;
5. Orthoptictreatmentsessions;
6. Plasticlensescostingmorethanequivalentglasslensesunlesstherearesixormoredioptersofsphericalcorrectionorthreeormoredioptersofastigmaticcorrection;
7. Absorptivelenses,exceptcataract;and
8. Ophthalmiclensesoropticalaidswhenthedioptercorrectionislessthan:
a. 0.50D.sphereformyopiaintheweakestmeridian;
b. +0.75D.sphereforhyperopiaintheweakestmeridian;
c. +0.75additionalforpresbyopia;
d. +0.75D.cylinderforastigmatism;
e. Achangeinaxisof5degreesforcylindersof1.00diopterormore;and
f. Atotalof4prismdiopterslateraloratotalof1prismdioptervertical.
B. Preauthorization is issued when the provider submits to the Program adequatedocumentation demonstrating that the service to be preauthorized is medicallynecessary."Medicallynecessarymeansthattheserviceorbenefitisdirectlyrelatedtodiagnostic,preventive,curative,palliative,rehabilitativeorameliorativetreatmentofan illness, injury, disability, or health condition; consistent with current acceptedstandards of good medical practice; the most cost efficient service that can beprovidedwithoutsacrificingeffectivenessoraccesstocare;andnotprimarilyfortheconvenienceoftheconsumer,theirfamilyortheprovider.
C. Preauthorizationisvalidonlyforservicesrenderedorinitiatedwithin60daysofthedateissued.
D. Preauthorizationmustberequestedinwriting.APreauthorizationRequestFormforVisionCareServices(DHMH4526)mustbecompletedandsubmittedto:
38
MedicalCareOperationsAdministrationDivisionofClaimsProcessing
P.O.Box17058Baltimore,MD21203
E. Documentation substantiating medical necessity must be attached to thepreauthorizationrequest.Acopyofthepatientrecordreportand/ornotesdescribingtheservicemust beincludedwiththerequest. If available, includeacopyof thelaboratoryinvoiceatthistime.Otherwise,acopyoftheinvoicemustbeattachedtotheclaimforproperpricingoftheitemaftertheservicehasbeenauthorizedbytheProgram.
F. Procedurecodesfollowedbya“P”inthismanualrequirewrittenpreauthorization.
G. TheProgramwill covermedicallyjustifiedcontact lensesforparticipantsyoungerthan 21 years old. The following criteria are used when reviewing writtenpreauthorizationrequestsforcontactlenses:
1. MonocularAphakia:
a. Whenvisualacuityofthetwoeyesisequalizedwithintwolines(standardSnellendesignation);
b. Whennosecondaryconditionordiseaseexiststhatcouldadverselyaltertheacuityofeithereyeorcontra-indicatesuchusage;and
c. When tests conclude that disrupted binocular function will be restored andenhancedwhencomparedtoalternativetreatment.
2. Anisometropia:
a. Whentheprescriptivedifferencebetweenthetwoeyesexceeds4.00diopters(S.E.)andvisualacuityofthetwoeyesisequalizedwithintwolines;
b. Whennosecondaryconditionordiseaseexiststhatcouldadverselyaltertheacuityofeithereyeorcontra-indicatesuchusage;and
c. When tests conclude that disrupted binocular function will be restored andenhancedwhencomparedtoalternativetreatment.
3. Keratoconus/CornealDyscrasies:
a. Whencontactlensesareacceptedasthetreatmentofchoicerelativetothephaseofaparticularcondition;
b. Whenthebestspectaclecorrectioninthebesteyeisworsethan20/60andwhenthecontactlensiscapableofimprovingvisualacuitytobetterthan20/40orfourlinesbetterthanthebestspectacleacuity;and
39
c. Whennosecondaryconditionordiseaseexiststhatcouldadverselyaltertheacuityofeithereyeorcontra-indicatesuchusage.
40
ProviderEnrollment
PLEASENOTE:UndertheMarylandMedicalAssistanceprogram,optometristsandopticalcentersthatarepartofaphysician’s groupcannotbill underthephysician’s provider number. Services renderedby the optometrist or opticalcentercannotbebilledunderthephysician’sprovidernumber.TheseprovidersmustcompleteanenrollmentapplicationandbeassignedaMedicalAssistanceprovidernumberthathasbeenspecificallyassignedtothem.Thenumberwillbeused when billing directly to Maryland Medical Assistance for optometric oropticalcenterservices.
ContacttheProviderMasterFileofficeat410-767-5340foranenrollmentpacketfor vision services (Provider Type 12). Ophthalmologists are enrolled underMedicalAssistance’sphysicianprogram(ProviderType20),andshouldfollowtheregulationsandmanualspecifictothatparticularprovidertype.
PaymentProcedures
TheprovidershallsubmitrequestsforpaymentforvisionservicesasstatedinCOMAR10.09.36.
The request for payment must include any required documentation, such as,preauthorizationnumber,needforcombinationormetalframe,patientrecordnotes,andlaboratoryinvoices,whenapplicable.
TheMedicalAssistanceProgramhasestablishedafeescheduleforcoveredvisioncare services providedbyoptometrists andoptical centers (MDMAProviderType12).ThefeeschedulelistsallcoveredservicesbyCPTandnationalHCPCScodesandthemaximumfee.
TheprovidershallsubmitarequestforpaymentonthebillingformCMS-1500.The request for payment must include any required documentation, such aspreauthorizationnumber,needforcombinationormetalframe,patientrecordnotes, and laboratory invoices, whenapplicable. MarylandMedical AssistanceBillingInstructionsfortheCMS-1500canbeobtainedfromProviderRelationsat(410)767-5503or(800)445-1159.
TheMedicalAssistanceProgramhasestablishedafeescheduleforcoveredvisioncare services providedbyoptometrists andoptical centers (MDMAProviderType12).ThefeeschedulelistsallcoveredservicesbyCPTandnationalHCPCScodesandthemaximumfeeallowedforeachservice.Visioncareprovidersmustbill their usual and customary charge to the general public for similarprofessionalservices.
41
TheProgramwill pay professional fees for covered services the lower of theprovider’s usual and customary charge or the Program’s fee schedule. Forprofessionalservices,providersmustbilltheirusualandcustomarycharges.TheProgramwillpayfor materialsatacquisitioncostsnottoexceedthemaximumestablishedbytheProgram.Formaterials,providersmustbilltheiracquisitioncosts.
Wherea“ByReport”(B/R)statusisindicatedontheschedule,attachacopyofthe lab invoice to the claim for pricing purposes as well as the records tosubstantiatemedicalnecessity(recordreport/notesdescribingtheservice).
Whenthe fee fora visioncare procedure is listedas “AcquisitionCost” (A/C) in thismanual, the value of the procedure is basedonacquisitioncost. Bill the Programtheacquisitioncostfortheitem.Thelabinvoicesubstantiatingthechargeaswellasotherrecordsmustremainonfilefora6yearperiodandmadeavailableuponrequestbytheProgram.
Procedureswithapreauthorizationrequirement(P)mustbeauthorizedpriortotreatingthepatient.Iftheprocedureisauthorized,thepreauthorizationnumbermustappearontheclaim.
Theprovidermustselecttheprocedurecodethatmostaccuratelyidentifiestheserviceperformed.Anyservicerenderedmustbeadequatelydocumentedinthepatientrecord. Therecordsmustberetainedfor6years.Lackofacceptabledocumentation may cause the Program to deny payment or if payment hasalreadybeenmade, torequest repayment, orto imposesanctions, whichmayinclude withholding of payment orsuspensionor removal fromthe Program.Paymentforservices is basedupontheprocedure(s) selectedbytheprovider.Althoughsomeprovidersdelegatethetaskofassigningcodes,theaccuracyoftheclaimissolelytheprovider’sresponsibilityandissubjecttoaudit.
TheNFAC(Non-Facility)feeispaidforplaceofservice11,12,and62.
TheFAC(facility)feeispaidforallotherplacesofservice.
Paymentsforlenses,frames,andthefittinganddispensingofspectaclesincludeanyroutinefollow-upandadjustments for60days. Noadditionalfeeswillbepaid. Providers must bill and will be paid for the supply of materials atacquisitioncostsnottoexceedthemaximumestablishedbytheProgram.Ifamaximum has not been established, the provider must attach laboratorydocumentationtotheinvoice.
Fittingincludesfacialmeasurements,frameselection,prescriptionevaluationandverificationandsubsequentadjustments. Themaximumfeeforlensesincludes
42
the cost for FDAhardening, testing, edging, assembling and surfacing. Themaximumfeeforframesincludesthecostofacase.
1. Usethefollowingprocedurecodesforthebillingofframes:
a. V2020forachild/adultZYLframe;
b. V2025forametalorcombinationframewhenrequiredforaproperfit;and
c. V2799(preauthorizationrequired)foraspecialorcustomframewhennecessaryandappropriate.
2. Useprocedurecodes92340-92342forthefittingofspectacles.
3. Useprocedurecode92370andattachacopyofthelabinvoicetotheclaimwhenbillingforarepair.PLEASENOTE:Repairchargesnottraditionallybilledtothegeneral public cannot be billed to Maryland Medical Assistance. (Review theregulationsforcoverageofeyeglassrepairs.)
Contact lensservices requirepreauthorizationand include the prescriptionofcontactlenses(specificationofopticalandphysicalcharacteristics), theproperfitting of contact lenses (including the instructionandtrainingof the wearer,incidentalrevisionofthelensandadaptation),thesupplyofcontactlenses,andthe follow-up of successfully fitted extended wear lenses. Use the followingprocedurecodesforthebillingoftheseservices:
1. 92310-26 for the professional services of prescription, fitting, training, andadaptation;
2. V2500-V2599,S0500forcontactlenses;
3. V2784forpolycarbonatelenses;and
4. 92012forfollow-upsubsequenttoaproperfitting.
Visioncareclaimsmustbereceivedwithin 12monthsofthedatethatserviceswererendered.Ifaclaimisreceivedwithinthe12monthlimitbutrejectedduetoerroneous or missing data, re-submittal will be accepted within 60 days ofrejection or within 12 months of the date that the service was rendered,whicheverislater.Ifaclaimisrejectedbecauseoflatereceipt,theparticipantmaynotbebilledforthatclaim.
Medicare/MedicalAssistanceCrossoverclaimsmustbereceivedwithin120daysofthedatethatpaymentwasmadebyMedicare.ThisisthedateofMedicare’sExplanationofBenefitsform.TheProgramrecognizesthebillingtimelimitationsofMedicareandwillnotmakepaymentwhenMedicarehasrejectedaclaimduetolatebilling.
43
TheMedicalAssistanceProgramisalwaysthepayeroflastresort.WheneveraMedicalAssistanceparticipantisknowntobeenrolledinMedicare,Medicaremustbebilledfirst.ClaimsforMedicare/MedicalAssistanceparticipantsmustbesubmittedontheCMS-1500directlytotheMedicareIntermediary.
ForadditionalinformationabouttheMDMedicalAssistanceProgram,gotothefollowinglink:
https://mmcp.dhmh.maryland.gov/Pages/Provider-Information.aspx.
Acopyoftheregulationscanbeviewedat:http://www.dsd.state.md.us/COMAR/subtitle_chapters/Titles.aspx(title10)(subtitle09)10.09.14.
44
PreauthorizationRequiredPriorToTreatment
Whenthefeeforavisioncareprocedureislistedas“ByReport” (B/R)onthisscheduleacopyoftheoptometrist’s patientrecordreportand/ornoteswhichdescribetheservicesrenderedandthelabinvoicemustbesubmittedwiththeclaim.
Whenthefeeforavisioncareprocedureislistedas“AcquisitionCost”(A/C)onthisschedule,thevalueoftheprocedureistobedeterminedfromacopyofacurrent laboratoryorotherinvoicewhichclearlyspecifiestheunitcostoftheitem.
Whenthe fee for a vision care procedure is listedwith a "P", a request forpreauthorizationmustbesubmittedonformDHMH4526.Acopyofthepatientrecord report and/or notes describing the services must be submitted to theProgrampriortorenderingtheservice.
ThemaximumfeeforlensesincludesthecostforFDAhardening,testing,edging,assemblingandsurfacing.ThemaximumfeeforframesincludesthecostofacaseServicesprovidedmustbemedicallynecessary.
45
ProfessionalServices/MaterialsReimbursementsforVisionCareProviders(ProviderType12Non-facility&FacilityIncluded)
EffectiveJuly1,2018
ProcedureCode
Description RequiresPre-Auth
MaximumPaymentNFAC
MaximumPaymentFAC
65205 Removalofforeignbodyfromeye $44.11 $34.43
65210 Removalofforeignbodyembeddedineye
$53.88 $41.63
65220 Removalofforeignbodyw/olamp $45.98 $33.4365222 Removalofforeignbodyw/lamp $52.46 $40.7792002 Eyeexamw/newpatient $63.71 $37.2092004 Eyeexamw/newpatient
comprehensive$116.51 $77.46
92012 Eyeexamandtreatmentofestablishedpatients
$67.09 $41.15
92014 EyeExamandtreatmentofestablishpatients,comprehensive
$96.99 $62.22
92015 DeterminationofRefractivestate $19.02 $15.0392020 SpecialEyeEvaluation-Gonioscopy $21.00 $16.4392025 ComputerizedCornealTopography $29.90 $29.90
92060 SensorimotorexamwithmultiplymeasureOculardeviation
$51.21 $51.21
92065 Orthoptic/pleoptictraining P $42.98 $42.9892071 Fittingcontactlensfortreatmentof
ocularsurfacedisease$31.59 $28.03
92072 Fittingcontactlensformanagementofkeratoconusinitialfitting
$104.54 $80.01
92081 Visualfieldexam(s)limited $33.37 $33.3792082 Visualfieldexam(s)Intermediate $49.38 $49.3892083 Visualfieldexam(s)extended $56.74 $56.7492100 SerialTonometryexam(s) $63.33 $34.29
92132 ScanningComputerizedophthalmicdiagnosticimaginganteriorsegment,withinterpretationandreport
$30.41 $30.41
46
ProcedureCode
Description RequiresPre-Auth
MaximumPaymentNFAC
MaximumPaymentFAC
92133 ScanningComputerizedophthalmicdiagnosticimagingposteriorsegment,withinterpretationandreportunilateralorbilateral;opticnerve
$37.09 $37.09
92134 ScanningComputerizedophthalmicdiagnosticimagingposteriorsegment,withinterpretationandreportunilateralorbilateral;retina
$37.09 $37.09
92225 Ophthalmoscopy,initial $20.98 $16.7092226 Ophthalmoscopy,subsequent $19.36 $14.8092250 Fundusphotographyw/interpretation
andreport$53.55 $53.55
92260 Ophthalmodynamometry $14.48 $8.49
92283 Colorvisionexaminationextended,e.g.,anomaloscopeorequivalent
$44.78 $44.78
92284 Darkadaptationexaminationw/interpretationandreport
$51.16 $51.16
92285 Externalocularphotographyw/interpretationandreportfordocumentationofmedicalprogress(e.g.,close-upphotography,slitlampphotography,goniophotography,stereo-photography)
$30.13 $30.13
92286 Specialanteriorsegmentphotographyw/interpretationandreport;withspecularendothelialmicroscopyandcellcount.
$93.71 $93.71
92310 Contactlensesfitting P $75.28 $46.2192311 Contactlensfitting-1/aphakia P $79.33 $43.1392312 Contactlensfitting-1/aphakia P $92.38 $49.9192313 Contactlensfitting-1/aphakia P $75.89 $36.5692314 FittingSpecialContactlens $62.97 $27.3492325 Modificationofcontactlens P $33.95 $33.9592326 Replacementofcontactlens P $36.82 $36.8292340 Fittingofspectacles,monofocal $27.88 $14.4892341 Fittingofspectacles,bifocal $31.71 $18.6092342 Fittingofspectacles,multifocal $34.16 $20.77
47
ProcedureCode
Description RequiresPre-Auth
MaximumPaymentNFAC
MaximumPaymentFAC
92354 Fittingofspectaclemountedlowvisionaid;singleelementsystem
P $61.53 $61.53
92355 Fittingofspectaclemountedlowvisionaid;telescopicorothercompoundlenssystem
P $43.11 $43.11
92370 Repair&refittingspectacles $24.26 $12.58
48
ProfessionalServices/MaterialsReimbursementsforVisionCareProviders(ProviderType12–FacilityOnly)
EffectiveJuly1,2018
ProcedureCode
Description RequiresPre-Auth
MaximumPaymentFAC
92499 Unlistedeyeserviceorprocedure B.R.S0500 Disposablecontactlens,perlens P A.C.V2020 Adult/childZYLframesw/case $20.00V2025 Metalorcombinationframe $25.00V2100 Lensspheresingleplano4.00,perlens $12.00V2101 Singlevisionsphere4.12-7.00,perlens $7.20V2102 Singlevisionsphere7.12-20.00,perlens $22.15V2103 Spherocylinder,SV,4.00d/.12-2.00,perlens $15.00V2104 Spherocylinder,SV,4.00d/2.12-4d,perlens $15.00V2105 Spherocylinder,SV,4.00d/4.25-6d,perlens $7.30V2106 Spherocylinder,SV,4.00d/over6.00d,perlens A.C.V2107 Spherocylinder,SV,+-4.25d/.12-2d,perlens $15.00V2108 Spherocylinder,SV,+-4.25d/2.12-4d,perlens $15.00V2109 Spherocylinder,SV,+-4.25d/4.25-6d,perlens $9.20V2110 Spherocylinder,SV,+-4.25d/over6d,perlens B.R.V2111 Spherocylinder,SV,+-7.25d/.25-2.25d,per
lens$22.15
V2112 Spherocylinder,SV,+-7.25d/2.25-4d,perlens $19.00V2113 Spherocylinder,SV,+-7.25d/4.25-6d,perlens A.C.V2114 Spherocylinder,SV,over+-12.00d,perlens $36.00V2115 Lenticular(myodisc),SV,perlens B.R.V2118 Aniseikoniclens,SV P A.C.V2121 Lenticularlens,PerLens,Single,perlens A.C.V2199 Nototherwiseclassified,SVlens P A.C.V2200 Sphere,bifcl,plano+-4.00d,perlens $21.00V2201 Sphere,bifcl,+-4.12/+-7.00d,perlens $13.00V2202 Sphere,bifcl,+-7.12/+-20d,perlens A.C.V2203 Spherocylinder,BF,4.00d/.12-2.00d,perlens $21.00V2204 Spherocylinder,BF,4.00d/2.12-4,perlens $14.50V2205 Spherocylinder,BF,4.00d/4.25-6,perlens $16.50V2206 Spherocylinder,BF,4.00d/over6,perlens B.R.V2207 Spherocylinder,BF,4.25-7/.12to2,perlens $14.50V2208 Spherocylinder,BF,4.25+-7/2.12to4,per
lens$15.50
V2209 Spherocylinder,BF,4.25+-7/4.25-6,perlens $17.50V2210 Spherocylinder,BF,4.25+-7/over6,perlens A.C.V2211 Spherocylinder,BF,7.25+-12/.25-2.25,per
lensA.C.
V2212 Spherocylinder,BF,7.25+-12/2.25-4,perlens A.C.V2213 Spherocylinder,BF,7.25+-12/4.25-6,perlens A.C.
49
ProcedureCode
Description RequiresPre-Auth
MaximumPaymentFAC
V2214 Spherocylinder,BF,sphereover+-12.00d,perlens
A.C.
V2215 Lenticular(myodisc)bifocal,perlens B.R.V2218 Aniseikonic,bifocal,perlens P A.C.V2219 Bifocalsegwidthover28mm P A.C.V2220 Bifocaladdover3.25d P A.C.V2221 Lenticularlens,bifocal,perlens $24.00V2299 Specialtybifocal P A.C.V2300 Sphere,trifcl,pl+-4.00d,perlens $16.50V2301 Sphere,trifcl+-4.12/-7.00d,perlens $19.00V2302 Sphere,trifcl+-7.12/+-20.00,perlens A.C.V2303 Spherocylinder,trifcl,pl+-4/.12-2,perlens $18.00V2304 Spherocylinder,trifcl,p+-4/2.25-4,perlens $20.50V2305 Spherocylinder,trifcl,p+-4/4.25-6,perlens $24.00V2306 Spherocylinder,trifcl,p+-4/over6,perlens A.C.V2307 Spherocylinder,trifcl,+-4.25/…2d,perlens $20.50V2308 Spherocylinder,trifcl,+-4.25/…4d,perlens $22.00V2309 Spherocylinder,trifcl,+-4.25/…6d,perlens $25.00V2310 Spherocylinder,trifcl,+-4.25/over6d,per
lensA.C.
V2311 Spherocylinder,trifcl,+-7.25/…2.25d,perlens
A.C.
V2312 Spherocylinder,trifcl,+-7.25/…4.00d,perlens
A.C.
V2313 Spherocylinder,trifcl,+-7.25/…6.00d,perlens
A.C.
V2314 Spherocylinder,trifcl,overp-12.00d,perlens A.C.V2315 Lenticular(myodisc),trifocal,perlens A.C.V2318 Aniseikoniclens,trifocal P A.C.V2319 Trifocalsegwidthover28mm P A.C.V2320 Trifocaladdover3.25d P A.C.V2321 Lenticularlens,trifocal,perlens A.C.V2399 Specialtytrifocal(byreport) P A.C.V2410 Variableasph,SV,fullfld,gl/pl P A.C.V2430 Variableasph,bifcl,fullfld,gl/pl P A.C.V2499 Variablesphericity,othertype P A.C.V2500 Contactlens,PMMAspherical P A.C.V2501 ContactlensPMMAtoric/prism P A.C.V2502 ContactlensPMMAbifocal P A.C.V2503 ContactlensPMMAcolorvisiondef P A.C.V2510 Contactlens,gaspermeable,spherical,per
lensP A.C.
V2511 Contactlens,gaspermeable,toric,prismballast,perlens
P A.C.
V2512 Contactlens,gaspermeable,bifocal,perlens P A.C.V2513 Contactlens,gaspermeable,extendedwear, P A.C.
50
ProcedureCode
Description RequiresPre-Auth
MaximumPaymentFAC
perlensV2520 Contactlens,hydrophilic,spherical,perlens P A.C.V2521 Contactlens,hydrophilic,toric,orprism
ballast,perlensP A.C.
V2522 Contactlens,hydrophilic,bifocal,perlens P A.C.V2523 Contactlens,hydrophilic,extendedwear,per
lensP A.C.
V2530 Contactlens,scleral,gasimperm,perlens P A.C.V2599 Contactlens,othertype P A.C.V2600 Handheldlowvisionaids P A.C.V2610 Singlelensspectaclemountlowvisionaids P A.C.V2615 Telescopic&othercompoundlens P A.C.V2700 Balancelens A.C.V2715 Prismlens P A.C.V2718 Press-onlens,Fresnelprism P A.C.V2745 Add.tint,anycolor/solid/grad B.R.V2784 Polycarbonatelens,anyindex(Greaterthan
6Dioptersorothermedicallynecessarycondition)
$6.50
V2799 Visionservice,miscellaneous P A.C.
51
ATTACHMENTA:MARYLANDMEDICALASSISTANCEPROGRAMFREQUENTLYREQUESTEDTELEPHONE
NUMBERS
AudiologyPolicy/CoverageIssues (410)767-3998VisionPolicy/CoverageIssues (410)767-3998HealthyStart/FamilyPlanningCoverage (800)456-8900
MarylandMedicalAssistanceChildren’sServices (410)767-3998RareandExpensiveCaseManagementProgram(REM) (800)565-8190
EligibilityVerificationSystem(EVS) (866)710-1447
BoardofAudiologists/HearingAidDispensers/SpeechLanguagePathologists
(410)764-4725
MarylandStateBoardofExaminersinOptometry (410)764-4710
ProviderEnrollmentP.O.Box17030Baltimore,MD21203
(410)767-5340
ProviderRelationsP.O.Box22811Baltimore,MD21203
(410)767-5503(800)445-1159
MissingPaymentVoucher/LostorStolenCheck (410)767-5503
ThirdPartyLiability/OtherInsurance (410)767-1771
Recoveries (410)767-1783
52
ATTACHMENTB:MARYLANDDEPARTMENTOFHEALTHANDMENTALHYGIENEPREAUTHORIZATIONREQUEST
FORM-AUDIOLOGYSERVICES
SECTIONI-PatientInformation
MedicaidNumber
LastName FirstName MI
DOB Sex Telephone
Address
SECTIONII-PreauthorizationGeneralInformation
PaytoProviderNumber
Name RequestDate
Address
Contact
Provider’sSignature Telephone()
SECTIONIII–AdditionalPreauthorizationInformation
PrescribingProvider
Name Telephone()
Address
SECTIONIV–PreauthorizationLineItemInformation
DESCRPTIONOFSERVICE
PROCEDURE
REQUESTED
DATESOFSERVICE
AUTHOR.AMOUN
COD
MOD
UNI
AMO
FRO
THR
UNITS
53
E TS
UNT
M U T
$ ///
/// $
$ ///
/// $
$ /// /// $$ /// /// $$ /// /// $
PREAUTHORIZATIONNUMBER
DOCUMENTCONTROLNUMBER SUBMITTOTELLIGENVIAQUALITRAC:(STAMPHERE)
SECTIONV–SpecificPreauthorizationInformation
PatientLocation:HomeNursingHomeHospitalIn-PatientDischargeDate
Addresswhereequipmentwillbeused(ifdifferentfromabove):Periodoftimerequested:
MFGR MODEL/PRODUCTNUMBER
SINGLEUNITPRICE
AMT.PKG
$$$$$
DiagnosisandPresentPhysicalCondition
54
Prognosis
TreatmentPlan
ExpectedTherapeuticEffect
ATTACMENTC:HEALTHINSURANCECLAIMFORM
(SEENEXTPAGE)
55
PLEASE PRINT OR TYPE APPROVED OMB-0938-1197 FORM 1500 (02-12)
56
ATTACHMENTD:MARYLANDDEPARTMENTOFHEALTHANDMENTALHYGIENEPREAUTHORIZATIONREQUEST
FORM-VISIONCARESERVICES
SECTIONI-PatientInformation
MedicaidNumber
LastName FirstName MI
DOB Sex Telephone
Address
SECTIONII-PreauthorizationGeneralInformation
PaytoProviderNumber
Name DateService
Address Requestedby
Contact Provider
Provider’sSignature Telephone()
SECTIONIII–AdditionalPreauthorizationInformation
GiveReason(s)forRequestedService
SECTIONIV–PreauthorizationLineItemInformation
DESCRIPTIONOFSERVICE
PROCEDURECODE
REQUESTED AUTHORIZEDUNITS AMOUNT UNITS AMOUNT
$ $$ $$ $
$ $$ $
PREAUTHORIZATIONNUMBER
DOCUMENTCONTROLNUMBER SUBMITTO: ProgramSystemsandOperationsAdministration(STAMPHERE) DivisionofClaimsProcessing
P.O.Box17058Baltimore,Maryland21203
SECTIONV–SpecificPreauthorizationInformation
NewPrescription: O.D. BestVisualActivity
O.D. BestVisualActivity
CONTACTLENSREQUESTS:
HealthConditionofeacheye: O.D. O.S.
DateofSurgery: O.D. O.S.
Bestvisualacuitywithcontactlenses: O.D. O.S.
Advantageofcontactlensesoverglasses:
SECTIONVI(DHMHOnly)
Approved Denied Returned
Reason(s)
MedicalConsultant’sSignature Date
58
59
