DOH Medicaid Update April 2001 Vol.16, No.4

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Computer Sciences Corporation (CSC) Healthcare, New York State's Medicaid fiscal agent, has available Regional Representatives who can help providers solve Medicaid billing problems. This service is available at no charge to the provider.

Regional Representatives provide individualized training for providers and/or their billing staff who need Medicaid billing assistance. This service is available throughout New York State.

New billers or previous billers experiencing claim denials due to multiple billing errors should request an appointment with a Regional Representative by calling CSC Provider Relations at the appropriate number listed below. These services are available between 9:00 AM and 5:00 PM, Monday through Friday. Please have your Provider ID number available when you call.

Note: Many billing situations can be resolved by telephone and may not require an onsite visit from a Regional Representative.

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Nursing providers who render services to children enrolled in the Medicaid Care At Home (CAH) waiver programs must bill the appropriate CAH waiver procedure code and the fee assigned by the local department of social services (LDSS) which is fiscally responsible for the child. The CAH procedure codes and locally assigned private duty nursing fees for each LDSS are not published in the MMIS nursing provider's manual. To assure that providers are billing the correct fee and receive accurate information, it is important that the provider obtain the necessary documentation from the LDSS.

It is the responsibility of each nursing provider to obtain a statement from the LDSS documenting the MMIS hourly fee that the LDSS has approved for that particular case and the procedure code to be utilized. The document should be signed by the provider and a signed copy returned to the LDSS to indicate that the provider acknowledges and agrees to bill the approved county fee. Each LDSS has a CAH coordinator that can provide the required information to providers. Provider's statements must retain these for their case specific records. Questions should be directed to Ms. Colleen Maloney, New York State Department of Health, Bureau of Maternal and Child Health, at 518-486-6562.

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The association of asthma and allergy has long been recognized. According to the National Institutes of Health, exposure of asthma patients to irritants or allergens to which they are sensitive has been shown to increase asthma symptoms and precipitate asthma exacerbations. For successful long-term asthma management, it is essential to identify and reduce exposures to relevant allergens and irritants and to control other factors that have been shown to increase asthma symptoms and/or precipitate asthma symptom exacerbations. These factors fall into four categories: inhalant allergens (i.e., animal allergens, house-dust mites, cockroach allergens, molds, outdoor allergens), occupational exposures, irritants (i.e., tobacco smoke), and other factors (i.e., GERD, beta blockers, rhinitis/sinusitis, viral respiratory infections, sensitivity to aspirin).

The following chart summarizes questions that have been prepared by the National Institutes of Health for the assessment of environmental and other trigger factors that can impact asthma patients. Further information may be found at: http://www.nhlbi.nih.gov/about/naepp/index.htm

The Medicaid program reimburses for medically necessary care, services, and supplies for the diagnosis and treatment of asthma. We encourage readers to share these publications with their clinical practitioners. Please contact the Bureau of Program Guidance at 518-474-9219 with suggestions on articles that would be of interest to you in improving health outcomes for your patients.

Inhalant Allergens

Does the patient have symptoms year round? (If yes, ask the following questions. If no, see next set of questions.)

• Does the patient keep pets indoors? What type?__________
• Does the patient have moisture or dampness in any room of his or her home (e.g., basement)? (Suggests house-dust mites, molds.)
• Does the patient have mold visible in any part of his or her home? (Suggests molds.)
• Has the patient seen cockroaches in his or her home in the past month? (Suggests significant cockroach exposure.)
• Assume exposure to house-dust mites unless patient lives in a semiarid region. However, if a patient living in a semiarid region uses a swamp cooler, exposure to house-dust mites must still be assumed.

Do symptoms get worse at certain times of the year? (If yes, ask when symptoms occur.)

• Early spring? (trees)
• Late spring? (grasses)
• Late summer to autumn? (weeds)
• Summer and fall? (Alternaria, Cladosporium)

Tobacco Smoke

• Does the patient smoke?
• Does anyone smoke at home or work?
• Does anyone smoke at the child's day care?

Indoor/Outdoor Pollutants and Irritants

• Is a wood-burning stove or fireplace used in the patient's home?
• Are there unvented stoves or heaters in the patient's home?
• Does the patient have contact with other smells or fumes from perfumes, cleaning agents, or sprays?

Workplace Exposures

• Does the patient cough or wheeze during the week, but not on weekends when away from work?
• Do the patient's eyes and nasal passages get irritated soon after arriving at work?
• Do coworkers have similar symptoms?
• What substances are used in the patient's worksite? (Assess for sensitizers.)

Rhinitis

• Does the patient have constant or seasonal congestion and/or postnasal drip?

Gastroesophageal Reflux

• Does the patient have heartburn?
• Does food sometimes come up into the patient's throat?
• Has the patient had coughing, wheezing, or shortness of breath at night in the past four weeks?
• Does the infant vomit followed by cough or have wheezy cough at night? Are symptoms worse after feeding?

Sulfite Sensitivity

• Does the patient have wheezing, coughing, or shortness of breath after eating shrimp, dried fruit, or processed potatoes or after drinking beer or wine?

Medication Sensitivities and Contraindications

• What medications does the patient use now (prescription and nonprescription)?
• Does the patient use eyedrops? What type?
• Does the patient use any medications that contain beta-blockers?
• Does the patient ever take aspirin or other nonsteroidal anti-inflammatory drugs?
• Has the patient ever had symptoms of asthma after taking any of these medications?

* These questions are samples and do not represent a standardized assessment or diagnostic instrument. The validity and reliability of these questions have not been assessed.

Source: Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma (Bethesda, MD): National Institutes of Health, National Heart, Lung and Blood Institute: 1997)

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In 1996, 2,199 cases of end stage renal diseases were diagnosed in New Yorkers with diabetes. Hypertension can contribute to diabetes-related renal disease and is often seen as part of a syndrome in people with Type 2 diabetes. This syndrome includes glucose intolerance, dyslipidemia, insulin resistance, obesity and coronary artery disease.

The most recent report from the American Diabetes Association recommends that all Type 1 patients with microalbuminuria and Type 1 and 2 patients with hypertension with or without albuminuria be tried on angiotensin converting enzyme inhibitors (ACE inhibitors) therapy unless contraindicated. Not only do they control blood pressure; they also help to reduce the development of renal complications.

As a result of these recommendations, the New York State Medicaid Drug Utilization Review Board conducted an educational initiative in the autumn of 2000 to improve care for Medicaid recipients with concomitant diabetes and hypertension. Below are the findings.

Phase I

In phase one of this project, approximately 70,000 fee-for-service Medicaid recipient claim histories were reviewed for co-morbid conditions of hypertension and diabetes who were not receiving the American Diabetes Association recommended ACE inhibitor therapy for the disease.

Over 4,000 letters were sent to providers informing them of this information and a response rate of 42% was achieved.

Approximately 25% of responses indicated that providers would consider adding ACE inhibitor therapy to their patients' regimens.

Phase II

In the second phase of this project, educational letters were sent to providers of patients who were non-compliant with ACE inhibitor therapy according to their claims history.

To date, 59 of 219 letters have been returned. Of the responses received, approximately 54% of the providers stated that they would verify use of these agents with their patients.

The Medicaid program appreciates provider response to these targeted letters. Similar mailings will occur in the future. We look forward to your participation in improving health outcomes for the Medicaid population.

The Medicaid program reimburses for medically necessary care, services and supplies for the diagnosis and treatment of diabetes. For information regarding Medicaid coverage of services related to diabetes, please go to http://www.health.state.ny.us/health_care/medicaid/program/2000/oct2000.htm or contact the Bureau of Program Guidance at 518-474-9219.

For more information on diabetes, contact the Diabetes Control Program at 518-474-1222 or the Department's web site at http://www.health.state.ny.us

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Young people experiment with or begin regular use of tobacco for a variety of reasons related to social and parental norms, advertising, peer influence, parental smoking, weight control, and curiosity. Because tobacco use often begins in preadolescence, clinicians should pay particular attention to this population, routinely assess and intervene. In addition to cigarettes, clinicians should also be aware of the use of smokeless tobacco products and novel tobacco products, such as bidis, in this population.

• Bidis (pronounced beedies) are small brown unfiltered cigarettes, consisting of tobacco hand-rolled in tendu (a broad-leafed Indian plant) or temburni leaf and secured with a string at one end. They usually have a grape, strawberry, mango, black licorice or chocolate flavoring with a sweet taste and are primarily produced in India and in some Southeast Asian countries.
• Research shows that bidis are a significant health hazard to users. When tested on a standard smoking machine, one bidi produced more than three times the amount of carbon monoxide and nicotine and more than five times the amount of tar than one cigarette.
• Bidi use may be gaining popularity in the United States. A Massachusetts study that surveyed 642 Massachusetts' urban youth found that 40% reported smoking bidis in their lifetime, 16% reported smoking bidis at least once in the past 30 days and 8% smoked 100 or more bidis in their lifetime. Among young people there is a misconception that bidis are a safe alternative to cigarettes.
• When asked why they used bidis instead of cigarettes, responses included the following: 23% smoked bidis because of "taste", 18% reported that bidis are "cheaper", 13% of students felt that bidis are "safer" than cigarettes and 12% felt that they are "easier to buy" compared to cigarettes. The study also found that nearly one of five male students (19%) and one of 10 female students (12%) reported using bidis at least once in the past month.
• Clinicians, youth and the general public should be alerted to the high toxicity of bidi products to dispel the notion that bidis are safer to smoke than cigarettes and that tobacco use initiated during the teen years can lead to a lifelong addiction.

CDC. Bidi Use Among Urban Youth-Massachusetts, March-April, 1999. Fact Sheet.

Fiore MC, Bailey WC, Cohen SJ, et. al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2000.

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Tobacco use is a pediatric concern. In the United States, more than 6,000 children and adolescents try their first cigarette each day. More than 3,000 children and adolescents become daily smokers every day, resulting in approximately 1.23 million new smokers under the age of 18 each year.

• ASK- systematically identify all tobacco users at every visit. Ask about other forms of tobacco use, including smokeless tobacco products and bidis.
• ADVISE- strongly urge all tobacco users to quit or advise preadolescents/teens not to start. Tie tobacco use to 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.

The NYS Smoker's Quitline is 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.

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Effective for order dates on or after May 1, 2001, all supplies for home drug infusion and/or administration supplies not otherwise listed in the fee schedule should be billed using the following code:

CODE	PRODUCT	QUANTITY	REFILLS	PRICE
A4221	#Supplies for maintenance of drug infusion catheter, per week (list drug separately) (bill monthly)	Each unit (up to 40 units per month)	5	$1.00 per unit

Code #A4221 is to be used for all supplies required for maintenance of drug infusion catheters and external pumps, and/or supplies necessary for the administration of drugs (except insulin) not otherwise listed in the fee schedule, including all supplies previously requested under codes A4211 and A4222 . Up to $40.00 (40 units) may be billed no more than once per month under code #A4221. A DVS authorization number must be obtained on the date the supplies are dispensed. Prior approval is required when more than $40.00 (40 units) of supplies per month is necessary. Prior approvals will be issued for the entire month's supply, not the amount that exceeds $40.00. Prior approval requests must be sent to the Albany Prior Approval Unit and contain documentation of medical necessity including the treatment plan and cost of necessary supplies.

Billing examples:

Calculated Medicaid amount due on code #A4221 is:

$9.49: obtain DVS authorization number for 9 units ($9.00)
$29.50: obtain DVS authorization number for 30 units ($30.00)
$40.50: do not obtain DVS authorization number, prior approval is required

For order dates on or after May 1, 2001, do not use the following codes for new orders for home drug infusion and/or administration supplies:

CODE	PRODUCT	QUANTITY	REFILLS	PRICE
A4211	Supplies for self-administered injection	once/month	5	PA
A4222	Supplies for external drug infusion pump, per cassette or bag (list drug separately)	once/month	5	PA

• Codes A4211 and A4222 will still be active on and after May 1, 2001 for prior approvals issued for order dates prior to May 1, 2001.
• Supplies for external insulin pumps and parenteral nutrition, as well as equipment such as pumps and IV poles should continue to be billed under their assigned codes.

Please insert this page in your MMIS Provider Manual (Rev. 4/01). Questions can be directed to the Bureau of Medical Review and Payment 518-474-8161.

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Medicaid reimbursement for hearing aids is dependent upon the following criteria,regardless of order source:

1. Monaural Hearing Aid:

1. Hearing loss in the better ear of 30 dBHL or greater (re - ANSI 1969) for the pure tone average of 500, 1000 and 2000 Hz.
2. A spondee threshold in the better ear of 30 dBHL or greater when pure tone thresholds cannot be established.
3. Hearing loss in each ear is less than 30 dBHL at the frequencies below 2,000 Hz and thresholds in each ear are greater than 40 dBHL at 2,000 Hz and higher.
4. Documentation of communication need and a statement that the patient is alert and oriented and able to utilize their aid appropriately.

2. Binaural Hearing Aids:

Same as the criteria for Monaural Hearing Aid plus one or more of the following:

1. Significant social, vocational or educational demands;
2. Previous user of binaural hearing aids;
3. Significant visual impairment;
4. Children.

FM Systems and Digital Hearing Aids are not reimbursable by Medicaid.

See the MMIS Hearing Aid Services Provider Manual for additional information.

Questions concerning Hearing Aid prior approval may be directed to the NYS Department of Health, Bureau of Medical Review and Payment, at 1-800-342-3005.

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Laboratories have been billing for procedures 82105 (alpha-fetoprotein, Serum), 82677 (Estriol), and 84702 (human chorionic gonadotropin; quantitative) on the same date of service. These three procedures are otherwise known as the "Triple Test" or "Multiple Marker Test". While Medicaid pays for these three procedures when ordered individually, there has been considerable discussion about whether to pay when they are ordered for purposes of assessing the prenatal risk for fetal defects associated with morphological and genetic disorders. Each individual procedure is approved by the Food and Drug Administration and Medicaid reimburses for each of the three procedures. The use of the three procedures ordered as a panel is not an FDA approved test. Policy reimbursement for these three procedures being ordered as one test is currently being evaluated. While this evaluation is occurring, Medicaid will permit payment of these three procedures ordered either individually or together. Medicaid audit staff will not recoup money for the "Triple Test" or "Multiple Marker Test" if ordered, while this policy evaluation is occurring. Of course, these procedures should not be ordered unless they are medically necessary.

If you have further questions on "Triple Test" or "Multiple Marker Test" coverage, please contact the Bureau of Policy Development and Agency Relations at 518-473-5873.

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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:

Additional 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. 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:

To register, please mail this completed page to:

Computer Sciences Corporation
Attn.: Provider Outreach
800 North Pearl Street
Albany, NY 12204

Or, 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.

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When the Departments of Health (DOH) and Correctional Services (DOCS) Eyeglass Project was fully implemented in October, 1994 in counties other than New York City, Medicaid recipients in District 97 (responsibility of the Office of Mental Health), District 98 (responsibility of the Office of Mental Retardation and Developmental Disabilities) and District 99(Oxford Home) were not included.

Effective April 1, 2001 all ophthalmic dispensers in Upstate (non-NYC) service locations have the option of ordering all eyeglass materials from the Wallkill Optical Laboratory in Wallkill, New York forMedicaid eligible recipients who meet the following criteria:

• are the fiscal responsibility of District 97, District 98 or District 99 (verifiable on EMEVS); and
• reside in one of the DOCS Counties (all counties except NYC). See page 3-2 in the MMIS Billing Manual for the list of county codes.

Please refer to Section 2.2.15 in the Policy Section of your MMIS Billing Manual for specific information about the DOH-DOCS Eyeglass Project and submitting orders for eyeglass materials to the Wallkill Optical Laboratory.

Questions about vision care can be directed to the Bureau of Policy Development and Agency Relations, Office of Medicaid Management, at 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