|
|
Checkwrite Schedule
EPSDT Applicability to Medicaid Services and Providers
Proposed Clinical Coverage Policies
NPI:
All Providers:
Certified Nurse Midwives:
Durable Medical Equipment Providers:
Enhanced Mental Health Services Providers:
HIV Case Management Providers:
Home Health Agencies:
Hospitals:
Local Management Entities:
Nurse Practitioners:
Nursing Facility Providers:
Outpatient Behavioral Health Service Providers:
Physicians:
Professional (CMS-1500/837P) Billers:
The Automated Voice Response (AVR) System now allows a provider to query by entering either a Medicaid Provider Number (MPN) or a National Provider Identifier (NPI). If an NPI is entered and the response is MPN-specific, such as claim status or prior approval information, the provider will have to choose the appropriate MPN from a list. If a provider has more than 15 MPNs associated with 1 NPI, the specific MPN related to the query may not be included. The provider must hang up, call again and query using the MPN. Providers can reach the AVR System by calling 1-800-723-4337.
NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!
EDS, 1-800-688-6696 or 919-851-8888
Attention: HIV Case Management Providers
N.C. Medicaid strongly recommends the use of the taxonomy code 2084P0015X for claims billed for HIV case management services. Taxonomy codes are used for claims processing only. Providers are not required to change the taxonomy code that was previously reported to NPPES or to DMA Provider Enrollment. Simply begin submitting the new taxonomy code on claims.
NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!
EDS, 1-800-688-6696 or 919-851-8888
N.C. Medicaid strongly recommends the use of the taxonomy codes 364SP0813X or 310500000X for all claims billed for head-level nursing facility services and 2278S1500X for vent-level nursing facility services. Taxonomy codes are used for claims processing only. Providers are not required to change the taxonomy code that was previously reported to NPPES or to DMA Provider Enrollment. Simply begin submitting the new taxonomy code on claims.
NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!
EDS, 1-800-688-6696 or 919-851-8888
It was previously announced that the PASARR segment of the Medicaid Uniform Screening Tool (MUST) would be implemented on September 12, 2008. DMA has decided to delay implementation of the PASARR segment of the screening tool to November 3, 2008, to ensure that the user community has a smooth transition to the new system.
Why Is DMA Delaying Implementation?
Numerous concerns
have been expressed by the provider community regarding the MUST registration
process. To address these concerns, a pre-registration period, which will
precede the implementation date indicated above, will be offered. The
focus of the pre-registration period will be to assist providers with completing
the registration process. The dates of the pre-registration period will
be announced on the MUST website as
well as by e-mail. Check the MUST website often for announcements.
What Can I Do To Prepare?
Providers should
acclimate themselves to the registration process by reviewing the Getting
Started page on the MUST website. This page will also list the date of the pre-registration
period as well as detailed instructions on how to register your organization.
What If I Already Submitted My Organization
Registration Form?
For those organizations
that have already submitted the Confidentiality and Security Agreement,
as well as the Organization Registration form, please be assured that those
forms will be retained and will be processed on the pre-registration start
date.
In order for these forms to be processed and approved, providers must complete the NCID registration process by assigning themselves to the USP Application Group. After completing this step, providers will also need to login and complete the user exam. Once both of these steps have been completed, registration can be approved. Please be sure to follow the instructions located on the Getting Started page.
What If I Need Help?
Help and support
is available from the MUST website. Contact information for both NCID
registration assistance and MUST assistance can be found on the new Help
and Support page. The
ability to provide Remote Assistance has also been added. Please be sure
to read about it on the Help
and Support page.
Training
Two additional
half-day training sessions for the PASARR segment of the new N.C. Uniform
Screening Program (USP) and the N.C. Medicaid Uniform Screening Tool have
been scheduled for October 14, 2008, in Greensboro at the site listed below.
Greensboro
October 14, 2008
Embassy Suites – Greensboro Airport
204 Centreport Dr.
Greensboro NC 27409
336-668-4535
The morning training session begins at 8:30 a.m. and ends at 12:00 noon. The afternoon session begins at 1:00 p.m. and ends at 4:30 p.m. Providers should arrive at least 30 minutes prior to each session to complete the registration process. Because meeting room temperatures vary, dressing in layers is strongly advised.
Pre-registration (using the online registration form) is required. A valid e-mail address is required to send a confirmation notice to each registered participant.
Training materials are available from the MUST website. Please print the Provider Training Manual and bring it with you to the training. Although an online training will also be available, attendance at a regional training session is strongly recommended.
Directions to the MUST Training Sessions
GREENSBORO
Embassy Suites – Greensboro Airport
Traveling North
from Charlotte
Take I-85 North
to I-40 West. Take Exit 210 (Airport exit). Turn right at the bottom
of the exit onto Hwy 68 North. Go to the first stoplight. Turn left onto
Triad Center Drive. The hotel driveway is immediately on the left.
Traveling East
on I-40
Take I-40 East
to Exit 210 (Airport exit). Turn left at the light onto Hwy 68 North. Go
to second stoplight. Turn left onto Triad Center Drive. The hotel driveway
is immediately on the left.
EDS, 1-800-688-6696 or 919-851-8888
The list of ICD-9-CM diagnosis codes that are not subject to the annual visit limitation has been revised.
EDS, 1-800-688-6696 or 919-851-8888
Attention: All Providers
The N.C. Medicaid Program reimburses for vaccines in accordance with guidelines from the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP). Information pertinent to influenza disease, vaccine, and recommendations regarding those who should receive vaccine for the 2008/09 flu season can be found in the July 17, 2008, Morbidity and Mortality Weekly Report (MMWR). Additional information regarding the 2008/09 flu season is available from the CDC's Seasonal Flu web page.
The 2008 recommendations include four principal changes or updates:
N.C. Universal Childhood Vaccine Distribution Program/Vaccine for Children (UCVDP/VFC)
The N.C. Immunization Branch distributes childhood vaccines to local health departments, hospitals, and private providers under UCVDP/VFC guidelines. UCVDP/VFC influenza vaccine is available at no charge to providers for children who meet one of the following criteria:
For the 2008/09 influenza season, these criteria effectively make all Medicaid children 6 months through 18 years of age eligible for state-supplied vaccine.
Please note that children 6 months through 8 years of age who have not received influenza vaccine in previous years, or who received only one dose in their first year of vaccination, should receive two doses, 30 days apart. The recommended dosage for children 6 months through 35 months of age is 0.25 ml per dose. The recommended dosage for children 3 years of age or older is 0.5 ml per dose.
Billing/Reporting Influenza Vaccines
The following
tables indicate the vaccine codes that can be either reported or billed
for an influenza vaccine, depending on the age of the recipient. The tables
also indicate the administration codes that can be billed, depending on
the age of the recipient.
Note: The information in the following tables is not detailed billing guidance. Specific information on billing all immunization administration codes can be found in the April 2008 Special Bulletin, Health Check Billing Guide 2008, on pages 20 through 32.
Table 1: Influenza Billing Codes for Recipients Less Than 19 Years of Age
|
90655 |
Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use |
|
90656 |
Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use |
|
90657 |
Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use |
|
90658 |
Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use |
|
90660 |
Influenza virus vaccine, live, for intranasal use (FluMist) |
|
Administration CPT Code(s) to Bill |
CPT Code Description |
|
Vaccine CPT Code to Report |
CPT Code Description |
|
90465EP |
Immunization administration under 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); when the physician counsels patient/family; first injection (single or combination vaccine/toxoid), per day |
|
90466EP |
Each additional injection (single or combination vaccine/toxoid), per day (list separately in addition to code for primary procedure) Note: Providers may bill more than one unit of 90466EP as appropriate. |
|
90467EP |
Immunization administration under age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day Note: Billing CPT code 90468 for a second administration of an intranasal/oral vaccine when physician counseling was performed is not applicable at this time. |
|
90468EP |
Each additional administration (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure) Note: Billing CPT code 90468 for a second administration of an intranasal/oral vaccine is not applicable at this time. |
|
90471EP |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) |
|
90472EP |
Each additional vaccine (single and combination vaccine/toxoid) (List separately in addition to code for primary procedure). Note: Providers may bill more than one unit of 90472EP as appropriate. |
|
90473EP |
Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid). Note: Billing CPT code 90474 for a second administration of an intranasal/oral vaccine is not applicable at this time. |
|
90474EP |
Each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure) Note: Billing CPT code 90474 for a second administration of an intranasal/oral vaccine is not applicable at this time |
Table 2: Influenza Billing Codes for Recipients 19 and 20 Years of Age
Use the following codes to bill Medicaid for an influenza vaccine purchased and administered to recipients 19 through 20 years of age.
|
Vaccine CPT Code to Bill |
CPT Code Description |
|
90656 |
Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use |
|
90658 |
Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use |
|
90660 |
Influenza virus vaccine, live, for intranasal use (FluMist) |
|
Administration CPT Code(s) to Bill |
CPT Code Description |
|
90471EP |
Immunization administration; (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) |
|
90472EP |
Each additional vaccine (single and combination vaccine/toxoid) (list separately in addition to code for primary procedure |
|
90473EP |
Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) |
|
90474EP |
Each additional vaccine (single and combination vaccine/toxoid) (list separately in addition to code for primary procedure) |
Table 3: Influenza Billing Codes for Recipients 21 Years of Age and Older
Use the following codes to bill Medicaid for an influenza vaccine purchased and administered to recipients 21 years of age and older.
|
Vaccine CPT Code to Bill |
CPT Code Description |
|
90656 |
Influenza virus vaccine, split virus, preservative free, for use in individuals 3 years and above, for intramuscular use |
|
90658 |
Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use |
|
Administration CPT Code(s) to Bill |
CPT Code Description |
|
90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) |
|
90472 |
Each additional vaccine (single and combination vaccine/toxoid) (list separately in addition to primary procedure) |
For a recipient 21 years of age or older receiving an influenza vaccine, an evaluation and management (E/M) code cannot be reimbursed to any provider on the same day that injection administration fee codes (90471 or 90471 and 90472) are reimbursed, unless the provider bills an E/M code for a separately identifiable service by appending modifier 25 to the E/M code.
Note: For federally qualified health centers and rural health clinics, influenza is one of the four vaccines that may be billed to Medicaid for recipients 21 years of age and older. The cost of the vaccine and the administration code should be included on the cost report.
EDS, 1-800-688-6696 or 919-851-8888
The following new or amended clinical coverage policies are now available on DMA’s Clinical Coverage Policies web page:
These policies
supersede previously published policies and procedures. Providers may
contact EDS at
1-800-688-6696 or 919-851-8888 with billing questions.
Clinical Policy and Programs
DMA, 919-855-4260
The Deficit Reduction Act of 2005 (DRA) includes provisions regarding state collection and submission of data for the purpose of collecting Medicaid drug rebates from manufacturers for all Professional and Institutional claims. The DRA 2005 does not exclude 340B drugs; therefore, all providers must also meet these requirements.
Effective with date of processing November 21, 2008, the N.C. Medicaid Program will implement the use of the UD modifier for claims with dates of service on or after December 28, 2007. In order for providers to identify 340B drugs that have been dispensed, the UD modifier must be utilized on the claim detail. This will allow N.C. Medicaid to identify primary and secondary claim details that are for 340B drugs and exclude these claim details from the rebate collection process. The UD modifier should be used on the CMS-1500/837P and the UB-04/837I claim forms, with the applicable HCPCS Level II procedure code and National Drug Code (NDC) with NDC units used to properly identify 340B drugs. The UD modifier should be used only in this circumstance.
All non-340B drugs should be billed without the UD modifier using the applicable HCPCS and NDC pair with the NDC units. When billing for compounds or mixtures, list 340B drugs in a separate detail from the non-340B drugs in the same compound/mixture.
Please refer to the paper claim examples showing the location of the UD modifier.
Claim Examples and the UD Modifier
For information related to 837 transactions please refer to the X12 Implementation Guides and N.C. Medicaid Companion Guides.
For additional information, refer to the October 2008 Special Bulletin, National Drug Code Implementation, Phase III, and also to the November 2007 National Drug Code seminar presentation.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service October 10, 2008, the N.C. Medicaid Outpatient Pharmacy Program will utilize a State-determined upper payment limit for select single-source specialty drugs that cost in excess of $1,500 per month. This is in compliance with a N.C. General Assembly mandate in Session Law 2008-107, Section 10.10(e). Specialty drugs in the following therapy categories will be affected:
The list of specialty drugs that are affected by this upper payment limit will be updated on a quarterly basis. This list is available on DMA’s New Enhanced Specialty Discount on Single-Source Specialty Drugs web page.
EDS, 1-800-688-6696 or 919-851-8888
Attention: All Providers
DMA is currently making changes for coverage of cytogenetic studies. The proposed policy , which has been reviewed by the N.C. Physician Advisory Group (NCPAG),will be available for comment on DMA’s Proposed Clinical Coverage Policies web page.
Providers will be notified in a future general Medicaid Bulletin when the policy is finalized.
EDS, 1-800-688-6696 or 919-851-8888
Effective November 1, 2008, the N.C. Medicaid Program will begin offering Medicaid coverage to working individuals with disabilities. Health Coverage for Workers with Disabilities (HCWD) will allow individuals with disabilities to work or increase their hours of work and protect their Medicaid eligibility through higher income and resource limits and a less-restrictive disability determination.
Effective November 1, 2008, the income limit will be 150 percent of the federal poverty level (FPL), currently $1,300 per month for a one-person household. Effective May 1, 2009, the limit will increase to 200 percent of the FPL, currently $1,734 per month for one person.
HCWD recipients will receive a blue Medicaid card and the same benefits as Medicaid recipients with full benefit coverage.
Individuals who think they may qualify are encouraged to apply at their county department of social services.
Medicaid Eligibility Unit
DMA, 919-855-4000
On November 3, 2008, the N.C. Medicaid Outpatient Pharmacy Program will require prior authorization (PA) on the antimalarial drug Qualaquin. Coverage will be provided when the drug is used for the treatment of malaria.
Prescribers can request PA by contacting ACS at 866-246-8505 (telephone) or 866-246-8507 (fax). The criteria and PA request form for this medication will be available on the N.C. Medicaid Enhanced Pharmacy Program website.
EDS, 1-800-688-6696 or 919-851-8888
On November 3, 2008, the N.C. Medicaid Outpatient Pharmacy Program will add the following indications to the prior authorization (PA) criteria for coverage of botulinum toxin Type A (Botox):
The following indication will be added to the PA criteria for coverage of botulinum toxin Type B (Myobloc):
Prescribers can request PA by contacting ACS at 866-246-8505 (telephone) or 866-246-8507 (fax). The updated criteria and PA request form for this medication will be available on the N.C. Medicaid Enhanced Pharmacy Program website.
EDS, 1-800-688-6696 or 919-851-8888
Basic Medicaid seminars are scheduled for October and November 2008. Registration information, a list of dates, and site locations for the seminars are listed below.
Seminars will begin at 9:00 a.m. and will end at 12:00 noon. Providers are encouraged to arrive by 8:45 a.m. to complete registration. Lunch will not be provided at the seminars. Because meeting room temperatures vary, dressing in layers is strongly advised.
Because of limited seating, registration is limited to two staff members per office. Pre registration is required. Unregistered providers are welcome to attend if space is available. Providers may register for the seminars by completing and submitting the Online Registration Form. Providers may also complete the paper Seminar Registration Form and submit it by fax to the number listed on the form. Please indicate on the registration form the session that you plan to attend.
The Basic Medicaid Billing Guide will be used as the primary training document for the seminar. Please review and print the October 2008 version and bring it to the seminar.
EDS will discuss and review basic N.C. Medicaid topics while providing an overall understanding of the N.C. Medicaid Program. New and established billers are encouraged to attend these training sessions.
|
Morganton |
Williamston |
|
Directions to the Basic Medicaid Seminars:
MORGANTON
I-40 West
From
I-40 East
From
Hwy. 18 from Lenoir
Turn left onto
Hwy. 64 from Rutherfordton
Driving into Morganton, cross over I-40.
WILLIAMSTON
Traveling East on US 64
Take US 64 West to the intersection at McDonald’s in Williamston. Turn left
on the Highway 13/17 Bypass. The name will change to Old Highway 64 Bypass. Continue
approximately 2.3 miles and turn left on
Traveling West on US 64
Take US 64 East to exit 512 (
Traveling North on US 13/US 17
Take US 13/US 17 South to Williamston. Continue to follow
Take I-440 to US 401 South/S. Saunders Street (exit 298). Stay to the right
to continue on US 401 South/Fayetteville Road. Continue to travel on US
401 South/Fayetteville Street towards Fuquay-Varina. The college is located
on the left approximately 1.0 mile from the intersection with NC 1010. Turn
left onto
EDS, 1-800-688-6696 or 919-851-8888
Independent Practitioner Program seminars are scheduled for November 2008. Registration information, a list of dates, and site locations for the seminars are listed below.
The seminars in Hickory and Wilmington will begin at 9:00 a.m. and will end at 12:00 noon. Providers are encouraged to arrive by 8:45 a.m. to complete registration. The seminar in Raleigh will begin at 1:00 p.m. and will end at 3:00 p.m. Providers are encouraged to arrive by 12:45 p.m. to complete registration. Lunch will not be provided at the seminars. Because meeting room temperatures vary, dressing in layers is strongly advised.
Because of limited seating, registration is limited to two staff members per office. Pre registration is required. Unregistered providers are welcome to attend if space is available. Providers may register for the seminars by completing and submitting the Online Registration Form. Providers may also complete the paper Seminar Registration Form and submit it by fax to the number listed on the form. Please indicate on the registration form the session that you plan to attend.
The October 2008 Special Bulletin, Independent Practitioner Services, will be used as the primary training document for the seminar. Please print the Special Bulletin and bring it to the seminar.
|
Raleigh 1:00 p.m. to 3:00 p.m. Wake Technical
Community College 919-866-5500 |
Hickory 9:00 a.m. to 12:00 noon Lenoir-Rhyne University 828-328-1741 |
Wilmington 9:00 a.m. to 12:00 noon Coastline Convention
Center 910-763-2800 |
Directions to the Independent Practitioner Seminars
RALEIGH
Wake Technical Community College
Take I-440 to US 401 South/S. Saunders Street (exit 298). Stay to the right to continue on US 401 South/Fayetteville Road. Continue to travel on US 401 South/Fayetteville Street through Fuquay-Varina. The college is located on the left approximately 1 mile from the intersection with NC 1010. Turn left onto Chandler Ridge Circle. Visitor parking is on the left.
HICKORY
Lenoir-Rhyne University
Traveling on I-40
Take Exit 125
(Lenoir-Rhyne University). Turn north onto Lenoir-Rhyne Boulevard. Pass
the Tripps and Rock-ola restaurants and go through three lights. At the
fourth stoplight turn left onto Tate Boulevard. At the next stoplight,
turn right onto US 127 North. At the fourth stoplight turn right. Go 0.4
mile and turn left onto Stasivich Place. Immediately turn right into the
parking lot. Visitor parking is directly across the street from the admissions
building in reserved parking spaces.
WILMINGTON
Coastline Convention Center
Traveling East
on I-40
Take I-40 East
toward Wilmington. As you approach Wilmington, look for the sign for MLK
Parkway/NC 74 West/Downtown. Turn right onto MLK Parkway. Continue on
this route toward downtown Wilmington. The road becomes Third Street. Follow
Third Street for five blocks until you reach Red Cross Street. Turn right
onto Red Cross Street and continue for two blocks. Turn right onto Nutt
Street. The entrance to the Coastline Convention Center is the second
driveway on the left.
Traveling South
on US 17
As you approach
Wilmington, US 17 becomes Market Street. Continue on Market Street until
you see the sign for MLK Parkway/NC 74 West/Downtown. Take NC 74 West
(MLK Parkway) toward downtown Wilmington (approximately 4 miles). Turn
right onto Red Cross Street and continue for two blocks. Turn right onto
Nutt Street. The entrance to the Coastline Convention Center is the second
driveway on the left.
Traveling North
on US 17 or NC 74/76
After crossing
the Cape Fear Memorial Bridge into Wilmington, turn left at the first stoplight
onto Third Street. Turn left onto Red Cross Street. At the bottom of
the hill (approximately 3 blocks), turn right onto Nutt Street. The entrance
to the Coastline Convention Center is the second driveway on the left.
EDS, 1-800-688-6696 or 919-851-8888
The list of standard national codes used on the Electronic Remittance Advice (ERA) has been cross-walked to EOB codes as an informational aid to adjudicated claims listed on the Remittance and Status Report (RA). An updated version of the list is available on DMA’s HIPAA Web Page.
With the implementation of standards for electronic transactions mandated by HIPAA, providers now have the option to receive an ERA in addition to the paper version of the RA.
The EOB codes that providers currently receive on a paper RA are not used on the ERA. Because the EOB codes on the paper RA provide a greater level of detail on claim denials, all providers will continue to receive the paper version of the RA, even if they choose to receive the ERA transaction. The list is current as of the date of publication. Providers will be notified of changes to the list through the general Medicaid bulletin.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service January 1, 2008, changes were made to Clinical Coverage Policy 5A, Durable Medical Equipment, to reflect the correction of the quantity limitations for HCPCS code B4088 (gastrostomy/jejunostomy tube) from 2 per month to 4 per year. This change was made to correct a typographical error; it does not reflect a change in actual coverage. Please refer to Attachment E in the policy for more details.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of request September 1, 2008, Children’s Special Health Services no longer authorizes payment for ramps, tie downs, car seats, and vests.
These items are not included in the durable medical equipment covered by Medicaid, nor are they covered under Early Periodic Screening, Diagnostic, and Treatment services, which cover medical equipment and supplies suitable for use in the home for Medicaid recipients under the age of 21. However, if the recipient is covered under a Medicaid waiver, these items may be considered.
EDS, 1-800-688-6696 or 919-851-8888
DMA has submitted a State Plan Amendment (SPA) to CMS for purposes of implementing the Diagnostic Related Groups (DRG) Grouper 25. At this time, SPA approval has not been received from CMS. Therefore, DMA will not be able to implement the new grouper on October 1, 2008. Additionally, new provider rates that were to be effective October 1, 2008, will also be delayed until such time as the SPA is approved. Until CMS approval is received, hospital inpatient claims for dates of service on or after October 1, 2008, will continue to be paid using the current grouper version and hospital specific rates.
Hospital providers can expect a future status update in upcoming general Medicaid Bulletins. The North Carolina Hospital Association will be receiving periodic updates on the approval and implementation status.
This year’s DRG Grouper implementation represents significant changes in DRG descriptions as well as the addition of 286 new DRGs. Specifically, earlier versions of the DRG did not include delineation of care to premature neonates and other newborns, which required special State DRG designation. The current DRG Grouper 25 now includes the relevant delineation of care for this population, and special State designation is no longer required. Other changes with this implementation include assignment of new psychiatric inpatient and rehabilitation service codes as well as the new list of 25 transfer DRGs.
The following chart highlights the significant changes mentioned above.
|
Grouper Version 24 |
Grouper Version 25 |
|
|---|---|---|
|
Neonates/Newborns |
385, 801, 802, 803, 804, 805, 810, 389, 390, and 391 |
790, 791, 792, 793, 794, and 795 |
|
Psychiatric Inpatient |
424, 425, 426, 427, 428, 429, 430, 431, 432, 433, 434, 435, 436, 437, 521, 522, and 523 |
876, 880, 881, 882, 883, 884, 885, 886, 887, 894, 895, 896, and 897 |
|
Transfers |
14, 113, 209, 210, 211, 236, 263, 264, 429, and 483 |
28, 29, 30,40, 41, 42, 219, 220, 221, 447, 478, 479, 480, 481, 482, 492, 493, 494, 500, 501, 502, 515, 516, 517, and 956 |
|
Rehabilitation |
462 |
945 and 946 |
Please note that “Present on Admission (POA)” editing will not be incorporated with this system upgrade. The presence of POA information on a claim will not impact claim adjudication until DRG Grouper Version 26 is implemented next year.
Claims adjudicated
after October 1, 2008, under DRG Grouper 24 will automatically be reprocessed
once
DRG Grouper 25 is implemented. Providers should not resubmit their claims.
EDS, 1-800-688-6696 or 919-851-8888
Effective with dates of service July 1, 2008, the guidance for behavioral health practitioners supervised by a physician has been modified for services provided to a recipient with Medicaid only. The physician does not have to be present in the office where the practitioner is providing the service. However, the physician must be readily accessible by phone or pager and able to return to the office if the recipient’s condition requires it.
Practitioners must continue to follow these guidelines for services provided “Incident To” the physician:
1. The physician has initially seen the patient.
2. The physician must be able to provide evidence of management of the patient’s care.
3. The physician employs the practitioner or the practitioner is employed by the same entity that employs the physician.
When services are provided to a dually eligible Medicare/Medicaid recipient, the physician must provide direct supervision. Direct supervision is defined as follows:
1. The physician has initially seen the patient.
2. The physician should be present in the office where the practitioner is providing the service and immediately accessible in the event of an emergency.
3. The physician must be able to provide evidence of management of the patient’s care.
Please refer to the May 2005 Special Bulletin, Expansion of Provider Types for Outpatient Behavioral Health Services Phase II, for additional information.
Behavioral Health Services
DMA, 919-855-4290
Effective with date of service January 1, 2008, the N.C. Medicaid Program covers hemin (Panhematin) when billed with HCPCS procedure code J1640. Panhematin is indicated for the treatment of recurrent attacks of acute intermittent porphyria (AIP), a rare genetic disorder.
Panhematin should be used only after an appropriate period of alternate therapy (carbohydrate loading) has been tried. It is intended to prevent porphyria attacks from becoming critical; it is not intended to repair neuronal damage resulting from attacks.
Panhematin should be administered under the supervision of a physician experienced in the management of porphyrias. Panhematin is administered as an intravenous infusion containing a dose of 1 to 4 mg/kg/day of hematin over a period of 10 to 15 minutes for 3 to 14 days, based on clinical signs. In more severe cases, this dose may be repeated no earlier than every 12 hours. No more than 6 mg/kg in any 24-hour period should be given. Safety and effectiveness for use in children younger than 16 years of age has not been established.
For Medicaid Billing
The Physician’s Drug Program Fee Schedule is available on the Fee Schedule web page on DMA’s website.
EDS, 1-800-688-6696 or 919-851-8888
The N.C. Medicaid Program covers oxaliplatin (Eloxatin) for the treatment of patients with metastatic carcinoma of the colon or rectum whose disease has recurred or progressed during, or within six months of, completion of first-line therapy with the combination regimen of 5-fluorouracil, leucovorin, and irinotecan.
DMA is changing the coverage of Eloxatin to include malignant neoplasm of the pancreas, effective with date of service December 1, 2007.
For Medicaid Billing
The ICD-9-CM diagnosis codes required for billing Eloxatin are
The Physician’s Drug Program Fee Schedule is available on the Fee Schedule web page on DMA’s website.
Providers who received claim detail denials related to the diagnosis of malignant neoplasm of the pancreas for dates of service December 1, 2007, and after, may resubmit the denied charges as a new claim (not as an adjustment request) for processing.
EDS, 1-800-688-6696 or 919-851-8888
The effective date for the following rate decreases that were published in the September 2008 general Medicaid bulletin has been changed from October 1, 2008, to January 1, 2009.
|
Service Code |
Service Description |
Service Unit |
Current Rate |
New Rate |
|---|---|---|---|---|
|
H0020 |
Opioid Treatment |
per event |
$ 19.17 |
$ 18.74 |
|
H0040 |
Assertive Community Treatment Team |
per event |
323.98 |
301.35 |
|
S9484 |
Professional Treatment Svcs in Facility Based Crisis |
per hour |
18.78 |
17.99 |
The effective date for the following rate increases remains October 1, 2008.
|
Service Code |
Service Description |
Service Unit |
Current Rate |
New Rate |
|
H0015 |
Substance Abuse (SA) Intensive Outpatient Program |
per diem |
$131.93 |
$148.52 |
|
H2035 |
SA Comprehensive Outpatient Treatment Program |
per hour |
45.76 |
51.20 |
|
H0012 HB |
SA Non-Medical Community Residential Treatment |
per diem |
145.50 |
175.91 |
|
H0013 |
SA Medically Monitored Community Res. Treatment |
per diem |
265.25 |
272.99 |
|
H0010 |
Non-Hospital Medical Detoxification |
per diem |
325.88 |
367.57 |
|
H0014 |
Ambulatory Detoxification |
per 15 min |
20.43 |
23.99 |
|
H2011 |
Mobile Crisis Management |
per 15 min |
31.79 |
34.37 |
|
T1023 |
Diagnostic Assessment MH/SA |
per event |
169.06 |
261.13 |
|
H0035 |
Partial Hospitalization |
per diem |
121.69 |
149.38 |
|
H2017 |
Psychosocial Rehabilitation |
per 15 min |
2.90 |
3.03 |
|
H2015 HT |
Community Support Team (MS/SA) |
per 15 min |
16.52 |
17.26 |
Fee schedules are available on DMA’s Behavioral Health Services Fee Schedule web page. Providers must always bill their usual and customary charges.
Rate Setting
DMA, 919-855-4200
DMA hereby provides notification of its amendment to the Medicaid State Plan. The change will provide reimbursement to cover the allowable portion of the Medicare payment reduction for outpatient psychiatric crossover claims for dually-eligible recipients of Medicare and Medicaid, up to 95 percent of the Medicare rate. This change is subject to existing eligibility restrictions.
This amendment will be implemented with an effective date of April 1, 2008. The implementation is subject to necessary system modifications. Please refer to future general Medicaid Bulletins for an implementation date. Providers should continue to file claims utilizing the current guidelines.
Rate Setting
DMA, 919-855-4200
CPT procedure code 76813 (ultrasound, pregnant uterus, real time image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation) is covered by N.C. Medicaid effective with date of service January 1, 2007.
Systems issues occurred that may have caused some claims billed with CPT procedure codes 76801, 76805, 76811, or 76815 to be denied when they were billed on the same date of service as CPT procedure code 76813. Changes have been made to the claims payment system to correct the problem. Claims that were denied with EOB 0613 (OB ultrasound allowed once per day, same provider) that have not exceeded the timely filing limit may be refiled as a new claim (not as an adjustment request) for processing.
EDS, 1-800-688-6696 or 919-851-8888
The Deficit Reduction Act of 2005 (DRA) includes provisions regarding state collection and submission of data for the purpose of collecting Medicaid drug rebates from manufacturers for all Professional and Institutional claim forms.
Effective with date of processing November 21, 2008, for claims with dates of service on or after December 28, 2007, the N.C. Medicaid Program will require providers to list the 11-digit National Drug Code (NDC) with NDC units in addition to the HCPCS codes and units on all professional claims that cross over from Medicare or are submitted directly to Medicaid by providers for all drugs administered by providers in offices, clinics, or outpatient facilities for dually eligible recipients. Claims will continue to be adjudicated in the same manner as before this requirement.
For additional information, refer to the October 2008 Special Bulletin, National Drug Code Implementation, Phase III, and also to the November 2007 National Drug Code seminar presentation.
EDS, 1-800-688-6696 or 919-851-8888
Effective with date of service October 1, 2008, the revenue codes used to bill Medicaid for reimbursement of home health skilled nursing visits have been revised. The change in coding is being made to provide a more adequate description of the service provided and to comply with CMS guidelines concerning the use of national code descriptions.
The revisions are listed in the charts below.
Revised Code List
|
Coding Description and Usage |
||
|
Revenue Code |
Visit Description/Use |
CMS Description |
|---|---|---|
|
550 |
Initial assessment/reassessment Initial assessment of a new patient or 60-day re-assessment |
SN HOME HEALTH |
|
551 |
Treatment, teaching/training, observation/evaluation |
SN VISIT |
|
559 |
For a dually eligible recipient when the visit does not meet Medicare criteria: ex. not home bound |
SN/OTHER |
|
580 |
Venipuncture |
HH-OTH VIS |
|
581 |
Pre-filling insulin syringes/ Medi-Planners |
HH-OTH VIS/VISIT |
|
589 |
Supply only visit. No other skilled service provided. |
HH-OTH VIS/OTHER |
|
Note: Revenue Code 590 will be invalid for billing effective with date of service October 1, 2008. Use applicable nursing visit code based on reason for visit. |
||
Current Coding Description and Usage With Crosswalk to Revised Codes
|
Codes Effective Until October 1, 2008 |
Codes to Be Used Beginning October 1, 2008 |
|||
|
Revenue Code |
Visit Description/Use |
CMS Description |
Revenue Code |
CMS Description |
|
550 |
Observ/eval of stable pt. |
SN HOME HEALTH |
551 |
SN VISIT |
|
551 |
Pre-filling insulin syringes |
SN VISIT |
581 |
HH-OTH VIS/VISIT |
|
559 |
Pre-filling Medi-Planners |
SN/OTHER |
581 |
HH-OTH VIS/VISIT |
|
580 |
Venipuncture |
HH-OTH VIS |
580 |
HH-OTH VIS |
|
581 |
Denied by Medicare for dually eligible |
HH-OTH VIS/VISIT |
559 |
SN/OTHER |
|
589 |
Visit meeting Medicare criteria |
HH-OTH VIS/OTHER |
559 |
SN/OTHER |
|
590 |
Not otherwise classified |
HH SVCS/UNIT |
551 |
SN VISIT (or applicable code based on reason for visit) |
The information in this article supersedes Attachment C of Clinical Coverage Policy 3A, Home Health Services. Providers will be notified when the policy has been updated to reflect this change.
EDS, 1-800-688-6696 or 919-851-8888
Service limitations on scope, amount, duration, frequency, location of service, and other specific criteria stated in this publication may be exceeded or may not apply to recipients under 21 years of age if the provider's documentation shows that
This applies to both proposed and current limitations. Providers should review any information in this publication that contains limitations in the context of EPSDT and apply that information to their service requests for recipients under 21 years of age. A brief summary of EPSDT follows.
EPSDT is a federal Medicaid requirement (42 U.S.C. § 1396d(r) of the Social Security Act) that requires the coverage of services, products, or procedures for Medicaid recipients under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination (including any evaluation by a physician or other licensed clinician).
This means that EPSDT covers most of the medical or remedial care a child needs to
Medically necessary services will be provided in the most economic mode possible, as long as the treatment made available is similarly efficacious to the service requested by the recipient’s physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the recipient’s right to a free choice of providers.
EPSDT does not require the state Medicaid agency to provide any service, product, or procedure that is unsafe, ineffective, experimental, or investigational; that is not medical in nature; or that is not generally recognized as an accepted method of medical practice or treatment.
If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does not eliminate the requirement for prior approval.
For important additional information about EPSDT, please visit the following websites:
In accordance with NCGS §108A-54.2, 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 Proposed Clinical Coverage Policies web page. Providers without Internet access can submit written comments to the address listed below.
Loretta Bohn
Division of Medical Assistance
Clinical Policy Section
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.
|
Month |
Electronic Cut-Off Date |
Checkwrite Date |
|
October |
10/02/08 |
10/07/08 |
|
10/09/08 |
10/14/08 |
|
|
10/16/08 |
10/21/08 |
|
|
10/23/08 |
10/30/08 |
|
|
November |
10/30/08 |
11/04/08 |
|
11/06/08 |
11/13/08 |
|
|
11/13/08 |
11/20/08 |
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.
| William W. Lawrence, Jr. M.D. Acting Director Division of Medical Assistance Department of Health and Human Services |
Melissa Robinson |