March 2004 Medicaid Bulletin

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In This Issue . . .

All Providers:

Durable Medical Equipment Providers:

Health Check Providers:

Hospitals:

Nursing Facility Providers:


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/.

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:

Reimbursement Guidelines

  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.
  2. 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.

  3. 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.
  4. 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.

  5. 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.
  6. 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

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


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.

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


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 6th 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 6th 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.

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


 

Attention: All Providers

Payment Accuracy Measurement Project for 2004-05

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:

    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.

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.

Medical Record Requests

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.

Chuck Brownfield, Program Integrity
DMA, 919-733-6681, ext. 275


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

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


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 HIPAA web page.

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

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


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.

New Code

Maximum Reimbursement Rate

Description

Old Code

Description

J0152

$ 68.37

Injection, adenosine, 30 mg (not to be used to report any adenosine phosphate compounds;

J0151

Injection, adenosine, 90 mg (not to be used to report any adenosine phosphate compounds;

J0215

$ 28.19
Invoice not required

Injection, alefacept 0.5 mg (Amevive)

J3490

Injection, alefacept, 7.5 mg or 15 mg (Amevive)

J0595

$ 3.94

Injection, butorphanol tartrate, 1 mg (Stadol)

S0009

Injection, butorphanol tartrate, 1 mg (Stadol)

J2001

$ 0.88

Injection, lidocaine HCl for intravenous infusion, 10 mg

J2000

Injection, lidocaine HCl, 50 cc

J2354

$ 3.81

Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg

S0079

Injection, octreotide acetate, 100 mcg (Sandostatin)

J2353

$138.19 - 10 mg
$ 79.35 - 20 mg
$ 71.12 - 30 mg
Invoice required

Injection, octreotide, depot form for intramuscular injection, 1 mg (Sandostatin)

J2352

Injection, octreotide acetate, 1 mg (Sandostatin LAR depot, pricing based on 10, 20 or 30 mg)

J2505

$ 2,507.50

Injection, pegfilgrastim, 6 mg (Neulasta)

S0135

Injection, pegfilgrastim, 6 mg, (Neulasta)

J9178

$ 24.73

Injection, epirubicin HCl, 2 mg

J9180

Injection, epirubicin hydrochloride, 50 mg

J9263

$ 8.45

Injection, oxaliplatin, 0.5 mg (Eloxatin)

J9999

Injection, oxaliplatin, 50 mg (Eloxatin)

J9395

$ 78.37

Injection, fulvestrant, 25 mg (Faslodex)

J9999

Injection, fulvestrant, 25 mg (Faslodex)

S0107

$ 76.68
Invoice not required

Injection, omalizumab, 25 mg (Xolair)

J3490

Injection, omalizumab, 150 mg (Xolair)

S0115

$ 930.24
Invoice not required

Injection, bortezomib, 3.5 mg

J9999

Injection, bortezomib, (Velcade) 3.5 mg

J3490

$ 6.94
Invoice is required

Injection, kutapressin, up to 1 ml

J1910

Injection, kutapressin, up to 2ml

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.

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


 

Attention: Nursing Facility Providers

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

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


 

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).

New HCPCS Code

Old State-Created Code

A9900

W4120
W4153
W4651
W4670
W4672
W4673
W4678

Disposable bags for Inspirease inhaler system, set of 3
Tracheostomy ties, twill
Blood glucose test strips
Sterile saline, 3cc vial
Gray adapter for use w/ external insulin pump
Piston rod for use w/ external insulin pump
Replacement battery for portable suction pump

B9998

Low profile gastrostomy equipment:

 

W4210
W4211
W4212

Low profile gastrostomy kit
Low profile gastrostomy extension/replace kit for continuous feed
Low profile gastrostomy extension/replace kit for bolus feed

E1399

Ambulatory devices:

 

W4688
W4689
W4690
W4691
W4695

Single point cane for weights 251# to 600#
Quad point cane for weights 251# to 600#
Crutches for weights 251# to 600#
Fixed height forearm crutches for weights to 600#
Glides/skis for use w/ walker

 

Bariatric replacement mattresses for hospital beds:

 

W4733
W4734
W4735
W4736
W4737

Replacement overszd innerspring matt for hosp bed w/ width to 39"
Replacement overszd innerspring matt for hosp bed w/ width to 48"
Replacement overszd innerspring matt for hosp bed w/ width to 54"
Replacement overszd innerspring matt for hosp bed w/ width to 60"
Trapeze bar, freestanding w/ grab bar for weights 451# to 750#

 

Bariatric hospital beds:

 

W4726
W4730
W4731
W4732

Total electric hosp bed weights 351# to 450# w/ matt and side rails
Total electric hosp bed 451# to 1000# w/ width 39"w/ matt and side rails
Total electric hosp bed 451# to 1000# w/ width 48"w/ matt and side rails
Total electric hosp bed 451# to 1000# w/ width 54"w/ matt and side rails

 

Other equipment:

 

W4001
W4002
W4016
W4047
W4633

CO/2 saturation monitor w/ accessories, probes
Manual ventilation bag
Bath seat, pediatric
Miscellaneous pediatric equipment
Eggcrate mattress pad

K0009

Manual pediatric wheelchairs:

 

W4122
W4123
W4124

Pediatric wheelchair, lightweight manual
Pediatric wheelchair, lightweight manual w/ growth system
Pediatric wheelchair, ultra lightweight manual

 

Manual bariatric wheelchairs:

W4696
W4697

Manual wheelchair for weights 451# to 600#
Manual wheelchair for weights 651# and greater

K0014

Power pediatric wheelchairs:

 

W4125
W4126

Pediatric wheelchair, power, rigid frame
Pediatric wheelchair, power, folding frame

 

Power bariatric wheelchairs:

 

W4704
W4705
W4706

Power wheelchair for weights 251# to 600#
Power wheelchair for weights 651# to 1000#
Power wheelchair for weights 1001# and greater

K0108

W4005
W4117
W4118
W4119
W4128
W4129
W4130
W4131
W4132
W4133
W4134
W4135
W4136
W4137
W4138
W4139
W4140
W4141
W4143
W4144
W4145
W4146

Unlisted replacement or repair parts
Wheelchair seat width, cost added option from manufacturer
Wheelchair seat depth, cost added option from manufacturer
Wheelchair seat height, cost added option from manufacturer
Solid back equipment with hardware (ea)
Solid seat equipment with hardware (ea)
Contoured or 3-piece head/neck supports with hardware (ea)
Basic head/neck support w/ hardware (ea)
Contoured or 3-piece head/neck supports with adj. hardware (ea)
Basic head/neck support w/ adj. hardware (ea)
Shoulder stabilizers w/ hardware, including pads (pr)
Shoulder stabilizers w/ hardware, including H-strap (ea)
Fixed thoracic supports w/ hardware (pr)
Adjustable thoracic supports w/ hardware (pr)
Hip/thigh supports w/ hardware (pr)
Sub-asis bars w/ hardware (ea)
Abductor pads w/ hardware (pr)
Knee blocks w/ hardware (pr)
Shoe holders w/ hardware (pr)
Foot/legrest cradle (ea)
Manual tilt-in-space option (ea)
Power tilt-in-space option (ea)

 

Bariatric wheelchair components:

 

W4147
W4148
W4150
W4151
W4152
W4155
W4698
W4699
W4700
W4701
W4702
W4703
W4707
W4708
W4709
W4710
W4711
W4712
W4713
W4714
W4715
W4716
W4717
W4718
W4719
W4720
W4721
W4722
W4723

Power recline (ea)
Modular back w/ hardware (ea)
Multi-adj. tray (ea)
Specialty controls w/ hardware (ea)
Growth kit (ea)
Abductor pads w/ hardware (pr)
Seat width 21" and 22" for oversized manual wheelchair
Seat width 23" and 24" for oversized manual wheelchair
Seat width 25" and greater for oversized manual wheelchair
Seat depth 19" and 20" for oversized manual wheelchair
Seat depth 21" and 22" for oversized manual wheelchair
Seat depth 23" and greater for oversized manual wheelchair
Seat width 21" and 22" for oversized power wheelchair
Seat width 23" and 24" for oversized power wheelchair
Seat width 25" and greater for oversized power wheelchair
Seat depth 19" and 20" for oversized power wheelchair
Seat depth 21" and 22" for oversized manual wheelchair
Seat depth 23"and greater for oversized power wheelchair
Oversized footplates for weights 301#
Swingaway special footrests for weight 401# and greater (pr)
Swingaway reinforced legrest elevating for weight 301# to 400# (pr)
Swingaway footrests, elevating for weight 401# and greater (pr)
Oversized calf pads (pr)
Oversized solid seat
Oversized solid back
Oversized 2" cushion
Group 27 Gel cell battery
Oversized full support footboard
Oversized full support calfboard

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.

Claim Submission

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.

Example

 

Type of Claim

 

Electronic

Paper

Dates of Service

03/01/04 – 03/31/04

03/01/04 – 03/31/04

Procedure Billed

K0108 RR

K0108 RR

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.

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


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.

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


 

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 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.

Roger Barnes, Financial Operations
DMA, 919-857-4015


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.

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


Proposed Medical Coverage Policies

In accordance with Session Law 2003-284, proposed new or amended Medicaid medical coverage policies are available for review and comment on DMA’s website. To submit a comment related to a policy, refer to the instructions on the website. Providers without Internet access can submit written comments to the address listed below.

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

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


Checkwrite Schedule

March 2, 2004

April 6, 2004

May 4, 2004

March 9, 2004

April 13, 2004

May 11, 2004

March 16, 2004

April 20, 2004

May 18, 2004

March 25, 2004

May 5, 2004

May 27, 2004

 

Electronic Cut-Off Schedule

February 27, 2004

April 2, 2004

May 7, 2004

March 5, 2004

April 8, 2004

May 14, 2004

March 12, 2004

April 16, 2004

May 21, 2004

March 19, 2004

April 30, 2004

 

 

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.


 

_____________________
_____________________
Gary M. Fuquay, Director
Patricia MacTaggart
Division of Medical Assitance
Executive Director
Department of Health and Human Services
EDS

 

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