ACA increase in reimbursement for primary care services ending December 31, 2014

ACA increase in reimbursement for primary care services ending December 31, 2014

As stated in Indiana Health Coverage Programs (IHCP) Provider Bulletins BT201247 and BT201302, Section 1202 of the Affordable Care Act (ACA) required a temporary increase in Medicaid payments for qualifying primary care services provided by qualifying physicians for dates of service (DOS) in calendar years (CYs) 2013 and 2014. The federally funded, temporary rate increase was authorized only for these two calendar years. This temporary increase will end December 31, 2014, and the Medicaid rate structure will return to its preexisting levels for DOS on or after January 1, 2015.

Consistent with previous quarterly payments, qualifying physicians will receive the fourth-quarter 2014 ACA primary care physician (PCP) quarterly supplemental payments approximately 6-8 weeks after the end of the quarter, or approximately mid- to late February 2015. To accommodate the one-year IHCP fee-for-service (FFS) timely claims filing limit, a final settlement payment will be made for each year of the program. The final settlement payment for claims with DOS in CY2013 will be paid in the first half of 2015, and the final settlement payment for claims with DOS in CY2014 will be paid the first half of 2016. The actual date for both final settlement payments will be communicated in future IHCP provider communications.

Changes in billing instructions

BT201247 issued billing instructions for the time period when ACA PCP rate increases applied. Some of these billing instructions will be continued, and others will end with the conclusion of the ACA PCP rate increase. Specific instructions follow.

Billing by individually enrolled nurse practitioners

BT201247 stated that, to qualify for the increased PCP rates under the ACA, individually enrolled nurse practitioners were required to bill the IHCP using the SA modifier and the rendering (supervising) physician's National Provider Identifier (NPI) in field 24J of the CMS-1500 claim form. Effective for DOS on or after January 1, 2015, individually enrolled nurse practitioners may resume billing using their own NPIs in field 24J of the CMS-1500 claim form.

Claims for Vaccine for Children (VFC) vaccines

BT201247 instructed providers using VFC-provided vaccines to bill the IHCP for the VFC vaccine administration fee by billing V20.2 as the primary diagnosis, the procedure code of the specific vaccine administered with a billed amount of $0.00, and the appropriate vaccine administration code with the SL modifier. A list of appropriate administration procedure codes is provided in Table 1. The allowed amount per claim for the administration of a VFC vaccine was set at $8.00.

Table 1 - VFC-provided vaccine administration procedure codes

Procedure Code Code Description
90471 SL Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid); VFC vaccine administration
90472 SL Each additional vaccine (single or combination vaccine/toxoid); VFC vaccine administration
90473 SL Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid); VFC vaccine administration
90474 SL Each additional vaccine (single or combination vaccine/toxoid); VFC vaccine administration

The IHCP will continue to follow these billing instructions for DOS on or after January 1, 2015. Providers should continue to bill the preceding vaccine administration codes with the SL modifier for VFC vaccines with a billed amount of $8.00 and the procedure code of the specific vaccine administered with a billed amount of $0.00.

Providers are reminded it is federally prohibited to bill an amount greater than $0.00 for vaccines provided through the VFC program. Claims for VFC vaccines with billed amounts of $0.00 will continue to receive denial notices with Explanation of Benefit (EOB) code 268 - Billed amount missing. Although providers receive this denial, providers should continue to bill these claims as instructed and not rebill the IHCP with a different billed amount.

Claims for non-VFC vaccines

BT201247 instructed providers billing for non-VFC vaccines to bill the IHCP for the most appropriate vaccine administration code from those listed in Table 2.

Table 2 - Non-VFC vaccine administration procedure codes

Procedure Code
Code Description
90471
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
90472
Each additional vaccine (single or combination vaccine/toxoid)
90473
Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
90474
Each additional vaccine (single or combination vaccine/toxoid)

The IHCP will continue to follow these billing instructions for DOS on or after January 1, 2015. Providers should continue to bill the preceding vaccine administration codes for non-VFC vaccines. Reimbursement for the vaccine administration continues to be included in the evaluation and management (E/M) code-allowed amount. Therefore, if an E/M service code is billed with the same DOS as an office-administered vaccination, providers will not be separately reimbursed for the vaccine administration code. Separate reimbursement for the vaccine administration is allowed when the administration of the drug is the only service billed by the practitioner. Additionally, if more than one vaccine is administered on the same DOS and no E/M code is billed, providers may bill an administration fee for each injection using the appropriate vaccine administration code.

 

 

 

 

 

 

 

 

 

 

90471 SL

Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid); VFC vaccine administration