DOH Medicaid Update October 2000 Vol.15, No.10

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Governor Pataki recently notified practitioners of an increase in Medicaid reimbursement for:

• Office visits by physicians, nurse practitioners, and nurse midwives;
• Anesthesia conversion factor;
• Emergency Room specialty fees - visits by physicians certified and designated as Emergency Medicine specialists by the Department of Health.

At the end of this article is a listing of all fees, associated procedure codes, and revised payment amounts. These fee increases will be effective for dates of service on and after October 1, 2000.

Claims that have been paid for dates of service on or after October 1, 2000 with the previous fee(s) can be adjusted by following the claim adjustment instructions in the billing section of your MMIS Provider Manual.

Questions may be directed to the Bureau of Policy Development and Agency Relations at 518-473-5873.

CODE	OFFICE VISIT FEES	FEE AS OF 10/1/00
99201	Office visit, E&M, new pt., minimal	$30.00
99202	Office visit, E&M, new pt., minor	$30.00
99203	Office visit, E&M, new pt., moderate complexity	$30.00
99204	Office visit, E&M, new pt., moderate complexity	$30.00
99205	Office visit, E&M, new pt., high complexity	$30.00
99211	Office visit, E&M, established pt., minimal	$30.00
99212	Office visit, E&M, established pt., minor	$30.00
99213	Office visit, E&M, established pt., low complexity	$30.00
99214	Office visit, E&M, established pt., moderate complexity	$30.00
99215	Office visit, E&M, established pt., high complexity	$30.00
92002	Office Serv. Eye Exam + Eval., intermediate, new pt.	$30.00
92004	Ophth. Serv. Eye Exam + Eval., comprehensive, new pt.	$30.00
92012	Ophth. Serv. Eye Exam + Eval., intermediate, est. pt.	$30.00
92014	Ophth. Serv. Eye Exam + Eval., comprehensive, est. pt.	$30.00
99381	C/THP preventive-under 1 yr., new pt.	$30.00
99382	C/THP preventive-early childhood-age 1-4 yrs., new pt.	$30.00
99383	C/THP late childhood-age 5-11 yrs., new pt.	$30.00
99384	C/THP adolescent-age 12-17 yrs., new pt.	$30.00
99385	C/THP 18-20 yrs., new pt.	$30.00
99391	C/THP preventive-under 1 yr., established pt.	$30.00
99392	C/THP preventive-early childhood- age 1-4 yrs.est. pt.	$30.00
99393	C/THP late childhood-age 5-11 yrs., established pt.	$30.00
99394	C/THP adolescent-age 12-17 yrs. established pt.	$30.00
99395	C/HTP 18-20 yrs. established pt.	$30.00
	EMERGENCY ROOM SPECIALTY FEES
99281	Emer. Dept. Visit, E&M, self limited or minor	$17.00
99282	Emer. Dept. Visit, E&M, low to moderate severity	$17.00
99283	Emer. Dept. Visit, E&M, moderate severity	$17.00
99284	Emer. Dept. Visit, E&M, high severity	$17.00
99285	Emer. Dept. Visit, E&M, high severity, threat to life	$17.00
	ANESTHESIA CONVERSION FACTOR
	Anesthesia conversion factor increased to $10.00

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Please make the following price change, effective July 1, 2000, in your MMIS Provider Manual (Rev. 7/00) (Pharmacy page 4-13, DME page 4-22):

CODE	DESCRIPTION	FEE AS OF 7/1/00
A6199	Alginate dressing, wound filler, per 6 inches	$2.63

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Governor Pataki recently notified practitioners of an increase in Medicaid reimbursement for optometry office visits.

Effective for dates of service on or after October 1, 2000, office visits, including complete eye examinations with refraction, will be increased to $30.00.

The following procedures can be billed at the $30.00 fee:

CODE	OFFICE VISIT FEES EFFECTIVE 10/1/00	FEE
99201	Office visit, E&M, new pt., minimal	$30.00
99202	Office visit, E&M, new pt., minor	$30.00
99211	Office visit, E&M, established pt., minimal	$30.00
99212	Office visit, E&M, established pt., minor	$30.00
92002	Ophth. Serv. Eye Exam + Eval.,intermed., new pt. (w/refraction)	$30.00
92004	Ophth. Serv. Eye Exam + Eval., comp., new pt. (w/refraction)	$30.00
92012	Ophth. Serv. Eye Exam + Eval., intermed., est. pt. (w/refraction)	$30.00
92014	Ophth. Serv. Eye Exam + Eval., comp., est. pt. (w/refraction)	$30.00

Claims that are paid for dates of service on or after October 1, 2000 with the previous fee(s) can be adjusted by following the claim adjustment instructions in the billing section of your MMIS Provider Manual.

Questions may be directed to the Bureau of Policy Development and Agency Relations at 518-473-5873

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Diabetes is a major public health problem and is becoming more prevalent in all age groups. Nationwide there are approximately 16 million people who have diabetes, of which roughly 90% have type 2 diabetes. The American Diabetes Association (ADA) estimates that the nation spends more than $98 billion annually on diabetes. Diabetes is a silent disease. In New York State, it is estimated that one in 12 people have diabetes; one in five of these people with diabetes go undiagnosed.

Improving the health of New Yorkers is essential for the future of our state. In an effort to promote quality health outcomes, the chart on the following page has been developed which summarizes services that are covered by the New York State Medicaid program in accordance with the standards of care as defined by the ADA.

The Medicaid program encourages clinicians to assess their patients for diabetes risk factors and provide or refer their patients for services in accordance with the ADA standards of care.

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ADA Standard	ADA Frequency	MA Covered
Physician/Clinic Visit Weight monitoring Blood pressure monitoring (Adult: <130/85) Patient education including self-management, dietary counseling Pharmacological management Physical therapy/exercise management	Bi-annually*	Yes
Key Laboratory Tests Glycated hemoglobin-HbA1C (<7%) Lipid profile (Adult Goal: Cholesterol <200, TRIGYLCERIDES <200MG/DL, HDL>35mg/dl in men>45mg/dl in women, LDL<100MG/DL) Urinalysis for protein Microalbumin measurement	Semi-annual* Annually* Annually* Annually*	Yes
Comprehensive Foot Exam	Annually*	Yes, when performed by primary care provider, by podiatrist for children under 21 or for Medicare crossover patients
Dilated Eye Exam by Ophthalmologist/Optometrist	Annually	Yes. The patient record must show medical necessity if done more frequently than once every two years.
Self-monitoring of Blood Glucose and Ketones	At least daily	Yes
Physiologically-based Insulin Regimens (in Type I and some Type 2)	At least daily	Yes-all insulin products (prescription & OTC) covered
Less-complex Insulin Regimens or Continuous Subcutaneous Insulin Infusion (insulin pumps)	As needed	Insulin pumps and supplies for subcutaneous infusions are covered with Prior Approval
Coverage of Oral Medications, including adjunctive medications: oral hypoglycemic agents, glucagon, antihypertensives, lipid-lowering agents, aspirin therapy, & other endocrine drugs	At least daily	Yes-all oral diabetic agents, adjuvant agents and injectable glucagon are covered
Smoking Cessation Pharmacologic Coverage	As needed	Yes-all forms covered for two courses of therapy
Annual Influenza Vaccine	Annually	Yes
Diabetes Supplies Diabetes daily care items: Needles Syringes Insulin cartridge delivery system Spring powered device for lancet Lancets Alcohol and alcohol wipes Infusion sets for insulin pump, needle, and non-needle type** Syringe with needle for external insulin pump** Diabetes diagnostic agents: Home blood glucose monitor*** Blood glucose monitor with special features (i.e. voice synthesizer, automatic times, etc.) ** Blood glucose test or reagent strips Replacement battery for use with home glucose monitor*** Blood glucose monitor calibrator solution/chips***	As prescribed	Yes

* More frequently based on medical necessity
** Medicaid Prior Approval required
*** Medicaid DVS required

For information, please contact the NYSDOH, Office of Medicaid Management, Bureau of Program Guidance, at (518) 474-9219.

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Starting immediately, Private Duty Nursing (PDN) providers requesting Prior Approval for recipients in Chemung County should forward their requests to the following address:

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Effective for dates of service on or after December 1, 2000 claims for compounded prescriptions must be submitted using the NDC codes for the ingredients. Applicable dispensing fees will be reimbursed. The following codes will be discontinued effective for dates of service on or after December 1, 2000:

CODE	DESCRIPTION
Z0900	Ointment
Z0920	Lotion
Z0930	Cream
Z0950	Tablet
Z0960	Other

Please indicate the above changes on the following pages in your Pharmacy Provider Manual effective for dates of service on or after December 1, 2000:

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Since its launch in January 2000, the New York State Smokers Quitline has been helping smokers across New York State stop their tobacco using habit. This month the State's Quitline has been gearing up for the American Cancer Society's Great American Smokeout on Thursday, November 16th. The focus of the Great American Smokeout has evolved from simply helping adults quit smoking to helping children and teenagers understand they should never start smoking in the first place. The Great American Smokeout is also a time for Americans to renew their commitment to a smoke-free environment for themselves and for their children.

The Quitline's Information Specialists, who are specially trained to provide information and consultation on a variety of stop smoking topics, will answer calls from 9:00 -5:30 for both English and Spanish speaking callers. The Information Specialists help smokers with topics like stop smoking medications, withdrawal symptoms and stop smoking programs. Callers can request the Break Loose stop smoking booklet and a list of stop smoking programs in their area.

Callers also have an option to listen to a taped message library offering them tips on specific stop smoking topics like weight control and withdrawal symptoms.

Physicians and health care providers can also use the Quitline to refer their patients for support and information. Quitline physician packets are available to health providers to support their education programs for patients. The packet includes:

• "NYS Medicaid Smoking Cessation Coverage Highlights" Fact Sheet
• Treating Tobacco Use and Dependence Summary- Guidelines for Clinicians
• Clinical Guidelines for prescribing pharmacotherapy for smoking cessation
• Management of Nicotine Addiction Fact Sheet: Surgeon General's Report on Reducing Tobacco Use
• "Break Loose Guide", self help stop smoking guide (orders up to ten are free)
• "Why Don't They Call Them What They Are" Teen cessation magazine (orders up to ten are free)
• "Give Me Breathing Room" secondhand smoke newsletter, STOP! Magazine

For additional information and resources contact:

The American Cancer Society at 1-800-ACS-2345 or

The New York State Smokers Quitline at 1-866-NYQUITS (1-866-697-8487)

Reminder: As a commitment to provide assistance to Medicaid recipients who want to stop smoking, Medicaid covers prescription and non-prescription smoking cessation agents. Contact the Bureau of Program Guidance at (518) 486-3209 for additional information. We appreciate your concern and participation in making New Yorkers healthier.

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Effective November 1, 2000, pregnant women and infants up to age one will be eligible for Medicaid if their family income does not exceed 200% of the comparable federal income official poverty line for families of the same size. Currently, Medicaid coverage to pregnant women and infants up to age one is available to those individuals whose family income does not exceed 185% of the federal poverty line.

Pregnant women whose family income falls between 100% and 200% of the federal poverty line are able to receive a specific package of Medicaid services. These services are:

Physician Care Outpatient Clinic Dental Transportation Personal Care Clinical Psychology Outpatient/Alcoholism Nutritional Counseling

Midwife Care Pharmacy Laboratory Home Health Care Nursing Services Outpatient/Mental Health Health Education Family Planning

A pregnant woman may be presumptively eligible for Medicaid on the date that a qualified provider screens her reported family income and determines that it falls below 200% of the poverty level. When the local social services district completes her eligibility determination and finds her eligible for Medicaid, a pregnant woman may also receive inpatient care. Fully eligible pregnant women with family incomes below 100% of the federal poverty line may receive all Medicaid covered services.

It is anticipated that this expansion of Medicaid eligibility will allow more pregnant women and infants under one year of age to obtain needed health care. Currently, some pregnant women who have incomes between 185% and 200% of the poverty level are eligible for Medicaid only by "spending down" their income to the standard Medicaid eligibility level. Such women will have the option to receive the limited package of services described above rather than spend down their excess income. Some, however, may choose to retain full coverage by continuing to spend down. For example, durable medical equipment is not a covered service for pregnant women whose incomes are above 100% of the federal poverty line. Because some pregnant women with incomes between 100% and 200% of the federal poverty line need durable medical equipment such as certain nebulizers and pregnancy support stockings, they may prefer to spend down to the standard Medicaid income level to qualify for durable medical equipment items.

Information on becoming a presumptive eligibility provider for pregnant women, please call Susan Brownell at (518) 473-5313.

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Please check the MMIS Provider Manual when referring a Medicaid recipient to an out-of-state provider for medical care and services. Note that Prior Approval is required in most instances.

Medicaid eligible individuals should obtain medical care and services from qualified providers located in New York State. An out-of-state provider will be reimbursed for services rendered to an eligible New York State Medicaid recipient only under the following circumstances:

• The provider practices in the "common medical marketing area" of the recipient's home social services district as defined by the New York State Health Department ;
• An emergency requires that immediate care be provided to a recipient who is temporarily out-of-state;
• Care is provided to a patient who is an approved out-of-state placement. Such placements include patients approved, for example, for nursing home or foster care services in another state;
• The patient is Medicare approved.

Any out-of-state medical service that does not fit within the above criteria requires Prior Approval. A request for Prior Approval for out-of-state medical services must include a letter of medical necessity from the in-state referring physician together with documentation that the requested out-of-state medical care and services are not available in New York State. Approval will be based on the Health Department's determination that care should be provided out-of-state. For a mentally disabled recipient, approval is also subject to the concurrence of the New York State Office of Mental Health or the New York State Office of Mental Retardation/Developmental Disabilities.

Please be advised that only providers in the United States (including the U.S. Virgin Islands, Puerto Rico and Guam) and Canada are eligible for enrollment in the New York State Medicaid program. Providers not currently enrolled must complete an enrollment application and be approved to participate in the program. Payment to enrolled/approved providers is governed by Title 18NYCRR, Part 527.1. Claims must be submitted to the State's fiscal agent, Computer Sciences Corporation. Facility claims must be submitted electronically; practitioner claims may be submitted either electronically or via paper.

If you have any questions, please call the Prior Approval Unit at (800) 342-3005 or (518) 474-3575

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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
• Explanation of MMIS Provider Manual
• Discussion of Medicaid Managed Care
• Overview of Billing Options
• Explanation of 90-day Regulation
• Explanation of Utilization Threshold Program

Please indicate the seminar(s) you wish to attend below:

November 28, 2000  1 PM
Gutherie Medical Center
Patterson Education Building, Lower Level
Gutherie Science Lecture Room
Sayre, Pennsylvania

December 11, 2000   10 AM
Monroe County Department of Social Services
1st Floor Auditorium
111 Westfall Road
Rochester, NY

January 23, 2001   10 AM
Computer Sciences Corporation
3rd Floor
800 North Pearl Street
Albany, NY

January 24, 2001   10 AM
Nassau County Department of Social Services
101 County Seat Drive
*Mineola, NY

February 27, 2001   1 PM
Utica, NY (address to be announced)

March 1, 2001   1 PM
Mexico, NY (address to be announced)

Other seminars may be scheduled as new programs are implemented or changes to existing billing procedures are announced.

Please complete the following registration information:

Provider Name:__________________________________Provider ID:__________________
Provider Category of Service:________________________________Number Attending:__________
Contact Name:____________________________________Phone Number:______________________

If the seminar address is not listed above, a CSC representative will contact you at least two weeks prior to the seminar date to confirm attendance and provide seminar address information. Each seminar will last approximately two hours. Providers who have questions about these seminars can call CSC at the following numbers:

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

To register, please mail this completed page to:
Computer Sciences Corporation
Attn.: Provider Outreach
800 North Pearl Street
Albany, NY 12204

Or, you may fax a copy of the completed page to: 518-447-9240

Note: Please keep a copy of your seminar choice for your records. No written confirmations will be sent.

Thank you for participating in New York State's Medicaid program.

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Description - The New York State C/THP is a Federally mandated program which provides comprehensive preventive health care and diagnostic and treatment follow-up to children who are eligible for Medicaid, up to the age of 21. It is designed to meet the Federal and State requirements for the EPSDT program which was created by the 1967 amendments to Title XIX of the Social Security Act and became effective in 1972.

Goal - Ensure Medicaid-eligible children a continuous and comprehensive program of health care encompassing the full range of preventive and primary health care services, as well as any necessary diagnosis and treatment that may be indicated.

Participation in C/THP - All Medicaid-enrolled physicians, nurse practitioners, and certain clinics, may provide well care to Medicaid recipients ages birth through 20 years, in accordance with the standards set forth in the C/THP section of the Medicaid provider manual. A provider is no longer required to enroll as a C/THP provider to bill Medicaid for well child care.

Medicaid Claim Submission - In order for C/THP examinations to be accurately reported to MMIS, providers should review the procedure code, C/THP referral code and diagnosis code fields of the MMIS HCFA-1500 Claim Form or Electronic Claim A specifications outlined below.

Procedure Codes

• PPAC physicians and nurse practitioners use PPAC procedure codes such as W5000 - office visit.
• Non-PPAC physicians and nurse practitioners conducting C/THP examinations use the following procedure codes.

Procedure Description	New Patient	Established Patient
Initial history and examination related to the healthy individual, including anticipatory guidance; adult (age 18 years through 20 years)	99385	99395
adolescent (age 12 years through 17 years)	99384	99394
late childhood (age 5 years through 11 years)	99383	99393
early childhood (age 1 year through 4 years)	99382	99392
infant (age under 1 year)	99381	99391

C/THP Referral Code - When billing for a C/THP visit, one of the following codes must be entered in the EPSDT C/THP field 22D on MMIS HCFA-1500 or Claim A electronic specifications, Record D2, position 44.

C/THP Referral Code	Definition
A	No referral necessary.
B	Referral to other provider for vision, hearing, or dental
C	Referral for other services.
G	Providers rendering services from a C/THP referral should use the "G" code so that these services will be excluded from the Utilization Threshold Program.

Diagnosis Codes - The appropriate diagnosis code from the ICD-9-CM describing the principal reason for the C/THP visit should be entered in field 24F on the MMIS HCFA-1500 claim form or Claim A electronic specifications Record D2, positions 26-31.

Note: Detailed information related to C/THP policy is referenced in the C/THP insert to the Medicaid Management Information System (MMIS) provider manual. Policy questions regarding C/THP may be referred to Judith Lenihan at (518) 473-6020.

If the seminar address is not listed above, a CSC representative will contact you at least two weeks prior to the seminar date to confirm attendance and provide seminar address information. Please register early to attend sites marked with (*) because seating is limited. Each seminar will last approximately two hours. Direct questions about these seminars to CSC as follows:

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 November 1, 2000, laboratory providers may claim reimbursement for HIV genotypic and phenotypic drug resistance test assays. Payment will be made to laboratories, which have been approved to perform HIV drug resistance testing under a valid permit in the category of HIV testing issued by the New York State Department of Health (DOH).

Laboratories should use MMIS procedure code Y8707 when billing for the HIV genotypic assay. The maximum reimbursable amount for code Y8707 is $350.00. Laboratories should use MMIS procedure code Y8708 when billing for the HIV phenotypic assay. The maximum reimbursable amount for code Y8708 is $750.00.

HIV drug resistance testing is a covered service when clinically indicated, up to a maximum of three tests per 12-month period/per patient.

Laboratories, Designated AIDS Centers, residential health care facilities and ordering practitioners are reminded of the following payment policies applicable to all laboratory testing, including HIV drug resistance testing:

• Laboratories may not fee bill for a test performed while a patient is in hospital inpatient status. Medicaid payment to the hospital includes all necessary laboratory services.
• All outpatient HIV drug resistance testing, including that ordered for outpatients of residential health care facilities, or Designated AIDS Centers operating under the Tier AIDS payment structure, is reimbursable fee-for-service directly by Medicaid to the laboratory performing the test.
• Medicaid regulation requires that payment be made to the provider actually performing the test, and only Medicaid-enrolled clinical laboratories with DOH approval to perform HIV genotypic and/or phenotypic assays for drug resistance are entitled to reimbursement.

Please direct questions on coverage for HIV drug resistance tests, to the Bureau of Policy Development and Agency Relations at (518) 473-5873.

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Prior approval is required for polycarbonate lenses. When a prior approval is submitted for polycarbonate lenses, the appropriate lens codes for the prescription must be used. i.e., V2103, V2203. An additional $10.00 for each polycarbonate lens should be added to the fee for each lens code listed in the MMIS Provider Manual. If polycarbonate lenses need to be replaced because the original lenses are lost, stolen or broken beyond repair, a new prior approval request is required. The "RP" modifier must be used with the appropriate lens codes being replaced on both the Prior Approval Form and the claim form. Documentation must be provided on the Prior Approval Form explaining the circumstances for the replacement of the polycarbonate lenses. Documentation is also required when a pair of lenses is being changed from plastic or glass to polycarbonate lenses.

Optometrists and opticians who order eyeglasses from the Wallkill Optical Laboratory should call the laboratory before filling out the prior approval form to obtain the appropriate lens coding for the polycarbonate lenses being ordered. The laboratory's toll-free number is 1-800-836-2636.

If you have any questions, please call (518) 473-5873.

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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