Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.06-078 - Physician/Independent Lab/CRNA/Radiation Therapy Center Policy Manual Update #112

Current through Register Vol. 49, No. 6, June, 2024
Section II
Physician/Independent Lab/CRNA/Radiation
				Therapy Center
201.000
Arkansas Medicaid Participation
			 Requirements 10-1-06
To participate in the Arkansas Medicaid Program, providers must
				adhere to all applicable professional standards of care and conduct. The
				following sections provide participation requirements for each provider type
				whose services are included in this manual.
201.130
Providers of Physician Services
			 in States Not Bordering Arkansas 10-1-06
A. Providers in states not bordering Arkansas
			 may enroll as closed-end providers after they have furnished services to an
			 Arkansas Medicaid beneficiary and have a claim to file with Arkansas Medicaid.
View or print Provider Enrollment Unit contact
			 information.
A non-bordering state provider may download the provider manual
				and provider application materials from the Arkansas Medicaid website,
www.medicaid.state.ar.us
/InternetSolution/Provider/Provider.aspx
, and then submit the application and claim to the Medicaid Provider Enrollment
				Unit.
B. Closed-end
			 providers remain enrolled for one year.
1. If
			 a closed-end provider treats another Arkansas Medicaid beneficiary during the
			 provider's year of enrollment and bills Medicaid, the enrollment may continue
			 for one year past the newer claim's last date of service, if the provider keeps
			 the enrollment file current.
2.
			 During the enrollment period the provider may file any subsequent claims
			 directly to EDS.
3. Closed-end
			 providers are strongly encouraged to submit claims through the Arkansas
			 Medicaid website because the front-end processing of web-based claims ensures
			 prompt adjudication and facilitates reimbursement.
201.330
Providers of CRNA
			 Services in States Not Bordering Arkansas 10-1-06
A. Providers in states not bordering Arkansas
			 may enroll as closed-end providers after they have furnished services to an
			 Arkansas Medicaid beneficiary and have a claim to file with Arkansas Medicaid.
View or print Provider Enrollment Unit contact
			 information
.
A non-bordering state provider may download the provider manual
				and provider application materials from the Arkansas Medicaid website,
www.medicaid.state.ar.us
/InternetSolution/Provider/Provider.aspx
, and then submit the application and claim to the Medicaid Provider Enrollment
				Unit.
B. Closed-end
			 providers remain enrolled for one year.
1. If
			 a closed-end provider treats another Arkansas Medicaid beneficiary during the
			 year of enrollment and bills Medicaid, the enrollment may continue for one year
			 past the newer claim's last date of service, if the provider keeps the
			 enrollment file current.
2. During
			 the enrollment period the provider may file any subsequent claims directly to
			 EDS.
3. Closed-end providers are
			 strongly encouraged to submit claims through the Arkansas Medicaid website
			 because the front-end processing of web-based claims ensures prompt
			 adjudication and facilitates reimbursement.
202.100
Documentation Required of All
			 Medicaid Providers 10-1-06
A.
			 Providers must contemporaneously create and maintain records that completely
			 and accurately explain all evaluations, care, diagnoses and any other
			 activities of the provider in connection with its delivery of medical
			 assistance to any Medicaid beneficiary.
B. Providers furnishing any Medicaid-covered
			 good or service for which a prescription, admission order, physician's order,
			 care plan or other order for service initiation, authorization or continuation
			 is required by law, by Medicaid rule, or both, must obtain a copy of the
			 prescription, care plan or order within five (5) business days of the date it
			 is signed. Providers also must maintain a copy of each prescription, care plan
			 or order in the beneficiary's medical record and follow all prescriptions, care
			 plans, and orders as required by law, by Medicaid rule, or both.
C. The provider must make available to the
			 Division of Medical Services, its contractors and designees and the Medicaid
			 Fraud Control Unit all records related to any Medicaid beneficiary. When
			 records are stored off-premise or are in active use, the provider may certify
			 in writing that the records in question are in active use or in off-premise
			 storage and set a date and hour within three (3) working days, at which time
			 the records will be made available. However, the provider will not be allowed
			 to delay for matters of convenience, including availability of
			 personnel.
D. All records must be
			 kept for a period of five (5) years from the ending date of service or until
			 all audit questions, appeal hearings, investigations or court cases are
			 resolved, whichever is longer. Failure to furnish medical records upon request
			 will result in sanctions being imposed. (See Section I of this
			 manual.)
203.140
Physician's Role in Family Planning Services 10-1-06
A. Arkansas Medicaid encourages reproductive
			 health and family planning by covering a comprehensive range of family planning
			 services.
1. Medicaid beneficiaries' family
			 planning services benefits are in addition to their other medical
			 benefits.
2. Family planning
			 services do not require PCP referral. PCPs electing not to provide some or all
			 family planning services can use the information in this manual to counsel
			 their Medicaid-eligible patients and help them locate family planning services.
a. Refer to Sections 221.000 and 221.100 of
			 this manual for family planning services benefit limitations.
b. Refer to Sections 243.000 through 243.500
			 of this manual for service descriptions and coverage information.
c. Refer to Section 292.550 of this manual
			 for family planning services billing instructions and procedure
			 codes.
B.
			 Arkansas Medicaid also covers family planning services for women in two limited
			 aid categories.
1. Pregnant Woman-Poverty
			 Level (PW-PL, Aid Category 61) and
2. Women's Health Waiver (FP-W, Aid Category
			 69).
a. Refer to Sections 221.100 and 243.000
			 through 243.500 for more information on coverage of family planning services
			 for these eligibility categories.
b. Refer to Section 292.676 for more
			 information on services available to women in the PW-PL category.
203.170
Physician's Role in Hospital Services 10-1-06
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).
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.
203.230
Physician's Role in the
			 Pharmacy Program 10-1-06
Medicaid covers prescription drugs in accordance with policies
				and regulations set forth in this section and pursuant to orders
				(prescriptions) from authorized prescribers. The Arkansas Medicaid Program
				complies with the Medicaid Prudent Pharmaceutical Purchasing Program (MPPPP)
				that was enacted as part of the Omnibus Budget Reconciliation Act (OBRA) of
				1990.
This law requires Medicaid to limit coverage to drugs
				manufactured by pharmaceutical companies that have signed rebate agreements.
Except for drugs in the categories excluded from coverage, Arkansas
				Medicaid covers all drug products manufactured by companies with listed labeler
				codes.
A. Prescribers must refer to the
			 Arkansas Medicaid Web site at
http://www.medicaid.state.ar.us/
to
			 obtain the following information:
1.
			 Multisource Drugs Listing/Generic Upper Limits.
2. Covered cough and cold preparations (see
			 part C, 7 of this section).
3.
			 Covered over-the-counter (OTC) products (see part C, 8 of this
			 section).
4. Drugs requiring prior
			 authorization (PA), the forms to be completed for PA requests and the
			 procedures required of the prescriber to request prior authorization.
5. List of alternative drugs that do not
			 require PA.
6. Information on
			 MedWatch, the Food and Drug Administration (FDA) Safety Information and Adverse
			 Event Reporting Program.
As additions or deletions by labelers are submitted to the
				state by Centers for Medicare and Medicaid Services (CMS), the Web site is
				updated.
B. The
			 following procedures are to be followed when prescribing drugs for Medicaid
			 beneficiaries.
1. In addition to the
			 prescriber's normal procedure for prescribing drugs, the prescriber must
			 include his or her Medicaid provider number on all prescriptions for Medicaid
			 beneficiaries, whether or not the drug prescribed is a controlled substance.
			 The prescriber's Medicaid provider number is essential for tracking and
			 utilization review purposes.
The requirement to include the prescriber's Medicaid provider
				number is a condition of participation in the Arkansas Medicaid Program.
				Administrative sanctions will be imposed for noncompliance. If prescription
				pads are not preprinted with the prescriber's name, it is essential that the
				physician's signature be legible.
2. When the prescriber determines that a
			 particular brand is medically necessary, the prescriber must write "This Brand
			 Medically Necessary" in his or her own handwriting on the face of the
			 prescription. A rubber stamp is not acceptable. The statements "Do not
			 substitute" or "Dispense as written" are not sufficient. For prescriptions
			 ordered by telephone, a written prescription that includes the required
			 statement must also be provided to the pharmacist.
C. Coverage Limitations
1. Medicaid beneficiaries aged 21 and older
			 are limited to three (3) prescriptions per month, each filled for a maximum of
			 one month's supply. Extensions of an individual's drug benefit up to six (6)
			 prescriptions per month may be considered for reasons of medical necessity. The
			 prescribing provider must request an extension.
2. A prescription may be filled for a maximum
			 of one month's supply. A thirty-one-day supply is allowed.
3. Up to five refills within six months of
			 the date the prescription is issued are covered if specified by the prescriber.
			 Renewals or continuations of drug therapy beyond six months require another
			 prescription.
4. Prescriptions for
			 family planning items will not be counted toward the beneficiary's monthly
			 three-prescription limit.
5.
			 Medicaid beneficiaries under age 21 are not subject to the prescription benefit
			 limit.
6. Long-term-care (LTC)
			 certified Medicaid beneficiaries are not subject to the prescription benefit
			 limit.
LTC patients must receive prescribed drugs within a specific
				period of time after the prescriber's order. For prescribed drugs that require
				PA and are administered in oral dosage forms for which a 5-day supply may be
				calculated and dispensed, one 5-day supply of the drug may be provided to the
				LTC beneficiary upon receipt of the prescription and reimbursed by Arkansas
				Medicaid without receipt of PA.
Within five (5) days of the prescription of a drug requiring
				prior authorization (PA) and for which no PA has been obtained, the pharmacist
				and the physician shall consult to determine if there is a therapeutically
				equivalent drug that does not require PA. The results of the consultation shall
				be documented in writing.
If a non-PA, therapeutically equivalent drug exists, the
				physician will immediately write a substitute prescription for the non-PA
				drug.
7. Cough and cold
			 preparations are not covered except for those listed on the Web site at
			 www.medicaid.state.ar.us in the covered cough and cold products list. Coverage
			 is restricted to Medicaid beneficiaries under age 21 and for certified
			 long-term care beneficiaries. Any over-the-counter cough and cold products
			 listed at the Web site are not covered for certified long-term care
			 beneficiaries.
8. Over-the-counter
			 (OTC) products are not covered except for those listed on the Web site at
			 www.medicaid.state.ar.us in the covered over-the-counter products list. OTC
			 products are not covered for certified long-term care beneficiaries.
9. When prescribing pharmaceuticals to
			 Medicaid beneficiaries who are excluded from the beneficiary cost sharing
			 coinsurance/copayment policy, the prescribing provider must write "Excluded
			 from copay" on the face of the prescription. (Refer to Section 133.400 of this
			 manual for more information.)
211.000
Introduction 10-1-06
A. The Arkansas Medicaid Program reimburses
			 enrolled providers for the medical care of Medicaid beneficiaries.
B. Medicaid reimbursement is conditional upon
			 providers' compliance with Program policy as stated in provider manuals, manual
			 update transmittals and official Program correspondence.
C. All Medicaid benefits are based on medical
			 necessity. Refer to the Glossary for a definition of medical necessity.
1. Service coverage will be denied and
			 reimbursement recouped if a service is not medically necessary.
2. The finding of medical necessity may be
			 made by the:
a. Medical Director for the
			 Medicaid Program, the
b. Quality
			 Improvement Organization (QIO)
212.000
Scope 10-1-06
A. Physician services are services provided
			 within the scope of the practice of medicine or osteopathy, as defined by State
			 law and by or under the personal supervision of an individual licensed under
			 State law to practice medicine or osteopathy (42 Code of Federal Regulations,
			 Section 440.50).
B. Many physician
			 services covered by the Arkansas Medicaid Program are restricted or limited.
1. Sections 220.000 through Section 227.000
			 describe limits on the quantity of covered services beneficiaries may
			 receive.
2. Sections 240.000
			 through section 258.000 describe the circumstances under which certain services
			 will be covered.
221.000
Family Planning Services
			 10-1-06
A. Medicaid covers one basic
			 family planning examination and three periodic family planning visits per
			 beneficiary, per state fiscal year (July 1 through June 30). Refer to Sections
			 243.000 through 243.500 of this manual for service descriptions and coverage
			 information.
B. Prescriptions for
			 family planning services are unlimited.
C. Levonorgestrel Implant System
1. The benefit limit for levonorgestrel
			 Implant system (kit) and insertion is two each per five-year period per
			 beneficiary.
2. The benefit limit
			 for removal of the kit is only once per 5-year period, with or without
			 reinsertion.
D. Extension
			 of benefits is not available for family planning services.
E. Special billing instructions for all
			 family planning services are in section 292.550 of this manual.
223.000
Injections
			 10-1-06
A. The Arkansas Medicaid
			 Program applies benefit limits to some covered injections.
B. For information on coverage of injections,
			 special billing instructions and procedure codes, refer to sections 292.590
			 through 292.595 of this manual.
225.100
Laboratory and X-Ray Services
			 10-1-06
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 code ranges 140.0 through
			 208.91;
b. ICD-9 code 042;
			 or
c. ICD-9 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 10-1-06
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
2. HIV/AIDS
			 ICD-9 code 042
3. Renal Failure
			 ICD-9 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.
241.000
Ambulatory Infusion Device 10-1-06
Arkansas Medicaid covers an Ambulatory Infusion Device when it
				is provided by the physician and prior authorized by the Division of Medical
				Services. This device is covered only when services are provided to Medicaid
				beneficiaries receiving chemotherapy, pain management or antibiotic treatment
				in the home. Refer to Section 261.200 of this manual for prior authorization
				procedures and Section 292.430 for the procedure code and billing
				instructions.
243.100
Women's Health Demonstration Waiver 10-1-06
A. The Arkansas Medicaid program administers
			 a Women's Health Demonstration Waiver. This waiver program extends Medicaid
			 coverage of family planning services to women of childbearing age throughout
			 Arkansas who meet the eligibility requirements for participation.
B. Women's Health Demonstration Waiver
			 beneficiaries must be of childbearing age. The target population is women age
			 14 to age 44, but all women at risk of unintended pregnancy may apply for
			 Women's Health Demonstration Waiver (FP-W) services.
C. The women in the FP-W category are
			 eligible for limited Medicaid coverage of
family planning services
			 only
. See section 292.552 for services covered. The PES eligibility
			 transaction response identifies them as eligible in Aid Category 69
			 (FP-W).
243.300
Basic Family Planning Visit 10-1-06
Medicaid covers one basic family planning visit per beneficiary
				per Arkansas state fiscal year (July 1 through June 30). This basic visit
				comprises the following:
A. Medical
			 history and medical examination, including head, neck, breast, chest, pelvis,
			 abdomen, extremities, weight and blood pressure
B. Counseling and education regarding
1. Breast self-exam
2. The full range of contraceptive methods
			 available
3. HIV/STD
			 prevention
C.
			 Prescription for any contraceptives selected by the beneficiary
D. Laboratory services, including, as
			 necessary
1. Pregnancy test
2. Hemoglobin and Hematocrit
3. Sickle cell screening
4. Urinalysis testing for albumin and
			 glucose
5. Papanicolaou smear for
			 cervical cancer
6. Testing for
			 sexually transmitted diseases
243.400
Periodic Family Planning Visit
			 10-1-06
Medicaid covers three periodic family planning visits per
				beneficiary per state fiscal year (July 1 through June 30). The periodic visit
				includes follow-up medical history, weight, blood pressure and counseling
				regarding contraceptives and possible complications of contraceptives. The
				purpose of the periodic visits is to evaluate the patient's contraceptive
				program, renew or change the contraceptive prescription and to provide the
				patient with additional opportunities for counseling regarding reproductive
				health and family planning.
243.500
Contraception 10-1-06
A. Prescription and Non-Prescription
			 Contraceptives
1. Medicaid covers for birth
			 control pills and other prescription contraceptives as a family planning
			 prescription benefit.
2. Medicaid
			 covers for non-prescription contraceptives as a family planning benefit, when a
			 physician writes a prescription for them.
B. Evonorgestrel Implant System
1. Medicaid covers the Levonorgestrel
			 (contraceptive) implant system, including implants and supplies
2. Alternatively, Medicaid reimburses
			 physicians and clinics that supply the kit at the time of insertion.
3. Medicaid covers for insertion, removal and
			 removal with reinsertion.
C. Intrauterine Device (IUD)
1. Medicaid pays for IUDs as a family
			 planning prescription benefit.
2.
			 Alternatively, Medicaid reimburses physicians that supply the IUD at the time
			 of insertion.
3. Medicaid pays
			 physicians for IUD insertion and removal.
D. Occlusion by Placement of Permanent
			 Implants (Essure)
Medicaid covers the Essure implant system including the
				physician's services, implant and the supplies and follow-up procedures.
E. Medroxyprogesterone Acetate
Medicaid covers medroxyprogesterone acetate injections for
				birth control.
F.
			 Sterilization
1. All adult (21 or older)
			 female Medicaid beneficiaries who are mentally competent are eligible for
			 sterilization procedures and medically necessary follow-ups as long as they
			 remain Medicaid-eligible.
2. All
			 adult (21 or older) male Medicaid beneficiaries who are mentally competent are
			 eligible for sterilization procedures and medically necessary follow-ups as
			 long as they remain Medicaid-eligible.
3. Adult (21 or older) women in the Women's
			 Health Waiver category, Aid Category 69, who are mentally competent, are
			 eligible for sterilization procedures.
4. Refer to Section 251.290 of this manual
			 for Medicaid policy regarding sterilization.
Refer to Section 292.550 of this manual for family planning
				procedure codes and billing instructions for family planning services.
244.000
Covered Drugs and Immunizations 10-1-06
The Arkansas Medicaid Program provides coverage of drugs for
				treatment purposes and for immunizations against many diseases. Most of these
				are administered by injection. Appropriate procedure codes may be found in the
CPT
and
HCPCS
books and in this manual. The
				following types of drugs are covered.
A. Chemotherapy and immunosuppressive drugs.
			 (See sections 292.590 and 292.591.) No take-home drugs are covered.
B. Desensitization (allergy) injections for
			 beneficiaries in the Child Health Services (EPSDT) program. (See section
			 292.420 of this manual for billing instructions.)
C. Immunizations, childhood and those covered
			 for adults. (See sections 292.592 through 292.595 of this manual for special
			 billing instructions.)
D. Other
			 injections that are covered for specific diagnoses and/or conditions. See
			 section 292.592. No take home drugs are covered.
244.001
Agalsidase Beta and Laronidase
			 Injections 10-1-06
A. Arkansas
			 Medicaid covers agalsidase beta injections. This procedure is covered for
			 treatment of Fabry's disease, ICD-9-CM diagnosis code 272.7.
B. Arkansas Medicaid covers laronidase
			 injections. This procedure is covered for treatment of mucopolysaccharidosis
			 (MPS I), ICD-9-CM diagnosis code 277.5.
C. Arkansas Medicaid covers imiglucerase
			 injections. This procedure
(J1785)
is covered for treatment of
			 Type I Gaucher disease with complications, ICD-9-CM diagnosis code
			 272.7.
D. These injections may be
			 provided in the outpatient hospital or emergency room. If the physician
			 provides the service in the office, the following conditions apply.
1. The provider must have nursing staff
			 available to monitor the patient's vital signs during the infusion.
2. The provider must be able to treat
			 anaphylactic shock in the treatment area where the drugs are infused.
E. When the physician determines a
			 Medicaid beneficiary needs the injection, he or she must obtain prior approval
			 from the Medical Director of the Division of Medical Services before beginning
			 therapy.
The prior approval request must include:
1. Documentation of an office visit that
			 includes a physical examination specifically identified by its date and must
			 note the diagnosis.
2. Medical
			 history that includes an annotated list of previous treatment protocols
			 administered and their results.
3.
			 Statement of medical necessity, including method of diagnosis, from genetics
			 physician.
F. See
			 section 292.592 for procedure codes and billing instructions.
244.002
Verteporfin (Visudyne) 10-1-06
Medicaid covers verteporfin injections for all ages under the
				following conditions.
A. There must be
			 documentation by eye exam of an ICD-9-CM diagnosis of:
1. Predominantly classic subfoveal choroidal
			 neovascularization due to age-related macular degeneration (ICD-9-CM diagnosis
			 code 362.50 or 362.52);
or
2. Pathologic myopia (ICD-9-CM diagnosis code
			 360.21);
or
3.
			 Presumed ocular histoplasmosis (ICD-9-CM diagnosis code 115.02 or 115.12 or
			 115.92).
B. The lesion
			 size determination should be included in the exam. Which eye will be treated
			 with that administration should also be clearly documented, along with the
			 current visual acuity. If previous treatments with other modalities have been
			 attempted, these also must be documented.
C. See section 292.592 for procedure code and
			 billing instructions.
244.100
Special Pharmacy, Therapeutic
			 Agents and Treatments 10-1-06
Providers must obtain prior approval, in accordance with the
				following procedures, for special pharmacy, therapeutic agents and
				treatments.
A. Before treatment is
			 begun, the Medical Director for the Division of Medical Services (DMS) must
			 approve any drug, therapeutic agent or treatment not listed as covered in this
			 provider manual or in official DMS correspondence.
This requirement also applies to any drug, therapeutic agent or
				treatment with special instructions regarding coverage in the provider manual
				or in official DMS correspondence.
B. The Medical Director's prior approval is
			 necessary to ensure approval for medical necessity.
1. The provider must submit a history and
			 physical examination with the treatment protocol before beginning the
			 treatment.
2. The provider will be
			 notified by mail of the DMS Medical Director's decision. No prior authorization
			 number is assigned if the request is approved, but a prior approval letter is
			 issued and must be attached to each claim. Any changes in treatment require
			 resubmission and a new approval letter.
Send requests for prior approval of pharmacy and therapeutic
				agents to the attention of the Medical Director of the Division of Medical
				Services.
View or print the contact information for the
				Arkansas Division of Medical Services Medical Director.
Refer to sections 292.591 - 292.595 for pharmacy and
				therapeutic agents for special billing procedures.
See sections 258.000 and 292.860 for coverage and billing
				procedures for hyperbaric oxygen therapy.
244.200
Radiopharmaceutical Therapy
			 10-1-06
Medicaid covers radiopharmaceutical therapy, radiolabeled
				monoclonal antibody by intravenous infusion.
Before beginning therapy the provider must submit the following
				documentation.
A. Patient history and
			 physical report is required.
B.
			 Drugs and therapeutic procedures previously administered must be included along
			 with documentation that conventional therapy has failed.
C. This information must be sent to the
			 attention of the Medical Director of the Division of Medical Services.
The provider will be notified by mail of the Medical Director's
				decision. If approval is received, the provider must file the claim for service
				with a copy of the approval letter and a copy of the invoices for the
				monoclonal antibody.
Refer to section 292.595 for special billing procedures.
250.500
Observation Status 10-1-06
When billing for services to a patient in "observation status,"
				physicians must adhere to Arkansas Medicaid definitions of inpatient and
				outpatient. Observation status is an outpatient designation. Physicians must
				also follow the guidelines and definitions in
Physician's Current
				Procedural Terminology (CPT),
under "Hospital Observation Services" and
				"Evaluation and Management Services Guidelines."
A. Arkansas Medicaid uses the following
			 criteria in determining inpatient and outpatient status:
1. If a patient is expected to remain in the
			 hospital for less than 24 consecutive hours and this expectation is realized,
			 the hospital and the physician should consider the patient an outpatient; i.e.,
			 the patient is an outpatient unless the physician has admitted them as an
			 inpatient.
2. If the physician or
			 hospital expects the patient to remain in the hospital for 24 hours or more,
			 Medicaid deems the patient admitted at the time the patient's medical record
			 indicates the existence of such an expectation, even though the physician has
			 not yet formally admitted the patient.
3. Medicaid also deems a patient admitted to
			 inpatient status at the time they have remained in the hospital for 24
			 consecutive hours, even if the physician or hospital had no prior expectation
			 of a stay of that or greater duration.
B. Medical Necessity Requirements
1. Physician inpatient services must meet the
			 Medicaid requirement of medical necessity. The Quality Improvement Organization
			 (QIO) will deny payments for inpatient admissions and subsequent inpatient
			 services when they determine that inpatient care was not necessary. Inpatient
			 services are subject to QIO review for medical necessity whether the physician
			 admitted the patient, or whether Medicaid deemed the patient admitted according
			 to the criteria above.
2. The
			 attending physician must document the medical necessity of admitting a patient
			 to observation status, whether the patient's condition is emergent or
			 non-emergent. Physician and hospital claims for hospital observation services
			 are subject to post payment review to verify medical necessity.
C. Coverage Limitations
Medicaid pays physicians all-inclusive "global" fees for
				outpatient surgical procedures. Physicians may not bill Medicaid separately for
				hospital observation services preceding, or subsequent to, outpatient
				surgery.
Please note that an attending physician may bill Medicaid only
				once per day per patient for "Evaluation and Management Services" including
				physician non-emergency outpatient visit.
The following table gives examples of appropriate physician
				billing for several common hospital scenarios. The billing instructions under
				the headings, "PHYSICIAN MAY BILL...," do not necessarily include all services
				for which the physician may bill. For instance, they do not state that you may
				bill for interpretation of X-rays or diagnostic tests. The purpose of this
				table is to illustrate Arkansas Medicaid observation status policy and to give
				guidance for billing related evaluation and management services.
Patient is admitted to observation
Patient Is
Physician may bill for Tuesday services:
Physician may bill for Wednesday services:
Tuesday, 3:00 PM
Still in Observation Wednesday, 3:00 PM
Appropriate level of Initial Observation Care
Appropriate level of Initial Hospital Care
Tuesday, 3:00 PM
Discharged Wednesday, 12:00 PM (noon)
Appropriate level of Initial Observation Care
Observation care discharge day management
Tuesday, 3:00 PM
Discharged Wednesday, 4:00 PM
Appropriate level of Initial Observation Care
Appropriate level of Initial Hospital Care
Tuesday, 3:00 PM, after outpatient surgery
Discharged Wednesday, 10:00 AM
Outpatient surgery
No evaluation and management
services
Tuesday, 3:00 PM, after exam in Emergency
						  Department-emergency or non-emergency
Discharged Tuesday, 7:00 PM
Appropriate level of Initial Observation Care
Not Applicable; patient was discharged Tuesday
251.230
Cochlear Implant and External
			 Sound Processor 10-1-06
The Arkansas Medicaid Program provides coverage for cochlear
				implantation and the external sound processor for beneficiaries under age 21 in
				the Child Health Services (EPSDT) Program. Also covered are headset,
				microphone, transmitting coil and transmitter cable. The cochlear implant
				device, implantation procedure, the sound processor and other necessary devices
				for use with the cochlear implant device require
prior authorization
from AFMC. Refer to Section 261.100 of this manual for prior
				authorization procedures.
251.304
Liver and Liver/Bowel
			 Transplants 10-1-06
A. Medicaid covers
			 liver transplants for beneficiaries of all ages.
B. Medicaid covers liver/bowel transplants
			 for beneficiaries under age 21 in the Child Health Services (EPSDT)
			 Program.
C. Covered physician
			 services related to the transplant include:
1.
			 The surgical procedure to remove a partial liver from a living donor (when
			 applicable).
2. Physician services
			 for transplanting the liver into the receiver.
3. Postoperative care (including
			 postoperative care for the living donor of a partial liver, when
			 applicable).
D. Liver
			 and liver/bowel transplants are exempt from the MUMP and the annual benefit
			 limit for inpatient hospital services.
Services excluded from the
			 annual benefit limit and the MUMP are the services provided from the date of
			 the transplant procedure to the date of discharge,
subject to any
			 limitations imposed by the current published Medicare National Coverage
			 Decisions and/or AFMC medical review. Refer to section 251.300 subpart
			 C.
253.000
Bilaminate Graft or Skin Substitute 10-1-06
Arkansas Medicaid covers bilaminate graft or skin substitute,
				known as dermal and epidermal tissue of human origin, with or without
				bioengineered or processed elements, with metabolically active elements. Prior
				authorization is required for the product but not the application
				procedure.
This product is designed to be used for treatment of
				non-infected partial and full-thickness skin ulcers due to venous insufficiency
				and for treatment of full-thickness neuropathic diabetic foot ulcers that
				extend through the dermis, but without tendon, muscle, capsule or bone exposure
				and which are located on the plantar, medial or lateral area of the foot
				(excluding the heel).
A. Indications
			 and Documentation:
Coverage of this modality/product will be considered when all
				of the following conditions are satisfied and documented:
1. Partial or full-thickness skin ulcers due
			 to venous insufficiency or full-thickness neuropathic diabetic foot
			 ulcers,
2. Ulcers of greater than
			 three (3) months duration and
3.
			 Ulcers that have failed to respond to documented conservative measures of
			 greater than two (2) months duration.
4. There must be measurements of the initial
			 ulcer size, the size of the ulcer following cessation of conservative
			 management and the size at the beginning of skin substitute
			 treatment.
5. For neuropathic
			 diabetic foot ulcers, appropriate steps to off-load pressure during treatment
			 must be taken and documented in the patient's medical record.
6. In addition, the ulcer must be free of
			 infection and underlying osteomyelitis and treatment of the underlying disease
			 (e.g., peripheral vascular disease) must be provided and documented in
			 conjunction with skin substitute treatment.
B. Diagnosis Restrictions:
Coverage of the bilaminate skin product and its application is
				restricted to the following ICD-9-CM codes:
454.0
454.2
250.8 (requires a fifth-digit subclassification)
707.10
707.13
707.14
707.15
940.0 through 949.5
257.000
Tobacco Cessation Products
			 Counseling Services 10-1-06
Arkansas Medicaid covers generic Zyban (bupropion for tobacco
				cessation) and nicotine replacement therapy (NRT), either nicotine gum or
				nicotine patches through the Medicaid Prescription Drug Program.
A. Physician providers may participate by
			 prescribing covered tobacco cessation products.
1. The reimbursement to the pharmacy provider
			 for the products is available for up to 2 ninety-three day courses of treatment
			 within a calendar year.
2.
			 Beneficiaries who are pregnant are allowed up to four ninety-three day courses
			 of treatment per calendar year.
3.
			 One course of treatment is three consecutive months.
B. Counseling by the prescriber is required
			 for to obtain initial prior authorization (PA) coverage of the products.
			 Counseling consists of reviewing the Public Health Service (PHS)
			 guideline-based checklist with the patient. The prescriber must retain the
			 counseling checklist in the patient records for audit. A copy of the checklist
			 is available on the Medicaid website at www.medicaid.state.ar.us.
Subsequent prior authorizations will require prescriber
				referral to an intensive tobacco cessation program, such as SOS Works. A
				referral form will also be available on the Medicaid website.
C. Counseling procedures do not count against
			 the twelve visits per state fiscal year (STY), but they are limited to no more
			 than two 15-minute units and two 30-minute units for a maximum allowable of 4
			 units per SFY.
D. Additional
			 prescription benefits will be allowed per month for tobacco cessation products
			 during the approved PA period and will not be counted against the monthly
			 prescription benefit limit. One benefit will be allowed for generic Zyban if
			 the physician believes that generic Zyban therapy is appropriate and one
			 benefit for NRT, either nicotine gum or patches.
E. Refer to section 292.900 for procedure
			 codes and billing instructions.
258.000
Hyperbaric Oxygen Therapy
			 10-1-06
Physicians may be reimbursed for attendance and supervision of
				hyperbaric oxygen therapy.
Hyperbaric oxygen therapy involves exposing the body to oxygen
				under pressure greater than one atmosphere. Such therapy is performed in
				specially constructed hyperbaric chambers holding one or more patients;
				although oxygen may be administered in addition to the hyperbaric treatment.
				Patients should be assessed for contraindications such as sinus disease or
				claustrophobia prior to therapy. In some diagnoses, hyperbarics is only an
				adjunct to standard surgical therapy. These indications are taken from "The
				Hyperbaric Oxygen Therapy Committee Report" (2003) of The Undersea and
				Hyperbaric Medical Society (Kensington, MD).
A. All hyperbaric therapy will require prior
			 approval, except in emergency cases such as for air embolism or carbon monoxide
			 poisoning. Prior approval will be for a certain number of treatments. A copy of
			 the approval letter must be filed with each claim and the number in the series
			 of treatments documented.
B.
			 Further treatments will require reapplication for a prior approval.
			 Documentation for prior approval should include, but not be limited to, a
			 complete physician SOAP note, a physical exam and prior therapy treatment
			 failures, including antibiotic therapies and surgical interventions.
1. It must include a clear description of the
			 wound with each claim. Documentation of no measurable signs of healing for at
			 least 30 consecutive days of wound care therapy prior to the start of HBO
			 therapy should be included (for those diagnoses requiring this treatment
			 plan).
2. If extension of treatment
			 period is needed, the above documentation must be submitted and fully
			 documented. Physician progress notes physical findings at each treatment and
			 the effects of treatment wound description will be needed for an extension. Any
			 questions may be addressed to the Medical Director at 501-682-9868.
3. Requests for prior approval may be mailed
			 or faxed.
Mailing address: Fax to
ATTN: Medical Director 501-682-8013 or
Division of Medical Services 501-683-4124
Slot S412 ATTN: Medical Director
Department of Health and Human Services
PO Box 1437
Little Rock, AR 72203-1437
C. The following tables provide explanation
			 of diagnosis requirements and treatment number of treatments and treatment
			 schedules.
Diagnosis
Description
Number of Treatments
6396, 67300, 9580,9991
Air or Gas Embolism
10
9930
Decompression Sickness
10
986
Carbon Monoxide Poisoning
5
0400, 0383
Clostridial Myositis and Myonecrosis (Gas
						  Gangrene)
10
8690-8691, 8871, 8873, 8875, 8877, 8971, 8973, 8975,
						  8977, 9251-9299, 99690-99699
Crush injuries, compartment syndrome, other acute
						  traumatic peripheral ischemias
See Table
25070-25073, 44023, 44024, 44381-4439, 4540, 4542,
						  70700-7079, 9895, 99859
Enhancement of healing in selected problem wounds;
						  diabetic foot ulcers, pressure ulcers, venous stasis ulcers; only in severe and
						  limb or life-threatening wounds that have not responded to other treatments,
						  particularly if ischemia that cannot be corrected by vascular procedures is
						  present
30
3240
Intracranial abscess, multiple abscesses, immune
						  compromise, unresponsive
20
72886, 7854
Necrotizing Soft Tissue Infections, immune
						  compromise
30
73000-73020
Refractory osteomyelitis after aggressive surgical
						  debredement
40
52689, 73010-73019, 7854, 9092, 990
Delayed Radiation Injury
60
99652, 99660-99670, V423
Compromised skin grafts and flaps
20
9400-9495
Thermal burns [GREATER THAN] 20% TSBA +/or involvement
						  of hands, face, feet or perineum that are deep, partial or full thickness
						  injury
40
Hyperbaric Treatment Schedules ("Doses") of
						  HBO2
ICD9 Code
Injury Type
Number & Schedule of
HBO2
Treatments
Number of
HBO2
Treatments Before Peer Review
						  (Days)
Comments
9251-929.9
Crush Injuries according to Gustilo
						  classification
TIDa 2 days
						  BIDb 2 days Daily for 2 days
6
9585
Compartment syndrome,
impending stage
fasciotomy not required
TIDa for 1 day
1
If post-fasciotomy,
see
problem wound
						  recommendations
9400-9495, 99652, 99666-99670, V423
Threatened flaps & grafts
Same as for crush injuries
6
92951-929.9
Problem wounds after primary management
BIDb for 7d; daily 7
						  days
14
Post-fasciotomy wounds, complications and residual
						  wounds after primary management of crush injuries
73000-73020
Refractory osteomyelitis
Daily for 21 days
21 +
May require continuation of HBO2
						  through 60 treatments, but reassessment and second stage peer review
						  recommended
after 40 treatments
aThree times a day 
				bTwice a day
Refer to section 292.860 of this manual for billing
				instructions.
261.000
Obtaining Prior Authorization
			 of Restricted Medical and Surgical 10-1-06
Procedures
A. Certain medical and surgical procedures
			 are not covered without prior authorization (PA). Most restricted procedures
			 are prior authorized by the Arkansas Foundation for Medical Care, Inc. (AFMC).
			 Refer to sections 261.100, 261.120 and 261.130 for instructions on requesting
			 PA from AFMC.
B. The Division of
			 Medical Services Utilization Review Section makes PA determinations for certain
			 procedures. Refer to sections 261.200 through 261.260 for instructions on
			 requesting PA from Utilization Review.
C. Refer to section 262.000 for a list of
			 procedures requiring prior authorization.
261.110
Post-Procedural Authorization
			 Process for Beneficiaries Under Age 10-1-06
21
A.
			 Providers performing surgical procedures that require prior authorization are
			 allowed 60 days from the date of service to obtain a prior authorization number
if the beneficiary is under age 21
.
B. The following post-procedural
			 authorization process must be followed when obtaining an authorization number
			 for the procedures in Section 262.000.
1. All
			 requests for post-procedural authorizations for eligible beneficiaries are to
			 be made to the Arkansas Foundation for Medical Care (AFMC) by telephone within
			 60 days of the date of service. The physician or the physician's office nurse
			 must contact AFMC.
View or print AFMC contact
			 information.
These calls will be tape recorded.
2. If the provider receives only the Medicaid
			 identification number from the beneficiary and is unable to obtain the actual
			 card to validate the eligibility dates, you may call the EDS Provider
			 Assistance Center to obtain the dates of eligibility.
View or
			 print the EDS Provider Assistance Center contact
			 information.
AFMC must be provided the beneficiary and
			 provider identifying criteria and all of the medical data necessary to justify
			 the procedures. As medical information will be exchanged for this procedure,
			 the physician or a nursing member of his/her staff must make these
			 calls.
3. The provider will be
			 issued a PA number at the time of the call if the procedure requested is
			 approved. A follow-up letter will be mailed the same day to the
			 physician.
4. Consulting physicians
			 are responsible for calling AFMC to have their required and/or restricted
			 procedures added to the PA file. They will be given the prior authorization
			 number at the time of the call on cases that are approved. A letter verifying
			 the PA number will be sent to the consultant upon request. When calling, all
			 patient identification information and medical information related to the
			 necessity of the procedure needing authorization must be provided.
C. The Arkansas Medicaid Program
			 continues to recommend providers obtain
prior
authorization for procedures requiring authorization in order
				to prevent risk of denial due to lack of medical necessity.
This policy applies only to those eligible Medicaid recipients
under age 21
. This policy does not alter policy
				currently applicable to retroactive-eligible beneficiaries.
261.120
Prior
			 Authorization of Bilaminate Graft or Skin Substitute 10-1-06
Arkansas Medicaid requires prior authorization (PA) of the
				product for bilaminate graft or skin substitute. Prior authorization for the
				product (dermal and epidermal tissue of human origin, with or without
				bioengineered or processed elements, with metabolically active elements, per
				square centimeter) is issued in units. One unit equals one square centimeter.
				Application procedures do not require prior authorization.
To request prior authorization, providers must submit a request
				for prior authorization to Arkansas Foundation for Medical Care, Inc. (AFMC).
				The AFMC Request for Bilaminate Skin Substitutes form must be completed and
				submitted to AFMC with supportive documentation.
View or
				print the AFMC Request for Bilaminate Skin Substitutes
				form.
(Refer to section 253.000 for coverage criteria and
				section 292.870 for billing instructions.) Providers who will be using this
				product should copy the prior authorization request form for later use.
261.130
Prior Authorization
			 of Cochlear Implant and External Sound 10-1-06
Processor
A. Arkansas Medicaid provides coverage for
			 cochlear implantation and for the external sound processor when provided to
			 recipients under age 21 in the Child Health Services (EPSDT) Program. Prior
			 authorization by AFMC is required.
B. A written request signed by the physician
			 performing the procedure is required. The request must be accompanied by
			 medical documentation to support medical necessity. See section 261.100 for
			 prior authorization instructions.
261.210
Prior Authorization of
			 Ambulatory Infusion Device 10-1-06
A.
			 Arkansas Medicaid covers an ambulatory infusion device when it is provided by
			 the physician and prior authorized. To obtain prior authorization, the
			 physician providing the equipment must complete and sign Form DMS-679, Medical
			 Equipment Request for Prior Authorization and Prescription.
View or print form DMS-679 and instructions for
			 completion.
The original and first copy of the form must be
			 submitted to the Division of Medical Services Utilization Review Section.
View or print the Division of Medical Services Utilization
			 Review Section contact information.
If the request is
			 approved, a prior authorization control number will be assigned. The PA number
			 will be indicated on the copy of the DMS-679 returned to the provider. The PA
			 control number in Item 10 of the DMS-679 must be entered on the claim form
			 filed for Medicaid payment of these services.
B. Approvals are authorized for a maximum of
			 six months (180 days). If services are needed for a longer period, a new
			 request must be submitted.
C. The
			 effective date of the prior authorization is the date the patient begins use of
			 the equipment or the date following the expiration date of the previous prior
			 authorization approval.
D. Denied
			 requests are returned to the provider indicating the reason for
			 denial.
261.220
Prior Approval of Transplant Procedures 10-1-06
A. The attending physician is responsible for
			 obtaining prior approval for organ transplant evaluations and for organ
			 transplants.
1. The attending physician must
			 request from UR prior approval of a transplant evaluation, naming the facility
			 at which the evaluation is to take place and the physician who will conduct the
			 evaluation.
View or print the UR Section contact
			 information.
This request must include the following:
a. History and physical and supporting
			 documentation
b. Previous
			 treatment
c. Copy of the most recent
			 hospitalization
d. Name of proposed
			 facility where patient will be referred for transplant
e. Third-party insurance information, when
			 applicable
2. UR reviews
			 the physician's request for transplant evaluation and forwards its approval to
			 the facility at which the referring physician has indicated the evaluation will
			 take place.
3. The evaluation
			 results are forwarded to UR with a request for the transplant
			 procedure.
4. UR forwards the
			 request and its supporting documentation to AFMC for a determination of
			 approval or denial.
5. AFMC advises
			 the requesting physician and the beneficiary of its decision.
B. The physician is responsible
			 for distributing documentation of prior approval to the hospital and to the
			 other participating providers, such as the anesthetist, assistant surgeon,
			 etc.
261.230
Reconsideration for Denied Prior Approvals 10-1-06
A request for administrative reconsideration of a denied prior
				approval must be in writing and sent to AFMC within 35 calendar days of the
				denial. The request must include a copy of the denial letter and additional
				supporting documentation.
The deadline for receipt of the reconsideration request will be
				enforced pursuant to sections 190.012 and 190.013 of this manual. A request
				received by AFMC within 35 calendar days of a denial will be deemed timely. A
				request received later than 35 calendar days will be considered on an
				individual basis. Reconsideration requests must be mailed or delivered by hand.
				Faxed or emailed requests will not be accepted.
261.231
Beneficiary Appeal Process for
			 Denied Prior Approvals 10-1-06
When DMS or its designee (AFMC in this case) denies a request
				for prior approval of a transplant or transplant evaluation, the beneficiary
				may appeal the denial and request a fair hearing.
A. An appeal request must be in
			 writing.
B. The appeal request must
			 be received by the Appeals and Hearings Section of the Department of Human
			 Services (DHS) within 30 days of the date on the provider notification denial
			 letter from the Utilization Review Section or AFMC.
View or
			 print the Department of Human Services, Appeals and Hearings Section contact
			 information.
261.250
Prior Authorization process for
			 Laboratory Procedures for Highly 10-1-06
Active Antiretroviral Therapy (HAART)
The following CPT procedure codes are covered for Medicaid
				beneficiaries when prior authorized.
87901
A maximum of 2 units per 12 month period can be
						  requested at one time
87903
A maximum of 1 unit per year can be requested at one
						  time.
87904
This procedure is an add-on code. The appropriate
						  number of units must be included with each prior authorization request.
Physicians ordering the test must obtain the prior
				authorization. For billing purposes, the physician must supply a copy of the
				prior authorization to the laboratory performing the test. The process for
				requesting prior authorization for these procedures is listed below.
A. A statement is required from the physician
			 stating that the patient presented with virologic failure during
			 HAART.
B. A copy of the results of
			 tests, CPT procedure code 87536 - "HIV-1, quantification" or procedure code
			 87539 - "HIV-2, quantification," must be attached to the prior authorization
			 requests. These tests must reflect that the patient has suboptimal suppression
			 of viral loads (i.e.[GREATER THAN]1000 HIV RNA copies/ml.) after initiation of
			 antiretroviral therapy.
C. Submit
			 request for prior authorization for these procedure codes to the Utilization
			 Review Section.
View or print the Division of Medical
			 Services Utilization Review Section address.
262.000
Procedures
			 That Require Prior Authorization 10-1-06
The following procedure codes require prior
				authorization:
Procedure Codes
J7320
J7340
L8614
L8615
L8616
L8617
L8618
L8619
S0512
S2213
V5014
00170
01966
11960
11970
11971
15400
15831
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
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
58280
58290
58291
58292
58293
58294
58345
58550
58552
58553
58554
58672
58673
58750
58752
59135
59840
59841
59850
59851
59852
59855
59856
59857
59866
60512
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
87903
87904
92081
92100
92326
92393
93980
93981
Procedure Code
Modifier
Description
E0779
RR
Ambulatory infusion device
D0140
EP
EPSDT interperiodic dental screen
J7330
Autologous cultured chondrocytes, implant
L8619
EP
External sound processor
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
Z1930
Non-emergency hysterectomy following c-section
92002
UB
Low vision services - evaluation
292.000
CMS-1500 Billing Procedures
			 10-1-06
292.100
Procedure Codes 10-1-06
292.110
Non-covered CPT Procedure
			 Codes 10-1-06
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.
Some procedure codes are non-payable, but the service is
				payable under another procedure code. Refer to Special Billing Procedures,
				sections 292.000 through 292.860.
Procedure Codes
01953
01968
09169
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
76986
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
94656
94657
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
99361
99362
99371
99372
99373
99374
99375
99377
99378
99379
99380
99386
99387
99396
99397
99403
99404
99411
99412
99420
99429
99431
99433
99435
99450
99455
99456
99499
99500
99501
99502
99503
99504
99505
99506
99507
99509
99510
99511
99512
292.410
Abortion Procedure Codes
			 10-1-06
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,
				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 exam are required for processing of claims. When
				filing paper claims, type of service code 2 must be used for the abortion
				procedure, and type of service code
"7"
must be used for
				anesthesia.
Use the following procedure codes when billing for
				abortions.
01966
*
59840
59841
59850
59851
59852
59855
59856
59857
*
Effective for dates of service on and after
				March 1, 2006, CPT anesthesia procedure code
01964
is non-payable
				and has been replaced with procedure code
01966
.
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.
292.430
Ambulatory Infusion Device
			 10-1-06
Procedure code
E0779
, modifier
RR
,
Ambulatory Infusion Device
, is payable only when services are
				provided to patients receiving chemotherapy, pain management or antibiotic
				treatment in the home. One unit of service equals one day. A reimbursement rate
				has been established and represents a daily rental amount. For paper claims,
				use type of service code
"1"
with the modifier
RR
.
				Refer to section 241.000 of this manual for coverage information and section
				261.220 for prior authorization procedures.
292.440
Anesthesia Services
			 10-1-06
Anesthesia procedure codes (
00100
through
01999
) must be bill 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, type of service code
"7,"
are eligible to be
				billed with a second modifier,
"22,"
referencing surgical field
				avoidance.
Any surgical procedure with local/topical anesthesia is
				computed to include the administration of the local anesthetic agent, as it is
				already computed into the reimbursement amount and is billed by the primary
				surgeon. No modifiers or time may be billed with these procedures.
A. Electronic Claims
PES or electronic claims submission may be used unless paper
				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.)
A type of service code is required along with applicable
				modifiers when filing paper claims. Providers must use type of service code
"7"
with procedure codes 00100 through 01999.
Any surgical procedure that includes local/topical anesthesia
				must be billed by the primary surgeon with a type of service code
"2."
The procedure codes listed under "Qualifying Circumstances" in
				the Anesthesia Guidelines of CPT require a type of service code (paper only)
				"1."
C. The following
			 national CPT procedure code for abortion and locally assigned procedure code
			 for anesthesia for abdominal hysterectomy are to be billed with a type of
			 service code "7" to indicate anesthesia, time units and modifiers as
			 appropriate. These codes must be billed on CMS-1500 (formerly HCFA-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
Z994
0
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
			 (formerly HCFA-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
Acknowledgement of Hysterectomy Information
						  (DMS-2606)
01963
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.
Anesthesiologist/anesthetists may bill procedure code
00170
with a type of service code (paper only) "
7
"
				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.
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.
292.443
Medicaid Coverage
			 for Therapeutic Infusions (Excludes 10-1-06
Chemotherapy)
Effective for dates of service on and after March 1, 2006,
				procedure codes
90780
and
90781
are non-payable.
				These codes have been replaced with procedure codes
99143
through
99150
.
292.480
Cataract Surgery 10-1-06
Post-cataract lens implant
must be billed using
				procedure code
V2630
. This procedure code may be billed
				electronically or on paper. When filing paper claims, use type of service code
1
.
The lens implant code is billed in conjunction with the
				cataract surgery and is covered for eligible Medicaid beneficiaries of all ages
				in the outpatient setting.
292.550
Family Planning Services
			 10-1-06
292.551
Family Planning Services For Beneficiaries in Full Coverage Aid 10-1-06
			 Categories
Family planning services are covered for beneficiaries in full
				coverage aid categories. Family planning procedures payable to physicians
				require a modifier "
FP
". For paper claims, physicians must use
				type of service code
"A"
with the modifier. All procedure codes in
				this table require a family planning or sterilization 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.
				When filing paper claims for either of these services for elective
				sterilizations, enter type of service code
"A"
. When using either
				of these codes for treatment of a medical condition, type of service code
"2"
must be entered for the primary surgeon or type of service
				code
"8"
for an assistant surgeon.
**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
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. If filing on paper, use type of
				service code
"J"
with the modifier.
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. When filing paper claims for this service,
			 use type of service code
"1"
.
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 electronic claims for these professional services, use
				modifier
FP
. On paper claims use type of service code
"A"
and 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.
				If billing on paper, type of service
"J"
is required. Whether
				billing on paper or electronically, the primary detail diagnosis code for each
				procedure must be a family planning diagnosis.
2. Effective for dates of service on and
			 after February 1, 2006, 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
58340
and
58345
must be
			 filed with modifier
FP
. Paper claims require a type of service
			 code
"A"
and modifier
FP
. Whether billing on paper
			 or electronically, the primary detail diagnosis for each procedure must be a
			 family planning diagnosis code.
Claims for professional services provided in an outpatient
				clinic associated with a hospital must be filed with a type of service code
"J"
. 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 type
			 of service code
"A"
and modifier
FP
. Whether
			 billing on paper or electronically, the primary detail diagnosis for each
			 procedure must be a family planning diagnosis code.
When these radiology procedures are performed as family
				planning services in an outpatient hospital clinic, claims for the professional
				component of procedures codes
72190
,
74740
and
74742
require type of service
"J"
on paper claims.
				Whether billing on paper or electronically, a family planning diagnosis code
				must be listed as primary on each detail.
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
.
292.552
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.
Covered family planning procedures furnished to beneficiaries
				in aid category 69 are payable to physicians and must be billed with a modifier
"FP"
. For paper claims, physicians must use type of service code
"A"
with the modifier.
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. If filing on paper, use type of
				service code
"J"
with the modifier.
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
).
To file electronic claims for these professional services, use
				modifier
FP
. On paper claims use type of service code
"A"
and 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.
				If billing on paper, type of service
"J"
is required. Whether
				billing on paper or electronically, the primary detail diagnosis code for each
				procedure must be a family planning diagnosis.
2. Effective for dates of service on and
			 after February 1, 2006, 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
58340
and
58345
must be
			 filed with modifier
FP
. Paper claims require a type of service
			 code
"A"
and modifier
FP
. Whether billing on paper
			 or electronically, the primary detail diagnosis for each procedure must be a
			 family planning diagnosis code.
Claims for professional services provided in an outpatient
				clinic associated with a hospital must be filed with a type of service code
"J"
. 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 type
			 of service code
"A"
and modifier
FP
. Whether
			 billing on paper or electronically, the primary detail diagnosis for each
			 procedure must be a family planning diagnosis code.
When these radiology procedures are performed as family
				planning services in an outpatient hospital clinic, claims for the professional
				component of procedures codes
72190
,
74740
and
74742
require type of service
"J"
on paper claims.
				Whether billing on paper or electronically, a family planning diagnosis code
				must be listed as primary on each detail.
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 10-1-06
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. Electronic claims require modifier
FP
when the service diagnosis indicates family planning. When
				filing paper claims use type of service code
"A"
along with
				modifier
FP
when the service diagnosis indicates family planning.
				Refer to section 292.730 for other applicable type of service codes (paper
				only) for laboratory procedures.
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 with type of service code (paper only) " A.
" *** Procedure codes 87491 and 87591 are payable as
				family planning services effective for
dates of service on and after February 1, 2006.
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
292.561
Genetic Testing 10-1-06
Medicaid will reimburse physician services for the following
				genetic testing procedures.
S3840
S3842
S3843
S3844
S3846
S3847
S3848
S3849
S3850
S3851
S3853
When filing paper claims, type of service codes
"C",
or
"T"
is required as applicable.
292.591
Injections and Oral
			 Immunosuppressive Drugs 10-1-06
A.
			 Administration of chemotherapy agents is payable only if provided in a
			 physician's office, place of service code: Paper
"3"
or electronic
"11."
These procedures are not payable to the physician if
			 performed in the inpatient or outpatient hospital setting. 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 range
96401
through
96549
for 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, or 042 is required.
Procedure Codes
J0120
J0128
J0190
J0200
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
J0570
J0580
J0592
J0595
J0600
J0610
J0620
J0630
J0640
J0670
J0690
J0692
J0694
J0696
J0697
J0698
J0702
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
J1270
J1320
J1325
J1330
J1364
J1380
J1390
J1410
J1435
J1436
J1450
J1452
J1455
J1457
J1470
J1570
J1580
J1590
J1610
J1620
J1626
J1630
J1631
J1642
J1644
J1645
J1650
J1652
J1655
J1670
J1700
J1710
J1720
J1730
J1742
J1800
J1810
J1815
J1825
J1830
J1835
J1840
J1850
J1885
J1890
J1910
J1940
J1950
J1955
J1956
J1960
J1980
J1990
J2000
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
J2912
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
J7190
J7191
J7192
J7194
J7197
J7308
J7310
J7501
J7504
J7505
J7506
J7507*
J7508*
J7509
J7510
J7511
J7513
J7518
J7599*
J8530
J9000
J9001
J9010
J9015
J9017
J9020
J9031
J9040
J9041
J9045
J9050
J9055
J9060
J9062
J9065
J9070
J9080
J9090
J9091
J9092
J9093
J9094
J9095
J9096
J9097
J9098*
J9100
J9110
J9120
J9130
J9140
J9150
J9151
J9165
J9170
J9178*
J9181
J9182
J9185
J9190
J9200
J9201
J9202
J9206
J9208
J9209
J9211
J9212
J9213
J9214
J9215
J9216
J9217
J9218
J9230
J9245
J9260
J9263*
J9264
J9265
J9266
J9268
J9270
J9280
J9290
J9291
J9293
J9300
J9305
J9310
J9320
J9340
J9355
J9357
J9360
J9370
J9375
J9380
J9390
J9600
J9999*
Q0163
Q0164
Q0165
Q0166
Q0167
Q0168
Q0169
Q0170
Q0171
Q0172
Q0173
Q0174
Q0175
Q0176
Q0177
Q0178
Q0179
Q0180
Q2009
Q2017
Q4075
S0017
S0021
S0023
S0028
S0030
S0032
S0034
S0039
S0040
S0073
S0074
S0077
S0080
S0081
S0092
S0093
S0164
S0171
S0187**
*Procedure code requires paper billing. Include the name of the
				drug and the dose given to patient..
**Effective for dates of service on and after October 1, 2006,
				procedure code
S0187
is limited to 2 units per
				day.
292.592
Other Covered Injections and Immunizations with Special 10-1-06
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.
On paper claims use type of service code
				"
1
."
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 under age 21.The following
				is a list of injections with special instructions for coverage and
				billing.
Procedure Code
Modifier(s)
Special Instructions
J0150
Procedure is covered for all ages with no diagnosis
						  restriction.
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.
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 244.001 for additional coverage information
						  and instructions for requesting prior approval.
J0585
Payable for individuals of all ages when medically
						  necessary. Botox A is reviewed for medical necessity based on diagnosis.
J0636
Payable for individuals of all ages receiving dialysis
						  due to renal failure (diagnosis codes 584-586).
J0637*
Caspofungin acetate injection is 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 must
						  be submitted with invoice. After 30 days of use, an updated medical exam and
						  history must be submitted.
J0702
Covered 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).
J0881 J0885
Payable for dates of service on and after March 1,
						  2006, for non-ESRD use. Covered by Medicaid only when provided to patients with
						  anemia associated with rheumatoid arthritis, sideroblastic anemia, anemia
						  associated with multiple myeloma, anemia associated with B-cell malignancies,
						  myelodysplastic anemia and chemotherapy induced anemia.
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).
J1100
Covered for beneficiaries of all ages. However, when
						  provided to beneficiaries aged 21 and older, there must be a diagnosis of
						  HIV/AIDS, cancer or complications during pregnancy (diagnosis code range 640 -
						  648.93).
J1440 J1441 J1460 J1470 J1480 J1490 J1500 J1510 J1520
						  J1530 J1540 J1550 J1560
Covered for individuals of all ages with no diagnosis
						  restrictions.
J1566 J1567
Electronic and paper 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 beneficiaries with
						  ICD-9-CM detail diagnosis 277.1).
J1745*
For beneficiaries under age 18 years, an approval
						  letter is required, regardless of the diagnosis.
For beneficiaries age 18 years and older, 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
Effective for dates of service on and after March 1,
						  2006, procedure codes J1750 became non-payable and was replaced with procedure
						  codes J1751 and J1752. These services are payable for individuals with a
						  diagnosis of ICD-9-CM code 280.9.
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. Prior approval from the DMS Medical Director is required. See section
						  244.001 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 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 428-428.9)
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.
Paper billing is required for all diagnoses for all
						  beneficiaries.
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*
Covered 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.
J2513
Covered when administered to beneficiaries of all ages
						  with no diagnosis restrictions.
J2788
Limited to one injection per pregnancy.
J2790 J2792
Payable with a primary diagnosis of 999.7; reviewed for
						  medical necessity prior to payment.
J2910
Payable for patients with a primary detail diagnosis of
						  rheumatoid arthritis (ICD-9 diagnosis codes 714.0 - 714.9).
J2916
Payable for beneficiaries aged 21 and older when there
						  is a diagnosis of cancer, aids, or acute renal failure with a diagnosis on the
						  claim that also includes 964.0. indicating that the beneficiary is allergic to
						  iron dextran. May be billed electronically or on paper.
J2997
Payable for beneficiaries of all ages with no diagnosis
						  restrictions. Limited to 2 units per day in the office place of service.
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 244.003
						  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 aged 18 and
						  older with a diagnosis of AIDS or cancer and one of the following diagnoses:
						  112.2, 112.3, 112.5, 112.84, 112.85, 112.9 or 117.3. Claims must be filed on
						  paper.
J3487
Payable to physicians when provided in the office if
						  one of the following diagnoses exist: AIDS or cancer along with diagnosis code
						  275.42
or
diagnosis code 198.5;
or
diagnosis code
						  203.0. Claim will be manually reviewed prior to payment.
J7198
Payable for all ages with no diagnosis
						  restrictions.
J7199
Must be billed on a paper claim form with the name of
						  the drug, dosage and the route of administration.
J7320
Requires prior authorization. Limited to 3 injections
						  per knee, per beneficiary, per lifetime. (This includes Synvisc.) See section
						  261.240.
J7330
Requires prior authorization from AFMC for all
						  providers. See sections 260.000, 261.000, 261.100 and 261.110.
J7341
Payable for beneficiaries of all ages with no diagnosis
						  restrictions.
J9025
Coverage of this procedure code requires an ICD-9-CM
						  diagnosis within the code range of 205.00 - 205.91 with applicable
						  4th and 5th digits per
						  ICD-9-CM,
or
a diagnosis of 238.7.
J9035*
Coverage of this procedure code requires an ICD-9-CM
						  diagnosis within the code range of 140.0 - 208.91, 230.0 - 238.9, 042, 362.50
						  or 362.52. A prior approval letter is required and must be attached to each
						  claim. See section 244.100 for information on requesting prior approval.
J9219
This procedure code is covered for males 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 beneficiaries with a diagnosis of malignant
						  neoplasm of prostate (ICD-9-CM code 185).
J9250
Payable for beneficiaries of all ages without
						  restriction.
J9350
Covered for beneficiaries of all ages with a primary
						  detail diagnosis of 162.9 or 183.0. Billable on electronic and paper claims.
						  Paper claims require type of service "1".
J9395*
Payable for beneficiaries of all ages, with a diagnosis
						  of 174.0 - 174.9 after treatment failure with antiestrogen drugs.
A prior approval letter is required. Requests for prior
						  approval must include the history, physical exam and plan of treatment stating
						  that request for this drug is due to a treatment failure. See section 244.001
						  for additional coverage information and instructions for requesting prior
						  approval. A copy of the prior approval letter must be attached to each
						  claim.
Q3025 Q3026
These procedure codes are covered for all ages based on
						  medical necessity.
Q4079*
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.
S0145 S0146
Procedures are payable when there is a primary detail
						  diagnosis ICD-9-CM 070.54
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, I units of service must be
						  identical 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.
						  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 5-49 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, i
						  units of service must be identical 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.
90698
Payable for beneficiaries aged 0 - 7 years.
90700
EP, TJ
VFC vaccine payable when administered to beneficiaries
						  under age 7 years. Modifiers are required. See section 292.593 for more
						  information.
90703
Payable for ages 18 years and older.
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.
90707
EP, TJ
Payable when administered to beneficiaries under age 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 under age 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 under age 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 under
						  age 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 under
						  age 19.years. See section 292.593.
90719
This vaccine is covered for individuals of all
						  ages.
90721
EP, TJ
Covered for beneficiaries under age 21 years. Modifiers
						  are required only when administered to beneficiaries under age 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
			 10-1-06
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 filing paper claims, type
				of service code
"6"
and modifiers
EP
,
TJ
, must be entered on the claim form. When vaccines are
				administered to beneficiaries of ARKids First-B services, only modifier
TJ
must be used for billing electronically or on paper. Paper
				claims for vaccines for ARKids First-B beneficiaries also require a type of
				service code
"1"
.
The following is a list of covered vaccines for children under
				age 19.
90633*
90634*
90636
90645
90646
90647
90648
90655
90656
90657
90658
90660
90669
90680**
90700
90707
90710*
90713
90714
90715*
90716
90718
90721
90723
90734*
90743
90744
90747
90748
*Effective for dates of service on and after March 1, 2006,
				these vaccines are available through the VFC program.
**Effective for dates of service on and after July 10, 2006,
				procedure code 90680 is available through the VFC program.
292.594
Influenza Virus Vaccine
			 10-1-06
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
. When filing paper claims, use type of service
6
with modifiers
EP
and
TJ
.
For ARKids First-B beneficiaries, use modifier
TJ
. When filing paper claims, use type of service
1
with modifier
TJ
.
B.
			 Effective for dates of service on and after October 1, 2005, Medicaid will
			 cover 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
. When
			 filing paper claims, use type of service
6
with the
			 modifiers.
2. For ARKids First-B
			 beneficiaries, use modifier
TJ
. When filing paper claims, use
			 type of service
1
with the modifier.
3. For individuals ages 19 and older, no
			 modifier is necessary and type of service
1
must be used when
			 filing paper claims.
C.
			 Effective for dates of service on and after October 1, 2005, procedure code
90660
, influenza virus vaccine, live, for intranasal use, is
			 covered. Coverage is limited to healthy individuals ages 5 through 49 who are
			 not pregnant.
1. When filing claims for
			 children 5 through18 years of age, use modifiers
EP
and
TJ
. When filing paper claims, use type of service
6
with the modifiers.
2. For ARKids
			 First-B beneficiaries, the procedure code must be billed using modifier
TJ
. When filing paper claims, use type of service
1
with the modifier.
3. No modifier
			 is required for filing claims for beneficiaries ages 19 through 49. Paper
			 claims require type of service
1
.
D. Procedure code
90657
,
			 influenza virus vaccine, split virus, for children ages 6 through 35 months, is
			 covered. Modifiers
EP
and
TJ
are required. Paper
			 claims require type of service
6
with the modifiers.
For ARKids First-B beneficiaries, use modifier
TJ
. When paper claims are filed, use type of service
1
with the
				modifier.
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 paper claims for individuals
			 under age 19, use type of service
6
with modifiers
EP
and
TJ
.
2.
			 For ARKids First-B beneficiaries, use modifier
TJ
. For paper
			 claims, use type of service
1
with the modifier.
3. No modifier is required for filing claims
			 for beneficiaries aged 19 and older. Use type of service
1
when
			 filing paper claims.
292.595
Special Pharmacy, Therapeutics
			 and Radiopharmaceutical Therapy 10-1-06
and Treatments
A. Special pharmacy and therapeutic agents
			 are covered with prior approval from the Division of Medical Services Medical
			 Director.
1. Claims must be submitted to EDS
			 on paper.
2. Each claim must
			 reflect, in the description of service field, the number in the treatment
			 series of each administration for which you are billing Medicaid.
3. No prior authorization number is issued;
			 therefore, a copy of the Medical Director's approval letter must be attached to
			 each claim filed.
Refer to section 244.100 for coverage information and
				instructions for requesting prior approval.
B. Radiopharmaceutical therapy is covered
			 with prior approval from the Medical Director of the Division of Medical
			 Services.
1. Claims must be submitted to EDS
			 on paper.
2. A copy of the Medical
			 Director's approval letter and a copy of the invoice for the monoclonal
			 antibody used must be attached to the claim form.
Refer to section 244.200 for coverage information and
				instructions for requesting prior approval.
292.600
Laboratory and X-Ray
			 Services 10-1-06
Only laboratory and X-ray services carried out in the
				physician's office or under his/her direct supervision may be billed by the
				physician to the Medicaid Program. Laboratory and X-ray services ordered by the
				physician but carried out in an outside facility must be billed directly to
				Medicaid by the outside facility. Physician will be reimbursed for collection
				fee only.
Medicaid regulations regarding collection, handling and/or
				conveyance of specimens are:
A.
			 Reimbursement will not be made for specimen handling fees.
B. A specimen collection fee may be allowed
			 only in circumstances including:
(1) drawing
			 a blood sample through venipuncture (e.g., inserting into a vein a needle with
			 syringe or vacutainer to draw the specimen); or,
(2) collecting a urine sample by
			 catheterization.
The following procedure codes should be used when billing for
				specimen collection:
P9612
P9615
Independent laboratories must meet the requirements to
				participate in Medicare. Independent laboratories may only be paid for
				laboratory tests they are certified to perform. Laboratory services rendered in
				a specialty for which an independent laboratory is not certified are not
				covered and claims for payment of benefits for these services will be
				denied.
292.602
Special Billing Requirements
			 for Lab and X-Ray Services 10-1-06
A.
			 Prior approval is required before services associated with the use of procedure
			 codes
A9542
,
A9543
,
A9544
and
A9545
may be provided. To obtain a prior approval letter from the
			 DMS Medical Director, the provider must furnish the following documentation.
			 (See sections 244.100 and 292.595.)
1. The
			 FDA approved diagnosis clearly stated
2. Treatment failures that the patient has
			 previously experienced
3. The
			 patient's history and physical report
B. Prior approval is required before services
			 associated with the use of procedure code
A9547
may be provided.
			 To obtain prior approval, the provider must submit the following documentation.
1. The patient's history and
			 physical
2. A report of the
			 ultrasound or computerized axial tomography (CAT) that was not
			 diagnostic
C. Prior
			 approval is required for the service associated with the use of procedure code
A9555
. To obtain prior approval, the provider must submit:
1. A history and physical
2. A report on what other profusion scans
			 have been tried and are non-diagnostic
D. Some HCPCS laboratory and radiology
			 services are payable only with diagnosis restrictions. For payment these
			 diagnoses must be entered on the claim.
1.
			 Procedure code
A9535
is restricted to ICD-9-CM diagnosis code
			 289.7.
2. Procedure code
A9549
is restricted to ICD-9-CM diagnosis code 154.8.
3. Procedure code
A9557
is
			 restricted to ICD-9-CM diagnosis code range 430 - 434.91.
4. Procedure code
A9559
is
			 restricted to ICD-9-CM diagnosis code 281.0.
5. Procedure code
A9563
is
			 restricted to ICD-9-CM diagnosis code 238.4.
292.620
Office Medical Supplies -
			 Beneficiaries Under Age 21 10-1-06
For beneficiaries under age 21, procedure code
99070
is payable to physicians for supplies and materials (except
				eyeglasses), provided by the physician over and above those usually included
				with the office visit or other services rendered. Procedure code
99070
must not be billed for the provision of drug supply samples
				and may not be billed on the same date of service as a surgery code. When
				filing paper claims physicians must bill procedure code
99070
with
				a type of service code
"6"
and a place of service code
"3".
Electronic claims require place of service code
"11"
. Procedure code
99070
is limited to
				beneficiaries under age 21.
292.671
Method 1 - "Global" or
			 "All-Inclusive" Rate 10-1-06
The global method of billing should be used when one or more
				physicians in a group see the patient for a prenatal visit and one of the
				physicians in the group does the delivery. The physician that delivers the baby
				should be listed as the attending physician on the claim that reflects the
				global method.
No benefits are counted against the recipient's physician visit
				benefit limit if the global method is billed.
A. One charge for total obstetrical care is
			 billed. The single charge includes the following:
1. Antepartum care which includes initial and
			 subsequent history, physical examinations, recording of weight, blood pressure
			 and fetal heart tones, routine chemical urinalyses, maternity counseling and
			 other office or clinic visits directly related to the pregnancy.
2. Admissions and subsequent hospital visits
			 for the treatment of false labor, in addition to admission for
			 delivery.
3. Vaginal delivery (with
			 or without episiotomy, with or without pudendal block, with or without forceps
			 or breech delivery), or cesarean section and resuscitation of newborn infant
			 when necessary.
4. Routine
			 postpartum care (sixty days), which includes routine hospital and office visits
			 following vaginal or cesarean section delivery.
B. The global method must be used when the
			 following conditions exist:
1. At least two
			 months of antepartum care were provided culminating in delivery. The global
			 billing beginning date of service is the date of the first visit that a
			 Medicaid beneficiary is seen with a documented possible pregnancy or a
			 confirmed pregnancy diagnosis.
2.
			 The patient was continuously Medicaid eligible for two months or more months
			 before delivery and on the delivery date.
If either of the two conditions is not met, the services will
				be denied, stating either "monthly billing required" or "recipient ineligible
				for service dates."
C. The correct codes for billing Medicaid for
			 global obstetric care are as follows.
National Codes
59400
59510
59610
59618
When billing these procedure codes, both the first date of
				antepartum care after Medicaid eligibility has been established and the date of
				delivery must be indicated on the claim in the date of service field. If these
				two dates are not entered and are not at least two months apart, payment will
				be denied. The 12-month filing deadline is calculated based on the date of
				delivery.
292.672
Method 2 - "Itemized Billing"
			 10-1-06
Use this method only when either of the following conditions
				exists:
A. Less than two months of
			 antepartum care was provided or
B.
			 The patient was NOT Medicaid eligible for at least the last two months of the
			 pregnancy.
Bill Medicaid for the antepartum care in accordance with the
				special billing procedures set forth in section 292.675. The visits for
				antepartum care will not be counted against the patient's annual physician
				benefit limit. Keep in mind that date-of-service spans may not include any
				dates for which the patient was not eligible for Medicaid.
Bill Medicaid for the delivery and postpartum care with the
				applicable procedure code from the following table:
National Codes
59410
59515
59525
59622
National Code
Local Code
Local Code Description
Bill on paper
Z1930
Non-Emergency Hysterectomy after C-Section [Requires
						  prior authorization from the Arkansas Foundation for Medical Care
						  (AFMC)]
If Method 2 is used to bill for OB services, care should be
				taken to ensure that the services are billed within the 12-month filing
				deadline.
If only the delivery is performed and neither antepartum nor
				postpartum services are rendered, procedure codes
59409
or
59612
should be billed for vaginal delivery and procedure codes
59514
or
59620
should be billed for cesarean section.
				Procedure codes
59400
,
59410
,
59510
and
59515
may not be billed in addition to procedure codes
59409, 59612, 59514
or
59620.
These procedures will
				be reviewed on a post-payment basis to ensure that these procedures are not
				billed in addition to antepartum or postpartum care.
Operative standby for a C-section must be billed using
				procedure code
99360.
Laboratory and X-ray services may be billed separately using
				the appropriate CPT codes, if this is the physician's standard office practice
				for billing OB patients. If lab tests and/or X-rays are pregnancy related, the
				referring physician must be sure to code appropriately when these services are
				sent to the lab or X-ray facility. The diagnostic facilities are completely
				dependent on the referring physician for diagnosis information necessary for
				Medicaid reimbursement.
The obstetrical laboratory profile procedure code
80055
consists of four components: Complete blood count, VDRL, Rubella and
				blood typing and RH. If the ASO titer (procedure code
86060
) is
				performed, the test should be billed separately using the individual
				code.
For laboratory procedures, if a blood specimen is sent to an
				outside laboratory, only a collection fee may be billed. No additional fees are
				to be billed for other types of specimens that are sent for testing to an
				outside laboratory. The laboratory could then bill Medicaid for the laboratory
				procedure. Refer to Section 292.600 of this manual.
NOTE: Payment will not be made for emergency room
				physician charges on an OB
patient admitted directly from the emergency room into
				the hospital for delivery.
292.673
Fetal Non-Stress Test and
			 Ultrasound 10-1-06
The Arkansas Medicaid Program covers the fetal non-stress test
				(procedure code
59025
) and the ultrasound (procedure codes
76801 - 76828
) when performed in conjunction with maternity
				care.
Arkansas Medicaid imposes a benefit limit of two medically
				necessary fetal non-stress test procedures per pregnancy. Fetal ultrasound is
				limited to two per pregnancy. If it is necessary to exceed these limits, the
				physician must request benefit extensions, when applicable, in accordance with
				benefit extension request instructions in this provider manual.
292.674
External Fetal
			 Monitoring 10-1-06
Procedure code
59050
must be used exclusively for
				external fetal monitoring when performed in a physician's office or clinic,
				place of service code
"3"
for paper claims or
"11"
for electronic claims. Physicians may bill for one unit per day of external
				fetal monitoring. Physicians may bill for external fetal monitoring in addition
				to a global obstetric fee. When itemizing obstetric visits, physicians may bill
				for medically necessary fetal monitoring in addition to obstetric office
				visits.
292.675
Obstetrical Care Without Delivery 10-1-06
A. Obstetrical care without delivery may be
			 billed using procedure code
59425
, modifier
UA
,
			 when 1 - 3 visits are provided and
59425
with no modifiers when 4
			 - 6 six visits are provided... Procedure code
59426
with no
			 modifiers is payable for 7 or more visits.
B. These procedure codes enable physicians
			 rendering care to the patient during the pregnancy, but not delivering the
			 baby, to receive reimbursement for these services. Units of service billed with
			 these procedure codes are not counted against the patient's annual physician
			 visit benefit limit. Reimbursement for each visit includes routine sugar and
			 protein analysis. Other lab tests may be billed separately within 12 months of
			 the date of service.
C. The
			 procedure codes must be billed with a type of service code
"1"
when filing paper claims. Providers must enter the dates of service in the
			 CMS-1500 claim format and the number of units being billed. One visit equals
			 one unit of service. Providers must submit the claim within 12 months of the
			 first date of service.
View a CMS-1500 sample
				form.
For example:
An OB patient is seen by Dr. Smith on
				1-10-05, 2-10-05, 3-10-05, 4-10-05, 5-10-05 and 6-10-05. The patient then moves
				and begins seeing another physician prior to the delivery. Dr. Smith may submit
				a claim with dates of service shown as 1-10-05 through 6-10-05 and 6 units of
				service entered in the appropriate field. EDS must receive the claim within the
				12 months from the first date of service. Dr. Smith must have on file the
				patient's medical record that reflects each date of service being billed. Dr.
				Smith must bill the appropriate code:
59425
with modifier
UA
when 1 - 3 visits are provided,
59425
with no modifiers
				when 4 - 6 visits are provided and procedure code
59426
when 7 or
				more visits are provided.
292.730
Professional and Technical
			 Components 10-1-06
Covered laboratory and radiology (procedure codes in code range
70010
through
89399
as well as covered services
				listed in the Medicine section of CPT and HCPCS procedure codes manuals that
				require the use of a machine may be billed electronically or on paper.
When filing paper claims, a type of service code must be used
				along with applicable modifiers. The type of service code indicates whether the
				charge billed is for the technical component, professional component or
				complete procedure. The type of service codes are:
A. Type of Service Code
C
-
Complete Procedure
. This charge consists of the
			 combination of both the technical and the professional components. A complete
			 procedure charge would be made if a physician has a private office and does the
			 procedure within his own office. In these circumstances, he is billing for what
			 is normally considered the technical component and the professional component
			 in one single charge. In a private office environment, the radiologist is
			 personally responsible for the personnel expenses, equipment expenses and also
			 for his own professional services.
B. Type of Service Code
P
-
Professional Component
. This charge consists of the
			 fee for the professional involvement of the physician in the procedure. This
			 consists of interpretation of the report, personal supervision of the
			 procedure, dictation of the report, consultation with referring physicians and
			 injection of contrast media where required.
C. Type of Service Code
T
-
Technical Component
. This would be the portion of the
			 charge relating exclusively to the execution of the procedure, exclusive of any
			 service rendered by the physician. The technical component consists of such
			 things as technician's time, salary, film costs, equipment costs, maintenance,
			 space rental, utilities and all other charges normally associated with the
			 provision of the radiology service.
Paper claims require the correct type of service code,
C
,
P
, or
T
, to be entered in Field
				24C in the CMS-1500 claim form. Applicable modifiers are required in Field 24D
				with the procedure code. Modifier
TC
must be used for the
				technical component and modifier
26
must be used for the
				professional component.
Electronic billing of covered laboratory and radiology services
				requires appropriate modifiers:
TC
for the technical component and
26
for the professional component.
292.742
Family/Group Psychotherapy
			 10-1-06
The following psychotherapy procedure codes are payable by the
				Arkansas Medicaid Program for family/group psychotherapy:
National Codes
90847
90849
90853
90857
Procedure codes
90847
and
90849
are
				payable when the place of service is the beneficiary's home, the physician's
				office, a hospital or a nursing home. Procedure code
90847
is
				payable only when the patient is present during the treatment. Procedure codes
90849
and
90853
are payable when the patient is not
				present; however, the patient may be present during the session, when
				appropriate.
292.760
Rural Health Clinic (RHC) Non-Core Services 10-1-06
Physician groups whose individual practitioners are contracting
				with a rural health clinic are limited to billing Medicaid for Rural Health
				Clinic (RHC) non-core services. These providers may bill the following
				procedure codes:
RHC NON-CORE SERVICES
Outpatient Hospital Visits
Inpatient Hospital Visits
Non-emergency: T1015 modifier U1
99217 through 99223
Emergency: 99281 through 99285
99231 through 99238 99251 through 99255 99291, 99295,
						  99296, 99297
Electrocardiog (Type of technical
rams and Echocardiography service code (paper
						  only) T- component- only)
Radiology
(Type of service code (paper
						  claims)
T- technical component only)
93005, 93012, 93232, 93236, 93312, 93320,
93041, 93225, 93226, 93231, 93270, 93271, 93307, 93308,
						  93321, 93325, 93350
70010 through 76946 76950 through 76977 76999 through
						  78813 78990 through 79999
Surgery, Outpatient and Inpatient
All payable CPT procedure codes within range 10040 through
				69990
NOTE: Inpatient and outpatient hospital services are RHC
				non-core services only if the physician's contract with the RHC does not state
				that the physician will be compensated by the RHC for those services.
				Interpretation of X-rays and diagnostic machine tests in the inpatient or
				outpatient hospital is a non-core service when the visit itself is a non-core
				service. Home visits, nursing facility visits or other off-site visits are RHC
				encounters if the physician's agreement with the RHC requires that he or she
				provide the services and seek compensation from the RHC. Any of these off-site
				services is payable separately (through the Physician Program) from the RHC
				encounter fee if it is not a part of the physician's contract with the
				RHC.
See Sections 201.120 and 246.000 of this manual for additional
				information.
292.801
Cochlear Implant and External Sound Processor 10-1-06
Procedure code
69930
- Cochlear device
				implantation, with or without mastoidectomy - may be billed only by the
				physician performing the surgical procedure up to 50 daily units. When the
				cochlear device is provided by the physician, the physician may bill procedure
				code
L8614
for the cochlear device using
EP
modifier.
				Paper claims require a type of service
"6"
with modifier
EP
for the device. Procedure code
69930
and
L8614
require prior authorization. The physician must attach a
				copy of the invoice to the CMS-1500 claim form. If the cochlear device is
				provided by the hospital, the physician may not bill for the device. Refer to
				Section 251.230 of this manual for coverage information.
External sound processors, procedure code
L8619
,
				are covered for eligible Medicaid recipients under age 21 in the EPSDT Program.
				Additional procedure codes
L8615
,
L8616
,
L8617
,
L8618
,
L8621
and
L8622
are also payable to the physician. These procedure codes require prior
				authorization and the physician must attach a copy of the invoice to the
				CMS-1500 claim form. Refer to Section 251.230 of this manual for coverage
				information.
Procedures are covered for beneficiaries under age 21 and must
				be billed with modifier
EP
and type of service
"6"
.
View a CMS-1500 sample
				form.
292.812
Telemedicine Evaluation and Management Procedure Codes 10-1-06
Arkansas Medicaid reimburses as telemedicine services, the
				evaluation and management services listed in this section when the services are
				billed by their correct procedure codes, type of service codes (paper only) and
				place of service codes as listed and defined in Sections 292.812 through
				292.814.
HCPCS Code
Modifier
Description
TOS Code (paper claims only) Local Site
TOS Code (paper claims only) Remote Site
T1015
U1
Non-emergency Outpatient Hospital Visit
*Z
V
Procedure Code
TOS (paper only) Local Site
TOS (paper only) Remote Site
99201
V
99202
V
99203
V
99204
V
99205
V
99211
*Z
V
99212
*Z
V
99213
*Z
V
99214
*Z
V
99215
*Z
V
99221
V
99222
V
99223
V
99231
*Z
V
99232
*Z
V
99233
*Z
V
99241
V
99242
V
99243
V
99244
V
99245
V
99251
V
99252
V
99253
V
99254
V
99255
V
99281
*Z
V
99282
*Z
V
99283
*Z
V
99284
*Z
V
99285
*Z
V
*NOTE: Arkansas Medicaid covers telemedicine evaluation
				and management services of an attending physician at the local site
only
when the physician is physically attending the patient
				and is presenting the case to a consulting physician at the remote site by
				means of telemedicine media.
292.827
Billing for Liver/Bowel
			 Transplants 10-1-06
A. Liver/bowel
			 transplant procedure codes require prior approval.
B. Procedure code
47135
is to be
			 used for the liver.
C. Procedure
			 codes
44135, 44136, 44132
and
44133
are to be used
			 for the intestine, as applicable.
292.870
Bilaminate Graft or Skin
			 Substitute Procedures 10-1-06
Arkansas Medicaid will reimburse physicians who furnish the
				manufactured viable bilaminate graft or skin substitute with prior
				authorization. The product is manually priced and requires paper claims using
				procedure code
J7340
, type of service code
"1"
(paper claims only). The manufacturer's invoice 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.
Surgical preparation procedures, CPT codes
15000
and
15001
, may be reimbursed when performed at the same surgical
				setting. These codes are to be listed separately in addition to the primary
				procedure and do not require PA.
292.900
Tobacco Cessation Counseling
			 Services 10-1-06
The prescribing provider of tobacco cessation products must
				provide counseling services and request prior authorization before the products
				are Medicaid covered for reimbursement. Procedure code
99401
,
				modifier
SE
, must be used for one 15-minute unit of service, and
				procedure code
99402
, modifier
SE
, must be used for
				one 30-minute unit of service.
Oral surgeons must use procedure code
D9920
for
				one 15-minute unit and procedure code
D1320
for one 30-minute unit
				when filing claims on the American Dental Association (ADA).
See section
				257.000 of this manual for
				coverage and benefit limit information.