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Attention: Health Departments, Developmental Evaluation Centers, Federally Qualified Health Centers, and Rural Health Clinics

Use of Codes Y2351 and Y2041 Correction and Addition to June 2001 Bulletin Article

The following table replaces the table printed in the June 2001 general Medicaid bulletin.
 
 

V22.0	V22.1	V22.2	V23.0	V23.1	V23.2	V23.3	V23.4	V23.5
V23.7	V23.81	V23.82	V23.83	V23.84	V23.89	V23.9	V24.2

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

Attention: All Providers

Laboratory Codes and Modifiers 76 and 77

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

Attention: All Providers

Denials on Sterilization and Abortion Procedures

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

DMA and EDS Telephone Contact List

Attention: Carolina ACCESS Primary Care Providers

Referral Policy for Specialty Care

When referring CA enrollees for specialty care (except mental health referrals for children under the age of 21), the PCP defines the scope of the referral. This includes the number of visits being authorized and the diagnostic evaluation needed to effectively evaluate the patient. To facilitate continuity of care for CA enrollees, any further diagnosis, evaluation or treatment of the patient not identified in the original referral is the responsibility of the PCP.

PCP referrals for children under the age of 21 to Licensed Psychologists, Licensed Clinical Social Workers, Advanced Practice Psychiatric Clinical Nurse Specialists, and Advanced Practice Psychiatric Nurse Practitioners are valid for up to 26 visits per calendar year. It is not a requirement for the PCP to limit the referral to a certain number of visits. Mental health providers are educated to communicate at regular intervals with the referring provider in order to ensure continuity of care and appropriate treatment planning.

The PCP may make referrals or authorize payment of medical services at other medical sites for their CA enrollees who have not contacted them for the purpose of establishing a patient/provider relationship.

PCPs are required to schedule appointments for enrollees to make an initial visit and to be established as a patient. The appointment(s) must be available in a timely manner based on the standards outlined in the Carolina ACCESS provider application packet.

PCPs must document all patient referrals in the patient record. The Division of Medical Assistance (DMA) sends a monthly referral report to each PCP so they can check the validity and accuracy of the referrals. Any inappropriate referrals should be reported to the county managed care representative (MCR) for follow-up. The MCR coordinates with DMA managed care staff to research, investigate, and resolve any discrepancy between authorized referrals and the referral report.

NOTE: PCP referrals do not replace prior approval when required.

If you have any questions or comments, contact your county MCR.
 

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

Attention: Physicians

Radiopharmaceuticals Used in Myocardial Perfusion Imaging and Echocardiography

HCPCS code A9700 will be reimbursed only when used in echocardiography services within CPT code range 93303 through 93350. CPT code 78990, Provision of diagnostic radiopharmaceuticals, may not be billed with codes A9500, A9505, and A9700.

Providers must bill the appropriate HCPCS code on the HCFA-1500 claim form and attach an invoice for reimbursement. Bill the usual and customary charges.

Italicized material is excerpted from the American Medical Association 2001 Current Procedural Terminology. CPT codes, descriptions, and other data only are copyrighted 2000 American Medical Association. All rights reserved.
 

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

Attention: Physicians

Reduction Mammaplasty

The recipient must meet all of the following criteria:

1. The recipient must be 19 years of age or older.
2. The recipient must not be pregnant.
3. The recipient must not have delivered a child within the past 12 months.
4. The recipient's weight for body configuration must not be more than 25 percent over the ideal weight according to the Metropolitan Life Insurance tables.
5. Debilitating symptoms are solely due to the breast enlargement.

1. Symptomatic kyphosis and osteoarthritis of the cervical spine as documented on x-ray.
2. Documented scoliosis of the thoracic spine greater than 15 degrees.
3. A history of chronic back, shoulder or chest pain, which incapacitates her ability to perform any work or personal duties.
4. Chronic intertrigo with or without pigmentation changes, which is recurrent or is unresponsive to antibiotic and antifungal therapy.
5. An axillary inlet syndrome with numbness and tingling that is specifically related to the enlarged breasts.

1. Height (in inches), weight (in pounds), age, body frame size, and bra size.
2. The measurement (in centimeters) from the suprasternal notch to each nipple. (Ptosis is one consideration in determination of medical necessity.)
3. Unclothed preoperative photographs from chin to waist (or lowest extent of breasts, if lower) including standing frontal and side views with arms straight down at the sides.
4. Documentation of debilitating symptoms. For example, certification of inability to perform activities of daily living, interference with employment or employability or inability to perform household tasks (including documentation of compensatory arrangements when unable to perform such tasks).
5. Evidence of exclusion of other medical problems that may cause or contribute to head, neck, shoulder or back pain (emotional/psychological, endocrinological, neurological or musculoskeletal).
6. Medical documentation, such as progress notes, of prior conservative management including physical therapy, medications, weight reduction, etc.
7. Evidence or certification of objective signs of medical necessity (e.g., kyphosis, lordosis, scoliosis, arthritis, intertrigo, axillary inlet syndrome, etc.).
8. A list and chronology of subjective symptoms.
9. A certification statement on the prior approval form by the requesting surgeon that the recipient has been informed that breast reduction may interfere with breast feeding in the future, destroy or impair sexual sensitivity of the breasts and nipples, and may cause other surgical complications such as necrosis of the nipple, hypertrophic scarring, and hematoma.
10. A certification statement on the prior approval form by the requesting surgeon of the intent to remove at least 500 grams of tissue from each breast. Pathology reports, including the weight in grams removed from each breast, may be requested in support of claims at the option of the reviewer.

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

Attention: Local Education Agencies, Head Start Programs, and the Independent Practitioners Program

Change to Procedures for Health-Related Therapy Services Provided to Children Ages Birth through 20

If more than one speech/language therapy service (Y2404 and Y2411 through Y2413) is provided to a recipient on the same day of service (DOS), the claim will deny.

Therapy services provided by LEAs, Head Start, and IP programs can only be provided to children ages birth through 20. Claims submitted for services, including psychological assessment (code Y2409) and psychological treatment services (code Y2410) will deny if the recipient is over 20 years of age. Note: IP programs cannot bill for psychological assessment (code Y2409) and psychological treatment (code Y2410) services.
 

Jency Abrams, RN, BSN, MS, Medical Policy Section
DMA, 919-857-4020

Attention: Physicians

Apligraf Coverage Criteria

Coverage Criteria

The Division of Medical Assistance (DMA) follows the same criteria as Medicare on indications for the use of Apligraf. Reimbursement may be made when all of the following conditions are met and documented in the recipient's health record:

Venous stasis ulcers

• Ulcers of more than three months duration.
• Ulcers that have failed to respond to documented conservative measures used for more than two months duration (failed to decrease the ulcer by 50 percent).
• Partial or full-thickness ulcers.
• Measurement must be made of the initial ulcer size, the ulcer size following cessation of conservative management, and the size at the beginning of skin substitute treatment.

• Ulcers of more than four weeks duration.
• Ulcers that have failed to respond to documented conservative measures used for greater than one-month duration (failed to decrease the ulcer by 50 percent).
• Partial or full-thickness ulcers.
• Measurement must be made of the initial ulcer size, the ulcer size following cessation of conservative management, and the size at the beginning of skin substitute treatment.
• Appropriate steps to off-load pressure during treatment must be taken.

Limitations

Coverage is limited to three separate applications to any given ulcer.
 

Venous Stasis Ulcers	Neuropathic Diabetic Foot Ulcers
No fewer than six weeks between applications.	No fewer than three weeks between applications.
Two applications of skin substitute are indicated. A third application of skin substitute will be considered for coverage if a 50 percent or greater improvement is noted and documented. Documentation must be submitted.	Reapplication of the skin substitute is not recommended after three applications when satisfactory healing progress is not noted (i.e., a 50 percent or greater improvement). Other treatment modalities should be considered.
Retreatment within one year of the date of initial treatment is not covered.

ICD-9-CM Codes

The following ICD-9-CM diagnosis codes must be used to support medical necessity:
 

Code	Description
250.80 - 250.83	Diabetes, with other specified manifestations. (Use additional code to identify manifestation 707.10 -707.19.)
454.0	Varicose veins of lower extremities, with ulcer.
454.2	Varicose veins of lower extremities, with ulcer and inflammation.
707.10 - 707.19	Ulcer of lower limb, except decubitus. (ICD-9-CM codes 250.80 - 250.83 must also be reported with these codes.)

The use of Apligraf is not covered for the following diagnoses and conditions:

• infected ulcer
• osteomyelitis
• allergy to bovine collagen
• arterial disease with an ankle brachial index (ABI) of less than 6.5 in the case of venous stasis ulcers and a lack of pedal pulses in the case of neuropathic diabetic foot ulcers
• uncontrolled diabetes (for purposes of this policy "controlled" diabetes is based on documentation in the medical record)
• active Charot's arthropathy of the ulcer extremity
• vasculitis
• uncontrolled rheumatoid arthritis and or rheumatoid ulcers
• other uncontrolled collagen vascular disease
• patients under treatment with high-dose corticosteroids or immunosuppressants
• patients who have undergone radiation and/or chemotherapy within the month immediately preceding proposed skin substitute treatment

The medical record must show that the listed criteria have been met. The ulcer must be measured at the beginning of conservative treatment, following cessation of conservative treatment, and at the beginning of the skin substitute treatment. The record must document that wound treatment by this method is accompanied by appropriate wound dressing during the healing period, by appropriate compressive dressings during follow-up, and, for neuropathic diabetic foot ulcers, appropriate steps to off-load wound pressure during follow-up.

Billing

HCPCS code Q0185, dermal and epidermal tissue, of human origin, with or without bioengineered or processed elements, with metabolically active elements, per square centimeter, must be used when billing this material.

Use the following codes to bill the application of Apligraf and preparation of the site.
 

Date of Service	Code	Description
November 1, 2000 through December 31, 2000	G0170  G0171	application of tissue cultured skin graft, initial 25 sq cm  application of tissue cultured skin graft, each additional 25 sq cm
January 1, 2001 or after	15000      15342    15343	surgical preparation or creation of recipient site by excision of  open wounds, burn eschar, or scar; first 100 sq cm or one percentof body area of infants and children  application of bilaminate skin substitute/neodermis; initial 25 sq cm  application of bilaminate skin substitute/neodermis; each additional 25 sq cm

Italicized material is excerpted from the American Medical Association 2001 Current Procedural Terminology. CPT codes, descriptions, and other data only are copyrighted 2000 American Medical Association. All rights reserved.
 

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

Attention: All Providers

Automated Voice Response System Reminder

Please refer to the July 2001 Special Bulletin II, Automated Voice Response System Provider Inquiry Instructions for additional information regarding the AVR system.
 

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

Attention: Physicians, Nurse Practitioners, and Psychologists

After Hours, Weekend Visits, and On-Call Services

CPT procedure codes 99050 through 99058 are for services provided outside normal office hours. Only one of the procedure codes listed below is allowed in addition to the Evaluation and Management (E/M) level of care code billed.

• 99050 - After office hours in addition to basic service
• 99052 - Between 10:00 p.m. and 8:00 a.m. in addition to basic service
• 99054 - Sundays and holidays in addition to basic service
• 99058 - Office services provided on an emergency basis

EDS, 1-800-688-6696 or 919-851-8888
 

EDS Mailing Addresses

Correspondence mailed to EDS by certified mail, UPS, or Federal Express should be sent to:

EDS
4905 Waters Edge Drive
Raleigh, NC 27606

Attention: Providers of Community Alternatives Program for Disabled Adults

Seminars for the Community Alternatives Program for Disabled Adults

Return CAP/DA 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 Seminar Schedule

Due to limited seating, preregistration is required and limited to two staff members per office. Unregistered providers are welcome to attend when reserved space is adequate to accommodate. Please select the most convenient site and return the completed registration form to EDS as soon as possible. Seminars begin at 10:00 a.m. and end at 1:00 p.m. Providers are encouraged to arrive by 9:45 a.m. to complete registration.

Return the Basic Medicaid Seminar Registration form to:

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

Directions to the sites
 

Tuesday, September 11, 2001 Coast Line Convention Center  501 Nutt Street  Wilmington, NC	Thursday, September 13, 2001 Catawba Valley Technical College  Highway 64-70  Hickory, NC
Wednesday, September 19, 2001 Blue Ridge Community College  College Drive  Flat Rock, NC	Wednesday, September 26, 2001 Wake Med  Andrews Conference Center  3000 New Bern Avenue  Raleigh, NC

Directions to the Basic Medicaid Seminars

WILMINGTON, NORTH CAROLINA

COAST LINE CONVENTION CENTER
Take I-40 east to Wilmington. Take the Highway 17 exit. Turn left onto Market Street. Travel approximately 4 or 5 miles to Water Street. Turn right onto Water Street. The Coast Line Inn is located one block from the Hilton on Nutt Street behind the Railroad Museum.   

HICKORY, NORTH CAROLINA

CATAWBA VALLEY TECHNICAL COLLEGE
Take I-40 to exit 125. Travel approximately ½ mile to Highway 70. Travel east on Highway 70. The college is approximately 1½ miles on the right. Ample parking is available. The entrance to the Auditorium is between Student Services and the Maintenance Center. Follow sidewalk (toward satellite dish) and turn right to Auditorium entrance.

 
  FLAT ROCK, NORTH CAROLINA

BLUE RIDGE COMMUNITY COLLEGE
Take I-40 to Asheville. Travel east on I-26 to exit 22. Turn right and then take the next right. Follow the signs to Blue Ridge Community College. Turn left at the large Blue Ridge Community College sign. The college is located on the right. Pass the college's main entrance and turn right into the college entrance past the pond. The parking lot is on the left. The Auditorium entrance is located to the right of the Patton Building main entrance.
 
  RALEIGH, NORTH CAROLINA

WAKE MED ANDREWS CONFERENCE CENTER
Driving and Parking Directions
Take the I-440 Raleigh Beltline to New Bern Avenue, exit 13A (New Bern Avenue, Downtown). Travel toward Wake Med. Turn left onto Sunnybrook Road.

Parking is available at the former CCB Bank parking lot, a short walk to the conference facility. The entrance to the Conference Center is at the top of the stairs to Wake Med's Andrews Conference Center.

Parking is also available on the top two levels of Parking Deck P3. To reach this deck, exit the I-440 Beltline, exit 13A. Proceed to the Emergency entrance of the hospital (on the left). Follow the access road up the hill to the gate for Parking Deck P3. After parking in P3, walk down the hill past the Medical Office Building and past the side of the Andrews Conference Center. Turn right at the front entrance of the building and follow the sidewalk to the Conference Center entrance.

Illegally parked vehicles will be towed. Parking is not permitted at East Square Medical Plaza, Wake County Human Services, the P4 parking lot or in front of the Conference Center.
 

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

Checkwrite Schedule

August 7, 2001	September 5, 2001	October 9, 2001
August 14, 2001	September 11, 2001	October 16, 2001
August 23, 2001	September 18, 2001	October 25, 2001
	September 27, 2001

Electronic Cut-Off Schedule

August 3, 2001	September 7, 2001	October 5, 2001
August 10, 2001	September 14, 2001	October 12, 2001
August 17, 2001	September 21, 2001	October 19, 2001
August 31, 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		Ricky Pope
Division of Medical Assitance		Executive Director
Department of Health and Human Services		EDS

 

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