Section 471-19-005 - BILLING AND PAYMENT FOR SERVICES005.01BILLING.005.01(A)GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that billing requirements in 471 NAC 3 conflict with billing requirements outlined in 471 NAC 19, the billing requirements in 471 NAC 19 will govern.005.01(B)SPECIFIC BILLING REQUIREMENTS.005.01(B)(i)BILLING INSTRUCTIONS. Providers must bill Nebraska Medicaid using the appropriate claim form or electronic format.005.02PAYMENT.005.02(A)GENERAL PAYMENT REQUIREMENTS. The department will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. in the event that payment regulations in 471 NAC 3 conflict with payment regulations outlined in 471 NAC 19, the payment regulations in 471 NAC 19 will govern.005.02(B)SPECIFIC PAYMENT REQUIREMENTS.005.02(B)(i)REIMBURSEMENT. Nebraska Medicaid pays for covered podiatry services in an amount equal to the lesser of: (1) The provider's submitted charge; and(2) The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service.005.02(B)(ii)MEDICARE AND NEBRASKA MEDICAID CROSSOVER CLAIMS. For information on the payment of Medicare and Nebraska Medicaid crossover claims, see 471 NAC 3.005.02(B)(iii) COPAYMENT. For Nebraska Medicaid copayment requirements, see 471 NAC 3.005.02(B)(iv)PAYMENT FOR SURGERY. Payment for surgeries is as follows: (1) Surgical procedures are arranged in descending order according to the Department's allowable charges. The major procedure is paid at 100 percent of the allowable charge; and(2) Subsequent procedures are paid at 50 percent of the allowable charge.(3) Except for the initial office visit, payment for major surgical procedures includes office visits on the day of surgery and 14 days of post-operative care. The department follows the surgery guidelines in the American Medical Association's Current Procedural Terminology (CPT).(4) Payment for surgical procedures that are primarily performed in office settings is reduced by 12 percent when performed in hospital outpatient settings, including emergency departments. 005.02(B)(v)STERILE SURGICAL TRAYS. Payment for a sterile surgical tray includes routine or special surgical instruments, office operating room cost, sutures, supplies, items used to prepare a sterile field for the surgical procedure, and the sterilization and maintenance of these items.005.02(B)(vi)SUPPORTIVE DEVICES FOR THE FEET. Payment for custom orthotic devices which require impression casting by the podiatrist includes: (2) Cost of parts and labor;(3) Repairs due to normal wear and tear within 90 days of the date dispensed; and(4) Adjustments made when fitting and for 90 days from the date dispensed.(a) Adjustments necessitated by changes in the recipient's medical condition, or the recipient's functional abilities, are reimbursed separately.005.02(B)(vii)CLINICAL LABORATORY SERVICES. Payment for specimens obtained in the podiatrist's office and sent to an independent clinical lab or hospital for processing must be claimed by the facility performing the tests. The Department does not reimburse the podiatrist for handling specimens or processing or interpreting tests performed outside the podiatrist's office.471 Neb. Admin. Code, ch. 19, § 005
Amended effective 12/5/2015.Amended effective 12/26/2021