Billing Update for Procedure Code T1999

As of November 1, 2015, procedure code T1999 (Miscellaneous therapeutic items and supplies, retail purchases, not otherwise classified) will have new service limitations applied.

The following rules will be applied to any T1999 dollars used since the beginning of the current State Fiscal Year (SFY) on July 1, 2015:

 ·  No PA is required for total dollars used up to $250.00

 ·  A PA is required for total dollars used from $250.01 to $1,500.00

o    For recipients under age 21, a PA is required for total dollars used from $250.01 to the amount specified on the PA

 ·  Claims with total dollars exceeding $1,500.00 will be denied

o    For recipients under age 21, claims with total dollars exceeding the maximum amount identified on the PA will be denied

o    EPSDT recipients under age 21 may exceed the $1500 limit if there is a validated need

 ·  For recipients over age 21, no more than $1500.00 per recipient per SFY may be billed, with or without prior approval

The provider taxonomy codes listed below will be subject to these restrictions when billing procedure code T1999:

·  251E00000X Home Health

·  261QF0400X FQHC Clinic

·  261QR1300X Rural Health Clinic

·  251J00000X Nursing Care

·  251B00000X Case Management

·  253Z00000X In Home Supportive Care

·  385H00000X Respite Care

·  333300000X Emergency Response System Company

·  332B00000X DME and Medical Supplies

·  332U00000X Home Delivered Meals

Prior Approval (PA) requests will only be accepted via the NCTracks secure Provider Portal. Prior Approval requests will not be accepted via fax, phone or mail. Providers will be able to verify service limit amounts via the Automated Voice Response System (AVRS), the NCTracks secure Provider Portal and X12 270/271 transactions.

Please refer to DMA Clinical Coverage Policy 3A, Home Health Services for additional information, which can be found on the DMA website. Also refer to the October 2015 DMA Special Bulletin titled “Updated Bill Type for Home Health Provider.”

Note: T1999 services will be measured in dollars while Home Health Aide or Skilled Nurse services will continue to be measured in visits.