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In This Issue. . .
||Home Health Agencies:
EDS, 1-800-688-6696 or 919-851-8888
EDS, 1-800-688-6696 or 919-851-8888
Component codes 83890, 83894, 83898, 83902, 83912, 87252, and 87253 cannot
be billed on the same date of service as CPT test codes 87901, 87903 or 87904.
|Comprehensive Test||Component Codes|
87901, 87903 or 87904
83890, 83894, 83898, 83902, 83912, 87252, 87253
EDS, 1-800-688-6696 or 919-851-8888
It is mandatory that a written and dated physician's order, including the physician's handwritten signature, be obtained and available for inspection within the Medicaid recipient's record. The written order must be obtained prior to the commencement of all assessment and treatment services rendered by qualified providers seeking to bill Medicaid under the LEA, Head Start, and IP Health Related Services programs for children under 21 years of age.
Note: The Health Related Services Provided in Public School and
the Health Related Services for Children Under 21 Years of Age Provided by
Independent Practitioner (IP) Providers manuals are being revised. Providers
will be notified when the revised manuals are available.
Jency L. Abrams R.N., BSN, M.S.
Independent Practitioner (IP) Services
The privacy rule establishes accountability and responsibility for the use or disclosure of any protected health information (PHI) for the purposes of treatment, payment or health care operations (TPO). This includes all medical records and health information used or disclosed in any form, whether electronic, written or oral.
Providers are required to obtain a patient's consent before using or disclosing protected health information (PHI) for treatment, payment or health care operations (TPO). The consent form must be written in simple language and inform the patient that PHI may be used or disclosed for TPO. The consent form must also state the patient's right to review a provider's written notice of privacy practices and inform the patient of the right to review, restrict, and revoke consent. All consent forms must be dated and signed by the patient and retained by the provider for a minimum of six years.
If a patient refuses to sign a consent form, providers may choose not to treat the patient. It is important to note that prior consent is not required in an emergency, where treatment is required by law or where a substantial communication barrier exists. Additionally, health care providers who are indirectly involved in the treatment of a patient are not required to obtain the patient's consent. For example, a laboratory that is running tests at the request of a physician as part of the patient's treatment does not require prior consent from the patient.
While it is necessary for physicians to have full access to a patient's medical records in order to provide treatment, disclosure of health information for purposes other than other treatment, payment or health care operations (TPO) must be limited to the minimum amount of information that is necessary to accomplish the intended purpose. What constitutes the minimum is determined by the provider. Providers must develop criteria to determine minimum necessity, and then document the policies and procedures for enforcing the standards. Reasonable safeguards must be in place to protect confidential information.
Exceptions to the requirements for minimum disclosure standards include using or disclosing health information to protect public health, to conduct medical research or to improve the quality of consumer health care. Use and disclosure of protected health information (PHI) required to comply with HIPAA regulations for electronic transactions are also allowed, as are those uses and disclosures that are required by other laws or under the rule for enforcement purposes. This includes disclosure of PHI to health oversight agencies for activities authorized by law including audit, investigation, and civil, criminal or administrative proceedings.
"Consent" is required for the use or disclosure of protected health information (PHI) for treatment, payment or health care operations (TPO). However, the use or disclosure of health information for purposes unrelated to TPO requires written "authorization" from a patient. While providers may deny treatment if a patient refuses to sign a consent form, treatment cannot be withheld if a patient refuses to sign an authorization form. In general, a written authorization gives permission to the provider to use specific health information for a specific purpose. An authorization is time-limited and must include an expiration date. For example, a physician would need authorization from a patient to release their name and address to a wholesale medical equipment supplier.
Health care plans, providers, and clearinghouses should begin assessing their organizations now to determine what actions are necessary to comply with HIPAA privacy regulations by April 13, 2003. An individual in their organization should be designated as the privacy officer or a committee should be appointed to learn the requirements of the privacy rule, ensure that privacy procedures are adopted, and train employees to understand the procedures.
All providers should draft a written notice of information practices and begin obtaining consent from their patients now. Policies and procedures should also be developed to allow patients to examine, copy, and request corrections to their health records. Ensure that patient records containing protected health information (PHI) are accessible only to those who need them.
Review who has access to protected health information (PHI) within your organization and document the procedure for transmitting information. Implement measures to account for disclosure of information for purposes other than treatment, payment or health care operations (TPO). Review all third party services - both contracted and informal arrangements - to ensure that PHI is not being accessed or disclosed without your knowledge or consent.
The U.S. Department of Health and Human Services' Office for Civil Rights (OCR)
is responsible for the implementation and enforcement of the HIPAA privacy regulations.
Compliance information and assistance is available from OCR on their website
or by contacting your provider association.
EDS, 1-800-688-6696 or 919-851-8888
Adjustments to the plan of care must be made for all cases exceeding the 14 unit per day maximum. Obtain the physician signature for the change in hours according to established guidelines listed in section 6.8 on page 6-15 of the N.C. Medicaid Community Care Manual. The 320 unit (80 hour) monthly maximum allowable remains unchanged.
All claims beginning with dates of service January 1, 2002 must be filed according to this new limitation.
This change does not apply to Adult Care Home PCS Providers.
Adelle Kingsberry, Medical Policy Section
Some of the codes currently used will be replaced by multiple codes, and some will be deleted and replaced with existing codes. Read each description carefully to ensure that the correct size, quantity or preparation is billed. For example, the current code for ostomy skin barrier is A4363. The new code will be A4369, A4370 or A4371 depending on whether a liquid, paste or powder skin barrier is used.
Current codes shown below will be end-dated effective with date of service December 31, 2001, with the new codes becoming effective with date of service January 1, 2002.
Home Health Supplies
|Current Code||New Code||New Description||Maximum Rate/Unit|
|W4648||A4320||Irrigation tray with bulb or piston syringe, any purpose||4.62|
|W4614||A4334||Urinary catheter anchoring device, leg strap, each||5.04|
|W4612||A4351||Intermittent urinary catheter, straight tip, each||1.57|
|W4607||A6222||Gauze, impregnated, other than water or normal saline, pad size 16 sq. in. or less, without adhesive border, each dressing||2.18|
|W4608||A6223||Gauze, impregnated, other than water or normal saline, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing||2.47|
|W4608||A6224||Gauze, impregnated, other than water or normal saline, pad size more than 48 sq. in., without adhesive border, each dressing||3.69|
|W4605||A6234||Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing||6.68|
|W4606||A6235||Hydrocolloid dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing||17.19|
|W4606||A6236||Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing||27.83|
|W4604||A6251||Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing||2.03|
|W4606||A6252||Specialty absorptive dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing||3.32|
|W4606||A6253||Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing||6.48|
|W4607||A6257||Transparent film, 16 sq. in. or less, each dressing||1.56|
|W4608||A6258||Transparent film, more than 16 sq. in., but less than or equal to 48 sq. in., each dressing||4.39|
|W4608||A6259||Transparent film, more than 48 sq. in., each dressing||11.17|
|A4202||A6264||Gauze, non-elastic, non-sterile, all types, per linear yard||.50|
|W4603||A6402||Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing||.12|
|W4603||A6403||Gauze, non-impregnated, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing||.44|
|W4603||A6404||Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing||.46|
|A4202||A6406||Gauze, non-elastic, sterile, all types, per linear yard||.82|
|Intravenous Therapy and Parenteral Supplies|
|W4667||A4206||Syringe with needle, sterile, 1 cc, each (or smaller)||.34|
|W4662||A4215||Needle only, sterile, any size, each||.14|
|W4639||A4554||Disposable underpads, all sizes||.55|
|A4363||A4369||Ostomy skin barrier, liquid (spray, brush, etc.), per oz.||2.47|
|A4363||A4370||Ostomy skin barrier, paste, per oz.||3.50|
|A4363||A4371||Ostomy skin barrier, powder, per oz.||3.73|
|Skin Care (Decubitus) Supplies|
|W4633||E0199||Dry pressure pad for mattress, standard mattress length and width||27.83|
|W4615||A4246||Betadine or pHisoHex solution, per pint||5.59|
Providers must bill their usual and customary charges.
Dot Ling, Medical Policy Section
Each Medicaid resident reviewed by the URC must be listed on the FL12 as usual. However, only the white copy of the FL2 for residents with recommended level of care changes should be mailed with the URC packet to DMA.
The FL2 for residents who do not have recommended level of care changes should not be mailed to DMA.
All other parts of the Utilization Review process will remain the same and
Medicaid residents must continue to be reviewed as scheduled.
Gloria Corbett, R.N., Medical Policy Section
Darlene Cagle, Provider Services
EDS is authorized to issue overrides when extenuating circumstances beyond control of the responsible parties affect access to medical care. Overrides may be issued when:
Laurie Giles, Managed Care Section
|November 6, 2001||December 11, 2001|
|November 14, 2001||December 18, 2001|
|November 20, 2001||December 28, 2001|
|November 29, 2001|
Electronic Cut-Off Schedule
|November 2, 2001||December 7, 2001|
|November 9, 2001||December 14, 2001|
|November 16, 2001||December 21, 2001|
|November 21, 2001|
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.
|Nina M. Yeager, Director||Ricky Pope|
|Division of Medical Assitance||Executive Director|
|Department of Health and Human Services||EDS|