January 2007 Medicare Bulletin - North Carolina Insert
Posted January 5, 2007
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Table of Contents
- 2007 Chiropractic Fee Schedule – North Carolina
- 2007 North Carolina Ambulance Fee Schedule
- 2007 North Carolina Medicare Clinical Psychologist Fee Schedule
- 2007 North Carolina Medicare Clinical Social Worker Fee Schedule
- Botox (Type A)
- North Carolina’s ASC Facility Adjusted Rate Effective 01/01/2007
- North Carolina Health Professionals Shortage Areas (HPSAs)
- North Carolina Mental Health Professional Shortage Areas (HPSAs)
- North Carolina– 2007 OPPS Payment Cap Amounts For The TC And Global Portion Of Imaging Services
- Utilization of Modifier 59 with Regards to Chemotherapy
Top2007 North Carolina Ambulance Fee Schedule
| CODE | URBAN RATE | RURAL RATE |
| A0425 | $6.25 | $6.25 |
| A0426 | $220.57 | $220.57 |
| A0427 | $349.23 | $349.23 |
| A0428 | $183.80 | $183.80 |
| A0429 | $294.09 | $294.09 |
| A0430 | $2,535.52 | $3,803.28 |
| A0431 | $2,947.92 | $4,421.87 |
| A0432 | $321.66 | $321.66 |
| A0433 | $505.46 | $505.46 |
| A0434 | $597.37 | $597.37 |
| A0435 | $7.49 | $11.24 |
| A0436 | $19.96 | $29.94 |
2007 Chiropractic Fee Schedule – North Carolina
| Code | PAR F/S | NON PAR F/S | Limiting Charge |
| 98940 | 23.43 | 22.26 | 25.60 |
| # 98940 | 19.59 | 18.61 | 21.40 |
| 98941 | 32.35 | 30.73 | 35.34 |
| # 98941 | 28.16 | 26.75 | 30.76 |
| 98942 | 42.62 | 40.49 | 46.56 |
| # 98942 | 38.07 | 36.17 | 41.60 |
| 98943 | NC | NC | NC |
# These amounts apply when service is performed in a facility setting.
Limiting charge applies to unassigned claims by non-participating providers.
NC indicates that the service is non-covered by Medicare.
© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted by the American Medical
Association.
2007 North Carolina Medicare Clinical Social Worker Fee Schedule
| Procedure Code | Non-Facility Fee | Facility Fee |
| 90801AJ | $105.46 | $94.97 |
| 90802AJ | $111.83 | $101.87 |
| * 90804AJ | $44.88 | $40.43 |
| * 90806AJ | $65.48 | $62.07 |
| * 90808AJ | $97.05 | $93.38 |
| * 90810AJ | $47.90 | $44.50 |
| * 90812AJ | $70.68 | $65.96 |
| * 90814AJ | $101.99 | $98.06 |
| * 90816AJ | $43.64 | $43.64 |
| * 90818AJ | $65.54 | $65.54 |
| * 90821AJ | $97.40 | $97.40 |
| * 90823AJ | $47.00 | $47.00 |
| * 90826AJ | $69.64 | $69.64 |
| * 90828AJ | $101.01 | $101.01 |
| * 90845AJ | $60.37 | $59.32 |
| *# 90846AJ | $63.86 | $63.34 |
| *# 90847AJ | $78.42 | $75.54 |
| *# 90849AJ | $22.76 | $21.45 |
| * 90853AJ | $22.06 | $21.01 |
| * 90857AJ | $24.50 | $22.67 |
| * 90880AJ | $81.00 | $73.14 |
| 96102AJ | $33.94 | $16.90 |
| 96103AJ | $26.27 | $17.36 |
| 96105AJ | $51.18 | $51.18 |
| 96110AJ | $7.94 | $7.94 |
| 96111AJ | $94.89 | $93.84 |
| 96119AJ | $47.29 | $21.61 |
| 96120AJ | $40.69 | $17.36 |
* The procedure code is subject to the 62.5% outpatient psychiatric payment limitation (i.e., the allowed amount is reduced to 62.5% of the allowable amount).
# The procedure code has a restricted coverage status. Documentation must be included in order to review for coverage.
© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted by the American Medical Association.
2007 North Carolina Medicare Clinical Psychologist Fee Schedule
| Procedure Code | Non Facility Fee | Facility Fee |
| 90801AH | $140.61 | $126.63 |
| 90802AH | $149.10 | $135.82 |
| * 90804AH | $59.84 | $53.90 |
| * 90806AH | $87.31 | $82.76 |
| * 90808AH | $129.40 | $124.51 |
| * 90810AH | $63.87 | $59.33 |
| * 90812AH | $94.24 | $87.95 |
| * 90814AH | $135.99 | $130.74 |
| * 90816AH | $58.19 | $58.19 |
| * 90818AH | $87.39 | $87.39 |
| * 90821AH | $129.87 | $129.87 |
| * 90823AH | $62.67 | $62.67 |
| * 90826AH | $92.85 | $92.85 |
| * 90828AH | $134.68 | $134.68 |
| * 90845AH | $80.49 | $79.09 |
| *# 90846AH | $85.15 | $84.45 |
| *# 90847AH | $104.56 | $100.72 |
| *# 90849AH | $30.35 | $28.60 |
| * 90853AH | $29.41 | $28.01 |
| * 90857AH | $32.67 | $30.23 |
| * 90880AH | $108.00 | $97.52 |
| 96101AH | $84.75 | $84.05 |
| 96102AH | $45.25 | $22.53 |
| 96103AH | $35.03 | $23.15 |
| 96105AH | $68.24 | $68.24 |
| 96110AH | $10.59 | $10.59 |
| 96111AH | $126.52 | $125.12 |
| 96116AH | $94.14 | $88.20 |
| 96118AH | $111.26 | $87.15 |
| 96119AH | $63.05 | $28.81 |
| 96120AH | $54.25 | $23.15 |
* The procedure code is subject to the 62.5% outpatient psychiatric payment limitation (i.e., the allowed amount is reduced to 62.5% of the allowable amount).
# The procedure code has a restricted coverage status. Documentation must be included in order to review for coverage.
© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted by the American Medical Association.
North Carolina’s ASC Facility Adjusted Rate Effective 01/01/2007
The following fees are the Adjusted ASC payment rates for the areas within North Carolina. These amounts were developed by following the instructions to carriers for wage adjusting the standard ASC payment rates. These instructions are in the CMS Manual Systems, Pub 100-04, Medicare Claims Processing Manual, Chapter 14, Section 40.2 (the Internet Only Manuals can be accessed at:
http://www.cms.hhs.gov/manuals/IOM/list.asp).
The standard ASC payment rates are found on the HCPCS ALL list on the CMS Web site at: www.cms.hhs.gov/apps/ama/license.asp?file=/ascpayment/downloads/07asc_hcpcs.zip
Botox (Type A)
The Medi/Medi Data Project Team for North Carolina recently conducted a study on Current Procedural Terminology (CPT) J0585 (Botox Botulinum Toxin [Type A]). This study included proactive data analysis, several provider onsite audits and interviews involving providers billing Medicare for J0585. This study also included North Carolina providers that specialize in ophthalmology, neurology, physical medicine and rehabilitation, and internal medicine that billed Current Procedural Terminology Code (CPT) J0585 for dates of service in 2004 and 2005; Medicare paid the North Carolina providers a total of $3,573,999 for J0585.
According to LCD for Botulinum Toxin (L13109), for providers to use the injection J0585 for treatment of “migraines,” there should be documentation stating that they have tried at least three (3) other failed trials, (such as beta blockers, calcium channel blockers, anticonvulsants, antidepressants). They should also have documentation that the patients experience headaches that may result in permanent cerebral dysfunction, or who are intractable because they cannot tolerate or do not benefit from standard therapies. For “spastic conditions,” “before consideration of coverage can be made, it should be established that the patient(s) has been unresponsive to conventional methods of treatments such as medication, physical therapy and other appropriate methods used to control and/or treat spastic conditions.” From our review of medical records, it was determined that some providers may not be adhering to this policy. The J0585 is utilized as the initial treatment instead of following the LCD.
Documentation requirements include the following elements:
- support for the medical necessity of the Botulinum toxin injection,
- a covered diagnosis.
- a statement that traditional methods of treatments have been tried and proven unsuccessful.
- dosage and frequency of injections
- support for the medical necessity of electromyography procedures
- support of the clinical effectiveness of the injections
- specify the site(s) injected
During the Medi/Medi Data Project Team provider onsite audits, it was determined that providers are performing cosmetic Botox injections. The Social Security Act § 1862 (a)(1)(A) [42 U.S.C. § 1395 Y (a)(1)(A)] states, “[N]o payment may be made under part A or part B…for any expenses incurred for items or services – which…are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
Utilization of Modifier 59 with Regards to Chemotherapy
The Medicare/Medicaid Data Project Team for North Carolina recently completed a medical records review and identified the inappropriate use of modifier 59 (distinct procedural service) in regards to chemotherapy services. The following information details the correct use of the modifier 59 for chemotherapy services.
Chapter 12, Section 30.5 of the Medicare Claims Processing Manual identifies billing guidelines for chemotherapy. These guidelines state the following:
If more than one “initial” service code is billed per day, the carrier shall deny the second initial service code unless the patient has to come back for a separately identifiable service on the same day or has two IV lines per protocol. For these separately identifiable services, instruct the physician to report with modifier 59.
The CPT includes a code for a concurrent infusion in addition to an intravenous infusion for therapy, prophylaxis or diagnosis. Allow only one concurrent infusion per patient per encounter. Do not allow payment for the concurrent infusion billed with modifier 59 unless it is provided during a second encounter on the same day with the patient and is documented in the medical record.
For more information regarding appropriate chemotherapy billing guidelines, please reference the following resource: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf
North Carolina– 2007 OPPS Payment Cap Amounts For The TC And Global Portion Of Imaging Services
North Carolina– 2007 OPPS Payment Cap Amounts For The TC And Global Portion Of Imaging Services
North Carolina Mental Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
|
1 Classified as a Mental Health HPSA, Effective February 2, 2005
2 Classified as a Mental Health HPSA, Effective June 30, 2005
3Classified as a Mental Health HPSA, Effective September 8, 2006
North Carolina Health Professional Shortage Areas (HPSAs)
Designated Geographic Areas
|
1 No longer classified as a HPSA, effective August 1, 2002.
2 Classifed as a HPSA, effective June 1, 2004.
3 No longer classified as a HPSA, effective December 1, 2004.
4No longer classified as a HPSA, effective September 8, 2006
