Ga. Medicaid Part II Policies & Procedures for Hospital Services § 910

910.1. Services through the HOT program require prior authorization. This

includes both evaluations and treatments. Providers must submit separate

prior authorizations for Evaluation codes vs. Treatment codes.

910.2. Prior Authorization for EVALUATIONS:

910.2.1. Request for evaluations through the Hospital Outpatient Therapy

program should be for ACUTE conditions only. Clinical and ICD 10

codes should reflect that the member has an “ACUTE” condition.

Exceptions include: DME evaluations for wheelchairs and equipment,

some swallowing studies and some hearing evaluations

910.2.2. Evaluation codes will populate for approval for a 90-day date span. This

will allow flexibility of scheduling and prevent the need for date

changes.

910.2.3. Modifiers are not required for evaluation codes

910.2.4. Backdating is defined as an “effective” date prior to the “request” date on

the PA. Back dating is ONLY allowed in the case of RETRO eligibility,

OR under Emergent/Urgent circumstances i.e. ED evaluation,

Observation stay, or under circumstances of an urgent evaluation done

after surgery when there was no time to request prior authorization.

Backdating is NOT allowed for failure to plan or provider error. Provider

should enter a statement in the Comment/messages section if request is

for OBSERVATION stay, RETRO, or evaluations performed in

Emergency Department.

910.2.5. Urgent/ Emergent relates to those cases where member has retro

eligibility for the date of service and/or patient suffered an urgent

medical condition requiring immediate therapy care. Requests submitted

on or after request date should be submitted as elective.

910.2.6. Providers should answer ALL questions on the Prior authorization.

Questions relate to policy and answers indicate adherence to policy

910.2.7. Family of Codes: PT and OT Evaluation codes are part of a “family of

codes”. This indicates that you will only need to enter one of the codes

in the family of codes. At the time claims are billed, the most

appropriate code in the family should be selected. There is no family of

codes for Speech evaluation codes as these evaluations are based on

specific diagnostic issues and not based on time to complete. Please only

select the appropriate speech evaluation codes for patient’s needs. Other,

unnecessary evaluation codes will be denied.

910.3. PT evaluation family of codes include:

910.3.1. 97161 Physical therapy evaluation: low complexity (20 minutes)

910.3.2. 97162 Physical therapy evaluation: moderate complexity (30 minutes)

910.3.3. 97163 Physical therapy evaluation: high complexity (45+ minutes)

910.4. OT evaluation family of codes include:

910.4.1. 97165 Occupational therapy: low complexity (30 minutes)

910.4.2. 97166 Occupational therapy: moderate complexity (45 minutes)

910.4.3. Occupational therapy: high complexity (60 minutes)

910.4.4. Evaluation Prior Approvals do not require an attachment. However, if

there is no attachment, providers must provide specific documentation in

the body of the PA of the ACUTE condition requiring treatment. Please

be specific as to the DATE of onset of the illness, injury or surgery. A

clear sentence of patient’s age, illness, injury or surgery and the EXACT

date it occurred in the comments/messages section will expedite

processing of your request. This statement must support that condition is

ACUTE

910.4.5. In the case of DME evaluations, provider should be specific in answering

the questions as to the type of equipment being requested by choosing

the appropriate equipment in the drop-down menu. 97542 – Wheelchair

management code can be requested with an equipment evaluation. This

code can be used for “delivery” of equipment requested. At this time, it

is the only code that can be submitted as both an “evaluation code” and a

“treatment code”.

910.4.6. Providers will answer an attestation question regarding “orders”. By

answering YES to this question, the provider is attesting that they have

written and signed orders from the Physician, NP, or PA.

910.4.7. Chronic conditions with acute exacerbations are NOT covered. If there is

a chronic condition with a superimposed new and acute injury such as

chronic back pain with a new strain as a result of a recent motor vehicle

accident or fall, it will be reviewed for acuity and medical necessity. It is

imperative that you are specific with details and date of onset.

910.5. For example:

910.5.1. Chronic condition: Low back pain. Acute exacerbation: Member was

in a car accident (date of accident) and sustained a new injury.

910.5.2. Chronic condition: Lymphedema. Acute exacerbation: Lymphedema

with new open wounds (provide details and date of onset of new

wounds).

910.6. Prior Authorization for TREATMENT:

910.6.1. All requests for treatment units should be for an “ACUTE” condition,

injury, illness or surgery. This information and DATE of onset should be

readily available in the documentation submitted

910.6.2. Treatment PA’s require an attachment. You must attach a copy of your

PLAN OF CARE to all requests for treatment units. If there is no

attachment, your PA will be automatically denied. The plan of care must

be signed and dated by the physician, PA or NP within 30 days of

starting treatment. By answering YES to the question regarding the plan

of care, provider attests they will have the plan of care signed and dated

within 30 days of starting treatment. By allowing the plan of care to be

signed within 30 days of starting treatment, this will prevent delays in

initiating patient care.

910.6.3. Provider must answer all questions on the PA. Failure to adhere to policy

will result in system denials.

910.6.4. Treatment units can be requested for a maximum of 3 calendar months.

910.6.5. Each line must have an effective and expiration date within the same

calendar month. The effective expiration date should not span over more

than one calendar month. Example: effective: 5/1/2021- expiration:

5/31/2021. Incorrect would be effective: 5/1/2021- expiration:

7/30/2021. Dates spanning over more than one calendar month will

cause edit errors to your PA and issues with payment in claims.

910.6.6. EFFECTIVE date for elective care must be on or AFTER the REQUEST

date on the prior authorization. Urgent/Emergent OR documented Retro-

eligibility for the dates being requested can have effective date prior to

REQUEST date. Documentation should clearly reflect RETRO

eligibility or the EXACT date of illness, injury or surgery and valid

reason for urgent/emergent request. Failure to plan is not urgent/

emergency and will be denied untimely.

910.6.7. All requests for treatment codes require use of a modifier in the Mod 1

column only. GP for Physical therapy. GO for Occupational therapy.

GN for Speech therapy. Only 1 discipline can be submitted per prior

authorization request. Please note, all PAs for therapy codes that do not

use modifiers or use two different modifiers on the same PA will be

denied and provider will be asked to enter a new PA with the correct

modifier. Reviewers are unable to make this correction. Claims

submitted without a modifier will be denied.

910.6.8. There are 3 “family of codes” for treatment units; Speech therapy:

92507 and 92526 Physical and Occupational therapy: 97110, 97112,

97116, 97530, 97535. These codes are part of a FAMILY OF CODES.

When you are approved for 1, you may bill any of the other codes within

the same family to claim. When requesting these codes, you should

request the total number of units needed. Use of the appropriate modifier

will identify your code to the correct discipline. Without a modifier, it

will appear to the system as a duplication. A treatment prior approval

submitted without a modifier, will result in the case being denied as the

modifier cannot be added by reviewer. Audiology codes 92651, 92652,

and 92653 do not require prior authorization.

910.6.9. Units should be calculated appropriately by the provider. Therapy

sessions should not exceed one hour and should be calculated based on 4

units per session when using 15 min timed codes or 1 unit per session

when using an untimed code (ex: 92507 or 92526). Units are submitted

based on the TOTAL number of units needed for the calendar month. 2x

weekly would be 8 units per week or 32-40 TOTAL units per month. 3x

weekly would be 12 units per week or 48-60 TOTAL units per month.

Max number of units should be divided over the CPT codes submitted.

910.6.10. The Plan of care approved by the Physician, PA, or NP must contain at

minimum the components listed below. The POC at a minimum must be

submitted for the Medicaid member as documentation of medical

necessity

910.6.10.1. Member’s name and member ID number

910.6.10.2. Date of Birth

910.6.10.3. Acute Diagnosis and/or condition requiring treatment

with clearly documented date of onset

910.6.10.4. Modalities

910.6.10.5. Procedures (i.e., description of the services requested)

910.6.10.6. Evaluation and date the evaluation was conducted

910.6.10.7. POC completion date (this must be on or after the

evaluation date)

910.6.10.8. Effective POC start and end dates along with the

frequency and duration of services.

910.6.10.9. Location of services

910.6.10.10. Team members that are treating the patient (i.e., OT,

SLP, PT, etc.)

910.6.10.11. Current level of function

910.6.10.12. Patient’s progress to date

910.6.10.13. Functional outcomes (potential for rehabilitation, long

term goals of therapy)

910.6.10.14. Goals to be achieved as well as timelines to reach

projected goals

910.6.10.15. Any other relevant medical information.

910.6.10.16. The therapist that develops the POC must sign and date

the document on the date completed.

At the time the claims are billed, the most appropriate code in the family of codes

should be billed. The modifiers approved on the PA should be in agreement with the

modifiers submitted on the claim or the claim may deny.

910.7. Observation

The purpose of observation is to treat patients expected to be stabilized and released within

twenty-four (24) hours, determine the need for further treatment or for inpatient admission.

Thus, a patient in observation may improve and be released or admitted as an inpatient.

Outpatient observation services Begin and End with a physician’s order.

Observation services are those services furnished by a hospital, including use of a bed and

periodic monitoring by a hospital’s nursing or other staff, which are reasonable and

necessary to evaluate an outpatient’s condition or determine the need for a possible

admission to the hospital as an inpatient. Appropriateness of observation services is

determined using qualifying criteria such as those published by a “nationally recognized

criteria”, severity of illness/intensity of services (SI/IS), and medical necessity reviewed by

peer reviewers

Observation services usually do not exceed twenty-four (24) hours and the physician’s

decision to admit, or discharge is typically determined within this time. Orders for

“observation” and “inpatient admission” can only be written by those physicians authorized

by the hospital’s medical staff bylaws to admit patients or order outpatient observation.

Some patients, however, may require more than twenty-four (24) hours of outpatient

observation services. In only rare and exceptional cases, outpatient observation services

span more than 24 hours. If a patient is retained on observation status for more than 24 hours

without being admitted as an inpatient, further observation services will be denied as not

reasonable and necessary for the diagnosis or treatment of a physical or mental health

condition. (See Part I Policies and Procedures Manual, Definitions, definition 48 Medical

necessity.). Count as the first hour of admission to an observation status. Claims submitted

with more than 24-hour observation will be denied. If the 24-hour observation limit is

exceeded and the patient does not meet the acute criteria for inpatient admission, the claim

and medical justification should be submitted to Medical Review.

If the patient’s medical condition meets medical necessity and using acute inpatient-

qualifying criteria published by a “nationally recognized criteria”, inpatient admission is

appropriate, and the patient must remain hospitalized until concurrent review performed by

the hospital indicates discharge is necessary. Such services are covered only when provided

by the order of a physician or another individual authorized by State licensure law and

hospital staff bylaws to admit patients to the hospital or to order outpatient tests and when

provided in compliance with all policies and procedures described in this manual.

A person is considered a hospital inpatient if formally admitted and acute inpatient

qualifying criteria designated by the Division, from a “nationally recognized criteria” are met.

When a hospital places a patient under observation, but has not formally admitted them as an

inpatient, the patient is considered an outpatient.

Observation is generally covered as an outpatient service. Observing the patient for up to 24

hours should be adequate in most cases. A hospital, which believes that exceptional

circumstances in a particular case justify approval of more than 24 hours in an outpatient

observation setting, may submit a claim by hard copy with documentation of the exceptional

circumstances. The claim may include the total number of observation units. The claims will

pend for medical review. If, after medical review, the determination is made that continued

observation beyond 24 hours was medically necessary, an observation status may be

approved. However, any services provided beyond the medically necessary time are non-covered.

If medical reviews determined that observation beyond 24 hours was not medically

necessary, payment will be made for the hours determined to be medically appropriate, up to

24 hours. When the patient’s condition does not meet inpatient criteria and the hospital does

not wish to file an appeal for the observation beyond 24 hours, all charges past the 24-hour

period are non- covered. The provider should then bill the department for only those hours

considered medically appropriate.

When medical necessity dictates an inpatient admission of a patient in observation, this

should be billed under revenue code 762, as referred to in the billing instructions, (form

locator 42) which reflects this transaction. Observation is a covered revenue code on an

inpatient claim.

Outpatient observation is not covered in the following situations: complex cases requiring

inpatient care, post-operative monitoring during the standard recovery period; routine

preparation services furnished prior to diagnostic testing in the hospital outpatient

department and the recovery afterwards; and the observation billed concurrently with

therapeutic services such as chemotherapy, physical therapy, etc.

The outpatient status becomes inpatient when the determination is made that inpatient

services are medically necessary. Inpatient services must be certified as explained in Chapter

800. Certification must be obtained within thirty calendar days of the beginning date of this

episode of care. In order to receive certification for the admission, documentation must be

provided evidencing that the criteria admission is medically necessary and appropriate.

The date of the inpatient admission will be the actual date the patient is formally admitted as

an inpatient and will count as the first inpatient day. When a patient is admitted to the

hospital from outpatient observation, all observation charges must be combined and billed

with inpatient charges. Elective procedures where the anticipated stay is 24 hours or less are

typically considered an observation stay, primarily if the primary reason for the stay is to

monitor for potential complications. Services, such as complex surgery, clearly requiring

inpatient care may not be billed as outpatient.

Request for updates to the precertification file and retroactive certification of inpatient

admissions following a procedure or service clearly indicating an inpatient level of care that

should have been anticipated will not be considered timely and will be denied.

Failure to obtain the required certification will result in denial of reimbursement of ALL

services provided.

The Division only covers services that are medically appropriate and necessary. The services

provided in the setting must be appropriate to the specific medical needs of the member. (See

Part I Policies and Procedures Manual, Definitions, 19 Medical Necessity.) The medical

record must substantiate the medical necessity and appropriateness including appropriateness

of the setting. When the outpatient observation setting is non-covered, all services provided

in the outpatient observation setting are also non-covered. Services that are not reasonable or

necessary for the diagnosis or treatment of the patient but are provided for the convenience

of the patient or a physician are not covered. (See Part I Policies and Procedures Manual,

Definitions, 19 Medical Necessity.)

Level of care and setting determination are based on patient assessment, medical condition

and anticipated or actual treatment as documented in the request for approval. Peer review, in

conjunction with inpatient/outpatient qualifying criteria from a “nationally recognized

criteria” may be used by PA/UM contractors to assess the patient’s medical condition and to

substantiate medical necessity for inpatient or outpatient status. The process is the standard

for providers, DCH, Gainwell, PA/UM and any other Division Contractors. Hospitals will be

required to conduct concurrent review and will be required to keep the hospitalized patient

until the same criteria indicate hospitalization is no longer necessary. DMA will notify

providers in writing at least 30 days prior to the date of any changes in the criteria or version

of criteria being used to certify inpatient admissions. Written notice would be provided on

banner messages, on remittances, and on the Gainwell Technology web site

(www.mmis.georgia.gov ). The same version of criteria will be used for any retrospective

medical reviews as were used prospectively or concurrently.

NOTE: Hospitals should not substitute outpatient observation services for medically

appropriate inpatient admissions. An inpatient is not considered to have been discharged if

placed in observation status after an inpatient admission. The availability of outpatient

observation does not mean that services, for which an inpatient stay is anticipated, may be

performed and billed to the Division on an outpatient basis. Services such as complex

surgery clearly requiring inpatient care and pre-certification may not be billed as Outpatient.

910.8. Delivery and Care of Newborn Infants

Effective dates of admission, July 1, 1998, and greater, charges for the mother and baby must

be billed separately. Please refer to the Newborn Medicaid Eligibility Certification (DMA-

550) in the Billing Manual for Hospital Services and Appendix H of Part II - Policies and

Procedures for Hospital Services.

Effective data with admission July 1, 2000, and greater newborn screening tests are covered

in the hospital. Revenue code 479 should be used when billing for the newborn hearing-

screening test. Please refer to the Billing Instructions for Hospital Services, Form Locator 42.

Effective January 1, 2007, Georgia law (OCGA 31-12-6 & 31-12-7) and Rules and

Regulations (Chapter 290-5-24) require that every live born infant have an adequate blood

testing for 28 disorders. Effective January 1, 2007, the Department of Community Health

will increase Georgia Medicaid payments to hospitals by $40 per newborn, when a newborn

screening is performed. This payment is once per newborn member per lifetime. Effective

July 1, 2010, the newborn screening add-on to hospitals increased from $50 to $63 for

screening performed on or after October 1, 2016. (Rev 01/2018)

In order for the hospital to receive the additional $40 payment, the provider must include

condition code “A1” on the newborn claim in field 18-28 on the UB-04. The $40 payment is

an add-on to the DRG payments and does not impact the adjudication of a claim, nor the

payment methodology currently used by the department. This is an add-on payment meant

to increase the DRG payment by $40 for newborn claims when a newborn screening has

been performed. (Rev 01/2019)

Effective for dates of service including and after July 1, 2018, a $1000 add-on payment for

newborn delivery in rural counties with populations of less than 35,000.

910.9. Magnetic Resonance Imaging (MRI)

Medically necessary MRIs are covered by the Division when CT scans or SPECT procedures

are not definitive or appropriate. Only one MRI per day will be paid without submission of

documentation for medical necessity. Please note that only enrolled Medicaid providers may

be reimbursed for MRI procedures.

910.10. Non-coverage of medically necessary services for members under twenty- one (21)

years of age may be appealed to:

Medical Policy Unit-Hospital Service

Division of Medicaid, 19th Floor

2 Martin Luther King Jr. Drive SE

East Tower

Atlanta, Georgia 30334-3159

910.11. Hospital-Based Rural Health Clinics

Hospitals providing primary care services through the Rural Health Clinic Program must be

certified by the Department of Health and Human Services (HHS) and appropriately enrolled

by the Division as a Hospital-Based Rural Health Clinic. Please refer to the conditions of

participation in Chapter 600 of the Policies and Procedures for Rural Health Services

manual.

910.12. Mammography Services

Screening and diagnostic mammography services are covered. Reimbursement for

mammography services is limited to one procedure per member, per year (July 1 - June 30)

unless medical documentation is provided, which justifies additional services.

In accordance with the MQSA of 1992, mammography services are reimbursed only when

provided by a facility that has been certified by the FDA for mammography services.

Effective with dates of service, October 1, 1994, and after, a facility that has not been

certified has been denied certification or whose accreditation has been revoked will not be

reimbursed for these services. Effective November 1, 2011, a facility’s Mammography

Certificate is to be sent to Gainwell Provider Enrollment Unit for placement in their provider

enrollment file.

910.13. HIV Education and Counseling

The Division, in support of the American Academy of Pediatrics (AAP) and the American

College of Obstetricians and Gynecologists (ACOG), strongly suggests that HIV education

and counseling be made part of the routine standard of care for Medicaid eligible pregnant

women.

910.14. Partial Hospitalization Program – Psychiatric

A Partial Hospitalization Program (PHP) for Medicaid purposes is defined as a

comprehensive structured program that uses a multidisciplinary team to provide

comprehensive coordinated services within an individual treatment plan for individuals

diagnosed with one or more psychiatric disorders.

It is a service in a continuum of care designed to prevent hospitalization or to facilitate the

movement of the acute psychiatric client to a status in which the client is capable of

functioning within the community with less frequent contact with the psychiatric health care

provider.

Partial Hospitalization is a time limited, ambulatory, active psychiatric and/or substance

abuse treatment program that offers therapeutically intensive, coordinated, and structured

clinical services within a stable therapeutic milieu. Partial Hospitalization Programs (PHP)

may be provided on a day and/or evening schedule. Such programs employ an integrated,

comprehensive and complementary schedule of recognized treatment approaches Programs

are designed to serve individuals with significant mental health impairments resulting from

a psychiatric emotional behavioral, and/or substance abuse disorder, and further serve to

avert hospitalization and/or increase a member’s level of independent functioning.

910.15. In order for partial hospitalization to be covered, the services must be:

910.15.1. Certified on admission by the physician that the individual would require

short-term acute inpatient psychiatric treatment in the absence of partial

hospitalization

910.15.2. Incident to physician’s services. The services must be furnished while

the individual is under the care of a physician. The services must be

prescribed by a physician under an individualized plan of treatment. The

plan of treatment must be established and periodically reviewed by a

physician in consultation with the appropriate staff.

910.15.3. A plan of treatment must be established within the first 7 days of a

patient’s participation in the program; reviews and updates to the plan

should be performed at least every 31 calendar days and must include

documentation supporting the need for continued acute care services.

910.15.4. The services must be reasonable and necessary for the diagnosis or active

treatment of the individual’s condition.

910.15.5. There is a reasonable expectation that the treatment will improve or

maintain the patient’s condition and functional level and prevent relapse

and/or acute care hospitalization.

910.15.6. Reimbursement for partial hospitalization services is dependent on two

critical points: 1) the initial decision as to the medical appropriateness of

entrance into the program for treatment; and 2) the decision concerning

discharge. Both determinations should take into account both the

diagnosis and the individual’s treatment needs.

910.15.7. The partial hospitalization program is designed to treat patients who

exhibit severe or disabling conditions related to an acute

psychiatric/psychological condition or an acute exacerbation of a severe

and persistent mental disorder. The partial hospitalization may occur in

lieu of an admission to an inpatient hospital or a continued inpatient

hospitalization. The following clinical information must be submitted

that supports the emergent nature of the services provided. Only the

following documents should be submitted to Georgia Medical Care

Foundation (GMCF) for review:

910.15.7.1. History and Physical

910.15.7.2. Discharge Summary

910.15.7.3. Physician Progress Notes

910.15.8. Medicaid eligible members may attend PHPs for a minimum of one (1)

to a maximum of five (5) days per week. A treatment day requires a

minimum of four (4) hours of scheduled programming inclusive of at

least one therapy session (individual, group, or family therapy) per day.

The daily programming usually includes a combination of treatment and

therapeutic activities. Examples of treatment include but are not limited

to: individual psychotherapy; group psychotherapy; family therapy /

medication reviews; on-going assessments; expressive therapy, such as,

dance, art, or psychodrama; theme specific (psycho- educational) groups,

such as, communication skills, assertiveness training, stress management,

symptom recognition, problem solving, relaxation training, and groups

which focus on substance abuse issues. Appropriate adjunctive

therapeutic activities include cooking, budgeting, personal hygiene skills,

recreation, and social activities designed to incorporate family

involvement. Adjunctive therapeutic activities are not counted toward

fulfilling the four-hour minimum treatment day requirement.

910.15.9. Members may not attend PHP and a Methadone clinic. Only one of these

services will be reimbursed.

910.16. Mandatory Services:

Psychiatric partial hospitalization programs must provide the following mandatory

services and at least two of the following optional services. Payment for both mandatory

services and optional services is included in the rate for day treatment. Providers shall

not make any additional charges to the Georgia Division of Medical Assistance or to the

member.

910.17. Medically Necessary Psychotherapy Services:

910.17.1. These services must demonstrate active treatment of a patient with a

psychiatric condition. These services are subject to program limitations

and must be provided by professionals operating within the appropriate

scope of practice.

910.17.1.1. Individual Psychotherapy

910.17.1.2. Group Psychotherapy.

910.17.1.3. Family Psychotherapy; and

910.17.1.4. Family Assessment if appropriate.

910.18. Medically Necessary Nursing Services:

910.18.1. Medical services directed by a Registered Nurse who evaluates the

particular medical nursing needs of each client and provides for the

medical care and treatment approved by the supervising practitioner.

910.19. Medically Necessary Psychological Diagnostic Services:

910.19.1. Testing and evaluation services must be expected to contribute to the

diagnosis and plan of care established for the individual client. A

Licensed Psychologist may perform testing and evaluation services. If

testing and evaluation services are provided by a specially licensed

psychologist or approved Master’s level person, the services must be

ordered by a supervising practitioner. The supervising practitioner must

document medical necessity.

910.20. Medically Necessary Pharmaceutical Services:

910.20.1. If medications are dispensed by the program, pharmacy services must be

provided under the supervision of a registered pharmacy consultant; or

the program may contract for these services through an outside

licensed/certified facility. All medications must be stored in a special

locked storage space and administered only by a physician, registered

nurse, or licensed practical nurse.

910.21. Medically Necessary Dietary Services:

910.21.1. If a day treatment program provides meals, services must be supervised

by a registered dietitian, based on the client’s individualized needs. The

program may contract for these services through an outside licensed

certified facility.

910.22. Optional Services:

910.22.1. The member must have a need for the services, a supervising practitioner

must order the services, and the services must be a part of the member’s

treatment plan. The therapies must be restorative in nature, not prescribed

for conditions that have plateaued or cannot be significantly improved by

the therapy, or which would be considered maintenance therapy. In

appropriate circumstances, occupational therapy may be covered if

prescribed as an activities therapy in a psychiatric program:

910.22.2. Services provided or supervised by a licensed or certified therapist may

be provided under the supervision of a qualified consultant or the

program may contract these services from a licensed/certified

professional as listed below:

910.22.2.1. Recreational Therapy

910.22.2.2. Speech Therapy

910.22.2.3. Occupational Therapy

910.22.2.4. Vocational Skills Therapy

910.22.2.5. Self-Care Services: Services supervised by a registered

nurse or occupational therapist that is oriented toward

activities of daily living and personal hygiene. This

includes toileting, bathing, grooming, etc.

910.22.2.6. Social Work provided by a bachelor’s level social

worker: Social services to assist with personal, family

and adjustment problems which may interfere with

effective use of treatment, i.e., case management type

services.

910.22.2.7. Social Skills Building

910.22.2.8. Life Survival Skills

910.23. Documentation Requirements:

910.23.1. The physician certification must include

910.23.2. The individual would require hospitalization in the absence of partial

hospitalization.

910.23.3. The individual is under his/her care.

910.23.4. The services were furnished under a written individualized plan of care.

The treatment plan must include, but is not limited to:

910.23.4.1. Physician’s diagnosis

910.23.4.2. Treatment goals

910.23.5. Type of service used to achieve the goals

910.23.6. Amount, frequency and duration of the modalities used to treat the

problems identified.

910.24. Treatment Goals:

910.24.1. Treatment goals are used to measure:

910.24.1.1. The patient’s response to therapy

910.24.1.2. Impact of treatment

910.24.1.3. Coverage of services

The physician determines the frequency and duration of the services,

taking into account accepted norms of medical practice and a reasonable

expectation of improvement in the patient’s condition or maintenance of an

appropriate functional level.

If a therapy (group or otherwise) is not indicated in the plan of care, it

cannot be covered as medically necessary.

910.25. Progress Notes:

910.25.1. Progress notes for each service must be present and relate to the patient’s

condition and the treatment plan.

910.25.2. Progress notes should reflect the patient’s response to the therapy.

910.25.3. Notes may be made on a weekly basis but should be comprehensive and

indicate the specific dates and group sessions or other services rendered

for the time period. (Example: Attended individual sessions on April 5,

7, and 9.)

910.26. Non-Covered Services:

910.26.1. Services which are considered non-covered and should not be included in

the day care charge:

910.26.1.1. Meals and transportation.

910.26.1.2. Activity therapies, group therapies, or other services and

programs, which are primarily recreational or divisional

in nature.

910.26.1.3. Day treatment or geriatric day care programs that consist

of:

910.26.1.3.1. Activity therapies provide social and

recreational activities to individuals who

need some supervision during the day

while family members are away from

home.

910.26.1.3.2. Psychosocial programs or community

support groups in non-medical settings

for chronically mentally ill persons for

the purpose of social interaction

910.26.1.3.3. Vocational and pre-vocational

assessment and training. Services related

to employment opportunities, work

skills or work settings are not covered.

910.26.1.3.4. Drugs and biological items that can be

self-administered.

910.26.1.3.5. General education programs or

education of the general public.

910.26.1.3.6. Any service that does not have a specific

treatment goal and is not outlined in the

individualized treatment plan.

910.26.1.3.7. Any services not documented in the

medical records and identified in the

itemized statement.

910.26.1.3.8. Services to members who:

910.26.1.3.8.1. Refuse or cannot

participate with the

treatment.

910.26.1.3.8.2. Are suicidal, homicidal or

severely demented

individuals.

910.26.1.3.8.3. Demonstrated inadequate

impulse control.

910.26.1.3.8.4. Require social, custodial,

and recreational or respite

care.

910.26.1.3.8.5. Have multiple unexcused

absences or is non-compliant with the

program

910.27. Genetic Counseling

Perinatal genetic counseling will be covered when provided by an employee/contracted

agent of a hospital. These services must be performed by a master’s prepared certified

genetic counselor in conjunction with a physician who is board certified in Genetic

medicine.

Genetic counseling services provided are to be non-directive, outcome planning related

and used to factually inform both the physician and parents of possible genetic impacts

and anomalies.

Services will be limited to three (3) counseling sessions within an eleven-month period

for an eligible Medicaid member. This is to include one (1) initial screening interview

and up to two (2) follow-up sessions for discussion and clarification of issues.

Billing for Perinatal genetic counseling should occur using the revenue code 561 and

the UB-04 claim form, bill type 131.

910.28. Limited Inpatient Services

With the exception of the limitation described in 904.6, there is no limit on the number

of medically necessary inpatient hospital days a Medicaid member is allowed.

Readmission for the same or related problem within three (3) days of discharge is

considered the same admission. Medical justification is the only criterion for

hospitalization for eligible members. Documentation to substantiate medical necessity

and appropriateness of setting may be requested in a prepayment or post payment

review by the Division. Lack of appropriate medical justification may be cause for

denial, reduction, or recoupment of reimbursement.

Inpatient emergency medical services are defined as those services that are medically

necessary as a result of a sudden onset of a medical condition manifesting itself by acute

symptoms of such severity that the absence of immediate medical attention could

reasonably be expected to result in serious dysfunction of any bodily part or death of the

individual.

910.29. Admission for diagnostic purposes is covered only when the diagnostic services cannot

be performed on an outpatient basis.

910.30. Chest X-rays and other diagnostic procedures performed as part of the admitting

procedure will be covered only when:

910.30.1. The test is specifically ordered by a physician responsible for the

patient’s care.

910.30.2. The test is medically necessary for the diagnosis or treatment of the

individual patient’s condition

910.30.3. The test does not unnecessarily duplicate the same test done on an

outpatient basis before admission, or done in connection with a recent

admission; and

910.30.4. The test is billed with the admission.

910.31. Certain services may only be reimbursed when performed on an outpatient basis unless

medical necessity for an inpatient admission is documented and pre- certified (see

Sections 802 and 903.6).

In some cases, the hospital determines that an outpatient hospital setting was appropriate

to the specific medical needs of the member after the services were provided on an

inpatient basis. A physician’s order must document the patient’s status at the time of

admission, and any changes in the patient’s status during the hospital stay should be

documented with a physician’s order. Changes made to the patient’s status must be

made on the basis of medical review and not due to any specific insurance criteria for

billing and reimbursement.

Outpatient services billed as inpatients that are identified for recoupment after review for

medical necessity by the Division or its authorized representatives cannot be re-billed as

outpatient.

910.32. See Section 911 for limits to abortion, sterilization and hysterectomy coverage.

910.33. Certain services are not reimbursable without precertification. Refer to Chapter 800 for

precertification requirements.

910.34. Reimbursement for psychiatric services is limited to short term acute care. The

maximum length of stay considered for reimbursement by the Division is 30 days.

Psychiatric admissions, which have a length of stay in excess of 30 days, will post an

edit for medical review. Prior Authorization is required for additional days in excess of

the 30 allowed days with clinical justification and review of the member’s medical

records for medical necessity.

910.35. Inpatient admissions of less than twenty-four hour’s duration are subject to review for

medical necessity of admission. A length of stay less than twenty-four hours may be

considered inpatient if the services can be provided only on an inpatient basis.

Outpatient services billed as inpatient are subject to recoupment after review for medical

necessity and cannot be re-billed as outpatient.

910.36. Co-payments

Effective with dates of service July 1, 1993, and after, the Division is implementing a

$3.00 member co-payment on all non-emergency outpatient hospital visits. Outpatient

hospital visits include those to clinics o w n e d and operated by a hospital (including

satellite clinics), hospital outpatient departments or hospital emergency rooms.

The Division is implementing a $12.50 member co-payment on all non-emergency

inpatient hospital admissions.

910.37. Pregnant women, members under 21 years of age, nursing facility residents, community

care members, dialysis members, hospice care participants and persons who have both

Medicare and Medicaid coverage are not subject to the co-payment. Family planning

services are also not subject to the co-payment. Beginning with dates of service January

1, 1995, co-payments apply to the following groups of members who were previously

exempt from participating in co-payments. The three groups affected are dialysis

members, Medicare/Medicaid dually eligible members, and members in waivered

services programs. These groups are required to co-pay beginning with dates of service

January 1, 1995, and after, for those services designated as co-pay services.

910.38. Maintenance dialysis services for end stage renal disease are not designated as co-pay

services. No co-pay is required for those services.

910.39. Members who may be subject to the co-payment may be identified by checking member

eligibility via the web or telephone.

On each outpatient visit, the hospital must verify that the member is subject to the co-payment.

Services may not be denied because of the members’ inability to pay the co- payment.

The co-payment is limited to non-emergency admissions.

910.40. Non-Covered Inpatient Services

The services and procedures listed below are non-covered by the Medicaid Division in

the Hospital Program. Services related to, required in preparation for, or as a result of

non-covered services are not covered. Medicaid members enrolled after receiving care

that is or would not have been covered by Georgia Medicaid do not have coverage for

care related to, or as a result of the non-covered services done prior to member

enrollment. Adverse action may be taken against hospitals that willfully continue to bill

the Division for non-covered services identified in this manual.

910.40.1. Services and supplies which are inappropriate or medically unnecessary

as determined by the Division, the Division’s peer review organization,

or other authorized agent.

910.40.2. Private rooms. Conditions that require an isolation room or special care

unit ICU, CCU) are reimbursable. All other accommodations are

reimbursed at the semiprivate room rate on file with the Division for the

date of service.

910.40.3. Patients should be notified upon admission that the Division will only

cover the semi-private room rate. Members who request a private room

after being informed of the Division’s policy will be responsible for the

difference between the hospital’s semi-private and private room rates.

910.40.4. The member cannot be billed for the difference between the amount paid

by Medicaid and the private room rate when the hospital has only private

rooms, has only private rooms available, or the patient has a condition

which requires an isolation room or special care unit.

910.40.5. Intermediate care: i.e., step-down units are reimbursable at the semi-private room rate.

910.40.6. Late charges - defined as a portion of the charges for a given service

omitted from the original billing which included some of the charges for

that given service. If the total charges for a given service were omitted

from the original billing, a positive adjustment may be requested.

Providers who repeatedly use the incorrect billing code generating the

need for a positive adjustment may be subject to adverse action by the

Division. Late Charges to previously paid revenue codes/claims are not

allowed to be changed once the previous claim is paid.

910.40.7. Take-home prescription drugs, medical supplies, durable medical

equipment, and artificial limbs and appliances.

910.40.8. Nursing service. This includes services traditionally accepted as nursing

care even though provided by other ancillary departments, e.g. blood

glucose testing, dressing changes, and labs drawn by nursing (i.e.

STAT), tracheostomy care, oral care, etc.

910.40.9. Private duty nurses, sitters or companions.

910.40.10. Ambulance or other transportation, including air ambulances.

910.40.11. Services which are not medically necessary to the patient’s well-being;

e.g., television, telephone, combs, brushes, guest meals, cots, etc.

910.40.12. Non-consumable multiple supply items; e.g., bath basins, admission kits,

disposable pillows, etc.

910.40.13. Service charges for individual areas within the hospital; e.g., pharmacy

dispensing fee, IV admixture fee (except for hyper alimentation), cover

charge for central supply, charges for handling and distribution of

supplies, transportation within the hospital, equipment installation,

thawing/splitting/pulling, specimen collection, venipuncture, standby

equipment, staff time and evaluations, etc.

910.40.14. Resuscitation, code, CPR (cardio-pulmonary resuscitation), etc. Supplies

associated with this service will be reimbursed.

910.40.15. Leave of absence.

910.40.16. Clinic services while the member is an inpatient.

910.40.17. Patient or family education or supplies

910.40.18. Utilization review.

910.40.19. Differential service charges, e.g., “STAT” or priority, after-hours or

“call-back” fees. Only those hospitals that do not provide twenty-four-hour emergency service may bill for the after hour and call-back

differential fee.

910.40.20. services provided free-of-charge to the public by the hospital or county

health departments, state laboratory or other state agencies, i.e.,

immunizations, metabolic screens for members under one year of age,

etc.; see Appendix E.

910.40.21. Services mandated to be performed only on an outpatient basis.

910.40.22. Investigational items and experimental services, drugs or procedures or

those not recognized by the Federal Drug Administration, Medicare and

the Division’s contracted peer review organization as universally

accepted treatment; including but not limited to, dual photon

absorptiometry, etc.

910.40.23. Any services or items furnished for which the hospital does not normally

charge.

910.40.24. Refer to Section 911 for non-covered situations concerning abortions,

sterilizations and hysterectomies

910.40.25. Services or procedures performed which are not in compliance with the

policies and procedures contained in this manual.

910.40.26. Tubal re-anastomosis procedures pertaining to sterilizations and

vasectomies

910.40.27. Services provided by an institution for mental disease or special

disorders

910.40.28. Separately billed equipment and supplies which are integral parts of

hospital care and the area in which care is being provided; e.g., cardiac

monitor in ICU, light source in OR, call system, blood pressure cuffs and

monitors, specimen collection devices and containers, ABG kits, IV

bottles/bags, IV administration kits, nutritional supplements, dressings,

blankets, oxygen sensors, pumps, under pads, depends/diapers, restraints,

gait belt, etc

910.40.29. Preventive health care. Members under age twenty-one (21) may receive

this care through the EPSDT screening process.

910.40.30. Miscellaneous and non-specific charges.

910.40.31. Non-acute levels of care.

910.40.32. Infertility procedures and related services.

910.40.33. Never Events or HAC Conditions and any HCPCS/CPT Procedure to

Procedure (PTP) co- pairs in billing Outpatient Hospital Services per

CMS’ directive in the NCCI/MUE regulations.

910.40.34. Services with a corresponding charge of zero. No zero-dollar charges

should be listed on the itemization checklist submitted to GMCF of

review. Additionally, do not white out the item, or strike through the

item.

910.40.35. Please use the Procedure Search panel for covered codes

910.41. Limited Emergency Room and Outpatient Services

910.41.1. Emergency medical services are defined as those services that are

medically necessary as a result of a sudden onset of a medical condition

manifesting itself by acute symptoms of such severity that the absence of

immediate medical attention could reasonably be expected to result in

serious dysfunction of any bodily part or death of the individual.

Emergency room visits that cannot be documented as true medical

emergencies or potential medical emergencies will be reimbursed at an

all- inclusive flat rate of $60 for (Urban hospital setting and OOS

Counties) and $70 for rural hospital setting. This rate is for all in-state

and out of state emergency medical services. This rate will cover all

ancillary services rendered as well as the fee for use of the emergency

room. It is for the medical screening and stabilization services provided

in the emergency room without regard to prior authorization. The rates

will not be subject to the hospital’s reimbursement rate.

910.41.2. Accurate coding is critical to ensure proper reimbursement. Coding of

certain diagnoses that represent diseases and conditions that are

recognized as medical emergency situations on a claim will result in the

claim being treated as an emergency service. If the medical record

supports the existence of an accurate emergency situation, but the

diagnosis is not identified as an emergency, the claim must be submitted

to GMCF along with documentation. The claim will be suspended for

medical review. If, after medical review, the determination is made that

an emergency or potential emergency did in fact exist, the services will

be reimbursed at the hospital’s specific outpatient rate

910.41.3. In non-emergency situations where the provider may be able to identify a

chronic abuser of the Emergency Room, the provider may exercise its

right to advise the member that they will not be accepted as a Medicaid

member. Should the members choose to receive services, they will be

responsible for all charges incurred

910.41.4. All hospitals should consider the following alternatives in the event a

member is not accepted and treated as a Medicaid member:

910.41.4.1. Refer the member to a specific alternate health care

setting where he or she can obtain the same level of care

that day or the next day.

910.41.4.2. Advise the member on conditions that necessitate visits

to the emergency room and explain the appropriate

settings for treatment.

910.41.4.3. There is no limit imposed on the number of visits

allowed per day per member in true medical

emergencies.

910.41.4.4. More than one non-emergency visit by the same member

in one day is subject to review for medical necessity and

possible denial depending on the individual situation.

910.41.4.5. See Chapter 800 for precertification requirements.

Without precertification certain outpatient services are

not reimbursable.

910.41.4.6. Reimbursement for psychiatric services is limited to

short-term acute care.

910.41.4.7. One series of birthing and parenting classes provided to

pregnant members will be reimbursed per twelve-month

period. This service is reimbursed under revenue code

942. Policies and Procedures can be found in Part II of

the Policies and Procedures for Childbirth Education

Program manual.

910.41.4.8. Services provided within three (3) days of inpatient

admission or discharge for the same or related diagnosis

is considered part of the admission.

910.41.4.9. The three (3) day payment window policy applies to

services furnished by the hospital (or an entity it wholly

owns or operates) and includes laboratory and radiology

services.

910.41.4.10. An entity wholly owned or operated by the hospital is: if

a hospital has direct ownership or control over another’s

entity’s operations, services provided by that entity are

subject to the DRG payment window; if a third

organization owns or operates both the hospital and the

entity the payment window does not apply.

910.42. Non-Covered Emergency Room and Outpatient Services

The services or procedures listed below are non-covered by the Division in the

outpatient Hospital Program. Services related to and required in preparation or as a

result of non-covered services are also non-covered. Adverse action may be taken

against hospitals that willfully continue to bill the Division for non-covered services

identified in this manual.

910.42.1. Services and supplies which are inappropriate or medically unnecessary

as determined by the Division, by the Division’s peer review

organization, or other authorized agents.

910.42.2. Late charges - defined as a portion of the charges for a given service

omitted from the original billing which included some of the charges for

that given service

910.42.3. If the total charges for a given service were omitted from the original

billing, a positive adjustment may be requested. Providers who

repeatedly use the incorrect billing code generating the need for a

positive adjustment may be subject to adverse action by the Division

910.42.4. Take-home medical supplies and appliances, durable medical equipment

910.42.5. Take-home prescription drugs.

910.42.6. Routine physical examinations.

910.42.7. Ambulances or other transportation services including air ambulances.

910.42.8. Any services or items furnished for which the hospital does not normally

charge.

910.42.9. Services provided free-of-charge to the public by the hospital, County

Health Departments, State Laboratory or other state agencies, i.e.,

immunizations, metabolic screens for members under one year of age,

etc. See Appendix E

910.42.10. Resuscitation, code, CPR (cardiopulmonary resuscitation), etc.; only the

supplies associated with this service will be reimbursed.

910.42.11. Differential service charges, e.g., “STAT” or priority, after-hours or

“call-back” fees. Only those hospitals that do not provide twenty-four-hour emergency service may bill for the after hour and call-back

differential fee.

910.42.12. Cosmetic surgery or mammoplasties for aesthetic purposes.

910.42.13. Service charges for individual areas within the hospital, e.g., pharmacy

dispensing fee, IV admixture fee (except for hyper alimentation), cover

charge for central supply, charges for handling and distribution of

supplies, transportation within the hospital, equipment installation,

specimen collection, venipuncture, standby equipment, staff time, and

evaluations

910.42.14. Investigational items and experimental services, drugs or procedures or

those not recognized by the Federal Drug Administration, Medicare and

the Division’s contracted peer review organization as universally

accepted treatment

910.42.15. Services or procedures performed which are not in compliance with the

policies and procedures contained in this manual.

910.42.16. Refer to Section 911 for non-covered situations concerning abortions,

sterilizations and hysterectomies.

910.42.17. All applicable procedures, codes, and charges are listed in Section 905.

910.42.18. Preventive Health care. Members under age twenty-one may receive this

care through the EPSDT screening program.

910.42.19. Tubal re-anastomosis procedures pertaining to sterilizations and

vasectomies.

910.42.20. Nursing service. This includes services traditionally accepted as nursing

care even though provided by other ancillary departments

910.42.21. Services non-covered or denied by the Division because they were

provided on an inpatient basis (see Section 903.6).

910.42.22. Services provided by an institution for mental disease or special

disorders.

910.42.23. Separately billed equipment and supplies which are integral parts of

hospital care and the area in which care is being provided, e.g., cardiac

monitor in ICU, light source in OR, call system, blood pressure cuffs and

monitors, specimen collection devices and containers, etc.

910.42.24. Patient or family education or supplies (except as described in Section

910.42.25. Miscellaneous and non-specific charges

910.42.26. Non-acute levels of care.

910.42.27. Infertility procedures and related services

910.42.28. Unlisted or Non-Specified Procedures

910.42.29. Physical Therapy, Occupational Therapy, and Speech Therapy that are

not immediately following and in treatment of acute illness, injury or

impairment are not covered in the outpatient hospital setting. Medicaid

Programs such as CIS (Children Intervention Services) and CISS

(Children Intervention School Services) cover members under 21 years

of age who require therapy not related to an acute illness, injury, or

impairment. Please refer the Part II Policies and Procedures for CIS and

CISS.

910.43. Other Hospital Related Services

In order to receive reimbursement for the services listed below, the hospital must be

separately enrolled as a provider of these services. A Policies and Procedures manual is

provided for each specific program. These services will not be reimbursed from a

hospital claim form.

910.43.1. Emergency Ambulance Ground Transportation-Prior Approval is

required for ground transportation over 150 miles (institution to

institution

910.43.2. Air Ambulance Transportation-Prior Approval is required for all air

ambulance transportation.

910.43.3. Nonemergency Ambulance Transportation (NET);

910.43.4. Durable Medical Equipment (DME);

910.43.5. Orthotics and Prosthetics O & P);

910.43.6. Pharmacy

910.43.7. Early Periodic Screening Diagnosis and Treatment;

910.43.8. Pregnancy Related Services;

910.43.9. Perinatal Case Management;

910.43.10. Children’s Intervention Services;

910.43.11. Rural Health Clinic; and

910.43.12. End Stage Renal Disease Routine Maintenance Dialysis

910.44. Out-of-State Providers and Service Limitations

Out-of-state hospital providers not enrolled in the Georgia Medicaid program as

participating providers will be reimbursed for covered services provided to eligible.

Georgia members while out-of-state if the claim is received within twelve months from

the month of service, and if at least one of the following conditions is met:

910.44.1. The service was prior authorized by the Division; or

910.44.2. The service was provided as a result of an emergency or life-endangering

situation occurring out of state. (If the out-of-state provider believes the

medical record supports the existence of an emergency situation but the

diagnosis does not justify an emergency, the claim must be submitted

with a copy of the medical record.)

910.44.3. Out-of-state providers located within 50 miles of the boundary of the

State of Georgia will be permitted to enroll for Medicaid and/or

Medicare on a participating basis, provided all other enrollment criteria

are met. These are referred to as Border Providers.

910.44.4. Emergency medical services are defined as those services that are

medically necessary as a result of a sudden onset of a medical condition

manifesting itself by acute symptoms of such severity that the absence of

immediate medical attention could reasonably be expected to result in

serious dysfunction of any bodily part or death of the individual.

Emergency room visits that cannot be documented as true medical

emergencies or potential medical emergencies will be reimbursed at an

all- inclusive flat rate of $60. This rate is for all urban and out of state

emergency medical services. This rate will cover all ancillary services

rendered as well as the fee for use of the emergency room. It is for the

medical screening and stabilization services provided in the emergency

room without regard to prior authorization. The $60 flat rate will not be

subject to the hospital’s reimbursement rate.

910.44.5. Georgia Medicaid does not cover services provided in foreign countries.

The Department will reimburse providers in the 50 states, the District of

Columbia, the Northern Mariana Islands, American Samoa, Guam,

Puerto Rico, and the Virgin Islands for services provided in an

emergency situation or when prior authorization was obtained from the

Department before the service is provided. Out-of-state providers must

be licensed in the United States and/or its territories. Out-of-State

providers are required to be licensed in their own state of practice and

enrolled in their own state’s Medicaid program. No payment can be

made unless the patient meets Georgia Medicaid eligibility criteria. Out-of-State providers must complete the enrollment process prior to any

commitment of payment. The Department will not reimburse providers

in foreign countries.

910.44.6. Routine health care or elective surgery provided by out-of-state providers

is not covered unless prior authorization is obtained.

910.44.7. Members should be transferred to another in-state Georgia facility before

transferring the member out-of-state for emergent care. The medical

record should document why the member was not transferred to another

Georgia facility.

910.44.8. The referring in-state provider is required to request prior approval by

documenting in writing the medical necessity of obtaining services out-of- state and providing the name and address of the out-of-state medical

provider.

910.44.9. The out-of-state provider cannot obtain a prior authorization request.

910.44.10. Reimbursement and coverage of out-of-state services are determined in

accordance with current policies and procedures of the Georgia Division

of Medical Assistance and are contingent upon the patient’s eligibility at

the time services are provided.

910.44.11. Contractual agreements will not apply to in-state facility to an out-of-state facility due to the different reimbursement types.

910.44.12. Out-of-state providers will be reimbursed in accordance with the policy

described in Subsection1001.4. Requests for prior approval or questions

regarding out-of-state services must be directed to the following:

Prior Authorization & Pre-Certification

Alliant Health Solutions

PO Box 105200

Atlanta, Georgia 30348

800-766-4456 (Toll free)

910.44.13. Out-of-state claims submitted for reimbursement must have a copy of the

authorization letter attached if services were prior authorized or medical

justification if the services were due to an emergency or life-endangering

situation.