April 2004 Medicaid Bulletin

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In This Issue . . .

All Providers:

Anesthesiologists:

Certified Registered Nurse Anesthetist:

Dental Providers:

Health Check Providers:

Health Departments:

Hospitals:

Local Education Agencies:

Personal Care Services:

Physicians:

Private Duty Nursing Providers:


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)

CPT Procedure Code

Description

Effective Date

78459

Myocardial imaging, positron emission tomography (PET)

January 1, 2004

78491

Myocardial imaging, positron emission tomography (PET), perfusion, single study at rest or stress

January 1, 2004

78492

Myocardial imaging, positron emission tomography (PET), perfusion: multiple studies at rest and/or stress

January 1, 2004

78810

Tumor imaging, positron emission tomography (PET), metabolic evaluation

January 1, 2004

78608

Brain imaging, positron emission tomography (PET), metabolic evaluation

September 1, 1998

78609

Brain imaging, positron emission tomography (PET), perfusion evaluation

September 1, 1998

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

Provider Rendering Service

Billing Provider

CMS-1500 Claim Form

UB-92 Claim Form

Anesthesiologist personally performs entire service

Anesthesiologist

AA is appended to the anesthesia CPT code.

No

CRNA employed by hospital performing without medical direction

Hospital facility

Charge

No

Bills RC 37X range

CRNA professional charge

Hospital professional number and CRNA number in block 33.

Append QZ modifier to CPT code

No

Surgeon

Bills CPT code.

No

CRNA employed by hospital performing with medical direction

Hospital facility

Charge

No

Bills RC 37X range

CRNA professional charge

Hospital professional number and CRNA number in block 33.

Append QX to CPT code.

No

Anesthesiologist providing medical direction

If one CRNA append QY to CPT code. If 2, 3 or 4 CRNAs append QK to CPT code.

No

CRNA employed by anesthesiologist performing with medical direction

Hospital facility charge

No

Bills RC 37X range

CRNA professional charge

QX is appended to the CPT code. Use anesthesiology group/attending number in block 33.

No

Anesthesiologist providing medical direction

On separate claim, append QY to the CPT if one CRNA. If 2, 3 or 4 CRNAs, append QK. Bill group/attending number in block 33.

No

CRNA employed by anesthesiologist performing without medical direction

Hospital facility charge

No

Bills RC 37X range

CRNA professional charge

QZ is appended to the CPT code. Anesthesia group bills group/attending in block 33.

No

Anesthesiologist employing CRNA

Anesthesiologist services are not billed when CRNA services are performed without medical direction.

No

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.

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


Schedule for the Health Check Seminars

Tuesday, May 4, 2004
Jane S. McKimmon Center
1101 Gorman St.
Raleigh, NC

Wednesday, May 5, 2004
Coast Line Convention Center
501 Nutt St.
Wilmington, NC

Tuesday, May 11, 2004
Holiday Inn Bordeaux
1707 Owen Dr.
Fayetteville, NC

Wednesday, May 12, 2004
Greenville Hilton
207 Greenville Blvd. SW
Greenville, NC

Tuesday, May 18, 2004
Holiday Inn Conference Center
530 Jake Alexander Blvd., S.
Salisbury, NC

Thursday, May 20, 2004
Ramada Inn
2703 Ramada Rd.
Burlington, NC

Tuesday, May 25, 2004
A-B Technical College
Laurel Building Auditorium
340 Victoria Rd.
Asheville, NC

Wednesday, May 26, 2004
Park Inn
909 Highway 70 SW
Hickory, NC


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.

Procedure Code

Maximum Reimbursement Rate

Procedure Code

Maximum Reimbursement Rate

Procedure Code

Maximum Reimbursement Rate

29075

$ 62.96

95833

$ 41.98

92567

$ 18.86

29085

62.96

95834

62.96

92568

18.86

29105

62.96

96100

79.80

92569

18.86

29125

41.98

96110

79.80

92571

37.72

29126

62.96

96111

79.80

92572

37.72

29130

27.99

96115

79.80

92576

37.72

29131

62.96

96117

79.80

92579

37.72

29240

41.98

97001

167.90

92582

37.72

29260

41.98

97002

83.95

92583

37.72

29280

41.98

97003

167.90

92585

150.90

29405

83.95

97004

83.95

92507

75.45

29505

104.94

97110

20.99

92510

75.45

29515

83.95

97112

20.99

92506

150.90

29530

41.98

97116

20.99

92612

94.31

29540

41.98

97140

20.99

92610

150.90

90801

79.80

97504

20.99

92607

150.90

90802

79.80

97520

20.99

92609

75.45

90804

39.90

97530

20.99

92608

75.45

90806

66.50

97533

20.99

92508

18.86

90808

106.39

97535

20.99

92587

18.86

90810

39.90

97542

20.99

92588

37.72

90812

66.50

97703

20.99

92589

113.17

90814

106.39

97750

20.99

92590

94.31

90846

79.80

92551

18.86

92591

113.17

90853

79.80

92552

18.86

92592

18.86

92065

41.98

92553

37.72

92593

37.72

92526

56.59

92555

18.86

92594

18.86

95831

20.99

92556

37.72

92595

37.72

95832

20.99

92557

75.45

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.

Invoice Required

Procedure Code

Description

Maximum Reimbursement Rate

J0130

Abciximab 10 mg

$ 459.02

J1120

Acetazolamide Sodium, up to 500 mg (Diamox)

18.36

J0150

Adenosine I.V., 6 mg (Adenocard)

34.80

J0152

Adenosine, 30 mg (Adenoscan)

66.56

J0170

Adrenalin, Epinephrine, up to 1 ml ampule

2.10

*

J3490

Agalsidase Beta, 1mg (Fabrazyme)

4,037.50

P9041

Albumin (human), 5%, 50 ml

13.01

P9047

Albumin (human), 25%, 50 ml

49.30

J0215

Alefacept 0.5 mg, injection (Amevive)

28.19

J0205

Alglucerase, per 10 units (Ceredase)

37.13

J0256

Alpha 1 Proteinase Inhibitor Human A, 10 mg (Prolastin)

2.38

J9015

Aldesleukin, per single use vial (Proleukin, IL-2, Interleukin) 22 million I.U.

657.15

J2997

Alteplase recombinant, 1 mg

32.83

J0207

Amifostine 500 mg (Ethyol)

405.29

S0016

Amikacin Sulfate 500 mg (Amikin)

15.95

S0072

Amikacin Sulfate (100 mg)

13.28

J0280

Aminophyllin, up to 250 mg

0.94

J1320

Amitriptyline HCL, up to 20 mg (Elavil, Enovil)

2.15

J0300

Amobarbital, up to 125 mg (Amytal)

2.38

J0285

Amphotericin B, 50 mg (Amphocin, Fungizone IV)

9.30

J0287

Amphotericin B lipid complex, 10 mg

19.55

J0288

Amphotericin B cholesteryl sulfate complex, 10 mg

13.60

J0289

Amphotericin B liposome, 10 mg

32.03

J0295

Ampicillin Sodium/Sulbactam Sodium, per 1.5 gm (Unasyn)

6.64

J0290

Ampicillin, up to 500 mg (Omnipen-N, Totacillin-N)

1.48

J0350

Anistreplase, per 30 units (Eminase)

2,169.22

S0115

Bortezomib 3.5 mg (Velcade)

930.24

J0945

Brompheniramine Maleate, 10mg

0.85

J0595

Butorphanol Tartrate, 1mg (Stadol)

3.94

J0636

Calcitriol, 0.1 mcg (Calcijex)

1.24

J0610

Calcium Gluconate, per 10 ml (Kaleinate)

0.90

J0620

Calcium Glycerophosphate and Calcium Lactate, per 10 ml (Calphosan)

5.55

J9045

Carboplatin, 50 mg (Paraplatin)

126.83

J9050

Carmustine, 100 mg (BiCNU)

121.84

J0690

Cefazolin Sodium, 500 mg (Ancef, Kefzol, Zolicef)

2.01

J0692

Cefepime HCL, 500 mg (Maxiprene)

7.28

J0698

Cefotaxime Sodium, per gm (Claforan)

8.51

J0694

Cefoxitin Sodium, 1 gm (Mefoxin)

9.56

J0713

Ceftazidime per 500 mg (Fortaz, Tazidime)

6.04

J0715

Ceftizoxime Sodium, per 500 mg (Cefizox)

4.44

J0696

Ceftriaxone Sodium, per 250 mg (Rocephin)

13.35

J0697

Cefuroxime Sodium, per 750 mg (Kefurox, Zinacef)

5.75

J1890

Cephalothin Sodium, up to 1 gm (Keflin)

9.18

J0710

Cephapirin Sodium, up to 1 gm (Cefadyl)

1.26

J0720

Chloramphenicol Sodium Succinate, up to 1 gm

6.46

J1990

Chlordiazepoxide HCL, up to 100 mg (Librium)

22.37

J2400

Chlorprocaine HCL 30 ml (Nesacaine, Nesacaine-MPF)

5.72

J0390

Chloroquine HCL, up to 250 mg (Aralen)

17.61

J1205

Chlorothiazide Sodium, 500 mg (Diuril Sodium)

9.38

J3230

Chlorpromazine HCL up to 50 mg (Thorazine)

3.93

J0725

Chorionic Gonadotropin, per 1,000 USP units

2.39

J0740

Cidofovir 375 mg (Vistide)

754.80

J0743

Cilastatin Sodium Imipenem, per 250 mg (Primaxin IM, Primaxin IV)

14.20

S0023

Cimetadine HCL, 300 mg (Tagamet)

1.27

J0744

Ciprofloxacin for IV infusion, 200 mg (Cipro)

12.25

J9062

Cisplatin, 50 mg (Platinol AQ)

67.79

J9060

Cisplatin, powder or solution, per 10 mg (Platinol, Plantinol AQ)

13.56

J9065

Cladribine, per 1 mg (Leustatin)

45.90

J0735

Clonidine Hydrochloride, 1 mg

49.35

J0745

Codeine Phosphate, per 30 mg

0.41

J0760

Colchicine, 1 mg

6.32

J0770

Colistimethate Sodium, up to 150 mg (Coly-Mycin M)

48.45

J0800

Corticotropin, up to 40 units (Acthar, ACTH)

83.15

J0835

Cosyntropin, per 0.25 mg (Cortrosyn)

75.06

J3420

Cyanocobalamin, vitamin B 12, 1000 mcg

0.15

J9096

Cyclophosphamide Lyophilized 1 gm (Cytoxan Lyophilized)

40.92

J9093

Cyclophosphamide Lyophilized, 100 mg (Cytoxan Lyophilized)

5.21

J9091

Cyclophosphamide, 1.0 gm (Cytoxan, Neosar)

40.92

J9070

Cyclophosphamide, 100 mg (Cytoxan, Neosar)

5.13

J9092

Cyclophosphamide, 2.0 gm (Cytoxan, Neosar)

81.82

J9080

Cyclophosphamide, 200 mg (Cytoxan, Neosar)

9.74

J9090

Cyclophosphamide, 500 mg (Cytoxan, Neosar)

20.45

J9094

Cyclophosphamide, Lyophilized, 200 mg (Cytoxan Lyophilized)

10.41

J9095

Cyclophosphamide, Lyophilized, 500 mg (Cytoxan Lyophilized)

20.45

J9097

Cyclophosphamide Lyophilized, 2gm

83.95

J9100

Cytarabine 100 mg (Cytosar-U)

7.33

J9110

Cytarbine, 500 mg (Cytosar-U)

7.65

J9130

Dacarbazine 100 mg (DTIC-Dome)

10.04

J9140

Dacarbazine 200 mg (DTIC-Dome)

19.47

J7513

Daclizumab, 25 mg (Zenapax)

380.36

J9120

Dactinomycin, .5 mg (Cosmegen)

12.41

J1645

Dalteparin, per 2500 I.U. (Fragmin)

14.04

J0880

Darbepoetin Alfa, 5 mcg (Aranesp)

21.20

J9150

Daunorubicin HCL, 10 mg (Cerubidine)

66.42

J9151

Daunorubicin Citrate Liposomal, 10 mg (DaunoXome)

57.80

J0895

Deferoxamine Mesylate, 500 mg (Desferal)

13.98

J9160

Denileukin Diftitox, 300mcg (Ontak)

1,190.85

J1000

Depoestradiol Cypionate, up to 5 mg

1.70

J1094

Dexamethasone Acetate 1 mg

0.64

J2597

Desmopression Acetate per 1 mcg (DDAVP)

3.09

J1100

Dexamethosone Sodium Phosphate, 1 mg (Cortastat, Dalalone)

0.10

J1190

Dexrazoxane HCL, 250 mg (Zinecard)

209.34

J7110

Dextran 75, 500 ml

12.72

J7042

Dextrose 5%/Normal Saline (500 ml = 1 unit)

8.45

J7070

D5W, 1000 cc

9.78

J7060

Dextrose 5%/Water (500 ml = 1 unit)

8.09

J3360

Diazepam, up to 5 mg (Valium, Zetran)

0.77

J1730

Diazoxide, up to 300 mg (Hyperstat IV)

110.01

J0500

Dicyclomine HCL, up to 20 mg (Bentyl, Dilomine, Antispas)

15.27

J9165

Diethylstilbestrol Diphosphate, 250 mg (Stilphostrol)

12.89

J1160

Digoxin, up to 0.5 mg (Lanoxin)

1.59

J1110

Dihydroergotamine Mesylate, up to 1 mg

6.04

J0470

Dimercaprol, per 100 mg

21.18

J1240

Dimenhydrinate, up to 50 mg

0.34

J1200

Diphenhydramine HCL, up to 50 mg (Benadryl)

1.43

J1245

Dipyridamole, per 10 mg (Persantine IV)

5.10

J1212

DMSO, Dimethyl Sulfoxide, 50%, 50 ml

39.91

J1250

Dobutamine HCL, 250 mg (Dobutrex)

4.24

J9170

Docetaxel, 20 mg (Taxotere)

301.40

J1260

Dolasetron Mesylate, 10 mg (Anzemet)

13.85

J1270

Doxercalciferol, 1 mg (Hectorol)

4.92

J9001

Doxorubicin HCL, all lipid formulations, 10 mg,

352.06

J9000

Doxorubicin HCL, 10 mg (Adriamycin PFS, Adriamycin RDF, Rubex)

8.16

J1810

Droperidol and Fentanyl Citrate, up to 2 ml ampule (Innovar)

8.45

J1790

Droperidol, up to 5 mg (Inapsine)

2.50

J1180

Dyphylline, up to 500 mg (Lufyllin, Dilor)

8.07

J0600

Edetate Calcium Disodium up to 1000 mg

39.46

J1650

Enoxaparin Sodium, 10 mg (Lovenox)

5.46

J9178

Epirubicin HCl, 2 mg (Ellence)

24.73

Q9920

EPO, per 1000 units, Patient HCT 20 or less

11.62

Q9921

EPO, per 1000 units, Patient HCT 21

11.62

Q9922

EPO, per 1000 units, Patient HCT 22

11.62

Q9923

EPO, per 1000 units, Patient HCT 23

11.62

Q9924

EPO, per 1000 units, Patient HCT 24

11.62

Q9925

EPO, per 1000 units, Patient HCT 25

11.62

Q9926

EPO, per 1000 units, Patient HCT 26

11.62

Q9927

EPO, per 1000 units, Patient HCT 27

11.62

Q9928

EPO, per 1000 units, Patient HCT 28

11.62

Q9929

EPO, per 1000 units, Patient HCT 29

11.62

Q9930

EPO, per 1000 units, Patient HCT 30

11.62

Q9931

EPO, per 1000 units, Patient HCT 31

11.62

Q9932

EPO, per 1000 units, Patient HCT 32

11.62

Q9933

EPO, per 1000 units, Patient HCT 33

11.62

Q9934

EPO, per 1000 units, Patient HCT 34

11.62

Q9935

EPO, per 1000 units, Patient HCT 35

11.62

Q9936

EPO, per 1000 units, Patient HCT 36

11.62

Q9937

EPO, per 1000 units, Patient HCT 37

11.62

Q9938

EPO, per 1000 units, Patient HCT 38

11.62

Q9939

EPO, per 1000 units, Patient HCT 39

11.62

Q9940

EPO, per 1000 units, Patient HCT 40

11.62

Q0136

Epoetin Alpha (for non ESRD use) per 1000 units (Epogen)

11.62

J1325

Epoprostenol 0.5 mg

16.16

J1330

Ergonovine Maleate, up to 0.2 mg

4.20

J1364

Erythromycin Lactobionate, per 500 mg (Erythrocin)

3.14

J1380

Estradiol Valerate, up to 10 mg

0.48

J1390

Estradiol Valerate, up to 20 mg

1.02

J0970

Estradiol Valerate, up to 40 mg (Delestrogen)

1.44

J1410

Estrogen Conjugated, per 25 mg (Premarin Intravenous)

55.04

J1435

Estrone, per 1 mg (Estone Aqueous, Estronol, etc.)

0.51

J1436

Etidronate Disodium, per 300 mg (Didronel)

68.85

J9181

Etoposide, 10 mg (VePesid)

1.53

J9182

Etoposide, 100 mg (VePesid)

15.30

J3010

Fentanyl Citrate, 0.1 mg (2 ml) (Sublimaze)

0.83

Q0187

Factor VIIa (Coagulation Factor, recombinant) per 1.2 mg (Novoseven)

1,681.50

J7190

Factor VIII (anti-hemophilic factor, human) per I.U.

0.87

J7191

Factor VIII (anti-hemophilic factor, porcine) per I.U.

2.04

J7192

Factor VIII (anti-hemophilic factor, recombinant) – per I.U.

1.29

J7194

Factor IX complex, per I.U.

0.40

J7193

Factor IX (Antihemophilic Factor, Purified, non-recombinant) – per I.U.

1.12

J7195

Factor IX (Antihemophilic Factor, recombinant) – per I.U.

0.95

J1440

Filgrastim , 300 mcg/1ml (Neupogen)

158.50

J1441

Filgrastim , 480 mcg/1.6ml (Neupogen)

267.79

J9200

Floxuridine, 500 mg (FUDR)

122.40

J9185

Fludarabine Phosphate, 50 mg (Fludara)

318.59

J9190

Fluorouracil, 500 mg (Adrucil)

1.85

J2680

Fluphenazine Decanoate, up to 25 mg (Prolixin Decanoate)

8.02

J1455

Foscarnet Sodium, per 1000 mg (Foscavir)

11.70

J9395

Fulvestrant, 25 mg (Faslodex)

78.36

J1940

Furosemide, up to 20 mg (Lasix, Furomide M.D.)

0.88

J1570

Ganciclovir Sodium, 500 mg (Cytovene)

31.53

J7310

Ganciclovir, Long-acting Implant, 4.5 mg (Vitrasert)

4,250.00

J9201

Gemcitabine HCl. 200 mg (Gemzar)

101.90

J1580

Gentamicin (Garamycin Sulfate) up to 80 mg (Gentamicin Sulfate, Jenamicin)

1.70

J1610

Glucagon Hydrochloride, per 1 mg

40.80

J1600

Gold Sodium Thiomaleate, up to 50 mg (Myochrysine)

12.10

J1620

Gonadorelin Hydrochloride, per 100 mcg (Factrel)

180.72

J9202

Goserelin Acetate Implant, per 3.6 mg (Zoladex)

375.99

J1626

Granisetron Hydrochloride, 100 mcg (Kytril)

15.62

J1631

Haloperidol Decanoate, per 50 mg (Haldol Decanoate – 50)

8.16

J1630

Haloperidol Lactate, up to 5 mg (Haldol)

6.11

J1642

Heparin Sodium, per 10 units (Heparin Lock Flush)

0.05

J1644

Heparin Sodium, per 1000 units

0.35

J3470

Hyaluronidase, up to 150 units (Wydase)

18.42

J0360

Hydralazine HCL, up to 20 mg (Apresoline)

14.34

J1700

Hydrocortisone Acetate, up to 25 mg

0.30

J1710

Hydrocortisone Sodium Phosphate, up to 50 mg

4.98

J1720

Hydrocortisone Sodium Succinate, up to 100 mg

1.55

J1170

Hydromorphone, up to 4 mg (Dilaudid)

1.38

J3410

Hydroxyzine HCL, up to 25 mg (Vistaril, Vistaject-25, Hyzine-50)

1.08

J7320

Hylan G-F 20, 16 mg, for intra-arterial injection (Synvisc)

201.24

J1980

Hyoscyamine Sulfate, up to 0.25 mg (Levsin)

7.66

J7130

Hypertonic Saline Solution, 50 or 100 mEq, 20 cc vial)

0.44

J1742

Ibutilide Fumarate 1 mg. (Corvert)

224.89

J9211

Idarubicin Hydrochloride, 5 mg (Idamycin)

375.73

J9208

Ifosfamide, 1 gm (Ifex)

134.55

J1785

Imiglucerase, per unit (Cerezyme)

3.71

J1745

Infliximab, 10 mg (Remicade)

58.79

J1815

Insulin, up to 100 units (Regular, NPH, Lente, or Ultralente))

0.09

J9213

Interferon, Alfa-2A, Recombinant, 3 million units (Roferon-A)

31.21

J9214

Interferon, Alfa-2B, Recombinant, 1 million units (Intron A)

13.31

J9215

Interferon, Alfa-N3, (human leukocyte derived) 250,000 IU (Alferon N)

7.03

J9212

Interferon, Alfacon-1, Recombinant, 1 mcg (Infergen)

3.67

J9216

Interferon, Gamma 1-B, 3 million units (Actimmune)

187.19

J9206

Irinotecan, 20 mg (Camptosar)

122.73

J1750

Iron Dextran, 50 mg (Infed)

16.03

J1756

Iron Sucrose injection, 1mg (Venofer)

0.58

J1840

Kanamycin Sulfate, up to 500 mg (Kantrex, Klebcil)

2.94

J1850

Kanamycin Sulfate, up to 75 mg (Kantrex, Klebcil)

0.44

J1885

Ketorolac Tromethamine, per 15 mg (Toradol)

3.19

*

J3490

Kutapressin, 1 ml

6.94

*

J3490

Laronidase, 2.9 mg/5 ml (Aldurazyme)

120.07

J0640

Leucovorin Calcium, per 50 mg (Wellcovorin)

3.00

J9217

Leuprolide Acetate, 7.5 mg (Lupron, for Depot Suspension)

500.58

J1950

Leuprolide Acetate, 3.5 mg (Lupron, for Depot Suspension)

453.79

J9218

Leuprolide Acetate, per 1 mg (Lupron)

23.26

J9219

Leuprolide Acetate Implant, 65 mg (Viadur)

4,831.40

J1955

Levocarnitine, per 1 gm (Carnitor)

30.60

J1956

Levofloxacin, 250 mg (Levaquin)

18.62

J1960

Levorphanol tartrate, up to 2 mg (Levo-Dromoran)

3.37

J2001

Lidocaine HCL, 10 mg IV (Xylocaine)

0.88

J2010

Lincomycin HCL, up to 300 mg (Lincocin)

2.84

J2060

Lorazepam, 2 mg (Ativan)

2.81

*

J3490

Leuprolide Acetate, 7.5 mg (Lupron Depot Pediatric) (Send in claim with invoice for manual pricing—pricing based on 7.5 mg package)

606.70

*

J3490

Leuprolide Acetate, 11.25 mg (Lupron Depot Pediatric) (Send in claim with invoice for manual pricing—based on 11.25 mg package)

1,101.46

*

J3490

Leuprolide Acetate, 15 mg (Lupron Depot Pediatric) (Send in claim with invoice for manual pricing—pricing based on 15 mg package)

1,213.15

J3475

Magnesium Sulfate, 500 mg.

0.20

J2150

Mannitol, 25% in 50 ml

2.92

J9230

Mechlorethamine Hydrochloride (Nitrogen Mustard), 10 mg

10.74

J1055

Medroxyprogesterone Acetate for Contraceptive Use, 150 mg (Depo-Provera)

48.12

J1051

Medroxyprogesterone Acetate, 50 mg (Depo-Provera)

4.50

J1056

Medroxyprogesterone Acetate/Estradiol Cypionate 5 mg/25 mg (Lunelle)

22.02

J9245

Melphalan Hydrochloride, 50 mg, (Alkeran)

375.88

J2180

Meperidine and Promethazine HCL, up to 50 mg (Mepergan Injection)

4.02

J2175

Meperidine Hydrochloride, per 100 mg (Demerol HCL)

0.48

J0670

Mepivacaine, per 10 ml (Carbocaine)

1.85

J9209

Mesna, 200 mg (Mesnex)

31.45

J0380

Metaraminol Bitartrate, 10 mg (Aramine)

1.14

J1230

Methadone HCL, up to 10 mg (Dolophine)

0.68

J2800

Methocarbamol, up to 10 ml (Robaxin)

3.40

J9250

Methotrexate Sodium, 5 mg

0.35

J9260

Methotrexate Sodium, 50 mg

4.25

J0210

Methyldopate HCL, up to 250 mg (Aldomet)

10.63

J2210

Methylergonovine Maleate, up to 0.2 mg (Methergine)

3.67

J1020

Methylprednisolone Acetate, 20 mg (Depo Medrol)

2.40

J1030

Methylprednisolone Acetate, 40 mg

3.70

J1040

Methylprednisolone Acetate, 80 mg

7.40

J2930

Methylprednisolone Sodium Succinate, up to 125 mg (Solu-Medrol, A-methaPred)

1.72

J2920

Methylprednisolone Sodium Succinate, up to 40 mg (Solu-Medrol, A-Metha Pred)

1.41

J2765

Metoclopramide HCL, up to 10 mg (Reglan)

1.67

J2250

Midazolam HCL, per 1 mg (Versed)

1.14

J2260

Milrinone Lactate, 5 mg per 5 ml (Primacor)

46.15

J9290

Mitomycin, 20 mg (Mutamycin)

185.64

J9291

Mitomycin, 40 mg (Mutamycin)

255.00

J9280

Mitomycin, 5 mg (Mutamycin)

57.12

J9293

Mitoxantrone HCL, per 5 mg (Novantrone)

321.52

J2275

Morphine Sulfate (preservative-free sterile solution), per 10 mg (Astramorph PF, Duramorph)

1.70

J2270

Morphine Sulfate, up to 10 mg

0.60

J2271

Morphine Sulfate (100 mg)

6.99

J2310

Nalaxone HCL, per 1 mg (Narcan)

2.12

J2300

Nalbuphine Hydrochloride, 10 mg

1.35

J2321

Nandrolone Decanoate, up to 100 mg

6.25

J2322

Nandrolone Decanoate, up to 200 mg

14.08

J2320

Nandrolone Decanoate, up to 50 mg

3.43

J2710

Neostigmine Methylsulfate, up to 0.5 mg (Prostigmin)

0.59

J7030

Normal Saline Solution, 1000 cc, infusion

8.89

J7050

Normal Saline Solution, 250 cc, infusion

2.22

J7040

Normal Saline Solution, Sterile (500 ml=1 unit), infusion

5.64

*

J2353

Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 30 mg

71.12

*

J2353

Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 20 mg

79.35

*

J2353

Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 10 mg

138.19

J2354

Octreotide Acetate, 25 mcg, non-depot, SC or IV

3.81

S0107

Omalizumab 25mg (Xolair)

76.68

J2405

Ondansetron Hydrochloride, per 1 mg (Zofran)

5.58

J2355

Oprelvekin, 5 mg (Newmega)

239.67

J2360

Orphenadrine Citrate, up to 60 mg (Norflex, etc.)

4.85

J2700

Oxacillin Sodium, up to 250 mg (Bactocile, Prostaphlin)

0.71

J9263

Oxaliplatin, 0.5 mg (Eloxatin)

8.45

J2410

Oxymorphone HCL, up to 1 mg (Numorphan)

2.64

J2460

Oxytetracycline HCL, up to 50 mg (Terramycin IM)

0.91

J2590

Oxytocin, up to 10 units (Pitocin, Syntocinon)

1.15

J9265

Paclitaxel, 30 mg (Taxol)

138.28

*

J3490

Palonosetron 0.25mg (Aloxi)

275.40

J2430

Pamidronate Disodium, per 30 mg (Aredia)

237.88

J2440

Papaverine HCL, up to 60 mg

2.98

J9266

Pegaspargase Single Dose vial, (5 ml) (Oncaspar)

1,277.13

J2505

Pegfilgrastim, 6 mg (Neulasta)

2,507.50

J0540

Penicillin G Benzathine and Penicillin G Procaine, up to 1,200,000 units (Bicillin C-R)

20.94

J0550

Penicillin G Benzathine and Penicillin G Procaine, up to 2,400,000 units (Bicillin C-R)

44.84

J0530

Penicillin G Benzathine and Penicillin G procaine, up to 600,000 units (Bicillin C-R)

10.67

J0570

Penicillin G Benzathine, up to 1,200,000 units (Bicillin L-A, Permapen)

17.70

J0580

Penicillin G Benzathine, up to 2,400,000 units (Bicillin L-A, Permapen)

35.39

J0560

Penicillin G Benzathine, up to 600,000 units (Bicillin L-A, Permapen)

8.85

J2540

Penicillin G Potassium, up to 600,000 units (Pfizerpen)

0.26

J2510

Penicillin G Procaine, Aqueous, up to 600,000 units (Wycillin, etc.)

8.59

J2545

Pentamidine Isethionate, inhalation solution, per 300 mg (Pentam 300, NebuPent, PentacaRinat)

40.12

S0080

Pentamidine Isethionate, IV, IM, per 300 mg

40.12

J3070

Pentazocine HCL, up to 30 mg (Talwin)

4.67

J2515

Pentobarbital Sodium (Nembutal Sodium Solution), per 50 mg

1.18

J9268

Pentostatin, per 10 mg (Nipent)

1,644.27

J2543

Piperacillin Sodium/Tazobactam Sodium 1gm/0.125 gm (1.125gm) (Zosyn)

4.36

J3310

Perphenazine, up to 5 mg (Trilafon)

6.38

J2560

Phenobarbital Sodium, up to 120 mg

1.44

J2760

Phentolamine Mesylate, up to 5 mg (Regitine)

28.56

J2370

Phenylephrine HCL, up to 1 ml (NeoSynephrine)

1.15

J1165

Phenytoin Sodium, per 50 mg (Dilantin)

0.77

J9270

Plicamycin, 2.5 mg (Mithracin)

83.93

J9600

Porfimer Sodium, 75 mg (Photofin)

2,329.60

J3480

Potassium Chloride, per 2 mEq.

0.07

J2730

Pralidoxime Chloride, up to 1 gm (Protopam Chloride)

92.12

J2650

Prednisolone Acetate, up to 1 ml

0.22

J2690

Procainamide HCL, up to 1 gm (Pronestyl)

1.24

J0780

Prochlorperazine Edisylate 10 mg (Compazine, Cotranzine, Compa-Z, Ultrazine-10)

3.74

J2675

Progesterone, per 50 mg

3.18

J2950

Promazine HCL, up to 25 mg (Sparine, Prozine-50)

0.41

J2550

Promethazine HCL, up to 50 mg (Phenergan, Phenazine)

2.55

J1800

Propranolol HCL, up to 1 mg (Inderal)

8.45

J2720

Protamine Sulfate, per 10 mg

0.68

J2725

Protirelin, per 250 mcg (Relefact TRH, Thypinone)

21.83

J2780

Rantidine HCL, 25 mg (Zantac)

1.29

J2993

Retaplase, 18.1 mg (Retavase)

1,168.75

J7120

Ringers Lactate Infusion, up to 1000 cc

11.13

*

J3490

Risperidone 25mg (Risperdal Consta)

117.98

*

J3490

Risperidone 37.5mg (Risperdal Consta)

176.97

*

J3490

Risperidone 50mg (Risperdal Consta)

235.96

J9310

Rituximab (Rituxan) 100 mg (Rituxan)

427.28

J2820

Sargramostim (GM-CSF), 50 mcg (Leukine, Prokine)

24.47

*

J3490

Sodium Bicarbonate 7.5% up to 50 ml

3.03

J2912

Sodium Chloride, 0.9% per 2 ml

0.44

J2916

Sodium Ferric Gluconate Complex in Sucrose, 12.5mg (Ferrlecit)

7.31

J7317

Sodium Hyaluronate, per 20-25 mg. for intra-articular injection (Biolon, Provisc, Vitrax, Hyalgan)

124.11

J3320

Spectinomycin Dihydrochloride, up to 2 gm (Trobicin)

25.30

J7051

Sterile Saline or Water (up to 5 cc)

0.68

J2995

Streptokinase, per 250,000 IU (Streptase)

79.69

J3000

Streptomycin, up to 1 gm (Streptomycin Sulfate)

5.67

J9320

Streptozocin, 1 gm (Zanosar)

126.58

J0330

Succinycholine Chloride, up to 20 mg (Anectine, Quelicin, Surostrin)

0.17

J3105

Terbutaline Sulfate, up to 1 mg (Brethine, Bricanyl Subcutaneous)

26.30

J1060

Testosterone Cypionate and Estradiol Cypionate, up to 1 ml

3.99

J1080

Testosterone Estradiol Cypionate, 1 cc, 200 mg

8.44

J1070

Testosterone Cypionate, up to 100 mg

4.43

J0900

Testosterone Enanthate and Estradiol Valerate up to 1 cc (Deladumone, etc.)

1.46

J3120

Testosterone Enanthate, up to 100 mg (Evarone, Delatestryl, etc.)

8.03

J3130

Testosterone Enanthate, up to 200 mg, (Evarone, Delatestryl, Andro L.A. 200, etc.)

16.07

J3150

Testosterone Propionate, up to 100 mg (Testex)

0.84

J3140

Testosterone Suspension, up to 50 mg (Andronaq 50, Testosterone Aqueous, etc.)

0.28

J0120

Tetracycline, up to 250 mg (Achromycin, Panmycin, Sumycin)

0.22

J3280

Thiethylperazine Maleate, up to 10 mg (Norzine, Torecan)

5.06

J9340

Thiotepa, 15 mg (Thioplex)

83.73

J3240

Thyrotropin Alfa, 0.9 mg (Thyrogen)

552.50

J3260

Tobramycin Sulfate, up to 80 mg (Nebcin)

3.99

J9350

Topotecan, 4 mg (Hycamtin)

706.17

J3265

Torsemide, 10 mg/ml (Demadex)

1.39

J2670

Tolazoline HCL, up to 25 mg (Priscoline HCL)

3.51

J9355

Trastuzumab, 10 mg (Herceptin)

52.01

J3301

Triamcinolone Acetonide, per 10 mg (Kenalog-10, Kenalog-40, Tri-Kort, etc.)

1.43

J3302

Triamcinolone Diacetate, per 5 mg (Aristocort Intralesional, Aristocort Forte, Amcort, etc.)

0.31

J3303

Triamcinolone Hexacetonide, per 5 mg (Aristospan Intralesional, Aristospan Intra-articular)

0.90

J3400

Triflupromazine HCL, up to 20 mg (Vesprin)

11.05

J3250

Trimethobenzamide HCL, up to 200 mg (Tigan, Ticon, Tiject-20, Arrestin)

1.25

J3305

Trimetrexate Glucoronate, per 25 mg (Neutrexin)

127.50

J3350

Urea, up to 40 gm (Ureaphil)

75.56

J3365

Urokinase, 250,000 I.U. Vial (Abbokinase)

457.66

J3364

Urokinase, 5000 I.U. vial (Abbokinase Open-Cath)

50.65

J9357

Valrubicin, intravesical, 200 mg (Valstar)

471.24

J3370

Vancomycin HCL, 500 mg (Varcocin, Vancoled)

2.58

J9360

Vinblastine Sulfate, 1 mg (Velban)

2.81

J9370

Vincristine Sulfate, 1 mg (Oncovin,)

30.40

J9375

Vincristine Sulfate, 2 mg (Oncovin)

60.81

J9380

Vincristine Sulfate, 5 mg (Oncovin,)

152.02

J9390

Vinorelbine Tartrate, per 10 mg (Navelbine)

76.19

J3430

Vitamin K, Phytonadione 1 mg/0.5ml

1.98

J2501

Zemplar (Paricalcitol) 1 mcg

4.49

J3487

Zoledronic Acid (Zometa), 1 mg

194.54

Immune Globulins

Procedure Code

Description

Maximum Reimbursement Rate

J1563

Immune globulin (IgIV), for intravenous use, 1g

$ 66.00

J1564

Immune globulin (IgIV), for intravenous use, 10 mg

0.72

90291

Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use, 1 ml

12.74

90371

Hepatitis B immune globulin (HBIg), human, for intramuscular use, 0.5 ml

581.40

90375

Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous use, 2 ml

65.18

90376

Rabies immune globulin, heat-treated (RIg-HT), human, for intramuscular and/or subcutaneous use, 2 ml

69.89

90379

Respiratory syncytial virus immune globulin (RSV-IgIV), human, for intravenous use, 1 ml

16.22

90384

Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use, 1500 IU/300 mcg

89.76

90385

Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use, 120 IU/50 mcg

32.13

90386

Rho(D) immune globulin (RhIglV), human, for intravenous use, 100 IU

18.98

90389

Tetanus immune globulin (TIg), human, for intramuscular use, 250 u/1 ml

111.57

90396

Varicella-zoster immune globulin, human, for intramuscular use, 125 u/1.25 ml

106.25

J1460

Gamma Globulin, Intramuscular, 1 cc (Gammar)

10.20

J1470

Gamma Globulin, Intramuscular, 2 cc

20.40

J1480

Gamma Globulin, Intramuscular, 3 cc

30.63

J1490

Gamma Globulin, Intramuscular, 4 cc

40.80

J1500

Gamma Globulin, Intramuscular, 5 cc

51.00

J1510

Gamma Globulin, Intramuscular, 6 cc

61.08

J1520

Gamma Globulin, Intramuscular, 7 cc

71.33

J1530

Gamma Globulin, Intramuscular, 8 cc

81.60

J1540

Gamma Globulin, Intramuscular, 9 cc

91.89

J1550

Gamma Globulin, Intramuscular, 10 cc

102.00

J1560

Gamma Globulin, Intramuscular, over 10 cc (use correct combinations of services)

 ^ ^

^ ^ Designates special pricing.

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

Medicaid does not reimburse for vaccines provided to recipients ages birth through 18 years that are available through the Universal Childhood Vaccine Distribution Program (UCVDP)/Vaccines for Children (VFC) Program. For Medicaid-eligible recipients ages 19 through 20 who are not age-eligible for the VFC program vaccines, Medicaid will reimburse providers for Medicaid-covered vaccines.

Procedure Code

Description

Maximum Reimbursement Rate

90585

Bacillus Calmette-Guerin vaccine (BCG), for tuberculosis, live, for percutaneous use, per vial

$ 143.28

90632

Hepatitis A vaccine, adult dosage, for intramuscular use, 1 ml

62.94

90633

Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use, 0.5 ml

26.66

90647

Hemophilus influenza b vaccine (Hib) PRP-OMP conjugate (3 Dose schedule), for intramuscular use, 0.5 ml

20.32

90658

Influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use, 0.5 ml

9.95

90675

Rabies vaccine, for intramuscular use, 2 ml

121.83

90680

Rotavirus vaccine, tetravalent, live, for oral use

16.40

90703

Tetanus toxoid adsorbed, for intramuscular or jet injection use, 0.5 ml

12.86

90704

Mumps virus vaccine, live, for subcutaneous or jet injection use

17.38

90705

Measles virus vaccine, live, for subcutaneous or jet injection use, 0.5 ml

13.45

90706

Rubella virus vaccine, live, for subcutaneous or jet injection use, 0.5 ml

14.97

90707

Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous or jet injection use

34.93

90713

Poliovirus vaccine, inactivated, (IPV), for subcutaneous use

23.00

90716

Varicella virus vaccine, live, for subcutaneous use, 0.5 ml

57.86

90718

Tetanus and diphtheria toxoids (Td) adsorbed for use in individuals seven years or older, for intramuscular or jet injection, 0.5 ml

10.31

90721

Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use

43.70

90732

Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use, 0.5 ml

18.62

90733

Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous or jet injection use, 0.05 mg

58.66

90746

Hepatitis B vaccine, adult dosage, for intramuscular use, 1 ml

55.46

90747

Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use, 40 mcg/2ml

110.92

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


Attention: Outpatient Hospital Providers

Crossover Claims Issues

A memo dated March 12, 2004 was sent from the Division of Medical Assistance (DMA) updating hospitals on crossover claims issues. In conjunction with the N.C. Hospital Association Medicaid Technical Advisory Group, DMA has worked in recent months to resolve concerns related to the administrative burden associated with the reporting/refunding of overpayments made by Medicaid on outpatient Medicare Part B claims from October 1, 2003 through December 5, 2003.

As described in the August 2003 and November 2003 general Medicaid bulletins, CDs have been sent to hospitals so that they could do analyses and report to DMA any required refunds associated with the 14-month time period. The first reporting period had a deadline of March 31, 2004; this has now been revised to June 30, 2004.

DMA has developed a methodology for a "data match" that compares Medicaid claims to the Medicare master file. This will reduce the administrative requirements for developing the reports for DMA as mentioned above. By May 1, 2004, a claim level report with all calculated overpayments for matched/overpaid claims for the 14-month period will be provided to all hospitals. Detailed instructions will accompany that information.

Some hospitals have already reported/refunded any overpayments to the State. DMA views the additional information as a complement to the work already done or being done by hospital billing staff. Hospitals are still responsible for complete, accurate reporting of any such overpayments, and it is hoped that this additional data will assist both the State and hospitals in accomplishing that goal. This process revision will mean that the hospitals' first and second reports/refunds (covering the period from October 1, 2002 through June 30, 2003) are now due June 30, 2004.

Tim Brookshire, Financial Opertions
DMA, 919-857-4015


Holiday Schedule

The Division of Medical Assistance and EDS will be closed on Friday, April 9, 2004 in observance of Good Friday.


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

April 6, 2004

May 4, 2004

June 8, 2004

April 13, 2004

May 11, 2004

June 15, 2004

April 20, 2004

May 18, 2004

June 22, 2004

May 5, 2004

May 27, 2004

June 29, 2004

 

Electronic Cut-Off Schedule

April 2, 2004

May 7, 2004

June 4, 2004

April 8, 2004

May 14, 2004

June 11, 2004

April 16, 2004

May 21, 2004

June 18, 2004

April 30, 2004

June 25, 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.

2004 Checkwrite Schedule


 

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

 

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