Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.08-035 - Physician/CRNA/Independent Lab/Radiation Therapy Center Provider Manual Update Transmittal #154

Universal Citation: AR Admin Rules 016.06.08-035

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

Section II Physician/Independent Lab/CRNA/Radiation Therapy Center

TOC required

203.170 Physician's Role in Hospital Services
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) for physician's and hospital services.
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.

220.000 Benefit Limits

Benefit limits are the limits on the quantity of covered services Medicaid-eligible beneficiaries may receive. Medicaid-eligible beneficiaries are responsible for payment for services beyond the established benefit limits, unless the Division of Medical Services (DMS) authorizes an extension of a particular benefit

If a service is denied for exceeding the benefit limit, and the Medicaid beneficiary had elected to receive the service by written informed consent prior to the delivery of the service, the Medicaid beneficiary is responsible for the payment, unless that service has been deemed not medically necessary.

Benefit extensions are considered after the service has been rendered and the provider has received a denial for "benefits exhausted." DMS considers requests for benefit extensions based on the medical necessity of the service. If a Medicaid provider chooses to file for an extension of benefits and is denied due to the service not being medically necessary, the beneficiary is not responsible for the payment. Once the extension of benefits request has been initiated on a particular service, the provider cannot abort the process before a final decision is rendered.

Please see Section 229.000 through Section 229.120 and Section 131.000 points A and C for benefit extension request procedures. DMS reviews extension of benefits requests for Home

Health, personal care, diapers and medical supplies. AFMC reviews extension of benefits requests for physician, lab, radiology and machine tests, using form DMS-671. All personal care services for beneficiaries under age 21 are reviewed by QSource of Arkansas.

225.100 Laboratory and X-Ray Services

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-CM code ranges 140.0 through 208.91; and 230.0 through 238.9, or

b. ICD-9-CM code 042; or

c. ICD-9-CM 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
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 or 230.0-238.9

2. HIV/AIDS ICD-9-CM code 042

3. Renal Failure ICD-9-CM 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.

227.100 Guidelines for Retrospective Review of Occupational, Physical and Speech Therapy Services

Arkansas Medicaid employed retrospective review of occupational, physical and speech therapy services for beneficiaries under age 21. The purpose of retrospective review is promotion of effective, efficient and economical delivery of health care services.

The Quality Improvement Organization (QIO), QSource of Arkansas, under contract to the Arkansas Medicaid Program, performs retrospective reviews by reviewing medical records to determine if services delivered and reimbursed by Medicaid meet medical necessity requirements.

Specific guidelines have been developed for occupational, physical and speech therapy retrospective reviews. These guidelines are included for information to physicians prescribing and/or providing therapy services. The guidelines may be found in sections 227.200 through 227.320.

227.200 Occupational and Physical Therapy Guidelines for Retrospective Review
A. Occupational and physical therapy services are medically prescribed services for the diagnosis and treatment of movement dysfunction, which results in functional disabilities.

Occupational and physical therapy services must be medically necessary to the treatment of the individual's illness or injury. To be considered medically necessary, the following conditions must be met:

1. The services must be considered under accepted standards of practice to be a specific and effective treatment for the patient's condition.

2. The services must be of such a level of complexity, or the patient's condition must be such that the services required can be safely and effectively performed only by or under the supervision of a qualified physical or occupational therapist.

3. There must be reasonable expectation that therapy will result in a meaningful improvement or a reasonable expectation that therapy will prevent a worsening of the condition (See medical necessity definition in the Glossary of this manual.)

A diagnosis alone is not sufficient documentation to support the medical necessity of therapy. Assessment for physical and/or occupational therapy includes a comprehensive evaluation of the patient's physical deficits and functional limitations, treatment planned and goals to address each identified problem.

B. Evaluations:

In order to determine that therapy services are medically necessary, an annual evaluation must contain the following:

1. Date of evaluation.

2. Child's name and date of birth.

3. Diagnosis applicable to specific therapy.

4. Background information including pertinent medical history and gestational age.

5. Standardized test results, including all subtest scores, if applicable. Test results, if applicable, should be adjusted for prematurity (less than 37 weeks gestation) if the child is 12 months of age or younger. The test results should be noted in the evaluation.

6. Objective information describing the child's gross/fine motor abilities/deficits, e.g., range of motion measurements, manual muscle testing, muscle tone or a narrative description of the child's functional mobility skills.

7. Assessment of the results of the evaluation, including recommendations for frequency and intensity of treatment.

8. Signature and credentials of the therapist performing the evaluation.

C. Standardized Testing:
1. Tests used must be norm-referenced, standardized tests specific to the therapy provided.

2. Tests must be age appropriate for the child being tested.

3. Test results must be reported as standard scores, Z scores, T scores or percentiles. Age equivalent scores and percentage of delay cannot be used to qualify for services.

4. A score of -1.5 standard deviations or more from the mean in at least one subtest area or composite score is required to qualify for services.

5. If the child cannot be tested with a norm-referenced standardized test, criterion-based testing or a functional description of the child's gross/fine motor deficits may be used. Documentation of the reason why a standardized test could not be used must be included in the evaluation.

6. The Mental Measurement Yearbook (MMY) is the standard reference to determine reliability and validity. Refer to sections 227.210 and 227.220 for a list of standardized tests recognized by the Quality Improvement Organization (QIO) for retrospective reviews.

D. Other Objective Tests and Measures:
1. Range of Motion: A limitation of greater than ten degrees and/or documentation of how deficit limits function.

2. Muscle Tone: Modified Ashworth Scale.

3. Manual Muscle Test: A deficit is a muscle strength grade of fair (3/5) or below that impedes functional skills. With increased muscle tone, as in cerebral palsy, testing is unreliable.

4. Transfer Skills: Documented as amount of assistance required to perform transfer, e.g., maximum, moderate, or minimal assistance. A deficit is defined as the inability to perform a transfer safely and independently.

E. Frequency, Intensity and Duration of Physical and/or Occupational Therapy Services:

Frequency, intensity and duration of therapy services should always be medically necessary and realistic for the age of the child and the severity of the deficit or disorder. Therapy is indicated if improvement will occur as a direct result of these services and if there is a potential for improvement in the form of functional gain.

1. Monitoring: May be used to ensure that the child is maintaining a desired skill level or to assess the effectiveness and fit of equipment such as orthotics and other durable medical equipment. Monitoring frequency should be based on a time interval that is reasonable for the complexity of the problem being addressed.

2. Maintenance Therapy: Services that are performed primarily to maintain range of motion or to provide positioning services for the patient do not qualify for physical or occupational therapy services. These services can be provided to the child as part of a home program that can be implemented by the child's caregivers and do not necessarily require the skilled services of a physical or occupational therapist to be performed safely and effectively.

3. Duration of Services: Therapy services should be provided as long as reasonable progress is made toward established goals. If reasonable functional progress cannot be expected with continued therapy, then services should be discontinued and monitoring or establishment of a home program should be implemented.

F. Progress Notes:
1. Child's name.

2. Date of service.

3. Time in and time out of each therapy session.

4. Objectives addressed (should coincide with the plan of care).

5. A description of specific therapy services provided daily and the activities rendered during each therapy session, along with a form measurement.

6. Progress notes must be legible.

7. Therapists must sign each date of entry with a full signature and credentials.

8. Graduate students must have the supervising physical therapist or occupational therapist co-sign progress notes.

227.400 Recoupment Process

The Division of Medical Services (DMS), Utilization Review (UR) is required to initiate the recoupment process for all claims that the Quality Improvement Organization (QIO) has denied for not meeting the medical necessity requirement. Based on QIO findings during respective reviews, UR will initiate recoupment as appropriate.

Medicaid will send the provider an Explanation of Recoupment Notice that will include the claim date of service, Medicaid beneficiary name and ID number, service provided, amount paid by Medicaid, amount to be recouped, and the reason the claim has been denied.

251.000 Surgery

There are certain medical and surgical procedures that are not covered without prior authorization either because of federal requirements or because of the elective nature of the surgery.

Surgeons must include ten (10) days of inpatient postoperative care as part of their surgical charges. Surgeons will not be allowed to bill Medicaid separately for surgery and the follow-up care visits associated with the surgery except in the following instances:

A. The physician doing inpatient postoperative visits when he or she did not perform the surgery and is seeing the patient for a condition not related to the surgery. This "condition not related to surgery" must be reflected in the primary detail ICD-9-CM diagnosis code billed with the visit.

B. Diagnostic endoscopy procedures.

Postoperative care includes care given by a physician other than the surgeon when the care is for the same condition that necessitated the surgery. If an attending physician consults with a surgeon and following the surgery, resumes the patient's care, the attending physician may not bill Medicaid for post-op care rendered during the first ten (10) days after the surgery.

251.280 Hysterectomies

Hysterectomies, except those performed for malignant neoplasm, carcinoma in-situ and severe dysplasia will require prior authorization regardless of the age of the beneficiary. (See Section 261.100 of this manual for instructions for obtaining prior authorization.) Those hysterectomies performed for carcinoma in-situ or severe dysplasia must be confirmed by a tissue report. The tissue report must be obtained prior to surgery. Cytology reports alone will not confirm the above two diagnoses, nor will cytology reports be considered sufficient documentation for performing a hysterectomy. Mild or moderate dysplasia is not included in the above and any hysterectomy performed for mild or moderate dysplasia will require prior authorization.

A. Any Medicaid beneficiary who is to receive a hysterectomy, regardless of her age, must be informed both orally and in writing that the hysterectomy will render her permanently incapable of reproduction. The patient or her representative may receive this information from the individual who secures the usual authorization for the hysterectomy procedure.

The patient or her representative, if any, must sign and date the Acknowledgement of Hysterectomy Information (Form DMS-2606) not more than 180 days prior to the hysterectomy procedure being performed. View or print form DMS-2606 and instructions for completion.Copies of this form can be ordered from EDS according to the procedures in Section III.

If the person is physically disabled and signs the consent form with an "X," two witnesses must also sign and include a statement regarding the reason the patient signed with an "X," such as stroke, paralysis, legally blind, etc

Please note that the acknowledgement statement must be submitted with the claim for payment. The Medicaid agency will not approve any hysterectomy for payment until the acknowledgement statement has been received.

If the patient needs the Acknowledgement of Hysterectomy Information Form (DMS-2606) in an alternative format, such as large print, contact our Americans with Disabilities Coordinator. View or print the Americans with Disabilities Coordinator contact information.

For hysterectomies for the mentally incompetent, the acknowledgement of sterility statement is required. A guardian must petition the court for permission to sign for the patient giving consent for the procedure to be performed. A copy of the court petition and the acknowledgement statement must be attached to the claim.

B. Random Audits of Hysterectomies

All hysterectomies paid by Federal and State funds will be subject to random selection for post-payment review. At the time of such review, the medical records must document the medical necessity of hysterectomies performed for carcinoma in-situ and severe dysplasia and must contain tissue reports confirming the diagnosis. The tissue must have been obtained prior to surgery.

The medical record of those hysterectomies performed for malignant neoplasms must contain a tissue report confirming such a diagnosis. However, the tissue may be obtained during surgery, e.g., frozen sections. Any medical record found on post-payment review which does not contain a tissue report confirming the diagnosis or any medical record found which does not document the medical necessity of performing such surgery will result in recovery of payments made for that surgery.

C. Hysterectomies Performed for Sterilization

Medicaid does not cover any hysterectomy performed for the sole purpose of sterilization.

251.290 Sterilization
A. Non-therapeutic sterilization means any procedure or operation for which the primary purpose is to render an individual permanently incapable of reproducing. Non-therapeutic sterilization is neither (1) a necessary part of the treatment of an existing illness or injury nor (2) medically indicated as an accompaniment of an operation of the female genitourinary tract. The reason the individual decides to take permanent and irreversible action is irrelevant. It may be for social, economic or psychological reasons or because a pregnancy would be inadvisable for medical reasons.
1. Prior authorization is not required for a sterilization procedure. However, all applicable criteria described in this manual must be met.

B. Federal regulations are very explicit concerning coverage of non-therapeutic sterilization. Therefore, Medicaid reimbursement will be made only when the following conditions are met:
1. The person on whom the sterilization procedure is to be performed voluntarily requests such services.

2. The person is mentally and legally competent to give informed consent.

3. The person is 21 years of age or older at the time informed consent is obtained.

4. The person to be sterilized shall not be an institutionalized individual. The regulations define "institutionalized individual" as a person who is:
a. involuntarily confined or detained, under a civil or criminal statute in a correctional or rehabilitative facility including those for a mental illness, or

b. confined under a voluntary commitment in a mental hospital or other facility for the care and treatment of mental illness.

If you have any questions regarding this requirement, contact the Arkansas Medicaid Program beforethe sterilization.

5. The person has been counseled, both orally and in writing, concerning the effect and impact of sterilization and alternative methods of birth control.

6. Informed consent and counseling must be properly documented. Only the official Form DMS-615 (4/96) - Sterilization Consent Form, properly completed, complies with documentation requirements. View or print form DMS-615.If the patient needs the Sterilization Consent Form (DMS-615) in an alternative format, such as large print, contact the Americans with Disabilities Act Coordinator. View or print the Americans with Disabilities Act Coordinator contact information.
a. By signing the consent form, the patient certifies that she or he understands the entire process. By signing the consent form, the person obtaining consent and the physician certify that, to the best of their knowledge, the patient is mentally competent to give informed consent. If any questions concerning this requirement exist, you should contact the Arkansas Medicaid Program for clarification BEFORE the sterilization procedure is performed.

b. The person obtaining the consent for sterilization must sign and date the form after the recipient and interpreter, if one is used. This may be done immediately after the recipient's and interpreter's signatures or it may be done at some later time, but always before the sterilization procedure. The signature will attest to the fact that all elements of informed consent were given and understood and that consent was voluntarily given.

c. A copy of the consent form given to the recipient of a sterilization procedure must be an identical copy of the one he or she signed and dated and must reflect the signature of the person obtaining the consent.

d. By signing the physician's statement on the consent form, the physician is certifying that shortly before the sterilization was performed, he again counseled the patient concerning the sterilization procedure. In keeping with federal interpretation of federal requirements, the State has defined "shortly before" as one week (seven days) prior to the performance of the sterilization procedure.

The physician's signature on the consent form must be an original signature and not a rubber stamp.

7. Informed consent may not be obtained while the person to be sterilized is:
a. In labor or during childbirth,

b. Seeking to obtain or obtaining an abortion, or c. Under the influence of alcohol or other substances that affect the individual's state of awareness.

8. The sterilization must be performed at least 30 days, but not more than 180 days, after the date of informed consent. The following are exceptions to the 30-day waiting period:
a. In the case of premature delivery, provided at least 72 hours have passed between giving the informed consent and performance of the sterilization procedure and counseling and informed consent was given at least 30 days before the expected date of delivery and

b. In the case of emergency abdominal surgery, provided at least 72 hours have passed between giving of informed consent and the performance of the sterilization procedure.

NOTE: Either of these exceptions to the 30-day waiting period must be properly documented on the DMS-615.

9. The person is informed, prior to any sterilization discussion or counseling, that no benefits or rights will be lost as a result of refusal to be sterilized and that sterilization is an entirely voluntary matter. This should be explained again just prior to the performance of the sterilization.

10. If the person is physically disabled and signs the consent form with an "X," two witnesses must also sign and include a statement regarding the reason the patient signed with an "X," such as stroke, paralysis, legally blind, etc. If a claim is received which does not have the statement attached, the claim will be denied.

C. A copy of the properly completed Sterilization Consent Form DMS-615, with all items legible, must be attached to each claim submitted from each provider before payment may be approved. Providers include hospitals, physicians, anesthesiologists and assistant surgeons. It is the responsibility of the physician performing the sterilization procedure to distribute correct legible copies of the signed consent form (DMS-615) to the hospital, anesthesiologist and assistant surgeon.

Though prior authorization is not required, an improperly completed Sterilization Consent Form DMS-615 results in the delay or denial of payment for the sterilization procedures. The checklist lists the items on the consent form that are reviewed before payment is made for any sterilization procedure. Use this checklist before submitting any consent form and claim for payment to be sure that all criteria have been met.

View or print form DMS-615 and checklist.

256.000 Gastrointestinal Tract Imaging with Endoscopy Capsule
A. Arkansas Medicaid covers wireless endoscopy capsule for diagnosis of occult gastrointestinal bleeding in the anemic patient under the conditions listed below.
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 of bleeding by endoscopic means.

3. Diagnosis of angiodysplasias of the Gl tract is suspected, or

4. Individuals with confirmed Crohn's disease to determine whether there is involvement of the small bowel.

B. This procedure is covered for individuals of all ages based on medical necessity when performed with FDA-approved devices and by providers formally trained in upper and lower endoscopies.

C. Documentation of medical necessity requires a primary detail diagnosis of one of the following ICD-9CM diagnosis codes: 280.9, 555.0-555.9, 578.1, 578.9, or 792.1.

D. Gl tract capsule endoscopy is not covered in the patient who has not undergone upper Gl endoscopy and colonoscopy during the same period of illness in which a source of bleeding is not revealed.

E. This test is covered only for those beneficiaries with documented continuing blood loss and anemia secondary to bleeding.

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

262.000 Procedures That Require Prior Authorization

The following procedure codes require prior authorization:

Procedure Codes

01966 11960

11970

11971

15400

15830

15847

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

27416

28446

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

58275

58280

58290

58291

58292

58293

58294

58345

58541*

58542*

58543*

58544*

58550

58552

58553

58554

58570***

58571***

58572***

58573***

58672

58673

58750

58752

59135

59840

59841

59850

59851

59852

59855

59856

59857

59866

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 J7320

87903 J7330

87904 S0500

92326 S2112

93980 V2623

93981 V2625

D9220**

J7319

* These procedure codes will be manually reviewed prior to payment and require prior authorization from AFMC and a paper claim with form DMS-2606 attached.

** Manually Priced

*** These procedure codes require a paper claim with form DMS-2606 attached.

E0779

RR

Ambulatory infusion device

D0140

EP

EPSDT interperiodic dental screen

J7330

Autologous cultured chondrocytes, implant

L8614

EP

Cochlear device includes all internal and external components.

L8615

EP

Headset/headpiece for use with cochlear implant device, replacement.

L8616

EP

Microphone for use with cochlear implant device, replacement.

L8617

EP

Transmitter coil for use with cochlear implant device, replacement.

L8618

EP

Transmitter cable for use with cochlear implant device, replacement.

L8619

EP

External sound processor

L8621

EP

Zinc air battery for use with cochlear implant device, replacement, each.

L8622

EP

Alkaline battery for use with cochlear implant device, any size, replacement, each.

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

V5014**

Repair/modification of a hearing aid

Z1930

Non-emergency hysterectomy following c-section

92002*

Low vision services - evaluation

*Procedures payable to physicians under the Visual Services program. See the Visual Services Provider manual or contact DMS, Medical Assistance for information on prior authorization protocol for these codes. View or print contact information for Arkansas Division of Medical Services, Visual Care Coordinator.

"Procedures payable to physicians under the Hearing Services program. See the Hearing Services provider manual or contact DMS, Utilization Review for information on prior authorization protocol for these codes. View or print contact information for Arkansas Division of Medical Services, Utilization Review Section.

292.110 Non-covered CPT Procedure Codes

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.

Procedure

Codes

01953

01968

01969

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

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

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

99362

99371

99372

99373

99374

99375

99377

99378

99379

99380

99386

99387

99396

99397

99403

99404

99411

99412

99420

99429

99433

99435

99450

99455

99456

99499

99500

99501

99502

99503

99504

99505

99506

99507

99509

99510

99511

99512

292.410 Abortion Procedure Codes

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, and 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 are required for processing of claims.

Use the following procedure codes when billing for abortions.

01966

59840

59841

59850

59851

59852

59855

59856

59857

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.

292.440 Anesthesia Services

Anesthesia procedure codes (00100 through 01999) must be billed 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 are eligible to be billed with a second modifier, "22," referencing surgical field avoidance.

Reimbursement for use and administration of local or topical anesthesia is included in the primary surgeon's reimbursement for the surgery that requires such anesthesia. No modifiers or time may be billed with these procedures.

A. Electronic Claims PES or electronic claims submission may be used unless 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.)

C. The following national CPT procedure code for abortion and locally assigned procedure code for anesthesia for abdominal hysterectomy are to be billed on CMS-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

Z9940

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 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 01963

Acknowledgement of Hysterectomy Information (DMS-2606) 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.

Z9950

Anesthesia for laparoscopic supracervical hysterectomy.

View or print form DMS-2606 and instructions for completion.

E. Anesthesiologist/anesthetists may bill procedure code 00170 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.

F. 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. Only one anesthesia service is billable for Arkansas Medicaid as the anesthesia for a delivery. The anesthesia service ultimately provided should contain all charges for the anesthesia. No add-on codes are payable.

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

The anesthesia time must be listed above the procedure code, but on the same detail.

Click here to view image

292.551 Family Planning Services For Beneficiaries in Full Coverage Aid Categories

Family planning services are covered for beneficiaries in full coverage aid categories. Family planning procedures payable to physicians require a modifier "FP". All procedure codes in these tables require a family planning 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.

**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

J7307

FP

J7307 is covered as a family planning benefit for regular full-coverage Medicaid beneficiaries. J7307 is not covered in family planning aide category 69. Benefit limited to two per seven years per beneficiary.

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.

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.

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 claims for these professional services, use 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. All claims billed require that the primary detail diagnosis code for each procedure must be a family planning diagnosis.

NOTE: For payment to be allowed for codes 99144 and 99145 for family planning, the beneficiary claim history must show a paid or pending claim for procedure code 58565.

2. 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. For post-Essure services limit, 6 months is 180 days, with the count beginning the day after the Essure procedure.
a. Professional claims for procedure codes 58340 and 58345 must be filed with modifier FP. All claims billed require that the primary detail diagnosis for each procedure must be a family planning diagnosis code.

b. Professional claims for procedure codes 72190, 7474 and 74742 must be filed with modifier FP All claims billed require that the primary detail diagnosis for each procedure must be a family planning diagnosis code.

c. Procedure codes J1055,11976 and 58301 are covered family planning services. 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. Medicaid allows post-Essure service for 6 months from the Essure procedure date of service, as specified in policy. For the post-Essure services limit, 6 months is 180 days, with the count beginning the day after the Essure procedure.

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. All procedure codes in these tables require a family planning diagnosis code in each claim detail.

Covered family planning procedures furnished to beneficiaries in aid category 69 are payable to physicians and must be billed with a modifier "FP.

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.

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

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). Sterilization procedure code 58565 requires billing on a paper claim with modifier FP.

To file electronic claims for professional services codes 99144 and 99145, use modifier FP. On paper claims use 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. Whether billing on paper or electronically, the primary detail diagnosis code for each procedure must be a family planning diagnosis.

NOTE: For payment to be allowed for 99144 and 99145 for family planning, beneficiary claim history must show a paid or pending claim for 58565

2. 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 58340and 58345 must be filed with modifier FP. Paper claims require a modifier of FP. Whether billing on paper or electronically, the primary detail diagnosis for each procedure must be a family planning diagnosis code.

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 modifier of FP. Whether billing on paper or electronically, the primary detail diagnosis for each procedure must be a family planning diagnosis code.

Whether billing on paper or electronically, a family planning diagnosis code must be listed as primary on each detail.

NOTE: For payment to be allowed for 58340, 58345, 72190, 74740, Or 74742, beneficiary claim history must show a paid or pending claim for 58565. The date of service for the post Essure procedure codes listed in the previous statement must be within 6 months after the date of service of 58565.

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.

292.553 Family Planning Laboratory Procedure Codes

This table contains laboratory procedure codes payable as family planning services for regular Medicaid beneficiaries and for beneficiaries in limited aid category 69. They are also payable when used for purposes other than family planning. Claims require modifier FP when the service diagnosis indicates family planning.

Independent Lab CPT Codes

Q0111

81000

81001

81002

81003

81025

83020

83520

83896

84703

85014

85018

85660

86592

86593

86687

86701

87075

87081

87087

87210

87390

87470

87490

87491

87536

87590

87591

87621**

88142*

88143*

88150**

88152

88153

88154

88155**

88164

88165

88166

88167

88174

88175

89300

89310

89320

*Procedure codes 88142 and 88143 are limited to one unit per beneficiary per state fiscal year. """Payable only to pathologists and independent labs.

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

292.560 Genetic Services

The Arkansas Medicaid Program covers the following procedure codes regarding genetic services.

National Code

Local Code

Local Code Description

Bill on paper

Z1729

Prenatal Diagnosis Counseling

84702

Prenatal screening for fetal anomalies using maternal serum HCG and AFP
A. Documentation

In addition to the medical records physicians are required to keep as detailed in Section 202.200 of this manual, the beneficiary's medical record must verify the physician providing genetic services is a board-certified maternal fetal medicine physician as required by Arkansas Medicaid genetic policy.

B. Prenatal Diagnosis Counseling

Prenatal Diagnosis Counseling must be performed by a maternal fetal medicine physician or a staff member under his or her direct supervision. This service includes, but is not limited to:

1. Family, medical, pregnancy history

2. Psychosocial assessment and counseling of couple regarding genetic testing and disorder

3. Diagnosis, prognosis, available options, pregnancy management are explained to the couple.

C. Services Not Performed by a Physician

When procedure codes Z1729 (must be billed on paper) and 84702 are provided and the services are not performed by a physician, the provider must have written policies with a physician who assumes the responsibility for the provision of the services rendered and agrees:

1. To be immediately available for consultation to the staff performing the services,

2. To ensure that the clinic staff has appropriate training and adequate skills for performing the procedures for which they are responsible and

3. To periodically review the staffs level of performance in administering these procedures.

The physician must be physically present (under the same roof) at all times during the service delivery.

,292.580 Hysterectomies

Physicians may use procedure code Z0663 when billing for a total hysterectomy procedure when the diagnosis is malignant neoplasm or severe dysplasia. See section 251.280 for additional coverage requirement. Procedure code Z0663 does not require prior authorization. All hysterectomies require paper billing using claim form CMS-1500. Form DMS-2606 must be properly signed and attached to the claim form.

Procedure code 59525 is covered for emergency hysterectomy immediately following C-section. It requires no PA but does require form DMS-2606 and an operative report/discharge summary to confirm the emergency status.

Procedure code Z1930 for non-emergency hysterectomy after C-section requires a PA. The claim must be filed on paper with required attachments. See sections 261.000-261.100.

.292.590 Injections

Providers billing the Arkansas Medicaid Program for covered injections should bill the appropriate CPT or HCPCS procedure code for the specific injection administered. The procedure codes and their descriptions may be found in the CPT coding book, in the HCPCS coding book and in this section of this manual.

Most of the covered drugs can be billed electronically. However, any drug marked with an asterisk (*) must be billed on paper with the name of the drug and dosage listed in the "Procedures, Services, or Supplies" column, Field 24D, of the CMS-1500 claim form. View a CMS-1500 sample form. If requested, additional documentation may be required to justify medical necessity. Reimbursement is based on the "Red Book" drug price. If preferred, a copy of the invoice verifying the provider's cost of the drug may be attached to the Medicaid claim form.

Effective for claims with dates of service on or after January 1, 2008, Arkansas Medicaid implemented billing protocol per the Federal Deficit Reduction Act of 2005 for drugs. See section 292.910 for further information.

292.591 Injections and Therapeutic Agents
A. Administration of therapeutic agents is payable only if provided in a physician's office, place of service code "11." These procedures are not payable to the physician if performed in any other setting. Therapeutic injections should only be provided by physicians experienced in the provision of these medications and who have the facilities to treat patients who may experience adverse reactions. The capability to treat infusion reactions with appropriate life support techniques should be immediately available. 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. Reimbursement for supplies is included in the administration fee. An administration fee is not allowed when drugs are given orally.

Multiple units may be billed when applicable. Take-home drugs are not covered. Drugs loaded into an infusion pump are not classified as "take home drugs." Refer to CPT code ranges 90765 through 90779 and 96401 through 96549 for therapeutic and chemotherapy administration procedure codes.

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 drug not listed, please contact the Medicaid Reimbursement Unit. View or print Medicaid Reimbursement Unit contact information.

This list includes drugs covered for beneficiaries of all ages. However, when provided to individuals aged 21 or older, a diagnosis of ICD-9-CM 140.0-208.91, 230.0-238.9, or 042 is required.

Procedure Codes

J0120

J0128

J0190

J0205

J0207

J0210

J0256

J0278

J0280

J0285

J0287

J0288

J0289

J0290

J0295

J0300

J0330

J0350

J0360

J0380

J0390

J0456

J0460

J0470

J0475

J0476

J0500

J0515

J0520

J0530

J0540

J0550

J0560

J0580

J0592

J0595

J0600

J0610

J 0620

J0630

J0640

J0670

J0690

J0692

J0694

J0696

J0697

J0698

J0704

J0706

J0710

J0713

J0715

J0720

J0725

J0735

J0740

J0743

J0744

J0745

J0760

J0770

J0780

J0795

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

J1450

J1452

J1455

J1457

J1570

J1580

J1590

J1610

J1620

J1626

J1630

J1631

J1642

J1644

J1645

J1655

J1670

J1700

J1710

J1720

J1730

J1742

J1800

J1810

J1815

J1825

J1830

J1835

J1840

J1850

J1885

J1890

J1940

J1950

J1955

J1956

J1960

J1980

J1990

J2001

J2010

J2020

J2060

J2150

J2175

J2180

J2185

J2210

J2250

J2270

J2271

J2275

J2278

J2280

J2300

J2310

J2320

J2321

J2322

J2355

J2360

J2370

J2400

J2405

J2410

J2425

J2430

J2440

J2460

J2469

J2501

J2510

J2515

J2540

J2543

J2550

J2560

J2590

J2597

J2650

J2670

J2675

J2680

J2690

J2700

J2710

J2720

J2725

J2730

J2760

J2765

J2770

J2780

J2783*

J2800

J2820

J2920

J2930

J2941

J2950

J2995

J3000

J3010

J3030

J3070

J3105

J3120

J3130

J3140

J3150

J3230

J3240

J3250

J3260

J3265

J3280

J3301

J3302

J3303

J3305

J3310

J3315

J3320

J3350

J3360

J3364

J3365

J3370

J3400

J3410

J3430

J3470

J3475

J3480

J3485

J3490*

J3520

J7197

J7308

J7310

J7501

J7504

J7505

J7506

J7507

J7509

J7510

J7511

J7513

J7518

J7599*

J8530

J9000

J9001

J9010

J9015

J9017

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

J9151

J9165

J9170

J9181

J9182

J9185

J9190

J9200

J9201

J9202

J9206

J9208

J9209

J9211

J9212

J9213

J9214

J9215

J9216

J9217

J9218

J9230

J9245

J9260

J9265

J9266

J9268

J9270

J9280

J9290

J9291

J9300

J9310

J9320

J9340

J9355

J9357

J9360

J9370

J9375

J9380

J9390

J9600

J9999*

Q2009

Q2017

S0017

S0021

S0023

S0028

S0030

S0032

S0034

S0039

S0040

S0073

S0074

S0077

S0080

S0081

S0092

S0093

S0108

S0164

S0177

S0179

S0187

*Procedure code requires paper billing. Include the name of the drug and the dose given to patient.

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.

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 underage 21.The following is a list of injections with special instructions for coverage and billing.

Procedure Code

Modifier(s)

Special Instructions

J0129*

Requires ICD-9-CM diagnosis code of 714.0-714.2 as primary diagnosis. Patient must have had inadequate response to one or more disease-modifying anti-rheumatic drugs such as Methotrexate or Tumor Necrosis Factor antagonists (Humira, Remicade, etc.). Records submitted with claim must include history and physical exam showing severity of rheumatoid arthritis, treatment with disease-modifying anti-rheumatic drugs, and treatment failure resulting in progression of joint destruction, swelling, tendonitis, etc. Prior approval letter from DMS Medical Director required to be attached to each claim. See 244.100 for information regarding requests for prior approval letters.

J0133

Payable for beneficiaries of all ages with diagnosis codes 053.0 -054.9.

J0150

Procedure is covered for all ages with no diagnosis restriction. Maximum units 4 per day.

J0152*

Payable for 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 cardiac shock and to provide advanced cardiac life support in the treatment area where the drug is infused. Requires paper claim with copy of report of diagnostic procedure. Maximum units 1 per day.

J0170

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

J0180*

This procedure is covered for treatment of Fabry's disease, ICD-9-CM diagnosis code 272.7. Procedure requires prior approval from DMS Medical Director. See section 244.100 for additional coverage information and instructions for requesting prior approval.

J0220*

Requires an ICD-9-CM diagnosis code of 271.0. Evaluation by a physician with a specialty in clinical genetics documenting progress required annually. A prior approval letter from DMS Medical Director required and must be attached to each claim. See 244.100 for information regarding acquiring the prior approval letter.

J0348

Valid for any condition below, along with ICD-9-CM diagnosis code of 112.5 or 112.8 (and any valid 5th digits), or 112.9. (1) End-stage Renal Disease (ICD-9-CM codes 584 - 586) or (2) AIDS or cancer (ICD-9-CM diagnosis codes 042, 140.0-208.9, 230.0-238.9) or (3) Post transplant status (i.e., ICD-9-CM diagnosis code 986.80-996.89) or specify transplanted organ and transplant date

J0570

Payable for beneficiaries of all ages with no diagnosis restrictions.

J0585

Payable for beneficiaries of all ages when medically necessary. Botox A is reviewed for medical necessity based on diagnosis.

J0636

Payable for beneficiaries of all ages receiving dialysis due to renal failure (diagnosis codes 584-586).

J0637*

Covered 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. After 30 days of use, an updated medical exam and history must be submitted.

J0702

Payable 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

J0881 J0885

Use the lowest dose that will gradually increase the Hgb concentration to the lowest level sufficient to avoid the need for red blood cell transfusion.

In addition to the primary diagnosis, an ICD-9-CM diagnosis code from each column below must be billed on the claim.

Column 1

Column II

Code

Description

285.9 Secondary Anemia

V58.11

Encounter for antineoplastic chemotherapy

V67.2

Following chemotherapy

E933.1

Antineoplastic and immunosuppressive drugs

Use ICD-9-CM code 285.29 (primary) with 070.54, 238.72-238.75, or 714.0-714.4 (secondary) to represent patients with anemia due to either hepatitis C (patients being treated with ribavirin and interferon alfa or ribavirin and peginterferon alfa), myelodysplastic syndrome, or rheumatoid arthritis.

Use the lowest dose that will gradually increase the HGB concentration to the lowest level sufficient to avoid the need for red blood cell transfusion.

In addition to the primary diagnosis, an ICD-9-CM diagnosis code from each column below must be billed on the claim.

Column I

Column II

Code

Description

285.29 Anemia of other chronic disease

070.54

Chronic Hepatitis C without mention of coma

238.72-238.75

Myelodysplastic

714.0-714.4

Rheumatoid Arthritis

J0882 J0886

Payable for dates of service on and after March 1, 2006. Covered when administered to patients diagnosed with ESRD (diagnosis range 584 - 586).

J0894*

Requires ICD-9-CM diagnosis codes of 205.00-205.91, 238.71-238.76, or 238.79. Prior approval letter from DMS Medical Director required to be attached to each claim. Refer to 244.100 for information regarding requesting prior approval.

J1100

Payable 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 640-648.93).

J1270

Payable for beneficiaries with diagnosis codes 042,140.0 -208.91 + 230. 0-238-9 + 787.2 + 588.81;

Or

ESRD 584 - 586 +787.2+ 588.81.

Claims will be manually reviewed prior to reimbursement.

J1440

Payable for beneficiaries of all ages with no diagnosis restrictions.

J1441

J1458*

Payable for treatment of mucopolysaccharidosis (MPS VI), diagnosis code 277.5. Prior approval letter from DMS Medical Director required. Copy of prior approval letter must be attached to each claim. See section 244.100 for additional coverage information and instructions for requesting prior approval.

J1460 J1470 J1480 J1490 J1500 J1510 J1520 J1530 J1540 J1550 J1560

Covered for individuals of all ages with no diagnosis restrictions.

J1561

Claims are reviewed for medical necessity based on the diagnosis code.

J1562

Payable for all ages without diagnosis restriction.

J1566 J1568 J1569

Claims are reviewed for medical necessity, based on the diagnosis code.

J1600

Payable for patients with a detail diagnosis of rheumatoid arthritis (diagnosis code range 714.0 - 714.9).

J1640

Payable when administered to all beneficiaries with ICD-9-CM detail diagnosis 277.1).

J1650

Payable for all ages with no diagnosis restriction.

J1652

Payable for beneficiaries of all ages with no diagnosis restrictions.

J1740

Payable for beneficiaries of all ages with no diagnosis restrictions.

J1743*

Requires ICD-9-CM diagnosis code of 277.5 (MPS II). An |valuation by a physician with a specialty in clinical genetics, documenting progress and response to the medication is required annually. Requires prior approval letter from DMS Medical Director and a copy must be attached to each paper claim. Refer to section 244.100 for information on how to acquire a prior approval letter.

J1745*

For beneficiaries under 18 years of age:

Effective for dates of service on and after 05/20/06, J1745 is payable without an approval letter for beneficiaries under age 18 years when the diagnosis is 555.0, 555.1 or 555.9. No other diagnosis is required. All other diagnoses for beneficiaries under age 18 years will continue to require a prior approval letter.

For beneficiaries aged 18 years and above:

Procedure code J1745 is payable when one of the following conditions exist:

1) ICD-9-CM code 555.9 as the primary detail diagnosis AND a secondary diagnosis of 565.1 or 569.81

OR

2) ICD-9-CM code range 556.0 - 556.9 OR

3) ICD-9-CM code 696.0 OR

4) ICD-9-CM code 714.0

NOTE:ICD-9 diagnosis code 714.0 requires a prior approval letter from the Medical Director. The request for approval must include documentation showing failed trial of Enbrel or Humira.

Claims must be submitted to EDS with any applicable attachments. Claims will be manually reviewed by Medicaid medical staff prior to payment.

OR

5) ICD-9-CM 724.9.

NOTE:ICD-9 diagnosis code 724.9 requires a prior approval letter from the Medical Director. The request for approval must include documentation showing failed trial of Enbrel or Humira.

Claims must be submitted to EDS with any applicable attachments. Claims will be manually reviewed by Medicaid medical staff prior to payment.

J1751 J1752

Payable for all ages with no diagnosis restriction.

J1785*

This procedure is covered for the treatment of Type I Gaucher disease with complications, with a detail diagnosis of ICD-9 code 272.7. A prior approval letter from the DMS Medical Director is required. See section 244.001 and 244.100 for additional coverage information and instructions for requesting prior approval. A copy of the prior approval letter must be attached to each claim.

J1931*

This procedure is covered for treatment of mucopolysaccharidosis (MPS I), ICD-9-CM diagnosis code 277.5. Prior approval from DMS Medical Director is required. See section 244.001 and 244.100 for additional coverage information and instructions for requesting prior approval. A copy of the prior approval letter must be attached to each claim.

J2260

Payable for Medicaid beneficiaries of all ages with congestive heart failure (ICD-9 diagnosis codes 428.0-428.9).

J2323*

Procedure requires a prior approval letter. See section 244.100. The history and physical showing a relapse of multiple sclerosis must be submitted with the request for the prior approval letter. This procedure must be billed on a paper claim. The approval letter must be attached to each claim. Requires review before payment.

J2353* J2354*

Payable for Medicaid beneficiaries of all ages. For ages 21 and older, J2353 and J2354 are covered for diagnosis of AIDs and cancer (ICD-9-CM diagnosis codes 140.0 - 208.91, 230.0 - 238.9 or 042). For other diagnoses, a prior approval letter is required and must be attached to each claim. See section 244.100 for information of requesting a prior approval letter.

J2503

Payable for beneficiaries diagnosed with macular degeneration (ICD-9-CM diagnosis code 362.50 - 362.52).

J2504

Payable for beneficiaries of all ages with a primary detail diagnosis of 279.2.

J2505

Payable for beneficiaries of all ages with a detail diagnosis from diagnosis code ranges 162.0- 165.9, or 174.0- 175.9 or 201.00 - 201.98 or 202.80 - 202.88. Diagnosis codes 288.00-288.04, 288.09 or 288.4 or 288.50-288.51 or 288.59, 289.53, V58.69, V67.51 and E933.1 are covered along with a diagnosis of AIDS or cancer. Diagnosis codes must be shown on the claim form.

J2513

Payable for beneficiaries of all ages with no diagnosis restrictions.

J2778*

Requires ICD-9-CM diagnosis code of 362.50 or 362.52 as primary diagnosis. Requires prior approval letter from DMS Medical Director attached to each claim. Refer to section 244.100 for information on how to acquire a prior approval letter.

J2788

Payable for beneficiaries of all ages with no diagnosis restrictions.

J2790 J2791

Payable for beneficiaries of all ages with no diagnosis restrictions.

J2792

Payable without restriction.

J2910

Payable for all beneficiaries with a primary detail diagnosis of rheumatoid arthritis (ICD-9 diagnosis codes 714.0 - 714.9).

J2916

Payable for beneficiaries of all ages with no restrictions.

J2993

Payable for beneficiaries of all ages with no diagnosis restrictions. Limited to 4 units per day in the office place of service. For the purpose of declotting catheters. Bill diagnosis 996.74 on the claim.

J2997

Payable for beneficiaries of all ages with no diagnosis restrictions. Limited to 4 units per day in the office place of service. For the purpose of declotting catheters. Bill diagnosis 996.74 on the claim.

J3396

Covered for all ages if one of the following diagnoses exist: ICD-9 diagnosis code 362.50 or 362.52; or ICD-9 diagnosis code 360.21; or ICD-9 diagnosis code 115.02 or 115.12 or 115.92. Claims may be filed electronically or on paper. See section 244.002 for additional coverage information.

J3420

Payable for patients with a primary detail diagnosis of pernicious anemia, 281.0. Coverage includes the B-12, administration and supplies. It must not be billed in multiple units.

J3465*

Covered for non-pregnant beneficiaries of all ages with no restrictions.

J3487 J3488

Payable to physicians when provided in the office if one of the following diagnoses exist: A primary diagnosis of AIDS or cancer, or diagnosis code 275.42, 198.5, 203.0, or 733.90. Claims will be manually reviewed prior to payment. Payable for beneficiaries of all ages with no diagnosis restrictions.

J7187 J7190 J7191 J7192 J7193 J7194 J7195 J7197

Payable for beneficiaries of all ages with no diagnosis restrictions.

J7198

Payable for all ages with no diagnosis restrictions.

J7199

For consideration, this code must be billed on a paper claim form with the name of the drug, dosage and the route of administration.

J7321 J7322 J7323 J7324

Requires prior authorization through Utilization Review Section of DMS. Providers must specify brand name of Hyaluronon (sodium hyaluronate) or derivative when requesting prior authorization. Written request must be submitted to DMS Utilization Review. Refer to 261.240 for PA information.

J7330

Requires prior authorization from AFMC for all providers. See sections 260.000, 261.000, 261.100 and 261.110.

J7340

Payable for beneficiaries of all ages with no diagnosis restrictions

J7341

Payable for beneficiaries of all ages with no diagnosis restrictions.

J7346

Requires submission of operative report with each claim.

J7502

Payable for beneficiaries of all ages with no diagnosis restrictions.

J7515

Payable for beneficiaries of all ages with no diagnosis restrictions.

J7516

Payable for beneficiaries of all ages with no diagnosis restrictions

J7517

Payable for beneficiaries of all ages with no diagnosis restrictions

J7520

For consideration, this code must be billed on a paper claim form

J7525 J7599*

with the name of the drug, dosage and the route of administration.

J9025

Coverage of this procedure code requires an ICD-9-CM diagnosis within the code range of 205.00 - 205.91, 238.71 - 238.76 or 238.79. A prior approval letter from the DMS Medical Director is required to be attached to each claim. Refer to 244.100 for information regarding requesting prior approval.

J9035*

Coverage of this procedure code requires an ICD-9-CM diagnosis within the code range of 153.0 - 154.8, 162.0 - 162.9, 174.0-175.9, or 189.0 - 189.9. A prior approval letter is required and must be attached to each claim. See section 244.100 for information on requesting prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9041

Coverage of this procedure code requires an ICD-9-CM diagnosis code of 203.0 - 203.8, and 200.40-200.48. A prior approval letter is required and must be attached to each claim. See section 244.100 for information on requesting prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9055

This procedure code requires an ICD-9-CM diagnosis code of 140.0-140.9, 153.0-154,, 160.0-161.9, 171.0, 172.0-172.4,173.0 - 173.4, or 195.0. A prior approval letter is required and must be attached to each claim. See section 244.100 for information on requesting prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9160

This procedure code is covered for all ages with ICD-9-CM diagnosis within the diagnosis range 202.10 - 202.18, 202.20 -202.28, or 202.80 - 202.88. A prior approval letter is required and must be attached to each claim. See section 244.100 for information on requesting prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9178

This procedure code requires an ICD-9-CM diagnosis code of 150.0-150.8, 151.0-151.9, 162.0-162.9, 171.0-171.9,174.0-175.9, 183.0, 200.0-200.8 or 202.0 - 202.90. A prior approval letter from the DMS Medical Director is required and must be attached to each claim. See section 244.100 for additional coverage information and instructions for requesting prior approval.

J9219

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

J9225

Payable for male beneficiaries with a diagnosis of malignant neoplasm of prostate (ICD-9-CM code 185).

J9226

Supprelin LA: Coverage of this procedure code requires an ICD-9-CM diagnosis code 259.1 Approved only for children 12 years of age and under. A prior approval letter from the DMS Medical Director is required to be attached to each claim. Prior to initiation of treatment a clinical diagnosis of CPP, 259.1, should be confirmed by measurement of blood concentrations of total sex steroids, luteinizing hormone (LH) and follicle stimulating hormone (FSH) following stimulation with a GnRH analog, and assessment of bone age versus chronological age. Baseline evaluations should include height and weight measurements, diagnostic imaging of the brain (to rule out intracranial tumor), pelvic/testicular/adrenal ultrasound (to rule out steroid secreting tumors), human chorionic gonadotropin levels (to rule out a chorionic gonadotropin secreting tumor, and adrenal steroids to exclude congenital adrenal hyperplasia. All tests and screenings must be documented by medical records and submitted with History and Physical examination when requesting prior approval. Refer to 244.100 for information regarding requesting prior approval.

J9250

Payable for beneficiaries of all ages without restriction.

J9261

Requires ICD-9-CM diagnosis codes of 202.80 - 202.89 or 204.0 -208.90. The disease must have not responded to, or either has relapsed, following treatment with at least 2 chemotherapy regimens. Prior approval letter from DMS Medical Director required. See section 244.100 for information on requesting prior approval.

J9263

Payable for beneficiaries of all ages with diagnosis of 151.0-151.9, 153.0-154.8, 183.0- 183.9 and 202.00-202.99. Prior approval letter from DMS Medical Director required with letter attached to claim. See section 244.100 for additional coverage information and instructions for prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9264

Coverage of this procedure code requires an ICD-9-CM diagnosis code of 141.0-151.9, 158.8, 158.9, 160.9, 161.9, 162.0-162.9, 174.0-176.9, 180.9, 182.0, 183.0-183.9, 185.0, 186.0-186.9, 188.0- 188.9, 195.9, 199.0 and 199.1. A prior approval letter from the DMS Medical Director is required and must be attached to each claim. See section 244.100 for additional coverage information and instructions for requesting prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9293

Payable for all ages. Will be manually reviewed for medical necessity based on diagnosis code for cancer or AIDS or diagnosis code 340.

J9303*

Requires ICD-9-CM diagnosis code of 153.0 - 154.8. Prior approval letter from DMS Medical Director required with copy attached to each claim. Refer to section 244.100 for information on how to acquire a prior approval letter.

J9305

Coverage of this procedure code requires an ICD-9-CM diagnosis code of 162.0 - 163.9. A prior approval letter from the DMS Medical Director is required and must be attached to each claim. See section 244.100 for additional coverage information and instructions for requesting prior approval. Any one of the diagnosis codes from the above listed ranges is acceptable.

J9350

Payable for beneficiaries of all ages with a primary detail diagnosis of 162.0-162.9 or 180.0-180.9 or 183.0 or 205.10-205.11 or 230.9-238.9.

J9395*

Payable for beneficiaries of all ages, with a diagnosis of 174.0 -175.9.

A prior approval letter from the DMS Medical Director is required and must be attached to each claim. See section 244.100 for additional coverage information and instructions for requesting prior approval. Any one of the diagnosis codes from the above listed range is acceptable.

P9041

Payable to beneficiaries of all ages with no restrictions.

P9045

Payable to beneficiaries of all ages with no restrictions.

P9046

Payable to beneficiaries of all ages with no restrictions.

P9047

Payable to beneficiaries of all ages with no restrictions.

Q3025 Q3026

These procedure codes are covered for all ages based on medical necessity.

S0145 S0146

Procedures are payable when there is a primary detail diagnosis ICD-9-CM 070.54

Z1847

Torecan oral tablets. Limit of (4) 10mg tabs per day.

90371

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

90375* 90376*

Covered for all ages. Billing requires 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, units of service must be identified for each date within the span. The manufacturer's invoice must be attached. Reimbursement rate includes administration fee.

90385

Limited to one injection per pregnancy.

90581*

Payable for ages 18 years and older. Indicate dose and attach manufacturer's invoice.

90585

Payable for all ages.

90586

Payable for ages 18 years and older.

90632

Payable when administered to beneficiaries ages 19 years and older.

90633 90634

EP, TJ

Payable when administered to beneficiaries ages 12 months - 18 years. See section 292.593.

90636

EP, TJ

Payable when administered to beneficiaries age 18 years and older. Modifiers are required only when administered to beneficiaries aged 18 years. See section 292.593.

90645 90646 90647

EP, TJ

Payable when administered to beneficiaries of all ages. Modifiers are required only when administered to beneficiaries aged 18 years and younger. See section 292.593 for billing instructions when administered to beneficiaries aged 18 years and younger.

90648

EP, TJ

Payable when administered to beneficiaries aged 18 years and younger. Refer to section 292.593 for more information.

90655 90657

EP, TJ

Influenza vaccines payable through the VFC program for beneficiaries 6-35 months of age. See section 292.593 for billing instructions.

90656 90658

EP, TJ

Influenza vaccines payable for beneficiaries aged 3 years and older. Modifiers required only when administered to children under age 19. Refer to sections 292.593 and 292.594 for influenza vaccine policy.

90660

EP, TJ

Covered for healthy individuals aged 2-49 and not pregnant. Modifiers required only when administered to beneficiaries under age 19. See sections 292.593 and 292.594 of this manual.

90665

Payable when administered to beneficiaries ages 19 years and older.

90669

EP, TJ

Administration of vaccine is covered for children under age 5 years. See section 292.593 for billing instructions.

90675* 90676*

Covered for all ages without diagnosis restrictions. Billing requires 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, appropriate units of service must be indicated and must be identified for each date within the span. The manufacturer's invoice must be attached. Reimbursement rate includes administration fee.

90680

EP, TJ

VFC vaccine payable when administered to beneficiaries ages 6 weeks - 32 weeks. See section 292.593 for more information.

90690

Payable for beneficiaries ages 6 years and older.

90691

Payable for beneficiaries aged 3 years and older.

90700

EP, TJ

VFC vaccine payable when administered to beneficiaries under age 7 years. Modifiers are required. See section 292.593 for more information.

90702

EP, TJ

Payable for beneficiaries ages 0-6 years of age.

90703

Payable for all ages without restrictions and without modifiers.

90704

Payable for beneficiaries aged 1 year and older.

90705

Payable for ages 9 months and older.

90706

Payable for ages 1 year and older.

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. U1 modifier is required for this age group.

Payable when administered to beneficiaries aged 19 and 20 years without modifiers.

90707

EP, TJ

Payable when administered to beneficiaries underage 19 years. Modifiers are required when administered to beneficiaries under age 19 years. See section 292.593.

90708

Payable for beneficiaries 9 months of age and older.

90710

EP, TJ

Payable for beneficiaries under age 21 years. Modifiers are required only when administered to children underage 19. See section 292.593 for additional information.

90713

EP, TJ

Payable for beneficiaries of all ages. However, modifiers are required only when administered to beneficiaries underage 19 years. See section 292.593.

90714

EP, TJ

Payable for beneficiaries ages 7 years and older. Modifiers are required when administered to beneficiaries under age 19 years. See section 292.593.

90715

EP, TJ

This vaccine is covered for individuals aged 7 years and older. Modifiers are required only when administered to beneficiaries underage 19 years. See section 292.593.

90716

EP, TJ

This vaccine is covered for beneficiaries under age 21. Modifiers are required only when administered to beneficiaries under age 19. See section 292.593.

90717

Payable for all ages. Submit invoice with claim.

90718

EP, TJ

This vaccine is covered for individuals aged 7 years and older. Modifiers are required only when administered to beneficiaries underage 19years. See section 292.593.

90719

This vaccine is covered for individuals of all ages.

90720

EP, TJ

This vaccine is covered under the VFC program forages 0-18 years of age. Modifiers are required.

90721

EP, TJ

Covered for beneficiaries under age 21 years. Modifiers are required only when administered to beneficiaries underage 19 years. See section 292.593.

90723

EP, TJ

Covered for beneficiaries under age 19 years. See section 292.593.

90725*

Payable for all ages; submit manufacturer's invoice.

90727*

Payable for all ages; submit manufacturer's invoice.

90732

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

90733

Covered for beneficiaries of all ages.

90734

EP, TJ

Covered for beneficiaries of all ages. Modifiers are required only when administered to beneficiaries under age 19 years. See section 292.593.

90735

Payable for individuals under age 21 years.

90740

Three dose schedule. Payable for individuals of all ages.

90743

EP, TJ

Two dose schedule. Payable only when administered to children aged 0-18 years. See section 292.593.

90744

EP, TJ

Three dose schedule. Payable for ages 0-18 years. See section 292.593.

90746

Payable for ages 19 years and older.

90747

EP, TJ

Covered for beneficiaries of all ages. Modifiers are required only when administered to beneficiaries under age 19 years. See section 292.593.

90748

EP, TJ

Covered for beneficiaries of all ages. Modifiers are required only when administered to beneficiaries under age 19 years. See section 292.593.

* Procedure code requires paper billing with applicable attachments.

292.593 Vaccines for Children Program

The Vaccines for Children (VFC) Program was established to generate awareness and access for childhood immunizations. Arkansas Medicaid established new procedure codes for billing the administration of VFC immunizations for children under the age of 19. To enroll in the VFC Program, contact the Arkansas Division of Health. Providers may also obtain the vaccines to administer from the Arkansas Division of Health. View or print Arkansas Division of Health contact information.

Medicaid policy regarding immunizations for adults remains unchanged by the VFC Program.

Vaccines available through the VFC program are covered for Medicaid-eligible children. Administration fee only is reimbursed. When filing claims for administering VFC vaccines, providers must use the CPT procedure code for the vaccine administered. Electronic and paper claims require modifiers EP and TJ. When vaccines are administered to beneficiaries of ARKids First-B services, only modifier TJ must be used for billing.

The following is a list of covered vaccines for children underage 19.

90633

90634

90636

90645

90646

90647

90648

90655

90656

90657

90658

90660

90669

90680

90700

90702

90707

90710

90713

90714

90715

90716

90718

90720

90721

90723

90734

90743

90744

90747

90748

292.594 Influenza Virus Vaccine
A. Procedure code 90655, influenza virus vaccine, split virus, preservative free, for children 6 to 35 months, is currently covered through the VFC program. Claims for Medicaid beneficiaries must be filed using modifiers EP and TJ.

For ARKids First-B beneficiaries, use modifier TJ.

B. Medicaid covers procedure code 90656, influenza virus vaccine, split virus, preservative free, for ages 3 years and older.
1. For individuals under 19 years of age, claims must be filed using modifiers EP and TJ.

2. For ARKids First-B beneficiaries, use modifier TJ.

3. For individuals ages 19 and older, no modifier is necessary.

C. Procedure code 90660, influenza virus vaccine, live, for intranasal use, is covered. Coverage is limited to healthy individuals ages 2 through 49 who are not pregnant.
1. When filing claims for children 5 through18years of age, use modifiers EP and TJ.

2. For ARKids First-B beneficiaries, the procedure code must be billed using modifier TJ.

3. No modifier is required for filing claims for beneficiaries ages 19 through 49.

D. Procedure code 90657, influenza virus vaccine, split virus, for children ages 6 through 35 months, is covered. Modifiers EP and TJ are required.

ForARKids First-B beneficiaries, use modifier TJ.

E. Procedure code 90658, influenza virus vaccine, split virus, for use in individuals ages 3 years and older, will continue to be covered.
1. When filing claims for individuals under age 19, use modifiers EP and TJ.

2. ForARKids First-B beneficiaries, use modifier TJ.

3. No modifier is required for filing claims for beneficiaries aged 19 and older.

292.790 Surgical Procedures with Certain Diagnosis Ranges

The following procedure codes are payable by the Arkansas Medicaid Program only if the diagnosis is in the range listed below:

Procedure Code

Procedure Description

Diagnosis Range

44950

Appendectomy

5400 - 5439

44955

Appendectomy w/other procedure

5400 - 5439

44960

Appendectomy with abscess

5400 - 5439

44970

Laparoscopic appendectomy

5400 - 5439

49520

Hernia

55000 - 55093

292.870 Bilaminate Graft or Skin Substitute Procedures

Arkansas Medicaid reimburses physicians who furnish the manufactured viable bilaminate graft or skin substitute. The product is manually priced and requires paper claims using procedure code J7340. The manufacturer's invoice, the wound size description and the operative report must be attached.

Application procedures for bilaminate skin substitute do not require prior authorization. The procedures are payable to the physician and must be listed separately on claims.

292.890 Gastrointestinal Tract Imaging with Endoscopy Capsule

Gastrointestinal Tract Imaging with Endoscopy Capsule, billed as 91110, is payable for all ages and must be billed with the primary detail diagnosis of 280.9, 555.0-555.9, 578.1, 578.9, or 792.1.

This procedure code should be billed with no modifiers when performed in the physician's office place of service.

Modifier 26 must additionally be used to indicate billing for the professional component when performed in the inpatient, outpatient hospital, or ambulatory surgical center place of service.

CPT code 91110 is payable on electronic and paper claims. For coverage policy, see section 256.000.

292.910 National Drug Codes (NDCs)

Effective for claims with dates of service on or after January 1, 2008, Arkansas Medicaid implemented billing protocol per the Federal Deficit Reduction Act of 2005. This explains policy and billing protocol for providers that submit claims for drug HCPCS/CPT codes with dates of service on and after January 1, 2008.

The Federal Deficit Reduction Act of 2005 mandates that Arkansas Medicaid require the submission of National Drug Codes (NDCs) on claims submitted with Health Care Financing Administration Common Procedure Code System, Level ll/Current Procedural Terminology, 4th edition (HCPCS/CPT) codes for drugs administered. The purpose of this requirement is to assure that the State Medicaid Agencies obtain a rebate from those manufacturers who have signed a rebate agreement with the Centers for Medicare and Medicaid Services (CMS).

A. Covered Labelers

Arkansas Medicaid, by statute, will only pay for a drug procedure billed with an NDC when the pharmaceutical labeler of that drug is a covered labeler with Centers for Medicare & Medicaid Services (CMS). A "covered labeler" is a pharmaceutical manufacturer that has entered into a federal rebate agreement with CMS to provide each State a rebate for products reimbursed by Medicaid Programs. A covered labeler is identified by the first 5 digits of the NDC. To assure a product is payable for administration to a Medicaid beneficiary, compare the labeler code (the first 5 digits of the NDC) to the list of covered labelers which is maintained on the Arkansas Medicaid website.

A complete listing of "Covered Labelers" is located on the Arkansas Medicaid Web page at www.medicaid.state.ar.us, click on Provider Services, select Prescription Drug information, and then select Covered Labelers. See Diagram 1 for an example of this screen. The effective date is when a manufacturer entered into a rebate agreement with CMS. The Labeler termination date indicates that the manufacturer no longer participates in the federal rebate program and therefore the products cannot be reimbursed by Arkansas Medicaid on or after the termination date.

Diagram 1

LABELER CODE

LABELER NAME

EFFECTIVE DATE

TERMINATION DATE

00002

ELI LILLY AND COMPANY

1/1/1991

00003

E.R. SQUIBB &SONS, INC

1/1/1991

00004

HOFFMANN-LA ROCHE

1/1/1991

00005

LEDERLE LABORATORIES

1/1/1991

00006

MERCK & CO., INC.

1/1/1991

00007

GLAXO SMITH KLINE

1/1/1991

00008

WYETH LABORATORIES

1/1/1991

00009

PFIZER, INC.

1/1/1991

00011

BECTON DICKINSON MICROBIOLOGY SYSTEMS

10/1/1991

7/1/1998

00013

PFIZER, INC.

1/1/1991

In order for a claim with drug HCPCS/CPT codes to be eligible for payment, the detail date of service must be prior to the NDC termination date. The NDC termination date represents the shelf-life expiration date of the last batch produced, as supplied on the Centers for Medicare and Medicaid Services (CMS) quarterly update. The date is supplied to CMS by the drug manufacturer/distributor.

Arkansas Medicaid will deny claim details with drug HCPCS/CPT codes with a detail date of service equal to or greater than the NDC termination date.

When completing a Medicaid claim for administering a drug, indicate the HIPAA standard 11 -digit NDC with no dashes or spaces. The 11 -digit NDC is comprised of three segments or codes: a 5-digit labeler code, a 4-digit product code and a 2-digit package code. The 10-digit NDC assigned by the FDA printed on the drug package must be changed to the 11-digit format by inserting a leading zero in one of the three segments. Below are examples of the FDA assigned NDC on a package changed to the appropriate 11-digit HIPAA standard format. Diagram 2 displays the labeler code as five digits with leading zeros; the product code as four digits with leading zeros; the package code as two digits without leading zeros, using the " 5-4-2 " format.

Diagram 2

00123

0456

78

LABELER

CODE (5 digits)

PRODUCT

CODE (4 digits)

PACKAGE

CODE (2 digits)

NDCs submitted in any configuration other than the 11 digit format will be rejected/denied. NDCs billed to Medicaid for payment must use the 11 digit format without dashes or spaces between the numbers.

See Diagram 3 for sample NDCs as they might appear on drug packaging and the corresponding format which should be used for billing Arkansas Medicaid:

Diagram 3

10-digit FDA NDC on PACKAGE

Required 11-digit NDC ( 5-4-2) Billing Format

12345 6789 1

12345678901

1111-2222-33

01111222233

01111 456 71

01111045671

B. Drug Procedure Code (HCPCS/CPT) to NDC Relationship and Billing Principles

HCPCS/CPT codes and any modifiers will continue to be billed per the policy for each procedure code. However, the NDC and NDC quantity of the administered drug is now also required for correct billing of drug HCPC/CPT codes. To maintain the integrity of the drug rebate program, it is important that the specific NDC from the package used at the time of the procedure be recorded for billing. HCPCS/CPT codes submitted using invalid NDCs or NDCs that were unavailable on the date of service will be rejected/denied. We encourage you to enlist the cooperation of all staff members involved in drug administration to assure collection or notation of the NDC from the actual package used. I t is not recommended that billing of NDCs be based on a reference list, as NDCs vary from one labeler to another, from one package size to another, and from one time period to another.

Exception: There is no requirement for an NDC when billing for vaccines radiopharmaceuticals, and allergen immunotherapy.

I I. Claims Filing

The HCPCS/CPT codes billing units and the NDC quantity do not always have a one-to-one relationship.

Example 1: The HCPCS/CPT code may specify up to 75 mg of the drug whereas the NDC quantity is typically billed in units, milliliters or grams. If the patient is provided 2 oral tablets, one at 25 mg and one at 50 mg, the HCPCS/CPT code unit would be 1 (1 total of 75 mg) in the example whereas the NDC quantity would be 1 each (1 unit of the 25 mg tablet and 1 unit of the 50 mg tablet). See Diagram 4.

Diagram 4

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Example 2: If the drug in the example is an injection of 5 ml (or cc) of a product that was 50 mg per 10 ml of a 10 ml single-use vial, the HCPCS/CPT code unit would be 1 (1 unit of 25 mg) whereas the NDC quantity would be 5 (5 ml). In this example, 5 ml or 25 mg would be documented as wasted. See Diagram 5.

Diagram 5

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A. Electronic Claims Filing - 837P (Professional) and 837I (Outpatient)

Electronic claims can be filed with a maximum of 5 NDCs per detail.

Procedure codes that do not require paper billing may be billed electronically. Any procedure codes that have required modifiers in the past will continue to require modifiers.

Arkansas Medicaid requires providers using Provider Electronic Solutions (PES) to use the required NDC format when billing HCPCS/CPT codes for administered drugs.

When billing multiple NDCs, the HCPCS/CPT should reflect the total charges and units of all administered NDCs. The NDC fields should reflect the price and units of each specific NDC, up to a maximum of five NDCs per detail.

For837P professional claims, from the Service 2 tab, in the RX Indicator field, select "Y" to open the RX tab. On the RX tab, enter the NDC, Unit of Measure, Quantity and Price for each NDC.

Example 2: If the drug in the example is an injection of 5 ml (or cc) of a product that was 50 mg per 10 ml of a 10 ml single-use vial, the HCPCS/CPT code unit would be 1 (1 unit of 25 mg) whereas the NDC quantity would be 5 (5 ml). In this example, 5 ml or 25 mg would be documented as wasted. See Diagram 5.

Diagram 5

If billing electronic claims using vendor software, check with your vendor to ensure your software will be able to capture the criteria necessary to submit these claims. Vendor companion guides are located on the Arkansas Medicaid Web page at https://www.medicaid.state.ar.us/. Click on Provider, select HIPAA, select Documents for vendors and then select Companion guides.

B. Paper Claims Filing - CMS-1500

Arkansas Medicaid will require providers billing drug HCPCS/CPT codes including covered unlisted drug procedure codes to use the required NDC format.

See Diagram 6 for CMS-1500.

For professional claims, CMS-1500, list the qualifier of "N4", the 11-digit NDC, the unit of measure qualifier (F2 - International Unit; GR - Gram; ML - Milliliter; UN - Unit), and the number of units of the actual NDC administered in the shaded area above detail field 24A, spaced & arranged exactly as in Diagram 6.

Each NDC, when billed under the same procedure code on the same date of service is defined as a "sequence". When billing a single HCPCS/CPT code with multiple NDCs as detail sequences, the first sequence should reflect the total charges in the detail field 24F and total HCPCS/CPT code units in detail field 24G. Each subsequent sequence number should show zeros in detail fields 24F and 24G. See Detail 1, sequence 2 in Diagram 6.

The quantity of the NDC will be the total number of units billed for each specific NDC. See Diagram 6, first detail, sequences 1 and 2. Detail 2 is a Procedure Code that does not require an NDC. Detail 3, sequence 1 gives an example where only one NDC is associated with the HCPCS/CPT code.

Diagram 6

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Procedure Code/NDC Detail Attachment Form- DMS-664

For drug HCPCS/CPT codes requiring paper billing (i.e., for manual review), complete every field of the DMS-664 "Procedure Code/NDC Detail Attachment Form." Attach this form and any other required documents to your claim when submitting it for processing. See Diagram 8 for an example of the completed form. A copy of form DMS-664 is attached and may be copied for claim submission. Copies of the DMS-664 will not be provided. Section V of the provider manual will be updated to include this form.

Diagram 8

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III. Adjustments

Paper adjustments for paid claims filed with NDC numbers will not be accepted. Any original claim will have to be voided and a replacement claim will need to be filed. Providers have the option of adjusting a paper or electronic claim electronically.

IV. Remittance Advices

Only the first sequence in a detail will be displayed on the remittance advice reflecting either the total amount paid or the denial EOB(s) for the detail.

V. Drug Efficacy Study Implementation (DESI) Drugs

The Federal Drug Administration (FDA) reviews the effectiveness of drugs approved between 1938 and 1962 through a program named the Drug Efficacy Study Implementation (DESI) program. Drugs that were approved by the FDA before 1962 were permitted to remain on the market while evidence of their effectiveness was reviewed. If the DESI review indicates a lack of substantial evidence of a drug's effectiveness, the FDA will publish its proposal to withdraw approval of the drug for marketing. In accordance with Section 1903(i)(5) of the Social Security Act, federal funds participation (FFP) is not available for Less than Effective (LTE) drugs or the Identical, Related or Similar (IRS) drugs identified by the FDA and published quarterly by the Centers for Medicare & Medicaid Services

This means that any HCPCS/CPT code will not be payable when linked to any NDC with a DESI indicator. If it is determined that all NDCs linked to a specific HCPCS/CPT are DESI, this is an instance where the procedure code will no longer be payable.

A list of "DESI" drugs with the effective and end dates will be on the Arkansas Medicaid website. From the main page, click "Provider," then select "Prescription Drug Information" and then select "DESI NDCs (non-payable) associated with HCPCS/CPT Codes." See Diagram 9 for an example of the DESI list.

Diagram 9

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VI. Record Retention

Each provider must retain all records for five (5) years from the date of service or until all audit questions, dispute or review issues, appeal hearings, investigations or administrative/judicial litigation to which the records may relate are concluded, whichever period is longer.

At times, a manufacturer may question the invoiced amount, which results in a drug rebate dispute. If this occurs, you may be contacted requesting a copy of your office records to include documentation pertaining to the billed HCPCS/CPT code. Requested records may include NDC invoices showing purchase of drugs and documentation showing what drug (name, strength and amount) was administered and on what date, to the beneficiary in question.

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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