Vermont Medicaid Provider Manual VTMedicaid

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Provider Manual
dvha.vermont.gov/
vtmedicaid.com/#/home
5/23/2018 Green Mountain Care Provider Manual 2
Summary of Updates
The Detailed Summary of Provider Manual Changes contains all detailed changes made to this Provider
Manual is maintained and available for review at http://www.vtmedicaid.com/#/manuals
Date
Section Information
05/23/2018
Rental/Loaned
05/23/2018
Rental Reimbursement Policies
05/23/2018
Durable Medical Equipment (DME), Prosthetics,
Orthotics & Medical Supplies
05/03/2018
Payment DVHA Primary/Manual Pricing
05/03/2018
Procedure Codes & Pricing
04/16/2018
Obstetrical Care (Section # change only)
04/16/2018
Midwife Services (Section # change only)
04/16/2018
Timely Filing Reconsideration Requests
04/16/2018
DME Face-to-Face Requirements
04/16/2018
Home Health Face-to-Face Requirements
03/21/2018
Payment DVHA Primary
01/23/2018
Durable Medical Equipment (DME), Prosthetics,
Orthotics & Medical Supplies
12/29/2017
Concurrent Review for Admissions at Vermont
& In-Network Border Hospitals
12/29/2017
Claim Copy Requests
12/08/2017
Refunds
12/08/2017
Audiological Services/Hearing Aids
11/09/2017
Subacute Care
10/26/2017
09/29/2017
Telemedicine Services
Telemedicine Services
08/23/2017
Payment – DVHA Primary
Payment – Dual Eligible / Medicare Primary
06/22/2017
Anesthesia
06/12//2017
Psychiatry/Psychology
TENS/NMES
Provider Reconsideration Requests
Timely Filing (Section # change only)
Timely Filing Reconsideration Requests
Adjustments (Section # change only)
Prior Authorization of Medical Services
Immunizations
Health Examination of Defined Subpopulation
National Correct Coding Initiative (NCCI) Guidelines
Bilateral Billing Procedures
02/10/2017
Telemedicine Outside a Facility
Supervised Billing
Concurrent Review for Admissions at Vermont and In-
Network Border Hospitals
12/23/2016
Reimbursable Services - Home Health Hospice
Home Health Agency & Hospice Services Billing
Instructions/Field Locators
Hospital Clinical Laboratory Tests
Place of Service (POS) Codes
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12/01/2016
Assistant Surgeon
10/13/2016
Rehabilitative Therapy
Wheelchairs & Seating Systems
08/17/2016
Claims System & Provider Services
Prior Authorization Requirements
07/01/2016
Provider Based Billing
06/02/2016
Choices for Care: ERC/Nursing Facilities/HBW,
Moderate Needs
Hospital Outpatient Billing Instructions/Field Locators
04/18/2016
Long Acting Reversible Contraceptives Provided in an
Inpatient Hospital Post-Partum Setting
04/01/2016
Supervised Billing for Behavioral Health Services
Psychiatry/Psychology
03/01/2016
Provider Based Billing
Place of Service (POS) Codes
Provider Claim Modification Process
Provider Administrative Review Process
Continuous Passive Motion (CPM) Devices
Electronic Health Record Program Reconsideration
Process
Appeal of EHR Incentive Program Reconsideration
02/10/2016
Inpatient Newborn Services
Correct Coding Practices
New, Revised and Deleted Codes
Fee Schedule
01/19/2016
Supervised Billing for Behavioral Health Services
12/18/2015
Payment DVHA Primary
Incident-To Billing For Licensed Physicians
Supervised Billing For Behavioral Health Services
12/01/2015
Provider Enrollment, Licensing & Certification
National Correct Coding Initiative (NCCI) Guidelines
11/01/2015
Inpatient Newborn Services (Physician)
Organ Transplant
Organ Transplant Donor Complication
Important Telephone Numbers, Addresses and
Websites
In-State & Out of State Psychiatric & Detoxification
Inpatient Services
10/15/2015
Obstetrical Care
10/01/2015
ICD-9/ICD-10 References (Throughout Entire Manual)
Abortions
Midwife Services
CMS 1500 Paper Claim Billing Instructions/Field
Locators
09/01/2015
Psychiatry/Psychology
ICD-9/ICD-10 References (Throughout Entire Manual)
08/01/2015
Organ Transplant Donor Complication
Electronic Health Record Incentive Program (EHRIP)
EHR Incentive Program Reconsideration Process
EHR Incentive Program Appeal Process
Medical Necessity
Obstetrical Care
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Midwife Services
Concurrent Review for Admissions at Vermont & In-
Network Hospitals
Timely Filing
Psychiatry/Psychology
07/13/2015
Provider Administrative Review Process
Program Integrity Reconsideration & Appeal Process
07/01/2015
Claims System & Provider Services
Third Party Liability (TPL)/Other Insurance (OI)
CMS 1500 Paper Claim Billing
06/01/2015
Telemonitoring
04/15/2015
Member Information
Medicaid and Medicare Crossover Billing
Rehabilitative Therapy
Bilateral Procedures Physician/Professional Billing
Enteral Nutrition
Inpatient/Outpatient Overlap
Hospital Inpatient Billing Instructions
Hospital Outpatient Billing Instructions
02/01/2015
Individual Consideration/Manual Pricing
Rehabilitative Therapy
Chiropractic Services
Midwife Services
Bilateral Billing Procedures
01/01/2015
Prior Authorization Reviewers
Telemedicine
Hospital Inpatient Billing Instructions/Field Locators
Hospital Outpatient Billing Instructions/Field Locators
Home Health Agency & Hospice Services Billing
Instructions/Field Locators
Short Term Stays
Home Based Waiver (HBW) Billing Instructions/Field
Locators
12/01/2014
Midwife Services
CMS 1500 Paper Claim Billing Instructions/Field
Locators
Home Health Agency & Hospice Services Billing
Instructions
Home Based Waiver (HBW) Billing Instructions/Field
Locators
11/03/2014
Contractual Allowance
Rehabilitative Therapy
Ambulance Services
EPSDT Program Well – Child Health Care
CMS 1500 paper Claim Billing Instructions/Field
Locators
Inpatient Claims: Medicare Part A Exhausts or Begins
During the Inpatient Stay
Provider Based Billing
10/01/2014
Claim Submission & Correspondence Mailing
Addresses
Member Bill of Rights
5/23/2018 Green Mountain Care Provider Manual 5
Contractual Allowance
Out-of-Network Elective Outpatient Referrals
Psychiatric/Psychology
Short Stays
Same/Next Day Readmission Policy
Transfer Cases
Dialysis
08/23/2014
Cardiac Rehabilitation
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Table of Contents
SUMMARY OF UPDATES ........................................................................................................................... 2
TABLE OF CONTENTS ............................................................................................................................... 6
SECTION 1 GENERAL INFORMATION AND ADMINISTRATION ......................................................... 14
Important Telephone Numbers, Addresses and Websites ......................................................... 14
Administration & Responsibilities ................................................................................................ 14
1.2.1 Member Eligibility Determination ....................................................................................................... 14
1.2.2 Administration of Insurance Programs .............................................................................................. 15
1.2.3 Claims System & Provider Services .................................................................................................. 15
1.2.4 Claim Submission & Correspondence Mailing Addresses ................................................................. 16
1.2.5 Claim Copy Requests ........................................................................................................................ 16
1.2.6 Provider Claim Modification Process ................................................................................................. 17
1.2.7 Provider Reconsideration Process .................................................................................................... 17
SECTION 2 GREEN MOUNTAIN CARE .................................................................................................. 18
Medicaid for Adults ..................................................................................................................... 18
Dr. Dynasaur (Children) .............................................................................................................. 18
Prescription Assistance Pharmacy-Only Programs .................................................................... 18
Medicare Savings Programs (MSP) ........................................................................................... 18
Primary Care Plus (PC PLUS) .................................................................................................... 18
2.5.1 Allowed Practitioner Types ................................................................................................................ 19
2.5.2 Application ......................................................................................................................................... 20
2.5.3 Enrollment Minimum/Maximum ......................................................................................................... 20
2.5.4 Monthly Enrollment List ..................................................................................................................... 20
2.5.5 Provider Enrollment Status Change .................................................................................................. 20
2.5.6 Notice of Termination of Participation in PCP Plus............................................................................ 20
2.5.7 Hospital Admitting Privileges ............................................................................................................. 20
2.5.8 Referrals ............................................................................................................................................ 20
2.5.9 Case Management Responsibilities .................................................................................................. 22
2.5.10 Case Management Fee and Treatment Plan .................................................................................. 22
SECTION 3 POLICIES & OTHER INFORMATIONAL RESOURCES ..................................................... 23
Advisory ...................................................................................................................................... 23
Vermont Medicaid Banner .......................................................................................................... 23
Claim Edit Standards .................................................................................................................. 23
3.3.1 Correct Coding Practices .................................................................................................................. 23
3.3.2 New, Revised and Deleted Codes ..................................................................................................... 24
Correct Form Versions ................................................................................................................ 24
Manuals for Providers ................................................................................................................. 24
Medicaid Rule & State Plan Resources ...................................................................................... 24
National Correct Coding Initiative (NCCI) Guidelines ................................................................. 25
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Remittance Advice ...................................................................................................................... 26
3.8.1 The 835 Transaction (Electronic Remittance Advice) ........................................................................ 27
SECTION 4 MEMBER INFORMATION .................................................................................................... 27
Eligibility ...................................................................................................................................... 27
4.1.1 Partial Eligibility ................................................................................................................................. 27
4.1.2 Eligibility Verification .......................................................................................................................... 27
Identification ................................................................................................................................ 29
Member Bill of Rights .................................................................................................................. 29
Member Cost Sharing/Co-pays and Premiums .......................................................................... 30
Qualified Medicaid Member (QMB) ............................................................................................ 31
Notice of Decision ....................................................................................................................... 31
Court Ordered Services .............................................................................................................. 31
Retroactive Eligibility ................................................................................................................... 31
Member Grievance Process ....................................................................................................... 31
Member Appeal Process ............................................................................................................ 31
Fair Hearing ................................................................................................................................ 32
Advanced Directives ................................................................................................................... 32
SECTION 5 PROVIDER ENROLLMENT, LICENSING & CERTIFICATION ........................................... 32
Enrollment & Certification ........................................................................................................... 32
5.1.1 Enrollment Agreement Signatures ..................................................................................................... 33
Payment Conditions .................................................................................................................... 34
Conditions of Participation .......................................................................................................... 34
Documentation of Services ......................................................................................................... 34
Rights & Responsibilities ............................................................................................................ 34
Termination ................................................................................................................................. 35
SECTION 6 COORDINATION OF BENEFITS/MEDICAID PAYMENT LIABILITY/THIRD PARTY
LIABILITY 35
Contractual Allowance ................................................................................................................ 35
Reimbursement of Overpayments .............................................................................................. 35
Who is Responsible for Payment? .............................................................................................. 36
6.3.1 Supplementation ............................................................................................................................... 36
Who Is Primary ........................................................................................................................... 36
Notice That Medicaid Will Not Be Accepted ............................................................................... 37
Medicaid & Medicare Crossover Billing ...................................................................................... 37
Third Party Liability (TPL)/Other Insurance (OI) ......................................................................... 38
6.7.1 Third Party Liability Coverage Codes ................................................................................................ 41
Workers Compensation/Accident Liability Billing ........................................................................ 42
SECTION 7 PRIOR AUTHORIZATION FOR MEDICAL SERVICES ....................................................... 43
Clinical Practice Guidelines ........................................................................................................ 43
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Prior Authorization Requirements ............................................................................................... 43
7.2.1 Required Documentation ................................................................................................................... 43
7.2.2 Immediate Need Exception ............................................................................................................... 44
Determination Time..................................................................................................................... 44
7.3.1 PA Decision Reconsiderations .......................................................................................................... 45
Medical Necessity ....................................................................................................................... 46
7.4.1 Medical Necessity Form (MNF) ......................................................................................................... 46
Utilization Review........................................................................................................................ 46
Prior Authorization Notice Of Decision ....................................................................................... 47
Services Requiring Prior Authorization ....................................................................................... 47
7.7.1 Concurrent Review for Admissions at Vermont & In-Network Border Hospitals ................................ 47
7.7.2 Out of-State Elective Inpatient Hospital Admissions.......................................................................... 47
7.7.3 Out-of-Network Elective Outpatient Referrals.................................................................................... 48
7.7.4 In-State & Out of State Psychiatric & Detoxification Inpatient Services ............................................. 48
7.7.5 Out-of-State Urgent/Emergent Inpatient Hospital Admissions ........................................................... 48
7.7.6 Rehabilitative Therapy ....................................................................................................................... 48
SECTION 8 REIMBURSEMENT, BILLING PROCEDURES AND CLAIM PROCESSING ..................... 50
Adjustments Requests ................................................................................................................ 50
Timely Filing ................................................................................................................................ 51
8.2.1 Timely Filing Reconsideration Requests ........................................................................................... 52
Usual & Customary Rate (UCR) ................................................................................................. 52
Incident-To Billing For Licensed Physicians ............................................................................... 52
Supervised Billing for Behavioral Health Services ...................................................................... 53
Locum Tenens ............................................................................................................................ 56
Time-based Procedure Codes – Billing Guidelines .................................................................... 57
Electronic Claim Submission ...................................................................................................... 57
Electronic Funds Transfer (EFT) ................................................................................................ 58
Claim Disposition Information Introduction ................................................................................. 58
Remittance Advice (RA) ............................................................................................................. 58
8.11.1 RA Sections..................................................................................................................................... 58
8.11.2 RA Headings & Descriptions ........................................................................................................... 59
8.11.3 Earnings Data & Message Codes ................................................................................................... 62
Refunds ....................................................................................................................................... 63
SECTION 9 BILLING PROCEDURES CMS1500 & UB04 CLAIM TYPES ............................................. 64
Abortions ..................................................................................................................................... 64
Aids/HIV ...................................................................................................................................... 64
Organ Transplant ........................................................................................................................ 64
9.3.1 Organ Transplant Donor Complication .............................................................................................. 65
CPT Category III Procedure Codes ............................................................................................ 65
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Factor HCPCS Codes ................................................................................................................. 65
Fee Schedule .............................................................................................................................. 65
Health Examination of Defined Subpopulation ........................................................................... 66
Interpreter Services/Limited English Proficiency (LEP) .............................................................. 66
9.8.1 Informed Consent .............................................................................................................................. 66
9.8.2 HIPAA ............................................................................................................................................... 66
9.8.3 Vermont Medicaid Billing ................................................................................................................... 66
9.8.4 Limited English Proficiency (LEP) Resources ................................................................................... 67
9.8.5 Deaf and Hard of Hearing Resources ............................................................................................... 67
9.8.6 Additional Online Information ............................................................................................................ 67
Inpatient Newborn Services ........................................................................................................ 67
Modifier ‘LT’ & ‘RT’...................................................................................................................... 68
Place of Service (POS) Codes ................................................................................................... 68
Rehabilitative Therapy see section 7.7.6 .................................................................................... 70
Spend-Down ............................................................................................................................... 70
Long Acting Reversible Contraceptives Provided in an Inpatient Hospital Post-Partum Setting71
SECTION 10 CMS 1500 CLAIM SUBMISSIONS ....................................................................................... 71
Payment DVHA Primary ............................................................................................................. 71
Non-Reimbursable Services ....................................................................................................... 73
CMS 1500 Claim Type – Billing Information ............................................................................... 74
10.3.1 Alcohol/Drug Detoxification Treatment ............................................................................................ 74
10.3.2 Ambulance Services ........................................................................................................................ 74
10.3.3 Anesthesia....................................................................................................................................... 76
10.3.4 Antineoplastic Drugs ....................................................................................................................... 78
10.3.5 Assistant Surgeon ........................................................................................................................... 78
10.3.6 Audiological Services/Hearing Aids ................................................................................................. 79
10.3.7 Bilateral Procedures Physician/Professional Billing ......................................................................... 80
10.3.8 Capsule Endoscopy (Esophagus through Ileum) ............................................................................ 80
10.3.9 Children with Special Health Needs Infant Toddler Programs ......................................................... 80
10.3.10 Chiropractic Services .................................................................................................................... 80
10.3.11 Consultation .................................................................................................................................. 80
10.3.12 Detail Processing .......................................................................................................................... 81
10.3.13 Developmental & Autism Screening of Young Children ................................................................ 81
10.3.14 Diabetic Teaching .......................................................................................................................... 82
10.3.15 Drugs Requiring Prior Authorization .............................................................................................. 82
10.3.16 Dual Eligibility ................................................................................................................................ 83
10.3.17 Emergency Indicator ..................................................................................................................... 83
10.3.18 Emergency Room Services ........................................................................................................... 83
10.3.19 EPSDT Program Well – Child Health Care ................................................................................... 83
10.3.20 ESRD Related Services ................................................................................................................ 84
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10.3.21 Evaluation & Management Services (Post-Operative Care) .......................................................... 85
10.3.22 Family Planning Services .............................................................................................................. 85
10.3.23 FQHC/RHC ................................................................................................................................... 85
10.3.24 Health Maintenance Organization (HMO) ..................................................................................... 87
10.3.25 Hospital Based Physicians ............................................................................................................ 87
10.3.26 Hysterectomy ................................................................................................................................ 88
10.3.27 Immunization ................................................................................................................................. 88
10.3.28 Independent Laboratory ................................................................................................................ 89
10.3.29 Injections ....................................................................................................................................... 90
10.3.30 Inpatient Services .......................................................................................................................... 91
10.3.31 Lead Screening ............................................................................................................................. 91
10.3.32 Maintenance Drug Prescriptions ................................................................................................... 91
10.3.33 Mastectomy ................................................................................................................................... 91
10.3.34 Medical Nutrition Therapy ............................................................................................................. 91
10.3.35 Multiple Surgery Pricing ................................................................................................................ 91
10.3.36 Naturopathic Physicians ................................................................................................................ 92
10.3.37 NDC (National Drug Code) ............................................................................................................ 92
10.3.38 Non-Emergency Medical Transportation (NEMT) .......................................................................... 93
10.3.39 Obstetrical Care ............................................................................................................................ 93
10.3.40 Midwife Services ........................................................................................................................... 95
10.3.41 Oral Surgery .................................................................................................................................. 97
10.3.42 Over-The-Counter (OTC) Medications .......................................................................................... 97
10.3.43 Oximetry Services ......................................................................................................................... 97
10.3.44 Pharmacologic Management (Psychiatric) .................................................................................... 97
10.3.45 Physician Visit Limits ..................................................................................................................... 97
10.3.46 Post-Operative Follow-up Visits .................................................................................................... 98
10.3.47 Psychiatry/Psychology .................................................................................................................. 98
10.3.48 Radiology .................................................................................................................................... 101
10.3.49 Smoking Cessation Counseling ................................................................................................... 102
10.3.50 Specimen Collection Fee............................................................................................................. 102
10.3.51 Sterilizations ................................................................................................................................ 103
10.3.52 Team Care Program .................................................................................................................... 103
10.3.53 Telemedicine Services ................................................................................................................ 103
10.3.54 Topical Fluoride Varnish .............................................................................................................. 104
10.3.55 Vision Care & Eyeglasses ........................................................................................................... 104
SECTION 11 DURABLE MEDICAL EQUIPMENT (DME), PROSTHETICS, ORTHOTICS & MEDICAL
SUPPLIES ............................................................................................................................................. 106
Rental Reimbursement Policies ................................................................................................ 106
Capped Rentals (CR) ............................................................................................................... 107
Rental/Loaned ........................................................................................................................... 107
Face-to-face Requirements ...................................................................................................... 108
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Reimbursable/Non-Reimbursable Services .............................................................................. 108
Payment DVHA Primary/Manual pricing ................................................................................... 109
Payment-Dual Eligible/Medicare Primary ................................................................................. 109
Prescribing Provider.................................................................................................................. 110
Dates of Service ........................................................................................................................ 110
Procedure Codes & Pricing ...................................................................................................... 111
Repairs ...................................................................................................................................... 111
Supply Returns ......................................................................................................................... 111
Durable Medical Equipment (DME) Recycling ......................................................................... 112
Rehabilitation Equipment Review ............................................................................................. 112
DME Billing Information - Equipment Specific (Alphabetical) ................................................... 112
11.15.1 Adaptive Weighted Eating Utensils ............................................................................................. 112
11.15.2 Apnea Monitors ........................................................................................................................... 112
11.15.3 BICROS/CROS (Contralateral Routing of Sound) ....................................................................... 113
11.15.4 Blood Pressure Monitors ............................................................................................................. 113
11.15.5 Breast Pumps .............................................................................................................................. 113
11.15.6 Continuous Passive Motion (CPM) Devices ................................................................................ 113
11.15.7 CPAP & BIPAP ............................................................................................................................ 114
11.15.8 Crutches ...................................................................................................................................... 114
11.15.9 Enteral Nutrition ........................................................................................................................... 114
11.15.10 Glucometers .............................................................................................................................. 114
11.15.11 Hospital Beds ............................................................................................................................ 114
11.15.12 Incontinence Supplies ............................................................................................................... 115
11.15.13 Medical Supplies ....................................................................................................................... 115
11.15.14 Oxygen ...................................................................................................................................... 115
11.15.15 Peak Flow Meters ...................................................................................................................... 115
11.15.16 Special Needs Feeder Bottles ................................................................................................... 115
11.15.17 Speech Augmentation Devices ................................................................................................. 115
11.15.18 Splints ....................................................................................................................................... 116
11.15.19 TENS/NMES ............................................................................................................................. 116
11.15.20 Tracheostomy Care Kits ............................................................................................................ 116
11.15.21 Ventricular Assist Devices ......................................................................................................... 116
11.15.22 Wheelchairs & Seating Systems ............................................................................................... 116
11.15.23 Wheelchair Repairs ................................................................................................................... 117
CMS 1500 Paper Claim Billing Instructions/Field Locators ...................................................... 117
SECTION 12 UB04 CLAIM SUBMISSIONS ............................................................................................ 121
Reimbursable Services ............................................................................................................. 121
Reimbursement Policy .............................................................................................................. 122
Patient Share (Applied Income) Reporting ............................................................................... 122
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General Hospital Billing Information ......................................................................................... 123
12.4.1 Bilateral Billing Procedures ........................................................................................................... 123
12.4.2 In-Network & Extended Network Hospitals .................................................................................... 123
12.4.3 Inpatient/Outpatient Overlap Examples ......................................................................................... 123
12.4.4 Inpatient Claims: No Medicare Part A; Has Medicare B Coverage ................................................ 124
12.4.5 Inpatient Claims: Medicare Part A Exhausts or Begins During the Inpatient Stay ......................... 124
12.4.6 Inpatient Claims: Medicare Primary but Medicaid Eligibility Termed During Stay.......................... 124
12.4.7 Interim Inpatient Claims ................................................................................................................. 125
12.4.8 Present on Admission (POA) - Inpatient Admissions .................................................................... 125
12.4.9 Short Stays .................................................................................................................................... 125
12.4.10 Same/Next Day Readmission Policy ........................................................................................... 126
12.4.11 Subacute Care ............................................................................................................................ 126
12.4.12 Transfer Cases ............................................................................................................................ 126
12.4.13 Outpatient Services Rendered During an Inpatient Stay ............................................................. 127
Out-Patient/Inpatient Hospital Services .................................................................................... 127
12.5.1 Cardiac Rehabilitation ................................................................................................................... 127
12.5.2 Dialysis .......................................................................................................................................... 127
12.5.3 Inhalation Therapy ......................................................................................................................... 127
12.5.4 Hospital Clinical Laboratory Tests ................................................................................................. 127
12.5.5 Observation Rooms ....................................................................................................................... 128
12.5.6 Private Room................................................................................................................................. 128
12.5.7 Provider Based Billing ................................................................................................................... 128
12.5.8 Hospital Inpatient Billing Instructions/Field Locators ..................................................................... 129
12.5.9 Hospital Outpatient Billing Instructions/Field Locators ................................................................... 132
SECTION 13 HOME HEALTH AGENCY SERVICES .............................................................................. 135
Conditions for Payment ............................................................................................................ 135
Face-to-face requirements ........................................................................................................ 136
Reimbursable Services ............................................................................................................. 136
13.3.1 Visit at Patient’s Place of Residence ............................................................................................. 136
13.3.2 Nursing Care Services .................................................................................................................. 137
13.3.3 Registered Nurse Services ............................................................................................................ 137
13.3.4 Licensed Practical Nurse Services ................................................................................................ 137
13.3.5 Home Health Aide Services........................................................................................................... 138
13.3.6 Personal Duties ............................................................................................................................. 138
13.3.7 Medical Duties ............................................................................................................................... 138
13.3.8 Household Services ...................................................................................................................... 138
13.3.9 Hospice ......................................................................................................................................... 138
13.3.10 Respite Billing .............................................................................................................................. 138
13.3.11 Telemonitoring ............................................................................................................................. 139
Home Health Agency & Hospice Services Billing Instructions/Field Locators.......................... 140
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Adult Day Services Billing Instructions/Field Locators.............................................................. 144
SECTION 14 ASSISTIVE COMMUNITY CARE SERVICES (ACCS) ...................................................... 147
Revenue Code & Date Span Billing .......................................................................................... 147
Assistive Community Care Services (ACCS) Billing Instructions/Field Locators .................... 148
SECTION 15 CHOICES FOR CARE: ENHANCED RESIDENTIAL CARE (ERC)/NURSING FACILITIES
HOME BASED WAIVER (HBW), MODERATE NEEDS .......................................................................... 151
ERC Paper Claim Submission Billing Instructions/Field Locators ............................................ 151
Choices for Care: Nursing Facilities - General Billing Information ........................................... 154
15.2.1 Authorization for Care & Non-Covered Services ........................................................................... 154
15.2.2 Member Placement Levels (RPL) .................................................................................................. 155
15.2.3 DME in Health Care Institutions .................................................................................................... 155
15.2.4 Duration of Coverage .................................................................................................................... 156
15.2.5 Hold Bed ....................................................................................................................................... 156
15.2.6 Leave of Absence .......................................................................................................................... 157
15.2.7 Nursing Home Claims & Patient Hospitalization ............................................................................ 157
15.2.8 Patient Share in a Nursing Facility ................................................................................................ 157
15.2.9 Prior Payments .............................................................................................................................. 157
15.2.10 Choices for Care Short-Term Respite Stays ............................................................................... 158
15.2.11 Services Included in Per Diem Rate ............................................................................................ 158
15.2.12 Short Term Stays ........................................................................................................................ 158
15.2.13 Nursing Facilities Billing Instructions/Field Locators .................................................................... 158
Home Based Waiver (HBW) Billing Instructions/Field Locators ............................................... 162
SECTION 16 PROGRAM INTEGRITY ..................................................................................................... 164
Fraud ......................................................................................................................................... 164
Private Litigation ....................................................................................................................... 165
Sanctions .................................................................................................................................. 165
Program Integrity Reconsideration & Appeal Process ............................................................. 165
16.4.1 Reconsideration of Improper Payment and the Recovery of Overpayments ................................. 165
16.4.2 Program Integrity Appeal of Improper Payment and Overpayment Deficient Practice .................. 166
Violations .................................................................................................................................. 166
SECTION 17 OTHER PROVIDER INFORMATION ................................................................................. 166
Provider Tax .............................................................................................................................. 166
Pharmacy Tax ........................................................................................................................... 167
SECTION 18 ELECTRONIC HEALTH RECORD INCENTIVE PROGRAM ............................................ 167
Electronic Health Record Program Reconsideration Process .................................................. 167
Appeal of EHR Incentive Program Reconsideration ................................................................. 168
APPENDIX 1 170
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Section 1 General Information and Administration
The Department of Vermont Health Access (DVHA) is responsible for the administration of the State of
Vermont’s publicly funded health insurance programs.
Green Mountain Care is the brand name for the family of publicly funded health coverage programs offered
by the State of Vermont. Programs include Medicaid, Dr. Dynasaur and premium assistance pharmacy-only
programs.
IMPORTANT TELEPHONE NUMBERS, ADDRESSES AND WEBSITES
Department of Vermont Health Access
280 State Drive
Waterbury, VT 05671
Telephone: 1.802.879.5900
Fax: 1.802.879.5619
Website: http://dvha.vermont.gov
DXC Technology
312 Hurricane Lane
Suite 101
Williston, VT 05495
Telephone: 1.802.878.7871 (Out-of-State) or 1.800.925.1706 (In-State)
Fax: 1.802.878.3440
Website: http://www.vtmedicaid.com/#/
DXC Technology Provider Call Center
Toll-Free In-State: 1.800.925.1706
Local and Out-Of-State: 1.802.878.7871
DXC Technology Enrollment Unit
1.802.879.4450, option 4
Email: vtproviderenrollment@DXC.com
DXC Technology Checks, Claim Submission and Correspondence Mail
For all Checks: DXC Technology, PO Box 1645, Williston, VT 05495
For all Claims and other correspondences: DXC Technology, PO Box 888, Williston, VT 05495
ADMINISTRATION & RESPONSIBILITIES
1.2.1 Member Eligibility Determination
Application for health benefit eligibility and other public benefit determinations may be made online at
http://dcf.vermont.gov/mybenefits/apply_for_benefits or at a DCF Economic Services Division (ESD) District
Office http://dcf.vermont.gov/esd/contact_us/district_offices. Eligible members are enrolled in the appropriate
health care assistance program by the Department for Children and Families, Economic Services Division
(ESD), Health Access Eligibility Unit (HAEU). Questions about applying and other information queries can be
made at any DCF District Office http://dcf.vermont.gov/ or by calling the Benefits Service Center/District
Office.
Benefits Service Center/District Offices:
Telephone (800) 479-6151
The Benefits Service Center’s call center interactive voice response (IVR) system services providers and
member statewide. Providers should stay on the line after the message for a separate queue, and will be
serviced directly.
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1.2.2 Administration of Insurance Programs
The Department of Vermont Health Access (DVHA) has the primary responsibility for establishing program
policy direction and administration of Vermont’s health insurance programs, determining service coverage,
establishing provider reimbursement rates, and provides funding for provider payments.
Department of Vermont Health Access:
Telephone (802) 879-5900
http://dvha.vermont.gov/
312 Hurricane Lane, Suite 201
Williston, VT 05495
DVHA operates the Green Mountain Care Member Services Unit to provide information to health benefit
applicants and respond to questions and problems from members.
Green Mountain Care Member Services:
Telephone (800) 250-8427
TTY: (888) 834-7898
101 Cherry Street, Suite 320
Burlington, VT 05401-9823
1.2.3 Claims System & Provider Services
The State of Vermont contracts with a fiscal agent DXC Technology (DXC) to process Medicaid claims and
perform other duties as required by the contract. This includes maintenance of the eligibility sub-system,
claims processing billing codes and rates, and electronic fund transfers for reimbursement of services.
The Provider Services Unit of DXC Technology consists of four components: Provider Relations
Representatives, Provider Call Center Agents, Provider Enrollment and the Publications Coordinator. This
unit is available to assist Vermont Medicaid providers and their billing personnel (at no cost), Monday
through Friday from 8:00am to 5:00pm (except for State holidays; see the Holiday Closure Schedule at
http://www.vtmedicaid.com/#/resources
Provider Services/DXC: Toll-free in Vermont (800) 925-1706
Local and Out-of-State (802) 878-7871
*Note: DXC does not assist or take calls from members. Please direct all member questions to Green
Mountain Care Member Services (800) 250-8427.
Provider Enrollment
Provider Enrollment facilitates the enrollment and revalidation of providers requesting to participate in the
Vermont Medicaid Program. Representatives are available during regular business hours to answer written
and verbal inquires; see Section 5 Provider Enrollment, Licensing & Certification.
Provider Call Center
Call Center Agents are available to assist providers with program eligibility questions, provide service
limitation information, assist with claim inquiries and other information not available through the Voice
Response System (VRS) or Vermont Medicaid website http://www.vtmedicaid.com/#/
DXC provides claim and member information only to enrolled Vermont Medicaid providers; therefore,
providers are required to state their provider number at the time of contact. The following information that
will be requested, when applicable:
Member ID Number
Internal Control Number (ICN)
Date of Service
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Date of Remittance Advice (RA)
The Help Desk is not authorized to verify eligibility for dates 9 or more days beyond the date of inquiry.
Provider Relations Representatives
Provider Relations Representatives are available to travel throughout the state for problem solving and
provider education. These representatives work to increase provider participation by speaking at
professional association meetings, scheduling provider visits, and presenting statewide workshops for
Vermont Medicaid. Providers wishing to schedule a visit or identify the representative assigned to their
area are directed to the Provider Representative Map at http://www.vtmedicaid.com/#/manuals
Written Inquiries
To ensure accuracy and consistency, submit written inquiries on the Provider Inquiry Form, available at
http://www.vtmedicaid.com/#/forms. Send completed inquiries to:
DXC Technology
Provider Services Unit
P.O. Box 888
Williston, Vermont 05495-0888
To expedite the handling of your request, complete boxes one through twelve of the Provider Inquiry Form
and attach the appropriate documentation.
Note: Provider Inquiry Forms may not be used to:
Resubmit corrected claims*
Request an adjustment on a paid claim
Check on the status of a claim.
*Corrected claims should be sent directly to DXC with copies of all required attachments, when applicable.
If there are no attachments, claims may be resubmitted electronically, see Section 8.1 Adjustment
Requests.
1.2.4 Claim Submission & Correspondence Mailing Addresses
To ensure your request is processed in a timely manner, use the correct PO Box specific to each
correspondence type mailed to DXC Technology.
PO Box 1645 – All Checks
PO Box 888 – All Claims, Other Mail & Inquiries
Williston, VT 05495-0888
Health care providers and administrators wishing to send paperwork using a registered or certified carrier
service are to use our physical office address:
DXC Technology 312 Hurricane Lane, Suite 101 Williston, VT 05495
1.2.5 Claim Copy Requests
When a member or an attorney for a member requests a copy of a claim which has been paid, please
inform them that copies should be requested in writing from: DVHA - COB Unit, 280 State Drive,
Waterbury, VT 05671.
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1.2.6 Provider Claim Modification Process
The Department of Vermont Health Access (DVHA) allows claim reviews by DXC Technology for the below
modifications to claims:
Modifiers: Changes (additions and/or removals) to modifiers. Requested modifications must be
submitted on appropriate claim form with supporting documentation to DXC Technology, PO Box 888,
Williston, VT 05495
Units: Changes to previously listed units may be reviewed when sent on appropriate claim form with
any applicable supporting documentation to DXC Technology, PO Box 888, Williston, VT 05495
Place of Service or Diagnosis Codes: Changes to previously listed Place of Service codes or
Diagnosis codes may be sent for review with appropriate claim form and any applicable supporting
documentation to DXC Technology, Attn: Utilization Review, PO Box 888, Williston, VT 05495
Provider Type and Specialty: If a provider would like a review of the services covered under their
specialty scope of practice, please send request and supporting documentation to DXC Technology,
Attn: Utilization Review, PO Box 888, Williston, VT 05495
1.2.7 Provider Reconsideration Process
The Department of Vermont Health Access (DVHA) allows an enrolled provider a process for requesting a
review of certain claims payments. DVHA’s position is that providing a “second look” for certain decisions
may help improve accuracy. DVHA will review a decision for the following:
• Timely filing denial (refer to section 8.2.1 on Timely Filing Reconsideration Requests
requirements)
• Improper payments or non-payments
• Coding errors
A. A request for review must be made no later than 30 calendar days after the DVHA gives notice to
the provider of its decision. Requests after 30 days will be returned with no action taken.
The request for review must be filed on the Reconsideration Request form (located at
http://www.vtmedicaid.com/#/forms)
B. All issues regarding providers’ objection to the findings must be documented. The request should
provide a brief background of the case, and the reasons why the provider believes the DVHA
should have ruled differently.
C. Requests will be reviewed by a qualified member of the DVHA when all information related to the
claim is submitted. Upon receipt of the request and all supporting information, the DVHA will
review all information received. The DVHA may consider additional information, either verbal or
written, from the provider or others, to further clarify the case.
D. The qualified DVHA reviewer will issue a written decision to the provider of its review decision or
notify the provider that an extension is needed within 30 calendar days of receipt of the request
for review.
E. There is no additional review or reconsideration after the written decision on the review. This
decision is final.
All requests for review must be addressed to:
DXC Technology
Administrative Review
PO Box 888
Williston VT 05495
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Section 2 Green Mountain Care
Green Mountain Care is a family of state-sponsored low-cost and free health insurance programs for
uninsured Vermonters.
MEDICAID FOR ADULTS
Medicaid programs for adults provide low-cost or free coverage for Vermonters who are eligible based on
income and resources. Medicaid provides a broad benefit package that may include acute care, long-term
care, dental, pharmacy and, if necessary, transportation to medical services.
Members are enrolled in PC Plus managed care and may be responsible for certain co-payments for
services performed in an inpatient and outpatient hospital setting as well as for pharmacy and dental benefits
(see section 4.4 Member Cost Sharing).
DR. DYNASAUR (CHILDREN)
Dr. Dynasaur encompasses all health care programs available for children up to age 19 Children’s Health
Insurance Program (CHIP) and Underinsured Children Members are enrolled in the PC Plus managed care
program.
PRESCRIPTION ASSISTANCE PHARMACY-ONLY PROGRAMS
Prescription assistance programs help Vermonters pay for prescription medicines based on income, disability
status and age. Pharmacy program requirements apply http://dvha.vermont.gov/for-providers.
There is a monthly premium based on income, and co-pays based on the cost of the prescription; see
Section 4.4 Member Cost Sharing/Co-pays and Premiums.
VPharm - VPharm assists Vermonters enrolled in Medicare Part D with payment for prescription medications.
In general, VPharm covers drug classes that are excluded from the Part D benefit, and may assist with
premiums and cost-sharing.
Healthy Vermonters - Healthy Vermonter’s provides a discount on both long-term and short-term
prescriptions for Vermonters not eligible for other pharmacy assistance programs.
MEDICARE SAVINGS PROGRAMS (MSP)
Qualified Medicare Beneficiary - A Qualified Medicare Beneficiary (QMB) is an aged, blind or disabled
individual with income at or below 100% FPL who is eligible for Medicaid payment of Medicare premiums,
deductibles and co-insurance but not for any other payments
Specified Low-Income Beneficiaries - A Specified Low-Income Medicare Beneficiary (SLMB) is an aged,
blind or disabled individual who is eligible for Medicaid payment of their Medicare Part B premium if the
individual would be eligible for QMB except for income with income above 100% but at or below 120%FPL.
Qualified Individuals – A Qualified Individual (QI-1) is an aged, blind or disabled individual with income at or
below 100% FPL who is eligible for Medicaid payment of Medicare Part B premium if the individual would be
eligible for QMB except for income with income above 100% but at or below 135%FPL and does not receive
any other federally-funded medical assistance except for coverage for excluded drug classes under part D
when the individual is enrolled in part D.
PRIMARY CARE PLUS (PC PLUS)
Primary Care Plus (PC Plus) is a primary care case management program developed by the DVHA as part of
Vermont’s Global Commitment. Vermont requires that all Medicaid and Dr. Dynasaur member enroll in PC
Plus. Many services covered under PC Plus need to be authorized by the Primary Care Provider (PCP).
Services rendered to a member enrolled in a primary care case management (PCCM) must follow the
guidelines for the PCCM program.
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The key goals of PC Plus are to:
Enhance the continuity of care through the creation of a “medical home”
Establish a partnership between the Medicaid administration and community providers
Maximize dollars spent for medical services
PCPs coordinate their members’ health care needs by providing the following services:
Primary care medical services, covered by Vermont Medicaid
Referral authorization for needed specialty and other covered medical services
Arrange 24-hour-a-day/seven days-a-week coverage
PCPs receive a monthly case management fee for each member enrolled with the PCP. This fee is for
coordinating members’ health care services. The case management payment structure is based on the
number of patients that are attributed to the practice. Vermont Medicaid will attribute members to the PCP
who has billed for appropriate services and who has seen the member within the last 24 months.
Membership in PC Plus is mandatory for all Medicaid and Dr. Dynasaur members who are not otherwise
exempt from managed care enrollment under the provisions of the 1115 waiver. Under the waiver, individuals
who have third party insurance, in addition to Medicaid/Dr. Dynasaur, and individuals who are on home and
community-based waivers, are exempted from PC Plus enrollment. In addition, individuals enrolled in the
Medicaid High Tech Program and individuals living in long-term care facilities are exempt from PC Plus
enrollment.
Once they are found eligible, members who are not exempt are sent an enrollment package from the Green
Mountain Care Member Services Unit and are asked to select a primary care provider. A primary care
provider is assigned to those members who do not make a selection within 30 days.
Members may change their PCP by contacting the Member Services Unit. Members can be verified as
members of PC Plus using the VRS and the Vermont Medicaid web site http://www.vtmedicaid.com/#/
A PCP enrolled in the PC Plus program must meet all of the following requirements listed in the below
sections.
2.5.1 Allowed Practitioner Types
The PCP must be enrolled and in good standing in the Vermont Medicaid program and be routinely providing
services as a:
Family Practice Physician
General Practice Physician
Internal Medicine Physician (general internists)
Pediatric Physician
Adult, Pediatric or Family Nurse Practitioner
Naturopaths
Physician specialists, with one or more sub-specialties, may enroll as PCPs for members with life-
threatening, degenerative or disabling conditions or disease. They must agree to meet the obligations of a
PCP and have experience in and are willing to provide primary care services.
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2.5.2 Application
Providers who wish to be a PCP in the PC Plus program must be actively enrolled in the Vermont Medicaid
program and are required to complete and return the PCP “Agreement For Participation”.
Providers who are enrolling with PC Plus as a group, must complete a single “Application for Participation”,
signed by a representative of the practice group. The PCP Agreement for Participation and the Provider
Enrollment Agreement can be accessed at: http://www.vtmedicaid.com/#/provEnrollDataMaint
2.5.3 Enrollment Minimum/Maximum
PC Plus PCPs can set a limit on the number of PC Plus members to be enrolled in their practice. Maximum
enrollment for a PCP is 1500.
Should a PCP desire to increase or decrease the maximum number of members to be managed, the PCP
must notify DXC in writing at least 60 days prior to the new change. A new Application for Participation will
not be required.
2.5.4 Monthly Enrollment List
PCPs will receive a monthly roster of enrolled members. The roster does not assure continuing eligibility;
therefore, eligibility should be verified for each date of service prior to rendering the service. It is required that
incorrect member information is noted and a revised roster be returned to the DXC Enrollment Unit for
updating. This information may be returned by fax to 802-878-3440, Attn: enrollment or mailed to: DXC
Technology, Attn: Enrollment, PO Box 888, Williston, VT 05495.
2.5.5 Provider Enrollment Status Change
PCPs must notify DXC in writing should any of the changes listed below occur which will affect participation
in the plan. Mail written notification to DXC Technology, PC Plus, and P.O. Box 888, Williston, Vermont
05495-0888 or faxed to (802) 878-3440.
Group Composition
If there is any change in the composition of individual providers in a group that originally agreed to participate
in the Primary Care Plus Plan, the moving PCP is required to complete a new Agreement for Participation
prior to the effective date of change.
In addition, any provider who has not previously participated in the PC Plus plan will need to complete the
Agreement for Participation located at http://www.vtmedicaid.com/#/provEnrollDataMaint
Office Location
Any change in PCP office address, telephone numbers or name of practice, must be communicated in writing
to DXC as soon as possible and prior to the effective date of the change.
2.5.6 Notice of Termination of Participation in PCP Plus
All individually participating or group identified PCPs must notify DXC of their intention to withdraw from
participation, in writing, at least 90 days prior to the termination date. Providers are required to give their
patients 30 day notice prior to termination.
2.5.7 Hospital Admitting Privileges
A PC Plus PCP must have either local hospital admitting privileges or a formal arrangement with a physician
who has local hospital admitting privileges and who agrees to abide by PC Plus requirements.
2.5.8 Referrals
Referral of PC Plus members can be made to any provider currently enrolled in the Vermont Medicaid
program.
The goals of the referral process are to:
Ensure that the PCP is involved in medical decisions affecting members
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Reduce utilization of unnecessary medical services
Reduce duplication of services
Promote continuity of care
The PCP will be responsible for coordinating care between the member and any specialty care that the
member may need through the referral system. A referral takes place when a participating PCP refers their
PC Plus member for medically necessary covered services not normally provided by the PCP. Referrals by
the member’s PCP will be required for payment of claims submitted by specialty providers. Members seeking
specialty care without a referral from their PCP will be responsible for the visit, if they are informed in
advance and in writing that because they have no referral, they will have to accept financial responsibility for
the visit. See Section 6.5 Notice That Medicaid Will Not Be Accepted.
Effective July 1, 2012, non-emergency (elective) out-of-state medical visits will require prior authorization
from the DVHA Clinical Unit. Out-of-State Network Hospitals and Extended Network Hospitals are excluded
from this requirement. In network referring providers must submit requests using the Out-of-
State Elective Office Visit Request Form located at:
http://dvha.vermont.gov/for-providers/forms-1. Fax requests to 802-879-5963.
Referrals may be made orally or in writing. Both the PCP and the referral to specialty provider are required to
keep documentation of the referral in the patient’s medical records. The referral must include the following
information:
Patient identification information
Date
Reason for referral
Requested service (evaluate, evaluate and treat)
Providers who make referrals in writing may do so using their own referral form. Referral forms do not need
to be attached when submitting claims. The referral provider will be reimbursed on a fee-for-service basis for
Vermont Medicaid covered services.
The following services do not require a referral from the PCP:
Chiropractic services
Dental services (Medicaid/Dr. Dynasaur only)
Emergency services
Family planning services, defined as services that prevent or delay pregnancy
Gynecological services
Naturopathic services
Personal care for children
Prenatal and maternity care
Routine eye exams for adults/children and eyeglasses for children
Mental health services
School-based health services
Services rendered by the PCP or those providing back-up coverage for the
PCP
Substance abuse services
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Local Transportation services (Medicaid/Dr. Dynasaur only)
2.5.9 Case Management Responsibilities
In addition to providing primary care services, PCPs must provide a number of case management services.
Responsibilities include:
For referrals, the PCP must use Vermont Medicaid participating providers or providers enrolled to
serve members enrolled in the PC Plus program, unless the required service is not otherwise
available from a currently enrolled Vermont Medicaid provider. If the PCP wants to use a provider
who is not enrolled, DXC should be notified to solicit the enrollment of the provider.
The PCP must have provisions for access to 24-hour/seven days-per-week coverage that will
assure practitioner availability in person or by phone.
The PCP (or PCP’s practice) must maintain office-visiting hours at least four days per week for at
least twenty-five hours per week for member appointments, unless this provision is waived by the
DVHA in order to assure access to services and providers. Participating PCPs who work in a
practice on a part-time basis, must inform the DVHA of the times they are available to see patients.
DVHA may request a corrective action plan from the PCP if timely access responsibilities are not
met.
The PCP must assure that all members have a current medical history and record, and must
maintain medical records for each member.
The PCP must agree to adhere to the appointment waiting times standards set out in the Medicaid
Rule 7101.3 O (1) (b). These appointment standards state that any member should have immediate
access to emergency care and for non-emergent care be seen within: 24 hours for urgent care, 2
weeks for non-urgent care with prompt follow-up and 90 days for preventive and routine physical
examinations and 30 days for routine, laboratory, x-ray, general optometry, and all other routine
services.
PCPs must provide all covered primary care services consistent with their qualifications.
The PCP must assure that every child or adolescent enrolled in the practice is screened according
to the requirements of the Vermont Department of Health’s EPSDT Periodicity Schedule.
The PCP must follow the provisions of the Generic Drug Act where it permits
substitution and will prescribe the lowest cost equivalent available.
After consultation with specialists, the PCP will review and approve medically necessary specialty
services as appropriate, except for services exempted or those approved by the DVHA or the
DVHA’s designated prior authorization agent.
The PCP must participate in quality improvement projects agreed to by participants in the PC Plus
network and the DVHA.
The PCP must cooperate with the DVHA’s accessibility surveyors. The DVHA will provide each
PCP practice site with the results of any accessibility survey conducted.
The PCP must notify the DVHA of any change in his/her office physical plant that might change
physical accessibility to The Department.
2.5.10 Case Management Fee and Treatment Plan
In addition to fee-for-service reimbursement, PCPs will be paid a monthly case management fee for each
member assigned to their practice. The PCP does not need to file a claim for the case management fee.
Claims for the monthly fee will be generated by DXC based on the number of members enrolled in the
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practice and payment will appear on the Remittance Advice (RA). Actual services provided to members will
be reimbursed on a fee-for-service basis in accordance with Vermont Medicaid fee-for-service payment
policies and procedures.
When a PCP develops a treatment plan for a member, the PCP may submit a claim to DXC for
reimbursement for the development of this plan using procedure code G9001. A PCP may submit no more
than one treatment plan claim, per member, per calendar year. A covering practitioner cannot bill for a
treatment plan. Payment will be made in accordance with the Vermont Medicaid fee schedule for this
service. The treatment plan does not have to be submitted with the claim; however, it must be kept in the
member’s medical records. Treatment plans must include, at a minimum, the following information:
Presenting clinical problems
Expected outcomes
Services required, including level of intensity
Provider(s) of services
Section 3 Policies & Other Informational Resources
ADVISORY
The Vermont Health Access Advisory is a bi-monthly publication of DXC and DVHA. This newsletter provides
important information which is necessary for accurate billing to Vermont Medicaid. Providers may retain
copies for the Advisory and consult them whenever a question arises regarding DVHA policy or procedure or
use the Advisory archive http://www.vtmedicaid.com/#/advisory.To request electronic delivery, e-mail vtpubs-
comm@DXC.com.
VERMONT MEDICAID BANNER
The first page of the Remittance Advice (RA), the weekly report listing the status of each claim and any
pertinent financial information, is referred to as the Vermont Medicaid Banner. Messages on the Banner page
keep providers informed of important changes in policy or billing procedures. The Vermont Medicaid Banner
may be the only or first notification of a change in billing procedure. It is the provider’s responsibility to obtain
this information from their RA regarding DVHA policy or procedure. The Vermont Medicaid Banner is posted
online weekly at www.vtmedicaid.com/#/bannerMain and is archived at the same online location.
The Vermont Medicaid Banner can be emailed directly to you when you join our communications email
distribution list. Send your email address to vtpubs-comm@DXC.com to receive this provider resource and
other communications relevant to Vermont Medicaid.
CLAIM EDIT STANDARDS
Vermont Medicaid adheres to the following edit standards:
AMA, CPT, HCPCS and NCCI;
National Specialty Society Edit Standards; or
Proprietary NCPDP-compliant pharmacy adjudication software provided through our Prescription
Benefit Management(PBM) Goold Health Systems ®
Other appropriate nationally-recognized edit standards, guidelines or conventions approved by the
commissioner.
3.3.1 Correct Coding Practices
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Providers are responsible for correct and accurate billing including proper use as defined in the current
manuals: AMA Current Procedural Terminology (CPT), Health Care Procedure Coding System (HCPCS),
Current Dental Terminology (CDT), the most recent International Classification of Diseases clinical
Modification (ICD-10-CM) and International Classification of Diseases Procedure coding system (ICD-10-
PCS).
Please refer to the most current coding manuals for full details on proper coding and complete
documentation. If your practice utilizes a billing agent, it is still the practice’s responsibility to make sure
correct coding of claims is occurring.
3.3.2 New, Revised and Deleted Codes
DVHA’s Fee Schedule is updated on a monthly basis to reflect any code changes. It is the responsibility of
the billing provider to refer to this schedule at: http://dvha.vermont.gov/for-providers/claims-processing-1
(See section 9.6 Fee Schedule.) Codes are a National Standard and may be updated on a quarterly basis.
Correct coding is the sole responsibility of the billing provider. DVHA is not authorized to give code selection
guidance.
CORRECT FORM VERSIONS
The Department of Vermont Health Access and DXC Technology requires the use of current form versions,
this includes but is not limited to: prior authorization requests and patient consent forms. All requests and
patient consent forms received on outdated form versions will be denied.
MANUALS FOR PROVIDERS
The Provider Manual, Dental Supplement and the Applied Behavior Analysis, Mental Health and Substance
Abuse Services Supplement are available at http://www.vtmedicaid.com/#/manuals
The Inpatient Psychiatric & Detoxification Authorization Manual Supplement is available at
http://dvha.vermont.gov/for-providers/mental-health-inpatient-detox
The 340B Medicaid Carve-In Manual and Amendments are located at http://www.vtmedicaid.com/#/forms
The Pharmacy Benefit Management Program Provider Manual is located at http://dvha.vermont.gov/for-
providers under the Pharmacy section. The Pharmacy Benefit Management Program is for prescription drugs
dispensed by retail pharmacies.
DVHA clinical coverage guidelines for Durable Medical Equipment (DME), Laboratory and Radiology,
Therapy, J Codes, Intensive Social Support Services, and other services are located at
http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines.
Check monthly for manual revisions.
MEDICAID RULE & STATE PLAN RESOURCES
Medicaid Rule, along with other DVHA rules, are located online at http://humanservices.vermont.gov/on-line-
rules/dvha.
Note: Per State statute, Vermont’s Secretary of State is charged with publication of a bulletin of rules. As
such, the Secretary of State is the official source for the most current and comprehensive rules for DVHA.
DVHA is not responsible for reliance on regulations posted should rules be different than those posted on the
Secretary of State website. An electronic copy of the rules maintained by the Secretary of State is available
via http://www.lexisnexis.com/hottopics/codeofvtrules/.
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NATIONAL CORRECT CODING INITIATIVE (NCCI) GUIDELINES
The Patient Protection and Affordable Care Act (PPACA) mandates that all claims submitted on or after
October 1st, 2010, must be filed in accordance with the National Correct Coding initiative (NCCI) guidelines.
The NCCI was developed by CMS to promote the correct coding of health-care services by providers and to
prevent improper payment when incorrect coding occurs.
For the Medicaid NCCI Policy Manual that contains the NCCI rules, relationships, and general information,
Medicaid NCCI FAQs, and the complete edit files, please refer to:
https://www.medicaid.gov/medicaid/program-integrity/ncci/index.html. Code combinations are refreshed
quarterly.
In accordance with the National Correct Coding Initiative (NCCI), Vermont Medicaid has implemented pre-
payment edits and applies NCCI guidelines for claims with a date of service on or after 10/01/2010.
The National Correct Coding Initiative (NCCI) contains two types of edits:
NCCI procedure-to-procedure (PTP) edits that define pairs of Healthcare Common Procedure Coding
System (HCPCS) / Current Procedural Terminology (CPT) codes that should not be reported together
for a variety of reasons. The purpose of the PTP edits is to prevent improper payments when incorrect
code combinations are reported.
Medically Unlikely Edits (MUEs) define for each HCPCS / CPT code the maximum units of service (UOS)
that a provider would report under most circumstances for a single beneficiary on a single date of service.
PTP Edits have been implemented apply to all:
Practitioner
Ambulatory surgical center (ASC) services
Outpatient services in hospitals (including emergency department, observation, and hospital laboratory
services)
Provider claims for durable medical equipment (DME)
MUE Edits have been implemented and apply to all:
Practitioner
Ambulatory surgical center (ASC) services
Outpatient services in hospitals (including emergency department, observation, and hospital laboratory
services)
Provider claims for durable medical equipment (DME)
Each NCCI code pair edit is associated with a CMS policy as defined in the National Correct Coding Initiative
Policy Manual. Effective dates apply to code pairs in NCCI and represent the date when CMS added the
code pair combination to the NCCI edits. Code combinations are processed based on the effective date.
Termination dates also apply to code pairs in NCCI. The date represents when CMS removed the code pair
combination from the NCCI edits.
NOTICE: The MUE files have been updated with the addition of a new field on the rationale for each MUE,
effective the third quarter of 2014. Please refer to Appendix B of the Medicaid National Correct Coding
Initiative Edit Design Manual for explanations of the MUE rationales.
NCCI Reconsideration
Claims or procedure codes that have been denied based on NCCI guidelines may be appealed with an
appropriate modifier or documentation of medical necessity. If the submitted procedure code is denied
because NCCI guidelines indicate the code is included in another procedure, the claim may be reconsidered
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with a modifier if applicable. If a modifier does not apply but medical necessity can be proven, the provider
must submit documentation of medical necessity that indicates both services were necessary on the same
date of service.
For reconsideration instructions refer to: 1.2.7 Provider Reconsideration Process for additional
information about claims reconsideration
REMITTANCE ADVICE
The Remittance Advice (RA) is a computer-generated report provided by the fiscal agent. It indicates the
status of all claims that have been submitted for processing and payment information. The RA is posted at
http://www.vtmedicaid.com/#/ under TransactionsLogin on a weekly basis. The banner page of the RA
provides important information about policy and billing.
When a provider submits VT Medicaid claims via electronic claim submission (ECS) directly or
through a clearinghouse or billing service, the Remittance Advice (RA) will be posted to the VT
Medicaid Portal at http://www.vtmedicaid.com/#/
When a provider is not set up for ECS and is only submitting paper claims to
Vermont Medicaid, the RA will be mailed weekly; however, if the provider switches to ECS, the RA
will be posted to the web and the RA mailing will stop.
When a provider is set up for ECS, all RA information will be posted to the Web
Portal regardless of whether the claims were submitted on paper, electronically or any combination
thereof.
Provider payments are made at the end of the week on Friday. The system retains the four most recent
Web RAs. When a fifth RA is posted to the Web Portal, the oldest dated RA will drop off the system. Once
an RA drops off the system, it cannot be reposted; therefore, it is highly recommended that RA copies are
saved/printed for future reference.
The Web RA can be accessed via two different account types a Trading Partner account, and a Provider
Web Services (PWS) account.
Go to http://www.vtmedicaid.com/#/
If you have a Trading Partner Account (User ID starts with 701), navigate to TransactionsLogin or if you
have a Provider Web Services (PWS), navigate to TransactionsLogin-UAT.
If you have a Trading Partner Account (User id starts with 701…) click on
Transaction Services, then Production Logon.
If you have a PWS account, click on Provider Web Services.
Use the Account ID and password to Logon
For either method of access after logging on, click on View RA Files
Pick the Provider Number from the drop down (if you have more than one)
Click Go
Click on the appropriate pdf
Click Open (this should display the RA on the screen)
For questions about an existing account, creating an account, or accessing the Web RA, please contact the
EDI Coordinator at 802-879-4450, select option 3 or email at vtedicoordinator@DXC.com.
Providers with questions about their RA’s content are to contact the DXC Technology Help Desk at 800-
925-1706 in-state or 802-878-7871 out-of-state.
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3.8.1 The 835 Transaction (Electronic Remittance Advice)
Vermont Medicaid posts the 835 weekly, to the web portal http://www.vtmedicaid.com/#/ for Trading
Partners who have elected the 835 transaction. The 835 is a pull from the website (i.e. must be
downloaded). There is no restriction on the number of times the 835 can be downloaded and it is available
until it rolls off the system; at a minimum, it is available for at least one month from the posting date.
Normal processing has financial cycle running on a Friday with the 835 posting late the following Monday
or Tuesday. The requirement for the 835 posting is +/- (plus or minus) 3 days from the EFT effective date
(always the Thursday following a financial cycle). In the event the 835 will be delayed past the required
Sunday posting date, a banner will be placed on the web site referencing the delay, and if known, the
cause and the expected posting time and date.
If your 835 is missing after Sunday (EFT+3), and no banner has been posted stating its release is delayed,
please contact the EDI Coordinator at 802 879-4450 Option 3, or email vtedicoordinator@DXC.com.
Include your Trading Partner ID and the week you are referencing.
Section 4 Member Information
ELIGIBILITY
"Member" is the term used to refer to a person who has been determined eligible for and enrolled in one of
the Vermont health insurance programs. Eligibility is determined at the Health Access Eligibility Unit or a
district office of the Vermont Department for Children and Families, based on a review of the applicant's
needs, income and resources. The various Vermont health insurance programs have differing eligibility
requirements and benefits. Effective January 1, 2014, individuals who are 65 or older, blind or are disabled
and not yet entitled to or don’t have Medicaid must apply for health care benefits through Vermont Health
Connect at http://healthconnect.vermont.gov/ or by calling 1-855-899-9600.
Each member is assigned a unique identification (UID) number and receives a Green Mountain Care
member card imprinted with their name and UID. The UID number will be 1 to 8 digits in length and is to be
entered on the claim exactly as it is shown on the member’s card.
When submitting an electronic claim for member with a one digit Unique ID Number insert a zero in front of
the single digit UID (04, 05, 06 and etc.); to allow the claim to be accepted. This instruction does not apply to
paper claims.
Providers must verify the patient's eligibility and other insurance information using the patient's Medicaid UID
number by accessing either of the automated eligibility verification systems.
4.1.1 Partial Eligibility
Providers are allowed to compliantly bill the correct monthly code that meets the definition of the actual
services provided in a month for members who have partial eligibly in that month. However, providers may
only bill the dates-of-service during the time frame in which the member is actively eligible for Medicaid.
4.1.2 Eligibility Verification
The Green Mountain Care Eligibility Verification System (EVS) provides member information to
participating health care providers. There are two components of the EVS that are described in this manual
and Appendix.
Voice Response System (VRS), 802-878-7871, option 1; or
Go to www.vtmedicaid.com/#/, navigate to the Transactions menu and select the appropriate Login
(Trading Partners use “Login”, Web Services use “Login - UAT”).
If for any reason you are unable to use either method, you may call the DXC Provider Services Help Desk
at (800) 925-1706 or (802) 878-7871.
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The EVS delivers a response that is clear to the user and appropriate for the method of access used in
making the inquiry. The DVHA encourages all providers to take full advantage of this system to verify a
patient’s eligibility status before services are rendered. This system offers the following functionality:
Available 24 hours a day, seven days a week (except for routine maintenance)
Responds with rapid verification information
Substantially minimizes the risk of non-payment for services rendered to ineligible
patients
Decreases the number of claim resubmissions due to inaccurate eligibility information
Providers should complete all VRS or website transactions to be sure that all the pertinent information is
captured. Compare the aid category given on the VRS or http://www.vtmedicaid.com/#/manuals to the aid
category listing (see Appendix to the Provider Manual), in order to determine the program in which the
member is enrolled in. This will assist you in determining covered services and co-payment requirements
where applicable. Providers may verify eligibility for the current date, up to one year in the past and rely on
the accuracy of the response for up to nine days beyond the current date.
Providers should retain the authorization number issued by the system to assure that the information
received can be verified by the system. The number is not a guarantee of payment. The member must be
eligible on the date of service and the services provided must be medically necessary and covered.
In addition to eligibility verification, providers can receive other insurance information and determine if
service limits are approaching or have been reached. Providers can also confirm the amount to be paid in
the next RA or if that amount is zero, the amount and date of the last payment given.
All provider calls to DXC are routed through the VRS. Spoken prompts will direct you on how to access the
service/information you require Contact the DXC Provider Services Unit for information that is not available
through VRS or the http://www.vtmedicaid.com/#/ website.
At the beginning of each call users are asked to enter their Vermont Medicaid provider number followed by
their PIN number. The provider number and PIN number are a security measure to ensure the user is
authorized to access the requested information. If the provider or PIN numbers entered are not valid or
current, access will be blocked.
To expedite the process, please have the following information ready when placing a call to the VRS:
Provider number
Provider PIN number
Member identification number
Dates of service
Transactions are limited to ten (10) per call are (example: five eligibility and five service limits)
Providers using the VRS have access to the following data:
Eligibility Verification
Date-specific eligibility
Third party liability information (up to five segments)
Member lock-in data
Date of birth
Co-pay indication
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Service Limitations when exhausted
Office visits
Visual refractions
Visual glasses
Adult dental benefits (dollars spent)
Last dental oral exam
Chiropractic visits
Current RA check amount
Carrier Codes
Carrier Codes are two or three digit codes that identify other insurance carriers. The complete list can be
accessed on the Vermont Medicaid Portal at http://www.vtmedicaid.com/#/resources
IDENTIFICATION
A Green Mountain Care identification card is issued to each person enrolled in a Vermont Medicaid
program. Members must present their card for any covered service. Because the card is not surrendered
when eligibility stops, providers must verify eligibility each time a medical service is delivered to be certain
that the member is eligible on the date that the service is provided. The system knows of each termination of
benefits nine days prior to the effective date. Verification can be made up to nine days in advance of the
appointment. Note: there are only room for 25 characters on the Green Mountain Care card for the
member’s name so some names will not be completely printed.
MEMBER BILL OF RIGHTS
DVHA is a Managed Care Organization (MCO) and must ensure that its enrolled health care providers are
aware of our Member Bill of Rights and that health care providers take these rights into account when
providing services to members.
The Member Bill of Rights
As a member of a Vermont health care program, an individual member has the right to:
Be treated with respect and courtesy
Be treated with thoughtfulness for his or her dignity and privacy
Choose and change providers
Get facts about program services and providers
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Get complete, current information about his or her health in understandable terms
Be involved in decisions about his or her health care, including having questions answered and
having the right to refuse treatment
Ask for and get a copy of his or her medical records and ask for changes to be made to them when
he or she believes the information is wrong
Get a second opinion from a qualified provider who is enrolled in Vermont Medicaid
Complain about the program or his or her health care
Be free from any form of restraint or isolation used as a means of bullying, discipline, convenience, or
retaliation
Ask for a reconsideration if services are denied that he or she thinks are needed
Members have the right to look at their medical records, and to obtain copies of the records. A reasonable
fee may be charged to cover making copies and postage. An office may not charge for copies of records
needed to support a claim or a reconsideration or Copying of medical records for the purpose of supplying
them to another health care provider.
MEMBER COST SHARING/CO-PAYS AND PREMIUMS
Certain members must participate in the cost of care for services.
Co-payments are never required of Medicaid members who are:
Under age 21;
Pregnant or in a 60-day post-pregnancy period;
Living in a long-term care facility, nursing home or hospice;
Copayments are not required for family planning services and supplies, emergency services (includes: dental
services covered by a GA Voucher), and durable medical equipment (DME) and medical supplies.
Although some members are required to make co-payments under Medicaid, if the member is unable to
make the payment, Medicaid providers may not deny services. Per section 1916(c) of the Social Security
Act, "no provider participating under the State [Medicaid] plan may deny care of services to an individual
eligible for [Medicaid] on account of such individual's inability to pay [the copayment]."
Medicaid Co-Pays
$1.00 - for prescription drugs costing less than $30.00
$2.00 - for prescription drugs costing $30.00 or more but
less than $50.00
$3.00 - for prescription drugs costing $50.00 or more
$3.00 - per dental visit
$3.00 - per day for hospital outpatient services
VPharm Pharmacy
Aid Categories VD, VE, VF, VG, VH, VI, VJ, VK, VL, VM, VN & VO:
$1.00 - Co-pays for prescriptions less than $30.00
$2.00 - Prescriptions $30.00 or more
VPharm covers drug classes that are excluded from the Part D benefit.
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Medicare Crossover Coverage: For members with category codes VG, VH, VI.
Vision Coverage: For members with category codes VG, VD, VJ & VM.
Healthy Vermonter’s Program
Aid Category VP
Offers access to drugs at a discounted price, which is the Vermont Medicaid rate for prescription drugs.
QUALIFIED MEDICAID MEMBER (QMB)
A QMBY’s only benefit is Medicare cost sharing coverage. They are not considered dual eligible.
PQ – Pure QMB
VG – %150 VPharm and QMB
VH – %175 VPharm and QMB
VI – %225 VPharm and QMB
NOTICE OF DECISION
The Department for Children and Families (DCF) notifies members in writing of its decisions made regarding
eligibility, retroactive eligibility, spend-down requirements and other determinations of status or program
changes. These letters are called “Notice of Decision” letters and are issued by the district office or HAEU. A
copy of the Notice of Decision is a required attachment for certain claims involving spend-down.
COURT ORDERED SERVICES
If a member is mandated by a court to seek a service, the service may be covered if it meets the medical
necessity and Vermont Medicaid guidelines.
RETROACTIVE ELIGIBILITY
Vermont Medicaid eligibility is occasionally granted retroactively. The provider may bill for services rendered
during the retroactive period. A note indicating the date of retroactive eligibility must accompany the claim to
waive the timely filing limit; see section, 8.1 Timely Filing.
MEMBER GRIEVANCE PROCESS
A member grievance is a complaint about issues other than actions, such as the location or convenience of
their health care provider or the quality of the health care provided. A member may file a Grievance by calling
the Green Mountain Care Member Customer Support Center when the member and provider are unable to
resolve the issue, and it is within 60 days of the problem. DVHA will respond to the grievance within 90 days
with a letter to the member. A member who filed a Grievance and is not satisfied with the results may ask for
a Grievance Review by a neutral person to ensure that the grievance process was handled fairly. Neither
member nor provider shall be subject to retribution or retaliation regarding the grievance. The member may
also call the Office of Health Care Advocate at 1-800-917-7787 for assistance.
MEMBER APPEAL PROCESS
Members may ask for review of certain actions if they disagree with the action. For decisions made by
DVHA, a request for an appeal or fair hearing may be requested through Green Mountain Care Member
Services by calling 1-800-250-8427 or by letter to: Green Mountain Care Member Services, Department of
Vermont Health Access, 101 Cherry Street, Suite 320, Burlington, VT 05401. Requests must be made within
90 days from the decision date and appeals are heard by a qualified person not responsible for the original
decision.
A provider may ask for an appeal on behalf of the member, if requested to do so by the member. In most
instances, a decision will be made within 45 days of the appeal request. In some instances, the process can
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be extended up to an additional 14 days. However, a decision will always be made within 59 days of the
appeal request.
If the need for the denied benefit is an emergency, an expedited appeal may be requested. If after review it is
determined that the appeal is an emergency, a decision will be made within three business days.
The following actions may be appealed:
Denial or limit of a covered service or eligibility for service, including the type, scope or level of
service;
Reduction, suspension or termination of a previously approved covered service or a service plan;
Denial, in whole or in part, of payment for a covered service;
Failure to provide a clinically-indicated covered service, by any provider;
Failure to act in a timely manner when required by State rule;
Denial of a request to obtain covered services from a provider who is not enrolled in Medicaid (note
that the provider who is not enrolled in Medicaid cannot be reimbursed by Medicaid).
Members with an employer –sponsored insurance plan may call the customer service number on the back of
their ID card to obtain information on appealing a decision made by that plan.
When a member is told that the benefit has changed because of a change in a federal or state law, the
member may not ask for an appeal but may request a fair hearing. For additional information, refer to the
Health Care Programs Handbook located at http://www.greenmountaincare.org/member_information.html,
Member Handbooks.
FAIR HEARING
A member that disagrees with the appeal decision may request a fair hearing by the department responsible
for the decision. The request must be made within 90 days from the date of the original notice of decision or
action, or 30 days from the date of an appeal decision.
ADVANCED DIRECTIVES
Hospitals, nursing homes, home health agencies, hospices and prepaid health care organizations are
required to provide certain patients with information about their right to formulate advance directives and
maintain written policies and procedures with respect to advance directives. They are also required to
document in patients’ files whether or not an advance directive is in effect, provide education for staff and the
community on issues concerning advance directives, and ensure compliance with State law on advanced
directives at their facilities. Providers are responsible to guard the confidentiality of member information in a
matter consistent with the confidentiality requirements in 45 CFR parts 160 and 164 and as required by state
law. http://www.cms.hhs.gov/securitystandard/downloads/securityfinalrule.pdf.
Providers can obtain Advance Directive (AD) forms and additional information on AD from the Vermont
Ethics Network website: http://www.vtethicsnetwork.org/ or by mailing your request to:
Vermont Ethics Network
61 Elm Street
Montpelier, Vermont 05602
Section 5 Provider Enrollment, Licensing & Certification
ENROLLMENT & CERTIFICATION
In order to participate in and receive reimbursement from Vermont Medicaid Programs, providers must be
enrolled. Licensed or certified health care providers may be enrolled as Vermont Medicaid providers if at least
one service they provide is recognized in the Vermont Medicaid State Plan. Any health care provider who is
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interested in becoming enrolled in the Vermont Medicaid program should contact the DXC Provider Enrollment
Unit. Enrollment requires that the provider submit applicable enrollment forms, a signed General Provider
Agreement and a copy of the applicable license/certification document and meet all federal and state
requirements. When the DVHA accepts an applicant, a Vermont Medicaid provider ID number will be issued
and a confirmation of enrollment letter will be sent. Payments will not be made until a provider number has
been assigned.
Enrollment may include the following:
Full enrollment is for participating providers who are in-state and out-of-state in network as well
providers that are determined by DVHA to contribute to the Green Mountain Care network and see
Vermont Medicaid members on a regular basis
Ordering, Prescribing, Referring and Attending providers and Residents, whether the physician or
practitioner who actually performs the services for the patient or the referring or prescribing provider,
must be enrolled as a participating Vermont Medicaid provider.
Court ordered enrollment is for providers whose services have been ordered by a court, a fair
hearing decision or by a Coverage Exception.
Request (M108/7104) decision of the commissioner. Court ordered providers would only be enrolled
for dates consistent with the order/decision.
Special status is granted for out-of-state and out-of-network providers who have seen a Vermont Medicaid
member in an emergency or urgent situation, or who have been prior approved for out-of-state services. The
DVHA does not deem a provider enrolled in Medicare as enrolled in Vermont Medicaid. DVHA will pay for
emergency and post-emergency stabilizations services delivered by providers who were not enrolled at the
time of the emergency.
Note: Non-participating enrollment is no longer accepted.
The difference between Enrollment, Re-Enrollment and Revalidation:
Enrollment is for providers that have never previously registered with Green Mountain Care
Re-Enrollment is for providers that have previously enrolled and their eligibility has lapsed
Revalidation is for providers that have previously enrolled and who revalidate within the 90-day
notification period
All providers interested in applying for enrollment, or need to Re-Enroll or Revalidate their eligibility, please visit
http://www.vtmedicaid.com/#/provEnrollAppPackets for all application packets.
Enrollment will be rejected if:
Mandatory information is not received
The provider is disbarred or sanctioned from participation in federal programs
The provider is disbarred or sanctioned by the State of Vermont
Clinical Laboratory Improvement Amendments (CLIA)
Providers that provide laboratory services are required to include a current copy of their CLIA certification at
time of enrollment, re-enrollment or revalidation.
5.1.1 Enrollment Agreement Signatures
All signatures must be original and signed in ink. Applications with signatures deemed not original will not
be processed. Stamped, faxed or copied signatures will not be accepted.
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Exception:
Faxed signatures are allowed for certain cases including but not limited to out-of-state special enrollment
for a single member and other special enrollment cases as identified by DVHA. Upon receipt of the faxed
provider enrollment agreement, DXC is directed to telephone the provider to confirm that the provider did in
fact send the fax. DXC may then begin the screening and enrollment process. Enrollment, including the
assignment of a Vermont Medicaid provider number, may be completed with the use of the faxed
agreement only. Original hardcopy signature must be submitted to DXC Technology for file. Signatures
should be in blue ink to denote authenticity.
PAYMENT CONDITIONS
Providers are entitled to payment for diagnostic, therapeutic, rehabilitative or palliative services when all of
the following conditions are met:
The provider is enrolled with Vermont Medicaid
The services are covered by the applicable program
The services are medically necessary
The services are within the scope of the provider’s license
The services are documented in the patient’s medical records
Prior approval, if required, has been obtained
The claim is submitted within the timely filing limits and contains all required
information
The provider complies with the Advance Directives Law
The member is eligible on the date of service
Billing may not be done in advance of any service to be performed or supplied
CONDITIONS OF PARTICIPATION
The Conditions of Participation are stated in the Provider Enrollment/Recertification Agreement and the
General Provider Agreement and the applicable provision by provider type. Please consult your current
agreement for details.
DOCUMENTATION OF SERVICES
Each provider must keep written documentation for all medical services, actual case record notes for any
services performed, or business records that pertain to members for services provided and payments
claimed or received. All documentation must be legible, contain complete and adequate information and
applicable dates. Providers must submit information upon request of the State Agency of Human
Services, Office of the Vermont Attorney General or U.S, Secretary of Health and Human Services and at no
charge to the requester. The documentation for any service that was billed must be kept for seven years.
This information must also be available at any time for on-site audits. Records of any business transactions
between the provider and any wholly owned supplier, or between the provider and any subcontractor, during
the 5 year period ending on the date of the request, must be submitted within 35 days of the request.
RIGHTS & RESPONSIBILITIES
Participation in Vermont Medicaid is voluntary. Participating health care providers:
May not discriminate on the basis of race, color, sexual orientation, or national origin
May not treat a Vermont Medicaid member any differently than a patient with other payer sources
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May not refuse service to a Vermont Medicaid member simply because the member is covered by other
health insurance
Must meet commonly accepted standards of professional practice.
Must submit claims and required documentation in a form acceptable to the State of Vermont
Must ensure that claims are received within the timely filing limits
May not bill Vermont Medicaid or member any fee for missing a scheduled appointment per Federal
Medicaid policy
Adhere to other applicable federal and State of Vermont laws, rules and procedures
TERMINATION
Providers who no longer wish to participate in the Vermont Medicaid Program are required to notify DVHA of
their intent to terminate their enrollment. This may be done at any time by either writing a letter to DXC
Technology or by indicating on the Vermont Medicaid Termination form. If requested, the provider’s
enrollment will be closed on the date specified. Providers are required to give their patients 30 day notice
prior to termination. Primary care providers in PC Plus are required to give 90 day notice before termination
of the PC Plus agreement.
Section 6 Coordination of Benefits/Medicaid Payment Liability/Third Party Liability
CONTRACTUAL ALLOWANCE
Vermont Medicaid is payer of last resort, and as such, will not consider and pay amounts that exceed the
Medicaid rate, even when payment is combined with payments from primary insurance
When another insurance carrier has made a payment, document the total payments received by other
insurance carriers in the appropriate field on your claim form.
When the entire allowed amount is applied to the primary insurance deductible, the claim may be submitted
to Vermont Medicaid but must be accompanied by an EOB. Vermont Medicaid will consider payment based
on the Vermont Medicaid allowed amount after deducting any payment made by a primary insurer.
The provider is prohibited from collecting an amount that exceeds the contractual amount that is agreed upon
in the contract with primary payer.
REIMBURSEMENT OF OVERPAYMENTS
Providers are reminded of the 2009 Fraud Enforcement and Recovery Act (FERA) which amended the False
Claims Act, 31 U.S.C §§3729-3733, by increasing the scope of the false claims liability to include persons
who knowingly conceal the retention of any overpayment of government money and the 2010 Patient
Protections and Affordable Care Act (PPACA) which directly linked the retention of overpayments to false
claims liability. PPACA requires the report and return of all overpayments within 60 days after the date on
which the overpayment was identified or the date the corresponding cost report was due, whichever is later.
Additionally, providers must submit notification in writing as to the reason of the overpayment. DXC will
forward any cases in which the discovered overpayment was not refunded during the timeline mandated by
PPACA to the DVHA Program Integrity Unit for their review.
Hospitals (in addition to the above information) DXC contracts with AIM HealthCare to audit hospitals for
credit balances on accounts. This arrangement does not negate the provider's responsibility to report and
return overpayments timely. DXC will forward any cases in which the discovered overpayment was not
refunded during the timeline mandated by PPACA to the DVHA Program Integrity Unit for their review.
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WHO IS RESPONSIBLE FOR PAYMENT?
Verifying eligibility before service:
Providers are expected to verify eligibility for every member prior to providing the service or item to be clear
about who has financial responsibility for the service. Eligibility can be verified up to nine days in advance
however, this is not a guarantee of payment. Eligibility can be verified through the automated Voice
Response System (VRS/Malcolm), online Transaction Services (http://www.vtmedicaid.com/#/) or by calling
the Provider Services Unit help desk. When an eligible aid category code is given, the provider should
determine that the service to be provided is covered within that aid category. This will also show what other
insurance is on file. To ensure timely processing of your claim, validate other insurance with member or refer
them to the Department for Children and Families.
Billing the Member
If the provider bills Vermont Medicaid for a service or item, the provider may not bill the patient for any
reason except the following:
The amount due is for unpaid Vermont Medicaid co-payments and deductibles
The claim was denied for lack of eligibility and the date of service was greater
than 60 days beyond the loss of eligibility date
The claim was denied because another insurer’s rules were not followed
The claim is submitted to Medicaid by Medicare for a patient enrolled in a
Medicaid pharmacy only plan or
If the DXC system reports that a member has other insurance, the provider
must bill the service or item to the other medical insurance prior to billing
Vermont Medicaid. If the member is no longer enrolled with the other insurer
and the member does not report the insurance change to Vermont Medicaid
within 30 days and after the 30 days have lapsed, the DXC system still reports that the patient has
other insurance, the provider may bill the member.
Under the Provider Enrollment Agreement (Conditions of Participation #9), failure to give advance
notice that a Vermont Medicaid payment will not be accepted prevents the provider from billing the
member. If the member is eligible for Vermont Medicaid and the provider has made the decision not to
bill Vermont Medicaid for the service or item requested, the member must be informed in advance of
providing the service.
Federal Medicaid policy does not permit providers to bill Vermont Medicaid or the member any fee for
missing a scheduled appointment.
6.3.1 Supplementation
Once Vermont Medicaid has been billed for a service or item, the provider may not attempt to collect any
additional reimbursement for that service or item from the member, the member’s family or anyone acting
on behalf of the member, except for:
The applicable conditions described below in section 6.4 Who is Primary
Permitted deductible and co-payment amounts
Specific allowed supplementations authorized in Medicaid Rule 7602
WHO IS PRIMARY
When the DVHA is the primary payer (i.e. the DXC system indicates no other insurer) and Vermont Medicaid
payment is accepted, the provider should submit all bills to the DVHA’s fiscal intermediary and never to the
patient. Under the provider agreement, the provider has agreed to accept the DVHA’s payment or denial
(except as enumerated above) as payment in full.
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When the DXC system shows a source other than the DVHA as the primary payer (such as Medicare or any
other insurance carrier) the DVHA is the payer of last resort. Under the provider agreement, certain
restrictions apply.
When Vermont Medicaid is secondary to a private insurer and a co-payment is required by the primary
insurer at time of service, the provider is to bill the claim to Vermont Medicaid and indicate the amount paid
by the primary insurance. Vermont Medicaid reimburses their allowed amount, minus the amount the other
insurer has paid.
Providers that do not wish to bill Vermont Medicaid for the co-payment are only allowed to bill the member if
they notify the member in writing, prior to rendering the service, that they will not bill Vermont Medicaid for
the co-payment. The member must sign and date this notification; please retain documentation in the
member’s file.
If the third party payment was made directly to the member, the provider may bill the member for the amount
paid by such third parties. In addition, the provider may collect patient liability or spend-down amounts.
NOTICE THAT MEDICAID WILL NOT BE ACCEPTED
If a provider does not intend to bill Vermont Medicaid for specific services, the patient must be fully informed
of the decision and its consequences prior to rendering the service. Patients must understand that they will
be financially responsible for the service(s). To document that proper notice was given; providers are
required to document the agreement/understanding between member and provider on their letterhead.
Comprehensive documentation showing evidence that proper notice was given to the member should include
the following information:
1. Provider’s name and Vermont Medicaid provider ID number
2. Member’s name and signature (or signature of a parent, if the member is a minor)
3. Description of service(s) sought
4. A clear statement that the provider is unwilling to accept Vermont Medicaid payment for the specific
service(s) sought and if the member wants to get this service from this provider, the member or
responsible adult must accept full financial responsibility
5. Date of signing
The provider is to give a copy to the member or responsible adult and retain a copy in the member’s file.
Failure to give advance notice prevents the provider from billing the member. When the member or
responsible adult accepts financial responsibility, the claim cannot be submitted to DXC for processing.
MEDICAID & MEDICARE CROSSOVER BILLING
A Green Mountain Care member may be eligible for both Vermont Medicaid and Medicare. When dual
eligibility exists, Medicare must be billed first on an assigned basis.
After Medicare payment, the DVHA pays deductibles and coinsurance for crossover claims.
Providers must include their NPI and taxonomy code on any claims sent to Medicare in order to assure
proper automatic crossover and subsequent Vermont Medicaid processing of your claims. Vermont Medicaid
is aware that Medicare does not have this same requirement but will include the taxonomy code, as
submitted on the claim, on the crossover file.
DXC Technology does not accept a CMS‐1500 crossover claim submitted with multiple Medicare Attachment
Summary Forms. When submitting a CMS‐1500 crossover claim that contains more than 6 details, each 6
details must be submitted as an individual claim with its Medicare Summary Attachment Form; indicate the
number of details and the total. The total must equal only the sum of the detail lines listed on that claim form.
The Department of Vermont Health Access reviews all Medicare crossover claims where the Medicaid
allowed amount (coinsurance / deductible) is over $10,000.00. These claims require DVHA’s review and
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approval prior to payments being made. To facilitate the processing of these claims, please attach the
following information to your claim if the expected coinsurance /deductible payment from Medicaid is over
$10,000.00: the Medicare Attachment Summary Form, the Medicare EOMB and the discharge summary at
the time of submission. Any claims submitted without the required supporting documentation will be denied.
A Medicare Attachment Summary Form should not be attached if an item or service is non-reimbursable by
Medicare. If the service or item is denied by Medicare, a completed claim along with the Medicare EOB
should be submitted within twelve months of the date of service.
The Medicare Attachment Summary Form is only to be used for beneficiaries who are enrolled in both
Medicare and Vermont Medicaid. It is not to be used for reporting actions by any other insurers.
Vermont and New Hampshire Providers:
In order to crossover, Vermont Medicaid eligibility information must be clearly indicated on the Medicare
claim. These claims, as well as any future adjustments to these claims, will crossover automatically to DXC
for payment. If you do not receive the DVHA payment within 30 days of the Medicare paid date, submit the
claim to DXC with the Medicare Attachment Summary Form.
If a service or item is denied by Medicare as non-reimbursable and is reimbursable by the DVHA, submit a
CMS 1500 claim, completed to the DVHA specifications, along with the Medicare denial to DXC within twelve
months of the date of service.
Other Out-of-State Providers (Except New Hampshire):
All out-of-state providers should first bill their regional Medicare carrier for services to dual eligible Vermont
residents. After Medicare payment is received, send a claim to DXC for payment of any coinsurance or
deductible as follows:
Send a claim completed to the DVHA specifications with a copy of the Medicare Attachment
Summary Form. The Medicare payment date must appear on the Medicare Attachment Summary
Form.
If a service or item is denied by Medicare as non-reimbursable and is reimbursable by the DVHA,
submit a CMS 1500 claim with the EOMB, completed to the DVHA specifications to DXC within
twelve months of the date of service; see section 8.1 Timely Filing
THIRD PARTY LIABILITY (TPL)/OTHER INSURANCE (OI)
Vermont Medicaid is the payer of last resort. Providers are required to pursue and apply all third party
payment resources prior to billing Vermont Medicaid. Third party resources include, but are not limited to,
Medicare, private/group health insurance plans, military and veteran’s benefits, Worker’s Compensation and
accident (automobile, homeowners, etc.) insurance. (See Section 6.9 for information specific to Workers
Compensation and Accident Liability Billing)
TPL-Verification
The member’s other insurance information, including the name of the other insurance company, address,
carrier code and type of coverage, is available on the Vermont Medicaid website, Provider Web Services
(http://www.vtmedicaid.com/#/, TransactionsLogin - UAT) and the Voice Response System (VRS) when
the provider checks the member’s eligibility. Providers will review the member’s eligibility information for the
date of service and must bill other insurance carrier(s) before billing Vermont Medicaid. Use of the available
information will guide providers in billing.
Timely Filing of OI Claims
Providers will respect the member’s right to receive all medically necessary services and equipment in a
timely manner and must submit claims to primary insurers promptly to mitigate issues with member primary
insurance benefits exhausting.
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Other Insurance Denial/DVHA Authorization Request
The following procedures are required for DVHA authorization requests when the primary insurer has
reviewed and denied a claim request for an item or service:
OI Denial for Non-Covered or Benefits Exhausted
The provider is required to submit to the DVHA the authorization request form (Medical Necessity Form or
other) with all standard documentation, the notice of denial from the primary insurer that indicates the item or
service is not a covered benefit or that the benefit limit was determined to be exhausted, and all necessary
documentation to support medical necessity. The DVHA will then review.
The provider does not need to appeal to the primary insurer before billing
Medicaid when the item/service is not covered or benefits are exhausted.
If the code/service does not require authorization from Vermont Medicaid, then
the provider can bill Medicaid directly with a copy of the primary insurer’s
denial attached.
OI Denial for Not Medically Necessary
The provider and/or member is required to pursue all levels of reconsideration and appeals with the primary
insurer. If the request remains denied by the primary insurer, the provider and/or member is required to seek
review by the Vermont Department of Financial Regulation if the cost of the item or service exceeds $100. If
the denial stands, then the provider may submit the request to the DVHA with copies of all of the original
documentation, the denials from the primary insurer and the Department of Financial Regulation’s support of
the denial. The provider should not submit any additional documentation than what was reviewed by the
primary insurer.
If the code/service does not require authorization from Vermont Medicaid, then
the provider can bill Medicaid directly, with copies of the primary insurer’s
denials (original and appeals) and the Department of Financial Regulation’s support of the denial
attached.
OI Blanket Denials
Providers are required to submit blanket denials from a primary insurer to DXC every calendar year, for
example: a blanket denial issued on July 7, 2013, will only be valid until December 31, 2013 and a new
denial will be required as of January 1, 2014. Blanket Denials are required each calendar year as health
insurance benefits are reviewed and health care policies are generally, renewed yearly.
Vermont Medicaid will accept a blanket denial for the same calendar year as the date(s) of service of the
claim(s) being submitted for payment.
All Blanket Denials are to include the following:
Name of the insurance company
Member name
Date(s) of service
Rev/Procedure code or description of service
Providers may obtain a “blanket statement” from an insurance company that states that the company never
covers a particular service for the member’s policy and attach it to the claim when billing for that service.
Blanket statement must be less than one year old and must be attached to each claim submitted. Providers
must indicate the member’s name and identification number and the applicable dates of service and the
provider must sign and date the blanket statement.
Medicare Qualified Independent Contractor
For members covered by Medicare, the requirement to go through the Medicare Qualified Independent
Contractor appeal level applies, with the exception of wheelchairs that Medicare denies or downgrades.
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Upon documentation of the Medicare action, Medicaid will review for medical necessity and payment
determination.
The DVHA will reject a request if there is reason to believe that the OI received incorrect or incomplete
information from the provider and based its decision on that incorrect or incomplete information. Providers
must determine OI/Medicare benefits before rendering the service to minimize the risk of non-coverage by
both OI or Medicare and the DVHA.
Other Insurance Attachments
Providers may submit electronically to DXC claims that have been denied by another insurance company
(third party payer/primary payer) when that payer has denied the claim using certain adjustment reason
codes. Providers are required to include the adjustment reason code used by the primary payer when
submitting the claim but will not need to send a copy of the primary insurance attachment. The list of
adjustment reason codes that will be accepted electronically is available at
http://www.vtmedicaid.com/#/resources, select 837 Adjustment Reason Codes. DXC may select your claim
for post payment review and request a copy of the explanation of benefits; if so, providers are required to
supply all supporting documentation in a timely manner. Failure to do so will result in the recoupment of your
paid claim.
When submitting a paper claim, an attachment is needed only when a third party insurance carrier has not
made a payment. Providers must attach documentation from the carrier that verifies the member’s name,
insurer’s name, dates of service, service code or exact description of service, the amount reimbursed and the
payment or denial date. If the carrier does not include this information in the documentation (i.e. the carrier
issues a blanket statement that the particular service is not covered), the provider must write the necessary
information on the attachment, then sign and date the attachment. It must be clear that the attachment
relates to the specific services billed on the Medicaid claim.
If there was a payment made by the third party, providers must indicate the amount paid in the “prior
payments” field. Documentation from the carrier is not required with the claim form if there is a payment
amount, thus allowing the claims to be submitted electronically. In cases where a member has more than
one other insurance, providers must indicate on paper, that payment was received (or denied) from each
insurance company.
If the other insurance amount is less than $3.00, the provider must include the “other insurance” attachment
verifying that exact payment amount.
Exceptions: Members are excluded from the third party liability requirements specified above for the
following services:
Prenatal Care Services: This includes routine supervision of normal pregnancy, prenatal screening of
mother or fetus, and care provided in the prenatal period to the mother for complications of pregnancy
Preventive Care Services: This includes immunizations, screening tests for congenital disorders, well-
child visits, preventive medicine visits, preventative dental care, and screening and preventive
treatment for infectious and communicable diseases
Court-enforced Medical Support Members: This is identified by an insurance
coverage type D1 through D9 which indicates “Absent Parent”
Claims exempt from TPL may be submitted directly to DXC. Indicate “not billed” in the “other insurance” field
when submitting paper claims. When submitting electronically, simply indicate “no” in the “other insurance”
field. The provider should only indicate that other insurance has not been billed if that is, in fact, true.
If the provider chooses to first bill the third party in these cases, he or she must wait 30 days from the date of
furnishing the service before billing Vermont Medicaid. Medicaid must be credited with any payments
received from the other third party payer.
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Accidents
Claims billed with a “yes” in the accident field and those with a trauma diagnosis will be tracked in the claims
processing system and monitored for post payment recovery from liable parties. In order to determine liability
information, DXC will send questionnaires to members regarding some trauma cases.
Discrepancy in TLP Information
When a provider believes that the other insurance listed in the eligibility file is incorrect, contact the DCF
district worker for clarification/correction or have the member contact Member Services.
HMOs
Are treated as other health insurance. When a Vermont Medicaid member does not comply with the rules of
their HMO, such as securing prior authorization, the HMO may choose not to cover the service. In such
cases, Vermont Medicaid will not pay for the service either and the member will be responsible for payment.
TPL Cost Avoidance: DXC maintains eligibility files, which contain member health insurance information.
This data is integrated in the claims processing system to coordinate benefits.
6.7.1 Third Party Liability Coverage Codes
The VRS and the Vermont Medicaid website use the following codes to describe the type of services
covered by a patient’s other insurance. The Coverage Codes (below) and the insurance matrix (see
Appendix) will help in understanding how to interpret the information provided about third party liability. For
example, if the VRS reports “07” for a member, the matrix shows that a dental claim for dental services will
fail for reason 408 if the third party information is not provided. Contact DXC if you do not know whether the
coverage code refers to the service you have provided.
Code
Type of Coverage
01
Hospital Inpatient Services
02
Hospital Outpatient Services
03
Hospital Inpatient/Outpatient Services
04
Physician Services
05
Physician Inpatient/Outpatient Services
06
Physician Inpatient/Outpatient Services/Major Medical
07
Dental Coverage
08
Vision Coverage
09
Drug Coverage
10
Physician Inpatient/Outpatient Services/Major Medical/Dental
11
Physician Inpatient/Outpatient Services/Major Medical/Vision
12
Physician Inpatient/Outpatient Services/Major Medical/Drug
13
Medicare Supplement A & B
14
Indemnity Coverage Payment to Client
15
Major Medical
16
Major Medical/Physician
17
Major Medical/Physician/Dental
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18
Major Medical/Physician/Vision
19
Major Medical/Physician/Drug
20
Major Medical/Physician/Dental/Vision/Drug
21
Inpatient/Outpatient/Physician/Dental/Major Medical/Drug/Vision
22
Medicare Supplement Part A
23
Medicare Supplement Part B
24
Specialty Coverage (e.g., cancer)
25
HMO
26
Nursing Home
27
Veterans Home
28
Worker's Compensation
50
Absent Parent (4D)
99
Unknown
A1
Medicare A
B1
Medicare B
WORKERS COMPENSATION/ACCIDENT LIABILITY BILLING
Providers have two choices regarding billing when a member is also covered by worker’s compensation or
accident insurance, such as auto insurance, homeowners, etc.
1. Bill Vermont Medicaid or
2. Bill workers compensation/auto insurance.
If the provider chooses to bill the workers compensation or the accident Insurance (i.e., auto insurance,
homeowners, etc.), the provider cannot bill Vermont Medicaid simultaneously. (Refer to your provider
enrollment/recertification agreement.)
If a provider decides at any point to bill Vermont Medicaid, the provider must withdraw the claim to the
workers compensation/auto insurer. The withdrawn claim is still subject to the 180 days timely filing limit.
Vermont Medicaid will pay the claim and bill the responsible insurance provider. Payments made by the
insurance provider will come directly to Vermont Medicaid. No reimbursement will be made to the provider.
When a provider bills worker's compensation or accident insurance, and the claim is denied by workers
compensation or accident insurance, the provider then has 1 year from the date of service to submit their
claim to Vermont Medicaid for payment.
If a payment is received from a worker’s compensation/accident insurer after the provider has received
payment from Vermont Medicaid, the provider must return or refund the payment to Vermont Medicaid.
In regards to billing the member, 42 USC § 1396a (a)(25)(C) states: “In the case of an individual who is
entitled to medical assistance under the State plan with respect to a service for which a third party is liable for
payment, the person furnishing the service may not seek to collect from the individual (or any financially
responsible relative or representative of that individual) payment of an amount for that service…”
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Section 7 Prior Authorization for Medical Services
Prior authorization (PA) is a process used to assure the appropriate use of health care services. The goal of
PA is to assure that the proposed health service, item or procedure meets the medical necessity criteria; that
all appropriate, less-expensive alternatives have been given consideration; and the proposed service
conforms to generally accepted practice parameters recognized by health care providers in the same or
similar general specialty who typically treat or manage the diagnosis or condition. It involves a request for
approval of each health service that is designated as requiring prior approval before the service is rendered.
Please review the fee scheduled at: http://dvha.vermont.gov/for-providers/claims-processing-1 for services
that require a PA. Authorization will not be granted after the service is rendered.
The DVHA PA criteria and regulations can be found in Medicaid Rule 7102. These rules and procedures
govern PAs performed by the DVHA and its agents. DVHA rules are available online at
http://dvha.vermont.gov/budget-legislative
No retroactive prior authorization will be granted. The DVHA PA requirements apply when the DVHA is
known to be the primary payer for the service or item or the service or item is not a covered benefit by the
member’s primary insurer.
Waiver of Prior Authorization (Exceptions):
Medicaid Rule 7102.3 allows two general exceptions to securing authorization prior to the date of service.
Emergency Services: Services normally requiring PA do not require PA when treating an emergency
condition.
This exception applies to both the emergency care and the post-emergency stabilization. Post-emergency
stabilization care will be provided until the attending emergency physician determines that the patient is
sufficiently stabilized for transfer or discharge.
Retroactive Eligibility: Covered services that normally require PA, which are provided to an individual in
the retroactive period (defined as eligibility start date to eligibility segment update date), do not require
PA.
CLINICAL PRACTICE GUIDELINES
The Department of Vermont Health Access has adopted various Clinical Practice Guidelines that are based
upon evidence based medicine. These guidelines outline the preferred approach for most patients and are
used to support the decision making processes. The guidelines can be found
http://dvha.vermont.gov/forproviders/clinical-coverage-guidelines
PRIOR AUTHORIZATION REQUIREMENTS
The DVHA Clinical Operations Unit (COU) enters prior authorizations with the exact procedure code(s) given
by the requesting provider on the request form. In those instances when the procedure code to be billed does
not exactly match the code requested/authorized, the provider must notify the COU in writing prior to claim
submission. Include the DVHA prior authorization number, the rationale for the code change and signature.
Fax information to (802) 879-5963.
All unlisted procedure codes require authorization from the DVHA COU prior to the service being rendered.
If it is determined during a surgical procedure that an unlisted procedure is appropriate and medically
necessary, prior authorization must be requested prior to claim submission. Fax information to (802) 879-
5963. Surgical procedure notes must be attached with the claim indicating the usual and customary charge
for the service.
7.2.1 Required Documentation
At a minimum, the documentation required to support a PA request must include a completed and legible
copy of a medical necessity form, or other appropriate documentation, with the prescribing provider’s
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signature, and all documents necessary for identification and pricing of the service requested, when
applicable. Providers are required to keep the original legible copy of the medical necessity form in the
patient’s record. It is not necessary to submit a completed claim form with a PA request. If a request for PA is
denied and a provider has questions or needs additional information, contact the DVHA Clinical Unit.at (802)
879-5903.
Notwithstanding any other review, the State reserves the right to review medical records at any time and
without advance notice.
7.2.2 Immediate Need Exception
1. URGENT: Authorization in advance does not have to occur if the service or item is rendered for
urgently needed care as defined below and if the urgent care is required outside of normal DVHA
business hours. If a request for authorization is shown to be for urgently needed care, and if the
request for authorization is made on the next business day, the request will be considered timely.
Payment for such services or items will further depend on a determination that they are medically
necessary. If any such item is not considered medically necessary, the DVHA will provide normal
reimbursement for a reasonable quantity of consumable items actually provided and/or the DVHA
will provide normal reimbursement for the rental of such items in the minimum allowable period for
the service.
2. IMMEDIATE: Authorization in advance does not have to occur if the service or item is rendered for
immediately needed care as defined below. However, the request for PA must be faxed to the
DVHA Clinical Unit by the next business day., The provider should submit documentation of
medical necessity and evidence that the care or item was immediately needed. This may take the
form of an order or a discharge plan. Payment for such services or items will further depend on a
determination that the service(s) are medically necessary. If any such item is not considered
medically necessary, the DVHA will provide normal reimbursement for a reasonable quantity of
consumable items actually provided and/or the DVHA will provide normal reimbursement for the
rental of such items in thirty-day increments.
Definitions:
“Emergency Medical Condition” means the sudden and, at the time, unexpected onset of an illness or
medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the
absence of immediate medical attention could reasonably be expected by the prudent layperson who
possess an average knowledge of health and medicine, to result in:
Placing the member’s physical or mental health in serious jeopardy; -or-
serious impairment to bodily functions; -or-
serious dysfunction of any bodily organ or part.
“Post Emergency Stabilization” is the care required after an emergency to stabilize the patient for transfer or
discharge. The attending emergency physician determines when a patient has been sufficiently stabilized for
transfer or discharge. Post-emergency stabilization care is covered 24 hours per day, 7 days per week as
necessary to stabilize a patient after an emergency.
“Urgently-Needed Care” or “Urgent Care” means those health care services that are necessary to treat a
condition or illness of an individual that if not treated within twenty-four (24) hours presents a serious risk of
harm.
“Immediately Needed” means that action is needed on the same day to avoid delay in discharge or to allow
the member to remain in a community setting.
These definitions are consistent with both Medicaid rules and Department of Financial Regulation
DETERMINATION TIME
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The timeframes now correspond to 42 CFR §438.210. DVHA will continue to issue a notice of decision within
three days of receipt of all the necessary information. However, the longest time to wait for a decision is now
28 days, not 30. A request must be decided within 14 days of receipt of the request, but that time frame may
be extended up to another 14 days if the beneficiary or provider request the extension, or if the extension is
needed to obtain additional information and an extension is in the beneficiary’s interest.
Also, when a provider indicates, or DVHA determines, that following this timeframe could seriously
jeopardize the beneficiary’s life, health, or ability to attain, maintain, or regain maximum function, DVHA must
make an expedited decision and provide notice as expeditiously as the beneficiary’s health condition requires
and no later than three working days after receipt of the request. This may be extended up to 14 days if the
beneficiary so requests, or if the extension is needed to obtain additional information and an extension is in
the beneficiary’s interest. Under federal law, the department is obligated to provide a response within 24
hours of a request for PA of a drug.
7.3.1 PA Decision Reconsiderations
The DVHA will conduct a review of a denied prior authorization (prior to submission of claims) at the
request of a provider. The DVHA will conduct the following review if requested by the provider (prior to
submission of claim):
1. PA denial by the DVHA at the request of a provider
2. Peer to Peer review with DVHA Physician
3. PA denial about the “immediate need” for durable medical equipment;
4. PA denial because documentation was inadequate;
5. Purchase versus rental decisions for durable medical equipment.
The DVHA will not review any decision other than those listed above. All request for the above
reconsiderations must be faxed to (802) 879-5963.
Prior Authorization Contact information:
DVHA Clinical Unit
(802) 879-5903
Fax
(802) 879-5963
Dental
(802) 879-5903
Prescription Drugs are reviewed by the Pharmacy Benefit Manager Change Healthcare
Change Healthcare Call
Center
(844) 679-5363
7:30am - 6:30pm, M-F
(844) 679-5366
after hours on call 24/7 365
day/year
Change Healthcare
Pharmacy Help Desk Phone:
1-844-679-5362
All drugs and supplies requiring prior authorization can be identified on the Preferred Drug List (PDL) which
can be found at http://dvha.vermont.gov/for-providers/pharmacy
Select outpatient elective diagnostic imaging procedures require prior authorization; please see the
Diagnostic Imaging Program Guidelines & list of radiology CPT codes requiring prior authorization located at
http://www.vtmedicaid.com/#/resources
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Elective Diagnostic Outpatient High Tech Imaging:
eviCore Customer Service
(888) 693-3211
eviCore Fax
(888) 693-3210
Web based PA Requests
http://www.medsolutionsonline.com
Fax forms can be obtained at http://www.medsolutionsonline.com or by calling MedSolutions Customer
Service (888) 693-3211, 8a.m. to 9 p.m., Monday through Friday. Diagnostic Imaging Program Guidelines
and a complete list of CPT codes requiring prior authorization can be accessed at
http://dvha.vermont.gov/for-providers/claims-processing-1
MEDICAL NECESSITY
Vermont Medicaid only pays for items that are medically necessary. Per the Medicaid Rule, 7103, medically
necessary is defined as health care services that are appropriate, in terms of type, amount, frequency, level,
setting and duration to the member’s diagnosis or condition. Medically necessary care must be consistent
with generally accepted practice parameters as recognized by health care providers in the same or similar
general specialty as typically treat or manage the diagnosis or condition and
• Help restore or maintain the member’s health -OR-
• Prevent deterioration or palliate the member’s condition -OR-
• Prevent the reasonably likely onset of a health problem or detect an incipient problem
Additionally, for EPSDT-eligible members, medically necessary includes a determination that a service is
needed to achieve proper growth and development or prevent the onset or worsening of a health condition.
7.4.1 Medical Necessity Form (MNF)
A completed DVHA Medical Necessity Form (DVHA 60) is the preferred documentation for Home
Respiratory Therapy programs, DME and certain prescribed medical supply items with a few exceptions. The
ordering physician or nurse practitioner needs to complete the MNF and give a clean copy to the patient or to
the DME supplier.
Submission of the form and any necessary information to clearly document medical need is all that is needed
to make the request for prior authorization.
If the code/service requires prior authorization, the DME supplier will send the MNF and all pertinent
information to the DVHA as a PA request.
Both the ordering providers and the DME vendor are required to keep legible copies of all information in the
patient record.
The signature date on the MNF/order must be within 6 months (before or after) of the dispensing date (billed
DOS) for all items except ostomy and urologic supplies. (The order on these supplies is good for one year).
Medical Necessity and prior authorization forms are available at http://dvha.vermont.gov/for-
providers/forms1.
UTILIZATION REVIEW
The DVHA conducts numerous utilization management and review activities. Reviews are intended to assure
that quality services are provided to members and that providers are using the program properly. The
reviews are generally an examination of records, known as a desk audit, although they may also include an
on-site visit from the utilization review unit.
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DVHA staff utilizes clinical criteria for making Utilization Review (UR) decisions that are objective and based
on sound medical evidence. Approved criteria include the following:
• Change Healthcare InterQual® Guidelines
• DVHA Clinical Guidelines
• Vermont State Medicaid Rules
• Hayes and Cochrane New Technology Assessments
• Other Nationally Recognized Evidence Based Criteria
Change Healthcare InterQual® Guidelines are now available to providers behind the Vermont Medicaid
secure provider web portal at http://www.vtmedicaid.com/#/, navigate to the Transactions menu and choose
login (Trading Partners use “Login”, Web Services use “Login - UAT).
DVHA Clinical Guidelines and Vermont Medicaid State Rules will continue to be available at the DVHA
website at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines.
PRIOR AUTHORIZATION NOTICE OF DECISION
The Notice of Decision is a system-generated form that the requesting and supplying provider receives as
well as the member from the DVHA in response to a Prior Authorization (PA) request.
The Notice of Decision contains the following information:
Box 2: The value will be either “A” (approved) or “D” (denied) or “I” (awaiting further information)
Box 3: The dates of service
Box 4: The procedure code
Box 5: The number of units and/or occurrences
SERVICES REQUIRING PRIOR AUTHORIZATION
7.7.1 Concurrent Review for Admissions at Vermont & In-Network Border Hospitals
The Inpatient Concurrent Review Procedures are available at http://dvha.vermont.gov/for-providers/clinical-
coverage-guidelines.
All Vermont hospitals, including in-network border hospitals, are not required to submit faxed daily census
sheets to the Department of Vermont Health Access (DVHA) Clinical Operations Unit (COU). Please note:
Continue to use the File Transfer Protocol (FTP) for submitting information as required by other DVHA
programs. This requirement only applies when Medicaid is the primary payer. This requirement does not
apply to Inpatient Rehabilitation stays, psychiatric unit and psychiatric hospital admissions. In addition,
notification of patient discharge is required.
Prior Authorization is required if the patient stay is to exceed 13 days. The admitting facility must fax a
completed Inpatient Concurrent Review Notification Form to the DVHA COU at (802) 879-5963 for all
inpatient admissions that have an expected length of stay exceeding 13 days, including time in the
emergency department and/or observation by day 13, but no earlier than day 10 of the admission. Failure to
get a PA
for an admission that exceeds 13 days will result in a denial of the claim. Forms are available at
http://dvha.vermont.gov/for-providers/forms-1.
Retrospective reviews will not be performed when DVHA is not notified of an admission by day 13, but no
earlier than day 10 of the admission.
7.7.2 Out of-State Elective Inpatient Hospital Admissions
(Excluding Designated Border Hospitals)
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All elective inpatient admissions to out-of-state/out-of-network hospitals require prior authorization from the
DVHA COU prior to admission. The admitting facility must fax a completed Vermont Medicaid Out of State
Preadmission Form located at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines, clinical
documentation and an explanation as to why this care cannot be performed within the State of Vermont to
(802) 879-5963. The prior authorization must be requested as early as possible and no less than 3 business
days prior to the planned admission.
7.7.3 Out-of-Network Elective Outpatient Referrals
Prior authorization is required for referrals to out-of-state/out-of-network medical visits that are
elective/nonemergency, for codes 99201-99215, 99381-99456, and 99341-99360; however, PA is not
required for referrals for office visits to:
Providers affiliated with Extended-network hospitals
Providers affiliated with Out-of-state In-network hospitals
All other PA requirements will apply. A list of Green Mountain Care in-network and extended network
hospitals is available at http://dvha.vermont.gov/for-providers/green-mountain-carenetwork.
Referring providers must submit requests using the OOS Medical Office Request Form located at
http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines. Fax all requests to the DVHA COU: (802)
879-5963.
Note: Only office visit(s) are being approved. Do not proceed with any non-emergent outpatient procedure
until you have first determined and documented that the service cannot be performed by an in-network
provider.
7.7.4 In-State & Out of State Psychiatric & Detoxification Inpatient Services
The Department of Vermont Health Access (DVHA) in collaboration with the Department of Mental Health
(DMH) requires concurrent review for psychiatric and detoxification inpatient admissions. This includes all
children and adults, including those enrolled in CRT. Admitting facilities must complete the Vermont Medicaid
Admission Notification form for Inpatient Psychiatric and Detoxification Services and fax it to the DVHA at 1-
855-275-1212 within 24 hours of an urgent or emergent admission. Elective or planned admissions will
require prior authorization by the DVHA. The admitting facility must fax a completed Vermont Medicaid Prior
Authorization form to 1-855-275-1212. Forms are available at:
http://dvha.vermont.gov/for-providers/clinical-prior-authorization-forms. For additional information please see
the Vermont Medicaid Inpatient Psychiatric & Detoxification Manual available at: http://dvha.vermont.gov/for-
providers/mental-health-inpatient-detox.
7.7.5 Out-of-State Urgent/Emergent Inpatient Hospital Admissions
(Excluding Designated Out-of-State Network Hospitals)
All urgent and emergent inpatient admissions to out-of-state (OOS) hospitals require notification to the DVHA
Clinical Unit of the admission within 24 hours or the next business day. Concurrent review will begin at the
time of notification and throughout the course of the inpatient hospital stay. The admitting hospital must fax a
completed Out-Of-State Urgent and Emergent Hospital Admissions form located at
http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines and clinical documentation to the DVHA at
(802) 879-5963.
The hospital is required to notify the DVHA upon patient discharge.
7.7.6 Rehabilitative Therapy
Speech-Language Pathology (SLP) providers may enroll as private practitioners with Vermont Medicaid.
Coverage of private practice SLP services are limited to those services provided outside of the school or
hospital systems for Medicaid members of any age. The following statements apply to all therapy services:
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Medicaid does not cover any treatments or any portions of a treatment, when the efficacy and/or safety of
that treatment is not sufficiently supported in current, peer reviewed medical literature.
All treatment must demonstrate medical necessity.
Per National Correct Coding regulations, treatment must be billed under the most specific code. Billing a non-
covered service under a less specific code in order to obtain coverage could constitute fraud and could
expose the provider to recoupment and fraud investigation.
Examples of treatment that do not have sufficient support in current medical literature at this time include, but
are not limited to: sensory integration therapy, craniosacral therapy, myofascial release therapy, visceral
manipulation therapy, auditory integration training, and facilitated communication.
Note also, that treatment with goals related to leisure, sports, recreation, and avocation are not covered
benefits because they do not meet the bar of medical necessity. Treatment with goals related to vocation and
education are not covered benefits because there are other resources for coverage, including the
Department of Vocational Rehabilitation and the Department of Education.
Adult Coverage
Physical, Occupational, and Speech Therapy outpatient services for Medicaid eligible adults are limited to 30
combined visits per calendar year.
Prior authorization for therapy visits beyond 30 combined visits in a calendar year may be requested for
members with the following diagnoses: spinal cord injury, traumatic brain injury, stroke, amputation, or
severe burn.
Changing programs or eligibility status within the calendar year does not reset the number of available visits.
See Frequently Asked Questions (FAQ), under Therapy Guidelines at
http://dvha.vermont.gov/forproviders/clinical-coverage-guidelines. Limitations and prior authorization
requirements do not apply when Medicare is the primary payer.
The limit does not apply to services provided in inpatient facilities or by home health agencies; inpatient
facilities and home health agencies should follow the rules and processes currently in place.
Members under age 21
Prior authorization for outpatient therapies (PT, OT, ST) changed for Medicaid members under age 21. The
initial eight visits from the start of the member’s acute care episode/condition are allowed, per therapy
discipline, before prior authorization is required. Providers must request prior authorization in advance of the
8th visit if additional therapy services are necessary. Providers are required to determine the first date of
treatment at any outpatient facility, regardless of coverage source. It is the responsibility of the therapists to
track therapy visit/service history.
For members with a primary insurance, a prior authorization is not required if the primary insurer pays a
portion of the claim. However if the primary insurer denies the claim for being a non-covered service, if the
primary insurance benefit has exhausted, or if the primary insurance applied all to the deductible, prior
authorization is required for over 8 visits.
Subsequent authorizations will be required at 4 month intervals, based on the start of care date.
This requirement does not apply to home health agencies.
Per the Physical, Occupational and Speech Therapy guidelines posted at
http://dvha.vermont.gov/forproviders/clinical-coverage-guidelines, therapy providers can bill a maximum of 4
units of timed therapy procedures codes that state “15 minutes” are allowed per treatment session. The 4-
unit maximum is the combined totaled of timed units, not a per-procedure code limit. Evaluation, re-
evaluation and other non-timed codes are not subject to the limit and may be billed in addition to the 4 timed
codes during a single session. The code for wheelchair management, direct one-on-one patient contact,
each 15 minutes” is an exception and is excluded from the 4-unit limit.
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Providers should refer to Medicaid Rule and Therapy Guidelines for additional information at
http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines
Therapists should use the Medicaid Request for Extension of Rehabilitation Therapy Services form. Be sure
to include the original start of care date by any facility or provider, for the condition listed.
Physical, Occupational and Speech Therapists who choose to submit rehabilitation therapy extension
requests on forms other than the DVHA Therapy Extension Request form are strongly encouraged to use the
new DVHA Cover Sheet, available at http://dvha.vermont.gov/for-providers/forms-1.
Use of this form with your alternative request documentation will ensure that DVHA receives the information
required to process your prior authorization (PA) request. DVHA expects that the use of this form will speed
the PA process.
Outpatient Therapy Modifiers
VT Medicaid follows Medicare’s requirement that speech, occupational and physical therapists bill with
modifier GN, GO or GP to identify the discipline of the plan of care under which the service is delivered.
GN = Services delivered under an outpatient speech-language pathology plan of care
GO = Services delivered under an outpatient occupational therapy plan of care
GP = Services delivered under an outpatient physical therapy plan of care
Medicare provides a link to the list of applicable therapy procedure codes, (this list is updated annually by
CMS). VT Medicaid therapists need only reference the code list itself; do not use the column information.
http://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html.
All therapy services (including codes listed as “Sometimes Therapy”) that are performed by a therapist (and
billed with the therapist as the attending) must be part of an outpatient therapy plan of care and the billing
codes must use one of the above therapy modifiers to bill.
Some codes on this list are “Always Therapy” services regardless of who performs them. These services
must be part of an outpatient therapy plan of care and the Billing codes must use one of the above therapy
modifiers to bill.
Practitioners other than therapists must use these modifiers when performing listed services which are
delivered under an outpatient therapy plan of care.
These modifiers are not to be used with codes that are not specified on the list of applicable therapy codes.
Modifiers may be reported in any order.
Prior Authorization Requests must give the exact codes and modifiers in the same order as they will be billed
on the claim.
Section 8 Reimbursement, Billing Procedures and Claim Processing
DVHA does not arbitrarily deny or reduce the amount, duration or scope of a required covered service solely
because of diagnosis, type of illness or condition of the member
DVHA does not incentivize or provide rewards to employees, providers or contractors for denial of services
or prior authorizations.
ADJUSTMENTS REQUESTS
Adjustment requests may be submitted to DXC when a claim is paid incorrectly. These requests can be
initiated by the provider, DXC or the DVHA. If the error originates with the provider, then the provider must
submit the adjustment. When requesting an adjustment, submit an adjustment form. Give a brief description
of the reason for the adjustment and the action required.
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A new claim form with the correct information is required when changing the pay to, provider number,
member number or funding source. Any request, which does not have the proper attachments, will be
returned. If timely filing also applies, then attach a copy of the RA.
Denied claims cannot be submitted as adjustment requests. A claim that has been denied should be
corrected and resubmitted with all attachments as a new claim.
Adjustments are the preferred method of correction because they eliminate the use of providers’ personal
checks for repayment of incorrectly processed claims. Adjustments also provide an accurate record of how
the claim was processed.
Once a claim has been processed and placed in a PAID status, providers have one year from the original
paid date to adjust claims that would result in a positive financial outcome for the provider.
Providers can request adjustments and recoupments to claims billed incorrectly that result in a negative
financial outcome for the provider within three years of the original date of service; the entire claim will be
recouped. Partial recoupment requests are to be submitted as refunds. If the claim is more than three years
old, the provider must refund the overpayment by completing the refund form and attaching the refund check.
The Medicaid Refund form is available on our website at http://www.vtmedicaid.com/#/forms
Late Charges (Applies to UB-04 Hospital charges)
Late charges to the original paid claims must be submitted as adjustments. These adjustments must be
submitted either using the DXC Technology paper adjustment form or electronically through the DXC
Technology Provider Electronic Solutions (PES) Application. Paper claims with type of bill 117 (adjustment
inpatient) or 137 (adjustment outpatient) will not be accepted.
For instructions on completing adjustments using DXC Technology’s PES software, please visit
http://www.vtmedicaid.com/#/pes
Forms for completing single and multiple adjustments can be downloaded from
http://www.vtmedicaid.com/#/forms
TIMELY FILING
When the system indicates that Vermont Medicaid is the primary payer, the timely filing limit for such claims
is 180 days from the date of service. In no case will a claim be considered if the date of service is greater
than two years prior to the DVHA’s receipt of the claim. If a claim has a date or dates of service past the
timely filing limit, it may be submitted for payment reconsideration directly to DXC if one or more of the
following conditions are met:
DXC denied the claim within the timely filing limit for a reason other than exceeding the time limit. A
copy of the remittance advice showing the denial must be attached to each claim
A member’s eligibility was made retroactive and the date of service is within the
retroactive period. The claim must be submitted within the first twelve months of the date on the Notice
of Decision.
Inpatient claim, the timely filing limit is 180 days from the date of
discharge
When a claim is billed to Medicare with Vermont Medicaid noted as the secondary payer (using the
crossover function), the crossover claim will be considered timely if it is received within two years of the date
of service.
Global bills for maternity and orthodontia, which must be filed within 12 months of the first date of service.
When the system indicates that Vermont Medicaid is not the primary payer, providers can either file all claims
(except Medicare crossover claims) within 180 days, or providers may separate these claims into two groups
each with a different timely filing requirement.
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For claims that are not “pay and chase” (see below), the timely filing limit is 12 months from the date of
service the timely filing limit is 180 days from the date of service for “pay and chase” claims (i.e. where the
system indicates that the member is covered by court ordered insurance D1, D2, D3, D5, D8 and D9) or the
claim is for any of the following procedure and diagnosis codes:
Procedure codes: 99381-99385, 99391-99394 and 99173
Diagnosis codes: Please see Appendix 1 for ICD-10 codes
Members covered by court ordered insurance can be identified by using the Voice Response System that
says “The recipient has other insurance with (name) with coverage type (coverage code D1 or D2, etc.).”
8.2.1 Timely Filing Reconsideration Requests
The Department of Vermont Health Access will review a decision of an untimely claim in unusual
circumstances, if the claim has previously denied for timely filing.
For timely filing reconsideration requests, providers must fully research and document in the request the
extenuating circumstances surrounding the claim (e.g. submission dates, adjusted dates, and denial dates).
Providers should submit all supporting documentation (e.g. account notes, emails, denials or other insurance
correspondence. Do not send Medical records with a timely filing reconsideration request).
Providers submitting a timely filing reconsideration request for a single claim should use the “Timely Filing
Reconsideration Form – Single Claim”. For reconsideration requests that contain more than one claim for the
same recipient, providers should use the “Timely Filing Reconsideration Form – Single Patient Multiple
Claims”. Both forms are located at http://www.vtmedicaid.com/#/forms. Completion instructions are included
in the form.
If there is no documentation or the documentation is insufficient to validate extenuating circumstances for the
late submission, your request will be denied.
All Timely Filing Reconsideration Requests should be mailed to:
DXC Technology
Attn: Timely Filing
PO Box 888
Williston, VT 05495
For non-timely filing reconsideration requests, please see Section 1.2.7 Provider Reconsideration
Requests.
USUAL & CUSTOMARY RATE (UCR)
Various claim forms (CMS 1500, UB 04 and 837) require the submission of “Charge” or “Total Charges” or
“Charge Amount” to be reported for each service billed. The provider’s “usual and customary charge” or
“uniform charge” is a dollar amount in effect at the time of the specific date of service. This is the amount to
be reported on the claim. This usual and customary charge is the amount that the provider bills to insured
and self-pay persons for the same service. If the provider has more than one charge for a service, the lowest
charge will be reported to Vermont Medicaid, except, if the charge has been reduced on an individual basis.
INCIDENT-TO BILLING FOR LICENSED PHYSICIANS
Incident-to billing is a way of billing for services in an office setting only, provided by a non-physician
practitioner (NPP) whose provider type does not allow them to enroll with Vermont Medicaid. There is no
incident-to billing in a facility. NPPs that are eligible to enroll in Vermont Medicaid must enroll and bill using
their own provider number and cannot bill incident-to.
When NPPs who are not eligible for enrollment in Vermont Medicaid provide services that are incident-to a
physician or other practitioner’s service, they may bill under the physician/practitioner’s Vermont Medicaid
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provider ID (NPI/Taxonomy) if they are employed by the billing provider (part-time, full-time, leased,
contracted) and when the service are:
An integral, although incidental, part of the professional services
Commonly rendered without charge or included in the physician’s bill
Of the type that is commonly furnished in physician offices or clinics
Furnished by the physician or auxiliary personnel under the physician’s direct
supervision
Documentation is critical for patient care and must clearly link the service to the clinically-supervising
provider, including for example, co-signature and credentials of both practicing and clinically supervising
provider and notation within the medical record of the clinically supervising provider’s involvement. Services
billed in this manner may be subject to post payment review.
The billing/clinically supervising provider must:
Be actively enrolled with Vermont Medicaid
Have seen the patient first, made a diagnosis and created a plan of care
Provide formal case oversight (documented one-on-one meetings to review the case)
Be present in the office suite on site or immediately available within 15 minutes commute to provide
assistance and direction throughout the time the service is performed
The service must:
Be within the scope of practice of person providing the service;
Follow the plan of care created by the billing/clinically supervising provider
Be only for the diagnosis in the original plan of care
• If the patient requires a service for another diagnosis, the visit does not qualify for “incident-to”
billing
• The billing/clinically supervising provider must see the patient to make a new diagnosis and
create a plan of care before s/he can bill incident-to for a different diagnosis.
Incident-to billing is NOT Allowed if:
It is a new patient visit
It is an established patient with a new problem/diagnosis
There is no clinically supervising provider present in the office suite and immediately available
within 15 minutes
SUPERVISED BILLING FOR BEHAVIORAL HEALTH SERVICES
Supervised billing (formerly known as “Incident-To” billing) requirements as described below apply
only to clinical services, and are not applicable to case management, specialized rehabilitation or
Emergency Care and Assessment Services.
These requirements apply to all providers being reimbursed for “supervised billing” under Medicaid.
“Supervised billing” is a way for a supervising provider who is enrolled in Vermont Medicaid to bill for clinical
behavioral health services provided by non-licensed personnel under their direct supervision. Providers who
are eligible to enroll in Vermont Medicaid must enroll and bill using their own provider number; they cannot
bill under another provider’s number.
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Supervision of unlicensed providers is critical for patient care, and the service must clearly link to the clinical
supervisor. Supervision requirements for professional licensure are described in the administrative rules
under the Secretary of State, and must be adhered to for the purpose of “supervised billing”. The supervising
provider must sign off on the treatment plan and demonstrate continuing involvement in supervising patient
care. Services billed in this manner may be subject to post payment review.
1. Supervising Providers
The following Medicaid contracted providers may bill for supervised services:
Licensed physician certified in psychiatry by the American Board of Medical Specialties;
Licensed psychiatric nurse practitioner;
Licensed psychologist;
Licensed marriage and family therapist;
Licensed clinical mental health counselor; and
Licensed clinical social worker
Licensed alcohol and drug abuse counselors
The following conditions apply to the Medicaid-contracted provider in order to bill for unlicensed clinical
services:
1. Supervisors must be licensed and actively enrolled in Vermont Medicaid.
2. All supervising providers must only supervise for services within their scope of practice.
3. Supervisors must adhere to the supervision requirements outlined in the Secretary of State’s
Administrative Rules for their specific provider type. For Licensed Alcohol and Drug Abuse Counselors,
supervisors must meet requirements outlined by the Vermont Alcohol and Drug Addiction Certification
Board.
o Note: For purposes of billing clinical services, any behavioral health provider licensed and
enrolled Medicaid behavioral health providers and supervising within their scope of practice may
provide supervision under this policy. Unlicensed providers who are seeking licensure from the
Office of Professional Regulation (OPR) will need to obtain supervised hours from a supervisor
meeting the requirements outlined by OPR in order to apply for licensure.
4. Supervisors do not need to provide direct services in order to bill for supervised services
5. Supervisors must provide regular, face-to-face ongoing supervision to the unlicensed provider, as
outlined in the Secretary of State’s or Vermont Department of Health’s Administrative Rules for the
specific provider type.
6. Supervisors must sustain an active part in the ongoing care of the patient.
7. A licensed provider qualified for scope of services must be immediately available in person or by phone
within 15 minutes.
2. Non-Licensed Providers
Supervisors may bill Medicaid for clinical services provided by the following non-licensed providers:
Master-level mental health practitioners, including clinical social workers, clinical mental health
counselors, and marriage and family therapists, actively fulfilling 3,000 hours of supervised practice.
Psychiatric Nurse Practitioners actively fulfilling 24 months and 2,400 hours of supervised practice.
Psychologists actively fulfilling 2,000 hours of supervised practice after receiving a doctoral or master’s
degree in psychology.
Addiction counselors who are:
o Actively fulfilling the required number of hours of supervised work experience providing
alcohol/drug counseling services, commensurate with their degree as outlined by the Vermont
licensing entity, -or-
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o Possessing (or will possess within 180 days of hire) a Vermont Addiction Apprentice
Professional certificate, -or-
o Possessing an Alcohol and Drug Counselor Certification.
The following conditions must apply to non-licensed providers in order for the supervisor to bill for non-licensed
services:
Mental health practitioners shall be entered on the roster of non-licensed and noncertified
psychotherapists, and must be actively working towards professional licensure.
Psychologists shall be entered on the roster of non-licensed and noncertified psychotherapists, and
must be actively working towards professional licensure.
Psychiatric Nurse Practitioners shall be a Registered Nurse with a Collaborative Provider Agreement,
and must be actively working towards professional licensure.
Non-certified addiction counselors must be actively working towards professional licensure.
Individuals who have been on the roster that is maintained by the Office of Professional Regulation in
the Office of the Secretary of State for more than five years after January 1, 2016 will no longer be
eligible under Medicaid to provide clinical services. Extensions may be granted on a case-by-case basis.
Designated Agency and Specialized Service Agency Providers only: For individuals seeking a waiver to
the “Five-Year Rule”, please fill out the Supervised Billing Five Year Rule Waiver form found at:
http://www.vtmedicaid.com/#/provEnrollDataMaint. Return all completed forms to: Provider Member Relations
Unit, Department of Vermont Health Access, 312 Hurricane Lane, Suite 201, Williston, VT 05495.
3. Billable services provided by supervised non-licensed providers
Clinical services within the provider’s scope of practice, including:
Diagnosis & Evaluation
Individual Therapy
Group Therapy
Family Therapy
Medical Evaluation/ Management
Medication/ Psychotherapy
The following services are not eligible for reimbursement:
Services rendered by any provider who is eligible to be enrolled as a Vermont Medicaid provider but
has not applied to be a Vermont Medicaid Provider.
Services performed by a non-licensed provider who cannot practice independently and is not actively
working towards licensure.
4. Procedures for Billing
1. Practices/Agencies must maintain documentation on unlicensed master’s level individuals providing
clinical services that includes the following:
a. Name of rostered, unlicensed provider
b. Degree and discipline
c. Name of supervising provider
d. Status of license-eligibility:
i. License-eligible
ii. Rostered non-licensed and noncertified psychotherapists
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iii. Psychiatric Nurse Practitioners fulfilling 24 months and 2,400 hours of supervised
practice.
iv. Addiction counselors fulfilling required hours of supervised work experience.
e. Date when individual was entered on the roster that is maintained by the Office of Professional
Regulation in the Office of the Secretary of State, if applicable.
2. Supervising provider must use their unique provider number for services provided by unlicensed
providers.
a. For claims submitted to Medicaid, the following pricing modifiers must be used:
Modifier
Definition
Information
AH
Licensed Clinical Psychologist
This modifier should not be used when the claim is
for supervised billing.
AJ
Licensed Clinical Social Worker
This modifier should not be used when the claim is
for supervised billing.
HO
Master’s Degree Level
This modifier is required when the claim is for
supervised billing when the non-enrolled provider
that is rendering the service is "Master's Degree
Level."
HN
Bachelor’s Degree Level
This modifier is required when the claim is for
supervised billing when the non-enrolled provider
that is rendering the service is "Bachelor's Degree
Level."
b. For Designated Agencies, Specialized Service Agencies, and ADAP Preferred Providers Only:
For claims submitted to DMH or ADAP fund sources, the modifiers in the above table are not
required.
3. In the event of a supervisor’s short-term absence (e.g. vacation) where another licensed provided is
providing supervision, the documented licensed supervisor should continue to be included on the claim
as the provider using the appropriate modifier indicated above. Length of absence appropriate for this
approach should be defined in provider’s internal policy.
4. For neuropsychological testing, the supervising provider must conduct an initial face-to-face
neurobehavioral status exam to determine the medical necessity for neuropsychological testing and the
extent of such testing. Evaluations, including initial neurobehavioral status exam, administration of all
tests, final report, and feedback session, if held, should be billed to Medicaid at the conclusion of the
process on a single claim. The patient’s record should include documentation of dates and times of
face-to-face ongoing supervision to the unlicensed clinician. For other documentation requirements and
best practice guidelines please see Local Coverage Determination (LCD) Psychological and
Neuropsychological Testing (L31990).
NONCOMPLIANCE WITH POLICY
MEDICAID CONTRACTED PROVIDERS MAY BE AUDITED REGARDING THESE REQUIREMENTS AND
MAY BE REQUESTED TO REIMBURSE DVHA THE MONIES BILLED FOR THE NON-LICENSED
PROFESSIONAL.
LOCUM TENENS
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A Locum Tenens is a physician to “step in” for another provider that is on leave or has permanently left a
practice. The Locum Tenens physician must be licensed in Vermont and be actively enrolled in Vermont
Medicaid.
If a Locum Tenens physician is covering for a physician on leave, they are then allowed to use that
physician’s NPI number for up to 60 days. Modifier Q6 (Service rendered by a Locum Tenens physician)
should be used to show that the service was provided by a Locum Tenens physician. The Billing provider is
100% liable for all locum tenens billing.
TIME-BASED PROCEDURE CODES – BILLING GUIDELINES
Please follow the below guidelines when billing time based procedure codes.
Critical care procedure codes that are time-based
The billed units must reflect the actual time spent in face-to-face contact with the member in the home
and/or on the way to the hospital.
The duration of time to be reported by a physician is the actual time spent evaluating, managing and
providing the critically ill or injured patient’s care. Services are not to be provided to any other patient.
Your full attention is limited to the critically ill or injured patient’s care.
In a facility setting, duration of time reflects time spent at the patient’s bedside or elsewhere on the floor
or unit. You must be immediately available to the patient. Only one physician may bill for critical care
services rendered to a patient during any billable period of time. Time counted toward critical care may
be continuous clock time or intermittent aggregated time.
Paper claims will be required if the number of units billed exceeds the allowed number of units. It is
required that clear copies of the provider’s actual records be submitted with each claim. The number of
units billed must be documented.
The total number of minutes and date of service must be clearly written in the documentation and
circled.
Failure to clearly mark the number of minutes will result in claim denial.
All other time-based procedure codes
The billed units must reflect the actual time spent.
Paper claims will be required if the number of units billed exceeds the allowed number of units. It is
required that clear copies of the provider’s actual records be submitted with each claim. The number of
units billed must be documented.
The total number of minutes and date of service must be clearly written in the documentation and
circled.
Failure to clearly mark the number of minutes will result in denial of the claim.
ELECTRONIC CLAIM SUBMISSION
The State of Vermont and DXC encourage the use of Electronic Claim Submission (ECS). ECS allows for
efficient, reliable and economic transfer of claims between the provider’s facility and DXC. The same
standards and conditions applicable to paper claims, with regard to accuracy and completeness also apply to
claims submitted electronically.
ECS is fast, easy to use and eliminates time-extensive paperwork. ECS prevents most errors, allowing
providers to submit “clean” claims the first time. Turn-around time for electronic claims is considerably faster
than for paper claims. For information on available methods of electronic billing, please contact the Electronic
Data Interchange (EDI) Coordinator at DXC.
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ELECTRONIC FUNDS TRANSFER (EFT)
Vermont Medicaid requires health care provider payments to be made through Electronic Funds
Transmission (EFT), as stated in the Conditions of Participation of the Provider Enrollment
Agreement/Recertification Agreement. Failure to do so may result in the suspension of payments.
EFT allows payment for “clean” claims within five business days. Funds are electronically deposited into a
specified bank account, avoiding stop payments and reissues due to damaged or misplaced checks.
EFT has no effect on billing procedures but does apply to all claim types submitted. Providers are not
required to submit claims electronically to receive direct deposits.
At time of enrollment, complete the Electronic Funds Transfer Request Form located on the Vermont
Medicaid Portal at http://www.vtmedicaid.com/#/provEnrollDataMaint. This form is also used to facilitate a
change or cancelation of EFT enrollment.
Select the above link to open the forms page of the Vermont Medicaid Web Portal; scroll down to Enrollment,
click the Electronic Funds Transfer Request Form. Once opened, select “save as” from the file drop down
menu and rename the document to save a copy to your PC. Open the saved Electronic Funds Transfer
Request Form from your PC. Light blue fields indicate where text can be entered. Please remember to save
the form whenever changes are made, complete all required sections and obtain the authorized signature.
One of the following documents must be attached to both new EFT enrollment and change enrollment
requests for verification of account owner and account number: (1) voided check or (2) a signed letter from
your bank that lists the account holder’s name, and the appropriate financial institution’s account and routing
numbers.
Return your completed Electronic Funds Transfer Request Form by mail to: DXC Technology, P.O. Box 888,
Williston, VT 05495 or fax to 802-878-3440. Please direct all questions and EFT status requests to the DXC
Enrollment Unit at 802-879-4450 (option 4).
CLAIM DISPOSITION INFORMATION INTRODUCTION
This section will assist providers in reviewing the status of each of their claims on the Remittance Advice
(RA). It will also explain steps providers must follow to make adjustments or refunds on paid claims. A strong
knowledge of these available resources and procedures will assist providers in maintaining accurate
payment records.
REMITTANCE ADVICE (RA)
The Remittance Advice (RA) is a computer-generated report provided by the fiscal agent. It indicates the
status of all claims that have been submitted for processing. The RA is posted at
http://www.vtmedicaid.com/#/ a weekly basis, with your four most current RAs available. The banner page of
the RA provides important information about policy and billing. See Appendix for RA example.
The Explanation of Benefits (EOB) codes printed on the RA explain the reason(s) why Vermont Medicaid
claims are paid or denied. Full descriptions for each code are printed at the end of the RA.
EOB codes for denials that pertain to the entire claim are printed directly under the patient’s name and the
ICN on the RA. Detail denials are printed under each billing detail on the RA. Please review all areas of the
claim before resubmitting directly to claims processing. If the reason for your denial is unclear, please contact
the DXC Provider Services Unit.
Providers that bill electronically will only receive electronic RAs. Please contact the DXC EDI Department at
DXC if you are interested in submitting and receiving this information electronically.
8.11.1 RA Sections
The RA is divided into the following sections:
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Paid Claims - All claims paid in the current cycle. EOB codes under the claim header and details indicate the
reason(s) for the payment amount. There may be as many as ten EOB codes per header and per denial.
Denied Claims - All claims denied in the current cycle. EOB codes under the claim header and details
indicate the reason(s) for the denial. There may be as many as ten EOBs per header and per detail.
Suspended Claims - Claims requiring manual review by either DXC or the DVHA will be identified in this
section prior to disposition. The purpose of this section is to inform the provider that DXC has received the
claim, and payment or denial will be forthcoming.
Adjusted Claims - Claims for which adjustments have been processed to correct information, overpayment,
underpayment or payment to the wrong provider.
Financial Items - Financial transactions such as recoupments, manual payouts and TPL recoveries.
TPL & Medicare Information - Other insurance and Medicare information for members with related denials on
the RA.
Earnings Data - This “Earnings Data” section of the RA is provided to show the current RA totals as well as
cumulative year-to-date details.
Message Codes - Definitions of the EOB codes listed on the RA.
8.11.2 RA Headings & Descriptions
Recipient Name - Member name is listed in alphabetical order. The name appears in last name, first name
format.
MID - The member’s Medicaid Identification Number also known as the UID.
ICN - Each claim and any attachments received by DXC are assigned a unique identifying number called the
Internal Control Number (ICN). This number is displayed in the third column on the RA. The fifteen digit
number aids in identifying, locating or researching the claim, either during or after processing.
The following summary describes what each number represents:
Digit
Description
1-2
Valid region code values for paper claims are: 10-Paper Claim without
attachments. 11- Paper claim with attachments Valid region code values for
ECS claims are: 40 - ECS
The valid region code values for financial items are listed in the description of
the financial items section
3-6
The year the claim was received at DXC
7-9
Three digits indicating the Julian Date on which DXC received the claim.
These numbers correspond with the calendar dates; see the Appendix
document. For example, 001 corresponds with January 1 and 365
correspond with December 31
10-15
The last six digits following the date are designed for DXC control purposes.
These numbers uniquely identify the claim and allow personnel to access the
claim both manually and through the computer
HVER - The version number of the claim. The original claim paid for the services rendered is version 00. The
first adjustment to any payment is version 01, etc.
PT ACCT/RX# - The patient account or medical record number is reported as it appeared on the claim.
BILLED AMT - The amount charged for the service.
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ALLOWED AMT -The Vermont Medicaid allowed reimbursement.
OI AMT - The amount paid by another insurance for this claim or detail.
LIAB AMT - The amount for which the patient is responsible, excluding co-pay.
COPAY AMT - The co-payment amount related to the claim.
PAID AMT - The amount included in the payment for this claim.
HEADER MESSAGES - These numbers relate to the EOB codes printed under the header information.
These numbers, which are referred to as EOB codes, indicate the reasons for payment or denial for the claim
on the header level (top portion of the claim).
DNUM - The detail number.
DVER - The version of the detail. The original detail paid is version 00. The first adjustment to any payment
is version 01, etc.
FDOS - The beginning date of service as it appears on the claim.
TDOS - The ending date of service as it appears on the claim.
PROC+MODS - The procedure code and corresponding modifiers as they appear on the claim.
QTY BLD - The number of units of service as it appears on the claim.
DETAIL MESSAGES - The numbers relate to the EOB codes printed under the detail information. These
numbers indicate the reasons for payment or denial on the detail level of the claim.
ADJUSTED CLAIMS - This section of the RA includes detailed information on both the original and the
adjusted claim. The original claim data is displayed first, followed b the adjusted claim data and an
explanation of the effect the adjustment had on the original claim.
RECIPIENT NAME - Member name on the adjusted claim is listed in alphabetical order. The name appears
in last name, first name format.
MID - The member’s Medicaid identification number on the adjusted claim.
ICN - The internal control number of the adjusted claim.
HVER - The version number of the adjusted claim. The original claim paid for the services rendered is
version 00. The first adjustment to any payment is version 01 etc.
PT ACCT/RX # -The patient account or medical record number is reported as it appeared on the adjusted
claim.
BILLED AMT - The amount charged for the service on the adjusted claim.
ALLOWED AMT - The Medicaid allowed reimbursement on the adjusted claim.
OI AMT - The amount paid by another insurance for this claim or detail on the adjusted claim.
LIAB AMT - The amount for which the patient is responsible, excluding co-pay on the adjusted claim.
COPAY AMT - The co-payment amount related to the adjusted claim.
PAID AMT - The amount included in the payment for this adjusted claim.
HEADER MESSAGES - These numbers relate to the message codes printed under the header information.
These numbers, which are referred to as EOBs, indicate the reasons for payment or denial for the claim on
the header level (top portion of the claim).
DNUM - The detail number on the adjusted claim.
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DVER - The version of the detail on the adjusted claim. The original detail paid is version 00. The first
adjustment to any payment is version 01, etc.
FDOS - The beginning date-of-service as it appears on the adjusted claim.
TDOS - The ending date-of-service as it appears on the adjusted claim.
PROC+MODS - The procedure code and corresponding modifiers as they appear on the adjusted claim.
QTY BLD - The number of units of service as it appears on the adjusted claim.
DETAIL MESSAGES - These numbers relate to the message codes printed under the detail information.
These numbers indicate the reasons for payment or denial on the detail level of the adjusted claim.
ADJUSTMENT REASON - A text field that explains why the adjustment took place.
NET ADJUSTMENT AMOUNT - This field indicates the net effect the adjustment had on the claim. The value
is equal to the difference between the Original Claim Paid Amount and the Adjusted Paid Amount.
FINANCIAL ITEMS: The “Financial Items” section of the RA is printed only when a financial activity other
than claims adjudication takes place. Please refer to the sample “Financial Items” section of the RA in this
section - Sample Remittance Advice. The following summary describes the information in the “Financial
Items” section:
CCN - The Cash Control Number of the financial transaction. The first two digits of the number indicate the
type of financial transaction (i.e., system payout, recoupment, refund).
A/L NUMBER - The number assigned to the provider's ledger to account for the transaction.
MID - The member's ID number is shown if the financial transaction is related to a specific claim. When the
transaction does not relate to a specific claim, this space is blank.
ICN - The Internal Control Number of the claim is shown if the financial transaction is related to a specific
claim. When the transaction does not relate to a specific claim, this space is blank.
HVER - The version number of the related claim, if applicable.
DNUM - The detail number on the related claim, if applicable.
DVER - The detail version number of the claim, if applicable.
TXN DATE - This field indicates the date the transaction was entered and logged in the provider's account
ledger.
ORIG AMT - The original amount to be exhausted by financial transactions.
TXN AMT - The dollar amount corresponding to the transaction. This is the actual amount of money included
or withheld from the payment and applied to the original amount.
BAL AMT - The remaining balance to be exhausted by future financial cash transactions (amount still owed
against the receivable or payable). This value is equal to the Original Amount less the Transaction Amount.
RSN CD - This field describes why the transaction was performed.
FINANCIAL ITEMS REASON CODE – The financial reason codes and their descriptions listed with any
financial transactions on the RA.
TPL & MEDICARE INFORMATION - The TPL AND MEDICARE INFORMATION REPORT displays the
members for who claims denied for other insurance during the week. It is generated only when such
transactions occur. The report lists only the insurance carrier that caused the claim to fail.
RECIPIENT NAME - The name of the member who had other insurance coverage for the denied claim.
ICN - The Internal Control Number assigned to each denied claim.
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HVER - The header version number corresponds to the ICN and indicates the version of the claim. The
original header has a version number of '00'. Subsequent version numbers (01, 02, etc.) are the result of
adjustments made to the header.
DVER - The detail version number corresponds to the detail and indicates the version of the detail. The
original detail has a version number of '00'. Subsequent version numbers (01, 02, etc.) are the result of
adjustments made to the detail.
DNUM - The detail number corresponds to the ICN and indicates the detail of the claim.
OTHER INSURANCE - The name and address of the insurance carrier with whom the member has other
insurance coverage.
CARRIER CODE - The carrier code of the insurance carrier listed above.
POLICY NAME - The name of the person who holds the insurance policy.
RELATIONSHIP DESCRIPTION - The relationship between the member and the policy holder.
POLICY - The policy number of the insurance policy that the member holds with the insurance carrier.
GROUP - The group number that the insurance policy falls under. This field is only populated if the member's
insurance policy is a group policy.
MEDICARE - This field indicates the Medicare type. Possible values are 'PART A' and 'PART B'.
MEDICARE ID - The Medicare ID of the member if applicable.
8.11.3 Earnings Data & Message Codes
The EARNINGS DATA AND MESSAGES CODES - displays the financial data for the current RA and year-
to-date as well as the message codes that were listed with any claims (EOB codes) on the RA.
NUMBER OF CLAIMS PROCESSED (CURRENT) - The total number of claims processed during the past
week. This figure includes all paid, denied, suspended, and adjusted claims appearing on the RA.
NUMBER OF CLAIMS PROCESSED (YTD) - The total number of claims processed this calendar year. This
figure includes all paid, denied, suspended, and adjusted claims appearing on the RA; it is equal to the sum
of the “Number of Claims Processed” fields on each RA year-to-date.
DOLLAR AMOUNT PROCESSED (CURRENT) - The dollar amount paid for claims processed during the
past week.
DOLLAR AMOUNT PROCESSED (YTD) - The dollar amount paid for claims processed this calendar year.
This figure is equal to the sum of the “Dollar Amount Processed” fields on each RA year-to-date.
SYSTEM PAYOUT AMOUNT (CURRENT) - The dollar amount paid out as a result of system generated
financial transactions during the past week.
SYSTEM PAYOUT AMOUNT (YTD) - The dollar amount paid out as a result of system generated financial
transactions for this calendar year. This figure is equal to the sum of the “System Payout Amount” fields on
each RA year-to-date.
MANUAL PAYMENT AMOUNT (CURRENT) - The dollar amount paid out through manual checks during the
past week.
MANUAL PAYMENT AMOUNT (YTD) - The total dollar amount paid out through manual checks for this
calendar year. This figure is equal to the sum of the “Manual Payout Amount” fields on each RA year-to-date.
RECOUP AMOUNT WITHHELD (CURRENT) - The dollar amount withheld as a result of recoupment
financial transactions during the past week.
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RECOUP AMOUNT WITHHELD (YTD) - The dollar amount withheld as a result of recoupment financial
transactions for this calendar year. This figure is equal to the sum of the “Recoup Amount Withheld” fields on
each RA year-to-date.
PAYMENT AMOUNT (CURRENT) - The total dollar amount paid for paid claims, system or manual payouts,
minus recoup amounts.
PAYMENT AMOUNT (YTD) - The total dollar amount paid for claims submitted and financial transactions
incurred for the calendar year. This figure is equal to the sum of the “Payment Amount” fields on each RA
year-to-date.
CREDIT ITEMS (CURRENT) - The dollar amount relating to any credit items for the past week. Credit items
are all Medicaid void transactions, State void transactions, and refund transactions.
CREDIT ITEMS (YTD) - The total dollar amount relating to any credit items for the calendar year. Credit
items are all Medicaid void transactions, State void transactions, and refund transactions.
NET ADJUSTMENT AMOUNT (CURRENT) - The total net adjustment amount from adjusted claims
processing during the past week. This figure is equal to the sum of the “Net Adjustment Amount” fields
located in the “Adjustments” section of the RA for each adjusted claim.
NET ADJUSTMENT AMOUNT (YTD) - The total net adjustment from adjusted claims processing for the
calendar year. This figure is equal to the sum of the “Net Adjustment” fields for each RA year-to-date.
NET 1099 ADJUSTMENT (CURRENT) - The net 1099 adjustment incurred from financial transactions during
the past week. This figure is equal to the net sum of all positive and negative 1099 transactions during the
past week.
NET 1099 ADJUSTMENT (YTD) - The total net 1099 adjustment incurred from financial transactions for the
calendar year. This figure is equal to the net sum of the “NET 1099 Adjustment” fields on each RA year-to-
date.
COVERED DAYS INCLUDING NURSERY (CURRENT) - This field only applies to hospital claims. It
indicates the total number of covered days (including nursery care) billed during the past week.
COVERED DAYS INCLUDING NURSERY (YTD) - This field only applies to hospital claims. It indicates the
total number of covered days (including nursery care) billed during the calendar year.
NET EARNINGS (CURRENT) - The net earnings for the past week. This figure is calculated as follows:
Claims Paid Amount
+ System Payout Amount
+ Manual Payout Amount
- Recoup Amount Withheld
- Credit Items
+/- Net 1099 Adjustment (may be positive or negative)
= Net Earnings
NET EARNINGS (YTD) - The total net earnings for the calendar year. This figure is equal to the sum of all
the Net Earnings fields on each RA year-to-date.
ELECTRONIC FUNDS TRANSFER STATEMENT – The dollar amount deposited electronically. This
statement includes the account number into which the money was deposited as well as the date the deposit
was sent to the provider’s bank.
MESSAGE CODES - The (EOB) codes displayed in other sections of the RA and a written explanation for
each.
REFUNDS
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In the event of a Medicaid overpayment, a refund check may be attached to a Medicaid “Refund Form”
(http://www.vtmedicaid.com/#/forms) and sent to DXC. The Refund Form requires providers to state the
reason for the refund and to designate the claim or account against which it should be applied. Refunds will
be reflected on the Financial Items page of the RA. The refund amounts will be deducted automatically from
the YEAR-TO-DATE total.
When other health insurance payments are received after Medicaid payment has been made, the provider
should refund to DXC the lesser of the amount paid by the insurer or the Medicaid payment. Failure to do so
may be criminally punishable as Medicaid fraud.
Check mailing address: DXC Technology, P.O. Box 1645 Williston, VT 05495
Section 9 Billing Procedures CMS1500 & UB04 Claim Types
ABORTIONS
Induced abortions are billable only when the Abortion Certification Form has been submitted and approved
by the appropriate funding source prior to the procedure being rendered. Forms can be found by clicking on
the applicable Abortion Certification link at http://ovha.vermont.gov/for-providers/forms-1. The two funding
source forms are described below.
1. Vermont Medicaid
Completion of form DVHA 219A is required for abortions performed if the pregnancy is a result of rape
or incest, or when the mother’s life is endangered by carrying the fetus to term. This consent form and
the medical documentation of the situation must be sent to DXC with each claim.
2. State Funds
Abortions considered medically necessary require the completion of Physician Certification form DVHA
219B, and are paid by the Department for Children and Families (DCF) funding.
The form must be completed, signed and attached to the claim when submitted for processing.
Spontaneous and missed abortions completed surgically are billable under Vermont Medicaid with use of the
appropriate procedure and diagnosis codes. A certification form is not required.
Vermont Medicaid does reimburse for abortions performed by Certified Nurse Midwives.
Abortion Diagnosis Codes
Unspecified abortion diagnosis codes will not be accepted by Vermont Medicaid. When billing, use a more
specific abortion diagnosis code. Providers should refer to a current ICD-10-CM manual for the correct code.
AIDS/HIV
Vermonters living with HIV infection who meet certain income guidelines may be eligible for help with
Medicaid co-payments for treatment drugs through the Vermont Medication Assistance Program (VMAP)
http://healthvermont.gov/prevent/aids/aids_index.aspx#Anchor-Th-57625.
Vermont residents not covered by the Medicaid may be eligible for coverage of HIV medications, and/or for
benefits. Application for this benefit may be obtained by writing to: VMAP Coordinator, Department of Health-
Vermont Medication Assistance Program (VMAP), P.O. Box 70, Burlington, VT 05402.
ORGAN TRANSPLANT
Vermont Medicaid covers organ transplantation services once the procedure is no longer considered
experimental or investigational. Reimbursement will be made for medically necessary health care services
provided to an eligible beneficiary or a live donor and for the harvesting, preservation, and transportation of
cadaver organs. Post-transplant services for live organ donors are covered under the recipients Medicaid
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benefit and should be billed under the recipient’s Medicaid ID as both the patient and the insured and include
the date of birth.
9.3.1 Organ Transplant Donor Complication
The instructions below are only for billing donor complications related to the transplant surgery.
Institutional Electronic Claims for organ donor complications:
Enter patient relationship code 18 in Form Locator 59 (Patient’s Relation to Insured)
Enter the Medicaid beneficiary’s (organ recipient) information in Form Locators: 08 (Patient
Name/Identifier), 09 (Patient Address), 10 (Patient Birth Date), and 11 (Patient Sex)
Add a value of 39 along with the Donor’s name to the 837I Loop 2300 , Billing Note Segment NTE02
(NTE01 = ADD)
Include Occurrence Code 36 (Date of Inpatient Hospital Discharge for covered transplant patients)
Paper UB-04 claims:
Enter patient relationship code 39 in Form Locator 59 (Patient’s Relation to Insured)
Enter the Medicaid beneficiary (organ recipient) information in Form Locators: 08 (Patient
Name/Identifier), 09 (Patient Address), 10 (Patient Birth Date), and 11 (Patient Sex)
Enter the Donor’s name Form Locator 80 (remarks)
Include Occurrence Code 36 (Date of Inpatient Hospital Discharge for covered transplant patients);
Electronic Professional Claims:
Enter the recipient’s Medicaid number 2010BA Loop. Subscriber Name, NMI1 Segment, Element 9
Enter the recipient’s name 2010BA Loop- Subscriber Name, NM1 Segment, Element 3-5
Enter 39 and the Donor’s Name and address 2300 Loop- Claim Note, NTE segment or 2400 Loop-Line
Note, NTE segment
For Paper CMS 1500 claims:
Enter the recipient’s Medicaid number on Item 1A- Insured’s I.D. Number
Enter the recipient’s name on Item 2- Patient’s Name
Enter 39 and the Donor’s Name and Address on Item 19- Reserved for Local Use
CPT CATEGORY III PROCEDURE CODES
Category III codes are non-covered because they represent “emerging technology, services and
procedures”. These services are universally considered experimental or investigational and therefore not
covered by Vermont Medicaid. Should a service/procedure represented by a Category III code become
accepted medical practice, providers may send written documentation to the DVHA Clinical Operations Unit
(fax: 802-879-5963) requesting a coverage review.
FACTOR HCPCS CODES
Factor HCPCS Codes are typically submitted through the pharmacy benefit (except in cases of emergency).
Claims for services billed through the medical benefit require notes be included. All claims submitted for
emergency room services are exempt from this requirement.
FEE SCHEDULE
The Fee Schedule is published at http://dvha.vermont.gov/for-providers/claims-processing-1 for providers to
access current reimbursement rates on file for all procedure codes accepted by Vermont Medicaid. Other
pertinent information includes pricing effective dates, whether the code requires a prior authorization and
allowable provider types and specialties.
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Services that are non-reimbursed by Vermont Medicaid are also identified. The PAC 8 (invalid codes) & 9
(non-covered) lists include all codes which are on file as “Do not pay”. It is imperative that providers
reference this list prior to rendering services to ensure validity of specific procedure codes. When a
procedure code is updated to a PAC 9 status, providers are notified 30 days prior to the change via banner.
HEALTH EXAMINATION OF DEFINED SUBPOPULATION
DVHA will only accept diagnosis code V70.5 (ICD-9) or Z02.89 (ICD-10) (Health examination of defined
subpopulations) when it is billed as the primary diagnosis for the subpopulation “Refugees”. All other claims
containing diagnosis code V70.5 or Z02.89 will be denied. Diagnosis code V70.5 or Z02.89 is acceptable
billing for new refugees, but only when used for their first domestic health examination and related diagnostic
tests; and when medically necessary for a follow-up visit. Each claim must indicate V70.5 or Z02.89 as the
primary diagnosis and must contain the notation “Refugee – Initial Exam” or “Refugee – Second Visit”. All
subsequent care must be billed with an appropriate medical diagnosis per standard billing practice.
INTERPRETER SERVICES/LIMITED ENGLISH PROFICIENCY (LEP)
Providers are required under federal and State laws to provide interpreters for patients with limited English
proficiency (LEP) and for those who are deaf or hard of hearing.
Title VI of the Civil Rights Act of 1964
Title VI regulations, prohibiting discrimination based on national origin
Executive Order 13166 issued in 2000
Vermont’s Patients’ Bill of Rights (18 VSA 1852)
Vermont Public Accommodations (9 VSA 4502)
9.8.1 Informed Consent
The Vermont Patients’ Bill of Rights provides that “the patient has the right to receive from the patients’
physician information necessary to give informed consent prior to the start of any procedure or treatment.”
Additionally, failing to obtain informed consent may be a factor in medical malpractice litigation, although
there are some exceptions. For the purposes of medical malpractice actions, “lack of informed consent” is
defined as a failure to disclose to the patient reasonably foreseeable risks, benefits, and alternatives to the
proposed treatment, in a manner permitting the patient to make a knowledgeable evaluation. In addition,
patients are entitled to reasonable answers to specific questions about foreseeable risks and benefits. [12
V.S.A. § 1909] Using interpreters, translations services or other communication aids and services may be
necessary to ensure that patients with LEP, who are deaf or hard-of-hearing receive appropriate information
about the proposed treatment to enable them to give informed consent to treatment.
9.8.2 HIPAA
An interpreter or bilingual employee is covered under the health care operations exception for purposes of
HIPAA, and the patient’s written authorization to disclose protected health information is not required.
Providers who utilize a private company for interpretation on an ongoing contractual basis should ensure that
their contract conforms to the HIPAA Privacy Rule business associate agreement requirements. In other
situations, with disclosures to family members, friends, or other persons identified by an individual as
involved in his or her care, when the individual is present, the health care professional or facility may obtain
the individual’s agreement or reasonably infer, based on the exercise of professional judgment, that the
individual does not object to the disclosure of protected health information to the interpreter.
9.8.3 Vermont Medicaid Billing
A provider who pays for interpreter services for Vermont Medicaid members may bill procedure code T1013
for each 15 minutes of paid interpreter services provided, on-site or via telephone. This may include
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interpreter service outside of the actual healthcare provider encounter in order to fill out forms or review
information/instructions.
The provider may not bill Vermont Medicaid or the member for a missed appointment per federal policy.
Claims are submitted using the CMS 1500 claim form with HCPCS code T1013, with the exception that
Home Health Agencies use the UB04 claim form with revenue code 940 with the HCPCS code T1013.
FQHC/RHC providers must bill T1013 for interpreter services using their non-FQHC/RHC provider numbers.
When a member receives services that are not eligible for reimbursement, the interpreter services are
ineligible for reimbursement.
9.8.4 Limited English Proficiency (LEP) Resources
Organization: AT&T On Demand Interpreter (PHONE)
Web: www.att.com/interpreter
Organization: Voiance (PHONE)
Phone/Web: 1-866-743-9010 www.voiance.com
Organization: Language Line Services (PHONE)
Phone/Web: 1-877-866-3885 www.languageline.com
Organization: Vermont Refugee Resettlement Program (IN-PERSON)
Phone/Email: 1-802-655-1963 vrrp@uscrivt.org
9.8.5 Deaf and Hard of Hearing Resources
Organization: Language Services Associates (IN-PERSON)
Phone/Web: 1-800-305-9573 www.lsaweb.com
Organization: Vermont Interpreter Referral Service (IN-PERSON)
Phone/Web: 1-802-254-3920 www.virs.org
Organization: Registry of Interpreters for the Deaf
Phone/Web: 1-703-838-0030 www.rid.org
Vermont Agency of Human Services: In-house contract for interpretation services.
9.8.6 Additional Online Information
http://www.vtmd.org/interpreter-issues-and-resources
http://www.aot.state.vt.us/civilrights/Documents/VermontTranslationServices-GeneralPublic.pdf
INPATIENT NEWBORN SERVICES
Members may apply for a newborn ID for their child at the time of delivery using forms available at the facility
or by application, at the Department for Children and Families (DCF) office. It is recommended providers wait
for the child’s ID number to be issued before billing Medicaid.
If the baby’s MID is not yet available when the provider needs to bill, the mother’s ID can be used only if the
baby and mother are inpatient together for the duration of the stay, up to 7 consecutive days. The mother’s
inpatient delivery charge must be paid or claim will deny. This information (of payment) can be verified
through the Provider Services help desk at 800-925-1706 or 802-878-7871.
Example: Mother leaves hospital after three days and baby stays. The mother’s ID can be used for the baby
only those first three days; further claims for the baby must use the baby’s ID.
Example: Both are hospitalized for more than seven days. Services for the baby on the eighth day and after
must be billed using the baby’s ID.
Since birthing room births are also billed as inpatient, the place of service would always be 21.
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The following information is required on the CMS1500 Claim Form:
Field Locator - Information
1a - Mother’s VT Medicaid ID number
2 - Baby’s name
Use the following name format to indicate twin and multiple-birth babies.
ABaby
BBaby
CBaby
3 - Baby’s date of birth
4 - Mother’s name
6 - Check “child”
19 - Write “billing for baby under mother’s ID number”.
The following information is required on the UB04 Claim Form:
Field Locator - Information
8b. - Baby's name
Use the following name format to indicate twin and multiple-birth babies.
ABaby
BBaby
CBaby
10 - Baby's date of birth
58 - Mother's name
60 - Mother's ID number
80 - Write "Billing for baby under mother's ID number"
Option 2: The provider can wait for the child’s permanent ID number to be issued.
MODIFIER ‘LT’ & ‘RT’
Vermont Medicaid does not utilize the modifier combinations ‘RTLT’ or ‘LTRT’ (right and left; bilateral). When
Correct Coding allows one of these combinations on the base procedure code and the item is supplied
bilaterally, the Vermont Medicaid provider must bill two separate line items: one with modifier RT on the base
code and another line with modifier LT on the base code. The RT and LT modifier must appear first when
used in combination with another modifier.
PLACE OF SERVICE (POS) CODES
POS codes are 2-digit codes placed on health care professional claims to indicate the setting in which a
service was provided. CMS maintains the nationwide use of POS codes.
DVHA follows CMS POS instruction when determining the correct facility/non-facility reimbursement. As an
entity covered under HIPAA, DVHA must comply with standards and implementation guides adopted by
regulations for ASC X12N 837 electronic claim transactions. All electronic and paper CMS 1500 claim forms
are required to include a POS code.
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A POS Code reflects the actual place where the member receives the face-to-face service and determines
whether the facility or non-facility rate is paid. The correct POS code ensures that reimbursement for the
overhead portion of the payment is not paid incorrectly to the physician when the service is performed in a
facility setting. POS assigned by the physician/practitioner is the setting in which the member received the
technical component service.
Further information is included in these CMS publications:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/
https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html
The list of settings where Professional services are paid at the facility rate:
Inpatient hospital
(POS 21)
Skilled nursing facility
(POS 31)
Psychiatry
facility – partial
hospitalization (POS
52)
Outpatient hospital
(POS 22)
Hospice for inpatient care
(POS 34)
Community mental
health facility
(POS 53)
Emergency room-
hospital (POS 23)
Ambulance – Land
(POS 41)
Psychiatric
Residential
Treatment Center
(POS 56)
ASC for HCPCS on
list of approved
procedures
(POS 24)
Ambulance – Air or water
(POS 42)
Comprehensive
Inpatient
Rehabilitation
Facility (POS 61)
Military treatment
facility (POS 26)
Inpatient
Psychiatry facility
(POS 51)
Telehealth
(POS 02)
Professional services are paid at non-facility rates for procedures in the following: settings:
School
(POS 03)
Birthing Center (POS 25)
Comprehensive
Outpatient
Rehabilitation
Facility (POS 62)
Office (POS 11)
Nursing facility (POS 32)
End-Stage Renal
Disease Treatment
Facility (POS 65)
Home or private
residence (POS 12)
Custodial Care Facility
(POS 33)
State or local Health
Clinic (POS 71)
Assisted living
facility (POS 13)
Federally Qualified Health
Center (POS 50)
Rural Health Clinic
(POS 72)
Mobile Unit (POS
15)
Intermediate Health Care
Facility
Developmentally disabled
(54)
Independent Lab
(POS 81)
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Well Child Clinic
(POS 17)
(CMS Walk-in
Retail Clinic)
Residential Substance
Abuse Treatment Facility
(POS 55)
Other Place of
Service (POS 99)
REHABILITATIVE THERAPY SEE SECTION 7.7.6
SPEND-DOWN
In some cases, eligibility is contingent upon the applicant having extraordinary expenses. In these cases, the
applicant must first become responsible for a specific dollar amount for medical expenses during a six-month
period. The actual amount is known as the “spend-down” amount as calculated by DCF. A spend-down
member becomes eligible for Vermont Medicaid on the day of the month in which the incurred medical
expense amount equals or exceeds the specified “spend-down” amount. When the member becomes
eligible, all providers performing a service on that first day of eligibility will receive a Notice of Decision letter
(ESD 220MP) from the district office. The letter explains that the spend-down amount has been met by the
member, or that a portion of the provider’s bill remains the responsibility of the member. The provider must
deduct the spend-down amount, if any, shown in the ESD 220MP prior to claim submission.
The following aid category codes indicate Notice of Decision (Spend Down) applies to services provided on
the first day of a member’s eligibility: PA, PB, PC, PD, PP PR, P3, P4, P5, P6, P7 and P8.
When completing the UB04 Claim Form involving spend-down, the provider must do the following:
1. Enter the spend-down amount shown on the Notice of Decision in field locator 54b. If there was a
payment by a third party insurance, add the other insurance payment and spend-down amount in field
locator 54b.
2. Enter the spend down amount on the UB04 Medicare Attachment Summary Form (MASF) for Medicare
crossover claim types: X and W.
a. If no Other Insurance payment, check box for NO (6b) on MASF; the provider is to enter the
spend down amount in the other insurance field on the MASF.
b. If there is an Other Insurance payment, check box for YES (6a) on MASF; the provider is to
enter the total combined amount of the other insurance payment and the spend down in the
other insurance field (6c) on the MASF.
3. Write “Spend-down deducted $(amount)” in field locator 80, labeled Remarks. If any or the entire
spend-down amount has been satisfied, write the applicable Internal Control Number (ICN) and the
total spend-down amount met by the member.
4. Attach a copy of the Notice of Decision to the claim and submit to DXC for processing. The Notice of
Decision must be specific to the provider that is submitting the claim.
When submitting a CMS1500 Claim Form involving spend-down, the provider must do the following:
1. Indicate “spend down” and the amount in field locator 19. If any or the entire spend-down amount
has been satisfied, write the applicable Internal Control Number (ICN) and the total spend-down
amount met by the member.
2. Put your usual and customary charge in field locator 24f.
3. Total all of the charges appearing on the claim form and write the total amount in field locator 28.
4. Put the amount of the spend down in field locator 29.
5. Enter the spend down amount on the Medicare Attachment Summary Form (MASF) for Medicare
crossover claim type: Y.
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a. If no Other Insurance payment, check box for NO (1b) on MASF; the provider is to enter the
spend down amount in the other insurance field on the MASF.
b. If there is an Other Insurance payment, check box for YES (1a) on MASF; the provider is to
enter the total combined amount of the other insurance payment and the spend down in the
other insurance field (1c) on the MASF.
6. Attach a copy of the Notice of Decision to the claim and submit to DXC for processing.
LONG ACTING REVERSIBLE CONTRACEPTIVES PROVIDED IN AN INPATIENT HOSPITAL
POST-PARTUM SETTING
Vermont unintended pregnancy rate is 47%. Through the Vermont Department of Health, Long Acting-
Reversible Contraceptives (LARC) utilization is being promoted as an efficient means to eliminate unplanned
pregnancy. Women facing an unplanned pregnancy are at greater risk for a number of social, economic and
health problems.
Effective dates of service with a discharge date of January 1, 2016 or after ,when a LARC is provided in an
inpatient hospital setting, post-partum, providers must submit claims utilizing the appropriate code from each
category listed in the below table. The claim will adjudicate and a LARC add-on payment of $200.00 will be
made in addition to the diagnosis-related group (DRG) portion.
ICD-10-PCS
Inpatient
Procedure
Codes
ICD- 10-CM
Diagnosis
Codes
0UH97HZ
Z30.014
0UH98HZ
Z30.430
0UHC7HZ
0UHC8HZ
0UL74CZ
0UL74DZ
0UL74ZZ
0UL78DZ
0UL78ZZ
Section 10 CMS 1500 Claim Submissions
This section contains billing information and instruction specific to the CMS 1500 Claim Form used to bill
physician and other specified practitioner services, providers include: audiologists, chiropractors, dentists,
naturopathic physicians, nurse practitioners, podiatrists, psychologists, and transportation (emergency and
non-emergency) providers. See section 11.12 to obtain CMS 1500 form field locator information and
requirements.
An alphabetical list of billable services is located in the following section. The billable services under the
Vermont Medicaid programs are too numerous to list in their entirety; therefore, only a selection of services is
noted in detail.
PAYMENT DVHA PRIMARY
The DVHA uses the CMS Common Procedure Coding System to describe reimbursable items. Certain
reimbursable services require prior authorization. For complete details and a list of codes that require
prior authorization, see the Fee Schedule available at http://www.vtmedicaid.com/#/manuals
Vermont Medicaid reimbursement policy for the various CMS 1500 billers is as follows:
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Ambulance Services-Reimbursement basis is the lower of the provider’s charge or Vermont Medicaid rate
on file. The unit of service is the loaded mile, see Section 10.3.2 Ambulance Services.
Anesthesia Assistants-Reimbursement basis is 100% of the Vermont Medicaid rate on file.
Audiologist-Reimbursement basis is the lower of the provider’s charge or Vermont Medicaid rate on file.
The unit of service is the procedure.
Chiropractor-Reimbursement basis is the lower of the provider’s charge or Vermont Medicaid rate on file.
For additional Chiropractic information, see Section 10.3.10 Chiropractic Services.
Certified Nurse-Midwife- Reimbursement basis is 100% of the Vermont Medicaid
rate on file.
CRNA- Reimbursement basis is 100% of the Vermont Medicaid rate on file.
Dentist-Reimbursement basis for CPT procedures is the lower of the provider’s charge or the Vermont
Medicaid rate on file when billing on a CMS1500 Claim Form. All other billings are on the ADA Dental
Claim Form (see Dental Supplement located at http://www.vtmedicaid.com/#/manuals)
Federally Qualified Health Center:
Primary Care - Reimbursement is on interim, cost-based encounter rates determined using
Medicare principles and receiving the higher of encounter cost of PPS payment at the final cost
settlement at year’s end. There is an upper limit to the encounter rate when applicable.
Dental Services - Reimbursement is fee-for-service with a cost settlement at year’s end.
Independent Lab - Reimbursement basis is the lower of the provider’s actual charge or the Vermont
Medicaid rate on file not to exceed the Medicare maximum allowable amount. There is no cost settlement.
Independent Radiology - Reimbursement basis is the lower of the provider’s actual charge for the Vermont
Medicaid rate on file not to exceed the Medicare maximum allowable amount. There is no cost settlement.
For additional Radiology information, see the CMS 1500 Manual.
Licensed Lay Midwife - Reimbursement basis is the lower of the provider’s charge or ninety percent (90%)
of the Vermont Medicaid rate on file for a physician providing the same service. Reimbursement is limited
to certain procedure codes.
Naturopathic Physicians – Reimbursement basis is the lower of the provider’s charge or Vermont Medicaid
rate on file.
Nurse Practitioner - Reimbursement basis is the lower of the provider’s charge or ninety percent (90%)
of the Vermont Medicaid rate on file for a physician providing the same service. The unit of service is
the procedure.
Optician - Reimbursement basis is the lower of the provider’s charge or Vermont Medicaid rate on
file. The unit of service is the procedure.
Optometrist - Reimbursement basis is the lower of the provider’s charge or Vermont Medicaid rate on
file. The unit of service is the procedure.
Physician:
Attending Physician - Reimbursement basis is the lower of the provider’s charge or Vermont
Medicaid rate on file. The unit of service is the CPT procedure.
Anesthesiologist - Reimbursement basis is the lower of the provider’s charge or Vermont
Medicaid rate on file for the procedure. The unit of service is 1 unit equals 1 minute.
Assistant Surgeon - Reimbursement is 25% of allowed amount paid to surgeons.
Reimbursement is limited to certain surgical procedures needing assistance.
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Pathologists - Reimbursement will be made in accordance with Medicare’s Medigram 83-11
and subsequent Medigrams. The unit of service is the CPT procedure.
Psychiatry - Reimbursement basis is the lower of the provider’s charge or Vermont Medicaid rate
on file. The unit of service is per visit or for time elapsed.
Surgeons - Reimbursement basis is the lower of the provider’s charges or the Vermont
Medicaid rate on file. The unit of service is the surgical procedure.
Physician Assistant - Reimbursement basis is the lower of the provider’s charge or ninety percent
(90%) of the Vermont Medicaid rate on file for a physician providing the same service. The unit of
service is the procedure.
Podiatrist - Reimbursement basis is the lower of the provider’s charge or Vermont Medicaid rate on
file. The unit of service is the procedure.
Psychological Services - see Section 10.3.47 Psychiatry/Psychology
Rural Health Clinic:
Primary Care - Reimbursement is on interim, cost-based encounter rates determined using Medicare
principles and a final cost settlement at year’s end. There is an upper limit to the encounter rate when
applicable.
Dental Services - Reimbursement is fee-for-service with a cost settlement at year’s end.
Other Ambulatory Services - Reimbursement is Vermont Medicaid fee-for-service rate on file.
NON-REIMBURSABLE SERVICES
No payment will be made for a service or item that is not eligible for reimbursement, unless authorized by the
DVHA for reimbursement via section 7104 of Medicaid rules. These authorizations may be made only when
serious detrimental health consequences would arise. Any member interested in applying, may contact the
Green Mountain Care Member Services Unit for the required forms.
The following list identifies some of the most frequently billed non-reimbursable services (this list is not an all-
inclusive list):
Acupuncture
Biofeedback Therapy
Cellular Therapy
Certain prescription drugs
Cochleostomy with neurovascular transplant for Meniere’s disease
Colonic irrigation
Cosmetic surgery-Providers are reminded that cosmetic surgery and expenses incurred in connection
with such surgery are not covered by Vermont Medicaid. Coverage is available only when such surgery
is required for the prompt repair of accidental injury or the improvement of the functioning of malformed
body members (that coincidentally serves some cosmetic purpose). Examples of such required
surgeries include the treatment of severe burns, facial repair following an auto accident, or severe
congenital malformations.
Electro sleep therapy
Endothelial cell photography
Experimental and/or investigational procedures
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Eyeglasses for adults
Hair analysis
Hemodialysis for the treatment of cancer
Hospital and ancillary services related to a non-covered surgery
In vitro fertilization
Laetrile and related substances
Low intensity direct current treatment of ischemic skin ulcers
Non-medically necessary services
Non-rebate National Drug Code (NDC)
Oxygen treatment of inner ear/carbon therapy
Plethysmography, category II
Poison ivy desensitization
Prolotherapy, joint sclerotherapy and ligamentous injections with sclerosing agents
Repeat sterilizations
Reversal of sterilizations
Routine foot care
Services performed for administrative reasons
Services related to any non-reimbursable service, such as services ancillary to the reversal of a
sterilization
State-supplied vaccines
Sterilization under age 21 at the time of signature on the consent form
Thermal (capsular) heating/shrinkage procedures/surgery
Thermogenic therapy
Transvenous (catheter) pulmonary embolectomy
CMS 1500 CLAIM TYPE – BILLING INFORMATION
10.3.1 Alcohol/Drug Detoxification Treatment
Physicians and Alcohol & Drug Abuse Programs (ADAP) provide services for inpatient alcohol/drug
detoxification and are payable when provided within the geographical limits of the state. Treatment facilities
outside the state that wish to bill the DVHA, including designated border facilities, must receive prior
authorization. A request for prior authorization must be made by or on behalf of the referring or admitting
physician. No telephone authorizations will be granted, see the Inpatient Psychiatric & Detoxification
Authorization Manual located at http://dvha.vermont.gov/for-providers/mental-health-inpatient-detox for
further instruction.
ADAP providers must bill services using their ADAP NPI (with taxonomy code when applicable) as the
attending number, as well as continue to put the ADAP NPI number in field locator 33a.
10.3.2 Ambulance Services
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All the following conditions must be met before reimbursement will be made:
1. The ambulance service must be certified for participation in Medicare.
2. A physician or nurse must order ambulance transport and certify it as medically necessary (any other
mode of transport would have endangered the health of the member).
3. The member is transported to the nearest appropriate facility.
Vermont Medicaid is the Payer of Last Resort
All other insurances, Medicare and town or city government must be billed prior to submitting a claim to
Vermont Medicaid.
The completed claim must show the total loaded miles, i.e. the full number of miles the member was on
board/transported.
Mileage must be rounded to the nearest whole number. When the digit following the decimal point is 0, 1,
2, 3, or 4, round down [keep the digit(s) before the decimal point and drop the digits following the decimal
point]. When the digit is 5, 6, 7, 8, or 9, round up by one number. Examples: 36.3 miles becomes 36 miles;
36.5 miles becomes 37 miles.
Other services incidental to the member’s condition such as disposable supplies, oxygen, tolls and ferry
expense are reimbursed when detailed on the claim. The invoice or receipt must be attached.
Ambulance providers must enter their own NPI in field locator 24j for each procedure code. The ambulance
provider NPI must also be entered in field locator 33a with the provider name and address.
Basic/base rates include all procedures (e.g. administration of medications, application of splints). The
DVHA does not accept the modifiers utilized by Medicare. Air mileage is no longer included within the
ambulance service code and may be billed out separately.
Some service may be covered under Non–Emergency Transportation (NEMT) Section 10.3.38
SERVICE FROM
SERVICE TO
ALLOWED
1. Member’s Home or
Nursing Home
Hospital, inpatient admission
Yes
2. Hospital Or Nursing Home
Or Discharged As Inpatient
Home, inpatient admission to
another hospital, nursing
home
Yes
3. Home or Nursing Home
Hospital and return for
specialized diagnostic or
therapeutic services (not
simple follow-up visits)
Yes
4. Inpatient Hospital Status
Another hospital and return
for specialized diagnostic or
therapeutic services not
available at first hospital
No*
5. Scene of Accident
Hospital for emergency room
or inpatient admission
Yes
6. Home or Nursing Home
Hospital based renal dialysis
facility & return
Yes
7. Home or Nursing Home
Physician’s office**
Yes
8. Physician’s Office
Home or nursing home**
Yes
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9. Home or Hospital
VT Respite House
Yes
*This service is paid for by the hospital where trip originates.
**Must be medically necessary, requires a Physician Certification Statement (PCS).
Medicaid does not reimburse for miles accumulated when the member is not on board, or for waiting time.
Physician Certification
Ambulance providers are required to keep a completed Certification of Medical Necessity (CMN) in every
Vermont Medicaid members file substantiating each claim submitted for payment. A physician, a registered
nurse or a licensed practical nurse must sign this CMN. If the Medicare CMN form is used, the origin and
destination must be written on the form.
Physicians are reminded that they are certifying “other methods of transportation are medically
contraindicated” or “means of transportation other than ambulance would endanger the member's health.”
Since Vermont Medicaid pays for other forms of transportation (e.g., taxi, bus) to and from medically
necessary services, members are able to access health care with no personal expense. Both the Vermont
Medicaid program and Vermont ambulance service providers ask physicians to order and certify only those
trips that are medically necessary, and to expedite their handling and return of the forms to the ambulance
service.
A copy of the ambulance CMN form is required to be sent in with claims for non-emergency transport
services for chemotherapy, dialysis and radiation treatment/services. The certification must state why other
means of transportation were not acceptable. A CMN is not required with claims for emergency transport.
See Section 10.3.39 Non-Emergency Medical Transportation (NEMT) for information regarding
transportation for eligible members to and from medically necessary medical services that are Medicaid
billable.
10.3.3 Anesthesia
Payment is provided for anesthesia administered by an anesthesiologist, certified registered nurse
anesthetist (CRNA) or anesthesia assistant that remains in constant attendance during the surgical
procedure, for the sole purpose of providing the anesthesia service. Payment is not reimbursable for the
operating physician when billing for the administration of anesthesia. The administration of anesthesia by
the operating M.D. is included in the reimbursement for the surgery.
Medical Direction of Anesthesia: When services are performed by non-physician anesthetists and
medically directed by the physician anesthesiologist, reimbursement may be made to the physician for
medical direction of the anesthetist. In order to be reimbursed for medical direction, the physician must:
Direct no more than four concurrent anesthesia procedures
Be physically present in the operating suite and available for immediate diagnosis and treatment of
emergencies
Perform a pre-anesthetic examination and evaluation
Prescribe the anesthesia plan
Personally participate in the most demanding procedures in the anesthesia plan, including induction
and emergent
Monitor the course of anesthesia administered at frequent intervals
Ensure that a qualified individual performs any procedures in the anesthesia plan not done by the
physician
Provide indicated post-anesthesia care
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Oral surgery billed on a CMS 1500 using CPT coding is subject to the same rules as a physician. The fee
for anesthesia provided during oral surgery by the operating physician or dentist is included within the
payment for the surgical procedure. This is different from payments for dentistry. See: Oral Surgery
Allowable Modifiers
Billable by the Anesthesiologist
AA-Services performed by an Anesthesiologist not medically directing.
QY-Medical direction of one case
QK-Medical direction of 2, 3 or 4 cases
AD-More than 4 cases (This change in current Vermont Medicaid policy follows Medicare’s reduction
in base units from 4 to 3 for this modifier).
Billable by the CRNA or Anesthesia Assistant
QX-Service with medical direction by Anesthesiologist
Billable by the CRNA only
QZ-Service without medical direction by Anesthesiologist
Billable by the CRNA or Physician
QS-Monitored anesthesiology care services
The QS modifier is for informational purposes. Providers must report actual anesthesia time on the
claim.
All anesthesia codes must be billed with the appropriate modifier. Reimbursement may be extended to the
services of more than one anesthesiologist when written justification is attached to the claim with a copy of
the operative report and the anesthesia record.
Epidural Catheter-Pain Management
In keeping with Medicare policy, the DVHA cannot pay either spinal cord catheter introduction or pain
management on the same date as surgery and/or general anesthesia. Spinal catheter introduction and pain
management is included within the surgical and anesthetic reimbursements. Daily management of epidural
or subarachnoid drug administration is payable only after the day on which the catheter was introduced.
Units of Service
Anesthesia services (procedure codes which begin with zero in the CPT) are required to bill units in actual
time spent in minutes. For example, one unit equals one minute of actual time spent in attendance. A limit
of 600 units (10 hours) has been imposed all anesthesia codes, with the exception for CPT codes 00211
and 00567 the unit limit is 480, and CPT code 01967 the unit limit is 360. When submitting a claim for
anesthesia services with units greater than the maximum allowed amount for the same date of service;
submit a paper CMS 1500 claim form and include the appropriate supporting documentation (e.g. an
anesthesia report), except for code 01967 for which the unit cap is set.
The DVHA payment methodology for anesthesia services is the lower of the actual charge or the Medicaid
rate on file. Under Level III PAC A pricing is the Medicare payment formula of (units of service + base unit)
multiplied by a conversion factor. The units of service billed are based on Medicare billing requirements.
The base unit values used by DVHA are those put in place by Medicare effective January 1, 2012. For
ongoing updates, the DVHA will follow Medicare's update schedule each January 1.
Time begins when the anesthesiologist/CRNA prepares the member for the introduction of anesthesia and
ends when the anesthesiologist/CRNA is no longer in constant attendance. Included within the scope of
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this payment are pre and post-operative visits, the administration of anesthetic, and the administration of
any fluid or blood incident to the anesthesia or surgery.
Local Anesthesia
Reimbursement for local anesthetic is included in the reimbursement for the procedure. Local anesthesia is
never reimbursed as a separate service. This includes Novocain or topical anesthesia used by dentists.
Monitoring Services
The services of an anesthesiologist required to monitor the member during surgery performed under local
anesthesia are reimbursable. A narrative justification for the service must accompany the claim.
Spinal Injection/Nerve Block
Nerve blocks performed concurrent with surgery or on the same date of service as surgery are reimbursed
as part of the surgical code payment and are not to be billed separately.
When a spinal injection or nerve block is performed as an independent procedure for diagnostic or
therapeutic reasons (not concurrent with surgery), and the code is covered by Medicaid, it is billed as the
surgical procedure. The physician, regardless of specialty (e.g. anesthesiologist, surgeon, etc.) must bill on
a CMS 1500 claim form using the specific procedure code for the type of nerve block performed. A unit of
service is not time expended: one nerve block equals one unit of service. Please refer to the Fee Schedule
for covered codes.
Pre-Surgical Examination
Pre-surgical examination is reimbursable as part of the surgical procedure code payment. Only when the
surgery is cancelled will the pre-surgical examination be reimbursed as a separate service.
10.3.4 Antineoplastic Drugs
Antineoplastic drugs or agents necessary in the treatment of malignant diseases are reimbursed by
Vermont Medicaid and are to be billed by the physician/physician group only when the physician/physician
group has purchased the drug. Only drugs administered by parenteral infusion, perfusion and intracavity
means will be paid. Reimbursement follows Medicare or by invoice. Use the appropriate HCPCS J----code
and NDC. For the administration of antineoplastic agents in the office or physician-based clinic, see
procedure codes in the 964-- section of the CPT manual. The appropriate-level evaluation and
management procedure code for the visit may also be billed.
10.3.5 Assistant Surgeon
Reimbursement of services is limited to the Medicare list of procedures requiring an assistant. It is further
limited to one assistant surgeon during an operative session. An assistant surgeon is reimbursed at 25% of
the allowed amount paid to the primary surgeon for the procedure. Only one of the assistant surgeon
modifiers is allowed to be billed with a procedure code since each modifier indicates a different provider
type and/or situation.
Use the appropriate modifier with the surgical code when billing for assistant surgeons:
80 - Assistant Surgeon (For physicians; not intended for Physician Assistants, Nurse Practitioners,
etc.)
81 - Minimum Assistant Surgeon (Used when assistance required is minimal or for only a portion of
the surgery) (For physicians; not intended for Physician Assistants, Nurse Practitioners, etc.)
82 - Assistant Surgeon (when qualified resident surgeon not available) (For physicians; not intended
for Physician Assistants, Nurse Practitioners, etc.)
AS - Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) for
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assistant at surgery
Many procedure codes do not require an assistant surgeon and therefore, Vermont Medicaid will not
reimburse for the service. Assistant surgeon services are not to be billed in cases of co-surgery. In the
case of co-surgery, each provider should bill on paper with the appropriate procedure code with the
appropriate modifier (not 80, 81, 82, AS) and attach all related operative notes.
10.3.6 Audiological Services/Hearing Aids
Audiology services are provided to members of any age. Coverage of hearing aids is limited to one hearing
aid per ear every three years for specified degree of hearing loss. Prior authorization is required for
requests prior to the three year limit.
Audiology services pre-approved for coverage are limited to:
Audiologic examinations;
Hearing screening;
Hearing assessments;
Diagnostic tests for hearing loss;
Analog hearing aids, plus their repair or replacement for members of any age
Digital hearing aids, plus their repair or replacement for members of any age
(see below for further instruction).
Prescriptions for hearing aid batteries – twelve batteries per month (see below for further instruction);
Fitting/orientation/checking of hearing aids; and
Ear molds.
Payment will be made for hearing aids for members who have at least one of the following conditions or if
otherwise necessary under EPSDT found at rule 4100:
Hearing loss in the better ear is greater than 30dB based on an average taken at
500, 1000, and 2000Hz.
Unilateral hearing loss is greater than 30dB, based on an average taken at
500, 1000, and 2000Hz.
Hearing loss in the better ear is greater than 40dB based on an average taken at 2000, 3000, and
4000Hz, or word recognition is poorer than 72 percent.
Batteries
Two packages of 6 batteries is reimbursable per month when there is a written prescription from the
physician. Prior authorization is not required. A completed Medical Necessity Form (MNF): Substantiating
the medical need for the hearing aid must be kept on file for auditing purposes.
Hearing Aid Repairs
Prior authorization is required if a second repair/modification is needed within 365 days of a previous repair
or any repair in excess of $100. The cost of repairs/modifications should be less than 50% of the cost of
replacing the aid. Repairs must never be billed on hearing aids that are still under warranty (new or
repair/replacement).
Only Digital Hearing Aids in code range V5255-V5261 allow modifier “TJ” (child and/or adolescent). The
“TJ” modifier triggers a higher allowed amount to cover more sophisticated programming capability when
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medically necessary. For monaural codes, “TJ” will be the second modifier because modifier RT and LT
must be given first (e.g. V5255RT/TJ).
Non-Covered Services
The following are non-covered services unless authorized for coverage via rule 7104: nonmedical items,
such as: air canal aids and maintenance items other than batteries, and fees associated with selection and
trial periods or loaners. DVHA does not pay for “CIC” (completely in the canal) hearing aids.
10.3.7 Bilateral Procedures Physician/Professional Billing
When bilateral surgical procedures are performed during the same operative session, and the CPT code’s
description does not already state “bilateral”, bill the CPT code only once using modifier 50 and bill one unit
only. The system will allow one 150% payment.
Modifier 50 is not to be used on claims submitted for bilateral radiology services.
10.3.8 Capsule Endoscopy (Esophagus through Ileum)
Capsule Endoscopy is a reimbursable service by Vermont Medicaid and requires prior authorization from
the DVHA. The cost of the capsule and the physician fee are included in the payment. This procedure code
should be billed as one unit and includes a global follow-up care period of 90 days post-procedure.
Providers should obtain prior authorization before scheduling the procedure.
Capsule endoscopy of only the esophagus is not covered.
10.3.9 Children with Special Health Needs Infant Toddler Programs
Aid Category Code – SH (Children with Special Health Needs) is used only when submitting medical
claims for Physical, Occupational and Speech Therapy (PT,OT,ST), Nutritionist (NU) or Autism Specialist
(AU) services only.
Dental claims for Children with Special Health Needs will continue to be processed through the Vermont
Department of Health, PO Box 70, Burlington, VT 05402.
10.3.10 Chiropractic Services
DVHA will not pay for any x-rays necessary to substantiate the subluxation. Physicians, hospitals and other
providers should be aware that Vermont Medicaid does not pay for any service ordered by a chiropractor.
Reimbursement for adult chiropractic is limited to manipulation of the spine.
Members under age 21 may only receive chiropractic services for the manipulation of the spine to correct a
subluxation. Chiropractic services for members under age 12 require prior authorization from the DVHA.
Visits for adults and children are limited to 10 visits per calendar year. Prior Authorization, from the DVHA,
is required for all members requiring additional visits over the 10 visit limit per calendar year. The PA
request, accompanied by all pertinent clinical data documenting the need for treatment must be submitted
to the DVHA in writing.
10.3.11 Consultation
A consultation includes those services provided by a physician whose opinion or advice is requested by the
attending physician in the evaluation or treatment of a member’s illness or condition. A consultation may
occur in any location or setting. A consultation must include a written report to the referring physician and
must be available to Vermont Medicaid upon request. The only time a consultation code is valid for a pre-
op exam is when the surgeon is not the member’s primary physician and is assessing the need for surgery.
In such a case, the billed diagnosis must indicate the medical condition, not the pre-op V-code.
When the surgery is already scheduled, the physician who performs the pre-op (history and physical) is to
bill the appropriate E & M code, not a consultation code. Consultation codes will be denied when the
diagnosis or other information indicates the service was a pre-op exam.
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To bill for a consultation service, use the CMS 1500 claim form, and refer to the CPT manual for procedure
codes and definitions. All initial consults are limited to one per member per diagnosis. The NPI number of
the referring physician is mandatory in field locator 17b when billing a consultation code.
10.3.12 Detail Processing
Each line on the CMS 1500 claim form is called a “detail” and is processed individually. All of the details on
a claim form have the same Internal Control Number (ICN). However, each detail has its own sequence
number that is listed on the remittance advice right after the claim’s ICN. Individual processing means that
one detail from a claim may appear on the remittance advice in the Paid Claims section while another
detail from the same claim may appear in the Suspended and/or Denied Claims section. This type of
processing allows each detail to be processed individually. No detail is delayed by the processing of
another detail.
10.3.13 Developmental & Autism Screening of Young Children
The American Academy of Pediatrics recommends that all infants and young children be screened with
valid, reliable screening instruments for developmental delays at regular intervals. To improve detection
rates through the use of standardized screening instruments by primary care providers, the DVHA will
reimburse for a developmental screening (CPT 96110) with a standardized screening tool to be billed on
the same day as a well-child visit or other E & M codes.
All infants or young children should have a general periodic developmental screening at the 9th, 18th, 24th
or 30th month well child visits. Developmental screening is recommended when surveillance indicates an
infant or young child may be at risk for developmental delay.
When billing for a general developmental screening of an infant or young child at the 9th, 18th, 24th or 30th
month visits providers should use CPT Code 96110 and the appropriate "V" diagnosis code. Providers are
required to maintain documentation in the patient medical record of the screening, the screening tool used,
and evidence of screening result or screening score.
To ensure children are screened with the most appropriate tools, the Vermont Child Health Improvement
Program reviewed information on developmental screening tools identified in the AAP policy statement,
and coordinated a committee of developmental and primary care pediatricians to review and comment on
this information resulting in a “preferred list” of developmental screening tools.
For most primary care physicians, tools that fall under the general screening category are going to be most
useful and appropriate for young children. There will be instances where secondary screening tools, or
domain specific tools, may be appropriate, and the decision to use such tools should be based on
individual practice needs, physician experience, population needs, etc.
General Screening Tools
Ages & Stages Questionnaire (ASQ) Third Edition (2009) www.agesandstages.com
Battelle Developmental Inventory: 2nd Edition (BDI-II) - Screening Test (2006) www.riverpub.com
Bayley Scales of Infant and Toddler Development: 3rd Edition (Bayley-III) Screener (2005)
www.pearsonassessments.com
Brigance Early Childhood Screens (2005) www.curriculumassociates.com
Infant Development Inventory (IDI) (1998) www.childdevrev.com
Parents’ Evaluation of Developmental Status (PEDS) (1997) www.pedstest.com
PEDS: Developmental Milestones (2006) www.pedstest.com
Secondary Screening Tools
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Ages & Stages Questionnaires: Social-Emotional (ASQ:SE) www.agesandstages.com
Child Behavior Checklist (CBCL) Achenbach System http://www.aseba.org/
Communication and Symbolic Behavior Scale-Developmental Profile (CSBS-DP):Infant Toddler
Checklist http://www.brookespublishing.com/store/books/wetherby-csbsdp/index.htm
Early Language Milestone Scale (ELM Scale-2)
http://www.proedinc.com/customer/ProductLists.aspx?SearchWord=ELM
Language Development Survey http://www.aseba.org/
Alberta Infant Motor Scale (AIMS) (1994)
http://www.us.elsevierhealth.com/product.jsp?isbn=9780721647210
Autism Screening
The AAP recommends that young children should be screened with valid, reliable screening tool for autism
at regular intervals. All children should have an autism specific screening at the 18th and 24th month well
child visits. To improve detection rates through the use of standardized screening tool by primary care
providers, the DVHA will allow for an autism screening (CPT 96110) with a standardized screening tool to
be billed on the same day as a well-child visit or other E & M codes.
Primary care providers must use a standardized screening tool to bill for autism screening that occurs in
conjunction with a well-child visit or other visit. Any standardized screening tool listed in the Academy of
Pediatrics policy statement Identifying Infants and Young Children with Developmental Disorders in the
Medical Home (Pediatrics, Vol. 18, #1, July 2006) can be used through December 31, 2011. As of January
1, 2012, reimbursement for child autism specific screening at the 18th and 24th month visits should only be
requested when the standardized screening tool listed at the bottom of this guidance is used.
When an autism screening is completed in addition to a developmental screening, using two separate
standardized screening instruments, bill both on the same claim form using the developmental screening
2013 CPT 96110 with two (2) units. Submit the claim with the required diagnosis for the routine child health
check (well child visit) plus an additional diagnosis to indicate that a second screen for special screening
for developmental delays in early childhood has been performed. This is necessary to differentiate for
reporting purposes.
Required documentation must be maintained in the child’s health record and at a minimum, includes the
name of the screening instrument(s) used, the score(s) and the anticipated guidance related to the results.
Preferred tool list for autism specific screening
Modified Checklist for Autism in Toddlers (MCHAT) (1999)
http://www.firstsigns.org/screening/tools/rec.htm#asd_screens
10.3.14 Diabetic Teaching
Routine diabetic teaching is included within payment for the medical visit. When it is medically necessary
for the member to be referred to a Certified Diabetic Educator for more in-depth counseling, billing
instructions are provided to the appropriate providers upon enrollment.
10.3.15 Drugs Requiring Prior Authorization
The following medications (listed in alphabetical order) will require a prior authorization when paid through
the medical benefit as physician or hospital outpatient billing. This allows the consistency of prior
authorization requirements between the medical and pharmacy benefits:
Amevive (alefacept), Boniva (ibandronate), Botox (botulinum Type A), Myobloc (botulinum Type B),
Orencia (abatacept), Reclast (zoledronic acid injection), Remicade (infliximab), and Tysabri (natalizumab).
For a list of ongoing changes, please see the DVHA website at http://dvha.vermont.gov/for-providers.
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Effective for dates of service on and after 10/01/13, all claims submitted for Zoledronic Acid must be billed
using HCPCS code Q2051.
Prior authorization is required from Goold Health Systems when this medication is to be used for
Osteoporosis or Paget’s disease, and
Prior authorization is not required when this medication is used to treat Hypercalcemia of
Malignancy and Multiple Myelona with bone metastasis from solid tumors.
This does not apply to Medicare crossover claims. The following J codes (listed in numerical order) are
affected:
J0129, J0215, J0585, J1740, J1745, and J2323
For members with a primary insurance, a prior authorization is not required in the medical benefit if the
primary insurer pays a portion of the claim. However, if the primary insurer denies the claim, the DVHA will
require a prior authorization.
The following medications (listed in alphabetical order) may not be billed through the medical benefit:
Soliris (eculizumab), Somatuline Depot (lanreotide), Synagis (palivizumab) and Xolair (omalizumab). For a
list of ongoing changes, please see the DVHA website at http://dvha.vermont.gov/for-providers/pharmacy.
Therefore, the following J codes, C codes or other codes (listed in numerical order) will not be accepted:
90378, C9003, C9237, J1300, J1743 and J2357.
These medications must be billed through the pharmacy benefit using NDCs. Please note that these
medications do require prior authorization for payment through the pharmacy benefit.
Prescribers are instructed to call or fax the Goold Health Systems Clinical Call Center to request prior
authorization for the above mentioned medications regardless of whether the medication will be billed
through the medical or pharmacy benefit. Phone: 1-844-679-5363; fax: 1-844-679-5366. For clinical criteria
and either the general or specific prior authorization forms at http://dvha.vermont.gov/for-
providers/pharmacy.
10.3.16 Dual Eligibility
See Section 6.6 Medicare & Medicaid Crossover Billing
10.3.17 Emergency Indicator
Providers must indicate on the CMS 1500 form if the service provided is the result of an emergency
situation. These situations must be indicated in the “EMG” field locator (24c) on the claim form.
10.3.18 Emergency Room Services
Emergency room services include, but are not limited to:
Consultations
ER physicians charges
Radiology
Laboratory services
Payment will not be made for professional services for medical follow-up services in the emergency
room.
10.3.19 EPSDT Program Well – Child Health Care
Vermont provides Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services to all Vermont
Medicaid members under age 21. The goal of the program is to prevent illness, complications and the need
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for long-term treatment by screening and detecting health problems in the early stages. Services are
tracked for appropriate follow-up and reported to CMS by collection of data from Vermont Medicaid claims.
The Vermont Department of Health (VDH) assists in EPSDT outreach and education through its’ Partners
in Health Program. Under an agreement to implement EPSDT services, the VDH has established protocols
and standards for screening services and is available to all providers.
Required EPSDT Screening Components
A. Comprehensive health and developmental history
B. Comprehensive unclothed physical exam
C. Appropriate immunizations
D. Laboratory tests (includes blood lead level and TB screening)
E. Health education/anticipatory guidance
F. Vision screens
G. Dental screens
H. Hearing screens
Screening Service Delivery and Content
A. Screening is provided according to AAP recommended intervals, Vermont Division of Dental Health
Services standards, DOH periodicity schedules and as medically indicated
B. Eligible individuals have free choice of qualified providers
Screens include developmental and nutritional assessment
Diagnosis and Treatment Services
A. Diagnostic procedures are reimbursable when medically indicated by a screening examination.
B. Treatment services to correct or improve defects and physical and mental illnesses and conditions
discovered by the screening services, are reimbursable, including:
Vision services
Dental services
Hearing services
Physical, Occupational, and Speech therapy (PT, OT and ST)
Supportive nursing service (Medicaid High Tech Program)
Case Management
C. Treatment services may require prior authorization and are limited to:
Medically necessary, as defined by the Medicaid Division
The most economical treatment approach
Authorized providers
EPSDT services are billed to Vermont Medicaid on the CMS 1500 claim form using CPT procedure codes
99381-99385 and 99391-99395 and the appropriate modifiers, “EP”.
Provider-Based Billing requires EPSDT services to be billed on the UB 04 claim form using CPT procedure
codes 99381-99385 and 99391-99395 and the appropriate modifier, “EP”.
10.3.20 ESRD Related Services
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Vermont Medicaid reimburses for End Stage Renal Disease (ESRD) related services provided by the
physician to members in the home, office, outpatient department, skilled nursing facility, or nursing home.
Do not bill “daily” and “per full month” codes for the same calendar month. Documentation (usually the
physician notes) must be available in the member’s record which shows that the service was given by the
physician and the dates involved. Providers should refer ESRD members to Medicare for possible
eligibility.
10.3.21 Evaluation & Management Services (Post-Operative Care)
Evaluation and Management: (99--- codes)
The following limits apply:
Services included within payment for E&M service
Office visits limited to 5 per calendar month per attending
New patient visits limited to one per member/attending/3 years
One office visit/day for same member and same attending provider
Post-Operative Care
When reporting with a surgical procedure with a 90 day, 30 day or a 10 day global period any E&M service
billed during the global period by the same provider will be included within the surgical procedure payment
and not reimbursed separately. Payments for surgical procedures with a 0 day global period will include
established patient E&M services.
10.3.22 Family Planning Services
Family Planning is defined as any medically approved diagnostic test, treatment, counseling, drug, supply,
or device which is prescribed or furnished by a provider to individuals of child-bearing age for purposes of
enabling such individuals to freely determine the number and spacing of their children. Abortion is not
considered Family Planning.
It is important that physicians and other providers identify such services as family planning in the
appropriate field locator on the claim form. Reimbursement for implantation and/or removal of contraceptive
devices includes all related services including the surgical tray, anesthetic, and physician visits within 30
days after the procedure. Implantation is reimbursable once every five years.
10.3.23 FQHC/RHC
Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) have at least two provider
numbers: one for services paid at cost, and one for services paid per fee schedule. Services paid at cost
are billed as encounters.
Encounters
An Encounter at a FQHC/RHC is defined as a face-to-face visit between a member and a provider. Face-
to-face visits with more than one provider and multiple visits with the same provider that take place on the
same day and the same location constitute a single visit, except when one of the following conditions exists
(1) After the first encounter, the member suffers illness or injury requiring additional diagnosis or
treatment
(2) The patient has a medical visit with a physician, physician assistant, nurse practitioner, nurse
midwife, or a visiting nurse, and a visit with a clinical psychologist, clinical social worker, or other health
professional for mental health services. Vermont Medicaid follows the same list of health professionals
as Medicare.
A Vermont Medicaid encounter does not include total OB care.
Centers must bill procedure code T1015 for the encounter in addition to CPT/HCPCS codes for the
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services provided. The T1015 encounter code is to be billed with a zero charge amount or a negligible
charge amount (i.e., $.01 or $1.00) if software prohibits using a zero charge amount. CPT/HCPCS codes
for the services must be billed using your usual and customary charge.
Encounter Examples
1. The member is treated for a headache in the morning at the office and returns home. The member
returns to the same office a few hours later because the headache is worse, sees the same or a
different practitioner, and returns home. The member returns for the third time to the same office for the
same problem, and is treated by a third physician and returns home.
This must be billed and reimbursed as one encounter since the encounters were for the same
diagnosis at the same location on the same day.
2. The member is treated during a single visit for both a headache and stomach ache.
This must be billed and reimbursed as one encounter.
3. The member is treated in the morning for a headache and returns home. The member returns the same
day for treatment of a laceration.
This is billed and reimbursed as two separate encounters. When the member has left the office and
returns for an unrelated reason, then the service can be billed and reimbursed as a second encounter.
4. The member is treated by a physician and a mental health provider on the same day.
This is billed and reimbursed as two separate encounters, even if the diagnoses are substantially the
same, because one encounter is with a medical provider and the other is with a mental health provider.
5. The member sees her OB for a standard pre-natal visit and returns home. The member returns the
same day to see her OB for a separate, pre-natal concern.
Neither of these antepartum (pre-natal) visits with an OB are considered an encounter by Vermont
Medicaid. Antepartum care visits are typically billed globally after the birth.
Hospital or Nursing Home Services
FQHC/RHC provider services delivered at hospitals may be billed as either encounters or fee for service.
The billing method used should be consistent throughout the fiscal year.
Encounter billing: Use the facility number if the services are billed as encounters. The time spent
by the provider should be attributed to the same account.
Fee for Service billing: Use the non-FQHC/RHC provider number and service billed with the
appropriate CPT code. These services would are subject to cost settlement and the provider’s time
spent at the hospital is not an FQHC/RHC allowable cost.
FQHC/RHCs shall report the method used to the cost report auditor.
Other Insurance
If an FQHC/RHC provides one or more services on the same day to a Vermont Medicaid member with
insurance other than Medicare, the visit should first be billed to the other insurer using the appropriate CPT
code(s). The facility may bill Vermont Medicaid for the balance between the other insurance payment and
the facility’s encounter rate using T1015 as the encounter code. (See also instructions for completing field
locator 29 on the CMS 1500 form.)
Insurance plans impose various rules for members covered by their plan including a commercial HMO. If a
Vermont Medicaid member has other insurance, the member must follow the rules (such as network
limitation) of that insurer. Vermont Medicaid will not make a payment for which another insurer is
responsible or would be responsible if the member had followed that insurer’s rules.
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If the other insurer requires a co-payment for office visits that are paid under the capitated rate, Vermont
Medicaid will reimburse the provider for this office visit co-pay charge only. To bill the co-pay amount, use
procedure code T1015. If FQHC/RHCs want to bill for the co-pay for visits under capitation, they can claim
a T1015 but must use the non-FQHC/RHC provider number.
Other Services
Laboratory services provided by a FQHC or RHC should be billed using the non-FQHC/RHC
provider number. These services are paid per fee schedule. See Specimen Collection.
Radiology services, except dental films, should be billed using the non-FQHC/RHC provider
number.
Dental services provided by FQHC should be billed using the appropriate dental code and the
FQHCs dental provider number. These services are paid on the Vermont Medicaid fee schedule,
but will be cost settled at year end.
When a FQHC or RHC bills for completing DVHA treatment plans or refugee forms, or providing
Healthy Babies services or planning for an IEP, the service should be billed using the non-
FQHC/RHC number.
Minor equipment and supplies (such as band aids and ace bandages) are assumed to be part of
the encounter and are not eligible for reimbursement on an individual basis.
DME items are to be billed using the appropriate HCPCS codes and would be reimbursed per the
fee schedule. A DME Provider Number is required to bill DME items. Your facilities NPI and
taxonomy number must indicate that you are a licensed DME provider. A copy of your NPI letter will
be required at time of enrollment.
Interim Settlements
After a FQHC or RHC files a cost report, it can request that an interim settlement be made by sending a
letter either to DVHA or the DVHA auditor requesting such. DVHA will pay up to 90% of the balance due to
the facility, based on the recommendations of the auditor.
10.3.24 Health Maintenance Organization (HMO)
HMOs are insurance plans and are treated as such by the DVHA. Vermont Medicaid members covered by
a commercial HMO must follow the HMO rules. Vermont Medicaid will make no payment for which an HMO
is responsible or when the member has not followed the HMO rules. Providers may notify the members
that he or she is responsible for payment when the HMO rules are not followed.
Vermont Medicaid will reimburse for HMO co-pay charges for physician office visits when the physician is
capitated by the primary HMO. To bill the HMO co-pay only, use the procedure code T1015.
T1015 can be used only to bill Vermont Medicaid for the co-payment required by another primary insurer
when that visit was included in a capitation agreement with the primary insurer.
Rural Health Centers and Federally Qualified Health Centers are not allowed to bill DXC Technology for
HMO co-payments. These will be included in the yearly cost settlement.
10.3.25 Hospital Based Physicians
Vermont Medicaid follows the billing procedures of the regional Medicare carrier. Reimbursement is made
in accordance with the Medicaid fee schedule for services and must be billed on the CMS 1500 Claim
Form.
The CPT codes for hospital inpatient services are used to report evaluation and management services
provided to hospital inpatients. When the member is admitted as an outpatient, physician visits are billed
with either the outpatient CPT codes or observation service CPT codes.
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10.3.26 Hysterectomy
All hysterectomy claims require prior approval from the DVHA Clinical Operation Unit. All hysterectomy
claims on members under the age of 55 also require either:
A valid hysterectomy consent form, or if a valid consent form is not available
A valid ‘Notice of Decision” to provide retroactive eligibility, -or-
Operative notes or a statement that the member was already sterile prior to the hysterectomy.
The hysterectomy consent form is available on the Department of Vermont Health Access site at
http://dvha.vermont.gov/for-providers/clinical-prior-authorization-forms
Note: No prior authorization is required, if the procedure billed is hysterectomy with the primary diagnosis
indicating cancer of the genital system.
10.3.27 Immunization
State supplied vaccines must be billed with modifier SL. When a vaccine is State supplied and billed with SL
modifier, billed amount can be either $0.00 or $0.01. Reimbursement amount will be $0.00
All vaccines and administrations for service provided on the same day, must be billed on one claim. Codes
for vaccine administrations must be rolled up and billed on one line with the appropriate number of units.
Number of units will depend on number of vaccines and components given.
If a claim where a billed immunization service is partially paid and partially denied, and either the vaccine or
the administration services must be re-billed, the paid part of the claim must be recouped, and the whole
claim must be rebilled at once. Otherwise, the partial new claim will be denied.
Immunization Administration Codes
There are several immunization administration codes, depending on age of the patient, whether counseling
has been provided or not, and depending on route of administration. There are also codes for the first
vaccine component and for each additional vaccine component. When more than one vaccine is
administered at the same visit, it is imperative that number of immunization administration units matches the
number of vaccine components given.
Administration Coding Example:
A 1-year old boy presents for a preventive visit (99382). In addition, the child’s father is counseled by the
physician on risks and benefits of the Pneumococcal (90670), MMR (90707) and Heamophilus influenza
(90648) vaccines. The father signs consent to administration of these vaccines. A nurse prepares and
administers each vaccine, completes chart documentation and vaccine registry entries, and verifies there is
no immediate adverse reaction.
99382 - Preventative visit, age 1 through 4
90670 - Pneumococcal vaccine
90460 - Administration first component (1 unit)
90707 - Measles, mumps, and rubella (MMR) vaccine
90460 - Administration first component (1 unit)
90461 - Each additional component (1 unit)
90461 - Each additional component (1 unit)
90648 - Heamophilus influenza vaccine
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90460 - Administration first component (1 unit)
When billing VT Medicaid program claims, you MUST use the billing method as explained here.
10.3.28 Independent Laboratory
The referring physician is the physician or practitioner who actually ordered the tests for the member; he or
she must be enrolled as a participating Vermont Medicaid provider. Enter the NPI/taxonomy code
combination of the referring physician in field locators 17a and 17b. The billing provider name and address,
to which payment will be made, must appear in field locator 33 and the NPI number must appear in field
locators 33a and 24j.
The DVHA follows the Medicare billing procedures for physician’s billing for laboratory testing. It permits a
physician to bill Vermont Medicaid for laboratory testing only when the physician or an employee of the
physician performs the test. Physicians who expect to be reimbursed for lab services performed on site
must indicate on the claim that the test was performed on site, by completing field locator 20 on the CMS
1500 claim form, and indicate the CLIA certification is on file with DVHA.
The professional component (modifier 26) is valid only when the test requires interpretation by the billing
physician. The result from the actual testing of a specimen usually requires no interpretation and in some
cases, is done by the lab specialist. The billing of the lab code with modifier 26 is not valid for these
services.
The Clinical Laboratory Improvement Amendments of 1988 (CLIA) require all providers of lab services to
meet quality standards and be certified by the U.S. Department of Health and Human Services. CLIA
applies to virtually all laboratory testing of human specimens.
The DVHA must have documentation of CLIA Certification with each provider enrollment period. Lapsed
certificates will result in claim denials. Immediately forward renewed/current CLIA certificates to DXC upon
receipt.
Providers who perform laboratory services that have not obtained the appropriate CLIA certification are
instructed to contact the Vermont Department of Health, 108 Cherry Street, Burlington, VT 05401 by phone
(802) 652-4145 or fax at (802) 865-7701 for information.
In order to be reimbursed for laboratory services furnished in an office setting, providers submitting claims
for laboratory services are required to have a CLIA certificate on file with DXC. The services being
submitted must be covered by the certificate and within the effective dates. DXC requires a copy of the
most current CLIA certificate used by each individual provider, group or facility be sent directly to DXC
Technology, Provider Enrollment Unit, PO Box 888, Williston, VT 05495. Please be sure to include your
NPI and Taxonomy Code(s) when mailing your copy to DXC.
Additionally, Vermont Medicaid will utilize the QW modifier to indicate a CLIA waived tests following CMS
guidelines for billing waived tests. To determine if your lab service requires at QW modifier please refer to
the list published at: http://www.cms.gov/CLIA/downloads/waivetbl.pdf.
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Lab Handling
Payment for the service of obtaining specimens is included in the reimbursement of the medical visit. For
exceptions to this rule and the corresponding procedure codes, please refer to Specimen Collection Fee.
10.3.29 Injections
Flu Shots
Immunization for flu and pneumonia are available at little or no cost in Vermont via a program of the
Vermont Agency of Human Services Department of Health. See the Vermont Immunization Manual at
http://healthvermont.gov/hc/imm/VermontImmunizationManual.aspx. Members are encouraged to use this
service. Local home health agencies and Area Agencies on Aging will administer flu vaccines in many
locations around the state.
All in-state providers MUST obtain vaccines through the Vermont Department of Health (VDH) Vaccine for
Children Program, for children through age 18. Influenza and H1N1 vaccines may be obtained through
VDH; however it is not a requirement. The SL modifier must be used with an appropriate procedure code
when billing the CPT or HCPCS code to assure correct payment. Report the charge as $0.00 to represent
the free vaccine.
Vaccines provided to adults over 18 or vaccines provided by out of state providers to patients of any age,
do not have to be obtained by the VDH Vaccine Program. The SL modifier will not be required in either of
those circumstances and payment will be based on the current fee schedule.
All vaccine administration fees must be supported with a vaccine code, even when there is no amount to
be reimbursed.
Prescribers are instructed to call (1-844-679-5363) or fax (1-844-679-5366) the Goold Health Systems
Clinical Call Center to find out which drugs require prior authorization regardless of whether the medication
will be billed through the medical or pharmacy benefit. For clinical criteria and either the general or specific
prior authorization forms, visit http://dvha.vermont.gov/for-providers/pharmacy.
Pharmacist-Administered
Flu Shots for Adults Effective September 30, 2011, DVHA-enrolled pharmacies may be reimbursed for
injectable influenza vaccinations administered by pharmacists to adults 19 years and older enrolled in
Vermont’s publicly funded programs. Pharmacists must be certified to administer vaccines in the state of
Vermont and must be in compliance with all Vermont laws governing vaccine administration. Failure to
comply with all Vermont immunization regulations will subject these claims to recoupment. Reimbursement
will be based on either a written prescription or a non-patient specific written protocol based on a
collaborative practice agreement per state law. These orders must be kept on file at the pharmacy. The
billing pharmacy and the ordering prescriber's NPI is required on the claim for the claim to be paid.
Reimbursement and billing: Under this program, pharmacies are reimbursed for the cost of the vaccine and
an administration fee. No dispensing fee is paid for these claims. Pharmacists should bill DVHA using
either the paper CMS-1500 claim form or the 837 electronic CMS-1500 Claim Form. A claim for the vaccine
must accompany a claim for administration; therefore these vaccinations cannot be billed at POS through
the pharmacy benefit. The appropriate billing codes to be used are as follows: Influenza vaccine codes:
90656, 90658 and administration code 90471.
For instructions on billing with a CMS 1500 claim form, see the Provider Manual at:
http://www.vtmedicaid.com/#/manuals
For information on reimbursement please refer to the Fee Schedule on the DVHA website:
http://dvha.vermont.gov/for-providers/claims-processing-1.
If you have additional billing questions, please contact DXC Technology provider services at 800-925-1706.
For other questions regarding this benefit, please contact a member of the DVHA pharmacy unit at 802-
879-5900.
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10.3.30 Inpatient Services
Certain elective procedures also require prior authorization (e.g., hysterectomies, bariatric surgery, etc.).
These are usually requested by the physician but the hospital is always/also responsible for making sure
the DVHA approval is in place prior to the procedure being performed. This pertains to all in-state and out-
of-state providers.
See Section 7 Prior Authorization of Medical Services for a complete listing of in-state and out-of-state
hospital admissions prior authorization and notification requirements. Additional information is also
available at http://dvha.vermont.gov/for-providers.
10.3.31 Lead Screening
CMS has mandated that children ages one through five be screened for lead unless the physician
determines it to be medically inappropriate. The act of obtaining the sample during a well-child or routine
office visit is included within payment for that medical visit. The processing laboratory will bill the proper
CPT code for the actual testing.
10.3.32 Maintenance Drug Prescriptions
When the DVHA is the primary payer; pharmacies are required to dispense designated classes of
maintenance drugs in 90-day supplies after the first fill. When the DVHA is the primary payer, prescriptions
written for maintenance drugs must be rewritten for 90 days for the drug to be covered. The maximum
quantity limit of 102 days still applies. This rule does not apply to members who have other primary
insurance, including Part D.
Maintenance drugs must be prescribed and dispensed for not less than 30 days and not more than 90
days, to which one dispensing fee will be applied. Excluded from this requirement are medications which
the member takes or uses on an “as needed” basis or generally used to treat acute conditions. If there are
extenuating circumstances in an individual case that, in the judgment of the prescriber, dictate a shorter
prescribing period for these drugs, the supply may be for less than 30 days as long as the prescriber
prepares in sufficient written detail a justification for the shorter period. The extenuating circumstance must
be related to the health and/or safety of the member and not for convenience reasons. It is the
responsibility of the pharmacy to maintain in the member’s record the prescriber’s justification of
extenuating circumstances. In these circumstances, regardless of whether or not extenuating
circumstances permit more frequent dispensing, only one dispensing fee may be billed.
For a complete listing of pharmacy related information and the Pharmacy Provider Manual, go to
http://dvha.vermont.gov/for-providers/pharmacy. See DVHA’s Clinical Criteria document for drugs with
other quantity limits at http://dvha.vermont.gov/for-providers/preferred-drug-list-clinical-criteria.
10.3.33 Mastectomy
Mastectomy procedures will be restricted to a diagnoses involving benign and malignant neoplasm of the
breast. When the primary diagnosis is any other, documentation is required to be submitted with the claim
to substantiate medical necessity."
Prior Authorization is not required for reconstructive breast surgery if the primary diagnosis indicates
malignant neoplasm of the breast/breast cancer.
10.3.34 Medical Nutrition Therapy
This service is paid through the enrolled primary care physician, inpatient hospital, outpatient hospital,
registered dietitians (RD) and school health services. Registered Dietitian billing is restricted to three codes
specific to RD services. These services are not reimbursable when billed by a physician.
10.3.35 Multiple Surgery Pricing
Vermont Medicaid will price multiple surgery payments in order of Relative Value Unit and will price all
surgical procedures in decreasing percentages of 100%, 50%, 40%, 30%, 30%...This includes surgical
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procedures billed with multiple units. Any codes that are add-on codes, or Modifier 51 exempt, as defined
by the CPT, will be priced at 100% of the allowed amount.
10.3.36 Naturopathic Physicians
Medically necessary health care services within the Vermont Medicaid benefit package provided by a
Naturopathic Physician (N.D.) are a covered service. N.D.s must be licensed in Vermont and provide
treatment within the scope of their practice as described in Chapter 81 of Title 26 of the Vermont Statutes.
N.D.s having local admitting hospital privileges or a formal agreement with a physician who has local
hospital admitting privileges and arranges 24 hour-a-day/seven days-a-week coverage for their members
may enroll as primary care providers (PCPs) with Vermont Medicaid.
Naturopathic physicians wishing to participate in the PCP in the Primary Care Plus Program, must provide
additional information. Please complete the Agreement for Participation for Naturopathic Physicians form
(inpatient hospital admission information is required).
Please access forms at: http://www.vtmedicaid.com/#/provEnrollDataMaint and mail the completed
Provider Enrollment Application, General Provider Agreement and the Agreement for Participation for
Naturopathic Physicians, along with any additional documentation, to: DXC Technology, Attn: Enrollment
Unit, P.O. Box 888, Williston, VT 05495-0888.
10.3.37 NDC (National Drug Code)
Vermont Medicaid requires the collection and submission of rebates for all drugs dispensed or
administered by providers other than a pharmacy. This allows for the collection of Medicaid drug rebates
from manufacturers on all drugs dispensed in any office setting. The NDC billed to Vermont Medicaid must
be the NDC that was dispensed to the member.
Drugs supplied by manufacturers currently participating in the rebate program will be the only drugs
reimbursed by Vermont Medicaid. A list of these manufacturers, by code and name, can be found at
http://www.vtmedicaid.com/#/resources.
In order to collect rebates from the correct manufacturers, Vermont Medicaid will require data elements at
the detail level in addition to the HCPCS codes. These elements are the 11 digit National Drug Code
(NDC) number, the Unit of Measurement Qualifier code, and the unit quantity. These must be reported on
paper and electronic submissions of all professional claims.
NDC Requirements on CMS 1500 Form
When entering an NDC on your claim form, please enter the following data elements in the following order:
NDC, measurement qualifier code and unit quantity. Do not insert brackets, spaces or dashes. Claims
formatted incorrectly will be denied.
FL 24D: HCPCS code
FL 24D Shaded area: 11 digit NDC number, Unit of Measurement Qualifier,
and Unit Quantity
FL 24G: HCPCS unit
24D CPT/HCPCS Modifier
E
DX
Pointer
F
Charges
G
Days
or Units
[60126598741][UN][1111.234]
J1234 XX
1,2,3
$637.00
5
↑ ↑ ↑
11 Digit NDC Unit of Unit Quantity
5/23/2018 Green Mountain Care Provider Manual 93
Some NDCs are displayed on drug packaging in a 10-digit format. Proper billing of an NDC requires an 11-
digit number in a 5-4-2 format. Converting NDCs from a 10 to 11-digit format requires a strategically placed
zero, dependent upon the 10-digit format. The following table shows common 10-digit NDC formats on
packaging and the associated conversion to an 11-digit format with the proper placement of a zero:
10-Digit
Format on
Package
10-Digit
Format
Example
11-Digit
Format
11-Digit Format
Example
Actual 10-Digit
NDC Example
11-Digit
Conversion
Example
4-4-2
9999-9999-99
5-4-2
09999-9999-99
0002-7597-01
Zyprexa IM
10mg vial
00002-7597-01
5-3-2
99999-999-99
5-4-2
99999-0999-99
50242-040-62
Xolair
50242-0040-62
5-4-1
99999-9999-9
5-4-2
99999-9999-09
60574-4112-1
Synagis
50mg vial
60574-4112-01
10.3.38 Non-Emergency Medical Transportation (NEMT)
Non-Emergency Medical Transportation (NEMT) is a covered service for members enrolled in traditional,
Primary Care Plus (PC Plus) Medicaid and the Dr. Dynasaur programs. NEMT is a statewide service,
providing transports for eligible members to and from medically necessary medical services that are
Medicaid billable. It is provided through personal services contracts between the State of Vermont, Agency of
Human Services (AHS), Department of Vermont Health Access (DVHA) and local public transit brokers.
All providers are required to confirm a member's appointment when verification is requested from a Medicaid
transportation provider. CMS requires transportation providers to verify that transportation is to and from
eligible medical appointments. At this time, the DVHA requires transportation providers to verify 5% of all ride
requests made by members.
For further NEMT information and requirements go to http://dvha.vermont.gov/for-providers/transportation.
10.3.39 Obstetrical Care
Vermont Medicaid covers obstetrical (OB) care (traditional and midwife services) by one of two methods
outlined in the CPT book under the Surgery/Maternity Care & Delivery section and reiterated here in the
Provider Manual. Services can be billed as total OB care (global billing) or partial (non-global billing).
Charges for both Total OB codes and Partial OB codes cannot be billed for the same pregnancy. The
combination of all partial OB charges for a given pregnancy cannot exceed the reimbursement rate for total
OB care.
A total OB procedure code is used when all OB-related care is provided by the same physician/practitioner or
practitioners in the same group practice. A total OB procedure code encompasses the services normally
Measurement
Qualifier *
* Unit of Measurement Qualifier
F2-International Unit
GR-gram
ML-Milliliter
UN-Unit
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provided in uncomplicated maternity cases, which include antepartum care, delivery, and postpartum care.
The date of service for total OB care is the day of delivery.
When different physician groups provide OB care for the same pregnancy, total OB codes cannot be used.
Please note: Confirmation of pregnancy during a preventative or a problem oriented visit is not considered
part of antepartum care and should be reported using the appropriate E/M service code.
Antepartum care includes: “initial and subsequent prenatal history and physical examinations; recording of
weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks
gestation; biweekly visits to 36 weeks gestation; and weekly visits until delivery”
Delivery includes: “admission to the hospital, the admission history and physical examination, management
of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean
delivery”
Postpartum includes: “office or other outpatient visits following vaginal or cesarean section delivery”
Partial OB code billing Instructions:
The combination of all partial OB charges for a given pregnancy cannot exceed the reimbursement rate for
total OB care.
Antepartum Care
Antepartum Care, billing 1-3 visits; use appropriate E/M codes for each visit.
Antepartum Care, billing 4-6 visits; use CPT code 59425 with the range of dates billed as 1 unit.
Antepartum Care, billing 7 or more visits; use CPT code 59426 with the range of dates billed as 1 unit.
Delivery Care
Only one delivery code can be billed for a member in a 9-month date span (with the exception of multiples.
Please see special instructions below)
Postpartum Care
Only one unit of the postpartum care only code can be billed for a member, per pregnancy, using a single
date of service (use the date of the final encounter completing postpartum care). This code includes all after-
delivery E/M visits related to the pregnancy (office or other outpatient visits) following a vaginal or cesarean
section delivery.
New Instructions for OB Code Billing Instructions for ICD-10
Global billing:
The date of service for total OB care is the day of delivery even though it includes antepartum care received
prior to this date and the postpartum check-up performed after the day of delivery.
Non-global billing:
Billing instructions for antepartum care:
Antepartum Care, billing 1-3 visits; use appropriate E/M codes for each visit.
Antepartum Care, billing 4-6 visits; use CPT code 59425 with the DOS of the sixth visit billed as 1 unit.
Antepartum Care, billing 7 or more visits; use CPT code 59426 with the DOS of the last visit billed as 1
unit.
Billing instructions for delivery:
Only one delivery code can be billed for a member in a 9-month date span (with the exception of twin
deliveries. Please see special instructions below). The delivery date is the DOS.
Billing instructions for postpartum care:
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Only one postpartum code can be billed for a member in a 9-month date span. This code includes office
or other outpatient visits following a vaginal or cesarean section delivery. Please use the 6 week check-
up as the DOS.
This code includes all after-delivery E/M visits related to the pregnancy
Special Instructions:
The Fetal Non-Stress Test
1 unit will cover the non-stress test for both twin A and twin B when billed with modifier 22. Notes are not
required when a twin diagnosis is indicated on the claim.
Twin Deliveries
The DVHA will reimburse for the delivery of twins at 100% (twin A) and 50% (twin B) of the prices on file. The
provider should bill both deliveries on the same claim and use a twin diagnosis code for both. One code has
to be a “delivery only” code.
Assist at Cesarean Delivery
A surgical assistant at a cesarean delivery cannot bill the “Total OB” procedure code because the assistant
did not give the prenatal care. To bill for service as the assistant, use the “delivery only” procedure code with
one of the following modifiers:
80-Assistant surgeon (MD or nurse practitioner)
AS-Physician’s assistant assisting at surgery (Only one assistant is covered per surgery).
External cephalic version (ECV) is only eligible for reimbursement for pregnancies at or beyond 36 weeks
gestational age. Notes are required to confirm the service was performed. Only one ECV (successful or not)
is reimbursable per pregnancy.
Abortion
Abortion includes miscarriages (“spontaneous abortion”), missed abortion, and induced abortion.
OB deliveries pertain only to infants who have an Estimated Gestational Age (EGA) of 30 or more weeks
(viability). When the fetus is less than 7 months EGA and a non-induced fetal demise occurs, see procedure
codes for surgical intervention and/or medical visit codes for medical assistance. Do not use “delivery” codes.
Example A
Member goes to Dr. A for 3 visits; Dr. A would bill the appropriate E/M code for each visit with each
applicable date of service.
Member switches to Dr. B for the remainder of her pregnancy. Dr. B sees the member for 6 visits; Dr. B bills
out ONLY code 59425 with range of days and 1 unit. If Dr. B delivers, he would also bill the appropriate
delivery code.
Example B
Member goes to Dr. A for 5 visits; Dr. A bills 59425. Member then goes to Dr. B for one visit; Dr. B will ONLY
bill the E/M code for the visit he provided. Member goes to Dr. C for 8 visits; Dr. C would bill 59426 with
range of days and 1 unit. Dr. C delivers and would bill the appropriate delivery code.
A Member may see more than one attending provider when billing multiple antepartum visits (CPT 59425 or
CPT 59426) within the same billing group/practice. It is up to the practice to determine which attending
provider number to use when submitting the claim.
10.3.40 Midwife Services
A "Licensed Midwife" means anyone who has met the requirements set down by the American College of
Nurse-Midwives and by the North American Registry of Midwives and who meets the eligibility criteria set
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forth in rule. These are the two types of Licensed Midwifes that Vermont Medicaid recognizes and
reimburses:
1. “Certified (Nurse) Midwives” are advanced practice nurses and are licensed independent providers who
possess a degree from a Vermont graduate program and are certified by the American College of
Nurse-Midwives. Nurse Midwives are subject to the nursing and midwifery rules
2. “Licensed (Professional) Midwives” are laypersons certified by North American Registry of Midwives
who possesses a high school degree or its equivalent; subject only to the midwifery rules.
Licensed Certified Nurse Midwives may be enrolled as independent practitioners or physicians may employ
them.
Important Billing Reminder for Licensed Midwives (Nurse and Professional):
Delivery codes are valid only for pregnancies with an estimated gestational age of 30 or more weeks
(viability)
Licensed Midwives (Nurse and Professional) will not be reimbursed for surgery of assistant-at-surgery
charges
See Section 10.3.40 Obstetrical Care for Total OB and Partial OB billing instructions. Total OB codes and
Partial OB codes cannot be billed for the same pregnancy.
When the MD, Licensed midwife (Nurse and Professional), or nurse practitioner monitors labor in the
member’s home (for a planned home birth) but then has to admit the mother to the hospital for delivery, and
the delivering MD is not a member of the same provider group, the initial provider can bill for the prolonged
services in the office or other outpatient setting.
The DVHA will reimburse prolonged services only when a planned home delivery results in a hospital
admission and the delivery is done by a different Medical Doctor/Medical Doctor group (these services are
included in regular OB billing when the providers are of the same billing group).
The billed units must reflect the time spent in face-to-face contact with the member in the home and/or on the
way to the hospital. Each claim will suspend for review. Please submit copies of the provider’s record(s) with
each bill documenting the number of units billed.
Examples
The Licensed midwife (Nurse and Professional) and MD were present in the member’s home to monitor the
labor. Due to a lack of progression and meconium staining in the amniotic fluid, the member was transported
to the hospital and her care transferred to the hospital physician, who delivered the baby. The initial MD was
with the member “for the entire labor, monitoring the baby, the mother and the progress of the labor.”
The documented time shows 5 hours. For these services (which include the midwife’s attendance), the
DVHA can be billed one unit of procedure code 99354 and 8 units of 99355.
The Licensed midwife (Nurse and Professional) monitored the labor in the home for 15 hours, transported
the member by car (1/2 hour) and stayed 4 more hours at the hospital after the transfer. Upon admission to
the hospital, the care was assigned to the hospital physician who delivered the baby by C-section. The
midwife had started an IV of ringers lactate while still at the home. The nurse midwife’s services may be
billed with one unit of 99354 and 29 units of 99355. All care given during the face to face contact, including
the IV insertion and supplies, is included within the reimbursement of these two procedure codes. There can
be no charge for the initial MD/midwives services as of the admission to the hospital since all care at this
point becomes part of the delivery payment.
Summary
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The DVHA will reimburse prolonged services codes only when a planned home delivery results in hospital
admission and the delivery is done by a different MD/MD group (these services are included in regular OB
billing when the providers are of the same billing group.) The billed units must reflect the actual time spent in
face-to-face contact with the member in the home and/or on the way to the hospital. Each claim will suspend
for review, so clear copies of the provider’s records must be submitted with each bill documenting the
number of units billed. The place of service (POS) must be a 12 (home).
Licensed midwives (Nurse and Professional) may receive reimbursement for RhoGAM injections using the
appropriate HCPCS & NDC code with a maximum of one unit. See NDC (National Drug Code).
Use the appropriate office visit and diagnosis codes when a member is seen at the office for a pregnancy
test. If you bill a pregnancy diagnosis for the purpose of testing for a pregnancy that has not yet been
established, your claim will cause subsequent prenatal claims to be denied as it is considered to be one
prenatal visit if a pregnancy diagnosis is recorded on the claim.
10.3.41 Oral Surgery
If oral surgery is billed with a CPT code, follow the physician’s rules for billing and bill on a CMS 1500 claim
form. If oral surgery is billed using ADA codes, follow the dentist’s rules for billing, and bill on an approved
dental claim form.
10.3.42 Over-The-Counter (OTC) Medications
Coverage of Over the Counter (OTC) medications is primarily limited to generics only in categories
determined to be medically necessary. All other OTC products will be excluded from coverage without the
option for a prior authorization request through the Clinical Call Center. The coverage guidelines apply to
Medicaid, Dr. Dynasaur and VPharm. DVHA pays for OTCs only when there is a specific medical necessity,
and requires a prescription for the OTC product. Some OTC medications are already managed on our
Preferred Drug list (PDL) and other restrictions may apply. Though the DVHA has restricted OTC
medications to primarily generics, members will continue to have at least one choice in all medically
necessary drug categories. Please refer to the DVHA website for a list of covered OTC medication
categories at http://dvha.vermont.gov/for-providers/pharmacy. The PDL can be found at
http://dvha.vermont.gov/for-providers/preferred-drug-list-clinical-criteria.
10.3.43 Oximetry Services
When billing any medical visit, the following procedures are considered included within the reimbursement for
the visit:
Ear or pulse oximetry saturation-single determination
Non-invasive ear or pulse oximetry for oxygen saturation; by multiple determinations
Non-invasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring
These services will be denied with EOB 091—Service denied; not reimbursed by Vermont Health Access
Program.
10.3.44 Pharmacologic Management (Psychiatric)
Pharmacologic management is payable only for mental health and developmentally disabled members when
providers must bill using appropriate procedure code with one unit of service per visit, regardless of time
spent.
10.3.45 Physician Visit Limits
Pursuant to Medicaid Rule 7301.1.1, the following physician visit limits apply:
1. Payment for office or home visits is limited to five visits per member, per month.
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2. Nursing facility visits are limited to one per provider per member per
week.
3. Hospital visits are limited to one per day for the same or similar diagnosis for acute care, or after denial of
acute care by utilization review, up to one visit per month for subacute care.
Visits in excess of those listed above may be reimbursed if the services are medically necessary. A medical
exception request documenting the medical necessity must be sent to the DVHA. Forms for prior
authorization are located at http://dvha.vermont.gov/for-providers/forms-1.
Non-emergency (elective) out-of-state medical visits will require prior authorization from DVHA (In network
OOS hospitals are excluded from this requirement). In network referring providers are to submit requests
using the OOS Medical Office Request Form located at http://dvha.vermont.gov/for-providers/clinical-
coverage-guidelines.
Mileage allowances for house calls apply only to the first member. If more than one member is seen during
the visit, no mileage will apply to those members.
10.3.46 Post-Operative Follow-up Visits
For all CPT surgical procedure codes, Medicare has assigned a follow-up/global period of either “000”, “010”
or “090” days. This means that office visits that are related to the procedure are included within the payment
for the procedure and may not be billed during the restricted follow-up period.
10.3.47 Psychiatry/Psychology
If no E/M services are provided, use the appropriate psychotherapy code (90832, 90834, 90837)
Psychotherapy with E/M is now reported by selecting the appropriate E/M service code and
the appropriate psychotherapy add-on code.
The E/M code is selected on the basis of the site of service and the key elements performed.
The psychotherapy add-on code is selected on the basis of the time spent providing psychotherapy
and does not include any of the time spent providing E/M services
Prescribing health care professionals, conducting pharmacologic management, will now use the
appropriate E/M code. When psychotherapy is done during the same session as the pharmacologic
management, one of the new psychotherapy codes should be used along with the E/M code. The
psychiatrist or other qualified health care professional will specify the level of E/M work done and add the
psychotherapy component based on the time spent delivering psychotherapy.
Vermont licensure for CPs (Clinical Psychologists) is limited to the provider’s scope of practice
which does not include prescription and medication management
Providers that are approved to bill E/M series codes are to report this service using the appropriate
E/M series code
Vermont Medicaid enrolls the following provider types for Mental Health service. Proper use of the
below modifiers is required to assure accurate reimbursement. Failure to use the correct modifier for
license type may result in post payment review of your claims
Vermont Medicaid is continuing to require the use of modifier AJ and AH. Modifier AJ is
reimbursed at 76% of allowed amount modifier AH at 93% of allowed amount
Designated Agencies, Specialized Service Agencies and ADAP Preferred provider are not required to
use the modifiers from the below table.
Provider Type
License
Modifier Required
Psychologist -Doctorate Level
Psychologist Doctorate
AH - Clinical Psychologist
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Psychologist -Masters Level
Psychologist – Master
AJ - Clinical Social Worker
Licensed Mental Health Counselor
LMHC
AJ - Clinical Social Worker
Licensed Clinical Social Worker
LCSW
AJ - Clinical Social Worker
Licensed Marriage & Family Therapist
LMFT
AJ - Clinical Social Worker
Licensed Drug and Alcohol Counselor
LADC
AJ - Clinical Social Worker
Physician –Psychiatric
Physician
No Mental Health Modifier
Required
Nurse Practitioner -Psychiatric
Advanced Practice
Registered Nurse
No Mental Health Modifier
Required
Psychiatric Diagnostic Evaluation
A distinction has been made between diagnostic evaluations without medical services and
evaluations with medical services
Interactive services are captured using an add-on code
These codes can be used in any setting
These codes can be used more than once in those instances where the patient and other
informants are included in the evaluation
These codes can be used for reassessments
Psychiatrists and other medical providers have the option of using the appropriate E&M code in
lieu of the 90792
Code Descriptions specifying “With medical services” refers to medical “thinking” as well as medical
activities, such as: physical examination, prescription of medication, and review & ordering of medical
diagnostic tests. Medical thinking must be documented, e.g. consideration of a differential diagnosis,
medication change, change in dose of medication, drug-drug interactions, etc.
Psychotherapy
The new series of psychotherapy codes (90832 – 90838) was established to replace individual
psychotherapy codes (90804 – 90829). Site of service is no longer a criterion for code selection and time
specifications were changed to be consistent with CPT convention.
Psychotherapy codes are no longer site specific
Psychotherapy time includes face-to-face time spent with the patient and/or family member and/or
legal guardian
Time is chosen according to the CPT time rule
Interactive psychotherapy is reported using the appropriate psychotherapy code along with the
interactive complexity add-on code
Group therapy (90853) is limited to no more than 3 sessions per week. Reimbursement is limited
to one session per day, per group and no more than 10 in a group.
Crisis Psychotherapy
Crisis is defined as:
“An urgent assessment and history of a crisis state, a mental status exam, and a disposition. The
treatment includes psychotherapy, mobilization of resources to defuse the crisis and restore safety, and
implementation of psychotherapeutic interventions to minimize the potential for psychological trauma.
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The presenting problem is typically life threatening or complex and requires immediate attention to a
patient in high distress.”
A new subsection, Psychotherapy for Crisis, with guidelines was established to report these services.
These are timed codes and additional instruction on the appropriate use of the new codes is included in the
2013 AMA CPT4 codebook.
90839, Psychotherapy for crisis, first 60 minutes
(CPT Rule applies: 30-74 minutes)
+90840 (add-on), Psychotherapy for crisis each additional 30 minutes
Important Billing Concepts to Consider
CPT Time Rule
“A unit of time is attained when the mid-point is passed”
“When codes are ranked in sequential typical times and the actual time is between two typical times, the
code with the typical time closest to the actual time is used.”
Example: 90832, 90833 is 16-37 minutes
90834, 90836 is 38-52 minutes |
90837, 90838 is 53 minutes and more
Interactive Complexity
A new subsection has been added to the Psychiatry section for reporting interactive complexity. Interactive
complexity is specific and recognized communication difficulties for various types of patients and situations
that represent significant complicating factors that may increase the intensity of the primary psychiatric
procedure.
Add-on Code 90785 is used to report interactive complexity services when provided in conjunction with
psychotherapy codes. See the 2013 AMA CPT4 codebook for further explanation of when and how this
code should be used. The guidelines include a list of requirements or factors to consider when determining
appropriate use of the interactive complexity code.
“Interactive” in previous codes was limited in use to times when physical aids,
translators, interpreters, and play therapy was used
“Interactive Complexity” extends the use to include other factors that complicate the delivery of a
service to a patient and may be reported when at least one of the following is present:
Arguing or emotional family members in a session that interfere with providing the service
Third party involvement with the patient, including parents, guardians, courts, and schools
Need for mandatory reporting of a sentinel event
Impaired patients
Young and verbally undeveloped
When performed with psychotherapy, the interactive complexity component (+90785) relates only to the
increased work intensity of the psychotherapy service, but does not change the time for the
psychotherapy service
Documentation Standards for Mental Health and Substance Abuse Health Records
At a minimum, the documentation in a mental health/substance abuse health record will include the
following core components:
1. Identifying data
Name/unique ID, date of birth, and other demographic information as needed,
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2. Dates of service
Documentation by the primary treatment provider of all dates and the amount of time clinical
services were provided
3. Comprehensive clinical assessment (e.g., biopsychosocial, medical history, etc.)
Evidence that a comprehensive clinical assessment has been completed, with documentation of a
presenting problem and patient placement to support clinical level of care, such as:
a. Outpatient
b. Intensive outpatient
c. Partial hospitalization
d. Residential
e. Inpatient,
Evidence of ongoing reassessment as needed
4. Treatment and continued care planning
Documentation of treatment plan, including the following:
a. Prioritization of problems and needs,
b. Evidence that goals and objectives are related to the assessment,
c. Evidence that goals and objectives are individualized, specific, and measurable, with
realistic timeframes for achievement,
d. Specific follow-up planning, including but not limited to anticipated response to treatment,
additional or alternative treatment interventions, and coordination with other treatment
providers
(e.g., PCP)
5. Progress Notes
Documentation supporting continued need for services based on clinical necessity, including the
following:
a. Dated progress notes that link to initial treatment plan,
b. Updates or modifications to treatment plan,
c. Interventions provided and client’s response,
d. Printed staff name and signature or electronic equivalent.
For additional information concerning DVHA’s Mental Health and Substance Abuse Health Record
Documentation Standards and resources see http://dvha.vermont.gov/for-providers and click on “Clinical
Initiatives”.
Community Mental Health Center Services
Covered services include rehabilitation services provided by qualified professional staff in a community
mental health center designated by the Department of Mental Health. These services may be provided by
qualified mental health providers as identified by the Vermont Department of Mental Health (DMH). For
further information, see the DMH manual at http://mentalhealth.vermont.gov/publications.
10.3.48 Radiology
Radiologic Components
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The professional component of radiologic services must be billed by the physician when those services are
done in a hospital radiology department. The professional component includes any examination of and
discussion with the member, supervision of technologist, interpretation of the results of diagnostic or
therapeutic procedures and consultation with the attending physician. Only a radiologist will be paid for the
radiology professional component. The appropriate CPT procedure code should be used with the modifier
“26” when billing for the professional component.
Technical component includes the services of non-radiologist or non-physician personnel, materials,
facilities, equipment and space used for diagnostic or therapeutic services. The appropriate CPT procedure
code should be used with the modifier “TC” when billing for the technical component.
Total component consists of the professional component and the technical component. The total
component is reimbursable only for diagnostic or therapeutic radiology procedures done in the physician’s
office. The appropriate CPT procedure code without the modifier should be used when a claim for total
component services is submitted to Vermont Medicaid.
The use of modifier 50 (bilateral) on CPT radiology codes (7**** series) is not valid because modifier 50
causes payment to be only 1.5 times the price on file. When the same radiology procedure code is done
more than once on the same date of service and is not done for reasons of comparison, the provider
should bill the appropriate radiology code once only with multiple units. Documentation must be
maintained in the member records substantiating the purpose and number of multiple x-rays. Radiology
services performed for comparison are not reimbursable.
High-tech outpatient elective diagnostic imaging scans require prior authorization from MedSolutions.
Diagnostic Imaging Program Guidelines and other provider resources are available at
http://www.vtmedicaid.com/#/resources
The DVHA implemented a multiple procedure payment structure for CT, CTA, MRI and MRA imaging
procedures. This structure will apply whenever multiple outpatient imaging services using the same or
similar modality (MRI and MRA, CT and CTA) are performed on the same day, by the same provider, on
contiguous body areas.
In these cases, the procedure with the highest intensity will be paid at 100% of the fee schedule rate and
subsequent procedures will be reimbursed at a lower rate. If two procedures are performed, the second
procedure will be reimbursed at 50% of the fee schedule rate. The third and all subsequent procedures will
be paid at 25% of the fee schedule rate. This rate structure applies only to the imaging procedure
component of the claim. The professional (physician) component is not affected by this change.
Providers who choose to bill worker's compensation or accident insurance first, instead of Vermont
Medicaid, will not be eligible for reimbursement if prior authorization is not obtained prior to the service
being rendered.
10.3.49 Smoking Cessation Counseling
Face-to-face smoking cessation counseling is covered for eligible Vermont Medicaid members of any age
who use tobacco. The maximum number of visits allowed per calendar year is 16. This coverage applies
when furnished by (or under the direction of) a physician or by any other health care professional who is
legally authorized to furnish such services under state law and licensure. “Qualified” Tobacco Cessation
Counselors are also allowed, (requires at least eight hours of training in tobacco cessation services from an
accredited institute of higher education).
Providers must code each claim with the correct diagnosis for tobacco use.
Pharmacological Coverage
See the most recent Clinical Criteria document at http://dvha.vermont.gov/for-providers/preferred-drug-list-
clinical-criteria for Smoking Cessation Therapy information, preferred drug list and PA requirements.
10.3.50 Specimen Collection Fee
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Payment for obtaining specimens is included in the reimbursement of the office visit. Physicians may bill
Vermont Medicaid for a specimen collection fee in two situations only; for the collection of blood via
venipuncture or for collection of a urine sample by catheterization. Federal Qualified Health Clinics and
Rural Health Clinics have different guidelines for this process:
Venipuncture (or blood draw fee) and the specimen handling fee are included as part of FQHC
services. They are not considered part of the diagnostic laboratory services.
Blood draws/venipuncture and specimen handling provided by nurses or technicians for services,
such as lab tests and blood draws, do not bill an encounter. These charges are included within the
encounter payment when the service was originally ordered. Clinical Diagnostic Laboratory tests
performed on site should be billed separately as a fee for service.
10.3.51 Sterilizations
Sterilizations of either a male or female member are covered only when the following conditions are met:
1. The member has voluntarily given informed consent and has so certified by signing the Sterilization
Consent Form located at http://www.vtmedicaid.com/#/forms
2. The member is mentally competent
3. The member is at least 21 years of age at the time consent is obtained
4. At least 31 days but not more than 180 days have passed between the date of informed consent
and the date of sterilization except in the case of premature delivery or emergency abdominal
surgery. In those cases, at least 72 hours must have passed between the informed consent and the
operation.
Operations or procedures performed for the purpose of reversing or attempting to reverse the effects of any
sterilization procedure are not covered. Federal law does not permit payment for sterilization of any
members under the age of 21.
10.3.52 Team Care Program
The Team Care Program restricts a member to one physician and one pharmacy. If a member is "locked-
in" to a provider, that provider’s name is available on the Voice Response System and the Vermont
Medicaid website. Claims for services by any provider other than the "lock-in" provider(s) are not
reimbursable by Vermont Medicaid, except in the case of an emergency or when a provider performs a
service by referral of the named provider.
The “lock-in” procedure also applies to a Primary Care (PC) Plus member. The “lock-in” reflects the
member’s choice of primary care physician. This information is also available through the VRS and the
Vermont Medicaid web site.
10.3.53 Telemedicine Services
Telemedicine is defined in Act 64 as “…the delivery of health care services… through the use of live
interactive audio and video over a secure connection that complies with the requirements the Health
Insurance Portability and Accountability Act of 1996, Public Law 104-191. Telemedicine does not include
the use of audio-only telephone, e-mail, or facsimile.” Act 64 is available at:
http://legislature.vermont.gov/assets/Documents/2018/Docs/ACTS/ACT064/ACT064%20As%20Enacted.pdf.
To bill Vermont Medicaid for clinically appropriate services delivered through telemedicine outside a health
care facility or from facility to facility, the following requirements must be met:
Must be a Medicaid-enrolled provider
Billing Rules for Telemedicine:
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1) All providers are required to follow correct coding rules, including application of modifiers, and only
bill for services within their scope of practice that can be done via telemedicine
2) All claims with services billed for telemedicine must have POS 02
3) Providers delivering “live” telemedicine services via interactive audio and video must apply the GT
modifier - CMS and/or Encoder Pro telemedicine codes excluding non-covered services
4) Originating facility site providers (patient site) may be reimbursed a facility fee (Q3014)
a) Facility fees will not be reimbursed if the provider is employed by the same entity as the
originating site.
*DVHA will not reimburse for teleophthalmology or teledermatology by store and forward means.
10.3.54 Topical Fluoride Varnish
Physicians, naturopaths, nurse practitioners and physicians assistants with one of the following specialty
types: general practice, family practice, internal medicine, pediatric medicine, nurse practitioner, family
practitioner, naturopathic physician with childbirth endorsement & without childbirth endorsement and
pediatric practitioner are allowed to administer and bill for Topical Fluoride Varnish treatments for children
ages 0-5.
10.3.55 Vision Care & Eyeglasses
Eye Exams
Reimbursement for eye exams is limited to one comprehensive visual analysis and one interim eye exam
within a two-year period. The quantity limitations for reimbursement of eyeglasses and associated fitting
fees are below. In line with current DVHA policy related to dates of service, providers may bill eyeglass
fitting fees on the day they order the glasses.
Eyeglasses
Eyeglass benefits (frames, lenses, dispensing and repairs) are reimbursed only for Medicaid members
under age 21.
When sending a Medicaid member's eyewear prescription to Classic Optical (the DVHA's sole-source
eyewear provider), please provide the NPI of the ordering/prescribing practitioner. A business, group or
company NPI Number will not be accepted. Classic Optical cannot fill the order without the NPI of the
person giving
the order.
Coverage for eyeglasses is limited to one pair of glasses every two years per member, see exception
noted below. Earlier replacement for any reason restarts the benefit period. Reimbursement for earlier
replacement is limited to the following:
Eyeglasses have been lost or broken beyond repair, or scratched to the extent that visual acuity is
compromised
Change of at least one-half diopter in lens strength.
Exception: Members under the age of six are allowed one pair of eyeglasses every year without obtaining
prior authorization. Clinical best-practice validates annual replacement for children under age 6 years due
to physical growth.
Eyeglasses are provided only under the terms of a contract between the state and the sole source
vendor, Classic Optical Laboratories, Inc. All frames and lenses must be ordered from:
Classic Optical Laboratories, Inc.
P.O. Box 1341
Youngstown, Ohio 44501
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Phone: 888-522-2020
www.classicoptical.com
Business Hours:
8:00 am-5:30 pm EST, Monday through Friday
Providers submitting requests for lost or broken eyeglasses (lenses & frames) are required to
include that information on the order form or add the KX modifier to indicate lost or broken.
Eyeglass cases can be billed only by Classic Optical as part of the sole-source contract.
Procedure Codes - Fitting vs. Repair and Refitting
Fitting of Spectacles CPT code descriptions should be viewed when fitting a new pair of eyeglasses
to the member and if glasses are replaced if lost or broken beyond repair to select the most
appropriate billing code. The claim must indicate the circumstance in form locator 19 on the
CMS1500 or electronically in the Notes section regarding replacements. One fitting fee code
applies, whether one or both eyes are involved.
Repair and Refitting Spectacles codes are used for the in-office repair of eyeglasses. Codes for
Repair and Refitting Spectacles are not applicable when ordering frames, lenses or eyeglasses or
for replacement.
Eligibility
Eligibility verification is the responsibility of the provider and must be verified before an order is sent to
Classic Optical. Providers may check eligibility through web access at http://www.vtmedicaid.com/#/ or call
the Voice Response System (VRS) at (800) 925-1706 (in-state only) or (802) 878-7871.
Prior Authorization (PA)
Medical necessity for special frames or lenses outside of Vermont Medicaid’s sole-source contract requires
that the prescribing optometrist or ophthalmologist seek prior authorization from DVHA. This applies for
new lenses when Classic Optical determines that the member's current lenses cannot be incorporated
safely and reasonably into the special frames.
The following circumstances require prior authorization:
Frame has been outgrown and needs to be replaced within the benefit period
Replacement for a change in Rx (must be at least +/- 0.50 D in at least one eye) within the benefit
period
Replacement of frames or lenses other than those that are broken or lost within benefit period
Scratched lenses to the extent that visual acuity is compromised.
The following benefits require prior authorization
V2025 (deluxe frames)
V2744 (photochromic lens)
V2745 (any other tint added to the lens)
V2762 (polarized lens)
V2199, V2299, V2399, V2799 (miscellaneous vision service)
The Prior Authorization Form is available from
Classicoptical.com or phone 1-888-522-2020
http://dvha.vermont.gov/for-providers/forms-1
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The requesting/dispensing provider's NPI and taxonomy combination must be listed on the Prior
Authorization Form and must match the NPI # and corresponding provider name on the CMS-1500 claim
form. Per federal regulation, do not use the Medicaid ID number.
Prior Authorization change requests must come from the original requesting provider. Any requests to
change or update an original or an existing prior authorization must be in the form of a detailed letter
referencing the PA number, stating the change(s) requested, and explaining why the change is needed. A
copy of the existing PA is not necessary.
Contact Lenses
Prior authorization is required.
Reimbursement may be available from the DVHA for contact lenses for the optimum management
of ocular conditions such as aphakia, keratoconus, or corneal transplant.
A single lens, not a pair, is considered one unit. When a physician supplies two contact lenses to a
member, one for each eye, the procedure code must be billed twice; once with modifier LT and
once with modifier RT.
Cataract Removal
Cataract procedures are reimbursable and prior authorization is not required.
Non-Reimbursable Items:
Oversized frames and lenses
Tints-Unless for ultra violet cataract lens
Additional clinical information is located at
http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines (Vision Care).
See Section 10.3.21 EVALUATION & MANAGEMENT SERVICES for information on billing non-routine
vision office visits.
Section 11 Durable Medical Equipment (DME), Prosthetics, Orthotics & Medical Supplies
This section of this Manual is unique to Durable Medical Equipment (DME), Prosthetics, Orthotics and Medical
Supplies. It contains information concerning billing, payment and specific instructions for completion of the
CMS 1500 Claim Form.
*Please note: when a service or an item is limited to, for example, one per year, a year is defined as 365 days,
unless otherwise specified.
The Vermont Medicaid website, http://www.vtmedicaid.com/#/, will have information regarding DME codes, the
modifiers allowed, unit limitations (i.e. one unit per 365 days) and pertinent prior authorization requirements.
This information will be located under http://www.vtmedicaid.com/#/resources.
DME guidelines are available on the DVHA website at: http://dvha.vermont.gov/for-providers/clinicalcoverage-
guidelines. It is imperative that you review the diagnosis restrictions in these guidelines.
RENTAL REIMBURSEMENT POLICIES
Effective January 1st, 2018 the DVHA has implemented new rental reimbursement policies which will deduct
payments issued for equipment rentals from the payment to purchase that same equipment. In addition, all
rentals will be subject to a 10-month cap on rentals at which time the item will be considered purchased and
paid in full. If the 10 month limit is reached for a capped rental (CR), ownership transfers to the DVHA. All
rentals will continue to be subject, like new and used equipment purchases, to the lesser of billed charges and
rate on file. The implementation of these rental policies is intended to reduce the overpayment of items so that
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the full purchase price of an item is paid, either in monthly rentals or a purchase, but not more than the
purchase price.
The DVHA rental reimbursement policies are specific to DME claims are specific to professional claims (type
‘M’), provider type 009, 014 or 015. Any rental (and must for capped rentals, see details below) are required to
be submitted with an ‘RR’ modifier. Any new or used equipment must be submitted with the appropriate
modifier (NU or UE). If a claim for a non-capped rental code is processed without the ‘RR’ modifier or with the
modifier ‘NU’ or ‘UE’ the indication is that the equipment is purchased. A 14 month historical look back period
will be used to assess the need to reconcile previous rental payments and/or apply the 10 month cap. The
historical look back period will be prospective such that claims with dates of service between 1/1/2018-
1/30/2018 will comprise the first month of historic data on which to the new rental policies will be based.
CAPPED RENTALS (CR)
In an effort to be consistent with Medicare’s requirements, the DVHA will use the Medicare capped rental code
list and, like Medicare, when renting, will only allow a RR rental modifier. The exception to this rule is the small
sub-set of codes included within the capped rental category with a rent OR purchase option. This change has
been in effect since 1/1/2018.
For a full list of codes, please see Medicare’s DMEPOS fee schedule here:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-
Schedule.html.
DVHA will not institute variable rental pricing depending on the month of rental and instead, will use Medicare
guidance to set the rental rates to equal 1/10 of the purchase price of the capped rental.
Specifically, CRs will be paid in the following manner:
Like Medicare, only the RR modifier can be billed for these codes
For CR items not classified as "Power Wheel Chairs", the purchase price reflected on the fee
schedule will be equal to the RR * 10. The DVHA RR rate in months 1 – 10 will be equal to the
Medicare Rate (Medicare RR Rate * 10)/10 but not adjusted differentially in months
1 -3 and 4-13 as Medicare does.
For CR items classified as "Power Wheel Chairs", the purchase price will be equal to the Medicare
RR / 0.15 to reflect that Medicare RR rates for these items represents 15% of the purchase price.
The DVHA RR rate therefore, will be equal to the purchase price/10. DVHA will not adjust the RR
rate in months 1 -3 and 4 -13 as Medicare does. At this time, DVHA will follow Medicare's
classification of what is considered "Power Wheel Chairs". A list of these codes will be provided
upon request.
At month 10, payments are capped and DVHA assumes ownership.
RENTAL/LOANED
The DVHA will rent equipment when it is expected to be cost-effective, medically necessary and short-term.
The Department of Vermont Health Access has transitioned most, but not all rental reimbursements to rental
(RR) logic. This logic calculates the rental modifier (RR) to allow 10% of the purchase price (rate on file) for the
procedure code. Providers are required to pro rate rentals when the rental period is less than 30 days.
Certain DME requires prior authorization to begin monthly rental. Rental equipment that does not initially
require prior authorization will require prior authorization when the rental time is to exceed three months.
If an item’s code does not specify Rental, use modifier RR. The rental will be priced at a monthly amount and is
to be billed at a monthly amount unless stated otherwise.
The DVHA provides forms and tools to facilitate the prior authorization process. These forms and tools are
available for the following DME items: wheelchairs, speech generating devices, TENS units, and custom
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orthotics, and can found at: http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines. Use of these
designated forms/tools is recommended to ensure that all required information is available for review by the
DVHA Clinical Unit.
Effective for dates of service on or after May 1, 2018 providers may bill for supplies up to the DVHA quantity
limit during the rental period for: E0445, E0465, E0466, E0470, E0471, E0565, E0600, and E0601. As part of
the DVHA’s annual Fee Schedule maintenance, the DVHA will solicit public comment on revisions to the code
list. When billing for supplies on member owned equipment, the supplier must state on the claim or medical
necessity form that the related piece of equipment is not being rented (e.g., “CPAP is not being rented” or “…is
owned by the member”).
When DME is loaned (provided without charge) or rented, as part of an equipment trial and the equipment is
then approved for purchase: The claim for the equipment is required to include the UE modifier when the
equipment is to be retained by the member and was not new at the time of the loan or initial rental. Only if the
equipment was new, or if the used equipment is being replaced by new equipment, should this modifier be
omitted. The provider is to document the DME serial number in the member’s record.
FACE-TO-FACE REQUIREMENTS
As of 4/1/2018, the Agency of Human Services (AHS) will require physicians enrolled in Vermont Medicaid to
document that a face-to-face encounter occurred for the initial ordering of specified durable medical
equipment and supplies. This change assures compliance with federal requirements at 42 CFR §440.70(f).
This requirement only applies to durable medical equipment, supplies, and services that are also covered by
Medicare as found at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-
Programs/Medicare-FFS-Compliance-Programs/Medical-
Review/Downloads/DME_List_of_Specified_Covered_Items_updated_March_26_2015.pdf.
Face-to-face Requirement also includes power wheelchairs.
The face-to-face encounter must be no more than 6 months prior to the start of service. Documentation of
the face-to-face visit is a required component of the physician’s order for services.
The following elements must be present in the documentation:
The face-to-face encounter must be related to the primary reason the patient requires services.
The face-to-face encounter may be conducted in person or through telemedicine.
The ordering physician must document:
That the face-to-face encounter is related to the primary reason the patient requires services,
That the face-to-face encounter occurred within the required timeframes,
The practitioner who conducted the encounter, and
The date of the encounter.
The non-physician practitioner performing the face-to-face encounter must communicate the clinical findings
of that face-to-face encounter to the ordering physician. Those clinical findings must be incorporated into a
written or electronic document included in the beneficiary’s medical record. Qualified Providers
The following non-physician practitioners may perform the face-to-face encounter:
A nurse practitioner, clinical nurse specialist, or certified nurse midwife working in collaboration with
the ordering physician,
-or-
A physician assistant under the supervision of the ordering physician.
REIMBURSABLE/NON-REIMBURSABLE SERVICES
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Reimbursable/non-reimbursable information and prior authorization information is available on the
Department of Vermont Health Access website at http://dvha.vermont.gov/for-providers/claims-processing-1 .
DME guidelines, including wheelchairs and other mobility devices, augmentative communication devices,
prosthetics, orthotics and medical supplies are available at http://dvha.vermont.gov/for-providers/clinical-
coverage-guidelines. See Medicaid Rules, 7504, 7505, 7506, 7507, and 7508; at
http://humanservices.vermont.gov/on-line-rules.
PAYMENT DVHA PRIMARY/MANUAL PRICING
When the DVHA is the primary payer, payment amounts for DME (including augmentative communication
devices and closed-circuit TV purchased from the Vermont Association for the Blind and Visually Impaired-
VABVI), orthotics, prosthetics and medical supplies will be calculated in the following manner:
1. When the rate on file is a specific dollar amount, the DVHA pays the lesser of the actual charge or the
rate on file;
2. If the rate on file is $0.00 and the PAC is 5 or 6 (manually Priced) and if there is a Manufacturer’s
Suggested Retail Price (MSRP) for the item, the DVHA pays the lesser of the actual charge or 85% of
the MSRP for all items;
3. If the rate on file is $0.00 and the PAC is 5 or 6 (manually priced) and if there is no MSRP, the DVHA
pays the lesser of the actual charge or 1.67 times the invoice or online sales aggregator cost.
The following pricing documentation requirements apply to MSRP (Manufacturer’s Suggested Retail Price) or
Invoice and must be billed on paper with the MSRP or invoice attachment:
The option to submit either the MSRP or Invoice is allowed. The MSRP or invoice must be submitted
in its entirety. If any information (including pages) are missing or lines are marked out or whited out
the claim will be denied.
o Online sales aggregator (such as Amazon) receipts are accepted only if the item is purchased
by the DME supplier and not available from any other vendor. All below pricing documentation
requirements still apply to online sales aggregator receipts.
All discounts and totals must be clearly documented and disclosed.
The MSRP sheet, invoice, or online sales aggregator receipt must be dated within 1 year from the
date of service indicated on the claim. If the MSRP, invoice, or online sales aggregator receipt date
exceeds one year, the claim will be denied.
The item(s) on the MSRP sheet, invoice, or online sales aggregator receipt must match the item(s)
that are being billed on the claim. The applicable correct code must be written next to the item(s) on
the MSRP, invoice, or online sales aggregator receipt. If the code for the item(s) are not documented
on the MSRP, invoice, or online sales aggregator receipt the claim will be denied. Item(s) applicable
to laterally must be clearly documented with the correct modifiers for right or left next to applicable
code. This applies to both MSRP, invoice, and online sales aggregator receipts.
Documentation that states “Quote”, “Remittance Advice”, “Estimate”, “Superbill”, etc., and handwritten scripts
or prescription papers, will result in claim denial. Exceptions are made for custom made items only, at the
discretion of the DVHA.
Vermont Medicaid is payer of last resort. The DVHA does not reimburse when a primary insurance has been
billed incorrectly and/or has insufficient information/coding.
PAYMENT-DUAL ELIGIBLE/MEDICARE PRIMARY
When Medicare is the primary payer, the provider must accept assignment of the claim in order to receive
any DVHA payment. This applies to all claims for services and items. See Section 6.6 Medicaid & Medicare
Crossover.
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If the claim is submitted to Medicare on an assigned basis, when the DVHA receives the crossover claim, it
will pay the coinsurance and deductible amounts due.
In order to assure access, the DVHA has created five exceptions to the above procedure. The exceptions are
limited to claims for:
systems
For these items, a provider may submit a prior authorization request to the DVHA asking for a medical
necessity determination and provisional [or conditional] authorization for Medicaid coverage. When a
provider submits a request for prior authorization of a wheelchair, seating system, cushions that are part
of a seating system or seat lift for a dually eligible member, the DVHA will review the request for medical
necessity and for sufficient information to support pricing. If the DVHA determines that the request is
medically necessary, it will provisionally [conditionally] approve the request. The claim must then be
submitted to Medicare.
If Medicare approves, the DVHA will pay the difference between the Medicare paid amount and the Vermont
Medicaid allowed amount. If Medicare denies, the DME provider must submit proof of denial including the
explanation of benefits (EOB) information. Then, Medicaid will review the request and, if approved, will pay
the Vermont Medicaid allowed amount.
In addition, when the primary wheelchair is found by the DVHA to need repair, modification, and/or battery
replacement; and Medicare denied or downgraded the purchase of the primary chair; or the DVHA
determines that Medicare is unlikely to accept new documentation of medical necessity for the primary chair;
the DVHA may approve the request with a prior authorization with specific wording that these items may be
billed directly to Vermont Medicaid.
To assure access, the DVHA will consider creating additional exceptions for items of DME which cost over
$100.00. Any request to add a service or item to the list (of exceptions for access reasons) must demonstrate
to the satisfaction of the commissioner of the DVHA that the item is inaccessible statewide due to the
Medicare payment level.
PRESCRIBING PROVIDER
Doctors of Medicine (M.D.s), Doctors of Osteopathy (D.O.s), Nurse Practitioners (NPs), Physician Assistants
(PAs) and certain other licensed practitioners may write prescriptions for DME and medical supplies.
Audiologists may prescribe hearing aids. Physical and occupational therapists may prescribe wheelchairs
and seating systems (MD endorsement of the prescription is required). Augmentative communication devices
require a prescription by a speech/language pathologist with MD endorsement of the prescription. All written
prescriptions must be legible, contain the required information and applicable dates.
The physician/nurse practitioner prescriber must be enrolled as a participating Vermont Medicaid provider
and the prescribing/attending NPI number on the CMS 1500 claim must be valid. When billing for services to
Vermont Medicaid, the prescribing/referring physician NPI number should appear in field locator 17a or b
when billing on a CMS 1500 Claim Form. The billing provider name and address must appear in field locator
33 and the NPI number must appear in field locators 33a and 24j.
DME providers must keep prescriptions on file for five years for members in DVHA programs.
DATES OF SERVICE
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The billed date of service on the claim must be the date that the item was dispensed /delivered to the
member. The date of service may not be earlier than the date the item was dispensed/delivered. There are
two exceptions:
When the billings are for monthly DME rentals, the dates of service should span the rental month;
When the member becomes ineligible after a customized item has been ordered but before it can be
dispensed, the date may be the actual date of the order.
Custom order items include: the evaluation, fitting, casting and taking of measurements in the allowance of
the item. There will be no separate payment for these services. Providers may not seek additional
reimbursement.
PROCEDURE CODES & PRICING
A list of procedure codes for DME equipment, orthotics, prosthetics and supplies is available in electronic
form which includes the code, rate on file, whether the code requires prior authorization, and other
pertinent information. Fee Schedules are at http://dvha.vermont.gov/for-providers/claims-processing-1.
Items on the fee schedule with a PAC of 5 or 6are manually priced. DME Restrictions, located at
http://www.vtmedicaid.com/#/resources, inform DME providers of current restrictions on certain DME
items/supplies.
Changes in the price on file will be reflected on the Fee Schedule. The DVHA reserves the right to change
the price on file for any item or service without prior notice. For these reasons providers should be careful
to retain the changes noted in the RAs and updated versions of the fee schedule. This file is for the
convenience of the provider. Although the DVHA will attempt to keep the file 100% accurate, the actual
price recorded in the computer system for payment is the only accurate price for the applicable date of
service.
For items not prior priced, when a vendor is requesting special pricing consideration, or manual pricing, an
invoice including the manufacturer’s price to the vendor and any discounts, must be submitted with the
claim. Individual Consideration/Manual Pricing The rate on file for certain procedure codes does not have a
specific dollar amount because no one amount is appropriate (ex. miscellaneous codes). In these cases,
the allowed amount will be calculated in accordance with the section titled “Payment, DVHA
Primary/Manual Pricing”. This process is often called “manual pricing”.
REPAIRS
Repairs to covered items are covered when the repairs are necessary to make the items useful, are not
included in a warranty, have been ordered by a physician, and do not total more than 50% of replacement
cost. Suppliers must check the procedure code listing in the Fee Schedule for the specific code
representing the repair being considered to determine the need for prior authorization. Payment will not be
made for repairs to equipment for use in skilled nursing homes, ICFs, ICF-MRs, mental or general hospitals
or psychiatric facilities.
Mileage
Mileage incurred by providers associated with the repair of a DME item, is reimbursable by Vermont
Medicaid and cannot be charged to the member. The mileage is billed with procedure code K0739. The
mileage should be determined from their closest facility, if the vendor is providing multiple deliveries; the
only portion that will be reimbursed is the portion of the mileage specific to the Vermont Medicaid member.
If the member is able to take the DME item that needs to be repaired to the vendor that is the expectation.
Charges for delivery of a DVHA reimbursed DME item, cannot be made to Vermont Medicaid or to a
member.
SUPPLY RETURNS
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DME purchased by Vermont Medicaid for eligible members, remains the property of Vermont Medicaid. If a
member no longer has a medical need for equipment purchased by Vermont Medicaid, the member should
be instructed to contact the DVHA Clinical Review Unit at: 802-879-6396. DME suppliers should also
contact this number if Vermont Medicaid owned DME is returned to them.
DURABLE MEDICAL EQUIPMENT (DME) RECYCLING
DME vendors who provide the following equipment to Medicaid members are required to affix a sticker on
the item at the time of delivery that identifies Medicaid as the owner of the device
Manual Wheelchairs
Power Operated Vehicles
Power Wheelchairs
Standers
Lifts
Hospital Beds
Rehab Shower Commode Chairs
Augmentative Communication Devices/Speech Generating Devices.
Medicaid provides the stickers with contact information regarding return of the device when it is no longer
required by the member. The sticker must be applied to an area of the device that is protected from daily
wear and tear but is visible without excessive effort. The accompanying Durable Medical Equipment
Ownership, Operation, and Maintenance Agreement form must be signed by the vendor and the member
or the member’s legal guardian. The completed form must be kept on file at the vendor’s office and be
available for inspection by DVHA, and a copy provided to the member for their records. The DVHA may
request a copy of the completed form as part of the clinical review process for items which require prior
authorization. The Durable Medical Equipment Ownership, Operation, and Maintenance Agreement form is
available on the DVHA website at http://dvha.vermont.gov/for-providers/forms-1. Contact DVHA at 802-
879-6396 to obtain stickers and forms.
Exception: equipment for dual eligible members whose primary insurance covered the cost of the device
does not require a sticker.
REHABILITATION EQUIPMENT REVIEW
The DVHA contracts with the Veteran’s Administration to provide second opinion consults for select
rehabilitation equipment that requires prior authorization. Members may be contacted by a VA
representative to arrange this consultation. Consultations will take place at the member’s home or at a VA
clinic. Members and providers will be notified when the DVHA has required a consult.
DME BILLING INFORMATION - EQUIPMENT SPECIFIC (ALPHABETICAL)
11.15.1 Adaptive Weighted Eating Utensils
Vermont Medicaid allows for the reimbursement of “Adaptive Weighted Eating Utensils” when medically
necessary for individuals who have significant tremors that interfere with daily activities (i.e., ability to feed
self).
These utensils must be ordered by a physician, must be medically necessary, supplied by a
DME/Pharmacy or DME vendor, and billed using non-specific HCPCS code A9999. Only one of each type
of utensil is allowed. The billing/supplying provider must submit an invoice with the claim in order to be
reimbursed.
11.15.2 Apnea Monitors
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Vermont Medicaid covers the rental of an Apnea Monitor for use in the home when medically necessary, as
per the DVHA Clinical Criteria, however purchase is not covered. The DVHA Clinical Guidelines for Apnea
Monitors is available online at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines. For
members under the age of one year (infants), prior authorization is not required. When the condition(s)
which caused a need for the monitor have been resolved or are stable for two to four months, monitor
rental must be discontinued.
11.15.3 BICROS/CROS (Contralateral Routing of Sound)
Vermont Medicaid does not cover CROS (Contralateral Routing of Sound) and BICROS hearing aids and
related services.
Per review of current medical literature, the effectiveness of these aids is unproven. Related current
HCPCS procedure codes are in the range of V5170 -V5240.
11.15.4 Blood Pressure Monitors
Vermont Medicaid covers two types of blood pressure monitors for home use when medically necessary
per the online DVHA guidelines at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines.
Providers are required to follow national correct coding requirements.
Non-Continuous Automatic Blood Pressure Monitors consist of a digital gauge and a stethoscope in one
unit and are powered by batteries. The cuff may be inflated manually or automatically depending on the
model.
Vermont Medicaid covers only the purchase of these monitors; coverage is not available for rental. The
Medical need must be clearly documented in the patient’s medical records. HCPCS has a specific billing
code for these common BP monitors.
Continuous Automatic Blood Pressure Monitors Measures blood pressure continuously in real time and
comes with a recording device. They are non-invasive and can be used with a cuff or finger sensor.
VT Medicaid covers only the rental of these monitors; coverage is not available for purchase. Prior
authorization is required. VT Medicaid will accept the miscellaneous durable medical equipment HCPCS
code, since a specific code is not yet in place for these special monitors.
Vermont Medicaid does not cover new or refurbished Dinamap Monitors.
11.15.5 Breast Pumps
Providers and suppliers are responsible for ensuring medical necessity and should refer to the Coverage
Guidelines for Electric Breast Pumps on the DVHA website http://dvha.vermont.gov/for-providers/clinical-
coverage-guidelines.
DME providers are allowed to bill using the mother’s name and UID; a diagnosis must be specified for the
baby.
11.15.6 Continuous Passive Motion (CPM) Devices
Per section 30.2.1 of CMS claims processing manual, CPM devices are to be billed as one billed unit = one
day of rental and are limited to a maximum of 21 days of rental. The DVHA follows these CMS guidelines,
“Continuous passive motion devices are covered for patients who have received a total knee replacement.
To qualify for coverage, use of the device must commence within 2 days following surgery. In addition,
coverage is limited to that portion of the 3 week period following surgery during which the device is used in
the patient’s home. Contractors make payment for each day that the device is used in the patient’s home.
No payment can be made for the device when the device is not used in the patient’s home or once the 21
day period has elapsed. Since it is possible for a patient to receive CPM services in their home on the date
that they are discharged from the hospital, this date counts as the first day of the three week limited
coverage period.”
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The current HCPCS code for the knee joint is E0935RR. Modifier RR is required since CPM devices are
only rented (never purchased). Each billed unit is reimbursed at a daily rate.
For consecutive, multiple days of rental, the claim must be billed with a date range and the corresponding
multiple units (total number of days).
Please note that HCPCS code E0936RR, a CPM device for joints other than the knee, is covered only with
prior authorization from the DVHA.
11.15.7 CPAP & BIPAP
Prior authorization is not required for the rental of CPAP & BIPAP devices. The purchase of CPAP and
BIPAP devices does require prior authorization. Prior authorization requests must include appropriate
documentation of medical need to support current best practice guidelines. (See McKesson Smart Sheets
on our website, www.vtmedicaid.com/#/, navigate to the Transactions menu and choose the appropriate
login [Trading Partners use “Login”, Web Services use “Login - UAT])
11.15.8 Crutches
A physician’s order for crutches usually refers to common, wooden, underarm crutches. If other types are
dispensed by the DME supplier, the medical necessity form must be specific as to the type ordered and
why the common wood crutches are not sufficient.
11.15.9 Enteral Nutrition
Vermont Medicaid allows a 10 day overlap in dates of service for enteral nutrition codes. This overlap will
allow for delivery or shipping of refills. The supplier must deliver the enteral nutrition no sooner than 10
days prior to the end of the usage for the current product. The DVHA Clinical Guidelines for enteral
nutrition is available online at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines.
11.15.10 Glucometers
The basic glucometer does not require prior authorization. The prescribing provider’s medical necessity
form must document that the member is a diagnosed diabetic.
Glucometers with special features (such as voice response) require prior authorization from the
Department of Vermont Health Access. The prescribing provider’s medical necessity form must document
that the member is a diagnosed diabetic. Information on the special feature(s) of the unit, why the unit is
medically necessary and pricing information is required.
The Department of Vermont Health Access limits the quantity of diabetic supplies for eligible Vermont
Medicaid members (such as glucose meters and test strips). Extra equipment and supplies require prior
authorization.
Vermont Medicaid will reimburse pharmacies only for the following meters and the test strips for those
meters:
FreeStyle® Lite, FreeStyle Flash®, FreeStyle Freedom®, Precision Xtra™, One Touch® Ultra® 2, One
Touch® UltraMini™ and One Touch® Ultra® Smart.
All other meters and test strips will require a prior authorization.
11.15.11 Hospital Beds
All semi-electric and electric/electronic hospital beds for use in the home require prior authorization from
the DVHA. This includes rentals and all other modifier-code combinations. Regardless of the procedure
code/modifier to be used, prior authorization must be obtained prior to placement of the bed in the home.
The only exception is the “Immediate Needs” exception as explained in Section 7 Prior Authorization. This
prior authorization requirement is not new, as semi-electric and electric/electronic hospital beds have
required prior authorization for many years.
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11.15.12 Incontinence Supplies
Incontinence supplies are covered under HCPCS procedure codes. Dispensing providers are required to
maintain a completed and current medical necessity form on file for each item, justifying the medical need
and quantities used.
11.15.13 Medical Supplies
Medical supplies will be covered when:
Prescribed by an enrolled physician or other authorized practitioner
Used in a member’s home due to a post-surgical or chronic condition
Billed first to Medicare when the member is eligible
Billed first to any other insurer or applicable organization
Prior authorization is obtained for excess quantities
Medical supplies may be dispensed in two month time periods. The “from” and “to” dates of service on the
CMS 1500 Claim Form must accurately reflect the two month date span.” Providers are not allowed to
dispense more than a two month supply.
11.15.14 Oxygen
The rental of respiratory equipment is on a monthly basis and includes all supplies necessary to use the
piece of equipment. Supplies in excess of the monthly amounts are covered only when prior authorization
from the DVHA has been granted. (This includes changes of supplies related to infection control means).
11.15.15 Peak Flow Meters
Members with a diagnosis of asthma or reactive airway disease may obtain Peak Flow Meters (e.g.,
Access, MiniWright, Pulmograph) from any qualified provider (physician or DME).
11.15.16 Special Needs Feeder Bottles
HCPCS procedure code S8265 is accepted by Vermont Medicaid to bill for the Haberman Feeder (special
needs bottle with nipple) when medically necessary for dysphasia due to cleft lip/palate. When the cause of
the dysphasia is other than cleft lip/palate or the bottle is not Haberman, unlisted procedure code A9999 is
allowed.
All special needs feeder bottles are reusable, must be ordered by a physician, and supplied by a
DME/pharmacy vendor. Quantity is limited to 10 bottles with nipples per six months. Prior authorization is
not required. The medical need must be clearly documented in the patients’ medical records and an invoice
is required with each claim submission.
11.15.17 Speech Augmentation Devices
Effective 6/01/2012, the Department of Vermont Health Access (DVHA) will begin covering iPad/iPod
devices as dedicated speech generating/augmentative communication devices for VT Medicaid members
whose severe communication impairment prevents writing, telephone use, and/or talking. DVHA does not
cover this or any other device to be used solely for educational, vocational, or avocational purposes.
Multiple devices are not covered.
Because the device supplier is not a standard Durable Medical Equipment (DME) provider, Speech
Language Pathologist (SLP) performing the evaluation will be considered the provider of record. The
prescribing SLP is required to be an enrolled Vermont provider. If the member has more than one SLP, for
example a school and a medical model SLP or an expert consultant, and one SLP is an enrolled VT
Medicaid provider, SLP collaboration will be allowed during the evaluation/ prescribing process; the
enrolled SLP submits the request.
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Note: There has been no change to Medicaid Rule and no change to the prior authorization process for all
other types of augmentative communication devices. Prior authorization is required for all augmentative
communication devices.
A packet that includes the DVHA evaluation and prescription form, the DVHA Ownership form, Rule related
to speech generating devices and a procedure checklist is available at http://www.dvha.vermont.gov/for-
providers/clinical-coverage-guidelines. See the link titled Augmentative Communication Device Packet.
11.15.18 Splints
When a miscellaneous splint code must be used because there is no included code available, providers
must submit a request for prior authorization and a completed Medical Necessity Form. Claims must also
be submitted with an invoice and an invoice for identification and cost.
11.15.19 TENS/NMES
TENS and NMES units must have a trial period of up to three months to determine effectiveness for the
member. Purchase is to be considered only when the continuing medical need is documented and benefit
is proven. Documentation by the physical therapist and/or physician must indicate the length of the trial
period and the reasoning to support the effectiveness for each individual member.
The DVHA provides forms and tools to facilitate the prior authorization process. These forms and tools are
found at: http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines. Use of these designated
forms/tools will ensure that all required information is available for review by the DVHA Clinical Unit.
11.15.20 Tracheostomy Care Kits
Tracheostomy care kits are not approved unless a compelling clinical case can be established and prior
authorization is obtained. The necessary supplies for tracheostomy care come in bulk quantities and
providers are advised to furnish bulk supplies when appropriate. All these supplies have individual
procedure codes.
11.15.21 Ventricular Assist Devices
Vermont Medicaid’s coverage of Ventricular Assist Devices is based on the CMS National Coverage
Determination 20.9, entitled “NCD for Artificial Hearts and Related Devices”. Hospital and physician
providers are referred to the current CPT and HCPCS manuals for proper coding.
11.15.22 Wheelchairs & Seating Systems
The purchase and rental of wheelchairs requires prior authorization. Wheelchairs and seating systems are
covered under various procedure codes (see current HCPCS manual). Refer to the Fee Schedule at
http://dvha.vermont.gov/for-providers to determine the procedure codes that require prior authorization. To
obtain prior authorization and individual consideration pricing, providers are required to submit a completed
medical necessity form and pricing information to the clinical staff at the DVHA. When a member is also
covered by Medicare, see Section 12.4 General Hospital Billing Information.
The DVHA provides forms and tools to facilitate the prior authorization process. These forms and tools are
found at: http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines. Use of these designated
forms/tools will ensure that all required information is available for review by the DVHA Clinical Unit.
Vermont Medicaid follows Medicare’s lead in requiring that certain wheelchairs must come from a supplier
employing a RESNA-certified Assistive Technology Professional (ATP) who is directly involved in the
wheelchair selection for the member. An ATP cannot review and sign off of the work of an individual who is
not an ATP. The ATP must submit documentation that clearly demonstrates their in-person presence at the
clinical evaluation. The wheelchairs that require ATP assessment are Group 2 single- or multiple-power
option power wheelchairs, All Group 3, Group 4 and Group 5 power wheelchairs, power assist devices,
ultra-lightweight manual wheelchairs, and tilt-in-space wheelchairs.
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All suppliers who have obtained their ATP certification should sign all documentation regarding the above
wheelchairs with their ATP designation. All ATP certified suppliers must send a copy of their certification to
Vermont Medicaid Enrollment department on an annual basis to demonstrate that they have kept their
certification current.
11.15.23 Wheelchair Repairs
All repairs on wheelchairs less than one year old require prior authorization from the DVHA. The DVHA
expects that these chairs would still be under the manufacturer’s warranty and therefore any repairs,
regardless of the dollar amount, require prior authorization. For wheelchairs over one year old and not
under warranty, prior authorization is required only for repairs greater than $300.00.
Requests for prior authorization for wheelchair repairs must include a completed Medical Necessity form in
addition to the following:
The date the wheelchair was purchased/delivered
When the chair is less than 4 years old, the cost of repair vs. cost of replacement
Equipment guarantees, warranty and denial of third party coverage
The condition of the existing equipment
Durable Medical Equipment (DME) providers who service wheelchairs may make repairs to wheelchairs
provided to a Medicaid member by another DME provider, if the initial provider has gone out of business or
the device records are unobtainable (for example, the records of the Scooter Store). In these instances,
DME providers are allowed to make repairs to the device in order to assure the safety and independence of
the Medicaid member. If there is any concern that the device is not medically appropriate to the medical
needs of the member, an assessment by a physical or occupational therapist is advisable. The Department
of Vermont Health Access website provides access to the following information regarding repairs:
Medicaid guidelines:
http://dvha.vermont.gov/for-providers/dme-repairs-guidelines050313.pdf.
Medicaid Rule (section 7506.4): http://humanservices.vermont.gov/on-line-rules/dvha.
Assistive Technology Suppliers (ATS)
Vermont Medicaid follows Medicare’s lead in requiring that certain wheelchairs must come from a supplier
employing a RESNA-certified Assistive Technology Supplier (ATS) who is directly involved in the
wheelchair selection for the member. This applies to the following wheelchairs: Group 2 single- or multiple-
power option power wheelchairs, any Group 3 or Group 4 power wheelchair or a push-rim power assist
device for a manual wheelchair. All suppliers who have obtained their ATS certification should sign all
documentation regarding the above wheelchairs with their ATS designation. All ATS certified suppliers
must send a copy of their certification to Vermont Medicaid Enrollment department on an annual basis to
demonstrate that they have kept their certification current.
It is understood that RESNA will be changing the Supplier certification to a Practitioner certification in the
near future. Providers should send a copy of all updated certificates to the DVHA.
CMS 1500 PAPER CLAIM BILLING INSTRUCTIONS/FIELD LOCATORS
Multiple Page Claims
When billing a multiple page claim, you must indicate "page x of y" in Box 19, "Local Use" of the CMS-1500
claim form. To indicate the conclusion of the entire claim, field 28 of the last page of the claim must also
include the total billed amount.
Example: page 1 of 3 (1st page of claim), 2 of 3 (2nd page of claim) & 3 of 3 (3rd page of claim).
Field Locators
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All information on the CMS 1500 Claim Form should be typed or legibly printed. Only the 02-12 version of
this form is accepted for processing. The field locators listed below are used by DXC when processing
Vermont Medicaid claims. The field locators designated by an asterisk (*) are mandatory; other field
locators are required when applicable. The field locators not listed below are not used in the Vermont
Medicaid program and do not need to be completed.
FIELD LOCATOR
REQUIRED INFORMATION
1. CARRIER IDENTIFICATION
Check the Medicaid box
1a. INSURED’S ID NUMBER*
Enter the Vermont Medicaid ID number as
shown on the member’s Member ID card.
2. PATIENT’S NAME*
Enter the member’s last and first name.
10. CONDITION RELATED TO*
Check appropriate box to indicate:
a. If condition is related to employment
b. If condition is related to an auto accident
c. If condition is related to any other type of
accident.
If yes is checked in any of these boxes, enter
the accident date in field locator 15.
11. INSURED’S POLICY NUMBER
If the member has other health insurance
(excluding Medicare), enter the applicable
policy number.
a. Enter the insured’s date of birth in MMDDYY
format; check the appropriate box to indicate
insured’s sex.
b. Enter the insured’s employer or school
name.
c. Enter the name of the other health insurance
carrier
11b. OTHER CLAIM ID
(DESIGNATED BY NUCCU)
Property casualty payers (e.g. automobile,
homeowner’s, or worker’s compensation
insurers and related entities are to use qualifier
“Y4” and the Agency (property casualty) claim
number as the identifier. Enter qualifier to the
left of the vertical, dotted line and the identifier
to the right. For workers compensation and
property casualty enter the claim number
assigned by the payer (if known).
11d. IS THERE ANOTHER HEALTH
BENEFIT PLAN*
Check the appropriate box. If yes, complete
fields 9 a-c. Health benefits provided under
Green Mountain Care are not considered other
insurance. Other insurance only pertains to a
private health insurance carrier.
14. DATE OF CURRENT ILLNESS,
INJURY, OR PREGNANCY
Enter the first date of present illness injury, or
pregnancy. For pregnancy, use the date of last
menstrual period. Use qualifier “431” - Onset of
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Current Symptoms or Illness or “484” – Last
Menstrual Period (LMP)
15. OTHER DATE (ACCIDENT
DATE)
If your response indicates a ‘yes’ in field
locators10b or 10c, enter the date of the
occurrence and qualifier “439”.
17. NAME OF REFERRING
PROVIDER OR OTHER SOURCE
Enter the name (First, Middle Initial, Last)
followed by the credentials of the professional
who referred/ordered the service or supply. If
multiple providers apply, enter one
provider/qualifier in the following order:
1) DN – Referring Provider
2) DK – Ordering Provider
3) DQ – Supervising provider
Exception: Professional/Professional Crossover
Claims require the Ordering qualifier “DK” to be
used 1st when the provider in Field 17 is an
Independent Lab, Independent Radiology,
DME Supplier, Prosthetics/Orthotics or Sole
source Eye Glass provider.
17a.
Enter the other ID number of the referring,
ordering, or supervising provider. Use the
appropriate qualifier to indicate what the ID
number represents; enter in field immediately
to the right of 17b. Refer to http://nucc.org/ for
list of valid qualifiers. Entry must support
information entered in field 17. If applicable,
field is required.
17b. NPI*
Enter the referring, ordering or supervising
provider’s NPI. Entry must support information
entered in field 17. If applicable, field is
required.
19. LOCAL USE
Use this field to explain unusual services or
circumstances and to indicate "page x of y" of a
multiple page claim.
21. ICD Ind.*
Enter “9” for ICD-9 diagnosis codes. ICD-10
codes are not valid until 10-1-15; enter “0” for
ICD-10.
21. DIAGNOSIS CODE(S)*
Enter the appropriate IDC-9-CM or ICD-10
diagnosis code that relates to the service
rendered. You may use up to twelve diagnosis
codes.
24a. DATE(S) OF SERVICE*
Enter the date of each service provided. If the
From and To dates are the same, the To date
is not required.
24b. PLACE OF SERVICE*
Enter the appropriate two digit place of service
code.
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24c. EMG
Enter ‘1’ to indicate if the service provided was
the result of an emergency. *This field is
mandatory only if emergency services were
provided.
24d. PROCEDURE CODE*
Enter the appropriate procedure code to
explain the service rendered.
24e. DIAGNOSIS POINTER*
Enter the appropriate diagnosis ‘pointer’ that
relates to the service rendered from field
locator 21. NOTE: The pointer character has
changed from numbers to letters.
24f. CHARGES*
Enter the usual and customary charge for the
service rendered.
24g. DAYS OR UNITS*
Enter the number of days or units of service
which were rendered.
24h. EPSDT/FAMILY PLAN
Enter one of the following Vermont Medicaid
EPSDT and Family Planning indicators:
1-Both EPSDT and Family Planning
2-Neither EPSDT nor Family Planning
3-EPSDT Only
4-Family Planning Only
24j. ATTENDING PROVIDER*
Enter attending physician’s NPI. Enter the
billing provider NPI for independent labs and
DME suppliers.
If Atypical, enter the 7-digit Vermont Medicaid
ID number in the shaded area.
26. PATIENT’S ACCOUNT NUMBER
Enter the account number you have assigned
to the member. DXC can accept up to 12 digits;
alpha, numeric, or alpha/numeric in this field.
This information will print on the Remittance
Advice summary for your accounting purposes.
28. TOTAL CHARGE*
Add the charges from field locator 24f for each
line and enter the total in this field.
29. AMOUNT PAID*
Enter the amount paid by other health
insurance coverage (exclude Medicare
payments). If this field is completed, field
locators 11a, 11b and 11c must also be
completed.
Enter spend down if applicable. Documentation
must be attached if the services are not
covered by the primary, or if the payment by
the primary is $3.00 or less.
31. SIGNATURE
Enter the provider’s signature or facsimile, or
signature of the provider’s authorized
representative. Enter the date of the signature.
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33. BILLING PROVIDER*
Enter the payee provider name and address
(Individual provider format: last name, first
name)
33a. BILLING PROVIDER’S NPI*
Enter the billing provider’s NPI.
33b. BILLING PROVIDER’S
TAXONOMY
Enter the billing provider’s taxonomy code
when applicable. If Atypical, enter the 7-digit
Vermont Medicaid ID number in the shaded
area.
Section 12 UB04 Claim Submissions
REIMBURSABLE SERVICES
Hospital Inpatient
Reimbursable services include: medically necessary care in a semi-private room; private room and intensive
care when medically necessary; nursing and related services; use of hospital facilities, supplies, appliances
and equipment; blood transfusions; therapeutic services; drugs furnished by the hospital; rehabilitation
services; diagnostic services.
See Section 7 Prior Authorization for Medical Services
Hospital Outpatient
Reimbursable services include the use of facilities in connection with accidental injury or minor surgery,
diagnostic tests, rehabilitative therapies and emergency room care.
Pre-certification review of hospital admissions for dental procedures is not required. When submitting claims
use the appropriate dental HCPCS coding (D…).
Medicare restricts certain medical services that should be only performed in an inpatient hospital setting.
These services are not eligible for reimbursement when provided by a physician in an outpatient setting. A
list of Medicaid Outpatient MUE of Zero procedures (Inpatient only list) is available at
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-
Correct-Coding-Initiative.html; see the links under Medicaid NCCI edit files.
Home Health
Reimbursable services include nursing care services when the services are related to the care of patients
who are experiencing acute or chronic periods of illness if ordered by and included in the treatment plan
established by the physician.
Reimbursable services include physical, occupational and speech therapy services. Therapy services must
be directly related to an active treatment plan, of a level that a qualified therapist is required, and reasonable
and necessary to the treatment of the patient’s condition.
Reimbursable services also include Services of a home health aide.
Home Health Hospice
Reimbursable services include: nursing, Home Health Aide, homemaker, rehabilitative therapy, social
service, nutrition services, bereavement assessment and counseling, drugs, equipment, medical supplies,
inpatient care and respite services in the home.
Vermont Medicaid pays a Per Diem rate.
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Beginning January 1, 2016, a service intensity add-on (SIA) payment was authorized under the ‘FY 2016
Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements” published on
August 5, 2015. CMS implemented payments to reflect changes in resource intensity in the provisions of
care services during hospice care.
Assistive Community Care Services
Reimbursable services include: case management, personal care services, nursing assessment & routine
tasks, medication assistance, on-site assistive therapy and restorative nursing.
Choices for Care
1. Enhanced Residential Care Services include: personal care, meal preparation, medication
management, nursing overview, activities, 24-hour supervision, and laundry/housekeeping.
2. Long Term Care Services include: personal care, meals/nutritional services, 24-hour skilled nursing,
rehab & therapy, activities, 24-hour supervision, social services, laundry/housekeeping.
3. Home Based Waiver Services include: case management, personal care, respite or companion care,
adult day services, personal emergency response systems.
REIMBURSEMENT POLICY
The Fee Schedule contains a complete list of services that are reimbursable by Vermont Medicaid.
Implementation of OPPS pricing has not changed the Vermont Medicaid policy regarding non-covered
services.
Providers are allowed to compliantly bill the correct monthly code that meets the definition of the actual
services provided for members subject to partial eligibility in any given month. However, providers may only
bill the dates of service in which the member is actively eligible for Medicaid.
Inpatient services will be paid according to DRG payment methodology.
Vermont-based Relative Weight Information is available at http://www.vtmedicaid.com/#/resources
Outpatient services will be paid according to OPPS methodology. Go to
http://www.vtmedicaid.com/#/resources for a listing of revenue codes that are required to be billed with a
HCPCS/CPT code. The full fee schedule for hospitals is also listed. The number of units billed on a detail line
with the revenue code will represent the number of units for the HCPCS code.
DRG Hospital Reimbursement-Vermont Medicaid Ineligibility:
With the DRG reimbursement methodology in effect, any claims for members who become ineligible for
Vermont Medicaid during the duration of an inpatient stay must be billed to any third party liability provider
prior to billing Medicaid/DXC in its entirety. DXC will prorate these claims based on member eligibility and
partially reimburse for the days the member was eligible for Vermont Medicaid.
Providers are instructed to bill the inpatient stay, including the Vermont Medicaid ineligible days for
reimbursement, then balance bill the member for the remainder. Vermont Medicaid will not reimburse for
days which the member was ineligible, thus it becomes the member’s financial responsibility.
PATIENT SHARE (APPLIED INCOME) REPORTING
The DXC claims processing system captures changes made to patient share amounts, the highest paid
providers and when the patient has moved to a new facility. Providers can submit electronic replacement
claim adjustments, for any claim that had deducted a different patient share amount, or if you are now the
highest paid provider or if you are no longer the highest paid provider. Providers can also submit electronic
adjustments when the patient was discharged to a new facility and no longer owes their patient share to the
previously admitted facility. DXC will generate a monthly report detailing these changes; we will adjust these
claims. However, to receive your corrected payment quicker, we recommend you submit electronic
adjustments.
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The DCF District office will send the facility a copy of the notification sent to the members. This notification
includes the amount of the patient’s share, if any, that the member must apply toward the cost of his or her
care. Patient Share obligations will be automatically deducted from Vermont Medicaid claims starting with the
first claims of the month.
GENERAL HOSPITAL BILLING INFORMATION
12.4.1 Bilateral Billing Procedures
CPT codes that are not defined as bilateral but are performed bilaterally must be billed on one detail, using
modifier 50 with 1 unit. Billing on one detail will result in the 150% reimbursement. Modifier 50 is not to be
used on claims submitted for bilateral radiology services.
12.4.2 In-Network & Extended Network Hospitals
In-Network Hospitals are subject to the same Vermont Medicaid policy as are those located within the
geographical confines of the state of Vermont. Their physicians must be enrolled in Vermont Medicaid. A
complete list of Green Mountain Care In-Network & Extended Network Hospitals is available at
http://dvha.vermont.gov/for-providers/green-mountain-care-network.
Out-of-state hospitals not designated as an In-Network Hospital must bill using the attending provider’s NPI
number in field locator 76, when the attending provider is not enrolled with Vermont Medicaid.
12.4.3 Inpatient/Outpatient Overlap Examples
The general rule is when the patient does not leave the hospital campus going from the outpatient to
inpatient setting, then all of the outpatient charges should be rolled into the inpatient claim and there should
be no separate outpatient claim. The following scenarios are to assist you in billing for out/inpatient overlap
claims.
A patient comes into the ER Friday at 10:00 pm; patient is seen and stays in the ER for 8 hours while
tests and consults are performed. On Saturday morning, the physician feels it is necessary to admit
that patient as inpatient.
When a patient receives continuous outpatient care and then is admitted as an inpatient, all of the
outpatient charges should be rolled into the inpatient claim.
A patient comes into the ER Thursday at 8:00 pm and is admitted as an outpatient in the observation
room. By Friday pm, the physician determines it is best to admit that patient as an inpatient.
When a patient is in the observation room, then transferred to an inpatient status, the admission date
is the date of service the patient was admitted into the inpatient room. All of the charges associated
with the observation room should be rolled into the inpatient claim.
A patient comes in as an outpatient on Thursday am for services and leaves, then later in the day, is
admitted as an inpatient
Some hospitals may treat the outpatient and inpatient stay as one event and bill all charges on the
inpatient claim. Other hospitals may treat these as two separate events since the patient left after the
outpatient and bill one outpatient and one inpatient claim. Either method is acceptable.
A patient comes in at 10:00 pm on Tuesday for ER services and leaves. Wednesday morning the
patient is admitted as inpatient.
These services are billed as two separate claims, one outpatient and one inpatient, as they are
different service events.
A patient is discharged on Tuesday am, but is readmitted Tuesday pm.
The services from the second admission are added to the first admission; the claim will be inclusive
of all inpatient days.
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A patient is discharged on Tuesday am but comes in for outpatient services
Tuesday pm.
These are billed separately, one inpatient claim and one outpatient claim, as they are different
service events.
12.4.4 Inpatient Claims: No Medicare Part A; Has Medicare B Coverage
When a Vermont Medicaid member has Medicare part B and no Medicare part A coverage, providers are
instructed to bill as follows:
1. Days not covered under Medicare part A must be billed to Medicare B for payment of covered
ancillary charges. Claims will crossover to Vermont Medicaid for payment of coinsurance and
deductible.
2. Add together Medicare’s part B payment, Medicare contractual adjustment amount on part B EOMB
and Vermont Medicaid’s crossover payment (part B) in field locator 54 (Prior Payments) of the UB-04
claim form.
3. Submit your claim and all attachments to your Vermont Medicaid Provider Representative.
(See http://www.vtmedicaid.com/#/manuals and click the Provider Representative Map link).
DVHA does not recognize Provider Liable charges, and therefore the charges are not to be deducted from
the billed amount. Do not indicate Provider liable charges in field locator 54 of the UB-04 Claim Form.
12.4.5 Inpatient Claims: Medicare Part A Exhausts or Begins During the Inpatient Stay
When a Vermont Medicaid member has Medicare part B coverage and Medicare part A has exhausted,
providers are instructed to bill as follows:
1. Bill part A charges to Medicare. Claim will crossover to Vermont Medicaid for payment of deductible
and/or coinsurance.
2. A claim for Inpatient dates of service not covered under Medicare part A must be billed to Medicare B
for payment of covered ancillary charges. Claim will crossover to Vermont Medicaid for payment of
coinsurance and deductible.
3. The inpatient claim for the entire stay should be billed to Vermont Medicaid with “Medicare benefits
exhausted or began on mm/dd/yy” indicated in field locator 80 on the UB.
4. Add together the Medicare B payment, the Medicare B contractual adjustment, and the Vermont
Medicaid crossover payment. Indicate this total amount in field locator 54a on the UB. Do not indicate
any payment by Medicare A.
5. Attach both the part A and B EOBs. On part A EOMB, write “Medicare benefits exhausted or began
on mm/dd/yy”. The charges will not match on part B EOMB. Sign and date part A EOMB.
6. Submit your claim and all attachments to your Vermont Medicaid Provider Representative. (See
http://www.vtmedicaid.com/#/manuals and click the Provider Representative Map link)
If an inpatient claim is submitted to Medicare as primary payer is denied by Medicare because the patient’s
Medicare covered benefits are exhausted, DVHA will pay the exhausted day(s) claim based on DRG
Payment methodologies for the patient’s Medicaid covered services.
If a patient becomes Medicare eligible during an inpatient stay, Medicare will pay Medicare covered days
as the primary payer. The claim will crossover to Vermont Medicaid for payment of deductible and/or
coinsurance. DVHA will pay an inpatient claim for the Medicaid covered days as a separated DRG
payment for the patient’s Medicaid covered services and DVHA will pay a crossover claim for the
coinsurance and deductible for the Medicare covered days.
12.4.6 Inpatient Claims: Medicare Primary but Medicaid Eligibility Termed During Stay
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When a Vermont Medicaid member has Medicare A but their Medicaid is termed during the stay, providers
are instructed to bill as follows:
1. Bill part A charges to Medicare
2. The inpatient claim for the entire stay should be billed to Vermont Medicaid.
3. If the patient is eligible for the first day of service the Medicare A deductible will be paid. Complete the
Medicare Attachment Summary. This claim can just be submitted directly to DXC Technology.
4. If the patient is eligible with Vermont Medicaid for co-insurance days, you must attach the Medicare A
EOB. On the Part A EOB write Medicare co-insurance start date is mm/dd/yy, write the co-insurance
due and sign and date the part A EOMB.
5. Submit your claim and all attachments to your Vermont Medicaid Provider Representative. (See
http://www.vtmedicaid.com/#/manuals and click the Provider Representative Map link).
12.4.7 Interim Inpatient Claims
Inpatient acute care hospitals that have a long term patient may bill interim claims in at least 60-day
intervals. Subsequent bills must be in the electronic adjustment bill format. Each bill must include all
applicable diagnoses and procedures. Indicate in the note field: long term inpatient stay greater than 60
days.
1. Type of bill 112 – interim bill-first claim use patient status – still a patient.
2. Type of bill for subsequent claims will be 117 - electronic replacement claim. Use Patient status - still a
patient or a valid patient status – discharge code.
Type of bill for subsequent claims will be 117 - electronic replacement claim. Patient status will be either
patient status 30, or a discharged patient status code.
12.4.8 Present on Admission (POA) - Inpatient Admissions
The present on admission indicator (POA) will be required for all inpatient admissions. Vermont Medicaid
will follow Medicare’s guidelines. The indicator options are: Y (Yes), N (No), U (Unknown), W (Not
Applicable). If exempt from POA reporting leave the field blank. The POA indicator is the eighth digit and is
required on all diagnoses codes listed on the UB 04 (principal field 67 and secondary field 67 A through Q).
This is not required for the admit diagnosis (69). For electronic claims using the 837 Institutional, submit the
POA indicator in HI01-9 of each appropriate HI segment. POA is always required first, followed by the
principal diagnosis. The last secondary diagnosis indicator is followed by the letter Z to indicate the end of
the data element. e.g., POAYNUW1YZ
A list of diagnosis codes exempt from requiring the POA indicator can be located at
http://www.vtmedicaid.com/#/resources
12.4.9 Short Stays
Short stays (defined as one calendar day) apply when a patient is admitted and discharged from the same
acute care facility on the same calendar day, see below examples.
Example: Patient is admitted 5:00 am on 12/4/07 and released 11:30 pm on 12/4/07. This is a same-
day stay.
Example: Patient is admitted at 10:00 pm on 12/4/07 and released at 7:00 am on 12/5/07. This is not
a same day stay.
Effective for inpatient claims with a date of service on or after 10-1-2014, if a claim has a discharge status
code (07) and the length of stay is less than the assigned DRG geometric mean length of stay as identified
by Medicare, the claim will also be considered a short stay.
Short Stay claims will be paid the lesser of the cost of the case or the DRG payment.
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12.4.10 Same/Next Day Readmission Policy
Effective for inpatient claims for dates of service on or after 10-1-2014, DVHA will not reimburse separate
DRG payments for two separate inpatient claims when the patient’s subsequent claim’s admit date is on
the same or next day after their original claim’s discharge date, both claims are for the same facility, and
both claims are for the same or a related condition.
Condition code B4 applies to inpatient admissions with a date of service on and after October 1, 2014,
when a beneficiary is readmitted to the same hospital on the same or next day after a previous discharge
for symptoms unrelated to, or not for evaluation and management of, the prior stay’s medical condition.
Condition code B4 will allow the separate episode of care by indicating it is unrelated to the first admission.
The code B4 is to be used only when appropriate and in addition to any other applicable condition codes.
For additional information and specific details pertaining to the proposed Inpatient Same/Next Day
Readmission Policy, please refer to: http://dvha.vermont.gov/administration/draft-versions-of-state-plan-
changes.
12.4.11 Subacute Care
Swing bed hospitals should bill revenue code 16X on a separate claim from the acute care episodes
(use appropriate discharge code) waiting for placement hospitals should bill revenue code 19X on the
same claim as the acute care episodes.
Payment to hospitals for subacute care is made either for swing bed care or while a patient is waiting
placement in a nursing facility. Vermont approved swing bed facilities are eligible for swing bed payments
but not waiting placement payments.
The Vermont Medicaid benefit package includes short-term Nursing Facility services based on a
physician’s order with documentation of medical necessity limited to not more than 30 days per episode
and 60 days per calendar year. As of November 1, 2014, individuals are not required to submit a Choices
for Care application for short-term swing bed placements. For a stay greater than 30 days per episode
or a cumulative stay greater than 60 days per calendar year, a Choices for Care Long-Term Care
application is required.
Medicare part B must be billed for those services usually billable. On the Medicare B EOMB, write:
“Member is not eligible for Medicare A, ancillary charges billed to Medicare B & Vermont Medicaid.
Charges do not match. Medicare B and Vermont Medicaid payment combined in field locator 54.”
Sign and date the Medicare B EOMB.
The following hospitals have been approved to offer swing bed services:
Vermont: Northeastern VT Regional, North Country, Porter, Grace Cottage, Gifford, Mt Ascutney, Copley,
Springfield.
New Hampshire: Upper CT Valley, Littleton, Valley Regional, Weeks
Hospitals not authorized to bill swing beds may bill for waiting placement for those days after it is
determined that a patient no longer requires acute care. If the patient continues to be hospitalized while
awaiting placement in a nursing facility and no bed within the area is available, the hospital must be
actively seeking placement. Payment is the same as a swing bed day.
12.4.12 Transfer Cases
Transfer cases are defined as patients who initiate an inpatient stay in one hospital and are
discharged/admitted from one acute care facility to another.
The receiving hospital will be paid under normal DRG payment logic.
The transferring hospital will be paid the lesser of the cost of the case or the DRG payment
(including any eligible outlier payment).
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Claims will be considered under the transfer methodology when an inpatient claim has a discharge status
code of either 02, 05, 06, 62, or 65. When the transfer status code is 02, the claim will automatically fall
under the transfer payment methodology.
Effective for inpatient claims with a date of service on or after 10-1-2014, when the transfer status code is
either 05, 06, 62, or 65, and the assigned DRG falls within the list of DRGs that Medicare considers to be
post-acute, the claim will fall under the transfer payment methodology.
12.4.13 Outpatient Services Rendered During an Inpatient Stay
Member is admitted to Hospital A for inpatient care. Member is transferred to Hospital B for outpatient
services not able to be provided by Hospital A, and then Member is transferred back to Hospital A to
complete their inpatient care. Hospital B is to bill Hospital A for the outpatient services provided. Hospital A
is to bill Medicaid for the inpatient stay and will be paid under the normal DRG logic.
OUT-PATIENT/INPATIENT HOSPITAL SERVICES
12.5.1 Cardiac Rehabilitation
Cardiac rehabilitation is billable under revenue code 943. One unit is equal to one day regardless of the
number of encounters.
Effective for date of service May 16, 2012 and thereafter, cardiac rehabilitation is limited to 36 sessions
within a 36 week timeframe. An additional 36 sessions may be approved by the DVHA Clinical Unit when
the claim includes the appropriate notes and meets the required criteria.
12.5.2 Dialysis
The DVHA has established a reimbursement policy for billing End Stage Renal Disease outpatient
treatment services. This reimbursement method is excluded from OPPS pricing; providers identified as free
standing dialysis centers are reimbursed under this method. Only the revenue codes listed below are
reimbursable. All other billed revenue codes will be denied as incidental.
Revenue codes 821, 831, 841 or 851, Hemodialysis - requires HCPCS code 90999 be billed. This
service is reimbursed at a per diem rate of $151.32
Revenue code 304, Lab services, non-routine dialysis - requires an appropriate HCPCS code be
billed. Reimbursement is 62% of the Level III price on file for the HCPCS code.
Revenue code 636, separately-payable drugs except EPO - is reimbursed with the appropriate
HCPCS and NDC coding (when applicable). Pricing is the current Level III price on file for the
HCPCS or NDC code billed on the claim.
Revenue codes 634 and 635 EPO - are reimbursed when billed with the appropriate HCPCS and
NDC coding. Pricing is the current Level III price on file for the HCPCS or NDC code billed on the
claim.
Revenue code 780, Telemedicine - is reimbursable when billed with the appropriate HCPCS code.
Pricing is the current Level II price on for the HCPCS code billed on the claim.
12.5.3 Inhalation Therapy
Vermont Medicaid will cover oxygen needed intermittently after a member has been discharged from acute
care. Payment will be made to the hospital for this outpatient service.
12.5.4 Hospital Clinical Laboratory Tests
Packaged Clinical Laboratory Procedures
Lab related charges must include the corresponding CPT or HCPCS code with the laboratory revenue
code on the UB-04 claim form.
Medicaid packages some Clinical Laboratory procedure codes when they are billed with a primary service
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on a hospital outpatient claim.
The general rule for OPPS payment methodology is that laboratory tests should be reported on a 13X bill
type. There are limited circumstances described below in which hospitals can bill separately for laboratory
tests on a 14x bill type.
Laboratory tests may be separately payable under the following limited exceptions;
the laboratory test is the only service provided to that member on that date of service -or-
the patient is neither an inpatient or outpatient of a hospital (the member is not physically present at
the hospital), but has a specimen that is submitted for analysis -or-
the laboratory test is on the same date of service as the primary service, but is ordered for a
different purpose than the primary service by a practitioner different than the practitioner who
ordered the primary service.
It is the hospital’s responsibility to determine when laboratory tests may be separately billed on the 14X bill
type under these limited exceptions.
Clinical Laboratory Tests Reimbursed Separately
Effective for claims submitted on or after 7/1/2014, CMS has created a new modifier, L1, to be used on the
13x bill type when non-referred clinical laboratory tests are eligible for separate payment under the
following two exceptions:
A hospital collects specimen and furnishes only the outpatient labs on a given date of service; or
A hospital conducts outpatient lab tests that are clinically unrelated to other hospital outpatient
services furnished the same day. “Unrelated” means the laboratory test is ordered by a different
practitioner than the practitioner who ordered the other hospital outpatient services, for a different
diagnosis.
A third exception is allowed for non-patient (referred) clinical laboratory specimens. Providers are to
continue billing these outpatient lab tests separately on a type of bill 14x; do not use the L1 modifier.
For additional information, please refer to CMS publication: http://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1412.pdf.
12.5.5 Observation Rooms
Vermont Medicaid is packaging observation services with OPPS primary procedures. There are no
exceptions for certain conditions as there are in Medicare. Charges for observation however will be
included in the determination of whether or not the claim is eligible for an outlier payment.
Alternatively, Vermont Medicaid will pay for observation separately when there is NO primary procedure.
Vermont Medicaid will pay the observation line on a claim provided that the G0378 HCPCS appears on the
labor room or observation room revenue code detail line and the number of hours in observation is
indicated in the units field. The DVHA will pay up to 24 hours of observation per stay at $35.00 per hour
with a maximum reimbursement benefit of $840.00 per claim. Lab details as well as other CPT/HCPCS for
which there is a separate OPPS fee assigned but are not designated as primary procedures in the OPPS
will be paid separately.
12.5.6 Private Room
Private rooms are allowed only if certified medically necessary by a physician to avoid jeopardizing the
health of the patient or to protect the health and safety of other patients.
12.5.7 Provider Based Billing
Effective for claims with dates of service 7/1/2016 and after, DVHA will no longer reimburse for the 51x
clinic revenue code series. These revenue codes (510-519) indicate clinic charges for providing diagnostic,
preventative, curative, rehabilitative, and education services to ambulatory patients.
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The following codes will also no longer be reimbursed as of 7/1/2016 when submitted on an outpatient
claim as these codes represent professional services provided in an office or clinic setting: G0463, 99201-
99205, 99211-99215 and 99381-99397.
Hospital-owned practices may continue to bill on both a UB-04 (facility) claim along with a CMS-1500
(professional) claim, as appropriate. The professional claim must be billed with the appropriate outpatient
place of service code if there is a corresponding facility claim being billed.
When hospital outpatient services are split billed on both a CMS-1500 and UB-04, the office place of
service should not be used on the corresponding professional claim. The office place of service should only
be used when the professional and facility charges are submitted together on the professional claim, with
no corresponding facility claim being billed.
12.5.8 Hospital Inpatient Billing Instructions/Field Locators
Admission Indicator
The billing field locator 14 requires one of four codes. It is the decision of the Admitting Physician when
there is a question as to which admission indicator code to use.
Attending Physician
The attending physician, whether the physician or practitioner who actually performs the services for the
patient or the referring or prescribing provider, must be enrolled as a participating Vermont Medicaid
provider. When billing Vermont Medicaid on the UB-04 Claim Form, the attending physician’s NPI (with
Taxonomy code when applicable) must appear in field locator 76.
Billing/Supplying Provider
The billing/supplying provider name and address on your enrollment application must appear in the field
locator 1 and the actual billing NPI (with taxonomy code when applicable) to which payment will be made
must appear in field locator 56. If an atypical provider, use the Vermont Medicaid number in locator 57C.
Nurse-Midwife Services
The nurse-midwife provider number should be entered in field locator 76 on the UB-04 claim form. The
provider number of an associated physician should NOT be used as the attending.
Field Locators
All information on the UB-04 Claim Form should be typed or legibly printed. The fields listed below are
used by DXC when processing Vermont Medicaid claims. The fields designated by an asterisk (*) are
mandatory; other fields are required when applicable. Only the fields listed below are used in the Vermont
Medicaid Program; other fields do not need to be completed.
FIELD LOCATORS
REQUIRED INFORMATION
1. UNLABELED FIELD*
Enter the Hospital name and address as it
appears on the Vermont Medicaid Provider
Enrollment form.
2. UNLABELED FIELD
Enter “Vermont Medicaid Hospital Inpatient”
3a. PATIENT CONTROL #
For accounting purposes, enter the patient
control # in the field locator. The number may
consist of up to 24 characters, alpha/numeric.
This information will appear on the Remittance
Advice (RA).
3b. MEDICAL RECORD #
Enter patient’s medical record #.
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4. TYPE OF BILL*
Enter the code indicating the specific type of bill
for Inpatient. The sequence is as follows:
1. Type of facility
1-Hospital
2. Bill Classification
1-Inpatient
3. Frequency
1-Admit through discharge claim
2-Interim-first claim
3-Interim-continuity claim
4-Interim-last claim
6. STATEMENT COVERS PERIOD
Enter the from and through service dates
8b. PATIENT’S NAME*
Enter the patient’s last name, first name and
middle initial.
10. BIRTHDATE
Enter the date of birth
12. ADMISSION DATE
Enter date of inpatient admission
13. ADMISSION HOUR*
Enter the hour in which patient was admitted
14. ADMISSION TYPE*
Enter the code indicating the priority of the
admission:
1-Emergency
2-Urgent
3-Elective
4-Nursery
16. DISCHARGE HOUR
Enter the hour in which the patient was
discharged.
17. STAT*
Enter the two digit code indicating the patient’s
status as of the ‘through date’ of the statement
period.
18-28. CONDITION CODES*
Enter code to identify if condition is related to
the following
02- Condition is Employment Related
A1-EPSDT Related Services
A4-Family Planning Related Services
C1-PSRO Approved as Billed
C5-PSRO Post-Payment Review
31-34. OCCURRENCE CODE &
DATE*
Enter one of the following two digit accident
codes, and the corresponding occurrence date,
if applicable or 52 if no other applies:
01-Auto Accident
02-Auto Accident/No Fault Insurance Involved
03-Accident/Tort Liability
04-Accident/Employment Related
05-Other Accident
06-Crime Victim
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11-No Accident/Onset of Symptoms or Illness
42-Date of Discharge
50-Medical Emergency-Non-accidental
51-Outpatient Surgery Related
52-Not an Accident
39. VALUE CODES AMOUNT*
Enter the number of covered days in the
amount/dollar column. Do not count the day of
discharge or the date of death. (The sum of all
the days should be equal to the amount of days
being billed.)
42. REVENUE CODES*
Enter the appropriate revenue code for the
service provided.
45. SERVICE DATE
Enter the ‘FROM’ date of the span of
consecutive service dates being billed.
46. SERVICE UNITS*
Enter the quantitative measure of service
rendered per revenue code.
47. TOTAL CHARGES*
Enter the total charges pertaining to each
revenue code billed for the current billing
period. Add the total charges for all revenue
codes being billed and enter at the bottom of
column 47 in the total field. (detail line 23)
50. PAYER*
On 50a, enter the primary payer name or
“Spend Down” if spend down amount applies to
the claim. On 50b, enter the other insurance
name if applicable. Enter “Vermont Medicaid”
on 50c.
54. PRIOR PAYMENTS*
Enter the payment amount associated with the
payer listed in field locator 50. Attach spend
down Notice of Decision. Documentation must
be attached if there was no payment, if the
services are not covered by the primary, or if
the payment by the primary is $3.00 or less.
55. ESTIMATED AMOUNT DUE
Enter the amount due after deducting any
amount entered in field locator 54 from the total
entered at the bottom of column 47.
56. NPI*
Enter the BILLING provider’s NPI number.
57a. TAXONOMY CODE(S)
Enter the BILLING provider’s Taxonomy Code
when applicable.
57c. VERMONT MEDICAID ID #
Atypical providers, enter your Vermont
Medicaid billing provider number.
60. INSURED'S MEMBER ID*
Enter the member's Vermont Medicaid ID #.
67. PRINCIPAL DIAGNOSES CODE*
(see Present On Admission -POA)
Enter the primary diagnosis code. Use the
appropriate ICD-9-CM code (for dates of
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service on or after October 1, 2015, ICD-10
codes must be used).
67 a-q. OTHER DIAGNOSES CODES
(Present On Admission-POA)
Enter the appropriate ICD-9-CM codes (for
dates of service on or after October 1, 2015,
ICD-10 codes must be used) see any condition
other than primary, which requires
supplementary treatment.
69. ADMITTING DIAGNOSES CODE*
Enter the admitting diagnosis code.
74. PRINCIPAL PROCEDURE CODE
& DATE
Enter the appropriate ICD-9-CM procedure
code and corresponding date (for dates of
service on or after October 1, 2015, ICD-10
codes must be used).
74 a-e. OTHER PROCEDURE CODE
& DATE
Enter the appropriate ICD-9-CM procedure
codes and dates other than the principal
procedure performed (for dates of service on or
after October 1, 2015, ICD-10 codes must be
used).
76. ATTENDING PHYSICIAN*
Enter the individual Attending Physician’s NPI
number. If billing with a Vermont Medicaid ID #,
leave the NPI field blank and enter the Vermont
Medicaid ID # to the right of the qualifier box.
78-79. OTHER PHYSICIAN. NPI
Enter the Vermont Medicaid ID # of the
physician who the patient was referred to for
further treatment, if applicable.
80. REMARKS
Enter any notations relating specific information
necessary to adjudicate the claim.
81CCa
Enter the taxonomy code for the attending
provider. Must correspond with the NPI number
in field locator 76.
12.5.9 Hospital Outpatient Billing Instructions/Field Locators
All information on the UB-04 claim form should be typed or legibly printed. The fields listed below are used by
DXC Technology when processing Vermont Medicaid claims. The fields designated by an asterisk (*) are
mandatory; other fields are required when applicable. Only the fields listed below are used in the Vermont
Medicaid Program; other fields do not need to be completed.
FIELD LOCATOR
REQUIRED INFORMATION
1. UNLABELED FIELD*
Enter the Hospital name and address as it appears
on the Vermont Medicaid Provider Enrollment form.
2. UNLABELED FIELD
Enter “Vermont Medicaid Hospital Outpatient”
3a. PATIENT CONTROL #
For accounting purposes, enter the patient control #
in the field locator. The number may consist of up to
24 characters, alpha/numeric. This information will
appear on the Remittance Advice (RA).
3b. MEDICAL RECORD #
Enter patient’s medical record #.
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4. TYPE OF BILL*
Enter the code indicating the specific type of bill for
Outpatient. The sequence is as follows:
1. Type of facility
1-Hospital
2. Bill Classification
3-Outpatient
4-Patient not present
3. Frequency
1-Admit through discharge claim
6. STATEMENT COVERS
PERIOD*
Enter the from and through service dates.
8b. PATIENT’S NAME*
Enter the patient’s last name, first name and middle
initial.
10. BIRTHDATE
Enter the date of birth
12. ADMISSION DATE
Enter date of admission
13. ADMISSION HOUR
If billing for emergency services that are the result of
an accident, enter the admission hour.
14. ADMISSION TYPE*
Enter the code indicating the priority of the
admission:
1-Emergency
2-Urgent
3-Elective
4-Nursery
16. DISCHARGE HOUR
Enter the hour in which the patent was discharged.
17. DISCHARGE STATUS*
Enter the appropriate discharge code.
18-28. CONDITONS CODES
Enter code to identify if condition is related to the
following:
02-Conditon is Employment Related
A1-EPSDT Related Services
A4-Family Planning Related Services
31-34. OCCURRENCE CODE &
DATE*
Enter one of the following two digit accident codes
and the corresponding occurrence date, if applicable
or 52 if no other applies:
01-Auto Accident
02-Auto Accident/No Fault Insurance Involved
03-Accident/Tort Liability
04-Accident/Employment Related
05-Other Accident
06-Crime Victim
11-No Accident/Onset of Symptoms or Illness
35-Physical Therapy
44-Occupational Therapy
45-Speech Therapy
50-Medical Emergency- Non-accidental
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51-Outpatient Surgery Related
52-Not an Accident
42. REVENUE CODES*
Enter the appropriate revenue code for the service
provided.
43. NDC CODE*
Enter the NDC code of the drug that was dispensed.
Use a “N4” indicator preceding the NDC to identify
the information in FL 43 as an NDC.
44. HCPCS/CPT
Enter the appropriate HCPCS/CPT code,
immediately followed by an applicable/appropriate
modifier
45. SERVICE DATE*
Enter the actual date the service was rendered. If the
service was rendered on more than one day, you
must bill a separate charge for each day.
46. SERVICE UNITS*
Enter the quantitative measure of service.
47. TOTAL CHARGES*
Enter the total charges pertaining to each code billed
for the current billing period. Add the total charges
for all revenue codes being billed and enter at the
bottom of column 47 in the total field. (detail line 23)
50. PAYER*
On 50a, enter the primary payer name or “Spend
Down” if spend down amount applies to the claim.
On 50b, enter the other insurance name if
applicable. Enter “Vermont Medicaid” on 50c.
54. PRIOR PAYMENTS*
Enter the payment amount associated with the payer
listed in field locator 50. Attach spend down Notice of
Decision. Documentation must be attached if there
was no payment, if the services are not covered by
the primary, or if the payment by the primary is $3.00
or less.
55. ESTIMATED AMOUNT DUE
Enter the amount due after deducting any amount
entered in field locator 54 from the total entered at
the bottom of column 47.
56. NPI*
Enter the BILLING provider’s NPI number.
57a. TAXONOMY CODE(S)
Enter the BILLING provider’s Taxonomy Code when
applicable.
57c. VERMONT MEDICAID ID #
Atypical providers, enter your Vermont Medicaid
billing provider number.
60. INSURED'S MEMBER ID*
Enter the member's Vermont Medicaid ID #.
67. PRINCIPAL DIAGNOSES
CODE*
Enter the primary diagnosis code. Use the
appropriate ICD-9-CM code (for dates of service on
or after October 1, 2015, ICD-10 codes must be
used).
67 a-q. OTHER DIAGNOSES
CODES
Enter the appropriate ICD-9-CM codes (for dates of
service on or after October 1, 2015, ICD-10 codes
must be used) for any condition other than primary,
which requires supplementary treatment.
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76. ATTENDING PHYSICIAN
NPI*
Enter the individual Attending Physician’s NPI
number.
If billing with a Vermont Medicaid ID #, leave the NPI
field blank and enter the Vermont Medicaid ID # to
the right of the qualifier box.
77. OPERATING PHYSICIAN
NPI
Enter the Vermont Medicaid ID # of the Operating
Physician
78-79. OTHER PHYSICIAN NPI
Enter the Vermont Medicaid ID # of the physician
who the patient was referred to for further treatment
if applicable.
80. REMARKS
Enter any notations relating specific information
necessary to adjudicate the claim.
81CCa
Enter the taxonomy code for the attending provider.
Must correspond with the NPI number in field locator
76.
Section 13 Home Health Agency Services
CONDITIONS FOR PAYMENT
If all conditions for Medicare are met and the patient is Medicare eligible, Medicare must be billed before
Vermont Medicaid reimbursement is requested. Payment for covered home health care services is
authorized when the conditions for Medicare (Part A or Part B) payment are met or when all of the following
conditions are met:
The service or item is furnished in the member’s place of residence. A place of residence includes:
Member’s own dwelling, an apartment, congregate such as senior citizen or adult day center, a
community care home, and a hospital, but the last only for the purpose of an initial observation,
assessment and evaluation visit.); and
Items and services are ordered and furnished under a written plan, signed by the attending physician
and incorporated into the agency’s permanent record for the patients, which relates the items and
services to the patient’s condition, as follows:
1. Includes the diagnosis and description of the patient’s functional limitation resulting from illness or
injury; and
2. Specifies the type and frequency of needed service, e.g., nursing services, drugs and medications,
special diet, permitted activities, rehabilitation and therapy services, home health aide services,
medical supplies and appliances; and
3. Provides a long-range forecast of likely changes in the patient’s condition; and
4. Specifies changes in the plan in writing, signed by the attending physician or by a registered
professional nurse on the agency staff pursuant to the physician’s verbal orders; and
5. Is reviewed by the attending physician, in consultation with professional agency personnel every
60 days, or more frequently as the severity of the patient’s condition requires, and shows the day
of each review and physician’s signature; and
6. The attending physician certifies that the services and items specified in the treatment plan can, as
a practical matter, be provided through a Home Health Agency in the patient’s place of residence.
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For Vermont Medicaid reimbursement, there is no homebound restriction, nor a three day prior
hospitalization required. Patient’s condition may be either an episode of acute illness or injury, or a chronic
condition requiring home health care under a physician’s order.
FACE-TO-FACE REQUIREMENTS
As of 4/1/2018, the Agency of Human Services (AHS) requires physicians enrolled in Vermont Medicaid to
document that a face-to-face encounter occurred for the initial ordering of home health services. The
ordering physician or non-physician practitioner must conduct a face-to-face encounter with the beneficiary
no more than 90 days prior to, or 30 days after the start of service. Documentation of the face-to-face visit is
a required component of the physician’s order for services.
The face-to-face visit requirement applies to home health services as defined by federal regulations at 42
CFR §440.70. Medicaid Covered Services Rule 7401, Home Health Agency Services reflects that
homebound status is not required.
Documentation indicating that the face-to-face visit occurred shall be included in the physician’s initial order
for services. The face-to-face encounter may be conducted in person or through telemedicine.
The ordering physician is required to document who conducted the face-to-face encounter and incorporate
findings into the beneficiary’s medical record. A specific form to document the face-to-face visit is not
required. How to incorporate the clinical findings into the medical record is at the discretion of the ordering
physician.
The following elements must be present in the documentation:
That the face-to-face encounter is related to the primary reason the patient requires services,
That the face-to-face encounter occurred within the required timeframes,
The practitioner who conducted the encounter, and
The date of the encounter
The following non-physician practitioners may perform the face-to-face encounter:
A nurse practitioner, clinical nurse specialist, or certified nurse midwife working in collaboration with the
ordering physician, or a physician assistant under the supervision of the ordering physician. Beneficiaries
admitted to home health immediately after an acute or post-acute stay, the attending acute or post-acute
physician may perform the face-to-face encounter. A certified nurse midwife may perform the face-to-face
encounter for home health services.
REIMBURSABLE SERVICES
General Information: Home health services are provided by certified home health agencies under a plan of
treatment authorized and approved by a physician. The objective of the home health services is to restore,
rehabilitate, or maintain patients in their own homes or in a domiciliary facility by providing professional
care and/or supervision. Approved home health services include nursing care services, services of home
health aides, speech therapy, physical therapy, occupational therapy, and medical supplies.
Covered services under the Vermont Medicaid Home Health Service Program are those which are
necessary to restore, rehabilitate or maintain health, including care for the terminally ill, when provided
under professional supervision in the home. Following are descriptions of home health visits covered under
the Vermont Medicaid Program.
13.3.1 Visit at Patient’s Place of Residence
A visit is a personal contact in the patient’s place of residence for providing a covered home health service
by a health worker on the staff of the home health agency or by others under contract or arrangement with
the home health agency.
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Initial Evaluation Visit: A visit to evaluate the patient, the patient’s status, the physical environment and
facilities available, attitudes of family members, availability of family members to assist in the care and to
assess the appropriateness of home health care for the patient.
Services provided by the home health agency, except for the initial evaluation visit, must be furnished
under a physician’s plan of care. The physician establishes a written plan of care for the patient and
supervises the plan in conjunction with the home health agency. The physician must sign the plan of care
initially and review and sign it every 60 days. The plan of care becomes a permanent part of the patient’s
records. It must be kept on file at the home health agency. If any changes in the plan of treatment are
ordered by the physician, these changes must also be signed. They may be given verbally by the
physician, and then reduced to writing by the registered nurse or qualified therapist (who must date and
sign the changes); however, the physician must countersign the order as soon as possible thereafter.
The plan of care must cover all pertinent diagnoses and include the following information:
Mental status
Types of professional services needed
Frequency of visits
Prognosis as a result of the services
Rehabilitation potential
Functional limitations
Activities permitted
Nutritional requirements
Medication and treatments
Any safety measures to protect against injury
Instruction for timely discharge or referral
Specific therapy services - This should include the specific procedures and modalities to be used, and the
amount, frequency and duration of the therapies.
The plan of care is reviewed periodically by the physician and home health agency personnel. The agency
professional staff is responsible for promptly reporting to the physician any changes in the patient’s
condition which would warrant altering the plan of care.
13.3.2 Nursing Care Services
Nursing care services provided on a part-time or intermittent basis by a home health agency or, in the case
where no agency exists in the area, by a registered nurse employed or contracted by the home health
agency, are covered. Nursing services must be provided in accordance with the physician’s plan of care.
13.3.3 Registered Nurse Services
Skilled nursing care consists of those services reasonable and necessary to the treatment of an illness or
injury and for evaluation and assessment of the patient’s condition. These services must be performed by
or under the direct supervision of a licensed nurse in accordance with the current Nurse Practice Act (State
Law) and the individual home health agency policy. Skilled services are covered for patients who have
reached a maintenance level but are able to remain in the home if supervised periodically by an RN or
therapist.
13.3.4 Licensed Practical Nurse Services
Intermittent or part-time nursing services may be provided to a patient by a licensed practical nurse when
these services are ordered by the patient’s physician and the licensed practical nurse is working under the
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direction of the registered nurse. LPN services are assigned and provided in accordance with the current
Nurse Practice Act (State Law) and individual home health agency policy. Duties of a licensed practical
nurse may include preparing clinical and progress notes, assisting the physician and/or registered nurse in
performing specialized procedures, preparing equipment and materials for treatment, observing aseptic
techniques as required, and assisting the patient in learning appropriate self-care techniques.
13.3.5 Home Health Aide Services
Home health aide services can be provided even if a skilled service is not needed; however, a registered
nurse or appropriate therapist must make a supervisory visit every 2 weeks. The primary function of a
home health aide is the personal care of a patient. The home health aide is assigned to a particular patient
by the nurse or therapist. Written instructions for the patient’s care are prepared by a registered nurse or
therapist as appropriate. Routine small cost items such as cotton balls and tongue depressors are included
in the home visit charges and will not be paid for separately.
13.3.6 Personal Duties
Personal duties provided in accordance with the written plan of care by the home health aide include
medical assistance, assistance in the activities of daily living, such as helping the patient to bathe, to get in
and out of bed, to care for hair and teeth, to exercise, assisting the patient in taking medicines specifically
ordered by the physician which are ordinarily self-administered, retraining the patient in necessary self-help
skills, and assisting with provision and maintenance of a desirable physical environment for the patient in
his home.
13.3.7 Medical Duties
Medical duties include taking temperature, pulse, respirations and blood pressure, weighing the patient,
reporting changes in the patient’s conditions and needs, and completing appropriate records for the home
health agency.
13.3.8 Household Services
Household services that are essential to the patient’s health care and incidental to the medical care of the
patient, such as light housekeeping, meal preparation, laundering essential to the comfort of the patient,
etc. are considered covered services of a home health aide when these activities can be documented as a
necessary adjunct to the patient’s prescribed therapeutic plan of care. Light housekeeping may include,
changing the bed, light cleaning, and rearrangement of room furnishings to accommodate patient’s needs.
Meal preparation, meeting patient’s nutritional needs, may include purchase of food, meal preparation, and
washing of utensils. Laundering may include being sure the patient has clean articles such as stump socks
for amputees, elastic stockings, sleepwear, or undergarments for the incapacitated patient.
13.3.9 Hospice
Vermont Medicaid reimburses for hospice services provided to patients in nursing homes. Under federal
regulations, hospice providers who contract with nursing homes to provide services become responsible for
management of the patient’s care and billing for all services, including the room and board normally paid to
the nursing home. The revenue code 659 should be used for these hospice services and the name of the
nursing home should be entered in field locator 80. Vermont Medicaid pays the hospice a rate which is
equal to 95% of the nursing home’s established per diem rate, and the hospice in turn, pays the nursing
home.
The date of death is not eligible for reimbursement from Vermont Medicaid.
13.3.10 Respite Billing
Only provider types of Aged/Disabled Waiver, with Waiver indicated as provider specialty, may bill for
respite care. Providers billing for respite must select a type of bill from the following:
1. Type of Facility
8-Hospice or Special Facility
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2. Bill Classification
6-Respite
3. Frequency
1-Admit through discharge claim
2-Interim-first claim
3-Interim-continuity claim
4-Interim-last claim
For additional information, please refer to: http://ddas.vermont.gov/ddas-policies/policies-cfc/policies-cfc-
highest/policies-cfc-highest-manual.
13.3.11 Telemonitoring
Home Telemonitoring is a health service that allows and requires scheduled remote monitoring of data
related to an individual’s health, and transmission of the data from the individual’s home to a licensed home
health agency. Scheduled periodic reporting of the individual’s data to a licensed physician is required,
even when there have been no readings outside the parameters established in the physician’s orders.
Eligibility Criteria:
Individuals receiving Medicaid telemonitoring services must:
Have Medicaid as primary insurance or be dually-eligible with “non-home bound” status; and
Have Congestive Heart Failure (any diagnosis; 428.xx); and
Be clinically eligible for home health services; and
Have a physician’s plan of care with an order for telemonitoring services.
Qualified Providers:
A qualified telemonitoring provider must be a designated home health agency and enrolled in Vermont
Medicaid.
Providers must use the following licensed health care professionals to review data:
Registered nurse (RN)
Nurse practitioner (NP)
Clinical nurse specialist (CNS)
Licensed practical nurse (LPN), under the supervision of an RN
Physician assistant (PA)
Providers must follow data parameters established by a licensed physician’s plan
of care.
In the event of a measurement outside of the established individual’s parameters, the provider shall use the
health care professionals noted above to be responsible for reporting the data to a physician.
The data transmission must comply with standards set by the Health Insurance Portability and
Accountability Act (HIPAA).
Reimbursement
When Telemonitoring services are provided to clinical eligible Medicaid patients, qualified providers may
bill CPT S9110 for once every 30 days for telemonitoring of patient in their home, including all necessary
equipment; computer system, connections, and software; maintenance; patient education and support; per
month. CPT 98969 may be billed once every 7 days for ongoing assessment and management of
telemonitoring data. Providers should use revenue code 780 for both S9110 and 98969.
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HOME HEALTH AGENCY & HOSPICE SERVICES BILLING INSTRUCTIONS/FIELD LOCATORS
Beginning January 1, 2016, for Hospice Care only, a Service Intensity Add-On Payment may be billed in
addition to the per diem rate for routine home care (RHC) level and is equal to the continuous home care
(CHC) hourly rate if the following requirements are met:
The day is an RHC level of care day
The care occurs during the last seven days of an individual’s life who is receiving hospice services and
the individual has died.
The skilled service is provided by a registered nurse (RN) or medical social worker (SW) for at least 15
minute but no more than four hours per day.
o RN and SW hours are combined and cannot exceed four hours total;
o RN and SW hours provided concurrently count separately;
o RN and SW hours can occur over multiple visits per day;
o the service is provided in per; and
o the skilled service provided is clearly documented.
The SIA payment will be determined by the number of hours, in 15-minute increments of service provided
multiplied by the hospice current CHC hourly rate.
Additional service code and two new billings codes, one for RN hours and one for SW hours have been
created for the submission of claims for the SIA payment. The final claim should include routine home care
level, the additional service codes for the SIA payment and a status code to indicate the death of the
beneficiary.
Current hospice revenue codes are listed below:
Listed below are the revenue codes that must used in order to receive the SIA payment:
Listed below are the current changes that will be effective 1/1/2016 for G codes for the valid
discipline values:
HCPCS Code
Description
G0154
Services of a skilled nurse in home health or hospice settings, each 15 minutes
Discontinue 12/31/2015 replaced with G0299 & G0300
G0155
Services of a clinical social worker in home health or hospice settings, each 15
minutes
Rev Code
Description
Required HCPCS G Codes
0651
Routine Home Care
No
0652
Continuous Home Care
Yes
0655
Inpatient Respite Care
No
0656
General Inpatient Care
No
Rev Code
Description
Required HCPCS G Codes
0551
Routine Home Care
Yes
0561
Continuous Home Care
Yes
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G0299
Direct skilled nursing services of a registered nurse (RN) in the home health or
hospice setting, each 15 minutes Effective 1/1/2016
G0300
Direct skilled nursing services of a license practical nurse (LPN) in the home health or
hospice settings, each 15 minutes Effective 1/1/2016
All information on the UB-04 Claim Form should be typed or legibly printed. The fields listed below are used
by DXC Technology when processing Vermont Medicaid claims. The fields designated by an asterisk (*) are
mandatory; other fields are required when applicable. Only the fields listed below are used in the Vermont
Medicaid Program; other fields do not need to be completed. See Section 12.3 Patient Share (Applied
Income) Reporting.
FIELD LOCATORS
REQUIRED INFORMATION
1. UNLABELED FIELD*
Enter the Home Health Agency name and address
as it appears on the Vermont Medicaid Provider
Enrollment form.
2. UNLABELED FIELD
Enter pay to name and pay to address
3a. PATIENT CONTROL #
For accounting purposes, enter the patient control #
in the field locator. The number may consist of up to
24 characters, alpha/numeric. This information will
appear on the Remittance Advice (RA).
3b. MEDICAL RECORD #
Enter patient’s medical record #.
4. TYPE OF BILL*
Enter the code indicating the specific type of bill for
Home Health. The sequence is as follows:
1. Type of facility
3-Home Health
8-Hospice or Special Facility
2. Bill Classification
1-Hospice (Non-hospital based)
2-Hospice (Hospital based)
2-Home Health
4-Ambulatory Surgical Center
6-Respite
3. Frequency
1-Admit through discharge claim
2-Interim-first claim
3-Interim-continuity claim
4-Interim-last claim
5-Late charge(s) only
6. STATEMENT COVERS
PERIOD*
Enter the from and through service dates.
8b. PATIENT’S NAME*
Enter the patient’s last name, first name and middle
initial.
10. BIRTHDATE
Enter the date of birth
12. ADMISSION DATE*
Enter date of admission
13. ADMISSION HOUR
Enter the hour in which patient was admitted.
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14. ADMISSION TYPE
Enter the code indicating the priority of the
admission:
1-Emergency
2-Urgent
3-Elective
4-Nursery
17. STAT*
Enter the two digit code indicating the patient’s
status as of the statement period. For SIA Payment,
please indicate date of death.
18-28. CONDITONS CODES
Enter code to identify if condition is related to the
following (*PSRO code is mandatory):
02-Conditon is Employment Related
A1-EPSDT Related Services
A4-Family Planning Related Services
*If the patient is found to have Medicare
benefits that would not cover the home
health visit for one of the following
reason, enter the condition code:
M3-Not home bound
M4-Non-chronic
M5-Non-acute
31-34. OCCURRENCE CODE &
DATE*
Enter one of the following two digit accident codes,
and the corresponding occurrence date, if
applicable or 52 if no other applies:
01-Auto Accident
02-Auto Accident/No Fault Insurance Involved
03-Accident/Tort Liability
04-Accident/Employment Related
05-Other Accident
06-Crime Victim
11-No Accident/Onset of Symptoms or Illness
35-Physical Therapy
42-Date of Discharge
44-Occupational Therapy
45-Speech Therapy
50-Medical Emergency- Non-accidental
51-Outpatient Surgery Related
52-Not an Accident
42. REVENUE CODES*
Enter the appropriate revenue code for the service
provided. Each date of service must be entered
separately at the detail.
45. SERVICE DATE*
Enter the actual date the service was rendered.
Enter the from date of the span of consecutive
service dates being billed.
46. SERVICE UNITS*
Enter the number of visits or units of time for which
reimbursement is being requested. Nursing care
and therapy services are reimbursed on a per visit
basis. One visit= 1 unit. Home Health Aide services
are reimbursed in 15 minute units; therefore, enter
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total number of units the aide was in the home (i.e.
45 minutes= 3 units.)
47. TOTAL CHARGES*
Enter the total charges pertaining to each code
billed for the current billing period. Add the total
charges for all revenue codes being billed and enter
at the bottom of column 47 in the total field. (detail
line 23)
50. PAYER*
Enter “Medicare” or “Spend Down” (if spend down
amount applies to the claim.) on 50a if Medicare is
the primary payer. On 50b, enter the other
insurance name if applicable. Enter “Vermont
Medicaid” on 50c.
54. PRIOR PAYMENTS*
Enter the payment amount associated with the
payer listed in field locator 50. Attach spend down
Notice of Decision. Documentation must be
attached if there was no payment, if the services are
not covered by the third party.
55. ESTIMATED AMOUNT DUE
Enter the amount due after deducting any amount
entered in field locator 54 from the total entered at
the bottom of column 47.
56. NPI*
Enter the BILLING provider’s NPI number.
57a. TAXONOMY CODE(S)
Enter the BILLING provider’s Taxonomy Code.
57c. VERMONT MEDICAID ID #
Atypical providers, enter your Vermont Medicaid
billing provider number.
60. INSURED'S MEMBER ID*
Enter the member's Vermont Medicaid ID #.
67. PRINCIPAL DIAGNOSES
CODE*
Enter the primary diagnosis code. Use the
appropriate ICD-9-CM code (for dates of service on
or after October 1, 2015, ICD-10 codes must be
used).
67 a-q. OTHER DIAGNOSES
CODES
Enter the appropriate ICD-9-CM codes (for dates of
service on or after October 1, 2015, ICD-10 codes
must be used) for any condition other than primary,
which requires supplementary treatment.
74. PRINCIPAL PROCEDURE
CODE & DATE
Enter the appropriate ICD-9-CM (for dates of
service on or after October 1, 2015, ICD-10 codes
must be used) procedure code and corresponding
date.
74 a-e. OTHER PROCEDURE
CODE & DATE
Enter the appropriate ICD-9-CM (for dates of
service on or after October 1, 2015, ICD-10 codes
must be used) procedure codes and dates other
than the principal procedure performed.
76. ATTENDING PHYSICIAN
NPI*
Enter the individual Attending Physician’s NPI
number.
If billing with a Vermont Medicaid ID #, leave the
NPI field blank and enter the Vermont Medicaid ID #
to the right of the qualifier box.
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78-79. OTHER PHYSICIAN NPI
Enter the Vermont Medicaid ID # of the physician
who the patient was referred to for further treatment
if applicable.
80. REMARKS
Enter any notations relating specific information
necessary to adjudicate the claim.
81CCa.
Enter the taxonomy code for the attending provider.
Must correspond with the NPI number in field
locator 76.
ADULT DAY SERVICES BILLING INSTRUCTIONS/FIELD LOCATORS
All information on the UB-04 claim form should be typed or legibly printed. The fields listed below are used by
DXC Technology when processing Vermont Medicaid claims. The fields designated by an asterisk (*) are
mandatory; other fields are required when applicable. Only the fields listed below are used in the Vermont
Medicaid Program; other fields do not need to be completed.
FIELD LOCATORS
REQUIRED INFORMATION
1. UNLABELED FIELD*
Enter the Home Health Agency name and
address as it appears on the Vermont Medicaid
Provider Enrollment form.
2. UNLABELED FIELD
Enter pay to name and pay to address
3a. PATIENT CONTROL #
For accounting purposes, enter the patient
control # in the field locator. The number may
consist of up to 24 characters, alpha/numeric.
This information will appear on the Remittance
Advice (RA).
3b. MEDICAL RECORD #
Enter patient’s medical record #.
4. TYPE OF BILL*
Enter the code indicating the specific type of bill
for Enhanced Residential Care. The sequence
is as follows:
1. Type of facility
3-Home Health
2. Bill Classification
1-Hospice (Non-hospital based)}
2-Hospice (Hospital based)
2-Home Health
4-Ambulatory Surgical Center
3. Frequency
1-Admit through discharge claim
2-Interim-first claim
3-Interim-continuity claim
4-Interim-last claim
5-Late charge(s) only
6. STATEMENT COVERS PERIOD*
Enter the “from” and “through” service dates.
8b. PATIENT’S NAME*
Enter the patient’s last name, first name and
middle initial.
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10. BIRTHDATE
Enter the date of birth
12. ADMISSION DATE*
Enter date of admission
13. ADMISSION HOUR
Enter the hour in which patient was admitted.
14. ADMISSION TYPE
Enter the code indicating the priority of the
admission:
1-Emergency
2-Urgent
3-Elective
4-Nursery
17. STAT*
Enter the two digit code indicating the patient’s
status as of the statement period.
18-28. CONDITONS CODES
Enter code to identify if condition is related to
the following (*PSRO code is mandatory):
02-Conditon is Employment Related
A1-EPSDT Related Services
A4-Family Planning Related Services
*If the patient is found to have Medicare
benefits that would not cover the home
health visit for one of the following
reason, enter the condition code:
M3-Not home bound
M4-Non-chronic
M5-Non-acute
31-34. OCCURRENCE CODE &
DATE*
Enter one of the following two digit accident
codes, and the corresponding occurrence date,
if applicable or 52 if no other applies:
01-Auto Accident
02-Auto Accident/No Fault Insurance
Involved
03-Accident/Tort Liability
04-Accident/Employment Related
05-Other Accident
06-Crime Victim
11-No Accident/Onset of Symptoms or
Illness
42-Date of Discharge
50-Medical Emergency-Non-accidental
51-Outpatient Surgery Related
52-Not an Accident
39. VALUE CODES AMOUNT*
Enter the number of covered days mandatory
for Residential Care Facility only in the
amount/dollar column.
42. REVENUE CODES*
Enter the appropriate revenue code for the
service provided.
45. SERVICE DATE*
Enter the ‘FROM’ date of the span of
consecutive service dates being billed.
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46. SERVICE UNITS*
Enter the number of units which reimbursement
is being requested.
47. TOTAL CHARGES*
Enter the total charges pertaining to each
revenue code billed for the current billing
period. Add the total charges for all revenue
codes being billed and enter at the bottom of
column 47 in the total field. (detail line 23)
50. PAYER NAME*
Enter “Medicare” or “Spend Down” (if spend
down amount applies to the claim.) on 50a if
Medicare is the primary payer. On 50b, enter
the other insurance name if applicable. Enter
“Vermont Medicaid” on 50c.
54. PRIOR PAYMENTS*
Enter the payment amount associated with the
payer listed in field locator 50. Attach spend
down Notice of Decision. Documentation must
be attached if there was no payment, if the
services are not covered by the third party.
55. ESTIMATED AMOUNT DUE
Enter the amount due after deducting any
amount entered in field locator 54 from the total
entered at the bottom of column 47.
56. NPI*
Enter the BILLING provider’s NPI number.
57a. TAXONOMY CODE(S)
Enter the BILLING provider’s Taxonomy Code
when applicable.
57c. VERMONT MEDICAID ID #
Atypical providers, enter your Vermont
Medicaid billing provider number.
60. INSURED'S MEMBER ID*
Enter the member's Vermont Medicaid ID #.
67. PRINCIPAL DIAGNOSES CODE*
Enter the primary diagnosis code. Use the
appropriate ICD-9-CM code (for dates of
service on or after October 1, 2015, ICD-10
codes must be used).
67 a-q. OTHER DIAGNOSES CODES
Enter the appropriate ICD-9-CM codes (for
dates of service on or after October 1, 2015,
ICD-10 codes must be used) for any condition
other than primary, which requires
supplementary treatment.
69. ADMITTING DIAGNOSES CODE*
Enter the admitting diagnosis code.
74. PRINCIPAL PROCEDURE CODE
& DATE
Enter the appropriate ICD-9-CM procedure
code (for dates of service on or after October 1,
2015, ICD-10 codes must be used) and
corresponding date.
74 a-e. OTHER PROCEDURE CODE
& DATE
Enter the appropriate ICD-9-CM procedure
codes (for dates of service on or after October
1, 2015, ICD-10 codes must be used) and
dates other than the principal procedure
performed.
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76. ATTENDING PHYSICIAN NPI*
If billing with a Vermont Medicaid ID #, leave
the NPI field blank and enter the Vermont
Medicaid ID # to the right of the qualifier box.
77. OPERATING PHYSICIAN NPI
Enter the Vermont Medicaid ID # of the
Operating Physician
78-79. OTHER PHYSICIAN NPI
Enter the Vermont Medicaid ID # of the
physician who the patient was referred to for
further treatment if applicable.
80. REMARKS
Enter any notations relating specific information
necessary to adjudicate the claim.
81CCa.
Enter the taxonomy code for the attending
provider. Must correspond with the NPI number
in field locator 76.
Section 14 Assistive Community Care Services (ACCS)
The below General Billing Instruction applies to all Assistive Community Care Services - Choices for Care
Programs (ACCS) for licensed Level III and Assisted Living Residences.
REVENUE CODE & DATE SPAN BILLING
ACCS providers must bill revenue code 0098 assigned by the Department of Disabilities, Aging and
Independent Living (DAIL) in field locator 42. Only consecutive days may be billed in field locator 6. If there is
a gap in service during a billing period, you must submit separate claims for each span of days. The day of
admission is paid but the day of discharge is not paid. Please find the examples below.
Example 1: (Continuous Stay)
Patient in the facility July 1, 2013 through July 31, 2013.
You would submit as follows:
Single claim Field locator 6= 07/01/13 to 07/31/13
042=0098
Field locator 46= 31 units
Example 2: (Leave Days)
Patient in the facility July 1, 2013 but leaves on July 15th to visit with family members. Patient returns on July
20th through July 31, 2013.
Submit two claims as follows:
First claim Field locator 6=07/01/13 to 07/15/13
Field locator 42= 0098
Field locator 46= 15 units
Second claim Field locator 6= 07/20/13 to 07/31/13
Field locator 42= 0098
Field locator 46= 5 units
Example 3: (Hospital Visit)
Patient in the facility July 1, 2013 but is discharged to the hospital on July 10th. Patient returns on July 27th
through July 31, 2013.
Submit two claims as follows:
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First claim Field locator 6= 07/01/13 to 07/10/13
Field locator 42= 0098
Field locator 46= 9 units
Second claim Field locator 6= 07/27/13 to 07/31/13
Field locator 42= 0098
Field locator 46= 12 units
Example 4: (Multiple Breaks)
Patient in the facility July 1, 2013 but is discharged to the hospital on July 10th. Patient returns on July 13th
but leaves with family on July 16th. Patient returns on July 18th through July 31, 2013.
Submit three claims as follows:
First claim Field locator6= 07/01/13 to 07/10/13
Field locator 42= 0098
Field locator 46= 9 units
Second claim Field locator 6= 07/13/13 to 07/16/13
Field locator 42= 0098
Field locator 46= 4 units
Third claim Field locator 6= 07/18/13 to 07/31/13
Field locator 42= 0098
Field locator 46= 14 units
ASSISTIVE COMMUNITY CARE SERVICES (ACCS) BILLING INSTRUCTIONS/FIELD
LOCATORS
All information on the UB-04 claim form is to be typed or legibly printed. The fields listed below are used by
DXC when processing Vermont Medicaid claims. The fields designated by an asterisk (*) are mandatory;
other fields are required when applicable. Only the fields listed below are used in the Vermont Medicaid
Program; other fields do not need to be completed.
FIELD LOCATORS
REQUIRED INFORMATION
1. UNLABELED FIELD*
Enter your Provider name and address as it
appears on the Vermont Medicaid Provider
Enrollment form.
2. UNLABELED FIELD
Enter “Assistive Community Care Services”.
3a. PATIENT CONTROL #
For accounting purposes, enter the patient
control # in the field locator. The number may
consist of up to 24 characters, alpha/numeric.
This information will appear on the Remittance
Advice (RA).
3b. MEDICAL RECORD #
Enter patient’s medical record #.
4. TYPE OF BILL*
Enter the code indicating the specific type of bill
for Enhanced Residential Care. The sequence
is as follows:
1. Type of facility
3-Home Health or Residential Care
Facility
2. Bill Classification
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2- Home Health or ACCS
3. Frequency
1-Admit through discharge claim
2-Interim-first claim
3-Interim-continuity claim
4-Interim-last claim
5-Late charge(s) only
6. STATEMENT COVERS PERIOD*
Enter the beginning and ending service dates
included on the bill.
8b. PATIENT’S NAME*
Enter the patient’s last name, first name,
middle initial.
10. BIRTHDATE
Enter the date of birth
12. ADMISSION DATE*
Enter date of admission
13. ADMISSION HOUR*
Enter the hour in which patient was admitted
14. ADMISSION TYPE*
Enter the code indicating the priority of the
admission:
1-Emergency
2-Urgent
3-Elective
4-Nursery
16. DISCHARGE HOUR
Enter the hour in which patient was Discharged
17. STAT*
Enter the two digit code indicating the patient’s
status as of the ‘through date’ of the statement
period.
18-28. CONDITONS CODES
Enter code to identify if condition is related to
the following
(*PSRO code is mandatory):
02-Conditon is Employment Related
A1-EPSDT Related Services
A4-Family Planning Related Services
31-34. OCCURRENCE CODE &
DATE*
Enter one of the following two digit accident
codes, and the corresponding occurrence date,
if applicable or 52 if no other applies:
01-Auto Accident
02-Auto Accident/No Fault Insurance
Involved
03-Accident/Tort Liability
04-Accident/Employment Related
05-Other Accident
06-Crime Victim
11-No Accident/Onset of Symptoms or
Illness
42-Date of Discharge
50-Medical Emergency-Non-accidental
51-Outpatient Surgery Related
52-Not an Accident
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39. VALUE CODES AMOUNT*
Enter the number of covered days mandatory
for Residential Care Facility only in the
amount/dollar column. Do not count the day
of discharge or the date of death. (The sum
of all days should be equal to the amount of
days being billed.)
42. REVENUE CODES*
Enter the appropriate revenue code for the
service provided.
45. SERVICE DATE*
Enter the ‘FROM’ date of the span of
consecutive service dates being billed.
46. SERVICE UNITS*
Enter the number of units which reimbursement
is being requested. One visit= 1 units. Home
Health Aide services are reimbursed in 15
minute units, therefore, enter total number of
units that aide was in the home (i.e. 45
minutes= 3 units).
47. TOTAL CHARGES*
Enter the total charges pertaining to each
revenue code billed for the current billing
period. Add the total charges for all revenue
codes being billed and enter at the bottom of
column 47 in the total field. (detail line 23)
50. PAYER NAME*
Enter “Medicare” or “Spend Down” (if spend
down amount applies to the claim.) on 50a if
Medicare is the primary payer. On 50b, enter
the other insurance name if applicable. Enter
“Vermont Medicaid” on 50c.
54. PRIOR PAYMENTS*
Enter the payment amount associated with the
payer listed in field locator 50. Attach spend
down Notice of Decision. Documentation must
be attached if there was no payment, if the
services are not covered by the third party.
55. ESTIMATED AMOUNT DUE
Enter the amount due after deducting any
amount entered in field locator 54 from the total
entered at the bottom of column 47.
56. NPI*
Enter the BILLING provider’s NPI number.
57a. TAXONOMY CODE(S)
Enter the BILLING provider’s Taxonomy Code
when applicable.
57c. VERMONT MEDICAID ID #
Atypical providers, enter your Vermont
Medicaid billing provider number.
60. INSURED'S MEMBER ID*
Enter the member's Vermont Medicaid ID #.
67. PRINCIPAL DIAGNOSES CODE*
Enter the primary diagnosis code. Use the
appropriate ICD-9-CM code (for dates of
service on or after October 1, 2015, ICD-10
codes must be used).
67 a-q. OTHER DIAGNOSES CODES
Enter the appropriate ICD-9-CM codes (for
dates of service on or after October 1, 2015,
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ICD-10 codes must be used) for any condition
other than primary, which requires
supplementary treatment.
69. ADMITTING DIAGNOSES CODE*
Enter the admitting diagnosis code.
74. PRINCIPAL PROCEDURE CODE
& DATE
Enter the appropriate ICD-9-CM (for dates of
service on or after October 1, 2015, ICD-10
codes must be used) procedure code and
corresponding date.
74 a-e. OTHER PROCEDURE CODE
& DATE
Enter the appropriate ICD-9-CM procedure
codes (for dates of service on or after October
1, 2015, ICD-10 codes must be used) and
dates other than the principal procedure
performed.
76. ATTENDING PHYSICIAN NPI*
Enter the individual Attending Physician’s NPI
number.
If billing with a Vermont Medicaid ID #, leave
the NPI field blank and enter the Vermont
Medicaid ID # to the right of the qualifier box.
77. OPERATING PHYSICIAN NPI
Enter the Vermont Medicaid ID # of the
Operating Physician
78-79. OTHER PHYSICIAN NPI
Enter the Vermont Medicaid ID # of the
physician who the patient was referred to for
further treatment if applicable.
80. REMARKS
Enter any notations relating specific information
necessary to adjudicate the claim.
81CCa
Enter the taxonomy code for the attending
provider. Must correspond with the NPI number
in field locator 76.
Section 15 Choices for Care: Enhanced Residential Care (ERC)/Nursing Facilities Home
Based Waiver (HBW), Moderate Needs
Due to the implementation of the long-term care 1115 waiver, patient share obligations will be automatically
deducted from Vermont Medicaid claims starting with the first claim of the month for nursing homes, ERC
and home-based providers. All nursing home claims will cost avoid for Medicare unless the provider has
indicated why the service was not covered by Medicare. See Section 12.3 Patient Share (Applied Income)
Reporting.
Eligibility for Choices for Care high/highest in all settings is based on specific clinical and financial eligibility
criteria and is determined through the Choices for Care application process. Applications may be found at
http://dcf.vermont.gov/benefits/LTC-Medicaid
Moderate Needs Program eligibility is based on clinical and financial criteria and is limited to available
provider funding. Applications can be found at http://www.ddas.vermont.gov/ddas-programs/programs-
cfc/programs-cfc-default-page#forms.
ERC PAPER CLAIM SUBMISSION BILLING INSTRUCTIONS/FIELD LOCATORS
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All information on the UB-04 claim form should be typed or legibly printed. The fields listed below are used by
DXC when processing Vermont Medicaid claims. The fields designated by an asterisk (*) are mandatory;
other fields are required when applicable. Only the fields listed below are used in the Vermont Medicaid
Program; other fields do not need to be completed.
FIELD LOCATORS
REQUIRED INFORMATION
1. UNLABELED FIELD*
Enter your Provider name and address as it appears
on the Vermont Medicaid Provider Enrollment form.
2. UNLABELED FIELD
Enter “Enhanced Residential Care”.
3a. PATIENT CONTROL #
For accounting purposes, enter the patient control #
in the field locator. The number may consist of up to
24 characters, alpha/numeric. This information will
appear on the Remittance Advice (RA).
3b. MEDICAL RECORD #
Enter patient’s medical record #.
4. TYPE OF BILL*
Enter the code indicating the specific type of bill for
Enhanced Residential Care. The sequence is as
follows:
1. Type of facility
3. Home Health or E.R.C
2. Bill Classification
2-Home Health or E.R.C
3. Frequency
1-Admit through discharge claim
2-Interim-first claim
3-Interim-continuity claim
4-Interim-last claim
5-Late charge(s) only
6. STATEMENT COVERS PERIOD*
Enter the beginning and ending service dates
included on the bill.
8b. PATIENT’S NAME*
Enter the patient’s last name, first name, middle
initial.
10. BIRTHDATE
Enter the date of birth
12. ADMISSION DATE*
Enter date of admission
13. ADMISSION HOUR*
Enter the hour in which patient was admitted
14. ADMISSION TYPE*
Enter the code indicating the priority of the
admission:
1-Emergency
2-Urgent
3-Elective
4-Nursery
16. DISCHARGE HOUR
Enter the hour in which patient was admitted.
17. STAT*
Enter the two digit code indicating the patient’s
status as of the ‘through date’ of the statement
period.
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18-28. CONDITONS CODES
Enter code to identify if condition is related to the
following (*PSRO code is mandatory):
02-Conditon is Employment Related
A1-EPSDT Related Services
A4-Family Planning Related Services
29. ACCIDENT STATE
31-34. OCCURRENCE CODE &
DATE*
Enter one of the following two digit accident codes
and the corresponding date when applicable or 52 if
no other applies:
01-Auto Accident
02-Auto Accident/No Fault Insurance Involved
03-Accident/Tort Liability
04-Accident/Employment Related
05-Other Accident
06-Crime Victim
11-No Accident/Onset of Symptoms or Illness
42-Date of Discharge
50-Medical Emergency-Non-accidental
51-Outpatient Surgery Related
52-Not an Accident
39. VALUE CODES AMOUNT
Enter the number of covered days in the
amount/dollar column. Do not count the day of
discharge or the date of death. (The sum of all
days should be equal to the amount of days
being billed.)
42. REVENUE CODES*
Enter the appropriate revenue code for the service
provided.
45. SERVICE DATE*
Enter the ‘FROM’ date of the span of consecutive
service dates being billed.
46. SERVICE UNITS*
Enter the number of units which reimbursement is
being requested.
47. TOTAL CHARGES*
Enter the total charges pertaining to each revenue
code billed for the current billing period. Add the total
charges for all revenue codes being billed and enter
at the bottom of column 47 in the total field. (detail
line 23)
50. PAYER NAME*
Enter “Medicare” or “Spend Down” (if spend down
amount applies to the claim.) on 50a if Medicare is
the primary payer. On 50b, enter the other insurance
name if applicable. Enter “Vermont Medicaid” on
50c.
54. PRIOR PAYMENTS*
Enter the payment amount associated with the payer
listed in field locator 50. Attach spend down Notice of
Decision. Documentation must be attached if there
was no payment, if the services are not covered by
the third party.
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55. ESTIMATED AMOUNT DUE
Enter the amount due after deducting any amount
entered in field locator 54 from the total entered at
the bottom of column 47.
56. NPI*
Enter the BILLING provider’s NPI number
57a. TAXONOMY CODE(S)
Enter the BILLING provider’s Taxonomy Code when
applicable.
57c. VERMONT MEDICAID ID #
Atypical providers, enter your Vermont Medicaid
billing provider number.
60. INSURED'S MEMBER ID*
Enter the member's Vermont Medicaid ID #.
67. PRINCIPAL DIAGNOSES
CODE*
Enter the primary diagnosis code. Use the
appropriate ICD-9-CM code (for dates of service on
or after October 1, 2015, ICD-10 codes must be
used).
67 a-q. OTHER DIAGNOSES
CODES
Enter the appropriate ICD-9-CM codes (for dates of
service on or after October 1, 2015, ICD-10 codes
must be used) for any condition other than primary,
which requires supplementary treatment.
74. PRINCIPAL PROCEDURE
CODE & DATE
Enter the appropriate ICD-9-CM procedure code (for
dates of service on or after October 1, 2015, ICD-10
codes must be used) and corresponding date.
74 a-e. OTHER PROCEDURE
CODE & DATE
Enter the appropriate ICD-9-CM procedure codes
(for dates of service on or after October 1, 2015,
ICD-10 codes must be used) and dates other than
the principal procedure performed.
76. ATTENDING PHYSICIAN NPI*
Enter the individual Attending Physician’s NPI
number.
If billing with a Vermont Medicaid ID #, leave the NPI
field blank and enter the Vermont Medicaid ID # to
the right of the qualifier box.
80. REMARKS
Enter any notations relating specific information
necessary to adjudicate the claim.
81CCa.
Enter the taxonomy code for the attending provider.
Must correspond with the NPI number in field locator
76.
CHOICES FOR CARE: NURSING FACILITIES - GENERAL BILLING INFORMATION
15.2.1 Authorization for Care & Non-Covered Services
Eligibility for long-term care is based on income available for care, admission/discharge status and the
medical need for the long-term care.
Personal comfort items, such as the following, are not covered under the Vermont Medicaid program:
Radio
Television
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Telephone
Air conditioner
Beauty and barber services
Deodorant
Denture cream
Hair brush
If the member requests any personal comfort items, the member must be advised that he or she will be
charged. The facility may charge the member for store items secured for the member such as magazines,
newspapers, candy, tobacco and dry cleaning.
15.2.2 Member Placement Levels (RPL)
The following placement levels are used for specific classifications of long-term care members in the DCF
ACCESS system long panel:
010
NH Highest Coverage
011
ERC Highest Coverage
012
HCBS Highest Coverage
014
NH Highest Special
015
ERC Highest Special
016
Cash& Counseling High
020
NH High Coverage
021
ERC High Coverage
022
HCBS High Coverage
030
HCBS Mod Coverage
040
NH Highest Rehab
The RPL is determined by DAIL and entered into the Access system by DCF (high/highest needs) or DAIL
(Moderate Needs Program). Placement is not reported on the UB-04 claim form.
15.2.3 DME in Health Care Institutions
Payment will not be made for DME and supplies ordered by a physician when the member is an inpatient in
a health care institution, specifically a general or psychiatric hospital, nursing facility, or intermediate care
facility for the mentally retarded (ICF-MR). In these cases, the all-inclusive payment made to these facilities
includes the equipment and supplies used by the members.
The one exception is that payment will be made for a seating system, including required accessories, for
an individual residing in a long-term care facility when the seating system is prescribed by a masters or
doctoral level physical or occupational therapist trained in rehabilitative equipment and is so unique to the
individual that it would not be useful to other nursing home residents. Cushions not integral to the seating
system are not covered by this exception.
Payment for orthotics and prosthetics, including ostomy supplies and elastic stockings, may be made to the
DME vendor when furnished to members in residential facilities, including nursing homes. The doctor and
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vendor must keep a medical necessity form and/or order, completed by the physician, and/or other
documentation of medical need in the member’s record.
15.2.4 Duration of Coverage
A continuous period of long-term care residence begins in any long-term care facility with the most recent:
Day of admission to the facility
Initial date of Vermont Medicaid eligibility
First day medical need for long-term care is established by the Utilization Review
Committee decision
Payment ends on the last day of eligibility, or the day before the day of discharge or death.
15.2.5 Hold Bed
Payment for hold bed days, when a patient is hospitalized, is limited to six consecutive days. A facility may
bill for hold bed days when the following criteria are met:
1. While the patient is Medicaid eligible
2. When the patient has been a resident of the nursing home and has been admitted directly to a
hospital
3. When the patient’s attending physician attests that the patient is expected to be readmitted to the
nursing home in ten days or less or when the hospital’s discharge planning unit provides notice that
the discharge will occur on a day within the 10-day time limit AND
4. When the facility has no other licensed bed available that is also suitable to the gender of the patient
for whom the bed will be held. (Example: If the hospitalized patient is male and there is no other
male beds available, a hold bed day can be billed even if one female bed is empty.)
Under hold bed restrictions, the Vermont Medicaid Program will not reimburse for the following:
Leave of absences during a hold bed stay
Hold bed days for members with MR or MH admissions
Hold bed days for swing bed facilities.
A Discharge Notice must be completed if the member is unlikely to be able to return to the nursing home
or, if during the ten days, the member’s condition changes such that he/she will not be able to return within
the ten days. The date of discharge when a hospital admission is needed is the date of admission to the
hospital. If the member’s condition changes the date of discharge is the day on which the determination
was made or the tenth day.
To bill for a hold bed situation, enter the appropriate revenue code (0185) in field locator 42 (Revenue
Code). The hold bed start date is entered in field locator 45 (Service Date) and the total number of days to
be billed should be entered in field locator 46 (Service Units). Enter total at the bottom of column 47 in the
totals field.
Note: If separate nonconsecutive services occur, the provider must enter a separate detail line with the
appropriate revenue code for the service. For example:
Rev. Code & Description
Start Date
Days/Units
Billed Amount
120 - Room/Board
02/01/07
15
$1500.00
185 - Hold Bed
02/16/07
3
$300.00
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120 - Room/Board
02/19/07
10
$1000.00
When billing a Hold Bed claim electronically, the information below is required in the claim note section.
Claim Note Section:
The information in the notes segment must state: CERT FORM and to and from dates the facility was at
maximum licensed occupancy. Electronic claims submitted without this information will be denied.
Providers submitting a Hold Bed claim on paper are required to include an Occupancy Certification Form
stating that the nursing home would otherwise be at its maximum licensed occupancy. Paper claims
submitted without the Occupancy Certification Form will be denied.
15.2.6 Leave of Absence
Leave days are counted by nights away from the facility for the purpose of a home visit. The maximum
number of leave days is 24 per calendar year. If a patient is gone the night of the 4th, both the start date
and the end date would be the 4th. If the patient leaves the 4th and returns on the 6th, the start date would
be the 4th and the end date would be the 5th. The patient is considered back at the facility to sleep the night
of the 6th.
To bill for a leave of absence situation, enter the appropriate revenue code (0182) in field locator 42
(Revenue Code). The leave of absence start date is entered in field locator 45 (Service Date) and the total
number of days to be billed should be entered in field locator 46 (Service Units). Enter total at the bottom of
column 47 in the totals field.
If separate non-consecutive services occur, the provider must enter a separate detail line with the
appropriate revenue code for the service. For example:
Rev. Code & Description
Start Date
Days/Units
Billed Amount
120 - Room/Board
02/01/07
15
$1500.00
182 - Leave of Absence
02/16/07
3
$300.00
120 - Room/Board
02/19/07
10
$1000.00
15.2.7 Nursing Home Claims & Patient Hospitalization
When a nursing home bills an entire month but the patient was hospitalized for a portion of the billed
month, the claim must be recouped and a corrected claim(s) resubmitted.
If the criteria is met to bill a hold bed, follow the directions stated in the Hold Bed, Section of this manual.
If the hold bed criteria is not met, 2 separate claims must be billed when a patient is discharged from a
nursing home and later readmitted into the same nursing home in any one given month.
Do not send a partial refund for the days the patient is hospitalized; this will not correct the actual days that
the patient was at the nursing home and does not constitute correct coding.
15.2.8 Patient Share in a Nursing Facility
Patient share amounts are deducted from nursing facilities the first claim of the month when a member is
still a patient. When the patient is discharged from a nursing facility prior to month’s end, providers are
required to adjust & recoup all claims paid for the month of discharge and resubmit one claim for the entire
month's service, using the appropriate patient status code. The claim will then be processed and
reimbursed without the patient share deduction. See Section 13.3 Patient Share (Applied Income)
Reporting.
15.2.9 Prior Payments
Providers are required to report all prior payments made on a claim. This includes Patient Share, Medicare
and all Third Party payments are to be totaled and recorded in field locator 54b of the UB04 Claim Form.
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15.2.10 Choices for Care Short-Term Respite Stays
Individuals enrolled in Choices for Care in the home or ERC settings may receive short-term respite in a
Vermont Medicaid licensed nursing facility by changing their Choices for Care setting. This is done by
notifying DCF and DAIL using the CFC 804 Change Form. Once the DCF ACCESS long panel is updated
with the nursing facility information, the facility may bill Medicaid using the appropriate revenue code.
(Respite stays exceeding 30-days may trigger a change in patient share.
15.2.11 Services Included in Per Diem Rate
The services included in the per diem rate for the nursing facility are described in the Division of Rate
Setting’s reimbursement regulations. Please contact that division if you are in need of a copy of the
regulations. A complete list of covered services included in a nursing facility’s per diem rate for long term
care can be found in DVHA’s Medicaid Covered Service Rule 7603 at
http://humanservices.vermont.gov/on-line-rules/dvha/medicaid-covered-services-7100-7700/view.
15.2.12 Short Term Stays
The Medicaid benefit package includes a short-term Skilled Nursing Facility (SNF) stay that is limited to not
more than 30 days per episode and 60 days per calendar year.
Admission of a Medicaid member to a Skilled Nursing Facility (SNF) per the benefit outlined above will be
based on a physician's order for SNF services with documentation of medical necessity for the treatment of
illness or injury. The admitting diagnosis must support all treatment and therapies ordered and maintain
that the service cannot be provided at a lower level of care.
As of November 1, 2014, individuals are not required to submit a Choices for Care application for short-
term SNF stays. Instead, the SNF will submit a notice of admission and discharge (long panel) to DCF
using form CFC 804C. The facility will submit Medicaid claims for coverage using revenue code 128 and
will be paid out of the Choices for Care budget under the Highest Need category.
For a stay greater than 30 days per episode or a cumulative stay greater than 60 days per calendar year, a
Choices for Care Long-Term Care application is required.
The Department of Disabilities, Aging and Independent Living website provides access to the following
information regarding this change:
1) Choices for Care 1115 Highest and High Needs Manual:
Section II: Eligibility: http://www.ddas.vermont.gov/ddas-policies/policies-cfc/policies-cfc-
highest/policies-cfc-highest-documents/cfc-high-manual-section-2
Section V.1: Application and Eligibility Determination Procedures: http://www.ddas.vermont.gov/ddas-
policies/policies-cfc/policies-cfc-highest/policies-cfc-highest-documents/cfc-high-manual-section-5-1
2) CFC 804C form: http://www.ddas.vermont.gov/ddas-programs/programs-cfc/programs-cfc-default-
page#highest
15.2.13 Nursing Facilities Billing Instructions/Field Locators
All information on the UB-04 Claim Form should be typed or legibly printed. The fields listed below are
used by DXC Technology when processing Vermont Medicaid claims. The fields designated by an asterisk
(*) are mandatory; other fields are required when applicable. Only the fields listed below are used in the
Vermont Medicaid Program; other fields do not need to be completed.
FIELD LOCATORS
REQUIRED INFORMATION
1. UNLABELED FIELD*
Enter your Nursing Home name and address as it
appears on the Vermont Medicaid Provider
Enrollment form.
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2. UNLABELED FIELD
Enter “Vermont Medicaid Nursing Home”.
3a. PATIENT CONTROL #
For accounting purposes, enter the patient control #
in the field locator. The number may consist of up to
24 characters, alpha/numeric. This information will
appear on the Remittance Advise (RA).
3b. MEDICAL RECORD #
Enter patient’s medical record #.
4. TYPE OF BILL*
Enter the code indicating the specific type of bill for
Enhanced Residential Care. The sequence is as
follows:
1. Type of facility
2-Skilled Nursing
6-Intermediate Care
8-Respite Special Facility
2. Bill Classification
1-Inpatient (Part A)
2-Hospital Based or Inpatient (Part B)
(Included HHA visits under a Part
B plan of treatment)
5-Intermediate Care-Level I
6-Intermediate Care-Level II
7-Sub-Acute Inpatient (Revenue code 19X
required)
8-Swing Bed (used to indicate billing for
SNF level of care in a hospital with an
approved swing bed agreement).
3. Frequency
1-Admit through discharge claim
2-Interim-first claim
3-Interim-continuity claim
4-Interim-last claim
5-Late charge(s) only
6. STATEMENT COVERS PERIOD*
Enter the from and through service dates
8b. PATIENT’S NAME*
Enter the patient’s last name, first name and middle
initial.
10. BIRTHDATE
Enter the date of birth
12. ADMISSION DATE*
Enter date of admission
13. ADMISSION HOUR*
Enter the hour in which patient was admitted
14. SOURCE OF ADMISSION
Enter the appropriate source of admission
1. Physician referral
2. Clinic referral
3. HMO referral
4. Transfer from a Hospital
5. Transfer from a Skilled Nursing Facility
6. Transfer from another Health Care Facility
7. Emergency Room
8. Direction of the Court or Law
Enforcement
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9. Information is not available.
A. Transfer from a Critical Access Hospital
B. Transfer from a Home Health Agency
16. DISCHARGE HOUR*
Enter the hour in which patient was discharged
17. STAT*
Enter the two digit code indicating the patient’s
status as of the ‘through date’ of the statement
period.
18-28. CONDITONS CODES*
Enter code to identify if condition is related to the
following (*PSRO code is mandatory):
M1- Benefits Exhausted
M2- Non Qualifying Stay
31-34. OCCURRENCE CODE &
DATE*
Enter one of the following two digit accident codes
and corresponding occurrence date if, applicable or
52 if no other applies:
01-Auto Accident
02-Auto Accident/No Fault Insurance Involved
03-Accident/Tort Liability
04-Accident/Employment Related
05-Other Accident
06-Crime Victim
11-No Accident/Onset of Symptoms or Illness
42-Date of Discharge
50-Medical Emergency-Non-accidental
51-Outpatient Surgery Related
52-Not an Accident
39. VALUE CODES AMOUNT*
Enter the number of covered days in the
amount/dollar column. Do not count the day of
discharge or the date of death. (The sum of all
days should be equal to the amount of days
being billed.)
42. REVENUE CODES*
Enter the appropriate revenue code for the service
provided.
Acceptable room revenue codes are as follows:
0120= Room/Board/Semi-private, 2 beds
0128= Short-term stay/Rehab
0130= Room/Board/Semi-private, 3-4 beds
0182= Leave of Absence
0185= Hold Bed Days
45. SERVICE DATE*
Enter the appropriate start date of the revenue code
being billed for this detail charge.
46. SERVICE UNITS*
Enter the number of days being billed for this detail
charge for the room charge and units of service for
any ancillary charges.
47. TOTAL CHARGES*
Enter the total charges pertaining to each revenue
code billed for the current billing period. Add the total
charges for all revenue codes being billed and enter
at the bottom of column 47 in the total field. (detail
line 23)
5/23/2018 Green Mountain Care Provider Manual 161
50. PAYER*
Enter “Patient Share” in 50a, “Medicare” on 50b (if
Medicare is the primary payer after patient share.) If
other third party, enter name of insurer in 50b. Enter
“Vermont Medicaid” on 50c. As of DOS 10/01/05,
claims do not need to list patient share. This field will
be auto-populated.
54. PRIOR PAYMENTS*
Enter the payment amount associated with the payer
listed in field locator 50.
55. ESTIMATED AMOUNT DUE
Enter the amount due after deducting any amount
entered in field locator 54 from the total entered at
the bottom of column 47.
56. NPI*
Enter the BILLING provider’s NPI number.
57a. TAXONOMY CODE(S)
Enter the BILLING provider’s Taxonomy Code when
applicable.
57c. VERMONT MEDICAID ID #
Atypical providers, enter your Vermont Medicaid
billing provider number.
60. INSURED'S MEMBER ID*
Enter the member’s Vermont Medicaid ID #.
67. PRINCIPAL DIAGNOSIS
CODE*
Enter the primary diagnosis code. Use the
appropriate ICD-9-CM code (for dates of service on
or after October 1, 2015, ICD-10 codes must be
used).
67a-q. OTHER DIAGNOSES
CODES
Enter the appropriate ICD-9-CM codes (for dates of
service on or after October 1, 2015, ICD-10 codes
must be used) for any condition other than primary,
which requires supplementary treatment.
69. ADMITTING DIAGNOSIS CODE
Enter the admitting diagnosis code.
74. PRINCIPAL PROCEDURE
CODE & DATE
Enter the appropriate ICD-9-CM procedure code (for
dates of service on or after October 1, 2015, ICD-10
codes must be used) and corresponding date.
74 a-e. OTHER PROCEDURE
CODE & DATE
Enter the appropriate ICD-9-CM procedure codes
(for dates of service on or after October 1, 2015,
ICD-10 codes must be used) and dates other than
the principal procedure performed.
76. ATTENDING PHYSICIAN*
Enter the individual Attending Physician’s NPI
number.
If billing with a Vermont Medicaid ID #, leave the NPI
field blank and enter the Vermont Medicaid ID # to
the right of the qualifier box.
80. REMARKS
Enter any notations relating specific information
necessary to adjudicate the claim.
81CCa.
Enter the taxonomy code for the attending provider.
Must correspond with the NPI number in field locator
76.
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HOME BASED WAIVER (HBW) BILLING INSTRUCTIONS/FIELD LOCATORS
This section applies to members receiving Choices for Care home based high/highest and Moderate Needs
services.
All information on the UB-04 claim form is to be typed or legibly printed. The fields listed below are used by
DXC when processing Vermont Medicaid claims. The fields designated by an asterisk (*) are mandatory;
other fields are required when applicable. Only the fields listed below are used in the Vermont Medicaid
Program; other fields do not need to be completed.
FIELD LOCATORS
REQUIRED INFORMATION
1. UNLABELED FIELD*
Enter your Provider name and address as it appears
on the Vermont Medicaid Provider Enrollment form.
2. UNLABELED FIELD
Enter “Home Based Waiver”.
3a. PATIENT CONTROL #
For accounting purposes, enter the patient control #
in the field locator. The number may consist of up to
24 characters, alpha/numeric. This information will
appear on the Remittance Advice (RA).
3b. MEDICAL RECORD #
Enter patient’s medical record #.
4. TYPE OF BILL*
Enter the code indicating the specific type of bill for
Enhanced Residential Care. The sequence is as
follows:
1. Type of facility
3-Home Health or H.B.W
2. Bill Classification
1-Hospice (Non-hospital based)
2-Hospice (Hospital based)
2-Home Health or H.B.W
4-Ambulatory Surgical Center
3. Frequency
1-Admit through discharge claim
2-Interim-first claim
3-Interim-continuity claim
4-Interim-last claim
5-Late charge(s) only
6. STATEMENT COVERS PERIOD*
Enter the from and through service dates
8b. PATIENT’S NAME*
Enter the patient’s last name, first name and middle
initial.
10. BIRTHDATE
Enter the date of birth
12. ADMISSION DATE*
Enter the date patient care started for Home Based
Waiver.
13. ADMISSION HOUR*
Enter the hour in which patient was admitted
14. ADMISSION TYPE*
Enter the code indicating the priority of the
admission:
1-Emergency
2-Urgent
3-Elective
4-Nursery
5/23/2018 Green Mountain Care Provider Manual 163
17. STAT*
Enter the two digit code indicating the patient’s
status as of the ‘through date’ of the statement
period.
18-28. CONDITONS CODES* Enter code to
identify if condition is related to the following (*PSRO
code is mandatory):
02-Conditon is Employment Related
A1-EPSDT Related Services
A4-Family Planning Related Services
31-34. OCCURRENCE CODE &
DATE*
Enter one of the following two digit accident codes,
and the corresponding occurrence date, if applicable
or 52 if no other applies:
01-Auto Accident
02-Auto Accident/No Fault Insurance Involved
03-Accident/Tort Liability
04-Accident/Employment Related
05-Other Accident
06-Crime Victim
11-No Accident/Onset of Symptoms or Illness
42-Date of Discharge
50-Medical Emergency-Non-accidental
51-Outpatient Surgery Related
52-Not an Accident
39. VALUE CODES*
Enter the number of covered days. Do not count the
day of discharge or the date of death. (The sum
of all days should be equal to the amount of days
being billed.)
42. REVENUE CODES*
Enter the appropriate revenue code for the service
provided.
45. SERVICE. DATE*
Enter the ‘FROM’ date of the span of consecutive
service dates being billed.
46. SERVICE. UNITS*
Enter the number of units which reimbursement is
being requested.
47. TOTAL CHARGES*
Enter the total charges pertaining to each revenue
code billed for the current billing period. Add the total
charges for all revenue codes being billed and enter
at the bottom of column 47 in the total field. (detail
line 23)
50. PAYER NAME*
Enter “Patient Liability” in 50a, “Medicare” on 50b (if
Medicare is the primary payer after Patient Share). If
other third party, enter name of insurer in 50b. Enter
“Vermont Medicaid” on 50c. As of DOS 10/01/05,
Claims do not need to list patient share. This field will
be auto-populated.
54. PRIOR PAYMENTS*
Enter the payment amount associated with the payer
listed in field locator 50. Attach spend down Notice of
Decision. Documentation must be attached if there
was no payment, if the services are not covered by
the third party.
5/23/2018 Green Mountain Care Provider Manual 164
55. ESTIMATED AMOUNT DUE
Enter the amount due after deducting any amount
entered in field locator 54 from the total entered at
the bottom of column 47.
56. NPI*
Enter the BILLING provider’s NPI number.
57a. TAXONOMY CODE(S)
Enter the BILLING provider’s Taxonomy Code when
applicable.
57c. VERMONT MEDICAID ID #
Atypical providers, enter your Vermont Medicaid
billing provider number.
60. INSURED'S MEMBER ID*
Enter the member’s Vermont Medicaid ID #.
67. PRINCIPAL DIAGNOSES
CODE*
Enter the primary diagnosis code. Use the
appropriate ICD-9-CM code (for dates of service on
or after October 1, 2015, ICD-10 codes must be
used).
67a-q. OTHER DIAGNOSES
CODES
Enter the appropriate ICD-9-CM codes (for dates of
service on or after October 1, 2015, ICD-10 codes
must be used) for any condition other than primary,
which requires supplementary treatment.
69. ADMITTING DIAGNOSES
CODE*
Enter the Admitting Diagnoses Code
74. PRINCIPAL PROCEDURE
Enter the appropriate ICD-9-CM procedure code (for
dates of service on or after October 1, 2015, ICD-10
codes must be used) and corresponding date.
74a-e. OTHER PROCEDURE
Enter the appropriate ICD-9-CM procedure codes
(for dates of service on or after October 1, 2015,
ICD-10 codes must be used) and dates other than
the principal procedure performed.
76. ATTENDING PHYSICIAN*
Enter the individual Attending Physician’s NPI
number.
If billing with a Vermont Medicaid ID #, leave the NPI
field blank and enter the Vermont Medicaid ID # to
the right of the qualifier box.
80. REMARKS
Enter any notations relating specific information
necessary to adjudicate the claim
81CCa
Enter the taxonomy code for the attending provider.
Must correspond with the NPI number in field locator
76.
Section 16 Program Integrity
FRAUD
Medicaid pays only for services that are actually provided and that are medically necessary. In filing a claim
for reimbursement, the code(s) should be chosen that most accurately describes the service that was
provided. It is a felony under Vermont law 33VSA Sec. 141(d) knowingly to do, attempt, or aid and abet in
any of the following when seeking for receiving reimbursement from Vermont Medicaid:
5/23/2018 Green Mountain Care Provider Manual 165
Billing for services not rendered or more services than actually performed
Providing and billing for unnecessary services
Billing for a higher level of services than actually performed
Charging higher rates for services to Medicaid than other providers
Coding billing records to get more reimbursement
Misrepresenting an unallowable service on bill as another allowable service
Falsely diagnosing so Medicaid will pay more for services
Suspected fraud, waste or abuse should be reported to the DVHA Program Integrity Unit at
http://dvha.vermont.gov/for-providers/program-integrity, telephone (802) 879-5900 or the Medicaid Fraud
Control Unit of the Vermont’s Attorney General’s Office, telephone (802) 828-5511.
PRIVATE LITIGATION
Providers are asked to notify Vermont Medicaid if they receive any information regarding private litigation in
which the DVHA may have an interest. These private litigations might include malpractice suits involving
Vermont Medicaid members, accident suits or personal injury suits.
SANCTIONS
The DVHA may take administrative action against providers found in violation of Vermont Medicaid policy.
See section 7106 of the Medicaid Rules for regulatory details pertaining to sanctions and appeals. A copy of
Medicaid Rules is posted at http://humanservices.vermont.gov/on-line-rules/dvha and at each DCF District
Office and at the state library in Montpelier.
PROGRAM INTEGRITY RECONSIDERATION & APPEAL PROCESS
The Department of Vermont Health Access (DVHA), Program Integrity Unit offers a Reconsideration and
Appeal process for improper payments and the recovery of overpayments.
16.4.1 Reconsideration of Improper Payment and the Recovery of Overpayments
A provider who receives a letter notifying of an overpayment determination has the option to request
reconsideration by the Program Integrity Unit.
A. The request must be made within thirty (30) calendar days of the date of the letter from
Program Integrity and must file the request on the Request for Reconsideration of the
Recovery of Overpayments by Program Integrity form located at http://dvha.vermont.gov/for-
providers/forms-1.
B. All issues regarding the provider’s objection to the findings must be documented and no
monetary threshold is applied. Failure to do so will result in the reconsideration request being
waived.
C. The reconsideration review will be conducted by a qualified person within the Program Integrity
Unit of DVHA.
D. DVHA has 30 calendar days to respond following the later of:
(1) Receipt of reconsideration form
(2) the date of a meeting with the provider, if one is scheduled,
(3) the date additional information is received from the provider (if requested by DVHA).
E. During the reconsideration process, the provider may request in writing an additional 14 days
to respond to a request by DVHA.
F. In some circumstances, DVHA may notify the provider that an additional 14 day extension is
invoked.
G. After review and reconsideration, DVHA will send the provider a final letter regarding its
determination. DVHA may send a decision in the event the provider does not reply to a
5/23/2018 Green Mountain Care Provider Manual 166
document request in a timely manner, or in the case a request for reconsideration is not filed in
a timely manner.
A provider who is dissatisfied with the result of the reconsideration decision may follow the process to
submit a Program Integrity Appeal. Submit Reconsideration Request and Forms to:
Program Integrity Appeals
Department of Vermont Health Access
312 Hurricane Lane, Suite 201
Williston, VT 05495
16.4.2 Program Integrity Appeal of Improper Payment and Overpayment Deficient Practice
In order to initiate a Program Integrity Appeal the following process needs to occur:
A. A Program Integrity appeal must be filed within 30 days of the receipt of the reconsideration
decision notice from DVHA or mail date. To file a Program Integrity appeal a provider must
complete the Request for Appeal of a reconsideration decision by Program Integrity located
at http://dvha.vermont.gov/for-providers/forms-1.
B. The provider is required to list all objections to the reconsideration decision notice at the time
of the Program Integrity Appeal, otherwise claims are waived.
C. Program Integrity appeals will be divided into two categories:
Cases in which a reconsideration decision was issued regarding an overpayment of
$15,000 or less will be reviewed the Chief Medical Officer (CMO) or designee. At the
discretion of the CMO or designee, written instructions will be issued to the provider
explaining the process or providing for a meeting with the provider.
Cases in which a reconsideration decision was issued regarding an overpayment of
$15,000 or more will be reviewed by the DVHA Commissioner or designee, who may
convene a hearing to be scheduled within 90 days from the date of the receipt of the
appeal. Appeal hearings shall be conducted under the same rules of conduct as in
current use for hearings for the Human Services Board.
D. Within 14 days of either a meeting by the Chief Medical Officer or designee, or an appeal
hearing by the Commissioner or their designee, the following will be mailed to the provider :
(1) A written request for additional information or an additional meeting to discuss, or
(2) A decision letter. The decision letter will indicate the next level of appeal, as indicated
below, should the provider be dissatisfied with the decision.
E. No money is collected from the provider or offset against claims until a final decision has
been rendered on the Program Integrity appeal.
F. Upon receipt of a Program Integrity Appeal decision letter, DVHA may demand payment from
the provider or offset the overpayment determination from pending claims. The provider may
request a payment plan from DVHA in order to reconcile the overpayment.
Program Integrity appeal decisions are final. Disagreement with the decision has the option to file a
civil action in Superior Court. Submit Appeal Request and Forms to: Program Integrity Appeals, 312
Hurricane Lane, Williston VT 05495
VIOLATIONS
Suspected violations of Vermont Medicaid policies should be reported to the Program Integrity Unit (802)
879-5900. All information will be treated confidentially.
Section 17 Other Provider Information
PROVIDER TAX
5/23/2018 Green Mountain Care Provider Manual 167
State law requires payments, according to a schedule established by The Department of Vermont Health
Access (DVHA). If a health care provider fails to pay its assessments, the commissioner may, after notice
and opportunity for hearing, deduct these assessments arrears and any late-payment penalties from
Vermont Medicaid payments otherwise due the provider pursuant to 33 V.S.A 1952(f).
The DVHA Commissioner retains the authority to adopt an alternative payment schedule for your
organization for good cause shown. If for some reason your financial position demands an alternative
payment schedule, you must seek and gain approval from the Commissioner in advance of the due date.
Contact the Reimbursement Administrator if you have questions at (802) 879-5937.
Your payments should be mailed to:
Lockbox
State of Vermont State Agency of Human Services
Supplemental/Tax Assessment
PO Box 1335
Williston, VT 05495
PHARMACY TAX
A monthly assessment is due to the State of Vermont for each prescription fill or refill sold by retail
pharmacies. This applies to all scripts, and not only to Vermont Medicaid scripts. The amount of the
assessment is $0.10 for each prescription fill or refill. The completed Pharmacy Assessment Monthly
Documentation Form, available online at http://dvha.vermont.gov/for-providers/pharmacy-forms along with
additional information regarding the tax, needs to accompany each monthly payment. Chain pharmacies with
more than one NPI number should complete a separate form for each facility every month.
Section 18 Electronic Health Record Incentive Program
The EHRIP team is responsible for the implementation of the Vermont Medicaid Electronic Health Record
Incentive Program (EHRIP). Established by the 2009 Health Information Technology for Economic and
Clinical Health (HITECH) Act of the American Recovery & Reinvestment Act (ARRA), the program is
designed to support providers during the transition to electronic systems and to improve the quality, safety,
and efficiency of patient healthcare through the use of electronic health records (EHRs).
The EHR Incentive Program provides incentive payments to eligible professionals, eligible hospitals, and
critical access hospitals as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR
technology.
To receive an EHR incentive payment, providers must demonstrate they are “meaningfully using” their
certified EHR technology by meeting certain measurement thresholds, which range from recording patient
information as structured data to exchanging summary of care records. CMS has established these
thresholds for eligible professionals and eligible hospitals. Meaningful Use objectives and measures evolve in
distinct stages.
More information about the Vermont Medicaid EHR Incentive Program’s policies and activities can be found
at the website: http://healthdata.vermont.gov/ehrip
ELECTRONIC HEALTH RECORD PROGRAM RECONSIDERATION PROCESS
The Department of Vermont Health Access (DVHA), Electronic Health Record Incentive Program
(EHRIP) offers a Reconsideration and Appeal process.
Reconsideration of EHRIP Decisions
A provider who receives notification regarding eligibility for: payment amount, overpayment amount, or
recoupment, has the option to request reconsideration by the EHRIP.
5/23/2018 Green Mountain Care Provider Manual 168
A. The request must be made within thirty (30) calendar days of the receipt of the overpayment notice
OR of the denial notice OR within thirty (30) calendar days of the date of the EHRIP payment in
dispute. The request must be filed on the Request for EHRIP Reconsideration form located at
http://healthdata.vermont.gov/ehrip/Audits/Appeals
B. All issues regarding the provider’s objection to the findings must be documented and no monetary
threshold is applied. Failure to do so will result in the reconsideration request being waived.
C. The reconsideration review will be conducted by a qualified person within the EHRIP of DVHA.
D. DVHA has 30 calendar days to respond following the later of:
(1) Receipt of reconsideration form
(2) The date of a meeting with the provider, if one is scheduled,
(3) The date additional information is received from the provider (if requested by DVHA).
E. During the reconsideration process, the provider may request in writing an additional 14 days to
respond to a request by DVHA.
F. In some circumstances, DVHA may notify the provider that an additional 14 day extension is
invoked.
G. After review and reconsideration, DVHA will send the provider a final letter regarding its
determination. DVHA may send a decision in the event the provider does not reply to a document
request in a timely manner, or in the case a request for reconsideration is not filed in a timely
manner.
A provider who is dissatisfied with the result of the reconsideration decision may follow the process to submit
an EHRIP Appeal.
Submit Reconsideration Request and Forms to:
Office of the General Counsel
EHRIP Appeals
Department of Vermont Health Access
NOB 1 South
280 State Drive
Waterbury, VT 05671-1010
APPEAL OF EHR INCENTIVE PROGRAM RECONSIDERATION
In order to initiate an EHR Incentive Program (EHRIP) Appeal the following process needs to occur:
A. An EHRIP appeal must be filed within 30 days of the receipt of the reconsideration decision notice
from DVHA or mail date. To file an EHRIP appeal a provider must complete the Request for
Appeal of EHRIP Reconsideration form located at
http://healthdata.vermont.gov/ehrip/Audits/Appeals
B. The provider is required to list all objections to the reconsideration decision notice at the time of
the EHRIP Appeal, otherwise claims are waived.
C. EHRIP appeals will be divided into two categories:
Cases in which a reconsideration decision was issued regarding an overpayment of $15,000
or less will be reviewed by the Chief Medical Officer (CMO) or designee. At the discretion of
the CMO or designee, written instructions will be issued to the provider explaining the process
or providing for a meeting with the provider.
Cases in which a reconsideration decision was issued regarding an overpayment of $15,000
or more will be reviewed by the DVHA Commissioner or designee, who may convene a
hearing to be scheduled within 90 days from the date of the receipt of the appeal. Appeal
hearings shall be conducted under the same rules of conduct as in current use for hearings for
the Human Services Board.
D. Within 14 days of either a meeting by the Chief Medical Officer or designee, or an appeal hearing
5/23/2018 Green Mountain Care Provider Manual 169
by the Commissioner or their designee, the following will be mailed to the provider :
1. A written request for additional information or an additional meeting to discuss,
-or-
2. A decision letter. The decision letter will indicate the next level of appeal, as indicated below,
should the provider be dissatisfied with the decision.
E. No money is collected from the provider or offset against claims until a final decision has been
rendered on the EHRIP appeal.
F. Upon receipt of an EHRIP Appeal decision letter, DVHA may demand payment from the provider
or offset the overpayment determination from pending claims. The provider may request a
payment plan from DVHA in order to reconcile the overpayment EHRIP appeal decisions are final.
Disagreement with the decision has the option to file a civil action in Superior Court.
Submit Appeal Request and Forms to:
Office of the General Counsel
EHRIP Appeals
Department of Vermont Health Access
NOB 1 South
280 State Drive
Waterbury, VT 05671-1010
5/23/2018 Green Mountain Care Provider Manual 170
Appendix 1
ICD-10
Code
ICD-10 Description
I50.1
Left ventricular failure
I50.20
Unspecified systolic (congestive) heart failure
I50.21
Acute systolic (congestive) heart failure
I50.22
Chronic systolic (congestive) heart failure
I50.23
Acute on chronic systolic (congestive) heart failure
I50.30
Unspecified diastolic (congestive) heart failure
I50.31
Acute diastolic (congestive) heart failure
I50.32
Chronic diastolic (congestive) heart failure
I50.33
Acute on chronic diastolic (congestive) heart failure
I50.40
Unspecified combined systolic (congestive) and diastolic (congestive) heart failure
I50.41
Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42
Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43
Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.9
Heart failure, unspecified
O09.00
Supervision of pregnancy with history of infertility, unspecified trimester
O09.01
Supervision of pregnancy with history of infertility, first trimester
O09.02
Supervision of pregnancy with history of infertility, second trimester
O09.03
Supervision of pregnancy with history of infertility, third trimester
O09.10
Supervision of pregnancy with history of ectopic or molar pregnancy, unspecified trimester
O09.11
Supervision of pregnancy with history of ectopic or molar pregnancy, first trimester
O09.12
Supervision of pregnancy with history of ectopic or molar pregnancy, second trimester
O09.13
Supervision of pregnancy with history of ectopic or molar pregnancy, third trimester
O09.211
Supervision of pregnancy with history of pre-term labor, first trimester
O09.212
Supervision of pregnancy with history of pre-term labor, second trimester
O09.213
Supervision of pregnancy with history of pre-term labor, third trimester
O09.219
Supervision of pregnancy with history of pre-term labor, unspecified trimester
O09.291
Supervision of pregnancy with other poor reproductive or obstetric history, first trimester
O09.292
Supervision of pregnancy with other poor reproductive or obstetric history, second trimester
O09.293
Supervision of pregnancy with other poor reproductive or obstetric history, third trimester
O09.299
Supervision of pregnancy with other poor reproductive or obstetric history, unspecified trimester
O09.30
Supervision of pregnancy with insufficient antenatal care, unspecified trimester
O09.31
Supervision of pregnancy with insufficient antenatal care, first trimester
O09.32
Supervision of pregnancy with insufficient antenatal care, second trimester
O09.33
Supervision of pregnancy with insufficient antenatal care, third trimester
O09.40
Supervision of pregnancy with grand multiparity, unspecified trimester
O09.41
Supervision of pregnancy with grand multiparity, first trimester
O09.42
Supervision of pregnancy with grand multiparity, second trimester
O09.43
Supervision of pregnancy with grand multiparity, third trimester
O09.511
Supervision of elderly primigravida, first trimester
O09.512
Supervision of elderly primigravida, second trimester
O09.513
Supervision of elderly primigravida, third trimester
O09.519
Supervision of elderly primigravida, unspecified trimester
O09.521
Supervision of elderly multigravida, first trimester
O09.522
Supervision of elderly multigravida, second trimester
O09.523
Supervision of elderly multigravida, third trimester
O09.529
Supervision of elderly multigravida, unspecified trimester
O09.611
Supervision of young primigravida, first trimester
O09.612
Supervision of young primigravida, second trimester
O09.613
Supervision of young primigravida, third trimester
O09.619
Supervision of young primigravida, unspecified trimester
5/23/2018 Green Mountain Care Provider Manual 171
O09.621
Supervision of young multigravida, first trimester
O09.622
Supervision of young multigravida, second trimester
O09.623
Supervision of young multigravida, third trimester
O09.629
Supervision of young multigravida, unspecified trimester
O09.70
Supervision of high risk pregnancy due to social problems, unspecified trimester
O09.71
Supervision of high risk pregnancy due to social problems, first trimester
O09.72
Supervision of high risk pregnancy due to social problems, second trimester
O09.73
Supervision of high risk pregnancy due to social problems, third trimester
O09.811
Supervision of pregnancy resulting from assisted reproductive technology, first trimester
O09.812
Supervision of pregnancy resulting from assisted reproductive technology, second trimester
O09.813
Supervision of pregnancy resulting from assisted reproductive technology, third trimester
O09.819
Supervision of pregnancy resulting from assisted reproductive technology, unspecified trimester
O09.821
Supervision of pregnancy with history of in utero procedure during previous pregnancy, first trimester
O09.822
Supervision of pregnancy with history of in utero procedure during previous pregnancy, second trimester
O09.823
Supervision of pregnancy with history of in utero procedure during previous pregnancy, third trimester
O09.829
Supervision of pregnancy with history of in utero procedure during previous pregnancy, unspecified
trimester
O09.891
Supervision of other high risk pregnancies, first trimester
O09.892
Supervision of other high risk pregnancies, second trimester
O09.893
Supervision of other high risk pregnancies, third trimester
O09.899
Supervision of other high risk pregnancies, unspecified 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
O09.93
Supervision of high risk pregnancy, unspecified, third trimester
O10.011
Pre-existing essential hypertension complicating pregnancy, first trimester
O10.012
Pre-existing essential hypertension complicating pregnancy, second trimester
O10.013
Pre-existing essential hypertension complicating pregnancy, third trimester
O10.019
Pre-existing essential hypertension complicating pregnancy, unspecified trimester
O10.02
Pre-existing essential hypertension complicating childbirth
O10.03
Pre-existing essential hypertension complicating the puerperium
O10.111
Pre-existing hypertensive heart disease complicating pregnancy, first trimester
O10.112
Pre-existing hypertensive heart disease complicating pregnancy, second trimester
O10.113
Pre-existing hypertensive heart disease complicating pregnancy, third trimester
O10.119
Pre-existing hypertensive heart disease complicating pregnancy, unspecified trimester
O10.12
Pre-existing hypertensive heart disease complicating childbirth
O10.13
Pre-existing hypertensive heart disease complicating the puerperium
O10.211
Pre-existing hypertensive chronic kidney disease complicating pregnancy, first trimester
O10.212
Pre-existing hypertensive chronic kidney disease complicating pregnancy, second trimester
O10.213
Pre-existing hypertensive chronic kidney disease complicating pregnancy, third trimester
O10.219
Pre-existing hypertensive chronic kidney disease complicating pregnancy, unspecified trimester
O10.22
Pre-existing hypertensive chronic kidney disease complicating childbirth
O10.23
Pre-existing hypertensive chronic kidney disease complicating the puerperium
O10.311
Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, first trimester
O10.312
Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, second trimester
O10.313
Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, third trimester
O10.319
Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy, unspecified trimester
O10.32
Pre-existing hypertensive heart and chronic kidney disease complicating childbirth
O10.33
Pre-existing hypertensive heart and chronic kidney disease complicating the puerperium
O10.411
Pre-existing secondary hypertension complicating pregnancy, first trimester
O10.412
Pre-existing secondary hypertension complicating pregnancy, second trimester
O10.413
Pre-existing secondary hypertension complicating pregnancy, third trimester
O10.419
Pre-existing secondary hypertension complicating pregnancy, unspecified trimester
O10.42
Pre-existing secondary hypertension complicating childbirth
O10.43
Pre-existing secondary hypertension complicating the puerperium
5/23/2018 Green Mountain Care Provider Manual 172
O10.911
Unspecified pre-existing hypertension complicating pregnancy, first trimester
O10.912
Unspecified pre-existing hypertension complicating pregnancy, second trimester
O10.913
Unspecified pre-existing hypertension complicating pregnancy, third trimester
O10.919
Unspecified pre-existing hypertension complicating pregnancy, unspecified trimester
O10.92
Unspecified pre-existing hypertension complicating childbirth
O10.93
Unspecified pre-existing hypertension complicating the puerperium
O11.1
Pre-existing hypertension with pre-eclampsia, first trimester
O11.2
Pre-existing hypertension with pre-eclampsia, second trimester
O11.3
Pre-existing hypertension with pre-eclampsia, third trimester
O11.9
Pre-existing hypertension with pre-eclampsia, unspecified trimester
O12.00
Gestational edema, unspecified trimester
O12.01
Gestational edema, first trimester
O12.02
Gestational edema, second trimester
O12.03
Gestational edema, third trimester
O12.20
Gestational edema with proteinuria, unspecified trimester
O12.21
Gestational edema with proteinuria, first trimester
O12.22
Gestational edema with proteinuria, second trimester
O12.23
Gestational edema with proteinuria, third trimester
O13.1
Gestational [pregnancy-induced] hypertension without significant proteinuria, first trimester
O13.2
Gestational [pregnancy-induced] hypertension without significant proteinuria, second trimester
O13.3
Gestational [pregnancy-induced] hypertension without significant proteinuria, third trimester
O13.9
Gestational [pregnancy-induced] hypertension without significant proteinuria, unspecified trimester
O14.00
Mild to moderate pre-eclampsia, unspecified trimester
O14.02
Mild to moderate pre-eclampsia, second trimester
O14.03
Mild to moderate pre-eclampsia, third trimester
O14.10
Severe pre-eclampsia, unspecified trimester
O14.12
Severe pre-eclampsia, second trimester
O14.13
Severe pre-eclampsia, third trimester
O14.20
HELLP syndrome (HELLP), unspecified trimester
O14.22
HELLP syndrome (HELLP), second trimester
O14.23
HELLP syndrome (HELLP), third trimester
O14.90
Unspecified pre-eclampsia, unspecified trimester
O14.92
Unspecified pre-eclampsia, second trimester
O14.93
Unspecified pre-eclampsia, third trimester
O15.02
Eclampsia in pregnancy, second trimester
O15.03
Eclampsia in pregnancy, third trimester
O15.1
Eclampsia in labor
O15.2
Eclampsia in the puerperium
O16.1
Unspecified maternal hypertension, first trimester
O16.2
Unspecified maternal hypertension, second trimester
O16.3
Unspecified maternal hypertension, third trimester
O16.9
Unspecified maternal hypertension, unspecified trimester
O20.0
Threatened abortion
O20.8
Other hemorrhage in early pregnancy
O20.9
Hemorrhage in early pregnancy, unspecified
O21.0
Mild hyperemesis gravidarum
O21.1
Hyperemesis gravidarum with metabolic disturbance
O21.2
Late vomiting of pregnancy
O21.8
Other vomiting complicating pregnancy
O21.9
Vomiting of pregnancy, unspecified
O23.00
Infections of kidney in pregnancy, unspecified trimester
O23.10
Infections of bladder in pregnancy, unspecified trimester
O23.20
Infections of urethra in pregnancy, unspecified trimester
O23.30
Infections of other parts of urinary tract in pregnancy, unspecified trimester
O23.40
Unspecified infection of urinary tract in pregnancy, unspecified trimester
5/23/2018 Green Mountain Care Provider Manual 173
O23.41
Unspecified infection of urinary tract in pregnancy, first trimester
O23.42
Unspecified infection of urinary tract in pregnancy, second trimester
O23.43
Unspecified infection of urinary tract in pregnancy, third trimester
O23.519
Infections of cervix in pregnancy, unspecified trimester
O23.529
Salpingo-oophoritis in pregnancy, unspecified trimester
O23.599
Infection of other part of genital tract in pregnancy, unspecified trimester
O23.90
Unspecified genitourinary tract infection in pregnancy, unspecified trimester
O23.91
Unspecified genitourinary tract infection in pregnancy, first trimester
O23.92
Unspecified genitourinary tract infection in pregnancy, second trimester
O23.93
Unspecified genitourinary tract infection in pregnancy, third trimester
O24.319
Unspecified pre-existing diabetes mellitus in pregnancy, unspecified trimester
O24.32
Unspecified pre-existing diabetes mellitus in childbirth
O24.419
Gestational diabetes mellitus in pregnancy, unspecified control
O24.429
Gestational diabetes mellitus in childbirth, unspecified control
O24.439
Gestational diabetes mellitus in the puerperium, unspecified control
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
O24.93
Unspecified diabetes mellitus in the puerperium
O25.10
Malnutrition in pregnancy, unspecified trimester
O25.11
Malnutrition in pregnancy, first trimester
O25.12
Malnutrition in pregnancy, second trimester
O25.13
Malnutrition in pregnancy, third trimester
O25.2
Malnutrition in childbirth
O25.3
Malnutrition in the puerperium
O26.00
Excessive weight gain in pregnancy, unspecified trimester
O26.01
Excessive weight gain in pregnancy, first trimester
O26.02
Excessive weight gain in pregnancy, second trimester
O26.03
Excessive weight gain in pregnancy, third trimester
O26.11
Low weight gain in pregnancy, first trimester
O26.12
Low weight gain in pregnancy, second trimester
O26.13
Low weight gain in pregnancy, third trimester
O26.20
Pregnancy care for patient with recurrent pregnancy loss, unspecified trimester
O26.21
Pregnancy care for patient with recurrent pregnancy loss, first trimester
O26.22
Pregnancy care for patient with recurrent pregnancy loss, second trimester
O26.23
Pregnancy care for patient with recurrent pregnancy loss, third trimester
O26.41
Herpes gestationis, first trimester
O26.42
Herpes gestationis, second trimester
O26.43
Herpes gestationis, third trimester
O26.611
Liver and biliary tract disorders in pregnancy, first trimester
O26.612
Liver and biliary tract disorders in pregnancy, second trimester
O26.613
Liver and biliary tract disorders in pregnancy, third trimester
O26.619
Liver and biliary tract disorders in pregnancy, unspecified trimester
O26.62
Liver and biliary tract disorders in childbirth
O26.811
Pregnancy related exhaustion and fatigue, first trimester
O26.812
Pregnancy related exhaustion and fatigue, second trimester
O26.813
Pregnancy related exhaustion and fatigue, third trimester
O26.819
Pregnancy related exhaustion and fatigue, unspecified trimester
O26.821
Pregnancy related peripheral neuritis, first trimester
O26.822
Pregnancy related peripheral neuritis, second trimester
O26.823
Pregnancy related peripheral neuritis, third trimester
O26.829
Pregnancy related peripheral neuritis, unspecified trimester
O26.831
Pregnancy related renal disease, first trimester
O26.832
Pregnancy related renal disease, second trimester
5/23/2018 Green Mountain Care Provider Manual 174
O26.833
Pregnancy related renal disease, third trimester
O26.839
Pregnancy related renal disease, unspecified trimester
O26.891
Other specified pregnancy related conditions, first trimester
O26.892
Other specified pregnancy related conditions, second trimester
O26.893
Other specified pregnancy related conditions, third trimester
O26.90
Pregnancy related conditions, unspecified, unspecified trimester
O30.001
Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimester
O30.002
Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second
trimester
O30.003
Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester
O30.009
Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified
trimester
O30.011
Twin pregnancy, monochorionic/monoamniotic, first trimester
O30.012
Twin pregnancy, monochorionic/monoamniotic, second trimester
O30.013
Twin pregnancy, monochorionic/monoamniotic, third trimester
O30.019
Twin pregnancy, monochorionic/monoamniotic, unspecified trimester
O30.031
Twin pregnancy, monochorionic/diamniotic, first trimester
O30.032
Twin pregnancy, monochorionic/diamniotic, second trimester
O30.033
Twin pregnancy, monochorionic/diamniotic, third trimester
O30.039
Twin pregnancy, monochorionic/diamniotic, unspecified trimester
O30.041
Twin pregnancy, dichorionic/diamniotic, first trimester
O30.042
Twin pregnancy, dichorionic/diamniotic, second trimester
O30.043
Twin pregnancy, dichorionic/diamniotic, third trimester
O30.049
Twin pregnancy, dichorionic/diamniotic, unspecified trimester
O30.091
Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, first trimester
O30.092
Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimester
O30.093
Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, third trimester
O30.099
Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, unspecified
trimester
O30.101
Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimester
O30.102
Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second
trimester
O30.103
Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third
trimester
O30.109
Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified
trimester
O30.111
Triplet pregnancy with two or more monochorionic fetuses, first trimester
O30.112
Triplet pregnancy with two or more monochorionic fetuses, second trimester
O30.113
Triplet pregnancy with two or more monochorionic fetuses, third trimester
O30.119
Triplet pregnancy with two or more monochorionic fetuses, unspecified trimester
O30.121
Triplet pregnancy with two or more monoamniotic fetuses, first trimester
O30.122
Triplet pregnancy with two or more monoamniotic fetuses, second trimester
O30.123
Triplet pregnancy with two or more monoamniotic fetuses, third trimester
O30.129
Triplet pregnancy with two or more monoamniotic fetuses, unspecified trimester
O30.191
Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, first trimester
O30.192
Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimester
O30.193
Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, third trimester
O30.199
Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, unspecified
trimester
O30.201
Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first
trimester
O30.202
Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second
trimester
O30.203
Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third
trimester
5/23/2018 Green Mountain Care Provider Manual 175
O30.209
Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs,
unspecified trimester
O30.211
Quadruplet pregnancy with two or more monochorionic fetuses, first trimester
O30.212
Quadruplet pregnancy with two or more monochorionic fetuses, second trimester
O30.213
Quadruplet pregnancy with two or more monochorionic fetuses, third trimester
O30.219
Quadruplet pregnancy with two or more monochorionic fetuses, unspecified trimester
O30.221
Quadruplet pregnancy with two or more monoamniotic fetuses, first trimester
O30.222
Quadruplet pregnancy with two or more monoamniotic fetuses, second trimester
O30.223
Quadruplet pregnancy with two or more monoamniotic fetuses, third trimester
O30.229
Quadruplet pregnancy with two or more monoamniotic fetuses, unspecified trimester
O30.291
Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, first
trimester
O30.292
Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, second
trimester
O30.293
Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, third
trimester
O30.299
Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, unspecified
trimester
O30.801
Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic
sacs, first trimester
O30.802
Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic
sacs, second trimester
O30.803
Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic
sacs, third trimester
O30.809
Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic
sacs, unspecified trimester
O30.811
Other specified multiple gestation with two or more monochorionic fetuses, first trimester
O30.812
Other specified multiple gestation with two or more monochorionic fetuses, second trimester
O30.813
Other specified multiple gestation with two or more monochorionic fetuses, third trimester
O30.819
Other specified multiple gestation with two or more monochorionic fetuses, unspecified trimester
O30.821
Other specified multiple gestation with two or more monoamniotic fetuses, first trimester
O30.822
Other specified multiple gestation with two or more monoamniotic fetuses, second trimester
O30.823
Other specified multiple gestation with two or more monoamniotic fetuses, third trimester
O30.829
Other specified multiple gestation with two or more monoamniotic fetuses, unspecified trimester
O30.891
Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs,
first trimester
O30.892
Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs,
second trimester
O30.893
Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs,
third trimester
O30.899
Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs,
unspecified trimester
O30.90
Multiple gestation, unspecified, unspecified trimester
O30.91
Multiple gestation, unspecified, first trimester
O30.92
Multiple gestation, unspecified, second trimester
O30.93
Multiple gestation, unspecified, third trimester
O31.00X0
Papyraceous fetus, unspecified trimester, not applicable or unspecified
O31.01X0
Papyraceous fetus, first trimester, not applicable or unspecified
O31.02X0
Papyraceous fetus, second trimester, not applicable or unspecified
O31.03X0
Papyraceous fetus, third trimester, not applicable or unspecified
O31.10X0
Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, not
applicable or unspecified
O31.10X1
Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, fetus 1
O31.10X2
Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, fetus 2
O31.10X3
Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, fetus 3
O31.10X4
Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, fetus 4
5/23/2018 Green Mountain Care Provider Manual 176
O31.10X5
Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, fetus 5
O31.10X9
Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, other fetus
O31.11X0
Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, not applicable or
unspecified
O31.11X1
Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 1
O31.11X2
Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 2
O31.11X3
Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 3
O31.11X4
Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 4
O31.11X5
Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 5
O31.11X9
Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, other fetus
O31.12X0
Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, not applicable or
unspecified
O31.12X1
Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 1
O31.12X2
Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 2
O31.12X3
Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 3
O31.12X4
Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 4
O31.12X5
Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 5
O31.12X9
Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, other fetus
O31.13X0
Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, not applicable or
unspecified
O31.13X1
Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 1
O31.13X2
Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 2
O31.13X3
Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 3
O31.13X4
Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 4
O31.13X5
Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 5
O31.13X9
Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, other fetus
O31.20X0
Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, not applicable or
unspecified
O31.20X1
Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, fetus 1
O31.20X2
Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, fetus 2
O31.20X3
Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, fetus 3
O31.20X4
Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, fetus 4
O31.20X5
Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, fetus 5
O31.20X9
Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, other fetus
O31.21X0
Continuing pregnancy after intrauterine death of one fetus or more, first trimester, not applicable or
unspecified
O31.21X1
Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 1
O31.21X2
Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 2
O31.21X3
Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 3
O31.21X4
Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 4
O31.21X5
Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 5
O31.21X9
Continuing pregnancy after intrauterine death of one fetus or more, first trimester, other fetus
O31.22X0
Continuing pregnancy after intrauterine death of one fetus or more, second trimester, not applicable or
unspecified
O31.22X1
Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 1
O31.22X2
Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 2
O31.22X3
Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 3
O31.22X4
Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 4
O31.22X5
Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 5
O31.22X9
Continuing pregnancy after intrauterine death of one fetus or more, second trimester, other fetus
O31.23X0
Continuing pregnancy after intrauterine death of one fetus or more, third trimester, not applicable or
unspecified
O31.23X1
Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 1
O31.23X2
Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 2
O31.23X3
Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 3
5/23/2018 Green Mountain Care Provider Manual 177
O31.23X4
Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 4
O31.23X5
Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 5
O31.23X9
Continuing pregnancy after intrauterine death of one fetus or more, third trimester, other fetus
O31.30X0
Continuing pregnancy after elective fetal reduction of one fetus or more, unspecified trimester, not
applicable or unspecified
O31.30X1
Continuing pregnancy after elective fetal reduction of one fetus or more, unspecified trimester, fetus 1
O31.30X2
Continuing pregnancy after elective fetal reduction of one fetus or more, unspecified trimester, fetus 2
O31.30X3
Continuing pregnancy after elective fetal reduction of one fetus or more, unspecified trimester, fetus 3
O31.30X4
Continuing pregnancy after elective fetal reduction of one fetus or more, unspecified trimester, fetus 4
O31.30X5
Continuing pregnancy after elective fetal reduction of one fetus or more, unspecified trimester, fetus 5
O31.30X9
Continuing pregnancy after elective fetal reduction of one fetus or more, unspecified trimester, other fetus
O31.31X0
Continuing pregnancy after elective fetal reduction of one fetus or more, first trimester, not applicable or
unspecified
O31.31X1
Continuing pregnancy after elective fetal reduction of one fetus or more, first trimester, fetus 1
O31.31X2
Continuing pregnancy after elective fetal reduction of one fetus or more, first trimester, fetus 2
O31.31X3
Continuing pregnancy after elective fetal reduction of one fetus or more, first trimester, fetus 3
O31.31X4
Continuing pregnancy after elective fetal reduction of one fetus or more, first trimester, fetus 4
O31.31X5
Continuing pregnancy after elective fetal reduction of one fetus or more, first trimester, fetus 5
O31.31X9
Continuing pregnancy after elective fetal reduction of one fetus or more, first trimester, other fetus
O31.32X0
Continuing pregnancy after elective fetal reduction of one fetus or more, second trimester, not applicable
or unspecified
O31.32X1
Continuing pregnancy after elective fetal reduction of one fetus or more, second trimester, fetus 1
O31.32X2
Continuing pregnancy after elective fetal reduction of one fetus or more, second trimester, fetus 2
O31.32X3
Continuing pregnancy after elective fetal reduction of one fetus or more, second trimester, fetus 3
O31.32X4
Continuing pregnancy after elective fetal reduction of one fetus or more, second trimester, fetus 4
O31.32X5
Continuing pregnancy after elective fetal reduction of one fetus or more, second trimester, fetus 5
O31.32X9
Continuing pregnancy after elective fetal reduction of one fetus or more, second trimester, other fetus
O31.33X0
Continuing pregnancy after elective fetal reduction of one fetus or more, third trimester, not applicable or
unspecified
O31.33X1
Continuing pregnancy after elective fetal reduction of one fetus or more, third trimester, fetus 1
O31.33X2
Continuing pregnancy after elective fetal reduction of one fetus or more, third trimester, fetus 2
O31.33X3
Continuing pregnancy after elective fetal reduction of one fetus or more, third trimester, fetus 3
O31.33X4
Continuing pregnancy after elective fetal reduction of one fetus or more, third trimester, fetus 4
O31.33X5
Continuing pregnancy after elective fetal reduction of one fetus or more, third trimester, fetus 5
O31.33X9
Continuing pregnancy after elective fetal reduction of one fetus or more, third trimester, other fetus
O31.8X10
Other complications specific to multiple gestation, first trimester, not applicable or unspecified
O31.8X11
Other complications specific to multiple gestation, first trimester, fetus 1
O31.8X12
Other complications specific to multiple gestation, first trimester, fetus 2
O31.8X13
Other complications specific to multiple gestation, first trimester, fetus 3
O31.8X14
Other complications specific to multiple gestation, first trimester, fetus 4
O31.8X15
Other complications specific to multiple gestation, first trimester, fetus 5
O31.8X19
Other complications specific to multiple gestation, first trimester, other fetus
O31.8X20
Other complications specific to multiple gestation, second trimester, not applicable or unspecified
O31.8X21
Other complications specific to multiple gestation, second trimester, fetus 1
O31.8X22
Other complications specific to multiple gestation, second trimester, fetus 2
O31.8X23
Other complications specific to multiple gestation, second trimester, fetus 3
O31.8X24
Other complications specific to multiple gestation, second trimester, fetus 4
O31.8X25
Other complications specific to multiple gestation, second trimester, fetus 5
O31.8X29
Other complications specific to multiple gestation, second trimester, other fetus
O31.8X30
Other complications specific to multiple gestation, third trimester, not applicable or unspecified
O31.8X31
Other complications specific to multiple gestation, third trimester, fetus 1
O31.8X32
Other complications specific to multiple gestation, third trimester, fetus 2
O31.8X33
Other complications specific to multiple gestation, third trimester, fetus 3
O31.8X34
Other complications specific to multiple gestation, third trimester, fetus 4
O31.8X35
Other complications specific to multiple gestation, third trimester, fetus 5
5/23/2018 Green Mountain Care Provider Manual 178
O31.8X39
Other complications specific to multiple gestation, third trimester, other fetus
O31.8X90
Other complications specific to multiple gestation, unspecified trimester, not applicable or unspecified
O31.8X91
Other complications specific to multiple gestation, unspecified trimester, fetus 1
O31.8X92
Other complications specific to multiple gestation, unspecified trimester, fetus 2
O31.8X93
Other complications specific to multiple gestation, unspecified trimester, fetus 3
O31.8X94
Other complications specific to multiple gestation, unspecified trimester, fetus 4
O31.8X95
Other complications specific to multiple gestation, unspecified trimester, fetus 5
O31.8X99
Other complications specific to multiple gestation, unspecified trimester, other fetus
O32.0XX0
Maternal care for unstable lie, not applicable or unspecified
O32.0XX1
Maternal care for unstable lie, fetus 1
O32.0XX2
Maternal care for unstable lie, fetus 2
O32.0XX3
Maternal care for unstable lie, fetus 3
O32.0XX4
Maternal care for unstable lie, fetus 4
O32.0XX5
Maternal care for unstable lie, fetus 5
O32.0XX9
Maternal care for unstable lie, other fetus
O32.1XX0
Maternal care for breech presentation, not applicable or unspecified
O32.1XX1
Maternal care for breech presentation, fetus 1
O32.1XX2
Maternal care for breech presentation, fetus 2
O32.1XX3
Maternal care for breech presentation, fetus 3
O32.1XX4
Maternal care for breech presentation, fetus 4
O32.1XX5
Maternal care for breech presentation, fetus 5
O32.1XX9
Maternal care for breech presentation, other fetus
O32.2XX0
Maternal care for transverse and oblique lie, not applicable or unspecified
O32.2XX1
Maternal care for transverse and oblique lie, fetus 1
O32.2XX2
Maternal care for transverse and oblique lie, fetus 2
O32.2XX3
Maternal care for transverse and oblique lie, fetus 3
O32.2XX4
Maternal care for transverse and oblique lie, fetus 4
O32.2XX5
Maternal care for transverse and oblique lie, fetus 5
O32.2XX9
Maternal care for transverse and oblique lie, other fetus
O32.3XX0
Maternal care for face, brow and chin presentation, not applicable or unspecified
O32.3XX1
Maternal care for face, brow and chin presentation, fetus 1
O32.3XX2
Maternal care for face, brow and chin presentation, fetus 2
O32.3XX3
Maternal care for face, brow and chin presentation, fetus 3
O32.3XX4
Maternal care for face, brow and chin presentation, fetus 4
O32.3XX5
Maternal care for face, brow and chin presentation, fetus 5
O32.3XX9
Maternal care for face, brow and chin presentation, other fetus
O32.4XX0
Maternal care for high head at term, not applicable or unspecified
O32.4XX1
Maternal care for high head at term, fetus 1
O32.4XX2
Maternal care for high head at term, fetus 2
O32.4XX3
Maternal care for high head at term, fetus 3
O32.4XX4
Maternal care for high head at term, fetus 4
O32.4XX5
Maternal care for high head at term, fetus 5
O32.4XX9
Maternal care for high head at term, other fetus
O32.6XX0
Maternal care for compound presentation, not applicable or unspecified
O32.6XX1
Maternal care for compound presentation, fetus 1
O32.6XX2
Maternal care for compound presentation, fetus 2
O32.6XX3
Maternal care for compound presentation, fetus 3
O32.6XX4
Maternal care for compound presentation, fetus 4
O32.6XX5
Maternal care for compound presentation, fetus 5
O32.6XX9
Maternal care for compound presentation, other fetus
O32.8XX0
Maternal care for other malpresentation of fetus, not applicable or unspecified
O32.8XX1
Maternal care for other malpresentation of fetus, fetus 1
O32.8XX2
Maternal care for other malpresentation of fetus, fetus 2
O32.8XX3
Maternal care for other malpresentation of fetus, fetus 3
O32.8XX4
Maternal care for other malpresentation of fetus, fetus 4
5/23/2018 Green Mountain Care Provider Manual 179
O32.8XX5
Maternal care for other malpresentation of fetus, fetus 5
O32.8XX9
Maternal care for other malpresentation of fetus, other fetus
O32.9XX0
Maternal care for malpresentation of fetus, unspecified, not applicable or unspecified
O32.9XX1
Maternal care for malpresentation of fetus, unspecified, fetus 1
O32.9XX2
Maternal care for malpresentation of fetus, unspecified, fetus 2
O32.9XX3
Maternal care for malpresentation of fetus, unspecified, fetus 3
O32.9XX4
Maternal care for malpresentation of fetus, unspecified, fetus 4
O32.9XX5
Maternal care for malpresentation of fetus, unspecified, fetus 5
O32.9XX9
Maternal care for malpresentation of fetus, unspecified, other fetus
O33.0
Maternal care for disproportion due to deformity of maternal pelvic bones
O33.1
Maternal care for disproportion due to generally contracted pelvis
O33.2
Maternal care for disproportion due to inlet contraction of pelvis
O33.3XX0
Maternal care for disproportion due to outlet contraction of pelvis, not applicable or unspecified
O33.3XX1
Maternal care for disproportion due to outlet contraction of pelvis, fetus 1
O33.3XX2
Maternal care for disproportion due to outlet contraction of pelvis, fetus 2
O33.3XX3
Maternal care for disproportion due to outlet contraction of pelvis, fetus 3
O33.3XX4
Maternal care for disproportion due to outlet contraction of pelvis, fetus 4
O33.3XX5
Maternal care for disproportion due to outlet contraction of pelvis, fetus 5
O33.3XX9
Maternal care for disproportion due to outlet contraction of pelvis, other fetus
O33.4XX0
Maternal care for disproportion of mixed maternal and fetal origin, not applicable or unspecified
O33.4XX1
Maternal care for disproportion of mixed maternal and fetal origin, fetus 1
O33.4XX2
Maternal care for disproportion of mixed maternal and fetal origin, fetus 2
O33.4XX3
Maternal care for disproportion of mixed maternal and fetal origin, fetus 3
O33.4XX4
Maternal care for disproportion of mixed maternal and fetal origin, fetus 4
O33.4XX5
Maternal care for disproportion of mixed maternal and fetal origin, fetus 5
O33.4XX9
Maternal care for disproportion of mixed maternal and fetal origin, other fetus
O33.5XX0
Maternal care for disproportion due to unusually large fetus, not applicable or unspecified
O33.5XX1
Maternal care for disproportion due to unusually large fetus, fetus 1
O33.5XX2
Maternal care for disproportion due to unusually large fetus, fetus 2
O33.5XX3
Maternal care for disproportion due to unusually large fetus, fetus 3
O33.5XX4
Maternal care for disproportion due to unusually large fetus, fetus 4
O33.5XX5
Maternal care for disproportion due to unusually large fetus, fetus 5
O33.5XX9
Maternal care for disproportion due to unusually large fetus, other fetus
O33.6XX0
Maternal care for disproportion due to hydrocephalic fetus, not applicable or unspecified
O33.6XX1
Maternal care for disproportion due to hydrocephalic fetus, fetus 1
O33.6XX2
Maternal care for disproportion due to hydrocephalic fetus, fetus 2
O33.6XX3
Maternal care for disproportion due to hydrocephalic fetus, fetus 3
O33.6XX4
Maternal care for disproportion due to hydrocephalic fetus, fetus 4
O33.6XX5
Maternal care for disproportion due to hydrocephalic fetus, fetus 5
O33.6XX9
Maternal care for disproportion due to hydrocephalic fetus, other fetus
O33.7
Maternal care for disproportion due to other fetal deformities
O33.8
Maternal care for disproportion of other origin
O33.9
Maternal care for disproportion, unspecified
O34.00
Maternal care for unspecified congenital malformation of uterus, unspecified trimester
O34.01
Maternal care for unspecified congenital malformation of uterus, first trimester
O34.02
Maternal care for unspecified congenital malformation of uterus, second trimester
O34.03
Maternal care for unspecified congenital malformation of uterus, third trimester
O34.10
Maternal care for benign tumor of corpus uteri, unspecified trimester
O34.11
Maternal care for benign tumor of corpus uteri, first trimester
O34.12
Maternal care for benign tumor of corpus uteri, second trimester
O34.13
Maternal care for benign tumor of corpus uteri, third trimester
O34.21
Maternal care for scar from previous cesarean delivery
O34.29
Maternal care due to uterine scar from other previous surgery
O34.30
Maternal care for cervical incompetence, unspecified trimester
O34.31
Maternal care for cervical incompetence, first trimester
5/23/2018 Green Mountain Care Provider Manual 180
O34.32
Maternal care for cervical incompetence, second trimester
O34.33
Maternal care for cervical incompetence, third trimester
O34.40
Maternal care for other abnormalities of cervix, unspecified trimester
O34.41
Maternal care for other abnormalities of cervix, first trimester
O34.42
Maternal care for other abnormalities of cervix, second trimester
O34.43
Maternal care for other abnormalities of cervix, third trimester
O34.511
Maternal care for incarceration of gravid uterus, first trimester
O34.512
Maternal care for incarceration of gravid uterus, second trimester
O34.513
Maternal care for incarceration of gravid uterus, third trimester
O34.519
Maternal care for incarceration of gravid uterus, unspecified trimester
O34.521
Maternal care for prolapse of gravid uterus, first trimester
O34.522
Maternal care for prolapse of gravid uterus, second trimester
O34.523
Maternal care for prolapse of gravid uterus, third trimester
O34.529
Maternal care for prolapse of gravid uterus, unspecified trimester
O34.531
Maternal care for retroversion of gravid uterus, first trimester
O34.532
Maternal care for retroversion of gravid uterus, second trimester
O34.533
Maternal care for retroversion of gravid uterus, third trimester
O34.539
Maternal care for retroversion of gravid uterus, unspecified trimester
O34.591
Maternal care for other abnormalities of gravid uterus, first trimester
O34.592
Maternal care for other abnormalities of gravid uterus, second trimester
O34.593
Maternal care for other abnormalities of gravid uterus, third trimester
O34.599
Maternal care for other abnormalities of gravid uterus, unspecified trimester
O34.60
Maternal care for abnormality of vagina, unspecified trimester
O34.61
Maternal care for abnormality of vagina, first trimester
O34.62
Maternal care for abnormality of vagina, second trimester
O34.63
Maternal care for abnormality of vagina, third trimester
O34.70
Maternal care for abnormality of vulva and perineum, unspecified trimester
O34.71
Maternal care for abnormality of vulva and perineum, first trimester
O34.72
Maternal care for abnormality of vulva and perineum, second trimester
O34.73
Maternal care for abnormality of vulva and perineum, third trimester
O34.80
Maternal care for other abnormalities of pelvic organs, unspecified trimester
O34.81
Maternal care for other abnormalities of pelvic organs, first trimester
O34.82
Maternal care for other abnormalities of pelvic organs, second trimester
O34.83
Maternal care for other abnormalities of pelvic organs, third trimester
O34.90
Maternal care for abnormality of pelvic organ, unspecified, unspecified trimester
O34.91
Maternal care for abnormality of pelvic organ, unspecified, first trimester
O34.92
Maternal care for abnormality of pelvic organ, unspecified, second trimester
O34.93
Maternal care for abnormality of pelvic organ, unspecified, third trimester
O35.0XX0
Maternal care for (suspected) central nervous system malformation in fetus, not applicable or unspecified
O35.0XX1
Maternal care for (suspected) central nervous system malformation in fetus, fetus 1
O35.0XX2
Maternal care for (suspected) central nervous system malformation in fetus, fetus 2
O35.0XX3
Maternal care for (suspected) central nervous system malformation in fetus, fetus 3
O35.0XX4
Maternal care for (suspected) central nervous system malformation in fetus, fetus 4
O35.0XX5
Maternal care for (suspected) central nervous system malformation in fetus, fetus 5
O35.0XX9
Maternal care for (suspected) central nervous system malformation in fetus, other fetus
O35.1XX0
Maternal care for (suspected) chromosomal abnormality in fetus, not applicable or unspecified
O35.1XX1
Maternal care for (suspected) chromosomal abnormality in fetus, fetus 1
O35.1XX2
Maternal care for (suspected) chromosomal abnormality in fetus, fetus 2
O35.1XX3
Maternal care for (suspected) chromosomal abnormality in fetus, fetus 3
O35.1XX4
Maternal care for (suspected) chromosomal abnormality in fetus, fetus 4
O35.1XX5
Maternal care for (suspected) chromosomal abnormality in fetus, fetus 5
O35.1XX9
Maternal care for (suspected) chromosomal abnormality in fetus, other fetus
O35.2XX0
Maternal care for (suspected) hereditary disease in fetus, not applicable or unspecified
O35.2XX1
Maternal care for (suspected) hereditary disease in fetus, fetus 1
O35.2XX2
Maternal care for (suspected) hereditary disease in fetus, fetus 2
5/23/2018 Green Mountain Care Provider Manual 181
O35.2XX3
Maternal care for (suspected) hereditary disease in fetus, fetus 3
O35.2XX4
Maternal care for (suspected) hereditary disease in fetus, fetus 4
O35.2XX5
Maternal care for (suspected) hereditary disease in fetus, fetus 5
O35.2XX9
Maternal care for (suspected) hereditary disease in fetus, other fetus
O35.3XX0
Maternal care for (suspected) damage to fetus from viral disease in mother, not applicable or unspecified
O35.3XX1
Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 1
O35.3XX2
Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 2
O35.3XX3
Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 3
O35.3XX4
Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 4
O35.3XX5
Maternal care for (suspected) damage to fetus from viral disease in mother, fetus 5
O35.3XX9
Maternal care for (suspected) damage to fetus from viral disease in mother, other fetus
O35.4XX0
Maternal care for (suspected) damage to fetus from alcohol, not applicable or unspecified
O35.4XX1
Maternal care for (suspected) damage to fetus from alcohol, fetus 1
O35.4XX2
Maternal care for (suspected) damage to fetus from alcohol, fetus 2
O35.4XX3
Maternal care for (suspected) damage to fetus from alcohol, fetus 3
O35.4XX4
Maternal care for (suspected) damage to fetus from alcohol, fetus 4
O35.4XX5
Maternal care for (suspected) damage to fetus from alcohol, fetus 5
O35.4XX9
Maternal care for (suspected) damage to fetus from alcohol, other fetus
O35.5XX0
Maternal care for (suspected) damage to fetus by drugs, not applicable or unspecified
O35.5XX1
Maternal care for (suspected) damage to fetus by drugs, fetus 1
O35.5XX2
Maternal care for (suspected) damage to fetus by drugs, fetus 2
O35.5XX3
Maternal care for (suspected) damage to fetus by drugs, fetus 3
O35.5XX4
Maternal care for (suspected) damage to fetus by drugs, fetus 4
O35.5XX5
Maternal care for (suspected) damage to fetus by drugs, fetus 5
O35.5XX9
Maternal care for (suspected) damage to fetus by drugs, other fetus
O35.6XX0
Maternal care for (suspected) damage to fetus by radiation, not applicable or unspecified
O35.6XX1
Maternal care for (suspected) damage to fetus by radiation, fetus 1
O35.6XX2
Maternal care for (suspected) damage to fetus by radiation, fetus 2
O35.6XX3
Maternal care for (suspected) damage to fetus by radiation, fetus 3
O35.6XX4
Maternal care for (suspected) damage to fetus by radiation, fetus 4
O35.6XX5
Maternal care for (suspected) damage to fetus by radiation, fetus 5
O35.6XX9
Maternal care for (suspected) damage to fetus by radiation, other fetus
O35.8XX0
Maternal care for other (suspected) fetal abnormality and damage, not applicable or unspecified
O35.8XX1
Maternal care for other (suspected) fetal abnormality and damage, fetus 1
O35.8XX2
Maternal care for other (suspected) fetal abnormality and damage, fetus 2
O35.8XX3
Maternal care for other (suspected) fetal abnormality and damage, fetus 3
O35.8XX4
Maternal care for other (suspected) fetal abnormality and damage, fetus 4
O35.8XX5
Maternal care for other (suspected) fetal abnormality and damage, fetus 5
O35.8XX9
Maternal care for other (suspected) fetal abnormality and damage, other fetus
O35.9XX0
Maternal care for (suspected) fetal abnormality and damage, unspecified, not applicable or unspecified
O35.9XX1
Maternal care for (suspected) fetal abnormality and damage, unspecified, fetus 1
O35.9XX2
Maternal care for (suspected) fetal abnormality and damage, unspecified, fetus 2
O35.9XX3
Maternal care for (suspected) fetal abnormality and damage, unspecified, fetus 3
O35.9XX4
Maternal care for (suspected) fetal abnormality and damage, unspecified, fetus 4
O35.9XX5
Maternal care for (suspected) fetal abnormality and damage, unspecified, fetus 5
O35.9XX9
Maternal care for (suspected) fetal abnormality and damage, unspecified, other fetus
O36.0110
Maternal care for anti-D [Rh] antibodies, first trimester, not applicable or unspecified
O36.0111
Maternal care for anti-D [Rh] antibodies, first trimester, fetus 1
O36.0112
Maternal care for anti-D [Rh] antibodies, first trimester, fetus 2
O36.0113
Maternal care for anti-D [Rh] antibodies, first trimester, fetus 3
O36.0114
Maternal care for anti-D [Rh] antibodies, first trimester, fetus 4
O36.0115
Maternal care for anti-D [Rh] antibodies, first trimester, fetus 5
O36.0119
Maternal care for anti-D [Rh] antibodies, first trimester, other fetus
O36.0120
Maternal care for anti-D [Rh] antibodies, second trimester, not applicable or unspecified
O36.0121
Maternal care for anti-D [Rh] antibodies, second trimester, fetus 1
5/23/2018 Green Mountain Care Provider Manual 182
O36.0122
Maternal care for anti-D [Rh] antibodies, second trimester, fetus 2
O36.0123
Maternal care for anti-D [Rh] antibodies, second trimester, fetus 3
O36.0124
Maternal care for anti-D [Rh] antibodies, second trimester, fetus 4
O36.0125
Maternal care for anti-D [Rh] antibodies, second trimester, fetus 5
O36.0129
Maternal care for anti-D [Rh] antibodies, second trimester, other fetus
O36.0130
Maternal care for anti-D [Rh] antibodies, third trimester, not applicable or unspecified
O36.0131
Maternal care for anti-D [Rh] antibodies, third trimester, fetus 1
O36.0132
Maternal care for anti-D [Rh] antibodies, third trimester, fetus 2
O36.0133
Maternal care for anti-D [Rh] antibodies, third trimester, fetus 3
O36.0134
Maternal care for anti-D [Rh] antibodies, third trimester, fetus 4
O36.0135
Maternal care for anti-D [Rh] antibodies, third trimester, fetus 5
O36.0139
Maternal care for anti-D [Rh] antibodies, third trimester, other fetus
O36.0190
Maternal care for anti-D [Rh] antibodies, unspecified trimester, not applicable or unspecified
O36.0191
Maternal care for anti-D [Rh] antibodies, unspecified trimester, fetus 1
O36.0192
Maternal care for anti-D [Rh] antibodies, unspecified trimester, fetus 2
O36.0193
Maternal care for anti-D [Rh] antibodies, unspecified trimester, fetus 3
O36.0194
Maternal care for anti-D [Rh] antibodies, unspecified trimester, fetus 4
O36.0195
Maternal care for anti-D [Rh] antibodies, unspecified trimester, fetus 5
O36.0199
Maternal care for anti-D [Rh] antibodies, unspecified trimester, other fetus
O36.0910
Maternal care for other rhesus isoimmunization, first trimester, not applicable or unspecified
O36.0911
Maternal care for other rhesus isoimmunization, first trimester, fetus 1
O36.0912
Maternal care for other rhesus isoimmunization, first trimester, fetus 2
O36.0913
Maternal care for other rhesus isoimmunization, first trimester, fetus 3
O36.0914
Maternal care for other rhesus isoimmunization, first trimester, fetus 4
O36.0915
Maternal care for other rhesus isoimmunization, first trimester, fetus 5
O36.0919
Maternal care for other rhesus isoimmunization, first trimester, other fetus
O36.0920
Maternal care for other rhesus isoimmunization, second trimester, not applicable or unspecified
O36.0921
Maternal care for other rhesus isoimmunization, second trimester, fetus 1
O36.0922
Maternal care for other rhesus isoimmunization, second trimester, fetus 2
O36.0923
Maternal care for other rhesus isoimmunization, second trimester, fetus 3
O36.0924
Maternal care for other rhesus isoimmunization, second trimester, fetus 4
O36.0925
Maternal care for other rhesus isoimmunization, second trimester, fetus 5
O36.0929
Maternal care for other rhesus isoimmunization, second trimester, other fetus
O36.0930
Maternal care for other rhesus isoimmunization, third trimester, not applicable or unspecified
O36.0931
Maternal care for other rhesus isoimmunization, third trimester, fetus 1
O36.0932
Maternal care for other rhesus isoimmunization, third trimester, fetus 2
O36.0933
Maternal care for other rhesus isoimmunization, third trimester, fetus 3
O36.0934
Maternal care for other rhesus isoimmunization, third trimester, fetus 4
O36.0935
Maternal care for other rhesus isoimmunization, third trimester, fetus 5
O36.0939
Maternal care for other rhesus isoimmunization, third trimester, other fetus
O36.0990
Maternal care for other rhesus isoimmunization, unspecified trimester, not applicable or unspecified
O36.0991
Maternal care for other rhesus isoimmunization, unspecified trimester, fetus 1
O36.0992
Maternal care for other rhesus isoimmunization, unspecified trimester, fetus 2
O36.0993
Maternal care for other rhesus isoimmunization, unspecified trimester, fetus 3
O36.0994
Maternal care for other rhesus isoimmunization, unspecified trimester, fetus 4
O36.0995
Maternal care for other rhesus isoimmunization, unspecified trimester, fetus 5
O36.0999
Maternal care for other rhesus isoimmunization, unspecified trimester, other fetus
O36.1110
Maternal care for Anti-A sensitization, first trimester, not applicable or unspecified
O36.1111
Maternal care for Anti-A sensitization, first trimester, fetus 1
O36.1112
Maternal care for Anti-A sensitization, first trimester, fetus 2
O36.1113
Maternal care for Anti-A sensitization, first trimester, fetus 3
O36.1114
Maternal care for Anti-A sensitization, first trimester, fetus 4
O36.1115
Maternal care for Anti-A sensitization, first trimester, fetus 5
O36.1119
Maternal care for Anti-A sensitization, first trimester, other fetus
O36.1120
Maternal care for Anti-A sensitization, second trimester, not applicable or unspecified
5/23/2018 Green Mountain Care Provider Manual 183
O36.1121
Maternal care for Anti-A sensitization, second trimester, fetus 1
O36.1122
Maternal care for Anti-A sensitization, second trimester, fetus 2
O36.1123
Maternal care for Anti-A sensitization, second trimester, fetus 3
O36.1124
Maternal care for Anti-A sensitization, second trimester, fetus 4
O36.1125
Maternal care for Anti-A sensitization, second trimester, fetus 5
O36.1129
Maternal care for Anti-A sensitization, second trimester, other fetus
O36.1130
Maternal care for Anti-A sensitization, third trimester, not applicable or unspecified
O36.1131
Maternal care for Anti-A sensitization, third trimester, fetus 1
O36.1132
Maternal care for Anti-A sensitization, third trimester, fetus 2
O36.1133
Maternal care for Anti-A sensitization, third trimester, fetus 3
O36.1134
Maternal care for Anti-A sensitization, third trimester, fetus 4
O36.1135
Maternal care for Anti-A sensitization, third trimester, fetus 5
O36.1139
Maternal care for Anti-A sensitization, third trimester, other fetus
O36.1190
Maternal care for Anti-A sensitization, unspecified trimester, not applicable or unspecified
O36.1191
Maternal care for Anti-A sensitization, unspecified trimester, fetus 1
O36.1192
Maternal care for Anti-A sensitization, unspecified trimester, fetus 2
O36.1193
Maternal care for Anti-A sensitization, unspecified trimester, fetus 3
O36.1194
Maternal care for Anti-A sensitization, unspecified trimester, fetus 4
O36.1195
Maternal care for Anti-A sensitization, unspecified trimester, fetus 5
O36.1199
Maternal care for Anti-A sensitization, unspecified trimester, other fetus
O36.1910
Maternal care for other isoimmunization, first trimester, not applicable or unspecified
O36.1911
Maternal care for other isoimmunization, first trimester, fetus 1
O36.1912
Maternal care for other isoimmunization, first trimester, fetus 2
O36.1913
Maternal care for other isoimmunization, first trimester, fetus 3
O36.1914
Maternal care for other isoimmunization, first trimester, fetus 4
O36.1915
Maternal care for other isoimmunization, first trimester, fetus 5
O36.1919
Maternal care for other isoimmunization, first trimester, other fetus
O36.1920
Maternal care for other isoimmunization, second trimester, not applicable or unspecified
O36.1921
Maternal care for other isoimmunization, second trimester, fetus 1
O36.1922
Maternal care for other isoimmunization, second trimester, fetus 2
O36.1923
Maternal care for other isoimmunization, second trimester, fetus 3
O36.1924
Maternal care for other isoimmunization, second trimester, fetus 4
O36.1925
Maternal care for other isoimmunization, second trimester, fetus 5
O36.1929
Maternal care for other isoimmunization, second trimester, other fetus
O36.1930
Maternal care for other isoimmunization, third trimester, not applicable or unspecified
O36.1931
Maternal care for other isoimmunization, third trimester, fetus 1
O36.1932
Maternal care for other isoimmunization, third trimester, fetus 2
O36.1933
Maternal care for other isoimmunization, third trimester, fetus 3
O36.1934
Maternal care for other isoimmunization, third trimester, fetus 4
O36.1935
Maternal care for other isoimmunization, third trimester, fetus 5
O36.1939
Maternal care for other isoimmunization, third trimester, other fetus
O36.1990
Maternal care for other isoimmunization, unspecified trimester, not applicable or unspecified
O36.1991
Maternal care for other isoimmunization, unspecified trimester, fetus 1
O36.1992
Maternal care for other isoimmunization, unspecified trimester, fetus 2
O36.1993
Maternal care for other isoimmunization, unspecified trimester, fetus 3
O36.1994
Maternal care for other isoimmunization, unspecified trimester, fetus 4
O36.1995
Maternal care for other isoimmunization, unspecified trimester, fetus 5
O36.1999
Maternal care for other isoimmunization, unspecified trimester, other fetus
O36.20X0
Maternal care for hydrops fetalis, unspecified trimester, not applicable or unspecified
O36.20X1
Maternal care for hydrops fetalis, unspecified trimester, fetus 1
O36.20X2
Maternal care for hydrops fetalis, unspecified trimester, fetus 2
O36.20X3
Maternal care for hydrops fetalis, unspecified trimester, fetus 3
O36.20X4
Maternal care for hydrops fetalis, unspecified trimester, fetus 4
O36.20X5
Maternal care for hydrops fetalis, unspecified trimester, fetus 5
O36.20X9
Maternal care for hydrops fetalis, unspecified trimester, other fetus
5/23/2018 Green Mountain Care Provider Manual 184
O36.21X0
Maternal care for hydrops fetalis, first trimester, not applicable or unspecified
O36.21X1
Maternal care for hydrops fetalis, first trimester, fetus 1
O36.21X2
Maternal care for hydrops fetalis, first trimester, fetus 2
O36.21X3
Maternal care for hydrops fetalis, first trimester, fetus 3
O36.21X4
Maternal care for hydrops fetalis, first trimester, fetus 4
O36.21X5
Maternal care for hydrops fetalis, first trimester, fetus 5
O36.21X9
Maternal care for hydrops fetalis, first trimester, other fetus
O36.22X0
Maternal care for hydrops fetalis, second trimester, not applicable or unspecified
O36.22X1
Maternal care for hydrops fetalis, second trimester, fetus 1
O36.22X2
Maternal care for hydrops fetalis, second trimester, fetus 2
O36.22X3
Maternal care for hydrops fetalis, second trimester, fetus 3
O36.22X4
Maternal care for hydrops fetalis, second trimester, fetus 4
O36.22X5
Maternal care for hydrops fetalis, second trimester, fetus 5
O36.22X9
Maternal care for hydrops fetalis, second trimester, other fetus
O36.23X0
Maternal care for hydrops fetalis, third trimester, not applicable or unspecified
O36.23X1
Maternal care for hydrops fetalis, third trimester, fetus 1
O36.23X2
Maternal care for hydrops fetalis, third trimester, fetus 2
O36.23X3
Maternal care for hydrops fetalis, third trimester, fetus 3
O36.23X4
Maternal care for hydrops fetalis, third trimester, fetus 4
O36.23X5
Maternal care for hydrops fetalis, third trimester, fetus 5
O36.23X9
Maternal care for hydrops fetalis, third trimester, other fetus
O36.4XX0
Maternal care for intrauterine death, not applicable or unspecified
O36.4XX1
Maternal care for intrauterine death, fetus 1
O36.4XX2
Maternal care for intrauterine death, fetus 2
O36.4XX3
Maternal care for intrauterine death, fetus 3
O36.4XX4
Maternal care for intrauterine death, fetus 4
O36.4XX5
Maternal care for intrauterine death, fetus 5
O36.4XX9
Maternal care for intrauterine death, other fetus
O36.5110
Maternal care for known or suspected placental insufficiency, first trimester, not applicable or unspecified
O36.5111
Maternal care for known or suspected placental insufficiency, first trimester, fetus 1
O36.5112
Maternal care for known or suspected placental insufficiency, first trimester, fetus 2
O36.5113
Maternal care for known or suspected placental insufficiency, first trimester, fetus 3
O36.5114
Maternal care for known or suspected placental insufficiency, first trimester, fetus 4
O36.5115
Maternal care for known or suspected placental insufficiency, first trimester, fetus 5
O36.5119
Maternal care for known or suspected placental insufficiency, first trimester, other fetus
O36.5120
Maternal care for known or suspected placental insufficiency, second trimester, not applicable or
unspecified
O36.5121
Maternal care for known or suspected placental insufficiency, second trimester, fetus 1
O36.5122
Maternal care for known or suspected placental insufficiency, second trimester, fetus 2
O36.5123
Maternal care for known or suspected placental insufficiency, second trimester, fetus 3
O36.5124
Maternal care for known or suspected placental insufficiency, second trimester, fetus 4
O36.5125
Maternal care for known or suspected placental insufficiency, second trimester, fetus 5
O36.5129
Maternal care for known or suspected placental insufficiency, second trimester, other fetus
O36.5130
Maternal care for known or suspected placental insufficiency, third trimester, not applicable or unspecified
O36.5131
Maternal care for known or suspected placental insufficiency, third trimester, fetus 1
O36.5132
Maternal care for known or suspected placental insufficiency, third trimester, fetus 2
O36.5133
Maternal care for known or suspected placental insufficiency, third trimester, fetus 3
O36.5134
Maternal care for known or suspected placental insufficiency, third trimester, fetus 4
O36.5135
Maternal care for known or suspected placental insufficiency, third trimester, fetus 5
O36.5139
Maternal care for known or suspected placental insufficiency, third trimester, other fetus
O36.5190
Maternal care for known or suspected placental insufficiency, unspecified trimester, not applicable or
unspecified
O36.5191
Maternal care for known or suspected placental insufficiency, unspecified trimester, fetus 1
O36.5192
Maternal care for known or suspected placental insufficiency, unspecified trimester, fetus 2
O36.5193
Maternal care for known or suspected placental insufficiency, unspecified trimester, fetus 3
5/23/2018 Green Mountain Care Provider Manual 185
O36.5194
Maternal care for known or suspected placental insufficiency, unspecified trimester, fetus 4
O36.5195
Maternal care for known or suspected placental insufficiency, unspecified trimester, fetus 5
O36.5199
Maternal care for known or suspected placental insufficiency, unspecified trimester, other fetus
O36.5910
Maternal care for other known or suspected poor fetal growth, first trimester, not applicable or unspecified
O36.5911
Maternal care for other known or suspected poor fetal growth, first trimester, fetus 1
O36.5912
Maternal care for other known or suspected poor fetal growth, first trimester, fetus 2
O36.5913
Maternal care for other known or suspected poor fetal growth, first trimester, fetus 3
O36.5914
Maternal care for other known or suspected poor fetal growth, first trimester, fetus 4
O36.5915
Maternal care for other known or suspected poor fetal growth, first trimester, fetus 5
O36.5919
Maternal care for other known or suspected poor fetal growth, first trimester, other fetus
O36.5920
Maternal care for other known or suspected poor fetal growth, second trimester, not applicable or
unspecified
O36.5921
Maternal care for other known or suspected poor fetal growth, second trimester, fetus 1
O36.5922
Maternal care for other known or suspected poor fetal growth, second trimester, fetus 2
O36.5923
Maternal care for other known or suspected poor fetal growth, second trimester, fetus 3
O36.5924
Maternal care for other known or suspected poor fetal growth, second trimester, fetus 4
O36.5925
Maternal care for other known or suspected poor fetal growth, second trimester, fetus 5
O36.5929
Maternal care for other known or suspected poor fetal growth, second trimester, other fetus
O36.5930
Maternal care for other known or suspected poor fetal growth, third trimester, not applicable or unspecified
O36.5931
Maternal care for other known or suspected poor fetal growth, third trimester, fetus 1
O36.5932
Maternal care for other known or suspected poor fetal growth, third trimester, fetus 2
O36.5933
Maternal care for other known or suspected poor fetal growth, third trimester, fetus 3
O36.5934
Maternal care for other known or suspected poor fetal growth, third trimester, fetus 4
O36.5935
Maternal care for other known or suspected poor fetal growth, third trimester, fetus 5
O36.5939
Maternal care for other known or suspected poor fetal growth, third trimester, other fetus
O36.5990
Maternal care for other known or suspected poor fetal growth, unspecified trimester, not applicable or
unspecified
O36.5991
Maternal care for other known or suspected poor fetal growth, unspecified trimester, fetus 1
O36.5992
Maternal care for other known or suspected poor fetal growth, unspecified trimester, fetus 2
O36.5993
Maternal care for other known or suspected poor fetal growth, unspecified trimester, fetus 3
O36.5994
Maternal care for other known or suspected poor fetal growth, unspecified trimester, fetus 4
O36.5995
Maternal care for other known or suspected poor fetal growth, unspecified trimester, fetus 5
O36.5999
Maternal care for other known or suspected poor fetal growth, unspecified trimester, other fetus
O36.60X0
Maternal care for excessive fetal growth, unspecified trimester, not applicable or unspecified
O36.60X1
Maternal care for excessive fetal growth, unspecified trimester, fetus 1
O36.60X2
Maternal care for excessive fetal growth, unspecified trimester, fetus 2
O36.60X3
Maternal care for excessive fetal growth, unspecified trimester, fetus 3
O36.60X4
Maternal care for excessive fetal growth, unspecified trimester, fetus 4
O36.60X5
Maternal care for excessive fetal growth, unspecified trimester, fetus 5
O36.60X9
Maternal care for excessive fetal growth, unspecified trimester, other fetus
O36.61X0
Maternal care for excessive fetal growth, first trimester, not applicable or unspecified
O36.61X1
Maternal care for excessive fetal growth, first trimester, fetus 1
O36.61X2
Maternal care for excessive fetal growth, first trimester, fetus 2
O36.61X3
Maternal care for excessive fetal growth, first trimester, fetus 3
O36.61X4
Maternal care for excessive fetal growth, first trimester, fetus 4
O36.61X5
Maternal care for excessive fetal growth, first trimester, fetus 5
O36.61X9
Maternal care for excessive fetal growth, first trimester, other fetus
O36.62X0
Maternal care for excessive fetal growth, second trimester, not applicable or unspecified
O36.62X1
Maternal care for excessive fetal growth, second trimester, fetus 1
O36.62X2
Maternal care for excessive fetal growth, second trimester, fetus 2
O36.62X3
Maternal care for excessive fetal growth, second trimester, fetus 3
O36.62X4
Maternal care for excessive fetal growth, second trimester, fetus 4
O36.62X5
Maternal care for excessive fetal growth, second trimester, fetus 5
O36.62X9
Maternal care for excessive fetal growth, second trimester, other fetus
O36.63X0
Maternal care for excessive fetal growth, third trimester, not applicable or unspecified
5/23/2018 Green Mountain Care Provider Manual 186
O36.63X1
Maternal care for excessive fetal growth, third trimester, fetus 1
O36.63X2
Maternal care for excessive fetal growth, third trimester, fetus 2
O36.63X3
Maternal care for excessive fetal growth, third trimester, fetus 3
O36.63X4
Maternal care for excessive fetal growth, third trimester, fetus 4
O36.63X5
Maternal care for excessive fetal growth, third trimester, fetus 5
O36.63X9
Maternal care for excessive fetal growth, third trimester, other fetus
O36.70X0
Maternal care for viable fetus in abdominal pregnancy, unspecified trimester, not applicable or unspecified
O36.70X1
Maternal care for viable fetus in abdominal pregnancy, unspecified trimester, fetus 1
O36.70X2
Maternal care for viable fetus in abdominal pregnancy, unspecified trimester, fetus 2
O36.70X3
Maternal care for viable fetus in abdominal pregnancy, unspecified trimester, fetus 3
O36.70X4
Maternal care for viable fetus in abdominal pregnancy, unspecified trimester, fetus 4
O36.70X5
Maternal care for viable fetus in abdominal pregnancy, unspecified trimester, fetus 5
O36.70X9
Maternal care for viable fetus in abdominal pregnancy, unspecified trimester, other fetus
O36.71X0
Maternal care for viable fetus in abdominal pregnancy, first trimester, not applicable or unspecified
O36.71X1
Maternal care for viable fetus in abdominal pregnancy, first trimester, fetus 1
O36.71X2
Maternal care for viable fetus in abdominal pregnancy, first trimester, fetus 2
O36.71X3
Maternal care for viable fetus in abdominal pregnancy, first trimester, fetus 3
O36.71X4
Maternal care for viable fetus in abdominal pregnancy, first trimester, fetus 4
O36.71X5
Maternal care for viable fetus in abdominal pregnancy, first trimester, fetus 5
O36.71X9
Maternal care for viable fetus in abdominal pregnancy, first trimester, other fetus
O36.72X0
Maternal care for viable fetus in abdominal pregnancy, second trimester, not applicable or unspecified
O36.72X1
Maternal care for viable fetus in abdominal pregnancy, second trimester, fetus 1
O36.72X2
Maternal care for viable fetus in abdominal pregnancy, second trimester, fetus 2
O36.72X3
Maternal care for viable fetus in abdominal pregnancy, second trimester, fetus 3
O36.72X4
Maternal care for viable fetus in abdominal pregnancy, second trimester, fetus 4
O36.72X5
Maternal care for viable fetus in abdominal pregnancy, second trimester, fetus 5
O36.72X9
Maternal care for viable fetus in abdominal pregnancy, second trimester, other fetus
O36.73X0
Maternal care for viable fetus in abdominal pregnancy, third trimester, not applicable or unspecified
O36.73X1
Maternal care for viable fetus in abdominal pregnancy, third trimester, fetus 1
O36.73X2
Maternal care for viable fetus in abdominal pregnancy, third trimester, fetus 2
O36.73X3
Maternal care for viable fetus in abdominal pregnancy, third trimester, fetus 3
O36.73X4
Maternal care for viable fetus in abdominal pregnancy, third trimester, fetus 4
O36.73X5
Maternal care for viable fetus in abdominal pregnancy, third trimester, fetus 5
O36.73X9
Maternal care for viable fetus in abdominal pregnancy, third trimester, other fetus
O36.80X0
Pregnancy with inconclusive fetal viability, not applicable or unspecified
O36.80X1
Pregnancy with inconclusive fetal viability, fetus 1
O36.80X2
Pregnancy with inconclusive fetal viability, fetus 2
O36.80X3
Pregnancy with inconclusive fetal viability, fetus 3
O36.80X4
Pregnancy with inconclusive fetal viability, fetus 4
O36.80X5
Pregnancy with inconclusive fetal viability, fetus 5
O36.80X9
Pregnancy with inconclusive fetal viability, other fetus
O36.8120
Decreased fetal movements, second trimester, not applicable or unspecified
O36.8121
Decreased fetal movements, second trimester, fetus 1
O36.8122
Decreased fetal movements, second trimester, fetus 2
O36.8123
Decreased fetal movements, second trimester, fetus 3
O36.8124
Decreased fetal movements, second trimester, fetus 4
O36.8125
Decreased fetal movements, second trimester, fetus 5
O36.8129
Decreased fetal movements, second trimester, other fetus
O36.8130
Decreased fetal movements, third trimester, not applicable or unspecified
O36.8131
Decreased fetal movements, third trimester, fetus 1
O36.8132
Decreased fetal movements, third trimester, fetus 2
O36.8133
Decreased fetal movements, third trimester, fetus 3
O36.8134
Decreased fetal movements, third trimester, fetus 4
O36.8135
Decreased fetal movements, third trimester, fetus 5
O36.8139
Decreased fetal movements, third trimester, other fetus
5/23/2018 Green Mountain Care Provider Manual 187
O36.8190
Decreased fetal movements, unspecified trimester, not applicable or unspecified
O36.8191
Decreased fetal movements, unspecified trimester, fetus 1
O36.8192
Decreased fetal movements, unspecified trimester, fetus 2
O36.8193
Decreased fetal movements, unspecified trimester, fetus 3
O36.8194
Decreased fetal movements, unspecified trimester, fetus 4
O36.8195
Decreased fetal movements, unspecified trimester, fetus 5
O36.8199
Decreased fetal movements, unspecified trimester, other fetus
O36.8910
Maternal care for other specified fetal problems, first trimester, not applicable or unspecified
O36.8911
Maternal care for other specified fetal problems, first trimester, fetus 1
O36.8912
Maternal care for other specified fetal problems, first trimester, fetus 2
O36.8913
Maternal care for other specified fetal problems, first trimester, fetus 3
O36.8914
Maternal care for other specified fetal problems, first trimester, fetus 4
O36.8915
Maternal care for other specified fetal problems, first trimester, fetus 5
O36.8919
Maternal care for other specified fetal problems, first trimester, other fetus
O36.8920
Maternal care for other specified fetal problems, second trimester, not applicable or unspecified
O36.8921
Maternal care for other specified fetal problems, second trimester, fetus 1
O36.8922
Maternal care for other specified fetal problems, second trimester, fetus 2
O36.8923
Maternal care for other specified fetal problems, second trimester, fetus 3
O36.8924
Maternal care for other specified fetal problems, second trimester, fetus 4
O36.8925
Maternal care for other specified fetal problems, second trimester, fetus 5
O36.8929
Maternal care for other specified fetal problems, second trimester, other fetus
O36.8930
Maternal care for other specified fetal problems, third trimester, not applicable or unspecified
O36.8931
Maternal care for other specified fetal problems, third trimester, fetus 1
O36.8932
Maternal care for other specified fetal problems, third trimester, fetus 2
O36.8933
Maternal care for other specified fetal problems, third trimester, fetus 3
O36.8934
Maternal care for other specified fetal problems, third trimester, fetus 4
O36.8935
Maternal care for other specified fetal problems, third trimester, fetus 5
O36.8939
Maternal care for other specified fetal problems, third trimester, other fetus
O36.8990
Maternal care for other specified fetal problems, unspecified trimester, not applicable or unspecified
O36.8991
Maternal care for other specified fetal problems, unspecified trimester, fetus 1
O36.8992
Maternal care for other specified fetal problems, unspecified trimester, fetus 2
O36.8993
Maternal care for other specified fetal problems, unspecified trimester, fetus 3
O36.8994
Maternal care for other specified fetal problems, unspecified trimester, fetus 4
O36.8995
Maternal care for other specified fetal problems, unspecified trimester, fetus 5
O36.8999
Maternal care for other specified fetal problems, unspecified trimester, other fetus
O36.90X0
Maternal care for fetal problem, unspecified, unspecified trimester, not applicable or unspecified
O36.90X1
Maternal care for fetal problem, unspecified, unspecified trimester, fetus 1
O36.90X2
Maternal care for fetal problem, unspecified, unspecified trimester, fetus 2
O36.90X3
Maternal care for fetal problem, unspecified, unspecified trimester, fetus 3
O36.90X4
Maternal care for fetal problem, unspecified, unspecified trimester, fetus 4
O36.90X5
Maternal care for fetal problem, unspecified, unspecified trimester, fetus 5
O36.90X9
Maternal care for fetal problem, unspecified, unspecified trimester, other fetus
O36.91X0
Maternal care for fetal problem, unspecified, first trimester, not applicable or unspecified
O36.91X1
Maternal care for fetal problem, unspecified, first trimester, fetus 1
O36.91X2
Maternal care for fetal problem, unspecified, first trimester, fetus 2
O36.91X3
Maternal care for fetal problem, unspecified, first trimester, fetus 3
O36.91X4
Maternal care for fetal problem, unspecified, first trimester, fetus 4
O36.91X5
Maternal care for fetal problem, unspecified, first trimester, fetus 5
O36.91X9
Maternal care for fetal problem, unspecified, first trimester, other fetus
O36.92X0
Maternal care for fetal problem, unspecified, second trimester, not applicable or unspecified
O36.92X1
Maternal care for fetal problem, unspecified, second trimester, fetus 1
O36.92X2
Maternal care for fetal problem, unspecified, second trimester, fetus 2
O36.92X3
Maternal care for fetal problem, unspecified, second trimester, fetus 3
O36.92X4
Maternal care for fetal problem, unspecified, second trimester, fetus 4
O36.92X5
Maternal care for fetal problem, unspecified, second trimester, fetus 5
5/23/2018 Green Mountain Care Provider Manual 188
O36.92X9
Maternal care for fetal problem, unspecified, second trimester, other fetus
O36.93X0
Maternal care for fetal problem, unspecified, third trimester, not applicable or unspecified
O36.93X1
Maternal care for fetal problem, unspecified, third trimester, fetus 1
O36.93X2
Maternal care for fetal problem, unspecified, third trimester, fetus 2
O36.93X3
Maternal care for fetal problem, unspecified, third trimester, fetus 3
O36.93X4
Maternal care for fetal problem, unspecified, third trimester, fetus 4
O36.93X5
Maternal care for fetal problem, unspecified, third trimester, fetus 5
O36.93X9
Maternal care for fetal problem, unspecified, third trimester, other fetus
O40.1XX0
Polyhydramnios, first trimester, not applicable or unspecified
O40.1XX1
Polyhydramnios, first trimester, fetus 1
O40.1XX2
Polyhydramnios, first trimester, fetus 2
O40.1XX3
Polyhydramnios, first trimester, fetus 3
O40.1XX4
Polyhydramnios, first trimester, fetus 4
O40.1XX5
Polyhydramnios, first trimester, fetus 5
O40.1XX9
Polyhydramnios, first trimester, other fetus
O40.2XX0
Polyhydramnios, second trimester, not applicable or unspecified
O40.2XX1
Polyhydramnios, second trimester, fetus 1
O40.2XX2
Polyhydramnios, second trimester, fetus 2
O40.2XX3
Polyhydramnios, second trimester, fetus 3
O40.2XX4
Polyhydramnios, second trimester, fetus 4
O40.2XX5
Polyhydramnios, second trimester, fetus 5
O40.2XX9
Polyhydramnios, second trimester, other fetus
O40.3XX0
Polyhydramnios, third trimester, not applicable or unspecified
O40.3XX1
Polyhydramnios, third trimester, fetus 1
O40.3XX2
Polyhydramnios, third trimester, fetus 2
O40.3XX3
Polyhydramnios, third trimester, fetus 3
O40.3XX4
Polyhydramnios, third trimester, fetus 4
O40.3XX5
Polyhydramnios, third trimester, fetus 5
O40.3XX9
Polyhydramnios, third trimester, other fetus
O40.9XX0
Polyhydramnios, unspecified trimester, not applicable or unspecified
O40.9XX1
Polyhydramnios, unspecified trimester, fetus 1
O40.9XX2
Polyhydramnios, unspecified trimester, fetus 2
O40.9XX3
Polyhydramnios, unspecified trimester, fetus 3
O40.9XX4
Polyhydramnios, unspecified trimester, fetus 4
O40.9XX5
Polyhydramnios, unspecified trimester, fetus 5
O40.9XX9
Polyhydramnios, unspecified trimester, other fetus
O41.00X0
Oligohydramnios, unspecified trimester, not applicable or unspecified
O41.00X1
Oligohydramnios, unspecified trimester, fetus 1
O41.00X2
Oligohydramnios, unspecified trimester, fetus 2
O41.00X3
Oligohydramnios, unspecified trimester, fetus 3
O41.00X4
Oligohydramnios, unspecified trimester, fetus 4
O41.00X5
Oligohydramnios, unspecified trimester, fetus 5
O41.00X9
Oligohydramnios, unspecified trimester, other fetus
O41.01X0
Oligohydramnios, first trimester, not applicable or unspecified
O41.01X1
Oligohydramnios, first trimester, fetus 1
O41.01X2
Oligohydramnios, first trimester, fetus 2
O41.01X3
Oligohydramnios, first trimester, fetus 3
O41.01X4
Oligohydramnios, first trimester, fetus 4
O41.01X5
Oligohydramnios, first trimester, fetus 5
O41.01X9
Oligohydramnios, first trimester, other fetus
O41.02X0
Oligohydramnios, second trimester, not applicable or unspecified
O41.02X1
Oligohydramnios, second trimester, fetus 1
O41.02X2
Oligohydramnios, second trimester, fetus 2
O41.02X3
Oligohydramnios, second trimester, fetus 3
O41.02X4
Oligohydramnios, second trimester, fetus 4
5/23/2018 Green Mountain Care Provider Manual 189
O41.02X5
Oligohydramnios, second trimester, fetus 5
O41.02X9
Oligohydramnios, second trimester, other fetus
O41.03X0
Oligohydramnios, third trimester, not applicable or unspecified
O41.03X1
Oligohydramnios, third trimester, fetus 1
O41.03X2
Oligohydramnios, third trimester, fetus 2
O41.03X3
Oligohydramnios, third trimester, fetus 3
O41.03X4
Oligohydramnios, third trimester, fetus 4
O41.03X5
Oligohydramnios, third trimester, fetus 5
O41.03X9
Oligohydramnios, third trimester, other fetus
O41.1010
Infection of amniotic sac and membranes, unspecified, first trimester, not applicable or unspecified
O41.1011
Infection of amniotic sac and membranes, unspecified, first trimester, fetus 1
O41.1012
Infection of amniotic sac and membranes, unspecified, first trimester, fetus 2
O41.1013
Infection of amniotic sac and membranes, unspecified, first trimester, fetus 3
O41.1014
Infection of amniotic sac and membranes, unspecified, first trimester, fetus 4
O41.1015
Infection of amniotic sac and membranes, unspecified, first trimester, fetus 5
O41.1019
Infection of amniotic sac and membranes, unspecified, first trimester, other fetus
O41.1020
Infection of amniotic sac and membranes, unspecified, second trimester, not applicable or unspecified
O41.1021
Infection of amniotic sac and membranes, unspecified, second trimester, fetus 1
O41.1022
Infection of amniotic sac and membranes, unspecified, second trimester, fetus 2
O41.1023
Infection of amniotic sac and membranes, unspecified, second trimester, fetus 3
O41.1024
Infection of amniotic sac and membranes, unspecified, second trimester, fetus 4
O41.1025
Infection of amniotic sac and membranes, unspecified, second trimester, fetus 5
O41.1029
Infection of amniotic sac and membranes, unspecified, second trimester, other fetus
O41.1030
Infection of amniotic sac and membranes, unspecified, third trimester, not applicable or unspecified
O41.1031
Infection of amniotic sac and membranes, unspecified, third trimester, fetus 1
O41.1032
Infection of amniotic sac and membranes, unspecified, third trimester, fetus 2
O41.1033
Infection of amniotic sac and membranes, unspecified, third trimester, fetus 3
O41.1034
Infection of amniotic sac and membranes, unspecified, third trimester, fetus 4
O41.1035
Infection of amniotic sac and membranes, unspecified, third trimester, fetus 5
O41.1039
Infection of amniotic sac and membranes, unspecified, third trimester, other fetus
O41.1090
Infection of amniotic sac and membranes, unspecified, unspecified trimester, not applicable or unspecified
O41.1091
Infection of amniotic sac and membranes, unspecified, unspecified trimester, fetus 1
O41.1092
Infection of amniotic sac and membranes, unspecified, unspecified trimester, fetus 2
O41.1093
Infection of amniotic sac and membranes, unspecified, unspecified trimester, fetus 3
O41.1094
Infection of amniotic sac and membranes, unspecified, unspecified trimester, fetus 4
O41.1095
Infection of amniotic sac and membranes, unspecified, unspecified trimester, fetus 5
O41.1099
Infection of amniotic sac and membranes, unspecified, unspecified trimester, other fetus
O41.1210
Chorioamnionitis, first trimester, not applicable or unspecified
O41.1211
Chorioamnionitis, first trimester, fetus 1
O41.1212
Chorioamnionitis, first trimester, fetus 2
O41.1213
Chorioamnionitis, first trimester, fetus 3
O41.1214
Chorioamnionitis, first trimester, fetus 4
O41.1215
Chorioamnionitis, first trimester, fetus 5
O41.1219
Chorioamnionitis, first trimester, other fetus
O41.1220
Chorioamnionitis, second trimester, not applicable or unspecified
O41.1221
Chorioamnionitis, second trimester, fetus 1
O41.1222
Chorioamnionitis, second trimester, fetus 2
O41.1223
Chorioamnionitis, second trimester, fetus 3
O41.1224
Chorioamnionitis, second trimester, fetus 4
O41.1225
Chorioamnionitis, second trimester, fetus 5
O41.1229
Chorioamnionitis, second trimester, other fetus
O41.1230
Chorioamnionitis, third trimester, not applicable or unspecified
O41.1231
Chorioamnionitis, third trimester, fetus 1
O41.1232
Chorioamnionitis, third trimester, fetus 2
O41.1233
Chorioamnionitis, third trimester, fetus 3
5/23/2018 Green Mountain Care Provider Manual 190
O41.1234
Chorioamnionitis, third trimester, fetus 4
O41.1235
Chorioamnionitis, third trimester, fetus 5
O41.1239
Chorioamnionitis, third trimester, other fetus
O41.1290
Chorioamnionitis, unspecified trimester, not applicable or unspecified
O41.1291
Chorioamnionitis, unspecified trimester, fetus 1
O41.1292
Chorioamnionitis, unspecified trimester, fetus 2
O41.1293
Chorioamnionitis, unspecified trimester, fetus 3
O41.1294
Chorioamnionitis, unspecified trimester, fetus 4
O41.1295
Chorioamnionitis, unspecified trimester, fetus 5
O41.1299
Chorioamnionitis, unspecified trimester, other fetus
O41.1410
Placentitis, first trimester, not applicable or unspecified
O41.1411
Placentitis, first trimester, fetus 1
O41.1412
Placentitis, first trimester, fetus 2
O41.1413
Placentitis, first trimester, fetus 3
O41.1414
Placentitis, first trimester, fetus 4
O41.1415
Placentitis, first trimester, fetus 5
O41.1419
Placentitis, first trimester, other fetus
O41.1420
Placentitis, second trimester, not applicable or unspecified
O41.1421
Placentitis, second trimester, fetus 1
O41.1422
Placentitis, second trimester, fetus 2
O41.1423
Placentitis, second trimester, fetus 3
O41.1424
Placentitis, second trimester, fetus 4
O41.1425
Placentitis, second trimester, fetus 5
O41.1429
Placentitis, second trimester, other fetus
O41.1430
Placentitis, third trimester, not applicable or unspecified
O41.1431
Placentitis, third trimester, fetus 1
O41.1432
Placentitis, third trimester, fetus 2
O41.1433
Placentitis, third trimester, fetus 3
O41.1434
Placentitis, third trimester, fetus 4
O41.1435
Placentitis, third trimester, fetus 5
O41.1439
Placentitis, third trimester, other fetus
O41.1490
Placentitis, unspecified trimester, not applicable or unspecified
O41.1491
Placentitis, unspecified trimester, fetus 1
O41.1492
Placentitis, unspecified trimester, fetus 2
O41.1493
Placentitis, unspecified trimester, fetus 3
O41.1494
Placentitis, unspecified trimester, fetus 4
O41.1495
Placentitis, unspecified trimester, fetus 5
O41.1499
Placentitis, unspecified trimester, other fetus
O41.8X10
Other specified disorders of amniotic fluid and membranes, first trimester, not applicable or unspecified
O41.8X11
Other specified disorders of amniotic fluid and membranes, first trimester, fetus 1
O41.8X12
Other specified disorders of amniotic fluid and membranes, first trimester, fetus 2
O41.8X13
Other specified disorders of amniotic fluid and membranes, first trimester, fetus 3
O41.8X14
Other specified disorders of amniotic fluid and membranes, first trimester, fetus 4
O41.8X15
Other specified disorders of amniotic fluid and membranes, first trimester, fetus 5
O41.8X19
Other specified disorders of amniotic fluid and membranes, first trimester, other fetus
O41.8X20
Other specified disorders of amniotic fluid and membranes, second trimester, not applicable or
unspecified
O41.8X21
Other specified disorders of amniotic fluid and membranes, second trimester, fetus 1
O41.8X22
Other specified disorders of amniotic fluid and membranes, second trimester, fetus 2
O41.8X23
Other specified disorders of amniotic fluid and membranes, second trimester, fetus 3
O41.8X24
Other specified disorders of amniotic fluid and membranes, second trimester, fetus 4
O41.8X25
Other specified disorders of amniotic fluid and membranes, second trimester, fetus 5
O41.8X29
Other specified disorders of amniotic fluid and membranes, second trimester, other fetus
O41.8X30
Other specified disorders of amniotic fluid and membranes, third trimester, not applicable or unspecified
O41.8X31
Other specified disorders of amniotic fluid and membranes, third trimester, fetus 1
5/23/2018 Green Mountain Care Provider Manual 191
O41.8X32
Other specified disorders of amniotic fluid and membranes, third trimester, fetus 2
O41.8X33
Other specified disorders of amniotic fluid and membranes, third trimester, fetus 3
O41.8X34
Other specified disorders of amniotic fluid and membranes, third trimester, fetus 4
O41.8X35
Other specified disorders of amniotic fluid and membranes, third trimester, fetus 5
O41.8X39
Other specified disorders of amniotic fluid and membranes, third trimester, other fetus
O41.8X90
Other specified disorders of amniotic fluid and membranes, unspecified trimester, not applicable or
unspecified
O41.8X91
Other specified disorders of amniotic fluid and membranes, unspecified trimester, fetus 1
O41.8X92
Other specified disorders of amniotic fluid and membranes, unspecified trimester, fetus 2
O41.8X93
Other specified disorders of amniotic fluid and membranes, unspecified trimester, fetus 3
O41.8X94
Other specified disorders of amniotic fluid and membranes, unspecified trimester, fetus 4
O41.8X95
Other specified disorders of amniotic fluid and membranes, unspecified trimester, fetus 5
O41.8X99
Other specified disorders of amniotic fluid and membranes, unspecified trimester, other fetus
O41.90X0
Disorder of amniotic fluid and membranes, unspecified, unspecified trimester, not applicable or
unspecified
O41.90X1
Disorder of amniotic fluid and membranes, unspecified, unspecified trimester, fetus 1
O41.90X2
Disorder of amniotic fluid and membranes, unspecified, unspecified trimester, fetus 2
O41.90X3
Disorder of amniotic fluid and membranes, unspecified, unspecified trimester, fetus 3
O41.90X4
Disorder of amniotic fluid and membranes, unspecified, unspecified trimester, fetus 4
O41.90X5
Disorder of amniotic fluid and membranes, unspecified, unspecified trimester, fetus 5
O41.90X9
Disorder of amniotic fluid and membranes, unspecified, unspecified trimester, other fetus
O41.91X0
Disorder of amniotic fluid and membranes, unspecified, first trimester, not applicable or unspecified
O41.91X1
Disorder of amniotic fluid and membranes, unspecified, first trimester, fetus 1
O41.91X2
Disorder of amniotic fluid and membranes, unspecified, first trimester, fetus 2
O41.91X3
Disorder of amniotic fluid and membranes, unspecified, first trimester, fetus 3
O41.91X4
Disorder of amniotic fluid and membranes, unspecified, first trimester, fetus 4
O41.91X5
Disorder of amniotic fluid and membranes, unspecified, first trimester, fetus 5
O41.91X9
Disorder of amniotic fluid and membranes, unspecified, first trimester, other fetus
O41.92X0
Disorder of amniotic fluid and membranes, unspecified, second trimester, not applicable or unspecified
O41.92X1
Disorder of amniotic fluid and membranes, unspecified, second trimester, fetus 1
O41.92X2
Disorder of amniotic fluid and membranes, unspecified, second trimester, fetus 2
O41.92X3
Disorder of amniotic fluid and membranes, unspecified, second trimester, fetus 3
O41.92X4
Disorder of amniotic fluid and membranes, unspecified, second trimester, fetus 4
O41.92X5
Disorder of amniotic fluid and membranes, unspecified, second trimester, fetus 5
O41.92X9
Disorder of amniotic fluid and membranes, unspecified, second trimester, other fetus
O41.93X0
Disorder of amniotic fluid and membranes, unspecified, third trimester, not applicable or unspecified
O41.93X1
Disorder of amniotic fluid and membranes, unspecified, third trimester, fetus 1
O41.93X2
Disorder of amniotic fluid and membranes, unspecified, third trimester, fetus 2
O41.93X3
Disorder of amniotic fluid and membranes, unspecified, third trimester, fetus 3
O41.93X4
Disorder of amniotic fluid and membranes, unspecified, third trimester, fetus 4
O41.93X5
Disorder of amniotic fluid and membranes, unspecified, third trimester, fetus 5
O41.93X9
Disorder of amniotic fluid and membranes, unspecified, third trimester, other fetus
O42.00
Premature rupture of membranes, onset of labor within 24 hours of rupture, unspecified weeks of
gestation
O42.011
Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, first trimester
O42.012
Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, second trimester
O42.013
Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, third trimester
O42.019
Preterm premature rupture of membranes, onset of labor within 24 hours of rupture, unspecified trimester
O42.02
Full-term premature rupture of membranes, onset of labor within 24 hours of rupture
O42.10
Premature rupture of membranes, onset of labor more than 24 hours following rupture, unspecified weeks
of gestation
O42.111
Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, first
trimester
O42.112
Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, second
trimester
5/23/2018 Green Mountain Care Provider Manual 192
O42.113
Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, third
trimester
O42.119
Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture,
unspecified trimester
O42.12
Full-term premature rupture of membranes, onset of labor more than 24 hours following rupture
O42.90
Premature rupture of membranes, unspecified as to length of time between rupture and onset of labor,
unspecified weeks of gestation
O42.911
Preterm premature rupture of membranes, unspecified as to length of time between rupture and onset of
labor, first trimester
O42.912
Preterm premature rupture of membranes, unspecified as to length of time between rupture and onset of
labor, second trimester
O42.913
Preterm premature rupture of membranes, unspecified as to length of time between rupture and onset of
labor, third trimester
O42.919
Preterm premature rupture of membranes, unspecified as to length of time between rupture and onset of
labor, unspecified trimester
O42.92
Full-term premature rupture of membranes, unspecified as to length of time between rupture and onset of
labor
O43.011
Fetomaternal placental transfusion syndrome, first trimester
O43.012
Fetomaternal placental transfusion syndrome, second trimester
O43.013
Fetomaternal placental transfusion syndrome, third trimester
O43.019
Fetomaternal placental transfusion syndrome, unspecified trimester
O43.021
Fetus-to-fetus placental transfusion syndrome, first trimester
O43.022
Fetus-to-fetus placental transfusion syndrome, second trimester
O43.023
Fetus-to-fetus placental transfusion syndrome, third trimester
O43.029
Fetus-to-fetus placental transfusion syndrome, unspecified trimester
O43.101
Malformation of placenta, unspecified, first trimester
O43.102
Malformation of placenta, unspecified, second trimester
O43.103
Malformation of placenta, unspecified, third trimester
O43.109
Malformation of placenta, unspecified, unspecified trimester
O43.111
Circumvallate placenta, first trimester
O43.112
Circumvallate placenta, second trimester
O43.113
Circumvallate placenta, third trimester
O43.119
Circumvallate placenta, unspecified trimester
O43.191
Other malformation of placenta, first trimester
O43.192
Other malformation of placenta, second trimester
O43.193
Other malformation of placenta, third trimester
O43.199
Other malformation of placenta, unspecified trimester
O43.811
Placental infarction, first trimester
O43.812
Placental infarction, second trimester
O43.813
Placental infarction, third trimester
O43.819
Placental infarction, unspecified trimester
O43.891
Other placental disorders, first trimester
O43.892
Other placental disorders, second trimester
O43.893
Other placental disorders, third trimester
O43.899
Other placental disorders, unspecified trimester
O43.90
Unspecified placental disorder, unspecified trimester
O43.91
Unspecified placental disorder, first trimester
O43.92
Unspecified placental disorder, second trimester
O43.93
Unspecified placental disorder, third trimester
O44.01
Placenta previa specified as without hemorrhage, first trimester
O44.02
Placenta previa specified as without hemorrhage, second trimester
O44.03
Placenta previa specified as without hemorrhage, third trimester
O44.10
Placenta previa with hemorrhage, unspecified trimester
O44.11
Placenta previa with hemorrhage, first trimester
O44.12
Placenta previa with hemorrhage, second trimester
5/23/2018 Green Mountain Care Provider Manual 193
O44.13
Placenta previa with hemorrhage, third trimester
O45.001
Premature separation of placenta with coagulation defect, unspecified, first trimester
O45.002
Premature separation of placenta with coagulation defect, unspecified, second trimester
O45.003
Premature separation of placenta with coagulation defect, unspecified, third trimester
O45.011
Premature separation of placenta with afibrinogenemia, first trimester
O45.012
Premature separation of placenta with afibrinogenemia, second trimester
O45.013
Premature separation of placenta with afibrinogenemia, third trimester
O45.021
Premature separation of placenta with disseminated intravascular coagulation, first trimester
O45.022
Premature separation of placenta with disseminated intravascular coagulation, second trimester
O45.023
Premature separation of placenta with disseminated intravascular coagulation, third trimester
O45.091
Premature separation of placenta with other coagulation defect, first trimester
O45.092
Premature separation of placenta with other coagulation defect, second trimester
O45.093
Premature separation of placenta with other coagulation defect, third trimester
O45.8X1
Other premature separation of placenta, first trimester
O45.8X2
Other premature separation of placenta, second trimester
O45.8X3
Other premature separation of placenta, third trimester
O45.8X9
Other premature separation of placenta, unspecified trimester
O45.91
Premature separation of placenta, unspecified, first trimester
O45.92
Premature separation of placenta, unspecified, second trimester
O45.93
Premature separation of placenta, unspecified, third trimester
O46.001
Antepartum hemorrhage with coagulation defect, unspecified, first trimester
O46.002
Antepartum hemorrhage with coagulation defect, unspecified, second trimester
O46.003
Antepartum hemorrhage with coagulation defect, unspecified, third trimester
O46.009
Antepartum hemorrhage with coagulation defect, unspecified, unspecified trimester
O46.011
Antepartum hemorrhage with afibrinogenemia, first trimester
O46.012
Antepartum hemorrhage with afibrinogenemia, second trimester
O46.013
Antepartum hemorrhage with afibrinogenemia, third trimester
O46.019
Antepartum hemorrhage with afibrinogenemia, unspecified trimester
O46.021
Antepartum hemorrhage with disseminated intravascular coagulation, first trimester
O46.022
Antepartum hemorrhage with disseminated intravascular coagulation, second trimester
O46.023
Antepartum hemorrhage with disseminated intravascular coagulation, third trimester
O46.029
Antepartum hemorrhage with disseminated intravascular coagulation, unspecified trimester
O46.091
Antepartum hemorrhage with other coagulation defect, first trimester
O46.092
Antepartum hemorrhage with other coagulation defect, second trimester
O46.093
Antepartum hemorrhage with other coagulation defect, third trimester
O46.099
Antepartum hemorrhage with other coagulation defect, unspecified trimester
O46.8X1
Other antepartum hemorrhage, first trimester
O46.8X2
Other antepartum hemorrhage, second trimester
O46.8X3
Other antepartum hemorrhage, third trimester
O46.8X9
Other antepartum hemorrhage, unspecified trimester
O46.90
Antepartum hemorrhage, unspecified, unspecified trimester
O46.91
Antepartum hemorrhage, unspecified, first trimester
O46.92
Antepartum hemorrhage, unspecified, second trimester
O46.93
Antepartum hemorrhage, unspecified, third trimester
O47.00
False labor before 37 completed weeks of gestation, unspecified trimester
O47.02
False labor before 37 completed weeks of gestation, second trimester
O47.03
False labor before 37 completed weeks of gestation, third trimester
O47.1
False labor at or after 37 completed weeks of gestation
O47.9
False labor, unspecified
O48.0
Post-term pregnancy
O48.1
Prolonged pregnancy
O60.00
Preterm labor without delivery, unspecified trimester
O60.02
Preterm labor without delivery, second trimester
O60.03
Preterm labor without delivery, third trimester
O60.10X0
Preterm labor with preterm delivery, unspecified trimester, not applicable or unspecified
5/23/2018 Green Mountain Care Provider Manual 194
O60.12X0
Preterm labor second trimester with preterm delivery second trimester, not applicable or unspecified
O60.13X0
Preterm labor second trimester with preterm delivery third trimester, not applicable or unspecified
O60.14X0
Preterm labor third trimester with preterm delivery third trimester, not applicable or unspecified
O64.1XX0
Obstructed labor due to breech presentation, not applicable or unspecified
O64.1XX1
Obstructed labor due to breech presentation, fetus 1
O64.1XX2
Obstructed labor due to breech presentation, fetus 2
O64.1XX3
Obstructed labor due to breech presentation, fetus 3
O64.1XX4
Obstructed labor due to breech presentation, fetus 4
O64.1XX5
Obstructed labor due to breech presentation, fetus 5
O64.1XX9
Obstructed labor due to breech presentation, other fetus
O64.2XX0
Obstructed labor due to face presentation, not applicable or unspecified
O64.2XX1
Obstructed labor due to face presentation, fetus 1
O64.2XX2
Obstructed labor due to face presentation, fetus 2
O64.2XX3
Obstructed labor due to face presentation, fetus 3
O64.2XX4
Obstructed labor due to face presentation, fetus 4
O64.2XX5
Obstructed labor due to face presentation, fetus 5
O64.2XX9
Obstructed labor due to face presentation, other fetus
O64.3XX0
Obstructed labor due to brow presentation, not applicable or unspecified
O64.3XX1
Obstructed labor due to brow presentation, fetus 1
O64.3XX2
Obstructed labor due to brow presentation, fetus 2
O64.3XX3
Obstructed labor due to brow presentation, fetus 3
O64.3XX4
Obstructed labor due to brow presentation, fetus 4
O64.3XX5
Obstructed labor due to brow presentation, fetus 5
O64.3XX9
Obstructed labor due to brow presentation, other fetus
O64.4XX0
Obstructed labor due to shoulder presentation, not applicable or unspecified
O64.4XX1
Obstructed labor due to shoulder presentation, fetus 1
O64.4XX2
Obstructed labor due to shoulder presentation, fetus 2
O64.4XX3
Obstructed labor due to shoulder presentation, fetus 3
O64.4XX4
Obstructed labor due to shoulder presentation, fetus 4
O64.4XX5
Obstructed labor due to shoulder presentation, fetus 5
O64.4XX9
Obstructed labor due to shoulder presentation, other fetus
O64.5XX0
Obstructed labor due to compound presentation, not applicable or unspecified
O64.5XX1
Obstructed labor due to compound presentation, fetus 1
O64.5XX2
Obstructed labor due to compound presentation, fetus 2
O64.5XX3
Obstructed labor due to compound presentation, fetus 3
O64.5XX4
Obstructed labor due to compound presentation, fetus 4
O64.5XX5
Obstructed labor due to compound presentation, fetus 5
O64.5XX9
Obstructed labor due to compound presentation, other fetus
O64.8XX0
Obstructed labor due to other malposition and malpresentation, not applicable or unspecified
O64.8XX1
Obstructed labor due to other malposition and malpresentation, fetus 1
O64.8XX2
Obstructed labor due to other malposition and malpresentation, fetus 2
O64.8XX3
Obstructed labor due to other malposition and malpresentation, fetus 3
O64.8XX4
Obstructed labor due to other malposition and malpresentation, fetus 4
O64.8XX5
Obstructed labor due to other malposition and malpresentation, fetus 5
O64.8XX9
Obstructed labor due to other malposition and malpresentation, other fetus
O64.9XX0
Obstructed labor due to malposition and malpresentation, unspecified, not applicable or unspecified
O64.9XX1
Obstructed labor due to malposition and malpresentation, unspecified, fetus 1
O64.9XX2
Obstructed labor due to malposition and malpresentation, unspecified, fetus 2
O64.9XX3
Obstructed labor due to malposition and malpresentation, unspecified, fetus 3
O64.9XX4
Obstructed labor due to malposition and malpresentation, unspecified, fetus 4
O64.9XX5
Obstructed labor due to malposition and malpresentation, unspecified, fetus 5
O64.9XX9
Obstructed labor due to malposition and malpresentation, unspecified, other fetus
O65.0
Obstructed labor due to deformed pelvis
O65.1
Obstructed labor due to generally contracted pelvis
O65.2
Obstructed labor due to pelvic inlet contraction
5/23/2018 Green Mountain Care Provider Manual 195
O65.3
Obstructed labor due to pelvic outlet and mid-cavity contraction
O65.4
Obstructed labor due to fetopelvic disproportion, unspecified
O65.8
Obstructed labor due to other maternal pelvic abnormalities
O65.9
Obstructed labor due to maternal pelvic abnormality, unspecified
O66.2
Obstructed labor due to unusually large fetus
O66.6
Obstructed labor due to other multiple fetuses
O67.0
Intrapartum hemorrhage with coagulation defect
O67.8
Other intrapartum hemorrhage
O67.9
Intrapartum hemorrhage, unspecified
O68
Labor and delivery complicated by abnormality of fetal acid-base balance
O75.5
Delayed delivery after artificial rupture of membranes
O77.0
Labor and delivery complicated by meconium in amniotic fluid
O77.1
Fetal stress in labor or delivery due to drug administration
O77.8
Labor and delivery complicated by other evidence of fetal stress
O77.9
Labor and delivery complicated by fetal stress, unspecified
O86.11
Cervicitis following delivery
O86.13
Vaginitis following delivery
O86.19
Other infection of genital tract following delivery
O86.20
Urinary tract infection following delivery, unspecified
O86.21
Infection of kidney following delivery
O86.22
Infection of bladder following delivery
O86.29
Other urinary tract infection following delivery
O88.011
Air embolism in pregnancy, first trimester
O88.012
Air embolism in pregnancy, second trimester
O88.013
Air embolism in pregnancy, third trimester
O88.019
Air embolism in pregnancy, unspecified trimester
O88.02
Air embolism in childbirth
O88.03
Air embolism in the puerperium
O88.111
Amniotic fluid embolism in pregnancy, first trimester
O88.112
Amniotic fluid embolism in pregnancy, second trimester
O88.113
Amniotic fluid embolism in pregnancy, third trimester
O88.119
Amniotic fluid embolism in pregnancy, unspecified trimester
O88.12
Amniotic fluid embolism in childbirth
O88.13
Amniotic fluid embolism in the puerperium
O88.211
Thromboembolism in pregnancy, first trimester
O88.212
Thromboembolism in pregnancy, second trimester
O88.213
Thromboembolism in pregnancy, third trimester
O88.219
Thromboembolism in pregnancy, unspecified trimester
O88.22
Thromboembolism in childbirth
O88.23
Thromboembolism in the puerperium
O88.311
Pyemic and septic embolism in pregnancy, first trimester
O88.312
Pyemic and septic embolism in pregnancy, second trimester
O88.313
Pyemic and septic embolism in pregnancy, third trimester
O88.319
Pyemic and septic embolism in pregnancy, unspecified trimester
O88.32
Pyemic and septic embolism in childbirth
O88.33
Pyemic and septic embolism in the puerperium
O88.811
Other embolism in pregnancy, first trimester
O88.812
Other embolism in pregnancy, second trimester
O88.813
Other embolism in pregnancy, third trimester
O88.819
Other embolism in pregnancy, unspecified trimester
O88.82
Other embolism in childbirth
O88.83
Other embolism in the puerperium
O90.5
Postpartum thyroiditis
O90.6
Postpartum mood disturbance
O90.81
Anemia of the puerperium
5/23/2018 Green Mountain Care Provider Manual 196
O90.89
Other complications of the puerperium, not elsewhere classified
O91.011
Infection of nipple associated with pregnancy, first trimester
O91.012
Infection of nipple associated with pregnancy, second trimester
O91.013
Infection of nipple associated with pregnancy, third trimester
O91.019
Infection of nipple associated with pregnancy, unspecified trimester
O91.02
Infection of nipple associated with the puerperium
O91.03
Infection of nipple associated with lactation
O91.111
Abscess of breast associated with pregnancy, first trimester
O91.112
Abscess of breast associated with pregnancy, second trimester
O91.113
Abscess of breast associated with pregnancy, third trimester
O91.119
Abscess of breast associated with pregnancy, unspecified trimester
O91.12
Abscess of breast associated with the puerperium
O91.13
Abscess of breast associated with lactation
O91.211
Nonpurulent mastitis associated with pregnancy, first trimester
O91.212
Nonpurulent mastitis associated with pregnancy, second trimester
O91.213
Nonpurulent mastitis associated with pregnancy, third trimester
O91.219
Nonpurulent mastitis associated with pregnancy, unspecified trimester
O91.22
Nonpurulent mastitis associated with the puerperium
O91.23
Nonpurulent mastitis associated with lactation
O92.011
Retracted nipple associated with pregnancy, first trimester
O92.012
Retracted nipple associated with pregnancy, second trimester
O92.013
Retracted nipple associated with pregnancy, third trimester
O92.019
Retracted nipple associated with pregnancy, unspecified trimester
O92.02
Retracted nipple associated with the puerperium
O92.03
Retracted nipple associated with lactation
O92.111
Cracked nipple associated with pregnancy, first trimester
O92.112
Cracked nipple associated with pregnancy, second trimester
O92.113
Cracked nipple associated with pregnancy, third trimester
O92.119
Cracked nipple associated with pregnancy, unspecified trimester
O92.12
Cracked nipple associated with the puerperium
O92.13
Cracked nipple associated with lactation
O92.20
Unspecified disorder of breast associated with pregnancy and the puerperium
O92.29
Other disorders of breast associated with pregnancy and the puerperium
O92.3
Agalactia
O92.5
Suppressed lactation
O92.6
Galactorrhea
O92.70
Unspecified disorders of lactation
O92.79
Other disorders of lactation
O98.011
Tuberculosis complicating pregnancy, first trimester
O98.012
Tuberculosis complicating pregnancy, second trimester
O98.013
Tuberculosis complicating pregnancy, third trimester
O98.019
Tuberculosis complicating pregnancy, unspecified trimester
O98.02
Tuberculosis complicating childbirth
O98.03
Tuberculosis complicating the puerperium
O98.111
Syphilis complicating pregnancy, first trimester
O98.112
Syphilis complicating pregnancy, second trimester
O98.113
Syphilis complicating pregnancy, third trimester
O98.119
Syphilis complicating pregnancy, unspecified trimester
O98.12
Syphilis complicating childbirth
O98.13
Syphilis complicating the puerperium
O98.211
Gonorrhea complicating pregnancy, first trimester
O98.212
Gonorrhea complicating pregnancy, second trimester
O98.213
Gonorrhea complicating pregnancy, third trimester
O98.219
Gonorrhea complicating pregnancy, unspecified trimester
O98.22
Gonorrhea complicating childbirth
5/23/2018 Green Mountain Care Provider Manual 197
O98.23
Gonorrhea complicating the puerperium
O98.311
Other infections with a predominantly sexual mode of transmission complicating pregnancy, first trimester
O98.312
Other infections with a predominantly sexual mode of transmission complicating pregnancy, second
trimester
O98.313
Other infections with a predominantly sexual mode of transmission complicating pregnancy, third trimester
O98.319
Other infections with a predominantly sexual mode of transmission complicating pregnancy, unspecified
trimester
O98.32
Other infections with a predominantly sexual mode of transmission complicating childbirth
O98.33
Other infections with a predominantly sexual mode of transmission complicating the puerperium
O98.42
Viral hepatitis complicating childbirth
O98.43
Viral hepatitis complicating the puerperium
O98.511
Other viral diseases complicating pregnancy, first trimester
O98.512
Other viral diseases complicating pregnancy, second trimester
O98.513
Other viral diseases complicating pregnancy, third trimester
O98.519
Other viral diseases complicating pregnancy, unspecified trimester
O98.52
Other viral diseases complicating childbirth
O98.53
Other viral diseases complicating the puerperium
O98.611
Protozoal diseases complicating pregnancy, first trimester
O98.612
Protozoal diseases complicating pregnancy, second trimester
O98.613
Protozoal diseases complicating pregnancy, third trimester
O98.619
Protozoal diseases complicating pregnancy, unspecified trimester
O98.62
Protozoal diseases complicating childbirth
O98.63
Protozoal diseases complicating the puerperium
O98.811
Other maternal infectious and parasitic diseases complicating pregnancy, first trimester
O98.812
Other maternal infectious and parasitic diseases complicating pregnancy, second trimester
O98.813
Other maternal infectious and parasitic diseases complicating pregnancy, third trimester
O98.819
Other maternal infectious and parasitic diseases complicating pregnancy, unspecified trimester
O98.82
Other maternal infectious and parasitic diseases complicating childbirth
O98.83
Other maternal infectious and parasitic diseases complicating the puerperium
O98.911
Unspecified maternal infectious and parasitic disease complicating pregnancy, first trimester
O98.912
Unspecified maternal infectious and parasitic disease complicating pregnancy, second trimester
O98.913
Unspecified maternal infectious and parasitic disease complicating pregnancy, third trimester
O98.919
Unspecified maternal infectious and parasitic disease complicating pregnancy, unspecified trimester
O98.92
Unspecified maternal infectious and parasitic disease complicating childbirth
O98.93
Unspecified maternal infectious and parasitic disease complicating the puerperium
O99.011
Anemia complicating pregnancy, first trimester
O99.012
Anemia complicating pregnancy, second trimester
O99.013
Anemia complicating pregnancy, third trimester
O99.019
Anemia complicating pregnancy, unspecified trimester
O99.02
Anemia complicating childbirth
O99.03
Anemia complicating the puerperium
O99.280
Endocrine, nutritional and metabolic diseases complicating pregnancy, unspecified trimester
O99.281
Endocrine, nutritional and metabolic diseases complicating pregnancy, first trimester
O99.282
Endocrine, nutritional and metabolic diseases complicating pregnancy, second trimester
O99.283
Endocrine, nutritional and metabolic diseases complicating pregnancy, third trimester
O99.284
Endocrine, nutritional and metabolic diseases complicating childbirth
O99.285
Endocrine, nutritional and metabolic diseases complicating the puerperium
O99.320
Drug use complicating pregnancy, unspecified trimester
O99.321
Drug use complicating pregnancy, first trimester
O99.322
Drug use complicating pregnancy, second trimester
O99.323
Drug use complicating pregnancy, third trimester
O99.324
Drug use complicating childbirth
O99.325
Drug use complicating the puerperium
O99.340
Other mental disorders complicating pregnancy, unspecified trimester
O99.341
Other mental disorders complicating pregnancy, first trimester
5/23/2018 Green Mountain Care Provider Manual 198
O99.342
Other mental disorders complicating pregnancy, second trimester
O99.343
Other mental disorders complicating pregnancy, third trimester
O99.344
Other mental disorders complicating childbirth
O99.345
Other mental disorders complicating the puerperium
O99.411
Diseases of the circulatory system complicating pregnancy, first trimester
O99.412
Diseases of the circulatory system complicating pregnancy, second trimester
O99.413
Diseases of the circulatory system complicating pregnancy, third trimester
O99.419
Diseases of the circulatory system complicating pregnancy, unspecified trimester
O99.42
Diseases of the circulatory system complicating childbirth
O99.43
Diseases of the circulatory system complicating the puerperium
O99.53
Diseases of the respiratory system complicating the puerperium
O99.63
Diseases of the digestive system complicating the puerperium
O99.810
Abnormal glucose complicating pregnancy
O99.814
Abnormal glucose complicating childbirth
O99.815
Abnormal glucose complicating the puerperium
O99.834
Other infection carrier state complicating childbirth
O99.835
Other infection carrier state complicating the puerperium
O99.89
Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium
O9A.23
Injury, poisoning and certain other consequences of external causes complicating the puerperium
Z00.00
Encounter for general adult medical examination without abnormal findings
Z00.01
Encounter for general adult medical examination with abnormal findings
Z00.110
Health examination for newborn under 8 days old
Z00.111
Health examination for newborn 8 to 28 days old
Z00.121
Encounter for routine child health examination with abnormal findings
Z00.129
Encounter for routine child health examination without abnormal findings
Z00.5
Encounter for examination of potential donor of organ and tissue
Z00.6
Encounter for examination for normal comparison and control in clinical research program
Z00.70
Encounter for examination for period of delayed growth in childhood without abnormal findings
Z00.71
Encounter for examination for period of delayed growth in childhood with abnormal findings
Z00.8
Encounter for other general examination
Z02.0
Encounter for examination for admission to educational institution
Z02.1
Encounter for pre-employment examination
Z02.2
Encounter for examination for admission to residential institution
Z02.3
Encounter for examination for recruitment to armed forces
Z02.4
Encounter for examination for driving license
Z02.5
Encounter for examination for participation in sport
Z02.6
Encounter for examination for insurance purposes
Z02.81
Encounter for paternity testing
Z02.82
Encounter for adoption services
Z02.83
Encounter for blood-alcohol and blood-drug test
Z02.89
Encounter for other administrative examinations
Z04.6
Encounter for general psychiatric examination, requested by authority
Z11.0
Encounter for screening for intestinal infectious diseases
Z11.1
Encounter for screening for respiratory tuberculosis
Z11.2
Encounter for screening for other bacterial diseases
Z11.3
Encounter for screening for infections with a predominantly sexual mode of transmission
Z11.51
Encounter for screening for human papillomavirus (HPV)
Z11.59
Encounter for screening for other viral diseases
Z11.6
Encounter for screening for other protozoal diseases and helminthiases
Z11.8
Encounter for screening for other infectious and parasitic diseases
Z11.9
Encounter for screening for infectious and parasitic diseases, unspecified
Z13.0
Encounter for screening for diseases of the blood and blood-forming organs and certain disorders
involving the immune mechanism
Z13.1
Encounter for screening for diabetes mellitus
Z13.21
Encounter for screening for nutritional disorder
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Z13.220
Encounter for screening for lipoid disorders
Z13.228
Encounter for screening for other metabolic disorders
Z13.29
Encounter for screening for other suspected endocrine disorder
Z13.4
Encounter for screening for certain developmental disorders in childhood
Z13.828
Encounter for screening for other musculoskeletal disorder
Z13.89
Encounter for screening for other disorder
Z20.01
Contact with and (suspected) exposure to intestinal infectious diseases due to Escherichia coli (E. coli)
Z20.09
Contact with and (suspected) exposure to other intestinal infectious diseases
Z20.1
Contact with and (suspected) exposure to tuberculosis
Z20.2
Contact with and (suspected) exposure to infections with a predominantly sexual mode of transmission
Z20.3
Contact with and (suspected) exposure to rabies
Z20.4
Contact with and (suspected) exposure to rubella
Z20.5
Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
Z20.6
Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
Z20.810
Contact with and (suspected) exposure to anthrax
Z20.811
Contact with and (suspected) exposure to meningococcus
Z20.820
Contact with and (suspected) exposure to varicella
Z20.828
Contact with and (suspected) exposure to other viral communicable diseases
Z20.89
Contact with and (suspected) exposure to other communicable diseases
Z20.9
Contact with and (suspected) exposure to unspecified communicable disease
Z22.0
Carrier of typhoid
Z22.1
Carrier of other intestinal infectious diseases
Z22.2
Carrier of diphtheria
Z22.31
Carrier of bacterial disease due to meningococci
Z22.321
Carrier or suspected carrier of Methicillin susceptible Staphylococcus aureus
Z22.322
Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus
Z22.330
Carrier of Group B streptococcus
Z22.338
Carrier of other streptococcus
Z22.39
Carrier of other specified bacterial diseases
Z22.4
Carrier of infections with a predominantly sexual mode of transmission
Z22.50
Carrier of unspecified viral hepatitis
Z22.51
Carrier of viral hepatitis B
Z22.52
Carrier of viral hepatitis C
Z22.59
Carrier of other viral hepatitis
Z22.8
Carrier of other infectious diseases
Z23
Encounter for immunization
Z33.1
Pregnant state, incidental
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
Z38.00
Single liveborn infant, delivered vaginally
Z38.01
Single liveborn infant, delivered by cesarean
Z38.1
Single liveborn infant, born outside hospital
Z38.2
Single liveborn infant, unspecified as to place of birth
Z38.30
Twin liveborn infant, delivered vaginally
Z38.31
Twin liveborn infant, delivered by cesarean
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Z38.4
Twin liveborn infant, born outside hospital
Z38.5
Twin liveborn infant, unspecified as to place of birth
Z38.61
Triplet liveborn infant, delivered vaginally
Z38.62
Triplet liveborn infant, delivered by cesarean
Z38.63
Quadruplet liveborn infant, delivered vaginally
Z38.64
Quadruplet liveborn infant, delivered by cesarean
Z38.65
Quintuplet liveborn infant, delivered vaginally
Z38.66
Quintuplet liveborn infant, delivered by cesarean
Z38.68
Other multiple liveborn infant, delivered vaginally
Z38.69
Other multiple liveborn infant, delivered by cesarean
Z38.7
Other multiple liveborn infant, born outside hospital
Z38.8
Other multiple liveborn infant, unspecified as to place of birth
Z41.8
Encounter for other procedures for purposes other than remedying health state
Z51.89
Encounter for other specified aftercare
Z76.1
Encounter for health supervision and care of foundling
Z76.2
Encounter for health supervision and care of other healthy infant and child
Z79.810
Long term (current) use of selective estrogen receptor modulators (SERMs)
Z79.811
Long term (current) use of aromatase inhibitors
Z79.818
Long term (current) use of other agents affecting estrogen receptors and estrogen levels
Z79.890
Hormone replacement therapy (postmenopausal)

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