N.C. DMA: January 2006 Medicaid Bulletin

Effective January 1, DMA will publish the new rates for the 2006 CPT codes. The codes were revised based on information from the Center for Medicare and Medicaid Services (CMS).

The fee schedules may be accessed through the DHHS website. Providers may also receive a current fee schedule by completing and submitting a copy of the Fee Schedule Request form.

Providers must bill their usual and customary charges.

For assistance, please call EDS @ 1-800-688-6696, local providers can call 919-851-8888.

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 the Division of Medical Assistance's website:

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

Clinical Policy and Programs
DMA, 919-855-4260

Attention: All Providers

Changes to the Prior Approval Process and Requests for Non-covered Services

Information regarding changes to the prior approval process and requests for non-covered services is available in the January 2006 Special Bulletin on the Division of Medical Assistance’s website.

Clinical Policy and Programs
DMA, 919-855-4260

Attention: All Providers

CPT Code Update 2006

The Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA) have added new and deleted current CPT codes effective with date of service January 1, 2006. New CPT codes are covered by the N.C. Medicaid program effective with date of service January 1, 2006. Claims submitted with deleted codes will deny for dates of service on or after January 1, 2006.

The following table lists the new CPT codes that are covered by N.C. Medicaid beginning with date of service January 1, 2006:

99300	99304	99305	99306	99307	99308	99309	99310	99318	99324	99325
99326	99327	99328	99334	99335	99336	99337	01965	01966	15040	15110
15111	15115	15116	15130	15131	15135	15136	15150	15151	15152	15155
15156	15157	15170	15171	15175	15176	15300	15301	15320	15321	15330
15331	15335	15336	15340	15341	15360	15361	15365	15366	15420	15421
15430	15431	22010	22015	32503	32504	33507	33768	33925	33926	33598
37184	37185	37186	37187	37188	37718	37722	44180	44186	44187	44188
44213	44227	45395	45397	45400	45402	45499	45990	46505	46710	46712
50250	50382	50384	50387	50389	51999	57295	58110	76376	76377	77421
77422	77423	80198	82271	82272	83695	83700	83701	83704	83900	83907
83908	83909	83914	86200	86355	86357	86367	86480	86923	86960	87209
87900	88333	88334	89049	90714	90760	90761	90765	90766	90767	90768
90772	90773	90774	90775	91022	92626	92627	92630	92633	95865	95866
95873	95874	96101	96116	96118	96401	96402	96409	96411	96413	96415
96416	96417	96521	96522	96523	97760	97761	97762	99051	99053	99060

The following table lists CPT codes that were end-dated effective with date of service December 31, 2005:

01964	15342	15343	15350	15351	15810	15811	16010	16015	21493	21494
31585	31586	32520	32522	32525	33918	33919	37720	37730	42325	42326
43638	43639	44200	44201	44239	69410	76375	78160	78162	78170	78172
78455	82273	83715	83716	86064	86379	86585	86587	90780	90781	90782
90783	90784	90788	90799	90871	90939	92230	92235	92390	92391	92392
92393	92395	92396	92510	95858	96100	96115	96117	96400	96408	96410
96412	96414	96520	96530	96545	97020	97504	97520	97703	99052	99054
99141	99142	99261	99262	99263	99271	99272	99273	99274	99275	99301
99302	99303	99311	99312	99313	99321	99322	99323	99331	99332	99333

The following table lists the new 2006 CPT codes that are not covered pending further review:

99340

64650

64653

83631

88384

88385

88386

The following table lists the new 2006 CPT codes that are not covered:

99339	22523	22524	22525	28890	33548	33880	33881	33883	33884	33886
33889	33891	43770	43771	43772	43773	43774	43886	43887	43888	50592
61630	61635	61640	61641	61642	75956	75957	75958	75959	83037	90649
90736	90779	95251	96102	96103	96119	96120	98960	98961	98962	99143
99144	99145	99148	99149	99150

The following CPT code was non-covered by N.C. Medicaid during the 2005 CPT Update. This code is now covered by N.C. Medicaid beginning with date of service January 1:

87807

Ambulatory Surgery Center (ASC)

The following table lists the new CPT codes that are covered by N.C. Medicaid for an Ambulatory Surgery Center (ASC) beginning with date of service January 1:

Code	ASC Payment Group	Code	ASC Payment Group	Code	ASC Payment Group	Code	ASC Payment Group	Code	ASC Payment Group
15040	2	15110	2	15111	1	15115	2	15116	1
15130	2	15131	1	15135	2	15136	1	15150	2
15151	1	15152	1	15155	2	15156	1	15157	1
15300	2	15301	1	15320	2	15321	1	15330	2
15331	1	15335	2	15336	1	15420	2	15421	1
15430	2	15431	1	16025	2	16030	2	37718	3
37722	3	45990	2

The following table lists CPT codes that were end-dated for an Ambulatory Surgery Center (ASC) effective with date of service December 31, 2005:

15350

15351

16015

21493

21494

31585

31586

37720

37730

42325

Additional information will be published in future general Medicaid bulletins as necessary.

Clinical Policy and Programs
DMA, 919-855-4260

Attention: All Providers

Medical Review of North Carolina (MRNC) Unveils New Name!

The programs affected are: Prior Authorization of Outpatient Specialized Therapies, Non-Qualified Alien Medical Review, Medicaid Community Alternatives Program for Disabled Adults Quality Assurance Program, Program Integrity Postpayment Hospital Review

MRNC has changed dramatically over the years, and now has a new identity and a new name.

The Carolinas Center for Medical Excellence
Improving healthcare quality since 1983

The Carolinas Center for Medical Excellence (CCME) unifies its operations in North and South Carolina. More importantly, it characterizes the work in quality improvement across the healthcare spectrum.

The address, phone and fax numbers remain the same:

100 Regency Forest Drive, Suite 200
Cary, NC 27511-8598

Main Phone	919-380-9860 or toll free at 800-862-2650
Main Fax	919-380-7637
Prior Authorization Phone	800-228-3365
Prior Authorization Fax	800-228-1437
AQUIP Help Desk Phone	919-380-9860 or 800-682-2650 ext 2000
AQUIP Help Desk Fax	919-380-9457

The new web address is www.thecarolinascenter.org (but www.mrnc.org will be active for the next several months).

Audra Troy
MRNC, 919-380-9860

Attention: All Providers

Mental Health Non-Licensed Clinician Fee Schedule Effective September 1, 2005

Effective with a September 1, 2005 service date, Medicaid will reimburse the following rates for Non-Licensed Clinicians. This represents 70% of the current rate paid to licensed MH/DD/SA providers.

SERVICE CODE	DESCRIPTION	Unit	9/1/05 RATE FOR SERVICE
H0001	Behavioral Health Assessment	15 minutes	$15.40
H0005	Alcohol and/or Drug Services; Group Counseling by Clinician	15 minutes	$5.68
H0031	Mental Health Assessment	15 minutes	$15.40

SERVICE CODE

DESCRIPTION

Unit

9/1/05 RATE FOR SERVICE

H0001

Behavioral Health Assessment

15 minutes

$15.40

H0005

Alcohol and/or Drug Services; Group Counseling by Clinician

15 minutes

$5.68

H0031

Mental Health Assessment

15 minutes

$15.40

Rate Setting
DMA, 919-855-4200

Attention: All Providers

Rate Change for Mirena IUD, J7302

Effective date of service January 1, 2006, the maximum rate for the Mirena IUD, J7302, is $407.70. Providers should continue to bill their usual and customary charges. The family planning modifier may apply to this procedure.

Rate Setting
DMA, 919-855-4200

Attention: All Providers

Updated EOB Code Crosswalk to HIPAA Standard Codes

The list of standard national codes used on the Electronic Remittance Advice (ERA) has been cross-walked to EOB codes as an informational aid to adjudicated claims listed on the Remittance and Status Report (RA). An updated version of the list is available on the Division of Medical Assistance’s HIPAA web page.

With the implementation of standards for electronic transactions mandated by the Health Insurance Portability and Accountability Act (HIPAA), providers now have the option to receive an ERA in addition to the paper version of the RA.

The EOB codes that providers currently receive on a paper RA are not used on the ERA. Because the EOB codes on the paper RA provide a greater level of detail on claim denials, all providers will continue to receive the paper version of the RA, even if they choose to receive the ERA transaction. The list is current as of the date of publication. Providers will be notified of changes to the list through the general Medicaid bulletin.

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

Attention: Adult Care Home Providers

Medicaid Payment for Recipients Residing in an Adult Care Home Special Care Unit for Persons with Alzheimer’s and Related Disorders

During the 2004/05 legislative session, Session Law 2005-276 was passed which provided additional funding for Special Care Units (SCUs) for persons with Alzheimer’s and Related Disorders located in Adult Care Homes. As part of that legislation, effective October 1, 2005, an enhanced state and county special assistance rate became available to cover an increased room and board charge in a SCU for Persons with Alzheimer’s and Related Disorders.

The legislation also required N.C. Medicaid to implement an enhanced personal care service rate to Medicaid recipients in such SCUs. Effective with date of service October 1, 2006, the N.C. Medicaid program will implement this SCU enhanced personal care service rate. However, this special care unit rate will not be automatic. Providers will need to obtain prior approval from Medicaid before admitting a Medicaid resident to a SCU and receiving this new enhanced rate.

The prior approval process and criteria for admission/continued stay are being developed at this time. Providers will be notified through an upcoming general Medicaid bulletin when the process and criteria are finalized.

Medicaid Clinical Policy and Programs
DMA, 919-855-4360

Attention: CDSA’s (Children’s Developmental Services Agencies)

CPT Code Changes for CDSA’s

Effective with date of service January 1, 2006, the following codes were end-dated and replaced with new CPT codes. Claims submitted with end-dated codes for dates of service January 1, 2006 and after will deny. CPT codes 92626 and 92627 have been added to the list of appropriate codes that audiologists may now bill beginning with date of service January 1, 2006.

End-Dated Code(s)	New CPT Code(s)	Description
92510	92626	Evaluation of auditory rehabilitation status; first hour 1 unit = 1 hour
	92627	Evaluation of auditory rehabilitation status; each additional 15 minutes (list separately in addition to code for primary procedure) 1 unit = 15 minutes Note: Use 92627 in conjunction with 92626.
	92630	Auditory rehabilitation; pre-lingual hearing loss 1 unit = 1 visit
	92633	Auditory rehabilitation; post-lingual hearing loss 1 unit = 1 visit
97520	97761	Prosthetic training, upper and/or lower extremity(s), each 15 minutes 1 unit = 15 minutes
97703	97762	Checkout for Orthotic/Prosthetic use, established patient, each 15 minutes 1 unit = 15 minutes
96100	96101	Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, mmpi, rorshach, wais), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report 1 unit = 1 hour
96115	96116	Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report 1 unit = 1 hour
96117	96118	Neuropsychological g test), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report 1 unit = 1 hour

Clinic Coverage Policy 8J has been updated to reflect these codes changes.

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

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

HCPCS Code Changes for Medical Supplies

The following changes to the HCPCS codes will be implemented to comply with national standard codes mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Code Deletions

The deleted codes can no longer be used after date of service December 31, 2005.

HCPCS CODE	DESCRIPTION	Billing
A4656	Needle, any size	Each
A5119	Skin barrier, wipes or swabs	Box 50

Code Additions

The codes listed below are being added effective with the date of service January 1, 2006.

HCPCS CODE	DESCRIPTION	Billing Unit	Maximum Reimbursement Rate
A5120	Skin barrier, wipes or swabs	Each	.24
A5119	Tubular dressing with or without elastic, any width, per linear yard	Per Linear Yard = 1 unit	1.19

HCPCS CODE

DESCRIPTION

Billing Unit

Maximum Reimbursement Rate

A5120

Skin barrier, wipes or swabs

Each

.24

A5119

Tubular dressing with or without elastic, any width, per linear yard

Per Linear

Yard = 1 unit

1.19

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

Attention: Dialysis Centers

Doxercalciferol, 1 mcg (Hectorol, J1270) - Billing Guidelines

Effective with date of processing, November 2, 2005, the list of ICD-9-CM diagnosis codes covered by N.C. Medicaid for Doxercalciferol, 1 mcg (Hectorol, J1270) was updated according to the 2004/2005 edition of the ICD-9-CM diagnosis codes.

ICD-9-CM Diagnosis Code	Diagnosis Description
588.81** or 588.89	Hyperparathyroidism of Renal Origin
588.0	Renal Osteodystrophy
252.1	Hyperparathyroidism

**Note: Diagnosis code 588.8 was expanded to the 5th digit in 2004. Claims submitted with ICD-9 CM diagnosis codes 588.8 will deny for EOB 82 (Service is not consistent with/or not covered for this diagnosis/or description does not match diagnosis). Providers must resubmit the claim with the diagnosis code to the highest level of specificity.

Dialysis Treatment Facility Billing Requirements for Hectorol, J1270
Use the UB-92 claim form for billing
Enter revenue code 250 in form locator 42
Enter the description of the drug in form locator 43
Enter HCPCS code J1270 in form locator 44
Enter the date of service in form locator 45
Enter the units given in form locator 46 (1 mcg = 1 unit)
Enter the total charges in form locator 47
Enter diagnosis code 588 81 or 588.89. 588.0 or 252.1 in form locator 67

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

Attention: Durable Medical Equipment Providers

HCPCS Code Changes for Durable Medical Equipment

Effective with date of service January 1, 2006, in order to comply with the Centers for Medicare and Medicaid Services (CMS) HCPCS coding changes, the following code conversions were made:

Old Code	New Code	Description	Lifetime Expectancy or Quantity Limitation	Maximum Reimbursement Rate
A4254	A4233	Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each	8 per year	New Purchase: $ 6.27#
	A4234	Replacement battery, alkaline, J cell, for use with medically necessary home blook glucose monitor owned by patient, each	8 per year	New Purchase: $ 6.27#
	A4235	Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each	8 per year	New Purchase: $ 6.27#
	A4236	Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each	8 per year	New Purchase: $ 6.27#
E0972	E0705	Transfer board or device, any type, each	1 year ages 0-20; 3 years ages 21 and older	New Purchase: $ 52.36# Used Purchase: $ 38.35# Rental: $ 5.33#
K0064	E2216	Manual wheelchair accessory, foam filled propulsion tire, any size, each	2 years	New Purchase: $ 28.89# Used Purchase: $ 21.65# Rental: $ 2.90#
K0066	E2220	Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, each	1 year	New Purchase: $ 28.52 Used Purchase: 21.81 Rental: 2.75
K0067	E2211	Manual wheelchair accessory, pneumatic propulsion tire, any size, each	1 year	New Purchase: 40.91 Used Purchase: 29.30 Rental: 4.01
K0068	E2212	Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each	1 year	New Purchase: 5.88 Used Purchase: 4.42 Rental: 0.61
K0074	E2214	Manual wheelchair accessory, pneumatic caster tire, any size, each	1 year	New Purchase: 30.61 Used Purchase: 22.96 Rental: 3.37
K0075	E2217	Manual wheelchair accessory, foam filled caster tire, any size, each	2 years	New Purchase: 39.75# Used Purchase: 29.82# Rental: 4.48#
K0076	E2221	Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, each	1 year	New Purchase: 25.55 Used Purchase: 19.18 Rental: 2.58
K0078	E2215	Manual wheelchair accessory, tube for pneumatic caster tire, any size, each	1 year	New Purchase: 9.60 Used Purchase: 7.18 Rental: 0.95
K0102	E2207	Wheelchair accessory, crutch and cane holder, each	3 years	New Purchase: 43.35 Used Purchase: 32.51 Rental: 4.34
K0104	E2208	Wheelchair accessory, cylinder tank carrier, each	3 years	New Purchase: 118.78 Used Purchase: 89.09 Rental: 11.87
K0106	E2209	Wheelchair accessory, arm trough, each	3 years	New Purchase: 107.16 Used Purchase: 80.38 Rental: 10.74
W4721	E2371*	Power wheelchair accessory, group 27 sealed lead acid battery, (e.g. gel cell, absorbed glassmat), each	1 year	New Purchase: 404.38# Used Purchase: 303.29# Rental: 40.44#
W4721	E2372*	Power wheelchair accessory, group 27 non-sealed lead acid battery, each	1 year	New Purchase: 404.38# Used Purchase: 303.29# Rental: 40.44#
W4737	E0911*	Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar	3 years	New Purchase: 2.274.65# Used Purchase: 1,705.99# Rental: 227.47#
W4737	E0912*	Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing, complete with grab bar	3 years	New Purchase: 2.274.65# Used Purchase: 1,705.99# Rental: 227.47#

Note: HCPCS codes with an asterisk indicate that prior approval is required.
HCPCS codes that are bolded indicate that the item is covered by Medicare.
Items with a # after the price indicate that Medicare has not established a rate for these items and the current will be considered an iterim rate.

In addition, the following code description changes were made effective with date of service January 1, 2006.

Code	New Description
A4215	Needle, sterile, any size, each
A6550 (Note A)	Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories
A7032	Cushion for use on nasal mask interface, replacement only, each
A7033	Pillow for use on nasal cannula type interface, replacement only, pair
B4149	Enteral formula, manufactured blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
E0935*	Continuous passive motion exercise device for use on knee only
E0971	Manual wheelchair accessory, anti-tipping device, each
E1038*	Transport chair, adult size, patient weight capacity up to and including 300 pounds

Note: HCPCS codes with an asterisk indicate that prior approval is required.
HCPCS codes that are bolded indicate that the item is covered by Medicare.

Note A: Because CMS combined this code with deleted code A6551, the rate will change to the Medicare rate of $27.42

The following HCPCS codes were added to the DME Fee Schedule effective with date of service January 1, 2006.

Code	Description	Lifetime Expectancy or Quantity Limitation		Maximum Reimbursement Rate
E1039* (Note B)	Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds	4 years		New Purchase: $ 342.00# Used Purchase: 256.50# Rental: 34.20
E2210	Wheelchair accessory, bearings, any type, replacement only, each	1 year		New Purchase: 6.55
E2213	Manual wheelchair accessory, pneumatic propulsion tire (removable), any type, any size, each	1 year		New Purchase: 30.41 Used Purchase: 22.79 Rental: 3.05
E2218	Manual wheelchair accessory, foam propulsion tire, any size, each	1 year		New Purchase: 31.00# Used Purchase: 23.25# Rental: 3.10#
E2219	Manual wheelchair accessory, foam caster tire, any size, each	1 year	New Purchase: 41.85 Used Purchase: 31.39 Rental: 4.72
E2222	Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, each	1 year	New Purchase: 82.20# Used Purchase: 61.65# Rental: 8.22#
E2223	Manual wheelchair accessory, valve, any type, replacement only, each	1 year	New Purchase: 7.00# Used Purchase: 5.25# Rental: 0.70#
E2224	Manual wheelchair accessory, propulsion wheel excludes tire, any size, each	1 year	New Purchase: 95.56 Used Purchase: 71.67 Rental: 9.56
E2225	Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each	1 year	New Purchase: 40.67# Used Purchase: 30.50# Rental: 4.06#
E2226	Manual wheelchair accessory, caster fork, any size, replacement only, each	1 year	New Purchase: 80.09# Used Purchase: 60.07# Rental: 8.00#

Note: HCPCS codes with an asterisk indicate that prior approval is required.
HCPCS codes that are bolded indicate that the item is covered by Medicare.
Items with # after the price indicate that Medicare has not established a rate for these items and the current rate will be considered an interim rate.

Note B: Due to the addition of E1039 and change in description of E1038, E1038 pricing has changed based on the Medicare rate to RR – 18.03, NU – 180.30#, UE – 135.23#.

The following codes have been discontinued by CMS and are being deleted from the DME Fee Schedule effective with date of service December 31, 2005.

Code	Description
A6551	Canister set for negative pressure wound therapy electrical pump, stationary or portable, each
E1025	Lateral thoracic support, non-contoured, for pediatric wheelchair, each (includes hardware)
E1026	Lateral thoracic support, contoured, for pediatric wheelchair, each (includes hardware)
E1027	Lateral/anterior support, for pediatric wheelchair, each (includes hardware)

Refer to Clinical Coverage Policy #5A, Durable Medical Equipment for detailed coverage and billing information. A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval. Providers are reminded that these are maximum reimbursement rates. Providers must bill their usual and customary rate for all DME.

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

Attention: Family Planning Waiver Providers

Code Update for Family Planning Services

Effective with date of service December 31, 2005, the following CPT procedure codes were end-dated for services provided through the N.C. Medicaid Family Planning Waiver.

99052	Services requested between 10:00 p.m. and 8:00 a.m. in addition to basic service
99054	Services requested on Sundays and holidays in addition to basic service

Refer to the January 2006 Special Bulletin, Family Planning Waiver “Be Smart,” on DMA’s website for additional information.

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

Attention: Home Infusion Therapists

HCPCS Code Changes for Parenteral Nutrition Supplies

The following changes to the HCPCS codes for parenteral nutrition supplies will be implemented to comply with national standard codes mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Code Deletions

The following codes are being end-dated and can no longer be used after date of service December 31, 2005.

HCPCS Code	Description	Billing Unit
B4184	Parenteral nutrition solution; lipids, 10% with administration set	500 ML = 1 UNIT
B4186	Parenteral nutrition solution, lipids, 20% with administration set	500 ML = 1 UNIT

Code Addition

The following code is being effective with date of service January 1, 2006.

HCPCS Code	Description	Billing Unit	Maximum Reimbursement Rate
B4185	Parenteral nutrition solution, per 10 grams lipids	10 GM Lipids = 1 unit	14.63

HCPCS Code

Description

Billing Unit

Maximum Reimbursement Rate

B4185

Parenteral nutrition solution, per 10 grams lipids

10 GM

Lipids = 1 unit

14.63

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

Attention: Hospitals and Physicians

HCPCS Code Changes for Radiopharmaceutical Agents

Effective with date of service January 1, 2006, the following HCPCS codes for radiopharmaceutical agents were end-dated and replaced with new codes. Claims submitted with end-dated codes for dates of service January 1, 2006 and after will deny. The new codes are priced according to the original invoice submitted with the claim. Claims submitted without original invoices will deny.

End-Dated HCPCS Code	Description	Unit	New HCPCS Code	Description	Unit
A9513	Radiopharmaceutical agent Technetium TC-99M, mebrofenin	Per MCI	A9537	Technetium TC-99M mebrofenin, diagnostic, per study dose	Up to 15 millicuries
A9514	Radiopharmaceutical agent Technetium TC-99M, pyrophosphate	Per MCI	A9538	Technetium TC-99M pyrophosphate, diagnostic, per study dose	Up to 25 millicuries
A9515	Radiopharmaceutical agent Technetium TC-99M, pentetate	Per MCI	A9539	Technetium TC-99M pentetate, diagnostic, per study dose	Up to 25 millicuries
A9520	Radiopharmaceutical agent Technetium TC-99M, sulfur colloid	Per MCI	A9541	Technetium TC-99M sulfur colloid, diagnostic, per study dose	Up to 20 millicuries

Effective with date of service January 1, 2006, Medicaid covers the following HCPCS codes for radiopharmaceutical agents. The new codes are priced according to the invoice submitted with the claim. Claims submitted without the original invoices will deny.

New HCPCS Code	Description	Unit
A9536	Technetium TC-99M depreotide, diagnostic, per study dose	Up to 35 millicuries
A9540	Technetium TC-99M macroaggregated albumin, diagnostic, per study dose	Up to 10 millicuries
A9542	Indium IN-111 ibritumomab tiuxetan, diagnostic, per study dose	Up to 5 millicuries
A9543	Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose	Up to 40 millicuries
A9544	Iodine I-131 Tositumomab, diagnostic	Per study dose
A9545	Iodine I-131 tositumomab, therapeutic	Per treatment dose
A9646	Cobalt CO-57/58, cyanocobalamin, diagnostic,	Per study dose, up to 1 microcurie
A9547	Indium IN-111 oxyquinoline, diagnostic,	Per 0.5 millicurie

New HCPCS Code	Description	Unit
A9548	Indium IN-111 pentetate, diagnostic,	Per 0.5 millicurie
A9549	Technetium TC-99M arcitumomab, diagnostic	Per study dose, up to 25 millicuries
A9550	Technetium TC-99M sodium gluceptate, diagnostic	Per study dose, up to 25 millicuries
A9551	Technetium TC-99M succimer, diagnostic (DMSA)	Per study dose, up to 10 millicuries
A9552	Fluorodeoxyglucose F-18 FDG, diagnostic	Per study dose, up to 45 millicuries
A9553	Chromium CR-51 sodium chromate, diagnostic	Per study dose, up to 250 microcuries
A9554	Iodine I-125 sodium iothalamate, diagnostic	Per study dose, up to 10 microcuries
A9555	Rubidium RB-82, diagnostic	Per study dose, up to 60 millicuries
A9556	Gallium GA-67 citrate, diagnostic	Per millicurie
A9557	Technetium TC-99M bicisate, diagnostic	Per study dose, up to 25 millicuries
A9560	Technetium TC-99M labeled red blood cells, diagnostic	Per study dose, up to 30 millicuries
A9561	Technetium TC-99M oxidronate, diagnostic	Per study dose, up to 30 millicuries
A9562	Technetium TC-99M mertiatide, diagnostic	Per study dose, up to 15 millicuries
A9563	Sodium phosphate P-32, therapeutic	Per millicurie
A9565	Indium IN-111 pentetreotide, diagnostic	Per millicurie
A9566	Technetium TC-99M fanolesomab, diagnostic (neutrospec)	Per study dose, up to 25 millicuries

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

Attention: Independent Practitioners and Local Education Agencies

Code Changes

End-Dated Code(s)	New CPT Code(s)	Description
92510	92626	Evaluation of auditory rehabilitation status; first hour. 1 unit = 1 hour
	92627	Evaluation of auditory rehabilitation status; each additional 15 minutes (list separately in addition to code for primary procedure). 1 unit = 15 minutes Note: Use 92627 in conjunction with 92626.
	92630	Auditory rehabilitation; pre-lingual hearing loss. 1 unit = 1 visit
	92633	Auditory rehabilitation; post-lingual hearing loss. 1 unit = 1 visit
97504	97760	Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes. 1 unit = 15 minutes Note: Codes 97760 and 97116 should not be billed together for the same extremity.
97520	97761	Prosthetic training, upper and/or lower extremity(s), each 15 minutes. 1 unit = 15 minutes
97703	97762	Checkout for orthotic/prosthetic use, established patient, each 15 minutes. 1 unit = 15 minutes
96100	96101	Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, mmpi, rorshach, wais), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report. 1 unit = 1 hour
96115	96116	Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report. 1 unit = 1 hour
96117	96118	Neuropsychological testing (eg, halstead-reitan neuropsychological battery, wechsler memory scales and wisconsin card sorting test), per hour of the psychologist's or physician's time, both face-to-face time with the patient and time interpreting test results and preparing the report. 1 unit = 1 hour

Clinic Coverage Policies 10B, Independent Practitioners and 10C, Local Education Agencies, have been updated to reflect these codes change.

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

Attention: Mental Health Practitioners

2006 Annual CPT Code Update

The American Medical Association (AMA) annually makes revisions to CPT codes. The following CPT codes will be end-dated 12/31/05 and the new codes will be effective January 1, 2006. Claims with codes deleted for 2005 will deny with dates of service on or after January 1, 2006. There will not be a “grace” period.

Procedure Code	Description	New Procedure Code
96100	Psychological Testing	96101
96115	Neurobehavioral Status Exam	96116
96117	Neuropsychological Testing Battery	96118

The following code change applies to Local Management Entities only:

Procedure Code	Description	New Procedure Code
90782	Therapeutic, Prophylactic or Diagnostic Injection	90772

Behavioral Health Services
DMA, 919-855-4291

Attention: Orthotic and Prosthetic Providers

HCPCS Code Changes for Orthotics and Prosthetics

Effective with date of service January 1, 2006, in order to comply with the Centers for Medicare and Medicaid Services (CMS) HCPCS coding changes, the following code conversions are being made:

Old Code	New Code	Description
K0628	A5512*	For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient’s foot, including arch, base layer minimum of ¼ inch material of shore a 35 durometer or 3/16 inch material of shore
K0629	A5513*	For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher, includes arch filler and other shaping material, custom fabricated, each
K0630	L0621	Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment
K0631	L0622	Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated
K0632	L0623	Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment

Old Code	New Code	Description
K0633	L0624	Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated
K0634	L0625	Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment
K0635	L0626	Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment
K0636	L0627	Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on theintervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment
K0637	L0628	Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment
K0638	L0629	Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated

Old Code	New Code	Description
K0639	L0630	Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment
K0640	L0631*	Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, pendulous abdomen design, prefabricated, includes fitting and adjustment
K0641	L0632*	Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated
K0642	L0633	Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment
K0643	L0634	Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated

Old Code	New Code	Description
K0644	L0635*	Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment
K0645	L0636*	Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated
K0646	L0637*	Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment
K0647	L0638*	Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated
K0648	L0639*	Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s) posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment

Old Code	New Code	Description
K0649	L0640*	Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated
L0860	L0859*	Addition to halo procedure, magnetic resonance image compatible systems, rings and pins, any material
L2039	L2034* ____________ L2387*	Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, mediallateral rotation control, with or without free motion ankle, custom fabricated _____________________________________________________ Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, each joint
L8100	A6530	Gradient compression stocking, below knee, 18-30 mmHg, each
L8110	A6531	Gradient compression stocking, below knee, 30-40 mmHg, each
L8120	A6532	Gradient compression stocking, below knee, 40-50 mmHg, each
L8130	A6533	Gradient compression stocking, thigh length, 18-30 mmHg, each
L8140	A6534	Gradient compression stocking, thigh length, 30-40 mmHg, each
L8150	A6535	Gradient compression stocking, thigh length, 40-50 mmHg, each
L8160	A6536	Gradient compression stocking, full length/chap style, 18-30 mmHg, each
L8170	A6537	Gradient compression stocking, full length/chap style, 30-40 mmHg, each
L8180	A6538	Gradient compression stocking, full length/chap style, 40-50 mmHg, each
L8190	A6539	Gradient compression stocking, waist length, 18-30 mmHg, each
L8195	A6540	Gradient compression stocking, waist length, 30-40 mmHg, each
L8200	A6541	Gradient compression stocking, waist length, 40-50 mmHg, each
L8210	A6542	Gradient compression stocking, custom made
L8220	A6543	Gradient compression stocking, lymphedema
L8230	A6544	Gradient compression stocking, garter belt
L8239	A6549*	Gradient compression stocking, not otherwise specified

Note: HCPCS codes with an asterisk indicate that prior approval is required.

HCPCS codes that are bolded indicate the item is covered by Medicare.

The following charts provides additional information about the coverage of these codes.

Old Code	New Code	Lifetime Expectancy or Quantity Limitation	Certification Requirement	LT/RT Modifier Requirement	Maximum Reimbursement Rate
K0628	A5512*	3 per foot, per year	CO, CP, CPO, or CPed	Yes	New Purchase: $ 24.22
K0629	A5513*	3 per foot, per year	CO, CP, CPO, or CPed	Yes	New Purchase: 36.14
K0630	L0621	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 72.17
K0631	L0622	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 195.70
K0632	L0623	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 205.67#
K0633	L0624	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 260.77#
K0634	L0625	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 44.60

Old Code	New Code	Lifetime Expectancy or Quantity Limitation	Certification Requirement	LT/RT Modifier Requirement	Maximum Reimbursement Rate
K0635	L0626	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: $ 63.10
K0636	L0627	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 332.72
K0637	L0628	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 67.89
K0638	L0629	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 214.10#
K0639	L0630	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 131.07
K0640	L0631*	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 830.92
K0641	L0632*	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 292.00#
K0642	L0633	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 232.10
K0643	L0634	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 309.92#
K0644	L0635*	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 860.71
K0645	L0636*	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 1,270.02

Old Code	New Code	Lifetime Expectancy or Quantity Limitation	Certification Requirement	LT/RT Modifier Requirement	Maximum Reimbursement Rate
K0646	L0637*	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: $ 67.89
K0647	L0638*	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 1,067.55
K0648	L0639*	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 1,101.92
K0649	L0640*	6 months: ages 0-20; 1 year: ages 21 and older	CO, CPO	No	New Purchase: 846.98
L0860	L0859*	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	No	New Purchase: 917.03
L2039	L2034* ______ L2387*	6 months: ages 0-20; 3 years: ages 21 and older 6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO ____________ CO, CPO	Yes _____________ Yes	New Purchase: 1,798.84# ________________________ New Purchase: 1,798.84#
L8100	A6530	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 39.56#
L8110	A6531	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 43.27
L8120	A6532	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 60.96

Old Code	New Code	Lifetime Expectancy or Quantity Limitation	Certification Requirement	LT/RT Modifier Requirement	Maximum Reimbursement Rate
L8130	A6533	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: $ 63.13#
L8140	A6534	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 74.88#
L8150	A6535	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 77.13#
L8160	A6536	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 95.55#
L8170	A6537	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 106.75#
L8180	A6538	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 115.30#
L8190	A6539	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 131.78#
L8195	A6540	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 136.50#
L8200	A6541	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 147.06#
L8210	A6542	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 172.50#
L8220	A6543	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 119.83#
L8230	A6544	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: 29.35#
L8239	A6549*	4 per year	CO, CP, CPO, RFO, COF, RFOM	Yes	New Purchase: manually priced

Note: HCPCS codes with an asterisk indicate that prior approval is required.

HCPCS codes that are bolded indicate that the item is covered by Medicare.

Items with# after the price indicate that Medicare has not established a rate for these items and the current rate will be considered an interim rate.

In addition, the following code description changes were made effective with date of service January 2006.

Code	New Description
L1832*	Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, includes fitting and adjustment
L1843*	Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment
L1844*	Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
L1845*	Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment
L1846*	Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
L2036*	Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated
L2037*	Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated
L2038*	Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom fabricated
L2405	Addition to knee joint, drop lock, each
L3170	Foot, plastic, silicone or equal, heel stabilizer, each
L3215+	Orthopedic footwear, ladies shoe, oxford, each
L3216+	Orthopedic footwear, ladies shoe, depth inlay, each
L3217+	Orthopedic footwear, ladies shoe, hightop, depth inlay, each
L3219+	Orthopedic footwear, men’s shoe, oxford, each
L3221+	Orthopedic footwear, men’s shoe, depth inlay, each
L3222+	Orthopedic footwear, men’s shoe, hightop, depth inlay, each
L3906	Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
L3923	Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Note: HCPCS codes with an asterisk indicate that prior approval is required.

HCPCS codes that are bolded indicate that the item is covered by Medicare.

HCPCS codes with a + indicate that prior approval is required for recipients age 21 and older.

The following HCPCS codes are being added to the Orthotic and Prosthetic Fee Schedule effective with date of service January 1, 2006.

Code	Description	Lifetime Expectancy or Quantity Limitation	Certification Requirement	LT/RT Modifier Requirement	Maximum Reimbursement Rate
L3671	Shoulder orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustments	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: $ 491.25#
L3672*	Shoulder orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 1,119.10#
L3673*	Shoulder orthosis, abduction positioning (airplane design), thoracic component and support bar, includes nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 1,289.10#
L3702	Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 253.00#
L3763	Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 430.50#
L3764*	Elbow wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 702.00#
L3765*	Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 834.00#
L3766*	Elbow wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 855.00#
L3905*	Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 701.75#
L3913	Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 239.57#
L3919	Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 186.00#

Code	Description	Lifetime Expectancy or Quantity Limitation	Certification Requirement	LT/RT Modifier Requirement	Maximum Reimbursement Rate
L3921	Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: $ 276.83#
L3933	Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 118.24#
L3935	Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 130.91#
L3961*	Shoulder elbow wrist hand orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 1,587.52#
L3967*	Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 1,795.98#

Code	Description	Lifetime Expectancy or Quantity Limitation	Certification Requirement	LT/RT Modifier Requirement	Maximum Reimbursement Rate
L3971*	Shoulder elbow wrist hand orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: $1,745.98#
L3973*	Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 1,469.93#
L3975*	Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 1,497.24#
L3976*	Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 1,647.12#

Code	Description	Lifetime Expectancy or Quantity Limitation	Certification Requirement	LT/RT Modifier Requirement	Maximum Reimbursement Rate
L3977*	Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: $1,597.74#
L3978*	Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment	6 months: ages 0-20; 3 years: ages 21 and older	CO, CPO	Yes	New Purchase: 1,795.98#
L5703*	Ankle, symes, molded to patient model, socket without solid ankle cushion heel (sach) foot, replacement only	6 months	CO, CPO	Yes	New Purchase: 3,149.75#
L5971	All lower extremity prosthesis, solid ankle cushion heel (sach) foot, replacement only	1 year: ages 0-20; 3 years 21 and older	CO, CPO	Yes	New Purchase: 163.00#
L6883*	Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power	6 months	CO, CPO	Yes	New Purchase: 2,100.00#
L6884*	Replacement socket, above elbow disarticulation, molded to patient model, for use with or without external power	6 months	CO, CPO	Yes	New Purchase: 2,704.00#

Code	Description	Lifetime Expectancy or Quantity Limitation	Certification Requirement	LT/RT Modifier Requirement	Maximum Reimbursement Rate
L6885*	Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power	6 months	CO, CPO	Yes	New Purchase: $3,451.00#
L7400	Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal)	1 year: ages 0-20; 3 years 21 and older	CO, CPO	Yes	New Purchase: 397.27#
L7401	Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal)	1 year: ages 0-20; 3 years 21 and older	CO, CPO	Yes	New Purchase: 523.86#
L7402*	Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal)	1 year: ages 0-20; 3 years 21 and older	CO, CPO	Yes	New Purchase: 628.00#
L7403	Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material	1 year: ages 0-20; 3 years 21 and older	CO, CPO	Yes	New Purchase: 255.00#
L7404	Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material	1 year: ages 0-20; 3 years 21 and older	CO, CPO	Yes	New Purchase: 347.37#
L7405	Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material	1 year: ages 0-20; 3 years 21 and older	CO, CPO	Yes	New Purchase: 431.00#
L7600	Prosthetic donning sleeve, any material, each	4 per year	CO, CPO	Yes	New Purchase: 74.87#

Note: HCPCS codes with an asterisk indicate that prior approval is required.

HCPCS codes that are bolded indicate the item is covered by Medicare.

Items with # after the price indicate that Medicare has not established a rate for these items and the current rate will be considered an interim rate.

Additionally, the following HCPCS codes have been discontinued by CMS and deleted from the Orthotic and Prosthetic Fee Schedule effective with date of service December 31, 2005.

Code	Description
L3963	Shoulder elbow wrist hand orthosis, molded shoulder, arm, forearm and wrist, with articulating elbow joint, custom-fabricated
L1750	Legg Perthes orthosis, Legg Perthes sling (Sam Brown type), prefabricated, includes fitting and adjustment

Refer to Clinical Coverage Policy #5B, Orthotics and Prosthetics for detailed coverage and billing information. A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval. Providers are reminded that these are maximum reimbursement rates. Providers must bill their usual and customary rate for all orthotic and prosthetic devices.

Note: Old codes can not be used per federal guidelines.

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

Attention: Physicians

HCPCS Code Changes for the Physician’s Drug Program

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

End-Dated Codes with No Replacement Codes

The following HCPCS codes were end-dated effective with date of service December 31, 2005. Claims submitted for dates of service on or after January 1, 2006 using the end-dated codes will deny.

End-Dated HCPCS Code	Description	Unit
J7051	Sterile saline or water	Up to 5 cc
J7320	Hylan G-F 20, for intra-articular injection	16 mg

New HCPCS Codes

The following HCPCS codes were added to the list of covered codes for the Physicians Drug Program effective with date of service January 1, 2006.

New HCPCS Code	Description	Unit	Maximum Reimbursement Rate
J0133	Acyclovir	5 mg	$0.03
J1265	Dopamine HCL	40 mg	$0.39

End-Dated Codes with Replacement Codes

The following codes were end-dated and replaced with new codes effective with date of service January 1, 2006. Claims submitted for dates of service on or after January 1, 2006 using the end-dated codes will deny.

End-Dated HCPCS Code	Description	Unit	New HCPCS Code	Description	Unit	Maximum Resimbursement Rate
J0880	Darbepoetin alfa (Aranesp)	5 mcg	J0881	Darbepoetin alfa (non-ESRD use) (Aranesp)	1 mcg	$15.06
J0880	Darbepoetin alfa (Aranesp)	5 mcg	J0882	Darbepoetin alfa (for ESRD on dialysis) (Aranesp)	1 mcg	$15.06
J1563 and J1564	Immune globulin, intravenous	1 G and 10 mg	J1566	Immune globulin, IV, lyophilized (powder) 500 mg	500 mg	$41.12
J1563 and J1564	Immune globulin, intravenous	1 G and 10 mg	J1567	Immune globulin, IV, non-lyophilized (liquid) 500 mg	500 mg	$41.12
J1750	Iron dextran (Infed)	50 mg	J1751	Iron dextran 165 (Infed)	50 mg	$11.22
J1750	Iron dextran (Infed)	50 mg	J1752	Iron dextran 267 (Dexferrum)	50 mg	$11.22
J7317	Sodium hyaluronate, for intra-articular injection	Per 20 to 25 mg dose	J7318	Hyaluronan (sodium hyaluronate) or derivative (Hyalgan)	1 mg	$4.68
S0016	Amikacin sulfate	500 mg	J0278	Amikacin sulfate	100 mg	$7.32
S0072	Amikacin sulfate	100 mg	J0278	Amikacin sulfate	100 mg	$7.32
S0168	Azacitidine (Vidaza)	100 mg	J9025	Azacitidine (Vidaza)	1 mg	$4.46
Q0187	Factor VIIa (antihemophilic factor, recombinant)	1.2 mg	J7189	Factor VIIA (antihemophilic factor, recombinant)	1 mcg	$1.02

New Codes that were previously billed with the Miscellaneous Drug Codes J3490 and J9999

Effective with date of service January 1, 2006, the N.C. Medicaid program covers the individual HCPCS codes for the drugs listed in the following table. Claims submitted for dates of service on or after January 1, 2006, using the unlisted drug codes J3490 or J9999 for these drugs will deny. Claims submitted for dates of service on or after January 1, 2006 using the miscellaneous drug codes, J3490 and J9999, instead of the new established codes for these drugs, will deny. An invoice is not required.

Old HCPCS Code	Description	Unit	New HCPCS Code	Description	Unit	Maximum Reimbursement Rate
J3490	Ziconotide intrathecal (Prialt)	25 mcg	J2278	Ziconotide (Prialt)	1 mcg	$6.59
J3490	Pegaptanib (Macugen)	0.3 mg	J2503	Pegaptanib sodium (Macugen)	0.3 mg	$1,001.97
J3490	Natalizumab (Tysabri)	300 mg	Q4079	Natalizumab (Tysabri)	1 mg	$6.78
J9999	Paclitaxel protein-bound particles (Abraxane)	1 mg	J9264	Paclitaxel protein-bound particles (Abraxane)	1 mg	$7.90

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

Attention: All Physicians

Anticipated 2006 CPT Code Rate Changes

As physicians are aware, CMS has indicated that there will be a decrease of more than 4% in the CPT physician reimbursement rates and that this rate change is to be effective January 1, 2006. The Division of Medical Assistance will not adjust its physician reimbursement rates as of January 1, 2006 to recognize these changes in CPT code rates.

Based on recent history where CMS has contemplated a decrease in CPT code reimbursement rates, CMS subsequently released a revised fee schedule such that there was an increase in the CPT code reimbursement rates. CMS did this is both calendar years 2003 and 2004.

Because we anticipate that there likely will be a reoccurrence and that 2006 will follow the 2003 and 2004 pattern, adjustments to CPT physician reimbursement rates will not be made on January 1, 2006. DMA will adjust its CPT rates when it becomes clear whether or not a second set of adjustments will be issued by CMS. In this regard, it might behoove providers to wait until this subject is finalized. In the interim, please continue to bill Medicaid your usual and customary charge.

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

Attention: UB-92 Billers

Payer Code H9999

Effective with date of processing, January 1, 2005, Medicaid will recognize payer code H9999. H9999 should be used for commercial HMO where the docket number is unassigned. Providers should list the payer code H9999 in FL 50 of the UB-92. Any claims that were submitted with payer code H9999 prior to the system modification can be resubmitted at this time.

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

NCLeads Update

Information related to the implementation of the new Medicaid Management Information System, NCLeads, can be found online. Please refer to the NCLeads website for information, updates, and contact information related to the NCLeads system.

Provider Relations
Office of MMIS Services
919-647-8315

Proposed Clinical Coverage Policies

In accordance with Session Law 2003-284, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA's website. To submit a comment related to a policy, refer to the instructions on the website. Providers without Internet access can submit written comments to the address listed below.

Gina Rutherford
Division of Medical Assistance
Clinical Policy Section
2501 Mail Service Center
Raleigh, NC 27699-2501

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

Holiday Closing

The Division of Medical Assistance (DMA) and EDS will be closed on Monday, January 2, 2006 in observance of the New Year’s Day and Monday, January 16, 2006 in observance of Martin Luther King’s Birthday.

2006 Checkwrite Schedule

Month	Electronic Cut-Off Date	Checkwrite Date
January	12/30/05	01/06/06
	01/06/06	01/10/06
	01/13/06	01/18/06
	01/20/06	01/26/06
February	02/03/06	02/07/06
	02/10/06	02/14/06
	02/17/06	02/23/06
March	03/03/06	03/07/06
	03/10/06	03/14/06
	03/17/06	03/21/06
	03/24/06	03/30/06

Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite. Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.

_____________________ _____________________

Mark T. Benton, Senior Deputy Director and
Chief Operating Officer Cheryll Collier

Division of Medical Assistance Executive Director

Department of Health and Human Services EDS

DMA Home

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