September 2003 Bulletin Title


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In This Issue . . .

All Providers:

Adult Care Home Providers:

Ambulance Service Providers:

Area Mental Health Centers:

CAP-MR/DD Case Managers and Providers:

Children’s Developmental Service Agencies:

Community Alternatives Program Case Managers:

Dental Providers:

Dialysis Treatment Facilities:

Durable Medical Equipment Providers:

Federally Qualified Health Centers:

Health Department Dental Clinics:

Health Departments:

HIV Case Management Services Providers:

Home Health Agencies:

Home Infusion Therapy Providers:

NCECS Billers:

Nurse Midwives:

Nurse Practitioners:

Personal Care Services (in Private Residences) Providers:

Physicians:

Private Duty Nursing Providers:

Residential Treatment Providers (Level II – IV Services for Children Under the Age of 21):

Rural Health Clinics:


Attention: All Providers

HIPAA Update: Change to Implementation Date

The American National Standard Institute (ANSI) Accredited Standards Committee (ASC) X12N standards, Version 4010A1 for electronic transactions will not be implemented on September 14, 2003 as announced in the August 2003 general Medicaid bulletin. The decision to delay the implementation of the standard transactions applies to the:

Note: NCPDP Version 5.1 Point-of-Sale was implemented on August 1, 2003 as previously published.

Providers will be notified in the October 2003 general Medicaid bulletin of the status of the implementation of HIPAA electronic transactions.

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


Attention: NCECS Billers

North Carolina Electronic Claims Submission Web-Based Tool

The introduction of the new North Carolina Electronic Claims Submission web-based tool (NCECS-Web) for electronic claim submission scheduled for September 14, 2003 has been delayed. Providers will be notified of the status of the implementation project in the October 2003 general Medicaid bulletin.

The current NCECS software for electronic claim submission is being replaced with a web-based program to comply with the implementation of data content standards required by the Health Insurance Portability and Accountability Act (HIPAA). The new claim submission program will be compatible with N.C. Medicaid only. NCECS-Web will support the Professional, Institutional, and Dental claims submission transactions.

Current NCECS software users may access the tool, using their current NCECS Login ID and password, at https://webclaims.ncmedicaid.com/ncecs.

Current users can access the Lists Management function of the NCECS-Web tool and begin creating and maintaining claims-related information for their clients, and compile procedure codes, diagnosis codes, etc. The Reference Materials function is also available.

Providers interested in using NCECS-Web may contact the EDS Electronic Commerce Services Unit at 1-800-688-6696, option 1 for more information.

Electronic Commerce Services Unit
EDS, 1-800-688-6696 or 919-851-8888


Attention: All Providers

Anesthesia Services – Conversion to CPT Anesthesia Codes

To comply with the implementation of national standard codes mandated by the Health Insurance Portability and Accountability Act (HIPAA), effective October 1, 2003, providers must bill anesthesia services using CPT anesthesia codes (00100 - 01999) instead of CPT surgical codes. The Division of Medical Assistance will not publish a crosswalk conversion guide. Providers should refer to the American Society of Anesthesiologists’ Crosswalk Guide and bill the anesthesia code that is indicated. There is no change in anesthesia base units. Providers should continue to bill the number of units as 1 minute = 1 unit. Additional information will be published in future general Medicaid bulletins.

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


Attention: All Providers

Endoscopy CPT Base Codes and Their Related Procedures

The following table represents a current and updated list of covered base and related endoscopy codes as designated in the 2002 and 2003 Resource Based Relative Value System (RBRVS). A new base code and a new related code were added to group 1. New codes were added to the related side for groups 10, 11, 17, 18, and 30.

Scopy Base and Related Code Group

Group

Base Code

Related Codes

Comments

1

29805

29806, 29819 - 29826

Effective 01/01/02 new "base" code added from 2002 RBRVS and new code added to related codes

2

29830

29834 - 29838

3

29840

29843 - 29847

4

29860

29861 - 29863

5

29870

29871, 29874 - 29877, 29879 - 29887

6

31505

31510 - 31513

7

31525

31527 - 31530, 31535, 31540, 31560, 31570

8

31526

31531, 31536, 31541, 31561, 31571

9

31622

31623 - 31625, 31628 - 31631, 31635, 31640 -31641, 31645

 

10

43200

43201 - 43202, 43204 - 43205, 43215 - 43217, 43219 - 43220, 43226 - 43228

Effective 03/01/03 new code added to related codes

11

43235

43231 - 43232, 43236, 43239, 43241 - 43247, 43249 - 43251, 43255 - 43256, 43258 - 43259

Effective 03/01/03 new code added to related codes

12

43260

43240, 43261 - 43265, 43267 - 43269, 43271-43272

 

13

44360

44361, 44363 - 44366, 44369, 44370, 44372-44373 

 

14

44376

44377 - 44379 

 

15

44388

44389 - 44394, 44397

 

16

45300

45303, 45305, 45307 - 45309, 45315, 45317, 45320 - 45321, 45327

 

17

45330

45331 - 45335, 45337 - 45340, 45345

Effective 03/01/03 new code added to related codes

18

45378

45379 - 45381, 45382 - 45387

Effective 03/01/03 new code added to related codes

19

46600

46604, 46606, 46608, 46610 - 46612, 46614 -46615

20

47552

47553 - 47556

21

50551

50555, 50557, 50559, 50561 

22

50570

50572, 50574-50576, 50578, 50580 

23

50951

50953, 50955, 50957, 50959, 50961 

24

50970

50974, 50976 

25

52000

52007, 52010, 52204, 52214, 52224, 52250, 52260, 52265, 52270, 52275 - 52277, 52281 -52283, 52285, 52290, 52300 - 52301, 52305, 52310, 52315, 52317-52318

26

52005

52320, 52325, 52327, 52330, 52332, 52334, 52341 - 52344 

 

27

52335

52336 - 52339

End-dated due to 2001 CPT update

28

56300

56301 - 56309, 56311, 56343 - 56344, 56314

End-dated due to 2000 CPT update

29

56350

56351 - 56356

End-dated due to 2000 CPT update

30

57452

57454 - 57456, 57460 - 57461

Effective 03/01/03 new code added to related codes

31

49320

38570, 49321 - 49323, 58550 - 58551, 58660 -58662, 58670

32

58555

58558 - 58563

33

52351

52345 - 52346, 52352 - 52355

34

31575

31576-31579

 

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


Attention: All Providers

Medicare – Medicaid Matching Project

In the coming months, the N.C. Medicaid program will participate in a project with Medicare to detect erroneous payments, abuse, and fraud. Medicare will receive the N.C. Medicaid claim file and combine it with the Medicare claim file to create a single database of all billings. A Medicare Program Safeguard Contractor (PSC) will then "data mine" the information to identify potentially improper billings.

Areas that will be targeted:

  1. Any alterations in billing information to Medicaid after Medicare payment has been received.
  2. Examples: changing units billed, reporting the incorrect Medicare payment on the Medicaid billing, changing procedure codes, etc.

  3. Billing for provision of more than 24 hours of services in one day.
  4. Providing treatment and services in ways more statistically significant than similar practitioner groups.
  5. Up-coding and billing for services that are more expensive than the services actually performed.

Medicare and Medicaid will jointly investigate all suspicious findings. The Office of the Inspector General and the N.C. Attorney General’s Medicaid Investigation Unit will also participate in the investigation and the prosecution of any criminal or civil fraud detected in this effort.

DMA Program Integrity staff will recover payments made to providers resulting from administrative errors not due to fraud. To report or refund payments from any erroneous billings to Medicaid, please contact Pat Delbridge at 919-733-6681 or by e-mail at Pat.Delbridge@dhhs.nc.gov.

Program Integrity Section
DMA, 919-733-6681


Attention: All Providers

Condition Codes D7 and D9 – Change for Medicare Overrides, Part A and Part B

To comply with the implementation of national codes mandated by the Health Insurance Portability and Accountability Act (HIPAA), state-created condition codes 87 and 89 will be end-dated effective with date of service September 30, 2003. Effective with date of service October 1, 2003, providers must submit national condition code D7 in place of 87 to override Medicare Part A, and D9 in the place of 89 to override Medicare Part B. These condition codes are entered in form locator fields 24 through 30 on UB-92 claims. Claims submitted with condition codes 87 and 89 after October 1, 2003 will deny.

This change applies to all electronic and paper claim formats.

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


Attention: All Providers

New Billing Guidelines for Sterilization Procedures

To comply with the implementation of national codes mandated by the Health Insurance Portability and Accountability Act (HIPAA), state-created procedure code W5075 will be end-dated effective with date of service September 30, 2003. Effective with date of service October 1, 2003, providers must bill with nationally recognized CPT and ICD-9-CM procedure codes. Claims billed with end-dated procedure codes for dates of service on and after October 1, 2003 will deny.

Diagnosis and Procedure Codes for Elective Sterilization

Physician Claims (CMS-1500)
The following codes are the only codes to be considered specifically for the purpose of elective sterilization:

Hospital Claims (UB-92)

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

New Billing Guidelines for Abortion Procedures

To comply with the implementation of national codes mandated by the Health Insurance Portability and Accountability Act (HIPAA), state-created procedure codes for abortion, W8206 and W8207, will be end-dated effective with date of service September 30, 2003. Effective with date of service October 1, 2003, nationally recognized CPT and ICD-9-CM procedure codes must be billed for abortion services. Claims billed with end-dated procedure codes for dates of service on and after October 1, 2003 will deny.

Abortion Billing Chart

Therapeutic Abortions:

Claim Type

Procedure Code

ICD-9-CM Diagnosis Code

Abortion Statement Required

Physician (CMS-1500)

59830 - 59857

59830 - 59857

59830 - 59857

59830 - 59857

635 - 635.92

638 - 638.92

V61.8

V71.5

Yes, with records

Yes, with records

Yes

Yes

Hospital (UB-92 69.01, 69.51, 74.91, 75.0, 96.49 635 - 635.92 Yes, with records
Hospital (UB-92) 69.01, 69.51, 74.91, 75.0, 96.49 638 - 638.9 Yes, with records
Hospital (UB-92) 69.01, 69.51, 74.91, 75.0, 96.49 V61.8 Yes
Hospital (UB-92) 69.01, 69.51, 74.91, 75.0, 96.49 V71.5 Yes

Non-Therapeutic Abortions:

Claim Type

Procedure Code

ICD-9-CM Diagnosis Code

Abortion Statement Required

Physician (CMS-1500)

59870

59812, 59820, 59821, 59830

630

631, 632, 634 - 634.92, 637 - 637.9

No

No

Hospital (UB-92)

68.0

630

No

Hospital (UB-92)

69.02, 69.52

Any OB diagnosis except 635 - 635.92, 638 - 638.92

Possible (medical records may be requested)

Hospital (UB-92)

69.09

630, 631, 632

Possible (medical records may be requested)

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


Attention: All Providers

State-Created Diagnosis Codes

Effective October 1, 2003, the following list of state-created diagnosis codes will be end-dated to comply with the implementation of national code sets mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Claims submitted using these state-created codes for dates of service after September 30, 2003 will deny. Providers must use appropriate national diagnosis codes from current coding manuals when submitting claims.

End-Dated Codes

042.0

042.1

042.20

042.9

043

043.0

043.1

043.2

043.3

043.9

044

044.0

044.9

095.56

095.59

303.1

303.2

303.3

305.1

305.11

305.12

305.13

404.2

404.3

640.02

640.04

640.82

640.84

640.92

640.94

641.02

641.04

641.12

641.14

641.22

641.24

641.32

641.34

641.82

641.84

641.92

641.94

643.02

643.04

643.12

643.14

643.22

643.24

643.82

643.84

643.92

643.94

651.02

651.04

651.12

651.14

651.22

651.24

651.82

651.84

651.92

651.94

652.02

652.04

652.12

652.14

652.22

652.24

652.32

652.34

652.42

652.44

652.52

652.54

652.62

652.64

652.72

652.74

652.82

652.84

652.92

652.94

653.02

653.04

653.12

653.14

653.22

653.24

653.32

653.34

653.42

653.44

653.52

653.54

653.62

653.64

653.72

653.74

653.82

653.84

653.92

653.94

654.22

654.24

655.02

655.04

655.12

655.14

655.22

655.24

655.32

655.34

655.42

655.44

655.52

655.54

655.62

655.64

655.82

655.84

655.92

655.94

656.02

656.04

656.12

656.14

656.22

656.24

656.32

656.34

656.42

656.44

656.52

656.54

656.62

656.64

656.72

656.74

656.82

656.84

656.92

656.94

657.02

657.04

658.02

658.04

658.12

658.14

658.22

658.24

658.32

658.34

658.42

658.44

658.82

658.84

658.92

658.94

659.02

659.04

659.12

659.14

659.22

659.24

659.32

659.34

659.42

659.44

659.52

659.54

659.82

659.84

659.92

659.94

660.02

660.04

660.12

660.14

660.22

660.24

660.32

660.34

660.42

660.44

660.52

660.54

660.62

660.64

660.72

660.74

660.82

660.84

660.91

660.94

661.02

661.04

661.12

661.14

661.22

661.24

661.32

661.34

661.42

661.44

661.92

661.94

662.02

662.04

662.12

662.14

662.22

662.24

662.32

662.34

663.02

663.04

663.12

663.14

663.22

663.24

663.32

663.34

663.42

663.44

663.52

663.54

663.62

663.64

663.82

663.84

663.92

663.94

664.02

664.03

664.12

664.13

664.22

664.23

664.32

664.33

664.42

664.43

664.52

664.53

664.82

664.83

664.92

664.93

665.02

665.04

665.12

665.13

665.14

665.21

665.23

665.32

665.33

665.42

665.43

665.52

665.53

665.62

665.63

665.73

666.01

666.03

666.11

666.13

666.21

666.23

666.31

666.33

667.01

667.03

667.11

667.13

669.31

669.33

669.52

669.53

669.54

669.62

669.63

669.64

669.72

669.73

669.74

670.01

670.03

671.32

671.34

671.41

671.43

672.01

672.03

674.11

674.13

674.21

674.23

674.31

674.33

674.41

674.43

674.81

674.83

674.91

674.93

712.0

712.4

712.5

712.6

712.7

715.01

715.02

715.03

715.05

715.06

715.07

715.08

715.19

715.29

715.39

715.81

715.82

715.83

715.84

715.85

715.86

715.87

715.88

715.99

716.69

718.06

718.16

718.61

718.62

718.63

718.64

718.66

718.67

718.68

718.69

718.96

719.71

719.72

719.73

719.74

795.8

948.01

948.02

948.03

948.04

948.05

948.06

948.07

948.08

948.09

948.12

948.13

948.14

948.15

948.16

948.17

948.18

948.19

948.23

948.24

948.25

948.26

948.27

948.28

948.29

948.34

948.35

948.36

948.37

948.38

948.39

948.45

948.46

948.47

948.48

948.49

948.56

948.57

948.58

948.59

948.67

948.68

948.69

948.78

948.79

948.89

V90.0

V90.1

V91.2

V91.8

Y00.0

Y09.1

001R

001RN

240R

240RN

280R

280RN

290R

290RN

320R

320RN

390R

390RN

460R

460RN

520R

520RN

580R

580RN

630R

630RN

680R

680RN

710R

710RN

740R

740RN

760R

760RN

780R

780RN

800R

800RN

V01R

V01RN

         

Deborah Ireland, Medical Policy Section
DMA, 919-857-4020


Attention: All Providers

CPT Code Update 2003

New 2003 CPT codes are covered by N.C. Medicaid retroactively to date of service March 1, 2003. Claims may be filed for services performed on or after March 1, 2003. Claims that were filed and received a denial for EOB 9, "service not covered by the Medicaid program" may be refiled at this time as a new claim. Claims with codes end-dated in 2003 will deny effective with dates of service on or after September 1, 2003.

The following table lists CPT codes that may be billed.

20612

21046

21047

21048

21049

29827

29873

29899

33215

33224

33225

33226

33508

34833

34834

34900

35572

36511

36512

36513

36514

36515

36516

36536

36537

37182

37183

37500

38205

38206

38242

43201

43236

44206

44207

44208

44210

44211

44212

44238

44701

45335

45340

45381

45386

46706

49419

49904

50542

50543

50562

51701

51702

51703

55866

56820

56821

57420

57421

57455

57456

57461

58146

58290

58291

58292

58293

58294

58545

58546

58552

58553

58554

61316

61322

61323

61517

61623

62148

62160

62161

62162

62163

62164

62165

62264

64416

64446

64447

64448

66990

75901

75902

75954

76071

76801

76802

76811

76812

76817

83880

84302

85004

85032

85049

85380

87255

87267

87271

88174

88175

89055

92601

92602

92603

92604

92607

92608

92609

92610

92611

92612

92614

92616

92700

93580

93581

95990

96920

96921

96922

99293

99294

99299

           

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


Attention: Ambulance Service Providers

New Ambulance Billing Guidelines

Effective with date of service October 15, 2003, the N.C. Medicaid program will end-date the following condition codes to comply with the implementation of national codes mandated by the Health Insurance Portability and Accountability Act (HIPAA): 81, 82, 83, 84, 85, 86, 90, 91, 92, 93, 94, 95, 96, 97, and 98. Providers must bill using the national condition codes listed below, effective with date of service October 16, 2003. Claims submitted after October 15, 2003 with end-dated condition codes will deny.

Condition Code

Description

When to Include on UB-92

AK

Air ambulance required – time needed to transport poses a threat

Use on any appropriate air ambulance claim.

AL

Specialized treatment/ bed unavailable

Use if recipient is taken to a hospital other than the nearest, due to treatment unavailable or beds unavailable.

AM

Non-emergency medically necessary stretcher transport

Use when recipient is bed-confined and his/her condition is such that a stretcher is the only safe mode of transportation.

Medicare Part B Override

Effective with date of service September 30, 2003, condition code 89 will be end-dated. Effective with date of service October 1, 2003, ambulance providers must submit national condition code D9 in the place of 89 to override Medicare Part B.

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


Attention: Area Mental Health Centers and Residential Treatment Providers (Level II – IV Services for Children Under the Age of 21)

Cancellation of Area Mental Health and Residential Child Care Treatment Seminars

Due to the fact that the implementation date published in the August 2003 general Medicaid bulletin and Special Bulletin III, HIPAA Code Conversion, has been delayed, the seminars scheduled for September 2, 3, 4, and 5, 2003 have been cancelled. Providers should continue to bill with existing procedure codes until further notice.

The seminars will be rescheduled for a later date. Providers will be notified in future general Medicaid bulletins of the new dates and registration information for the seminars.

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


Attention: Area Mental Health Centers and CAP-MR/DD Case Managers and Providers

Billing Update and Population Groups for CAP-MR/DD Services

The July 2003 general Medicaid bulletin listed the new national codes and descriptions for the CAP-MR/DD program. One rate adjustment was required. Effective with the date of service October 1, 2003, the new rate will be as noted below.

Current Local Code

Local Code Description

Current Rate

New National Code

National Code Description

New Rate

W8194

Day Habilitation, Periodic-Group (over 2 clients), per 15 minutes

$2.10 per 15 minute unit

T2021 HQ

Day Habilitation, Waiver, per 15 minutes

$3.00 per 15 minute unit

W8195

Day Habilitation, Periodic-Group (2 clients), per 15 minutes

$3.68 per 15 minute unit

Population Groups

DMA implemented population groups in 2001 to control and track specific benefit packages for designated groups of Medicaid recipients. For a provider, population groups mean two things:

  1. The provider must be enrolled to provide services to members of the CAP-MR/DD population group for claims to be paid. Existing CAP providers were enrolled in the appropriate CAP population group(s) according to current enrollment information on file with DMA as of July 11, 2003.
  2. The Remittance and Status Report (RA) provides information by population group. The population payer code is printed at the beginning of each claim detail line on the RA. The code denotes the special program/population group from which a recipient is receiving Medicaid benefits. The code for CAP-MR/DD is "CAPMR." (The CAP-MR/DD indicator on the recipient’s Medicaid identification card will remain "CM.") This information helps providers track receipts in their accounting systems by each CAP population group for which they are providing services.

Diane Holder, R.N., Behavioral Health Services
DMA, 919-857-4040


Attention: Children’s Developmental Service Agencies

Medical Coverage Policy 8J, Children’s Developmental Service Agencies

The medical coverage criteria and guidelines for the administration of North Carolina Infant-Toddler Program by Children’s Developmental Service Agencies (CDSAs) are now available in Medical Coverage Policy 8J on DMA’s website.

Monica Teasley, Behavioral Health Services
DMA, 919-857-4040


Attention: Area Mental Health Centers and Residential Treatment Providers (Level II – IV Services for Children Under the Age of 21)

Clarification on the Use of the F2 Stamp

Special Bulletin III, HIPAA Code Conversion, November 2003, included information regarding the use of the F2 stamp. In addition to the three scenarios listed in the special bulletin regarding when a provider may use the F2 stamp, the following scenario should be added:

If there is no enrolled Medicaid provider in the local Area Mental Health Center, the program will inform the client of other alternatives to treatment by Medicare-enrolled providers. If there are no enrolled Medicare providers within a 30-mile radius of the facility, the local Area Mental Health Center is allowed to serve the client and bill Medicaid.

Carol Robertson, Behavioral Health Services
DMA, 919-857-4040


Attention: Dialysis Treatment Facilities, Nurse Midwives, Nurse Practitioners, and Physicians

Calcitriol Injection, 0.1 mcg (J0636) – Billing Guidelines

The N.C. Medicaid program end-dated HCPCS code J0635 (Injection, calcitriol, 1 mcg ampule), effective with date of service August 31, 2003. Effective with date of service September 1, 2003, providers must bill J0636 (Injection, calcitriol, 0.1 mcg).

Providers must indicate the number of units given in block 24G on the CMS-1500 claim form. Dialysis treatment facilities must indicate the units given in form locator 46 of the UB-92 claim form and must enter the total charges in form locator 47. Providers must bill their usual and customary charge. The maximum reimbursement rate per unit is $1.31.

Add this code to the lists of injectable drugs published in the June 2002 and August 2002 general Medicaid bulletins.

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


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

HCPCS Code Changes for Home Health Supplies

Effective with date of service September 30, 2003, the following HCPCS codes will be end-dated to comply with the implementation of national standard codes mandated by the Health Insurance Portability and Accountability Act (HIPAA). New codes will become effective with date of service October 1, 2003.

Old Code

New Code

Description

Billing Unit

Maximum Reimbursement Rate

W4617

T1999 (misc.)

Personal care item, NOS (Fleet enema)

Each

N/A

W4640

S1015

IV tubing extension set (IV administration set)

Each

$ 4.34

W4663

A4656

Needle, any size (Needle, sterile, filter)

Each

.44

W4740

B9999

NOC for parenteral supplies (IV infusion start kit – sterile drape, tourniquet, 2x2’s, tape, alcohol/iodine wipe, dressing)

Each

2.72

W4741

T1999 (misc.)

Personal care item, NOS (venipuncture kit)

Each

N/A

W4742

T1999 (misc.)

Personal care item, NOS (cotton-tip applicator, sterile)

Each

N/A

 

K0621

Gauze, packing strips, non-impregnated, up to 2 inches in width

Linear yard

1.88

Providers must bill their usual and customary charges.

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


Attention: Durable Medical Equipment Providers

Deletion of Codes W4007 and W4035

Codes W4007, isolette, and W4035, compressor (Bunn equivalent) for administration of aerosol Pentamidine, were end-dated and deleted from the DME Fee Schedule effective with dates of service September 1, 2003. This action is being taken due to non-usage of the codes.

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


Attention: Durable Medical Equipment Providers

HCPCS Code Changes

The following HCPCS codes were changed effective with date of service September 1, 2003. This change was made to comply with the implementation of national codes mandated by the Health Insurance Portability and Accountability Act (HIPAA).

Old Code

New Code

Description

Quantity Limitation or Lifetime Expectancy

Maximum Reimbursement Rate

W4004

E0600

Respiratory suction pump, home model, portable or stationary, electric

2 years

Rental (modifier RR):

New Purchase (modifier NU):

Used Purchase (modifier UE):

$ 42.85

428.53

 

321.40

W4006

E0691*

Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, treatment area two square feet or less

N/A

Rental (modifier RR):

127.13

W4006

E0692*

Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, four foot panel

N/A

Rental (modifier RR):

127.13

W4045

A4483

Moisture exchanger, disposable, for use with invasive mechanical ventilation

60 per month

New Purchase (modifier NU):

5.97

W4667

S8490

Insulin syringes (100 syringes, any size)

2 units of 100 per month

New Purchase (modifier NU):

0.31

Note: Codes E0691 and E0692 require prior approval. Codes E0600, A4483, and S8490 do not require prior approval. However, as with all durable medical equipment, a Certificate of Medical Necessity and Prior Approval form must be completed.

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


Attention: HIV Case Management Services Providers

Change to Implementation Date and Rate Change for Procedure Code T1017

The September 1, 2003 implementation date published in the June 2003 general Medicaid bulletin instructing providers to begin using the new procedure code T1017 has been delayed until October 1, 2003. Continue to use procedure code Y2331 to bill for HIV Case Management Services for September dates of service.

Effective with date of service October 1, 2003, use procedure code T1017 when billing for HIV case management services. Refer to the billing instructions published in the June 2003 general Medicaid bulletin.

Effective with date of service October 1, 2003, the maximum Medicaid reimbursement rate for HIV case management services is $13.82 per 15 minutes. Providers must continue to bill their usual and customary charge.

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


Attention: Personal Care Services (in Private Residences) Providers

Change to Implementation Date for New Codes and Claim Form

The October 1, 2003 implementation date published in the July 2003 general Medicaid bulletin regarding changes for billing Personal Care Services (PCS) in private residences has been delayed. Continue to bill PCS on a UB-92 claim form using revenue code 599 until further notice. Providers will be notified of the new implementation date in a future general Medicaid bulletin.

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


Attention: Private Duty Nursing Providers

Change to Implementation Date for New Codes and Claim Form

The October 1, 2003 implementation date published in the July 2003 general Medicaid bulletin regarding changes for billing Private Duty Nursing (PDN) has been delayed. Continue to bill PDN services on a UB-92 claim form using revenue code 590 until further notice. Providers will be notified of the new implementation date in a future general Medicaid bulletin.

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


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

Home Visit for Postnatal Assessment and Follow-Up Care When There is No Delivery Code

When a home visit for postnatal assessment and follow-up care (CPT 99501) is provided and there is not a delivery code in claims history, providers receive a denial with EOB 211, "dates of service not within the authorized time period." Providers must submit an adjustment using the Medicaid Claim Adjustment form and include supporting documentation. Examples of supporting documentation include, but are not limited to: the child’s birth/death certificate; the provider’s verification/statement that delivery occurred; or the child’s full name, date of birth, and Medicaid identification number.

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


Attention: Federally Qualified Health Centers, Health Departments, Nurse Midwives, Nurse Practitioners, Physicians, and Rural Health Clinics

Purchasing Drugs for Administration in a Provider’s Office

Providers may only bill the N.C. Medicaid program for drugs they have purchased and administered to a recipient. Medicaid reimburses for drugs in one of two ways. The provider may purchase the drug and then bill the Medicaid program on the CMS-1500 claim form or the recipient may obtain the drug by prescription from a pharmacy and bring to the office for administration. When the recipient obtains the drug from a pharmacy, the pharmacy bills the Medicaid program.

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


Attention: Health Departments

Family Planning Claims Denials

Claims submitted by health departments for complete family planning visits for dates of service between December 1, 2002 and June 30, 2003 that have denied with EOB 0773 may be resubmitted as a new claim.

Beth Osborne, Medical Policy Section
DMA, 919-857-4020


Attention: Health Departments, Nurse Practitioners, and Physicians

Immune Globulin Intravenous Injection (J1563, 1 gm and J1564, 10 mg) – Billing Guidelines

Effective with date of service September 1, 2003, the N.C. Medicaid program no longer covers intravenous immune globulin when billed with CPT code 90283. This immune globulin must be billed with HCPCS code J1563 (1 gram) and/or J1564 (10 mg).

Providers must indicate their number of units given in block 24G on the CMS-1500 claim form and must bill their usual and customary charge. The maximum reimbursement rate per unit for J1563 is $74.25 and for J1564 is $0.81.

Add these immune globulin codes to the list of injectable drugs published in the August 2002 general Medicaid bulletin.

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


Attention: Home Health Agencies

Use of Revenue Codes for Home Health Skilled Nursing Claims

Effective with date of service October 1, 2003, providers must use revenue codes when submitting claims for home health skilled nursing visits. These revenue codes replace HCPCS codes W9952 through W9959, which will be end-dated with date of service September 30, 2003. Revenue codes 550 and 559, previously used to describe visits by a registered nurse and a licensed practical nurse, will now be used for the visits described in the table below. A separate code will no longer be used to bill the "one-time" skilled nursing visit. This will now be billed as a "not otherwise classified" visit. This change is being made to comply with the implementation of national standard codes mandated by the Health Insurance Portability and Accountability Act (HIPAA).

HCPCS Code

Old Description

Rev Code

New Description

W9952

Observation/Eval. of stable patient

550

SKILLED NURSING

W9953

Prefilling insulin syringes

551

SKILLED NURS/VISIT

W9954

Prefilling medicine planners

559

SKILLED NURS/OTHER

W9955

Venipuncture

580

VISIT/HOME HEALTH

W9959

Denied by Medicare for dually-eligible patient

581

VISIT/HOME HLTH/VISIT

W9957

Visit meeting Medicare criteria

589

VISIT/HOME HLTH/OTHER

W9958
W9956

Not otherwise classified

590

UNIT/HOME HEALTH

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


Attention: Home Infusion Therapy Providers

Use of Modifiers for Home Infusion Therapy Claims

Effective with date of receipt October 1, 2003, type of service codes (TOS) will be replaced with modifiers when billing HCPCS codes B9002, B9004, B9006, and E0776 for Home Infusion Therapy (HIT). The following modifiers must be used when billing these HCPCS codes.

NU for new purchase
UE for used purchase
RR for rental

The appropriate modifier must be entered in block 24D on the CMS-1500 claim form and will replace the following TOS codes: N for new purchase, U for used purchase, and E for rental.

Providers Filing Paper Claims
To ensure correct processing of paper claims, effective September 1, 2003, enter both the TOS code and the modifier on the claim until further notice.

Providers Filing Electronically
Effective October 1, 2003, providers filing electronically must bill using the appropriate modifiers only.

Beth Karr, RN, Community Care Section
DMA, 919-857-4021


Attention: Nurse Practitioners and Physicians

Amphotericin B – Change In Billing Guidelines

Effective with date of service September 1, 2003, the N.C. Medicaid program no longer covers amphotericin B when billed with HCPCS code J0286. Medicaid will continue to cover this drug when billed with HCPCS code J0285 (amphotericin B, 50 mg), and will add J0287 (amphotericin B lipid complex, 10 mg), J0288 (amphotericin B cholesteryl sulfate complex, 10 mg), and J0289 (amphotericin B liposome, 10 mg).

Providers must indicate the number of units given in block 24G on the CMS-1500 claim form and must bill their usual and customary charge. The maximum reimbursement rates per unit for these codes are:

J0285 $10.48 per 50 mg
J0287 $20.70 per 10 mg
J0288 $14.40 per 10 mg
J0289 $33.91 per 10 mg

Add these drug codes to the lists of injectable drugs published in the June 2002 and August 2002 general Medicaid bulletins.

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


Attention: Nurse Practitioners and Physicians

Oxaliplatin, 50 mg (Eloxatin, J9999) – Billing Guidelines

Effective with date of service September 1, 2003, the N.C. Medicaid program covers oxaliplatin (Eloxatin) for use in the Physician’s Drug Program. The FDA states that oxaliplatin, an antineoplastic agent, is used in combination with infusional 5-fluorouracil/leucovorin for the treatment of patients with metastatic carcinoma of the colon or rectum whose disease has recurred or progressed during or within six months of completion of first line therapy with the combination of bolus 5-fluorouracil/leucovorin and irinotecan.

The ICD-9-CM diagnosis codes that support medical necessity for oxaliplatin are:

Providers must bill J9999, the unclassified antineoplastic drug code, with an invoice attached to the CMS-1500 claim form. An invoice must be submitted with each claim. The paper invoice must indicate the name of the recipient, the recipient’s Medicaid identification number, the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, the number of vials used, and the cost per dose.

Providers must indicate the number of units given in block 24G on the CMS-1500 claim form. For Medicaid billing, one unit of coverage is 50 mg. The maximum reimbursement rate per unit is $894.85. Providers must bill their usual and customary charge.

Add this drug to the lists of injectable drugs published in the June 2002 and August 2002 general Medicaid bulletins.

Providers will not be reimbursed for an E/M code in addition to an administration code, unless the E/M code is appended with modifier 25 for a separately identifiable service. Routine supplies necessary to administer this antineoplastic drug are included in the reimbursement for the administration and are not separately reimbursed.

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


Attention: Adult Care Home Providers

Change to Implementation Date for Adult Care Home Personal Care Services Code Conversion

The October 1, 2003 implementation date published in the August 2003 general Medicaid bulletin regarding billing changes for personal care services (basic and enhanced) has been delayed. Continue to bill for these services using existing procedure codes until further notice. Providers will be notified of the new implementation date in future general Medicaid bulletins.

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


Attention: Dental Providers and Health Department Dental Clinics

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

The May 2003 general Medicaid bulletin described upcoming changes in American Dental Association (ADA) codes as well as the anticipated implementation of the 2002 ADA dental claim form. This article describes several additional changes in Current Dental Terminology codes (CDT-4) to be covered by the N.C. Medicaid program effective October 1, 2003. The information in this bulletin supersedes the information published in the May 2003 general Medicaid bulletin.

Delay for the 2002 ADA Claim Form
Due to unanticipated delays in implementing HIPAA-compliant electronic transactions, N.C. Medicaid will not be ready to implement the 2002 ADA dental claim form on October 1, 2003 as originally planned. At this time, no firm date has been set to switch to the new ADA claim form. Dental providers must continue to use the 2000 version of the ADA claim form as directed in both Medical Coverage Policy 4A, Dental Services, and Medical Coverage Policy 4B, Orthodontic Services, (Dental Services provider manual) on DMA’s website. Once a final date has been set to implement the new claim form, a three-month transition period will be established. Both the current claim form and the new claims form will be accepted during the transition period. Dental providers will be notified of the final date for the implementation of the new ADA claim form in future general Medicaid bulletins.

ADA Procedure Codes Must be Billed with the "D" Prefix
Effective with date of service October 1, 2003, all dental procedure codes must be billed with the "D" prefix (e.g., D0120, D0150) for both electronic and paper claims. Dental 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 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 date 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 or revised codes.

The following codes will be added effective with date of service October 1, 2003. Codes in bold font are in addition to those published in the May 2003 general Medicaid bulletin.

Procedure Code

Description

D0473

Accession of tissue, gross and microscopic examination, preparation and transmission of written report

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

D4211

Gingivectomy or gingivoplasty – one to three teeth, per quadrant

D4241

Gingival flap procedure, including root planing – one to three teeth, per quadrant

D4342

Periodontal scaling and root planing – one to three teeth, per quadrant

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

Note: Prior approval will be required for codes D4211, D4241, and D4342.

The following procedure code descriptions were revised. These new descriptions are effective with date 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
These changes are effective with date of service after September 30, 2003.

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).

D2393

Resin-based composite-three surfaces, posterior

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

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. Use only quadrant codes UR, UL, LR and LL. Arch codes UP and LO will no longer be accepted as of 10/01/2003.

D4211

Gingivectomy or gingivoplasty – one to three teeth, per quadrant

Use instead of D4210 if only one to three teeth remain in a quadrant. Use only quadrant codes UR, UL, LR and LL. Arch codes UP and LO will no longer be accepted as of 10/01/2003.

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. Use only quadrant codes UR, UL, LR and LL. Arch codes UP and LO will no longer be accepted as of 10/01/2003.

D4241

Gingival flap procedure, including root planing – one to three teeth, per quadrant

Use instead of D4240 if only one to three teeth remain in a quadrant. Use only quadrant codes UR, UL, LR and LL. Arch codes UP and LO will no longer be accepted as of 10/01/2003.

D4341

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

At least four teeth must be present to qualify for a quadrant. Use only quadrant codes UR, UL, LR and LL. Arch codes UP and LO will no longer be accepted as of 10/01/2003.

D4342

Periodontal scaling and root planing – one to three teeth, per quadrant

Use instead of D4341 if only one to three teeth remain in a quadrant. Use only quadrant codes UR, UL, LR and LL. Arch codes UP and LO will no longer be accepted as of 10/01/2003.

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.

New Coding for Supernumerary Teeth
In February 2003, the ADA published a revised coding system for supernumerary teeth. In this coding system, supernumerary teeth in the primary dentition are numbered relative to the nearest natural primary tooth. The letter "S" is added to the primary tooth letter to create a range of tooth numbers from "AS" to "TS." In the permanent dentition, supernumerary teeth are numbered from 51 to 82. The numbering begins in the upper right quadrant, continues around the upper arch to the upper left quadrant, and then continues from the lower left to the lower right. Use of this new numbering system will be required on N.C. Medicaid claims effective with date of service October 1, 2003 and after. As of that date, the old code of "40" for supernumerary teeth ceases to be valid. Please refer to Medical Coverage Policy 4A, Dental Services, for specific procedure codes requiring valid tooth numbers.

Valid Quadrant Indicators
Due to HIPAA regulations, quadrant indicators UA (upper anterior) and LA (lower anterior) will no longer be accepted on N.C. Medicaid claims effective with date of service October 1, 2003 and after. These quadrant indicators remain valid for selected procedure codes through date of service September 30, 2003. Please refer to Medical Coverage Policy 4A, Dental Services, for specific procedure codes and valid quadrant indicators.

Eight-Digit Dates Required for Dental Paper Claims
Effective October 1, 2003, all dates on the paper ADA 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 having missing or invalid dates.

CPT Codes Covered in the Medicaid Dental Program
The N.C. Medicaid Dental Program currently reimburses providers using both CDT codes and Current Procedural Terminology (CPT) codes published by the American Medical Association. These selected CPT codes are used primarily to reimburse for surgical services provided by dentists, including oral and maxillofacial surgeons.

HIPAA has designated the CDT-4 procedure codes as the standard national code set for electronic dental claim transactions. This regulation applies to all health care providers and health plans who conduct electronic transactions. To comply with this regulation, DMA must convert to the CDT-4 codes by October 16, 2003.

While reimbursement for CPT codes represents a very small proportion of Medicaid dental expenditures in the last fiscal year, these procedures are important to the recipients being served. The Division of Medical Assistance has been working with EDS to find a solution that can be implemented quickly and effectively to maintain the current scope of dental coverage with the least administrative burden to dental providers. It is anticipated that:

  1. additional CDT-4 codes will be covered through the dental program to replace the currently covered CPT codes; and
  2. reimbursement rates will be adjusted to ensure that all provider types are reimbursed equally for comparable services.

Billing instructions, code changes, and implementation dates will be published in future general Medicaid bulletins. These changes will also be incorporated into Medical Coverage Policy 4A, Dental Services.

Medical Coverage Policy Updates
A revised version of Medical Coverage Policy 4A, Dental Services, and Medical Coverage Policy 4B, Orthodontic Services will be available on October 1, 2003 on DMA’s website.

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


Holiday Closing

The Division of Medical Assistance (DMA) and EDS will be closed on Monday, September 1, in observance of Labor Day.


Checkwrite Schedule

September 3, 2003

October 7, 2003

November 4, 2003

September 9, 2003

October 14, 2003

November 12, 2003

September 16, 2003

October 21, 2003

November 18, 2003

October 30, 2003

November 26, 2003

 

Electronic Cut-Off Schedule

September 5, 2003

October 3, 2003

October 31, 2003

September 12, 2003

October 10, 2003

November 7, 2003

 

October 17, 2003

November 14, 2003

October 24, 2003

November 21, 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.


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

 

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