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July 2007
Medicaid Bulletin

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In This Issue . . .

NPI Articles:

All Providers:

Children's Developmental Service Agencies:

CAP/MR-DD Case Managers, and CAP/MR-DD Service Providers:

Community Alternative Program Providers - Disabled Adults (CAP-DA), Children (CAP-Ch) and Choice (CAP-Ch):

Durable Medical Equipment Providers:

Health Departments:

Home Health Agencies:

Independent Laboratories:

Independent Practitioners:

Local Management Entities:

Medical Doctors and Doctors of Osteopathic Medicine:

Mental Health Providers:

Nurse Practitioners:

Orthotic and Prosthetic Device Providers:

Outpatient Hospital Clinics:

PCS and PCS-Plus Providers:

Physicians:

Residential Childcare Facility Providers:

Private Duty Nursing Providers:



NPI Logo 

Attention:  All Providers

Include Zip+4 on Claims

Providers are now required to include the last four digits of the ZIP code in the billing address and service facility location address fields on all claims.  Requirements for each claim form regarding ZIP+4 are listed below.

To locate your ZIP+4, use the following link:  USPS - ZIP Code Lookup.  Once NPI is implemented, the ZIP+4 will be an important component for claims processing. Therefore, it is imperative for providers to begin including this information on claims.

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

17th Baby Love Conference

Join us for the 2007 Baby Love Conference, August 27-28, 2007, at the Sheraton Imperial Hotel & Convention Center in Durham, N.C.  This year’s theme is Celebrating Victories, Promoting Partnerships.  This is an important event that will provide training, skill building, and networking opportunities for a broad variety of professionals who provide essential services to women, children, and families.

Conference participants will include social workers, nurses, paraprofessionals, and other human service professionals providing services through many program areas.  Program areas include maternity care coordination, maternal outreach worker services, child service coordination, health and behavior intervention, early intervention, home visiting programs, childbirth education, health education, and other programs that support North Carolina’s families.

Participants may register for the conference by completing the registration form that will be available beginning mid-July at Northwest Area Health Education Center’s Web site: http://northwestahec.wfubmc.edu/.

Please click on the following link to view the Baby Love flyer.

Clinical Policy
DMA, 919-855-4329



Attention: All Providers

2007 Legislative Rate Allocation

Effective with date of service January 1, 2007, the legislature allocated $12 million to be used for rate increases for Medicaid providers.  All providers’ rates were reviewed for an allocation by a third party and rate increases were subsequently allotted to the following provider types: dialysis centers; intermediate care facilities for the mentally retarded; dentists; physicians and other professionals; nursing facilities; ambulatory surgery centers and birthing centers; ambulances; independent laboratories; optical program; the Community Alternatives Program; adult care homes and personal care services; private duty nursing; home health agencies, home infusion therapy, community personal care services; and durable medical equipment and orthotic and prosthetic devices.

The claims payment system was not updated for these rate increases until after the effective date of the rate changes.  Therefore, providers should check for changes to the maximum allowable rates on the applicable fee schedules on DMA's Fee Schedule web page.  Providers with individual accommodation rates will receive an official notification letter from the Division of Medical Assistance (DMA).  Providers should continue to bill their usual and customary charges. DMA will request that EDS review and recalculate affected claims filed prior to the update.  Providers should not file adjustment claims.  Any additional reimbursement will be reflected in future payments and indicated on the RA as an adjustment.

Financial Management
DMA, 919-855-4200



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: All Providers

Coverage of Perflutren Lipid Microspheres, per ml (HCPCS procedure code Q9957), in the Physician’s Drug Program

Effective with date of service January 1, 2006, HCPCS procedure code Q9957 is covered by the N.C. Medicaid program. Providers may file claims that have previously been denied, keeping in mind the rules regarding timely filing.

For Medicaid billing, one unit of Q9957 is 1 ml.  The maximum reimbursement rate for 1 unit is $61.89.

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



Attention:  All Providers

CPT Code 77003 Denials

CPT code 77003 (fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures, including neurolytic agent destruction) was a new code effective January 1, 2007.  Audits were established to prevent procedure 77003 from being billed with certain surgical or radiological procedures as detailed in the 2007 CPT book.   Seven of the CPT codes placed on the audits are causing incorrect denials:  27096, 62270, 62272, 62273, 62280, 62281, and 62282.  Claims payment system changes have been made to correct the problem.  Providers who received claim denials related to EOB 4237 or 4238 for CPT code 77003 may resubmit new claims (not adjustments) for processing.

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


Attention:  All Providers

Obesity Resource Information

Obesity resource information is available on the N.C. Division of Medical Assistance (DMA) Quality, Evaluation and Health Outcomes web page.  This information may be helpful to providers in educating recipients about obesity issues (pediatric and adult).  Links will also be added to help identify provider education related to obesity.  Providers are encouraged to check the Web site on a regular basis for additional resource links regarding obesity. To inquire about adding obesity resources to the DMA Web site, please e-mail Nubya Shabazz at nubya.shabazz@dhhs.nc.gov.

Quality, Evaluation, and Health Outcomes Unit
DMA, 919-855-4173



Attention: All Providers

HCPCS Procedure Code Changes for the Physician’s Drug Program

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

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

New HCPCS Code

Description

Unit

Maximum Reimbursement Rate

Q4089

Injection RHO(D) Immune Globulin (Human) (Rhophylac), IM or IV

100 IU

$80.00

Q4090

Injection, Hepatitis B Immune Globulin (HepaGam B), IM

0.5 ml

$64.74

Q4095

Injection, Zoledronic Acid (Reclast). See separate article in this bulletin.

1 mg

$44.16

End-Dated Codes with Replacement Codes
HCPCS procedure code J1567 (Injection, Immune globulin, IV, non-lyophilized (e.g., liquid)), 500 mg, was end-dated with date of service June 30, 2007, and replaced with the following four new procedure codes effective with date of service July 1, 2007. Claims submitted for dates of service on or after July 1, 2007 using the end-dated code will be denied. 

End Dated HCPCS Code

Description

Unit

New HCPCS Code

Description

Unit

Maximum Reimbursement Rate

J1567

Injection, Immune globulin, IV, non-lyophilized (e.g., liquid)

500 mg

Q4087

Injection, Immune Globulin (Octagam), IV, non-lyophilized (e.g. liquid)

500 mg

$33.48

Q4088

Injection, Immune Globulin (Gammagard liquid), IV, non-lyophilized (e.g. liquid)

500 mg

$31.20

Q4091

Injection, Immune Globulin (Flebogamma), IV, non-lyophilized, (e.g. liquid)

500 mg

$32.61

Q4092

Injection, Immune Globulin (Gamunex), IV, non-lyophilized (e.g., liquid)

500 mg

$31.86

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



Attention:  All Providers

Palatoplasty or Modified Palatoplasty for Sleep Apnea

The Division of Medical Assistance (DMA) has determined that palatoplasty, modified palatoplasty, or other procedure of the palate or uvula for the treatment of sleep apnea is not considered first-line therapy for most pediatric patients, according to clinical guidelines developed by the American Academy of Pediatrics.  Most children with snoring and/or sleep apnea have resolution of symptoms with tonsillectomy and/or adenoidectomy when these symptoms are due to an obstructive etiology.  Therefore, DMA will not reimburse for palatoplasty, modified palatoplasty, or other procedure of the palate or uvula in recipients under the age of 18 when performed for sleep apnea, snoring, or any related conditions. 

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


Attention:  All Providers

Upcoming National Drug Code (NDC) Seminars NDCs on Professional and Outpatient Dialysis-Administered Drug Claims

The Deficit Reduction Act of 2005 (DRA) includes provisions regarding State collection and submission of data for the purpose of collecting Medicaid drug rebates from manufacturers for all outpatient drug claims. In order to do this, North Carolina Medicaid will require that professional and outpatient dialysis drug claims include both the National Drug Code (NDC) and the NDC units in addition to the HCPCS code and units. This change will be implemented in December 2007 for providers who bill for drugs on the CMS-1500 claim form and for dialysis providers who bill drugs on the UB-04 claim form. The NDC numbers and NDC units will be required on the 837P and 837I transaction sets. Please look for future bulletin articles regarding this change.

Seminars on National Drug Code (NDC) Medicaid billing guidelines are scheduled for September 2007. Registration information, a list of dates, and site locations for the seminars will be published in the August 2007 General Medicaid bulletin.

With this change, providers should consider these and other items related to their office/practice setting:

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 of Outpatient Specialized Therapies: Post-Payment Validation Begins August 2007

As announced in the June bulletin, The Carolinas Center for Medical Excellence (CCME) will initiate post-payment validation of therapy authorizations in August 2007.  A sample of cases will be drawn each month from authorizations with an end date six months prior to the sample month.  Providers will be notified via fax or e-mail to submit cases for validation.  (The notification process will be similar to the method currently used to notify providers of authorization outcomes.)  The documentation requested will include the therapy order, evaluation, and progress notes for the identified authorization period.  Four validations may be performed on each authorization:

Providers who exceed established validation thresholds will be subjected to a more intensive validation process. 

Information about post-payment validation is also available on CCME’s prior authorization Web site.

CCME, 1-800-682-6250



Attention:  Community Alternative Program Providers – Disabled Adults (CAPDA), Children (CAPCH), and Choice (CAPCO)

Rate Change

Effective with date of service January 1, 2007, providers were allocated a rate increase by the Legislature.  This inflationary rate increase for the 2006-2007 fiscal year was based on Senate Bill 1741. 

Please note the following rate changes for CAP-DA service codes:

Service Code

Old Rate

New Rate

H0045

$113.91/unit

$179.02/unit

S5102

$36.51/unit

$41.51/unit

S5125

$3.60/unit

$3.65/unit

S5150

$3.60/unit

$3.65/unit

S5161

$29.67/unit

$30.32/unit

S5170

$3.14/unit

$3.21/unit

T1016

$13.82/unit

$15.25/unit

T4535

$0.34/unit

$0.36/unit

Please note the following rate changes for CAP-CH service codes:

Service Code

Old Rate

New Rate

H0045

$113.91/unit

$179.02/unit

S5125

$3.60/unit

$3.65/unit

S5150

$3.60/unit

$3.65/unit

T1000

$9.11/unit

$9.31/unit

T1005

$9.11/unit

$9.31/unit

T1016

$13.82/unit

$15.25/unit

T4535

$0.34/unit

$0.36/unit

Please note the following rate changes for CAP-CO service codes:

Service Code

Old Rate

New Rate

H0045

$113.91/unit

$179.02/unit

S5102

$36.51/unit

$41.51/unit

S5125

$3.60/unit

$3.65/unit

S5135

$3.60/unit

$3.65/unit

S5150

$3.60/unit

$3.65/unit

S5161

$29.67/unit

$30.32/unit

S5170

$3.14/unit

$3.21/unit

T2040

$12.50/unit

$25.00/unit

T2041

$13.82/unit

$15.25/unit

T4535

$0.34/unit

$0.36/unit

This rate is effective as of January 1, 2007. Providers are not required to resubmit their claims. An automatic recoupment and repayment will be done by EDS.

Rate Setting
DMA, 919-855-4200



Attention: Independent Laboratories and Physicians

CLIA Certification–Related Claim Denials

The Division of Medical Assistance has made recent system changes to the lists of CPT-4 codes that are subject to and exempt from Clinical Laboratory Improvement Amendment (CLIA) editing based on CLIA guidelines.  In order to ensure that claims are coded appropriately when submitting and resubmitting claims, providers should refer to the Centers for Medicare and Medicaid (CMS) Web site at http://www.cms.hhs.gov/CLIA/10_Categorization_of_Tests.asp for current lists of

The lists may be printed and retained for future reference.  This information is periodically updated and new tests are added as they are approved.

Billing Reminders

If the CPT code indicates that the code must be billed with a QW modifier, the modifier must be appended to the CPT code to process for reimbursement. Failure to append the QW, will result in claims being denied for EOB 0936, “Certification not valid for DOS/Level and a delay in payment.”  Claims submitted with a QW modifier and CPT codes that are not considered “waived” will also deny for EOB 0936, “Certification not valid for DOS/Level.

If a test is not included on the list, providers should contact CLIA at the Licensure and Certification Section of the North Carolina Division of Facility Services at 919-733-1610 to discuss their certificate type and the tests that can be performed based on the certificate type.

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



Attention:  Local Management Entities and Private Providers of Mental Health Services

Mental Health Cost Report Training Sessions

During 2007 there will be two types of cost report training sessions offered simultaneously.  One session will be for Local Management Entities (LMEs) which are required to file the 2006-2007 Mental Health Cost Report if any enhanced mental/behavioral health services were provided.  The other type of session will be for private providers who provide any enhanced mental/behavioral health service for any fiscal year ending on or after December 31, 2007. 

We have established training sites throughout the state.  There will be two days to choose from in the Central Region, two days in the West, two days in the East and four days in Raleigh.  All full day LME sessions will begin at 8:30 a.m. and end at 4:30 p.m.  For the private providers, half day morning sessions will begin at 8:30 a.m. and end at 12:00 p.m., and the half day afternoon sessions will begin at 1:00 p.m. and end at 4:30 p.m.

DHHS Controller’s Office
DMA, 919-855-3680


Attention:  Local Management Entities, CAP/MR-DD Case Managers, and CAP/MR-DD Service Providers

Rate Change

Effective with date of service January 1, 2007, providers were allocated a rate increase by the Legislature.  This inflationary rate increase for the 2006-2007 fiscal year was based on Senate Bill 1741.  Please note the following rate changes for CAP/MR-DD service codes:

Service Code

Old Rate

New Rate

H2025

$7.61/unit

$7.80/unit

H2025HQ

$1.97/unit

$2.01/unit

S5102

$36.51/unit

$41.51/unit

S5150

$3.60/unit

$3.65/unit

S5150HQ

$2.78/unit

$2.83/unit

S5161

$29.67/unit

$32.00/unit

T1005TD

$9.11/unit

$9.31/unit

T1005TE

$9.11/unit

$9.31/unit

This rate is effective as of January 1, 2007.  Providers are not required to resubmit their claims.  An automatic recoupment and repayment will be done by EDS.

Rate Setting
DMA, 919-855-4200



Attention: Medical Doctors and Doctors of Osteopathic Medicine

Orthotic and Prosthetic Devices in the Office

Effective with date of service July 1, 2007, medical doctors (MDs) and doctors of osteopathic medicine (DOs) may bill for the orthotic and prosthetic devices listed in the table below.  Providers must follow all requirements stated in Clinical Coverage Policy 5B, Orthotics and Prosthetics.  Please note that a Certificate of Medical Necessity and Prior Approval form (CMN/PA) must be completed for all devices provided.  (See Attachment A of the policy for complete instructions.)  Coverage criteria for these items are provided in Section 5.3 of the policy.  The CMN/PA must be maintained in the medical record as specified in Section 7.1. 

The EDS prior approval unit can be reached through the automated attendant telephone line, 1-800-688-6696 or 919-851-8888.

HCPCS CODE

ORTHOTIC & PROSTHETIC DEVICES DESCRIPTION

MAXIMUM RATE

 

Diabetic foot codes

 

A5512*

For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Farenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or

24.89

A5513*

For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher, includes arch filler and other shaping

37.14

 

Elastic supports

 

A6530

Gradient compressions stocking, below knee, 18-30 mm Hg, each

40.43

A6531

Gradient compressions stocking, below knee, 30-40 mm Hg, each

43.27

A6532

Gradient compressions stocking, below knee, 40-50 mm Hg, each

60.96

A6533

Gradient compressions stocking, thigh length, 18-30 mm Hg, each

64.51

A6534

Gradient compressions stocking, thigh length, 30-40 mm Hg, each

76.52

A6535

Gradient compressions stocking, thigh length, 40-50 mm Hg, each

78.82

A6536

Gradient compressions stocking, full length/chap style, 18-30 mm Hg, each

97.65

A6537

Gradient compressions stocking, full length/chap style, 30-40 mm Hg, each

109.09

A6538

Gradient compressions stocking, full length/chap style, 40-50 mm Hg, each

117.84

A6539

Gradient compressions stocking, waist length, 18-30 mm Hg, each

134.67

A6540

Gradient compressions stocking, waist length, 30-40 mm Hg, each

139.50

A6541

Gradient compressions stocking, waist length, 40-50 mm Hg, each

150.30

A6543

Gradient compressions stocking, lymphedema, each

122.46

A6544

Gradient compressions stocking, garter belt, each

30.00

 

Cervical

 

L0120

Cervical, flexible, nonadjustable (foam collar)

23.28

L0140

Cervical, semi-rigid, adjustable (plastic collar)

58.05

L0210

Thoracic, rib belt

41.48

L0625

Lumbar orthosis, flexible, provides lumbar support, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder str

45.85

L0626

Lumbar orthosis,sagittal control, with rigid posterior panel(s), posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder

64.86

L0976

LSO, full corset

164.97

L0980

Peroneal straps, pair

13.51

L0982

Stocking supporter grips, set of four (4)

14.72

L0984

Protective body sock, each

46.98

 

Lower limb - hip

 

L1800

KO, elastic with stays, perfabricated, includes fitting and adjustment

68.63

L1810

KO, elastic with joints, prefabricated, includes fitting and adjustment

100.73

L1815

KO, elastic or other elastic type material with condylar pad(s), prefabricated, includes fitting and adjustment

92.32

L1820

KO, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment

100.33

L1825

KO, elastic knee cap, prefabricated, includes fitting and adjustment

44.72

L1830

KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment

83.93

L1831

KO, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment

244.88

L1836

KO, rigid, without joint(s), includes soft interface material, prefabricated, includes fitting and adjustment

111.01

L1901

AO, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, lycra)

14.72

L1902

AFO, ankle gauntlet, prefabricated, includes fitting and adjustment

63.56

L1906

AFO, multiligamentous ankle support, prefabricated, includes fitting and adjustments  

106.33

L2112

AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment

392.58

 

Orthopedic shoes

 

L3002+

Foot insert, removable, molded to patient model, Plastazote or equal, each

134.38

L3003+

Foot insert, molded to patient model, silicone gel, each

144.88

L3010+

Foot insert, removable, molded to patient model, longitudinal arch support, each

144.97

L3020+

Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each

165.09

L3030+

Foot insert, removable, formed to patient foot, each

63.49

L3040+

Foot, arch support, removable, premolded, longitudianl, each

39.15

L3050+

Foot, arch support, removable, premolded, metatarsal, each

39.15

L3060+

Foot, arch support, removable, premolded, longitudinal/metatarsal, each

61.37

L3070+

Foot, arch support, non-removable, attached to shoe, longitudinal, each

26.46

L3080+

Foot, arch support, non-removable, attached to shoe, metatarsal, each

26.45

L3090+

Foot, arch support, non-removable, attached to shoe, longitudinal/metatarsal, each

33.87

L3100+

Hallus-valgus night dynamic splint

35.96

L3140+

Foot, abduction rotation bar, including shoe(s)

74.07

L3150+

Foot, abduction rotation bar, without shoe(s)

67.72

L3160+

Foot, adjustable shoe-styled positioning device

83.29

L3170

Foot, plastic, silicone or equal, heel stabilizer, each

42.34

L3208

Surgical boot, each, infant

37.43

L3209

Surgical boot, each, child

38.20

L3211

Surgical boot, each, junior

33.73

L3216+

Orthopedic footwear, ladies shoe, depth inlay, each

148.34

L3217+

Orthopedic footwear, ladies shoe, hightop, depth inlay, each

115.52

L3221+

Orthopedic footwear, mens shoe, depth inlay, each

189.71

L3222+

Orthopedic footwear, mens shoe, hightop, depth inlay, each

139.84

L3260+

Surgical boot/shoe, each

48.42

L3265+

Plastazote sandal, each

60.55

L3332+

Lift, elevation, inside shoe, tapered, up to one-half inch

61.37

L3334+

Lift, elevation, heel, per inch

31.74

L3350+

Heel wedge

19.03

L3480+

Heel, pad and depression for spur

51.81

L3485+

Heel, pad, removable for spur

23.10

 

Upper limb orthoses

 

L3650

SO, figure of eight design abduction restrainer, prefabricated, includes fitting and adjustment

45.32

L3651

SO, single shoulder, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, lycra)

49.85

L3652

SO, double shoulder, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, lycra)

150.18

L3660

SO, figure of eight design abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment

77.83

L3807

WHFO, without joint(s), perfabricated, includes fitting and adjustments, any type

189.34

L3908

WHO, wrist extension control cock-up, non-molded, prefabricated, includes fitting and adjustment

45.36

L3909

WO, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, lycra)

10.71

L3910

WHFO, Swanson design, prefabricated, includes fitting and adjustment

335.17

L3911

WHFO, orthosis, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra)

18.78

L3917

HO, metacarpal fracture orthosis, prefabricated, includes fitting and adjustment

79.99

L3918

HFO, knuckle bender, prefabricated, includes fitting and adjustment

64.99

L3920

HFO, knuckle bender, with outrigger, prefabricated, includes fitting and adjustment

77.49

L3922

HFO, knuckle bender, two segment to flex joints, prefabricated, includes fitting and adjustment

88.89

L3923

HFO, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustments

29.46

L3924

Whfo, Oppenheimer, prefabricated, includes fitting and adjustment

95.07

L3926

WHFO, Thomas suspension, prefabricated, includes fitting and adjustment

78.12

L3928

HFO, finger extension, with clock spring, prefabricated, includes fitting and adjustment

46.16

L3930

WHFO, finger extension, with wrist support, prefabricated, includes fitting and adjustment

47.66

L3932

FO, safety pin, spring wire, prefabricated, includes fitting and adjustment

41.34

L3934

FO, safety pin, modified, prefabricated, includes fitting and adjustment

36.46

L3936

WHFO, Palmer, prefabricated, includes fitting and adjustment

67.45

L3938

WHFO, dorsal wrist, prefabricated, includes fitting and adjustment

70.95

L3940

WHFO, dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment

81.35

L3942

HFO, reverse knuckle bender, prefabricated, includes fitting and adjustment

56.26

L3944

HFO, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment

92.66

L3946

HFO, composite elastic, prefabricated, includes fitting and adjustment

76.08

L3948

FO, finger knuckle bender, prefabricated, includes fitting and adjustment

50.94

L3980

Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment

234.09

L3982

Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment

289.22

L3984

Upper extremity fracture orthosis, wrist, prefabricated, inlcudes fitting and adjustment

308.72

 

Ancillary orthoses

 

L4350

Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment

81.37

L4360

Walking boot, pneumatic, with or without joints, with our without interface material, prefabricated, includes fitting and adjustment

227.64

L4370

Pneumatic full leg splint, prefabricated, includes fitting and adjustment

146.08

L4380

Pneumatic knee splint,  prefabricated, includes fitting and adjustment

89.57

L4386

Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment

131.93

Please note:  *Requires prior approval (PA) for all recipients

+Requires PA for all recipients 21 years of age or older

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



Attention:  All Mental Health Providers

Rate Update on 2007 CPT codes for Mental Health Specialties

Effective July 1, 2007, rates for the 2007 CPT codes were revised for all mental health specialties based on information from the Centers for Medicare and Medicaid Services (CMS).  These specialties include the following:

Providers may receive a current fee schedule by completing and submitting a copy of the Fee Schedule Request form.

As of July 1, 2007, revised mental health fee schedules will be available on the DMA Fee Schedule web page.  Providers must bill their usual and customary charges.

Financial Management
DMA, 919-855-4200



Attention:  PCS and PCS-Plus Providers

PCS and PCS-Plus Recoupments

This is republished from October 2004 General Medicaid Bulletin.

Effective with checkwrite May 8, 2007, EDS started recouping any PCS overpayments since the implementation of PCS-Plus in November 2003.  Recoupments occurred for covered dates of service from November 1, 2003 to July 31, 2004 and be automatically deducted from the provider’s checkwrite. Providers who have received PCS payments that exceeded 60 hours (240 units) a month or 3.5 hours a day (14 units) for PCS clients without PCS-Plus prior approval will have these payments recouped. Any providers who have received payments that exceeded 80 hours (or 320 units) a month for Medicaid recipients with PCS-Plus prior approval will have also these payments recouped. As a reminder, PCS is limited to 60 hours and 3.5 hours a day for each eligible Medicaid recipient. Medicaid recipients with DMA prior approval for PCS-Plus are eligible for up to 80 hours a month of PCS without daily limits.

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


Attention: Physicians and Nurse Practitioners

Linezolid, 200mg (Zyvox, J2020) Billing Guidelines

Effective with date of service July 1, 2007, N.C. Medicaid covers Zyvox for use in the Physician’s Drug Program when billed with HCPCS procedure code J2020. Zyvox is indicated for treatment in patients with

One Medicaid unit of coverage is 200 mg. The maximum reimbursement rate per unit is $25.72.

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



Attention: Physicians and Nurse Practitioners

Zoledronic Acid, 1mg (Reclast, Q4095) Billing Guidelines

Effective with date of service July 1, 2007, the N.C. Medicaid program covers zoledronic acid (Reclast) for use in the Physician’s Drug Program when billed with HCPCS code Q4095. Reclast is indicated for treatment in patients with Paget’s disease of the bone.

The recommended dose of Reclast is a 5mg/100ml intravenous infusion administered as a single treatment. The infusion is to be given at a constant infusion rate and the infusion time must not be less than 15 minutes.

For Medicaid Billing:

The Medicaid unit of coverage is 1 mg. The maximum reimbursement rate per unit is $44.16. 

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


Attention:  Private Duty Nursing Providers

Rate Change

Effective with date of service January 1, 2007, providers were allocated a rate increase by the Legislature.  This inflationary rate increase for the 2006-2007 fiscal year was based on Senate Bill 1741. 

Please note the following rate change for PDN service code:

Service Code

Old Rate

New Rate

T1000

$9.11/unit

$9.31/unit

This rate is effective as of January 1, 2007. Providers are not required to resubmit their claims. An automatic recoupment and repayment will be done by EDS.

Rate Setting
DMA, 919-855-4200



Attention: Residential Child Care Treatment Facilities

Enrollment Effective Dates

Effective September 1, 2006, new Residential Childcare Treatment Facility providers licensed as 10A NCAC 27G.1300 (Level II), 10A NCAC 27G.1700 (Level III) and 10A NCAC 27G.1800 (Level IV) seeking enrollment with the Division of Medical Assistance (DMA) were required to submit a completed Residential Childcare Treatment Facility provider enrollment packet, a copy of their current facility license, and a notification of endorsement action (NEA) letter.  Those already enrolled in Medicaid on September 1, 2006, were required to submit a completed Residential Childcare Treatment Facility provider enrollment packet, a copy of their renewed facility license, and an NEA letter prior to the end date of their provider number in order to maintain their eligibility. 

Effective March 19, 2007, Residential Childcare Treatment Facility new enrollment and re-enrollment requests were effective the date the corrected and complete provider enrollment/re-enrollment packet with required attachments is date-stamped as received by DMA.  DMA does not authorize the provider to place eligible Medicaid recipients in the facility or to render services prior to the facility’s assignment of a Medicaid provider number.  DMA requires that each Residential Childcare Treatment Facility be enrolled separately and assigned a site-specific Medicaid provider number.

In May 2007, a joint memorandum from the Division of Facility Services (DFS), Division of Mental Health (MH/DD/SAS), and DMA was mailed to all Residential 10A NCAC 27G.1300 (Level II), 10A NCAC 27G.1700 (Level III) and 10A NCAC 27G.1800 (Level IV) facilities explaining these divisions’ joint endeavor to coordinate the 2008 license renewal, endorsement, and Medicaid re-enrollment process and timeline for residential providers.  This memorandum details the providers’ and Divisions’ responsibilities and lists a timeline with important dates regarding when to submit DFS renewal applications, Local Management Entity (LME) applications, and Medicaid enrollment and re-enrollment applications.  Please review the memorandum.

Provider Services
DMA, 919 855-4050



Attention: Durable Medical Equipment Providers

Change in Requests for Prior Approval for Pediatric Mobility Devices

Effective with date of request August 1, 2007, Children’s Special Health Services will no longer be reviewing requests for prior approval for pediatric mobility devices on behalf of DMA.  On that date, EDS will begin the review for prior approval of these devices.  Please see Clinical Coverage Policy 5A, Durable Medical Equipment, located on DMA’s Web site and refer to Attachment B, How a Recipient Obtains Durable Medical Equipment and Supplies, for detailed instructions regarding submission of prior approval requests.

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


Attention: Durable Medical Equipment and Orthotic and Prosthetic Device Providers

Change in Prior Approval Process for Non-Listed DME, Orthotic and Prosthetic Devices, and Medical Supplies for Recipients Under 21 Years of Age

Effective with date of request August 1, 2007, providers must submit prior approval requests for items that are not listed on the durable medical equipment or orthotic and prosthetic fee schedules when these items are medically necessary for Medicaid recipients under 21 years of age.  Providers should submit the requests to the Assistant Director for Clinical Policy and Programs, Division of Medical Assistance (DMA).  Please use the Non-Covered State Medicaid Plan Services Request Form for Recipients less than 21 Years of Age form.

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



Attention:  CAP/MR-DD Providers

CAP/MR-DD Cost Report Training

Providers of Community Alternatives Program for persons with Mental Retardation/Developmental Disabilities (CAP-MR/DD) are required to submit a cost report due to DMA by September 30, 2007.  Providers will complete the cost report for their most recently closed fiscal year for which they have financial statements.  Training on the cost report was held in May.  We have added three new training classes for providers who were unable to attend.  The date, time, and location of the classes are below.

Date

Time

Location

Monday, August 13, 2007

9am – 12pm

The Guilford Center
Bellemeade Building
201 N. Eugene Street
Greensboro, NC  27401

Friday, August 24, 2007    

9am-12pm

Western Piedmont Community College
1001 Burkemont Avenue
Morganton, NC  28655

Thursday, August 30, 2007

9am – 12pm

NC DOT Training Center
313 Chapanoke Road
Room 203
Garner, NC  27603

The deadline to register for training is Friday, July 27, 2007.  Training dates and times are tentative based on provider response.  The CAP-MR/DD cost report, instructions and training registration form can be found online.

Rate Setting
DMA, 919-855-4200


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

 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

 

12/13/07

12/20/07

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

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