June 2002 Medicaid Bulletin title image

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In This Issue..  
All Providers: Federally Qualified Health Centers: Health Check Providers: Mecklenburg County Providers: Physicians: Residential Child Care Facility Providers: Rural Health Clinics:


Attention: All Providers

Proposed Medical Coverage Policies

In accordance with S.L. 2001-424, SB 1005, proposed new or amended Medicaid medical coverage policies are available for review and comment on DMA's website. To submit a comment related to a policy, refer to the instructions on the website. 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.
 

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


Attention: All Providers

CPT Code Update 2002 - Code Description Correction

The correct description for CPT code 10022 is Fine needle aspiration; with imaging guidance. This replaces the description published in the April 2002 general Medicaid bulletin.
 

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


Attention: Mecklenburg County Providers

Managed Care Update

Mecklenburg County now offers two types of Medicaid managed care programs to recipients. Recipients may choose between HMO or Carolina ACCESS enrollment. The names of the two HMOs are United Healthcare and SouthCare. The name of the HMO is printed on its members' Medicaid card. There are three groups of Carolina ACCESS providers available to recipients: Carolinas Medical Center-ACCESS II, Metrolina Comprehensive, and a group of independent Carolina ACCESS providers. The name, address, and telephone number of the individual Carolina ACCESS/ACCESS II provider or Metrolina is printed on the recipient's Medicaid card. This information can also be obtained through the Automated Voice Response (AVR) system. (Refer to Special Bulletin II, July 2001 for more information.)

Providers who serve HMO enrollees must obtain referral authorization and payment from the HMO for in-plan services. Providers who serve another provider's Carolina ACCESS enrollee must obtain referral authorization from the Carolina ACCESS primary care provider listed on the recipient's card. The referral authorization number must be entered in block 19 of the HCFA-1500 claim form submitted to Medicaid for reimbursement. Many procedures and services covered by the Medicaid program require prior approval. The referral authorization does not replace the prior approval process required by Medicaid.
 

Darryl Frazier, Managed Care Section
DMA, 919-857-4022


Attention: Physicians

Miscellaneous Supplies

Effective with date of service July 1, 2002, procedure code W5120 will be end-dated and replaced with HCPCS procedure code A9900, miscellaneous supplies. Claims submitted for over-the-counter supplies that can be purchased without a physician's prescription are noncovered and will deny. Items excluded from the N.C. Medicaid program must not be billed.

An invoice must be submitted with the claim. HCPCS procedure code A9900 is priced from the invoice. Items or supplies that are noncovered will be denied with EOB 009, "Service not covered by the Medicaid program."
 

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


Attention: Physicians

Injectable Drug List Update

The following table is an updated list of FDA approved drugs currently covered by the N.C. Medicaid program when provided in a physician's office for the FDA approved indications. This list replaces previously published lists. Fees are effective with date of service July 1, 2002. Vaccines and immune globulins are not included on this list and will be published separately.

Physicians will continue to bill on the HCFA-1500 claim form using the appropriate drug code and indicating the specified number of units administered.

(*) Designates that an invoice is required to accompany the HCFA-1500 claim form. Payment is based on the invoice price.
 
* Procedure Code Description Fee
  J0130  Abciximab 10 mg 
487.37 
  J1120  Acetazolamide Sodium, up to 500 mg (Diamox) 
28.16 
  J0150  Adenosine I.V., 6 mg (Adenocard) 
32.54 
  J0151  Adenosine, 90 mg (Adenoscan) 
201.93 
  J0170  Adrenalin, Epinephrine, up to 1 ml ampule 
1.52 
  J0205  Alglucerase, per 10 units (Ceredase) 
35.65 
  J0256 Alpha 1 Proteinase Inhibitor Human A, 10 mg (Prolastin) 
1.99 
  J9015  Aldesleukin, per single use vial (Proleukin, IL-2, Interleukin) 22 million I.U. 
664.24 
  J0207  Amifostine 500 mg (Ethyol) 
372.45 
  S0016  Amikacin Sulfate (250 mg) 
14.67 
  S0072  Amikacin Sulfate (100 mg) 
7.02 
  J0280  Aminophyllin, up to 250 mg 
1.00 
  J1320  Amitriptyline HCL, up to 20 mg (Elavil, Enovil) 
2.11 
  J0300  Amobarbital, up to 125 mg (Amytal) 
2.10 
  J0285  Amphotericin B, 50 mg (Amphocin, Fungizone IV) 
10.51 
  J0286  Amphotericin B Any Lipid Formulation, 50 mg 
84.23 
  J0295  Ampicillin Sodium/Sulbactam Sodium, per 1.5 gm (Unasyn) 
7.13 
  J0290  Ampicillin, up to 500 mg (Omnipen-N, Totacillin-N) 
1.42 
  J0350  Anistreplase, per 30 units (Eminase) 
2,296.82 
  J7197  Antithrombin II (human) per I.U. (Throbate III) 
1.00 
  J0395  Arbutamine HCL, 1 mg (GenESA) 
173.28 
  J9020  Asparaginase, 10,000 units (Elspar) 
56.72 
  J0460  Atropine Sulfate, up to 0.3 mg 
.06 
  J2910  Aurothioglucose, up to 50 mg (Solganal) 
13.84 
J3490  Azithromycin, oral suspension 1 unit = 1 gm packet (Zithromax), only oral drug on list   
  J0456  Azithromycin, 500 mg. (Zithromax) 
22.06 
  J0475  Baclofen, Kit 1*20 ml. Amp. (10 mg/20ml. 500 meg/ml.) 
222.02 
J3490  Baclofen, Kit 2*5 ml. Amp. (10 mg./5 ml. 2000 meg/ml.)   
J3490  Baclofen, Kit 4*5 ml. Amp. (10 mg./5ml. 2000 meg/ml.)   
  J0476  Baclofen, for intrathecal trial, 50 mcg (Lioresal for intrathecal trial) 
75.81 
  J9031  BCG live (intravesical) per installation (Tice, TheraCys) 
162.91 
  J0585  Botulinum toxin type A, per unit (Botox) 
4.43 
  J0702  Betamethasone Acetate and Betamethasone Sodium Phosphate, per 3 mg 
4.64 
  J0704  Betamethasone Sodium Phosphate, per 4 mg 
2.15 
  J0520  Bethanechol Chloride, mytonachol or urecholine, up to 5 mg (Urecholine) 
4.55 
  J9040 Bleomycin Sulfate, 15 units (Blenoxane) 
274.90 
  J0945  Brompheniramine Maleate, 10mg 
.81 
  S0009  Butorphanol Tartrate, 1mg (Stadol) 
6.48 
  J0635  Calcitriol, 1 mcg amp (Calcijex) 
13.13 
  J0610  Calcium Gluconate, per 10 ml (Kaleinate) 
1.22 
  J0620  Calcium Glycerophosphate and Calcium Lactate, per 10 ml (Calphosan) 
4.89 
  J9045  Carboplatin, 50 mg (Paraplatin) 
117.42 
  J9050  Carmustine, 100 mg (BiCNU) 
120.90 
  J0690  Cefazolin Sodium, 500 mg (Ancef, Kefzol, Zolicef) 
1.03 
  J0692  Cefepime HCL, 500 mg (Maxiprene) 
7.22 
  J0698  Cefotaxime Sodium, per gm (Claforan) 
9.93 
  J0694  Cefoxitin Sodium, 1 gm (Mefoxin) 
9.84 
  J0713  Ceftazidime per 500 mg (Fortaz, Tazidime) 
6.42 
  J0715  Ceftizoxime Sodium, per 500 mg (Cefizox) 
5.85 
  J0696  Ceftriaxone Sodium, per 250 mg (Rocephin) 
13.47 
  J0697  Cefuroxime Sodium, per 750 mg (Kefurox, Zinacef) 
6.10 
  J1890  Cephalothin Sodium, up to 1 gm (Keflin) 
9.75 
  J0710  Cephapirin Sodium, up to 1 gm (Cefadyl) 
1.33 
  J0720  Chloramphenicol Sodium Succinate, up to 1 gm 
5.99 
  J1990  Chlordiazepoxide HCL, up to 100 mg (Librium) 
23.75 
  J2400  Chlorprocaine HCL 30 ml (Nesacaine, Nesacaine-MPF) 
9.98 
  J0390  Chloroquine HCL, up to 250 mg (Aralen) 
17.92 
  J1205  Chlorothiazide Sodium, 500 mg (Diuril Sodium) 
9.50 
  J3230  Chlorpromazine HCL up to 50 mg (Thorazine) 
2.44 
  J0725  Chorionic Gonadotropin, per 1,000 USP units 
1.54 
  J0740  Cidofovir 375 mg (Vistide) 
763.52 
  J0743  Cilastatin Sodium Imipenem, per 250 mg (Primaxin IM, Primaxin IV) 
14.73 
  S0023  Cimetadine HCL, 300 mg (Tagamet) 
4.99 
  J0744  Ciprofloxacin, 200 mg (Cipro) 
13.00 
  J9062  Cisplatin, 50 mg (Platinol AQ) 
200.36
  J9060  Cisplatin, powder or solution, per 10 mg (Platinol, Plantinol AQ) 
40.07 
  J9065  Cladribine, per 1 mg (Leustatin) 
50.72 
  J0735  Clonidine Hydrochloride, 1 mg 
52.40 
  J0745  Codeine Phosphate, per 30 mg 
1.02 
  J0760  Colchicine, 1 mg 
6.72 
  J0770  Colistimethate Sodium, up to 150 mg (Coly-Mycin M) 
37.91 
  J0800  Corticotropin, up to 40 units (Acthar, ACTH) 
4.51 
  J0835  Cosyntropin, per 0.25 mg (Cortrosyn) 
14.57 
  J3420  Cyanocobalamin, vitamin B 12, 1000 mcg 
.06 
  J9096  Cyclophosphamide Lyophilized 1 gm (Cytoxan Lyophilized) 
46.42 
  J9093  Cyclophosphamide Lyophilized, 100 mg (Cytoxan Lyophilized) 
5.82 
  J9091  Cyclophosphamide, 1.0 gm (Cytoxan, Neosar) 
45.26 
  J9070  Cyclophosphamide, 100 mg (Cytoxan, Neosar) 
5.68 
  J9092  Cyclophosphamide, 2.0 gm (Cytoxan, Neosar) 
90.51 
  J9080  Cyclophosphamide, 200 mg (Cytoxan, Neosar) 
10.77 
  J9090  Cyclophosphamide, 500 mg (Cytoxan, Neosar) 
22.62 
  J9094  Cyclophosphamide, Lyophilized, 200 mg (Cytoxan Lyophilized) 
11.06 
  J9095  Cyclophosphamide, Lyophilized, 500 mg (Cytoxan Lyophilized) 
23.20 
  J9097  Cyclophosphamide Lyophilized, 2gm 
92.86 
  J9100  Cytarabine 100 mg (Cytosar-U) 
5.72 
  J9110  Cytarbine, 500 mg (Cytosar-U) 
23.49 
  J9130  Dacarbazine 100 mg (DTIC-Dome) 
12.05 
  J9140  Dacarbazine 200 mg (DTIC-Dome) 
21.43 
  J7513  Daclizumab, 25 mg (Zenapax) 
377.43 
  J9120  Dactinomycin, .5 mg (Cosmegen) 
12.57 
  J1645  Dalteparin, per 2500 I.U. (Fragmin) 
10.17 
  J9150  Daunorubicin HCL, 10 mg (Cerubidine) 
76.04 
  J9151  Daunorubicin Citrate Liposomal, 10 mg (DaunoXome) 
61.37 
  J0895  Deferoxamine Mesylate, 500 mg (Desferal) 
12.83 
  J9160  Denileukin Diftitox, 300mcg (Ontak) 
1,044.87 
  J1000  Depoestradiol Cypionate, up to 5 mg 
2.47 
  J1095  Dexamethasone Acetate 8 mg 
2.19 
  J2597  Desmopression Acetate per 1 mcg (DDAVP) 
4.54 
  J1100  Dexamethosone Sodium Phosphate, 1 mg (Cortastat, Dalalone) 
.10 
  J1190  Dexrazoxane HCL, 250 mg (Zinecard) 
184.80 
  J7110  Dextran 75, 500 ml 
97.96 
  J7042  Dextrose 5%/Normal Saline (500 ml = 1 unit) 
7.89 
  J7070  D5W, 1000 cc 
11.36 
  J7060  Dextrose 5%/Water (500 ml = 1 unit) 
8.84 
  J3360  Diazepam, up to 5 mg (Valium, Zetran) 
1.12 
  J1730  Diazoxide, up to 300 mg (Hyperstat IV) 
111.18 
  J0500  Dicyclomine HCL, up to 20 mg (Bentyl, Dilomine, Antispas) 
9.64 
  J9165  Diethylstilbestrol Diphosphate, 250 mg (Stilphostrol) 
13.69 
  J1160  Digoxin, up to 0.5 mg (Lanoxin) 
2.05 
  J1110  Dihydroergotamine Mesylate, up to 1 mg 
13.86 
  J0470  Dimercaprol, per 100 mg 
22.49 
  J1240  Dimenhydrinate, up to 50 mg 
.36 
  J1200  Diphenhydramine HCL, up to 50 mg (Benadryl) 
1.11 
  J1245  Dipyridamole, per 10 mg (Persantine IV) 
20.80 
  J1212  DMSO, Dimethyl Sulfoxide, 50%, 50 ml 
39.66 
  J1250  Dobutamine HCL, 250 mg (Dobutrex) 
10.31 
  J9170  Docetaxel, 20 mg (Taxotere) 
297.08 
  J1260  Dolasetron Mesylate, 10 mg (Anzemet) 
15.63 
  J9001  Doxorubicin HCL, all lipid formulations, 10 mg, 
359.42 
  J9000  Doxorubicin HCL, 10 mg (Adriamycin PFS, Adriamycin RDF, Rubex) 
41.07 
  J1810  Droperidol and Fentanyl Citrate, up to 2 ml ampule (Innovar) 
10.95 
  J1790  Droperidol, up to 5 mg (Inapsine) 
5.17 
  J1180  Dyphylline, up to 500 mg (Lufyllin, Dilor) 
7.48 
  J0600  Edetate Calcium Disodium up to 1000 mg 
38.09 
  J1650  Enoxaparin Sodium, 10 mg (Lovenox) 
5.25 
  Q9920  EPO, per 1000 units, Patient HCT 20 or less 
11.69 
  Q9921  EPO, per 1000 units, Patient HCT 21 
11.69 
  Q9922  EPO, per 1000 units, Patient HCT 22 
11.69 
  Q9923  EPO, per 1000 units, Patient HCT 23 
11.69 
  Q9924  EPO, per 1000 units, Patient HCT 24 
11.69 
  Q9925  EPO, per 1000 units, Patient HCT 25 
11.69 
  Q9926  EPO, per 1000 units, Patient HCT 26 
11.69 
  Q9927  EPO, per 1000 units, Patient HCT 27 
11.69 
  Q9928  EPO, per 1000 units, Patient HCT 28 
11.69 
  Q9929  EPO, per 1000 units, Patient HCT 29 
11.69 
  Q9930  EPO, per 1000 units, Patient HCT 30 
11.69 
  Q9931  EPO, per 1000 units, Patient HCT 31 
11.69 
  Q9932  EPO, per 1000 units, Patient HCT 32 
11.69 
  Q9933  EPO, per 1000 units, Patient HCT 33 
11.69 
  Q9934  EPO, per 1000 units, Patient HCT 34 
11.69 
  Q9935  EPO, per 1000 units, Patient HCT 35 
11.69 
  Q9936  EPO, per 1000 units, Patient HCT 36 
11.69 
  Q9937  EPO, per 1000 units, Patient HCT 37 
11.69 
  Q9938  EPO, per 1000 units, Patient HCT 38 
11.69 
  Q9939  EPO, per 1000 units, Patient HCT 39 
11.69 
  Q9940  EPO, per 1000 units, Patient HCT 40 
11.69 
  Q0136  Epoetin Alpha (for non ESRD use) per 1000 units (Epogen) 
11.69 
  J1325  Epoprostenol 0.5 mg 
17.16 
  J1330  Ergonovine Maleate, up to 0.2 mg 
4.28 
  J1364  Erythromycin Lactobionate, per 500 mg (Erythrocin) 
5.64 
  J1380  Estradiol Valerate, up to 10 mg 
9.18 
  J1390  Estradiol Valerate, up to 20 mg 
12.94 
  J0970  Estradiol Valerate, up to 40 mg (Delestrogen) 
21.48 
  J1410  Estrogen Conjugated, per 25 mg (Premarin Intravenous) 
52.35 
  J1435  Estrone, per 1 mg (Estone Aqueous, Estronol, etc.) 
.18 
  J1436  Etidronate Disodium, per 300 mg (Didronel) 
60.47 
  J9181  Etoposide, 10 mg (VePesid) 
9.93 
  J9182  Etoposide, 100 mg (VePesid) 
99.28 
  J3010  Fentanyl Citrate, 0.1 mg (2 ml) (Sublimaze) 
1.23 
  J7190  Factor VIII (anti-hemophilic factor, human) per I.U. 
.82 
  J7191  Factor VIII (anti-hemophilic factor, porcine) per I.U. 
1.99 
  J7192  Factor VIII (anti-hemophilic factor, recombinant) - per I.U. 
1.06 
  J7194  Factor IX complex, per I.U. 
.29 
  J7193  Factor IX (Antihemophilic Factor, Purified, non-recombinant) - per I.U. 
1.00 
  J7195  Factor IX (Antihemophilic Factor, recombinant) - per I.U. 
1.07 
  J1440  Filgrastim , 300 mcg/1ml (Neupogen) 
170.13 
  J1441  Filgrastim , 480 mcg/1.6ml (Neupogen) 
284.38 
  J9200  Floxuridine, 500 mg (FUDR) 
123.08 
  J9185  Fludarabine Phosphate, 50 mg (Fludara) 
295.57 
  J9190  Fluorouracil, 500 mg (Adrucil) 
2.47 
  J2680  Fluphenazine Decanoate, up to 25 mg (Prolixin Decanoate) 
13.39 
  J1455  Foscarnet Sodium, per 1000 mg (Foscavir) 
11.48 
  J1940  Furosemide, up to 20 mg (Lasix, Furomide M.D.) 
1.18 
  J1460  Gamma Globulin, Intramuscular, 1 cc (Gammar) 
3.24 
  J1470  Gamma Globulin, Intramuscular, 2 cc 
6.48 
  J1480  Gamma Globulin, Intramuscular, 3 cc 
9.72 
  J1490  Gamma Globulin, Intramuscular, 4 cc 
12.96 
  J1500  Gamma Globulin, Intramuscular, 5 cc 
16.20 
  J1510  Gamma Globulin, Intramuscular, 6 cc 
19.44 
  J1520  Gamma Globulin, Intramuscular, 7 cc 
22.68 
  J1530  Gamma Globulin, Intramuscular, 8 cc 
25.92 
  J1540  Gamma Globulin, Intramuscular, 9 cc 
29.16 
  J1550  Gamma Globulin, Intramuscular, 10 cc 
32.40 
  J1560  Gamma Globulin, Intramuscular, over 10 cc (use correct combinations of above codes)   
  J1570  Ganciclovir Sodium, 500 mg (Cytovene) 
32.20 
  J7310  Ganciclovir, Long-acting Implant, 4.5 mg (Vitrasert) 
4,512.50 
  J9201  Gemcitabine HCl. 200 mg (Gemzar) 
106.45 
  J1580  Gentamicin (Garamycin Sulfate) up to 80 mg (Gentamicin Sulfate, Jenamicin) 
1.85 
  J1610  Glucagon Hydrochloride, per 1 mg 
43.32 
  J1600  Gold Sodium Thiomaleate, up to 50 mg (Myochrysine) 
10.66 
  J1620  Gonadorelin Hydrochloride, per 100 mcg (Factrel) 
182.75 
  J9202  Goserelin Acetate Implant, per 3.6 mg (Zoladex) 
424.17 
  J1626  Granisetron Hydrochloride, 100 mcg (Kytril) 
17.61 
  J1631  Haloperidol Decanoate, per 50 mg (Haldol Decanoate - 50) 
25.37 
  J1630  Haloperidol Lactate, up to 5 mg (Haldol) 
6.77 
  J1642  Heparin Sodium, per 10 units (Heparin Lock Flush) 
.05 
  J1644  Heparin Sodium, per 1000 units 
.33 
  J3470  Hyaluronidase, up to 150 units (Wydase) 
5.78
  J0360  Hydralazine HCL, up to 20 mg (Apresoline) 
16.92 
  J1700  Hydrocortisone Acetate, up to 25 mg 
.32 
  J1710  Hydrocortisone Sodium Phosphate, up to 50 mg 
5.04 
  J1720  Hydrocortisone Sodium Succinate, up to 100 mg 
1.72 
  J1170  Hydromorphone, up to 4 mg (Dilaudid) 
.96 
  J3410  Hydroxyzine HCL, up to 25 mg (Vistaril, Vistaject-25, Hyzine-50) 
.67 
  J7320  Hylan G-F 20, 16 mg, for intra-arterial injection (Synvisc) 
212.09 
  J1980  Hyoscyamine Sulfate, up to 0.25 mg (Levsin) 
7.51 
  J7130  Hypertonic Saline Solution, 50 or 100 mEq, 20 cc vial) 
.45 
  J1742  Ibutilide Fumarate 1 mg. (Corvert) 
228.61 
  J9211  Idarubicin Hydrochloride, 5 mg (Idamycin) 
411.18 
  J9208  Ifosfamide, 1 gm (Ifex) 
153.28 
  J1785  Imiglucerase, per unit (Cerezyme) 
3.56 
  J1561  Immune Globulin, Intravenous, 500 mg (Panglobulin) 
36.10 
  J1745 Infliximab, 10 mg (Remicade) 
62.42 
  J1820  Insulin, up to 100 units (Regular, NPH, Lente, or Ultralente)) 
2.40 
  J9213  Interferon, Alfa-2A, Recombinant, 3 million units (Roferon-A) 
33.14 
  J9214  Interferon, Alfa-2B, Recombinant, 1 million units (Intron A) 
12.82 
  J9215  Interferon, Alfa-N3, (human leukocyte derived) 250,000 IU (Alferon N) 
7.47 
  J9212  Interferon, Alfacon-1, Recombinant, 1 mcg (Infergen) 
3.90 
  J9216  Interferon, Gamma 1-B, 3 million units (Actimmune) 
271.36 
  J9206  Irinotecan, 20 mg (Camptosar) 
133.66 
  J1750  Iron Dextran, 50 mg (Infed) 
17.01 
  J1840  Kanamycin Sulfate, up to 500 mg (Kantrex, Klebcil) 
2.03 
  J1850  Kanamycin Sulfate, up to 75 mg (Kantrex, Klebcil) 
2.94 
  J1885  Ketorolac Tromethamine, per 15 mg (Toradol) 
5.46 
  J1910  Kutapressin, up to 2 ml 
12.62 
  J0640  Leucovorin Calcium, per 50 mg (Wellcovorin) 
16.64 
  J9217  Leuprolide Acetate, 7.5 mg (Lupron, for Depot Suspension) 
580.98 
  J1950  Leuprolide Acetate, 3.5 mg (Lupron, for Depot Suspension) 
483.05 
  J9218  Leuprolide Acetate, per 1 mg (Lupron) 
24.84 
  J1955  Levocarnitine, per 1 gm (Carnitor) 
32.49 
  J1956  Levofloxacin, 250 mg (Levaquin) 
17.87 
  J1960  Levorphanol tartrate, up to 2 mg (Levo-Dromoran) 
3.57 
  J2000  Lidocaine HCL, 50 cc (Xylocaine) 
1.38 
  J2010  Lincomycin HCL, up to 300 mg (Lincocin) 
1.30 
  J2060  Lorazepam, 2 mg (Ativan) 
1.30 
J3490  Leuprolide Acetate, 11.25 mg (Lupron Depot Pediatric)
(Send in claim with invoice for manual pricing) 
 
J3490  Leuprolide Acetate, 15 mg (Lupron Depot Pediatric)
(Send in claim with invoice for manual pricing) 
 
J3490  Leuprolide Acetate, 7.5 mg (Lupron Depot Pediatric)
(Send in claim with invoice for manual pricing) 
 
  J3475  Magnesium Sulfate, 500 mg. 
.21 
  J2150  Mannitol, 25% in 50 ml 
2.87 
  J9230  Mechlorethamine Hydrochloride (Nitrogen Mustard), 10 mg 
10.88 
  J1055  Medroxyprogesterone Acetate for Contraceptive Use, 150 mg (Depo-Provera) 
43.29 
  J1050  Medroxyprogesterone Acetate, 100 mg (Depo-Provera) 
9.45 
  J9245  Melphalan Hydrochloride, 50 mg, (Alkeran) 
395.93 
  J2180  Meperidine and Promethazine HCL, up to 50 mg (Mepergan Injection) 
3.73 
  J2175  Meperidine Hydrochloride, per 100 mg (Demerol HCL) 
.57 
  J0670  Mepivacaine, per 10 ml (Carbocaine) 
1.80 
  J9209  Mesna, 200 mg (Mesnex) 
34.66 
  J0380  Metaraminol Bitartrate, 10 mg (Aramine) 
1.15 
  J1230  Methadone HCL, up to 10 mg (Dolophine) 
.71 
  J2800  Methocarbamol, up to 10 ml (Robaxin) 
6.09 
  J9250  Methotrexate Sodium, 5 mg 
.46 
  J9260  Methotrexate Sodium, 50 mg 
5.36 
  J0210  Methyldopate HCL, up to 250 mg (Aldomet) 
8.53 
  J2210  Methylergonovine Maleate, up to 0.2 mg (Methergine) 
3.37 
  J1020  Methylprednisolone Acetate, 20 mg (Depo Medrol) 
2.26 
  J1030  Methylprednisolone Acetate, 40 mg 
4.09 
  J1040  Methylprednisolone Acetate, 80 mg 
8.18 
  J2930  Methylprednisolone Sodium Succinate, up to 125 mg (Solu-Medrol, A-methaPred) 
2.95 
  J2920  Methylprednisolone Sodium Succinate, up to 40 mg (Solu-Medrol, A-Metha Pred) 
1.82 
  J2765  Metoclopramide HCL, up to 10 mg (Reglan) 
1.81 
  J2250  Midazolam HCL, per 1 mg (Versed) 
.64 
  J2260  Milrinone Lactate, 5 mg per 5 ml (Primacor) 
40.47 
  J9290  Mitomycin, 20 mg (Mutamycin) 
392.23 
  J9291  Mitomycin, 40 mg (Mutamycin) 
825.79 
  J9280  Mitomycin, 5 mg (Mutamycin) 
118.30 
  J9293  Mitoxantrone HCL, per 5 mg (Novantrone) 
252.87 
  J2275  Morphine Sulfate (preservative-free sterile solution), per 10 mg (Astramorph PF, Duramorph) 
7.32 
  J2270  Morphine Sulfate, up to 10 mg 
1.35 
  J2271  Morphine Sulfate (100 mg) 
9.26 
  J2310  Nalaxone HCL, per 1 mg (Narcan) 
3.99 
  J2300  Nalbuphine Hydrochloride, 10 mg 
1.37 
  J2321  Nandrolone Decanoate, up to 100 mg 
6.00 
  J2322  Nandrolone Decanoate, up to 200 mg 
12.01 
  J2320  Nandrolone Decanoate, up to 50 mg 
4.94 
  J2710  Neostigmine Methylsulfate, up to 0.5 mg (Prostigmin) 
.67 
  J7030  Normal Saline Solution, 1000 cc, infusion 
11.31 
  J7050  Normal Saline Solution, 250 cc, infusion 
10.81 
  J7040  Normal Saline Solution, Sterile (500 ml=1 unit), infusion 
10.29 
  S0079  Octreotide Acetate, 100 mcg (Sandostatin) 
15.75 
  J2352  Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 30 mg 
1,385.54 
J3490  Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 20 mg   
J3490  Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 10 mg   
  J2405  Ondansetron Hydrochloride, per 1 mg (Zofran) 
5.79 
  J2355  Oprelvekin, 5 mg (Newmega) 
233.52 
  J2360  Orphenadrine Citrate, up to 60 mg (Norflex, etc.) 
1.44 
  J2700  Oxacillin Sodium, up to 250 mg (Bactocile, Prostaphlin) 
.62 
  J2410  Oxymorphone HCL, up to 1 mg (Numorphan) 
2.66 
  J2460  Oxytetracycline HCL, up to 50 mg (Terramycin IM) 
.90 
  J2590  Oxytocin, up to 10 units (Pitocin, Syntocinon) 
.72 
  J9265  Paclitaxel, 30 mg (Taxol) 
155.88 
  J2430  Pamidronate Disodium, per 30 mg (Aredia) 
252.58 
  J2440  Papaverine HCL, up to 60 mg 
3.38 
J9266  Pegaspargase Single Dose vial, (5 ml) (Oncaspar)   
  J0540  Penicillin G Benzathine and Penicillin G Procaine, up to 1,200,000 units (Bicillin C-R) 
13.67 
  J0550  Penicillin G Benzathine and Penicillin G Procaine, up to 2,400,000 units (Bicillin C-R) 
27.37 
  J0530  Penicillin G Benzathine and Penicillin G procaine, up to 600,000 units (Bicillin C-R) 
8.36 
  J0570  Penicillin G Benzathine, up to 1,200,000 units (Bicillin L-A, Permapen) 
18.79 
  J0580  Penicillin G Benzathine, up to 2,400,000 units (Bicillin L-A, Permapen) 
42.18 
  J0560  Penicillin G Benzathine, up to 600,000 units (Bicillin L-A, Permapen) 
11.89 
  J2540  Penicillin G Potassium, up to 600,000 units (Pfizerpen) 
.28 
  J2510  Penicillin G Procaine, Aqueous, up to 600,000 units (Wycillin, etc.) 
6.39 
  J2545  Pentamidine Isethionate, inhalation solution, per 300 mg (Pentam 300, NebuPent, PentacaRinat) 
89.12 
  S0080  Pentamidine Isethionate, IV, IM, per 300 mg 
88.88 
  J3070  Pentazocine HCL, up to 30 mg (Talwin) 
4.08 
  J2515  Pentobarbital Sodium (Nembutal Sodium Solution), per 50 mg 
.50 
  J9268  Pentostatin, per 10 mg (Nipent) 
1,571.43 
  J2543  Piperacillin Sodium/Tazobactam Sodium 1gm/0.125 gm (1.125gm) (Zosyn) 
4.64 
  J3310  Perphenazine, up to 5 mg (Trilafon) 
6.45 
  J2560  Phenobarbital Sodium, up to 120 mg 
1.54 
  J2760  Phentolamine Mesylate, up to 5 mg (Regitine) 
30.96 
  J2370  Phenylephrine HCL, up to 1 ml (NeoSynephrine) 
1.22 
  J1165  Phenytoin Sodium, per 50 mg (Dilantin) 
.09
  J9270  Plicamycin, 2.5 mg (Mithracin) 
89.11 
  J9600  Porfimer Sodium, 75 mg (Photofin) 
2,473.49 
  J3480  Potassium Chloride, per 2 mEq. 
.16 
  J2730  Pralidoxime Chloride, up to 1 gm (Protopam Chloride) 
97.81 
  J2650  Prednisolone Acetate, up to 1 ml 
.32 
  J2690  Procainamide HCL, up to 1 gm (Pronestyl) 
10.48 
  J0780  Prochlorperazine Edisylate 10 mg (Compazine, Cotranzine, Compa-Z, Ultrazine-10) 
2.48 
  J2950  Promazine HCL, up to 25 mg (Sparine, Prozine-50) 
.44 
  J2550  Promethazine HCL, up to 50 mg (Phenergan, Phenazine) 
2.71 
  J1800  Propranolol HCL, up to 1 mg (Inderal) 
11.04 
  J2720  Protamine Sulfate, per 10 mg 
.73 
  J2725  Protirelin, per 250 mcg (Relefact TRH, Thypinone) 
23.18 
  J2780  Rantidine HCL, 25 mg (Zantac) 
1.37 
  J7120  Ringers Lactate Infusion, up to 1000 cc 
12.70 
  J9310  Rituximab (Rituxan) 100 mg (Rituxan) 
431.82 
  J2820  Sargramostim (GM-CSF), 50 mcg (Leukine, Prokine) 
27.61 
J3490  Sodium Bicarbonate 7.5% up to 50 ml   
  J2912  Sodium Chloride, 0.9% per 2 ml 
.09 
  J7316  Sodium Hyaluronate, 5 mg. for intra-articular injection (Biolon, Provisc, Vitrax, Hyalgan) 
26.49 
  J3320  Spectinomycin Dihydrochloride, up to 2 gm (Trobicin) 
25.46 
  J7051  Sterile Saline or Water (up to 5 cc) 
.18 
  J2995  Streptokinase, per 250,000 IU (Streptase) 
114.90 
  J3000  Streptomycin, up to 1 gm (Streptomycin Sulfate) 
6.02 
  J9320  Streptozocin, 1 gm (Zanosar) 
111.76 
  J0330  Succinycholine Chloride, up to 20 mg (Anectine, Quelicin, Surostrin) 
.10 
  J9170  Docetaxel, 20 mg (Taxotere) 
297.08 
  J3105  Terbutaline Sulfate, up to 1 mg (Brethine, Bricanyl Subcutaneous) 
2.02 
  J1060  Testosterone Cypionate and Estradiol Cypionate, up to 1 ml 
3.52 
  J1080  Testosterone Estradiol Cypionate, 1 cc, 200 mg 
7.12 
  J1070  Testosterone Estradiol Cypionate, up to 100 mg 
4.10 
  J0900  Testosterone Enanthate and Estradiol Valerate up to 1 cc (Deladumone, etc.) 
1.56 
  J3120  Testosterone Enanthate, up to 100 mg (Evarone, Delatestryl, etc.) 
6.47 
  J3130  Testosterone Enanthate, up to 200 mg, (Evarone, Delatestryl, Andro L.A. 200, etc.) 
12.94 
  J3150  Testosterone Propionate, up to 100 mg (Testex) 
.89 
  J3140  Testosterone Suspension, up to 50 mg (Andronaq 50, Testosterone Aqueous, etc.) 
.92 
J0120  Tetracycline, up to 250 mg (Achromycin, Panmycin, Sumycin)   
  J3280  Thiethylperazine Maleate, up to 10 mg (Norzine, Torecan) 
4.37 
  J9340  Thiotepa, 15 mg (Thioplex) 
111.12 
  J3240  Thyrotropin Alfa, 0.9 mg (Thyrogen) 
538.34 
  J3260  Tobramycin Sulfate, up to 80 mg (Nebcin) 
4.98 
  J9350  Topotecan, 4 mg (Hycamtin) 
660.26 
  J3265  Torsemide, 10 mg/ml (Demadex) 
2.10 
  J2670  Tolazoline HCL, up to 25 mg (Priscoline HCL) 
3.72 
  J9355  Trastuzumab, 10 mg (Herceptin) 
50.19 
  J3301  Triamcinolone Acetonide, per 10 mg (Kenalog-10, Kenalog-40, Tri-Kort, etc.) 
1.44 
  J3302  Triamcinolone Diacetate, per 5 mg (Aristocort Intralesional, Aristocort Forte, Amcort, etc.) 
.19 
  J3303  Triamcinolone Hexacetonide, per 5 mg (Aristospan Intralesional, Aristospan Intra-articular) 
2.47 
  J3400  Triflupromazine HCL, up to 20 mg (Vesprin) 
8.24 
  J3250  Trimethobenzamide HCL, up to 200 mg (Tigan, Ticon, Tiject-20, Arrestin) 
.90 
  J3305  Trimetrexate Glucoronate, per 25 mg (Neutrexin) 
112.81 
  J3350  Urea, up to 40 gm (Ureaphil) 
80.02 
  J3365  Urokinase, 250,000 I.U. Vial (Abbokinase) 
442.86 
  J3364  Urokinase, 5000 I.U. vial (Abbokinase Open-Cath) 
53.78 
  J9357  Valrubicin, intravesical, 200 mg (Valstar) 
500.35 
  J3370  Vancomycin HCL, 500 mg (Varcocin, Vancoled) 
4.94 
  J9360  Vinblastine Sulfate, 1 mg (Velban) 
3.90 
  J9370  Vincristine Sulfate, 1 mg (Oncovin,) 
30.47 
  J9375  Vincristine Sulfate, 2 mg (Oncovin) 
49.54 
  J9380  Vincristine Sulfate, 5 mg (Oncovin,) 
146.84 
  J9390  Vinorelbine Tartrate, per 10 mg (Navelbine) 
94.32 
  J3430  Vitamin K, Phytonadione 1 mg/0.5ml 
2.21 
  J2500  Zemplar (Paricalcitol) 5 mcg 
23.84 

Revised April 18, 2002
 

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


Attention: Health Check Providers

Health Check Seminar

Health Check seminars for all providers except health departments are scheduled for August 2002. The July general Medicaid bulletin will have the registration form and a list of site locations for the seminars. Attendance at these seminars is very important because Health Check billing requirements will change on October 1, 2002. Due to the magnitude of the changes in Health Check billing, these seminars will only focus on the new Health Check billing requirements and will not include any basic Medicaid billing instructions.

A separate teleconference sponsored by the Division of Public Health is scheduled for health department providers. The July general Medicaid bulletin will include registration information for the teleconference.
 

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


Attention: All Providers

Fee Schedules and Reimbursement Plans

Fee Schedule Request Form

There is no charge for fee schedules or reimbursement plans requested from the Division of Medical Assistance (DMA).  DMA stipulates that the information provided is to be used only for internal analysis. Providers are expected to bill their usual and customary rate.  All requests for fee schedules and reimbursement plans must be made on the Fee Schedule Request form and mailed to:

Division of Medical Assistance
Financial Operations - Fee Schedules
2509 Mail Service Center
Raleigh, N. C. 27699-2509

Or fax your request to DMA's Financial Operations section at 919-715-0896.

NOTE: PHONE REQUESTS ARE NOT ACCEPTED


Attention: Residential Child Care Facility Providers

Accreditation Requirement and Provider Status Changes

Effective February 1, 2002, the Division of Medical Assistance no longer requires a compliance verification credential from the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. Licensure through the Division of Facility Services (DFS) for a Residential Child Care Facility (Levels II through IV) satisfies the accreditation requirement for enrollment with the N.C. Medicaid program.

Providers who are currently enrolled as a Residential Child Care Facility but choose to change the number of beds available in the facility must apply for a new license from DFS and submit a copy of the new license to the address listed below. Failure to maintain appropriate licensure reflecting the number of beds available in the facility may result in a denied claim.

Division of Medical Assistance
Provider Services
2506 Mail Service Center
Raleigh, NC 27699-2506

Providers must report all other changes in status (address and telephone number changes, name changes, change of ownership, etc.) to the N.C. Medicaid program using the Notification of Change in Provider Status form.
 

Joe Ann McCullough, Provider Services
DMA, 919-857-4017


Attention: Rural Health Clinics and Federally Qualified Health Centers

Core Service Code Conversion

Effective with date of service June 30, 2002, state-created codes Y2058 and Y2089 will be end-dated to comply with the implementation of national procedure codes mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Effective with date of service July 1, 2002, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) providers must bill procedure code T1015 - Clinic visit/encounter, all inclusive -for all core services. An RHC/FQHC core service visit must be billed using the provider's six-digit provider number with alpha suffix "A."
 
End-dated Code New Code
Y2058 - RHC Core Service  T1015 - Clinic visit/encounter, all inclusive 
Y2059 - FQHC Core Service  T1015 - Clinic visit/encounter, all inclusive 

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


 

Checkwrite Schedule
June 11, 2002 
July 16, 2002 
August 13, 2002 
June 18, 2002 
July 23, 2002 
August 20, 2002 
June 27, 2002 
July 31, 2002 
August 29, 2002 

Electronic Cut-Off Schedule
June 7, 2002 
July 12, 2002 
August 9, 2002 
June 14, 2002 
July 19, 2002 
August 16, 2002 
June 21, 2002 
July 26, 2002 
August 23, 2002 

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.



 
______________________ _______________________
Nina M. Yeager, Director Ricky Pope
Division of Medical Assitance Executive Director
Department of Health and Human Services  EDS

 
 
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