NC DMA: Annual Visit Limit

Division of Medical Assistance
Providing access to high quality, medically necessary health care for eligible North Carolina residents through cost effective purchasing of health care services and products.

Annual Visit Limit

On August 1, 2008, DMA implemented a new annual visit limitation for Medicaid recipients effective with dates of service July 1, 2007 and after. This change is the result of Session Law 2007-323.

The Code of Federal Regulations (CFR) defines the services that must be provided by each state Medicaid program. These services are mandatory services. Each state may decide which, if any, optional services, as defined by the CFR, will be covered. The optional services that are covered by the N.C. Medicaid Program include optometry, chiropractic services, and podiatry.

According to the Centers for Medicare and Medicaid Services (CMS), a visit limit may not combine both mandatory and optional services.

Mandatory Services

Annual Visit Limit Period	Number of Visits	Provider Types Included in Visit Count
July 1 through June 30	22	Physicians (except for physicians enrolled in N.C. Medicaid with a specialty of oncology, radiology, or nuclear medicine) Nurse practitioners Nurse midwives Health departments Rural health clinics Federally qualified health centers

Optional Services

Annual Visit Limit Period	Number of Visits	Provider Types Included in Visit Count
July 1 through June 30	8	Chiropractors Optometrists Podiatrists

CPT Procedure Codes Subject to the Annual Visit Count

DMA has designated specific CPT procedure codes that are counted towards the annual visit limitation. The codes will be reviewed on a regular basis and updated as appropriate.

CPT Procedure Codes Spreadsheet

ICD-9-CM Diagnosis Codes that Are Not Subject to the Annual Visit Limitation

DMA has designated specific ICD-9-CM diagnosis codes that do not count towards the annual visit limitation. The codes will be reviewed on a regular basis and updated as appropriate.

ICD-9-CM Diagnosis Code Spreadsheet

Microsoft Excel Format revised 10/1/08
Adobe Acrobat Format revised 10/1/08

Recipients Who Are Not Subject to the Annual Visit Limitation

The following recipients are exempt from the annual visit limitation.

Recipients under the age of 21
Recipients enrolled in a Community Alternatives Program (CAP)
Pregnant recipients who are receiving prenatal and pregnancy-related services

Requesting an Exemption

An exemption for the annual visit limitation may be requested by a physician if medically necessary treatment for a specific condition will require multiple office visits. The instructions and guidelines for this process are currently being developed. DMA will notify providers through the general Medicaid Bulletins when the process has been implemented.

Notification Process

In addition to the visit limit change, the law requires the N.C. Department of Health and Human Services (DHHS) to

establish a visit limitation threshold that indicates that a recipient is nearing the total allowed visits
implement a process of notification to the appropriate Community Care of North Carolina/Carolina ACCESS (CCNC/CA) network or primary care provider when a recipient reaches the visit limitation threshold

Effective August 1, 2008, DMA implemented a process to assist primary care providers in managing their patients' visits that count toward the annual visit limitations. The CCNC/CA network will be notified when a recipient has used 15 visits (in any combination) of the mandatory services listed above. CCNC/CA will then notify the recipient’s primary care provider.

Updated September 30, 2008