Carolina Community Health Partnership |
According to the standard, if a patient is diagnosed with one of the exempt illness and exceeds their visit for the year but needs to be treated for something such as the flu, the office visit will not be covered by Medicaid. For this reason, providers are encouraged to submit paper claims for the exempt illnesses stating July 1, 2007 if they feel the patient will inevitably require more than 24 visits throughout the year. In accordance with Medicaid guidelines, providers may bill patients the usual and customary charges for an office visit if a patient exceeds the limit for the year; under this circumstance, Medicaid will continue to pay for covered services. Ambulatory Visits and Diagnosis Code V82.9 Diagnosis code V82.9 should only be billed to indicate the recipient is being treated for an illness that is eminently life threatening and, as such, the recipient should be exempted from the legislated 24 ambulatory visit limit. Ambulatory visits include Evaluation and Management services such as office visits, hospital visits, and consultations. If a claim does not include one of these types of visits, diagnosis code V82.9 should not appear on the claim. Claims that include diagnosis code V82.9 without including an ambulatory visit code will be returned to the provider for correction. The following paragraphs detail the requirements for appropriate use of diagnosis code V82.9. The primary diagnosis code listed on the claim must be the specific ICD-9-CM diagnosis code that describes the reason for the encounter and the secondary diagnosis code must be listed as V82.9/ When a provider submits a claim with diagnosis code V82.9, a medical review is performed to determine if additional documentation is required to support the exemption. Claims for visits that exceed the 24 visit limit and do not list code V82.9 as the secondary diagnosis will deny. Ambulatory medical visits are limited to 24 visits per year beginning July 1 of each year through June 30 of the next year. These include any one or a combination of visits to the following: physicians, clinics, hospital outpatient other than emergency room, optometrists, chiropractors, and podiatrists. Once this limit has been reached, claims will deny with EOB 525, "Exceeds legislative limits for provider visits for fiscal year." Providers may bill the patient the usual and customary charge for the visit. Exemptions to the 24-visit limit include:
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Medical HomeThe Community Care of NC Program and the Carolina Community Health Partnership Network encourage participating providers to reinforce the " Medical Home" concept when providing care to their Medicaid and HealthChoice patients. As providers coordinate care for these patients guidance on appointment availability can be found on the Division of Medical Assistance Website. (Managed Care Provider information: section 4) Adult Medicaid Patients: 24 Visit Limit Ambulatory medical visits are limited to 24 visits per year beginning July 1 through June 30 for Medicaid patients over 21. These include any one or a combination of visits to the following: physicians, clinics, optometrists, chiropractors, and podiatrists. Once the limit has been reached, claims will deny with EOB 525, "exceed legislative limits for provider visits for fiscal year." Providers who use claim type CMS-1500 and Outpatient Hospitals may continue to submit medical documentation and letter of support, on provider letterhead, to the Medical Director at EDS to obtain an exemption from the 24-visit limit for Medicaid patients. These can be faxed to: EDS at (919) 816-3139 or (919) 233-6834 or mailed to address below. Or they can file the Medicaid claim in the following way:
Services for illnesses that may be granted exemptions from the 24-visit limit include:
If a claim is submitted electronically, it will count towards the 24 regardless of the diagnosis with the exception of the following: patients receiving CAP services, home health services, inpatient hospital services (inpatient physician services are NOT exempt from the 24 visit limit), services provided to residents of nursing facilities or ICF-MRs, prenatal and pregnancy related services, dental services, and mental health services. |
