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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-9. MEDICAID PROGRAM |
Section 29-991. OTHER LABORATORY AND X-RAY SERVICES
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991.1Medicaid reimbursable other laboratory and x-ray services shall be professional and technical laboratory and radiological services that are:
(a) Medically necessary;
(b) Ordered, in writing, by a physician or advanced practice registered nurse (APRN) who is screened and enrolled as a District Medicaid program provider pursuant to 29 DCMR §§ 9400 et seq.; and
(c) Provided in an office or similar facility other than a hospital outpatient department or clinic.
991.2All ordering clinicians shall be licensed pursuant to the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1202 et seq.).
991.3Coverage of and Medicaid reimbursement for other laboratory and x-ray services shall be limited as follows:
(a) Other laboratory and x-ray services performed in connection with a routine physical examination shall not be billed separately;
(b) Services primarily for, or in connection with, cosmetic purposes shall require prior approval by the Department of Health Care Finance or its designee;
(c) Services primarily for, or in connection with, dental or oral surgery services, shall be limited to those required as a result of the emergency repair or accidental injury to the jaw or related structure; and
(d) Other laboratory and x-ray services provided to an individual who is in an outpatient setting, including services referred to an outside office or facility shall be included in a hospital outpatient claim.
991.4 To receive Medicaid reimbursement, a provider of other laboratory services shall meet the following requirements:
(a) Be certified under Title XVIII of the Social Security Act and the Clinical Laboratories Improvement Amendments of 1988;
(b) Be licensed or registered in accordance with D.C. Official Code § 44-202;
(c) Hold an approved District Medicaid program Provider Agreement as an independent laboratory provider; and
(d) Be screened and enrolled as a District Medicaid provider pursuant to 29 DCMR § 9400.
991.5 To receive Medicaid reimbursement, a provider of x-ray services shall be:
(a) Licensed or registered in accordance with D.C. Official Code § 44-202 and other applicable District of Columbia laws;
(b) In compliance with manufacturer’s guidelines for use and routine inspection of equipment; and
(c) Screened and enrolled as a District Medicaid provider pursuant to 29 DCMR § 9400.
991.6 Medicaid reimbursement rates for other laboratory or x-ray services shall be eighty percent (80%) of the rates established by Medicare, and will not exceed Medicare on a per test basis.
991.7 The Department of Health Care Finance shall publish Medicaid reimbursement rates for other laboratory or x-ray services on the District Medicaid fee schedule, available online at www.dc-medicaid.com.
991.99 DEFINITIONS
For purposes of this section, the following terms shall have the meanings ascribed.
Outpatient - A patient of an organized medical facility, or distinct part of that facility who is expected by the facility to receive and who does receive professional services for less than a twenty-four (24) hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the patient remains in the facility past midnight in accordance with the requirements set forth in 42 C.F.R. § 440.2.
Professional service - A service that may only be provided by a physician or Advanced Practice Registered Nurse who is qualified to analyze a procedure or service and providing a written report of findings.
Technical services - Services necessary to secure a specimen and prepare it for analysis, or to take an x-ray and prepare it for reading and interpretation, e.g., machines test, laboratory, and radiology procedures.