Provider Guidelines, Manuals and Policies

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Download guidelines for provider enrollment and Medicaid-covered services (1203 KB) - July 2023

General Information for Providers Manual


Specialty Manuals and Guidelines

Refer to the General Information for Providers Manual for additional information and guidelines that may apply. It is the provider’s responsibility to ensure they are adhering to all published manuals, guidelines and other ND Medicaid sources of information.

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Behavioral Health
Dental

Manuals

Dental Provider Manual (July 2023)

Training

Durable Medical Equipment
Family Support
Institutions for Mental Diseases (IMD)

IMD policy (Updated June 2023)

Non-Emergency Medical Transportation

Non-Emergency Documentation Guidelines

Published by Centers for Medicare & Medicaid Services (CMS). As the document indicates, it is a general reference and policies and procedures vary by state.

Visit website: Non-Emergency Medical Transportation Toolkit

Nursing Facility

The department’s vendor Ascend, a Maximus company, has updated its manuals and forms. Some information is proprietary. Providers should visit Ascend’s website to access current versions of this information. The link appears below.

Visit website: Ascend PASRR/Level of Care manual and forms

For assistance, call 1-833-997-2777

Targeted Case Management

Serious Mental Illness/Serious Emotional Disturbance (Updated October 1, 2022) (174kb pdf)

Child Welfare (Updated July 2022) (181 kb pdf)

  • Visit website: ONLINE Training - Medicaid Targeted Case Management for Child Welfare Professionals

High-Risk Pregnant Women (Updated Oct. 2020) (216 kb pdf)

Pharmacy
Under 21 Psychiatric Providers

The department’s vendor Ascend, a Maximus company, has updated its manuals and forms. Some information is proprietary. Providers should visit Ascend’s website to access current versions of this information.

Visit website: Ascend tools, forms and resources

For assistance, call 1-629-230-5034

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Medicaid Coding Guidelines

CPT codes, descriptions and other data only are copyright 2023 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.

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Chiropractic Services

Coding Guideline for Chiropractic Services

CPT® Codes:   

98940        Chiropractic manipulative treatment (cmt); spinal, 1-2 regions

98941        Chiropractic manipulative treatment (cmt); spinal, 3-4 regions

98942        Chiropractic manipulative treatment (cmt); spinal, 5 regions   

72020        Radiologic examination, spine, single view, specify level

72040        Radiologic examination, spine, cervical; 2 or 3 views

72050        Radiologic examination, spine, cervical; 4 or 5 views

72052        Radiologic examination, spine, cervical; 6 or more views

72070        Radiologic examination, spine, thoracic, 2 views

72072        Radiologic examination, spine, thoracic, 3 views

72074        Radiologic examination, spine, thoracic, minimum of 4 views

72080        Radiologic examination, spine, thoracolumbar, 2 views

72100        Radiologic examination, spine, lumbosacral; 2 or 3 views

72110        Radiologic examination, spine, lumbosacral; minimum of 4 views

72114        Radiologic examination, spine, lumbosacral; complete, incl bending views, min  6 views

72120        Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views

72220        Radiologic examination, sacrum, and coccyx, minimum of 2 views

Criteria for Reimbursement:

  • Payment for manual manipulation of the spine is limited to one manipulation per day and may not exceed 20 manipulations per calendar year. Effective for dates of service on or after January 1, 2005, North Dakota Medicaid will allow reimbursement to chiropractors for Evaluation and Management (E/M) office and other outpatient Services – New Patient (99202-99203). These E/M services may be billed in addition to the chiropractic manipulative treatment (98940-98942) ONLY when the patient has not received any professional (face-to-face) services from the chiropractor, or another chiropractor of the same group practice, within the past three years.
  • Payment for X-rays may not exceed two (2) per year and are limited to radiological examinations of the full spine; the cervical, thoracic, lumbar, and lumbosacral areas of the spine.
  • Chiropractic services are billed on paper using the CMS-1500 form, or electronically using the standard 837-P HIPAA transaction.

Diagnosis Code Requirements:

  • Two diagnostic codes must be listed on the claim to support medical necessity:
  • The level of subluxation must be specified on the claim and must be listed as the primary diagnosis.
  • The associated neuromusculoskeletal condition necessitating the treatment must also be listed as the secondary diagnosis.

   

ICD-10-CM Covered Diagnosis

Subluxation Codes

 M99.00    Segmental and somatic dysfunction of head region

 M99.01    Segmental and somatic dysfunction of cervical region

 M99.02    Segmental and somatic dysfunction of thoracic region

 M99.03    Segmental and somatic dysfunction of lumbar region

 M99.04    Segmental and somatic dysfunction of sacral region

 M99.05    Segmental and somatic dysfunction of pelvic region

Associated Neuromusculoskeletal Condition Codes

G44.1          Vascular headache, not elsewhere classified

G44.209    Tension-type headache, unspecified, not intractable

G44.219    Episodic tension-type headache, not intractable

G54.0      Brachial plexus disorders

G54.1      Lumbosacral plexus disorders

G54.2      Cervical root disorders, not elsewhere classified

G54.3      Thoracic root disorders, not elsewhere classified

G54.4      Lumbosacral root disorders, not elsewhere classified

G54.8      Other nerve root and plexus disorders

G55        Nerve root and plexus compressions in diseases classified elsewhere

M24.50     Contracture, unspecified joint

M25.50     Pain in unspecified joint

M43.01     Spondylolysis, occipito-atlanto-axial region

M43.02     Spondylolysis, cervical region

M43.03     Spondylolysis, cervicothoracic region

M43.04     Spondylolysis, thoracic region

M43.05     Spondylolysis, thoracolumbar region

M43.06     Spondylolysis, lumbar region

M43.07     Spondylolysis, lumbosacral region

M43.08     Spondylolysis, sacral and sacrococcygeal region

M43.09     Spondylolysis, multiple sites in spine

M43.10     Spondylolisthesis, site unspecified

M43.11     Spondylolisthesis, occipito-atlanto-axial region

M43.12     Spondylolisthesis, cervical region

M43.13     Spondylolisthesis, cervicothoracic region

M43.14     Spondylolisthesis, thoracic region

M43.15     Spondylolisthesis, thoracolumbar region

M43.16     Spondylolisthesis, lumbar region 

M43.17     Spondylolisthesis, lumbosacral region

M43.18     Spondylolisthesis, sacral and sacrococcygeal region

M43.19     Spondylolisthesis, multiple sites in spine

M43.20     Fusion of spine, site unspecified

M43.21     Fusion of spine, occipito-atlanto-axial region

M43.22     Fusion of spine, cervical region

M43.23     Fusion of spine, cervicothoracic region

M43.24     Fusion of spine, thoracic region

M43.25     Fusion of spine, thoracolumbar region

M43.26     Fusion of spine, lumbar region

M43.27     Fusion of spine, lumbosacral region

M43.28     Fusion of spine, sacral and sacrococcygeal region

M43.6      Torticollis

M43.8X9    Other specified deforming dorsopathies, site unspecified

M46.01     Spinal enthesopathy, occipito-atlanto-axial region

M46.02     Spinal enthesopathy, cervical region

M46.03     Spinal enthesopathy, cervicothoracic region

M46.04     Spinal enthesopathy, lumbar region 

M46.05     Spinal enthesopathy, thoracolumbar region

M46.06     Spinal enthesopathy, lumbar region 

M46.07     Spinal enthesopathy, lumbosacral region

M46.08     Spinal enthesopathy, sacral and sacrococcygeal region

M46.09     Spinal enthesopathy, multiple sites in spine

M47.10     Other spondylosis with myelopathy, site unspecified

M47.21     Other spondylosis with radiculopathy, occipito-atlanto-axial region

M47.22     Other spondylosis with radiculopathy, cervical region

M47.23     Other spondylosis with radiculopathy, cervicothoracic region

M47.24     Other spondylosis with radiculopathy, thoracic region

M47.25     Other spondylosis with radiculopathy, thoracolumbar region

M47.26     Other spondylosis with radiculopathy, lumbar region

M47.28     Other spondylosis with radiculopathy, sacral and sacrococcygeal region

M47.811    Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region

M47.812    Spondylosis without myelopathy or radiculopathy, cervical region

M47.813    Spondylosis without myelopathy or radiculopathy, cervicothoracic region

M47.814    Spondylosis without myelopathy or radiculopathy, thoracic region

M47.815    Spondylosis without myelopathy or radiculopathy, thoracolumbar region

M47.816    Spondylosis without myelopathy or radiculopathy, lumbar region

M47.817    Spondylosis without myelopathy or radiculopathy, lumbosacral region

M47.818    Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region

M47.819    Spondylosis without myelopathy or radiculopathy, site unspecified

M47.891    Other spondylosis, occipito-atlanto-axial region

M47.892    Other spondylosis, cervical region

M47.893    Other spondylosis, cervicothoracic region

M47.894    Other spondylosis, thoracic region

M47.895    Other spondylosis, thoracolumbar region

M47.896    Other spondylosis, lumbar region

M47.897    Other spondylosis, lumbosacral region

M47.898    Other spondylosis, sacral and sacrococcygeal region

M48.01     Spinal stenosis, occipito-atlanto-axial region

M48.02     Spinal stenosis, cervical region

M48.03     Spinal stenosis, cervicothoracic region

M48.04     Spinal stenosis, thoracic region

M48.05     Spinal stenosis, thoracolumbar region

M48.06     Spinal stenosis, lumbar region

M48.07     Spinal stenosis, lumbosacral region

M48.10     Ankylosing hyperostosis [Forestier], site unspecified

M48.11     Ankylosing hyperostosis [Forestier], occipito-atlanto-axial region

M48.12     Ankylosing hyperostosis [Forestier], cervical region

M48.13     Ankylosing hyperostosis [Forestier], cervicothoracic region

M48.14     Ankylosing hyperostosis [Forestier], thoracic region

M48.15     Ankylosing hyperostosis [Forestier], thoracolumbar region

M48.16     Ankylosing hyperostosis [Forestier], lumbar region 

M48.17     Ankylosing hyperostosis [Forestier], lumbosacral region

M48.18     Ankylosing hyperostosis [Forestier], sacral and sacrococcygeal region

M48.19     Ankylosing hyperostosis [Forestier], multiple sites in spine

M48.31     Traumatic spondylopathy, occipito-atlanto-axial region

M48.32     Traumatic spondylopathy, cervical region

M48.33     Traumatic spondylopathy, cervicothoracic region

M48.34     Traumatic spondylopathy, thoracic region

M48.35     Traumatic spondylopathy, thoracolumbar region

M48.36     Traumatic spondylopathy, lumbar region 

M48.37     Traumatic spondylopathy, lumbosacral region

M48.38     Traumatic spondylopathy, sacral and sacrococcygeal region

M50.00     Cervical disc disorder with myelopathy, unspecified cervical region

M50.01     Cervical disc disorder with myelopathy, high cervical region

M50.020    Cervical disc disorder with myelopathy, mid-cervical region, unspecified level

M50.021    Cervical disc disorder at C4-C5 level with myelopathy

M50.022    Cervical disc disorder at C5-C6 level with myelopathy

M50.023    Cervical disc disorder at C6-C7 level with myelopathy

M50.03     Cervical disc disorder with myelopathy, cervicothoracic region

M50.10     Cervical disc disorder with radiculopathy, unspecified cervical region

M50.11     Cervical disc disorder with radiculopathy, high cervical region

M50.120    Mid-cervical disc disorder, unspecified

M50.121    Cervical disc disorder at C4-C5 level with radiculopathy

M50.122    Cervical disc disorder at C5-C6 level with radiculopathy

M50.123    Cervical disc disorder at C6-C7 level with radiculopathy

M50.13     Cervical disc disorder with radiculopathy, cervicothoracic region

M50.20     Other cervical disc displacement, unspecified cervical region

M50.21     Other cervical disc displacement, high cervical region

M50.220    Other cervical disc displacement, mid-cervical region, unspecified level

M50.221    Other cervical disc displacement at C4-C5 level

M50.222    Other cervical disc displacement at C5-C6 level

M50.223    Other cervical disc displacement at C6-C7 level

M50.23     Other cervical disc displacement, cervicothoracic region

M50.30     Other cervical disc degeneration, unspecified cervical region

M50.31     Other cervical disc degeneration, high cervical region

M50.320    Other cervical disc degeneration, mid-cervical region, unspecified level

M50.321    Other cervical disc degeneration at C4-C5 level

M50.322    Other cervical disc degeneration at C5-C6 level

M50.323    Other cervical disc degeneration at C6-C7 level

M50.33     Other cervical disc degeneration, cervicothoracic region

M50.820    Other cervical disc disorders, mid-cervical region, unspecified level

M50.821    Other cervical disc disorders at C4-C5 level

M50.822    Other cervical disc disorders at C5-C6 level

M50.823    Other cervical disc disorders at C6-C7 level

M50.83     Other cervical disc disorders, cervicothoracic region

M50.90     Cervical disc disorder, unspecified, unspecified cervical region

M50.91     Cervical disc disorder, unspecified, high cervical region

M50.920    Unspecified cervical disc disorder, mid-cervical region, unspecified level

M50.921    Unspecified cervical disc disorder at C4-C5 level

M50.922    Unspecified cervical disc disorder at C5-C6 level

M50.923    Unspecified cervical disc disorder at C6-C7 level

M50.93     Cervical disc disorder, unspecified, cervicothoracic region

M51.06     Intervertebral disc disorders with myelopathy, lumbar region

M51.14     Intervertebral disc disorders with radiculopathy, thoracic region

M51.15     Intervertebral disc disorders with radiculopathy, thoracolumbar region

M51.16     Intervertebral disc disorders with radiculopathy, lumbar region

M51.17     Intervertebral disc disorders with radiculopathy, lumbosacral region

M51.24     Other intervertebral disc displacement, thoracic region

M51.25     Other intervertebral disc displacement, thoracolumbar region

M51.26     Other intervertebral disc displacement, lumbar region

M51.27     Other intervertebral disc displacement, lumbosacral region

M51.34     Other intervertebral disc degeneration, thoracic region

M51.35     Other intervertebral disc degeneration, thoracolumbar region

M51.36     Other intervertebral disc degeneration, lumbar region

M51.37     Other intervertebral disc degeneration, lumbosacral region

M51.84     Other intervertebral disc disorders, thoracic region

M51.85     Other intervertebral disc disorders, thoracolumbar region

M51.86     Other intervertebral disc disorders, lumbar region

M53.0      Cervicocranial syndrome

M53.1      Cervicobrachial syndrome

M53.2X7    Spinal instabilities, lumbosacral region

M53.2X8    Spinal instabilities, sacral and sacrococcygeal region

M53.3      Sacrococcygeal disorders, not elsewhere classified

M53.80     Other specified dorsopathies, site unspecified

M53.81     Other specified dorsopathies, occipito-atlanto-axial region

M53.82     Other specified dorsopathies, cervical region

M53.83     Other specified dorsopathies, cervicothoracic region

M53.84     Other specified dorsopathies, thoracic region

M53.85     Other specified dorsopathies, thoracolumbar region

M53.86     Other specified dorsopathies, lumbar region

M53.87     Other specified dorsopathies, lumbosacral region

M53.88     Other specified dorsopathies, sacral and sacrococcygeal region

M53.9      Cervicocranial syndrome

M54.11     Radiculopathy, occipito-atlanto-axial region

M54.12     Radiculopathy, cervical region

M54.13     Radiculopathy, cervicothoracic region

M54.14     Radiculopathy, thoracic region

M54.15     Radiculopathy, thoracolumbar region

M54.16     Radiculopathy, lumbar region

M54.17     Radiculopathy, lumbosacral region

M54.2      Cervicalgia

M54.30     Sciatica, unspecified site

M54.31     Sciatica, right side

M54.32     Sciatica, left side

M54.40     Lumbago with sciatica, unspecified side

M54.41     Lumbago with sciatica, right side

M54.42     Lumbago with sciatica, left side

M54.50      Low back pain, unspecified

M54.51      Vetebrogenic low back pain

M54.59     Other low back pain

M54.6      Pain in thoracic spine

M54.81     Occipital neuralgia

M54.89     Other dorsalgia

M54.9      Dorsalgia, unspecified

M60.811    Other myositis, right shoulder

M60.812    Other myositis, left shoulder

M60.821    Other myositis, right upper arm

M60.822    Other myositis, left upper arm

M60.831    Other myositis, right forearm

M60.832    Other myositis, left forearm

M60.841    Other myositis, right hand

M60.842    Other myositis, left hand

M60.851    Other myositis, right thigh

M60.852    Other myositis, left thigh

M60.861    Other myositis, right lower leg

M60.862    Other myositis, left lower leg

M60.871    Other myositis, right ankle and foot

M60.872    Other myositis, left ankle and foot

M60.89     Other myositis, multiple sites

M60.9      Myositis, unspecified

M62.830    Muscle spasm of back

M79.10     Myalgia, unspecified site 

M79.11     Myalgia of mastication muscle 

M79.12     Myalgia of auxiliary muscles, head and neck

M79.18     Myalgia, other site

M79.7      Fibromyalgia

M96.1      Post-laminectomy syndrome, not elsewhere classified

M99.20     Subluxation stenosis of neural canal of head region

M99.21     Subluxation stenosis of neural canal of cervical region

M99.22     Subluxation stenosis of neural canal of thoracic region

M99.23     Subluxation stenosis of neural canal of lumbar region

M99.30     Osseous stenosis of neural canal of head region

M99.31     Osseous stenosis of neural canal of cervical region

M99.32     Osseous stenosis of neural canal of thoracic region

M99.33     Osseous stenosis of neural canal of lumbar region

M99.40     Connective tissue stenosis of neural canal of head region

M99.41     Connective tissue stenosis of neural canal of cervical region

M99.42     Connective tissue stenosis of neural canal of thoracic region

M99.43     Connective tissue stenosis of neural canal of lumbar region

M99.50     Intervertebral disc stenosis of neural canal of head region

M99.51     Intervertebral disc stenosis of neural canal of cervical region

M99.52     Intervertebral disc stenosis of neural canal of thoracic region

M99.53     Intervertebral disc stenosis of neural canal of lumbar region

M99.60     Osseous and subluxation stenosis of intervertebral foramina of head region

M99.61     Osseous and subluxation stenosis of intervertebral foramina of cervical region

M99.62     Osseous and subluxation stenosis of intervertebral foramina of thoracic region

M99.63     Osseous and subluxation stenosis of intervertebral foramina of lumbar region

M99.70     Connective tissue and disc stenosis of intervertebral foramina of head region

M99.71     Connective tissue and disc stenosis of intervertebral foramina of cervical region

M99.72     Connective tissue and disc stenosis of intervertebral foramina of thoracic region

M99.73     Connective tissue and disc stenosis of intervertebral foramina of lumbar region

N47.27     Connective tissue and disc stenosis of intervertebral foramina of thoracic region

Q76.2       Congenital spondylolisthesis

R51.0       Headache with orthostatic component, not elsewhere classified 

R51.9       Headache, unspecified

S13.4XXA   Sprain of ligaments of cervical spine, initial encounter

S13.4XXD   Sprain of ligaments of cervical spine, subsequent encounter

S13.4XXS   Sprain of ligaments of cervical spine, sequela

S13.8XXA   Sprain of joints and ligaments of other parts of neck, initial encounter

S13.8XXD   Sprain of joints and ligaments of other parts of neck, subsequent encounter

S13.8XXS   Sprain of the other specified parts of the thorax, initial encounter

S16.1XXA   Sprain of ligaments of thoracic spine, initial encounter

S16.1XXD   Strain of muscle, fascia and tendon at neck level, subsequent encounter

S16.1XXS   Strain of muscle, fascia and tendon at neck level, sequela

S23.3XXA   Sprain of ligaments of thoracic spine, initial encounter

S23.3XXD   Sprain of ligaments of thoracic spine, subsequent encounter

S23.3XXS   Sprain of ligaments of thoracic spine, sequela

S23.8XXA   Sprain of other specified parts of thorax, initial encounter

S23.8XXD   Sprain of other specified parts of thorax, subsequent encounter

S23.8XXS   Sprain of other specified parts of thorax, sequela

S33.5XXA   Sprain of ligaments of lumbar spine, initial encounter

S33.5XXD   Sprain of ligaments of lumbar spine, subsequent encounter

S33.5XXS   Sprain of ligaments of lumbar spine, sequela

S33.6XXA   Sprain of ligaments of lumbar spine, initial encounter

S33.6XXD   Sprain of sacroiliac joint, subsequent encounter

S33.6XXS   Sprain of sacroiliac joint, sequela

S33.8XXA   Sprain of other parts of lumbar spine and pelvis, initial encounter

S33.8XXD   Sprain of other parts of lumbar spine and pelvis, subsequent encounter

S33.8XXS   Sprain of other parts of lumbar spine and pelvis, sequela

S39.012A   Strain of muscle, fascia and tendon of lower back, initial encounter

S39.012D   Strain of muscle, fascia and tendon of lower back, subsequent encounter

S39.012S   Strain of muscle, fascia and tendon of lower back, sequela

________________________________________

Created:  October 2002

Updated: March 2004, February 2010, June 2015, October 2016, July 2019 (format), July 2023

 

Developmental Screenings and Brief Behavioral Assessments

Coding Guideline for Developmental Screenings and Brief Behavioral Assessments

 CPT© Code: 96110

Developmental screen (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument

 CPT© Code: 96127

Brief emotional/behavioral assessment (e.g., depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument

 Criteria for Coverage

ND Medicaid allows these services when billed in conjunction with a preventative medicine service, Evaluation and Management service, or EPSDT service. Code 96110 should be used to report screening for healthy, physical development (speech and language development, physical growth). Code 96127 should be used to report a brief assessment for ADHD, depression, suicidal risk, anxiety, substance abuse, eating disorders, etc. This code was created in response to the Affordable Care Act’s federal mandate to include mental health services as part of the essential benefits that must be included in all insurance plans offered in individual and small group markets. The mandate covers services such as depression screening for adolescents, alcohol and drug use in adolescents, and behavioral assessments in children and adolescents.

 ND Medicaid aligns with the American Academy of Pediatrics (AAP) Bright Futures guidelines which include the   following screening tools:  For more information refer to Bright Futures Toolkit: Links to Commonly Used Screening   Instruments and Tools | AAP Toolkits | American Academy of Pediatrics

 

Instrument

Abbreviation

CPT code

Ages and Stages Questionnaire - Third Edition

ASQ-3

96110

Ages and Stages Questionnaire: Social-Emotional 2nd Edition

ASQ:SE-2

96127

Ask Suicide-Screening Questions

ASQ

96127

Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide

(No Abbreviation)

96127

Baby Pediatric Symptoms Checklist

BBSC

96127

Brief Screener for Alcohol, Tobacco, and Other Drugs

BSTAD

96127

Columbia -Suicide Severity Rating Scale  

C-SSRS

96127

Modified Checklist for Autism in Toddlers

M-CHAT or M-CHAT-R/F

96110

Patient Health Questionnaire

PHQ-2, PHQ-9 or PHQ-A

96127

Patient Safety Screener

PSS-3

96127

Parents' Evaluation of Developmental Status

PEDS

96110

Pediatric Symptom Checklist

PSC, PSC-Y or PSC-17

96127

Preschool Pediatric Symptoms Checklist

PPSC

96127

Screening to Brief Intervention

S2BI

96127

Strength and Difficulties Questionnaire

SDQ

96127

Car, Relax, Alone, Forget, Friends, Trouble

CRAFFT

96127

Survey of Well-being of Young Children

SWYC

96110

 

 


Created: January 2015

Updated: December 2018; October 2019 (format only) August 2022

Encounters for Routine and Administrative Services

Coding Guideline for Certain Encounters for Routine and Administrative Purposes

Encounters / Services for the following ICD-10 codes are allowed under the following circumstances:

Z02.2        Encounter for examination for admission to a residential institution

  • Nursing Home Admission Physical Examinations
  • Annual Physicals are required for members living in an ICF/IID

Z02.89      Encounter for other administrative examinations

  • Refugee/New American / Immigration Physicals
    • A description of the service i.e. “refugee” or “New American” must be noted in Box 19 of the CMS 1500 or 837-P equivalent field or Box 80 of the CMS UB-04 or 837-I equivalent field

Z04.8        Encounter for examination and observation for other specified reason

  • Documentation supporting medical necessity must be submitted for all claims containing this diagnosis

Non-Covered General and Administrative Services

  • Occupational Health Screenings
  • Pre-Employment Screenings
  • DOT Physicals
  • Volunteer Activity Screenings
  • Medical Clearance for incarceration without an acute injury/illness/symptom
  • Camp Physicals

Created: July 2017

Updated: June 2018; September 2019 (format only); September 2021

Fluoride Varnish

Coding Guideline for Application of Fluoride Varnish

CDT© Codes

D1206            Topical application of fluoride varnish

D1208            Topical application of fluoride – excluding varnish

99188             Application of topical fluoride varnish by a physician or other qualified health care professional when performed in a non-dental clinic of facility setting

Criteria for Reimbursement:

Children Coverage

Fluoride treatment is covered for members ages 6 months through 20 years old. A maximum of three applications per year, per member is covered. Dental offices may bill utilizing codes D1206 or D1208.

Fluoride varnish performed in a non-dental clinic or facility setting is covered for members ages 6 months through 20 years old. A maximum of two applications per year, per member is covered.  Clinics and facilities may bill utilizing code 99188.  It is recommended the fluoride varnish be applied at the time of a well-child visit /  Health Tracks screening.

Adult Coverage

Fluoride treatment is covered for members ages 21 and older. A maximum of two applications per year, per member is covered. Dental offices may bill utilizing codes D1206 or D1208.  

 

D1206

D1208

99188

Children

3/year *shared with D1208

3/year *shared with D1206

2/year *separate limit

Adults

2/year *shared with D1208

2/year *shared with D1206

no coverage

 

  • Dentists, physicians, and physician assistants may bill ND Medicaid for the application of fluoride varnish in accordance with their scope of practice and in accordance with any rules adopted by their respective licensing boards.
  • The following practitioners may bill ND Medicaid for the application of fluoride varnish after receiving training that has been approved by the North Dakota Board of Dental Examiners:
  • Nurse Practitioners
  • Registered Nurses and Licensed Practical Nurses under the supervision* of a physician, family nurse practitioner, or physician assistant
  • Registered Dental Hygienist or Registered Dental Assistant under the supervision* of a licensed dentist.

*Supervision requirements are dictated by state law, administrative rules, and the applicable licensing boards.

ICD-10-CM Covered Diagnosis

Z00.121        Encounter for routine child health examination with abnormal findings

Z00.129        Encounter for routine child health examination without abnormal findings

Z29.3            Encounter for prophylactic fluoride administration

Z41.8            Encounter for other procedures for purposes other than remedying health state

 

Additional Resources

Benefits of Fluoride Varnish FAQ

Inform Sheet: Dental Fluoride Varnish Comparison

 

Created:   July 2007

Updated:  January 2013; May 2015, August 2017; July 2018, July 2019, August 2020; April 2021; October 2021; November 2022                    

HIV Screenings

Coding Guideline for HIV Screening

HCPCS©/ CPT© Codes

G0432            Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and / or HIV-2, screening

G0433            Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening

G0435            Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening

G0475            HIV antigen/antibody, combination assay, screening 80081                                   Obstetric panel (includes HIV testing)

Criteria for Coverage

Members must meet one of the following:

  • Be at increased risk for HIV infection
  • Anyone who asks for a test
  • Pregnant woman

Frequency of Screening

  • Annually for members between 15 - 65 years without regard to perceived risk
  • Annually for members under 15 years and adults older than 65 who are at increased risk for HIV infection:
    • Men who have sex with men
    • Men and women having unprotected vaginal or anal intercourse
    • Past of present injection drug users
    • Men and women who exchange sex for money or drugs or have sex partners who do
    • Individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users,
    • Persons who have acquired or request testing for other sexually transmitted infectious diseases,
    • Persons with a history of blood transfusions between 1978 and 1985,
    • Persons who request an HIV test despite reporting no individual risk factors,
    • Persons with new sexual partners,
    • Persons who, based on individualized physician interview and examination
  • Pregnant members covered three times during pregnancy
    • When diagnosed as pregnant
    • During the third trimester
    • At labor, if ordered by a clinician

ICD-10-CM Code Requirements

  Increased risk factors not reported

  •    Z11.4 – Encounter for screening for human immunodeficiency virus            

  Increased risk factors reported                 

  • Z11.4 – Encounter for screening for human immunodeficiency virus; and
  • Z72.89 – Other problems related to lifestyle
  • Z72.51 – High-risk heterosexual behavior
  • Z72.52 – High-risk homosexual behavior; or
  • Z72.53 – High-risk bisexual behavior

Pregnant Medicaid Members

  • Z11.4 – Encounter for screening for human immunodeficiency virus; and
  • Z34.00 – Encounter for supervision of normal first pregnancy, unspecified trimester
  • Z34.01 – Encounter for supervision of normal first pregnancy, first trimester
  • Z34.02 – Encounter for supervision of normal first pregnancy, second trimester
  • Z34.03 – Encounter for supervision of normal first pregnancy, third trimester
  • Z34.80 – Encounter for supervision of other normal pregnancy, unspecified trimester
  • Z34.81 – Encounter for supervision of other normal pregnancy, first trimester
  • Z34.82 – Encounter for supervision of other normal pregnancy, second trimester
  • Z34.83 – Encounter for supervision of other normal pregnancy, third trimester
  • Z34.90 – Encounter for supervision of normal pregnancy, unspecified, unspecified trimester
  • Z34.91 – Encounter for supervision of normal pregnancy, unspecified, first trimester
  • Z34.92 – Encounter for supervision of normal pregnancy, unspecified, second trimester
  • Z34.93 – Encounter for supervision of normal pregnancy, unspecified, third trimester
  • O09.90 – Supervision of high-risk pregnancy, unspecified, unspecified trimester
  • O09.91 – Supervision of high-risk pregnancy, unspecified, first trimester
  • O09.92 – Supervision of high-risk pregnancy, unspecified, second trimester; or
  • O09.93 – Supervision of high-risk pregnancy, unspecified, third trimester

 

Created: April 2020

Maternal Depression Screenings

Coding Guideline for Maternal Depression Screening

CPT© Code: 96161

Administration of a caregiver-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument

Indications

Maternal depression affects up to 18% of mothers during the first year after delivery. Untreated maternal depression can have major, long-term adverse effects on the mother and her child, including placing the child at risk for delays in social-emotional development. Early detection, referral, and treatment of maternal depression can greatly reduce adverse consequences. A pediatric provider may be the only provider that a mother sees within the first year after delivery. As a result, pediatric providers can identify and refer mothers for depression through routine screening at the child’s Health Tracks (EPSDT) screening, Well-Child Check, or other pediatric office visits.

Effective July 1, 2011, North Dakota Medicaid reimburses maternal depression screening as a separate service when performed in conjunction with a Health Tracks screening, Well-Child Check, or any other pediatric visit, as a risk assessment for the child. Providers are encouraged to screen mothers who have a North Dakota Medicaid-eligible child under the age of one for maternal depression.

Criteria for Coverage

  • Screen any time within the child’s first year

Coding Requirements

  • CPT Code
    • 96161 Administration of a caregiver-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument
  • ICD10-CM Covered Diagnosis
    • Z00.110   Health Examination for a newborn under 8 days old
    • Z00.111   Health Examination for a newborn 8 to 28 days old
    • Z00.121   Encounter for routine child health exam with abnormal findings 
    • Z00.129   Encounter for routine child health exam w/out abnormal findings 

Billing Requirements

When a Maternal Depression Screening occurs during a Health Tracks screening, Well-Child Check, or other pediatric office visit for a child eligible for North Dakota Medicaid under one year of age, the following guidelines apply:

  • Bill only when one of the standardized screening instruments is used
  • Bill using the child’s North Dakota Medicaid recipient ID number

Limits

North Dakota Medicaid allows up to four (4) Maternal Depression Screenings for a child up to age one. 

 


Created: July 2017

Updated: September 2019 (format only); April 2020 (screening tools); October 2022

Medical Nutrition Therapy

Coding Guideline for Medical Nutrition Therapy 

CPT © / HCPCS Codes: 

97802         Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minuites
97803         Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97804        Medical nutrition therapy; group (2 or more individuals); each 30 minutes
G0270        Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis medical condition, or treatment regimen(including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes
G0271         Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis medical condition, or treatment regimen(including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes

Criteria for Coverage 

Coverage is allowed for up to four hours per calendar year.   Services must be provided by a licensed registered dietitian (LRD) or nutrition professional meeting certain requirements.  

ICD10-CM Covered Diagnosis 

E11.9 Type 2 diabetes mellitus without complications
E13.9 Other specified diabetes mellitus without complications
E10.9 Type 1 diabetes mellitus without complications
E11.65 Type 2 diabetes mellitus with hyperglycemia
E10.65 Type 1 diabetes mellitus with hyperglycemia
E11.69 Type 2 diabetes mellitus with other specified complication
E13.10 Other specified diabetes mellitus with ketoacidosis without coma
E10.10 Type 1 diabetes mellitus with ketoacidosis without coma
E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC)
E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma
E10.641 Type 1 diabetes mellitus with hypoglycemia with coma
E10.69 Type 1 diabetes mellitus with other specified complication
E10.8 Type 1 diabetes mellitus with unspecified complications
E13.01 Other specified diabetes mellitus with hyperosmolarity with coma
E11.641 Type 2 diabetes mellitus with hypoglycemia with coma
E13.11 Other specified diabetes mellitus with ketoacidosis with coma
E13.641 Other specified diabetes mellitus with hypoglycemia with coma
E10.11 Type 1 diabetes mellitus with ketoacidosis with coma
E11.21 Type 2 diabetes mellitus with diabetic nephropathy
E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease
E11.29 Type 2 diabetes mellitus with other diabetic kidney complication
E13.21 Other specified diabetes mellitus with diabetic nephropathy
E13.22 Other specified diabetes mellitus with diabetic chronic kidney disease
E13.29 Other specified diabetes mellitus with other diabetic kidney complication
E10.21 Type 1 diabetes mellitus with diabetic nephropathy
E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease
E10.29 Type 1 diabetes mellitus with other diabetic kidney complication
E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema
E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema
E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema
E11.36 Type 2 diabetes mellitus with diabetic cataract
E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication
E13.311 Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema
E13.319 Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema
E13.321 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E13.329 Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
E13.331 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E13.339 Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema
E13.341 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E13.349 Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema
E13.351 Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema
E13.359 Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema
E13.36 Other specified diabetes mellitus with diabetic cataract
E13.39 Other specified diabetes mellitus with other diabetic ophthalmic complication
E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema
E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema
E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema
E10.329 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema
E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema
E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema
E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema
E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema
E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema
E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema
E10.36 Type 1 diabetes mellitus with diabetic cataract
E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication
E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy
E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy
E11.44 Type 2 diabetes mellitus with diabetic amyotrophy
E11.49 Type 2 diabetes mellitus with other diabetic neurological complication
E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E13.40 Other specified diabetes mellitus with diabetic neuropathy, unspecified
E13.41 Other specified diabetes mellitus with diabetic mononeuropathy
E13.42 Other specified diabetes mellitus with diabetic polyneuropathy
E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
E13.44 Other specified diabetes mellitus with diabetic amyotrophy
E13.49 Other specified diabetes mellitus with other diabetic neurological complication
E13.610 Other specified diabetes mellitus with diabetic neuropathic arthropathy
E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy
E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
E10.44 Type 1 diabetes mellitus with diabetic amyotrophy
E10.49 Type 1 diabetes mellitus with other diabetic neurological complication
E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.59 Type 2 diabetes mellitus with other circulatory complications
E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene
E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
E13.59 Other specified diabetes mellitus with other circulatory complications
E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.59 Type 1 diabetes mellitus with other circulatory complications
E11.618 Type 2 diabetes mellitus with other diabetic arthropathy
E11.620 Type 2 diabetes mellitus with diabetic dermatitis
E11.621 Type 2 diabetes mellitus with foot ulcer
E11.622 Type 2 diabetes mellitus with other skin ulcer
E11.628 Type 2 diabetes mellitus with other skin complications
E11.630 Type 2 diabetes mellitus with periodontal disease
E11.638 Type 2 diabetes mellitus with other oral complications
E11.649 Type 2 diabetes mellitus with hypoglycemia without coma
E13.618 Other specified diabetes mellitus with other diabetic arthropathy
E13.620 Other specified diabetes mellitus with diabetic dermatitis
E13.621 Other specified diabetes mellitus with foot ulcer
E13.622 Other specified diabetes mellitus with other skin ulcer
E13.628 Other specified diabetes mellitus with other skin complications
E13.630 Other specified diabetes mellitus with periodontal disease
E13.638 Other specified diabetes mellitus with other oral complications
E13.649 Other specified diabetes mellitus with hypoglycemia without coma
E13.65 Other specified diabetes mellitus with hyperglycemia
E13.69 Other specified diabetes mellitus with other specified complication
E10.618 Type 1 diabetes mellitus with other diabetic arthropathy
E10.620 Type 1 diabetes mellitus with diabetic dermatitis
E10.621 Type 1 diabetes mellitus with foot ulcer
E10.622 Type 1 diabetes mellitus with other skin ulcer
E10.628 Type 1 diabetes mellitus with other skin complications
E10.630 Type 1 diabetes mellitus with periodontal disease
E10.638 Type 1 diabetes mellitus with other oral complications
E10.649 Type 1 diabetes mellitus with hypoglycemia without coma
E11.8 Type 2 diabetes mellitus with unspecified complications
E13.8 Other specified diabetes mellitus with unspecified complications
E34.9 Endocrine disorder, unspecified
E70.0 Classical phenylketonuria
E78.0 Pure hypercholesterolemia
E78.1 Pure hyperglyceridemia
E78.2 Mixed hyperlipidemia
E78.3 Hyperchylomicronemia
E78.4 Other hyperlipidemia
E78.5 Hyperlipidemia, unspecified
E78.6 Lipoprotein deficiency
E88.1 Lipodystrophy, not elsewhere classified
E75.10 Unspecified gangliosides
E75.19 Other gangliosides
E75.21 Fabry (-Anderson) disease
E75.22 Gaucher disease
E75.240 Niemann-Pick disease type A
E75.241 Niemann-Pick disease type B
E75.242 Niemann-Pick disease type C
E75.243 Niemann-Pick disease type D
E75.248 Other Niemann-Pick disease
E75.249 Niemann-Pick disease, unspecified
E75.3 Sphingolipidosis, unspecified
E77.0 Defects in post-translational modification of lysosomal enzymes
E77.1 Defects in glycoprotein degradation
E77.8 Other disorders of glycoprotein metabolism
E77.9 Disorder of glycoprotein metabolism, unspecified
E71.30 Disorder of fatty-acid metabolism, unspecified
E75.5 Other lipid storage disorders
E78.79 Other disorders of bile acid and cholesterol metabolism
E78.81 Lipoid dermatoarthritis
E78.89 Other lipoprotein metabolism disorders
E88.2 Lipomatosis, not elsewhere classified
E75.6 Lipid storage disorder, unspecified
E78.70 Disorder of bile acid and cholesterol metabolism, unspecified
E78.9 Disorder of lipoprotein metabolism, unspecified
E66.9 Obesity, unspecified
E66.01 Morbid (severe) obesity due to excess calories
E66.3 Overweight
E65 Localized adiposity
F50.00 Anorexia nervosa, unspecified
F50.01 Anorexia nervosa, restricting type
F50.02 Anorexia nervosa, binge eating/purging type
F50.2 Bulimia nervosa
F50.8 Other eating disorders
F98.29 Other feeding disorders of infancy and early childhood
I10 Essential (primary) hypertension
I11.9 Hypertensive heart disease without heart failure
I11.0 Hypertensive heart disease with heart failure
I12.9 Hypertensive CKD with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
I13.10 Hypertensive heart and CKD without heart failure, with stage 1 through stage 4 CKD, or unspecified CKD
I13.0 Hypertensive heart and CKD with heart failure and stage 1 through stage 4 CKD, or unspecified CKD
I13.11 Hypertensive heart and CKD without heart failure, with stage 5 chronic kidney disease, or end stage renal disease
I13.2 Hypertensive heart and CKD with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
I15.0 Renovascular hypertension
I15.8 Other secondary hypertension
I15.9 Secondary hypertension, unspecified
I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site
I24.1 Dressler's syndrome
I20.0 Unstable angina
I23.7 Postinfarction angina
I24.0 Acute coronary thrombosis not resulting in myocardial infarction
I24.8 Other forms of acute ischemic heart disease
I24.9 Acute ischemic heart disease, unspecified
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris
I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris
I25.719 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris
I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris
I25.729 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris
I25.810 Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris
I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris
I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris
I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris
I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris
I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris
I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris
I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm
I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris
I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris
I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina
I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm
I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris
I25.759 Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris
I25.811 Atherosclerosis of native coronary artery of transplanted heart without angina pectoris
I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina
I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm
I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris
I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris
I25.812 Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris
I25.3 Aneurysm of heart
I25.41 Coronary artery aneurysm
I25.42 Coronary artery dissection
I25.89 Other forms of chronic ischemic heart disease
I25.9 Chronic ischemic heart disease, unspecified
K90.0 Celiac disease
N18.1 Chronic kidney disease, stage 1
N18.2 Chronic kidney disease, stage 2 (mild)
N18.3 Chronic kidney disease, stage 3 (moderate)
N18.4 Chronic kidney disease, stage 4 (severe)
N18.5 Chronic kidney disease, stage 5
N18.6 End stage renal disease
N18.9 Chronic kidney disease, unspecified
O24.019 Pre-existing diabetes mellitus, type 1, in pregnancy, unspecified trimester
O24.119 Pre-existing diabetes mellitus, type 2, in pregnancy, unspecified trimester
O24.319 Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester
O24.819 Other pre-existing diabetes mellitus in pregnancy, unspecified trimester
O24.919 Unspecified diabetes mellitus in pregnancy, unspecified trimester
O24.011 Pre-existing diabetes mellitus, type 1, in pregnancy, first trimester
O24.012 Pre-existing diabetes mellitus, type 1, in pregnancy, second trimester
O24.013 Pre-existing diabetes mellitus, type 1, in pregnancy, third trimester
O24.02 Pre-existing diabetes mellitus, type 1, in childbirth
O24.111 Pre-existing diabetes mellitus, type 2, in pregnancy, first trimester
O24.112 Pre-existing diabetes mellitus, type 2, in pregnancy, second trimester
O24.113 Pre-existing diabetes mellitus, type 2, in pregnancy, third trimester
O24.12 Pre-existing diabetes mellitus, type 2, in childbirth
O24.311 Unspecified pre-existing diabetes mellitus in pregnancy, first trimester
O24.312 Unspecified pre-existing diabetes mellitus in pregnancy, second trimester
O24.313 Unspecified pre-existing diabetes mellitus in pregnancy, third trimester
O24.32 Unspecified pre-existing diabetes mellitus in childbirth
O24.811 Other pre-existing diabetes mellitus in pregnancy, first trimester
O24.812 Other pre-existing diabetes mellitus in pregnancy, second trimester
O24.813 Other pre-existing diabetes mellitus in pregnancy, third trimester
O24.82 Other pre-existing diabetes mellitus in childbirth
O24.911 Unspecified diabetes mellitus in pregnancy, first trimester
O24.912 Unspecified diabetes mellitus in pregnancy, second trimester
O24.913 Unspecified diabetes mellitus in pregnancy, third trimester
O24.92 Unspecified diabetes mellitus in childbirth
O24.03 Pre-existing diabetes mellitus, type 1, in the puerperium
O24.13 Pre-existing diabetes mellitus, type 2, in the puerperium
O24.33 Unspecified pre-existing diabetes mellitus in the puerperium
O24.410 Gestational diabetes mellitus in pregnancy, diet controlled
O24.414 Gestational diabetes mellitus in pregnancy, insulin controlled
O24.419 Gestational diabetes mellitus in pregnancy, unspecified control
O24.420 Gestational diabetes mellitus in childbirth, diet controlled
O24.424 Gestational diabetes mellitus in childbirth, insulin controlled
O24.429 Gestational diabetes mellitus in childbirth, unspecified control
O24.430 Gestational diabetes mellitus in the puerperium, diet controlled
O24.434 Gestational diabetes mellitus in the puerperium, insulin controlled
O24.439 Gestational diabetes mellitus in the puerperium, unspecified control
O24.83 Other pre-existing diabetes mellitus in the puerperium
O24.93 Unspecified diabetes mellitus in the puerperium
O99.810 Abnormal glucose complicating pregnancy
O99.814 Abnormal glucose complicating childbirth
O99.815 Abnormal glucose complicating the puerperium
R73.01 Impaired fasting glucose
R73.02 Impaired glucose tolerance (oral)
R73.02 Impaired glucose tolerance (oral)
R73.09 Other abnormal glucose
R73.9 Hyperglycemia, unspecified

Created: July 2017

Updated: March 2019; September 2019 (format only); June 2020
 

Synagis (Palivizumab)

Coding Guideline for Synagis® (palivizumab)

CPT© Code: 90378

Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each

Criteria for Coverage:

Synagis® (palivizumab) will be allowed for up to five weight-based doses within six months of RSV season onset as defined by using the CDC’s National Respiratory and Enteric Virus Surveillance System (NREVSS) Midwest Region data, which can be found at: RSV Regional Trends - NREVSS | CDC. RSV season onset will be defined as the first of two consecutive weeks when the percentage of PCR tests positive for RSV is greater than 3%; season offset will be defined as the last of two consecutive weeks when the percentage of PCR tests positive for RSV is less than 3%. No further prior authorization requests will be approved following the season offset.

Patients must meet the most current AAP guidelines which can be found at: www.aap.org  or Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection | From the American Academy of Pediatrics | Pediatrics         

Prior Authorization:

Prior Authorization (PA) must be obtained through Kepro by completing the online Synagis PA Form. The approval letter will include the ND MMIS Service Authorization number and the number of authorized units with the duration of the approval. The ND MMIS Service Authorization Number must be entered on the claim at the time of submission. Failure to do so will result in claim denial.

Coding and Billing Instruction:

CPT© 90378 must be billed electronically via an 837P transaction with the correlating NDC code for the Synagis® administered.  

Synagis® is available in both 50mg and 100 mg vials. Multiple vial dosages should be reported with the most accurate combination to reflect the actual amount of drug administered. Each unique NDC must be reported on a separate line on the 837P with the correlating number of HCPCS units. 

Effective for dates of service on or after 10/19/2018 standard National Correct Coding Initiative (NCCI) Procedure to Procedure (PTP) editing will be applied to the administration code (CPT 96372) and Evaluation and Management (E/M) Service combination when rendered on the same date of service by the same provider. 


 

Created: July 2017

Updated: October 2019 (format only), September 2022

Vaccine/Toxoids

Vaccines / Toxoids Coding Guideline

 

Vaccines / Toxoids

This Immunization coding guideline provides a summary of benefits and billing guidelines for North Dakota Medicaid providers who administer vaccines to children and adults.  North Dakota Medicaid periodically reviews and modifies immunization benefits and services. Therefore, the information in this guideline is subject to change, and the document is updated as new policies are implemented.

ND Medicaid works to promote and facilitate the prevention of vaccine-preventable diseases.   ND Medicaid works closely with the North Dakota Department of Health / Vaccine for Children Program to implement immunization recommendations by the Advisory Committee on Immunization (ACIP) of the U.S. Department of Health and Human Services.

Covered Services

ND Medicaid members through age 18 are eligible to receive all immunization available from the federal Vaccine for Children (VFC) Program, at VFC-enrolled provider offices. Therefore, ND Medicaid will not reimburse ND Medicaid enrolled providers for a vaccine that is not supplied through the VFC program. 

  • Refer to ND Department of Health for the most recent Vaccine Coverage Table and Influenza Dosage Chart.  This information is published by the ND Department of Health and is updated yearly.

ND Medicaid members ages 19 and over are eligible to receive annual influenza vaccine and other vaccines as indicated in Table A below per the Advisory Committee on Immunization (ACIP). 

Covered Vaccine Administration

90471       Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

90472       Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure)

90473       Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)

90474       Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (list separately in addition to code for primary procedure)

Covered Vaccines/ Toxoids (Table A)

CPT Code

Description

Valid Ages

Maximum Allowable Reimbursement

VFC / 317

90619

Meningococcal conjugate vaccine, serogroups A,C,W,Y, quadrivalent, tetanus toxoid carrier (MenACWY-TT), for intramuscular use.  MenQuadfi™

2-18 yrs

$0.00

19+ yrs

Per Fee Schedule

 

90620

 

Meningococcal recombinant   Bexsero®

 

10-18 yrs

$0.00

19-26 yrs

Per Fee schedule

 

90621

Meningococcal B  Trumenba®

 

10-18 yrs

$0.00

19-26 yrs

Per Fee schedule

 

90630

Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative-free, for intradermal use Fluzone®

19+

No longer available

 

 

90632

 

Hepatitis A, adult dosage Vaqta®  Havrix®

19 + yrs

Per Fee Schedule

 

90633

 

Hepatitis A, pediatric /adolescent  - 2 dose  Vaqta® Havrix®

 

1-18 yrs

$0.00

90636

Hepatitis A and Hepatitis B, adult dose Twinrix®

 

19+ yrs

Per Fee schedule

 

90647

Hib - 3 dose   PedvaxHIB®

 

6 wks – 4 yrs

$0.00

90648

Hib - 4 dose  ActHIB®  Hiberix®

 

6 wks – 4 yrs

$0.00

90651

HPV types 6,11,16,18,31,22,45,52,58 nonvalent 3 dose Gardasil 9®

 

9-18 yrs

$0.00

19-45 yrs

Per Fee Schedule

 

90653

Influenza vaccine, inactivated (iiv), subunit, adjuvanted Fluad®

 

65 + yrs

Per Fee Schedule

 

90654

Influenza virus vaccine, trivalent, split virus, preservative free, intradermal 

 

19 +yrs

Not Available

 

90656

Influenza virus vaccine, trivalent, split virus, preservative free, 0.5 mL Afluria ® Fluvirin®

3-18 yrs

Not covered

 

19 + yrs

No longer available

 

90658

Influenza virus vaccine, trivalent (IIV3), split virus, 0.5 mL dosage, for IM use Afluria®

4 -18 yrs

Not covered

 

19 + yrs

No longer

available

90662

Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for IM use Fluzone High-Dose®

 

65 + yrs

Per Fee Schedule

 

90670

Pneumococcal conjugate vaccine, 13 valent (PCV13), for IM use Prevnar13®

 

6 wks - 4 yrs

$0.00

19+

Per Fee Schedule

 

90671

Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use Vaxneuvance™

19+

Per Fee Schedule

 

90672

Influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use FluMIst Quadrivalent®

2-18 yrs

$0.00

19-49 yrs

Per Fee Schedule

 

 

90673

Influenza virus vaccine, trivalent (RIV3), derived from recombinant DNA, hemagglutinin (HA) protein only, preservative and antibiotic free, for IM use Flublok®

 

19 + yrs

No longer available

 

90674

Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for IM use Flucelvax Quadrivalent®

 

4 years-18 yrs

$0.00

19 + yrs

Per Fee Schedule

 

90677

Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use Prevnar 20™

19+ yrs

Per Fee Schedule

 

90680

Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use Rota Teq®

 

6 wks –  8 mos

$0.00

 

90681

Rotavirus vaccine, human, attenuated (RV1), 2 dose schedule, live, for oral use Rotarix®

 

6 wks  – 8 mos

$0.00

90682

Influenza virus vaccine, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin protein only, preservative and antibiotic free, for IM use. Flublok®

19 +

Per Fee Schedule

 

90685

Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.25 mL dosage, for IM use Afluira Quadrivalent®

 

6 mos – 35 mos

$0.00

90686

Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for IM use  Fluarix Quadrivalent®  Afluria Quadrivalent® Fluzone Quadrivalent® Flulaval®

 

6 mos-

18 yrs

$0.00

19 + yrs

Per fee schedule

 

90687

Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.25 mL, for IM use Fluzone Quadrivalent® Afluria Quadrivalent®

6 mos – 35 mos

$0.00

90688

Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for IM use Afluira Quadrivalent®  Fluzone Quadrivalent®

 

6 mos – 18 yrs

$0.00

19 + yrs

Per Fee Schedule

 

90694

Influenza virus vaccine, quadrivalent (aIIV4), inactivated, adjuvanted, preservative free, 0.5mL dosage for IM use  Fluad Quadrivalent

65+ years

Per Fee Schedule

 

90696

Diphtheria, tetanus toxoids, acellular pertussis vaccine and inactivated poliovirus vaccine, (DTaP-IPV) Kinrix™Quadracel™

 

4-6 yrs

$0.00

90697

Diphtheria, tetanus toxoids, acellular pertussis vaccine, inactivated poliovirus vaccine, Haemophilus influenzae type b PRP-OMP conjugate vaccine, and hepatitis B vaccine (DTaP-IPV-Hib-HepB), for intramuscular use. Vaxelis™

6wks-4 yrs 

$0.00

90698

Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and inactivated poliovirus vaccine, (DTaP-IPV / Hib) Pentacel®

6 wks –  4 yrs

 

$0.00

90700

Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than seven years, for IM use Daptacel®  Infarix®

 

6 wks –  6 yrs

$0.00

90702

Diphtheria and tetanus toxoids adsorbed (DT) when administered to individuals younger than 7 years, for IM use

 

6 wks –  6 yrs

$0.00

90707

Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use M-M-R-II® Priorix®

12 mos -  18 yrs

$0.00

19+ yrs

Per Fee Schedule

 

90710

Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use  ProQuad®

 

12 mos – 12 yrs

$0.00

 

 

 

 

90713

Poliovirus vaccine, inactivated, (IPV), for subcutaneous or IM use IPOL®

 

 

6 wks – 18 years

$0.00

19+

Per Fee Schedule

 

90714

Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for IM use Tetanus-Diphtheria Toxoids®

 

7 years – 18 yrs

$0.00

19 +

Per Fee Schedule

 

90716

Varicella virus vaccine (VAR), live, for subcutaneous use Varivax®

12 mos – 18 yrs

$0.00

19+

Per Fee Schedule

 

90715

Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for IM use Boostrix® Adacel®

 

7-18 yrs

$0.00

19+ yrs

Per Fee Schedule

 

90723

Diphtheria, tetanus toxoids, acellular pertussis vaccine, hepatitis B, and inactivated poliovirus vaccine,- (DTaP-HepB-IPV) for IM use Pediarix®

6 wks –

6 yrs

$0.00

 

 

 

90732

Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or IM use Pneumovax 23®

 

2-18 yrs

$0.00

19+

Per Fee Schedule

90734

Meningococcal conjugate vaccine, serogroups A, C, Y and W-135, quadrivalent (MCV4 or MenACWY), for IM use  Menactra® Menveo®

 

2 mos – 18 yrs

$0.00

19 – 55 yrs

Per Fee Schedule

 

90736

Zoster (shingles) vaccine (HZV), live, for subcutaneous injection Zostavax®

 

60+ yrs

Per Fee Schedule

 

90739

Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for IM use Heplisav-B™

 

19+

Per Fee Schedule

 

90740

Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3-dose schedule, for IM use Recombivax HB®

 

19+ yrs

Per Fee Schedule

 

90743

Hepatitis B vaccine (HepB), adolescent, 2-dose schedule, for IM use Recombivax HB®

 

11-15 yrs

$0.00

90744

Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3-dose schedule, for IM use Enberix-B® Recombivax HB®

 

Birth -18 yrs

$0.00

90746

Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for IM use Engerix-B® Recombivax HB®

 

19+ yrs

Per Fee Schedule

 

90747

Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 4-dose schedule, for IM use Engerix-B®

19+ yrs

Per Fee Schedule

 

90749

Unlisted vaccine/toxoid

0 +

By report

 

 

90750

Zoster (Shingles) vaccine (hzv), recombinant, sub-unit, adjuvanted, for IM use  SHINGRIX®

 

50+yrs

Per Fee Schedule

 

90756

Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5 mL dosage, for intramuscular use Flucelvax®

4 years – 18 years

$0.00

19+ years

Per Fee Schedule

 

Modifier

SL - State Supplied Vaccine to be used to indicate vaccine supplied through the VFC program.

Non-Covered Services

  • The cost of vaccine that is available through the VFC or 317 Program.             
  • Immunizations and the administration of vaccine for the sole purpose of international travel

Non-Covered Vaccine / Toxoid

CPT Code

Description

90477

Adenovirus vaccine, type 7, live, for oral use

90581

Anthrax vaccine, for subcutaneous or intramuscular use

80584

Dengue vaccine, quadrivalent, live, 2 dose schedule, for subcutaneous use

90585

Bacillus Calmette-Guerin vaccine (bcg) for tuberculosis, live, for percutaneous use

90587

Dengue vaccine, quadrivalent, live, 3 dose schedule, for subcutaneous use

90625

Cholera vaccine, live, adult dosage, 1 dose schedule, for oral use Vaxchora®

90626

Tick-borne encephalitis virus vaccine, inactivated; 0.25 ml dosage, for intramuscular use

90627

Tick-borne encephalitis virus vaccine, inactivated; 0.5 ml dosage, for intramuscular use

90634

Hepatitis A vaccine (HepA), pediatric/adolescent dosage-3 dose schedule, for intramuscular use

90655

Influenza virus vaccine, trivalent (iiv3), split virus, preservative free, 0.25 ml dosage, for intramuscular use

90664

Influenza virus vaccine, live (laiv), pandemic formulation, for intranasal use

90666

Influenza virus vaccine, pandemic for intranasal use

90667

Influenza virus vaccine (iiv), pandemic formulation, split virus, adjuvanted, for intramuscular use

90668

Influenza virus vaccine (iiv), pandemic formulation, split virus, for intramuscular use

90690

Typhoid vaccine, live, oral Vivotif®

90691

Typhoid vaccine, vi capsular polysaccharide (vicps), for intramuscular use Typhim Vi®

90694

Influenza vaccine, quadrivalent (allV4), inactivated, adjuvanted, preservative free, 0.5mL dosage, for intramuscular use

90717

Yellow fever vaccine, live, for subcutaneous use Stamaril®

90738

Japanese encephalitis virus vaccine, inactivated, for intramuscular use Ixiaro®

90758

Zaire ebolavirus vaccine, live, for intramuscular use

Billing Instructions by Claim Type

For professional services billed on a CMS 1500 / 837 P claim form, bill the Vaccine / Toxoid CPT Code along with its correlating administration code (90471-90474).  

RHCs / FQHCs / Outpatient Hospital - Vaccine / Toxoid CPT Codes must be billed using Revenue Code 0636 following the coverage guidelines in Table A.  The administration must be billed using Revenue Code 0771 with the appropriate CPT code. Both the vaccine and administration must be billed on the same claim.

IHS / Tribally Operating 638 Facilities - Administration must be billed using Revenue Code 0500 with the appropriate CPT code.


Created: March 2017

Updated: September 2018, August 2019; November 2019; January 2020, August 2020, June 2021, February 2022, September 2022

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