New York State Medicaid Update - June 2024 Volume 40 - Number 6
In this issue …
- Policy and Billing
- All Providers
- Pharmacy
Clarification: Coverage of Licensed Mental Health Counselor and Licensed Marriage and Family Therapist Services Provided in Article 28 Outpatient Hospital Clinics and Free-Standing Diagnostic and Treatment Centers
This article is intended to provide clarification on the rate codes that Article 28 hospital outpatient departments (OPDs) and free-standing diagnostic and treatment centers (D&TCs), as well as School-Based Health Centers (SBHCs), should use to request reimbursement from New York State (NYS) Medicaid for mental health counseling when provided by Licensed Mental Health Counselors (LMHCs) and Licensed Marriage and Family Therapists (LMFTs), within their scope of practice, as defined by the NYS Education Department (NYSED).
Article 28 Clinics
Hospital OPDs and free-standing D&TCs should use the following rate codes:
| Rate Code | Rate Description | Reimbursement | |
|---|---|---|---|
| OPDs | D&TCs | ||
| 4222 | Individual LMHC/LMFT Services 20 to 30 minutes with patient | $44.10 | $41.41 |
| 4223 | Individual LMHC/LMFT Services 45 to 50 minutes with patient | $66.69 | $62.62 |
| 4224 | Family Services LMHC/LMFT with or without patient present | $75.30 | $70.70 |
SBHCs
SBHCs should use the following rate codes:
| Rate Code | Rate Description | Reimbursement | |
|---|---|---|---|
| OPDs | D&TCs | ||
| 3260 | SBHC-Individual LMHC/LMFT Services 20 to 30 minutes with patient | $44.10 | $41.41 |
| 3261 | SBHC-Individual LMHC/LMFT Services 45 to 50 minutes with patient | $66.69 | $62.62 |
| 3262 | SBHC-Family services LMHC/LMFT with or without patient present | $75.30 | $70.70 |
Federally Qualified Health Centers and Rural Health Clinics
Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) that have opted out of Ambulatory Payment Groups (APGs) should bill the Prospective Payment System (PPS) rate. For additional information on APG reimbursement methodology as it relates to Hospital OPDs and D&TCs, providers should visit the NYS Department of Health (DOH) "Alternative Payment Fee Schedule" web page.
Questions and Additional Information:
- Fee-for-service (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.
Submission of Prenatal and Postpartum Service Claims for Each Pregnancy Related Visit
To better understand the timing and delivery of perinatal (prenatal and postpartum) services to New York State (NYS) Medicaid members and Medicaid Managed Care (MMC) enrollees, additional information is needed from NYS Medicaid providers. Effective for service delivered as of July 1, 2024 , providers using bundled/global procedure codes for billing will also be required to submit claims with non-payment Category II Current Procedural Terminology (CPT) codes for perinatal services to NYS Medicaid fee-for-service (FFS) and MMC. The bundled/global bill procedure codes are "59400" , "59410" , "59510" , "59515" , "59610" , "59614" , "59618" , "59622" , "59426" and "59425" .
Effective July 1, 2024 , providers are required to submit a claim with a Category II CPT code for each prenatal/postpartum service provided to a NYS Medicaid member when the provider is billing using the global bill codes or a bundled bill. These Category II CPT code claims are in addition to the global or bundled code claims. Claims for NYS Medicaid FFS members must be submitted directly to NYS Medicaid. Claims for MMC enrollees must be submitted to the MMC Plan of the enrollee. Additionally, the following Category II CPT codes must be used:
| CPT Code | Code Description |
|---|---|
| 0500F | INITIAL PRENATAL VISIT |
| 0502F | SUBSEQUENT PRENATAL VISIT |
| 0503F | POSTPARTUM VISIT |
MMC Plans are required to submit this information, alongside other encounter data, to NYS Medicaid via the Original Source Data Submitter (OSDS) system.
Questions
Questions should be directed to MaternalandChild.HealthPolicy@health.ny.gov.
Reminder: Licensed Providers Must Enroll with New York State Medicaid to Serve Medicaid Members
NYRx, the New York State (NYS) Medicaid Pharmacy program, continuously monitors claim responses. Nurse practitioners (NPs) and physician assistants (PAs) show a higher incidence of non-enrollment, which impacts accessibility to medications for NYS Medicaid members.
As previously communicated in the Reminder: Ordering, Prescribing, Referring, Attending (OPRA) Prescription Requirements for Unlicensed Providers Only article published in the December 2018 issue of the Medicaid Update, and the January 2023 NYRx Pharmacy Benefit Transition Special Edition - Part Two issue of the Medicaid Update, all licensed prescribers, including physicians, NPs, PAs, podiatrists, dentists, optometrists, audiologists and certified nurse midwives (CNMs), must enroll in NYS Medicaid as required by the Centers for Medicare and Medicaid Services (CMS) and federal regulations.
Enrollment Requirements:
- Licensed providers who prescribe drugs and supplies, including diabetic supplies, must enroll in NYS Medicaid as either a fee-for-service (FFS) Individual Billing provider or as an Ordering/Prescribing/Referring/Attending (OPRA) non-billing provider.
- Some provider types require Medicare enrollment first. Providers should check requirements for their profession on the eMedNY "Provider Enrollment and Maintenance" web page.
- To access the enrollment application, providers should visit the eMedNY "Provider Enrollment and Maintenance" web page.
Enrollment Application Process
To apply for enrollment, providers must visit the eMedNY website, then complete the appropriate enrollment application. Once submitted, the NYS Department of Health (DOH) will then review and issue determinations. Exceptions to the enrollment requirement and pharmacy billing instructions for unlicensed prescribers and out-of-state (OOS) licensed prescribers can be found in the Important Communication: Unlicensed Interns, Residents & Foreign Physicians in Training Programs are Authorized Prescribers for Medicaid Members document.
Questions and Additional Resources:
- Enrollment questions should be directed to providerenrollment@health.ny.gov or (800) 343-9000.
- Providers should visit the eMedNY "Introduction to Provider Enrollment" web page, which acts as an enrollment guide.
Attention Pharmacy Providers: Cold Storage Requirement
Providers are advised that the eMedNY "Pharmacy Manual" web page, includes a new section titled, "Storage Requirements – Vaccine and Medication. Effective, June 5, 2024", which applies to all new pharmacy applicants that are enrolling, revalidating, or facilitating a change of ownership to the New York State (NYS) Medicaid program.
Storage Requirement – Vaccine and Medication
NYS Medicaid pharmacy providers are required to follow regulations set forth by the Commissioner of Education, which can be found on the "NYS Education Law (NYSED) §63.6(b)(3) web page, under “Registration and operation of New York establishments,” as well as the Center for Disease Control and Prevention (CDC) guidelines found in the CDC Vaccine Storage and Handling Toolkit, for vaccines and medications requiring cold storage.
Pharmacies must have a purpose-built or pharmaceutical grade refrigerator as dorm-style and bar-style units do not qualify. NYS Medicaid providers who are part of the Vaccine for Children (VFC) program must meet criteria for refrigeration and vaccine storage set forth in the guidelines outlined in the New York State Vaccines for Children Program (NYS VFC) Vaccine Stand-Alone Storage Unit Purchasing Guidance and the New York State Vaccines for Children (NYS VFC) Program – Temperature Monitoring Requirements document.
Questions:
- Questions regarding this policy may be directed to NYRx@health.ny.gov.
- Enrollment questions may be directed to ProviderEnrollment@health.ny.gov.
The Medicaid Update is a monthly publication of the New York State Department of Health.
Kathy Hochul
Governor
State of New York
James McDonald, M.D., M.P.H.
Commissioner
New York State Department of Health
Amir Bassiri
Medicaid Director
Office of Health Insurance Programs
