DOH Medicaid Update June 2000 Vol.15, No.6

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In May you were sent an update to the Dental Manual with an effective date of June 1, 2000. On Computer Sciences Corporation's (CSC's) cover letter, we listed the updated pages as follows:

Section	Pages
Policy	2-1, 2-3, 2-39 through 2-47
Billing	3-39 through 3-43
Procedure Codes	5-1 through 5-28

The Policy and Billing sections contain fewer pages than the sections being replaced in the Manual. Listed below are the additional outdated pages, which should be retained only for the purpose of billing dates of service prior to June 1, 2000.

Section	Pages
Policy	2-48 through 2-77
Billing	3-43a through 3-43c

If you have any questions regarding this article or the Dental Manual update, please call CSC's Provider Relations at 800-522-5518 or 518-447-9860.

Additional Information:

• Prior approvals spanning the June 1, 2000 fee schedule changes do not have to be reissued for dates of service June 1, 2000 or after if the "Excess Pay Indicator" is listed as an "N." Please refer to Section 3 of the prior approval form.
• To obtain proper reimbursement for service dates on/after June 1, 2000, the new fee must be entered in the claim. MMIS will not automatically pay claims at the new fees.
• All questions regarding orthodontic services should go directly to the Bureau of Medical Review and Payment at 1-800-342-3005. Select #2 for Westchester County recipients. Select #3 for all other recipients.

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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:

August 23    10 AM
Westchester County Department of Social Services
85 Court Street
White Plains, NY

August 29  10 AM
Livingston County Campus
Building 1, 2nd Floor Auditorium
Mt. Morris, NY

September 18   10 AM
Ulster County Department of Social Services
Albany Avenue
Kingston, NY

September 19   10 AM
Computer Sciences Corporation
800 North Pearl Street, 3rd Floor
Albany, NY

September 27   10 AM
Suffolk County Department of Social Services
3085 Veterans Memorial Highway
Ronkonkoma, NY

October 26   10 AM
Allegany County
(address to be announced - see below)
Belmont, NY

November 13   10 AM
Computer Sciences Corporation
800 North Pearl Street, 3rd Floor
Albany, NY

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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Optometrists certified by the State Education Department (SED) to write prescriptions for phase one therapeutic pharmaceutical agents only will have a "special privilege code" (U) preceding their six-digit license number (i.e., U123456).

The following topically applied ophthalmic agents have been designated as phase one therapeutic agents:

• antibiotic/antimicrobials
• decongestants/anti-allergenics
• non-steroidal anti-inflammatory agents
• steroidal anti-inflammatory agents
• antiviral agents
• hyperosmotic/hypertonic agents
• cycloplegics
• artificial tears
• lubricants

Optometrists certified by SED to write prescriptions for both phase one and phase two therapeutic pharmaceutical agents will have the "special privilege code" (V) preceding their six-digit license number (i.e., V123456).

The following topically applied ophthalmic agents have been designated as phase two therapeutic agents:

• blockers
• alpha agonists
• direct acting cholinergic agents

SUBMISSION OF PHARMACY CLAIMS

Electronic Claim Capture (EMEVS): If the MMIS Provider ID number is available, enter this eight-digit number, left justified, in the Prescriber ID field. If the MMIS Provider ID number is not available, use the license number. In the Prescriber ID field, enter 25 (in-state) or 35 (out-of state), then zero (0), then the six-digit license number preceded by the U or V. For example: 250U123456 or 250V123456.

Diskette/Electronic Submission (to CSC) on MMIS Pharmacy Format: If the MMIS Provider ID number is available enter this eight-digit number, left justified, in the Prescriber license number field. Space fill the Type of Prescriber field. If the MMIS Provider ID number is not available, use the license number. In the Type of Prescriber field, enter 25 (in-state) or 35 (out-of-state). In the Prescriber license number field, enter 0 (zero), then the six-digit license number preceded by the U or V.

Paper Submission: If the MMIS Provider ID number is available, enter this eight-digit number in the Ordering/Prescribing Provider ID/license number field. Leave the Type field blank. If the MMIS Provider ID number is not available, use the license number. Enter 25 (in-state) or 35 (out-of-state) in the Type field and the six-digit license number preceded by the U or V in the Ordering/Prescriber Provider ID/license field.

Claims for therapeutic pharmaceutical agents prescribed by optometrists whose licenses contain only six digits not preceded by the letter U or V will not be reimbursed by New York State Medicaid.

Questions concerning this matter should be directed to (518) 473-5953.

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As you are aware, in the April 2000 Medicaid Update, several additional procedures were identified by the New York State Medicaid program to accommodate the expanded scope of practice of optometrists. It has come to our attention that there is some confusion about when to use and/or how to bill for some of the new procedures.

The following information should clarify Procedure Codes 99242, 99243 and 99244 (Office Consultations) and the billing for the cost of materials for Procedure Code 68761 (Closure of lacrimal punctum; by plug, each).

Office Consultations (Procedure Codes 99242 through 99244)

A consultation is a type of service provided by a medical practitioner whose opinion or advice regarding evaluation and/or management of a specific problem is requested by a physician.

The procedure codes for Office Consultations are to be used only when a Medicaid recipient is referred by a physician or other appropriate source. A "consultation" initiated by a patient and/or family is not reported using the consultation codes, but, as appropriate, may be reported using the codes for visits. (See pages 4-1 through 4-2 of the Ophthalmic Provider Billing Manual and the additional office visit codes identified in the June 1998, Vol. 13 issue of the Medicaid Update.)

Any specifically identifiable procedure (i.e., identified with a specific procedure code) performed on or subsequent to the consultation should be reported separately.

On and subsequent to the date a consultant assumes responsibility for management of a portion or all of the patient's condition(s), the consultation codes should not be used. The appropriate evaluation and management codes should be used.

The patient's medical records should document the request for a consultation from the referring medical practitioner and the need for the consultation. In addition, the consultant's opinion and any services that were ordered or performed should be documented in the patient's records and communicated to the requesting physician or other appropriate source.

Billing for the Cost of Materials in Conjunction with Procedure Code 68761 (Closure of Lacrimal Punctum by Plugs)

Procedure Code V2799 - Not Otherwise Classified (Unlisted ophthalmic service or material) is to be reported if an optometrist incurs a cost for materials which are used during a procedure, i.e., the punctum plug(s). The cost of materials procedure code V2799 requires prior approval, which must be obtained before the procedure is performed and billed to Medicaid. In addition, Code V2799 is a "BR" (By Report) procedure. The cost of materials is currently reimbursed at the itemized invoice cost. (See pages 2-50 and 4-4 of the Ophthalmic Provider Billing Manual.)

At the time the optometrist makes the prior approval request, the itemized invoice that documents the cost of the plug(s) must be submitted along with the medical indication for the procedure. The reimbursement amount will be established in the prior approval process. When prior approval is obtained, the claim for the cost of the materials should be billed to Medicaid.

The June 1998 and April 2000 issues of the Medicaid Update are available on the Department of Health web site at: http://www.health.state.ny.us/health_care/medicaid/program/main.htm.

Additional questions concerning the above should be directed to the Office of Medicaid Management, Bureau of Policy Development and Agency Relations, at (518) 473-5953.

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Previous Medicaid Update Articles advised you of the impending implementation of a front-end EMEVS prescriber license verification edit. This edit will be activated effective July 1, 2000.

Please be aware that some categories of licensed New York State professionals require special approval by the State Education Department in order to prescribe drugs or order services. This approval is issued in the form of an alpha character which is printed on their license. The license verification edit will require the entry of the alpha character for the following categories:

NURSE PRACTITIONERS and NURSE MIDWIVES - Both categories require the letter F on their license in order to prescribe or order services. A correct entry for license F000123 would be 290F000123 (license type, zero, special alpha approval letter, license number)

OPTOMETRISTS - Require either the letter U or V on their license in order to prescribe drugs. A correct entry for license V004567 would be 250V004567.

The EMEVS denial messages that will be returned upon implementation of the license verification project are:

REENTER ORDERING PROVIDER - This reject message will be returned when the ordering license or provider number entry has the incorrect format (wrong length or characters in the wrong position). Providers who access EMEVS using methods other than the Telephone or Verifone Terminal will see this message as Denial Code 056. These alternate access methods include PC, CPU, NCPDP, RJE, etc.

INVALID LICENSE TYPE - This reject message will be returned when the two-digit license type is not valid. A list of valid license types was published in the March, 2000 Medicaid Update. Providers using alternate access methods will see this message as Denial Code 059.

INVALID ORDERING PROVIDER - This reject message will be returned when the ordering provider license or provider number entry is not found on the license or provider file. Providers using alternate access methods will see this message as Denial Code 068. Pharmacies will also receive NCPDP Code 25.

DISQUALIFIED ORDERING PROVIDER or DISQUALIFIED ORDERER - This reject message will be returned when the license or provider number entry belongs to a provider who is not allowed to prescribe or order Medicaid services. Providers using alternate access methods will see this message as Denial Code 066. Pharmacies will also receive NCPDP Code 25.

DECEASED ORDERING PROVIDER or DECEASED ORDERER - This reject message will be returned when the license or provider number entry belongs to a provider who is deceased. Except for pharmacies, providers using alternate access methods will see this message as Denial Code 067. For an original prescription, pharmacies will receive new Table 7 Denial Code 721 (DECEASED ORDERING PROVIDER; NEW PRESCRIPTIONS NOT ALLOWED). Pharmacies will also receive NCPDP code 25.

REMINDER - When entering a license number ordered by an out-of-state provider, the two-character state alpha code must be entered after the license type but before the license number. An entry for a New Jersey physician with license number 45678 would be 11NJ045678. NOTE: Effective with this project, telephone transactions where the ordering provider is out-of-state must include the converted alpha state code. 99 or 00 should no longer be used in lieu of the state code. A correct entry via the telephone for the above number would be 116251045678.

Questions regarding the project's edit criteria, correct entry format or denial messages should be directed to the EMEVS Provider Relations staff at 1-800-343-9000.

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Pregnancy may present a motivational opportunity for women to quit smoking. Women can use this time in their lives to quit for themselves and for their babies. Physicians can be an especially influential factor when they suggest smoking cessation to patients. Ask your patients about smoking, including second-hand smoke. Advise your patients to quit smoking and assist your patients with a quit plan. All pregnant women should be urged to quit smoking throughout pregnancy or advised not to start smoking after the baby is born. When a woman returns for the postpartum visit, a time of increased risk for relapse, physicians should reinforce the importance of not smoking for the mother's and baby's health.

Messages that can be used by health care providers to prompt smoking cessation before, during and after pregnancy include

• You can do it!
• You will have a healthier pregnancy (lower risk of bleeding, miscarriage, and premature babies).
• Your baby will have more oxygen it needs to grow.
• You will help your baby avoid health problems associated with smoking, such as ear infections, bronchitis, pneumonia, and SIDS (Sudden Infant Death Syndrome).
• Your baby will have a healthier birth weight and have less health problems.
• Your breast milk will be free of cigarette chemicals that are passed on to your baby.
• You will save money.
• Do it for your baby, the life that is depending on you!

An additional support available to Medicaid recipients is a toll-free smoking help-line staffed by employees of the Roswell Park Cancer Institute. The Quitline offers smokers 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.

TOLL-FREE SMOKER'S QUITLINE: 1-866-NYQUITS (1-866-697-8487). Other Department of Health publications available include: "How to Have a Healthy Baby" #2949 and "101 Reasons to Quit Smoking" #3404. These publications, which can be given to patients, are available by calling 518-474-5370.

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Please make the following price changes, effective July 1, 2000, in your MMIS Pharmacy Provider Manual (Rev. 7/00) and/or your MMIS DME Provider Manual (Rev. 7/00). When the description is preceded by a "#", Electronic Medicaid Eligibility Verification System (EMEVS) dispensing validation is required.

CODE	PRODUCT	PRICE	MANUAL
A5105	#Urinary suspensory; with leg bag, with or without tube	71.12	Pharmacy/DME
Z2001	Butterfly closures (100's)	11.00	Pharmacy/DME
E0601	#Continuous airway pressure device (CPAP)	496.20	DME only

Please add the following codes to your MMIS DME Provider Manual (Rev. 7/00).

CODE	PRODUCT	PRICE	MANUAL
L2800	Addition to lower extremity orthosis, knee control, knee cap, medial or lateral pull	75.00	DME only
L3540	#Orthopedic shoe addition, sole, full (each) (L3540 is effective for dates of service on or after August 1, 2000).	7.50	DME only

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Effective for dates of service on or after April 7, 2000, Medicaid reimbursement is now available for ultrasound bone growth stimulators when medically necessary, prior approved, and ordered by a board certified or board eligible orthopedic surgeon for non-union fractures of the tibial shaft as evidenced by the following:

• an assessment of why the fracture is non-union (inadequate blood supply, etc.)
• no evidence of healing based on a minimum of three sequential monthly examinations
• at least 50% of the fracture surfaces are in apposition
• no more than ten degrees of anterior or posterior angulation
• no more than fifteen degrees of lateral angulation in either varus or valgus, and
• other contributing factors that would affect bone growth such as age, smoking, etc.

Under no circumstances will ultrasound bone growth stimulation be approved for true synovial synarthrosis.

The maximum reimbursable amount for use of the system for the entire treatment period is $2,000, including any integral parts or service, and can be claimed using E0760, osteogenesis stimulator, low intensity ultrasound, non-invasive.

In order to assess the benefit of this treatment modality on patient outcome and whether Medicaid resources are being spent wisely, follow-up on the status of patients who have used this system will be done. For prior approval requests that are approved, the following information is required for submission at the time the non-union is healed or when other interventions are initiated (surgery, etc.) :

• summary of patient progress
• copy of the most recent pertinent x-rays
• patient's final disposition

This information should be sent to Harvey Bernard, M.D., Medical Director, NYSDOH/OMM, Room 2038, Corning Tower, Empire State Plaza, Albany, NY 12237.

Please contact the Bureau of Program Guidance at (518) 473-5452 if you have questions about this policy.

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Section 2.2.6.8.a of your MMIS Dental Provider Manual (Rev. 6/00) indicates that payment for services provided to recipients residing in an in-state ICF-DD should be sought from the facility. This is true only if dental services are included in the facility rate for the specific ICF-DD. It is the responsibility of the ICF-DD to inform the dental provider if dental services are included in the facility rate.

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Prescriptions, over-the counter medications, supplies or durable medical equipment (DME) shall be prepared in accordance with instructions provided on the prescription or fiscal order.

• All shipping and/or delivery costs shall be the responsibility of the provider of service.
• The pharmacy or DME provider must first contact the recipient or caregiver to ensure that a delivery is needed. Confirmation of needed delivery shall be maintained in the patient record. Automatic refills will not be permitted.
• The recipient or caregiver must receive delivery. Electronic signatures for receipt of product are permitted only if retrievable and kept on file by the pharmacy or DME provider.
• If a pharmacy or DME provider utilizes a delivery service, the pharmacy or DME provider will remain responsible for delivery of product to the intended recipient or caregiver. Replacement of lost, stolen or misdelivered medication, supplies and DME is the sole financial responsibility of the pharmacy or DME provider. NYS Medicaid will not reimburse for replacement supplies of lost, stolen or misdirected medication or DME deliveries.
• The pharmacy or DME provider must also guarantee appropriate delivery of intact, usable product (i.e., if product requires refrigeration, the provider must ensure delivery under appropriate product storage conditions).

Questions concerning this article should be directed to the Pharmacy Policy Unit at 518-486-3209.

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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