In This Issue . . .

All Providers:

• Anesthesia Services – Conversion to CPT Anesthesia Codes
• Condition Codes D7 and D9 – Change for Medicare Overrides, Part A and Part B
• HIPAA Update: Change to Implementation Date
• CPT Code Update 2003
• Endoscopy CPT Base Codes and Their Related Procedures
• Medicare – Medicaid Matching Project
• New Billing Guidelines for Abortion Procedures
• New Billing Guidelines for Sterilization Procedures
• Proposed Medical Coverage Policies
• State-Created Diagnosis Codes
• Checkwrite Schedule
• Electronic Cut-Off Schedule
• Holiday Closing

Adult Care Home Providers:

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

Ambulance Service Providers:

• New Ambulance Billing Guidelines

Area Mental Health Centers:

• Billing Update and Population Groups for CAP-MR/DD Services
• Cancellation of Area Mental Health and Residential Child Care Treatment Seminars
• Clarification on the Use of the F2 Stamp

CAP-MR/DD Case Managers and Providers:

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

Children’s Developmental Service Agencies:

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

Community Alternatives Program Case Managers:

• HCPCS Code Changes for Home Health Supplies

Dental Providers:

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

Dialysis Treatment Facilities:

• Calcitriol Injection, 0.1 mcg (J0636) – Billing Guidelines

Durable Medical Equipment Providers:

• Deletion of Codes W4007 and W4035
• HCPCS Code Changes

Federally Qualified Health Centers:

• Home Visit for Postnatal Assessment and Follow-Up Care When There is No Delivery Code
• Purchasing Drugs for Administration in a Provider’s Office

Health Department Dental Clinics:

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

Health Departments:

• Family Planning Claims Denials
• Home Visit for Postnatal Assessment and Follow-Up Care When There is No Delivery Code
• Immune Globulin Intravenous Injection (J1563, 1 gm and J1564, 10 mg) – Billing Guidelines
• Purchasing Drugs for Administration in a Provider’s Office

HIV Case Management Services Providers:

• Change to Implementation Date and Rate Change for Procedure Code T1017

Home Health Agencies:

• HCPCS Code Changes for Home Health Supplies
• Use of Revenue Codes for Home Health Skilled Nursing Claims

Home Infusion Therapy Providers:

• Use of Modifiers for Home Infusion Therapy Claims

NCECS Billers:

• North Carolina Electronic Claims Submission Web-Based Tool

Nurse Midwives:

• Calcitriol Injection, 0.1 mcg (J0636) – Billing Guidelines
• Purchasing Drugs for Administration in a Provider’s Office

Nurse Practitioners:

• Amphotericin B – Change in Billing Guidelines
• Calcitriol Injection, 0.1 mcg (J0636) – Billing Guidelines
• Immune Globulin Intravenous Injection (J1563, 1 gm and J1564, 10 mg) – Billing Guidelines
• Oxaliplatin, 50 mg (Eloxatin, J9999) – Billing Guidelines
• Purchasing Drugs for Administration in a Provider’s Office

Personal Care Services (in Private Residences) Providers:

• Change to Implementation Date for New Codes and Claim Form

Physicians:

• Amphotericin B – Change in Billing Guidelines
• Calcitriol Injection, 0.1 mcg (J0636) – Billing Guidelines
• Immune Globulin Intravenous Injection (J1563, 1 gm and J1564, 10 mg) – Billing Guidelines
• Oxaliplatin, 50 mg (Eloxatin, J9999) – Billing Guidelines
• Purchasing Drugs for Administration in a Provider’s Office

Private Duty Nursing Providers:

• Change to Implementation Date for New Codes and Claim Form
• HCPCS Code Changes for Home Health Supplies

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
• Clarification on the Use of the F2 Stamp

Rural Health Clinics:

• Home Visit for Postnatal Assessment and Follow-Up Care When There is No Delivery Code
• Purchasing Drugs for Administration in a Provider’s Office

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:

• Health Care Claim (Professional, Institutional, Dental) – 837 Transaction
• Health Care Claim Payment Advice – 835 Transaction
• Claim Inquiry and Response – 276/277 Transaction
• Payroll Deducted and Other Group Premium Payment for Insurance Products – 820 Transaction
• National Council for Prescription Drug Programs (NCPDP), Version 1.1 Batch Transaction

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

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.

Examples: changing units billed, reporting the incorrect Medicare payment on the Medicaid billing, changing procedure codes, etc.

2. Billing for provision of more than 24 hours of services in one day.
3. Providing treatment and services in ways more statistically significant than similar practitioner groups.
4. 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@ncmail.net.

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:

• ICD-9-CM diagnoses for sterilization: V25.2 or V61.5
• CPT procedure code for vasectomy: 55250
• CPT procedure codes for female sterilization: 58600, 58605, 58611, 58615, 58670, and 58671

Hospital Claims (UB-92)

• ICD-9-CM procedure codes: 63.70, 63.71, 63.73, 66.21, 66.22, 66.29, 66.31, 66.32, and 66.39

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 at http://www.dhhs.state.nc.us/dma/mp/proposedmp.htm. 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:

Non-Therapeutic Abortions:

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

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.

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.

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.

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 at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm.

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.

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).

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).

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:

• 153.0-153.9, 154.0 (malignant neoplasm of rectosigmoid junction),
• 154.1 (malignant neoplasm of rectum), and
• 154.8 (malignant neoplasm of other sites of rectum rectosigmoid junction and anus).

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 at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm. 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.

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.