July 2006 NC Medicaid Bulletin

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In This Issue...

All Providers:

Adult Care Home Providers: 

AQUIP Users:

CAP/DA Lead Agencies:

Community Health Providers:

Dental Providers:

Federally Qualified Health Centers (FQHCs):

Health Departments:

Home Health Agencies:

Hospice:

Hospitals:

Nurse Practitioners:

Nursing Facilities:

Pharmacists and Prescribers:

Physicians:

Rural Health Centers (RHCs):

Social Services:



Attention: All Providers

Applying for the National Provider Identifier

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of a standard unique identifier for healthcare providers.  The final rule for the National Provider Identifier (NPI) was issued on January 23, 2004, and adopts the NPI as this national standard.

Healthcare providers can apply now for their NPI at the following website: https://nppes.cms.hhs.gov.  All HIPAA-covered physicians, suppliers, and other health care providers must apply for and be issued an NPI by May 23, 2007.  In addition, all health plans must be able to accept the NPI instead of the plan specific provider identifiers on all HIPAA standard transactions by May 23, 2007.  In other words, after this date claims submitted to Medicaid must be billed with your NPI number instead of your current Medicaid provider number.

ALERT:   When applying for an NPI, you are urged to include all Medicaid provider numbers on the NPI application form.  Be sure to indicate North Carolina as your state name.  It is our understanding that at some point CMS will make enumeration information available to states.  At that time, this information will assist DMA in the development of crosswalks between your NPI and your Medicaid provider numbers. 

The Division of Medical Assistance has initiated its NPI project.  Please look for future bulletins regarding procedures for gathering NPIs and taxonomies.

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


Attention: All Providers

Clarification for Completing the W-9

The Medicaid provider enrollment process includes the completion of the Internal Revenue Service’s (IRS) W-9 form.  The Division of Medical Assistance (DMA) must collect this information in order to correctly report income paid to the provider.  The W-9 form is retained by DMA and is not sent to the IRS.  The instructions that the IRS provides with the W-9 form explain that payments you receive may be subject to backup withholding if you do not report your correct tax identification number (TIN).  The instructions further explain the TIN provided must match the name given on Line 1.  Failure to provide your correct TIN may result in a penalty.  (The W-9 form and instructions for completing the form are available at http://www.irs.gov.) 

Some individual providers who are also associated with a group practice submitted their W-9 with the group’s TIN listed instead of their SSN.  Now that DMA is aware of this issue, the IRS instructions and guidelines for completion of the W-9 form will be followed.  Providers who have supplied incorrect TINs in the past may correct their W-9 at any time by completing a Provider Change Form and attaching a corrected W-9.

Earnings reported on the 1099 form are based on the provider number entered on the claim form. If incorrect earnings are reported it may be because claims are incorrectly filed without the group number, which results in income being reported to the individual (attending) provider number entered on the claim.  Incorrect earnings are NOT reported based on the W-9.  It is important that all providers carefully review the Financial Section of Remittance and Status Report (RA) to verify that the claim is submitted properly and income is reported to the correct TIN. 

Provider Services
DMA, 919-855-4050          



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 and Programs
DMA, 919-855-4260


Attention: Adult Care Home Providers

Medicaid Payments for Recipients Residing in an Adult Care Home Special Care Unit for Persons with Alzheimer’s and Related Disorders

Session Law 2005-276, passed during the 2004–2005 legislative session, provided additional funding for special care units for persons with Alzheimer’s and related disorders located in adult care homes (SCU-A). As part of that legislation, effective October 1, 2005, an enhanced state and county special assistance rate became available to cover an increased room and board charge in a SCU-A.

The legislation also requires the N.C. Medicaid program to implement an enhanced personal care service rate for Medicaid recipients in the SCU-A. Effective with date of service October 1, 2006, the N.C. Medicaid program will implement this SCU-A, enhanced personal care service rate. Providers must obtain prior approval from Medicaid before admitting a Medicaid resident to a SCU-A and receiving this new enhanced rate. The prior approval process will be explained in an article in the July 2006 general Medicaid bulletin.

Clinical Policy and Programs
DMA, 919-855-4360


Attention: CAP/DA Lead Agencies and AQUIP Users

Quarterly Automated Quality Utilization and Improvement Program Training Seminar

The second quarterly Automated Quality Utilization and Improvement Program (AQUIP) training seminar for new AQUIP users in a CAP/DA Lead Agency is scheduled for June 27, 2006, at the Hilton Charlotte University Place.

Attendance at this meeting is of the utmost importance for new AQUIP users.  CAP/DA lead agency contacts have been informed via e-mail of any identified new AQUIP users in their counties who should attend this session.  Any current AQUIP users who would like to attend the session may do so if space permits.

The AQUIP seminar is scheduled to begin at 9:00 a.m. (registration 8:30 to 9:00 a.m.) and end at 4:00 p.m.  The morning session will focus on how to accurately complete the Client Information Sheet, Data Set Assessment, and Plan of Care.  After a break for lunch (on your own), the afternoon session will address the system overview and use.

Preregistration is required.  Contact your CAP/DA lead agency to verify if your name is on the required attendance list.  You may register for the seminar online by going to https://www2.mrnc.org/aquip and clicking on Registrations.  You will receive a computer-generated confirmation number, which you should bring to the seminar.

Driving Directions

Hilton Charlotte University Place—Charlotte

Exit from I-85 North or South at exit 45A, W.T. Harris Boulevard East.  Hilton Charlotte University Place is 0.25 mile 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 directly into the hotel parking lot.

Facility and Community Care
DMA, 919-855-4360



Attention:  All Dental Providers Including Health Department Dental Clinics

Dental Rate Change

Effective with dates of service October 1, 2005, reimbursement rates for the following dental procedures were increased.  The rate changes were entered into the MMIS system on May 5, 2006; therefore, claims processed after this date will pay with these new rates.  Claims that processed prior to May 5, 2006, will be automatically reprocessed through system adjustments to pay the additional reimbursement.  Providers will be notified through the general Medicaid bulletin and/or a banner message on the remittance advice regarding the scheduled date for system adjustments.  No adjustments will be accepted from providers for these dental rate changes.  Providers are reminded to bill their usual and customary charges rather than the Medicaid rate.

CDT 2005
Code


Description

Reimbursement
Rate

D0250

Extraoral – first film

16.81

D0260

Extraoral – each additional film

13.94

D0270

Bitewing – single film

8.20

D0290

Posterior-anterior or lateral skull and facial bone survey film

34.85

D0310

Sialography

68.88

D0320

Temporomandibular joint arthrogram, including injection

153.75

D0340

Cephalometric film

36.90

D0473

Accession of tissue, gross and microscopic examination, preparation and transmission of written report

33.62

D2390

Resin-based composite crown, anterior

123.82

D2931

Prefabricated stainless steel crown–permanent tooth

146.25

D2940

Sedative filling

31.98

D2950

Core buildup, including any pins

78.31

D3310

Anterior (excluding final restoration)

204.18

D3410

Apicoectomy/periradicular surgery – anterior

233.50

D4210

Gingivectomy or gingivoplasty – four or more contiguous teeth or bounded teeth spaces, per quadrant

223.00

D4211

Gingivectomy or gingivoplasty – one to three teeth contiguous teeth or bounded teeth spaces per quadrant

80.00

D4240

Gingival flap procedure, including root planing – four or more contiguous teeth or bounded teeth spaces, per quadrant

260.00

D4241

Gingival flap procedure, including root planing – one to three teeth, per quadrant

217.50

D4342

Periodontal scaling and root planing – one to three teeth per quadrant

42.64

D4910

Periodontal maintenance

48.50

D5110

Complete denture – maxillary

461.25

D5120

Complete denture – mandibular

461.25

D5130

Immediate denture – maxillary

500.20

D5140

Immediate denture – mandibular

500.20

D5211

Maxillary partial denture – resin base (including any conventional clasps, rests, and teeth)

357.00

D5212

Mandibular partial denture – resin base (including any conventional clasps, rests, and teeth)

357.00

D5213

Maxillary partial denture–cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth)

504.00

D5214

Mandibular partial denture–cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth)

504.00

D5410

Adjust complete denture – maxillary

25.42

D5411

Adjust complete denture–mandibular

25.42

D5421

Adjust partial denture – maxillary

25.42

D5422

Adjust partial denture – mandibular

25.42

D5520

Replace missing or broken teeth – complete denture (each tooth)

62.50

D5620

Repair cast framework

100.00

D5640

Replace broken teeth – per tooth

62.50

D5650

Add tooth to existing partial denture

76.50

D5730

Reline complete maxillary denture (chairside)

107.83

D5731

Reline complete mandibular denture (chairside)

107.83

D5740

Reline maxillary partial denture (chairside)

105.37

D5741

Reline mandibular partial denture (chairside)

105.37

D5750

Reline complete maxillary denture (laboratory)

139.40

D5751

Reline complete mandibular denture (laboratory)

139.40

D5760

Reline maxillary partial denture (laboratory)

137.35

D5761

Reline mandibular partial denture (laboratory)

137.35

D6985

Pediatric partial denture, fixed

282.90

D7210

Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth

78.72

D7220

Removal of impacted tooth – soft tissue

92.25

D7240

Removal of impacted tooth–completely bony

157.50

D7241

Removal of impacted tooth–completely bony, with unusual surgical complications

165.23

D7250

Surgical removal of residual tooth roots (cutting procedure)

86.10

D7270

Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth

187.50

D7283

Placement of device to facilitate eruption of impacted tooth

158.67

D7285

Biopsy of oral tissue – hard (bone, tooth)

130.00

D7310

Alveoloplasty in conjunction with extractions–per quadrant

82.00

D7320

Alveoloplasty not in conjunction with extractions – per quadrant

147.50

D7411

Excision of benign lesion greater than 1.25 cm

205.00

D7412

Excision of benign lesion, complicated

257.00

D7413

Excision of malignant lesion up to 1.25 cm

234.00

D7414

Excision of malignant lesion greater than 1.25 cm

308.00

D7415

Excision of malignant lesion, complicated

375.00

D7440

Excision of malignant tumor – lesion diameter up to 1.25 cm

189.00

D7441

Excision of malignant tumor – lesion diameter greater than 1.25 cm

350.00

D7472

Removal of torus palatinus

256.50

D7473

Removal of torus mandibularis

250.00

D7490

Radical resection of maxilla or mandible

2,511.25

D7530

Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue

101.27

D7560

Maxillary sinusotomy for removal of tooth fragment or foreign body

308.32

D7610

Maxilla–open reduction (teeth immobilized, if present)

1,229.18

D7620

Maxilla–closed reduction (teeth immobilized, if present)

940.95

D7630

Mandible–open reduction (teeth immobilized, if present)

1,213.19

D7640

Mandible–closed reduction (teeth immobilized, if present)

906.10

D7650

Malar and/or zygomatic arch–open reduction

1,154.15

D7660

Malar and/or zygomatic arch–closed reduction

852.80

D7670

Alveolus – closed reduction, may include stabilization of teeth

338.66

D7680

Facial bones – complicated reduction with fixation and multiple surgical approaches

1,854.84

D7710

Maxilla–open reduction

1,337.83

D7720

Maxilla–closed reduction

902.00

D7730

Mandible–open reduction

1,328.40

D7740

Mandible–closed reduction

990.56

D7750

Malar and/or zygomatic arch – open reduction

1,224.67

D7760

Malar and/or zygomatic arch–closed reduction

1,116.02

D7770

Alveolus – open reduction stabilization of teeth

686.75

D7780

Facial bones – complicated reduction with fixation and multiple surgical approaches

2,304.20

D7810

Open reduction of dislocation

1,180.39

D7820

Closed reduction of dislocation

146.37

D7840

Condylectomy

1,575.63

D7850

Surgical discectomy, with/without implant

1,586.70

D7858

Joint reconstruction

1,401.15

D7860

Arthrotomy

624.65

D7870

Arthrocentesis

72.98

D7872

Arthroscopy – diagnosis, with or without biopsy

485.84

D7873

Arthroscopy – surgical: lavage and lysis of adhesions

578.26

D7920

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

666.66

D7940

Osteoplasty – for orthognathic deformities

953.66

D7941

Osteotomy – mandibular rami

2,690.42

D7943

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

2,453.03

D7944

Osteotomy – segmented or subapical – per sextant or quadrant

2,071.32

D7945

Osteotomy – body of mandible

2,114.78

D7946

LeFort I (maxilla – total)

2,525.60

D7947

LeFort I (maxilla – segmented)

2,522.73

D7948

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

2,922.48

D7949

LeFort II or LeFort III – with bone graft

3,509.60

D7963

Frenuloplasty

282.08

D7972

Surgical reduction of fibrous tuberosity

188.60

D7981

Excision of salivary gland, by report

564.01

D7982

Sialodochoplasty

459.20

D7990

Emergency tracheotomy

356.70

D7991

Coronoidectomy

1,173.42

D8670

Periodic orthodontic treatment visit (as part of contract)

76.68

D9110

Palliative (emergency) treatment of dental pain – minor procedure

34.85

D9221

Deep sedation/general anesthesia–each additional 15 minutes

45.92

D9241

Intravenous conscious sedation/analgesia–first 30 minutes

115.62

D9242

Intravenous conscious sedation/analgesia–each additional 15 minutes

41.00

D9410

House/extended care facility call

61.50

D9440

Office visit–after regularly scheduled hours

42.64

D9610

Therapeutic drug injection, by report

25.83

Effective with dates of service July 1, 2006, reimbursement rates for the following dental procedures will be changed:

CDT 2005
Code


Description

Reimbursement
Rate

D1510

Space maintainer – fixed – unilateral

200.00

D1515

Space maintainer–fixed–bilateral

280.00

D7450

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

169.00

D7451

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

225.00

D7460

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

247.50

D7510

Incision and drainage of abscess–intraoral soft tissue

116.25

D7520

Incision and drainage of abscess–extraoral soft tissue

250.00

D7550

Partial ostectomy/sequestrectomy for removal of non-vital bone

319.00

D7971

Excision of pericoronal gingiva

160.00

For current pricing on these and all dental codes, refer to DMA’s Fee Schedule web page.  For coverage criteria and additional billing guidelines, please refer to Clinical Coverage Policy 4A, Dental Services.

Dental Program
DMA, 919-855-4280


Attention: Hospitals, Nursing Facilities, Hospice, Dept. of Social Services, Physicians, Home Health Agencies, Health Departments, Federally Qualified Health Centers (FQHCs), and Rural Health Centers (RHCs) 

Preadmission Screening and Annual Resident Review (PASARR) Seminars

Seminars for the PASARR program are scheduled for June and July 2006.  The seminars are designed to educate providers on the changes to procedures for processing PASARR.

Preregistration for this seminar is required.  Providers register for the seminar by completing and submitting the registration form or by registering online beginning June 1st.  A confirmation notice will be mailed to each registered participant.  The deadline for registration is the date of each seminar.

The seminars begin at 10:00 am. and end at 1:00 p.m.  Providers should arrive at least 30 minutes early to complete the registration process.  Lunch will not be served.

Providers must print a copy of the Special Bulletin, PASARR Program and Training from the DMA website and bring it to the seminar.

Dates and Locations:

Wednesday, June 7, 2006

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

Wednesday, June 14, 2006

Holiday Inn Conference Center
530 Jake Alexander Boulevard South
Salisbury, NC

Wednesday, July 12, 2006

Coastline Convention Center
501 Nutt Street
Wilmington, NC

Wednesday, June 21, 2006

Jane S. McKimmon Center
1101 Gorman Street
Raleigh, NC

Wednesday, June 28, 2006

Greenville Hilton
207 SW Greenville Boulevard
Greenville, NC

 


Directions:

Flat Rock- Bo Thomas Auditorium

Take I-40 to Asheville. Travel east on I-26 to exit 53, Upward Rd. Turn right and end of ramp. At second light, turn right onto S. Allen Drive. Turn left at sign onto College Drive. First building on right is the Sink Building. Bo Thomas Auditorium is on the left side of the Sink Building.

Salisbury- Holiday Inn

Traveling South on I-85
Take exit 75.  Turn right onto Jake Alexander Boulevard. Travel approximately ½ mile.  The Holiday Inn is located on the right.

Traveling North on I-85
Take exit 75.  Turn left onto Jake Alexander Boulevard.  Travel approximately ½ mile.  The Holiday Inn is located on the right.

Raleigh- McKimmon Center

Traveling East on I-40
Take exit 295 and turn left onto Gorman Street. Travel approximately 2½ miles.  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 2½ miles.  The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

Greenville- Hilton Hotel

Take Highway 264 east to Greenville.  Turn right onto Allen Road in Greenville.  Travel approximately 2 miles.  Allen Road becomes Greenville Boulevard/Alternate 264.  Follow Greenville Boulevard for 2½ miles to the Hilton Greenville, which is located on the right.

Wilmington- Coast Line Convention Center

Take I-40 east to Wilmington.  Turn right onto Martin Luther King, Jr., Parkway (U.S. 74 West).  Follow signs for downtown Wilmington; the Parkway becomes Third Street.  At first light on Third Street, turn right on Red Cross Street.  Travel two blocks on Red Cross and turn right onto Nutt Street.  Take the second driveway on the left into the Hotel and Convention Center.



Attention: Pharmacists and Prescribers

Outpatient Pharmacy Program Special Bulletin

Effective May 16, 2006, the Outpatient Pharmacy Program Special Bulletin was updated.  This special bulletin supersedes previously published policies and procedures. For your convenience, highlighting in the bulletin will indicate all new information.

The most significant change is a new telephone number of 1-800-688-6696 or 919-851-8888 to call when requesting changes to pharmacy lock-in providers or when identifying new recipients who are restricted to a single pharmacy and managed through the Medication Management Program. Specialty providers will also have to call this number to register with EDS to be added to the recipient’s lock-in file.

Providers may access the May 2006 Special Bulletin, Outpatient Pharmacy Program.  Providers should contact EDS with any billing questions.

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



Attention: Physicians and Nurse Practitioners

Daptomycin Injection, 1 mg, (Cubicin, J0878) – Billing Guidelines

The following article is reprinted from the May bulletin because Cubicin was incorrectly coded.

Daptomycin Injection, 1 mg (Cubicin, J0878) - Billing Guidelines

Effective with date of service January 1, 2006, the N.C. Medicaid program covers daptomycin for injection (Cubicin) for use in the Physician’s Drug Program, when billed with HCPCS code J0878.  Cubicin is an antibacterial agent of a new class of antibiotics, the cyclic lipopeptides.  The FDA approved indication for Cubicin is the treatment of complicated skin and skin structure infections caused by susceptible strains of the following Gram-positive microorganisms:

Combination therapy may be clinically indicated if the documented or presumed pathogens include Gram-negative or anaerobic organisms.  Cubicin is not recommended for the treatment of pneumonia.

The FDA indicates that the usual adult dose is 4 mg/kg administered over a 30-minute period by IV infusion in 0.9% sodium chloride injection once every 24 hours for 7-14 days.  Doses of Cubicin higher than 4 mg/kg/day have not been studied in Phase 3 controlled clinical trials.  Cubicin should not be dosed more frequently than once a day.

One of the following ICD-9-CM diagnosis codes is required when billing for Cubicin: 

035

373.13

376.01

380.10 through 380.16

528.5

608.4

616.4

680.0 through 680.9

681.0 through 681.9

682.0 through 682.9

685.0

686.00 through 686.09

686.1 through 686.9

     

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

035

02012006

11

J0878

$

 

For Medicaid billing, one unit of coverage is 1 mg.  The maximum reimbursement rate per unit is $0.29.  The fee schedule for the Physician’s Drug Program is available on DMA’s Fee Schedule web page.

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



NCLeads Update

Information related to the implementation of the new Medicaid Management Information System, NCLeads, can be found online.  Please refer to the NCLeads website for information, updates, and contact information related to the NCLeads system.

Provider Relations
Office of MMIS Services
919-647-8315


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.


 

2006 Checkwrite Schedule

Month

Electronic Cut-Off Date

Checkwrite Date

June

06/02/06

06/06/06

 

06/09/06

06/13/06

 

06/16/06

06/22/06

July

06/30/06

07/06/06

 

07/07/06

07/11/06

 

07/14/06

07/18/06

 

07/21/06

07/27/06

 August

08/04/06

08/08/06

 

08/11/06

08/15/06

 

08/18/06

08/22/06

 

08/25/06

08/30/06

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