Physician
Supervision
All delivery services must be done by or under the direct supervision of the physician.
Direct supervision means the supervising physician must:
• Be on the premises when the services are rendered; and
• Review, sign and date the medical record.
Neonatal Billing
Limitations
RPICC neonatal billing can only be utilized in any of the following situations:
• RPICC neonates who are discharged home or expire in the RPICC NICU;
• RPICC neonates who are transferred to another RPICC facility; or
• RPICC neonates transferred to another unit in the RPICC center with the neonatologist's continuing daily participation in the neonate's care with medical record documentation.
The provider must bill using Medicaid fee-for-service methodology if the RPICC patient is transferred to a non-RPICC Level III or Level II facility or to another unit in the RPICC when a neonatologist transfers care to another physician.
Recipients with
Third Party Liability
RPICC services cannot be reimbursed by Medicaid for recipients who have other health insurance.
Reimbursement for RPICC services to a Medicaid HMO recipient must be negotiated between the RPICC provider group and the respective HMO.
Undocumented Non-citizens (Aliens)
Providers can be reimbursed only for emergency services provided to undocumented non-citizens (aliens) who are not eligible for full Medicaid benefits due to their alien status. The global fee for RPICC services does not apply in the case of undocumented non-citizens (alien) deliveries.
Routine prenatal and postpartum services, ultrasound, and sterilization procedures are not emergency services. Medicaid cannot reimburse non-emergency services for undocumented non-citizen recipients.
Note: See the Florida Medicaid Provider General Handbook for additional information on undocumented non-citizens who are eligible for emergency services only.
Regional Perinatal Intensive Care Center (RPICC) Services
, continuedMedically Needy Providers cannot receive reimbursement through the RPICC program for medically needy recipients. Services for medically needy recipients must be billed through the Medicaid fee-for-service methodology.
Note: See the Florida Medicaid Provider General Handbook for information regarding medically needy eligibility.
Fee-for-Service Any of the following services provided to a RPICC recipient are reimbursed on a fee-for-service basis using CPT procedure code billing:
• Outpatient services;
• Medically-necessary consultations provided by physicians who are not part of the RPICC group;
• Radiology and pathology services provided by physicians who are not part of the RPICC group; and
• Nurse midwife services including those provided under the direct supervision of the RPICC medical consultant.
These services should be billed using the non-RPICC Medicaid group number.
Antepartum and Postpartum Inpatient Professional Reimbursement
One all-inclusive fee is paid for a total number of antepartum or postpartum hospital days accumulated during one or more hospitalizations.
When billing multiple antepartum or postpartum hospitalizations for the same recipient, enter the appropriate CPT code with the TG modifier along with a modifier 22 on each claim line for each hospitalization. Include from-through days, length of stay (LOS), usual and customary fee, and submit the RPICC Entitlement Report. The usual and customary charges must be at least equal to the entitlement.
Deliveries of less than 20 full weeks gestation are reimbursed as an antepartum hospitalization and not a delivery.
An antepartum hospitalization that progresses to a delivery is reimbursed only as a delivery.
All claims for antepartum services must have an “F” in the family planning indicator in order to exempt the claim from the recipient copayment.
Antepartum hospitalization of less than one day is considered an outpatient service and cannot be billed as an Obstetrical Care Group (OBCG).
Regional Perinatal Intensive Care Center (RPICC) Services
, continuedNon-hospital
Delivery
If the recipient does not deliver in the hospital, the delivery is not reimbursable. However, Medicaid will reimburse for the postpartum hospitalization.
Paper Claims All paper claims must include the RPICC Entitlement Report obtained from the RPICC Data System.
The following situations must be submitted on paper claims and sent to the Medicaid fiscal agent:
• Antepartum or postpartum hospitalizations that are inclusive of two or more hospitalizations;
• Hospitalizations that include a hysterectomy;
• Hospitalizations that include a sterilization; or
• Transfers of a neonate from one RPICC facility to another RPICC facility, if that neonate has been in the facility at least two days.
The following situations must be submitted on paper claims and sent to the RPICC Coordinator:
• A neonate expires and has a length of stay that equals 1 day, or
• A neonate transfers from one RPICC facility to another RPICC facility, and the length of stay for the facility equals 1 day.
RPICC claims may be mailed to:
Agency for Health Care Administration Bureau of Medicaid Services
RPICC Coordinator
2727 Mahan Drive, MS #20 Tallahassee, FL 32308
Assistant at Delivery An assistant surgeon cannot be reimbursed in addition to the RPICC reimbursement.
Sterilization and
Hysterectomy
Sterilizations and hysterectomies are reimbursable using the appropriate CPT code, TG modifier, and diagnosis code.
Note: See the Florida Medicaid Provider Reimbursement Handbook, CMS-1500, for instructions on completing the Sterilization Consent Form, Hysterectomy Acknowledgment Form, and the Exception to Hysterectomy Acknowledgment Requirement Form. Copies of these forms are available on the Medicaid fiscal agent’s Web site at www.mymedicaid-florida.com. Select Public Information for Providers, then Provider Support and then Forms.
Abbreviations and signature stamps are not acceptable on these forms.
Regional Perinatal Intensive Care Center (RPICC) Services
, continuedExcluded Services A prenatal visit and a delivery service cannot be reimbursed on the same day, same recipient, same provider or provider group.
Neonatal Eligibility Criteria
Only neonates of more than 20 weeks gestation who are admitted to Level III nurseries and are considered viable are eligible for RPICC reimbursement.
Hospice type care is not eligible for RPICC reimbursement.
Neonates must be in the RPICC Level III nursery a minimum of 48 hours to be eligible for RPICC reimbursement.
Exception to Required 48 Hour Nursery Stay
RPICC reimbursement can be billed for a neonate who is in a RPICC Level III nursery less than 48 hours, only if:
• The neonate expires prior to 48 hours, or
• The neonate is transferred to another RPICC facility with ongoing RPICC services.
RPICC Transfer When a neonate is transferred from one RPICC to another RPICC, both neonatal physician provider groups share the one RPICC fee. RPICC claims should not be submitted until the infant is discharged from the last RPICC center and the RPICC program.
If an infant is transferred from a RPICC to a non-RPICC hospital, the RPICC payment stops and all future billing must be fee-for-service using CPT
procedure codes. If the treating provider at the non-RPICC hospital is enrolled as a RPICC provider, all professional services at both hospitals must be billed fee-for-service by the individual treating provider.
If an infant is transferred from one RPICC to another RPICC, a modifier 22 must be used with the appropriate CPT code and TG modifier for RPICC reimbursement. The RPICC Exception Report must be submitted with the claim. The dates of service for the multiple RPICC facilities cannot overlap, as this will cause the subsequent claims to deny.
All RPICC transfers must have a RPICC Exception Report generated by the RPICC Data System staff at the University of Florida.
Child Health Check-Up
Child Health Check-Up screenings are considered part of the RPICC care and cannot be reimbursed separately.
Regional Perinatal Intensive Care Center (RPICC) Services
, continuedNeonatal
Reimbursement
Neonates are eligible for RPICC payment up to 365 days if they remain hospitalized continuously in RPICC hospitals, and the RPICC physician group continues to provide the care.
On day 365 of continuous hospitalization, RPICC payment ends and subsequent days are reimbursed under Medicaid fee-for-service using CPT codes.
The 12-month claim submission deadline begins with the date of discharge from the RPICC program.
Note: See Timely Submission of Claims in Chapter 1 in the Florida Medicaid Provider Reimbursement Handbook, CMS-1500, for information on the claim submission deadline.
Procedure Codes
and Fees
RPICC services have specific procedure codes, modifiers and diagnosis code requirements for the neonatal and obstetrical care groups.
Retail Clinics
Description Retail clinics are located in a retail setting and function similarly to a
practitioner’s office. These clinics are utilized for care that is minor in nature and act as a diversion from emergency room services. With claim
submissions, the place of service code is 17, Walk-in Retail Health Clinic.
There is a limited list of procedures that are approved for this setting.
ARNPs (Advanced Registered Nurse Practitioners) are the primary rendering providers.
Covered Procedures The following services are covered in the retail clinic setting.
CPT Description
81002 Urine Dip Stick – non-automated without microscopy 82947 Blood Sugar (glucose) – quantitative
87040 Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates
87650 Streptococcus - group A, direct prove technique 87880 Streptococcus - Quick Strep Test
99201 New Patient Problem Focused Visit 99202 New Patient Expanded Visit 99203 New Patient Detailed Visit
99212 Established Patient Problem Focused Visit 99213 Established Patient Expanded Visit 99214 Established Patient Detailed Visit