Provider Guidelines, Manuals and Policies

Behavioral Health Services Provider Manual (October 2023)

Manuals

Dental Provider Manual (July 2023)

• CDT Code: D1352 (Dental Policy Guideline)
• CDT Codes Requiring Tooth Numbers/Quadrants (Excel File - Revised December 2021)
• CDT Code - D9410 House/Extended Care Facility Call (Dental Policy Guideline - Effective April 1, 2017)
• CDT Code D1354 - Silver Diamine Fluoride (Revised March 1, 2021)
• Dental Case Management  (Effective July 1, 2023)
• Dental Screening and Assessment  (Effective September 19, 2023)
• Documentation Requirements for Periodontal Services (January 2023)
• Health Track Orthodontia Screening Policy (Updated July 2022)
• North Dakota Dental Periodicity Schedule (Posted May 2020)
• Orthodontia and Third Party Liability Policy (Updated Feb. 2022)
• Orthodontic Transfers (Dental Policy Guideline)
• Palliative Treatment of Dental Pain (January 2023)
• Prosthodontics Policy (January 2023)
• Teledentistry Policy (July 2023)

Training

• NEW - Dental Provider Training Video - Common Errors (Total running time 39 minutes) (April 2022)
• Dental Provider Video Training - Sept. 2017 (Total running time 1:05)
• Training Materials (402kb pdf)

Durable Medical Provider Information

Family Support Services Policy and Procedures (Revised March 2018)

IMD policy (Updated June 2023)

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 Rate Manual (July 2023)
• RUG IV Classification Manual (July 2020)
• MDS 3.0 Submission Guidelines (October 2023)
  • MDS Appeal Request Form (SFN 247)
  • Basic Medicaid MDS 3.0 PowerPoint Presentation (January 2016)
• ND Nursing Facility Payment System Booklet (January 2012) - May be printed in booklet form. Choose under 'Page Scaling' in the Adobe print screen.

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

Substance Use Disorder Services and Housing Providers Policy - November 2023

Serious Mental Illness/Serious Emotional Disturbance (Updated October 2023) (174kb pdf)

• ONLINE Training (April 23, 2020)

Child Welfare (Updated October 2023) (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 Provider Manual (January 2023)
• Pharmacy Medical Billing Manual (July 2023)

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

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

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

Created: January 2015

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

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

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.  

• 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                    

• 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

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 for 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 another pediatric office visit.

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
• American Academy of Pediatrics – Bright Futures guidelines recommend screening at the 1-month visit, 2-month visit, 4-month visit, and 6-month visit.   For more information refer to Bright Futures Toolkit: Links to Commonly Used Screening Instruments and Tools
• Use one of the following standardized screening tools:

• Edinburgh Postnatal Depression Scale (EPDS)
• Patient Health Questionnaire - 9 (PHQ-9) Screener

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

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 percentage of PCR tests positive for RSV is greater than 3%; season offset will be defined as the last of two consecutive weeks when percentage of PCR tests positive for RSV is less than 3%. No further prior authorization requests will be approved following season offset.

Patient 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 RSV Prophylaxis 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

Vaccines / Toxoids Coding Guideline

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 the 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 ND HHS 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 immunizations 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 vaccine that is not supplied through the VFC program, except for those specified in the table below. 

• Refer to the NDHHS Immunization Unit for the most recent Vaccine Coverage Table and Influenza Dosage Chart.  This information is published by the NDHHS Immunization Unit and is updated yearly.

ND Medicaid members aged 19 and over are eligible to receive all ACIP-recommended vaccines. Effective October 1, 2023, this also includes vaccines required for international travel.

updated November 2023

• Third Party Billers Policy (November 2023)
• Timely Filing Policy (November 2023)
  • Timely Filing Override Request
• Durable Medical Equipment (DME) Reuse Policy (November 2018)
• Revenue Code 278 Memo (March 2019)

Medical Policy (53kb pdf)

Dental Policy (34kb pdf)

SFN 447 Exemption for Submitting Electronic Claims

Please see the General Information for Providers Manual for the complete Telehealth Policy

Telehealth Covered Services