DHHS Logo NC Medicaid Logo

September 2009
Medicaid Bulletin

Printer Friendly Version

In This Issue . . .

All Providers:

Adult Care Home Providers:

Children's Developmental Services Agencies:

Community Alternatives Program Case Managers:

Dental Providers:

Durable Medical Equipment Providers:

Federally Qualified Health Centers:

Health Department Dental Centers:

Health Departments:

HIV Case Management Providers:

Home Health Agencies:

Hospital Outpatient Clinics :

Hospitals:

Independent Practitioners:

Local Management Entities:

Nurse Midwives:

Nurse Practitioners:

Nursing Facilities:

Pharmacists:

Physicians:

Prescribers:

Private Duty Nursing Providers:

Rural Health Clinics:


Attention:  All Providers

Provider Enrollment and Re-credentialing Fee

Session Law 2009-451 mandated that DMA begin collecting a $100 enrollment fee from providers upon initial enrollment with the N.C. Medicaid Program and at 3-year intervals when the provider is re-credentialed.  This process will begin on September 1, 2009, and will apply to applications received on or after that date. 

CSC, 1-866-844-1113


Attention:  All Providers

Electronic Funds Transfer Requirement

Effective with the second checkwrite in September 2009, the N.C. Medicaid Program will no longer issue paper checks for claims payment.  All payments will be made electronically by automatic deposit to the account specified in the provider’s Electronic Funds Transfer (EFT) Authorization Agreement for Automatic Deposits

Providers were first notified of this cost-saving measure in the June 2009 Medicaid Bulletin.  Additional information about the electronic funds transfer requirement and other budget initiatives are available on DMA’s Budget Initiatives web page.

Providers who are currently receiving paper checks for claims payment must complete and submit an EFT Authorization Agreement for Automatic Deposits immediately to ensure that there is no disruption to payments.  The form is available on DMA’s Provider Forms web page.

Once the EFT Authorization Agreement has been submitted, a test with the bank will be performed to validate the account information.  This test will be done on the first checkwrite in which financial activity occurs, following receipt of the completed form.  Normally it will require one checkwrite to complete the process.  Once the testing process is complete, payments will be electronically deposited directly to the provider’s bank account one business day after the checkwrite day

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


Attention:  All Providers

Notice of Medicaid Identification Card Changes

On September 8, 2009, the N.C. Medicaid Program will begin issuance of one Medicaid identification (MID) card per year to each recipient.  Currently, the N.C. Medicaid Program issues each recipient a new MID card each month.  The new annual cards will be printed on gray card stock.  DMA will phase out the blue, pink, green, and buff-colored MID cards.  The new cards will include the case head name, recipient’s name, MID number, issue date, and CCNC/CA primary care provider information (if applicable).  The new cards do not indicate dates of eligibility.  Recipients who are issued new cards may have been approved for prior months only, the current month only, or an ongoing period of up to 12 months.  (See new card sample.)

Because the new card no longer serves as proof of eligibility, it is essential that at each visit providers verify the recipient’s

Current recipients and individuals approved for Medicaid prior to September 8, 2009, will be issued an old version of the monthly MID card.  Providers will continue to see the blue, pink, green, and buff-colored cards and the new gray-colored cards during the month of September 2009.  Old monthly cards with September or earlier eligibility dates continue to serve as proof of eligibility for the months shown on the card.

It is anticipated that a web-based recipient eligibility verification tool will be available in September (refer to the article titled Electronic Recipient Eligibility Verification Tool for additional information).  Instructions for using the tool are available in the September 2009 Special Bulletin, North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instruction Guide.  For additional information about verifying recipient eligibility, refer to the Basic Medicaid Billing Guide.

Medicaid Eligibility Unit
DMA, 919-855-4000


Attention:  All Providers

Electronic Claim Submission Exceptions

As a cost-saving measure and to increase efficiency, beginning October 2, 2009, the N.C. Medicaid Program will require all providers to file claims electronically.  Claims received on or after October 2, 2009, are subject to denial if the claim is not in compliance with the electronic claim mandate.  Information on the electronic claim mandate was originally published in the June 2009 Medicaid Bulletin.

The list of exceptions (originally published in the July 2009 Medicaid Bulletin) to the requirement for electronic claim submissions has been revised and is available on DMA’s Electronic Claim Exceptions web page.  Only claims that comply with these exceptions may be submitted on paper.  All other claims are required to be submitted electronically.  Providers will be notified of updates to the list through the Medicaid Bulletin on DMA's Medicaid Bulletin web page.

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


Attention:  All Providers

Electronic Recipient Eligibility Verification Tool

In September, the N.C. Medicaid Program will implement an electronic recipient eligibility verification tool.  This tool will allow providers to access electronic recipient eligibility via the North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool.

Use of this tool will allow providers to immediately verify recipient information such as

This will be the same information that providers receive today through the Automated Voice Response (AVR) system but the Recipient Eligibility Tool will be quicker and easier to use.  In order to use this tool, providers must have access to the Web Tool.  DMA encourages you to begin immediately the process of obtaining this access.

Providers who currently have an Web logon ID and password can utilize this same logon information to access recipient eligibility verification.  You do not need to take any further action.

Providers who do not currently have access to the Web Tool must take the following action.

Step One:
Submit a completed and signed Electronic Claims Submission (ECS) Agreement to CSC.  (Refer to the NC Tracks website for a copy of the form and instructions.)

Note:  Providers who have previously submitted the ECS Agreement do not need to resubmit the form.

Step Two:
Contact the EDS Electronic Commerce Services Unit (1-800-688-6696 or 919-851-8888, option 1) to obtain instructions and a logon ID and password for the Web Tool.

For additional information on verifying recipient eligibility refer to the Basic Medicaid Billing Guide.  For detailed information on the Web Tool, refer to the September 2009 Special Bulletin, North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instruction Guide.

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


Attention:  All Providers

Helpful Hints When Billing National Drug Codes

Providers are reminded that the dose reported by the HCPCS units must equal the dose reported by the National Drug Code (NDC) units.  Refer to the following examples.

Additionally, in an outpatient setting, providers are reminded to write a prescription for maintenance medications or acute treatment medications, like oral antibiotic tablets or suspensions, for patient pick-up at a local pharmacy, if appropriate.

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


Attention:  All Providers

Clinical Coverage Policies

The following new or amended clinical coverage policies are now available on DMA'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

Top 10 EOBs

The following table contains the top eight EOB codes for all claims denied during June 2009. 

EOB

EOB Description

Resolution

286

Incorrect authorization number on claim form.  Verify number and refile claim

Referring NPI on processed claim does not match the recipient’s eligibility file for submitted date of service.  Contact referring PCP, obtain the correct referral information and resubmit claim.

9271

Payment included in DRG reimbursement on first accommodation detail

Refer to first accommodation detail.  If payment is indicated, no action necessary.  If denial code is indicated, correct and resubmit claim based on EOB description given.

270

Billing provider is not the recipient’s Carolina Access PCP.  Authorization is missing or unresolved.  Contact PCP for authorization or EDS Prov. Svcs. if authorization is correct

Submitted claim requires a referring NPI.  The referring NPI is either not found on the claim or is unresolved (cannot map to single MPN).  Correct and resubmit the claim.

1170

This procedure or procedure/modifier combination is edited for units, therefore billing a span of days is not allowed.  Please bill each date of service on a separate detail

Affected procedure or procedure/modifiers should be submitted on separate details with corresponding units.  Correct and resubmit the claim.

8925

Allowable reduced for deductible/patient liability

Prior payment amount exceeds the N.C. Medicaid allowable, or reduces the N.C. Medicaid allowable by the prior payment amount.  No action necessary.

21

Exact duplicate

Exact claim has previously paid in history.  If previous payment is incorrect, submit a replacement claim to address overpayment or underpayment.  If payment is correct, no action necessary.

153

Ancillary charges included in per diem rate

Refer to first accommodation detail.  If payment is indicated, no action necessary.  If denial code is indicated, correct and resubmit claim based on EOB description given.

11

Recipient not eligible on service date

Verify recipient eligibility via a 270/271 transaction or via the Automated Voice Response System (1-800-723-4337, option 6).  Refer to the Basic Medicaid Billing Guide, Appendix F for more details.  If recipient’s eligibility has updated since the original claim has processed, resubmit the claim. 


The following table contains the top two EOB codes for NPI claims during June 2009. 

EOB

EOB Description

Resolution

270

Billing provider is not the recipient’s Carolina Access PCP.  Authorization is missing or unresolved.  Contact PCP for authorization or EDS Prov. Svcs. if authorization is correct

Submitted claim requires a referring NPI.  The referring NPI is either not found on the claim or is unresolved (cannot map to single MPN).  Correct and resubmit the claim.

8326

Attending provider ID is missing or unresolved.  Attending prov is required.  Verify attending provider ID and resubmit as a new claim or contact EDS prov svcs if ID is correct

Submitted claim requires an attending NPI.  The attending NPI is either not found on the claim or is unresolved (cannot map to single MPN).  Correct and resubmit the claim.

Although the suggested resolution is for common denial cases, each claim may propose a unique processing scenario.  For further questions or claim research, contact EDS Provider Services for claim-specific diagnostics.

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


Attention:  All Providers

Legislative Mandate for Uniform Screening Program Tool for PASARR Screenings

Effective September 1, 2009, Medicaid providers who are required to conduct a Preadmission Screening and Annual Resident Review (PASARR) for individuals before admission to North Carolina's nursing facilities are required to submit the PASARR screening through DMA’s web-based PASARR tool or through a third-party vendor that can interface with the Uniform Screening Program (USP) tool.

To learn more about MUST, go to the MUST website. To register and to start using the tool, refer to the Getting Started web page. Registration will not interfere with your current web-based method of submitting data.

Help is always available to make this transition as smooth as possible.  Please feel free to contact EDS at 1-800-688-6696, option 7.

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


Attention:  All Providers

Immune Globulin (Octagam), Intravenous, HCPCS Procedure Code J1568:  Renewed Coverage

Because federal guidelines prohibit the N.C. Medicaid Program from reimbursement for non-rebatable drugs, coverage of immune globulin (Octagam), intravenous, nonlyophilized (e.g., liquid), 500 mg, (HCPCS procedure code J1568) was previously end-dated.  Effective with date of service June 30, 2009, coverage of Octagam was renewed due to the availability of rebatable National Drug Codes (NDCs) for this product. 

Octagam is covered through the Physician’s Drug Program and for outpatient hospitals when billed with HCPCS procedure code J1568 and a rebatable 11-digit National Drug Code (NDC).  Providers who received claim detail denials for rebatable NDCs billed on or after June 30, 2009, may resubmit the denied charges as new day claims (not as adjustment requests) for processing.  

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


Attention:  All Providers

Medicaid Credit Balance Reporting

All providers participating in the Medicaid Program are required to submit a quarterly Credit Balance Report to the DMA Third-Party Recovery Section identifying balances due to Medicaid.  Providers must report any outstanding credits owed to Medicaid that have not been reported previously on a Medicaid Credit Balance Report.  However, hospital and nursing facility providers are required to submit a report every calendar quarter even if there are no credit balances.  The report must be submitted no later than 30 days following the end of the calendar quarter (March 31, June 30, September 30, and December 31).

The Medicaid Credit Balance Report is used to monitor and recover “credit balances” owed to the Medicaid Program.  A credit balance results from an improper or excess payment made to a provider.  For example, refunds must be made to Medicaid if a provider is paid twice for the same service (e.g., by Medicaid and a medical insurance policy, by Medicare and Medicaid, by Medicaid and a liability insurance policy) or if the patient liability was not reported in the billing process or if computer or billing errors occur.

For the purpose of completing the report, a Medicaid Credit Balance is the amount determined to be refundable to the Medicaid Program.  When a provider receives an improper or excess payment for a claim, it is reflected in the provider's accounting records (patient accounts receivable) as a “credit.”  However, credit balances include money due to Medicaid regardless of its classification in a provider's accounting records.  If a provider maintains a credit balance account for a stipulated period (e.g., 90 days) and then transfers the account or writes it off to a holding account, this does not relieve the provider of liability to the Medicaid Program.  The provider is responsible for identifying and repaying all monies owed the Medicaid Program.

The Medicaid Credit Balance Report requires specific information for each credit balance on a claim-by-claim basis.  The reporting form provides space for 15 claims but may be reproduced as many times as necessary to accommodate all the credit balances being reported.  Specific instructions for completing the report are on the reverse side of the reporting form.

Submitting the Medicaid Credit Balance Report does not result in the credit balances automatically being reimbursed to the Medicaid Program.  Electronic adjustments are the preferred method of satisfying the credit balances and can be performed through the North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool.  Refer to the September 2009 Special Bulletin, North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instruction Guide, for specific filing instructions.

In the event, a billing error caused an individual provider to be paid for a service in which a provider group should have been paid, a refund check will need to be sent to EDS to correct the error as it is unlikely the individual provider will have future claims to adjust.  In these circumstances only, a check must be made payable to EDS and sent to EDS using the Medicaid Provider Refund Form.  The information on the form must be complete and accurate in order to process the provider refund check.  

Submit the Medicaid Credit Balance Report Form to:

Electronic Adjustments using the North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool

Submit Refund Checks to:

Third Party Recovery Section
Division of Medical Assistance
2508 Mail Service Center
Raleigh  NC  27699-2508

Refer to the September 2009 Special Bulletin, North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instruction Guide

EDS Refunds
P.O. Box 300011
Raleigh  NC  27622-3011

(Do not send these refund checks to DMA or to the Controller’s Office.)

Submit only the completed Medicaid Credit Balance Report to DMA.  Failure to submit a Medicaid Credit Balance Report to DMA will result in the withholding of Medicaid payment until the report is received.

Send to DMA:

Send to EDS Refunds Department:

Debbie Odette, Third Party Recovery Section
DMA, 919-647-8100


Attention:  All Providers

Prior Authorization for Non-emergency Outpatient High-tech Radiology and Ultrasound Procedures

Dates related to the implementation of prior authorization (PA) of high-tech radiology and ultrasound procedures are as follows:

Date

Procedures

Instructions for Providers

October 13, 2009
October 14, 2009
October 20, 2009
October 29, 2009
November 4, 2009

Online Training Sessions

Online provider training sessions will be provided at 9:00 a.m. and 1:00 p.m. on each day. MedSolutions will be sending a packet of information via the mail regarding the dates of the training and how to access it.

October 19, 2009

CT, CTA, MR, MRA, PET

All ordering providers will begin requesting PA for tests scheduled November 1, 2009, and after. 

November 1, 2009

CT, CTA, MR, MRA, PET

Institutional and professional claims submitted to EDS for testing performed on November 1, 2009, and after will require PA on file.  Outpatient claims will require Revenue Codes and CPT codes on the UB-04 detail.

December 15, 2009

Ultrasounds

All ordering providers will begin requesting PA for tests scheduled January 1, 2010, and after.

January 1, 2010

Ultrasounds

Institutional and professional claims submitted to EDS for testing performed on January 1, 2010, and after will require PA on file.  Outpatient claims will require Revenue Codes and CPT codes on the UB-04 detail.

MedSolutions will accept authorization requests by web, phone, and fax.  Please visit the MedSolutions website to register for PA services and to view MedSolutions’ imaging guidelines. 

The ordering physician is required to obtain the PA.  This authorization should be obtained before the testing is scheduled.  The authorization number should be provided to the facility performing the test.  The authorization is good for 60 days following its issuance.

Procedures performed during an inpatient stay, during an emergency department visit, during an observation stay or as a referral from a hospital emergency department do not require prior approval.  Refer to the following information on billing for procedures provided in these circumstances.

Type of Stay

Billing Instruction

Inpatient stay

Enter Bill type 11x in Form Locator 4

Emergency department visit

Enter Revenue Code 450 in Form Locator 42

Observation stay

Enter Revenue Code 762 in Form Locator 42

Hospital emergency department referral

Institutional Claims:  Enter appropriate CPT code with modifier U2 in Form Locator 44.

Professional Claims:  Enter appropriate CPT code with modifier U2 in field 24D.

The following procedure codes require prior approval:

Positron Emission Tomography (PET) Scans

CPT Code

Description

78608

Brain imaging, positron emission tomography (PET); metabolic evaluation

78609

Brain imaging, positron emission tomography (PET); perfusion evaluation

78811

Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)

78812

Positron emission tomography (PET) imaging; skull base to mid-thigh

78813

Positron emission tomography (PET) imaging; whole body

78814

Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)

78815

Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh

78816

Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body

Computed Tomography Angiography (CTA)

CPT Code

Description

70496

Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing

70498

Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing

71275

Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing

72191

Computed tomography angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

73206

Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

73706

Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

74175

Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing

75635

Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed and image postprocessing

Computed Tomography (CT) Scans

CPT Code

Description

70450

Computed tomography, head or brain; without contrast material

70460

Computed tomography, head or brain; with contrast material(s)

70470

Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections

70480

Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material

70481

Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material

70491

Computed tomography, soft tissue neck; with contrast material

70492

Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections

71250

Computed tomography, thorax; without contrast material

71260

Computed tomography, thorax; with contrast material(s)

71270

Computed tomography, thorax, without contrast material, followed by contrast material(s) and further sections

72125

Computed tomography, cervical spine; without contrast material

72126

Computed tomography, cervical spine; with contrast material(s)

72127

Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections

72128

Computed tomography, thoracic spine; without contrast material

72129

Computed tomography, thoracic spine; with contrast material(s)

72130

Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections

72131

Computed tomography, lumbar spine; without contrast material

72132

Computed tomography, lumbar spine; with contrast material(s)

72133

Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections

72192

Computed tomography, pelvis; without contrast material

72193

Computed tomography, pelvis; with contrast material(s)

72194

Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections

73200

Computed tomography, upper extremity; without contrast material

73201

Computed tomography, upper extremity, with contrast material(s)

73202

Computed tomography, upper extremity, without contrast material, followed by contrast material(s) and further sections

73700

Computed tomography, lower extremity; without contrast material

73701

Computed tomography, lower extremity, with contrast material(s)

73702

Computed tomography, lower extremity, without contrast material, followed by contrast material(s) and further sections

74150

Computed tomography, abdomen; without contrast material

74160

Computed tomography, abdomen; with contrast material(s)

74170

Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections

76380

Computed tomography, limited or localized follow-up study

76497

Unlisted computed tomography procedure (eg, diagnostic, interventional)

77078

Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)

77079

Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)

Magnetic Resonance Angiography (MRA)

CPT Code

Description

70544

Magnetic resonance angiography, head; without contrast material(s)

70545

Magnetic resonance angiography, head; with contrast material(s)

70546

Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences

70547

Magnetic resonance angiography, neck; without contrast material(s)

70548

Magnetic resonance angiography, neck; with contrast material(s)

70549

Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences

71555

Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s)

72159

Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)

72198

Magnetic resonance angiography, pelvis, with or without contrast material(s)

73225

Magnetic resonance angiography, upper extremity, with or without contrast material(s)

73725

Magnetic resonance angiography, lower extremity, with or without contrast material(s)

74185

Magnetic resonance angiography, abdomen, with or without contrast material(s)

Magnetic Resonance Imaging (MRI)

CPT Code

Description

70336

Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)

70540

Magnetic resonance (eg, proton) imaging, orbit, face and/or neck; without contrast material(s)

70542

Magnetic resonance (eg, proton) imaging, orbit, face and/or neck; with contrast material(s)

70543

Magnetic resonance (eg, proton) imaging, orbit, face and/or neck; without contrast material(s), followed by contrast material(s) and further sequences

70551

Magnetic resonance angiography, brain (including brain stem); without contrast material(s)

70552

Magnetic resonance angiography, brain (including brain stem);; with contrast material(s)

70553

Magnetic resonance angiography, brain (including brain stem);; without contrast material(s), followed by contrast material(s) and further sequences

71550

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)

71551

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s)

71552

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences

72141

Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material

72142

Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)

72146

Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material

72147

Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s)

72148

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material

72149

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)

72156

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical

72157

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic

72158

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar

72195

Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s)

72196

Magnetic resonance (eg, proton) imaging pelvis; with contrast material(s)

72197

Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences

73218

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s)

73219

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s)

73220

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences

73221

Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)

73222

Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s)

73223

Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences

73718

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s)

73719

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s)

73720

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences

73721

Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material

73722

Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)

73723

Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences

74181

Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s)

74182

Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s)

74183

Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences

76498

Unlisted magnetic resonance procedure (eg, diagnostic, interventional)

77058

Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral

77059

Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral

Ultrasound

CPT Code

Description

76506

Echoencephalography, real time with image documentation (gray scale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnormalities), including A-mode encephalography as secondary component where indicated

76510

Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter

76511

Ophthalmic ultrasound, diagnostic; quantitative A-scan only

76512

Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan)

76513

Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy

76514

Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness)

76516

Ophthalmic biometry by ultrasound echography, A-scan:

76519

Ophthalmic biometry by ultrasound echography, A-scan: with intraocular lens power calculation

76529

Ophthalmic ultrasonic foreign body localization

76536

Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid) real time with image documentation

76604

Ultrasound, chest (includes mediastinum), real time with image documentation

76645

Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation

76700

Ultrasound, abdominal, real time with image documentation; complete

76705

Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)

76770

Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete

76775

Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited

76776

Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation

76800

Ultrasound, spinal canal and contents

76801

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation

76802

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation

76805

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or + 14 weeks 0 days), transabdominal approach; single or first gestation

76810

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or + 14 weeks 0 days), transabdominal approach; each additional gestation

76811

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation

76812

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation

76813

Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation

76814

Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation

76815

Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses

76816

Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus

76817

Ultrasound, pregnant uterus, real time with image documentation, transvaginal

76818

Fetal biophysical profile; with non-stress testing

76819

Fetal biophysical profile; without non-stress testing

76820

Doppler velocimetry, fetal; umbilical artery

76821

Doppler velocimetry, fetal; middle cerebral artery

76825

Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording;

76826

Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; follow-up or repeat study

76827

Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete

76828

Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study

76830

Ultrasound, transvaginal

76831

Saline infusion sonohysterography (SIS), including color flow Doppler, when performed

76856

Ultrasound, pelvic (nonobstetric), real time with image documentation; complete

76857

Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)

76870

Ultrasound, scrotum and contents

76872

Ultrasound, transrectal;

76873

Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure)

76880

Ultrasound, extremity, nonvascular, real time with image documentation

76885

Ultrasound, infant hips, real time with imaging documentation; dynamic (requiring physician manipulation)

76886

Ultrasound, infant hips, real time with imaging documentation; limited, static (not requiring physician manipulation)

76970

Ultrasound study follow-up

76999

Unlisted ultrasound procedure (eg, diagnostic, interventional)

93875

Noninvasive physiologic studies of extracranial arteries, complete bilateral study (eg, periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis)

93880

Duplex scan of extracranial arteries; complete bilateral study

93882

Duplex scan of extracranial arteries; unilateral or limited study

93886

Transcranial Doppler study of the intracranial arteries; complete study

93888

Transcranial Doppler study of the intracranial arteries; limited study

93890

Transcranial Doppler study of the intracranial arteries; vasoreactivity study

93892

Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection

93893

Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection

93922

Non-invasive physiologic studies of upper or lower extremity arteries, single level, bilateral

93923

Non-invasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative testing, complete bilateral study

93924

Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study

93925

Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study

93926

Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study

93930

Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study

93931

Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study

93965

Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography)

93970

Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study

93971

Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study

93975

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study

93976

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study

93978

Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study

93979

Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study

93990

Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow)

Other

CPT Code

Description

76376

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring imaging postprocessing on an independent workstation

76377

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring imaging postprocessing on an independent workstation

Revenue Codes

RC Code

Description

350

CT Scan – General Classification

351

CT Scan – Head Scan

352

CT Scan – Body Scan

359

CT Scan – Other

402

Other Imaging Services – Ultrasound

404

Other Imaging Services – Positron Emission Tomography

409

Other Imaging Services – Other Imaging Services

610

Magnetic Resonance Technology (MRT) – General Classification

611

Magnetic Resonance Technology (MRT) – MRI Brain/Brainstem

612

Magnetic Resonance Technology (MRT) – MRI Spinal Cord/Spine

614

Magnetic Resonance Technology (MRT) – MRI Other

615

Magnetic Resonance Technology (MRT) – MRA Head and Neck

616

Magnetic Resonance Technology (MRT) – MRA Lower Extremities

618

Magnetic Resonance Technology (MRT) – MRA Other

619

Magnetic Resonance Technology (MRT) – Other MRT

A policy will be posted on DMA's Radiology Services web page prior to implementation. 

Practitioner and Clinic Services
DMA, 910-355-1883


Attention:  Durable Medical Equipment Providers

Coverage for Augmentative and Alternative Communication Devices

Effective with date of service September 1, 2009, prior approval is required for HCPCS procedure code E2511 (speech generating software program, for personal computer or personal digital assistant).  Lifetime expectancy and quantity limitations has been modified for HCPCS procedure code E2500 (speech generating device, digitized speech, using prerecorded messages, less than or equal to eight minutes recording time).

Refer to Clinical Coverage Policy 5A, Durable Medical Equipment, on DMA’s website for prior approval requirements (Subsection 5.3.23) and changes in quantity limitations (Attachment E).

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


Attention:  Hospitals

Transfer Pricing and Patient Discharge Status Codes

Inpatient hospital claims received on or after August 28, 2009, are subject to new requirements for transfer pricing and patient discharge status codes. 

Transfer pricing logic has been modified to meet the requirements of Grouper 25 and UB-04/837I claims processing.  The transfer pricing logic is as follows:

  1. When an inpatient claim is processed with a Discharge Status Code “02,” the claim is considered a transfer claim and the reimbursement is prorated as required in the State Plan Amendment 4.19-A, page 24, Special Situation section, paragraph (c). 
  2. For inpatient claims processed with one of the Discharge Status Codes from column 1 in the table below and one of the Diagnostic Related Groups (DRGs) listed in column 2, reimbursement is made using the transfer logic method defined in the State Plan Amendment 4.19-A, page 24, Special Situations section, paragraphs (c) and (d).

Column 1

Column 2 – DRG

Discharge Status Code

Prior to October 1, 2008
(Grouper Version 24 and older)

On or After October 1, 2008
(Grouper 25)

03, 05, 06, 62, 63, 65 (New)

14, 113, 209, 210, 211, 236, 263, 264, 429, 483

28, 29, 30, 40, 41, 42, 219, 220, 221, 477, 478, 479, 480, 481, 482, 492, 493, 494, 500, 501, 502, 515, 516, 517, 956

New Discharge Status Codes
In addition to the patient discharge status codes currently allowed, the claims processing system is able to process discharge status codes 43, 50, 51, 65, and 66.  These status codes should be placed on the UB-04 claim form in form locator 17. Refer to the NUBC Manual for description and usage guidelines. Providers should use the code that is supported by the patient's medical record to file the claim for reimbursement or any subsequent adjustment claims.

Updates to the Hospital Manual and the Basic Medicaid Billing Guide are forthcoming.

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


Attention:  Hospitals and Nursing Facilities

Medicare Crossover Claim Adjustments

On August 13, 2009, the N.C. Medicaid Program began processing electronic 837 void and replacement transactions from hospitals and nursing facilities when the adjustments were submitted directly to EDS by GHI, the Medicare Coordination of Benefits Contractor (COBC).  Providers will notice that on their Remittance and Status Reports, the Internal Claim Number assigned to these adjustment claims begins with either a 90 or 95 for a void transaction or a 97 for a replacement transaction.

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


Attention:  Nurse Practitioners and Physicians

Antithrombin (Recombinant) for Injection (ATryn, HCPCS Procedure Code J3590):  Billing Guidelines

Effective with date of service June 5, 2009, the N.C. Medicaid program covers antithrombin (recombinant) injectable (ATryn) for use in the Physician’s Drug Program when billed with HCPCS procedure code J3590 (unclassified biologics).  ATryn is available as single-use vials containing approximately 1,750 IU per vial.

ATryn is a recombinant antithrombin and is not formulated with human plasma proteins.  It is indicated for the prevention of perioperative and peripartum thromboembolic events in hereditary antithrombin deficient patients.

Treatment with ATryn should be initiated before delivery or approximately 24 hours prior to surgery and should be individualized for each patient.  The goal should be restoring and maintaining antithrombin activity levels between 80% and 120% (0.8 to 1.2 U/mL) of normal.

For Medicaid Billing

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


Attention:  Nurse Practitioners and Physicians

Degarelix Single-use Vials for Injection (Firmagon, HCPCS Procedure Code J3490):  Billing Guidelines

Effective with date of service April 1, 2009, the N.C. Medicaid program covers degarelix injectable (Firmagon) for use in the Physician’s Drug Program when billed with HCPCS procedure code J3490 (unclassified drug).  Firmagon is available as single-use vials containing either 80 mg or 120 mg of powder for injection.

Firmagon is a gonadotropin-releasing hormone (GnRH) receptor antagonist indicated for the treatment of advanced prostate cancer.  Firmagon is for use in males only and can cause fetal harm if administered to pregnant women.

Firmagon is administered as a subcutaneous injection (SC) and is not to be administered intravenously.  Treatment is started with a dose of 240 mg, given as two injections of 120 mg each.  The starting dose is followed by maintenance doses of 80 mg administered as a single SC injection every 28 days.

For Medicaid Billing

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


Attention:  Community Alternatives Program Case Managers, Home Health Agencies, and Private Duty Nursing Providers

Venipuncture Supplies

Effective with date of service September 1, 2009, HCPCS procedure code T5999 was end-dated and can no longer be used to bill for venipuncture supplies.  These supplies are covered as an administrative cost and cannot be billed as a separate charge.  The cost is included in the reimbursement for the skilled nursing visit.

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


Attention:  Nurse Practitioners and Physicians

Fibrinogen Concentrate (Human) Single-use Vials for Injection (RiaSTAP, HCPCS Procedure Code J3590):  Billing Guidelines

Effective with date of service June 12, 2009, the N.C. Medicaid program covers fibrinogen concentrate (human) injectable (RiaSTAP) for use in the Physician’s Drug Program when billed with HCPCS procedure code J3590 (unclassified biologics).  RiaSTAP is available in single-use vials that contain approximately 1 gm (900 mg to 1300 mg) of lyophilized fibrinogen concentrate powder for reconstitution.  Note:  The actual fibrinogen potency for each lot is printed on the vial label and carton.

RiaSTAP is a fibrinogen concentrate made from pooled human plasma that is indicated for the treatment of acute bleeding episodes in patients with congenital fibrinogen deficiency, including afibrinogenemia and hypofibrinogenemia.  RiaSTAP is not indicated for dysfibrinogenemia.

Fibrinogen dosing, duration of dosing, and frequency of administration should be individualized based on the extent of bleeding, laboratory values, and the clinical condition of the patient.

For Medicaid Billing

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


Attention:  Nurse Practitioners and Physicians

Temozolomide Single-use Vials for Injection (Temodar, HCPCS Procedure Code J9999):  Billing Guidelines

Effective with date of service April 1, 2009, the N.C. Medicaid program covers temozolomide injectable (Temodar) for use in the Physician’s Drug Program when billed with HCPCS procedure code J9999 (not otherwise classified, antineoplastic drugs).  Temodar is available as single-use vials that contain 100 mg of temozolomide lyophilized powder for reconstitution.

Temodar is an alkylating antineoplastic agent indicated for the initial treatment of newly diagnosed glioblastoma multioforme (GBM), in combination with radiotherapy, and then as maintenance treatment.  It is also indicated for the treatment of refractory anaplastic astrocytoma.

For the treatment of newly diagnosed GBM, a 75-mg/ml injection of Temodar is administered for 42 days concomitantly with focal radiotherapy.  This is followed by initial maintenance injections of 150 mg/ml once daily for days 1 through 5 of a 28-day cycle for 6 cycles.  For the treatment of refractory anaplastic astrocytoma, an initial 150-mg/ml dose is administered as an injection once daily for 5 consecutive days per 28-day treatment cycle.

As bioequivalence to the oral dosage form of Temodar has been established only when given over a period of
90 minutes, infusion over a shorter or longer period of time may result in suboptimal dosing.

For Medicaid Billing

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


Attention:  Private Duty Nursing Providers

Provision of Medical Supplies for Recipients Without Private Duty Nursing Coverage

Effective with date of service September 1, 2009, private duty nursing (PDN) providers may provide certain medical supplies (see table below) for any eligible Medicaid recipient without providing PDN services.  This provision is limited to incontinent, ostomy, and urological (IOU) medical supplies.  The item supplied must be medically necessary and ordered by the physician.  The following criteria must be met.

The monthly quantity limit provision also includes IOU supplies provided to DMA-approved PDN recipients.  There is no change in the guidelines for provision of other types of medical supplies to these recipients.  PDN agencies should continue to use the information from Home Health Fee Schedule to bill all other medical supplies for DMA-approved PDN recipients.

Incontinent Supplies

Procedure Code

Description

Billing Unit

Maximum Allowable

Maximum Monthly Limit

A4554

Disposable underpads, all sizes (e.g. Chux's)

each

$0.56

200

T4521

Adult sized disposable incontinence product, brief/diaper, small

each

$0.97

192

T4522

Adult sized disposable incontinence product, brief/diaper, medium

each

$0.97

192

T4523

Adult sized disposable incontinence product, brief/diaper, large

each

$0.97

192

T4524

Adult sized disposable incontinence product, brief/diaper, extra large

each

$0.97

192

T4529

Pediatric sized disposable incontinence product, brief/diaper

each

$0.97

192

T4530

Pediatric sized disposable incontinence product, brief/diaper, large size

each

$0.97

192

T4533

Yw/oh-sized disposable incontinence product, brief/diaper

each

$0.97

192

 

Ostomy Supplies

Procedure Code

Description

Billing Unit

Maximum Allowable

Maximum Monthly Limit

A4362

Skin Barrier; Solid, 4 X 4 or eq

each

 $     3.46

15

A4364

Adhesive (for ostomy or catheter),

1 ounce

 $     5.97

10 oz

A4365

Adhesive remover wipes, any type

1 box

 $    11.32

1 BOX

A4367

Ostomy belt, each

 each

 $     6.25

2/mo

A4369

Ostomy skin barrier, liquid (spray, brush, etc.)

 1 ounce 

 $     3.96

6 oz

A4371

Ostomy skin barrier, powder

1 ounce

 $     6.93

2 oz

A4372

Ostomy skin barrier, solid 4X4 or eq, bui

each

 $     4.18

20

A4373

Ostomy skin barrier, flange, built-in convexity, any size

each

 $     6.28

20

A4375

Ostomy pouch, drainable, faceplate attached, plastic

each

 $    17.18

15

A4377

Ostomy pouch, drainable, for  faceplate, plastic

each

 $     4.29

30

A4379

Ostomy pouch, urinary, faceplate attached, plastic

each

 $    15.02

15

A4381

Ostomy pouch, urinary, for  faceplate, plastic

each

 $     4.61

30

A4385

Ostomy skin barrier, solid 4X4 or eq, ext

each

 $     5.10

20

A4388

Ostomy pouch, drainable, ex wear barrier attached, (1 Piece)

each

 $     4.36

60

A4390

Ostomy pouch, drainable, ex wear barrier attached, built in convexity (1 piece)

each

 $     9.61

60

A4394

Ostomy Deodorant, or, w/o lubricant,

fl. Oz.

 $     2.58

16 oz

A4397

Irrigation supply; sleeve

each

 $     4.07

6

A4398

Ostomy irrigation supply; bag

each

 $    13.81

1/6 mo

A4399

Ostomy irrigation supply; cone/catheter, c brush

each

 $    12.15

3

A4400

Ostomy irrigation set

each

 $    41.54

2

A4404

Ostomy rings

each

 $     1.44

2

A4405

Ostomy skin barrier, non pectin based, paste

1 ounce

 $     4.25

6 oz

A4406

Ostomy skin barrier, pectin-based, paste

1 ounce

 $     6.30

6 oz

A4407

Ostomy skin barrier, flange , ex wear, built-in convexity, 4X4 in. or smaller

each

 $     8.82

20

A4408

Ostomy skin barrier, with flange (solid, flexible or accordion), ex wear, built-in convexity, larger than 4 x 4 inches

each

 $     9.87

20

A4409

Ostomy skin barrier, flange (solid, flexible or accordion), ex wear, w/o built-in convexity, 4 x 4 inches or smaller

each

 $     6.22

20

A4410

Ostomy skin barrier, flange , ex wear, w/o built-in convexity, larger than 4X4 in.

each

 $     9.04

20

A4411

Ostomy skin barrier, solid 4x4 or eq, ex wear, built-in convexity

each

 $     5.10

20

A4414

Ostomy skin barrier, flange (solid, flexible or accordion), w/o built-in convexity, 4 x 4 inches or smaller

each

 $     4.93

20

A4415

ostomy skin barrier, flange (solid, flexible or accordion), w/o built-in convexity, larger than 4x4 inches, each

each

 $     6.00

20

A4416

Ostomy pouch, closed, barrier attached, filter,

each

 $     2.75

30

A4417

Ostomy pouch, closed, barrier attached, built-in convexity, filter,

each

 $     3.72

20

A4418

Ostomy pouch, closed; w/o barrier, filter

each

 $     1.81

60

A4419

Ostomy pouch, closed; for  barrier

each

 $     1.74

20

A4423

Ostomy pouch, closed; for  barrier, locking flange,

each

 $     1.86

20

A4424

Ostomy pouch, drainable, barrier attached, filter

each

 $     4.75

20

A4425

Ostomy pouch, drainable; for barrier, non-locking flange, filter

each

 $     3.58

20

A4426

Ostomy pouch, drainable; for barrier, locking flange 

each

 $     2.73

20

A4427

Ostomy pouch, drainable; for barrier, locking flange, filter,

each

 $     2.78

20

A4428

Ostomy pouch, urinary, ex wear barrier attached, faucet-type tap, valve,

each

 $     6.51

20

A4429

Ostomy pouch, urinary, barrier attached, built-in convexity, faucet-type tap, valve,

each

 $     8.25

20

A4430

Ostomy pouch, urinary, ex wear barrier attached, built-in convexity, faucet-type tap, valve (1 piece)

each

 $     8.52

15

A4431

Ostomy pouch, urinary; barrier attached, faucet-type tap, valve,

each

 $     6.22

20

A4432

Ostomy pouch, urinary; for  barrier, non-locking flange, faucet-type tap, valve (2 piece)

each

 $     3.59

15

A4433

Ostomy pouch, urinary; for  barrier, locking flange (two piece)

each

 $     3.34

20

A4455

Adhesive remover or solvent (for tape, cement or other adhesive)

1 ounce

 $     3.84

4 oz

A4558

Conductive paste or gel

1 jar

 $     5.45

1

A5051

Ostomy pouch, closed; barrier attached,

each

 $     2.75

31

A5052

Ostomy pouch, closed; w/o barrier attached,

each

 $     1.70

31

A5054

Ostomy pouch, closed; for barrier, flange (two piece)

each

 $     1.72

90

A5055

Stoma cap

each

 $     1.26

30

A5061

Ostomy pouch, drainable;, barrier attached,

each

 $     4.22

65

A5062

Ostomy pouch, drainable; w/o barrier attached,

each

 $     2.50

31

A5063

Ostomy pouch, drainable; for  barrier, flange,

each

 $     3.07

31

A5071

Ostomy pouch, urinary; barrier attached,

each

 $     4.79

31

A5072

Ostomy pouch, urinary; w/o barrier attached,

each

 $     3.47

31

A5073

Ostomy pouch, urinary; for  barrier, flange (two piece)

each

 $     3.18

31

A5120

Skin barrier, wipes or swabs, each

each

 $     0.24

25

A5121

Skin barrier; solid, 6 X 6 or eq (wafer)

each

 $     8.97

15

A5122

Skin barrier; solid, 8 X 8 or eq (wafer)

each

 $    12.54

15

A5126

Adhesive or non-adhesive; disk or foam pad

each

 $     1.12

36

 

Urological Supplies

Procedure Code

Description

Billing Unit

Maximum Allowable

Maximum Monthly Limit

A4310

Insertion tray, w/o drainage bag and, w/o catheter (accessories only)

each

 $     6.56

2

A4311

Insertion tray, w/o drainage bag, indwelling catheter, Foley type, two-way latex, coating (Teflon, silicone, silicone elastomer or hydrophilic, etc)

each

 $    14.84

2

A4313

Insertion tray, w/o drainage bag, indwelling catheter, Foley type, three-way, for continuous irrigation

each

 $    18.52

2

A4314

Insertion tray, drainage bag, indwelling catheter, Foley type, two-way latex, coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)

each

 $    25.29

2

A4316

Insertion tray, drainage bag, indwelling catheter, Foley type, three-way, for continuous irrigation

each

 $    28.40

2

A4320

Irrigation tray, bulb or piston syringe, any purpose

each

 $     4.53

3

A4321

Therapeutic agent for urinary catheter irrigation (acetic acid - 250 to 1,000 cc)

$4.53

 $     2.93

2

A4322

Irrigation syringe, bulb or piston

each

 $    10.25

2

A4328

Female external urinary collection device; pouch

each

 $     3.18

2

A4334

Urinary catheter anchoring device, leg strap

each

 $     4.93

2

A4335

Incontinence supply; miscellaneous (catheter care kit)

each

 $     4.40

2

A4338

Indwelling catheter; Foley type, two-way latex, coating 

each

 $    10.87

2

A4340

Indwelling catheter; specialty type, (e.g., Coude, mushroom, wing, etc.)

each

 $    26.99

2

A4344

Indwelling catheter, Foley type, two-way, all silicone

each

 $    14.35

2

A4349

Male external catheter, or, w/o adhesive, disposable

each

 $     2.02

36

A4351

Intermittent urinary catheter; straight tip, or, w/o coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.)

each

 $     1.54

93

A4352

Intermittent urinary catheter; coude (curved) tip, or, w/o coating

each

 $     5.94

93

A4353

Intermittent urinary catheter, insertion supplies

each

 $     7.00

10

A4354

Insertion tray, drainage bag but, w/o catheter

each

 $    11.80

2

A4357

Bedside drainage bag, day or night, or, w/o anti-reflux device, or, w/o tube

each

 $     9.70

2

A4358

Urinary leg bag; vinyl, or, w/o tube

each

 $     6.63

4

 

Miscellaneous Supplies

Procedure Code

Description

Billing Unit

Maximum Allowable

Maximum Monthly Limit

A4450

Tape, non-waterproof, per 18 sq. in.

18 sq in

 $     0.09

80u

A4452

Tape, waterproof, per 18 sq. in.

18 sq in

 $     0.36

80u

A4927

Non-sterile exam gloves

100/box

 $    11.38

1 BOX

A4217

Sterile saline or water, 500ml

500 ml

 $     2.66

2

A4244

Alcohol or Peroxide, per pint

1 pint

 $     1.02

3

A4246

Betadine or PhisoHex solution, per pint

1 pint

 $     5.94

3

A4321

Therapeutic agent for urinary catheter irrigation (acetic acid - 250 to 1,000 cc)

1 bottle

 $     7.50

2

A6216

Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border

each

 $     0.05

200

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


Attention:  Federally Qualified Health Centers, Health Departments, Nurse Midwives, Nurse Practitioners, Physicians (Except for Physicians Enrolled with a Specialty of Oncology, Radiology or Nuclear Medicine), and Rural Health Clinics

Requesting an Exception to the Legislative Visit Limit

Providers of mandatory Medicaid services may request an exception to the legislative visit limit.  (Information about the limit can be found on DMA’s Annual Visit Limit web page and in the August 2008 North Carolina Medicaid Bulletin.)  This request can be made when a provider is actively managing a life-threatening disorder for a recipient and knows that the care of this condition will require an extended number of office visits. 

To submit a request, the provider should complete the General Request for Prior Approval Form (372-118) and submit it with records documenting the reason for the request before the service is rendered.  Please complete boxes 2 through 7, 12, and 14 through 16.  For the Type of Request, check the box by 05 and write in “visit limit.”  This request should be sent to the EDS address listed at the top of the form.

The EDS Medical Director will review the request within five business days of receipt.  If the request is approved, the form will be returned to the provider indicating what was approved.  If the request is denied, the form will be returned along with a copy of the letter that will be sent to the recipient about the denial.  The recipient will be provided with information on how to appeal the denial. 

At this time, the EDS system cannot automatically process claims for exceptions to the visit limit.  Please submit the claims electronically with the approved diagnosis code(s).  If denied due to the visit limit, complete a Medicaid Claim Adjustment Form for the claim and attach a copy of the approval form to the adjustment form.  These adjustments will override the denial and allow the claim to process.

Should a post-denial review be necessary for services not submitted for prior approval, claim documentation should be sent through the adjustment process. 

DMA will inform providers when the system is ready for automatic processing of electronic claims for approved exceptions.  Please contact EDS with any questions concerning this procedure.

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


Attention:  Pharmacists and Prescribers

New Prior Authorization Requirements for Brand-name ACE Inhibitors, Angiotensin Receptor Blockers, and Renin Inhibitors

Effective with date of service August 10, 2009, the N.C. Outpatient Pharmacy Program began requiring prior authorization (PA) for brand name ACE inhibitors, angiotensin receptor blockers, and renin inhibitors.  Prescribers can request PA by contacting ACS at 866-246-8505 (telephone) or 866-246-8507 (fax).  The criteria and PA request form for these medications are available on the N.C. Medicaid Enhanced Pharmacy Program website.  Generic ACE inhibitors do not require prior authorization.

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


Attention:  Pharmacists and Prescribers

Changes to Prior Authorization Requirements for Antinarcolepsy/Antihyperkinesis Agents

Effective with date of service August 10, 2009, the N.C. Outpatient Pharmacy Program added prior authorization (PA) requirements for Nuvigil (armodafinil).  Prescribers can request PA by contacting ACS at 866-246-8505 (telephone) or 866-246-8507 (fax).  The criteria and PA request form for these medications are available on the N.C. Medicaid Enhanced Pharmacy Program website.

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


Attention:  Pharmacists and Prescribers

Changes to Prior Authorization Requirements for Proton Pump Inhibitors

Effective with date of service August 10, 2009, the N.C. Outpatient Pharmacy Program amended the prior authorization (PA) requirements for proton pump inhibitors to allow patients receiving Plavix (clopidogrel) concomitantly with pantoprazole to be exempt from PA criteria on pantoprazole.  The criteria are available on the N.C. Medicaid Enhanced Pharmacy Program website.

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


Attention:  Adult Care Home (Family Care Home) Providers

Cost Report for Personal Care Services in Adult Care Homes/Family Care Homes for 2009

Each year, DMA requests cost data from adult care home personal care service (ACH-PCS) providers in accordance with the Medicaid Participation Agreement.  In contrast to previous years, the ACH-PCS cost reports will not be mailed to facilities and providers.  The cost report package is available online on DMA's Family Care Homes Cost Reports web page.  Instructions on how to complete the cost report, the deadline for submitting the report, and where to send the report are included in the package.

Rate Setting
DMA, 919-855-4200


Attention: HIV Case Mangement Providers

Limits for Medicaid HIV Case Management Services

In accordance with Session Law 2009-451, Section 10.68A.(a)(2)(b), on October 1, 2009, the N.C. Medicaid Program will implement limits on the number of units that may be reimbursed each calendar month per recipient. The number of billable units of HIV Case Management services provided to a recipient shall not exceed 16 units per calendar month.

This limit may not apply to recipients under the age of 21 years as long as all criteria for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), Medicaid for Children, are met. For further informatoin about EPSDT, visit DMA's EPSDT web page.

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


Attention:  Dental Providers and Health Department Dental Centers

Dental Program Changes Included in the 2009 Budget Bill (SL 2009-451)

Effective with date of service October 1, 2009, the following changes will be implemented for the N.C. Medicaid Dental Program.  These changes are outlined in the Conference Committee Money Report attached to the budget bill (SL 2009-451), which refers to dental policy adjustments resulting in program cost savings of approximately $3.7 million in State appropriations.  Acting upon the direction of DHHS/DMA leadership, the Dental Program staff worked with a fiscal workgroup composed of dentists from the enrolled provider community and our colleagues at the Department of Public Health’s Oral Health Section to identify policy changes that would save money and at the same time make sense from a clinical perspective.  These proposed changes to Clinical Coverage Policy 4A, Dental Services, can be reviewed on DMA’s Proposed Medicaid Clinical Coverage Policies web page.

Other dental policy adjustments may be forthcoming depending on the need for further cost-saving measures.

In addition to the changes listed above, the Medicaid reimbursement for all covered procedure codes will be reduced by approximately 3% for SFY 2010.  The effective date of this change has not been determined; however, when the effective date is determined, the complete Dental Fee Schedule, located on DMA's Fee Schedule web page, will be updated.  Providers are reminded to bill their usual and customary charges rather than the Medicaid rate.

For current coverage criteria and additional billing guidelines, please refer to Clinical Coverage Policy 4A, Dental Services, on DMA’s website.

Dental Program
DMA, 919-855-4280


Attention: Children's Developmental Service Agencies, Health Departments, Home Health Agencies, Independent Practitioners, Local Management Entities, Outpatient Hospital Clinics, and Physicians

Outpatient Specialized Therapies

Clinical Coverage Policy # 10A, Outpatient Specialized Therapies, which was finalized earlier this year, will be posted to DMA's Clinical Coverage Policy and Provider Manual web page on November 1, 2009. At that time, a revised prior approval process will be put into place for all therapy treatment visits. Instructions on how to obtain prior approval will be announced in the October Medicaid Bulletin.

Nora Poisella, Clinical Policy and Programs
DMA, 919-855-4310


Attention:  Dental Providers

Dental Seminars

Dental seminars are scheduled for the month of October 2009.  Information presented at these seminars will include a review of clinical coverage guidelines, prior approval, and billing procedures for dental services.  The seminars are scheduled at the locations listed below.  Clinical Coverage Policy 4A, Dental Services,
(October 1, 2009 revision) will be used as the primary training document for the seminar.  The revised policy will be available after October 1, 2009.  Please review and print the Policy (on DMA’s Clinical Coverage Policy and Provider Manuals web page) once it is available, and bring it to the seminar.

Pre-registration 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.

Providers may register for the dental seminars by completing and submitting the online registration form.  Sessions will begin at 10:00 a.m. and end at 1:00 p.m.  Providers are encouraged to arrive by 9:45 a.m. to complete registration.  Lunch will not be provided at the seminars.  Because meeting room temperatures vary, dressing in layers is strongly advised.

Date

Location

Wednesday, October 14, 2009

Wilmington
Hampton Inn – Medical Park
2320 S. 17th Street
Wilmington  NC  28401

Monday, October 19, 2009

Raleigh
Hilton North Raleigh
3415 Wake Forest Road
Raleigh  NC  27609-7330

Wednesday, October 21, 2009

Williamston
Martin Community College
1161 Kehukee Park Road
Williamston  NC  27892-4425

Wednesday, October 28, 2009

Salisbury
Holiday Inn Salisbury
530 Jake Alexander Boulevard, South
Salisbury  NC  28147

Thursday, October 29, 2009

Asheville
Mountain Area Health Education Center
501 Biltmore Avenue
Asheville  NC  28801

Directions to the Dental Seminars

ASHEVILLE
Mountain Area Health and Education Center
Traveling East on I-40:  Take I-40 East to Exit 50.  Turn onto Hendersonville Road.  Stay in the right-hand lane through five traffic lights.  At the 6th traffic light, turn left onto the Mission Hospitals emergency entrance.  Take the first right and then another immediate right into the parking deck.

Traveling West on I-40:  Take I-40 West to Exit 50B onto Hendersonville Road.  Stay in the right-hand lane through five traffic lights.  At the 6th traffic light, turn left into the Mission Hospitals emergency entrance.  Take the first right and then another immediate right into the parking deck.

Traveling East on I-26:  Take I-26 to I-240 East to Exit 5B for Charlotte Street.  Exit right onto Charlotte Street.  At the 4th traffic light, turn left onto Biltmore Avenue.  Proceed through three traffic lights.  At the 4th light, turn right into the Mission Hospitals emergency entrance.  Take the first right and then another immediate right into the parking deck.

RALEIGH
Hilton North Raleigh
Traveling East on I-40:  Take I-40 to I-440 East (inner beltline).  Follow I-440 North to Exit 10 for Wake Forest Road.  At the bottom of exit ramp turn left.  The hotel is located on the left approximately 0.5 mile from the exit ramp.

Traveling West on I-40:  Take I-40 to I-440 West (outer beltline).  Follow I-440 South to Exit 10 for Wake Forest Road.  At the bottom of exit ramp turn right.  The hotel is located on the left approximately 0.5 mile from the exit ramp.

SALISBURY
Holiday Inn Salisbury
Traveling South on I-85:  Take I-85 to Exit 75.  At the end of the exit ramp, turn right onto Jake Alexander Boulevard.  Travel approximately 0.5 mile.  The Holiday Inn is located on the right.

Traveling North on I-85:  Take I-85 to Exit 75.  At the end of the exit ramp, turn left onto Jake Alexander Boulevard.  Travel approximately 0.5 mile.  The Holiday Inn is located on the right.

WILLIAMSTON
Martin Community College
Building 2 Auditorium
Traveling East on US 64:  Take US 64 West to the intersection at McDonald’s in Williamston.  Turn left on the US 13/US 17 Bypass.  The name will change to Old Highway 64 Bypass.  Continue approximately 2.3 miles and turn left on Kehukee Park Road.  The college is located on the right approximately 0.5 mile from the intersection.

Traveling West on US 64:  Take US 64 East to Exit 512 (Prison Camp Road).  (Look for the sign just before Exit 512 for Senator Bob Martin Agricultural Center and Martin Community College.)  Turn right on Prison Camp Road.  Drive for approximately 0.5 mile and turn left on Kehukee Park Road.  The college is located on the right approximately 0.5 mile from the intersection. 

Traveling North on US 13/US 17:  Take US 13/US 17 South to Williamston.  Continue to follow US 13/US 17 until it becomes Old Highway 64 Bypass.  Continue driving for approximately 2.5 miles.  Turn left on Kehukee Park Road.  The college is located on the right approximately 0.5 mile from the intersection.

WILMINGTON
Hampton Inn – Medical Park
Traveling East on I-40:  Take I-40 East into Wilmington.  I-40 becomes Highway 132/College Road.  Follow
S. College Road to Shipyard Boulevard.  Bear right onto Shipyard Boulevard.  Turn right onto 17th Street.  The hotel is located on the left approximately 0.5 mile from the intersection.

Traveling South on US 17/US 74/76:  Follow US 17 South into Wilmington.  US 17/US 74/76 becomes Dawson Street.  Turn right onto 16th Street at the 4th stoplight.  (16th Street merges with S. 17th Street.)  Travel approximately 2.5 miles.  The hotel is located on the right, two blocks past the New Hanover Regional Medical Park.

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


Early and Periodic Screening, Diagnosis and Treatment and Applicability to Medicaid Services and Providers

Service limitations on scope, amount, duration, frequency, location of service, and other specific criteria stated in this publication may be exceeded or may not apply to recipients under 21 years of age if the provider's documentation shows that

This applies to both proposed and current limitations. Providers should review any information in this publication that contains limitations in the context of EPSDT and apply that information to their service requests for recipients under 21 years of age. A brief summary of EPSDT follows.

EPSDT is a federal Medicaid requirement (42 U.S.C. § 1396d(r) of the Social Security Act) that requires the coverage of services, products, or procedures for Medicaid recipients under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination (including any evaluation by a physician or other licensed clinician).

This means that EPSDT covers most of the medical or remedial care a child needs to

Medically necessary services will be provided in the most economic mode possible, as long as the treatment made available is similarly efficacious to the service requested by the recipient's physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the recipient's right to a free choice of providers.

EPSDT does not require the state Medicaid agency to provide any service, product, or procedure that is unsafe, ineffective, experimental, or investigational; that is not medical in nature; or that is not generally recognized as an accepted method of medical practice or treatment.

If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does not eliminate the requirement for prior approval.

For important additional information about EPSDT, please visit the following websites:


Proposed Clinical Coverage Policies

In accordance with NCGS §108A-54.2, 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 Proposed Clinical Coverage Policies web page.  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.


2009 Checkwrite Schedule

 

Month

Electronic Cut-Off Date

Checkwrite Date

September

9/3/09

9/9/09

9/10/09

9/15/09

9/17/09

9/24/09

October

10/1/09

10/6/09

10/8/09

10/14/09

10/15/09

10/20/09

10/22/09

10/29/09

10/29/09

11/3/09

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.

Craigan L. Gray, MD, MBA, JD
Director
Division of Medical Assistance
Department of Health and Human Services

Melissa Robinson
Executive Director
EDS, an HP Company

 

 

 

DMA Home Page