Printer Friendly Version

In This Issue..

All Providers:

• Billing of Radiopharmaceuticals and Pharmaceutical Stress Agents for Myocardial Perfusion Testing
• CPT Code Update for 2002 - Coverage of Additional Codes
• Directions to Medicare Part B Seminars
• Drug Coverage for Impotence Drugs
• Electronic Data Interchange Update
• Health Insurance Portability and Accountability Act Update
• Injectable Drugs
• Injectable Drugs in the Physician's Drug Program - Code Conversion Update
• Medicare Part B Seminar Schedule
• Modifier 76 and 77 and Laboratory Codes
• Proposed Medical Coverage Policies
• Sodium Hyaluronate for Intra-Articular Injection - Billing Guidelines
• Checkwrite Schedule
• Electronic Cutoff Schedule

Ambulatory Surgical Center Providers:

• Billing When Dental Services are Rendered in an Ambulatory Surgical Center

CAP Case Managers:

• Conversion of Home Health Supply Codes to National Codes

Carolina ACCESS Providers:

• Change in Carolina ACCESS Override Policy

Dental Providers:

• Billing When Dental Services are Rendered in an Ambulatory Surgical Center

Durable Medical Equipment Providers:

• Addition of HCPCS Code K0195
• Completion of Certificate of Medical Necessity and Prior Approval Forms

Federally Qualified Health Centers:

• Billing for Laboratory Services
• Core Service Code Conversion - Correction to End-Dated Code

Health Departments:

• Conversion of Refugee Health Assessment Code, STD Control Treatment Code, and TB Control Treatment Code
• Varicella-Zoster Immune Globulin, Human, for Intramuscular Use (CPT 90396), Billing Guidelines

Home Health Providers:

• Conversion of Home Health Supply Codes to National Codes

Hospitals:

• Revision of Utilization Review Plans

Maternity Services Providers:

• New Codes for Maternal and Child Services
• Termination of Coverage

Nurse Midwives:

• Varicella-Zoster Immune Globulin, Human, for Intramuscular Use (CPT 90396), Billing Guidelines

Nurse Practitioners:

• Varicella-Zoster Immune Globulin, Human, for Intramuscular Use (CPT 90396), Billing Guidelines

Outpatient Specialized Therapy Providers:

• Directions to the Outpatient Specialized Therapy Prior Approval Process Workshops
• Prior Approval of Outpatient Specialized Therapy Services

Physicians:

• New Codes for the Oral Screening Preventive Package for Use in Primary Care Physician Offices
• Varicella-Zoster Immune Globulin, Human, for Intramuscular Use (CPT 90396), Billing Guidelines

Prescribers and Pharmacists:

• Valid DEA Numbers Required on Pharmacy Prescriptions

Private Duty Nursing Providers:

• Conversion of Home Health Supply Codes to National Codes

Psychiatric Residential Treatment Facility Providers:

• Billing Guidelines for Psychiatric Residential Treatment Facility Services

Rural Health Clinics:

• Billing for Laboratory Services
• Core Service Code Conversion - Correction to End-Dated Code

Attention: Rural Health Clinics and Federally Qualified Health Centers

Core Service Code Conversion - Correction to End-Dated Code

Effective with date of service June 30, 2002, state-created codes Y2058 and Y2089 will be end-dated to comply with the implementation of national procedure codes mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Effective with date of service July 1, 2002, Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) providers must bill procedure code T1015 - Clinic visit/encounter, all inclusive -for all core services. An RHC/FQHC core service visit must be billed using the provider's six-digit provider number with alpha suffix "A."
 

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

Attention: All Providers

Drug Coverage for Impotence Drugs

For males under the age of 25, the physician (or designee) must call 919-857-4037 to obtain a prior approval form. The physician must complete the requested information for medical necessity and return the completed form to the following address:

N.C. Division of Medical Assistance
Attn: Sharman Leinwand, MPH, R.Ph.
2511 Mail Service Center
Raleigh, North Carolina 27699-2511

FAX: 919-733-2796

An authorization code will be assigned to all requests that are approved. This code must be included on the prescription to notify the pharmacist that the prescription has been approved for dispensing. Claims for prescriptions dispensed to recipients under the age of 25 must be submitted on paper and not through Point of Sale.
 

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

Attention: All Providers

Proposed Medical Coverage Policies

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

Attention: All Providers

Modifier 76 and 77 and Laboratory Codes

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

Attention: All Providers

Health Insurance Portability and Accountability Act Update

• 834 transaction (Benefit Enrollment and Maintenance-MCO Enrollment)
• 278 transaction (Health Care Services Review and Response-Prior Approval)
• 270 and 271 (Health Care Eligibility Benefit Inquiry and Response)

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 on third party certification and remaining transaction implementation and testing dates will be provided in future Medicaid bulletinsand on DMA's HIPAA website.
 

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

Attention: All Providers

Sodium Hyaluronate for Intra-Articular Injection - Billing Guidelines

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

Attention: All Providers

Billing of Radiopharmaceuticals and Pharmaceutical Stress Agents for Myocardial Perfusion Testing

The invoice must be attached and include the:

• name of the patient
• name of the agent
• dose administered
• cost per dose

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

Attention: All Providers

Electronic Data Interchange Update

WebMD Corporation (formerly Envoy)
15 Century Blvd., Suite 600
Nashville, TN 37214
1-800-366-5716 (marketing)
www.webmd.com

MedifaxEDI
1283 Murfreesboro Rd
Nashville, TN 37217-2421
1-800-819-5003 (marketing)
marketing@medifax.com

Healthcare Data Exchange Corporation (HDX)
300 Lindenwood Dr., Suite 200
Malvern, PA 19355-1751
1-610-219-1859 (marketing, Brian Gill)
brian.gill@hdx.com

Passport Health Communications, Inc.
720 Cool Springs Blvd., Suite 450
Franklin, TN 37067
1-888-661-5657 (marketing, Lloyd Baker)
Lloyd.baker@passporthealth.com

Providers interested in subscribing for EDI services are encouraged to contact the above vendors. Updated lists will be published in the general Medicaid bulletin as new vendors are approved and enrolled.
 

Susan Ryan, Recipient and Provider Services
DMA, 919-857-4019

Attention: All Providers

Injectable Drugs in the Physician's Drug Program - Code Conversion Update

An invoice is required for those drugs that are billed with J3490. The invoice must include the name of the Medicaid recipient, the Medicaid identification (MID) number, the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, the number of vials used per NDC code, and the cost per dose. The NDC number is printed on each drug product.
 

Old Code	New Code	Description of Replacement Code
Q0156	P9041	Albumin (human), 5%, 50 ml**
Q0157	P9047	Albumin (human), 25%, 50 ml
J2996	J2997	Alteplase Recombinant, 1 mg**
W5181	S0016	Amikacin Sulfate, 500 mg
W5156	Q0144	Azithromycin, oral suspension 1 unit = 1 gm packet (Zithromax)
90586	J9031	BCG live (intravesical), per installation
W5170	J3490*	Baclofen Kit, 2 5 ml Ampules
W5169	J3490*	Baclofen Kit, 4 5 ml Ampules
X1270	S0009	Butorphanol Tartrate, 1 mg (Stadol)
W5185	J0692	Cefepime HCL, 500 mg
W5176	S0023	Cimetadine HCL, 300 mg
W5183	J0744	Ciprofloxacin for intravenous infusion, 200 mg
W5195	J9160	Denileukin Diftitox, 300 mcg (Ontak)
Q0160	J7193	Factor IX (antihemophilic factor, purified, non-recombinant), per I.U.
Q0161	J7195	Factor IX (antihemophilic factor, recombinant), per I.U.
W5127	J3490*	Lupron Depot Pediatric, 7.5 mg
W5128	J3490*	Lupron Depot Pediatric, 11.25 mg
W5129	J3490*	Lupron Depot Pediatric, 15 mg
W5198	S0079	Octreotide Acetate, 100 mcg (Sandostatin)**
J2352	J3490	Octreotide Acetate, 1mg (Sandostatin). Pricing based on 20 mg**
J2352	J3490	Octreotide Acetate, 1mg (Sandostatin). Pricing based on 10 mg**
W5192	S0080	Pentamidine Isethionate, 300 mg
J2994	J2993	Reteplase, 18.1 mg (Retavase)**
Y1856	J3490*	Sodium Bicarbonate 7.5% up to 50 ml
J7315	J7316	Sodium Hyaluronate, 5 mg for intra-articular injection**

* Indicates that an invoice is required with the claim.

** Indicates a description change.
 

End-dated Codes for Injectable Drugs

The following codes will be end-dated from the Physician's Drug Program effective with date of service September 30, 2002. Vaccine codes are being end-dated in accordance with information obtained from the drug manufacturers and the Centers for Disease Control. These vaccines are no longer manufactured or available in the United States or are no longer recommended.

Injectable Drugs
 

Code	Description of End-Dated Codes
J0510	Benzquinamide HCl, up to 50 mg
J0190	Biperiden, 5 mg (Akineton)
J0695	Cefonicid Sodium, 1 gm
J0730	Chlorpheniramine Maleate, per 10 mg
J3080	Chlorprothixene, up to 50 mg
J0810	Cortisone, up to 50 mg
J2480	Hydrochlorides of Opium Alkaloids (Pantopan)
J1739	Hydroxyprogesterone Caproate, 125 mg/ml
J1741	Hydroxyprogesterone Caproate, 250 mg/ml
J3270	Imipramine HCl, up to 25 mg
W5128	Lupron Depot Pediatric, 11.25 mg
W5129	Lupron Depot Pediatric, 15 mg
J3450	Mephentermine, up to 30 mg
J2970	Methicillin Sodium, up to 1 gm (Staphcillin)
J1970	Methotrimeprazine, up to 20 mg
J3390	Methoxamine, up to 20 mg (Basoxyl)
J0340	Nandrolone Phenpropionate, up to 50 mg (Duradolin)
J2640	Prednisolone Sodium Phosphate, up to 20 mg
J1690	Prendisolone Terbutate, up to 20 mg
J2675	Progesterone, per 50 mg
J1930	Propiomazine HCl, up to 20 mg
J2330	Thiothixene, up to 4 mg (Navane)
J0400	Trimethapan Camsylate, up to 500 mg

Vaccines/Toxoids
 

Code	Description of End-Dated Codes
90646	Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, for intramuscular use
90659	Influenza virus vaccine, whole virus, for intramuscular or jet injection use
90676	Rabies vaccine, for intradermal use
90701	Diptheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use
90708	Measles and rubella virus vaccine, live for subcutaneous or jet injection use
90709	Rubella and mumps virus vaccine, live, for subcutaneous use
90712	Poliovirus vaccine, (any type(s) (OPV), live, for oral use
90719	Diphtheria toxoid, for intramuscular use
90720	Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib), for intramuscular use
90725	Cholera vaccine for injectable use

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

Attention: All Providers

Injectable Drugs

Physicians will continue to bill on the CMS-1500 claim form using the appropriate drug code, indicating the number of units administered as specified in the listing. Free vaccines from the Vaccines for Children (VFC) program are not included in this list.

New Codes
 

Old Code	New Code	Description	Fee
Q0156	P9041	Albumin (human), 5%, 50 ml	$ 26.28
Q0157	P9047	Albumin (human), 25%, 50 ml	88.65
J2996	J2997	Alteplase recombinant, 1 mg**	24.82
J2994	J2993	Reteplase, 18.1 mg (Retavase)**	1,240.94

** Indicates a description change.

Immune Globulins
 

Code	Description	Fee
90283	Immune globulin (IgIV), human, for intravenous use, 500 mg	$ 42.84
90291	Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use, 1 ml	13.31
90371	Hepatitis B immune globulin (HBIg), human, for intramuscular use, 0.5 ml	68.04
90375	Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous use, 2 ml	151.20
90376	Rabies immune globulin, heart-treated (RIg-HT), human, for intramuscular and/or subcutaneous use, 2 ml	143.68
90379	Respiratory syncytial virus immune globulin (RSV-IgIV), human, for intravenous use, 1 ml	15.47
90384	Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use, 1500 IU/300 mcg	99.90
90385	Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use, 120 IU/50 mcg	34.02
90386	Rho(D) immune globulin (RhIglV), human, for intravenous use, 100 IU	20.38
90389	Tetanus immune globulin (TIg), human, for intramuscular use, 250 u/1 ml	108.00
90396	Varicella-zoster immune globulin, human, for intramuscular use, 125 u/1.25 ml	112.50
J1460	Gamma Globulin, Intramuscular, 1 cc (Gammar)	3.24
J1470	Gamma Globulin, Intramuscular, 2 cc	6.48
J1480	Gamma Globulin, Intramuscular, 3 cc	9.72
J1490	Gamma Globulin, Intramuscular, 4 cc	12.96
J1500	Gamma Globulin, Intramuscular, 5 cc	16.20
J1510	Gamma Globulin, Intramuscular, 6 cc	19.44
J1520	Gamma Globulin, Intramuscular, 7 cc	22.68
J1530	Gamma Globulin, Intramuscular, 8 cc	25.92
J1540	Gamma Globulin, Intramuscular, 9 cc	29.16
J1550	Gamma Globulin, Intramuscular, 10 cc	32.40
J1560	Gamma Globulin, Intramuscular, over 10 cc (use correct combinations of services)	^^

^^ Designates special pricing.

Vaccines/Toxoids
 

Code	Description	Fee
90585	Bacillus Calmette-Guerin vaccine (BCG), for tuberculosis, live, for percutaneous use, per vial	$ 151.50
90632	Hepatitis A vaccine, adult dosage, for intramuscular use, 1 ml	57.83
90633	Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use, 0.5 ml	29.52
90645	Hemophilus influenza b vaccine (Hib), Hb0C conjugate (4 dose schedule), for intramuscular use, 0.5 ml	25.54
90647	Hemophilus influenza b vaccine (Hib) PRP-OMP conjugate (3 Dose schedule), for intramuscular use, 0.5 ml	21.86
90648	Hemophilus influenza b vaccine (Hib) PRP-T conjugate (4 dose schedule), for intramuscular use, 0.5 ml	22.58
90658	Influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use, 0.5 ml	6.77
90675	Rabies vaccine, for intramuscular use, 2 ml	140.32
90680	Rotavirus vaccine, tetravalent, live, for oral use	17.37
90703	Tetanus toxoid adsorbed, for intramuscular or jet injection use, 0.5 ml	7.88
90704	Mumps virus vaccine, live, for subcutaneous or jet injection use	18.80 per dose
90705	Measles virus vaccine, live, for subcutaneous or jet injection use, 0.5 ml	14.94
90706	Rubella virus vaccine, live, for subcutaneous or jet injection use, 0.5 ml	15.65
90707	Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous or jet injection use	40.75 per dose
90713	Poliovirus vaccine, inactivated, (IPV), for subcutaneous use	26.05 per dose
90716	Varicella virus vaccine, live, for subcutaneous use, 0.5 ml	61.52
90704	Mumps virus vaccine, live, for subcutaneous or jet injection use	18.80 per dose
90718	Tetanus and diphtheria toxoids (Td) adsorbed for use in individuals seven years or older, for intramuscular or jet injection, 0.5 ml	10.35
90721	Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use	42.30 per dose
90732	Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use, 0.5 ml	12.88

90733	Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous or jet injection use, 0.05 mg	$ 72.31
90746	Hepatitis B vaccine, adult dosage, for intramuscular use, 1 ml	63.42
90747	Hepatitis B vaccine, dialysis or immunosuppressed patient dosage  (4 dose schedule), for intramuscular use, 40 mcg/2ml	105.38

Corrections to the Injectable Drug List Update Published in the June 2002 Medicaid Bulletin
 

Old Code	New Code	Description	Fee
W5181	S0016	Amikacin Sulfate, 500 mg (Amikin) **	$ 30.83
W5156	Q0144	Azithromycin, oral suspension 1 unit = 1 gm packet (Zithromax), only oral drug on list	20.07
J1070	J1070	Testosterone Cypionate, up to 100 mg **	4.10

** Indicates a description change.

Billing Guidelines When Billing by Invoice for J3490 (Miscellaneous Drug Code)

The following drugs are billed with the miscellaneous drug code, J3490. An invoice must be submitted with the claim when these drugs are billed. The invoice must include the name of the Medicaid recipient, the Medicaid identification (MID) number, the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, the number of vials used per NDC code, and the cost per dose. The NDC number is printed on each drug product.
 

Old Code	Old Description	New Code	New Description
W5170	Baclofen kit, 2 5 ml ampules	J3490	Baclofen kit, 2 5 ml ampules
W5169	Baclofen kit, 4 5 ml ampules	J3490	Baclofen kit, 4 5 ml ampules
W5127	Lupron depot pediatric, 7.5 mg	J3490	Lupron depot pediatric 7.5 mg, pricing based on 7.5 mg package
W5128	Lupron depot pediatric, 11.25 mg	J3490	Lupron depot pediatric 11.25 mg, pricing based on 11.25 mg package
W5129	Lupron depot pediatric, 15 mg	J3490	Lupron depot pediatric 15 mg, pricing based on 15 mg package
W5198	Octreotide acetate LAR depot, 1 mg	J3490	Octreotide acetate, 1 mg, pricing based on 20 mg (Sandostatin)
W5198	Octreotide acetate LAR depot, 1 mg	J3490	Octreotide acetate, 1 mg, pricing based on 10 mg (Sandostatin)
Y1856	Sodium bicarbonate	J3490	Sodium bicarbonate, 7.5%, up to 50 ml

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

Attention: All Providers

CPT Code Update for 2002 - Coverage of Additional Codes

The 2001 CPT description of code 20550 Injection, tendon sheath, ligament, trigger points or ganglion cyst was changed to Injection; tendon sheath, ligament, ganglion cyst in CPT 2002. Three codes were added to 2002 CPT to differentiate the techniques associated with multiple muscle group injections for trigger points and injection of a tendon at the site of origin or insertion.
 

Deleted Code	Revised Code	New Code	Description
	20550	20551	Injection; tendon origin/insertion
	20550	20552	Injection; single or multiple trigger point(s), one or two muscle group(s)
	20550	20553	Injection; single or multiple trigger point(s), three or more muscle group(s)
86683		82274	Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations

Denied claims related to billing these new codes may be corrected and resubmitted.
 

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

Attention: Health Departments

Conversion of Refugee Health Assessment Code, STD Control Treatment Code, and TB Control Treatment Code

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

Attention: Physicians

New Codes for the Oral Screening Preventive Package for Use in Primary Care Physician Offices

Procedure code W8002 (Initial Oral Screening) will be replaced with the following procedure codes:
 

The following criteria apply for the Initial Oral Screening:

• Includes early caries screening and detection of other notable findings in the oral cavity.
• Includes prevention and dietary counseling.
• Includes prescribing a fluoride supplement, if indicated.
• Includes application of fluoride varnish.
• Medicaid will only allow reimbursement for this oral screening when teeth are present and fluoride varnish is applied to the teeth.
• Limited to recipients under 3-years-old.
• Allowed once per provider for each recipient.
• Periodic oral screening is recommended 4 to 6 months after the initial oral screening.
• Exempt from third party liability.

The following criteria still apply for the Periodic Oral Screening:

• Includes early caries screening and detection of other notable findings in the oral cavity.
• Includes prevention and dietary counseling.
• Includes application of fluoride varnish.
• Medicaid will only allow reimbursement for this oral screening when teeth are present and fluoride varnish is applied to the teeth.
• Limited to recipients under 3-years-old.
• Periodic oral screening is recommended four 4 to 6 months after the initial oral screening.
• Periodic oral screening and fluoride varnish application are recommended two times per year at 4 to 6 month intervals for the same or different provider.
• Exempt from third party liability.

Prior approval is not required for these services. These services are billed on the CMS-1500 claim form or electronically through ECS. Refer to the claim examples listed below. Refer to the Basic Medicaid handout for additional billing instructions.

Claim Example 1:  Periodic Oral Screening as a Separate Procedure
Claim Example 2:  Initial oral Screening in Conjunction with an Office Visit
Claim Example 3:  Initial Oral Screening in Conjunction with a Health Check Screening

For health departments, these services are billed through HSIS. Refer to the HSIS screen entry examples.

Note: Medicaid will only allow reimbursement of these ADA codes if all three procedures are billed on the same claim for the same date of service.

Note: These procedure codes all begin with an alpha "D" character followed by four numeric characters.
 

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

Attention: Prescribers

Valid DEA Numbers Required on Pharmacy Prescriptions

A prescriber Medicaid identification number (ID) will be issued in lieu of the DEA number. The ID number follows the same format as the DEA number and will always begin with a Z (for example, ZF1234567).

Prescribers must enter this number on their Medicaid prescriptions. This number is referred to as a PRESCRIBER MEDICAID IDENTIFICATION NUMBER only, and should not be referred to as a DEA number.

If updated information has not been submitted to EDS Provider Enrollment, please copy, complete, and return the DEA Number form for each prescriber in your practice. Please send the information to the following address:

EDS Provider Enrollment Unit
P.O. Box 300009
Raleigh, North Carolina 27622

FAX: 919-851-4014
 

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

Attention: Rural Health Clinics and Federally Qualified Health Centers

Billing for Laboratory Services

Billing Guidelines

• RHC/FQHC providers must bill laboratory services that are performed at the RHC/FQHC using their "C" suffix provider number. Laboratory services not rendered in the RHC/FQHC that are sent to a referring laboratory must be billed by the referring laboratory. The laboratory that performs the service must meet CLIA certification requirements and bill for the service rendered.

Nominal reimbursement is available for collecting samples for lab testing in addition to the amounts paid under the laboratory fee schedule. Only one collection fee is allowed for each venipuncture for each recipient encounter, regardless of the number of specimens drawn. When a series of specimens is required to complete a single test (e.g., glucose tolerance test), the series is treated as a single encounter. Only the provider who has extracted the specimen from the recipient may bill the collection code. Bill G0001 on the CMS-1500 claim under the RHC/FQHC's "C" suffix provider number.

• Because there is a national cap on payment for laboratory services, the maximum allowable rate for laboratory services is established through the laboratory fee schedule. No additional reimbursement for laboratory services is provided through cost adjustments at the end of the year.

Adjusting the Cost Report

The cost of the technical aspects of the test must be adjusted from the cost report. These costs include associated space, equipment, supplies, facility overhead, and personnel.
 

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

Attention: Maternity Care Coordination, Maternity Support, and Child Service Coordination Services

Termination of Coverage

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

Attention: Maternity Care Coordination, Maternity Support, Child Service Coordination, and Maternal Outreach Worker Services

New Codes for Maternal and Child Services

For a description of the policies relative to these new codes, please refer to August 2002 Special Bulletin IV, HIPAA Code Conversion. This information supersedes previously published policies and guidelines.
 

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

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

Conversion of Home Health Supply Codes to National Codes

Some of the codes currently used will be replaced by multiple codes, and some will be deleted and replaced with existing codes. Read each description carefully to ensure that the correct size, quantity or preparation is billed. For example, the current code for gauze elastic bandages (Kling, Kerlix, roller gauze) is W4602 and is priced per roll; the replacement codes will be A6263, A6264, A6405, and A6406. The new codes are priced per linear yard.

Current codes shown below will be end-dated effective with date of service September 30, 2002. The new codes will be effective with date of service October 1, 2002.
 

* Denotes existing codes. Please note that these are existing codes replacing W4624.

Providers must bill their usual and customary charges.
 

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

Attention: Durable Medical Equipment Providers

Addition of HCPCS Code K0195

Prior approval is required. The lifetime expectancy of these legrests is three years. Providers must bill their usual and customary charges.
 

Melody B. Yeargan, P.T., Medical Policy Section
DMA, 919-857-4020

Attention: Psychiatric Residential Treatment Facility Providers

Billing Guidelines for Psychiatric Residential Treatment Facility Services

Required changes and additional fields are:

1. Form Locator 4 - TYPE OF BILL

The type of bill remains the same as 891.
 
2. Form Locator 7 - COVERED DAYS

Enter the number of covered days that correspond with the dates of service that are being billed. Claims must always be billed for more than one day of service and can span different months on the same claim. For example, if a recipient is admitted on April 30, the last day of the month, the "from" date of service is 04302002. The "through" date of service must be any date greater than 04302002.
 
3. Form Locator 17 - ADMISSION DATE

The admission date must always be entered on the claim <MMDDYYYY>.
 
4. Form Locator 18 - ADMISSION HOUR

A valid admission hour, 00 through 23, is required.

00 = 12:00-12:59 Midnight 12 = 12:00-12:59 Noon
01 = 01:00-01:59 13 = 01:00-01:59
02 = 02:00-02:59 14 = 02:00-02:59
03 = 03:00-03:59 15 = 03:00-03:59
04 = 04:00-04:59 16 = 04:00-04:59
05 = 05:00-05:59 17 = 05:00-05:59
06 = 06:00-06:59 18 = 06:00-06:59
07 = 07:00-07:59 19 = 07:00-07:59
08 = 08:00-08:59 20 = 08:00-08:59
09 = 09:00-09:59 21 = 09:00-09:59
10 = 10:00-10:59 22 = 10:00-10:59
11 = 11:00-11:59 23 = 11:00-11:59
 

5. Form Locator 21 - DISCHARGE HOUR

When the recipient has been discharged, a valid discharge hour, 00 through 23, is also required (see chart above).
 
6. Form Locator 22 - PATIENT STATUS

A valid patient status is now required.

01 = Discharged to home or self care (routine discharge).
02 = Discharged/transferred to another short-term general hospital.
05 = Discharged/transferred to another type of institution for inpatient care or referred for outpatient services to another institution.
07 = Left against medical advice.
20 = Expired.
30 = Still a patient or expected to return for outpatient services.
 

7. Form Locator 39 - VALUE CODES

Use value code 23 to indicate the Patient Monthly Liability (PML) amount. The PML amount is required on all claims beginning the first of the month following the thirtieth day from the date of admission. Failure to enter the code and PML amount (even if the amount is $0.00) will result in denial of the claim.
 
8. Form Locator 76 - ADMITTING DIAGNOSIS CODE
9. The admitting diagnosis code is now required in form locator 76, as well as in the principal diagnosis section of the claim. These diagnoses are also required to be further subdivided. For example, 296 (Affective Psychoses) is now required to be further subdivided to 296.2. Please refer to the ICD-9-CM code book for accurate codes.

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

Attention: Durable Medical Equipment Providers

Completion of Certificate of Medical Necessity and Prior Approval Forms

Please ensure that each request corresponds to the instructions for completion of the CMN/PA form given in step 2 of subsection 6.4 of the N.C. Medicaid Durable Medical Equipment manual. It is not necessary to complete fields 3, 6, and 10. Entering ICD-9-CM codes in fields 11 and 12 and a CPT code in field 13 is optional. All of the remaining fields must be completed. Field 24 is required for the following HCPCS codes: E0202, E0607, E0608, E0609, E0480, E0650, E0651, E0652, E0784, E0935, W4006, and W4007.

N/A must only be used in the following fields under the following circumstances:

• field 4 - if the patient does not have a Medicare number
• field 16 - if the patient is an infant or child or the request is not for a bed
• field 18 - if the patient is an infant or a child, check "Other: specify" and write "infant" in the space provided
• field 24 - if the request is not for one of the HCPCS codes listed above

When completing field 26, be sure to fully identify the equipment that is being requested. The provider's return address must be entered in field 29. Failure to do so will delay the return of the form. A stamped address may be used. All of the information provided must be accurate and thorough.

Note: Each page of documentation with the CMN/PA must contain the recipient's name and Medicaid identification (MID) number. Effective immediately, EDS will retain all documentation attached to the CMN/PA and the white (original) copy of the form. The yellow and pink copies will be returned to the provider. It is the provider's responsibility to maintain copies for their records.
 

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

Attention: Dental Providers and Ambulatory Surgical Center Providers

Billing When Dental Services are Rendered in an Ambulatory Surgical Center

If a Medicaid recipient is physically unmanageable, medically compromised or severely mentally retarded and will not cooperate for treatment in the dental office, treatment can be completed in an Ambulatory Surgical Center (ASC). The ADA claim form is used by dentists for billing dental services. The dentist's billing instructions do not change, except for the place of service. Since the service is rendered in the ASC, the place of service code "F" must be entered in block 49 on the ADA claim form. Services that normally require prior approval are handled in the usual manner.

Ambulatory Surgical Center Providers

ASC bills for facility use. The ASC claims are filed on the CMS-1500 claim form. The facility rates for ambulatory dental services are priced based on total time, utilizing ASC Groups 1 through 4, as outlined below:
 

For ASC dental treatment, specific changes in ASC billing procedures are listed below:

• For a dental service in the ASC, the place of service code "22" must be entered in block 24B on the CMS-1500 claim form.
• The ADA and/or CPT dental procedures codes for the services that the dentist performed are the procedure codes that must be entered in block 24D of the CMS-1500 claim form.
• Modifier SG must be entered in block 24D on the CMS-1500 claim form.
• The number of units for each ADA and/or CPT dental procedure code must be entered in block 24G of the CMS-1500 claim form.
• When dental services are rendered in an ASC, the operating room time must be indicated on the CMS-1500 claim form (e.g., "total surgical time - 11:14 - 11:55"). This must be entered in any available space in block 24 on the CMS-1500 claim form.

 

Attention: Carolina ACCESS Providers

Change in Carolina ACCESS Override Policy

• Emergency immediately upon presentation or notification
• Urgent within 24 hours
• Routine sick care within 3 days
• Routine well care within 90 days (15 days if pregnant)

Override requests must be submitted using the Override Request form and sent to EDS within six months of the date of service. EDS has 30 days to evaluate the request.

The Division of Medical Assistance (DMA) sends a monthly enrollment report to each PCP to assist in identification of their enrollees. DMA also sends a monthly referral report to each PCP so they can verify the validity and accuracy of the referrals. PCPs must document all referrals in the patient record. It is the responsibility of the PCP to review the reports and report discrepancies to their regional Managed Care Consultant for investigation.
 

Managed Care Section
DMA, 919-857-4022

Attention: Hospital Providers

Revision of Utilization Review Plans

Revision of a hospital UR plan is necessary only when one of the following occurs:

1. The hospital name changes.
2. The hospital has a change in ownership.
3. The physical location of the facility changes.
4. There is a change in the number or type of specialty beds.

Division of Medical Assistance
Medical Policy Section
Hospital Utilization Review
2511 Mail Service Center
Raleigh, NC 27699-2511
 

Ann H. Kimbrell, R.N., Institutional Services
DMA, 919-857-4020

Attention: Physicians, Nurse Practitioners, Nurse Midwives, and Health Departments

Varicella-Zoster Immune Globulin, Human, for Intramuscular Use (CPT 90396), Billing Guidelines

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

Attention: Independent Practitioner Providers, Developmental Evaluation Centers, Public Health Agencies, Area Mental Health Centers, Home Health Providers, Hospital Outpatient Clinics, and Physician Services

Prior Approval of Outpatient Specialized Therapy Services

After the trigger points have been reached, claims will not process without prior approval authorization.

Note: HMO and Medicare recipients are exempt from this policy.

Note: For Local Educational Agencies (LEAs), the prior approval process is deemed met by the IEP process.

Workshops for Outpatient Specialized Therapy Prior Approval Process

Detailed instructions about the prior approval process will be provided in workshops scheduled for September 2002. There is no charge for the workshops. However, to ensure adequate seating, please complete and submit the Outpatient Specialized Therapy Prior Approval Process Workshop registration form or register online beginning September 1, 2002, at http://www.mrnc.org under the News and Upcoming Events section. Workshops will begin at 10:00 a.m. and end at 1:00 p.m.

Please access and print the PDF version of the September 2002 Special Bulletin V, Outpatient Specialized Therapies, from the DMA website and bring it with you.

Directions to the sites.

Registration form for the Outpatient Specialized Therapy Prior Approval Process Workshops.
 
 

September 10, 2002 Park Inn Gateway Conference Center 909 US Highway 70 SW Hickory, NC

September 11, 2002 Hilton Greenville 207 Greenville Blvd SW Greenville, NC

September 12, 2002 McKimmon Center Raleigh, NC

Directions to the Outpatient Specialized Therapy Prior Approval Process Workshops

Hilton - 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.

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 between Avent Ferry Road 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.

Carol Robertson
Nora Poisella
Behavioral Health Services
DMA, 919-857-4020
 

Attention: All Providers

Medicare Part B Seminar Schedule

The process for billing these services will be published in the September 2002 Special Bulletin VI, Medicare Part B, for use in the Medicare Part B 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 Medicare Part B Special Bulletin will not be distributed to providers attending the seminars. Providers must access and print the PDF version of the September 2002 Special Bulletin VI, Medicare Part B 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 Medicare Part B seminar by completing and submitting the Medicare Part B Seminar registration form or providers can register online. Please select the most convenient site and return the completed registration form to EDS as soon as possible. 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.

Directions to the sites.

Wednesday, September 4, 2002 Holiday Inn Conference Center 530 Jake Alexander Blvd., S. Salisbury, NC	Thursday, September 5, 2002 Ramada Inn Plaza 3050 University Parkway Winston-Salem, NC	Tuesday, September 10, 2002 WakeMed Andrews Conference Center 3000 New Bern Avenue  Raleigh, NC
Thursday, September 12, 2002 Blue Ridge Community College Bo Thomas Auditorium College Drive Flat Rock, NC	Tuesday, September 17, 2002 Coast Line Convention Center  501 Nutt Street  Wilmington, NC	Wednesday, September 18, 2002 Hilton Greenville 207 Greenville Blvd SW Greenville, NC

Directions to the Medicare Part B Seminars

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

Ramada Inn 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).

Blue Ridge Community College - 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. Pass the college's main entrance and turn right into the college entrance past the pond. The parking lot is on the left.

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.

Greenville Hilton - 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.

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

DMA Home	Top