DOH Medicaid Update February 2001 Vol.16, No.2

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The New York State Department of Health is pleased to announce an increase in certain rates for the HCBS/TBI Waiver effective April 1, 1999 and April 1, 2000. The following rates have been raised:

1. Independent Living Skills (Rate Code 9858) from $30 to $31 per hour effective April 1, 1999 and from $31 to $32 per hour effective April 1, 2000.
2. Substance Abuse Program (Rate Code 9859) from $160 to $165 per full day effective April 1, 1999 and from $165 to $170 per full day effective April 1, 2000.
3. Intensive Behavioral Program (Rate Code 9860) from $45 to $46 per hour effective April 1, 1999 and from $46 to $48 per hour effective April 1, 2000.
4. Community Integration Counseling (Rate Code 9861) from $60 to $62 per hour effective April 1, 1999 and from $62 to $64 per hour effective April 1, 2000.
5. Home and Community Support Service (Rate Code 9863) from $15 to $15.45 per hour effective April 1, 2000.
6. Respite, Per Diem (Rate Code 9875) from $288 to $297 per day effective April 1, 1999 and from $297 to $306 per day effective April 1, 2000.

These increases are retroactive to April 1, 1999 and April 1, 2000. Checks reflecting the retroactive payment will be sent to providers. For further information, please contact Mr. Bruce Rosen, Bureau of Medicaid Operations, Office of Medicaid Management, at 518-474-6580.

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The following list of enteral formulae is provided as a guideline for dispensers when the prescriber has ordered an enteral formula using a brand name. This is not an all-inclusive list, but is meant to assist providers in determining the correct item code for use in MMIS billing. Powdered, liquid and fiber-added forms of the same formula are billed under the same code. For products not listed below, providers are to use their judgment in selecting the appropriate product classification based upon the physician's order and the general categorical descriptions.

The calculation for pricing Enteral Therapy is as follows: Number of calories per can divided by 100 = number of caloric units per can. Medicaid will pay for up to 600 caloric units per item code per month. Each claim for B4150-B4156, Z2111 and Z2112 requires an EMEVS Dispensing Validation System (DVS) number. B9998 requires prior approval.

Please keep this information in the Enteral Therapy section of your MMIS Provider Manual.

PRODUCT	CODE
Accupepha	B4153
Acerflex	B4154
Advera	B4154
Alimentum	B4154
Alitraq	B4154
Amin-Aid	B4154
Analog Formulas	B4154
Apple Fiber	B9998
Aquasol E	B9998
ATMF	B4150
Attain	B4150
Bio-care	B4150
Boost	B4150
Boost High Protein	B4150
Boost Plus	B4152
Boost Pudding	B4150
Casec	B4155
Choice DM	B4154
Citrisource	B4150
Citrotein	B4154
Compleat Modified	B4151
Compleat Pediatric	B4151
Compleat-B	B4151
Comply	B4152
Criticare-HN	B4153
Crucial	B4154
Cyclinex-1	B4154
Cyclinex-2	B4154
Deliver 2.0	B4152
Diabetisource	B4154
Duocal	B4154
Egg/Pro	B4155
EleCare	B4153
Elemental 028 Extra	B4154
Elementra	B4155
Enfamil AR	B9998
Enlive	B4150
Enriched Antiox. Formula	B4155
Ensure	B4150
Ensure High Protein	B4150
Ensure HN	B4150
Ensure Light	B4150
Ensure Plus	B4152
Ensure Plus HN	B4152
Ensure Pudding	B4150
Ensure w/Calcium	B4150
Entera	B4150
Entera Isotonic	B4150
Entera OPD	B4154
Enteralife HN	B4150
Enteralife HN-2	B4150
Entrition 1.5	B4152
Entrition HN	B4150
Epulor	B4152
Essential Pro Plus	B4155
Essential Protein	B4155
Fiberlan	B4150
Fibersource	B4150
Fibersource HN	B4150
Flavonex	B9998
Forta Drink	B4150
Forta Shake	B4150
Fortison	B4150
Gevral Protein	B4155
Glucerna	B4154
Glucerna OS	B4154
Gluco-Pro	B4154
Glutamine-Plain	B4155
Glutamine-Regular	B4155
Glutasorb RTU	B4153
Glytrol	B4150
Hearty Balance	B4150
Hepatic-Aid	B4154
Hom-2	B4155
HPF Plus	B4155
Immun-Aid	B4154
Immune System Boost	B4155
Immunocal	B4155
Impact	B4154
Impact 1.5	B4154
Impact Oral	B4154
Imu-Plus	B4155
Introlite	B4150
Isocal	B4150
Isocal HN Plus	B4150
Isocal II	B4150
Isocal-HN	B4150
Isofiber	B4150
Isolan	B4150
Isomil	B4150
Isosource	B4150
Isosource 1.5	B4152
Isosource VHN	B4154
Isosource-HN	B4150
Isotein-HN	B4153
Jevity	B4150
Jevity Plus	B4150
Juven	B4155
Kindercal	B4150
LactAid tablets	B9998
L-Emental	B4153
L-Emental Hepatic	B4154
L-Emental Pediatric	B4153
Lipisorb	B4154
Lipomul	B4155
Lofenelac	B4154
Lonalac	B4150
Lorenzo Oil	B4154
Magnacal Renal	B4154
Maxamaid	B4154
Maxamum	B4154
MCT Oil	B4155
Meritene	B4150
Microlipid	B4155
Moducal	B4155
MSUD Diet	B4154
MSUD Maxamum	B4154
MSUD-1	B4154
MSUD-2	B4154
Naturite	B4150
Naturite Plus	B4152
NeoCalglucon	B9998
Neocate	B4153
Neocate One +	B4153
Nepro	B4154
Neutra-Phos	B9998
Newtrition (flavors)	B4150
Newtrition 1.5	B4152
Newtrition HN	B4150
Newtrition Isofiber	B4150
Newtrition Isotonic	B4150
Nitrolan	B4150
NovaSource 2.0	B4152
NovaSource Pulmonary	B4154
Novasource Renal	B4154
NuBasics 2.0 Complete	B4152
NuBasics Juice Drink	B4150
NuBasics Plus	B4152
NuBasics VHP	B4150
Nutramigen	B4150
Nutrassist-1.5	B4152
Nutren Junior	B4150
Nutren-1	B4150
Nutren-1.5	B4152
Nutren-2	B4152
Nutri-Drink	B4150
Nutri-Drink Plus	B4152
Nutrihep	B4154
Nutrilan	B4150
NutriRenal	B4154
NutriVent	B4154
NutriVir	B4153
Optimental	B4153
OS 1	B4154
OS 2	B4154
Osmolite	B4150
Osmolite-HN	B4150
Osmolite-HN Plus	B4150
Pediasure	B4150
Peptamen	B4154
Peptamen 1.5 Diet	B4153
Peptamen Jr	B4154
Peptamen VHP	B4154
Peptical	B4153
Perative	B4154
Periflex	B4154
Phenex 1	B4154
Phenex 2	B4154
PhenyAde	B4154
Phenylfree	B4154
Phlexy-10 Capsules	B4155
Phlexy-10 Drink Mix	B4155
PKU2	B4154
Polycose	B4155
Portagen	B4150
Pregestimil	B4154
ProBalance	B4150
ProCel	B4155
Product 3232A	B4155
Product 80056	B4154
Profiber	B4150
Promix	B4155
ProMod	B4155
Promote	B4150
Propac	B4150
Pro-Peptide	B4154
Pro-Peptide VHN	B4154
Pro-Phree	B4155
Propimex 1	B4154
Propimex 2	B4154
ProSobee	B4151
Protain XL	B4154
Provide	B4154
ProViMin	B4154
Pulmocare	B4154
Reabilan	B4153
Reabilan-HN	B4154
ReGain Plus	B4154
Renalcal	B4154
Re-Neph	B4154
Re-Neph Free	B4154
Replete	B4154
Resource	B4150
Resource Arginaid	B4155
Resource Diabetic	B4150
Resource for Kids	B4150
Resource Fruit Beverage	B4150
Resource Plus	B4152
Resource Protein Powder	B4155
Resource Select	B4154
Respalor	B4152
Restore-X	B4155
Ross Carbohydrate Free	B4155
Sandosource Peptide	B4154
Scandi-Shake	B4152
SLD	B4154
SoyPro	B4155
Stresstein Powder	B4154
Subdue	B4153
Subdue Plus	B4153
Sumacal	B4155
Suplena (Replena)	B4154
Sustacal	B4150
Sustacal Plus	B4152
Sustacal Pudding	B4150
Sustacal w/ fiber	B4150
Sustagen	B4150
Sympt-X Glutamine	B4155
Tolerex	B4156
Traumacal	B4154
Traum-Aid HBC	B4154
Travasorb Hepatic	B4154
Travasorb -MCT	B4154
Travasorb Renal	B4154
Travasorb Standard	B4156
Travasorb-HN	B4153
TwoCal-HN	B4152
Ultracal	B4150
Ultracal HN Plus	B4150
Ultracare for Kids	B4154
Ultralan	B4152
Vital-HN	B4153
Vitaneed	B4151
Vivonex flavor packets	B9998
Vivonex Pediatric	B4153
Vivonex Plus	B4154
Vivonex Standard	B4156
Vivonex-TEN	B4154
XMET Maxamaid	B4154
XMET Maxamum	B4154
XP Maximum	B4154
Food Thickener (eg Thick-It) regular strength per oz	Z2111
Food Thickener (eg Thick-It) concentrated per oz	Z2112

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Participation in the Medicaid Program is defined by New York State Regulation 18 NYCRR 504.1(d)(16) as the ability and authority to furnish care, services or supplies to eligible recipients and to receive payment from the medical assistance program for such care, services or supplies.

Employees of Diagnostic and Treatment Centers are not eligible to receive "fee-for-service" payment as individual providers for services provided in the clinic. The costs of physician services are included in the calculation of the Medicaid threshold visit rate which is the rate paid by the Medicaid Program to the center. Physicians may be eligible for enrollment as a "fee-for-service" provider if they provide hospital inpatient services and the clinic rate does not include this service. Reimbursement for these services can only be made to the individual practitioner and not to the clinic or a group owned by the clinic. Therefore, enrollment is needed only if a practitioner needs to bill "fee-for-service".

Employees of a hospital may or may not be eligible to receive "fee-for-service" payments. The determination is based on whether physician costs are included in the Medicaid rate paid to the hospital for patient services. Therefore, before a determination can be made regarding an application for enrollment, a letter signed by the facility's chief financial officer must be submitted which explains the complete details of how physician costs are reported in the hospital's Institutional Cost Report. If, based on this process, you determine that you are able to bill for these services, you must bill consistent with the provisions below.

If an application for enrollment is received and "fee-for-service" payment is not needed, the application will be returned to the applicant with a letter of explanation.

Physicians or other practitioners may not bill the Medicaid program for a $30 "office visit" for a service rendered in a hospital or clinic. Services rendered in hospital inpatient or outpatient settings, if billable based on the preceding paragraph, may be billed only with the appropriate hospital visit code (see MMIS Provider Manual, pages 7-3, 7-22 and 7-30).

Exception to the above may exist where a physician orders in excess of $75,000 in ambulatory services. These services may include pharmacy, laboratory services and durable medical equipment. If a physician reaches this amount for ordered services, the physician may be required to enroll as a non-biller. The Department of Health will determine if enrollment is required and the physician will be sent an application with an explanation of why enrollment is necessary.

If you have any questions, please contact Ms. Patricia Meyer, Bureau of Enrollment at (518) 486-9440.

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New research suggests that performing fasting plasma glucose tests in the afternoon rather than the morning to diagnose diabetes may mean some cases are missed. According to research published in the December 27, 2000 edition of "The Journal of the American Medical Association", doctors who give their afternoon patients the fasting plasma glucose test are likely to miss half of the diabetes cases in this group. In this study, the afternoon patients had blood glucose levels suggestive of diabetes at half the rate of the morning group.

Current recommendations for diagnosing diabetes are that patients have their blood sugar tested after an overnight fast of at least eight hours.

The Medicaid program reimburses for medically necessary care, services, and supplies for the diagnosis and treatment of diabetes. For information regarding Medicaid payment of these services, please contact the Bureau of Program Guidance at (518) 474-9219.

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Asthma is a chronic disease which has shown striking increases in incidence and prevalence. In New York State, asthma represents a major expense to the Medicaid program and is second only to obstetrical admissions as a leading cause of hospitalizations by dollars spent. To address this major public health concern, the National Institutes of Health's (NIH) National Heart, Lung and Blood Institute published "Guidelines for the Diagnosis and Management of Asthma".

As presented by the Expert Panel Report II, the goals of asthma treatment are to:

• Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the night, in the early morning, or after exertion)
• Maintain (near) "normal" pulmonary function
• Maintain normal activity levels (including exercise and other physical activity)
• Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits or hospitalizations
• Provide optimal pharmacotherapy with minimal or no adverse effects
• Meet patients' and families' expectations of, and satisfaction with, asthma care

The following tables, adapted from the Expert Panel Report II, "Guidelines for the Diagnosis and Management of Asthma", are stepwise approaches for managing asthma in infants and young children five years of age and younger, and adults and children older than five years of age. In the continuing effort to make Medicaid recipients with asthma healthier, the New York State Medicaid program provides reimbursement

	Days with Symptoms	Nighttime Symptoms	Long-Term Control	Quick Relief
Step 4 Severe Persistent	Continual symptoms	Frequent	Daily anti-inflammatory medicine High-dose inhaled corticosteroid with spacer/holding chamber and face mask If needed, add systemic corticosteroids 2mg/kg/day and reduce to lowest daily or alternate-day dose that stabilizes symptoms	Bronchodilator as needed for symptoms (see step 1) up to 3 times a day
Step 3 Moderate Persistent	Daily symptoms	greater than or equal to 5 times a month	Daily anti-inflammatory medication. Either: Medium- dose inhaled corticosteroid with spacer/holding chamber and face mask OR, once control is established: Medium- dose inhaled corticosteroid and nedocromil, OR Medium-dose inhaled corticosteroid and long-acting bronchodilator (theophylline)	Bronchodilator as needed for symptoms (see step 1) up to 3 times a day
Step 2 Mild Persistent	Symptoms 3-6 times a week	3-4 times a month	Daily anti-inflammatory medication. Either: Cromolyn (nebulizer is preferred; or MDI) or nedocromil (MDI only) Infants and young children usually begin with a trial of cromolyn or nedocromil, OR Low-dose inhaled corticosteroid with spacer/holding chamber and face mask	Bronchodilator as needed for symptoms (see step 1)
Step 1 Mild Intermittent	Symptoms less than or equal to twice a week	less than or equal to twice a month	No daily medication needed.	Bronchodilator as needed for symptoms less than or equal to 2 times a week. Intensity of treatment will depend upon severity of exacerbation. Either: Inhaled short-acting beta2-agonist by nebulizer or face mask and spacer/holding chamber, OR Oral beta2-agonists for symptoms With viral respiratory infection Bronchodilator q 4-6 hours up to 24 hours (longer with physician consult) but, in general, repeat no more than once every 6 weeks Consider systemic corticosteroid if Current exacerbation is severe, OR Patient has history of previous severe exacerbations

Step Down
Review treatment every 1 to 6 months. If control is sustained for at least 3 months, a gradual stepwise reduction in treatment may be possible.

Step Up
If control is not achieved, consider step up. But first: review patient medication technique, adherence, and environmental control (avoidance of allergens or other precipitant factors).

Note:

• The stepwise approach presents general guidelines to assist clinical decision-making. Asthma is highly variable; clinicians should tailor specific medication plans to the needs and circumstances of individual patients.
• Gain control as quickly as possible; then decrease treatment to the least medication necessary to maintain control. Gaining control may be accomplished by either starting treatment at the step most appropriate to the initial severity of their condition or starting at a higher level of therapy (e.g., a course of systemic corticosteroids or higher dose of inhaled corticosteroids).
• A rescue course of systemic corticosteroid (prednisolone) may be needed at any time and at any step.
• In general, use of short-acting beta2-agonist on a daily basis indicates the need for additional long-term- control therapy.
• It is important to remember that there are very few studies on asthma therapy for infants.
• Consultation with an asthma specialist is recommended for patients with moderate or severe persistent asthma in this age group. Consultation should be considered for all patients with mild persistent asthma.

Adapted from: 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), and The U.S. Department of Health and Human Services, Public Health Service, National Institute of Health, National Heart, Lung and Blood Institute, NIH Publication NO. 99-4055B, June 1999.

Source: NYS Department of Health, Office Of Medicaid Management

Stepwise Approach for Managing Asthma in Adults and Children Older Than Five Years of Age

Severity Classification				Treatment (Preferred treatments are in bold print)
	Symptoms	Nighttime Symptoms	Peak Expiratory Flow	Long-Term Control	Quick Relief
Step 4 Severe Persistent	Continual symptoms Limited physical activity Frequent exacerbations	Frequent	less than or equal to 60% predicted variability > 30%	Daily medications: Anti-inflammatory: inhaled corticosteroid (high dose) AND Long-acting bronchodilator: either long-acting inhaled beta2-agonists, sustained-release theophylline, or long-acting beta2-agonist tablets AND Corticosteroid tablets or syrup	Short-acting bronchodilator: inhaled beta2-agonists as needed Use of a short-acting inhaled beta2-agonists daily or increasing use indicates the need for additional long-term control therapy
Step 3 Moderate Persistent	Daily symptoms Daily use of inhaled short acting beta2-agonist Exacerbations affect activity Exacerbations twice a week	> Once a week	60% - < 80% predicted variability > 30%	Daily medication: Anti-inflammatory: inhaled corticosteroid (medium dose) OR Inhaled corticosteroid (low-medium dose) and a long-acting bronchodilator, especially for nighttime symptoms; either long-acting inhaled beta2-agonists, sustained-release theophylline, or long-acting beta2-agonist tablets	Short-acting bronchodilator: inhaled beta2-agonists as needed Use of a short-acting inhaled beta2-agonists daily or increasing use indicates the need for additional long-term control therapy
Step 2 Mild Persistent	Symptoms > twice a week but < once a day Exacerbations may affect activity	> Twice a month	greater than or equal to 80% predicted variability 20%-30%	One daily medication: Anti-inflammatory: inhaled corticosteroid (low dose) or cromolyn or nedocromil (children usually begin with a trial of cromolyn or nedocromil). Sustained-release theophylline is an alternative but not preferred. Zafirlukast, zileuton or montelukast may also be considered for patients greater than or equal to 12 years of age.	Short-acting bronchodilator: inhaled beta2-agonists as needed Use of a short-acting inhaled beta2-agonists daily or increasing use indicates the need for additional long-term control therapy
Step 1 Mild Intermittent	Symptoms less than or equal to twice a week Asymptomatic and normal peak expiratory flow between exacerbations Exacerbations brief	less than or equal to Twice a month	greater than or equal to 80% predicted variability < 20%	No daily medication needed.	Short-acting bronchodilator: inhaled beta2-agonists as needed Inhaled beta2-agonists or cromoglycate before exercise or exposure to allergen Use of a short-acting inhaled beta2-agonists > twice a week may indicate the need to initiate long-term control therapy

Step Down
Review treatment every 1 to 6 months; a gradual stepwise reduction in treatment may be possible.

Step Up
If control is not maintained, consider step up. First, review patient medication technique, adherence, and environmental control (avoidance of allergens or other factors that contribute to asthma severity).

NOTE:

• The stepwise approach presents general guidelines to assist clinical decision-making; it is not intended to be a specific prescription. Asthma is highly variable; clinicians should tailor specific medication plans to the needs and circumstances of individual patients.
• Gain control as quickly as possible; then decrease treatment to the least medication necessary to maintain control. Gaining control may be accomplished by either starting treatment at the step most appropriate to the initial severity of the condition or starting at a higher level of therapy (e.g., a course of systemic corticosteroids or higher dose of inhaled corticosteroids).
• A rescue course of systemic corticosteroids may be needed at any time and at any step.
• Some patients with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. This may be especially common with exacerbations provoked by respiratory infections. A short course of systemic corticosteroids is recommended.
• At each step, patients should control their environment to avoid or control factors that make their asthma worse (e.g., allergens, irritants); this requires specific diagnosis and education.
• Referral to an asthma specialist for consultation or co-management is recommended if there are difficulties achieving or maintaining control of asthma or if the patient requires Step 4 care. Referral may be considered if the patient requires Step 3 care.

Adapted from: 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).

Source: NYS Department of Health, Office Of Medicaid Management

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The following information on secondhand smoke is intended for patient use. Please feel free to copy this article and distribute this information to your patients.

Secondhand Smoke In Your Home

More time is spent in our homes than anywhere else; so the thought of cancer-causing chemicals circulating throughout our houses and apartments can be disturbing. Yet, according to the Environmental Protection Agency, that is exactly what happens when someone lights a cigarette in your home.

Children and Secondhand Smoke

• Because children's bodies are still developing, exposure to the poisons in secondhand smoke can interfere with the growth of their lungs.
• Children exposed to secondhand smoke face an increased risk for ear infections and for respiratory infections, such as bronchitis and pneumonia. These children take longer to recover from such illnesses.
• Secondhand smoke increases the number and severity of asthma attacks in asthmatic children and can cause asthma in children with no previous signs of asthma.

How to Make (and Keep) Your Home Smoke-Free

• Put a sign in your home and vehicle telling people it is a smoke-free environment. Call the American Cancer Society for more information. (1-800-ACS-2345).
• Tell people not to smoke in your home - No one wants to make guests uncomfortable, but if you simply explain the facts about secondhand smoke, they should understand completely.
• Tell people they can smoke outside, if they absolutely must smoke. Tell them that for the sake of your family's health, you simply cannot allow smoking in your home.
• Encourage household members to stop smoking. If someone in your household smokes, let that person know you care and you want to help, but cigarette smoke affects everyone, not just the smoker. Again, if someone absolutely must smoke, insist that they do so outside.

Don't Forget Schools and Day Care

• Make sure your child's school and day care program are smoke-free. Insist that babysitters not smoke around your children.

The NYS Smokers Quitline offers a cost-free Secondhand Smoke Packet for patients. For more information call
1-866-NYQUITS (1-866-697-8487).

Reminder: 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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Each patient with asthma should have an individualized action plan which is initiated by the practitioner. This written plan for guided self-management is a useful tool which allows individuals with asthma to take control of their asthma. The action plan directs patients to adjust their medications and take action depending on their symptoms and peak flow readings.

Components of an asthma action plan should include:

• Self management of asthma symptoms including what to do when:
  • the patient awakens at night with symptoms
  • the patient needs to increase treatments to manage asthma symptoms
  • the patient experiences early warning signs of an asthmatic episode
• Peak flow recordings and a guide to the three color management zones
• Asthma medications and when to take control medications, preventive medications, and rescue medications
• Emergency contact numbers including physician, ambulance, and nearest emergency department
• Specific instructions such as:
  • when to call the physician
  • when to seek emergency care
  • when a bronchodilator treatment is not relieving symptoms
  • when or if inhaled steroids should be increased
  • when or if oral steroids should be started

The Medicaid Program reimburses for medically necessary care, services, and supplies needed in the diagnosis and treatment of asthma. For information regarding Medicaid payment of these services, please contact the Bureau of Program Guidance at (518) 474-9219.

For further information regarding asthma action plans including sample action plans, the following websites are available:

• http://www.lungusa.org
• http://www.ci.nyc.ny.us/health
• http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_WhatIs.html

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Pharmacy claims will pend for 30 days for these edits while other claims will pend for 60 days (from the date of the remittance where the first pend appeared).

Edit 01154 - No UT Service Authorization Record On File - This edit fails when a Utilization Threshold (UT) service authorization record is not on file at the time a claim is initially processed. If the provider obtains the UT service authorization via Electronic Medicaid Eligibility Verification System (EMEVS) while the claim is pending for edit 01154, the UT will be found during the claim recycling process, and the claim will be adjudicated in a subsequent remittance statement. Do not resubmit pending claims.

Edit 01155 - UT Service Authorization Exhausted - This edit may occur when, for example, a lab or pharmacy obtains a partial approval and bills for more procedures/items than authorized via EMEVS. This edit may also occur, for example, when a provider has already been paid for this procedure/item or clinic visit. When a claim pends for this edit, the provider should review previous remittance statements to determine if the service has already been paid. If the service has not been previously paid, and if the provider obtains the UT service authorization while the claim is pending for edit 01155, the UT will be found during the claim recycling process, and the claim will be adjudicated in a subsequent remittance statement. Do not resubmit pending claims.

Please be aware that remittance statements are held for approximately two weeks prior to mailing. Therefore, providers who did not correctly obtain the necessary UT service authorizations prior to billing will not see claims change from pending to adjudicated status for at least two subsequent remittance statements after obtaining the UT service authorization.

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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During March 2001, revised New York State Fee Schedules will be sent to all enrolled Pharmacy and DME providers. Coding and fee changes will be effective for dates of service on or after April 1, 2001. Please review the revised Fee Schedule carefully and insert it into your MMIS Provider Manual and adjust billing accordingly. New codes are in bold type. Your July 2000 and April 1999 fee schedules should be kept on hand for billing purposes for periods of service prior to April 1, 2001. Major coding changes effective April 1, 2001 include:

Underpads/Diapers: New York Medicaid will now utilize new national codes for incontinence pants (S8400), diapers, all sizes, age three and up (S8402), and incontinence liners (S8405). These items will require EMEVS Dispensing Validation System (DVS) approval effective April 1, 2001. Do not attempt to obtain DVS approval using "Z" codes for these products after March 31, 2001.

Wound Dressings: Addition of several codes, including hydrogel gauze, alginate dressing, composite dressing and collagen dressing.

Durable Medical Equipment: Addition of several codes for parts/equipment for positive airway pressure devices, addition of codes for wheeled mobility equipment and parts, new coding for augmentative communication devices, and changes in coding for heavy duty walkers, commode chair and hospital bed.

Orthotics, Prosthetics and Prescription Footwear: Elimination of many "Z" codes to be substituted with national "L" codes. For example, all mismating shoe size claims should now be billed using code L3257 #Orthopedic footwear, additional charge for split size.

If you do not receive a revised Fee Schedule by March 15, 2001, please contact Computer Sciences Corporation, Provider Relations, at (800) 522-5535.

Questions regarding coding changes should be directed to the Bureau of Medical Review and Payment at (518) 474-8161.

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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