Physicians Services Provider Manual Updates
The South Carolina Department of Health and Human Services (SCDHHS) is announcing changes to two policies in the Physicians Services provider manual. The agency is also clarifying the alignment between its vaccine and vaccine administration policy and Advisory Committee on Immunization Practices’ (ACIP) recommendations. The policy changes described below are effective for dates of service on or after Jan. 1, 2024.
Interprofessional Consultation
SCDHHS will reimburse providers for interprofessional consultation services as distinct services under the Medicaid physician fee schedule.
Interprofessional consultation is defined as an interaction in which the patient’s treating physician or other qualified health care practitioner (hereafter referred to as the treating practitioner) requests the opinion and/or treatment advice of a physician or other qualified health care practitioner with specific specialty expertise (hereafter referred to as the consulting practitioner) to assist the treating practitioner with the patient’s care.
Interprofessional consultation is intended to expand access to specialty care and foster interdisciplinary input on patient care. It is not intended to be a replacement for direct specialty care when such care is clinically indicated.
Reimbursement of interprofessional consultation is permissible, even when the Medicaid member is not present, as long as the consultation is for the direct benefit of the member. SCDHHS will reimburse for interprofessional consultation services delivered via telehealth.
The current procedural terminology (CPT) codes and reimbursement rates listed in the table below will be added to the base physician fee schedule available on SCDHHS’ website by Jan. 1, 2024. The first five codes in the table are for use by the consulting practitioner. The sixth code is for the use by the treating practitioner.
| Code | Description | Rate | Base Rate | Specialty Rate | Pediatric Subspecialty Rate |
|---|---|---|---|---|---|
| 99446 | Interprofessional telephone/internet/electronic health assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review | $14.01 | N/A | $18.49 | $20.07 |
| 99447 | 11-20 minutes of medical consultative discussion and review | $27.75 | N/A | $36.63 | $39.75 |
| 99448 | 21-30 minutes of medical consultative discussion and review | $42.29 | N/A | $55.12 | $59.82 |
| 99449 | 31 minutes or more of medical consultative discussion and review | $56.04 | N/A | $73.25 | $79.50 |
| 99451 | 5 minutes of medical consultative discussion and review | $27.75 | N/A | $37.71 | $40.93 |
| 99452 | Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes | $25.90 | $29.23 | $37.71 | $40.93 |
Addition of Nucleic Acid Amplification Test (NAAT) Coverage
SCDHHS will cover the NAAT laboratory test when performed by qualified laboratory providers. NAAT will be covered for the diagnosis of bacterial vaginosis for full-benefit Medicaid members and those enrolled in the Family Planning Limited-benefit program.
The procedure code and reimbursement rate, criteria and limitations for this service are listed in the table below and will be added to the Independent Lab and Radiology fee schedule available on SCDHHS ’ website by Jan. 1, 2024.
| Code | Description | Benefit Criteria and Limitation | Rate |
|---|---|---|---|
| 81513 | Molecular test used for diagnosing bacterial vaginosis (BV) | Service allowed for quantitative real-time amplification of RNA markers for Atopobium vaginae, Gardnerella vaginalis, and Lactobacillus species; service is allowed without prior-authorization | $111.25 |
Vaccine and Vaccine Administration Coverage
SCDHHS is clarifying its policy issued on Sept. 8, 2023 in Medicaid Bulletin #MB 23-044 regarding vaccine and vaccine administration coverage in alignment with ACIP recommendations and in compliance with the Centers for Medicare and Medicaid Services’ preventive services requirements. SCDHHS will continuously monitor ACIP recommendations and will update the Medicaid benefit accordingly to add vaccine and vaccine administration coverage starting no later than one calendar day from the issuance of ACIP recommendations, pending that a CPT code or Healthcare Common Procedure Coding System code is available for submission.
South Carolina’s Healthy Connections Medicaid managed care organizations (MCOs) are responsible for the coverage and reimbursement of services described in this bulletin for members enrolled in an MCO.
Updated policy language will be available in the Physicians Services provider manual by Jan. 1, 2024.
Providers should direct any questions related to this bulletin to the Provider Service Center (PSC). PSC representatives can be reached at (888) 289-0709 from 7:30 a.m.-5 p.m. Monday-Thursday and 8:30 a.m.-5 p.m. Friday. Providers can also submit an online inquiry at http://www.scdhhs.gov/contact-us.
Resources Providers Can Use to Help with Medicaid Member Annual Reviews
As SCDHHS continues its federally required review of Medicaid member eligibility, a process frequently referred to as “unwinding,” it is reminding providers of resources available to them that can help with this process. SCDHHS has produced several member-facing communications and marketing items and is encouraging providers to post its “submit your review, when it’s time to renew” flyer in patient-facing areas. The flyer is available for download from SCDHHS’ website in English and in Spanish along with other provider resources on SCDHHS’ annual reviews website.
The Centers for Medicare and Medicaid Services have also produced outreach and educational resources about this process that are available on their website.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.