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)