Medical Procedures

Correct Medicaid Health Care Finance Administration (HCFA) and Current Procedural Terminology (CPT) codes are used to determine the amount to be authorized/paid for services, unless otherwise specified. With the exception of fees authorized in this manual for specific services, RS pays the Medicaid rate for medical services provided to clients as part of their IPEs. Medicaid payment is payment in full and no additional payment is authorized. Providers shall not request or accept additional payment from clients.

Medical card/other insurance: If the client has a medical card or other medical insurance, either Medicaid or the insurance must be used before Rehabilitation Services (RS) may pay. A Medicaid payment is payment in full and no additional payment may be made. If private insurance pays part of the bill, RS will pay the balance that would be charged the client up to the maximum Medicaid allows for a specific service. Providers shall not bill for any “write-offs.”

Payment: The physician or medical provider should provide the services authorized and should notify the counselor if any additional services are to be provided. Although RS may authorize a service by procedure code and description, the medical provider may change the code to indicate services actually provided in accordance with allowable established codes. If the code billed does not appear on Kansas Management Information System (KMIS) either with or without a rate, it is not valid. If the procedure code supplied by the provider allows less than the amount authorized, the lesser amount is paid.

All medical providers should be able to provide the proper procedure code (including modifiers necessary) for services they provide. Staff should not hesitate to request this information. All Kansas physicians and providers should have this information since it is needed to file insurance claims.

Non-covered Medicaid services: KMIS shows the amount Medicaid allows for a specific procedure. If the procedure code shows a blank, zero, seven or nine in the allowed cost, Medicaid does not cover the services or has special requirements. RS staff should verify with the provider that the non-covered Medicaid procedure code is the service actually provided. If the service was actually correct, the RS Central Office should be contacted about the rate.

Substance abuse services: Use the referral process established by DCF Alcohol and Drug Abuse Services for inpatient and outpatient substance abuse treatment.

Anesthesia: All anesthesia services are paid by points indicated in the surgical procedure code with the modified code “IND” on KMIS. The “IND” number relative value (procedure code plus modifier) plus time in units of 15 minutes are added and multiplied by a conversion factor of $19.50.

Anesthesia Example: The procedure code of 66984-3000 has an “IND” code of 8 (relative value). If the time used of 121 minutes is divided by the 15 minute unit to determine time points, the time points would equal 9. A partial time unit is considered a full unit. Together the relative units of 8 plus the time units of 9 would equal 17 units times $19.50.
Medical Report/Definitive- $20 Medical/Hospital Records- $10

Medical Records Search Fee- $1.00 per quarter hour or portion thereof.

Payment for health insurance premiums
This is an allowable VR expense, if it is a cost-effective alternative to paying actual medical costs. An analysis of the cost effectiveness and search for comparable benefits must be included in the record of services.

Effective Date: April 26, 2005