Alabama Administrative Code Chapter 560-X-39 — Extracorporeal Shock Wave Lithotripsy (ESWL)

560 Alabama Medicaid Agency

Ala. Admin. Code r. 560-X-39-.01 General

(1) ESWL is a covered benefit for treatment of kidney stones in the renal pelvis, uretero-pelvic junction, and the upper one-third of the ureter.

(2) ESWL is not a covered service for urinary stones of the bladder and the lower two-thirds of the ureter.

History

• Author: Charles A. Reasner, Luann C. McQueen
• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§482.11,482.12, 482.22, 482.54.
• Rule effective October 13, 1987. Amended: Effective December 14, 1990.Emergency rule effective February 4, 1991. Amended: Effective May 14, 1991.

Ala. Admin. Code r. 560-X-39-.02 Facility Services

(1) In order for the Alabama Medicaid Agency to reimburse the facility for ESWLtreatment, the facility must have a signed ESWL Contract with the Agency.

(2) For ESWL treatment to both kidneys during the same treatment period, Medicaid will pay the facility one-and-a-half times the regular reimbursement rate for this procedure.

(3) Repeat ESWL treatments on the same recipient within a ninety-day period will be reimbursed at half the regular reimbursement rate for this procedure.

(4) The ESWL reimbursement rate is an all-inclusive rate for each encounter and all services rendered in conjunction with the treatment (with the exception of the physician's and the anesthesiologist's) are included in the rate, such as lab, x-ray,and observation.

History

• Author: Charles A. Reasner
• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, etseq.
• Rule effective October 13, 1987.

Ala. Admin. Code r. 560-X-39-.03 Physician Services

(1) For ESWL treatment to both kidneys during the same treatment period, Medicaid will pay the surgeon one-and-a-half times the regular reimbursement rate for the surgical procedure.

(2) For repeat ESWL treatments on the same recipient within a ninety-day period,Medicaid will reimburse the surgeon at half the regular reimbursement rate for the surgical procedure.

History

• Author: Charles A. Reasner
• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, etseq.
• Rule effective October 13, 1987.

Ala. Admin. Code r. 560-X-39-.04 Anesthesiologist Services

Anesthesiologist services are not included in the facility's or physician's reimbursement rate and therefore can be billed separately.

History

• Author: Charles A. Reasner
• Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, etseq.
• Rule effective October 13, 1987.

Ala. Admin. Code r. 560-X-39-.05 Participation

(In order to participate in the Title XIX Medicaid Program As an ESWL provider, the following requirements must be met:

(a) Submit written request for enrollment

(b) Submit documentation that the lithotripsy machine is FDA approved

(c) Provide documentation to indicate the lithotripsy machine is being operated under the authority of a valid Certificate of Need (CON). Documentation can be a copy of the valid CON or a copy of the contract between the provider of care and the holder of the CON.

History

• Author: Luann C. McQueen
• Authority: State Plan, Attachment 3.1-A, Page 1; Title XIX, Social SecurityAct; 42 C.F.R. §§482.11, 482.12, 482.22, 482.54.
• Rule effective December 14, 1990.