In This Issue . . .

All Providers:

• Corrected 1099 Requests
• Medical Coverage Policies
• Referrals and Service Coordination for the Community Alternatives Program for Disabled Adults
• Refiling Denied 2003 New CPT Codes
• W-9 Form
• Checkwrite Schedule
• Electronic Cut-off Schedule
• Proposed Medical Coverage Policies

All Providers Performing Laboratory Services:

• CLIA Certification Information Form
• Clinical Laboratory Improvements Amendment
• Clinical Laboratory Improvements Amendment Certification Number Requirements

Area Mental Health Centers:

• HIPAA Code Conversion Clarification

Community Alternatives Program Providers:

• Recipient Eligibility Response System Update

Dental Providers:

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

Durable Medical Equipment Providers:

• Addition of Code E0760, Ultrasonic Osteogenesis Stimulator to DME Fee Schedule

Health Check Providers:

• Developmental Screening and Surveillance

Nursing Facility Providers:

• A Reminder about Retroactive Prior Approval

Pharmacists:

• Cialis

Physicians:

• Hospital Discharge Services – Billing Clarification

Prescribers:

• Cialis

---

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 reflects 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

Referrals and Service Coordination for the Community Alternatives Program for Disabled Adults

The Community Alternatives Program for Disabled Adults (CAP/DA) provides a variety of home and community services as an alternative to nursing facility care. The program serves disabled adults and the elderly. Each county has designated a lead administrative agency to oversee the day-to-day operation of the program at the local level. In most counties, the lead agency is the entry point for the program and provides the case management for program participants. There are a few counties in which the lead agency has arranged for another agency to handle these functions. Each year the Division of Medical Assistance publishes a list of the local primary contacts for CAP/DA in the general Medicaid bulletin. The following list specifies the name, location, and phone number of the primary CAP/DA case management agency for each county. If the case management agency is not the lead agency, the name of the lead agency is shown in parentheses.

Providers of Medicaid home care services should refer to the list to coordinate any services that they provide to a CAP/DA client with the client’s CAP/DA case manager. The case managers need to be aware when home health services, personal care services, durable medical equipment, home infusion therapy, private duty nursing or hospice are being considered or provided to a CAP/DA client. A "CI" or "CS" in the CAP block of the Medicaid identification card identifies CAP/DA clients.

Barbara Schwab, CAP/DA Administrative Officer
DMA, 919-857-4021

Attention: All Providers

Refiling Denied 2003 New CPT Codes

The September 2003 general Medicaid bulletin lists the new 2003 CPT codes that are covered by N.C. Medicaid. These codes are now covered retroactively to date of service January 1, 2003. Claims that were filed for services performed between January 1, 2003 and February 28, 2003 that received a denial for EOB 9, "service not covered by the Medicaid program," may be refiled at this time as a new claim.

Providers who billed with and were paid for deleted 2002 CPT codes for dates of service January 1, 2003 through August 31, 2003, may request the payment to be recouped and be repaid for the new 2003 CPT codes using the Medicaid Claim Adjustment Request process. These requests are subject to the adjustment time limit guidelines.

• CPT Code UPdate 2003, September 2003 Medicaid Bulletin
• Medicaid Claim Adjustment Request form

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

Attention: Physicians

Hospital Discharge Services – Billing Clarification

Refer to the following information when billing for hospital discharge services. These services include, as appropriate, final examinations, instructions for ongoing care, hospital stay information, and preparation of discharge records.

CPT code 99217 is used to report observation care discharge services provided to a patient when admission and discharge do not occur on the same date of service.

CPT codes 99234 through 99236 are used to report observation care or inpatient hospital care services provided to patients who are admitted and discharged on the same date of service.

CPT codes 99238 and 99239 are used to report all hospital discharge day management services provided to a patient (including newborns) on the day of hospital discharge when admission and discharge do not occur on the same date of service.

CPT code 99435 is used to report discharge services provided to newborns admitted and discharged on the same date of service.

The following CPT codes will not be reimbursed when billed with 99217 for the same date of service:

EDS, 1-800-699-6696 or 919-851-8888

Attention: Area Mental Health Centers and their Contract Agencies

HIPAA Code Conversion Clarification

The end-dating of the Y codes for community-based services (CBS) and the change to H codes did not change the service definition or the requirements for an order or authorization from the mental health center. It simply changed the code to be billed. Everything else remains the same.

The November 2003 Special Bulletin IV, HIPAA Code Conversions, incorrectly states the service limitation for CBS group services as 8 hours per day. The correct service limitation for CBS group service is 2¾ consecutive hours, as indicated in the service records manual published by the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services. If more than 2¾ consecutive hours of a group service is provided, it should be billed as day treatment.

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

Attention: Community Alternatives Program Providers

Recipient Eligibility Response System Update

As a result of the implementation of population group payer (POP) codes for recipients enrolled in the Community Alternatives Program (CAP), the 271 Eligibility Response transaction was updated effective January 1, 2004.

In addition to the 3-digit Medicaid Program Code, the 271 Eligibility Response returns the appropriate POP code for the requested recipient, if they are eligible for a POP group on the requested dates of service. This information is located in the Subscriber Eligibility or Benefit Information loop (2210C), in the SUBSCRIBER ELIGIBILITY OR BENEFIT INFORMATION (EB) segment, in the plan coverage description field (EB05), and the message text field (MSG01).

For information on this transaction, please refer to the June 2003 Special Bulletin II, HIPAA Update.

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

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:

• 1A-6 – Electrical Osteogenic Stimulators
• 4A – Dental Services
• 5 – Durable Medical Equipment

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: All Providers Performing Laboratory Services

Clinical Laboratory Improvements Amendment

Providers must enter the complete Clinical Laboratory Improvements Amendment (CLIA) certification number for the laboratory performing the service on the CMS-1500 claim form. The complete CLIA number is 10 characters in length with the third character an alpha and the other nine characters numeric (example: 34D1000000). Claims without the complete CLIA number will deny.

Where the CLIA number is entered on the claim depends on how the claim is filed.

• For paper claims, enter the CLIA number in block 23.
• For electronic claims, enter the CLIA number in record type 1R beginning at byte 26.
• For electronic claims submitted on tape, enter the CLIA number in record type I beginning at byte 132.
• For NCECS-Web claims, enter the complete CLIA number in the field titled CLIA Number under the Provider Information heading.

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

Attention: All Providers Performing Laboratory Services

Clinical Laboratory Improvements Amendment Certification Number Requirements

Effective June 1, 1998, the Clinical Laboratory Improvements Amendment (CLIA) requires that any provider performing laboratory tests have a CLIA certificate in order to receive reimbursement from federal programs. Providers must have their CLIA certificate number on file with the N.C. Medicaid program. The Division of Facility Services issues a CLIA certificate for each laboratory location. Providers with multiple locations must submit the certificate issued for the site where the lab services are rendered. Failure to have a CLIA number on file will result in denied claims. Return a completed form and a copy of your CLIA certificate to:

EDS
Provider Enrollment Unit
PO Box 300009
Raleigh, NC 27622

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

CLIA Certification Information form

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 no longer covers CPT codes. Effective with dates of service on or after February 1, 2004, the dental procedure codes listed below have been 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 required.

New Prior Approval Requirement for Code D7340
With the addition of coverage for code D7960, Medicaid no longer uses code D7340 to cover a labial or buccal frenectomy procedure. Code D7340 is 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 requires prior approval 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 the current Medical Coverage Policy #4A, Dental Services. 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 required. The "EM" indicator designates an emergency service as defined in Medical Coverage Policy #4A, Dental Services.

Revised Medical Coverage Policy for Dental Services
The changes described above have been incorporated into Medical Coverage Policy #4A, Dental Services. Revisions have been made primarily in sections 1.0 and 5.3 of that policy.

Ronald Venezie, DDS, MS, Dental Advisor
DMA, 919-857-4025

Attention: Nursing Facility Providers

A Reminder about Retroactive Prior Approval

It is the responsibility of the nursing facility to ensure that the initial FL2 request for prior approval is on file with EDS when a recipient is admitted to their facility.

Requests for approval of retroactive coverage for nursing facility services must be made to EDS if the coverage period is less than 90 days from the date of the initial FL2 request. The request may be made by telephone.

Requests for approval of retroactive coverage exceeding 90 days but less than 180 days from the initial FL2 request must be made to the Division of Medical Assistance. The request must be made in writing and include all pertinent medical justification for the dates of service requested.

DMA will not approve requests for retroactive coverage exceeding 180 days.

Linda Perry, R.N. Long-term Nurse Consultant
DMA, 919-857-4020

Attention: Durable Medical Equipment Providers

Addition of Code E0760, Ultrasonic Osteogenesis Stimulator to DME Fee Schedule

Effective with date of service February 1, 2004, ultrasonic osteogenesis stimulators were added to the Capped Rental category of the DME Fee Schedule. The code and maximum reimbursement rates are as follows:

Providers must bill their usual and customary rate. Prior approval is required. Medical necessity must be documented on the Certificate of Medical Necessity and Prior Approval form.

An ultrasonic osteogenesis stimulator (code E0760) is covered only if all of the following criteria are met:

1. non-union of a fracture (ICD-9-CM codes listed below) documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including multiple views of the fracture site, and with a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs; and
2. documented failure of at least one open surgical intervention for the treatment of the fracture; and
3. fracture is not of the skull or vertebrae; and
4. fracture is not tumor-related.

A non-union of a fracture other than the skull or vertebrae is described in ICD-9-CM code 733.82 plus the code for the fracture site. ICD-9-CM covered codes include the following:

• 807.00 – 807.3 ribs and sternum
• 808.0 – 808.9 acetabulum, pubis, ilium, and ischium
• 810.00 – 816.13 clavicle, scapula, humerus, radius, ulna, carpals, metacarpals, phalanges
• 820.00 – 826.1 femur, patella, tibia, fibula, ankle (malleoli), calcaneus, tarsals, metatarsals, astragalus, navicular (scaphoid), cuboid, cuneiform, phalanges.
  

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

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

Attention: All Health Check Providers

Developmental Screening and Surveillance

Did you know that about 16 percent of children have disabilities including speech and language delays, mental retardation, learning, and emotional/behavioral problems? Only 50 percent are detected prior to school entrance, which eliminates the possibility of early intervention. More than 20 years of research have proven that early intervention produces immediate and long-term benefits for children with disabilities, their families, and society.

Child development, a dynamic process, is often difficult to measure. Identifying children with developmental delays is important in the medical setting because a child’s primary care provider is generally the best-informed professional with whom families have regular contact over the first five years of the child’s life.

Developmental screening including mental, emotional, and behavioral is one of the many components of a complete Health Check visit. The AAP Committee on Children with Disabilities is recommending the use of standardized screening tests at well child visits.

So what standardized developmental screening tools are available and what is practical to use in the primary care practice? Primary care practices in North Carolina, within two different demonstration projects, have put standardized screening tools "to the test" and have successfully integrated developmental screening and surveillance into their office workflow. If you are interested in learning more about what is practical and what works contact Curtis Honeycutt, Health Check staff, at Curtis.Honeycutt@ncmail.net.

Angela Floyd, Health Check Program
DMA, 919-857-4022

Attention: Pharmacists and Prescribers

Cialis

Effective December 1, 2003, Cialis was added to the list of drugs for impotency covered by the N.C. Medicaid program. There is a limit of two units per month. The physician must document in his/her own handwriting "erectile dysfunction" on the face of the prescription. Impotence drugs for males 25 years of age and older do not require prior approval. For males under 25 years of age, the physician (or designee) must obtain prior approval from the Division of Medical Assistance. The prior approval request must include documentation for the medical necessity. Requests should be sent to the following address:

N.C. Division of Medical Assistance
Attention: Pharmacy Section
2501 Mail Service Center
Raleigh, NC 27699-2501

Fax: 919-715-1255

Sharman Leinwand, Medical Policy Section
DMA, 919-857-4020

Proposed Medical Coverage Policies

In accordance with Session Law 2003-284, proposed new or amended Medicaid medical coverage policies are available for review and comment on DMA’s website at http://www.dhhs.state.nc.us/dma/mp/proposedmp.htm. To submit a comment related to a policy, refer to the instructions on the website. Providers without Internet access can submit written comments to the address listed below.

Darlene Creech
Division of Medical Assistance
Medical Policy Section
2501 Mail Service Center
Raleigh, NC 27699-2501

The initial comment period for each proposed policy is 45 days. An additional 15-day comment period will follow if a proposed policy is revised as a result of the initial comment period.

Checkwrite Schedule

Electronic Cut-Off Schedule

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.

• 2004 Checkwrite Schedule
• 2004 Holiday Observance Schedule