April 2005 Medicaid Bulletin

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In This Issue…  

All Providers:

CAP/DA, CAP/C, CAP/AIDS, and CAP/Choice Case Managers:

Durable Medical Equipment Providers:

Health Check Providers:

Health Departments:

Hospice Providers:

Hospitals and Nursing Facilities:

Mental Health and Substance Abuse Providers:

Nurse Practitioners:

Physicians:

Podiatrists:


Attention: All Providers

Radiation Treament Delivery and Management Codes Billing Guidelines

Use the following guidelines to bill radiation treatment delivery (CPT codes 77401 through 77416), portal verification films (77417), and radiation treatment management (CPT codes 77427 through 77470).

Radiation Treatment Delivery Codes

Treatment Delivery Codes

CPT Code

Description  of Radiation Treatment Delivery

Energy Level

77401

One or more separate sites

Superficial and/or ortho voltage

77402

Single treatment area, single port or parallel opposed ports, simple blocks or no blocks

Up to 5 MeV

77403

Single treatment area, single port or parallel opposed ports, simple blocks or no blocks

6 – 10 MeV

77404

Single treatment area, single port or parallel opposed ports, simple blocks or no blocks

11 – 19 MeV

77406

Single treatment area, single port or parallel opposed ports, simple blocks or no blocks

20 MeV or greater

77407

Two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks

Up to 5 MeV

77408

Two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks

6 – 10 MeV

77409

Two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks

11 – 19 MeV

77411

Two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks

20 MeV or greater

77412

Three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam (e.g., electron or neutrons)

Up to 5 MeV

77413

Three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam (e.g., electron or neutrons)

6 – 10 MeV

77414

Three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam (e.g., electron or neutrons)

11 – 19 MeV

77416

Three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam (e.g., electron or neutrons)

20 MeV or greater

Portal Verification Film(s) – Code 77417

Radiation Treatment Management Codes

Radiation Treatment Management Codes

CPT Code

Description

Comments

77427

Radiation treatment management, five treatments

Reported in units of five treatment sessions, regardless of the actual time period in which the services are furnished.  Weekly is interpreted as five treatments, not a calendar week.  The services need not be furnished on consecutive days.  Multiple treatment sessions furnished on the same day may be counted separately, as long as there has been a distinct break in therapy sessions and are usually furnished on different days.  Examination for medical evaluation and management is included and a separate E/M code is not reported during treatment.  This code is also reported if there are three or four sessions beyond a multiple of five at the end of a course of treatment.

77431

Radiation therapy management with complete course of therapy consisting of one or two sessions only

One or two treatments comprise the full course of therapy.  Not to be used to report the last one or two days of a longer treatment course.  Only two units allowed in a seven day period.

77432

Stereotactic radiation treatment management of cerebral lesion(s) (complete course of treatment consisting of one session)

Charged only once for each course of treatment of the cerebral lesion.  If more than one treatment is delivered, use 77432 on day one, then use 77427 or 77431 per these codes’ rules and criteria.

77470

Special treatment procedure (e.g. total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation)

Report only once per course of therapy.  This code is used in clinical situations where additional physician effort and work for special radiation procedures are needed.

Medicaid will not reimburse for office visits, burn treatment, care of infected skin, follow-up exams or infusion therapy for 30 days after the last date of service for radiation treatment management codes.  Medicaid policy is based on the Correct Coding Initiative (CCI) Manual, Version 11.0.  According to CCI, the codes listed below are considered to be included within the weekly management and should not be billed separately.

CPT Codes Included in the Weekly Management Codes:

11920

11921

16000

16010

16015

16020

16025

16030

36425

51701

51702

51703

90804

90805

90806

90807

90808

90809

90816

90817

90818

90819

90821

90822

90847

96150

96151

96152

96153

96154

97802

97803

97804

99183

99185

99211

99212

99213

99214

99215

99238

99281

99282

99283

99284

99285

99354

99355

99356

99357

99360

 

Additionally, code 61795 is included with 77432 in the weekly management and should not be billed separately from 77432.

Example of Billing on the CMS-1500 Form

24. A

B

D

E

F

G

Dates of Service

Place of Service

Procedures, services, or supplies

Diagnosis Code

Charges

Days or Units

From

mm   dd      yy

To

mm   dd     yy

06

08

05

06

08

05

21

77404

TC

 

50

00

1

06

09

05

06

10

05

21

77403

TC

 

100

00

2

06

11

05

06

11

05

21

77404

TC

 

50

00

1

06

12

05

06

12

05

21

77406

TC

 

50

00

1

06

12

05

06

12

05

21

77427

   

200

00

1

06

15

05

06

15

05

21

77408

TC

 

100

00

2

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


Attention: All Providers

Sincalide (Kinevac)

Effective with date of service December 31, 2004, CPT code 78990, provision of diagnostic radiopharmaceutical(s), was discontinued by the American Medical Association (AMA).  Effective January 1, 2005, providers billing Sincalide (Kinevac) must bill using HCPCS code A4641, supply of radiopharmaceutical diagnostic imaging agent, not otherwise classified. 

Billing Guidelines:

If A9510 or A9513 and 78223 are not billed with A4641 on the same claim with the same date of service by the same provider, the claim will deny.

Claims submitted without an invoice will deny.  Reimbursement is based on the actual invoice price of the agent only (less the shipping and handling).

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


Attention: CAP/DA, CAP/C, CAP/AIDS, and CAP/Choice Case Managers

Coding Change

Effective with date of service April 1, 2005 HCPCS code S8409, Disposable Liner/Shield for Incontinence, will no longer be valid for billing this service.  The code will be replaced by T4535, Disposable Liner/Shield/Pad for Incontinence. 

Continue use of code S8409 through March 31, 2005 dates of service.

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


Attention: All Providers

Medicaid Provider Survey

Provider Input Requested!

The Office of Medicaid Management Information System Services (OMMISS) has prepared a survey to identify opportunities to better serve providers who participate in Medicaid and other DHHS reimbursement programs that will be replaced by the new NCLeads system in 2006.

This survey is intended to identify the provider community’s current access to systems and the Internet, along with technical support availability. It is also important for us to understand and track your claims submittal process and satisfaction levels with the current MMIS+.

You are encouraged to complete the survey located at http://ncleads.dhhs.state.nc.us/survey to ensure the new NCLeads system will address your access requirements and system education preferences. Survey participants can be assured that their responses will be considered for NCLeads improvement opportunities as well as to tailor provider education and communication about the NCLeads solution.

If you have any questions about the survey, please contact Provider Relations. Thank you for your participation in this effort!

Tom Liverman, OMMISS Provider Relations
919-647-8315


Attention: All Providers

NCLeads Update

Information related to the implementation of the new Medicaid Management Information System, NCLeads, scheduled for implementation in mid-2006 can be found online at http://ncleads.dhhs.state.nc.us.  Please refer to this website for information, updates, and contact information related to the NCLeads system.

Thomas Liverman, Provider Relations
Office of MMIS Services
919-647-8315


Attention: Durable Medical Equipment Providers

Correction Fluid and Correction Tape on CMN/PA Forms

The use of correction fluid and/or correction tape is not allowed on medical documents.  EDS will continue to deny any requests submitted with either of those products applied to the Certificate of Medical Necessity and Prior Approval forms.

EDS, 1-800-668-6696 or 919-851-8888


Attention: Durable Medical Equipment Providers

Enteral Nutrition HCPCS Codes Rate Change

Effective with date of service February 1, 2005, the Medicaid maximum reimbursement rate for the following DME enteral medical supplies has been increased.               

HCPCS Code

Description

Reimbursement Rate

B4034

Enteral feeding supply kit; syringe, per day

$5.78

B4035

Enteral feeding supply kit; pump fed, per day

11.02

B4036

Enteral feeding supply kit; gravity fed, per day

7.55

B4081

Nasogastric tubing with stylet

20.42

B4082

Nasogastric tubing without stylet

15.20

B4083

Stomach tube – Levin type

2.32

Providers must bill their usual and customary charges.  Fee schedules are available on DMA’s Fee Schedule web page.

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


Attention: Health Check Providers

Health Check Seminars

Health Check seminars for all providers except health departments are scheduled for May 2005. Attendance at these seminars is very important. The seminars will focus on Health Check billing requirements, as well as vision and hearing assessments and developmental screenings.

A separate teleconference for local health departments sponsored by the Division of Public Health is scheduled for Monday, May 23, 2005. Health departments should refer to the next page for information on registering for the teleconference. Both the seminars and the teleconference will use the April 2005 Special Bulletin III, Health Check Billing Guide 2005, as the primary handout for the session. Providers must access and print the PDF version of the special bulletin from DMA’s website and bring it to the session.

Pre-registration is required. Providers not registered are welcome to attend the seminars if space is available. Providers may register by completing the form on the next page or by registering online. Please indicate on the registration form the session you plan to attend. Seminars are scheduled to begin at 10:00 a.m. and end at 1:00 p.m. or earlier. Lunch will not be served. Providers are encouraged to arrive by 9:45 a.m. to complete registration.

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


Schedule for the Health Check Seminars:

Wednesday, May 11, 2005

Jane S. McKimmon Center
1101 Gorman Street
Raleigh, NC

Thursday, May 12, 2005

Greenville Hilton
207 Greenville Blvd. SW
Greenville, NC

Wednesday, May 18, 2005

Blue Ridge Community College
Bo Thomas Auditorium
College Drive
Flat Rock, NC 

Thursday, May 19, 2005

Hilton University Place
8629 J.M. Keynes Drive
Charlotte, NC  28262


Directions to the Health Check Seminars

Jane S. McKimmon CenterRaleigh, North Carolina

Traveling East on I-40
Take exit 295 and turn left onto Gorman Street.  Travel approximately one mile.  The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

Traveling West on I-40
Take exit 295 and turn right onto Gorman Street.  Travel approximately one mile.  The McKimmon Center is located on the right before you reach Western Boulevard.

Greenville Hilton – Greenville, North Carolina

Take Highway 64 East to Highway 264 East.  Follow 264 East to Greenville. Once you enter Greenville, turn right on Allen Road.  After approximately 2 miles, Allen Road becomes Greenville Boulevard/Alternate 264.  Follow Greenville Boulevard for 2 ½ miles.  The Greenville Hilton is located on the right.

Blue Ridge Community College, Bo Thomas Auditorium – Flat Rock, North Carolina

Take I-40 to Asheville.  Travel east on I-26 to exit 22.  Turn right and then take the next right.  Follow the signs to Blue Ridge Community College.  Turn left at the large Blue Ridge Community College sign.  The college is located on the right.  Take the first right-hand turn into the parking lot for the Bo Thomas Auditorium.

Hilton University PlaceCharlotte, North Carolina

Exit from I-85 exit 45A, Harris Boulevard Eastbound, from either North or South on 85. Hilton Charlotte University Place is on the left in the University Place complex. The hotel is the high rise building in the complex, totally visible from Harris Boulevard. The left turn at J M Keynes Drive goes right into the hotel parking lot.


Attention: Health Departments

Training for Local Health Deparments on Health Check Requirements

A training session is scheduled for local health department staff from 1:00 p.m. through 4:00 p.m. on May 23, 2005 via the Public Health Training and Information Network (PHTIN). This session, entitled Health Check - 2005 Update, will cover vision and hearing assessments and the developmental screening requirements for the Health Check Program.

Registration information has been sent to local health departments. If you do not receive this registration information by April 15, 2005, please contact the Public Health Nursing & Professional Development Unit in the Division of Public Health at 919-733-6850. The target audience for this session is both clinical staff who perform the Health Check screenings and billing staff.

The April 2005 Special Bulletin III, Health Check Billing Guide 2005, is the primary handout for this session. Attendees must access and print the PDF version of this special bulletin from the Division of Medical Assistance’s website.  Copies of this handout will not be provided onsite.

Joy Reed, Local Technical Assistance and Training
Division of Public Health
919-715-4385


Attention: Hospice Providers

Pharmacy Charges for Hospice Recipients

Effective with date of service February 25, 2005, transactions submitted through the pharmacy point of sale (POS) system for a recipient who has elected the hospice benefit will be denied because medications related to the recipient’s terminal illness are covered through the hospice program.  Reimbursement arrangements must be made between the hospice agency and the pharmacy regarding the dispensing of medications related to the treatment of the recipient’s terminal illness.  Medicaid continues to cover medications for hospice recipients when the medication is not related to the recipient’s terminal illness.  To override the POS system when billing for a medication unrelated to the recipient’s terminal illness, the pharmacist must enter the appropriate ICD-9-CM diagnosis code.  The pharmacy must contact the recipient’s hospice provider to obtain the diagnosis code.

Overrides are not allowed for the following drug classes: narcotic analgesics, hematinics, antiemetics, and most chemotherapeutics.  

Pharmacies may contact the Division of Medical Assistance (919-855-4300) for assistance with determining if a medication is related to the recipient’s terminal illness.

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


Attention: All Mental Health and Substance Abuse Providers

New Contract for Utilization Review

ValueOptions, Inc. (VO) has been awarded the North Carolina Medicaid contract for Utilization Review for Mental Health and Substance Abuse Services for Medicaid recipients across the state.  This new contract period begins July 1, 2005.  VO will continue to perform utilization review for the following services:  acute inpatient/substance abuse hospital care for Medicaid recipients through age 64; Psychiatric Residential Treatment Facilities (PRTF);  Levels II through IV  Residential Treatment Facilities; outpatient psychiatric services; elective and emergency admission reviews; concurrent continued stay reviews; post payment reviews and post discharge reviews; out-of-state services for Residential Level IV and PRTF; and Criterion 5 services for recipients under 17 years of age.  VO will broaden the scope of utilization review to incorporate the following services:  Assertive Community Treatment Team (ACTT), Case Management; Day Treatment; Partial Hospitalization; Community Based Services; Psychosocial Rehabilitation; Professional Treatment Services in Facility Based Crisis Program; Outpatient Treatment; and Levels II-IV Residential Treatment Services beginning with the initial authorization and authorizing continued stay. 

Note: When the Local Management Entity/ (LME) are deemed ready by the Department of Health and Human Resources (DHHS), these listed Community Based Services may be authorized by the LME for their catchment area.  Information about provider training and seminar sites will be published in the general Medicaid bulletin in May along with a Special Medicaid Bulletin for use as a training manual.

Behavioral Health Services
919-855-4291


Attention: Physicians

Pegaptanib, 0.3 mg (Macugen, J3490) - Billing Guidelines

Effective with date of service April 1, 2005, the N.C. Medicaid program covers pegaptanib (Macugen) for use in the Physician’s Drug Program.  Macugen is a vascular endothelia growth factor (VEGF) inhibitor.  The FDA states that it is indicated for the treatment of neovascular (wet) age-related macular degeneration (AMD).  The FDA indicates that the usual adult dose is 0.3 mg intravitreous injection into affected eye every six weeks. 

The ICD-9-CM diagnosis code required when billing for Macugen is 362.52 (Exudative senile macular degeneration of retina). 

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 recipient’s name and Medicaid identification 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 CMS-1500 claim form.  For Medicaid billing, one unit of coverage is 0.3mg/0.9mL.  The maximum reimbursement rate per unit is $1,119.37.  Providers must bill their usual and customary charge.  Add this drug to the list of injectable drugs published in the November 2004 general Medicaid bulletin.

Physicians’ Billing Requirements:

Example:

21

Diagnosis

24A

Date(s) of Service

24B

Place of Service

24D

Procedures, Services or Supplies

24F

Charges*

24G

Days or Units

362.52

04152005

11

J3490

$

1

Note: The asterisk (*) indicates the provider must bill their usual and customary charge.

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


Attention: Physicians and Nurse Practitioners

Alemtuzumab, 10 mg (Campath, J9010) - Billing Guidelines

Effective with date of service April 1, 2005, the N.C. Medicaid program covers alemtuzumab (Campath) for use in the Physician’s Drug Program.  Campath is indicated for the treatment of B-cell chronic lymphocytic leukemia (B-CLL) in patients who have been treated with alkylating agents and who have failed fludarabine therapy.  The FDA’s recommended administration of Campath is initiation at a dose of 3 mg administered as a 2 hour IV infusion daily.  When the 3 mg daily dose is tolerated (e.g., infusion-related toxicities are Grade 2), the daily dose should be escalated to 10 mg and continued until tolerated.  When the 10 mg dose is tolerated, the maintenance dose of Campath 30 mg may be initiated.  The maintenance dose of Campath is 30 mg/day administered three times per week on alternate days (i.e., Monday, Wednesday, and Friday) for up to 12 weeks.

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

AND EITHER

OR

Providers must use HCPCS code J9010 to bill for Campath.  For Medicaid billing, 1 unit of coverage is 10mg.  The maximum reimbursement rate per unit is $553.77.  Providers must bill their usual and customary charge.  This drug should be added to the list of drugs in the Physician’s Drug Program, published in the November 2004 general Medicaid bulletin.

Physicians’ Billing Requirements:

Example:

21

Diagnosis

24A

Date(s) of Service

24B

Place of Service

24D

Procedures, Services or Supplies

24F

Charges*

24G

Days or Units

V581.1 and 204.10

04152005

11

J9010

$

3

Note: The asterisk (*) indicates the provider must bill their usual and customary charge.

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


Attention: Physicians and Podiatrists

Dermagraft Coverage (J7342)

Effective with date of service January 1, 2003, the N.C. Medicaid program covers the wound dressing Dermagraft when supplied by a physician.  Dermagraft is a cryopreserved human fibroblast-derived dermal substitute. 

Dermagraft Coverage Criteria

Dermagraft is covered for the treatment of full-thickness diabetic foot ulcers when all of the following conditions are met:

Non- covered Conditions

Dermagraft is contraindicated and, therefore, not covered for the following conditions:

Billing Instructions

• Bill on the CMS 1500 form using HCPCS code J7342.
• One unit equals 1 sq. cm.
• A single application of Dermagraft totals 37.5 square centimeters (sq. cm.).
• No more than eight applications of Dermagraft may be applied in a 12 week period.
• The maximum reimbursement rate is $14.58 per sq. cm.
• CPT codes 15000 and 15001 may be used to bill for the site preparation.
• CPT codes 15342 and 15343 may be used to bill for the application of Dermagraft.

24.   A

B

C

D

F

G

          DATES(S) OF SERVICE                   From                                        To            MM    DD    YY        MM     DD         YY

Place of Service

Type of Service

PROCEDURES, SERVICES, OR SUPPLIES                                      Explain Unusual Circumstances          CPT/HCPCS        MODIFIER

CHARGES

DAY OR UNITS

01

01

05

01

01

05

11

 

J7342

 

Usual and customary

37.5

Claims Filing Instructions:

New claims submitted for dates of service January 1, 2003 through May 31, 2004 require a time limit override.  These claims must be submitted on paper with a Medicaid Resolution Inquiry form attached to the claim and must be received for processing by July 31, 2005.  Providers must identify these claims by clearly writing DERMAGRAFT in large block letters on both the mailing envelope and the Medicaid Resolution Inquiry form.  Previously submitted claims that were denied that have not exceeded the time limit may be resubmitted.

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


Attention: Physicians

Ziconotide Intrathecal, 25mcg/ml and 100mcg/ml (Prialt, J3490) - Billing Guidelines

Effective with date of service April 1, 2005, N.C. Medicaid covers ziconotide intrathecal (PrialtÒ) for use in the Physician’s Drug Program.  The manufacturer states that PrialtÒ is indicated for the management of severe chronic pain in patients for whom intrathecal therapy is warranted and who are intolerant of or refractory to other treatment. The maximum recommended daily dose at the beginning of treatment is 2.4 mcg/day. While monitoring for adverse effects, titration of the dose takes several weeks until pain relief is adequate.  The maximum recommended daily dose is 19.2mcg/day.

Providers must bill J3490, with an invoice attached to the CMS-1500 claim form. An invoice must be submitted with each claim. The paper invoice must include the recipient’s name and Medicaid identification 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 CMS-1500 claim form.  For Medicaid billing, one unit of coverage is 25 mcg.  The maximum reimbursement rate per unit is $171.09.  Providers must bill their usual and customary charge.  This drug should be added to the list of injectable drugs published in the November 2004 general Medicaid bulletin.

Physicians’ Billing Requirements:

Example:

21

Diagnosis

24A

Date(s) of Service

24B

Place of Service

24D

Procedures, Services or Supplies

24F

Charges

24G

Days or Units

 

04152005

11

J3490

$

5

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


Attention:  Hospitals and Nursing Facilities

Reimbursement Rate for Swing Beds and Lower Levels of Care Services

Effective with date of service March 1, 2005, the maximum allowable rate for the following swing beds and lower levels of care services were modified.  The new rates are $123.00.

Note:  At this time, swing beds and lower levels of care (INC, SNC, H-INC, and H-SNC) are reimbursed at the same rate.

Providers must bill their usual and customary charges.  Adjustments will not be accepted for rate changes.

Fee schedules are available on DMA’s Fee Schedule web page.

Rate Setting, DMA
919-855-4200


Attention: Hospitals and Nursing Facilities

Reimbursement Rate for Vent Beds

Effective with date of service March 1, 2005, the maximum allowable rates for the Vent beds were modified.

Rate Setting, DMA
919-855-4200


Proposed Clinical Coverage Policies

In accordance with Session Law 2003-284, 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.

Gina Rutherford
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.


Electronic Cut-Off Schedule

April 8, 2005

May 6, 2005

April 15, 2005

May 13, 2005

April 22, 2005

May 20, 2005

April 29, 2005

 

Checkwrite Schedule

April 12, 2005

May 10, 2005

April 19, 2005

May 17, 2005

April 28, 2005

May 26, 2005

May 3, 2005

 

2005 Checkwrite Schedule

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, Interim Director   Cheryll Collier
Division of Medical Assitance   Executive Director
Department of Health and Human Services   EDS

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