Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.11-002 - Official Notices ON-002-11 & ON-003-11- 2011 Conversions - 2011 CPT and HCPCS Procedure Code Conversion

I. General Information

A review of the 2011 Current Procedural Terminology (CPT®) procedure codes has been completed, and the Arkansas Medicaid Program will begin accepting CPT 2011 procedure codes for dates of service on and after March 15, 2011.

Procedure codes that are identified as deletions in CPT 2011 (Appendix B) are non-payablefor dates of service on and after March 15, 2011.

For the benefit of those programs impacted by the conversions, the Arkansas Medicaid website fee schedule will be updated soon after the implementation of the 2011 CPT and Healthcare Common Procedural Coding System Level II (HCPCS) conversions.

II. Non-Covered 2011 CPT Procedure Codes

III. Prior Authorization

When obtaining a prior authorization from the Arkansas Foundation for Medical Care, please send your request to the following:

The following 2011 CPT procedure codes require prior authorization from AFMC.

IV. 2011 CPT Lab Procedure Codes with International Classification of Diseases, 9th Revision, and Clinical Modification (ICD-9-CM) Diagnosis Restrictions

The following 2011 CPT procedure codes will be payable with a primary (ICD-9-CM) diagnosis as is indicated below.

V. Independent Radiology

The following 2011 CPT procedure codes are payable to Independent Radiology Providers.

VI. Oral Surgeons

The following 2011 CPT procedure codes are payable to Oral Surgeons.

VII. Vision Program

The following 2011 CPT procedure codes are payable to Vision Service Providers.

VIII. Ambulatory Surgical Centers

The following 2011 CPT procedure codes are payable to Ambulatory Surgical Centers.

If you have questions regarding this notice, please contact the HP Enterprise Services Provider Assistance Center at In-State WATS 1-800-457 -4454, or locally and Out-of-State at (501) 376-2211.

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at 501-682-0593 (Local); 1-800-482 -5850, extension 2-0593 (Toll-Free) or to obtain access to these numbers through voice relay, 1-800-877 -8973 (TTY Hearing Impaired).

Arkansas Medicaid provider manuals, official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.

Thank you for your participation in the Arkansas Medicaid Program.

Eugene I. Gessow, Director

I. General Information

A review of the 2011 HCPCS procedure codes has been completed and the Arkansas Medicaid Program will begin accepting updated Healthcare Common Procedural Coding System Level II (HCPCS) procedure codes on claims with dates of service on and after March 15, 2011. Drug procedure codes require National Drug Code (NDC) billing protocol. Drug procedure codes that represent radiopharmaceuticals, vaccines and allergen immunotherapy are exempt from the NDC billing protocol.

Procedure codes that are identified as deletions in 2011 HCPCS Level II will become non-payable for dates of service on and after March 15, 2011.

Please note: The Arkansas Medicaid website fee schedule will be updated soon after the implementation of the 2011 CPTand HCPCS conversions.

II. 2011 HCPCS Payable Procedure Codes Tables Information

III. International Classification of Diseases. 9th Revision. Clinical Modification (ICD-9-CM). Diagnosis Range and Diagnosis Lists

Diagnosis is documented using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Certain procedure codes are covered only for a specific primary diagnosis or a particular diagnosis range. Diagnosis list 003 is specified below. For any other diagnosis restrictions, reference the table for each individual program.

III. International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), Diagnosis Range and Diagnosis Lists

Diagnosis List 003

042

140.0 through 209.30

209.31 through 209.36

209.70 through 209.75

209.79

230.0 through 238.9

511.81

V58.11 through V58.12

V87.41

IV. HCPCS Procedure Codes Payable to Ambulatory Surgical Centers (ASC)

The following information is related to procedure codes payable to the ASC Program.

V. HCPCS Procedure Codes Payable to ARKids First-B

VI. HCPCS Procedure Codes Payable to Certified Nurse Midwife

The following information is related to procedure codes payable to the Certified Nurse Midwife Program. See Section III of this notice for ICD-9-CM diagnosis codes contained in diagnosis list 003.

VII. HCPCS Procedure Codes Payable to Hospitals

The following information is related to procedure codes payable to hospital providers. For section VII, reference the superscript alpha character following the procedure code in the table to determine what coverage protocol listed below applies to that procedure code in the list. Claims that require attachments (such as op-reports and prior approval letters) must be billed on a paper claim. See Section II of this notice for information on requesting a prior approval letter. See Section III of this notice for ICD-9-CM diagnosis codes contained in diagnosis list 003.

In addition to the special circumstances listed below with each alpha character, any other processes or requirements indicated in the table are also applicable.

C9272ACovered for female, post menopausal beneficiaries with osteoporosis and inability to tolerate oral medications for osteoporosis, (ICD-9-CM 733.1). Inability to tolerate oral medications must be documented in medical history and physical exam with reason for intolerance clearly documented and name of oral medications that patient was unable to tolerate. Inability to tolerate oral medication must include signs and symptoms of esophageal disease. Patient must be at high risk for osteoporotic fracture or have multiple risk factors for fracture. Physicians should document that they have informed the patient of the risks of therapy in accordance with the Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy Program. Use this procedure code for Prolia.

Note:Arkansas Medicaid requires that Xgeva be filed under J3590 on a paper claim with the drug name and dose. Xgevais only approved for prevention of skeletal-related events in patients with bone metastases from breast and prostate cancer and solid tumors. Xgevais not indicated for the prevention of skeletal-related events in patients with multiple myeloma. Xgevarequires documentation in the medical record of the rationale for why Zometawas not used. A complete history and physical exam documenting the type of cancer and what chemotherapy is prescribed is required to be in the medical record.

C9277BPayable for beneficiaries aged 8 and older who have the ICD-9-CM detail diagnosis of 271.0. The history and physical by a geneticist showing a diagnosis of late onset, not infantile, Pompe's disease must be submitted with the request for the prior approval letter. The beneficiary, physician and infusion center should be enrolled in the Lumizyme Alglucosidase Alfa Control (ACE) Program. The history and physical should document compliance with this program including discussion of the risks of anaphylaxis, severe allergic reactions and immune-mediated reactions according to the Black Box warning from the Food and Drug Administration. This drug should only be administered in a facility equipped to deal with anaphylaxis, including Advanced Life Support capability. The approval letter must be attached to each claim. (See Section 272.103 of the hospital manual or Section II B. of this notice for instructions for obtaining a prior approval letter.) Use this procedure code for Lumizyme.

C9278cPayable for beneficiaries ages 18 and older when medically necessary. This drug is reviewed for medical necessity based on the ICD-9-CM diagnosis code billed.

J0597DPayable for beneficiaries ages 13 and older. This drug will be considered for claims with a primary ICD-9-CM diagnosis of 277.6 and will be reviewed for medical necessity based on the clinical documentation submitted.

J1290EPayable for beneficiaries ages 16 and older. This drug will be considered for claims with a primary ICD-9-CM diagnosis of 277.6 and will be reviewed for medical necessity based on the clinical documentation submitted.

J1599FClaims are reviewed for medical necessity, based on the ICD-9-CM diagnosis code billed.

J3262GThis procedure code is only approved for rheumatoid arthritis, (ICD-9-CM 714.0) in adult patients ages 18 years and older. A prior approval letter is required. The patient must have tried and failed therapy with documented progression of symptoms on Humira and Enbrel prior to the request for this drug. The physician medical record must document a history and physical examination that clearly shows failure of Humira and Enbrel with submission for a prior approval letter. Doses exceeding 800 mg. per infusion will not be approved, as they are not recommended. The physician must follow all Food and Drug Administration (FDA) recommendations on monitoring of laboratory and serious infections. This procedure must be billed on a paper claim. (See Section 272.103 of the hospital manual or Section II B. of this notice for instructions for obtaining a prior approval letter). The prior approval letter must be submitted with each claim.

J3357HThis procedure code is covered for the diagnosis of moderate to severe plaque psoriasis (ICD-9-CM 696.1) in adult patients ages 18 years and older. A prior approval letter is required. There must be clear documentation that the patient has failed Humira and Enbrel, with documentation of progression of the disease or documented inability to tolerate Humira and Enbrel. A physician history and physical must be submitted with a request for prior approval letter. Documentation of patient counseling of the adverse effects of the drug should also be included. This drug should only be administered to patients who will be closely monitored and have regular follow-up visits by a physician. This procedure must be billed on a paper claim. (See Section 272.103 of the hospital manual or Section II B. of this notice for instructions for obtaining a prior approval letter). The prior approval letter must be submitted with each claim.

J33851This procedure code is for pediatric and adult beneficiaries ages 4 years and older with Type I Gaucher Disease (ICD-9-CM 272.7) who are symptomatic and require enzyme replacement therapy. This drug requires prior approval by the Medical Director for Clinical Affairs. A history and physical exam by a geneticist is required yearly for approval. The history and physical exam should document the prognosis of the patient as well as current symptoms. (See Section 272.103 of the hospital manual or Section II B. of this notice for instructions for obtaining a prior approval letter). This procedure must be billed on a paper claim. The prior approval letter must be attached to each claim.

J7312JThis procedure code is covered for adults 18 years and older for the diagnosis of macular edema following branch retinal vein occlusion (BRVO), (ICD-9-CM 362.30), or central retinal vein occlusion (CRVO), (ICD-9-CM 362.35) and noninfectious uveitis of the posterior segment, (ICD-9-CM 363.20) which has failed oral treatments and is untreatable by any other method. This procedure code requires a prior approval letter. There should be documentation of vein occlusion and studies documenting macular edema. Visual acuity should be noted after the vein occlusion or after failed treatments for uveitis. The patients should be monitored after the injection for elevation in intraocular pressure and endophthalmitis. Counseling of side effects should be documented in the medical record. The history and physical exam including all tests should be sent with the request for prior approval letter. (See Section 272.103 of the hospital manual or Section II B. of this notice for instructions for obtaining a prior approval letter). This procedure must be billed on a paper claim. The prior approval letter must be attached to each claim.

*Denotes paper claim.

VIII. HCPC Procedure Codes Payable to Independent Radiology

The following information is related to procedure codes payable to the Independent Radiology Program.

IX. HCPCS Procedure Codes Payable to Nurse Practitioners

The following information is related to procedure codes payable to Nurse Practitioner providers. See Section III of this notice for ICD-9-CMdiagnosis codes contained in diagnosis list 003.

Centers (AHECs)

The following information is related to procedure codes found in the Physicians and AHECs section table. For section X, reference the superscript alpha character following the procedure code in the table to determine what coverage protocol applies to that procedure code in the list. Claims that require attachments (such as operative reports and prior approval letters) must be billed on a paper claim. (See Section II of this notice for information on requesting a prior approval letter.) See Section III of this notice for using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes contained in diagnosis list 003. In addition to the special circumstances listed below with each alpha character, any other processes or requirements indicated in the table are also applicable.

X. HCPCS Procedure Codes Payable to Physicians and Area Health Care Education

XI. HCPCS Procedure Codes Payable to Prosthetics

XII. HCPCS Procedure Codes Payable to Transportation

The following information is related to procedure codes payable to Transportation providers.

XIII. Non-Covered 2011 HCPCS with Elements of CPT or Other Procedure Codes

The following new 2011 HCPCS procedure codes are not payable because these services are covered by a CPT code, another HCPCS code or a revenue code.

XIV. Non-Covered 2011 HCPCS Procedure Codes

The following procedure codes are not covered by Arkansas Medicaid.

XV. Modification to the Healthcare Common Procedure Coding System (HCPCS)

The Centers for Medicare and Medicaid (CMS) has released a modification to the HCPCS code set. The following procedure codes were reinstated with their original language. There is no longer a termination date of 12/31/2010 for these HCPCS procedure codes. These codes are still valid HCPCS codes.

If you have questions regarding this notice, please contact the HP Enterprise Services Provider Assistance Center at In-State WATS 1-800-457 -4454, or locally and Out-of-State at (501) 376-2211.

If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at 501-682-0593 (Local); 1-800-482 -5850, extension 2-0593 (Toil-Free) or to obtain access to these numbers through voice relay, 1-800-877 -8973 (TTY Hearing Impaired).

Arkansas Medicaid provider manuals, official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.

Thank you for your participation in the Arkansas Medicaid Program.

Eugene I. Gessow, Director