016-06-08 Ark. Code R. § 10

Current through Register Vol. 49, No. 6, June, 2024

Rule 016.06.08-010 - Podiatrist Provider Manual Update Transmittal #99; Ambulatory Surgical Center Provider Manual Update Transmittal #103; Hospital, Critical Access Hospital (CAH), End-Stage Renal Disease (ESRD) Provider Manual Update Transmittal #138; Physician/Independent Lab/CRNA/Radiation Therapy Center Provider Manual Update Transmittal #153

Section II Podiatrist

213.100Bilaminate Graft or Skin Substitute Coverage Restriction 5-1-08

Arkansas Medicaid covers bilaminate graft or skin substitute, known as dermal and epidermal tissue of human origin, with or without bioengineered or processed elements, with metabolically active elements. The physician's application procedure is covered separately and must be indicated separately on the claim.

This product is designed for treatment of burn injuries and non-infected partial and full-thickness skin ulcers caused by venous insufficiency and for treatment of full-thickness neuropathic diabetic foot ulcers that extend through the dermis, but without tendon, muscle, capsule or bone exposure and which are located on the plantar, medial or lateral area of the foot (excluding the heel).

A.Indications and Documentation:

When the diagnosis is a burn injury, (ICD-9-CM code range 940.0 through 949.5, indicated on the claim form), no additional medical treatment documentation is required.

This modality/product and related procedures will be covered for other restricted diagnoses (indicated below) when all of the following conditions are met and are documented in the beneficiary's medical record:

1. Partial or full-thickness skin ulcers caused by venous insufficiency or full-thickness neuropathic diabetic foot ulcers,

2. Ulcers of greater than three (3) months duration and

3. Ulcers that have failed to respond to documented conservative measures of greater than two (2) months' duration.

4. There must be measurements of the initial ulcer size, the size of the ulcer following cessation of conservative management, and the size at the beginning of skin substitute treatment.

5. For neuropathic diabetic foot ulcers, appropriate steps to off-load pressure during treatment must be taken and documented in the patient's medical record.

6. The ulcer must be free of infection and underlying osteomyelitis; treatment of the underlying disease (e.g., peripheral vascular disease) must be provided and documented in conjunction with skin substitute treatment.

B.Diagnosis Restrictions:

Coverage of the bilaminate skin product and its application is restricted to the following ICD-9-CM codes:

454.0

454.2

250.8 (requires a fifth-digit sub classification)

707.10

707.13

707.14

707.15

940.0 through 949.5

242.100Procedure Codes 5-1-08

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.

E. In addition to the CPT codes shown below, T1015 , a HCPCS code, is payable to podiatrists.

F. Procedure code 99353 must be billed for a service provided in a beneficiary's home.

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
J7340*	T1015	10060	10061	10120	10140	10160	10180
11000	11040	11041	11042	11043	11044	11055	11056
11057	11100	11200	11201	11420	11421	11422	11423
11424	11426	11620	11621	11622	11623	11624	11626
11719	11720	11721	11730	11732	11740	11750	11752
11760	11762	12001	12002	12004	12020	12021	12041
12042	12044	13102	13122	13131	13132	13153	13160
14040	14350	15000	15050	15100	15101	15120	15121
15220	15221	15240	15241	15620	15999*	16000	17000
17003	17004	17110	17111	17999*	20000	20005	20200
20205	20206	20220	20225	20240	20500	20501	20520
20525	20550	20551	20552	20553	20600	20605	20612
20615	20650	20670	20680	20690	20692	20693	20694
20900	20910	20974**	20975**	27605	27606	27610	27612
27620	27625	27626	27648	27650	27654	27687	27690
27695	27696	27698	27700	27702	27703	27704	27792
27808	27810	27814	27816	27818	27822	27823	27840
27842	27846	27848	27860	27870	27888	27889	28001
28002	28003	28005	28008	28010	28011	28020	28022
28024	28035	28043	28045	28046	28050	28052	28054
28060	28062	28070	28072	28080	28086	28088	28090
28092	28100	28102	28103	28104	28106	28107	28108
28110	28111	28112	28113	28114	28116	28118	28119
28120	28122	28124	28126	28130	28140	28150	28153
28160	28171	28173	28175	28190	28192	28193	28200
28202	28208	28210	28220	28222	28225	28226	28230
28232	28234	28238	28240	28250	28260	28261	28262
28264	28270	28272	28280	28285	28286	28288	28290
28292	28293	28294	28296	28297	28298	28299	28300
28302	28304	28305	28306	28307	28308	28310	28312
28313	28315	28320	28322	28340	28341	28344	28345
28360	28400	28405	28406	28415	28420	28430	28435
28436	28445	28450	28455	28456	28465	28470	28475
28476	28485	28490	28495	28496	28505	28510	28515
28525	28530	28540	28545	28546	28555	28570	28575
28576	28585	28600	28605	28606	28615	28630	28635
28645	28660	28665	28666	28675	28705	28715	28725
28730	28735	28737	28740	28750	28755	28760	28800
28805	28810	28820	28825	28899*	29345	29355	29358
29365	29405	29425	29435	29440	29445	29450	29505
29515	29520	29540	29550	29580	29750	29893	29894
29895	29897	29898	29899	29999*	64450	64550	64704
64782	73592	73600	73610	73615	73620	73630	73650
73660	82962	87070	87101	87102	87106	87184	93922
93923	93924	93925	93926	93930	93931	93965	93970
93971	95831	95851	99201	99202	99203	99204	99205
99211	99212	99213	99214	99215	99221	99222	99223
99231	99232	99233	99238	99241	99242	99243	99244
99245	99251	99252	99253	99254	99255	99281	99282
99283	99284	99341	99342	99343	99347	99348	99349
99353

*Procedure codes 15999 , 17999, 28899 , 29999 , and J7340 are manually priced and require an operative report attached to a paper claim.

** Procedure codes 20974 and 20975 require prior authorization. See Section 221.000 for detailed instructions.

242.120Procedure Codes Requiring Prior Authorization 5-1-08

The following procedure codes require prior authorization before services may be provided.

20974

20975

242.440Bilaminate Graft or Skin Substitute Procedures 5-1-08

Arkansas Medicaid reimburses podiatrists who furnish the manufactured viable bilaminate graft or skin substitute. The product is manually priced and requires paper claims using procedure code J7340 . The manufacturer's invoice and the operative report must be attached.

Application procedures of bilaminate skin substitute are payable to the podiatrist using the appropriate procedure code(s). These codes must be listed separately when filing claims: CPT procedure codes 15170, 15175, 15340, 15341, 15365, and 15366. These codes do not require prior authorization but are reviewed for medical necessity.

Section II

Ambulatory Surgical Center

216.604 Bilaminate Graft or Skin Substitute Coverage Restriction 5-1-08

Arkansas Medicaid covers bilaminate graft or skin substitute, known as dermal and epidermal tissue of human origin, with or without bioengineered or processed elements, with metabolically active elements. The physician's application procedure is covered separately and must be indicated separately on the claim.

This product is designed for treatment of burn injuries and non-infected partial and full-thickness skin ulcers caused by venous insufficiency and for treatment of full-thickness neuropathic diabetic foot ulcers that extend through the dermis, but without tendon, muscle, capsule or bone exposure and which are located on the plantar, medial or lateral area of the foot (excluding the heel).

A.Indications and Documentation:

When the diagnosis is a burn injury (ICD-9 Code range 940.0 through 949.5, indicated on the claim form) not additional medical treatment documentation is required.

This modality/product is covered for other restricted diagnoses (indicated below) when all of the following conditions are met and are documented in the beneficiary's medical record:

1. Partial or full-thickness skin ulcers caused by venous insufficiency or full-thickness neuropathic diabetic foot ulcers,

2. Ulcers of more than three (3) months duration and

3. Ulcers that have failed to respond to documented conservative measures of more than two (2) months' duration.

4. There must be measurements of the initial ulcer size, the size of the ulcer following cessation of conservative management, and the size at the beginning of skin substitute treatment.

5. For neuropathic diabetic foot ulcers, appropriate steps to off-load pressure during treatment must be taken and documented in the patient's medical record.

6. The ulcer must be free of infection and underlying osteomyelitis; treatment of the underlying disease (e.g., peripheral vascular disease) must be provided and documented in conjunction with skin substitute treatment.

B.Diagnosis Restrictions:

Coverage of the bilaminate skin product and its application is restricted to the diagnoses represented by the ICD-9-CM codes:

454.0

454.2

250.8 (requires a fifth-digit subclassification)

707.10

707.13

707.14

707.15

940.0 through 949.50

The manufactured viable bilaminate graft or skin substitute product is manually priced and must be billed to Medicaid by paper claim with procedure code J7340. The manufacturer's invoice and the operative report must be attached. Application procedures of bilaminate skin substitute are payable using the appropriate procedure code(s). These codes must be listed separately when filing claims.

222.000Outpatient Surgeries That Require Prior Authorization 5-1-08

An asterisk (*) following a procedure code indicates that the claim for the procedure is manually reviewed and manually priced. Submit claims for those procedures on paper, with an operative report attached.

Outpatient Surgeries That Require Prior Authorization
11960	11970	11971	15400	15831	19301	19318	19324
19325	19328	19330*	19340	19342*	19350	19355*	19357
19361*	19364*	19366*	19367	19368	19369	19370	19371*
19380	20974*	20975*	21076*	21077	21079*	21080*	21081*
21082*	21083*	21084*	21085*	21086*	21087*	21088*	21089*
21120*	21121*	21122*	21123*	21125*	21127*	21137	21138*
21139*	21141*	21142*	21143*	21145*	21146*	21147*	21150*
21151*	21154*	21155*	21159*	21160*	21172*	21175*	21179*
21180*	21181*	21182*	21183*	21184*	21188*	21193*	21194*
21195*	21196	21198	21208	21209*	21244*	21245*	21246*
21247*	21248*	21249*	21255*	21256*	27412	27415	29866
29867	29868	30220*	30400	30410	30420	30430	30435
30450	30460	30462	33282	33284*	36470*	36471*	37785
37788*	38242	42820	42821	42825	42826	42842*	42844*
42845*	42860	42870	43257	43644	43645	43842*	43845
43846*	43847*	43848*	43850*	43855*	43860*	43865*	50320*
50340*	50360*	50365*	50370*	50380*	51925	54360	54400
54415	54416	54417	55400	57335	58150*	58152*	58180
58260	58262*	58263*	58267*	58270*	58275*	58280*	58290
58291	58292	58293	58294	58345	58550	58552	58553
58554	58672	58673	58750*	58752*	59135*	59840*	59841*
59850*	59851*	59852*	59855*	59856*	59857*	61850*	61860*
61870*	61875*	61880*	61885	61888	63650	63655*	63660
64555*	64809*	64818*	65710	65730	65750	65755	67900*
69300	69310	69320	69714	69715	69717	69718	69930

Section II

Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD)

217.090Bilaminate Graft or Skin Substitute Coverage Restriction 5-1-08

A.Indications and Documentation:

When the diagnosis is a burn injury (ICD-9-CM code range 940.0 through 949.5 indicated on the claim form) no additional medical treatment documentation is required.

This modality/product will be covered for other restricted diagnoses (indicated below) when all of the following provisions are met and are documented in the beneficiary's medical record:

1. Partial or full-thickness skin ulcers due to venous insufficiency or full-thickness neuropathic diabetic foot ulcers,

2. Ulcers of more than three (3) months duration and

3. Ulcers that have failed to respond to documented conservative measures of more than two (2) months' duration.

4. There must be measurements of the initial ulcer size, the size of the ulcer following cessation of conservative management, and the size at the beginning of skin substitute treatment.

5. For neuropathic diabetic foot ulcers, appropriate steps to off-load pressure during treatment must be taken and documented in the patient's medical record.

6. The ulcer must be free of infection and underlying osteomyelitis; treatment of the underlying disease (e.g., peripheral vascular disease) must be provided and documented in conjunction with skin substitute treatment.

B.Diagnosis Restrictions:

Coverage of the bilaminate skin product and its application is restricted to the diagnosed represented by the following ICD-9-CM codes:

454.0

454.2

250.8 (requires a fifth-digit subclassification)

707.10

707.13

707.14

707.15

940.0 through 949.50

C.Billing:

The manufactured viable bilaminate graft or skin substitute product is manually priced. It must be billed to Medicaid by paper claim with procedure code J7340. The manufacturer's invoice and the operative report must be attached.

Outpatient procedures to apply bilaminate skin substitute are payable using the appropriate procedure code(s). These codes must be listed separately when filing claims and may be billed electronically.

244.000Procedures that Require Prior Authorization 5-1-08

A. The procedures represented by the CPT and HCPCS codes in the following table require prior authorization (PA). The performing physician or dentist (or the referring physician or dentist, when lab work is ordered or injections are given by non-

physician staff) is responsible for obtaining required PA and forwarding the PA control number to appropriate hospital staff for documentation and billing purposes. A claim for any hospital services that involve a PA-required procedure must contain the assigned PA control number or Medicaid will deny it.

J1565	Q0182	11960	11970	11971	15342	15343	15831
19318	19324	19325	19328	19330	19340	19342	19350
19355	19357	19361	19364	19366	19367	19368	19369
19370	19371	19380	20974	20975	21076	21077	21079
21080	21081	21082	21083	21084	21085	21086	21087
21088	21089	21120	21121	21122	21123	21125	21127
21137	21138	21139	21141	21142	21143	21145	21146
21147	21150	21151	21154	21155	21159	21160	21172
21175	21179	21180	21181	21182	21183	21184	21188
21193	21194	21195	21196	21198	21199	21208	21209
21244	21245	21246	21247	21248	21249	21255	21256
22520	22521	22522	30220	30400	30410	30420	30430
30435	30450	30460	30462	33140	33282	33284	36470
36471	37785	37788	38242	42820	42821	42825	42826
42842	42844	42845	42860	42870	43842	43846	43847
43848	43850	43855	43860	43865	50320	50340	50360
50365	50370	50380	51925	54360	54400	54415	54416
54417	55400	57335	58150	58152	58180	58260	58262
58263	58267	58270	58275	58280	58290	58291	58292
58293	58294	58345	58550	58552	58553	58554	58672
58673	58750	58752	59135	59840	59841	59850	59851
59852	59855	59856	59857	59866	61850	61860	61870
61875	61880	61885	61886	61888	63650	63655	63660
63685	63688	64573	64585	64809	64818	65710	65730
65750	65755	67900	69300	69310	69320	69714	69715
69717	69718	69930	87901	87903	87904	92607	92608
93980	93981	92393

B. The following revenue codes require prior authorization.

Revenue Code	Description
0361	Outpatient dental surgery, Group I
0360	Outpatient dental surgery, Group II
0369	Outpatient dental surgery, Group III
0509	Outpatient dental surgery, Group IV

Section II

Physician/Independent Lab/CRNA/Radiation Therapy Center

253.000Bilaminate Graft or Skin Substitute 5-1-08

Arkansas Medicaid covers bilaminate graft or skin substitute, known as dermal and epidermal tissue of human origin, with or without bioengineered or processed elements, with metabolically active elements. The physician's application procedure is covered separately and must be indicated separately on the claim.

This product is designed for treatment of burn injuries and non-infected partial and full-thickness skin ulcers caused by venous insufficiency and for treatment of full-thickness neuropathic diabetic foot ulcers that extend through the dermis, but without tendon, muscle, capsule or bone exposure and which are located on the plantar, medial or lateral area of the foot (excluding the heel).

A.Indications and Documentation:

When the diagnosis is a burn injury (ICD-9-CM code range 940.0 through 949.5, indicated on the claim form) no additional medical treatment documentation is required.

This modality/product will be covered for other restricted diagnoses (indicated below) when all of the following conditions are met and are documented in the beneficiary's medical record:

1. Partial or full-thickness skin ulcers caused by venous insufficiency or full-thickness neuropathic diabetic foot ulcers

2. Ulcers of more than three (3) months duration

3. Ulcers that have failed to respond to documented conservative measures of more than two (2) months duration.

4. There must be measurements of the initial ulcer size, the size of the ulcer following cessation of conservative management and the size at the beginning of skin substitute treatment.

5. For neuropathic diabetic foot ulcers, appropriate steps must be taken to off-load pressure during treatment and documented in the patient's medical record.

6. The ulcer must be free of infection and underlying osteomyelitis; treatment of the underlying disease (e.g., peripheral vascular disease) must be provided and documented in conjunction with skin substitute treatment.

B.Diagnosis Restrictions:

Coverage of the bilaminate skin product and its application is restricted to the diagnoses represented by the following ICD-9-CM codes:

454.0

454.2

250.8 (requires a fifth-digit subclassification)

707.10

707.13

707.14

707.15

940.0 through 949.5

262.000Procedures That Require Prior Authorization 5-1-08

The following procedure codes require prior authorization:

Procedure Codes
00170	01966	11960	11970	11971	15400	19318	19324
19325	19328	19330	19340	19342	19350	19355	19357
19361	19364	19366	19367	19368	19369	19370	19371
19380	20974	20975	21076	21077	21079	21080	21081
21082	21083	21084	21085	21086	21087	21088	21089
21120	21121	21122	21123	21125	21127	21137	21138
21139	21141	21142	21143	21145	21146	21147	21150
21151	21154	21155	21159	21160	21172	21175	21179
21180	21181	21182	21183	21184	21188	21193	21194
21195	21196	21198	21199	21208	21209	21244	21245
21246	21247	21248	21249	21255	21256	27412	27415
29866	29867	29868	30220	30400	30410	30420	30430
30435	30450	30460	30462	32851	32852	32853	32854
33140	33282	33284	33945	36470	36471	37785	37788
38240	38241	38242	42820	42821	42825	42826	42842
42844	42845	42860	42870	43257	43644	43645	43842
43845	43846	43847	43848	43850	43855	43860	43865
47135	48155	48160	48554	48556	50320	50340	50360
50365	50370	50380	51925	54360	54400	54415	54416
54417	55400	57335	58150	58152	58180	58260	58262
58263	58267	58270	58280	58290	58291	58292	58293
58294	58345	58550	58552	58553	58554	58672	58673
58750	58752	59135	59840	59841	59850	59851	59852
59855	59856	59857	59866	60512	61850	61860	61862
61870	61875	61880	61885	61886	61888	63650	63655
63660	63685	63688	64555	64573	64585	64809	64818
65710	65730	65750	65755	67900	69300	69310	69320
69714	69715	69717	69718	69930	87901	87903	87904
92081	92100	92326	92393	93980	93981	J7319	J7320
J7330	L8614	L8615	L8616	L8617	L8618	L8619	S2213

Procedure Code	Modifier	Description
E0779	RR	Ambulatory infusion device
D0140	EP	EPSDT interperiodic dental screen
J7330		Autologous cultured chondrocytes, implant
L8619	EP	External sound processor
SO512*		Daily wear specialty contact lens, per lens
V2501*	UA	Supplying and fitting Keratoconus lens (hard or gas permeable) - 1 lens
V2501*	U1	Supplying and fitting of monocular lens (soft lens) - 1 lens
V5014**		Repair/modification of a hearing aid
Z1930		Non-emergency hysterectomy following c-section
92002*	UB	Low vision services - evaluation

*Procedures payable to physicians under Visual Services program. Contact DMS, Medical Assistance, for information on prior authorization protocol for these codes. View or print contact information for Arkansas Division of Medical Services, Visual Care Coordinator.

**Procedures payable to physicians under Hearing Services program. Contact DMS, Utilization Review, for information on prior authorization protocol for these codes. View or print contact information for Arkansas Division of Medical Services, Utilization Review Section .

292.870Bilaminate Graft or Skin Substitute Procedures 5-1-08

Arkansas Medicaid reimburses physicians who furnish the manufactured viable bilaminate graft or skin substitute. The product is manually priced and requires paper claims using procedure code J7340 . The manufacturer's invoice and the operative report must be attached.

Application procedures for bilaminate skin substitute are payable to physicians and must be listed separately on claims.

016.06.08 Ark. Code R. § 010

4/8/2008