In This Issue . . .

All Providers:

• Corrected 1099 Requests
• CPT Code Update 2004
• EOB Code Crosswalk to HIPAA Standard Codes
• FluMist Influenza Vaccine (CPT Code 90660) – Billing Guidelines
• ICD-9-CM Code Changes for 2004
• Influenza – New Diagnosis Code V04.81
• Inpatient Hospital Claims
• Medical Coverage Policies
• W-9 Form
• Checkwrite Schedule
• Electronic Cut-off Schedule
• Holiday Observance
• Proposed Medical Coverage Policies

Ambulatory Surgical Centers:

• CPT Code Update 2004 for Ambulatory Surgical Centers

Area Mental Health Centers:

• End-Dated HCPCS Code for Behavioral Health
• Risperidone (Risperdal Consta, J3490) – Billing Guidelines

Children’s Development Service Agencies:

• Conversion to National Codes

Community Alternatives Program for Children:

• HCPCS Code Change for Pediatric Enteral Formulae

Dental Providers:

• Conversion from CPT to CDT-4 Codes for Dental Services

Developmental Evaluation Centers:

• Conversion to National Codes

Durable Medical Equipment Providers:

• Conversion to National Miscellaneous Codes
• End-dated HCPCS Codes for Orthotics and Prosthetics
• HCPCS Code Changes for DME
• HCPCS Code Changes for Orthotics and Prosthetics
• HCPCS Code Deletions for DME
• Place of Service for DME

Federally Qualified Health Centers:

• Arsenic Trioxide, 1mg (Trisenox, J9017) – Billing Guidelines
• Omalizumab (Xolair, J3490) – Billing Guidelines
• Palonosetron 0.25 mg (Aloxi, J3490) – Billing Guidelines
• Risperidone (Risperdal Consta, J3490) – Billing Guidelines

Health Departments:

• Arsenic Trioxide, 1mg (Trisenox, J9017) – Billing Guidelines
• Breast and Cervical Cancer Medicaid Procedures
• Omalizumab (Xolair, J3490) – Billing Guidelines
• Palonosetron 0.25 mg (Aloxi, J3490) – Billing Guidelines
• Risperidone (Risperdal Consta, J3490) – Billing Guidelines

Home Infusion Therapy Providers:

• End-Dated Codes for Low Profile Gastrostomy Kits
• HCPCS Code Change for Pediatric Enteral Formulae

Nurse Practitioners:

• Arsenic Trioxide, 1mg (Trisenox, J9017) – Billing Guidelines
• Omalizumab (Xolair, J3490) – Billing Guidelines
• Palonosetron 0.25 mg (Aloxi, J3490) – Billing Guidelines
• Risperidone (Risperdal Consta, J3490) – Billing Guidelines

Physicians:

• Arsenic Trioxide, 1mg (Trisenox, J9017) – Billing Guidelines
• Breast and Cervical Cancer Medicaid Procedures
• Omalizumab (Xolair, J3490) – Billing Guidelines
• Palonosetron 0.25 mg (Aloxi, J3490) – Billing Guidelines
• Risperidone (Risperdal Consta, J3490) – Billing Guidelines

Rural Health Clinics:

• Arsenic Trioxide, 1mg (Trisenox, J9017) – Billing Guidelines
• Omalizumab (Xolair, J3490) – Billing Guidelines
• Palonosetron 0.25 mg (Aloxi, J3490) – Billing Guidelines
• Risperidone (Risperdal Consta, J3490) – Billing Guidelines

Attention: All Providers

Corrected 1099 Requests – Action Required by March 1, 2004

Providers receiving Medicaid payments of more than $600 annually receive a 1099 MISC tax form from EDS. The 1099 MISC tax form is generated as required by IRS guidelines. It will be mailed to each provider no later than January 31, 2004. The 1099 MISC tax form will reflect the tax information on file with Medicaid as of the last Medicaid checkwrite cycle date, December 29, 2003.

If the tax name or tax identification number on the annual 1099 MISC you receive is incorrect, a correction to the 1099 MISC must be requested. This ensures that accurate tax information is on file with Medicaid and sent to the IRS annually. When the IRS receives incorrect information on your 1099 MISC, it may require backup withholding in the amount of 28 percent of future Medicaid payments. The IRS could require EDS to initiate and continue this withholding to obtain correct tax data.

A correction to the original 1099 MISC must be submitted to EDS by March 1, 2004 and must be accompanied by the following documentation:

• a copy of the original 1099 MISC
• a signed and completed IRS W-9 form clearly indicating the correct tax identification number and tax name. (Additional instructions for completing the W-9 form can be obtained at http://www.irs.gov under the link "Forms and Pubs.")

Fax both documents to 919-816-4399, Attention: Corrected 1099 Request - Financial

Or

Mail both documents to:

EDS
Attention: Corrected 1099 Request - Financial
4905 Waters Edge Drive
Raleigh, NC 27606

A copy of the corrected 1099 MISC will be mailed to you for your records. All corrected 1099 MISC requests will be reported to the IRS. In some cases, additional information may be required to ensure that the tax information on file with Medicaid is accurate. Providers will be notified by mail of any additional action that may be required to complete the correction to their tax information.

IRS W-9 form

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

Attention: All Providers

CPT Code Update 2004

New 2004 CPT codes are covered by N.C. Medicaid effective with date of service January 1, 2004. Claims with codes deleted for 2004 by the American Medical Association (AMA) will deny effective with dates of service on or after April 1, 2004.

The following table lists the new CPT codes that may be billed.

The following table lists the Medicaid covered CPT codes that will be end-dated effective March 31, 2004.

The following table lists the new 2004 CPT codes that are noncovered pending further review.

The following table lists the new 2004 CPT codes that are noncovered.

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

Attention: All Providers

EOB Code Crosswalk to HIPAA Standard Codes

With the implementation of standards for electronic transactions mandated by the Health Insurance Portability and Accountability Act, providers now have the option to receive an Electronic Remittance Advice (ERA) in addition to the paper version of the Remittance and Status Report (RA).

The EOB codes that providers currently receive on a paper RA are not used on the ERA. Because the EOB codes on the paper RA provide a greater level of detail on claim denials, all providers will continue to receive the paper version of the RA, even if they choose to receive the ERA transaction.

A list of standard national codes used on the ERA has been cross-walked to EOB codes as an informational aid to adjudicated claims listed on the RA. The list is available online at http://www.dhhs.state.nc.us/dma/prov.htm. The list is current as of the date of publication. Providers will be notified of changes to the list through the general Medicaid bulletin.

EOB Crosswalk to Standard Codes

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

Attention: All Providers

Influenza - New Diagnosis Code V04.81

Effective with date of service October 1, 2003, the N.C. Medicaid program covers the new diagnosis code for influenza, V04.81. Diagnosis code V04.8 is no longer a valid diagnosis code. Providers who have had claims denied with V04.81 may resubmit them for payment.

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

Attention: All Providers

FluMist Influenza Vaccine (CPT Code 90660) – Billing Guidelines

Effective with date of service December 15, 2003, the N.C. Medicaid program began coverage of the intranasal FluMist vaccine for healthy recipients ages 5 years through 49 years. These Medicaid recipients must be household contacts of Medicaid recipients who are at high risk for complications from influenza. Information regarding the risk categories pertinent to influenza according to the guidelines from the Advisory Committee on Immunization Practices (ACIP) can be accessed online at http://www.cdc.gov/nip/ACIP/default.htm. This policy will remain in effect through March 31, 2004.

Medicaid covers the FluMist vaccine only when dispensed by local health departments. FluMist should be administered according to the ACIP guidelines. Providers must use CPT code 90660, influenza virus vaccine, live, for intranasal use when billing for FluMist. The appropriate diagnosis code for the influenza vaccine is ICD-9-CM diagnosis code V04.81. An administration fee will not be reimbursed in addition to the cost of the vaccine.

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

Attention: All Providers

ICD-9-CM Code Changes for 2004

Effective October 1, 2003, the following list of ICD-9-CM diagnosis codes became invalid. A three-month grace period allowed providers to bill these codes until December 31, 2003. After December 31, 2003, claims submitted with the following codes will deny.

Most of these codes have been replaced with more diagnosis-specific five-digit codes. Providers must use current national codes from the 2004 ICD-9-CM manual when submitting claims to N.C. Medicaid.

Deborah Ireland, R.N.C., Medical Policy Section
DMA, 919-857-4020

Attention: All Providers

Inpatient Hospital Claims

In order to comply with regulations mandated by the Health Insurance Portability and Accountability Act (HIPAA) and with Medicaid regulations, effective February 1, 2004, ICD-9-CM procedure codes will only be accepted on claims submitted for inpatient hospital services. Other claim types (i.e., outpatient claims) must be billed using CPT procedure codes or HCPCS procedure codes. These other types of claims will deny if they are billed with ICD-9-CM procedure codes.

Deborah Ireland, R.N.C., Medical Policy Section
DMA, 919-857-4020

Attention: Ambulatory Surgery Centers

CPT Code Update 2004 for Ambulatory Surgical Centers

The following table lists the new CPT codes that may be billed by ambulatory surgical centers effective with date of service January 1, 2004.

The following table lists the Medicaid covered CPT codes that have been deleted for ambulatory surgical centers.

Claims submitted with codes deleted for 2004 by the American Medical Association (AMA) will deny effective with dates of service on or after April 1, 2004.

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

Attention: Area Mental Health Centers

End-Dated HCPCS Code for Behavioral Health

HCPCS procedure codes W9906, Clozaril lab and counseling, was end-dated effective with date of service December 1, 2003. This action was taken due to non-usage of the code.

Carol Robertson, Medical Policy Section
DMA, 919-857-4020

Attention: Area Mental Health Centers, Federally Qualified Health Centers, Health Departments, Nurse Practitioners, Physicians, and Rural Health Clinics

Risperidone (Risperdal Consta, J3490) – Billing Guidelines

Effective with date of service January 1, 2004, the N.C. Medicaid program covers injectable risperidone (Risperdal Consta) for use in the Physician’s Drug Program. The FDA states that risperidone, a benzisoxazole antipsychotic agent, is indicated for the treatment of schizophrenia. Risperdal Consta is available in dosage strengths of 25 mg, 37.5 mg, and 50 mg for intramuscular administration every two weeks. One of the ICD-9-CM diagnosis codes in the range 295.0 through 295.9 must be entered on the CMS-1500 claim form when billing for Risperdal Consta.

Providers must bill J3490, the unclassified drug code, with an invoice attached to the claim form. An invoice must be submitted with each claim. The paper invoice must indicate the name of the recipient, the recipient’s Medicaid identification (MID) number, the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, the number of vials used, and the cost per dose. Providers must indicate the number of units given in block 24G on the claim form. The maximum reimbursement rate is $249.84 for the 25 mg vial, $374.77 for the 37.5 mg vial, and $499.69 for the 50 mg vial. Providers must bill their usual and customary charge.

Add this drug to the lists of injectable drugs published in the June 2002 and August 2002 general Medicaid bulletins.

• Injectable Drug List Update, June 2002 Medicaid Bulletin
• Injectable Drugs, August 2002 Medicaid Bulletin
• Injectable Drugs in the Physician’s Drug Program – Code Conversion Update, August 2002 Medicaid Bulletin

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

Attention: Children’s Development Service Agencies and Developmental Evaluation Centers

Conversion to National Codes

Effective with date of service January 1, 2004, national HCPCS codes replaced state-created codes as indicated below. This change is being made to comply with the implementation of standard national codes mandated by the Health Insurance Portability and Accountability Act (HIPAA). Claims billed after January 1, 2004 using these state-created codes will deny.

Monica Teasley, Medical Policy Section
DMA, 919-857-4020

Attention: Durable Medical Equipment Providers

HCPCS Code Changes for Durable Medical Equipment

The following HCPCS codes were changed effective with date of service January 1, 2004. The DME Fee Schedule has been updated to reflect this change. The changes were made to comply with code changes from the Centers for Medicare and Medicaid Services (CMS).

Note: HCPCS codes with an asterisk require prior approval.

The coverage criteria for these items have not changed. Refer to Medical Coverage Policy #5, Durable Medical Equipment for detailed coverage information. A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval.

• DME Fee Schedule
• Medical Coverage Policy #5, Durable Medical Equipment

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

Attention: Durable Medical Equipment Providers

HCPCS Code Deletions for Durable Medical Equipment

Effective with dates of service January 1, 2004, the following codes were end-dated and deleted from the DME Fee Schedule. This action is being taken because the Centers for Medicare and Medicaid Services (CMS) has deleted these codes.

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

Attention: Durable Medical Equipment Providers

Place of Service for Durable Medical Equipment

Durable medical equipment (DME) providers are reminded that they may only bill for DME and related supplies when the recipient resides in a private residence or an adult care home. Therefore, DME providers may not bill N.C. Medicaid for DME or related supplies when the recipient resides in a skilled nursing facility or intermediate care facility. Remember that your designation of place of service "12" in block 24B on the CMS-1500 claim form indicates that you are have verified the recipient’s place of residence as his/her home or an adult care home.

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

Attention: Durable Medical Equipment Providers

HCPCS Code Changes for Orthotics and Prosthetics

The following HCPCS codes were changed effective with date of service January 1, 2004. The Orthotic and Prosthetic Fee Schedule has been updated to reflect this change. The changes were made to comply with code changes from the Centers for Medicare and Medicaid Services (CMS).

All of these codes require prior approval. The coverage criteria for these items have not changed. Refer to Medical Coverage Policy #5, Durable Medical Equipment for detailed coverage information. A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval.

• Orthotic and Prosthetic Fee Schedule
• Medical Coverage Policy #5, Durable Medical Equipment

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

Attention: Durable Medical Equipment Providers

End-Dated HCPCS Code for Orthotics and Prosthetics

Effective with date of service January 1, 2004, HCPCS code L2122, knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, plaster type casting material, custom-fabricated, was end-dated and deleted from the Orthotic and Prosthetic Fee Schedule. This action is being taken because the Centers for Medicare and Medicaid Services (CMS) has deleted this code.

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

Attention: Federally Qualified Health Centers, Health Departments, Nurse Practitioners, Physicians, and Rural Health Clinics

Arsenic Trioxide, 1 mg (Trisenox, J9017) – Billing Guidelines

Effective with date of service October 1, 2003, the N.C. Medicaid program covers injectable arsenic trioxide (Trisenox) for use in the Physician’s Drug Program when billed with HCPCS code J9017. The FDA states that arsenic trioxide, an antineoplastic agent, is indicated for induction of remission and consolidation in patients with acute promyelocytic leukemia (APL) who are refractory to, or have relapsed from, retinoid and anthracycline chemotherapy, and whose APL is characterized by the presence of the t (15; 17) translocation or PML/RAR-alpha gene expression. It is recommended that Trisenox be infused intravenously over a period of one to two hours.

The ICD-9-CM diagnosis codes required when billing for Trisenox are:

• V58.1 – Admission or encounter for chemotherapy;

AND EITHER

• 205.00 – Myeloid leukemia, acute; promyelocytic leukemia, acute: without mention of remission;

OR

• 205.01 – Myeloid leukemia, acute; promyelocytic leukemia, acute: in remission

For Medicaid billing, one unit of coverage is 1 mg. Providers must indicate the number of units given in block 24G on the CMS-1500 claim form. The maximum reimbursement rate per unit is $35.10. Providers must bill their usual and customary charge.

Add this drug to the lists of injectable drugs published in the June 2002 and August 2002 general Medicaid bulletins.

• Injectable Drug List Update, June 2002 Medicaid Bulletin
• Injectable Drugs, August 2002 Medicaid Bulletin
• Injectable Drugs in the Physician’s Drug Program – Code Conversion Update, August 2002 Medicaid Bulletin

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

Attention: Federally Qualified Health Centers, Health Departments, Nurse Practitioners, Physicians, and Rural Health Centers

Omalizumab (Xolair, J3490) – Billing Guidelines

Effective with date of service January 1, 2004, the N.C. Medicaid program covers injectable omalizumab (Xolair) for use in the Physician’s Drug Program. The FDA states that Xolair, an anti-asthmatic monoclonal antibody, is indicated for adults and adolescents (12 years of age and older) with moderate to severe persistent asthma who have a positive skin test or in vitro reactivity to a perennial aeroallergen and whose symptoms are inadequately controlled with inhaled corticosteroids. One of the following ICD-9-CM diagnosis codes must be entered on the CMS-1500 claim form when billing for Xolair:

• 493.00 – Unspecified extrinsic asthma
• 493.01 – Unspecified extrinsic asthma with status asthmaticus
• 493.02 – Unspecified extrinsic asthma with acute exacerbation

Providers must bill J3490, the unclassified drug code, with an invoice attached to the claim form. An invoice must be submitted with each claim. The paper invoice must indicate the name of the recipient, the recipient’s Medicaid identification (MID) number, the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, and the cost per dose. For Medicaid billing, one unit of coverage is the 150 mg vial for subcutaneous injection. Providers must indicate the number of units given in block 24G on the claim form. The maximum reimbursement rate is $487.13 for the 150 mg vial. Providers must bill their usual and customary charge.

Add this drug to the lists of injectable drugs published in the June 2002 and August 2002 general Medicaid bulletins.

• Injectable Drug List Update, June 2002 Medicaid Bulletin
• Injectable Drugs, August 2002 Medicaid Bulletin
• Injectable Drugs in the Physician’s Drug Program – Code Conversion Update, August 2002 Medicaid Bulletin

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

Attention: Home Infusion Therapy Providers

End-Dated Codes for Low Profile Gastrostomy Kits

Effective with date of service December 31, 2003, the following HCPCS procedure codes were end-dated and deleted from the Home Infusion Therapy Fee Schedule due to limited usage. These supplies are still available to Medicaid recipients through durable medical equipment (DME) providers. If you are currently providing these kits to clients, after January 1, 2004, please refer them to a DME supplier.

W4210 Low profile gastrostomy kit
W4211 Low profile gastrostomy extension replacement kit for continuous feeding
W4212 Low profile gastrostomy extension replacement kit for bolus feeding

Beth Karr, Medical Policy Section
DMA, 919-857-4021

Attention: Federally Qualified Health Centers, Health Departments, Nurse Practitioners, Physicians, and Rural Health Clinics

Palonosetron 0.25 mg (Aloxi, J3490) – Billing Guidelines

Effective with date of service January 1, 2004, the N.C. Medicaid program covers injectable palonosetron (Aloxi) for use in the Physician’s Drug Program. The FDA states that palonosetron, a selective 5-HT3 receptor antagonist and antiemetic, is indicated for the prevention of acute nausea and vomiting associated with initial and repeat courses of moderately and highly emetogenic cancer chemotherapy. It is also indicated for the prevention of delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy. It is given intravenously.

Providers must bill J3490, the unclassified drug code, with an invoice attached to the CMS-1500 claim form. An invoice must be submitted with each claim. The paper invoice must indicate the name of the recipient, the recipient’s Medicaid identification (MID) number, the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, the number of vials used, and the cost per dose. For Medicaid billing, one unit of coverage is .25 mg/5 ml. Providers must indicate the number of units given in block 24G on the claim form. The maximum reimbursement rate is $291.60 per 5 ml vial. Providers must bill their usual and customary charge.

Add this drug to the lists of injectable drugs published in the June 2002 and August 2002 general Medicaid bulletins.

• Injectable Drug List Update, June 2002 Medicaid Bulletin
• Injectable Drugs, August 2002 Medicaid Bulletin
• Injectable Drugs in the Physician’s Drug Program – Code Conversion Update, August 2002 Medicaid Bulletin

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

Attention: Health Departments and Physicians

Breast and Cervical Cancer Medicaid Procedures

Applications for Breast and Cervical Cancer Medicaid (form DMA-5079) and the Breast and Cervical Cancer Medicaid Verification form for Screening, Diagnosis, and Treatment (form DMA-5081) must be completed and returned to the county department of social services in the county where the resident resides. Do not send the forms to the Division of Medical Assistance (DMA).

Providers must complete every item on the forms and ensure that they are using the most current version of the forms. The current version of the DMA-5079 is August 2003; the most current version of the DMA-5081 is July 2003. The date is located in the lower left-hand corner of the forms. Current version of the forms are available on DMA’s website at http://www.dhhs.state.nc.us/dma/forms.html.

At recertification many providers are returning the verification form with tamoxifen indicated as treatment. Tamoxifen is not covered through the BCCM program. Do not submit the verification form with tamoxifen indicated as the treatment.

• Breast and Cervical Cancer Medicaid (form DMA-5079)
• Breast and Cervical Cancer Medicaid Verification form for Screening, Diagnosis, and Treatment (form DMA-5081)
• County DSS Directory

Susan Ryan, Medicaid Eligibility Unit
DMA, 919-857-4019

Attention: Home Infusion Therapy Providers

HCPCS Code Change for Pediatric Enteral Formulae

Effective with date of service January 1, 2004, HCPCS code W9934, pediatric enteral formulae, was end-dated and deleted from the Home Infusion Therapy Fee Schedule due to limited usage. To bill for enteral formulae, either adult or pediatric, use one of the following HCPCS codes.

To determine the appropriate HCPCS code for a specific product name, refer to the Enteral Nutrition Product Classification List located online at http://www.palmettogba.com.

Providers must bill their usual and customary charges.

Home Infusion Therapy Fee Schedule

Beth Karr, Medical Policy Section
DMA, 919-857-4021

Attention: All Providers

Medical Coverage Policies

The following new or amended medical coverage policies are now available on DMA’s website at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm:

• 1A14 – Gender Transformation
• 1A17 – Stereotactic Pallidotomy
• 5 – Durable Medical Equipment
• 8J – Children’s Development Service Agencies

These policies supersede previously published policies and procedures. Providers may contact EDS at 1-800-688-6696 or 919-851-8888 with billing questions.

Darlene Creech, Medical Policy Section
DMA, 919-857-4020

Attention: Durable Medical Equipment Providers

Conversions to National Miscellaneous Codes

The N.C. Medicaid program will not convert to national miscellaneous codes effective with date of service January 1, 2004 as announced in the December 2003 general Medicaid bulletin article titled Conversions to National Miscellaneous Codes. Therefore, DME providers must continue to use the state-created codes listed in that article.

Note: The following codes listed in that article have now been converted to national standard codes effective with date of service January 1, 2004.

For dates of service from January 1, 2004 through February 29, 2004, only those state-created codes listed on the DME Fee Schedule with an asterisk beside them require prior approval. The coverage criteria for those items has not changed. Refer to Medical Coverage Policy #5, Durable Medical Equipment for detailed coverage information.

The following state-created codes will be converted to national miscellaneous codes effective with date of service March 1, 2004.

Providers are not required to enter the service review number (SRN) on claim submitted for dates of service from January 1, 2004 through February 29, 2004. Additional instructions regarding prior approval and submitting claims will be published in the general Medicaid bulletin prior to the date of conversion for these codes.

• DME Fee Schedule
• Medical Coverage Policy #5, Durable Medical Equipment
• Conversions to National Miscellaneous Codes, December 2003 Medicaid Bulletin

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

Attention: Providers of Services for the Community Alternatives Program for Children

HCPCS Code Change for Pediatric Enteral Formulae

Effective with date of service January 1, 2004, HCPCS code W9934, pediatric enteral formulae, was end-dated and deleted from the CAP/C Fee Schedule due to limited usage. To bill for pediatric enteral formulae, use one of the following HCPCS codes from the CAP/C Fee Schedule with the modifier "BO" to indicate that it is administered orally.

To determine the appropriate HCPCS code for a specific product name, refer to the Enteral Nutrition Product Classification List located online at http://www.palmettogba.com. Providers must bill their usual and customary charges.

Beth Karr, Medical Policy Section
DMA, 919-857-4021

Attention: All Dental Providers

Conversion from CPT to CDT-4 Codes for Dental Services

To assure compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Medicaid program will no longer be able to accept dental claims with Current Procedural Terminology (CPT) codes filed on the American Dental Association (ADA) claim form. Federal regulations recognize only the Current Dental Terminology (CDT) code set published by the ADA as being HIPAA-compliant for dental claims. As a result, Medicaid is making the following changes to the dental program to assure continued coverage for the small percentage of oral health services that typically have been billed as covered CPT codes in any given year.

Changes in Procedure Codes Covered in the Dental Program
Effective with dates of service on or after February 1, 2004, the Medicaid Dental Program will no longer cover CPT codes. Effective with dates of service on or after February 1, 2004, the dental procedure codes listed below will be added to the dental program. An indicator of "R" means that the service is considered routine and does not require prior approval. An indicator of "PA" means that prior approval is needed to allow payment for the service.

New Prior Approval Requirement for Code D7340
With the addition of coverage for code D7960, Medicaid will no longer use code D7340 to cover a labial or buccal frenectomy procedure. Code D7340 will be used exclusively as defined in the CDT-4 manual Vestibuloplasty – ridge extension (secondary epithelialization). As a result, the reimbursement rate has been adjusted (see below), and code D7340 will require prior authorization effective with dates of service on or after February 1, 2004.

Revised Dental Reimbursement Rates
Effective with dates of service on or after February 1, 2004, reimbursement rates for the following dental procedure codes have been revised to be more consistent with rates paid for comparable procedures billed as CPT codes. With the exception of code D7340, the prior approval indicator remains unchanged from that published in current the Dental Policy Manual for the dental codes listed below.