Section II - Arkansas Medicaid
Podiatrist Section II
SECTION II - PODIATRIST
CONTENTS
PODIATRIST GENERAL INFORMATION
Arkansas Medicaid Participation Requirements for Podiatrists
Participation Requirements for Individual Podiatrists
Group Providers of Podiatrists’ Services
Podiatrists in Arkansas and Bordering States
Podiatrists in States Not Bordering Arkansas
Podiatrist’s Role in the Pharmacy Program
Medicare Mandatory Assignment of Claims for Physician’s Services
Role in the Child Health Services (EPSDT) Program
Clinical Laboratory Improvement Amendments (CLIA) Implementation
Medical Visits and Surgical Services
Procedure for Obtaining Extension of Benefits for Podiatry Services
AFMC Extension of Benefits Review Process
Administrative Reconsideration of Extension of Benefits Denial
Prior Authorization through the Arkansas Foundation for Medical Care, Inc. (AFMC)
Procedure for Requesting Prior Authorization
Approvals and Denials of Prior Authorization Requests
Procedure Codes Payable in a Nursing Care Facility
Procedure Codes Requiring Prior Authorization
Procedure Codes Payable for Laboratory and X-Ray Services
Podiatrist National Place of Service Codes
National Place of Service Codes
Billing Instructions —Paper Only
Completion of CMS-1500 Claim Form
Completion of Forms for Medicare/Medicaid Deductible and Coinsurance
Section II-1
Podiatrist
Services Prior to Medicare Entitlement
Services Not Medicare Approved
National Drug Code Billing Protocols
200.000 PODIATRIST GENERAL INFORMATION
Section II
201.000 Arkansas Medicaid Participation Requirements for Podiatrists
201.001 Electronic Signatures 10-8-10
Medicaid will accept electronic signatures provided the electronic signatures comply with
Arkansas Code § 25-31-103 et seq.
201.100 Participation Requirements for Individual Podiatrists 7-15-11
Podiatrists must meet the Provider Participation and enrollment requirements contained within
Section 140.000 of this manual as well as the following criteria to be eligible to participate in the
Arkansas Medicaid Program:
A. A provider must be licensed to practice podiatry services in his or her state.
B. A copy of the current state license must accompany the provider application packet.
C. In order for Arkansas Medicaid to pay for services provided to an Arkansas Medicaid beneficiary who is dually eligible for Medicare and Medicaid, and is provided services that are not covered by both Medicare and Medicaid, the provider must first bill Medicare. The
Omnibus Budget Reconciliation Act of 1989 requires the mandatory assignment of
Medicare claims for services provided by podiatrists. Podiatrists must submit their
Medicare provider number to Arkansas Medicaid to ensure the Medicare claims will electronically cross over. To enroll and accept assignment in the Title XVIII – Medicare
Program, see Section 202.000.
D. The provider must submit Clinical Laboratory Improvement Amendments (CLIA) certification, if applicable. (Section 205.000 contains information regarding CLIA certification.)
201.200 Group Providers of Podiatrists’ Services 10-15-09
Group providers of podiatric services must meet the following criteria in order to be eligible for participation in the Arkansas Medicaid Program.
If a podiatrist is a member of a group, each individual podiatrist and the group must both enroll according to the following criteria:
A. Each individual podiatrist within the group must enroll following the criteria established in
Section 201.100.
B. All group providers are “pay to” providers only. The service must be performed and billed by a Medicaid-enrolled licensed podiatrist with the group.
201.300 Podiatrists in Arkansas and Bordering States 12-15-14
Podiatrists in Arkansas and the six bordering states (Louisiana, Mississippi, Missouri,
Oklahoma, Tennessee and Texas) may be enrolled as routine services providers if they meet all
Arkansas Medicaid participation requirements outlined in Section 201.100.
Routine Services Providers
Section II-2
Podiatrist
A. Routine services providers may be enrolled in the program as providers of routine services.
Section II
B. Reimbursement may be available for all podiatrist services covered in the Arkansas
Medicaid Program.
C. Claims must be filed according to Section II of this manual. This includes assignment of
ICD and HCPCS codes for all services rendered.
201.400 Podiatrists in States Not Bordering Arkansas 3-1-11
A. Providers in states not bordering Arkansas may enroll in the Arkansas Medicaid program as limited services providers only after they have provided services to an Arkansas
Medicaid eligible beneficiary and have a claim or claims to file with Arkansas Medicaid.
To enroll, a non-bordering state provider must download an Arkansas Medicaid application and contract from the Arkansas Medicaid website and submit the application, contract and claim to Arkansas Medicaid Provider Enrollment. A provider number will be assigned upon approval of the provider application and the Medicaid contract. View or print the provider enrollment and contract package (Application Packet ).
View or print
Medicaid Provider Enrollment Unit contact information.
B. Limited services providers remain enrolled for one year.
1. If a limited services provider provides services to another Arkansas Medicaid beneficiary during the year of enrollment and bills Medicaid, the enrollment may continue for one year past the most recent claim’s last date of service, if the enrollment file is kept current.
2. During the enrollment period, the provider may file any subsequent claims directly to the Medicaid fiscal agent.
3. Limited services providers are strongly encouraged to file subsequent claims through the Arkansas Medicaid website because the front-end processing of web-based claims ensures prompt adjudication and facilitates reimbursement.
201.600 Podiatrist’s Role in the Pharmacy Program 12-18-15
PRESCRIPTION DRUG INFORMATION
Medicaid covers prescription drugs in accordance with policies and regulations set forth in this section and pursuant to orders (prescriptions) from authorized prescribers in relation to their specialty of practice. 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.
Prescribers may also refer to the website at https://arkansas.magellanrx.com/provider/documents/ to obtain the latest information regarding prescription drug coverage.
202.000 Medicare Mandatory Assignment of Claims for Physician’s Services 10-15-09
See Section 142.700 for detailed information regarding Medicare participation and Sections
332.000 through 332.300 for detailed information regarding Medicare-Medicaid Crossover Claim procedures.
Section II-3
Podiatrist Section II
NOTE: The podiatrist provider must notify the Provider Enrollment Unit of a Medicare identification number. View or print Provider Enrollment Unit contact information.
203.000 Documentation Requirements 10-15-09
Documentation and provider participation requirements are detailed within Section 140.000,
Provider Participation, of this manual. Documentation should consist of, at a minimum, material that includes:
A. History and physical examination.
B. Chief complaint on each visit.
C. Tests and results.
D. Diagnosis.
E. Treatment including prescriptions.
F. Signature or initials of podiatrist after each visit.
G. Copies of office, clinic, hospital and/or emergency room records that are available to disclose services.
H. Each record must reflect date of visit when services were provided.
204.000 Role in the Child Health Services (EPSDT) Program 10-13-03
The Child Health Services (EPSDT) Program is a federally mandated child health component of
Medicaid. It is designed to bring comprehensive health care to individuals eligible for medical assistance from birth up to their 21 st birthday. The purpose of this program is to detect and treat health problems in the early stages and to provide preventive health care, including necessary immunizations. Child Health Services (EPSDT) combines case management and support services with screening, diagnostic and treatment services delivered on a periodic basis.
If a condition is diagnosed through a Child Health Services (EPSDT) screen that requires treatment services not normally covered under the Arkansas Medicaid Program, those treatment services will also be considered for reimbursement if the service is medically necessary and permitted under federal Medicaid regulations.
For more information regarding the EPSDT program, providers may view the Child Health
Services (EPSDT) Manual.
205.000 Clinical Laboratory Improvement Amendments (CLIA)
Implementation
10-13-03
Medicaid implemented the Clinical Laboratory Improvement Amendments (CLIA) to edit claims for:
A. Laboratories that do not have a CLIA certificate,
B. Laboratories submitting claims for services not covered by their CLIA certificate and
C. Laboratories submitting claims for services rendered outside the effective dates of the
CLIA certificate.
There are no special billing requirements related to the CLIA implementation. The claims processing system will edit laboratory procedure codes against the billing provider’s Medicaid
Section II-4
Podiatrist Section II enrollment file. Claims will be edited in accordance with the criteria listed in A, B and C above.
If these requirements are not met, claims will automatically deny.
210.000 PROGRAM COVERAGE
211.000 Introduction 10-1-08
A. The Arkansas Medicaid Program reimburses enrolled providers for the program covered medical care of eligible 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. View or print the Glossary.
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 any of the following: a. Medical Director for the Medicaid Program b. Quality Improvement Organization (QIO) c. Peer Review Committee for the Medicaid Program
212.000 Scope 10-1-08
A. The Arkansas Medicaid Program covers podiatrist services through 42 Code of Federal
Regulations, Section 440.60.
B. Arkansas Medicaid covers podiatrist services for eligible Medicaid beneficiaries of all ages.
C. Podiatrist services require a primary care physician (PCP) referral.
D. Podiatrist services include, but are not limited to, office and outpatient services, home visits, office and inpatient consultations, laboratory and X-ray services, physical therapy and surgical services. Section 242.100 contains the full list of procedure codes applicable to podiatry services.
E. Many podiatrist services covered by the Arkansas Medicaid Program are restricted or limited.
1. Section 214.000 describes the benefit limits on the quantity of covered services clients may receive.
2. Section 220.000 describes prior-authorization requirements for certain services.
212.100 Assistant Surgeon 1-1-05
The Arkansas Medicaid Program does not cover assistant surgeon services in the podiatry program.
3-15-14 213.000
213.100
Reserved
Reserved 3-15-14
Section II-5
Podiatrist Section II
213.200 Reserved 3-15-14
214.000 Benefit Limits 1-1-06
Medicaid-eligible patients are responsible for payment for services beyond the established benefit limits, unless the Division of Medical Services (DMS) contractor authorizes an extension of a particular benefit. If a Medicaid-eligible patient elects to receive a service for which DMS contractor has denied a benefit extension or for which DMS contractor subsequently denies a benefit extension, the patient is responsible for payment. View or print the AFMC contact information.
214.100 New Patient Visit 10-1-08
Providers are allowed to bill one new patient visit procedure code per beneficiary, per attending provider in a three (3) year period.
214.200 Medical Visits and Surgical Services 10-1-08
The Arkansas Medicaid Program covers two medical visits per state fiscal year (July 1 through
June 30) for medical services provided by a podiatrist in an office, a beneficiary’s home or in a nursing facility for eligible beneficiaries age 21 and over. Benefit extensions may be granted in cases of documented medical necessity.
Medical visits for individuals under the age of 21 in the Child Health Services (EPSDT) Program do not have a benefit limit.
Surgical services provided by a podiatrist are not included in the two visits per state fiscal year
(SFY) benefit limit for individuals age 21 and over.
214.300 Laboratory and X-Ray Services 10-13-03
Laboratory and X-ray services provided by a podiatrist will be included in the $500 per state fiscal year benefit limit for outpatient laboratory services, radiology services and machine tests for individuals age 21 and over. There is no benefit limit for individuals under age 21. Benefit extensions may be granted in cases of documented medical necessity. Section 242.130 contains procedure codes payable for laboratory and X-ray services.
215.000 Extension of Benefits
Benefit extensions may be requested in the following situations:
A. Extension of Benefits for Medical Visits
10-1-15
Extensions of benefits may be requested for medical visits that exceed the two visits per state fiscal year (SFY) for individuals age 21 and over with documented medical necessity provided along with the request.
B. Extension of Benefits for Laboratory and X-Ray Services
Extension of the benefit limit for laboratory and X-ray services may be granted for individuals age 21 and over when documented to be medically necessary.
NOTE: The Arkansas Medicaid Program exempts the following diagnoses from the extension of benefit requirements when the diagnosis is entered as the primary diagnosis: Malignant Neoplasm (View ICD codes.) ; HIV Infection, including AIDS (View ICD codes.) and renal failure (View ICD codes.) .
Section II-6
Podiatrist Section II
215.100 Procedure for Obtaining Extension of Benefits for Podiatry Services 11-1-09
A. Requests for extension of benefits for podiatry services for beneficiaries over age 21 must be mailed to the Arkansas Foundation for Medical Care, Inc. (AFMC). View or print the
Arkansas Foundation for Medical Care, Inc., contact information.
A request for extension of benefits must meet the medical necessity requirement, and adequate documentation must be provided to support this request.
1. Requests for extension of benefits are considered only after a claim is denied because a benefit is exhausted/exceeds benefit limit.
2. The request for extension of benefits must be received by AFMC within 90 calendar days of the date of the benefits-exhausted denial. The count begins on the next working day after the date of the Remittance and Status Report (RA) on which the benefits-exhausted denial appears.
3. Submit with the request a copy of the Medical Assistance Remittance and Status
Report reflecting the claim’s denial for exhausted benefits. Do not send a claim.
4. AFMC will not accept extension of benefits requests sent via e-mail or electronic facsimile (FAX).
C.
B. Use form DMS-671, Request for Extension of Benefits for Clinical, Outpatient, Laboratory and X-Ray Services, to request extension of benefits for podiatry services. View or print form DMS-671.
Consideration of requests for extension of benefits requires correct completion of all fields on this form. The instructions for completion of this form are located on the b ack of the form. The provider’s signature (with his or her credentials) and the date of the request are required on the form. Stamped or electronic signatures are accepted. All applicable records that support the medical necessity of the extended benefits request should be attached.
AFMC will approve or deny an extension of benefits request – or ask for additional information – within 30 calendar days of their receiving the request. AFMC reviewers will simultaneously advise the provider and the beneficiary when a request is denied.
215.110 Documentation Requirements 5-1-06
A. To request extension of benefits for any benefit limited service, all applicable records that support the medical necessity of extended benefits are required.
B. Documentation requirements are as follows.
1. Clinical records must: a. Be legible and include records supporting the specific request b. Be signed by the performing provider c. Include clinical, outpatient and/or emergency room records for dates of service in chronological order d. Include related diabetic and blood pressure flow sheets e. Include current medication list for date of service f. Include obstetrical record related to current pregnancy g. Include clinical indication for laboratory and x-ray services ordered with a copy of orders for laboratory and x-ray services signed by the physician
2. Laboratory and radiology reports must include: a. Clinical indication for laboratory and x-ray services ordered b. Signed orders for laboratory and radiology services c. Results signed by performing provider
Section II-7
Podiatrist Section II d. Current and all previous ultrasound reports, including biophysical profiles and fetal non-stress tests
215.115 AFMC Extension of Benefits Review Process
The following is a step-bystep outline of AFMC’s extension of benefits review process:
11-1-09
A. Requests received via mail are screened for completeness and researched to verify the beneficiary’s eligibility for Medicaid when the service was provided and to verify the claim’s denial for benefits exhausted/exceeded.
B. The documentation submitted is reviewed by a registered nurse (R.N.). If, in the judgment of the R.N., the documentation supports medical necessity, they may approve the request.
An approval letter is generated and mailed to the provider the following day.
C. If the R.N. review determines the documentation does not justify the service or it appears that the service is not medically necessary, they will refer the case to the appropriate physician advisor for a decision.
D. The physician advisor’s rationale for approval or denial is entered into the data system and the appropriate notification is created. If services are denied for medical necessity, the physician advisor’s reason for the decision is included in the denial letter. A denial letter is mailed to the provider and the beneficiary the following work day.
E. Providers may request administrative reconsideration of an adverse decision or appeal as provided in Section 190.003 of this manual.
F. If the denial is due to incomplete documentation, and complete documentation, that supports medical necessity, is submitted with the reconsideration request, the R.N. may approve the extension of benefits without referral to a physician advisor.
G. If the denial is due to lack of proof of medical necessity or the documentation does not allow for approval by the R.N., the original documentation, reason for denial and new information submitted will be referred to a different physician advisor for reconsideration.
H. All parties will be notified in writing of the outcome of the reconsideration.
215.120 Administrative Reconsideration of Extension of Benefits Denial 5-1-06
A request for administrative reconsideration of an extension of benefits denial 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 and will not be accepted via facsimile or email.
215.130 Appealing an Adverse Action
Please see Section 190.003 for information regarding administrative appeals.
220.000 PRIOR AUTHORIZATION
5-1-06
There are certain surgical procedures and medical services and procedures that are not reimbursable without prior authorization, either because of federal requirements or because of the nature of the service.
Section II-8
Podiatrist Section II
The Arkansas Medicaid Program contracts with the Arkansas Foundation for Medical Care, Inc.,
(AFMC) to perform prior authorizations for several medical and/or surgical procedures. Certain procedures are restricted to the outpatient setting unless prior authorized by AFMC for inpatient services. Other services may only be billed when performed in a nursing home or skilled nursing facility setting.
Section 242.120 contains the list of all procedure codes that require prior authorization.
221.000 Prior Authorization through the Arkansas Foundation for Medical
Care, Inc. (AFMC)
10-13-03
Prior authorization determinations are made by the Arkansas Foundation for Medical Care, Inc.,
(AFMC) by utilizing established medical or administrative criteria combined with the professional judgment of AFMC’s physician advisors. Payment of services is made to participating providers in accordance with federal regulations.
Written documentation is not required for the prior authorization request. However, medical record documentation and reports must substantiate the oral information given to AFMC by a provider.
221.100 Procedure for Requesting Prior Authorization 4-1-07
It is the responsibility of the podiatrist to initiate the prior authorization request. The podiatrist or his or her office nurse must contact AFMC to request prior authorization. View or print AFMC contact information.
To request authorization, call AFMC at 1-800-426-2234, between the hours of 8:30 a.m.-12:00 noon and 1:00 p.m.-5:00 p.m., Monday through Friday, with the exception of holidays.
CPT codes that require prior authorization by AFMC are located in Section 242.120 of this manual.
A. When calling AFMC to perform a review for medical necessity of a prior authorization procedure, the following information will be required: (All calls will be tape-recorded for quality assurance purposes.)
1. Patient name and address (including ZIP code)
2. Patient birth date
3. Patient Medicaid identification number
4. Podiatrist name and license number
5. Podiatrist provider identification number
6. Hospital or ambulatory surgery center name
7. Date of service for requested procedure
8. Facility provider identification number
9. CPT code for procedure(s)
10. Principal diagnosis and any other diagnoses
11. Signs/symptoms of illness
12. Medical indication for justification of procedure(s)
B. All patient identification information and medical information related to the necessity of the procedure must be provided for services to be authorized.
221.200 Approvals and Denials of Prior Authorization Requests 7-1-07
Section II-9
Podiatrist
AFMC will give approval or denial of the PA request by phone with a follow-up in writing.
Section II
A. If approved, AFMC will assign a prior authorization control number that must be entered in the appropriate field in the CMS-1500 claim format when billing for the procedure.
B. If surgery is involved, a copy of the prior authorization will be mailed to the hospital where the service will be performed. If the hospital has not received a copy of the authorization before the time of admission, the hospital will contact the admitting podiatrist or AFMC to verify that prior authorization has been granted.
It is the responsibility of the primary podiatrist to distribute a copy of the authorization to the anesthesiologist and the assistant podiatrist if the assistant has been requested and approved.
C. The prior authorization control number must be entered in the appropriate field in the
CMS-1500 claim format when billing for the procedure. The Medicaid Program will not pay for inpatient hospital services that require prior authorization if the prior authorization has not been requested and approved.
D. Consulting podiatrists must have a separate prior authorization and are responsible for calling AFMC to receive prior authorization for their procedures. They will be given a prior authorization number at the time of the call on those cases that are approved. A letter verifying the PA number will be sent to the consultant upon request.
Prior authorization of a service does not guarantee eligibility for a beneficiary. Payment is subject to verification that the beneficiary was eligible at the time the services were provided.
221.300 Post-Authorization 10-1-08
Post-authorization will be granted only for emergency procedures and/or retroactively eligible beneficiaries. Requests for emergency procedures must be applied for on the first working day after the procedure has been performed. In cases of retroactive eligibility, AFMC must be contacted for post-authorization within 60 days of the authorization date.
230.000 REIMBURSEMENT
10-13-03
Reimbursement is based on the lesser of:
A. The amount billed or
B. The Title XIX (Medicaid) maximum.
231.000 Rate Appeal Process 11-1-09
A provider may request reconsideration of a program decision by writing to the Assistant
Director, Division of Medical Services. This request must be received within 20 calendar days following the application of policy and/or procedure or the notification of the provider of its rate.
Upon receipt of the request for review, the Assistant Director will determine the need for a program/provider conference and will contact the provider to arrange a conference if needed.
Regardless of the program decision, the provider will be afforded the opportunity for a conference, if he or she so wishes, for a full explanation of the factors involved and the program decision. Following review of the matter, the Assistant Director will notify the provider of the action to be taken by the Division within 20 calendar days of receipt of the request for review or the date of the program/provider conference.
When the provider disagrees with the decision made by the Assistant Director, Division of
Medical Services, the provider may appeal the question to a standing rate review panel
Section II-10
Podiatrist Section II established by the Director of the Division of Medical Services. The rate review panel will include one member of the Division of Medical Services, a representative of the provider association and a member of the Department of Human Services (DHS) management staff, who will serve as chairperson.
The request for review by the rate review panel must be postmarked within 15 calendar days following the notification of the initial decision by the Assistant Director, Division of Medical
Services. The rate review panel will meet to consider the question(s) within 15 calendar days after receipt of a request for such appeal. The question(s) will be heard by the panel and a recommendation will be submitted to the Director of the Division of Medical Services.
231.010 Fee Schedules 12-1-12
Arkansas Medicaid provides fee schedules on the Arkansas Medicaid website. The fee schedule link is located at https://www.medicaid.state.ar.us
under the provider manual section. The fees represent the fee-for-service reimbursement methodology.
Fee schedules do not address coverage limitations or special instructions applied by Arkansas
Medicaid before final payment is determined.
Procedure codes and/or fee schedules do not guarantee payment, coverage or amount allowed.
Information may be changed or updated at any time to correct a discrepancy and/or error.
Arkansas Medicaid always reimburses the lesser of the amount billed or the Medicaid maximum.
240.000 BILLING PROCEDURES
241.000 Introduction to Billing 7-1-07
Podiatrist providers use the CMS-1500 form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim may contain charges for only one beneficiary.
Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission.
242.000 CMS-1500 Billing Procedures
242.100 Procedure Codes 9-1-14
Sections 242.100 through 242.120 list the procedure codes payable to podiatrists. Any special billing or other requirements are described in parts A through F of this section and in Sections
242.110 and 242.120.
A. Procedure codes for podiatry services provided in a nursing home or skilled nursing facility are listed in Section 242.110.
B. Procedure codes 20974 and 20975 for podiatry services require prior authorization. To request prior authorization, providers must contact the Arkansas Foundation for Medical
Care, Inc. (AFMC) (see Section 221.000 – 221.100).
C. Procedure codes payable to podiatrists for laboratory and X-ray services are located in
Section 242.130.
D. Procedure code 99238 , Hospital Discharge Day Management, may not be billed by providers in conjunction with an initial or subsequent hospital care code (procedure codes
99221 through 99233 ). Initial hospital care codes and subsequent hospital care codes may not be billed on the day of discharge.
Section II-11
Podiatrist
E. In addition to the CPT codes shown below, Q4101, Q4102, Q4103, Q4104, Q4105,
Q4106, Q4107, Q4108, Q4121, Q4141, Q4145 and T1015 are HCPCS codes and are payable to podiatrists. HCPCS code Q4121 requires a paper claim. HCPCS codes
Q4141 and Q4145 must be billed with the manufacturer’s invoice.
F. Procedure code 99353 must be billed for a service provided in a beneficiary’s home.
Section II
27696
27810
27846
28003
28035
28062
28100
28111
28122
The listed procedure codes and their descriptions are located in the Physician’s Current
Procedural Terminology (CPT) book. Section III of the Podiatrist Manual contains information on how to purchase a copy of the CPT publication.
Procedure Codes
Q4101
Q4121
Q4102
Q4124
Q4103
Q4141
Q4104
Q4145
Q4105
T1015
Q4106
10060
Q4107
10061
Q4108
10120
10121
11055
11422
11624
11740
12020
10140
11056
11423
11626
11750
12021
10160
11057
11424
11719
11752
12041
10180
11100
11426
11720
11760
12042
11000
11200
11620
11721
11762
12044
11042
11201
11621
11730
12001
13102
11043
11420
11622
11731
12002
13122
11044
11421
11623
11732
12004
13131
13132
15003
15120
15221
13133
15004
15121
15240
15276
17003
15277
17004
17999* 20000
20240 20500
20553
20690
20600
20692
20605
20693
20974** 20975** 27605
27626 27648 27650
13153
15005
15135
15241
15278
17110
20005
20501
27698
27814
27848
28005
28043
28070
28102
28112
28124
27700
27816
27860
28008
28045
28072
28103
28113
28126
13160
15050
15136
15271
15620
17111
20200
20520
20612
20694
27606
27654
27702
27818
27870
28010
28046
28080
28104
28114
28130
14040
15100
15155
15272
15777
17250
20205
20525
20615
20696
27610
27685
27703
27822
27888
28011
28050
28086
28106
28116
28140
14041
15101
15156
15273
15999* 16000
17311
20206
20550
20650
20697
27612
27687
27704
27823
27889
28020
28052
28088
28107
28118
28150
14350
15115
15157
15274
17312
20220
20551
20670
20900
27620
27690
27792
27840
28001
28022
28054
28090
28108
28119
28153
27808
27842
28002
28024
28060
28092
28110
28120
28160
15002
15116
15220
15275
17000
17315
20225
20552
20680
20910
27625
27695
Section II-12
Podiatrist Section II
28515
28575
28635
28725
28800
29355
29450
29893
29906
64632
73630
87184
28171
28208
28234
28270
28292
28302
28313
28358
28435
28475
28173
28210
28238
28272
28293
28304
28315
28360
28436
28476
28525
28576
28645
28730
28805
29358
29505
29894
29907
64704
73650
93922
28175
28220
28240
28280
28294
28305
28320
28400
28445
28485
28530
28585
28660
28735
28810
29365
29515
29895
28190
28222
28250
28285
28296
28306
28322
28405
28450
28490
28540
28600
28665
28737
28820
29405
29520
29897
29999* 36591
64782
73660
93923
73592
82962
93924
28192
28225
28260
28286
28297
28307
28340
28406
28455
28495
28545
28605
28666
28740
28825
29425
29540
29898
36592
73600
87070
93925
28193
28226
28261
28288
28298
28308
28341
28415
28456
28496
28546
28606
28675
28750
28200
28230
28262
28289
28299
28310
28344
28420
28465
28505
28890* 28899*
29435
29550
29899
64450
73610
87101
93926
28555
28615
28705
28755
29440
29580
29904
64455
73615
87102
93930
28202
28232
28264
28290
28300
28312
28345
28430
28470
28510
93965
99203
99221
99242
93970
99204
99222
99243
93971
99205
99223
99244
95831
99211
99231
99245
95851
99212
99232
99251
97597
99213
99233
99252
99201
99214
99238
99253
99202
99215
99241
99254
99255 99281 99282 99283 99284 99341 99342 99343
99347 99348 99349 99353
*Procedure codes 15999 , 17999, 28890, 28899 , and 29999 are manually priced and require an operative report attached to a paper claim.
28570
28630
28715
28760
29345
29445
29750
29905
64550
73620
87106
93931
**Procedure codes 20974 and 20975 require prior authorization. See Section 221.000 for detailed instructions.
242.110 Procedure Codes Payable in a Nursing Care Facility 9-1-14
The following procedure codes may be billed when these services are provided in a nursing care facility.
Section II-13
Podiatrist
Q4101 Q4102 Q4103 Q4104 Q4105 Q4106 Q4107 Q4108
Q4121 Q4124 Q4141 Q4145 10060 10061 10120 10121
10160
11420
10180
11421
11040
11422
11055
11423
11056
11424
11057
11426
11200
11720
11201
11721
11730
12041
15274
20551
11731
15002
15275
20552
11732
15003
15276
20553
11740
15004
15277
20612
11750
15005
15278
28190
12001
15271
15777
28630
12020
15272
16000
28660
12021
15273
20550
64455
82962
99304
87070
99305
87102
99306
99241
99307
99242
99308
99243
99309
99244
99310
99245
99318
Section II
242.120 Procedure Codes Requiring Prior Authorization
The following procedure codes require prior authorization before services may be provided.
20974 20975
5-1-08
242.130 Procedure Codes Payable for Laboratory and X-Ray Services 8-1-04
The following procedure codes may be billed for laboratory and X-ray services. Section 214.300 contains information regarding the $500.00 benefit limit for laboratory and X-ray services established for individuals age 21 and over.
73592 73600 73610 73615 73620 73630 73650
73660 82962 87070 87101 87102 87106 87184
242.200 Podiatrist National Place of Service Codes
242.210 National Place of Service Codes
Electronic and paper claims require the same National Place of Service Code.
Place of Service Place of Service Codes
Inpatient Hospital
Outpatient Hospital
Emergency Room
Doctor’s Office
Patient’s Home
Nursing Facility
Skilled Nursing Facility
Other Locations
21
22
23
11
12
32
31
99
7-1-07
Section II-14
Podiatrist Section II
Place of Service
Ambulatory Surgical Center
Inpatient Psychiatric Facility
Place of Service Codes
24
51
242.300 Billing Instructions —Paper Only
7-1-07
Hewlett Packard Enterprise offers providers several options for electronic billing. Therefore, claims submitted on paper are lower priority and are paid once a month. The only claims exempt from this rule are those that require attachments or manual pricing.
Bill Medicaid for professional services with form CMS-1500. The numbered items in the following instructions correspond to the numbered fields on the claim form. View a sample form
CMS-1500.
Carefully follow these instructions to help Hewlett Packard Enterprise efficiently process claims.
Accuracy, completeness, and clarity are essential. Claims cannot be processed if necessary information is omitted.
Forward completed claim forms to the Hewlett Packard Enterprise Claims Department. View or print the Hewlett Packard Enterprise Claims Department contact information.
NOTE: A provider delivering services without verifying beneficiary eligibility for each date of service does so at the risk of not being reimbursed for the services.
242.310 Completion of CMS-1500 Claim Form
Field Name and Number Instructions for Completion
1. (type of coverage)
1a. INSURED’S I.D. NUMBER
(For Program in Item 1)
2. PATIENT’S NAME (Last
Name, First Name, Middle
Initial)
3. PATIENT’S BIRTH DATE
Not required.
12-15-14
Beneficiary’s or participant’s 10-digit Medicaid or
ARKids First-A or ARKids First-B identification number.
Beneficiary’s or participant’s last name and first name.
SEX
4. INSURED’S NAME (Last
Name, First Name, Middle
Initial)
5. PATIENT’S ADDRESS (No.,
Street)
CITY
STATE
ZIP CODE
Beneficiary’s or participant’s date of birth as given on the individual’s Medicaid or ARKids First-A or ARKids
First-B identification card. Format: MM/DD/YY.
Check M for male or F for female.
Required if insurance affects this claim. Insured’s last name, first name, and middle initial.
Optional. Beneficiary’s or participant’s complete mailing address (street address or post office box).
Name of the city in which the beneficiary or participant resides.
Two-letter postal code for the state in which the beneficiary or participant resides.
Five-digit zip code; nine digits for post office box.
Section II-15
Podiatrist Section II
Field Name and Number
TELEPHONE (Include Area
Code)
6. PATIENT RELATIONSHIP TO
INSURED
7. INSURED’S ADDRESS (No.,
Street)
CITY
STATE
ZIP CODE
TELEPHONE (Include Area
Code) i
Instructions for Completion
The beneficiary’s or participant’s telephone number or the number of a reliable message/contact/ emergency telephone.
If insurance affects this claim, check the box ndicating the patient’s relationship to the insured.
Required if insured’s address is different from the patient’s address.
8. RESERVED
9. OTHER INSURED’S NAME
(Last name, First Name,
Middle Initial) a. OTHER INSURED’S
POLICY OR GROUP
NUMBER b. RESERVED
SEX
Reserved for NUCC use.
If patient has other insurance coverage as indicated in Field 11d, the other insured’s last name, first name, and middle initial.
Policy and/or group number of the insured individual. c. RESERVED d. INSURANCE PLAN
NAME OR PROGRAM
NAME
10. IS PATIENT’S CONDITION
RELATED TO: a. EMPLOYMENT? (Current or Previous) b. AUTO ACCIDENT? c. d.
PLACE (State)
OTHER ACCIDENT?
CLAIM CODES
Reserved for NUCC use.
Not required.
Reserved for NUCC use.
Name of the insurance company.
Check YES or NO.
Required when an auto accident is related to the services. Check YES or NO.
If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place.
Required when an accident other than automobile is related to the services. Check YES or NO.
The “Claim Codes” identify additional information about the beneficiary’s condition or the claim. When applicable, use the Claim code to report appropriate claim codes as designated by the NUCC. When required to provide the subset of Condition Codes, enter the condition code in this field. The subset of approved condition Codes is found at www.nucc.org
under Code Sets.
Section II-16
Podiatrist Section II
Field Name and Number
11. INSURED’S POLICY GROUP
OR FECA NUMBER a. INSURED’S DATE OF
BIRTH
SEX b. OTHER CLAIM ID
NUMBER c. INSURANCE PLAN
NAME OR PROGRAM
NAME d. IS THERE ANOTHER
HEALTH BENEFIT
PLAN?
12. PATIENT’S OR AUTHORIZED
PERSON’S SIGNATURE
13. INSURED’S OR
AUTHORIZED PERSON’S
SIGNATURE
14. DATE OF CURRENT:
ILLNESS (First symptom) OR
INJURY (Accident) OR
PREGNANCY (LMP)
15. OTHER DATE
Instructions for Completion
Not required when Medicaid is the only payer.
Not required.
Not required.
Not required.
Not required.
When private or other insurance may or will cover any of the services, check YES and complete items
9, 9a and 9d. Only one box can be marked.
Enter “Signature on File,” “SOF” or legal signature.
Enter “Signature on File,” “SOF” or legal signature.
Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident.
Enter the qualifier to the right of the vertical dotted line. Use Qualifier 431 Onset of Current symptoms or
Illness; 484 Last Menstrual Period.
Enter another date related to the beneficiary’s condition or treatment. Enter the qualifier between the left-hand set of vertical dotted lines.
The “Other Date” identifies additional date information about the beneficiary’s condition or treatment. Use qualifiers:
454 Initial Treatment
304 Latest Visit or consultation
453 Acute Manifestation of a Chronic Condition
439 Accident
455 Last X-Ray
471 Prescription
090 Report Start (Assumed Care Date)
091 Report End (Relinquished Care Date)
444 First Visit or Consultation
Not required. 16. DATES PATIENT UNABLE
TO WORK IN CURRENT
OCCUPATION
Section II-17
Podiatrist Section II
Field Name and Number
17. NAME OF REFERRING
PROVIDER OR OTHER
SOURCE
17a. (blank)
17b. NPI
18. HOSPITALIZATION DATES
RELATED TO CURRENT
SERVICES
19. ADDITIONAL CLAIM
INFORMATION
20. OUTSIDE LAB?
$ CHARGES
21. DIAGNOSIS OR NATURE OF
ILLNESS OR INJURY
Instructions for Completion
Primary Care Physician (PCP) referral is required for
Podiatrist Services. If services are the result of a
Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title.
The 9-digit Arkansas Medicaid provider ID number of the referring physician.
Not required.
When the serving/billing provider’s services charged on this claim are related to a beneficiary’s or participant’s inpatient hospitalization, enter the individual’s admission and discharge dates. Format:
MM/DD/YY.
Identifies additional information about the beneficiary’s condition or the claim. Enter the appropriate qualifiers describing the identifier. See www.nucc.org
for qualifiers.
Not required.
Not required.
Enter the applicable ICD indicator to identify which version of ICD codes is being reported.
Use “9” for ICD-9-CM.
Use “0” for ICD-10-CM.
Enter indicator between the vertical, dotted lines in the upper right-hand portion of the field.
Diagnosis code for the primary medical condition for which services are being billed. Use the appropriate
International Classification of Diseases (ICD). List no more than 12 diagnosis codes. Relate lines A-L to the lines of service in 24E by the letter of the line.
Use the highest level of specificity.
Reserved for future use. 22. RESUBMISSION CODE
ORIGINAL REF. NO.
23. PRIOR AUTHORIZATION
NUMBER
Any data or other information listed in this field does not/will not adjust, void or otherwise modify any previous payment or denial of a claim. Claim payment adjustments, voids and refunds must follow previously established processes in policy.
The prior authorization or benefit extension control number if applicable.
Section II-18
Podiatrist Section II
Field Name and Number
24A. DATE(S) OF SERVICE
Instructions for Completion
The “from” and “to” dates of service for each billed service. Format: MM/DD/YY.
1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month.
2. Providers may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence.
B.
C.
PLACE OF SERVICE
EMG
Two-digit national standard place of service code.
See Section 242.200 for codes.
Enter “Y” for “Yes” or leave blank if “No.” EMG identifies if the service was an emergency.
D. PROCEDURES,
SERVICES, OR
SUPPLIES
CPT/HCPCS
E.
F.
G.
MODIFIER
DIAGNOSIS POINTER
$ CHARGES
DAYS OR UNITS
Enter the correct CPT or HCPCS procedure code from Sections 242.100 through 242.130.
Not applicable to Podiatrist Services claims.
Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate to the date of service and the procedures performed to the primary diagnosis. When multiple services are performed, the primary reference letter for each service should be listed first; other applicable services should follow.
The reference letter(s) should be A-L or multiple letters as applicable. The “Diagnosis Pointer” is the line letter from Item Number 21 that relates to the reason the service(s) was performed.
The full charge for the service(s) totaled in the detail.
This charge must be the usual charge to any client, patient, or other beneficiary of the provide r’s services.
The units (in whole numbers) of service(s) provided during the period indicated in Field 24A of the detail.
H. EPSDT/Family Plan Enter E if the services resulted from a Child Health
Services (EPSDT) screening/referral.
Not required. I. ID QUAL
J. RENDERING
PROVIDER ID #
The 9-digit Arkansas Medicaid provider ID number of the individual who furnished the services billed for in the detail.
Not required. NPI
25. FEDERAL TAX I.D. NUMBER Not required. This information is carried in the provider’s Medicaid file. If it changes, please contact
Provider Enrollment.
Section II-19
Podiatrist Section II
Field Name and Number
26. PATIENT’S ACCOUNT NO.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. RESERVED
31. SIGNATURE OF PHYSICIAN
OR SUPPLIER INCLUDING
DEGREES OR
CREDENTIALS
32. SERVICE FACILITY
LOCATION INFORMATION a. (blank) b. (blank)
33. BILLING PROVIDER INFO &
PH # a. (blank) b. (blank)
Instructions for Completion
Optional entry that may be used for accounting purposes; use up to 16 numeric or alphabetic characters. This number appears on the Remittance
Advice as “MRN.”
Not required. Assignment is automatically accepted by the provider when billing Medicaid.
Total of Column 24F —the sum all charges on the claim.
Enter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. *Do not include in this total the automatically deducted Medicaid or ARKids First-B co-payments.
Reserved for NUCC use.
The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider’s direction. “Provider’s signature” is defined a s the provider’s actual signature, a rubber stamp of the provider’s signature, an automated signature, a typewritten signature, or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable.
If other than home or office, enter the name and street, city, state, and zip code of the facility where services were performed.
Not required.
Not required.
Billing provider’s name and complete address.
Telephone number is requested but not required.
Not required.
Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider.
242.400 Special Billing Procedures
242.410 Completion of Forms for Medicare/Medicaid Deductible and
Coinsurance
10-1-08
When a beneficiary is dually eligible for Medicare and Medicaid and is provided services that are covered by both Medicare and Medicaid, Medicaid will not reimburse for those services if
Medicare has not been billed and payment determination finalized prior to billing Medicaid.
Medicaid will also cover coinsurance, co-payment and deductible amounts for dually eligible beneficiaries, less any Medicaid cost-share amounts, when applicable. See Sections 332.000 through 332.300 of this manual for detailed information regarding Medicare/Medicaid crossover claim filing procedures and follow-up.
Section II-20
Podiatrist Section II
242.420 Services Prior to Medicare Entitlement 10-13-03
Services that have be en denied by Medicare with the explanation “Services Prior to Medicare
Entitlement” may be filed with Medicaid. No special billing procedures are required.
242.430 Services Not Medicare Approved 10-13-03
Services that are not Medicare approved for patients with joint Medicare/Medicaid coverage usually are not payable by Medicaid.
242.440 Reserved 3-15-14
242.450 National Drug Code Billing Protocols
A. Covered Labelers
7-15-11
Arkansas Medicaid, by statute, will only pay for a drug procedure billed with an NDC when the pharmaceutical labeler of that drug is a covered labeler with Centers for Medicare &
Medicaid Services (CMS). A “covered labeler” is a pharmaceutical manufacturer that has entered into a federal rebate agreement with CMS to provide each State a rebate for products reimbursed by Medicaid Programs. A covered labeler is identified by the first 5 digits of the NDC. To assure a product is payable for administration to a Medicaid beneficiary, compare the labeler code (the first 5 digits of the NDC) to the list of covered labelers which is maintained on the Arkansas Medicaid website.
A complete listing of “Covered Labelers” is located on the Arkansas Medicaid page at www.medicaid.state.ar.us
, click on Provider Services, select Prescription Drug information, and then select Covered Labelers. See Diagram 1 for an example of this screen. The effective date is when a manufacturer entered into a rebate agreement with
CMS. The Labeler termination date indicates that the manufacturer no longer participates in the federal rebate program and therefore the products cannot be reimbursed by
Arkansas Medicaid on or after the termination date .
Diagram 1
In order for a claim with drug HCPCS/CPT codes to be eligible for payment, the detail date of service must be prior to the NDC termination date . The NDC termination date represents the shelf-life expiration date of the last batch produced, as supplied on the
Centers for Medicare and Medicaid Services (CMS) quarterly update. The date is supplied to CMS by the drug manufacturer/distributor.
Section II-21
Podiatrist Section II
Arkansas Medicaid will deny claim details with drug HCPCS/CPT codes with a detail date of service equal to or greater than the NDC termination date.
When completing a Medicaid claim for administering a drug, indicate the HIPAA standard
11-digit NDC with no dashes or spaces. The 11-digit NDC is comprised of three segments or codes: a 5-digit labeler code, a 4-digit product code and a 2-digit package code. The
10-digit NDC assigned by the FDA printed on the drug package must be changed to the
11-digit format by inserting a leading zero in one of the three segments. Below are examples of the FDA assigned NDC on a package changed to the appropriate 11-digit
HIPAA standard format. Diagram 2 displays the labeler code as five digits with leading zeros; the product code as four digits with leading zeros; the package code as two digits without leading zeros, using the “5-4-2” format.
Diagram 2
00123
LABELER
CODE
(5 digits)
0456
PRODUCT
CODE
(4 digits)
78
PACKAGE
CODE
(2 digits)
NDCs submitted in any configuration other than the 11-digit format will be rejected/denied.
NDCs billed to Medicaid for payment must use the 11-digit format without dashes or spaces between the numbers.
See Diagram 3 for sample NDCs as they might appear on drug packaging and the corresponding format which should be used for billing Arkansas Medicaid:
Diagram 3
10-digit FDA NDC on PACKAGE
12345 6789 1
1111-2222-33
01111 456 71
Required 11-digit NDC
(5-4-2) Billing Format
123456789 0 1
0 1111222233
01111 0 45671
B. Drug Procedure Code (HCPCS/CPT) to NDC Relationship and Billing Principles
HCPCS/CPT codes and any modifiers will continue to be billed per the policy for each procedure code. However, the NDC and NDC quantity of the administered drug is now also required for correct billing of drug HCPC/CPT codes. To maintain the integrity of the drug rebate program, it is important that the specific NDC from the package used at the time of the procedure be recorded for billing. HCPCS/CPT codes submitted using invalid
NDCs or NDCs that were unavailable on the date of service will be rejected/denied. We encourage you to enlist the cooperation of all staff members involved in drug administration to assure collection or notation of the NDC from the actual package used. It is not recommended that billing of NDCs be based on a reference list, as NDCs vary from one labeler to another, from one package size to another, and from one time period to another.
Exception: There is no requirement for an NDC when billing for vaccines.
II. Claims Filing
The HCPCS/CPT codes billing units and the NDC quantity do not always have a one-to-one relationship.
Section II-22
Podiatrist Section II
Example 1: The HCPCS/CPT code may specify up to 75 mg of the drug whereas the NDC quantity is typically billed in units, milliliters or grams. If the patient is provided 2 oral tablets, one at 25 mg and one at 50 mg, the HCPCS/CPT code unit would be 1 (1 total of 75 mg) in the example whereas the NDC quantity would be 1 each (1 unit of the 25 mg tablet and 1 unit of the
50 mg tablet). See Diagram 4.
Diagram 4
Example 2: If the drug in the example is an injection of 5 ml (or cc) of a product that was 50 mg per 10 ml of a 10 ml single-use vial, the HCPCS/CPT code unit would be 1 (1 unit of 25 mg) whereas the NDC quantity would be 5 (5 ml). In this example, 5 ml or 25 mg would be documented as wasted. See Diagram 5.
Diagram 5
A. Electronic Claims Filing – 837P (Professional) and 837I (Outpatient)
Electronic claims can be filed with a maximum of 5 NDCs per detail.
Procedure codes that do not require paper billing may be billed electronically. Any procedure codes that have required modifiers in the past will continue to require modifiers.
Arkansas Medicaid will require providers using Provider Electronic Solutions (PES) to use the required NDC format when billing HCPCS/CPT codes for administered drugs.
When billing multiple NDCs, the HCPCS/CPT should reflect the total charges and units of all administered NDCs. The NDC fields should reflect the price and units of each specific
NDC, up to a maximum of five NDCs per detail.
1. For 837P professional claims, from the Service 2 tab, in the RX Indicator field, select
“Y” to open the RX tab. On the RX tab, enter the NDC, Unit of Measure, Quantity and Price for each NDC.
Section II-23
Podiatrist Section II
2. For 837I outpatient claims, from the Service tab, in the RX Indicator field, select “Y” to open the RX tab. On the RX tab, enter the NDC, Unit of Measure, Quantity and
Price for each NDC.
If billing electronic claims using vendor software, check with your vendor to ensure your software will be able to capture the criteria necessary to submit these claims. Vendor companion guides are located on the Arkansas Medicaid page at www.medicaid.state.ar.us
. Click on Provider, select HIPAA, select Documents for vendors and then select Companion guides.
B. Paper Claims Filing – CMS-1500 and CMS-1450 (UB-04)
Arkansas Medicaid will require providers billing drug HCPCS/CPT codes including covered unlisted drug procedure codes to use the required NDC format.
See Diagram 6 for CMS-1500 and Diagram 7 for CMS-1450 (UB-04).
CMS-1500
For professional claims, CMS1500, list the qualifier of “N4”, the 11-digit NDC, the unit of measure qualifier (F2 - International Unit; GR - Gram; ML - Milliliter; UN - Unit), and the number of units of the actual NDC administered in the shaded area above detail field 24A, spaced and arranged exactly as in Diagram 6.
Each NDC, when billed under the same procedure code on the same date of service is defined as a “sequence”. When billing a single HCPCS/CPT code with multiple NDCs as detail sequences, the first sequence should reflect the total charges in the detail field 24F and total HCPCS/CPT code units in detail field 24G. Each subsequent sequence number should show zeros in detail fields 24F and 24G. See Detail 1, sequence 2 in Diagram 6.
The quantity of the NDC will be the total number of units billed for each specific NDC.
See
Diagram 6, first detail, sequences 1 and 2. Detail 2 is a Procedure Code that does not require an NDC
.
Detail 3, sequence 1 gives an example where only one NDC is associated with the HCPCS/CPT code.
Diagram 6
CMS-1450 (UB-04)
For institutional outpatient claims on the UB-04, use the locator field 43 (Description) to list the qualifier of “N4”, the 11-digit NDC, the unit of measure qualifier (F2 - International Unit;
GR - Gram; ML - Milliliter; UN - Unit), and number of units of the actual NDC administered, spaced and arranged exactly as in Diagram 7.
Each NDC, when billed under the same procedure code on the same date of service is defined as a “sequence”. When billing a single HCPCS/CPT code with multiple NDCs as detail sequences, the first sequence should reflect the total charges in the detail locator field 47 and total HCPCS/CPT code units in locator field 46. Each subsequent sequence
Section II-24
Podiatrist Section II number should show zeros in locator fields 46 and 47. See Detail 1, sequence 2 in
Diagram 7.
The quantity of the NDC will be the total number of units billed for each specific NDC. See
Diagram 7, first detail, sequences 1 and 2. Detail 2 is a Procedure Code that does not require an NDC.
Detail 3, sequence 1 gives an example where only one NDC is associated with the HCPCS/CPT code.
Diagram 7
Procedure Code/NDC Detail Attachment Form - DMS-664
For drug HCPCS/CPT codes requiring paper billing (i.e., for manual review), complete every field of the DMS664 “Procedure Code/NDC Detail Attachment Form.” Attach this form and any other required documents to your claim when submitting it for processing. See Diagram 8 for an example of the completed form. A copy of form DMS-664 is attached and may be copied for claim submission. Copies of the DMS-664 will not be provided. Section V of the provider manual will be updated to include this form.
Diagram 8
III. Adjustments
Paper adjustments for paid claims filed with NDC numbers will not be accepted. Any original claim will have to be voided and a replacement claim will need to be filed. Providers have the option of adjusting a paper or electronic claim electronically.
IV. Remittance Advices
Only the first sequence in a detail will be displayed on the remittance advice reflecting either the total amount paid or the denial EOB(s) for the detail.
V. Drug Efficacy Study Implementation (DESI) Drugs
The Federal Drug Administration (FDA) reviews the effectiveness of drugs approved between
1938 and 1962 through a program named the Drug Efficacy Study Implementation (DESI) program. Drugs that were approved by the FDA before 1962 were permitted to remain on the market while evidence of their effectiveness was reviewed. If the DESI review indicates a lack
Section II-25
Podiatrist Section II of substantial evidence of a drug’s effectiveness, the FDA will publish its proposal to withdraw approval of the drug for marketing. In accordance with Section 1903(i)(5) of the Social Security
Act, federal funds participation (FFP) is not available for Less than Effective (LTE) drugs or the
Identical, Related or Similar (IRS) drugs identified by the FDA and published quarterly by the
Centers for Medicare & Medicaid Services.
This means that any HCPCS/CPT code will not be payable when linked to any NDC with a DESI indicator. If it is determined that all NDCs linked to a specific HCPCS/CPT are DESI, this is an instance where the procedure code will no longer be payable.
A list of “DESI” drugs with the effective and end dates will be on the Arkansas Medicaid website.
From the main page, click “Provider,” then select “Prescription Drug Information” and then select
“DESI NDCs (non-payable) associated with HCPCS/CPT Codes.” See Diagram 9 for an example of the DESI list.
Diagram 9
Section II-26
