ATTENTION: LABORATORIES, DESIGNATED AIDS CENTERS, PHYSICIANS, RESIDENTIAL HEALTH CARE FACILITIES AND OTHER ORDERING PROVIDERS CLARIFICATION OF MEDICAID PAYMENT FOR HIV DRUG RESISTANCE TESTING Return to Table of Contents
This is to clarify Medicaid payment policy for the HIV phenotypic and genotypic drug resistance tests.
Payment is limited to a maximum of three HIV drug resistance tests for a recipient per patient treatment year. The limit applies to tests employing either one specific test procedure or to tests employing a combination of multiple procedures (e.g., one HIV phenotypic and two HIV genotypic tests would be the maximum permitted for a patient in a 12-month treatment period).
An article on page 11 of the October 2000 Medicaid Update announced coverage for HIV drug resistance testing. The article stated that the lab tests are reimbursable on a fee-for-service basis for patients receiving services in certain clinic and residential settings. This is to clarify that HIV drug resistance testing may be billed to Medicaid on a fee-for-service basis by the testing laboratory for services provided to:
Inpatient and outpatients of an Article 28 certified Residential Health Care Facility;
Patients of Designated AIDS Centers operating under the Tier AIDS payment structure; and
Patients receiving care from all Article 28 certified outpatient clinics.
Please direct questions to the NYS Department of Health, Bureau of Policy Development and Agency Relations, at 518-473-5873.
This is to advise providers of a new payment edit "1319" for Office of Mental Retardation and Developmental Disabilities (OMRDD) Home and Community Based Services (HCBS) waiver claims in the MMIS Medicaid payment system. The edit was activated November 1, 2000 and does not permit claims to be paid for HCBS waiver services unless the service recipient is identified in the Welfare Management System (WMS) as an HCBS enrollee. Consumers enroll in the HCBS waiver program with approval from the OMRDD Developmental Disabilities Services Office (DDSO) or the NYC Regional Office (NYCRO). Enrollment is confirmed through the issuance of a Waiver Authorization Notice of Decision (NOD).
HCBS waiver enrollees are identified in WMS with a restriction exception (R/E) code of "46", "47", or "48". Edit 1319 will only allow payment for HCBS waiver services when the service recipient has one of these three R/E codes on WMS, for the date of service. The appropriate social services district or the OMRDD Revenue Support Field Office (RSFO) enters one of these three codes in WMS when a consumer is officially enrolled in the HCBS waiver.
During the past year, OMRDD and the Department of Health have identified and corrected R/E coding errors that might cause edit 1319 to incorrectly deny an HCBS waiver claim. As a result, there should be very little disruption resulting from the activation of this edit. Claims that hit Edit 1319 will "pend" for 60 days before they are denied. Please instruct your billing staff to contact the RSFO during this "pend cycle" to identify potential coding issues. The RSFO will work with your staff to resolve any consumer R/E coding issues.
Please note that this edit is consistent with long-standing State policy. Individuals must be enrolled in the HCBS waiver to receive services provided by this waiver.
Questions concerning this edit can be directed to Kevin Patricia, Director of the OMRDD Field Operations Unit, at (518) 402-4339.
The Department of Health is promoting disease management for Medicaid recipients. The purpose of this program is to partner with the provider community in an effort to promote quality care.
In support of the disease management program, the Medicaid Update is being enhanced to include monthly articles on various health care issues. A special emphasis will be placed on providing practitioners with information regarding nationally accepted standards of care for treatment of acute and chronic conditions. Initially, the program will focus on asthma, diabetes, and smoking cessation.
This clinical enhancement to the Medicaid Update may be useful to Medicaid practitioners. We encourage readers to share these publications with their clinical practitioners. Please contact the NYS Department of Health, Bureau of Program Guidance, at (518) 474-9219 with suggestions on articles that would be of particular interest to you in improving health outcomes for your Medicaid patients
The American Diabetes Association (ADA) supports monitoring glycemic levels by patients and health care providers as a cornerstone of diabetes care. Closely monitoring and maintaining normal blood sugar levels has been shown to slow the onset and progression of eye, kidney, cardiovascular and nerve diseases caused by diabetes. Recent studies show that any sustained lowering of blood sugar helps, even if the person has a history of poor control.
A landmark study, the Diabetes Control and Complications Trial (DCCT), was released in June 1993. This study established the benefits of intensive therapy to maintain glucose control for individuals with type 1 diabetes. A second study, the United Kingdom Prospective Diabetes Study (UKPDS), published in 1998, also concluded that similar benefits of intensive therapy occur for patients with type 2 diabetes. These studies provide strong support that vigorous treatment of diabetes can decrease the morbidity and mortality of the disease by decreasing its chronic complications. The ADA recommends the following glycemic guidelines to be used in conjunction with clinical judgment:
Non-pregnant adults should have an average fasting/preprandial glucose goal of 80-120 mg/dl and a bedtime glucose of 100-140 mg/dl
Patients should be closely monitored using glycated hemoglobin - HbA1c levels, a measure of a patient's glucose control over the past two to three months (recommended goal is <7%). THE ADA RECOMMENDS SEMI-ANNUAL HBA1C LEVELS AND MORE FREQUENTLY BASED ON MEDICAL NECESSITY.
The DCCT and UKPDS studies warn of the dangers of hypoglycemia and advise that intensive glycemic control is not recommended for the following types of patients:
children under age 13
those with heart disease or advanced complications
people with a history of frequent severe hypoglycemia
One goal of the State Medicaid program is to reduce long-term complications and improve the quality of life for people with diabetes. We encourage practitioners to educate their patients with diabetes about the importance of self-monitoring of blood glucose levels. As a reminder, the Medicaid program pays for blood glucose monitors and test strips for patients with type 1 or type 2 diabetes. The HbA1c laboratory test is also reimbursable by Medicaid.
For further information visit the following websites:
Computer Sciences Corporation (CSC), the fiscal agent for the New York State Medicaid Management Information System (MMIS), announces the following schedule of Introductory Seminars. Topics will include:
Overview of MMIS
Explanation of MMIS Provider Manual
Discussion of Medicaid Managed Care
Overview of Billing Options
Explanation of 90-day Regulation
Explanation of Utilization Threshold Program
February 14, 2001 [_______] 10 AM Westchester County Department of Social Services 85 Court Street White Plains NY
February 27, 2001 [_______] 1 PM Utica, NY (address to be announced
March 1, 2001 [_______] 1 PM Mexico, NY (address to be announced)
March 14, 2001 [_______] 10 AM Putnam County Department of Social Services Old Route 6 Carmel, NY
Additional seminars may be scheduled as new programs are implemented or changes to existing billing procedures are announced.
<Please complete the following registration information:
Provider Category of Service:________________________________
Policy section revisions to the <DME Provider Manual were recently sent to all enrolled DME providers. Please note the following clarifications that reiterate the payment methodology change effective September 1, 1999, pursuant to 18 NYCRR 505.5 (d)(2).
Page <2-47 (Rev. 4/99), Part A should read as follows:
The Medicaid program does not establish maximum reimbursable fees for orthopedic footwear. The prices listed in the fee schedule, section 4.6, are screen prices. A screen price is a guideline to determine when an invoice must be attached to the Medicaid claim for payment. An invoice is required when the amount charged to Medicaid for the item exceeds the screen price.
Page <2-48 (Rev. 11/00), Part C should read as follows:
Reimbursement for durable medical equipment is limited to the lower of:
the price as indicated in the fee schedule for durable medical equipment; or
the usual and customary price charged to the general public.
Reimbursement for durable medical equipment with no price indicated in the fee schedule is limited to the lower of:
the acquisition cost (by invoice to the provider) plus 50%; or
the usual and customary price charged to the general public.
Please place this notice in your DME Provider Manual. Revised pages in the policy section will be included with the next revision of the fee schedule. For date of service claim information, please see page 4-1(Rev. 7/00) of your DME Provider Manual. Questions regarding this notice may be directed to the NYS Department of Health, Bureau of Medical Review and Payment, at (518) 474-8161.
Smoking cessation therapy consists of prescription and non-prescription agents. Covered agents include nicotine patches, inhalers, nasal sprays, gum, and Zyban (bupropion).
Two courses of smoking cessation therapy per recipient, per year are allowed. A course of therapy is defined as no more than a 90-day supply (an original prescription and two refills, even if less than a 30-day supply is dispensed in any fill).
Multiple smoking cessation therapies, using different routes of administration, are allowed (e.g., Zyban and nicotine patches may be used concomitantly if warranted). Professional judgment should be exercised when dispensing multiple smoking cessation products.
Duplicative use of any one agent is not allowed (i.e., same drug/same dosage form/same strength).
An additional support available to Medicaid recipients is a toll-free smoking help-line staffed by employees of the Roswell Park Cancer Institute. The Quitline offers smokers a confidential and convenient way to access immediate help when they are ready to stop smoking or need support to remain smoke-free. Health care providers can also call the Quitline to obtain office materials that can be shared with patients.
NYS SMOKERS QUITLINE
An excellent smoking cessation guide is on the Department of Health website at: www.health.state.ny.us/healthaz/.
If you would like more information about the Medicaid program's Smoking Cessation Initiative, please contact the NYS Department of Health, Bureau of Program Guidance, at 518-474-9219.
The Medicaid Update: Your Window Into The Medicaid Program
The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.
Please send suggestions to the editor, Timothy Perry-Coon:
NYS Department of Health Office of Medicaid Management Bureau of Program Guidance 99 Washington Ave., Suite 720
Albany, NY 12210 (e-mail MedicaidUpdate@health.state.ny.us )