February 2005 Medicaid Bulletin

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In This Issue...

All Providers:

  • Clinical Coverage Policies
  • Medicaid Provider Survey Provider Input Requested
  • NC Leads Update
  • Reimbursement Rate and HCPCS Code Changes for the Physician’s Drug Program
  • Community Alternatives Program Case Managers:

  • HCPCS Code Changes fo2005 for Enteral Nutrition Products
  • HCPCS Code Updates for Medical Supplies
  • New Pediatric Enteral Supply Codes
  • Transitioning Between CAP Program
  • Dental Providers:

  • Correction for ADA Code Updates Printed in the January 2005 Bulletin
  • Dialysis Facilities:

  • Erythropoietin (EPO) Billing Instructions
  • Rates for Dialysis Facilities
  • Durable Medical Equipment Providers:

  • 2005 HCPCS Code Deletions and Crosswalks
  • 2005 Enteral HCPC Codes
  • HCPCS Code Description Changes for 2005 for Durable Medical Equipment Enteral Nutrition Products
  • End Stage Renal Disease Providers:

  • Rates for Dialysis Facilities
  • Home Health Agencies:

  • HCPCS Code Updates for Medical Supplies
  • Home Infusion Therapy:

  • HCPCS Code Changes for 2005 for Enteral Nutrition Products
  • New Pediatric Enteral Supply Codes
  • Medical Doctors:

  • HCPCS Codes A4550
  • Mental Health Providers:

  • Enrollment for Mental Health Providers
  • Nurse Practitioners:

  • Bevacizumab (Avastin)
  • Pemetrexed, 500 mg (Alimta)
  • Nursing Facility Providers:

  • Nursing Facility Rates Increase Effective 1/17/05
  • Osteopaths:

  • HCPCS Codes A4550
  • Pharmacists and Prescribers:

  • Correction for Removal of Smoking Cessation Medications
  • Physicians:

  • Bevacizumab (Avastin)
  • Code Change for Gastric Bypass Surgery
  • Pemetrexed, 500 mg (Alimta)
  • Private Duty Nursing Providers:

  • HCPCS Code Updates for Medical Supplies
  • UB-92 Billers:

  • Revenue Codes: RC070 and RC077

  • Attention: All Providers

    Clinical Coverage Policies

    The following new or amended clinical coverage policies are now available on the Division of Medical Assistance’s website:

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

    Gina Rutherford, Clinical Policy and Programs
    DMA, 919-855-4260


    Attention: All Providers

    Medicaid Provider Survey

    Provider Input Requested!

    The Office of Medicaid Management Information System Services (OMMISS) has prepared a survey to identify opportunities to better serve providers who participate in Medicaid and other DHHS reimbursement programs that will be replaced by the new NCLeads system in 2006.

    This survey is intended to identify the provider community’s current access to systems and the Internet, along with technical support availability. It is also important for us to understand and track your claims submittal process and satisfaction levels with the current MMIS+.

    You are encouraged to complete the survey located at http://ncleads.dhhs.state.nc.us/survey to ensure the new NCLeads system will address your access requirements and system education preferences. Survey participants can be assured that their responses will be considered for NCLeads improvement opportunities as well as to tailor provider education and communication about the NCLeads solution.

    If you have any questions about the survey, please OMMIS Provider Relations. Thank you for your participation in this effort!

    Tom Liverman, OMMISS Provider Relations
    919-647-8315


    Attention: All Providers

    Reimbursement Rate and HCPCS Code Changes for the Physician’s Drug Program

    Effective with date of service January 1, 2005, the N.C. Medicaid program covers the individual HCPCS codes for the drugs listed in the following table. Claims submitted on or after January 1, 2005 using the discontinued codes for these drugs will deny.

    OLD CODE

    DESCRIPTION

    UNIT

    NEW
    CODE

    DESCRIPTION

    UNIT

    MAXIMUM
    REIMBURSEMENT
    RATE

    J3395

    Verteporfin (Visudyne)

    15 mg

    J3396

    Verteporfin

    (Visudyne)

    0.1 mg

    $10.13

    S0115

    Bortezomib (Velcade)

    3.5 mg

    J9041

    Bortezomib

    (Velcade)

    0.1 mg

    $30.76

    S0163

    Risperidone, long acting

    12.5 mg

    J2794

    Risperidone, long acting

    0.5 mg

    $5.12

    S0159

    Agalsidase Beta (Fabrazyme)

    35 mg

    J0180

    Agalsidase Beta (Fabrazyme)

    1 mg

    $128.57

    S0158

    Laronidase (Aldurazyme)

    0.58 mg/1 ml

    J1931

    Laronidase (Aldurazyme)

    0.1 mg

    $24.13

    S0107

    Omalizumab (Xolair)

    25 mg

    J2357

    Omalizumab (Xolair)

    5 mg

    $17.05

    S0116

    Bevacizumab (Avastin)

    100 mg

    J9035

    Bevacizumab (Avastin)

    10 mg

    $61.88

    J9999

    Cetuximab (Erbitux)

    100 mg/50 ml

    J9055

    Cetuximab (Erbitux)

    10 mg

    $54.00

    J9999

    Pemetrexed (Alimta)

    500 mg

    J9305

    Pemetrexed (Alimta)

    10 mg

    $43.88

    J3490

    Palonosetron (Aloxi)

    0.25 mg/5 ml

    J2469

    Palonosetron (Aloxi)

    25 mcg

    $30.62

    J9999

    Abarelix, (Plenaxis)

    100 mg

    J0128

    Abarelix, (Plenaxis)

    10 mg

    $88.54

    J9999

    Azacitidine (Vidaza)

    25 mg

    S0168

    Azacitidine (Vidaza)

    100 mg

    $428.63

    Note: The unit of coverage and fees on these drugs has changed. Effective with date of service January 1, 2005, the maximum reimbursement rate for sargramostim (GM-CSF) 50 mcg (Leukine) has been increased from $27.53 to $29.04. Add these changes to the list of injectable drugs published in the November 2004 general Medicaid bulletin.

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


    Attention: All Dental Providers Including Health Department Dental Clinics

    Corrections to ADA Code Updates Published in the January 2005 General Medicaid Bulletin

    The following fees were reported incorrectly in the January 2005 general Medicaid bulletin. The dental procedure codes and fees listed below were added effective with date of service January 1, 2005 for the N.C. Medicaid Dental Program. These additions were a result of the CDT (Current Dental Terminology) 2005 ADA code updates.

    CDT 2005 Code

    Description

    Reimbursement
    Rate

    D2932

    Prefabricated resin crown

  • limited to recipients under age 21
  • limited to primary and permanent anterior teeth
  • $163.01

    D2934

    Prefabricated esthetic coated stainless steel crown – primary tooth

  • limited to recipients under age 21
  • limited to primary anterior teeth
  • $175.00

    The following procedure code was not end-dated effective with date of service December 31, 2004 as previously stated in the January 2005 general Medicaid bulletin. Coverage and reimbursement for this procedure has not changed.

    Procedure Code

    Description

    Reimbursement
    Rate

    D2933

    Prefabricated stainless steel crown with resin window

  • limited to recipients under age 21
  • limited to primary anterior teeth
  • $181.77

    Providers are reminded to bill their usual and customary charges rather than the Medicaid rate. For coverage criteria and additional billing guidelines, please refer to Clinical Coverage Policy #4A, Dental Services.

    Darlene Baker, Dental Policy Analyst
    DMA, 919-855-4280


    Attention: Dialysis Facilities

    Erythropoietin (EPO) Billing Instructions

    Effective February 1, 2005, dialysis facilities now have an option to bill EPO claims on paper with attached medical documentation when the number of units of EPO billed exceeds 14 units per date of service or when HCPCS codes Q9937 through Q9940 are billed. This may be done instead of filing an adjustment.

    Paper Claims Billed Using Q9920 through Q9936

    Claims submitted on paper with HCPCS codes Q9920 through Q9936 and more than 14 units of EPO on the same date of service, may be submitted with laboratory reports indicating a 90-day average hematocrit level of 36.5% or less and other documentation to support the need for the units billed. If medical documentation supports that more than 14 units of EPO were required, the allowed units will be paid. An adjustment will not be required.

    Paper Claims Billed Using Q9937 through Q9940

    Claims submitted on paper with HCPCS codes Q9937 through Q9940 will be reviewed when laboratory reports and other documentation are attached. The laboratory reports must indicate a 90-day average hematocrit level of 36.5% or less. If medical documentation supports that the units of EPO were required, the allowed units will be paid. An adjustment will not be required.

    Submitting the claims on paper with the appropriate medical documentation will expedite payment to the provider, in lieu of waiting for a denial and then initiating an adjustment.

    Claims Submitted Electronically

    Claims submitted electronically with HCPCS codes Q9920 through Q9936 and greater than 14 units of EPO will continue to be cut back to 14 units. Units exceeding 14 per day will deny with EOB 792: "Epogen units exceeded. Please resubmit as an adjustment with lab results and documentation to support payment for additional units." When filing an adjustment, providers must provide laboratory documentation indicating a 90-day average hematocrit level of 36.5% or less. Providers must remember this is a two step process. The claim must be adjusted after the electronic claim is denied with EOB 792.

    Claims submitted electronically with HCPCS codes Q9937 through Q9940 will deny with EOB 3004: "Refile claim as an adjustment with documentation to support medical necessity," regardless of the number of EPO units billed.

    Billing Reminders

    Effective with date of service October 1, 2004, claims submitted for EPO must include the following or the claim will deny with EOB 082, "Service is not consistent with/or not covered for this diagnosis/ or description does not match diagnosis":

    AND

    One of the following additional diagnosis codes:

    EPO must be billed with revenue code 634 and an appropriate procedure code.

    All EPO charges for the same date of service must be billed as one detail on the claim. If EPO charges are billed on two or more details on the claim for the same date of service, each of the details will deny with EOB 1198 "Service billed multiple times. If on this claim, combine units on single detail and resubmit new claim. If paid on previous claim, combine units and file as an adjustment."

    Recipient’s hematocrit must be 36.5% or less for EPO to be covered.

    Dialysis facility providers are reminded of the following details when billing Medicaid for EPO on the UB-92 claim form:

    Refer to the billing example below:

    42

    43

    44

    45

    46

    47

    48

    Rev Code

    Description

    HCPCS/Rates

    Serv Date

    Serv Units

    Total Charges

    Noncovered Charges

    634

    EPO 9000U

    Q9934

    01152005

    25

    135.00

     

    Select the "Q" code that reflects the recipient’s current HCT level.

    Q9920 EPO

    per 1000 units

    Patient HCT 20 or less

    Q9921 EPO

    per 1000 units

    Patient HCT 21

    Q9922 EPO

    per 1000 units

    Patient HCT 22

    Q9923 EPO

    per 1000 units

    Patient HCT 23

    Q9924 EPO

    per 1000 units

    Patient HCT 24

    Q9925 EPO

    per 1000 units

    Patient HCT 25

    Q9926 EPO

    per 1000 units

    Patient HCT 26

    Q9927 EPO

    per 1000 units

    Patient HCT 27

    Q9928 EPO

    per 1000 units

    Patient HCT 28

    Q9929 EPO

    per 1000 units

    Patient HCT 29

    Q9930 EPO

    per 1000 units

    Patient HCT 30

    Q9931 EPO

    per 1000 units

    Patient HCT 31

    Q9932 EPO

    per 1000 units

    Patient HCT 32

    Q9933 EPO

    per 1000 units

    Patient HCT 33

    Q9934 EPO

    per 1000 units

    Patient HCT 34

    Q9935 EPO

    per 1000 units

    Patient HCT 35

    Q9936 EPO

    per 1000 units

    Patient HCT 36

    Q9937 EPO

    per 1000 units

    Patient HCT 37

    Q9938 EPO

    per 1000 units

    Patient HCT 38

    Q9939 EPO

    per 1000 units

    Patient HCT 39

    Q9940 EPO

    per 1000 units

    Patient HCT 40

    N.C. Medicaid will implement use of HCPCS code Q4055 for billing EPO in order to comply with the end –dating of HCPCS codes in the range Q9920 through Q9940. Billing instructions and the effective date of the change will be published in a future Medicaid Bulletin when the system is ready to receive claims.

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


    Attention: Durable Medical Equipment Providers

    2005 HCPCS Code Deletions and Crosswalks

    The following codes were end-dated effective with date of service January 31, 2005, and removed from the fee schedule:

    K0059

    K0655

    E0176

    W4126

    K0060

    K0656

    E0177

    W4128

    K0061

    K0657

    E0178

    W4129

    K0081

    K0660

    E0179

    W4134

    K0650

    K0661

    E1091

    W4135

    K0651

    K0662

    W4122

    W4136

    K0652

    K0663

    W4123

    W4137

    K0653

    K0664

    W4124

    K0654

    K0665

    W4125

    Effective with date of service February 1, 2005, the following codes were added to the DME fee schedule:

    Old Code(s)

    New Code

    Description

    Modifier

    Maximum Reimbursement Rate

    Life Expectancy

    W4134
    W4135
    W4136
    W4137
    E0960* Wheelchair accessory, shoulder harness/straps or chest strap including any type mounting hardware

    Rental:

    New Purchase:

    UsedPurchase:

    9.10

    90.98

    68.24

    3yrs/ 2 yrs 000-020
    W4134
    W4135
    W4136
    W4137
    E1025* Lateral thoracic support, non-contoured, for pediatric wheelchair, each (includes hardware)

    Rental:

    New Purchase:

    UsedPurchase:

     

    41.32#

    413.25#

    309.94#

    2 yrs
    W4134
    W4135
    W4136
    W4137
    E1026* Lateral thoracic support, contoured, for pediatric wheelchair, each (includes hardware)

    Rental:

    New Purchase:

    Used Purchase:

    41.32#

    413.25#

    309.94#

    2 yrs

    W4134 W4135 W4136
    W4137

    E1027

    Lateral/anterior support for pediatric wheelchair, each (includes hardware)

    Rental:

    New Purchase:

    Used Purchase:

    41.32#

    413.25#

    309.94#

    2 yrs

    E1091
    W4122
    W4123
    W4124

    E1229*

    Wheelchair, pediatric size, not otherwise specified

    Rental:

    New Purchase:

    Used Purchase:

    Individually Priced

    3 yrs

    W4125 W4126

    E1239*

    Power wheelchair, pediatric size, not otherwise specified

    Rental:

    New Purchase:

    Used Purchase:

    Individually Priced

    4 yrs

    K0059
    K0060
    K0061

    E2205

    Manual wheelchair accessory, handrim without projections, any type, replacement only, each

    Rental:

    New Purchase:

    Used Purchase:

    3.25

    32.67

    24.52

    3 yrs

    K0081

    E2206

    Manual wheelchair accessory, wheel lock assembly, complete, each

    Rental:

    New Purchase:

    Used Purchase:

    4.06

    40.68

    30.50

    3 yrs

    W4128

    E2291*

    Back, planar, for pediatric size wheelchair including fixed attaching hardware

    Rental:

    New Purchase:

    Used Purchase:

    44.46

    444.56

    333.42

    2yrs/000-020

    W4129

    E2292*

    Seat, planar for pediatric size wheelchair including fixed attaching hardware

    Rental:

    New Purchase:

    Used Purchase:

    42.06

    420.55

    315.42

    2yrs/000-020

    W4128

    E2293*

    Back, contoured, for pediatric size wheelchair including fixed attaching hardware

    Rental:

    New Purchase:

    Used Purchase:

    44.46

    444.56

    333.42

    2yrs/000-020

    W4129

    E2294*

    Seat, contoured, for pediatric size wheelchair including fixed attaching hardware

    Rental:

    New Purchase:

    Used Purchase:

    42.06

    420.55

    315.42

    2yrs/000-020

    K0108
    W4005

    E2368*

    Power wheelchair component, motor, replacement only

    Rental:

    New Purchase:

    Used Purchase:

    51.67

    516.57

    387.44

    2 yrs

    K0108
    W4005

    E2369*

    Power wheelchair component, gear box, replacement only

    Rental:

    New Purchase:

    Used Purchase:

    45.00

    449.94

    337.45

    2 yrs

    K0108
    W4005

    E2370*

    Power wheelchair component, motor and gear box, replacement only

    Rental:

    New Purchase:

    Used Purchase:

    80.29

    802.84

    602.12

    2 yrs

    K0650

    E2601

    General use wheelchair seat cushion, width less than 22 inches, any depth

    Rental:

    New Purchase:

    Used Purchase:

    8.86

    88.65

    66.49

    3yrs/2yrs 000-020

    K0651

    E2602*

     

     

     

     

    General use wheelchair seat cushion, width 22 inches or greater, any depth

     

    Rental:

    New Purchase:

    Used Purchase:

     

     

    16.20

    161.88

    121.43

     

     

    3yrs/2yrs 000-020

     

     

    K0651 E2609* Custom fabricated wheelchair seat cushion, any size

    Rental:

    New Purchase:

    Used Purchase:

    Individually priced 3 yrs

    K0652
    E0176
    E0177
    E0178
    E0179

    E2603*

    Skin protection wheelchair seat cushion, width less than 22 inches, any depth

    Rental:

    New Purchase:

    Used Purchase:

    22.31

    223.04

    167.28

    3yrs

    K0653
    E0176
    E0177
    E0178

    E2604*

    Skin protection wheelchair seat cushion, width 22 inches or greater, any depth

    Rental:

    New Purchase:

    Used Purchase:

    31.56

    315.76

    236.83

    3yrs

    K0654

    E2605*

    Positioning wheelchair seat cushion, width less than 22 inches, any depth

    Rental:

    New Purchase:

    Used Purchase:

    32.19

    321.69

    241.29

    3yrs

    K0655

    E2606*

    Positioning wheelchair seat cushion, width 22 inches or greater, any depth

    Rental:

    New Purchase:

    Used Purchase:

    43.61

    436.07

    327.06

    3yrs

    K0656

    E2607*

    Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth

    Rental:

    New Purchase:

    Used Purchase:

    29.56

    295.60

    221.70

    3yrs

    K0657

    E2608*

    Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depth

    Rental:

    New Purchase:

    Used Purchase:

    35.42

    354.00

    265.51

    3yrs

    K0660

    E2611

    General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware

    Rental:

    New Purchase:

    Used Purchase:

    31.23

    312.35

    234.29

    3yrs

    K0661

    E2612

    General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware

    Rental:

    New Purchase:

    Used Purchase:

    42.25

    422.54

    316.89

    3yrs

    K0662

    E2613*

    Positioning wheelchair back cushion, posterior, width less than 22 inches, any height, including any type mounting hardware

    Rental:

    New Purchase:

    Used Purchase:

    39.31

    393.04

    294.78

    3yrs

    K0663

    E2614*

    Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height, including any type mounting hardware

    Rental:

    New Purchase:

    Used Purchase:

    54.40

    543.93

    407.97

    3yrs

    K0664

    E2615*

    Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height, including any type mounting hardware

    Rental:

    New Purchase:

    Used Purchase:

    45.24

    452.32

    339.23

    3yrs

    K0665

    E2616*

    Positioning wheelchair back cushion, posterior-lateral, width greater than 22 inches, any height, including any type mounting hardware

    Rental:

    New Purchase:

    Used Purchase:

    60.86

    608.58

    456.45

    3yrs

    K0664

    E2620*

    Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 inches, any height, including any type mounting hardware

    Rental:

    New Purchase:

    Used Purchase:

    57.47

    574.76

    431.08

    3yrs/2yrs 000-020

    K0665

    E2621*

    Positioning wheelchair back cushion, planar back with lateral supports, width greater than 22 inches, any height, including any type mounting hardware

    Rental:

    New Purchase:

    Used Purchase:

    54.77

    547.70

    410.79

    3yrs/2yrs 000-020

    W4122
    W4123
    W4124
    E1091

    E1231*

    Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system

    Rental:

    New Purchase:

    Used Purchase:

    213.81#

    2138.09#

    1603.57#

    3 yrs

    W4122
    W4123
    W4124
    E1091

    E1232*

    Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system

    Rental:

    New Purchase:

    Used Purchase:

    213.85

    2138.41

    1603.82

    3 yrs

    W4122
    W4123
    W4124
    E1091

    E1233*

    Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system

    Rental:

    New Purchase:

    Used Purchase:

    221.57

    2215.73

    1661.79

    3 yrs

    W4122
    W4123
    W4124
    E1091

    E1234*

    Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system

    Rental:

    New Purchase:

    Used Purchase

    192.91

    1928.95

    1446.70

    3 yrs

    W4122
    W4123
    W4124
    E1091

    E1235*

    Wheelchair, pediatric size, rigid, adjustable, with seating system

    Rental:

    New Purchase:

    Used Purchase:

    185.75

    1857.43

    1393.07

    3 yrs

    W4122
    W4123
    W4124
    E1091

    E1236*

    Wheelchair, pediatric size, folding, adjustable, with seating system

    Rental:

    New Purchase:

    Used Purchase:

    163.87

    1638.73

    1229.05

    3 yrs

    W4122
    W4123
    W4124
    E1091

    E1237*

    Wheelchair, pediatric size, rigid, adjustable, without seating system

    Rental:

    New Purchase:

    Used Purchase:

    165.30

    1653.05

    1239.80

    3 yrs

    W4122
    W4123
    W4124
    E1091

    E1238*

    Wheelchair, pediatric size, folding, without seating system

    Rental:

    New Purchase:

    Used Purchase:

    172.37

    1723.55

    1292.64

    3 yrs

    Note: The pound sign (#) indicates a temporary rate, which will change when Medicare’s established rates are published. Temporary rates for Wheelchair Seat Frames and Cushions were published in the October 2004 general Medicaid bulletin. Some of those codes have now been crosswalked to new codes with appropriate rates and are listed in the table above. The codes listed in the table below have not been crosswalked to new HCPCS codes, but their rates have now been established by Medicare. Effective February 1, 2005, the rates reflect those published by Medicare.

     

    HCPCS
    Code

    Description

    Modifier

     

    Maximum
    Reimbursement
    Rate

    E2201*

    Manual wheelchair accessory, non-standard seat frame, width greater than or equal to 20 inches and less than 24 inches

    Rental:

    New Purchase:

    Used Purchase:

    37.31

    373.10

    279.83

    E2202*

    Manual wheelchair accessory, non-standard seat frame, width 24-27 inches

    Rental:

    New Purchase:

    Used Purchase:

    47.40

    473.98

    355.50

    E2203*

    Manual wheelchair accessory, non-standard seat frame depth , 20 t0 less than 22 inches

    Rental:

    New Purchase:

    Used Purchase::

    47.89

    479.05

    359.28

    E2204*

    Manual wheelchair accessory, non-standard seat frame depth , 22-25 inches

    Rental:

    New Purchase:

    Used Purchase:

    81.35

    813.40

    610.05

    E2340*

    Power wheelchair accessory, non-standard seat frame, width 20-23 inches

    Rental:

    New Purchase:

    Used Purchase:

    35.85

    358.36

    268.79

    E2341*

    Power wheelchair accessory, non-standard seat frame, width 24-27 inches

    Rental:

    New Purchase:

    Used Purchase:

    53.76

    537.58

    403.19

    E2342*

    Power wheelchair accessory, non-standard seat frame, depth 20-21 inches

    Rental:

    New Purchase:

    Used Purchase:

    44.80

    447.98

    335.99

    E2343*

    Power wheelchair accessory, non-standard seat frame, depth 22-25 inches

    Rental:

    New Purchase:

    Used Purchase:

    71.67

    716.78

    537.58

    Note: In both of the tables above, HCPCS codes with an asterisk (*) require prior approval and bold type indicates the item is covered by Medicare. A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval. The coverage criteria for these items have not changed. Refer to Clinical Coverage Policy #5, Durable Medical Equipment for detailed coverage information.

    Providers are reminded that the rates listed are the maximum reimbursement rates. Rates have not changed for codes with only description changes. Providers must bill their usual and customary rate for all DME.

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


    Attention: Durable Medical Equipment Providers.

    HCPCS Codes Changes for 2005 Pediatric Enteral Nutrition Products

    Effective with the date of Service January 31, 2005, the HCPCS codes B4151 and B4156 were end dated and deleted from the fee schedule. The following table provides the crosswalk for the deleted codes:

    Deleted Code

    Existing Code

    B4151

    B4150 or B4152

    B4156

    B4153, B4154 or B4155

     

     

    Old
    Code

    New
    Code

    Description

    Maximum Reimbursement Rate

    B4151

    B4157

    Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins, & minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

    $1.15#

    B4151

    B4158

    Enteral formula, for pediatric nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins & minerals, may include fiber, administered through an enteral feeding tube, 100 cal = 1 unit

    $0.63#

    B4151

    B4159

    Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins & minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 cal = 1 unit

    $0.63#

    B4151

    B4160

    Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins & minerals, may include fiber, administered through an enteral feeding tube, 100 cal = 1 unit

    $0.53#

    B4151

    B4162

    Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins & minerals, may include fiber, administered through an enteral feeding tube, 100 cal = 1 unit

    $1.15#

    B4156

    B4161

    Enteral formula, for pediatrics, hydrolyzed/amino acids & peptide chain proteins, includes fats, carbohydrates, vitamins & minerals, may include fiber, administered through an enteral feeding tube, 100 cal = 1 unit

    $1.80#

    Note: The pound sign (#) indicates the rates are temporary rates until Medicare’s established rates are published. HCPCS codes that are bold indicate Medicare covered service. These codes do not require prior approval. A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval.

    The coverage criteria for these items have not changed. Refer to Clinical Coverage Policy #5, Durable Medical Equipment for detailed coverage information.

    Providers are reminded that the rates listed are the maximum reimbursement rates. Rates have not changed for codes with only description changes. Providers must bill their usual and customary rate for all DME.

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


    Attention: Physicians

    Code Change for Gastric Bypass Surgery

    Effective with date of service January 1, 2005, the unlisted procedure code 43659 should not be used to bill for the laparoscopic version of gastric bypass/Roux-en-Y surgery (CPT code 43846). Providers should bill this procedure using the 2005 CPT code 43644, Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastoenterostomy (roux limb 150 cm or less).

    Clinical Coverage Policy 1A-15, Surgery for Clinically Severe Obesity has been updated to reflect this code change.

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


    Attention: Community Alternatives Program Providers

    Transitioning between Community Alternatives Program

    When a CAP recipient is moving from one CAP program to another CAP program (for example from CAP/C to CAP/MR DD), the effective date for the new program must be the first day of the first full month of services with the new program. The timing of the termination from one CAP program and enrollment in another CAP program must be carefully coordinated with the recipient, both CAP program case managers, DMA staff in the Home Care Initiatives Unit (HCI unit), provider agencies and the local DSS Medicaid worker. The transition must also be approved through EDS.

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


    Attention: Durable Medical Equipment Providers

    HCPCS Code Description Changes for 2005 for Durable Medical Equipment and Enteral Nutrition Products

    Effective with date of service February 1, 2005, the following code descriptions were revised on the DME fee schedule:

    Code

    Revised Description

    B4150

    Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories= 1 unit

    B4152

    Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

    B4153

    Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

    B4154

    Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

    B4155

    Enteral formula nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers),proteins/amino (e.g. glutamine, arginine), fat (e.g. medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories= 1unit

    E0141

    Walker, rigid, wheeled, adjustable or fixed height

    E0143

    Walker, folding, wheeled, adjustable or fixed height

    E0450*

    Volume control ventilator, without pressure support mode, may include, pressure control mode, used with invasive interface (e.g. tracheostomy tube)

    E0951

    Heel loop/holder, any type, with or without ankle strap, each

    E0952

    Toe loop/ holder, any type, each

    E0967*

    Manual wheelchair accessory, hand rim with projections, any type, replacement only, each

    E0978

    Wheelchair accessory, positioning belts/safety belt/pelvic strap, each

    E1038*

    Transport chair, adult size, patient weight capacity less than 250 pounds

    E1226*

    Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each

    Note: HCPCS codes followed by an asterisk (*) indicates that the item requires prior approval. Codes listed in bold type indicate the item is covered by Medicare. A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval as before.

    The coverage criteria for these items have not changed. Refer to Clinical Coverage Policy #5, Durable Medical Equipment for detailed coverage information.

    Providers are reminded that the rates listed are the maximum reimbursement rates. Rates have not changed for these codes. Providers must bill their usual and customary charges for all DME.

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


    Attention: End Stage Renal Disease Providers

    Rates for Dialysis Facilities

    The Division of Medical Assistance implemented a Medicaid composite rate change for Hemodialysis/Peritoneal Dialysis and CAPD/CCPD based on CMS Manual System Pub. 100-02 Transmittal 27, Change Request 3554. The new end stage renal disease composite rates (1.6 percent for 2005) are effective with date of service January 1, 2005. No adjustments are allowed for prior billing.

    Sherrill Johnson, Rate Analyst
    DMA, 919-855-4180


    Attention: Home Health Agencies, Private Duty Nursing Providers, and Community Alternatives Program Case Managers.

    HCPCS Code Updates for Medical Supplies

    Effective with date of service January 31, 2005, the following HCPCS codes were end-dated to comply with national standard codes mandated by the Health Insurance Portability and Accountability Act (HIPAA). The new codes are effective with dates of service February 1, 2005.

    Current
    HCPCS
    Code

    New
    HCPCS
    Code

    Description

    Billing
    Unit

    Maximum Reimbursement
    Rate

    A4347

    A4349

    Male External Catheter With Or Without Adhesive, Disposable

    Each

    1.48

    A4521

    T4521

    Adult-Sized(Disposable) Incontinence Product, Brief/Diaper, Small Size

    Each

    .90

    A4522

    T4522

    Adult-Sized(Disposable) Incontinence Product, Brief/Diaper Medium Size

    Each

    .90

    A4523

    T4523

    Adult-Sized(Disposable) Incontinence Product, Brief/Diaper Large Size

    Each

    .90

    A4524

    T4524

    Adult-Sized(Disposable) Incontinence Product, Brief/Diaper Extra Large Size

    Each

    .90

    A4525

    T4521

    Adult-Sized(Disposable) Incontinence Product, Brief/Diaper, Small Size

    Each

    .90

    A4526

    T4522

    Adult-Sized(Disposable) Incontinence Product, Brief/Diaper Medium Size

    Each

    .90

    A4527

    T4523

    Adult-Sized(Disposable) Incontinence Product, Brief/Diaper Large Size

    Each

    .90

    A4528

    T4524

    Adult-Sized(Disposable) Incontinence Product, Brief/Diaper Extra Large Size

    Each

    .90

    A4529

    T4529

    Pediatric Sized(Disposable) Incontinence Product, Brief/ Diaper, Small/Medium

    Each

    .90

    A4530

    T4530

    Pediatric Sized(Disposable) Incontinence Product, Brief/ Diaper, Large

    Each

    .90

    A4531

    T4529

    Pediatric Sized(Disposable) Incontinence Product, Brief/ Diaper, Small/Medium

    Each

    .90

    A4532

    T4530

    Pediatric Sized(Disposable) Incontinence Product, Brief/ Diaper, Large

    Each

    .90

    A4533

    T4533

    Youth Pediatric Sized(Disposable) Incontinence Product, Brief/ Diaper

    Each

    .90

    A4534

    T4533

    Youth Pediatric Sized(Disposable) Incontinence Product, Brief/ Diaper

    Each

    .90

    T1500

    *T4539

    Incontinence Product diaper/brief reusable, each

    Each

    22.36

    Note: The asterisk (*) indicates that the item is a waiver supply, which can only be billed by CAP providers. A waiver supply cannot be billed by home health and private duty nursing services.

    The coverage criteria for these items have not changed. Refer to the Community Care Provider Manual on DMA’s website for detailed coverage information.

    Providers are reminded that the rates listed are the maximum reimbursement rates. Providers must bill their usual and customary charges for all services.

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


    Attention: Home Infusion Therapy and Community Alternatives Program Case Managers.

    HCPCS Code Changes for 2005 Enteral Nutrition Products

    Effective with date of service January 31, 2005, HCPCS codes B4151 and B4156 were end-dated to comply with national standard codes mandated by the Health Insurance Portability and Accountability Act (HIPAA). The descriptions of the existing enteral codes were revised to be inclusive of the items covered by the two deleted categories. Please review the new descriptions in the chart below. The maximum reimbursement rates for the existing codes have not changed.

    Code

    Revised Description

    B4150

    Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories= 1 unit

    B4152

    Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

    B4153

    Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

    B4154

    Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories=1 unit

    B4155

    Enteral formula nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g. glucose polymers),proteins/amino (e.g. glutamine, arginine), fat (e.g. medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories= 1unit

    The coverage criteria for these items have not changed. Refer to DMA's Clinical Coverage Policy web page for detailed coverage information.

    Providers are reminded that the rates listed are the maximum reimbursement rates. Providers must bill their usual and customary charges for all services.

    CAP Case Managers are reminded to use the modifier BO to indicate that the formula is being taken by mouth.

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


    Attention: Medical Doctors and Osteopaths

    HCPCS Code A4550

    Medical doctors and osteopaths can now refile claims for HCPCS supply code A4550 for dates of service February 11, 2004 through July 16, 2004 that were incorrectly denied with EOB 79 "this service is not payable to your provider type in accordance with Medicaid guidelines."

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


    Attention: Mental Health Providers

    Enrollment for Mental Health Providers

    By March 1, 2005, Medicaid will accept enrollment applications from mental health providers and facilities in South Carolina, Virginia, Tennessee, and Georgia that are located within a 40 mile radius of the North Carolina border. To determine if you are located with 40 miles of the North Carolina border refer to our zip code list at Participation requirements for these providers will be available on our website and published in the March bulletin.

    Provider Services
    DMA, 919-855-4050


    Attention: All Providers

    NCLeads Update

    Information related to the implementation of the new Medicaid Management Information System, NCLeads, scheduled for implementation in mid-2006 can be found online at http://ncleads.dhhs.state.nc.us. Please refer to this website for information, updates, and contact information related to the NCLeads system.

    Thomas Liverman, Provider Relations
    Office of MMIS Services
    919-647-8315


    Attention: Nursing Facility Providers

    Nursing Facility Rate Increase

    Effective with date of service January 17, 2005, a rate increase has been calculated and approved for nursing facilities. This is an average increase of 1.85 percent based on due to both inflation and a change in the efficiency factor. All services provided on January 17, 2005 through March 31, 2005 will be reimbursed at this revised rate.

    Nancy Vincent, Rate Setting
    DMA, 919-855-4180


    Attention: Prescribers and Pharmacists

    Correction for Removal of Smoking Cessation Medications and Products from the Prior Authorization Drug List

    The article published in the November 2004 general Medicaid bulletin on the Removal of Smoking Cessation incorrectly defined Nicotrol NS as a nicotine patch. Nicotrol NS is actually the acronym for nasal spray. The corrected article is as follows:

    Removal of Smoking Cessation Medications and Products from the Prior Authorization Drug List

    Effective with date of service August 25, 2004, the following smoking cessation medications and products no longer require prior authorization from Medicaid:

    There is no limit to the number of times a recipient can receive these medications and products.

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


    Attention: Physicians and Nurse Practitioners

    Pemetrexed, 500 mg (Alimta) - Billing Guideline Changes

    The effective date of coverage by the Physician’s Drug Program for Alimta has changed from June 1, 2004 to March 1, 2004. Detailed billing instructions were published in the June 2004 general Medicaid bulletin. Effective with date of service January 1, 2005, the code was changed to J9305. Providers should bill with the code that was in effect for specific dates of service as shown in the table below. Providers may refile claims that denied for dates of service between March 1, 2004 and June 1, 2004.

    Dates of Service

    HCPCS Codes

    March 1, 2004 through December 31, 2004

    J9999 with invoice

    January 1, 2005 and after

    J9305 without invoice

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


    Attention: Physicians and Nurse Practitioners

    Bevacizumab (Avastin) - Billing Guideline Changes

    The effective date of coverage by the Physician’s Drug Program for Avastin has changed from June 1, 2004 to March 1, 2004. Detailed billing guidelines were published in the June 2004 general Medicaid bulletin. Providers were notified in the October 2004 general Medicaid bulletin that, effective with date of service October 1, 2004, the code was changed to S0116. Effective with date of service January 1, 2005, the code was changed to J9035. Providers should bill with the code that was in effect for specific dates of service as shown in the table below. Providers may refile claims that denied for dates of service between March 1, 2004 and June 1, 2004.

    Dates of Service

    HCPCS Code

    March 1, 2004 through September 30, 2004

    J9999 with invoice

    October 1, 2004 through December 31, 2004

    S0116 without invoice

    January 1, 2005 and after

    J9035 without invoice

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


    Attention: Home Infusion Therapy (HIT) Providers and Community Alternatives Programs (CAP) Case Managers

    New Pediatric Enteral Supply Codes

    The following pediatric enteral supply codes have been added to the fee schedule effective with date of service February 1, 2005 and after.

    New
    Code

    Description

    Maximum Reimbursement Rate

    B4157

    Enteral formula, nutritionally complete, for special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins, & minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

    $1.15#

    B4158

    Enteral formula, for pediatric nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins & minerals, may include fiber, administered through an enteral feeding tube, 100 cal = 1 unit

    $0.63#

    B4159

    Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins & minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 cal = 1 unit

    $0.63#

    B4160

    Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins & minerals, may include fiber, administered through an enteral feeding tube, 100 cal = 1 unit

    $0.53#

    B4162

    Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins & minerals, may include fiber, administered through an enteral feeding tube, 100 cal = 1 unit

    $1.15#

    B4161

    Enteral formula, for pediatrics, hydrolyzed/amino acids & peptide chain proteins, includes fats, carbohydrates, vitamins & minerals, may include fiber, administered through an enteral feeding tube, 100 cal = 1 unit

    $1.80#

    Note: The pound sign (#) indicates the rates are temporary rates until Medicare's established rates are published.

    Refer to DMA's Clinical Coverage Policy web page for detailed coverage information. Providers are reminded that the rates listed are the maximum reimbursement rates. Providers must bill their usual and customary rate for all enteral supplies CAP Case Managers are reminded to use the modifier BO to indicate that the formula is being taken by mouth.

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


    Attention: UB-92 BILLERS

    Revenue Codes: RC070 and RC077

    The following revenue codes were end dated retroactively for any dates of service on or after January 1, 2004.

    Revenue Codes

    RC 070

    Adolescent Psychiatric R&B

    RC 071

    Child Psychiatric R&B

    RC 072

    Substance Abuse Rehab

    RC 073

    Other Rehab Private

    RC 074

    Adolescent Psychiatric Semi Private

    RC 075

    Child Psychiatric Semi Private

    RC 076

    Substance Abuse Semi Private

    RC 077

    Other Rehab Semi Private

    Claims filed with these revenue codes after March 1, 2005 for dates of service on or after January 1, 2004 will deny with EOB 537 (Procedure Code or Procedure/Modifier code combination is not covered for this date of service).

    Refer to the following chart of the revenue code that should now be billed for these services:

    Previous Revenue Code

    New Revenue Code

    RC 070

    RC 114

    RC 071

    RC 114

    RC 072

    RC 116

    RC 073

    RC 118*

    RC 074

    RC 124

    RC 075

    RC 124

    RC 076

    RC 126

    RC 077

    RC 128*

     

    Note: The asterisk (*) indicates revenue codes that were effective with dates of service January 1, 2004. Claims that were previously paid with the revenue codes 070-077 will not be recouped.

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


    Proposed Clinical Coverage Policies

    In accordance with Session Law 2003-284, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA’s website. 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.

    Gina Rutherford
    Division of Medical Assistance
    Clinical 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

    January 6, 2005

    February 8, 2005

    March 15, 2005

    January 11, 2005

    February 15, 2005

    March 22, 2005

    January 19, 2005

    February 24, 2005

    March 31, 2005

    January 27, 2005

    March 8, 2005

    April 12, 2005

    Electronic Cut-Off Schedule

    December 30, 2004

    February 4, 2005

    March 11, 2005

    January 7, 2005

    February 11, 2005

    March 18, 2005

    January 14, 2005

    February 18, 2005

    March 24, 2005

    January 21, 2005

    March 4, 2005

    April 8, 2005

    2005 Checkwrite Schedule

    _____________________   _____________________
    Gary H. Fuquay, Director   Cheryll Collier
    Division of Medical Assitance   Executive Director
    Department of Health and Human Services   EDS

     

    DMA Home

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    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.