Arkansas Administrative Code, Division 06, Rule 016.06.06-078 - Physician/Independent Lab/CRNA/Radiation Therapy Center Policy Manual Update #112 | Arkansas Administrative Code

201.000 Arkansas Medicaid Participation Requirements 10-1-06

To participate in the Arkansas Medicaid Program, providers must adhere to all applicable professional standards of care and conduct. The following sections provide participation requirements for each provider type whose services are included in this manual.

201.130 Providers of Physician Services in States Not Bordering Arkansas 10-1-06

A. Providers in states not bordering Arkansas may enroll as closed-end providers after they have furnished services to an Arkansas Medicaid beneficiary and have a claim to file with Arkansas Medicaid. View or print Provider Enrollment Unit contact information.

A non-bordering state provider may download the provider manual and provider application materials from the Arkansas Medicaid website,

www.medicaid.state.ar.us/InternetSolution/Provider/Provider.aspx, and then submit the application and claim to the Medicaid Provider Enrollment Unit.

B. Closed-end providers remain enrolled for one year.

1. If a closed-end provider treats another Arkansas Medicaid beneficiary during the provider's year of enrollment and bills Medicaid, the enrollment may continue for one year past the newer claim's last date of service, if the provider keeps the enrollment file current.

2. During the enrollment period the provider may file any subsequent claims directly to EDS.

3. Closed-end providers are strongly encouraged to submit claims through the Arkansas Medicaid website because the front-end processing of web-based claims ensures prompt adjudication and facilitates reimbursement.

201.330 Providers of CRNA Services in States Not Bordering Arkansas 10-1-06

A. Providers in states not bordering Arkansas may enroll as closed-end providers after they have furnished services to an Arkansas Medicaid beneficiary and have a claim to file with Arkansas Medicaid. View or print Provider Enrollment Unit contact information .

A non-bordering state provider may download the provider manual and provider application materials from the Arkansas Medicaid website,

www.medicaid.state.ar.us/InternetSolution/Provider/Provider.aspx, and then submit the application and claim to the Medicaid Provider Enrollment Unit.

B. Closed-end providers remain enrolled for one year.

1. If a closed-end provider treats another Arkansas Medicaid beneficiary during the year of enrollment and bills Medicaid, the enrollment may continue for one year past the newer claim's last date of service, if the provider keeps the enrollment file current.

2. During the enrollment period the provider may file any subsequent claims directly to EDS.

3. Closed-end providers are strongly encouraged to submit claims through the Arkansas Medicaid website because the front-end processing of web-based claims ensures prompt adjudication and facilitates reimbursement.

202.100 Documentation Required of All Medicaid Providers 10-1-06

A. Providers must contemporaneously create and maintain records that completely and accurately explain all evaluations, care, diagnoses and any other activities of the provider in connection with its delivery of medical assistance to any Medicaid beneficiary.

B. Providers furnishing any Medicaid-covered good or service for which a prescription, admission order, physician's order, care plan or other order for service initiation, authorization or continuation is required by law, by Medicaid rule, or both, must obtain a copy of the prescription, care plan or order within five (5) business days of the date it is signed. Providers also must maintain a copy of each prescription, care plan or order in the beneficiary's medical record and follow all prescriptions, care plans, and orders as required by law, by Medicaid rule, or both.

C. The provider must make available to the Division of Medical Services, its contractors and designees and the Medicaid Fraud Control Unit all records related to any Medicaid beneficiary. When records are stored off-premise or are in active use, the provider may certify in writing that the records in question are in active use or in off-premise storage and set a date and hour within three (3) working days, at which time the records will be made available. However, the provider will not be allowed to delay for matters of convenience, including availability of personnel.

D. All records must be kept for a period of five (5) years from the ending date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer. Failure to furnish medical records upon request will result in sanctions being imposed. (See Section I of this manual.)

203.140 Physician's Role in Family Planning Services 10-1-06

A. Arkansas Medicaid encourages reproductive health and family planning by covering a comprehensive range of family planning services.

1. Medicaid beneficiaries' family planning services benefits are in addition to their other medical benefits.

2. Family planning services do not require PCP referral. PCPs electing not to provide some or all family planning services can use the information in this manual to counsel their Medicaid-eligible patients and help them locate family planning services.

a. Refer to Sections 221.000 and 221.100 of this manual for family planning services benefit limitations.

b. Refer to Sections 243.000 through 243.500 of this manual for service descriptions and coverage information.

c. Refer to Section 292.550 of this manual for family planning services billing instructions and procedure codes.

B. Arkansas Medicaid also covers family planning services for women in two limited aid categories.

1. Pregnant Woman-Poverty Level (PW-PL, Aid Category 61) and

2. Women's Health Waiver (FP-W, Aid Category 69).

a. Refer to Sections 221.100 and 243.000 through 243.500 for more information on coverage of family planning services for these eligibility categories.

b. Refer to Section 292.676 for more information on services available to women in the PW-PL category.

203.170 Physician's Role in Hospital Services 10-1-06

A. Medicaid covers medically necessary hospital services, within the constraints of the Medicaid Utilization Management Program (MUMP) and applicable benefit limitations.

B. The care and treatment of a patient must be under the direction of a licensed physician or dentist with hospital staff affiliation. Most inpatient admissions require a PCP referral. (Refer to Section I of this manual.)

C. Arkansas Foundation for Medical Care, Inc., (AFMC) is the Medicaid agency's Quality Improvement Organization (QIO).

1. AFMC reviews for the Medicaid Utilization Management Program, all inpatient hospital transfers and all inpatient stays longer than four days.

2. The QIO also performs post-payment reviews of hospital stays of any length for medical necessity determinations.

D. Hospital claims are also subject to review by the Medical Director for the Medicaid Program.

1. If Medicaid denies a hospital's claim for lack of medical necessity, payments to practitioners for evaluation and management services incidental to the hospitalization are subject to recoupment by the Medicaid agency.

2. Practitioners and hospitals may not bill a Medicaid beneficiary for a service Medicaid has declared not medically necessary.

3. Practitioners and hospitals may not bill as outpatient services, inpatient services previously denied for lack of medical necessity.

4. Refer to Sections I and III of this manual for Medicare deductible and coinsurance information.

203.230 Physician's Role in the Pharmacy Program 10-1-06

Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers. The Arkansas Medicaid Program complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP) that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990.

This law requires Medicaid to limit coverage to drugs manufactured by pharmaceutical companies that have signed rebate agreements. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes.

A. Prescribers must refer to the Arkansas Medicaid Web site at http://www.medicaid.state.ar.us/to obtain the following information:

1. Multisource Drugs Listing/Generic Upper Limits.

2. Covered cough and cold preparations (see part C, 7 of this section).

3. Covered over-the-counter (OTC) products (see part C, 8 of this section).

4. Drugs requiring prior authorization (PA), the forms to be completed for PA requests and the procedures required of the prescriber to request prior authorization.

5. List of alternative drugs that do not require PA.

6. Information on MedWatch, the Food and Drug Administration (FDA) Safety Information and Adverse Event Reporting Program.

As additions or deletions by labelers are submitted to the state by Centers for Medicare and Medicaid Services (CMS), the Web site is updated.

B. The following procedures are to be followed when prescribing drugs for Medicaid beneficiaries.

1. In addition to the prescriber's normal procedure for prescribing drugs, the prescriber must include his or her Medicaid provider number on all prescriptions for Medicaid beneficiaries, whether or not the drug prescribed is a controlled substance. The prescriber's Medicaid provider number is essential for tracking and utilization review purposes.

The requirement to include the prescriber's Medicaid provider number is a condition of participation in the Arkansas Medicaid Program. Administrative sanctions will be imposed for noncompliance. If prescription pads are not preprinted with the prescriber's name, it is essential that the physician's signature be legible.

2. When the prescriber determines that a particular brand is medically necessary, the prescriber must write "This Brand Medically Necessary" in his or her own handwriting on the face of the prescription. A rubber stamp is not acceptable. The statements "Do not substitute" or "Dispense as written" are not sufficient. For prescriptions ordered by telephone, a written prescription that includes the required statement must also be provided to the pharmacist.

C. Coverage Limitations

1. Medicaid beneficiaries aged 21 and older are limited to three (3) prescriptions per month, each filled for a maximum of one month's supply. Extensions of an individual's drug benefit up to six (6) prescriptions per month may be considered for reasons of medical necessity. The prescribing provider must request an extension.

2. A prescription may be filled for a maximum of one month's supply. A thirty-one-day supply is allowed.

3. Up to five refills within six months of the date the prescription is issued are covered if specified by the prescriber. Renewals or continuations of drug therapy beyond six months require another prescription.

4. Prescriptions for family planning items will not be counted toward the beneficiary's monthly three-prescription limit.

5. Medicaid beneficiaries under age 21 are not subject to the prescription benefit limit.

6. Long-term-care (LTC) certified Medicaid beneficiaries are not subject to the prescription benefit limit.

LTC patients must receive prescribed drugs within a specific period of time after the prescriber's order. For prescribed drugs that require PA and are administered in oral dosage forms for which a 5-day supply may be calculated and dispensed, one 5-day supply of the drug may be provided to the LTC beneficiary upon receipt of the prescription and reimbursed by Arkansas Medicaid without receipt of PA.

Within five (5) days of the prescription of a drug requiring prior authorization (PA) and for which no PA has been obtained, the pharmacist and the physician shall consult to determine if there is a therapeutically equivalent drug that does not require PA. The results of the consultation shall be documented in writing.

If a non-PA, therapeutically equivalent drug exists, the physician will immediately write a substitute prescription for the non-PA drug.

7. Cough and cold preparations are not covered except for those listed on the Web site at www.medicaid.state.ar.us in the covered cough and cold products list. Coverage is restricted to Medicaid beneficiaries under age 21 and for certified long-term care beneficiaries. Any over-the-counter cough and cold products listed at the Web site are not covered for certified long-term care beneficiaries.

8. Over-the-counter (OTC) products are not covered except for those listed on the Web site at www.medicaid.state.ar.us in the covered over-the-counter products list. OTC products are not covered for certified long-term care beneficiaries.

9. When prescribing pharmaceuticals to Medicaid beneficiaries who are excluded from the beneficiary cost sharing coinsurance/copayment policy, the prescribing provider must write "Excluded from copay" on the face of the prescription. (Refer to Section 133.400 of this manual for more information.)

211.000 Introduction 10-1-06

A. The Arkansas Medicaid Program reimburses enrolled providers for the medical care of Medicaid beneficiaries.

B. Medicaid reimbursement is conditional upon providers' compliance with Program policy as stated in provider manuals, manual update transmittals and official Program correspondence.

C. All Medicaid benefits are based on medical necessity. Refer to the Glossary for a definition of medical necessity.

1. Service coverage will be denied and reimbursement recouped if a service is not medically necessary.

2. The finding of medical necessity may be made by the:

a. Medical Director for the Medicaid Program, the

b. Quality Improvement Organization (QIO)

212.000 Scope 10-1-06

A. Physician services are services provided within the scope of the practice of medicine or osteopathy, as defined by State law and by or under the personal supervision of an individual licensed under State law to practice medicine or osteopathy (42 Code of Federal Regulations, Section 440.50).

B. Many physician services covered by the Arkansas Medicaid Program are restricted or limited.

1. Sections 220.000 through Section 227.000 describe limits on the quantity of covered services beneficiaries may receive.

2. Sections 240.000 through section 258.000 describe the circumstances under which certain services will be covered.

221.000 Family Planning Services 10-1-06

A. Medicaid covers one basic family planning examination and three periodic family planning visits per beneficiary, per state fiscal year (July 1 through June 30). Refer to Sections 243.000 through 243.500 of this manual for service descriptions and coverage information.

B. Prescriptions for family planning services are unlimited.

C. Levonorgestrel Implant System

1. The benefit limit for levonorgestrel Implant system (kit) and insertion is two each per five-year period per beneficiary.

2. The benefit limit for removal of the kit is only once per 5-year period, with or without reinsertion.

D. Extension of benefits is not available for family planning services.

E. Special billing instructions for all family planning services are in section 292.550 of this manual.

223.000 Injections 10-1-06

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 292.595 of this manual.

225.100 Laboratory and X-Ray Services 10-1-06

The Medicaid Program's laboratory and X-ray services benefit limits apply to outpatient laboratory services, radiology services and machine tests (such as electrocardiograms).

A. Medicaid has established a maximum paid amount (benefit limitation) of $500 per state fiscal year (July 1 through June 30) for beneficiaries aged 21 and older, for outpatient laboratory and machine tests and outpatient radiology.

1. There is no lab and X-ray benefit limit for beneficiaries under age 21.

2. There is no benefit limit on professional components of laboratory, X-ray and machine tests for hospital inpatients.

3. There is no benefit limit on laboratory services related to family planning. See Section 292.550 for the family planning-related clinical laboratory procedures exempt from benefit limits.

4. There is no benefit limit on laboratory, X-ray and machine-test services performed as emergency services.

B. Extension-of-benefit requests are considered for medically necessary services.

1. The claims processing system automatically overrides benefit limitations for services supported by the following diagnoses:

a. ICD-9 code ranges 140.0 through 208.91;

b. ICD-9 code 042; or

c. ICD-9 code range 584 through 586

2. Benefits may be extended for other conditions for documented reasons of medical necessity. Providers may request extensions of benefits according to instructions in Section 228.100 of this manual.

C. Magnetic resonance imaging (MRI) is exempt from the $500 outpatient laboratory and X-ray annual benefit limit.

1. Medical necessity for each MRI must be documented in the beneficiary's medical record.

2. Refer to Section 292.610 of this manual for billing instructions and Section 272.600 for reimbursement information.

D. Cardiac catheterization procedures are exempt from the $500 annual benefit limit for outpatient laboratory and X-ray. Medical necessity for each procedure must be documented in the beneficiary's medical record.

226.000 Physician Services Benefit Limit 10-1-06

A. Physician services in a physician's office, patient's home or nursing home for beneficiaries aged 21 or older are limited to 12 visits per state fiscal year (July 1 through June 30). Beneficiaries under age 21 in the Child Health Services (EPSDT) Program are not subject to this benefit limit.

The following services are counted toward the 12 visits per state fiscal year limit established for the Physician program:

1. Physician services in the office, patient's home or nursing facility.

2. Rural health clinic (RHC) encounters.

3. Medical services provided by a dentist.

4. Medical services furnished by an optometrist.

5. Certified nurse-midwife services.

B. Extensions of this benefit are considered when documentation verifies medical necessity. Refer to sections 229.100 through 229.120 of this manual for procedures for obtaining extension of benefits for physician services.

C. The Arkansas Medicaid Program exempts the following diagnoses from the extension of benefit requirements when the diagnosis is entered as the primary diagnosis:

1. Malignant Neoplasm ICD-9-CM code ranges 140.0 through 208.91

2. HIV/AIDS ICD-9 code 042

3. Renal Failure ICD-9 code range 584.5 through 586

4. Additionally, physician visits in the outpatient hospital are exempt from the extension of benefit requirements for pregnancy (ICD-9 code range 630 through 677, diagnosis codes V22.0 through V24.2 and V28.0 through V28.9

When a Medicaid beneficiary's primary diagnosis is one of those listed above and the beneficiary has exhausted the Medicaid established benefit for physician services, outpatient hospital services or laboratory and X-ray services, a request for extension of benefits is not required.

241.000 Ambulatory Infusion Device 10-1-06

Arkansas Medicaid covers an Ambulatory Infusion Device when it is provided by the physician and prior authorized by the Division of Medical Services. This device is covered only when services are provided to Medicaid beneficiaries receiving chemotherapy, pain management or antibiotic treatment in the home. Refer to Section 261.200 of this manual for prior authorization procedures and Section 292.430 for the procedure code and billing instructions.

243.100 Women's Health Demonstration Waiver 10-1-06

A. The Arkansas Medicaid program administers a Women's Health Demonstration Waiver. This waiver program extends Medicaid coverage of family planning services to women of childbearing age throughout Arkansas who meet the eligibility requirements for participation.

B. Women's Health 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 Women's Health Demonstration Waiver (FP-W) services.

C. The women in the FP-W category are eligible for limited Medicaid coverage of family planning services only. See section 292.552 for services covered. The PES eligibility transaction response identifies them as eligible in Aid Category 69 (FP-W).

243.300 Basic Family Planning Visit 10-1-06

Medicaid covers one basic family planning visit per beneficiary per Arkansas state fiscal year (July 1 through June 30). This basic visit comprises the following:

A. Medical history and medical examination, including head, neck, breast, chest, pelvis, abdomen, extremities, weight and blood pressure

B. Counseling and education regarding

1. Breast self-exam

2. The full range of contraceptive methods available

3. HIV/STD prevention

C. Prescription for any contraceptives selected by the beneficiary

D. Laboratory services, including, as necessary

1. Pregnancy test

2. Hemoglobin and Hematocrit

3. Sickle cell screening

4. Urinalysis testing for albumin and glucose

5. Papanicolaou smear for cervical cancer

6. Testing for sexually transmitted diseases

243.400 Periodic Family Planning Visit 10-1-06

Medicaid covers three periodic family planning visits per beneficiary per state fiscal year (July 1 through June 30). The periodic visit includes follow-up medical history, weight, blood pressure and counseling regarding contraceptives and possible complications of contraceptives. The purpose of the periodic visits is to evaluate the patient's contraceptive program, renew or change the contraceptive prescription and to provide the patient with additional opportunities for counseling regarding reproductive health and family planning.

243.500 Contraception 10-1-06

A. Prescription and Non-Prescription Contraceptives

1. Medicaid covers for birth control pills and other prescription contraceptives as a family planning prescription benefit.

2. Medicaid covers for non-prescription contraceptives as a family planning benefit, when a physician writes a prescription for them.

B. Evonorgestrel Implant System

1. Medicaid covers the Levonorgestrel (contraceptive) implant system, including implants and supplies

2. Alternatively, Medicaid reimburses physicians and clinics that supply the kit at the time of insertion.

3. Medicaid covers for insertion, removal and removal with reinsertion.

C. Intrauterine Device (IUD)

1. Medicaid pays for IUDs as a family planning prescription benefit.

2. Alternatively, Medicaid reimburses physicians that supply the IUD at the time of insertion.

3. Medicaid pays physicians for IUD insertion and removal.

D. Occlusion by Placement of Permanent Implants (Essure)

Medicaid covers the Essure implant system including the physician's services, implant and the supplies and follow-up procedures.

E. Medroxyprogesterone Acetate

Medicaid covers medroxyprogesterone acetate injections for birth control.

F. Sterilization

1. All adult (21 or older) female Medicaid beneficiaries who are mentally competent are eligible for sterilization procedures and medically necessary follow-ups as long as they remain Medicaid-eligible.

2. All adult (21 or older) male Medicaid beneficiaries who are mentally competent are eligible for sterilization procedures and medically necessary follow-ups as long as they remain Medicaid-eligible.

3. Adult (21 or older) women in the Women's Health Waiver category, Aid Category 69, who are mentally competent, are eligible for sterilization procedures.

4. Refer to Section 251.290 of this manual for Medicaid policy regarding sterilization.

Refer to Section 292.550 of this manual for family planning procedure codes and billing instructions for family planning services.

244.000 Covered Drugs and Immunizations 10-1-06

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 CPT and 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 and those covered for adults. (See sections 292.592 through 292.595 of this manual for special billing instructions.)

D. Other injections that are covered for specific diagnoses and/or conditions. See section 292.592. No take home drugs are covered.

244.001 Agalsidase Beta and Laronidase Injections 10-1-06

A. Arkansas Medicaid covers agalsidase beta injections. This procedure is covered for treatment of Fabry's disease, ICD-9-CM diagnosis code 272.7.

B. Arkansas Medicaid covers laronidase injections. This procedure is covered for treatment of mucopolysaccharidosis (MPS I), ICD-9-CM diagnosis code 277.5.

C. Arkansas Medicaid covers imiglucerase injections. This procedure (J1785) is covered for treatment of Type I Gaucher disease with complications, ICD-9-CM diagnosis code 272.7.

D. These 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.

E. 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.

F. See section 292.592 for procedure codes and billing instructions.

244.002 Verteporfin (Visudyne) 10-1-06

Medicaid covers verteporfin injections for all ages under the following conditions.

A. There must be documentation by eye exam of an ICD-9-CM diagnosis of:

1. Predominantly classic subfoveal choroidal neovascularization due to age-related macular degeneration (ICD-9-CM diagnosis code 362.50 or 362.52); or

2. Pathologic myopia (ICD-9-CM diagnosis code 360.21); or

3. Presumed ocular histoplasmosis (ICD-9-CM diagnosis code 115.02 or 115.12 or 115.92).

B. The lesion size determination should be included in the exam. Which eye will be treated with that administration should also be clearly documented, along with the current visual acuity. If previous treatments with other modalities have been attempted, these also must be documented.

C. See section 292.592 for procedure code and billing instructions.

244.100 Special Pharmacy, Therapeutic Agents and Treatments 10-1-06

Providers must obtain prior approval, in accordance with the following procedures, for special pharmacy, therapeutic agents and treatments.

A. Before treatment is begun, the Medical Director for the Division of Medical Services (DMS) must approve any drug, therapeutic agent or treatment not listed as covered in this provider manual or in official DMS correspondence.

This requirement also applies to any drug, therapeutic agent or treatment with special instructions regarding coverage in the provider manual or in official DMS correspondence.

B. The Medical Director's prior approval is necessary to ensure approval for medical necessity.

1. The provider must submit a history and physical examination with the treatment protocol before beginning the treatment.

2. The provider will be notified by mail of the DMS Medical Director's decision. No prior authorization number is assigned if the request is approved, but a prior approval letter is issued and must be attached to each claim. Any changes in treatment require resubmission and a new approval letter.

244.200 Radiopharmaceutical Therapy 10-1-06

Medicaid covers radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion.

Before beginning therapy the provider must submit the following documentation.

A. Patient history and physical report is required.

B. Drugs and therapeutic procedures previously administered must be included along with documentation that conventional therapy has failed.

C. This information must be sent to the attention of the Medical Director of the Division of Medical Services.

The provider will be notified by mail of the Medical Director's decision. If approval is received, the provider must file the claim for service with a copy of the approval letter and a copy of the invoices for the monoclonal antibody.

Refer to section 292.595 for special billing procedures.

250.500 Observation Status 10-1-06

When billing for services to a patient in "observation status," physicians must adhere to Arkansas Medicaid definitions of inpatient and outpatient. Observation status is an outpatient designation. Physicians must also follow the guidelines and definitions in Physician's Current Procedural Terminology (CPT), under "Hospital Observation Services" and "Evaluation and Management Services Guidelines."

A. Arkansas Medicaid uses the following criteria in determining inpatient and outpatient status:

1. If a patient is expected to remain in the hospital for less than 24 consecutive hours and this expectation is realized, the hospital and the physician should consider the patient an outpatient; i.e., the patient is an outpatient unless the physician has admitted them as an inpatient.

2. If the physician or hospital expects the patient to remain in the hospital for 24 hours or more, Medicaid deems the patient admitted at the time the patient's medical record indicates the existence of such an expectation, even though the physician has not yet formally admitted the patient.

3. Medicaid also deems a patient admitted to inpatient status at the time they have remained in the hospital for 24 consecutive hours, even if the physician or hospital had no prior expectation of a stay of that or greater duration.

B. Medical Necessity Requirements

1. Physician inpatient services must meet the Medicaid requirement of medical necessity. The Quality Improvement Organization (QIO) will deny payments for inpatient admissions and subsequent inpatient services when they determine that inpatient care was not necessary. Inpatient services are subject to QIO review for medical necessity whether the physician admitted the patient, or whether Medicaid deemed the patient admitted according to the criteria above.

2. The attending physician must document the medical necessity of admitting a patient to observation status, whether the patient's condition is emergent or non-emergent. Physician and hospital claims for hospital observation services are subject to post payment review to verify medical necessity.

C. Coverage Limitations

Medicaid pays physicians all-inclusive "global" fees for outpatient surgical procedures. Physicians may not bill Medicaid separately for hospital observation services preceding, or subsequent to, outpatient surgery.

Please note that an attending physician may bill Medicaid only once per day per patient for "Evaluation and Management Services" including physician non-emergency outpatient visit.

The following table gives examples of appropriate physician billing for several common hospital scenarios. The billing instructions under the headings, "PHYSICIAN MAY BILL...," do not necessarily include all services for which the physician may bill. For instance, they do not state that you may bill for interpretation of X-rays or diagnostic tests. The purpose of this table is to illustrate Arkansas Medicaid observation status policy and to give guidance for billing related evaluation and management services.

Patient is admitted to observation	Patient Is	Physician may bill for Tuesday services:	Physician may bill for Wednesday services:
Tuesday, 3:00 PM	Still in Observation Wednesday, 3:00 PM	Appropriate level of Initial Observation Care	Appropriate level of Initial Hospital Care
Tuesday, 3:00 PM	Discharged Wednesday, 12:00 PM (noon)	Appropriate level of Initial Observation Care	Observation care discharge day management
Tuesday, 3:00 PM	Discharged Wednesday, 4:00 PM	Appropriate level of Initial Observation Care	Appropriate level of Initial Hospital Care
Tuesday, 3:00 PM, after outpatient surgery	Discharged Wednesday, 10:00 AM	Outpatient surgery	No evaluation and management services
Tuesday, 3:00 PM, after exam in Emergency Department-emergency or non-emergency	Discharged Tuesday, 7:00 PM	Appropriate level of Initial Observation Care	Not Applicable; patient was discharged Tuesday

251.230 Cochlear Implant and External Sound Processor 10-1-06

The Arkansas Medicaid Program provides coverage for cochlear implantation and the external sound processor for beneficiaries under age 21 in the Child Health Services (EPSDT) Program. Also covered are headset, microphone, transmitting coil and transmitter cable. The cochlear implant device, implantation procedure, the sound processor and other necessary devices for use with the cochlear implant device require prior authorization from AFMC. Refer to Section 261.100 of this manual for prior authorization procedures.

251.304 Liver and Liver/Bowel Transplants 10-1-06

A. Medicaid covers liver transplants for beneficiaries of all ages.

B. Medicaid covers liver/bowel transplants for beneficiaries under age 21 in the Child Health Services (EPSDT) Program.

C. Covered physician services related to the transplant include:

1. The surgical procedure to remove a partial liver from a living donor (when applicable).

2. Physician services for transplanting the liver into the receiver.

3. Postoperative care (including postoperative care for the living donor of a partial liver, when applicable).

D. Liver and liver/bowel transplants are exempt from the MUMP and the annual benefit limit for inpatient hospital services. Services excluded from the annual benefit limit and the MUMP are the services provided from the date of the transplant procedure to the date of discharge, subject to any limitations imposed by the current published Medicare National Coverage Decisions and/or AFMC medical review. Refer to section 251.300 subpart C.

253.000 Bilaminate Graft or Skin Substitute 10-1-06

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 but not 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

257.000 Tobacco Cessation Products Counseling Services 10-1-06

Arkansas Medicaid covers generic Zyban (bupropion for tobacco cessation) and nicotine replacement therapy (NRT), either 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 to obtain initial prior authorization (PA) 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.

Subsequent prior authorizations will require prescriber referral to an intensive tobacco cessation program, such as SOS Works. A referral form will also be available on the Medicaid website.

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 per SFY.

D. Additional prescription benefits will be allowed per month for tobacco cessation products during the approved PA period and will not be counted against the monthly prescription benefit limit. One benefit will be allowed for generic Zyban if the physician believes that generic Zyban therapy is appropriate and one benefit for NRT, either nicotine gum or patches.

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

258.000 Hyperbaric Oxygen Therapy 10-1-06

Physicians may be reimbursed for attendance and supervision of hyperbaric oxygen therapy.

Hyperbaric oxygen therapy involves exposing the body to oxygen under pressure greater than one atmosphere. Such therapy is performed in specially constructed hyperbaric chambers holding one or more patients; although oxygen may be administered in addition to the hyperbaric treatment. Patients should be assessed for contraindications such as sinus disease or claustrophobia prior to therapy. In some diagnoses, hyperbarics is only an adjunct to standard surgical therapy. These indications are taken from "The Hyperbaric Oxygen Therapy Committee Report" (2003) of The Undersea and Hyperbaric Medical Society (Kensington, MD).

A. All hyperbaric therapy will require prior approval, except in emergency cases such as for air embolism or carbon monoxide poisoning. Prior approval will be for a certain number of treatments. A copy of the approval letter must be filed with each claim and the number in the series of treatments documented.

B. Further treatments will require reapplication for a prior approval. Documentation for prior approval should include, but not be limited to, a complete physician SOAP note, a physical exam and prior therapy treatment failures, including antibiotic therapies and surgical interventions.

1. It must include a clear description of the wound with each claim. Documentation of no measurable signs of healing for at least 30 consecutive days of wound care therapy prior to the start of HBO therapy should be included (for those diagnoses requiring this treatment plan).

2. If extension of treatment period is needed, the above documentation must be submitted and fully documented. Physician progress notes physical findings at each treatment and the effects of treatment wound description will be needed for an extension. Any questions may be addressed to the Medical Director at 501-682-9868.

3. Requests for prior approval may be mailed or faxed.

Mailing address: Fax to

ATTN: Medical Director 501-682-8013 or

Division of Medical Services 501-683-4124

Slot S412 ATTN: Medical Director

Department of Health and Human Services

PO Box 1437

Little Rock, AR 72203-1437

C. The following tables provide explanation of diagnosis requirements and treatment number of treatments and treatment schedules.

Diagnosis	Description	Number of Treatments
6396, 67300, 9580,9991	Air or Gas Embolism	10
9930	Decompression Sickness	10
986	Carbon Monoxide Poisoning	5
0400, 0383	Clostridial Myositis and Myonecrosis (Gas Gangrene)	10
8690-8691, 8871, 8873, 8875, 8877, 8971, 8973, 8975, 8977, 9251-9299, 99690-99699	Crush injuries, compartment syndrome, other acute traumatic peripheral ischemias	See Table
25070-25073, 44023, 44024, 44381-4439, 4540, 4542, 70700-7079, 9895, 99859	Enhancement of healing in selected problem wounds; diabetic foot ulcers, pressure ulcers, venous stasis ulcers; only in severe and limb or life-threatening wounds that have not responded to other treatments, particularly if ischemia that cannot be corrected by vascular procedures is present	30
3240	Intracranial abscess, multiple abscesses, immune compromise, unresponsive	20
72886, 7854	Necrotizing Soft Tissue Infections, immune compromise	30
73000-73020	Refractory osteomyelitis after aggressive surgical debredement	40
52689, 73010-73019, 7854, 9092, 990	Delayed Radiation Injury	60
99652, 99660-99670, V423	Compromised skin grafts and flaps	20
9400-9495	Thermal burns [GREATER THAN] 20% TSBA +/or involvement of hands, face, feet or perineum that are deep, partial or full thickness injury	40

Hyperbaric Treatment Schedules ("Doses") of HBO2
ICD9 Code	Injury Type	Number & Schedule of HBO2 Treatments	Number of HBO2 Treatments Before Peer Review (Days)	Comments
9251-929.9	Crush Injuries according to Gustilo classification	TIDa 2 days BIDb 2 days Daily for 2 days	6
9585	Compartment syndrome, impending stage fasciotomy not required	TIDa for 1 day	1	If post-fasciotomy, see problem wound recommendations
9400-9495, 99652, 99666-99670, V423	Threatened flaps & grafts	Same as for crush injuries	6
92951-929.9	Problem wounds after primary management	BIDb for 7d; daily 7 days	14	Post-fasciotomy wounds, complications and residual wounds after primary management of crush injuries
73000-73020	Refractory osteomyelitis	Daily for 21 days	21 +	May require continuation of HBO2 through 60 treatments, but reassessment and second stage peer review recommended after 40 treatments

aThree times a day bTwice a day

Refer to section 292.860 of this manual for billing instructions.

261.000 Obtaining Prior Authorization of Restricted Medical and Surgical 10-1-06

Procedures

A. Certain medical and surgical procedures are not covered without prior authorization (PA). Most restricted procedures are prior authorized by the Arkansas Foundation for Medical Care, Inc. (AFMC). Refer to sections 261.100, 261.120 and 261.130 for instructions on requesting PA from AFMC.

B. The Division of Medical Services Utilization Review Section makes PA determinations for certain procedures. Refer to sections 261.200 through 261.260 for instructions on requesting PA from Utilization Review.

C. Refer to section 262.000 for a list of procedures requiring prior authorization.

261.110 Post-Procedural Authorization Process for Beneficiaries Under Age 10-1-06

21

A. Providers performing surgical procedures that require prior authorization are allowed 60 days from the date of service to obtain a prior authorization number if the beneficiary is under age 21.

B. The following post-procedural authorization process must be followed when obtaining an authorization number for the procedures in Section 262.000.

1. All requests for post-procedural authorizations for eligible beneficiaries are to be made to the Arkansas Foundation for Medical Care (AFMC) by telephone within 60 days of the date of service. The physician or the physician's office nurse must contact AFMC. View or print AFMC contact information. These calls will be tape recorded.

2. If the provider receives only the Medicaid identification number from the beneficiary and is unable to obtain the actual card to validate the eligibility dates, you may call the EDS Provider Assistance Center to obtain the dates of eligibility. View or print the EDS Provider Assistance Center contact information. AFMC must be provided the beneficiary and provider identifying criteria and all of the medical data necessary to justify the procedures. As medical information will be exchanged for this procedure, the physician or a nursing member of his/her staff must make these calls.

3. The provider will be issued a PA number at the time of the call if the procedure requested is approved. A follow-up letter will be mailed the same day to the physician.

4. Consulting physicians are responsible for calling AFMC to have their required and/or restricted procedures added to the PA file. They will be given the prior authorization number at the time of the call on cases that are approved. A letter verifying the PA number will be sent to the consultant upon request. When calling, all patient identification information and medical information related to the necessity of the procedure needing authorization must be provided.

C. The Arkansas Medicaid Program continues to recommend providers obtain prior

authorization for procedures requiring authorization in order to prevent risk of denial due to lack of medical necessity.

This policy applies only to those eligible Medicaid recipients under age 21. This policy does not alter policy currently applicable to retroactive-eligible beneficiaries.

261.120 Prior Authorization of Bilaminate Graft or Skin Substitute 10-1-06

Arkansas Medicaid requires prior authorization (PA) of the product for bilaminate graft or skin substitute. Prior authorization for the product (dermal and epidermal tissue of human origin, with or without bioengineered or processed elements, with metabolically active elements, per square centimeter) is issued in units. One unit equals one square centimeter. Application procedures do not require prior authorization.

To request prior authorization, providers must submit a request for prior authorization to Arkansas Foundation for Medical Care, Inc. (AFMC). The AFMC Request for Bilaminate Skin Substitutes form must be completed and submitted to AFMC with supportive documentation. View or print the AFMC Request for Bilaminate Skin Substitutes form. (Refer to section 253.000 for coverage criteria and section 292.870 for billing instructions.) Providers who will be using this product should copy the prior authorization request form for later use.

261.130 Prior Authorization of Cochlear Implant and External Sound 10-1-06

Processor

A. Arkansas Medicaid provides coverage for cochlear implantation and for the external sound processor when provided to recipients under age 21 in the Child Health Services (EPSDT) Program. Prior authorization by AFMC is required.

B. A written request signed by the physician performing the procedure is required. The request must be accompanied by medical documentation to support medical necessity. See section 261.100 for prior authorization instructions.

261.210 Prior Authorization of Ambulatory Infusion Device 10-1-06

A. Arkansas Medicaid covers an ambulatory infusion device when it is provided by the physician and prior authorized. To obtain prior authorization, the physician providing the equipment must complete and sign Form DMS-679, Medical Equipment Request for Prior Authorization and Prescription. View or print form DMS-679 and instructions for completion. The original and first copy of the form must be submitted to the Division of Medical Services Utilization Review Section. View or print the Division of Medical Services Utilization Review Section contact information. If the request is approved, a prior authorization control number will be assigned. The PA number will be indicated on the copy of the DMS-679 returned to the provider. The PA control number in Item 10 of the DMS-679 must be entered on the claim form filed for Medicaid payment of these services.

B. Approvals are authorized for a maximum of six months (180 days). If services are needed for a longer period, a new request must be submitted.

C. The effective date of the prior authorization is the date the patient begins use of the equipment or the date following the expiration date of the previous prior authorization approval.

D. Denied requests are returned to the provider indicating the reason for denial.

261.220 Prior Approval of Transplant Procedures 10-1-06

A. The attending physician is responsible for obtaining prior approval for organ transplant evaluations and for organ transplants.

1. The attending physician must request from UR prior approval of a transplant evaluation, naming the facility at which the evaluation is to take place and the physician who will conduct the evaluation. View or print the UR Section contact information. This request must include the following:

a. History and physical and supporting documentation

b. Previous treatment

c. Copy of the most recent hospitalization

d. Name of proposed facility where patient will be referred for transplant

e. Third-party insurance information, when applicable

2. UR reviews the physician's request for transplant evaluation and forwards its approval to the facility at which the referring physician has indicated the evaluation will take place.

3. The evaluation results are forwarded to UR with a request for the transplant procedure.

4. UR forwards the request and its supporting documentation to AFMC for a determination of approval or denial.

5. AFMC advises the requesting physician and the beneficiary of its decision.

B. The physician is responsible for distributing documentation of prior approval to the hospital and to the other participating providers, such as the anesthetist, assistant surgeon, etc.

261.230 Reconsideration for Denied Prior Approvals 10-1-06

A request for administrative reconsideration of a denied prior approval must be in writing and sent to AFMC within 35 calendar days of the denial. The request must include a copy of the denial letter and additional supporting documentation.

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 will be considered on an individual basis. Reconsideration requests must be mailed or delivered by hand. Faxed or emailed requests will not be accepted.

261.231 Beneficiary Appeal Process for Denied Prior Approvals 10-1-06

When DMS or its designee (AFMC in this case) denies a request for prior approval of a transplant or transplant evaluation, the beneficiary may appeal the denial and request a fair hearing.

A. An appeal request must be in writing.

B. The appeal request must be received by the Appeals and Hearings Section of the Department of Human Services (DHS) within 30 days of the date on the provider notification denial letter from the Utilization Review Section or AFMC. View or print the Department of Human Services, Appeals and Hearings Section contact information.

261.250 Prior Authorization process for Laboratory Procedures for Highly 10-1-06

Active Antiretroviral Therapy (HAART)

The following CPT procedure codes are covered for Medicaid beneficiaries when prior authorized.

87901	A maximum of 2 units per 12 month period can be requested at one time
87903	A maximum of 1 unit per year can be requested at one time.
87904	This procedure is an add-on code. The appropriate number of units must be included with each prior authorization request.

Physicians ordering the test must obtain the prior authorization. For billing purposes, the physician must supply a copy of the prior authorization to the laboratory performing the test. The process for requesting prior authorization for these procedures is listed below.

A. A statement is required from the physician stating that the patient presented with virologic failure during HAART.

B. A copy of the results of tests, CPT procedure code 87536 - "HIV-1, quantification" or procedure code 87539 - "HIV-2, quantification," must be attached to the prior authorization requests. These tests must reflect that the patient has suboptimal suppression of viral loads (i.e.[GREATER THAN]1000 HIV RNA copies/ml.) after initiation of antiretroviral therapy.

C. Submit request for prior authorization for these procedure codes to the Utilization Review Section. View or print the Division of Medical Services Utilization Review Section address.

262.000 Procedures That Require Prior Authorization 10-1-06

The following procedure codes require prior authorization:

Procedure Codes
J7320	J7340	L8614	L8615	L8616	L8617	L8618	L8619
S0512	S2213	V5014	00170	01966	11960	11970	11971
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	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
J7330	Autologous cultured chondrocytes, implant
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 - evaluation

292.000 CMS-1500 Billing Procedures 10-1-06

292.100 Procedure Codes 10-1-06

292.110 Non-covered CPT Procedure Codes 10-1-06

The following is a list of CPT procedure codes that are non-covered by the Arkansas Medicaid Program to providers of Physician/Independent Lab/CRNA/Radiation Therapy Center services.

Some procedure codes are non-payable, but the service is payable under another procedure code. Refer to Special Billing Procedures, sections 292.000 through 292.860.

Procedure Codes
01953	01968	09169	11900	11901	11920	11921	11922
11950	11951	11952	11954	15775	15776	15780	15781
15782	15783	15786	15787	15819	15820	15821	15822
15823	15824	15825	15826	15828	15829	15832	15833
15834	15835	15836	15837	15838	15839	15876	15877
15878	15879	17360	17380	21497	27193	27591	27881
28531	32850	32855	32856	33930	33933	33935	33940
33944	36416	36468	36469	36540	43265	43770	43771
43772	43774	43886	43887	43888	44132	44133	44135
44136	44715	44720	44721	44979	45520	46500	47133
47136	47143	47144	47145	47146	47147	48551	48552
49400	50300	50323	50325	50327	50328	50329	54401
54405	54406	54408	54410	54411	54660	54900	54901
55870	55970	55980	56805	57170	58321	58322	58323
58970	58974	58976	59072	59430	59898	65760	65771
65781	65782	68340	69090	69710	69711	76948	76986
78890	78891	80103	83087	84061	87001	87003	87472
87477	87902	88000	88005	88007	88012	88014	88016
88020	88025	88027	88028	88029	88036	88037	88040
88045	88099	88188	88189	89250	89251	89253	89254
89255	89257	89258	89259	89260	89261	89264	89268
89272	89281	89290	89291	89335	89342	89343	89344
89346	89352	89353	89354	89356	90378	90379	90384
90465	90466	90467	90468	90471	90472	90473	90474
90476	90477	90586	90680	90693	90717	90719	90723
90725	90727	90736	90760	90761	90773	90783	90845
90846	90865	90875	90876	90880	90885	90887	90889
90901	90911	90918	90919	90920	90921	91060	92065
92070	92285	92310	92311	92312	92313	92314	92315
92316	92317	92325	92326	92330	92335	92340	92341
92342	92352	92353	92354	92355	92358	92370	92371
92592	92593	92596	92597	92605	92606	92609	93668
93701	93797	93798	94452	94453	94656	94657	94660
94662	94667	94668	94762	95078	95250	95806	96000
96001	96002	96003	96004	96102	96103	96110	96116
96150	96151	96152	96153	96154	96155	97002	97004
97005	97006	97010	97012	97014	97016	97018	97020
97022	97024	97026	97028	97032	97033	97034	97035
97036	97039	97112	97113	97116	97124	97139	97140
97530	97532	97535	97537	97542	97545	97546	97755
97802	97803	97804	97810	97811	97813	97814	99000
99001	99002	99024	99026	99027	99056	99070	99071
99075	99078	99080	99090	99091	99239	99261	99262
99263	99315	99316	99324	99325	99326	99327	99328
99334	99335	99336	99337	99339	99340	99344	99345
99350	99358	99359	99361	99362	99371	99372	99373
99374	99375	99377	99378	99379	99380	99386	99387
99396	99397	99403	99404	99411	99412	99420	99429
99431	99433	99435	99450	99455	99456	99499	99500
99501	99502	99503	99504	99505	99506	99507	99509
99510	99511	99512

292.410 Abortion Procedure Codes 10-1-06

Abortion procedures performed when the life of the mother would be endangered if the fetus were carried to term require prior authorization from the Arkansas Foundation of Medical Care, Inc. (AFMC).

Abortion for pregnancy resulting from rape or incest must be prior authorized by the Division of Medical Services, Administrator, Utilization Review.

The physician must request prior authorization for the abortion procedures and for anesthesia. Refer to section 260.000 of this manual for prior authorization procedures. The physician is responsible for providing the required documentation to other providers (hospitals, anesthetist, etc.) for billing purposes.

All claims must be made on paper with attached documentation. A completed Certification Statement for Abortion (form DMS-2698 Rev. 8/04), patient history and physical exam are required for processing of claims. When filing paper claims, type of service code 2 must be used for the abortion procedure, and type of service code "7" must be used for anesthesia.

Use the following procedure codes when billing for abortions.

01966*	59840	59841	59850	59851	59852
59855	59856	59857

* Effective for dates of service on and after March 1, 2006, CPT anesthesia procedure code 01964 is non-payable and has been replaced with procedure code 01966.

Refer to section 251.220 of this manual for policies and procedures regarding coverage of abortions and section 261.000, 261.100, 261.200, 261.260 for prior authorization instructions.

292.430 Ambulatory Infusion Device 10-1-06

Procedure code E0779, modifier RR, Ambulatory Infusion Device, is payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home. One unit of service equals one day. A reimbursement rate has been established and represents a daily rental amount. For paper claims, use type of service code "1" with the modifier RR . Refer to section 241.000 of this manual for coverage information and section 261.220 for prior authorization procedures.

292.440 Anesthesia Services 10-1-06

Anesthesia procedure codes (00100 through 01999) must be bill in anesthesia time. Anesthesia modifiers P1 through P5 listed under Anesthesia Guidelines in the CPT must be used. When appropriate anesthesia procedure codes that have a base of 4 or less, type of service code "7," are eligible to be billed with a second modifier, "22," referencing surgical field avoidance.

Any surgical procedure with local/topical anesthesia is computed to include the administration of the local anesthetic agent, as it is already computed into the reimbursement amount and is billed by the primary surgeon. No modifiers or time may be billed with these procedures.

A. Electronic Claims

PES or electronic claims submission may be used unless paper attachments are required.

B. Paper Claims

If paper billing is required, enter the procedure code, time and units as shown in section 292.447. Enter again the number of units (each 15 minutes of anesthesia equals 1 time unit) in Field 24G. (See cutaway section of a completed claim in Section 292.447.)

A type of service code is required along with applicable modifiers when filing paper claims. Providers must use type of service code "7" with procedure codes 00100 through 01999.

Any surgical procedure that includes local/topical anesthesia must be billed by the primary surgeon with a type of service code "2."

The procedure codes listed under "Qualifying Circumstances" in the Anesthesia Guidelines of CPT require a type of service code (paper only) "1."

C. The following national CPT procedure code for abortion and locally assigned procedure code for anesthesia for abdominal hysterectomy are to be billed with a type of service code "7" to indicate anesthesia, time units and modifiers as appropriate. These codes must be billed on CMS-1500 (formerly HCFA-1500) paper claims only because they require attachments.

National Code

Local Code

Description

Documentation Required

01966*

Anesthesia for induced abortion procedures

Use for billing anesthesia service for all elective, induced abortions, including abortions performed for rape or incest

Certification Statement for Abortion (DMS-2698) (See sections 251.220, 261.000, 261.100, 261.200 and 261.260 of this manual.) View or print form DMS-2698 and instructions for completion.

None

Z994

0

Anesthesia for Abdominal Hysterectomy

Acknowledgement of Hysterectomy (DHS-2606) View or print form DMS-2606 and instructions for completion.

D. The following CPT procedure codes must be billed on CMS-1500 (formerly HCFA-1500) paper claims because they require attachments or documentation:

Procedure Code	Documentation Required
00846	Acknowledgement of Hysterectomy Information (DMS-2606) View or print form DMS-2606 and instructions for completion.
00848	Operative Report
01962	Acknowledgement of Hysterectomy Information (DMS-2606)
01963	View or print form DMS-2606 and instructions for completion.
00922	Operative Report
00944	Acknowledgement of Hysterectomy Information (DMS-2606)) View or print form DMS-2606 and instructions for completion.
01999	Procedure Report
00800	On females only, required to name each procedure done by surgeon in "Procedures, Services or Supplies" column. Example - 1. colon resection 2. lysis of adhesions 3. appendectomy
00840	On females only, required to name each procedure done by surgeon in "Procedures, Services or Supplies" column.
00940	Required to name each procedure done by surgeon in "Procedures, Services or Supplies" column.

Anesthesiologist/anesthetists may bill procedure code 00170 with a type of service code (paper only) "7 " for any inpatient or outpatient dental surgery using place of service code "B ," "1 ," "2 " or "3 ," as appropriate. This code does not require prior approval for anesthesia claims.

A maximum of 17 units of anesthesia is allowed for a vaginal delivery or C-Section. Refer to Anesthesia Guidelines of the CPT book for procedure codes related to vaginal or C-section deliveries.

292.443 Medicaid Coverage for Therapeutic Infusions (Excludes 10-1-06

292.480 Cataract Surgery 10-1-06

Post-cataract lens implant must be billed using procedure code V2630 . This procedure code may be billed electronically or on paper. When filing paper claims, use type of service code 1.

The lens implant code is billed in conjunction with the cataract surgery and is covered for eligible Medicaid beneficiaries of all ages in the outpatient setting.

292.550 Family Planning Services 10-1-06

292.551 Family Planning Services For Beneficiaries in Full Coverage Aid 10-1-06 Categories

Family planning services are covered for beneficiaries in full coverage aid categories. Family planning procedures 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.

A. The following tables include procedure codes that are covered as family planning services for beneficiaries in full coverage aid categories

Procedure Codes
11975	11976	11977	55250	55450	58300	58301	58340**
58345**	58565	58600	58605	58611	58615	58661*	58670
58671	58700*	72190**	74740**	74742**	99144**	99145**

*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.

**These procedures require special billing instructions. Refer to part C of this section.

Procedure Code	Modifier(s)	Description
J1055	FP	Medroxyprogesterone acetate for contraceptive use
J7300	FP	Intrauterine copper contraceptive
J7302	FP	Levonorgestrel-releasing intrauterine contraceptive system
J7303	FP	Contraceptive supply, hormone containing vaginal ring
J7306	FP	Levonorgestrel (contraceptive) implant system, including implants and supplies
36415	FP	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 modifier U6 for the basic family planning visit and the periodic family planning visit. If filing on paper, use type of service code "J" with the modifier.

B. Effective for dates of service on and after June 28, 2006, procedure code S0612 is not covered as a family planning procedure. It is covered for regular Medicaid beneficiaries for annual gynecological examinations. When filing paper claims for this service, use type of service code "1".

C. Additional procedures have been added as family planning services when related to procedure 58565 - hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants (Essure).

1. Effective for dates of service on and after March 1, 2006, conscious sedation procedure codes 99144 and 99145 may be covered as family planning service only when administered in conjunction with the Essure procedure (58565).

To file electronic claims for these professional services, use modifier FP . On paper claims use type of service code "A" and modifier FP . Whether billing on paper or electronically, the primary detail diagnosis code for each procedure must be a family planning diagnosis.

Claims filed for these professional services when provided in an outpatient hospital clinic do not require modifiers if filed electronically. If billing on paper, type of service "J" is required. Whether billing on paper or electronically, the primary detail diagnosis code for each procedure must be a family planning diagnosis.

2. Effective for dates of service on and after February 1, 2006, procedure codes 58340, 58345, 72190, 74740 and 74742 are only payable as family planning services within the 6 months after the Essure procedure's date of service.

a. Professional claims for procedure codes 58340 and 58345 must be filed with modifier FP . Paper claims require a type of service code "A" and modifier FP . Whether billing on paper or electronically, the primary detail diagnosis for each procedure must be a family planning diagnosis code.

Claims for professional services provided in an outpatient clinic associated with a hospital must be filed with a type of service code "J" . Whether billing on paper or electronically, the primary detail diagnosis code for each procedure must be a family planning diagnosis.

b. Professional claims for procedure codes 72190, 74740 and 74742 must be filed with modifier FP. Paper claims require a type of service code "A" and modifier FP . Whether billing on paper or electronically, the primary detail diagnosis for each procedure must be a family planning diagnosis code.

When these radiology procedures are performed as family planning services in an outpatient hospital clinic, claims for the professional component of procedures codes 72190, 74740 and 74742 require type of service "J" on paper claims. Whether billing on paper or electronically, a family planning diagnosis code must be listed as primary on each detail.

3. Procedure codes J1055, 11976 and 58301 are covered family planning services. Effective for dates of service on and after February 1, 2006, these procedures are also covered up to six months as necessary for follow-up services to the Essure procedure. When provided as post-Essure follow-up care, billing protocol is unchanged for J1055, 11976 and 58301 for all providers.

All visits related to post-Essure services during the 6 months following the Essure procedure are included in the fee allowed for 58565.

292.552 Family Planning Services for Beneficiaries in Limited Aid Category 69

Arkansas covers many family planning services for women of child-bearing age who are Medicaid-eligible in aid category 69 and who participate in the Arkansas Women's Health Waiver.

Covered family planning procedures furnished to beneficiaries in aid category 69 are payable to physicians and must be billed with a modifier "FP" . For paper claims, physicians must use type of service code "A" with the modifier.

A. The following services are covered for this limited service category.

Procedure Codes
11975	11976	11977	58300	58301	58340*	58345*	58565
58600	58615	58670	58671	72190*	74740*	74742*	99144*
99145*

*Asterisked codes require special billing procedures. Refer to part C of this section.

Procedure Code	Modifier(s)	Description
J1055	FP	Medroxyprogesterone acetate for contraceptive use
J7300	FP	Intrauterine copper contraceptive
J7302	FP	Levonorgestrel-releasing intrauterine contraceptive system
J7303	FP	Contraceptive supply, hormone containing vaginal ring
J7306	FP	Levonorgestrel (contraceptive) implant system, including implants and supplies
36415	FP	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 modifier U6 for the basic family planning visit and the periodic family planning visit. If filing on paper, use type of service code "J" with the modifier.

B. Effective for dates of service on and after June 28, 2006, the following procedure codes are not covered for aid category 69 beneficiaries.

58605

58611

58661

58700

S0612