October 2006 Medicaid Bulletin

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 In This Issue...

All Providers:

Adult Care Home Providers:

CMS-1500 Billers:

Children’s Developmental Service Agencies (CDSAs):

Durable Medical Equipment Providers:

Health Departments:

Home Health Agencies:

Hospital Outpatient Clinics:

ICF-I/DD Providers:

Independent Practitioners:

Local Management Entities:

Nursing Facility Providers:

Optical Service Providers:

Personal Care Services and Personal Care Services – Plus Providers:


UB-92 Billers:

Attention:  All Providers

Gadolinium-Based Magnetic Resonance Contrast Agent, per ml, (HCPCS Procedure Code Q9952) – Billing Guidelines

The NC Medicaid Bulletin dated November 2005 informed providers that for dates of service April 1, 2005, and after, HCPCS procedure codes Q9945 through Q9951 must be billed for low osmolar contrast media (LOCM) used in radiologic diagnostic studies.  Recognizing that Q9952 (gadolinium-based magnetic resonance contrast agent) is frequently billed for MRI studies, Medicaid will reimburse for Q9952 effective with date of service January 1, 2006.

For Medicaid billing, one unit of Q9952 equals 1 ml.  The maximum reimbursement rate per unit of Q9952 is $2.89.  Providers who have had claims denied because of billing HCPCS procedure code Q9952 for dates of service on or after January 1, 2006, may resubmit the claims for processing.

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

Attention:  All Providers

Non-Covered Services

The following services have been determined by Divisional of Medical Assistance (DMA) to be experimental or investigational and are not covered.  Please note that this is not an inclusive list of all Medicaid non-covered services.  When these services are billed to Medicaid, reimbursement will be denied.  Providers are reminded that it is fraudulent to bill for non-covered services using a covered CPT code.

  • Intralesional/intra-articular pain management systems, including, but not limited to, ON-Q, Stryker, Pain Buster, C-bloc, Homepump Eclipse, I-Pump, ambIT, Accufuser, AutoMed, and On-Q Soaker Infusor System
  • Horizontal therapy, also referred to as Hako-Med horizontal therapy
  • Vestibular autorotation test—a computerized test to measure the vestibular ocular reflex during high-frequency head rotations
  • Ambulatory attended cardiac event monitoring of less than 24 hours/day
  • Intervertebral differential dynamics therapy, or IDD (such as Accu Spina)
  • Category II and Category III CPT procedure codes
  • Applications of radiofrequency ablation for tumors outside of the liver and osteoid osteoma, including, but not limited to, renal cell carcinoma, breast cancer, breast fibroadenomas, tumors of the lung and head and neck, adrenal cancer, chordoma, ovarian cancer, and pelvic/abdominal metastases of unspecified origin
  • Stretta procedure—a minimally invasive endoscopic procedure for the treatment of gastroesophageal reflux disease
  • According to the Basic Medicaid Billing Guide, March 2006:  “When a non-covered service is requested by a recipient, the provider must inform the recipient either orally or in writing that the requested service is not covered under the Medicaid program and will, therefore, be the financial responsibility of the recipient. This must be done prior to rendering the service.”  The Basic Medicaid Billing Guide is available online at the DMA Website.

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

    Attention:  All Providers

    Physician Drug Program Pricing List Update

    Effective with date of service October 1, 2006, the maximum reimbursement rates for procedure codes in the Physician Drug Program have been updated.  Rates are based on the average sales price plus six percent (ASP+6%), the pricing point used by Medicare.  For drugs not covered by Medicare and where the ASP+6% price is not available, the rates are based on the average wholesale price less ten percent (AWP-10%) of the lowest generic.

    Providers must continue to bill electronically or on the CMS-1500 or UB-92 claim form, as previously instructed, with their usual and customary charge.  Adjustments will not be made to previously processed claims.

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

    For procedure codes J3490, J3590, and J9999, providers must continue to submit a copy of the original invoice along with the CMS-1500 claim form as previously instructed.  Providers must write the name of the recipient, the recipient’s Medicaid identification number, the name of the medication, the dosage given, the National Drug Code(s) (NDC) from the vial(s) used, the number of each vial administered, and the cost per dose on the invoice. Payment is based on the invoice cost, less shipping and handling.

    Financial Management
    DMA, 919-855-4200

    Attention: All Providers

    Policy and Procedures for Prescribing Synagis for 2006–2007 Respiratory Syncytial Virus Season

    On October 15, 2006, N.C. Medicaid will begin coverage of Synagis prescriptions for respiratory syncytial virus (RSV).  This year, Synagis prescriptions will not require prior approval.  However, health care and pharmacy providers are expected to ensure the appropriate usage of Synagis.  The clinical criteria utilized in this policy are consistent with currently published American Academy of Pediatrics guidelines at http://aappolicy.aappublications.org/cgi/content/full/pediatrics.

    Please ensure that either

    Note:  Processing delays can occur if the patient does not have a Medicaid identification number or the form is not complete.

    Note:  During the RSV season, no more than five monthly doses of Synagis can be obtained for each recipient by using these forms.  The number of doses should be adjusted if an infant received the first dose prior to a hospital discharge.

    Submitting the In-Criteria Form

    Infants born on or after October 15, 2004, meet the medical criteria for Synagis if they have one or more of the following conditions:



    Chronic lung disease of prematurity (bronchopulmonary dysplasia)

    The infant has chronic lung disease (bronchopulmonary dysplasia) and has needed treatment (supplemental oxygen, bronchodilator, diuretic, or corticosteroid) in the six months before the start of the season.

    Hemodynamically significant congenital heart disease

    Infants less than 12 months of age who are most likely to benefit include those receiving medication to control congestive heart failure, moderate to severe pulmonary hypertension, or cyanotic heart disease.  Infants NOT at increased risk from respiratory syncytial virus who generally should NOT receive immunoprophylaxis include those with hemodynamically insignificant heart disease such as secundum atrial/septal defect, small ventricular septal defect, pulmonic stenosis, uncomplicated aortic stenosis, mild coarctation of the aorta, patent ductus arteriosus, lesions adequately corrected by surgery unless the infant continues on medication for congestive heart failure, and mild cardiomyopathy where the infant is not receiving medical therapy.

    Cystic fibrosis

    The infant has cystic fibrosis and either requires chronic oxygen or has been diagnosed with nutritional failure.

    Severe congenital immunodeficiency

    Severe combined immunodeficiency disease or severe acquired immunodeficiency syndrome.

    Other infants may meet the medical criteria for Synagis as follows:

    Infant Is Born at an Estimated Gestational Age of

    Other Criteria

    Less than or equal to 28 weeks AND

    Date of birth on or after October 15, 2005

    29 weeks through 32 weeks AND

    Date of birth on or after April 15, 2006

    32 weeks and 1 day through 35 weeks and 0 days AND

    Date of birth on or after April 15, 2006 AND two or more of the following risk factors:

    --Has school-age siblings

    --Attends day care

    --Has severe neuromuscular disease

    --Is exposed to prolonged wood-burning heaters as the primary source of heat for the family (tobacco smoke is NOT a risk factor because it can be controlled by the family)

    --Has congenital abnormalities of the airways

    When it has been verified that one or more of the above conditions exist and are accurate, submit the in-criteria form by doing the following:

    Submitting the Request for Medical Review Form

    When a patient does not explicitly meet the guidelines but the provider still wishes to prescribe Synagis, submit the Request for Medical Review Form by doing the following:

    Medicaid will allow Synagis claims processing to begin on October 10, 2006, to allow sufficient time for pharmacies to provide Synagis by October 15, 2006.  Payment of Synagis claims prior to October 10, 2006, and after March 31, 2007, will not be allowed.  Pharmacy providers should always indicate an accurate days’ supply when submitting claims to N.C. Medicaid.  Physicians and pharmacy providers are subject to audits of Synagis records by DMA Program Integrity. 

    Pharmacy and Ancillary Services
    DMA, 919-855-4300

    Attention: All Providers

    Quarterly Update to the 2006 Physician Fee Schedule Database

    The Centers for Medicare and Medicaid Services (CMS) develops payment files annually based upon the Medicare Physician Fee Schedule Final Rule.  CMS issues quarterly updates as deemed necessary.  Based on the quarterly updates, the N.C. Medicaid program has made the following changes effective with date of service October 1, 2006.  The CPT codes listed below are valid codes with N.C. Medicaid.  All applicable edits, audits, limitations, and modifier combinations continue to apply to these codes.  

    Codes Billed with Modifier 51, Multiple Procedures

    Codes Billed with Modifier 50, Bilateral

    The following CPT codes are no longer valid services when billed in combination with Modifier 50:




































    If billed with Modifier 50 for date of service on or after October 1, 2006, the above codes will be denied.

    The following CPT codes are now valid services when billed in combination with Modifier 50:













































































    Codes Billed with Modifier 62, Co-surgery

    CPT codes 63304 and 63308 are now valid services when billed in combination with Modifier 62.

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

    Attention:  All Providers

    Tetanus, Diphtheria Toxoids and Acelluar Pertussis Vaccine (TDAP) - HCPCS Code 90715

    The reimbursement rate for the HCPCS code 90715 has been changed to reflect the AWP minus 10% effective March 1, 2006.  The new rate is $38.21.

    Prior claims submitted for HCPCS code 90715 will not be adjusted.

    Financial Management
    DMA, 919-855-4200

    Attention:  Adult Care Home Providers

    Fee Schedule for Adult Care Home Special Care Unit for Persons with Alzheimer’s and Related Disorders

    N. C. Session Law 2005-276 provided for additional Medicaid funding for the care of residents with a Primary Diagnosis of Alzheimer’s and Related Disorders residing in Special Care Units for Persons with Alzheimer’s and Related Disorders (SCU-A) located in Adult Care Homes (ACHs) and who meet the Prior Approval criteria.  Effective with date of service October 1, 2006, the N.C. Medicaid Program will implement a special care rate for ACH providers operating a SCU-A. 

    The applicable HCPCS codes and daily rates are as follows:



    ACH facilities with 1 to 30 beds and a SCU-A



    ACH facilities with more than 30 beds and a SCU-A

    Please note:

    1.                  Recipients must receive, and providers must bill for, Basic PCS at the same time as SCU-A services.

    2.                  Providers will not receive payment for Enhanced ACH services for  recipients in a SCU-A.

    3.                  The SCU-A rate is only for those residents that receive prior approval from DMA.

    Direct questions regarding rates to:

    Patricia “Trish” Harper @919-855-4216

    Elizabeth Grady @919-855-4207

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

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

    Outpatient Specialized Therapies Prior Authorization Process – Update to New Web Site and Submission Process

    As indicated in the July 2006 N.C. general Medicaid bulletin, testing of the Web-based electronic submission process for prior approval has been completed by members of the Therapy Advisory Group. Based on feedback from the pilot sites, modifications were made to improve user friendliness and decrease the amount of data required.

    The biggest change is to the evaluation component. When the new process is implemented, the required evaluation information will be reduced to the following:

    The medical necessity determination will be based on the medical history and measurable goals with objective baselines or, in the case of reauthorizations, objective progress. Supplemental information will be requested only if medical necessity cannot be determined from the required data.

    Through the Web site, providers will also have the option to submit authorizations using a file transfer protocol (FTP).  However, FTP will be the last component to be completed in the new system. Since the providers’ IT vendors will need to create a data format to transfer the information, the process and data fields must first be finalized. Once the system is in place for a few months and any identified changes have been completed, a file format will be provided.  For providers who choose to continue submitting prior authorization requests via fax or mail, a new form has been created to mirror the format and data fields of the Web site.

    Although still required for therapy, copies of the following documentation will no longer be required at the time of prior authorization submission:

  • Order for therapy
  • Evaluation
  • Plan of care with goals and frequency/duration of therapy
  • Instead, all required documentation will be submitted by completing the new 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 Codes
    7. Evaluation
    8. Goals
    9. Progress Towards Goals

    The system changes will be pilot tested by Therapy Advisory Group members in early October. Following review of the pilot feedback, an implementation date for the new system will be determined.  The provider community will be notified through bulletin articles, faxed communication from the Carolinas Center for Medical Excellence (CCME), and information on CCME’s Web site available at http://www.mrnc.org.

    Adequate time between notification and implementation will be given for providers to access the Web-based training and become familiar with the new prior authorization forms. Training on CCME’s Web site will include audio-video clips demonstrating the electronic submission process and Web site options, FAQs, helpful hints, and a help desk for technical support.

    While the prior approval submission process will be changing, DMA’s Clinical Coverage Policy 10A, Outpatient Specialized Therapies, is not is available.  Continue to follow all current policy guidelines.  All services are subject to post-payment review.

    CCME, 1-800-228-3365, ext 2045

    Attention: CMS-1500 Billers

    Medicare Health Maintenance Organization (HMO)

    In order for Medicaid to consider payment for Medicare Health Maintenance Organization, providers are requested to bill only the co-payment amount shown on the Medicare Explanation of Benefits (EOB).   Medicaid liability is only for the Medicare HMO co-payment. When filing on the CMS-1500 the following blocks must be completed:

    All CMS-1500 Medicare HMO claims should be submitted with the Medicaid Resolution Inquiry Form indicating that the claim attached is a Medicare HMO. The Medicaid Resolution inquiry form as well as the CMS-1500 claim form and Medicare HMO EOB should be mailed to:

    PO Box 300009
    Raleigh, NC 27622.

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

    Attention: UB-92 Billers

    Medicare Health Maintenance Organization (HMO)

    In order for Medicaid to consider payment for Medicare Health Maintenance Organization, providers are requested to bill all charges on the UB-92. The claims should not be altered for processing purposes.  The claim should be billed to Medicaid as it was billed to Medicare Health Maintenance Organization. Medicaid liability is only for the Medicare HMO co-payment. The following information is required for claim processing:

    The UB-92 claim form and Medicare HMO EOB should be mailed to:

    DMA/Third Party Recovery
    2508 Mail Service Center
    Raleigh, NC  27699-2508.
    EDS, 1-800-688-6696 or 919-851-8888

    Attention:  Durable Medical Equipment Providers

    Durable Medical Equipment Rental Items

    Durable medical equipment providers are reminded that the reimbursement for rental items includes service, delivery, assembly, set-up, repairs, and supplies.  Refer to Clinical Coverage Policy #5A, Durable Medical Equipment, sections 1.1, 7.1, and 8.1, for additional information. 

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

    Attention: Nursing Facility Providers

    Minimum Data Set Validation Review Update

    Beginning with Federal fiscal year 2007 (October 1, 2006), DMA will exercise the right to re-review the documentation of the nursing facilities that fail their minimum data set (MDS) validation review.  The facility’s documentation will not be reviewed any earlier than 120 days following the exit interview of the failed MDS validation review.

    DMA’s right to re-review is stated in the Nursing Facilities Provider Manual (chapter 5, p. 3, MDS review process #10). 

    Contacts for questions about the MDS validation review are as follows:

    Myers and Stauffer’s Help Desk

    North Carolina MDS Help Line
    Cindy DePorter, State RAI/MDS Coordinator

    MDS Validation Program
    Peggy Scott, R.N., CRNAC, Nursing Facility Consultant
    DMA, 919-855-4356

    Margaret Comin, R.N., Facility Services Manager
    DMA, 919-855-4355

    Facilities Services
    DMA, 919-855-4350

    Attention:  Optical Service Providers

    Introducing the New Request for Prior Approval for Visual Aids Form (372-017) and Instructions

    The Request for Prior Approval for Visual Aids form (372-017) has been updated.  The current form will not expire; therefore providers should exhaust current supplies and the new form will be introduced gradually, as the warehouse supply of old forms is depleted.

    While obsolete sections have been removed, several new sections have been added to incorporate information that must be maintained in the recipient’s visual aid medical record.  Revisions were implemented to provide more thorough medical records, improved clarity, and ease of use for providers, the optical contractor laboratory, and the Division of Medical Assistance.   Please pay special attention to the areas that require signatures and dates.

    Providers must continue to retain the fourth copy of this four-part form for office records.

    The back of the form contains new provider information, including pertinent Web sites.

    Example of the new Request for Prior Approval for Visual Aids form (372-017) and instructions.

    NOTE: All sections with asterisks (*) require documentation.

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

    Attention:  Personal Care Services and Personal Care Services-Plus Providers

    Personal Care Services Provider Training Session II

    The Carolinas Centers for Medical Excellence (CCME), formerly Medical Review of North Carolina (MRNC), under contract with the Division of Medical Assistance (DMA), will continue quarterly Personal Care Services (PCS) training sessions statewide.

    The training will be for registered nurses, agency administrators, and agency owners.  A complete agenda will be finalized and posted in the November N.C. general Medicaid bulletin.  Please choose the training session that is most convenient for you from among those listed below.

    December 1, 2006
    Hilton Charlotte Executive Park
    5624 Westpark Drive
    Charlotte NC 28217

    December 4, 2006
    Benton Convention Center
    301West Fifth Street
    Winston-Salem NC 27101

    December 5, 2006
    Embassy Suites/RTP
    201 Harrison Oaks Boulevard
    Cary NC 27513

    December 7, 2006
    Wilmington/Wrightsville Beach
    Shell Island Resort
    2700 North Lumina Avenue
    Wrightsville Beach NC 28480

    December 8, 2006
    New Bern
    Sheraton Hotel
    One Bicentennial Park
    New Bern NC 28560

    Pre-registration is required. Space is limited to the first 200 participants at each site. To register online, go to http://www.mrnc.org/ and follow the instructions for registration. A computer-generated confirmation number will confirm your registration.

    To register via fax, complete the attached registration form and fax it to the attention of Jennifer Manning at 919-380-9457. A member of the PCS team will call you with a confirmation number.

    Registration began Tuesday, September 5, 2006, for all sites and will close Friday, November 17, 2006.  If you need to cancel at any time, please contact Jennifer Manning at 919-380-9860, x2018.

    Check-in for each session begins at 8:30 a.m.; the trainings are scheduled from 9:00 a.m. to 4:00 p.m.  Lunch will be on your own.

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

    Attention: ICF-I/DD Providers

    ICF-I/DD Provider Assessment Database

    The Division of Medical Assistance (DMA) provider assessment database will go live on October 1, 2006.    The purpose of the provider assessment database is to enhance the providers’ ability to correctly complete their monthly assessment sheets via the Internet. By utilizing the available technology, providers will be able to file monthly assessments that are currently due and manage historical transactions by viewing completed assessments from prior months for all facilities within their management company. 

    If you would like to obtain additional information regarding your facility utilizing the assessment database, please contact Mishawn Davis or Stacey Crute at (919)855-4200.

    Rate Setting
    DMA, 919-855-4200

    NCLeads Update

    Information related to the implementation of the new Medicaid Management Information System, NCLeads, can be found online.  Please refer to the NCLeads website for information, updates, and contact information related to the NCLeads system.

    Provider Relations
    Office of MMIS Services

    Proposed Clinical Coverage Policies

    In accordance with Session Law 2005-276, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA's website.  To submit a comment related to a policy, refer to the instructions on the website.  Providers without Internet access can submit written comments to the address listed below.

    Gina Rutherford
    Division of Medical Assistance
    Clinical Policy Section
    2501 Mail Service Center
    Raleigh, NC 27699-2501

    The initial comment period for each proposed policy is 45 days.  An additional 15-day comment period will follow if a proposed policy is revised as a result of the initial comment period.

    2006 Checkwrite Schedule

    Electronic Cut-Off Date
    Checkwrite Date




























    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.

    _____________________   _____________________
    Mark T. Benton, Senior Deputy Director and
    Chief Operating Officer
      Cheryll Collier
    Division of Medical Assistance   Executive Director
    Department of Health and Human Services   EDS

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