September 2019
BCCHPSM Providers: What You Need to Know About Maternal and Child Health vs. Primary Care Physician (PCP) Add-on Codes
Blue Cross and Blue Shield of Illinois (BCBSIL) is committed to educating and informing providers of certain highly discussed topics throughout the year. This month’s topic, Maternal and Child Health (MCH) and PCP add-on codes, is specific to providers who provide care and services to our Blue Cross Community Health PlansSM (BCCHP) members. The MCH and PCP add-ons are codes on the Illinois Department of Healthcare and Family Services (HFS) fee schedule that give an increased reimbursement amount. The add-on amount may vary depending on whether the patient is a child or adult.
In a News and Updates article posted April 11, 2019, we stated that, on Feb. 11, 2019, BCBSIL identified a system issue involving PCP add-on fee payments. Since then, all identified affected claims have been reprocessed. Below is a review of the MCH vs. PCP criteria and examples.
Criteria to Include MCH Add-On Fees
According to HFS, increased reimbursement rates for selected MCH services are available to physicians who meet the following criteria and sign the HFS MCH Primary Care Provider Agreement, in addition to being enrolled as a Medical Assistance Provider:
- Maintain hospital admitting privileges;
- Provide Early and Periodic Screening, Diagnostic and Treatment (EPSDT) and primary care as needed;
- Provide obstetrical care and delivery services as appropriate;
- Perform risk assessment for pregnant women and/or children;
- Maintain 24-hour telephone coverage for consultation including ensuring “sick” children and “at-risk” pregnant women are treated as needed, based on a triage of need;
- Schedule diagnostic consultant and specialty visits as appropriate; and
- Provide adequate equal access to medical care for clients in cooperation with the department or its designated case management entity.
Criteria to Include PCP Add-On Fees
According to HFS, the Affordable Care Act (ACA) allows increased payment for certain Medicaid primary care services provided by certain qualified primary care providers.
To receive the enhanced payments, physicians must attest to providing primary care services within a specialty designation of family medicine, general internal medicine or pediatric medicine. In addition, the physician must attest that they meet at least one of the following criteria:
- Hold board certification from the American Board of Medical Specialties, the American Board of Physician Specialties or the American Osteopathic Association in pediatric medicine, internal medicine or family medicine or an associated subspecialty; and
- Physicians who have furnished primary care services (see procedures on HFS site) that equal at least 60% of the Medicaid codes paid during the most recently completed calendar year, or for newly eligible providers, the prior month.
Maternal and Child Health Procedure Codes
The following Current Procedural Terminology (CPT®) codes are eligible for the MCH Add-Ons from the HFS practitioner fee schedule:
90791, 90792, 99241, 99242, 99243, 99244, 99245, 99291
Example 1: Per the HFS fee schedule below, CPT code 90791 has a state maximum reimbursement of $70, but it indicates that there is an add-on of $52.11 for a child or adult. Therefore, the total reimbursement for this code is $122.11.
Primary Care Physician CPT Codes
The following CPT codes are eligible for the PCP Add-Ons from the HFS practitioner fee schedule:
99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99489, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99391, 99392, 99393, 99394, 99395
Example 2: Per the HFS fee schedule below, CPT Code 99201 has a state maximum reimbursement of $27.95, but it indicates that there is an add-on of $1.60 for a child or adult. Therefore, the total reimbursement for this code is $29.55. Notice that the PCP add-on code has a “P” in the note field.
CPT copyright 2018 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.