DOH Medicaid Update March 2003 Vol.18, No.3

Office of Medicaid Management
DOH Medicaid Update
March 2003 Vol.18, No.3

State of New York
George E. Pataki, Governor

Department of Health
Antonia C. Novello, M.D., M.P.H., Dr. P.H.

Medicaid Update
is a monthly publication of the
New York State Department of Health,
Office of Medicaid Management,
14th Floor, Room 1466,
Corning Tower, Albany,
New York 12237


Based on a decision by the New York State Appellate Division, the Medicaid Program will begin paying optometrists for three procedures previously only covered when performed by ophthalmologists.

These procedures, now billable by ophthalmologists and optometrists, are:

  • 68761, closure of the lacrimal punctum by plug, each                     $16.00
  • 68810, probing of the nasolacrimal duct with or without irrigation   $12.00
  • 68840, probing of the lacrimal canaliculi, with or without irrigation    $8.00

Effective March 1, 2003, optometrists may resume providing these services and submit claims to Medicaid. In addition, optometrists can retroactively bill for these procedures performed since October 20, 2002, if they were provided to eligible Medicaid recipients and monetary reimbursement from any source has not been received for the service.

Note: When submitting a claim that is over 90 days old, the procedures for late claim submission should be followed. These instructions are found on P. 3-51 through P. 3-53 of the MMIS Ophthalmic Provider Manual. The acceptable reason to use for the late submission of a claim should be "Administrative Delay" and a copy of this article can be used as a 90-day waiver letter.

If you have any questions, please contact the Medicaid Bureau of Policy Development and Agency Relations at (518) 473-2160.

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During March 2003, revised New York State Fee Schedules will be sent to all enrolled:

  • Dentists;
  • Durable Medical Equipment Dealers;
  • Laboratory Services Providers; and,
  • Pharmacies

These revised fee schedules contain important HIPAA related coding changes.

If you do not receive a revised Fee Schedule by March 15, 2003, please contact Computer Sciences Corporation's Provider Relations staff. Dentists call (800) 522-5518 or (518) 447-9860. DME, Laboratory Services providers call (800) 522-5535 or (518) 447-9830, and Pharmacies call (800) 343-9000.


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As stated above, revisions to the Dental Provider Manual will be mailed in March, which contain changes to the Fee Schedule effective April 1, 2003. Among the changes are a lead "D" for all procedure codes and other changes for conformity with the Common Dental Terminology-4 (CDT-4) issued by the American Dental Association (ADA).

Questions may be referred to the Medicaid Bureau of Medical Review and Payment, Dental Prior Approval/Pend Unit at (800) 342-3005, option 3.

The Medicaid Program
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The Medicaid Program's Bureau of Program Guidance (BPG) is now providing educational tools to support Medicaid's disease management program, which is dedicated to partnering with the provider community to promote quality of care in a cost effective and efficient manner. Our goal is to provide educational tools on a routine basis. This month, the following two pages focus on diabetes: definition of types, signs and symptoms. Initially, we intend to focus on diabetes and asthma; however, in the future we plan to expand to other chronic illnesses and conditions.

It is hoped that the tools issued through the Medicaid Update will be useful to Medicaid practitioners. BPG encourages practitioners to copy and distribute these materials to their patients and to also share them with their colleagues.

Please contact the Medicaid Bureau of Program Guidance at (518) 474-9219 with your comments and suggestions on these and future patient educational tools.

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Question Man

Diabetes is a disease that a person gets when his/her body does not make insulin (Type 1 diabetes) or does not make enough insulin (Type 2 diabetes). Most of the food we eat is changed into sugar (glucose). Our body uses glucose for energy. The pancreas, an organ located near the stomach, makes the hormone insulin. Insulin helps glucose enter the body's cells. When a person's body does not make enough natural insulin to help the glucose enter the cells, glucose will build up in the blood stream. This build up of glucose in the blood stream is what causes the medical problems people develop from diabetes.


  • Unusual or extreme thirst
  • Frequent urination
  • Blurred vision
  • Unintentional weight loss
  • Dry skin
  • Cuts, bruises or sores on your body that will not heal or are slow to heal
  • Frequent infections, especially urinary or vaginal yeast infections
  • Fatigue or lack of energy
  • Loss of feeling or tingling or numbness in feet
  • Vomiting


  • If you are overweight or have most of your body fat around your middle abdomen (apple shape)
  • If you are a member of a high risk group (American Indian, American African, Asian or Hispanic)
  • If you have a family member with diabetes (parent, sister, brother)
  • If you do not get enough exercise or physical activity
  • If you have high cholesterol
  • If you have high blood pressure
  • If you have any heart conditions
  • If you have any sexual difficulties
  • If you had diabetes while you were pregnant (called gestational diabetes)

If you have some of the above symptoms or risk factors, you should be tested for diabetes.

Your doctor can do a urine test and also order a blood test.

You should plan to do the blood test in the morning before you eat.

Remember: if diabetes goes untreated, it can lead to serious life threatening conditions such as heart disease, blindness, kidney problems or failure, amputations and erectile dysfunction.

Sources: American Diabetes Association,
CDC Diabetes Public Health Resource

Prepared by the NYSDOH, Office of Medicaid Management, Bureau of Program Guidance, 3/03


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  • Type 1 used to be called "juvenile onset diabetes" because most people who have this type are usually under age 30. (But they can be older!)
  • People with Type 1 are usually thin.
  • The pancreas cannot make insulin.
  • Type 1 diabetes is not common. Only 5 - 10 % of all diabetics have Type 1.
  • Type 1 diabetes is the hardest type of diabetes to control.
  • Treatment for Type 1 diabetes is insulin injections timed with meals and activity.


  • Type 2 used to be called "adult onset diabetes"; people who get Type 2 are usually over age 55. (But they can be younger!)
  • People who are in a high-risk group are more likely to get Type 2 (American Indian, African American, Asian or Hispanic).
  • People who get Type 2 diabetes are usually overweight.
  • The pancreas can make insulin, but it is not enough for the body to move glucose into the cells.
  • Type 2 is the most common form of diabetes, 90 - 95% of all diabetics have Type 2.
  • Type 2 diabetes is a major health concern among overweight adults and children, due to their inactive lifestyles and eating habits.
  • Type 2 diabetes is treated with changes in diet, activity levels, and sometimes with oral medications.


  • Gestational diabetes occurs during pregnancy usually in the 24th - 28th week.
  • Gestational diabetes occurs in women who did not have diabetes before becoming pregnant.
  • Gestational diabetes most often occurs in young women, over age 25, who are overweight and in a high-risk group.
  • The mother usually needs a Cesarean Section delivery to prevent injury to herself and the baby.
  • The baby gets more sugar than it needs to grow and is born overweight (over 9 lbs).
  • The baby is at risk for developing breathing problems and obesity after birth.
  • Treatment for gestational diabetes is insulin injections, changes in diet and activity levels for the mother. Treatment must be done during pregnancy for the health of the mother and baby.
  • Gestational diabetes goes away after delivery (usually in 6 weeks).
  • Mothers who have gestational diabetes are at higher risk for developing Type 2 diabetes 5 - 10 years after delivery.

Sources: American Diabetes Association,
CDC Diabetes Public Health Resource

Prepared by the NYSDOH, Office of Medicaid Management, Bureau of Program Guidance, 3/03

April 1, 2003 Coding Changes for Pharmacy and DME Providers
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Below is a suggested cross-reference for providers reflecting major changes to billing codes. Consult your revised April 1, 2003 MMIS Provider Manuals to obtain fee, quantity and other necessary information.

Major Changes To Billing Codes

DMEApnea monitor w/recorderE0608E0619
DMEManual adult wc w/tilt in spaceK0009E1161
DMERigid pediatric wc w/tilt in spaceK0009E1233
DMEFolding pediatric wc w/tilt in spaceK0009E1234
DMENasal application deviceK0183A7034
DMEReplacement nasal cushionK0184A7032
DMEReplacement nasal pillowsK0184A7033
DMEPositive airway press headgearK0185A7035
DMEPositive airway press chinstrapK0186A7036
DMEPositive airway pressure tubingK0187A7037
DMEOximeter non-invasiveS8105E0445
FootwearLadies surgical boot eachL3218L3260
FootwearMens surgical boot eachL3223L3260
FootwearWhitman plateZ5830L3649
FootwearCustom schaefer plateZ5831L3000
FootwearCustom whitman plateZ5832L3000
OrthoticsTorso/ptosis supportL0900L0500
OrthoticsTorso/pend. abdominal supportL0920L0500
OrthoticsTorso/post surgical supportL0940L0500
OrthoticsTorso & ptosis support, customL0910L0510
OrthoticsPend. abdomen support, customL0930L0510
OrthoticsPost surgical support, customL0950L0510
OrthoticsHelmet w/face guard prefabZ4754E0701
PharmacyPharmacy compoundingZ0900-60S9430
PharmacyDisposable enemaZ2151NDC
PharmacyCO2 releasing suppositoriesZ2152NDC
PharmacyDocusate sodium enemaZ2153NDC
ProstheticsSocket insert w/lock mechanismL5660-4K0556
ProstheticsSocket insert w/o lock mechanismL5660-4K0557
ProstheticsInitial custom cong/atyp insertL5660-4K0558
ProstheticsInitial custom socket insertL5660-4K0559
SuppliesDiaphragm kitA4261A4266
SuppliesAdult size diaper sm eachA4360A4521
SuppliesAdult size diaper med eachA4360A4522
SuppliesAdult size diaper lg eachA4360A4523
SuppliesAdult size diaper xl eachA4360A4524
SuppliesNonpectin based ostomy pasteA4370A4405
SuppliesPectin based ostomy pasteA4370A4406
SuppliesMod compression bandage >=3<5"A4460A6434
SuppliesHi compression bandage >=3<5"A4460A6436
SuppliesPrefab ankle orthosisA4464L1901
SuppliesPrefab elbow orthosisA4464L3701
SuppliesPrefab wrist orthosisA4464L3909
SuppliesPrefab hand finger orthosisA4464L3911
SuppliesHaberman feederA4649S8265
SuppliesLight compression bandage >=3<5"A6263A6430
SuppliesLight compression bandage >=5"A6263A6432
SuppliesConforming bandage non-sterile >=3<5"A6264A6422
SuppliesConforming bandage non-sterile >=5"A6264A6424
SuppliesNon-waterproof tapeA6265A4450
SuppliesWaterproof tapeA6265A4452
SuppliesConforming bandage sterile >=3<5"A6406A6426
SuppliesConforming bandage sterile >=5"A6406A6428
SuppliesPositive airway pressure filterK0188A7038
SuppliesPositive airway pressure filter, non-dispK0189A7039
SuppliesRib beltA4572L0210
SuppliesReusable diaper/pantS8400T1500
SuppliesChild size diaper sm/med eachS8401A4529
SuppliesChild size diaper lg eachS8401A4530
SuppliesYouth size diaper eachS8401A4533
SuppliesDisp incont liner/shield eachS8405A4535
SuppliesFood thickener, regular & concen.Z2110-1B4100
SuppliesSterile eye padZ2333A6410
SuppliesNon-sterile eye padZ2333A6411
SuppliesOcclusive eye patchZ2337A6412
SuppliesMale condomZ2352A4267
SuppliesFemale condomZ2358A4268
SuppliesNon-sterile glovesZ2561A4927
SuppliesBlood pressure kitZ2660A4660
SuppliesReusable oral thermometerZ2761A4931
SuppliesReusable rectal thermometerZ2762A4932
SuppliesUnderpad reusable any size eachZ2770A4537
  • Effective April 1, 2003, Enteral Codes B4150, B4151, B4152, B4153, B4154, B5155 and B4156 require Voice Interactive Telephone Prior Authorization and DME Repair Code E1340 requires Dispensing Validation System authorization.
  • Questions on items in the DME, Footwear, Orthotic, Prosthetic and Supply categories (noted above) may be referred to the Bureau of Medical Review and Payment at (518) 474-8161.
  • Questions on items in the Pharmacy category (noted above) may be referred to the Pharmacy Policy and Operations Unit at (518) 486-3209.

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This article was first published in the November 2002 Medicaid Update with a follow up article in the December 2002 Medicaid Update. Additional information is being provided for Year Two of the project.

The Office of Medicaid Management has received grants from the Centers for Medicare and Medicaid Services (CMS) to participate in a multi-year CMS Medicaid Payment Accuracy Measurement (PAM) Project. The goals of this project are to assist States in developing PAM methodologies, conduct pilot tests of alternative approaches and explore the feasibility of estimating payment accuracy for the Medicaid program at the national level.

An essential part of this project will consist of a review of a sample of Medicaid claims and the corresponding medical records/documentation. The sample claims are randomly selected from a universe of all Medicaid claims for the review period.

For the Year One study, the Department of Health (DOH) contracted with the Island Peer Review Organization (IPRO) to conduct the record reviews. IPRO began contacting providers in October 2002 for documentation. The Year One study is currently underway.

For the Year Two study, the DOH will begin contacting providers in March 2003 to obtain the records and documentation for the Year Two sample claims.

Should you be contacted, we are asking for your cooperation and a timely response, as receipt of the documentation is essential to the success of the project. Requests, and subsequent receipt/non-receipt of documentation, will be tracked. Your timely response will facilitate the PAM review and minimize the need for direct DOH contact with the providers in the sample.

Questions regarding this article should be directed to Payment Accuracy Measurement Project staff at (518) 474-9328.


New Edits to be Activated
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Beginning in April 2003, the Office of Medicaid Management will be activating edits that require part-time clinic providers to enter a part-time clinic certification number when billing the part-time clinic rates '1629' or '2880'. The Version 4 and Version 5 claim formats have been updated to include a new field called "Part Time Clinic Certification Number". Your assigned part-time clinic number should be entered into this new field.

This field is a 13 character alphanumeric field starting in position 26 of Record Type 15 (Provider Data). The first 11 characters of this field should contain the Part-Time certification number assigned to your clinic. The last two characters should contain the letters "PT"

You will receive a separate mailing from the Office of Health Systems Management, which will provide you with your assigned number.

If you have questions, please contact Computer Sciences Corporation, Provider Relations at (800) 522-1892.

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Don't Forget

  • The Prior Authorization number is good for the life of the prescription (original prescription and its refills). A new prescription will require a new prior authorization number. Controlled substance prescriptions are valid for 30 days from the date written. All other prescriptions are valid for 60 days from the date written.
  • Prescriptions for brand drugs with "A" rated generics filled prior to November 17th 2002 that have refills are "grandfathered" in. They will not require prior authorization for the life of that prescription. When a new prescription is issued to the patient, it will require a prior authorization.
  • The State will not put a prior authorization requirement on brand name drugs until six months after the generic is released to market. You may continue to fill without prior authorization. After the six months, new prescriptions will require prior authorization.

In response to the many questions regarding the status of SYNTHROID,
currently SYNTHROID does not require Prior Authorization, as there is no "A" rated generic.


Construction Worker

The online eMedNY formulary is currently under construction!

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 )

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: