Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.13-022 - Implementation of Coverage for the Percutaneous Cecostomy Tube and Skin Level Gastronomy Tube for All Ages

Current through Register Vol. 49, No. 6, June, 2024
Summary for
State Plan Amendment #2013-024 and
Prosthetics 5-13
Effective for claims with dates of service March 1, 2014 and
				after, the Arkansas Department of Human Services is implementing coverage of
				the MIC-KEY Percutaneous Cecostomy Tube for all ages. In addition, the MIC-KEY
				Skin Level Gastrostomy Tube will be expanded to coverage for all ages. Arkansas
				Medicaid has estimated an annual budget impact of $31,000.
Section IIProsthetics
212.209
(DME) MIC-KEY Skin Level
			 Gastrostomy Tube (MIC-KEY Button) and Supplies for Beneficiaries of All
			 Ages
The Arkansas Medicaid Program reimburses for the MIC-KEY Skin
				Level Gastrostomy Tube (MIC-KEY button) and supplies for Medicaid-eligible
				beneficiaries of all ages. Prior authorization (PA) from AFMC is
				required.
When requesting prior authorization, form DMS-679A titled
Prescription & Prior Authorization Request for Medical Equipment
				Excluding Wheelchairs & Wheelchair Components,
must be completed
				and sent, along with sufficient medical documentation, to AFMC.
The MIC-KEY Kit is benefit-limited to 2 per state fiscal year
				(SFY). The accessories, extension sets and adapters are covered under the $250
				medical supply benefit limit.
Benefit extensions will be considered on a case-by-case basis
				if proven to be medically necessary. Prior authorization must be obtained from
				AFMC for any extensions using form DMS-679A.
View or print
				AFMC contact information. View or print form DMS-679A and instructions for
				completion.
212.210
DME MIC-KEY Percutaneous
			 Cecostomy Tube (MIC-KEY button) for Beneficiaries of All Ages
The Arkansas Medicaid Program reimburses for the MIC-KEY
				Percutaneous Cecostomy Tube (MIC-KEY button) for Medicaid-eligible
				beneficiaries of all ages. Arkansas Medicaid will reimburse the MIC-KEY Skin
				Level Gastrostomy Tube for all ages, when used for the management of severe
				fecal incontinence (see diagnosis codes below) requiring percutaneous cecostomy
				tube placement for bowel evacuation. Prior authorization (PA) from AFMC is
				required.
When requesting prior authorization, form DMS-679A titled
Prescription & Prior Authorization Request for Medical Equipment
				Excluding Wheelchairs and Wheelchair Components,
must be completed and
				sent, along with sufficient medical documentation, to AFMC.
View or print AFMC contact information. View or print form
				DMS-679A and instructions for completion.
The MIC-KEY button is benefit-limited to 2 per state fiscal
				year (SFY).
The MIC-KEY button for a Percutaneous Cecostomy Tube requires
				use of the following diagnosis codes:
Diagnosis Code
Description
564.00-564.09
Constipation
787.60
Fecal Incontinence
787.61
Incomplete Defecation
787.62
Fecal Soiling
The MIC-KEY button for a Percutaneous Cecostomy Tube requires
				use of the following CPT codes:
44300
49442
49450
242.153
MIC-KEY Skin Level Gastrostomy
			 Tube (MIC-KEY Button)
and MIC-KEY Percutaneous Cecostomy Tube and Supplies for
				Beneficiaries of All Ages
NOTE: When billing for the MIC-KEY Percutaneous Cecostomy
				Tube and/or supplies, an additional third modifier UA will be
				required.
Modifiers in this section are indicated by the headings M1 and
				M2. Prior authorization requirements are shown under the heading PA. If prior
				authorization is needed, that information is indicated with a "Y" in the
				column; if not, an "N" is shown.
Procedure Code
M1
M2
PA
Description
Payment Method
B9998
Y
MIC-KEY Kit
Purchase
B9998
NU
U1
Y
SECUR-LOK Extension Set with 2 Port 'Y' and Clamp 12"
						  Length
Purchase
B9998
NU
U2
Y
SECUR-LOK Extension Set with 2 Port 'Y' and Clamp 24"
						  Length
Purchase
B9998
NU
U3
Y
Bolus Extension Set with Single Port Clamp 12"
						  Length
Purchase
B9998
NU
U4
Y
Bolus Extension Set with Single Port Clamp 24"
						  Length
Purchase
B9998
NU
U5
Y
Bolus SECUR-LOK Extension Set Single Portw/Clamp 12"
						  Length
Purchase
B9998
NU
U6
Y
Bolus SECUR-LOK Extension Set Single Port w/Clamp 24"
						  Length
Purchase
B9998
NU
U7
Y
Microvasive Adapter
Purchase
B9998
NU
U8
Y
Microvasive Decompression Tube
Purchase
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
ATTACHMENT 3.1-A
4b.
			 Early and Periodic Screening and Diagnosis of Individuals Under 21 Years of
			 Age, and Treatment of Conditions Found.
21.
			 Other Licensed Practitioners
1. Licensed
			 Marriage and Family Therapist (LMFT)
a.
			 Services are limited to Medicaid eligible recipients under age 21 in the Child
			 Health Services (EPSDT) Program.
b.
			 Services must be provided by a licensed marriage and family therapist (LMFT)
			 who must possess a Master's degree in mental health counseling from an
			 accredited college or university. The LMFT must be licensed as a Licensed
			 Marriage and Family Therapist and in good standing with the Arkansas Board of
			 Examiners in Counseling.
c. A
			 referral must be made by a Medicaid enrolled physician documenting services are
			 medically necessary. Covered outpatient LMFT services are:
1. Diagnosis
2. Interpretation of Diagnosis
3. Crisis Management Visit
4. Individual Outpatient - Therapy
			 Session*
5. Marital/Family
			 Therapy*
6. Individual Outpatient -
			 Collateral Services*
7. Group
			 Outpatient - Group Therapy*
* Effective April 1,2002, these services require prior
				authorization for eligible Medicaid recipients under age 21 to determine and
				verify the patient's need for services.
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
ATTACHMENT 3.1-B
4b. Early and Periodic
			 Screening and Diagnosis of Individuals Under 21 Years of Age, and Treatment of
			 Conditions Found.
21. Other Licensed
			 Practitioners
2. Licensed Marriage and Family
			 Therapist (LMFT)
a. Services are limited to
			 Medicaid eligible recipients under age 21 in the Child Health Services (EPSDT)
			 Program.
b. Services must be
			 provided by a licensed marriage and family therapist (LMFT) who must possess a
			 Master's degree in mental health counseling from an accredited college or
			 university. The LMFT must be licensed as a Licensed Marriage and Family
			 Therapist and in good standing with the Arkansas Board of Examiners in
			 Counseling.
d. A referral must be
			 made by a Medicaid enrolled physician documenting services are medically
			 necessary. Covered outpatient LMFT services are:
1. Diagnosis
2. Interpretation of Diagnosis
3. Crisis Management Visit
4. Individual Outpatient - Therapy
			 Session*
5. Marital/Family
			 Therapy*
6. Individual Outpatient -
			 Collateral Services*
7. Group
			 Outpatient - Group Therapy*
* Effective April 1,2002, these services require prior
				authorization for eligible Medicaid recipients under age 21 to determine and
				verify the patient's need for services.
METHODS AND STANDARDS
FOR
ESTABLISHING PAYMENT
				RATES -OTHER TYPES
OF
CARE
ATTACHMENT 4.19-B
4.b. Early and Periodic
			 Screening and Diagnosis of Individuals Under 21 Years of Age and Treatment of
			 Conditions Found
(24) Other Licensed
			 Practitioners
1. Licensed Certified Social
			 Worker (LCSW)
Reimbursement is based on the lesser of the amount billed or
				the Title XIX (Medicaid) Maximum charge allowed. The Title XIX Maximum is 80%
				of the psychologist fee schedule.
2. Licensed Professional Counselor (LPC)
Reimbursement is based on the lesser of the amount billed or
				the Title XIX (Medicaid) Maximum charge allowed. The Title XIX Maximum is 80%
				of the psychologist fee schedule.
3. Licensed Marriage and Family Therapist
			 (LMFT)
Reimbursement is based on the lesser of the amount billed or
				the Title XIX (Medicaid) Maximum charge allowed. The Title XIX Maximum is 80%
				of the psychologist fee schedule.
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES -OTHER
				TYPES OF CARE
ATTACHMENT 4.19-B
7.HOME HEALTH SERVICES
c. Medical Supplies, Equipment and Appliances
			 Suitable for Use in the Home
(12) MIC-KEY
			 Skin Level Gastrostomy Tube and Percutaneous Cecostomy Tube and
			 SuppliesEffective for dates of service on or after September 1, 2000,
			 reimbursement is based on the lesser of the provider's actual charge for the
			 MIC-KEY kits and accessories or the Title XIX (Medicaid) maximum. The agency's
			 rates were set as of September 1, 2000, and are effective for services on or
			 after that date. All rates are published on the agency's website
(
www.medicaid.state.ar.us
)
.
			 Except as otherwise noted in the plan, state developed fee schedule rates are
			 the same for both governmental and private providers of DME services. There is
			 only one manufacturer of the MICKEY kits and accessories. The Title XIX
			 (Medicaid) maximum for the kit and accessories is based on the manufacturer's
			 list prices to the DME providers as of July 1, 2000 plus 10%. The State Agency
			 will review the manufacturer's list prices annually and may adjust the Medicaid
			 maximums if necessary. Arkansas Medicaid will reimburse providers for the kit
			 and accessories as purchase only items.
Effective for dates of service on or after March 1,2014,
				coverage of the MIC-KEY for Percutaneous Cecostomy Tube will be reimbursed
				based on the above-mentioned methodology.
d. Physical Therapy
			 RefertoItem4.b.(19).