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RESOURCES & ADDITIONAL INFOAdditional information is available on the CMS website:http://www.cms.gov/MedicaidNCCICoding/This site is complete with the following information:oGeneralOverviewoMedicaidNCCI Coding Policy ManualoAdditionaloFederaloFAQs52Information on Coding Policies and EditsAppeals Guidelines and Informationand a How To Manual Copyright 2010 Hewlett-Packard Development Company L.P.

RESOURCES & ADDITIONAL INFO53 Copyright 2010 Hewlett-Packard Development Company L.P.

RESOURCES & ADDITIONAL INFO54 Copyright 2010 Hewlett-Packard Development Company L.P.

RESOURCES & ADDITIONAL INFO55 Copyright 2010 Hewlett-Packard Development Company L.P.

RESOURCES & ADDITIONAL INFOAdditional information is available on the DMA mThis site is complete with the following information:oGeneral56OverviewoNorthCarolina Implementation InformationoLinksto NCCI related BulletinsoLinksto CMS website Copyright 2010 Hewlett-Packard Development Company L.P.

RESOURCES & ADDITIONAL INFO57 Copyright 2010 Hewlett-Packard Development Company L.P.

RESOURCES & ADDITIONAL INFOProviders/suppliers who have concerns regardingspecific NCCI edits can submit comments in writing to:National Correct Coding InitiativeCorrect Coding Solutions LLCP.O. Box 907Carmel, IN 46082-0907Attention: Niles R. Rosen M.D. Medical Director andLinda S. Dietz RHIA CCS CCS-P Coding SpecialistFax #: 317-571-174558 Copyright 2010 Hewlett-Packard Development Company L.P.

EARLY AND PERIODICSCREENING, DIAGNOSIS, ANDTREATMENT (EPSDT)MEDICAID FOR CHILDREN59Contacts: Frank Skwara, MA, LMFT, BSN, RNEPSDT Nurse ConsultantDivision of Medical AssistanceTelephone #: 919-855-4260FAX #: 919-715-76793/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.59

WHY HEALTH CHECK/ EPSDT AREIMPORTANT Promotes preventative health care by providing for early and regularmedical and dental screenings. Provides medically necessary health care to correct or ameliorate adefect, physical or mental illness, or a condition [health problem]identified through a screening.603/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.60

HEALTH CHECK/EPSDT OVERVIEW Early and Periodic Screening, Diagnosis, and Treatment(EPSDT) defined by federal law and includes:Periodic Screening Services Vision Services Dental Services Hearing Services Other Necessary Health Care 613/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.61

EPSDT OVERVIEWCON’T. Recipients under 21 must be afforded access tothe full array of EPSDT services within the scopeof the category of services listed in the federallaw at 42 U.S.C. § 1396d(a) [1905(a) of theSocial Security Act]. Refer to the EPSDTprovider web page or the Health Check or BasicMedicaid Billing Guides for a listing of theseservices.NOTE: Under EPSDT, North Carolina Medicaidmust make available a variety of individual andgroup providers qualified and willing to provideEPSDT services.623/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.62

EPSDT CRITERIA Must be listed in the federal law at 42 U.S.C. § 1396d(a) [1905(a) ofthe Social Security Act]. Must be medically necessary "to correct or ameliorate a defect,physical or mental illness, or a condition [health problem] identified byscreening”.633/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.63

EPSDT CRITERIACON’T.“Ameliorate” means to: improveor maintain the recipient’s healthin the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additionalhealth problems.643/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.64

EPSDT Criteria65CON’T. Must be determined to be medical in nature. Must be generally recognized as an accepted methodof medical practice or treatment. Must not be experimental, investigational. Must be safe.3/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P. Must be effective.65

EPSDT FEATURES No Waiting List for EPSDT Services No Monetary Cap on the Total Cost of EPSDTServices No Upper Limit on the Number of Hours underEPSDT66 No Limit on the Number of EPSDT Visits to aPhysician, Therapist, Dentist or Other LicensedClinician3/21/201166 Copyright 2010 Hewlett-Packard Development Company L.P.

EPSDT FEATURESCON’T. No Set List that Specifies When or WhatEPSDT Services or Equipment May Be Covered No Co-payment or Other Cost to the Recipient Coverage for Services that Are Never Coveredfor Recipients Over 21 Years of Age Coverage for Services Not Listed in the N.C.State Medicaid Plan673/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.67

IMPORTANT POINTS ABOUT EPSDT The full array of EPSDT services must becoverable within the scope of those listed in thefederal law at 42 U.S.C. § 1396d(a) [1905(a) ofthe Social Security Act]. EPSDT requiresMedicaid to cover these services if they aremedically necessary to correct or ameliorate adefect, physical or mental illness, or a condition[health problem].683/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.68

Important Points AboutEPSDT CON’T. 69EPSDT services do not have to be services that are coveredunder the North Carolina State Medicaid Plan or under any of theDivision of Medical Assistance’s (DMA) clinical coverage policiesor service definitions or billing codes.3/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.69

Important Points AboutEPSDT CON’T. EPSDTcovers short-term and long-term services as long as the requested serviceswill correct or ameliorate the child's condition. For example, a service must becovered under EPSDT if it is necessary for immediate relief (e.g., pain medication).Treatment need not ameliorate the child's condition taken as a whole, but need onlybe medically necessary to ameliorate one of the child's diagnoses or medicalconditions.703/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.70

EPSDT OPERATIONALPRINCIPLES The specific coverage criteria (e.g., particulardiagnoses, signs, or symptoms) in the DMA clinicalcoverage policies or service definitions do NOThave to be met. The specific numerical limits (number of hours,number of visits, or other limitations on scope,amount or frequency) in DMA clinical coveragepolicies, service definitions, or billing codes doNOT apply. This includes the hourly limits onMedicaid Personal Care Services (PCS).713/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.71

EPSDT OPERATIONALPRINCIPLES CON’T. Other restrictions in the clinical coverage policies, such asthe location of the service (e.g., PCS only in the home),prohibitions on multiple services on the same day or at thesame time (e.g., day treatment and residential treatment)must also be waived under EPSDT. Out of state services are NOT covered if medicallynecessary similarly efficacious services are available inNorth Carolina. Out of state services delivered without priorapproval will be denied unless there is retroactive Medicaideligibility.723/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.72

EPSDT OPERATIONALPRINCIPLES CON’T. Durable medical equipment (DME), assistive technology, orthotics,prosthetics, or other service requested do NOT have to be includedon DMA’s approved lists or be covered under a CAP waiver programin order to be covered under EPSDT subject to meeting the criteriaspecified in this policy.733/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.73

EPSDT OPERATIONALPRINCIPLES CON’T. The prohibition in CAP/C on skilled nursing forpurposes of monitoring does not apply to EPSDTservices if skilled monitoring is medicallynecessary. (Example: PDN) Case management is an EPSDT service andmust be provided to a child with a Medicaid cardif medically necessary to correct or ameliorateregardless of eligibility for a CAP waiver.743/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.74

EPSDT COVERAGE AND CAP WAIVERS75 CAP Waiver services are available only to participantsin the CAP waiver programs and are not a part of theEPSDT benefit unless the waiver service is ALSO anEPSDT service. Additionally, a child financially eligible for Medicaidoutside of the waiver is entitled to elect EPSDTservices without any monetary cap instead of waiverservices.3/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.75

EPSDT COVERAGE AND CAP WAIVERSCON’T. ANY child enrolled in a CAP program canreceive BOTH waiver services and EPSDTservices. However, the cost of the recipient’scare must not exceed the waiver cost limit. If enrolled in the Community AlternativesProgram for Persons with Mental Retardationand Developmental Disabilities (CAP-MRDD),prior approval to exceed 100,000 per year mustbe obtained.763/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.76

EPSDT COVERAGE AND CAP WAIVERSCON’T. A recipient under 21 years of age on a waiting list for CAPservices is eligible for necessary EPSDT services withoutany waiting list being imposed. EPSDT services must be provided to recipients under 21years of age in a CAP program under the same standardsas other children receiving Medicaid services and may beprovided in the school setting, including to CAP-MRDDrecipients.773/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.77

EPSDT COVERAGE AND MH/DD/SASERVICES 78Staff employed by local management entities (LMEs) CANNOTdeny requests for services, formally or informally. Requests mustbe forwarded to ValueOptions or other appropriate DMA vendorsif supported by a licensed clinician.3/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.78

EPSDT COVERAGE AND MH/DD/SASERVICES CON’T. LMEs may NOT use the Screening, Triage, andReferral (STR) process or the DD eligibility process asa means of denying access to Medicaid services.Even if the LME STR screener does not believe thechild needs enhanced services, the family must bereferred to an appropriate Medicaid provider toperform a clinical evaluation of the child for anymedically necessary service. Only DMA and itscontractors can determine if a Medicaid recipientmeets criteria for a covered Medicaid service.793/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.79

EPSDT COVERAGE AND MH/DD/SASERVICES CON’T. 80Requests for prior approval of MH/DD/SA services for recipientsunder 21 must be sent to ValueOptions or to an LME if handlingPA in their catchment area.3/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.80

EPSDT COVERAGE AND MH/DD/SASERVICES CON’T. If a recipient under 21 years of age has adevelopmental disability diagnosis, this doesnot necessarily mean that the requestedservice is habilitative and may not be coveredunder EPSDT. The EPSDT criteria of whetherthe service is medically necessary to correct orameliorate a defect, physical or mental illness,or condition [health problem] apply. Examplesinclude dual diagnoses and behavioraldisorders. All individual facts must beconsidered.813/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.81

REQUESTING PA FOR ACOVERED STATE MEDICAIDPLAN SERVICE Covered state Medicaid plan services aredefined as requests for services, products, orprocedures covered by the North Carolina StateMedicaid Plan. EPSDT does NOT eliminate the need for priorapproval if prior approval is required.823/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.82

REQUESTING PA FOR ACOVERED STATE MEDICAIDPLAN SERVICE CON’T. Requests for EPSDT services do NOT have to be labeled assuch. Any proper request for services for a recipient under21 years of age is a request for EPSDT services. Whenstate staff or vendors review a covered state Medicaid planservices request for PA or continuing authorization (UR) foran individual under 21 years of age, the reviewer will applythe EPSDT criteria. For recipients under 21 years of ageenrolled in a CAP waiver, a request for services must beconsidered under EPSDT as well as under the waiver if thatservice is both a CAP and a waiver service.833/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.83

REQUESTING PA FOR ACOVERED STATE MEDICAIDPLAN SERVICE CON’T. EPSDT requests for prior approval for servicesmust be fully documented to show medicalnecessity. This requires current information fromthe recipient’s physician, other licensed clinicians,the requesting qualified provider, and familymembers or legal representative. If this informationis not provided, Medicaid or its vendor will have toobtain the needed information, and this will delaythe prior approval decision.843/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.84

REQUESTING PA FOR ACOVERED STATE MEDICAIDPLAN SERVICE CON’T. If the recipient does not meet the clinical coverage criteriaor needs to exceed clinical coverage policy limits, submitdocumentation with the prior approval request that showshow the service at the requested frequency and amountis medically necessary to correct or ameliorate a defect,physical or mental illness, or condition [health problem]. Additionally, all other EPSDT criteria must be met.853/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.85

REQUESTING PA FOR ACOVERED STATE MEDICAIDPLAN SERVICE CON’T. It is not sufficient to cover a standard, lower cost service instead of arequested specialized service if the lower cost service is not equallyeffective in that individual case.863/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.86

SERVICES FORMALLY COVEREDBY CSHS– Cochlear Implant and AccessoriesFax all requests for external parts replacement andrepair, in letter format, to the appropriate cochlearor auditory brainstem implant manufacturer. Themanufacturer will process requests, obtain priorapproval for external speech or sound processors,and file claims. Guidelines for the letter requestingexternal parts replacement or repair can beobtained from the implant manufacturer.873/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.87

SERVICES FORMALLY COVERED BYCSHS CON’T.–Pediatric mobility systems,including non-listed components,should be sent to HP Enterprise Services usingthe Certificate of Medical Necessity/PriorApproval (CMN/PA form).–Augmentative and Alternate CommunicationDevices should be sent to HP EnterpriseServices.883/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.88

SERVICES FORMALLY COVERED BYCSHS CON’T.– Oral NutritionMetabolic formula requests should be sent to DPH.All other requests for formula that appear on theDMA fee schedules should be sent to HP EnterpriseServices.Formula that does not appear on the DMA feeschedules should be sent as an EPSDT request to:Assistant DirectorClinical Policy and Programs893/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.89

INAPPROPRIATE PA REQUESTSRECEIVED BY VENDORS Vendors (CCME, HP Enterprise Services, ACSPharmacy, MedSolutions, and ValueOptions,PBH, LMEs) may receive service requests forwhich the vendor is not responsible forconducting the prior approval reviews. Asvendors can only authorize specific services inaccordance with DMA-vendor contracts, thoserequests will be forwarded to the appropriatevendor for review.903/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.90

REQUESTING PA FOR NONCOVERED STATE MEDICAID PLANSERVICES Requests for non-covered state Medicaid plan services are requestsfor services, products, or procedures that are not included at all in theNorth Carolina State Medicaid Plan but coverable under federalMedicaid law, 1905(r) of the Social Security Act for recipients under21 years of age.913/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.91

REQUESTING PA FOR NONCOVERED STATE MEDICAID PLANSERVICES CON’T.Over-the-counter (OTC) MedicationsIf the OTC has a National Drug Code (NDC)number and the manufacturer has a valid rebateagreement with the Centers for Medicare andMedicaid Services (CMS) but the drug does notappear on DMA’s approved coverage listing ofOTC medications, send the request to theAssistant Director, Clinical Policy and Programs,Division of Medical Assistance.923/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.92

REQUESTING PA FOR NONCOVERED STATE MEDICAID PLANSERVICES CON’T. Requests for Medicaid prior approval of DME, orthotics andprosthetics, and home health supplies that do not appear on DMA’slists of covered equipment should be submitted to the AssistantDirector, DMA.933/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.93

REQUESTING PA FOR NONCOVERED STATE MEDICAID PLANSERVICES CON’T. Oral NutritionFormula that does not appear on theDMA fee schedules should be sent asan EPSDT request to:Assistant DirectorClinical Policy and Programs943/21/2011 Copyright 2010 Hewlett-Packard Development Company L.P.94

REQUESTING PA FOR NONCOVERED STATE MEDICAID PLANSERVICES CON’T.Effective with date of request September 1, 2008,Children’s Special Health Services no longer authorizespayment for ramps, tie downs, car seats, and vests.These items are not included in the durable medicalequipment covered by Medicaid, nor are they coveredunder Early Periodic Screening, Diagnostic, andTreatment services, which cover medical equipment andsuppl

The coding policies are based on coding conventions defined in the American Medical Association's Current Procedural Terminology (CPT) manual, national Medicare policies, coding guidelines developed by national societies, standard medical and surgical practice, and/or current coding practice.