October 2000 North Carolina Medicaid Bulletin

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Providers are responsible for informing their billing agency for information in this bulletin.

In this Issue:

All Providers:

Community Alternatives Program Case Managers:

Durable Medical Equipment Providers:

FQHC Providers:

Health Departments:

Hearing Aid Providers:

Home Health Agencies:

Home Infusion Therapy Providers:

Hospitals and Emergency Room Physicians:

Nurse Practitioners and Midwives:

Optical Providers:

Physicians:

Prescribers:

Private Duty Nursing Providers:

Rural Health Providers:



 

Attention: All Providers
Renovation of the MMIS System - Identification Tracking Measurement Enhancement (ITME) Project

The Division of Medical Assistance (DMA) is upgrading and enhancing the Medicaid Management Information System (MMIS). The goals of the renovation, as noted in the April, 2000 Bulletin, are:

The enhancements will include minimal changes to the Remittance and Status Advice (RA), submission of adjustment requests, prior approval, and voice response and eligibility verification systems.

Changes to the following parts are detailed in the Provider Impact section of this article.

Part I - Remittance and Status Advice
Part II - Adjustment Requests - NEW FORM
Part III - Prior Approval (PA)
Part IV - Automated Voice Response (AVR) System and Eligibility Verification System (EVS)
 

Implementation Schedule
The system changes will be implemented with an effective date of December 1, 2000. The RA will reflect the changes noted in Part I beginning December 1, 2000. Part II reflects the new NC Medicaid adjustment form. Use of this form is required as of December 1, 2000. Part III provides new instructions for submitting services that have been prior approved. Part IV addresses changes to the AVR System and EVS resulting from this enhancement.
 

Provider Impact
Part I: Remittance and Status Advice (RA) - See Example 1

RA modifications/format changes will be kept to only those that are necessary in conjunction with the ITME project. Overall, the RA will look very similar to the current format. Please note the format changes on the RA sample following this article (Example 1).

Addition of Financial Payer Code
A financial payer code follows the claim internal control number (ICN) in the first line of the claim data reflected on the RA. This financial payer code denotes the entity responsible for payment of the claims listed on the RA. Upon implementation, NC Medicaid will be the only financially responsible payer; therefore, the North Carolina Medicaid payer code of NCXIX (five characters) will be reflected.

Addition of Population Group Payer Code
The RA reflects the population payer code for each claim detail. The population payer code is printed at the beginning of each claim detail line on the RA. The population payer code denotes the special program/population group from which a recipient is receiving Medicaid benefits. Examples of population payer codes are as follows:
 
Code Name Description
CA-I Carolina ACCESS All recipients enrolled in Medicaid's Carolina ACCESS program
CA-II ACCESS II All recipients enrolled in Medicaid's ACCESS II program
CAB ACCESS III - Cabarrus County All recipients enrolled in Medicaid's ACCESS III program for Cabarrus County
PITT ACCESS III - Pitt County All recipients enrolled in Medicaid's ACCESS III program for Pitt County
HMOM Health Management Organization (HMO) All recipients enrolled in Medicaid's HMO program
NCXIX Medicaid All recipients not enrolled in any of the above noted population payer programs. Any recipient not identified with Carolina ACCESS, ACCESS II, ACCESS III, or HMO will be assigned the NCXIX population payer code to identify them with the Medicaid fee-for-service program.

Other population payers may be designated by DMA in the future.

Addition of new totals following the current claim total line
An additional line is added following each claim total line of the paid and denied claim sections of the RA for the following claim types: Medical (J), Dental (K), Home Health, Hospice and Personal Care (Q), Medical Vendor (P), Outpatient (M), and Professional Crossover (O). This additional line reflects original claim billed amount, original claim detail count, and total number of financial payers. Upon implementation in December 2000, NC Medicaid will be the only financial payer; these new totals will reflect the submitted claim totals.

These additional totals do not appear for claim types Drug (D), Inpatient (S), Nursing Home (T), and Medicare crossover (W) since they are not processed at the claim detail level and will not have multiple financial payers assigned, based on current NC Medicaid billing policy.

Addition of a new summary page at end of RA
For each Medicaid population payer identified on the paper RA, a new summary page showing total payments by population payer is provided at the end of the RA. This provides population payer detail information for tracking and informational purposes.

New specifications for Tape RA
Updated specifications have been mailed to all Tape RA Providers. If you are currently receiving a Tape RA and have not received the updated specifications, or have questions regarding the changes, please contact Glenda Raynor, Manager of EDS Electronic Commerce Services, at 919-851-8888 extension 5-3099.
 

Part II: Adjustment Requests - NEW FORM (Example 2)

The North Carolina Medicaid program will begin using a new RA format in December, 2000. This new format affects the way adjustment request forms are completed by the provider and processed by EDS. The appropriate "financial payer" information found on the new RA will be required on all adjustment request forms after December 1, 2000. DMA and EDS have implemented a new adjustment request form to help with these changes. One of the predominant changes is in the "claim number" field. This area is now identified with twenty boxes, each box for one number of the referenced claim number. Until December 1, 2000, there will be five empty boxes at the end of the claim number. After the December 1, 2000 implementation of the MMIS enhancements, these spaces will be used for the financial payer code information. Providers may begin using this new adjustment request form now if it facilitates implementing these changes. (Refer to example of claim field below.) Please contact EDS Provider Services with questions about the new format and processing of an adjustment request.

Claim # field on Adjustment form from RA prior to December 1, 2000:
Claim #:
# # # # # # # # # # # # # # #
Claim # field on Adjustment form from RA after December 1, 2000:
Claim #:
# # # # # # # # # # # # # # # N C X I X
Part III: Prior Approval (PA)

Effective December 1, 2000, entering the prior approval number on the claim form by the provider to receive payment for services rendered will no longer be required. This holds true for all prior approved Medicaid services, regardless of the entity giving the prior approval.

Prior approval requirements and the criteria for approval of services have not changed. Those services that previously required prior approval before the implementation of the enhanced MMIS will continue to require prior approval. If a service was approved prior to December 1, 2000 but was not provided or billed until after December 1, 2000, the original prior approval is still valid. The MMIS will verify that prior approval was obtained before claims payment can occur. If the services being submitted on the claim form require prior approval, and approval has not been obtained, that claim will be denied. The only change is that the input of the prior approval number is no longer required on the claim form by the provider as of December 1, 2000.

Part IV: Automated Voice Response (AVR) System and Eligibility Verification System (EVS)

These systems will be enhanced with new messages that will explain under which special Medicaid program or programs a recipient is enrolled as a participant. Additional information regarding these system enhancements will be provided in subsequent bulletin articles.
 

EDS, 1-800-688-6696 or 919-851-8888
 

Remittance and Status Advice Samples

Medicaid Claims Adjust Request Form
 



 

Attention: All Providers
Modifications to the Automated Voice Response System through the ITME Project

Modifications will be made to the Automated Voice Response (AVR) System to accommodate the enhancements to the North Carolina Medicaid Management Information System (NCMMIS) through the Identification Tracking and Measurement Enhancement (ITME) Project. The modifications will be implemented on November 30, 2000. These modifications to the AVR system will have minimal impact on the provider community. The AVR system will be modified to provide requested information found for all financial payers and population group codes. The requested information will be provided based on the provider and the recipient enrollment. Both the provider and the recipient must be enrolled in the same population group on the date of service in order for information to be provided. Information entered by the provider will not change, and a valid Medicaid provider number will still be required to access the system.

Some messages will include new terminology with the modifications made to the AVR system. The following is a general glossary of ITME terms.

  1. ITME - Identification Tracking and Measurement Enhancement - the enhancement to the NCMMIS to support multiple state-sponsored waiver program initiatives.
  2. Financial Payer - The entity that is financially responsible for paying a claim. A financial payer may divide its population into smaller population groups to manage them more effectively. The financial payer is responsible for payment for services covered by all of its population groups that are not financially responsible. Medicaid will be the only financial payer when NCMMIS ITME modifications are implemented. Other financial payers will come on line at a later date.
  3. Population Group - The entity deemed responsible for the management of a particular section of the recipient population. The population group on a claim is determined by a combination of recipient eligibility, provider eligibility, and service coverage. Population groups may or may not be financially responsible for payment of claims. When ITME is implemented, six population groups will be identified within Medicaid (Carolina ACCESS, ACCESS II, ACCESS III for Pitt County, ACCESS III for Cabarrus County, HMO for Health Maintenance Organizations, and straight Medicaid). Population groups may have unique processing and eligibility rules.
  4. Recipient Enrollment Information - Information for each recipient available in the enrollment file. Recipients will have an enrollment segment for each population group with whom they are enrolled, so a recipient can have multiple enrollment records. Once the AVR system is modified, an option to check a recipient's enrollment information will be included in the eligibility section. This will return all population groups that the recipient is enrolled with on the inquired date of service.
EDS, 1-800-688-6696 or 919-851-8888


Attention: Home Health Agencies, Private Duty Nursing Providers, Community Alternatives Program (CAP) Case Managers
Use of HCPCS Code W4655 - Covered Supplies Not Elsewhere Classified

Post-payment reviews by Program Integrity indicate that HCPCS code W4655 on the Home Health fee schedule is being used incorrectly. Some providers are billing supplies that are used with Durable Medical Equipment (DME) rentals and Home Infusion Therapy (HIT) equipment to this code. Items billed in error include IV administration sets for ambulatory infusion pumps, administration supplies for pumps used for enteral and parenteral nutrition, and administration supplies for drug therapy. HCPCS code W4655 may not be used to bill Medicaid for DME- or HIT-related supplies.

HCPCS code W4655 allows billing for nonlisted home health supplies that meet Medicaid coverage criteria. Supplies must meet the requirements listed in Section 5.1.6 of the Community Care Manual. An item is covered when the following criteria are met:

"Covered supplies" means the item is considered a Home Health supply by Medicaid. Drugs, biological products, medical equipment, orthotics and prosthetics, and nutritional supplements are not considered Home Health supplies.

"Not elsewhere classified" means that the supply is not on the DME fee schedule (including DME-related supplies) or the HIT fee schedule, and does not have an existing code on the Home Health fee schedule.

When using HCPCS code W4655 providers must bill their usual and customary rate. Billing Medicaid for supplies that do not meet coverage requirements may result in recoupment of payments.

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


Attention: All Physicians
Update to Injectable Drug List

Effective with date of service October 1, 2000, the following changes are made to the list of injectable drugs billable in a physician's office when administered for the FDA-approved indications.

Changes:
 
New Code Description Old Code Description Maximum Reimbursement Rate
J9170 Docetaxel 20 mg W5158 Taxotere 20 mg
$269.47
J9170 Docetaxel 20 mg W5159 Taxotere 80 mg
$269.47
J9350 Topotecan 4 mg W5168 Hycamtin 4 mg
$572.32
J1885 Ketorolac tromethamine per 15mg W5171 Ketorolac tromethamine 30 per mg
$5.46
J1885 Ketorolac tromethamine per 15 mg W5172 Ketorolac tromethamine per 60 mg
$5.46
J0286 Amphotericin B, any Lipid fomulation 50 mg W5189 Amphotericin B, Lipid Complex (Abelcet) 100 mg
$90.25
W5198 Sandostatin (Octreotide Acetate) 50 mcg W5198 Sandostatin (Octreotide Acetate) 100 mcg
$4.70

Additions:
 
New Code Description Maximum Reimbursement Rate
J0456 Azithromycin (Zithromax) 500 mg, injectable
$22.06
J2352 Octreotide Acetate
(Sandostatin LAR Depot) 1mg
(Special pricing per 10mg or 20mg)
$1283.47

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


Attention: All Prescribers
Conversion from UPIN Numbers to DEA Numbers

The Division of Medical Assistance (DMA) is now requiring DEA numbers on all recipient claims instead of UPIN numbers. Providers must have their DEA registration number on file. Failure to do so may result in denied claims. If a prescriber does not have a DEA number and needs to issue prescriptions to recipients served by the Medicaid program, the prescriber should contact the DUR Section at 919-733-3590.

An identification number (ID) will be issued in lieu of the DEA number. The ID number, following the same format as the DEA number, will always begin with a Z (for example, ZF1234567). Prescribers will need to enter this number on their Medicaid prescriptions. This number is referred to as a MEDICAID IDENTIFICATION NUMBER only and should not be referred to as a DEA number.

If EDS Provider Enrollment does not have your updated information, 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

DEA Number form

Sharman Leinwand, DUR Coordinator with Program Integrity
DMA, 919-733-3590 ext. 229


Attention: All Providers
Where to Obtain Copies of the Federal Register

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires the adoption of standards for numerous electronic health care transactions and administrative simplifications by the Medicaid program. These standards are published in the Federal Register, the official daily publication for rules, proposed rules, and notices of federal agencies and organizations.

Copies of the Federal Register are available at a cost of $8.00 per issue. To order copies of the Federal Register, send your request to:

New Orders
Superintendent of Documents
P.O. Box 371954
Pittsburgh, PA 14250-7954

Specify the date of the issue requested and enclose a check or money order payable to the Superintendent of Documents, or enclose your VISA or MasterCard number and expiration date. Credit card orders may also be placed by calling the order desk at 202-512-1800 or by faxing requests to 202-512-2250.

Photocopies of the Federal Register can be made at most libraries designated as Federal Depository Libraries and at many other public and academic libraries. The Federal Register is also available online.

Information about the administrative simplification provisions of HIPAA, proposed rules, and comments can be found at http://aspe.hhs.gov/admnsimp/

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


Attention: Physicians, Health Departments, Nurse Practitioners, Nurse Midwives, Rural Health, and FQHC Providers
Norplant Insertion Kit

Effective on date of service July 1, 2000 the Norplant insertion kit procedure code W5135 was replaced with procedure code A4260. Please refer to page 14 of the May 2000 bulletin for detailed information on Implantable Contraceptive Capsules.

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


Attention: Durable Medical Equipment (DME) Providers
New Coverage Criteria for Code E0747, Non-Invasive Electrical Osteogenesis Stimulators for Non-Spinal Applications

Effective with date of service October 1, 2000, the following newly established coverage criteria will be used to establish medical necessity for code E0747, osteogenesis stimulator, electrical, non-invasive, other than spinal applications:

  1. Non-union of a long bone fracture defined as radiographic evidence that fracture healing has ceased for three or more months prior to starting treatment with the osteogenesis stimulator, OR
  2. Failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last surgery, OR
  3. Congenital pseudarthrosis.
Non-union of a long bone fracture must be documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including multiple views of the fracture site, and with a written interpretation by a physician stating that there has been no evidence of fracture healing between the two sets of radiographs.

A long bone is a clavicle, humerus, radius, ulna, femur, tibia, fibula, metacarpal, or metatarsal.

Prior approval of code E0747 is required.

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


Attention: All Providers
Physical Therapy, Occupational Therapy, Speech Therapy, and Developmental Evaluation Center Services

Effective with date of service October 1, 2000, Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) services provided to children ages 0 through 5 will be included in the capitation rates paid to the HMOs that participate in the Medicaid program. The HMOs will now be responsible for reimbursement of these services.

Developmental Evaluation Center Services will continue to be excluded from the HMO's capitation rates and Medicaid should be billed directly for these services.

Melanie Watkins, RN, Managed Care Section
DMA, 919-857-4231


Attention: Hospital and Physician Providers
Out-of-State Prior Approval Procedure for Acute and Rehabilitation Hospital Care

Prior approval requirements must be initiated prior to the recipient's referral to the out-of-state provider.

The attending physician is responsible for obtaining prior approval before referring a recipient for out-of-state hospital care. Out-of-state is defined as beyond 40 miles of the borders of North Carolina. A written request for prior approval must be submitted to the EDS Prior Approval Unit. Emergency services can be provided to a North Carolina recipient by an out-of-state provider without meeting prior approval requirements.

The following information is required:

  1. A completed "Request for Prior Approval" form (surgery or other services).
  2. A letter from the North Carolina physician requesting out-of-state medical services.
  3. Current medical history summary.
  4. Reason why the care cannot be provided within North Carolina.
  5. Name and address of the facility/provider that will provide care.
  6. Anticipated duration of care.
In addition, the following guidelines apply:
  1. Out-of-state facilities/providers must obtain a North Carolina provider number. The providers must contact DMA Provider Services at 919-857-4017 for information on obtaining a North Carolina provider number.
  2. When prior approval is granted, it is for the specific facility requested. Prior approval cannot be transferred to another facility nor may a recipient be transferred from one out-of-state facility to another without obtaining additional prior approval for the new facility.
  3. In order for the treating out-of-state provider to be paid, Carolina ACCESS (CA) providers must obtain prior approval and authorize any care the recipient receives out-of-state. The CA Primary Care Physician (PCP) must contact the out-of-state provider to authorize care and furnish the provider with the PCP authorization number to be submitted with the prior approval authorization.
EDS Prior Approval Unit, 1-800-688-6696 or 919-851-8888
 

Prior Approval Form


Attention: All Providers
Resubmission of a Previously Denied Claim

If one of the following EOBs is received and the validity is questionable, do not appeal by submitting an adjustment request. Please contact EDS Provider Services at 1-800-688-6696 or 919-851-8888. Adjustments submitted for these EOB denials will be denied with EOB 998 which states "Claim does not require adjustment processing, resubmit claim with corrections as a new day claim" or EOB 9600 which states "Adjustment denied; if claim was with adjustment it has been resubmitted. The EOB this claim previously denied for does not require adjusting. In the future, resubmit a new or corrected claim in lieu of sending an adjustment request." (Last Revision 06/28/00)
 
0002 0069 0128 0181 0236 0326 0574 0669 0825
0003 0074 0129 0182 0237 0327 0575 0670 0860
0004 0075 0131 0183 0240 0356 0576 0671 0863
0005 0076 0132 0185 0241 0363 0577 0672 0864
0007 0077 0133 0186 0242 0364 0578 0673 0865
0009 0078 0134 0187 0244 0394 0579 0674 0866
0011 0079 0135 0188 0245 0398 0580 0675 0867
0013 0080 0138 0189 0246 0424 0581 0676 0868
0014 0082 0139 0191 0247 0425 0584 0677 0869
0017 0084 0141 0194 0249 0426 0585 0679 0875
0019 0085 0143 0195 0250 0427 0586 0680 0888
0023 0089 0144 0196 0251 0428 0587 0681 0889
0024 0090 0145 0197 0253 0430 0588 0682 0898
0025 0093 0149 0198 0255 0435 0589 0683 0900
0026 0094 0151 0199 0256 0438 0590 0685 0905
0027 0095 0153 0200 0257 0439 0593 0688 0908
0029 0100 0154 0201 0258 0452 0604 0689 0909
0033 0101 0155 0202 0270 0462 0607 0690 0910
0034 0102 0156 0203 0279 0465 0609 0691 0911
0035 0103 0157 0204 0282 0505 0610 0698 0912
0036 0104 0158 0205 0283 0511 0611 0732 0913
0038 0105 0159 0206 0284 0513 0612 0734 0916
0039 0106 0160 0207 0286 0516 0616 0735 0917
0040 0108 0162 0208 0289 0523 0620 0749 0918
0041 0110 0163 0210 0290 0525 0621 0755 0919
0042 0111 0164 0211 0291 0529 0622 0760 0920
0046 0112 0165 0213 0292 0536 0626 0777 0922
0047 0113 0166 0215 0293 0537 0635 0797 0925
0049 0114 0167 0217 0294 0548 0636 0804 0926
0050 0115 0170 0219 0295 0553 0641 0805 0927
0051 0118 0171 0220 0296 0556 0642 0814 0929
0058 0120 0172 0221 0297 0557 0661 0817 0931
0062 0121 0174 0222 0298 0558 0662 0819 0932
0063 0122 0175 0223 0299 0559 0663 0820 0933
0065 0123 0176 0226 0316 0560 0665 0822 0934
0067 0126 0177 0227 0319 0569 0666 0823 0936
0068 0127 0179 0235 0325 0572 0668 0824 0940
0941 1050 1442 5001 7904 7948 7992 9211 9256
0942 1057 1443 5002 7905 7949 7993 9212 9257
0943 1058 1502 5201 7906 7950 7994 9213 9258
0944 1059 1506 5206 7907 7951 7996 9214 9259
0945 1060 1513 5216 7908 7952 7997 9215 9260
0946 1061 1866 5221 7909 7953 7998 9216 9261
0947 1062 1868 5222 7910 7954 7999 9217 9263
0948 1063 1873 5223 7911 7955 8174 9218 9264
0949 1064 1944 5224 7912 7956 8175 9219 9265
0950 1078 1949 5225 7913 7957 8326 9220 9266
0952 1079 1956 5226 7914 7958 8327 9221 9267
0953 1084 1999 5227 7915 7959 8400 9222 9268
0960 1086 2024 5228 7916 7960 8401 9223 9269
0967 1087 2027 5229 7917 7961 8901 9224 9272
0968 1091 2235 5230 7918 7962 8902 9225 9273
0969 1092 2236 6703 7919 7963 8903 9226 9274
0970 1152 2237 6704 7920 7964 8904 9227 9275
0972 1154 2238 6705 7921 7965 8905 9228 9291
0974 1156 2335 6707 7922 7966 8906 9229 9295
0986 1170 2911 6708 7923 7967 8907 9230 9600
0987 1175 2912 7700 7924 7968 8908 9231 9611
0988 1177 2913 7701 7925 7969 8909 9232 9614
0989 1178 2914 7702 7926 7970 9036 9233 9615
0990 1181 2915 7703 7927 7971 9054 9234 9625
0991 1183 2916 7704 7928 7972 9101 9235 9630
0992 1184 2917 7705 7929 7973 9102 9236 9631
0995 1186 2918 7706 7930 7974 9103 9237 9633
0997 1197 2919 7707 7931 7975 9104 9238 9642
0998 1198 2920 7708 7932 7976 9105 9239 9684
1001 1204 2921 7709 7933 7977 9106 9240 9801
1003 1232 2922 7712 7934 7978 9174 9241 9804
1008 1233 2923 7717 7935 7979 9175 9242 9806
1022 1275 2924 7733 7936 7980 9180 9243 9807
1023 1278 2925 7734 7937 7981 9200 9244 9919
1035 1307 2926 7735 7938 7982 9201 9245 9947
1036 1324 2927 7736 7939 7983 9202 9246 9993
1037 1350 2928 7737 7940 7984 9203 9247
1038 1351 2929 7738 7941 7985 9204 9248
1043 1355 2930 7740 7942 7986 9205 9249
1045 1380 2931 7741 7943 7987 9206 9250
1046 1381 2944 7788 7944 7988 9207 9251
1047 1382 3001 7794 7945 7989 9208 9252
1048 1400 3002 7900 7946 7990 9209 9253
1049 1404 3003 7901 7947 7991 9210 9254

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


Attention: Durable Medical Equipment (DME) Providers
Addition of Code E0748, Non-Invasive Electrical Osteogenesis Stimulator for Spinal Applications, to DME Fee Schedule

Effective with date of service October 1, 2000, non-invasive electrical osteogenesis stimulators will be added to the Capped Rental category of the DME Fee Schedule. The code, and maximum reimbursement rates are as follows:
 
CODE DESCRIPTION RENTAL NEW USED
E0748 osteogenesis stimulator, electrical, non-invasive, spinal applications $334.25 $3342.55 $2506.92

Providers are expected to bill their usual and customary rate.

Prior approval is required. Medical necessity must be documented on the Certificate of Medical Necessity and Prior Approval form. The patient's medical needs must fit one of the following coverage criteria:

  1. Failed spinal fusion where a minimum of nine months has elapsed since the last surgery, OR
  2. Following a multilevel spinal fusion surgery, OR
  3. Following spinal fusion surgery where there is a history of a previously failed spinal fusion at the same site.
A multilevel spinal fusion is one which involves three or more vertebrae (e.g., L3-L5, L4-S1, etc.).

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


Attention: Hospital Providers
Billing Emergency Room Visits Using Revenue Codes 450 and 451

The Division of Medical Assistance recognizes Revenue Codes 450 and 451 for Emergency Room visits for EMTALA screening and treatment beyond screening. EMTALA regulations require medical screening examinations to be performed when a Medicaid recipient presents to the Emergency Room. Hospitals must use Revenue Code 451 in form locator 42 on the UB-92 when only medical screening examination services are provided to a Medicaid recipient in the Emergency Room.

If the medical screening examination determines that the recipient requires stabilizing treatment, hospitals must use Revenue Code 450 in form locator 42 on the UB-92. Revenue Code 450 includes the medical screening examination and any services provided to treat/stabilize the recipient.

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


Attention: All Providers
Tax Identification Information

Alert - Tax Update Requested
North Carolina Medicaid must have the proper tax information for all providers. This ensures correct issuance of 1099 MISC forms each year and that the correct tax information is provided to the IRS. Inappropriate information on file can result in the IRS withholding 31% of a provider's Medicaid payments. Be sure the individual responsible for maintenance of tax information receives the following information.

How to Verify Tax Information
The last page of the Medicaid Remittance and Status Advice (RA) indicates the provider tax name and number that Medicaid has on file. Refer to the Medicaid RA throughout the year for each provider number to ensure Medicaid has the correct tax information on file. The tax information needed for a group practice is as follows: (1) Group tax name and group tax number; (2) Attending Medicaid provider numbers in the group. If a Medicaid RA is needed, call EDS Provider Services 919-851-8888 or 1-800-688-6696 to verify the tax information on file for each provider number.

Providers should complete a Special W-9 (see page 27) for all provider numbers with incorrect information on file. Instructions for completing the Special W-9 are listed below.

Send completed and signed forms by December 8, 2000 to:

EDS
4905 Waters Edge Drive
Raleigh, NC 27606
Attention: Provider Services

OR

FAX to 919-851-4014
Attention: Provider Services
 

Change of ownership
Contact DMA Provider Services at 919-857-4017 to report all changes in business ownership. If necessary, a new Medicaid provider number will be assigned and Provider Services will ensure the correct tax information is on file for Medicaid payments.

If DMA is not contacted and the incorrect provider number is used, that provider will be liable for taxes on income not necessarily received by the provider's business. DMA will assume no responsibility for penalties assessed by the IRS or for misrouted payments prior to written receipt of notification of ownership changes.

Group practice changes
When a physician leaves or a physician is added to a group practice, contact DMA Provider Services to update Medicaid enrollment and tax information.

Remember, without notifying DMA Provider Services, the incorrect tax information could remain on file and your business could become liable for taxes on Medicaid payments you did not receive.

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

Special W-9
 


Attention: All Providers
Correction to the August 2000 Bulletin Article "Modifier 25 and Minor Procedures"

The August 2000 bulletin article titled "Modifier 25 and Minor Procedures" indicates in example #2 that CPT code 93000, electrocardiogram, is a minor procedure with 0 to 10 postoperative days.

CPT code 93000 is not a minor procedure but is designated in the Relative Value System as an XXX code, which indicates the global concept does not apply. Therefore, modifier 25 does not apply to CPT code 93000 and should not be appended to the evaluation and office visit when a minor procedure or service is performed on the same day.

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


Attention: All Providers
Venipuncture and Specimen Collection

North Carolina Medicaid reimburses for venipuncture specimen collection fee, code G0001, only to the provider who extracts the specimen. Providers billing for this collection fee must send the laboratory specimen outside their office for the test to be performed.

When the recipient is an inpatient in the hospital, venipuncture and specimen collection is included in the Diagnostic Related Grouping (DRG) payment and will not be reimbursed separately.

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


Attention: All Providers
Reporting Electronic Commerce Services (ECS) Changes

A change in vendors or billing services by providers who are currently filing claims electronically may result in changes to the submitter identification number or billing information that is used when transmitting electronic claims. Providers are required to report these changes to the Electronic Commerce Services (ECS) unit at EDS. Contact the new vendor or billing service to obtain the submitter identification number that will be used to transmit claims. Report the change to ECS by calling 1-800-688-6696 (select option "1"). Providers are not required to complete a new ECS agreement when changing vendors or billing services.

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


Attention: Durable Medical Equipment (DME) and Home Infusion Therapy Providers
Rate Adjustment for Ambulatory Infusion Pump (E0781)

Effective with date of service October 1, 2000, the maximum reimbursement rate for Ambulatory Infusion Pump with administrative equipment (procedure code E0781) changed to $8.42. This represents a daily rate.

Please make this change on the DME fee schedule published August 1, 2000.

The rate is unchanged for Home Infusion Therapy providers. Refer to the Home Infusion Therapy fee schedule published August 1, 2000.

Debbie Barnes, Financial Operations
DMA, 919-857-4015


Attention: Hospitals and Emergency Room Physicians
Carolina ACCESS Emergency Room Claims Paid Prior to April 18, 2000

Claims for emergency room services with dates of service prior to April 18, 2000 that were paid with the W9922 Medical Screening Exam fee will not be adjusted. The payment of the W9922 Medical Screening Exam is considered payment in full for dates of service prior to April 18, 2000. Please refer to the September 2000 Medicaid Bulletin for additional information regarding billing changes for emergency room services.

Terri Bruner, Managed Care Section, Quality Management Unit
DMA, 919-857-4022


 

Need a Form?

The most frequently requested Medicaid forms are now available online at:

www.dhhs.state.nc.us/dma



Attention: All Prescribers
Synagis Coverage

Synagis will be reimbursable through the pharmacy program and not the physician's program. Synagis has been approved for prevention of respiratory syncytial virus (RSV) disease in children less than 24 months of age with bronchopulmonary dysplasia (BPD) or with a history of premature birth. The drug is administered once per month during the RSV season, which has been identified as being from October 2000 to March 2001 for our state.

Below is a list of guidelines that are approved by the American Academy of Pediatrics, which must be adhered to for drug coverage to be obtained.

Synagis will be reimbursable from October 1, 2000 to March 31, 2001 unless it is determined that the season has changed for our state. If it is determined, upon audit of physicians and pharmacist records, that the drug is being used outside the guidelines, the Medicaid program will consider a strict prior approval on all coverage of the drug.
 

Benny Ridout, R.Ph., Pharmacy Director, Medical Policy
DMA, 919-857-4034


Attention: Hearing Aid Providers
Dispensing Fee Adjustments

The following dispensing fee adjustments are effective with the date of service August 1, 2000.
 
Hearing Aid/Aids
Supplies/Accessories
Code
Cost
Code
Fee
Prior Approval
Required
Hearing Aid (1)
  Monaural
V5050
Invoice
V5090
$230.57
Yes
Hearing Aids (2)
  Binaural
V5130
Invoice
V5110
$371.93
Yes
Replacement Aid (Same Model)
  Covered under Manufacturer's
  Warranty or LS&D Policy
No Charge
V5160*
$90.69
Yes
Replacement Aid (Same Model)
  Not Covered under Manufacturer's
  Warranty or LS&D Policy
V5050
Invoice
V5160*
$90.69
Yes
Custom Earmold
Y2170
Invoice
Y2167
$14.06
Yes
Accessories
Y2171
Invoice
Y2168
$7.03
Yes
Hearing Aid Repair
  Covered under Manufacturer's
  Warranty or LS&D Policy
No Charge
Y2164
$34.76
Yes
Hearing Aid Repair
  Not Covered under Manufacturer's
  Warranty or LS&D Policy
Y2169
Invoice
Y2164
$34.76
Yes
Initial Care Kit (Stethoscope and 
  Forced Air Blower) Only Covered
  Once per Recipient
Y2173
Invoice
Y2168
$7.03
Yes
30-Day Trial Rental
  Aid and Accessories
No Charge
Y2165
$63.07
Yes
Hearing Aid Loaner
  (Maximum: 10 weeks)
No Charge
Y2166
$7.03
Yes
Hearing Aid Batteries
  Maximum: $35.00 per claim
  Allow 6 claims per 365 days
Y2172
Retail
No

*V5160 cannot be billed if a dispensing fee is paid to the provider by the manufacturer.

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


Attention: Optical Providers
Optical Seminar Schedule

Seminars for Optical providers are scheduled for November 2000. These seminars will focus on Medicaid guidelines for Optical providers, billing instructions, claim form completion and follow-up, and common denials. Medicaid billing supervisors, office managers, and billing personnel are encouraged to attend.

Due to limited seating, preregistration is required. Providers not registered are welcome to attend when reserved space is adequate to accommodate. Return the Optical Provider Seminar Registration Form to:

Provider Services
EDS
P.O. Box 300009
Raleigh, NC  27622

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
 
Thursday
November 2, 2000
Martin Community College
Kehakee Park Road
Williamston, NC
Auditorium
Wednesday
November 8, 2000
Four Points Sheraton
5032 Market Street
Wilmington, NC
Tuesday
November 14, 2000
Ramada Inn Plaza
3050 University Parkway
Winston-Salem, NC
Thursday
November 16, 2000
Catawba Valley Technical College
Highway 64-70
Hickory, NC
Auditorium
Tuesday
November 28, 2000
Holiday Inn Conference
Center
530 Jake Alexander Blvd., S.
Salisbury, NC
Thursday
November 30, 2000
WakeMed 
MEI Conference Center
3000 New Bern Avenue
Raleigh, NC
*See new parking instructions


 

Directions to the Optical Seminars

WILLIAMSTON, NORTH CAROLINA
MARTIN COMMUNITY COLLEGE

Highway 64 into Williamston. Martin Community College is approximately 1 to 2 miles west of Williamston. The Auditorium is located in Building 2. WILMINGTON, NORTH CAROLINA
FOUR POINTS SHERATON I-40 East into Wilmington to Highway 17 - just off I-40. Turn left onto Market Street. The Four Points Sheraton is located approximately .5 miles on the left. WINSTON-SALEM, NORTH CAROLINA
RAMADA INN PLAZA I-40 Business to 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. HICKORY, NORTH CAROLINA
CATAWBA VALLEY TECHNICAL COLLEGE Take I-40 to exit 125 and go approximately ½ mile to Highway 70. Travel east on Highway 70. The college is approximately 1.5 mile on the right. Ample parking is available. Entrance to Auditorium is between the Student Services and the Maintenance Center. Follow sidewalk (toward satellite dish) and turn right to Auditorium entrance.

SALISBURY, NORTH CAROLINA
HOLIDAY INN CONFERENCE CENTER

Traveling South on I-85:
Take exit 75 and turn right on Jake Alexander Blvd.

Traveling North on I-85:
Take exit 75 and turn left on Jake Alexander Blvd. Travel approximately .5 miles. The Holiday Inn is located on the right.

RALEIGH, NORTH CAROLINA
WAKEMED MEI CONFERENCE CENTER

Driving and Parking Directions
Take the I-440 Raleigh Beltline to New Bern Avenue, exit 13A (New Bern Avenue, Downtown). Travel toward WakeMed. Turn left onto Sunnybrook Road.

Parking is available at the former CCB Bank parking lot, a short walk to the conference facility. The entrance to the Conference Center is at the top of the stairs to Wake Med's Medical Education Institute.

Parking is also available on the top two levels of Parking Deck P3. To reach this deck, exit the I-440 Beltline, exit 13A. Proceed to the Emergency entrance of the hospital (on the left). Follow the access road up the hill to the gate for Parking Deck P3. After parking in P3, walk down the hill past the Medical Office Building and past the side of the Medical Education Institute. Turn right at the front entrance of the building and follow the sidewalk to the Conference Center entrance.

Illegally parked vehicles will be towed. Parking is not permitted at East Square Medical Plaza, Wake County Human Services, the P4 parking lot or in front of the Conference Center.



 

DIVISION OF MEDICAL ASSISTANCE MAILING ADDRESSES
 


Checkwrite Schedule
October 10, 2000 November 7, 2000 December 5, 2000
October 17, 2000 November 14, 2000 December 12, 2000
October 26, 2000 November 21, 2000 December 21, 2000
November 30, 2000

 

Electronic Cut-Off Schedule
October 6, 2000 November 3, 2000 December 1, 2000
October 13, 2000 November 10, 2000 December 8, 2000
October 20, 2000 November 17, 2000 December 15, 2000
  November 22, 2000  

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.
 


Paul R. Perruzzi, Director John W. Tsikerdanos
Division of Medical Assitance Executive Director
Department of Health and Human Services EDS

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