NYS DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS

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Division of Health Plan Contracting and Oversight

Guidelines for the Provision of Tuberculosis Directly Observed Therapy

Overview

Medicaid Redesign Team (MRT) proposal #1458 includes expansion of the Medicaid Mainstream Managed Care benefit package to include benefits previously carved out to Medicaid fee-for-service. Directly Observed Therapy for Tuberculosis (TB/DOT) is the direct observation of oral ingestion of TB medications to assure patient compliance with the prescribed medication regimen. Effective August 1, 2013, the provision of TB/DOT services becomes the responsibility of the Medicaid Managed Care organization (MCO). The following guidelines identify the roles and responsibilities of MCOs and TB/DOT services providers relative to this transition.

  1. Scope of TB/Directly Observed Therapy
    DOT is the standard of care for every individual with active TB.
    1. The service may be provided in the community (including in the home) or on an inpatient basis.
    2. Outpatient TB/DOT involves the observation of dispensing of medication, assessing any adverse reactions to the medications and case follow up.
      • Upstate location of services is the local health department (LHD), or in the home/other community setting
      • New York City locations are Department of Health and Mental Hygiene (DOHMH) clinics and approved Health and Hospitals Corporation (HHC) hospitals (Bellevue, Elmhurst, Kings County) or in the home/other community setting.

    3. Inpatient long term treatment may be indicated where the LHD has determined the patient has a poor treatment response, has medical complications, remains infectious with no other appropriate residential placement available, or other intensive residential placement is not possible.
  2. Contracting
    1. The Medicaid Managed Care model contract requires MCO payment for DOT services.
    2. MCOs may not require prior authorization for these services if provided under the authority of the Local Health Department.
    3. MCOs may amend existing provider contracts or enter into new provider contracts for these services.
    4. LHD must follow plan submission guidelines for claims.
    5. Participating LHDs must follow requirements for notification.
    6. MCOs may not mandate which provider will provide the service or location of service.

  3. Claims Payment
    1. MCOs must provide coverage for this service beginning August 1, 2013.
    2. This service is provided under the authority of the local government and must be reimbursed if provided by the local health department or designated site (NYC).
    3. MCOs must pay the Medicaid fee-for-service (FFS) rate if the provider is not contracted with the MCO.
    4. The FFS rate is $82.58 upstate and $95.90 downstate (Westchester County and points south). The rate is a weekly rate, regardless of the frequency of treatment (daily, twice or three times weekly). If there is a revision of the rates within the first year, then plans will have to mirror those rates for the balance of the first year.
    5. The rate does not include TB medications, which are also the responsibility of the plan. The patient may fill the prescriptions and keep medications, and remain in receipt of DOT care.

Optional / Suggested Claims Coding:

Service HCPCS/ICD-9 HCPCS/ICD-9 Description Modifier Units Provider Specialty Code MEDS COS FFS Rate Codes
TB/DOT (see notes below) H0033 Oral medication administration, direct observation U1 1 Varies Varies 5312, 5313, 5317, 5318
Inpatient TB Therapy (ordered by LDSS) ICD-9 Dx
01000-01286		 Various TB diagnoses The Dx codes shown all group to APR-DRG 137, but other Dxs and DRGs are possible for TB and may apply. The full range of codes extends up to ICD-9 Dx code 01896. Varies 11

The first line medications, used as part of DOT to treat TB, are isoniazid (ING), rifampin (RIF), ethambutol and pyrazinamide. These are all oral medications and are obtained through a prescription filled by a pharmacy. There are other oral medications that may be used, but these are prescribed on a less frequent basis.

In some cases, patients may require injectable/infused medications. The standard injectable medications for TB are Streptomycin (J3000), Kanamycin (J1850), Amikacin (J0278) or Capreomycin (J3490). These medications are administered and billed to Medicaid by a Certified Home Health Agency (CHHA) or by the local health department. The National Drug Code (NDC) that should be reported is the NDC listed on the medication package label. (Plans are responsible for J-code medications and medications administered in the home).