DOH Medicaid Update March 2003 Vol.18, No.3

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Based on a decision by the New York State Appellate Division, the Medicaid Program will begin paying optometrists for three procedures previously only covered when performed by ophthalmologists.

These procedures, now billable by ophthalmologists and optometrists, are:

• 68761, closure of the lacrimal punctum by plug, each                     $16.00
• 68810, probing of the nasolacrimal duct with or without irrigation   $12.00
• 68840, probing of the lacrimal canaliculi, with or without irrigation    $8.00

Effective March 1, 2003, optometrists may resume providing these services and submit claims to Medicaid. In addition, optometrists can retroactively bill for these procedures performed since October 20, 2002, if they were provided to eligible Medicaid recipients and monetary reimbursement from any source has not been received for the service.

Note: When submitting a claim that is over 90 days old, the procedures for late claim submission should be followed. These instructions are found on P. 3-51 through P. 3-53 of the MMIS Ophthalmic Provider Manual. The acceptable reason to use for the late submission of a claim should be "Administrative Delay" and a copy of this article can be used as a 90-day waiver letter.

If you have any questions, please contact the Medicaid Bureau of Policy Development and Agency Relations at (518) 473-2160.

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During March 2003, revised New York State Fee Schedules will be sent to all enrolled:

• Dentists;
• Durable Medical Equipment Dealers;
• Laboratory Services Providers; and,
• Pharmacies

These revised fee schedules contain important HIPAA related coding changes.

If you do not receive a revised Fee Schedule by March 15, 2003, please contact Computer Sciences Corporation's Provider Relations staff. Dentists call (800) 522-5518 or (518) 447-9860. DME, Laboratory Services providers call (800) 522-5535 or (518) 447-9830, and Pharmacies call (800) 343-9000.

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As stated above, revisions to the Dental Provider Manual will be mailed in March, which contain changes to the Fee Schedule effective April 1, 2003. Among the changes are a lead "D" for all procedure codes and other changes for conformity with the Common Dental Terminology-4 (CDT-4) issued by the American Dental Association (ADA).

Questions may be referred to the Medicaid Bureau of Medical Review and Payment, Dental Prior Approval/Pend Unit at (800) 342-3005, option 3.

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The Medicaid Program's Bureau of Program Guidance (BPG) is now providing educational tools to support Medicaid's disease management program, which is dedicated to partnering with the provider community to promote quality of care in a cost effective and efficient manner. Our goal is to provide educational tools on a routine basis. This month, the following two pages focus on diabetes: definition of types, signs and symptoms. Initially, we intend to focus on diabetes and asthma; however, in the future we plan to expand to other chronic illnesses and conditions.

It is hoped that the tools issued through the Medicaid Update will be useful to Medicaid practitioners. BPG encourages practitioners to copy and distribute these materials to their patients and to also share them with their colleagues.

Please contact the Medicaid Bureau of Program Guidance at (518) 474-9219 with your comments and suggestions on these and future patient educational tools.

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Diabetes is a disease that a person gets when his/her body does not make insulin (Type 1 diabetes) or does not make enough insulin (Type 2 diabetes). Most of the food we eat is changed into sugar (glucose). Our body uses glucose for energy. The pancreas, an organ located near the stomach, makes the hormone insulin. Insulin helps glucose enter the body's cells. When a person's body does not make enough natural insulin to help the glucose enter the cells, glucose will build up in the blood stream. This build up of glucose in the blood stream is what causes the medical problems people develop from diabetes.

SIGNS AND SYMPTOMS OF DIABETES:

• Unusual or extreme thirst
• Frequent urination
• Blurred vision
• Unintentional weight loss
• Dry skin
• Cuts, bruises or sores on your body that will not heal or are slow to heal
• Frequent infections, especially urinary or vaginal yeast infections
• Fatigue or lack of energy
• Loss of feeling or tingling or numbness in feet
• Vomiting

RISK FACTORS FOR DIABETES:

• If you are overweight or have most of your body fat around your middle abdomen (apple shape)
• If you are a member of a high risk group (American Indian, American African, Asian or Hispanic)
• If you have a family member with diabetes (parent, sister, brother)
• If you do not get enough exercise or physical activity
• If you have high cholesterol
• If you have high blood pressure
• If you have any heart conditions
• If you have any sexual difficulties
• If you had diabetes while you were pregnant (called gestational diabetes)

If you have some of the above symptoms or risk factors, you should be tested for diabetes.

Your doctor can do a urine test and also order a blood test.

You should plan to do the blood test in the morning before you eat.

Remember: if diabetes goes untreated, it can lead to serious life threatening conditions such as heart disease, blindness, kidney problems or failure, amputations and erectile dysfunction.

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TYPE 1 DIABETES

• Type 1 used to be called "juvenile onset diabetes" because most people who have this type are usually under age 30. (But they can be older!)
• People with Type 1 are usually thin.
• The pancreas cannot make insulin.
• Type 1 diabetes is not common. Only 5 - 10 % of all diabetics have Type 1.
• Type 1 diabetes is the hardest type of diabetes to control.
• Treatment for Type 1 diabetes is insulin injections timed with meals and activity.

TYPE 2 DIABETES

• Type 2 used to be called "adult onset diabetes"; people who get Type 2 are usually over age 55. (But they can be younger!)
• People who are in a high-risk group are more likely to get Type 2 (American Indian, African American, Asian or Hispanic).
• People who get Type 2 diabetes are usually overweight.
• The pancreas can make insulin, but it is not enough for the body to move glucose into the cells.
• Type 2 is the most common form of diabetes, 90 - 95% of all diabetics have Type 2.
• Type 2 diabetes is a major health concern among overweight adults and children, due to their inactive lifestyles and eating habits.
• Type 2 diabetes is treated with changes in diet, activity levels, and sometimes with oral medications.

GESTATIONAL DIABETES

• Gestational diabetes occurs during pregnancy usually in the 24^th - 28^th week.
• Gestational diabetes occurs in women who did not have diabetes before becoming pregnant.
• Gestational diabetes most often occurs in young women, over age 25, who are overweight and in a high-risk group.
• The mother usually needs a Cesarean Section delivery to prevent injury to herself and the baby.
• The baby gets more sugar than it needs to grow and is born overweight (over 9 lbs).
• The baby is at risk for developing breathing problems and obesity after birth.
• Treatment for gestational diabetes is insulin injections, changes in diet and activity levels for the mother. Treatment must be done during pregnancy for the health of the mother and baby.
• Gestational diabetes goes away after delivery (usually in 6 weeks).
• Mothers who have gestational diabetes are at higher risk for developing Type 2 diabetes 5 - 10 years after delivery.

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Below is a suggested cross-reference for providers reflecting major changes to billing codes. Consult your revised April 1, 2003 MMIS Provider Manuals to obtain fee, quantity and other necessary information.

Major Changes To Billing Codes

Category	Product	Old	New
DME	Apnea monitor w/recorder	E0608	E0619
DME	Manual adult wc w/tilt in space	K0009	E1161
DME	Rigid pediatric wc w/tilt in space	K0009	E1233
DME	Folding pediatric wc w/tilt in space	K0009	E1234
DME	Nasal application device	K0183	A7034
DME	Replacement nasal cushion	K0184	A7032
DME	Replacement nasal pillows	K0184	A7033
DME	Positive airway press headgear	K0185	A7035
DME	Positive airway press chinstrap	K0186	A7036
DME	Positive airway pressure tubing	K0187	A7037
DME	Oximeter non-invasive	S8105	E0445
Footwear	Ladies surgical boot each	L3218	L3260
Footwear	Mens surgical boot each	L3223	L3260
Footwear	Whitman plate	Z5830	L3649
Footwear	Custom schaefer plate	Z5831	L3000
Footwear	Custom whitman plate	Z5832	L3000
Orthotics	Torso/ptosis support	L0900	L0500
Orthotics	Torso/pend. abdominal support	L0920	L0500
Orthotics	Torso/post surgical support	L0940	L0500
Orthotics	Torso & ptosis support, custom	L0910	L0510
Orthotics	Pend. abdomen support, custom	L0930	L0510
Orthotics	Post surgical support, custom	L0950	L0510
Orthotics	Helmet w/face guard prefab	Z4754	E0701
Pharmacy	Pharmacy compounding	Z0900-60	S9430
Pharmacy	Disposable enema	Z2151	NDC
Pharmacy	CO2 releasing suppositories	Z2152	NDC
Pharmacy	Docusate sodium enema	Z2153	NDC
Prosthetics	Socket insert w/lock mechanism	L5660-4	K0556
Prosthetics	Socket insert w/o lock mechanism	L5660-4	K0557
Prosthetics	Initial custom cong/atyp insert	L5660-4	K0558
Prosthetics	Initial custom socket insert	L5660-4	K0559
Supplies	Diaphragm kit	A4261	A4266
Supplies	Adult size diaper sm each	A4360	A4521
Supplies	Adult size diaper med each	A4360	A4522
Supplies	Adult size diaper lg each	A4360	A4523
Supplies	Adult size diaper xl each	A4360	A4524

Category	Product	Old	New
Supplies	Nonpectin based ostomy paste	A4370	A4405
Supplies	Pectin based ostomy paste	A4370	A4406
Supplies	Mod compression bandage >=3<5"	A4460	A6434
Supplies	Hi compression bandage >=3<5"	A4460	A6436
Supplies	Prefab ankle orthosis	A4464	L1901
Supplies	Prefab elbow orthosis	A4464	L3701
Supplies	Prefab wrist orthosis	A4464	L3909
Supplies	Prefab hand finger orthosis	A4464	L3911
Supplies	Haberman feeder	A4649	S8265
Supplies	Light compression bandage >=3<5"	A6263	A6430
Supplies	Light compression bandage >=5"	A6263	A6432
Supplies	Conforming bandage non-sterile >=3<5"	A6264	A6422
Supplies	Conforming bandage non-sterile >=5"	A6264	A6424
Supplies	Non-waterproof tape	A6265	A4450
Supplies	Waterproof tape	A6265	A4452
Supplies	Conforming bandage sterile >=3<5"	A6406	A6426
Supplies	Conforming bandage sterile >=5"	A6406	A6428
Supplies	Positive airway pressure filter	K0188	A7038
Supplies	Positive airway pressure filter, non-disp	K0189	A7039
Supplies	Rib belt	A4572	L0210
Supplies	Reusable diaper/pant	S8400	T1500
Supplies	Child size diaper sm/med each	S8401	A4529
Supplies	Child size diaper lg each	S8401	A4530
Supplies	Youth size diaper each	S8401	A4533
Supplies	Disp incont liner/shield each	S8405	A4535
Supplies	Food thickener, regular & concen.	Z2110-1	B4100
Supplies	Sterile eye pad	Z2333	A6410
Supplies	Non-sterile eye pad	Z2333	A6411
Supplies	Occlusive eye patch	Z2337	A6412
Supplies	Male condom	Z2352	A4267
Supplies	Female condom	Z2358	A4268
Supplies	Non-sterile gloves	Z2561	A4927
Supplies	Blood pressure kit	Z2660	A4660
Supplies	Reusable oral thermometer	Z2761	A4931
Supplies	Reusable rectal thermometer	Z2762	A4932
Supplies	Underpad reusable any size each	Z2770	A4537

• Effective April 1, 2003, Enteral Codes B4150, B4151, B4152, B4153, B4154, B5155 and B4156 require Voice Interactive Telephone Prior Authorization and DME Repair Code E1340 requires Dispensing Validation System authorization.
• Questions on items in the DME, Footwear, Orthotic, Prosthetic and Supply categories (noted above) may be referred to the Bureau of Medical Review and Payment at (518) 474-8161.
• Questions on items in the Pharmacy category (noted above) may be referred to the Pharmacy Policy and Operations Unit at (518) 486-3209.

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The Office of Medicaid Management has received grants from the Centers for Medicare and Medicaid Services (CMS) to participate in a multi-year CMS Medicaid Payment Accuracy Measurement (PAM) Project. The goals of this project are to assist States in developing PAM methodologies, conduct pilot tests of alternative approaches and explore the feasibility of estimating payment accuracy for the Medicaid program at the national level.

An essential part of this project will consist of a review of a sample of Medicaid claims and the corresponding medical records/documentation. The sample claims are randomly selected from a universe of all Medicaid claims for the review period.

For the Year One study, the Department of Health (DOH) contracted with the Island Peer Review Organization (IPRO) to conduct the record reviews. IPRO began contacting providers in October 2002 for documentation. The Year One study is currently underway.

For the Year Two study, the DOH will begin contacting providers in March 2003 to obtain the records and documentation for the Year Two sample claims.

Should you be contacted, we are asking for your cooperation and a timely response, as receipt of the documentation is essential to the success of the project. Requests, and subsequent receipt/non-receipt of documentation, will be tracked. Your timely response will facilitate the PAM review and minimize the need for direct DOH contact with the providers in the sample.

Questions regarding this article should be directed to Payment Accuracy Measurement Project staff at (518) 474-9328.

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Beginning in April 2003, the Office of Medicaid Management will be activating edits that require part-time clinic providers to enter a part-time clinic certification number when billing the part-time clinic rates '1629' or '2880'. The Version 4 and Version 5 claim formats have been updated to include a new field called "Part Time Clinic Certification Number". Your assigned part-time clinic number should be entered into this new field.

This field is a 13 character alphanumeric field starting in position 26 of Record Type 15 (Provider Data). The first 11 characters of this field should contain the Part-Time certification number assigned to your clinic. The last two characters should contain the letters "PT"

You will receive a separate mailing from the Office of Health Systems Management, which will provide you with your assigned number.

If you have questions, please contact Computer Sciences Corporation, Provider Relations at (800) 522-1892.

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• The Prior Authorization number is good for the life of the prescription (original prescription and its refills). A new prescription will require a new prior authorization number. Controlled substance prescriptions are valid for 30 days from the date written. All other prescriptions are valid for 60 days from the date written.
• Prescriptions for brand drugs with "A" rated generics filled prior to November 17^th 2002 that have refills are "grandfathered" in. They will not require prior authorization for the life of that prescription. When a new prescription is issued to the patient, it will require a prior authorization.
• The State will not put a prior authorization requirement on brand name drugs until six months after the generic is released to market. You may continue to fill without prior authorization. After the six months, new prescriptions will require prior authorization.

PRESCRIBERS AND PHARMACISTS
In response to the many questions regarding the status of SYNTHROID,
currently SYNTHROID does not require Prior Authorization, as there is no "A" rated generic.

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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