In This Issue..
All Providers:
|
Health Departments: Hospitals: ICF/MR Facility Providers: Long Term Care Pharmacists: Nursing Facility Providers: Prescribers and Pharmacists: Physicians: |
EDS, 1-800-688-6696 or 919-851-8888
Darlene Cagle
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 Cagle, Medical Policy Section
DMA, 919-857-4020
Federal legislation allows states to apply for a one-year extension. Extending the implementation deadline to October 16, 2003 will allow N.C. Medicaid to complete cost savings initiatives that need to be implemented in the MMIS prior to implementing HIPAA changes.
N.C. Medicaid now plans to implement HIPAA standard transactions by May 1, 2003. Providers must continue to submit electronic claims in the current format until May 1, 2003. After May 1, 2003, Medicaid will accept electronic claims in the new HIPAA format. However, N.C. Medicaid will also accept claims in the current electronic format until October 16, 2003. After October 16, 2003, all claims submitted to N.C. Medicaid, must use the new HIPAA format.
For additional information on HIPAA, refer to HIPAA
- Questions and Answers.
EDS, 1-800-688-6696 or 919-851-8888
Labor and Delivery Billing
| Service | Code | Modifier | Units |
| Vaginal delivery only under general anesthesia | 59409 | Modifier YA | 1 min = 1 unit |
| C-section delivery only under general anesthesia | 59514 | Modifier YA | 1 min = 1 unit |
| Planned vaginal labor and delivery under epidural or spinal anesthesia | 01967 | No modifier |
1 unit
(Flat rate) |
| C-section after planned vaginal labor under epidural or spinal anesthesia |
01967
and 01968 |
No modifier
No modifier |
1 unit
(Flat rate) 1 unit (Flat rate) |
| Planned C-section delivery under epidural or spinal anesthesia | 01961 | No modifier |
1 unit
(Flat rate) |
| Labor under epidural or spinal anesthesia, and vaginal delivery under general |
01967
and 59409 |
No modifier
YA |
1 unit
(Flat rate) 1 min = 1 unit |
| Labor under epidural or spinal anesthesia, and C-section delivery under general |
01967
and 59514 |
No modifier
Modifier YA |
1 unit
(Flat rate) 1 min = 1 unit |
| C-section hysterectomy after labor under epidural or spinal anesthesia |
01967
and 01969 |
No modifier
No modifier |
1 unit
(Flat rate) 1 unit (Flat rate) |
| C-section delivery following Intrathecal block, same date of service |
01961
and 62311 |
No modifier
Modifier 59 |
1 unit
(Flat rate) 1 unit (Flat rate) |
| C-section delivery following Intrathecal block, different dates of service |
01961
and 62311 |
No modifier
No modifier |
1 unit
(Flat rate) 1 unit (Flat rate) |
EDS, 1-800-688-6696 or 919-851-8888
General Questions
Although provider education will be sponsored for North Carolina's
Medicaid providers, providers must understand that education will be limited
to general HIPAA information and its outcome and effects as it relates
to the N.C. Medicaid program only.
Training and information offered by the N.C. Medicaid program does not
relieve providers from the responsibility of educating their staff on HIPAA
regulations regarding transaction and code set standards, privacy regulations,
and security regulations. Providers are encouraged to review the HIPAA
rules and discuss required changes with their billing departments, billing
agents, and clearinghouses.
Specific changes implemented by N.C. Medicaid to comply with HIPAA regulations
will be published in 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.
Yes. There is one final rule for transactions and code sets. The
HIPAA Transaction and Code Set Final Rule, published August 17, 2000 in
the Federal Register, applies to all covered entities. The rule (CFR 160
and 162) can be accessed at http://www.access.gpo.gov/su_docs.
According to regulation, the deadline to implement the HIPAA electronic
transaction and code set standards is October 16, 2002.
N.C. Medicaid plans to be fully compliant by May 1, 2003. Some transaction
sets may be implemented at an earlier date. Please pay close attention to
future Medicaid bulletins and to DMA's HIPAA webpage
for additional information.
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 policy and billing requirements. Providers should be aware
that changes to standardize and promote electronic data interchange may
require health plans to also modify the information requirements for paper
claims.
Payment 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 North Carolina uses for some services. Providers will be notified
of changes to billing guidelines through Medicaid bulletins.
Paper claims will continue to be accepted by N.C. Medicaid. However,
providers are encouraged to use electronic claims submission and remittance
advice (RA) receipt for expedient claims processing. HIPAA does not require
providers to submit claims electronically.
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.
No. The electronic transaction standards regulation does not apply
to providers who file their claims on paper. The regulation only applies
to the electronic data interchange.
Changes may be required as a result of HIPAA code sets, which essentially
delete local codes and require payers to recognize standard billing codes
such as ICD-9-CM, CPT-4, CDT-3, NDC, and HCPCS. Any changes made to North
Carolina's local codes will be communicated in future Medicaid bulletins.
We will continue to support PA requests on paper. It is the provider's
decision to elect using the 278 Health Care Services Review Request and
Response (electronic prior authorization) transaction.
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. Providers will still need to provide the appropriate PA
form in order to provide the medical necessity 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
medical documentation necessary for a decision.
Yes. Providers will be notified through Medicaid bulletins of AVR
access changes and changes in the information that is available through
AVR.
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 is a required data element on the
837 institutional claim, 837 professional claim, and 278 prior authorization
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.
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 their website at http://wedi.org/.
Coding
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.
The August 17, 2000 HIPAA Transaction and Code Sets final rule named
the NDC as the required code set for reporting all drugs and biologics
on all HIPAA transactions. It is anticipated that the final rule will be
amended to rescind the initial ruling regarding the NDC. N.C. Medicaid
will continue to require the NDC to be billed on retail pharmacy claims.
However, N.C. Medicaid will continue to accept HCPCS J-codes on professional
and institutional claims. In the event the final rule is not amended or
payment policies for N.C. Medicaid change, the NDC may be required on these
claim types at a later time.
Remittance Advice
The ERA consists of two transactions: the 835 claim payment/advice
transaction and the 277 pending (unsolicitated) 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 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.
ERAs in the tape format currently produced by N.C. Medicaid will be
discontinued on October 16, 2003.
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
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.
For questions regarding legal liability, please contact the Centers
for Medicare and Medicaid Services (CMS). Their website is http://www.cms.gov.
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 at http://www.wpc-edi.com.
Consult the NCPDP website at http://www.ncpdp.org
for the NCPDP transaction standards for retail pharmacy services.
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 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 is currently
under development. However, this agreement will contain, at a minimum,
information regarding testing, what type of transactions will be exchanged,
and protocol information for the exchange of those transactions.
The projected time to begin testing directly with N.C. Medicaid
is mid-February 2003. In lieu of testing directly with N.C. Medicaid, providers
may test with a third party certification agency. 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 at http://snip.wedi.org. Additional information will be provided in future Medicaid bulletins and on DMA's website at http://www.dhhs.state.nc.us/dma.
EDS, 1-800-688-6696 or 919-851-8888
EDS, 1-800-688-6696 or 919-851-8888
The list will be phased in over time, with the first classes of drugs scheduled to be implemented in December 2002.
An impartial Physicians Advisory Group will identify clinically effective, brand-name drugs for each drug class, regardless of cost. They will recommend to N.C. Medicaid that these drugs be considered for creating the preferred drug list. N.C. Medicaid will choose the two most cost-effective of the recommended drugs for the preferred drug list, plus all other drugs in that class that are less expensive.
The 40-member Physicians Advisory Group has an 11-member board of directors, plus three committees, including a Pharmacy Advisory Committee, who will be involved with the preferred drug list. They will hold public hearings regarding the drugs they recommend as the most clinically effective drugs.
The Physicians Advisory Group will start by looking at classes of drugs that are the most expensive. Thereafter, new classes of drugs will be added to the preferred drug list on a quarterly basis.
The preferred drug list also allows N.C. Medicaid to negotiate for better prices. If a drug company wants an expensive drug to be included on the preferred drug list, they will have the opportunity to offer the state a supplemental rebate to make that drug more cost effective.
Doctors may still prescribe drugs that are not on the list, but they must first obtain prior authorization. Medicaid will still pay for the higher cost drug, provided there is no lower cost drug that will provide the same benefit.
Because of the difficulty in finding a medication or combination of medications that work for each individual patient, all drugs to treat HIV will automatically be preferred. Also, patients taking drugs to treat psychosis and depression will be grandfathered into the program: that is, physicians who have already prescribed non-preferred drugs for Medicaid patients will not have to get approval for those prescriptions.
The medication regimen for Medicaid patients in long-term care facilities will not be affected. This population will be grandfathered into the program.
We pledge to you that we will provide prompt, easy service when you seek approval for drugs not on the list. The program will be run alongside our prior authorization program, with similar procedures. You will have 30 days after decisions are made regarding preferred drugs in each class before the change is implemented.
This letter is meant to provide you with general information regarding
the preferred drug list. Updates will be available on the Medicaid pharmacy
program website at http://www.ncmedicaidpbm.com
and in upcoming Medicaid bulletins.
Medical Policy Section
DMA, 919-857-4020
Prescribers may request exemptions to PA when the they believe that the prescribed drug is medically necessary for the patient but ACS State HealthCare has determined that the PA request does not meet the criteria for approval. Requests must be on a case-by-case basis and follow the process outlined below.
ACS State Healthcare
1-866-246-8505
This grace period allows additional time to gather the medical information necessary to request PA from ACS State Healthcare, the contractor administering the Prescription Drug PA program. If ACS determines that the request does not meet the PA criteria, the prescriber may submit a request for exemption according to the instructions outlined on page 10 of this bulletin.
Changes to the Medicaid claims payment system will automate this 34-day
grace period. Until these changes are finalized, it is necessary to contact
ACS at 1-866-246-8505 (telephone) or 1-866-246-8507 (fax) to initiate the
34-day grace period. The caller must identify the patient as a resident
of one of the long-term care facilities listed above and must provide the
information requested on the top part of the Miscellaneous Drug Request
form. The form can be obtained online at http://www.ncmedicaidpbm.com.
ACS State Healthcare
1-866-246-8505
Criterion #5 services can only be provided if community placement is not available at the discharge date and both the hospital and LME are actively working on discharge planning. This service requires prior approval from the Program Accountability Section in the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services at 919-881-2446.
Claims must be submitted on a UB-92 form (hospital outpatient claim
type M) using Revenue Center code 902, procedure code Y2343 and bill type
141. The Medicaid rate is $248.40 per day. Only one (1) unit is allowable
per date of service. Only physician visits and case management may be billed
in addition to procedure code Y2343.
Carol Robertson, Behavioral Health Services
DMA, 919-857-4020
Coverage for Vitrasert (Ganciclovir) is limited to recipients with a diagnosis of AIDS-related cytomegalovirus (CMV) retinitis. Both ICD-9-CM diagnosis codes 363.20, chorioretinitis, unspecified and 042, Human Immunodeficiency Virus (HIV) disease must, be entered on the claim. Claims without both diagnoses will deny.
Billing Instructions for Hospitals
Effective with date of service, August 1, 2002, bill Revenue Center code 636 in form locator 42 of the UB-92 claim form and HCPCS procedure code J7310, Ganciclovir, 4.5mg, long-acting implant, in form locator 44.
Effective with date of service, August 1, 2002, bill HCPCS code J7310 without a modifier.
Physicians are to bill CPT code 67027, Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous.
The surveys provided the Managed Care section with information necessary to ensure Medicaid recipients have access to quality medical care. In addition, the Provider Satisfaction Survey gave PCPs an opportunity to provide feedback to DMA regarding the effectiveness of Carolina ACCESS and make suggestions to improve quality and access to care.
Survey results will be shared in an upcoming Medicaid bulletin.
Laurie Giles, Managed Care Section
DMA, 919-857-4022
Registration information for this session has been sent to local health departments. If you did not receive registration information, please contact the office of Public Health Nursing and Professional Development, Division of Public Health at 919-733-6850. Space will be limited due to site capacity. We encourage you to register early and limit the number of participants from each agency so that all health departments can send staff to this critical session.
The August 2002 Special Bulletin for Local Health Departments will serve as
the primary handout for the session. The July 2002 Special Bulletin, Health
Check Billing Guide, will also be used. Providers must access and print the
PDF versions of both the August
2002 Special Bulletin IV and the July
2002 Special Bulletin III, Health Check Billing Guide, from DMA's website
and bring them to the seminar.
Joy Reed, Public Health Nursing and Professional Development
Division of Public Health, 919-715-4385
Durable Medical Equipment (DME) providers should bill HCPCS code E0608, Apnea monitor, which includes all items required for the intended operation of the monitor, from receipt of the physician order to downloading and submitting the data to the physician for review and interpretation. The DME provider must provide initial and ongoing support services.
Physicians must bill CPT code 93272, Patient demand single or
multiple event recording with presymptom memory loop, per 30-day period
of time; physician review and interpretation only.
EDS, 1-800-688-6696 or 919-851-8888
ACS State Healthcare
1-866-246-8505
The Health Check billing requirements will be published in the July 2002 Health Check Special Bulletin III for use in the Health Check seminar. However, the Division of Medical Assistance (DMA) is unable to print copies of special and general Medicaid bulletins for distribution to providers due to the State's severe budget problems. The Health Check Special Bulletin will not be distributed to providers attending the seminars. Providers must access and print the PDF version of the July 2002 Special Bulletin III, Health Check Billing Guide, and bring it to the seminar.
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 Health Check seminars by completing and submitting the Health Check Seminar Registration form, or providers can register online. Seminars begin at 10:00 a.m. and end at 1:00 p.m. Providers are encouraged to arrive by 9:45 a.m. to complete registration.
| Thursday,
August 1
WakeMed Andrews Conference Center 3000 New Bern Avenue Raleigh, NC |
Friday,
August 2
WakeMed Andrews Conference Center 3000 New Bern Avenue Raleigh, NC |
Tuesday,
August 6
Auditorium Catawba Valley Technical College Highway 64-70 Hickory, NC |
| Thursday, August
8
Auditorium Martin Community College Kehakee Park Road Williamston, NC |
Tuesday,
August 13
Holiday Inn Conference Center 530 Jake Alexander Blvd., S. Salisbury, NC |
Thursday, August 15
Ramada Inn Plaza 3050 University Parkway Winston-Salem, NC |
| Tuesday,
August 20
Blue Ridge Community College College Drive Flat Rock, NC |
RALEIGH, NORTH CAROLINA
WAKEMED ANDREWS CONFERENCE
CENTER
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).
HICKORY, NORTH CAROLINA
CATAWBA VALLEY TECHNICAL COLLEGE
Take I-40 to exit 125. Travel approximately ½ mile to Highway
70. Travel east on Highway 70. The college is located approximately 1½
miles on the right. Ample parking is available in the rear lower parking
areas. The entrance to the Auditorium is between Student Services and the
Maintenance Center. Follow sidewalk (toward satellite dish) and turn right
to Auditorium entrance.
WILLIAMSTON, NORTH CAROLINA
MARTIN COMMUNITY COLLEGE
Take Highway 64 into Williamston. Martin Community College is located
approximately 1 to 2 miles west of Williamston. The Auditorium is located
in Building 2.
SALISBURY, NORTH CAROLINA
HOLIDAY INN CONFERENCE CENTER
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.
WINSTON-SALEM, NORTH CAROLINA
RAMADA INN PLAZA
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.
FLAT ROCK, NORTH CAROLINA
BLUE RIDGE COMMUNITY COLLEGE
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. Pass the college's main entrance and turn
right into the college entrance past the pond. The parking lot is on the
left. The Auditorium entrance is located to the right of the Patton Building
main entrance.
EDS, 1-800-688-6696 or 919-851-8888
EDS, 1-800-688-6696 or 919-851-8888
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July 16, 2002
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August 13, 2002
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September 4, 2002
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July 23, 2002
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August 20, 2002
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September 10, 2002
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July 31, 2002
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August 29, 2002
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September 17, 2002
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September 26, 2002
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July 12, 2002
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August 9, 2002
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August 30, 2002
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July 19, 2002
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August 16, 2002
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September 6, 2002
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July 26, 2002
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August 23, 2002
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September 13, 2002
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September 20, 2002
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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.
| ______________________ | _______________________ | ||
| Nina M. Yeager, Director | Ricky Pope | ||
| Division of Medical Assitance | Executive Director | ||
| Department of Health and Human Services | EDS | ||
| DMA Home | |