July 2000 Medicaid Bulletin title

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Providers are responsible for informing their billing agency for information in this bulletin
In This Issue

All Providers:

Carolina ACCESS Providers:

Dental Providers:

Durable Medical Equipment (DME) Providers:

FQHC/RHC Providers:

Health Department Dental Staff:

Nursing Facility Providers:

Personal Care Services (PCS) Providers:


Attention: All Providers
Holiday Observance

The Division of Medical Assistance (DMA), First Mental Health, Medical Review of North Carolina and EDS will be closed on Tuesday, July 4, in observance of Independence Day.

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

Attention: All Dental Providers
Changes to the Dental Program Effective July 1, 2000

The American Dental Association (ADA) updated the ADA claim form and the Current Dental Terminology Users Manual (CDT-3) for the year 2000. The implementation date for the 1999 ADA claim form is July 1, 2000. A transition period of three months will allow the 1994 and the 1999 claim forms to be accepted from July 1, 2000 through September 30, 2000. Effective October 1, 2000, any claims or prior approval requests received on the 1994 claim form will be returned to the provider.

Note: See a sample of the 1999 ADA claim form

Updated North Carolina Medicaid Dental Services Manuals were distributed to providers at the dental workshops that were held in May. In June new manuals were mailed to all dental providers who were unable to attend a dental workshop. Refer to a copy of the new manual for instructions on completing the 1999 claim form.

Procedure Code Updates

Updates to the CDT-3 contain revised procedure code descriptions, procedure code deletions, and new ADA procedure code additions. Also, to be more consistent with billing of oral and maxillofacial surgical codes that are billed by physicians, many ADA codes have been recoded to CPT codes (from the Physicians' Current Procedural Terminology). The N.C. Medicaid Dental program will implement the changes listed below.

The following codes are end dated effective with dates of service after July 1, 2000:
D7470 Removal of exostosis - maxilla or mandible
D7840 Condylectomy
D7850 Surgical discectomy, with/without implant
D7860 Arthrotomy
D7865 Arthroplasty
D7870 Arthrocentesis
D7872 Arthroscopy - diagnosis, with or without biopsy
D7873 Arthroscopy - surgical: lavage and lysis of adhesions
D9240 Intravenous sedation base rate (no time involved)
Y9241 One unit intravenous sedation = 15 minutes

The following codes are added for dental providers effective with date of service July 1, 2000:
Code Description Facility Non-Facility
Resin-based composite - three surfaces, posterior - permanent
Resin-based composite - four or more surfaces, posterior-permanent
Removal of exostosis - per site
Intravenous sedation/analgesia - first 30 minutes
Intravenous sedation/analgesia - each additional 15 minutes
Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, or olecranon bursa)
Arthrotomy, temporomandibular joint
Condylectomy, temporomandibular joint (separate procedure)
Meniscectomy, partial or complete, temporomandibular joint (separate procedure)
Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure)
Arthroscopy, temporomandibular joint, surgical
Excision of osseous tuberosities, dentoalveolar structures

Removal of the Service Code Requirement

The requirement for a service code was removed effective July 1, 2000. Previously, the service code (1, 2, or 3) was entered in the "for administrative use only" column (beside the fee on the ADA claim form) to indicate if the service was rendered as a routine, prior approved, or emergency service.

Procedure code indicators are listed in the North Carolina Medicaid Dental Services Manual to offer a quick reference to determine if a procedure requires prior approval. These indicators are defined below:
Routine Service Prior approval is not required
Emergency Service The nature of the emergency must be documented in the recipient's chart as well as on the claim form
Prior Approved Service Prior approval is required

The following code indicators were revised as a result of removing the service code requirement:
Procedure Code Description Indicator in the Dental Manual
Anterior (excluding final restoration)
Molar (excluding final restoration)
Apicoectomy/periradicular surgery - anterior
Radical resection of mandible with bone graft
Open reduction of dislocation
Closed reduction of dislocation
Manipulation under anesthesia
Skin grafts (identify defect covered, location, and type of graft)
Repair of maxillofacial soft and hard tissue defect
Excision of salivary gland, by report
Closure of salivary fistula
Analgesia, anxiolysis, inhalation of nitrous oxide
Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)
Arthroplasty, temporomandibular joint, with allograft
Arthroplasty, temporomandibular joint, with prosthetic joint replacement

  Revision of Billing and Reimbursement for General Anesthesia and Intravenous Sedation

To be consistent with the ADA descriptions, billing and reimbursement was changed for general anesthesia and intravenous sedation effective with date of service July 1, 2000. The following charts will show examples of one hour of general anesthesia and intravenous sedation:
General anesthesia - first 30 minutes
General anesthesia - each additional 15 minutes
General anesthesia - each additional 15 minutes
1 hour of general anesthesia

Intravenous sedation/analgesia - first 30 minutes
Intravenous sedation/analgesia - each additional 15 minutes
Intravenous sedation/analgesia - each additional 15 minutes
1 hour of intravenous sedation

Orthodontic Case Completion and Code for Final Claim Payment

Effective July 1, 2000, the following procedure code will be used for final claim payment when orthodontic treatment is complete and less than 23 maintenance visits were paid:
Procedure Code
Orthodontic retention (removal of appliances, construction and placement of retainer(s))
  • limited to recipients under age 21
  • once in a lifetime service
  • only use for final claim when orthodontic treatment is complete and less than 23 maintenance visits were paid
  • requires a post treatment summary
  • retainers are not covered as a separate procedure

Providers are allowed payment for the banding and 23 monthly maintenance visits. Payment received for banding constitutes about one third of the maximum allowed for the entire treatment. The balance is paid incrementally with each periodic maintenance visit.

In rare instances, it may take fewer than 23 visits to complete treatment. In such cases, a provider may submit a final claim for payment of the balance of remaining visits. Complete the 1999 ADA claim form for procedure code D8680 (orthodontic retention). EDS will manually price the claim, based on the number of remaining visits.

If fewer than 12 maintenance visits were paid, record review is required to substantiate the final claim payment. If it is determined that treatment was not "completed", but rather "terminated", the final payment will not be allowed.

At case completion, submit a final claim and a written post treatment summary, which includes the results of the treatment and assessment of the recipient's cooperation. It is important that we receive a post treatment summary in order to complete our case records. If fewer than 12 maintenance visits paid, attach copies of the recipient's chart notes. The final orthodontic claim will not be paid unless a post treatment summary is also submitted. A sample of the Orthodontic Post Treatment Summary is printed in the May 2000 North Carolina Medicaid Dental Services Manual on page 148. Copies of the summary will be accepted. The Orthodontic Post Treatment Summary and final claim should be sent to:

EDS Prior Approval Unit
ATTN: Orthodontic Review Board
P.O. Box 31188
Raleigh, NC 27622

Refer to the new North Carolina Medicaid Dental Services Manual for complete prior approval and billing instructions.

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

Dental claim form sample

Attention: Local Health Department Dental Staff
Conversion from Clinic Visit Medicaid Billings to ADA Coded Billings

Public Health and Medicaid are working to revise the reimbursement mechanism for billing Medicaid dental services by Public Health Department dental facilities. This is a joint endeavor fostering more efficient delivery of dental services to the citizens of the state. This revision is effective with date of service October 1, 2000.

Updated North Carolina Medicaid Dental Services Manuals were distributed to providers at the dental workshops in May. In June new manuals were mailed to all dental providers and Public Health Departments that were unable to attend a dental workshop.

Refer to future Medicaid bulletins for updates on dental issues, including additional workshops that may be scheduled. The workshops are designed to provide Medicaid Dental Program and billing information needed to make this transition.

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


Attention: All Providers
Endoscopy CPT Base Codes and Their Related Procedures

Scopy Base and Related Code Group
Group Base Code Related Codes Comments
1 29815 29819-29823, 29825-29826  
2 29830 29834-29838  
3 29840 29843-29847  
4 29860 29861-29863  
5 29870 29871, 29874-29877, 29879-29887  
6 31505 31510-31513  
7 31525 31527-31530, 31535, 31540, 31560, 31570  
8 31526 31531, 31536, 31541, 31561, 31571  
9 31622 31625, 31625-31631, 31635, 31640-31641, 31645  
10 43200 43202, 43204-43205, 43215-43217, 43219-43220, 43226-43228  
11 43235 43239, 43241, 43243-43247, 43249-43251, 43255, 43258-43259  
12 43260 43261-43265, 43267-43269, 43271-43272  
13 44360 44361, 44363-44366, 44369, 44372-44373   
14 44376 44377-44378   
15 44388 44389-44394  
16 45300 45303, 45305, 45307-45309, 45315, 45317, 45320-45321  
17 45330 45331-45334, 45337-45339  
18 45378 45379-45380, 45382-45385  
19 46600 46604, 46606, 46608, 46610-46612, 46614-46615  
20 47552 47553-47556  
21 50551 50555, 50557, 50559, 50561   
22 50570 50572, 50574-50576, 50578, 50580   
23 50951 50953, 50955, 50957, 50959, 50961   
24 50970 50974, 50976   
25 52000 52250, 52260, 52265, 52270, 52275-52277, 52281, 52283, 52285, 52290, 52300, 52305, 52310, 52315, 52317-52318, 52282  
26 52005 52320, 52325, 52327, 52330, 52332, 52334   
27 52335 52336-52339  
28 56300 56301-56309, 56311, 56343-56344, 56314 End-dated 04/01/00 due to 2000 CPT updates
29 56350 56351-56356 End-dated 04/01/00 due to 2000 CPT updates
30 57452 57454, 57460  
31 49320 38570, 49321-49323, 58550, 58551, 58660-58662, 58670, 58671 Effective 01/01/00, new family of codes for 2000 based on RBRVS 
32 58555 58558-58563 Effective 01/01/00, new family of codes for 2000 based on RBRVS 

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

Attention: Physicians
Patient Demand Single or Multiple Event Recording - CPT 93268

The Resource Based Relative Value System (RBRVS) designation for Patient demand single or multiple event recording with presymptom memory loop, CPT 93268, does not allow for a technical and professional component. Effective July 1, 2000, the technical and professional components are not separately reimbursed by North Carolina Medicaid.

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

Attention: Carolina ACCESS Providers
Carolina ACCESS Expectations of Primary Care Providers

Carolina ACCESS (CA) primary care providers (PCPs) are responsible for coordinating the care of enrollees listed on their monthly enrollment report. New patients enrolled with the practice may not have an established medical record with the practice before requiring medical care. It is at the discretion of the PCP to authorize payment of medical services at other medical sites for their Medicaid Carolina ACCESS enrollees who have not contacted them for the purpose of establishing a patient/provider relationship.

The Carolina ACCESS program is creating strategies and implementing procedures for contacting patients to assist them in getting established with their PCP. The Division of Medical Assistance (DMA) encourages PCPs to use the enrollment report to identify new patients enrolled with their practice and welcome them to the practice. The local managed care representative will be working closely with PCPs and CA patients in this effort.

It is a requirement of the Carolina ACCESS program that your practice make appointments available in a timely manner for the enrollee to make the initial visit. This will help in achieving the goals of creating medical homes for Medicaid recipients and creating a system of coordinated quality care.

The CA program appointment availability standards are as follows:
Emergency *:  Immediately upon presentation or notification
Urgent**:  Within 24 hours
Routine sick care:  Within 3 days
Routine well care:  Within 90 days 15 days in case of pregnancy
Telephone medical advice: 24 hours a day with 1-hour response time after office hours

*Emergency Medical Condition is defined as:

  1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that in the absence of immediate attention, the medical condition could reasonably be expected to result in:
    1. Placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy)
    2. Serious impairment to bodily functions
    3. Serious dysfunction of any organ or part
  1. With respect to a pregnant woman who is having contractions:
    1. That there is inadequate time to effect a safe transfer to another hospital before delivery
    2. That transfer may pose a threat to the health or safety of the woman or the unborn child
** Urgent conditions are defined as a medical condition that warrants medical attention and intervention within 12-24 hours. If medical care is not rendered, the "urgent" condition could seriously compromise the patient's condition and outcome for a full recovery.

Betty West, Managed Care Section
DMA, 919-857-4245

Attention: Durable Medical Equipment (DME) Providers
Coverage of Diabetic Supplies

This article is being published subsequent to inquiries from Medicaid recipients about Medicaid coverage and access of diabetic supplies.

Both DME and home health providers may furnish the following diabetic supplies to Medicaid recipients:
Blood glucose test strips for use with monitor
Spring-powered device for lancet
Blood glucose test strips (visual strips)
Insulin syringe with needle, 1 cc or smaller
Urine test strips for combination ketones and glucose
Urine test strips or tablets for ketones
Urine test strips or tablets for glucose

In addition, DME providers may furnish the following diabetic supplies to Medicaid recipients:
Dial-a-dose insulin delivery device
Needle for use with dial-a-dose system

DME providers should refer to Section 6 of the North Carolina Medicaid Durable Medical Equipment Manual, March 1, 1999 Reprint and to the September 1998 Medicaid Bulletin article, "Coverage of Diabetic Equipment and Supplies" for complete instructions for providing diabetic supplies.

Home health providers should refer to Section 5.1.6 of the North Carolina Medicaid Community Care Manual, October 1999 Revision for complete instructions for providing medical supplies.

Dot Ling, Medical Policy
DMA, 919-857-4021

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

Attention: All Providers
Medicaid Managed Care HMO Risk Contract Update

Below is a list of the Health Plans contracting with DMA to serve Medicaid recipients in Mecklenburg County and the Triad Region.
Name and Address of HMO
Available in these Counties
2815 Coliseum Centre Drive, Suite 550
Charlotte, NC 28217-4522
(800) 350-6294
United Healthcare of North Carolina, Inc.
PO Box 26403 
3200 Northline Avenue, Suite 160
Greensboro, NC 27408
(800) 362-0655
Mecklenburg, Guilford, Forsyth, Davidson and Rockingham
The Wellness Plan of North Carolina, Inc. 
4601 Park Road, Suite 550
Charlotte, NC 28209-3239
(800) 794-9355
Mecklenburg and Gaston

Name and Address of FQHC
Available in this County
Metrolina Comprehensive Health Center 
3333 Wilkinson Boulevard
Charlotte, NC 28208
(704) 393-7720

Enrollment in an HMO or Metrolina (formerly C.W. Williams), a Federally Qualified Health Center, is mandatory for most Medicaid recipients in Mecklenburg County. Recipients in Guilford, Forsyth, Davidson, Rockingham and Gaston must choose between Carolina ACCESS or an HMO.

For information regarding participation with an HMO, please contact the specific HMO from the telephone numbers listed above.

Julia McCollum, Managed Care Section
DMA, 919-857-4022

Attention: FQHC/RHC Providers

EDS is offering individual provider visits for Federally Qualified Health Center/Rural Health Center (FQHC/RHC) providers. Please complete and return the FQHC/RHC Provider Visit Request Form. An EDS Provider Representative will contact you to schedule a visit and discuss the type of issues to be addressed.

Print and return FQHC/RHC Provider Visit Request Form to:
Provider Services
P.O. Box 300009
Raleigh, NC 27622

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

Attention: Nursing Facility Providers
Nursing Facility Seminars

Nursing Facility seminars are scheduled for September 2000. The August Medicaid Bulletin will have the registration form and a list of site locations for the seminars. Please list any issues you would like addressed at the seminars. Return the Nursing Facility Seminar Issues Form to:

Provider Services
P.O. Box 300009
Raleigh, NC 27622

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

Attention: Personal Care Services (PCS) Providers (excluding Adult Care Home Providers)
Personal Care Services Seminar Schedule

Seminars for Personal Care Services (PCS) providers will be held in August 2000. Provider numbers for PCS provider's range from 6600000-6601000. Note: This workshop is NOT for Adult Care Home Personal Care Services (ACH-PC). Each PCS provider is encouraged to send appropriate administrative, clinical, and clerical personnel. An overview of the criteria for PCS coverage, service limitation, and assessment process, including completion of the DMA-3000 PCS Physician Authorization and Plan of Care, will be discussed. In addition, procedures for filing PCS claims, common billing errors, and follow-up procedures will be reviewed.

NOTE: Providers should bring their Community Care Manuals as a reference. Additional manuals will be available for purchase at $20.00 each at the workshop.

Due to limited seating, pre-registration is required. Providers not registered are welcome to attend when reserved space is adequate to accommodate. Please select the most convenient site and return the completed registration form to EDS as soon as possible. Seminars begin at 10:00 a.m. and end at 1:00 p.m. Providers are encouraged to arrive by 9:45 a.m. to complete registration.

Tuesday, August 1, 2000
Four Points Sheraton
5032 Market Street
Wilmington, NC
Tuesday, August 8, 2000
Ramada Inn Plaza
3050 University Parkway
Winston-Salem, NC
Wednesday, August 9, 2000
Holiday Inn Conference Center
530 Jake Alexander Blvd., S.
Salisbury, NC
Monday, August 28, 2000
Wake Med 
MEI Conference Center
3000 New Bern Avenue
Raleigh, NC
Park at East Square Medical Plaza

Print and return the PCS Seminar Registration Form to:
Provider Services
P.O. Box 300009
Raleigh, NC 27622

Directions to the Personal Care Services (PCS) Seminars


I-40 East into Wilmington to Highway 17 - just off I-40. Turn left onto Market Street. The Four Points Sheraton is located approximately .5 miles on the left.


I-40 Business to Cherry Street Exit. Continue on Cherry Street for approximately 2 to 3 miles. Turn left at the IHOP Restaurant. The Ramada Inn Plaza is located on the right.


Traveling South on I-85:
Take Exit 75 and turn right on Jake Alexander Blvd.

Traveling North on I-85:
Take Exit 75 and turn left on Jake Alexander Blvd. Travel approximately .5 miles. The Holiday Inn is located on the right.

Directions to the Parking Lot:
Take the I-440 Raleigh Beltline to New Bern Avenue, Exit 13A (New Bern Avenue, Downtown). Travel toward WakeMed. Turn left onto Sunnybrook Road and park at the East Square Medical Plaza which is a short walk to the conference facility. Parking is not allowed in the parking lot in front of the Conference Center. Vehicles will be towed if not parked in the East Square Medical Plaza parking lot located at 23 Sunnybrook Road.

Directions to the Conference Center from Parking Lot:
Cross Sunnybrook Road and follow sidewalk access up to Wake County Health Department. Walk across the Health Department parking lot and ascend steps (with blue handrail) to MEI Conference Center. Entrance doors at left.


Checkwrite Schedule

July 11, 2000
August 8, 2000
September 6, 2000
July 18, 2000
August 15, 2000
September 12, 2000
July 27, 2000
August 24, 2000
September 19, 2000
September 28, 2000


Electronic Cut-Off Schedule

July 7, 2000
August 4, 2000
September 1, 2000
July 14, 2000
August 11, 2000
September 8, 2000
July 21, 2000
August 18, 2000
September 15, 2000
September 22, 2000

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.

Paul R. Perruzzi, Director John W. Tsikerdanos
Division of Medical Assistance Executive Director
Department of Health and Human Services EDS

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