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STATE OF NEVADA DEPARTMENT OF HEALTH AND HUMAN SERVICES

JIM GIBBONS Governor

DIVISION OF HEALTH CARE FINANCING AND POLICY 1100 E. William Street, Suite 101 Carson City, Nevada 89701 (775) 684-3600 Nevada Medicaid Nursing Facility Fact Sheet

MICHAEL J. WILLDEN Director

CHARLES DUARTE Administrator

What services are included in the Nursing Facility Per Diem? Routine services and supplies such as room and board, dietary needs, nursing services, social services, activities, medical supplies, oxygen and the use of equipment and supplies.

What services can be billed outside of the Nursing Facility Per Diem? Below are examples of services that may be billed outside of the facility per diem rate. Under each category there are services that are the responsibility of the nursing facility. This is a guideline to assist a person in finding the specific regulations for each service. This list is not all-inclusive.

Audiology: These medically necessary services include consultation, evaluation, diagnosis, testing, counseling the individual of the hearing impairment and if needed the fitting of hearing aid (s). It may also include the recommendation of a Cochlear Implant, Auditory Brainstem Implant (ABI) or a Bone Anchored hearing aid (BAHA). Services are billed by an Audiologist (provider type 76), Physician (provider type 20) and Hearing Aid Dispenser and Related Supplies (provider type 23). DCHFP is introducing a new Audiology Chapter in June 2009. Prior to that, the policies can be found Medicaid Services Manual, Chapter 1300 DME Services and Chapter 600 (Attachment A, policy # 6-05) Physician Services. Durable Medical Equipment (DME): Durable Medical Equipment that cannot be utilized by another recipient due to its unique custom features (e.g. custom made seating system), are not part of the institution's inclusive rate. These services are provided by a licensed Durable Medical Equipment provider (provider type 33). Reference Medicaid Services Manual, Chapter 1300, DME. Lab: Services include medically necessary diagnostic laboratory tests (such as blood, urine or tissue tests) that aid in the diagnosis, prevention, assessment, or treatment of disease. These services can be provided by independent clinical laboratories (provider type 43). CLIA waived tests performed by the nursing facility are part of the facility per diem. Reference Medicaid Service Manual, Chapter 800, Laboratory Services.

Mental Health Services (Outpatient): Services include assessment/diagnosis, testing, and basic medical and therapeutic services by a Psychiatrist or Psychologist. Examples of services are assessments; screens; neuro-cognitive, psychological and mental status testing; and mental health therapy. Services may be delivered in the nursing home facility. These services may be billed by a Psychiatrist (provider type 20) or a Psychologist (provider type 26). Reference Medicaid Services Manual, Chapter 400, Behavioral Health Services.

This document is a reference guide for the listed Nevada Medicaid service. This is not policy and will not be upheld in a appeals hearing. Providers are responsible for delivering service according to the Medicaid Services Manual. April 2009 1 of 2

Ocular: Medically necessary services to eligible Medicaid recipients 21 years and older are only eligible for medical vision services (i.e. medical eye exams, eye infections, glaucoma screening, vision therapy, ocular prostheses and care associated with the prostheses, cross over Medicare claims for one pair of glasses following cataract surgery, etc.). Recipients under the age of 21 are eligible for most ocular services including lenses, frames, etc. These services may be billed by a Ophthalmologist (provider type 20), Optometrist (provider type 25), Optician (provider type 23) and Ocularist (provider type 41). Reference the Medicaid Services Manual, Chapter 600 Physician and Chapter 100 Ocular. Pharmacy: Prescription pharmaceuticals are excluded from the daily NF per diem facility rate for pharmacy and IV pharmacy providers. Prescriptions may be billed by a pharmacy (provider number 28) or IV pharmacy (provider number 37) through Point-of-Sale. Most nursing facilities have a contracted pharmacy that bills under PT 28 or PT 37. Over the counter medications are not separately reimbursable. Items stocked at nursing stations in gross supply such as syringes, IV equipment, diabetic supplies, glucometers are included in the per diem rate. Reference the Medicaid Services Manual Chapter 500 Nursing Facility and Chapter 1200 Pharmacy. Physician Services provided in a Nursing Facility are a covered benefit when the service is medically necessary. Physician visits must be conducted in accordance with federal requirements for licensed facilities. CPT codes are 99304-99318 and be billed by provider type 20, 24 and 77.

Therapy (Physical, Occupational, Speech): Services are covered for an illness or injury resulting in functional limitations which can respond or improve as a result of the prescribed treatment plan in a reasonable, predictable period of time. Services are performed by licensed professionals. Services are billed under provider type 34. Reference the Medicaid Services Manual, Chapter 1700 Therapy.

This document is a reference guide for the listed Nevada Medicaid service. This is not policy and will not be upheld in a appeals hearing. Providers are responsible for delivering service according to the Medicaid Services Manual. April 2009 2 of 2

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