November 2004 Medicaid Bulletin

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In This Issue . . .

All Providers:

  • Directions to the Expansion of Provider Types for Outpatient Behavioral Health Services Seminars
  • General Medicaid Billing Seminars
  • Influenza Vaccine Coverage
  • Medicaid Credit Balance Report
  • Medicaid Credit Balance Reporting
  • NCLeads Update
  • Seminar Schedule for the Expansion of Provider Types
  • for Outpatient Behavioral Health Services

    Chiropractors:

  • New Guidelines for Enrollment
  • Community Alternatives Program Providers:

  • HCPCS Code Changes for Home Health Supplies
  • Proposed CAP-MR/DD Rates
  • Reimbursement Rate Increase for Community Alternatives Program Services
  • Dental Providers:

  • ADA Code Updates
  • DMA’s Dental Program Website
  • New Guidelines for Enrollment
  • Durable Medical Equipment Providers:

  • HCPCS Code Conversions from A4323 and K0409 to A4217
  • Home Health Agencies:

  • HCPCS Code Changes for Home Health Supplies
  • Revision to Rates for Home Health Agencies
  • Hospice Providers:

  • Medicaid Reimbursement Rates for Hospice Services
  • Hospitals:

  • Outpatient Observation Charges for Hysterectomies
  • Stem Cell Transplants-Prior Approval Effective Dates
  • Independent Practitioner Program Providers:

  • Revision to Rates for Independent Practitioner Program Services
  • Local Education Agencies:

  • Revision to Rates for Local Education Agency Services
  • Mental Health Providers:

  • Proposed Enhanced Benefits and Existing Mental Health Rates
  • ValueOptions
  • Nursing Facility Providers:

  • Medical Data Sets Validation Program for Nursing Facilities
  • Optometrists:

  • New Guidelines for Enrollment
  • Osteopaths:

  • New Guidelines for Enrollment
  • Physicians:

    Private Duty Nursing Providers:

  • HCPCS Code Changes for Home Health Supplies
  • Podiatrists:

  • New Guidelines for Enrollment
  • Prescribers and Pharmacy Providers:

  • Discontinuation of Coverage for Anorexia, Weight Loss, and Weight Gain Products and Medications
  • Discontinuation of Coverage for Vioxx
  • Medical Necessity Criteria for Approval of Oxycontin
  • Medical Necessity Criteria for Approval of Provigil
  • Removal of Smoking Cessation Medications and Products from the Prior Authorization Drug List
  • Revised Criteria 1a through 1d Synagis Form
  •  


    Attention: All Providers

    General Medicaid Billing Seminars

    Seminars on general Medicaid billing guidelines are scheduled for January 2005. Registration information and a list of dates and site locations for the seminars will be published in the December 2004 general Medicaid bulletin.

    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

    Medicaid Credit Balance Reporting

    All providers participating in the Medicaid program are required to submit to the Division of Medical Assistance (DMA), Third Party Recovery Section a quarterly Credit Balance Report indicating balances due to Medicaid. Providers must report any outstanding credits owed to Medicaid that have not been reported previously on a Medicaid Credit Balance Report. However, hospital and nursing facility providers are required to submit a report every calendar quarter even if there are no credit balances. The report must be submitted no later than 30 days following the end of the calendar quarter (March 31, June 30, September 30, and December 31).

    The Medicaid Credit Balance Report is used to monitor and recover "credit balances" owed to the Medicaid program. A credit balance results from an improper or excess payment made to a provider. For example, refunds must be made to Medicaid if a provider is paid twice for the same service (e.g., by Medicaid and a medical insurance policy, by Medicare and Medicaid, by Medicaid and a liability insurance policy, if the patient liability was not reported in the billing process or if computer or billing errors occur).

    For the purpose of completing the report, a Medicaid Credit Balance is the amount determined to be refundable to the Medicaid program. When a provider receives an improper or excess payment for a claim, it is reflected in the provider’s accounting records (patient accounts receivable) as a "credit." However, credit balances include money due to Medicaid regardless of its classification in a provider's accounting records. If a provider maintains a credit balance account for a stipulated period (e.g., 90 days) and then transfers the account or writes it off to a holding account, this does not relieve the provider of liability to the Medicaid program. The provider is responsible for identifying and repaying all monies owed the Medicaid program.

    The Medicaid Credit Balance Report requires specific information on each credit balance on a claim-by-claim basis. The reporting form provides space for 15 claims but may be reproduced as many times as necessary to accommodate all the credit balances being reported. Specific instructions for completing the report are on the reverse side of the reporting form.

    Submitting the Medicaid Credit Balance Report does not result in the credit balances automatically being reimbursed to the Medicaid program. A check is the preferred form of satisfying the credit balances; the check must be made payable to EDS and sent to EDS with the required documentation for a refund. If an adjustment is to be made to satisfy the credit balance, an adjustment form must be completed and submitted to EDS with all the supporting documentation for processing.

    Submit
    Medicaid Credit Balance Report Form
    to:

    Submit
    refund checks
    to:

    Submit
    Medicaid Claim Adjustment Request Form
    to:

    Third Party Recovery Section
    Division of Medical Assistance
    2508 Mail Service Center
    Raleigh, NC 27699-2508

    EDS
    Refunds
    P.O. Box 300011
    Raleigh, NC 27622-3011

    EDS
    Adjustment Unit
    P.O. Box 300009
    Raleigh, NC 27622-3009

    Submit only the completed Medicaid Credit Balance Report to DMA. Do not send refund checks or adjustment forms to DMA. Do not send the Credit Balance Report to EDS. Failure to submit a Medicaid Credit Balance Report will result in the withholding of Medicaid payments until the report is received.

    Anita Ray, Third Party Recovery Section
    DMA, 919-647-8100


    Attention: Community Alternatives Program Providers

    Reimbursement Rate Increase for Community Alternatives Program Services

    Effective with date of service August 16, 2004, the Medicaid maximum reimbursement rate for the following Community Alternatives Program (CAP) services was increased. This was an interim rate increase that will be effective through December 2004. Results from a pending audit of PCS providers may result in a subsequent rate change. Providers are to be notified of any further rate changes in future general Medicaid bulletins.

    Reimbursement

    In addition, S5150 HQ, CAP-MR/DD Respite Care (group of 2 to 3 clients) has been revised effective October 1, 2004 to $2.74 per 15 minute unit.

    Procedure Code

    Description

    Reimbursement Rate

    T1000

    CAP/C Nursing Services

    $9.11/15 min unit

    T1005TD

    CAP/AIDS Respite Care – Nursing Level RN

    $9.11/15 min unit

    T1005TE

    CAP/AIDS Respite Care – Nursing Level LPN

    $9.11/15 min unit

    T1005TD

    CAP-MR/DD Respite Care – Nursing Level RN

    $9.11/15 min unit

    T1005TE

    CAP-MR/DD Respite Care – Nursing Level LPN

    $9.11/15 min unit

    Pat Jeter, Rate Setting
    DMA, 919-855-4200


    Attention: All Dental Providers Including Health Department Dental Clinics

    ADA Code Updates

    Effective with date of service October 1, 2004, the following dental procedure codes have been added to the NC Medicaid Dental Program. These additions were published on September 1, 2004 in Special Bulletin VI: Dental Services Coverage Policy and Billing Guidelines.

    CDT-4
    Code


    Description

    Reimbursement
    Rate

    D0170

    Re-evaluation – limited, problem focused

    *use as a follow-up exam for a specific problem that has been evaluated previously using D0140

    *document in the patient’s chart the nature of the emergency and the treatment provided

    $20.00

    D1204

    Topical application of fluoride (prophylaxis not included) – adult

    *limited to recipients 13 through 20 years old

    $15.44

    D3230

    Pulpal therapy (resorbable filling) – anterior, primary tooth
    (excluding final restoration)

    *limited to recipients under age 6

    *not allowed for the same tooth on the same date of service as D3220

    $150.00

    D3240

    Pulpal therapy (resorbable filling) – posterior, primary tooth
    (excluding final restoration)

    *limited to recipients under age 9

    *allowed for primary second molars only

    *not allowed for the same tooth on the same date of service as D3220

    $200.00

    D3320

    Bicuspid (excluding final restoration)

    *limited to recipients under age 21

    *not allowed for the same tooth on the same date of service as D3220

    $259.57

    The following procedure codes were end-dated effective with date of service September 30, 2004.

    Procedure code

    Description

    D2910

    Recement inlay

    D2920

    Recement crown

    D3110

    Pulp cap – direct (excluding final restoration)

    In addition, the following changes are effective with date of service October 1, 2004:

  • Code D0220 [Intraoral – periapical first film] is now reimbursed at a rate of $14.60 to coincide with a coverage policy revision.
  • Code D1203 [Topical application of fluoride (prophylaxis not included) – child] is now covered only for recipients who are between ages 0 and 12 years; the age limit for D1203 covered in the physician fluoride varnish program remains 0 to 2 years.
  • Providers are reminded to bill their usual and customary charges rather than the Medicaid rate. For coverage criteria and additional billing guidelines, please refer to Clinical Coverage Policy 4A, Dental Services.

    Dr. Ron Venezie, Dental Director
    DMA, 919-855-4280


    Attention: Dental Providers Including Health Department Dental Clinics

    DMA’s Dental Program Website

    The Division of Medical Assistance (DMA) has a new website for the NC Medicaid Dental Program. This website includes links to the current dental and orthodontic policy manuals as well as the current dental fee schedule. You also will find a list of frequently asked questions, instructions for the Automated Voice Response (AVR) system, and a list of tips for correcting the most common dental claim denials. The Dental Program website also includes links to those Medicaid forms that are most often used by dental providers. Please let us know if you have suggestions for other helpful links that could be included.

    Dr. Ron Venezie, Dental Director
    DMA, 919-855-4280


    Attention: Durable Medical Equipment Providers

    HCPCS Code Conversion from A4323 and K0409 to A4217

    In order to comply with the Centers for Medicare and Medicaid Services’ coding changes, codes A4323, sterile saline, 1000 ml, and K0409, sterile water, 1000 ml, will be end-dated on November 30, 2004. They will be replaced with code A4217, sterile water/saline, 500 ml.

    Effective with date of service December 1, 2004, providers must bill for sterile water/saline with code A4217. The maximum reimbursement rate will be $2.66. Prior approval is not required. However, a Certificate of Medical Necessity and Prior Approval form must be completed regardless of the requirement for prior approval.

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


    Attention: Home Health Agencies, Private Duty Nursing Providers, and Community Alternatives Program Case Managers

    HCPCS Code Changes for Home Health Supplies

    Reimbursement Rate Increase for Private Duty Nursing Services

    Effective with date of service October 1, 2004, the Medicaid maximum reimbursement rate for In-Home Private Duty Nursing is being changed to $9.11 per 15 minute unit. This is an annual rate increase per the State Plan.

    Effective with date of service November 30, 2004, the following HCPCS codes will be end-dated to comply with the national standard codes mandated by the Health Insurance Portability and Accountability Act (HIPAA). The new codes will become effective December 1, 2004.

    HCPCS Code List

    Current
    HCPCS
    Code

    New
    HCPCS Code

    Description

    Billing
    Unit

    Maximum Reimbursement Rate

    A4214

    A4216

    Sterile /saline or water, 10ml

    10ml

    $ .40

    A4323
    K0409

    A4217

    Sterile /saline or water, 500ml

    500ml

    2.66

    A4621

    A7525

    Tracheostomy mask each

    Each

    2.07

    A7526

    Tracheostomy tube, collar and holder

    Each

    3.37

    A4622

    A7520

    Tracheostomy/laryngectomy tube, non-cuffed, polyvinylchloride (pvc), silicone or equal each

    Each

    47.48

    A7521

    Tracheostomy/laryngectomy tube, cuffed polyvinylchloride (pvc), sil1cone or equal each.

    Each

    47.05

    A7522

    Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable or reusable), each

    Each

    45.16

    A6422

    A6443

    Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to three inches and less than 5 inches, per yard

    Per yard

    .29

    A6424

    A6444

    Conforming bandage, non-elastic, knitted/woven, nonsterile greater than or equal to five inches per yard.

    Per yard

    .56

    A6426

    A6446

    Conforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to three inches and less than 5 inches, per yard

    Per yard

    .41

    A6428

    A6447

    Conforming bandage, nonelastic, knitted/woven, sterile, greater than or equal to five inches per yard

    Per yard

    .67

    A6430

    A6449

    Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than 5 inches, per yard

    Per yard

    1.75

    A6432

    A6450

    Light compression bandage, elastic, knitted/woven, width greater than or equal to 5 inches, per yard

    Per yard

    1.00

    A6440

    A6456

    Zinc paste impregnated bandage, nonelastic, knit/woven, width greater than or equal to 3 inches and less than 5 inches, per yard

    Per yard

    1.28

    B4084

    B4086

    Gastrostomy/jejunostomy tube any type

    Each

    17.09

    K0621

    A6407

    Packing strips, non-impregnatal, up to 2 inched wide

    Each

    1.88

    S8181

    See A7526 Above

    Tracheostomy tube, collar and holder

    Each

    3.37

    W4651

    Use current code A4253

    Blood glucose test strips

    50/pkg

    33.22

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


    Attention: Home Health Providers

    Revision to Rates for Home Health Agencies

    The Home Health Fee Schedule has been updated to reflect the following rates for all home health visits. The update is effective for dates of service July 1, 2004. EDS will generate automated adjustments for claims processed and paid at the old rate. Providers do not need to submit adjustment requests.

    Revenue

    Code

    Home Health Services
    Description

    Billing

    Unit

    Maximum Rate

    Reimbursement

    420

    Physical Therapy

    1 visit

    $99.94

    424

    Physical Therapy - Evaluation

    1visit

    99.94

    430

    Occupational Therapy

    1 visit

    99.94

    434

    Occupational Therapy - Evaluation

    1visit

    99.94

    440

    Speech Therapy

    1 visit

    99.94

    444

    Speech Therapy - Evaluation

    1visit

    99.94

    550

    Observation/Evaluation of stable patient

    1 visit

    101.41

    551

    Skilled Nursing Visit Prefilling insulin syringes

    1 visit

    101.41

    559

    Skilled Nursing Visit for Prefilling medicine planners

    1 visit

    101.41

    570

    Home Health Aide

    1 visit

    46.39

    580

    Skilled Nursing Visit for Venipuncture

    1 visit

    101.41

    581

    Skilled Nursing Visit for Denied by Medicare for dually-eligible patient

    1 visit

    101.41

    589

    Skilled Nursing Visit meeting Medicare criteria

    1 visit

    101.41

    590

    Skilled Nursing Visit/Not Otherwise Classified

    1 visit

    101.41

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


    Attention: Hospitals and Physicians

    Outpatient Observation Charges for Hysterectomies

    The N.C. Medicaid program does not routinely cover observation charges for hysterectomies. These charges are covered only in situations where a patient exhibits an uncommon or unusual reaction or other postoperative complications that require monitoring or treatment beyond the usual provided in the immediate post operative period. When observation charges are billed and no records are included with the claim, the claim will be denied for medical records to substantiate necessity for the service. Providers will receive the denial EOB 1396 "Observation is not routinely allowed. Submit records to review for medical necessity, include: History and Physical, Operative records, Pathology report and Discharge summary."

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


    Attention: Independent Practitioner Program Providers

    Revision to Rates for Independent Practitioner Program Services

    Effective with date of service September 17, 2004, the rates for some services provided by the Independent Practitioners Program were changed. Below is a list of the changes.

    Refer to Clinical Policy #10B (previously numbered as #8G) for additional information and for a complete list of billing codes.

    Note: Not all rates are changing at this time. Please refer to future bulletin articles for further information. Providers should continue to bill their usual and customary charges.

    Procedure Code

    Maximum Reimbursement Rate

    29075

    $ 69.79

    29085

    74.33

    29105

    72.68

    29125

    55.15

    29126

    68.14

    29130

    33.91

    29131

    44.49

    29240

    54.90

    29260

    45.37

    29280

    45.93

    29405

    72.21

    29425

    78.52

    29505

    63.99

    29515

    55.72

    29530

    47.73

    29540

    32.73

    31502

    73.36

    31720

    87.02

    92065

    31.39

    92510

    123.43

    92526

    74.77

    92551

    9.69

    92552

    15.41

    92567

    18.49

    92569

    14.09

    92571

    13.43

    92572

    3.19

    92576

    15.63

    92583

    31.14

    92587

    52.81

    92588

    70.00

    92590

    39.94

    92591

    59.99

    92592

    17.56

    92593

    26.31

    92594

    18.98

    92595

    28.82

    92610

    115.35

    94010

    28.81

    94060

    49.52

    94150

    18.77

    94200

    19.09

    94240

    32.00

    94375

    31.80

    94657

    63.34

    95831

    21.38

    95832

    18.76

    95833

    31.75

    95834

    38.23

    97010

    4.00

    97012

    13.71

    97016

    12.88

    97018

    5.98

    97020

    4.33

    97022

    13.51

    97024

    5.32

    97026

    4.33

    97028

    5.37

    97032

    14.37

    97033

    18.91

    97034

    12.95

    97035

    11.30

    97036

    21.05

    97110

    26.09

    97112

    26.31

    97116

    22.55

    97124

    20.23

    97140

    24.28

    97504

    27.74

    97520

    25.65

    97530

    26.61

    97533

    23.75

    97535

    27.30

    97542

    25.43

    97601

    35.01

    97602

    15.77

    97703

    22.85

    97750

    26.31

    Laurie Edwards, Financial Management
    DMA, 919-855-4200


    Attention: Local Education Agencies

    Revision to Rates for Local Education Agency Services

    Effective with date of service September 17, 2004, the rates for some services provided by Local Education Agencies (LEAs) were changed. Below is a list of the changes. This table replaces information published in the April 2004 general Medicaid bulletin.

    The below are maximum reimbursement rates; however, providers must bill their usual and customary charges. Schools that bill Medicaid are only paid the federal share of the Medicaid reimbursement rate listed below. Reimbursement rates will change as the Federal Financial Participation (FFP) percentage changes.

    Refer to the Clinical Coverage Policy #10C (previously numbered at 8H) for additional information on billing for LEA services and a complete list of billing codes.

    Note: Not all rates are changing at this time. Please refer to future bulletin articles for further information.

    Procedure Code

    Maximum Reimbursement
    Rate

    29075

    $ 69.79

    29085

    74.33

    29105

    72.68

    29125

    55.15

    29126

    68.14

    29130

    33.91

    29131

    44.49

    29240

    54.90

    29260

    45.37

    29280

    45.93

    29405

    72.21

    29505

    63.99

    29515

    55.72

    29530

    47.73

    29540

    32.73

    90801

    139.49

    90802

    148.15

    90804

    59.98

    90806

    90.19

    90808

    134.73

    90810

    64.21

    90812

    97.28

    90814
    141.27
    90846
    87.47
    90853
    29.40
    92065
    31.39
    92510
    123.43
    92526
    74.77
    92551
    9.69
    92552
    15.41
    92567
    18.49
    92569
    14.09
    92572
    3.19
    92576
    15.63
    92583
    31.14
    92585
    89.93
    92587
    52.81
    92588
    70.00
    92590
    39.94
    92591
    59.99
    92592
    17.56
    92593
    26.31
    92594
    18.98
    92595
    28.82

    95831

    21.38

    95832

    18.76

    95833

    31.75

    95834

    38.23

    96100

    62.40

    96110

    10.22

    96111

    131.50

    96115

    62.40

    96117

    62.40

    97110

    26.09

    97112

    26.31

    97116

    22.55

    97140

    24.28

    97504

    27.74

    97520

    25.65

    97530

    26.61

    97533

    23.75

    97535

    27.30

    97542

    25.43

    97703

    22.85

    97750

    26.31

    Laurie Edwards, Financial Management
    DMA, 919-855-4200


    Attention: Licensed or Certified Psychologists, Licensed Clinical Social Workers, Certified Clinical Nurse Specialists in Psychiatric Mental Health Advanced Practice, Nurse Practitioners Certified as Clinical Nurse Specialists in Psychiatric Mental Health Advanced Practice, Licensed Psychological Associates, Licensed Professional Counselors, Licensed Marriage and Family Therapists, Certified Clinical Addictions Specialists, and Certified Clinical Supervisors

    Seminar Schedule for the Expansion of Provider Types for Outpatient Behavioral Health Services

    Seminars for the expansion of provider types for Outpatient Behavioral Health Services are scheduled for December 2004. This seminar will focus on the expansion of access to services for Medicaid eligible recipients by increasing the provider community and the age group that they serve.

    Providers are encouraged to arrive 30 minutes before the seminar begins to complete registration. Unregistered providers are welcome to attend if space is available. No food or drinks will be provided.

    Providers may register for the seminars by completing and submitting the Outpatient Behavioral Health Services Registration form or through by Online Registration.

    The December 2004 Special Bulletin VII, Outpatient Behavioral Health Services Provided by Direct Enrolled Providers, will be used as the primary training document for the seminar. The special bulletin will be available on DMA’s website beginning December 2004 at http://www.ncdhhs.gov/dma/bulletin/index.htm. Please print the special bulletin and bring it to the seminar.

    Tuesday, Decemer 7, 2004
    (9:00 am - 12:00 pm)

    Park Inn Gateway Conference Center
    909 Highway 70 SW
    Hickory, NC

    Wednesday, December 8, 2004
    (9:00 am - 12:00 pm)

    Blue Ridge Community College
    Bo Thomas Auditorium
    Flat Rock, NC

    Thursday, December 9, 2004
    (9:00 am - 12:00 pm)

    Greenville Hilton
    207 Greenville Blvd. SW
    Greenville, NC

     

    Friday, December 10, 2004
    (12:30 pm - 3:30 pm)

    Wake Med Andrews Conference Center
    3000 New Bern Ave.
    Raleigh, NC


    Directions to the Expansion of Provider Types for Outpatient Behavioral Health Services Seminars:

    Park Inn Gateway Conference Center – Hickory, North Carolina

    Take I-40 to exit 123. Follow signs to Highway 321 North. Take the first exit (Hickory exit) and follow the ramp to the stoplight. Turn right at the light onto Highway 70. The Gateway Conference Center is on the right.

    Blue Ridge Community College, Bo Thomas Auditorium – Flat Rock, North Carolina

    Take I-40 to Asheville. Travel east on I-26 to exit 22. Turn right and then take the next right. Follow the signs to Blue Ridge Community College. Turn left at the large Blue Ridge Community College sign. The college is located on the right. Take the first right-hand turn into the parking lot for the Bo Thomas Auditorium.

    Greenville Hilton – Greenville, North Carolina

    Take Highway 264 east to Greenville. Turn right onto Allen Road in Greenville. Travel approximately 2 miles. Allen Road becomes Greenville Boulevard/Alternate 264. Follow Greenville Boulevard for 2½ miles to the Hilton Greenville, which is located on the right.

    WakeMed Andrews Conference Center – Raleigh, North Carolina

    Take the I-440 Raleigh Beltline to exit 13A, New Bern Avenue.

    Paid parking ($3.00 maximum per day) is available on the top two levels of parking deck P3. To reach the parking deck, turn left at the fourth stoplight on New Bern Avenue, and then turn left at the first stop sign. Parking for oversized vehicles is available in the overflow lot for parking deck P3. Handicapped accessible parking is available in parking lot P4, directly in front of the conference center.

    To enter the Andrews Conference Center, follow the sidewalk toward New Bern Avenue past the Medical Office Building to entrance E2 of the William F. Andrews Center for Medical Education. A map of the WakeMed campus is available online at http://www.wakemed.org.

    Illegally parked vehicles will be towed. Parking is not permitted at East Square Medical Plaza, Wake County Human Services or in parking lot P4 (except for handicapped accessible parking).

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


    Attention: Nursing Facility Providers

    Medical Data Sets Validation Program for Nursing Facilities

    On October 1, 2004, the Division of Medical Assistance (DMA) will begin a new Medical Data Sets (MDS) Validation Program as a component of the Medicaid Case Mix Reimbursement System. All facilities participating in the Medicaid Case Mix Reimbursement System are required to participate in the MDS Validation Program. The overall goal of the Case Mix Reimbursement System is to align payments with the level of care needed by the residents in the facility. Completion of the MDS reports is a very important function of the nursing facility staff and ensures that the nursing facility receives accurate payments from the N.C. Medicaid program.

    The MDS Validation Program provides DMA and the nursing facility with assurance that the Medicaid payments are accurately based on the recorded medical and functional needs of the nursing facility resident as documented in the medical record. The MDS Validation Program replaces the FL2 and FL12 utilization review program performed by the facility staff and contract physicians, which was discontinued as of September 30, 2003.

    DMA has contracted with Myers and Stauffer, LLP, to provide registered nurse reviewers to conduct onsite MDS reviews of each nursing facility in North Carolina. The reviews were scheduled to begin on October 1, 2004. All of the reviews will be completed by September 30, 2005. This first year (October 1, 2004 through September 30, 2005) of reviews are considered as educational reviews and are intended to assist facility staff in understanding the process and the requirements for MDS supportive documentation.

    Important Definitions for the MDS Validation Program

    RUG-III Reimbursement System – Medicaid uses the RUG III system to assign the facility Case Mix Index (CMI) rate. RUG III groups classify residents into 34 groups that use similar quantities of resources defined as nursing time, therapy time, and nursing assistant time. There are 108 MDS 2.0 elements that determine the RUG III classification system.

    Case Mix – refers to a combination of different individual resident profiles seen in a specific setting or facility.

    Case Mix Index (CMI) – each RUG-III group is assigned a weight, or numeric score, which reflects the relative resources predicted to provide care to the resident. The higher the case mix index, the greater the resource requirement for the resident.

    Resident Roster – identifies all non-discharged residents and includes information on the MDS RUG-III elements transmitted on the sample set of assessments. In addition, it provides a summary of the number of MDS records in each RUG-III category.

    Supportive Documentation Guidelines

    DMA uses the Supportive Documentation Guidelines approved by the Centers for Medicare and Medicaid Services (CMS) to define the supporting documentation necessary to verify a RUG-III item during an MDS review.

    MDS Validation Program Protocols

    1. The list of residents or resident roster is produced on a Case Mix Index Report (CMI Report) every quarter on the "snapshot date" and sent to the facility. The "snapshot dates" are March 31, June 30, September 30, and December 31. For a facility review occurring in October 2004, the review sample will be drawn from the CMI Report dated June 30, 2004. For a facility review, occurring in February 2005, the review sample will be drawn from the CMI Report of residents in the facility dated September 30, 2004.

    2. The sample will be drawn from all residents listed on the final CMI report regardless of payer source.

    3. Both the primary and expanded samples shall include a minimum of 80 percent Medicaid recipients.

    4. In the second year of case mix reviews, facilities will experience an expanded review when the primary assessment sample results in an unsupported percent are equal to or greater than the state threshold. This expanded review will include an additional 10 percent of the residents on the final CMI report or an additional 10 assessments, whichever is greater.

    5. The results of the MDS Validation Program may result in re-rugging and a change in the case mix index rate for the nursing facility, as defined below.

    MDS Review Process

      1. Nursing facilities will be notified by the contract nurse reviewers both by phone and by fax three (3) business days prior to the visit.

      2. An entrance conference will be held with the nursing facility administrator, the MDS coordinator, and any other facility personnel the administrator selects to discuss the overall objectives of the review and to allow the facility personnel to ask questions.

      3. The nurse reviewer will prepare a list of the MDS's and resident records selected for review and ask the facility personnel to pull the records. If possible, the primary sample will include at least one assessment from each of the seven RUG-III classification groups.

      4. The review begins immediately after the entrance conference. The reviewers will use the MDS documentation guidelines as issued by CMS (http://www.cms.hhs.gov/).

      5. The reviewer will verify the MDS items and determine if the RUG-III category reported on the Final Case Mix Report is supported with documentation in the medical record.

      6. Documentation for the activities of daily living (ADL's) must reflect 24/7 of the observation periods to verify the submitted values on the MDS.

      7. Immediately following the review of the MDS assessments, the medical records, and other supportive documentation, the nurse reviewers will hold an exit interview with the facility staff to review preliminary results. Any unresolved issues or trends will be identified and discussed.

      8. No supporting documentation will be accepted after the close of the exit conference.

      9. A case mix review summary letter will be mailed to the provider by the nurse reviewers from Myers and Stauffer indicating the results of the review.

      10. DMA reserves the right to conduct follow-up reviews as needed. These reviews would occur no earlier than 120 days following the exit interview.

    Delinquent MDS Assessment:

    Any assessment with an R2b date greater than 121 days from the previous R2b date will be deemed delinquent and assigned a RUG-III code of BC1, which is the lowest possible case mix index.

    Unsupported MDS Assessment

    The MDS is unsupported when the MDS nurse reviewers do not find adequate documentation for the RUG-III Classification level in the patient record. An unsupported MDS assessment can result in a different RUG-III classification from the one submitted by the facility.

    Effect of Unsupported Thresholds

      1. First year of program (October 2004 through September 2005) – No penalties for unsupported MDS values.

      2. Second year of program (October 2005 through September 2006) – 40 percent unsupported MDS values will result in re-rugging of all unsupported MDS assessments and a recalculation of the direct rate. May also result in a retrospective rate adjustment.

      3. Third year of the program (October 2006 through September 2007) – 35 percent unsupported MDS values will result in re-rugging of all unsupported MDS assessments and a recalculation of the direct rate. May also result in a retrospective rate adjustment.

      4. Fourth and succeeding years of program (October 2007 through September 2008) – 25 percent unsupported will result in the recalculation as above.

    The following resources are available to facility staff for questions related to the MDS and MDS Validation Program

    MDS State Contact – For all questions related to coding.
    Cindy DePorter, Division of Facility Services
    919-715-1872, ext. 214

    MDS Help Desk
    919-715-1872

    Myers and Stauffer’s Help Desk – For questions other than coding issues.
    Documentation Guidelines
    1-800-763-2278

    MDS Validation Program Oversight and Administration
    Margaret Comin, RN, Facility Unit Manager
    DMA, 919-855-4350


    Attention: Physicians

    Physician’s Drug Program List Update

    The following table lists the FDA-approved-drugs currently covered by the N.C. Medicaid program when the drugs are provided in a physician’s office for the FDA-approved indications. This list replaces all previously published lists. Rates are effective with the April 1, 2004 date of service and reflect a change to 90 percent AWP. Since the effect is both increases and decreases to the rates, systematic adjustments will be made to align paid claims with these fees retroactive to April 1, 2004 for claims paid between April 1, 2004 and implementation of these rates.

    Physicians will continue to bill on the CMS-1500 claim form using the appropriate drug code and indicating the specified number of units administered. Providers must bill their usual and customary charges.

    An asterisk (*) indicates that an invoice must be submitted with the CMS-1500 claim form. An invoice must be submitted with each claim. The paper invoice must indicate the name of the recipient, the recipient’s Medicaid identification number, the name of the medication, the dosage given, the National Drug Code (NDC) number from the vial(s) used, the number of vials used, and the cost per dose. Providers must indicate the number of units given in block 24G on the CMS-1500 claim form. Payment is based in accordance with Medicaid’s State Plan for reimbursement. Providers will be reimbursed the lower of the invoice price or maximum allowable fee on file.

    Injectable Drug List

    Invoice Required

    Procedure Code

    Description

    Maximum Reimbursement Rate

    J0130

    Abciximab 10 mg

    $486.02

    J1120

    Acetazolamide Sodium, up to 500 mg (Diamox)

    19.44

    J0150

    Adenosine I.V., 6 mg (Adenocard)

    36.85

    J0152

    Adenosine, 30 mg (Adenoscan)

    72.40

    J0170

    Adrenalin, Epinephrine, up to 1 ml ampule

    2.22

    *

    J3490

    Agalsidase Beta, 1mg (Fabrazyme)

    4500.00

    P9047

    Albumin (human), 25%, 50 ml

    52.20

    P9041

    Albumin (human), 5%, 50 ml

    13.78

    J9015

    Aldesleukin, per single use vial (Proleukin, IL-2, Interleukin) 22 million I.U.

    695.81

    J0215

    Alefacept 0.5 mg, injection (Amevive)

    29.85

    J0205

    Alglucerase, per 10 units (Ceredase)

    35.56

    J0256

    Alpha 1 Proteinase Inhibitor Human A, 10 mg (Prolastin)

    2.52

    J2997

    Alteplase recombinant, 1 mg

    34.77

    J0207

    Amifostine 500 mg (Ethyol)

    429.13

    S0072

    Amikacin Sulfate (100 mg)

    14.06

    S0016

    Amikacin Sulfate 500 mg (Amikin)

    16.88

    J0280

    Aminophyllin, up to 250 mg

    1.00

    J1320

    Amitriptyline HCL, up to 20 mg (Elavil, Enovil)

    2.28

    J0300

    Amobarbital, up to 125 mg (Amytal)

    2.52

    J0288

    Amphotericin B cholesteryl sulfate complex, 10 mg

    14.40

    J0287

    Amphotericin B lipid complex, 10 mg

    20.70

    J0289

    Amphotericin B liposome, 10 mg

    33.91

    J0285

    Amphotericin B, 50 mg (Amphocin, Fungizone IV)

    10.48

    J0295

    Ampicillin Sodium/Sulbactam Sodium, per 1.5 gm (Unasyn)

    7.03

    J0290

    Ampicillin, up to 500 mg (Omnipen-N, Totacillin-N)

    1.57

    J0350

    Anistreplase, per 30 units (Eminase)

    2552.02

    J7197

    Antithrombin II (human) per I.U. (Throbate III)

    1.19

    J0395

    Arbutamine HCL, 1 mg (GenESA)

    172.80

    J9017

    Arsenic Trioxide 1mg (Trisenox)

    35.10

    J9020

    Asparaginase, 10,000 units (Elspar)

    59.32

    J0460

    Atropine Sulfate, up to 0.3 mg

    0.78

    J2910

    Aurothioglucose, up to 50 mg (Solganal)

    16.40

    J0456

    Azithromycin, 500 mg. (Zithromax)

    24.20

    Q0144

    Azithromycin, oral suspension 1 unit = 1 gm packet (Zithromax), only oral drug on list

    23.02

    J0476

    Baclofen, for intrathecal trial, 50 mcg (Lioresal for intrathecal trial)

    75.60

    J0475

    Baclofen, Kit 1*20 ml. Amp. (10 mg/20ml. 500 meg/ml.)

    221.40

    *

    J3490

    Baclofen, Kit 2*5 ml. Amp. (10 mg./5 ml. 2000 meg/ml.)

    464.40

    *

    J3490

    Baclofen, Kit 4*5 ml. Amp. (10 mg./5ml. 2000 meg/ml.)

    815.40

    J9031

    BCG live (intravesical) per installation (Tice, TheraCys)

    151.70

    J0702

    Betamethasone Acetate and Betamethasone Sodium Phosphate, per 3 mg

    4.72

    J0704

    Betamethasone Sodium Phosphate, per 4 mg

    1.02

    J0520

    Bethanechol Chloride, mytonachol or urecholine, up to 5 mg (Urecholine)

    5.06

    J9040

    Bleomycin Sulfate, 15 units (Blenoxane)

    172.80

    S0115

    Bortezomib 3.5 mg (Velcade)

    1076.63

    J0585

    Botulinum toxin type A, per unit (Botox)

    4.69

    J0945

    Brompheniramine Maleate, 10mg

    0.90

    J0595

    Butorphanol Tartrate, 1mg (Stadol)

    4.17

    J0636

    Calcitriol, 0.1 mcg (Calcijex)

    1.31

    J0610

    Calcium Gluconate, per 10 ml (Kaleinate)

    0.96

    J0620

    Calcium Glycerophosphate and Calcium Lactate, per 10 ml (Calphosan)

    6.08

    J9045

    Carboplatin, 50 mg (Paraplatin)

    140.92

    J9050

    Carmustine, 100 mg (BiCNU)

    129.01

    J0690

    Cefazolin Sodium, 500 mg (Ancef, Kefzol, Zolicef)

    2.13

    J0692

    Cefepime HCL, 500 mg (Maxiprene)

    7.70

    J0698

    Cefotaxime Sodium, per gm (Claforan)

    9.90

    J0694

    Cefoxitin Sodium, 1 gm (Mefoxin)

    10.13

    J0713

    Ceftazidime per 500 mg (Fortaz, Tazidime)

    6.40

    J0715

    Ceftizoxime Sodium, per 500 mg (Cefizox)

    4.70

    J0696

    Ceftriaxone Sodium, per 250 mg (Rocephin)

    14.14

    J0697

    Cefuroxime Sodium, per 750 mg (Kefurox, Zinacef)

    6.08

    J1890

    Cephalothin Sodium, up to 1 gm (Keflin)

    9.72

    J0710

    Cephapirin Sodium, up to 1 gm (Cefadyl)

    1.33

    J0720

    Chloramphenicol Sodium Succinate, up to 1 gm

    6.84

    J1990

    Chlordiazepoxide HCL, up to 100 mg (Librium)

    23.68

    J0390

    Chloroquine HCL, up to 250 mg (Aralen)

    18.65

    J1205

    Chlorothiazide Sodium, 500 mg (Diuril Sodium)

    9.94

    J2400

    Chlorprocaine HCL 30 ml (Nesacaine, Nesacaine-MPF)

    6.06

    J3230

    Chlorpromazine HCL up to 50 mg (Thorazine)

    4.17

    J0725

    Chorionic Gonadotropin, per 1,000 USP units

    2.93

    J0740

    Cidofovir 375 mg (Vistide)

    799.20

    J0743

    Cilastatin Sodium Imipenem, per 250 mg (Primaxin IM, Primaxin IV)

    15.04

    S0023

    Cimetadine HCL, 300 mg (Tagamet)

    1.34

    J0744

    Ciprofloxacin for IV infusion, 200 mg (Cipro)

    12.97

    J9062

    Cisplatin, 50 mg (Platinol AQ)

    75.60

    J9060

    Cisplatin, powder or solution, per 10 mg (Platinol, Plantinol AQ)

    15.12

    J9065

    Cladribine, per 1 mg (Leustatin)

    48.60

    J0735

    Clonidine Hydrochloride, 1 mg

    52.25

    J0745

    Codeine Phosphate, per 30 mg

    0.48

    J0760

    Colchicine, 1 mg

    6.70

    J0770

    Colistimethate Sodium, up to 150 mg (Coly-Mycin M)

    51.30

    J0800

    Corticotropin, up to 40 units (Acthar, ACTH)

    88.05

    J0835

    Cosyntropin, per 0.25 mg (Cortrosyn)

    17.28

    J3420

    Cyanocobalamin, vitamin B 12, 1000 mcg

    0.13

    J9096

    Cyclophosphamide Lyophilized 1 gm (Cytoxan Lyophilized)

    46.29

    J9093

    Cyclophosphamide Lyophilized, 100 mg (Cytoxan Lyophilized)

    5.29

    J9097

    Cyclophosphamide Lyophilized, 2gm

    92.60

    J9091

    Cyclophosphamide, 1.0 gm (Cytoxan, Neosar)

    43.33

    J9070

    Cyclophosphamide, 100 mg (Cytoxan, Neosar)

    5.43

    J9092

    Cyclophosphamide, 2.0 gm (Cytoxan, Neosar)

    86.63

    J9080

    Cyclophosphamide, 200 mg (Cytoxan, Neosar)

    10.31

    J9090

    Cyclophosphamide, 500 mg (Cytoxan, Neosar)

    21.65

    J9094

    Cyclophosphamide, Lyophilized, 200 mg (Cytoxan Lyophilized)

    10.58

    J9095

    Cyclophosphamide, Lyophilized, 500 mg (Cytoxan Lyophilized)

    23.14

    J9100

    Cytarabine 100 mg (Cytosar-U)

    3.02

    J9110

    Cytarbine, 500 mg (Cytosar-U)

    8.10

    J7070

    D5W, 1000 cc

    10.40

    J9130

    Dacarbazine 100 mg (DTIC-Dome)

    12.02

    J9140

    Dacarbazine 200 mg (DTIC-Dome)

    20.90

    J7513

    Daclizumab, 25 mg (Zenapax)

    402.73

    J9120

    Dactinomycin, .5 mg (Cosmegen)

    13.14

    J1645

    Dalteparin, per 2500 I.U. (Fragmin)

    14.87

    J0880

    Darbepoetin Alfa, 5 mcg (Aranesp)

    22.45

    J9151

    Daunorubicin Citrate Liposomal, 10 mg (DaunoXome)

    61.20

    J9150

    Daunorubicin HCL, 10 mg (Cerubidine)

    70.33

    J0895

    Deferoxamine Mesylate, 500 mg (Desferal)

    14.81

    J9160

    Denileukin Diftitox, 300mcg (Ontak)

    1260.90

    J1000

    Depoestradiol Cypionate, up to 5 mg

    1.80

    J7340

    Dermal and epidermal tissue of human origin, with or without bioengineered or

    27.76

    J2597

    Desmopression Acetate per 1 mcg (DDAVP)

    3.27

    J1094

    Dexamethasone Acetate 1 mg

    0.68

    J1100

    Dexamethosone Sodium Phosphate, 1 mg (Cortastat, Dalalone)

    0.10

    J1190

    Dexrazoxane HCL, 250 mg (Zinecard)

    221.65

    J7110

    Dextran 75, 500 ml

    13.46

    J7042

    Dextrose 5%/Normal Saline (500 ml = 1 unit)

    8.95

    J7060

    Dextrose 5%/Water (500 ml = 1 unit)

    8.57

    J3360

    Diazepam, up to 5 mg (Valium, Zetran)

    0.82

    J1730

    Diazoxide, up to 300 mg (Hyperstat IV)

    116.48

    J0500

    Dicyclomine HCL, up to 20 mg (Bentyl, Dilomine, Antispas)

    16.16

    J9165

    Diethylstilbestrol Diphosphate, 250 mg (Stilphostrol)

    13.65

    J1160

    Digoxin, up to 0.5 mg (Lanoxin)

    1.69

    J1110

    Dihydroergotamine Mesylate, up to 1 mg

    38.16

    J1240

    Dimenhydrinate, up to 50 mg

    0.36

    J0470

    Dimercaprol, per 100 mg

    22.43

    J1200

    Diphenhydramine HCL, up to 50 mg (Benadryl)

    1.52

    J1245

    Dipyridamole, per 10 mg (Persantine IV)

    5.40

    J1212

    DMSO, Dimethyl Sulfoxide, 50%, 50 ml

    42.26

    J1250

    Dobutamine HCL, 250 mg (Dobutrex)

    4.49

    J9170

    Docetaxel, 20 mg (Taxotere)

    339.08

    J1260

    Dolasetron Mesylate, 10 mg (Anzemet)

    15.59

    J1270

    Doxercalciferol, 1 mg (Hectorol)

    5.21

    J1810

    Droperidol and Fentanyl Citrate, up to 2 ml ampule (Innovar)

    8.95

    J1790

    Droperidol, up to 5 mg (Inapsine)

    2.66

    J1180

    Dyphylline, up to 500 mg (Lufyllin, Dilor)

    8.54

    J0600

    Edetate Calcium Disodium up to 1000 mg

    41.78

    J1650

    Enoxaparin Sodium, 10 mg (Lovenox)

    6.13

    J9178

    Epirubicin HCl, 2 mg (Ellence)

    26.18

    Q9920

    EPO, per 1000 units, Patient HCT 20 or less

    12.02

    Q9921

    EPO, per 1000 units, Patient HCT 21

    12.02

    Q9922

    EPO, per 1000 units, Patient HCT 22

    12.02

    Q9923

    EPO, per 1000 units, Patient HCT 23

    12.02

    Q9924

    EPO, per 1000 units, Patient HCT 24

    12.02

    Q9925

    EPO, per 1000 units, Patient HCT 25

    12.02

    Q9926

    EPO, per 1000 units, Patient HCT 26

    12.02

    Q9927

    EPO, per 1000 units, Patient HCT 27

    12.02

    Q9928

    EPO, per 1000 units, Patient HCT 28

    12.02

    Q9929

    EPO, per 1000 units, Patient HCT 29

    12.02

    Q9930

    EPO, per 1000 units, Patient HCT 30

    12.02

    Q9931

    EPO, per 1000 units, Patient HCT 31

    12.02

    Q9932

    EPO, per 1000 units, Patient HCT 32

    12.02

    Q9933

    EPO, per 1000 units, Patient HCT 33

    12.02

    Q9934

    EPO, per 1000 units, Patient HCT 34

    12.02

    Q9935

    EPO, per 1000 units, Patient HCT 35

    12.02

    Q9936

    EPO, per 1000 units, Patient HCT 36

    12.02

    Q9937

    EPO, per 1000 units, Patient HCT 37

    12.02

    Q9938

    EPO, per 1000 units, Patient HCT 38

    12.02

    Q9939

    EPO, per 1000 units, Patient HCT 39

    12.02

    Q9940

    EPO, per 1000 units, Patient HCT 40

    12.02

    Q0136

    Epoetin Alpha (for non ESRD use) per 1000 units (Epogen)

    12.02

    J1325

    Epoprostenol 0.5 mg

    17.11

    J1330

    Ergonovine Maleate, up to 0.2 mg

    4.45

    J1364

    Erythromycin Lactobionate, per 500 mg (Erythrocin)

    3.32

    J1380

    Estradiol Valerate, up to 10 mg

    0.50

    J1390

    Estradiol Valerate, up to 20 mg

    1.00

    J0970

    Estradiol Valerate, up to 40 mg (Delestrogen)

    1.54

    J1410

    Estrogen Conjugated per 25 mg(Premarin intravenous)

    58.28

    J1435

    Estrone, per 1 mg (Estone Aqueous, Estronol, etc.)

    0.54

    J1436

    Etidronate Disodium, per 300 mg (Didronel)

    72.9

    J9181

    Etoposide, 10 mg (VePesid)

    1.62

    J9182

    Etoposide, 100 mg (VePesid)

    16.20

    J7193

    Factor IX (Antihemophilic Factor, Purified, non-recombinant) – per I.U.

    1.06

    J7195

    Factor IX(Antihemophilic Factor recombinant)per I.U.

    1.06

    J7194

    Factor IX complex, per I.U.

    0.35

    Q0187

    Factor VIIa (Coagulation Factor, recombinant) per 1.2 mg (Novoseven)

    15.93

    J7190

    Factor VIII (anti-hemophilic factor, human) per I.U.

    0.83

    J7191

    Factor VIII (anti-hemophilic factor, porcine) per I.U.

    1.94

    J7192

    Factor VIII(anti-hemophilic factor recombinant)per I.U.

    1.20

    J3010

    Fentanyl Citrate, 0.1 mg (2 ml) (Sublimaze)

    0.88

    J1440

    Filgrastim , 300 mcg/1ml (Neupogen)

    176.11

    J1441

    Filgrastim , 480 mcg/1.6ml (Neupogen)

    297.54

    J9200

    Floxuridine, 500 mg (FUDR)

    129.6

    J9185

    Fludarabine Phosphate, 50 mg (Fludara)

    337.33

    J9190

    Fluorouracil, 500 mg (Adrucil)

    1.96

    J2680

    Fluphenazine Decanoate up to 25mg(Prolixin Decanoate)

    8.93

    J1455

    Foscarnet Sodium, per 1000 mg (Foscavir)

    12.38

    J9395

    Fulvestrant, 25 mg (Faslodex)

    82.98

    J1940

    Furosemide, up to 20 mg (Lasix, Furomide M.D.)

    0.93

    J1570

    Ganciclovir Sodium, 500 mg (Cytovene)

    33.40

    J7310

    Ganciclovir, Long-acting Implant, 4.5 mg (Vitrasert)

    4500.00

    J9201

    Gemcitabine HCl. 200 mg (Gemzar)

    114.64

    J1580

    Gentamicin (Garamycin Sulfate) up to 80 mg (Gentamicin Sulfate, Jenamicin)

    1.80

    J1610

    Glucagon Hydrochloride, per 1 mg

    43.20

    J1600

    Gold Sodium Thiomaleate, up to 50 mg (Myochrysine)

    12.81

    J1620

    Gonadorelin Hydrochloride, per 100 mcg (Factrel)

    191.35

    J9202

    Goserelin Acetate Implant, per 3.6 mg (Zoladex)

    422.99

    J1626

    Granisetron Hydrochloride, 100 mcg (Kytril)

    17.57

    J1631

    Haloperidol Decanoate, per 50 mg (Haldol Decanoate – 50)

    8.64

    J1630

    Haloperidol Lactate, up to 5 mg (Haldol)

    6.47

    J1642

    Heparin Sodium, per 10 units (Heparin Lock Flush)

    0.05

    J1644

    Heparin Sodium, per 1000 units

    0.38

    J3470

    Hyaluronidase, up to 150 units (Wydase)

    19.50

    J0360

    Hydralazine HCL, up to 20 mg (Apresoline)

    15.19

    J1700

    Hydrocortisone Acetate, up to 25 mg

    0.32

    J1710

    Hydrocortisone Sodium Phosphate, up to 50 mg

    5.27

    J1720

    Hydrocortisone Sodium Succinate, up to 100 mg

    2.36

    J1170

    Hydromorphone, up to 4 mg (Dilaudid)

    1.47

    J3410

    Hydroxyzine HCL, up to 25 mg (Vistaril, Vistaject-25, Hyzine-50)

    1.14

    J7320

    Hylan G-F 20, 16 mg, for intra-arterial injection (Synvisc)

    220.87

    J1980

    Hyoscyamine Sulfate, up to 0.25 mg (Levsin)

    8.11

    J7130

    Hypertonic Saline Solution, 50 or 100 mEq, 20 cc vial)

    0.50

    J1742

    Ibutilide Fumarate 1 mg. (Corvert)

    238.12

    J9211

    Idarubicin Hydrochloride, 5 mg (Idamycin)

    397.84

    J9208

    Ifosfamide, 1 gm (Ifex)

    142.46

    J1785

    Imiglucerase, per unit (Cerezyme)

    3.56

    J1745

    Infliximab, 10 mg (Remicade)

    62.24

    J1815

    Insulin, up to 100 units (Regular, NPH, Lente, or Ultralente))

    0.10

    J9213

    Interferon, Alfa-2A, Recombinant, 3 million units (Roferon-A)

    33.05

    J9214

    Interferon, Alfa-2B, Recombinant, 1 million units (Intron A)

    14.09

    J9212

    Interferon, Alfacon-1, Recombinant, 1 mcg (Infergen)

    3.88

    J9215

    Interferon, Alfa-N3, (human leukocyte derived) 250,000 IU (Alferon N)

    7.74

    J9216

    Interferon, Gamma 1-B, 3 million units (Actimmune)

    198.21

    J9206

    Irinotecan, 20 mg (Camptosar)

    138.07

    J1750

    Iron Dextran, 50 mg (Infed)

    16.97

    J1756

    Iron Sucrose injection, 1mg (Venofer)

    0.62

    J1840

    Kanamycin Sulfate, up to 500 mg (Kantrex, Klebcil)

    3.11

    J1850

    Kanamycin Sulfate, up to 75 mg (Kantrex, Klebcil)

    0.47

    J1850

    Kanamycin Sulfate, up to 75 mg (Kantrex, Klebcil)

    0.47

    J1885

    Ketorolac Tromethamine, per 15 mg (Toradol)

    3.38

    J3490

    Kutapressin, 1 ml

    7.65

    *

    J3490

    Laronidase, 2.9 mg/5 ml (Aldurazyme)

    699.75

    J0640

    Leucovorin Calcium , per 50 mg (Wellcovorin)

    3.52

    J9219

    Leuprolide Acetate Implant, 65 mg (Viadur)

    5115.60

    *

    J3490

    Leuprolide Acetate, 11.25 mg (Lupron Depot Pediatric)

    1166.26

    *

    J3490

    Leuprolide Acetate, 15 mg (Lupron, for Depot Pediatric)

    1284.51

    J1950

    Leuprolide Acetate, 3.5 mg (Lupron, for Depot Suspension)

    490.10

    *

    J3490

    Leuprolide Acetate, 7.5 mg (Lupron, for Depot Pediatric)

    642.39

    J9217

    Leuprolide Acetate, 7.5 mg (Lupron, for Depot Suspension)

    579.38

    J9218

    Leuprolide Acetate, per 1 mg (Lupron)

    66.58

    J1955

    Levocarnitine, per 1 gm (Carnitor)

    32.40

    J1956

    Levofloxacin, 250 mg (Levaquin)

    19.72

    J1960

    Levorphanol tartrate, up to 2 mg (Levo-Dromoran)

    3.56

    J2001

    Lidocaine HCL, 10 mg IV (Xylocaine)

    0.93

    J2010

    Lincomycin HCL, up to 300 mg (Lincocin)

    3.02

    J2060

    Lorazepam, 2 mg (Ativan)

    2.98

    J3475

    Magnesium Sulfate, 500 mg.

    0.25

    J2150

    Mannitol, 25% in 50 ml

    3.10

    J9230

    Mechlorethamine Hydrochloride (Nitrogen Mustard), 10mg

    11.38

    J1055

    Medroxyprogesterone Acetate for Contraceptive Use, 150 mg (Depo-Provera)

    53.06

    J1051

    Medroxyprogesterone Acetate, 50 mg (Depo-Provera)

    4.78

    J1056

    Medroxyprogesterone Acetate/Estradiol Cypionate 5 mg/25 mg (Lunelle)

    23.32

    J9245

    Melphalan Hydrochloride, 50 mg, (Alkeran)

    397.99

    J2180

    Meperidine and Promethazine HCL, up to 50 mg (Mepergan Injection)

    4.47

    J2175

    Meperidine Hydrochloride, per 100 mg (Demerol HCL)

    0.53

    J0670

    Mepivacaine, per 10 ml (Carbocaine)

    2.03

    J9209

    Mesna, 200 mg (Mesnex)

    34.56

    J0380

    Metaraminol Bitartrate, 10 mg (Aramine)

    1.21

    J1230

    Methadone HCL, up to 10 mg (Dolophine)

    0.71

    J2800

    Methocarbamol, up to 10 ml (Robaxin)

    14.00

    J9250

    Methotrexate Sodium, 5 mg

    0.37

    J9260

    Methotrexate Sodium, 50 mg

    4.50

    J0210

    Methyldopate HCL, up to 250 mg (Aldomet)

    11.26

    J2210

    Methylergonovine Maleate, up to 0.2 mg (Methergine)

    3.89

    J1020

    Methylprednisolone Acetate, 20 mg (Depo Medrol)

    2.54

    J1030

    Methylprednisolone Acetate, 40 mg

    3.92

    J1040

    Methylprednisolone Acetate, 80 mg

    7.84

    J2930

    Methylprednisolone Sodium Succinate, up to 125 mg (Solu-Medrol, A-methaPred)

    3.07

    J2920

    Methylprednisolone Sodium Succinate, up to 40 mg (Solu-Medrol, A-Metha Pred)

    1.85

    J2765

    Metoclopramide HCL, up to 10 mg (Reglan)

    1.88

    J2250

    Midazolam HCL, per 1 mg (Versed)

    1.22

    J2260

    Milrinone Lactate, 5 mg per 5 ml (Primacor)

    48.86

    J9290

    Mitomycin, 20 mg (Mutamycin)

    196.56

    J9291

    Mitomycin, 40 mg (Mutamycin)

    270.00

    J9280

    Mitomycin, 5 mg (Mutamycin)

    60.48

    J9293

    Mitoxantrone HCL, per 5 mg (Novantrone)

    340.43

    J2271

    Morphine Sulfate (100 mg)

    10.49

    J2275

    Morphine Sulfate (preservative-free sterile solution), per 10 mg (Astramorph PF, Duramorph)

    2.26

    J2270

    Morphine Sulfate, up to 10 mg

    0.73

    J2310

    Nalaxone HCL, per 1 mg (Narcan)

    2.24

    J2300

    Nalbuphine Hydrochloride, 10 mg

    1.43

    J2321

    Nandrolone Decanoate, up to 100 mg

    7.26

    J2322

    Nandrolone Decanoate, up to 200 mg

    14.91

    J2320

    Nandrolone Decanoate, up to 50 mg

    3.64

    J2710

    Neostigmine Methylsulfate, up to 0.5 mg (Prostigmin)

    0.64

    J7030

    Normal Saline Solution, 1000 cc, infusion

    10.21

    J7050

    Normal Saline Solution, 250 cc, infusion

    2.56

    J7040

    Normal Saline Solution, Sterile (500 ml=1 unit), infusion

    5.10

    *

    J2353

    Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 10 mg

    146.32

    *

    J2353

    Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 20 mg

    84.02

    *

    J2353

    Octreotide Acetate, 1 mg (Sandostatin LAR Depot), Pricing Based on 30 mg

    75.30

    J2354

    Octreotide Acetate, 25 mcg, non-depot, SC or IV

    4.03

    S0107

    Omalizumab 25mg (Xolair)

    81.19

    J2405

    Ondansetron Hydrochloride, per 1 mg (Zofran)

    5.77

    J2355

    Oprelvekin, 5 mg (Newmega)

    253.80

    J2360

    Orphenadrine Citrate, up to 60 mg (Norflex, etc.)

    5.14

    J2700

    Oxacillin Sodium, up to 250 mg (Bactocile, Prostaphlin)

    0.76

    J9263

    Oxaliplatin, 0.5 mg (Eloxatin)

    8.95

    J2410

    Oxymorphone HCL, up to 1 mg (Numorphan)

    2.80

    J2460

    Oxytetracycline HCL, up to 50 mg (Terramycin IM)

    0.96

    J2590

    Oxytocin, up to 10 units (Pitocin, Syntocinon)

    1.63

    J9265

    Paclitaxel, 30 mg (Taxol)

    155.45

    J2430

    Pamidronate Disodium, per 30 mg (Aredia)

    251.87

    J2440

    Papaverine HCL, up to 60 mg

    3.38

    J9266

    Pegaspargase Single Dose vial, (5 ml) (Oncaspar)

    1462.50

    J2505

    Pegfilgrastim, 6 mg (Neulasta)

    2655.00

    J0540

    Penicillin G Benzathine and Penicillin G Procaine, up to 1,200,000 units (Bicillin C-R)

    22.17

    J0550

    Penicillin G Benzathine and Penicillin G Procaine, up to 2,400,000 units (Bicillin C-R)

    47.48

    J0530

    Penicillin G Benzathine and Penicillin G procaine, up to 600,000 units (Bicillin C-R)

    11.30

    J0570

    Penicillin G Benzathine, up to 1,200,000 units (Bicillin L-A, Permapen)

    18.74

    J0580

    Penicillin G Benzathine, up to 2,400,000 units (Bicillin L-A, Permapen)

    37.48

    J0560

    Penicillin G Benzathine, up to 600,000 units (Bicillin L-A, Permapen)

    9.37

    J2540

    Penicillin G Potassium, up to 600,000 units (Pfizerpen)

    0.28

    J2510

    Penicillin G Procaine, Aqueous, up to 600,000 units (Wycillin, etc.)

    9.10

    J2545

    Pentamidine Isethionate, inhalation solution, per 300 mg (Pentam 300, NebuPent, PentacaRinat)

    48.10

    S0080

    Pentamidine Isethionate, IV, IM, per 300 mg

    42.48

    J3070

    Pentazocine HCL, up to 30 mg (Talwin)

    4.96

    J2515

    Pentobarbital Sodium (Nembutal Sodium Solution), per 50 mg

    1.25

    J9268

    Pentostatin, per 10 mg (Nipent)

    1825.20

    J3310

    Perphenazine, up to 5 mg (Trilafon)

    6.76

    J2560

    Phenobarbital Sodium, up to 120 mg

    1.54

    J2760

    Phentolamine Mesylate, up to 5 mg (Regitine)

    30.24

    J2370

    Phenylephrine HCL, up to 1 ml (NeoSynephrine)

    1.22

    J1165

    Phenytoin Sodium, per 50 mg (Dilantin)

    0.82

    J2543

    Piperacillin Sodium/Tazobactam Sodium 1gm/0.125 gm (1.125gm) (Zosyn)

    4.62

    J9270

    Plicamycin, 2.5 mg (Mithracin)

    88.87

    J9600

    Porfimer Sodium, 75 mg (Photofin)

    2466.64

    J3480

    Potassium Chloride, per 2 mEq.

    0.07

    J2730

    Pralidoxime Chloride, up to 1 gm (Protopam Chloride)

    97.54

    J2650

    Prednisolone Acetate, up to 1 ml

    0.30

    J2690

    Procainamide HCL, up to 1 gm (Pronestyl)

    1.36

    J0780

    Prochlorperazine Edisylate 10 mg (Compazine, Cotranzine, Compa-Z, Ultrazine-10)

    3.96

    J2675

    Progesterone, per 50 mg

    3.49

    J2950

    Promazine HCL, up to 25 mg (Sparine, Prozine-50)

    0.43

    J2550

    Promethazine HCL, up to 50 mg (Phenergan, Phenazine)

    2.70

    J1800

    Propranolol HCL, up to 1 mg (Inderal)

    11.02

    J2720

    Protamine Sulfate, per 10 mg

    0.72

    J2725

    Protirelin, per 250 mcg (Relefact TRH, Thypinone)

    23.11

    J2780

    Rantidine HCL, 25 mg (Zantac)

    1.36

    J2993

    Retaplase, 18.1 mg (Retavase)

    1292.63

    J7120

    Ringers Lactate Infusion, up to 1000 cc

    11.80

    *

    J3490

    Risperidone 25mg (Risperdal Consta)

    249.84

    *

    J3490

    Risperidone 37.5mg (Risperdal Consta)

    374.77

    *

    J3490

    Risperidone 50mg (Risperdal Consta)

    499.69

    J9310

    Rituximab (Rituxan) 100 mg (Rituxan)

    474.76

    J2820

    Sargramostim (GM-CSF), 50 mcg (Leukine, Prokine)

    27.53

    J3490

    Sodium Bicarbonate 7.5% up to 50 ml

    3.20

    J2912

    Sodium Chloride, 0.9% per 2 ml

    0.47

    J2916

    Sodium Ferric Gluconate Complex in Sucrose, 12.5mg (Ferrlecit)

    7.74

    J7317

    Sodium Hyaluronate, per 20-25 mg. for intra-articular injection (Biolon, Provisc, Vitrax, Hyalgan)

    131.41

    J3320

    Spectinomycin Dihydrochloride, up to 2 gm (Trobicin)

    26.78

    J7051

    Sterile Saline or Water (up to 5 cc)

    0.72

    J2995

    Streptokinase, per 250,000 IU (Streptase)

    84.38

    J3000

    Streptomycin, up to 1 gm (Streptomycin Sulfate)

    6.01

    J9320

    Streptozocin, 1 gm (Zanosar)

    134.03

    J0330

    Succinycholine Chloride, up to 20 mg (Anectine, Quelicin, Surostrin)

    0.19

    J3105

    Terbutaline Sulfate, up to 1 mg (Brethine, Bricanyl Subcutaneous)

    27.85

    J1060

    Testosterone Cypionate and Estradiol Cypionate, up to 1 ml

    4.40

    J1070

    Testosterone Cypionate, up to 100 mg

    4.69

    J0900

    Testosterone Enanthate and Estradiol Valerate up to 1 cc (Deladumone, etc.)

    1.55

    J3120

    Testosterone Enanthate, up to 100 mg (Evarone, Delatestryl, etc.)

    8.51

    J3130

    Testosterone Enanthate, up to 200 mg, (Evarone, Delatestryl, Andro L.A. 200, etc.)

    17.02

    J1080

    Testosterone Estradiol Cypionate, 1 cc, 200 mg

    8.94

    J3150

    Testosterone Propionate, up to 100 mg (Testex)

    1.62

    J3140

    Testosterone Suspension, up to 50 mg (Andronaq 50, Testosterone Aqueous, etc.)

    0.38

    J0120

    Tetracycline, up to 250 mg (Achromycin, Panmycin, Sumycin)

    0.23

    J3280

    Thiethylperazine Maleate, up to 10 mg (Norzine, Torecan)

    5.36

    J9340

    Thiotepa, 15 mg (Thioplex)

    110.82

    J3240

    Thyrotropin Alfa, 0.9 mg (Thyrogen)

    585.00

    J3260

    Tobramycin Sulfate, up to 80 mg (Nebcin)

    4.22

    J2670

    Tolazoline HCL, up to 25 mg (Priscoline HCL)

    3.72

    J9350

    Topotecan, 4 mg (Hycamtin)

    756.61

    J3265

    Torsemide, 10 mg/ml (Demadex)

    1.48

    J9355

    Trastuzumab, 10 mg (Herceptin)

    55.07

    J3301

    Triamcinolone Acetonide, per 10 mg (Kenalog-10, Kenalog-40, Tri-Kort, etc.)

    1.51

    J3302

    Triamcinolone Diacetate, per 5 mg (Aristocort Intralesional, Aristocort Forte, Amcort, etc.)

    0.32

    J3303

    Triamcinolone Hexacetonide, per 5 mg (Aristospan Intralesional, Aristospan Intra-articular)

    0.95

    J3400

    Triflupromazine HCL, up to 20 mg (Vesprin)

    11.70

    J3250

    Trimethobenzamide HCL, up to 200 mg (Tigan, Ticon, Tiject-20, Arrestin)

    1.47

    J3305

    Trimetrexate Glucoronate, per 25 mg (Neutrexin)

    135.00

    J3350

    Urea, up to 40 gm (Ureaphil)

    80.00

    J3365

    Urokinase, 250,000 I.U. Vial (Abbokinase)

    484.58

    J3364

    Urokinase, 5000 I.U. vial (Abbokinase Open-Cath)

    9.69

    J9357

    Valrubicin, intravesical, 200 mg (Valstar)

    498.96

    J3370

    Vancomycin HCL, 500 mg (Varcocin, Vancoled)

    6.66

    J9360

    Vinblastine Sulfate, 1 mg (Velban)

    3.89

    J9370

    Vincristine Sulfate, 1 mg (Oncovin,)

    32.19

    J9375

    Vincristine Sulfate, 2 mg (Oncovin)

    64.39

    J9380

    Vincristine Sulfate, 5 mg (Oncovin,)

    151.92

    J9390

    Vinorelbine Tartrate, per 10 mg (Navelbine)

    84.65

    J3430

    Vitamin K, Phytonadione 1 mg/0.5ml

    2.30

    J2501

    Zemplar (Paricalcitol) 1 mcg

    4.75

    J3487

    Zoledronic Acid (Zometa), 1 mg

    205.98

    Note: The following list of drugs has been added since April 2004 bulletin or the code number and/or fee has changed since April 2004. The fees listed for these drugs are current as of the date of this publication.

    Invoice Required

    Procedure Code

    Description

    Maximum Reimbursement Rate

    J9999

    Azacitidine (Vidaza) 25 mg

    $107.40

    S0159

    Agalsidase Beta, 35mg(Fabrazyme)

    4500.00

    S0116

    Bevacizumab (Avastin) 100 mg

    618.75

    J9999

    Cetuximab (Erbitux) 100 mg/50 ml vial

    489.60

    J9300

    Gemtuzumab ozogamicin (Mylotarg) 5 mg

    1953.94

    S0158

    Laronidase (Aldurazyme) .58 mg

    139.95

    *

    J9999

    Pemetrexed (Alimta) 500 mg

    2071.88

    S0163

    Risperidone, long acting (Risperdal Consta) 12.5 mg

    124.92

    J3395

    Verteporfin (Visudyne) 15 mg

    1404.26

    Immune Globulins

    Invoice Required

    Procedure Code

    Description

    Maximum Reimbursement Rate

    90291

    Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use, 1 ml

    $13.49

    J1460

    Gamma Globulin, Intramuscular, 1 cc (Gammar)

    11.53

    J1470

    Gamma Globulin, Intramuscular, 2 cc

    23.07

    J1480

    Gamma Globulin, Intramuscular, 3 cc

    34.63

    J1490

    Gamma Globulin, Intramuscular, 4 cc

    46.13

    J1500

    Gamma Globulin, Intramuscular, 5 cc

    57.66

    J1510

    Gamma Globulin, Intramuscular, 6 cc

    69.05

    J1520

    Gamma Globulin, Intramuscular, 7 cc

    80.64

    J1530

    Gamma Globulin, Intramuscular, 8 cc

    92.26

    J1540

    Gamma Globulin, Intramuscular, 9 cc

    103.89

    J1550

    Gamma Globulin, Intramuscular, 10 cc

    115.32

    J1560

    Gamma Globulin, Intramuscular, over 10 cc (use correct combinations of above codes)

    ^^

    90371

    Hepatitis B immune globulin (HBIg), human, for intramuscular use, 0.5 ml

    615.6

    J1563

    Immune Globulin, Intravenous, 1 gm (Sandoglobulin)

    82.24

    J1564

    Immune Globulin, Intravenous, 10 mg (Sandoglobulin)

    0.82

    90375

    Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous use, 2 ml

    69.01

    90376

    Rabies immune globulin, heat-treated (RIg-HT), human, for intramuscular and/or subcutaneous use, 2 ml

    74.00

    90379

    Respiratory syncytial virus immune globulin (RSV-IgIV), human, for intravenous use, 1 ml

    17.17

    90384

    Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular use, 1500 IU/300 mcg

    95.04

    90385

    Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use, 120 IU/50 mcg

    32.94

    90386

    Rho(D) immune globulin (RhIglV), human, for intravenous use, 100 IU

    20.10

    90389

    Tetanus immune globulin (TIg), human, for intramuscular use, 250 u/1 ml

    118.13

    90396

    Varicella-zoster immune globulin, human, for intramuscular use, 125 u/1.25 ml

    112.50

    (^ ^) Designates special pricing.

    Vaccines/Toxoids

    Medicaid reimburses for vaccines in accordance with the guidelines from the Advisory Committee on Immunization Practices (ACIP). Information regarding the risk categories pertinent to vaccines may be found at http://www.cdc.gov/nip/ACIP/default.htm.

    Medicaid does not reimburse for vaccines provided to recipients ages birth through 18 years that are available through the Universal Childhood Vaccine Distribution Program (UCVDP)/Vaccines for Children (VFC) Program. For Medicaid-eligible recipients ages 19 through 20 who are not age-eligible for the VFC program vaccines, Medicaid will reimburse providers for Medicaid-covered vaccines.

    Vaccines/Toxoids Drug List

    Invoice Required

    Procedure Code

    Description

    Maximum Reimbursement Rate

    90585

    Bacillus Calmette-Guerin vaccine (BCG), for tuberculosis, live, for percutaneous use, per vial

    $151.70

    90721

    Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for intramuscular use

    46.27

    90647

    Hemophilus influenza b vaccine (Hib) PRP-OMP conjugate (3 Dose schedule), for intramuscular use, 0.5 ml

    21.52

    90648

    Hemophilus influenza b vaccine (Hib) PRP-T conjugate (4 dose schedule), for intramuscular use, 0.5 ml

    22.86

    90632

    Hepatitis A vaccine, adult dosage, for intramuscular use, 1ml

    66.65

    90633

    Hepatitis A vaccine, pediatric/adolescent dosage-2 dose schedule, for intramuscular use, 0.5 ml

    28.22

    90746

    Hepatitis B vaccine, adult dosage, for intramuscular use, 1 ml

    52.54

    90747

    Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use, 40 mcg/2ml per dose

    105.08

    90658

    Influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use, 0.5 ml

    9.42

    90705

    Measles virus vaccine, live, for subcutaneous or jet injection use, 0.5 ml

    14.24

    90707

    Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous or jet injection use

    36.98

    90733

    Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous or jet injection use, 0.05 mg

    62.11

    90704

    Mumps virus vaccine, live, for subcutaneous or jet injection use

    $18.41

    90732

    Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use, 0.5 ml

    17.64

    90713

    Poliovirus vaccine, inactivated, (IPV), for subcutaneous use

    24.35

    90675

    Rabies vaccine, for intramuscular use, 2 ml

    129.00

    90680

    Rotavirus vaccine, tetravalent, live, for oral use

    17.37

    90706

    Rubella virus vaccine, live, for subcutaneous or jet injection use, 0.5 ml

    15.85

    90718

    Tetanus and diphtheria toxoids (Td) adsorbed for use in individuals seven years or older, for intramuscular or jet injection, 0.5 ml

    10.92

    90703

    Tetanus toxoid adsorbed, for intramuscular or jet injection use, 0.5 ml

    13.62

    90716

    Varicella virus vaccine, live, for subcutaneous use, 0.5 ml

    61.26

    Aydlett Hunike, Financial Management
    DMA, 919-855-4200


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

    New Guidelines for Enrollment

    Effective January 1, 2005, physician-type providers will enroll directly with the Division of Medical Assistance to participate in the Medicaid program. Blue Cross Blue Shield of North Carolina has processed enrollment for these practitioners for many years, but will no longer do so after December 31, 2004.

    By December 1, 2004, applications, agreements, change forms and instructions will be available on the DMA website. Physician-type providers will be able to download these forms to enroll in the Medicaid program. They will also be able to change their existing enrollment information, including addresses, by downloading and completing DMA enrollment change forms from the DMA website.

    If you have questions about this change in procedure, please contact DMA Provider Services.

    Angela Floyd, Provider Services
    DMA, 919-855-4050


    Attention: Prescribers and Pharmacists

    Discontinuation of Coverage for Anorexia, Weight Loss, and Weight Gain Products and Medications

    Legislation was passed July 1, 2004 removing anorexia, weight loss and weight gain products from the N.C. Medicaid Pharmacy Program. On September 28, 2004, all weight loss products were end-dated to non-coverage status, with an effective date of July 1, 2004 (claims previously paid will not be recouped). N.C. Medicaid will deny claims for weight loss drugs: (J8A - Anorexic Agents, D5A - Fat Absorption Decreasing Agents) including Meridia and Xenical.

    Sharman Leinwand, Pharmacy Manager
    DMA, 919-855-4260


    Attention: Prescribers and Pharmacists

    Discontinuation of Coverage for Vioxx

    Due to the voluntary withdrawl of Vioxx from the U.S. and worldwide market by Merck & Co., Inc., effective with date of service October 1, 2004, the N.C. Medicaid program end-dated coverage for all forms of Vioxx.

    Prior approval overrides will not be issued by the N.C. Medicaid program for Vioxx. Individual prescribers must prescribe an alternative medication for their patients.

    Sharman Leinwand, Pharmacy Manager
    DMA, 919-855-4260


    Attention: Prescribers and Pharmacists

    Medical Necessity Criteria for Approval of Oxycontin

    Effective with date of service August 24, 2004, the medical necessity criteria for the approval of Oxycontin was revised to address the following situations.

    Criteria for Cancer or Patients with Other Terminal Illnesses

    1. Patient must have failed therapy with generic products (oxycodone or similar narcotic analgesics).

    2. A maximum of six tablets per day may be authorized.

    3. Length of therapy may be approved for up to one year.

    Criteria for Chronic, Nonmalignant Pain

    1. Patient must have failed therapy with generic products (oxycodone or similar narcotic analgesics).

    2. Patient must have a diagnosis of chronic pain syndrome of at least four weeks duration.

    3. Patient must have a pain agreement on file at the physician’s office.

    4. A copy of this form may be requested by the Division of Medical Assistance.

    5. A maximum of four tablets per day may be authorized.

    6. Length of therapy may be approved for up to one year.

    Additional information, including prior authorization criteria, frequently asked questions, and prior authorization forms is available online at http://www.ncmedicaidpbm.com.

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


    Attention: Prescribers and Pharmacists

    Medical Necessity Criteria for Approval of Provigil

    Effective with date of service August 24, 2004, the medical necessity criteria for the approval of modafinil (Provigil) was revised.

    Approval of Provigil is considered as a treatment to improve wakefulness for patients who:

  • Are at least 16 years old and have a diagnosis of narcolepsy.
  • Are at least 16 years old and have excessive sleepiness associated with shift work sleep disorder.
  • Require adjunct treatment for a diagnosis of obstructive sleep apnea/hypopnea syndrome (OSAHS) with concurrent use of continuous positive airway pressure (CPAP) if CPAP is the treatment of choice.
  • The maximum daily dose should be two tablets per day for all strengths.

    Additional information, including prior authorization criteria, frequently asked questions, and prior authorization forms is available online at http://www.ncmedicaidpbm.com.

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


    Attention: Prescribers and Pharmacists

    Removal of Smoking Cessation Medications and Products from the Prior Authorization Drug List

    Effective with date of service August 25, 2004, the following smoking cessation medications and products no longer require prior authorization from Medicaid:

  • Zyban (buproprion)
  • Nicotrol NS (nicotine patch)
  • Nicotrol Cartridge Inhaler
  • There is no limit to the number of times a recipient can receive these medications and products.

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


    Attention: Prescribers and Pharmacists

    Revised Criteria 1a through 1d Synagis Form

    The Criteria 1a-1d form for Synagis has been revised to correct an error in the date of birth requirement for patients with Hemodynamically Significant Heart Disease. The date of birth for this group of patients must be on or after October 15, 2002, which will allow receipt of Synagis for patients 24 months or younger. This change is consistent with the Red Book 2003 guidelines as follows:

    "Children who are 24 months of age or younger with hemodynamically significant cyanotic and acyanotic congenital heart disease will benefit from 5 monthly intramuscular injections of palivizumab (15mg/kg). Decisions regarding prophylaxis with palivizumab in children with congenital heart disease should be made on the basis of the degree of physiologic cardiovascular compromise. Infants younger than 12 months of age with congenital heart disease who are most likely to benefit from immunoprophylaxis include:

  • Infants who are receiving medication to control congestive heart failure
  • Infants with moderate to severe pulmonary hypertension
  • Infants with cyanotic heart disease"
  • Also, there has been some confusion regarding requirements for prematurity in criteria 1a. Chronic Lung Disease is the same as Bronchopulmonary Dysplasia (BPD) which is generally a lung disease of prematurity. This is not asthma.

    Synagis Policies and Procedure for the RSV season 2004-2005.

    Sharman Leinwand, Pharmacy Manager
    DMA, 919-855-4260


    Attention: Physician and Hospital Providers

    Stem Cell Transplants-Prior Approval Effective Dates

    Prior approval for stem cell transplants will only be effective for a six month period, from the date the prior approval is granted. If services extend beyond the six month period, providers will need to notify the hospital consultant, and a new request, along with additional clinical information may be requested.

    Debbie Garrett, RNC, Hospital Consultant
    Clinical Policy and Programs
    DMA, 919-857-4020


    Attention: Community Alternative Providers

    Proposed CAP-MR/DD Rates

    The proposed CAP-MR/DD rates and service changes to be effective April 1, 2005, have been published on the following web sites as of October 19, 2004:

  • DMA web site
  • DMH/DD/SAS
  • These rates are based on the service definitions contained within the CAP-MR/DD waiver posted on the DMH/DD/SAS web site.

    In arriving at the proposed CAP-MR/DD Medicaid rates, there were some new services added as well as other services being eliminated based on the new waiver. Service rates were updated for increases which had occurred across all specialties regarding personal care and nurse visits. Additionally, multiple cost models for the new services were developed that factored in direct labor costs, supervisory labor costs, supply costs, and other administrative costs. Subject matter experts were consulted and asked for input into the calculations of the cost models. Once all of this data was collected, the rate setting staff of DMA and the DMH/DD/SAS jointly reviewed the forecasted volume of service costs and the cost models and agreed on rates and anticipated utilizations to arrive at the proposed CAP-MR/DD Medicaid rates.

    The Department of Health and Human Services is appreciative of and welcomes input regarding these proposed rates prior to finalization. In order to effectively address and respond to concerns regarding these rates, it is necessary for DMA, DMH/DD/SAS and the Controller’s Office to focus on issues brought to us from a representative sample of actual service providers. For consideration of any discussion of the new proposed rates, DMA, DMH/DD/SAS, and Controller’s Office rate setting staff will seek data and analyses from at least three providers for each service for comparison. This data must include the assumptions and the calculations to arrive at cost figures from financial statements which need to accompany the cost data.

    The selection of providers to submit cost data will be performed in a new manner. The selection of providers will come from a provider database being developed by DMH/DD/SAS. DMH/DD/SAS and DMA will select a representative sample of providers from the providers currently listed in the provider database in addition to specific provider recommendations from various provider organizations in order to review the attached proposed rates for implementation April 1, 2005. The process will bring together the providers with DMA, DMH/DD/SAS and Controller’s Office staff to walk through the new services and rates. If providers disagree with any of the proposed rates, they will have the opportunity to submit data to DMA, DMH/DD/SAS and the Controller’s Office, as described above, for the purpose of rate reconsideration. The participating providers will have until November 19, 2004 to submit their cost data. The providers selected for this review process will be listed on each Division’s web page. Following this review, final rates will be presented to the DHHS Rate Review Board for approval and implementation.

    In the future, it is our intent for the provider database to become more comprehensive. The database will consist of providers who have expressed a willingness to participate with DHHS staff in future meetings around rate and policy issues. This database will be developed as follows:

    1. DMH/DD/SAS and DMA will send out a communication to providers, provider organizations, LMEs, etc., prior to November 1, 2004, informing them of the provider database and indicating how providers can express their willingness to participate;

    2. DMH/DD/SAS will set up the database on its public web page through which providers can indicate their willingness to participate by entering the required provider information such as, services provided, agency budget, sources of revenues, incorporation status of the provider, number of consumers served, etc.

    DMA and DMH/DD/SAS will make development of the provider listing an open and widely publicized process to ensure that all providers who are willing to participate have the opportunity to sign up. By rotating provider participation around subsequent rate and policy issues, DHHS will seek to broaden provider representation and input into the various rate and policy issues which impact MH/DD/SA service development and operation. Rotation of provider representation will also help ensure that providers with relevant experience are involved in related rate and policy issues.

    Jamie Christensen, Rate Setting
    DMA, 919-855-4200


    Attention: Mental Health Providers

    Proposed Enhanced Benefits and Existing Mental Health Rates

    The proposed Enhanced Benefits and existing Mental Health Service rates to be effective July 1, 2005, have been published on the following web sites as of October 19, 2004 on:

  • DMA web site
  • DMH/DD/SAS
  • The rates are based on the service definitions posted on the DMHDDSAS web site

    In arriving at the proposed FY 2006 Medicaid rates, there were many factors that were considered in the calculation methodologies. The first factor was taking historical actual claims paid in FY 2003 multiplied by the rate in place for FY 2004 to give a real expended figure for projection into the new service definitions established jointly by DMA and DMH/DD/SAS. This volume of service costs was cross walked into the new service definitions with an anticipated utilization developed by DMH/DD/SAS. In addition to referencing rate information provided by TAC, multiple cost models were developed that factored in direct labor costs, supervisory labor costs, supply costs, and other administrative costs. Subject matter experts in all areas of service delivery were polled and asked for input into the calculations of the numerous cost models. Once all of this data was collected, the rate setting staff of DMA and the DMH/DD/SAS jointly reviewed the forecasted volume of service costs and the cost models and agreed on rates and anticipated utilizations to arrive at the proposed FY 2006 Medicaid rates.

    The Department of Health and Human Services is appreciative of and welcomes input regarding these proposed rates prior to finalization. In order to effectively address and respond to concerns regarding these rates, it is necessary for DMA, DMH/DD/SAS and the Controller’s Office to focus on issues brought to us from a representative sample of actual service providers. For consideration of any discussion of the new proposed rates, DMA, DMH/DD/SAS and the Controller’s Office rate setting staff will seek data and analyses from at least three providers for each service for comparison. This data must include the assumptions and the calculations to arrive at cost figures from financial statements which must accompany the cost data.

    The selection of providers to submit cost data will be performed in a new manner. The selection of providers will come from a provider database being developed by DMH/DD/SAS. We find this is necessary since many providers currently bill for services through area programs; thus they are not visible to the State. DMH/DD/SAS and DMA will select a representative sample of providers from the providers currently listed in the provider database in addition to specific provider recommendations from various provider organizations in order to review the attached proposed rates for implementation July 1, 2005. The process will bring together the providers with DMA, DMH/DD/SAS and the Controller’s Office staff to walk through the new services and rates. If providers disagree with any of the proposed rates, they will have the opportunity to submit data to DMA, DMH/DD/SAS and the Controller’s Office, as described above, for the purpose of rate reconsideration. The participating providers will have until November 19, 2004 to submit their cost data. The providers selected for this review process will be listed on each Division’s web page. Following this review, final rates will be presented to the DHHS Rate Review Board for approval and implementation.

    In the future, it is our intent for the provider database to become more comprehensive. The database will consist of providers who have expressed a willingness to participate with DHHS staff in future meetings around rate and policy issues. This database will be developed as follows:

    1. DMH/DD/SAS and DMA will send out a communication to providers, provider organizations, LMEs, etc., prior to November 1, 2004, informing them of the provider database and indicating how providers can express their willingness to participate;

    2. DMH/DD/SAS will set up the database on its public web page through which providers can indicate their willingness to participate by entering the required provider information such as, services provided, agency budget, sources of revenues, incorporation status of the provider, number of consumers served, etc.

    DMA and DMH/DD/SAS will make development of the provider listing an open and widely publicized process to ensure that all providers who are willing to participate have the opportunity to sign up. By rotating provider participation around subsequent rate and policy issues, DHHS will seek to broaden provider representation and input into the various rate and policy issues which impact MH/DD/SA service development and operation. Rotation of provider representation will also help ensure that providers with relevant experience are involved in related rate and policy issues.

    In addition this bulletin, the same communications were sent on October 19, 2004, to Area/County MHDDSAS Directors, and various providers, stakeholders and professional organizations.

    Bill Connelly, Rate Setting
    DMA, 919-855-4200


    Attention: Outpatient Mental Health Providers

    ValueOptions

    Effective immediately, ValueOptions has revised their Outpatient Treatment Report. This form will reflect utilization of H codes and CPT codes. Providers can access these forms on the web at http://www.ValueOptions.com.

    Carolyn Wiser, Behavioral Health Services
    DMA, 919-855-4290


    Attention: Hospice Providers

    Medicaid Reimbursement Rates for Hospice Services

    Effective with date of service October 1, 2004, the maximum allowable rate for the following hospice services are outlined below:

         

    Routine Home Care

    Continuous Home Care

    Inpatient Respite Care

    General Inpatient Care

    Metropolitan Statistical Area

    SC

    MSA

    RC 651

    Daily

    RC 652

    Hourly

    RC 655

    Daily

    RC 656

    Daily

    Asheville

    39

    480

    125.16

    30.41

    135.41

    555.11

    Charlotte/Gastonia/Rock Hill

    41

    1520

    125.51

    30.49

    135.71

    556.57

    Fayetteville

    42

    2560

    118.59

    28.81

    129.78

    527.92

    Greensboro/Winston-Salem/High Point

    43

    3120

    120.20

    29.20

    131.16

    534.59

    Hickory/Morganton/Lenoir

    44

    3290

    120.88

    29.37

    131.74

    537.40

    Jacksonville

    45

    3605

    114.64

    27.85

    126.39

    511.56

    Raleigh/Durham/Chapel Hill

    46

    6640

    127.29

    30.93

    137.23

    563.94

    Wilmington

    47

    9200

    123.75

    30.07

    134.20

    549.28

    Rural Counties

    53

    9934

    113.87

    27.67

    125.74

    508.40

    Goldsboro

    105

    2980

    115.33

    28.02

    126.99

    514.44

    Greenville

    106

    3150

    119.60

    29.06

    130.64

    532.09

    Norfolk (Currituck County)

    107

    5720

    115.31

    28.02

    126.97

    514.34

    Rocky Mount

    108

    6895

    119.40

    29.01

    130.47

    531.25

    At this time, the rate for RC 659 is still reimbursed at $131.14

    Key to the Hospice Rate Table

    SC

    Specialty Code

    RC

    Revenue Code

    1. A minimum of eight hours of continuous home care per day must be provided.
    2. There is a maximum of five consecutive days including the date of admission but not the date of discharge for inpatient respite care. Bill for the sixth day and any subsequent days at the routine home care rate.
    3. When a Medicare/Medicaid recipient is in a nursing facility, Medicare is billed for routine or continuous home care, as appropriate, and Medicaid is billed for the appropriate long-term care rate. When a Medicaid only hospice recipient is in a nursing facility, the hospice may bill for the appropriate long-term care rate in addition to the home care rate provided in RC 651 or RC 652.
    4. The hospice refunds any overpayments to the Medicaid program.
    5. Date of Discharge: For the day of discharge from an inpatient unit, the appropriate home care rate must be billed instead of the inpatient care rate unless the recipient expires while inpatient. When the recipient is discharged as deceased, the inpatient care rate (general or respite) is billed for the discharge date.
    6. Providers are expected to bill their usual and customary charges. Adjustments will not be accepted for rate changes.

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


    Attention: All Providers

    Influenza Vaccine Coverage

    North Carolina faces a shortage of influenza vaccine this year due to the loss of approximately one half of the United States supply of trivalent inactivated vaccine for the 2004-2005 influenza season. As a result of this shortage, the N.C. Medicaid program and the N.C. Division of Public Health are following the CDC’s recommendations for prioritizing the use of the remaining vaccine supplies.

    CDC urges vaccination of the following priority groups:

  • all children aged 6-23 months,
  • adults aged > 65 years,
  • persons aged 2-64 years with underlying chronic medical conditions,
  • all women who will be pregnant during influenza season,
  • residents of nursing homes and long-term care facilities,
  • children 6 months-18 years of age on chronic aspirin therapy,
  • health-care workers providing direct patient care, and
  • out-of-home caregivers and household contacts of children aged <6 months
  • Information regarding the risk categories pertinent to influenza vaccine can be accessed online at http://www.cdc.gov/nip/ACIP/default.htm.

    FluMist Nasal Vaccine

    The N.C. Medicaid program is also responding to the vaccine shortage by covering the FluMist nasal vaccine for healthy recipient’s ages 5 years through 49 years who are household contacts of medically high-risk Medicaid recipients. The coverage is effective with date of service October 1, 2004. FluMist is only covered when it is dispensed at the local health department according to the guidelines from the Advisory Committee on Immunization Practices. This policy will remain in effect through March 31, 2005.

    The inactivated influenza vaccine is preferred over LAIV, known commercially as FluMist, for household members, health-care workers, and others who have close contact with severely immunosupressed persons (e.g., patients with hepatopoietic stem cell transplants) during those periods when the person requires care in a protective environment.

    No preference exists, however, for inactivated influenza vaccine use by some members of the last two high-risk groups mentioned above. Health-care workers providing direct patient care, and out-of-home caregivers and household contacts of children aged <6 months may be candidates for the FluMist vaccine.

    The following people should not receive the intranasal influenza vaccine (FluMist).

  • People less than 5 years of age.
  • People 50 years of age and over.
  • People with a medical condition that places them at high risk for complications from influenza, including those with chronic heart or lung disease, such as asthma or reactive airways disease; people with medical conditions such as diabetes or kidney failure; or people with illnesses that weaken the immune system, or who take medications that can weaken the immune system.
  • Children or adolescents receiving aspirin.
  • People with a history of Guillain-Barré syndrome, a rare disorder of the nervous system.
  • Pregnant women.
  • People with a history of allergy to any of the components of LAIV or to eggs.
  • Reimbursement Guidelines

    Reimbursement for the Injectable Vaccine for Recipients through Age 18

    The Immunization Branch distributes childhood vaccines to local health departments, hospitals, and private providers to be used in accordance with the N.C. Universal Childhood Vaccine Distribution Program/Vaccine for Children (UCVDP/VFC) coverage criteria and state law/administrative code. The N.C. Medicaid program does not routinely reimburse for vaccines that are supplied through UCVDP/VFC for recipients through 18 years of age. However, due to the shortage of the influenza vaccine for the 2004-2005 flu season, Medicaid will reimburse providers who have purchased a supply of the injectable vaccine because the supply of free vaccine has been exhausted when it is used for recipients through 18 years of age. Reimbursement for purchased vaccine will be made for dates of service October 1, 2004 through March 31, 2005.

    Changes are underway to allow for processing of claims for the purchased injectable vaccine. Providers should watch future bulletins for notification that the system is prepared to accept claims.

    Reimbursement for the Injectable Vaccine for Recipients 19 Years of Age and Older

    Providers may bill Medicaid for influenza vaccine for high-risk adults 19 and 20 years of age using CPT code 90658. Refer to the 2004 Health Check Special Bulletin, page 7, for billing guidelines.

    All providers may bill Medicaid for influenza vaccine for high-risk adults > 19 years of age using CPT code 90658 and for the administration fee using CPT code 90471. 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.

    Reimbursement for FluMist Vaccine

    Changes are underway to allow for processing of Local Health Department claims for FluMist. An administration fee will not be reimbursed in addition to the cost of the vaccine. Providers should watch future Medicaid bulletins for notification that the system is prepared to accept claims. FluMist will be reimbursed only when administered at the Local Health Department.

    Billing Reminders for Vaccine Supplied Through VFC

    Medicaid does not reimburse for influenza vaccine that is supplied through UCVDP/VFC for recipients through 18 years of age. Report CPT code 90655 or 90657 for children < 6 months through 35 months of age and CPT code 90658 for children > 3 years of age through 18 years of age.

    Providers may bill for an administration fee using CPT code 90471 or 90471 and 90472, as appropriate. Local health departments, however, may only bill CPT code 90471 with the EP modifier for any visit other than a Health Check screening. Refer to the 2004 Health Check Special Bulletin, page 7, for billing guidelines.

    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.


    Holiday Closing

    The Division of Medical Assistance (DMA) and EDS will be closed on Thursday, November 11, 2004 in observance of Veteran’s Day and on Thursday, November 25, 2004 and Friday, November 26, 2004 in observance of Thanksgiving.


    Checkwrite Schedule

    November 2, 2004

    December 7, 2004

    November 9, 2004

    December 14, 2004

    November 16, 2004

    December 22, 2004

    November 24, 2004

    Electronic Cut-Off Schedule

    October 29, 2004

    December 3, 2004

    November 5, 2004

    December 10, 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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