DAR File No. 27315

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-26

Implementation and Maintenance of the Health Care Financing Administration Common Procedure Coding System (HCPCS)

NOTICE OF PROPOSED RULE

DAR File No.: 27315
Filed: 07/28/2004, 04:56
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule is being repealed due to the Health Insurance Portability and Accountability Act (HIPAA), which established standard medical data code sets to be used to code and bill for health care services furnished to recipients.

Summary of the rule or change:

This rule needs to be repealed because the coding is not standardized and is based solely on Centers for Medicare and Medicaid Services, Utah Medical Association, and local policy guidelines. For example, local codes that were specific to Utah Medicaid and previously allowed to be developed by the agency are no longer valid. Thus, the repeal of this rule is in accordance with HIPAA definitions and codes. This rule is repealed in its entirety.

State statutory or constitutional authorization for this rule:

Section 26-1-5 and 65 FR 50312 (2000)

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this repeal because Standard Medical Data Code Sets were previously implemented to be in compliance with HIPAA.

local governments:

There is no budget impact to local governments as a result of this repeal because Standard Medical Data Code Sets were previously implemented to be in compliance with HIPAA.

other persons:

There is no budget impact to other persons as a result of this repeal because Standard Medical Data Code Sets were previously implemented to be in compliance with HIPAA.

Compliance costs for affected persons:

There are no compliance costs for affected persons because Standard Medical Data Code Sets were previously implemented to be in compliance with HIPAA.

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule is being repealed due to HIPAA which established standard medical data code sets to be used to code and bill for health care services furnished to recipients. There should be no fiscal impact on business due to this action. Scott D. Williams, MD Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

09/14/2004

This rule may become effective on:

09/15/2004

Authorized by:

Scott D. Williams, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

[R414-26. Implementation and Maintenance of the Health Care Financing Administration Common Procedure Coding System (HCPCS).

R414-26-1. Policy.

1. The rule entitled "Health Common Procedure Coding System (HCPCS), published in the Federal Register Vol. 50, No. 194, Monday, October 7, 1985, is incorporated by reference, and will become effective no later than November 1, 1986. Specific effective dates which apply to each program will be identified as the scope of service is reviewed, revised and the specific codes identified for each service.

2. The following sections are the modifications of this rule that apply to Utah.

a. The CPT-4 Manual with the accompanying descriptive terms, identifying codes and instructions will be limited to use only by physicians to identify the code medical services and procedures provided to a patient by the Physician. (Other providers as identified and limited by CFR 405.232 (a) may be authorized to use selected CPT-4 codes, but only if HCPCS codes are not available for the specialty.)

b. Providers of service other than physician services, covered by the Medicaid program will use the HCPCS codes developed by the Health Care Financing Administration specifically for the service provided by the specialty.

Laboratory and x-ray services listed in the CPT-4 Manual are special diagnostic services provided by or under the direction of a Physician pathologist or radiologist.

c. Policy staff will have the responsibility to review each new edition of the CPT-4 Manual and each new publication of HCPCS codes for the other specialties. The purpose of this review will be to identify new services, eliminated services or procedures, and altered descriptions of service. Where additions, deletions, and/or changes have occurred, research will be initiated with subsequent development of appropriate policy recommendations and rulemaking to establish service coverage and/or limitations determined to be appropriate for Medicaid.

d. Policy staff will have the responsibility to review "X" codes established by Blue Cross, "S" codes established by the Utah Medical Association, and "Z" codes established by Medicare to determine appropriate service coverage and/or Limitations for Medicaid.

ICD9-CM diagnosis or surgical procedure codes will also be reviewed and evaluated by Policy staff.

Policy recommendations and rulemaking will be initiated when indicated.

e. Policy staff will have the responsibility for assignment and review of "Y" codes which are specific to Medicaid. Policy recommendations and rulemaking will be initiated as indicated.

f. No service, procedure, technology or individual code will be added, covered or deleted without benefit of the established policy development process.

Health Care Financing has the option to limit the amount, duration, or scope of services or to exclude a service or procedure from coverage by Medicaid. Policy recommendations will be based on medical necessity, appropriateness, utilization control concerns (CFR 440.230) and will take into consideration the following:

Existing policy for noncoverage of cosmetic, experimental or nonproven medical practices.

Information available from the Special Coverage Issues Bureau; Bureau of Eligibility, Reimbursement, and Coverage; Health Care Financing Administration; Department of Health and Human Services.

Information and recommendations from physician consultants employed by Utah Department of Health, Division of Health Care Financing.

Consultation with appropriate groups or individuals from various professional organizations.

Legal Counsel

Consultation with policy staff of the local Medicare carrier.

Consultation with policy staff of Medicaid programs in other states (selected).

Other sources determined appropriate by the specific issue being addressed.

KEY: medicaid

1987

Notice of Continuation December 31, 2002

26-1-5]

ADDITIONAL INFORMATION

PLEASE NOTE:

• Text to be deleted is struck through and surrounded by brackets (e.g., [example]). Text to be added is underlined (e.g., example). Some browsers may not depict some or any of these attributes on the screen or when the document is printed.
• Please see the DISCLAIMER regarding information available from state web pages.

For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.