New York State Medicaid Update - September 2022 Volume 38 - Number 10

In this issue …

• Policy and Billing
  • Update to New York State Medicaid Fee-for-Service Program Pharmacists as Immunizers Fact Sheet
  • New York State Medicaid Fee-for-Service: Modifier 33 Waiving Copayment, Deductible, and Coinsurance for United States Preventive Services Task Force A and B Medical Services
  • Pharmacy Professional Dispensing Fee Update
  • New York State Medicaid Expansion of Remote Patient Monitoring for Maternal Care
  • New York State Medicaid Pharmacy Coverage of Polio Vaccine
  • New York State Medicaid Reimbursement for Gambling Disorder Treatment Provided by Office of Addiction Services and Supports Certified Programs

Information in gray boxes in this issue indicates material abridged but linked from the succinct interactive Portable Document Format (PDF) version.

---

Update to New York State Medicaid Fee-for-Service Program Pharmacists as Immunizers Fact Sheet

Updates are highlighted in yellow

In accordance with New York State (NYS) Education law, pharmacists certified to administer immunizations are authorized to administer to patients 18 years of age and older, as recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control and Prevention (CDC). The following vaccines can now be obtained by NYS Medicaid members, 18 years of age and older:

• Coronavirus Disease 2019 (COVID-19)
• Hepatitis A
• Hepatitis B
• Herpes zoster (shingles)
• Human papillomavirus
• Influenza (two years of age and older)
• Measles, mumps, and rubella
• Meningococcal
• Pneumococcal
• Tetanus, diphtheria, and pertussis
• Varicella

Providers can refer to the NYS Department of Health New York State Medicaid Coverage Policy and Billing Guidance for the Administration of COVID-19 Vaccines, for more information.

Billing Instructions for FFS

Consistent with Medicaid immunization policy, pharmacies will bill the administration fee and, when applicable, acquisition cost of the vaccine using the appropriate procedure codes. Procedure codes can be found on the Pharmacy Fee Schedule.

Please note: National Drug Codes (NDCs) are not to be used for billing the vaccine product to Medicaid FFS. Reimbursement for the cost of the vaccine for individuals 19 years of age and older will be made at no more than the actual acquisition cost to the pharmacy. No dispensing fee or enrollee co-payment applies. Pharmacies will bill with a quantity of "1" and a day supply of "1."

Vaccine claims submitted via the National Council for Prescription Drug Programs (NCPDP) D.0 format

NCPDP D.0. Claim Segment Field	Value
436-E1 (Product/Service ID Qualifier)	Enter value of "09" which qualifies the code submitted in field 407-D7 (Product/Service ID) as a procedure code.
407-D7 (Product/Service ID)	Enter an applicable procedure code listed in Table B and/or C. Up to four claim lines can be submitted with one transaction.

For guidance on origin code and serial number values that must be submitted on the claim, providers can refer to the Matching Origin Codes to Correct Prescription Serial Number Within Medicaid Fee-For-Service article published in the July 2020 issue of the Medicaid Update. Additionally, the NCPDP D.0 Companion Guide can be found on the eMedNY "5010/D.0 Transaction Instructions" web page.

Billing for Immunizations of Members 19 Years of Age and Older:
For administration of multiple vaccines on the same date to members 19 years of age and older, procedure code "90471" should be used for administration of the first vaccine and "90472" for administration of any other vaccines administered on that day. One line should be billed for "90472" indicating the additional number of vaccines administered (insert quantity of 1 or 2).

Billing for Immunizations for Members Younger than 19 Years of Age:
For VFC-eligible vaccines, whether enrolled in the VFC program or not, the pharmacy would submit procedure code "90460" (administration of free vaccine) for administration of first or subsequent doses, then submit the appropriate vaccine procedure code(s) with a cost of $0.00. A system edit will ensure that, when there is an incoming claim for the administrative fee (procedure code "90460"), there is also a claim in history for a VFC-eligible vaccine procedure code, reimbursed at $0.00. If no history claim is found, then the claim will be denied for the edit 02291.

For NCPDP claims transactions that are denied for edit 02291, the corresponding Medicaid Eligibility Verification System (MEVS) Denial Reason code "738" will be returned as "History Not Found for Administrative Vaccine Claim" and NCPDP Reject code "85" "Claim Not Processed".

Vaccine Counseling

Pharmacists offering vaccine counseling services to members 18 years of age or younger can reference the coverage and reimbursement policy outlined in the Early and Periodic Screening, Diagnostic, and Treatment Program Childhood Vaccine Counseling Coverage Benefit article published in the March 2022 issue of the Medicaid Update.

Billing Instructions for MMC Pharmacy Billing

Individual MMC Plans should be contacted for their specific reimbursement and billing guidance. Plan information can be found by visiting New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center website.

• FFS billing questions should be directed to the eMedNY Call Center at (800) 343-9000.
• Managed Care Organization (MCO) billing questions should be directed to the individual MMC Plan.
• CDC vaccine and immunization information can be found on the CDC "Vaccines & Immunizations" web page. Providers should periodically check the OTC and Supply Fee Schedule found on the eMedNY "Pharmacy Manual" web page, for updates on procedure codes found in the tables above for vaccines.

Questions and Additional Information:

• Additional information on influenza is available on the NYS DOH "What You Should Know About the Flu" web page.
• FFS billing and claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• FFS Pharmacy coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
• MMC reimbursement, billing, and/or documentation requirement questions should be directed to enrollee's MMC Plan(s). Additional MMC reimbursement and billing guidance is available on the New York State Medicaid Managed Care (MMC) Pharmacy Benefit Information Center website.

|top of page|

---

New York State Medicaid Fee-for-Service: Modifier 33 Waiving Copayment, Deductible, and Coinsurance for United States Preventive Services Task Force A and B Medical Services

The United States Preventive Services Task Force (USPSTF) A and B medical services are exempt from New York State (NYS) Medicaid fee-for-service (FFS) copayments. A listing of all the recommendations with either USPSTF A or B medical services can be found on the USPSTF "A & B Recommendations" web page.

When providing a USPSTF A or B medical service, providers should append modifier "33" to the applicable Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code when submitting the claim. Reporting modifier "33" will exempt the claim from all NYS Medicaid FFS copayments. The copayment exemption applies to clinic, ordered ambulatory, and laboratory claims. Please note: If you are billing for an Ambulatory Patient Group (APG) clinic claim, reporting modifier "33" on any claim line will exempt the entire claim from a copayment.

Questions and Additional Information:

• FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
• Medicaid Managed Care (MMC) reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee's MMC Plan.
• MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

|top of page|

---

Pharmacy Professional Dispensing Fee Update

Effective September 22, 2022, the New York State (NYS) Medicaid fee-for-service (FFS) professional dispensing fee will change from $10.08 to $10.18 for covered outpatient drugs, when applicable. The NYS Department of Health (DOH) amended this fee to comply with the one percent across-the-board (ATB) Medicaid rate increase, which was based on the enacted budget and was effectuated by the Centers for Medicare and Medicaid Services (CMS) NYS Plan approval. Additional information on the one percent ATB Medicaid rate increase can be found on the NYS DOH "1% Across the Board (ATB) Medicaid Rate Increase" web page.

Please note: This does include retroactive adjustments to the dispensing fee back to April 1, 2022. Those adjustments will be processed at a future date; details will be forthcoming.

Questions and Additional Information:

• All questions regarding this update should be sent to NYRx@health.ny.gov.
• FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• Medicaid Managed Care (MMC) reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee's MMC Plan.
• MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers Managed Care Information document.

|top of page|

---

New York State Medicaid Expansion of Remote Patient Monitoring for Maternal Care

Effective October 1, 2022, for fee-for-service (FFS), and December 1, 2022, for Medicaid Managed Care (MMC) Plans, New York State (NYS) Medicaid is expanding coverage for remote patient monitoring (RPM) during pregnancy and up to 84 days postpartum to further improve and expand access to prenatal and postpartum care. This expansion of coverage includes an additional monthly fee to cover the cost of RPM devices/equipment.

Billing Guidance

FFS:

• Current Procedural Terminology (CPT) Code "99091" is to be billed for the RPM service as per general NYS Medicaid telehealth guidance:
  • A minimum of 30 minutes per month must be spent collecting and interpreting NYS Medicaid member RPM data.
  • CPT Code "99091" may be billed no more than one time per member per month.
  • RPM services should be billed on the last day of each month in which RPM is delivered.
  • Federally Qualified Health Centers (FQHCs) reimbursed via the federal all-inclusive prospective payment system (PPS) rate are unable to bill for RPM services, as these services are furnished incident to an FQHC visit and, therefore, are included in the FQHC PPS rate.
• CPT Code "99453" with HD modifier, denoting pregnant/postpartum service, may be billed once per patient per pregnancy for the initial set-up of the RPM device/equipment. CPT Code "99453" is to be used once per episode of clinical care (the time from service activation of the device/equipment to when the RPM period ends).
• CPT Code "99454" with an HD modifier, denoting pregnant/postpartum services, may be billed once per 30-day period when the provider supplies and uses a medical device/equipment to remotely monitor and collect patient-generated health data during the member's pregnancy and/or the post-partum period(s). CPT Code "99454" is billed for continuous RPM medical device supply and patient monitoring.
• Billing CPT code "99453" and CPT code "99454" requires usage of a medical device that digitally collects and transmits 16 or more days of data every 30 days.
• CPT Code "99454" is billed along with CPT Code "99091".

CPT Code	Description	Fee
99091	Collection and interpretation of physiologic data [e.g., electrocardiogram (ECG), blood pressure, glucose monitoring] digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days.	$48.00
99453 + HD (maternal service) modifier	Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.	$14.85
99454 + HD (maternal service) modifier	Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. Every 30 days when a minimum of 16 days of data is collected within the 30-day period. This is a once per 30-day fee regardless of the number of devices used to monitor the pregnant/post-partum individual. To be billed with CPT Code "99091".	$43.23

MMC
Providers participating in MMC are to consult with the individual MMC Plans to determine how each MMC Plan will implement this policy.

Reminders:

• The device(s) must be ordered and billed by a provider enrolled in NYS Medicaid.
• Participating providers can contract with an outside vendor for RPM equipment; however, the NYS Medicaid-enrolled provider must bill NYS Medicaid directly.
• Providers should not bill NYS Medicaid for non-compliant members or equipment/devices and/or monitoring covered by another funding source.
• Appropriate records must be maintained for audit purposes.
• This expanded coverage for RPM to include device supply with daily recording is separate and distinct from coverage for Healthcare Common Procedure Coding System (HCPCS) code A4670 - Automatic Blood Pressure Monitor Coverage Criteria. Devices covered by CPT Codes "99453" and "99454" are medical devices as defined by the Food and Drug Administration (FDA) and are fully configured for RPM.

Questions and Additional Information:

• FFS coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
• FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• MMC reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee's MMC Plan.
• MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.
• Coverage and policy questions regarding expansion of RPM for maternal care should be directed to maternalandchild.healthpolicy@health.ny.gov or telehealth.policy@health.ny.gov.

|top of page|

---

New York State Medicaid Pharmacy Coverage of Polio Vaccine

Effective September 9, 2022 through October 9, 2022, or any subsequent extensions, and in accordance with New York State (NYS) Governor Kathy Hochul's Executive Order No. 21, NYS Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans cover the inactivated poliovirus vaccine (IPV) for administration of IPV to Medicaid FFS members and MMC enrollees.

FFS Pharmacy Billing Guidance

The NYS FFS Medicaid program provides reimbursement to NYS Medicaid-enrolled pharmacies for IPV vaccine administration and the acquisition cost. Pharmacies should not seek reimbursement for the IPV vaccine when acquired at no cost. Pharmacies should submit a claim using the National Council for Prescription Drug Program (NCPDP) D.0 format described below.

Please note: National Drug Codes (NDCs) are not to be used for billing the vaccine product to NYS Medicaid FFS. No dispensing fee or enrollee copayment applies.

Vaccine Counseling

As a reminder, providers offering vaccine counseling services to members 18 years of age or younger should follow the coverage and reimbursement policy outlined in the Early and Periodic Screening, Diagnostic, and Treatment Program Childhood Vaccine Counseling Coverage Benefit article published in the March 2022 issue of the Medicaid Update.

Medical FFS Billing Guidance

For other provider type billing guidance, providers should refer to the New York State Medicaid Polio Vaccine Coverage article published in the August 2022 issue of the Medicaid Update.

MMC Providers

NYS MMC providers must contact the Medicaid MMC enrollee's individual plan for specific billing instructions for vaccines, vaccine administration, and vaccine counseling services.

Questions and Additional Information:

• FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• FFS coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at NYRx@health.ny.gov.
• MMC reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee's MMC Plan.
• MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.
• For additional information regarding NYS Pharmacy FFS vaccine billing guidance, providers can refer to the New York State Medicaid Fee-for-Service Program: Pharmacists as Immunizers Fact Sheet.
• Additional information regarding the poliovirus, IPV vaccine, and NYS specific poliovirus vaccine recommendations can be found on the NYS DOH "Polio" web page.
• Additional information on the VFC Program, based on location, can be found at the following links:
  • New York City
  • Outside New York City

|top of page|

---

New York State Medicaid Reimbursement for Gambling Disorder Treatment Provided by Office of Addiction Services and Supports Certified Programs

Effective January 1, 2023, New York State (NYS) Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) Plans will begin covering Gambling Disorder treatment provided to individuals receiving services from the Office of Addiction Services and Supports (OASAS) certified programs listed below.

Outpatient:

• OASAS Certified Title 14 New York Codes, Rules, and Regulations (NYCRR) Part 822 Outpatient Clinic Programs, with a problem gambling designation.
• OASAS Certified Title 14 NYCRR Part 825 Integrated Outpatient Services Programs, with the OASAS gambling designation.

Please note: Programs will submit claims using the 837I claim form, which is the same as the prevailing outpatient substance use disorder (SUD) treatment reimbursement and follows the Ambulatory Patient Group (APG) methodology. The OASAS Ambulatory Patient Groups (APG) Clinical and Medicaid Billing Guidance, will be updated to incorporate the appropriate references to acknowledge reimbursement for individuals with a primary gambling diagnosis. These services may be delivered face to face on-site at the certified location, via telehealth, and in the community.

Inpatient

OASAS Certified Title 14 NYCRR Part 818 Inpatient Rehabilitation Programs

Residential

OASAS Certified Title 14 NYCRR Part 820 Residential Treatment Programs

Please note: For individuals not enrolled in an MMC Plan, the claims should be submitted to Medicaid FFS. For individuals enrolled in an MMC Plan, the claim must be submitted to the enrollee's MMC Plan, and the program must be part of the MMC Plan contracted network of providers.

Questions and Additional Information:

• Questions regarding Medicaid FFS policy should be directed to the OASAS Practice Innovation and Care Management (PICM) at picm@oasas.ny.gov.
• FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
• MMC reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee's MMC Plan.
• MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers - Managed Care Information document.

|top of page|

---

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

Kathy Hochul
Governor
State of New York

Mary T. Bassett, M.D., M.P.H.
Commissioner
New York State Department of Health

Amir Bassiri
Medicaid Director
Office of Health Insurance Programs