Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.16-020 - 2016 CPT and HCPCS Procedure Code Conversion

I. Requests for molecular pathology laboratory services must be requested and a prior authorization received prior to billing the claims.

II. The Request for Molecular Pathology Laboratory Services (Form DMS-841) must accompany the supporting clinical record when submitting a paper request.

III. Molecular Pathology Laboratory Services requests will be denied if received after the timely filing time frame (12 months beyond the date of service).

IV. AFMC Molecular Pathology Laboratory requests will be considered if all of the following documentation is received with the request.

I. General Information

A review of the 2016 Current Procedural Terminology (CPT®) procedure codes has been completed, and the Arkansas Medicaid Program will begin accepting CPT® 2016 procedure codes for dates of service on and after August 26, 2016.

Procedure codes that are identified as deletions in CPT® 2016 (Appendix B) are non-payable for dates of service on and after August 26, 2016.

For the benefit of those programs impacted by the conversions, the Arkansas Medicaid website fee schedules will be updated soon after the implementation of the 2016 CPT® and Healthcare Common Procedure Coding System Level II (HCPCS) conversions.

II. Process for Obtaining Prior Authorization

When obtaining a Prior Authorization (PA) from the Arkansas Foundation for Medical Care (AFMC), please send your request to the following:

III. Non-Covered 2016 CPT® Procedure Codes

IV. CPT® Lab and Molecular Pathology Procedure Codes

Molecular Pathology procedure codes in this section listed in points A and B below, require Prior Authorization (PA). Providers are to acquire Prior Authorization before a claim for Molecular Pathology is filed for payment. Providers may request the PA from Arkansas Foundation for Medical Care (AFMC) before or after the procedure is performed as long as it is acquired within the 365-day filing deadline. Providers of these procedures may submit Molecular Pathology requests and medical record documentation to AFMC via mail, fax or electronically through a web portal. See additional contact information for AFMC in Section II of this notice.

Molecular Pathology PA requests must be submitted by the performing provider with submission of a completed Arkansas Medicaid Request for Molecular Pathology Laboratory Services (Form DMS-841) and the attachment of all pertinent clinical documentation needed to justify the procedure. If the request is approved, a Prior Authorization number will be assigned and the provider will receive notification of the approval in writing by mail. If the request does not meet the medical necessity criteria and is denied, the requesting provider will receive notification of the denial in writing by mail. Reconsideration is allowed if new or additional information is received by AFMC within 30 days of the initial denial. A sample copy of Form DMS-841 is attached. This form may be found in Section V of the provider manual. Copies may be made of this form. The enclosed form is for informational purposes only. Please do not complete the enclosed form unless you are submitting a Molecular Pathology PA request.

Molecular Pathology procedure codes must be submitted on a redline paper claim form with the PA listed on the claim and the itemized invoice attached that supports the charges for the test billed.

V. Hearing Providers

The following 2016 CPT® procedure codes are payable to Hearing Providers:

VI. Hospital Providers

The following 2016 CPT® procedure code is payable to Hospital Providers with special instructions:

NOTE: Requires paper billing and documentation attached that describes that sclerotherapy of fluid collections is indicated for the treatment of cysts, seromas or lymphoceles which are causing bleeding, infection, severe pain, organ torsion or organ dysfunction.

VII. Independent Radiology Providers

The following 2016 CPT® procedure codes are payable to Independent Radiology Providers:

NOTE: Fetal MRI is covered when all of the following conditions are met:

VIII. Nurse Practitioner

The payment for Laboratory codes listed on the Nurse Practitioner Fee Schedule is based on Clinical Laboratory Improvement Amendments (C.L.I.A.) certification. Note that only C.L.I.A.-certified providers may bill for lab procedures performed in the provider's office, place of service 11. Nurse Practitioner Providers that bill C.L.I.A.-required Laboratory procedure codes must have the current C.L.I.A. certification on file with the Arkansas Medicaid Provider Enrollment Unit.

*The technical component of Radiology procedure codes listed on the Nurse Practitioner Fee Schedule is payable when performed in the office place of service (11) if the Nurse Practitioner Provider owns the equipment. The technical component must be billed on the claim with modifier TC added to the procedure code on the claim detail.

NOTE: Fetal MRI is covered when all of the following conditions are met:

IX. Oral Surgeons

The following 2016 CPT® procedure codes are payable to Oral Surgeon Providers:

X. Physicians

The 2016 CPT® procedure code 33477 is payable to Physicians with Prior Authorization from the Arkansas Foundation for Medical Care (AFMC).

XI. Miscellaneous Information

I. General Information

A review of the 2016 HCPCS procedure codes has been completed and the Arkansas Medicaid Program will begin accepting updated Healthcare Common Procedure Coding System Level II (HCPCS) procedure codes on claims with dates of service on and after August 26, 2016. 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 2016 HCPCS Level II and 2016 Current Dental Terminology (CDT) will become non-payable for dates of service on and after August 26, 2016.

Please NOTE: The Arkansas Medicaid website fee schedules will be updated soon after the implementation of the 2016 CPT and HCPCS conversions.

II. 2016 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 seven 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.

IV. 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.

V. HCPCS Procedure Codes Payable to Certified Nurse Midwife Providers

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

NOTE: J7298 with an FP modifier requires a primary diagnosis of family planning

_________on the claim.___________________________________________________

*For females only

VI. Dental

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:

VIII. HCPCS Procedure Codes Payable to Federally Qualified Health Centers (FQHC)

The following information is related to procedure codes payable to Federally Qualified Health Center providers:

NOTE: J7298 with an FP modifier requires a primary diagnosis of family planning on the claim.

*For females only

IX. HCPCS Procedure Codes Payable to Home Health Providers

The following information is related to procedure codes payable to Home Health provider

*Existing code being made payable in 2016. The description for T4525 NU is as follows: Adult-sized disposable incontinent product, protective underwear/pull-on, small sized, each.

X. HCPCS Procedure Codes Payable to Hospitals

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

NOTE: Kengreal is a P2Y12 platelet inhibitor indicated as an adjunct to percutaneous coronary intervention (PCI) for reducing the risk of periprocedure myocardial infarction (MI), repeat coronary revascularization, and stent thrombosis (ST) in patients who have not been treated with a P2Y12 platelet inhibitor and are not being given a glycoprotein IIB/IIIA inhibitor.

NOTE: J7297 requires a primary diagnosis of family planning when administered for this purpose.

NOTE: J7298 requires a primary diagnosis of family planning when administered for this purpose.

*For females only

XI. HCPCS Procedure Codes Payable to Nurse Practitioners

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

NOTE: Kengreal is a P2Y12 platelet inhibitor indicated as an adjunct to percutaneous coronary intervention (PCI) for reducing the risk of periprocedure myocardial infarction (MI), repeat coronary revascularization, and stent thrombosis (ST) in patients who have not been treated with a P2Y12 platelet inhibitor and are not being given a glycoprotein IIB/IIIA inhibitor.

NOTE: J7297 with an FP modifier requires a primary diagnosis of family planning on the claim.

NOTE: J7298 with an FP modifier requires a primary diagnosis of family planning on the claim.

*For females only

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: Kengreal is a P2Y12 platelet inhibitor indicated as an adjunct to percutaneous coronary intervention (PCI) for reducing the risk of periprocedure myocardial infarction (MI), repeat coronary revascularization, and stent thrombosis (ST) in patients who have not been treated with a P2Y12 platelet inhibitor and are not being given a glycoprotein IIB/IIIA inhibitor.

NOTE: J7297 with an FP modifier requires a primary diagnosis of family planning on the claim.

NOTE: J7298 with an FP modifier requires a primary diagnosis of family planning on the claim.

*For females only

XIII. HCPCS Procedure Codes Payable to Private Duty Nursing Providers

The following information is related to procedure codes payable to Private Duty Nursing 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 Arkansas Foundation for Medical Care (AFMC) 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.

*Existing code being made payable in 2016. The description for T4525 NU is as follows: Adult-sized disposable incontinent product, protective underwear/pull-on, small sized, each.

XV. HCPCS Procedure Codes Payable to Ventilator Providers

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

*(...)This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

XVI. Miscellaneous Information

XVII. Non-Covered HCPCS Procedure Codes

The following 2016 HCPCS 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.