When billing MMIS for services provided by a hospital-based or freestanding clinic:
appropriate CPT-4 procedure code(s) that identify the service(s) rendered to a recipient < must be used in addition to the rate code;
the procedure code entered on the claim must reflect the actual service rendered to the patient;
when multiple services are rendered in the same clinic visit, appropriate procedure codes (up to a total of three) should be used; and,
for HIPAA 837 (Institutional) claims, the procedure code must be reported in Loop 2400, SV Segment.
Note: Dental clinics should enter the five-character CDT-4 dental procedure code. Dental clinics < cannot use ICD-9-CM. Also, a hospital-based or freestanding clinic that is the sponsoring provider for a school based health center(s), must use the appropriate specialty code in addition to the appropriate rate code(s).
Questions can be directed to the Bureau of Policy Development and Agency Relations at (518) 473-2160.
In the February 2004 < Medicaid Update, we printed a table of the 20 most frequently billed Diagnosis Related Groups (DRGs). The Department's Bureau of Health Economics has amended this table.
REVISED LIST OF TOP 20 DRGs
A CHANGE TO THE
FEBRUARY 2004 MEDICAID UPDATE ARTICLE
Annually, the Bureau of Health Economics determines the 20 most frequently billed DRGs. Below is the new DRG table for Medicaid payments to New York State hospitals. The new table is effective for discharges beginning January 1, 2004.
<When payment for one of these DRGs is indicated, the remittance statement will list rate code
2996 rather than 2946.
Effective discharge date January 1, 2004, the top 20 DRGs are:
88 Chronic Obstructive Pulmonary Disease
89 Simple Pneumonia & Pleurisy Age > 17 w CC
97 Bronchitis & Asthma Age > 17 w/o CC
127 Heart Failure & Shock
143 Chest Pain
167 Appendectomy w/o Complicated Principal Diag w/o CC
183 Esophagitis, Gastroent & Misc Digest Disorder Age >17 w/o CC
359 Uterine & Adnexa Proc for CA In Situ & Nonmalig w/o CC
370 Cesarean Section w CC
371 Cesarean Section w/o CC
372 Vaginal Delivery w Complicating Diagnoses
373 Vaginal Delivery w/o Complicating Diagnoses
383 Other Antepartum Diagnoses w Medical Complications
494 Laparoscopic Cholecystectomy w/o CDE w/o CC
627 Neonate, Bwt >2499G, w/o Sig OR Proc, w/Major Problem
628 Neonate, Bwt >2499G, w/o Sig OR Proc, w Minor Problem
629 Neonate, Bwt >2499G, w/o Sig OR Proc, w norm newb diag
775 Bronchitis & Asthma Age <18 w/o CC
814 Non Bacterial Gastroenteritis & Abdominal Pain Age >17 w/o CC
852 Percutaneous Cardiovasc Proc w Non Drug Eluting Stent w/o AMI
For questions, please contact the Bureau of Medical Review and Payment, Rate Based Provider Unit, at (518) 474-8161.
About 65 percent of people with diabetes will die from a heart attack or stroke, yet two out of every three people with diabetes are unaware of their increased risk.
The National Diabetes Education Program (NDEP), the U.S. Department of Health and Human Services (DHHS), and the American Diabetes Association (ADA) have joined forces to alert people that good diabetes management is more than just lowering your glucose. < "Be Smart About Your Heart: Control the ABCs of Diabetes" campaign is based on scientific studies showing a dramatic and deadly link between diabetes and heart disease.
The < "ABCs of Diabetes" have been developed to communicate the importance of comprehensive care in simple language.
< A stands for the A1C or hemoglobin A1C test;
< B is for blood pressure; and
< C is for cholesterol.
New research shows that people with diabetes can live longer and healthier lives with relatively small improvement in these three critical areas.
The urgency of this nationwide campaign is underscored by the latest statistics showing that diabetes increased 49% from 1990 to 2000 and ADA projections indicating a 165% increase by the year 2050. The NDEP is seeking new members to join their network of over 200 partners at the federal, State and local levels. Find out more about how to become an NDEP partner in this and their many other campaigns designed to educate people with diabetes and their families. Take advantage of all the support, resources, tools, and expertise the NDEP offers for educating your organization's constituents.
For more information on how to join the campaign and to also download patient educational < tip sheets, fact sheets, flyers, brochures, and http://www.ndep.nih.gov/campaigns/campaigns.htm or order material from the < National Diabetes Information Clearinghouse, by calling < (800) 438-5383.
The New York State Medicaid program has developed a number of initiatives to increase the quality of life and healthcare for New Yorkers with asthma and diabetes. These programs have been developed in response to Governor Pataki's and Commissioner Novello's priority to address the consequences of asthma and diabetes in New York.
The New York State Medicaid program, in concert with the Island Peer Review Organization, is pleased to make available to health care practitioners and their patients brochures on asthma and diabetes. Each brochure has a complementary poster. The brochures and posters are written at a sixth grade reading level and are available in both English and Spanish.
The asthma brochure, entitled "What is Asthma? Simple Facts to Help You Breathe Easier," includes information on signs and symptoms of asthma and their possible cause. The brochure includes a six-question quiz designed to encourage patients with positive responses for asthma to seek assistance from their health care practitioner. The brochure also provides information on Medicaid coverage for asthma treatment and management and smoking cessation. The complementary asthma poster is entitled "Got Asthma?"
The diabetes brochure is entitled "What is Diabetes? Simple Facts to Help You Live Healthier." This brochure provides information on common types of diabetes, common symptoms of diabetes and ways to prevent or delay Type 2 Diabetes. A six-question quiz is also included to encourage patients with positive responses to seek assistance from their health care practitioner. The brochure also provides information on Medicaid coverage of diabetes treatment and management and smoking cessation. The complementary diabetes brochure is entitled "Got Diabetes?"
We hope that these asthma and diabetes brochures will be used to educate patients with these chronic diseases and that the posters will be displayed to alert people of the need for appropriate diagnosis and management of asthma and diabetes.
Additional information on New York State programs for asthma and diabetes, and New York State Medicaid, may be found at:
Medicaid reimburses for medically necessary care, services, and supplies for the diagnosis and treatment of asthma and diabetes. For more information, please contact the Bureau of Program Guidance at (518) 474-9219.
____"What is Diabetes?" (English) 0918 15 25 50 100
____"What is Diabetes?" (Spanish) 0919 15 25 50 100
Medicaid Diabetes Posters:
____"Got Diabetes?" (English) 0916 15 25 50 100
____"Got Diabetes?" (Spanish) 0917 15 25 50 100
As many Medicaid recipients have been diagnosed with arthritis, this educational tool has been published to provide you with additional information on the resources available to your patients. Please contact the Arthritis program (below) for more information, or refer your patients to the program.
Arthritis is one of the oldest diseases known to humankind. It has been found in the mummies of Egypt and in the excavated remains of other ancient civilizations. While there are as many as 120 different types of arthritis, the most common include osteoarthritis, fibromyalgia, juvenile rheumatoid arthritis, and gout.
In the United States, arthritis affects nearly 70 million persons <1 . Arthritis occurs at all ages, but it is most prevalent in old age. Of persons 65 and older, nearly half are diagnosed with the disease <2 . Three out of five persons diagnosed with arthritis are below age 65, and 285,000 of them are children <3 . Women age 15 years and older account for 60% of arthritis cases<4
In New York State, arthritis affects 4.7 million adult New Yorkers <5 . Of those, 1.5 million are age 65 or older <6. More New York women are living with arthritis than men, with 36% of female respondents stating that they have some form of arthritis or chronic joint symptoms <7. We also know that New York adults who are overweight or obese experience more arthritis than those who are not.
The costs of arthritis are great, not only economically but also in levels of disability and quality of life. In 1999, 17.5% of all adults with a disability reported that the main health condition associated with their disability was arthritis and rheumatism <8. Persons with arthritis report decreased quality of life, which impacts them, their families, employers, and the health care system. Estimates put the total direct and indirect costs to treat persons diagnosed with arthritis and related diseases at $125 billion annually <9. Currently, estimates show that the total costs of treating arthritis, including prescription drug costs, the complications, and the disability that results from uncontrolled disease is $7.8 billion annually in New York State <10 .
People with arthritis often do not think that anything can be done to help them. They may not seek medical attention because they believe arthritis is an inevitable consequence of aging. To the contrary, there are many strategies that can be followed to prevent arthritis or to ease its debilitating effects. Arthritis prevention, for example, focuses on good nutrition and moderate physical activity to maintain a healthy body weight. Precautions should be taken to avoid repetitive joint use, and sport
and work-related injuries.
For those living with arthritis, proper diagnosis by a health care professional is a key component of effective treatment. Fundamental interventions include good nutrition and moderate physical activity. In the area of physical activity, three types of exercises are beneficial to people with arthritis. They include range-of-motion, strengthening, and endurance exercises. Other recommendations include rest at appropriate times, heat or cold applications, and other self-management techniques.
The Arthritis Self-Help Course (ASHC) is a form of self-management. The course was designed to help people with arthritis change their activities and abilities, decrease their pain, and develop more self-confidence in being their own caregivers. It expands an individual's knowledge of arthritis, providing the skills to manage the disease and function as independently as possible. The success of the program is widely recognized for certain benefits. ASHC has been proven to reduce arthritis pain
by 20% and physician visits by 40% <11 . Its impact is still limited however. Currently, the ASHC program reaches only an estimated 1% of the population of persons affected by arthritis.
1 CDC. Prevalence of self-reported arthritis or chronic joint symptoms among adults - United States, 2001. MMWR 2001; 51(42): 948-50. 2 National Arthritis Action Plan (1999). Who is at risk for arthritis? p. 8. 3 National Arthritis Action Plan (1999). Common Myths about Arthritis. p. 7. 4 CDC. Arthritis prevalence and activity limitation - United States. 1990. MMWR 1994; 43(24): 433-8. 5 Behavioral Risk Factor Surveillance Survey, 2001, Arthritis Module. 6 Ibid. 7 Ibid. 8 CDC. Prevalence of disabilities and associated health conditions among adults. United States,1999. MMWR
2001;50:120(5) 9 Arthritis Foundation, March 2003. 10 CDC. Direct and indirect costs of arthritis and other rheumatic conditions - United States, 1997. MMWR 2003; 52(46): 11 24-26. 11 Lorig, K., Mazonson, P., Holman, H.R. (1993). Evidence suggesting that health education for self-management in
patients with chronic arthritis has sustained health benefits while reducing health care costs. Arthritis and Rheumatism
Pesticide poisonings were added to the list of reportable medical conditions in New York State in late 1990 as part of the
effort to reduce the risk of pesticide poisoning in New York. Under these regulations, physicians and health facilities are
required to report suspected or confirmed cases of pesticide poisoning. Clinical laboratories are also required to report
depressed blood cholinesterase levels or abnormally high levels of pesticides in human tissue samples.
Reporting suspect pesticide poisonings is simple:
A definitive diagnosis is not needed prior to calling and there is no paperwork for physicians to complete. Department staff investigate the reported case to collect information to monitor the health effects of pesticides. They may intervene in situations where a continued risk of pesticide poisoning exists. The work of the Pesticide Poisoning Registry complements the work of the regional poison control center. These centers supply information on immediate treatment and other emergency responses.
Poisonings may result from structural applications, yard applications, manufacturing or formulation settings, farm settings, or any other location where pesticides are used or stored. Because of their toxicity and easy availability, accidental or intentional ingestion of pesticides is also an ever-present threat.
An important public health issue in New York State this year is < West Nile Virus (WNV). Some counties may apply pesticides to control mosquito populations. The Department will be conducting surveillance of reported health effects possibly resulting from exposure to the application of WNV-related pesticides. Any physician who suspects or confirms that their patient is experiencing health effects, due to exposure to WNV-related pesticides, should report that case to the Pesticide Poisoning Registry at < (800) 322-6850.
The Pesticide Poisoning Registry strives to increase awareness in the medical community of the possibility of pesticide-related health effect and to develop interventions to reduce the risk of pesticide poisoning.
Additional information on the Pesticide Poisoning Registry, industrial hygiene assistance, and cholinesterase testing may be obtained by calling < (800) 322-6850.
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
Discussion of Medicaid Managed Care
Explanation of 90-day Regulation
Explanation of MMIS Provider Manual
Overview of Billing Options
Explanation of Utilization Threshold Program
Overview of HIPAA
Please indicate the seminar you wish to attend below:
May 25, 2004 10:00 AM or 1:30 PM
Franklin County Courthouse
Kitchen Conference Room 3
355 West Main Street
Malone, NY 12953
June 9, 2004 10:00 AM or 1:30 PM
Oneida County DSS
7th Floor Conference Room
800 Park Avenue
Utica, NY 13501
June 29, 2004 10:00 AM
Computer Sciences Corporation
3rd Floor Conference Room
800 North Pearl Street
Albany, NY 12204
June 8, 2004 10:00 AM
Computer Sciences Corporation
3rd Floor Conference Room
800 North Pearl Street
Albany, NY 12204
June 16, 2004 9:00 AM
Ontario County Safety Training Facility
2914 County Road #48
Canandaigua, NY 14424
Additional seminars may be scheduled as new programs are implemented or changes to existing billing procedures are
Please complete the following registration information: