March 2007 Medicaid Bulletin

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In This Issue...

NPI Articles:

All Providers:

CAP/DA Lead Agencies and AQUIP USERS:

Mental Health Providers:

Nursing Facility Providers:

Pharmacy Providers:

Physicians and Nurse Practitioners:

 


Attention:  All Providers

Correction to Updated National Provider Identifier (NPI) Collection Forms

The Division of Medical Assistance (DMA) is currently collecting National Provider Identifier (NPI) numbers from Medicaid providers. Healthcare providers are required to complete one NPI collection form for each Medicaid provider number to ensure that North Carolina Medicaid captures the NPIs which will be used for claims processing. There are now two different collection forms on the DMA Web site: one for individual provider numbers and one for group provider numbers. Providers who have obtained an organizational or group NPI must complete an NPI collection form for the group provider number. In addition, an individual NPI collection form must be completed for each individual provider number within the group.

The required fields for completing the NPI collection form are: Medicaid Provider Number, NPI, Physical and Billing address including ZIP +4 and taxonomy code(s). If more than three taxonomy codes need to be linked to one NPI number, an additional taxonomy page has been provided on the Web site. Providers can link up to 15 taxonomies to one NPI. Also, providers need to include a copy of the notification letter from the National Plan and Provider Enumeration System (NPPES). We will be adding the NPI information and ZIP code +4 to our database. If the address information does not match what is currently in our system, the address information will not be overlaid. Any change will require a separate change request form.

The collection forms are located on DMA's NPI web page. Forms must be typed and returned no later than March 31, 2007. The form can be returned by the mail, fax or email addresses listed on the form. Providers will receive a confirmation notice once the NPIs have been added.

NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!  

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


Attention:  All Providers

Have you Reported your National Provider Identifier (NPI) to the Division of Medical Assistance (DMA)?

Only 25 percent of providers have reported their National Provider Identifier (NPI) to the Division of Medical Assistance (DMA). You must report an NPI for each of your Medicaid provider numbers to the DMA’s Provider Enrollment unit to comply with HIPPA guidelines. (Atypical providers excluded.) At this time, the National Plan and Provider Enumerator are not providing NPI information to health plans.

Instructions and addresses to report the NPI and taxonomy number can be found on the DMA's NPI web page. Two options are available for submitting this information: the NPI Collection Spreadsheet (EDI) and the NPI Collection form. Instructions for both are posted on DMA's NPI web page. A copy of the NPI certification (either letter or email) from the National Plan and Provider Enumeration System (NPPES) must be included with each submission to update your DMA provider enrollment file. (If the same NPI represents multiple Medicaid provider numbers, only one NPPES certification is needed.) The NPI reporting process will not be complete without this information. The NPI must be reported and the NPPES certification must be submitted to DMA Provider Enrollment by March 31, 2007.

NPI Poses No Change in Medicaid Policy or Billing Requirements:

The implementation of NPI requirements does not change Medicaid policy or current billing requirements. Claims processing will not be affected by such NPI changes as taxonomy codes and NPI numbers. Program coverage, reimbursement and Medicaid policy remain the same. Please continue to refer to program enrollment and guidelines to file claims.

How NPI Will Affect Remittance and Status Reports:

Beginning with NPI implementation on May 18, 2007, providers will no longer be able to submit Medicaid provider numbers on claims. Remittance and Status Reports (RAs) will be affected by this change. Paper RAs will change to contain both the NPI submitted on the claim and the Medicaid provider number. On 835 transactions, only the NPI will be reported. Since claims are processed on the Medicaid provider number, providers may receive multiple 835 transactions.

How NPI Implementation Relates to Taxonomy Codes:

Taxonomy codes will be required on claims upon NPI implementation. The taxonomy codes are mandatory on both paper and electronic claims. For electronic claims, follow the rules of the 837 Implementation Guides to populate the taxonomy for billing and attending provider numbers. For paper claims, the taxonomy must be populated for both billing and attending provider numbers. Claims missing taxonomy codes will deny.

Get It! Share It! Use It! Now! Getting one is free - Not having one can be costly!

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


 

Attention: All Providers

National Provider Identifier (NPI) Seminars (Reprint from February 2007 General Medicaid Bulletin)

National Provider Identifier (NPI) seminars are being held during the month of March 2007. Seminars are intended for providers that would like more detailed information on how N.C. Medicaid will be implementing NPI.

The seminars are scheduled at the locations listed below. Pre-registration is required. Due to limited seating, registration is limited to two staff members per office. Unregistered providers are welcome to attend if space is available.

Providers may register for the NPI seminars by completing and submitting the following registration form or by registering online. Sessions will begin at 9 a.m. and end at 12 noon. Providers are encouraged to arrive by 8:45 a.m. to complete registration.

Tuesday, March 6, 2007
Hickory Metro Convention Center
1960 13th Ave Drive S.E.
Hickory, North Carolina

Wednesday, March 7, 2007
Crowne Plaza and Resort
One Holiday Inn Drive
Asheville, North Carolina

Thursday, March 8, 2007
Holiday Inn Express
1700 Winkler Street
Wilkesboro, North Carolina

Tuesday, March 13, 2007
Crystal Coast Civic Center
3505 Arendell St.
Morehead City, North Carolina

Thursday, March 15, 2007
Coastline Convention Center
501 Nutt Street
Wilmington, North Carolina

Monday, March 19, 2007
Holiday Inn Select
5790 University Parkway
Winston-Salem, North Carolina

Tuesday, March 20, 2007
The Blake Hotel
555 S. McDowell Street
Charlotte, North Carolina

Thursday, March 22, 2007
Jane S. McKimmon Center
1101 Gorman Street
Raleigh, North Carolina

Tuesday, March 27, 2007
Hilton
207 S.W. Greenville Blvd
Greenville, North Carolina

Wednesday, March 28, 2007
Hampton Inn
115 Hampton Drive
Edenton, North Carolina

Directions to the NPI Seminars

Hickory Metro Convention Center – Hickory
Traveling East on I-40: Take Exit 125 toward Lenoir-Rhyne College/Hickory and bear right on Lenoir-Rhyne Blvd SE. Travel 0.1 mile and turn left on 13th Ave SE.

Traveling West on I-40: Take exit 125 toward Lenoir-Rhyne College/Hickory- go 0.4 mi. Turn left on Lenoir-Rhyne Blvd SE and travel 0.3 miles. Turn left on 13th Ave SE.

Crowne Plaza and Resort – Asheville
Traveling West on I-40: Take Exit 53 to I-240 West. Pass downtown Asheville. As you cross the French Broad River Bridge, stay in the right lane and take Exit 3B, Westgate and Resort Drive (formerly Holiday Inn Drive). Pass the Westgate Shopping Center on your right. After passing Mr. Transmission, you will see our entrance sign. Turn right onto Resort Drive and proceed to the main entrance.

Traveling East on I-40: Take Exit 46 (left exit) for I-240 East. Continue on I-240 and stay in the left lane. Take Exit 3A. Circle around right and exit onto Patton Avenue. Turn right at the second light into Regent Business Park (between Denny’s and Pizza Hut). Turn right; the entrance is on the left around a curve approximately 1000 yards. Follow Resort Drive to the main entrance of the resort on the left.

Holiday Inn Express- Wilkesboro
Traveling West: Take 421N and turn right on Winkler Mill Rd. Turn Left on Winkler St.
Traveling East: Take 421S and turn left on Winkler Mill Rd. Turn Left on Winkler St.

Crystal Coast Civic Center- Morehead City
Traveling from the West: Take I-40 to US 70E to Morehead City. The Civic Center is located on the right on Hwy 70/Arandall St. near Carteret General Hospital and adjacent to Carteret Community College.

Traveling from the North or South: Take I-95 to US 70E to Morehead City. The Civic Center is located on the right on Hwy 70/Arandall St. near Carteret General Hospital and adjacent to Carteret Community College.

Coastline Convention Center – Wilmington
From I-40 East / Raleigh Durham Area: Follow Interstate 40 East to Wilmington. As you approach Wilmington, turn right onto MLK Parkway/74 West/Downtown. Continue on route to downtown and it will become 3rd Street. Follow 3rd Street for five blocks until you reach Red Cross Street. Turn right onto Red Cross Street and follow for two blocks. Turn right onto Nutt Street. Second drive way on left is the entrance to the convention center.

From Hwy 17 S. (Jacksonville area): Stay on Hwy 17 S. as it turns into Market Street. Follow Market Street until you see the sign for 74 West / Downtown (MLK Parkway). Take 74 West (MLK Parkway) to downtown (approx 4 miles), turn right on Red Cross Street, come 2 blocks, turn right on Nutt Street. Second drive way on left is the entrance to the convention center.

From Hwy 17 N. or Hwy 74-76 (Myrtle Beach or Fayetteville area): Come across the Cape Fear Memorial Bridge into Wilmington. Take a left at the first stoplight onto 3rd Street and come downtown. Follow 3rd Street to Red Cross Street and turn left at the stoplight. Go to the bottom of the hill (approximately 3 blocks). Take a right onto Nutt Street, turn left into the main parking lot of the Coast Line Center.

Holiday Inn Select- Winston-Salem
From the East or West: Take I-40 to NC Hwy 52 North, travel 8 miles to exit 115B (University Pkwy South). Hotel is on the right.

From the North: Take Hwy 52 South, to University Parkway exit- EXIT 115. Keep right at the fork toward University Parkway. Hotel is on the left.

From the South: Take Hwy 52 North to exit 115B (University Pkwy South). Hotel is on the right.

The Blake Hotel – Charlotte
From I-77, take exit 9B onto I-277/John Belk Freeway. From I-277, take Exit 1E and take Caldwell St. Exit. Merge left onto Caldwell St, then right on Stonewall at first signal. Turn left onto South McDowell. The Blake Hotel is on the right.

Jane S. McKimmon Center – Raleigh
Traveling East on I-40: Take Exit 295 and turn left onto Gorman Street. Travel approximately 2.5 miles. The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

Traveling West on I-40: Take Exit 295 and turn right onto Gorman Street. Travel approximately 2.5 miles. The McKimmon Center is located on the right at the corner of Gorman Street and Western Boulevard.

Hilton – Greenville
Traveling East- take 64 east to 264 east. Follow 264 east to Greenville. Turn right on Allen Rd. once you enter Greenville. Go approx. 2 miles and Allen Rd. turns into Greenville Blvd/Alternate 264. Follow Greenville Blvd. for 2 1/2 miles, the Hilton Greenville is located on the right.

Traveling South: Take 64 to US-13 S/NC-11 S. Continue to follow NC-11 S. Turn left onto US-Greenville Blvd. The hotel is on the left.

Traveling North: Take NC Highway 11 North to Greenville. Turn right onto Greenville Blvd. Hotel is
approximately one mile ahead on the right.

Hampton Inn- Edenton
From Hwy. 17 - Take Exit 227 then turn on Hwy 32 North for a Quarter of a mile. Make a right onto Hampton Drive.

NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!

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


Attention:  All Providers

2007 CPT Update

Effective March 1, 2007, rates for the 2007 CPT codes were revised based on information from the Centers for Medicare and Medicaid Services (CMS). This revision includes the CPT codes for Independent Labs. Due to the rate freeze that is currently in effect, only those rates that CMS decreased were revised.  All other codes remained at their current rate. 

Providers may receive a current fee schedule by completing and submitting a copy of the Fee Schedule Request form.

As of March 2, 2007, revised fee schedules will be available on the Division of Medical Assistance (DMA) Fee Schedule web page. Providers must bill their usual and customary charges.

Financial Management
DMA, 919-855-4200


Attention: All Providers

Basic Medicaid Seminars

Basic Medicaid seminars are being held during the month of April 2007. Seminars are intended to educate providers on the basics of Medicaid billing.

The seminars are scheduled at the locations listed below. Pre-registration is required. Due to limited seating, registration is limited to two staff members per office. Unregistered providers are welcome to attend if space is available.

Providers may register for the Basic Medicaid seminars by completing and submitting the following registration form or online. Sessions will begin at 9 a.m. and end at 12 noon. Providers are encouraged to arrive by 8:45 to complete registration.

Providers must print the PDF version of the April 2007 Basic Medicaid Billing Guide, which will be available on Friday, April 13, 2007, from DMA’s website and bring it to the seminar.

Tuesday, April 17, 2007
Holiday Inn
1707 Owen Drive
Fayetteville, N.C.

Wednesday, April 18, 2007
Jane S. McKimmon Center
1101 Gorman Street
Raleigh, N.C.

Tuesday, April 24, 2007
Holiday Inn
6426 Burnt Poplar Road
Greensboro, N.C.

Monday, April 30, 2007
Crown Plaza
One Resort Drive
Asheville, N.C.

Directions to Basic Medicaid Seminars

Holiday Inn Bordeaux – Fayetteville
Traveling East on I-40: Take exit 38 toward Sanford. Turn right onto Martin Luther King Jr / US-421. Continue to follow US-421 S. Turn right onto NC-87 S. Turn right onto Santa Fe Dr. Turn left to take the All American Freeway/ Wilkes Road ramp. All American Freeway becomes Owen Drive.

Traveling West on I-40: Take exit 328A for I-95 S. Merge onto I-95 BR S / US-301 S via Exit 56. Travel approximately 8.6 miles. Turn right onto Owen Drive.

Jane S. McKimmon Center – Raleigh
Traveling East on I-40: Take exit 295 and turn left onto Gorman Street. Travel approximately 2.5 miles. The McKimmon Center is located on the right on the corner of Gorman Street and Western Boulevard.

Traveling West on I-40: Take exit 295 and turn right into Gorman Street. Travel approximately 2.5 miles. The McKimmon Center is located on the right on the corner of Gorman Street and Western Boulevard.

Holiday Inn – Greensboro
Traveling East on I-40: Take exit 211 and turn left off exit ramp. At first light turn left on Burnt Poplar Road. Holiday Inn will be on right.

Traveling West on I-40: Take exit 211 and turn right off exit ramp. At first light turn left on Burnt Poplar Road. Holiday Inn will be on right.

Crowne Plaza – Asheville
Traveling West on I-40: Take Exit 53 to I-240 West. Pass downtown Asheville. As you cross the French Broad River Bridge, stay in the right lane and take Exit 3B, Westgate and Resort Drive (formerly Holiday Inn Drive). Pass the Westgate Shopping Center on your right. After passing Mr. Transmission, you will see our entrance sign. Turn right onto Resort Drive and proceed to the main entrance.

Traveling East on I-40: Take Exit 46 (left exit) for I-240 East. Continue on I-240 and stay in the left lane. Take Exit 3A. Circle around right and exit onto Patton Avenue. Turn right at the second light into Regent Business Park (between Denny’s and Pizza Hut). Turn right; the entrance is on the left around a curve approximately 1000 yards. Follow Resort Drive to the main entrance of the resort on the left.


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. 

Clinical Policy and Programs
DMA, 919-855-4260


Attention: All Providers

Corrected 1099 Requests – Action Required by March 1, 2007

Providers who received more than $600 in Medicaid payments in calendar year 2006 have been sent 1099 MISC tax forms from EDS. The 1099 MISC tax forms, which were generated as required by IRS guidelines, were mailed to providers in January 2007 and reflect the tax information on file with Medicaid as of the last Medicaid checkwrite cycle date, December 21, 2006.

Providers whose tax name or tax identification number is incorrect on the 1099 MISC (for example, misspelled or transposed) must request a correction to the form to ensure that accurate tax information is on file with Medicaid and is sent to the IRS annually. When the IRS receives incorrect information on a 1099 MISC, it may require backup withholding in the amount of 28 percent of future Medicaid payments. The IRS could require EDS to initiate and continue this withholding to obtain correct tax data.

 Please Note: Claims billed under an individual provider number rather than a group number are considered income to the individual, so the 1099 will reflect the individual's tax ID rather than a Federal ID number (which is associated with a group provider number). Corrected 1099s will not address this discrepancy. Instead, please bill under the group number as soon as the issue is identified.

Requests for correction to original 1099 MISC forms must be submitted to EDS by March 1, 2007, and must be accompanied by the following documentation:

Fax both documents to 919-816-3186 (Attention: Corrected 1099 Request – Financial) 

Or

Mail both documents to: 

EDS
Attention: Corrected 1099 Request - Financial
4905 Waters Edge Drive
Raleigh NC 27606

A copy of the corrected 1099 MISC will be mailed to you for your records. All corrected 1099 MISC requests will be reported to the IRS. In some cases, additional information may be required to ensure that the tax information on file with Medicaid is accurate. Providers will be notified by mail of any additional action that may be required to complete the correction to their tax information. 

EDS, 1-800-688-6696 or 919-851-8888 


Attention: All Providers

Correction to Updated CPT Codes 90467, 90468, 90473 and 90474—Coverage of Immunization Administration Codes for Oral/Intranasal Vaccines

The following article is reprinted with an addition from the January 2007 issue of the general Medicaid bulletin. The first table, injectable vaccines from private sector providers, was inadvertently omitted.

 Effective with date of service August 1, 2006, the N.C. Medicaid program covers CPT codes for the intranasal and oral administration of vaccines/toxoids. Their code descriptors are as follows.

 90467: Immunization administration under 8 years of age (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid) per day. (For N.C. Medicaid, do not report in addition to 90465.)

 90468: Each additional administration (single or combination vaccine/toxoid) per day (list separately in addition to code for primary procedure). (For N.C. Medicaid, use 90468 in conjunction with 90465.)

 90473: Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid). (For N.C. Medicaid, do not report in addition to 90471.)

 90474: Each additional vaccine (single or combination vaccine/toxoid). (List separately in addition to code for primary procedure.) (For N.C. Medicaid, use 90474 in conjunction with 90471.)

The current codes used for immunization administration and their descriptors are as follows.

 90465: Immunization administration under 8 years of age (includes percutaneous, intradermal, subcutaneous or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid) per day. (For N.C. Medicaid, do not report 90465 in conjunction with 90467.)

 90466: Immunization administration under 8 years of age (includes percutaneous, intradermal, subcutaneous or intramuscular injections) when the physician counsels the patient/family; each additional injection (single or combination vaccine/toxoid) per day. (List separately in addition to code for primary procedure.) (For N.C. Medicaid, use in conjunction with 90465 or 90467.)

 90471: Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections); one vaccine (single or combination vaccine/toxoid). (For N.C. Medicaid, do not report 90471 in conjunction with 90473.)

 90472: Immunization administration (includes percutaneous, intradermal, subcutaneous or intramuscular injections); one vaccine (single or combination vaccine/toxoid) each additional vaccine (single or combination vaccine/toxoid). (List separately in addition to code for primary procedure.) (For N.C. Medicaid, use 90472 in conjunction with 90471.)

The following principles should guide the billing of the eight codes described above:   
1. Apply the appropriate code depending on the age of the recipient and whether or not the physician has counseled the recipient and family.
2. CPT codes 90465 and 90466 are in the same code family, and 90471 and 90472 are in the same code family. A code from one injectable code family cannot be used with a code from another injectable code family.
3. CPT codes 90467 and 90468 are in one code family and 90473 and 90474 are in another code family. A code from one intranasal/oral code family cannot be used with a code from the other intranasal/oral code family.
4. The physician counseling codes should not be used as an “add-on” counseling code to the other administration codes.
5. Physicians, nurse practitioners and physician assistants may perform these services.
6. When billing 90465, 90466, 90467 or 90468 the physician, nurse practitioner or physician assistant must perform face-to-face vaccine counseling associated with the administration and should document such. The physician, nurse practitioner, or physician assistant is not required to administer the vaccine.
7. A “first” administration is defined as the first vaccine administered to a recipient during a single patient encounter.
8. At the present time, there should not be an occasion to bill a second intranasal/oral vaccine administration code.
9. When billing one or more injectable vaccines along with one oral/intranasal vaccine, the code for the first injectable vaccine is the primary code.

Billing Guideline Examples for Immunizations for Recipients Birth through Age 20

Vaccine: Injectable            
Provider Type: Private Sector Providers

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one vaccine, bill 90465EP.

For two or more vaccines, bill 90465EP and 90466EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

For one vaccine bill 90471EP.

For two or more vaccines bill 90471EP and 90472EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one vaccine, bill 90465EP.

For two or more vaccines, bill 90465EP and 90466EP.

Report CPT vaccine code(s).

One immunization diagnosis code is required.

For one vaccine, bill 90471EP.

For two or more vaccines, bill 90471EP and 90472EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

For one vaccine, bill 90465EP.

For two or more vaccines, bill 90465EP and 90466EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

For one vaccine, bill 90471EP.

For two or more vaccines, bill 90471EP and 90472EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

Core Visit with Immunization(s)

N/A

N/A

 

Vaccine:  Injectable
Provider Type:  FQHC/RHC

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one vaccine, bill 90465EP.

For two vaccines or more, bill 90465EP and 90466EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

For one vaccine, bill 90471EP.

For two vaccines or more, bill 90471EP and 90472EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one vaccine, bill 90465EP.

For two vaccines or more, bill 90465EP and 90466EP.

Report CPT vaccine code(s).

One immunization diagnosis code is required.

For one vaccine, bill 90471EP.

For two vaccines or more, bill 90471EP and 90472EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

N/A

N/A

Core Visit with Immunization(s)

Cannot bill 90465EP or 90466EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) are not required.

Cannot bill 90471EP or 90472EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) are not required.

 

Vaccine:  Injectable
Provider Type:  Local Health Departments

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

Cannot bill 90465EP.

Report vaccine CPT code(s).

Immunization diagnosis code(s) not required.

Cannot bill 90471EP.

Report vaccine CPT code(s).

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one vaccine, bill 90465EP.

For two vaccines or more, bill 90465EP.

Report CPT vaccine code(s).

One immunization diagnosis code is required.

For one vaccine, bill 90471EP.

For two vaccines or more, bill 90471EP.

Report CPT vaccine code(s).

One immunization diagnosis code is required.

Office Visit with Immunization(s)

For one vaccine, bill 90465EP.

For two or more vaccines, bill 90465EP.

Report CPT vaccine code(s).

Immunization diagnosis code(s) not required.

For one vaccine, bill 90471EP.

For two or more vaccines, bill 90471EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Core Visit with Immunization(s)

N/A

N/A

 

Vaccine:  Intranasal/Oral
Provider Type:  Private Sector Providers

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is not required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is not required.

Immunization(s) Only

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is required.

Office Visit with Immunization(s)

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is not required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two or more vaccines – N/A at this time.

Immunization diagnosis code is not required.

Core Visit with Immunization(s)

N/A

N/A

 

Vaccine:  Intranasal/Oral
Provider Type:  FQHC/RHC

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is not required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is not required.

Immunization(s) Only

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is required.

Office Visit with Immunization(s)

N/A

N/A

Core Visit with Immunization(s)

Cannot bill 90467EP.

Report vaccine CPT code.

Immunization diagnosis code is not required.

Cannot bill 90473EP.

Report vaccine CPT code.

Immunization diagnosis code is not required.

 

Vaccine:  Intranasal/Oral
Provider Type:  Local Health Departments

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

Cannot bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A.

Immunization diagnosis code is not required.

Cannot bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A.

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code is required.

Office Visit with Immunization(s)

For one vaccine, bill 90467EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code not required.

For one vaccine, bill 90473EP.

Report vaccine CPT code.

Two vaccines or more – N/A at this time.

Immunization diagnosis code not required.

Core Visit With Immunization(s)

N/A

N/A

 

Vaccine:  Injectable with Intranasal/Oral
Provider Type:  Private Sector Providers

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report CPT vaccine code(s)

Immunization diagnosis code(s) not required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Core Visit With Immunization(s)

N/A

N/A

 

Vaccine:  Injectable with Intranasal/Oral
Provider Type:  FQHC/RHC

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report vaccine CPT codes.

Immunization diagnosis code(s) not required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report vaccine CPT codes.

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP, 90466EP and 90468EP.

Report vaccine CPT codes.

One immunization diagnosis code is required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP, 90472EP and 90474EP.

Report vaccine CPT codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

N/A

N/A

Core Visit with Immunization(s)

Cannot bill 90465EP, 90466EP or 90468EP.

Report vaccine CPT codes.

Immunization diagnosis code(s) are not required.

Cannot bill 90471EP, 90472EP or 90474EP.

Report vaccine CPT codes.

Immunization diagnosis code(s) are not required.

 

Vaccine:  Injectable with Intranasal/Oral
Provider Type:  Local Health Departments

Service Type

With Physician Counseling

Without Physician Counseling

Health Check Screening with Immunization(s)

Cannot bill 90465EP and 90468EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Cannot bill 90471EP and 90474EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Immunization(s) Only

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

Report CPT vaccine codes.

One immunization diagnosis code is required.

Office Visit with Immunization(s)

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90465EP and 90468EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

For one INJECTABLE vaccine and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

For two or more INJECTABLE vaccines and one ORAL/INTRANASAL vaccine, bill 90471EP and 90474EP.

Report CPT vaccine codes.

Immunization diagnosis code(s) not required.

Core Visit with Immunization(s)

N/A

N/A

Billing Guidelines for Immunization Codes for Recipients Aged 21 and Above

Vaccine:  Injectable
Provider Type:  Private Sector Providers

Service Type

Number of Vaccines

 

One

Two or More

Immunization(s) Only

Bill 90471 administration code

Bill vaccine CPT code.

Report diagnosis code as appropriate.

Bill 90471 and 90472

Bill CPT vaccine codes.

Report diagnosis codes as appropriate.

Office Visit with Immunization(s)

Bill 90471 administration code or E/M code. May bill E/M code with modifier 25 appended in addition to 90471 if a separately identifiable service was performed.

Bill vaccine CPT code.

Bill 90471 and 90472. May bill E/M code with modifier 25 appended in addition to 90471 and 90472 if a separately identifiable service was performed.

Bill CPT vaccine codes.

 

Vaccine:  Injectable
Provider Type:  FQHCs and RHCs

Service Type

Number of Vaccines

 

One

Two or More

Immunization(s) Only

Bill under the C suffix .

Bill 90471 administration code.                                      

Report the vaccine CPT code if vaccine was provided at no charge from the state of North Carolina.    

OR

Bill the vaccine CPT code if vaccine was purchased.

Report diagnosis code as appropriate.

Bill under the C suffix.

Bill 90471 and 90472 administration codes.

Report the vaccine CPT codes if vaccines were provided at no charge from the state of North Carolina.

OR

Bill the CPT vaccine codes if the vaccines were purchased.

Report diagnosis codes as appropriate.

Core Visit with Immunization(s)

Immunization administration fees cannot be billed with core visits.

Immunization administration fees cannot be billed with core visits.

 

Vaccine:  Injectable               Provider Type:  Local Health Departments

Service Type

Number of Vaccines

 

One

Two or More

Immunization(s) Only

Bill 90471 administration code.

Bill vaccine CPT code.

Report diagnosis code as appropriate.

Bill 90471 and 90472.

Bill CPT vaccine codes.

Report diagnosis codes as appropriate.

Office Visit with Immunization(s)

Bill 90471 administration code or E/M code. May bill E/M code with modifier 25 appended in addition to the administration code if a separately identifiable service was performed.

Bill vaccine CPT code.

Bill 90471 and 90472. May bill E/M code with modifier 25 appended in addition to 90471 and 90472 if a separately identifiable service was performed.                                                                           

Bill vaccine CPT codes.

Currently, providers cannot bill for an intranasal or oral vaccine alone or in addition to an injectable vaccine for recipients 21 years of age and older. 

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



Attention: All Providers

CPT Code Update 2007 Additions

New Category II and Category III CPT Codes for 2007 were omitted from the January 2007 Medicaid Bulletin Article “CPT Code Update 2007.” Category II and Category III codes are not covered by N. C. Medicaid.

New Category II CPT Codes Not Covered

0012F

1015F

1018F

1019F

1022F

1026F

1030F

1034F

1035F

1036F

1038F

1039F

2010F

2014F

2018F

2022F

2024F

2026F

2028F

3006F

3011F

3014F

3017F

3020F

3021F

3022F

3023F

3025F

3027F

3028F

3036F

3037F

3040F

3042F

3046F

3047F

3048F

3049F

3050F

3060F

3061F

3062F

3066F

3072F

3076F

3077F

3078F

3079F

3080F

4025F

4030F

4033F

4035F

4037F

4040F

4045F

4050F

6055F

 

 

 

New Category III CPT Codes Not Covered

0141T

0142T

0143T

0144T

0145T

0146T

0147T

0148T

0149T

0150T

0151T

0153T

0154T

0155T

0156T

0157T

0158T

0159T

0160T

0161T

0162T

0163T

0164T

0165T

0166T

0167T

0168T

0169T

0170T

 

EDS, 1-800-6696 or 919-851-8888  


Attention: All Providers

Delay in Discontinuing Automatic Newborn Coverage to Children Born to Mothers Receiving Emergency Medicaid

 The Division of Medical Assistance (DMA) was scheduled to implement a policy on March 1, 2007 to eliminate automatic newborn coverage for children born to mothers receiving emergency Medicaid.  This policy change has been delayed until further notice due to pending legislation in U.S. Congress. 

We will notify you of any changes to this coverage through future Medicaid bulletins and contact with provider associations.

 Medicaid Eligibility
DMA, 919-855-4000


Attention:  All Providers

New Claim Form Instructions (Reprint from December 2006 General Medicaid Bulletin)

 The CMS 1500 (12/90), the UB92 and the American Dental Association (ADA) 2002 paper forms have been revised and will be replaced with the new CMS 1500 (08/05), the UB-04 and ADA 2006 claim forms, respectively. 

Providers may access the Special December 2006 Bulletin, New Claim Form Instructions on DMA's website. Providers should contact EDS with any billing questions.

 EDS, 1-800-688-6696 or 919-851-8888


Attention: All Providers

Updated Effective Dates for Revised CMS 1500, UB04 and ADA 2006 Claim Forms

 The National Uniform Claim Committee (NUCC), the National Uniform Billing Committee (NUBC) and the American Dental Association (ADA) have issued revised professional, institutional and dental paper claim formats. 

The revised CMS 1500 (08/05) professional claim form is accepted by Medicaid as of Jan. 1, 2007. In keeping with the NUCC advisory, N.C. Medicaid will require that any paper CMS 1500 claims received by EDS as of April 1, 2007, be filed using the new claim form. To accommodate a transition period for providers, the Division of Medical Assistance will allow providers the option of submitting either the current CMS 1500 (12/90) form or the new CMS 1500 (08/05) form from Jan. 1, 2007, through March 31, 2007, for Medicaid claims as well as provider-submitted Medicare crossover claims. During this transition period, EDS will process using either claim format; however, claims received on or after April 1, 2007, must be filed on the CMS 1500 (08/05).

The new UB04 claim form released by the NUBC for institutional providers to replace the current UB92 claim form will be accepted by N.C. Medicaid beginning March 1, 2007.  As with the CMS 1500 (08/05), the Division of Medical Assistance will allow a transition period for providers to submit either the UB92 or the UB04 until April 30, 2007. Any paper claims received on or after May 1, 2007, must be filed on the UB04 format.   

The revised ADA 2006 claim form (released by the ADA for dental providers to replace the current ADA 2002 claim form) will be accepted by North Carolina Medicaid beginning March 1, 2007. The Division of Medical Assistance will allow a transition period from March 1, 2007, through April 30, 2007, for providers to submit either the ADA 2002 or the ADA 2006 claim forms. Any requests for prior approval or paper claims received on or after May 1, 2007, must be filed on the ADA 2006 form.        

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


Attention:  CAP/DA Lead Agencies and AQUIP Users

Quarterly Automated Quality and Utilization Improvement Program (AQUIP) Training Seminar

The Carolinas Center for Medical Excellence (CCME; www.thecarolinascenter.org) announces continued quarterly training for new AQUIP users in CAP/DA lead agencies.

The first quarterly training session this year will be held on March 27, 2007, at the Hilton Charlotte University Place in Charlotte. Attendance at this meeting is of the utmost importance for new AQUIP users. CAP/DA lead agency contacts have been informed via e-mail of any identified new AQUIP users in their counties who should attend this session. (Current AQUIP users who would like to attend the session may do so if space permits.  However, the information presented will be designed for new AQUIP users.) We recommend that all attendees read and become familiar with the AQUIP User Manual (select “Downloads” at https://www2.mrnc.org/aquip) before the training session. 

The AQUIP seminar is scheduled to begin at 9:00 a.m. and end at 3:00 p.m. The session will focus on understanding how to use the AQUIP 2 system and how to accurately complete the three parts of the AQUIP tool—the Client Information Sheet, the Data Set Assessment and the Plan of Care. 

Pre-registration is required. Contact your CAP/DA lead agency to verify if your name is on the required attendance list. Beginning March 1, 2007, you may register for the seminar by going online to https://www2.mrnc.org/aquip and clicking on Registrations. You will receive a computer-generated confirmation number, which you should bring to the seminar. Check-in will be from 8:30 until 9:00 a.m. on the day of the seminar; lunch will be on your own.

 Directions

 Charlotte: Hilton Charlotte at University Place

From I-85 North or South, take Exit 45A onto W. T. Harris Boulevard East. From the ramp, travel about three-fourths of a mile. The high-rise hotel is located in the University Place complex and is visible from Harris Boulevard. Turn left onto J.M. Keynes Drive, which goes directly into the hotel’s parking lot. 

CCME, 1-800-682-2650


Attention: Mental Health Providers

New Contact Information for ValueOptions

 ValueOptions, the agency that handles mental-health–related prior approvals, is relocating its office and will be unable to retain its current local telephone and fax numbers. ValueOptions’ toll free numbers are not affected by the office move.

Beginning February 24, 2007, the following new fax numbers are operational. Current fax numbers will remain operational until March 31, 2007 to facilitate the transition. Please reset your fax machines accordingly.

SECTION 

FAX LINE  NEW NUMBER   

Medicaid Inpatient

919-461-0967

Medicaid other MH/SA

919-461-0599

Medicaid Developmental Disabilities

919-461-0669

Health Choice

919-379-9035

Beginning February 24, 2007, a voice message advises persons calling current VO employee phone numbers of the new number.

We apologize for any inconvenience this may cause. If you have any questions, please contact ValueOptions Customer Service at  

Medicaid            1-888-510-1150

Health Choice    1-800-753-3224  


Attention: All Nursing Facility Providers

Reminder: Fair Rental Value – North Carolina Medicaid Capital Data Survey 2006

 The Division of Medical Assistance (DMA) is proceeding with the development and implementation of a Fair Rental Value as a capital reimbursement methodology for nursing facilities. A key component to development of the Fair Rental Value rate model is the input by providers on the historical bed additions, bed replacements, and major renovations to each facility.

DMA has posted Nursing Facility Capital Data Survey Information to its Nursing Facility Fair Rental Value web page.

The link contains previously submitted 2004-2005 Capital Survey Data for each facility as well as the forms and instructions to complete the North Carolina Medicaid Capital Data Survey 2006.

Providers are reminded to complete the 2006 survey and submit the completed survey to DMA Rate Setting Section at the address below no later than March 31, 2007. 

Division of Medical Assistance
2501 Mail Service Center
Raleigh, N.C. 27699-2501
Attention: Trish Harper
Direct number: 919-855-4216


Attention: Pharmacy Providers

Synagis Pharmacy Claims for 2006–2007 Season

The last accepted date of service for Synagis pharmacy claims for the 2006–2007 season is March 31, 2007. Synagis claims processing began on October 10, 2006, for this season.

All Synagis requests must be completed on criterion-specific forms, which can be found at the Division of Medical Assistance (DMA) Provider Forms web page. Up to five monthly doses of Synagis can be obtained for each eligible recipient.

Each week, pharmacy distributors should mail DMA copies of the North Carolina Medicaid Synagis for RSV Prophylaxis form. Please mail forms to:

NC Division of Medical Assistance
Pharmacy Program
2501 Mail Service Center
Raleigh NC 27699-2501

Pharmacy distributors with a large volume of Synagis claims should submit the information on a diskette. Microsoft Access is preferred, but an Excel spreadsheet is acceptable; file structure is the most important element of compatibility. Please call Charlene Sampson at (919) 855-4300 for specific instructions and further assistance on diskette submissions.

The N.C. Medicaid program should not be billed for Synagis unless the pharmacy has on file an accurate and complete Synagis for RSV Prophylaxis Form OR a copy of an approval letter by DMA from the Request for Medical Review for Synagis Outside of Criteria Form. Payment of Synagis claims will be reviewed and may be subject to recoupment by Program Integrity if the appropriate forms are not on file.

Clinical Policy
DMA, 919-855-4300


Attention:   Physicians and Nurse Practitioners

Idursulfase/Elaprase (HCPCS Procedure Code J3490)—Billing Guidelines

Effective with date of service August 1, 2006, the N.C. Medicaid program covers idursulfase (Elaprase) injection for use in the Physician’s Drug Program when billed with HCPCS procedure code J3490 (unclassified drugs). Elaprase injection is indicated for the treatment of Hunter Syndrome (mucopolysaccharidosis II, MPS II). The recommended dose of Elaprase is 0.5 mg/kg of body weight administered every week as an intravenous infusion.

 For Medicaid Billing:

One Medicaid unit of coverage is 1 ml. The maximum reimbursement rate per unit is $441.10.

 EDS, 1-800-688-6696 or 919-851-8888 


Proposed Clinical Coverage Policies

In accordance with Session Law 2005-276, 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.

Loretta Bohn
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.


2007 Checkwrite Schedule

Month

Electronic Cut-Off Date

Checkwrite Date

March

03/01/07

03/06/07

 

03/08/07

03/13/07

 

03/15/07

03/20/07

 

03/22/07

03/29/07

 April

04/05/07

04/10/07

 

04/12/07

04/17/07

 

04/19/07

04/26/07

May

05/03/07

05/08/07

 

05/10/07

05/15/07

 

05/17/07

05/22/07

 

05/24/07

05/31/07

 

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.

  

Mark T. Benton, Senior Deputy Director and Chief Operating Officer   Cheryll Collier
Division of Medical Assistance   Executive Director
Department of Health and Human Services   EDS

                                                                                                                  

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