Provider Notice issued 10/10/14

Important Family Planning Policy Change and Payment Increases

The purpose of this notice is to provide further information regarding patient centered family planning services as follow up to the Illinois Family Planning Action Plan.

High quality, effective and voluntary contraceptive education and services help families control the number, timing and spacing of birth. The Illinois Department of Healthcare and Family Services (HFS) encourages providers to ensure that participants receive education and counseling on all FDA-approved birth control methods (pdf) with emphasis on presenting the most effective methods first, specifically long acting reversible contraceptives (LARCs) such as intrauterine devices (IUD) and the implant (pdf) . Systems that support primary prevention of unplanned pregnancy are critical to improve outcomes for both mother and baby. All changes are effective for dates of service on, and after October 1, 2014 unless otherwise noted.

Increased Reimbursement Rate for Insertion/Removal Procedures of Long Acting Reversible Contraceptives (LARCs)

Chart below details the new rates:

Removal and reinsertion is calculated at 100% of the higher CPT code rate plus 50% of the lower CPT code rate. Note that no single CPT code currently exists for IUD removal with reinsertion; therefore, providers should submit CPT codes for each service.

Evaluation/Management (E/M) visit on the Same Day as LARC Insertion or Removal

Providing same day family planning services is critical to support patient centered family planning services. LARCs do not require on-going patient maintenance, have an excellent safety profile, and have very few contraindications for girls and women of childbearing age. In the asymptomatic client, there are no clinical indications to delay insertion due to lack of sexually transmitted infection screening or cervical cancer screening results. This policy supports providing screenings and exams on the same day as insertion.

Payment for an annual preventive or problem focused E/M visit along with a LARC insertion or removal procedure is allowable when the medical record documents the significant, separately identifiable services and modifier 25 is appended to the E/M service. See below for examples:

• When the provider and patient discuss contraceptive options during an initial or annual preventive visit (99381-99397) and subsequently, the device is placed, a preventive service code with modifier 25 in addition to the insertion procedure code is reimbursable. If the provider removed a device and reinserted a new device with the preventive visit, rates as noted in chart above plus the preventive visit is reimbursable.

• When the provider and patient discuss contraceptives during a problem focused E/M visit (99201-99215) that was initiated for a reason other than LARC insertion, and on the same date of service the provider places the device, a problem focused E/M service code with modifier 25 in addition to the insertion procedure is reimbursable. If the provider removed a device and reinserted a new device with the problem focused visit, rates as noted in chart above plus the problem focused visit is reimbursable.

• When the provider and the patient review a previously chosen LARC method and proceed with placement of the LARC, only the insertion procedure code may be submitted.

Providers must use the appropriate diagnosis code from the V25.xx (encounter for contraceptive management) series in the ICD-9-CM, or the appropriate ICD-10–CM (upon implementation) for the primary code attached to the insertion (and/or removal) procedure code.

Vasectomy Reimbursement Rate Increase

Vasectomy is the only long term method men can use to achieve their reproductive life plans. Post operative complications are lower than female sterilization, recovery time is minimal, and the procedure can be safely done in the office or out-patient setting. Providers who bill for this service with CPT code 55250 will be reimbursed at $408. Such claims must be submitted on a paper claim form with the consent form HFS 2189 (pdf) attached, which must be completed at least 30 days, but no more than 180 days, prior to the procedure. Accuracy and legibility of procedures, dates and providers on the sterilization consent form are critical to prevent delayed payment

Federally Qualified Health Centers (FQHC) and Rural Health Center (RHC) Fee for Service Billing for Transcervical Sterilization Device

Permanent female sterilization with placement of inserts in the fallopian tube via the cervix is an alternative to hospital based, surgical sterilization. The procedure does not require an incision, does not require general anesthesia, and has a very high efficacy rate. An FQHC or RHC may bill fee for service for the transcervical sterilization kit following the fee-for-service billing guidelines for LARC devices:

• Reimbursement shall be made at the FQHC or RHC’s actual acquisition cost or the rate on the department’s practitioner fee schedule, whichever is lowest;

• This service must be billed separately from, and reimbursement shall be made separately from, any encounter payment the FQHC or RHC may receive for the insertion procedure.

As a reminder, IUDs and transcervical sterilization devices are the only items separately reimbursable to FQHCs and RHCs from the encounter rate.

Increase in Medical Dispensing Fee Add-On for Certain 340B Birth Control Methods and Change in allowable coding for Emergency Contraceptive Pills

Effective with dates of service July 1, 2014 and after, the following birth control methods purchased through the 340B program will receive an increase in the dispensing fee add-on. In order to receive the $35 medical dispensing fee add-on, providers must identify 340B purchased drugs by reporting modifier “UD” in conjunction with the appropriate procedure code. The provider charge should be the actual acquisition cost plus the $35 dispensing fee. Providers should monitor the department’s Claims Processing System Issues page for information regarding adjustments.

Effective with dates of service July 1, 2014 and after, the department will no longer reimburse emergency contraceptive pills (ECPs) billed with procedure code J8499. All ECPs must be billed using S4993.

• Providers who billed and were paid for procedure code J8499 for ECPs dispensed on or after July 1, 2014 must complete replacement claims following these new guidelines.

• Providers who billed J8499 and received rejections for ECPs dispensed on or after July 1, 2014 may re-bill following these new guidelines.

*Providers must dispense the three (3) month supply allowable by the department whenever possible. In most cases, providing patients with sufficient supply increases adherence to the method. Exceptions may be made when medically contraindicated as documented in the chart or if patient and provider medical decision making does not require 3 packs to be dispensed. Please ensure medical records document reason for NOT dispensing the required 3 packs.

**HFS has updated the dispensing policy for ECPs allowing for advance provision of up to 3 doses. Clinical guidelines encourage timely provision and patients should be counseled on a more effective form of birth control.

Special Information Regarding Care Coordination Billing and Eligibility

The specific billing instructions in this notice apply to patients enrolled in traditional fee-for-service, Accountable Care Entities (ACEs) and Care Coordination Entities (CCEs). Managed Care Organizations (MCOs) and Managed Care Community Networks (MCCNs) will reimburse at these new rates though their implementation date is 1-2 months out depending on the plan.

It is imperative that providers check HFS electronic eligibility systems regularly to determine beneficiaries’ enrollment in a plan. Electronic Data Interchange vendors (formerly the Recipient Eligibility Verification (REV) System), the Automated Voice Response System (AVRS) at 1-800-842-1461, and the Medical Electronic Data Interchange (MEDI) system will identify the enrollee’s care coordination plan. Questions related to coverage and billing requirements as well as information regarding the way each plan is displayed in the department’s electronic eligibility systems may be located in the June 24, 2014 informational notice titled, Revised - Care Coordination Enrollment for Children, Families and ACA Adults (pdf)

Final Reminders

• Providers interested in LARC training/refreshers should refer to the links for pharmaceutical contacts that can bring training to a practitioner’s office. Further education for providers and staff will be offered later this fall with details to be posted on the department’s Family Planning and Birth Control web page. Additionally, if practitioners and/or patients encounter issues related to contraceptive access, please communicate concerns in writing via the Feedback Forum.

• HFS is exploring innovative ways to provide devices at your office without incurring the high upfront costs. Coming soon, we will pilot a system where providers are provided sufficient devices at the office, employing a technological solution for streamlined auto replenishing. The department will notify providers when this system is operational.

• Illinois Healthy Women (IHW) ends 12/31/2014. Women enrolled in IHW will now have the opportunity to obtain comprehensive healthcare coverage through either Expanded Medicaid or the Health Insurance Marketplace. For more information, see the IHW informational notice update from 6/4/2014 (pdf).

Thank you for your commitment to helping ensure every pregnancy is a planned pregnancy. HFS is committed to ensuring timely reimbursement for all medical assistance providers. Questions related to this notice should be directed to the Bureau of Professional and Ancillary Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Programs