016.06.06 Ark. Code R. 015

Current through Register Vol. 49, No. 9, September, 2024

Rule 016.06.06-015 - Ambulatory Surgical Center Provider Manual Update Transmittal #66

Section IIAmbulatory Surgical Center

201.100Ambulatory Surgical Centers (ASCs) in States Not Bordering Arkansas

A. ASCs in states not bordering Arkansas are called limited services providers because they may enroll in Arkansas Medicaid only after they have treated an Arkansas Medicaid beneficiary and have a claim to file, and because their enrollment automatically expires.

1. A non-bordering state ASC may send a claim to Provider Enrollment and Provider Enrollment will forward by return mail a provider manual and a provider application and contract. View or print Provider Enrollment Unit Contact information.

2. Alternatively, a non-bordering state ASC may download the provider manual and provider application materials from the Arkansas Medicaid website, www.medicaid.state.ar.us, and then submit its application and claim to the Medicaid Provider Enrollment Unit.

B. Limited services providers remain enrolled for one year.

1. If a limited services provider treats another Arkansas Medicaid beneficiary during its year of enrollment and bills Medicaid, its enrollment may continue for one year past the newer claim's last date of service, if the ASC keeps the provider file current.

2. During its enrollment period the provider may file any subsequent claims directly to EDS.

3. Limited services providers are strongly encouraged to submit claims through the Arkansas Medicaid website because the front-end processing of web-based claims ensures prompt adjudication and facilitates reimbursement.

216.800Verteporfin (Visudyne)

A. Arkansas Medicaid covers Verteporfin for all ages for certain diagnoses and subject to certain conditions and documentation requirements.

1. Coverage of Verteporfin is separate from coverage of the injection procedure.

2. The injection procedure is covered as an outpatient surgery (see section 242.146 for billing requirements).

B. The beneficiary's medical record in the provider's files must document an eye exam recent enough to establish the patient's current visual acuity. See section 242.146 for billing requirements.

C. The diagnosis must be among the following.

1. Predominantly classic subfoveal choroidal neovascularization due to age-related macular degeneration

2. Pathologic myopia

3. Presumed ocular histoplasmosis

D. The lesion size determination must be included in the documentation of the eye exam.

E The eye or eyes to be treated by Verteporfin administration must be identified, with current visual acuity noted.

F. If previous treatments with other modalities have been attempted, those attempts and outcomes must be documented as well.

242.146Verteporfin (Visudyne)

A. Medicaid reimburses outpatient hospitals for Verteporfin (Visudyne), HCPCS procedure code J3396 when it is furnished to Medicaid beneficiaries of any age With an appropriate diagnosis..

1. Reimbursement for Verteporfin is not included in the reimbursement for the related surgical procedure;

2. Providers may bill Medicaid separate charges for Verteporfin and the related surgical procedure.

B. Claims for Verteporfin administration must include one of the following ICD-9-CM diagnosis codes.

115.02

115.12

115.92

360.21

362.50

362.52

C. Use anatomical modifiers to identify the eye(s) being treated.

D.J3396 may be billed electronically or on a paper claim.

E. See section 216.800 for coverage information

016.06.06 Ark. Code R. 015

5/5/2006