In This Issue . . .

All Providers:

• Checkwrite Schedule Change
• Electronic Funds Transfer Form – Fax Number Change for Submittals
• Electronic Funds Transfer Form
• Fee Schedule Request Form
• Positron Emission Tomography Scans - Billing Guidelines
• Revised Rates for 2004 CPT Codes
• Checkwrite Schedule
• Electronic Cut-off Schedule
• Holiday Observance

Anesthesiologists:

• Billing for Anesthesia Services Using Anesthesia Modifiers

Certified Registered Nurse Anesthetist:

• Billing for Anesthesia Services Using Anesthesia Modifiers

Dental Providers:

• Surgery of the Lingual Frenulum

Health Check Providers:

• Directions to Health Check Seminars
• Health Check Seminars
• Registration Form for Health Check Seminars

Health Departments:

• Training for Local Health Departments on Changes in Health Check Requirements and Billing

Hospitals:

• Billing for Anesthesia Services Using Anesthesia Modifiers
• Crossover Claims Issues

Local Education Agencies:

• Revision to Rates for Local Education Agency Services

Personal Care Services:

• Seminars for Personal Care Services, Personal Care Services-Plus, and Private Duty Nursing Services

Physicians:

• Billing for Ocular Photodynamic Therapy with Verteporfin
• Surgery of the Lingual Frenulum
• Physicians Drug Program List Update

Private Duty Nursing Providers:

• Seminars for Personal Care Services, Personal Care Services-Plus, and Private Duty Nursing Services

Attention: All Providers

Checkwrite Schedule Change

The June 24, 2004 checkwrite date has changed to June 22, 2004. The electronic cut-off date for this checkwrite will remain June 18, 2004.

2004 Checkwrite Schedule

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

Attention: All Providers

Electronic Funds Transfer Form – Fax Number Change for Submittals

Providers are instructed to use the following fax number when submitting the Electronic Funds Transfer (EFT) Authorization Agreement for Automatic Deposits form to the EDS Financial Unit: 919-816-3192.

EDS offers EFT as an alternative to paper checks. This service enables Medicaid payments to be automatically deposited in the provider’s bank account. EFT guarantees payment in a timely manner and prevents checks from being lost or stolen.

To initiate the automatic deposit process, providers are required to complete and return an EFT form. To confirm the provider’s account number and bank transit number, a voided check must be attached to the form. A separate EFT form and voided check must be submitted for each provider number. Providers must also submit a new EFT form and voided check if they change banks or bank accounts.

Completed forms may be faxed to the number listed above or mailed to the address listed on the form.

Note: Providers will continue to receive paper checks for two checkwrite periods before automatic deposit begins or resumes to a new bank account. Providers may verify that the EFT process for automatic deposit has been completed by checking the top left corner of the last page of their Remittance and Status Report, which will indicate EFT number rather than check number.

Electronic Funds Transfer Form

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

Attention: All Providers

General Medicaid Billing Seminars

Seminars on general Medicaid billing guidelines are scheduled for June 2004. Registration information and a list of dates and site locations for the seminars will be published in the May 2004 general Medicaid bulletin.

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

Attention: All Providers

Positron Emission Tomography Scans – Billing Guidelines

Positron emission tomography (PET) is covered in both an inpatient and outpatient setting. No prior approval is needed. The following codes are covered for billing PET scans:

Physician Claims (CMS-1500)

For Medicaid billing, providers must enter the CPT code in block 24D and indicate the billing unit as a 1 in block 24G on the CMS-1500 claim form.

Hospital Claims (UB-92)
The following code is effective with date of service February 14, 2004:

RC404 – Other Imaging Services-Positron Emission Tomography

For Medicaid billing, providers must enter the revenue code in form locater 42 and indicate the service unit as a 1 in field locator 46 on the UB-92 claim form.

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

Attention: Anesthesiologists, Certified Registered Nurse Anesthetists, and Hospitals

Billing for Anesthesia Services using Anesthesia Modifiers

Effective with date of processing May 15, 2004, the Division of Medical Assistance (DMA) will implement the use of anesthesia modifiers. The following guidelines must be used when billing anesthesia services.

Anesthesia Modifiers and their Definitions
QX - CRNA Service: with medical direction

QZ - CRNA Service: without medical direction

QY - medical direction of one CRNA by an anesthesiologist

QK - medical direction of 2, 3 or 4 concurrent anesthesia procedures

AA - anesthesia services performed personally by anesthesiologist

One of the modifiers listed above must be appended to the anesthesia CPT code each time anesthesia is billed. The AA modifier indicates that the entire service was performed personally by the anesthesiologist. Modifier AA indicates that no medical direction was provided to a Certified Registered Nurse Anesthetists (CRNAs) and that the anesthesiologist performed the entire service. When medical direction has been provided, the appropriate anesthesia modifier must be appended to the anesthesia CPT code for the anesthesiologist claim (either QY or QK) and the CRNA claim (QX). If the CRNA performs the service without medical direction, the QZ modifier must be appended to the anesthesia CPT code.

QS - Monitored Anesthesia Care|
When monitored anesthesia care is billed, the QS modifier must be billed with one of the modifiers listed above to indicate that the service was either personally performed (AA, QZ) or medically directed (QK, QX or QY).

Medical Direction Criteria
To bill for medical direction, the anesthesiologist must:

1. perform the pre-anesthesia evaluation and exam;2. prescribe the anesthesia;

2. prescribe the anesthesia;

3. participate personally in the induction and emergence of the anesthesia procedure;

4. assure that any part of the anesthesia plan not personally performed by the anesthesiologist is performed by a qualified CRNA;

5. monitor the course of anesthesia administration at frequent intervals;

6. remain physically present (in the operating suite) to provide diagnosis and treatment in an emergency situation; and

7. provide post anesthesia care.

Documentation Requirements for Medical Direction
If a CRNA rendered the service, the service must be billed with the applicable modifier, either QZ or QX, to distinguish if the service was provided with medical direction or provided without medical direction. Medical direction must be documented in the medical record. When all of the criteria for medical direction listed above are not met, the CRNA services must be billed on the CMS-1500 claim form with modifier QZ indicating that the CRNA performed services without medical direction. Should review of medical records fail to document medical direction, recoupment of paid claims will be initiated and further investigation of the practice will be pursued by DMA.

A. CRNA performs services without medical direction:

1. CRNA is employed by hospital or facility and no anesthesiologist is present:

The hospital bills the CRNA professional charges on the CMS-1500 claim form using the hospital's professional number in the group area in block 33 and the CRNA’s number as the attending number in block 33. Modifier QZ must be appended to the CPT code indicating CRNA services were performed without medical direction.

The hospital’s facility charges are billed on the UB-92 claim form with a Revenue Code (RC) in the 37X range. Only the facility charges are included in the RC code. CRNA professional charges must not be included in the RC code. The surgeon bills for the surgical charges on the CMS-1500 claim form.

2. CRNA is employed by anesthesiologist:

When the CRNA is employed by an anesthesiologist(s) and renders services without medical direction of an anesthesiologist, the CRNA services are billed on the CMS-1500 claim form using the physician’s group number in block 33 and the CRNA’s number in the attending field. Modifier QZ is appended to the CPT code to indicate that the service was performed without medical direction.

B. CRNA renders services with medical direction provided by anesthesiologist:

1. CRNA is employed by hospital or facility:

The CRNA professional charges are billed on the hospital’s professional claim appending modifier QX to the CPT code, indicating that medical direction was provided. The hospital’s professional number is entered in block 33 and the CRNA’s attending number is entered in the attending area in block 33.

The hospital’s facility charges are billed on the UB-92 claim form with RC in the 37X range. Only the facility charges are included in the RC code. CRNA professional charges must not be included in the RC code.

The anesthesiologist performing medical direction appends either modifier QY or QK to the anesthesia CPT code on the CMS-1500 claim form.

2. CRNA is employed by anesthesiologist:

When the anesthesiologist provides medical direction of a CRNA who is employed by the anesthesiologist, the anesthesiologist bills the medical direction and the CRNA service on separate claims. The medical direction modifier QK or QY is appended to the CPT code on the physician claim. The physician’s group number is placed in block 33 of the CMS-1500 claim form with the physician’s individual number in the attending area of block 33. The medical direction modifier QX is appended to the CPT code on the CMS-1500 claim for the CRNA service. The physician group number is placed in block 33 and the CRNA number is placed in block 33 in the attending area.

Guidelines for Billing Anesthesia Services With or Without Medical Direction

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

Attention: All Providers

Revised Rates for 2004 CPT Codes

Effective January 1, 2004, rates for the 2004 CPT codes were revised based on information from the Centers for Medicare and Medicaid Services (CMS). These rates were subsequently revised on February 18, 2004 based on additional information released by CMS on January 7, 2004. Systematic adjustments will be made for claims that have processed for dates of service January 1, 2004 through February 18, 2004.

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

Providers must bill their usual and customary charges.

Fee Schedule Request Form

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

Attention: Health Check Providers

Health Check Seminars

Health Check seminars for all providers except health departments are scheduled for May 2004. Attendance at these seminars is very important due to changes in Health Check billing requirements. The seminars will emphasize vision and hearing assessments and developmental screening requirements.

A separate teleconference for local health departments sponsored by the Division of Public Health is scheduled for Thursday, May 6, 2004. Health departments should refer to article titled Training for Local Health Departments on Changes in Health Check Requirements and Billing for information on registering for the teleconference. Both the seminars and the teleconference will use the April 2004 Special Bulletin I, Health Check Billing Guide 2004, as the primary handout for the session. Providers must access and print the PDF version of the special bulletin from DMA’s website and bring it to the session.

Preregistration is required. Unregistered providers are welcome to attend the seminars if space is available. Providers may register by completing the Health Check Seminar Registration Form or through Online Registration. Please indicate on the registration form the session you plan to attend. Seminars are scheduled to begin at 10:00 a.m. and end at 1:00 p.m. or earlier. Lunch will not be served. Providers are encouraged to arrive by 9:45 a.m. to complete registration.

• Health Check Seminar Schedule
• Directions to Seminars
• Health Check Seminar Registration Form
• Health Check Seminar Online Registration
• April 2004 Special Bulletin I, Health Check Billing Guide 2004
• Training for Local Health Departments on Changes in Health Check Requirements and Billing

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

Schedule for the Health Check Seminars

Directions to the Health Check Seminars

Jane S. McKimmon Center – Raleigh, North Carolina
Traveling East on I-40
Take exit 295 and turn left onto Gorman Street. Travel approximately one mile. 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 one mile. The McKimmon Center is located on the right before you reach Western Boulevard.

Coast Line Convention Center – Wilmington, North Carolina
Take I-40 east to Wilmington. Take the Highway 17 exit. Turn left onto Market Street. Travel approximately 4 or 5 miles to Water Street. Turn right onto Water Street. The Coast Line Inn is located one block from the Hilton on Nutt Street behind the Railroad Museum.

Holiday Inn Bordeaux – Fayetteville, North Carolina
Traveling South on I-95
Take exit 56 to Hwy 301 to Owen Drive. Turn right at the light.

Traveling North on I-95
Take exit 56 to Hwy 301 to Owen Drive. Turn left at the light.

Greenville Hilton – Greenville, North Carolina
Take Highway 64 East to Highway 264 East. Follow 264 East to Greenville. Once you enter Greenville, turn right on Allen Road. After approximately 2 miles, Allen Road becomes Greenville Boulevard/Alternate 264. Follow Greenville Boulevard for 2 ½ miles. The Greenville Hilton is located on the right.

Holiday Inn Conference Center – Salisbury, North Carolina
Traveling South on I-85
Take exit 75. Turn right onto Jake Alexander Boulevard. Travel approximately ½ mile. The Holiday Inn is located on the right.

Traveling North on I-85
Take exit 75. Turn left onto Jake Alexander Boulevard. Travel approximately ½ mile. The Holiday Inn is located on the right.

Ramada Inn – Burlington, North Carolina
Traveling East on I-85/40
Take exit 143 and turn right onto Alamance Road. Turn left at the first stop light onto Ramada Road. The Ramada Inn is on the right.

Traveling West on I-85/40
Take exit 143 and turn left onto Alamance Road. Turn left at the first stop light onto Ramada Road. The Ramada Inn is on the right.

A-B Technical College – Asheville, North Carolina
Directions to the College
Take I-40 to exit 50. Travel north on Hendersonville Road, which becomes Biltmore Avenue. Continue on Biltmore Avenue toward Memorial Mission Hospital. Turn left onto Victoria Road.

Campus
Stay on Victoria Road. Turn right between the Holly Building and the Simpson Building. The Laurel Building/Auditorium is located on the right, behind the Holly Building.

Park Inn Gateway Conference Center – Hickory, North Carolina
Take I-40 to exit 123. Follow signs to Highway 321 North. Take the first exit (Hickory exit) and follow the ramp to the stoplight. Turn right at the light onto Highway 70. The Gateway Conference Center is on the right.

Attention: Health Departments

Training for Local Health Departments on Changes in Health Check Requirements and Billing

A training session is scheduled for local health department staff from 9:00 a.m. through 1:00 p.m. on May 6, 2004 via the Public Health Training and Information Network (PHTIN). This session, entitled Health Check - 2004 Update, will cover the changes in clinical requirements and billing for the Health Check Program.

Registration information has been sent to local health departments. If you do not receive this registration information by April 1, 2004, please contact the Public Health Nursing & Professional Development Unit in the Division of Public Health at 919-733-6850. The target audience for this session is both clinical staff who perform the Health Check screenings (since the developmental screening changes will have a major impact on the clinical delivery of the Health Check service) and billing staff.

The April 2004 Special Bulletin I, Health Check Billing Guide 2004, is the primary handout for this session. Attendees must access and print the PDF version of this special bulletin from the Division of Medical Assistance’s website. Copies will not be provided onsite.

Joy Reed, Local Technical Assistance and Training
Division of Public Health, 919-715-4385

Attention: Personal Care Services Providers and Private Duty Nursing Providers

Seminars for Personal Care Services, Personal Care Services-Plus, and Private Duty Nursing Services

Seminars for Personal Care Services (PCS), Personal Care Services-Plus (PCS-Plus), and Private Duty Nursing (PDN) Services are scheduled for June 2004. The seminars will focus on changes to billing as a result of the implementation of the national code sets mandated by the Health Insurance Portability and Accountability Act (HIPAA). Registration information and a list of dates and site locations for the seminars will be published in the May 2004 general Medicaid bulletin.

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

Attention: Local Education Agencies Providers

Revision to Rates for Local Education Agency Services

Effective with date of service January 1, 2003, the rates for services provided by Local Education Agencies (LEAs) were changed. This table replaces the information published in Appendix B of the December 2002 Special Bulletin VII, HIPAA Code Conversion for Independent Practitioners and Local Education Agencies.

Systematic adjustments will be made for claims that were billed with a provider’s usual and customary rate and who received the FFP cutback.

Note: Reimbursement rates will change as the FFP percentages change.

Refer to the Medical Coverage Policy #8H, Local Education Agencies on DMA’s website for additional information on billing for LEA services.

• December 2002 Special Bulletin VII, HIPAA Code Conversion for Independent Practitioners and Local Education Agencies
• Medical Coverage Policy #8H, Local Education Agencies

Jackie Holloway and Pam Munson, Financial Operations
DMA, 919-857-4015

Attention: Physicians

Billing for Ocular Photodynamic Therapy with Verteporfin

Effective with date of service January 1, 2001, the N.C. Medicaid program covers ocular photodynamic therapy (OPT) with verteporfin (Visudyne). Claims that were previously denied for dates of service between January 1, 2001 and March 31, 2004 may be refiled as a new claim. The requirement to request a time limit override for claims billed with CPT codes J3490 or J3395 for dates of service between January 1, 2001 and March 31, 2003 has been waived. Providers are encouraged to file claims electronically.

The Medicaid unit of coverage is one 15 mg vial. The maximum reimbursement rate per unit is $1,381.50.

Refer to Medical Coverage Policy # 1A-13, Ocular Photodynamic Therapy for additional coverage criteria.

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

Attention: Dental Providers and Physicians

Surgery of the Lingual Frenulum

The policy guidelines for surgery of the lingual frenulum on recipients less than 30 days of age have changed. If the recipient is less than 30 days old and is having problems feeding due to tongue tie, the procedures described by CPT codes 41010 or 41115 can be provided without requesting prior approval. The provider must bill CPT code 41010 or 41115 along with both ICD-9-CM diagnoses codes 750.0 (tongue tie) and 779.3 (feeding problems in the newborn). Prior approval continues to be required for surgery of the lingual frenulum that does not meet the criteria listed above.

Medical Coverage Policy # 1A-16, Surgery of the Lingual Frenulum, has been revised to reflect this change and is now available on the Division of Medical Assistance’s website.

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

Attention: Physicians

Physician’s Drug Program List Update

The following table lists the FDA approved drugs currently covered by the N.C. Medicaid program when the drugs are provided in a physician’s office for the FDA approved indications. This list replaces previously published lists. Rates are effective with date of service April 1, 2004.

Physicians will continue to bill on the CMS-1500 claim form using the appropriate drug code and indicating the specified number of units administered. Providers must bill their usual and customary charges.

(*) Designates that an invoice must be submitted with the CMS-1500 claim form. An invoice must be submitted with each claim. The paper invoice must indicate the name of the recipient, the recipient’s Medicaid identification number, 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. Providers must indicate the number of units given in block 24G on the CMS-1500 claim form. Payment is based in accordance with Medicaid’s State Plan for reimbursement. Providers will be reimbursed the lower of the invoice price or maximum allowable fee on file.