2010-2011 nebraska medicaid reimbursement american academy of pediatrics

Medicaid Reimbursement Survey, 2010/11Nebraska

Survey Summary

As part of its effort to monitor the impact of the Medicaid program on pediatrics, the American Academy of Pediatrics (AAP) conducts its Medicaid Reimbursement Survey periodically.

Copyright 2011 American Academy of Pediatrics.

Nebraska - 2010/11 AAP Medicaid Reimbursement Survey

The Survey, which collects state-administered fee-for-service program payment rates for commonly reported pediatric Current Procedural Terminology/CPT® codes and dental codes, was most recently mailed to State Medicaid Directors in the 50 states and the District of Columbia between July 2010 and February 2011 to request payment rates effective July 1, 2010, the beginning of the 2010-11 fiscal year for most states.

As of publication of this report, 46 states have responded to the survey. Tennessee, which does not have a state-administered fee-for-service Medicaid program, is not included in this report series.

This and earlier AAP Medicaid Reimbursement Survey reports can be found at URL: http://www.aap.org/research/medreimintro.htm

In this Report...

This report provides state-reported fees paid for pediatric services represented by over 200 CPT and dental codes used by state-administered fee-for-service Medicaid programs to reimburse providers. Medicaid fees are compared to Medicare where available, or to other benchmark fees (such as prices listed in the Clinical Diagnostic Lab Fee Schedule, or prices based on the Ingenix Essential RBRVS) where Medicare comparisons are unavailable.

Codes are selected for inclusion in the survey based on (i) utilization, and (ii) importance to Academy priorities, such as Bright Futures and the pediatric medical home. Also included in this report are summary updates on Medicaid managed care (MMC) enrollment, state-monitoring of MMC physician reimbursement, coverage of Bright Futures benefits, availability of enhanced payment for pediatric services, availability of pediatric medical home program and provider payment, availability of Pediatric Primary Care Case Management (PCCM) program and provider payment, and reimbursement of pediatricians for providing certain mental and preventive oral health services to children.

Caveats and Notes

CPT® is a trademark of the American Medical Association. Dental codes (CDT Codes) are copyright 2006 American Dental Association. Reprinted with permission.

Medicaid fees shown in this report represent fee-for-service payments reported by states for state-administered Medicaid programs at the time of the study. The rates are subject to change.



Medicare rates in this report are (a) based on non-facility Medicare payment published by the Centers for Medicare and Medicaid Services for 2011, and (b) adjusted with Geographic Practice Cost Index (GPCIs) published by CMS. Certain codes, including not not limited to 99381-5 and 99391-5, are assigned RVUs but not covered by Medicare.

21% of Nebraska' Medicaid children were enrolled in HMOs according to FY2008 CMS data. Rates shown in this report may not apply to payment of services for Medicaid children enrolled in these and other prepaid plans. Nebraska did not provide information regarding monitoring of Medicaid managed care plan-to-provider payment rates

Nationally, the majority of children enrolled in Medicaid programs are enrolled in managed care plans, which may or may not benchmark provider payment rates to fees shown in this report. Depending on managed care penetration levels, the impact of state-administered fee-for-service Medicaid payment rates varies by state.

Unless noted otherwise, non-facility rates and enhanced payment rates for pediatric services, where available and reported by the state, are included in this report.

Contact Suk-fong Tang, Department of Practice, for comments on this report. Contact Dan Walter, Division of State Government Affairs, for Medicaid questions and advocacy advice. Contact Elizabeth Sobczyk, Division of Pediatric Practice, for pediatric immunization questions and advocacy advice. Contact the Division of Health Care Finance and Quality Improvement at [email protected] for information on child health financing or RBRVS.

Contact Information

2010/11 AAP Medicaid Reimbursement Survey. American Academy of Pediatrics. Elk Grove Village, Illinois. Available for download at the AAP Website, at URL: http://www.aap.org/research/medreimintro.htm

Suggested Citation

Abbreviations


AAP: American Academy of Pediatrics

BC: Billed amount / billed charges

BI / BR/ IC/ MP/ PR: By invoice/ by report/ individual consideration/manually priced/per review, i.e., Carrier will establish payment amounts for these services on a case-by-case basis following review of documentation, such as an operative report.

BO: Bundled with other services, i.e., Payment for covered services is always bundled into payment for other services not specified. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident.

CMS: Centers for Medicare and Medicaid Services

FFS: Discounted fee-for-service

IER: RVUs not published for this code in the Medicare RBRVS; values are based on the Ingenix Essential RBRVS. Ratio (percentage listed under “%Medicare” column) represents Medicaid payment as a percentage of the rate calculated using the RVUs published in the Ingenix Essential RBRVS.

LFS: Amount per Clinical Diagnostic Lab Fee Schedule. Ratio (percentage listed under “%Medicare” column) represents Medicaid payment as a percentage of the mount listed for the state in the Clinical Diagnostic Lab Fee Schedule.

NA: Not applicable

NC: Not covered

NIS: Not priced by the current Physician Fee Schedule, or RVUs not included in RBRVS

NL: Payment information specific to procedure code not listed on state Medicaid website or physician fee schedule. Note: absence of such information from fee schedule often indicates that the service is either not covered, or covered under alternate code(s).

NP: Information not provided by state in returned AAP survey

OM: Other method used

P2010: 2010 pricing; code replaced prior to publication of this report

QMB: Qualified Medicare Beneficiary

RBRVS: Resource-Based Relative Value Scale, the physician payment schedule for Medicare

RNE: Rate not established

RVU(s): Relative Value Unit(s), the numeric value of the resources needed to provide services according to the Resource-Based Relative Value Scale

UCF: Usual and customary fees

VFC: Vaccines for Children Program. Providers are typically paid a vaccine administration fee for administering vaccines made available free of charge through VFC programs.


List of CPT and Dental Codes Included in Report

Service Type Code Description Page# 99381 New patient, under 1 year 1 99382 New patient, 1 through 4 years 1 99383 New patient, 5 through 11 years 1 99384 New patient, 12 though 17 years 1 99385 New patient, 18 though 39 years 1 99391 Established patient, under 1 year 1 99392 Established patient, 1 through 4

years 1 99393 Established patient, 5 through 11

years 1 99394 Established patient, 12 though 17

years 1 99395 Established patient, 18 though 39

years 1 99401 Individual counseling, 15 min 1 99402 Individual counseling, 30 min 1 99403 Individual counseling, 45 min 1 99404 Individual counseling, 60 min 1 99078 Group health education 1 99411 Preventive counseling group - 30

min 1 99412 Preventive counseling group - 60

min 1 99420 Health risk assessment test 1 99450 Basic life and/or disability

evaluation 1

Preventive Medicine Services

99455 Work related or medical disability evaluation 1

99341 New patient, problem focused 1 99342 New patient, expanded 1 99343 New patient, detailed 1 99344 New patient, moderate complexity 1 99345 New patient, high complexity 1 99347 Established patient, problem

focused 1 99348 Established patient, expanded 1 99349 Established patient, detailed 1

Home Services

99350 Established patient, comprehensive 1

99201 New patient, problem-focused 2 99202 New patient, expanded 2 99203 New patient, low complexity 2 99204 New patient, moderate complexity 2 99205 New patient, high complexity 2 99211 Established patient, nurse only 2 99212 Established patient, problem-

focused 2 99213 Established patient, low complexity 2 99214 Established patient, moderate

complexity 2 99215 Established patient, high

complexity 2 92551 Screening test, hearing evaluation 2 92567 Tympanometry, hearing evaluation 2 99173 Screening test, visual acuity 2 96110 Developmental testing; limited 2

Office and Other Outpatient Services

99174 Ocular photoscreening 2

Service Type Code Description Page# 99460 Initial newborn care 2 99462 Subsequent newborn care 2 99463 Admit and discharge on same day 2 99464 Physician attendance at delivery 2 99465 Newborn resuscitation 2

Newborn Care

54150 Circumcision w/ regional block 2 90465 One immunization administration,

physician counseling < 8 yrs 2 90466 Each additional immunization

administration, physician counseling < 8 yrs 2

90467 One immunization administration, oral or intranasal, physician counseling < 8 yrs.. 2

90468 Each additional immunization administration, oral or intranasal, physician counseling < 8 yrs 2

90471 One immunization administration 2 90472 Each additional immunization

administration 2 90473 One immunization administration,

oral or intranasal 3 90474 Each additional administration,

oral or intranasal 3 90470 Immune admin H1N1 im/nasal 3 90645-8 Hemophilus Influenza B 3 90649 Hpv vaccine 4 valent im 3 90650 Hpv vaccine 2 valent im 3 90657 Influenza virus (6-35 months) 3 90658 Influenza virus (3+ years) 3 90660 Influenza virus, intranasal use 3 90663 Flu vacc pandemic H1N1 3 90669 Pneumococcal vacc 7 val im 3 90670 Pneumococcal vacc 13 val im 3 90680 Rotavirus 3 90700 DTaP (< 7 years) 3 90701 DTP 3 90702 DT (< 7 years) 3 90707 Measles-Mumps-Rubella 3 90713 IPV 3 90715 Tdap 3 90716 Varicella 3 90718 Td (³ 7 years) 3 90721 DTaP-HIB 3 90723 DTaP-HepB-IPV 3 90734 Meningococcal vaccine im 3

Immunizations

90744 Hepatitis B, (pediatric/adolescent age) 3 99217 Observation care discharge, day

management 3 99218 Initial observation care, low

severity 3 99219 Initial observation care,

intermediate severity 3 99220 Initial observation care, high

severity 3

Evaluation and Management

99354 Prolonged service outpatient, 1st hour, face-to-face 3

List of CPT and Dental Codes Included in Report (Continued)

Service Type Code Description Page# 99355 Same as 99354, each additional

30 min 3 99356 Prolonged service, inpatient, 1st

hour, face-to-face 3 99357 Same as 99356, each additional 30

min 3 99358 Prolonged service, 1st hour, non-

face-to-face 3 99359 Same as 99358, each additional

30 min 3 99366 Medical team conference by hc

pro(face-to-face), 30 min 4 99367 Team conf w/o patient by

physicians 4 99368 Team conf w/o pat by hc pro, 30 min 4 99339 Care plan oversight, 15-29 min/mo 4 99340 Same as 99339, 30 min or more 4 99374 Home health care supervision, 15-

29 min/mo 4 99375 Same as 99374, 30 min or more 4 99377 Hospice care supervision, 15-29 min 4 99378 Same as 99377, 30 min or more 4 99379 Nursing facility supervision, 15-29

min 4 99380 Same as 99379, 30 min or more 4 99441 Phone e/m by phys 5-10 min 4 99442 Phone e/m by phys 11-20 min 4 99443 Phone e/m by phys 21-30 min 4

Evaluation and Management (continued)

99444 Online e/m by physician 4 96150 Health and Behavior assessment 4 96151 Health and Behavior intervention 4 96153 same as above, group 4 96154 same as above, patient present 4 96155 same as above, patient not

present 4 97802 Medical Nutrition Therapy,

individual, initial 4 97803 Medical Nutrition Therapy,

individual, follow-up 4 97804 Medical Nutrition Therapy, group,

30 min 4 98966 Telephone assessment /

management, 5-10 min 4 98967 Telephone assessment /

management, 11-20 min 4 98968 Telephone assessment /

management, 21-30 min 4

Non-physician Provider (NPP) Services

98969 On-line assessment and management service 4

99221 Initial hospitalization, per day, low complexity 5

99222 Initial hospitalization, per day, moderate complexity 5

99223 Initial hospitalization, per day, high complexity 5

99231 Subsequent hospitalization, per day, low complexity 5

Hospital Care

99232 Subsequent hospitalization, per day, mod Complexity 5

Service Type Code Description Page# 99233 Subsequent hospitalization, per

day, high complexity 5 99238 Hospital discharge, day

management, =<30 min 5

Hospital Care (Continued)

99239 Hospital discharge, day management, > 30 min 5

99241 Office consultation, problem focused 5 99242 Office consultation, expanded 5 99243 Office consultation, low complexity 5 99244 Office consultation, moderate

complexity 5 99245 Office consultation, high

complexity 5 99252 Initial inpatient consultation, low

severity problem 5 99253 Same as above, moderate severity

problem 5

Consultation

99254 Same as above, moderate to high severity problem 5

81000 Urinalysis, non-automated with microscopy 5

81002 Urinalysis, non-automated without microscopy 5

86580 Tuberculosis, intradermal 5 87081 Throat culture 5

Pathology and Laboratory

87880 Rapid Streptococcus screen 5 90801 Psychiatric diagnostic interview

examination 5 90804 Individual psychotherapy, 20-30

min face-to-face 5 90806 Individual psychotherapy, 45-50

min face-to-face 5 90808 Individual psychotherapy, 75-80

min face-to-face 5 90862 Pharmacologic management 5 96111 Developmental testing, extended 5 90887 Consultation with family 5

Mental Health

90889 Preparation of report 5 95004 Percutaneous tests with allergenic

extracts 6 95010 Percutaneous tests, sequential

and incremental 6 95015 Intracutaneous tests, with

biologicals 6 95024 Intracutaneous tests, with

allergenic extracts 6 95115 Allergen immunotherapy, single

injection 6

Allergy/ Immunology

95117 Allergen immunotherapy, two or more injections 6

32551 Tube thoracostomy, includes water seal 6

92950 Cardiopulmonary resuscitation 6 93303 Transthoracic echocardiography 6 93307 Echocardiography, real-time w/

image documentation 6 93320 Doppler echocardiograph 6 93501 Right heart catheterization 6

Cardiology

93510 Left heart catheterization 6

List of CPT and Dental Codes Included in Report (continued)Service Type Code Description Page#

31500 Intubation, endotracheal 6 36555 Insertion of non-tunneled center

venous cathether; < 5 yrs 6 36568 Insertion of peripherally inserted

CVC; under 5 years 6 36600 Arterial puncture, diagnostic 6 36620 Arterial line placement 6 99291 Critical care, first hour 6

Critical Care

99292 Critical care, additional 30 min 6 10120 Simple surgical removal of foreign

body 6 12015 Simple surgical repair of facial

wounds (7.6 - 12.5 cm) 6 36400 Venipuncture necessitating

physician skill; < 3 yrs 6 36410 Venipuncture necessitating

physician skill; >= 3 yrs 6 36415 Routine venipuncture 6 36416 Finger, heel, ear stick 6 62270 Lumbar puncture, diagnostic 6 99143 Moderate sedation by same phys

< 5 yrs 6 99144 Moderate sedation by same phys

5 yrs + 6 99145 Moderate sedation by same phys

add-on 6 99148 Moderate sedation diff phys < 5

yrs 7 99149 Moderate sedation diff phys 5 yrs

+ 7 99150 Moderate sedation diff phys add-

on 7 99282 ED visit, problem focused 7 99283 ED visit, expanded 7

Emergency Care

99284 ED visit, detailed 7 43239 Upper gastrointestinal endoscopy

with biopsy 7 44389 Colonoscopy with biopsy 7

Gastro-intestinal

45331 Sigmoidoscopy with biopsy 7 67311 Strabismus surgery, horizontal 7 67314 Strabismus surgery, vertical 7

Ophthalmology

68810 Nasolacrimal probing 7 42820 Tonsillectomy/adenoidectomy,

under 12 years 7 42821 Tonsillectomy/adenoidectomy,

over 12 years 7

Otolaryngology

69436 Tympanostomy and tubes 7 36510 Umbilical vein catheterization 7 36660 Umbilical artery catheterization 7 99471 Initial pediatric critical care (29d-

24m) 7

Neonatal and Pediatric Critical Care

99472 Subsequent pediatric critical care (29d-24m) 7

Service Type Code Description Page# 99475 Initial pediatric critical care (2-5

yrs) 7 99476 Subsequent pediatric critical care

(2-5 yrs) 7 99468 Initial neonatal critical care 7

Neonatal and Pediatric Critical Care (continued)

99469 Subsequent neonatal critical care 7 99477 Initial neonatal intensive care 7 99478 Subsq intensive care, < 1500 gm 7 99479 Subsq intensive care, 1500-2500

gm 7

Initial and Continuing Intensive Care Services

99480 Subsq intensive care, 2501-5000 gm 7

31622 Bronchoscopy 8 32421 Thoracentesis for aspiration 8 94010 Spirometry, including graphic

record 8 94640 Inhalation treatment 8 94644 Continuous inhalation treatment,

first hour 8 94645 Same as 94644, each additional

hour 8

Pulmonology

94664 Demonstration/evaluation 8 Radiology 71010 Frontal chest x-ray 8

40700 Cleft lip repair 8 Plastic Surgery 42200 Cleft palate repair 8

28262 Extensive clubfoot release 8 44950 Appendectomy 8 49500 Bilateral inguinal hernia, 6 mos to

< 5 years 8

Surgery

49505 Bilateral inguinal hernia, 5 years or over 8

50200 Renal biopsy; percutaneous, by trocar or needle 8

90957 ESRD services; 12-19 yrs, 4+ physician visits/mo 8

90958 Same as above, 2-3 physician visits/mo 8

90959 Same as above, 1 physician visits/mo 8

90965 Same as above, home dialysis for full month 8

90966 Same as above, for dialysis per day 8

Urology and Dialysis

90945 Peritoneal dialysis 8 D0120 Periodic exam 9 D1203 Topical fluoride treatment, child 9 D1120 Prophylaxis, child 9 D2150 Amalgam – two surfaces, primary

or permanent 9 D2330 Resin-based composite – one

surface anterior 9 D1351 Sealant, per tooth 9 D2930 Stainless steel crown on a primary

tooth 9 D3220 Pulpotomy 9 D7140 Extraction 9

Dental Services

D0145 Caries Risk Assessment 9

$95.16$100.17

$80.14$85.15$90.16$95.16

$100.17NLNL

$110.19$120.21$130.22

2010/11 Medicaid Payments for Commonly Reported Pediatric CPT Codes

99381 - New Patient, under 1 year 99382 - New Patient, 1 through 4 years 99383 - New Patient, 5 through 11 years 99384 - New Patient, 12 through 17 years 99385 - New Patient, 18 through 39 years 99391 - Established Patient, under 1 year 99392 - Established Patient, 1 through 4 years

99394 - Established Patient, 12 through 17 years 99395 - Established Patient, 18 through 39 years

Preventive Medicine Services

99401 - Individual Counseling, 15 min 99402 - Individual Counseling, 30 min

99393 - Established Patient, 5 through 11 years

TM

Medicaid Medicare %Medicare

AAP Medicaid Reimbursement Survey: Nebraska


99078 - Group health education

99403 - Individual Counseling, 45 min 99404 - Individual Counseling, 60 min

99411 - Preventive counseling group, 30 min 99412 - Preventive counseling group, 60 min 99420 - Health risk assessment test 99450 - Basic life and/or disability evaluation 99455 - Work related or medical disability evaluationHome Services

99341 - Individual Counseling, 15 min 99342 - Individual Counseling, 30 min 99343 - Individual Counseling, 45 min 99344 - Individual Counseling, 60 min 99345 - New patient, high complexity 99347 - Established patient, problem focused 99348 - Established patient, expanded 99349 - Established patient, detailed 99350 - Established patient, comprehensive

NCNCNCNCNCNCNC

NC

$49.70

$93.60$109.34$144.13

$39.76$58.29$85.23

$124.25

$62.12

** State did not provide information regarding coverage of AAP-recommended services (i.e., Bright Futures).

107.0%103.3%

106.3%102.0%108.4%104.0%109.5%

----

114.4%114.7%124.2%

----------

--

$88.93 $96.95

$75.37 $83.49 $83.17 $91.50 $91.50 $34.54 $58.95

$96.31 $104.84 $104.84

$106.48NIS

$14.80 $19.48 $9.39

$82.60

95.6%

76.0% 65.8% 72.3% 77.0% 74.4% 73.4% 76.9%

82.3% $51.96

$123.24 $166.27 $199.43 $51.62 $78.30 $116.06 $161.60

$75.44

**

--NIS--NIS


Office and Other Outpatient Services

92567 - Tympanometry, hearing evaluation

99203 - New Patient, low complexity 99204 - New Patient, moderate complexity 99205 - New Patient, high complexity

92551 - Screening test, hearing evaluation

99211 - Established Patient, office visit 99212 - Established Patient, expanded office visit 99213 - Established Patient, low complexity 99214 - Established Patient, moderate complexity 99215 - Established Patient, high complexity

99173 - Screening test, visual acuity 96110 - Developmental testing; limited

99174 - Ocular photoscreening Newborn Care

99463 - Admit and discharge on same day

99460 - Initial newborn care 99462 - Subsequent newborn care

99464 - Physician attendance at delivery 99465 - Newborn resuscitation 54150 - Circumcision w/regionl block

$69.58$104.22$131.19

$17.40$29.82$45.07$67.78$96.92$13.30$12.76

$1.90

Immunizations

90471 - One immunization administration 90472 - Each additional immunization administration

90465 - One immunization admin, phys counseling < 8 yrs 90466 - Each additional immunization administration,

90467 - One immunization administration, oral or intranasal,

90468 - Each additional immunization administration, oral

physician counseling < 8 yrs

physician counseling < 8 yrs

or intranasal, physician counseling < 8 yrs $5.80$5.80

NCNC

NC

NC

Note: State did not provide information whether it pays for multiple units of 96110 on the same day.

AAP Medicaid Reimbursement Survey Report, 2010/11 - Nebraska, Continued (page 2 of 9)

Immunization administration of vaccines provided by VFC NA NA

99201 - New Patient, office visit 99202 - New Patient, expanded office visit

$13.68

NC

$32.30$47.22

$126.74$96.90

$106.40$87.43

$109.34$49.70

71.7% 69.9% 70.5% 93.0% 76.2% 69.0% 69.6% 74.0%124.7% 87.5% 81.3%183.3%

82.6% 70.3%

$97.00 $149.15 $186.21 $18.71 $39.12 $65.34 $97.41 $131.01 $10.67 $14.58 $2.34 $7.46

$39.12 $67.19

$26.05

$76.08 $68.93 $131.44 $157.74

$55.61 $29.78

--

166.6%140.6% 80.9% 55.4%

196.6%166.9%

$21.89 $10.96

$20.22 (P2010) $10.28 (P2010)

$13.73 (P2010)

$9.94 (P2010)

26.5% 52.9%

----

--

--


NA

NCNC

$19.14$10.50

$48.07

$74.56

Immunizations

90701 - DTP 90702 - DT (< 7 years)

90718 - Td (>= 7 years) 90721 - DTaP, HIB

90744 - Hepatitis B, (pediatric/adolescent age)

90707 - Measles, mumps, rubella

90716 - Varicella

$10.50

90713 - IPV $10.50

NC

$10.50$10.50 90658 - Influenza virus (3+ years)

90645-8 - Hemophilus Influenza B

90657 - Influenza virus (6-35 months)

90669 - Pneumococcal vacc 7 val im $10.50

90700 - DTaP (< 7 years) $10.50


Medicare reimburses for

vaccine products using

106% of the product's

average sale price (ASP)

$11.22 90660 - Influenza virus, intranasal use

$120.75 90649 - Hpv vaccine 4 valent im

90680 - Rotavirus $10.50

90715 - Tdap $41.22

$10.50 90723 - DTaP-HepB-IPV

$34.20$45.60$81.70

$102.60

99217 - Observation care discharge, day management

99219 - Initial observation care, intermediate severity 99218 - Initial observation care, low severity

99220 - Initial observation care, high severity


$66.04 $61.55 $102.56 $143.22

90650 - Hpv vaccine 2 valent im

90663 - Flu vacc pandemic H1N1

90670 - Pneumococcal vacc 13 val im

90734 - Meningococcal vaccine im

(Continued)


$76.00 99354 - Prolonged service, outpatient, 1st hour, face-to-face$38.00 99355 - Same as 99354, each additional 30 min$83.60 99356 - Prolonged service, inpatient, 1st hour, face-to-face$41.80 99357 - Same as 99356, each additional 30 min

NC 99358 - Prolonged service, 1st hour, non face-to-faceNC 99359 - Same as 99358, each additional 30 min

90473 - One immunization administration, oral or intranasal 90474 - Each additional administration, oral or intranasal

$5.80$5.80

NC

NC

NC

$10.50

90470 - Immune admin H1N1 im/nasal, incl counseling NP

$90.98 $90.02 $83.50 $83.50 $102.80 $49.70

51.8% 74.1% 79.7% 71.6% 83.5% 42.2%100.1% 50.1%

----

$21.89 $10.96 $19.71

26.5% 52.9%

--


Payment rates, if shown, apply where service recipient is not eligible for free

vaccine provided by VFC (Vaccine

for Children program), such as when recipient is

19 or older.


99367 - Team conf w/o patient by physicians 99366 - Medical team conference by hc pro(face-to-face), 30 min

NC99374 - Home health care supervision, 15-29 min/mo NC99375 - Same as 99374, 30 min or more per month

NC99339 - Care plan oversight, 15-29 min/moNC99340 - Same as 99339, 30 minutes or more per month

Non-physician Provider (NPP) Services


99368 - Team conf w/o patient by hc pro, 30 min


99377 - Hospice care supervision, 15-29 min 99378 - Same as 99377, 30 min or more 99379 - Nursing facility supervision, 15-29 min99380 - Same as 99379, 30 min or more99441 - Phone e/m by physician 5-10 min 99442 - Phone e/m by physician 11-20 min 99443 - Phone e/m by physician 21-30 min 99444 - Online e/m by physician

96150 - Health and Behavior assessment, by NPP 96151 - Health and Behavior intervention, by NPP 96153 - same as above, group 96154 - same as above, patient present 96155 - same as above, patient not present 97802 - Medical Nutrition Therapy, by NPP, individual, initial 97803 - Medical Nutrition Therapy, by NPP, individual, follow-up97804 - Medical Nutrition Therapy, by NPP, group, 30 min98966 - Telephone assessment/management, by NPP, 5-10 min 98967 - Same as above, 11-20 min 98968 - Same as above, 21-30 min 98969 - On-line assessment and management service, by NPP

State did not provide information regarding the availability of any medical home program covering Medicaid-enrolled children. State did not provide information regarding the availability of any Primary Care Case Management (PCCM) program covering Medicaid-enrolled children.

NC

NL

NCNC

NCNCNCNCNCNCNC

NCNCNCNCNCNCNCNCNCNCNCNC

$65.27 $100.84

$72.39 $101.39

$34.78

$65.27

$40.19 $53.10

$102.76 $65.27 $98.27 $13.40 $25.28 $37.49

$29.04 (IER)

----

----

--

--

----

--------------

$20.61 $19.93 $4.45 $18.59 $21.64 $30.47 $26.47 $13.40 $13.40 $25.28 $37.49

$19.76 (IER)

------------------------

Medicaid Medicare %Medicare(Continued)

Medical Home and Primary Care Case Management: Program Availability and Provider Payment Summary

AAP Medicaid Reimbursement Survey Report, 2010/11 Nebraska, Continued (page 5 of 9)

$64.60$83.60

$106.40

99242 - Office consultation, expanded 99243 - Office consultation, low complexity 99244 - Office consultation, moderate complexity

Consultations$45.60 99241 - Office consultation, problem focused


$144.40 99245 - Office consultation, high complexity

99253 - Same as above, moderate severity problem 99254 - Same as above, moderate to high severity problem

$4.54$3.66$6.98$9.50

Pathology and Laboratory 81000 - Urinalysis, non-automated with microscopy 81002 - Urinalysis, non-automated without microscopy 86580 - Tuberculosis, intradermal 87081 - Throat culture

NL 87880 - Rapid Streptococcus screen

102.0%101.7%102.3%101.8%

--

$4.45 (LFS)

$6.82

$163.28Mental Health 90801 - Psychiatric diagnostic interview examination

NL 90804 - Individual psychotherapy, 20-30 min face-to-faceNL 90806 - Individual psychotherapy, 45-50 min face-to-faceNL 90808 - Individual psychotherapy, 75-80 min face-to-faceNL 90862 - Pharmacological management

NL 90887 - Consultation with family $138.70 96111 - Developmental testing, extended

99252 - Initial inpatient consultation, low severity problem

90889 - Preparation of report

Medicaid Reimbursement for Mental Health Services Provided by Pediatricians:State did not provide information regarding reimbursement of general pediatricians and developmental/behavioral pediatric subspecialists for mental health services.

$47.50$83.60

$108.30$28.50$45.60$76.00

99221 - Initial hosptialization, per day, low complexity

99223 - Initial hosptialization, per day, high complexity

Hospital Care

99222 - Initial hosptialization, per day, moderate complexity

99231 - Subsequent hosptialization, per day, low complexity 99232 - Same as above, moderate complexity 99233 - Same as above, high complexity

$68.40 99238 - Hospital discharge, day management, <= 30 min$114.00 99239 - Hospital discharge, day management, >30 min

NL

$68.40$87.40

$114.00

$3.60 (LFS)

$9.33 (LFS) $16.88 (LFS)

$82.10 $112.37 $167.50

$43.56

$204.54

$91.30 $124.73 $183.89 $36.55 $66.57 $95.37 $66.26

$97.00

$68.77 $105.47 $152.90

78.7% 74.4% 63.5%

104.7%

70.6%

52.0% 67.0% 58.9% 78.0% 68.5% 79.7%103.2%

117.5%

99.5% 82.9% 74.6%

$148.08 $61.04 $82.45 $121.06 $55.41

$82.96 $119.66

$62.99 (IER)

110.3%--------

--115.9%

--




Specialty Care Codes

$2.66$5.32$6.08$3.80$5.28$5.28

95004 - Percutaneous tests with allergenic extracts 95010 - Percutaneous tests, sequential and incremental

95115 - Allergenic immunotherapy, single injection 95117 - Allergen immunotherapy, two or more injections

Allergy/Immunology

95015 - Intracutaneous tests, with biologicals 95024 - Intracutaneous tests with allergenic extracts

95004 - Percutaneous tests with allergenic extracts 95010 - Percutaneous tests, sequential and incremental

95115 - Allergenic immunotherapy, single injection 95117 - Allergen immunotherapy, two or more injections

$1558.00

$140.60$209.00$224.20$106.40$798.00

Cardiology

93510 - Left heart catheterization

92950 - Cardiopulmonary resuscitation 93303 - Transthoracic echocardiography

93320 - Doppler echocardiograph 93501 - Right heart catheterization

93307 - Echocardiography, real-time with image documentation

32551 - Tube thoracostomy, includes water seal

$77.14$66.86$51.43$20.57$56.57 36620 - Arterial line placement

Critical Care 31500 - Intubuation, endotracheal

36568 - Insertion of peripherally inserted CVC~; <5 yrs old 36600 - Arterial puncture, diagnostic

36555 - Insertion of non-tunneled CVC~ ; <5 yrs old

$79.80$159.60

99292 - Critical care, additional 30 minutes 99291 - Critical care, first hour

Emergency Care10120 - Simple surgical removal of foreign body $66.86

$118.29$20.57

36410 - Venipuncture necessitating physician skill, >= 3 years $15.4336415 - Routine venipuncture $4.40

62270 - Lumbar puncture, diagnostic $102.86

36400 - Venipuncture necessitating physician skill, < 3 yrs, 12015 - Simple surgical repair of facial wound(7.6-12.5cm)

36416 - Finger, heel, ear stick NC

99143 - Moderate sedation by same physician < 5 yrs 99144 - Moderate sedation by same physician 5 yrs + 99145 - Moderate sedation by same physician add-on

$104.12$78.09$26.03

$5.88 $17.37 $13.52 $6.84 $9.39 $11.63

45.2% 30.6% 45.0% 55.5% 56.3% 45.4%

$154.29

$1114.19 (P2010)

$266.19 $200.36 $140.89 $59.56

$695.97 (P2010)

$101.34 $256.23 $283.54 $29.10 $48.03

$112.44 $250.65

$125.69 $165.25 $27.16 $16.97

$144.21NIS

$59.38 (IER) $58.92 (IER) $19.76 (IER)

$159.66

139.8%

52.8%104.3%159.1%178.6%114.7%

76.1% 26.1% 18.1% 70.7%117.8%

71.0% 63.7%

53.2% 71.6% 75.7% 90.9%146.7%

71.3%--

175.3%132.5%131.7%

96.6%

$3.00




99149 - Moderate sedation diff physician 5 yrs + 99150 - Moderate sedation diff physician add-on 99282 - ED visit, problem focused $34.2099283 - ED visit, expanded $51.3199284 - ED visit, detailed $60.80

99148 - Moderate sedation diff physician < 5 yrs $104.12$78.09$26.03

$221.15$252.01

43239 - Upper gastrointestinal endoscopy with biopsy 43239 - Upper gastrointestinal endoscopy with biopsy 44389 - Colonoscopy with biopsy

$92.57 45331 - Sigmoidoscopy with biopsy

Gastrointestinal

Emergency Care

$925.74$925.74$102.86

67314 - Strabismus surgery, vertical 68810 - Nasolacrimal probing

Ophthalmology 67311 - Strabismus surgery, horizontal

$313.72$339.44$205.72 69436 - Tympanostomy and tubes

Otolaryngology 42820 - Tonsillectomy/adenoidectomy, under 12 years 42821 - Tonsillectomy/adenoidectomy, 12 years or over 69436 - Tympanostomy and tubesNeonatal and Pediatric Critical Care 36510 - Umbilical vein catheterization $51.43

$72.00 36660 - Umbilical artery catheterization

Initial and Continuing Intensive Care Services

99471 - Initial pediatric critical care (29d-24m) 99472 - Subsequent pediatric critical care (29d-24m) 99475 - Initial pediatric critical care (2-5 yrs) 99476 - Subsequent pediatric critical care (2-5 yrs) 99468 - Initial neonatal critical care 99469 - Subsequent neonatal critical care

99477 - Initial neonatal intensive care 99478 - Subsq intensive care, < 1500 gm 99479 - Subsq intensive care, 1500-2500 gm99480 - Subsq intensive care, 2501-5000 gm

$543.40$271.70$361.00$220.40$627.00$334.40

$255.38$133.80

$91.96$91.96

$38.25 $58.01 $108.94

$54.40 (IER) $44.52 (IER) $19.76 (IER)

$322.58 $372.77 $160.29

$536.21 $602.69 $214.53

$275.94 $287.07 $153.11

$97.63 $68.10 $742.50 $372.48 $518.90 $314.39 $849.92 $375.43

$331.48 $130.71 $120.10 $112.22

89.4% 88.4% 55.8%

191.4%175.4%131.7%

68.6% 67.6% 57.8%

172.6%153.6% 47.9%

113.7%118.2%134.4%

52.7%105.7% 73.2% 72.9% 69.6% 70.1% 73.8% 89.1%

77.0%102.4% 76.6% 81.9%

Medicaid Medicare %Medicare(Continued)



$241.72

$39.90$17.10$22.80

$32.30$11.40

$23.29

$822.88$833.17

$1028.60$591.45$534.87$504.01

$144.00

$176.32

$66.86

$380.00$254.60$163.40$254.60$133.00

31622 - Bronchoscopy

94010 - Spriometry, including graphic record

Pulmonology

94640 - Inhalation treatmen94644 - Continuous inhalation treatment, first ho

94664 - Demonstration/evaluation94645 - Same as 94644, each additional hour

32421 - Thoracentesis for aspiration

Radiology

71010 - Frontal chest x-rayPlastic Surgery40700 - Cleft lip repair42200 - Cleft palate repair

28262 - Extensive clubfoot release 44950 - Appendectomy 49500 - Bilateral inguinal hernia, 6 mos to under 5 yrs 49505 - Bilateral inguinal hernia, 5 years or over

Surgery

Urology and Dialysis50200 - Renal biopsy

90945 - Peritoneal dialysis

90957 - ESRD services for 12-19 yrs, 4+ physician visits/mo90958 - Same as above, 2-3 physician visits/mo 90959 - Same as above, 1 physician visits/mo 90965 - Same as above, home dialysis for full month 90966 - Same as above, dialysis for day

$294.41

$33.20 $14.83 $37.58

$14.83 $13.55

$22.33

$901.18 $816.45

$1244.46 $566.87 $338.70 $457.02

$545.99

$74.91

$146.57

$613.26 $415.45 $276.65 $423.27 $222.51

82.1%

120.2%115.3% 60.7%

217.8% 84.1%

104.3%

91.3%102.0%

82.7%104.3%157.9%110.3%

26.4%

235.4%

45.6%

62.0% 61.3% 59.1% 60.2% 59.8%



Dental and Oral Health Services

D0120 - Periodic exam $17.00

D1120 - Prophylaxis, child $22.00D1203 - Topical fluoride treatment, child $9.00

D2150 - Amalgam – two surfaces, primary or permanent $63.00D2330 - Resin-based composite – one surface anterior $62.00D1351 - Sealant, per tooth $23.00D2930 - Stainless steel crown on a primary tooth $123.00D3220 - Pulpotomy $70.00D7140 - Extraction $56.00

Dental codes (CDT Codes) are copyright 2006 American Dental Association.


D0145 - Caries Risk Assessment $28.00

Medicaid Reimbursement for Preventive Oral Health Services Performed by Non-dental Medical ProvidersState did not provide information regarding reimbursement of non-dental medical providers (e.g., pediatricians and family physicians) for periodic oral exam (D0120), topical fluoride treatment to children (D1203/6) or caries risk assessment (D0145).

NIS


--------------------

2010-2011 nebraska medicaid reimbursement american academy of pediatrics

Documents