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Florida MedicaidFee Schedule OverviewBureau of Medicaid PolicyAgency for Health Care AdministrationMarch 20, 20182:00 – 3:00 pm
Disclaimer The information provided in this presentation is only intendedto be general summary information to the public. It is notintended to take the place of existing policy, rule, state, orfederal regulation.2
Fee Schedule Training Overview SummaryBasics2018 UpdatesClaims SubmissionUseCovered Services and Billing CodesRate Setting and Updates– Timeline– Process National Correct Coding InitiativePlease note: slides from this presentation will be posted in the Additional ReferenceInformation section of the Agency’s Primary and Preventive Care Policy Web site:http://ahca.myflorida.com/Medicaid/Policy and Quality/Policy/behavioral health coverage/primary care policy/index.shtml3
Fee Schedule Summary
Summary States establish and administer their own Medicaidprograms and determine the type, amount, duration, andscope of services within broad federal guidelines. Federal law requires states to provide certain“mandatory” benefits and allows states the choice ofcovering other “optional” benefits. Florida Medicaid covers services as listed in Section409.905 and 409.906, Florida Statutes (F.S.).5
Summary Rule 59G-4.002 Florida Administrative Code (F.A.C.): ProviderReimbursement Schedules and Billing Codes– This rule applies to providers rendering Florida Medicaidservices to recipients in the fee-for-service delivery system.6
Summary Florida Medicaid fee schedules are available on the Agency’sWeb site.– These can be located at:http://ahca.myflorida.com/medicaid/review/fee schedules.shtml. The fees listed are only applicable in the fee-for-servicedelivery system.7
Summary Codes that appear on fee schedules include– Current Procedural Terminology (CPT)– Common Dental Terminology (CDT)– Healthcare Common Procedure Coding System (HCPCS)– Revenue Codes8
Fee Schedule Basics
Fee Schedules Fee schedules must be used in conjunction with:– Federal Regulation– Florida Statutes– Agency rules– Agency policies10
Fee Schedules: Fee-For-Service Provider fee schedules are a comprehensive list of codespublished by Florida Medicaid to inform providers of thereimbursement rate in the fee-for-service delivery system forspecific services performed. Billing code lists inform the providers of the billing codes thatFlorida Medicaid accepts for specific covered services.11
Fee Schedules: Statewide MedicaidManaged Care Statewide Medical Managed Care (SMMC, health plans) planshave the flexibility to:– Provide reimbursement for alternate codes and additionalservices.– Negotiate mutually agreed upon reimbursement rates with itsnetwork of contracted providers. Negotiated rates can be different than those listed on the feeschedule.– In no instance may the health plan impose limitations orexclusions more stringent than those specified in the contract.– Health plans may exceed specific coverage criteria included inthe coverage policies and fee schedules and any specificcoverage exclusions that are specified in the contract.12
Fee Schedules Updated Fee Schedules– Fee schedules are updated annually.– Services and rates are reimbursed through the fee-for-servicedelivery system. Promulgated Fee Schedules– Florida Medicaid updated fee schedules are promulgated intoAdministrative Rule.– The Managed Care Plan shall comply with all currentpromulgated Florida Medicaid Coverage and Limitationshandbooks (Handbooks) and Florida Medicaid Coverage Policiesas noticed in the Florida Administrative Register (FAR), andincorporated by reference in rules relating to the provision ofservices, except where the provision of the Contract alter therequirements set forth in the Handbooks and Medicaid feeschedules.13
Fee Schedules Providers must use fee schedules in conjunction withcoverage policies to view:– Reimbursement rates– Prior authorization requirements (indicated for certainservices)– Special modifiers– Facility fees– Professional component fees– Technical component fees14
The 2018 UpdatesAll Fee Schedules Annual fee-for-service fee schedule, billing code, and rate updates for calendaryear 2018Practitioner Fee Schedule Streamlined implementation of Medicare’s facility fee The Incident to Services policy is now titled the Advanced Registered NursePractitioner (ARNP) and Physician Assistant (PA) Reimbursement Rates policy.The policy has been revised and is posted on the 2018 Practitioner Fee Schedule.Laboratory Fee Schedules Separation of the Physician and Outpatient Laboratory Fee Schedule.– Outpatient laboratory services are now reimbursed using the Enhanced AmbulatoryPatient Grouping (EAPG) methodology.– The “Physician and Outpatient Laboratory Fee Schedule” will be renamed into the“Practitioner Laboratory Fee Schedule” and the “Outpatient Laboratory Fee Schedule”.15
The 2018 Updates, continued Laboratory Fee Schedules– In compliance with Section 1903(i)(7) of theSocial Security Act, State Medicaid programs mustreimburse for clinical diagnostic laboratoryservices at a rate that does not exceed the currentMedicare rate.– Reduction of the fee-for-service reimbursementrate for the laboratory codes listed on the nextslide, in compliance with Section 1903(i)(7) of theSocial Security Act.16
The 2018 Updates, continuedCPT CodeDescription80047METABOLIC PANEL IONIZED81294MLH1 GENE DUP/DELETE VARIANT81295MSH2 GENE FULL SEQ81297MSH2 GENE DUP/DELETE VARIANT81298MSH6 GENE FULL SEQ81433HRDTRY BRST CA-RLATD DSORDRS81434HEREDITARY RETINAL DISORDERS81437HEREDTRY NURONDCRN TUM DSRDR81438HEREDTRY NURONDCRN TUM DSRDR81442NOONAN SPECTRUM DISORDERS81535ONCOLOGY GYNECOLOGIC86356MONONUCLEAR CELL ANTIGEN86850RBC ANTIBODY SCREEN87536HIV-1 QUANT&REVRSE TRNSCRPJ87625HPV TYPES 16 & 18 ONLY87900PHENOTYPE INFECT AGENT DRUG87901PHENOTYPE INFECT AGENT DRUG87903PHENOTYPE INFECT AGENT DRUG87904PHENOTYPE INFECT AGENT DRUG17
The 2018 Updates, continued The fee schedules for Durable MedicalEquipment and Medical Supply Services for allMedicaid recipients and for Medicaid recipientsunder the age of 21 years have been combinedinto one fee schedule. An age column nowspecifies which age categories are eligible foreach service. This column can be sorted by age. Updates to the Prescribed Pediatric ExtendedCare Services fee schedule daily rates areinclusive of Therapy Services.18
Claims Submission19
Claims SubmissionFlorida Medicaid has two coverage policies toassist with claim form completion, they are: Medicaid Providers Who Bill on the CMS1500 Medicaid Providers Who Bill on the UB-04These coverage policies can be located on theFlorida Medicaid Web site that is provided on thefinal slide of this presentation.20
Claims Submission Florida Medicaid has a Provider Services ContactCenter. Provider Contact Center Specialists arededicated to responding professionally andaccurately to provider inquiries. Medicaid field offices, in conjunction with thefield services staff, offers a variety of monthlytraining sessions for Medicaid providers. Pleasevisit the Recipient and Provider Services page fortraining details and region information.21
Claims Submission Medicaid providers may call for assistance atthe following phone number: 1-800-289-7799. Provider Services Contact Center – Option 7:available 7am – 6pm ET, Monday through Friday Provider Enrollment – Option 4: available 8am –5pm ET, Monday through Friday. Field Services - Option 7: available 7am – 6pmET, Monday through Friday.22
Florida Medicaid 2018 FeeSchedules
Florida Medicaid 2018Fee Schedules Ambulatory Surgical Center (ASC) ServicesAssistive Care ServicesBehavior AnalysisBehavioral Health Overlay ServicesBirth CenterChild Health Services Targeted Case ManagementServicesCommunity-Based Substance Abuse County MatchServicesCommunity Behavioral Health ServicesCounty Health Department Certified Match Program24
Florida Medicaid 2018FeeSchedulesDentalDurable Medical Equipment and Medical SupplyServices for All Medicaid RecipientsEarly Intervention ServicesEmergency Transportation ServicesHearing ServicesHome Health Visit ServicesImmunizationIndependent LaboratoryInjectable Medication Oncology25
Florida Medicaid Fee Schedules Licensed MidwifeMedicaid Certified School Match ProgramMedical Foster Care ServicesMental Health Targeted Case Management ServicesOccupational Therapy ServicesOutpatient Laboratory ServicesPersonal Care ServicesPhysical Therapy ServicesPhysician Pediatric SurgeryPractitionerPractitioner LaboratoryPrescribed Drug26
Florida Medicaid Fee Schedules Prescribed Pediatric Extended Care ServicesPrivate Duty Nursing ServicesRadiologyRegional Perinatal Intensive Care Center (RPICC)Services NeonatalRegional Perinatal Intensive Care Center (RPICC)Services ObstetricalRespiratory TherapySpecialized Therapeutic ServicesSpeech-language Pathology ServicesTargeted Case Management for Children at Risk ofAbuse and Neglect ServicesVisual services27
Billing Codes County Health DepartmentFederally Qualified Health CenterHospiceHospital Outpatient ServicesIntermediate Care Facility for Individuals with IntellectualDisabilities Services Nursing Facility Services Rural Health Clinic Statewide Inpatient Psychiatric Program Services28
Florida Medicaid Fee Schedules andBilling Codes Florida Medicaid fee schedules, billing codes, and coveragepolicies are located on the Agency’s Web site .shtml. The Florida Medicaid fee schedules, billing codes, andcoverage policies should be resourced for covered services.29
Practitioner Fee Schedule Review30
Practitioner Fee Schedule Use Practitioners licensed within their scope of practice to performservices may use the Practitioner Fee Schedule.– Statute, licensure, and professional boards govern eachpractitioner’s scope of practice/standard of care.– The Agency does not regulate practitioner standards of carenor licensure.31
Practitioner Fee ScheduleUpdated 1/1/2018 A legend is provided on the fee schedule toprovide the definition of the titles andacronyms seen on the fee schedule.32
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Practitioner Fee ScheduleUpdated 1/1/18 Following the legend the second section of thePractitioner Fee Schedule explains the 4% and24% rate increases for recipients34
Practitioner Fee ScheduleUpdated 1/1/2018 The third section of the Practitioner FeeSchedule addresses the Rate Increase forPediatric Physicians.35
Practitioner Fee ScheduleUpdated 1/1/2018 The fourth section of the Practitioner FeeSchedule demonstrates the method forcalculating all the rate increase that have beenmentioned (4%, 10.2% and 24%).36
Practitioner Fee ScheduleUpdated 1/1/2018 The fifth section of the Practitioner FeeSchedule addresses the Primary CareEvaluation and Management Rate Increase.37
Practitioner Fee ScheduleUpdated 1/1/2018 Section six lists the services that are noteligible for the rate increases.38
Practitioner Fee ScheduleUpdated 1/1/2018 Section seven addresses assistant at surgeryreimbursement.39
Practitioner Fee ScheduleUpdated 1/1/2018 Section eight is the 2018 Advanced RegisteredNurse Practitioner (ARNP) and PhysicianAssistant (PA) Reimbursement Rates policythat replaced the 2017 Incident to Servicespolicy.40
Practitioner Fee ScheduleUpdated 1/1/2018 The ninth section of the Practitioner FeeSchedule is the anesthesia reimbursement rule.41
Fee-For-Service Rate Setting42
Fee-For-Service Rate Setting andUpdate Process Medicaid Program Finance (MPF) sets all rates on feeschedules Process takes place annually in December43
Why are Codes Added or Deleted? Reasons codes may be added or deleted from a fee scheduleinclude:– Additions: Annual release of new codes Medically necessary as approved by the generallyaccepted medical professional standards (GAPMS)process– Deletions: Annual discontinuation of codes Temporary codes become permanent44
Reimbursement Rates The Agency considers the following in the rate setting process:– Utilization– Medicare pricing– Other state Medicaid pricing– Resource based, relative value scale (RBRVS) published byCMS– Relative Value Units (RVUs) Provider time Materials Other costs– Florida Legislature appropriated additional funding45
National Correct CodingInitiative (NCCI)
What is NCCI? CMS’s National Correct Coding Initiative (NCCI) promotesnational correct coding methodologies and reduces impropercoding which may result in inappropriate payments ofMedicare Part B and Medicaid claims.– For information on edits for the Medicare NCCI program,please visit this Web site.– Pursuant to applicable provisions of the Social SecurityAct, ss. 1903(r)(1)(B)(iv).47
NCCI in Medicaid The Affordable Care Act of 2010 required CMS to notifystates by September 1, 2010 of the NCCI methodologies thatwere compatible with Medicaid. State Medicaid Director Letter #10-017 notified states that allfive Medicare NCCI methodologies were compatible withMedicaid. The Affordable Care Act required state Medicaid programs toincorporate compatible NCCI methodologies in their systemsfor processing Medicaid claims by October 1, 2010.48
Types of NCCI Edits in Medicaid The National Correct Coding Initiative (NCCI) containstwo types of edits:1. NCCI procedure-to-procedure (PTP) edits that definepairs of HCPCS/CPT codes that should not bereported together for a variety of reasons. Thepurpose of the PTP edits is to prevent improperpayments when incorrect code combinations arereported.2. Medically Unlikely Edits (MUEs) define for eachHCPCS / CPT code the maximum units of service(UOS) that a provider would report under mostcircumstances for a single beneficiary on a singledate of service.49
NCCI Methodologies in Medicaid The Medicaid NCCI program consists of six methodologies:1.2.3.4.5.6.PTP edits for practitioner and ambulatory surgical center(ASC) services.PTP edits for outpatient services in hospitals (includingemergency department, observation, and hospital laboratoryservices).PTP edits for durable medical equipment.MUEs for practitioner and ASC services.MUEs for outpatient services in hospitals.MUEs for durable medical equipment. Medicaid NCCI methodologies apply to Medicaid fee-forservice and managed care claims except for allowable NCCIedit exclusions in accordance with 42 CFR 433.116 and 45CFR 95.50
NCCI Methodologies in Medicaid Medicaid NCCI methodologies apply to Medicaid fee-forservice and managed care claims.– Per the SMMC Contract, Attachment II, Core ContractProvision, the Managed Care Plan shall incorporate into itsclaim processing and claims payment system the NCCIediting programs for the Healthcare Common ProcedureCoding System (HCPCS)/Current Procedural Terminology(CPT) codes to promote correct coding and control codingerrors, except for allowable NCCI edits exclusions inaccordance with 42 CFR 433.116 and 45 CFR 95.51
Medicaid NCCI Edit Files Florida Medicaid primarily follows NCCI edits. The complete updated Medicaid NCCI edit files are posted toCMS’s Web site at the beginning of each calendar quarter. These files completely replace the Medicaid NCCI edit filesfrom previous calendar quarters.– The presence of a HCPCS / CPT code in a PTP edit or ofan MUE value for a HCPCS / CPT code does notnecessarily indicate that the code is covered by any stateMedicaid program or by all state Medicaid programs.52
Contact UsFlorida Medicaid Web site– http://ahca.myflorida.com/Medicaid/index.shtml– Complaint hub and other tools can be located here53
Medicaid field offices, in conjunction with the field services staff, offers a variety of monthly training sessions for Medicaid providers. Please visit the Recipient and Provider Serv
