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LARC Reimbursement to Hospitals

Thursday, June 27, 2019   (0 Comments)
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Effective for dates of service June 3, 2019, and thereafter, the Alabama Medicaid Agency (Medicaid) will reimburse the cost of long-acting reversible contraceptives to the facility when provided in the inpatient hospital setting immediately after a delivery or up to the time of the inpatient discharge for postpartum women, or in the outpatient setting immediately after discharge from the inpatient hospital for postpartum women.

What steps are necessary for the hospital to receive reimbursement for LARC services when provided in the inpatient setting?

1. The hospital must submit a UB04 claim (bill type 111) to Medicaid for inpatient delivery services with an International Classification of Diseases, Tenth Edition (ICD–10) delivery diagnosis code within the range O00.0 – O9A.53 and one of the following ICD–10 surgical codes for insertion of the device:

·   0UH97HZ

·   0UH98HZ

·   0UHC8HZ

Note for the delivery claim: Submit prior to the LARC claim and do not include a LARC code.

2. The hospital must submit a separate UB-04 claim (bill type 131) to Medicaid with one of the following Healthcare Common Procedure Coding System (HCPCS) codes with the appropriate National Drug Code (NDC) to receive reimbursement for the LARC:

·   J7296 — Kyleena®

·   J7297 — Liletta®

·   J7298 — Mirena®

·   J7300 — Paragard®

·   J7301 — Skyla®

·   J7307 — Nexplanon®

Note for the LARC claim: Do not submit prior to the delivery claim and do not include an insertion code. In addition, the date of service for this claim should be for the actual date of insertion and must overlap the submitted dates of services for delivery.

What steps are necessary for the hospital to receive reimbursement for LARC services when provided in the outpatient setting?

1. The hospital must submit a UB04 claim (bill type 131) to Medicaid.

2. The hospital must use one of the following insertion Common Procedural Terminology (CPT) codes:

·   58300 — Insertion of IUD

·   11981 — Insertion, non-biodegradable drug delivery implant (must add ‘FP’ modifier)

·   11983 — Removal with reinsertion, non-biodegradable drug delivery implant (must add ‘FP’ modifier)

3. The hospital must use one of the following ICD-10 codes:

·   Z30.018 — Encounter for initial prescription of other contraceptives

·   Z30.430 — Encounter for insertion of intrauterine contraceptive device

·   Z30.49 — Encounter for surveillance of other contraceptives

4. The hospital must use one of the following HCPCS codes with the appropriate NDC to receive reimbursement for LARC:

·   J7296 — Kyleena®

·   J7297 — Liletta®

·   J7298 — Mirena®

·   J7300 — Paragard®

·   J7301 — Skyla®

·   J7307 — Nexplanon®

What steps are necessary for the physician to receive reimbursement for LARC services provided in the inpatient or outpatient hospital setting?

1. The physician must submit a CMS 1500 claim form to Medicaid.

2. The physician must use one of the following insertion CPT codes:

·   58300 — Insertion IUD

·   11981 — Insertion, non-biodegradable drug delivery implant (must add ‘FP’ modifier)

·   11983 — Removal with reinsertion, non-biodegradable drug delivery implant (must add ‘FP’ modifier)

3. The physician must use one of the following ICD-10 codes:

·   Z30.018 — Encounter for initial prescription of other contraceptives

·   Z30.430 — Encounter for insertion of intrauterine contraceptive device

·   Z30.49 — Encounter for surveillance of other contraceptives

4. The physician must indicate the place of service as one of the following:

·   21 — Inpatient hospital setting

·   22 — Outpatient hospital setting

For questions regarding hospital program, contact Solomon Williams at solomon.williams@medicaid.alabama.gov.

For questions regarding physician program, contact Elizabeth Huckabee at elizabeth.huckabee@medicaid.alabama.gov.

For questions regarding the family planning program, contact Pamela Moore at pamela.moore@medicaid.alabama.gov.

For questions regarding billing, contact the DXC Provider Assistance Center at 
(800) 688-7989.


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