In This Issue . . .

• Claim Adjustments for Physician, Laboratory, and Independent Mental Health Procedure Codes
• Hepatitis A and Hepatitis B Vaccine, Adult Dosage, for Intramuscular Use (CPT Code 90636, 1 ml, Twinrix) Coverage Criteria
• Influenza – New Diagnosis Code for the Need for Vaccination Against Influenza
• Optional Sixth Dose of Synagis for the 2003-04 RSV Season for Previously Approved Infants
• Payment Accuracy Measurement Project for 2004-05
• Physicians Drug Program Changes
• Updated EOB Code Crosswalk to HIPAA Standard Codes
• Checkwrite Schedule
• Electronic Cutoff Schedule
• Proposed Medical Coverage Policies

Durable Medical Equipment Providers:

• Addition to Medical Coverage Policy #5, Durable Medical Equipment
• National Miscellaneous HCPCS Codes

Health Check Providers:

• Health Check Seminars

Hospitals:

• Medicaid Cost Reports

Nursing Facility Providers:

• Correction to Instructions for Obtaining Retroactive Prior Approval

Attention: All Providers

Hepatitis A and Hepatitis B Vaccine, Adult Dosage, for Intramuscular Use (CPT Code 90636, 1 ml, Twinrix) Coverage Criteria

Effective with date of service January 1, 2004, the N.C. Medicaid program covers Twinrix, the combination hepatitis A and hepatitis B vaccine. Twinrix is FDA approved for persons 18 years of age and older who are at risk of both hepatitis A and hepatitis B infection. Twinrix is normally given as a series of three 1.0 ml injections over a six-month period of time at intervals of 0, 1, and 6 months. CPT code 90636 must be billed for Twinrix.

The N.C. Medicaid program reimburses for vaccines in accordance with guidelines from the Advisory Committee on Immunization Practices (ACIP). Information regarding the risk categories pertinent to hepatitis vaccines may be found at http://www.cdc.gov/nip/ACIP/default.htm.

The North Carolina Immunization Branch distributes Twinrix vaccine at no charge to health departments only. It is to be administered to those persons 18 years of age and older who present to the local health department for any reason with any of the following risk criteria:

• men who have sex with men
• IV drug users
• persons with multiple sex partners
• any person who has been incarcerated
• persons who are hepatitis C or are HIV positive
• persons with chronic liver disease, including persons with chronic HBV/HCV infection who have evidence of chronic liver disease
• persons seeking treatment for a sexually transmitted disease (STD)

1. Medicaid does not reimburse local health departments for the cost of Twinrix vaccine supplied by the North Carolina Immunization Branch. Medicaid only reimburses local health departments for the administration of Twinrix vaccine.

Local health departments must bill CPT code 90471 for the administration of Twinrix vaccine. When billing for Health Check recipients aged 18 through 20, refer to Special Bulletin I, April 2003, Health Check Billing Guide 2003.

2. Because Twinrix can only be supplied at no cost from the North Carolina Immunization Branch to local health departments, private providers may bill Medicaid for the cost of Twinrix vaccine for high-risk adults aged 18 years and over using CPT code 90636.

Private providers may bill for the administration of Twinrix vaccine using CPT code 90471. When billing for Health Check recipients aged 18 through 20, refer to Special Bulletin I, April 2003, Health Check Billing Guide 2003.

3. For recipients aged 21 years and over, an Evaluation and Management (E/M) code cannot be reimbursed on the same day that injection administration fee code 90471 is reimbursed unless the provider bills an E/M code for a separately identifiable service by appending modifier 25 to the E/M code.
   
4. For recipients aged 21 years and older, diagnosis code V05.3 must be billed. When billing for Health Check recipients aged 18 through 20, refer to Special Bulletin I, April 2003, Health Check Billing Guide 2003 for diagnosis code billing guidelines.

For Medicaid billing, one unit of coverage is 1 ml. Providers must indicate the number of units given in block 24G on the CMS-1500 claim form. The maximum reimbursement rate for Twinrix is $85.04 per unit. Providers must bill their usual and customary charges.

Claims that were denied for dates of service January 1, 2004 and after may be refiled as new claims.

Special Bulletin I, April 2003, Health Check Billing Guide 2003

Attention: All Providers

Claim Adjustments for Physician, Laboratory, and Independent Mental Health Procedure Codes

N.C. Medicaid will be adjusting claims for physician procedure codes, laboratory procedure codes, and independent mental health procedure codes that had a rate change in 2003. These adjustments will begin on the March 2, 2004 checkwrite and will continue for at least three of the following checkwrites. Should you have any questions, please contact EDS Provider Services at 1-800-688-6696.

Attention: All Providers

Optional Sixth Dose of Synagis for the 2003-04 RSV Season for Previously Approved Infants

In September 2003, the criteria for prescribing Synagis for the 2003-04 respiratory syncytial virus (RSV) season was posted on ACS State Healthcare’s website at http://www.ncmedicaidpbm.com. The criteria calls for up to five total doses of Synagis during the 2003-04 RSV season. This decision is supported both in the literature and in the American Association of Pediatrics’ Redbook guidelines.

In February 2004, a group of pediatric and infectious disease specialists met to evaluate the current RSV season in North Carolina. They determined that in certain parts of North Carolina the RSV season may extend an additional month. Thus, depending on the prevalence of RSV in their community, N.C. Medicaid providers may choose to prescribe a 6^th dose of Synagis given on or before March 31, 2004 for those infants who have already received approval for the 2003-04 season. The end date for the 6^th dose is based on evidence that effectiveness of the drug extends well past 30 days.

In accordance with the American Association of Pediatrics’ guidelines, children born in March should receive their March dose prior to discharge from the hospital.

If an additional dose is required due to prevalence of RSV in the community, medical providers should contact their pharmacy provider. The pharmacy provider will be able to adjudicate the prescription claim through point of sale (POS) by March 1, 2004.

The Improper Payments Act of 2002 (HR 4878) requires federal government agencies to provide an estimate of their improper payments annually. CMS has awarded funding to 27 states to pilot and test a sampling and to review methodology in preparation for a nationwide implementation in the near future. The Division of Medical Assistance (DMA) will again be participating with this effort.

Sampling

DMA Program Integrity staff will:

• Select a statisically valid, random stratified sample for both Medicaid and the N.C. Health Choice programs. The mandatory strata will be:

1. inpatient hospital services,
2. long-term care services,
3. independent practitioners and clinics,
4. prescription drugs,
5. home and community based services
6. other supplies and services, and
7. primary care case management.

• Select approximately 500 claims that paid in calendar year 2003.
• Contact each provider associated with a sampled paid claim and request specific medical documentation and records that support the services provided. (Note: If you are contacted, it is critical that you return this information as quickly as possible.)
• Review each claim and capitation payment in detail to determine whether or not the claim was paid accurately (there was sufficient medical documentation in the provider’s medical record to support the claim, all necessary prior approvals were obtained; the provider complied with DMA policies and procedures, recipient was eligible on date of service, etc.).

Consequences of Non-response

If the medical documentation is not submitted, the claim will be coded as an error and will be recouped. Because the dollars in error are projected onto the total claims universe in North Carolina, the consequence of each error or non-response magnifies its impact. If the error rate is excessive, DMA may have to add controls or other limitations to address any problem areas that are identified. Therefore, even a small dollar claim payment can have a significant impact on how a particular service area is perceived.

Also, please note that requests for medical records are a permitted disclosure under HIPAA privacy regulations. 45 CFR 164.512 states that " a covered entity may disclose protected health information to a health oversight agency for oversight activities authorized by law, including audits…or other activities necessary for the appropriate oversight of (1) the health care system; (2) government benefit programs for which health information is relevant to beneficiary eligibility; (3) entities subject to government regulatory programs for which health information is necessary for determining compliance with program standards; or (4) entities subject to civil rights laws for which health information is necessary for determining compliance." In addition, Medicaid providers are required to comply with a medical records request from an authorized Medicaid employee.

We appreciate your continued cooperation. If you have any questions, please contact Chuck Brownfield, DMA Program Integrity at 919-733-6681, ext. 275. More information about the PAM project can be found at http://www.pampilot.org/tiki-custom_home.php

Attention: All Providers

Influenza - New Diagnosis Code for the Need for Vaccination Against Influenza

This article was originally printed in the January 2004 general Medicaid bulletin under the title Influenza - New Diagnosis Code V04.81. This article is being reprinted to clarifiy that ICD-9-CM diagnosis code V04.81 is used to indicate that there is a need for a vaccination against influenza. This code is not used to indicate that the recipient has influenza.

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

Influenza - New Diagnosis Code V04.81, January 2004 Medicaid Bulletin

Attention: All Providers

Updated EOB Code Crosswalk to HIPAA Standard Codes

The list of standard national codes used on the Electronic Remittance Advice (ERA) has been cross-walked to EOB codes as an informational aid to adjudicated claims listed on the RA. An updated version of the list will be available on March 10, 2004 on the Division of Medical Assistance’s website at http://www.dhhs.state.nc.us/dma/prov.htm.

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

The EOB codes that providers currently receive on a paper RA are not used on the ERA. Because the EOB codes on the paper RA provide a greater level of detail on claim denials, all providers will continue to receive the paper version of the RA, even if they choose to receive the ERA transaction. The list is current as of the date of publication. Providers will be notified of changes to the list through the general Medicaid bulletin.

EOB Crosswalk to Standard Codes

Attention: All Providers

Physician’s Drug Program Changes

Effective with date of service January 1, 2004, the N.C. Medicaid program covers the new HCPCS codes listed in the table below. Effective with dates of service March 31, 2004, the old codes will be end-dated. Claims submitted for dates of service on or after April 1, 2004 with the end-dated codes will deny. Refer to the table below for the new HCPCS codes and their corresponding end-dated codes.

Note: The units of coverage on several drugs have changed and some drugs no longer require an invoice to be submitted with the claim. As a reminder, the paper invoice must include the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, the number of vials used, and the cost per dose. Where an invoice is required, one must be submitted with each claim.

Providers must indicate the number of units given in block 24G on the CMS-1500 claim form. Providers must bill their usual and customary charges.

Correction to Instructions for Obtaining Retroactive Prior Approval

A correction has been made to the February 2004 general Medicaid bulletin article titled A Reminder about Retroactive Prior Approval. EDS may only approve up to 30 days of retroactive coverage by telephone. Retroactive coverage exceeding 30 days, but less than 90 days must be made in writing and include all pertinent medical records for the dates of service requested.

Requests for retroactive coverage exceeding 90 days must be submitted to DMA. The request must be made in writing and include all pertinent medical records for the dates requested. DMA will not approve requests for retroactive coverage exceeding 180 days from the date of receipt of the records that document the level of care requested.

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.

A Reminder about Retroactive Prior Approval, February 2004 Medicaid Bulletin

Attention: Durable Medical Equipment Providers

National Miscellaneous HCPCS Codes

Effective with date of service March 1, 2004, national miscellaneous HCPCS codes will replace state-created codes as indicated below. The change is being made to comply with the implementation of standard national codes mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Prior Approval

All of these national miscellaneous HCPCS codes require prior approval beginning with dates of service March 1, 2004. Both the national miscellaneous HCPCS code and the state-created code must be indicated on the Certificate of Medical Necessity and Prior Approval Form (CMN/PA). Enter the national miscellaneous HCPCS code in the "HCPCS Code" block on the CMN/PA form. The state-created code must be entered in the "Equipment Description" field.

For example, if providing a "Basic head/neck support w/ hardware (ea)" and a "Solid back equipment with hardware (ea)," indicate that you are requesting prior approval for rental of K0108 for W4131, "Basic head/neck support w/ hardware (ea)" by entering the K0108 in the "HCPCS Code" field with the state-created code W4131 entered in the "Equipment Description" field. On the next line, enter K0108 in the "HCPCS Code" field with the state-created code W4128, "Solid back equipment with hardware (ea)" entered in the Equipment Description field. Include the "from" and "to" dates for each piece of equipment that is needed. All existing documentation requirements remain the same.

Note: Prior approval will be given for a year for state-created codes listed under national miscellaneous HCPCS code A9900 and B9998 if the prescribing physician, physician’s assistant or nurse practitioner deems them medically necessary for a year and writes the prescription for a year.

The EDS prior approval staff will enter an 11-digit number in the "Service Review Number" field beside each item approved with a national miscellaneous code. Providers must use this number when submitting claims for payment for national miscellaneous codes.

When submitting a claim, providers must enter the 11-digit service request number (SRN) from the approved CMN/PA form in block 23 of the CMS-1500 claim form or in the "PA-Num" field if submitting electronically (EVS, NCECS, 837 or tape). This is different from previous billing procedures. If the SRN is not included on the claim when billing for a national miscellaneous code, the claim cannot be processed for payment and will be denied.

Providers can only submit one national miscellaneous code per claim. If a provider submits multiple national miscellaneous codes on the same claim, the claim cannot be processed for payment. Providers may submit other HCPCS codes on the claim with the national miscellaneous code as long as there is only one miscellaneous code per claim.

Note: The appropriate modifier must be included on the claim in order for the claim to process.

Providers who have already received an approval for any of these items that crosswalked to any of the national miscellaneous codes and who have approval dates that extend into March 2004 will receive by mail the appropriate SRNs for use on those claims. For any item requested on or after March 1, 2004, providers must use the SRN entered by the EDS prior approval staff on the CMN/PA form.

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

Attention: Durable Medical Equipment Providers

Addition to Medical Coverage Policy #5, Durable Medical Equipment

A new attachment has been added to Medical Coverage Policy #5, Durable Medical Equipment. Attachment D, Frequently Asked Questions, has been renumbered as Attachment E. The new Attachment D is a listing of lifetime expectancies and quantity limitations for items on the DME Fee Schedule.

Attention: Hospitals

Medicaid Cost Reports

During the week of February 9, 2003, the Medicaid Provider Statistics and Reimbursements (PS&Rs) for the fiscal year ending June 30, 2003 were mailed to the Hospital Chief Financial Officers. The due date for the June 30, 2003 Medicaid Cost Report will be the later of 30 days after the due date of the Medicare Cost Report or March 19, 2003.

EDS is currently preparing the PS&Rs for the fiscal year ending September 30, 2003 but does not have a projected mailing date at this time. The due date for the September 30, 2003 Medicaid Cost Report will be the later of 30 days after the due date of the Medicare Cost Report or 30 days after the mailing of the Medicaid PS&Rs.

The Division of Medical Assistance’s Supplemental Cost Report forms are available to download from DMA’s website at http://www.dhhs.state.nc.us/dma/prov.htm under the heading "Cost Reports." When filing the Medicaid Cost Report, DMA will need a paper copy and an electronic file of the Medicare Cost Report as well as a paper copy and electronic file of the Medicaid Supplemental Forms.

DMA will update the Cost Report filing deadlines as more information becomes available from EDS and Palmetto GBA.

Supplemental Cost Report forms

Attention: Health Check Providers

Health Check Seminars

Health Check seminars for all providers except health departments are scheduled for May 2004. The April 2004 general Medicaid bulletin will have the registration form and a list of site locations for the seminars. Attendance at these seminars is very important due to changes in Health Check billing requirements. The seminars will also focus on vision and hearing assessments and developmental screening requirements.

A separate teleconference sponsored by the Division of Public Health is scheduled for health department providers. The April general Medicaid bulletin will include registration information for the teleconference.

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.

Electronic Cut-Off Schedule

• 2004 Checkwrite Schedule
• 2004 Holiday Observance Schedule