April 29, 2014

State of Alabama
Press Release: Medicaid

Durable Medical Equipment (DME) Program Changes and Reminders

TO:     DME Providers, Prosthetics & Orthotics (P&O) Providers, Pharmacies, Physicians, Physician Assistants, Nurse Practitioners

 

 

In this five-page ALERT, the Alabama Medicaid Agency’s Durable Medical Equipment Program is informing providers of the following information:

 

Changes:

 

·         A4230 and A4232 Benefit Limit Changes

 

·         A4351, A4352, and/or A4349  Benefit Limit Changes

 

·         E0570 (Nebulizer) Continuous Rental Policy Change

 

·         Form 384 (Wheelchair/Seating Evaluation Form, Revised)

 

·         A4351, A4352, and/or A4349  (Catheter supplies) New Billing Process

 

·         A4221 Contra Audits

 

Reminders

 

·            Billable Modifiers for  BiPAP

 

·            Billable Modifiers for  CPAP 

 

·            Exceeds Benefit Limit Requests

 

·            NCCI Edits

 

      ·            Criteria Compliance

 

·            ICD-10 Implementation Delayed

 

Benefit Limit Changes Effective for dates of service on or after April 1, 2014:

 

Procedure Code

Procedure Code Description

Benefit Limit

Affected Recipients

Insulin Supplies

A4230

 

 

-----------------------

A4230-U6

Infusion set for external insulin pump, non-needle cannula type

------------------------------------

30 units per two calendar months per recipient

------------------------

70* units per two calendar months per recipient

 

 

 

Age 0-20; insulin dependent

 

------------------------------

Age 0-20; insulin dependent

 

Payment for this quantity will also require use of the appropriate diagnosis code in the range of 250.01 and 250.93 and U6 modifier

A4232

 

 

-----------------------

A4232-U6

Syringe with needle for external insulin pump, sterile, 3cc

------------------------------------

30 units per two calendar months per recipient

------------------------

70* units per two calendar months per recipient

 

 

Age 0-20; insulin dependent

 

------------------------------

Age 0-20; insulin dependent

 

Payment for this quantity will also require use of the appropriate diagnosis code in the range of 250.01 and 250.93 and U6 modifier

*The maximum number of units using A4230 (with or without a modifier) is 70.  Example: If  30 units are billed without U6 modifier, then 40 is maximum number of units billable with the U6 modifier during any two calendar months.

Providers may bill the maximum allowed units in a one month period.

All appropriate documentation must be kept in the recipient’s file and will be monitored by Alabama Medicaid on a quarterly basis.

Catheter Supplies

A4349

 

Male external catheter, with or without adhesive, disposable, each

31 units per month per recipient

------------------------

150 units per month per recipient

 

Age 0-999: no PA or EPSDT-referral required

------------------------------

Age 0-20; EPSDT-referral required

 

A4351

 

Intermittent urinary catheter; straight tip, with or without coating

A4352

Intermittent urinary catheter; Coude (curved) tip, with or without coating

 

E0570 (Nebulizer) Continuous Rental Policy Change

Effective for dates of service on or after April 1, 2014, Alabama Medicaid will reimburse E0570 (Nebulizer) as purchase only, excluding cross-over claims. Cross over claims will continue to be reimbursed as a continuous rental when submitted as a rental. There is no change in the current criteria.

 

Form 384 (Wheelchair/Seating Evaluation Form, Revised)

Effective for dates of submission on or after April 1, 2014, the revised Wheelchair/Seating Evaluation Form, Form 384, must be submitted to the Agency’s Fiscal Agent (HP Enterprise Services) for wheelchair/seating PAs.

 

The revised Form 384 has been added to the Agency’s website and can be viewed by clicking the following link:

http://medicaid.alabama.gov/documents/5.0_Resources/5.4_Forms_Library/5.4.1_Billing/
5.4.1_Form_384_Wheelchair_Revised_2-18-14.pdf

 

Form 384 must be completed by an Alabama licensed Physical Therapist (PT)/Occupational Therapist (OT).  Alabama Medicaid will only reimburse for the physical therapy evaluation for wheelchairs (manual with accessories and all power wheelchairs) for adults if the PT/OT is employed by a hospital enrolled with Alabama Medicaid.  The evaluation must be performed in the hospital outpatient setting.

 

A4351, A4352, and/or A4349  (Catheter supplies) New Billing Process

Effective for dates of service on or after May 1, 2014, providers must submit a PA request and supporting documentation for procedure codes A4351, A4352 and/or A4349 to the Agency’s Fiscal Agent (HP) for the Prior Authorization Vendor’s (Qualis Health) approval for

 

(1) recipient age 0-20 needing more than 150 units per calendar month with an EPSDT screening, and  

(2) recipient age 21-999 needing more  than 31 units per calendar month.

 

The provider will receive the PA decision letter with the approval or denial.  If approved, the provider will submit the claim(s) electronically with the appropriate procedure code(s): A4351, A4352 and/or A4349 and the U8 modifier.

 

This change means that providers will no longer submit override requests for these items and quantities to the Agency for review. Hard copy claims of this type (for dates of service on or after May 1, 2014), submitted by providers to the DME Unit, will not be processed.  All appropriate documentation must be kept in the recipient’s file and will be monitored by Alabama Medicaid on a quarterly basis.

 

A4221:  Contra Audits

 

For dates of service on or after January 1, 2014, Alabama Medicaid will no longer reimburse for the below listed procedure codes when billed in combination with procedure code A4221- Supplies for Maintenance of Drug Infusion Catheter, Per Week:

A4244      A4245      A4246      A4247      A4450       A4452      A4455

A4927      A4930      A6216      A6230      A6250      A6257       A6258

A6259      A6266      A6403      A6404      J1642

 

NOTE:   A4221 will only be reimbursed by Alabama Medicaid once per week and up to three units per week. The reimbursement amount for code A4221 includes all necessary supplies for one week in whatever quantity is needed by the recipient for that week. Providers that submit claims including A4221 are required to furnish the items and services described in the quantities needed by the recipient for the entire week.

 

These changes are in compliance with the 2010 federal regulation regarding A4221.

 

REMINDERS:

 

Billable Modifiers for BiPAP

PAs submitted for dates of service on or after January 1, 2014 must comply with the following instructions:

 

LL modifier - Submitted for BiPAP’s

·         initial three month trial period and

·         next six months

No modifier - Submitted for the final month (totaling 10 months capped)

RA modifier - Submitted for replacement of machine only, within the 8-year period.

      (Replacement has to be prior approved by Agency as directed by policy.)

 

Billable Modifiers for CPAP

PAs submitted for dates of service on or after January 1, 2013 must comply with the following instructions: 

LL modifier - Submitted for CPAP initial three (3) months approval

No modifier - Submitted for final payment (starts benefit limit count)

RA modifier - Submitted for replacement of machine only, within the 8-year period

      (Replacement has to be prior approved by Agency as directed by policy.)

RR modifier was terminated for Medicaid claims effective December 31, 2012

      (Accepted for cross-over claims only, after December 31, 2012)


 

Exceeds Benefit Limit Requests

If the prescription to be paid by Alabama Medicaid exceeds the maximum benefit limit established by Alabama Medicaid, the DME provider must request an override or prior authorization for the prescribed item(s). If the override/prior authorization request is denied, then the item(s) above the maximum benefit limit is non-covered and the recipient can be charged as a cash recipient for the item(s) in excess of the maximum benefit limit.

 

 

NCCI Edits

It is the provider’s responsibility to ensure that requested items and/or quantities are in compliance with NCCI edits prior to submitting claims and/or prior authorization requests.

 

Prior authorization approval will not override NCCI edits.

 

The Medicaid NCCI Coding is available on the CMS NCCI website at:

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html

 

 

Criteria Compliance

Please ensure compliance with the requirements listed in the Agency’s Provider Manual and Administrative Code documents. Frequently, documentation is required to be maintained in the recipient’s file on the DME site although the item(s) may not require prior authorization. An appropriate signature is also required for ALL items provided/delivered to recipients.

 

 

ICD-10 Implementation Delayed

 

On April 1, 2014, President Obama signed into law legislation (HR 4302) that delayed the ICD-10 compliance date until at least October 2015.  As we learn more, we will keep you informed.  The Alabama Medicaid Agency’s claims processing system was updated in October 2013 to accommodate ICD-10. 

 



  • For more information, visit http://medicaid.alabama.gov
  • For more state-wide press releases, click here