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In This Issue..  

All Providers: Claim Payments Suspend Holiday Observance Medicaid Payment Accuracy Measurement Demonstration Project Medical Coverage Policies Proposed Medical Coverage Policies Provider Information Update Tax Identification Information W-9 Form Checkwrite Schedule Electronic Cut-off Schedule Adult Care Home Providers: Personal Care Physician Authorization and Care Plan Revised Assessment and Care Plan Form Ambulance Providers: New Ambulance Billing Guidelines Anesthesiologists: Billing for Certified Registered Nurse Anesthetist Services CAP/AIDS, CAP/DA, and CAP/C Case Managers: Requests for Additional Information for Long-Term Care Prior Approval (FL2) Certified Registered Nurse Anesthetists: Billing for Certified Registered Nurse Anesthetist Services Durable Medical Equipment Providers: Code Definitions and Additions to the Orthotic and Prosthetic Fee Schedule Federally Qualified Health Centers: Medical Nutrition Therapy Diagnosis Code Clarification

Health Check Providers: Health Check Hearing and Vision Screening Health Check Lead Screening Health Departments: Billing Instructions for Procedure Code T1002 Family Planning Billing Clarification Medical Nutrition Therapy Diagnosis Code Clarification Hospice Providers: Reimbursement Rate Increase for Hospice Services Hospital Outpatient Clinics: Clarification of Prior Authorization for Outpatient Specialized Therapy Hospitals: Billing for Certified Registered Nurse Anesthetist Services Requests for Additional Information for Long-Term Care Prior Approval (FL2) Utilization Review Plans Mental Health Providers: ValueOptions Website Nursing Facility Providers: Requests for Additional Information for Long-Term Care Prior Approval (FL2) Optical Providers: Incomplete/Illegible Request for Prior Approval for Visual Aids Forms Rural Health Clinics: Medical Nutrition Therapy Diagnosis Code Clarification

Attention: All Providers

Holiday Observance

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

Attention: All Providers

Medicaid Payment Accuracy Measurement Demonstration Project

An essential part of this project consists of a review of a stratified sample of Medicaid claims and a review of the corresponding medical records. Program Integrity staff and Medical Review of North Carolina will contact providers whose claims fall in the sample to obtain medical records for the services billed to Medicaid. Samples will be taken from inpatient hospital services, long-term care services, independent practitioners and clinics, prescription drugs, home- and community-based services, and other supplies and services.

Claim payment will be recouped due to lack of documentation for the service billed if medical records are not supplied by the deadline. The claim payment will be projected as an overpayment if the requests for records are not returned by the deadline. This will inflate the overall state payment error rate. That will also overestimate the error rate for the services involved.

If your office is contacted for records, we ask for your cooperation and timely response to our request. This will facilitate the review and minimize the need for direct contact with the providers in the sample. We will clearly indicate on our letters or faxes that the request is part of the PAM Grant sample. Thank you in advance for your cooperation.

Questions regarding this project or the sample can be directed to Chuck Brownfield at 919-733-6681. We look forward to working with you.

Bo Nowell, Program Integrity Section
DMA, 919-733-6681

Attention: All Providers

Proposed Medical Coverage Policies

Darlene Creech
Medical Policy Section
Division of Medical Assistance
2511 Mail Service Center
Raleigh, NC 27699-2511

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.

Darlene Creech, Medical Policy Section
DMA, 919-857-4020

Attention: All Providers

Claim Payments Suspend

When EDS receives a returned RA or check, all claims for the provider number will be suspended and the subsequent RAs and/or checks will no longer be printed. EFT payments will also be discontinued. Once EDS has placed this suspension on the provider number, the provider will have 90 days to submit address changes. After 90 days, if the address has not been corrected, claims in suspension will deny and the provider number will be terminated.

Providers will be notified in writing and will have 21 days from the date of the letter to respond to the Division of Medical Assistance (DMA) Provider Services unit. If the letter is returned to DMA as undeliverable, the provider number will be terminated. Once terminated, providers will be subject to the full re-enrollment process and experience a period of ineligibility as a Medicaid provider.

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

Attention: All Providers

Provider Information Update

To report a change of ownership, name, address, tax identification number changes, group member, or licensure status, please use the Notification of Change in Provider Status form. Managed Care providers (Carolina ACCESS, ACCESS II, and ACCESS III) must also report changes using the Carolina ACCESS Provider Information Change form, including changes in daytime or after-hours phone numbers.

Return the completed Provider Information Update form to:

EDS Provider Enrollment
PO Box 300009
Raleigh, NC 27622
Fax: 919-851-4014

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

Attention: All Providers

Tax Identification Information

The N.C. Medicaid program must have the correct tax information on file for all providers. This ensures that 1099 MISC forms are issued correctly each year and that correct tax information is provided to the IRS. Incorrect information on file with Medicaid can result in the IRS withholding 30 percent of a provider's Medicaid payments. The individual responsible for maintenance of tax information must receive the information contained in this article.

How to Verify Tax Information
The last page of the Medicaid Remittance and Status Report (RA) indicates the tax name and number on file with Medicaid for the provider number listed. Review the Medicaid RA throughout the year to ensure that the correct tax information is on file for each provider number. If you do not have access to a Medicaid RA, call EDS Provider Services at 919-851-8888 or 1-800-688-6696 to verify the tax information on file for each provider.

The tax information listed for a group practice is as follows:

1. group tax name and group tax number
2. attending Medicaid provider number in the group

• Physicians must submit completed and signed W-9 form to their Blue Cross Blue Shield of North Carolina (BCBSNC) representative
• Other providers, including Managed Care providers, must submit completed and signed W-9 forms along with a completed and signed Notification of Change in Provider Status form to the Division of Medical Assistance (DMA) Provider Services Unit at the address listed below

Refer to the following instructions for completing the W-9 form. Additional instructions can be found on the IRS website at http://www.irs.gov under the link "Forms and Pubs."

• List the N.C. Medicaid provider number in the block titled "List account number(s) here."
• List the N.C. Medicaid provider name in the block titled "Business Name." It should appear EXACTLY as the IRS has on file.
• Indicate the appropriate type of business.
• Fill in either a social security number OR a tax identification number. Indicate the number EXACTLY as the IRS has on file for the provider's business. Do not enter a social security number unless the business is a sole proprietorship or individually owned and operated.
• An authorized person MUST sign and date this form or it will be returned as incomplete and the tax information on file with Medicaid will not be updated.

• Physicians must contact BCBSNC to report all changes in business ownership.
• All other providers, including Managed Care providers, must report changes to DMA Provider Services using the Notification of Change in Provider Status form.
• Carolina ACCESS (CA) providers must report changes to DMA Provider Services using the Carolina Access Provider Information Change form.

If DMA is not contacted and the incorrect tax identification number is used, that provider will be liable for taxes on income not necessarily received by the provider's business. DMA will assume no responsibility for penalties assessed by the IRS or for misrouted payments prior to written receipt of notification of ownership changes.

Physician Group Practice Changes
When a physician leaves or a physician is added to a group practice, contact BCBSNC to update Medicaid enrollment and tax information. Carolina ACCESS (CA) providers must also report changes to DMA Provider Services using the Carolina ACCESS Provider Information Change Form.

• W-9 Form

Attention: All Providers

Medical Coverage Policies

1A Physicians

• 1A-1 Compression Sleeves/Stockings
• 1A-2 Preventive Medicine Annual Health Assessment
• 1A-3 Noninvasive Pulse Oximetry

• 1D-1 Refugee Health Assessments Provided in Health Departments
• 1D-2 Sexually Transmitted Disease Treatment Provided in the Health Department
• 1D-3 TB Control and Treatment Provided in Health Departments

• 1M-1 Child Service Coordination
• 1M-2 Childbirth Education
• 1M-3 Health and Behavior Intervention
• 1M-4 Home Visit for Newborn Care and Assessment
• 1M-5 Home Visit for Postnatal Assessment and Follow-up Care
• 1M-6 Maternal Care Skilled Nurse Home Visit
• 1M-7 Baby Love Maternal Outreach Worker Program
• 1M-8 Maternity Care Coordination

4B Orthodontic Services

8F Outpatient Specialized Therapies

8G Independent Practitioners

8I Psychological Services Provided by Health Departments and School-Based Health Centers Sponsored by Health Departments to the Under 21 Population

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

Darlene Creech, Medical Policy Section
DMA, 919-857-4020

Attention: Health Check Providers

Health Check Hearing and Vision Screening

In accordance with the periodicity schedule and the Recommendationsfor Preventive Pediatric Health Care, objective hearing screenings using electronic equipment (i.e., audiometer) must be performed at birth, 4 years, 5 years, 6 years, 9 years, 12 years, 15 years, and 18 years. Health Check hearing screenings must be indicated on the claim with CPT code 92551. Subjective screenings (e.g., rattling coins in a cup) must be performed at interperiodic visits.

Objective vision screenings (i.e., Snellen chart), following the guidance of the periodicity schedule and the Recommendations, are required at periodic visits at ages 3 years, 4 years, 5 years, 6 years, 9 years, 12 years, 15 years, and 18 years. CPT code 99173 must be on the claim. Subjective screenings (i.e., tracking) must be performed at interperiodic visits.

If hearing and vision screenings cannot be performed during a periodic visit due to a condition such as deafness or blindness and the claim is denied, the denied claim may be submitted through the adjustment process with supporting medical record documentation attached.

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

Attention: Adult Care Home Providers

Revised Assessment and Care Plan Form

Providers can also obtain copies of the form by calling EDS at 1-800-688-6696 or 919-851-8888.

Adult Care Home Personal Care Physician Authorization and Care Plan form (DMA-3050-R)

Bill Hottel, Medical Policy, Adult Care Home Services Unit
DMA, 919-857-4020

Attention: Ambulance Providers

New Ambulance Billing Guidelines

As noted above, A0425 must be used when billing for ground mileage with basic life support (BLS) or advanced life support (ALS) services. Other codes currently in place for ambulance services should continue to be billed until further instructions are published. These codes are Y0001, Y0002, Y0050, Y0060, Y0070, Y0003, and Y0004. Other billing instructions detailed in the 1999 N.C. Medicaid Ambulance Services Manual still apply.

Basic Life Support
Definition: BLS is transportation by ground ambulance vehicle and the provision of medically necessary supplies and services, including BLS ambulance services as defined by the state. The ambulance must be staffed by an individual who is qualified in accordance with state and local laws as an Emergency Medical Technician - Basic (EMT-Basic). These laws may vary from state to state or within a state. For example, only in some jurisdictions is an EMT - Basic permitted to operate limited equipment onboard the vehicle, assist more qualified personnel in performing assessments and interventions, and establish a peripheral intravenous (IV) line. According to the N.C. Office of Emergency Medical Services, monitoring or establishing a peripheral IV must be performed by an EMT - Intermediate or a Paramedic, and is, therefore, an ALS service.

Note: Even if local protocols require an ALS response for all calls, N.C. Medicaid pays only for the level of service provided, and then only when the service is medically necessary.

Advanced Life Support Assessment
Definition: An ALS assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment.

Advanced Life Support Intervention
Definition: An ALS intervention is a procedure that is, in accordance with state and local laws, beyond the scope of practice of an EMT - Basic.

An ALS intervention must be medically necessary to qualify as an intervention for payment of an ALS level of service. An ALS intervention applies only to ground transports.

Advanced Life Support, Level 1
Definition: ALS Level 1 (ALS 1) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including the provision of an ALS assessment or at least one ALS intervention.

Advanced Life Support, Level 2
Definition: ALS Level 2 (ALS 2) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including:

1.    at least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids such as 5 percent Dextrose in Water, Saline and Lactated Ringer's), or

2.    ground ambulance transport and the provision of at least one of the ALS 2 procedures listed below.

Application of ALS 2:

• Medications that are administered by means other than intravenous do not qualify to determine whether the ALS 2 level rate is payable. For example, intramuscular/subcutaneous injection, oral, sublingual or nebulized medications do not qualify (this is not an all-inclusive list).

• A single dose of medication administered fractionally (i.e., one-third of a single dose quantity) on three separate occasions does not qualify for the ALS 2 payment rate. The criterion of multiple administrations of the same drug requires a suitable quantity and amount of time between administrations that is in accordance with standard medical practice guidelines. The fractional administration of a single dose (for this purpose meaning a standard or protocol dose) on three separate occasions does not qualify for ALS 2 payment. In other words, the administration of 1/3 of a qualifying dose three times does not equate to three qualifying doses for purposes of indicating ALS 2 care. One-third of X given three times might = X (where X is a standard/protocol drug amount), but the same sequence does not equal three times X. Thus, if three administrations of the same drug are required to show that ALS 2 care was given, each of those administrations must be in accord with local protocols. The run will not qualify on the basis of drug administration if that administration was not according to protocol.

• An example of a single dose of medication administered fractionally on three separate occasions that would not qualify for the ALS 2 payment rate would be the use of intravenous (IV) epinephrine in the treatment of pulseless Ventricular Tachycardia/Ventricular Fibrillation (VF/VT) in the adult patient. Administering this medication in increments of 0.25 mg, 0.25 mg, and 0.50 mg would not qualify for the ALS 2 level of payment. This medication, according to the American Heart Association (AHA), Advanced Cardiac Life Support (ACLS) protocol, calls for epinephrine to be administered in 1 mg increments every 3 to 5 minutes. Therefore, in order to receive payment for an ALS 2 level of service, three separate administrations of epinephrine in 1 mg increments must be administered for the treatment of pulseless VF/VT.
 
• A second example that would not qualify for the ALS 2 payment level is the use of adenosine in increments of 2 mg, 2 mg, and 2 mg for a total of 6 mg in the treatment of an adult patient with Paroxysmal Supraventricular Tachycardia (PSVT). According to ACLS guidelines, 6 mg of adenosine should be given by rapid intravenous push (IVP) over 1 to 2 seconds. If the first dose does not result in the elimination of the PSVT within 1 to 2 minutes, 12 mg of adenosine should be administered by IVP. If the PSVT persists, a second 12 mg dose of adenosine can be administered for a total of 30 mg of adenosine. Three separate administrations of the drug adenosine in the dosage amounts outlined in the later case would qualify for ALS 2 payment.

1. manual defibrillation/cardioversion.
2. endotracheal intubation.
3. central venous line.
4. cardiac pacing.
5. chest decompression.
6. surgical airway.
7. intraosseous line.

Advanced Life Support Personnel
Definition: ALS personnel are individuals trained to the level of EMT - Intermediate or Paramedic.

Emergency Medical Technician - Intermediate
Definition: An EMT - Intermediate is an individual who is qualified, in accordance with state and local laws, as an EMT - Basic and who is also certified in accordance with state and local laws to perform essential advanced techniques and to administer a limited number of medications.

Emergency Medical Technician - Paramedic
Definition: An EMT - Paramedic possesses the qualifications of the EMT - Intermediate and, in accordance with state and local laws, has enhanced skills that include being able to administer additional interventions and medications.

Emergency Response
Definition: An emergency response is a BLS or ALS 1 level of service that has been provided in immediate response to a 911 call or the equivalent. An immediate response is one in which the ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call.

Fixed Wing Air Ambulance
Definition: Fixed Wing (FW) air ambulance is the transportation by an FW aircraft that is certified by the Federal Aviation Administration (FAA) as an FW air ambulance and the provision of medically necessary services and supplies.

Rotary Wing Air Ambulance
Definition: Rotary Wing (RW) air ambulance is the transportation by a helicopter that is certified by the FAA as an RW ambulance, including the provision of medically necessary supplies and services.

Loaded Mileage
Definition: Loaded Mileage is the number of miles that the Medicaid beneficiary is transported in the ambulance vehicle. For N.C. Medicaid, the ambulance provider's base area is the county in which they are located. Ground mileage is considered "outside base area mileage" that begins at the provider's county line.

Application: Payment is made for each loaded mile. Air mileage is based on loaded miles flown, as expressed in statute miles. For air ambulance, the point of origin includes the beneficiary loading point and runway taxiing until the beneficiary is offloaded from the air ambulance.

Point of Pick-Up
Definition: Point of Pick-Up is the location of the recipient at the time he/she is placed on board the ambulance.

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

Attention: Health Check Providers

Health Check Lead Screening

Medical follow-up begins with a blood lead level greater than or equal to 10 ug/dL. Capillary blood level samples are adequate for the initial screening test. Venous blood level samples should be collected for confirmation of all elevated blood lead results.
 

Blood Lead Concentration	Recommended Response
<10 ug/dL	Rescreen at 24 months of age.
10 to 19 ug/dL	Confirmation (venous) testing should be conducted within 3 months. If confirmed, repeat testing should be conducted every 2 to 4 months until the level is shown to be <10 ug/dL on three consecutive tests (venous or fingerstick). The family should receive lead education and nutrition counseling. A detailed environmental history should be taken to identify any obvious sources of exposure. If the blood lead level is confirmed at ?10 ug/dL, environmental investigation will be offered.
20 to 44 ug/dL	Confirmation (venous) testing should be conducted within 1 week. If confirmed, the child should be referred for medical evaluation and should continue to be retested every 2 months until the blood lead level is shown to be <10 ug/dL on three consecutive tests (venous or fingerstick). Environmental investigations are required and remediation for identified lead hazards shall occur for all children less than 6 years old with confirmed blood lead levels >20 ug/dL.
?45 ug/dL	The child should receive a venous lead test for confirmation as soon as possible. If confirmed, the child must receive urgent medical and environmental follow-up. Chelation therapy should be administered to children with blood lead levels in this range. Symptomatic lead poisoning or a venous lead level >70 ug/dL is a medical emergency requiring inpatient chelation therapy.

State Laboratory of Public Health for Blood Lead Screening
The State Laboratory Services of Public Health will analyze blood lead specimens for all children less than 6 years of age at no charge. To obtain information regarding free blood lead screening process and supplies contact the State Laboratory at 919-733-3937. Providers requiring results of specimens from children outside this age group also need to contact the State Laboratory of Public Health.

Note: When the above laboratory tests are processed in the provider's office, Medicaid will not reimburse separately for these procedures. Payment for these procedures is included in the reimbursement for a Health Check screening.

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

Attention: Health Departments

Family Planning Billing Clarification

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

Attention: Health Departments, Rural Health Clinics, and Federally Qualified Health Centers

Medical Nutrition Therapy Diagnosis Code Clarification

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

Attention: Health Departments

Billing Instructions for Procedure Code T1002

Note: Procedure code T1002 cannot be billed on the same day that a preventive medicine service is provided.

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

Attention: Durable Medical Equipment Providers

Code Deletions and Additions to the Orthotic and Prosthetic Fee Schedule

The following codes have been provided by CMS as replacements for the deleted codes and are effective with date of service December 1, 2002.
 

Code	Description	Maximum Reimbursement Rate
K0556	Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism	$564.04
K0557	Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism	470.02
K0558	Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use HCPCS codes K0556 or K0557)	999.64
K0559	Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use HCPCS codes K0556 or K0557)	999.64
L5671	Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert	456.12

Prior approval is required. Providers are expected to bill their usual and customary rates.

Melody B. Yeargan, P.T., Medical Policy
DMA, 919-857-4020

Attention: Hospice Providers

Reimbursement Rate Increase for Hospice Services

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

Key to 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 and any subsequent days at the routine home care rate.

3.    Payments to a hospice for inpatient care are limited in relation to all Medicaid payments to the agency for hospice care. During the 12-month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient respite and general inpatient days may not exceed 20 percent of the aggregate total number of days of hospice care provided during the same time period for all the hospice's Medicaid patients. Hospice care provided for patients with acquired immune deficiency syndrome (AIDS) is excluded in calculating the inpatient care limit. The hospice refunds any overpayments to Medicaid.

4.    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 an inpatient. When the recipient is discharged as deceased, the inpatient rate (general or respite) is billed for the discharge date.

5.    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 (SNF/ICF) rate in addition to the home care rate provided in revenue code 651 or 652. See section 8.15.1, page 8-12, of the N.C. Medicaid Community Care Manual for details.

Attention: Hospitals

Utilization Review Plans

All UR Plan updates are submitted to:

Hospital Nurse Consultant
Medical Policy Section
Division of Medical Assistance
2511 Mail Service Center
Raleigh, NC 27699-2511

Debbie Garrett, RNC, Medical Policy Section
DMA, 919-857-4020

Attention: Hospital Outpatient Clinics

Clarification of Prior Authorization for Outpatient Specialized Therapy

Example: If a recipient is seen for physical therapy two times a week for one hour and the provider is requesting authorization for an 8-week period, providers would request RC 420 for 16 units.

Nora Poisella, Specialized Therapy Services
DMA, 919-857-4040

Attention: Hospitals, Anesthesiologists, and Certified Registered Nurse Anesthetists

Billing for Certified Registered Nurse Anesthetist Services

A.    CRNA performs services without medical direction:

        1.    CRNA is employed by hospital or facility and no anesthesiologist is present:

The surgeon works in collaboration with the CRNA. The hospital bills the CRNA professional charges on the CMS-1500 claim form using the hospital's professional number in the group area in block 33 and the CRNA's number as the attending number in block 33. Modifier QZ must be appended to the CPT code indicating CRNA services were performed without medical direction. The CRNA's professional charges are reimbursed 90 percent of the calculated payment.

The hospital's facility charges are billed on the UB-92 claim form with a Revenue Code (RC) in the 37X range. Only the facility charges are included in the RC code. CRNA professional charges must not be included in the RC code. The surgeon bills for the surgical charges on the CMS-1500 claim form.


2. CRNA is employed by the anesthesiologist:
 

When the CRNA is employed by an anesthesiologist(s) and renders services without medical direction of an anesthesiologist, the CRNA services are billed on the CMS-1500 claim form using the physician's group number in block 33 and the CRNA's number in the attending field. Modifier QZ is appended to the CPT code to indicate that the service was performed without medical direction.

        1.    CRNA is employed by hospital or facility:

The CRNA professional charges are billed on the hospital's professional claim appending modifier QX to the CPT code, indicating that medical direction was provided. When QX is billed, the CRNA's professional charges are paid at 50 percent of the calculated payment. The hospital's professional number is placed in block 33 and the CRNA's attending number is placed in the attending area in block 33.

The hospital's facility charges are billed on the UB-92 claim form with RC in the 37X range. Only the facility charges are included in the RC code.

CRNA professional charges must not be included in the RC code. The anesthesiologist performing medical direction appends either modifier QY or QK to the CPT code on the CMS-1500 claim form. When either modifier is billed, the anesthesiologist receives 50 percent of the calculated payment.

When the anesthesiologist provides medical direction of a CRNA that is employed by the physician, the physician bills the medical direction and the CRNA service on separate claims. The medical direction modifier QK or QY is appended to the CPT code on the physician claim. The physician's group number is placed in block 33 of the CMS-1500 claim form with the physician's individual number in the attending area of block 33. The medical direction modifier QX is appended to the CPT code on the CMS-1500 claim for the CRNA service. The physician group number is placed in block 33 and the CRNA number is placed in block 33 in the attending area.

New Modifiers and their Definitions
QX     CRNA Service: with medical direction
QZ     CRNA Service: without medical direction
QY     Medical direction of one CRNA by an anesthesiologist
QK     Medical direction of 2, 3 or 4 concurrent anesthesia procedures

Modifier AD for medical direction of more than four CRNAs is not available. When more than four CRNAs are medically directed, this is considered supervision and is not separately reimbursed.

Medical Direction Criteria
To bill for medical direction the anesthesiologist must:

1. perform the pre-anesthesia evaluation and exam;
2. prescribe the anesthesia;
3. participate personally in the induction and emergence of the anesthesia procedure;
4. assure that any part of the anesthesia plan not personally performed by the anesthesiologist is performed by a qualified CRNA;
5. monitor the course of anesthesia administration at frequent intervals;
6. remain physically present to provide diagnosis and treatment in an emergency situation; and
7. provide post anesthesia care.

Guidelines for Billing CRNA Services Without Medical Direction
 

Provider Rendering Service	Billing Provider	CMS-1500 Claim Form	UB-92 Claim Form	Pricing
CRNA employed by hospital or facility performing without medical direction	Hospital facility Charge	No	Bills RC 37X range	Prices DRB or RCC
	CRNA professional charge	Hospital professional number and CRNA number in block 33 Append QZ modifier to CPT code	No	90% of allowable
	Surgeon	Bills CPT code	No	Fee schedule
CRNA employed by anesthesiologist performing without medical direction	Hospital facility charge	No	Bills RC 37X range	Prices DRG or RCC
	CRNA professional charge	QZ is appended to the CPT code. Anesthesia group bills group/attending in block 33.	No	50% of allowable
	Anesthesiologist employing CRNA	Anesthesiologist does not bill when services are performed without medical direction.	No	50% of allowable.

Guidelines for Billing CRNA Services With Medical Direction
 

Provider Rendering Service	Billing Provider	CMS-1500 Claim Form	UB-92 Claim Form	Pricing
CRNA employed by hospital or facility performing with medical direction	Hospital facility Charge	No	Bills RC 37X range	Prices DRG or RCC
	CRNA professional charge	Hospital professional number and CRNA number in block 33. Append QX to CPT code.	No	50% of allowable
	Anesthesiologist providing medical direction	If one CRNA append QY to CPT code. If 2, 3, or 4 CRNAs append QK to CPT code	No	50% of allowable
CRNA employed by anesthesiologist performing with medical direction	Hospital facility charge	No	Bills RC 37X range	Price DRG or RCC
	CRNA professional charge	QX is appended to the CPT code. Use anesthesiology group/attending number in block 33.	No	50% of allowable
	Anesthesiologist providing medical direction	On separate claim, append QY to the CPT if one CRNA. If 2, 3, or 4 CRNAs, append QK. Bill group/attending number in block 33.	No	50% of allowable

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

Attention: Nursing Facility Providers, CAP/AIDS, CAP/DA, and CAP/C Case Managers, and Hospital Discharge Planners

Requests for Additional Information for Long-Term Care Prior Approval (FL2)

Previously, requests for additional information were sent to the recipient's local department of social services (DSS) who then forwarded the request to the appropriate provider or CAP case manager. This process often delayed the return of necessary information and resulted in an increase of retroactive prior approval requests as well as delaying claim payment.

Requests for long-term prior approval can be further expedited by ensuring that the following information is included on the original FL2:

• Nursing Facilities and Hospitals: Block 6 of the FL2 form must contain the provider's complete name and address.
• CAP Case Managers: Block 6 of the FL2 form must contain the complete address of the CAP agency, including ATTN: CAP Unit.

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

Attention: Mental Health Providers

ValueOptions Website

The Residential Authorization form is available on this website and has been updated to include a signature and date.

Note: The ValueOptions website also includes links to the Department of Health and Human Services and the Division of Medical Assistance for information specific to Medicaid.

Renee Hamlett
ValueOptions, 919-941-5367

Attention: Optical Providers

Incomplete/Illegible Request for Prior Approval for Visual Aids Forms

Click here to view an example of the cover letter:  Cover Letter Example

NOTE TO ALL OPTICAL PROVIDERS: Please make every effort to complete each Request for Prior Approval for Visual Aids form correctly. Missing, incomplete or illegible information will delay the eyeglass order.

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

Checkwrite Schedule

December 10, 2002	January 14, 2003	February 11, 2003
December 17, 2002	January 22, 2003	February 18, 2003
December 27, 2002	January 30, 2003	February 27, 2003

 
 

Electronic Cut-Off Schedule

December 6, 2002	January 10, 2003	February 7, 2003
December 13, 2002	January 17, 2003	February 14, 2003
December 20, 2002	January 24, 2003	February 21, 2003
		February 28, 2003

 
 

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

_____________________		_____________________
Nina M. Yeager, Director		Ricky Pope
Division of Medical Assitance		Executive Director
Department of Health and Human Services		EDS

 
 

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