NC Mediciad Bulletin April 2001 title

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In This Issue...

All Providers:

Dental Providers:

Hospice Providers:

ICF-IDD Group Home and CAP-I/DD Providers:


 

Attention: All Providers

Holiday Observance


The Division of Medical Assistance (DMA) and EDS will be closed on Friday, April 13, 2001, in observance of Good Friday.
 

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

Attention: All Providers

A New Look for the Medicaid Bulletin

Recent efforts to reduce costs associated with the administration of the Medicaid program have resulted in a new look for the general Medicaid bulletin. Beginning May 2001, the bulletin will be printed with black ink on white paper.

General Medicaid bulletins, as well as special bulletins, are also available through Internet access on the Division of Medical Assistance’s website at www.dhhs.state.nc.us/dma. Providers are encouraged to consider accessing the bulletin online as an alternative to receiving the bulletin through the mail.
 

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

Attention: ICF/I-DD Group Home and CAP-IDD Providers

Amendment to Medicaid Policy/Revision of the MR2 Form

North Carolina statutes require that area programs implement a single portal of entry and exit process for all persons with developmental disabilities in need of day/night or 24-hour services. To facilitate the monitoring of this policy as defined in G.S. 122C-3, an additional signature is now required when completing an MR2 for persons with mental retardation/developmental disabilities receiving services and supports paid for by the N.C. Medicaid program. Effective May 1, 2001, the MR2 form must be signed and dated by the area program single portal coordinator or their authorized representative for all initial placements into ICFs/I-DD and annually for those in CAP-I-DD services. This is in addition to the current requirement of a signature by a physician or, in the case of a CAP-MR/DDcontinuing need review, a qualified developmental disabilities professional (QDDP).

For ICF-I/DD group home providers, payment will not be made by EDS if the MR2 is not signed by the single portal representative at the time of initial placement. All ICF/I-DD providers are responsible for ensuring that all persons who reside in their group homes have participated in the single portal process at their home area program.

For CAP-IDD providers, the initial plan of care and continued needs review will not be approved by the lead agency local approval office if the MR2 is not signed by the single portal representative.

The area program single portal coordinator should sign, authenticate, and date the MR2 form below the signature line now being completed by the physician or the QDDP.
 

Nora Poisella, Medical Policy Section
DMA, 919-857-4020

Attention: All Providers

Endoscopy CPT Base Codes and Their Related Procedures

The following table represents a current and updated list of base and related endoscopy codes as designated in the Resource Based Relative Value System (RBRVS). There are two new groups of codes for 2001. The effective date of service for new group 33 is January 1, 2001. The effective date of service for new group 34 is March 1, 2001. Groups 11, 12, 13, 14, 15, 16, 17, 18, and 26 have new codes added to the related side. Group 27 has been end-dated effective with date of service April 1, 2001. This list replaces the list published in the August 2000 general Medicaid bulletin.

Scopy Base and Related Code Group
Group
Base Code
Related Codes
Comments
1 29815 29819-29823, 29825-29826  
2 29830 29834-29838  
3
29840
29843-29847  
4
29860
29861-29863  
5
29870
29871, 29874-29877, 29879-29887  
6
31505
31510-31513  
7
31525
31527-31530, 31535, 31540, 31560, 31570  
8
31526
31531, 31536, 31541, 31561, 31571  
9
31622
31625, 31628-31631, 31635, 31640-31641, 31645  
10
43200
43202, 43204-43205, 43215-43217, 43219-43220, 43226-43228  
11
43235
43231, 43232, 43239, 43241-43247, 43249-43251, 43255, 43256, 43258-43259 Effective 01/01/01 new "related" codes added from 2001 RBRVS
12
43260
43240, 43261-43265, 43267-43269, 43271-43272 Effective 01/01/01 new "related" codes added from 2001 RBRVS
13
44360
44361, 44363-44366, 44369, 44370, 44372-44373  Effective 01/01/01 new "related" codes added from 2001 RBRVS
14
44376
44377-44379  Effective 01/01/01 new "related" codes added from 2001 RBRVS
15
44388
44389-44394, 44397 Effective 01/01/01 new "related" codes added from 2001 RBRVS
16
45300
45303, 45305, 45307-45309, 45315, 45317, 45320-45321, 45327 Effective 01/01/01 new "related" codes added from 2001 RBRVS
17
45330
45331-45334, 45337-45339, 45345 Effective 01/01/01 new "related" codes added from 2001 RBRVS
18
45378
45379-45380, 45382-45385, 45387 Effective 01/01/01 new "related" codes added from 2001 RBRVS
19
46600
46604, 46606, 46608, 46610-46612, 46614-46615  
20
47552
47553-47556  
23
50951
50953, 50955, 50957, 50959, 50961   
24
50970
50974, 50976   
25
52000
52250, 52260, 52265, 52270, 52275-52277, 52281-52283, 52285, 52290, 52300, 52305, 52310, 52315, 52317-52318  
26
52005
52320, 52325, 52327, 52330, 52332, 52334, 52341-52344  Effective 01/01/01 new "related" codes added from 2001 RBRVS
27
52335
52336-52339 End-dated 04/01/00 due to 2001 CPT update
28
56300
56301-56309, 56311, 56343-56344, 56314 End-dated due to 2000 CPT update
29
56350
56351-56356 End-dated due to 2000 CPT update
30
57452
57454, 57460  
31
49320
38570, 49321, 49322, 49323, 58550, 58551, 58660, 58661, 58662, 58670, 58671 Effective 01/01/00 new family of codes for 2000 based on RBRVS 
32
58555
58558, 58559, 58560, 58561, 58562, 58563 Effective 01/01/00 new family of codes for 2000 based on RBRVS 
33
52351
52345, 52346, 52352, 52353, 52354, 52355 Effective 01/01/01 new family of codes for 2001 based on RBRVS 
34
31575
31576, 31577, 31578, 31579 Effective 03/01/01 new family of codes for 2001 based on RBRVS 

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

Attention: All Providers

Clarification of Policy on "Stat" Charges

The Division of Medical Assistance does not recognize "stat" charges. Stat charges represent an additional fee for diagnostic tests performed on a priority basis. Diagnostic tests include both laboratory and radiology services. Costs related to performing a diagnostic test on a stat basis represent the priorities of the departmental workload and not an actual direct patient care service. Therefore, stat charges should not be billed.

Because the claim form does not provide separate details for ancillary charges, stat charges will be disallowed upon verification of hospital records and billing procedures through postpayment and audit review.
 

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

Attention: Hospice Providers

Hospice Election Statement Signatures

Prior to providing services, a Hospice agency must have the patient or patient's representative sign a Hospice agreement that includes a Medicaid Hospice election statement as outlined on pages 8-6 and 8-7, section 8.5 of the N.C. Medicaid Community Care Manual. An election statement to receive Hospice care is considered to continue through the initial election period as well as through subsequent election periods as long as the individual remains in the care of the Hospice and does not revoke the election. Additional signatures are not required at the beginning of each benefit period as long as these conditions are met and there is no break in services. The statement should also be signed for patients with pending Medicaid as well as those who indicate that they will be applying for Medicaid benefits to cover any eligibility that might be approved retroactively.

Hospice providers are reminded that Medicaid payment for Hospice is dependent upon the prompt reporting of Hospice participation. EDS must be notified when a Medicaid recipient initially elects the Hospice Medicaid benefit, begins a new benefit period, transfers to another Hospice, revokes the benefit or is discharged. This includes Medicare/Medicaid Hospice patients in nursing facilities for whom Medicaid is paying room and board. Providers should also promptly report pending Medicaid cases that have elected the Medicaid Hospice benefit.
 

Adelle Kingsberry, Medical Policy Section
DMA, 919-857-4021

Attention: Hospice Providers

Update To Physician Certification Requirement Guidelines

Physician certification of terminal illness is required for all Hospice recipients prior to assessing for the appropriateness of the service. Current Medicaid guidelines as listed on page 8-8, section 8.5 of the N.C. Medicaid Community Care Manual indicate that the physician certification must "State that the patient has a medical prognosis of six months or less to live." As a result of the Benefits Improvement and Protection Act (BIPA) of 2000, there is further clarification that certification of the terminal illness of an individual who elects Hospice "shall be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness."

The clarification emphasizes that medical prognostication of life expectancy is not always exact. Therefore, physician certifications should not be unduly scrutinized or "second guessed," thereby unnecessarily delaying or preventing the provision of Hospice care to Medicaid recipients. This update to guidelines is effective for certifications made for Medicaid Hospice patients on or after December 21, 2000, the date of enactment of BIPA 2000.
 

Adelle Kingsberry, Medical Policy Section
DMA, 919-857-4021

Attention: All Providers

Modifier 51

Modifier 51 indicates that on the same day or at the same operative session the same provider performed several procedures. Multiple related surgical procedures or a combination of medical and surgical procedures performed at the same session must be designated with modifier 51. It is not appropriate to append modifier 51 to all procedure codes.

Procedure codes defined as "add-on" codes cannot be performed without the primary procedure and are not appropriate with modifier 51.

When billing multiple endoscopy procedure codes, it is not appropriate to append modifier 51.

The following procedure codes are exempt from modifier 51:
 
11001 11101 11201 11720 11721 11732 11922 11975
11977 13102 13122 13133 13153 15001 15101 15121
15201 15221 15241 15261 15343 15351 15401 15787
15850 16036 17003 17004 17304 17305 17306 17307
17310 19001 19126 19291 19295 19340 20660 20931
20936 20937 20938 20974 20975 20979 21088 21089
22103 22116 22216 22226 22328 22522 22585 22614
22632 22840 22841 22842 22843 22844 22845 22846
22847 22848 22851 26125 26861 26863 27358 27692
29819 29820 29821 29822 29823 29825 29826 29834
29835 29836 29837 29838 29843 29844 29845 29846
29847 29861 29862 29863 29871 29874 29875 29876
29877 29879 29880 29881 29882 29883 29884 29885
29886 29887 31510 31511 31512 31513 31527 31528
31529 31530 31531 31535 31536 31540 31541 31560
31561 31570 31571 31576 31577 31578 31579 31625
31628 31629 31630 31631 31635 31640 31641 31645
32000 32002 32020 32501 32850 33141 33517 33518
33519 33521 33522 33523 33530 33572 33924 33930
33940 33960 33961 33968 34808 34813 34826 35390
35400 35500 35600 35681 35682 35683 35700 36218
36248 36415 36430 36488 36489 36491 36540 36550
36620 36625 36660 37195 37206 37208 37250 37251
38102 38570 38746 38747 43202 43204 43205 43215
43216 43217 43219 43220 43226 43227 43228 43231
43232 43239 43240 43241 43242 43243 43244 43245
43245 43246 43247 43249 43250 43251 43255 43256
43258 43259 43261 43262 43263 43264 43265 43267
43268 43269 43271 43272 43635 43752 44015 44121
44132 44133 44135 44136 44139 44361 44363 44364
44365 44366 44369 44370 44372 44373 44377 44378
44379 44389 44390 44391 44392 44393 44394 44397
44500 44955 45303 45305 45307 45308 45309 45315

 
45317 45320 45321 45327 45331 45332 45333 45334
45337 45338 45339 45345 45379 45380 45382 45383
45384 45385 45387 46604 46606 46608 46610 46611
46612 46614 46615 47001 47133 47550 47553 47554
47555 47556 48160 48400 48550 48554 49321 49322
49323 49568 49905 50300 50555 50557 50559 50561
50572 50574 50575 50576 50578 50580 50953 50955
50957 50959 50961 50974 50976 52007 52010 52204
52214 52224 52250 52260 52265 52270 52275 52276
52277 52281 52282 52283 52285 52290 52300 52301
52305 52310 52315 52317 52318 52320 52325 52327
52330 52332 52334 52336 52337 52338 52339 52341
52342 52343 52344 52345 52346 52352 52353 52354
52355 56606 57454 57460 58300 58550 58551 58558
58559 58560 58561 58562 58563 58611 58660 58661
58662 58670 58671 58672 58673 59050 59051 59412
59425 59426 59525 60512 61055 61107 61210 61609
61610 61611 61612 61795 62252 62284 62367 62368
63035 63043 63044 63048 63057 63066 63076 63078
63082 63086 63088 63091 63308 64472 64476 64480
64484 64550 64623 64627 64727 64778 64783 64787
64832 64837 64859 64872 64874 64876 64901 64902
65760 65765 65767 65771 67331 67332 67334 67340
67335 69300 69710 69990        

Except for the following procedure codes, all Radiology procedure codes are exempt from modifier 51:
 
78306 78320 78803
78802 78806 78807

All Pathology and Laboratory procedure codes are exempt from modifier 51.

The only Medicine procedure codes that are appropriate with modifier 51 are in the following table:
 
92975 92980 92982 92986
92987 92990 92992 92993
92995 92997 93501 93505
93508 93510 93511 93514
93524 93526 93527 93528
93529 93530 93531 93532
93533 93536 96405 96406
99170      

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

Attention: Hospice Providers

Hospice Services Reimbursement Rate Increase

Effective with date of service April 1, 2001, the maximum allowable rate for the following Hospice services increased. These rates are in response to the Benefits Improvement and Protection Act (BIPA) transmitted by HCFA Region IV. These rates are in effect from April 2001 to January 2002 when Hospice rates are normally scheduled for review. Please update the Hospice rate schedule appearing in the March 2001 general Medicaid bulletin with this schedule.
 
 
Routine Home Care
Continuous Home Care
Inpatient Respite Care
General Inpatient Care 
Hospice Intermediate R & B
Hospice Skilled 
R & B
Metropolitan Statistical Area
SC
RC 651
Daily
RC 652
Hourly
(1)
RC 655
Daily
(2) (3) (4)
RC 656
Daily
(3) (4)
RC 658
Daily
(5)
RC 659
Daily 
(5)
Asheville
39
103.14
25.06
113.07
459.43
93.64
124.44
Charlotte
41
107.45
26.11
116.76
477.24
93.64
124.44
Fayetteville
42
100.09
24.32
110.46
446.79
93.64
124.44
Greensboro/
Winston-Salem/
High Point
43
104.34
25.35
114.10
464.39
93.64
124.44
Hickory
44
104.93
25.50
114.61
466.83
93.64
124.44
Jacksonville
45
95.06
23.10
106.15
425.97
93.64
124.44
Raleigh/Durham
46
108.32
26.32
117.51
480.87
93.64
124.44
Wilmington
47
109.59
26.63
118.60
486.13
93.64
124.44
Rural
53
98.48
23.93
109.08
440.13
93.64
124.44
Goldsboro
105
98.82
24.01
109.38
441.56
93.64
124.44
Greenville
106
107.97
26.24
117.22
479.44
93.64
124.44
Norfolk
Currituck County
107
99.66
24.22
110.09
445.03
93.64
124.44
Rocky Mount
108
101.97
24.78
112.07
454.59
93.64
124.44

Note: Providers are expected to bill their usual and customary charges. Adjustments will not be accepted.

Key to Hospice Rate Table:

SC = Specialty Code
RC = Revenue Code
 

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


Debbie Barnes, Financial Operations
DMA, 919-857-4015

Attention: All Providers

Lead Awareness Month

United Parents Against Lead of North Carolina (UPAL/NC) is pleased to announce that Governor Mike Easley issued a proclamation declaring April 2001 as Lead Awareness Month. UPAL/NC and the Division of Medical Assistance (DMA) would like to take this opportunity to recognize the Medicaid providers who are already testing all one- and two-year-old children for lead poisoning, and to encourage those Medicaid providers who may not have begun testing to do so now.

Federal Medicaid regulations state that all children participating in Medicaid are required to have a blood lead test at 12 and 24 months of age. Children between 36 and 72 months of age must be tested if not previously tested. Providers can always perform a lead screen if it is clinically indicated.

If you would like more information about how lead poisoning affects families over a long-term period, call Kris Joyner, Director, UPAL/NC at 252-937-4112 or e-mail UPAL/NC at upalnc1@hotmail.com. If you would like more information on billing for lead screening, contact EDS.
 

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

Attention: All Providers

Platelet-derived Wound Healing Formula, Procuren

Providers have been billing a platelet-derived formula, Procuren, which is intended to treat non-healing wounds as part of a comprehensive wound care program. To date, there is insufficient data to establish the safety and effectiveness of Procuren. Therefore, Procuren is noncovered and must not be billed under RC386.

Postpayment review of records reflecting payment of Procuren will result in recoupment.
 

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

Attention: All Providers

Provider Visit Request

The Division of Medical Assistance and EDS encourage providers to attend program-specific seminars as advertised in the general Medicaid bulletin and to utilize printed training materials to supplement the information supplied at the time of enrollment.

EDS Provider Services also offers providers support through the Automated Voice Response System for eligibility and claims inquiry; telephone attendants available to assist in answering detailed questions when resolving claims issues; and travel representatives for one-on-one training.

Individual provider visits are offered to all Medicaid providers, regardless of type and specialty, and may be requested any time during the year. To request an individual visit, complete and return the form below. An EDS Provider Representative will contact you to schedule a visit and discuss the type of issues you would like addressed.

Return completed Provider Visit Request form to:

EDS Provider Services
PO Box 300009
Raleigh, North Carolina 27622


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

Attention: Dental Providers

Dental Seminars

Dental seminars are scheduled for June 2001. The May general Medicaid bulletin will have the registration form and a list of site locations for the seminars. Please list any issues you would like addressed at the seminars. Return Dental Seminar Issues form to:

Provider Services
EDS
P.O. Box 300009
Raleigh, NC 27622
EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers

Basic Medicaid Seminars Rescheduled to June 2001

The Basic Medicaid seminars that were scheduled for April 2001, have been cancelled and rescheduled for June 2001. The May general Medicaid bulletin will have the registration form and a list of site locations for the seminars.

Providers who registered for the Basic Medicaid seminars that were scheduled for April 2001 will need to re-register for the seminars that are scheduled for June 2001.

Please list any issues you would like addressed at the seminars. Return Basic Medicaid Seminar Issues form to:

Provider Services
EDS
P.O. Box 300009
Raleigh, NC 27622


EDS, 1-800-688-6696 or 919-851-8888
 


Checkwrite Schedule

April 10, 2001
May 8, 2001
June 12, 2001
April 17, 2001
May 15, 2001
June 19, 2001
April 26, 2001
May 22, 2001
June 28, 2001
May 31, 2001

 

Electronic Cut-Off Schedule

April 6, 2001
May 4, 2001
June 8, 2001
April 12, 2001
May 11, 2001
June 15, 2001
April 20, 2001
May 18, 2001
June 22, 2001
 
May 25, 2001
 

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.

Paul R. Perruzzi, Director Christopher T. Deelsnyder, CE
Division of Medical Assitance Administrative Process Management
Department of Health and Human Services EDS
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