016.06.19 Ark. Code R. 014

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.19-014 - ARKids First-B

222.750Health Education

Health education is a required component of screening services and includes anticipatory guidance. The developmental assessment, comprehensive, physical examination, and the visual, hearing or dental screening provide the initial opportunity for providing health education. Health education and counseling to parents (or guardians) and children are required. Health education and counseling are designed to assist in understanding what to expect in terms of the child's development and to provide information about the benefits of healthy lifestyles and practices, as well as accident and disease prevention. See Section 262.130 for procedure codes.

Health education can include but isn't limited to tobacco cessation counseling services to the parent/legal guardian of the child.

A. Counseling Visits (two (2) per SFY):

Current Procedure Code	Current Modifier	Arkansas Medicaid Description
99406*	SE	*** (Smoking and tobacco use cessation counseling visit; intermediate, 15-minutes)
99406*	CG	*** (Smoking and tobacco use cessation counseling visit, intermediate, 15-minutes provided to parents of children birth through twenty (20) years of age)
99407*	SE	*** (Smoking and tobacco use cessation counseling visit; intensive, 30-minutes)
99407*	CG	*** (Smoking and tobacco use cessation counseling visit, intensive, 30-minutes provided to parents of children birth through twenty (20) years of age)

* Exempt from PCP referral requirements.

*** (...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the service. When using a procedure code with this symbol, the service must meet the indicated Arkansas Medicaid description.

B. Referral of patient to an intensive tobacco cessation referral program.

C. These counseling sessions can be billed in addition to an office visit or EPSDT.

D. If the beneficiary is under the age of eighteen (18), and the parent/legal guardian smokes, he or she can be counseled as well, and the visit billed under the minor's beneficiary Medicaid number. The provider cannot prescribe meds for the parent under the child's Medicaid number. A parent/legal guardian session will count towards the four (4) counseling sessions limit described in section C above.

E. Tobacco cessation sessions do NOT require a PCP referral.

F. The provider must complete the counseling checklist and place in the patient records for audit. View or Print the Arkansas Be Well Referral Form.

Refer to Section 257.000 and Section 292.900 of the Primary Care Physician manual for more information.

272.452 Tobacco Cessation Counseling Services

A. Tobacco cessation counseling and products are covered services to eligible Medicaid beneficiaries. Tobacco cessation products either prescribed or initiated through statewide pharmacist protocol are available without prior authorization (PA) to eligible Medicaid beneficiaries. Additional information can be found on the DHS Contracted Pharmacy Vendor website or in the Prescription Drug Program Prior Authorization Criteria.

Current Procedure Code	Current Modifier	Arkansas Medicaid Description
99406*	SE	*** (Smoking and tobacco use cessation counseling visit; intermediate, 15-minutes)
99406*	CG	*** (Smoking and tobacco use cessation counseling visit, intermediate, 15-minutes provided to parents of children birth through twenty (20) years of age)
99407*	SE	*** (Smoking and tobacco use cessation counseling visit; intensive, 30-minutes)
99407*	CG	*** (Smoking and tobacco use cessation counseling visit, intensive, 30-minutes provided to parents of children birth through twenty (20) years of age)

* Exempt from PCP referral requirements.

*** (...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the covered service. When using a procedure code with this symbol, the service must meet the indicated Arkansas Medicaid description.

B. Two (2) Counseling visits per state fiscal year.

C. Health education can include but is not limited to tobacco cessation counseling services to the parent/legal guardian of the child.

D. Can be billed in addition to an office visit or EPSDT.

E. Sessions do not require a PCP referral.

F. If the beneficiary is under the age of eighteen (18) and the parent/legal guardian smokes, he or she can be counseled as well, and the visit billed under the minor's beneficiary Medicaid number. The provider cannot prescribe meds for the parent under the child's Medicaid number. A parent/legal guardian session will count towards the four (4) counselling sessions limit described in section C above.

The provider must complete the counseling checklist and place in the patient records for audit. A copy of the checklist is available at View or Print Be Well Arkansas Referral Form

Section II

Child Health Services/Early and Periodic Screening, Diagnosis, and Treatment

215.290Health Education

Health education is a required component of screening services and includes anticipatory guidance. The developmental assessment, comprehensive physical examination, visual, hearing or dental screening provides the initial opportunity for providing health education. Health education and counseling to parents (or guardians) and children are required. Health education and counseling are designed to assist in understanding what to expect in terms of the child's development and to provide information about the benefits of healthy lifestyles and practices, as well as accident and disease prevention. See Section 242.100 for procedure codes.

Health education can include but isn't limited to tobacco cessation counseling services to the parent/legal guardian of the child.

A. Counseling Visits:

Current Procedure Code	Current Modifier	Arkansas Medicaid Description
99406*	SE	(Smoking and tobacco use cessation counseling visit; intermediate, 15-minutes)
99406*	CG	*** (Smoking and tobacco use cessation counseling visit, intermediate, 15-minutes provided to parents of children birth through twenty (20) years of age)
99407*	SE	*** (Smoking and tobacco use cessation counseling visit; intensive, 30-minutes)
99407*	CG	*** (Smoking and tobacco use cessation counseling visit, intensive, 30-minutes provided to parents of children birth through twenty (20) years of age)

* Exempt from PCP referral requirements.

B. Referral of patient to an intensive tobacco cessation referral program.

C. Can be billed in addition to an office visit or EPSDT.

E. These counseling sessions do NOT require a PCP referral.

F. The provider must complete the counseling checklist and place in the patient records for audit. View or Print the Arkansas Be Well Referral Form.

Refer to Section 257.000 and Section 292.900 of the Physician's manual for more information.

242.100Procedure Codes

The table below contains procedure codes, the associated modifiers to be used with the individual code, and a description of each EPSDT service.

Procedure Code	Modifier 1	Modifier 2	Description
99381-99385	EP	U1	EPSDT Periodic Complete Medical Screen (New Patient)
99381-99385¹	EP	H9	EPSDT Periodic Complete Medical Screen (Foster Care)
99391-99395	EP	U2	EPSDT Periodic Complete Medical Screen (Established Patient)
99391-99395¹	EP	H9	EPSDT Periodic Complete Medical Screen (Foster Care)
99460	EP	UA	Initial Hospital/birthing center care, normal newborn (global)
99461	EP	UA	Initial care normal newborn other than hospital/birthing center (global)
99463	EP	UA	Initial hospital/birthing center care, normal newborn admitted/discharged same date of service (global)
99173¹	EP	EPSDT Periodic Vision Screen
V5008¹	EP	EPSDT Periodic Hearing Screen
T1502	EP	Admin, of oral, intramuscular, or subcutaneous medication by health care agency/professional, per visit.
DO120¹	CHS/EPSDT Oral Examination
D0140¹	EPSDT Interperiodic Dental Screen, with prior authorization
99401	EP	EPSDT Health Education - Preventive Medical Counseling
99406¹	SE	*** (Smoking and tobacco use cessation counseling visit; intermediate, 15-minutes)
99406	CG	*** (Smoking and tobacco use cessation counseling visit, intermediate, 15-minutes provided to parents of children birth through twenty (20) years of age)
99407¹	SE	*** (Smoking and tobacco use cessation counseling visit; intensive, 30-minutes)
99407	CG	*** (Smoking and tobacco use cessation counseling visit, intensive, 30-minutes provided to parents of children birth through twenty (20) years of age)
99070	EP	Supplies and materials provided by physician over and above those covered by the office visit or other services rendered.
36415²	Collection of venous blood by venipuncture
83655	Lead

*** (...)This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the service. When using a procedure code with this symbol, the service must meet the indicated Arkansas Medicaid description.

Other coding information found in the chart:

1 Exempt from PCP referral requirements

2 Covered when specimen is referred to an independent lab

Electronic and paper claims require use of modifiers. When filing paper claims for a Child Health Services (EPSDT) screening service, the applicable modifier must be entered on the claim form.

See Section 212.000 for Child Health Services (EPSDT) screening terminology.

NOTES

A. Arkansas Medicaid is no longer able to process both a sick visit and an EPSDT screening visit when performed on the same date of service without the appropriate modifier (Modifier 25). Modifier 25 must be indicated in the first position of the second billed service. This change surpasses the Medicaid policy to not bill modifiers on a sick visit when performed on the same date of service as an EPSDT screening.

B. New born screenings can be performed by a Certified Nurse Midwife or Nurse Practitioner without a PCP referral.

C. Procedure codes 99381-99385 and 99391-99395, used in conjunction with the EP and H9 modifiers, are to be used only for the required intake physical examination for Medicaid beneficiaries in the Arkansas foster care system. (See Section 214.300 for more information.)

D. Claims for EPSDT medical screenings must be billed electronically or by using the CMS-1500 claim form. 99460, 99461, and 99463 may be billed on the CMS-1500 claim form, by paper or electronically. (View or print a CMS-1500 sample form.) 99460, 99461 and 99463 may also be billed as EPSDT in the electronic transaction format or on the CMS-1500 paper form.

E. Laboratory/X-ray and immunizations associated with a Child Health Services (EPSDT) screen may be billed on the CMS-1500 claim form.

F. Immunizations and laboratory tests may be billed separately from comprehensive screens.

G. The verbal assessment of lead toxicity risk is part of the complete Child Health Services (EPSDT) screen. The cost for the administration of the risk assessment is included in the fee for the complete screen.

H.T1502 may be used for billing in the office place of service (11) for the administration of subcutaneous or IM injections ONLY when the provider administers, but does not supply the drug.

1.T1502 cannot be billed when the medication is administered orally. No fee is billable for drugs administered orally.

2.T1502 cannot be billed to administer any medication given for family planning purposes.

3.T1502 cannot be billed when the drug administered is not FDA approved.

I. Procedure code 99070 is payable to physicians for supplies and materials (except eyeglasses), provided by the physician over and above those usually included with the office visit or other services rendered. Procedure code 99070 must not be billed for the provision of drug supply samples and may not be billed on the same date of service as a surgery code. Claims require National Place of Service code "11". Procedure code 99070 is limited to beneficiaries under age twenty-one (21).

214.100Tobacco Cessation Products and Counseling Services

Tobacco cessation products either prescribed or initiated through statewide pharmacist protocol are available without prior authorization (PA) to eligible Medicaid beneficiaries. Additional information can be found on the DHS Contracted Pharmacy Vendor website or in the Prescription Drug Program Prior Authorization Criteria.

Counseling services and benefits are defined below:

A. Prescribers must review the Public Health Service (PHS) guideline-based checklist with the patient.

B. The prescriber must retain the counseling checklist and file in the patient records for auditing. View or print the checklist.

C. Counseling procedures do not count against the twelve (12) visits per state fiscal year (SFY), but they are limited to no more than two (2) 15-minute units and two (2) 30-minute units for a maximum allowable of four (4) units per SFY.

D. For beneficiaries age twenty-one (21) and over, counseling procedures will count against the $500 adult dental benefit limit. If the beneficiary is under the age of eighteen (18), and the parent/legal guardian smokes, he or she can be counseled as well, and the visit billed under that minor's beneficiary Medicaid number. The provider cannot prescribe meds for the parent under the child's Medicaid number. A parent/legal guardian session will count towards the four (4) counseling sessions limit described in section C above.

E. Beneficiaries who are pregnant are allowed up to four (4) 93-day courses of treatment per calendar year.

NOTE: The course of treatment is defined as three consecutive months.

F. If the beneficiary is in need of intensive tobacco cessation services, the provider may refer the beneficiary to an intensive tobacco cessation program: View or print the Arkansas Be Well Referral Form.

G. Additional prescription benefits will be allowed per month for tobacco cessation products and will not be counted against the monthly prescription benefit limit. Tobacco cessation products are not subject to co-pay.

H. D1320 - Tobacco counseling for the control and prevention of oral disease must be billed when the provider counsels and refers the beneficiary to an intensive tobacco cessation program.

I. D9920 - Behavior management by report must be billed when tobacco counseling for the control and prevention of oral disease has been provided to the beneficiary.

J. Refer to Section 262.100 and 262.200 for procedure codes and billing instructions.

252.454Tobacco Cessation Products and Counseling Services

Current Procedure Code	Current Modifier	Arkansas Medicaid Description
99406*	SE	*** (Smoking and tobacco use cessation counseling visit; intermediate, 15-minutes)
99406*	CG	*** (Smoking and tobacco use cessation counseling visit, intermediate, 15-minutes provided to parents of children birth through twenty (20) years of age)
99407*	SE	*** (Smoking and tobacco use cessation counseling visit; intensive, 30-minutes)
99407*	CG	*** (Smoking and tobacco use cessation counseling visit, intensive, 30-minutes provided to parents of children birth through twenty (20) years of age)

* Exempt from PCP referral requirements.

B. Two (2) Counseling visits per state fiscal year.

C. Health education can include but is not limited to tobacco cessation counseling services to the parent/legal guardian of the child.

D. Can be billed in addition to an office visit or EPSDT.

E. Sessions do not require a PCP referral.

F. If the beneficiary is under the age of eighteen (18), and the parent/legal guardian smokes, he or she can be counseled as well, and the visit billed under the minor's beneficiary Medicaid number. The provider cannot prescribe meds for the parent under the child's Medicaid number. A parent/legal guardian session will count towards the four (4) counselling sessions limit described in section C above.

The provider must complete the counseling checklist and place in the patient records for audit. A copy of the checklist is available at View or Print Be Well Arkansas Referral Form

201.100Arkansas Medicaid Participation Requirements for Pharmacies Administering Vaccines

The Arkansas Medicaid Program will reimburse pharmacies the cost and administration fee for selected vaccines and immunizations for Medicaid beneficiaries seven (7) years of age to eighteen (18) years of age under a general written protocol and written consent of the parent or legal guardian of the minor. Consent must be obtained before the administration of the vaccine or immunization. Written protocol and consent must be retained and is subject to reporting requirements. The Arkansas Medicaid Program will continue to reimburse pharmacies the cost and administration fee of selected vaccines for Medicaid beneficiaries nineteen (19) years of age and older. For a complete list of covered vaccines and CMS-1500 billing instructions, please refer to the CMS-1500 Claim Form Billing Instructions.

The Arkansas Medicaid Program will reimburse pharmacies the administration fee for selected vaccines that are obtained through the Vaccine for Children Program (VFC) or ARKids-B SCHIP Vaccine Program. Please refer to section 292.950 of the Physician manual for VFC vaccines billing procedures and section 262.430 for ARKids-B SCHIP vaccine. All Arkansas State Board of Pharmacy laws and regulations will apply.

To be eligible for participation, the pharmacy must meet the following criteria, in addition to those specified in Section 201.000:

A. Complete Section III, I tem 22, of the enrollment application (view or print Provider Enrollment application material) if the pharmacist is certified to administer the influenza virus and pneumococcal polysaccharide vaccines and

B. Pharmacies must be enrolled in the Title XVIII (Medicare) Program to administer the vaccines.

Refer to Section 210.100 for scope of coverage; Section 213.000 for benefit limits.

211.000Scope

The Arkansas Medicaid Pharmacy Program conforms to 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. A numeric listing of approved pharmaceutical companies and their respective labeler codes is located on the DHS Contracted Pharmacy Vendor website. View or print numeric listing of approved pharmaceutical companies and their respective labeler codes. Except for drugs in the categories excluded from coverage, Arkansas Medicaid covers all drug products manufactured by companies with listed labeler codes. Additions or deletions by labelers are submitted to the State by the Centers for Medicare and Medicaid Services (CMS), the website will be updated.

The Arkansas Medicaid Program will cover the following drug categories:

A. Prescription drugs are covered by the Arkansas Medicaid Program pursuant to an order from an authorized prescribes The Drug Listing located on the DHS Contracted Pharmacy Vendor website lists those products covered by the Arkansas Medicaid Program that have a State Actual Acquisition Cost (SAAC).

As changes are made to the drug coverage, providers will be notified of the revisions.

B. Over-the-counter items are listed on the DHS Contracted Pharmacy Vendor website. These items are covered only if they contain an appropriate National Drug Code on their label and are manufactured by a company that has signed a rebate agreement. Over-the-counter items are not covered for long-term care facility residents. View or print a list of over-the-counter items.

The Arkansas Medicaid Program will reimburse pharmacies the cost and administration fee for selected vaccines and immunizations for Medicaid beneficiaries age seven (7) years of age to eighteen (18) years of age under a general written protocol and written consent of the parent or legal guardian of the minor. Consent must be obtained before the administration of the vaccine or immunization. Written protocol and consent must be retained and is subject to reporting requirements. The Arkansas Medicaid Program will continue to reimburse pharmacies the cost and administration fee of selected vaccines for Medicaid beneficiaries age nineteen (19) and older. For a complete list of covered vaccines and CMS-1500 billing instructions, please refer to the CMS-1500 Claim Form Billing Instructions . No primary care physician (PCP) referral is required to administer the vaccines.

The influenza virus vaccine is limited to one (1) per state fiscal year (July through June). The pneumococcal polysaccharide vaccine is limited to one every ten (10) years.

The Arkansas Medicaid Program will reimburse pharmacies the administration fee for selected vaccines that are obtained through the Vaccine for Children Program (VFC) or ARKids-B SCHIP Vaccine program. Please refer to section 292.950 of the Physician manual for VFC vaccines billing procedures and section 262.430 for ARKids-B SCHIP vaccine. No primary care physician (PCP) referral is required to administer the vaccines. All Arkansas State Board of Pharmacy laws and regulations will apply.

Effective 8/1/15, ARKids-B beneficiaries are no longer eligible for the VFC program. However, providers are still able to obtain vaccines to administer to ARKids-B beneficiaries by contacting the Arkansas Department of Health (ADH) and indicating the need to order "ARKids-B SCHIP vaccines or Vaccines for Children (VFC)." VFC vaccines can also still be obtained by contacting ADH. For dates of service on or after 8/1/15, modifier "SL" will be required when billing for the administration of SCHIP vaccines to ARKids-B beneficiaries. Modifier EP, TJ is required when billing for administration of VFC vaccines for ARKids-A beneficiaries.

Medicaid will reimburse the Medicare deductible or coinsurance for all beneficiaries receiving both Medicare and Medicaid benefits in reference to vaccines.

Pharmacies must use the CMS-1500 claim form when billing Medicaid for these vaccines.

241.000Coverage of Tobacco Cessation Products

Effective for claims with dates of service on or after January 1, 2020, coverage of tobacco cessation products either prescribed or initiated through statewide pharmacist protocol is available without prior authorization (PA) to eligible Medicaid beneficiaries. Additional information can be found on the DHS Contracted Pharmacy Vendor website or in the Prescription Drug Program Prior Authorization Criteria.

Coverage and Limitations

A. Reimbursement for tobacco cessation products is available for all prescription and over the counter (OTC) products, and subject to be within FDA prescribing and dosing limitations.

B. Additional prescription benefits are allowed per month for tobacco cessation products and will not count against the monthly prescription benefit limit. Tobacco cessation products are not subject to co-pay.

C. OTC as well as any prescription products are eligible for reimbursement. OTC products are not covered for long-term care residents.

D. Arkansas Medicaid will provide coverage of prescription and OTC smoking/tobacco cessation covered outpatient drugs for pregnant women as recommended in "Treating Tobacco Use and Dependence - 2008 Update: A Clinical Practice Guideline" published by the Public Health Service in May 2008 or any subsequent modification of such guideline.

257.000Tobacco Cessation Products and Counseling Services

A. Physician providers may participate by prescribing covered tobacco cessation products. Reimbursement for tobacco cessation products is available for all prescription and over the counter (OTC) products and subject to be within U.S. Food and Drug Administration prescribing guidelines.

B. Counseling by the prescriber is required to obtain initial prior authorization (PA) coverage of the products. Counseling consists of reviewing the Public Health Service (PHS) guideline-based checklist with the patient. The prescriber must retain the counseling checklist in the patient records for audit. View or Print the Arkansas Be Well Referral Form.

D. Counseling sessions can be billed in addition to an office visit or EPSDT. These sessions do not require a PCP referral.

E. If beneficiary is under the age of eighteen (18), and the parent/legal guardian smokes, he or she can be counseled as well, and the visit billed under the minor's beneficiary Medicaid number. The provider cannot prescribe meds for the parent under the child's Medicaid number. A parent/legal guardian session will count towards the four (4) counseling sessions limit described in section C above.

F. Additional prescription benefits will be allowed per month for tobacco cessation products and will not be counted against the monthly prescription benefit limit. Tobacco cessation products are not subject to co-pay.

G. Arkansas Medicaid will provide coverage of prescription and over the counter (OTC) smoking/tobacco cessation covered outpatient drugs for pregnant women as recommended in "Treating Tobacco Use and Dependence - 2008 Update: A Clinical Practice Guideline" published by the Public Health Service in May 2008 or any subsequent modification of such guideline.

H. Refer to Section 292.900 for procedure codes and billing instructions.

292.900Tobacco Cessation Counseling Services

Current Procedure Code	Current Modifier	Arkansas Medicaid Description
99406*	SE	*** (Smoking and tobacco use cessation counseling visit; intermediate, 15-minutes)
99406*	CG	*** (Smoking and tobacco use cessation counseling visit, intermediate, 15-minutes provided to parents of children birth through twenty (20) years of age)
99407*	SE	*** (Smoking and tobacco use cessation counseling visit; intensive, 30-minutes)
99407*	CG	*** (Smoking and tobacco use cessation counseling visit, intensive, 30-minutes provided to parents of children birth through twenty (20) years of age)

* Exempt from PCP referral.

B. Two (2) Counseling visits per state fiscal year.

C. Health education can include but is not limited to tobacco cessation counseling services to the parent/legal guardian of the child.

D. Can be billed in addition to an office visit or EPSDT.

E. Sessions do not require a PCP referral.

F. If the beneficiary is under the age of eighteen (18), and the parent/legal guardian smokes, he or she can be counseled as well, and the visit billed under the minor's beneficiary Medicaid number. The provider cannot prescribe meds for the parent under the child's Medicaid number. A parent/legal guardian session will count toward the four (4) counseling session limit described in section C above.

G. The provider must complete the counseling checklist and place in the patient records for audit. View or Print the Arkansas Be Well Referral Form

Oral surgeons must use procedure code D9920 for one 15-minute unit and procedure code D1320 for one 30-minute unit when filing claims on the American Dental Association (ADA).

See Section 257.000 of this manual for coverage and benefit limit information.

016.06.19 Ark. Code R. 014

Adopted by Arkansas Register Volume MMXX Number 08, Effective 2/1/2020