January 2006 Medicaid Bulletin

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In This Issue...

All Providers:

Adult Care Home Providers: 

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

Community Alternatives Program Case Managers:

Dialysis Centers:

Durable Medical Equipment Providers:

Family Planning Waiver Providers:

Home Health Agencies:

Home Infusion Therapists:

Hospitals:

Independent Practitioners:

Local Education Agencies:

Mental Health Practitioners:

Orthotic and Prosthetic Providers:

Physicians:

Private Duty Nursing Providers:

UB-92 Billers:

 


Attention: All Providers

Rates for 2006 CPT Codes

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

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

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#
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#
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

 

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

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

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

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

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

 

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

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
                                                                                                                                               

                                                                                                                                                           

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