PHYSICIANS SERVICES PROVIDER MANUAL - SC DHHS

PHYSICIANS SERVICES PROVIDER MANUAL

JULY 1, 2022

South Carolina Department of Health and Human Services

PHYSICIANS SERVICES PROVIDER MANUAL

SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

CONTENTS

1. Program Overview ......................................................................................................................1 2. Eligible Providers ........................................................................................................................2

? Provider Qualifications ..........................................................................................................2 ? Provider Enrollment and Licensing ........................................................................................8 3. Covered Services and Definitions ............................................................................................. 12 ? Primary Care Services ........................................................................................................ 12 ? Physician Services .............................................................................................................. 12 ? Office/Outpatient Exams Definitions .................................................................................... 13 ? Ambulatory Care Visit Guidelines ........................................................................................ 13 ? Evaluation and Management Services ................................................................................ 15 ? Non-Covered Services ...................................................................................................... 157 4. Utilization Management...........................................................................................................165 ? Prior Authorization.............................................................................................................165 ? Other Service Limitations .................................................................................................. 177 5. Reporting/Documentation ....................................................................................................... 192 ? Co-Signatures ................................................................................................................... 195 ? Evaluation and Management Services Records and Documentation Requirements..........195 ? Documentation of the Teaching Physician.........................................................................193 ? Convenient Care Clinics .................................................................................................... 193 ? Telemedicine.....................................................................................................................193

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PHYSICIANS SERVICES PROVIDER MANUAL

SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

? Obstetrics and Gynecology ............................................................................................... 193 ? Psychiatric and Counseling Services.................................................................................196 ? Tuberculosis (TB) Policy.................................................................................................... 198 ? Breast Cancer Susceptibility Gene 1 and 2 (BRCA) .......................................................... 198 ? Chiropractic Services ........................................................................................................ 199 ? Pain Management Services...............................................................................................202 6. Billing Guidance ...................................................................................................................... 203 ? Services Outside of the Country ........................................................................................ 203 ? Direct Physician Supervision ............................................................................................. 203 ? Physician's Office within an Institution ............................................................................... 203 ? Physician Administered Drugs...........................................................................................203 ? Teaching Physician Policy Billing Requirements ............................................................... 207 ? Reciprocal Billing and Locum Tenens Arrangements ........................................................ 205 ? Evaluation and Management Services .............................................................................. 206 ? Immunizations ................................................................................................................... 219 ? Pediatrics and Neonatology...............................................................................................219 ? Tobacco Cessation............................................................................................................ 230 ? Obstetrics and Gynecology ............................................................................................... 230 ? Psychiatric and Counseling Services.................................................................................236 ? Nephrology and End Stage Renal Disease Services ......................................................... 236 ? Part II -- Diagnostic Ophthalmology Services ................................................................... 238 ? Hyperbaric Oxygen Therapy..............................................................................................242

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PHYSICIANS SERVICES PROVIDER MANUAL

SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

? General Surgery Guidelines .............................................................................................. 243 ? Surgical Guidelines for Specific Systems .......................................................................... 249 ? Anesthesia Services..........................................................................................................250 ? Pain Management Services...............................................................................................252 ? Pathology and Laboratory Services ................................................................................... 253 ? Radiology and Nuclear Medicine ....................................................................................... 258 ? Federally Qualified Health Center Services ....................................................................... 259 ? Clinic-Based Physician Policy ........................................................................................... 261 ? Rural Health Clinic............................................................................................................. 262 ? Wrap-Around Payment Methodology.................................................................................265

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PHYSICIANS SERVICES PROVIDER MANUAL

SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

1

PROGRAM OVERVIEW

The State of South Carolina (South Carolina or State) Medicaid program recognizes professional medical services that are medically necessary, unless limitations are noted within the Other Service Limitations section of this manual. Information in this manual includes South Carolina Medicaid policies for general medical care, such as, office exams.

These services are predominantly billed to Medicaid by Primary Care Physicians (PCPs), such as family physicians, internists, general practitioners, obstetricians/gynecologists (OB/GYN) pediatricians, Nurse Practitioners (NPs) and Certified Nurse Midwives (CNMs). However, the guidelines are written for all providers rendering services to South Carolina citizens who are Medicaid beneficiaries.

Note: References to supporting documents and information are included throughout the manual. This information is found at the following locations:

? Provider Administrative and Billing Guide

? Forms

? Procedure Codes

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