April 2002 NC Medicaid Bulletin title

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In This Issue…… 
All Providers: Area Mental Health Centers: Durable Medical Equipment Providers: Health Departments: Home Health Agencies: Hospital Providers: Independent Practitioner Program Providers: Local Education Agencies: Nursing Facility Providers: Nurse Practitioners: Outpatient Therapy Services: Physicians: Psychiatric Residential Treatment Facility Providers: Residential Treatment Facility Providers for Levels II through IV:


Attention: All Providers

Carolina ACCESS Provider Application Available on the Internet

The Carolina ACCESS Provider Application for Participation and the instructions for completing it are now available on the Division of Medical Assistance’s website under the heading "Provider Enrollment Applications."

It is extremely important that the information on file with DMA for all Carolina ACCESS (CA) practices remains current and accurate to avoid potential claim denials or contract sanctions. Providers are responsible for ensuring that information on file with the Medicaid program for their practice or facility remains up-to-date. The Carolina ACCESS Provider Information Change form is available on DMA’s website under the heading "Forms." (Refer to the article entitled Reporting Changes in Provider Status to Medicaid in the October 2001 general Medicaid bulletin for information on notifying Medicaid of changes within your practice.)

Questions about participating with the CA program or general questions about CA should be directed to the regional Managed Care Consultant (refer to the January 2002 general Medicaid bulletin) or DMA Managed Care at 919-857-4022.
 

Provider Services
DMA, 919-857-4017


Attention: Durable Medical Equipment Providers

HCPCS Code Changes

The following code changes are effective with date of service April 1, 2002:
 
Old Code New Code Description Quantity Limitation Maximum Reimbursement Rate
W4063  A4215  Needle only, sterile, any size  200 per month        $ .14 new purchase
W4050  E1390  Oxygen concentrator, capable of   delivering 85 percent or greater   oxygen concentration at the prescribed rate  N/A        $223.30 monthly rental 
W4142  K0031  Safety belt/pelvic strap  1 per 2 years        $ 4.03 monthly rental 
      $ 40.30 new purchase 
      $ 30.24 used purchase
W4149  K0107  Wheelchair tray  1 per 2 years        $ 10.12 monthly rental
      $101.03 new purchase
      $ 75.58 used purchase

Only code E1390 requires prior approval. However, as with all durable medical equipment, a Certificate of Medical Necessity and Prior Approval form must be completed.
 

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


Attention: Independent Practitioner Program Providers, Local Education Agencies, All Providers of Outpatient Occupational, Physical, Speech, and Respiratory Therapy Services, Home Health Agencies, and Physicians

Prior Approval Process

Effective with dates of service June 1, 2002, a prior approval process will be utilized for all outpatient occupational, physical, speech, and respiratory therapy services regardless of provider or setting. A contract is being initiated with Medical Review of North Carolina (MRNC) to review these services and authorize care at designated trigger points. After these trigger points have been reached, claims will not process without prior approval.

Workshops regarding the prior approval process and billing are scheduled for the third week of May 2002. Please read your May general Medicaid bulletin promptly. The registration form and a list of the workshop locations will be included in the May general Medicaid bulletin.
 

Nora Poisella, Behavioral Health Services
Carol Robertson, Behavioral Health Services
DMA, 919-857-4020


Attention: Health Departments

Provision of Psychological Services in Health Departments

Effective July 1, 2002, health departments and school-based health centers sponsored by health departments may bill the following Current Procedural Terminology (CPT) codes for psychological services for the under 21 population.

90801, 90802, 90804, 90806, 90808, 90810, 90812, 90814 and 90846, 90847 and 90853

Psychological services must be provided by a Licensed Clinical Social Worker (LCSW), an Advanced Practice Psychiatric Clinical Nurse Specialist (CNS), Advanced Practice Psychiatric Nurse Practitioner (NP) or Licensed Psychologist. All providers must function within the scope and practice of their state license and certification.

One of the following ICD-9-CM diagnosis codes must be present for the claim to process:

The CPT codes are subject to prior approval from ValueOptions prior to the 27th visit in any calendar year.
 

Carol Robertson, Behavioral Health Services
DMA, 919-857-4020


Attention: Nursing Facility Providers

Tracking Forms for the Preadmission Screening and Annual Resident Review Process

Because providers continue to neglect to forward a Tracking Form to First Health (FH) for new admissions, the following article is reprinted from the January 2001 general Medicaid bulletin. Facilities that do not have the Level I and, if appropriate, Level II information as part of the medical record will be out of compliance with the Preadmission Screening and Annual Resident Review (PASARR) regulations and subject to penalty.

To assure compliance with the federally mandated PASARR requirements, all Medicaid certified nursing facilities must complete the PASARR Tracking Form for every admission, regardless of pay source, and forward it to FH, the Division of Medical Assistance’s contractor for the PASARR program. The information documented on the Tracking Form communicates to FH the name of the admitting facility and assures that the facility will receive a copy of the Level I and, if appropriate, Level II screening results.

The requirements also mandate that when a screening has not been completed prior to admission or an annual review is not performed within the fourth quarter after the previous preadmission screen or annual resident review, Medicaid reimbursement must be denied. Once the Level I and, if appropriate, Level II screen is completed, Medicaid reimbursement will resume.

The Level I or Level II screening results must be kept in the resident’s medical record to allow availability to the facility’s care planning team and to federal and state auditors.

Tracking Forms must be completed for the following:

1. All first time admissions in the Level I process:

2.  All first time admissions in the Level II process and if:


Margaret O. Langston, RN, Institutional Services, Medical Policy Section
DMA, 919-857-4020


Attention: Nursing Facility Providers

Requests for Retroactive Prior Approval

Because providers continue to request retroactive prior approval for time periods exceeding the maximum 90 days allowed, the following article is reprinted from the January 2001 general Medicaid bulletin.

Effective January 1, 2001, nursing facilities may request consideration of retroactive prior approval for nursing facility (NF) level of care with the initial FL2 submission to EDS. If the retroactive request is within thirty (30) days from the telephone prior approval or FL2 criteria review, medical records may not be needed by EDS to make a level of care decision. If the retroactive request is for a time period exceeding thirty (30) days, medical record documentation will be required by EDS to support the retroactive request and level of care decision.

EDS will also consider retroactive prior approval requests in the following instances:


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


Attention: All Providers

Changes to the Initial Hemoglobin or Hematocrit Health Check Screening Component

Effective April 1, 2002, hemoglobin or hematocrit levels must initially be measured in infants between the ages of 9 to 12 months as recommended in the American Academy of Pediatrics (AAP) guidelines. Previously, Health Check policy required that hemoglobin or hematocrit levels initially be measured between the ages of 1 to 9 months of age.

This change allows providers to perform hemoglobin or hematocrit screenings at the same time as the initial lead screenings performed at 12 months of age. As a reminder, federal regulations require lead screenings be performed at 12 and 24 months of age.
 

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


Attention: All Providers

CPT Code Bundling

Over the next several months, the Division of Medical Assistance will be implementing bundling of Current Procedural Terminology (CPT) codes according to version 7.3 and 8.0 of the Correct Coding Initiative (CCI). The CCI was developed by the Centers for Medicare and Medicaid Services (CMS) when the Resource-Based Relative Value System (RBRVS) fee schedule for physician payment was implemented.

Since procedures should be billed using the most comprehensive code to describe the service performed, the CCI bundles the component procedures of the service into the comprehensive code. Only the comprehensive code is paid.

Providers will receive an Explanation of Benefits (EOB) denial code if a component code is billed with the comprehensive code. The EOB indicates that the component code cannot be billed in addition to the comprehensive code.

Modifiers that define a separately identifiable service, such as modifier 59, will allow some coding pairs to unbundle. Medical records documenting the appropriate use of the modifier must be kept on file for at least five years to allow for post-payment reviews.
 

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


Attention: Physicians

Case Conference for Sexually Abused Children

Effective with date of service April 1, 2002, procedure code W8241 will be end-dated to comply with the implementation of national procedure codes mandated by the Health Insurance Portability and Accountability Act.

Effective with date of service, April 1, 2002, Current Procedural Terminology (CPT) procedure code 99361 or 99362 should be billed to report a face-to-face case conference by a physician with health professionals or community agency representatives to coordinate patient care for sexually abused children.
 
99361 Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient not present); approximately 30 minutes
99362 approximately 60 minutes

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


Attention: Hospital Providers

Revenue Code Changes

The Health Insurance Portability and Accountability Act of l996 (HIPAA) requires all health care providers to comply with the implementation of standardized national code sets. Therefore, the N.C. Medicaid program has revised definitions for the revenue codes (RC) listed below effective February 1, 2002.
 
Revenue Code Old Definition New Definition
RC 206  Intensive Care Post – ICU  Intensive Care: Intermediate ICU 
RC 214  Coronary Care Post – CCU  Coronary Care: Intermediate ICU 
RC 254  Drugs Less Than Effective  Pharmacy: Drugs Incident to Other Diagnostic Services 
RC 274  Supplies and Solutions for Nutritional Therapy  Medical /Surgical Supplies and Devices: Prosthetic/Orthotic Devices 
RC 780  Teleconsult Spoke Visit  Telemedicine: General Classification 
RC 829  Facility Retrain Fee Per Session: Hemodialysis  Hemodialysis - Outpatient or Home: Other Outpatient Hemodialysis 
RC 839  Facility Retraining Session: Peritoneal  Peritoneal Dialysis - Outpatient or Home: Other Outpatient Peritoneal Dialysis 
RC 882  Miscellaneous Dialysis –Ultrafiltration  Miscellaneous Dialysis: Home Dialysis Aide Visit 
RC 911  Not Defined  Psychiatric/Psychological Services: Rehabilitation 
RC 912  Psychiatric/Psychological Service – Day Care  Psychiatric/Psychological Services: Partial Hospitalization - Less Intensive 
RC 913  Psychiatric/Psychological Services – Night Care  Psychiatric/Psychological Services: Partial Hospitalization - Intensive 

The following obsolete revenue codes were discontinued effective October 2001:
 
Revenue Code Definition
RC 175  Nursery Neonatal – ICU 
RC 701  Cast Room – Other 
RC 890  Other – Donor Bank – General 
RC 891  Other – Donor Bank – Bone 
RC 892  Other – Donor Bank - Organ (Other Than Kidney) 
RC 893  Other – Donor Bank – Skin 
RC 899  Other – Donor Bank – Other 

Ann H. Kimbrell, R.N., Institutional Services
DMA, 919-857-4020


Attention: All Providers

CPT Codes End-Dated for 2002

Effective with date of service April 1, 2002, N.C. Medicaid providers can no longer bill procedure codes deleted from the 2002 Current Procedural Terminology (CPT) by the American Medical Association (AMA). Claims submitted with covered, deleted procedure codes for dates of service prior to April 1, 2002 will be accepted for processing. The following table lists the deleted codes that are currently covered:
 
Deleted Code Description
00857  Neuraxial analgesia/anesthesia for labor ending in cesarean delivery 
00955  Neuraxial analgesia/anesthesia for labor ending in a vaginal delivery 
26585  Repair bifid digit 
26597  Release of scar contracture, flexor or extensor, with skin grafts, rearrangement flaps, or Z-plasties, hand and/or finger 
29815  Arthroscopy, shoulder, diagnostic, with or without synovial biopsy 
29909  Unlisted procedure, arthroscopy 
53443  Urethroplasty with tubularization of posterior urethra and/or lower bladder for incontinence 
54510  Excision of local lesion of testis 
80072  Arthritis panel 
85095  Bone marrow; aspiration only 
85102  Bone marrow biopsy, needle or trocar 
85535  Iron stain (RBC or bone marrow smears) 
88170  Fine needle aspiration; superficial tissue 
88171  Fine needle aspiration; deep tissue under radiologic guidance 
93536  Percutaneous insertion of intra-aortic balloon catheter 
93607  Left ventricular recording 
93737  Electronic analysis of single or dual chamber pacing cardioverter-defibrillator only; without reprogramming 
93738  Electronic analysis of single or dual chamber pacing cardioverter-defibrillator only; with reprogramming 

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


Attention: All Providers

CPT Code Update 2002

Effective with date of service January 1, 2002, N.C. Medicaid providers may bill the following Current Procedural Terminology (CPT) codes, which replace codes deleted by the American Medical Association (AMA) for 2002:
 
Deleted Code New Code Description
00955  01967  Neuraxial labor analgesia/anesthesia for planned vaginal delivery 
00857  01968  Cesarean delivery following neuraxial labor analgesia/anesthesia 
00857  01969  Cesarean hysterectomy following neuraxial labor analgesia/anesthesia 
88170  10021  Fine needle aspiration, without imaging guidance 
88171  10022  Fine needle aspiration, without imaging guidance with imaging guidance 
29815  29805  Arthroscopy, shoulder, diagnostic, with or without synovial biopsy 
93536  33967  Insertion of intra-aortic balloon assist device, percutaneous 
85095  38220  Bone marrow aspiration 
85102  38221  Bone marrow biopsy, needle or trocar 
53443  53431  Urethroplasty with tubularization of posterior urethra and/or lower bladder for incontinence 

Claims submitted for dates of service January 1, 2002 through March 31, 2002 with deleted codes will be accepted for processing. Claims for dates of service on or after April 1, 2002 must be filed using the 2002 CPT codes listed in the table above.

The annual review of new CPT codes is ongoing. Providers will be notified concerning coverage of other new codes in future general Medicaid bulletins.
 

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


Attention: Health Departments

Diabetes Outpatient Self-Management Training: Supervision Clarification

Diabetes outpatient self-management training performed in health departments should be provided by or under the overall direction and supervision of a physician or other individuals approved to perform medical acts, tasks or functions (nurse practitioner, certified nurse midwives, physician assistants). The supervising practitioner may be employed by or under contract with the health department.

The health department provider number should be used when billing the service. Refer to the November 1999 general Medicaid bulletin for additional coverage information.
 

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


Attention: All Providers

Copayment Amounts for Recipients

The following copayments apply to all Medicaid recipients except those specifically exempted by law from copayment:
 
Service Copayment
Chiropractic  $1.00 per visit 
Dental  $3.00 per visit 
Prescription Drugs and Insulin
     Generic
     Brand

$1.00 per prescription
$3.00 per prescription
Ophthalmologist  $3.00 per visit 
Optical Supplies and Services  $2.00 per visit 
Optometrist  $2.00 per visit 
Outpatient  $3.00 per visit 
Physician  $3.00 per visit 
Podiatrist  $1.00 per visit 

Providers may not charge copayments for the following services:

Providers may bill the patient for applicable copayment amounts, but may not refuse services for inability to pay the copayment. Do not enter copayment as a prior payment on the Medicaid claim. The copayment will be deducted automatically when the claim is processed.
 

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


Attention: All Providers

Health Insurance Portability and Accountability Act Compliance Survey

The N.C. Medicaid program plans to offer seminars focusing on how the implementation of the Health Insurance Portability and Accountability Act (HIPAA) will specifically impact electronic Medicaid claims processing. (Upcoming general Medicaid bulletins will list the dates and site locations for the HIPAA seminars along with the registration form.) Provider participation in the following Health Insurance Portability and Accountability Act Compliance Survey will assist the N.C. Medicaid program in the development of the HIPAA seminars.

Additional information regarding HIPAA can be found on the Division of Medical Assistance’s website.
 

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


Attention: Physicians and Nurse Practitioners

Apligraf HCPCS Code Change

Apligraf is indicated for the treatment of noninfected partial and full-thickness skin ulcers due to venous insufficiency or neuropathic diabetic foot ulcers. The HCPCS code that is currently used to bill apligraf, Q0185, has been deleted as of 2002. The new HCPCS code is J7340. Reimbursement will be per unit. One unit equals one square centimeter. Bill the appropriate code according to the dates of service listed below:
 
Date of Service Code Description
November 1, 2000 through March 31, 2002 Q0185  Dermal and epidermal tissue, of human origin, with or without bioengineered or processed elements, with metabolically active elements, per square centimeter 
April 1, 2002 and after  J7340  Dermal and epidermal tissue, of human origin, with or without bioengineered or processed elements, with metabolically active elements, per square centimeter 

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


Attention: Area Mental Health Center and Residential Treatment Facility Providers for Levels II through IV

Completion of the Residential Authorization Form

Effective May 1, 2002, Area Mental Health Centers must use only the most recent version (12/21/01) of the Residential Authorization Form (RAF). A copy of the form can be obtained on the Division of Medical Assistance’s website. Information submitted for admission or changes during the initial 120-day period for Levels II and III or the initial 30-day period for Level IV will not be accepted if providers use the older version of the RAF.

It is the responsibility of the Area Mental Health Center to submit the completed RAF to ValueOptions and EDS. The Area Mental Health Center may submit the completed RAF to ValueOptions either by fax at 919-941-0433 or by e-mail at ncmedicaid@valueoptions.com. A copy must also be submitted to EDS by fax at 919-233-6834.

Residential Treatment Facility providers for Levels II through IV are encouraged to obtain a copy of the RAF for their records for each and every child admitted to their facilities through the Area Mental Health Center, and to verify that the dates of admission and other information are accurate. Medicaid reimbursement will not occur until the RAF has been received and processed. In order to ensure that the RAF is received, the Residential Treatment Facility providers for Levels II through IV may also submit a copy of the RAF to ValueOptions and EDS.
 

Reba Hamm, Behavioral Health Services
DMA, 919-857-4020


Attention: Psychiatric Residential Treatment Facility Providers

Denials Relative to Patient Monthly Liability

Psychiatric treatment in a Psychiatric Residential Treatment Facility (PRTF) is considered an inpatient service for Medicaid recipients. Because of this status, a monthly patient liability (PML) must be determined for recipients beginning the first of the month following the thirtieth (30th) day from the date of admission. The PRTF is responsible for informing the county department of social services (DSS) of the recipient's admission.

Effective April 1, 2002, when a child is admitted to a PRTF bed, the DSS in the child's county of eligibility must be notified of the admission so the PML can be determined. The DSS will issue a Notification of Eligibility for Medicaid/Amount and Effective Date of Patient’s Liability form (DMA-5016), which indicates the amount of PML to be entered on the claim. Continue to bill on the UB-92 claim form using Bill Type 891 in form locator 4 and Revenue Code 911 in form locator 42. The PML must be entered in form locator 39 with a Value Code of 23. Failure to enter the code and a PML amount (even if the amount is $0.00) will result in denial of the claim.
 

Carolyn Wiser, Behavioral Health Services
DMA, 919-857-4025


Attention: All Providers

Carolina ACCESS Override Requests

Effective April 1, 2002, the procedure to request a Carolina ACCESS (CA) override for past dates of service has changed. When services have been rendered to a CA recipient without first obtaining a CA authorization number from the primary care provider (PCP), written request must be made using the attached Carolina ACCESS Override Request Form. EDS will respond to your written request by fax or phone.

The procedure to request an override before a service is rendered has not changed. Please continue to call the EDS Managed Care Unit at 1-800-688-6696 or 919-816-4321. Providers rendering medical care to a CA enrollee must contact the PCP for authorization. Providers must verify the PCP by viewing the recipient’s current Medicaid identification card or calling the Automated Voice Response (AVR) system at 1-800-723-4337. Overrides (verbal or written) will not be considered unless the PCP has been contacted and refused to authorize treatment.

PCPs are contractually required to provide services or authorize another provider to provide services until the county department of social services changes the CA status of a recipient. EDS is authorized to issue CA overrides only when extenuating circumstances beyond the control of the responsible parties affect access to medical care and the PCP refused to authorize treatment.
 

Laurie Giles, Managed Care Section
DMA, 919-857-4022



 
 

Checkwrite Schedule

April 9, 2002  May 7, 2002  June 11, 2002 
April 16, 2002  May 14, 2002  June 18, 2002 
April 25, 2002  May 21, 2002  June 27, 2002 
May 30, 2002 

Electronic Cut-Off Schedule

April 5, 2002  May 3, 2002  June 7, 2002 
April 12, 2002  May 10, 2002  June 14, 2002 
April 19, 2002  May 17, 2002  June 21, 2002 
May 24, 2002 

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



 
______________________ _______________________
Nina M. Yeager, Director Ricky Pope
Division of Medical Assitance Executive Director
Department of Health and Human Services  EDS

 
 
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