DOH Medicaid Update December 2001 Vol.16, No.12

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Unless there are changes to federal law, effective October 16, 2002, New York Medicaid intends to be HIPAA compliant and we expect our providers who bill electronically to submit only HIPAA compliant transactions

This article is the fifth to appear in recent Medicaid Update editions:

• An introduction to HIPAA (Health Insurance Portability and Accountability Act) and its requirements are in the March 2001 issue;
• An explanation of the privacy requirements is in the June 2001 issue;
• Website information, systems activities, and a list of members of the New York State HIPAA coalition are contained in the August 2001 issue;
• A discussion of those areas of New York's Medicaid program which may be "non-compliant" with HIPAA requirements is contained in the October 2001 issue;

These articles are contained in each edition available on the New York State Medicaid program website at:

This article will focus on our progress in addressing those areas of New York's Medicaid program which may be "non-compliant" with HIPAA requirements, areas which diverge from general HIPAA guidelines.

Transactions Gap Analysis

The State has completed gap analysis for the following Implementation Guides:

837          Health Care Claim: Institutional, Professional, And Dental
835          Health Care Claim Payment/Advice
276/277   Health Care Claim Status Request and Response
820          Payroll Deducted/Premium Payment

Identified gaps include Category of Service, Specialty Codes, Locator Codes and others. State and Computer Sciences Corporation (CSC) staff are reviewing all gaps. It is anticipated that key gaps and data content issues will be resolved by early December 2001. Medicaid HIPAA systems specifications and claiming requirements may be developed by February 2002. We will share systems requirements with you as they are developed and finalized.

Category of Service/Specialty Codes

The HIPAA standards do not accommodate a number of our Medicaid Management Information System (MMIS) data elements, including Category of Service and Specialty Code. These two data elements drive our MMIS claims processing and payment system. Their absence from the HIPAA standards has forced us to pursue viable work around solutions. We have determined that the National Health Care Provider Taxonomy Codeset offers us the best alternative. Provider Taxonomy classifies health care providers, provider type or classification, and specialization. Taxonomy codes are 10 characters and are segregated by category, e.g. Physicians, Dental, etc. The coding structure will be used by Medicaid to capture Category of Service and/or Specialty Code information. We have been able to crosswalk most of our Categories of Service and Specialty Codes to existing Taxonomy codes.

For HIPAA claiming purposes, each of your MMIS Categories of Service and Specialty Codes will be replaced with a Taxonomy Code. More information will be provided in the future as we proceed to develop our HIPAA specifications.

HIPAA Testing

Beta testing of selected provider types may begin the end of April 2002. A more precise testing timeframe will be published in upcoming Medicaid Updates, or via fiscal agent provider letters, as we finalize our systems requirements.

Provider Education/Training

CSC Provider Relations staff are finalizing a comprehensive HIPAA education/training plan which will include:

• publishing HIPAA billing specifications; and,
• regional HIPAA training seminars.

The anticipated regional training will focus on Medicaid claiming requirement changes as mandated by the HIPAA legislation. All of our HIPAA requirements will be compliant with the Transactions standards. As such, we strongly encourage providers to undertake necessary steps, well in advance of our training seminars, to assure their systems and business processes are HIPAA compliant. If you contract with a vendor, billing service, or clearinghouse, do not assume that they will necessarily be able to accommodate your HIPAA data submission needs. Make sure you are apprised of their compliance and testing certification activities. Remember, New York Medicaid intends to be HIPAA compliant effective October 16, 2002, and unless Congress approves an extension, we expect our providers who bill electronically to submit only HIPAA compliant transactions.

Statewide HIPAA Website

In New York, the Office For Technology (OFT) has been designated as the lead agency for HIPAA implementation. We are working with OFT to develop a Statewide HIPAA website.

However, we are excited to announce the creation of a HIPAA site within the New York State Department of Health website! This site, available in December 2001, can be accessed at:

The HIPAA Transactions will have a very significant impact on our Medicaid enterprise and will alter our way of doing business, but they will not change what our business is -- to provide efficient and cost-effective healthcare for our needy adults and children. Our Medicaid program is one of the most comprehensive in the country and we take great pride in what we have been able to accomplish.

We also realize that much of our success is due to the dedication and commitment of our provider community. As such, we have every intention to achieve, to the extent possible, a seamless transition to the HIPAA standards. However, the fact remains that significant changes will be occurring and business processes will need to be modified. The Medicaid program is not in a position to provide HIPAA software or technical assistance, but we are available to discuss any of your concerns and address all your questions which relate to our HIPAA approach. Please do not hesitate to contact us. Telephone Mario Tedesco, Medicaid HIPAA Project Manager, at (518) 257-4496, or e-mail Mr. Tedesco at mxt07@health.state.ny.us

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The Albany County Supreme Court has recently issued a ruling in a lawsuit relating to Medicaid coverage of several procedures which have been previously reimbursable to optometrists.
Based on this ruling, the following procedure codes will not be reimbursable to optometrists on or after October 20, 2001

• 68761, closure of the lacrimal punctum by plug;
• 68810, probing of the nasolacrimal duct;
• 68840, probing of the lacrimal caniculi, with or without irrigation

These procedures remain reimbursable when performed by an ophthalmologist.

If you have any questions regarding this article, please contact Myrna Bernstein in the Division of Policy and Program Guidance at (518) 473-5953

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For more than 50 years, physicians worldwide have relied on antibiotics for rapid and effective management of many of the most common infections. Antimicrobials were hailed as "miracle drugs," and any potentially serious problems associated with them were downplayed. Today, however, their indiscriminate use is no longer embraced as a universal remedy without potential harm to the patients being treated.
This is primarily due to drug resistance clones that emerge with the use of antibiotics, whether or not the antibiotic is indicated. Resistance may arise as a result of therapy or as a result of a previous exposure to a given drug, or may be intrinsic to the microbe itself. Additionally, resistance is found not only in the hospital environment but also in the community setting and in long-term care facilities, with some hospital outbreaks directly traceable to resistant bacteria introduced from the community.

Researchers at the Centers for Disease Control and Prevention have estimated that some 50 million of the 150 million outpatient prescriptions for antibiotics every year are unnecessary. Because of this, clinicians must adjust their prescribing behaviors to ensure that this situation does not worsen.

• Clinicians should not accommodate patient demands for unnecessary antibiotics.
• The public needs to learn about the prudent use of these drugs.
• Prescriptions should be for narrow-spectrum antibiotics, when appropriate, to help preserve the normal susceptible flora.
• Clinicians need to learn how to cope with misguided patients who demand antibiotics to treat colds and other viral infections that cannot be cured by the drugs.
• Clinicians should try to identify causative bacteria before beginning therapy for upper respiratory infections, so they can prescribe an antibiotic targeted specifically to that microbe, instead of empirically choosing a broad-spectrum product.
• Wash hands after seeing each patient. This is a major and obvious, but too often an overlooked, precaution.

One way to inform the patient about managing the symptoms of viral infections is by using a Viral Prescription Pad. The New York State Upper Respiratory Infection Project (NYSURIP) has developed this pad to facilitate patient/clinician interaction and to educate the patient on a course of treatment for their viral illness.

The committee is creating a pilot study to evaluate the Viral Prescription Pad and would like any interested practitioners to please contact any of the names at the end of this article to participate.

At the NYSURIP First Annual Statewide Conference on Antibiotic Resistance, to be held on April 17, 2002, at the Hudson Valley Community College in Troy, NY, strategies for clinicians to deal with patient expectations will be discussed. Interactive sessions and active panels will allow participants to discuss successful ways in satisfying patients while not prescribing antibiotics when they are not needed. Practitioners and stakeholder organizations are invited to attend.

Please contact the names at the end of this article for more information or check our website:

For further information call Richard Propp, M.D., Medical Consultant at (518) 473-5876, Denise Spor, R.N., at (518) 473-0185, or Elizabeth Villamil, M.P.H., Project Administrator at (518) 473-5499.

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There are five million children and 12 million adults diagnosed with asthma in the United States. Unfortunately, these numbers are increasing each year at an alarming rate. Since 1980, the number of people with asthma has more than doubled, with a disproportionately high impact found among the nation's children, minorities, and inner-city groups. Although there is no known cure for this disease, experts agree that there are a variety of easy ways to reduce the number of attacks. This new public information campaign, sponsored by the U.S. Environmental Protection Agency (EPA) and produced by the Ad Council, plans to build awareness on how to reduce Americans' exposure to indoor asthma triggers. The EPA public service campaign provides parents:

KEYS TO PREVENTING YOUR CHILD'S ATTACKS

• Work with a doctor to develop a written Asthma Management Plan that's right for you and your child.
• Learn what triggers your child's asthma and eliminate or reduce your child's exposure to those allergens and irritants.
• Make sure your child takes medications as prescribed and tell your doctor if there are any problems.
• Keep a daily symptom diary and use a peak flow meter every day to note your child's progress.

HOW TO MANAGE YOUR CHILD'S INDOOR ENVIRONMENT

Clear Your Home of Asthma Triggers

• Second Hand Smoke
• Pets
• Dust Mites
• Pests
• Molds

To speak to an information specialist about asthma and environmental triggers, please call 1-800-NO-ATTACKS (1-800-315-8056)

The New York State Medicaid Program reimburses for medically necessary care, services, and supplies for the diagnosis and treatment of asthma. For more information, please contact the Bureau of Program Guidance at (518) 474-9219.

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Many smokers relapse soon after stopping smoking. But relapse can occur months or even years later. Practitioners can help their patients prevent relapse by congratulating patients on their success, encouraging continued abstinence, and addressing concerns or threats to maintaining abstinence.

The following chart offers recommendations for problems that may threaten abstinence from tobacco.

Problems	Responses
Lack of support for cessation	Schedule follow-up visits or telephone calls with the patient. Help the patient identify sources of support within his or her environment Refer the patient to an appropriate organization that offers cessation counseling or support.
Negative mood or depression	If significant, provide counseling, prescribe appropriate medications, or refer the patient to a specialist.
Strong or prolonged withdrawal symptoms	If the patient reports prolonged craving or other withdrawal symptoms,consider extending the use of an approved pharmacotherapy or adding/combining pharmacologic medications to reduce strong withdrawal symptoms.
Weight gain	Recommend starting or increasing physical activity; discourage strict dieting. Reassure the patient that some weight gain after quitting is common and appears to be self-limiting. Emphasize the importance of a health diet. Maintain the patient on pharmacotherapy known to delay weight gain (e.g.,buproprion SR, NRTs, particularly nicotine gum). Refer the patient to a specialist or program.
Flagging motivation/feeling deprived	Reassure the patient that these feelings are common. Recommend rewarding activities. Probe to ensure that the patient is not engaged in periodic tobacco use. Emphasize that beginning to smoke (even a puff) will increase urges and make quitting more difficult.

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.

NYS Medicaid covers both prescription and non-prescription smoking cessation agents. For more information on Medicaid's smoking cessation coverage policy, contact the Pharmacy Policy and Operations Unit at (518) 486-3209.

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The Place of Service code indicates the location where a service was performed. The one-digit place of service code is notthe same as the two-digit locator code(s) assigned to the provider at the time of enrollment.

Physicians must enter the appropriate place of service code from the list below in paper field 24B or electronic Claim A specifications record D2, position 57.

0   Emergency Room
1   Office
2   Recipient's Home
3   Inpatient Service*
4   Health Related Facility
5   Skilled Nursing Facility
6   Diagnostic and Treatment Center(Free Standing Clinic)
7   Hospital Outpatient Service
8   Health Maintenance Organization
9   Other

*Please note that Utilization Threshold Service Authorization is not required when the place of service code is 3, 4, or 5.

Providers making inquiries or requesting billing training by Regional Representatives should contact Computer Sciences Corporation (CSC) by calling the appropriate number below. Please be prepared to supply your Medicaid Provider ID number.

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Births to women in receipt of Family Health Plus must be reported to the New York State Department of Health...within 5 business days of a birth.

Hospitals are advised that births to women in receipt of Family Health Plus must be reported to the New York State Department of Health (SDOH), in the same manner as births to women in receipt of Medicaid.

Within five (5) business days of a birth to a woman in receipt of Medicaid, the hospital must report the birth to the SDOH. This requirement, which has been in effect since July 1, 2000, is met by reporting the birth via the existing Electronic Birth Certificate (EBC). Births to women who are in receipt of Family Health Plus must be reported in the same manner. In these instances, the birth registrar should indicate the code for Medicaid in one of the payor fields; this will allow the SDOH to review the birth information and, if appropriate, create Medicaid eligibility for the infant.

The Family Health Plus card should have a client identification number (CIN) that follows the same pattern as a Medicaid CIN: two letters, followed by five numbers, followed by a letter. The CIN should also be reported via the EBC. The presence of the CIN on the woman's health plan card should help hospitals in identifying women who are in receipt of Family Health Plus.

The "Dear Parent" letter that is given out to new parents will be revised to include language telling parents that if the mother is in Family Health Plus when she gives birth, her infant is entitled to one year of Medicaid. Please begin using this revised letter immediately upon receipt of a copy from the SDOH.

If you have any questions regarding this article, please contact Linda LeClair at (518) 474-9130

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Effective for dates of service on and after July 1, 2001, the coverage for Positron Emission Tomography (PET) has been expanded to include the procedure codes listed below. These procedure codes are available to both Physician and Ordered Ambulatory Services providers. New York State Medicaid coverage for PET is limited to current Medicare covered indications, limitations and requirements for usage. Reimbursement for PET studies utilizing FDG as a tracer is limited to $2,400 for the complete procedure. Reimbursement for PET studies utilizing Rubidium 82 as tracer is limited to $1,850 for the complete procedure. These maximum reimbursement amounts are for the complete procedure (professional and technical/administrative components) including the tracer. To receive reimbursement for only the professional or the technical/administrative component, see modifier '26' Professional Component or modifier 'TC' Technical Component.

For more information about Radiology component billing see the Medicaid Management Information System (MMIS) Physician or Ordered Ambulatory Services Manuals, Radiology Rules.

G0125   PET imaging regional or whole body; single pulmonary nodule
G0210   PET imaging regional or whole body; diagnosis lung cancer, non-small cell
G0211   initial staging,lung cancer, non-small cell
G0212   restaging,lung cancer, non-small cell
G0213   diagnosis, colorectal cancer
G0214   initial staging,colorectal cancer
G0215   restaging,colorectal cancer
G0216   diagnosis, melanoma
G0217   initial staging melanoma
G0218   restaging melanoma
G0219   melonoma for non-covered indications
G0220   diagnosis, lymphoma
G0221   initial staging, lymphoma
G0222   restaging lymphoma
G0223   PET imaging whole body or regional; diagnosis, head and neck cancer,excluding thyroid and CNS cancers
G0224   initial staging head and neck cancer, excluding thyroid and CNS cancers
G0225   restaging head and neck cancer, excluding thyroid and CNS cancers
G0226   PET imaging whole body; diagnosis esophageal cancer
G0227   initial staging esophageal cancer
G0228   restaging esophageal cancer
G0229   PET imaging: Metabolic brain imaging for pre-surgical evaluation of refractory seizures
G0230   PET imaging; Metabolic assessment for myocardial viability following inconclusive SPECT study
78491   Myocardial imaging, positron emission tomography (PET), perfusion, single study at rest or stress
78492   multiple studies at rest and/or stress

If you have any questions regarding coverage of PET, please telephone the Bureau of Medical Review and Payment at (518) 474-8161.

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Effective January 15, 2002, the New York State Medicaid Program will require prior authorization for prescribing and dispensing Serostim in the outpatient setting. Serostim is FDA approved for the treatment of AIDS wasting and cachexia. Prescribers and pharmacies have been notified by direct mail of the prior authorization requirements.

• Prescribers will be responsible for obtaining the prior authorization number by calling the toll free prior authorization telephone number and answering questions regarding the Serostim prescription. The toll free number is: (877) 309-9493.
• The eight-digit prior authorization number must be entered on the face of the prescription along with the prescriber submitted MMIS or license number and can be filled at any NYS Medicaid enrolled pharmacy that stocks the drug.
• Prior authorizations will be limited to a maximum 28 injections(28 day supply), with no refill
• To continue treatment, the patient must be re-examined, with a positive therapeutic response documented, before another prior authorization is requested.
• Telephone and fax orders for Serostim will be allowed. The prescriber is required to provide the pharmacy with the original script within 5 business days.
• A prescription may not be filled unless the pharmacy provider calls the prior authorization system and submits the necessary information first.

Additional information regarding the Serostim prior authorization requirements will be in upcoming editions of the Medicaid Update.

Questions regarding this article, coverage of Serostim, and the prior authorization process, may be directed to the Pharmacy Policy and Operations Unit at (518) 486-3209.

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Please place a copy of this notice in your MMIS Provider Manual. Questions may be referred to the Bureau of Medical Review and Payment at (518) 474-8161.

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Certain pharmaceutical items have been determined not to be included within the drug cost components of Article 28 Nursing Facility rates and Child (Foster) Care Agency rates.

The listing on the following pages updates the May 2001 Medicaid Update and includes additions that have been determined not to be included within the drug cost components of Article 28 Nursing Facility Rates and Child (Foster) Care Agency Rates. Claims for drugs on this list may be billed directly to Medicaid by a Medicaid Management Information System (MMIS) enrolled pharmacy. If a drug has an "NH" indicator, it is included on the Nursing Home Carveout List. If a drug has an "FC" indicator, it is included on the Child (Foster) Care Carveout List.

Questions regarding the addition of drugs to the Nursing Home Carveout List may be addressed to Health Systems Management at (518) 474-1988.
Questions regarding the Child (Foster) Care Carveout List may be addressed to Gail Charlson at (518) 474-6398.
Questions regarding submission of pharmacy claims may be addressed to Computer Sciences Corporation at (800) 522-5535.

NDC CODE	NAME OF DRUG	NH START	FC START
00597004724	Viramune Susp 50mg/ml	NH 8/1/2001	FC 8/1/2001
00597004601	Viramune Tab 200mg	NH 8/1/2001	FC 8/1/2001
00597004660	Viramune Tab 200mg	NH 8/1/2001	FC 8/1/2001
00013264902	Gentropin Inj 0.2mg		FC 8/1/2001
00013265002	Gentropin Inj 0.4mg		FC 8/1/2001
00013265102	Gentropin Inj 0.6mg		FC 8/1/2001
00013265202	Gentropin Inj 0.8mg		FC 8/1/2001
00013265302	Gentropin Inj 1.0mg		FC 8/1/2001

PRODUCT	CODE
Parenteral nutrition solution; carbohydrates (Dextrose), 50% or less (500 ml = I Unit) - Homemix	B4164
Parenteral nutrition solution; Amino Acid, 3.5%, (500 ml = I Unit) - Homemix	B4168
Parenteral nutrition solution; Amino Acid, 5.5% through 7%, (500 ml = I Unit) - Homemix	B4172
Parenteral nutrition solution; Amino Acid, 7% through 8.5%, (500 ml = I Unit) - Homemix	B4176
Parenteral nutrition solution; Amino Acid, greater than 8.5% (500 ml = I Unit) - Homemix	B4178
Parenteral nutrition solution; carbohydrates (Dextrose), greater than 50% (500 ml = I Unit) - Homemix	B4180
Parenteral nutrition solution; Lipids, 10% with administration set (500 ml = I Unit)	B4184
Parenteral nutrition solution, Lipids, 20% with administration set (500 ml = I Unit)	B4186
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 10 to 51 Grams of protein - Premix	B4189
Parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements, and vitamins, including preparation, any strength, 52 to 73 Grams of protein - Premix	B4193

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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