MaineCare General and Policy E-Message - December 23, 2015
Maine Department of Health & Human Services sent this bulletin at 12/23/2015 02:10 PM EST
MAINECARE CODE CHANGES
On December 31, 2015, certain codes covered by MaineCare Services will be discontinued and replaced by new codes, effective January 1, 2016. Below is a listing of code openings and closings, as well as additional instructions for the billing changes. The policy unit will conduct rulemaking in the upcoming months to add these changes to the MaineCare Benefits Manual. For additional information or assistance, please contact your Provider Relations Specialist.
SECTION 15, CHIROPRACTIC SERVICES
December 31, 2015: 72090 - Radiologic examination, scoliosis study is being discontinued, and will be replaced with codes: 72081- Radiologic examination, spine- entire thoracic and lumbar, including skull, cervical and sacral spine, 1 view, 72082 - Radiologic examination- 2 or 3 views, and 72083- Radiologic examination-4 or 5 views, and 72084- Radiologic examination-minimum of 6 views, effective January 1, 2016.
The new chiropractic codes and rates will be:
Billing Code Description Maximum Allowance
72081 X-ray of spine, 1 view $25.42, per session
72082 X-ray of spine, 2 or 3 views $40.72, per session
72083 X-ray of spine, 4 or 5 views $44.25, per session
72084 X-ray of spine, minimum of 6 views $52.67, per session
SECTION 19 HOME AND COMMUNITY BASED SERVICES FOR THE ELDERLY AND FOR ADULTS WITH DISABILITIES
December 31, 2015: G1054 TD (rev code 0559) - Skilled Nursing Visit (RN) and G0154 TE (rev code 0559) - Nursing Visit (LPN) are being discontinued and will be replaced as follows effective January 1, 2016:
G0299 (rev code 0551), Direct skilled nursing services of a Registered Nurse (RN) in the home health or hospice setting, each 15 minutes.
G0330 (rev code 0559) direct skilled nursing of a Licensed Practical Nurse (LPN) in the home health or hospice setting, each 15 minutes.
SECTION 25 DENTAL SERVICES
December 31, 2015: D2060, Extra-oral—each additional radiographic image is being discontinued and will be replaced by D0251, Extra-oral posterior dental radiographic image, effective January 1, 2016.
December 31, 2015, D9220, Deep sedation/general anesthesia – first 30 minutes, D9221, Deep sedation/general anesthesia – each additional 15 minutes, D9241, Intravenous moderate (conscious) sedation/analgesia – first 30 minutes, and D9242, Intravenous moderate (conscious) sedation/analgesia – each additional 15 minutes, are being discontinued and will be replaced by D9223, Deep sedation /general anesthesia – each 15 minute increment, and D9243, Intravenous moderate (conscious) sedation/analgesia – each 15 minute increment, effective January 1, 2016. The reimbursement rates for the two new codes are still under development and will be addressed in a separate provider notice.
SECTION 40 HOME HEALTH SERVICES
December 31, 2015: codes G1054 TD and G0154 TW are being discontinued and will be replaced as follows effective January 1, 2016:
G0299, Direct skilled nursing services of a Registered Nurse (RN) in the home health or hospice setting, each 15 minutes. Reimbursement rate of $28.32 per 15 minutes will remain the same.
G0300, direct skilled nursing of a Licensed Practical Nurse (LPN) in the home health or hospice setting, each 15 minutes. Reimbursement rate of $19.82 per 15 minutes will remain the same.
SECTION 43 HOSPICE SERVICES
Hospice Provider Billing Instructions Beginning January 1, 2016:
Routine Home Care Reimbursement
There will be two different per diem rates for Routine Home Care (RHC), dependent on the timing of the day of service within the patient’s episode of care. Days one (1) through sixty (60) will be paid at a higher RHC rate, while days sixty-one (61) and after will be paid at a lower RHC rate.
Hospice providers will be required to set their charge rate to appropriately reflect the transition to the lower RHC rate after sixty (60) days. The Department will conduct a prepayment audit to determine if providers have appropriately adjusted their RHC charge rates.
MaineCare will be utilizing the same method of counting the 60 days as Medicare; as such the 60 days are counted from the date of admission regardless of whether some days are covered or non-covered as RHC. If the member is discharged and readmitted to hospice services within 60 days of the discharge, the count of the hospice days will continue upon readmission. If the discharge lasts more than 60 days before a new election of hospice services, the RHC clock will reset.
Service Intensity Add-On Payments
Effective for hospice services with dates of service on and after January 1, 2016, hospice providers may bill MaineCare for end-of-life Service Intensity Add-On (SIA) payments for services provided by a Registered Nurse (RN) or clinical social worker (excluding services via the telephone) during the last seven (7) days of a member’s life. The SIA payment is only paid when the day of service is an RHC level of care day. In addition, the service must be at least fifteen (15) minutes and the provider may only bill up to four (4) hours total (for RN and social worker combined) per day.
Eligible SIA services must be billed as follows:
- A new 2016 HCPCS code, G0299, Direct skilled nursing services of a Registered Nurse (RN) in the home health or hospice setting, each 15 minutes has been created effective for use on January 1, 2016.* Services by an RN must be billed with the revenue code 0551.
- G0155, Services of clinical social worker in home health or hospice settings, each 15 minutes must be used for services delivered by a social worker. Clinical social worker services must be billed with a revenue code of 0561.
* HCPCS code G0154, Direct skilled nursing services of a licensed nurse (LPN or RN) in the home health or hospice setting, each 15 minutes, is being replaced by G0299, Direct skilled nursing services of a Registered Nurse (RN) in the home health or hospice setting, each 15 minutes and G0300, Direct skilled nursing of a Licensed Practical Nurse (LPN) in the home health or hospice setting, each 15 minutes effective January 1, 2016.
The two tiers of RHC reimbursement rates and the reimbursement of the SIA payments will be as follows:
Section 43 - Hospice Services Fee Schedule
Updated for the time period, January 1, 2016 - September 30, 2016
Procedure Code Description
T2042 Routine Home Care (per diem) 1-60 days
Androscoggin rate-$210.19
Cumberland rate-$230.95
Penobscot rate-$227.34
Sagadahoc rate-$230.95
York rate-$230.95
Rural rate-$230.95 * Rural Maine - All other counties
T2042 Routine Home Care (per diem) 61+ days
Androscoggin rate-$165.18
Cumberland rate-$181.49
Penobscot rate-$178.66
Sagadahoc rate-$181.49
York rate-$181.49
Rural rate-$163.23 * Rural Maine - All other counties
G0299 Service Intensity Add-On (Direct skilled nursing services of a Registered Nurse (RN) in the home health or hospice setting, each 15 minutes)
Androscoggin rate-$8.99
Cumberland rate-$9.88
Penobscot rate-$9.73
Sagadahoc rate-$9.88
York rate-$9.88
Rural rate-$8.89 * Rural Maine - All other counties
G0155 Service Intensity Add-On (Services of a clinical social worker in the home health or hospice setting, each 15 minutes)
Androscoggin rate-$8.99
Cumberland rate-$9.88
Penobscot rate-$9.73
Sagadahoc rate-$9.88
York rate-$9.88
Rural rate-$8.89 * Rural Maine - All other counties
SECTION 109 SPEECH AND HEARING SERVICES
Effective January 1, 2016, the Centers for Medicare & Medicaid Services is decreasing reimbursement rates for codes 92587 and 92588. As a result, Medicare Part B rates for 92587 (Agency Rate only) and 92588 (Agency and Independent Rates) will be lower than the rates listed in Chapter III, Section 109.
According to Chapter II, Section 109.10, the maximum amount of payment for services rendered is the lowest of the following:
- The provider's usual and customary charge,
- The amount listed in Chapter III, Section 109 of the MaineCare Benefits Manual,
- The lowest amount allowed by Medicare Part B, when applicable.
In accordance with Section 109.10, provider may expect to see the following reimbursement rates beginning January 1, 2016:
Billing Code Description
92587 Evoked otoacoustic emissions; limited (single stimulus level, either trasient or distortion product(s)
Agency Rate per session Independent Rate per session
$20.89 $19.37 (unchanged)
92588 Evoked otoacoustic emissions; comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)
Agency Rate per session Independent Rate per session
$32.01 $32.01