January 2004 Medicaid Bulletin

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In This Issue . . .

All Providers:

Ambulatory Surgical Centers:

Area Mental Health Centers:

Children’s Development Service Agencies:

Community Alternatives Program for Children:

Dental Providers:

Developmental Evaluation Centers:

Durable Medical Equipment Providers:

Federally Qualified Health Centers:

Health Departments:

Home Infusion Therapy Providers:

Nurse Practitioners:

Physicians:

Rural Health Clinics:


Attention: All Providers

Corrected 1099 Requests – Action Required by March 1, 2004

Providers receiving Medicaid payments of more than $600 annually receive a 1099 MISC tax form from EDS. The 1099 MISC tax form is generated as required by IRS guidelines. It will be mailed to each provider no later than January 31, 2004. The 1099 MISC tax form will reflect the tax information on file with Medicaid as of the last Medicaid checkwrite cycle date, December 29, 2003.

If the tax name or tax identification number on the annual 1099 MISC you receive is incorrect, a correction to the 1099 MISC must be requested. This ensures that accurate tax information is on file with Medicaid and sent to the IRS annually. When the IRS receives incorrect information on your 1099 MISC, it may require backup withholding in the amount of 28 percent of future Medicaid payments. The IRS could require EDS to initiate and continue this withholding to obtain correct tax data.

A correction to the original 1099 MISC must be submitted to EDS by March 1, 2004 and must be accompanied by the following documentation:

Fax both documents to 919-816-4399, Attention: Corrected 1099 Request - Financial

Or

Mail both documents to:

EDS
Attention: Corrected 1099 Request - Financial
4905 Waters Edge Drive
Raleigh, NC 27606

A copy of the corrected 1099 MISC will be mailed to you for your records. All corrected 1099 MISC requests will be reported to the IRS. In some cases, additional information may be required to ensure that the tax information on file with Medicaid is accurate. Providers will be notified by mail of any additional action that may be required to complete the correction to their tax information.

EDS, 1-800-688-6696 or 919-851-8888


Attention: All Providers

CPT Code Update 2004

New 2004 CPT codes are covered by N.C. Medicaid effective with date of service January 1, 2004. Claims with codes deleted for 2004 by the American Medical Association (AMA) will deny effective with dates of service on or after April 1, 2004.

The following table lists the new CPT codes that may be billed.

00529

01173

01958

21685

31632

31633

34805

35510

35512

35522

35525

35697

36555

36556

36557

36558

36560

36561

36563

36565

36566

36568

36569

36570

36571

36575

36576

36578

36580

36581

36582

36583

36584

36585

36589

36590

36595

36596

36597

36838

43237

43238

53500

57425

61537

61540

61566

61567

61863

61864

61867

61868

63101

63102

63103

64449

64517

64681

67912

70557

70558

70559

75998

76082

76083

76514

76937

76940

78804

79403

84156

84157

85055

85396

87269

87329

87660

88112

88361

89220

89225

89230

89235

89240

90734

91110

95991

The following table lists the Medicaid covered CPT codes that will be end-dated effective March 31, 2004.

36488

36489

36490

36491

36493

36530

36531

36532

36533

36534

36535

36536

36537

47134

61862

76085

76490

89350

89355

89360

89365

89399

The following table lists the new 2004 CPT codes that are noncovered pending further review.

20982

22532

22533

22534

37765

37766

47140

47141

47142

59070

59074

59076

59897

65780

65781

65782

68371

0001F

0002F

0003F

0004F

0005F

0006F

0007F

0008F

0009F

0010F

0011F

The following table lists the new 2004 CPT codes that are noncovered.

59072

89268

89272

89280

89281

89290

89291

89335

89342

89343

89344

89346

89352

89353

89354

89356

90698

90715

97755

99601

99602

0045T

0046T

0047T

0048T

0049T

0050T

0051T

0052T

0053T

0054T

0055T

0056T

0057T

0058T

0059T

0060T

0061T

EDS, 1-800-688-6696 or 919-851-8888


Attention: All Providers

EOB Code Crosswalk to HIPAA Standard Codes

With the implementation of standards for electronic transactions mandated by the Health Insurance Portability and Accountability Act, providers now have the option to receive an Electronic Remittance Advice (ERA) in addition to the paper version of the Remittance and Status Report (RA).

The EOB codes that providers currently receive on a paper RA are not used on the ERA. Because the EOB codes on the paper RA provide a greater level of detail on claim denials, all providers will continue to receive the paper version of the RA, even if they choose to receive the ERA transaction.

A list of standard national codes used on the ERA has been cross-walked to EOB codes as an informational aid to adjudicated claims listed on the RA. The list is available on the DMA HIPAA web page. The list is current as of the date of publication. Providers will be notified of changes to the list through the general Medicaid bulletin.

EOB Crosswalk to Standard Codes

EDS, 1-800-688-6696 or 919-851-8888


Attention: All Providers

Influenza - New Diagnosis Code V04.81

Effective with date of service October 1, 2003, the N.C. Medicaid program covers the new diagnosis code for influenza, V04.81. Diagnosis code V04.8 is no longer a valid diagnosis code. Providers who have had claims denied with V04.81 may resubmit them for payment.

EDS, 1-800-688-6696 or 919-851-8888


Attention: All Providers

FluMist Influenza Vaccine (CPT Code 90660) – Billing Guidelines

Effective with date of service December 15, 2003, the N.C. Medicaid program began coverage of the intranasal FluMist vaccine for healthy recipients ages 5 years through 49 years. These Medicaid recipients must be household contacts of Medicaid recipients who are at high risk for complications from influenza. Information regarding the risk categories pertinent to influenza according to the guidelines from the Advisory Committee on Immunization Practices (ACIP) can be accessed online at http://www.cdc.gov/nip/ACIP/default.htm. This policy will remain in effect through March 31, 2004.

Medicaid covers the FluMist vaccine only when dispensed by local health departments. FluMist should be administered according to the ACIP guidelines. Providers must use CPT code 90660, influenza virus vaccine, live, for intranasal use when billing for FluMist. The appropriate diagnosis code for the influenza vaccine is ICD-9-CM diagnosis code V04.81. An administration fee will not be reimbursed in addition to the cost of the vaccine.

EDS, 1-800-688-6696 or 919-851-8888


Attention: All Providers

ICD-9-CM Code Changes for 2004

Effective October 1, 2003, the following list of ICD-9-CM diagnosis codes became invalid. A three-month grace period allowed providers to bill these codes until December 31, 2003. After December 31, 2003, claims submitted with the following codes will deny.

Code Description
255.1 Hyperaldosteronism
277.8 Other specified disorder of metabolism
282.4 Thalassemias
289.8 Other specified diseases of blood and blood-forming organs
331.1 Pick’s disease
348.3 Encephalopathy, unspecified
358.0 Myasthenia gravis
458.2 Iatrogenic hypotension
530.2 Ulcer of esophagus
600.0 Hypertrophy (benign) of prostate
600.1 Nodular prostate
600.2 Benign localized hyperplasia of prostate
600.9 Hyperplasia of prostate, unspecified
719.70 Difficulty in walking, unspecified
719.75 Difficulty in walking, pelvic region and thigh
719.76 Difficulty in walking, lower leg
719.77 Difficulty in walking, ankle and foot
719.78 Difficulty in walking, other specified sites
719.79 Difficulty in walking, multiple sites
752.8 Other specified anomalies of genital organs
766.2 Post term infant, not "heavy for dates"
767.1 Birth trauma, injuries to scalp
790.2 Abnormal glucose tolerance test
799.8 Other ill-defined conditions
850.1 Concussion, with brief loss of consciousness
959.1 Injury, trunk
V04.8 Need for prophylactic vaccination and inoculation against certain viral disease, Influenza
V43.2 Status, organ or tissue replaced by other means, Heart
V53.9 Fitting and adjustment of other device, Other and unspecified device
V54.0 Aftercare involving removal of fracture plate or other internal fixation device
V64.4 Laparoscopic surgical procedure converted to open procedure
V65.1 Person consulting on behalf of another person

Most of these codes have been replaced with more diagnosis-specific five-digit codes. Providers must use current national codes from the 2004 ICD-9-CM manual when submitting claims to N.C. Medicaid.

Deborah Ireland, R.N.C., Medical Policy Section
DMA, 919-857-4020


Attention: All Providers

Inpatient Hospital Claims

In order to comply with regulations mandated by the Health Insurance Portability and Accountability Act (HIPAA) and with Medicaid regulations, effective February 1, 2004, ICD-9-CM procedure codes will only be accepted on claims submitted for inpatient hospital services. Other claim types (i.e., outpatient claims) must be billed using CPT procedure codes or HCPCS procedure codes. These other types of claims will deny if they are billed with ICD-9-CM procedure codes.

Deborah Ireland, R.N.C., Medical Policy Section
DMA, 919-857-4020


Attention: Ambulatory Surgery Centers

CPT Code Update 2004 for Ambulatory Surgical Centers

The following table lists the new CPT codes that may be billed by ambulatory surgical centers effective with date of service January 1, 2004.

36555

36556

36557

36558

36560

36561

36563

36565

36566

36568

36569

36570

36571

36575

36576

36578

36580

36581

36582

36583

36584

36585

36589

36590

The following table lists the Medicaid covered CPT codes that have been deleted for ambulatory surgical centers.

36489

36491

36530

36531

36532

36533

36534

36535

Claims submitted with codes deleted for 2004 by the American Medical Association (AMA) will deny effective with dates of service on or after April 1, 2004.

EDS, 1-800-688-6696 or 919-851-8888


Attention: Area Mental Health Centers

End-Dated HCPCS Code for Behavioral Health

HCPCS procedure codes W9906, Clozaril lab and counseling, was end-dated effective with date of service December 1, 2003. This action was taken due to non-usage of the code.

Carol Robertson, Medical Policy Section
DMA, 919-857-4020


Attention: Area Mental Health Centers, Federally Qualified Health Centers, Health Departments, Nurse Practitioners, Physicians, and Rural Health Clinics

Risperidone (Risperdal Consta, J3490) – Billing Guidelines

Effective with date of service January 1, 2004, the N.C. Medicaid program covers injectable risperidone (Risperdal Consta) for use in the Physician’s Drug Program. The FDA states that risperidone, a benzisoxazole antipsychotic agent, is indicated for the treatment of schizophrenia. Risperdal Consta is available in dosage strengths of 25 mg, 37.5 mg, and 50 mg for intramuscular administration every two weeks. One of the ICD-9-CM diagnosis codes in the range 295.0 through 295.9 must be entered on the CMS-1500 claim form when billing for Risperdal Consta.

Providers must bill J3490, the unclassified drug code, with an invoice attached to the claim form. An invoice must be submitted with each claim. The paper invoice must indicate the name of the recipient, the recipient’s Medicaid identification (MID) number, the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, the number of vials used, and the cost per dose. Providers must indicate the number of units given in block 24G on the claim form. The maximum reimbursement rate is $249.84 for the 25 mg vial, $374.77 for the 37.5 mg vial, and $499.69 for the 50 mg vial. Providers must bill their usual and customary charge.

Add this drug to the lists of injectable drugs published in the June 2002 and August 2002 general Medicaid bulletins.

EDS, 1-800-688-6696 or 919-851-8888


Attention: Children’s Development Service Agencies and Developmental Evaluation Centers

Conversion to National Codes

Effective with date of service January 1, 2004, national HCPCS codes replaced state-created codes as indicated below. This change is being made to comply with the implementation of standard national codes mandated by the Health Insurance Portability and Accountability Act (HIPAA). Claims billed after January 1, 2004 using these state-created codes will deny.

New HCPCS Code

Old State-Created Code

H0031 (1 unit = 15 minutes)

Y2104, Social/Family Diagnosis and Assessment

96110 and 96111

Y2110, Educational/Developmental Testing

T1023

Y2136, Intermediate Assessment (not time based)

Monica Teasley, Medical Policy Section
DMA, 919-857-4020


Attention: Durable Medical Equipment Providers

HCPCS Code Changes for Durable Medical Equipment

The following HCPCS codes were changed effective with date of service January 1, 2004. The DME Fee Schedule has been updated to reflect this change. The changes were made to comply with code changes from the Centers for Medicare and Medicaid Services (CMS).

Old Code

New Code

Description

Quantity Limitation or Lifetime Expectancy

Maximum Reimbursement Rate

A4621

A7525

Tracheostomy mask, each

N/A

Purchase:

$ 1.34

A4622

A7520

Tracheostomy/laryngectomy tube, non-cuffed, polyvinylchloride (PVC), silicone or equal, each

N/A

Purchase:

52.13

A7521

Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each

N/A

Purchase:

52.13

A7522

Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each

N/A

Purchase:

52.13

K0016

E0973*

Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each

3 years

Rental:
New Purchase:
Used Purchase:

10.24
107.61
80.71

K0022
K0026
K0027

E0982

Wheelchair accessory, back upholstery, replacement only, each

1 year for ages 0 through 20

2 years for ages 21 and older

Rental:
New Purchase:
Used Purchase:

4.47
44.72
33.53

K0025

E0966*

Manual wheelchair accessory, headrest extension, each

1 year for ages 0 through 20

2 years for ages 21 and older

Rental:
New Purchase:
Used Purchase:

6.56
65.55
49.16

K0028

E1226*

Manual wheelchair accessory, fully reclining back, each

1 year for ages 0 through 20

2 years for ages 21 and older

Rental:
New Purchase:
Used Purchase:

44.68
434.11
325.56

K0029
K0032
K0033

E0981

Wheelchair accessory, seat upholstery, replacement only, each

1 year for ages 0 through 20

2 years for ages 21 and older

Rental:
New Purchase:
Used Purchase:

4.54
45.37
34.02

K0030

E0992*

Manual wheelchair accessory, solid seat insert

1 year for ages 0 through 20

2 years for ages 21 and older

Rental:
New Purchase:
Used Purchase:

8.66
89.05
66.80

K0031

E0978

Wheelchair accessory, safety belt/pelvic strap, each

1 year for ages 0 through 20

2 years for ages 21 and older

Rental:
New Purchase:
Used Purchase:

3.88
38.81
29.12

K0035

E0951

Heel loop/holder, with or without ankle strap

2 years

Rental:
New Purchase:
Used Purchase:

2.42
24.03
18.02

K0036

E0952

Toe loop/holder, each

2 years

Rental:
New Purchase:
Used Purchase:

1.84
17.63
13.23

K0048

E0990*

Wheelchair accessory, elevating legrest, complete assembly, each

3 years

Rental:
New Purchase:
Used Purchase:

10.52
103.12
77.35

K0049

E0995

Wheelchair accessory, calf rest/pad, each

2 years

Rental:
New Purchase:
Used Purchase:

2.69
27.00
20.26

K0062
K0063

E0967*

Manual wheelchair accessory, hand rim with projections, each

1 year for ages 0 through 20

2 years for ages 21 and older

Rental:
New Purchase:
Used Purchase:

6.71
67.07
50.28

K0079

E0961

Manual wheelchair accessory, wheel lock brake extension (handle), each

1 year for ages 0 through 20

2 years for ages 21 and older

Rental:
New Purchase:
Used Purchase:

4.95
47.35
23.68

K0080

E0974

Manual wheelchair accessory, anti-rollback device, each

1 year for ages 0 through 20

2 years for ages 21 and older

Rental:
New Purchase:
Used Purchase:

13.24
124.75
94.27

K0082

E2360

Power wheelchair accessory, 22 NF non-sealed lead acid battery, each

1 year

Rental:
New Purchase:
Used Purchase:

10.57
105.16
78.87

K0083

E2361

Power wheelchair accessory, 22 NF sealed lead acid batter, each, (e.g. gel cell, absorbed glassmat)

1 year

Rental:
New Purchase:
Used Purchase:

13.06
130.54
97.92

K0084

E2362

Power wheelchair accessory, Group 24 non-sealed lead acid battery, each

1 year

Rental:
New Purchase:
Used Purchase:

8.62
86.09
64.57

K0085

E2363

Power wheelchair accessory, Group 24 sealed lead acid battery, each, (e.g. gel cell, absorbed glassmat)

1 year

Rental:
New Purchase:
Used Purchase:

17.42
174.10
130.57

K0086

E2364

Power wheelchair accessory, U-1 non-sealed lead acid battery, each

1 year

Rental:
New Purchase:
Used Purchase:

10.57
105.16
78.87

K0087

E2365

Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)

1 year

Rental:
New Purchase:
Used Purchase:

10.50
104.99
78.76

K0088

E2366*

Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each

2 years

Rental:
New Purchase:
Used Purchase:

21.03
209.73
157.30

K0089

E2367*

Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or non-sealed, each

2 years

Rental:
New Purchase:
Used Purchase:

39.22
392.25
294.19

K0100

E0959

Manual wheelchair accessory, adapter for amputee, each

1 year for ages 0 through 20

2 years for ages 21 and older

Rental:
New Purchase:
Used Purchase:

8.00
79.99
60.00

K0103

E0972

Wheelchair accessory, transfer board or device, each

1 year for ages 0 through 20

2 years for ages 21 and older

Rental:
New Purchase:
Used Purchase:

5.25
51.59
37.78

K0107

E0950

Wheelchair accessory, tray, each

1 year for ages 0 through 20

2 years for ages 21 and older

Rental:
New Purchase:
Used Purchase:

9.74
97.30
72.98

K0268

E0561

Humidifier, non-heated, used with positive airway pressure device

2 years

Rental:
New Purchase:
Used Purchase

13.16
131.57
96.68

K0531

E0562

Humidifier, heated, used with positive airway pressure device

2 years

Rental:
New Purchase:
Used Purchase

79.72
797.23
597.93

K0532

E0470*

Respiratory assist device, bi-level pressure capability, without back-up rate feature, used with non-invasive interface, e.g. nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

5 years

Rental:
New Purchase:
Used Purchase

247.24
2,472.42
1,854.31

K0533

E0471*

Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with non-invasive interface, e.g. nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

N/A

Rental:

580.30

K0538

E2402*

Negative pressure wound therapy electrical pump, stationary or portable

N/A

Rental:

1,654.77

K0539

A6550

Dressing set for negative pressure wound therapy electrical pump, stationary or portable, each

15 per month

Purchase:

26.42

K0540

A6551

Canister set for negative pressure wound therapy electrical pump, stationary or portable, each

10 per month

Purchase:

23.66

K0549

E0303*

Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress

5 years

Rental:
New Purchase:
Used Purchase

436.14
6,341.28
4,003.74

K0550

E0304*

Hospital bed, extra heavy duty, with weight capacity greater than 600 pounds, with any type side rails, with mattress

5 years

Rental:
New Purchase:
Used Purchase:

767.43
7.694.23
5,801.80

S8181

A7526

Tracheostomy tube collar/holder, each

12 per month

Purchase:

4.07

W4113
W4114
W4687

E0240

Bath/shower chair, with or without wheels, any size

3 years

New Purchase:
Used Purchase:

64.11
40.98

W4115

E0247

Transfer bench for tub or toilet with or without commode opening

3 years

New Purchase:
Used Purchase:

91.00
68.25

W4685
W4686

E0248

Transfer bench, heavy duty, for tub or toilet with or without commode opening

3 years

New Purchase:
Used Purchase:

248.08
186.06

Note: HCPCS codes with an asterisk require prior approval.

The coverage criteria for these items have not changed. Refer to Medical Coverage Policy #5, Durable Medical Equipment for detailed coverage information. A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval.

Melody B. Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020


Attention: Durable Medical Equipment Providers

HCPCS Code Deletions for Durable Medical Equipment

Effective with dates of service January 1, 2004, the following codes were end-dated and deleted from the DME Fee Schedule. This action is being taken because the Centers for Medicare and Medicaid Services (CMS) has deleted these codes.

Code

Description

E0165

Commode chair, stationary, with detachable arms

K0054

Seat width of 10", 11", 12", 15", 17", or 20" for a high strength, lightweight or ultralightweight wheelchair

K0055

Seat depth of 15", 17", or 18" for a high strength, lightweight or ultralightweight wheelchair

K0057

Seat width 19" or 20" for heavy duty or extra heavy duty chair

K0058

Seat depth 17" or 18" for motorized/power wheelchair

Melody B. Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020


Attention: Durable Medical Equipment Providers

Place of Service for Durable Medical Equipment

Durable medical equipment (DME) providers are reminded that they may only bill for DME and related supplies when the recipient resides in a private residence or an adult care home. Therefore, DME providers may not bill N.C. Medicaid for DME or related supplies when the recipient resides in a skilled nursing facility or intermediate care facility. Remember that your designation of place of service "12" in block 24B on the CMS-1500 claim form indicates that you are have verified the recipient’s place of residence as his/her home or an adult care home.

Melody B. Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020


Attention: Durable Medical Equipment Providers

HCPCS Code Changes for Orthotics and Prosthetics

The following HCPCS codes were changed effective with date of service January 1, 2004. The Orthotic and Prosthetic Fee Schedule has been updated to reflect this change. The changes were made to comply with code changes from the Centers for Medicare and Medicaid Services (CMS).

Old Code

New Code

Description

Maximum Reimbursement Rate

K0556

L5673

Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, Elastomeric or equal, for use with locking mechanism

Purchase:

$ 564.04

K0557

L5679

Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, Elastomeric or equal, for use with locking mechanism

Purchase:

470.02

K0558

L5681

Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, Elastomeric or equal, for use with or without locking mechanism, initial only

Purchase:

999.64

K0559

L5683

Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, Elastomeric or equal, for use with or without locking mechanism, initial only

Purchase:

999.64

All of these codes require prior approval. The coverage criteria for these items have not changed. Refer to Medical Coverage Policy #5, Durable Medical Equipment for detailed coverage information. A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval.

Melody B, Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020


Attention: Durable Medical Equipment Providers

End-Dated HCPCS Code for Orthotics and Prosthetics

Effective with date of service January 1, 2004, HCPCS code L2122, knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, plaster type casting material, custom-fabricated, was end-dated and deleted from the Orthotic and Prosthetic Fee Schedule. This action is being taken because the Centers for Medicare and Medicaid Services (CMS) has deleted this code.

Melody B. Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020


Attention: Federally Qualified Health Centers, Health Departments, Nurse Practitioners, Physicians, and Rural Health Clinics

Arsenic Trioxide, 1 mg (Trisenox, J9017) – Billing Guidelines

Effective with date of service October 1, 2003, the N.C. Medicaid program covers injectable arsenic trioxide (Trisenox) for use in the Physician’s Drug Program when billed with HCPCS code J9017. The FDA states that arsenic trioxide, an antineoplastic agent, is indicated for induction of remission and consolidation in patients with acute promyelocytic leukemia (APL) who are refractory to, or have relapsed from, retinoid and anthracycline chemotherapy, and whose APL is characterized by the presence of the t (15; 17) translocation or PML/RAR-alpha gene expression. It is recommended that Trisenox be infused intravenously over a period of one to two hours.

The ICD-9-CM diagnosis codes required when billing for Trisenox are:

AND EITHER

OR

For Medicaid billing, one unit of coverage is 1 mg. Providers must indicate the number of units given in block 24G on the CMS-1500 claim form. The maximum reimbursement rate per unit is $35.10. Providers must bill their usual and customary charge.

Add this drug to the lists of injectable drugs published in the June 2002 and August 2002 general Medicaid bulletins.

EDS, 1-800-688-6696 or 919-851-8888


Attention: Federally Qualified Health Centers, Health Departments, Nurse Practitioners, Physicians, and Rural Health Centers

Omalizumab (Xolair, J3490) – Billing Guidelines

Effective with date of service January 1, 2004, the N.C. Medicaid program covers injectable omalizumab (Xolair) for use in the Physician’s Drug Program. The FDA states that Xolair, an anti-asthmatic monoclonal antibody, is indicated for adults and adolescents (12 years of age and older) with moderate to severe persistent asthma who have a positive skin test or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids. One of the following ICD-9-CM diagnosis codes must be entered on the CMS-1500 claim form when billing for Xolair:

Providers must bill J3490, the unclassified drug code, with an invoice attached to the claim form. An invoice must be submitted with each claim. The paper invoice must indicate the name of the recipient, the recipient’s Medicaid identification (MID) number, the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, and the cost per dose. For Medicaid billing, one unit of coverage is the 150 mg vial for subcutaneous injection. Providers must indicate the number of units given in block 24G on the claim form. The maximum reimbursement rate is $487.13 for the 150 mg vial. Providers must bill their usual and customary charge.

Add this drug to the lists of injectable drugs published in the June 2002 and August 2002 general Medicaid bulletins.

EDS, 1-800-688-6696 or 919-851-8888


Attention: Home Infusion Therapy Providers

End-Dated Codes for Low Profile Gastrostomy Kits

Effective with date of service December 31, 2003, the following HCPCS procedure codes were end-dated and deleted from the Home Infusion Therapy Fee Schedule due to limited usage. These supplies are still available to Medicaid recipients through durable medical equipment (DME) providers. If you are currently providing these kits to clients, after January 1, 2004, please refer them to a DME supplier.

W4210 Low profile gastrostomy kit
W4211 Low profile gastrostomy extension replacement kit for continuous feeding
W4212 Low profile gastrostomy extension replacement kit for bolus feeding

Beth Karr, Medical Policy Section
DMA, 919-857-4021


Attention: Federally Qualified Health Centers, Health Departments, Nurse Practitioners, Physicians, and Rural Health Clinics

Palonosetron 0.25 mg (Aloxi, J3490) – Billing Guidelines

Effective with date of service January 1, 2004, the N.C. Medicaid program covers injectable palonosetron (Aloxi) for use in the Physician’s Drug Program. The FDA states that palonosetron, a selective 5-HT3 receptor antagonist and antiemetic, is indicated for the prevention of acute nausea and vomiting associated with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy. It is also indicated for the prevention of delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy. It is given intravenously.

Providers must bill J3490, the unclassified drug code, with an invoice attached to the CMS-1500 claim form. An invoice must be submitted with each claim. The paper invoice must indicate the name of the recipient, the recipient’s Medicaid identification (MID) number, the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, the number of vials used, and the cost per dose. For Medicaid billing, one unit of coverage is .25 mg/5 ml. Providers must indicate the number of units given in block 24G on the claim form. The maximum reimbursement rate is $291.60 per 5 ml vial. Providers must bill their usual and customary charge.

Add this drug to the lists of injectable drugs published in the June 2002 and August 2002 general Medicaid bulletins.

EDS, 1-800-688-6696 or 919-851-8888


Attention: Health Departments and Physicians

Breast and Cervical Cancer Medicaid Procedures

Applications for Breast and Cervical Cancer Medicaid (form DMA-5079) and the Breast and Cervical Cancer Medicaid Verification form for Screening, Diagnosis, and Treatment (form DMA-5081) must be completed and returned to the county department of social services in the county where the resident resides. Do not send the forms to the Division of Medical Assistance (DMA).

Providers must complete every item on the forms and ensure that they are using the most current version of the forms. The current version of the DMA-5079 is August 2003; the most current version of the DMA-5081 is July 2003. The date is located in the lower left-hand corner of the forms. Current version of the forms are available on DMA’s provider forms web page.

At recertification many providers are returning the verification form with tamoxifen indicated as treatment. Tamoxifen is not covered through the BCCM program. Do not submit the verification form with tamoxifen indicated as the treatment.

Susan Ryan, Medicaid Eligibility Unit
DMA, 919-857-4019


Attention: Home Infusion Therapy Providers

HCPCS Code Change for Pediatric Enteral Formulae

Effective with date of service January 1, 2004, HCPCS code W9934, pediatric enteral formulae, was end-dated and deleted from the Home Infusion Therapy Fee Schedule due to limited usage. To bill for enteral formulae, either adult or pediatric, use one of the following HCPCS codes.

HCPCS Code

Description

Maximum Allowable Rate

B4150

Category I: semi-synthetic intact protein/protein isolates

$0.58 per 100 cal.

B4151

Category I: natural intact protein/protein isolates.

1.37 per 100 cal.

B4152

Category II: intact protein/protein isolates (calorically dense)

0.49 per 100 cal.

B4153

Category III: hydrolyzed protein/amino acids

1.66 per 100 cal.

B4154

Category IV: defined formula for special metabolic need

1.07 per 100 cal.

B4155

Category V: modular components

0.83 per 100 cal.

B4156

Category VI: standardized nutrients

1.18 per 100 cal.

To determine the appropriate HCPCS code for a specific product name, refer to the Enteral Nutrition Product Classification List located online at http://www.palmettogba.com.

Providers must bill their usual and customary charges.

Home Infusion Therapy Fee Schedule

Beth Karr, Medical Policy Section
DMA, 919-857-4021


Attention: All Providers

Medical Coverage Policies

The following new or amended medical coverage policies are now available on DMA’s website:

These policies supersede previously published policies and procedures. Providers may contact EDS at 1-800-688-6696 or 919-851-8888 with billing questions.

Darlene Creech, Medical Policy Section
DMA, 919-857-4020


Attention: Durable Medical Equipment Providers

Conversions to National Miscellaneous Codes

The N.C. Medicaid program will not convert to national miscellaneous codes effective with date of service January 1, 2004 as announced in the December 2003 general Medicaid bulletin article titled Conversions to National Miscellaneous Codes. Therefore, DME providers must continue to use the state-created codes listed in that article.

Note: The following codes listed in that article have now been converted to national standard codes effective with date of service January 1, 2004.

Old Code

New Code

Description

Quantity Limitation or Lifetime Expectancy

Maximum Reimbursement Rate

W4113
W4114
W4687

E0240

Bath/shower chair, with or without wheels, any size

3 years

New Purchase:
Used Purchase:

64.11
40.98

W4115

E0247

Transfer bench for tub or toilet with or without commode opening

3 years

New Purchase:
Used Purchase:

91.00
68.25

W4685
W4686

E0248

Transfer bench, heavy duty, for tub or toilet with or without commode opening

3 years

New Purchase:
Used Purchase:

248.08
186.06

For dates of service from January 1, 2004 through February 29, 2004, only those state-created codes listed on the DME Fee Schedule with an asterisk beside them require prior approval. The coverage criteria for those items has not changed. Refer to Medical Coverage Policy #5, Durable Medical Equipment for detailed coverage information.

The following state-created codes will be converted to national miscellaneous codes effective with date of service March 1, 2004.

New HCPCS Code

Old State-Created Code

A9900

W4046
W4120
W4153
W4651
W4670
W4672
W4673
W4678

Disposable electrodes
Disposable bags for Inspirease inhaler system, set of 3
Tracheostomy ties, twill
Blood glucose test strips
Sterile saline, 3cc vial
Gray adapter for use w/ external insulin pump
Piston rod for use w/ external insulin pump
Replacement battery for portable suction pump

B9998

Low profile gastrostomy equipment:

W4210
W4211
W4212

Low profile gastrostomy kit
Low profile gastrostomy extension/replace kit for continuous feed
Low profile gastrostomy extension/replace kit for bolus feed

E1399

Ambulatory devices:

W4688
W4689
W4690
W4691
W4695

Single point cane for weights 251# to 600#
Quad point cane for weights 251# to 600#
Crutches for weights 251# to 600#
Fixed height forearm crutches for weights to 600#
Glides/skis for use w/ walker

Bariatric replacement mattresses for hospital beds:

W4733
W4734
W4735
W4736
W4737

Replacement overszd innerspring matt for hosp bed w/ width to 39"
Replacement overszd innerspring matt for hosp bed w/ width to 48"
Replacement overszd innerspring matt for hosp bed w/ width to 54"
Replacement overszd innerspring matt for hosp bed w/ width to 60"
Trapeze bar, freestanding w/ grab bar for weights 451# to 750#

Bariatric hospital beds:

W4726
W4730
W4731
W4732

Total electric hosp bed weights 351# to 450# w/ matt and side rails
Total elec hosp bed 451# to 1000# w/ width 39"w/ matt & side rails
Total elec hosp bed 451# to 1000# w/ width 48"w/ matt & side rails
Total elec hosp bed 451# to 1000# w/ width 54"w/ matt & side rails

Other equipment:

W4001
W4002
W4016
W4047
W4633

CO/2 saturation monitor w/ accessories, probes
Manual ventilation bag
Bath seat, pediatric
Miscellaneous pediatric equipment
Eggcrate mattress pad

K0009

Manual pediatric wheelchairs:

W4122
W4123
W4124

Pediatric wheelchair, lightweight manual
Pediatric wheelchair, lightweight manual w/ growth system
Pediatric wheelchair, ultra lightweight manual

Manual bariatric wheelchairs:

W4696
W4697

Manual wheelchair for weights 451# to 600#
Manual wheelchair for weights 651# and greater

K0014

Power pediatric wheelchairs:

W4125
W4126

Pediatric wheelchair, power, rigid frame
Pediatric wheelchair, power, folding frame

Power bariatric wheelchairs:

W4704
W4705
W4706

Power wheelchair for weights 251# to 600#
Power wheelchair for weights 651# to 1000#
Power wheelchair for weights 1001# and greater

K0108

 

 

W4117
W4118
W4119
W4128
W4129
W4130
W4131
W4132
W4133
W4134
W4135
W4136
W4137
W4138
W4139
W4140
W4141
W4143
W4144
W4145
W4146
W4147
W4148
W4150
W4151
W4152
W4155

Wheelchair seat width, cost added option from manufacturer
Wheelchair seat depth, cost added option from manufacturer
Wheelchair seat height, cost added option from manufacturer
Solid back equipment with hardware (ea)
Solid seat equipment with hardware (ea)
Contoured or 3-piece head/neck supports with hardware (ea)
Basic head/neck support w/ hardware (ea)
Contoured or 3-piece head/neck supports with adj. hardware (ea)
Basic head/neck support w/ adj. hardware (ea)
Shoulder stabilizers w/ hardware, including pads (pr)
Shoulder stabilizers w/ hardware, including H-strap (ea)
Fixed thoracic supports w/ hardware (pr)
Adjustable thoracic supports w/ hardware (pr)
Hip/thigh supports w/ hardware (pr)
Sub-asis bars w/ hardware (ea)
Abductor pads w/ hardware (pr)
Knee blocks w/ hardware (pr)
Shoe holders w/ hardware (pr)
Foot/legrest cradle (ea)
Manual tilt-in-space option (ea)
Power tilt-in-space option (ea)
Power recline (ea)
Modular back w/ hardware (ea)
Multi-adj. tray (ea)
Specialty controls w/ hardware (ea)
Growth kit (ea)
Abductor pads w/ hardware (pr)

Bariatric wheelchair components:

W4698
W4699
W4700
W4701
W4702
W4703
W4707
W4708
W4709
W4710
W4711
W4712
W4713
W4714
W4715
W4716
W4717
W4718
W4719
W4720
W4721
W4722
W4723

Seat width 21" and 22" for oversized manual wheelchair
Seat width 23" and 24" for oversized manual wheelchair
Seat width 25" and greater for oversized manual wheelchair
Seat depth 19" and 20" for oversized manual wheelchair
Seat depth 21" and 22" for oversized manual wheelchair
Seat depth 23" and greater for oversized manual wheelchair
Seat width 21" and 22" for oversized power wheelchair
Seat width 23" and 24" for oversized power wheelchair
Seat width 25" and greater for oversized power wheelchair
Seat depth 19" and 20" for oversized power wheelchair
Seat depth 21" and 22" for oversized manual wheelchair
Seat depth 23"and greater for oversized power wheelchair
Oversized full support footboard
Swingaway special footrests for weight 401# and greater (pr)
Swingaway reinforced legrest elevating for weight 301# to 400# (pr)
Swingaway footrests, elevating for weight 401# and greater (pr)
Oversized calf pads (pr)
Oversized footplates for weights 301#
Oversized solid seat
Oversized solid back
Oversized 2" cushion
Group 27 Gel cell battery
Oversized full support calfboard

Providers are not required to enter the service review number (SRN) on claim submitted for dates of service from January 1, 2004 through February 29, 2004. Additional instructions regarding prior approval and submitting claims will be published in the general Medicaid bulletin prior to the date of conversion for these codes.

EDS, 1-800-688-6696 or 919-851-8888


Attention: Providers of Services for the Community Alternatives Program for Children

HCPCS Code Change for Pediatric Enteral Formulae

Effective with date of service January 1, 2004, HCPCS code W9934, pediatric enteral formulae, was end-dated and deleted from the CAP/C Fee Schedule due to limited usage. To bill for pediatric enteral formulae, use one of the following HCPCS codes from the CAP/C Fee Schedule with the modifier "BO" to indicate that it is administered orally.

HCPCS Code

Description

Maximum Allowable Rate

B4150 BO

Category I: semi-synthetic intact protein/protein isolates

$0.58 per 100 cal.

B4151 BO

Category I: natural intact protein/protein isolates.

1.37 per 100 cal.

B4152 BO

Category II: intact protein/protein isolates (calorically dense)

0.49 per 100 cal.

B4153 BO

Category III: hydrolyzed protein/amino acids

1.66 per 100 cal.

B4154 BO

Category IV: defined formula for special metabolic need

1.07 per 100 cal.

B4155 BO

Category V: modular components

0.83 per 100 cal.

B4156 BO

Category VI: standardized nutrients

1.18 per 100 cal.

To determine the appropriate HCPCS code for a specific product name, refer to the Enteral Nutrition Product Classification List located online at http://www.palmettogba.com. Providers must bill their usual and customary charges.

Beth Karr, Medical Policy Section
DMA, 919-857-4021


Attention: All Dental Providers

Conversion from CPT to CDT-4 Codes for Dental Services

To assure compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Medicaid program will no longer be able to accept dental claims with Current Procedural Terminology (CPT) codes filed on the American Dental Association (ADA) claim form. Federal regulations recognize only the Current Dental Terminology (CDT) code set published by the ADA as being HIPAA-compliant for dental claims. As a result, Medicaid is making the following changes to the dental program to assure continued coverage for the small percentage of oral health services that typically have been billed as covered CPT codes in any given year.

Changes in Procedure Codes Covered in the Dental Program
Effective with dates of service on or after February 1, 2004, the Medicaid Dental Program will no longer cover CPT codes. Effective with dates of service on or after February 1, 2004, the dental procedure codes listed below will be added to the dental program. An indicator of "R" means that the service is considered routine and does not require prior approval. An indicator of "PA" means that prior approval is needed to allow payment for the service.

CDT-4 Procedure Code

Description

Indicator

Reimbursement Rate

D7412

Excision of benign lesion, complicated

R

$ 230.00

D7413

Excision of malignant lesion up to 1.25 cm

R

182.20

D7414

Excision of malignant lesion greater than 1.25 cm

R

182.20

D7415

Excision of malignant lesion, complicated

R

230.00

D7465

Destruction of lesion(s) by physical or chemical method, by report

R

125.41

D7485

Surgical reduction of osseous tuberosity

R

234.47

D7560

Maxillary sinusotomy for removal of tooth fragment or foreign body

R

243.72

D7840

Condylectomy

R

879.99

D7850

Surgical discectomy, with or without implant

R

849.11

D7858

Joint reconstruction

PA

1,009.57

D7860

Arthrotomy

R

621.89

D7865

Arthroplasty

PA

1,055.64

D7870

Arthrocentesis

R

38.37

D7872

Arthroscopy – diagnosis, with or without biopsy

R

386.27

D7873

Arthroscopy – surgical: lavage and lysis of adhesions

R

434.90

D7940

Osteoplasty – for orthognathic deformities

PA

590.37

D7941

Osteotomy – mandibular rami

PA

1,047.15

D7943

Osteotomy – mandibular rami with bone graft; includes obtaining the graft

PA

1,115.28

D7944

Osteotomy – segmented or subapical – per sextant or quadrant

PA

881.19

D7945

Osteotomy – body of mandible

PA

1,094.72

D7946

LeFort I (maxilla – total)

PA

1,081.11

D7947

LeFort I (maxilla – segmented)

PA

815.20

D7948

LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) – without bone graft

PA

1,409.55

D7949

LeFort II or LeFort III – with bone graft

PA

1,946.33

D7950

Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones – autogenous or nonautogenous, by report

PA

893.38

D7960

Frenulectomy (frenectomy or frenotomy) – separate procedure

PA

149.71

D7972

Surgical reduction of fibrous tuberosity

R

175.37

D7991

Coronoidectomy

R

486.45

New Prior Approval Requirement for Code D7340
With the addition of coverage for code D7960, Medicaid will no longer use code D7340 to cover a labial or buccal frenectomy procedure. Code D7340 will be used exclusively as defined in the CDT-4 manual Vestibuloplasty – ridge extension (secondary epithelialization). As a result, the reimbursement rate has been adjusted (see below), and code D7340 will require prior authorization effective with dates of service on or after February 1, 2004.

Revised Dental Reimbursement Rates
Effective with dates of service on or after February 1, 2004, reimbursement rates for the following dental procedure codes have been revised to be more consistent with rates paid for comparable procedures billed as CPT codes. With the exception of code D7340, the prior approval indicator remains unchanged from that published in current the Dental Policy Manual for the dental codes listed below.

CDT-4 Procedure Code

Description

Indicator

Reimbursement Rate

D0160

Detailed and extensive oral evaluation – problem focused, by report

R

$ 59.40

D0290

Posterior-anterior or lateral skull and facial bone survey film

R

31.43

D0320

Temporomandibular joint arthrogram, including injection

R

39.11

D7260

Oroantral fistula closure

R

398.87

D7286

Biopsy of oral tissue – soft (all others)

R

113.30

D7340

Vestibuloplasty – ridge extension (secondary epithelialization)

PA

548.59

D7350

Vestibuloplasty – ridge extension (including soft tissue grafts)

PA

1,016.32

D7410

Excision of benign lesion up to 1.25 cm

R

169.11

D7450

Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm

R

370.61

D7451

Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25 cm

R

370.61

D7460

Removal of benign nonodontogenic cyst or tumor – lesion diameter up to 1.25 cm

R

370.61

D7461

Removal of benign nonodontogenic cyst or tumor – lesion diameter greater than 1.25 cm

R

370.61

D7510

Incision and drainage of abscess – intraoral soft tissue

EM

152.62

D7520

Incision and drainage of abscess – extraoral soft tissue

EM

289.05

D7540

Removal of reaction producing foreign bodies, musculoskeletal system

EM

179.37

D7550

Partial ostectomy/sequestrectomy for removal of non-vital bone

EM

486.13

D7630

Mandible – open reduction (teeth immobilized, if present)

EM

677.24

D7640

Mandible – closed reduction (teeth immobilized, if present)

EM

388.90

D7680

Facial bones – complicated reduction with fixation and multiple surgical approaches

EM

804.38

D7730

Mandible – open reduction

EM

692.07

D7740

Mandible – closed reduction

EM

442.65

D7750

Malar and/or zygomatic arch – open reduction

EM

901.78

D7780

Facial bones – complicated reduction with fixation and multiple surgical approaches

EM

851.76

D7810

Open reduction of dislocation

EM

675.56

D7820

Closed reduction of dislocation

EM

81.20

D7910

Suture of recent small wounds up to 5 cm

EM

174.94

D7911

Complicated suture – up to 5 cm

EM

271.80

D7912

Complicated suture – greater than 5 cm

EM

337.33

D7920

Skin graft (identify defect covered, location and type of graft)

PA

468.94

D7980

Sialolithotomy

PA

319.17

D7981

Excision of salivary gland, by report

PA

441.43

D7982

Sialodochoplasty

PA

396.28

D7990

Emergency tracheotomy

EM

204.89

D9610

Therapeutic drug injection, by report

R

15.92

D9630

Other drugs and/or medicaments, by report

R

15.92

Revised Medical Coverage Policy for Dental Services
A revised version of Medical Coverage Policy #4A, Dental Services, incorporating the changes described in this article will be available on February 1, 2004, on DMA’s website.

Ronald Venezie, DDS, MS, Dental Advisor
DMA, 919-857-4025


Proposed Medical Coverage Policies

In accordance with Session Law 2003-284, proposed new or amended Medicaid medical coverage policies are available for review and comment on DMA’s website. To submit a comment related to a policy, refer to the instructions on the website. Providers without Internet access can submit written comments to the address listed below.

Darlene Creech
Division of Medical Assistance
Medical Policy Section
2501 Mail Service Center
Raleigh, NC 27699-2501

The initial comment period for each proposed policy is 45 days. An additional 15-day comment period will follow if a proposed policy is revised as a result of the initial comment period.


Holiday Observance

The Division of Medical Assistance and EDS will be closed on Thursday, January 1, 2004 in observance of New Year’s Day, and on Monday, January 19, 2004 in observance of Dr. Martin Luther King’s birthday.


Checkwrite Schedule

December 9, 2003

January 13, 2004

February 3, 2004

December 15, 2003

January 22, 2004

February 10, 2004

December 29, 2003

January 27, 2004

February 17, 2004

 

Electronic Cut-Off Schedule

December 5, 2003

January 9, 2004

January 30, 2004

December 12, 2003

January 16, 2004

February 6, 2004

December 19, 2003

January 23, 2004

February 13, 2004

Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite. Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.

2004 Checkwrite Schedule


 

_____________________
 
_____________________
Gary M. Fuquay, Acting Director
 
Patricia MacTaggart
Division of Medical Assitance
 
Executive Director
Department of Health and Human Services
 
EDS

 

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