Physician and Professional Services
Physician Services
Physician: A person who is licensed to provide health services within the scope of his or her profession under Minnesota Statutes, 147. A physician means a licensed doctor of medicine or osteopathy for purposes of this manual section.
Enrollment Requirements
Physicians must enroll with Minnesota Department of Human Services (DHS) to receive payment. Physicians must receive an individual National Provider Identifier (NPI) even if they are a member of a group or clinic or are 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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Covered Physician Services
Services provided by a physician are not restricted to a specific place of service unless specified by a CPT or (HCPCS) code description. Physicians may provide services in the Minnesota Health Care Programs (MHCP) member’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 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 Minnesota Statutes.
Outpatient Physician-Administered Drugs
Bill drugs that are administered to a member as part of a clinic or other outpatient visit to MHCP using the appropriate HCPCS codes. Do not bill drugs administered during an outpatient visit through the pharmacy point of sale system. MHCP does not allow “brown-bagging” (member obtains prescription drug from a pharmacy and takes it to physician’s office to be administered) or “white-bagging” (provider obtains prescription drug from a pharmacy and member visits the physician’s office for administration).
Pharmacies, including mail order pharmacies, who are providing the drugs for a clinic visit, must bill the clinic and not MHCP for the drugs dispensed. MHCP will make an exception only if a member 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 member if the drugs are intended for use during a clinic or other outpatient visit.
For injections that involve multiple national drug codes (NDCs), bill the initial line item with the HCPC code, units and NDC with modifier KP (first drug of a multiple drug unit dose formulation). Bill the second, and any subsequent line items of the same HCPC code with modifier KQ (second or subsequent drug of a multiple drug unit dose formulation). If billing the same HCPC code on more than two lines, the KQ modifier and an additional modifier are needed on each subsequent line.
Outpatient Physician-Administered Drugs NDC Reporting
The federal Deficit Reduction Act of 2005 (DRA) requires states to collect rebates for covered outpatient drugs administered by physicians. To comply, states must gather utilization data including the 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. Add the UD modifier to drugs purchased through the 340B program. Refer to the HCPCS Codes Requiring NDC when submitting claims for reimbursement.
NDC Reporting of Outpatient Physician-Administered Compound Drug
Multiple service lines are necessary to report a compound drug. One NDC is allowed per line. Report the HCPC code as a separate line for each associated NDC.
The NDC quantity and dose form are reported in the Quantity and Unit or Basis for Measurement Code or on MN–ITS Interactive in the “Drug Pricing” field on the “Services” tab.
Reporting the Discarded Portion of Administered Drugs
When a provider must discard the remainder of a single-use vial or other single-use package after administering a dose or quantity of the drug or biological, report the amount of the unused and discarded drug on a separate claim line using the JW modifier. Providers are expected to use the package size that minimizes the amount of waste billed to MHCP. For example, if a member needs 50 mg of drug and the product comes in 50 mg and 100 mg vials, use the 50 mg vial.
The JW modifier is not permitted when the actual dose of the drug or biological administered is less than the billing unit. The JW modifier is not appropriate for drugs that are from multiple-dose vials or packages.
Authorization Requirements for Outpatient and Physician-Administered Drugs
Pharmacies and prescribing providers must submit all drug PA requests for outpatient prescription drugs and physician-administered drugs that require authorization to the MHCP prescription drug PA review agent, Prime Therapeutics. Refer to the Drug Authorizations manual page for additional information.
Evaluation and Management Services (E/M)
MHCP follows CPT guidelines for Evaluation and Management Services.
Concurrent Care
Concurrent care services: The provision of similar services (for example, hospital visits to the same member by more than one physician on the same day). If a consulting physician subsequently assumes the responsibility for a portion of member management, it is considered concurrent care.
MHCP pays concurrent care when the medical condition of the member requires the services of more than one physician. Generally, a member’s condition that requires physician input in more than one specialty area establishes medical necessity for concurrent care.
Noncovered Concurrent Care Services
MHCP will not pay for concurrent care when one of the following occur:
Consultations
MHCP follows CPT guidelines for office, outpatient and inpatient consultations.
Critical Care
MHCP follows CPT guidelines for reporting critical care. Services not included in critical care may be reported separately.
Observation Services
A report using hospital observation codes following CPT guidelines.
Up to 48 hours of observation services are allowed, and, in some circumstances, up to 72 hours.
Physician Services for Members in Inpatient Status
For procedures done while the member is considered in an inpatient status, use place of service code 21 (inpatient hospital).
Professional Services for Incarcerated Members
If a member is incarcerated in a state or local correctional facility, Medical Assistance (MA) will only cover professional services associated with inpatient hospital care. Professional services will not be covered if the member is not admitted to an inpatient hospital.
Incarcerated Member’s Eligibility
A person residing in a correctional facility in Minnesota is eligible only for inpatient hospital services under Medical Assistance.
Incarceration Professional Services Billing for Inpatient Stay
When Medicare does not cover Professional Services for an Incarcerated Member’s Inpatient Stay
If the incarcerated member has Medicare as the primary insurance, submit the professional charges to Medicare to obtain an explanation of benefits (EOB).
Refer to Inpatient Hospital Services for instructions on billing incarceration inpatient hospital services.
Physician Services in Long-Term Care (LTC) Facilities
Payment for physician and professional services in an LTC must be medically necessary. Refer to the Physician Extenders section of this manual section for use of physician extender services provided in LTC facilities. Refer to MHCP Long-Term Care policy for more information on covered services in LTC facilities.
Prolonged Physician Services
Prolonged services involving direct (face-to-face) member contact are covered. Use CPT guidelines to report prolonged services.
Physician Standby Services
Standby services are covered when another physician requests them and involve prolonged attendance without direct (face-to-face) member contact. Standby services are covered only in the case of a documented existing risk or distress.
Physician Case Management (Team Conferences)
A medical team conference conducted for the purpose of coordinating the activities of a member'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.
Medical Conference or Counseling (as part of E/M code)
Physician services related to counseling are covered as part of the evaluation and management (E/M) codes if the counseling is conducted face-to-face with the member, relative or guardian.
When counseling or coordination of care dominates (more than 50 percent) the encounter between the physician and the member or family, 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 or coordination.
Care Plan Oversight
Care plan oversight services are not covered by MHCP.
Preventive Medicine Services
Preventive Health Services: A health service provided to a member to avoid or minimize the occurrence or recurrence of illness, infection, disability or other health condition. Follow CPT guidelines for billing preventive health services.
MHCP covers Grade A and B preventive services that the United States Preventive Services Task Force recommends.
Noncovered Preventive Services
The following services are not covered as a preventive service:
Preventive Medicine Services or Counseling, and Risk Factor Reduction
Preventive health counseling to promote health and prevent illness or injury is a covered service. Bill for these services with the appropriate E/M code for preventive medicine, individual counseling and group counseling.
Education and Counseling
Eligible Providers
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 | HCPCS | Eligible providers | Billing directions |
Education or counseling is the primary reason for the visit: Services to healthy individuals for the purpose of promoting health and anticipatory guidance (for example, family planning, tobacco cessation, including Quitline services effective Jan. 1, 2024, infant safety, and so forth). | 99401–99409 99411–99412 | Use modifier U7 when a physician extender provides the service. | |
Education or counseling is the primary reason for the visit: services to people with symptoms, a diagnosis or an established illness (for example, prenatal, joint care, pain, HIV, asthma). Refer also to nutritional, diabetic and weight reduction guidelines. | 98960 98961–62 | Use modifier U7 when a physician extender provides the service. | |
Education or counseling is an add-on to the office visit (for example, if provided as part of the regular office visit and dominating more than 50% of the clinician and 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) 99211–99215 | ||
Asthma education, per session. Asthma education may be reported outside of the office visit when a clinician writes an asthma action plan (AAP) and discusses it with the patient or family, documents in the medical record and gives a copy to the asthma educator. | S9441 | Report asthma education with S9441 by using the supervising clinicians’ NPI for one of the following: | Bill one unit for each class. |
Birthing classes per session. | S9442 | 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. | S9443 | 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 (for example, ACOG’s Obstetric Medical history). | H1003 | Bill one unit for the entire class: 3 weeks of nutrition, education equals 1 unit. | |
Counseling to assess and minimize problems hindering normal nutrition, and to improve the patient’s nutritional status. | 97802 – initial individual 97803 – reassess individual 97804 – group | Bill 15-minute unit. Medical nutritional therapy (MNT) is reimbursed when a licensed dietician or 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. | G0270 – individual G0271 – group | Bill 15-minute unit. MNT is reimbursed when a licensed dietician or 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. | G0108 – individual G0109 – group | Bill 30-minute unit. Initial training 10-hour limit per 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.
Noncovered Education and Counseling Services
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.
Documentation
A physician order for educational or counseling services is required. Documentation of the member'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.
Education and Counseling Services Billing
Refer to the following billing guidelines:
Enhanced Asthma Care Services
The Minnesota Legislature has amended Minnesota Statutes, 256B.0625, to allow MHCP to cover enhanced asthma care services and related products in the homes of children with poorly controlled asthma.
A child is defined as having poorly controlled asthma when they have received emergency care services or hospitalization for the treatment of asthma within the past year and they have received a referral and standing orders from a qualified health care provider listed in Eligible Providers in this section. A referral must be written from the provider stating enhanced asthma care services are needed which gives the county the authority to provide these services.
A home assessment is required to determine if there are asthma triggering agents in the home, thus identifying what the child needs regarding education and supplies. A home assessment is not required for a provider to order supplies as long as there is documentation of medical necessity for product use kept in the member’s record.
A home assessment is defined as a home visit to identify asthma triggers in children’s homes and provide education on trigger-reducing agents. A child is limited to two home assessments for the year, except when a child moves to a new home, a new asthma trigger (including tobacco smoke) enters the home, or if the child’s primary provider identifies a new allergy for the child (including mold, pests, pets, or dust mites).
Eligible Asthma Services Providers
Asthma services must be referred and ordered by one of the following individual MHCP-enrolled providers:
After a written order has been given by an individual MHCP-enrolled provider, a home assessment can be completed. A home assessment must be provided by the following credentialed local public health workers:
Local public health workers are not enrolled with MHCP and cannot bill for the home assessment.
Eligible Members
All MHCP members under the age of 21 for MA and under the age of 19 for MinnesotaCare members.
Billing for Asthma Services
The following providers may bill for a home assessment:
To bill for asthma services:
No service authorization is required for the T1028 code when providing enhanced asthma care services.
Documentation
MHCP-enrolled providers are required to have a physician’s order and the order must be part of the member’s records.
Documentation in the member’s record must also include the name of the healthy homes specialist, lead risk assessor, or the registered environmental health specialist who completed the service.
Medical Supplies Provided by a Physician Office
Eligible Providers
The following are eligible providers: physicians, advanced practice registered nurses (APRNs), physician assistants (PAs) and physician clinics.
Payment Limitations
Payment limitations for medical supplies provided by a physician’s office are the same as for medical supplies from durable medical equipment providers. Refer to the Equipment and Supplies section of the MHCP Provider Manual. Routine supplies are not paid for separately. Supplies applied or used in the physician’s 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.
Noncovered Medical Supplies Services
Supplies sent home with the members are not covered by MHCP.
The following is a list of routine physician office supplies that cannot be billed separately. This is not an all-inclusive list:
Adhesive tape, all sizes | IVP dyes (Intravenous Pyelogram) |
Alcohol or peroxide, per pint | Kerlix, Kling bandages |
Alcohol wipes | Masks |
Autolet (for blood sample collection) | Microporous tape |
Band-Aids | Needles, sterile |
Betadine, Iodine, Providine swabs or wipes | Opsite (post-operative dressing) |
Betadine, Phisohex, per pint | Patient electrode pads |
Chux pads (bed pads) | Razor |
Cold packs | Sanitary belt, napkins, tampons |
Cotton balls | Silver nitrate stick |
Cotton tip application (sterile or nonsterile) | Specimen collection |
Culturette | Steri-strips |
Emesis basins | Sterile saline, 30cc |
Enema kits | Sterile water, 30cc |
Gauze pads, sterile or non-sterile | Suction tubing |
Gelfoam | Surgical drapes |
Gloves (latex, plastic, rubber, sterile, etc.) | Suture removal tray |
Gowns | Syringe (with or without needles) |
Hemostatic cellulose (for example, surgical any size) | Thermometer (any size) |
Casting Provided in a Physician Office
If no surgery or manipulation is done, bill the appropriate evaluation and management (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.
Immunizations and Vaccinations
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. Most routine childhood vaccines and some adult vaccines are available through the MnVFC program. Refer to the Immunizations & Vaccinations section of the MHCP Provider Manual.
EKG Interpretations
EKG interpretation services may be billed in addition to the E/M service. MHCP covers one physician interpretation for each EKG.
Allergy Immunotherapy–Allergy Testing
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 or 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.
Covered Allergy Immunotherapy Services
MHCP covers the following allergy immunotherapy or allergy testing services:
Evaluation and Management services are eligible for separate payment on the same day as allergen immunotherapy only when a significant, separately identifiable service is performed.
Noncovered Allergy Immunotherapy Services
Testing
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:
Treatment
The following allergy treatments are considered investigative and therefore are not covered:
Coverage Limitations
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.
Services with a gender or procedure code conflict
The KX modifier is required on professional claims (837P) to identify services that are gender specific (services that are considered female or male only). The KX modifier will allow gender-specific edits to be bypassed.
Institutional providers should report condition code 45 (Ambiguous Gender Category) to identify claims for inpatient or outpatient services that can be subjected to gender-specific editing. This condition code will allow gender-specific edits to be bypassed.
Surgical Services
Global Surgery Package
The global surgical package period consists of the 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 member 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.
Postoperative care includes the following:
Complications
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.
Refer to the Medicare global surgery guidelines if further specifics are required.
Assistant-at-Surgery
MHCP follows Medicare's assistant-at-surgery guidelines. MHCP does not cover assistant-at-surgery services provided by surgical technicians, surgical assistants or registered nurse first assists (RNFA).
MD assistant surgeons must bill using modifier 80 or 82. Physician assistants, clinical nurse specialists and Advance Practice Registered Nurses (APRN) must use the modifier AS.
Surgical Services Billing
Refer to the following billing guidelines for physician services:
Bilateral Procedures – Modifier 50
Use modifier 50 only when the exact same service or code is reported for each bilateral anatomical site, as follows:
Locum Tenens Physicians
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 the following are established:
Covered Locum Tenens Services
MHCP covers locum tenens physician services using Medicare guidelines. Locum tenens services provided by an APRN are covered. Current licensure is required.
Documentation
The regular physician must keep a record of each service provided by the locum tenens physician along with the substitute physician’s NPI.
Locum Tenens Billing
Refer to the following billing guidelines for locum tenens physicians:
Physician Services in Teaching Settings
MHCP follows Medicare guidelines for teaching physicians, interns and residents.
Substitute Physicians
A member’s regular physician may submit a claim for a covered service that 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.
Covered Services for Substitute Physicians
MHCP covers substitute physician services using Medicare guidelines.
Documentation
The regular physician must keep a record of each service provided by the substitute physician along with the substitute physician’s unique physician identification number (UPIN) found in the Centers for Medicare & Medicaid Services System of Records.
Substitute Physician Billing
Refer to the following billing guidelines for reciprocal billing:
Telehealth (formerly telemedicine)
The Minnesota Legislature revised DHS policy for telehealth services in 2021 to expand the services covered. Telehealth is defined as the delivery of health care services or consultations through the use of real time, two-way interactive audio and visual communications. The purpose of telehealth is to provide or support health care delivery and facilitate the assessment, diagnosis, consultation, treatment education, and care management of a member’s health care while the member is at an originating site and the licensed health care provider is at a distant site. The information provided in this manual section explains the specific requirements related to physician and professional services. Refer to the Telehealth Services section of the MHCP Provider Manual for an overview and requirements that apply to all telehealth services.
Eligible Telehealth Providers
Providers must self-attest that they meet all of the conditions of the MHCP telehealth policy by completing and submitting the Telehealth Provider Assurance Statement (DHS-6806) (PDF) to be eligible for reimbursement. The following provider types are eligible to provide telehealth services:
Eligible Members
Telemedicine coverage applies to MHCP members in fee-for-service programs.
Covered Telehealth Services
The CPT and HCPC codes that describe a telehealth service are generally the same codes that describe an encounter when the health care provider and member are at the same site. Examples of telehealth services include but are not limited to the following:
Noncovered Telehealth Services
Refer to the Telehealth Services section of the MHCP Provider Manual for noncovered telehealth services.
Billing Telehealth Services
Providers should have a Telehealth Provider Assurance Statement (DHS-6806) (PDF) on their provider file to bill claims for services provided via telehealth. Providers who submit professional claims for services via telehealth should use claim format 837P (professional), including the CPT or HCPCS code that describes the services rendered and the place of service 02 or new place of service 10 for services via telehealth. Include the 93 modifier when billing for services provided via audio only (telephone communication).
Place of service 02 (newly redefined): Telehealth provided other than the member’s home. It’s the location where health services and health-related services are provided or received through telecommunication technology. The member is not located in their home when receiving health services or health-related service through telecommunication technology.
Place of service 10 (new place of service): Telehealth provided in member’s home. The location where health services and health-related services are provided or received through telecommunication technology. Member is located in their home (which is a location other than a hospital or other facility where the member receives care in a private residence) when receiving health services or health-related services through telecommunication technology.
When reporting a service with place of service 02 or 10, you are certifying that you are rendering services to a member located in an eligible originating site via an interactive audio and visual telecommunications system.
New Telehealth Modifier and Use of Current Telehealth Modifiers
Modifier 93, Audio only: Synchronous telehealth service rendered via telephone or other real-time interactive audio-only telecommunications system. MHCP requires this modifier when audio-only telehealth is used.
All other telehealth modifiers: All the other telehealth modifiers (GT, GQ, GO, 95) can be used for informational purposes but will not be required. The telehealth place of service codes explain that the service is rendered through telehealth. No telehealth modifiers can be used without place of service 02 or 10 or the claim will deny.
MHCP does not pay an originating site facility fee. Services billed on an outpatient claim with the GQ modifier will pay zero.
General Diagnostic Tests
In addition to other requirements, refer to the following general telehealth information:
Telemonitoring (Remote Physiological Monitoring Services)
Telemonitoring services are the remote monitoring of data related to a member’s vital signs or biometric data by a monitoring device or equipment that transmits the data electronically to a provider for analysis. Telemonitoring is a tool that can assist the provider in managing a member’s complex health needs.
Eligible Members
MHCP covers telemonitoring services for MHCP members in fee-for-service programs.
Eligible Telemonitoring Providers
The assessment and monitoring of the health data transmitted by telemonitoring must be performed by the following licensed health care professionals:
Covered Telemonitoring Services
MHCP covers telemonitoring services for members in high-risk, medically complex patient populations. These members have medical conditions like congestive heart failure, chronic obstructive pulmonary disease (COPD) or diabetes.
MHCP covers telemonitoring services based on the following medical necessity criteria:
Noncovered Telemonitoring Services
Any service that does not meet medical necessity criteria will not be covered.
Billing Telemonitoring Services
Transitional Care Management Services
Transitional Care Management services are services provided to aid members transitioning from an inpatient care setting to the community setting who may need additional medical or psychosocial support. Transitional care management services allow for eligible providers to coordinate services and provide additional support for members needing to complete activities of daily living.
Eligible Transitional Care Management Providers
Eligible Members
MHCP members returning to the community from a stay at an acute care facility who may require additional support.
Covered Transitional Care Management Services
MHCP covers transitional care management services within 30 days of discharge to help members transition back to a community setting (home, domiciliary, nursing home, or assisted living) after an inpatient hospital stay.
The transitional care management period begins the date the member is discharged from one of the following inpatient stay facilities and continues for the next 29 days:
One face-to-face visit (or visit via telehealth) is required within 7-14 days of discharge by one of the eligible providers. During the visit, the provider must do the following:
Noncovered Transitional Care Management Services
Billing Transitional Care Management
Advanced Practice Registered Nurse Services
Advanced practice registered nurse (APRN): an individual licensed as an advanced practice 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, 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 APRN and the other provider are practicing within their scopes of practice as defined in state law.
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 member's physician, dentist or podiatrist.
Clinical nurse specialist practice (CNS): The provision of member 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 members.
Eligible Providers
DHS enrolls all APRNs listed previously in this manual section. A registered nurse certified (RN, C) is not eligible to enroll.
An enrolled CRNA, CNS or NP receives 90 percent of the physician rate. An enrolled certified nurse-midwife receives 100 percent of the physician rate.
Refer to Physician Extenders policy for APRNs who choose not to enroll.
Covered APRN Services
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.
Billing APRN Services
Bill for APRN services using HCPCS and CPT codes and follow MHCP requirements for covered physician and professional services. Also note the following:
Physician Assistants (PA)
Physician assistant: A person who is qualified by academic or practical training or both to provide patient services as specified in Minnesota Statutes, 147A under the supervision of a supervising physician.
Eligible PA Providers
Enrolled PAs receive 90 percent of the physician rate and should not use the physician extender modifier when billing MHCP. The services of those who choose not to enroll will be paid as physician extender services through the supervising physician at 65 percent of the physician rate and requires modifier U7 when billing MHCP.
Covered PA Services
Services performed by a PA are covered if the services are a covered physician service within the scope of practice for a PA as described in Minnesota Statutes, 147A, and meet all required criteria by the appropriate certifying, regulatory or licensing entities. MHCP enrolls PAs as treating providers not pay-to providers (providers who receive payment).
Supervision of PAs
MHCP allows off-site or remote supervision of PAs, provided the terms of the physician and physician assistant agreement are being met and the physician and 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 following:
The physician must be available through direct telecommunication for consultation, assistance with medical emergencies and patient referral.
Noncovered PA Services
Clinical nurse specialists are not covered for assisting at surgery.
Billing PA Services
Bill PA services using the appropriate CPT and HCPCS codes. Follow these MHCP requirements for covered physician services:
Physician Extenders
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: A person who is board certified by the American Board of Genetic Counseling (ABGC).
Supervision of Physician Extenders (Except PAs)
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:
Role of Physician Extenders in Long-Term Care (LTC) Facilities
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:
Genetic Counselor or Geneticist
Genetic counselors or geneticists are physician extenders and may conduct a consultation to render an opinion or advice. The following conditions apply:
Use of Modifiers
Do not use modifier U7 for a minimal service evaluation and management (E/M) code, as defined in CPT, because it represents a level of service supervised by a physician but does not necessarily require his or 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 percent 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 both the Family Planning and the Obstetric Services sections of the MHCP Provider Manual.
Billing Physician Extender Services
Include the following for these services:
Noncovered Physician Extender Services
Services provided by personnel such as office and clerical workers, lab workers, assistants (for example, 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 Services
Provider-Based Status for Clinics
Provider-based clinics are hospital-owned clinics authorized with provider-based status according to federal regulations.
Off-Campus Provider-Based Hospital Department Services
Bill for outpatient services furnished at an off-campus provider-based department using:
Off-campus provider-based hospital department services must identify nonexcepted service lines on their claims using modifier PN (Nonexcepted off-campus service). Refer to January 2017 Update of the Hospital Outpatient Prospective Payment System (PDF).
Billing Outpatient Hospital Services
Outpatient Hospital Clinic: For clinic services provided in an outpatient hospital setting, physicians must bill the appropriate HCPCS or 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 facility components. Providers billing and delivering professional services in outpatient hospitals will be paid for the professional component. The outpatient hospital will receive the facility component.
Professional component
For this part of outpatient clinic services provided in a hospital-owned clinic, bill professional services in the MN–ITS 837P claim format using the appropriate HCPCS or 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.
Facility Fee
For this part of outpatient clinic services performed in a hospital-owned clinic, bill facility fees in the MN–ITS 837I claim format using the appropriate revenue and HCPCS or CPT coding.
Urgent care in emergency department: Nonemergency care provided in an emergency department is urgent care and must be billed as urgent care services.
Emergency Department: Care that meets the definition of an emergency (Emergency Medical Assistance) 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.
Hospital Physician Services
Eligible Providers
Physicians, APRNs and PAs under the supervision of the physician under the physician and physician assistant agreement, and according to the hospital by-laws, may provide inpatient hospital services.
Billing Hospital Physician Services
Bill physician services provided in an inpatient hospital setting using the 837P: MN–ITS Interactive (837P) Professional. Enter the dates of hospital admission and discharge in Additional Dates in the Claim Information tab. If the member has not been discharged, do not enter a discharge date in the Additional Dates field.
Urgent Care Clinic Services
The following apply for urgent care clinic services:
Authorization Policy
Authorization is required for some MHCP-covered services including all investigative procedures and procedures that may be considered cosmetic. Refer to the prior authorization indicator (PA IND) 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 the diverse information necessary for each case, the medical review agent will request additional information as the situation requires.
Investigative procedures: is defined as 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 is screened using the following Blue Cross and Blue Shield of Minnesota criteria to move it from the investigative procedures category:
Implantable Neurostimulators
Cranial Nerve Neurostimulator
The surgery CPT code 64568 requires prior authorization for the insertion of a cranial nerve neurostimulator electrode and generator. Claims for the devices will not pay unless there is an approved prior authorization for the surgical procedure.
Devices:
Hypoglossal Nerve Stimulation
MHCP covers hypoglossal nerve stimulation with approved prior authorization for adults and children ages 13-18 years diagnosed with down syndrome who have obstructive sleep apnea. MHCP follows Medicare coverage policy guidelines and indications for adults with obstructive sleep apnea.
Providers must follow the FDA guideline indications for using the FDA-approved hypoglossal nerve stimulation device “Inspire” in children diagnosed with down syndrome:
Plastic and Reconstructive Surgery
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.
Botulinum Toxin
Review Authorization Criteria for use of Botulinum toxin, Type A or Type B.
Male Circumcision
MHCP covers male circumcision only 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.
Hysterectomy
Refer to the Reproductive Health Hysterectomy section and to the MHCP Authorization policy for prior authorization process.
Transplant Services
Eligible Transplant Services Providers
All organ transplants provided to Medicaid members must be performed in a Medicare-certified transplant facility.
All transplant procedures must comply with all applicable laws, rules and regulations governing all three of the following:
It is the responsibility of the transplant center to submit their certification documentation to Provider Eligibility and Compliance.
Eligible Members
Transplant coverage applies to MA and MinnesotaCare members. Refer MinnesotaCare members to their county human services agency to apply for MA. If a member is not eligible for MA, any maximum benefit limits applicable to the MinnesotaCare member will apply. Refer to the MinnesotaCare section of the MHCP Health Care Programs and Services policy for further information.
Individuals enrolled in Emergency Medical Assistance (EMA) are eligible for kidney transplants when the transplant is approved through an EMA Care Plan Certification. EMA does not cover any other organ transplants.
Covered Transplant Services
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.
MHCP policy includes the following transplant types:
Transplant coverage includes:
All transplant-related services are billed under the member’s ID number. Refer to the Transplant Authorization Code list.
Transplant Authorization
Authorization is required for the following transplant procedures:
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 physician’s office or by calling the MHCP Provider Resource Center at 651-431-2700 or 800-366-5411.
The medical report must include the following information:
Obtain authorization before rendering the service for a transplant that is to be performed out of state. 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 the Foundation for the Accreditation of Cellular Therapy (FACT).
Heart Transplant
Heart transplants are covered when performed in a facility on the Medicare list of approved heart transplant centers.
Heart-Lung Transplant Coverage
Heart-lung transplants for people with primary pulmonary hypertension are covered when performed in a Medicare-certified transplant facility. Heart-lung transplants require authorization (except for those performed on members with Medicare coverage).
Lung Transplant Coverage
Lung transplants using cadaveric donors and lung lobe transplants from living donors are covered when performed in a Medicare-certified transplant facility. All lung transplants require authorization (except for those performed on members with Medicare coverage).
Kidney Transplant 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 before the service is rendered.
Pancreas and Pancreas-Kidney Transplant Coverage
Pancreas transplants for uremic diabetic members of kidney transplants and people with hypoglycemic unawareness, are covered when performed in a Medicare-certified transplant facility. All pancreas and pancreas-kidney transplants require authorization.
Liver Transplant Coverage
Liver transplants in children (under age 18) 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, the following conditions apply:
Liver transplants require authorization, including those covered by other third-party payers. Transplants for members with Medicare coverage do not require authorization.
Intestine Transplant Coverage
Intestine transplants for a member 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 Medicare-certified transplant facility. All intestine transplants require authorization.
Intestine-liver Transplant Coverage
Intestine-liver transplants are covered for people who develop liver disease secondary to TPN treatment. Intestine transplants must be performed in a Medicare-certified transplant facility. Intestine-liver transplants require authorization.
Stem Cell Transplant Coverage
Stem cell or bone marrow transplant centers must meet the standards established by the Foundation for the Accreditation of Hematopoietic Cell Therapy.
Transplant centers must be participating providers of the Medicare program, meet Foundation for the Accreditation of Cellular Therapy (FACT) criteria for stem cell transplants, and be located in Minnesota or out-of-state counties that border Minnesota to receive payment for stem cell transplants.
All stem cell transplants require authorization.
Stem cell transplantation: A procedure where stem cells are obtained from a donor's or member’s bone marrow or peripheral blood and prepared for intravenous infusion. DHS follows Medicare guidelines and is replacing references to bone marrow transplantation with stem cell transplantation.
Allogenic stem cell transplants are covered for the treatment of leukemia, aplastic anemia, or myelodysplastic syndromes when it is reasonable and necessary for the individual member to receive this therapy.
Allogenic Hematopoietic Stem Cell Transplantation for myelodysplastic syndromes is considered medically necessary for members who have prognostic risk scores of:
Autologous Pancreatic Islet Cell Transplant (after pancreatectomy) Coverage
Autologous pancreatic islet cell transplant (after pancreatectomy) coverage is not to be confused with pancreatic islet cell allograft transplant (noncovered) for a member with a diagnosis of Type I diabetes.
Pancreatectomy is covered for a member 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 the United Network for Organ Sharing (UNOS) criteria. All autologous pancreatic islet cell transplants (after pancreatectomy) require authorization.
Billing Transplants
Include the cost of organ, tissue and stem cell procurement on the inpatient hospital claim. The hospital stay for the donor is included in the DRG payment for the donee (MHCP member). Bill all charges for the donor using the donee's member ID number.
Other Payers for Transplant Services
Liable third-party coverage must be used to the fullest extent before MHCP payment will be made for a transplant. If a third-party payer denies payment, 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 member 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 Testing
Sleep studies include selected diagnostic and therapeutic services provided for sleep-related disorders. In-lab sleep studies or polysomnograms are covered by MHCP. Document medical necessity in the member’s medical record.
Eligible Sleep Testing Providers
A sleep specialist must administer an in-lab sleep study or polysomnogram.
Eligible Members
MHCP will cover sleep studies for members with the following conditions:
Sleep Testing Covered Services
In-lab sleep testing considered medically necessary must be:
Attended in-home (portable) sleep studies will be covered only in cases where the member is unable to undergo an in-lab study due to circumstances such as:
Unattended home sleep studies are covered under the following special circumstances for adults 18 years and older:
All home sleep studies must be under the supervision of the accredited hospital-based sleep lab or sleep clinic that is a direct extension of the physician’s office or an independent diagnostic testing facility.
Types of monitors considered medically necessary for members suggestive of OSA when performing a home sleep study as part of a comprehensive sleep evaluation:
Providers must provide adequate and proper education to members for unattended home sleep tests. The education must be documented in the medical record.
Sleep studies using devices that do not provide a measurement of apnea-hypopnea index (AHI) and oxygen saturation are considered not medically necessary because they do not provide sufficient information to prescribe treatment.
Sleep Testing Noncovered Services
Unattended home sleep tests are not covered for the diagnosis of OSA in members with significant comorbid medical conditions or comorbid sleep disorders that may degrade the accuracy of the test. This includes, but is not limited to, moderate to severe pulmonary disease, neuromuscular disease or congestive heart failure.
Sleep testing is not covered as a general screening for members who are asymptomatic and is considered not medically necessary.
Unattended sleep studies are not covered when the member has a negative or inconclusive home sleep apnea test. If the member continues to have clinical symptoms of OSA, the member should have an attended in-laboratory polysomnography.
Repeat home sleep testing is considered not medically necessary.
Billing Sleep Testing Services
Bill sleep testing services in the MN–ITS 837P claim format using the appropriate HCPCS and CPT codes.
Medical Nutritional Therapy (MNT)
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 member’s medical record.
Licensed dieticians and licensed nutritionists enrolled with MHCP may provide MNT and Diabetic Outpatient Self-Management (DSMT) services for MHCP fee-for-service (FFS) members when prescribed or referred by a physician.
The medical professionals who may prescribe or refer members for MNT and DSMT services include:
Providers should contact the managed care organization (MCO) provider services call center about coverage before providing services to MHCP members enrolled in an MCO.
Eligible Providers
Eligible Members
MA and MinnesotaCare members are eligible for MNT.
MNT is a preventive health service and is not a covered service under the following programs:
Covered Medical Nutritional Therapy Services
Covered services include the following:
Billing Medical Nutritional Therapy
MHCP reimburses dietician or nutritionist services 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:
Billing information for Medical Nutritional Therapy (MNT) providers
MHCP Enrolled Providers | Billing |
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 agency’s NPI as the billing provider, and the dietician’s or nutritionist’s 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 physician’s NPI as the billing provider, and the dietician’s or nutritionist’s NPI as the rendering provider. |
If services are rendered somewhere other than the listed billing provider address or in the member’s home, include the service facility location and NPI number.
Weight Loss Services
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 member elects to participate in a weight loss program, the member may be billed for components of the program that are not covered, as long as the member is informed of charges in advance.
*Authorization may be required for mental health services. Refer to MHCP Mental Health Services policy for requirements.
MHCP does not cover the following weight loss services:
National Diabetes Prevention Program (DPP)
The National Diabetes Prevention Program (DPP) is an evidence-based lifestyle change program designed by the Centers for Disease Control and Prevention (CDC). The National DPP is a year-long program intended for adults at high risk for developing type 2 diabetes, the National DPP includes lifestyle health coaching through weekly classes that teach skills needed to lose weight, become more physically active and manage stress.
The program must include an initial six-month phase during which a minimum of 16 sessions are offered over a period lasting at least 16 weeks and not more than 26 weeks. Each session must be at least one hour long.
The second six-month phase must consist of at least one session each month. Each session must be at least one hour long. Additional sessions may be delivered if participants require additional support.
The National DPP may be provided in a clinic, outpatient hospital or community setting. The covered code was effective January 1, 2016.
Organizations can use the curriculum available on the CDC website. If your organization chooses to use a different curriculum, send the curriculum to the CDC Diabetes Prevention Recognitions Program (DPRP) to be evaluated to ensure that it is consistent with the current evidence base.
Eligible Providers
An organization must have full or pending CDC recognition as a DPRP to provide the National DPP to MHCP members. The CDC determines eligibility.
CDC-recognized organizations are responsible for training coaches to the 2012 National DPP curriculum or the Prevent T2 curriculum. DPP coaches may have credentials (for example, registered dietician or registered nurse), but credentials are not required. Coaches do not need to enroll with MHCP.
Eligible Members
Members must meet all the following requirements:
Billing DPP
Diabetic Self-Management Training (DSMT) Services
DSMT is a preventative outpatient health service for people diagnosed with diabetes. An outpatient diabetes self-management and training program includes education about self-monitoring of blood glucose, diet and exercise, and an insulin treatment plan developed specifically for the member who is insulin dependent. The goal of the program is to motivate members 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 member.
Eligible Providers
The following are eligible to provide diabetic self-management services:
A provider of services for dually eligible MHCP members must be a "certified provider" according to Medicare's definition. Certified providers for Medicare's purposes must meet the National Diabetes Advisory Board Standards.
Eligible Members
MA and MinnesotaCare members are eligible for diabetic self-management services.
DSMT is a preventive health service and is not a covered service under the following programs:
Covered DSMT Services
A physician or non-physician practitioner must order all diabetic DSMT services. DSMT services include the following:
Billing DSMT
Do not bill nutritional counseling, office visit E/M codes, facility codes or other procedure codes with DSMT codes. Use one of the following DSMT codes when billing, as appropriate:
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 member. 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 Products
Nutritional products are commercially formulated substances that provide nourishment and affect the nutritive and metabolic processes of the body. Nutritional products are covered by MHCP.
Eligible Providers
A parenteral nutritional product must be dispensed as a pharmacy service as prescribed by a physician. Refer to Pharmacy Services section of the MHCP Provider Manual.
An enteral nutritional product may be supplied by a pharmacy, home health agency or medical supply provider with a written physician's order.
Covered Nutritional Products
MHCP covers enteral nutritional products when the member’s diagnosis can be linked to the need for a nutritional product. Refer to Equipment and Supplies section of the MHCP Provider Manual for additional information.
Podiatry
Eligible Providers
Podiatrists who practice as defined in Minnesota Statutes, 153 and physicians are eligible for payment for podiatry services.
Covered Podiatry Services
The following are covered services for podiatry:
Payment Limitations for Debridement or Reduction of Nails, Corns and Calluses
Payment for debridement or reduction of nonpathological toenails and of noninfected or noneczematized corns or calluses is limited to the services defined in Minnesota Rules, 9505.0350, subpart 3. These services are considered routine foot care, unless the member has a systemic condition that 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 that may justify coverage for routine foot care:
Noncovered Podiatry Services
The following list includes, but is not limited to, podiatry services that are not covered by MHCP:
Coverage Limitations
The following coverage limitations apply to podiatry services:
Billing Podiatry Services
For more information about billing for podiatry services, refer to the following:
Refer to the Relocation Service Coordination-Targeted Case Management (RSC-TCM) section of the MHCP Provider Manual for Relocation Services Coordination and Targeted Case Management information.
Legal References
Minnesota Rules, 9505.0325 (Nutritional Products)
Minnesota Rules, 9505.0330 (Outpatient Hospital Services)
Minnesota Rules, 9505.0345; (Physician Services)
Minnesota Rules, 9505.0355 (Preventative Health Services)
Minnesota Rules, 9505.0350 (Podiatry Services)
Minnesota Rules, 9505.5010 (Prior Authorization Requirement)
Minnesota Rules, 9505.5035 (Surgical Procedures Requiring Second Medical Opinion)
Minnesota Statutes, 147A.01 (Definitions: Physician Assistant)
Minnesota Statutes, 148.624, subdivision 1 (Licensed Dietician)
Minnesota Statutes, 148.624, subdivision 2 (Licensed Nutritionist)
Minnesota Statutes, 153 (Podiatry)
Minnesota Statutes, 256B.0625, subdivisions 3 and 4 (Physicians’ services) (Outpatient and physician-directed clinic services)
Minnesota Statutes, 256B.0625, subdivision 3h (Telemonitoring services)
Minnesota Statutes, 256B.0625, subdivision 4a (Second medical opinion for surgery)
Minnesota Statutes, 256B.0625, subdivision 25 (Prior authorization required: physician assistant standards)
Minnesota Statutes, 256B.0625, subdivision 27 (Organ and tissue transplants)
Minnesota Statutes, 256B.0625, subdivision 28 (Certified nurse practitioner services)
Minnesota Statutes, 256B.0625, subdivision 28a (Licensed physician assistant services)
Minnesota Statutes, 256B.0625, subdivision 32 (Nutritional products)
Minnesota Statutes, 256B.0625, subdivision 3b (Telehealth services)
Minnesota Statutes, section 256B.0625 HF 1793 as introduced - 92nd Legislature (2021 - 2022) (mn.gov) (Enhanced Asthma Care Services)
Code of Federal Regulations, title 42, section 413.65 (Public Health: provider-based clinics)
Code of Federal Regulations, title 42, section 440.130(c) (Public Health: preventive services definition
Code of Federal Regulations, title 42, section 440.166 (Public Health: nurse practitioners services)
Code of Federal Regulations, title 42, section 440.20 (Public Health: outpatient hospital and rural health services)
Code of Federal Regulations, title 42, section 440.50 (Public Health: physicians’ services and medical and surgical services of a dentist)
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