Subsection 144-101-II-94.06 - BILLING AND REIMBURSEMENT94.06-1Bright Futures Health Assessment VisitsMaineCare will reimburse providers for one health assessment visit per member for each age shown on the MaineCare Bright Futures periodic health assessment schedule (Appendix 1).
A.Physicians, Physician's Assistants, Advanced Practice Registered Nurses in Private Practice Use the Evaluation and Management Preventive Medicine Services and Newborn Care codes set forth in the Early and Periodic Screening, Diagnosis and Treatment Services Appendix to the Billing Instructions. Contact MaineCare Services, Provider Relations Unit to get a copy of the Appendix to the Billing Instructions.
Bill in accordance with the Billing Instructions of the Department for the CMS 1500.
B.Federally Qualified Health Centers (FQHC)/Rural Health Clinics (RHC) Use core visit code established in the MaineCare Benefits Manual, Chapter III, Section 31 (FQHCs) or Section 103 (RHCs).
Bill in accordance with the Billing Instructions of the Department for the CMS 1500.
C.Hospital Based/Owned Physician Practices Bill in accordance with the Department's Billing Instructions for the CMS 1500 or the UB 04 as appropriate.
D.Ambulatory Care ClinicsUse codes established in the MaineCare Benefits Manual, Chapter III, Ambulatory Care Clinics Section 3.
Bill in accordance with the Billing Instructions of the Department for the CMS 1500.
E.Durable Medical Equipment providers Use codes established in the MaineCare Benefits Manual, Chapter III, Section 60, Medical Supplies and Durable Medical Equipment.
Bill in accordance with the Billing Instructions of the Department for the CMS 1500.
94.06-2.Lead TestingA.Blood Lead Testing MaineCare will pay physicians, physicians' assistants, advanced practice registered nurses and other appropriately licensed providers rendering services within the scope of their practice an enhanced reimbursement for blood draws performed for the purpose of testing blood lead levels in MaineCare members at ages one (1) and two (2). Newly MaineCare eligible children between the ages of three (3) and five (5) years of age may also receive a screening blood lead test if they have not been previously screened for lead poisoning
Use codes/modifiers in the Early and Periodic Screening, Diagnosis and Treatment Appendix to the Billing Instructions.
Bill in accordance with the Billing Instructions of the Department for the CMS 1500.
B.Environmental Investigations MaineCare will pay the Maine Department of Health and Human Services, Maine Disease Control and Prevention, for professional staff time and activities during an on-site investigation of a member's home (or primary residence) when the child has been diagnosed as having an elevated blood lead level. MaineCare will not reimburse for any testing of substances (e.g. soil, dust, water, paint) that are sent to a laboratory for analysis.
Use the code in the Early and Periodic Screening, Diagnosis and Treatment Appendix to the Billing Instructions.
Bill in accordance with the Billing Instructions of the Department for the CMS 1500.
94.06-3.Home Visits for Children Age Two (2) and Under MaineCare will pay for direct services provided in the child's home that are part of a plan of care approved by the member's physician, physician's assistant, or advanced practice registered nurse. MaineCare will pay for up to two point five (2.5) hours of direct service per family per month provided by a registered nurse or other specially trained professional employed either by a home health agency; a Federally Qualified Health Center; a Rural Health Clinic; or an Ambulatory Care Clinic.
Use the code in the Early and Periodic Screening, Diagnosis and Treatment Appendix to the Billing Instructions.
Bill in accordance with the Billing Instructions of the Department for the CMS 1500.
94.06-4.Treatment Services MaineCare will pay the lower of:
A. The provider's usual and customary charge as evidenced by a written fee schedule in accordance with Medicare guidelines; orB. The reimbursement rate established by MaineCare for treatment services in accordance with the guidelines of the originating section of MaineCare policy; orC. The lowest published Durable Medical Equipment fee schedule, when applicable. Bill using the Billing Instructions of the Department for the CMS 1500, UB 04 or ADA claim form, as appropriate.
NOTE: Billing instructions are included in the provider enrollment packet or are available by contacting the MaineCare Services Billing and Information Unit at 1-800-321-5557 Option 8.
Recommendations for Preventive Pediatric Health Care Committee on Practice and Ambulatory Medicine Appendix 1
Each child and family is unique; therefore, these Recommendations for Preventive Pediatric Health Care are designed for the care of children who are receiving competent parenting, have no manifestations of any important health problems, and are growing and developing in satisfactory fashion. Additional visits may become necessary if circumstances suggest variations from normal.
These guidelines represent a consensus by the Committee on Practice and Ambulatory Medicine in consultation with national committees and sections of the American Academy of Pediatrics. The Committee emphasizes the great importance of continuity of care in comprehensive health supervision and the need to avoid fragmentation of care.
The following Bright Futures/AAP Periodicity Schedule with corresponding footnotes 1-23 is for visual reference only. Refer to Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents of the American Academy of Pediatrics at http://brightfutures.aap.org/clinical_practice.htmlfor complete details.
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1. If a child comes under care the first time at any point on the schedule, or if any of the items are not accomplished at the suggested age, the schedule should be brought up to day at the earliest possible time.2. A prenatal visit is recommended for parents who are at high risk, for first-time parents, and for those who request a conference. The prenatal visit should include anticipatory guidance, pertinent medical history, and a discussion of benefits of breastfeeding and planned method of feeding per AAP statement. "The Prenatal Visit (2001) [URL: http://aapolicy.aappublications.org/cgi.content/full/pediatrics;107/6/1456 [File Link Not Available]].3. Every infant should have a newborn evaluation after birth, breastfeeding encouraged, and instruction and support offered.4. Every infant should have an evaluation within 3 to 5 days of birth and within 48 to 72 hours after discharge from the hospital to include evaluation for feeding and jaundice. Breastfeeding infants should receive formal breastfeeding evaluation, encouragement, and instruction as recommended in AAP statement "Breastfeeding and the Use of Human Milk" (2005) [URL: http://aappolicy.aappublications.org/content.full/pediatrics;113/5/1434 [File Link Not Available]].5. Blood pressure measurement in infants and children with certain risk conditions should be performed at visits before age 3 years.6. If the patient is uncooperative, rescreen within 6 months per the AAP statement "Eye Examinations in Infants, Children, and Young Adults by Pediatricians" (2007) [URL: http://aappolicy.aappublications.org/cgi.content/full/pediatrics;111/4/902 [File Link Not Available]].7. All newborns should be screened per AAP statement "Year 2000 Positions Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs" (2000) [URL: http://aappolicy.aappublications.org.cgi/content/full/pediatrics;106/4/798 [File Link Not Available]], Joint Committee on Infant Hearing. Year 2007 position statement principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007;120:898-921.8. AAP Council on Children With Disabilities, AAP Section on Developmental Behaviors Pediatrics, AAP Bright Futures Steering Committee, AAP Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006; 118:405-420 {URL: http://aappolicy.aappublications.org/cgi/content/full/119/1/152 [File Link Not Available]].10. At each visit age-appropriate physical examination is essential, with infant totally unclothed, older child undressed and suitably draped.11. These may be modified, depending on entry point into schedule and individual need.12. Newborn metabolic and hemoglobinopathy screening should be done according to state law. Results should be reviewed at visits and appropriate retesting or referral done as needed.13. Schedules per the Committee on Infection Diseases, published annually in the January issue of Pediatrics. Every visit should be an opportunity to update and complete a child's immunizations.14. See AAP Pediatric Nutrition Handbook, 5th Edition (2003) for a discussion of universal and selective screening options. See also Recommendations to prevent and control iron deficiency in the United States, MMWR. 1998; 47{RR-3):1-36.15. For children at this of lead exposure, consult the AAP statement "Lead Exposure in Children: Prevention, Detection, and Management" (2005) [URL: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;116/4/1036 [File Link Not Available]]. Additionally, screening should be done in accordance with state law where applicable.16. Perform risk assessments or screens as appropriate, based on universal screening requirements for patients with Medicaid or high prevalence.17. Tuberculosis testing per recommendations of the Committee on infectious Diseases, published in the current edition of Red Book: Report of the Committee on Infectious Diseases. Testing should be done on recognition of high-risk factors.18. "Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report" (2002) [URL: http://circ.ahajournals.org/cgi/content/full/106/25/3143] and "The Expert Committee Recommendations on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity." Supplement to Pediatrics. In press.19. All sexually active patients should be screened for sexually transmitted infections (STIs).20. All sexually active girls should have a screening for cervical dysplasia as part of a pelvic examination beginning within 3 years of onset of sexually activity or age 21 (whichever comes first).21. Referral to dental home, if available. Otherwise administer oral health risk assessment. If the primary water source is deficient in fluoride, consider oral fluoride supplementation,22. At the visits for 3 years and 6 years of age, it should be determined whether the patient has a dental home. If the patient does not have a dental home, a referral should be made to one. If the primary water source is deficient in fluoride, consider oral fluoride supplementation.23. Refer to the specific guidance by age as listed in the Bright Futures Guidelines. (Hagan JF, Shaw JS, Duncan PM, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd Ed. Elk Grove Village, IL: American Academy of Pediatrics: 2008.) 10-144 C.M.R. ch. 101, II-94.06