Review information about the newly implemented Pay-for-Performance Program.
Physician: A person who is licensed to provide health services within the scope of his/her profession under MS 147. For purposes of this section, a physician means a licensed doctor of medicine or osteopathy.
Physicians must enroll with DHS to receive payment. Physicians must receive an individual National Provider Identifier (NPI) even if they are a member of a group, clinic, employed by an outpatient hospital, or other organized health care delivery system that employs physicians. (Refer to the Locum Tenens section.)
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Services provided by a physician are not restricted to a specific place of service unless specified by CPT or HCPCS code description. Physicians may provide services in the recipient's home, nursing home, outpatient hospital, inpatient hospital, or other facility.
Physicians may not bill separately for performing administrative or medical functions that are paid through an institution's per diem rate.
A health service must be medically necessary in order to be a covered service. Services listed as provided by a physician in this chapter may be provided by other health care professionals if the service is within the scope of their practice as defined in the Minnesota Statues.
Drugs which are administered to a patient as part of a clinic or other outpatient visit should be billed to MHCP using the appropriate HCPCS code(s). Do not bill drugs administered during an outpatient visit through the pharmacy POS system. MHCP does not allow brown-bagging or white-bagging of prescription drugs administered in an office setting.
Pharmacies, including mail order pharmacies, who are providing the drugs for a clinic visit, should bill the clinic and not MHCP for the drugs dispensed. MHCP will make an exception only if a recipient has third-party liability and the third-party payer requires that the drugs be billed through the pharmacy benefit.
Pharmacies should not dispense drugs directly to a patient if the drugs are intended for use during a clinic or other outpatient visit.
The federal Deficit Reduction Act of 2005 (DRA) requires states to collect rebates for covered outpatient drugs administered by physicians. In order to comply, states must gather utilization data including the National Drug Code (NDC), quantity, and unit of measure from claims submitted for physician-administered drugs.
Include the correct NDC information on all claims, including Medicare and other third party claims, when billing non-vaccine drugs using HCPCS codes. Participants in the 340B Drug Pricing Program are included in the NDC reporting requirements; however, drugs purchased through 340B are exempt from NDC reporting. Add the UD modifier to drugs purchased through the 340B Program. Refer to the HCPCS Codes Requiring NDC when submitting claims for reimbursement.
Enter one compound drug (HCPCS code) per claim transaction with up to 25 individual NDCs in the Drug Identification loop, The NDC quantity and dose form are reported in the Quantity and Unit or Basis for Measurement Code or on MNITS Interactive in the Drug Pricing field on the Services Tab.
The submitted line should include the amount discarded with the amount administered. Providers are expected to use the package size which minimizes the amount of waste billed to MHCP. For example, if a patient needs 50mg of drug and the product comes in 50mg and 100mg vials, providers should use the 50mg vial unless the rest of the 100mg vial will be used for another patient scheduled for treatment the same day. Both MHCP and Medicare encourage scheduling patients to make the most efficient use of the drugs administered.
Contact Health Information Designs (HID), the MHCP Prescription Drug PA review agent when providing a physician administered drug that requires authorization. All authorization requests will require a primary diagnosis and may require supporting documentation.
Submit authorization requests in one of these ways:
MHCP follows CPT guidelines for Evaluation and Management Services.
Concurrent Care Services: The provision of similar services (e.g., hospital visits to the same patient by more than one physician on the same day). If a consulting physician subsequently assumes the responsibility for a portion of patient management, it is considered concurrent care.
MHCP pays concurrent care when the medical condition of the recipient requires the services of more than one physician. Generally, a recipient's condition that requires physician input in more than one specialty area establishes medical necessity for concurrent care.
MHCP will not pay for concurrent care when one of the following occur:
MHCP follows CPT guidelines for Office, Outpatient and Inpatient consultations.
Follow CPT guidelines for reporting critical care. Services not included in Critical Care may be reported separately.
Report E/M observation codes and follow CPT guidelines:
For procedures done while the patient is considered in an inpatient status, use place of service code 21 (inpatient hospital).
Payment for physician and professional services in an LTC must be medically necessary. Refer to the Physician Extender section of this chapter for use of physician extender services provided in LTC facilities. Refer to MHCP Long Term Care policy for additional information on covered services in LTC facilities.
Prolonged services involving direct (face-to-face) patient contact are covered. Use CPT guidelines to report Prolonged Services.
Standby services are covered when requested by another physician and involve prolonged attendance without direct (face-to-face) patient contact. Standby services are covered only in the case of a documented existing risk or distress.
A medical team conference conducted for the purpose of coordinating the activities of a recipient's care with an interdisciplinary team of health professionals or a representative of community agencies is a covered service.
The medical record must document the contents of the conference and the amount of time spent in the conference.
Bill the appropriate CPT E/M code.
Physician services related to counseling are covered as part of the E/M codes if the counseling is conducted face-to-face with the patient, relative, or guardian.
When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter, time may be considered the key or controlling factor to qualify for a particular level of E/M service. Medical record documentation must reflect the content of the counseling, coordination of care, and the amount of time spent in counseling/coordination.
Telephone calls are not covered by MHCP.
Care plan oversight services are not covered by MHCP.
Preventive Health Services: A health service provided to a patient to avoid or minimize the occurrence or recurrence of illness, infection, disability, or other health condition. Preventive health services are covered if the service:
The following services are not covered as a preventive service:
Preventive health counseling to promote health and prevent illness or injury is a covered service. These services should be billed with the appropriate E/M code for preventive medicine, individual counseling, and group counseling.
Eligible providers include: enrolled physicians, physician clinics, community clinics, outpatient hospitals, public health clinics, family planning agencies, certified nurse practitioners, physician assistants, clinical nurse specialists, certified nurse midwives, community mental health centers, and physician extenders.
Covered Education or Counseling Services
Reason for Education or Counseling
Education/counseling is the primary reason for the visit.
Use modifier U7 when a physician extender providers the service.
Education/counseling is the primary reason for the visit.
Use modifier U7 when a physician extender providers the service.
Education/counseling is an add-on to the office visit (e.g., provided as part of the regular office visit and dominating more than 50% of the clinician/patient visit, then time may be considered the key or controlling factor to qualify for a particular level of E/M service.
99201-99205 (new patient)
Asthma education, per session.
Asthma education may be reported outside of the office visit when an asthma action plan (AAP) has been written by the clinician and discussed with patient/family, documented in the medical record and a copy provided to the asthma educator.
Asthma education may be reported with S9441 by using the supervising clinicians NPI for one of the following:
Bill one unit for each class.
Birthing classes per session.
Clinics and outpatient hospitals whose prenatal education program is directed by an MHCP enrolled provider may report S9442, S9443 and H1003 with one of the following:
Bill one unit for each time the class meets.
Lactation classes per session.
Bill one unit for each time the class meets.
Enhanced prenatal services provided to at-risk pregnant women only. An at-risk determination is based on the results of a prenatal risk assessment (e.g., ACOGs Obstetric Medical history).
Bill one unit for the entire class: 3 wks of nutrition education = 1 unit.
Counseling to assess and minimize problems hindering normal nutrition, and to improve the patients nutritional status.
97802 initial individual
Bill 15 minute unit. MNT is reimbursed when a licensed dietician/nutritionist is under the supervision of a physician.
Reassessment due to change in diagnosis, medical condition or treatment regimen requiring a second referral in the same year.
Bill 15 minute unit. MNT is reimbursed when a licensed dietician/nutritionist is under the supervision of a physician.
Diabetic Outpatient Self-management Training services (DSMT) including education about self-monitoring blood glucose, diet, exercise, and sliding scale insulin treatment for the patient who is insulin dependent.
Bill 30 minute unit.
Initial training 10 hour limit/12 months
Additional training limited to 1 hour per year.
Refer to the Community Health Worker (CHW) section of the manual for the MHCP covered education services provided by a CHW.
Services provided as part of a day treatment program, partial hospitalization, or other similar health care programs may not be billed as physician services provided in an educational or counseling setting.
A physician order for educational or counseling services is required. Documentation of the recipient's participation, number of participants in the educational or counseling group, name and credentials of person who provided the service and topic content must be in the medical record or class record.
MHCP covers smoking cessation education, counseling and products when they are ordered by a primary care provider and provided by an MHCP enrolled provider or Physician Extender. Smoking cessation products must be approved by the Food and Drug Administration (FDA) and covered under the Medicaid Drug Rebate Agreement. Prescriptions for smoking cessation products are subject to quantity limits. Prescriptions may not be dispensed for quantities in excess of the FDA-approved dose for any smoking cessation product. See also the DHS QUITPLAN Services page.
For the purpose of this chapter: physicians, APRNs, PAs, and physician clinics.
Payment limitations for medical supplies provided by a physicians office are the same as for medical supplies. Refer to MHCP Equipment and Supplies policy. Routine supplies are not paid separately. Supplies applied or used in the physicians office or clinic in direct relationship to an illness or injury are generally considered incident to the service and are not separately billable to DHS.
Supplies sent home with the recipients are not covered by MHCP.
The following is a list of routine physician office supplies which cannot be billed separately. This is not an all-inclusive list:
Adhesive tape, all sizes
Alcohol or peroxide, per pint
Kerlix, Kling bandages
Betadine, Iodine, Providine swabs/wipes
Betadine, Phisohex, per pint
Patient electrode pads
Sanitary belt/napkins, tampons
Silver nitrate stick
Cotton tip application (sterile/non-sterile)
Sterile saline, 30cc
Sterile water, 30cc
Gauze pads, sterile or non-sterile
Gloves (latex, plastic, rubber, sterile, etc.)
Suture removal tray
Syringe (with/without needles)
Hemostatic cellulose (e.g., surgical, any size)
Thermometer (any size)
If no surgery or manipulation is done, bill the appropriate E/M code and HCPCS casting supply code.
If surgery or manipulation is done, bill the appropriate CPT surgery code and HCPCS casting supply code.
If recasting is done, bill the appropriate CPT casting code and HCPCS casting supply code.
MHCP covers vaccines, toxoids, and an administration fee.
MHCP covers only the administration fee for vaccines and toxoids provided free by the Minnesota Vaccines for Children (MnVFC), available through the Minnesota Department of Health (MDH). Most routine childhood vaccines and some adult vaccines are available through the MnVFC program. Refer to the Immunizations & Vaccinations section of the Provider Manual.
EKG interpretation services may be billed in addition to the E&M service. MHCP covers one physician interpretation for each EKG.
Antigen: The raw form of pollen, (venom, stinging insect, etc.) prior to refinement for administration to humans.
Allergenic Extract: The refined injectable form of antigen either commercially prepared or refined in the physician's office under his/her supervision.
Immunotherapy: The parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage which is maintained as maintenance therapy.
Allergy testing includes the performance, evaluation, and reading of cutaneous and mucous membrane testing.
The physician work of taking a history, performing the physical examination, deciding on the antigens to be used, interpretation of results, counseling and prescribing treatment should be reported using an Evaluation and Management code.
The following allergy testing procedures are considered investigative, and therefore are not covered:
The following allergy treatments are considered investigative and therefore are not covered:
Allergenic extracts may be administered with either one or multiple injections. Documentation in the medical record must support the number of injections administered.
Preparation of Raw Antigen to Allergenic Extract: Only physicians who perform the refinement of raw antigens to allergenic extract may bill for this service. This service involves:
Neither purchasing refined antigens, measuring dosages nor adding diluent is considered "refining raw antigens".
Adding Diluent: As in any other medication administration, it is not a separately covered service. This service is an integral part of the professional services for providing an allergenic extract.
Identifiable services not included in an office visit may be billed separately.
The global surgical package period: Surgery and the time following surgery during which routine care by the physician is considered postoperative and included in the surgical fee. Office visits or other routine care related to the original surgery cannot be separately reported if the care occurs during the global period. MHCP covers medically necessary surgical services. MHCP reimbursement for all surgeries is based on a global surgery package, which follows Medicare global surgery guidelines and includes pre, post, and intraoperative work related to the surgical procedure. MHCP follows Medicare guidelines for the number of days in the global package. Preoperative physicals by a primary physician are not included in the global package. Evaluation of the need for surgery by the surgeon is also covered outside of the global surgical package.
The visit identifying the need for surgery is not included in the global fee even if occurring on the preoperative day, or on the day of surgery. Use CPT modifier 57 to bill the E/M service for established patient visit or consultation the day before or the day of major surgery when the decision for surgery is made during the visit.
E/M services provided on the same day as the procedure are generally not payable unless they are significant, separately identifiable, and billed with modifier 25.
Complications requiring additional services from the surgeon that do not require a return trip to the operating room are included in the global payment. Surgical complications requiring a return to the operation room are not included in the global fee. Report complications requiring a return trip to the operating room with modifier 78 appended to the original procedure code.
If further specifics are required, refer to the Medicare global surgery guidelines.
MHCP follows Medicare's assistant-at-surgery guidelines. MHCP does not cover assistant-at-surgery services provided by surgical technicians, surgical assistants, RN first assists (RNFA), clinical nurse specialists, or certified nurse practitioners.
MD assistant surgeons or physician assistants are covered for assistant-at-surgery. MD assistant surgeons must bill using modifier 80 or 82, and physician assistants must use the modifier AS.
Use modifier 50 only when the exact same service/code is reported for each bilateral anatomical site.
For dates of service on and after October 1, 2011, MHCP:
Bill all procedures on the same claim.
Locum Tenens Physician: MHCP recognizes that physicians often retain a substitute physician to take over their professional practices while they are absent for reasons such as illness, vacations, continuing medical education and pregnancy. MHCP further recognizes locum tenens arrangements and pays the regular physician for the services provided by the substitute physician if:
MHCP covers locum tenens physician services using Medicare guidelines.
The regular physician must keep a record of each service provided by the locum tenens physician along with the substitute physicians UPIN.
Reciprocal Billing Arrangements: A recipient regular physician may submit a claim for a covered service which the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis if:
These requirements do not apply to the substitution arrangements among physicians in the same medical group where claims are submitted in the name of the group. On claims submitted by the group, the group physician who actually performed the services must be identified as the rendering physician.
MHCP covers substitute physician services using Medicare guidelines.
The regular physician must keep a record of each service provided by the substitute physician along with the substitute physicians UPIN.
Distant site: The site where the physician or practitioner, providing the professional service, is located at the time the service is provided via a telecommunications system.
Telemedicine: The use of telecommunications to furnish medical information and services. Telemedicine consultations must be made via two-way, interactive video or store-and-forward technology.
Two-way Interactive Video: A type of technology that permits a "real time" consultation to take place. This is used when a consultation involving the patient, the primary caregiver, and a specialist is medically necessary. Video-conferencing equipment at two different locations permits a live non-face-to-face consultation to take place.
"Store and Forward": The asynchronous transmission of medical information to be reviewed at a later time by a physician or practitioner at the distant site. Medical information may include, but not be limited to, video clips, still images, x-rays, MRIs, EKGs, laboratory results, audio clips and text. The physician at the distant site reviews the case without the patient being present. Store and forward substitutes for an interactive encounter with the patient present; the patient is not present in real-time.
Hub Site: A medical facility telemedicine site where the medical specialist is located.
Spoke Site: A remote site where the referring health professional and patient are located.
Consultation: A type of service provided by a physician whose opinion or advice is requested by another provider.
Asynchronous telecommunication systems in single media format does not include telephone calls, images transmitted via facsimile machines, and test messages without visualization of the recipients (electronic mail). Photographs must be specific to the recipients condition and adequate for rendering or confirming a diagnosis or treatment plan.
The "spoke," or referring provider, may be any enrolled MHCP provider including a physician, nurse practitioner, clinical nurse specialist, physician assistant, certified nurse midwife, podiatrist or mental health professional.
The "hub," or consulting provider, is limited to a specialty physician or an oral surgeon.
Telemedicine coverage applies to MHCP recipients in fee-for-service programs. Prepaid health plans may or may not choose to pay for services delivered in this manner.
Coverage for telemedicine includes payment for physician consultations that are performed via two-way interactive video, or via store and forward technology.
Two-way interactive video consultation may be billed when there is no physician in the ER and the nursing staff is caring for the patient at the "spoke" site. The ER physician at the "hub" site bills the ER CPT codes with the GT modifier. Nursing services at the "spoke" site would be included in the ER facility code.
If the ER physician requests the opinion or advice of a specialty physician at a "hub" site, the ER physician bills the ER CPT codes without the GT modifier. The consulting physician bills the consultation E/M code with the GT modifier.
Advanced Practice Registered Nurse (APRN): An individual licensed as a registered nurse by the Minnesota Board of Nursing and certified by a national nurse certification organization acceptable to the Minnesota Board of Nursing to practice as a clinical nurse specialist, nurse anesthetist, certified nurse-midwife, or nurse practitioner. The practice of advanced practice registered nursing also includes accepting referrals from, consulting with, cooperating with, or referring to all other types of health care providers, including but not limited to physicians, chiropractors, podiatrists, and dentists, provided that the advanced practice registered nurse and the other provider are practicing within their scopes of practice as defined in state law. The advanced practice registered nurse must practice within a health care system that provides for consultation, collaborative management, and referral as indicated by the health status of the patient.
Certified registered nurse anesthetist practice: The provision of anesthesia care and related services within the context of collaborative management, including selecting, obtaining, and administering drugs and therapeutic devices to facilitate diagnostic, therapeutic, and surgical procedures upon request, assignment, or referral by a patient's physician, dentist, or podiatrist.
Clinical nurse specialist practice (CNS): The provision of patient care in a particular specialty or subspecialty of advanced practice registered nursing within the context of collaborative management, and includes: (1) diagnosing illness and disease; (2) providing nonpharmacologic treatment, including psychotherapy; (3) promoting wellness; and (4) preventing illness and disease. The certified clinical nurse specialist is certified for advanced practice registered nursing in a specific field of clinical nurse specialist practice.
Nurse practitioner practice: Practice within the context of collaborative management: (1) diagnosing, directly managing, and preventing acute and chronic illness and disease; and (2) promoting wellness, including providing nonpharmacologic treatment. The certified nurse practitioner is certified for advanced registered nurse practice in a specific field of nurse practitioner practice.
Certified nurse-midwife practice: The management of women's primary health care, focusing on pregnancy, childbirth, the postpartum period, care of the newborn, and the family planning and gynecological needs of women and includes diagnosing and providing nonpharmacologic treatment within a system that provides for consultation, collaborative management, and referral as indicated by the health status of patients.
DHS enrolls all APRNs listed above. Registered nurse certified (RN, C) is not eligible to enroll.
An enrolled CRNA, CNS, or NP receives 90% of the physician rate. An enrolled certified nurse-midwife receives 100% of the physician rate.
Refer to Physician Extender policy for APRNs who choose not to enroll.
Services performed by APRNs are covered if the services are covered through MHCP and the services are within the scope of practice for an APRN as described in MS 148.171 through 148.285.
Bill for APRN services using HCPCS/CPT codes and follow MHCP requirements for covered physician and professional services.
Physician Assistant: A person registered pursuant to MS 147A who is qualified by academic or practical training or both to provide patient services as specified in MS 147A under the supervision of a supervising physician.
Enrolled PAs receive 90% of the physician rate and should not use the physician extender modifier when billing DHS. The services of those who choose not to enroll will be paid as physician extender services through the supervising physician at 65% of the physician rate and requires modifier U7 when billing MHCP.
Services performed by a PA are covered if otherwise, the services are a covered physician service, are within the scope of practice for a PA as described in MS 147A, and meet all required criteria by the appropriate certifying, regulatory, or licensing entities. MHCP enrolls PAs as treating providers not pay-to-providers.
MHCP allows off-site or remote supervision of PAs, provided the terms of the physician/physician assistant agreement are being met and the physician/physician assistant are, or can be, easily in contact with one another by radio, telephone, or other communication device.
Off-site or remote supervision does not apply to Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), which, under federal regulations, require that a physician is present for sufficient periods of time, at least once every two week period (except in extraordinary circumstances, which must be documented in the records of the clinic) to provide:
The physician must be available through direct telecommunication for consultation, assistance with medical emergencies, and patient referral.
Bill PA services using the appropriate CPT/HCPCS codes. Follow MHCP requirements for covered physician services.
Nurse practitioners and clinical nurse specialists are not covered for assisting-at-surgery.
MHCP covers health services provided by a physician extender under the supervision of the physician. Physician extender services are not covered unless they replace or substitute for the physician service.
Physician Extender: PA or APRN who chooses not to enroll with MHCP, genetic counselor, registered nurse, licensed acupuncturist or pharmacist who is in one of the following professional environments:
Registered Nurse (RN): A nurse licensed under and within the scope of Minnesota statutes.
Genetic Counselor or Geneticist: An individual who is board certified by the American Board of Genetic Counseling (ABGC).
The process of control and direction by which the physician accepts full professional responsibility for the supervisee, instructs the supervisee in their work, and oversees or directs the work of the supervisee. The process must meet the following conditions:
Physician services provided by a physician extender in an LTC facility must be provided under the direction of a physician who is an enrolled MHCP provider. This means the physician has authorized and is personally responsible for the physician services performed by the physician extender and has reviewed and signed the record of the service no more than five days after the service was performed.
Physician extenders may provide any service within their scope of practice and as delegated and directed by a physician.
As permitted by Minnesota rules, licensure, and facility policy, APRNs, or PAs who are not enrolled with MHCP and are not employees of the facility (but are working in collaboration with a physician) may provide the following physician services in an LTC facility:
A genetic counselor or geneticist may conduct a consultation to render an opinion and/or advice.
Do not use modifier U7 for a minimal service E/M code, as defined in CPT, as it represents a level of service supervised by a physician but does not necessarily require his/her immediate ongoing presence.
Use modifier U7 with all other E/M codes when the physician extender provides services, unless the physician is directly involved more than 50% of the time that is required to provide the health service.
Do not use modifier U7 for physician extender services associated with the enhanced prenatal care services for "at risk" pregnancies. Refer to the Family Planning and Obstetrics & Gynecology Services sections of MHCP Reproductive Health Obstetrics and Gynecology policy.
Services provided by personnel such as office and clerical workers, lab workers, assistants (e.g., surgical and ophthalmic) and aides are not considered physician extender services. These services are considered part of a physician's overhead and cannot be billed separately.
Outpatient Hospital Clinic: For clinic services provided in an outpatient hospital setting, physicians must bill the appropriate HCPCS/CPT code and use place of service 22. Failure to identify the place of service as outpatient hospital services may be considered fraudulent or abusive billing, subject to monetary recovery or program sanctions.
MHCP has designated specific HCPCS codes in which the individual code may be separated into professional and technical components. Providers billing and delivering professional services in outpatient hospitals will be paid for the professional component. The outpatient hospital will receive the technical component in the form of a "facility fee."
Provider-based clinics are hospital owned clinics authorized with provider based status according to federal regulations.
For this part of outpatient clinic services provided in a hospital owned clinic, bill professional services in the MNITS 837P claim format using the appropriate HCPCS/CPT code; use place of service 22. Failure to identify the place of service as outpatient hospital may be considered fraudulent or abusive billing, and is subject to monetary recovery or program sanctions.
For this part of outpatient clinic services performed in a hospital owned clinic, bill facility fees in the MNITS 837I claim format using the appropriate revenue and HCPCS/CPT coding.
Urgent Care in Emergency Department: Non-emergency care provided in an emergency department is urgent care and must be billed as urgent care services.
Emergency Department: Emergent care provided in an emergency department is emergency care and must be billed as emergency services. If, in a physician's professional opinion, emergency treatment for the patient's condition cannot be provided in the emergency department, the physician may seek inpatient admission certification for the patient and bill inpatient admission services. Refer to MHCP Inpatient Hospital Authorization policy.
Physicians, APRNs, and PAs under the supervision of the physician in accordance with the physician/physician assistant agreement and in accordance with the hospital by-laws, may provide inpatient hospital services.
Bill physician services provided in an inpatient hospital setting using the 837P:
MNITS Interactive (837P) Professional: Enter the dates of hospital admission and discharge in the Additional Dates field in the Claim Information tab. If the recipient has not been discharged, do not enter a Discharge Date in the Additional Dates field.
Providers must complete the Non-participating Facility Births Evidence-based Childbirth Program (DHS-6469) form for all elective inductions between January 1, 2012 and July 31, 2012, delivered in a hospital without a hard stop policy in place.
For births on or after August 1, 2012, providers doing elective inductions prior to 39 weeks gestation no longer have to submit the Non-participating Facility Births Evidence-based Childbirth Program form (DHS-6469).
Refer to Evidence-Based Childbirth Program Policy in the Hospital section for a full explanation of the evidence-based childbirth program policy.
Authorization is required for some MHCP covered services including all investigative procedures and procedures that may be considered cosmetic. Refer to the PA Indicator column on the MHCP Fee Schedule for procedures that always or sometimes require authorization.
Submit authorization requests to the Medical Review Agent. Authorizations are reviewed on a case-by-case basis.
The Medical Review Agent uses nationally recognized criteria to determine medical necessity. It is the responsibility of the provider requesting authorization to submit sufficient documentation to establish that coverage standards have been met. Certain situations may require a unique piece of information that will aid the medical review agent in the decision-making process. Since it is impossible to identify all of the diverse information necessary for each case, a request will be made for additional information as the situation requires.
Investigative Procedures: A health service that has progressed to limited human application and trial, lacks wide recognition as a proven and effective procedure in clinical medicine as determined by the National Blue Cross and Blue Shield Association Medical Advisory Committee, and used by Blue Cross and Blue Shield of Minnesota in the administration of their program using the following criteria:
If staged plastic and reconstructive surgery is being proposed for correction of a congenital anomaly, the complete plan for future surgeries must be submitted with the first authorization.
Review Authorization Criteria for use of Botulinum toxin, Type A or Type B.
MHCP only covers male circumcision when the procedure is medically necessary (in the opinion of the attending physician, a pathologic condition exists where circumcision is required), and it is approved by authorization. Refer to MHCP Authorization policy for prior authorization process.
Please refer to the MHCP Provider Manual Reproductive Health Hysterectomy section and to the MHCP Authorization policy for prior authorization process.
MHCP coverage for organ and tissue transplant procedures is limited to those procedures covered by the Medicare program or approved by the DHS consulting contractor.
Transplant coverage includes: preoperative evaluation, recipient and donor surgery, follow-up care for the recipient and live donor, and retrieval of organs, tissues. All transplant related services are billed under the recipients ID number. Refer to the Transplant Authorization Code (PDF) List.
Transplants provided to Medicare/Medicaid dually eligible recipients must be performed in a Medicare certified transplant facility.
All organ transplants must be performed at transplant centers meeting United Network for Organ Sharing Criteria (UNOS) or be Medicare Approved Heart, Lung, Heart-Lung, Liver, and Intestinal Transplant Centers.
Stem cell transplants must be performed in a tissue transplant center which is certified by and meets the Foundation for the Accreditation of Cellular Therapy (FACT) for stem cells or bone marrow transplants, or be approved by the Advisory Committee on Organ and Tissue Transplants.
All transplant procedures must comply with all applicable laws, rules, and regulations governing:
(1) coverage by the Medicare program,
(2) federal financial participation by the Medicaid program, and
(3) coverage by the MA program. All transplants performed out of state must have prior authorization.
It is the responsibility of the transplant center to submit their certification documentation to provider enrollment.
Transplant coverage applies to MA and MinnesotaCare recipients. MinnesotaCare recipients should be referred to their county human services agency for application to MA. If a recipient is not eligible for MA, any maximum benefit limits applicable to the MinnesotaCare recipient will apply. Refer to the MinnesotaCare section of the MHCP Health Care Programs and Services policy for further information.
Persons eligible for EMA are not eligible for organ transplant coverage, or care services related to the transplant procedure.
Authorization is required for the following transplant procedures: stem cell, heart-lung, lung, pancreas, pancreas-kidney, liver, intestine, intestine-liver, and autologous pancreatic islet cell transplant (after pancreatectomy).
Transplant prior authorization request must be submitted to Authorization Medical Review Agent by the physician rather than the transplant facility. The transplant facility may request documentation of the prior authorization approval from the physicians office or by calling the MHCP Provider Call Center at (651) 431-2700 or 1-800-366-5411.
The medical report must include the following information:
If a transplant is to be performed out-of-state, the provider must obtain authorization prior to the service being rendered. Refer to the instructions in the MHCP Authorization policy for out-of-state services. If the procedure will be performed in an out-of-state hospital the prior authorization request must include evidence that the hospital meets the requirements of Medicare, UNOS, and Foundation for the Accreditation of Cellular Therapy (FACT).
Heart transplants are covered when performed in a facility on the Medicare list of approved heart transplant centers.
Artificial heart transplants are not covered.
Heart-lung transplants for persons with primary pulmonary hypertension are covered when performed in a Minnesota facility that meets UNOS criteria to perform heart-lung transplants. Heart-lung transplants require authorization (except for those performed on recipients with Medicare coverage).
Lung transplants using cadaveric donors and lung lobe transplants from living donors are covered when performed in a Minnesota facility that meets UNOS criteria to perform lung transplants. All lung transplants require authorization (except for those performed on recipients with Medicare coverage).
Kidney transplants must be performed in a hospital that is a participating provider of the Medicare program. If performed in an out-of-state facility, kidney transplants require authorization prior to the service being rendered.
Pancreas transplants for uremic diabetic recipients of kidney transplants and persons with hypoglycemic unawareness, are covered when performed in a Minnesota facility which meets UNOS criteria to perform pancreas and pancreas-kidney transplants. All pancreas and pancreas-kidney transplants require authorization.
Liver transplants in children (under age 18 years) with extrahepatic biliary atresia, or other forms of end-stage liver disease are covered.
Liver transplants for children with a malignancy extending beyond the margins of the liver, or those with persistent viremia are not covered.
Liver transplants using live donors are covered.
Liver transplants are covered for adults with one of the following conditions:
In cases involving alcoholic cirrhosis:
Liver transplants require authorization, including those covered by other third- party payers. Transplants for recipients with Medicare coverage do not require authorization.
Intestine transplants for a patient with a diagnosis of short bowel syndrome, parenterally dependent and experiencing life-threatening or potentially life- threatening complications due to the original disease or to complications of total parenteral nutrition (TPN), are covered. Intestine transplants must be performed in a facility which meets UNOS criteria to perform this transplant. All intestine transplants require authorization.
Intestine-liver transplants are covered for persons who develop liver disease secondary to TPN treatment. Intestine transplants must be performed in a facility that meets UNOS criteria to perform this transplant. Intestine-liver transplants require authorization.
Stem Cell Transplantation: A procedure where stem cells are obtained from a donor's or recipient's bone marrow or peripheral blood, and prepared for intravenous infusion. DHS follows Medicare guidelines and is replacing references to bone marrow, and is replacing the terminology with stem cell transplantation.
Transplant centers must be participating providers of the Medicare program and meet Foundation for the Accreditation of Cellular Therapy (FACT) criteria for stem cell transplants, and be located in Minnesota or contiguous counties to receive payment for stem cell transplants.
All stem cell transplants require authorization.
Allogenic stem cell transplants are covered for the treatment of leukemia or aplastic anemia when it is reasonable and necessary for the individual patient to receive this therapy.
Autologous pancreatic islet cell transplant (after pancreatectomy) coverage is not to be confused with pancreatic islet cell allograft transplant (non-covered) for a recipient with a diagnosis of Type I diabetes.
Pancreatectomy is covered for a recipient with a diagnosis of chronic pancreatitis with intractable pain. With pancreatectomy, the pain is relieved, but without the autologous pancreas islet cell transplant, the result is insulin dependent diabetes mellitus. The autologous pancreatic islet cell transplant has the potential to prevent diabetes or make the diabetes mild. This procedure is covered when performed in a Minnesota facility that meets UNOS criteria. All autologous pancreatic islet cell transplants (after pancreatectomy) require authorization.
The cost of organ, tissue, and stem cell procurement should be included on the inpatient hospital claim. The hospital stay for the donor is included in the DRG payment for the donee (MHCP recipient). All charges for the donor should be billed using the donee's recipient ID number.
Liable third-party coverage, monies must be used to the fullest extent before MHCP payment will be made for a transplant. If payment is denied by a third-party payer, the denial and documentation of efforts to secure payment must be submitted with the claim. If appeals are available through the insurer, DHS will ask the recipient to pursue these appeals. Providers must obtain authorization, for transplants that require authorization even though private insurance may pay a portion of the charges.
Sleep studies include selected diagnostic and therapeutic services provided for sleep-related disorders. In-lab sleep studies/polysomnograms are covered by MHCP. Medical necessity must be documented in the recipients medical record.
In-lab sleep study/polysomnogram must be administered by a sleep specialist.
MHCP will cover sleep studies for recipients with the following conditions:
Sleep Testing must be:
Attended in-home (portable) studies will be covered only in cases where the patient is unable to undergo an in-lab study due to circumstances such as:
Split-night studies should be performed whenever possible.
MHCP will not cover unattended home sleep studies as they are considered investigative and not medically necessary.
Bill Sleep Testing services in the MNITS 837P claim format using the appropriate HCPCS/CPT code(s).
Medical Nutritional Therapy (MNT) is a preventive health service designed to assess and minimize the problems hindering normal nutrition, and to improve the patient's nutritional status. MNT services may be provided in a physician's office, clinic, or outpatient hospital setting. Medical necessity must be documented in the recipients medical record.
Licensed Dieticians and Licensed Nutritionists enrolled with MHCP may provide MNT & Diabetic Outpatient Self-Management (DSMT) services for MHCP fee-for-service (FFS) recipients when prescribed/referred by a physician.
The medical professionals who may prescribe/refer recipients for MNT & DSMT services include:
Providers should contact the managed care organization (MCO) provider services call center about coverage before providing services to MHCP recipients enrolled in an MCO.
MA and MinnesotaCare recipients.
MNT is a preventive health service and is not a covered service under the following programs:
MHCP covers physician visits, medical nutritional therapy, mental health services*, and laboratory work provided for weight management. Services must be billed by enrolled providers on a component basis with current CPT codes.
If an MHCP recipient elects to participate in a weight loss program, the recipient may be billed for components of the program that are not covered, as long as the recipient is informed of charges in advance.
Coverage standards for gastric restrictive surgery.
*Authorization may be required for mental health services. Refer to MHCP Mental Health Service policy for requirements.
MHCP reimburses Dietician or Nutritionist services listed only when prescribed by a physician and provided in an office or outpatient setting. MNT and DSMT are separate benefits and may not be billed for the same date of service. Payment for medical nutritional therapy is limited to the following codes:
Note: For medical nutrition therapy assessment/intervention performed by a physician see Evaluation and Management or Preventive Medicine service codes 99201 - 99499
Licensed Dieticians or Nutritionists in private practice
Use your NPI as the billing provider and the rendering provider.
Licensed Dieticians or Nutritionists who contract with a private agency to provider services
To directly receive payment: Use your NPI as the billing provider and the rendering provider.
If the private agency receives payment: It must be an enrolled MHCP Provider. Use the private agencys NPI as the billing provider, and the Dieticians or Nutritionists NPI as the rendering provider.
Licensed Dieticians or Nutritionists employed by hospitals, public health or community health clinic, clinic, or an individual physician
Use the hospital, public or community health clinic, clinic, or individual physicians NPI as the billing provider, and the Dieticians or Nutritionists NPI as the rendering provider.
If services are rendered somewhere other than the listed billing provider address or in the recipients home, include the Service Facility Locations name, address NPI #, or the qualifier 1D followed by their 9-digit MHCP ID.
Diabetic Self-Management Treatment (DSMT) Services: A preventative outpatient health service for persons diagnosed with diabetes. An outpatient diabetes self-management and training program includes education about self-monitoring of blood glucose, diet and exercise, an insulin treatment plan developed specifically for the patient who is insulin-dependent, and motivates patients to use the skills for successful self-management of diabetes. Diabetic outpatient self-management training services minimize the occurrence of disease and disability through instructions on maintaining health and well-being of the patient.
A provider of dually eligible MHCP recipients must be a "certified provider" according to Medicare's definition. Certified providers for Medicare's purposes must meet the National Diabetes Advisory Board Standards.
MA , and MinnesotaCare recipients.
DSMT is a preventive health service and is not a covered service under the following programs:
A physician must order all diabetic DSMT services. DSMT services include:
Use the appropriate DSMT codes below when billing. Do not bill nutritional counseling, office visit (E/M) codes, facility codes, or other procedure codes with DSMT codes.
Bill one unit per each 30 minutes of DSMT services, with a maximum of not more than 10 hours within a continuous 12-month period for each recipient. After the initial training, additional DSMT services are limited to one session (group or individual) no longer than two hours in length per year.
Nutritional Product: A commercially-formulated substance that provides nourishment, and affects the nutritive and metabolic processes of the body. Nutritional products are covered by MHCP.
A parenteral nutritional product must be dispensed as a pharmacy service as prescribed by a physician. Refer to MHCP Pharmacy Services policy.
An enteral nutritional product may be supplied by a pharmacy, home health agency, or medical supply provider with a written physician's order.
MHCP covers enteral nutritional products when the recipient's diagnosis can be linked to the need for a nutritional product. Refer to MHCP Equipment and Supplies policy, for additional information.
Podiatrists who practice as defined in MS 153 and physicians are eligible for payment for podiatry services.
Payment for debridement or reduction of non-pathological toenails, and of non-infected or non-eczematized corns or calluses is limited to the services defined in MN Rule 9505.0350 Subp 3. These services are considered routine foot care, unless the patient has a systemic condition which may require the expertise of a professional.
Although not intended as a comprehensive list, the following metabolic, neurologic, and peripheral vascular diseases most commonly represent the underlying conditions which may justify coverage for routine foot care:
The following list includes, but is not limited to, podiatry services which are not covered by MHCP:
The following coverage limitations apply to podiatry services:
Refer to the RSC-TCM section for Relocation Services Coordination and Targeted Case Management information.
MS 256B.0625, subd.3; subd.4 (general information)
Minnesota Rules 9505.0345; 9505.0355 (general information)
Minnesota Rules 9505.0330 (outpatient hospital)
MS 256B.0625, subd.25 (physician assistant standards)
Minnesota Rules 9505.5010 (prior authorization)
MS 256B.0625, subd. 28a
MS 147A.01 (physician assistant)
MS 256B.0625, subd.28 (nurse practitioner)
MS 256B.0625, subd.27; 256B.0629 (organ transplants)
MS 256B.0625, subd.4a (second medical opinion)
MS 256D.03, subd.7 (second medical opinion)
Minnesota Rules 9505.5035 (second medical opinion)
MS 256B.0625, subd.32 (nutritional products)
Minnesota Rules 9505.0325 (nutritional products)
MS 153 (podiatry licensing)
Minnesota Rules 9505.0350 (podiatry)
42 CFR 413.65 (provider-based clinics)
42 CFR 440.20 (outpatient hospital and rural health services)
42 CFR 440.166 (nurse practitioners services)
42 CFR 440.50 (services: general provisions)
42 CFR 440.130 (c) (preventive services definition)
MS 148.624 Subd 1 (Licensed Dietician)
MS 148.624 Subd. 2.(Licensed Nutritionist)