All Providers:
Community Alternatives Program Case Managers:
Dental Providers:
Dialysis Facilities:
Durable Medical Equipment Providers:
End Stage Renal Disease Providers:
Home Health Agencies:
Home Infusion Therapy:
Medical Doctors:
Mental Health Providers:
Nurse Practitioners:
Nursing Facility Providers:
Osteopaths:
Pharmacists and Prescribers:
Physicians:
Private Duty Nursing Providers:
UB-92 Billers:
Attention: All Providers
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
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
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 |
DESCRIPTION |
UNIT |
MAXIMUM |
|
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
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 |
|
D2932 |
Prefabricated resin crown |
$163.01 |
|
D2934 |
Prefabricated esthetic coated stainless steel crown – primary tooth |
$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 |
|
D2933 |
Prefabricated stainless steel crown with resin window |
$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
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
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 |
E1027 |
Lateral/anterior support for pediatric wheelchair, each (includes hardware) |
Rental: New Purchase: Used Purchase: |
41.32# 413.25# 309.94# |
2 yrs |
|
E1091 |
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 |
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 |
E2368* |
Power wheelchair component, motor, replacement only |
Rental: New Purchase: Used Purchase: |
51.67 516.57 387.44 |
2 yrs |
|
K0108 |
E2369* |
Power wheelchair component, gear box, replacement only |
Rental: New Purchase: Used Purchase: |
45.00 449.94 337.45 |
2 yrs |
|
K0108 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
E1235* |
Wheelchair, pediatric size, rigid, adjustable, with seating system |
Rental: New Purchase: Used Purchase: |
185.75 1857.43 1393.07
|
3 yrs |
|
W4122 |
E1236* |
Wheelchair, pediatric size, folding, adjustable, with seating system |
Rental: New Purchase: Used Purchase: |
163.87 1638.73 1229.05
|
3 yrs |
|
W4122 |
E1237* |
Wheelchair, pediatric size, rigid, adjustable, without seating system |
Rental: New Purchase: Used Purchase: |
165.30 1653.05 1239.80 |
3 yrs |
|
W4122 |
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 |
Description
|
Modifier |
Maximum |
|
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.
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 |
New |
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
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
EDS, 1 800-688-6696 or 919-851-8888
Attention: Durable Medical Equipment Providers
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
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.
|
Current |
New |
Description |
Billing |
Maximum Reimbursement |
|
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.
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 A4550Medical 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
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
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
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
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
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
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 |
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
|
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.
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 |
|
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 |
| _____________________ | _____________________ | |
| Gary H. Fuquay, Director | Cheryll Collier | |
| Division of Medical Assitance | Executive Director | |
| Department of Health and Human Services | EDS |
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.