In order for Minnesota Health Care Programs (MHCP) to cover outpatient hospital services they must be provided in a facility qualified to participate in Medicare. Outpatient hospital services must be medically necessary and provided by or under the supervision of a physician, dentist or other provider having medical staff privileges in the facility.

Eligible Providers

An eligible provider for outpatient hospital services is a facility that meets the definition of, and is licensed as, a hospital or hospital clinic and is qualified to participate in Medicare. This includes hospitals that are part of the federal Indian Health Service (IHS), and are designated by the federal government to provide acute care.

Eligible Members

All MHCP members are eligible to receive outpatient hospital services.

Covered Services

Outpatient Hospital Clinic

An outpatient hospital clinic is a nonemergency service providing diagnostic, preventive, curative and rehabilitative services on a scheduled basis.

There may be medically indicated situations when it is not in the best interest of the member to be moved due to the member’s physical or mental disability. In these situations, the outpatient hospital facility may bill a specialty clinic facility fee for each distinctly different specialty clinic service that is brought to the member at one clinic site.

Observation Services

Outpatient observation services are covered when they are reasonable and necessary to treat or diagnose a member, and are independent of other procedures. Observation services are covered for up to 48 hours. MHCP will consider observation services for up to 72 hours for unusual circumstances observation billing when submitted with additional documentation. See the Observation Billing on how to submit a claim for unusual circumstances.

MHCP also covers direct admissions to observation status. A direct admission occurs when a physician in the community refers the member to the hospital for observation, bypassing the emergency department.

See the Noncovered Observation Services section for when outpatient observation services are not covered.

Hydration, Infusion, Drug Injections and Chemotherapy Administration

Service delivery does not drive coding selection. Report the one initial code with the highest level of service provided during that visit or day regardless of the time administered during the visit. After initial code selection, report all additional related services provided with add on, subsequent or concurrent codes. Refer to the following code information:

· Add on, subsequent and concurrent codes

· Concurrent infusions only reportable once per encounter

· Modifier 59: Reporting of modifier 59 is only appropriate when the member has return visit(s) on the same day or more than one IV site. (Multiple IV lines running into a single IV site do not qualify as multiple sites.) Documentation is required

· IV irrigation: not reportable if an injection, infusion or evaluation and management (E/M) is provided on the same day

Cardiac Rehabilitation

Cardiac rehabilitation is described by the U.S. Public Health Service as consisting of "comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk factor modification, education and counseling." Outpatient hospitals and physician-directed clinics with a Medicare-approved cardiac rehabilitation program may provide cardiac rehabilitation services to MHCP members.

A cardiac rehabilitation program is 36 sessions. Request authorization for additional sessions when more than 36 sessions will be provided.

MHCP follows Medicare criteria for cardiac rehabilitation services, which includes the following:

· Aftercare for myocardial infarction, coronary bypass surgery, stable angina, and other similar diagnoses

· Angioplasty

· Congestive heart failure

· Heart or heart-lung transplant

· Heart valve replacement

· Cardiac rehabilitation services include a recovery program primarily consisting of monitored exercise or exercise therapy with member instruction and diagnostic testing services

· All settings must have a physician immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program. MHCP follows the Centers for Medicare & Medicaid Services (CMS) for services furnished in the hospital or critical access hospital (CAH) or in an on-campus outpatient department of the hospital or CAH.

Prolonged Intravenous Therapy

Prolonged IV therapy begins when the IV needle is in place, continues through the administration, and ends when the insertion site care is complete. The following are billable in addition to the prolonged IV therapy:

· Blood

· Blood products

· Biologicals

· Chemotherapy agents

· Other drugs that require prolonged infusion

· Specialty catheters not routinely supplied

Blood Transfusions

A single transfusion code is submitted once per service regardless of the number of units of blood or blood product transfused. The code for the blood or blood product should be submitted on the same claim.

Pulse Oximetry

Pulse oximetry is considered part of the emergency department, ambulatory surgical center, or outpatient specialty clinic.

Pulse oximetry is part of the Ambulatory Payment Classification (APC) payment. Pulse oximetry can be separately billed only when an E/M visit is the only other service provided.

Mental Health Partial Hospitalization

Partial hospitalization is a time-limited, structured program provided in an outpatient hospital setting or a Medicare-certified community mental health center (CMHC). Partial hospitalization provides person- and family-centered treatment by a multidisciplinary team under the direction of a physician.

Refer to Mental Health Services - Partial Hospitalization Program for additional requirements and billing instructions.

Additional Services

Professional services (for example, anesthesiologist, and physician) are covered in addition to outpatient hospital services. Other services, such as lab, radiology, supplies, or injectable drugs, may also be separately covered services when outpatient hospital services are provided. Refer to the specific service sections of this manual for coverage and billing policy.

Noncovered Services

The following outpatient hospital services are not covered and are ineligible for payment:

· Services provided by an employee of the hospital, such as an intern or a resident

· Services lasting 24 hours or more, except for observation status

· Detoxification not medically necessary to treat an emergency

· Patient convenience items revenue code 990–999

· Facility fees, ancillary charges and other procedure or service charges related to outpatient hospital charges for noncovered services

· Hospital charges when related to outpatient hospital care for investigative services, plastic surgery or cosmetic surgery, which are not covered unless determined medically necessary through the medical review authorization process and services designated as noncovered in Minnesota Statutes or Rules. A physician may donate his or her services to perform a noncovered service, but MHCP does not cover facility fees, ancillary charges and other procedure or service charges related to performing the noncovered services

· Outpatient observation services provided in addition to a surgical procedure, unless the observation is monitoring or treatment beyond the community standard for the surgical procedure

· For the convenience of the member, member’s family or provider

· Outpatient claims for a person incarcerated in a state or local correctional facility. Submit the charges to the responsible city or county correctional authority following the responsible city or correctional facility’s billing policies and procedures

Billing

General Billing

Submit claims electronically using the MN–ITS 837I Outpatient Services. Use the UB-04 Data Specifications Manual for reference.

Evaluation and management (E/M) services are priced using a composite rate when there are eight or more hours of observation. Refer to CMS Medicare Learning Network (MLN) Matters MM8653 and MM9486.

Refer to the following general billing requirements:

· MHCP will deny an entire outpatient claim if one line of the claim is denied

· Bill outpatient hospital claims using type of bill 13X or 14X

· Bill outpatient authorized services on a separate claim from non-authorized services

· When more than one clinic visit (distinctly separate E/M service) is provided, bill with condition code G0 on the same or separate claims

· Urgent care facilities must follow Medicare guidelines for the facility charge

· Identify the place of service with either 19 (Off-Campus Outpatient Hospital) or 22 (On-Campus Outpatient Hospital)

Observation Billing

Observation requires a physician’s order and must be part of the member’s records.
MHCP uses Medicare criteria for billing observation status care. Follow these billing requirements:

· Bill the facility component of observation services on the 837I Outpatient Claim Format using the appropriate revenue code and procedure code

· Bill observation services separately from surgical services

· When observation services continue from one day to the next (over midnight), bill the beginning observation service date

· When observation services are provided on two consecutive days, interrupted by a discharge, bill two distinct line items, each reflecting the specific service dates

· If the member’s coverage changes from fee-for-service to MCO or MCO to fee-for-service, you must split bill the services you provide. Bill the appropriate payer for services provided under their coverage.

· When observation services are provided on two consecutive days but separate months, bill the beginning observation service date

· For observation, one hour equals one unit. Round fractions of time less than 30 minutes down. Round fractions of time greater than 30 minutes up

· Bill fetal monitoring using the appropriate revenue code and procedure code

· Bill the unusual observation service with modifier "22," and include an explanation of the unusual circumstances

Inpatient Services that Require Outpatient Billing

Use the outpatient billing instructions for the following two inpatient circumstances when the member’s MHCP eligibility changes during an inpatient stay and the member does not meet inpatient criteria:

· MHCP Eligibility Beginning After the Date of Inpatient Admission

· Refer to Inpatient Hospital Services section on MHCP Eligibility Begins After the Date of Inpatient Admission for the billing instruction.

· Inpatient Hospital Services When Inpatient Authorization is Denied

· Refer to the billing section of Inpatient Hospital Services when Inpatient Authorization is Denied

Copay Policies

Copays apply to some services provided to MA members. Copay guidelines are listed in the Billing the Member section, under Copays and Family Deductible.

The copay for a nonemergency visit to a hospital-based emergency department will be deducted from the outpatient hospital facility claim. MHCP will use the type of admission in conjunction with the revenue code to determine whether the visit was considered an emergency visit or a nonemergency visit. MHCP will consider a type of admission equal to “1” in conjunction with revenue code 45X to be an emergency.

Definitions

Refer to Definitions section of Hospital Services home page.

Legal References

Minnesota Statutes, 144.50 (Hospital, Licenses; Definitions)
Minnesota Statutes, 256B.0625, subdivision 4 (Outpatient and physician-directed clinic services)
Minnesota Statutes, 256B.32 (Facility Fee Payment)
Minnesota Statutes, 256.969 (Payment Rates)
Minnesota Statutes, 256.9695 (Appeal of Rates; Prohibited Practices for Hospitals; Transition Rates)

Code of Federal Regulations, title 42, section 410.27 (Therapeutic outpatient hospital or CAH services and supplies incident to a physician’s or nonphysician practitioner’s service: Conditions)
Code of Federal Regulations, title 42, section 410.49 (b)(3)(ii) (Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverage)
Code of Federal Regulations, title 42, section 440.20 (Outpatient hospital services and rural health clinic services)

Sec. 641.15 MN Statutes Subdivision 2 (Incarceration Medical Aid)

Report this page

Provider Manual