January 2007 Medicaid Bulletin

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In This Issue…

*See Revised Article

All Providers:

Children’s Developmental Service Agencies:

Dental Providers:

Durable Medical Equipment:

Federally Qualified Health Centers (FQHC's):

Health Departments:

Health Departments Dental Centers:

Home Health Agencies:

Independent Practitioners:

Local Management Entities:

Nurse Practitioners:

Outpatient Hospital Clinics:

Orthotic and Prosthetic Providers:

Personal Care Service and Personal Care Service–Plus Providers:

Physicians:

Rural Health Centers (RHC's):


Attention: Orthotic and Prosthetic Providers

Billing (Supplier) and Attending (Fitting) (NPI) National Provider Identification Information

When applying for a National Provider Identification (NPI) number, orthotic and prosthetic providers should note that the Centers for Medicare and Medicaid Services (CMS) requests different information from individual providers and organizations.  Providers should go to the CMS Web site at https://nppes.cms.hhs.gov for clarification of the rules regarding their NPIs.

The N.C. Medicaid NPI web page contains links to important information regarding NP  Included in these references is how individuals’ and organizations’ NPIs will be collected by N.C. Medicaid.

The CMS NPI fact sheet gives further clarification of who should apply for an NPI and other important information.

NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!

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



Attention: All Providers

National Provider Identifier (NPI) Seminar

National Provider Identifier (NPI) seminars are being held during the month of January 2007.  Seminars are intended for providers that would like more detailed information on how N.C. Medicaid will be implementing NPI. Please go to DMA's NPI web page to access the agenda to see specific topics that will be discussed.

The seminars are scheduled at the locations listed below.  Pre-registration is required.  Due to limited seating, registration is limited to two staff members per office.  Unregistered providers are welcome to attend if space is available.

Providers may register for the NPI seminars by completing and submitting the registration form online.  If you are planning on attending the Raleigh location that has two sessions, please indicate the session you plan to attend on the registration form.

Morning sessions of the seminars will begin at 9:30 a.m. and end at 11:30 a.m.  Providers are encouraged to arrive by 9:15 a.m. to complete registration. Afternoon sessions will begin at 1:30 p.m. and end at 3:30 p.m.  Providers are encouraged to arrive by 1:15 to complete registration.

Providers may access the Special December 2006 Bulletin, New Claim Form Instructions on DMA's website. Providers should contact EDS with any billing questions.

Providers must print the PDF version of the Special December 2006 Bulletin, New Claim Form Instructions and bring it to the seminar.

Monday, Jan. 8, 2007
Jane S. McKimmon Center
1101 Gorman St.
Raleigh, NC  27606

Tuesday, Jan. 9, 2007
Coastline Convention Center
501 Nutt St.
Wilmington, NC 28401

Tuesday, Jan. 16, 2007
Matthews Community Center
100 McDowell St. E.
Matthews, NC 28105

Wednesday, Jan. 24, 2007
Crown Plaza Hotel and Resort
One Holiday Inn Drive
Asheville, NC 28806

NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!


Attention:  All Providers

National Provider Identifier (NPI) Collection Form Now Available in Spreadsheet Format

N.C. Medicaid is actively collecting NPI numbers from providers.  Providers are required to report NPI numbers to Medicaid no later than March 31, 2007.  To accommodate organizations with large numbers of providers, an NPI spreadsheet is now available on the DMA Web site.  The spreadsheet can be completed for both group and individual provider numbers.  Required fields for the spreadsheet are similar to the NPI Collection Form.  Blocks A through L on the spreadsheet must be completed.

Printed Name/Title/Date, Phone Number, Fax Number and Email Address — List the person completing this information and the contact information for questions.

A. Group (G)/Individual (I) — You may submit both group and individual information on the same spreadsheet. Enter the group information first by putting a “G” in column A.  The indicator G is for the Group NPI.  Next, enter an “I” for each individual in the group.  Please complete a separate line to report the NPI for each Medicaid Provider Number.

B. Carolina ACCESS Provider — Place a “Y” or “N” in column B for each Medicaid Provider Number to indicate whether the group or the individual is a Carolina ACCESS provider.

C. Medicaid Provider Number — Enter the seven- or eight-digit numeric or alphanumeric Medicaid Provider Number.  Please check the most recent remittance advice (RA) to make sure the provider number is accurately recorded.  Complete a separate line to report the NPI for each Medicaid Provider Number.

D. National Provider Number (NPI) — Enter the 10-digit number assigned by NPPES for each Medicaid Provider Number.  In addition to submitting the spreadsheet, providers must submit a copy of their NPPES certification letter for each NPI reported.  If you do not submit this letter, your NPI will not be accepted.  If you need to apply for an NPI, go to https://nppes.cms.hhs.gov/NPPES/Welcome.do and click on the link to National Provider Identifier. Follow the instructions for applying.

If you need a copy of your NPPES Certification letter, contact the NPI Enumerator at 1-800-465-3203, or go to https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do to have another NPI notification generated.  If the provider was enumerated via EFI, the health care provider must contact the EFI organization (EFIO) for a copy of the EFIO’s notification.  Notifications generated by the NPPES are created in the same manner in which they were originally issued (i.e., NPI notification letter for paper applicants or an e-mail notification for Web-based applicants).

E. Taxonomy — Enter the 10 digit code ending in X.  You may submit up to 15 taxonomies.  If you need to report additional taxonomy codes, please complete the “Additional Taxonomy Form”.  For a listing of taxonomy codes, go to http://www.wpc-edi.com/taxonomy.  You will need this taxonomy information when applying for an NPI.

F. Organization/Individual Name

o Organization Name — The name of the group or business.  Please check the most recent RA to verify how your organization is listed in our provider system.  If the name on the spreadsheet does not match the name listed in the provider system, the updates will not be made.

o Individual Name — The name of the provider as listed in our system or on the NPPES certification. If the name on the spreadsheet does not match the name listed in the provider system the updates will not be made.

G-L. Physical/Accounting Address — Must be completed even if the addresses are the same.

o Physical Address —  The location where services are performed or care is coordinated. Please be sure to include the ZIP Code+4 number.

o Accounting Address — The address where payments, remittance advices and correspondence are sent. Please be sure to include the ZIP Code+4 number. Please check the most recent RA to determine the accounting address listed in our provider system. If the accounting address is the same as the physical address, please indicate “SAME” in this block.

NOTE: If the address on this spreadsheet does not match what is currently in our provider system, we will automatically update our records with the address provided on the NPI spreadsheet. For reporting changes other than address, complete the Provider Change Form.

Upon completion, choose one of the options below to send the spreadsheet to DMA:

Please Mail to:
DMA Provider Services
Attention:  NPI Form
2501 Mail Service Center
Raleigh, NC  27699-2501

Please Fax to:
(919) 715-7140

Please E-mail to:
npi.dma@ncmail.net

NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!

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



Attention: All Providers

March 2007 National Provider Identifier (NPI) Seminars

Informational seminars regarding National Provider Identifier (NPI) are scheduled for March 2007.   Registration information and a complete list of dates and site locations for the seminars will be published in the February 2007 general Medicaid bulletin and published on DMA’s NPI web page.

NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!

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


Attention: All Providers

Required Fields on New Provider Enrollment Applications and Provider Change Form

Effective Jan. 1, 2007, to facilitate National Provider Identifier (NPI) implementation, the Division of Medical Assistance (DMA) will no longer accept enrollment applications or change forms without the following information:

Federally mandated requirements for NPI implementation is May 23, 2007.  This information is required.  If this information is not provided, your new application or change forms will be returned.

If you have not enumerated, please check DMA's NPI web page for information or enumerate at NPI at https://nppes.cms.hhs.gov/NPPES/Welcome.do

NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!

Providers Services
DMA, 919-855-4050


Attention:  All Providers

Submitting Both National Provider Identifier (NPI) and Provider Number on Claims

N.C. Medicaid would like to encourage providers to begin submitting both the National Provider Identifier (NPI) and the Medicaid provider number on electronic claims no later than Jan. 1, 2007. If your software is not updated to submit the NPI number, please contact your clearinghouse or software vendor as soon as possible to obtain the appropriate updates. Please ensure that you keep the capability to submit the Medicaid provider number along with the NPI. N.C. Medicaid will continue to process claims using the Medicaid provider number until NPI is implemented in May 2007.

The NCECS Webtool already contains a field for submitting the NPI, so providers can begin to populate that field. For providers who bill on paper, the new paper claim forms will be available in 2007. We plan to begin testing changes to the MMIS in January 2007, and at that time we will need both the NPI and Medicaid provider numbers.

NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!

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


Attention:  All Providers

Updated National Provider Identifier (NPI) Collection Forms

The Division of Medical Assistance (DMA) is currently collecting National Provider Identifier (NPI) numbers from Medicaid providers. Health care providers are required to complete one NPI collection form for each Medicaid provider number to ensure that North Carolina Medicaid captures the NPIs, which will be used for claims processing. There are now two different collection forms on the DMA Web site: one for individual provider numbers and one for group provider numbers. Providers who have obtained an organizational or group NPI must complete an NPI collection form for the group provider number. In addition, an individual NPI collection form must be completed for each individual provider number within the group.

The required fields for completing the NPI collection form are: Medicaid Provider Number, NPI, Physical and Billing address including Zip+4 and taxonomy code(s). If more than three taxonomy codes need to be linked to one NPI number, an additional taxonomy page has been provided on the Web site. Providers can link up to 15 taxonomies to one NPI. Also, providers need to include a copy of the notification letter from the National Plan and Provider Enumeration System (NPPES). The address information provided will overlay the information currently in the system. Any other change request will require a separate change request form

The collection forms and instructions are located on DMA's NPI web page. Forms must be typed and returned no later than March 15, 2007. The form can be returned by the mail, fax or e-mail addresses listed on the form. Providers will receive a confirmation notice once the NPIs have been added.

NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!

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


Attention: All Providers

Corrected 2007 Checkwrite Schedule

This article from the December General Medicaid bulletin is being re-run with corrections. Corrections have also been made to the Checkwrite schedule.

Beginning February 2007, the cutoff day for electronic claims submission will change from Friday to Thursday due to anticipated increased processing time for the National Provider Identifier (NPI) implementation. It is important that you make any required system changes to accommodate this cutoff day.  The following is the 2007 checkwrite schedule:

Month

Electronic Cut-Off Checkwrite Date

January

01/05/07

01/09/07

 

01/12/07

01/17/07

 

01/19/07

01/25/07

     

February

02/02/07

02/06/07

 

02/08/07

02/13/07

 

02/15/07

02/20/07

 

02/22/07

02/28/07

     

March

03/01/07

03/06/07

 

03/08/07

03/13/07

 

03/15/07

03/20/07

 

03/22/07

03/29/07

     

April

04/05/07

04/10/07

 

04/12/07

04/17/07

 

04/19/07

04/26/07

     

May

05/03/07

05/08/07

 

05/10/07

05/15/07

 

05/17/07

05/22/07

 

05/24/07

05/31/07

     

June

05/31/07

06/05/07

 

06/07/07

06/12/07

 

06/14/07

06/21/07

July

06/28/07

07/03/07

 

07/05/07

07/10/07

 

07/12/07

07/17/07

 

07/19/07

07/26/07

     

August

08/02/07

08/07/07

 

08/09/07

08/14/07

 

08/16/07

08/23/07

     

September

08/30/07

09/05/07

 

09/06/07

09/11/07

 

09/13/07

09/18/07

 

09/20/07

09/27/07

     

October

10/04/07

10/09/07

 

10/11/07

10/16/07

 

10/18/07

10/23/07

 

10/25/07

10/31/07

     

November

11/01/07

11/06/07

 

11/08/07

11/14/07

 

11/15/07

11/21/07

     

December

11/29/07

12/04/07

 

12/06/07

12/11/07

 

12/13/06

12/20/07

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


Attention:  All Providers

Clinical Coverage Policies

The following new or amended clinical coverage policies are now available on the Division of Medical Assistance'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.

Clinical Policy
DMA, 919-855-4260


Attention:  All Providers

CPT Code Update 2007

Effective with date of service Jan. 1, 2007, the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) have added some new CPT codes, deleted others and changed the descriptions of some existing codes. (For complete information regarding all CPT codes and descriptions, refer to the 2007 edition of Current Procedural Terminology, published by the American Medical Association.) New CPT codes are covered by the N.C. Medicaid Program effective with date of service Jan. 1, 2007. Claims submitted with deleted codes will be denied for dates of service on or after Jan. 1, 2007. Previous policy restrictions continue in effect unless otherwise noted.

New Covered CPT Codes

00625

00626

15002

15003

15004

15005

15731

15830

15847

17311

17312

17313

17314

17315

19300

19301

19302

19303

19304

19305

19306

19307

22865

25109

25606

25607

25608

25609

27325

27326

28055

33202

33203

33254

33255

33256

33265

33266

33675

33676

33677

33724

33726

35302

35303

35304

35305

35306

35537

35538

35539

35540

35637

35638

35883

35884

37210

44157

44158

47719

48105

48548

49324

49325

49326

49402

49435

49436

54865

55875

56422

57296

57558

58541

58542

58543

58544

58548

58957

58958

67346

72291

72292

76776

76813

76814

76998

77001

77002

77003

77011

77012

77013

77014

77021

77022

77031

77032

77051

77052

77053

77054

77055

77056

77057

77058

77059

77072

77073

77074

77075

77076

77077

77078

77079

77080

77081

77082

77083

77084

77371

77372

77373

77435

82107

83913

86788

86789

87305

87498

87640

87641

87653

87808

88576

92025

92640

94002

94003

94004

94610

94644

94645

94777

           

 

End-Dated CPT Codes

01995

15000

15001

15831

17304

17305

17306

17307

17310

19140

19160

19162

19180

19182

19200

19220

19240

21300

25611

25620

26504

27315

27320

28030

31700

31708

31710

33200

33201

33245

33246

33253

35381

35507

35541

35546

35641

44152

44153

47716

48005

48180

49085

54152

54820

55859

56720

57820

67350

75998

76003

76005

76006

76012

76013

76020

76040

76061

76062

76065

76066

76070

76071

76075

76076

76077

76078

76082

76083

76086

76088

76090

76091

76092

76093

76094

76095

76096

76355

76360

76362

76370

76393

76394

76400

76778

76986

78704

78715

78760

91060

92573

94656

94657

95078

         

 

New CPT Codes Not Covered Pending Further Review

22526

22527

22857

22862

32998

92640

 

New CPT Codes Not Covered

19105

43647

43648

43881

43882

64910

64911

70554

70555

77071

83698

91111

94005

94774

94775

94776

95012

96020

96040

96904

99364

99636

               

Billing Information

CPT CODE

BILLING INFORMATION

DIAGNOSIS EDITING

PRIOR APPROVAL

15847

N/A

N/A

Prior approval is required and allowed for the following criteria:

  • Medically necessary to provide additional abdominal support.

15731

N/A

N/A

Prior approval is required and allowed for the following criteria:

  • Medically necessary to improve/restore/correct significant deformity resulting from trauma or cancer .
  • Not for cosmetic reasons.

22865

N/A

N/A

Prior approval is required and allowed for the following criteria:

  • Medical necessity based on complications directly related to the artificial disc.

33675 33676 33677

N/A

Allowed with one of the following primary diagnoses: 

745.5, 747.0

N/A

37210

N/A

Allowed with one of the following primary diagnoses: 

218.0, 218.1, 218.2, 218.9

N/A

57296

N/A

N/A

Prior approval is required and allowed for the following criteria:

  • Medical documentation substantiates that the congenital anomaly and/or ambiguous genitalia was present prior to the age of two.
  • Medical documentation substantiates that the development of pronounced secondary sex characteristics occurred during puberty.
  • Medical documentation substantiates that certain conditions are due to pelvic malignancies, such as repair of vaginal vault prolapse, treatment of female genitourinary disease, and/or treatment of malignant cancers.

67346

  • For a single muscle biopsy, one eye, bill 67346 for one unit.
  • For a single muscle biopsy, both eyes, bill 67346 with modifier 50 for one unit.
  • For two biopsies, left eye, bill 67346, modifier LT, two units.
  • For two biopsies, right eye, bill 67346, modifier RT, two units.
   

72291

72292

Must be billed as a professional component with modifier 26.

N/A

N/A

77371 77372 77373 77435

Refer to April 2005 Medicaid Bulletin for instructions on billing a radiation treatment delivery code.

Allowed with one of the following diagnoses:

191.0 through 191.9, 192.1, 192.2, 192.3, 194.3, 198.3, 198.4, 225.0, 225.1, 225.2, 225.3, 225.4, 225.8, 225.9, 227.3, 237.0, 237.5, 237.6, 237.70 through 237.72, 239.6, 239.7, 350.1, 377.51 through 377.54, 742.9, 747.81, 747.82, 747.89

N/A

92025

  • The description includes “unilateral or bilateral,” therefore limited to one unit.
  • Not covered for routine follow-up scans.
  • Routine scans of an uninvolved eye are not covered.
  • Repeat testing is indicated only if a change of vision is reported in connection with the allowable diagnosis code(s).

Allowed with one of the following diagnoses:

V42.5, 370.00 through 370.07, 371.00, 371.23, 371.50 through 371.58, 371.60 through 371.62, 372.40 through 372.45, 372.52, 996.51

N/A


Ambulatory Surgery Centers (ASCs)

New CPT Codes Covered for ASCs (effective with date of service Jan. 1, 2007)

Code

ASC Payment Group

Code

ASC Payment Group

Code

ASC Payment Group

Code

ASC Payment Group

15002

2

15003

1

15004

2

15005

1

15731

3

15847

3

19300

4

19301

3

19302

7

19303

4

19304

4

25606

3

25607

5

25608

5

25609

5

27325

2

27326

2

49402

2

54865

1

55875

9

56442

1

57558

3

67346

2

 

 

CPT Codes End-Dated for ASCs (effective with date of service Dec. 31, 2006)

15000

15001

19140

19160

19162

19180

19182

25611

25620

26504

27315

27320

49085

54800

56720

57820

 

Additional information will be published in future general Medicaid bulletins as necessary.

Clinical Policy and Programs
DMA, 919-855-4260



Attention:  All Providers

Corrected CPT Codes 90467, 90468, 90473 and 90474 - Coverage of Immunization Administration Codes for Oral/Intranasal Vaccines

Effective with date of service Aug. 1, 2006, the N.C. Medicaid program covers CPT codes for the intranasal and oral administration of vaccines/toxoids.  Their code descriptors are as follows:

90467 — Immunization administration under 8 years of age (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid) per day. (For N.C. Medicaid, do not report in addition to 90465.)

90468 — Each additional administration (single or combination vaccine/toxoid) per day (list separately in addition to code for primary procedure). (For N.C. Medicaid, use 90468 in conjunction with 90465.)

90473 — Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid). (For N.C. Medicaid, do not report in addition to 90471.)

90474 — Each additional vaccine (single or combination vaccine/toxoid). (List separately in addition to code for primary procedure.) (For N.C. Medicaid, use 90474 in conjunction with 90471.)

The current codes used for immunization administration and their descriptors are as follows:

90465 — Immunization administration under 8 years of age (includes percutaneous, intradermal, subcutaneous or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid) per day. (For N.C. Medicaid, do not report 90465 in conjunction with 90467.)

90466 — Immunization administration under 8 years of age (includes percutaneous, intradermal, subcutaneous or intramuscular injections) when the physician counsels the patient/family; each additional injection (single or combination vaccine/toxoid) per day. (List separately in addition to code for primary procedure.) (For N.C. Medicaid, use in conjunction with 90465 or 90467.)

90471 — Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections); one vaccine (single or combination vaccine/toxoid). (For N.C. Medicaid, do not report 90471 in conjunction with 90473.)

90472 — Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections); one vaccine (single or combination vaccine/toxoid) each additional vaccine (single or combination vaccine/toxoid). (List separately in addition to code for primary procedure.) (For N.C. Medicaid, use 90472 in conjunction with 90471.)

The following principles should guide the billing of the eight codes described above:

1.                  Apply the appropriate code depending on the age of the recipient and whether or not the physician has counseled the recipient and family.

2.                  CPT codes 90465 and 90466 are in the same code family, and 90471 and 90472 are in the same code family.  A code from one injectable code family cannot be used with a code from another injectable code family.

3.                  CPT codes 90467 and 90468 are in one code family, and 90473 and 90474 are in another code family. A code from one intranasal/oral code family cannot be used with a code from the other intranasal/oral code family.

4.                  The physician counseling codes should not be used as an “add-on” counseling code to the other administration codes.

5.                  Physicians, nurse practitioners and physician assistants may perform these services.

6.                  When billing 90465, 90466, 90467 or 90468, the physician, nurse practitioner or physician assistant must perform face-to-face vaccine counseling associated with the administration and should document such.  The physician, nurse practitioner or physician assistant is not required to administer the vaccine.

7.                  A “first” administration is defined as the first vaccine administered to a recipient during a single patient encounter.

8.                  At the present time, there should not be an occasion to bill a second intranasal/oral vaccine administration code.

9.                  When billing one or more injectable vaccines along with one oral/intranasal vaccine, the code for the first injectable vaccine is the primary code.

Vaccine:  Injectable
Provider Type:  FQHC/RHC

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one vaccine, bill 90465EP.

For two vaccines or more, bill 90465EP and 90466EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

For one vaccine, bill 90471EP.

For two vaccines or more, bill 90471EP and 90472EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one vaccine, bill 90465EP.

For two vaccines or more, bill 90465EP and 90466EP.

Report CPT vaccine code(s).

One immunization diagnosis code is required.

For one vaccine, bill 90471EP.

For two vaccines or more, bill 90471EP and 90472EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

N/A

N/A

Core Visit with Immunization(s)

Cannot bill 90465EP or 90466EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) are not required.

Cannot bill 90471EP or 90472EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) are not required.

 

Vaccine:  Injectable
Provider Type:  Local Health Departments

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

Cannot bill 90465EP.

Report vaccine CPT code(s).

Immunization diagnosis code(s) not required.

Cannot bill 90471EP.

Report vaccine CPT code(s).

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one vaccine, bill 90465EP.

For two vaccines or more, bill 90465EP.

Report CPT vaccine code(s).

One immunization diagnosis code is required.

For one vaccine, bill 90471EP.

For two vaccines or more, bill 90471EP.

Report CPT vaccine code(s).

One immunization diagnosis code is required.

Office Visit with Immunization(s)

For one vaccine, bill 90465EP.

For two or more vaccines, bill 90465EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

For one vaccine, bill 90471EP.

For two or more vaccines, bill 90471EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Core Visit with Immunization(s)

N/A

N/A

 

Vaccine:  Intranasal/Oral
Provider Type:  Private Sector Providers

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is not required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is not required.

Immunization(s) Only

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is required.

Office Visit with Immunization(s)

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is not required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is not required.

Core Visit with Immunization(s)

N/A

N/A

 

Vaccine:  Intranasal/Oral
Provider Type:  FQHC/RHC

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is not required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is not required.

Immunization(s) Only

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is required.

Office Visit with Immunization(s)

N/A

N/A

Core Visit with Immunization(s)

Cannot bill 90467EP.

Report vaccine CPT code.

Immunization diagnosis code is not required.

Cannot bill 90473EP.

Report vaccine CPT code.

Immunization diagnosis code is not required.

 

Vaccine:  Intranasal/Oral
Provider Type:  Local Health Departments

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

Cannot bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A.

Immunization diagnosis code is not required.

Cannot bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A.

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is required.

Office Visit with Immunization(s)

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code not required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code not required.

Core Visit With Immunization(s)

N/A

N/A


Vaccine:  Injectable with Intranasal/Oral
Provider Type:  Private Sector Providers

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report CPT vaccine code(s)

Immunization diagnosis code(s) not required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Core Visit With Immunization(s)

N/A

N/A


Vaccine:  Injectable with Intranasal/Oral
Provider Type:  FQHC/RHC

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report vaccine CPT codes.

Immunization diagnosis code(s) not required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report vaccine CPT codes.

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report vaccine CPT codes.

One immunization diagnosis code is required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report vaccine CPT codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

N/A

N/A

Core Visit with Immunization(s)

Cannot bill 90465EP, 90466EP or 90468EP.

Report vaccine CPT codes.

Immunization diagnosis code(s) are not required.

Cannot bill 90471EP, 90472EP or 90474EP.

Report vaccine CPT codes.

Immunization diagnosis code(s) are not required.


Vaccine:  Injectable with Intranasal/Oral
Provider Type:  Local Health Departments

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

Cannot bill 90465EP and 90468EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Cannot bill 90471EP and 90474EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Core Visit with Immunization(s)

N/A

N/A

Billing Guidelines for Immunization Codes for Recipients Aged 21 and Above

Vaccine:  Injectable
Provider Type:  Private Sector Providers

Service Type

Number of Vaccines

 

One

Two or More

Immunization(s) Only

Bill 90471 administration code

Bill vaccine CPT code.

Report diagnosis code as appropriate.

Bill 90471 and 90472

Bill CPT vaccine codes.

Report diagnosis codes as appropriate.

Office Visit with Immunization(s)

Bill 90471 administration code or E/M code. May bill E/M code with modifier 25 appended in addition to 90471 if a separately identifiable service was performed.

Bill vaccine CPT code.

Bill 90471 and 90472. May bill E/M code with modifier 25 appended in addition to 90471 and 90472 if a separately identifiable service was performed.

Bill CPT vaccine codes.

 

Vaccine:  Injectable
Provider Type:  FQHCs and RHCs

Service Type

Number of Vaccines

 

One

Two or More

Immunization(s) Only

Bill under the C suffix .

Bill 90471 administration code.                                      

Report the vaccine CPT code if vaccine was provided at no charge from the state of North Carolina.    

OR

Bill the vaccine CPT code if vaccine was purchased.

Report diagnosis code as appropriate.

Bill under the C suffix.

Bill 90471 and 90472 administration codes.

Report the vaccine CPT codes if vaccines were provided at no charge from the state of North Carolina.

OR

Bill the CPT vaccine codes if the vaccines were purchased.

Report diagnosis codes as appropriate.

Core Visit with Immunization(s)

Immunization administration fees cannot be billed with core visits.

Immunization administration fees cannot be billed with core visits.

 

Vaccine:  Injectable               Provider Type:  Local Health Departments

Service Type

Number of Vaccines

 

One

Two or More

Immunization(s) Only

Bill 90471 administration code.

Bill vaccine CPT code.

Report diagnosis code as appropriate.

Bill 90471 and 90472.

Bill CPT vaccine codes.

Report diagnosis codes as appropriate.

Office Visit with Immunization(s)

Bill 90471 administration code or E/M code. May bill E/M code with modifier 25 appended in addition to the administration code if a separately identifiable service was performed.

Bill vaccine CPT code.

Bill 90471 and 90472. May bill E/M code with modifier 25 appended in addition to 90471 and 90472 if a separately identifiable service was performed.                                                                           

Bill vaccine CPT codes.

Currently, providers cannot bill for an intranasal or oral vaccine alone or in addition to an injectable vaccine for recipients 21 years of age and older.

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



Attention:  All Providers

HCPCS Procedure Code Changes for the Physician’s Drug Program

The following HCPCS procedure code changes have been made to comply with the Centers for Medicare and Medicaid Services (CMS) HCPCS procedure code changes.

End-Dated Codes with No Replacement Codes

Effective with date of service December 31, 2006, the following HCPCS procedure code was end-dated. Claims submitted for dates of service on or after January 1, 2007, using the end-dated code will be denied.

End-Dated HCPCS Code

Description

Unit

J9212

Injection, sodium chloride, 0.9%

Per 2 ml

New HCPCS Codes

The following HCPCS procedure codes were added to the list of covered codes for the Physician’s Drug Program effective with date of service January 1, 2007.

New HCPCS Code

Description

Unit

Maximum Reimbursement Rate

J1562

Immune globulin, subcutaneous

100 mg

$13.50

J3473

Hyaluronidase, recombinant

1 USP unit

$0.40

End-Dated Codes with Replacement Codes

The following HCPCS procedure codes were end-dated with date of service December 31, 2006, and replaced with a new code effective with date of service January 1, 2007. Claims submitted for dates of service on or after January 1, 2007, using the end-dated codes will be denied.

End-Dated HCPCS Code

Description

Unit

New HCPCS Code

Description

Unit

Max. Reimb. Rate

J7317

Sodium hyaluronate

20–25 mg

J7319

Hyaluronan (sodium hyaluronate) or derivative, intra-articular injection

Per injection

$130.50

J7320

Hylan G-F 20, for intra-articular injection

16 mg


New Codes That Were Previously Billed with the Miscellaneous Drug Codes J3490 and J3590

Effective with date of service January 1, 2007, the N.C. Medicaid program covers the individual HCPCS procedure codes for the drugs listed in the following table.  Claims submitted for dates of service on or after January 1, 2007, using the unlisted drug codes J3490 or J3590 for these drugs will be denied.  An invoice is not required.

Old HCPCS Code

Description

Unit

New HCPCS Code

Description

Unit

Max. Reimb. Rate

J3490

Etonogestrel contraceptive implant system (Implanon)

 

S0180

Etonogestrel contraceptive implant system, including implants and supplies (Implanon)*

each

$588.38

J3490

Ibandronate sodium (Boniva)

3 mg

J1740

Ibandronate sodium (Boniva)

1 mg

$138.85

J3590

Abatacept (Orencia)

250 mg

J0129

Abatacept (Orencia )

10 mg

$18.70

*For Implanon, please append the FP modifier to the new HCPCS procedure code S0180.

Radiopharmaceuticals—New Codes with and without Replacement Codes

Old

New

HCPCS Code

Description

Unit

HCPCS Code

Description

Unit

Max. Reimb. Rate

N/A

A9527

Iodine I-125, sodium iodide solution, therapeutic

Per mCi

Per Invoice

A9549

Technetium TC-99M arcitumomab, diagnostic per study dose

Up to 25 mCi

A9568

Technetium TC-99M arcitumomab, diagnostic per study dose

Up to 45 mCi

Per Invoice

Note:  Providers must attach the original invoice or copy of the original invoice to the claim form when billing for the two radiopharmaceuticals indicated above. 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 agent, the dosage administered, and the cost per dose. Claims submitted without this information on the invoice will be denied. Reimbursement is based on the actual invoice price of the agent only (less the shipping and handling).

Providers are reminded to bill their usual and customary charges.

EDS, 1-800-688-6696 or 919-851-8888  



 Attention: All Providers

New Claim Form Instructions Special Bulletin

The CMS 1500 (12/90), the UB92 and the American Dental Association (ADA) 2002 paper forms have been revised and will be replaced with the new CMS 1500 (08/05), the UB-04 and ADA 2006 claim forms, respectively.

Providers may access the Special December 2006 Bulletin, New Claim Form Instructions, from DMA's website. Providers should contact EDS with any billing questions.

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



Attention:  Children’s Developmental Service Agencies, Home Health Agencies, Outpatient Hospital Clinics, Independent Practitioners, Health Departments, Local Management Entities, and Physicians

Prior Authorization for Outpatient Specialized Therapies—Web Site Registration

As announced in the December 2006 bulletin, providers will have the option to submit prior authorization (PA) requests electronically beginning Feb. 5, 2007.  To do so, providers must first register their provider numbers with the Carolinas Center for Medical Excellence (CCME) and obtain log-on information. Registered users will have Web site access, which offers more details about electronically submitting PAs as well as training videos demonstrating the submission process.

The registration process is as follows:

1)                  The facility’s designated provider administrator (maximum of two per provider number) must complete the two-page Provider Registration Form Prior Authorization for Outpatient Specialized Therapies—Web Site Registration and fax or mail it to CCME.

2)                  CCME will validate the submitted provider information and issue a provider PIN, user ID and user password.

3)                  Log-on information will be returned to the provider via regular mail to maintain security.

4)                  Provider administrators who have received the Web site log-on information can register users in their facility.

5)                  All users at the same facility will have the same provider number and PIN for log-on; individual users will have their own user IDs and passwords.

CCME, 1-800-682-2650


Attention: Durable Medical Equipment Providers

2007 HCPCS Code Changes: Discontinued Codes, Description Changes and Code Additions for Durable Medical Equipment

Effective with date of service December 31, 2006, in order to comply with the Centers for Medicare and Medicaid Services (CMS) HCPCS coding changes, the following codes were end-dated and removed from the DME fee schedule:

E0164

E0166

E0180

E2320

K0090

K0091

K0092

K0093

K0094

K0095

K0096

K0097

K0098

W4704

W4705

W4706

K0010

K0011

Effective with date of service January 1, 2007, the following code description changes were made:

Code

New Description

E0163

Commode chair, mobile or stationary, with fixed arms

E0165

Commode chair, mobile or stationary, with detachable arms

E0167

Pail or pan for use with commode chair, replacement only

E0181

Powered pressure-reducing mattress overlay/pad, alternating, with pump, includes heavy duty

E0182

Pump for alternating pressure pad, for replacement only

E0720

Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation

E0730

Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, multiple nerve stimulation

E0967

Manual wheelchair accessory, hand rim with projections, any type, each

E2209

Arm trough, with or without hand support, each

Effective with date of service January 1, 2007, the following codes were added to the DME fee schedule:

New Code

Description

Lifetime Expectancy/Quantity Limitations

E2373*

Power wheelchair accessory, hand or chin control interface, mini-proportional, compact, or short throw remote joystick or touchpad, proportional, including all related electronics and fixed mounting hardware

4 yrs/ 2yrs 00 thru 20

E2374*

Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only

4 yrs/ 2yrs 00 thru 20

E2375*

Power wheelchair accessory, non-expandable controller, including all related electronics and mounting hardware, replacement only

4 yrs/ 2yrs 00 thru 20

E2376*

Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only

4 yrs/ 2yrs 00 thru 20

E2377*

Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue

4 yrs/ 2yrs 00 thru 20

E2381

Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each

1 year

E2382

Power wheelchair accessory, tube for pneumatic drive tire, any size replacement only, each

1 year

E2383

Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each

1 year

E2384

Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each

1 year

E2385

Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each

1 year

E2386

Power wheelchair accessory, foam-filled drive wheel tire, any size, replacement only, each

1 year

E2387

Power wheelchair accessory, foam-filled caster tire, any size, replacement only, each

1 year

E2388

Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each

1 year

E2389

Power wheelchair accessory, foam caster tire, any size, replacement only, each

1 year

E2390

Power wheelchair accessory, solid (rubber/plastic}drive wheel tire, any size, replacement only, each

1 year

E2391

Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

1 year

E2392

Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

1 year

E2393

Power wheelchair accessory, valve for pneumatic tire tube, any type, replacement only, each

1 year

E2394

Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each

1 year

E2395

Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

1 year

E2396

Power wheelchair accessory, caster fork, any size, replacement only, each

1 year

K0733*

Power wheelchair accessory, 12 to 24 AMP hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

1 year

K0813*

Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds

4 years

K0814*

Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0815*

Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds

4 years

K0816*

Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0820*

Power wheelchair, group 2, standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0821*

Power wheelchair, group 2 standard, portable, captain’s chair, patient weight capacity up to and including 300 pounds

4 years

K0822*

Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0823*

Power wheelchair, group 2 standard, captains seat, patient weight capacity up to and including 300 pounds

4 years

K0824*

Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0825*

Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 301 to 450 pounds

4 years

K0826*

Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds

4 years

K0827*

Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds

4 years

K0828*

Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more

4 years

K0829*

Power wheelchair, group 2 extra heavy duty, captains chair, patient weight capacity 601 pounds or more

4 years

K0830*

Power wheelchair, group 2, seat elevator, sling/solid seat/back, patient capacity up to and including 300 pounds

4 years

K0831*

Power wheelchair, group 2, seat elevator, captains chair, patient capacity up to and including 300 pounds

4 years

K0835*

Power wheelchair, group 2 standard, single power option, sling/solid seat back, patient weight capacity up to and including 300 pounds

4 years

K0836*

Power wheelchair, group 2 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0837*

Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0838*

Power wheelchair, group 2 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds

4 years

K0839*

Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

4 years

K0840*

Power wheelchair, group 2 extra heavy duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more

4 years

K0841*

Power wheelchair, group 2 standard, multiple power options, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0842*

Power wheelchair, group 2 standard, multiple power options, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0843*

Power wheelchair, group 2 heavy duty, multiple power options, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0848*

Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0849*

Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0850*

Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0851*

Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450 pounds

4 years

K0852*

Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds

4 years

K0853*

Power wheelchair, group 3 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds

4 years

K0854*

Power wheelchair, group 3 extra heavy duty, sling/back seat/back, patient weight capacity 601 pounds or more

4 years

K0855*

Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more

4 years

K0856*

Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0857*

Power wheelchair, group 3 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0858*

Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0859*

Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds

4 years

K0860*

Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

4 years

K0861*

Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0862*

Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0863*

Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds

4 years

K0864*

Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more

4 years

K0868*

Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0869*

Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0870*

Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0871*

Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds

4 years

K0877*

Power wheelchair, group 4 standard, single power option, sling/solid seat back, patient weight capacity up to and including 300 pounds

4 years

K0878*

Power wheelchair, group 4 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0879*

Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0880*

Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds

4 years

K0884*

Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

4 years

K0885*

Power wheelchair, group 4 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds

4 years

K0886*

Power wheelchair, group 4 heavy duty, multiple, power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds

4 years

K0890*

Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds

4 years

K0891*

Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds

4 years

K0898*

Power wheelchair, not otherwise classified

4 years

Note: In the tables above, HCPCS codes with an asterisk (*) require prior approval and bold type indicates the item is covered by Medicare.  A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval.  The coverage criteria for these items have not changed.  Refer to Clinical Coverage Policy #5A, Durable Medical Equipment, on DMA’s Web site for detailed coverage information. 

For current pricing on these and all DME codes, refer to DMA’s Fee Schedule web page.  For all billings, providers are reminded to bill their usual and customary rates.  Do not automatically bill the established maximum reimbursement rate.

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


Attention: Independent Practitioners

CPT Code Changes - Respiratory Therapy

Effective with date of service Jan. 1, 2007, CPT code 94657, Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing, subsequent days, was end-dated.  Claims submitted with end-dated codes for dates of service Jan. 1, 2007 and after will be denied. 

CPT code 99504, Home visit for mechanical ventilation care, has been added to the list of appropriate codes that respiratory therapists may now bill beginning with date of service Jan. 1, 2007.

Billing Guidelines for CPT Code 99504

Clinical Coverage Policy 10B, Independent Practitioners, has been updated to reflect this code change and is available on DMA’s Web site.

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


Attention: Orthotic and Prosthetic Providers

HCPCS Code Changes, Code Additions, Description Changes and Discontinued Codes for Orthotics and Prosthetics

Effective with date of service Jan. 1, 2007, the following codes will be added to the Orthotic and Prosthetic Fee Schedule.

HCPCS Code

Description

Lifetime Expectancy

*A8000

Helmet, protective, soft, prefabricated, includes all components and accessories

6 months: ages 00-20

3 years: ages 21-115

*A8001

Helmet, protective, hard, prefabricated, includes all components and accessories

6 months: ages 00-20

3 years: ages 21-115

*A8002

Helmet, protective, soft, custom fabricated, includes all components and accessories

6 months: ages 00-20

3 years: ages 21-115

*A8003

Helmet, protective, hard, custom fabricated, includes all components and accessories

6 months: ages 00-20

3 years: ages 21-115

*A8004

Soft interface for helmet, replacement only

6 months

*L1001

Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, prefabricated, includes fitting and adjustment

6 months

*L3806

Wrist-hand-finger orthosis, includes one or more non-torsion joint(s), elastic bands, turnbuckles, may include soft interface material, straps, custom fabricated, includes fitting and adjustment

6 months: ages 00-20

3 years: ages 21-115

*L3808

Wrist-hand-finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment

6 months: ages 00-20

3 years: ages 21-115

*L3915

Wrist-hand orthosis, includes one or more non-torsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustment

6 months: ages 00-20

3 years: ages 21-115

*L5993

Addition to lower extremity prosthesis, heavy-duty feature, foot only (for patient weight greater than 300 lbs.)

1 year: ages 00-20

3 years: ages 21-115

*L5994

Addition to lower extremity prosthesis, heavy-duty feature, knee only (for patient weight greater than 300 lbs.)

1 year: ages 00-20

3 years: ages 21-115

*L6624

Upper extremity addition, flexion/extension and rotation wrist unit

6 months: ages 00-20

3 years: ages 21-115

*L6639

Upper extremity addition, heavy-duty feature, any elbow

6 months: ages 00-20

3 years: ages 21-115

*L6703

Terminal device, passive hand/mitt, any material, any size

1 year: ages 00-20

3 years: ages 21-115

*L6704

Terminal device, sport/recreational/work attachment, any material, any size

1 year: ages 00-20

3 years: ages 21-115

*L6706

Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined

1 year: ages 00-20

3 years: ages 21-115

*L6707

Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined

1 year: ages 00-20

3 years: ages 21-115

*L6708

Terminal device, hand, mechanical, voluntary opening, any material, any size

1 year: ages 00-20

3 years: ages 21-115

*L6709

Terminal device, hand, mechanical, voluntary closing, any material, any size

1 year: ages 00-20

3 years: ages 21-115

As the asterisks indicate, all codes require prior approval.  Codes shown in boldface are covered by Medicare.  The updated coverage policies are published in Clinical Coverage Policy 5B, Orthotics and Prosthetics, on DMA’s Web site.  All of the items will be individually priced at the time prior approval is given, based on the provider’s documentation of cost.

Effective with date of service Jan. 1, 2007, the following code description changes will be made on the Orthotics and Prosthetics Fee Schedule.

HCPCS Code

Description

L0631

Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

L5848

Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability

L5995

Addition to lower extremity prosthesis, heavy-duty feature, other than foot or knee (for patient weight greater than 300 lbs.)

L6805

Addition to terminal device, modifier wrist unit

L6810

Addition to terminal device, precision pinch device

L6884

Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power

Effective with date of service Dec. 31, 2006, the following codes will be end-dated and removed from the Orthotics and Prosthetics Fee Schedule.

L0100

L0110

L3902

L3914

L6700

L6705

L6710

L6715

L6720

L6725

L6730

L6735

L6740

L6745

L6750

L6755

L6765

L6770

L6775

L6780

L6790

L6795

L6800

L6806

L6807

L6808

L6809

L6825

L6830

L6835

L6840

L6845

L6850

L6855

L6860

L6865

L6867

L6868

L6870

L6872

L6873

L6875

L6880

 

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


Attention: Personal Care Service and Personal Care Service–Plus Providers

Personal Care Services Provider Training Sessions

The Carolinas Center for Medical Excellence (CCME; www.thecarolinascenter.org) announces continued provider training for Personal Care Services (PCS) as approved by the Division of Medical Assistance (DMA).

Training sessions for the first calendar quarter, which will be conducted in March 2007, will target continued issues facing PCS providers and provide guidance in resolving them.

The training is for registered nurses (RNs), agency administrators and agency owners. All participants planning to attend should already be familiar with N.C. Medicaid’s clinical coverage policies 3C, Personal Care Services, and 3J, PCS–Plus. RNs are required to pass the PCS certification exam before performing their first assessment; DMA and CCME recommend that RN attendees have already passed the exam before the seminar.

There is no cost for attending these sessions, but online or faxed pre-registration is required, and space is limited to 200 participants at each session. Registration details were not available at press time; please e-mail Jennifer Manning at CCME for information on how and when to register: jmanning@thecarolinascenter.org.

The dates and cities of the sessions are as follows. Specific venues will be announced in a later issue of the Bulletin.

March   2

Winston-Salem

March   6

Fayetteville

March 16

Raleigh–Durham

March 23

Greenville

March 30

Asheville

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


Attention: Physicians and Nurse Practitioners

Corrected Bevacizumab (Avastin, J9035)—Update to Billing Guidelines

This article from the December General Medicaid bulletin is being re-run with corrections.

The N.C. Medicaid program covers bevacizumab (Avastin) for use in the Physician’s Drug Program for the diagnosis of malignant neoplasm of the colon, rectum, rectosigmoid junction and anus. The Food and Drug Administration has also approved Avastin for the diagnosis of non–small cell lung carcinoma.

In accordance with the new FDA-approved diagnosis for Avastin, the following ICD-9-CM diagnosis codes are required when billing for Avastin:

V58.11—admission or encounter for chemotherapy must be billed

and

•an ICD-9-CM diagnosis code in one of the following groups:

1. 153.0 through 154.8

2. 162.2 through 162.9

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



Attention:  Physicians and Nurse Practitioners

Panitumumab, 20 mg/ml Injectable (Vectibix, J9999) Billing Guidelines

Effective with date of service Nov. 1, 2006, the N.C. Medicaid program covers panitumumab (Vectibix) for use in the Physician’s Drug Program when billed with HCPCS procedure code J9999 (not otherwise classified, antineoplastic drug).  Vectibix is indicated for treatment of epidermal growth factor receptor (EGFR) — expressing, metastatic colorectal carcinoma with disease progression on or following fluoropyrimidie-, oxaliplatin- and irinotecan-containing chemotherapy regimens. Vectibix is a monoclonal antibody that binds specifically to EGFR, which is overexpessed in certain cancers, including those of the colon and rectum. The binding of panitumumab to EGFR inhibits cell growth and survival of tumor cells that express EGFR.

The recommended dose of Vectibix is 6 mg/kg administered over 60 minutes as an intravenous infusion every 14 days.

For Medicaid Billing:

One unit of coverage is 100 mg (5 ml), which is equivalent to the smallest single-use vial. The maximum reimbursement rate per unit is $900.

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


Attention: All Dental Providers and Health Department Dental Centers

*American Dental Association Code Updates

Effective with date of service Jan. 1, 2007, the following dental procedure codes have been added for the N.C. Medicaid Dental Program.  These additions are a result of the Current Dental Terminology (CDT) 2007 American Dental Association (ADA) code updates.  Clinical Coverage Policy 4A, Dental Services has been updated to reflect these changes.

CDT 2007
Code


Description and Limitations

Reimbursement
Rate

D0273

Bitewings – three films

*      allowed one (1) time per 12 calendar month period

*      not allowed on the same date of service as D0270, D0272 or D0274

*      not allowed within the same 12 calendar month period as D0210

$24.46

D1206

Topical fluoride varnish; therapeutic application for moderate to high-caries-risk patients

*      limited to recipients under age 21

*      allowed one time per recipient per six calendar month period for the same provider

$15.44

D2970

Temporary crown (fractured tooth)

*      limited to recipients under age 21

$126.91

D7311

Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

*      must be at least three edentulous units in a quadrant to qualify for payment for alveoloplasty

*      requires a quadrant indicator in the area of oral cavity or tooth number field

*$82.00

D7321

Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

*      requires prior approval

*      must be at least three edentulous units in a quadrant to qualify for payment for alveoloplasty

*      requires a quadrant indicator in the area of oral cavity or tooth number field

$131.61

The following procedure codes were end-dated effective with date of service Dec. 31, 2006.

End-Dated CDT Code

Description

D1201

Topical application of fluoride (including prophylaxis) - child

D1205

Topical application of fluoride (including prophylaxis) - adult

The following procedure code descriptions were revised effective with date of service Jan. 1, 2007.

Revised CDT Code

Description and Limitations

D7310

Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces per quadrant

D7320

Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces per quadrant

D7944

Osteotomy – segmented or subapical

D7950

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

D9610

Therapeutic parenteral drug, single administration

*      allowed for a single administration of antibiotics, steroids, anti-inflammatory drugs or other therapeutic medications.

*      not allowed for the administration of sedatives, anesthetic or reversal agents.

*      identify the drug, dosage, and rationale in the recipient’s dental record and on the claim form if filed as a paper claim

Providers are reminded to bill their usual and customary charges rather than the Medicaid rate. For coverage criteria and additional billing guidelines, please refer to Clinical Coverage Policy 4A, Dental Services, on the Division of Medical Assistance Web site.

Dental Program
DMA, 919-855-4280



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

American Dental Association Code Updates for the Physician Fluoride Varnish (Into the Mouths of Babes) Program

Effective with date of service Jan. 1, 2007, the dental procedure codes used for the Physician Fluoride Varnish (Into the Mouths of Babes) Program have been changed.  These deletions and additions are a result of the Current Dental Terminology (CDT) 2007 American Dental Association code updates.

The following procedure codes were end-dated effective with date of service Dec. 31, 2006.

End-Dated CDT Code

Description

D0150

Comprehensive oral evaluation – new or established patient

D0120

Periodic oral evaluation – established patient

D1203

Topical application of fluoride (including prophylaxis) – child

D1330

Oral hygiene instructions

The following procedure codes were added to replace the above deleted codes effective with date of service Jan. 1, 2007.

CDT 2007
Code

Description and Limitations

Reimbursement
Rate

D0145

Oral evaluation for a patient under 3 years of age and counseling with primary caregiver

*      replacing procedure codes D0150, D0120, and D1330

*      must be billed in conjunction with D1206

*      limited to recipients under age 3

*      allowed once every 90 days

*      limited to six times prior to the recipient’s third birthday

$38.07

D1206

Topical fluoride varnish; therapeutic application for moderate to high-caries-risk patients

*      replacing procedure code D1203

*      must be billed in conjunction with D0145

*      limited to recipients under age 3

*      allowed once every 90 days

*      limited to six times prior to the recipient’s third birthday

$15.44

The rate for the following procedure code has been increased effective with date of service Jan. 1, 2007.

For questions regarding the coverage criteria or billing guidelines, contact the Division of Medical Assistance Dental Program at 919-855-4280.

Dental Program
DMA, 919-855-4280


Proposed Clinical Coverage Policies

In accordance with Session Law 2005-276, proposed new or amended Medicaid clinical 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.

Loretta Bohn
Division of Medical Assistance
Clinical 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.


2007 Checkwrite Schedule

Month

Electronic Cut-Off Date

Checkwrite Date

January

01/05/07

01/09/07

 

01/12/07

01/17/07

 

01/19/07

01/25/07

February

02/02/07

02/06/07

 

02/08/07

02/13/07

 

02/15/07

02/20/07

 

02/22/07

02/28/07

March

03/01/07

03/06/07

 

03/08/07

03/13/07

 

03/15/07

03/20/07

 

03/22/07

03/29/07

      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.

Mark T. Benton, Senior Deputy Director and Chief Operating Officer   Cheryll Collier
Division of Medical Assistance   Executive Director
Department of Health and Human Services   EDS
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