May 2003 Medicaid Bulletin

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In This Issue……

All Providers:

Ambulance Providers:

Ambulatory Surgical Centers:

Area Mental Health Centers:

At-Risk Case Management:

Community Alternatives Program Case Managers:

Dental Providers:

Developmental Evaluation Centers:

Electronic Billers:

Home Health Agencies:

Hospital Providers:

Independent Practitioners:

Local Education Agencies:

Local Health Departments:

Mecklenburg County Providers:

Physician Services:

Private Duty Nursing Providers:


Attention: All Providers

Severe Acute Respiratory Syndrome Assessment

The following memo was issued by Jeffrey Engel, M.D., State Epidemiologist on April 24, 2003 to all North Carolina health care providers.

As the worldwide SARS epidemic unfolds, it has become clear that SARS has entered into the differential diagnosis of all patients presenting with an acute febrile illness associated with respiratory tract symptoms. This memorandum is to help clinicians rule out SARS quickly in their early assessment of patients. The intention is to streamline activities associated with the evaluation of acutely ill patients and to protect the public health.

The definition for a suspected case of SARS is:

It is also important to know what exposures are NOT considered risk factors for SARS including:

Thus, the vast majority of people presenting with the nonspecific clinical syndrome can have SARS rapidly ruled out because of the lack of a consistent exposure history. An acute febrile syndrome with or without atypical pneumonia is a common presentation with multiple etiologies, but without the proper exposure history, SARS need not be entertained as a possible cause.

Laboratory testing for SARS remains experimental, but validated tests should be available in the coming weeks. These tests include acute and convalescent (>21 days after symptom onset) serology, and PCR and viral culture of respiratory specimens (NP/OP swab, tracheal aspirate, BAL, etc.) all performed at the CDC. These tests, however, are only indicated in suspected SARS cases and will not be done unless case definition is met and a CDC case number has been assigned.

If a patient appears to meet case definition, immediately notify your hospital infection control staff or your local health department. The health department will assist you with completion of the CDC intake form (the process required to obtain a CDC case number), disease investigation, contact tracing, and infection control measures. The State SARS Public Health Command Center is available 24 hours a day 7 days a week, and can be reached at (919) 715-0988. As a final resource, the CDC Emergency Operation Center can be reached at (770) 488-7100.

* As of April 24, 2003, these regions are Hong Kong, China, Singapore, Hanoi, and Toronto. Check the CDC website frequently for updates.

Public Health Command Center
919-715-0988


Attention: All Providers

Anesthesia – Conversion from CPT Surgical Coding to CPT Anesthesia Coding

In the January 2003 general Medicaid Bulletin, providers were instructed to begin using CPT anesthesia codes beginning June 1, 2003. The implementation date has been changed to October 1, 2003. After that date, anesthesia services must be billed with CPT anesthesia codes. Claims submitted for anesthesia services billed with surgical codes after October 1, 2003 will be denied.

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


Attention: All Providers

Business Associate Agreements

The Division of Medical Assistance has reviewed the provisions of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and determined that the relationship between the N.C. Medicaid program and enrolled N.C. Medicaid providers does not require a business associate agreement in order to comply with the HIPAA privacy regulations.

According to information posted on the U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) website, "Generally, providers are not business associates of payers." Health plans (payers) and those providers who conduct transactions electronically are defined as covered entities. If the only relationship between the health plan (payer) and the provider is one where the provider submits claims for payment to the health plan, then the provider is not a business associate of the health plan. Each covered entity is acting on its own behalf when a provider submits a claim to a health plan, and when the health plan assesses and pays the claim.

Therefore, business associate agreements are not required between providers and DMA or EDS.

The OCR is responsible for the implementation and enforcement of the HIPAA privacy regulations. Compliance information and assistance is available from OCR or by contacting your provider association.

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


Attention: All Providers

CPT Code Update for 2002

The Division of Medical Assistance has completed its review of the 2002 CPT codes. EDS is in the process of making the necessary system changes to allow the codes to be billed. Updates on covered CPT codes will be available in May on DMA’s website. A complete list of covered codes will be published in a future general Medicaid bulletin.

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


Attention: All Providers

Proposed Medical Coverage Policies

In accordance with Session Law 2001-424, Senate Bill 1005, 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
Medical Policy Section
Division of Medical Assistance
2511 Mail Service Center
Raleigh, NC 27699-2511

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.

Darlene Creech, Medical Policy Section
DMA, 919-857-4020


Attention: All Providers

Electronic Funds Transfer Form

Providers are reminded to use the following fax number when submitting the Electronic Funds Transfer (EFT) Authorization Agreement for Automatic Deposit forms to the EDS Financial Unit: 919-816-4399.

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.

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

EFT Automatic Deposit Agreement Form


Attention: All Providers

Health Insurance Portability and Accountability Act – Questions and Answers

The Division of Medical Assistance (DMA) is committed to implementing all of the regulations introduced as a result of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. This commitment is reflected in the following bulleted mission statement:

DMA also strives to communicate HIPAA information, as it pertains to N.C. Medicaid, to the provider community. In addition to bulletin articles, such as this article on frequently asked questions, information regarding N.C. Medicaid’s HIPAA effort may be found on DMA’s HIPAA webpage.

General Questions

    1. Who is responsible for training providers about HIPAA?

    Each provider must assess his/her business practice and implement necessary changes to comply with the regulations introduced as a result of HIPAA. Each provider is responsible for ensuring that his/her staff, vendors, clearinghouse, and other associates are HIPAA compliant.

    Training offered by the N.C .Medicaid program will be limited to the new web-based versions of the North Carolina Electronic Claims Submission (NCECS) tool. This training will be available to the providers currently using NCECS software to bill Medicaid electronically and to providers who choose to begin using the new software to bill electronically. (NCECS Seminar information)

    All other change to the Medicaid program that are implemented as a result of HIPAA regulations will be communicated as necssary to provider through the general Medicaid bulletin and special bulletins.

    2. How will providers be notified of changes in the NC Medicaid program?

    Specific changes implemented by N.C .Medicaid to comply with HIPAA regulations will be published in future Medicaid bulletins.

    General information about HIPAA, including the federal regulations, implementation deadlines, and transaction standards can be accessed online at http://www.hhs.gov and http://www.cms.gov.

    3. Is there one final rule regarding transactions and codes set for health plans and providers?

    Yes. The initial rule, known as the HIPAA Transaction and Code Set Final Rule, was published August 17, 2000 in the Federal Register and applies to all covered entities. The rule (CFR 160 and 162) can be accessed at http://www.access.gpo.gov/su_docs.

    Addenda to the Final Rule, adopting changes to the HIPAA Electronic Transactions and Code Set Standards, was published in the Federal Register on February 20, 2003. These addenda modified a number of the electronic transactions and code sets adopted as national standards under HIPAA. The addenda can be found at http://www.cms.hhs.gov/HIPAAGenInfo/. The modifications are published as Addenda to the ASC X12N Implementation Guides and are available through Washington Publishing Company at http://www.wpc-edi.com.

    4. What is the compliance deadline for the standard transactions and code sets regulation?

    According to regulation, the deadline to implement the HIPAA electronic transaction and code set standards is October 16, 2002, unless an extension was filed with the Centers for Medicare and Medicaid Services (CMS). The N.C. Department of Health and Human Services HIPAA Office filed for an extension on behalf of the N.C. Medicaid program.

    5. When will the N.C. Medicaid program be HIPAA compliant for electronic transactions and code sets?

    N.C. Medicaid plans to receive and respond to all HIPAA transactions by August 1, 2003.

    Currently, N.C. Medicaid has implemented the ASC X12N 270/271 004010X092, Eligibility Benefit Inquiry/Response; ASC X12N 278 004010X094, Request for Services; and ASC X12N 834 004010X095, Benefit Enrollment and Maintenance transactions. Criteria set forth in the HIPAA Addenda regarding these transactions, will be implemented by October 16, 2003.

    Please pay close attention to future Medicaid bulletins and to DMA’s HIPAA webpage for additional information regarding implementation.

    6. Will HIPAA make claim submissions to other state Medicaid programs easier?

    The purpose of the administrative simplification provision of HIPAA is to standardize the electronic data interchange in the health care industry overall. Because there are over 400 different electronic claim formats within the health care industry, HIPAA standards will create a more uniform mechanism for electronic data interchange. However, some health care plans, including Medicaid and Medicare, may still require situational data elements that other health plans do not require. Each health care plan will still direct their medical policy and billing requirements.

    7. Will billing requirements change?

    Medical policies will not change due to HIPAA requirements but how providers bill for a certain service may change. HIPAA regulations will allow health care plans and payers significant flexibility in how they administer programs. As stated in DMA’s HIPAA Mission Statement: "DMA has deemed that no Medicaid covered services will be eliminated as a result of this legislation." HIPAA does, however, mandate the elimination of local codes, which N.C. Medicaid uses for some services. Providers will be notified of changes to billing guidelines through Medicaid bulletins.

    8. Will providers be required to submit claims electronically or can we continue to submit paper claims?

    Paper claims will continue to be accepted by N.C. Medicaid. However, providers are encouraged to use electronic claims submission and electronic remittance advice (ERA) receipt for expedient claims processing. HIPAA does not require providers to submit claims electronically to Medicaid. However, providers may be required to file Medicare claims electronically. Please contact your Medicare agent for more information.

    9. Will the CMS-1500 (HCFA-1500) claim form become obsolete? What about other claim forms currently accepted by N.C. Medicaid?

    Because HIPAA regulations only apply to electronic transactions, the paper versions of the CMS-1500, ADA-1999 version 2000, and the UB-92 claim forms can still be submitted to N.C. Medicaid for payment. However, N.C. Medicaid encourages providers to submit claims electronically.

    10. Does HIPAA affect providers who file 100 percent of their claims on paper?

    No. The electronic transaction standards regulation does not apply to providers who file all of their claims on paper. The regulation only applies to the electronic data interchange.

    However, billing codes may change as a result of the requirement to implement national standard codes such as ICD-9-CM, CPT-4, CDT, NDC, and HCPCS. Code conversions are published in the general Medicaid bulletins.

    11. Will providers be required to submit prior approval (PA) requests electronically or can we continue to submit paper PA request forms?

    Although this transaction supports an electronic mechanism for requesting PA, N.C. Medicaid will still require paper supporting documentation for PA requests. The electronic prior authorization transaction lacks the medical necessity information necessary for N.C. Medicaid to render a medical decision for the request. Therefore, providers must continue to provide the appropriate PA form in order to provide the medical information necessary to render a decision. N.C. Medicaid will accept the electronic prior authorization transactions and provide a response advising the provider of the appropriate documentation necessary for a decision.

    12. Will the Automated Voice Response (AVR) system still be available after October 16, 2003?

    Yes. Providers will be notified through Medicaid bulletins of the AVR access changes and changes in the information that is available through AVR.

    13. What is taxonomy?

    The provider taxonomy is a code set that codifies provider type and provider area of specialization for all medical related providers. The National Uniform Claim Committee maintains the taxonomy code set. A provider may have more than one taxonomy code, depending on the provider’s area of specialization. The taxonomy code is an optional data element on the 837 institutional claim, 837 professional claim, and 837 dental claim transactions. The taxonomy is not a unique number per provider. A full provider taxonomy code set can be found at http://www.wpc-edi.com.

    14. What is WEDI?

WEDI is the acronym for Workgroup for Electronic Data Interchange. WEDI works with the implementation of electronic data interchange in the health care industry. For more information, visit the WEDI website.

Coding

    1. Will local codes be eliminated?

To comply with the implementation of HIPAA transaction and code set standards, N.C. Medicaid will convert all local codes to standard national codes. Providers are notified of code conversions through Medicaid bulletins.

Remittance Advice

    1. What is the difference between the electronic remittance advice (ERA) and the paper remittance advice (RA)?

    The ERA consists of two transactions: the 835 claim payment/advice transaction and the 277 pending (unsolicited) claim status transaction. These two transactions provide information on paid claims, adjusted claims, refunds, and pending claims payments. The ERA transactions and the 277 unsolicited claims status are intended to be used as an aid to account balancing and direct posting to patient accounts. The unsolicited claim status transaction is not a HIPAA-mandated transaction. Providers are not mandated to implement this transaction. However, if a provider elects to receive an 835 transaction, the 277 transaction will be created automatically for that provider when there are pending claims on file. Providers may elect to ignore the unsolicited 277.

    The paper RA also provides information on claims payment but includes a greater level of detail on claim denials. All providers will continue to receive the paper version of the RA, even if they choose to receive the ERA transactions.

    2. Will the EOB codes on the ERA be the same as the EOB codes on the paper RA?

N.C. Medicaid will implement the use of the standard Claims Adjustment Reason Code set, Remittance Remark Code set, Claim Status Category Code set, and Claim Status Code set for the ERA transactions as mandated by HIPAA. The EOBs currently used for paper RAs will not change. The AVR system will continue to provide explanations for paper EOB codes.

Claims Software Vendors and Clearinghouses

    1. What is the process for providers who work with a clearinghouse?

    The health care clearinghouse must comply with the standards outlined in the August 17, 2000 rule. There are additional requirements found in 45 CFR 162.923 (c) (1-2) and 45 CFR 162.930 that are specific to clearinghouses. Requirements for covered entities are outlined in 45 CFR 162.923. Because a clearinghouse is contracted by a provider to act as their agent, it is the provider’s responsibility to verify that the clearinghouse is HIPAA compliant.

    2. Will providers be held liable if their clearinghouse or billing agent is not compliant with the HIPAA transaction and code set standards regulation by October 16, 2003?

    For questions regarding legal liability, please contact the Centers for Medicare and Medicaid Services (CMS).

    3. Is N.C. Medicaid working with software companies and clearinghouses to ensure that they are HIPAA compliant? How will vendors and clearinghouses be notified of what changes are necessary?

    It is the provider’s responsibility to ensure that their software or clearinghouse is HIPAA compliant.

    The X12N transaction HIPAA implementation guides are available on the Washington Publishing Company’s website. Consult the NCPDP website for the NCPDP transaction standards for retail pharmacy services.

    4. What is a trading partner agreement and how does it affect me?

    As defined in § 160.103 of the Transaction and Code Sets final rule, a trading partner agreement is defined as an agreement related to the exchange of information in electronic transactions, whether the agreement is distinct or part of a larger agreement, between each party to the agreement. (For example, a trading partner agreement may specify, among other things, the duties and responsibilities of each party to the agreement in conducting a standard transaction.)

    Providers who conduct electronic transactions with N.C. Medicaid will either need to enter into a trading partner agreement directly with N.C. Medicaid or through their clearinghouse depending on how they submit electronic transactions. The trading partner agreement for N.C. Medicaid contains information regarding testing, what type of transactions will be exchanged, and protocol information for the exchange of those transactions.

    5. When will testing with providers begin?

The projected time to begin testing directly with N.C. Medicaid is June 2003. In lieu of testing directly with N.C. Medicaid, providers may test with a third party certification service. Once certification information is on file with N.C. Medicaid, providers will have the capability to submit and receive HIPAA compliant transactions.

For more information regarding third party certification, please refer to the WEDI/SNIP Testing and Certification white paper.

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


Attention: All Providers

Health Insurance Portability and Accountability Act Transaction Implementation

In October 2002, the N.C. Medicaid program implemented the following Health Insurance Portability and Accountability Act (HIPAA) electronic transactions:

If you are interested in submitting either of these transactions, please contact the EDS Electronic Commerce Services Department at 1-800-688-6696, option 1.

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


Attention: All Providers

Termination of Coverage for Parenting Education

Effective with date of service June 30, 2003, Parenting Education (W8205) will be discontinued. The N.C. Medicaid program will no longer cover this service.

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


Attention: Ambulance Providers

New Ambulance Billing Guidelines

Effective with date of service May 31, 2003, the N.C. Medicaid program will end-date the following codes to comply with the Health Insurance Portability and Accountability Act (HIPAA): Y0050, Y0060, Y0070, Y0002, Y0003, Y0004, and Y0001. Providers must bill the replacement codes listed in the following table, effective with date of service June 1, 2003. The N.C. Medicaid program reimburses according to the level of care provided to the recipient. Call Reports must validate the level of care provided to the recipient.

Old Code

Description

New Code

Description

Y0050

Helicopter, per nautical mile

A0436

Rotary wing air mileage, per statute mile

Y0060

Fixed wing, lift off

A0430

Ambulance service, conventional air services, transport, one-way (fixed wing)

Y0070

Fixed wing, per nautical mile

A0435

Fixed wing air mileage, per statute mile

Y0001

Non-emergency transport, round-trip

T2003

Non-emergency transportation, encounter/trip (round-trip)

Y0002

State-to-state placement, base rate one-way, prior approval required

RC 549

Ambulance/other (state-to-state), prior approval required*

Y0003

Fixed wing, lift off, state-to-state placement, prior approval required

   

Y0004

Helicopter, lift off, state-to-state placement, prior approval required

   

* Beginning June 1, 2003, providers will indicate state-to-state placement by using Revenue Code 549 in conjunction with the appropriate HCPCS code indicated in this bulletin article or the article in the December 2002 general Medicaid bulletin article. Prior approval is required for state-to-state transport.

Fixed Wing Air Ambulance

Definition: Fixed Wing (FW) air ambulance is transportation by FAA-certified FW aircraft providing medically necessary services and supplies.

Rotary Wing Air Ambulance

Definition: Rotary Wing (RW) air ambulance is transportation by FAA-certified helicopter providing medically necessary supplies and services.

Round Trip

Definition: Round trip is non-emergency transportation by ambulance from point of pick-up to destination and return to point of pick-up on the same day by the same provider. If the ambulance remained in the vicinity of the destination, did not return to base, and did not respond to other calls for transport, a round trip should be billed.

Point of Pick-Up

Definition: Point of Pick-Up is the location of the recipient at the time he/she is placed on board the ambulance.

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


Attention: Ambulatory Surgical Centers

ADA Procedure Codes Must be Billed with the "D" Prefix

Effective with dates of service October 1, 2003, all dental procedure codes must be billed with the "D" prefix (such as D0120, D0150, etc) for electronic and paper claims. Dental ADA procedure codes will not be accepted with the numeric zero prefix after September 30, 2003. Services billed using the numeric zero prefix procedure codes will deny with the explanation of benefit (EOB) message 0024, which states: "Procedure code, procedure/modifier combination or revenue code is missing, invalid, or invalid for this bill type. Correct and rebill denied detail as a new claim."

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


Attention: All Providers

Progesterone, per 50 mg (HCPCS Code J2675) – Coverage Reinstated

The N.C. Medicaid program has reinstated the code for progesterone, J2675, for use in the Physician’s Drug Program effective with dates of service January 1, 2003 and after. Previous billing guidelines apply.

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


Attention: At-Risk Case Management

HIPAA Code Conversion for Case Management Services for Adults and Children at Risk of Abuse, Neglect or Exploitation

To comply with the implementation of national code sets mandated by the Health Insurance Portability and Accountability Act (HIPAA), it is necessary to end-date all N.C. Medicaid state-created (local) codes and convert to national codes. Effective with date of service May 31, 2003, local code Y2321 for at-risk services to adults and local code Y2322 for at-risk services to children will be end-dated. Effective with date of service June 1, 2003, providers must submit national code T1017 for all at-risk services. T1017 will be the only billable code for services provided to either adults or children. This change applies to both paper and electronic claim formats.

Please continue to use the CMS-1500 claim form (formerly HCFA-1500). T1017 must be indicated in the same, block 24D, on the claim form as the previous "Y" codes. Continue to indicate diagnosis code V65.8 in block 21 on the claim form.

Bill Hottel, Adult Care Home Services Unit, Medical Policy Section
DMA, 919-857-4020


Attention: Area Mental Health Centers, Developmental Evaluation Centers, Independent Practitioners, Local Health Departments, and Physician Services

Addition of V Code Diagnosis for Outpatient Specialized Therapies

All claims for physical therapy, occupational therapy, respiratory therapy, and speech therapy – including claim adjustments and resubmitted claims – submitted for billing June 1, 2003 or after, must include one of the discipline-specific ICD-9-CM diagnosis codes listed below as a secondary diagnosis on the claim. This allows EDS to correctly accrue the units billed for each specialized therapy authorized during the prior approval process.

V57.0 – Respiratory Therapy

V57.1 – Physical Therapy

V57.2 – Occupational Therapy

V57.3 – Speech Therapy

This does not change the requirement to bill the primary diagnosis that justifies the need for the specialized therapy. Remember: The primary treatment ICD–9-CM diagnosis code must be entered first on the claim form. The discipline-specific V code should follow the primary treatment code.

Nora Poisella, Medical Policy Section
DMA, 919-857-4020


Attention: Dental Providers (Excluding Health Departments)

Dental Rate Change

Effective with dates of services April 1, 2003 the following dental rates are changed:

Procedure Code

Description

Rate

D0120

Periodic Oral Evaluation

$ 27.01

D0140

Limited Oral Evaluation - Problem Focused

35.77

D0150

Comprehensive Oral Evaluation

52.56

D0220

Intraoral-Periapical - First Film

13.14

D0230

Intraoral-Periapical - Each Additional Film

11.68

D0240

Intraoral Occlusal Film

14.60

D0272

Two Bitewing X-rays

17.52

D0274

Four Bitewings for 13 Years of Age and Older

31.39

D0330

Panoramic Film

57.67

D1351

Pit and Fissure Sealant per Tooth

$ 29.93

D1510

Space Maintainer – Fixed - Unilateral

208.05

D1515

Space Maintainer - Fixed - Bilateral

418.29

D2110

Amalgam - One Surface, Primary

56.21

D2120

Amalgam - Two Surfaces, Primary

74.46

D2140

Amalgam - One Surface, Permanent

62.78

D2150

Amalgam - Two Surfaces, Permanent

77.38

D2160

Amalgam - Three Surfaces, Permanent

91.25

D2330

Composite Resin - One Surface Restoration

62.78

D2331

Composite Resin - Two Surfaces Restoration

77.38

D2332

Composite Resin 3 - Surfaces Restoration

91.25

D2335

Composite Resin 4 - or More Surfaces

116.07

D2380

One Surface Resin, Primary Molar

73.00

D2381

Two Surface Resin, Primary Molar

109.50

D2385

Resin - One Surface, Posterior - Permanent

77.38

D2386

Resin-Two Surfaces, Posterior - Permanent

116.07

D2930

Prefabricated Stainless Steel Crown, Primary

127.75

D2933

Prefabricated Stainless Steel Crown, Resin Window

$ 181.77

D2940

Fillings (Sedative)

77.38

D3220

Vital Pulpotomy

78.11

D4341

Periodontal Scaling and Root Planning per Quadrant

78.11

D7110

Extraction Single Tooth

51.10

D7120

Tooth Extraction Each Additional

48.91

D7210

Surgical Extraction of Tooth, Erupted

78.11

D7230

Removal of Impacted Tooth - Partial Bony

154.76

D9230

Analgesia

52.56

D9420

Hospital Call

113.88

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


Attention: All Dental Providers and Health Department Dental Clinics

ADA Code Updates for the Year 2003 and the New Dental Claim Form

In January 2003, the American Dental Association (ADA) updated the ADA claim form and the Current Dental Terminology (CDT-4) Users Manual. DMA and EDS are currently implementing system changes to comply with the new codes and claim form.

ADA Procedure Codes Must be Billed with the "D" Prefix

Effective with dates of service October 1, 2003, all dental procedure codes must be billed with the "D" prefix (such as D0120, D0150, etc) for electronic and paper claims. Dental ADA procedure codes will not be accepted with the numeric zero prefix after September 30, 2003. Services billed using the numeric zero prefix procedure codes will deny with the explanation of benefit (EOB) message 0024, which states: "Procedure code, procedure/modifier combination or revenue code is missing, invalid, or invalid for this bill type. Correct and rebill denied detail as a new claim."

Procedure Code Updates

Updates to the CDT-4 contain procedure code deletions, procedure code additions, and revised procedure code descriptions. The N.C. Medicaid Dental Program will implement the changes listed in the following tables.

The following codes will be end-dated effective with dates of service after September 30, 2003.

Procedure Code

Description

D0501

Histopathologic examinations

D2110

Amalgam-one surface, primary

D2120

Amalgam-two surfaces, primary

D2130

Amalgam-three surfaces, primary

D2131

Amalgam-four or more surfaces, primary

D2336

Resin-based composite crown-anterior-primary

D2380

Resin-based composite-one surface, posterior-primary

D2381

Resin-based composite-two surfaces, posterior-primary

D2385

Resin-based composite-one surface, posterior-permanent

D2386

Resin-based composite-two surfaces, posterior- permanent

D2387

Resin-based composite-three surfaces, posterior- permanent

D2388

Resin-based composite-four or more surfaces, posterior- permanent

D7110

Single tooth

D7120

Each additional tooth

D7130

Root removal-exposed roots

D7420

Radical excision-lesion diameter greater than 1.25 cm

D7430

Excision of benign tumor-lesion diameter up to 1.25

D7431

Excision of benign tumor-lesion diameter greater than 1.25

Note: All end-dated codes will be replaced with new codes or revised codes.

The following codes will be added effective with dates of service October 1, 2003.

Procedure Code

Description

D2390

Resin-based composite crown-anterior

D2391

Resin-based composite-one surface, posterior

D2392

Resin-based composite-two surfaces, posterior

D2393

Resin-based composite-three surfaces, posterior

D2394

Resin-based composite-four or more surfaces, posterior

D6985

Pediatric partial denture, fixed

D7140

Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

D7280

Surgical access of an unerupted tooth

D7411

Excision of benign lesion greater than 1.25 cm

D7472

Removal of torus palatinus

D7473

Removal of torus mandibularis

87205

Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types

The following procedure code descriptions were revised. These new descriptions are effective with dates of service October 1, 2003.

Procedure Code

Description

D0150

Comprehensive oral evaluation – new or established patient

D2140

Amalgam-one surface, primary or permanent

D2150

Amalgam-two surfaces, primary or permanent

D2160

Amalgam-three surfaces, primary or permanent

D2161

Amalgam-four or more surfaces, primary or permanent

D4210

Gingivectomy or gingivoplasty-four or more contiguous teeth or bounded teeth spaces, per quadrant

D4240

Gingival flap procedure, including root planing-four or more contiguous teeth or bounded teeth spaces, per quadrant

D4341

Periodontal scaling and root planing-four or more contiguous teeth or bounded teeth spaces, per quadrant

D4355

Full mouth debridement to enable comprehensive evaluation and diagnosis

D4910

Periodontal maintenance

D7270

Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth

D7410

Excision of benign lesion up to 1.25 cm

D7450

Removal of benign odontogenic cyst or tumor-lesion diameter up to 1.25 cm

D7451

Removal of benign odontogenic cyst or tumor-lesion diameter greater than 1.25 cm

D7460

Removal of benign nonodontogenic cyst or tumor-lesion diameter up to 1.25 cm

D7461

Removal of benign nonodontogenic cyst or tumor-lesion diameter greater than 1.25 cm

D7471

Removal of lateral exostosis (maxilla or mandible)

D7530

Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue

D7550

Partial ostectomy/sequestrectomy for removal of non-vital bone

D7670

Alveolus-closed reduction, may include stabilization of teeth

D7770

Alveolus-open reduction stabilization of teeth

D9220

Deep sedation/general anesthesia-first 30 minutes

D9221

Deep sedation/general anesthesia-each additional 15 minutes

D9241

Intravenous conscious sedation/analgesia- first 30 minutes

D9242

Intravenous conscious sedation/analgesia- each additional 15 minutes

Clarification of Policy and Criteria Due to Procedure Code Revisions and Additions

Code

Description

Criteria

D0150

Comprehensive oral evaluation – new or established patient

This is allowed as the initial exam once per provider for each recipient.

D2390

Resin-based composite crown, anterior

This is allowed for primary anterior teeth only (C-H, M-R, 40).

D2393

Resin-based composite-three surfaces, posterior

This is allowed for permanent posterior teeth only (1-5, 12-21, 28-32, 40).

D2394

Resin-based composite-four or more surfaces, posterior

This is allowed for permanent posterior teeth only (1-5, 12-21, 28-32, 40).

D4210

Gingivectomy or gingivoplasty-four or more contiguous teeth or bounded teeth spaces, per quadrant

At least four teeth must be present to qualify for a quadrant.

D4240

Gingival flap procedure, including root planing-four or more contiguous teeth or bounded teeth spaces, per quadrant

At least four teeth must be present to qualify for a quadrant.

D4341

Periodontal scaling and root planning-four or more contiguous teeth or bounded teeth spaces, per quadrant

If seven or less teeth remain per arch, use UP or LO in the tooth number or surface field.

D7471

Removal of lateral exostosis (maxilla or mandible)

This is allowed as an arch procedure (UP, LO).

D7472

Removal of torus palatinus

This is allowed as an upper arch procedure (UP).

D7473

Removal of torus mandibularis

This is allowed as a lower arch procedure (LO).

For a complete list of criteria specific to these procedure codes, refer to Medical Coverage Policy #4A, Dental Services (dental services provider manual).

Eight-Digit Dates Required for Dental Paper Claims

Effective October 1, 2003, all dates on the dental paper claim form must be formatted with eight digits (October 1, 2003 would be listed as 10012003). Using six digits for the date of service will no longer be accepted. Beginning October 1, 2003, dental claims that are submitted without eight-digit dates will deny as missing or invalid.

New Dental ADA Claim Form

DMA and EDS are currently updating the system to accept the 2002 ADA claim form. The anticipated implementation date for the new form is October 1, 2003. However, providers should continue to use the 2000 ADA claim form until the final implementation date is confirmed. Please refer to future general Medicaid bulletins for notification of the final implementation date. Once the system has been updated to accept the 2002 ADA claim form, providers will be given a three-month transition period to begin using the new form. During the transition period, both the 2000 and 2002 ADA claim form will be accepted.

Forms can be ordered from the ADA. Listed below is the ADA address and toll-free telephone number:

American Dental Association
Attn: Salable Materials Office
211 E. Chicago Avenue
Chicago, IL 60611
1-800-947-4746

The form is available as a single or two-part form. The single form must be used when submitting claims for payment. The two-part form must be used when requesting prior approval. The original is returned to the provider and serves as the prior approval/claim copy. The second page is retained by EDS.

Review upcoming general Medicaid bulletins for exact dates and additional information regarding implementation of the 2002 ADA claim form and 2003 ADA procedure code updates.

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


Attention: All Providers

Managed Care Seminar Schedule

Managed Care seminars are scheduled for June 2003. Seminars are intended for providers who serve Carolina ACCESS, ACCESS II, and ACCESS III enrollees. Topics to be discussed will include, but are not limited to, provider enrollment requirements, recipient enrollment requirements, obtaining referrals and authorization, and new Managed Care initiatives.

Due to limited seating, preregistration is required and limited to two staff members per office. Unregistered providers are welcome to attend when reserved space is adequate to accommodate. Providers may register for the Managed Care seminars by completing and submitting the Managed Care Seminar Registration Form or through Online Registration beginning May 1, 2003. Seminars begin at 10:00a.m. and end at 1:00 p.m. Providers are encouraged to arrive by 9:45 a.m. to complete registration.

Providers must access and print the PDF version of May 2003 General Medicaid Billing/Carolina ACCESS Policies and Procedures Guide and bring it to the seminar. The Managed Care Provider Information section of the guide will be used as the handout for this seminar.

Tuesday, June 10, 2003
WakeMed
Andrews Conference Center
3000 New Bern Ave.
Raleigh, NC

Wednesday, June 11, 2003
Ramada Inn Plaza
3050 University Pkwy.
Winston-Salem, NC

Tuesday, June 17, 2003
College of the Albemarle
Auditorium
1208 N. Road Street
Elizabeth City, NC

Thursday, June 19, 2003
Coast Line Convention Center
501 Nutt St.
Wilmington, NC

Tuesday, June 24, 2003
Blue Ridge Community College
Bo Thomas Auditorium
College Dr.
Flat Rock, NC

Thursday, June 26, 2003
Holiday Inn Conference Center
530 Jake Alexander Blvd., S.
Salisbury, NC

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


Attention: Electronic Billers

North Carolina Electronic Claims Submission Software Seminar Schedule

The current North Carolina Electronic Claims Submission (NCECS) software obtained by providers at no cost from EDS will be replaced with a web-based version to comply with the implementation of data content standards mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Seminars on the new web-based NCECS program are scheduled at the locations listed below. Preregistration is required and limited to providers currently using NCECS and providers who choose to begin using the new web-based NCECS program. 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 NCECS seminars by completing and submitting the NCECS Registration Form or through online registration beginning May 1, 2003. Please indicate on the registration form the session you plan to attend. Seminars begin at 9:00 a.m. and end at 5:00 p.m. Providers are encouraged to arrive by 8:45 a.m. to complete registration.

Tuesday, June 17, 2003
Jane S. McKimmon Center
1101 Gorman Street
Raleigh, NC

Wednesday, June 18, 2003
Coast Line Convention Center
501 Nutt Street
Wilmington, NC

Tuesday, June 24, 2003
Park Inn
Gateway Conference Center
909 US Highway 70 SW
Hickory, NC

Thursday, June 26, 2003
Ramada Inn Plaza
3050 University Parkway
Winston-Salem, NC

Tuesday, July 1, 2003
Holiday Inn-Bordeaux
1707 Owen Drive
Fayetteville, NC

Tuesday, July 8, 2003
Holiday Inn Conference Center
530 Jake Alexander Blvd., S.
Salisbury, NC

Thursday, July 10, 2003
Blue Ridge Community College
Bo Thomas Auditorium
College Drive
Flat Rock, NC

Tuesday, July 15, 2003
College of the Albemarle
Auditorium
1208 N. Road Street
Elizabeth City, NC

Wednesday, July 16, 2003
Hilton Greenville
207 Greenville Blvd SW
Greenville, NC

Tuesday, July 22, 2003
Ramada Inn
2703 Ramada Road
Burlington, NC

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


Directions to the Managed Care Seminars and the NCECS Seminars

Blue Ridge Community College, Bo Thomas Auditorium – Flat Rock, North Carolina
Take I-40 to Asheville. Travel east on I-26 to exit 22. Turn right and then take the next right. Follow the signs to Blue Ridge Community College. Turn left at the large Blue Ridge Community College sign. The college is located on the right. Take the first right-hand turn into the parking lot for the Bo Thomas Auditorium.

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.

College of the Albemarle – Elizabeth City, North Carolina
Take US 17 to the US 17 Bypass. The College of the Albemarle is located on the Bypass, next door to Albemarle Hospital.

Hilton Greenville – Greenville, North Carolina
Take Highway 264 East to Greenville. Turn right onto Allen Road in Greenville. Travel approximately 2 miles. Allen Road becomes Greenville Boulevard/Alternate 264. Follow Greenville Boulevard for 2½ miles to the Hilton Greenville, which is located on the right.

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 40 to Hwy 301 to Owen Drive. Turn left at the light.

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.

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 on 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 between Avent Ferry Road and Western Boulevard.

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.

Ramada Inn – Burlington, North Carolina
Take I-40 to exit 143. Turn left at the first stop light onto Ramada Road. The Ramada Inn is on the right.

Ramada Inn Plaza – Winston-Salem, North Carolina
Take I-40 Business to the Cherry Street exit. Continue on Cherry Street for approximately 2 to 3 miles. Turn left at the IHOP Restaurant. The Ramada Inn Plaza is located on the right.

WakeMed Andrews Conference Center – Raleigh, North Carolina
Driving and Parking Directions
Take the I-440 Raleigh Beltline to exit 13A, New Bern Avenue.

Paid parking ($3.00 maximum per day) is available on the top two levels of parking deck P3. To reach the parking deck, turn left at the fourth stoplight on New Bern Avenue, and then turn left at the first stop sign. Parking for oversized vehicles is available in the overflow lot for parking deck P3. Handicapped accessible parking is available in parking lot P4, directly in front of the conference center.

To enter the Andrews Conference Center, follow the sidewalk toward New Bern Avenue past the Medical Office Building to entrance E2 of the William F. Andrews Center for Medical Education.

Illegally parked vehicles will be towed. Parking is not permitted at East Square Medical Plaza, Wake County Human Services or in parking lot P4 (except for handicapped accessible parking).

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


Attention: Home Health Agencies, Private Duty Nursing Providers, and Community Alternatives Program Case Managers

HCPCS Code Changes for Home Health Supplies

The following HCPCS codes will be end-dated effective with date of service June 30, 2003. New codes will become effective with date of service July 1, 2003.

Home Health Supplies

Deleted Codes

New Codes

Description

Billing Unit

Maximum Rate

Dressing Supplies

A4454

A4450

Tape, non-waterproof

18 sq. in.

$ .09

K0573

A4452

Tape, waterproof

18 sq. in.

.47

A4460

A6263

A6405

A6430

Light compression bandage, elastic, knitted/woven, load resistance less than 1.25 foot pounds at 50% maximum stretch, width greater than or equal to 3 in. and less than 5 in., at least 3 yards, unstretched

Roll

1.00

A4460

A6263

A6405

A6432

Light compression bandage, elastic, knitted/woven, load resistance less than 1.25 foot pounds at 50% maximum stretch, width greater than or equal to 5 in., at least 3 yards, unstretched

Roll

1.00

A6264

A6422

Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 3 in. and less than 5 in., at least 3 yards, unstretched

Roll

1.50

A6264

A6424

Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 5 in., at least 3 yards, unstretched

Roll

1.50

A6406

A6426

Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to 3 in. and less than 5 in., at least 3 yards, unstretched

Roll

2.37

A6406

A6428

Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to 5 in., at least 3 yards, unstretched

Roll

2.37

Ostomy Supplies

A4370

A4405

Ostomy skin barrier, non-pectin based, paste

1 oz.

$ 3.50

A4370

A4406

Ostomy skin barrier, pectin-based, paste

1 oz.

3.50

A5123

A4407

Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4x4 inches or smaller

Each

4.92

A5123

A4410

Ostomy skin barrier, with flange (solid flexible or accordion) extended wear, without built-in convexity, larger than 4x4 inches

Each

4.92

Catheter Supplies

A5074

Not covered

Pouch, urinary with face plate attached, plastic or rubber

   

Tracheostomy Supplies

W4153

S8189

Tracheostomy supply not otherwise classified (tracheostomy ties, twill)

Each

$ .30

Miscellaneous Supplies

W4609

A4550

Surgical trays (suture removal set)

Each

$ 4.16

W4626

Not covered

Gowns

   

W4655

T1999

Miscellaneous therapeutic items and supplies (covered supplies not elsewhere classified)

   

W4659

A4335

Incontinence supply, misc. (catheter care kit)

Each

$ 4.08

W4665

Not covered

Specimen containers

   

Solutions

W4666

A4321

Therapeutic agent for urinary catheter irrigation (acetic acid – 250 to 1000 cc)

Bottle

$ 7.09

Intravenous Supplies

 

A4657

Syringe, with or without needle (less than 20 cc)

Each

$ .31

Providers must bill their usual and customary charges.

Dot Ling, Medical Policy Section
DMA, 919-857-4021


Attention: Mecklenburg County Providers

Injectable Drug Clarification

Injectable drugs are included in the monthly capitation rates paid to HMOs. Therefore, providers must submit claims for injectable drugs directly to their HMO.

Injectable drug claims submitted to Medicaid have been returned to the HMO for processing.

This action affects claims submitted to United HealthCare through November 30, 2002, and all claims submitted to SouthCare/Coventry to date.

Julia McCollum, Managed Care Section
DMA, 919-857-4022


Attention: Local Education Agencies

Outpatient Specialized Therapies

Please refer to the Division of Medical Assistance web page for an announcement about Outpatient Specialized Therapies.

Nora Poisella, Medical Policy Section
DMA, 919-857-4020


Attention: Hospital Providers

New Patient Status Codes

The National Uniform Billing Committee (NUBC) has revised the instructions for completing the UB-92 claim form to include three new patient status codes. These codes are entered in form locater 22 on the UB-92. The following patient status codes became effective January 1, 2002:

62 - Discharged/transferred to another rehabilitation facility including rehabilitation distinct part units of a hospital.

    63 - Discharged/transferred to a long term care hospital.

The following patient status code became effective October 1, 2002:

    64 - Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare.

Providers may begin using these codes immediately.

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


Attention: Independent Practitioner Providers

Respiratory Therapists

In accordance with the North Carolina Respiratory Care Practice Act, the N.C. Medicaid State Plan has been amended to require that respiratory therapists be licensed in order to provide Medicaid reimbursed respiratory therapy services.

Medical Coverage Policy #8G - Independent Practitioners, has been revised to reflect this change.

Nora Poisella, Medical Policy Section
DMA, 919-857-4020


 

Checkwrite Schedule

April 8, 2003

May 6, 2003

June 10, 2003

April 15, 2003

May 13, 2003

June 17, 2003

April 22, 2003

May 20, 2003

June 26, 2003

May 29, 2003

Electronic Cut-Off Schedule

April 4, 2003

May 2, 2003

June 6, 2003

April 11, 2003

May 9, 2003

June 13, 2003

April 17, 2003

May 16, 2003

June 20, 2003

May 23, 2003

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.

Holiday Closing

The Division of Medical Assistance (DMA) and EDS will be closed on Monday, May 26, 2003, in observance of Memorial Day.



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

 
 
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