DOH Medicaid Update July 2000 Vol.15, No.7

Office of Medicaid Management
DOH Medicaid Update
July 2000 Vol.15, No.7

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

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This is to remind Medicaid providers of policies that provide for immediate access to medical care for Medicaid newborns.

When there is medical verification of a pregnancy, the local Department of Social Services issues a Medicaid card for the expected child. This card is a valid Medicaid card, and may be used to obtain medical care once the child is born. Providers MUST accept this card. They CAN bill and receive payment through the Medicaid Management Information System (MMIS) using this card, as long as the newborn or mother is not enrolled in a Medicaid Managed Care Plan (MCP).

For this card, the Electronic Medicaid Eligibility Verification System (EMEVS) will show a "U" in the sex code field and 000 as the date of birth. The provider can bill Medicaid fee-for-service if eligibility is on file. In this instance, the MMIS will default to the date of birth and sex on the claim in order to pay the claim, provided that no Medicaid MCP is indicated for the child or the mother.

Providers must continue to determine whether the newborn and/or mother is enrolled in a Medicaid MCP. If either is enrolled and the service to be provided is a covered service, the provider should contact the MCP before rendering service, except in an emergency.

In New York State, an infant whose mother is in receipt of Medicaid at the time of the infant's birth is entitled to Medicaid for at least the first 12 months from the date of birth. Therefore, if a woman with an infant in need of care presents her active Medicaid card, providers should assume that the child is also eligible, even though the child may not yet have a Medicaid card, and provide the service.

If you have any questions regarding billing, please contact the appropriate Computer Sciences Corporation (CSC) inquiry unit:

Practitioner Services     (800) 522-5518   (518) 447-9860
Institutional Services     (800) 522-1892   (518) 447-9810
Professional Services     (800) 522-5535   (518) 447-9830

Thank you for your assistance in ensuring that newborns receive quality care while their formal Medicaid eligibility is being processed.

Three thousand young people will smoke their first cigarette today. Of these 3,000 young people, nearly 750 will die from diseases caused by cigarettes. Teen smoking can lead to a lifelong addiction to nicotine. Advertising, peer pressure, and parents who smoke all contribute to an increased incidence of teen smoking. Health care providers can have a great impact on smoking cessation by just asking, assisting and listening to patients. Please take a moment to review the following information.


  1. Most people start using tobacco before they finish high school.
  2. Most teens who smoke are addicted to nicotine. They experience nasty withdrawal symptoms - just like adults do.
  3. Tobacco is often the first drug used by kids who use alcohol and illegal drugs like marijuana.
  4. Kids who start smoking are more likely to get lower grades in school. They tend to hang out with other kids who smoke. They may have a low self-image, and they don't know how to say no to tobacco.
  5. Cigarette advertisements are designed to make people think that smoking is cool and that everybody does it. These misleading ads appear to increase kids' risk of smoking.
  6. Finally, here's some good news! People working in their communities, kids who warn each other about the dangers of smoking, and programs that make it harder for stores to sell cigarettes to kids are helping to keep kids away from tobacco.


How to help your patients stop smoking. Bethesda, Md. NCI;1991. NIH publication no. 92-3064

  • Ask patients about tobacco use. Ask about participation in sports or other activities incompatible with smoking. Physicians, including pediatricians, should anticipate smoking in older children and teens.
  • Advise patients to stop or not to start. Highlight the short-term negative effects of tobacco: smelly clothes, breath and hair, negative changes in skin complexion, less money for other things, and loss of athletic endurance.
  • Assist children and teens in developing skills or techniques to say no to tobacco. Assist patients who smoke to quit.
  • Compliment tobacco free behavior


  • Toll-Free Smokers' Quitline 1-866-NYQUITS (1-866-697-8487) - A toll-free smoking help-line staffed by employees of the Roswell Park Cancer Institute. The Quitline offers smokers, including teens, a confidential and convenient way to access immediate help when they are ready to stop smoking or need support to remain smoke-free. Health care providers can also call the Quitline to obtain office materials that can be shared with patients.
  • Smoke-Screeners - A media literacy program (video and curriculum guide) aimed at increasing young people's awareness of tobacco use. Developed by the Massachusetts Department of Health and distributed FREE by the Centers for Disease Control (CDC), it is designed for young people in middle school or early high school. To order contact, CDC/Office on Smoking and Health at (770) 488-5701.

No Smoking

Utilization Threshold Service Authorization Exception Codes and TOAs
Can a provider get paid if the patient is "at service limit"?
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There are two situations where a provider can be paid if a patient has reached his/her limit.
Situation 1: Service Authorization (SA) exceptions such as Emergency or Urgent Care situations, or
Situation 2: Submit a Threshold Override Application (TOA) to request an increase in service limits.


Emergency services should be rendered regardless of the patient's Utilization Threshold - UT - status. Authorization should be obtained for emergency services at the earliest opportunity. When a patient is at his/her service limit and an authorization cannot be obtained, place the appropriate service authorization exception code (J, K, L, M, N, or P) in the correct field as noted below:

HCFA-1500 claim formField 25E
Claim form AField 9
Electronic claim A specificationsD1 record, position 41
Version 4 and Version 5Record 65, field 4, position 25


J =Immediate or Urgent Care
K =Services rendered in a retroactive period - those services rendered in the 90-day period prior to the recipient's Medicaid application if it has been determined that the recipient is eligible for Medicaid, and would have been eligible in the prior period if they had made application at that time
L =Emergency Care
M =Recipient has temporary Medicaid Authorization (DSS-2831A) - This document is issued to a recipient who has just been determined to be eligible for Medicaid services and has indicated an immediate need for medical care and is valid for a period of 15 days from the date of issuance
N =Request from county for second opinion to determine if recipient can work
P =Request for increase in recipient service limit pending

(Please note - TOA and Claim may be submitted to each respective address at the same time.)


TOAs can be submitted to increase the number of services a patient can receive or to obtain an exemption from the UT Service Authorization Program, depending on the patient's medical needs.

Please note that increases in service limits may only be requested for the recipient's current benefit year. (A benefit year is a 12 month period which usually begins the month in which the recipient becomes Medicaid eligible.) For example, if a recipient's benefit year begins in September (month 09), and the increased limit request is made after September, the provider may submit a TOA to request an increase only for dates occurring after September, but not for dates of service prior to September.

TOAs are obtained from Computer Sciences Corporation (CSC) at (800) 421-3893.

Providers making inquiries or requesting billing training by Regional Representatives should contact CSC by calling the appropriate number below. Please be prepared to supply your Medicaid provider ID number.

Practitioner Services     (800) 522-5518   (518) 447-9860
Institutional Services     (800) 522-1892   (518) 447-9810
Professional Services     (800) 522-5535   (518) 447-9830

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Effective for dates of service on or after September 1, 2000, the following pricing changes will take effect for enteral supplies. Please note clarifications of supplies included in each code. Code B4085 Gastronomy (gastrostomy) tube, silicone with sliding ring, each will be discontinued for dates of service on or after September 1, 2000.

All enteral feeding supply kits (B4034, B4035 and B4036) include whatever supplies are necessary to administer the specific type of feeding and maintain the feeding site. This includes, but is not limited to, syringes, measuring containers, tip adapters, anchoring device, gauze pads, protective-dressing wipes, tape, and tube cleaning brushes.

B4034#Enteral feeding supply kit;-syringe (per day)up to 30/mo$1.8772
B4035#Enteral feeding supply kit;-pump fed (per day)
Includes any type pump compatible bag
up to 30/mo$8.3203
B4036#Enteral feeding supply kit;-gravity fed (per day)
Includes any type gravity fed bag
up to 30/mo$5.1638
B4081#Nasogastric tubing with Styletup to 1/mo$16.1692
B4082#Nasogastric tubing without Styletup to 2/mo$10.0633
B4083#Stomach tube - Levine typeup to 2/mo$1.0748
B4084#Gastrostomy/jejunostomy tubing
This code includes both standard gastrostomy tubes and replacement
extension/decompression tubing for a low-profile tube/button/port
up to 2/3 mo$21.4450
Z2110 Low profile gastrostomy tube/port/button kit
For patients who cannot tolerate the size of a standard gastrostomy tube or have experienced failure
of a standard gastrostomy tube. This kit includes the tube/button/port, syringes, extension/decompression tubing and obturator if indicated
up to 1/3 mo$114.5833

Please insert a copy of this notice in your MMIS Provider Manual Rev. 7/00 (Pharmacy: p. 4-9; DME: p. 4-18)

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Please be advised that code L4210 Repair of orthotic device, repair or replace minor parts (includes parts and labor) $35.00 is still an active code. Please make a note of this on page 4-51 in your DME Provider Manual (Rev. 7/00). L4210 should not be used in conjunction with the new code, L4205 Repair of orthotic device, labor component, per 15 minutes. L4205 should be used as a labor component for repairs not covered by L4210.


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The New York State Department of Health (DOH) has implemented a toll-free hotline, 1-877-87FRAUD (1-877-873-7283), for the reporting of Medicaid fraud, waste and abuse.

This toll-free hotline will be staffed during DOH business hours to receive complaints from the public regarding possible Medicaid fraud committed by either providers or recipients. Calls after hours will be followed-up the next business day. All information will be kept confidential and all calls will result in a review or investigation by DOH staff. Where appropriate, the DOH has the authority to recover overpayments, exclude providers from participation in the Medicaid program or refer cases for criminal prosecution.

This initiative is part of a continuing effort by Governor Pataki and the DOH to fight Medicaid fraud and abuse and to ensure that Medicaid recipients receive the highest quality of medical care.

Within the next 30 to 60 days, the public will also be able to access the DOH's website at and view our new fraud web page. Information regarding Medicaid fraud, as well as our disqualified provider list (PVR-292) will be available at this site.

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Manual wheelchair coding has been added to specify standard (K0001), hemi (K0002), lightweight (K0004), ultralightweight (K0005) and custom/special (K0009) wheelchairs. These codes replace E1091, E1130, E1170, and E1220.

Power wheelchairs are covered for individuals who are unable to propel a manual wheelchair and are able to safely operate a power wheelchair. Coverage is dependent on documented medical necessity. Power wheelchair codes for standard (K0011), lightweight (K0012) or custom/special (K0014) have been added to replace E1210 and E1220. Batteries, battery cases and electronics are included in the maximum reimbursable amount (MRA) for the wheelchair.

The explanations printed below each wheelchair code (see pages 4-25 - 4-27 in your DME Provider Manual, Rev. 7/00) describe the type of wheelchair the code represents and the typical medical needs the wheelchair meets. The MRA for all manual and power wheelchairs includes any type of footrest, standard leg rest (except elevating or articulating), any type of armrest, safety belt and a seat and/or cushion. The type of seat or cushion that is typically included varies according to the wheelchair that is provided. Cushion codes are intended to be used for replacement cushions. The only exception is a medically indicated seat or back cushion that is not included with the new wheelchair by the manufacturer or distributor. In such instances, use codes specific to the seat or back in addition to the wheelchair code.

Questions concerning this article can be addressed by calling the Bureau of Medical Review and Payment at 518-474-8161.

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: