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KANSAS

MEDICAL

ASSISTANCE

PROGRAM PROVIDER MANUAL

Hospital

PART II

HOSPITAL PROVIDER MANUAL Introduction Section BILLING INSTRUCTIONS Page 7000 UB-04 Billing Instructions .... ......... ......... ......... ......... ........ 7-1

Submission of Claim . ......... ......... ......... ......... ........ 7-7 7010 MS-2126 Billing Instructions . ......... ......... ......... ......... ........ 7-8 7020 Hospital Specific Billing Information . ......... ......... ......... ........ 7-13 7030 State Institution for Mental Health

Billing Instructions .... ......... ......... ......... ......... ........ 7-21

BENEFITS AND LIMITATIONS 8100 Copayment .... ........ ......... ......... ......... ......... ......... ........ 8-1 8200 Medical Assessment .. ......... ......... ......... ......... ......... ........ 8-2 8300 Benefit Plans .. ........ ......... ......... ......... ......... ......... ........ 8-15 8400 Medicaid ....... ........ ......... ......... ......... ......... ......... ........ 8-16 8410 Medicaid-Inpatient Only ....... ......... ......... ......... ......... ........ 8-26 8420 Medicaid-Outpatient Only ..... ......... ......... ......... ......... ........ 8-31 8430 Family Planning/Sterilization . ......... ......... ......... ......... ........ 8-36

HCPCS Procedure Codes and Nomenclature .. ......... ......... ........ Appendix I Ambulatory Surgery/Outpatient Surgery -

Procedure Codes and Nomenclature ... ......... ......... ........ Appendix II DME/Medical Supplies in a Swing Bed NF .... ......... ......... ........ Appendix III Hospital Cost Report .. ......... ......... ......... ......... ......... ........ Appendix IV

FORMS SECTION DRG RATES AND WEIGHTS

PART II HOSPITAL PROVIDER MANUAL

This is the provider specific section of the manual. This section (Part II) was designed to provide information and instructions specific to hospital providers. It is divided into three subsections: Billing Instructions, Benefits and Limitations, and Appendices. The Billing Instructions subsection gives examples of the billing forms applicable to hospital services. The forms are followed by directions for completing and submitting them. The Benefits and Limitations subsection defines specific aspects of the scope of hospital services allowed within the Kansas Medical Assistance Program (KMAP). The Appendix subsection contains information concerning procedure codes, emergency diagnosis codes and swing bed nursing facility supplies. The appendices were developed to make finding and using codes easier for the biller. HIPAA Compliance As a KMAP participant, providers are required to comply with compliance reviews and complaint investigations conducted by the Secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. The provider is required to provide the same forms of access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A. 21-3853 and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider shall not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations.

KANSAS MEDICAL ASSISTANCE PROGRAM HOSPITAL PROVIDER MANUAL

BILLING INSTRUCTIONS

7-1

7000. HOSPITAL BILLING INSTRUCTIONS Updated 03/08 Introduction to the UB-04 Claim Form Hospital providers must use the UB-04 red claim form when requesting payment for medical services and supplies provided under the Kansas Medical Assistance Program. Any UB-04 claim not submitted on the red claim from will be returned to the provider. An example of the UB-04 claim form is in the Forms section at the end of this manual. Instructions for completing this claim form are included in the following pages. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the UB-04 claim form to providers. Refer to Section 1100. The following numbered form locators (FL) are to be completed when required or if applicable. Completing the UB-04 Claim Form:

FL 1 Required. Enter the name and address of the billing provider.

FL 3A Patient Control No. Enter a patient account number if desired. (This number will be referenced on the Remittance Advice [RA].)

FL 3B Medical Record No.-Desired. Enter the patient’s medical record number.

(This number will appear on the provider’s RA.) FL 4 Type of Bill - Required. Enter the 3-digit number specific to the type of

claim.

1st digit indicates facility. (Always a "1".) 2nd digit indicates location within facility. 3rd digit indicates the frequency of the claim billed.

Medicaid allowed codes:

1st digit: 1 Hospital (IP/OP) 8 Outpatient – Critical Access 2nd digit: 1 Inpatient

3 Outpatient 5 Critical Access Hospital 8 Swing bed NF

3rd digit: 0 Nonpayment/zero claim 1 Admit through discharge claim 2 Interim - first claim 3 Interim - continuing claim 4 Interim - last claim (thru date is discharge date)



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7000. Updated 5/07

FL 6 Statement Covers Period - From/Through - Required. Enter inpatient dates of admission and discharge or outpatient from and through dates in MM/DD/YY format.

FL 7 Covered Days - Required - Inpatient Only. Enter the number of days for

which you are billing. NOTE: Count date of admission, but not date of discharge.

FL 8 Non-Covered Days - Required - Enter the total number of non-covered days.

FL 12 8B Patient Name - Required - Enter patient's last name, first name and middle

initial exactly as it appears on the ID card. If patient is a newborn, enter "newborn", "baby boy", or "baby girl" in the first name field and enter the last name.

FL 14 10 Birthdate - Required. Enter patient's date of birth in MM/DD/YYYY

format. If newborn, enter baby's date of birth (not mother's).

FL 15 11 Sex - Required. Enter "M" for male or "F" for female. If newborn services, enter "M" or "F" for the baby.

FL 17 12 Admission Date - Required. Enter date patient was admitted as inpatient or

date of outpatient care in MM/DD/YY format.

FL 18 13 Admission Hour - Required - Inpatient Only. Enter treatment hour using the continental time system (i.e., 6:00 p.m. = 1800 hours).

FL 19 14 Admission Type - Required - Inpatient Only. Enter a one-digit code to

indicate type of admission. 1 – Emergency 3 – Elective 2 – Urgent, etc. 4 – Newborn 5 – Trauma

FL 20 15 Admission Source - Required - Enter a one digit code to indicate admission

source. 4 - Transfer from Hospital 5 - Transfer from Nursing Home 6 - Transfer from Another Facility



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7000. Updated 03/08

FL 17 Patient Status - Required - Inpatient Only. Enter a two-digit code to indicate status of patient: 01 Discharged to home or self care (routine discharge). 02 Discharged/transferred to another short-term general hospital for

inpatient care. 03 Discharged/transferred to skilled nursing facility (SNF) with Medicare

certification. 04 Discharged/transferred to an Intermediate Care Facility (ICF). 05 Discharge/transfer to a designated cancer center or children’s hospital. Discharged/transferred to a non-Medicare PPS children’s hospital or

non-Medicare PPS cancer hospital for inpatient care. 06 Discharged/transferred to a home under care of organized home health

service organization. 07 Left against medical advice or discontinued care. 08 Discharged/transferred to home under care of a home IV drug therapy

provider. This is not a certified Medicare provider. 09 Admitted as an inpatient to this hospital (for use on Medicare

Outpatient Hospital claims only). 20 Expired (or did not recover - Christian Science Patient). 30 Still patient. 40 Expired at home. (Hospice claims only.) 41 Expired in a medical facility, such as a hospital, SNF, ICF, or

freestanding hospice. (Hospice claims only.) 42 Expired - place unknown. (Hospice claims only.) 43 Discharge/transferred to a Federal Health Care Facility. 50 Discharge to hospice – home. 51 Discharge to hospice - medical facility. 61 Discharged/transferred within this institution to a hospital-based,

Medicare-approved, swing bed. 62 Discharged/transferred to another rehabilitation facility an inpatient

rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital.

63 Discharged/transferred to a Medicare certified long term care hospital (LTCH).

64 Discharge/transferred to a nursing facility certified under Medicaid but not certified under Medicare.

65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital (for future use). Providers shall continue to use Patient Status Code 05 until further notice.

66 Discharged/transferred to a Critical Access Hospital (CAH) for discharge dates on or after January 1, 2006.

70 Discharge/transfer to another type of health care institution not defined elsewhere in the code list.



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7000. Updated 12/07 Note: Hospitals will be eligible for full DRG reimbursement when a discharge occurs using discharge code 01, 03, 04, 05, 06, 07, 08, 20, 50, or 51. Distinct claim forms must be submitted for each discharge. In the case of transfers to same specialty providers (discharge code 02), the transferring hospital’s reimbursement may be reduced, based upon a transfer prorated reimbursement determination, and the receiving hospital will be eligible to receive a full DRG reimbursement.

FL 18-28 Condition Codes - Enter one of these two-digit codes to indicate a

condition(s) relating to inpatient or outpatient claims, special programs or procedures (e.g., KAN Be Healthy, sterilization, etc.) Note: This is not a complete list. For a complete list of Condition Codes contact EDS Customer Service.

01 Military service related 02 Condition is employment related 03 Patient covered by insurance not reflected here 67 Beneficiary elects not to use life time reserve (LTR) days

Note: This will now replace the Z1 Medicare Part A benefits exhausted condition code. The verbiage in the explanation of condition code 67 means the patient’s benefits are exhausted.

80 Home Dialysis – Nursing Facility A1 KAN Be Healthy (EPSDT) A4 Family Planning AA Abortion performed due to rape AB Abortion performed due to incest AI Sterilization D9 Any other change Note: This will now replace the XO swing bed condition code.

FL 31-34 Occurrence Codes/Dates: OCCURRENCE CODES CAN ONLY BE

SUBMITTED ON LINE A. The following occurrence codes must be indicated if reporting information on type of accident, crime victim, other insurance denial or date of TPR termination, or aborted surgery, false labor or nondelivery claim where associated services are indicated.

01 Accident/medical coverage 02 No fault insurance involved – including auto accident/other

03 Accident/tort liability 04 Accident/employment related 05 Accident/no medical or liability coverage 06 Crime victim 24 Date insurance denied 25 Date benefits terminated by primary payer A3 Benefits exhausted, Payer A B3 Benefits exhausted, Payer B

C3 Benefits exhausted, Payer C



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7000. Updated 12/07

All EDS/SRS guidelines remain the same regarding attachments required for TPR proof and SSA/Medicare EOMBs.

FL 39 Value Codes/Amount – Required if applicable (for State Institutions Only).

• Enter D3 for nonpatient obligation as the value code. Enter the nonpatient obligation dollar amount in the “Amount” field. Examples of nonpatient obligation are Parental, Spousal, and Trust.

• Enter 80 for covered days and enter the number of covered days in the Amount field.

Note: Count the date of admission but not the date of discharge.

FL 42 Rev. Cd. - Required - Inpatient Only. Enter the three-digit number identifying the type of accommodation and ancillary service(s). DO NOT INDICATE REVENUE CODE(S) IF THE SERVICE IS NONCOVERED. Note: Revenue codes are not to be indicated for outpatient services.

FL 44 HCPCS/Rates/HIPPS Code - Required - Outpatient Only. List the HCPCS

procedure code for each specific outpatient procedure. DO NOT INDICATE PROCEDURE(S) IF THE SERVICE IS NONCOVERED.

FL 45 Serv. Date - Required - Outpatient Only. Enter the date services were

provided in MM/DD/YY format.

FL 46 Serv. Units - Required. Enter number of days for each accommodation revenue code or appropriate units for each outpatient service billed.

FL 47 Total Charges - Required. Enter total charges for each coded line item.

List each outpatient procedure with a specific (itemized) charge. DO NOT INDICATE CHARGES FOR NONCOVERED SERVICES.

Enter the total claim charge on the last line of this detail section with a revenue code of 001 in FL 42 and total charges in FL 47.

FL 48 Noncovered Charges - Optional. Enter noncovered charges.

FL 50 Payer Name - Required. Indicate all third party resources (TPR). If TPR

does exist, it must be billed first. Lines B and C should indicate secondary and tertiary coverage. Medicaid will be either the secondary or tertiary coverage and the last payer. When B and C are completed, the remainder of this line must be completed as well as FL 58-62. Medicare needs to always be the last entry.



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7000. Updated 12/07

FL 54 Prior Payments - Required if other insurance is involved. Enter amount paid by other insurance. Medicare needs to always be the last entry. (Do not

enter spenddown or copayment amounts. These reductions will be made automatically during claim processing.)

FL 56 NPI: Enter the billing provider’s NPI.

FL 57 Other Provider ID: Enter either qualifier ‘1D’ and the billing provider’s KMAP provider ID or qualifier ‘ZZ’ and the taxonomy code.

FL 60 Insured’s Unique ID Required. Enter the 11-digit beneficiary number from

patient's medical ID card on line C. If newborn services, use mother's beneficiary number if newborn's ID number is unknown.

FL 61-62 Group Name/Insurance Group No. - Required if Medicaid is not primary

payer. Enter the primary insurance information on line A and Medicare on line C.

FL 63 Treatment Authorization Codes - Leave blank. (This number, if applicable,

is system generated.)

FL 64 Document Control Number – Desired if this claim is a resubmission. Enter the previous ICN.

Note: This field is for timely filing purposes. FL 67A-Q DX - Required. Enter the ICD-9-CM code indicating the primary diagnosis

and additional diagnoses.

FL 74 Principal Procedure - Required - Inpatient/Outpatient, if applicable. Enter the ICD-9-CM procedure code for the primary procedure and date of service. DO NOT INDICATE THE PROCEDURE IF THE SERVICE IS NONCOVERED.

FL 74A-E Other Procedure - Required - Inpatient/Outpatient, if applicable. Enter

other procedures performed, using ICD-9-CM procedure codes and date of service. DO NOT INDICATE THE PROCEDURE IF THE SERVICE IS NONCOVERED.

FL 76 Attending - Required.

a. Enter attending physician's NPI, or the appropriate qualifier and physician’s KMAP provider ID or taxonomy code.

b. Enter attending physician's Medicaid provider name as last name and then first name.

Note: DO NOT ENTER A GROUP PROVIDER NUMBER.



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7000. Updated 12/07 FL 77 Operating - Required if applicable.

a. Enter operating physician's NPI, or the appropriate qualifier and physician’s KMAP provider ID or taxonomy code. b. Enter operating physician's Medicaid provider name as last name and then

first name.

FL 78-79 Other - Required if applicable. a. Enter other physician's NPI or the appropriate qualifier and physician’s

KMAP provider ID or taxonomy code. b. Enter other physician's Medicaid provider name as last name and then first

name. Note: If the claim is for a sterilization, the surgeon performing the sterilization procedure must be identified by their KMAP provider ID in field 78. FL 80 Remarks - Specify additional information as necessary.



7-8

7000. Updated 12/07 Submission of Claim: Send completed claim to:

Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas 66601-3571



7-9

7010. MS-2126 BILLING INSTRUCTIONS Updated 5/07 Introduction to the Notification of Nursing Facility Admission/Discharge MS-2126

The completion of the MS-2126 (Notification of Nursing Facility Admission/Discharge) shall be completed by the provider and a copy sent to the local SRS office Economic & Employment Specialist (EES). Submission of the MS-2126 is not required as a prerequisite for a hospital "reserve day" (Section IV). However, the MS-2126 must be retained in the beneficiary's file for documentation. Completion of the MS-2126 is not required for payment of a therapeutic reserve day.

This form will need to be copied or duplicated by providers since neither the fiscal agent nor the state will furnish the form to providers.

When to Use the MS-2126:

Sections I, II, and III, "Facility Placement/Discharge" shall be initiated by the nursing facility when:

1. An eligible Kansas Medical Assistance Program resident is initially admitted to or

discharged from the nursing facility (NF), nursing facility for mental health (NF/MH) or intermediate care facility for the mentally retarded (ICF/MR).

2. A resident of an NF, NF/MH, or ICF/MR becomes eligible for Kansas Medical Assistance Program.

3. An eligible Kansas Medical Assistance Program resident transfers from one facility to another facility.

4. A resident's eligibility has been reinstated after suspension for more than two months. (If two calendar months or less, a new form will be needed.)

5. An eligible Kansas Medical Assistance Program resident is out of the facility for more than 30 days. (This is the same as a new admission.) When a resident returns to the facility on the 31st day, a new form will not be required. When a resident fails to return on the 31st day, a new form is required.

6. An eligible Kansas Medical Assistance Program resident has a change in his/her level of care.

Section IV, Hospital Leave Information shall be initiated by the facility to report any hospital admission and to report reserve days for a medical leave being claimed by the facility. Completion of this section is not required for therapeutic (home) leave days.

When a single hospital stay exceeds 30 days, the facility shall send another form to the local SRS office indicating the stay has exceeded 30 days and listing the estimated number of days the consumer will remain in the hospital.



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7010. Updated 5/07 Return to the Facility:

Whether Section III or IV is being completed, the EES retains a copy of this form for their files. The original MS-2126, completed by the facility, and the Notice of Action must be retained by the nursing facility.

How to Complete the MS-2126: Section I:

Name: Enter the resident's first name, middle initial, and last name as it appears on the medical identification (ID) card.

SSN: Enter the resident's Social Security number. If the resident does not have a Social Security number, enter the "NA."

Date of Birth: Enter the resident's birth date in month, day, and year - MM/DD/YYYY format. (Example: May 15, 1925 should appear as 05-15-1925.)

Sex: Indicate "M" for male and "F" for female.

Client ID Number: Enter the 11-digit resident number from the individual's Kansas Medical Assistance Program card.

Responsible Person's Name: Enter the first and last name of the responsible party.

Responsible Person's Address: Enter the responsible person's street address, P.O. Box number, along with his/her city, state, and zip code.

Phone: Enter the responsible party's area code and phone number.

Section II:

Facility Name: Enter the name under which the facility operates.

Provider Number: Enter your 10-digit Medicaid provider number.

Address: Enter the street address, city, and zip code where the facility is located



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7010. Updated 5/07

Date of Placement: Date resident was admitted to the facility.

Anticipated Length of Stay: Enter the number of months the resident is expected to be in the facility. If unknown, write "unknown."

Screened By: Enter the name of the person or facility completing the assessment. The State of Kansas requires that "each individual prior to admission to an NF .... receive assessment and referral services." To achieve this, the CARE program was created "for the data collection and individual assessment and referral to community-based services and appropriate placement in long-term care facilities.

Date: Date screening was completed (if known).

Signature: The facility administrator or his/her designee signs here.

Phone: In the event there are questions, please indicate the area code and telephone number to call.

Section III: Enter a check mark in the appropriate space to indicate (A) Admission, (B) Discharge, or (C) Deceased. Providers will also need to indicate the method of payment in place at the time of admission or discharge.

A1. Admitted From: Indicate where the resident is being admitted to and the name of the facility they are coming from.

A2. Indicate method of payment at time of admission.

B1. Discharged On: Check the appropriate space to indicate where the resident is being

discharged to, name of facility, and date of discharge.

B2. Indicate method of payment at time of discharge.

C. Deceased Date: Enter the resident's date of death. Section IV:

A. Entered: Enter the name of the hospital and the date entered.

B. Reason Admitted: If known, indicate reason for admission. If unknown, write "UNKNOWN".

C. Estimated Days in Hospital: Indicate the number of days the admitting physician

reasonably believes the resident will be in the hospital



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7010. Updated 5/07 Reserve Day Notice - Once the facility has completed this form, it should be submitted to the local SRS office. Since the information sent to the SRS office will not be returned, it is important for the facility to keep the original in their files. Nursing Facility Processes Form

III. Facility Placement/Discharge: The facility is required to retain the completed form in the facility. These records shall be made available to SRS and/or the fiscal agent upon request. Suspension of payment to the facility may result in the absence of this form.

IV. Hospital Leave Day Form: Retain the completed form in the beneficiary's records for documentation of medical reserve day approval



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7020. HOSPITAL SPECIFIC BILLING INFORMATION Updated 03/08 Inpatient

Accommodation and Ancillary Charges: If the individual accommodation and ancillary services exceed the detail lines on the UB-04 claim form, providers may combine all similar revenue code charges together (e.g., lab, radiology) when necessary. Accommodation codes may also be 'lumped' together when necessary. This will not affect the reimbursement of the claim.

Admission and Readmission (Same Day):

Admission An inpatient admission starts when the physician writes an order for an inpatient admission. It is not considered inpatient until that order has been written. Documented verbal admission orders are considered the same as written orders. • Scenario #1: A patient is sent to the medical floor on September 23 at 11:00 p.m. The

physician writes an order to admit the patient on September 24 at 3:00 a.m. According to KMAP, the inpatient admission starts on September 24 at 3:00 a.m.

• Scenario #2: A physician writes an order for a patient to be admitted inpatient on September 23 at 11:00 p.m. The patient arrives on the medical floor on September 24 at 3:00 a.m. According to KMAP, the inpatient admission starts on September 23 at 11:00 p.m.

• Scenario #3: A physician contacts a hospital on September 23 at 11:00 p.m. about a direct admission and gives a verbal order for admission once the patient arrives at the hospital. The patient arrives at the hospital on September 24 at 3:00 a.m. According to KMAP, the inpatient admission starts on September 24 at 3:00 a.m.

Readmission (Same Day) When a patient is discharged or transferred from an inpatient hospital and is readmitted to the same inpatient hospital on the same day for symptoms related to or for evaluation and management of the prior stay’s medical condition, hospitals must adjust the original claim generated by the original stay by combining the original and subsequent stay onto a single claim. When a patient is discharged or transferred from an inpatient hospital and is readmitted to the same inpatient hospital on the same day for symptoms unrelated to and not for evaluation and management of the prior stay’s medical condition, hospitals must bill for two separate stays on two separate claims.

Emergency Renal Dialysis: Inpatient emergency renal dialysis must be billed utilizing revenue code 809 in FL 42 of the UB-04 claim form.

Interim Billing: Interim billing is restricted to once every 180 days. Interim bills received more frequently than 180 days will be denied. When interim billing, be sure to enter the appropriate 'Type of Bill' code (e.g., 112, 113, 114). A 'Patient Status' code of 30 (still a patient) must be indicated when 'Type of Bill' is 112 or 113.

Medicare B Services: When Medicare B payment is made on an inpatient claim, indicate the amount paid as Prior Payment in FL 54 on the UB-04 claim form.



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7020. Updated 03/08 Newborn Services (When the Mother Is NOT in an HMO): When billing for a newborn who does not have a beneficiary ID number, use "Newborn", "Baby Girl", or "Baby Boy" in the first name field of patient name. Use the newborn's date of birth and the mother's beneficiary ID number. The claim will suspend in the claims processing system for up to 45 days pending the fiscal agent's receipt of the newborn's beneficiary ID number from the local SRS office. If the newborn's beneficiary ID number is received within the 45 days, the claim will be processed using that number. If the newborn's beneficiary ID number is not received within the 45 days, the claim will complete processing with the mother's beneficiary ID number.

Newborn Services (When the Mother Is in an HMO): Notify the HMO that is on the mother's Medicaid ID card of the birth. The HMO will provide further instructions if the provider is part of that HMO's network. The mother's HMO will notify KHPA and the fiscal agent of the birth. Outpatient/Inpatient: Outpatient procedures (i.e., surgery, X-rays, EKGs) provided within three days of a hospital admission or discharge for the same or similar diagnosis are considered 'content of service' and should be billed on the same inpatient hospital claim. The outpatient procedure date should be changed on the claim to correspond with the actual hospital admission date. Note: There is one exception to this policy. Complications from an outpatient sterilization resulting in an inpatient admission. In this instance, the outpatient charges and the inpatient charges should be billed on two separate claims. This is necessary in order for the service dates on the claim form to match the service dates on the sterilization consent form.

Outpatient Services Provided During Inpatient Admission: Outpatient services provided during an inpatient hospital stay must be included by the hospital on the UB-04 claim form and reimbursed through the DRG. The outpatient provider should receive reimbursement from the hospital. Outpatient services provided to residents of state institutions shall be billed by the hospital providing the outpatient service.

Psychiatric Observation Beds: When an inpatient hospital admission follows a psychiatric observation stay, the observation days should be billed on the inpatient claim. The observation bed days then become part of the DRG payment to the hospital.

Transfers: When billing medically necessary incoming transfers, in FL 80 on claims for incoming transfers from other hospitals under "Remarks" enter "direct transfer from (hospital, city)".

Swing Bed Nursing Facility:

When billing for a swing bed nursing facility (NF), the following must be observed: 1) Your hospital must be certified by the Kansas Department of Health and

Environment as a swing bed NF hospital.



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7020. Updated 5/07

2) Notify the local SRS Income Maintenance (IM) Worker immediately when an SRS consumer is placed in a swing bed NF. Notification shall be performed by completing parts I and II of the MS-2126. (Refer to Section 7010.) Once the IM Worker has received the MS-2126, the consumer's case will be budgeted for long-term care. The hospital will then be notified via a "Notice of Action" as to the consumer's liability to the hospital while in the swing bed NF. Providers must bill the full amount and patient liability will be deducted during processing. When billing for a Swing bed, a separate claims must be submitted for each calendar month.

Do not attach a copy of either the MS-2126 or Notice of Action to your claim form.

3) Bill all NF days for eligible Medicare patients to Medicare first. Medicaid can be

billed for any remaining amounts using the inpatient Medicare claim crossover method. (Refer to Section 3200.) If Medicare will not pay for the NF days, a copy of either the Medicare Report of Eligibility (ROE) or a Medicare denial must be attached to the Medicaid billing supporting non-payment by Medicare.

4) Before a transfer to a swing bed NF occurs, the patient must be discharged from the

inpatient unit. Use the appropriate 3-digit type of bill code in FL 4 on the UB-92 UB-04 claim form. (Refer to Section 7000.) Remember, the inpatient unit is not reimbursed for the date of discharge since the swing bed NF will be reimbursed for the date of admission.

5) The appropriate accommodation revenue code applicable to the patient's level of care

shall be entered in FL 42. Bill the total number of days in FL 46 (units). In FL 47, place the total charge of days billed.

Ancillary charges: Cannot be billed on the swing bed NF claim. Any ancillary services received by the patient while in a swing bed NF, must be billed on a UB-92 UB-04 claim form using the outpatient type of bill code (FL 4) and the correct HCPCS code and revenue code for the ancillary services provided. (See items 7 and 8 for supplies/services which are content of service for swing bed NF and cannot be billed separately). Indicate condition code D9 (any other change) X0 (swing bed ancillary) in FL 18-28 24-30, and enter the from and through dates of service in FL 6 on the UB-92 UB-04 claim form. When multiple dates of service are being billed, enter only the first date of service in FL 45 on the UB-92 UB-04 claim form.



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7020. Updated 5/07

Pharmacy: Pharmacy services for swing bed claims need to be billed on a pharmacy claim form from a Medicaid-enrolled outpatient pharmacy. Refer to the Pharmacy Provider Manual for billing instructions.

Supplies: When billing for supplies provided by the swing bed facility over and above the supplies included in the reimbursement rate, use procedure code 99070 - bill one unit per day. Claims must include both revenue codes and HCPCS codes.

Therapy: Physical, occupational and speech therapy may be billed as outpatient hospital services for clients in hospital swing beds and long term care units attached to hospitals.

6) With the exception of the billing guidelines addressed above, the remainder of the

claim form is to be completed in the same manner as an inpatient submission. Refer to instructions in Section 7000 of this manual.

7) A hospital may not charge Medicaid consumers for providing routine supplies and

services since: (1) The hospital is required to provide routine supplies and services to Medicaid swing bed patients; and (2) the cost of providing routine supplies and services is included in the hospital's swing bed per diem reimbursement.

8) "Routine" is defined as an item that is commonly stocked for use by anyone. It is an

item that may or may not be specifically assigned or prescribed to any one patient. Routine items covered by the drug program when ordered by a physician for occasional use are included in the per diem reimbursement. Since items considered to be routine for residents of adult care homes are also considered to be routine for swing bed NF patients, refer to Appendix III for a descriptive list of routine items. Any routine item billed on the outpatient hospital claim form will be denied.

"Non-routine" is defined as a specifically prescribed item for a resident for an acute or chronic need. Medication orders may be considered non-routine if: (1) It is not a stock item of the facility; or (2) it is a stock item with unusually high usage by the individual.



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7020. Updated 05/07 Outpatient NOTE: Outpatient hospital claims which require medical necessity documentation may be

billed electronically. Medical necessity documentation must be retained in the provider's file and made available for review on a post-pay basis. Refer to your EMS Operators manual for additional information.

It is not required that providers roll-up their charges into the covered HCPCS code they are billing. Providers can bill the HCPCS code they are providing and the processing system will allow the covered charges and deny the services that are content or non-covered. Durable Medical Equipment/Prosthetics and Orthotics:

Hospitals must enroll as DME or P&O providers and bill on the professional claim form (HCFA-1500 CMS-1500) when providing these services. Contact the Provider Assistance Unit at 1-800-933-6593 or (785) 291-4145 (local).

DME, prosthetic and orthotic items cannot be billed as ancillary services on the UB-92 UB-04 claim form.

Exception: Prosthesis implanted by a surgical procedure may be billed on the hospital claim form for inpatient services.

Procedure codes for covered items can be found in Appendix I of the Durable Medical Equipment and Prosthetic and Orthotic manuals.

Emergency Renal Dialysis:

Outpatient emergency renal dialysis must be billed utilizing the following diagnosis codes in FL 67 and/or 68 of the UB-92 UB-04 claim form.

Diagnosis Codes

5845 � 5849 63630 6393 63430 63730 66930 63530 63830 9585

Emergency Room/Department Services:

Enter the time of day (using the Continental Time System, i.e., 0000-2300) in FL 13 18, admission hour.

Emergency services provided in the emergency department shall be billed using the appropriate Evaluation and Management (E&M) emergency department or critical care procedure code from the CPT manual



7-18

7020. Updated 5/07

Please reference the Physician's Current Procedural Terminology (CPT) manual for information on the Centers for Medicare & Medicaid Services (CMS) Health Care Financing Administration (HCFA) and American Medical Association's (AMA) documentation guidelines as well as directions for assigning codes for emergency services. Copies of "detailed" documentation guidelines have been published by CMS HCFA, Blue Cross & Blue Shield (BCBS), and the Kansas Foundation for Medical Care (KFMC).

E&M procedure codes applicable to emergency department services include:

99281 99285 99282 99291 99283 99292 99284

Refer to the CPT manual for procedure code nomenclature.

Mid-Level Practitioners:

Physician Assistants (PA) and Advanced Registered Nurse Practitioners (ARNP) must be enrolled as a Medicaid provider to bill for services. Indicate the PA’s or ARNP’s number as the attending physician on the UB-92 UB-04 claim form.

ARNPs and PAs are reimbursed 75% of the Medicaid allowed amount for services provided.

Modifiers for ER Services:

The ET modifier must be added to the base E&M procedure code when billing the hospital ER/observation room and supplies.

When billing for the hospital-based physician, indicate the base code only (no modifier).

Non-Emergency:

A revenue code is not required for any outpatient service. Use HCPCS procedure codes. In the instance of a non-emergent visit, procedure code 99281 may be used. Submit only your charges for the hospital-based physician professional fee and covered diagnostic tests, endoscopic procedures, therapy, etc.



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7020. Updated 5/07

Enter the time of day using the Continental Time System if the services are provided between 6:00 p.m. and 8:00 a.m. (1800 and 0800 hours) in FL 13 18, admission hour.

99281 Hospital- based physician professional fee in a non-emergency situation 99281ET Emergency department encounters 99070ET Medical supplies required for non-emergency treatment

Bilateral Procedures:

Bilateral procedures performed during the same operative session shall be billed with the appropriate procedure code. To be consistent with Medicare, if a procedure is identified in the CPT manual as one that should have a '50' modifier added when performed bilaterally, bill the procedure as a single line item with the '50' modifier. For example, to bill the excision of bilateral nasal polyps, the provider should indicate procedure code '3011050' on one detail line on the claim. Reimbursement will be made for the bilateral procedure.

'E' Diagnosis Codes:

External causes of injury and poisoning diagnosis ('E') codes are accepted on a claim as a secondary diagnosis when billed in conjunction with a covered primary diagnosis code.

Observation Room: Procedure code 99218WP ET should be billed for any service which requires monitoring a patient's condition beyond the usual amount of time in an outpatient setting. This code shall not be used to bill for the recovery room. Sterilization Procedures:

When a sterilization is performed in conjunction with, or secondary to an inpatient procedure (e.g., delivery) and the sterilization is not covered (e.g., failure to obtain the sterilization consent form), remove all procedure codes and charges related to the sterilization from the claim and bill the primary procedure only. Carefully document in the medical record the reason the sterilization was not billed on the claim.



7-20

7020. Updated 05/07 Physician Clinic Services:

Currently, some physicians make scheduled visits once or twice a week to rural hospitals and see patients in the emergency room which functions as their office. Physician clinic services provided in a hospital location are considered content of the physician service and should not be billed to Medicaid or the consumer. However; in this instance the hospital can bill procedure code 99070 (supplies and materials) for use of room and supplies.

Professional Fees:

The only physician services which can be billed by the hospital on the UB-92 UB-04 claim form are hospital based physicians assigned to the emergency department.

Professional/Technical Component Billing:

Components: Professional: Enter the HCPCS base code for services rendered, including modifier "26". (Example: 7207026).

Technical: Enter the HCPCS base code of the service performed, including modifier "TC". (Example: 72070TC). Note: Hospitals that bill the base code for radiology procedures will be reimbursed at the TC rate.

Professional and Technical: Enter the HCPCS base code of the radiology service performed. (Example: 72070)

The same procedures performed on the same day:

• Must be billed on the same claim. • Must clarify the reason for billing more than one procedure (e.g., 2 x-rays at two

different times; left arm, right arm).

When same procedures are not billed on the same claim, the additional claim(s) will be denied as a duplicate.

To seek reimbursement for additional services when this occurs:

Submit an underpayment adjustment using the Internal Control Number (ICN) from the Remittance Advice (RA) of the paid claim, and state on the adjustment request that more than one procedure was performed on the same day. Refer to Section 5600 for details.

Unit Billing:

When billing for outpatient hospital services, round units to the nearest whole number. Do not bill fractions of units.



7-21

7030. STATE INSTITUTION FOR M/H BILLING INSTRUCTIONS Updated 02/08 Introduction to the UB-04 Claim Form State institution for mental health providers must use the UB-04 red claim form (or accepted electronic equivalent) when requesting payment for medical services and supplies provided under the Kansas Medical Assistance Program. Any UB-04 claim not submitted on the red claim form will be returned to the provider. An example of the UB-04 claim form is in the Forms section at the end of this manual. Instructions for completing this form are included in the following pages. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. EDS does not furnish the UB-04 claim form to providers. Refer to Section 1100. The following numbered form locators (FL) fields are to be completed when required or if applicable. Billing Instructions:

FL 1 (No Field Name) - Required. Enter the name and address of the billing provider.

FL 3A Patient Control No. Enter a patient account number if desired. (This number

will be referenced on the Remittance Advice [RA].)

FL 3B Medical Record No.-Desired. Enter the patient’s medical record number. (This number will appear on the provider’s RA.)

FL 4 Type of Bill - Required. Enter the 3-digit number specific to the type of

claim.

1st digit indicates facility. (Always a 2 or 6.) 2nd digit indicates location within facility. 3rd digit indicates the frequency of the claim billed.

Medicaid allowed codes:

1st digit: 1 Hospital (IP/OP)

2nd digit: 1 Inpatient

3rd digit: 0 Non-payment/zero claim 1 Admit through discharge claim 2 Interim - first claim 3 Interim - continuing claim 4 Interim - last claim (thru date is discharge date)

FL 6 Statement Covers Period - From/Through - Required. Enter dates of

admission and discharge from and through dates in MM/DD/CCYY format.



7-22

7030. Updated 03/08

FL 7 Covered Days - Required - Inpatient Only. Enter the number of days for which you are billing.

Note: Count date of admission, but not date of discharge.

FL 8B Patient Name - Required - Enter patient's last name, first name and middle initial exactly as it appears on the ID card.

FL 10 Birthdate - Required. Enter patient's date of birth in MM/DD/YYYY format

(i.e. October 1, 1957 would be listed as 10/01/1957).

FL 12 Admission Date - Required. Enter date patient was admitted to the facility in MM/DD/CCYY format.

FL 17 Patient Status - Required - Inpatient Only. Enter a two-digit code to

indicate status of patient: 01 Discharged to home or self care (routine discharge). 02 Discharged/transferred to another short-term general hospital for

inpatient care. 03 Discharged/transferred to skilled nursing facility (SNF) with Medicare

certification. 04 Discharged/transferred to an Intermediate Care Facility (ICF). 05 Discharge/transfer to a designated cancer center or children’s hospital. Discharged/transferred to a non-Medicare PPS children’s hospital or

non-Medicare PPS cancer hospital for inpatient care. 06 Discharged/transferred to a home under care of organized home health

service organization. 07 Left against medical advice or discontinued care. 08 Discharged/transferred to home under care of a home IV drug therapy

provider. This is not a certified Medicare provider. 09 Admitted as an inpatient to this hospital (for use on Medicare

Outpatient Hospital claims only). 20 Expired (or did not recover - Christian Science Patient). 30 Still patient. 40 Expired at home. (Hospice claims only.) 41 Expired in a medical facility, such as a hospital, SNF, ICF, or

freestanding hospice. (Hospice claims only.) 42 Expired - place unknown. (Hospice claims only.) 43 Discharge/transferred to a Federal Health Care Facility. 50 Discharge to hospice – home. 51 Discharge to hospice - medical facility. 61 Discharged/transferred to a hospital-based, Medicare-approved,

swing bed.



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7030. Update 03/08

62 Discharged/transferred to an inpatient rehabilitation facility (IRF) distinct part units of a hospital.

63 Discharged/transferred to a Medicare certified long term care hospital (LTCH).

64 Discharge/transferred to a nursing facility certified under Medicaid but not certified under Medicare.

65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital (for future use). Providers shall continue to use Patient Status Code 05 until further notice.

66 Discharged/transferred to a Critical Access Hospital (CAH) for discharge dates on or after January 1, 2006.

70 Discharge/transfer to another type of health care institution not defined elsewhere in the code list.

FL 18-28 Condition Codes – Optional. Enter one of these two-digit codes to indicate a

condition(s) relating to inpatient or outpatient claims, special programs or procedures (e.g. KAN Be Healthy, sterilization, etc.).

Note: This is not a complete list. For a complete list of Condition Codes contact EDS Customer Service.

01 Military service related 02 Condition is employment related 03 Patient covered by insurance not reflected here 67* Beneficiary elects not to use life time reserve (LTR) days

*This will now replace the Z1 Medicare Part A benefits exhausted condition code. The verbiage in the explanation of condition code 67 means the patient’s benefits are exhausted.

80 Home Dialysis – Nursing Facility A1 KAN Be Healthy (EPSDT) A4 Family Planning AA Abortion performed due to rape AB Abortion performed due to incest AI Sterilization D9* Any other change *This will now replace the XO swing bed condition code.



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7030. Updated 12/07

FL 31-34 Occurrence Codes/Dates: OCCURRENCE CODES CAN ONLY BE SUBMITTED ON LINE A. The following occurrence codes must be indicated if reporting information on type of accident, crime victim, other insurance denial or date of TPR termination, or aborted surgery, false labor or nondelivery claim where associated services are indicated. Note: This is not a complete list. For a complete list of Occurrence Codes contact EDS Customer Service.

01 Accident/medical coverage 02 No fault insurance involved – including auto accident/other 03 Accident/tort liability 04 Accident/employment related 05 Accident/no medical or liability coverage 06 Crime victim 24 Date insurance denied 25 Date benefits terminated by primary payer A3 Benefits exhausted, Payer A B3 Benefits exhausted, Payer B C3 Benefits exhausted, Payer C

All EDS/SRS guidelines remain the same regarding attachments required for TPR proof and SSA/Medicare EOMBs.

FL 39 Value Codes/Amount – Required if applicable (for State Institutions Only).

• Enter D3 for nonpatient obligation as the value code. Enter the nonpatient obligation dollar amount in the “Amount” field. Examples of nonpatient obligation are Parental, Spousal, and Trust.

• Enter 80 for covered days and enter the number of covered days in the Amount field.

Note: Count the date of admission but not the date of discharge.

*FL 42 Revenue Code – Required. Enter the three-digit code identifying the type of accommodation services. Use only the revenue codes listed below:

101 All inclusive room and board 180 NF/MH reserve days 181 Home therapeutic reserve days ICF/MH – 21 days per calendar year 183 Home leave days / Therapeutic leave days 185 Hospital leave days 189 Noncovered days

*FL 45 Service Date – Required. Enter first date of service for the detail line.

*FL 46 Service Units - Required. Enter the total number of days for each detail line.



7-25

7030. Updated 09/07 FL 47 Total Charges - Required. Enter total charges billed.

FL 50 Payer Name - Required. Enter all third party resources (TPR). If TPR does exist, it must be billed first. Lines B and C should indicate secondary and tertiary coverage. Medicaid will be either the secondary or tertiary coverage and the last payer. When B and C are completed, the remainder of this line must be completed as well as FL 58-62. Medicare needs to always be the last entry.

FL 54 Prior Payments - Required if other insurance is involved. Enter amount paid by other insurance. Medicare needs to always be the last entry. Do not enter patient liability amount. It is automatically deducted during claim processing.

FL 57 Other Provider ID: Enter either qualifier ‘1D’ and the billing provider’s KMAP provider ID or qualifier ‘ZZ’ and the taxonomy code.

FL 60 Insured’s Unique ID: Enter the 11-digit number from the beneficiary’s medical card on line C.

FL 61-62 Group Name/Insurance Group No. - Required if Medicaid is not primary payer. Enter the primary insurance information on line A and Medicare on line C.

FL 67A-Q Prin. Diag. Cd. - Required. Enter the ICD-9-CM code indicating the primary diagnosis and additional diagnoses.

FL 76 Attending - Optional. a. Enter attending physician's NPI, or the appropriate qualifier and

physician’s KMAP provider ID or taxonomy code. b. Enter attending physician's Medicaid provider name as last name and then

first name.

FL 80 Remarks – Optional. Specify additional information as necessary.

Submission of Claim:

Send completed claim to:

Kansas Medical Assistance Program Office of the Fiscal Agent P.O. Box 3571

Topeka, Kansas 66601-3571



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7030. Updated 9/07 STATE INSTITUTION FOR M/H SPECIFIC BILLING INFORMATION

Accommodation and Ancillary Charges:

If the individual accommodation and ancillary services exceed the detail lines on the UB-04 claim form, providers may combine all similar revenue code charges together (e.g., lab, radiology) when necessary. Accommodation codes may also be 'lumped' together when necessary. This will not affect the reimbursement of the claim.

State institutions may bill for ancillary services without indicating an accommodation code.

Medicare B Services:

When Medicare B payment is made on an inpatient claim, indicate the amount paid as "Prior Payment" in FL 54 on the UB-04 claim form.

Other Insurance:

When a consumer has other insurance, proof of payment or denial is required. Enter the amount paid by the other insurance carrier in FL 54 on the claim form. Refer to Section 3300 for specific instructions on submitting claims when other insurance is involved.

Patient/Parental Liability:

Indicate any patient or parental liability in FL 54 on the UB-04 claim form. Payment will be deducted accordingly.

Transfers:

When billing medically necessary incoming transfers, the following should be entered on claims for incoming transfers from other hospitals:

In FL 84 "Remarks", enter "direct transfer from (hospital, city)".

Reserve Days:

Indicate revenue code 189 in FL 42 when billing for reserve days.


BENEFITS & LIMITATIONS

8-1

BENEFITS AND LIMITATIONS

8100. COPAYMENT Updated 11/03 General hospital inpatient services require a copayment of $48.00 per inpatient admission. General hospital outpatient surgery requires a copayment of $3.00 per surgery. General hospital non-emergency outpatient services in place of a doctor's office visit require a copayment of $3.00 per visit. Ambulatory surgical center services require a copayment of $3.00 per day. Inpatient free standing private psychiatric facility services require a copayment of $48.00 per admission. Specialty hospital (rehabilitation facilities, teaching facilities, etc.) inpatient services require a copayment of $48.00 per inpatient admission. State psychiatric facility consumers are exempt from copayment requirements. Transferring inpatient hospital admissions are exempt from copayment requirements. Copayment will be deducted from the receiving hospital. Bill all services occurring on the same date on the same claim form. If multiple claims are submitted for the same date(s) of service, the copayment requirement will be deducted for each claim submitted. Do not reduce charges or balance due by the copayment amount. This reduction will be made automatically during claim processing.

Refer to Section 3000 for exceptions.



8-2

BENEFITS AND LIMITATIONS 8200. MEDICAL ASSESSMENT Updated 08/07 Documentation:

To verify services provided in the course of a postpayment review, documentation in the patient's medical record must support the service billed. Documentation can be requested at any time to verify that services have been provided within program guidelines. Refer to Section 5000 of the General Billing Provider Manual. Autoauthentication (computerized authentication) of documentation for the medical record is acceptable documentation for the Kansas Medical Assistance Program. Autoauthentication must meet federal guidelines. It may be necessary to contact the ordering physician for medical necessity information.

Federal regulation 42 CFR 482.24 (c) (1) (i) requires that there must be a method of determining that the physician authenticated the document after transcription. All entries must be legible and complete and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished. The author of each entry must be identified and must authenticate his or her entry. Authentication may include the author's signature, written initials, or computer entry.

The information below indicates medical information which may be necessary to document medical necessity of those diagnoses designated as “sometimes payable” on the screen.

Abdominal Plain Films and Ultrasound:

Abdominal plain films and ultrasound are medically necessary if the diagnosis indicates abdominal pain, nausea/vomiting, complications associated with ulcers, intestinal obstruction, gall bladder disease, malignant neoplasm of the abdominal organs, injury to the abdomen or nephrolithiasis. It may be necessary to contact the ordering physician for medical necessity information.

An abdominal plain film may be warranted in a pregnant patient if:

• Fetal position is questionable • Obstetrical ultrasound is unavailable and patient is in labor

Electrocardiograms (EKGs):

Electrocardiograms (up to 12 leads) are considered medically necessary when the diagnosis and/or condition clearly indicates one or more of the following:

• Relevant cardiopulmonary diagnosis • Significant electrolyte imbalance • Drug induced EKG changes (identify the drug) • Progressive renal disease • Unstable thyroid disease • Specific central nervous system (CNS) disorders causing EKG changes



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8200. Updated 9/06

• Congenital disorders causing EKG changes • Symptomatic hypothermia • Shortness of breath • Fainting spells • Monitoring the effects of psychotropic drugs for potential cardiac effects

(identify the drug)

Preoperative EKGs are medically necessary for patients over age 40, or those patients under 40 with a history of cardiac problems. It may be necessary to contact the ordering physician for medical necessity information.

Cardiac Rehabilitation:

Phase II Cardiac Rehabilitation is covered using procedure code 93798. This procedure is covered when performed in an outpatient or cardiac rehabilitation unit setting, with the following criteria:

• Beneficiary must have a recent cardiology consultation within three months of starting the cardiac rehabilitation program.

• Beneficiary must have completed Phase I Cardiac Rehabilitation: • Beneficiary must have one or more of the following diagnoses/conditions.

o Acute myocardial infarction (410.00 – 410.92, 414.8) within the preceding three months, post inpatient discharge

o Coronary bypass (V45.81) surgery within the preceding three months, post inpatient discharge

o Stable angina pectoris (413.9 and 413.0) within three months post diagnosis

Chest X-Rays:

Chest X-rays are determined medically necessary if: • History or indication of cardiopulmonary disease, malignancy, cardiovascular

accident (CVA), or long bone fracture • Recent thoracic surgery • Thoracic injury • Chronic cough of over one month duration

o (Specify as chronic in the diagnosis field. If this designation is not supplied, the condition will be considered acute and the X-ray denied.)

Pre-operative and routine admission chest X-rays are non-covered unless documentation of medical necessity (one or more of the following factors) is noted on the claim:

• Sixty years of age or older • Pre-existing or suspected cardiopulmonary disease • Smoker over age forty • Acute medical/surgical conditions such as malignancy or trauma



8-4

8200. Updated 9/06 Claims denied because other factors are listed, will be reconsidered if appealed (refer to Section 5300).

It may be necessary to contact the ordering physician for medical necessity information.

CT Scans - Abdominal:

A CT scan of the abdomen is medically necessary if the diagnosis indicates a malignant neoplasm of the intra-abdominal cavity, lung or genital organs, lymphoma, diseases of the spleen, liver abscess, peritonitis, pancreatitis, abdominal trauma, or abdominal mass.

A CT scan of the abdomen may be medically necessary for abdominal pain, abdominal aneurysm, acute lymphocytic leukemia, or any malignant neoplasm not located in the intra-abdominal cavity, lung or genital organs. Inclusion of the following documentation will assist in the adjudication of your claim.

Abdominal Pain: Indicate the severity and chronicity of the pain, presenting symptoms and suspected conditions or complications. Abdominal Aneurysms: Indicate the presenting symptoms and suspected complications. Acute Lymphocytic Leukemia: Indicate the presenting symptoms and a detailed description of area(s) involved. Malignant Neoplasm not located in the Intra-Abdominal Cavity, Lung or Genital Organs: Indicate pertinent symptoms and if performed as part of staging the disease process.


CT Scans - Head or Brain:

CT scan of the head or brain is medically necessary if the diagnosis indicates intracranial masses/tumors, intracranial congenital anomalies, hydrocephalus, brain infarcts, parencephalic cyst formation, open or closed head injury, progressive headache with or without trauma, intracranial bleeding, aneurysms, or the presence of a neurological deficit.

A CT scan of the head or brain may also be medically necessary with the indication of headache, epilepsy, syncope, dizziness, or acute lymphocytic leukemia. Inclusion of the following documentation will assist in adjudication of your claim:

Headache - Indicate length of chronicity and any accompanying Central Nervous System (CNS) symptoms.

Epilepsy - Specify if initial or repeat scan, indicate if suspected injury occurred during seizure.

Syncope - Specify if recurrent or single episode. Dizziness - Specify if recurrent or single episode. Acute Lymphocytic Leukemia - Indicate any accompanying CNS symptoms.




8-5

8200. Updated 3/06 Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy is a covered service under KMAP with prior authorization. The following criteria must be met before a PA will be approved.

1. the services must be for one of the following conditions: a. Acute carbon monoxide intoxication b. Decompression illness c. Gas embolism d. Gas gangrene e. Acute traumatic peripheral ischemia f. Compromised skin grafts g. Chronic refractory osteomyelitis h. Osteoradionecrosis i. Soft tissue radionecrosis j. Cyanide poisoning k. Actinomycosis l. Crush injuries and suturing of severed limbs m. Progressive necrotizing infections n. Acute peripheral arterial insufficiency o. Diabetic wounds of lower extremities

2. It must be documented that other treatments have been attempted with no improvement.

Facilities bill for this procedure using either 99183 (one unit equals 30 minutes) or C1300 (four units equals one session, up to two hours). The facility must choose which procedure code they will bill prior to the approval of the PA. If there are multiple sessions on the same day (more than four units for facilities), each subsequent session must be billed on a separate line detail with a 76 modifier.

MRI - Head or Brain:

MRI scan of the head or brain is medically necessary if the diagnosis indicates intracranial injury, intracranial mass/tumor, CNS malignancies, cerebrovascular disorder, cerebral malformations, disorders of the cerebral hemispheres and higher brain functions, demyelinating diseases, extrapyramidal and cerebellar disorders, brain abscesses, encephalitis, tuberculous meningitis, or the presence of a neurological deficit. MRI scan of the head or brain may also be medically necessary with the indication of headache, seizure disorders, syncope, dizziness, or non-CNS malignancies. Inclusion of the following information will assist in adjudication of your claim:

Headache - Indicate length of chronicity and any accompanying neurologic symptoms. Seizure - Specify if initial or repeat scan, and if seizures (or convulsions) are of Disorders - (or convulsions) are of recent onset, frequency of their occurrence, and any

accompanying neurologic symptoms. Syncope - Specify if recurrent or single episode and any accompanying neurologic

symptoms.



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8200. Updated 3/06

Dizziness - Specify if recurrent or single episode and any accompanying neurologic symptoms.

Non-CNS Malignancies - Indicate any accompanying neurologic symptoms.

It may be necessary to contact the ordering physician for medical necessity information. MRI - Breast

MRI of the breast will be covered with the following indications: • Staging and therapy planning in patients diagnosed with breast cancer • Occult primary breast cancer when there are positive axillary nodes and no known

primary tumor • Inconclusive diagnosis after a standard mammography evaluation, for example

when scar tissue from previous surgery, dense breast tissue of breast implants render mammographic images inconclusive

MRI used for screening for breast cancer is not justified. Skull X-Rays:

Skull X-rays are medically necessary if diagnosis indicates cranial trauma, primary or metastatic tumors of the skull, or tumors of the pituitary gland.

A skull X-ray may also be medically necessary for indication of chronic sinusitis, trigeminal neuralgia, or anomalies relating to the head. Inclusion of the following documentation will assist in the adjudication of your claim:

Chronic Sinusitis - Indicate any pertinent specific suspected complications resulting from chronicity. Trigeminal Neuralgia - Specify type of lesion suspected. Anomalies relating to the head - Specify if done as a scout film for non-cosmetic reconstructive surgery. Indicate type of surgery under consideration.


Sonograms - Non-Obstetrical Pelvic:

Non-obstetrical pelvic sonograms are determined medically necessary if the diagnosis indicates pelvic mass or pain, ovarian cyst, pelvic inflammatory disease, endometriosis, possible retained products of conception, or question/history of metastatic disease.

Non-obstetrical pelvic sonograms may be medically necessary if there is an indication of vaginal bleeding or irregular menstrual cycles. It may be necessary to contact the ordering physician for medical necessity information.



8-7

8200. Updated 05/07 Obstetrical Pelvic Sonograms:

Routine obstetrical sonograms for a normal pregnancy are not covered.

Primary diagnosis shall support medical necessity for an OB sonogram. Some examples are: indication of vaginal bleeding, multiple birth, diabetes, size/date discrepancy, fetal anomalies, threatened abortion, placental/uterine abnormalities, fetal demise, or maternal drug/alcohol/tobacco use; history of previous miscarriage, Cesarean Section, stillbirth, ectopic pregnancy, eclampsia, or intra-uterine growth retardation.

Medical necessity may also be determined based on maternal age, maternal weight or fetal position. If applicable, this information should be submitted with the claim. It may be necessary to contact the ordering physician for medical necessity information.

A biophysical profile will not be reimbursed when a complete OB sonogram has been billed for the same date of service.

Upper Gastrointestinal Series:

Upper Gastrointestinal (UGI) series, which require precertification, are medically necessary if the primary diagnosis indicates persistent dysphagia, melena, symptoms of UGI tract bleeding or signs and symptoms of ulcers affecting the UGI tract after a trial of medicinal therapy has failed to relieve the symptoms. State guidelines allow one UGI series per day, per beneficiary, regardless of provider.

UGI series may also be medically necessary when diagnoses such as abdominal pain and dyspepsia are used. When these common non-specific diagnosis codes are used, additional symptoms and/or circumstances that relate to the medical necessity of the procedure must be indicated. Examples of additional information which will assist in adjudication of your claim are as follows:

• Is the symptom persistent? If so, how long has the symptom persisted? • Is the symptom recurrent? When was the last episode? • Has the symptom or condition increased in severity? • Was medicinal therapy initiated prior to any procedure being performed? If

so, indicate the date each therapy was initiated, name(s) of medication (list all GI related medications tried) and the length of time each medication was tried. What was the patient's response to each treatment?

• If a chronic condition, has there been a change in symptoms? If so, describe the change(s).

• If cancer diagnosis codes are used, what symptoms are present that indicate UGI involvement?

Claims for UGI X-rays are denied reimbursement when the diagnosis code on the claim is either too non-specific or is the result, rather than the reason, for the procedure. Whenever possible, use the symptoms that most clearly describe the reason for the test.




8-8

8200. Updated 3/06 Emergency Room/Department (Outpatient Hospital):

General Information: The State of Kansas defines emergency services as follows:

KAR 30-5-58 (42) "Emergency services are those services provided after the sudden onset of a medical condition manifested by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part."

KAR 30-5-81 (b) (4) "Services provided in the Emergency Department shall be emergency services."

Emergency status is determined based on conditions relating to the emergency visit, not the patient's age and time of admission to the emergency department. Emergency department claims are limited to one visit per consumer, per date of service unless accompanying documentation verifies the necessity for more than one emergency room/department visit.

Direct physical attendance by a physician or mid-level practitioner is required in "emergency" situations. If the physician or mid-level practitioner has not made entries on the record other than his/her signature and/or diagnosis and documentation does not indicate that he/she had examined the patient, the visit will not be considered emergent. Phone or standing orders do not support emergency treatment.

Axillary temperatures are not considered accurate and will be disregarded when determining emergent status.

Consumers may go to the emergency room without a referral from their physician based on the definition of an emergency according to a prudent layperson (as defined by the Balanced Budget Act, 1997): What a layperson would consider an emergency in the absence of medical knowledge. Such an emergency could include, but is not limited to: serious impairment to bodily functions; serious dysfunction of any bodily organ or part; severe pain; or an injury/illness that places the health of the individual in serious jeopardy (and in the case of a pregnant woman, her health or that of her unborn child).

Other Examples of Emergencies are:

o Initial treatment for medical emergencies including indications of severe chest pain, dyspnea, gastrointestinal hemorrhage, spontaneous abortion, loss of consciousness, status epilepticus or other conditions considered "life-threatening."

o Patients who require transfer to another facility for further treatment or who expire.



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8200. Updated 3/06

Non-Emergent Situations: o Intentional non-compliance with previously ordered medications and treatments

resulting in continued symptoms of the same condition. o Refusal to comply with currently ordered procedures/treatments such as drawing

blood for laboratory work. o Leaving the emergency room against medical advice. o Scheduled visits to the emergency room for procedures, examinations or medication

administration. Examples include cast changes, suture removal, dressing changes, follow-up examinations and second opinion consultations.

o Visits made to receive a "tetanus" injection in the absence of other emergent conditions.

o Visits made to obtain medication(s) in the absence of other emergent conditions.

The following conditions will not be considered emergent unless the criteria described has been met:

Alcoholism in and of itself is considered nonemergent unless documentation supports an emergent status (i.e., gastric bleeding or coma/stupor).

Ambulance: A patient brought in by ambulance does not necessarily justify an emergency room visit.

Guidelines for Use of Air Ambulance Services: Time: If time is a critical factor in the patient’s recovery or survival, or duration of ground transport would be excessive and potentially detrimental, air transport may be indicated. In general, if the ground ambulance can arrive at the destination institution within 20 minutes, it is the preferred mode of transport. Expertise: If the health care institution does not possess the expertise to provide the definitive care required to stabilize the patient (i.e., advanced life support) and the ground ambulance providers in the near vicinity cannot provide assistance in providing that care, air transport may be indicated. Coverage: If ground ambulance utilization leaves the service area without adequate ground coverage and patient outcome will be compromised by arranging other ground transport, air transport may be indicated. Documentation: The above guidelines serve as a guide to documentation which is necessary to determine proper reimbursement and must specify the indication and justification for air transport. If guidelines are not met, or are met but not documented, the billed transportation will be reimbursed at ground ambulance rates or denied altogether.

Depression/Anxiety: Documentation must support the individual to be an immediate danger to self or others.



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8200. Updated 3/06

Disposition: If a patient's disposition is one of the following, the visit would be considered emergency:

a) requires transfer to another facility for further treatment, b) has expired, expires enroute to the hospital or in the emergency room, c) requires extended observation or admission.

Fevers must be considered with other documented symptoms. Generally, temperatures less than 103 rectally (children) or 102 orally (adults) are not considered emergent. Ear and axillary temperatures will be considered along with additional symptoms. Reported temperatures by patients are not acceptable for determining emergent status.

Insect Bites, Stings, Embedded Ticks: Minor insect bites (tick) with simple local reactions only (i.e., erythema, local edema, itching) are not considered emergent.

Medical Emergency: Initial treatment and/or stabilization for medical emergencies including indications of severe chest pain, dyspnea, gastrointestinal hemorrhage, spontaneous abortion, loss of consciousness, status epilepticus or other conditions considered "life-threatening" would be considered emergent. Just because these conditions may be considered "life-threatening" at times, does not automatically indicate a Level of Care III. The Level of Care assignment is dependent upon the severity of the situation and the services provided.

Mental Disorders such as depression or anxiety as an individual diagnosis is considered nonemergency unless the patient is noted to be suicidal or of immediate risk to self or others.

Minor Burns/Sunburns: Minor burns/sunburns are considered nonemergent unless documentation supports the presence of complications such as severe swelling, infection, or the young age of the patient. Eye and chemical burns are considered emergent.

Otitis Media: If tympanic membrane is bulging or ruptured, drainage from the ear(s), fever of 103 or above or is a child of age 3 or under and is crying inconsolably, a visit to the emergency room would be considered emergent for consideration of otitis media. If the physical examination reveals evidence of acute otitis media (after office hours or on the weekend), but does not meet any of the above criteria, the ED visit may be considered emergent because of the time of day/week.

Patient Non-Compliance: Intentional non-compliance with previously ordered medications and treatments resulting in continued symptoms of the same condition are considered nonemergent. Refusal to comply with currently ordered procedures/treatments such as drawing blood for laboratory work will also be considered nonemergent.



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8200. Updated 3/06

Removal of Cutaneous Foreign Bodies: Removal of cutaneous foreign bodies (i.e., simple splinters, cactus needles) are considered nonemergent unless sedation or the use of extensive medical supplies such as cutdowns are required.

Seizures are considered emergent when:

a) this is an initial seizure b) there is a secondary diagnosis noted (i.e., infection or headache) c) the patient is 12 years old or younger d) the seizure is still in progress or status epilepticus e) this is a febrile seizure f) the condition is aggravated by alcohol/drug ingestion g) this is a previously undiagnosed condition

Scheduled Visits: Scheduled visits to the emergency department for procedures, examinations or medication administration (i.e., cast changes, suture removal, dressing changes, follow-up examinations and second opinion consultations) are considered nonemergent.

When a patient leaves the emergency department against medical advice (AMA) the service is generally considered nonemergent. However, if the facility provided considerable services before the patient left AMA, the visit will be given consideration as emergent.

Sickle Cell Anemia: If a person has sickle cell anemia and presents with suspicion of an infectious or hypoxic process, or complains of pain, the visit may be considered emergent.

Skin Rash/Hives: Documentation must support presence of systemic complications beyond the local skin discomforts resulting from the rash. If the rash causes eye complications or the beneficiary has a history of anaphylactic (allergic) reactions, the visit is considered emergent.

If the rash causes eye edema or impairment to eye function and the visit is over a weekend when there is no access to a physician's office, the visit may be considered emergent.

A history of anaphylaxis along with the rash is considered emergent.

Trauma/Injury: Recent trauma or injury is considered emergent. Recent is defined as an injury occurring within 48 hours prior to the emergency room visit. Minor abrasions/lacerations not requiring suture or other injuries not requiring treatment are not emergent.

If the injury is older than 48 hours and symptoms have deteriorated to the point of requiring emergency care, consider as emergent.



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8200. Updated 3/06

An injury that requires only simple first aid treatment that can be done in the home (such as cleansing and/or bandaging an abrasion) is not considered emergent.

A laceration requiring steri-strips indicates a gaping wound and would be considered emergent.

X-rays do not define the level of care.

Tetanus Injection: A tetanus injection is not considered emergent, and does not change the visit to emergent. However, the patient should not have to make two visits (one to the emergency room and one to an office or public health department) in order to receive the tetanus injection. When needed, a tetanus injection should be given within 48-72 hours of the injury, if possible.

Time of Visit: The time of the visit is a consideration in determining emergent vs. nonemergent status. If the condition require immediate attention and it is after office hours, a weekend, or holiday, consider as emergent.

If a patient is brought in by the police at any time, consider as emergent.

If a patient had previously been in the same or different emergency department or physician's office for the same condition and the condition has not worsened, the visit will be considered nonemergent.

Vital Signs: If the vital signs are outside a reasonable range for the age, consider the visit as emergent (see "fever").

Emergency Department/Room Guidelines for E&M Codes:

History: The age of a patient is a component of every medical record. Documentation of age in relationship to issues such as antisocial behavior or mental status is important; however, age alone is not considered a social history.

Examination: A "comprehensive exam" is considered a "hands on" specialist examination. Telephone consultation with a specialist is not the equivalent of comprehensive exam (per Dr. Aaron Primack, HCFA/AMA consultant).

Medical Decision Making: Transfers from the emergency department to another facility for additional care should be considered in management options as either the "new problem, additional work-up" or the category of "established problem, worsening" (per Dr. Aaron Primack, HCFA/AMA consultant).

A vascular examination is included in the cardiovascular category.



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8200. Updated 3/06

A notation that the patient should "follow-up" with his family physician in the morning or return to the physician's office for stitch removal does not justify use of the "additional work-up" statement when considering management options (per Dr. Aaron Primack, HCFA/AMA consultant).

In evaluating the "Table of Risk", infection is the usual risk that pops into mind when talking about minor surgery. To consider infection as a "risk" from minor surgery, there must be documentation to support increased risk due to the quality or condition of the injury or illness (per Dr. Aaron Primack, HCFA/AMA consultant).

"Self-limited/minor problems" are defined as those representative of basic emergency department care such as lacerations, stings, insect bites (per Dr. Aaron Primack, HCFA/AMA consultant).

"New problems with or without additional work-up" is defined as representing new, long-standing problems that will need attention again at some time (per Dr. Aaron Primack, HCFA/AMA consultant).

Observation Room:

Observation in the outpatient setting is a service which requires monitoring the patient's condition beyond the usual amount of time in an outpatient setting. Examples of the appropriate use of the observation room include: monitoring head trauma, drug overdose, cardiac arrhythmias and false labor. A physician or mid-level practitioner must see the patient within two hours prior to admission to the observation room except for obstetrical labor or scheduled administration of IV medication or blood products. The observation room stay must be medically necessary.

There is no time limit restriction for the observation room. The same reimbursement rate applies regardless of the number of hours required for monitoring. This reimbursement is all inclusive of services and supplies. If there is a discharge and readmission to the observation room from midnight to midnight, only one reimbursement rate will be allowed.

Observation room is content of service of a minor surgery.

ER physician fee, non-scheduled fetal oxytocin stress tests and fetal non-stress tests are content of service of the observation room. Additional reimbursement for these services will not be made.

Observation room should not be billed for the following:

o Recovery room services following inpatient or outpatient surgery. o Recovery/observation following scheduled diagnostic tests such as arteriograms,

cardiac catherization, etc. o Scheduled fetal oxytocin stress tests and fetal non-stress tests.



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8200. Updated 3/06

NOTE: Additional information may be added to the face of your claim if applicable. Tape billers who have had initial billings denied with EOB 548 (Service denied. This claim and all attachments have been reviewed by the medical staff and the medical necessity of the service rendered is not supported by the documentation provided. Refer to the provider manual section 8200 for further discussion.), may resubmit a paper claim with the applicable documentation noted on the face of the claim.

If the claim and/or attachments do not support the medical necessity of the service rendered, the service will be denied.



8-15

BENEFITS AND LIMITATIONS 8300 Benefit Plan Updated 11/03 Kansas Medical Assistance beneficiaries will be assigned to one or more Medical Assistance benefit plans. The assigned plan or plans will be listed on the beneficiary ID card. These benefit plans entitle the beneficiary to certain services. From the provider's perspective, these benefit plans are very similar to the type of coverage assignment in the previous MMIS. If there are questions about service coverage for a given benefit plan, contact the Medical Assistance Customer Service Center at 1-800-933-6593 or (785) 274-5990 For example all policies and coverages under the current Medicaid Program apply to the MediKan benefit plan except:

Inpatient general hospital services are covered for MediKan consumers for the following conditions only:

• Alcohol and Drug Detoxification • Burns • Mental Health • Severe Traumatic Injuries • Tuberculosis

DRGs for covered inpatient hospital services are 424-442, 444-445, and 447. Additional DRGs are covered when the hospital admission is related to tuberculosis and a TB diagnosis is billed on the claim.

Claims for MediKan consumers that group to any of the following DRGs will be reviewed: 002, 217, 443, 456-460, 472, 483-487. Coverage determination is based on the nature of the injury indicated by the diagnosis on the claim.

Psychiatric Admissions:

The only psychiatric services covered are those for acute psychotic episodes. Inpatient psychiatric admissions to acute care general and specialty hospitals are covered only after a psychiatric preadmission assessment has been completed and a determination made that the most appropriate treatment setting is the hospital. Only the following diagnosis codes are covered for MediKan consumers:

293.00 - 293.90 298.00 - 298.90 307.00 - 307.90 295.00 - 295.90 299.00 - 299.90 296.00 - 296.99 300.00 - 300.90

Coverage determinations are based on the emergent nature of the service.



8-16

BENEFITS AND LIMITATIONS 8400. MEDICAID - INPATIENT/OUTPATIENT Updated 11/03 Enrollment:

Hospitals must sign a Hospital/Peer Review Organization Agreement with the Utilization Review Contractor before becoming enrolled as a Kansas Medical Assistance provider.

Change of Ownership:

Each hospital must notify the Adult and Medical Services, SRS, in writing at least 60 days prior to the change of ownership closing transaction date. Failure to do so may result in: 1) the forfeiture of rights to payment for covered services provided to consumers by the previous owner or owners in the 60-day period prior to the effective date of the change of ownership; and 2) the new owner or owners assuming responsibility for any overpayment made to previous owner(s) before the effective date of the change of ownership. (This shall not release the previous owner of responsibility for such overpayment.)

The new owner (and affiliated providers) must apply for a Medicaid provider number through the Adult and Medical Services by contacting:

Department of Social and Rehabilitation Services Adult and Medical Services, Medical Programs The Docking State Office Building, 6th Floor 915 S.W. Harrison Topeka, Kansas 66612

The new owner will receive the full reimbursement for any patients admitted before and discharged after the change of ownership effective date. The old owner shall not receive Medicaid payment for these services.

Advance Directives:

Hospital providers participating in the Kansas Medical Assistance Program must comply with federal legislation (OBRA 1990, Sections 4206 and 4751) concerning advance directives. An "advance directive" is otherwise known as a living will or durable power of attorney. Every hospital provider must maintain written policies, procedures and materials about advance directives.

Specific Requirements 1. Each hospital must provide written information to every adult individual receiving

medical care by or through the hospital. This information must contain: the individual's right to make decisions concerning his or her own medical care.

- the individual's right to accept or refuse medical or surgical treatment.



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8400. Updated 11/03

- the individual's right to make advanced directives. - the Department of Social and Rehabilitation Services' "Description of the Law

of Kansas Concerning Advance Directives." SRS does not provide copies of the description to providers. It is up to providers to reproduce the description. Providers are free to supplement this description as long as they do not misstate Kansas law.

2. Additionally, each hospital must provide written information to every adult individual

about the hospital's policy on implementing these rights. 3. A hospital must document in every individual's medical record whether the individual

has executed an advance directive. 4. A hospital may not place any conditions on health care or otherwise discriminate

against an individual based upon whether that individual has executed an advance directive.

5. Each hospital must comply with State law about advance directives. 6. Each hospital must provide for educating staff and the community about advance

directives. This may be accomplished by brochures, newsletters, articles in the local newspapers, local news reports or commercials.

Incapacitated Individuals An individual may be admitted to a facility in a comatose or otherwise incapacitated state, and be unable to receive information or articulate whether he or she has executed an advance directive. If this is the case, families of, surrogates for, other concerned persons of the incapacitated individual must be given the information about advance directives. If the incapacitated individual is restored to capacity, the hospital must provide the information about advance directives directly to him or her even though the family, surrogate or other concerned person received the information initially.

If an individual is incapacitated, otherwise unable to receive information or articulate whether he or she has executed an advance directive, the hospital must note this in the medical record.

Mandatory Compliance with the Terms of the Advanced Directive

When a patient, relative, surrogate or other concerned/related person presents a copy of the individual's advance directive to the hospital, the facility must comply with the terms of the advance directive to the extent allowed under State law. This includes recognizing powers of attorney.



8-18

8400. Updated 11/03 Description of the Law of Kansas Concerning Advance Directives:

There are two types of "advance directives" in Kansas. One is commonly called a "living will" and the second is called a "durable power of attorney for health care decisions."

The Kansas Natural Death Act, K.S.A. 65-28,106, et seq.

This law provides that adult persons have the fundamental right to control decisions relating to their own medical care. This right to control medical care includes the right to withhold life-sustaining treatment in case of a terminal condition.

Any adult may take a declaration which would direct the withholding of life-sustaining treatment in case of a terminal condition. Some people call this declaration a "living will." The declaration must be:

1. In writing; 2. Signed by the adult making the declaration; 3. Dated; and 4. Signed in front of two adult witnesses, or notarized.

There are specific rules set out in the law about the signature in case of an adult who can't write. There are specific rules about the adult witnesses. Relatives by blood or marriage, heirs, or people who are responsible for paying for the medical care may not serve as witnesses. A woman who is pregnant may not make a declaration.

The declaration may be revoked in three ways:

1. By destroying the declaration; 2. By signing and dating a written revocation; and 3. By speaking an intent to revoke in front of an adult witness. The

witness must sign and date a written statement that the declaration was revoked.

Before the declaration becomes effective, two physicians must examine the patient and diagnose that the patient has a terminal condition.

The desires of a patient shall at all times supersede the declaration. If a patient is incompetent, the declaration will be presumed to be valid.

The Kansas Natural Death Act imposes duties on physicians and provides penalties for violations of the laws about declarations.



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8400. Updated 11/03

The Kansas Durable Power of Attorney for Health Care Decisions Law, K.S.A. 58-625, et seq.

A "durable power of attorney for health care decisions" is a written document in which an adult gives another adult (called an "agent") the right to make health care decisions. The power of attorney applies to health care decisions even when the adult is not in a terminal condition. The adult may give the agent the power to: 1. Consent or to refuse consent to medical treatment; 2. Make decisions about donating organs, autopsies, and disposition of the body; 3. Make arrangements for hospital, nursing home, or hospice care; 4. Hire or fire physicians and other health care professionals; or 5. Sign releases and receive any information about the adult.

A "durable power of attorney for health care decisions" may give the agent all those five powers or may choose only some of the powers. The power of attorney may not give the agent the power to revoke the adult's declaration under the Kansas Natural Death Act ("living will"). The power of attorney only takes effect when the adult is disabled unless the adult specifies that the power of attorney should take effect earlier.

The adult may not make a health care provider treating the adult the agent except in limited circumstances.

The power of attorney may be made by two methods:

1. In writing; 2. Signed by the adult making the declaration; 3. Dated; 4. Signed in front of two adult witnesses;

Or: Written and notarized.

Relatives by blood or marriage, heirs, or people who are responsible for paying for the medical care may not serve as witnesses.

The adult, at the time the power of attorney is written, should specify how the power of attorney may be revoked.



8-20

8400. Updated 02/07 The Patient Self-Determination Act, Section 1902(w) of the Social Security Act This federal law, codified at 42 U.S.C. Sec. 1396a(w), was effective December 1, 1991. It applies to all Medicaid and Medicare hospitals, nursing facilities, home health agencies, hospices, and prepaid health care organizations. It requires these organizations to take certain actions about a patient's right to decide about health care and to make advance directives. This law also required that each state develop a written description of the State law about advance directives. This description was written by the Health Care Policy Section of the Kansas Department of Social and Rehabilitation Services to comply with that requirement. If you have any questions about your rights to decide about health care and to make advance directives, please consult with your physician or attorney. Third Edition: January 14, 2003 Abortions:

Abortions are covered only under the following conditions: • In the case where a woman suffers from a physical disorder, physical injury, or

physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself.

• If the pregnancy is the result of an act of rape or incest.

The physician must complete the abortion necessity form below to certify that the woman's physical health is in danger, or that this pregnancy is a result of rape or incest. A copy of the form can be found in the forms section at the end of this manual. The form, located at the end of this manual in the Forms section, Abortion_necessity_form , or on the Provider Web site under Publications/Forms/Abortion necessity form may be photocopied for your use. All blanks must be completed, including the patient's complete address.

Claims submitted for abortions due to rape or incest must be accompanied by a statement signed by the physician stating that he/she was informed by the patient that the pregnancy was the result of rape or incest. No further documentation is required to process the claim. However, all pertinent information must be retained with the medical record.

Children and Family Services (CFS) Contractors:

Medicaid reimbursable services will not be paid by child welfare contractors. All services for children assigned to contractors, including behavior management and mental health, must be billed directly to the Kansas Medical Assistance Program and will be reimbursed at the approved Medicaid rate. Prior authorization and other restrictions apply.

Refer to Section 2900 of your General Provider Manual for an all-inclusive list of the categories of service covered under the CFS contract.



8-21

8400. Updated 09/07 Immunization/Vaccine:

Reimbursement for covered immunizations for children is limited to the administration of the vaccine only. Vaccines are supplied at no cost to the provider through Vaccines for Children, a federal program administered by the Kansas Department of Health and Environment.

Intrathecal Baclofen Pump: Intrathecal baclofen pumps are covered for Medicaid beneficiaries. This includes the initial and all subsequent implantation(s), revision(s), repairs, catheters, batteries, refills, removals, and maintenance of the intrathecal baclofen pumps when indicated. Three services require prior authorization, 62350, 62351, and 62362.The following conditions must be met:

• The beneficiary must have responded favorably to a trial of intrathecal baclofen and

documentation of previously used medication

• The beneficiary’s ICD – diagnosis code must be a covered code and the source of the spasticity must be documented

• The beneficiary must be over the age of four years or there must be documentation that there is sufficient space within the child’s chest wall for the pump to be implanted.

• Contraindications include pregnancy and active infection at time of surgery

Procedure codes 62311, 62319, 62355, 62365, 95990, 95991, and 62368 do not require PA but HealthConnect beneficiaries do need a referral from their PCPs.

Renal Dialysis and Kidney Transplant: When it has been determined a beneficiary has chronic renal disease (CRD) requiring renal dialysis, the beneficiary or his representative should apply for Medicare CRD eligibility.

Medicare allows for payment of claims for eligible beneficiaries with chronic renal disease and will reimburse for maintenance dialysis the third month after the maintenance dialysis starts. Medicare will reimburse for maintenance dialysis in the first three months if the beneficiary has been involved in self training in a self-care dialysis unit or through a self-care home dialysis support service provided by a qualified provider. They also reimburse for expenses incurred for a kidney transplant including those for the kidney donor.

Medicaid will reimburse claims for services related to chronic renal dialysis and/or kidney transplants only after proof has been attached to one claim that the beneficiary has applied for Medicare and coverage has been approved or denied. The Medicare CRD eligibility information will be retained in the claims processing system. Therefore, subsequent claims do not need to have proof of Medicare CRD eligibility approval or denial attached.

Acceptable proof of application and coverage or denial by Medicare are:

• Medicare EOMB/RA • Beneficiary Health Insurance Card • Report of Confidential Social Security Benefit Information • Letter from Medicare or Social Security explaining that the beneficiary has applied for

Medicare and whether beneficiary is eligible



8-22

8400. Updated 09/07 Hospitals Qualifying For Federal Renal Program:

Univ. of Kansas Med. Center St. Francis Regional Med. Center 39th & Rainbow Boulevard 929 North St. Francis Kansas City, Kansas 66103 Wichita, Kansas 67211

St. Luke's Hospital Research Hospital & Medical Ctr. 44th and Wornall Road Meyer Boulevard & Prospect Kansas City, Missouri 64111 Kansas City, Missouri 64132

St. Francis Hosp. & Health Center* Humana Hospital Dodge City* 1700 West Seventh Street Dodge City, Kansas 67801 Topeka, Kansas 66606

Children's Mercy Hospital Kansas City Dialysis & Training 24th at Gillham Road Center* Kansas City, Missouri 64108 Located at Research Hospital (CAPD Training & Support Services) Meyer Boulevard & Prospect Kansas City, Missouri 64132 Salina Regional Health Center

400 S. Santa Fe Salina, Kansas 67406

FOR VETERANS:

Kansas City V.A. Hospital Wichita V.A. Hospital 4801 Linwood Boulevard 5500 East Kellogg Kansas City, Missouri 64128 Wichita, Kansas 67218

* Approved for dialysis only



8-23

8400. Updated 09/07 Surgery - Ambulatory/Outpatient:

Ambulatory surgery centers and outpatient hospitals will be reimbursed for multiple unrelated outpatient surgical procedures performed on the same day as follows: 100% of the current Medicaid rate for the highest value procedure; 50% of the current Medicaid rate for the second procedure; and 25% of the current Medicaid rate for all subsequent procedures.

IV's, medications, supplies and injections provided on the same day as an ambulatory/outpatient surgery procedure are considered content of service of the surgery and cannot be billed separately. EXCEPTION: The following thrombolytic enzymes are not considered content of service when billed in conjunction with outpatient surgery: Alteplase-J2997, Reteplase-J2993, Urokinase-J3364, Streptokinase-J2995, and Anistreplase-J0350.

Anesthesia (equipment and supplies), drugs, surgical supplies and other equipment of the operating room and the recovery room are considered content of service of the ambulatory/outpatient surgical procedure.

Surgery - Breast Reconstruction: Breast reconstruction is covered when the beneficiary had a mastectomy for breast cancer on or after March 1, 2005. Only the breast reconstruction procedure codes listed in Appendix II are covered. This coverage is limited to one breast reconstruction process per breast per lifetime.

Surgery - Cosmetic:

All surgeries which are cosmetic in nature (and related complications) are not covered. Any medically necessary procedure which could ever be considered cosmetic in nature must receive prior authorization (PA). The hospital must have a copy of the physician's PA for claim processing purposes.

Surgery - Elective:

The Medicaid program will not reimburse for inpatient/outpatient elective surgery unless the beneficiary is a KAN Be Healthy participant.

Certain surgical procedures will be reviewed on a post-pay random sample basis by the KHPA physician. Retain all documentation supporting the non-elective nature of the surgery for review. Supporting documentation includes admission notes/history and physical, operative report and pathology report. If the documentation does not support the non-elective nature of the surgery, reimbursement for all claims relating to the surgery will be recovered.

Therapy: Therapy treatments are not covered for a psychiatric diagnosis.

Habilitative - Therapy is covered for any birth defects/developmental delays only when approved and provided by an Early Childhood Intervention (ECI), Head Start or Local Education Agency (LEA) program. Therapy treatments performed in the Local Education Agency (LEA) settings may be habilitative or rehabilitative for disabilities due to birth defects or physical trauma/illness. Therapy of this type is covered only for participants age 0 to under the age of 21. Therapy must be medically necessary. The purpose of this therapy is to maintain maximum possible functioning for children.



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8400. Updated 09/07

Rehabilitative - All therapies must be physically rehabilitative. Therapies are covered only when rehabilitative in nature and provided following physical debilitation due to an acute physical trauma or physical illness and prescribed by the attending physician.

Therapy services are limited to 6 months for non-KAN Be Healthy participants (except the provision of therapy under HCBS), per injury, to begin at the discretion of the provider. There is no limitation for KAN Be Healthy participants. Effective with dates of service on and after December 1, 2006, providers of rehabilitative therapy can submit claims with a combination of the following rehabilitation therapy procedure codes and a diagnosis code in the range of V57.0-V57.9 as the primary diagnosis. Providers are required to submit a secondary diagnosis code to describe the origin of the impairment for which rehabilitative therapy is needed when one of these V-codes is billed as a primary diagnosis.

97001 97003 97010 97012 97014

97016 97018 97022 97024 97026

97028 97032 97033 97034 97035

97036 97110 97112 97113 97116

97124 97140 97150 97530 97535

97750

Transplants: Liver transplants for Medicaid beneficiaries will only be reimbursed at the University of Kansas Medical Center or at a hospital recommended by their staff.

Heart, lung, and heart/lung transplants performed in approved in-state or border city hospitals are covered for KAN Be Healthy participants only.

Heart transplants will be allowed at St. Luke's Hospital in Kansas City, Missouri or Via Christi (St. Francis Campus) in Wichita, Kansas, or at a hospital recommended by either of these facilities.

Bone marrow, cornea, kidney, and pancreas transplants performed in approved in-state or border city hospitals are covered and do not require prior authorization.

Pancreas transplants are only covered when performed simultaneously with or following a kidney transplant.

Tuberculosis: Inpatient services related to a tuberculosis diagnosis, including physician and laboratory services, are covered for beneficiaries with the TB benefit plan.

Inpatient hospitalization, including physicians’ services for diagnostic evaluation of beneficiaries highly suspected of tuberculosis, is covered for completion of the diagnosis.



8-25

8400. Updated 09/07 Tuberculosis continued:

Acute problems, which are present on admission or arise during hospitalization, are covered services. Hospitalization for monitoring toxicity of anti-tuberculosis drugs is covered.

Inpatient claims may be billed directly to KMAP.

Coverage and payment of inpatient or outpatient services are subject to compliance with infectious disease reporting requirements as directed by K.A.R. 28-1-2.

Coverage and payment of outpatient services are coordinated between Kansas Department of Health and Environment (KDHE) and KMAP in accordance with the current interagency agreement. Contact KDHE at (785) 296-0739 for determination of coverage.

Anti-tuberculosis drugs to treat the beneficiary and family members are provided at no cost by KDHE. Contact your local health department or KDHE at (785) 296-2547.

Vagal Nerve Stimulators:

Vagal nerve stimulators (VNS) are covered for beneficiaries with epileptic disorders. With the exception of procedure codes 95970 and 95974, all services must be prior authorized VNS services must meet the following conditions:

• The beneficiary must have an epileptic disorder. VNS will not be covered for individuals with previous epileptic brain surgery or individuals with progressive disorders.

• Mental retardation with epilepsy is not a contraindication for VNS but must be considered with other factors.

• The beneficiary must be over the age of 12, with documentation showing that the VNS will improve quality of life.

• All other courses of treatment must be documented, such as conventional and anticonvulsant drugs.

Refer to Appendix II for a list of covered codes.

Vacuum Assisted Wound Closure Therapy: Vacuum assisted wound closure therapy is covered for specific benefit plans. Prior authorization is required and criteria must be met. Refer to the KMAP DME Provider Manual for criteria For questions about service coverage for a given benefit plan, contact the KMAP Customer Service Center at 1-800-933-6593 or 785-274-5990. All prior authorization must be requested in writing by a KMAP DME provider. All medical documentation must be submitted to the KMAP DME provider.



8-26

BENEFITS AND LIMITATIONS 8410. MEDICAID - INPATIENT ONLY Updated 09/07 General Hospital Reimbursement Policies:

Payment for general inpatient hospital services is based on the following equation: DRG weight times (X) group payment rate plus (+) outlier costs, if appropriate.

Medicaid does not reimburse for days not medically necessary or deemed "not payable" by federal or state laws, regulations, or state policy.

All DRGs have the potential for day or cost outliers.

When a stay is eligible for both day and cost outliers, the greater of the two is paid.

Only day outlier payment is made for hospitalization extending beyond 360 days.

If a Medicaid beneficiary is transferred from one hospital to another, the transferring hospital will receive outlier payments when the length of stay is greater than the DRG day or cost outlier. The hospital billing the final discharge receives the standard DRG payment including outliers, if applicable.

When a Medicaid beneficiary is discharged prematurely and subsequently readmitted within 30 days, only the DRG payment for the first stay will be made if the discharging and readmitting hospital are the same. If the discharging and readmitting hospitals are not the same, only the readmitting hospital will be reimbursed.

When the Medicaid beneficiary is not eligible for the entire inpatient stay, the DRG payment is prorated and reimbursement is made only for the days the beneficiary was eligible. Reimbursement shall not exceed the standard DRG payment plus any applicable outlier payment. (Only covered days are used to calculate outliers.)

Hospitals can issue a continued stay denial to a beneficiary only after the attending physician has written a discharge order. The hospital must supply the beneficiary with the necessary notification that the beneficiary will assume responsibility for payment since a continued stay is not considered medically necessary and is no longer a covered service.

Admissions or day outliers found to be unnecessary by the utilization review contractor cannot be billed to the beneficiary.



8-27

8410. Updated 09/07 Dental Admissions:

Dental admissions are covered when medically necessary. Documentation supporting the medical or dental condition making hospitalization necessary must be in the medical record. Prior authorization is required for adults. Medical review is required for children age 21 and under. Claims for this service are to be billed with procedure code 41899 and must include a detailed description of the actual service provided.

Emergency Renal Dialysis:

Emergency renal dialysis (revenue code 809) is only allowed once in an 18 month period per beneficiary.

State Institutions for Mental Health:

State institution services are only covered for Medicaid beneficiaries under 21 years of age, or 65 years of age and older. (However, if a beneficiary is an inpatient in a state institution on their 21st birthday, state institution services will be covered until the age of 22.)

State institutions are reimbursed 100% of the amount billed.

Long-Term Care Units:

Long-term care units must be a distinct or separate unit of a hospital certified to provide skilled and/or intermediate care under the Kansas Medical Assistance Program subject to the same federal and state rules and regulations as a free-standing adult care home. This includes compliance with federal regulations for standards of care and related reimbursement.

Non-Covered Services:

Take home drugs.

Non-medical hospital supplies (e.g., hospital kits). Psychiatric:

A psychiatric preadmission assessment is not required for inpatient medical treatment when the admission was the result of a medical manifestation of a psychiatric disorder and the beneficiary was not admitted to the psychiatric unit.

Inpatient general hospital psychiatric admissions are covered only after a psychiatric preadmission assessment has been completed and a determination made that the most appropriate treatment setting is the hospital. [As required by Mental Health Reform, Community Mental Health Centers (CMHCs) review all admissions to state hospitals.] No payment will be made for the hospital admission or related physician services without the completion of the preadmission assessment and determination that the hospital admission meets criteria. When seeking to admit a Kansas Medical Assistance Program beneficiary for inpatient treatment call 1-800-466-2222 to arrange for the assessment to be completed. This toll free number is staffed 24 hours a day by the Mental Health Consortium (MHC).



8-28

8410. Updated 09/07

All individuals, determined by the hospital, to be potentially eligible for Kansas Medical Assistance Program benefits must have a psychiatric preadmission assessment performed prior to admission into an acute care general or special hospital. The following criteria is a guideline that should assist hospitals in determining which individuals are potential candidates for Kansas Medical Assistance Program benefits: • Individuals receiving Supplemental Security Income (SSI) or have applied for SSI, • Individuals on Social Security, • Individuals who have been unemployed longer than six months, • Individuals who have applied or will be applying for Kansas Medical Assistance Program.

After receiving a request for a psychiatric preadmission assessment the MHC will contact the appropriate CMHC, or other approved provider if the admission is out of state, to complete the assessment face-to-face with the patient. The hospital and admitting physician will be notified of the results verbally and via a letter from the MHC. If the admission is approved a prior authorization (PA) number will be included in the letter for the hospital to utilize when billing for the admission and related services.

A referral from the beneficiary's primary care provider is not required for a psychiatric hospital stay or related physician and ancillary services provided during the psychiatric hospitalization approved through the preadmission assessment process.

Free Standing Psychiatric Hospitals:

Federal regulations classify free standing psychiatric hospitals as Institutions for Mental Disease (IMDs). Medicaid reimbursement to IMDs is restricted to treatment of beneficiaries 20 years of age and younger, or 65 and older. Even though an admission may be authorized by a pre-admission screening, Medicaid reimbursement to free standing psychiatric hospital providers (with a specialty of B3) will be made only for beneficiaries under the age of 21, or 65 and older at admission.

Emergency Psychiatric:

Screening for inpatient services following the sudden onset of severe psychiatric symptoms, which could reasonably be expected to make the individual harmful to self or others if not immediately under psychiatric care. The individual is in crisis and not currently in a place of safety. A screening is completed immediately (no later than 3 hours) to determine appropriate placement.

Urgent Psychiatric:

Screening is initiated if the individual meets one of the four independent criteria and is currently in a place of safety. An observation bed may be used to provide security and “observation” for individuals in imminent danger and to assist in the determination of the need for psychiatric hospitalization. In this instance, the screening must be completed as soon as possible and within two (2) days of the Consortium’s receipt of the request.



8-29

8410. Updated 09/07 Planned Psychiatric:

Noncrisis in nature, the screening must be completed within two (2) days of the Consortium’s receipt of the request. The admission must occur within two (2) days of the completion of the screening.

Retroactive Psychiatric:

Individuals whose Medicare or other primary insurance denied payment for treatment, and who were Medicaid eligible at the time of admission. Other retroactive screens may be authorized for denied requests when eligibility is in question. If the individual receives a valid Medicaid card after a hospital admission has been completed, the Consortium requests the admission information, and completes a pre-admission screening within five (5) working days of the receipt of that information.

Cases Involving Retroactive Eligibility:

The assessment must be requested and completed prior to the admission and related services being billed to Medicaid. The assessment will not be face-to-face and will be completed by the MHC. The MHC must complete the assessment within five (5) working days of receiving the request.

Cases Involving Other Insurance or Medicare:

If the admission and related services are billed to other insurance or Medicare first, the psychiatric preadmission assessment is not necessary. If the other insurance or Medicare makes no payment on the claim, prior to the claim being billed to Medicaid, an assessment must be completed. The MHC will complete the assessment within five (5) working days of receiving the request. The assessment will not be face-to-face.

A face-to-face psychiatric preadmission assessment consists of a psychiatric diagnostic interview examination including history, mental status examination, and communication with family members and other collateral contacts in order to develop an appropriate treatment plan.

Placement problems for children in SRS custody: The SRS office suggests that efforts to make arrangements for placement in a state hospital or appropriate long-term care facility should begin as soon as the need for prolonged non-acute inpatient care becomes apparent. The local SRS office, the physician, or the hospital should contact the Adult and Medical Services for assistance in placement, if necessary. Please request this assistance by the 6-10th day of stay in an acute hospital.

Substance Abuse:

Acute detoxification is covered in any acute general hospital, when medically necessary.

Alcohol and drug addiction treatment services provided in an inpatient hospital setting are not covered.



8-30

8410. Updated 09/07 Utilization Review General Hospitals:

Utilization review (UR) is performed on a postpayment basis for general hospitals with the exception of some readmissions, some interim bills and some adjustments. (Utilization reviews are performed internally at state institutions.)

Review of outlier cases are conducted on all cases with day or cost outliers. Reviews are performed on a post-pay basis, unless interim bills are submitted and the beneficiary is still an inpatient.

Readmissions within 30 days of a discharge are reviewed on a postpayment basis.

All patient initiated transfers are subject to utilization review.

When a patient is transferred from an inpatient hospital bed to a swing-bed unit and acute care continues to be provided, payment for the swing-bed will be denied or recouped. The only purpose for this type of transfer is for the hospital to obtain reimbursement beyond the DRG payment.

Following DRG coding evaluation and adjustment by the UR contractor, payment of claims will be adjusted upward or downward. In this instance, the fiscal agent will initiate the adjustment.

When a hospital admission is determined to be nonmedically necessary by the Medicaid utilization review contractor (KFMC), resulting in recoupment of payment, the provider shall not rebill the claim as an outpatient service.

UR may be performed either on-site or by reviewing records sent as required to the UR contractor. If a hospital fails to provide the UR contractor with the complete requested information within the allowable time frames, the case will be denied, resulting in recoupment of payment. These "technical denials" are not eligible for reconsideration. If the facility supplies the UR contractor the information within 90 days of the "technical denial" date, the case may be reopened for review. Pending the review results, repayment for the case may occur.

Discharge Day Not Medically Necessary:

When a beneficiary's hospital discharge day is determined by the UR contractor to not be medically necessary, the discharge day is redefined as the last medically necessary day. This redefined discharge day is not reimbursed.



8-31

BENEFITS AND LIMITATIONS 8420. MEDICAID - OUTPATIENT ONLY Updated 09/07 Emergency Medical Services for Aliens (SOBRA):

In addition to inpatient hospital and emergency room hospital, emergency services performed in outpatient facilities and related physician, lab, and x-ray services will be allowed for the following places of service: office, outpatient hospital, Federally Qualified Health Clinics, state or local public health clinics, Rural Health Clinics, ambulance, and lab for SOBRA claims. Inpatient hospital reimbursement will not be limited to 48 hours. Follow-up care will not be allowed once the emergent condition has been stabilized.

Refer to Section 2040 of the General Provider Manual for specific information.

Blood:

Blood transfusions, including whole blood, red blood cells, plasma, platelets and cryoprecipitate, and IV infusions are covered services.

Set-ups including volume controller cassettes are content of service of the procedure billed.

Crisis Resolution Services:

Hospitals may be reimbursed when Medicaid patients are admitted to observation/stabilization beds for crisis resolution services in accordance with the following conditions: • There is an affiliation agreement between the admitting hospital and the licensed

community mental health center. • The patient must be referred by the primary care case manager, agency, or health

professional currently providing care (whichever is applicable). • The patient shall have demonstrated an acute change in mood or thought that is

reflected in behavior, indicating the need for crisis intervention to stabilize and prevent hospitalization.

• The patient must have a diagnosed psychiatric disorder. • The patient shall not be in need of acute detoxification or experiencing withdrawal

symptoms. • The patient must be medically stable. • The following documentation shall be completed:

- nursing assessment (including physical review, mental status, and medication) - strength assessment - personal crisis plan, and - at least one progress note

Crisis resolution services are covered up to two consecutive days and shall be billed under procedure code H2013. Developmental Testing

Providers are reimbursed one visit per day, up to three visits per beneficiary per year for developmental testing: extended (which includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments), with interpretation and report. The procedure code for this service is 96111.



8-32

8420. Updated 03/08 Diagnostic Tests:

Although not all HCPCS codes are covered, most procedure codes for laboratory, radiology, EKG, EEG, hearing and speech testing (if provided following physical debilitation) are covered.

Drugs:

All drugs are content of service of surgery. Oral drugs are content of service of emergency treatment. Take home drugs are noncovered.

Injections, IVs, blood infusions, and aerosol inhalant additives are covered if not associated with surgery.

Electro-Convulsive Treatments:

Electro-convulsive treatments are covered and include all ancillary services needed to provide the treatment, including the charge for use of a bed.

Emergency Room Services:

Emergency room encounters will not deny based on ICD-9 diagnosis codes. Nonemergent claims will be reduced to the 99281 rate.

Medical necessity documentation must accompany the claim when more than one ER visit is made on the same day for the same individual.

The ER visit is content of service to any surgical and therapeutic treatment procedures performed in an emergency room.

Laboratory:

Handling fee (drawing/collection) is considered content of service of the outpatient visit/lab procedure and is not covered if billed separately. The beneficiary cannot be billed for the drawing or collection since it is considered content of another service or procedure. Laboratory procedures performed on inpatients are content of service of the DRG reimbursement to the hospital and should not be billed by either the independent laboratory or hospital.

Pathologists not contracted by the hospital may bill the professional component (modifier 26) for pathology services provided on inpatients.

Reimbursement will only be made for one complete blood count (CBC) per day. The Kansas Medical Assistance Program considers the following procedures to be component parts of a CBC. Refer to the CPT manual for a complete description of these procedures.

83026 85009 85018 85007 85013 85041

85008 85014 85048 Only the provider performing the laboratory analysis can bill.



8-33

8420. Laboratory continued: Updated 11/07 When ordered laboratory tests make up a panel or profile, the all-inclusive procedure code should be used to bill. Components should not be billed separately. Three or more multichannel tests are considered a SMA/SMAC profile when performed on the same date of service. Medicaid follows the guidelines outlined in the CPT manual to identify automated multichannel tests (SMACs, profiles) performed. When billing for a multichannel test use the appropriate CPT procedure code (80002-80019).

Urinalysis (UA) is considered content of service of the reimbursement to the physician for antepartum care when the UA is obtained for a diagnosis of pregnancy. The hospital/independent laboratory will not be reimbursed by Medicaid for the UA in this situation. Cytogenetic (chromosome) studies are covered for pregnant women (when medically necessary) and KAN Be Healthy participants only. A medical necessity form must accompany the claim when billing for a cytogenetic study for a pregnant woman older than 21 years of age. The following HIV testing is limited to four per calendar year, regardless of provider. Refer to the CPT manual for complete description of these procedures: 86701, 86702, 86689.

HIV-1, viral load, quantitative, HCPCS code 87536 is covered.

HIV-1, Infectious agent genotype analysis by nucleic acid (DNA or RNA), reverse transcriptase and protease (87901) is covered. Medical necessity documentation must include information that the patient meets at least one of the following criteria: (1) that the patient presents with virologic failure during Highly Active Antiretroviral Therapy (HAART), and/or (2) that the patient has suboptimal suppression of viral load after initiation of antiretroviral therapy. Testing is limited to two per calendar year.

Life Sustaining Therapy:

Chemotherapy, radiation therapy and renal dialysis are covered. Non-Covered Services:

Medical supplies used in conjunction with outpatient surgery and/or the emergency room/observation room are considered content of service and cannot be billed separately.

The rental or sale of DME and certain prosthetic and orthotic items.

Operating Room:

Anesthesia (equipment and supplies), drugs, surgical supplies and other equipment of the operating room, the recovery room and supplies are considered content of service of the operating and/or delivery room charges.

Outpatient Procedures:

Outpatient services provided within three days of an admission or discharge from the same hospital for the same or similar diagnosis are considered 'content of service' of the inpatient hospital stay. In this instance, bill the outpatient charges together on the inpatient claim.



8-34

8420. Outpatient Procedures cont. Updated 09/07

There is one exception to this policy, complications from an outpatient sterilization resulting in an inpatient admission. In this instance the outpatient charges and the inpatient charges should be billed on two separate claims.

HealthConnect/Managed Care Documentation:

Acceptable outpatient hospital referral documentation includes an entry in the hospital outpatient or emergency department medical record noting that the primary care provider (PCP) was contacted at the time the service was rendered and approval was given. The statement must be signed by the individual who received the approval. If the PCP cannot be reached, approval must be secured from one of his/her covering physicians.

Prosthetic & Orthotic Services: Outpatient hospitals will be allowed to bill the following prosthetic & orthotic codes: L3700 Elbow orthoses, elastic with stays, prefabricated, includes fitting and adjustment L3720 Elbow orthoses, double upright with forearm/arm cuffs, free motion, custom-

fabricated L3845 Wrist-hand-finger orthoses, addition to short and long opponens, thumb I.P. extension

assist, with M.P. stop L3906 Wrist-hand orthoses, wrist gauntlet, custom-fabricated L3907 Wrist-hand-finger orthosis, wrist gauntlet with thumb spica, custom-fabricated

L3908 Wrist-hand orthoses, wrist extension control cock-up, non-molded, prefabricated, includes fitting and adjustment

L3912 Hand-finger orthoses, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment

L3914 Wrist-hand orthoses, wrist extension cock-up, prefabricated, includes fitting/adjustment

L3916 Wrist-hand-finger orthoses, wrist extension cock-up, with outrigger, prefabricated, includes fitting and adjustment

L3918 Hand-finger orthoses, knuckle bender, prefabricated, includes fitting and adjustment L3928 Hand-finger orthoses, finger extension, with clock spring, prefabricated, includes

fitting and adjustment L3930 Wrist-hand-finger orthoses, finger extension, with wrist support, prefabricated,

includes fitting and adjustment L3934 Finger orthoses, safety pin, modified, prefabricated, includes fitting and adjustment L3938 Wrist-hand-finger othoses, dorsal wrist, prefabricated, includes fitting and adjustment L3942 Hand-finger orthoses, reverse knuckle bender, prefabricated, includes fitting and

adjustment L3948 Finger orthoses, finger knuckle bender, prefabricated, includes fitting and adjustment L3954 Hand-finger orthoses, spreading hand, prefabricated, includes fitting and adjustment L3980 Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and

adjustment DeFlux, an injectable medical device, is covered with prior authorization. Use procedure code L8606.



8-35

8420. Updated 09/07 Psychiatric Observation Beds:

Psychiatric observation beds are covered up to two consecutive days. During the observation period the patient shall receive:

• a physical examination • history and psychiatric assessment containing recommendations for ongoing treatment • an initial nursing assessment • nursing progress notes written each shift • a discharge summary

A physician must admit the patient to an observation bed and discharge him/her at the end of the observation stay. When an admission follows an observation stay, the physical examination report and the psychiatric assessment must be included in the patient's medical record. The observation bed stay becomes part of the DRG payment to the hospital. Refer to Section 7020 for billing instructions.

Psychiatric Partial Hospitalization:

These services are covered only in those hospitals where such a program has been approved by SRS.



8-36

8430. FAMILY PLANNING/STERILIZATIONS Updated 09/07 Family Planning:

Family planning is any medically approved treatment, counseling, drugs, supplies, or devices which are prescribed or furnished by a provider to individuals of child-bearing age for purposes of enabling such individuals to freely determine the number and spacing of their children.

Insertion or removal of an implantable contraceptive requires medical necessity documentation when performed in an outpatient setting.

Complete the family planning block on the claim form whenever a procedure or service is performed which relates to family planning.

The following information is provided to facilitate coding the FL 18-28 of the UB-04 claim form. The two-digit indicator "A4" is to be placed in this field.

The following procedures are family planning related. The sterilization consent form must be attached to the surgeon's claim at the time of submission. Related claims (anesthesia, assistant surgeon, ambulatory surgery center, hospital or Rural Health Clinic) do not require an attached sterilization consent form. However, if not attached, processing will be delayed until the consent form with the surgeon's claim is reviewed and determined to be correct.

ICD-9-CM Procedure Code (IP) Description HCPCS / Procedure Code 63.70-.73 Vasectomy, unilateral or bilateral (separate procedure), 55250 including post-op examinations. Ligation (percutaneous) of vas deferens 55450 unilateral or bilateral, (separate procedure) 63.70-.73 Vasectomy, unilateral or bilateral 55250 (separate procedure), including post-op examinations. Ligation (percutaneous) of vas deferens 55450 unilateral or bilateral, (separate procedure) 66.39, 66.92 Ligation or transection of fallopian tube(s), 58600 abdominal or vaginal approach, unilateral or bilateral. Ligation or transection of fallopian tube(s), 58605 abdominal or vaginal approach, postpartum, unilateral or bilateral, during the same hospitalization (separate procedure) V25.2 Laparoscopy, surgical; with removal of adnexal structures 58661 (partial or total oophorectomy and/or salpingectomy). 66.20-.21, 66.29, Laparoscopy, surgical, with fulguration of the 58670 66.31-.32, 66.39, oviducts (with or without transection) 66.92 Laparoscopy, surgical, with occlusion of the oviducts 58671 by device (e.g. band, clip or Falope ring)



8-37

8430. Updated 03/08 Sterilizations:

Hysterectomy: Hysterectomies are covered only for medically indicated reasons. Medicaid will reimburse for this service only if at least one of the following three conditions is met and documented. One of the following conditions must also be met and documented. If one of these three options does not apply to the situation for which you have provided service, you may not be reimbursed.

1. The individual or her representative signs the Hysterectomy Necessity Form acknowledging receipt of information that the surgery will make her permanently incapable of reproducing. The Sterilization Consent Form is not an acceptable substitute.

2. The physician shall certify in writing that the individual was already sterile and state the cause or reason for the sterility on an attachment to the claim. The signature in field 85 of the claim form will not suffice.

3. For the sterilization consent form only, the physician shall certify in writing that the surgery was performed under a life-threatening situation and individual certification was not possible. Include a description of the nature of the emergency. The signature in field 85 of the claim form will not suffice. Refer to Section 4300.

A copy of the Hysterectomy Necessity Form must be attached to the surgeon's claim at the time of submission. The form is located at the end of this manual in the Forms section, Hysterectomy_Necessity_Form, or on the KMAP Web site under Publications, Forms, Hysterectomy Necessity Form. It may be photocopied for your use. A copy of the Hysterectomy Necessity Form does not have to be attached to related claims (anesthesia, assistant surgeon, hospital, or Rural Health Clinic) at the time of submission. However, a related claim will not be paid until the Hysterectomy Necessity Form with the surgeon's claim has been reviewed and determined to be correct, unless the related claim has the correct Hysterectomy Necessity Form attached.

All Sterilizations:

Guidelines: Sterilizations on mentally incompetent individuals or individuals institutionalized for mental illness are not covered.

The following guidelines must be accurately followed before reimbursement can be made for any sterilization procedure (including, but not limited to, hysterectomy, tubal ligation sterilization, and vasectomy). If each item is not followed completely, it will result in the denial of your claim. KMAP or other authorized agencies may ask for documentation at any time, either during the claims processing period or after payment of a claim, to verify that services have been provided within program guidelines.

1) The sterilization consent form mandated by federal regulation is located at the end of

this manual in the Forms section, Sterilization Consent_Form or on the KMAP Web site under Publication, Forms, Sterilization Consent Form. All voluntary sterilization claims submitted without this specific sterilization consent form will be denied.

2) The sterilization consent form must be signed so that 30 days have passed before the date the sterilization is performed with the following exceptions:



8-38

8430. Updated 09/07

Premature Delivery: • The date of the beneficiary’s consent must be at least three (3) calendar days prior

to the date the sterilization was performed. • The expected date of delivery must be indicated on the consent form and the date

of the beneficiary’s consent must be at least 30 days prior to the expected date of delivery.

Emergency Abdominal Surgery: • The date of the beneficiary’s consent must be at least three (3) calendar days prior

to the date the sterilization was performed. • The circumstances of the emergency abdominal surgery must be described by the

physician sufficiently to substantiate the waiver of the 30 day requirement.

Three (3) calendar days is used in the above exceptions to guarantee compliance with the minimum federal requirement of 72 hours.

3) The sterilization consent form is valid for 180 days from the date it is signed by the

beneficiary. Sterilization claims for individuals that reflect dates of service beyond 180 days from the date the consent form was signed will be denied.

4) The individual must be at least 21 years of age or older on the date the consent form

is signed, or the sterilization claim will be denied. (This includes those situations in which the individual has misrepresented his or her age on the consent form to the provider.) The birth date information provided by SRS will be used to determine whether the individual meets the age requirement. This information can be obtained through KMAP Customer Service.

5) Sterilizations on mentally incompetent individuals are not covered. "Mentally

incompetent individual" is defined as an individual who has been declared mentally incompetent by a federal, state or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes which include the ability to consent to sterilizations (42 CFR 441.251).

6) The sterilization is not covered when consent is obtained from anyone in "labor",

under the influence of alcohol or other drugs, or seeking or obtaining an abortion.

7) Interpreters must be provided when there are language barriers, and special arrangements must be made for handicapped individuals.

8) The physician's statement must be signed and dated no more than two (2) days prior

to the surgery, the day of the surgery, or any day after sterilization was performed.

9) The physician statement on the consent form must be signed by the physician who performed the sterilization. No other signatures will be accepted.



8-39

8400. Updated 01/08

When sterilization results from the treatment of a medical condition, a consent form is not required. However, there must be a note on the face of the claim that states what medical condition caused the sterility. Claims billed involving these situations will be denied for no sterilization consent form when an explanatory notation is not present on the face of the claim.

The form must be legible in its entirety. Providers may photocopy this form from the manual. Refer to the Forms section at the end of the manual for a copy of the sterilization consent form. Note: Instruction on how to complete the Sterilization form is posted following the forms.

Transcervical Sterilizations: Procedure code 58579 is not covered for transcervical sterilization procedures. Procedure code 58565 is to be used. The procedure must meet all sterilization requirements. Prior authorization is required. The Essure Kit is included in procedure code 58565 and should not be billed separately. The invoice does not need to be attached to the claim. Procedure code 58340 (SIS/HSG test) is covered as part of the transcervical sterilization process. This code will be paid only if the transcervical sterilization has been paid previously and the sterilization was performed more than three months prior to the date of service. If a beneficiary has had a transcervical hysteroscopy sterilization, a federal sterilization consent form is required. Additionally, three months must have passed before having the catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography (HSG) - procedure code 58340. To indicate proof of sterilization, ICD-9 CM diagnosis code V25.2 must be used. Prior authorization is not required.


APPENDIX I

AI-1

APPENDIX I Updated 5/07

HCPCS PROCEDURE CODES The Health Care Policy / Medical Policy unit at SRS, requires Kansas Medical Assistance Program hospital billers to submit claims using the Health Care Financing Administration Common Procedure Code System (HCPCS). HCPCS is a combination of codes which includes CPT (Current Procedural Terminology) codes created and controlled by the American Medical Association; Centers for Medicare & Medicaid Services (CMS) Health Care Finance Administration (HCFA) codes created and controlled by CMS HCFA; and local codes created and controlled by the regional CMS HCFA office. HCPCS codes consist of a 5-digit base code with the capability of being up to 9 digits in length when modifiers are used. A modifier code is a two-digit code that identifies a specific type of service, for example anesthesia, or a variation of the service identified by the base code. Certain services require a modifier code be given in addition to the HCPCS base code. The modifier codes listed below are the only covered hospital modifier codes; use of any other modifier codes may cause your claim to be denied. Modifier Description 26 Professional Component 50 Bilateral Procedure *TC Technical Component 59 Multiple Surgeries thru Separate Incisions ET Emergency Services *Note: Hospitals that bill the base code for radiology procedures will be reimbursed at

the TC rate Hospital billers should use CPT codes (refer to Section 1300) for outpatient services when available or when specifically instructed to do so; otherwise the CMS HCFA or local codes printed in the following pages should be used. Not all CPT procedure codes are covered. Contact the EDS Provider Assistance Unit with questions regarding coverage (refer to Section 1000). When a CPT, CMS HCFA or local code is not available, the service is non-covered by Kansas Medical Assistance Program. NOC (not otherwise classified) codes are non-covered. (Refer to Section 4200.)


APPENDIX I

AI-2

PROCEDURE CODES AND NOMENCLATURE Updated 9/04

COVERAGE INDICATORS PA - Prior authorization is required. PROCEDURE COV. CODE NOMENCLATURE

LABORATORY SERVICES - BLOOD P9010 Blood (whole), for transfusion, per unit P9012 Cryoprecipitate, each unit P9016 Red blood cells, leukocytes reduced, each unit P9017 Fresh frozen plasma ((single donor), frozen within 8 hours of

collection, each unit P9019 Platelet concentrate, each unit P9021 Red blood cells, each unit P9022 Washed red blood cells, each unit

P9023 Plasma, pooled multiple donor, solvent/detergent treated, frozen, each unit

P9031 Platelets, leukocytes reduced, each unit P9032 Platelets, irradiated, each unit P9033 Platelets, leukocytes reduced, irradiated, each unit P9034 Platelets, pheresis, each unit P9035 Platelets, pheresis, leukocytes reduced, each unit P9036 Platelets, pheresis, irradiated, each unit P9037 Platelets, pheresis, leukocytes reduced, irradiated, each unit P9038 Red blood cells, irradiated, each unit P9039 Red blood cells, deglycerolized, each unit P9040 Red blood cells, leukocytes reduced, irradiated, each unit P9041 Infusion, albumin (human), 5%, 50 ml P9043 Infusion, plasma protein fraction (human), 5%, 50 ml P9044 Plasma, cryoprecipitate reduced, each unit P9045 Infusion, albumin (human), 5%, 250 ml P9046 Infusion, albumin (human), 25%, 20 ml P9047 Infusion, albumin (human), 25%, 50 ml P9048 Infusion, plasma protein fraction (human), 5%, 250ml P9050 Granulocytes, pheresis, each unit

P9051 Whole blood or red blood cells, leukocytes reduced CMV-negative, each unit

P9052 Platelets, HLA-matched leukocytes reduced, apheresis/pheresis, each unit

P9053 Platelets, pheresis, leukocytes reduced,CMV-negative, irradiated each unit

P9054 Whole blood or red blood cells, leukocytes reduced, frozen, glycerol, washed, each unit


APPENDIX I

AI-3

PROCEDURE Updated 4/05 COV. CODE NOMENCLATURE P9055 Platelets, leukocytes reduced, CMV-negative, apheresis/pheresis, each unit P9056 Whole blood, leukocytes reduced, irradiated, each unit P9057 Ted blood cells, frozen/deglycerolized/washed, leukocytes reduced,

irradiated, each unit P9058 Red blood cells, leukocytes reduced, CMV-negative, irradiated, each unit

P9059 Fresh frozen plasma between 8-24 hours of collection each unit P9060 Fresh frozen plasma, donor retested, each unit

(The above codes include processing and collection for transfusion; IV infusion sets include volume controller cassettes and buretrols.)

MISCELLANEOUS PSYCHIATRIC SERVICES SUPPORTIVE PSYCHIATRIC SERVICES H2013 Psychiatric Health Facility, per diem

DENTOALVEOLAR STRUCTURES

PA* 41899 Unlisted Procedure, Dentoalveolar Structures is covered for the following procedures. Claims must include a detailed description of the actual service provided. If the description of the service is other than what is included on the list below, the service will be non-covered.

• Surgical removal, soft tissue impact each additional • Pediatric dental procedures • Simple extractions • Full mouth extractions • Dental service for non KAN Be Healthy recipients

*Prior authorization is required for adults. Medical review is required for children age 21 and under.


APPENDIX I

AI-4

INJECTIONS Updated 12/07 Injection procedures listed below are placed in alphabetical order by generic name. Reference this listing using the generic drug name to find the procedure code. Utilize units to designate the dosage administered if there is not a specific injection code for the dosage.

COVERAGE INDICATORS KBH - Covered for KAN Be Healthy participants only MCD - Injection covered for Medicaid recipients only MN - Medical Necessity documentation required PA - Prior authorization is required

PROCEDURE COV. CODE NOMENCLATURE STRENGTH QUANTITY PA J0129 Abatacept 10 mg - - -

J1120 Acetazolamide Sodium up to 500 mg vial Q047S Acyclovir, Zovirax up to 500 mg - - - Q4075 Acyclovir 5 mg

J0135 Adalimumab 20 mg J0150 Adenosine for therapeutic use, 6 mg (not to be used to report any

adenosine phosphate compounds, instead use A9270) J0152 Adenosine for diagnostic use, 30 mg (not to be used to report any

adenosine phosphate compounds; instead use A9270) J0170 Adrenalin, Epinephrine up to 1 ml 1 cc

J0180 Agalsidase beta 1 mg J0200 Alatrofloxacin Mesylate 100 mg - - -

J7609 Albuterol (unit dose) 1 mg J7610 Albuterol (concentrated form) 1 mg

PA J0215 Alefacept 0.5 mg J9015 Aldesleukin - - - vial

MCD J0205 Alglucerase - - - 10 units C9234 Alglucosidase Alfa 10 mg J0220 Alglucosidase Alfa 10 mg J2997 Alteplase Recombinant 1 mg

J0207 Amifostine 500 mg - - -

* Administration only (patient brings own medication). Medication shall not be billed in conjunction with this procedure.


APPENDIX I

AI-5

Updated 12/07 PROCEDURE

COV. CODE NOMENCLATURE STRENGTH QUANTITY S0072 Amikacin Sulfate up to 500 mg - - - S0017 Aminocaproic 250 mg 1 cc J0280 Aminophyllin up to 250 mg - - - J0282 Amiodarone HCL 30 mg J1320 Amitriptyline HCL up to 20 mg 2 cc J0300 Amobarbital up to 125 mg vial J0285 Amphotericin B 50 mg - - - J0287 Amphotericin B lipid complex 10 mg J0289 Amphotericin B Liposome 10 mg J0290 Ampicillin Sodium 500 mg vial J0295 Ampicillin Sodium/Sulbactam 1.5 gm vial J0348 Anadulafungin 1 mg J0350 Anistreplase 30 units vial J7197 Antithrombin III (Human) - - - 1 unit

MCD Z2064 Antivenin Polyvant (crotalide) - - - 1 ml J0128 Arbarelix 10 mg J0400 Aripiprazole, intramuscular 0.25 mg

J9020 Asparaginase, Elspar up to 10,000 10 cc units

J2910 Aurothioglucose up to 50 mg 1 cc J7501 Azathioprine (e.g., Imuran)- 100 mg 20 ml

parenteral, vial J0456 Azithromycin 500 mg - - - J3490 Aztreonam 500 mg 15 cc J3490 Bacitracin 50,000 units vial

MCD J0475 Baclofen 10 mg - - - (NDC and product name must be provided)

J0476 Baclofen, for intrathecal trial 50 mcg J9025 Azacitidine 1 mg J9031 BCG Live (Intravesical) 50 mg vial J9050 BCNU, Bischlorethyl Nitrosourea, 100 mg vial

Carmustine J0515 Benztropine 1 mg 1 cc J0702 Betamethasone Acetate and 3 mg 1 cc

Betamethasone Sodium Phosphate J0704 Betamethasone Sodium Phosphate 4 mg 1 cc J0520 Bethanechol Chloride, up to 5 mg 1 cc

Myotonachol or Urecholine


APPENDIX I

AI-6

PROCEDURE Updated 12/06 COV. CODE NOMENCLATURE STRENGTH QUANTITY J9035 Bevacizumab, 10 mg J0583 Bivalirudin 1 mg

J9040 Bleomycin Sulfate 15 units amp J9041 Bortezomib 0.1 mg PA J0585 Botulinum Toxin Type A per unit - - - PA J0587 Botulinum Toxin Type B per 100 units

J0595 Butorphanol Tartrate 1 mg J7626 Budesonide Inhalation Solution, 0.5 mg

Non-compounded, Administered Through DME, Unit Dose Form

J7633 Budesonide Inhalation Solution 0.25 mg Administered through DME, Concentrated form

J7634 Budesonide Inhalation Solution, 0.25 mg Compounded product, Administered Through DME, Concentrated Form

S0020 Bupivacaine Hydrochloride 0.5 % - - - J0592 Buprenorphine Hydrochloride 0.1 mg J0592 Buprenorphine 0.3 mg 1 cc J0595 Butorphanol Tartrate 1 mg 1 cc J0706 Caffeine Citrate 5 mg J0630 Calcitonin Salmon up to 400 - - -

units J0636 Calcitriol 0.1mcg

J3490 Calcium Chloride 1 gm 10 cc J3490 Calcium Gluceptate standard 5 cc J0610 Calcium Gluconate 10% 10 cc J9045 Carboplatin 50 mg vial J0637 Caspofungin Acetate 5 mg J0690 Cefazolin Sodium 500 mg 10 cc J0692 Cefepime Hydrochloride 500 mg S0021 Cefoperazone, Cefobid up to 1 gm - - - J0698 Cefotaxime Sodium 1 gm vial S0074 Cefotetan Disodium (Cefotan) 1 gm vial J0694 Cefoxitin up to 1 gm 10 cc J0713 Ceftazidime 500 mg J0715 Ceftazidime Sodium 500 mg - - - J0696 Ceftriaxone Sodium 250 mg vial J1890 Cephalothin Sodium up to 1 gm 10 cc J0710 Cephapirin Sodium up to 1 gm vial

J9055 Cetuximab 10 mg J0720 Chloramphenicol Sodium up to 1 gm - - -

Siccomate


APPENDIX I

AI-7


COV. CODE NOMENCLATURE STRENGTH QUANTITY J1205 Chlorothiazide Sodium 500 mg 20 cc J3230 Chlorpromazine HCL up to 50 mg - - - 90725 Cholera vaccine for injectable use standard 1 cc J0725 Chorionic Gonadotropin 100 units - - - J0743 Cilastatin Sodium; Imipenem 250 mg vial J0744 Ciprofloxacin for Intravenous Infusion 200 mg J9060 Cisplatin 10 mg vial J9062 Cisplatin 50 mg - - - S0077 Clindamycin up to 300 mg - - - J0745 Codeine Phosphate 30 mg 1 cc J0760 Colchicine up to 2 mg 2 cc J0770 Colistimethate Sodium up to 150 mg 2 cc J0835 Cosyntropin 0.25 mg - - - J9070 Cyclophosphamide 100 mg 10 cc J9080 Cyclophosphamide 200 mg 20 cc J9090 Cyclophosphamide 500 mg 30 cc J9091 Cyclophosphamide 1 gm - - - J9092 Cyclophosphamide 2 gm - - - J9093 Cyclophosphamide, Lyophilized 100 mg - - - J9094 Cyclophosphamide, Lyophilized 200 mg - - - J9095 Cyclophosphamide, Lyophilized 500 mg - - - J9096 Cyclophosphamide, Lyophilized 1.0 gm - - - J9097 Cyclophosphamide, Lyophilized 2.0 gm - - - J7516 Cyclosporine (e.g., Sandimmune)- 250 mg - - -

Parentera J9098 Cytarabine 10 mg

J9100 Cytarabine 100 mg - - - J9110 Cytarabine 500 mg - - - J9130 Dacarbazine 100 mg 10 cc J9140 Dacarbazine 200 mg 10 cc J7513 Daclizumab, parenteral 25 mg J9120 Dactinomycin, Actinomycin D 0.5 mg 3 cc

MCD J1645 Dalteparin Sodium 2500 IU - - - J0878 Daptomycin 1 mg

J9150 Daunorubicin 10 mg vial J9151 Daunorubicin Citrate 10 mg

Liposomal Formulation Q0137 Darbepoetin Alfa 1 mcg (non ESRD use) J0894 Decitabine 1 mg

J0895 Deferoxamine Mesylate 500 mg amp J9160 Denileukin Diftitox 300 mcg


APPENDIX I

AI-8


COV. CODE NOMENCLATURE STRENGTH QUANTITY J1060 Depandrogyn standard 1 cc J1000 Depo-Estradiol Cypionate up to 5 mg 1 cc J1094 Dexamethasone Acetate 1 mg J1100 Dexamethasone Sodium 1 mg 1 cc

Phosphate J1100 & J0670 Dexamethasone Acetate .5 cc and standard - - -

Mepivacaine Hydrochloride 1% .5 cc J1190 Dexrazoxane HCL 250 mg - - - J0500 Dicyclomine up to 20 mg 2 cc J9165 Diethylstilbestrol Diphosphate 250 mg - - - J1160 Digoxin up to 0.5 mg 1 cc J1110 Dihydroergotamine up to 0.1 mg 1 cc

MCD J1240 Dimenhydrinate up to 50 mg - - - J1200 Diphenhydramine HCL up to 50 mg 1 cc J1245 Dipyridamole 10 mg 2 ml J1250 Dobutamine HCL 250 mg 1 cc J9170 Docetaxel (Taxotere) 20 mg 1 ml J1260 Dolasetron Mesylate 10 mg J1270 Doxercalciferol 1 mcg J9000 Doxorubicin HCL 10 mg vial J9001 Doxorubicin HCL, all lipid formulations 10 mg - - - J1810 Droperidol and Fentanyl Citrate up to 2 ml amp (NDC and product name/description must be provided)

J1300 * Eculizumab 10 mg J3520 Edetate Disodium 150 mg - - -

PA J1324 Enfuvirtide 1 mg MCD J1650 Enoxaparin Sodium 30mg 1 ml

J0170 Epinephrine Hydrochloride 1:200 mg 0.3 cc J9178 Epirubicin HCL 2 mg MCD J1325 Epoprostenol 0.5 mg - - -

J1330 Ergonovine Maleate up to 0.2 mg 1 cc J1335 Ertapenem Sodium 500 mg J1364 Erythromycin Lactobionate 500 mg - - - J0885 Injection, epoetin alfa, 1000 units (for non-ESRD use)

*This code will be placed on medical review until the Drug Utilization Review (DUR) Board meets to set PA criteria. Once PA criteria has been determined, the code will be taken off of medical review. Providers will be notified when the code is removed from medical review.


APPENDIX I

AI-9

PROCEDURE Updated 4/04 COV. CODE NOMENCLATURE STRENGTH

QUANTITY J1380 Estradiol Valerate up to 10 mg 1 cc J1390 Estradiol Valerate up to 20 mg 1 cc J0970 Estradiol Valerate up to 40 mg 1 cc J1410 Estrogen Conjugated 25 mg - - - J1435 Estrone 1 mg - - -

PA J1438 Etanercept 25 mg - - - J3490 Ethacrynic Acid 50 mg 1 cc J1436 Etidronate Disodium 300 mg 6 ml amp J9181 Etoposide 10 mg 2.5 cc J9182 Etoposide 100 mg 5 cc J7190 Factor VIII (Antihemophilic Factor per i.u. - - -

(NDC and product name/description must be provided) J7191 Factor VIII (Antihemophilic Factor per i.u. - - -

[Porcine]) J7192 Factor VIII (Antihemophilic Factor per unit - - -

[Recombinant]) J7193 Factor IX (Antihemophilic Factor, per i.u.

Purified, Non-Recombinant) J7195 Factor IX (Antihemophilic Factor, per i.u.

Recombinant) MCD S0028 Famotidine 10 mg/ml 1 ml

J3010 Fentanyl Citrate 0.1 mg 2 cc MCD J1440 Filgrastim (G-CSF) 300 mcg - - - MCD J1441 Filgrastim (G-CSF) 480 mcg - - -

J9200 Floxuridine 500 mg 5 cc J1450 Fluconazole 200 mg - - - J9185 Fludarabine Phosphate 50 mg 1 ml

J7641 Flunisolide, Inhalation Solution per mg Administered Through DME, Unit Dose Form


APPENDIX I

AI-10


COV. CODE NOMENCLATURE STRENGTH QUANTITY J7311 Fluocinolone acetonide 0.59 mg J9190 Fluorouracil 500 mgm amp J2680 Fluphenazine Decanoate up to 25 mg 1 cc J1452 Fomivirsen Sodium, Intraocular 1.65 mg J1652 Fondaparinux Sodium 0.5 mg J1455 Foscarnet Sodium 1000 mg vial J9395 Fulvestrant 25 mg J1940 Furosemide up to 20 mg 2 cc J1458 Galsulfase 1 mg J1460 Gamma Globulin, Intramuscular standard 1 cc J1470 Gamma Globulin, Intramuscular standard 2 cc J1480 Gamma Globulin, Intramuscular standard 3 cc J1490 Gamma Globulin, Intramuscular standard 4 cc J1500 Gamma Globulin, Intramuscular standard 5 cc J1510 Gamma Globulin, Intramuscular standard 6 cc J1520 Gamma Globulin, Intramuscular standard 7 cc J1530 Gamma Globulin, Intramuscular standard 8 cc J1540 Gamma Globulin, Intramuscular standard 9 cc J1550 Gamma Globulin, Intramuscular standard 10 cc J1560 Gamma Globulin, Intramuscular standard 10 cc J1570 Ganciclovir Sodium 500 mg vial J1580 Garamycin, Gentamycin up to 80 mg 2 cc J1590 Gatifloxacin 10 mg J9201 Gemcitabine HCL 200 mg - - - J9300 Gemtuzumab, Ozogamicin 5 mg J1610 Glucagon Hydrochloride 1 mg 1 cc J1600 Gold Sodium Thiomaleate up to 50 mg 1 ml J1620 Gonadorelin Hydrochloride 100 mcg - - - J9202 Goserelin Acetate Implant 3.6 mg 1

MCD J1626 Granisetron Hydrochloride 100 mcg 1 ml J1631 Haloperidol Decanoate 50 mg 1 cc J1642 Heparin Sodium (Heparin 10 units tubex

Lock Flush) J1644 Heparin Sodium 1000 units vial

J1571 Hepatitis B immune globulin 0.5 ml (Hepagam B), intramuscular J1573 Hepatitis B immune globulin 0.5 ml (Hepagam B), intravenous Q4090 Hepatitis B immune globulin (Hepagam B), intramuscular, 0.5ml Q4083 Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection,

per dose Q4084 Hyaluronan or derivative, synvisc, for intra-articular injection, per dose Q4085 Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose

Q4086 Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose


APPENDIX I

AI-11


COV. CODE NOMENCLATURE STRENGTH QUANTITY J7321 Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection,

per dose J7322 Hyaluronan or derivative, synvisc, for intra-articular injection, per dose J7323 Hyaluronan or derivative, euflexxa, for intra-articular injection, per dose J7324 Hyaluronan or derivative, orthovisc, for intra-articular injection, per dose

J3470 Hyaluronidase up to 150 units 1 cc J0360 Hydralazine HCL up to 20 mg amp J1700 Hydrocortisone Acetate, up to 25 mg 1 cc J1720 Hydrocortisone Sodium Succinate up to 100 mg 2 cc J1710 Hydrocortisone Sodium Phosphate up to 50 mg 1 cc J1170 Hydromorphone up to 4 mg 1 cc J3410 Hydroxyzine HCL up to 25 mg 1 cc

J7320 * Hylan G-F (Synvisc®) 16 mg J1740 Ibandronate Sodium 1 mg MCD J9211 Idarubicin Hydrochloride 5 mg vial C9232 Idursulfase 1 mg J1743 Idursulfase 1 mg

J9208 Ifosfomide per gm 1 gm vial MCD J1785 Imiglucerase - - - unit Q4087 Immune globulin, intravenous, non-lyophilized, 500mg Q4088 Immune globulin, (Gammagard), intravenous, non-lyophilized, 500mg Q4091 Immune globulin, (Flebogamma), intravenous, non-lyophilized, 500mg Q4092 Immune globulin, (Gamunex), intravenous, non-lyophilized, 500mg Q9941 Immune globulin, intravenous, lyophilized 1 g

Q9942 Immune globulin, intravenous, lyophilized 10 mg - - - Q9943 Immune globulin, intravenous, 1 g non-lyophilized Q9944 Immune globulin, intravenous, 10 mg non-lyophilized

J1561 Immune globulin (gamunex), 500 mg intravenous, non-lyophilized (e.g. liquid)

J1562 Immune globulin (vivaglobin) 100 mg Subcutaneous J1568 Immune globulin (octagam), 500 mg intravenous, non-lyophilized (e.g. liquid) J1569 Immune globulin (gammagard 500 mg liquid), intravenous, non-lyophilized (e.g. liquid) J1572 Immune globulin (flebogamma), 500 mg intravenous, non-lyophilized (e.g. liquid)

PA J1745 Infliximab (Remicade) 10 mg vial J9213 Interferon, Alfa-2A, Recombinant 3 mill. units vial J9214 Interferon, Alfa-2B, Recombinant 1 mill. units - - -

*Second series requires prior authorization


APPENDIX I

AI-12


COV. CODE NOMENCLATURE STRENGTH QUANTITY J9215 Interferon, Alfa-N3 (Human 250,000 units - - -

Leukocyte Derived) J9212 Interferon, Alfacon-1, Recombinant 1 mcg J1825 Interferon Beta-1A 33 mcg

MCD J1830 Interferon Beta 1-B 0.25 mg - - - J9216 Interferon, Gamma 1-B 3 mill. units vial J9206 Irinotecan HCI 20 mg/ml 1 ml J1751 Iron Dextran 165 50 mg J1752 Iron Dextran 267 50 mg J1756 Iron Sucrose 21 mg J7647 Isoetharine HCL concentrated form per mg J7650 Isoetharine HCL unit dose form per mg J7657 Isoproterenol HCL concentrated form per mg J7657 Isoproterenol HCL unit dose form per mg J7658 Isoproterenol Hydrochloride per mg

conc. form J7659 Isoproterenol Hydrochloride, unit dose per mg

form (NDC and product name/description must be provided) J1835 Itraconazole 50 mg J1840 Kanamycin Sulfate up to 500 mg 2 cc J1850 Kanamycin Sulfate up to 75 mg 2 cc J1885 Ketorolac Tromethamine 15 mg ml (NDC and product name/description must be provided)

J1931 Laronidase 0.1 mg J0640 Leucovorin Calcium 50 mg vial J1950 Leuprolide Acetate (For Depot) 3.75 mg - - -

Suspension) J9218 Leuprolide Acetate 1 mg

1 ml J9217 Leuprolide Acetate, For Depot 7.5 mg/ml 1.5 ml

Suspension J9219 Leuprolide Acetate Implant 65 mg

(NDC and product name/description must be provided) J7607 Levalbuterol concentrated form 0.5 mg J7615 Levalbuterol unit dose form 0.5 mg C9238 Levetiracetam 10 mg J1956 Levofloxacin 250 mg - - - J2001 Lidocaine HCL (For intravenous infusion) 10 mg J2010 Lincomycin HCL up to 300 mg 1 cc

MCD J2001 Lidocaine HCL 1 - 0.0005 per ml (Lidocaine HCL w/epinephrine)

J2020 Linezolid 200 mg J7511 Lymphocyte Immune Globulin, 25 mg

Antihymocyte Globulin, Rabbit, Parenteral


APPENDIX I

AI-13

PROCEDURE Updated 04/07 COV. CODE NOMENCLATURE STRENGTH QUANTITY

J3475 Magnesium Sulfate 500 mg - - - J2150 Mannitol 25% 50 ml J2170 Mecasermin 1 mg J9230 Mechlorethamine HCL (Nitrogen 10 mg 20 cc

Mustard), HN2 J1051 Medroxyprogesterone Acetate 50 mg

J1055 Medroxyprogesterone Acetate 150 mg 1 cc For Contraceptive Use J1056 Medroxyprogesterone Acetate/

Estradiol Cypionate, 5 mg/25 mg J2180 Meperidine and Promethazine HCL up to 50 mg 2 cc J2175 Meperidine 100 mg 1 cc J0670 Mepivacaine 1% 1 cc J2185 Meropenem 100 mg J9209 Mesna 200 mg vial J3490 Mesoridazine Besylate 25 mg 1 cc J7667 Metaproterenol Sulfate concentrated form per 10 mg J7670 Metaproterenol Sulfate unit dose form per 10 mg J0380 Metaraminol up to 10 mg 1 cc J2800 Methocarbamol up to 10 ml 10 cc J9250 Methotrexate 5 mg - - - J9260 Methotrexate Sodium Mix 50 mg 2 cc J2210 Methylergonovine Maleate up to 0.2 mg 1 cc J1020 Methylprednisolone Acetate 20 mg 1 cc J1040 Methylprednisolone Acetate 80 mg 2 cc J2920 Methylprednisolone Sodium up to 40 mg 1 cc

Succinate J2930 Methylprednisolone Sodium up to 125 mg 2 cc

Succinate J2765 Metoclopramide HCL up to 10 mg 2 cc S0030 Metronidazole up to 500 mg 100 ml J2248 Micafungin Sodium 1 mg J2260 Milrinone Lactate 5 mg J9280 Mitomycin 5 mg - - - J9290 Mitomycin 20 mg - - - J9291 Mitomycin 40 mg - - - J9293 Mitoxantrone HCL 5 mg 10 ml J2270 Morphine Sulfate up to 10 mg 1 cc J2271 Morphine Sulfate 100 mg - - -

MCD J2275 Morphine Sulfate, preservative-free 10 mg ml sterile solution)

J2280 Moxifloxacin 100 mg J2300 Nalbuphine HCL 10 mg 2 cc


APPENDIX I

AI-14


COV. CODE NOMENCLATURE STRENGTH QUANTITY J2310 Naloxone HCL 1 mg 1 cc J2315 Naltrexone, depot form 1 mg J2320 Nandrolone Decanoate up to 50 mg 0.5 cc J2321 Nandrolone Decanoate up to 100 mg 1 cc J2322 Nandrolone Decanoate up to 200 mg 2 cc J2710 Neostigmine Bromide 1:1000 (1 mg) 1 cc J2710 Neostigmine Methylsulfate up to 0.5 mg 1 cc J2353 Octreotride (Depot form) 1 mg J2354 Octreotride (non-depot form) 25 mg J2357 Omalizumab 5 mg

MCD J2405 Ondansetron Hydrochloride 1 mg 0.5 ml J2355 Oprelvekin 5 mg J2700 Oxacillin Sodium up to 250 mg vial J9263 Oxaliplatin 0.5 mg J2410 Oxymorphone HCL up to 1 mg 1 cc J2460 Oxytetracycline HCL up to 50 mg 1 ml J2460 Oxytetracycline HCL 500 mg 10 cc J2590 Oxytocin up to 10 units 1 cc J9264 Paclitaxel protein-bound particles 1 mg J9265 Paclitaxel 30 mg 5 ml

KBH,PA 90378 Palivizumab (Synagis) up to 50 mg vial J2469 Palonosetron hcl 25 mcg

J2430 Pamidronate Dissodium 30 mg vial C9235 Panitumumab 10 mg J9303 Panitumumab 10 mg J2440 Papaverine HCL up to 60 mg 2 cc J2501 Paricalacitol 1 mcg J2505 Pegfilgrastim 6 mg J9305 Pemetrexed 10 mg J0530 Penicillin G Benzathine & Penicillin up to 600,000 1 cc

G Procaine units J0540 Penicillin G Benzathine & Penicillin up to 1,200,000 2 cc

G Procaine units J0550 Penicillin G Benzathine & Penicillin up to 2,400,000 4 cc

G Procaine units J0560 Penicillin G Benzathine up to 600,000 1 cc

units J0570 Penicillin G Benzathine up to 1,200,000 2 cc

units J0580 Penicillin G Benzathine up to 2,400,000 4 cc

units J2540 Penicillin G Potassium up to 600,000 1 cc

units


APPENDIX I

AI-15


COV. CODE NOMENCLATURE STRENGTH QUANTITY J2510 Penicillin G Procaine, Aqueous up to 600,000 1 cc J3070 Pentazocine HCL up to 30 mg 1 cc J2515 Pentobarbital Sodium 50 mg 1 cc J3310 Perphenazine up to 5 mg 1 cc

units J2560 Phenobarbital Sodium up to 120 mg 2 cc J1165 Phenytoin Sodium 100 mg 2 cc J2543 Piperacillin Sodium/Tazobactum Sodium 1 gm/0.125 gm vial J9270 Plicamycin (Mithramycin) 2.5 mg Z2069 Polymyxin B Sulfate 500,000 units vial J9600 Porfimer Sodium 75 mg - - - J3480 Potassium Chloride 2 meq - - - J2650 Prednisolone Acetate up to 1 ml - - - J0743 Primaxin 250 mg - - - J2690 Procainamide HCL up to 1 gm 2 cc J0780 Prochlorperazine up to 10 mg 2 cc J3490 Prolixin Enanthate 25 mg 1 cc J2550 Promethazine HCL up to 50 mg 1 cc J1800 Propranolol HCL up to 1 mg 1 cc J2720 Protamine Sulfate 10 mg - - - J2724 Protein C concentrate, intravenous, human 10 IU J3415 Pyridoxine 100 mg 90375 Rabies Immune Globulin (RIG), human

for intramuscular and/or subcutaneous use 90376 Rabies Immune Globulin, heat-treated (RIG-HT), human

for intramuscular and/or subcutaneous use C9233 Ranibizumab 0.5 mg

J2778 * Ranibizumab 0.1 mg J2780 Ranitidine HCL 25 mg J2783 Rasburicase 0.5 mg J1565 Resp Sync Vir Immug (Respigam) 50 mg/ml 1 ml 90378 Respiratory Synctyial Virus Immune 50 mg Globulin (RSV-IGIM), for intramuscular use, each

*This code will be placed on medical review until the Drug Utilization Review (DUR) Board meets to set PA criteria. Once PA criteria has been determined, the code will be taken off of medical review. Providers will be notified when the code is removed from medical review


APPENDIX I

AI-16


COV. CODE NOMENCLATURE STRENGTH QUANTITY J2993 Reteplase (two single use vials) 18.1 mg 90384 Rho(D) immune globulin (RhIg), human, full-dose for intramuscular use

J2788 Rho(D) immune globulin, human, mini-dose 50 mg 90385 Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use 90386 Rho(D) immune globulin (RhIgIV), human,

for intravenous use J2791 Rho(D) immune globulin, human 100 IU (rhophylac) intramuscular or intravenous

J2792 Rho(D) immune globulin, human 100 IU solvent detergent

Q4089 Rho(D) Immune Globulin, Human, (Rhophylac), intravenous, 100 IU J2794 Risperidone, long acting 0.5 mg

J9310 Rituximab 100 mg MCD J2820 Sargramostin (GM-CSF) 50mcg vial

J2912 Sodium Chloride 0.9% 2 ml J2916 Sodium Ferric Gluconate 12.5 mg

PA,KBH J2940 Somatrem 1 mg J2941 Somatropin 1 mg J3320 Spectinomycin Dihydrochloride up to 2 gm 3.2 cc J0697 Sterile Cefuroxime Sodium 750 mg vial S0040 Sterile Ticarcillin Disodium and 3.1 gm vial

Clavulanate J2995 Streptokinase 250,000 unit vial J0330 Succinycholine Chloride up to 20 mg vial J3030 Sumatriptan Succinate 6 mg - - - J7525 Tacrolimus, Parenteral 5 mg C9239 Temsirolimus 1 mg J3100 Tenecteplase 50 mg Q2017 Teniposide - - - 1 ml


APPENDIX I

AI-17


COV. CODE NOMENCLATURE STRENGTH QUANTITY

J3105 Terbutaline Sulfate up to 1 mg - - - J3140 Testosterone Suspension up to 50 mg 1 cc J1060 Testosterone Cypionate & up to 1 ml 1 ml

Estradiol Cypionate J1070 Testosterone Cypionate up to 100 mg 1 cc J1080 Testosterone Cypionate 200 mg 1 cc J3120 Testosterone Enanthate up to 100 mg .5 cc J3130 Testosterone Enanthate up to 200 mg 1 cc J0900 Testosterone Enanthate and up to 1 cc - - -

Estradiol Valerate J3150 Testosterone Propionate up to 100 mg 2 cc 90389 Tetanus Immune Globulin (TIG), Human, For Intramuscular Use 90707 Measles, Mumps and Rubella virus vaccine (MMR), live for subcutaneous

use 90784 Therapeutic or diagnostic injection

(NDC and product name/description must be provided) J3280 Thiethylperazine Maleate up to 10 mg 2 cc J9340 ThioTepa 15 mgm - - -

J3243 Tigecycline 1 mg J1655 Tinzaparin Sodium 1000 IU

J3246 Tirofiban HCL 0.25mg J3260 Tobramycin Sulfate up to 80 mg 2 cc

MCD J9350 Topotecan HCL (Hycamtin) 4 mg vial J9355 Trastuzumab (Herceptin) 10 mg J3302 Triamcinolone Diacetate 5 mg/ml 1 ml J3303 Triamcinolone Hexacetonide 5 mg/ml 1 ml J3400 Triflupromazine HCL up to 20 mg 1 cc J3250 Trimethobenzamide HCL up to 200 mg 2 cc J3315 Triptorelin Pamoate 3.75 mg 90690 Typhoid Vaccine, Live, Oral 90691 Typhoid Vaccine, VI Capsular

Polysaccharide (VICPS), For Intramuscular Use 90692 Typhoid Vaccine, Heat- and Phenol-Inactivated (H-P)

For Subcutaneous or Intradermal Use J3364 Urokinase 5000 units 1 ml J9357 Valrubicin, intravesical 200 mg J3370 Vancomycin HCL 500 mg 10 cc J3490 Verapamil Hydrochloride 5 mg/2 ml 2 ml

J3396 Verteporfin 0.1 mg


APPENDIX I

AI-18


COV. CODE NOMENCLATURE STRENGTH QUANTITY J9360 Vinblastine Sulfate 1 mg 1 cc J9370 Vincristine Sulfate 1 mg/ml 1 ml vial J9375 Vincristine Sulfate 2 mg 2 ml vial J9380 Vincristine Sulfate 5 mg 5 ml vial J9390 Vinorelbine Tartrate 10 mg 1 ml J3420 Vitamin B-12 Cyanocobalamin up to 1000 mcg - - - J3430 Vitamin K, Phytonadione, up to 10 mg 1 cc

Menadione, Menadiol Sodium Diphosphate J3486 Zipasidone 10 mg J3487 Zoledronic acid (Zometa) 1 mg J3488 Zoledronic acid (Reclast) 1 mg Q4095 Zoledronic Acid (Reclast) 1 mg

IV INFUSIONS

PROCEDURE CODE NOMENCLATURE DOSE J7030 Infusion, normal saline soln. 1000 cc J7040 Infusion, normal saline soln. 500 ml J7042 5% dextrose/normal saline 500 ml J7050 Infusion, normal saline soln. 250 cc J7060 5% dextrose/Water 500 ml = 1 unit J7070 Infusion, D5W 1000 cc

MCD J7100 Infusion, Dextran 40 500 ml MCD J7110 Infusion, Dextran 75 500 ml

J7120 Ringers lactate infusion up to 1000 cc J7130 Hypertonic saline soln 50 or 100 meq., 20 cc vial

NOT OTHERWISE CLASSIFIED INJECTIONS

J3490 Unclassified drugs J7303 Contraceptive supply, hormone containing vaginal ring, each J7599 Immunosuppressive drug, not otherwise classified J8499 Prescription drug, oral, non-chemotherapeutic, not otherwise classified J8999 Prescription drug, oral, chemotherapeutic, not otherwise classified J9999 Antineoplastic drug, not otherwise classified

NOTE: The NDC and drug name must be included on the claim or the claim will deny.


APPENDIX I

AI-19

AEROSOL ADDITIVES Updated 12/07 FOR OUTPATIENT HOSPITAL USE ONLY

PROCEDURE CODE NOMENCLATURE DOSE J3535 Drug administered through a metered dose inhaler

(NDC and product name/description must be provided) J7602 Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per 1 mg (Albuterol) or per 0.5 mg (Levalbuterol) J7603 Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, per 1 mg (Albuterol) or per 0.5 mg (Levalbuterol) J7604 Acetylcysteine, inhalation solution, compounded product, administered through DME, unit dose form, per gram

J7619 Albuterol Inhalant Solution , unit dose form 1 mg J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, non-compounded inhalation solution, administered through DME

J7622 Beclomethasome, inhalation solution per mg administered through DME, unit dose form

J7624 Betamethasome, inhalation solution per mg administered through DME, unit dose form

J7632 Cromolyn sodium, inhalation solution, 10 mg compounded product, administered through DME, unit dose form

Q4093 Albuterol, all formations including separated per mg isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form Q4094 Albuterol, all formations including separated per mg isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose J7648 Isoetharine HCL, Inhalation Soln. Conc. form per mg J7649 Isoetharine HCL, Inhalation Soln. unit dose form per mg

(NDC and product name/description must be provided) J7645 Ipratropium Bromide, inhalation solution, per mg compounded product, administered through DME, unit dose form J7668 Metaproterenol sulfate, Inhalation Soln. 10 mg

Conc. form J7669 Metaproterenol sulfate, Inhalation Soln. 10 mg

unit dose form 94642 Pentamidine, aerosol inhalation 300 mg


APPENDIX I

AI-20

AEROSOL ADDITIVES continued Updated 12/07 FOR OUTPATIENT HOSPITAL USE ONLY

PROCEDURE CODE NOMENCLATURE DOSE

J7676 Pentamidine isethoionate, inhalation solution, 300 mg compounded product, administered through DME, unit dose form

J7608 Acetylcysteine, inhalation solution, FDA-approved per gram final product, non-compounded, administered per mg through DME, unit dose form


APPENDIX I

AI-21

IMMUNIZATION ADMINISTRATION Updated 12/07 Providers must bill the appropriate administration code in addition to the vaccine and toxoid code for each dose administered. CPT codes for vaccines covered under the VFC program will be noncovered for children 18 years of age and younger.

COVERAGE INDICATORS

ADLT Vaccine covered for adults (19 years of age and older). VFC Vaccine covered by VFC (18 years of age and younger).

PROCEDURE COV. CODE NOMENCLATURE

ADMINISTRATION CODES 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) 90472 each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) 90473 Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) 90474 each additional vaccine (single or combination vaccine/toxoid) )List separately in addition to code for primary procedure) 90465 Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day 90466 each additional injection (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure) 90467 Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day 90468 each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)

VACCINE CODES VFC 90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP-Hib-IPV), for intramuscular use VFC 90700 Diphtheria, tetanus toxoids and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use ADLT 90701 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use VFC 90702 Diphtheria and tetanus toxoids (DT) adsorbed when administered to individuals younger than 7 years, for intramuscular use VFC 90720 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and hemophilus influenza B vaccine (DTP-Hib), for intramuscular use


APPENDIX I

AI-22

Updated 12/07 PROCEDURE COV. CODE NOMENCLATURE

VACCINE CODES (cont.) VFC 90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DTaP-HepB-IPV), for intramuscular use ADLT 90632 Hepatitis A vaccine, adult dosage, for intramuscular use VFC 90633 Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use VFC 90634 Hepatitis A vaccine, pediatric/adolescent dosage-3 dose schedule, for intramuscular use ADLT 90636 Hepatitis A and hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use ADLT 90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use VFC 90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use VFC 90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use ADLT 90746 Hepatitis B vaccine, adult dosage, for intramuscular use ADLT 90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use VFC 90748 Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use VFC 90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use VFC 90646 Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use VFC 90647 Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use VFC 90648 Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use VFC, 90649 Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 ADLT (quadrivalent), 3 dose schedule, for intramuscular use VFC 90655 Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use VFC, 90656 Influenza virus vaccine, split virus, preservative free, when administered ADLT to individuals 3 years and older, for intramuscular use VFC 90657 Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use VFC, 90658 Influenza virus vaccine, split virus, when administered to individuals 3 years ADLT of age and older, for intramuscular use VFC, 90660 Influenza virus vaccine, live, for intranasal use ADLT VFC, 90661 Influenza virus vaccine, derived from cell cultures, subunit, preservative ADLT and antibiotic free, for intramuscular use VFC, 90662 Influenza virus vaccine, split virus, preservative free, enhanced ADLT immunogenicity via increased antigen content, for intramuscular use


APPENDIX I

AI-23

Updated 12/07 PROCEDURE COV. CODE NOMENCLATURE

VACCINE CODES (cont.)

VFC, 90663 Influenza virus vaccine, pandemic formulation ADLT VFC, 90707 Measles, mumps, and rubella virus vaccine (MMR), live, for subcutaneous ADLT use VFC, 90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for ADLT subcutaneous use VFC 90733 Meningococcal polysaccharide vaccine (any groups[s]), for subcutaneous use VFC, 90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 ADLT (tetravalent), for intramuscular use VFC 90669 Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use VFC, 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or ADLT immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use VFC 90713 Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use 90675 Rabies vaccine, for intramuscular use VFC 90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use VFC 90703 Tetanus toxoid absorbed, for intramuscular use VFC, 90714 Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, when ADLT administered to 7 years or older, for intramuscular use VFC, 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when ADLT administered to 7 years or older, for intramuscular use VFC, 90718 Tetanus and diphtheria toxoids (Td) adsorbed, when administered to ADLT individuals 7 years or older, for intramuscular use VFC, 90716 Varicella virus vaccine, live, for subcutaneous use ADLT ADLT 90736 Zoster (shingles) vaccine, live, for subcutaneous injection


APPENDIX I

AI-24

Updated 12/07 Defibrillator codes:

G0297 – Insertion of single chamber pacing cardioverter defibrillator pulse generator G0298 – Insertion of dual chamber pacing cardioverter defibrillator pulse generator G0299 – Insertion or repositioning of electrode lead for single chamber pacing cardioverter

defibrillator and insertion of pulse generator G0300 – Insertion or repositioning of electrode lead(s) for dual chamber pacing cardioverter

defibrillator and insertion of pulse generator Pacemaker surgical Codes: 33203 – Insertion of epicardial electrode(s); endoscopic approach

33206 – Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial

33207 – Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular

33208 – Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular


APPENDIX II

AII-1

APPENDIX II Updated 6/05

AMBULATORY SURGERY/OUTPATIENT SURGERY PROCEDURE CODES AND NOMENCLATURE

COVERAGE INDICATORS

KBH - Services covered for KAN Be Healthy participants only.


BREAST RECONSTRUCTION

OUTPATIENT CODES

19342 Delayed Insertion of Breast Prosthesis 19350 Nipple/Areola Reconstruction 19357 Breast Reconstruction with Tissue Expander 19366 Breast Reconstruction with other Technique PHYSICIAN CODES 19340 Immediate Insertion of Breast Prosthesis Following Mastopexy, Mastectomy, or in Reconstruction 19342 Delayed Insertion of Breast Prosthesis Following Mastopexy, or in Reconstruction 19350 Nipple/Areola Reconstruction 19357 Breast Reconstruction, Immediate or Delayed, With Tissue Expander 19361 Breast Reconstruction with Latisimus Dorsi Flap, With or Without Prosthetic Implant 19364 Breast Reconstruction with Free Flap 19366 Breast Reconstruction with Other Technique 19367 Breast Reconstruction with Transverse Rectus Abdominis Myocutaneous Flap (TRAM), Single Pedicel, Including Closure of Donor Site 19368 Breast Reconstruction with Transverse Rectus Abdominis Myocutaneous Flap (TRAM), Single Pedicel, Including Closure of Donor Site; with Micro Vascular Anastomosis 19369 Breast Reconstruction with Transverse Rectus Abdominis Myocutaneous Flap (TRAM), Double Pedicel, Including Closure of Donor Site


APPENDIX II

AII-2


COV. CODE NOMENCLATURE MASTECTOMY CODES 19160 Mastectomy, Partial (eg Lumpectomy, Tylectomy, Quadrantectomy, Segmentectomy); 19162 Mastectomy, Partial (Quadrectomy or more); with Axillary Lymphadenectomy 19180 Mastectomy, Simple, Complete 19182 Mastectomy, Subcutaneous 19200 Mastectomy, Radical, Including Pectoral Muscles, Axillary Lymph Nodes 19220 Mastectomy, Radical, Including Pectoral Muscles, Axillary and Internal Mammary Lymph Nodes 19240 Mastectomy, Modified Radical, Including Axillary Lymph Nodes, with or without Pectoralis Minor Muscle, but Excluding Pectoralis Major Muscle 19301 Mastectomy; partial 19302 Mastectomy; partial with axillary lymphadenectomy 19303 Mastectomy, simple, complet 19304 Mastectomy, subcutaneous

19305 Mastectomy, radical, including pectoral muscles, axillary lymph nodes

19306 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes

19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle

BREAST CANCER DIAGNOSES 174.0-175.9 Malignant Neoplasm of the Breast 198.2 Secondary Malignant Neoplasm of Skin 217 Benign Neoplasm of Breast 233.0 Carcinoma in situ of Breast 239.3 Neoplasm of Unspecified Nature of Breast


APPENDIX II

AII-3

Updated 12/06 DENTOALVEOLAR STRUCTURES

PA* 41899 Unlisted Procedure, Dentoalveolar Structures is covered for the

following procedures. Claims must include a detailed description of the actual service provided. If the description of the service is other than what is included on the list below, the service will be non-covered.

• Surgical removal, soft tissue impact each additional • Pediatric dental procedures • Simple extractions • Full mouth extractions • Dental service for non KAN Be Healthy recipients

*Prior authorization is required for adults. Medical review is required for children age 21 and under.


APPENDIX II

AII-4

Updated 12/06


VAGAL NERVE STIMULATOR CODES

PA 61885 Incision and subcutaneous placement of cranial neurostimulator pulse

generator or receiver, direct or inductive coupling; with connection to a single electrode array

PA 61888 Revision or removal or cranial neurostimulator pulse generator receiver

PA 64573 Incision for implantation of neurostimulator electrodes; cranial nerve PA 64585 Revision or removal of peripheral neurostimulator electrodes PA 64590 Incision and subcutaneous placement of peripheral neurostimulator

pulse generator or receiver, direct or indicative coupling PA 64595 Revision or removal of peripheral neurostimulator pulse generator or

receiver 95970 Electronic analysis of implanted neurostimulator pulse generator

system (such as rate, pulse, amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling impedance, and patient compliance measures); simple or complex brain, spinal cord, or peripheral (such as neuromuscular) neurostimulator pulse generator/transmitter without reprogramming

95974 Complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour

PA 95975 Complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, each additional 30 minutes after first hour


APPENDIX IV

AIII-1

APPENDIX III Updated 11/03

DME/MEDICAL SUPPLIES IN A SWING BED NF PROGRAM

Nutritional Therapy: Total nutritional replacement therapy is covered with prior authorization when billed through a durable medical equipment provider. (Enteral or parenteral nutrition must be the sole source of nutrition.) Nutritional supplements are not covered and are a part of the adult care home per diem rate.

Oxygen Concentrator:

This will be covered for rental when billed through the durable medical equipment provider and only when it is more economical than the tank oxygen method. Blood gas levels must demonstrate the medical necessity for oxygen. Refer to Section 8200.

Urinary Supplies:

Urinary supplies and accessories are covered services when billed through the durable medical equipment provider.

Wheelchairs:

Wheelchairs are included in the per diem rate with the exception that coverage through the Durable Medical Equipment Program will be considered by prior authorization for cases of exceptional wheelchair requirements.

The following DME/medical supply items are considered routine and the responsibility of the Swing bed NF Program (unless used in excessive quantities):

Alternating pressure pads and pumps

Armboards Bedpans, urinals, basins Bed rails, beds & mattress

and mattress covers Blood glucose, monitors

and supplies Canes Commodes Compressors Crutches Denture Cups Dialysis, supplies &

maintenance Dressing items (applicators, tongue

blades, tape, gauze, bandages, bandaids, pads and compresses, ace bandages, vaseline gauze, cotton balls, slings, triangle

bandages, pressure pads, and tracheostomy care kits)

Emesis basins, bath basins Enemas and enema equipment Facial tissues & toilet paper First aid type ointments (e.g, Vaseline,

Metholatum, Ben-Gay, K-Y Jelly) Footboards Footcradles Gel pads or cushion (e.g., Action Cushion) Geri-chairs

Gloves, rubber or plastic Heating pads Heat lamps, examination light Humidifiers Ice bags, hot water bottles Intermittent Positive

Pressure Breathing (IPPB) machines Irrigation solution (i.e., H2O

normal saline) I.V. stands, clamps


APPENDIX IV

AIII-2

Lifts Updated 11/03 Lotions, creams and powders

(e.g., Dermassage, Noxema, baby lotion, oil and powders)

Nebulizers Orthotics and splints to

prevent or correct contractures Oxygen Masks, stands,

tubing, regulators, hoses, catheters, cannulas, and humidifiers

Parenteral, enteral infusion pumps Patient gowns, pajamas, bed linens Restraints

Sheepskins, foam pads Skin antiseptics (e.g., Tinc of Benzoine,

Tinc of Zephrin, Betadine, alcohol) Sphygmomanometers, stethoscopes, &

other examination equipment Stretchers Suction pumps and tubing Syringes & needles (except insulin

syringes and needles for diabetics that are covered by pharmacy program)

Thermometers Traction apparatus & equipment Underpads & adult diapers

(disposable/non-disp.) Walkers Water pitchers, glasses, Weighing scales Wheelchairs (manual)


APPENDIX IV

AIV-1

APPENDIX IV Updated 5/06

Hospital Cost Report To be eligible for payment from the Kansas Medical Assistance Program (KMAP), each hospital located in Kansas must complete, sign, and submit a copy of the cost report form (CMS 2552-96). An electronic copy of the Electronic Cost Report (ECR) and Print Image (PI) files are required along with the signed certification page. This must be done annually. The cost report and its instructions can be obtained from Medicare. Numerous private vendors offer services to assist in completing this cost report. KMAP has adopted this cost report, since it is already used by hospitals enrolled in the Medicare program. KMAP does not require any Medicaid specific schedules to be completed, although they may be referred to in the instructions. All general schedules of the report must be completed. Submit the report to the following address: Myers and Stauffer, LC. Certified Public Accountants 4123 SW Gage Center Drive, Suite 200 Topeka, KS 66604-1833 For questions regarding the cost report, contact the above company at: Telephone: 800-255-2309 Telephone: 785-228-6700 Fax: 800-228-6701 E-mail: [email protected]

FORMS SECTION

UB-04 MS-2126

ABORTION NECESSITY HYSTERECTOMY NECESSITY FORM NDC DETAIL ATTACHMENT FORM

STERILIZATION CONSENT (ENGLISH) STERILIZATION CONSENT (SPANISH)

HOW TO COMPLETE THE STERILIZATION FORM

MS-2126 NOTIFICATION OF FACILITY ADMISSION/DISCHARGE Rev 07-07

1. RESIDENT INFORMATION

Name: SSN: Sex:

Date of Birth: Client ID #:

Responsible Person or Agency: Relationship:

Responsible Person Address:

II. FACILITY INFORMATION

Facility Name/Location: Phone:

Name of Agency/Person Placing Resident: Facility Fax:

CARE or Screening Completed? Yes Date No Reason:

Administrator’s Signature (or Designee): Date:

III. FACILITY PLACEMENT/DISCHARGE

A. ADMISSION 1. Admission Date: Anticipated Length of Stay:

2. Admitted From (check one): NF ICF/MR NF/MH Hospital

Private Home Swing Bed State Institution

Assisted Living Other

If admitted from facility, name of facility:

3. Pay Status on Admission (check one): Private Pay Medicare or Private Insurance Medicaid Other

4. Current Level of Care in Your Facility:

Nursing Facility (NF SN) NF - Mental Health (NF MH) State Hospital - MR (SH SD)

Swing Bed (NF SB) Head Injury/Rehb. (NF HI) State Hospital - MH (SH SM)

PRTF (BF MH) ICF/MR (NF SD)

B. DISCHARGE INFORMATION

1. Discharged to: (check one) 2. Discharge Date: 3. Date Deceased:

Private Home Facility Swing Bed Assisted Living

Hospital Other

3. If discharged to facility or hospital, name of facility: Level of Care:

IV. HOSPITAL LEAVE (Complete for absences over 30 days only):

Hospital: Date Admitted: Estimated:

This form must be filed with the local SRS office within five working days of the date of admission, discharge, death, or hospital leave. Distribution: Original toFacility; Copy to Local SRS Office.

MS-2126 Instructions 1. The facility initiates the MS-2126 under the conditions specified in KEESM 8184.1 within five days of the event/request. Specific conditions prompting an MS-2126 include:

A medical recipient is admitted or discharged from the facility A resident files an application for medical assistance A resident has been absent from the facility for 30 days or longer A resident changes level of care

2. Sections I and II are always completed. Sections III or IV are completed as necessary. 3. If the resident is in SRS or JJA custody, note this in Section 1 under responsible person/agency. Contact the designated individual in the SRS Regional Service Center if additional information is needed. 4. For Psychiatric Rehabilitation Treatment Facility, follow processing guidelines outlined in the appropriate KMAP provider manual regarding prior authorization and prescreening. 5. Indicate the results of any required pre-admission screening. It is the responsibility of the admitting facility to ensure these requirements are met. Note: A CARE assessment is NOT required for swing bed placements. 6. The facility shall retain the original MS-2126 and submit a copy to the SRS eligibility contact. 7. SRS will notify the facility when the MS-2126 is approved or denied. The facility will also be notified of the effective date and any applicable patient liability.

KANSAS HEALTH INSURANCE PROGRAM ABORTION NECESSITY FORM I, ________________________________ (Please print name of physician), certify that on the basis of my professional judgment, the pregnancy of ____________________________(Name of patient) of _____________________________________ (address), _______1. Is endangering the life of the mother. _______2. Is a result of rape. _______3. Is a result of incest. _______________________________________ _______________________ (Signature of Physician) (Date) _______________________________________

_______________________________________ (Physician’s Address)

Hysterectomy Necessity Form

To be completed by the individual receiving the hysterectomy or her representative, if any:_____________________________________.(Please print name and relation to patient) Please select one of the following choices and place your initials on the line next to the statement that best describes your situation. ____Prior to surgery, I received, orally and in writing, information stating that the hysterectomy would render me permanently incapable of reproducing. I understand that I will not be able to become pregnant or bear children. ___ I am already sterile and incapable of bearing children. My physician and I have orally discussed my illness and he/she has given me written information on my illness that has led to the decision for this surgery. The illness/disease/symptoms that I have is called: _____________________________________________________________________. ______________________________________________ _______________________ (Signature of Patient or Representative) (Date 00/00/00) ______________________________________________ _______________________ (Signature of Physician ) (Date 00/00/00)

Kansas Medical Assistance Programs P. O. Box 3571 Topeka, KS 66601-3571

Provider Line: Consumer Line:

1-800-933-6593 1-800-766-9012

From the office of the Fiscal Agent

NDC Detail Attachment This form is a required attachment for any Kansas Medicaid paper claim billed using a drug HCPCS code on a CMS-1500 or a UB-92

Provider Name __________________________ Provider Number____________________

Beneficiary Name________________________ Beneficiary ID Number_______________ Date of Service___________

LINE NDC DESCRIPTION UNITS BASIS OF MEASUREMENT *UNIT

PRICE

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $

GR ML UN F2 $ Please fill in: Legend:

• The corresponding line number from the CMS-1500 (HCFA-1500) or the UB-92 GR – Gram • NDC number used ML - Milliliter • The drug description UN - Unit • The actual quantity (units) given to the patient F2 – International Unit • Circle the appropriate basis of measurement

* The unit price (If known)

Mo-8812 CONSENT FORM

NOTICE YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY THE PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.

8 CONSENT TO STERILIZATION 8

I have asked for and received information about sterilization from __________________________________ when I first asked for the Doctor or Clinic information I was told the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving federal funds such as A.F.D.C. or Medicaid that I am now getting or for which I may become eligible. I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN. I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father children in the future. I have rejected these alternatives and chosen to be sterilized. I understand that I will be sterilized by an operation known as a ________________________. The discomforts, risks, and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction. I understand that the operation will not be done until at least thirty days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs. I am at least 21 years of age and was born on ___________ I _____________________________________ hereby consent of my own free will to be sterilized by _____________________ by a method called __________________________. My consent expires 180 days from the date of my signature below. I also consent to the release of this form and other medical records about the operation to: Representatives of the Department of Health and Human Services, or Employees of programs or projects funded by that Department but only for determining if Federal laws were observed. I have received a copy of this form. _________________________________ Date_______________ Signature Month Day Year You are requested to give the following information, but it is not required: 0 American Indian or 0 Black (not of Hispanic origin) Alaska Native 0 Hispanic 0 Asian or Pacific Islander 0 White (not of Hispanic origin)

8 INTERPRETER'S STATEMENT8 If an interpreter is provided to assist the individual to be sterilized: I have translated the information and advice presented orally to the individual to be sterilized b the person obtaining this consent I have also read to him/her the consent form in ______________ language and explained its contents to him/her. To the best of my knowledge and belief he/she understood this explanation. ____________________________________________________ Interpreter Date

8 STATEMENT OF PERSON OBTAINING CONSENT 8

Before ____________________________________ signed the consent form. I explained to him/her the nature of the sterilization operation ___________________, the fact that it is intended to be a final and irreversible procedure and the discomforts, risks, and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any tine and that he/she will not lose any health services or any benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears to be mentally competent. He/she knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequences of the procedure. ___________________________________________________ signature Date ___________________________________________________ Facility ___________________________________________________ Address

8 PHYSICIANS STATEMENT 8 Shortly before I performed a sterilization operation upon ________________________________ on _______________, I explained to him/her the nature of the sterilization operation ___________________________________, the fact that it is intended to be a final and irreversible procedure and the discomforts, risks, and benefits associated with it. I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent. I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds. To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears to be mentally competent. He/she knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequences of the procedure. (Instructions for use of alternative final paragraphs: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual's signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph not used.) (1) At least thirty days have passed between the date of the individual's signature on this consent form and the date the sterilization was performed. (2) This sterilization was performed less than 30 days but not more than 72 hours after the date of the individual's signature on this consent form because of the following circumstances (check applicable box and fill in information requested) 0 Premature delivery 0 Individual's expected date of delivery: 0 Emergency abdominal surgery: (describe circumstances): __________________________________________________ Physician ____________________________Date __________________ Provider Number

(Revised 1/79)

Updated 02/07 HOW TO COMPLETE THE STERILIZATION FORM Consent to Sterilization: The consumer beneficiary must sign and date the left portion of the consent form. All dates must include month, day and year.

Field 1 Required. Enter the name of the doctor or clinic from which the beneficiary received sterilization information.

Field 2 Required. Enter the name of the procedure to be performed.

Field 3 Required. Enter the consumer's beneficiary’s date of birth in MM/DD/YYYY

format.

Field 4 Required. Enter the name of the consumer beneficiary.

Field 5 Required. Enter the name of the physician who will be performing the sterilization procedure.


Field 7 Federally Mandated Field. The consumer beneficiary must enter his/her

signature here. This field cannot be altered or changed. Field 8 Federally Mandated Field. The consumer beneficiary must enter the date he/she signed the consent form. This field cannot be altered or changed. The date must be entered in MM/DD/YY format. The consumer beneficiary must be 21 years of age on or before this date.

Field 9 Optional. Enter the race and ethnic designation of the consumer beneficiary.

Field 10 Enter if applicable. If the consumer beneficiary is not able to fully understand the description of service in English, then an interpreter must be present to explain the procedure and must sign and date this section.

Field 11 Required. The interpreter must sign and date the form.

Field 12 Required. Enter the beneficiaries first name, middle initial, and last name.


Field 14 Required. The person obtaining consent must sign and date here (for example, physician or qualified individual who explained the procedure to the consumer beneficiary). The date should be on or after the date the consumer beneficiary signed the consent form.

Completing the Sterilization Consent form cont. Updated 02/07 Field 15 Required. Enter the name of the facility where the sterilization procedure was performed.

Field 16 Required. Enter the address of the facility.

Field 17 Required. Enter the beneficiaries first name, middle initial, and last name.

Field 18 Required. The date entered here must be at least 30 days after but no more than 180 days from the date the consumer beneficiary signed the consent form. This date and the date on the claim form must match and be in MM/DD/YY format.


Field 20 If applicable. Check appropriate box. Enter the expected date of delivery.

This date must be 30 days after the date the consumer beneficiary signed the consent form. This date is required if either block is checked. The date must be in MM/DD/YY format.

Field 21 Required. The physician who performed the sterilization must sign here. This physician must be the same as the performing physician indicated on the claim.

Field 22 Required. Enter the performing physician's 10-digit Kansas Medical Assistance Program provider number.

Field 23 Required. Enter the date the physician signed the consent form.

Distribution of Form:

1 copy to patient

1 copy for physician's file

1 copy should be attached to the surgeon's claim at the time of submission (State Agency copy). A copy is not required to be attached to related claims (anesthesia, assistant surgeon, ambulatory surgical center, hospital, or rural health clinic) at the time of submission. However, no related claims will be paid until the sterilization form with the surgeon's claim has been reviewed and determined to be correct, unless the related claim has the correct sterilization

consent form attached.

DRG RATES AND WEIGHTS

Note: KMAP DRG weights and rates were not updated October 1, 2007. The DRG weights and rates effective October 1, 2006, will

continue to be used through October 1, 2008. The next DRG weights and rates update is anticipated for January 2009.

DRG Rates 1

Kansas 2007 DRG Weights and Limits Effective 10/1/2006

DRG DRG Day Cost Cost Cost Transfer Relative Daily Outlier Outlier Outlier Outlier

DRG ALOS Weight Rate Limit Adj. % Limit Adj. %

001 8.3 5.1820 2,035

36 75 55,891 75

002 3.9 2.7454 2,295

9 75 18,751 75

003 4.2 2.4934 1,935

31 75 70,013 75

004 0.0 0.0000 005 0.0 0.0000 006 2.0 0.8016

1,307 6 75 13,530 75

007 4.0 2.5639 2,090

26 75 29,660 75

008 2.5 2.1225 2,768

7 75 17,307 75

009 3.6 1.1068 1,002

15 75 23,497 75

010 3.9 1.6054 1,342

13 75 17,657 75

011 2.5 0.8429 1,099

8 75 16,033 75

012 6.1 2.0982 1,121

23 75 24,284 75

013 5.8 1.8067 1,015

21 75 22,442 75

014 4.7 2.4630 1,708

24 75 32,354 75

015 2.8 1.3482 1,570

10 75 9,742 75

016 4.1 1.1093 882

15 75 24,290 75

017 2.2 0.7215 1,069

8 75 11,968 75

018 5.0 1.7489 1,140

16 75 19,447 75

019 2.4 0.7078 961

7 75 13,730 75

020 0.0 0.0000 021 2.7 0.8253

996 7 75 8,295 75

022 3.6 1.1747 1,064

12 75 26,140 75

023 1.8 0.7020 1,271

6 75 6,060 75

024 0.0 0.0000 025 0.0 0.0000 026 1.9 0.6410

1,100 11 75 12,139 75

DRG Rates 2



DRG ALOS Weight Rate Limit Adj. % Limit Adj. % 027 2.7 1.2107

1,462 12 75 26,099 75

028 3.5 1.1851 1,104

13 75 24,591 75

029 2.2 0.7281 1,079

6 75 12,523 75

030 1.8 0.5666 1,026

9 75 13,529 75

031 1.9 1.2307 2,112

6 75 11,696 75

032 1.5 0.5027 1,093

5 75 9,250 75

033 1.2 0.4130 1,122

3 75 8,206 75

034 2.7 1.1442 1,382

10 75 13,819 75

035 2.3 0.6527 925

8 75 12,969 75

036 1.4 0.8456 1,969

5 75 12,955 75

037 2.5 1.3414 1,749

9 75 23,608 75

038 2.2 0.6829 1,012

12 75 12,271 75

039 1.6 0.9525 1,941

8 75 16,541 75

040 3.3 1.0846 1,071

8 75 14,408 75

041 0.0 0.3818 10 75 8,396 75 042 1.5 0.8880

1,930 5 75 11,866 75

043 2.4 0.6804 924

12 75 12,238 75

044 2.6 0.4019 504

6 75 8,814 75

045 2.3 0.7320 1,037

6 75 11,454 75

046 1.6 0.7042 1,435

4 75 4,299 75

047 2.0 0.4778 779

6 75 8,971 75

048 2.5 0.5238 683

3 75 2,786 75

049 3.4 2.1487 2,060

12 75 43,961 75

050 1.5 0.8696 1,890

7 75 12,451 75

051 1.8 0.8782 7 75 12,252 75

DRG Rates 3



DRG ALOS Weight Rate Limit Adj. % Limit Adj. % 1,591

052 1.1 0.5982 1,773

1 75 3,170 75

053 2.5 1.5167 1,978

12 75 32,643 75

054 2.7 1.2714 1,535

13 75 36,358 75

055 2.2 1.3117 1,944

11 75 28,818 75

056 2.0 1.0383 1,692

8 75 23,614 75

057 1.8 0.7402 1,341

8 75 18,595 75

058 2.5 0.7065 921

7 75 13,751 75

059 1.9 0.6355 1,090

5 75 10,789 75

060 1.6 0.5281 1,076

6 75 8,936 75

061 3.7 1.7638 1,554

13 75 26,184 75

062 1.6 0.6902 1,406

5 75 10,786 75

063 2.1 1.4161 2,198

9 75 26,771 75

064 4.6 1.3550 960

18 75 36,948 75

065 2.0 0.6675 1,088

9 75 9,433 75

066 1.9 0.6563 1,126

4 75 4,214 75

067 2.1 0.6576 1,021

8 75 35,407 75

068 2.5 0.7864 1,026

7 75 6,267 75

069 2.0 0.5988 976

4 75 4,803 75

070 1.9 0.5587 959

6 75 5,883 75

071 1.4 0.3863 900

3 75 3,194 75

072 2.0 0.6920 1,128

10 75 14,262 75

073 2.7 0.7645 923

9 75 17,633 75

074 2.1 0.4610 716

9 75 14,264 75

075 8.7 4.2261 22 75 33,954 75

DRG Rates 4




076 7.8 3.3272 1,391

26 75 33,965 75

077 3.2 1.2385 1,262

11 75 21,115 75

078 5.9 2.2146 1,224

24 75 26,286 75

079 7.4 2.7258 1,201

29 75 33,116 75

080 3.2 1.0256 1,045

8 75 8,068 75

081 5.5 1.9845 1,176

19 75 19,456 75

082 4.9 2.0596 1,370

23 75 25,883 75

083 3.6 0.9159 829

12 75 16,757 75

084 2.2 0.6006 890

6 75 9,754 75

085 4.4 1.1893 881

15 75 24,196 75

086 2.8 0.7261 845

10 75 13,533 75

087 5.8 2.4155 1,358

28 75 33,478 75

088 3.6 1.3005 1,178

15 75 14,165 75

089 4.1 1.5156 1,205

13 75 17,782 75

090 2.9 0.8758 985

7 75 8,206 75

091 2.3 0.7177 1,017

7 75 7,644 75

092 4.4 1.1151 826

16 75 23,276 75

093 3.0 0.7262 789

10 75 18,443 75

094 5.6 1.9284 1,123

15 75 17,643 75

095 2.6 0.5596 702

8 75 10,420 75

096 2.7 0.9368 1,131

9 75 10,156 75

097 2.2 0.7452 1,104

7 75 6,729 75

098 2.0 0.6397 1,043

6 75 6,706 75

099 2.2 0.9383 11 75 12,746 75

DRG Rates 5




100 1.8 0.7622 1,380

9 75 8,208 75

101 2.1 0.9567 1,485

9 75 12,169 75

102 2.0 0.6891 1,123

4 75 5,416 75

103 21.0 25.5025 3,959

77 75 445,246

75

104 11.4 8.9961 2,573

30 75 76,326 75

105 10.1 8.9961 2,904

24 75 64,360 75

106 8.8 7.3916 2,738

21 75 112,138

75

107 0.0 0.0000 108 10.3 6.4930

2,055 19 75 46,040 75

109 0.0 0.0000 110 6.3 5.0271

2,601 24 75 45,167 75

111 3.1 2.5824 2,716

10 75 38,299 75

112 0.0 0.0000 113 9.0 2.9208

1,058 29 75 64,086 75

114 10.3 2.8584 905

15 75 17,825 75

115 0.0 0.0000 116 0.0 0.0000 117 2.5 1.4149

1,845 17 75 37,251 75

118 2.0 2.0699 3,374

11 75 35,926 75

119 2.8 1.2570 1,464

11 75 25,595 75

120 6.9 2.5475 1,204

23 75 25,761 75

121 5.3 2.3878 1,469

14 75 23,459 75

122 2.7 1.4989 1,810

5 75 13,487 75

123 2.6 1.4142 1,773

14 75 37,601 75

124 3.6 1.9084 1,728

15 75 21,529 75

125 1.8 1.1980 2,170

6 75 10,112 75

DRG Rates 6




948 28 75 53,047 75

127 4.2 1.7259 1,340

16 75 22,081 75

128 4.0 0.6046 493

10 75 11,632 75

129 1.8 1.1066 2,004

10 75 24,639 75

130 4.1 1.4120 1,123

20 75 23,220 75

131 3.0 0.5333 580

8 75 10,863 75

132 1.8 0.8107 1,468

4 75 7,435 75

133 1.6 0.5729 1,167

7 75 12,911 75

134 2.0 0.7711 1,257

7 75 6,862 75

135 3.0 0.8508 925

10 75 18,194 75

136 1.8 0.6207 1,124

5 75 10,750 75

137 0.0 0.9258 10 75 15,397 75 138 2.8 1.2680

1,476 10 75 13,056 75

139 1.8 0.5049 914

5 75 8,630 75

140 1.9 0.5485 941

6 75 9,709 75

141 2.2 0.9307 1,379

11 75 14,692 75

142 1.8 0.5763 1,044

5 75 9,505 75

143 1.6 0.7119 1,450

6 75 7,551 75

144 4.8 1.9628 1,333

19 75 24,424 75

145 2.0 0.6288 1,025

8 75 12,285 75

146 8.1 2.5487 1,026

18 75 42,839 75

147 5.6 1.6056 935

11 75 21,579 75

148 0.0 0.0000 149 4.8 1.9636

1,334 12 75 15,938 75

150 7.2 3.3486 1,516

21 75 32,055 75

DRG Rates 7




1,126 11 75 19,708 75

152 6.0 1.6968 922

23 75 46,575 75

153 3.9 1.0835 906

9 75 15,497 75

154 0.0 0.0000 155 2.2 1.6876

2,501 11 75 16,580 75

156 3.1 1.1784 1,239

7 75 10,990 75

157 3.5 1.1461 1,068

12 75 24,030 75

158 2.0 0.6610 1,077

6 75 10,671 75

159 4.2 2.1532 1,671

13 75 25,997 75

160 2.6 1.3338 1,672

7 75 10,677 75

161 2.9 1.1881 1,336

12 75 24,965 75

162 1.5 0.6987 1,518

4 75 9,840 75

163 1.2 0.5142 1,397

1 75 3,096 75

164 5.3 2.1787 1,340

14 75 22,172 75

165 2.9 1.4147 1,590

8 75 10,669 75

166 2.0 1.3296 2,167

7 75 11,222 75

167 1.6 0.9445 1,924

4 75 6,717 75

168 2.9 1.3719 1,542

15 75 43,252 75

169 1.8 0.7327 1,327

5 75 11,127 75

170 5.5 2.5971 1,539

19 75 24,944 75

171 2.9 1.3839 1,556

7 75 8,692 75

172 4.6 1.2916 915

17 75 31,958 75

173 2.4 0.6600 897

9 75 12,483 75

174 3.7 1.5941 1,405

17 75 20,707 75

175 1.6 0.6027 4 75 4,917 75

DRG Rates 8




176 3.6 1.0376 940

12 75 22,155 75

177 3.3 0.8687 858

10 75 15,272 75

178 2.2 0.6689 991

6 75 10,665 75

179 3.5 1.1678 1,088

10 75 13,247 75

180 3.4 1.2111 1,161

13 75 14,714 75

181 2.7 0.8372 1,011

7 75 8,450 75

182 2.5 0.9405 1,226

9 75 9,551 75

183 2.0 0.7305 1,191

6 75 6,251 75

184 1.8 0.5075 919

6 75 5,341 75

185 2.3 0.6862 973

9 75 16,460 75

186 2.1 0.4449 691

6 75 10,922 75

187 2.4 0.7245 984

8 75 13,210 75

188 4.0 1.4439 1,177

13 75 14,159 75

189 2.1 0.5953 924

6 75 10,867 75

190 1.9 0.6281 1,078

9 75 27,448 75

191 9.1 4.1423 1,484

32 75 91,330 75

192 4.7 2.0043 1,390

13 75 29,716 75

193 9.2 3.4977 1,239

16 75 21,007 75

194 4.7 1.7038 1,182

12 75 23,052 75

195 7.2 2.5245 1,143

21 75 48,652 75

196 3.9 1.5724 1,314

9 75 22,135 75

197 6.4 2.4696 1,258

13 75 19,589 75

198 3.4 1.2008 1,151

9 75 18,484 75

199 5.5 2.1795 21 75 44,401 75

DRG Rates 9




200 5.7 2.8758 1,645

23 75 79,187 75

201 11.4 3.9999 1,144

37 75 80,563 75

202 4.5 1.7339 1,256

16 75 21,249 75

203 4.9 1.6139 1,074

14 75 16,474 75

204 3.7 1.2871 1,134

13 75 13,802 75

205 4.0 1.4537 1,185

20 75 22,577 75

206 2.5 0.6844 892

9 75 12,749 75

207 3.5 1.0593 987

12 75 22,633 75

208 2.4 1.0171 1,382

7 75 8,060 75

209 0.0 0.0000 210 6.3 3.0832

1,595 28 75 43,058 75

211 3.6 1.8965 1,717

8 75 13,638 75

212 2.6 1.3700 1,718

5 75 12,997 75

213 5.7 1.8901 1,081

22 75 46,121 75

214 0.0 0.0000 215 0.0 0.0000 216 4.2 2.0396

1,583 11 75 12,656 75

217 6.5 2.7531 1,381

28 75 68,857 75

218 4.4 2.3240 1,722

16 75 22,598 75

219 2.0 1.3729 2,238

4 75 10,181 75

220 1.6 1.0395 2,118

4 75 9,222 75

221 0.0 0.0000 222 0.0 0.0000 223 2.1 1.4698

2,282 7 75 11,388 75

224 1.6 0.8853 1,804

4 75 12,569 75

225 2.6 1.1489 1,441

11 75 23,604 75

DRG Rates 10




1,216 22 75 42,162 75

227 2.1 0.9555 1,483

5 75 6,152 75

228 2.7 1.2186 1,471

13 75 26,392 75

229 1.7 0.8102 1,554

5 75 12,273 75

230 3.0 1.2757 1,386

14 75 32,392 75

231 0.0 0.0000 232 2.0 0.9952

1,622 11 75 18,482 75

233 5.4 2.2336 1,348

20 75 50,333 75

234 2.2 1.9277 2,856

7 75 16,656 75

235 2.2 0.7855 1,164

5 75 5,128 75

236 4.1 0.7055 561

17 75 17,538 75

237 2.7 0.6147 742

10 75 12,766 75

238 5.2 1.1688 733

21 75 25,540 75

239 4.6 0.9963 706

15 75 21,812 75

240 4.6 1.5433 1,094

19 75 56,003 75

241 2.8 0.7352 856

9 75 14,979 75

242 4.1 0.8025 638

15 75 16,368 75

243 2.8 1.0618 1,236

12 75 12,869 75

244 3.7 0.6924 610

12 75 14,262 75

245 3.0 0.4553 495

9 75 8,757 75

246 2.7 0.6359 768

8 75 12,634 75

247 2.2 0.7595 1,125

9 75 8,295 75

248 3.0 0.6872 747

10 75 14,918 75

249 3.9 0.6987 584

36 75 16,762 75

250 2.7 0.6678 10 75 20,313 75

DRG Rates 11



DRG ALOS Weight Rate Limit Adj. % Limit Adj. % 806

251 1.7 0.4555 873

7 75 7,748 75

252 1.1 0.4170 1,236

2 75 6,077 75

253 3.2 0.6895 702

11 75 18,060 75

254 2.1 0.4593 713

9 75 8,359 75

255 1.4 0.5300 1,234

4 75 3,855 75

256 3.3 0.7585 749

14 75 17,217 75

257 2.0 1.2493 2,036

4 75 8,326 75

258 1.3 0.9960 2,498

3 75 8,727 75

259 1.9 0.9979 1,712

8 75 15,910 75

260 1.2 0.7359 1,999

3 75 10,175 75

261 1.6 1.0827 2,206

5 75 17,586 75

262 2.7 0.8408 1,015

8 75 13,591 75

263 7.3 2.6213 1,171

21 75 27,317 75

264 4.3 1.0728 813

12 75 20,041 75

265 4.0 1.6286 1,327

16 75 36,067 75

266 2.4 1.0309 1,400

11 75 18,403 75

267 2.2 0.6917 1,025

8 75 12,178 75

268 2.2 1.2211 1,810

10 75 21,669 75

269 5.1 1.6732 1,070

20 75 43,998 75

270 2.5 0.8012 1,045

9 75 13,621 75

271 5.1 0.9490 607

20 75 23,277 75

272 4.0 0.9490 773

19 75 35,680 75

273 2.4 0.4850 659

7 75 10,113 75

274 4.3 1.0463 17 75 27,701 75

DRG Rates 12




275 2.4 0.6536 888

12 75 11,893 75

276 2.4 0.5111 694

8 75 19,720 75

277 4.9 1.4591 971

14 75 14,940 75

278 2.8 0.8235 959

7 75 7,659 75

279 2.4 0.6648 903

7 75 8,918 75

280 1.3 0.6143 1,540

3 75 4,471 75

281 1.5 0.6143 1,335

4 75 4,780 75

282 1.3 0.4402 1,104

3 75 7,689 75

283 3.0 0.6540 711

11 75 16,350 75

284 1.9 0.3625 622

5 75 6,604 75

285 7.0 1.8707 871

20 75 38,451 75

286 4.2 2.1450 1,665

19 75 46,414 75

287 6.6 1.6486 814

24 75 37,354 75

288 3.4 2.0230 1,940

10 75 32,542 75

289 1.6 0.9247 1,884

8 75 21,213 75

290 1.6 0.9962 2,030

6 75 7,504 75

291 1.3 0.6439 1,615

11 75 11,768 75

292 7.1 2.5576 1,174

26 75 55,456 75

293 3.5 1.5322 1,427

13 75 23,203 75

294 3.2 1.0341 1,054

10 75 11,440 75

295 2.5 0.8493 1,108

7 75 8,526 75

296 3.2 1.0883 1,109

12 75 12,338 75

297 2.0 0.6500 1,060

11 75 7,636 75

298 1.8 0.4558 6 75 5,754 75

DRG Rates 13




299 2.9 0.7992 898

12 75 22,318 75

300 3.8 0.9578 822

13 75 21,124 75

301 1.9 0.6930 1,189

4 75 5,901 75

302 5.6 7.1300 4,151

13 75 78,737 75

303 4.4 2.1948 1,626

11 75 18,067 75

304 4.9 1.9774 1,316

20 75 42,427 75

305 2.8 1.3410 1,561

7 75 11,849 75

306 3.8 1.2765 1,095

15 75 25,844 75

307 1.7 0.6242 1,197

3 75 7,722 75

308 3.0 1.1250 1,222

12 75 22,261 75

309 1.7 0.8267 1,585

5 75 11,963 75

310 2.9 1.4476 1,627

8 75 11,130 75

311 1.5 0.7141 1,552

4 75 9,614 75

312 2.9 1.2871 1,447

13 75 33,215 75

313 1.7 0.7870 1,509

4 75 9,990 75

314 29.4 0.5599 62

34 75 10,688 75

315 6.6 3.1151 1,539

26 75 34,901 75

316 4.6 1.9507 1,382

16 75 21,462 75

317 2.3 0.7731 1,096

11 75 22,900 75

318 4.0 1.1006 897

13 75 23,126 75

319 3.2 0.7911 806

15 75 15,538 75

320 3.1 1.0205 1,073

8 75 9,438 75

321 2.2 0.7194 1,066

7 75 6,682 75

322 2.5 0.6847 7 75 6,464 75

DRG Rates 14




323 1.9 0.9596 1,647

6 75 10,027 75

324 1.6 0.7090 1,445

4 75 6,889 75

325 2.7 0.5957 719

9 75 14,428 75

326 1.9 0.4239 727

5 75 7,702 75

327 1.4 0.3503 816

3 75 5,136 75

328 2.5 0.6761 882

8 75 19,684 75

329 1.4 0.5749 1,339

11 75 10,881 75

330 0.0 0.3604 10 75 8,121 75 331 3.5 1.3280

1,237 10 75 13,122 75

332 2.1 0.5814 903

7 75 11,344 75

333 3.0 0.7220 785

12 75 24,773 75

334 3.4 1.3609 1,305

9 75 22,243 75

335 2.7 1.1337 1,369

6 75 14,608 75

336 2.7 0.8455 1,021

10 75 16,911 75

337 1.9 0.6111 1,049

5 75 7,982 75

338 2.9 1.1140 1,252

13 75 21,304 75

339 2.1 0.9428 1,464

14 75 25,757 75

340 1.2 0.5600 1,521

4 75 7,758 75

341 2.2 1.0273 1,522

10 75 21,064 75

342 2.4 0.7592 1,031

10 75 13,480 75

343 0.0 0.1742 10 75 5,723 75 344 2.4 1.2848

1,745 14 75 31,325 75

345 3.4 1.4352 1,376

13 75 21,953 75

346 4.0 0.9366 763

16 75 19,740 75

347 2.0 0.5956 11 75 11,146 75

DRG Rates 15




348 2.9 0.7162 805

8 75 16,469 75

349 2.1 0.5081 789

12 75 10,022 75

350 2.8 0.6037 703

8 75 13,719 75

351 0.0 0.2671 10 75 6,920 75 352 2.8 0.7791

907 10 75 16,577 75

353 3.7 1.7905 1,578

13 75 38,847 75

354 4.0 1.5258 1,244

11 75 28,660 75

355 1.7 1.0621 2,037

4 75 8,763 75

356 1.8 0.9983 1,808

4 75 6,266 75

357 5.2 2.1269 1,333

16 75 48,150 75

358 2.9 1.3629 1,532

7 75 12,489 75

359 1.9 1.0353 1,776

4 75 8,281 75

360 2.0 0.8415 1,372

7 75 16,775 75

361 2.1 0.9490 1,473

6 75 13,370 75

362 1.0 0.3415 1,113

11 75 7,876 75

363 2.2 1.1125 1,649

8 75 19,772 75

364 2.1 0.7849 1,219

8 75 13,561 75

365 3.3 1.4674 1,450

15 75 39,184 75

366 4.2 1.2915 1,002

17 75 29,489 75

367 2.3 0.7238 1,026

9 75 15,042 75

368 2.4 0.7455 1,013

5 75 5,523 75

369 1.6 0.5304 1,081

4 75 4,704 75

370 3.3 1.1281 1,114

10 75 12,929 75

371 2.7 0.9494 1,146

7 75 6,772 75

DRG Rates 16




1,166 9 75 8,368 75

373 1.7 0.6197 1,188

4 75 4,602 75

374 2.0 0.8906 1,452

6 75 6,505 75

375 2.7 0.6447 778

8 75 11,771 75

376 2.4 0.8513 1,156

11 75 14,279 75

377 3.4 1.8837 1,806

15 75 20,770 75

378 1.7 1.0045 1,926

4 75 7,603 75

379 2.1 0.6141 953

7 75 6,587 75

380 1.3 0.5823 1,460

3 75 7,016 75

381 1.4 0.7150 1,665

4 75 5,372 75

382 1.1 0.1667 494

3 75 3,270 75

383 2.2 0.7022 1,040

11 75 10,196 75

384 2.0 0.5726 933

7 75 5,578 75

385 0.0 0.3543 1 75 3,494 75 386 #N/A #N/A See

DRGs 801 - 805

387 #N/A #N/A See DRGs 801 - 805

388 #N/A #N/A See DRGs 801 - 805

389 4.4 1.2782 947

16 75 17,364 75

390 2.7 0.6134 741

9 75 8,871 75

391 1.7 0.2943 564

4 75 2,352 75

392 4.9 2.0843 1,387

16 75 44,851 75

393 3.5 1.3431 1,251

7 75 17,872 75

394 3.2 1.6286 1,659

18 75 53,602 75

DRG Rates 17




1,163 10 75 10,807 75

396 3.2 0.9897 1,008

10 75 9,559 75

397 3.2 1.1902 1,213

12 75 37,041 75

398 3.6 1.2136 1,099

10 75 10,328 75

399 2.0 0.5883 959

7 75 4,922 75

400 0.0 0.0000 401 7.8 3.1508

1,317 29 75 76,356 75

402 3.3 1.6413 1,621

12 75 29,357 75

403 5.5 1.9014 1,127

22 75 49,979 75

404 3.1 1.0263 1,079

12 75 23,236 75

405 6.7 3.7423 1,821

33 75 109,202

75

406 7.1 3.0485 1,400

33 75 97,227 75

407 3.3 1.4609 1,443

9 75 19,412 75

408 5.1 2.3508 1,503

22 75 60,037 75

409 4.0 1.1151 909

22 75 24,033 75

410 3.0 1.1932 1,297

18 75 21,501 75

411 1.6 0.4060 827

11 75 8,707 75

412 1.5 0.9441 2,052

11 75 15,633 75

413 4.7 1.4042 974

18 75 31,622 75

414 3.0 0.8456 919

12 75 14,365 75

415 0.0 0.0000 416 0.0 0.0000 417 3.3 1.1117

1,098 10 75 13,417 75

418 4.1 0.8935 710

15 75 20,897 75

419 2.9 0.9703 1,091

7 75 7,132 75

420 2.4 0.5856 6 75 10,786 75

DRG Rates 18




421 2.7 0.7126 860

10 75 19,839 75

422 2.0 0.5373 876

4 75 4,751 75

423 5.0 1.6645 1,085

23 75 59,997 75

424 8.4 2.0035 778

34 75 42,646 75

425 2.8 0.8709 1,014

10 75 8,057 75

426 3.2 0.7751 790

10 75 7,161 75

427 3.3 0.7879 778

10 75 8,143 75

428 4.8 1.1808 802

14 75 12,532 75

429 5.1 1.2871 823

15 75 12,695 75

430 4.5 0.9979 723

13 75 10,432 75

431 4.2 0.8511 661

9 75 6,524 75

432 5.0 0.9187 599

26 75 19,068 75

433 1.6 0.6238 1,271

6 75 6,456 75

434 0.0 0.0000 435 0.0 0.0000 436 0.0 0.0000 437 0.0 0.0000 438 0.0 0.0000 439 4.8 1.9015

1,291 20 75 42,414 75

440 4.1 1.6296 1,296

26 75 65,777 75

441 2.1 1.0765 1,671

8 75 23,426 75

442 4.8 2.1746 1,477

21 75 51,792 75

443 2.0 1.1470 1,870

6 75 8,919 75

444 2.5 0.7064 921

11 75 19,618 75

445 1.7 0.4866 933

5 75 8,664 75

446 1.3 0.5835 1,463

3 75 5,039 75

DRG Rates 19




954 7 75 12,452 75

448 1.3 0.3028 759

3 75 6,868 75

449 2.5 1.1624 1,516

12 75 17,469 75

450 1.3 0.5274 1,322

4 75 4,552 75

451 1.4 0.5400 1,258

4 75 5,135 75

452 3.3 1.0357 1,023

16 75 41,998 75

453 1.9 0.5192 891

8 75 11,866 75

454 2.2 0.8594 1,274

15 75 26,845 75

455 1.3 0.4206 1,055

4 75 7,315 75

456 0.0 0.0000 457 0.0 0.0000 458 0.0 0.0000 459 0.0 0.0000 460 0.0 0.0000 461 4.9 1.7809

1,185 34 75 43,984 75

462 12.9 3.4151 863

40 75 34,661 75

463 2.5 0.8432 1,100

7 75 7,823 75

464 1.3 0.4210 1,056

3 75 2,998 75

465 2.5 0.6557 855

12 75 11,920 75

466 5.8 0.5640 317

25 75 15,858 75

467 2.1 0.3008 467

27 75 10,918 75

468 6.7 3.6936 1,797

27 75 44,743 75

469 0.0 0.0000 470 0.0 0.0000 471 4.1 3.0571

2,431 10 75 39,171 75

472 0.0 0.0000 473 8.3 4.9685

1,951 42 75

125,259 75

474 0.0 0.0000 475 0.0 0.0000

DRG Rates 20




1,016 24 75 42,104 75

477 5.0 2.5364 1,654

30 75 35,684 75

478 0.0 0.0000 479 2.1 1.6124

2,503 8 75 25,912 75

480 14.9 10.3442 2,263

30 75 62,173 75

481 21.7 10.3728 1,558

44 75 181,960

75

482 8.4 4.0739 1,581

17 75 32,191 75

483 0.0 0.0000 484 9.3 7.2487

2,541 53 75

143,274 75

485 7.7 4.0349 1,708

22 75 80,146 75

486 7.3 4.4783 2,000

26 75 93,883 75

487 4.4 1.7417 1,290

15 75 36,132 75

488 9.7 4.1000 1,378

30 75 79,533 75

489 8.6 3.9338 1,491

38 75 61,969 75

490 3.2 1.0088 1,028

12 75 24,139 75

491 2.5 1.7617 2,297

8 75 26,378 75

492 4.4 1.3381 991

13 75 19,085 75

493 4.1 2.0209 1,607

13 75 19,651 75

494 2.0 1.2865 2,097

4 75 9,143 75

495 15.9 17.2917 3,545

83 75 358,870

75

496 5.7 6.5318 3,736

19 75 47,896 75

497 4.3 4.3548 3,302

16 75 37,639 75

498 3.3 3.0351 2,998

8 75 28,843 75

499 3.7 1.9216 1,693

15 75 18,470 75

500 2.1 1.2430 1,930

7 75 8,300 75

DRG Rates 21




1,099 20 75 43,331 75

502 4.4 1.2324 913

11 75 19,388 75

503 2.8 1.6512 1,922

7 75 12,422 75

504 20.8 12.3773 1,940

27 75 162,796

75

505 2.8 2.9053 3,383

12 75 40,876 75

506 8.2 2.7140 1,079

27 75 53,748 75

507 4.7 1.3771 955

19 75 22,823 75

508 5.3 1.5629 961

14 75 23,598 75

509 3.7 0.9207 811

13 75 15,332 75

510 3.5 0.7827 729

15 75 19,791 75

511 2.2 0.4646 688

10 75 12,011 75

512 11.1 6.9061 2,028

19 75 92,372 75

513 8.9 4.3744 1,602

17 75 59,786 75

514 0.0 0.0000 515 3.2 5.4953

5,598 13 75 47,199 75

516 0.0 0.0000 517 0.0 0.0000 518 1.6 1.4280

2,909 6 75 11,044 75

519 2.7 2.7652 3,339

14 75 30,508 75

520 1.3 2.1191 5,314

3 75 15,058 75

521 3.2 0.9890 1,008

14 75 16,340 75

522 5.0 0.5402 352

27 75 10,364 75

523 2.2 0.5681 842

7 75 5,036 75

524 2.1 0.8580 1,332

7 75 7,013 75

525 7.7 13.4470 5,693

16 75 176,563

75

526 0.0 0.0000

DRG Rates 22



DRG ALOS Weight Rate Limit Adj. % Limit Adj. % 527 0.0 0.0000 528 12.7 9.2992

2,387 26 75 56,041 75

529 5.2 2.7921 1,750

26 75 67,444 75

530 1.9 1.1233 1,927

4 75 6,027 75

531 6.2 3.1419 1,652

22 75 64,655 75

532 3.7 1.7206 1,516

10 75 31,660 75

533 2.6 1.5913 1,995

12 75 32,939 75

534 1.5 1.1980 2,604

4 75 8,007 75

535 8.6 9.1448 3,466

23 75 119,764

75

536 5.7 5.6922 3,256

10 75 33,985 75

537 4.1 1.7698 1,407

18 75 19,617 75

538 2.1 1.1096 1,723

8 75 18,598 75

539 7.4 3.6242 1,597

32 75 86,697 75

540 2.9 1.3414 1,508

10 75 21,920 75

541 37.9 24.2144 2,083

164 75 280,930

75

542 22.7 14.4006 2,068

81 75 138,467

75

543 8.5 4.8756 1,870

33 75 90,833 75

544 4.4 3.0084 2,229

13 75 23,006 75

545 5.0 3.1721 2,068

14 75 24,021 75

546 6.1 5.7911 3,095

17 75 84,815 75

547 11.7 7.7721 2,166

27 75 60,735 75

548 8.5 5.5997 2,148

19 75 43,700 75

549 7.6 5.7168 2,452

12 75 38,003 75

550 6.6 5.3034 2,620

13 75 35,193 75

551 4.3 3.3715 16 75 52,692 75

DRG Rates 23




552 3.2 2.8198 2,873

10 75 21,942 75

553 7.7 4.1104 1,740

20 75 35,695 75

554 3.7 2.8103 2,476

15 75 26,799 75

555 3.7 2.8764 2,534

13 75 24,513 75

556 1.5 1.9917 4,329

4 75 13,402 75

557 3.3 3.7090 3,664

17 75 37,447 75

558 1.8 2.6088 4,725

8 75 20,535 75

559 5.4 2.4510 1,480

15 75 39,896 75

560 6.6 2.5368 1,253

20 75 52,077 75

561 4.9 1.6100 1,071

17 75 39,571 75

562 2.6 1.0110 1,268

14 75 14,255 75

563 2.2 0.8168 1,210

7 75 8,055 75

564 2.1 0.7705 1,196

7 75 7,154 75

565 15.3 7.8646 1,676

51 75 75,787 75

566 5.7 3.1830 1,820

27 75 34,566 75

567 11.2 4.6966 1,367

35 75 101,362

75

568 7.3 3.0984 1,384

26 75 71,383 75

569 11.8 6.0148 1,662

38 75 73,388 75

570 9.6 4.8713 1,654

56 75 84,819 75

571 3.0 0.9671 1,051

10 75 21,145 75

572 3.9 1.2643 1,057

13 75 15,297 75

573 8.0 3.0087 1,226

22 75 57,434 75

574 4.3 1.7692 1,341

21 75 27,548 75

575 10.5 6.4854 24 75 46,244 75

DRG Rates 24




576 5.8 2.4696 1,388

20 75 24,520 75

577 1.6 1.9682 4,010

11 75 28,815 75

578 16.9 8.8437 1,706

49 75 99,942 75

579 6.4 2.2376 1,140

28 75 65,442 75

801 51.8 21.2161 1,335

152 75 203,255

75

802 35.5 8.9459 822

77 75 80,659 75

803 16.6 4.5243 889

46 75 47,727 75

804 12.3 4.1169 1,091

43 75 51,718 75

805 9.0 2.5352 918

29 75 29,696 75

Hospital Rates 1

Hospital Rates Effective 10/02/2007

City Hospital Charge Ratio Rate

Peer Group 1

KANSAS CITY Bethany Medical Center 0.4658 -

KANSAS CITY Kaw Valley 0.4658

4,178

KANSAS CITY Providence Medical Center 0.3829

4,178

KANSAS CITY Select Specialty Hospital Overland Park 0.4658

4,178

LAWRENCE Lawrence Memorial Hospital 0.4861

4,178

LEAWOOD Doctors Specialty Hospital LLC 0.6260

4,178

LEAWOOD Kansas City Orthopedic 0.4658

4,178

OLATHE Olathe Medical Center 0.4451

4,178

OVERLAND PARK Children's Mercy Hospital South 1.0000

4,178

OVERLAND PARK Heartland Surgical 0.4658

4,178

OVERLAND PARK Menorah Medical Center 0.3595

4,178

OVERLAND PARK Mid-America Rehab Hospital 0.4647

4,178

OVERLAND PARK Overland Park Regional Medical Cente 0.2374

4,178

OVERLAND PARK Rehab Institute South 0.4658

4,178

OVERLAND PARK Saint Lukes South Hospital, Inc. 0.2832

4,178

OVERLAND PARK Specialty Hospital of Mid America 0.4572

4,178

SHAWNEE MISSION Shawnee Mission Medical Center, Inc. 0.2723

4,178

TOPEKA Kansas Rehabilitation Hospital 0.7811

4,178

TOPEKA Saint Francis Health Center 0.4320

4,178

TOPEKA Select Specialty Hospital Topeka 0.4173

4,178

TOPEKA Stormont Vail Regional Health Center 0.3788

4,178

WICHITA Galichia Heart Hospital LLC 0.3957

4,178

WICHITA Kansas Heart Hospital LLC 0.4048

4,178

WICHITA Kansas Spine Hospital 0.3420

4,178 WICHITA Kansas Surgery & Recovery Center 0.6016

Hospital Rates 2

4,178

WICHITA Via Christi Regional Medical Center 0.2939

4,178

WICHITA Via Christi Rehabilitation Center 0.5265

4,178

WICHITA Via Christi Riverside Medical Center 0.8406

4,178

WICHITA Wesley Medical Center 0.2817

4,178

WICHITA Wesley Rehabilitation Center 0.5434

4,178

WICHITA Wichita Specialty Hospital 0.5080

4,178

Peer Group 2

CHANUTE Neosho Regional Medical Center 0.6916

4,087

DODGE CITY Western Plains Regional Hospital 0.4047

4,087

EL DORADO Susan B. Allen Memorial Hospital 0.6197

4,087

EMPORIA Newman Memorial County Hospital 0.7315

4,087

FORT SCOTT Mercy Health Systems of Kansas 0.4488

4,087

GARDEN CITY Saint Catherine Hospital 0.4678

4,087

GREAT BEND Central Kansas Medical Center - St. 0.5484

4,087

GREAT BEND Surgical & Diagnostic Center 0.3330

4,087

HAYS Hays Medical Center, Inc. 0.4513

4,087

HUTCHINSON Hutchinson Hospital Corporation 0.4622

4,087

JUNCTION CITY Geary Community Hospital 0.4949

4,087

LEAVENWORTH Cushing Memorial Hospital 0.3851

4,087

LEAVENWORTH Saint John Hospital 0.3835

4,087

MANHATTAN Manhattan Surgical Hospital 1.0000

4,087

MANHATTAN Mercy Regional Health Center of Manh 0.5278

4,087

NEWTON Newton Medical Center 0.4769

4,087

NEWTON Prairie View Hospital 0.5206

4,087

PAOLA Miami County Medical Center 0.4269

4,087

PARSONS Labette County Medical Center 0.5808

4,087 PITTSBURG Mt. Carmel Medical Center 0.2791

Hospital Rates 3

4,087

SALINA Salina Regional Health Center 0.5099

4,087

SALINA Salina Surgical Hospital 0.3248

4,087

WINCHESTER Jefferson County Memorial Hospital 1.0000

4,087

Peer Group 3

ABILENE Memorial Hospital 0.7083

3,704

ANTHONY Hospital District No. 6 of Harper Co 1.0000

3,704

ARKANSAS CITY South Central Kansas Regional Medica 0.5920

3,704

ASHLAND Ashland Health Center 1.0000

3,704

ATCHISON Atchison Hospital Association 0.7621

3,704

ATWOOD Rawlins County Health Center 0.9441

3,704

BELLEVILLE Republic County Hospital 1.0000

3,704

BELOIT Mitchell County Hospital 0.7539

3,704

BURLINGTON Coffey County Hospital 0.5761

3,704

CALDWELL Sumner County Hospital 1.0000

3,704

CLAY CENTER Clay County Medical Center 0.7136

3,704

COFFEYVILLE Coffeyville Regional Medical Center 0.5270

3,704

COLBY Citizens Medical Center 0.5257

3,704

COLDWATER Comanche County Hospital 1.0000

3,704

COLUMBUS Maude Norton Memorial Hospital 0.7909

3,704

CONCORDIA Cloud County Health Center 0.7626

3,704

COUNCIL GROVE Morris County Hospital 0.6828

3,704

DIGHTON Lane County Hospital 0.8907

3,704

ELKHART Morton County Hospital 0.6284

3,704

ELLINWOOD Ellinwood District Hospital 0.8931

3,704

ELLSWORTH Ellsworth County Medical Center 0.7976

3,704

EMPORIA Emporia Surgical Hospital LLC 0.7871

3,704 EUREKA Greenwood County Hospital 0.7383

Hospital Rates 4

3,704

FREDONIA Fredonia Regional Hospital 0.6471

3,704

GARNETT Anderson County Hospital 0.6642

3,704

GIRARD Hospital District #1 Crawford County 0.5925

3,704

GOODLAND Goodland Regional Medical Center 0.8246

3,704

GREENSBURG Kiowa County Memorial Hospital 1.0000

3,704

HANOVER Hanover Hospital aka Washington Coun 0.7650

3,704

HARPER Harper County Hospital District #5 0.8573

3,704

HERINGTON Herington Municipal Hospital 0.7725

3,704

HIAWATHA Hiawatha Community Hospital 1.0000

3,704

HILL CITY Graham County Hospital 0.9995

3,704

HILLSBORO Hillsboro Community Hospital 0.7871

3,704

HOISINGTON Clara Barton Hospital Association 0.8109

3,704

HOLTON Holton Community Hospital 1.0000

3,704

HORTON Northeast Kansas Center for Health a 0.6307

3,704

HOXIE Sheridan County Health Complex 1.0000

3,704

HUGOTON Stevens County Hospital 1.0000

3,704

INDEPENDENCE Mercy Health Systems of Kansas 0.4611

3,704

IOLA Allen County Hospital 0.4325

3,704

JETMORE Hodgeman County Health Center 0.9304

3,704

JOHNSON Stanton County Hospital 1.0000

3,704

KINGMAN Ninnescah Valley Health Systems-King 1.0000

3,704

KINSLEY Edwards County Hospital 1.0000

3,704

KIOWA Kiowa District Hospital 0.7871

3,704

LACROSSE Rush County Memorial Hospital 0.6074

3,704

LAKIN Kearny County Hospital 1.0000

3,704

LARNED Central Kansas Medical Center - Sain 0.8455

3,704

LEOTI Wichita County Hospital 1.0000

3,704

Hospital Rates 5

LIBERAL Southwest Medical Center 0.5503

3,704

LINCOLN Lincoln County Hospital 0.8918

3,704

LINDSBORG Lindsborg Community Hospital 0.6293

3,704

LYONS Hospital District 1 of Rice County 1.0000

3,704

MANKATO Jewell County Hospital 0.9390

3,704

MARION Saint Luke Hospital 0.7610

3,704

MARYSVILLE Community Memorial Healthcare 0.5471

3,704

MCPHERSON Memorial Hospital 0.6449

3,704

MEADE Meade Hospital District 0.7226

3,704

MEDICINE LODGE Medicine Lodge Memorial Hospital 0.7307

3,704

MINNEAPOLIS Ottawa County Health Center 1.0000

3,704

MINNEOLA Minneola District Hospital 0.6922

3,704

MOUNDRIDGE Mercy Hospital 0.7964

3,704

NEODESHA Wilson County Hospital 0.9271

3,704

NESS CITY Ness County Hospital District #2 0.9244

3,704

NORTON Norton County Hospital 0.9307

3,704

OAKLEY Logan County Hospital 0.7376

3,704

OBERLIN Decatur County 0.7871

3,704

ONAGA Community Hospital Onaga, Inc. 0.7143

3,704

OSBORNE Osborne County Hospital 1.0000

3,704

OSWEGO Oswego Medical Center LLC 0.9777

3,704

OTTAWA Ransom Memorial Hospital 0.7505

3,704

PHILLIPSBURG Phillips County Hospital 1.0000

3,704

PLAINVILLE Rooks County Health Center 1.0000

3,704

PRATT Pratt Regional Medical Center 0.5776

3,704

QUINTER Gove County Medical Center 0.7732

3,704

RANSOM Grisell Memorial Hospital District # 1.0000

3,704

RUSSELL Russell Regional Hospital 0.5443

3,704

Hospital Rates 6

SABETHA Sabetha Community Hospital 0.7105

3,704

SATANTA Satanta District Hospital 1.0000

3,704

SCOTT CITY Scott County Hospital, Inc. 0.8644

3,704

SEDAN Sedan City Hospital 1.0000

3,704

SENECA Nemaha Valley Community Hospital 0.7701

3,704

SMITH CENTER Smith County Memorial Hospital 0.7871

3,704

ST FRANCIS Cheyenne County Hospital 0.9100

3,704

STAFFORD Stafford District Hospital #4 1.0000

3,704

SYRACUSE Hamilton County Hospital 1.0000

3,704

ULYSSES Bob Wilson Memorial Hospital 0.7413

3,704

WAKEENEY Trego County Lemke Memorial Hospital 0.5598

3,704

WAMEGO Wamego City Hospital 0.8967

3,704

WASHINGTON Washington County Hospital 0.8170

3,704

WELLINGTON Sumner Regional Medical Center 0.5841

3,704

WICHITA Select Specialty Hospital Wichita In 0.7871

3,704

WINFIELD William Newton Memorial Hospital 0.7773

3,704

Out of State Ave. Peer Group 2 w/o Prov. Assessment 0.5111 3,249

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