August 2005  Medicaid Bulletin

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In This Issue...

All Providers:

 All Child Services Coordination Providers:

Area Mental Health Centers:

CAP-MR/DD Case Managers and Service Providers:

 Durable Medical Equipment Providers:

 Enhanced Mental Health Services:

General Hospitals:

Home Health Services:

Home Infusion Therapy (HIT) Providers:

Hospice Providers:

Hospital Discharge Planners:

Hospitals: 

Hospital Outpatient Departments:

Independent Laboratories:

Local Management Entities:

Mental Health Practitioners Who are Employed in Physicians Offices/Clinics:

Nursing Facility Providers:

OB/GYN Providers:

Optical Providers:

Outpatient Hospitals:

Personal Care Services (PCS) Providers:

Physicians:

Private Duty Nursing (PDN) Providers:

Psychiatric Hospitals:


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 Orthotic and Prosthetic Devices

Effective with date of service August 1, 2005, Medicaid will begin coverage of orthotic and prosthetic devices to include recipients age birth through 115 years. Prior to date of service August 1, 2005, coverage was limited to recipients ages birth through 20 years. Providers must follow clinical policy guidelines for these devices located on DMA’s Clinical Coverage Policies web page.

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


Attention: Direct Enrolled DD/MR Targeted Case Management Providers

Clarification to July 2005 Special Bulletin IV for Targeted Case Management for MR/DD

Effective with the implementation of DD/MR Targeted Case Management, employees of provider agencies who have a baccalaureate degree in other than a human service field and have a minimum of 5 years documented targeted case management experience with this population will be “grandfathered” to allow them to continue to provide MR/DD case management services. This “grandfathering” will be permitted for employees of any MR/DD Targeted Case Management agency that directly enrolls to provide the service by 12/31/05. The endorsement process for these agencies has been accelerated and should be completed no later than 12/31/05. For the period 9/1/05 forward until a case management agency has been endorsed, the agency may bill Targeted Case Management through the LME. Upon endorsement, the agency must directly enroll, and will no longer be able to bill through the LME. By 12/31/05, all agencies must be direct enrolled. LMEs who wish to provide TCM must also enroll as a case management agency with a new type and specialty. The billing code for this service is T1017 HI.

If you have questions, please call the Behavioral Health Section at 919-855-4290.

Behavioral Health Section
DMA, 919-855-4290


Attention:  All Providers

Medicaid Family Planning Waiver Training Schedule

On October 1, 2005, the N.C. Medicaid program will implement the new Family Planning Waiver program.  The program is designed to reduce unintended pregnancies and to improve the well being of children and families in North Carolina by providing family planning services to eligible men and women. 

Training on the Waiver program is scheduled for September 2005 and will focus on recipient eligibility, covered services, and billing for family planning services covered through the Waiver program.  

Preregistration for the training is required.  Due to limited seating, registration is limited to two staff members per office.  Unregistered providers are welcome to attend if space is available.  Lunch will not be provided at the training.

Providers may register for the training by completing and submitting the registration form or by registering online. 

Providers may choose to attend either the morning session or the afternoon session.  The morning session begins at 9:00 a.m. and ends at 12:00 p.m.  The afternoon session begins at 1:30 p.m. and ends at 4:30 p.m.  Please arrive 30 minutes prior to the beginning of the training to complete registration.  Providers may also choose either a land or teleconference site.  Please indicate on the registration form the session you plan to attend.

Providers must print the PDF version of the August 2005 Special Bulletin, Medicaid Family Planning Waiver Program from DMA’s website and bring it to the training.

Land Locations

Thursday, September 1, 2005
McKimmon Center
1101 Gorman S.
Raleigh, NC

Wednesday, September 7, 2005
Bo Thomas Auditorium
Blue Ridge Community College
Flat Rock, NC

Thursday, September 8, 2005
Holiday Inn Conference Center
530 Jake Alexander Blvd.S.
Salisbury, NC

Thursday, September 22, 2005
Greenville Hilton
207 SW Greenville Blvd.
Greenville, NC

Teleconference Locations

The teleconference is accessible from each of the sites listed below on Wednesday, September 21, 2005 and Wednesday, September 28, 2005.

Albemarle Regional Health Services
711 Roanoke Avenue
Elizabeth City, NC

Cooper Building
225 North McDowell
Ground Floor
Raleigh, NC

Jackson County Health Department
Community Services Building
538 Scotts Creek Road, Suite 100
 Sylva, NC

Catawba County Health
Department
3070 11th Avenue Drive, SE
Hickory, NC

Cumberland County Health Department
E. Newton Smith Public Health Center
227 Fountainhead Lane
Fayetteville, NC

Wilson County Health Department
1801 Glendale Drive
Wilson, NC

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


Directions to the Medicaid Family Planning Waiver Land Training

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

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

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

Holiday Inn Conference CenterSalisbury, North Carolina
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 on Jake Alexander Boulevard.  Travel approximately ½ mile.  The Holiday Inn is located on the right.

Hilton Hotel -  Greenville, North Carolina
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 2 ½ miles to the Hilton Greenville, which is located on the right.

Directions to the Medicaid Family Planning Waiver Teleconference Training

Albemarle Regional Health Services – Elizabeth City
Take US 17 north to Elizabeth City.  Take US 17 Business (Ehringhaus Street) to Halstead Boulevard (beside Burger King).  Turn right on Halstead Boulevard and travel approximately ¾ miles to Roanoke Avenue.  Turn left onto Roanoke Avenue and travel approximately ½ mile.  The Albemarle Regional Health Services building is located on the right.

Catawba County Health Department – Hickory
Take I-40 to Hickory.  Take Exit 128 onto Fairgrove Church Street.  Travel approximately ¾ miles to the second stoplight.  Turn left onto Eleventh Avenue Drive.  The Catawba County Health Department is located on the right just past the Catawba Memorial Hospital.   Parking is available in the first parking lot in front of the building.  Teleconference room 117 is located at the end of the first hallway on the right.

Cooper BuildingRaleigh
Traveling East on I-40
Take I-40 into Raleigh.  After the Harrison Boulevard exit, get into the right-hand lane and follow the signs for Wade Avenue.  Follow Wade Avenue until it ends at Capital Boulevard.  Exit to the right onto Capital Boulevard.  Capital Boulevard becomes Dawson Street.  Stay in the left lane and continue around the curve to the second stoplight.  Turn left onto Jones Street.  Travel one block and then turn left onto McDowell Street.  The visitor’s parking lot is located on the right just past the intersection of McDowell Street and Lane Street.  The Cooper Building is located on the corner of McDowell Street and Lane Street adjacent to the parking deck.

Traveling West on I-40
Take I-440 Beltline to exit 289, Wade Avenue.  Turn right at the bottom of the exit ramp.  Follow Wade Avenue until it ends at Capital Boulevard.  Exit to the right onto Capital Boulevard.  Capital Boulevard becomes Dawson Street.  Stay in the left lane and continue around the curve to the second stoplight.  Turn left onto Jones Street.  Travel one block and then turn left onto McDowell Street.  The visitor’s parking lot is located on the right just past the intersection of McDowell Street and Lane Street.  The Cooper Building is located on the corner of McDowell Street and Lane Street adjacent to the parking deck.

E. Newton Smith Public Health Center, Cumberland County Health Department – Fayetteville
Traveling South on I-95
Take I-95 south to Fayetteville.  Near Fayetteville, bear right onto I-95 Business/US 301 Business.  Travel on I-95 Business/US 301 Business to E. Russell Street (third stoplight).  Turn right onto E. Russell Street and follow it to the end.  Turn left onto McIver Street.  Bear right onto McGilvary Street.  Turn right at the first street to the right onto Fountainhead Lane.  The Public Health Center is the four-story, tan building on the right.

Traveling North on I-95
Take I-95 north to I-95 Business/US 301 Business.  Turn left onto Gillespie Street. Turn left onto W. Russell Street and follow it to the end.  Turn left onto McIver Street.  Bear right onto McGilvary Street.  Turn right at the first street to the right onto Fountainhead Lane.  The Public Health Center is the four-story, tan building on the right.

Community Services Building, Jackson County Health Department – Sylva
From Asheville, take I-40 west to Waynesville.  From Waynesville, take US 19/US 23 South/US 74 West to Sylva.  Take exit 78.  Travel approximately 3 miles to Harris Regional Hospital and turn right.  Travel approximately ½ miles to the Community Services Building on the right.  The teleconference center is located in the brown colonial-style modular unit beside the main building.

Wilson County Health Department – Wilson
Take US 264 east to Wilson.  After crossing I-95, turn at the third stoplight onto Forest Hill Road.  Turn left at the second stoplight onto Tarboro Street.  Turn right at the first stoplight onto Glendale Drive.  The Wilson County Health Department is located immediately after the next stoplight.  Turn into the second drive after the stoplight.  Enter the building through the doors under the blue awning.  The teleconference room is located on the right.


Attention:  All Providers

Meningococcal Conjugate Vaccine, MCV4 (Menactra, CPT Code 90734) Billing Guidelines

Effective March 1, 2005, N.C. Medicaid program covers Menactra (MCV4), the new FDA approved meningococcol conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for intramuscular use, under the Physicians Drug Program according to the February 10, 2005 guidelines of the Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control and Prevention (CDC).

Two meningococcal vaccines are available in the U.S.:
• Meningococcol polysaccharide vaccine (MPSV4, Menomune) has been available since the 1970s, and is billed with CPT code 90733.
• Meningococcol conjugate vaccine (MCV4, Menactra) was licensed in 2005, and is billed with CPT code 90734.

Both vaccines can be given for the prevention of four types of meningococcal disease, including two of three types most common in the United States and a type that causes epidemics in Africa. Meningococcol vaccines cannot prevent all types of disease, but they do protect many people who might become sick if they had not received the vaccine.

Menactra is recommended for:
• All children at their routine pre-adolescent visit (11 through 12 years of age).
• Adolescents before high school entry (approximately 15 years of age) if not received previously.
• College freshmen living in dormitories.
• Anyone who has a damaged spleen, or whose spleen has been removed.
• Anyone who has terminal complement component deficiency (an immune system disorder).
• People who might have been exposed to meningitis during an outbreak.

MCV4 (Menactra) is the preferred vaccine for people 11 through 55 years of age in these risk groups, but MPSV4 can be used if MCV4 is unavailable. MPSV4 should be used for children 2 through 10 years old and adults over 55 who are at risk.

To review the complete Menactra recommendations of the Advisory Committee on Immunization Practices (ACIP), go to http://www.cdc.gov/mmwr/PDF/rr/rr5407.pdf.

Billing Guidelines
• The procedure code for billing Menactra is CPT code 90734.
• Diagnosis code V01.84 must be used when billing for Menactra, if applicable. Providers should refer to the April 2005 Special Bulletin III, Health Check Billing Guide 2005, for additional information on billing Medicaid for vaccines.
• The maximum reimbursement rate for purchased Menactra per unit (0.5 ml) is $88.56. Providers must bill their usual and customary charge. Add this vaccine to the list published in the November 2004 general Medicaid bulletin.

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


Attention: All Providers

NCLeads Update

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

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


Attention: All Child Services Coordination Providers

Intermediate Assessment Process

Effective August 1, 2005, Child Service Coordination Providers (CSCs) are no longer required to provide an Intermediate Assessment at 15 to 18 months and at 30 to 36 months.  CSC providers must ensure that parents or legal guardians are aware of the importance all age appropriate EPSDT developmental screenings and refer parents or guardians to physicians or clinics for these services for their children.  Education and referral efforts must be documented in accordance with CSC policies. 

Clinical Policy
DMA, 919-855-4320


Attention: All Optical Providers

Changes in Eye Examination and Visual Aid Frequency for Recipients 21 Through 24 Years of Age

Effective with date of service September 1,  2005, Medicaid coverage for eye examinations and visual aids for recipients who are 21 through 24 years of age has been changed.  Previously, Medicaid covered one eye examination and one set of visual aids once every year for this age group.  According to the Center for Medicare and Medicaid Services, the Code of Federal Regulations requires that all services available to categorically needy individuals be equal in amount, duration, and scope within the group. Therefore, the following changes have been made to comply with federal guidelines.

Eye Examinations and Refractions
Routine eye examinations with a refraction, or a refraction only, are allowed once every two years for recipients 21 years of age and older.

Visual Aids
Visual aids are allowed once every two years for recipients 21 years of age and older. All visual aids continue to require prior approval.

Request for Exception
When justified by medical necessity, the provider may request prior approval for a second refraction or additional visual aids.  Each request is reviewed on a case-by-case basis.  Refer to the Optical Services Provider Manual on DMA’s Clinical Coverage Policies web page for detailed instructions regarding prior approval requests for exceptions.

Note:  No changes have been made in coverage for Medicaid recipients that are under 21 years of age.  

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


Attention: Area Mental Health Centers, and CAP-MR/DD Case Managers and Service Providers

Billing Update and Population Groups for CAP-MR/DD Services

The July 2003 general Medicaid bulletin listed the new national codes and descriptions for the CAP-MR/DD program.  With the implementation of the new CAP-MR/DD 1915C waiver scheduled for implementation on September 1, 2005, several rate adjustments will be made, as well as the addition of new local code descriptions.  Please note that the memo descriptions for this waiver may not be exactly the same as the HIPAA compliance variables and that we have cross walked this information for your convenience.  These changes will be effective on September 1, 2005.

 

Procedure Code

     Rate
Current

Production
Description

HIPAA  National
Code Description

 Memo Description

New
Rate

 

S5102

$36.51/Day

Day Care Services, Adult; per diem

Day Care Services, Adult; per diem

Adult Day Health

$36.51/Day

 

T2028

      *

Specialized Supply, not Otherwise Specified, Waiver

Specialized Supply, not Otherwise Specified, Waiver

Augmentative Communication Device - Purchase

        *

 

V5336

      *

Repair/Modification of Augmentative Communication System or Device

Repair/Modification of Augmentative Communicative System or Device (Excludes Adaptive Hearing Aid)

Augmentative Communication Device – Repair and

Service

      *

 

H2011

$6.04/per 15 minutes

Crisis Intervention Service, per 15 minutes

Crisis Intervention Service, per 15 minutes

Crisis Services

$6.04/per 15 minutes

 

T2021

$5.57/per 15 minutes

Day Habilitation, Waiver; per 15 minutes

Day Habilitation, waiver; per 15 minutes

Day Supports Individual

$5.94/per 15 minutes

 

T2021HQ

$3.68/per 15 minutes

Day Habilitation, Waiver, per 15 minutes

Day Habilitation, waiver; per 15 minutes

Day Supports Group (2 or more clients)

$3.31/per 15 minutes

 

S5125

$3.60/per 15 minutes

Attendant Care Services; per 15 minutes

Attendant Care Services; per 15 minutes

Personal Care Services

$3.60/per 15 minutes

 

T1999

     *

Miscellaneous Therapeutic Items and Supplies, Retail Purchases, not otherwise classified

Miscellaneous Therapeutic Items and Supplies, Retail Purchases, not otherwise classified; identify product in remarks

Specialized Equipment and Supplies

        *

 

S5161

$29.67/Month

Emergency Response System; Service Fee, per Month (Excludes Installation and Testing)

Emergency Response System;  Service Fee, per Month (Excludes Installation and Testing)

PERS (Personal Emergency Response System)

$29.67/Month

 

H0045

$222.96/Day

Respite Care Services, not in the home, per diem

Respite Care Services, not in the home, per diem

Respite Institutional

$222.96/Day

 

S5150

$3.60/per 15 minutes

Unskilled Respite Care, not Hospice; per 15 minutes

Unskilled Respite Care, not Hospice; per 15 minutes

Respite Non-Institutional – Individual

$3.60/per 15 minutes

 

S5150HQ

$2.78/per 15 minutes

Unskilled Respite Care; not Hospice, per 15 minutes, Groups

Unskilled Respite Care, not Hospice, per 15 minutes, Groups

Respite Non-Institutional – Group (2-3 clients)

$2.78/per 15 minutes

 

T1005

New service

Respite Care Services, up to 15 Minutes

Respite Care Services, up to 15 Minutes

Enhanced Respite Care – Non Institutional

$5.00/per 15 minutes

 

T1005TE

 

Respite Care Services – LPN, up to 15 minutes

Respite Care Services up to 15 minutes

Respite Nursing – LPN

$9.11/per 15 minutes

 

T1005TD

 

Respite Care Services – RN, up to 15 minutes

Respite Care Services up to 15 minutes

Respite Nursing – RN

$9.11/per 15 minutes

 

H2025

$7.61/per 15 minutes

Ongoing Support to Maintain Employment, per 15 minutes

Ongoing Support to Maintain Employment, per 15 minutes

Supported Employment – Individual

$7.61/per 15 minutes

 

H2025HQ

$1.97/per 15 minutes

Ongoing Support to Maintain Employment; per 15 minutes; Group

Ongoing Support to Maintain Employment; per 15 minutes

Supported Employment – Group

$1.97/per 15 minutes

 

T2025

$18.75/per 15 minutes

Waiver Services; not Otherwise Specified (NOS)

Waiver Services; not Otherwise Specified (NOS)

Specialized Consultative  Services

$18.75/per 15 minutes

 

T2001

$1,200.00/per waiver year

Non-Emergency Transportation; Patient Attendant/Escort

Non-Emergency Transportation; Patient Attendant/Escort

Transportation

$1,200.00/per waiver year

 

S5165

$2,500.00/per waiver year

Home Modifications; per service

Home Modifications; per service

Home Modifications

$15,000.00/over 3 year waiver duration

 

S5110

$9.00/per 15 minutes

Home Care Training, Family; per 15 minutes

Home Care Training, Family; per 15 minutes

Individual/caregiver Training and Education

$9.00/per 15 minutes

 

H2016

$84.00/daily

Comprehensive Community Support Services, per diem

Comprehensive Community Support Services, per diem

Residential Supports Level I

$102.33/daily

 

T2014

$113.40/daily

Habilitation Services, per diem

Habilitation Services, per diem

Residential Supports Level II

$125.45/daily

 

T2020

$141.75/daily

Day Habilitation, per diem

Day Habilitation, per diem

Residential Supports Level III

$145.17/daily

 

H2016HI

$157.50/daily

Comprehensive Community Support Services, per diem, Level 4

Comprehensive Community Support Services, per diem

Residential Supports Level IV

$175.35/daily

 

H2015

$5.57/per 15 minutes

Comprehensive Community Support Services, per 15 minutes

Comprehensive Community Support Services, per 15 minutes

Home and Community Supports – Individual

$5.65/per 15 minutes

 

T1019

New Service

Personal care services, per 15 minutes

Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)

Enhanced Personal Care Services

$5.00/per 15 minutes

 

T2039

$15,000.00/per duration of waiver – 3 years

Vehicle Modifications, waiver; per service

Vehicle Modifications, waiver; per service

Vehicle Adaptations

$15,000.00 per duration of waiver – 3 years

 

H2015HQ

$3.68/per 15 minutes

Comprehensive Community Support Services, per 15 minutes

Comprehensive Community Support Services, per 15 minutes

Home and Community Supports – Group (2 or more clients)

$3.15/per 15 minutes

Note: The asterisk (*) indicates as needed, variable cost.

Population Groups
DMA implemented population groups in 2001 to control and track specific benefit packages for designated groups of Medicaid recipients.  For a provider, population groups mean two things:

1.  The provider must be enrolled to provide services to members of the CAP-MR/DD population group for claims to be paid.  Existing CAP providers were enrolled in the appropriate CAP population group(s) according to current enrollment information on file with DMA as of July 11, 2003.  Providers wishing to provide the new Residential Supports services must  enroll with DMA Provider Services.  Provider Enrollment Packages may be found on the DMA Webside under Provider Links or contact Provider Services at 919-855-4050.

2.  The Remittance and Status Report (RA) provides information by population group. The population payer code is printed at the beginning of each claim detail line on the RA.  The code denotes the special program/population group from which a recipient is receiving Medicaid benefits.  The code for CAP-MR/DD is “CAPMR.”  (The CAP- MR/DD indicator on the recipient’s Medicaid identification card will remain “CM.”) This information helps providers track receipts in their accounting systems by each CAP population group for which they are providing services.

Billing Update and Population Groups for CAP-MR/DD Services
DMA, 919-855-4290


Attention: Dialysis Facilities, Outpatient Hospitals and Physicians

Epogen for End-Stage Renal Disease-Change to Billing Guidelines

Effective with date of service September 1, 2005, the N.C. Medicaid program will cover Epogen (EPO) for recipients with end-stage renal disease (ESRD) who are on dialysis when billed with HCPCS code Q4055 rather than codes Q9920-Q9940. HCPCS codes Q9920 – Q9940 will be end-dated effective with date of service August 31, 2005. Details billed with Q9920 – Q9940 after August 31, 2005 will be denied.

The description of HCPCS code Q4055 is epoetin alfa, 1000 units (for ESRD on dialysis). One Medicaid unit of Q4055 equals 1000 units of EPO.

Dialysis Facilities
For dates of service September 1, 2005, and after, the following billing guidelines must be followed or the claim will deny.

• ICD-9-CM diagnosis code 585, chronic renal failure, must be entered on the claim (UB-92) as the primary diagnosis,
along with one of the following additional diagnosis codes:

• 285.8, Other specified anemia,
• 285.9, Anemia, unspecified, and
• 285.21, Anemia in end-stage renal disease.

• Bill one unit for each 1000 units of EPO administered.
• EPO must be billed with either RC 634 or RC 635 (placed in form locator 42).
• RC634 and RC635 must be billed with Q4055 (placed in form locator 43) for EPO.
• Bill RC634 if EPO administered is up to and including 10,000 units.
• Bill RC635 if EPO administered is over 10,000 units.
• Enter the service date in form locator 45.
• Enter the number of units administered in form locator 46.
• Enter the total charge in form locator 47.
• All EPO charges for the same date of service must be billed as one detail on the claim. If EPO charges are billed on two or more details on the claim for the same date of service, each of the details will deny.
• Value code 49 (for HCT) or 48 (for HGB) must be billed to represent the HCT or HGB blood level at the beginning of the billing period (the date of service on the claim). Place the number “49” and the HCT value in form locator 39a. Place the number “48” and the HGB value in form locator 40a.
• Value code 68 must be billed to represent the total amount of EPO given during the billing period. Place the number “68” and the value for the total amount of EPO given during the billing period in form locator 41a.
• Billing must be done on a calendar month basis. Do not bill for dates of service spanning more than one calendar month: Bill on two separate claims.

Note: If there is more than one claim in one month, follow this example:
1. Claim #1 is for dates of service 1-1-2005 thru 1-15-2005 (billing period). EPO 20,000 units were given during this time period and are billed as a total of 20 units on various details of the claim. Value code 68 on the claim would have 20 units.
2. Claim #2 is for dates of service 1-16-2005 thru 1-31-2005 (billing period). EPO 15,000 units were administered during that time. The claim is billed with a total of 15 units of EPO on various details of the claim. Value code 68 for this claim would show 15 units.

Monthly EPO unit totals will be monitored and providers should maintain documentation to be used for calculation of a 90-day rolling average of the HCT and/or HGB. This documentation may be requested to review for medical necessity.

Outpatient Hospitals
For dates of service September 1, 2005, and after, the following billing guidelines must be followed or the claim will deny.
• Bill on the UB-92 claim form.
• ICD-9-CM diagnosis code 585, chronic renal failure, must be entered on the claim (UB-92) as the primary diagnosis
along with one of the following additional diagnosis codes:

• 285.8, Other specified anemia
• 285.9, Anemia, unspecified, and
• 285.21, Anemia in end-stage renal disease.

• Bill one unit for each 1000 units of EPO administered.
• EPO must be billed with either RC 634 or RC 635 (placed in form locator 42).
• RC634 and RC 635 must be billed with Q4055 (placed in form locator 43) for EPO.
• Bill RC634 if EPO is up to and including 10,000 units.
• Bill RC635 if EPO is over 10,000 units.
• Enter the service date in form locator 45.
• Enter the number of units in form locator 46.
• Enter the service date in form locator 47.
• All EPO charges for the same date of service must be billed as one detail on the claim. If EPO charges are billed on two or more details on the claim for the same date of service, each of the details will deny.
• Value code 49 (for HCT) or 48 (for HGB) must be billed to represent the HCT or HGB blood level at the beginning of the billing period (the date of service on the claim). Place the number “49” and the HCT value in form locator 39a. Place the number “48” and the HGB value in form locator 40a.
• Value code 68 must be billed to represent the total amount of EPO given during the billing period. Place the number “68” and the value for the total amount of EPO given during the billing period in form locator 41a.
• Billing must be done on a calendar-month basis. Do not bill for dates of service spanning more than one calendar month: Bill on two separate claims.

Note: If there is more than one claim in one month, follow this example:
1. Claim #1 is for dates of service 1-1-2005 thru 1-15-2005 (billing period). EPO 20,000 units were given during this time period and are billed as a total of 20 units on various details of the claim. Value code 68 on the claim would have 20 units.

2. Claim #2 is for dates of service 1-16-2005 thru 1-31-2005 (billing period). EPO 15,000 units were administered during that time. The claim is billed with a total of 15 units of EPO on various details of the claim. Value code 68 for this claim would show 15 units.

Monthly EPO unit totals will be monitored and providers should maintain documentation to be used for calculation of a 90-day rolling average of the HCT and/or HGB. This documentation may be requested to review for medical necessity.

Physicians
The following billing guidelines must be followed for dates of service September 1, 2005 and after or the claim will deny.

• ICD-9-CM diagnosis code 585, chronic renal failure, must be entered on the claim (UB-92) as the primary diagnosis
along with one of the following additional diagnosis codes:

• 285.8, Other specified anemia,
• 285.9, Anemia, unspecified, and
• 285.21, Anemia in end-stage renal disease.

• Bill HCPCS code Q4055 for EPO; enter the number of units given in block 24-G on the CMS-1500 claim form.

Reminder: HCPCS code Q0136 must be billed for the administration of EPO for non-ESRD use.

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


Attention: Durable Medical Equipment (DME), Home Health Services, Home Infusion Therapy (HIT), Hospice, Hospital Discharge Planners, Personal Care Services (PCS), and Private Duty Nursing (PDN) Providers

Limitations on Medicaid Services Provided to Hospice Recipients-Clarification of Policy

Medicaid recipients choosing to receive hospice benefits must elect hospice before receiving the service.  The recipient or the recipient’s representative must confirm the choice of hospice election by signing an election statement or informed consent form.  The recipient waives his/her right to Medicaid coverage of certain other Medicaid services that replicate the services covered under the hospice benefit.  The clarification of this policy is as follows:

  1. Medicaid coverage for home health, DME, and HIT services is not allowed for hospice recipients when the service pertains to the treatment of terminal illness or related conditions.
  2. Medicaid coverage for PDN and PCS services is not available for recipients receiving hospice services.  The recipient must choose the most appropriate service to fit his/her individual medical needs.

Hospice providers should be aware of all of the home care services being provided to a recipient electing the hospice benefit.  The hospice agency should contact or notify the other service providers prior to accepting the recipient as a hospice patient.  This policy is inclusive of Medicare covered hospice benefits for dually eligible recipients.

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



Attention: Enhanced Mental Health Services Providers

Enhanced Mental Health Services Seminar Schedule

Enhanced Benefit Mental Health Services seminars are scheduled for September 2005. Seminars are intended for provider agencies who meet the approval and endorsement criteria to bill for one or more of the Enhanced Benefit Mental Health Services on or after October 1, 2005. Topics to be discussed will include, but are not limited to, provider enrollment requirements, eligibility issues, billing instructions, and clinical coverage policies. Those who will be billing for these services to N.C. Medicaid are encouraged to attend.

The seminars are scheduled at the locations listed below. Pre-registration is required. It is recommended that the operations manager, clinical professional and a billing person from each “Community Intervention Agency” provider office attend these seminars. Due to limited seating, registration is limited to three staff members per office. Unregistered providers are welcome to attend if space is available.

Provider agencies may register for the Enhanced Benefit Mental Health Services seminars by completing and submitting the registration form available or by registering online. The seminars will begin at 9:00 am and will end at 4:45 pm with a break for lunch from 12:00 pm to 1:00 pm. Providers are encouraged to arrive by 8:45 a.m. to complete registration. Refreshments will not be provided during the seminar.

The September 2005 Special Bulletin VII, Providers of Enhanced Benefit Mental Health/Substance Abuse Services, will be used as the primary training document for the seminars. The special bulletin will be available on DMA’s website. Please print the special bulletin and bring it to the seminar.

Monday, September 12, 2005
Blue Ridge Community College
Bo Thomas Auditorium
Flat Rock, NC

Tuesday, September 13, 2005
Holiday Inn Statesville
1215 Garner Bagnal Blvd.
Statesville, NC

Wednesday, September 14, 2005
Nash Community College
522 North Old Carriage Road
Rocky Mount, NC

Thursday, September 15, 2005
Robeson Community College
Lewis Auditorium
5160 Fayetteville, NC
Lumberton, NC

Friday, September 16, 2005
Jane S. McKimmon Center
1101 Gorman Street
Raleigh, NC

 

Community Intervention Agency Providers of the Enhanced Mental Health Benefit(s) Service who meet the endorsement and enrollment criteria and would like to provide the array of available services must direct enroll with the N.C. Medicaid program. You may access Medicaid enrollment information by going to DMA’s website Enrollment applications can be found at this location.

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


Directions to the Enhanced Mental Health Services Seminars

Blue Ridge Community College, Bo Thomas Auditorium – Flat Rock, North Carolina
Take I-40 to Asheville. Travel east on I-26 to exit 53, Upward Rd. Turn right at 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.

Holiday Inn - Statesville, North Carolina
I-77 North or South to Exit 49A

Rocky Mount location- Rocky Mount, North Carolina
From Raleigh (West)
Take 64 East .  Take the Red Oak exit.  Turn right off ramp at stop sign (Old Carriage Rd).  Go approximately 1/4 mile.  Nash Community College will be on your right.

From Rocky Mount (East)
Take 64 West.  Take the Red Oak Exit (exit past the 95 overpass).  Turn left off ramp at stop sign.  Go approximately 1/4 mile.  Nash Community College will be on your right.

Robeson Community College- Lumberton, North Carolina
I-95 to exit 22.  Turn onto Fayetteville Rd.

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

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


Attention: General Hospitals and Psychiatric Hospitals

Revenue Codes - CORRECTION

Effective July 1, 2005, corrections have been made to the following Revenue Codes for Behavioral Health Treatments/Services.  The facility component for inpatient and outpatient services must be billed on the UB-92 claim form.  Professional services must be billed on a CMS-1500 claim form.

The Revenue Codes listed below replace the Revenue Codes listed in the June 2005 General Medicaid Bulletin.

Behavioral Health Treatments/Services

0901  Electroshock Treatment

BH/ELECTRO SHOCK

0902  Milieu Therapy

BH/MILIEU THERAPY

0905  Intensive Outpatient Services- 

Psychiatric

BH/INTENS OP/PYSCH

0906  Intensive Outpatient Services-Chemical 

BH/INTENS OP/CHEM DEP

0911  Rehabilitation                          

BH/REHAB

0914  Individual Therapy

BH/INDIV RX

0915  Group Therapy

BH/GROUP RX

0916  Family Therapy

BH/FAMILY RX

0918  Testing                                    

BH/TESTING

0919  Other Behavioral Health

Treatments/Services

BH/OTHER

Behavioral Health Treatments/Services – Not covered in current benefit package

0903  Play Therapy

BH/PLAY THERAPY

0904  Activity Therapy

BH/ACTIVITY THERAPY

0917  Bio Feedback                         

BH/BIOFEED

Note: 909 and 910 are no longer covered.  Claims submitted with these codes for dates of service July 1, 2005 and after will deny.

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


Attention: General Hospitals and Psychiatric Hospitals

Revenue Codes for Piedmont Participants

Effective July 1, 2005, corrections have been made to the following Revenue Codes for Behavioral Health Treatments/Services.  The facility component for inpatient and outpatient services must be billed on the UB-92 claim form.  Professional services must be billed on a CMS-1500 claim form.

The Revenue Codes listed below replace the Revenue Codes listed in the June 2005 General Medicaid Bulletin.

Behavioral Health Treatments/Services

0901  Electroshock Treatment

BH/ELECTRO SHOCK

0902  Milieu Therapy

BH/MILIEU THERAPY

0903  Play Therapy

BH/PLAY THERAPY

0904  Activity Therapy

BH/ACTIVITY THERAPY

0905  Intensive Outpatient Services-Psychiatric

BH/INTENS OP/PYSCH

0906  Intensive Outpatient Services-Chemical

BH/INTENS OP/CHEM DEP

0911  Rehabilitation

BH/REHAB

0914  Individual Therapy

BH/INDIV RX

0915  Group Therapy

BH/GROUP RX

0916  Family Therapy

BH/FAMILY RX

0918  Testing                                     

BH/TESTING

0919  Other Behavioral Health

Treatments/Services

BH/OTHER

Behavioral Health Treatments/Services – Not covered in current benefit package

0917 Bio Feedback

BH/BIOFEED

Note: 909 and 910 are no longer covered.  Claims submitted with these codes for dates of service July 1, 2005 and after will deny.

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


Attention: Nursing Facilities and Hospitals

Preadmission Screening Annual Resident Review Seminars

Seminars on the Preadmission Screening Annual Resident Review (PASARR) process have been scheduled for September and October 2005. The seminars will be conducted by the First Health Services Corporation (FHSC), the agent contracted by the N.C. Medicaid program to conduct PASARR. The seminars will provide an overview of the screening process, helpful tips and hints for completing requests, and a brief overview of the free web-based request system available through FHSC. Registration and training information is available of FHSC’s website.

The PASARR training schedule is as follows:

Monday, September 12, 2005
8:00 a.m. -12:00 p.m.
Holiday Inn Sunspree Resort
Asheville, NC

Tuesday, September 13, 2005
1:00 p.m.-4:30 pm
Sheraton at Four Seasons
Greensboro, NC

Thursday, September 15, 2005
8:00 a.m.-12:00 p.m.
Sheraton Capital Center
Raleigh, NC

Friday, September 16, 2005
8:00 a.m.-12:00 p.m.
Hilton
Greenville, NC

Monday, October 3, 2005
8:00 a.m.-12:00 p.m.
Marriott Executive Park
Charlotte, NC

Wednesday, October 5, 2005
8:00 a.m.-12:00 p.m.
Holiday Inn I-95
Fayetteville, NC

Friday, October 7, 2005
8:00 a.m.-12:00 p.m.
Shell Island Resort
Wrightsville Beach, NC

 

For additional information, please call FHSC at 1-800-639-6514 or visit their website.

FHSC, 1-800-639-6515



Attention:  Mental Health Practitioners Who are Employed in Physicians Offices/Clinics, Hospital Outpatient Departments, Local Management Entities, Local Health Departments/School Based Health Centers, and All Other Direct Enrolled Mental Health Practitioners

Outpatient Behavaioral Health Services

The following clarifications are in response to questions from providers attending the seminar on Expansion of Provider Types for Outpatient Behavioral Health Services in May, 2005.

The difference between Psychotherapy and Behavioral Counseling is:

Billing for dually eligible Medicare/Medicaid recipients:

If you have any questions, please contact the Behavioral Health Section of Clinical Policy and Programs at 919-855-4290.

Clinical Policy and Programs
DMA, 919-855-4290

 

Attention: Independent Laboratories and Physicians

CLIA Certification Related Claim Denials

This is additional clarification to the article published in the May 2005 general Medicaid bulletin entitled CLIA Certification Related Claim Denials.

In order to ensure claims are coded appropriately when submitting and resubmitting claims, providers should refer to the Clinical Laboratory Improvement Amendments (CLIA) website for a listing of CLIA tests along with correct procedure codes for waived and provider performed microscopy procedures (PPMP) certificate levels.  The lists may be printed and retained for future reference.  This information is periodically updated and new tests are added as they become approved for "waived" status.

CLIA Certificate Level

Tests Allowed

Website for List of Tests

Certificate Level 2

CLIA waived tests

http://www.cms.hhs.gov/CLIA/

Certificate Level 4

CLIA waived tests
PPMP

http://www.cms.hhs.gov/CLIA/

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 denying for EOB 0936, “Certification not valid for DOS/Level and a delay in payment.” 

Claims submitted incorrectly with CPT codes that are not considered “waived” will deny for EOB 0936, “Certification not valid for DOS/Level and a delay in payment.”

If a test is not included on either of these lists, 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: Nursing Facility Providers

Minimum Data Set Supportive Documentation Guidelines

The revised Minimum Data Set (MDS) Supportive Documentation Guidelines (SDGs) from the Centers for Medicare and Medicaid Services (CMS) went into effect on June 15, 2005.  All MDSs with an A3a date of June 15, 2005 or later must be reviewed using the revised guidelines.  A copy of the new SDGs was mailed to all North Carolina nursing facilities on June 13, 2005, and is also available on DMA’s website.  

MDS Help Desk
919-715-1872, ext. 214

Myers and Stauffer’s Help Desk
1-800-763-2278

MDS Validation Program Oversight and Administration
Margaret Comin, RN, Facility Services Unit Manager
DMA, 919-855-4350


Attention: Nursing Facility Providers

Restorative Nursing Defined for Case Mix

Restorative nursing programs may be initiated when a Nursing Facility resident is discharged from formalized physical, occupational or speech rehabilitation therapy, or when a restorative need arises for a resident who is not a candidate for a more formalized therapy program.  Because it is a nursing function, a restorative nursing program does not require a physician’s order or oversight by a licensed therapist.  However, accurate assessments are crucial to ensure that the nursing facility is appropriately providing and receiving reimbursement for restorative nursing programs to residents. 

A nursing restorative program maintains or retains the level of function that is appropriate to the resident.  To qualify for and to continue with a restorative nursing program, the recipient must meet all of the following criteria:

Documentation Requirements for Case Mix
The Restorative Nurse Supervisor must care plan each problem, establish measurable goals and interventions, and provide periodic evaluation of each individual restorative program specific for each individual resident on a Restorative Nursing Program.

The MDS requirement is that each technique, procedure or activity practiced totals a minimum of 15 minutes during a 24-hour period.  The MDS validation reviewers are required to review actual minutes provided each day that have been signed by the staff responsible for providing the programs. Although interventions may be carried out by nurse aides, other staff or volunteers, a periodic evaluation for each restorative program the resident is receiving must be documented by a licensed nurse.

Peggy Scott, RN, Nursing Facility Consultant
DMA, 919-855-4350


Attention:  OB/GYN Providers

OB/GYN Billing Seminars

Seminars on OB/GYN billing guidelines are scheduled for October 2005.  Registration information and a list of dates and site locations for the seminars will be published in the September 2005 general Medicaid bulletin.

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


Attention:  Personal Care Services (PCS) Providers

PCS Recoupments

In October 2004, EDS began recouping overpayments to Personal Care Services (PCS) since the implementation of PCS-Plus in November 2003.  Some of the recoupments from this time period have not been completed. The recoupment process will start again in mid to late summer and will continue until all of the overpayments have been corrected.  The overpayment amount will be automatically deducted from the provider’s payment.  Providers who have received PCS payments for services that exceeded the 3.5 hour per day limit (or 14 units) for PCS clients without PCS-Plus prior approval will have these payments recouped.  Any providers who have received payments for services that exceeded 60 hours (or 240 units) a month for PCS clients without PCS-Plus prior approval will also have these payments recouped. 

As a reminder, PCS is limited to 60 hours a month for each eligible Medicaid recipient.  Medicaid recipients with prior approval from the Division of Medical Assistance for PCS-Plus services are eligible for up to 80 hours a month of PCS.

EDS will contact PCS providers with large overpayments before initiating a recoupment.  EDS will arrange a recoupment plan with these providers to allow for repayment over several Checkwrite periods.

Tracy Colvard, Acting Manager for PCS/PCS-Plus
DMA, 919-855-4360


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.


 2005 Checkwrite Schedule

 

Month

    Electronic Cut-Off Date

 Checkwrite Date

August

 

7/29/2005

 

         8/2/2005

   

8/5/2005

 

         8/9/2005

   

8/12/2005

 

         8/16/2005

   

8/19/2005

 

         8/25/2005

September

 

9/2/2005

 

         9/7/2005

   

9/9/2005

 

         9/13/2005

   

9/16/2005

 

         9/20/2005

   

9/23/2005

 

         9/29/2005

October

 

10/7/2005

 

         10/11/2005

   

10/14/2005

 

         10/18/2005

   

10/21/2005

 

         10/27/2005

      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.


2005 Checkwrite Schedule


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

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