Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

The End of ACA Increases for Primary Care Reimbursement

medicaid

The Affordable Care Act’s temporary increase in Medicaid payments for qualifying primary care services provided by qualifying physicians for 2013 and 2014 dates of service (DOS) is coming to an end. The federally funded, temporary rate increase was authorized only for these two calendar years and will end December 31, 2014. The Medicaid rate structures will return to pre-existing levels for DOS on or after January 1, 2015.

Consistent with previous quarterly payments, qualifying physicians will receive the fourth-quarter 2014 ACA primary care physician (PCP) quarterly supplemental payments approximately 6-8 weeks after the end of the quarter, or approximately mid- to late February 2015.

For Indiana providers, to accommodate the one-year Indiana Health Coverage Programs (IHCP) fee-for-service (FFS) timely claims filing limit, a final settlement payment will be made for each year of the program. The final settlement payment for claims with DOS in CY2013 will be paid in the first half of 2015, and the final settlement payment for claims with DOS in CY2014 will be paid in the first half of 2016.

While the ACA PCP rate increases applied, new billing instructions were issued for Indiana Medicaid providers. Some of these billing instructions will be continued, and others will end with the conclusion of the ACA PCP rate increase.

  • To qualify for the increased PCP rates under the ACA, individually enrolled nurse practitioners were required to bill the IHCP using the SA modifier and the rendering (supervising) physician’s National Provider Identifier (NPI) in field 24J of the CMS-1500 claim form. Effective for DOS on or after January 1, 2015, individually enrolled nurse practitioners may resume billing using their own NPIs in field 24J of the CMS-1500 claim form.
  • Providers using VFC-provided vaccines were instructed to bill the IHCP for the VFC vaccine administration fee by billing V20.2 as the primary diagnosis, the procedure code of the specific vaccine administered with a billed amount of $0.00, and the appropriate vaccine administration code with the SL modifier. The allowed amount per claim for the administration of a VFC vaccine was set at $8.00. The IHCP will continue to follow these billing instructions for DOS on or after January 1, 2015. Providers should continue to bill the vaccine administration codes with the SL modifier for VFC vaccines with a billed amount of $8.00 and the procedure code of the specific vaccine administered with a billed amount of $0.00./li>
  • For non-VFC vaccines, providers were instructed to bill the IHCP for the most appropriate vaccine administration code available, and they should continue to follow those instructions. Reimbursement for the vaccine administration continues to be included in the evaluation and management (E/M) code-allowed amount. Therefore, if an E/M service code is billed with the same DOS as an office-administered vaccination, providers will not be separately reimbursed for the vaccine administration code. Separate reimbursement for the vaccine administration is allowed when the administration of the drug is the only service billed by the practitioner. Additionally, if more than one vaccine is administered on the same DOS and no E/M code is billed, providers may bill an administration fee for each injection using the appropriate vaccine administration code.

For more information about the end of the ACA increases for primary care reimbursement, review your state’s Medicaid guidelines. Indiana providers can review the recent IHCP Banner Page which discusses these guidelines.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com.

Share with Your Networks:
mm

Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

© Copyright 2018