Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.16-001 - Notice of Rule Making 002-15 (CPT) and 003-15 (HCPCS) Conversion Notices

I. General Information

A review of the 2015 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 December 18, 2015. 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 2015 HCPCS Level II will become non-payable for dates of service on and after December 18, 2015.

Please NOTE: The Arkansas Medicaid website fee schedules will be updated soon after the implementation of the 2015 CPT and HCPCS conversions.

II. 2015 HCPCS Payable Procedure Codes Tables Information

Procedure codes are in separate tables. Tables are created for each affected provider type (i.e., prosthetics, home health, etc.).

The tables of payable procedure codes for all affected programs are designed with eight columns of information. All columns may not be applicable for each covered program, but are devised for ease of reference.

Please NOTE: An asterisk indicates that the procedure code requires a paper claim.

III. Acquisition of Prior Approval Letter

A prior approval letter, when required, must be attached to a paper claim when it is filed. Providers must obtain prior approval in accordance with the following procedures for special pharmacy, therapeutic agents and treatments:

IV. Process for Obtaining Prior Authorization

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

V. International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), Diagnosis Range and Diagnosis Lists

Diagnosis is documented using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM). Certain procedure codes are covered only for a specific primary diagnosis or a particular diagnosis range. Diagnosis list 103 is specified here (View ICD Codes.). For any other diagnosis restrictions, reference the table for each individual program.

VI. Dental

The following 2015 ADA Dental procedure codes are not covered by Arkansas Medicaid.

VII. HCPCS Procedure Codes Payable to End-Stage Renal Disease Providers

The following information is related to procedure codes payable to End-Stage Renal Disease providers:

NOTE: The primary diagnosis should be (View ICD Codes.) with a secondary diagnosis of (View ICD Codes.). For patients with CKD on dialysis:

* Initiate Mircera treatment when the hemoglobin level is less than 10 g/dL.

* If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of Mircera.

* The recommended starting dose of Mircera for the treatment of anemia in adult CKD patients who are not currently treated with an ESA is 0.6 mcg/kg body weight administered as a single IV or SC injection once every two weeks. The IV route is recommended for patients receiving hemodialysis because the IV route may be less immunogenic.

* Once the hemoglobin has been stabilized, Mircera may be administered once monthly using a dose that is twice that of the every-two-week dose and subsequently titrated as necessary.

NOTE: For patients with CKD not on dialysis:

* Consider initiating Mircera treatment only when the hemoglobin level is less than 10 g/dL and the following considerations apply:

* The rate of hemoglobin decline indicates the likelihood of requiring an RBC transfusion, and

* Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal.

* If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of Mircera and use the lowest dose of Mircera sufficient to reduce the need for RBC transfusions.

VIII. HCPCS Procedure Codes Payable to Home Health Providers

The following information is related to procedure codes payable to Home Health providers.

NOTE: The primary diagnosis should be (View ICD Codes.) with a secondary diagnosis of (View ICD Codes.). For patients with CKD on dialysis:

* Initiate Mircera treatment when the hemoglobin level is less than 10 g/dL.

* If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of Mircera.

* The recommended starting dose of Mircera for the treatment of anemia in adult CKD patients who are not currently treated with an ESA is 0.6 mcg/kg body weight administered as a single IV or SC injection once every two weeks. The IV route is recommended for patients receiving hemodialysis because the IV route may be less immunogenic.

* Once the hemoglobin has been stabilized, Mircera may be administered once monthly using a dose that is twice that of the every-two-week dose and subsequently titrated as necessary.

NOTE: For patients with CKD not on dialysis:

* Consider initiating Mircera treatment only when the hemoglobin level is less than 10 g/dL and the following considerations apply:

* The rate of hemoglobin decline indicates the likelihood of requiring an RBC transfusion, and

* Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal.

* If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of Mircera and use the lowest dose of Mircera sufficient to reduce the need for RBC transfusions.

IX. HCPCS Procedure Codes Payable to Hospitals

The following information is related to procedure codes payable to Hospital providers:

NOTE: Entyvio is an integrin receptor antagonist for adult ulcerative colitis (UC). For adults with UC it must be moderately to severely active and have had an inadequate response with, or lost response to, or were intolerant to a tumor necrosis factor (TNF) blocker or immunomodulator, or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids:

X. HCPCS Procedure Codes Payable to Independent Radiology

The following information is related to procedure codes payable to Independent Radiology providers:

XI. HCPCS Procedure Codes Payable to Nurse Practitioners

The following information is related to procedure codes payable to Nurse Practitioner providers:

NOTE: The primary diagnosis should be (View ICD Codes.) with a secondary diagnosis of (View ICD Codes.). For patients with CKD on dialysis:

* Initiate Mircera treatment when the hemoglobin level is less than 10 g/dL.

* If the hemoglobin level approaches or exceeds 11 g/dL, reduce or interrupt the dose of Mircera.

* The recommended starting dose of Mircera for the treatment of anemia in adult CKD patients who are not currently treated with an ESA is 0.6 mcg/kg body weight administered as a single IV or SC injection once every two weeks. The IV route is recommended for patients receiving hemodialysis because the IV route may be less immunogenic.

* Once the hemoglobin has been stabilized, Mircera may be administered once monthly using a dose that is twice that of the every-two-week dose and subsequently titrated as necessary.

NOTE: For patients with CKD not on dialysis:

* Consider initiating Mircera treatment only when the hemoglobin level is less than 1 g/dL and the following considerations apply:

* The rate of hemoglobin decline indicates the likelihood of requiring an RBC transfusion, and

* Reducing the risk of alloimmunization and/or other RBC transfusion-related risks is a goal.

* If the hemoglobin level exceeds 10 g/dL, reduce or interrupt the dose of Mircera and use the lowest dose of Mircera sufficient to reduce the need for RBC transfusions.

XII. HCPCS Procedure Codes Payable to Physicians and Area Health Education Centers (AHECs)

The following information is related to procedure codes payable to Physician and AHEC providers:

NOTE: Entyvio is an integrin receptor antagonist for adult ulcerative colitis (UC). For adults with UC it must be moderately to severely active and have had an inadequate response with, or lost response to, or were intolerant to a tumor necrosis factor (TNF) blocker or immunomodulator, or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroids:

XIII. HCPCS Procedure Codes Payable to Podiatrists

The following information is related to procedure codes payable to Podiatrist providers:

XIV. HCPCS Procedure Codes Payable to Prosthetics Providers

The following information is related to procedure codes payable to Prosthetics providers:

Procedure codes in the table must be billed with appropriate modifiers. For procedure codes that require a prior authorization, the written PA request must be submitted to the Utilization Review Section of the Division of Medical Services (DMS) for wheelchairs and wheelchair related equipment and services.

For other durable medical equipment (DME), a written request must be submitted to the Arkansas Foundation for Medical Care. Please refer to your Arkansas Medicaid Prosthetics Provider Manual for details on requesting a DME prior authorization.

XV. HCPCS Procedure Codes Payable to Transportation Providers

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

XVI. Miscellaneous Information

An asterisk (*) after the procedure code denotes the requirement of a paper claim.

XVII. Non-Covered 2015 HCPCS with Elements of CPT or Other Procedure Codes

The following new 2015 HCPCS procedure codes are not payable because these services are covered by a CPT code, another HCPCS code or a revenue code.

XVIII. Non-Covered 2015 HCPCS Procedure Codes

The following procedure codes are not covered by Arkansas Medicaid.

If you have questions regarding this notice, please contact the Hewlett Packard Enterprise Provider Assistance Center at 1-800-457 -4454 (Toll-Free) within Arkansas 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 the Program Development and Quality Assurance Unit at (501) 320-6429.

Arkansas Medicaid provider manuals (including update transmittals), official notices, notices of rule making and remittance advice (RA) messages are available for download from the Arkansas Medicaid website: www.medicaid.state.ar.us.

Thank you for your participation in the Arkansas Medicaid Program.

____________________________________________________

Dawn Stehle Director

Summary for 2015 CPT and HCPCS Procedure Code Conversion

To comply with federal regulation 45 CFR Subpart J, Section 162.1002, these Notices of Rulemaking informs providers of the implementation of the annual Current Procedure Codes, (CPT), and the annual Healthcare Common Procedure Codes Systems, (HCPCS). These data sets are created and published by the American Medical Association and the Centers for Medicare and Medicaid on an annual basis. This Rule is necessary for consistency with the utilization of procedure codes used by Medicare and other third party payers of medical claims. These data sets are standardized and are used nationally for claims processing. This emergency notice will help expedite claims processing. Payable procedure codes will be added to the provider fee schedules and policy manuals will be updated as necessary. This will ensure that additional claims system testing will not be needed before implementation, resulting in subsequent delays and further lost efficiency of time. It will also help to put 2016 CPT/HCPCS planning, programming, testing, and promulgation processes back on its regular timelines.

Emergency filing is necessary to allow providers to bill on the 2015 codes. Due to the implementation of ICD-10, work could not begin on implementing these codes until August 2015. The work will not be completed until December 2015.