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November 2009
Medicaid Bulletin

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In This Issue . . .

 

All Providers:

CAP/MR-DD Providers:

Children’s Developmental Service Agencies:

Durable Medical Equipment Providers:

Enhanced Behavioral Health (Community Intervention) Services Providers:

Health Departments:

Home Health Agencies:

Hospital Outpatient Clinics:

Independent Practitioners:

Local Education Agencies:

Local Management Entities:

Nurse Practitioners:

Pharmacists:

Physicians:

Prescribers:

Residential Child Care Treatment Facilities:


Attention:  All Providers

EDS Announces New Name

In August 2008, Hewlett-Packard (HP) acquired EDS, fiscal agent for the N.C. Medicaid Program.  As a result of this acquisition, EDS is changing its name to HP Enterprise Services.

North Carolina Medicaid providers will not be affected by this change and will probably notice very few changes.  Providers will begin to see the HP logo or the HP Enterprise Services name on correspondence and forms.  The mailing address is not changing but providers should address the mail to HP Enterprise Services.  E-mail correspondence will come from an “@hp.com” e-mail address rather than an “@eds.com” e-mail address.  And, providers will hear the HP name when contacting the Raleigh call center.  Think of it as a sports team changing jerseys.  The same players are on the field working hard to deliver the outstanding Medicaid services you’ve come to expect from a trusted business ally.

The new name reflects HP’s commitment to the longtime success of its clients.  It also reminds our clients of the enhanced value they now get from the combination of EDS’ proven operational excellence PLUS the best-in-class technology of HP.

HP Enterprise Services
1-800-688-6696 or 919-851-8888


Attention:  All Providers

Electronic Funds Transfer

The N.C. Medicaid Program will no longer issue paper checks for claims payments.  All payments will be made electronically by automatic deposit to the account specified in the provider's Electronic Funds Transfer (EFT) Authorization Agreement for Automatic Deposits.

Providers must complete and submit an EFT Authorization Agreement immediately to ensure that there is no disruption to payments.  Claims will suspend if an EFT Authorization Agreement has not been submitted to and processed by the N.C. Medicaid Program.

Below are fax numbers available for providers to send EFT Authorization Agreements to HP Enterprise Services (EDS):

The e-mail address for submitting EFT Authorization Agreements to HP Enterprise Services (EDS) is NCXIXEFT@eds.com.

HP Enterprise Services
1-800-688-6696 or 919-851-8888


Attention:  All Providers

Electronic Claim Submission EOB Code

Effective with date of processing October 2, 2009, the N.C. Medicaid Program requires all providers to file claims electronically.  Claims received on or after October 2, 2009, are subject to denial if the claim is not in compliance with the electronic claim mandate.  Information on the electronic claim mandate, originally published in the July 2009 Medicaid Bulletin, is available on DMA’s Budget Initiatives web page.

Prior to submitting electronic claims, providers must have an Electronic Claim Submission (ECS) Agreement on file with N.C. Medicaid.  If an ECS Agreement is not on file, providers may obtain the form on the NC Tracks Provider Forms web page.

To prepare for the electronic claim submission requirement, providers should familiarize themselves with the following EOB code.

EOB 8700 – Per legislative mandate this Medicaid claim must be filed electronically for adjudication.

If a paper claim is submitted and is not included on the list of ECS exceptions, the claim will be denied.  The list of exceptions to the requirement for electronic claim submissions has been revised and is available on DMA’s ECS Exceptions web page.  Only claims that comply with these exceptions may be submitted on paper.  All other claims are required to be submitted electronically.

HP Enterprise Services
1-800-688-6696 or 919-851-8888


Attention: All Providers

Paper Claim Submissions

If a claim meets one of the exceptions to the electronic claims submission requirement, providers should submit the original claim and not a carbon copy or photocopy of the claim.  Because paper claims are manually keyed into the system, submitting the original will decrease the number of denials that providers receive due to keying errors.

When completing the paper claim form, use black ink only.  Do not submit carbon copies or photocopies.  HP Enterprise Services (EDS) uses optical scanning technology to store an electronic image of the claim and the scanners cannot detect carbon copies, photocopies, highlighted data or any color of ink other than black.  For auditing purposes, all claim information must be visible in an archive copy.  Carbon copies, photocopies, and claims containing a color of ink other than black will not be processed and will be returned to the provider.

HP Enterprise Services
1-800-688-6696 or 919-851-8888

ECS Exceptions Web Page


Attention:  All Providers

Urine Drug Testing

Providers are reminded to use the appropriate codes when billing for urine drug testing.  Providers must use CPT code 80100 (drug screen, qualitative; multiple drug classes chromatographic method, each procedure) or CPT code 80101 (single drug class method [eg, immunoassay, enzyme assay], each drug class) for initial drug screenings. 

CPT code 80102 (drug confirmation, each procedure) must be used by laboratories for drug confirmation.  When sending a urine drug test to an outside laboratory for confirmation, the provider should specify the positive results of the drug screen that need to be confirmed.  The laboratory should confirm only the drugs that were positive and bill CPT code 80102 with the correct number of units. 

HP Enterprise Services
1-800-688-6696 or 919-851-8888


Attention:  All Providers

Obtaining Informed Consent on Sterilization Consent Forms

DMA has become aware that some providers have been referring Medicaid recipients to the local department of social services (DSS) to complete the federally mandated Sterilization Consent form and to obtain informed consent prior to a sterilization procedure.  According to Clinical Coverage Policy 1E-3, Sterilization Procedures, “Providers must complete a valid sterilization consent form prior to rendering a sterilization procedure.” 

Moreover, review of federal guidelines located in 42 CFR 441.257 and 441.258 indicates that an individual who can answer specific questions about the procedure and potential complications should be counseling the recipient.  Therefore, it is the medical provider’s responsibility to obtain informed consent and this should not be delegated to DSS. 

Beginning December 1, 2009, consent forms cannot be completed by DSS.  Any consent form completed by a DSS agency on which the date completed is on or after December 1, 2009, will be considered an invalid consent.  Claims submitted with these consent forms on file will be denied.

HP Enterprise Services
1-800-688-6696 or 919-851-8888


Attention:  All Providers

Suspension of New Enrollment for At-Risk Case Management Providers

DMA has temporarily suspended enrollment for providers of Case Management Services for Children and Adults Who Are at Risk for Abuse, Neglect or Exploitation.  Due to this action, the Division of Aging and Adult Services (DAAS) is not currently accepting applications for certification as an “At Risk Case Management Certified Agency” from any provider agencies except local county departments of social services.  This policy will be evaluated at the conclusion of the work of the Consolidated Case Management Task Force and subsequent payment study.  We apologize for any inconvenience due to these actions.

Julie Budzinski
DMA, 919-855-4368

Charles Williams
DAAS, 919-733-3818


Attention:  All Providers

North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool

In September 2009, the N.C. Medicaid Program implemented the North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool.  This tool allows providers to access electronic recipient eligibility information via the North Carolina Electronic Claims Submission (NCECS) Web Tool.

Use of this tool allows providers to immediately verify recipient information such as

This is the same information that providers receive today through the Automated Voice Response (AVR) system but the tool is quicker and easier to use.  In order to use this tool, providers must have access to the NCECSWeb Tool.  DMA encourages you to begin immediately the process of obtaining this access.

Providers who currently have an NCECSWeb logon ID and password can utilize this same logon information to access recipient eligibility verification.  You do not need to take any further action.

Providers who do not currently have access to the NCECSWeb must take the following action.

Step One:

Submit a completed and signed Electronic Claims Submission (ECS) Agreement to CSC.  (Refer to the
NC Tracks Provider Forms web page for a copy of the form and instructions.)

Note:  Providers who have previously submitted the ECS Agreement do not need to resubmit the form.

Step Two:

Contact the HP Enterprise Services (EDS) Electronic Commerce Services Unit (1-800-688-6696 or
919-851-8888, option 1) to obtain instructions and a logon ID and password for the NCECSWeb Tool.

For additional information on verifying recipient eligibility, refer to the Basic Medicaid Billing Guide.  For detailed information on the NCECSWeb Tool, refer to the September 2009 Special Bulletin, North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instruction Guide.

HP Enterprise Services
1-800-688-6696 or 919-851-8888


Attention:  All Providers

Notice of Medicaid Identification Card Changes

On September 8, 2009, the N.C. Medicaid Program began issuance of one Medicaid identification (MID) card per year to each recipient (refer to the September 2009 Medicaid Bulletin article titled Notice of Medicaid Identification Card Changes).  The new annual cards (see new card sample) are printed on gray card stock.  The blue, pink, green, and buff-colored MID cards are being phased out.  The new cards include the case head name, recipient name, MID number, issue date, and Community Care of North Carolina/Carolina ACCESS (CCNC/CA) primary care provider information (if applicable).  The new cards do not indicate dates of eligibility, Medicaid program or special coverage.  Recipients who are issued new cards may have been approved for prior months only, the current month only, or an ongoing period of up to 12 months.

Because the new card no longer serves as proof of eligibility, it is essential that at each visit providers verify the recipient’s

To verify eligibility, a provider can choose to use the North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool (NCECSWeb Tool), the real time or batch Eligibility Verification System (EVS), or the HP Enterprise Services (EDS) Automated Voice Response (AVR) system.  Information on how to enroll and use the NCECSWeb tool can be found in the September 2009 Special Bulletin, North Carolina Electronic Claims Submission/Recipient Eligibility Verification Web Tool Instruction Guide.  For information regarding real-time and batch eligibility, contact the HP Enterprise Services (EDS) ECS Unit at 1-800-688-6696 (option 1).  Information about the AVR system is available in the July 2001 Special Bulletin, Automated Voice Response (AVR) System Provider Inquiry Instructions.  To access the AVR system, call HP Enterprise Services (EDS) at 1-800-723-4337. 

The methods listed above will not only serve to verify eligibility, but also to inform the provider as to whether the recipient is entitled to any special services, such as the Program of All-inclusive Care for the Elderly (PACE) or the Community Alternatives Program, or enrolled in a restrictive program, such as the Family Planning Waiver or Medicaid for Pregnant Women.  Recipients enrolled in PACE receive their medical care exclusively through the PACE organization.  When using the AVR system, it is, therefore, important that providers listen to the entire recorded message and follow the prompts as directed or important parts of eligibility information may be missed.

Each year a recipient will receive a new card.  The new card will be issued on the anniversary of the issuance of the previous card.  When the recipient receives the card depends on the month in which the recipient received the previous card.  Recipients should be referred to their local department of social services to request a replace card, if needed.

Medicaid Eligibility Unit
DMA, 919-855-4000


Attention:  All Providers

Influenza A (H1N1) 2009 Monovalent Vaccine and Reimbursement Guidelines for 2009/2010

The N.C. Medicaid Program reimburses for vaccines in accordance with guidelines from the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP).  ACIP recommendations on 2009/2010 H1N1 influenza vaccine can be found on the CDC website at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5810a1.htm?s_cid=rr5810a1_e.

N.C. Distribution Program for the H1N1 Vaccine

The federal government has purchased the H1N1 influenza vaccines to distribute for administration to persons of all ages, based on the established priority groups.  H1N1 vaccine will not be available for providers to purchase.  The majority of the H1N1 vaccine manufactured is expected to be injectable, with the balance being intranasal.  The N.C. Immunization Branch of the Division of Public Health will distribute the H1N1 vaccines to providers.

Reporting the H1N1 Influenza Vaccine and Billing for Administration Costs

The H1N1 vaccine, regardless of formulation, CANNOT be billed to Medicaid.  The CPT code for all formulations of the H1N1 vaccine is 90663.  All providers are required to report the vaccine code, with a charge of $0.00.  Providers may bill the N.C. Medicaid Program for the administration costs of the vaccines.  Because the live intranasal seasonal (FluMist, CPT code 90660) AND live intranasal H1N1 influenza vaccines (CPT code 90663) CANNOT be administered simultaneously (same day), Medicaid cannot cover these two procedure codes billed on the same day.

The following tables indicate the vaccine code that must be reported for all of the formulations of the H1N1 influenza vaccine.  The tables also indicate the administration codes that can be billed by providers, depending on the age of the recipient.  The ICD-9-CM diagnosis for H1N1 influenza vaccine, V04.81, may be billed, as appropriate.

Note:  The information in the following tables is not detailed billing guidance.  Specific information on billing all immunization administration codes for recipients 0 through 20 years of age (6 months through 20 years of age for influenza vaccines) can be found in the April 2009 Special Bulletin, Health Check Billing Guide 2009.

Table 1:  H1N1 Influenza Billing Codes for Recipients Age 6 Months through 20 Years of Age

All Providers

Use the following CPT procedure code to report (with a charge of $0.00) the H1N1 vaccine administered to a recipient 6 months through 20 years of age. 

Vaccine CPT Code to Report

CPT Code Description

90663

Influenza virus vaccine, pandemic formulation

Private Providers, Federally Qualified Health Centers, Rural Health Clinics, and Local Health Departments

The table below includes options for billing H1N1 as the ONLY vaccine administered on that day to a recipient 6 months through 20 years of age that day or as an additional vaccine administered that day.  An injectable vaccine administered on the same day as an oral or intranasal vaccine should be considered the primary administration code.

Administration CPT Code(s) to Bill

CPT Code Description

90465EP

Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day

90466EP

Each additional injection (single or combination vaccine/toxoid), per day (list separately in addition to code for primary procedure). 

Note:  Providers may bill more than one unit of 90466EP as appropriate.

90467EP

Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day.

Note:  Billing CPT code 90468 for a second administration of an intranasal/oral vaccine when physician counseling was performed is not applicable at this time.

90468EP

Each additional administration (single or combination vaccine/toxoid) per day (list separately in addition to code for primary procedure).

Note:  Billing CPT code 90468 for a second administration of an intranasal/oral vaccine is not applicable at this time.

90471EP

Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)

90472EP

Each additional vaccine (single and combination vaccine/toxoid) (list separately in addition to code for primary procedure).

Note:  Providers may bill more than one unit of 90472EP as appropriate.

90473EP

Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid).

Note:  Billing CPT code 90474 for a second administration of an intranasal/oral vaccine is not applicable at this time.

90474EP

Each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure).

Note:  Billing CPT code 90474 for a second administration of an intranasal/oral vaccine is not applicable at this time.

Table 2:  H1N1 Influenza Billing Codes for Recipients 21 Years of Age and Older

All Providers

Use the following CPT procedure code to report an H1N1 influenza vaccine administered to a recipient 21 years of age and older.

Vaccine CPT Code to Report

CPT Code Description

90663

Influenza virus vaccine, pandemic formulation

Private Providers and Local Health Departments

Use the following codes to bill for an administration fee for recipients 21 years of age or older.  The table below includes options for billing H1N1 as the ONLY vaccine administered that day or as an additional vaccine administered that day.  An injectable vaccine administered on the same day as an oral or intranasal vaccine should be considered the primary administration code.


Administration CPT Code(s) to Bill

CPT Code Description

90471

Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)

90472

Each additional vaccine (single and combination vaccine/toxoid) (list separately in addition to primary procedure)

90473

Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid).

Note:  Billing CPT code 90474 for a second administration of an intranasal/oral vaccine is not applicable at this time.

90474

Each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure).

Note:  Billing CPT code 90474 for a second administration of an intranasal/oral vaccine is not applicable at this time.

For a recipient 21 years of age or older receiving an influenza vaccine, an evaluation and management (E/M) code cannot be reimbursed to any provider on the same day that injection administration fee codes are reimbursed unless the provider bills an E/M code for a separately identifiable service by appending modifier 25 to the E/M code.

Note:   In addition to local health departments and other identified providers, the federal government is supplying the H1N1 vaccine to federally qualified health centers (FQHCs) and rural health clinics (RHCs) at no charge.  Therefore, FQHCs and RHCs cannot bill Medicaid for the cost of the vaccine for any recipient.  Follow the guidelines in the April 2009 Special Bulletin, Health Check Billing Guide 2009 for instructions on billing administration codes for recipients 0 through 20 years of age (6 months through 20 years of age for influenza vaccines) under the C suffix provider number for H1N1 influenza vaccine.  For recipients 21 years of age and older seen in an FQHC or RHC, the cost of the administration may be included on the cost report for those recipients.

Private providers, local health departments, FQHCs, and RHCs may bill Medicaid for the administration fee for the H1N1 vaccine administered to Medicaid Pregnant Women (MPW) recipients.  Refer to the guidelines above. 

HP Enterprise Services
1-800-688-6696 or 919-851-8888


Attention:  All Providers

Dietary Evaluation and Counseling

Providers are reminded that the diagnosis codes listed in Attachment A of the Clinical Coverage Policy 1-I, Dietary Evaluation and Counseling, must be used when a pregnant or postpartum recipient is 21 years of age or older. Children ages 0 through 20 years are not limited to the diagnosis list in Attachment A of the policy.

HP Enterprise Services
1-800-688-6696 or 919-851-8888


Attention:  All Providers

Prior Authorization for Non-emergency Outpatient High-tech Radiology and Ultrasound Procedures:  Update

Prior authorization will be required for non-emergency outpatient high-tech radiology and ultrasound procedures.  The recipient categories exempt from this requirement been updated to include:

The other recipient categories exempt from prior authorization are:

Dates related to the implementation of prior authorization (PA) of high-tech radiology and ultrasound procedures are as follows:

Date

Procedures

Instructions for Providers

November 4, 2009

Online Training Sessions

Online provider training sessions will be provided at 9:00 a.m. and 1:00 p.m. on each day.  MedSolutions will be sending a packet of information to providers via the mail with instructions on how to access the online training sessions.

October 19, 2009

CT, CTA, MR, MRA, PET

All ordering providers will begin requesting PA for tests scheduled November 1, 2009, and after. 

November 1, 2009

CT, CTA, MR, MRA, PET

Institutional and professional claims submitted to HP Enterprise Services (EDS) for testing performed on November 1, 2009, and after will require PA on file.  Outpatient claims will require Revenue Codes and CPT codes on the UB-04 detail.

December 15, 2009

Ultrasounds

All ordering providers will begin requesting PA for tests scheduled January 1, 2010, and after.

January 1, 2010

Ultrasounds

Institutional and professional claims submitted to EDS for testing performed on January 1, 2010, and after will require PA on file.  Outpatient claims will require Revenue Codes and CPT codes on the UB-04 detail.

MedSolutions will accept authorization requests by web, phone, and fax.  Please visit the MedSolutions website to register for PA services and to view MedSolutions’ imaging guidelines. 

The ordering physician is required to obtain the PA.  This authorization should be obtained before the testing is scheduled.  The authorization number should be provided to the facility performing the test.  The authorization is good for 30 days following its issuance.

Procedures performed during an inpatient stay, during an emergency department visit, during an observation stay or as a referral from a hospital emergency department do not require PA.  Refer to the following information on billing for procedures provided in these circumstances.

Type of Stay

Billing Instruction

Inpatient stay

Enter Bill Type 11x in Form Locator 4

Emergency department visit

Enter Revenue Code 450 in Form Locator 42

Observation stay

Enter Revenue Code 762 in Form Locator 42

Hospital emergency department referral

Institutional Claims:  Enter appropriate CPT code with modifier U2 in Form Locator 44.

Professional Claims:  Enter appropriate CPT code with modifier U2 in field 24D.

The following procedure codes require prior approval:

Positron Emission Tomography (PET) Scans

CPT Code

Description

78608

Brain imaging, positron emission tomography (PET); metabolic evaluation

78609

Brain imaging, positron emission tomography (PET); perfusion evaluation

78811

Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)

78812

Positron emission tomography (PET) imaging; skull base to mid-thigh

78813

Positron emission tomography (PET) imaging; whole body

78814

Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)

78815

Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh

78816

Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body

Computed Tomography Angiography (CTA)

CPT Code

Description

70496

Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing

70498

Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing

71275

Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing

72191

Computed tomography angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

73206

Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

73706

Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

74175

Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing

75635

Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed and image postprocessing


Computed Tomography (CT) Scans

CPT Code

Description

70450

Computed tomography, head or brain; without contrast material

70460

Computed tomography, head or brain; with contrast material(s)

70470

Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections

70480

Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material

70481

Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material

70491

Computed tomography, soft tissue neck; with contrast material

70492

Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections

71250

Computed tomography, thorax; without contrast material

71260

Computed tomography, thorax; with contrast material(s)

71270

Computed tomography, thorax, without contrast material, followed by contrast material(s) and further sections

72125

Computed tomography, cervical spine; without contrast material

72126

Computed tomography, cervical spine; with contrast material(s)

72127

Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections

72128

Computed tomography, thoracic spine; without contrast material

72129

Computed tomography, thoracic spine; with contrast material(s)

72130

Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections

72131

Computed tomography, lumbar spine; without contrast material

72132

Computed tomography, lumbar spine; with contrast material(s)

72133

Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections

72192

Computed tomography, pelvis; without contrast material

72193

Computed tomography, pelvis; with contrast material(s)

72194

Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections

73200

Computed tomography, upper extremity; without contrast material

73201

Computed tomography, upper extremity, with contrast material(s)

73202

Computed tomography, upper extremity, without contrast material, followed by contrast material(s) and further sections

73700

Computed tomography, lower extremity; without contrast material

73701

Computed tomography, lower extremity, with contrast material(s)

73702

Computed tomography, lower extremity, without contrast material, followed by contrast material(s) and further sections

74150

Computed tomography, abdomen; without contrast material

74160

Computed tomography, abdomen; with contrast material(s)

74170

Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections

76380

Computed tomography, limited or localized follow-up study

76497

Unlisted computed tomography procedure (eg, diagnostic, interventional)

77078

Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)

77079

Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)


Magnetic Resonance Angiography (MRA)

CPT Code

Description

70544

Magnetic resonance angiography, head; without contrast material(s)

70545

Magnetic resonance angiography, head; with contrast material(s)

70546

Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences

70547

Magnetic resonance angiography, neck; without contrast material(s)

70548

Magnetic resonance angiography, neck; with contrast material(s)

70549

Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences

71555

Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s)

72159

Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)

72198

Magnetic resonance angiography, pelvis, with or without contrast material(s)

73225

Magnetic resonance angiography, upper extremity, with or without contrast material(s)

73725

Magnetic resonance angiography, lower extremity, with or without contrast material(s)

74185

Magnetic resonance angiography, abdomen, with or without contrast material(s)

Magnetic Resonance Imaging (MRI)

CPT Code

Description

70336

Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)

70540

Magnetic resonance (eg, proton) imaging, orbit, face and/or neck; without contrast material(s)

70542

Magnetic resonance (eg, proton) imaging, orbit, face and/or neck; with contrast material(s)

70543

Magnetic resonance (eg, proton) imaging, orbit, face and/or neck; without contrast material(s), followed by contrast material(s) and further sequences

70551

Magnetic resonance angiography, brain (including brain stem); without contrast material(s)

70552

Magnetic resonance angiography, brain (including brain stem);; with contrast material(s)

70553

Magnetic resonance angiography, brain (including brain stem);; without contrast material(s), followed by contrast material(s) and further sequences

71550

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)

71551

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s)

71552

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences

72141

Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material

72142

Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)

72146

Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material

72147

Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s)

72148

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material

72149

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)

72156

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical

72157

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic

72158

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar

72195

Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s)

72196

Magnetic resonance (eg, proton) imaging pelvis; with contrast material(s)

72197

Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences

73218

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s)

73219

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s)

73220

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences

73221

Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)

73222

Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s)

73223

Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences

73718

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s)

73719

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s)

73720

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences

73721

Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material

73722

Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)

73723

Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences

74181

Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s)

74182

Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s)

74183

Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences

76498

Unlisted magnetic resonance procedure (eg, diagnostic, interventional)

77058

Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral

77059

Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral

Ultrasound

CPT Code

Description

76506

Echoencephalography, real time with image documentation (gray scale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnormalities), including A-mode encephalography as secondary component where indicated

76510

Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter

76511

Ophthalmic ultrasound, diagnostic; quantitative A-scan only

76512

Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan)

76513

Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy

76514

Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness)

76516

Ophthalmic biometry by ultrasound echography, A-scan:

76519

Ophthalmic biometry by ultrasound echography, A-scan: with intraocular lens power calculation

76529

Ophthalmic ultrasonic foreign body localization

76536

Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid) real time with image documentation

76604

Ultrasound, chest (includes mediastinum), real time with image documentation

76645

Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation

76700

Ultrasound, abdominal, real time with image documentation; complete

76705

Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)

76770

Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete

76775

Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited

76776

Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation

76800

Ultrasound, spinal canal and contents

76801

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation

76802

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation

76805

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or + 14 weeks 0 days), transabdominal approach; single or first gestation

76810

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or + 14 weeks 0 days), transabdominal approach; each additional gestation

76811

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation

76812

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation

76813

Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation

76814

Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation

76815

Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses

76816

Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus

76817

Ultrasound, pregnant uterus, real time with image documentation, transvaginal

76818

Fetal biophysical profile; with non-stress testing

76819

Fetal biophysical profile; without non-stress testing

76820

Doppler velocimetry, fetal; umbilical artery

76821

Doppler velocimetry, fetal; middle cerebral artery

76825

Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording;

76826

Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; follow-up or repeat study

76827

Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete

76828

Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study

76830

Ultrasound, transvaginal

76831

Saline infusion sonohysterography (SIS), including color flow Doppler, when performed

76856

Ultrasound, pelvic (nonobstetric), real time with image documentation; complete

76857

Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)

76870

Ultrasound, scrotum and contents

76872

Ultrasound, transrectal;

76873

Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure)

76880

Ultrasound, extremity, nonvascular, real time with image documentation

76885

Ultrasound, infant hips, real time with imaging documentation; dynamic (requiring physician manipulation)

76886

Ultrasound, infant hips, real time with imaging documentation; limited, static (not requiring physician manipulation)

76970

Ultrasound study follow-up

76999

Unlisted ultrasound procedure (eg, diagnostic, interventional)

93875

Noninvasive physiologic studies of extracranial arteries, complete bilateral study (eg, periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis)

93880

Duplex scan of extracranial arteries; complete bilateral study

93882

Duplex scan of extracranial arteries; unilateral or limited study

93886

Transcranial Doppler study of the intracranial arteries; complete study

93888

Transcranial Doppler study of the intracranial arteries; limited study

93890

Transcranial Doppler study of the intracranial arteries; vasoreactivity study

93892

Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection

93893

Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection

93922

Non-invasive physiologic studies of upper or lower extremity arteries, single level, bilateral

93923

Non-invasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative testing, complete bilateral study

93924

Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study

93925

Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study

93926

Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study

93930

Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study

93931

Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study

93965

Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography)

93970

Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study

93971

Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study

93975

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study

93976

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study

93978

Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study

93979

Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study

93990

Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow)

Other

CPT Code

Description

76376

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring imaging postprocessing on an independent workstation

76377

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring imaging postprocessing on an independent workstation

Revenue Codes

RC Code

Description

350

CT Scan – General Classification

351

CT Scan – Head Scan

352

CT Scan – Body Scan

359

CT Scan – Other

402

Other Imaging Services – Ultrasound

404

Other Imaging Services – Positron Emission Tomography

409

Other Imaging Services – Other Imaging Services

610

Magnetic Resonance Technology (MRT) – General Classification

611

Magnetic Resonance Technology (MRT) – MRI Brain/Brainstem

612

Magnetic Resonance Technology (MRT) – MRI Spinal Cord/Spine

614

Magnetic Resonance Technology (MRT) – MRI Other

615

Magnetic Resonance Technology (MRT) – MRA Head and Neck

616

Magnetic Resonance Technology (MRT) – MRA Lower Extremities

618

Magnetic Resonance Technology (MRT) – MRA Other

619

Magnetic Resonance Technology (MRT) – Other MRT

A policy will be posted on DMA's Radiology Services web page prior to implementation. 

Practitioner and Clinic Services
DMA, 910-355-1883


Attention:  All Providers

Retroactive Eligibility for Family Planning Waiver

As of November 1, 2009, there will no longer be retroactive eligibility for Family Planning Waiver (FPW).  Medicaid applicants with a medical need in the three months prior to the month of application will be evaluated for eligibility for all other Medicaid programs.

Medicaid Eligibility Unit
DMA, 919-855-4000


Attention:  Pharmacists and Prescribers

New Prior Authorization Requirements for Leukotriene Modifiers

Effective with date of service of October 28, 2009, the N.C. Outpatient Pharmacy Program began requiring prior authorization for Leukotriene Modifiers.  Prescribers can request prior authorization by contacting ACS at 1-866-246-8505 (telephone) or 866-246-8507 (fax).  The criteria and PA request form for these medications are available on the N.C. Medicaid Enhanced Pharmacy Program website.  Medications that now require prior authorization include Accolate, Singulair, and Zyflo.

HP Enterprise Services
1-800-688-6696 or 919-851-8888


Attention:  CAP/MR-DD Providers, Enhanced Behavioral Health (Community Intervention) Services Providers, Local Management Entities, and Residential Child Care Treatment Facilities

Mental Health Cost Report Training Sessions

Training is being offered for those providers who have a fiscal year end of September 30, 2009, or December 31, 2009.  The training is being offered at several locations across the state during the month of December 2009 and January 2010.  Those providers with a fiscal year end of March 31, 2010, or June 30, 2010, should wait to go to training when sessions are offered next summer.

To learn more about training, locations, times, and information on how to register for training, visit the Office of the Controller's website and click on the link to the click on Mental Health Cost Report Training Memo.  The memo also provides the link to the website where you can register.

For questions concerning this training or the Mental Health Cost Report, contact Wilma Marrow at Wilma.marrow@dhhs.nc.gov or 919-855-3681.  

Wilma Marrow
Office of the Controller, 919-855-3681


Attention:  Durable Medical Equipment Providers

Coverage for Servicing and Repairing Durable Medical Equipment

Effective with date of service October 31, 2009, the following HCPCS code was end-dated and removed from the Durable Medical Equipment (DME) Fee Schedule on DMA's Fee Schedule web page

HCPCS Code

Description

E1340

Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes

Effective with date of service November 1, 2009, the following HCPCS code was added to the DME Fee Schedule. 

HCPCS Code

New Description

K0739

Repair or nonroutine service for durable medical equipment other than oxygen requiring the skill of a technician, labor component, per 15 minutes

The coverage criteria for servicing and repairing DME have not changed.  Prior approval is required.  Refer to Section 5.8 of Clinical Coverage Policy 5A, Durable Medical Equipment.

HP Enterprise Services
1-800-688-6696 or 919-851-8888

  • Clinical Coverage Policy 5A, Durable Medical Equipment
  • Fee Schedule Web Page

  • Attention:  Durable Medical Equipment Providers

    Coverage for Standers

    Effective with date of service November 1, 2009, newly established coverage criteria for standers were implemented.  This policy revision includes the addition of four new codes for standers and coverage of standers for recipients ages 0 through 20 years of age. 

    HCPCS Code

    New Description

    Lifetime Expectancy or Quantity Limitation

    E0637

    Combination sit to stand system, any size including pediatric, with seatlift feature, with or without wheels

    0 through 20 only; 3 years

    E0638

    Standing frame system, one position (e.g., upright, supine, or prone stander), any size including pediatric, with or without wheels

    0 through 20 only; 3 years

    E0641

    Standing frame system, multi-position (e.g., three-way stander), any size including pediatric, with or without wheels

    0 through 20 only; 3 years

    E0642

    Standing frame system, mobile (dynamic stander), any size including pediatric

    0 through 20 only; 3 years

    Prior approval guidelines for standers have been added.  Refer to Section 5.3.24 of Clinical Coverage Policy 5A, Durable Medical Equipment for more coverage details. 

    HP Enterprise Services
    1-800-688-6696 or 919-851-8888


    Attention:  Durable Medical Equipment Providers

    Medically Necessary Incontinence, Ostomy, and Urological Supplies

    Effective November 1, 2009, durable medical equipment (DME) providers can seek reimbursement for medically necessary incontinence, ostomy, and urological supplies.  Please refer to Clinical Coverage Policy 5A, Durable Medical Equipment for specific coverage details.

    DME providers can submit their claims for these supplies (when the recipient meets the coverage criteria) through HP Enterprise Services (EDS). 

    Note: Any recipient who currently receives other home health services should continue to receive their incontinence, ostomy, and urological supplies though the home health provider.

    HP Enterprise Services
    1-800-688-6696 or 919-851-8888


    Attention:  Nurse Practitioners and Physicians

    Infliximab (Remicade, HCPCS Code J1745) and Rituximab (Rituxan, HCPCS Code J9310):  New Billing Guidelines

    Effective with date of service October 1, 2009, claims billed for Remicade or Rituxan will be checked for a covered diagnosis codes in accordance with the Food and Drug Administration guidelines.  The N.C. Medicaid Program cannot reimburse for drugs or services considered to be investigative or experimental.  

    Remicade

    The ICD-9-CM diagnosis codes required when billing for J1745 are:

    Rituxan

    The ICD-9-CM diagnosis codes required when billing for J9310 are:

    HP Enterprise Services
    1-800-688-6696 or 919-851-8888


    Attention:  Nurse Practitioners and Physicians

    Canakinumab Single-use Vials (180 mg) (Ilaris, HCPCS Code J3590):  Billing Guidelines

    Effective with date of service August 1, 2009, the N.C. Medicaid program covers canakinumab injectable (Ilaris) for use in the Physician’s Drug Program when billed with HCPCS code J3590 (unclassified biologics).  Ilaris is available as single-use vials containing 180 mg of Ilaris as a lyophilized powder for reconstitution.

    Ilaris is a monoclonal antibody that blocks the activity of IL-1β.  It is indicated for the treatment of Cryopyrin-Associated Periodic Syndrome (CAPS), including Familial Cold Autoinflammatory Syndrome (FCAS) and Muckle-Wells Syndrome (MWS), in adults and children four years of age and older.

    A single does of Ilaris should be administered every 8 weeks as a subcutaneous injection.  The dose is 150 mg for adults and children with body weight greater than 40 kg, and 2 mg/kg for patients with body weight between
    15 kg and 40 kg. For children between 15 kg to 40 kg with an inadequate response, the dose can be increased to
    3 mg/kg. 

    For Medicaid Billing

    The new fee schedule for the Physician’s Drug Program is available on DMA’s Fee Schedule web page.

    HP Enterprise Services
    1-800-688-6696 or 919-851-8888

  • Fee Schedule Web Page
  • National Drug Code Implementation, Phase III, March 2009 Special Bulletin

    Attention:  Children's Developmental Service Agencies, Health Departments, Home Health Agencies, Hospital Outpatient Clinics, Independent Practitioners, Local Education Agencies, Local Management Entities, and Physicians

    Changes to Outpatient Specialized Therapies

    Effective with date of service December 1, 2009, prior authorization (PA) for outpatient specialized therapies (occupational therapy, physical therapy, speech therapy, respiratory therapy, and audiology services) will once again be required for recipients under 21 years of age.  Effective with date of service January 1, 2010, PA for outpatient specialized therapies will also be required for recipients 21 years of age and older.  Prior authorization will be required for all therapy treatments regardless of the setting.  The Carolinas Center of Medical Excellence (CCME) will introduce a new prior authorization website (http://www.medicaidprograms.org/nc/therapyservices/) where providers can access detailed information and instructions for registering and submitting requests.  All requests must be submitted via this website. 

    Prior authorization is not required for dually eligible Medicaid/Medicare recipients.  For Local Education Agencies (LEAs), the prior authorization is deemed met by the IEP process.

    All requests for PA must be submitted via CCME’s new website.  Providers will need to register and obtain password information to access these secure pages.  Requests for recipients ages 21 and older will not be accepted until at least December 1, 2009.  Online provider training will be available.  CCME’s website will also include instructions and training material for the electronic submission process and FAQs, helpful hints, and a help desk for technical support. 

    Required information must be submitted by completing the online form, which is composed of the following sections:

    1. Recipient Demographics
    2. Provider Demographics
    3. Requested Dates of Service/Units or Visits
    4. Order for Therapy
    5. Treatment Plan of Care
    6. ICD-9-CM Codes
    7. Evaluation
    8. Goals
    9. Progress Towards Goals

    The medical necessity determination will be based on the recipient’s medical history, measurable goals with objective baselines or, in the case of reauthorizations, measurable progress and the provider’s rationale for skilled intervention.  Supplemental information will be requested only if a medical necessity determination cannot be made from the submitted data.

    Since adults will have visit limits, it is important that providers submit discharge information via the website.  This information must include the number of visits completed and the date of discharge.  Timely submission of this information is imperative for determination of medical necessity for future authorization requests.  A paper version of this form will be available online as a tool for providers.   

    CCME will also conduct post-payment reviews to ensure that all policy requirements and medical necessity criteria are met.  Providers will be expected to provide documentation as requested by CCME via mail or fax.  Recoupment of overpayments based on review findings will occur.  While services provided by LEAs are excluded from prior authorization, they will be subject to post-payment review. 

    Remember:

    Obtaining PA does not guarantee payment or ensure recipient eligibility on the date of service.  In addition to obtaining PA, providers must follow the established guidelines for their respective programs.  Clinical Coverage Policy 10A, Outpatient Specialized Therapies, is not all inclusive of program requirements.

    Implementation Timeline

    Date Procedure Instructions to Providers
    10/26/09 Launch of New Prior Authorization Website

    Providers can access general information about the PA process and instructions on how to register for access for submitting requests electronically.

    CCME will begin processing registrations upon receipt from the provider.

    11/16/09 CCME Will Begin Accepting PA Submissions for Recipients Under 21 via the New Prior Authorization Website

    Provider notification of review outcomes will not begin until 12/1/09.

    PA requests received prior to 12/1/09 will be processed as if the received date is 12/1/09 and will be reviewed within five business days (12/8/09). (Note: 12/5/09 is a Saturday and 12/6/09 is a Sunday.)

    Technical assistance will be available beginning 11/16/09.

    12/15/09 CCME will Begin Accepting PA Submissions for Recipients 21 and Older via the New Prior Authorization Website
    All PAs received prior to 1/4/10 will be processed as if the received date is 1/4/10 and will be reviewed within five business days (1/11/10) (Note: 1/1/10 is a holiday, 1/2/10 is a Saturday, and 1/3/10 is a Sunday.)

    A provider training webinar is scheduled for November 12, 2009. Please check CCME's Prior Authorization Website for detatiled information, including the time of the webinar session, and instructions on how to register for the webinar. Provider will receive an e-mail confirmation of their successful registration to participate in the webinar.

    CCME, 1-800-228-3365

  • CCME Website
  • Clinical Coverage Policy 10A, Outpatient Specialized Therapies

  • Attention:  Durable Medical Equipment Providers and Pharmacy Providers

    Prodigy Diabetic Supplies Under the Durable Medical Equipment and Pharmacy Programs

    Effective November 15, 2009, Prodigy Diabetes Care, LLC, will be N.C. Medicaid's designated preferred manufacturer for glucose meters, diabetic test strips, control solutions, lancets, lancing devices, and syringes. Beginning on this date of service, only Prodigy test strips, control solutions, lancets, lancing devices, and syringes will be covered by N.C. Medicaid.  This change will apply only to Medicaid-primary recipients (dually eligible and third-party recipients are not affected). Note: These requirements will not apply to private duty nursing and home health providers until February 1, 2010.

    The following table lists the National Drug Codes (NDCs) that are included under this program; for meters, please call your wholesaler or Prodigy Diabetes Care, LLC.

    Covered Product

    Package Size

    Unit Type

    NDC-11

    Prodigy Pocket™ Meter Kit - Black

    1 Meter Kit

    1 Meter

    08484-0708-00

    Prodigy Pocket™ Meter Kit - Pink

    1 Meter Kit

    1 Meter

    08484-0708-01

    Prodigy Pocket™ Meter Kit - Blue

    1 Meter Kit

    1 Meter

    08484-0708-02

    Prodigy Pocket™ Meter Kit -Green

    1 Meter Kit

    1 Meter

    08484-0708-03

    Prodigy Pocket™ Meter Kit -Camouflage

    1 Meter Kit

    1 Meter

    08484-0708-04

    Prodigy Pocket™ Meter Kit –Pink Camouflage

    1 Meter Kit

    1 Meter

    08484-0708-05

    Prodigy AutoCode® Talking Meter Kit

    1 Meter Kit

    1 Meter

    08484-0701-20

    Prodigy Voice™ Meter Kit

    1 Meter Kit

    1 Meter

    08484-0719-50

    Prodigy™ No Coding Test Strips

    50 ct Bottle

    1 Bottle

    08484-9902-50

    Prodigy Control Solution (Low)

    1 Bottle

    1 Bottle

    08484-9903-10

    Prodigy Twist Top Lancets 28G

    100 ct Box

    1 Box

    08484-9903-28

    Prodigy Lancing Device, Adj. Depth w/ Clear Cap

    100 ct Box

    1 Box

    08484-9903-55

    Prodigy Syringe 28G 12.7mm – 1 cc (100 ct)

    100 ct Box

    1 Box

    08484-9904-30

    Prodigy Syringe 31G 8mm – ½ cc   (100 ct)

    100 ct Box

    1 Box

    08484-9904-35

    In addition, effective November 15, 2009, diabetic test strips, control solutions, lancets, and lancing devices will be added to the list of over-the-counter products covered under the Outpatient Pharmacy Program.  These products will be covered under the pharmacy point-of-sale system with a prescription.  

    Billing Instructions for Submitting Claims for Diabetic Supplies under Durable Medical Equipment

    Claims for diabetic test strips, control solutions, lancets, lancing devices, and syringes submitted under the Durable Medical Equipment (DME) Program must be billed using the NDC in addition to the HCPCS code. The NDC will be entered in the shaded area of block 24A of the CMS-1500 claim form. (For information on how to bill with NDCs, please refer to the March 2009 Special Bulletin, National Drug Code Implementation, Phase III, on DMA's website. 

    Test strips must be billed in units (1 unit = 50 strips) and syringes and lancets must also be billed in units (1 unit = 100 syringes or lancets).

    A transition period will be in place from November 15, 2009, through February 15, 2010 (this transition period is not a postponement), in which a one-time, per-recipient, per-product override will be allowed. In addition to modifier NU, DME providers will need to place the SC modifier in block 24D of the CMS-1500 claim form to bypass the requirement to bill for Prodigy NDCs (as listed in the chart above). Following February 15, 2010, this modifier will no longer be acceptable for use with diabetic supplies for DME and only the Prodigy NDCs referenced above will be covered. 

    HCPCS codes and supply limits for diabetic supplies remain the same as outlined in Clinical Coverage Policy 5A, Durable Medical Equipment, as indicated below:


    HCPCS Code

    Product Description

    Quantity

    S8490

    Insulin syringes (1 unit = 100 syringes)

    200 syringes per month

    A4253

    Blood glucose test or reagent strips (1 unit = 50 strips)

    200 strips per month

    A4259

    Lancets (1 unit = 100 lancets)

    200 per month

    A4258

    Lancing Device

    2 per year

    A4256

    Normal, high, low calibrator solution

    4 per year

    E0607

    Home blood glucose monitor

    1 every 2 years

    E2100

    Blood glucose monitor with voice synthesizer

    1 every 3 years

    Effective November 15, 2009, HCPCS codes E0607 and E2100 will be end-dated.

    Note:   These requirements do not apply to private duty nursing and home health providers until February 1, 2010. 

    Billing Instructions for Submitting Diabetic Supplies under Pharmacy Point-of-Sale System

    Claims for diabetic test strips, control solutions, lancets, lancing devices, and syringes submitted at point-of-sale must be billed using the NDC.  Test strips must be billed in multiples of 50 and syringes and lancets must be billed in multiples of 100.  For Medicaid billing, 1 lancing device = 1 unit. Rates apply to these diabetic supplies; therefore, no copayments and no dispensing fees apply. 

    A transition period will be in place from November 15, 2009, through February 15, 2010 (this transition period is not a postponement), in which a one-time, per-recipient, per-product override will be allowed under the pharmacy point-of-sale system for covered diabetic supplies that are not the Prodigy brand.  Pharmacy providers can place a “1” in the prior authorization type code field (461-EU) or a “2” in the submission clarification code field (420-DK) to override the requirement to bill for Prodigy NDCs.  Following February 15, 2010, this override will no longer be available and only the Prodigy NDCs referenced above will be covered.  Diabetic supply limits will be the same as under the DME Program.  Prior authorization requests for additional quantities or for non-Prodigy diabetic supplies must go through the DME Program.

    Diabetic supplies do not have to be purchased at the same pharmacy unless the recipient is locked into a pharmacy.  Recipients identified for the Focused Risk Management (FORM) Program who require more than
    11 unduplicated prescriptions each month are restricted to a single pharmacy.  In these cases, the diabetic supplies must be purchased at the same pharmacy.  

    For additional information, providers may call Prodigy Diabetic Care, LLC at 1-866-540-4816, DMA Clinical Policies and Programs at 919-855-4310 (DME) or 919-855-4300 (Pharmacy).

    Durable Medical Equipment Program
    DMA, 919-855-4310

    Outpatient Pharmacy Program
    DMA, 919-855-4300


    Attention: Enhanced Behavioral Health (Community Intervention) Services Providers

    Provider Verification and Credentialing Activities

    As noted in the July 2009 Medicaid Bulletin, the process to re-verify information and to credential enrolled Medicaid Community Intervention Services providers is scheduled to begin immediately. CSC will be notifying providers by mail and sending the notification packet to the provider's billing/accounting address. This will include a pre-printed report of information currently on file with N.C. Medicaid plus a checklist of credentialing-related documents that must be returned to CSC. (Providers may verify their billing/accounting address via the DMA Provider Services NPI and Address Database or by calling the EVC Call Center at 1-866-844-1113.)

    The pre-printed NC MMIS Verification Form includes demographic data and NPI information currently on file with N.C. Medicaid and also contains space for providers to enter license/certification numbers, type of ownership, and contact information. Providers must complete the form, attach copies of documents required for credentialing, and return the verification packet to CSC within 30 days of the date of receipt. The verification process will take up to three weeks from the time CSC receives the correct and complete verification packet from the provider; the return of incomplete or incorrect information may lead to an interruption in enrollment. Lack of compliance in these procedures could result in suspension of enrollment and eventual termination.

    Please pay special attention to the designation for Community Support Team. Community Support Team providers are required to submit the verification packet with appropriate credentials, including all current Notifications of Endorsement Actions, to qualify for enrollment as a provider of Community Support Team services. This will effectively separate Community Support Child (H0036 HA), Community Support Adult (H0036 HB), and Community Support Group (H0036 HQ) services from Community Support Team services.

    Behavioral Health Section
    DMA, 919-855-4290


    Early and Periodic Screening, Diagnosis and Treatment and Applicability to Medicaid Services and Providers

    Service limitations on scope, amount, duration, frequency, location of service, and other specific criteria stated in this publication may be exceeded or may not apply to recipients under 21 years of age if the provider's documentation shows that

    This applies to both proposed and current limitations. Providers should review any information in this publication that contains limitations in the context of EPSDT and apply that information to their service requests for recipients under 21 years of age. A brief summary of EPSDT follows.

    EPSDT is a federal Medicaid requirement (42 U.S.C. § 1396d(r) of the Social Security Act) that requires the coverage of services, products, or procedures for Medicaid recipients under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination (including any evaluation by a physician or other licensed clinician).

    This means that EPSDT covers most of the medical or remedial care a child needs to

    Medically necessary services will be provided in the most economic mode possible, as long as the treatment made available is similarly efficacious to the service requested by the recipient's physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the recipient's right to a free choice of providers.

    EPSDT does not require the state Medicaid agency to provide any service, product, or procedure that is unsafe, ineffective, experimental, or investigational; that is not medical in nature; or that is not generally recognized as an accepted method of medical practice or treatment.

    If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does not eliminate the requirement for prior approval.

    For important additional information about EPSDT, please visit the following websites:


    Proposed Clinical Coverage Policies

    In accordance with NCGS §108A-54.2, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA's website.  To submit a comment related to a policy, refer to the instructions on the Proposed Clinical Coverage Policies web page.  Providers without Internet access can submit written comments to the address listed below.

    Lorie Williams
    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.


    2009 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.

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