State of New York
George E. Pataki, Governor
Department of Health
Antonia C. Novello, M.D., M.P.H., Dr. P.H.
is a monthly publication of the
New York State Department of Health,
Office of Medicaid Management
Kathryn Kuhmerker, Deputy Commissioner
Table of Contents
Added Benefit for New York City Medicaid Managed Care Package
Did You Know? The Medicare Prescription Drug Program will Cover Smoking Cessation Products Beginning January 1, 2006
Medicaid Smoking Cessation Policy
Medicaid Recipient Stop Smoking Coverage Fact Sheet
Medicaid Coverage of Hysteroscopic Sterilization (Essure®)
Reimbursement to Nurse Practitioners and Midwives for Practitioner Office Laboratory
Erectile Dysfunction Procedures Now Require Prior Approval
Hospital Billing Changes
Do You Need Rate Code and Rate Amount Printouts?
ePACES: The Alternative to Paper Claims
eMedNY Update: Enhanced Electronic Remittances Information for Denied Claims
New Rate Codes for Nursing Home Billing
Emergency Procedures for Durable Medical Equipment Requiring Prior Approval
New Prior Approval Fax Capability
Providers of ambulette services are required to submit vehicle information on an annual basis in accordance with Title 18 NYCRR (New York Code, Rules and Regulations) 502.6(b):
Each provider of ambulette services must, during the month of January of each year, disclose to the department in writing information concerning those vehicles currently owned or leased by the provider. The information to be disclosed must include at a minimum the name and address of the provider, each vehicle's license number and Department of Transportation identification number and a statement regarding whether the vehicle is owned or leased. A provider of ambulette services that fails to disclose this information will have its participation in the medical assistance program terminated.
Failure to comply will result in the termination of enrollment as a Medicaid provider.
The form below must be returned by February 15, 2006 to:
Certified/Return Receipt mail is suggested. A copy of the form and proof of mailing should be retained for your records. In the event of non-receipt of the form by the Department, this proof will be used to validate compliance.
Provider Name: ________________________________________________________________________
Provider Address: ______________________________________________________________________
Provider Phone #:______________________________________________________________________
eMedNY Provider #: ____________________________________________________________________
Name of Person Completing This Form: ____________________________________________________
Title of Person Completing This Form: _______________________________________________________
Signature of Person Completing This Form: __________________________________________________
DAYS OPEN AND HOURS OF OPERATION
S ______ M _______ T _______ W _______ TH ______ F _______ S _______
|DMV Plate Number||Vehicle Identification Number (VIN#)||Passenger Capacity||Owned||Leased||Leased from|
NYS DOT OPERATING CERTIFICATE # ____________________
New York City
Effective October 1, 2005, the New York City Medicaid managed care benefit package has added a new service:
Transitional Home Health Services Pending Placement of Personal Care (Home Attendant) Services
Transitional home health services are home health services provided by a certified home health agency to a Medicaid managed care enrollee for up to a thirty (30) day period while the New York City Human Resources Administration (HRA) completes the assessment and placement process for a personal care services aide (home attendant). Please note the following:
This form, commonly referred to as the M11Q, requires physician orders, must be signed by the licensed physician, and must be received by HRA within thirty (30) calendar days of the physician's examination.
Certified Home Health Agencies must submit a nursing assessment (N27R) along with the M11Q for these consumers.
For questions about transitional home health care, please call (518) 473-7467.
Return to Table of Contents
Smoking cessation therapy consists of prescription and non-prescription agents.
NYS Smokers Quitline (866)NY-QUITS (866-697-8487)
The NYS Smokers Quitline staffs trained specialists who will screen patients for Replacement Therapy and provides cessation counseling. Free Quitline services are also offered for providers and include:
|American Cancer Society||(800) 227-2345|
|American Lung Association||(800) 586-4872|
|Centers for Disease Control and Prevention
(Request the Office of Smoking and Health)
|National Cancer Institute||(800) 4-CANCER (800-422-6237)|
For information on New York State Medicaid's Smoking Cessation Policy, please call (518) 486-3209.
There are many cost free programs and resources available to help you quit and stay tobacco free. Some are listed below.
Local cessation support program information can be obtained from:
New York State Smokers' Quitline
Centers for Disease Control and Prevention
National Cancer Institute
Effective for dates of service on or after November 1, 2005, New York Medicaid provides reimbursement for Essure® hysteroscopic sterilization.
Physicians with Specialty 089 (Obstetrics and Gynecology) and 210 (General Surgeon) may receive reimbursement for this procedure. It is anticipated that this procedure will be performed in a physician's office. However, depending on the patient, it could be performed in a freestanding or hospital-based ambulatory surgery center.
Physicians should bill 58565 for the surgical procedure. Medicaid reimbursement is set at $320. For the Essure kit, use code 99070 (cost of materials).
A post-test proof of occlusion (58340, Catheterization and introduction of saline or contrast material for hysterosonography or hysterosalpingography) should be performed 90 days following the procedure.
NOTE: Diagnostic hysteroscopy (58555) and cervical dilation (57800) are inclusive components and should not be billed separately when performed in conjunction with hysteroscopic sterilization (58565).
When the procedure is performed in an operating room on an anesthetized patient, a freestanding or hospital-based ambulatory surgery center may bill for the procedure. It will group into PAS (Products of Ambulatory Surgery) 31, GYN Diagnostic/Therapeutic. The cost of materials (Essure® kit) is included in the PAS rate paid to the facility. The physician would bill 58565 for the surgical procedure.
The patient must:
Forms can be requested from:
or printed from:
Questions concerning Essure® hysteroscopic sterilization billing should be addressed to the Bureau of Policy Development & Agency Relations at (518) 473-2160.
Effective on or after February 1, 2006, Medicaid enrolled nurse practitioners and midwives receive Medicaid reimbursement for performing certain laboratory tests for their own patients, provided they hold the required Clinical Laboratory Improvement Amendments (CLIA) certification.
The following list of laboratory services will be covered by Medicaid when performed by a nurse practitioner or a midwife:
|81000||'Urinalysis', by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specificgravity, urobilinogen, any number of these constituents; non-automated, with microscopy||$4.00|
|81002||'Non-automated', without microscopy||$2.00|
|81015||'Urinalysis'; microscopic only||$2.00|
|81025||Urine pregnancy test, by visual color comparison methods||$2.00|
|85007||Blood count; blood smear, microscopic examination with manual differential WBC count (includes RBC morphology and platelet estimation)||$1.43|
|85025||Complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count||$3.17|
|85041||Red blood cell (RBC) automated||$3.17|
|85048||Leukocyte (WBC), automated||$3.17|
|85651||'Sedimentation rate', erythrocyte; non-automated||$2.00|
|87081||Culture, presumptive, pathogenic organisms, screening only (throat only)||$5.20|
|87880||Infectious agent detection by immunoassay with direct optical observation; streptococcus, group A (throat only)||$3.75|
Medicare reimburses for these services at 100 percent. No Medicare co-insurance payments may be billed for the above listed procedure codes.
To claim reimbursement, nurse practitioners and licensed midwives must:
To register with Medicaid as a practitioner office laboratory, nurse practitioners and licensed midwives must:
< If the practice at which you will perform reimbursable testing does not already hold a CLIA certificate, nurse practitioners and licensed midwives must:
The payment system has linked lab test procedure codes to the type of CLIA certification as follows:
CLIA Certificate of Compliance/Accreditation: Use the 14 CPT-4 codes listed above for billing purposes.
CLIA Certificate - Physician Performed Microscopy Procedures (PPMP): Payment is available for the following laboratory procedure codes ONLY:
81000, 81002, 81015, 81025, 85013, 85018, 85651, and 87880.
CLIA Certificate of Waiver: Payment is available for the following procedure codes ONLY:
81002, 81025, 85013, 85018, 85651, and 87880
If post-payment review reveals that the payment was inappropriate because you performed and billed for a test method OUTSIDE your scope of practice, collaborative agreement and/or CLIA certificate, the payment may be disallowed.
For additional information regarding coverage for practitioner office laboratory test billing, please contact the Bureau of Policy Development and Agency Relations staff at (518) 473-2160.
January 1, 2006!
To implement Chapter 645 of the Laws of 2005, which seeks to ensure that the Medicaid program will not provide coverage for erectile dysfunction (ED) drugs, procedures or supplies to convicted sex offenders, prior approval is required for the following CPT/HCPCS procedure codes, effective for dates of service on and after January 1, 2006.
The provider type listed below must submit the prior approval request.
|37788||Penile revascularization, artery, with or without vein graft||Physician|
|37790||Penile venous occlusive procedure||Physician|
|54400||Insertion of penile prosthesis; non-inflatable (semi-rigid)||Physician|
|54401||Insertion of penile prosthesis, inflatable (self-contained)||Physician|
|54405||Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir||Physician|
|54408||Repair of component(s) of a multi-component, inflatable penile prosthesis||Physician|
|54410||Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session||Physician|
|54411||Removal and replacement of all components of a multi-component, inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue||Physician|
|54416||Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session||Physician|
|54417||Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue||Physician|
|J0270||Injection, alprostadil, 1.25 mcg (aka Caverject)||Physician/NP|
|J0275||Alprostadil urethral suppository (aka MUSE)||Physician/NP|
|J2440||Injection, papaverine hcl, up to 60 mg||Physician/NP|
|J2760||Injection, phentolamine mesylate, up to 5 mg||Physician/NP|
|L7900||Vacuum erection system||DME|
A diagnosis of ED is identified by the following ICD-9 diagnoses codes:
|ICD-9 DIAGNOSES CODES||DESCRIPTION|
|302.71||Psychosexual dysfunction with hypoactive sexual desire disorder|
|302.72||Psychosexual dysfunction with inhibited sexual excitement (includes impotence)|
|302.74||Male orgasmic disorder|
|607.84||Impotence of organic origin|
For inpatient providers, the following ICD-9 procedure codes identify ED:
|ICD-9 PROCEDURE CODES||DESCRIPTION|
|64.94||Fitting of external prosthesis of penis|
|64.95||Insertion or replacement of non-inflatable penile prosthesis|
|64.97||Insertion or replacement of inflatable penile prosthesis|
Providers must report the applicable CPT/HCPCS, ICD diagnosis and/or ICD procedure code(s) when requesting or billing erectile dysfunction services for Medicaid recipients.
Questions? Please call the Bureau of Medical Review and Payment at (518) 474-8161.
A new Service Intensity Weights (SIW) table will be used when processing Diagnosis Related Groups (DRGs) payments to New York State hospitals.
The new table, effective for discharges on or after January 1, 2006, contains additions, deletions, and revisions when compared to the table used for discharges from January 1, 2004 - December 31, 2005.
The new table can be accessed at:
The Department has developed a policy for considering high-cost outlier payments when a patient's Medicare entitlement begins during the inpatient stay.
Last month a letter was mailed to representatives in hospital fiscal offices and to each hospital's IPRO (Independent Peer Review Organization) liaison. Details of the new policy and the procedures for case reviews were included with that letter.
For copies of the policy and procedures, please contact the Rate-Based Provider Unit at (518) 474-8161.
Every six months, you may request a summary of the rate codes and dollar amounts used to make Medicaid payments to your facility.
When requesting this information, the request must:
Requests should be mailed to:
Computer Sciences Corporation
PO Box 4610
Rensselaer, NY 12144
Questions? Please call Computer Sciences at (800) 343-9000, option 5
Do you submit paper claims to eMedNY?
Consider the convenience of using ePACES, the electronic Provider Assisted Claim Entry System!
ePACES is a web-based software application that allows you to:
ePACES edits your claim information as you enter it, allowing you to correct some invalid data before you submit the claim to eMedNY for processing!
After submitting your claim to eMedNY, it is processed (usually) within 24-48 hours, and you can view your results right on ePACES!
This means that you can know the status of your claims submitted via ePACES, before your otherwise mailed paper claim would have reached eMedNY!
Electronic claims on the average have a 10% better approval rate than paper claims.
The Department provides ePACES free of charge through eMedNY!
Providers submitting Professional claims can take advantage of ePACES real-time option. When you select the real-time option, your claim will be processed as soon as it is received by eMedNY, and the status of your claim (including payment amount) will be available for viewing in ePACES within seconds!
ePACES is also a convenient way to enter your requests for prior approval . A reference number will be returned to your ePACES screen, which can be later used to check the approval status on ePACES.
To find out more about how to sign up for ePACES, please visit our website at http://www.emedny.org/HIPAA/QuickRefDocs/index.html#epaces. Click on ePACES Enrollment in the center of the screen.
If you are printing paper claim forms, you can still take advantage of electronic claim submission. Contact your software vendor and ask him/her for an option to create an electronic HIPAA compliant file in lieu of printing paper forms. If your vendor needs information about creating a HIPAA compliant file, ask him/her visit www.emedny.org and download the appropriate Companion Guides.
If your vendor still has questions after reviewing the Companion Guides, have his/her representative call the eMedNY Call Center at (800) 343-9000, and identify themselves as a vendor working on HIPAA compliance. We will put a technical support individual in touch with the vendor to answer any questions they may have.
Once you have created a HIPAA compliant file of claims, you can send your claims over the Internet to eMedNY using the eXchange option.
Signing up for ePACES will also give you access to eMedNY eXchange.
If you do not have access to the Internet or prefer to use a dial-up option, you can send your claim batches to eMedNY using a dial-up file transfer program (FTP). For information on how to sign up and use eMedNY dial-up FTP, please call (800) 343-9000.
If you have questions regarding this article, please contact the eMedNY Call Center at (800) 343-9000.
Do you receive electronic remittances? The 835/820 Supplementary Files delivered with your remittances are being enhanced to include extensive information on denied claims. With the enhancements, detailed information will be provided for up to 27 eMedNY edits for each denied claim.
The enhancements will be effective with payment cycle 1487, February 20, 2006. Reporting for pended claims will not change. Providers who receive their remittances electronically may need to update their systems to handle the new Supplementary Files format.
Please review the new eMedNY Companion Guides very carefully. The Guides are available on our website at:
If you have any questions, please contact the eMedNY Call Center at (800) 343-9000.
The Edit & Error Knowledge Base has been updated and expanded to include eMedNY edits. This is a great tool for providers to use to interpret the eMedNY edits that have impacted their submitted claims. Providers can use this tool to see a detailed explanation for each edit, and to review the possible causes of why a claim has hit a specific edit. Access the Edit & Error Knowledge Base at:
Questions? Please contact the eMedNY Call Center at (800) 343-9000.
As a result of the new Medicare Part D drug coverage program, nursing homes were advised in November 2005 of a change in the way Medicaid is to be billed for nursing home per diem rates for dates of service on and after January 1, 2006.
The Department of Health has established several new rate codes to reflect the new Medicare Part D benefit (see table below).
Nursing homes must select the proper rate code to bill based upon the recipient's Medicare Part D and Part B benefits.
|NEW MEDICARE PART D AND PART B RATE CODES|
|3838||Medicare Part D Coverage|
|3839||Medicare Parts B and D Coverage|
|3840||Special Care Medicare Part D - OOS only (HB)(FS)|
|3841||Special Care Medicare Parts B and D - OOS only (HB)(FS)|
|3842||Special Care, High Level Medicare Part D - OOS only (HB)(FS)|
|3843||Special Care, High Level Medicare Parts B and D - OOS only (HB)(FS)|
|3844||Neuro Behavioral, Medicare Part D (HB)(FS)|
|3845||Neuro Behavioral, Medicare Parts B and D (HB)(FS)|
|3846||Pediatric, Medicare Part D(HB)(FS)|
|3847||Pediatric, Medicare Parts B and D (HB)(FS)|
|3848||Aids, Medicare Part D (HS)(FS)|
|3849||Aids, Medicare Parts B and D (HB)(FS)|
|3773||Head Injury, Medicare Part D (HS)(FB)|
|3774||Head Injury, Medicare Parts B and D (HB)(FS)|
|3775||Ventilator Dependent, Medicare Part D (HB)(FS)|
|3776||Ventilator Dependent, Medicare Parts B and D (HB)(FS)|
|3777||Respite, Medicare Part D (HB)(FS)|
|3778||Respite, Medicare Parts B and D (HB)(FS)|
For questions pertaining to the actual rate amount, please contact the Bureau of Long Term Care Reimbursement at (518) 473-9213.
Billing questions may be addressed to Computer Sciences Corporation at (800) 343-9000.
All other questions may be addressed to the Bureau of Medical Review and Payment Rate Based Provider Unit at (518) 474-8161.
The following procedures will be available to Durable Medical Equipment (DME) providers for dates of service on and after January 23, 2006, for emergency situations in lieu of requesting normal prior approval. Following the procedures described below, you will be able to bypass the prior approval requirement when an emergency situation occurs.
An emergency medical condition (for Medicaid) is defined as:
a medical condition ... manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part.
Only a qualified ordering practitioner may determine, using his or her professional judgement, whether a situation constitutes an emergency. The ordering practitioner's documentation of the specific need for emergency must be maintained in the patient records of the ordering practitiioner and DME provider, along with the fiscal order. In such emergency situations, prior approval is not required
DME providers must indicate the service is of an emergency nature by using the Emergency Indicator on the paper claim form [Box 16a on the paper Claim Form 15001] or electronic claim<p></p> [Loop 2400(Detail), DE 0884 of the 837P].
There are several different situations which may occur:
If a prior approval is subsequently requested for non-emergency repairs on equipment previously repaired on an emergency basis by the same provider, the provider must supply the emergency repair fiscal order and practitioner documentation of need with the current prior approval request.
Urgent supply and respiratory items are available through the Dispensing Validation System (DVS) and do not require prior approval.
Rental of acceptable alternatives is available to address the urgent needs of clients awaiting receipt of specific items of DME otherwise requiring prior approval.
This process cannot be utilized for initial purchase of items using the miscellaneous services code, E1399 or K0108, or where an otherwise approved code does not exist. The Department must be assured that any item being claimed using these codes are federally reimbursable.
As with all Medicaid services, the use of the emergency process, in lieu of prior approval, will be periodically reviewed and audited.
Any questions on the above can be addressed to CSC at (800) 343-9000.
Effective January 23, 2006, materials in support of submitted prior approvals may be faxed to Computer Sciences Corporation (CSC). These materials must be on 8.5" X 11" plain background paper (which is scannable), and must be submitted with one of the following:
These forms contain the key information (prior approval number and Reviewer ID as appropriate) to match the faxed materials to the original prior approval. These forms will be revised to include the CSC fax number and a place for your fax number.
Only the revised form will be accepted via fax for processing.
CSC will fax back to the sender a cover sheet of explanation when an unreadable fax is received. There will be no change in where you obtain the forms (e.g., Return Information Routing Sheet comes with a Missing Information Letter, or "Invoice" Letter, and both the Prior Approval Change Request form and Electronic Transaction Attachment Scanning Sheet are available on the eMedNY website).
The original Prior Approval Request will still be required to be submitted to CSC via paper, electronic 278, or ePACES submission. This will be the source of the prior approval number that needs to be recorded on the appropriate form or sheet above.
Questions? Please call CSC at (800) 343-9000
Computer Sciences Corporation (CSC) issues 1099 forms to providers at the beginning of each year for the previous year's Medicaid payments.
The 1099 amount is not based on the date of the checks; rather it is based on the date the checks were released to providers.
Due to the two-week check lag between the date of the check and the date the check is issued, the 1099 amount will not correspond to the sum of all checks issued for your provider identification number during the calendar year. The 1099 amount is based on check release date.
The 1099s that will be issued for the year 2005 will include the following:
Additionally, in order for group practice providers to direct Medicaid payments to a group identification number and corresponding 1099, providers are reminded that they must submit the group identification number in the appropriate field on the claim (paper or electronic). Claims that do not have the group identification number entered will cause payment to go to the individual provider and his/her 1099.
1099s for the year 2005 will be mailed no later than January 31, 2006.
The above information is provided to assist providers with reconciling the 1099 amount.
Any questions should be directed to CSC's Provider Services at (800) 343-9000.
The Medicaid Update, now indexed by subject area, can be accessed online at the New York State Department of Health website: http://www.health_care/medicaid/program/update/main.htm
Hard copies can be obtained upon request by emailing: MedicaidUpdate@health.state.ny.us or by calling (518) 474-9219.
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.
Questions should be directed to CSC at (800) 343-900, option 5.
Call the Touchtone Telephone Verification System (800) 997-1111, (800) 225-3040 or (800) 343-9000.
Fee-for-service Provider Enrollment </<br /> A change of address form is available at:
Rate-based/Institutional Provider Enrollment
A change of address form is available at:
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 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
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_care/medicaid/program/update/main.htm