CurrentAlliance HealthPolicy 1D-3

NC Medicaid Tuberculosis Control and Treatment Provided in Health Departments

Policy governs NC Medicaid coverage for tuberculosis (TB) control and treatment services delivered in local health departments, including diagnosis, treatment, prevention, and referral; applies to enrolled NC Medicaid beneficiaries and providers delivering these services.

Policy Summary

PayerAlliance Health

PolicyNC Medicaid Tuberculosis Control and Treatment Provided in Health Departments

Policy CodePolicy 1D-3

Change TypeNo material change

Effective Date

Next Review Date

Key ActionBill HCPCS T1002 for public health RN services up to 15 minutes (maximum 4 units/day); request adjustment with supporting documentation for additional units.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCApplicable state

4Max units/day

Aug 15, 2023Amended date

Job/college TB testNot covered

T1002Billing code

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Coverage Criteria for TB Control and Treatment

Public Health RN Services (T1002) — Coverage Criteria

Public Health RN Services (T1002) — Coverage Criteria — Covered when ALL of the following are met:

ALL of the following

Services are provided by a public health registered nurse (RN) in a local health department.
The service components for HCPCS code T1002 (RN services, up to 15 minutes) are all provided for each billed unit.
The services meet Medicaid eligibility and medical necessity criteria in Sections 2.0 and 3.0 of this policy.
Services are not duplicative of another provider’s procedure, product, or service for the same beneficiary and date of service.
T1002 is not billed together with a preventive medicine, prenatal, or treatment code for the same encounter; if another health department provider sees the beneficiary the same date for a separately identifiable medical condition, bill the appropriate E/M code and include the diagnosis indicating the separately identifiable condition.
A maximum of 4 units per day are billed unless documentation supports medical necessity for additional units (see operational note).

Coding and Unit Limits

HCPCS codes for public health nursingHCPCSCovered

T1002

RN services up to 15 minutes

Claim types/instructionsmixed

CMS-1500/837P

Professional claim type

Covered HCPCS Codes for public health nursing in health departmentsHCPCSCovered

T1002

RN services up to 15 minutes

Guidance for Unlisted Procedure or Servicemixed

unlisted CPT	Unlisted Procedure or Service — follow CPT codebook instructions and special report
unlisted HCPCS	Unlisted Procedure or Service — follow HCPCS instructions and special report

Unlisted code usage notemixed

(guidance)

Report unlisted procedure/service when no specific CPT/HCPCS exists; follow CPT/HCPCS instructions and special report requirements

inv-15: Maximum units per day

Maximum units per day4 units per day

Exception processReimbursement for additional units considered when documentation supports medical necessity via Medicaid Claim Adjustment Request form

Billing guidanceDo not submit a corrected claim when requesting adjustment; fiscal agent will perform adjustment using original claim and adjustment form

inv-16: Maximum billable units for T1002 per day

Maximum billable units (T1002)4 units per day

Additional unitsAdditional units may be considered for reimbursement when medical necessity is documented and requested via Medicaid Claim Adjustment Request form

Billing unit statementT1002 is billable when all service components are provided; follow Medicaid unit limits

Provider Actions, Billing Rules, and Documentation

Denial Risk

Denial Triggers

Services may be denied when the beneficiary does not meet eligibility requirements in Section 2.0, does not meet the coverage criteria in Section 3.0, the procedure/product/service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial.

Beneficiary not meeting eligibility (Section 2.0)
Beneficiary not meeting coverage criteria (Section 3.0)
Duplicate services from another provider
Experimental, investigational, or clinical trial services

Denial Risk

Specific Non-Coverage — Occupational/College Testing

TB skin testing performed solely for job, college, or employment-related requirements is not a covered service and may be denied.

TB skin testing for occupational or college requirements is not covered

Billing Rule

Unit Limitation and Excess Units Denial Risk

There is a maximum of 4 units per day that may be billed for HCPCS code T1002 (RN services up to 15 minutes). Billing more than 4 units/day may be denied unless medical necessity is documented; reimbursement for additional units will be considered only when supported by sufficient documentation.

HCPCS T1002 billable up to 4 units per day
Excess units may be denied without supporting medical documentation
Reimbursement for additional units considered when documentation supports medical necessity

Documentation Required

Documentation of Medical History and Diagnostic Exams

Provider must document the beneficiary's medical history on the initial visit and update the history on follow-up visits. Documentation should also include diagnostic exams (which may include X-rays and laboratory tests), evaluation of current status, treatment provided, prevention measures, and any referrals as appropriate.

Document medical history at initial visit and updates on follow-ups
Document diagnostic exams (e.g., X-rays, labs) and evaluation of current status
Document treatment, prevention, and referrals as appropriate

Documentation Required

Documentation Required for Adjustment Requests

When requesting adjustments for additional units denied, include the medical indication and supporting documentation (examples: allergic reaction to treatment, STD and TB visit for the same client on same date of service, history of false positive complicating treatment, comorbid conditions). Use the Medicaid Claim Adjustment Request form; do not submit a corrected claim. NC Medicaid's fiscal agent will perform adjustments using the adjustment form and the original claim.

Include medical indication and supporting documentation when requesting adjustment
Examples of acceptable indications: allergic reaction to treatment; STD and TB visit same date; history of false positive; comorbid conditions
Use Medicaid Claim Adjustment Request form — do not submit a corrected claim

Definitions and Qualifications

inv-36: Definitions

DefinitionsNone Apply.

ScopeNo additional definition entries provided in this policy.

ReferenceSee section 1.1 for definitions statement.

inv-37: T1002

Code descriptionHCPCS T1002: RN services up to 15 minutes; billable when all service components are provided.

Billing constraintsMaximum of 4 units per day may be billed for T1002 unless additional units are justified and requested via adjustment form.

Coding adviceReport the most specific billing code; if none exists use appropriate unlisted code and follow reporting instructions.

inv-38: RN services up to 15 minutes (public health nurses)

ServiceRN services up to 15 minutes (public health nurses)

Applicable codeHCPCS T1002

Billing noteT1002 is billable when all service components are provided and subject to unit limits per day.

inv-39: Public Health Nurse qualification

Qualification requirementPublic health nurses (RNs) must be supervised by the RN responsible for the TB Control Program and complete the Introduction to Tuberculosis Management course.

SupervisionPublic health nurses are supervised by the designated TB Control Program RN.

Program roleSupervising RN is responsible for oversight of public health nurses within the TB Control Program.

OpenPayer

NC Medicaid Tuberculosis Control and Treatment Provided in Health Departments

Coverage Criteria for TB Control and Treatment

Coding and Unit Limits

Provider Actions, Billing Rules, and Documentation

Background

Definitions and Qualifications