October 2004 Medicaid Bulletins

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In This Issue . . .

All Providers:

  • Billing Guidelines for ICD-9-CM Diagnosis Code 799.9
  • Clinical Coverage Policies
  • New Managed Care Consultant Regions
  • NCLeads Update
  • Remittance and Status Report Changes for MedicarePrimary Claims
  • Adult Care Home Providers:

  • Adult Care Home Personal Care Service Rate Increase
  • FYE-2004 Medicaid Cost Report - Family Care Homes
  • Medicaid ACH-PCS Cost Settlements – FYE 2005
  • CMS-1500 Billers:

  • Changes to NCECSWeb to Accommodate Medicare Payment information
  • Chiropractors:

  • Provider Enrollment Directly through DMA
  • Dental Providers:

  • 2002 American Dental Association (ADA) Claim Form
  • Provider Enrollment Directly through DMA
  • Durable Medical Equipment Providers:

  • HCPCS Code Conversions for Wheelchair Seat Frames and Cushions
  • HCPCS Code Conversions from B4084 to B4086
  • Federally Qualified Health Centers:

  • Medicare Part B Crossovers
  • Use of the FP Modifier for Family Planning Services
  • Hospitals:

  • Emergency Services for Undocumented Aliens
  • Lower Level of Care Bed Billing
  • Independent Laboratories:

  • Use of the Family Planning Modifier for Family Services
  • Mental Health Service Providers:

  • Prior Approval and Medicare
  • Nurse Practitioners:

  • Azacitidine, 25 mg (Vidaza, HCPCS Code J9999)Billing Guidelines
  • Gemtuzumab Ozogamicin, 5 mg. (Mylotarg, J9300)Billing Guidelines
  • Nursing Facility Providers:

  • Therapeutic Leave
  • OBGYN Providers:

  • Emergency Services for Undocumented Aliens
  • Optical Providers:

  • Reminder Medicare Part B Billing and Optical Copayments
  • Optometrists:

  • Provider Enrollment Directly through DMA
  • Osteopaths:

  • Provider Enrollment Directly through DMA
  • Personal Care Services (PCS) Providers:

  • PCS and PCS-Plus Recoupments
  • Physicians:

  • Azacitidine, 25 mg (Vidaza, HCPCS Code J9999) – Billing Guidelines
  • Gemtuzumab Ozogamicin, 5 mg. (Mylotarg, J9300) – Billing Guidelines
  • HCPCS Code Changes for the Physicians Drug Program
  • Physician Management of ESRD- Code Changes and Billing Guidelines for CMS-1500
  • Provider Enrollment Directly through DMA
  • Podiatrists:

  • Provider Enrollment Directly through DMA
  • Prescriber and Pharmacy Providers:

  • Synagis and Respigam Forms
  • Rural Health Clinics:

  • Medicare Part B Crossovers
  • Use of the FP Modifier for Family Planning Services

  • Attention: All Providers

    Billing Guidelines for ICD-9-CM Diagnosis Code 799.9

    The following information is a clarification of the Mental Health and Substance Abuse Services Guidelines, Special Bulletin IV, December 2001:

    For new clients, Medicaid covers six unmanaged visits without a diagnosis of mental illness. The first two visits can be coded with ICD-9-CM diagnosis code 799.9 and the following four visits should be coded with "V" diagnosis codes.

    OR

    The first visit should be coded with diagnosis 799.9 and the remaining five should be coded with "V" diagnosis codes.

    A specific diagnosis code must be used as soon as a diagnosis is established.

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


    Attention: All Providers

    NCLeads Update

    Information related to the implementation of the new Medicaid Management Information System, NCLeads, scheduled for implementation in mid 2006 can be found online at http://ncleads.dhhs.state.nc.us. Please refer to this website for information, updates, and contact information related to the NCLeads system.

    Thomas Liverman, Provider Relations
    Office of MMIS Services
    919- 855-3112


    Attention: All Providers

    New Managed Care Consultant Regions

    Effective October 1, 2004, the regions that the Division of Medical Assistance’s Managed Care Consultants serve have been reorganized. Refer to the following table for a list of the consultants and the region they serve.

    Region 1
    Lisa Catron

    (828) 683-8812

    Region 2 LaRhonda Cain

    (919) 647-8190

    Region 3
    Lisa Gibson

    (919) 319-0301

    Region 4
    Julia McCollum

    (919) 647-8179

    Region 5
    Jerry Law

    (252) 321-1806

    Region 6
    Rosemary Long

    (910) 738-7399

    Avery

    Alexander

    Davidson

    Alamance

    Beaufort

    Bladen

    Buncombe

    Alleghany

    Davie

    Caswell

    Bertie

    Brunswick

    Burke

    Anson

    Forsyth

    Chatham

    Camden

    Carteret

    Cherokee

    Ashe

    Guilford

    Durham

    Chowan

    Columbus

    Clay

    Cabarrus

    Hoke

    Franklin

    Currituck

    Craven

    Cleveland

    Caldwell

    Montgomery

    Granville

    Dare

    Cumberland

    Graham

    Catawba

    Moore

    Harnett

    Edgecombe

    Duplin

    Haywood

    Gaston

    Randolph

    Johnston

    Gates

    Jones

    Henderson

    Iredell

    Richmond

    Lee

    Greene

    Lenoir

    Jackson

    Lincoln

    Rockingham

    Orange

    Halifax

    New Hanover

    Macon

    Mecklenburg

    Scotland

    Person

    Hertford

    Onslow

    Madison

    Rowan

    Stokes

    Vance

    Hyde

    Pamlico

    McDowell

    Stanly

    Surry

    Wake

    Martin

    Pender

    Mitchell

    Union

    Wilkes

    Warren

    Nash

    Robeson

    Polk

    Watauga

    Yadkin

    Wilson

    Northampton

    Sampson

    Rutherford

    Pasquotank

    Wayne

    Swain

    Perquimans

    Transylvania

    Pitt

    Yancey

    Tyrrell

    Washington

    Darryl Frazier, Managed Care
    DMA, 919-647-8177


    Attention: Adult Care Home Providers

    Adult Care Home Personal Care Service Rate Increase

    A rate increase to the Basic and Enhanced ACH/PC has been calculated and approved for reimbursement of Personal Care Services provided on or after October 1, 2004. The reimbursement rates effective on October 1, 2004 are:

    Procedure Code

    Description

    Old Rate

    New Rate

    W8251

    Basic ACH/PC

    Facility Beds 1 - 30

    $16.74

    $17.33

    W8258

    Basic ACH/PC

    Facility Beds 31 and Above

    $18.34

    $18.98

    W8255

    Enhanced ACH/PC

    Ambulation and Locomotion

    $2.64

    $2.73

    W8256

    Enhanced ACH/PC

    Eating

    $10.33

    $10.69

    W8257

    Enhanced ACH/PC

    Toileting

    $3.69

    $3.82

    W8259

    Enhanced ACH/PC

    Eating and Toileting

    $14.02

    $14.51

     

     

     

     

     

     

    Providers must bill their usual and customary charges. Adjustments will not be made to previously processed claims.

    Bruce Habeck, Finance Operations
    DMA, 919-857-4015


    Attention: All Providers

    Remittance and Status Reports Changes for Medicare Primary Claims

    Effective with the October 5, 2004 checkwrite, Medicaid claims that process with Medicare as the primary payer will be reported under a new section of the Remittance and Status Report called Medicare Primary Claims. This Medicare primary section was formerly titled the crossover section. Claims that are filed directly to Medicaid from Medicare and those claims filed directly to Medicaid from the provider indicating Medicare's payment on the claim will be reported in this new section.

    Remittance and Status Reports will also carry a new EST AMT DUE field. This field will populate with the dollar value entered in estimated amount due field (form locator 55) of the UB-92. This field will only be populated when the field is completed by the provider and the claim is processed as a Medicare Primary claim. The Original Billed Amount field will now show the Medicare Coinsurance and Deductible when a claim is processed as a Medicare primary claim.

    Example of Remittamce and Status Report

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


    Attention: Adult Care Home Providers

    Medicaid ACH-PCS Cost Settlements – FYE-2005

    Pending approval from the Centers for Medicare and Medicaid Services (CMS), effective with the Fiscal Year Ending in 2005, the Medicaid ACH-PCS Cost Settlement will no longer be required of private or public providers. The North Carolina Administrative Code (NCAC) 10A, Attachment 4.19-B, Section 23 (f), Page 6 has been amended as follows:

    "Reimbursement is determined by the Division of Medical Assistance based on a capitation per diem fee derived from review of industry costs and determination of reasonable costs with annual inflation adjustments. The initial basic per diem fee is based on one hour of services per patient day. Additional payments may be made utilizing the basic one hour per diem fee as a factor, for Medicaid eligible that have a demonstrated need for additional care. The initial basic one hour fee is computed by determining the estimated salary, fringes, direct supervision and allowable overhead. Effective January 1, 2000 the cost of medication administration and personal care services direct supervision shall be added to the basic per diem. The per diem rates may be recalculated from a cost reporting period selected by the state. Notwithstanding any other provision, if specified these rates will be adjusted as shown on supplement 1 to the 4.19-B section of the state plan. Payments may not exceed the limits set in 42 CFR 447.362. Effective with the Cost Report fiscal year ending June 30, 2005 or September 30, 2005, payments to private providers of Medicaid ACH-PCS will no longer be cost settled."

    Note: Providers will be notified should CMS not approve our State Plan Amendment to move cost settlement to prospective payment.

    and:

    "Public providers will be paid on an interim basis using the same reimbursement methods applicable to private providers. Effective with the Cost Report fiscal year ending June 30, 2005 or September 30, 2005, payments to public providers of Medicaid ACH-PCS will no longer be cost settled."

    Bruce Habeck, Finance Operations
    DMA, 919-857-4015


    Attention: Medicaid ACH - PCS Cost Settlements

    FYE-2004 Medicaid Cost Report - Family Care Homes

    The "Medicaid Cost Report - Family Care Homes" and the instructions for the reporting period of October 1, 2003 through September 30, 2004 are available on the Division of Medical Assistance's website. The "Medicaid ACH-PCS Cost Settlement" reports for Adult Care Homes with 6 or less beds and for Adult Care Homes with 7 beds or more for the Fiscal Year Ending 2004 are also available.

    To receive the FYE-2004 reports by mail, please contact Bruce Habeck at (919) 857-4015.

    Bruce Habeck, Finance Operations
    DMA, 919- 857-4015


    Attention: CMS-1500 Billers

    Changes to NCECS-Web to Accommodate Medicare Payment Information

    Beginning September 6, 2004, changes went into effect regarding Medicare Crossover claims. These changes are detailed in the August 2004, Special Bulletin V, Medicare Part B Billing. As a result of this implementation, changes have been made to NCECS-Web to allow users to submit Medicare primary claims to Medicaid for processing. An Insured Information Section has been added to the CMS-1500 Add/Edit Screen where service detail information is entered. The fields in the Insured Information Section include:

  • Insurer Detail Allowed Amount
  • Insurer Detail Paid Amount
  • Insurer Detail Deductible
  • Insurer Detail Coinsurance
  • Insurer Detail Paid Date
  • Users should only complete the fields in the Insured Information Section when Medicare has made a payment. Do not complete the Insured Information Section when Medicare has denied. Do not complete the Insured Information Section for commercial insurance.

    For assistance and questions, please contact EDS Provider Services at 1-800-688-6696 or 919-851-8888, option 3.

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


    Attention: Dental Providers (Including Health Department Dental Clinics)

    2002 American Dental Association (ADA) Claim Form

    The Division of Medical Assistance (DMA) and EDS have updated the Medicaid claims processing system to accept the 2002 ADA claim form. The implementation date for the new form is October 1, 2004. Providers will be given a three-month transition period, October 1, 2004 through December 31, 2004, to begin using the 2002 claim form. During this transition period, both the 1999 and 2002 forms will be accepted. Effective January 1, 2005, only the 2002 ADA claim form will be accepted. Claim forms can be ordered directly from the ADA. Listed below are the web address, toll-free telephone number, and mailing address:

    1-800-947-4746

    American Dental Association
    Attn: Salable Materials Office
    211 E. Chicago Avenue
    Chicago, IL 60611

    The claim form is available as a single or two-part form. The single form must be used when submitting claims for payment. The two-part form must be used when requesting prior approval. The original is returned to the provider and serves as the prior approval/claim copy. The second page is retained by EDS.

    For specific information regarding required fields for prior approval requests or claims for payment, refer to Clinical Policy #4A, Dental Services, which has been updated to include the 2002 ADA claim form.

    Dr. Ron Venezie, Dental Director
    DMA, 919-857-4033


    Attention: Durable Medical Equipment Providers

    HCPCS Code Conversions for Wheelchair Seat Frames and Cushions

    In order to comply with Centers for Medicare and Medicaid Services HCPCS coding changes, the following code conversions are effective with date of service October 1, 2004.

    Old

    Code

    New Code

    Description

    Quantity Limitation or Lifetime Expectancy

    Maximum Reimbursement Rate

    E0192

    K0652*

    Skin protection wheelchair seat cushion, width less than 22 inches, any depth

    3 years

    New Purchase: $386.44

    Used Purchase: $289.93

    K0653*

    Skin protection wheelchair seat cushion, width 22 inches or greater, any depth

    3 years

    New Purchase: $386.44

    Used Purchase: $289.93

    K0654*

    Positioning wheelchair seat cushion, width less than 22 inches, any depth

    3 years

    New Purchase: $185.00

    Used Purchase: $138.75

    K0655*

    Positioning wheelchair seat cushion, width 22 inches or greater, any depth

    3 years

    New Purchase: $386.44

    Used Purchase: $289.93

    K0656*

    Skin protection and positioning wheelchair cushion, width less than 22 inches, any depth

    3 years

    New Purchase: $386.44

    Used Purchase: $289.93

    K0657*

    Skin protection and positioning wheelchair cushion, width 22 inches or greater, any depth

    3 years

    New Purchase: $386.44

    Used Purchase: $289.93

    E0964

    K0650

    General use wheelchair seat cushion, width less than 22 inches, any depth

    3 years

    New Purchase: $75.32

    Used Purchase: $56.51

    K0023

    K0024

    K0660*

    General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware

    3 years

    Rental: $10.38

    New Purchase: $103.80

    Used Purchase: $77.85

    K0661*

    General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware

    3 years

    Rental: $10.38

    New Purchase: $103.80

    Used Purchase: $77.85

    W4148

    K0662*

    Positioning wheelchair back cushion, posterior, width less than 22 inches, any height, including any type mounting hardware

    3 years

    Rental: $63.14

    New Purchase: $631.35

    Used Purchase: $473.51

    K0663*

    Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height, including any type mounting hardware

    3 years

    Rental: $63.14

    New Purchase: $631.35

    Used Purchase: $473.51

    K0664*

    Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height, including any type mounting hardware

    3 years

    Rental: $63.14

    New Purchase: $631.35

    Used Purchase: $473.51

    K0665*

    Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any height, including any type mounting hardware

    3 years

    Rental: $63.14

    New Purchase: $631.35

    Used Purchase: $473.51

    W4698

    W4699

    W4700

    E2201*

    Manual wheelchair accessory, non-standard seat frame, width greater than or equal to 20 inches and less than 24 inches

    3 years

    Rental: $28.61

    New Purchase: $286.10

    Used Purchase: $214.58

    E2202*

    Manual wheelchair accessory, non-standard seat frame width 24-27 inches

    3 years

    Rental: $89.67

    New Purchase: $896.72

    Used Purchase: $672.54

    W4701

    W4702

    E2203*

    Manual wheelchair accessory, non-standard seat frame depth, 20 to less than 22 inches

    3 years

    Rental: $60.66

    New Purchase: $606.57

    Used Purchase: $454.93

    W4703

    E2204*

    Manual wheelchair accessory, non-standard seat frame depth 22-25 inches

    3 years

    Rental: $59.47

    New Purchase: $594.78

    Used Purchase: $446.08

    W4707

    W4708

    E2340*

    Power wheelchair accessory, non-standard seat frame width, 20-23 inches

    4 years

    Rental: $77.84

    New Purchase: $778.44

    Used Purchase: $583.83

    W4708

    W4709

    E2341*

    Power wheelchair accessory, non-standard seat frame width, 24-27 inches

    4 years

    Rental: $108.68

    New Purchase: $1086.78

    Used Purchase: $815.08

    W4710

    W4711

    E2342*

    Power wheelchair accessory, non-standard seat frame depth, 20 or 21 inches

    4 years

    Rental: $88.96

    New Purchase: $889.64

    Used Purchase: $667.23

    W4711

    W4712

    E2343*

    Power wheelchair accessory, non-standard seat frame depth, 22-25 inches

    4 years

    Rental: $93.92

    New Purchase: $939.18

    Used Purchase: $703.88

    W4720

    K0651*

    General use wheelchair cushion, width 22 inches or greater, any depth

    3 years

    New Purchase: $141.53

    Used Purchase: $106.15

    Note: HCPCS codes with an asterisk (*) require prior approval.

    The coverage criteria for these items have not changed. Refer to Clinical Coverage Policy #5, Durable Medical Equipment for detailed coverage information. A Certificate of Medical Necessity and Prior Approval form must be completed for all items regardless of the requirement for prior approval.

    Providers are reminded that these are maximum reimbursement rates. You must bill your usual and customary rate for all DME. Refer to Clinical Coverage Policy #5, Durable Medical Equipment Section 8.0 Billing, for detailed billing guidelines. The rates provided are temporary until Medicare’s established rates are published.

    In addition to the code conversions, the descriptions of the following codes were changed effective with date of service October 1, 2004:

    Code

    Description

    K0108/W4117

    Wheelchair seat width greater than 27 inches

    K0108/W4118

    Wheelchair seat depth greater than 25 inches

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


    Attention: Durable Medical Equipment Providers

    HCPCS Code Conversion from B4084 to B4086

    In order to comply with the Centers for Medicare and Medicaid Services HCPCS coding changes, HCPCS code B4084, gastrostomy/jejunostomy tubing, will be converted to code B4086, gastrostomy/jejunostomy tube, any material, each, effective with date of service September 30, 2004. The maximum reimbursement rate will remain at $17.09. Prior approval is not required. A Certificate of Medical Necessity and Prior Approval form must be completed regardless of the requirement for prior approval.

    Providers should continue to use HCPCS code B9998 for low profile gastrostomy and extension kits for Medicaid recipients.

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


    Attention: Federal Qualified Health Centers and Rural Health Clinics

    Medicare Part B Crossovers

    Effective with date of service September 6, 2004, the N.C. Medicaid program returned to processing crossovers for claims billed on a CMS-1500 form to Medicare. Currently, the only two Medicare intermediaries that Medicaid accepts Medicare Part B crossovers from are Cigna and Palmetto. For providers that are required to bill to Medicare Part B on a UB-92 claim form and to Medicaid on a CMS-1500 claim form, these claims will not automatically crossover from Medicare. These claims should be filed as a secondary claim to Medicaid as an 837 professional transaction indicating the coinsurance and deductible in the COB loop or on the CMS-1500 form with the Medicare voucher attached. Medicaid will reimburse a percentage of the coinsurance and deductible from Medicare. Please refer to the Part B Reimbursement Schedule to determine the percentage reimbursement for your facility.

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


    Attention: Federally Qualified Health Centers and Rural Health Clinics

    Use of the FP Modifier for Family Planning Services

    Providers were instructed in the May 2004 general Medicaid bulletin that effective with date of service April 26, 2004, the FP modifier must be appended to the CPT or HCPCS code billed for the family planning service and that a family planning diagnosis code (V25.0-V25.9, except for V25.3) must be entered on the claim for family planning services. However, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) CANNOT append the FP modifier to the core visit code, T1015.

    If the FQHC or RHC is certain that a procedure that is normally billed with the "C" suffix provider number was performed for family planning reasons, the FP modifier SHOULD be appended to the HCPCS code andthe appropriate family planning diagnosis should be billed. An example of this situation is the administration of Depo-Provera for contraception. The family planning diagnosis code should be billed and the FP modifier should be appended to the HCPCS code, J1055.

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


    Attention: Hospitals and OB/GYN Providers

    Emergency Services for Undocumented Aliens

    Undocumented residents are eligible for Medicaid emergency services only. Undocumented aliens are only authorized for Medicaid services for the actual days they receive an emergency medical service. Certain documented aliens are only eligible for emergency services during their first five years in the country.

    The county departments of social services (DSS) determine the eligibility coverage dates when the emergency service is for labor and vaginal delivery or C-section delivery. For all other emergency services, including miscarriages and other pregnancy terminations, the Division of Medical Assistance (DMA) determines the eligibility coverage. Application for emergency Medicaid is made at the local DSS in the alien’s county of residence.

    Medicaid eligibility will not be authorized until after the emergency service has occurred.

    Following is a listing of Medicaid program codes for aliens who are only eligible for emergency services:

    HSFF MAAF MABF MADF MAFF MICF
    HSFH MAAH MABH MADO MAFH MICH
    HSFO MAAO MABO MADH MAFO MPWF
    HSFR MAAR MABR MADR MAFR MPWH

    The definition of an emergency medical service includes a vaginal or C-section delivery. The only procedure codes covered are 59409 for a vaginal delivery or 59514 for a C-section delivery. Global codes that include prenatal, postpartum care or 60-day continuation are non-covered by Medicaid for emergency services and should not be billed to Medicaid.

    Non-covered codes include the following:

    63.70

    63.71

    63.72

    63.73

    66.21

    66.22

    66.29

    66.31

    66.32

    66.39

    CPT codes:

    55250

    55450

    58600

    58605

    58611

    58615

    58661*

    58670

    58671

    58700*

    58720*

    59400

    59410

    59425

    59426

    59430

    59510

    59515

       

    *Note: These codes will only be considered for coverage if medical documentation submitted with the claim supports that service was provided as the result of an emergency situation (such as an ectopic pregnancy). Sterilization procedures are not included in the definition of emergency services and, therefore, are non-covered for undocumented aliens.

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


    Attention: All Hospital Providers

    Lower Level of Care and Swing Bed Billing

    Effective June 1, 2004, hospitals billing lower levels of care beds must bill only for a single level of care – nursing facility level of care. There are no separate levels for "Skilled Nursing Care" and "Intermediate Care". All lower level of care beds are now described as "nursing facility level". Hospitals requesting reimbursement for patients in a lower level of care beds will receive the state average for nursing facility reimbursement rate for those beds.

    Effective with date of service June 1, 2004 the nursing facility per diem reimbursement rates are:

    Please continue to submit claims for lower-level of care stays following the current per diem guidelines.

    Prior Approval

    When a patient no longer meets acute care requirements and is approved for nursing facility level of care, the hospital must bill for a lower level of care while the patient remains in the hospital. Prior approval must be obtained from EDS by submitting an FL-2 or FL-2E form before billing for the lower level of care. The FL-2E

    Form may be accessed online at http://www.providerlink.com

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


    Attention: Independent Laboratories

    Use of the Family Planning Modifier for Family Planning Services

    Providers were instructed in the May 2004 general Medicaid bulletin that effective with date of service April 26, 2004, the FP modifier must be appended to the CPT or HCPCS code billed for family planning services and that a family planning diagnosis code (V25.0-V25.9, except for V25.3) must be entered on the claim for family planning services.

    When the independent laboratory is provided a diagnosis that clearly indicates a service was performed for family planning purposes and one of the following laboratory services is performed, the FP modifier should be appended to the CPT procedure code. If the laboratory is not provided a diagnosis that indicates the service was performed for family planning purposes, the CPT procedure code should not be appended with the FP modifier.

    The following CPT procedure codes are billable when a family planning service was performed.

    Procedure Code

    Description

    81000

    Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy

    81001

    Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy

    81002

    Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy

    81003

    Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy

    81005

    Urinalysis; qualitative or semiquantitative, except immunoassays

    81007

    Urinalysis; bacteriuria screen, except by culture or dipstick

    81015

    Urinalysis; microscopic only

    81020

    Urinalysis; two or three glass test

    81025

    Urine pregnancy test, by visual color comparison methods

    84702

    Gonadotropin, chorionic (hCG); quantitative

    84703

    Gonadotropin, chorionic (hCG); qualitative

    85004

    Blood count; automated differential WBC count

    85007

    Blood count; blood smear, microscopic examination with manual differential WBC count

    85008

    Blood count; blood smear, microscopic examination without manual differential WBC count

    85009

    Blood count; manual differential WBC count, buffy coat

    85013

    Blood count; spun microhematocrit

    85014

    Blood count; hematocrit (Hct)

    85018

    Blood count; hemoglobin (Hgb)

    85025

    Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count

    85027

    Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)

    85041

    Blood count; red blood cell (RBC) automated

    85044

    Blood count; reticulocyte , manual

    85045

    Blood count; reticulocyte, automated

    85046

    Blood count; reticulocytes, hemoglobin concentration

    85048

    Blood count; leukocyte (WBC), automated

    85049

    Blood count; platelet, automated

    86592

    Syphilis test; qualitative (e.g., VDRL, RPR, ART)

    86593

    Syphilis test; quantitative

    86631

    Antibody; chlamydia

    86632

    Antibody; Chlamydia, IgM

    86689

    Antibody; HTLV or HIV antibody, confirmatory test (e.g., Western Blot)

    86694

    Antibody; herpes simplex, non-specific type test

    86695

    Antibody; herpes simplex, type 1

    86696

    Antibody; herpes simplex, type 2

    86701

    Antibody, HIV-1

    86702

    Antibody; HIV-2

    86703

    Antibody; HIV-1 and HIV-2, single assay

    86762

    Antibody; rubella

    86781

    Antibody; Treponema pallidum, confirmatory test (e.g., FTA-abs)

    86900

    Blood typing; ABO

    86901

    Blood typing; Rh (D)

    86903

    Blood typing; antigen screening for compatible blood unit using reagent serum, per unit screened

    86904

    Blood typing; antigen screening for compatible unit using patient serum, per unit screened

    87081

    Culture, presumptive, pathogenic organisms, screening only

    87110

    Culture, Chlamydia, any source

    87207

    Smear, primary source with interpretation; special stain for inclusion bodies or parasites (e.g., malaria, coccidian, microsporidia, typanosomes, herpes viruses)

    87210

    Smear, primary source with interpretation; wet mount for infectious agents (e.g., saline, India ink, KOH preps)

    87270

    Infectious agent antigen detection by immunofluorescent technique; �Chlamydia trachomatis

    87273

    Infectious agent antigen detection by immunofluorescent technique; herpes simplex, type 2

    87274

    Infectious agent antigen detection by immunofluorescent technique; herpes simplex, type 1

    87285

    Infectious agent antigen detection by immunofluorescent technique; treponema pallidum

    87320

    Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; Chlamydia trachomatis

    87390

    Infectious agent antigen detection by immunofluorescent technique; HIV-1

    87391

    Infectious agent antigen detection by immunofluorescent technique; HIV-2

    87490

    Infectious agent detection by nucleic acid (DNA or RNA); chlamydia trachomatis, direct probe technique

    87491

    Infectious agent detection by nucleic acid (DNA or RNA); chlamydia trachomatis, amplified probe technique

    87492

    Infectious agent detection by nucleic acid (DNA or RNA); chlamydia trachomatis, quantification

    87528

    Infectious agent detection by nucleic acid (DNA or RNA); herpes simplex virus, direct probe technique

    87529

    Infectious agent detection by nucleic acid (DNA or RNA); herpes simplex virus, amplified probe technique

    87530

    Infectious agent detection by nucleic acid (DNA or RNA); herpes simplex virus, quantification

    87534

    Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique

    87535

    Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique

    87536

    Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification

    87537

    Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique

    87538

    Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique

    87539

    Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification

    87590

    Infectious agent detection by nucleic acid (DNA or RNA); neisseria gonorrhoeae, direct probe technique

    87591

    Infectious agent detection by nucleic acid (DNA or RNA); neisseria gonorrhoeae, amplified probe technique

    87592

    Infectious agent detection by nucleic acid (DNA or RNA); neisseria gonorrhoeae, quantification

    87810

    Infectious agent detection by immunoassay with direct optical observation; chlamydia trachomatis

    87850

    Infectious agent detection by immunoassay with direct optical observation; neisseria gonorrhea

    88141

    Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician (list separately in addition to code for technical support)

    88142

    Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision

    88143

    Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening under physician supervision

    88147

    Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision

    88148

    Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision

    88150

    Cytopathology, slides, cervical or vaginal; manual screening under physician supervision

    88152

    Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under physician supervision

    88153

    Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision

    88154

    Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

    88160

    Cytopathology, smears, any other sources; screening and interpretation

    88161

    Cytopathology, smears, any other sources; preparation, screening and interpretation

    88162

    Cytopathology, smears, any other sources; extended study involving over 5 slides and/or multiple stains

    88164

    Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision

    88165

    Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision

    88166

    Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening under physician supervision

    88167

    Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

    88174

    Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision

    88175

    Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening, under physician supervision

    88302

    Surgical pathology, gross and microscopic examination

    89300

    Semen analysis; presence and/or motility of sperm including Huhner test (post coital)

    89310

    Semen analysis; motility and count (not including Huhner test)

    89320

    Semen analysis; complete (volume, count, motility and differential)

    89325

    Sperm antibodies

    G0001

    Routine venipuncture for collection of specimen(s)

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


    Attention: Mental Health Services Providers

    Prior Approval and Medicare

    Prior approval is not required for Medicare covered mental health services rendered to Medicare/Medicaid dually eligible recipients when Medicare is their primary payer. Because Medicare does not require providers to request prior approval for services, it is not necessary for Medicaid providers to request authorization from ValueOptions for inpatient or outpatient services to these clients. Authorization must be obtained from ValueOptions in accordance with Medicaid requirements for Medicare non-covered services when services are rendered or billed by Area Mental Health Programs/Local Management Entities.

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


    Attention: Nursing Facility Providers

    Therapeutic Leave

    When billing for therapeutic leave days, please remember to bill RC 183 and not RC 100. RC 100 is for room and board when the recipient is in the nursing facility.

    Please note, page 8-29 of the N.C. Medicaid Nursing Facility Provider Manual, under "Billing Therapeutic Leave Days", "Claim 2", the dates for billing therapeutic leave in the example should be 04-12-2000 to 04-14-2000, and not 04-13-2000. This allows for the 2 covered therapeutic leave days in the example that are billable.

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


    Attention: Optical Providers

    Reminder: Medicare Part B Billing and Optical Copayments

    The current North Carolina Medicaid copayment amount for optical services is $2.00 per visit as illustrated in the May 2004 general Medicaid Billing/Carolina Access Policies and Procedures Guide.

    Optical providers should not place the $2.00 copayment amount in the block 29 when filing claims to North Carolina Medicaid.

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


    Attention: Personal Care Services Providers

    PCS and PCS-Plus Recoupments

    Effective October 2004, EDS will begin recouping any PCS overpayments since the implementation of PCS-Plus in November 2003. Recoupments will cover dates of service from November 1, 2003 to July 31, 2004 and be automatically deducted from the provider’s checkwrite. Providers who have received PCS payments that exceeded 60 hours (240 units) a month or 3.5 hours a day (14 units) for PCS clients without PCS-Plus prior approval will have these payments recouped. Any providers who have received payments that exceeded 80 hours (or 320 units) a month for Medicaid recipients with PCS-Plus prior approval will have also these payments recouped. As a reminder, PCS is limited to 60 hours and 3.5 hours a day for each eligible Medicaid recipient. Medicaid recipients with DMA prior approval for PCS-Plus are eligible for up to 80 hours a month of PCS without daily limits.

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


    Attention: Physicians, Nurse Practitioners

    Azacitidine, 25 mg (Vidaza, HCPCS Code J9999) – Billing Guidelines

    Effective with date of service October 1, 2004, the N.C. Medicaid program covers azacitidine for injectable suspension (Vidaza). The FDA approved the use of Vidaza for the treatment of the following myelodysplastic syndrome (MDS) subtypes:

    Refractory anemia (RA) or refractory anemia with ringed sideroblasts (RARS) (if accompanied by neutropenia or thrombocytopenia or requiring transfusions) Refractory anemia with excess blasts (RAEB)

    Refractory anemia with excess blasts in transformation (RAEB-T) Chronic myelomonocytic leukemia (CMMoL)

    The recommended starting dose is 75 mg/m2 subcutaneously, daily for seven days, every four weeks.

    The ICD-9-CM diagnosis codes required when billing for Vidaza are:

    V58.1 – admission or encounter for chemotherapy

    AND EITHER

    238.7 – Neoplasm of uncertain behavior of other lymphatic and hematopoietic tissues

    (for anemias associated with the myelodysplastic syndrome)

    OR

    205.10 – Myeloid leukemia, chronic, without mention of remission (for chronic myelomonocytic leukemia)

    Providers must bill J9999, the unclassified drug code for antineoplastic agents, with an invoice attached to the CMS-1500 claim form. An invoice must be submitted with each claim. The paper invoice must indicate the recipient’s name and 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 25 mg. The maximum reimbursement rate per unit is $107.40. Providers must bill their usual and customary charge.

    Add this drug to the list of injectable drugs published in the April 2004 general Medicaid bulletin.

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


    Attention: Physicians, Nurse Practitioners

    Gemtuzumab Ozogamicin, 5 mg. (Mylotarg, J9300) - Billing Guidelines

    Effective with date of service May 1, 2004, the N.C. Medicaid program covers gemtuzumab ozogamicin (Mylotarg) for use in the Physician’s Drug Program when billed with HCPCS code J9300. The FDA indication for Mylotarg is the treatment of acute myeloid leukemia in patients with first relapse who are 60 years of age or older and who are not considered candidates for other cytotoxic chemotherapy. The FDA’s recommended dosing schedule is 9 mg/m2, administered as a 2-hour infusion, with a total of two doses with 14 days between the doses.

    The ICD-9-CM diagnosis codes required when billing for Mylotarg are:

    V58.1 – admission or encounter for chemotherapy

    AND

    A diagnosis code in the range of 205.00 through 205.01 – acute myeloid leukemia

    For Medicaid billing, one unit of coverage is the 5 mg vial. Providers must indicate the number of units given in block 24G on the CMS-1500 claim form. The maximum reimbursement rate per unit is $1,953.94. Providers must bill their usual and customary charge.

    Add this drug to the list of injectable drugs published in the April 2004 general Medicaid bulletin.

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


    Attention: Physicians

    HCPCS Code Changes for the Physician’s Drug Program

    Effective with date of service October 1, 2004, the N.C. Medicaid program covers the individual HCPCS codes for the drugs listed in the following table. Claims submitted for dates of service on or after October 1, 2004 using the unlisted drug codes J3490 or J9999 for these drugs will deny.

    OLD CODE

    DESCRIPTION

    UNIT

    NEW CODE

    DESCRIPTION

    UNIT

    MAXIMUM FEE

    J9999

    Bevacizumab

    (Avastin)

    4 ml

    vial

    S0116

    Bevacizumab

    100mg

    $618.75

    J3490

    Laronidase

    (Aldurazyme)

    2.9

    mg/5ml

    S0158

    Laronidase

    (Aldurazyme)

    .58mg

    $139.95

    J3490

    Agalsidase beta

    (Fabrazyme)

    35mg

    S0159

    Agalsidase beta

    (Fabrazyme)

    35mg

    $4500.00

    J3490

    Risperidone (Risperdal Consta)

    25 mg

    S0163

    Risperidone, long acting (Risperdal Consta)

    12.5 mg

    $124.92

    Note: The unit of coverage and fees on some of these drugs has changed. The units and fees that have changed are in bold print in the above table.

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


    Attention: Physicians

    Physician Management of ESRD - Code Changes and Billing Guidelines

    Effective with date of service October 1, 2004, the Division of Medical Assistance (DMA) has aligned with Medicare in the coverage of HCPCS "G" codes for billing End- Stage Renal Disease (ESRD) related services for recipients receiving dialysis. HCPCS codes G0308 through G0327 may be billed retroactive to January 1, 2004 but they must not be billed in conjunction with CPT codes for the same service. CPT codes 90918 through 90925 will be end-dated effective November 30, 2004. Only the G codes may be billed effective with dates of service on or after December 1, 2004.

    Billing and Documentation Guidelines for Recipients Other Than Home Dialysis

    HCPCS codes G0308 through G0319 are used to bill ESRD related services for recipients who receive dialysis treatment in a setting other than the home. The codes are based on the age of the recipient and the number of face-to-face physician visits per month but not per full month. If a recipient is hospitalized during the month, bill the code that reflects the number of face-to-face visits during the month on days when the patient was not in the hospital (either admitted as an inpatient or in observation status).

    Home Dialysis Recipients - Full Month

    HCPCS codes G0320 through G0323 are used to bill ESRD related services for recipients who receive dialysis treatment in the home. The codes are based on the age of the recipient. The codes are billed for the full month but do not specify the frequency of visits made during the month.

    Home Dialysis Recipients – Partial Month

    HCPCS codes G0324 through G0327 may be billed for the days the recipient is not in the hospital, if a recipient is hospitalized during the month. If the recipient receives dialysis in a dialysis center or other facility during the month, the physician receives the management fee for the appropriate home dialysis code billed in the range G0324 through G3027. HCPCS codes G0308 through G0319 and CPT codes 90935 or 90937 may not be billed even though the physician may see the recipient at the dialysis center.

    Other Guidelines

    Providers must continue to bill monthly ESRD related services once per month on the last day of the month that the service is provided. The physician must document the face-to face visits in the recipient’s record. The documentation should reflect that the recipient was seen and include the decisions that were made relevant to the recipient’s care. The physician must perform some portion of the service in a face-to-face encounter, one or more visits per month, when non-physician practitioners are utilized to provide service. Only one practitioner may receive payment for the monthly ESRD related service codes. The physician who provides the complete assessment, establishes the recipient’s plan of care and provides ongoing management must bill for the monthly service. Providers should bill CPT code 90935 when rendering service to a recipient for whom they are not the primary provider when the recipient is traveling or is seen away from their home service area.

    The following table below includes the HCPCS codes and descriptions.

    Code

    Description

    G0308

    End Stage Renal Disease (ESRD) related services during the course of treatment, for patients under 2 years of age to include monitoring the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month.

    G0309

    End Stage Renal Disease (ESRD) related services during the course of treatment, for patients under 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month.

    G0310

    End Stage Renal Disease (ESRD) related services during the course of treatment, for patients under 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month.

    G0311

    End Stage Renal Disease (ESRD) related services during the course of treatment, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month.

    G0312

    End Stage Renal Disease (ESRD) related services during the course of treatment, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month.

    G0313

    End Stage Renal Disease (ESRD) related services during the course of treatment, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month.

    G0314

    End Stage Renal Disease (ESRD) related services during the course of treatment, for patients between 12 and 19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month.

    G0315

    End Stage Renal Disease (ESRD) related services during the course of treatment, for patients between 12 and 19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month.

    G0316

    End Stage Renal Disease (ESRD) related services during the course of treatment, for patients between 12 and 19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month.

    G0317

    End Stage Renal Disease (ESRD) related services during the course of treatment, for patients 20 years of age and over; with 4 or more face-to-face physician visits per month.

    G0318

    End Stage Renal Disease (ESRD) related services during the course of treatment, for patients 20 years of age and over; with 2 or 3 face-to-face physician visits per month.

    G0319

    End Stage Renal Disease (ESRD) related services during the course of treatment, for patients 20 years of age and over; with 1 face-to-face physician visit per month.

    G0320

    End stage renal disease (ESRD) related services for home dialysis patients per full month; for patients under two years of age to include monitoring for adequacy of nutrition, assessment of growth and development, and counseling of parents

    G0321

    End stage renal disease (ESRD) related services for home dialysis patients per full month; for patients two to eleven years of age to include monitoring for adequacy of nutrition, assessment of growth and development, and counseling of parents.

    G0322

    End stage renal disease (ESRD) related services for home dialysis patients per full month; for patients 12 to 19 years of age to include monitoring for adequacy of nutrition, assessment of growth and development, and counseling of parents.

    G0323

    End stage renal disease (ESRD) related services for home dialysis patients per full month; for patients twenty years of age and older.

    G0324

    End stage renal disease (ESRD) related services for home dialysis (less than full month), per day; for patients under two years of age.

    G0325

    End stage renal disease (ESRD) related services for home dialysis (less than full month), per day; for patients between two and 11 years of age.

    G0326

    End stage renal disease (ESRD) related services for home dialysis (less than full month), per day; for patients between 12 and 19 years of age.

    G0327

    End stage renal disease (ESRD) related services for home dialysis (less than full month), per day; for patients 20 years of age and over.

    Refer to the following table when billing for ESRD related services.

    For dates of service January 1, 2004 through November 30, 2004, Bill

    For dates of service on or after December 1, 2004, Bill

    90918 or G0308, G0309, G0310

    G0308 or G0309 or G0310

    90919 or G0311, G0312, G0313

    G0311or G0312 or G0313

    90920 or G0314, G0315, G0316

    G0314 or G0315 or G0316

    90921 or G0317, G0318, G0319

    G0317 or G0318 or G0319

    G0320

    G0320

    G0321

    G0321

    G0322

    G0322

    G0323

    G0323

    90922 or G0324

    G0324

    90923 or G0325

    G0325

    90924 or G0326

    G0326

    90925 or G0327

    G0327

    Billing Examples:

    Dialysis

    Site

    Number of Face-to-Face Visits

    Recipient Age

    Recipient Hospitalized

    Bill HCPCS G Code

    Number of Units

    Other than home

    4 or more

    Under 2 years

    No

    G0308

    1

    Other than home

    2

    12-19 years

    Yes

    G0315

    1

    Home

    Any number

    Under 2 years

    No

    G0320

    1

    Home

    Bill the number of days recipient was not in the hospital

    12-19 years

    Yes. 10 days of a 30 day month

    G0327

    20

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


    Attention: Physicians, Dentists, Chiropractors, Osteopaths, Optometrists and Podiatrists

    Provider Enrollment Directly through DMA

    In the near future, the practitioners listed above who are seeking initial enrollment or updating information on their provider status in the N.C. Medicaid program will access application forms on the DMA’s website. Effective with this implementation, providers will no longer enroll with Blue Cross Blue Shield of North Carolina to enroll as a Medicaid provider. Upcoming bulletins will provide more information regarding this change.

    Angela Floyd, Provider Services
    DMA, 919-857-4015


    Attention: All Providers

    Clinical Coverage Policies

    The following new or amended clinical coverage policies are now available on DMA’s website:

    1A–12 Breast Surgeries
    4A Dental Services
    4B Orthodontic Services
    5 – Durable Medical Equipment
    8A Area Mental Health, Developmental Disabilities, and Substance Abuse Services

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

    Gina Rutherford, Clinical Policy and Programs Section
    DMA, 919-857-4020


    Attention: Prescriber and Pharmacy Providers

    Synagis and Respigam Forms

    For the upcoming RSV season, Synagis will not require prior approval (PA) for Medicaid recipients. However, the responsibility for appropriate usage for both Synagis and Respigam will be placed on prescribers and pharmacy providers. PA may be resumed at any time if the Division of Medical Assistance (DMA) suspects inappropriate drug utilization. The North Carolina Physicians Advisory Group (NCPAG) has met with specialists in the state and members of the Pediatric Red Book committee to develop three Synagis usage criteria forms. Please ensure that the person completing the forms has verified that the conditions exist and are accurate. If a patient does not fit the criteria explicitly for category 1, 2 or 3, and you still wish to prescribe Synagis, you must submit your request to DMA on the Request for Medical Review for Synagis Outside of Criteria form and fax the request to DMA at 919-715-1255.

    The start of the Synagis season is October 15, 2004. No more than 5 monthly doses of Synagis or RespiGam can be obtained by using these forms. The number of doses should be adjusted if an infant received the first dose prior to a hospital discharge. Delays in getting a request processed can occur if the patient does not have a Medicaid identification number or the form is not complete.

    The criteria forms must be signed by the prescriber and submitted to the pharmacy distributor of choice.

    The Request for Medical Review for Synagis Outside of Criteria form must be signed by the prescriber and submitted to DMA.

    Please refer to the following guidelines when submitting a request:

    Criteria 1a through 1d – Infants (24 months or younger) with CLD (Chronic Lung Disease), CF (Cystic Fibrosis), CHD (Congenital Heart Disease), or Severe Immunodeficiency

    Criteria 2a and 2b – Infants born at 32 weeks, 0 days gestation or earlier without CLD

    Once a child qualifies for initiation of prophylaxis at the start of the RSV season, administration should continue throughout the season and not stop at the point that the infant reaches 6 or 12 months of age.

    Criteria 3 – Infants Born at 32 Weeks, 1 day – 35 Weeks, 0 day Gestation without CLD

    High-risk infants should be kept away from crowds and from situations in which exposure to infected individuals cannot be controlled. Participation in child care should be restricted during the RSV season for high-risk infants whenever feasible.

    Request for Medical Review for Synagis Outside of Criteria

    This form will be used for patients who do not explicitly meet criteria 1, 2 or 3, whose providers still wish to prescribe Synagis. Please fill out the requested information, and fax to DMA at 919-715-1255.

    Synagis Policies and Procedure

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


    Proposed Clinical Coverage Policies

    In accordance with Session Law 2003-284, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA’s website. To submit a comment related to a policy, refer to the instructions on the website. Providers without Internet access can submit written comments to the address listed below.

    Gina Rutherford
    Division of Medical Assistance
    Clinical Policy Section
    2501 Mail Service Center
    Raleigh, NC 27699-2501

    The initial comment period for each proposed policy is 45 days. An additional 15-day comment period will follow if a proposed policy is revised as a result of the initial comment period.


    Checkwrite Schedule

    October 5, 2004

    November 2, 2004

    December 7, 2004

    October 12, 2004

    November 9, 2004

    December 14, 2004

    October 19, 2004

    November 16, 2004

    December 22, 2004

    November 24, 2004

    Electronic Cut-Off Schedule

    October 1, 2004

    October 29, 2004

    December 3, 2004

    October 8, 2004

    November 5, 2004

    December 10, 2004

    October 15, 2004

    November 12, 2004

    December 17, 2004

     

    November 19, 2004

     

    2004 Checkwrite Schedule

    Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite. Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.

     

    _____________________
    _____________________
    Gary H. Fuquay, Director
    Cheryll Collier
    Division of Medical Assitance
    Executive Director
    Department of Health and Human Services
    EDS

     

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