New York State Medicaid Update - May 2016 Volume 32 - Number 5

In this issue …

Captcha: ePACES To Add New Feature on June 1, 2016

In an effort to make user data more secure and to improve system performance, eMedNY will be installing a new feature that will impact ePACES users when signing on to the ePACES application. This new feature, commonly called Captcha, is a program that can distinguish whether the user attempting to sign-on is a human or a computer.

Effective June 1, 2016 when users attempt to sign-on to ePACES from the eMedNY website, the user will be asked to verify that he/she is a person and not a computer by selecting specific images. Once the user has successfully verified the correct images he or she will be allowed to sign into the ePACES account. If the incorrect images are selected, the user will be asked to verify another set of images before being allowed access to ePACES.

To familiarize yourself with the new verification function, please go to https://www.google.com/recaptcha/api2/demo

This new feature is widely utilized by other secure websites. Many people are familiar with it and have probably had to use it to gain access to those secure websites. The New York State Department of Health is adding this feature to help secure your data, and to prevent unauthorized computer-automated access to ePACES that could adversely impact ePACES performance.

Important Note: All users will need to have installed Internet Explorer (Ie) version 10 or greater or any alternative browsers including Google Chrome, Mozilla Firefox, or Apple Safari. IE versions 9 and below will not be supported. Please be sure to coordinate with your IT department to upgrade your internet browser, if necessary, before the effective date shown above.

Questions about ePACES can be directed to the eMedNY Call Center at 800-343-9000.

New York Medicaid Management Information System (NYMMIS) Learning Management System and Computer-Based Trainings

Computer-based trainings (CBTs) are now available in the new NYMMIS Learning Management System (LMS). The LMS is an online repository for CBT videos and supporting materials that learners can access directly from any computer connected to the internet to learn more about NYMMIS. Webinar and in-person training classes are also available.

Registration is required to access CBTs and materials. To register, please visit: https://nymmisexternal.learnercommunity.com/account/login/secure?returnUrl=%2Fhome.

Computer Based Trainings (CBTs)

The following CBTs are currently available on the NYMMIS LMS:

  • Using the LMS – This lesson focuses on the creation of and sign in to a user's account. It also provides information on how to navigate through courses and how to enroll in the different courses provided.
  • Introduction to NYMMIS – The Introduction to NYMMIS training is for first-time users of the system.
  • Features and Functionality – This training is for first-time learners of the system and explains the basic features and functionality of NYMMIS.
  • Basic and Advanced Searching – In this lesson, learners build on their knowledge of NYMMIS by explaining the Search functions that are available in the system.
  • Introduction to Provider Enrollment – This training is for new provider enrollments only and focuses on how to use NYMMIS to complete an electronic enrollment application.
  • Completed Provider Enrollment Applications Individual – This course shows learners how to complete the enrollment application online for an individual provider.
  • How to Recall an Application – This course shows the learner how to recall a Provider Enrollment application and if any additional information is required on the application for completion.
  • Check Application Status – This course helps users determine the status of their application and understand the status of their application.

Please contact NYMMIS Training by sending an email to Nymmistraining@xerox.com for inquiries and assistance related to these trainings.

Webinars and in-person training

NYMMIS training is also available via webinar and in-person classes. Webinars are available in these formats:
Live, online educational presentations or recorded presentations you can review and playback

You can sign up to attend a NYMMIS webinar or in-person training by visiting the Training and Events Calendar on http://www.interimnymmis.com/training-and-event-calendar.

The following webinars and in-person classes are currently available:

  • Introduction to NYMMIS - Features and Functionality - This lesson introduces the Medicaid Management Information System that is being rolled out for New York. This system is called NYMMIS, which stands for the New York Medicaid Management Information System (NYMMIS).
  • Introduction to Provider Enrollment - This class begins with an introduction to NYMMIS and focuses on the enrollment application process.

Please contact NYMMIS Training by sending an email to Nymmistraining@xerox.com for inquiries and assistance related to these trainings.

New York Medicaid EHR Incentive Program Update

The New York Medicaid Electronic Health Record (EHR) Incentive Program provides financial incentives to eligible professionals and hospitals to promote the transition to Ehrs. Providers who practice using Ehrs are in the forefront of improving quality, reducing costs and addressing health disparities. Since December 2011 over $768 million in incentive funds have been distributed within 23,619 payments to New York State Medicaid providers.

23,619
Payments

$768+
Million Paid

Are you eligible? For more information, visit www.emedny.org/meipass

Did you know?

2016 is the last year that eligible professionals (EPs) may begin participating in the Medicaid EHR Incentive Program. EPs may receive up to $63,750 over the course of six years for the adoption and meaningful use of certified EHR technology.

Unsure if your EHR is certified? Visit the Certified Health IT Product List at http://healthit.gov/chpl to see if your EHR qualifies you for the incentive program.

2016 attestations for Adopt, Implement, or Upgrade (AIU) are available in MEIPASS. For step-by-step guidance, please review the AIU walkthrough or contact the support team at 877-646-5410 Option 2.

MEIPASS Availability

It is anticipated that MEIPASS will not be available during the summer while the system undergoes maintenance for Meaningful Use attestations for 2015 and beyond. Additional announcements about MEIPASS availability, including information about the extended deadline for 2015 Meaningful Use attestations, will be made via LISTSERV and the program website.

Questions? Contact hit@health.ny.gov for program clarifications and details.

Billing Policy for Transfers between Hospitals for Acute Services

Reminder

Medicaid regulations provide for the ability to transfer patients between an acute care facility reimbursed under the DRG case-based payment system, to another acute care facility reimbursed under this system, to ensure the most appropriate care for the patient. In order to reimburse hospitals appropriately, a transfer payment methodology was developed by the Department of Health. This method reimburses the transferring hospital for the services provided to a patient while under their care, while the receiving hospital is also reimbursed for services they provide while the patient is under their care.

For further Information regarding the transfer policy refer to the Inpatient Manual Policy Guidelines at the following website address:
https://www.emedny.org/ProviderManuals/Inpatient/Pdfs/Inpatient_Policy_Guidelines.pdf

For hospitals that undergo a merger with another hospital, the Department of Health is reminding providers that, once the individual hospitals are receiving a merged reimbursement rate that reflects a combination of the costs and statistics of the merged hospitals, transfer claims between the divisions receiving the merged rate can no longer be submitted for payment. Based on regulations, transfers between merged facilities are reimbursed as if the hospital that first admitted the patient also discharged the patient. Due to this transfer requirement, only one claim can be submitted for the merged entity which includes the diagnosis and procedure codes for the services performed at both hospitals; both hospitals cannot submit a claim.

If you have any questions regarding this policy, please submit an email to the Bureau of Acute and Managed Care Rate Setting at hospFFSunit@health.ny.gov.

New York State Medicaid Expansion of Allergy Testing

Effective June 1, 2016 for Medicaid Fee-For-Service (FFS) and August 1, 2016 for Medicaid Managed Care (MMC), the New York State Medicaid program will begin covering allergy testing under the parameters outlined below. Allergy testing may be necessary in the diagnosis and management of individuals with clinically significant allergic symptoms to identify the allergen(s) responsible for the symptoms.

General Background:

The most utilized types of allergy testing are in vivo (scratch, puncture, prick, intradermal and patch) and in vitro (blood-based) testing. In recognition that not all individuals are candidates for in vivo testing, Medicaid is expanding its allergy policy to include other methods of testing for these individuals.

Allergy testing should be performed only by licensed physicians who possess the competency to interpret results, manage possible adverse reactions and determine an appropriate course of treatment.

In vivo/In vitro Allergy Testing

Qualified physicians may now order in vitro allergy testing for Medicaid members where in vivo (skin) testing is not available for a particular allergen or for members who are unable to participate in traditional skin testing due to one or more of the following contraindications:

  • Extensive skin condition, such as psoriasis, severe eczema or symptomatic dermagraphism;
  • Inability to discontinue medications, such as antihistamines, that will affect test results;
  • Children age 3 years and younger.

Allergy testing (in vivo/in vitro) may be covered only for the following conditions:

  • Suspected food allergies;
  • Suspected stinging insect allergies;
  • Chronic rhinitis or conjunctivitis where the cause is suspected environmental allergies and the patient has been nonresponsive to avoidance and pharmacologic therapy;
  • Suspected medication allergy, when no alternative is available and treatment is medically necessary;
  • Suspected allergic dermatitis.

Oral Ingestion Challenge Testing

The addition of oral ingestion challenge testing may be medically necessary for those patients for whom a diagnosis of a food allergy or allergy to an oral drug has been inconclusive or inconsistent with clinical symptoms. In general, oral ingestion challenge testing should not be used as first-line testing for allergies. Oral ingestion challenge testing should only be performed in a carefully supervised allergy specialist setting, with emergency support immediately available. Oral ingestion challenge testing is a covered service when considered medically necessary to confirm a positive in vivo/in vitro test result or to test for an allergic response to:

  • Foods/ingested substances when in vivo/in vitro testing is inconclusive or inconsistent with clinical symptoms; or
  • Oral medications, when all of the following are met:
    • Patient has a history of allergy to a specified drug; and
    • There is no effective alternative or equivalent drug; and
    • Patient requires treatment with the drug class.

Reminders:

  • A complete physical exam and a detailed review of the patient's clinical history is expected prior to performing allergy testing.
  • Testing should be performed only by licensed physicians who possess the competency to interpret results, manage possible adverse reactions and determine an appropriate course of treatment.
  • Appropriate billing is the responsibility of all Medicaid providers and retrospective reviews may be conducted periodically through a Medicaid-funded utilization management contractor or the Office of the Medicaid Inspector General. The ordering physician must maintain sufficient documentation regarding the required patient history to clearly support the medical necessity of the test. In accordance with the New York Code of Rules and Regulations, 18 Nycrr 504.8 (a) (2); per 18 Nycrr 540.7 (a) (8), medical records must be maintained by providers for a period of not less than six years from the date of payment.
CPT code Description Number of tests eligible for reimbursement
in a 5 year period
(for members
that meet the criteria)
95004 Percutaneous tests (scratch, puncture, prick) with allergenic. extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests 60
95017 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests 60
95018 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests 60
95024 Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests 40
95027 Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report by a physician, specify number of tests 40
95028 Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading, specify number of tests 40
95044 Patch or application tests(s) (specify number of tests) 40
95076 Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); initial 120 minutes of testing As medically necessary
95079 Ingestion challenge test - each additional 60 minutes of testing (list separately in addition to code for primary procedure) As medically necessary
86003 Allergen specific IgE; quantative or semiquantative, each allergen 30

Questions regarding Medicaid FFS policy should be directed to the Division of Program Development and Management at(518) 473-2160 . Questions regarding MMC reimbursement and/or documentation requirements should be directed to the enrollee's MMC plan.

Updated Guidance and Clarification
on Use of the JW Modifier

The following article is to provide clarification and additional guidance associated with the use of the Jw modifier. Directions on required documentation and how to report drug units administered are provided in the italicized print.

The JW modifier is used to report the unused portion of a drug or biologic, appropriately discarded, from a single-use vial/package. Medicaid fee-for-service (FFS) will reimburse providers for the unused portion of single-use drugs or biologics, when the provider uses the JW modifier. Drug waste from multi-use vials/packages will not be reimbursed.

FFS Billing Guidance:

The provider must report both the portion of the drug that was administered along with the portion that was wasted. Payment will not exceed the maximum amount of the drug or biologic as indicated on the single-use vial or package's label. Note: The claim must include an amount that was administered in order for the wastage from the single-use vial/package to be billable.

This information should be reported on two lines:

  • Line one – HCPCS drug code and the number of units administered. Providers administering a portion of a unit are to round up to the nearest unit. If through rounding up to the nearest unit, the number of units reported on line one equals the total number units contained in the single-use vial/package, the JW modifier should not be reported.
  • Line two – HCPCS drug code appended with the JW modifier and the number of units not administered (discarded). When the units discarded are reported on line one (through rounding up to the nearest unit), they should not be reported again on line two.

Examples:

  • One billing unit is equal to 10 mg of a drug. A single-use vial contains 10 mg or one unit. A 7 mg dose is administered to a patient while 3 mg is discarded. The 7 mg dose is rounded up to 10 mg (one unit) and is reported on line one. Billing another unit on line two with the Jw modifier for the discarded 3 mg of drug is not permitted, because it would result in overpayment.
  • One billing unit is equal to 10 mg of a drug. A single-use vial contains 20 mg or two units. A 7 mg dose is administered to a patient while 13 mg are discarded. The 7 mg dose is rounded up to 10 mg or one unit. This is reported on line one. The additional 10 mg (one unit) that was discarded is reported on line two with the JW modifier.

Providers must clearly document in the medical record the amount of the single-use vial/package that was administered, the amount that was wasted, and the total amount that the vial/package contained. Failure to include this information could result in denial of the claim. The total number of units reported on lines one and two should not exceed the total number of units contained in the single dose vial/package.

Note: When submitting a paper claim, multiple drug procedure codes reported for the same date of service must be submitted on separate claim forms so that the J-code is reported on the first claim line of each claim.

For additional guidance, please see the December 2008 Medicaid Update article titled, “Billing Instructions for Physician-Administered Drugs (J-codes) Submitted on Paper Claims.”

For additional guidance on use of the JW modifier, please see the August 2015 Medicaid Update article titled, “Clarification of Policy for Practitioner, Ordered Ambulatory, and APG Reimbursement and New Billing Instructions for Wasted Drugs Using JW Modifier.”

Policy questions regarding Medicaid FFS may be directed to Office of Health Insurance Programs, Division of Program Development and Management at(518) 473-2160.

Questions regarding MMC billing and reimbursement should be directed to the enrollee's MMC Plan. Questions on billing or claims should be directed to CSC at 1-800-343-9000.

Elective Deliveries Prior to 39 Weeks Gestation
(Inductions of Labor and Cesarean Sections)

This article is an update to the June 2013, June 2014, April 2015, and April 2016 articles and supersedes all previously published guidelines.

Background:

The New York State Medicaid Redesign Team Basic Benefit Work Group's final recommendations include reducing payments for elective C-section deliveries and inductions of labor under 39 weeks gestation unless a documented medical indication is present. Evidence suggests that infants delivered prior to 39 weeks have an increased chance of complications and double the mortality rate of infants delivered at full term. Maternal concerns include an increased risk of infection, injury to reproductive and other organs and subsequent infertility, complications related to anesthesia, and difficulty with breast-feeding.

New York State Medicaid has been reducing payments for elective deliveries (C-section and induction of labor) less than 39 weeks gestation without an acceptable indication for Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC) enrollees.

Effective April 1 2016, claims for elective deliveries prior to 39 weeks gestation, without medical indication, were further reduced from 25% to 50% for Medicaid FFS. This further reduction will also be applicable to MMC effective July 1, 2016. The increased penalty reflects the Medicaid Program's commitment to providing high quality prenatal care by ensuring appropriate delivery for both mothers and babies. This penalty also applies to GME claims submitted on behalf of MMC members.

Appendix 1 in this article contains a list of ICD-10 acceptable diagnosis codes. These codes must be reported on the medical claim in the primary position as the principal diagnosis on the claim.

Introduction:

The Medicaid program has become aware of claiming issues related to early elective deliveries resulting from the ICD-10 transition in October 2015. To address these issues, the Department is providing updated guidance, including ICD-10 procedure codes and ICD-10 diagnosis codes, for billing obstetrical deliveries. For the purpose of Medicaid billing, an obstetrical delivery occurring at less than 39 weeks gestation is considered “preterm.”

Note: The ICD-10 diagnosis codes included in Appendix 1 apply to claims submitted for dates of service beginning October 1, 2015 forward.

Inpatient Hospital Claim Billing Guidance:

Elective C-sections or inductions of labor, whether prior to 39 weeks gestation or after 39 weeks gestation, require the use of a condition code (81, 82, or 83). If the delivery is the result of a spontaneous vaginal delivery after 39 weeks (and does not require augmentation of labor, result in a C-section delivery, or require artificial rupture of membranes), no condition code is reported on the claim as the procedure code is not included among those that require condition codes.

Table 1 in this article contains the ICD-10 procedure codes requiring a condition code regardless of gestational age.

Note: Only obstetrical deliveries involving either an induction of labor/augmentation of labor, artificial rupture of membranes, or C-sections require the use of a condition code. All other vaginal deliveries resulting from a spontaneous labor do not require the use of a condition code.

If any of the ICD-10 procedure codes in Table 1 are reported following spontaneous labor, please report with ICD-10 diagnosis code O60.10X0 (Preterm labor with preterm delivery, unspecified trimester, not applicable or unspecified) in the primary position as the principal diagnosis.

Note: Do not report code O60.10X0 if procedures listed in Table 1 have been completed as an elective induction of labor prior to 39 weeks gestation.

Failure to report a condition code (81, 82, or 83) for those ICD-10 procedure codes included in Table 1 will result in the claim being denied.

Condition Codes:

  • Condition code 81 - C-sections or inductions performed at less than 39 weeks gestation for medical necessity.
  • Condition code 82 - C-sections or inductions performed at less than 39 weeks gestation electively.
  • Condition code 83 - C-sections or inductions performed at 39 weeks gestation or greater.
Table 1: ICD-10 Procedure Codes Requiring a Condition Code
ICD-10 Procedure Code Description
10900ZC Drainage of amniotic fluid, therapeutic from products of conception, open approach
10903ZC Drainage of amniotic fluid, therapeutic from products of conception, percutaneous approach
10904ZC Drainage of amniotic fluid, therapeutic from products of conception, endoscopic approach
10907ZC Drainage of amniotic fluid, therapeutic, from products of conception, via natural or artificial opening
10908ZC Drainage of amniotic fluid, therapeutic from products of conception, via natural or artificial opening endoscopic
0U7C7ZZ Dilation of cervix, via natural or artificial opening
3E030VJ Introduction of other hormone into peripheral vein, open approach.
3E033VJ Introduction of other hormone into peripheral vein, percutaneous approach
3E0P7GC Introduction of other therapeutic substance into female reproductive, via natural or artificial opening
10D00Z0 Extraction of products of conception, classical open approach
10D00Z1 Extraction of products of conception, low cervical, open approach
10D00Z2 Extraction of products of conception, extraperitoneal, open approach

Practitioner Claim Billing Guidance:

Elective C-sections or inductions of labor, when reported with one of the procedure codes in Table 2, whether prior to 39 weeks gestation or after 39 weeks gestation, require the use of a modifier (U8 or U9). If the delivery is the result of a spontaneous labor after 39 weeks (and does not require augmentation of labor or result in a C-section), no modifier is required as the procedure code is not included in Table 2.
Medicaid FFS and MMC claims submitted by practitioners for the obstetric delivery procedure codes included in Table 2 will require a modifier.

Spontaneous labor resulting in a delivery less than 39 weeks gestation.

If the delivery occurs prior to 39 weeks gestation and the delivery (C-section or vaginal) occurs as a result of spontaneous labor, report modifier U8 and the claim will pay in full if the following ICD-10 diagnosis code is reported In The Primary Position: O60.10X0 - Preterm labor with preterm delivery

Table 2: Cpt Procedure Codes Requiring a Modifier
CPT Procedure Code Description
59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care.
59409 Vaginal delivery only (with or without episiotomy and/or forceps).
59410 Including postpartum care
59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care.
59514 Cesarean delivery only.
59515 Including postpartum care
59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps).
59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps).
59614 Including postpartum care
59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery
59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery.
59622 Including postpartum care

Practitioner claims for obstetric deliveries, when reported with one of the procedure codes in Table 2, must include one of the following modifiers:

  • U8 – delivery prior to 39 weeks gestation
  • U9 – delivery at 39 weeks gestation or later

Failure to include a U8 or U9 modifier, as appropriate, on a claim will result in denial of the claim.

Claim Denials:

If a practitioner and/or hospital claim is denied for payment due to lack of an appropriate condition code or modifier, please resubmit the claim with the appropriate modifier or condition code. Questions should be directed to the eMedNY Call Center at(800) 343–9000 .

Appeal Process:

  1. A 50% reduction in either the hospital inpatient claim or a practitioner claim may be appealed through the following process:
  2. Medicaid FFS practitioners or hospitals may request an appeal by contacting the Division of Program Development and Management at(518) 473–2160 .
  3. Medicaid FFS appeals will be referred to Island Peer Review Organization (IPRO) for review.
  4. A decision will be rendered by Ipro following clinical review. Providers will be asked to submit a written clinical justification, along with a medical record. If the appeal is upheld, no additional payment will be made. If the appeal is overturned, the claim will be re-adjudicated and payment will be restored to 100%.

A provider who wishes to appeal a payment reduction made by a MMC plan should contact the MMC plan to get details on the appeal process. Practitioners and hospitals are responsible for ensuring that the codes (and modifiers when applicable) submitted for reimbursement accurately reflect the diagnosis and procedure(s) that were reported. Post payment reviews may be conducted by the Office of the Medicaid Inspector General and/or through a Medicaid-funded utilization management contractor, as appropriate (pursuant to 18 Nycrr 504.8) on adjudicated claims. Medical records must be maintained by providers for a period of not less than six years from the date of payment.

Appendix 1: ICD-10 Acceptable Diagnosis Codes
L40.1 O29.293 O31.8X39 O35.1XX4 O35.9XX5 O36.1929 O36.5930 O40.2XX1 O41.1432 O46.093 O60.23X9
O10.03 O29.3X2 O32.0XX0 O35.1XX5 O35.9XX9 O36.1930 O36.5931 O40.2XX2 O41.1433 O46.8X2 O62.3
O10.112 O29.3X3 O32.0XX1 O35.1XX9 O36.0120 O36.1931 O36.5932 O40.2XX3 O41.1434 O46.8X3 O68
O10.113 O30.002 O32.0XX2 O35.2XX0 O36.0121 O36.1932 O36.5933 O40.2XX4 O41.1435 O60.10X0 O69.0XX0
O10.212 O30.003 O32.0XX3 O35.2XX1 O36.0122 O36.1933 O36.5934 O40.2XX5 O41.1439 O60.10X1 O69.0XX1
O10.213 O30.012 O32.0XX4 O35.2XX2 O36.0123 O36.1934 O36.5935 O40.2XX9 O42.012 O60.10X2 O69.0XX2
O10.312 O30.013 O32.0XX5 O35.2XX3 O36.0124 O36.1935 O36.5939 O40.3XX0 O42.013 O60.10X3 O69.0XX3
O10.313 O30.022 O32.0XX9 O35.2XX4 O36.0125 O36.1939 O36.62X0 O40.3XX1 O42.02 O60.10X4 O69.0XX4
O10.412 O30.023 O32.1XX0 O35.2XX5 O36.0129 O36.22X0 O36.62X1 O40.3XX2 O41.1020 O60.10X5 O69.0XX5
O10.413 O30.032 O32.1XX1 O35.2XX9 O36.0130 O36.22X1 O36.62X2 O40.3XX3 O41.1021 O60.10X9 O69.0XX9
O10.42 O30.033 O32.1XX2 O35.3XX0 O36.0131 O36.22X2 O36.62X3 O40.3XX4 O41.1022 O60.12X0 O69.4XX0
O10.43 O30.042 O32.1XX3 O35.3XX1 O36.0132 O36.22X3 O36.62X4 O40.3XX5 O41.1023 O60.12X1 O69.4XX1
O10.913 O30.043 O32.1XX4 O35.3XX2 O36.0133 O36.22X4 O36.62X5 O40.3XX9 O41.1024 O60.12X2 O69.4XX2
O11.2 O30.092 O32.1XX5 O35.3XX3 O36.0134 O36.22X5 O36.62X9 O41.02X0 O41.1025 O60.12X3 O69.4XX3
O11.3 O30.093 O32.1XX9 O35.3XX4 O36.0135 O36.22X9 O36.63X0 O41.02X1 O41.1029 O60.12X4 O69.4XX4
O12.12 O30.102 O32.2XX0 O35.3XX5 O36.0139 O36.23X0 O36.63X1 O41.02X2 O41.1030 O60.12X5 O69.4XX5
O12.13 O30.103 O32.2XX1 O35.3XX9 O36.0920 O36.23X1 O36.63X2 O41.02X3 O41.1031 O60.12X9 O69.4XX9
O12.22 O30.112 O32.2XX2 O35.4XX0 O36.0921 O36.23X2 O36.63X3 O41.02X4 O41.1032 O60.13X0 O71.02
O12.23 O30.113 O32.2XX3 O35.4XX1 O36.0922 O36.23X3 O36.63X4 O41.02X5 O41.1033 O60.13X1 O71.03
O14.02 O30.122 O32.2XX4 O35.4XX2 O36.0923 O36.23X4 O36.63X5 O41.02X9 O41.1034 O60.13X2 O75.82
O14.03 O30.123 O32.2XX5 O35.4XX3 O36.0924 O36.23X5 O36.63X9 O41.03X0 O41.1035 O60.13X3 O76
O14.12 O30.192 O32.2XX9 O35.4XX4 O36.0925 O36.23X9 O36.72X0 O41.03X1 O41.1039 O60.13X4 O77.0
O14.13 O30.193 O32.3XX0 O35.4XX5 O36.0929 O36.4XX0 O36.72X1 O41.03X2 O42.112 O60.13X5 O77.1
O14.22 O30.202 O32.3XX1 O35.4XX9 O36.0930 O36.4XX1 O36.72X2 O41.03X3 O42.113 O60.13X9 O77.8
O14.23 O30.203 O32.3XX2 O35.5XX0 O36.0931 O36.4XX2 O36.72X3 O41.03X4 O42.12 O60.14X0 O80
O14.92 O30.212 O32.3XX3 O35.5XX1 O36.0932 O36.4XX3 O36.72X4 O41.03X5 O42.912 O60.14X1 O88.212
O14.93 O30.213 O32.3XX4 O35.5XX2 O36.0933 O36.4XX4 O36.72X5 O41.03X9 O42.913 O60.14X2 O88.213
O15.02 O30.222 O32.3XX5 O35.5XX3 O36.0934 O36.4XX5 O36.72X9 O41.1220 O42.92 O60.14X3 O88.22
O15.03 O30.223 O32.3XX9 O35.5XX4 O36.0935 O36.4XX9 O36.73X0 O41.1221 O43.012 O60.14X4 O88.32
O15.1 O30.292 O32.6XX0 O35.5XX5 O36.0939 O36.5120 O36.73X1 O41.1222 O43.013 O60.14X5 O88.312
O15.2 O30.293 O32.6XX1 O35.5XX9 O36.1120 O36.5121 O36.73X2 O41.1223 O43.021 O60.14X9 O88.313
O22.52 O30.802 O32.6XX2 O35.6XX0 O36.1121 O36.5122 O36.73X3 O41.1224 O43.022 O60.20X0 O88.82
O22.53 O30.803 O32.6XX3 O35.6XX1 O36.1122 O36.5123 O36.73X4 O41.1225 O43.023 O60.20X1 O88.812
O24.02 O30.812 O32.6XX4 O35.6XX2 O36.1123 O36.5124 O36.73X5 O41.1229 O44.02 O60.20X2 O88.813
O24.012 O30.813 O32.6XX5 O35.6XX3 O36.1124 O36.5125 O36.73X9 O41.1230 O44.03 O60.20X3 O98.712
O24.013 O30.822 O32.6XX9 O35.6XX4 O36.1125 O36.5129 O36.8120 O41.1231 O44.12 O60.20X4 O98.713
O24.913 O30.823 O34.21 O35.6XX5 O36.1129 O36.5130 O36.8121 O41.1232 O44.13 O60.20X5 O98.719
O26.43 O30.892 O34.522 O35.6XX9 O36.1130 O36.5131 O36.8122 O41.1233 O45.012 O60.20X9 O98.72
O26.613 O30.893 O34.523 O35.8XX0 O36.1131 O36.5132 O36.8123 O41.1234 O45.013 O60.22X1 O99.112
O26.62 O31.8X21 O35.0XX0 O35.8XX1 O36.1132 O36.5133 O36.8124 O41.1235 O45.022 O60.22X2 O99.113
O26.832 O31.8X22 O35.0XX1 O35.8XX2 O36.1133 O36.5134 O36.8125 O41.1239 O45.023 O60.22X3 O99.12
O26.833 O31.8X23 O35.0XX2 O35.8XX3 O36.1134 O36.5135 O36.8129 O41.1420 O45.092 O60.22X4 O99.412
O29.013 O31.8X24 O35.0XX3 O35.8XX4 O36.1135 O36.5139 O36.8130 O41.1421 O45.093 O60.22X5 O99.413
O29.112 O31.8X25 O35.0XX4 O35.8XX5 O36.1139 O36.5920 O36.8131 O41.1422 O45.8X2 O60.22X9 O99.42
O29.113 O31.8X29 O35.0XX5 O35.8XX9 O36.1920 O36.5921 O36.8132 O41.1423 O45.8X3 O60.23X0 O9A.112
O29.122 O31.8X31 O35.0XX9 O35.9XX0 O36.1921 O36.5922 O36.8133 O41.1424 O46.012 O60.23X1 O9A.113
O29.123 O31.8X32 O35.1XX0 O35.9XX1 O36.1922 O36.5923 O36.8134 O41.1425 O46.013 O60.23X2 O9A.12
O29.212 O31.8X33 O35.1XX1 O35.9XX2 O36.1923 O36.5924 O36.8135 O41.1429 O46.022 O60.23X3 Q79.3
O29.213 O31.8X34 O35.1XX2 O35.9XX3 O36.1924 O36.5925 O36.8139 O41.1430 O46.023 O60.23X4 Z37.1
O29.292 O31.8X35 O35.1XX3 O35.9XX4 O36.1925 O36.5929 O40.2XX0 O41.1431 O46.092 O60.23X5

Policy questions regarding Medicaid FFS may be directed to the Office of Health Insurance Programs, Division of Program Development and Management at(518) 473–2160 .

Questions on Medicaid FFS billing or claims should be directed to Csc at 1-800-343-9000.
Questions regarding MMC billing and reimbursement should be directed to the enrollee's MMC plan.

Transgender Related Care and Services Update

This article is an update to the June 2015 Medicaid Update article entitled, “New York State Medicaid Updates Regulations.” New York State Medicaid has amended its regulations at 18 Nycrr 505.2(l), effective April 27, 2016, to make the following changes:

  1. Gender reassignment surgery is covered for individuals 18 years and older who meet all criteria for surgery, regardless of whether the surgery will result in sterilization.
  2. Psychiatric nurse practitioners have been added to the list of health care professionals who may write either the first or the second letter recommending the patient for gender reassignment surgery.

As a reminder, physicians performing gender reassignment surgery must obtain, and retain in their records, letters from two New York State licensed health professionals recommending such surgery for the patient. One letter must be written by a New York State licensed psychiatrist, psychologist, or psychiatric nurse practitioner who has an ongoing relationship with the patient. The second letter may be written by a New York State licensed psychiatrist, psychologist, physician, psychiatric nurse practitioner, or licensed clinical social worker working within their scope of practice. The recommendation for surgery in each letter must be based on an independent assessment/evaluation of the individual.

At a minimum, these letters must establish that the individual:

  1. Has a persistent and well-documented case of gender dysphoria;
  2. Has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless hormone therapy is medically contraindicated or the individual is otherwise unable to take hormones;
  3. Has lived for 12 months in a gender role congruent with the individual's gender identity, and has received mental health counseling, as deemed medically necessary, during that time;
  4. Has no other significant medical or mental health conditions that would contraindicate gender reassignment surgery, or if so, that those conditions are reasonably well-controlled prior to surgery;
  5. Has the capacity to make a fully informed decision and to consent to treatment.

For complete billing guidance for gender reassignment surgery, please see the Physician-Surgery provider manual.

For questions regarding Medicaid fee-for-service policy, providers should contact the Division of Program Development and Management at(518) 473–2160 . For questions regarding Medicaid Managed Care (MMC), providers should contact the enrollee's MMC plan directly for implementation details.

Medicaid Pharmacy
Prior Authorization Programs Update

On April 27, 2016, the New York State Medicaid Drug Utilization Review Board (DURB) recommended changes to the Medicaid Fee-For-Service (FFS) pharmacy Prior Authorization (PA) programs. The Commissioner of Health has reviewed the recommendations of the Board and has approved changes to the Preferred Drug Program (PDP):

Effective May 26, 2016, PA requirements will change for some drugs in the Hepatitis C – Direct Acting Antivirals class:

  • Preferred Agents: ribavirin, Daklinza, Harvoni, Sovaldi, Technivie, Viekira Pak, Zepatier
  • Non-Preferred Agents: Copegus, Moderiba, Olysio, Rebetol, Ribapak, Ribasphere

In addition, the Hepatitis C – Direct Acting Antiviral clinical criteria has changed. Disease prognosis and severity has been eliminated. Remaining criteria includes:

  • FDA labeling and compendia supported use: Verification of diagnosis, genotype, dosing and duration, etc.
  • Prescriber experience and training
    • Prescribed by hepatologist, gastroenterologist, infectious disease specialist, transplant physician or health care practitioner experienced and trained in the treatment of HCV or a healthcare practitioner under the direct supervision of a listed specialist.
      And
    • Clinical experience is defined as the management and treatment of at least 10 patients with HCV infection in the last 12 months and at least 10 Hcv- related CME credits in the last 12 months.
      Or
    • Management and treatment of HCV infection in partnership (defined as consultation, preceptorship, or via telemedicine) with an experienced HCV provider who meets the above criteria.
  • Patient readiness and adherence: Evaluation by using scales or assessment tools readily available to healthcare practitioners at: http://www.integration.samhsa.gov/clinical-practice/screening-tools or https://prepc.org/ to determine a patient's readiness to initiate Hcv treatment, specifically drug and alcohol abuse potential.

Effective June 30, 2016, PA requirements will change for some drugs in the following classes:

  • Non-steroidal anti-inflammatory drugs (NSAIDS) – Prescription
  • Opioids – Long Acting
  • Antipsychotics - Injectable
  • Selective Serotonin Reuptake Inhibitors (Ssris)
  • Antibiotics - Topical
  • Fluoroquinolones – Otic
  • Antihistamines – Second Generation*
  • Beta-2 Adrenergic Agents – Inhaled Long-Acting
    •

*cetirizine OTC tablets will remain preferred due to a recent change in pricing as impacted by new Federal Upper Limits (FULs)

The PDP has also expanded to include an additional drug class. Non-preferred drugs in the following class will require PA: Acne Agents – Prescription, Topical

For more detailed information on the DURB, please refer to:

http://www.health.ny.gov/health_care/medicaid/program/dur/index.htm

Below is a link to the most up-to-date information on the Medicaid FFS Pharmacy PA Programs. This document contains a full listing of drugs subject to the Medicaid FFS Pharmacy Programs:

https://newyork.fhsc.com/downloads/providers/Nyrx_PDP_PDL.pdf
To obtain a PA, please contact the clinical call center at 1-877-309-9493. The clinical call center is available 24 hours per day, 7 days per week with pharmacy technicians and pharmacists who will work with you, or your agent, to quickly obtain a PA.

Medicaid enrolled prescribers can also initiate PA requests using a web-based application. PAXpress® is a web based pharmacy PA request/response application accessible through a button “PAXpress” located on eMedNY.org under the MEIPASS button.

Additional information, such as the Medicaid Standardized PA form and clinical criteria are available at the following websites:

http://www.nyhealth.gov or http://newyork.fhsc.com or http://www.eMedNY.org

Medicaid Fee-For-Service Providers
Dispense Brand Name Drug When Less Expensive Than Generic Program

Revised

Effective 05/26/2016, the following changes will be made to the Dispense Brand Name Drug when Less Expensive than Generic Program:

  • Imitrex Kit (pens and Cartridges) will be added to the program.
  • Ability Tablets*, Cymbalta and Renvela Tablets will be removed from the program.
*Ability Solution remains in the program

In conformance with State Education Law which intends that patients receive the lower cost alternative, brand name drugs included in this program:

  • Do not require 'Dispense as Written' (DAW) or 'Brand Medically Necessary' on the prescription.
  • Have a generic copayment.
  • Are paid at the Brand Name Drug reimbursement rate or usual and customary price, whichever is lower (Smac/Ful are not applied).
  • Do not require a new prescription if the drug is removed from this program.

Important Billing Information

Prescription claims submitted to the Medicaid program do not require the submission of Dispense as Written/Product Selection Code of '1'; Pharmacies can submit any valid NCPDP field (408-D8) value.

List of Brand Name Drugs included in this program* (Updated): 05/16/2016

  • Ability Solution
  • Adderall XR
  • Aggrenox
  • Aldara
  • Alphagan P 0.15%
  • Astepro
  • Baraclude
  • Catapres-TTS
  • Cellcept suspension
  • Combivir
  • Copaxone 20ml SQ
  • Diastat
  • Epivir HBV tablet
  • Exelon Patch
  • Focalin XR 5mg, 10mg, 15mg,20mg,30mg,40mg
  • Gabitril 2mg, 4mg
  • Gleevec
  • Hepsera
  • Imitrex Kit (pens and Cartridges)
  • Kapvay
  • Mepron
  • Myfortic
  • Nasonex
  • Niaspan
  • Patanase
  • Protopic
  • Pulmicort Respules
  • Soriatane
  • Tegretol XR
  • Tegretol suspension
  • Tobradex suspension
  • Tricor
  • Trilipix
  • Trizivir
  • Valcyte
  • Voltaren Gel
  • Xeloda
  • Xenazine

*List is subject to change

Please keep in mind that drugs in this program may be subject to prior authorization requirements of other pharmacy programs, promoting the use of the most cost-effective product.

Provider Directory

Office of the Medicaid Inspector General:
For suspected fraud complaints/allegations, call 1-877-87FRAUD, (877) 873-7283, or visit www.omig.ny.gov.

Provider Manuals/Companion Guides, Enrollment Information/Forms/Training Schedules:
Please visit the eMedNY website at: www.emedny.org.

Providers wishing to listen to the current week's check/EFT amounts:
Please call (866) 307-5549 (available Thursday PM for one week for the current week's amount).

Do you have questions about billing and performing MEVS transactions?
Please call the eMedNY Call Center at (800) 343-9000.

Provider Training:
To sign up for a provider seminar in your area, please enroll online at: http://www.emedny.org/training/index.aspx. For individual training requests,call (800) 343-9000.

Enrollee Eligibility:
Call the Touchtone Telephone Verification System at (800) 997-1111.

Medicaid Prescriber Education Program:
For current information on best practices in pharmacotherapy, please visit the following websites: http://www.health.ny.gov/health_care/medicaid/program/prescriber_education/presc-educationprog
http://nypep.nysdoh.suny.edu/home

Need to change your address? Does your enrollment file need to be updated because you have experienced a change in ownership? Do you want to enroll another NPI? Did you receive a letter advising you to revalidate your enrollment?
Visit http://www.emedny.org/info/ProviderEnrollment/index.aspx and choose the link appropriate for you (e.g., physician, nursing home, dental group, etc.).

Medicaid Electronic Health Record Incentive Program questions?
Contact the New York Medicaid EHR Call Center at (877) 646-5410 for assistance.

Comments and Suggestions Regarding This Publication?
Please contact the editor, Amy Siegfried, at medicaidupdate@health.ny.gov

The Medicaid Update is a monthly publication of the New York State Department of Health.

Andrew M. Cuomo
Governor
State of New York

Howard A. Zucker, M.D., J.D.
Commissioner
New York State Department of Health

Jason A. Helgerson
Medicaid Director
Office of Health Insurance Programs