N.C. DMA: October 2001 Medicaid Bulletin

Effective October 1, 2001, The Wellness Plan of North Carolina, Inc. is no longer serving as a Health Maintenance Organization (HMO) to Medicaid recipients in Mecklenburg County.

Southcare/Coventry Health Care of the Carolinas, Inc. and United HealthCare of North Carolina, Inc. will remain as HMO providers in this county. Additionally, Metrolina (formerly C.W. Williams), a Federally Qualified Health Center (FQHC), will remain as another Medicaid option in Mecklenburg County.

Julia McCollum, Managed Care Section
DMA, 919-857-4022

Attention: All Providers

Changes to Copayment for Brand Name Medicines

Effective October 1, 2001, there is a change for Medicaid recipients required to pay copayments for prescriptions. The copayment for brand name drugs is now $3.00. Copayment for generic drugs remains at $1.00.

Denise Rogers, Recipient and Provider Services
DMA, 919-857-4019

Attention: Emergency Department Physicians

After-Hours, Weekend Visits, and On-Call Services

The N.C. Medicaid program does not allow separate reimbursement for CPT procedure codes 99050, 99052, 99054, and 99058 for services provided in an emergency department. Medicaid defines normal hours as those hours when the emergency department is routinely open. Emergency rooms are open and services are available to recipients 24 hours a day, 7 days a week. The following CPT procedure codes must not be billed:

99050 Services requested after office hours in addition to basic service
99052 Services requested between 10:00 p.m. and 8:00 a.m. in addition to basic services
99054 Services requested on 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

Attention: Anesthesiologists, Certified Registered Nurse Anesthetists, Hospitals

Separate Billing for Supervision of Certified Registered Nurse Anesthesiologists

The N.C. Medicaid program does not reimburse supervision of Certified Registered Nurse Anesthetists (CRNA) as a separate service. This policy applies to all CRNAs whether they are enrolled as:

independent providers, or
employed by a hospital, or
employed through a physician's office.

When a CRNA is employed by an anesthesiologist, the CRNA services are incident to the physician and should be billed under the physician provider number. No supervisory fee can be billed. When a CRNA is employed by the hospital, the CRNA services should be billed on the HCFA-1500 claim form using the hospital's professional number. No supervisory fee can be billed. There is also no supervisory fee should a physician supervise a CRNA by phone after normal business hours.

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

Attention: Physicians and Other Practitioners

Medicaid Fee Schedule

Effective with date of service September 1, 2001, the North Carolina Medicaid Fee Schedule shall be based on ninety-five percent (95%) of the Medicare Fee Schedule Resource Based Relative Value System (RBRVS) in effect on the date of service.

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

Attention: All Providers

Fee Schedules and Reimbursement Plans

Fee Schedule Request Form

There is no charge for fee schedules or reimbursement plans requested from the Division of Medical Assistance (DMA). However, all requests for publications must be made on the Fee Schedule Request formand mailed to:

Division of Medical Assistance
Financial Operations - Fee Schedules
2509 Mail Service Center
Raleigh, NC 27699-2509

Or, fax your request to DMA's Financial Operations section at 919-715-0896.

NOTE: PHONE REQUESTS ARE NOT ACCEPTED

Request for Diskettes

Some fee schedules, the after-care surgery schedule, and the anesthesia base units schedule are also available on diskette or by e-mail. NOTE: To reduce costs, where available, schedules will be sent by e-mail.

DMA stipulates that the information provided is to be used only for internal analysis. Providers are expected to bill their usual and customary rate.

Please complete the information below with each request:

Mail the request to:   Division of Medical Assistance
                                 Financial Operations - Fee Schedules
                                 2509 Mail Service Center
                                 Raleigh, NC 27699-2509

Or, fax your request to DMA's Financial Operations section at 919-715-0896.

Attention: All Providers

Circumcision Policy for Newborns

Effective with date of service November 1, 2001, the N.C. Medicaid program will no longer cover routine newborn circumcisions. Medically necessary circumcisions will continue to be covered for all male recipients.

The American Academy of Pediatrics (AAP) policy on circumcision states that the benefits are not significant enough for the AAP to recommend circumcision as a routine procedure.

Physicians who perform routine circumcisions must follow the guidelines set forth in the North Carolina Administrative Code at 10 NCAC 26K.0106 concerning billing recipients for this noncovered service. Medicaid must not be billed for noncovered services.

Hospital claims must list all expenses related to routine newborn circumcisions as noncovered services and must not bill the family.

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

Attention: All Providers

Billing Nerve Conduction Studies

The N.C. Medicaid program reimburses for nerve conduction studies when they are medically necessary. Current procedural terminology codes 95900, 95903, and 95904 refer to testing performed using standard electro-diagnostic equipment. These devices must be capable of recording amplitude, duration, and response configuration as well as latency and sensory nerve action potential amplitude. Reimbursement for examinations using portable hand-held devices is included in the office visit and cannot be billed separately.

Procedure codes 95900 and 95903 cannot be billed for testing of the same nerve on the same day. Procedure code 95903 with F-wave study includes the services of a test without F-wave study. When one nerve is tested without F-wave study and a different nerve is tested with an F-wave study, bill both 95900 and 95903.

One unit of service represents all studies performed on a single nerve, including latency, velocity, amplitude, and response with antidromic or othodromic stimulation. The medical record must clearly document the medical necessity and identify each type of test performed.

The clinical efficacy and applicability of Current Perception Threshold testing in diagnosing or managing a disease has not been established. Therefore, Current Perception Threshold testing is not covered by Medicaid and will not be reimbursed.

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

Attention: All Providers

Response Time for Provider Inquiries

Due to budget constraints for the July 2001/2002 fiscal year, the Division of Medical Assistance (DMA) is experiencing a shortage in staff. As a result, providers may experience delays when contacting DMA with issues that require a response. DMA appreciates your patience and understanding during this temporary inconvenience.

To ensure that issues are handled effectively when calling Medicaid, refer to the following list for the contact source and telephone number related to your question.

DMA and EDS Telephone Contact List

The Automated Voice Response (AVR) system (1-800-723-4337) can be used to inquire about:

Recipient Eligibility Hospice Participation Hysterectomy Statement Status

Managed Care Enrollment Drug Coverage Information Sterilization Consent Status

Prior Approval Information Dental Benefit Limitations Claim Status

Procedure Code Pricing Refraction Benefit Limitations Checkwrite Information

Modifier Information

The Automated Attendant telephone line (1-800-688-6696 or 919-851-8888) can be used to access the EDS Provider Services unit, Prior Approval unit or the Electronic Commerce Services (ECS) unit.

Automated Attendant Telephone Instructions

To ensure that correspondence and documents are processed in a timely manner, refer to the following list of mailing addresses for the Medicaid program.

DMA and EDS Address List

Jane S. Johnson, Claims Analysis Unit
DMA, 919-857-4018

Attention: All Prescribers

Synagis Coverage

Synagis is reimbursable through the pharmacy program and not the physician's program. It has been approved for prevention of RSV disease in children less than 24 months of age with bronchopulmonary dysplasia (BPD) or with a history of premature birth. The drug is administered once per month during the RSV season, which has been identified as being from October 2001 - March 2002 in our state.

Below is a list of guidelines that are approved by the American Academy of Pediatrics, which must be adhered to for drug coverage to be obtained.

Synagis prophylaxis should be considered for infants and children younger than two years with BPD that are currently receiving or have received oxygen therapy within the six months prior to the anticipated RSV season.

Infants with a gestational age of 28 weeks or less may benefit from prophylaxis until 12 months of age.

Infants with a gestational age of 29 to 32 weeks may benefit from prophylaxis until 6 months of age.

Infants with a gestational age of 32 to 35 weeks may benefit from prophylaxis until 6 months of age if they are also predisposed to at least two to of the following risk factors: A number of young siblings, exposure to tobacco smoke in the home, child care center attendance, multiple births.

Synagis has not been approved by the Food and Drug Administration (FDA) for patients with congenital heart disease and therefore, will not be covered by the Medicaid program for this condition alone, since Medicaid can only cover FDA approved indications.

The physician is required to write in his own handwriting on the face of the prescription the weight and date of birth of the child. (Pharmacist will not be allowed to fill the prescription without this documentation.)

Not every child under two years of age needs to be placed on Synagis. Only those at high risk or those who already have complicated respiratory problems should be considered. Decisions regarding each patient should be individualized.

Synagis will be reimbursable from October 1, 2001 to March 31, 2002 unless it is determined that the season has changed for our state. If it is determined, upon audit of physicians and pharmacist records, that the drug is being used outside the guidelines, the Medicaid program will consider a strict prior approval on all coverage of this drug.

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

Attention: Nursing Facility Providers

Change in Assigning Retroactive Prior Approval Level of Care on the FL2 Form

Effective with date of service October 1, 2001, the Division of Medical Assistance will implement a new prior approval procedure to allow the EDS Prior Approval Unit to assign more than one level of care on an individual FL2 form.

When EDS receives an FL2 retroactive level of care request with medical records, the record documentation may indicate more than one level of care for the retroactive request period. If more than one level of care is approved, EDS staff will document both the time-limited level of care and the most current level of care on the FL2 form. Once completed, EDS will forward the approved FL2 to the appropriate county department of social services (DSS). The county DSS will then forward a copy of the approved FL2 form to the appropriate nursing facility.

Example of FL2 form

For example, on March 10, 2001, EDS receives medical records with an FL2 requesting approval for skilled level of care for Jimmy Doe beginning January 1, 2001. EDS determines that the medical record supports the criteria for skilled level of care beginning January 1, 2001 to February 12, 2001. The medical record documentation supports the intermediate level of care beginning February 13, 2001. EDS documents the following on the FL2:

Upper Right-Hand Corner:

Service Review Number (SRN) - 2001001112345
January 1 to February 12, 2001 - the time-limited skilled level of care
MI - mail in request
LH - initials of the nurse reviewer

Block 12:

SRN - 2001044102055

Block 13:

Approved - circled
2/13/01 - beginning approval date
IC - intermediate level of care
MI - mail in as the type of review
LH - initials of the EDS nurse reviewer

Reminder: For the retroactive prior approval policy, refer to the January 2001 general Medicaid bulletin.

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

Attention: All Providers

Cytogenetic Studies

Recently, the Division of Medical Assistance implemented diagnosis editing on CPT codes 88230 through 88239 and 88245 through 88291. For the diagnosis and treatment of the following conditions, one of the diagnoses listed must be on the claim in order for the claim to process:

Antepartum Condition or Complication
659.43
659.53
659.63

Genetic Disorders in a Fetus
758.0 through 758.9
655.11 through 655.13
655.21 through 655.24

Failure of Sexual Development
259.0

Chronic Myelogenous Leukemia
205.10 through 205.11
205.80 through 205.81

Acute Leukemia Lymphoid, Myeloid, and Unclassified
204.00 through 204.01
204.90 through 204.91
205.00 through 205.01
208.00 through 208.01

Myelodysplasia
238.7

Although medical records will not be required, documentation supporting the diagnosis billed must be maintained for a period of not less than five years.

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

Attention: All Providers

Reporting Changes in Provider Status to Medicaid

Providers, including Managed Care providers (Carolina ACCESS, ACCESS II, ACCESS III, and HMO Risk Contracting), are required to report all changes in status to the N.C. Medicaid program. This includes changes of address, ownership, name, tax identification number, and addition or deletion of group members. Because failure to provide timely notice may prevent or delay payments to the provider, all changes should be sent to the Medicaid program within 30 calendar days.

The procedure for reporting changes to the Medicaid program is determined by the provider type. Physicians report changes to Medicaid through Blue Cross and Blue Shield of North Carolina. Other providers report changes to the Division of Medical Assistance (DMA) using the Notification of Change in Provider Status form. Managed Care providers must also report changes within their practice to DMA's Managed Care Section.

Revisions have been made to the Notification of Change in Provider Status form. Providers are now required to submit a copy of their W9 for changes of ownership, name, and tax identification number.

The Notification of Change in Provider Status form, the Carolina ACCESS Provider Information Change form, and the W9 form are available from the DMA website.

Darlene Cagle, Provider Services Unit
DMA, 919-857-4017

Attention: Physician and Physician Extenders Providing the Oral Screening Preventive Package under Codes W8002 and W8003

Oral Screening Preventive Package Update

A reminder to offices providing the oral screening preventive package: Medicaid will reimburse for a total of six oral screening preventive package visits per patient, from the time of tooth eruption UNTIL the third birthday. Services provided on or after the third birthday will NOT be reimbursed. These services can be provided at well child checkups, during a sick visit or at a separately scheduled visit.

Example of Oral Screening Preventive Package Visits:

Well Child Visit (months) Procedure Performed?

Six Yes (if teeth are erupted)

Nine Yes (if teeth are erupted)

Twelve Yes

Eighteen Yes

Twenty-four Yes

Before thirty-six Yes

Well Child Visit (months)	Procedure Performed?
Six	Yes (if teeth are erupted)
Nine	Yes (if teeth are erupted)
Twelve	Yes
Eighteen	Yes
Twenty-four	Yes
Before thirty-six	Yes

Begin providing the services as soon as the first teeth erupt. If services are provided at the six- or nine-month well child checkup, you must wait at least three months before providing the services again. Ideally, the procedure should be performed every 4 to 6 months, but flexibility is allowed to get patients on schedule.

Complete information regarding the Oral Screening Preventive Package was printed in the January 2001 general Medicaid bulletin. For training information call Kelly Haupt, Project Coordinator at 919-833-2466.

Kelly Haupt, Project Coordinator
919-833-2466

Checkwrite Schedule

October 9, 2001

November 6, 2001

December 11, 2001

October 16, 2001

November 14, 2001

December 18, 2001

October 25, 2001

November 20, 2001

December 28, 2001

November 29, 2001

Electronic Cut-Off Schedule

October 5, 2001

November 2, 2001

December 7, 2001

October 12, 2001

November 9, 2001

December 14, 2001

October 19, 2001

November 16, 2001

December 21, 2001

November 21, 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.

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

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Recipient Eligibility	Hospice Participation	Hysterectomy Statement Status
Managed Care Enrollment	Drug Coverage Information	Sterilization Consent Status
Prior Approval Information	Dental Benefit Limitations	Claim Status
Procedure Code Pricing	Refraction Benefit Limitations	Checkwrite Information
Modifier Information

October 9, 2001	November 6, 2001	December 11, 2001
October 16, 2001	November 14, 2001	December 18, 2001
October 25, 2001	November 20, 2001	December 28, 2001
	November 29, 2001

October 5, 2001	November 2, 2001	December 7, 2001
October 12, 2001	November 9, 2001	December 14, 2001
October 19, 2001	November 16, 2001	December 21, 2001
	November 21, 2001