December 2002 NC Medicaid Bulletin title

Printer Friendly Version

In This Issue..  
All Providers: Adult Care Home Providers: Ambulance Providers: Anesthesiologists: CAP/AIDS, CAP/DA, and CAP/C Case Managers: Certified Registered Nurse Anesthetists: Durable Medical Equipment Providers: Federally Qualified Health Centers: Health Check Providers: Health Departments: Hospice Providers: Hospital Outpatient Clinics: Hospitals: Mental Health Providers: Nursing Facility Providers: Optical Providers: Rural Health Clinics:


Attention: All Providers

Holiday Observance

The Division of Medical Assistance (DMA) and EDS will be closed on Tuesday, December 24, 2002 through Thursday, December 26, 2002 in observance of Christmas, and on Wednesday, January 1, 2003 in observance of New Year's Day.

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


Attention: All Providers

Medicaid Payment Accuracy Measurement Demonstration Project

DMA Program Integrity received a grant from the Centers for Medicare and Medicaid Services (CMS) to participate in a Medicaid Payment Accuracy Measurement (PAM) demonstration project. The goal of the project is to help CMS determine the feasibility of estimating Medicaid claim payment accuracy for the Medicaid program at the state and national level. This is an effort supported by the U.S. House of Representatives (HR 4878) and the Office of Inspector General (OIG).

An essential part of this project consists of a review of a stratified sample of Medicaid claims and a review of the corresponding medical records. Program Integrity staff and Medical Review of North Carolina will contact providers whose claims fall in the sample to obtain medical records for the services billed to Medicaid. Samples will be taken from inpatient hospital services, long-term care services, independent practitioners and clinics, prescription drugs, home- and community-based services, and other supplies and services.

Claim payment will be recouped due to lack of documentation for the service billed if medical records are not supplied by the deadline. The claim payment will be projected as an overpayment if the requests for records are not returned by the deadline. This will inflate the overall state payment error rate. That will also overestimate the error rate for the services involved.

If your office is contacted for records, we ask for your cooperation and timely response to our request. This will facilitate the review and minimize the need for direct contact with the providers in the sample. We will clearly indicate on our letters or faxes that the request is part of the PAM Grant sample. Thank you in advance for your cooperation.

Questions regarding this project or the sample can be directed to Chuck Brownfield at 919-733-6681. We look forward to working with you.

Bo Nowell, Program Integrity Section
DMA, 919-733-6681


Attention: All Providers

Proposed Medical Coverage Policies

In accordance with Session Law 2001-424, Senate Bill 1005, proposed new or amended Medicaid medical coverage policies are available for review and comment on DMA's website. To submit a comment related to a policy, refer to the instructions on the website. Providers without internet access can submit written comments to the address listed below.

Darlene Creech
Medical Policy Section
Division of Medical Assistance
2511 Mail Service Center
Raleigh, NC 27699-2511

The initial comment period for each proposed policy is 45 days. An additional 15-day comment period will follow if a proposed policy is revised as a result of the initial comment period.

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


Attention: All Providers

Claim Payments Suspend

Effective November 1, 2002, EDS began suspending claim payments for all providers who did not have a correct address on file. EDS currently receives returned Remittance and Status Reports (RAs) and checks that cannot be delivered due to an incorrect billing address on file for providers.

When EDS receives a returned RA or check, all claims for the provider number will be suspended and the subsequent RAs and/or checks will no longer be printed. EFT payments will also be discontinued. Once EDS has placed this suspension on the provider number, the provider will have 90 days to submit address changes. After 90 days, if the address has not been corrected, claims in suspension will deny and the provider number will be terminated.

Providers will be notified in writing and will have 21 days from the date of the letter to respond to the Division of Medical Assistance (DMA) Provider Services unit. If the letter is returned to DMA as undeliverable, the provider number will be terminated. Once terminated, providers will be subject to the full re-enrollment process and experience a period of ineligibility as a Medicaid provider.

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


Attention: All Providers

Provider Information Update

The N.C. Medicaid program is updating provider files to include a fax number and e-mail address. These two methods of communication will complement the already existing methods of communication and provide a quick avenue for providers to receive information. Because only one e-mail address and one fax number can be entered for a provider number, please submit the most appropriate information for the provider number given. Please complete and return the Provider Information Update form to EDS Provider Enrollment at the address listed below.

To report a change of ownership, name, address, tax identification number changes, group member, or licensure status, please use the Notification of Change in Provider Status form. Managed Care providers (Carolina ACCESS, ACCESS II, and ACCESS III) must also report changes using the Carolina ACCESS Provider Information Change form, including changes in daytime or after-hours phone numbers.

Return the completed Provider Information Update form to:

EDS Provider Enrollment
PO Box 300009
Raleigh, NC 27622
Fax: 919-851-4014

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


Attention: All Providers

Tax Identification Information

Alert - Tax Update Requested

The N.C. Medicaid program must have the correct tax information on file for all providers. This ensures that 1099 MISC forms are issued correctly each year and that correct tax information is provided to the IRS. Incorrect information on file with Medicaid can result in the IRS withholding 30 percent of a provider's Medicaid payments. The individual responsible for maintenance of tax information must receive the information contained in this article.

How to Verify Tax Information
The last page of the Medicaid Remittance and Status Report (RA) indicates the tax name and number on file with Medicaid for the provider number listed. Review the Medicaid RA throughout the year to ensure that the correct tax information is on file for each provider number. If you do not have access to a Medicaid RA, call EDS Provider Services at 919-851-8888 or 1-800-688-6696 to verify the tax information on file for each provider.

The tax information listed for a group practice is as follows:

  1. group tax name and group tax number
  2. attending Medicaid provider number in the group
How to Correct Tax Information
All providers are required to complete a W-9 form for each provider number with incorrect information on file. Correct information must be received by December 15, 2002. The procedure for submitting corrected tax information to the Medicaid program is determined by the provider type. Division of Medical Services
Provider Services
2506 Mail Service Center
Raleigh, NC 27699-2506

Refer to the following instructions for completing the W-9 form. Additional instructions can be found on the IRS website at http://www.irs.gov under the link "Forms and Pubs."

Change of Ownership DMA Provider Services will assign a new Medicaid provider number if necessary and will ensure the correct tax information is on file for Medicaid payments.

If DMA is not contacted and the incorrect tax identification number is used, that provider will be liable for taxes on income not necessarily received by the provider's business. DMA will assume no responsibility for penalties assessed by the IRS or for misrouted payments prior to written receipt of notification of ownership changes.

Physician Group Practice Changes
When a physician leaves or a physician is added to a group practice, contact BCBSNC to update Medicaid enrollment and tax information. Carolina ACCESS (CA) providers must also report changes to DMA Provider Services using the Carolina ACCESS Provider Information Change Form.

 

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


Attention: All Providers

Medical Coverage Policies

Updated policies for the following programs are now located on the Division of Medical Assistance's website:

1A Physicians

1D Clinics 1M Baby Love/Child Service Coordination 4A Dental Services

4B Orthodontic Services

8F Outpatient Specialized Therapies

8G Independent Practitioners

8I Psychological Services Provided by Health Departments and School-Based Health Centers Sponsored by Health Departments to the Under 21 Population

These policies supersede previously published policies and procedures. Providers may contact EDS at 1-800-688-6696 or 919-851-8888 with billing questions.

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


Attention: Health Check Providers

Health Check Hearing and Vision Screening

Health Check follows the Recommendations for Preventive Pediatric Health Care from the American Academy of Pediatrics for hearing and vision screening requirements as well as for other screening components. The Recommendations may be accessed at http://www.aap.org/policy/re9939.html.

In accordance with the periodicity schedule and the Recommendationsfor Preventive Pediatric Health Care, objective hearing screenings using electronic equipment (i.e., audiometer) must be performed at birth, 4 years, 5 years, 6 years, 9 years, 12 years, 15 years, and 18 years. Health Check hearing screenings must be indicated on the claim with CPT code 92551. Subjective screenings (e.g., rattling coins in a cup) must be performed at interperiodic visits.

Objective vision screenings (i.e., Snellen chart), following the guidance of the periodicity schedule and the Recommendations, are required at periodic visits at ages 3 years, 4 years, 5 years, 6 years, 9 years, 12 years, 15 years, and 18 years. CPT code 99173 must be on the claim. Subjective screenings (i.e., tracking) must be performed at interperiodic visits.

If hearing and vision screenings cannot be performed during a periodic visit due to a condition such as deafness or blindness and the claim is denied, the denied claim may be submitted through the adjustment process with supporting medical record documentation attached.

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


Attention: Adult Care Home Providers

Revised Assessment and Care Plan Form

A new version of the Adult Care Home Personal Care Physician Authorization and Care Plan form (DMA-3050-R) and instructions are now available on the Division of Medical Assistance (DMA) website. Providers may begin using the form on December 1, 2002. However, providers may continue to use the current version of the form (DMA-3050) until June 30, 2003. The DMA-3050 will no longer be a valid assessment form after June 30, 2003.

Providers can also obtain copies of the form by calling EDS at 1-800-688-6696 or 919-851-8888.

Adult Care Home Personal Care Physician Authorization and Care Plan form (DMA-3050-R)

Bill Hottel, Medical Policy, Adult Care Home Services Unit
DMA, 919-857-4020


Attention: Ambulance Providers

New Ambulance Billing Guidelines

Effective with date of service December 31, 2002, the N.C. Medicaid program will end-date the following codes: A0320, A0322, A0324, A0326, A0330, A0380, A0390, A0090, and A0040. Providers must bill the replacement codes listed in the following table, effective with date of service January 1, 2003. N.C. Medicaid reimburses for the level of care provided to the recipient. Call Reports must validate the level of care provided to the recipient.
 
Old Code Description New Code Description
A0320  BLS non-emergency  A0428  Ambulance service, basic life support, non-emergency (BLS) 
A0322  BLS emergency  A0429  Ambulance service, basic life support, emergency (BLS-Emergency) 
A0324  ALS non-emergency  A0426  Ambulance service, advanced life support, non-emergency transport, level 1 (ALS 1) 
A0326  ALS non-emergency, specialized services rendered  A0426  Ambulance service, advanced life support, non-emergency transport, level 1 (ALS 1) 
A0330  ALS emergency  A0427  Ambulance service, advanced life support, emergency transport, level 1 (ALS 1-Emergency) 
    A0433  Advanced life support, level 2 (ALS 2) 
A0380  BLS ground mileage, emergency  A0425  Ground mileage, per statute mile 
A0390  ALS ground mileage, emergency  A0425  Ground mileage, per statute mile 
A0090  Non-emergency ground mileage  A0425  Ground mileage, per statute mile 
A0040  Helicopter lift-off  A0431  Ambulance service, conventional, air services, transport, one-way (Rotary Wing) 

As noted above, A0425 must be used when billing for ground mileage with basic life support (BLS) or advanced life support (ALS) services. Other codes currently in place for ambulance services should continue to be billed until further instructions are published. These codes are Y0001, Y0002, Y0050, Y0060, Y0070, Y0003, and Y0004. Other billing instructions detailed in the 1999 N.C. Medicaid Ambulance Services Manual still apply.

Basic Life Support
Definition: BLS is transportation by ground ambulance vehicle and the provision of medically necessary supplies and services, including BLS ambulance services as defined by the state. The ambulance must be staffed by an individual who is qualified in accordance with state and local laws as an Emergency Medical Technician - Basic (EMT-Basic). These laws may vary from state to state or within a state. For example, only in some jurisdictions is an EMT - Basic permitted to operate limited equipment onboard the vehicle, assist more qualified personnel in performing assessments and interventions, and establish a peripheral intravenous (IV) line. According to the N.C. Office of Emergency Medical Services, monitoring or establishing a peripheral IV must be performed by an EMT - Intermediate or a Paramedic, and is, therefore, an ALS service.

Note: Even if local protocols require an ALS response for all calls, N.C. Medicaid pays only for the level of service provided, and then only when the service is medically necessary.

Advanced Life Support Assessment
Definition: An ALS assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment.

Advanced Life Support Intervention
Definition: An ALS intervention is a procedure that is, in accordance with state and local laws, beyond the scope of practice of an EMT - Basic.

An ALS intervention must be medically necessary to qualify as an intervention for payment of an ALS level of service. An ALS intervention applies only to ground transports.

Advanced Life Support, Level 1
Definition: ALS Level 1 (ALS 1) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including the provision of an ALS assessment or at least one ALS intervention.

Advanced Life Support, Level 2
Definition: ALS Level 2 (ALS 2) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including:

1.    at least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids such as 5 percent Dextrose in Water, Saline and Lactated Ringer's), or

2.    ground ambulance transport and the provision of at least one of the ALS 2 procedures listed below.

Application of ALS 2:

For purposes of this definition, the ALS 2 procedures are:
  1. manual defibrillation/cardioversion.
  2. endotracheal intubation.
  3. central venous line.
  4. cardiac pacing.
  5. chest decompression.
  6. surgical airway.
  7. intraosseous line.
Endotracheal intubation is one of the services that qualifies for the ALS 2 level of payment. It is, therefore, not necessary to consider medications administered by endotracheal intubation for the purpose of determining whether the ALS 2 rate is payable. The monitoring and maintenance of an endotracheal tube that was previously inserted prior to the transport also qualifies as an ALS 2 procedure.

Advanced Life Support Personnel
Definition: ALS personnel are individuals trained to the level of EMT - Intermediate or Paramedic.

Emergency Medical Technician - Intermediate
Definition: An EMT - Intermediate is an individual who is qualified, in accordance with state and local laws, as an EMT - Basic and who is also certified in accordance with state and local laws to perform essential advanced techniques and to administer a limited number of medications.

Emergency Medical Technician - Paramedic
Definition: An EMT - Paramedic possesses the qualifications of the EMT - Intermediate and, in accordance with state and local laws, has enhanced skills that include being able to administer additional interventions and medications.

Emergency Response
Definition: An emergency response is a BLS or ALS 1 level of service that has been provided in immediate response to a 911 call or the equivalent. An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call.

Fixed Wing Air Ambulance
Definition: Fixed Wing (FW) air ambulance is the transportation by an FW aircraft that is certified by the Federal Aviation Administration (FAA) as an FW air ambulance and the provision of medically necessary services and supplies.

Rotary Wing Air Ambulance
Definition: Rotary Wing (RW) air ambulance is the transportation by a helicopter that is certified by the FAA as an RW ambulance, including the provision of medically necessary supplies and services.

Loaded Mileage
Definition: Loaded Mileage is the number of miles that the Medicaid beneficiary is transported in the ambulance vehicle. For N.C. Medicaid, the ambulance provider's base area is the county in which they are located. Ground mileage is considered "outside base area mileage" that begins at the provider's county line.

Application: Payment is made for each loaded mile. Air mileage is based on loaded miles flown, as expressed in statute miles. For air ambulance, the point of origin includes the beneficiary loading point and runway taxiing until the beneficiary is offloaded from the air ambulance.

Point of Pick-Up
Definition: Point of Pick-Up is the location of the recipient at the time he/she is placed on board the ambulance.

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


Attention: Health Check Providers

Health Check Lead Screening

Federal regulations state that all Medicaid-enrolled children are required to have a blood lead test at 12 and 24 months of age. Children between 36 and 72 months of age must be tested if they have not been previously tested. Providers should perform a lead screening when it is clinically indicated.

Medical follow-up begins with a blood lead level greater than or equal to 10 ug/dL. Capillary blood level samples are adequate for the initial screening test. Venous blood level samples should be collected for confirmation of all elevated blood lead results.
 
Blood Lead Concentration Recommended Response
<10 ug/dL Rescreen at 24 months of age.
10 to 19 ug/dL Confirmation (venous) testing should be conducted within 3 months. If confirmed, repeat testing should be conducted every 2 to 4 months until the level is shown to be <10 ug/dL on three consecutive tests (venous or fingerstick). The family should receive lead education and nutrition counseling. A detailed environmental history should be taken to identify any obvious sources of exposure. If the blood lead level is confirmed at ?10 ug/dL, environmental investigation will be offered. 
20 to 44 ug/dL Confirmation (venous) testing should be conducted within 1 week. If confirmed, the child should be referred for medical evaluation and should continue to be retested every 2 months until the blood lead level is shown to be <10 ug/dL on three consecutive tests (venous or fingerstick). Environmental investigations are required and remediation for identified lead hazards shall occur for all children less than 6 years old with confirmed blood lead levels >20 ug/dL. 
?45 ug/dL The child should receive a venous lead test for confirmation as soon as possible. If confirmed, the child must receive urgent medical and environmental follow-up. Chelation therapy should be administered to children with blood lead levels in this range. Symptomatic lead poisoning or a venous lead level >70 ug/dL is a medical emergency requiring inpatient chelation therapy. 

State Laboratory of Public Health for Blood Lead Screening
The State Laboratory Services of Public Health will analyze blood lead specimens for all children less than 6 years of age at no charge. To obtain information regarding free blood lead screening process and supplies contact the State Laboratory at 919-733-3937. Providers requiring results of specimens from children outside this age group also need to contact the State Laboratory of Public Health.

Note: When the above laboratory tests are processed in the provider's office, Medicaid will not reimburse separately for these procedures. Payment for these procedures is included in the reimbursement for a Health Check screening.

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


Attention: Health Departments

Family Planning Billing Clarification

Reimbursement of any of the following CPT codes used for family planning services is limited to once per 365 days. The FP modifier must be appended to the appropriate code.
 
99383  99384  99385  99386  99387 
99393  99394  99395  99396  99397 

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


Attention: Health Departments, Rural Health Clinics, and Federally Qualified Health Centers

Medical Nutrition Therapy Diagnosis Code Clarification

When medical nutrition therapy services (CPT 97802 and 97803) are provided to a pregnant or postpartum recipient, providers must use the appropriate diagnosis code from the list below. This applies to all pregnant and postpartum recipients, regardless of their age.
 
Code Description
V22.0  Supervision of normal first pregnancy 
V22.1  Supervision of other normal pregnancy 
V22.2  Pregnant state, incidental 
V23.0  Pregnancy with history of infertility 
V23.1  Pregnancy with history of trophoblastic disease 
V23.2  Pregnancy with history of abortion 
V23.3  Grand multiparity 
V23.4  Pregnancy with other poor obstetric history 
V23.5  Pregnancy with other poor reproductive history 
V23.7  Insufficient prenatal care 
V23.81  Elderly primigravida 
V23.82  Elderly multigravida 
V23.83  Young primigravida 
V23.84  Young multigravida 
V23.89  Other high-risk pregnancy 
V23.9  Unspecified high-risk pregnancy 
V24.2  Routine postpartum follow-up 

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


Attention: Health Departments

Billing Instructions for Procedure Code T1002

Effective with date of service December 1, 2002, do not append modifier 25 to procedure code T1002 when billing for public health nurse services or to procedure codes for other services rendered on the same date of service as T1002. If a separately identifiable service is rendered on the same day as T1002, bill the appropriate code with the diagnosis that supports the need for the additional service.

Note: Procedure code T1002 cannot be billed on the same day that a preventive medicine service is provided.

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


Attention: Durable Medical Equipment Providers

Code Deletions and Additions to the Orthotic and Prosthetic Fee Schedule

Based upon technological advances and coding changes from the Centers for Medicare and Medicaid Services (CMS), the following codes will be deleted from the Orthotic and Prosthetic Fee Schedule effective with date of service December 1, 2002: L5660, L5662, L5663, L5664.

The following codes have been provided by CMS as replacements for the deleted codes and are effective with date of service December 1, 2002.
 
Code Description Maximum Reimbursement Rate
K0556  Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism 
$564.04 
K0557  Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism 
470.02 
K0558  Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use HCPCS codes K0556 or K0557) 
999.64 
K0559  Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use HCPCS codes K0556 or K0557) 
999.64 
L5671  Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert 
456.12 

Prior approval is required. Providers are expected to bill their usual and customary rates.

Melody B. Yeargan, P.T., Medical Policy
DMA, 919-857-4020


Attention: Hospice Providers

Reimbursement Rate Increase for Hospice Services

Effective with date of service January 1, 2003, the maximum allowable rate for the following hospice services will increase. The hospice rates are as follows:
 
    Routine Home Care Continuous Home Care Inpatient Respite Care General Inpatient Care  Hospice Intermediate 
R & B
Hospice Skilled 
R & B
Metropolitan Statistical Area  SC  RC 651
Daily 
RC 652
Hourly
(1) 
RC 655
Daily
(2) (3) (4) 
RC 656
Daily
(3) (4) 
RC 658
Daily
(5) 
RC 659
Daily 
(5) 
Asheville  39 
$112.65 
$27.37 
$122.89 
$500.95 
$96.80 
$128.77 
Charlotte  41 
113.78 
27.65 
123.87 
505.67 
96.80 
128.77 
Fayetteville  42 
111.21 
27.02 
121.66 
495.00 
96.80 
128.77 
Greensboro/
Winston-Salem/
High Point 
43 
115.48 
28.06 
125.32 
512.69 
96.80 
128.77 
Hickory  44 
114.04 
27.71 
124.09 
506.74 
96.80 
128.77 
Jacksonville  45 
99.46 
24.17 
111.59 
446.39 
96.80 
128.77 
Raleigh/Durham  46 
117.81 
28.62 
127.32 
522.35 
96.80 
128.77 
Wilmington  47 
114.40 
27.79 
124.39 
508.21 
96.80 
128.77 
Rural  53 
107.09 
26.02 
118.13 
477.96 
96.80 
128.77 
Goldsboro  105 
108.54 
26.37 
119.38 
483.98 
96.80 
128.77 
Greenville  106 
113.39 
27.55 
123.53 
504.04 
96.80 
128.77 
Norfolk
Currituck County 
107 
107.46 
26.11 
118.45 
479.49 
96.80 
128.77 
Rocky Mount  108 
111.89 
27.19 
122.24 
497.83 
96.80 
128.77 

Note: Providers must bill their usual and customary charges. Adjustments will not be made to previously processed claims.

Key to Hospice Rate Table
 
SC = Specialty Code 
RC = Revenue Code 

1.    A minimum of eight hours of continuous home care per day must be provided.
    2.    There is a maximum of five consecutive days including the date of admission but not the date of discharge for inpatient respite care. Bill for the sixth and any subsequent days at the routine home care rate.
    3.    Payments to a hospice for inpatient care are limited in relation to all Medicaid payments to the agency for hospice care. During the 12-month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient respite and general inpatient days may not exceed 20 percent of the aggregate total number of days of hospice care provided during the same time period for all the hospice's Medicaid patients. Hospice care provided for patients with acquired immune deficiency syndrome (AIDS) is excluded in calculating the inpatient care limit. The hospice refunds any overpayments to Medicaid.
    4.    Date of Discharge: For the day of discharge from an inpatient unit, the appropriate home care rate must be billed instead of the inpatient care rate unless the recipient expires while an inpatient. When the recipient is discharged as deceased, the inpatient rate (general or respite) is billed for the discharge date.
    5.    When a Medicare/Medicaid recipient is in a nursing facility, Medicare is billed for routine or continuous home care, as appropriate, and Medicaid is billed for the appropriate long-term care rate. When a Medicaid only hospice recipient is in a nursing facility, the hospice may bill for the appropriate long-term care (SNF/ICF) rate in addition to the home care rate provided in revenue code 651 or 652. See section 8.15.1, page 8-12, of the N.C. Medicaid Community Care Manual for details.
Debbie Barnes, Financial Operations
DMA, 919-857-4015


Attention: Hospitals

Utilization Review Plans

According to federal guidelines, 42 CFR 456.101, before a hospital can receive a Medicaid provider number, the Division of Medical Assistance (DMA) must approve the hospital's Utilization Review (UR) Plan. Any major change or qualifying event, such as a change in hospital operations, a change in hospital ownership, an increase or decrease in the number of beds or a change in the hospital's location, requires that a new UR Plan be submitted and approved by DMA at the time of this change. If there is no qualifying event, the hospital's UR Plan must be updated, submitted, and approved every four years.

All UR Plan updates are submitted to:

Hospital Nurse Consultant
Medical Policy Section
Division of Medical Assistance
2511 Mail Service Center
Raleigh, NC 27699-2511

Debbie Garrett, RNC, Medical Policy Section
DMA, 919-857-4020


Attention: Hospital Outpatient Clinics

Clarification of Prior Authorization for Outpatient Specialized Therapy

When requesting prior authorization from Medical Review of North Carolina (MRNC) for outpatient specialized therapy services, the units requested should be based on the Revenue Center (RC) code.

Example: If a recipient is seen for physical therapy two times a week for one hour and the provider is requesting authorization for an 8-week period, providers would request RC 420 for 16 units.

Nora Poisella, Specialized Therapy Services
DMA, 919-857-4040


Attention: Hospitals, Anesthesiologists, and Certified Registered Nurse Anesthetists

Billing for Certified Registered Nurse Anesthetist Services

Effective with date of service February 1, 2003 the following guidelines must be used to bill Certified Registered Nurse Anesthetist (CRNA) services.

A.    CRNA performs services without medical direction:

        1.    CRNA is employed by hospital or facility and no anesthesiologist is present:

      The surgeon works in collaboration with the CRNA. The hospital bills the CRNA professional charges on the CMS-1500 claim form using the hospital's professional number in the group area in block 33 and the CRNA's number as the attending number in block 33. Modifier QZ must be appended to the CPT code indicating CRNA services were performed without medical direction. The CRNA's professional charges are reimbursed 90 percent of the calculated payment.

      The hospital's facility charges are billed on the UB-92 claim form with a Revenue Code (RC) in the 37X range. Only the facility charges are included in the RC code. CRNA professional charges must not be included in the RC code. The surgeon bills for the surgical charges on the CMS-1500 claim form.


    2. CRNA is employed by the anesthesiologist:
     

      When the CRNA is employed by an anesthesiologist(s) and renders services without medical direction of an anesthesiologist, the CRNA services are billed on the CMS-1500 claim form using the physician's group number in block 33 and the CRNA's number in the attending field. Modifier QZ is appended to the CPT code to indicate that the service was performed without medical direction.
B.    CRNA renders services with medical direction provided by anesthesiologist:

        1.    CRNA is employed by hospital or facility:

The CRNA professional charges are billed on the hospital's professional claim appending modifier QX to the CPT code, indicating that medical direction was provided. When QX is billed, the CRNA's professional charges are paid at 50 percent of the calculated payment. The hospital's professional number is placed in block 33 and the CRNA's attending number is placed in the attending area in block 33.

The hospital's facility charges are billed on the UB-92 claim form with RC in the 37X range. Only the facility charges are included in the RC code.

CRNA professional charges must not be included in the RC code. The anesthesiologist performing medical direction appends either modifier QY or QK to the CPT code on the CMS-1500 claim form. When either modifier is billed, the anesthesiologist receives 50 percent of the calculated payment.

        2.    CRNA is employed by the anesthesiologist:
When the anesthesiologist provides medical direction of a CRNA that is employed by the physician, the physician bills the medical direction and the CRNA service on separate claims. The medical direction modifier QK or QY is appended to the CPT code on the physician claim. The physician's group number is placed in block 33 of the CMS-1500 claim form with the physician's individual number in the attending area of block 33. The medical direction modifier QX is appended to the CPT code on the CMS-1500 claim for the CRNA service. The physician group number is placed in block 33 and the CRNA number is placed in block 33 in the attending area.
Modifiers YA and QS
Modifiers YA or QS must always be appended to the CPT code when billing for anesthesia services. Anesthesia claims without either YA or QS will deny.

New Modifiers and their Definitions
QX     CRNA Service: with medical direction
QZ     CRNA Service: without medical direction
QY     Medical direction of one CRNA by an anesthesiologist
QK     Medical direction of 2, 3 or 4 concurrent anesthesia procedures

Modifier AD for medical direction of more than four CRNAs is not available. When more than four CRNAs are medically directed, this is considered supervision and is not separately reimbursed.

Medical Direction Criteria
To bill for medical direction the anesthesiologist must:

  1. perform the pre-anesthesia evaluation and exam;
  2. prescribe the anesthesia;
  3. participate personally in the induction and emergence of the anesthesia procedure;
  4. assure that any part of the anesthesia plan not personally performed by the anesthesiologist is performed by a qualified CRNA;
  5. monitor the course of anesthesia administration at frequent intervals;
  6. remain physically present to provide diagnosis and treatment in an emergency situation; and
  7. provide post anesthesia care.
Documentation of Medical Direction
If a CRNA rendered the service, the service must be billed with the applicable modifier, either QZ or QX, to distinguish if the service was provided under medical direction or provided without medical direction. Medical direction must be documented in the medical record. When all the above criteria for medical direction is not met, the CRNA services must be billed on the CMS-1500 claim form with modifier QZ indicating that the CRNA performed services without medical direction. Should review of medical records fail to document medical direction, recoupment of paid claims will be initiated and further investigation of the practice will be pursued by the Division of Medical Assistance.

Guidelines for Billing CRNA Services Without Medical Direction
 
Provider Rendering Service Billing Provider CMS-1500 Claim Form UB-92 Claim Form Pricing
CRNA employed by hospital or facility performing without medical direction  Hospital facility

Charge

No  Bills RC 37X range  Prices DRB or RCC 
CRNA professional charge  Hospital professional number and CRNA number in block 33

Append QZ modifier to CPT code

No  90% of allowable 
Surgeon  Bills CPT code  No  Fee schedule
CRNA employed by anesthesiologist performing without medical direction  Hospital facility charge  No Bills RC 37X range  Prices DRG or RCC
CRNA professional charge  QZ is appended to the CPT code. Anesthesia group bills group/attending in block 33. No  50% of allowable 
Anesthesiologist employing CRNA  Anesthesiologist does not bill when services are performed without medical direction.  No  50% of allowable. 

Guidelines for Billing CRNA Services With Medical Direction
 
Provider Rendering Service Billing Provider CMS-1500 Claim Form UB-92 Claim Form Pricing
CRNA employed by hospital or facility performing with medical direction  Hospital facility

Charge

No  Bills RC 37X range  Prices DRG or RCC 
CRNA professional charge  Hospital professional number and CRNA number in block 33.

Append QX to CPT code.

No  50% of allowable 
Anesthesiologist providing medical direction  If one CRNA append QY to CPT code. If 2, 3, or 4 CRNAs append QK to CPT code  No  50% of allowable
CRNA employed by anesthesiologist performing with medical direction  Hospital facility charge No  Bills RC 37X range  Price DRG or RCC 
CRNA professional charge  QX is appended to the CPT code. Use anesthesiology group/attending number in block 33. No  50% of allowable 
Anesthesiologist providing medical direction  On separate claim, append QY to the CPT if one CRNA. If 2, 3, or 4 CRNAs, append QK. Bill group/attending number in block 33.  No  50% of allowable 

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


Attention: Nursing Facility Providers, CAP/AIDS, CAP/DA, and CAP/C Case Managers, and Hospital Discharge Planners

Requests for Additional Information for Long-Term Care Prior Approval (FL2)

Effective December 1, 2002, requests from the EDS Prior Approval Unit for additional information necessary to complete a review for long-term care prior approval (FL2) are sent directly to the individual provider or Community Alternatives Program (CAP) case manager. The provider or CAP case manager is responsible for responding to the request and providing the information in a timely manner.

Previously, requests for additional information were sent to the recipient's local department of social services (DSS) who then forwarded the request to the appropriate provider or CAP case manager. This process often delayed the return of necessary information and resulted in an increase of retroactive prior approval requests as well as delaying claim payment.

Requests for long-term prior approval can be further expedited by ensuring that the following information is included on the original FL2:

If the information in block 6 is missing, the EDS Prior Approval unit will return the request to the local DSS.

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


Attention: Mental Health Providers

ValueOptions Website

Providers can now access flowcharts and forms related to the N.C. Medicaid program on ValueOptions website at http://www.valueoptions.com. Click on "For Providers" then scroll down to the heading "Regional Provider Focus." The link to the N.C. Medicaid Account Information is located under this heading.

The Residential Authorization form is available on this website and has been updated to include a signature and date.

Note: The ValueOptions website also includes links to the Department of Health and Human Services and the Division of Medical Assistance for information specific to Medicaid.

Renee Hamlett
ValueOptions, 919-941-5367


Attention: Optical Providers

Incomplete/Illegible Request for Prior Approval for Visual Aids Forms

Effective December 1, 2002, Nash Optical Plant will return all incomplete or illegible Request for Prior Approval for Visual Aids (PA) forms to the provider with a cover sheet indicating the information that is missing, incomplete or illegible. Please correct or complete the PA and return it to Nash Optical Plant as soon as possible.

Click here to view an example of the cover letter:  Cover Letter Example

NOTE TO ALL OPTICAL PROVIDERS: Please make every effort to complete each Request for Prior Approval for Visual Aids form correctly. Missing, incomplete or illegible information will delay the eyeglass order.

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


Checkwrite Schedule


December 10, 2002 January 14, 2003 February 11, 2003
December 17, 2002 January 22, 2003 February 18, 2003
December 27, 2002 January 30, 2003 February 27, 2003

 
 

Electronic Cut-Off Schedule


December 6, 2002 January 10, 2003 February 7, 2003
December 13, 2002 January 17, 2003 February 14, 2003
December 20, 2002 January 24, 2003 February 21, 2003
February 28, 2003

 
 

Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite. Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.
 
 
 
 
 
_____________________ _____________________
Nina M. Yeager, Director Ricky Pope
Division of Medical Assitance Executive Director
Department of Health and Human Services EDS

 
 
DMA Home Top
Dividing line