New York State Medicaid Update - April 2021 Volume 37 - Number 5

In this issue …

NYS Medicaid EHR Incentive Program: Program Close Environmental Scan Survey

Through the New York State (NYS) Medicaid Electronic Health Record (EHR) Incentive Program, Eligible Professionals (EPs) and Eligible Hospitals (EHs) in NYS that adopt, implement or upgrade Certified EHR Technology (CEHRT) and then become meaningful users of CEHRT, can qualify for financial incentives.

Program Close Environmental Scan Survey

The NYS Medicaid EHR Incentive Program is conducting two final surveys, hosted on SurveyMonkey, for participating EPs and participating EHs. All providers and organizations that have successfully attested in the program are strongly encouraged to participate. The surveys ask questions pertaining to the adoption of Meaningful Use (MU) and the impact of CEHRT as experienced by practices. Survey responses will be collected from Monday, April 5, 2021 to Monday, July 5, 2021. Aggregate data will be compiled and published. All responses will be kept anonymous.

Questions

Providers can visit the NYS EHR Incentive Program web site for additional information. Providers can contact the support team by phone at (877) 646‑5410 (Option 2) for live support or email at hit@health.ny.gov.

|top of page|

The eMedNY Edit/Error Knowledge Base Search Tool

Providers needing assistance in understanding why a Medicaid fee-for-servce (FFS) claim has pended or was denied and possible solutions to resolve the problem, can refer to the Edit/Error Knowledge Base (EEKB) Search Tool. The EEKB analyzes pended or denied claim responses returned on: paper/PDF (Portable Document Format) remittance statements, New York State (NYS) Department of Health (DOH) 835 X12 Remittance Advice Transaction, or NYS DOH 277 X12 Claim Status Response. The EEKB returns detailed explanations about specific edits, including potential causes and possible solutions to resolve the problem.

How to Use EEKB

The eMedNY EEKB Search Tool web page allows providers to filter and search the EEKB by providing information to one of the three search methods:

  1. "Search by eMedNY Edit": using the five-digit "Edit Number" found on the paper/PDF remit;
  2. "Search by HIPAA Codes": using the Claim Adjustment Reason Code/Remark Code found in 835 Remit or the Healthcare Claim Status Code/Entity Identifier Code found in the 277 claim status response; or
  3. "Search by Title Text": using the text contained in the main title/header of the EEKB.

The eMedNY EEKB Search Tool web page can also be found by selecting the "eMedNY HIPAA Support tab" from the eMedNY home web page, then selecting the last option in the drop-down menu.

|top of page|

Help Stop the Spread of COVID-19 by Sharing the COVID Alert NY App

As more New Yorkers download the State Department of Health's COVID Alert NY app every day, providers are encouraged to continue COVID Alert NY app information with partners and consumers. Together everyone can help stop the spread of this virus.

|top of page|

Reminder: Sign Up for eMedNY Training Webinars

eMedNY offers several online training webinars to providers and their billing staff, which can be accessed via computer and telephone.

Valuable provider webinars offered include:

  • ePACES for: Dental, Durable Medical Equipment (DME), Free-Standing and Hospital-Based Clinics, Home Health, Institutional, Nursing Home, Physician, Private Duty Nursing, Professional (Real-Time), Transportation, and Vision Care
  • ePACES Dispensing Validation System (DVS) for DME
  • ePACES Dispensing Validation System (DVS) for Rehabilitation Services
  • eMedNY Website Review
  • Medicaid Eligibility Verification System (MEVS)
  • New Provider / New Biller

Webinar registration is fast and easy. To register and view the list of topics, descriptions and available session dates, providers should visit the eMedNY Provider Training web page. Providers are reminded to review the webinar(s) descriptions carefully to identify the webinar appropriate for their specific training needs.

Questions

All questions regarding training webinars should be directed to the eMedNY Call Center at (800) 343‑9000.

|top of page|

The eMedNY "What's New" Website Resource Tab

eMedNY encourages all providers to routinely use the eMedNY "What's New" tab to stay updated on recent additions, updates and links to affected areas of the eMedNY website. Fee schedule updates, procedure code and prior approval guideline changes are just a few of the resources providers can access when visiting the website. For past updates and changes, providers can refer to the "Archives" section listed at the bottom of the "What's New" web page then select the desired year.

Questions

All questions regarding the "What's New" tab should be directed to the eMedNY Call Center at (800) 343‑9000.

|top of page|

Medicaid Consumer Fact Sheets Now Available

Following a recommendation from the Medicaid Redeisn Team (MRT) II, the New York State Department of Health (DOH) Office of Health Insurance Programs (OHIP) created Medicaid consumer fact sheets focused on chronic health conditions. Each fact sheet provides information regarding how a condition can help be prevented and managed, as well as relevant Medicaid benefits that can be used to help members stay healthy. Topics include sickle cell disease, diabetes, high blood pressure, asthma control, HIV-PrEP (Human Immunodeficiency Virus - Pre-Exposure Prophylaxis), and smoking cessation. Fact sheets can be found on the MRT II Policies and Guidance web page and are available in English, Spanish, Traditional Chinese, Russian, Haitian Creole, Bengali and Korean.

|top of page|

NY State of Health: Significant New Tax Credits Available Now to Lower the Cost of Health Coverage

Increased financial assistance to help pay for health insurance is now available to current and new consumers enrolling in a health plan through NY State of Health, the State's official health plan marketplace. This financial assistance is made available by the American Rescue Plan Act, which President Biden recently signed into law. More than 150,000 consumers who are already enrolled in coverage will receive increased tax credits, further lowering their health care costs.

In addition, in June 2021, NY State of Health will expand tax credits to tens of thousands of additional New Yorkers who previously did not qualify for financial assistance based on their income level. NY State of Health will provide addtional information in the coming weeks.

To allow as many consumers as possible to access these enhanced tax credits and, in light of the ongoing public health emergency, the 2021 Open Enrollment Period has been extended through December 31, 2021. Consumers can apply for coverage through the NY State of Health website, by phone at (855) 355‑5777, or by connecting with a free enrollment assistor via the NY State of Health "Find a Broker/Navigator" search tool.

Additional Information:

|top of page|

Medicaid Expands Coverage for Asthma Self-Management Training

Effective April 1, 2021, Medicaid expanded the list of practitioners who can be reimbursed for providing Asthma Self-Management Training (ASMT) services to members to include licensed clinical social workers, licensed master social workers, physical therapists, and occupational therapists. Reimbursement for ASMT services for these new provider types became available for both Medicaid FFS and MMC claims, including Medicaid Managed Care [which in turn includes Mainstram MMC Plans, Human Immunodeficiency Virus (HIV) Special Needs Plans (HIV-SNPs), and Health and Recovery Plans (HARPS)], submitted for dates of service on or after April 1, 2021.

Overview

ASMT services are reimbursable when provided through an Article 28 clinic (hospital outpatient department or free-standing diagnostic and treatment center) that has been accredited or recognized by a Centers for Medicare and Medicaid Services (CMS)-approved National Accreditation Organization (NAO).

Under the clinic's accreditation or recognition, ASMT services can only be performed by one of the following New York State (NYS) licensed, registered, or certified professionals affiliated with an ASMT program billed through an Article 28 clinic and who practices in one of the following professional disciplines:

  • Registered Nurse
  • Registered Nurse Practitioner
  • Physician [Medical Doctor (MD), Doctor of Osteopathy (DO)]
  • Pharmacist
  • Physician Assistant
  • Respiratory Therapist
  • Licensed Clinical Social Worker *New
  • Licensed Master Social Worker *New
  • Physical Therapist; *New
  • Occupational Therapist *New

Article 28 Clinics

Article 28 clinics must complete the Clinic Certification of Staff Certified as Asthma Educators form and submit it to the NYS Department of Health (DOH) Bureau of Provider Enrollment and provide proof that the clinic has received accreditation from a CMS approved NAO. In addition, the clinic must also maintain proof that each staff member who will be rendering ASMT as a Certified Asthma Educator (CAE) on its behalf, has also received certification by the National Asthma Educator Certification Board (NAECB). Proof of CAE certification must be made available to the Medicaid program at any time, upon request.

Private Practitioners

ASMT services are also reimbursable to physicians, nurse practitioners and certified midwives in an office-based setting when provided by one of the above licensed, registered, or certified health care professionals who is also certified as a CAE by the NAECB. CAEs must have their employer complete and submit the Employment Certification for Certified Educator form to identify the group practice or individual practitioner on whose behalf they will be rendering ASMT services.

ASMT is an essential element of asthma care and may be provided to:

  • members who are newly diagnosed with asthma;
  • members with asthma who are stable; or
  • members with asthma who have a medically complex condition such as an exacerbation of asthma, poor asthma control, diagnosis of a complication, etc.

ASMT services can be provided in individual sessions or group sessions of no more than eight members. Claims must include a valid International Classification of Diseases (ICD)-10 code for asthma. ASMT services are billed in single unit increments with one unit equaling 30 minutes of service using the following Current Procedural Technology (CPT) codes:

  • "98960" - Individual education for 30 minutes.
  • "98961" - Group education, for a 30-minute session, two to four members.
  • "98962" - Group education, for a 30-minute session, five to eight members.

No more than 10 hours, or 20 units, of asthma self-management training for newly diagnosed members or for members with a medically complex condition can be billed during a continuous six-month period. Members who are medically stable can receive up to one hour, or two units of ASMT in a continuous six-month period.

Questions and Additional Resources:

|top of page|

Medicaid Expands Coverage for Diabetes Self-Management Training

Effective April 1, 2021, Medicaid expanded the list of practitioners who can be reimbursed for providing Diabetes Self-Management Training (DSMT) services to members to include clinical psychologists, optometrists, occupational therapists, and podiatrists. Reimbursement for DSMT services for these new provider types became available for both Medicaid FFS and MMC claims, including Medicaid Managed Care [which in turn includes Mainstream MMC Plans, Human Immunodeficiency Virus (HIV) Special Needs Plans (HIV SNPs), and Health and Recovery Plans (HARPs)],submitted for dates of service on or after April 1, 2021.

Overview

DSMT services are reimbursable when provided through an Article 28 clinic (hospital outpatient department or free-standing diagnostic and treatment center) that has been accredited or recognized by a Centers for Medicare and Medicaid Services (CMS) approved National Accreditation Organization (NAO). Currently, CMS recognizes the American Diabetes Association (ADA), the Association of Diabetes Care and Education Specialists (ADCES) [formerly known as the American Association of Diabetes Educators (AADE)], as well as Indian Health Services (IHS) as approved NAOs. The ADCES uses the term "accreditation," while ADA uses the term "recognition".

Under the clinic's accreditation or recognition, DSMT services may only be performed by one of the following New York State (NYS) licensed, registered, or certified professionals affiliated with a DSMT program billed through an Article 28 clinic and who practicies in one of the following professional disciplines:

  • Registered Nurse
  • Registered Nurse Practitioner
  • Registered Dietitian
  • Physician [Medical Doctor (MD), Doctor of Osteopathy (DO)]
  • Pharmacist
  • Physician Assistant
  • Physical Therapist
  • Clinical Psychologist *New
  • Optometrist *New
  • Occupational Therapist *New
  • Podiatrist *New

Article 28 Clinics

Article 28 clinics must have a completed Clinic Certification to Provide Diabetes Education form on file with the NYS Department of Health (DOH) Bureau of Provider Enrollment and provide proof upon that the clinic has received accreditation or recognition from a CMS approved NAO. In addition, the clinic must also maintain proof that each staff member who renders DSMT services as a Certified Diabetes Educator (CDE) on its behalf has also received certification by the Certification Board for Diabetes Care and Education (CBDCE) (formerly known as the National Certification Board for Diabetes Educators) or a successor national certification board. Proof of CDE certification must be made available to the Medicaid program at any time, upon request.

Private Practitioners

DSMT services are also reimbursable in an office-based setting when provided by one of the above licensed, registered, or certified health care professionals who is also certified as a CDE by the CBDCE. CDEs must have their employer complete and submit the Employment Certification for Certified Educator form to identify the Medicaid enrolled physician on whose behalf they will be rendering DSMT services.

DSMT is an essential element of diabetes care and may be provided to:

  • members who are newly diagnosed with diabetes;
  • members with diabetes who are stable; or
  • members with diabetes who have a medically complex condition such as poor control of diabetes or another complicating factor.

DSMT services can be provided in individual sessions or in group sessions of no more than eight members. Claims must include a valid International Classification of Diseases (ICD)-10 code for diabetes mellitus. DSMT services are billed in single unit increments with one unit equaling 30 minutes of service using the following Healthcare Common Procedure Coding System (HCPCS) codes:

  • "G0108" - Diabetes outpatient self-management training services, individual, per 30 minutes.
  • "G0109" - Diabetes outpatient self-management training services, group (two to eight patients), per 30 minutes.

No more than 10 hours, or 20 units, of diabetes self-management training for newly diagnosed members or for members with a medically complex condition can be billed during a continuous six-month period. Members who are medically stable can receive up to one hour, or two units, of DSMT in a continuous six-month period.

Questions and Additional Resources:

|top of page|

Medicaid Expands Coverage for Smoking Cessation Counseling

Effective April 1, 2021, Medicaid expanded the list of practitioners who can be reimbursed for providing Smoking Cessation Counseling (SCC) services to members to include registered nurses, clinical psychologists, licensed clinical social workers, licensed master social workers, and licensed practical nurses. Reimbursement for SCC services for these new provider types became available for both Medicaid FFS and MMC claims submitted for dates of service on or after April 1, 2021.

Overview

SCC services are reimbursable when provided through an Article 28 hospital outpatient departments (OPDs), free-standing diagnostic and treatment centers (D&TCs) and federally qualified health centers (FQHCs) including FQHC school-based health centers (SBHCs) that bill using Ambulatory Patient Groups (APGs) and office-based providers. Smoking cessation services are included in the prospective payment system (PPS) rate for those FQHCs that do not participate in APG reimbursement.

SCC services can only be performed by one of the following NYS licensed, registered, or certified professionals affiliated with an SCC program billed through an Article 28 clinic and who practices in one of the following professional disciplines:

  • Registered Nurse Practitioner
  • Physician [Medical Doctor (MD), Doctor of Osteopathy (DO)]
  • Physician Assistant
  • Licensed Midwife
  • Registered Nurse *New
  • Clinical Psychologist *New
  • Licensed Clinical Social Worker *New
  • Licensed Master Social Worker *New
  • Licensed Practical Nurse *New

SCC may take place during individual or group counseling sessions. Only one procedure code per day may be billed. NYS Medicaid allows for as many sessions as medically necessary for all Medicaid members. Claims must include a valid International Classification of Diseases (ICD)-10 code for nicotine dependence.

  • "99406" — Intermediate SCC, three to ten minutes (billable only as an individual session).
  • "99407" — Intensive SCC, greater than ten minutes (billable as an individual or group session; using the "HQ" modifier to indicate a group SCC session, up to eight patients in a group).
  • "D1320" — Tobacco counseling for the control and prevention of oral disease. Billable only as an individual session, > (i.e. greater than) three minutes.

Medicaid coverage includes all medications to treat smoking cessation listed on the eMedNY Medicaid Pharmacy List of Reimbursable Drugs web page. Criteria for Food and Drug Administration (FDA) approved pharmaceutical medications used to treat smoking cessation can be found in article titled Update on the Smoking Cessation Benefit in Medicaid Fee-for-Service and Medicaid Managed Care in the March 2017 issue of the Medicaid Update.

Questions and Additional Resources:

|top of page|

Clinic Billing for Additional Dental Prophylaxis for Medicaid Members

An additional dental prophylaxis may be considered within a twelve-month period for those individuals identified with a recipient exception code of RE "81" [Traumatic Brain Injury (TBI) Ineligible] or RE "95" [Office for Persons with Developmental Disabilities (OPWDD)/Managed Care Exemption] per page 32 of the New York State Medicaid Dental Policy and Procedure Code Manual. Previously, Current Dental Terminology (CDT) code "D1999" was used to submit additional prophylaxis. Effective January 1, 2021, additional prophylaxis should be submitted using CDT codes "D1120" for members under 13 years old or "D1110" for members 13 years old and older.

Questions

All questions regarding this article should be directed to dentalpolicy@health.ny.gov.

|top of page|

Change to Physical Therapy, Occupational Therapy, and Speech Therapy Visit Limit

Effective January 1, 2021, pursuant to enacted changes in Social Services Law SSL §365-a, the Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) annual visit limits for fee-for-service (FFS) and Medicaid Managed Care (MMC) have been removed. The law change means that Medicaid will pay for more than 40 physical therapy visits a year when more therapy is medically necessary. Medicaid will pay for more than 20 occupational and 20 speech therapy visits per year when more therapy is medically necessary. Medicaid FFS will require prior authorization (PA) for most medically necessary therapy visits. The PA request is an attestation of the medical necessity for the service being requested. Providers will not need to obtain FFS PA for the following members:

  • Children from birth to age 21 (until their 21st birthday)
  • Individuals with developmental disabilities (members with restriction/exception code "95" on file)
  • Individuals with a traumatic brain injury (TBI) [members with TBI* (use procedure code modifier ST on claims) or restriction/exception code "81" on file]
  • Individuals with both Medicare Part B and Medicaid (dually eligible) when the service is covered by Medicare
  • Individuals receiving rehabilitation services as a hospital inpatient
  • Individuals receiving rehabilitation services in a nursing home in which they reside
  • Individuals receiving rehabilitation services provided by a certified home health agency (CHHA)

* TBI as defined in Public Health Law Article 27-cc: §2741. "Traumatic brain injury" means an acquired injury to the brain caused by an external physical force resulting in total or partial disability or impairment and shall include but not be limited to damage to the central nervous system from anoxic/hypoxic episodes or damage to the central nervous system from allergic conditions, toxic substances, and other acute medical/clinical incidents. Such term shall include, but not be limited to, open and closed brain injuries that may result in mild, moderate or severe impairments in one or more areas, including cognition, language, memory, attention, reasoning, abstract thinking, judgment, problem-solving, sensory perceptual and motor abilities, psycho-social behavior, physical functions, information processing, and speech. Such term shall not include progressive dementias and other mentally impairing conditions, depression and psychiatric disorders in which there is no known or obvious central nervous system damage, neurological, metabolic and other medical conditions of chronic, congenital or degenerative nature or brain injuries induced by birth trauma.

Reminders for Medicaid FFS Billing:

  • Requirement to use modifiers: All providers submitting claims for PT, OT or ST must use a procedure code modifier. The modifier identifies the therapy type and provides a mechanism for counting and matching. Without a modifier, the claim will be denied.
    • "GN" - ST service
    • "GO" - OT service
    • "GP" - PT service
  • Medicaid FFS utilizes the PA mechanism to track therapy visits. A PA must be obtained for each medically necessary therapy visit. The PA request is an attestation of the medical necessity for the service being requested. The PA number must be included on the claim at the time of submission. If there is no PA number on the claim, and one is required, the claim will be denied. PA must be obtained through the PA/Dispensing Validation System (DVS). A unique PA number must be obtained through the DVS for each visit. The DVS operates on "real-time" and will give an immediate response to a request for PA. DVS authorization does not guarantee payment. However, the claim will be denied without a PA. A request for a PA should be submitted before the provision of service. The request may be made after the date of the service and can be approved if the member has not already been authorized. Further instructions on obtaining a DVS authorization number can be found on the eMedNY ePACES Reference Sheet web page.

Additional Information and Questions:

  • Additional information regarding this article can be found in the eMedNY Rehabilitation Services Manual.
  • Policy questions for Medicaid FFS members should be directed to the Office of Health Insurance Programs (OHIP) via phone at (518) 473‑2160.
  • Questions regarding MMC reimbursement and/or billing requirements should be directed to the member's MMC Plan.
  • MMC benefit coverage questions should be directed to OHIP Division of Health Plan Contracting and Oversight (DHPCO) by email at covques@health.ny.gov or by phone at (518) 473‑1134.

|top of page|

New York State Medicaid Coverage of Real-Time Continuous Glucose Monitors

New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC), to include Mainstream MMC Plans, HIV Special Needs Plans (HIV SNPs), and Health and Recovery Plans (HARPs), cover real-time continuous glucose monitors (RT-CGM) for members who have diagnoses of type 1 diabetes when the members meet the criteria outlined in this policy. RT-CGM coverage for members with type 1 diabetics was effective November 1, 2017 for FFS, and January 1, 2018 for MMC. Criteria updates bolded and italicized throughout this guidance are effective July 1, 2021.

Overview

RT-CGM is a glucose monitoring technology that continuously measures and displays interstitial glucose levels. Alarms and alerts are used to notify members when their blood glucose level is exceeding or falling below specified thresholds. This information is used by members to self-manage their diabetes. Please note: According to the National Diabetes Statistics Report, a periodic publication of the Centers for Disease Control and Prevention (CDC), "1.4 million adults aged 20 years or older — 5.2% of all US adults diagnosed with diabetes — reported having type 1 diabetes and using insulin."

NYS Medicaid coverage for RT-CGM may be available for members who are diagnosed with type 1 diabetes and meet all the following criteria:

  • Member is under the care of an endocrinologist, or an enrolled Medicaid provider with experience in diabetes treatment, who orders the device
  • Member is currently performing multiple finger-stick glucose tests daily
  • Member is on an insulin treatment plan that requires frequent adjustment of insulin dosing
  • Member is able, or has a caregiver who is able, to hear and view RT-CGM alerts and respond appropriately

This guidance is aligned with the NYS Medicaid Program's criteria for external insulin pumps, which can be found in the eMedNY Durable Medical Equipment, Prosthetics, Orthotics, Supplies — Procedure Codes and Coverage Guidelines document.

Billing

FFS

If the device being dispensed is not found on the Preferred Diabetic Supply Program (PDSP) list, PA is required. For specific FFS billing instructions, providers can refer to the Durable Medical Equipment (DME) Manual and all provider communication found on the eMedNY DME Manual web page. If the device is on the preferred diabetic supply list, the member still needs to meet the above criteria. If the member does not meet all the criteria, the provider must submit a PA request to Magellan Medicaid Administration by phone at (877) 309‑9493.

MMC Plan

Providers participating in MMC should check with the individual health plans to determine how each MMC Plan will implement this policy. Questions regarding MMC reimbursement and/or documentation requirements should be directed to the member's MMC Plan. For an MMC Plan directory, providers can refer to the NYS Medicaid Program Information for All Providers — Managed Care Information document.

Important Reminders:

  • Providers who've had a recent visit with their patient (within the last six months) should order a CGM only.
  • Prescribers should be actively monitoring their patients to ensure adherence to treatment plans. Diabetes education is strongly encouraged.
  • Providers should not order new equipment when current equipment is operational.
    • Smart phones are not a reimbursable expense.

Additional Information and Questions:

  • Questions regarding CGM PA or Dispensing Validation System (DVS) authorization for Medicaid FFS members should be directed to the DME Program at (800) 342‑3005.
  • Policy questions regarding Medicaid FFS should be directed to the Office of Health Insurance Program (OHIP) Division of Program Development and Management (DPDM) at (518) 473‑2160.
  • Questions regarding the PDSP Policy should be directed by phone to (518) 486‑3209 or by email to ppno@health.ny.gov.
  • For PA requests, via the Pharmacy Benefit, providers can contact the Magellan Clinical Call Center at (877) 309‑9493.
  • Questions regarding Medicaid FFS billing or claims should be directed to the eMedNY Call Center at (800) 343‑9000.

|top of page|

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

Donna Frescatore
Medicaid Director
Office of Health Insurance Programs