January 2003 NC Medicaid Bulletin title

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In This Issue..

All Providers:

Adult Care Home Providers: Durable Medical Equipment Providers: Home Health Agencies: Home Infusion Therapy Providers: Hospitals: Mental Health Providers: Nursing Facility Providers: Outpatient Clinics: Personal Care Services Providers: Physicians: Private Duty Nursing Providers:

Attention: All Providers

Holiday Observance

The Division of Medical Assistance (DMA) and EDS will be closed on Wednesday, January 1, 2003 in observance of New Year's Day, and on Monday, January 20, 2003 in observance of Dr. Martin Luther King, Jr.'s Birthday.

EDS, 1-800-688-6696 or 919-851-8888
 

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

CPT Update for 2003

The annual review of the new Current Procedural Terminology (CPT) codes has not been completed. Providers must bill the 2002 covered codes until the Division of Medical Assistance (DMA) provides directions for filing the 2003 codes. Providers will be notified of covered 2003 CPT codes in future general Medicaid bulletins.

EDS, 1-800-688-6696 or 919-851-8888
 

Attention: All Providers

HIPAA Implementation Training Seminars

Seminars on the implementation of the Health Insurance Portability and Accountability Act (HIPAA) transaction sets are scheduled for Spring 2003. Dates and site locations for the seminars will be published in the March general Medicaid bulletin.

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

Attention: All Providers

Corrected 1099 Requests - Action Required by March 1, 2003

Providers receiving Medicaid payments of more than $600 annually receive a 1099 MISC tax form from EDS. The 1099 MISC tax form is generated as required by IRS guidelines. It will be mailed to each provider no later than January 31, 2003. The 1099 MISC tax form reflects the tax information on file with Medicaid as of the last Medicaid checkwrite cycle date, December 27, 2002.

If the tax name or tax identification number on the annual 1099 MISC you receive is incorrect, a correction to the 1099 MISC must be requested. This ensures that accurate tax information is on file with Medicaid and sent to the IRS annually. When the IRS receives incorrect information on your 1099 MISC, it may require backup withholding in the amount of 30 percent of future Medicaid payments. The IRS could require EDS to initiate and continue this withholding to obtain correct tax data.

A correction to the original 1099 MISC must be submitted to EDS by March 1, 2003 and must be accompanied by the following documentation:

Fax both documents to 919-816-4399, Attention: Corrected 1099 Request - Financial

Or

Mail both documents to:

EDS
4905 Waters Edge Drive
Raleigh, NC 27606
Attention: Corrected 1099 Request - Financial

A copy of the corrected 1099 MISC will be mailed to you for your records. All corrected 1099 MISC requests are reported to the IRS. In some cases, additional information may be required to ensure that the tax information on file with Medicaid is accurate. Providers will be notified by mail of any additional action that may be required to complete the correction to their tax information.

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

Attention: All Providers

Endoscopy CPT Base Codes and Their Related Procedures

The following table represents an updated list of covered base and related endoscopy codes as designated in the 2002 Resource Based Relative Value System (RBRVS). Group 1 reflects a new base code of 29805, effective with dates of service January 1, 2002. Existing codes previously omitted were added to the related side for groups 9 and 25.

Endoscopy Base and Related Code Group
Group Base Code Related Codes Comments
1  29805 29819 - 29826 Effective 01/01/02 new "base" code added from 2002 RBRVS 
2  29830  29834 - 29838   
3  29840  29843 - 29847   
4  29860  29861 - 29863   
5  29870  29871, 29874 - 29877, 29879 - 29887   
6  31505  31510 - 31513   
7  31525  31527 - 31530, 31535, 31540, 31560, 31570   
8  31526  31531, 31536, 31541, 31561, 31571   
9  31622  31623, 31624, 31625, 31628-31631, 31635, 31640 - 31641, 31645  Existing procedure codes added from 2002 RBRVS 
10  43200  43202, 43204 - 43205, 43215 - 43217, 43219 -43220, 43226 - 43228   
11  43235  43231 - 43232, 43239, 43241 - 43247, 43249 -43251, 43255 - 43256, 43258 - 43259   
12  43260  43240, 43261 - 43265, 43267 - 43269, 43271 -43272   
13  44360  44361, 44363 - 44366, 44369, 44370, 44372-44373   
14  44376  44377 - 44379   
15  44388  44389 - 44394, 44397   
16  45300  45303, 45305, 45307 - 45309, 45315, 45317, 45320 - 45321, 45327   
17  45330  45331 - 45334, 45337 - 45339, 45345   
18  45378  45379 - 45380, 45382 - 45385, 45387   
19  46600  46604, 46606, 46608, 46610 - 46612, 4661 -46615   
20  47552  47553 - 47556   
21  50551  50555, 50557, 50559, 50561   
22  50570  50572, 50574-50576, 50578, 50580   
23  50951  50953, 50955, 50957, 50959, 50961   
24  50970  50974, 50976   
25  52000  52007, 52010, 52204, 52214, 52224, 52250, 52260, 52265, 52270, 52275 - 52277, 52281 -52283, 52285, 52290, 52300 - 52301, 52305, 52310, 52315, 52317 - 52318  Existing procedure code added from 2002 RBRVS 
26  52005  52320, 52325, 52327, 52330, 52332, 52334, 52341 - 52344   
27  52335  52336-52339  End-dated due to 2001 CPT update 
28  56300  56301 - 56309, 56311, 56343 - 56344, 56314  End-dated due to 2000 CPT update 
29  56350  56351 - 56356  End-dated due to 2000 CPT update 
30  57452  57454, 57460   
31  49320  38570, 49321 - 49323, 58550 - 58551, 58660 -58662, 58670 - 58671   
32  58555  58558 - 58563   
33  52351  52345 - 52346, 52352 - 52355   
34  31575  31576 - 31579   

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

Attention: All Providers

Anesthesia - Billing CPT Anesthesia Codes Instead of Surgical Codes

Effective with date of service June 1, 2003, providers must bill CPT anesthesia codes for anesthesia services instead of billing the CPT surgical codes with modifier YA or QS. The Division of Medical Assistance (DMA) is making this conversion in order to comply with the implementation of national code sets mandated by the Health Insurance Portability and Accountability Act (HIPAA). Local state-created modifier YA will not be accepted, effective with date of service June 1, 2003. Instead, providers must bill the appropriate CPT anesthesia code with no modifier or with modifier QS to designate monitored anesthesia care. Units will remain calculated as 1 unit = 1 minute.

DMA will schedule seminars to discuss these changes. A list of dates and locations for these seminars will be published in future general Medicaid bulletins.

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

Attention: All Providers

Performance Bonds

The N.C. General Assembly has approved legislation that requires the purchase of performance bonds or a validly executed letter of credit as a condition for Medicaid payment to enrolled providers. The legislation also authorized the Department of Health and Human Services to waive or limit the requirement based on the provider's dollar amount of monthly billings or the length of time the provider has been licensed to provide services in the State. The Division of Medical Assistance (DMA) and the Office of the Attorney General are developing administrative rules and procedures to implement this requirement. The requirement will be phased in by provider type. We anticipate that the first phase will be implemented during Spring 2003. Providers enrolled for Personal Care Services and Durable Medical Equipment will be the first phase. No specific information about procedures is available at this time. DMA will publish updated information in the general Medicaid bulletin on DMA's website as it becomes available.

The authorizing legislation can be found on the N.C. General Assembly website. The relevant text reads as follows:

Payment is limited to Medicaid enrolled providers that purchase a performance bond in an amount not to exceed one hundred thousand dollars ($100,000) naming as beneficiary the Department of Health and Human Services, Division of Medical Assistance, or provide to the Department a validly executed letter of credit or other financial instrument issued by a financial institution or agency honoring a demand for payment in an equivalent amount. The Department may waive or limit the requirements of this paragraph for one or more classes of Medicaid enrolled providers based on the provider's dollar amount of monthly billings to Medicaid or the length of time the provider has been licensed in this State to provide services. In waiving or limiting requirements of this paragraph the Department shall take into consideration the potential fiscal impact of the waiver or limitation on the State Medicaid Program.
Barbara Brooks, Recipient and Provider Services Section
DMA, 919-857-4019

Attention: Hospital Providers

Cochlear Implant Device - Billing Clarification

When billing for an FDA-approved cochlear implant device, use Revenue Code 278. N.C. Medicaid coverage of the cochlear implant device is limited to pre-linguistically and post-linguistically deafened children ages birth to 21 who meet medical necessity criteria.

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

Attention: All Providers

Zoledronic Acid, 1 mg (Zometa, J3487) - Billing Guidelines Update

Effective with date of service January 1, 2003, the N.C. Medicaid program covers Zometa for use in the Physician's Drug Program when billed with HCPCS code J3487. Providers may no longer bill J3490 for Zometa. For Medicaid billing, one unit of coverage is now 1 mg. The maximum reimbursement rate for one unit is $192.69. An invoice is no longer required for dates of service on or after January 1, 2003.

Only the following ICD-9-CM diagnoses are covered:

            a.  Hypercalcemia - 275.42
            b.  Secondary malignant neoplasm of bone and bone marrow - 198.5
            c.  Multiple myeloma - 203.00 or 203.01             a.  Prostate cancer - 185 primary with 198.5 secondary
            b.  Non-small-cell lung cancer - 162.0 through 162.9 primary with 198.5 secondary
            c.  Breast cancer (female) - 174.0 through 174.9 primary with 198.5 secondary
            d.  Breast cancer (male) - 175.0 through 175.9 primary with 198.5 secondary

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

Attention: Nursing Facility Providers

Medicaid Nursing Facility Payments

In accordance with Session Law 2002-126, Senate Bill 1115, residents of nursing facilities who are eligible for Medicare coverage of nursing facility services must be placed in a Medicare-certified bed. Effective with dates of service December 1, 2002, Medicaid considers reimbursement for nursing facility services only after the appropriate services have been billed to Medicare. Nursing facility providers have until April 30, 2003 to certify additional Medicare beds if necessary. If beds have not been certified by April 30, 2003, reimbursement may be affected. Providers should contact the Division of Facility Services at 919-733-7461 to request Medicare certification of additional beds.

Lloyd Pattison, Institutional Services Section
DMA, 919-857-4020

Attention: Licensed Psychologists, Licensed Clinical Social Workers, Psychiatric Clinical Nurse Specialists, Psychiatric Nurse Practitioners, and Mental Health Multi-Specialty Groups

Mental Health Services for HMO Enrollees Provided by Direct-Enrolled Mental Health Providers

Beginning with dates of service on or after February 1, 2003, direct-enrolled mental health providers may begin to bill Medicaid for services rendered to HMO-enrolled recipients without a referral from the Area Mental Health Authority. Currently, HMO enrollment is restricted to Mecklenburg County with Southcare as the sole HMO option. Affected providers include licensed psychologists, licensed clinical social workers, psychiatric clinical nurse specialists, psychiatric nurse practitioners, and mental health multi-specialty groups. Mental health services are limited to Medicaid recipients under the age of 21.

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

Attention: Physicians, Hospitals, and Outpatient Clinics

Modifier YS for Teleconsults

Effective December 1, 2002, modifier YS, representing services provided during a teleconsult in the spoke site, was end-dated to comply with the implementation of national code sets mandated by the Health Insurance Portability and Accountability Act (HIPAA). This modifier is no longer available. Teleconsults should be billed by the consulting facility/physician with modifier GT, which states "Via interactive audio and video telecommunication systems." The following codes may be billed with modifier GT:
99201  99202  99203  99204  99205  99211 
99212  99213  99214  99215  99221  99222 
99223  99231  99232  99233  99241  99242 
99243  99244  99245  99251  99252  99253 
99254  99255  99261  99262  99263  99271 
99272  99273  99274  99275     

EDS, 1-800-688-6696 or 919-851-8888
 

Attention: Personal Care Services (in Private Residences) Providers, Home Health Agencies, Durable Medical Equipment Providers, Home Infusion Therapy Providers, Private Duty Nursing Providers, and Adult Care Home Providers

Implementation of Transfer of Assets Policy for Specified Home Care Services

Effective with date of service February 1, 2003, payments for specified home care services may be affected by a new transfer of assets policy that applies to certain Medicaid recipients. This policy is similar to the transfer of assets requirements currently in place for Medicaid recipients receiving nursing facility and ICF-MR care, as well as for those recipients participating in the Community Alternatives Programs.

Transfer of Assets Sanctions
If an applicant/recipient has transferred assets in a manner contrary to the policy, he will not qualify for payment for any of the specified services provided during the sanction period. Sanction periods are by calendar month. They may be retroactive as well as extend through the current time period. This policy does not apply to transfers prior to February 1, 2003; therefore, there will be no sanction periods that begin before that date.

Services Included in the Policy
The Medicaid services included in the policy are:

Medicaid Recipients Subject to the Policy
The policy applies to individuals in the following Medicaid eligibility categories: Adult care home providers should note that this policy does not apply to their residents receiving State/County Special Assistance. It does apply to a private pay adult care home resident if the individual is in one of the four eligibility categories (MAA, MAD, MAB, and MQB-Q).

MAA, MAD, and MAB recipients have a blue Medicaid identification (MID) card with the abbreviation listed under "Program" on the card. MQB-Q recipients have a buff card labeled as a "MEDICARE-AID ID CARD."

Community Alternatives Program (CAP) participants are not subject to a transfer of assets determination for the specified services. Providers may identify a CAP participant by the entry in the "CAP" block of the MID card.

Transfer of Assets Determination
The county department of social services will make a transfer of assets determination when it is aware that a recipient is seeking any of the specified services. The determination and any resulting sanction will apply to all of the services. A separate determination for each service is not required.

How the Policy Affects Payment
Payment for a date of service on and after February 1, 2003, depends on the information that is in the claims processing system.

1.  No Transfer of Assets Information in System - If there is no transfer of assets information in the system, the claim will suspend for up to 60 days. The suspension will end before 60 days if transfer of assets information is received. (Refer to Current Service Recipients for information about individuals for whom Medicaid has paid for services in December 2002 and January 2003.)

    a.  The provider will be notified on the Remittance and Status Report that the claim is suspended. The explanation of benefits statement will indicate that the claim is pended awaiting a transfer of asset assessment by the county department of social services (DSS). The provider may contact the recipient to request that the recipient contact the county DSS office. The provider should not resubmit the claim.

    b.  The recipient's county DSS will be notified to contact the recipient and make a transfer of assets determination.

2. Transfer of Assets Information in System - If there is transfer of assets information in the system, the claim will process. If a transfer of assets sanction is entered into the claims processing system after payment is made for a date within the sanction period, the county DSS will pursue recoupment from the recipient. The payment will not be recouped from the provider agency.

Transfer of Asset Information
Providers may access the Automated Voice Response (AVR) system to get a recipient's transfer of assets status as of a specified date. The AVR response provides information that is in the claims processing system at the time of the inquiry. AVR information is not a guarantee of payment. Because a penalty period can be applied retroactively, transfer of assets information for a given date may change after the provider obtains the information.

To access transfer of assets information, the provider selects option 6 at the main menu for information about recipient eligibility. The call flow to get to transfer of assets information is as follows:
 

Provider Number Verification - When the provider selects option 6 from the main menu, AVR prompts the provider to enter their N.C. Medicaid provider number for verification. After the provider number is verified, the prompt will allow a caller to go in either of two directions: Recipient Eligibility and Coordination of Benefits or Hospice Eligibility. Choose selection 1.
Recipient Access Method Prompt - To obtain recipient eligibility information, the provider must enter a valid recipient MID number OR a combination of the recipient's date of birth and social security number, and a "FROM" date of service. AVR prompts the provider to select a method for accessing the recipient data.
"Please select one of the following recipient identification options. To enter a recipient identification number, press 1. To enter a recipient date of birth and social security number, press 2."
Date of Service Prompt - The provider must enter either a pound sign (#) only (for the current date) or a "FROM" date of service in a MMDDCCYY format.

Host Response - After receiving a valid provider number and recipient MID number, and "FROM" date of service, AVR determines whether or not the provider is authorized to access recipient eligibility information from the eligibility file.

Eligibility/Enrollment Prompt - The AVR will give the following response asking the provider to choose one of these two options:
"For eligibility information, press 1. For enrollment information, press 2."
Choose selection 1 for eligibility information. Transfer of assets information will be the last information given. The provider will be told one of the following: Providers also may verify the recipient's transfer of assets status by seeing the recipient's notice about the results of a transfer of assets determination. The county DSS will provide the recipient a notice indicating that transfer of assets has been reviewed and any penalty period assessed.
Current Service Recipients
Transfer of assets information will be entered into the claims processing system for recipients for whom Medicaid paid for any of the specified services during December 2002 and January 2003. While this will not capture all of the recipients of the specified services, it will reduce the number of claims suspended while awaiting a transfer of assets determination. The county department of social services will review transfer of assets for these recipients at their next eligibility review.

Billing the Recipient
A provider may bill the recipient if Medicaid payment is denied due to a transfer of assets sanction and the provider has advised the recipient of his responsibility for payment before the services are rendered. The provider should maintain documentation that the recipient was notified of and accepted the responsibility.

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

Attention: All Providers

Index to General and Special Bulletins for 2002

EDS, 1-800-6688-6696 or 919-851-8888


 


Checkwrite Schedule

January 14, 2003  February 11, 2003  March 4, 2003 
January 22, 2003  February 18, 2003  March 11, 2003 
January 30, 2003  February 27, 2003  March 18, 2003 
March 27, 2003 

Electronic Cut-Off Schedule

January 10, 2003  February 7, 2003  March 7, 2003 
January 17, 2003  February 14, 2003  March 14, 2003 
January 24, 2003  February 21, 2003  March 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

 
 
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