DOH Medicaid Update August 2005 Vol. 20, No. 9

Office of Medicaid Management
DOH Medicaid Update
August 2005 Vol. 20, No. 9

 

State of New York
George E. Pataki, Governor

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

Medicaid Update
is a monthly publication of the
New York State Department of Health,
Office of Medicaid Management,
14th Floor, Room 1477,
Corning Tower, Albany,
New York 12237

 


Doctor

Physician Case Management Providers
and
Health Maintenance Organizations

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A Physician Case Management Provider (PCMP) is different from a Health Maintenance Organization (HMO). PCMPs, unlike an HMO, are only responsible for providing primary care services and have only Primary Care Providers (PCP) in their networks.

All other services are provided outside of the PCMP by referral. These services include:

  • specialty care;
  • laboratory;
  • inpatient hospital;
  • radiology;
  • durable medical equipment; and
  • home health.

Recipients enrolled with one of these providers must receive primary care services from their PCP, except when the service is being provided during treatment for an emergency condition; in an urgent situation when the recipient is out of the area; or when the service being provided is a family planning and reproductive health service.

Because PCMPs are only responsible for providing primary care services, enrollees receive other medically necessary Medicaid-covered services from Medicaid enrolled fee-for-service providers. Services which require a referral from the PCMP/PCP will appear as covered services on the Medicaid Eligibility Verification System (MEVS). Unlike an HMO, the PCMP does not pay for these services; Medicaid pays for these services. Claims for referred services are submitted directly to eMedNY.

The recipient should present a referral form from the PCMP or PCP when he/she seeks care. If the recipient does not bring the referral, contact the PCMP or the recipient's PCP to get a referral.

CLAIMS

You can bill Medicaid and receive payment for any Medicaid service for which you have a referral that is not the responsibility of the PCMP (i.e., primary care). If, at any time, you are unsure whether or not to provide a service, call the PCMP or the recipient's PCP prior to rendering the service.

Claims for referred services must have the PCMP referring identification number on the claim. For instructions on entering the referring provider identification number on the claim, please consult your Provider Manual or the appropriate Companion Guide for electronic billing located at:

www.emedny.org

Doctor

PAYMENT RULES

Because referred services are reimbursed by Medicaid fee-for-service, all applicable fee-for-service payment rules must be followed.

For example, if a referred service requires a Medicaid prior approval, in addition to the referral from the PCP, the Medicaid prior approval must be obtained prior to rendering the service.

MEDICAID SERVICES THAT DO NOT REQUIRE A REFERRAL

Behavioral health and eye care are examples of services that do not require a referral from the PCMP or the PCP, and will not appear in MEVS as a covered service. You may provide these services without a referral form. Claims for these services are submitted directly to eMedNY and are processed according to Medicaid fee-for-service rules, (i.e., prior approval, etc.).

BILLING MEDICAID

There are currently five PCMPs operating in the following counties in New York State: Broome, Erie, Chemung, Schuyler, and Steuben.

To determine if you can bill Medicaid, please see the table on the next page for names and other insurance codes which identify the PCMP and the services covered (those provided directly by the PCP and those that require a referral from the PCMP).

Providers must check the eMedNY MEVS prior to rendering services to determine the recipient's eligibility and the conditions of Medicaid coverage. If the recipient is enrolled in a PCMP, the message will read: "Managed Care Coordinator" which means "Eligible PCP," or "Other or Additional Payer" which means "Eligible Capitation Guarantee".

Please note that the MEVS coverage codes are general service categories, and do not necessarily mean that the PCMP covers all services.

Ins CodePhysician Case Management Provider NameContact
Broome County
 Broome MAX - Ins Codes.
Office hrs Monday - Friday 8:30 am - 5 pm
 
G3
DD
AT
VG
DY
AR
WR
SL
M4
DC
FO
Broome MAX - Gauri Bhard-Waj, MD
Broome MAX - Dan Driscoll
Broome MAX - Stephen Dygert
Broome MAX - Vincent Giordano
Broome MAX - Lourdes Primary Care
Broome MAX - Arjun Patel
Broome MAX - R. A. Ramanujan
Broome MAX - Azmat Saeed
Broome MAX - Samuel Addo
Broome MAX - United Medical Associates
Broome MAX - United Health Services
Broome County DSS -
(607) 778-2702
After hours, call the PCP.
Erie County
E4Erie County PCMP 2A - Rosenthal (Gold Choice)
Monday - Friday 8:30am - 4:30pm
(716) 898-5986, or
(888) 419-1722
After hours, call the PCP
ENErie County PCMP 3 - Univ Medicine Services
(Academic Medicine)
Monday - Friday, 8:30 am - 4:30 pm
(716) 898-4286, or
(888) 589-1749
After hours, call the PCP
Chemung, Schuyler and Steuben Counties
PHSouthern Tier Priority Healthcare - Twin Tiers
Monday - Friday, 8:30 am - 4:30 pm
(607) 795-5215, (607) 795-5216, or
(888) 447-8528
After hours, call the PCP
SYSouthern Tier Pediatrics(607) 734-2264, (607) 937-5317,
or,
(866) 787-5437

Would You Like Future Medicaid Updates Emailed To You?
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You will receive the Update approximately three weeks before the mailed copy!

Email your request, along with your provider identification number (found on the mailing address label of the update) to: MedicaidUpdate@health.state.ny.us.

Please let us know if you want to continue receiving the hard copy in the mail, in addition to the emailed version.

Please Note: Requesting the email version does not remove you from our hardcopy list. You will only be removed from our hardcopy list if requested from you.


Pharmacist

Attention
Pharmacy
Providers

RECIPIENT CO-PAYMENT CHANGES
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Chapter 58 of the Laws of 2005 has increased pharmacy co-payments, beginning August 1, 2005.

For all Medicaid recipients, including Medicaid managed care enrollees, the increased co-payments are:

ITEMCO-PAYMENT AMOUNTDETAILS ABOUT CO-PAYMENT
Brand-Name Prescription Drugs$3.00One co-payment charge for each new prescription and for each refill
NO CO-PAY FOR:
Drugs to treat mental illness (psychotropic), tuberculosis, and birth control.
Generic Prescription Drugs$1.00One co-payment charge for each new prescription and for each refill
NO CO-PAY FOR:
Drugs to treat mental illness (psychotropic), tuberculosis, and birth control.

INCREASE IN CO-PAYMENT MAXIMUM

The annual co-payment maximum per recipient per year has been increased to $200.

Medicaid recipients who cannot afford to pay and tell the pharmacist that they are unable to pay must be provided with the ordered pharmacy items.

The pharmacy cannot refuse to provide pharmacy items because of a recipient's inability to pay. (Recipients still owe the unpaid co-pay amounts to the pharmacy and may be asked/billed.)

Doctor

CO-PAYMENT EXEMPTIONS

  • Recipients younger than 21 years old.
  • Recipients who are pregnant.
    • Pregnant women are exempt during pregnancy and for the two months after the month in which the pregnancy ends.
  • Family planning (birth control) services.
    • This includes family planning drugs or supplies like birth control pills and condoms.
  • Residents of an Adult Care Facility licensed by the New York State Department of Health (for pharmacy services only).
  • Residents of a Nursing Home.
  • Residents of an Intermediate Care Facility for the Developmentally Disabled (ICF/DD).
  • Residents of an Office of Mental Health (OMH) or Office of Mental Retardation and Developmental Disabilities (OMRDD) certified Community Residence.
  • Enrollees in a Comprehensive Medicaid Case Management (CMCM) or Service Coordination Program.
  • Enrollees in an OMH or OMRDD Home and Community Based Services (HCBS) Waiver Program.
  • Enrollees in a Department of Health HCBS Waiver Program for Persons with Traumatic Brain Injury (TBI).
  • Enrollees in a Managed Long Term Care plan.

NOTE: Recipients who are eligible for both Medicare and Medicaid and/or receive Supplemental Security Income (SSI) payments are not exempt from Medicaid co-payments, unless they also fall into one of the groups listed above.

For questions regarding the New York State Medicaid Recipient Co-payment Program, please call the Medicaid Helpline at 800-541-2831.


Fraud impacts all taxpayers.

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Do you suspect that a recipient or a provider has engaged in fraudulent activities?

Please call:

1-877-87FRAUD

Your call will remain confidential.


Attention
Optical
Providers

Eye

Optometry Services
Medicaid Participation and Reimbursement

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MEDICAID PARTICIPATION

Participation in the Medicaid program is defined by the New York State Code of Rules and Regulations as:

The ability and authority to furnish care, services or supplies to eligible recipients and to receive payment from the medical assistance program for such care, services or supplies.

MEDICAID REIMBURSEMENT

Eye Exam

To be reimbursed for optical services, a servicing provider must be enrolled either as:

  • a salaried provider of an optical establishment in which claims are submitted under the provider number of that establishment; or
  • a fee-for-service provider in which payment is made to the actual individual rendering the service.

The use of any other provider number is prohibited.

ELIGIBLE CATEGORIES OF SERVICE

The following categories of service are eligible for reimbursement:

(COS) Category of Service Definitions
(0401) Optical Establishment with a salaried optometrist A commercial establishment engaged primarily in the sale of eyeglasses or other vision aids, and may also provide eye examinations performed by qualified licensed optometrists employed by the establishment and could also employ or contract with a self-employed optician.
(0402) Optical Establishment without a salaried optician A commercial establishment engaged primarily in the sale and dispensing of eyeglasses or other vision aids with a licensed optician.
(0403) Optician (ophthalmic dispenser) Salaried The Optician must be licensed, currently registered by the New York State Education Department and employed by one or more optical establishments. If out of state, applicant must be licensed by the appropriate agency of that state.
(0404) Optician (ophthalmic dispenser) Self-employed The Optician must be licensed, currently registered by New York State Education Department and in private practice (not employed by an optical establishment) by himself. If out of state, applicant must be licensed by the appropriate agency of that state.
(0405) Ocularist/Eye Prosthesis Fitter (Artificial Eye Maker)An Ocularist/Prosthesis is an individual who makes and fits artificial eyes. An Ocularist must have a valid certificate.
(0421) Optometrist (salaried)The Optometrist must be licensed, currently registered by the New York State Education Department and employed by one or more optical establishments. If out of state, applicant must be licensed by the appropriate agency of that state.
(0422) Optometrist (self-employed)The self-employed Optometrist must be licensed and currently registered by the New York State Education Department and in private practice (not-employed by an optical establishment) by himself. If out of state, the applicant must be licensed by the appropriate agency of that state.

An optometrist or optician may be enrolled at one or more service locations as both a salaried individual and self-employed individual at the same time, depending on their service location.

It is the responsibility of all providers to maintain current service locations on file with the Medicaid program and report any changes.

An application for enrollment may be obtained by visiting the following website:

http://www.emedny.org/info/ProviderEnrollment/index.html

All phone inquiries relating to the application process should be directed to Computer Sciences Corporation at: (800) 343-9000, Option 5.


CHANGE IN COVERAGE OF
EMERGENCY CONTRACEPTION

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Doctor

Preven, used for emergency contraception, is no longer available for dispensing.

The emergency contraception drug now being dispensed is Plan B®.

This drug is available to female Medicaid recipients with a prescription.


Attention
Anesthesiologists!

Billing for Epidurals
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Recent Medicaid audits have found errors in billing for anesthesia services. Specifically, we have found that anesthesia providers are billing for the entire time a patient receives epidural anesthesia, rather than the time the physician is physically present and monitoring the patient.

To ensure compliance and avoid potential audit disallowances, please be aware of the correct method of billing for epidurals:

BILLING REQUIREMENTS

Billing for anesthesia services requires a combination of Basic Value Units and Time Units:

Stork
  • Basic Value Units are a pre-determined number of units attached to each surgical procedure code in the Medicaid fee schedule.
  • One time unit equals 15 minutes.
  • Anesthesia is the only specialty that continues to use Time Units for claim submission purposes. The maximum conversion factor is $10.00 per unit.
  • Total Anesthesia Value is calculated as follows:

    Basic Value + Time Units = Total Anesthesia Value (Total Units)

Additional billing information can be found in the Procedure Codes and Fee Schedule of the Physician Provider Manual, pages 161-163 of Version 2005-1 (4/1/05). The manual can be found online at:

http://www.emedny.org/ProviderManuals/Physician/index.html

EXAMPLE

  • The physician enters the labor room and places the epidural (this usually takes about 30 minutes, or two time units) and then leaves the room.
  • After delivery, the physician returns and removes the epidural (15 minutes or one additional time unit).
  • The epidural was in place for a total of three hours from the time of insertion to the time of discontinuation.

The physician is allowed three basic value units plus his personal attendance. The physician should bill Medicaid for a Total Anesthesia Value of six units (3.0 basic value units + three time units for personal attendance). Medicaid should be billed $60 (six units x $10).

REMINDERS

  • Anesthesia time starts with the beginning of the administration of the anesthetic agents and ends when the physician is no longer in personal attendance.
  • Personal attendance, or time in attendance, is time spent face-to-face with the patient.
  • Documentation of time in attendance must always be recorded in the patient's record.
  • When billing anesthesia services for epidurals during labor, the date of service is the delivery date.

Additional billing information can be found in the Medicaid Physician's Manual on pages 161-163 of Version 2005-1 (4/1/05). The Medicaid Physician's Manual can also be found online at:

http://www.emedny.org

.

Questions regarding this article should be directed to Mary Rondeau, Bureau of Policy Development and Agency Relations, at (518) 473-2160.


Laboratory

Anti-Kickback Advisory
for
Laboratory and Clinic Providers

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It is an unacceptable practice for clinical laboratories and diagnostic and treatment centers, specifically rate-based facilities such as dialysis facilities, to provide or receive laboratory services at no charge.

FEDERAL LAW

Federal anti-kickback statute (Stark law) makes it a criminal offense to knowingly and willingly offer, pay, solicit, or receive any compensation to induce or reward referrals of services reimbursable by a federal health program, including a state Medicaid program.

AT RISK LAB TEST PREPARATION SERVICES

An Advisory Opinion issued by the federal Office of the Inspector General (OIG) on November 18, 2004 stated that a proposed arrangement under which a laboratory would provide "lab test preparation services" by situating "lab assistants" on-site of a dialysis facility is similar to swapping arrangements previously prohibited in a 1994 OIG Special Fraud Alert, and therefore places both parties at risk of engaging in prohibited kick-backs.

Under the proposed arrangement for "lab test preparation services," an inference arises that provision of free services, a tangible benefit to the facility, is intended to induce the referral of specimens and produce a functional discount or price reduction applicable to testing reimbursed under composite (Medicare) or all-inclusive (Medicaid) rates.

NEW YORK STATE REGULATIONS

Medicaid providers that engage in practices prohibited under federal anti-kickback rules and/or New York State (NYS) laboratory business practice law and implementing regulations are at substantial risk for exclusion from the Medicaid program.

NYS rules expressly prohibit a laboratory's supplying "employees, agents or other fiduciaries... to a referring health services purveyor to perform functions and duties in the facility of the health services purveyor."

NYS regulations provide an exception when the purveyor is a hospital, and the laboratory and hospital have entered into a contract for laboratory management services, including provision of technical services and employees for the performance of functions, including phlebotomy, directly related to laboratory operations at the hospital.

Questions on laboratory business practices may be directed to Tom Heckert at (518) 485-5357.


Attention
All
Providers!

Sort Order of Paper Remittances
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Dot

The following options of sort order are available for paper remittances:

  • Default Order - Sorted by Status, Client ID, TCN
  • TCN Order - Sorted by TCN, Claim Status, Client ID, Date of Service
  • Client ID - Sorted by Client ID, Claim Status, TCN
  • Date of Service - Sorted by Date of Service, Claim Status, Client ID, TCN

If you would like to sort your paper remittances by an option other than the default order, you may request a change by using the online Remittance Sort Request form at:

http://www.emedny.org/info/ProviderEnrollment/Provider%20Maintenance%20Forms/Paper%20Remitt%20Sort%20Request%20Form.pdf

OR

Contact CSC Provider Services at 800-343-9000, option 5.


Attention
Practitioners
and
Ordered Ambulatory Providers!

Procedure Code Review
Information

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The Bureau of Medical Review and Payment will conduct prepayment review of the following procedure codes billed by practitioners and/or ordered ambulatory providers.

Procedure Code Description
A4647Supply of Paramagnetic contrast, e.g., gadolinium.
G0125-G0336All Positron Emission Tomography (PET) scans--For descriptions refer to the physician Procedure Codes and Fee Schedule, pages 506-507 at: http://www.emedny.org/ProviderManuals/Physician/index.html
J0150Injection, adenosine for therapeutic use 6mg (not to be used to report any adenosine phosphate compounds).
J0475Baclofen 10 mg.
J0585Botulinum Toxin Type A, per unit.
J0587Botulinum Toxin Type B, per 100 units.
J9212Injection Interferon Alfacon - 1, Recombinant 1mcg.
L8603Injectable bulking agent, collagen implant, urinary tract 2.5m. syringe.
11043Debridement skin subcutaneous tissue and muscle.
11044Debridement skin, subcutaneous tissue muscle and bone.
11950Subcutaneous injection of filling material (e.g., collagen) 1cc or less.
11951Subcutaneous injection of filling material (e.g., collagen) 1.1 to 5cc.
11952Subcutaneous injection of filling material (e.g., collagen) 5.1-10cc.
11954Subcutaneous injection of filling material (e.g., collagen) over 10cc.
12001Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5cm or less.
12011Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5cm or less.
15850Removal of sutures under anesthesia (other than local).
51703Insertion of temporary indwelling bladder catheter complicated.
51710Change of cystostomy tube; complicated.
91110Gastrointestinal tract imaging (e.g., capsule endoscopy) esophagus through ileum.
96111Developmental testing; extended (includes assessment of motor, language social adaptive and/or cognitive functioning by standardized developmental instruments with interpretation and report).

Effective for dates of service on or after September 1, 2005, Physician, Ordered Ambulatory, and Nurse Practitioner providers will be required to submit paper claim forms with the appropriate documentation.

Be sure the documentation is legible and includes client name, date of service, and billing provider. Send to:

Computer Sciences Corporation
P.O. Box 4601
Rensselaer, New York 12144-4601

Reminder: the New York State Physician, Ordered Ambulatory, and Nurse Practitioner Manuals, April 1, 2005 editions, are now available online at www.emedny.org.


FEE SCHEDULE CHANGES!
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Fee schedules are available on the eMedNY website at:

http://www.emedny.org/ProviderManuals/index.html

Books

Below are changes to the fee schedules.

Nurse Practitioner, Version 2005 - 1 (4/1/05):

  • Pg. 36 correct procedure code 90921 to 90291
  • Pg. 36 correct procedure code 90823 to 90283
  • Pg. 37 add procedure code 90660, Influenza virus vaccine, for intranasal use
  • Pg. 40 add procedure code J0630, Calcitonin Salmon, up to 400 units
  • Pg. 43 add procedure code J2794, Risperidone, long acting, 0.5 mg

Free Standing/Hospital Based Ordered Ambulatory Fee Schedule, Version 2005 - 1 (4/1/05):

  • Pg. 12 procedure code 72196, correct fee to $500.00
  • Pg. 43 add procedure code 90660, Influenza virus vaccine, for intranasal use
  • Pg. 45 delete J1565, code inactive, use valid code 90379

Physician Fee Schedule, Version 2005 - 1 (4/1/05):

Medicine Section:

  • Pg. 11 correct reimbursement for SL modifier fee to $17.85
  • Pg. 48 procedure code 99291, change description: report is not required
  • Pg. 58 correct Established Patient codes to 99211, 99212, 99213, 99214 and 99215
  • Pg. 110 add procedure code 90660, Influenza virus vaccine, for intranasal use
  • Pg. 113 procedure code J0585, correct units to per unit
  • Pg. 142 procedure code 93620, correct fee to $383.00
  • Pg. 154 add procedure code 95990, Refilling and maintenance of implantable pump or reservoir for drug delivery, $15.00

Surgery Section:

  • Pg. 216 procedure code 23420, correct fee to $280.00
  •        procedure code 23450, correct fee to $280.00
  •        procedure code 23455, correct fee to $320.00
  • Pg. 227 correct procedure code 25145 to 25415
  •        correct procedure code 24526 to 25426
  •  
  • Pg. 373 procedure code 50590, correct fee to $223.00
  • Pg. 458 procedure code 67966, correct fee to $200.00

Radiology Section:

  • Pg. 473 procedure code 71550, correct fee to $500.00

Questions regarding the above changes may be referred to The Bureau of Medical Review and Payment at (518) 474-8161.


Reimbursement and Coding Changes for Enteral Formula
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Powder Powder

SCREEN PRICING FOR B4161

Effective for dates of service on and after April 1, 2005, products categorized under code B4161 (Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit) are reimbursable using "By Report" rules when the charge is greater than the price listed ($1.35 per caloric unit) in the fee schedule.

To submit using "By Report" rules, the claim must be filed on paper with an attached itemized invoice for pricing at acquisition cost plus 30%. If needed, you may submit an adjustment for previously paid claims for B4161 using "By Report" rules for dates of service on and after April 1, 2005.

B4160 ADDED

Effective for dates of service on or after August 1, 2005, the Medicaid program has added code B4160 (Enteral formula, for pediatrics, nutritionally complete calorically dense [equal to or greater than 0.7 kcal/ml] with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit).

The maximum quantity is 600 caloric units per month; the maximum fee is $0.60 per caloric unit.

REIMBURSEMENT CHANGES

Due to a change in Department regulations, the Medicaid reimbursement methodology for enteral nutrition has been changed.

The maximum allowable fee is now the lower of:

  • the acquisition price plus thirty-percent for generically equivalent products as indicated in the fee schedule; or
  • the usual and customary price charged to the general public.

Acquisition price means that price determined and periodically adjusted by the State Health Department, which it deems a prudent Medicaid provider would pay for a reasonable quantity of generically equivalent enteral products.

Manually priced specialized formulas have been priced per the regulatory change for dates of service on or after January 1, 2005 (see January Medicaid Update).

Effective for dates of service on or after August 1, 2005, the maximum fees for the following standard formulas have been changed:

CODE FEE/CALORIC UNIT

B4150 $0.49
B4152 $0.38
B4153 $1.99

CHANGES TO ENTERAL PRODUCT CLASSIFICATION LIST

New formulas have been added and some formulas have been reclassified since the list was published in the May 2005 Medicaid Update. Please make the following changes, noted in bold. Refills for existing prior authorizations must bill using the code under which the authorization was obtained. Use the new coding classification for new orders.

PRODUCTCODE
Enfamil A.R.B4158
GA B4157
HCY 1 B4162
HCY 2 B4157
KindercalB4160
LMD B4157
LophlexB4155
MSUD 1B4155
MSUD 2B4155
Nutren Junior B4160
OA 1 B4162
OA 2 B4157
OS 1 B4155
OS 2 B4155
PediasureB4160
PFD 1 B4155
PKU 1B4155
PKU 2B4155
PKU 3B4155
Product 3200AB B4162
Resource for Kids B4160
TYR 1 B4155
TYR 2 B4155
UCD 1 B4155
UCD 2 B4155
WND 1 B4162
WND 2 B4157
Lophlex B4155

For more information on Medicaid coverage and payment for enteral formulas, go to: http://www.health.state.ny.us/health_care/medicaid/program/medup-index.htm

Questions? Please contact the Bureau of Medical Review and Payment at (518) 474-8161.


Billing Requirements for Clinics
Certified by
The Department of Health and The Office of Mental Health

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Building

The purpose of this article is to clarify Medicaid billing policy for a clinic certified by both the Department of Health (DOH) - under Article 28 of the Public Health Law, and by the Office of Mental Health (OMH) - under Article 31 of the Mental Hygiene Law.

Our policy maintains that clinic programs which are operated by diagnostic and treatment centers and outpatient departments of acute care hospitals, which are certified by both OMH and DOH, should bill the OMH rate/rate code for mental health clinic treatment services (including all services required under Part 587 of OMH regulations), and the DOH rate/rate code for medical clinic services.

The policy is based on Section 43.02 of the Mental Hygiene Law, which requires that OMH determine the Medicaid rates of payment for outpatient mental health services in programs licensed by OMH.

Questions? Please contact the Bureau of Policy Development and Agency Relations at (518) 473-2160.


Attention
Orthotic, Prosthetic
and Prescription
Footwear Providers

Using the LT and RT Modifiers
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The eMedNY system has now been programmed to recognize the use of LT (Left Side) and RT (Right Side) modifiers with procedure codes for orthotic and prosthetic devices and prescription footwear. These modifiers should be used when appropriate to further describe the service provided.

Boy

Do not use these modifiers with procedure codes for devices which are not side-specific or when the code description is a pair.

If an item requires Dispensing Validation System (DVS) authorization or prior approval, use the LT or RT modifier on the request and on the claim. For a DVS authorization, the modifier must immediately follow the procedure code, with no spaces between the modifier and code. The modifier must be the first occurrence of the possible four modifiers on the claim, and the entire seven characters (five digit procedure code plus two digit modifier) must exactly match the seven characters which were authorized through DVS or prior approval.

For general claim form and prior approval instructions, and the DME Procedure Code/Fee Schedule, go to: http://www.emedny.org/ProviderManuals/DME/index.html

For instructions on obtaining DVS authorizations, go to http://www.emedny.org/ProviderManuals/AllProviders/MEVS/MEVS_Provider_Manual/1_7/MEVS%20Provider%20Manual.pdf

If you have further questions on claim form completion or obtaining DVS authorizations, call:
Computer Sciences Corporation at (800) 343-9000.

For additional prior approval or coding questions, please call the Bureau of Medical Review and Payment at (518) 474-8161.


DIAGNOSIS ON MEDICAID LAB
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Claims for laboratory services must include one or more appropriate ICD-9-CM codes to indicate patient diagnosis, symptomology, and/or reason for the test(s).

The ordering practitioner is obligated to provide the laboratory with patient-specific information, either in the form of:

Laboratory

  • ICD-9 codes; or
  • narrative descriptors.

Laboratories that accept narratives are responsible for accurate translation to ICD-9 coding; the laboratory should contact the practitioner with questions or concerns.

Use of the ICD-9-CM code V72.6 (general laboratory exam) or other non-specific coding is not acceptable.

Questions? Please call 518-473-2160.


New York State Occupational Health Clinic Network
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In 1987, the New York State Department of Health established the New York State Occupational Health Clinic Network (OHCN) to meet the increasing demand for medical services related to the diagnosis, treatment and prevention of occupational disease. The OHCN is unique in the United States as a public health based occupational disease clinical and preventive service and includes eight clinical centers, including one with statewide responsibility in the area of agricultural safety and health.

OHCN CLINICS

The clinics of the OHCN are a resource for health care providers treating patients with potential work-related illnesses and injuries. They have diverse treatment teams of physicians, nurses, industrial hygienists and social workers that assist providers in assessing and managing their patients' work-related conditions and, if necessary, provide worksite and social work interventions. The OHCN's board certified occupational medicine physicians and staff are also experts in dealing with the Workers' Compensation system and assisting patients during the compensation process.

The five OHCN clinics are open to workers, retirees and residents of New York State with potential work-related illness and injuries. Because they receive public funding, they offer a sliding fee scale to assure access for uninsured and underinsured patients and can bill directly to most major health insurance carriers. Moreover, because of their occupational focus, the clinics are able to offer services that compliment the care patients receive from their primary care physicians and other specialists.

SPECIALTY SERVICES

Specialty services include: occupational illness and injury prevention education, medical surveillance examinations, respirator fit testing and clearance examinations, fit for duty examinations and a variety of wellness safety programs.

Physicians in New York State are encouraged to contact the OHCN clinic in their region to determine how they can utilize the clinics' occupational health services for their patients with potential work- related conditions. For additional information about the OHCN representative in your region, contact the New York State Department of Health at 1-800-458-1158, or go on-line at: http://www.nyhealth.gov/environmental/workplace/clinic_network.htm

AlbanyOccupational & Environmental Health Center of Eastern New York; New Paltz Satellite
BuffaloUnion Occupational Health Center
CooperstownSpecialty Clinic - New York Center for Agricultural Medicine and Health
Long IslandLong Island Occupational & Environmental Health Center
New York CityBellevue/NYU Occupational & Environmental Medicine Clinic
New York CityMount Sinai - I. J. Seilkoff Center for Occupational & Environmental Medicine; Westchester & Queens Satellites
RochesterFinger Lakes Occupational Health Services; Elmira Satellite: Arnot Ogden Medical Center
SyracuseCentral New York Occupational Health Clinical Center; Binghamton Satellite

Seminar Schedule and Registration
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Computer Sciences Corporation (CSC) announces a schedule of seminars to be offered to providers and their billing staff. CSC will conduct the following training seminars:

  • New Provider Seminar
    Provider Specific Seminars
    - CSC will offer three Provider Specific Seminars:
    • Physician
    • Dental
    • Private Duty Nursing

Meeting

  • eMedNY Phase II Seminars - CSC will offer four eMedNY Phase II Seminars
    • Rate-Based Residential
    • Rate-Based Non-Residential
    • Fee-For-Service A
    • Fee-For-Service B

Seminar locations and dates are available at the eMedNY website. Registration is fast and easy.

Go to http://www.emedny.org/training/index.aspx to register for the eMedNY Training Seminar appropriate for your provider category and location.

If you are unable to access the internet to register, please contact CSC's call center at (800) 343-9000 to obtain a registration form.

Please refer to these resources frequently for additional seminar offerings.

CSC representatives look forward to meeting with you at upcoming seminars!


News

Did You Know that Medicaid Pharmacy Information Can Be Found on the Department's Website?
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That's right!

Just go to: http://www.health.state.ny.us/health_care/medicaid/program/pharmacy.htm for information on pharmacy topics including:

  • the Mandatory Generic Drug Program;
  • Prior Authorization; and, the recently added
  • Nursing Home/Child Care Agency Drug Carve Out List.

Info   

PROVIDER SERVICES
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Missing Issues?
The Medicaid Update, now indexed by subject area, can be accessed online at the New York State Department of Health website: http://www.health.state.ny.us/health_care/medicaid/program/main.htm
Hard copies can be obtained upon request by calling (518) 474-9219.

Would You Like Future Updates Emailed To You?
Email your request to our mailbox, MedicaidUpdate@health.state.ny.us
Let us know if you want to continue receiving the hard copy in the mail in addition to the emailed copy.

Do You Suspect Fraud?
If you suspect that a recipient or a provider has engaged in fraudulent activities, please call the fraud hotline at: 1-877-87FRAUD. Your call will remain confidential.

As a Pharmacist, Where Can I Access the List of Medicaid Reimbursable Drugs?
The list of Medicaid reimbursable drugs is available at: http://www.eMedNY.org/info/formfile.html

Questions About an Article?
For your convenience each article contains a contact number for further information, questions or comments.

Do You Want Information On Patient Educational Tools and Medicaid's Disease Management Initiatives?
Contact Department staff at (518) 474-9219.

Questions About HIPAA?
Please contact CSC Provider Services at (800) 343-9000.

Address Change?
A change of address form is available at: http://www.emedny.org/info/ProviderEnrollment/Provider%20Maintenance%20Forms/6101-Address%20Change%20Form.pdf.
Provider Enrollment questions should be directed to CSC at (800) 343-900, option 5.

Billing Question? Call Computer Sciences Corporation:
Provider Services (800) 343-9000.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Timothy Perry-Coon at MedicaidUpdate@health.state.ny.us or via telephone at (518) 474-9219 with your concerns.


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)

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: http://www.health.state.ny.us/health_care/medicaid/program/main.htm

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