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In This Issue . . .

All Providers:

• About ACS
• Medicaid Denial of Medicare Part B Covered Services
• Medical Coverage Policies
• Medicare Crossovers
• Medicare Crossover Reference Request Form
• NCMMIS Update
• Resubmission of a Previously Denied Claim
  
• Checkwrite Schedule
• Electronic Cut-Off Schedule
• Holiday Observance
• Proposed Medical Coverage Policies

Anesthesia Providers:

• Documentation Guidelines for Medical Direction

Dental Providers:

• Billing for Dental Procedure Codes D7270, D7280, and D7971
• Handwritten Service Review Numbers on Prior Approval Forms

Federally Qualified Health Centers:

• Maternal Outreach Worker Services - Revised Billing Guidelines

Hearing Aid Providers:

• Handwritten Service Review Numbers on Prior Approval Forms

Local Health Departments:

• Maternal Outreach Worker Services - Revised Billing Guidelines

Optical Services:

• Handwritten Service Review Numbers on Prior Approval Forms

Physicians:

• Coverage of New HCPCS "G" Codes for End-Stage Renal Disease Related Services
• Ocular Photodynamic Therapy with Verteporfin – Revised Billing Guidelines

Rural Health Clinics:

• Maternal Outreach Worker Services - Revised Billing Guidelines

Attention: All Providers

NCMMIS Update

Leading-edge Technology
Efficiency and Effectiveness
Application Knowledge
Delivery
Staffing Excellence

DHHS is committed to supplying comprehensive provider training by delivering thorough training at convenient locations. The State will work with provider representatives to ensure that training offerings that best meet providers’ needs are delivered through various easily accessible mechanisms. Watch for training details coming soon. Statistics show that advance training lays the foundation that is necessary for effective use of system functionality. During the evaluation of the NCMMIS proposals, the Department solicited numerous references from states that had implemented systems similar to the base Medicaid systems proposed for North Carolina. Corrective actions to address lessons learned from other states were incorporated into the North Carolina request for proposal. Providers who attended training found the transition to the new system to be a more positive experience. Remember–NCLeads–we know that North Carolina will lead other states in provider service and provider participation!

While you can continue to submit claims using any current method(s) with the new system, we hope you’ll also learn about some new options to improve your business such as:

• More timely payments because you can enter and adjudicate claims online ("real time" processing instead of overnight processing);
• Web-based options to expedite the entry, adjustment and voiding of claims;
• Increased efficiencies through online prior approval requests processing; and
• Free software that allows you to enter, submit, and adjust claims electronically.

We will be soliciting your involvement during the implementation phase. If you think you may be interested in participating in the NCLeads implementation process, please e-mail ncmmis.provider@ncmail.net and indicate your provider type (e.g., physician, hospital, pharmacy, long-term care facility, etc.) in the Subject line. There will be more details about provider participation in the August 2004 general Medicaid bulletin. We look forward to working with you!

Portia Asbridge, Communications Manager, NCMMIS Initiative
DHHS, 919-855-3112

About ACS

ACS is a Fortune 500 company traded on the New York Stock Exchange (NYSE: ACS) with $3.8 billion in annual revenue. ACS provides services that enable business and government agencies to focus on core operations, respond to rapidly changing technologies, and reduce expenses associated with business processes and information processing. ACS provides data processing and/or business process outsourcing services to 15 Blue Cross Blue Shield Plans—including BC/BS of North Carolina—and to nine of the Top 10 commercial health insurers.  

ACS implemented the first federally certified Medicaid Management Information System (MMIS) in 1972 and has gone on to successfully implement MMIS in 30 states over 32 years. Over the past 8 years, ACS has implemented more new Medicaid systems than any other vendor.  

Today, ACS administers Medicaid programs as the MMIS Fiscal Agent for 12 states (including Florida and Texas) and Washington, D.C., the nation’s capital. ACS processes 400 million Medicaid claims worth $50 billion in payments each year to several hundred thousand doctors, hospitals, pharmacies, nursing homes, clinics, and other healthcare providers. ACS also administers six state Child Health Insurance Programs (S-CHIP), manages pharmacy benefits for 23 state programs (Medicaid and Seniors), and operates data warehouses and decision support systems for 12 Medicaid programs (including North Carolina, Texas, and Florida).  

In North Carolina, ACS employs approximately 600 people in 10 locations around the State. For the N.C. Department of Health and Human Services, ACS manages pharmacy benefit prior authorizations and provides a large data warehouse with analytical tools to support program planning and evaluation and to detect waste, fraud, and abuse.  

The new MMIS system for North Carolina, called NCLeads, is operationally proven in four states and will be among the most technologically advanced in the nation. NCLeads will support 24 x 7 accessibility, with appropriate security safeguards for program participants. Providers will be able to submit claims, check on claims and eligibility status, and receive claims payment electronically anytime—day or night. Provider questions and requests for information are handled by experienced help desk operators or can be addressed electronically.  

Attention: All Providers

Medicaid Denial of Medicare Part B Covered Services

Effective with claims processed on or after July 1, 2004, Medicaid will deny claims that can be paid by Medicare Part B for recipients age 65 and over who are entitled to Medicare Part B benefits but fail to enroll.  Providers may bill the recipient for Medicare Part B covered services if the recipient fails to enroll with Medicare Part B.  Medicaid recipients age 65 and older who are eligible for Medicare received notice with their June 2004 Medicaid card that they must enroll in Medicare Part B or the provider may bill them for those claims.  Claims will be denied with EOB #1001, "Recipient is entitled to Medicare but failed to enroll.  Bill the recipient."   

Except for legal aliens who have not lived in the United States for five consecutive years, all Medicaid recipients age 65 or older are required to apply for Medicare Part B coverage.  Medicaid pays the Medicare Part B premium for Medicare-eligible recipients through the buy-in program.

If you receive a denial and you determine that the recipient is not entitled to Medicare Part B benefits because he/she is under age 65 or because he/she is a legal alien who has not lived in the United States for five years or more, submit a copy of the claim with documentation of age or alien status to:

Division of Medical Assistance
Claims Analysis Unit
2501 Mail Service Center
Raleigh, NC 27699-2501

The Division of Medical Assistance will determine if Medicaid payment can be made for these individuals.

Claims Analysis Unit
DMA, 919-855-4045          

Attention: Federally Qualified Health Centers, Local Health Departments, and Rural Health Clinics

Maternal Outreach Worker Services – Revised Billing Guidelines

Effective with date of service July 1, 2004, the billing guidelines for Maternal Outreach Worker Services have been revised. Providers may bill up to seven units per month using HCPCS code S9445, Patient education, not otherwise classified, non-physician provider, individual per session. For Medicaid billing, one unit equals 15 minutes. Services must be billed per date of service.

Medical Coverage Policy # 1M-7, Baby Love Maternal Outreach Worker Program has been revised to reflect this change.

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

Attention: All Providers

Medical Coverage Policies

1A-13 – Occular Photodynamic Therapy
1M-7 – Baby Love Maternal Outreach Worker Program
3J – Personal Care Services-Plus
4A – Dental Services
8F – Outpatient Specialized Therapies
8H – Local Education Agencies

These policies supersede previously published policies and procedures. Providers may contact EDS at 1-800-688-6696 or 919-851-8888 with billing question.

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

 Attention: All Providers

Medicare Crossovers

The N.C. Medicaid program will return to processing all crossover claims billed on a CMS-1500 form or as an 837 professional transaction as direct crossovers from Medicare. The expected date for this transition is September 6, 2004.

In anticipation of this change, providers should verify that their Medicare provider numbers are cross-referenced to their Medicaid provider numbers. Providers can verify this by contacting EDS Provider Services at 1-800-688-6696 or 919-851-8888.

If your Medicaid and Medicare provider numbers are not cross-referenced, please complete and submit the following form by fax or mail to EDS at the address indicated on the form. Additional information on crossover claims will be published in upcoming general Medicaid bulletins.

Medicare Crossover Reference Request Form

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

Attention: All Providers

Resubmission of a Previously Denied Claim

EDS, 1-800-688-6696 or 919-851-8888  

Attention: Anesthesia Providers

Documentation Guidelines for Medical Direction

The Centers for Medicare and Medicaid Services (CMS) seven requirements are:

1. "Perform a pre-anesthetic examination and evaluation."
The physician should evaluate the patient, performing an appropriate history and physical examination to adequately plan the anesthetic. This must be specifically documented in the medical record.

2. "Prescribe the anesthesia plan."
The physician should personally prescribe and document the anesthesia plan.

3. "Personally participate in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence."
During anesthetics that are not considered to be general, (i.e., regional and/or MAC anesthetic), there is no period of induction or emergence. During general anesthetics, the physician should document his or her presence and availability by appropriate signing of the anesthetic record, to indicate in a chronological fashion, participation in induction and emergence. Monitoring of the patient during emergence can occur at any time in the process of emergence.

4. "Ensure that any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual."
Although no specific documentation in each patient's record is required, records of current licensure and training certification should be maintained. Knowledge of the individual's skill set and training is recommended.

6. "Remain physically present and available for immediate diagnosis and treatment of emergencies."
No specific documentation is required.

7. "Provide indicated post-anesthesia care."
Standing orders in the post-anesthesia care unit (PACU) are sufficient but should be dated and signed appropriately.

A legible identification of the directing anesthesiologist is required on each page of the patient’s record. Change of medical direction must be documented. 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.

Billing for Anesthesia Services using Anesthesia Modifiers, April 2004 general Medicaid bulletin

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

Attention: Dental Providers (Including Health Department Clinics)

Billing for Dental Procedure Codes D7270, D7280, and D7971

The following dental procedures must be billed with valid tooth numbers entered in field 59 on the 1999 (version 2000) ADA dental claim form. Valid tooth numbers are listed for each of these specific procedure codes.

If claims for these procedure codes were denied as duplicates for multiple teeth on the same date of service, refile the denied procedure with a valid tooth number.

Note: D7280 and D7971 are not allowed on the same date of service as an extraction for the same tooth number.

Medical Coverage Policy #4A, Dental Services, has been updated to incorporate this information.

Ronald Venezie, DDS, MS, Dental Director
DMA, 919-857-4020

Attention: Dental Providers, Hearing Aid Providers, and Optical Services

Handwritten Service Review Numbers on Prior Approval Forms

Effective August 1, 2004, the EDS prior approval staff will no longer hand write the Service Review Number (SRN) on the provider’s copy of approved prior request forms because entering the SRN on ADA claim forms submitted by dental providers and the CMS-1500 claim forms submitted by optical services and hearing aid providers is not a requirement for reimbursement. The provider’s copy of the approved prior approval request form will continue to be stamped with the word "approved" and will be dated, and initialed by the prior approval staff.

Approval criteria for services and the requirements for completing the approval request form have not changed.

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

Attention: Physicians

Coverage of New HCPCS "G" Codes for End-Stage Renal Disease Related Services

N.C. Medicaid is in the process of implementing system changes to allow new HCPCS "G" codes implemented by Medicare to be billed for end-stage renal disease (ESRD) related services for recipients receiving dialysis. The HCPCS code descriptions include the applicable number of visits provided within each month for ESRD related services and the age of the recipient. HCPCS codes G0308 through G0327 will be used in place of CPT codes 90918 through 90925. The CPT codes will be end-dated. The table below includes the HCPCS codes and descriptions.

Providers will be notified through a general Medicaid bulletin or by an announcement on the Division of Medical Assistance’s website if the system is ready prior to the next bulletin publication. Additional coverage criteria and the effective date of coverage will be included in this notification.

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

Attention: Physicians

Ocular Photodynamic Therapy with Verteporfin – Revised Billing Guidelines

The N.C. Medicaid program covers ocular photodynamic therapy (OPT) with verteporfin (Visudyne) effective with date of service January 1, 2001. Claims that were previously denied may be refiled as a new claim. The requirement to request a time limit override for claims billed for dates of service between January 1, 2001 and June 30, 2003 has been waived. These claims must be received for processing by 12:00 a.m. on October 1, 2004.

For dates of service January 1, 2002 and after, bill:

• CPT code 67221, photodynamic therapy (includes intravenous infusion) for destruction of localized lesion of choroid – for the procedure
• CPT code 67225, photodynamic therapy, second eye, at single session
• HCPCS code J3395, injection, verteporfin, 15 mg. – for the injection
• ICD-9-CM diagnosis code 362.52

For dates of service January 1, 2001 through December 31, 2001, bill:

• CPT code 67221, photodynamic therapy (includes intravenous infusion) for destruction of localized lesion of choroid – for the procedure
• HCPCS code G0184 – for the second eye at a concurrent session
• HCPCS code J3490, unclassified drug – for the injection
• ICD-9-CM diagnosis code 362.52

Note: When billing for verteporfin with HCPCS code J3490, the unclassified drug code, providers must attach an invoice to the 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 (MID) number, the name of the medication, the dosage given, the National Drug Code (NDC) number(s) 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 claim form.

The Medicaid unit of coverage for verteporfin is one 15 mg. vial.

• For dates of service January 1, 2001 through December 31, 2003, the maximum reimbursement rate is $1,381.50.

• For dates of service January 1, 2004 through March 31, 2004, the maximum reimbursement rate per unit is $1,304.75.

• For dates of service April 1, 2004 and after, the maximum reimbursement rate per unit is $1,404.26.

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

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

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.

Gina Rutherford
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.

Holiday Observance

The Division of Medical Assistance and EDS will be closed on Monday, July 5, 2004 in observance of Independence Day.

Checkwrite Schedule

Electronic Cut-Off Schedule

2004 Checkwrite Schedule

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.