New York State Medicaid Update - October 2015 Volume 31 - Number 11

In this issue...

ALL PROVIDERS POLICY AND BILLING GUIDANCE PHARMACY UPDATE PROVIDER DIRECTORY
ALL PROVIDERS

Attention Long Island Medical Providers and Transportation Vendors
Fee-for-Service Transportation Management Includes the Offices of Mental Health and People with Developmental Disabilities

Historically, the transportation of enrollees residing on Long Island whose Medicaid eligibility is with the New York State Office of Mental Health (OMH, county code 97) or Office for People With Developmental Disabilities (OPWDD, county code 98) has been handled in one of two ways:

1. When the cost of transportation is included in the rate paid to a Medicaid facility (e.g., adult day health care, day habilitation, etc.), that facility arranges transportation to and from that location;
-or-

2. When transportation is fee-for-service (FFS), prior authorization is generated by the OMH or OPWDD central office staff located in Albany.

Effective December 1, 2015, the management of FFS transportation for OMH and OPWDD enrollees residing in the following counties will be undertaken by our Long Island transportation manager, LogistiCare Solutions (LGTC):

  • Nassau
  • Suffolk

For dates of service on or after December 1, 2015, the ordering medical provider must seek authorization from LGTC instead of central office staff of OMH or OPWDD. Staff in each agency's Albany-based central office will not process prior authorization requests with service dates on or after December 1, 2015. To secure approval prior to the trip, please call LGTC at (844) 678-1103. Payment for trips performed without prior approval from LGTC may be denied.

Ambulance vendors providing emergency transport to these enrollees must seek authorization from LGTC for the correct reimbursement within 90 days of the date of service.

Information regarding Medicaid transportation, including required forms and a list of participating transportation vendors, is available online at: https://www.longislandmedicaidride.net.

The LGTC outreach team is available to discuss the new transportation processes onsite at each facility. To request an onsite visit, please call LGTC at (844) 678-1101.

Questions? Please contact the Medicaid Transportation Unit at (518) 473-2160 or via email to MedTrans@health.ny.gov.

New York State Medicaid Management Information System (NYMMIS) Update Provider Training Opportunities

The New York State Department of Health and Xerox Healthcare, LLC, are pleased to announce that training opportunities are now available for the new New York State Medicaid Management Information System - NYMMIS.

The interim website, www.interimnymmis.com is the source for the most current information on NYMMIS. The current schedule of training sessions is available under the Training and Events Calendar link on the website.

As previously advised in the August 2015 Medicaid Update, training includes a variety of in-person and web- based learning sessions, with the in-person sessions offered in several regional locations. In addition, training opportunities will be available in a variety of methods including self-taught computer based training and on-site provider training by field representatives from Xerox. The Training and Events Calendar will be updated as additional sessions are scheduled.

Current Training Session Descriptions:

  • Introduction to NYMMIS - A course for first time users with a focus on understanding the basic system elements and how they work.
  • NYMMIS Features and Functionality - a course to learn the basic features and functionality of NYMMIS including how to login, page layout, working with tables, how to enter information, and key links.
  • Introduction to Provider Enrollment - For new Provider Enrollments only - Learn how to use the NYMMIS to complete an electronic enrollment.
  • Enterprise Login and Navigation - External users will be shown how to login and navigate the MMIS.

The Training and Events Calendar will display a complete list of all training dates, times, and locations. All efforts are being taken to develop the trainings in a manner that will maximize learning and minimize impact to the provider.

To sign up for training on the new system, please send registration requests via email to USA.all.nymmis.training.inquiries@xerox.com, with the following information: attendee name, organization, email address, phone number, requested date, time, and location. Classroom sizes are limited and will be confirmed on a first come, first served basis.

In addition, to stay up-to-date on future announcements as well as additional training sessions and topics, please sign up for the ListServ on the interim site. www.interimnymmis.com

NY Medicaid EHR Incentive Program Update

The NY Medicaid Electronic Health Record (EHR) Incentive Program provides financial incentives to eligible professionals and hospitals to promote the transition to EHRs. Providers who practice using EHRs are in the forefront of improving quality, reducing costs and addressing health disparities. Since December 2011 over $718 million in incentive funds have been distributed within 20,849 payments to New York State Medicaid providers.

20,849 Payments.

$718 Million Paid.

Are you eligible? For more information, visit www.emedny.org/meipass

New website design

We are pleased to announce the launch of the redesigned NY Medicaid EHR Incentive Program website at www.emedny.org/meipass. Now you can easily navigate the website on your mobile devices.

Pre-validation Services for 2015

Don't delay! Pre-validation is available to both individual and group providers that have already determined their Medicaid patient volume for payment year 2015. Contact hit@health.ny.gov to request a pre-validation file. Please make sure to include your NPI and patient volume method (individual or group aggregate).

Note: We cannot review Medicaid data that is within the past 90 days because this clearance period is needed for claims to be processed and finalized.

Questions? Contact hit@health.ny.gov for program clarifications and details.

Get Smart (Know When Antibiotics Work) Campaign

Your patient sits miserably before you, sneezing, with a runny nose, and a productive cough. She is pleading with you to "just give me a pill" that will make her better and allow her to have one night's uninterrupted sleep.

So, to keep the patient happy, you consider prescribing an antibiotic, right? Even though you know deep down that antibiotics don't work on viral infections (and it's likely that's exactly what this upper respiratory infection is).

Don't do it! Says the New York "Get Smart (Know When Antibiotics Work) Campaign".

The "Get Smart" Campaign is a collaborative effort between the New York State Department of Health (NYSDOH) and the Centers for Disease Control and Prevention (CDC). CDC has provided grant funding to New York State in an effort to combat antibiotic resistance and the "superbugs" that arise from avoidable prescribing of antibiotics. The concern is that we face a frightening future where many antibiotics we have come to rely on to fight infection will no longer be effective.

The issue is timely: in March, the White House issued a "National Action Plan for Combating Antibiotic- Resistant Bacteria." And in June, there was a White House summit on the critical need to combat these "superbugs".

To get a handle on where New York stands, the New York "Get Smart (Know When Antibiotics Work) Campaign" analyzed 2013 Medicaid claims data on prescribing for adult upper respiratory infections and found that in 11 counties in New York State, over 55 percent of provider visits resulted in antibiotics being prescribed for adults with upper respiratory infections (URIs). URIs are generally viral in nature, meaning antibiotics would be ineffective treatment.

In July, DOH sent out a "Dear Provider" letter to all providers in those counties who might prescribe antibiotics in their daily practices, regardless of whether or not as individuals, they were high prescribers. This outreach allows all prescribers to join forces to combat high rates of avoidable antibiotic prescribing. The map (on page 6 of this newsletter), with data from the 11 counties, accompanied the letter.

Some healthcare providers say they prescribe antibiotics even when they know they are not indicated because of pressure from patients for a post-office visit "takeaway". There is concern that they might get negative reviews on patient satisfaction forms if patients are denied antibiotics.

The provider letter was intended to:

If you are interested in joining the "Get Smart" effort in New York State or becoming a "champion" of appropriate antibiotic prescribing (setting an example helps every community), please contact Mary Beth Wenger, Project Coordinator of the New York "Get Smart" Campaign at 518-474-1036 or email her at: marybeth.wenger@health.ny.gov And don't hesitate to get involved in national "Get Smart Week" (November 16-22). Follow this link to learn how you and your practice can join in: http://www.cdc.gov/getsmart/week/index.html.

Potentially Avoidable Outpatient Map (PDF,1pg)

POLICY AND BILLING GUIDANCE

New York State Medicaid Coverage of Testing for Lynch Syndrome

This article clarifies coverage by New York State (NYS) Medicaid Fee-For-Service (FFS) and Medicaid Managed Care (MMC) of genetic testing for Lynch Syndrome DNA mismatch repair (MMR) gene mutations (MLH1, MSH2, MSH6, and PMS2). The billing guidance outlined in this article is effective as of November 1, 2015 for FFS and January 1, 2016 for MMC.

General Background:

Lynch Syndrome, also known as hereditary nonpolyposis colorectal cancer or HNPCC, is the cause of approximately 3 percent (1 in 30) of cases of colorectal cancer. Patients identified with Lynch Syndrome have an increased risk for developing colorectal and extracolonic cancers in a variety of tissues before 50 years of age. This genetic condition is usually caused by an inherited mutation in a DNA MMR gene. First degree relatives of an individual positive for a MMR mutation have a 50 percent chance of inheriting the mutation.

Approximately 70 percent of individuals affected by Lynch Syndrome have mutations in the MLH1 or MSH2 gene. As a result, MSH6 testing should only be performed following a negative test result in the MLH1 and MSH2 genes.

Reimbursement

Reimbursement is available for initial screening of the MLH1 and MSH2 genes when medical criteria are met. Reimbursement for testing of the MSH6 gene is available only following a negative test result in the MLH1 and MSH2 genes. Similarly, testing of the PMS2 gene is only covered following a negative test result in the MLH1, MSH2 and MSH6 genes. Testing is to be reflexed, and it should be indicated on the laboratory requisition form that a new order is not required. This policy does not apply to Lynch Syndrome testing for known familial variants represented by CPT codes: 81293, 81296, 81299 and 81318.

Criteria:

Genetic testing for Lynch Syndrome mutations will be covered when one or more of the following criteria are met:

  • Individuals diagnosed with colorectal cancer (CRC) under age 70.
  • Individuals age 70 or older who meet the Bethesda criteria outlined below as applicable.
  • Women who were diagnosed with endometrial cancer at less than 50 years of age.
  • Individuals who meet the Amsterdam II criteria outlined below.

Revised Bethesda Guidelines for testing colorectal tumors for microsatellite instability (Adapted from National Comprehensive Cancer Network Guidelines [NCCN], 2015)

  • Colorectal cancer diagnosed in a patient less than 50 years old.
  • Presence of synchronous, metachronous colorectal, or other Lynch Syndrome-associated* tumors, regardless of age.
  • Colorectal cancer with microsatellite instability-high histology** diagnosed in a patient who is less than 60 years old.
  • Colorectal cancer diagnosed in a patient with one or more first-degree¹ relatives with a Lynch Syndrome-associated tumor, with one of the cancers being diagnosed under 50 years of age.
  • Colorectal cancer diagnosed in a patient with two or more first or second-degree² relatives with Lynch Syndrome-associated tumors, regardless of age.
  • Lynch Syndrome-associated cancers include: colorectal, endometrial, gastric, ovarian, pancreatic, ureter and renal pelvis, biliary tract, brain (usually glioblastoma as seen in Turcot syndrome), sebaceous gland adenomas and kertatocanthomas in Muir-Torre syndrome, or carcinoma of the small bowel.

**Changes in two or more of the National Cancer Institute-recommended panels of microsatellite markers including: presence of tumor infiltrating lymphocytes, Crohn's-like lymphocytic reaction, mucinous/signet-ring differentiation, or medullary growth pattern.

Amsterdam Criteria II
(Adapted from National Comprehensive Cancer Network Guidelines [NCCN], 2015)

At least three relatives with a Lynch-syndrome associated cancer (colorectal, endometrial, small bowel, ureter or renal pelvis); all of the following criteria should be present:

  • One relative should be a first-degree1 relative of the other two;
  • At least two successive generations should be affected;
  • At least one person should be affected before age 50;
  • In the case of colorectal cancer, Familial Adenomatous Polyposis should be excluded;
  • The tumor should be verified whenever possible.

¹ 1st degree relatives: Parents, children, siblings
²2nd degree relatives: Grandparents, aunts and uncles, nieces and nephews, grandchildren and half-siblings

Current Procedural Terminology (CPT) Codes and Descriptions Associated with Testing for Lynch Syndrome

CPT CODES DESCRIPTION
81292 MLH1 (MUTL HOMOLOG 1, COLON CANCER, NONPOLYPOSIS TYPE 2) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; FULL SEQUENCE ANALYSIS
81294 MLH1 (MUTL HOMOLOG 1, COLON CANCER, NONPOLYPOSIS TYPE 2) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; DUPLICATION/DELETION VARIANTS
81295 MSH2 (MUTS HOMOLOG 2, COLON CANCER, NONPOLYPOSIS TYPE 1) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; FULL SEQUENCE ANALYSIS
81297 MSH2 (MUTS HOMOLOG 2, COLON CANCER, NONPOLYPOSIS TYPE 1) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; DUPLICATION/DELETION VARIANTS
81298 MSH6 (MUTS HOMOLOG 6 ÝE, COLI“) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; FULL SEQUENCE ANALYSIS
81300 MSH6 (MUTS HOMOLOG 6 ÝE, COLI“) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; DUPLICATION/DELETION VARIANTS
81317 PMS2 (POSTMEIOTIC SEGREGATION INCREASED 2 ÝS. CEREVISIAE“) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; FULL SEQUENCE ANALYSIS
81319 PMS2 (POSTMEIOTIC SEGREGATION INCREASED 2 ÝS. CEREVISIAE“) (EG, HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; DUPLICATION/DELETION VARIANTS

Reminders:

  • Follow-up genetic counseling should be provided to patients who test positive for a genetic condition.
  • Testing for known familial variants (represented by the following CPT codes: 81293, 81296, 81299 and 81318) continues to be covered for individuals with a first1 degree relative with a known MMR gene mutation.
  • Patient records must indicate that the individual tested has met the required criteria outlined in this guidance.
  • All documentation must be maintained for a minimum of six years for audit purposes.
  • Consistent with existing policy, NYS Regulations at 18NYCRR Section 505.7(g)(4) require that providers order tests individually. No payment will be made for tests ordered as groupings or combinations of tests. For more information on this and additional regulations pertaining to laboratory services please visit the following link: https://regs.health.ny.gov/content/section-5057-laboratory-services

Questions regarding Medicaid FFS policy should be directed to the Division of Program Development and Management at (518) 473-2160. Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee's MMC plan.

Changes in Personal/Familial History Criteria for Medicaid Breast Cancer (BRCA) Genetic Testing

<<<UPDATE>>>

This article replaces the September 2014 BRCA Genetic Testing Medicaid Update. Effective immediately, New York State Medicaid has implemented changes to the BRCA coverage policy for Medicaid recipients. Physicians, nurse practitioners, physician assistants and midwives may order this laboratory test for their patients when clinically indicated and medically necessary. The updated policy coverage criteria are listed below.

Testing for a BRCA1 or BRCA2 mutation may be appropriate in individuals with the following risk factors:

A personal history of:

  • Breast cancer (includes invasive and ductal carcinoma in situ):
    • Diagnosed at age 45 or younger;
    • Diagnosed at age 50 or younger with 1 or more close relatives* with a diagnosis of breast cancer, pancreatic cancer, or aggressive prostate cancer;
    • Diagnosed at age 50 or younger and unknown or limited family history;
    • Two or more primary tumors of the breast (includes bilateral tumors or two or more clearly separate ipsilateral primary tumors occurring either synchronously or asynchronously) when first breast cancer was diagnosed at age 50 or younger;
    • Diagnosed at age 60 or younger with triple-negative breast cancer;
    • Diagnosed at any age with 1 or more close relatives* with breast cancer at age 50 or younger;
    • Diagnosed at any age with 1 or more close relatives* with invasive ovarian cancer;
    • Diagnosed at any age with 1 or more close male relatives with breast cancer at any age;
    • Diagnosed at any age with 2 or more close relatives* with breast cancer at any age;
    • Diagnosed at any age with 2 or more close relatives* with pancreatic and/or aggressive prostate cancer; OR
    • Diagnosed at any age and of an ethnicity associated with higher mutation frequency (e.g., Ashkenazi Jewish), no additional family history may be required.
  • Breast cancer in a male at any age.
  • Invasive ovarian cancer at any age.
  • Aggressive prostate cancer at any age with 1 or more close relatives* who have been diagnosed with breast (=50 years of age), ovarian, pancreatic or aggressive prostate cancer.
  • Pancreatic cancer at any age with 1 or more close relatives* who have been diagnosed with breast (=50 years of age), ovarian, or pancreatic cancer. For individuals of Ashkenazi Jewish ancestry who have pancreatic cancer, no additional relative is needed for testing.
OR

A maternal or paternal family history of**:

  • First or second-degree relative meeting any of the above criteria;
  • Third-degree relative with breast and/or invasive ovarian cancer with 2 or more close relatives* with breast cancer (at least one with breast cancer at age 50 or younger) and/or invasive ovarian cancer;
  • Confirmed BRCA1 or BRCA2 mutation in a close relative.*

Close relative is defined as a first, second or third-degree blood relative on the same side of the family (either maternal or paternal).

  • First-degree relatives: parents, siblings, children;
  • Second-degree relatives: grandparents, aunts and uncles, nieces and nephews, grandchildren, half- siblings;
  • Third-degree relatives: great-grandparents, great-aunts and great-uncles, great-grandchildren, and first cousins.

** In individuals without a personal history of breast or ovarian cancer and with family history only, clinical judgment should be used when determining if the individual has a reasonable likelihood of a mutation. Limitations of test result interpretation should be discussed with the individual prior to testing, as part of the informed consent and genetic counseling processes.

It should be noted that, in accordance with 18 NYCRR 504.3(a) the ordering practitioner must maintain sufficient documentation regarding the required patient history to clearly support the medical necessity of the ordered test.

The criteria were developed based on a review of the National Comprehensive Cancer Network's Genetic/Familial High-Risk Assessment: Breast and Ovarian Cancer clinical practice guidelines located at www.nccn.org and http://www.nccn.org/professionals/physician_gls/pdf/genetics_screening.pdf.

Patient-specific information about cancer genetics and risk for having a BRCA1 or BRCA2 mutation can be found at http://www.health.ny.gov/diseases/cancer/genetics/index.htm.

Questions regarding Medicaid Managed Care (MMC) reimbursement and/or documentation requirements should be directed to the enrollee's MMC plan. Medicaid Fee-for-Service policy questions may be directed to the Office of Health Insurance Programs' Division of Program Development and Management at 518-473-2160.

Medicaid Disallows Payment for Outpatient and Inpatient on Same Date of Service

<<<REMINDER>>>

Medicaid utilizes a Diagnosis Related Group (DRG) payment methodology for services provided on an inpatient basis (rendered to a patient between the date of admission and date of discharge). The DRG facility payment is all inclusive and includes all services provided the patient during the inpatient stay. To enforce the policy, New York State Medicaid recently implemented a payment edit to reinforce billing policy that disallows payment for an outpatient visit concurrent with an inpatient stay.

The only exception to this policy is for emergency service procedures done in an Emergency Department. When emergency services are provided on the same date as the date of discharge and the primary diagnosis is different, the Emergency Department visit is Medicaid reimbursable.

Policy questions on this matter may be directed to the Division of Program Development and Management at 518-473-2160.

<<<UPDATE>>>
PHARMACY UPDATE

Medicaid Fee-for-Service Program Pharmacists as Immunizers Fact Sheet

Pharmacies are not able to enroll into the New York State Vaccines for Children (VFC) Program.

The Fact Sheet that was published in the August 2015 Medicaid Update has been modified accordingly, and can be accessed at the following website: http://www.health.ny.gov/health_care/medicaid/program/pharmacy.htm

Please note that pharmacies should not be billing Medicaid for those vaccines that are available to Medicaid enrollees free of charge through the VFC program. New York State Medicaid is the payer of last resort. All claims submitted to New York State Medicaid are subject to audit.

Medicaid Fee-for-Service Pharmacy Prior Authorization Programs Update

Effective October 16, 2015, the Fee-for-Service (FFS) pharmacy program implemented the following parameters for palivizumab (Synagis). These changes are the result of recommendations made by the Drug Utilization Review Board (DURB) at the September 17, 2015 DURB meeting:

Align criteria with the most recent American Academy of Pediatrics palivizumab guidelines

  • Quantity Limit: 5 doses during the respiratory syncytial virus (RSV) season; defined as October 16 to March 31 for Medicaid FFS
  • Clinical Criteria
    • For Infants aged <12 months at start of RSV season
      • Gestational age (GA) <29 weeks; or
      • Chronic lung disease (CLD) of prematurity:
        • GA <32 weeks, and
        • Requiring >21% oxygen use for =28 days post-birth; or
      • Congenital airway abnormality or neuromuscular disorder that decreases the ability to manage airway secretion; or
      • Hemodynamically significant heart disease; for example:
      • Infant with acyanotic heart disease receiving medication to control congestive heart failure and will require cardiac surgery; or
      • Infant with moderate to severe pulmonary hypertension; or
      • Potentially, infant with cyanotic heart disease, with consultation by cardiologist
  • For infants and children aged <24 months at start of RSV season
    • CLD of prematurity, and requiring medical support (oxygen, bronchodilator, diuretic, or chronic steroid therapy) within 6 months prior to start of second RSV season; or
    • Solid organ transplantation during RSV season; or
    • Profoundly immunocompromised during RSV season, for example (and not limited to):
      • Human immunodeficiency virus; or
      • Receiving treatment for cancer; or
      • Hematopoietic stem cell transplantation; or
      • On corticosteroid therapy; or
      • Any degree of lymphopenia

      The updated palivizumab (Synagis(®)) worksheet provides instructions for completing the prior authorization process.

      For more detailed information on the DURB, please refer to:http://www.health.ny.gov/health_care/medicaid/program/dur/index.htm

      Below is a link to the most up-to-date information on the Medicaid FFS Pharmacy Prior Authorization (PA) Programs. This document contains a full listing of drugs subject to the Medicaid FFS Pharmacy Programs:https://newyork.fhsc.com/downloads/providers/NYRx_PDP_PDL.pdf

      To obtain a PA, please contact the clinical call center at 1-877-309-9493. The clinical call center is available 24 hours per day, 7 days per week with pharmacy technicians and pharmacists who will work with you, or your agent, to quickly obtain a PA.

Provider Directory

Office of the Medicaid Inspector General:
For suspected fraud complaints/allegations, call 1-877-87FRAUD, (877) 873-7283, or visit www.omig.ny.gov.

Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules:
Please visit the eMedNY website at: www.emedny.org.

Providers wishing to listen to the current week's check/EFT amounts:
Please call (866) 307-5549 (available Thursday PM for one week for the current week's amount).

Do you have questions about billing and performing MEVS transactions?
Please call the eMedNY Call Center at (800) 343-9000.

Provider Training:
To sign up for a provider seminar in your area, please enroll online at: http://www.emedny.org/training/index.aspx. For individual training requests,call (800) 343-9000 or e-mail: emednyproviderrelations@csc.com.

Enrollee Eligibility:
Call the Touchtone Telephone Verification System at (800) 997-1111.

Medicaid Prescriber Education Program:
For current information on best practices in pharmacotherapy, please visit the following websites: http://www.health.ny.gov/health_care/medicaid/program/prescriber_education/presc-educationprog and http://nypep.nysdoh.suny.edu/home

Need to change your address? Does your enrollment file need to be updated because you have experienced a change in ownership? Do you want to enroll another NPI? Did you receive a letter advising you to revalidate your enrollment?
Visit http://www.emedny.org/info/ProviderEnrollment/index.aspx and choose the link appropriate for you (e.g., physician, nursing home, dental group, etc.).

Medicaid Electronic Health Record Incentive Program questions?
Contact the New York Medicaid EHR Call Center at (877) 646-5410 for assistance.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Amy Siegfried, at medicaidupdate@health.ny.gov

The Medicaid Update is a monthly publication of the New York State Department of Health.

Andrew M. Cuomo
Governor
State of New York

Howard A. Zucker, M.D., J.D.
Commissioner
New York State Department of Health

Jason A. Helgerson
Medicaid Director
Office of Health Insurance Programs