ND Medicaid Procedure Code Look-Up

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Procedure Code Look-up Tool

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The procedure code information displayed is limited to one code per search.

The Procedure Code Look-up Tool is used to identify procedure codes that ND Medicaid covers, with key requirements for each code divided into the following sections:

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Summary

Category – Category to which a procedure code is assigned to
- Dental
- DME (Durable Medical Equipment)
- Drugs
- Labs
- Professional
Covered – Identifies if ND Medicaid covers the code
Telemedicine Allowed - Identifies if the code can be provided via Telehealth

Rates

Anesthesia Base – Anesthesia base rate established by CMS.
Professional Rate – Rate applied with modifier -26
Technical Rate – Rate applied with modifier -TC
General Rate – Procedures paid on RVU, flat rate, or total component

Rental Rate – Rate applied with modifier RR for DME
ASC Rate - Facility Rate for ASC. The procedure is not reimbursed in an ASC setting if no rate exists.
Child Rate - Rate applied to CDT© dental codes for members through age 20
Adult Rate - Rate applied to CDT© dental codes for members 21 and over.

*Only the current rate is displayed, please refer to the Rates and Fee Schedule page for previous rates.

Requirements

NDC Required – Identifies if a procedure code requires submitting a National Drug Code on the claim.

Federally Qualified Health Center (FQHC) Generate Encounter – Identifies if the procedure code qualifies to be paid at an encounter rate.

Rural Health Clinic (RHC) Generate Encounter – Identifies if the procedure code qualifies to be paid at an encounter rate.

Ordering/Referring/Prescribing Provider NPI required – Identifies if a procedure code requires submitting an ORP NPI on the claim.

Durable Medical Equipment (DME)

Identifies if the durable medical equipment (DME) item is the responsibility of a;

Intermediate Care Facility (ICFID)
Nursing Facility
Swing Bed

Dental

Identifies if the procedure code requires the submission of;

Tooth number
Tooth quadrant
Tooth surface

Authorization and Notes

Identifies the following;

Service Authorization Requirements, including the URL to obtain the SA form.
General notes related to the procedure code
Links to related policies that apply to the procedure code

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The information in the tool does not guarantee payment. Claims may be denied for other reasons, such as system edits or failure to meet ND Medicaid eligibility or enrollment criteria. Providers should refer to Provider Guidelines, Manuals, and Policies for detailed coverage information, limitations, and Rates and Fee Schedules to help determine if a specific code is covered for their provider type.

Data contained in the Procedure Code Look-up Tool is refreshed weekly on Sunday morning.