Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-082 - Physician/Independent Lab/CRNA/Radiation Therapy Center Update #105

Universal Citation: AR Admin Rules 016.06.05-082

Current through Register Vol. 49, No. 9, September, 2024

201.100 Arkansas Medicaid Participation Requirements for Physicians

All physicians are eligible for participation in the Arkansas Medicaid Program if they meet the following criteria:

A. A provider of physician's services must be licensed to practice in his or her state.

B. A provider of physician's services (with the exception of a pediatrician) must be enrolled in the Title XVIII (Medicare) Program.

C. A provider of physician's services must complete a provider application (form DMS-652), Medicaid contract (form DMS-653), Request for Taxpayer Identification Number and Certification (Form W-9) and Arkansas Medicaid Primary Care Physician Managed Care Program Primary Care Physician Participation Agreement (form DMS-2608). View or print form DMS-652, form DMS-653, Form W-9 and form DMS-2608.

D. A copy of the following documents must accompany the application and contract:
1. The physician must submit a copy of his or her current license to practice in his or her state.

2. Out-of-state physicians must submit a copy of verification that reflects current enrollment in the Title XVIII (Medicare) Program.

3. Subsequent licensure and certifications must be forwarded to Provider Enrollment within 30 days of issuance. If the renewal document(s) have not been received within this timeframe, the provider will have an additional 30 and final days to comply.

E. Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid Provider Agreement.

F. Persons and entities that are excluded or debarred under any state or federal law, regulation, or rule, are not eligible to enroll, or to remain enrolled, as Medicaid providers.

201.200 Arkansas Medicaid Participation Requirements for Independent Laboratories

All Independent Laboratories are eligible for participation in the Arkansas Medicaid Program if they meet the following criteria:

A. A provider of Independent Laboratory services must be registered and have been issued a certificate and identification number under the Clinical Laboratory Improvement Amendment (CLIA) of 1988. If you need information on the Centers for Medicare and Medicaid Services (CMS) CLIA program, please contact the Arkansas Department of Health Division of Health Facility Services. View or print the Arkansas Department of Health Division of Health Facility Services contact information.

B. The Independent Laboratory must be certified as a Title XVIII (Medicare) provider in its home state.

C. The provider must complete a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). (See Section I of this manual.)
1. A copy of the CLI A certificate and a copy of the current Title XVI II (Medicare) certification must accompany the provider application and Medicaid contract. Verification of subsequent certifications must be submitted to the Medicaid Provider Enrollment Section within 30 days of issuance.

2. Out-of-state laboratories must verification of current Title XVIII (Medicare) Program certification.

3. Subsequent certifications must be forwarded to Provider Enrollment within 30 days of issuance. If the renewal document(s) have not been received within this timeframe, the provider will have an additional and final 30 days to comply.

D. Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid Provider Agreement.

E. Persons and entities that are excluded or debarred under any state or federal law, regulation, or rule, are not eligible to enroll, or to remain enrolled, as Medicaid providers.

201.300 Arkansas Medicaid Participation Requirements for Certified

Regi stered Nurse Anesthetist (CRNA)

Providers of Certified Registered Nurse Anesthetist (CRNA) services must meet the following criteria in order to be eligible for participation in the Arkansas Medicaid Program:

A. A provider of CRNA services must be currently licensed as a Certified Registered Nurse Anesthetist in his/her state and be nationally certified by the Council on Recertification of Nurse Anesthetists.

B. A provider of CRNA services must be certified as a Title XVIII (Medicare) CRNA provider.

C. A provider of CRNA services must complete a provider application (form DMS-652), Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). (See Section I of this manual.) View or print form DMS-652, form DMS-653 and Form W-9.

D. The following verifications must accompany the application and contract:
1. A copy of current state CRNA licensure and a current copy of national certification from the Council on Recertification of Nurse Anesthetists.

2. Verification of current Title XVIII (Medicare) Program certification. (Out-of-state CRNAs)

3. Subsequent certifications and license renewals must be submitted to Provider Enrollment within 30 days of their issuance. If the renewal document(s) have not been received within this timeframe, the provider will have an additional and final 30 days to comply.

E. Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid Provider Agreement.

F. Persons and entities that are excluded or debarred under any state or federal law, regulation, or rule, are not eligible to enroll, or to remain enrolled, as Medicaid providers.

201.400 Arkansas Medicaid Participation Requirements for RadiationTherapy Centers

Providers of radiation therapy services must meet the following criteria in order to be eligible to participate in the Arkansas Medicaid Program:

A. The provider must obtain and maintain a current license, certification or other proof of qualifications to operate, in conformity with the laws and rules of the state in which the provider is located.

B. The provider must be certified as a Title XVIII (Medicare) radiation therapy center in their home state.

C. The provider must complete a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). (See Section I of this manual.) The following information must be submitted with the application and contract:
1. A copy of the provider's current state license or certification.

2. A copy of the provider's Title XVIII (Medicare) certification.

3. Subsequent certifications and license renewals must be submitted to the Arkansas Medicaid Program within 30 days of issuance. If the renewal document(s) have not been received within this timeframe, the provider will have an additional and final 30 days to comply.

D. Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid Provider Agreement.

E. Persons and entities that are excluded or debarred under any state or federal law, regulation, or rule, are not eligible to enroll, or to remain enrolled, as Medicaid providers.

213.110 Physician Assistant Services

Physician assistant services are services furnished under the direct supervision of the physician for which the physician takes full responsibility. A physician assistant providing services during a surgical procedure is not covered as an assistant surgeon. The service is not considered to be separate from the physician's service.

221.100 Additional Family Planning Benefit Information Regarding Aid Categories 69 and 61

A. Women in Aid Category 69, FP-W, are eligible for all family planning services, subject to the benefit limits listed in this manual.
1. Women in the FP-W category who elect sterilization are covered for one post-sterilization visit per State fiscal year (July 1 through June 30).

2. Please refer to Section 243.100 for additional information regarding the Family Planning Services Demonstration Waiver.

B. Family planning services, including sterilization procedures, are also covered for women eligible in the Pregnant Woman-Poverty Level (PW-PL) category, Aid Category 61. Beneficiaries in aid category 61 are eligible for family planning services through the last day of the month in which the 60th day postpartum falls.

223.000 Injections

A. The Arkansas Medicaid Program applies benefit limits to some covered injections.

B. For information on coverage of injections, special billing instructions and procedure codes, refer to sections 292.590 through 292.599 of this manual.

225.000 Outpatient Hospital Benefit Limit

Medicaid-eligible recipients age 21 and older are limited to a total of 12 outpatient hospital visits a year. This benefit limit includes outpatient hospital services provided in an acute care/general or a rehabilitative hospital. This yearly limit is based on the State Fiscal Year (July 1 through June 30).

A. Outpatient hospital services include the following:
1. Non-emergency professional visits in the outpatient hospital and related physician services.

2. Outpatient hospital therapy and treatment services and related physician services.

B. Extension of benefits will be considered for patients based on medical necessity.

C. The Arkansas Medicaid Program automatically extends the outpatient hospital visit benefit for certain primary diagnoses. Those diagnoses are:
1. Malignant Neoplasm (diagnosis code range 140.0 through 208.91);

2. HIV disease (includes AIDS) (diagnosis code 042);

3. Renal failure (diagnosis code range 584 and 585) and

4. Pregnancy (diagnosis code range 630 through 677, and diagnosis codes V22.0, V22.1 ,and V28.0 through V28.9.

D. When a Medicaid eligible recipient's primary diagnosis is one of those listed above and the Medicaid eligible recipient has exhausted the Medicaid established benefit limit for outpatient hospital services and related physician services, the provider does not have to file for an extension of the benefit limit.

E. All outpatient hospital services for recipients under age 21 in the Child Health Services (EPSDT) Program are not benefit limited.

F. Emergency and surgical physician services provided in an outpatient hospital setting are not benefit limited.

227.000 Physical and Speech Therapy Services

A. Arkansas Medicaid applies the following benefit limits for beneficiaries of all ages.
1. Evaluations for physical and speech therapy services for beneficiaries of all ages are limited to four (4) units (1 unit = 30 minutes) per State Fiscal Year (July 1 through June 30).

2. Individual and group physical therapy services for beneficiaries of all ages are limited to a maximum of four (4) 15-minute units of therapy per day. Group therapy must be provided in a group size of no more than four clients per group.

3. Arkansas Medicaid will reimburse the physician for make-up therapy sessions in the event a physical therapy session is canceled or missed. Make-up therapy sessions are covered when medically necessary and prescribed by the beneficiary's primary care physician (PCP). A new prescription, signed by the PCP, is required for each make-up therapy session.

B. Extension of the benefit may be provided for physical and speech therapy services based on medical necessity for Medicaid beneficiaries underage 21. Refer to section 229.100 of this manual for procedures for obtaining extension of benefits.

229.130 Administrative Reconsideration of Extensions of Benefits Denial

A. A request for administrative reconsideration of an extension of benefits denial must be in writing and sent to AFMC within 30 calendar days of the denial. The request must include a copy of the denial letter and additional supporting documentation pursuant to section 229.120.

B. The deadline for receipt of the reconsideration request will be enforced pursuant to sections 190.012 and 190.013 of this manual. A request received by AFMC within 35 calendar days of a denial will be deemed timely. A request received later than 35 calendar days gives rise to a rebuttable presumption that it is not timely.

229.140 Appealing an Adverse Action

Please see section 190.000etal. for information regarding administrative appeals.

243.000 Family Planning Services

A. Arkansas Medicaid encourages reproductive health and family planning by reimbursing physicians, nurse practitioners, clinics and hospitals for a comprehensive range of family planning services.
1. Family planning services do not require a PCP referral.

2. Medicaid beneficiaries' family planning services benefits are in addition to their other medical benefits, when providers bill the services specifically as family planning services.

3. Abortion is not a family planning service in the Arkansas Medicaid Program.

B. Physicians desiring to participate in the Medicaid Family Planning Services Program may do so by providing the services listed in sections 243.300 through 243.500 to Medicaid clients of childbearing age.

C. Physicians preferring not to provide family planning services may refer their patients to other providers. DHHS County Offices maintain listings of local and area providers qualified to provide family planning services. Listed providers include:
1. Arkansas Division of Health local health units

2. Obstetricians and gynecologists

3. Nurse practitioners

4. Rural Health Clinics

5. Federally Qualified Health Centers

6. Family planning clinics

D. Complete billing instructions for family planning services are in section 292.550 of this manual.

243.100 Family Planning Services Demonstration Waiver

A. The Arkansas Medicaid program administers a Family Planning Services Demonstration Waiver. This waiver program extends Medicaid coverage of family planning services to women throughout Arkansas who meet the eligibility requirements for participation.

B. Family Planning Services Demonstration Waiver beneficiaries must be of childbearing age. The target population is women age 14 to age 44, but all women at risk of unintended pregnancy may apply for Family Planning Services Demonstration Waiver (FP-W) eligibility.

C. Women certified eligible under this waiver will generally remain eligible for the duration of the waiver. Loss of FP-W eligibility occurs only when an FP-W woman:
1. Moves out of the state

2. Becomes Medicaid-eligible in another Aid Category

3. Becomes pregnant or

4. Requests that her case be closed.

D. The women in the FP-W category are eligible for Medicaid coverage of family planning services only. The PES eligibility transaction response identifies them as eligible in Aid Category 69 (FP-W).

243.200 Family Planning Services for Women in Aid Category 61, PW-PL

Women in Aid Category 61, Pregnant Woman - Poverty Level (PW-PL), are eligible for all Medicaid-covered family planning services. The Medicaid Program expects, however, that many of those women who desire family planning services will apply for and obtain eligibility under the Family Planning Services Demonstration Waiver. Beneficiaries in aid category 61 are eligible for family planning services through the last day of the month in which the 6(fh day postpartum falls.

244.000 Covered Drugs and Immunizations

The Arkansas Medicaid Program provides coverage of drugs for treatment purposes and for immunizations against many diseases. Most of these are administered by injection. Appropriate procedure codes may be found in the CPTand HCPCS books and in this manual. The following types of drugs are covered.

A. Chemotherapy and immunosuppressive drugs. (See sections 292.590 and 292.591.) No take-home drugs are covered.

B. Desensitization (allergy) injections for beneficiaries in the Child Health Services (EPSDT) program. (See section 292.420 of this manual for billing instructions.)

C. Immunizations, childhood immunizations and those covered for adults. (See sections 292.592 through 292.598 of this manual for special billing instructions.)

D. Other injections that are covered for specific diagnoses and/or conditions. (See sections 292.592 through 292.595.) No take-home drugs are covered.

251.100 Co-Surgery

Covered surgical procedures performed simultaneously on a Medicaid beneficiary are covered as separate procedures. Refer to section 292.451 for billing instructions.

251.110 Assistant Surgery

For medical payment to be made to an assistant surgeon, the physician who wishes to use an assistant surgeon must obtain prior authorization from the Arkansas Foundation for Medical Care (AFMC). Assistant surgeon services are reimbursed only when provided by a physician. See section 261.000 of this manual for prior authorization instructions. This provision applies to all surgery.

251.120 Surgical Residents

In order for surgeons enrolled in the Arkansas Medicaid Program to be reimbursed for services provided by a surgical resident, the surgeon must be physically present in the operating room with the resident while services are being provided.

253.000 Bilaminate Graft or Skin Substitute

Arkansas Medicaid covers bilaminate graft or skin substitute, known as dermal and epidermal tissue of human origin, with or without bioengineered or processed elements, with metabolically active elements. Prior authorization is required for the product and the application procedure.

This product is designed to be used for treatment of non-infected partial and full-thickness skin ulcers due to venous insufficiency and for treatment of full-thickness neuropathic diabetic foot ulcers that extend through the dermis, but without tendon, muscle, capsule or bone exposure and which are located on the plantar, medial or lateral area of the foot (excluding the heel).

A. Indications and Documentation:

Coverage of this modality/product will be considered when all of the following conditions are satisfied and documented:

1. Partial or full-thickness skin ulcers due to venous insufficiency or full-thickness neuropathic diabetic foot ulcers,

2. Ulcers of greater than three (3) months duration and

3. Ulcers that have failed to respond to documented conservative measures of greater than two (2) months duration.

4. There must be measurements of the initial ulcer size, the size of the ulcer following cessation of conservative management and the size at the beginning of skin substitute treatment.

5. For neuropathic diabetic foot ulcers, appropriate steps to off-load pressure during treatment must be taken and documented in the patient's medical record.

6. In addition, the ulcer must be free of infection and underlying osteomyelitis and treatment of the underlying disease (e.g., peripheral vascular disease) must be provided and documented in conjunction with skin substitute treatment.

B. Diagnosis Restrictions:

Coverage of the bilaminate skin product and its application is restricted to the following ICD-9-CM codes:

454.0

454.2

250.8 (requires a fifth-digit subclassification)

707.10

707.13

707.14

707.15

940.0 through 949.5

Prior authorization (PA) is required for the product and the application procedure. Application procedures do not require PA when the diagnosis code range is ICD-9-CM 940.0 through 949.5. Refer to section 261.120 of this manual for PA process. Refer to section 228.000 of this manual for benefit limits.

254.000 Enterra Therapy for Treatment of Gastroparesis

A. Effective for dates of service on and after March 1, 2005, Arkansas Medicaid covers Enterra, implantable neurostimulator therapy.

B. Coverage of Enterra therapy is limited to individuals ages 18 through 69 with diabetic and idiopathic gastroparesis (diagnosis codes 536.3 and 250.6).
1. Service includes the implantable neurostimulator electrode(s) and the neurostimulator pulse generator.

2. Implantation procedures for neurostimulator pulse generator and the neurostimulator electrodes are covered as inpatient surgical procedures.
a. The surgical procedures require prior authorization (PA) by AFMC.

b. An approval letter from the Institutional Review Board is required. Patient's record must include documentation that further total parental nutrition (TPN) therapy is not an option.

3. Procedure for revision or removal of the peripheral neurostimulator electrodes does not require PA, but claim will be manually reviewed prior to reimbursement.

C. See section 292.880 of this manual for procedure codes and billing instructions.

255.000 Ultrasonic Osteogenic Stimulator for Treatment of Non-Union Fractures (Exogen)

A. Effective for dates of service on and after March 1, 2005, Arkansas Medicaid added coverage of ultrasonic osteogenic stimulator (Exogen) for the treatment of non-union fractures for beneficiaries of all ages.

B. The prior authorization (PA) process is the same as for all durable medical equipment (DME) procedure codes that require PA. The patient's physician must prescribe the device and make a referral to the DME provider.

Prior authorization request requires documentation of the following:

1. A minimum of two sets of radiographs, separated by a minimum of 90 days, and obtained prior to starting treatment with the osteogenic stimulator.

2. Multiple views of the fracture site for each radiograph.

3. The physician's written statement that there has been no clinically significant evidence of fracture healing in the interval between the two sets of radiographs.

C. Prior authorization of the device may be approved for up to 180 days. If the need for the device extends beyond 180 days, an additional PA is required. Documentation which includes updated evaluations must be submitted with the PA request.

D. Coverage of the device does not include:
1. Non-unions of the skull, vertebrae and those tumor-related.

2. Concurrent use with other non-invasive osteogenic devices

256.000 Gastrointestinal Tract Imaging with Endoscopy Capsule

A. Arkansas Medicaid covers wireless endoscopy capsule for evaluation of occult gastrointestinal bleeding in the anemic patient under the conditions listed blow.
1. The site of the bleeding has not been identified by previous gastrointestinal endoscopy, colonoscopy push endoscopy or other radiological procedures.

2. An abnormal x-ray of the small intestine is documented without an identified site bleeding.

3. An initial diagnosis of suspected Crohn's disease without the evidence of disease is made based on conventional diagnostic tests such as small bowel follow through and upper and lower endoscopy.

4. The evaluation indicates obscure gastrointestinal bleeding suspected of being small bowel in origin as evidenced by prior inconclusive upper and lower endoscopic studies.

B. Coverage of this procedure is limited to individuals 10 years through 20 years of age. Medical necessity requires one of the following ICD-9-CM diagnosis codes: 280.9, 578.1, 578.9 or 792.1.

C. Coverage of this procedure is limited to individuals 10 years through 20 years of age. Medical necessity requires one of the following ICD-9-CM diagnosis codes: 280.9, 578.1, 578.9 or 792.1.

D. See section 292.890 for procedure code and billing instructions.

257.000 Tobacco Cessation Products Counseling Services

Arkansas Medicaid covers generic Zyban (bupropion for tobacco cessation), nicotine gum or nicotine patches through the Medicaid Prescription Drug Program.

A. Physician providers may participate by prescribing covered tobacco cessation products.
1. The reimbursement to the pharmacy provider for the products is available for up to 2 ninety-three day courses of treatment within a calendar year.

2. Beneficiaries who are pregnant are allowed up to four ninety-three day courses of treatment per calendar year.

3. One course of treatment is three consecutive months.

B. Counseling by the prescriber is required for coverage of the products. Counseling consists of reviewing the Public Health Service (PHS) guideline-based checklist with the patient. The prescriber must retain the counseling checklist in the patient records for audit. A copy of the checklist is available on the Medicaid website at www.medicaid.state.ar.us.

C. Counseling procedures do not count against the twelve visits per state fiscal year (STY), but they are limited to no more than two 15-minute units and two 30-minute units for a maximum allowable of 4 units perSFY.

D. Refer to section 292.900 for procedure codes and billing instructions.

262.000 Procedures That Require Prior Authorization

A. Retroactive to March 1, 2005, procedure codes 76012 and 76013 are payable without prior authorization.

B. The following procedure codes require prior authorization:

Procedure Codes

J7320

J7340

S0512

S2213

V5014

00170

01964

11960

11970

11971

15342

15343

15400

15831

19318

19324

19325

19328

19330

19340

19342

19350

19355

19357

19361

19364

19366

19367

19368

19369

19370

19371

19380

20974

20975

21076

21077

21079

21080

21081

21082

21083

21084

21085

21086

21087

21088

21089

21120

21121

21122

21123

21125

21127

21137

21138

21139

21141

21142

21143

21145

21146

21147

21150

21151

21154

21155

21159

21160

21172

21175

21179

21180

21181

21182

21183

21184

21188

21193

21194

21195

21196

21198

21199

21208

21209

21244

21245

21246

21247

21248

21249

21255

21256

27412

27415

29866

29867

29868

30220

30400

30410

30420

30430

30435

30450

30460

30462

32851

32852

32853

32854

33140

33282

33284

33945

36470

36471

37785

37788

38240

38241

38242

42820

42821

42825

42826

42842

42844

42845

42860

42870

43257

43644

43645

43842

43843

43845

43846

43847

43848

43850

43855

43860

43865

47135

48155

48160

48554

48556

50320

50340

50360

50365

50370

50380

51925

54360

54400

54415

54416

54417

55400

57335

58150

58152

58180

58260

58262

58263

58267

58270

58280

58290

58291

58292

58293

58294

58345

58550

58552

58553

58554

58672

58673

58750

58752

59135

59840

59841

59850

59851

59852

59855

59856

59857

59866

60512

61850

61860

61862

61870

61875

61880

61885

61886

61888

63650

63655

63660

63685

63688

64555

64573

64585

64809

64818

65710

65730

65750

65755

67900

69300

69310

69320

69714

69715

69717

69718

69930

87901

87903

87904

92081

92100

92326

92393

93980

93981

Procedure Code

Modifier

Description

E0779

RR

Ambulatory infusion device

D0140

EP

EPSDT interperiodic dental screen

L8619

EP

External sound processor

S0512

Daily wear specialty contact lens, per lens

V2501

UA

Supplying and fitting Keratoconus lens (hard or gas permeable) -1 lens

V2501

U1

Supplying and fitting of monocular lens (soft lens) -1 lens

Z1930

Non-emergency hysterectomy following c-section

92002

UB

Low vision services - low vision evaluation

292.111 Non-Covered ICD-9-CM Diagnosis Codes

A. The following ICD-9-CM diagnosis codes are not acceptable when filing claims for services provided to beneficiaries of all ages:

V57. 1, V57.2, V57.3, V72.5 and V72.6

B. The following ICD-9-CM diagnosis codes are not acceptable when filing claims for services provided to individuals under age 21:

V70. 0, V70.3, V70.7, V70.9 and V72.85

292.310 Completion of CMS-1500 Claim Form

Field Name and Number

Instructions for Completion

1. Type of Coverage 1a. Insured's I.D. Number

This field is not required for Medicaid.

Enter the patient's 10-digit Medicaid identification number.

2. Patient's Name

Enter the patient's last name and first name.

3. Patient's Birth Date Sex

Enter the patient's date of birth in MM/DD/YY format as it appears on the Medicaid identification card.

Check "M" for male or "F" for female.

4. Insured's Name

Required if there is insurance affecting this claim. Enter the insured's last name, first name and middle initial.

5. Patient's Address

Optional entry. Enter the patient's full mailing address, including street number and name (post office box or RFD), city name, state name and ZIP code.

6. Patient Relationship to Insured

Check the appropriate box indicating the patient's relationship to the insured if there is insurance affecting this claim.

7. Insured's Address

Required if insured's address is different from the patient's address.

8. Patient Status

This field is not required for Medicaid.

9. Other Insured's Name a. Other Insured's Policy or Group Number b. Other Insured's Date of Birth

Sex c. Employer's Name or School Name d. Insurance Plan Name or Program Name

If patient has other insurance coverage as indicated in Field 11D, enter the other insured's last name, first name and middle initial.

Enter the policy or group number of the other insured.

This field is not required for Medicaid.

This field is not required for Medicaid. Enter the employer's name or school name.

Enter the name of the insurance company.

10. Is Patient's Condition Related to:

a. Employment b. Auto Accident

Check "YES" if the patient's condition was employment related (current or previous). If the condition was not employment related, check "NO."

Check the appropriate box if the patient's condition was auto accident related. If "YES," enter the place (two letter state postal abbreviation) where the accident took place. Check "NO" if not auto accident related.

c. Other Accident 10d. Reserved for Local Use

Check "YES" if the patient's condition was other accident related. Check "NO" if not other accident related.

This field is not required for Medicaid.

11. Insured's Policy Group or FECA Number a. Insured's Date of Birth Sex b. Employer's Name or School Name c. Insurance Plan Name or Program Name d. Is There Another Health Benefit Plan?

Enter the insured's policy group or FECA number.

This field is not required for Medicaid. This field is not required for Medicaid. Enter the insured's employer's name or school name.

Enter the name of the insurance company.

Check the appropriate box indicating whether there is another health benefit plan.

12. Patient's or Authorized Person's Signature

This field is not required for Medicaid.

13. Insured's or Authorized Person's Signature

This field is not required for Medicaid.

14. Date of Current:

4. Illness Injury Pregnancy

Required only if medical care being billed is related to an accident. Enter the date of the accident.

15. If Patient Has Had Same or Similar Illness, Give First Date

This field is not required for Medicaid.

16. Dates Patient Unable to Work in Current Occupation

This field is not required for Medicaid.

17. Name of Referring Physician or Other Source

17a. I.D. Number of Referring Physician

Primary Care Physician (PCP) referral is required for most Physician/Independent Lab/CRNA/Radiation Therapy Center services provided by non-PCPs. Enter the referring physician's name and title.

Enter the 9-digit Medicaid provider number of the referring physician.

18. Hospitalization Dates Related to Current Services

For services related to hospitalization, enter hospital admission and discharge dates in MM/DD/YY format.

19. Reserved for Local Use

Not applicable.

20. Outside Lab?

This field is not required for Medicaid

21. Diagnosis or Nature of Illness or Injury

Enter the diagnosis code from the ICD-9-CM. Up to four diagnoses may be listed. Arkansas Medicaid requires providers to comply with CMS diagnosis coding requirements found in the ICD-9-CM edition current for the claim dates of service.

22. Medicaid Resubmission Code Original Ref No.

Reserved for future use. Reserved for future use.

23. Prior Authorization Number

Enter the prior authorization number, if applicable.

24. A. Dates of Service

B. Place of Service

C. Type of Service

D. Procedures, Services or Supplies

CPT/HCPCS

Modifier

E. Diagnosis Code

F. $ Charges

G. Days or Units

H. EPSDT/Family Plan

1. EMG J. COB

Enter the "from" and "to" dates of service, in MM/DD/YY format, for each billed service.

1. On a single claim detail (one charge on one line), bill only for services within a single calendar month.

2. Providers may bill, on the same claim detail, for two (2) or more sequential dates of service within the same calendar month when the provider furnished equal amounts of service on each day of the span.

Enter the appropriate place of service code. See Section 292.200 for codes.

Enter the appropriate type of service code. See Section 292.200 for codes.

Enter the correct CPT or HCPCS procedure code for service delivered. Unlisted codes require a description of the service and pertinent attachments.

Use applicable modifier.

Enter a diagnosis code that corresponds to the diagnosis in Field 21. If preferred, simply enter the corresponding line number ("1," "2," "3," "4") from Field 21 on the appropriate line in Field 24E instead of reentering the actual corresponding diagnosis code. Enter only one diagnosis code or one diagnosis code line number on each line of the claim. If two or more diagnosis codes apply to a service, use the code most appropriate to that service. The diagnosis codes are found in the ICD-9-CM.

Enter the charge for the service. This charge should be the provider's usual charge to private clients. If more than one unit of service is being billed, enter the charge for the total number of units billed.

Enter the units (in whole numbers) of service rendered within the time frame indicated in Field 24A.

Enter "E" if services rendered were a result of a Child Health Services (EPSDT) screening/referral.

Emergency - This field is not required for Medicaid.

Coordination of Benefit - This field is not required for Medicaid.

K. Reserved for Local Use

When billing for a clinic or group practice, enter the 9-digit Medicaid provider number of the performing provider in this field and enter the group provider number in Field 33 after "GRP#."

When billing for an individual practitioner whose income is reported by 1099 under a Social Security number, DO NOT enter the provider number here. Enter the number in Field 33 after "GRP#."

25. Federal Tax I.D. Number

This field is not required for Medicaid. This information is carried in the provider's Medicaid file. If it changes, please contact Provider Enrollment.

26. Patient's Account No.

This is an optional entry that may be used for accounting purposes. Enter the patient's account number, if applicable. Up to 16 numeric or alphabetic characters will be accepted.

27. Accept Assignment

This field is not required for Medicaid. Assignment is automatically accepted by the provider when billing Medicaid.

28. Total Charge

Enter the total of Field 24F. This field should contain a sum of charges for all services indicated on the claim form. (See NOTE below Field 30.)

29. Amount Paid

Enter the total amount of funds received from other sources. The source of payment should be indicated in Field 11 and/or Field 9. Do not enter any amount previously paid by Medicaid. Do not enter any payment by the beneficiary.

30. Balance Due

Enter the net charge. This amount is obtained by subtracting the amount received from other sources from the total charge.

NOTE: For Fields 28, 29 and 30, up to 26 lines may be billed per claim. To bill a continued claim, enter the page number of the continued claim here (e.g., page 1 of 3, page 2 of 3). On the last page of the claim, enter the total charges due.

31. Signature of Physician or

Supplier, Including Degrees or Credentials

The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider's direction. "Provider's signature" is defined as the provider's actual signature, a rubber stamp of the provider's signature, an automated signature, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable.

32. Name and Address of Facility Where Services Were Rendered (If Other Than Home or Office)

If other than home or office, enter the name and address, specifying the street, city, state and ZIP code of the facility where services were performed.

33. Physician's/Supplier's Billing Name, Address, ZIP Code & Phone#

PIN#

GRP#

Enter the billing provider's name and complete address. Telephone number is requested but not required.

This field is not required for Medicaid.

Clinic or Group Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#" and the individual practitioner's number in Field 24K.

Individual Providers: Enter the 9-digit pay-to provider number in Field 33 after "GRP#."

292.443 Medicaid Coverage for Therapeutic Infusions (Excludes Chemotherapy) Procedure codes 90780 and 90781 are payable for all ages.

292.447 Example of Proper Completion of Claim

The following is a cutaway section of the CMS-1500 claim form demonstrating the proper method of entering the following information:

Line No. 1 - Anesthesia for Procedure Line No. 2 - Qualifying Circumstance

DATE (S) OF SERVICE

Place of Service

Type of

Service

PROCEDURES, SERVICES OR SUPPLIES (Explains Unusual Circumstances)

DIAGNOSIS CODE

S CHARGES

DAYS

OR

UNITS

EPSDT Family Plan

EMG

COB

RESERVED

FOR LOCAL

USE

From

To

MM

DD

YY

MM

DD

YY

CPT HCPCS

Modifier

07

15

03

1

7

00560

P3

441.3

XXX XX

12

105967001

180 min.

12 units

07

15

03

1

1

99116

441.3

XXX XX

1

105967001

292.450 Assistant Surgery

Assistant surgeon's fees require prior authorization. For paper claims, use type of service code "8" with the same procedure code billed by the surgeon. When filing electronically, use modifier 80.

292.451 Co-Surgery

Co-surgeon billing is indicated with modifier 62. Modifier 62 must be used in accordance with CPT guidelines. Paper claims require type of service code "2" in addition to modifier 62. Operative reports from all physicians performing surgery during the same operative session must be attached to the claim that includes modifier 62.

292.550 Family Planning Services Program Procedure Codes

Family Planning Services Program procedure codes payable to physicians require a modifier "FP". For paper claims, physicians must use type of service code "A" with the modifier. All procedure codes in this table require a family planning or sterilization diagnosis code in each claim detail.

Procedure Codes

11975

11976

11977

55250

55450

58300

58301

58600

58605

58611

58615

58661*

58670

58671

58700*

* CPT codes 58661 and 58700 represent procedures to treat medical conditions as well as for elective sterilizations. When filing paper claims for either of these services for elective sterilizations, enter type of service code "A". When using either of these codes for treatment of a medical condition, type of service code "2" must be entered for the primary surgeon or type of service code "8" for an assistant surgeon.

Effective for dates of service on and after April 1, 2005, procedure code 58565 is covered as a family planning service. Procedure code 58565 includes payment for the device.

Procedure Code

Modifier(s)

Description

A4260

FP

Norplant System (Complete Kit)

J1055

FP

Medroxyprogesterone acetate for contraceptive use

J7300

FP

Supply of Intrauterine Device

J7302

FP

Levonorgestrel-releasing intrauterine contraceptive system

J7303

FP

Contraceptive Supply, Hormone Containing Vaginal Ring

S0612**

FP, TS

Annual Post-Sterilization Visit After sterilization, this is the only service covered for individuals in aid category 69.)

36415

Routine Venipuncture for Blood Collection

99401

FP, UA, UB

Periodic Family Planning Visit

99401

FP, UA, U1

Arkansas Division of Health Periodic/Follow-Up Visit

99402

FP, UA

Arkansas Division of Health Basic Visit

99402

FP, UA, UB

Basic Family Planning Visit

When filing family planning claims for physician services in an outpatient clinic, use modifiers U6, UA for the basic family planning visit and the periodic family planning visit. If filing on paper, use type of service code "J" with the modifiers.

292.551 Family Planning Laboratory Procedure Codes

This table contains laboratory procedure codes payable in the Family Planning Services Program. They are also payable when used for purposes other than family planning. Bill procedure codes in this table with type of service code (paper only) "A" when the service diagnosis indicates family planning. Refer to section 292.730 for other applicable type of service codes (paper only) for laboratory procedures.

Independent Lab CPT Codes

81000

81001

81002

81003

81025

83020

83520

83896

84703

85014

85018

85660

86592

86593

86687

86701

87075

87081

87087

87210

87390

87470

87490

87536

87590

88142*

88143*

88150***

88152

88153

88154

88155***

88164

88165

88166

88167

88174

88175

87621**

89300

89310

89320

Q0111

* Procedure codes 88142 and 88143 are limited to one unit per beneficiary per state fiscal year.

** Effective for dates of service on and after July 1, 2005, procedure code 87621 is payable as a family planning service. This code is payable only to pathologists and independent labs.

*** Payable only to pathologists and independent labs with type of service code (paper only) "A."

Procedure Code

Required Modifiers

Description

88302

FP

Surgical Pathology, Complete Procedure, Elective Sterilization

88302

FP, U2

Surgical Pathology, Professional Component, Elective Sterilization

88302

FP, U3

Surgical Pathology, Technical Component, Elective Sterilization

292.591 Injections and Oral Immunosuppressive Drugs

A. The following procedure codes for the administration of chemotherapy agents are payable only if provided in a physician's office, place of service code: Paper "3" or electronic "11." These procedures are not payable if performed in the inpatient or outpatient hospital setting:

96400

96408

96414

96423

96545

96405

96410

96420

96425

96549

96406

96412

96422

96520

Only one administration fee is allowed per date of service unless "multiple sites" are indicated in the "Procedures, Services, or Supplies" field in the CMS-1500 claim format. Supplies are included as part of the administration fee. The administration fee is not allowed when drugs are given orally.

Multiple units may be billed. Take-home drugs are not covered. Drugs loaded into an infusion pump are not classified as "take home drugs."

B. The following is a list of covered therapeutic agents payable to the physician when furnished in the office. Multiple units may be billed, if appropriate. Take-home drugs are not covered. Drugs loaded into an infusion pump are not classified as "take-home drugs."

For coverage information regarding any chemotherapy agent not listed, please contact the Medicaid Reimbursement Unit. View or print Medicaid Reimbursement Unit contact information.

This list includes drugs covered for recipients of all ages. However, when provided to individuals aged 21 or older, a diagnosis of malignant neoplasm or HIV disease is required.

Procedure Codes

J0120

J0190

J0205

J0207

J0210

J0256

J0280

J0285

J0290

J0295

J0300

J0330

J0350

J0360

J0380

J0390

J0460

J0470

J0475

J0500

J0515

J0520

J0530

J0540

J0550

J0560

J0570

J0580

J0595*

J0600

J0610

J0620

J0630

J0640

J0670

J0690

J0694

J0696

J0697

J0698

J0702

J0704

J0710

J0713

J0715

J0720

J0725

J0735

J0740

J0743

J0745

J0760

J0770

J0780

J0800

J0835

J0850

J0895

J0900

J0945

J0970

J1000

J1020

J1030

J1040

J1051

J1060

J1070

J1080

J1094

J1100

J1110

J1120

J1160

J1165

J1170

J1180

J1190

J1200

J1205

J1212

J1230

J1240

J1245

J1250

J1260

J1320

J1325

J1330

J1364

J1380

J1390

J1410

J1435

J1436

J1440

J1441

J1455

J1570

J1580

J1610

J1620

J1626

J1630

J1631

J1642

J1644

J1645

J1650

J1670

J1700

J1710

J1720

J1730

J1742

J1750

J1785

J1800

J1810

J1815

J1825

J1830

J1840

J1850

J1885

J1890

J1910

J1940

J1950

J1955

J1960

J1980

J1990

J2000

J2001

J2010

J2060

J2150

J2175

J2180

J2185

J2210

J2250

J2270

J2275

J2280

J2300

J2353*

J2354*

J2310

J2320

J2321

J2322

J2360

J2370

J2400

J2405

J2410

J2430

J2440

J2460

J2510

J2515

J2540

J2550

J2560

J2590

J2597

J2650

J2670

J2675

J2680

J2690

J2700

J2710

J2720

J2725

J2730

J2760

J2765

J2783*

J2800

J2820

J2912

J2920

J2930

J2950

J2995

J3000

J3010

J3030

J3070

J3105

J3120

J3130

J3140

J3150

J3230

J3240

J3250

J3260

J3265

J3280

J3301

J3302

J3303

J3305

J3310

J3320

J3350

J3360

J3364

J3365

J3370

J3400

J3410

J3430

J3470

J3475

J3480

J3490*

J3520

J7190

J7191

J7192

J7194

J7197

J7310

J7501

J7504

J7505

J7506

J7507*

J7508*

J7509

J7510

J7599*

J8530

J9000

J9001

J9010

J9015

J9020

J9031

J9040

J9045

J9050

J9060

J9062

J9065

J9070

J9080

J9090

J9091

J9092

J9093

J9094

J9095

J9096

J9097

J9098*

J9100

J9110

J9120

J9130

J9140

J9150

J9165

J9170

J9178*

J9181

J9182

J9185

J9190

J9200

J9201

J 92 02

J9206

J9208

J9209

J9211

J9212

J9213

J9214

J9215

J9216

J9217

J9218*

J9230

J9245

J9250

J9260

J9263*

J9265

J9266

J9268

J9270

J9280

J9290

J9291

J9293

J9300

J9310

J9320

J9340

J9355

J9360

J9370

J9375

J9380

J9390

J9600

J9999*

Q0163

Q0164

Q0165

Q0166

Q0167

Q0168

Q0169

Q0170

Q0171

Q0172

Q0173

Q0174

Q0175

Q0176

Q0177

Q0178

Q0179

Q0180

Q4075

S0187

* Procedure code requires paper billing. Include the name of drug and dose given to patient. Attach invoice of the drug is not listed in the current Red Book.

292.592 Other Covered Injections and Immunizations with Special

Instructions

Physicians may bill for immunization procedures on either the Child Health Services (EPSDT) DMS-694 claim form or the CMS-1500 claim form. View a DMS-694 sample form. View a CMS-1500 sample form. On paper claims use type of service code "1."

When a patient is scheduled for immunization only, reimbursement is limited to the immunization. The provider may bill for the immunization only. Unless otherwise noted in this section of the manual, covered vaccines are payable only for beneficiaries under age 21.

The following is a list of injections with special instructions for coverage and billing.

Procedure Code

Modifier(s)

Special Instructions

J0150

Procedure is covered for all ages with no diagnosis restriction.

J0152

Code is payable or all ages. When administered in the office, the provider must have nursing staff available to monitor the patient's vital signs during infusion. The provider must be able to treat anaphylactic shock and to provide advanced cardiac life support in the treatment area where the drug is infused.

J0170

The code is payable if the service is performed on an emergency basis and is provided in a physician's office.

J0585

The code is payable for individuals of all ages. Botox A is reviewed for medical necessity based on diagnosis code.

J0636

This code is payable for individuals of all ages receiving dialysis due to acute renal failure (diagnosis codes 584-586).

J0702

This code is covered for beneficiaries of all ages. However, when provided to beneficiaries aged 21 and older, there must be a diagnosis of aids, cancer or complications during pregnancy (diagnosis code range 640 - 648.9).

J0180

See section 292.595 for conditions of coverage and billing instructions.

J1100

This code is covered for beneficiaries of all ages. However, when provided to beneficiaries aged 21 and older, there must be a diagnosis of aids, cancer or complications during pregnancy (diagnosis code range 640 - 648.9).

J1460 J1470 J1480 J1490 J1500 J1510 J1520 J1530 J1540 J1550 J1560

Covered for individuals of all ages with no diagnosis restrictions.

J1563

Payable when administered to individuals of all ages with no diagnosis restrictions. Electronic claim and paper claims are manually reviewed for medical necessity, based on diagnosis code.

J1564

Payable when administered to individuals of all ages with no diagnosis restrictions.

J1600

This code is payable for patients with a diagnosis of rheumatoid arthritis.

J1745*

See section 292.594 for billing instructions.

J1931

See section 292.595 for conditions of coverage and billing instructions.

J2260

Payable for Medicaid beneficiaries of all ages with congestive heart failure (diagnosis codes 428-428.9) with places of service 2, X, 3 or 4 (for paper only) or 22, 23 or 11 (electronic).

J2505*

Covered for beneficiaries of all ages for beneficiaries with diagnoses 288.0, E933.1 and a cancer diagnosis. Procedure is also covered for individuals with a cancer diagnosis and documentation of a low white count, fever and current treatment with a myelosuppressive drug.

J2788

Limited to one injection per pregnancy.

J2790

Limited to one injection per pregnancy.

J2910

Payable for patients with a diagnosis of rheumatoid arthritis.

J2916*

Payable for beneficiaries aged 21 and older when there is a diagnosis of malignant neoplasm, diagnosis range 140.0-208.9, HIV disease, diagnosis code 042, or acute renal failure, diagnosis range 584-586. Paper claim is required with a statement that recipient is allergic to iron dextran.

J3420

Payable for patients with a diagnosis of pernicious anemia. Coverage includes the B-12, administration and supplies. It must not be billed in multiple units.

J3465*

Covered for non-pregnant beneficiaries aged 18 and older with a diagnosis of aids or cancer and one of the following diagnoses: 112.2, 112.3, 112.5, 112.84, 112.85, 112.9 or 117.3. Claims must be filed on paper.

J3487*

See section 292.596 for conditions of coverage and billing procedures.

J3490*

This unlisted code is payable forCancidas injection when administered to patients with refractory aspergillosis who also have a diagnosis of malignant neoplasm or HIV disease. Complete history and physical exam, documentation of failure with other conventional therapy and dosage must be submitted with invoice. After 30 days of use, an updated medical exam and history must be submitted.

J7199

Must be billed on a paper claim form with the name of the drug, dosage and the route of administration.

J7320

Requires prior authorization. Limited to 3 injections per knee, per beneficiary, per lifetime. See section 261.240.

J9219

This procedure code is covered for males of all ages with ICD-9-CM diagnosis code 185, 198.82 or V10.46. Benefit limit is one procedure every 12 months.

Q0136 Q0137

Payable for non-ESRD use. See section 292.593 for diagnosis restrictions and special instructions.

Q0187

Payable for treatment of bleeding episodes in hemophilia A or B patients with inhibitors to Factor VIII or Factor IX. Only payable with diagnosis codes 286.0, 286.1, 286.2 and 286.4.

Q4054 Q4055

Payable for ESRD use. See section 292.593 for diagnosis restrictions and special instructions.

Q4076

Payable for all ages with no diagnosis restrictions.

90371

U1

One unit equals 1/2 cc, with a maximum of 10 units billable per day. Payable for eligible Medicaid beneficiaries of all ages in the physician's office.

90375* 90376*

Covered for all ages. Services require paper claims with procedure code and dosage entered infield 24.D of claim form CMS-1500 for each date of service. If date spans are used, indicate appropriate units of service. The manufacturer's invoice must be attached. Reimbursement rate includes administration fee.

90385

Limited to one injection per pregnancy.

90581*

Payable for all ages.

90645 90646 90647 90655 90657 90658

EP, TJ

Modifiers required when administered to children underage 19. See section 292.597 for billing instructions.

90656

EP, TJ

Modifiers required when administered to children under age 19. Refer to section 292.598 for influenza vaccine policy.

90655

Effective October 1, 2005, this vaccine is covered for beneficiaries aged 19 and older. See section 292.598 of this manual.

90658

Vaccine is covered for beneficiaries aged 19 and older. See section 292.598 of this manual.

90660

Covered for healthy individuals ages 5-49 and not pregnant. See section 292.598 of this manual.

90669

EP, TJ

Administration of vaccine is covered for children under age 5. See section 292.597 for billing instructions.

90675* 90676*

Covered for all ages without diagnosis restrictions. Services require paper claims with procedure code and dosage entered in field 24.D of claim form CMS-1500 for each date of service. If date spans are used, indicate appropriate units of service. The manufacturer's invoice must be attached. Reimbursement rate includes administration fee.

90700 90702

EP, TJ

Modifiers required when administered to children underage 19. See section 292.597 for billing instructions.

90703

Payable for all ages.

90707

U1

Payable when provided to women of childbearing age, ages 21 through 44, who may be at risk of exposure to these diseases. Coverage is limited to two (2) injections per lifetime.

90707 90712 90713 90716 90718 90720 90721 90723

EP, TJ

Modifiers required when administered to children underage 19. See section 292.597 for billing instructions.

90715

This vaccine is covered for individuals aged 7 years and older.

90718

This vaccine is covered for individuals ages 19 and 20. Effective for dates of service on and after July 1, 2005, coverage of this vaccine has been extended to individuals age 21 and older.

90732

This code is payable for individuals aged 2 and older. Patients age 21 and older who receive the injection should be considered by the provider as high risk. All beneficiaries over age 65 may be considered high risk.

90735

Payable for individuals under age 21.

90743 90744 90748

EP, TJ

Modifiers required when administered to children underage 19. See section 292.597 for billing instructions.

* Procedure code requires paper billing with applicable attachments.

292.594 Infliximab Injection

The Arkansas Medicaid Program will reimburse physicians for HCPCS procedure code J1745 with a type of service "1". The Medicaid agency's medical staff must manually review claims for infliximab injections before payment is approved.

A. Claims must be submitted to EDS on paper with any applicable attachments.

B. The claim must include one of the following diagnoses:
1. ICD-9-CM code 555.9 as the primary diagnosis AND a secondary diagnosis of 565.1 OR 569.81;

2. ICD-9-CM code range 556.0 - 556.9:

3. ICD-9-CM code 696.0:

4. ICD-9-CM code 714.0; or

5. ICD-9-CM 724.9

292.595 Adgalsidase Beta and Laronidase Injections

A. Effective for dates of service on and after August 1, 2005, procedure code J0180 -Adgalsidase beta, per 1 mg, was made payable. This procedure is covered for treatment of Fabry's disease, ICD-9-CM diagnosis code 272.7.

B. Effective for dates of service on and after August 1, 2005, procedure code J1931 -Laronidase, per 2.9 mg, was made payable. This procedure is covered for treatment of mucopolysaccharidosis (MPS I), ICD-9-CM diagnosis code 277.5.

C. The injections may be provided in the outpatient hospital or emergency room. If the physician provides the service in the office, the following conditions apply.
1. The provider must have nursing staff available to monitor the patient's vital signs during the infusion.

2. The provider must be able to treat anaphylactic shock in the treatment area where the drugs are infused.

D. When the physician determines a Medicaid beneficiary needs the injection, he or she must obtain prior approval from the Medical Director of the Division of Medical Services before beginning therapy.

The prior approval request must include:

1. Documentation of an office visit that includes a physical examination specifically identified by its date and must note the diagnosis

2. Medical history that includes an annotated list of previous treatment protocols administered and their results

3. Statement of medical necessity, including method of diagnosis, from genetics physician

292.596 Zoledronic Acid Injection

A. Zoledronic acid injection, procedure code J3487, is payable to the physician when provided in the office for patients of all ages. However, beneficiaries aged 21 and older must have one of the following:
1. A diagnosis of AIDS or cancer along with diagnosis code 272.42; or

2. A diagnosis of 198.5; or

3. A diagnosis of 203.0

B. Procedure code J3487 must be billed on paper with a type of service code "1" and the number of units indicated. If ICD-9-CM diagnosis criteria is used in point A above, no medical records are required.

C. Utilization Review's medical staff must manually review claims for zoledronic acid injections before payment is approved.

292.640 Multiple Surgery

If multiple surgical procedures are done on the same day of service, whether in the same operative session or not, each procedure should be listed in field 24.D on one claim form, including all appropriate modifiers. For paper claims, attach all necessary documentation to the claim. Filing all services that are performed on the same date of service on one claim is necessary to expedite correct payment of each procedure.

292.870 Bilaminate Graft or Skin Substitute Procedures

Arkansas Medicaid will reimburse physicians who furnish the manufactured viable bilaminate graft or skin substitute with prior authorization. The product is manually priced and requires paper claims using procedure code J7340, type of service code "1" (paper claims only). The manufacturer's invoice and the operative report must be attached.

Application procedures for bilaminate skin substitute, procedure codes 15342 and 15343, require prior authorization except when the diagnosis code range is 940.0 through 949.5. The procedures are payable to the physician and must be listed separately on claims.

Surgical preparation procedures, CPT codes 15000 and 15001, may be reimbursed when performed at the same surgical setting. These codes are to be listed separately in addition to the primary procedure and do not require PA.

292.880 Enterra Therapy for Gastroparesis

When filing claims for Enterra therapy for treatment of gastroparesis use procedure code S2213 for implantation of gastric electrical stimulation and 64555 for implantation of peripheral neurostimulator electrodes. A prior authorization number is required on the claim.

Procedure code 64595 must be used when filing claims for revision or removal of the peripheral neurostimulator. This procedure does not require prior authorization but the claim must be filed on paper with operative report attached.

All paper claims require a type of service code "2" for surgery and, if necessary, type of service code "8" for assistant surgeon.

292.890 Gastrointestinal Tract Imaging with Endoscopy Capsule

For gastrointestinal tract imaging with endoscopy capsule, claims must be filed on paper with the patient's medical history and physical exam attached. Claims will be manually reviewed prior to reimbursement.

Procedure code 91110 must be used with type of service "P" for professional component when performed as inpatient, outpatient hospital or ambulatory surgical center. Type of service "C" must be used when performed in the physician's office.

292.900 Tobacco Cessation Counseling Services

When prescribing covered tobacco cessation products, the provider must provide counseling services when one of these products is prescribed. Procedure code 99401, modifier SE, must be used for one 15-minute unit of service, and procedure code 99402, modifier SE, must be used for one 30-minute unit of service.

Oral surgeons must use procedure code D9920 for one 15-minute unit and procedure code D1320 for one 30-minute unit when filing claims on the American Dental Association (ADA).

See section 257.000 of this manual for coverage and benefit limit information.

Disclaimer: These regulations may not be the most recent version. Arkansas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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