016.06.04 Ark. Code R. 087

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.06.04-087 - DMS-2004-A-7; DMS-2004-L-17; DMS-2004-R-18

I.Introduction

Effective for dates of service on and after February 1, 2005, Arkansas Medicaid will cover gastrointestinal tract imaging with wireless endoscopy capsule.

II.Coverage

Wireless endoscopy capsule is a procedure utilized for visualization of small bowel mucosa.

A. The capsule will be covered for evaluation of occult gastrointestinal bleeding in the anemic patient when:

1. The site of the bleeding has not been identified by previous gastrointestinal endoscopy, colonoscopy push endoscopy or other radiological procedures.

2. An abnormal x-ray of the small intestine is documented without an identified site of bleeding.

3. An initial diagnosis of suspected Crohn's disease without the evidence of disease is made based on conventional diagnostic tests such as small bowel follow through and upper and lower endoscopy.

4. The evaluation indicates obscure gastrointestinal bleeding suspected of being small bowel in origin as evidenced by prior inconclusive upper and lower endoscopic studies.

B. Coverage of this procedure is limited to individuals 10 years through 20 years of age.

C. Coverage is limited to individuals with one of the following diagnoses: 280.9 578.1 578.9 792.1

D. Services are payable when performed in the physician's office, inpatient and outpatient hospital and ambulatory surgical center.

When administered to an inpatient, the cost of the capsule will be included in the per diem and cannot be reimbursed separately.

The cost of the capsule is included in the technical component when performed outpatient or in the complete component if performed in the office.

III.Billing Instructions

A. Claims must be filed on paper with patient's medical history and physical exam attached. Claims will be manually reviewed prior to reimbursement.

B. Procedure code 91110 should be used when filing claims for this service. Types of service P, C or T must be used. Places of service codes are inpatient hospital - 1, outpatient hospital - 2, physician's office - 3 and ambulatory surgical center - B.

Thank you for your participation in the Arkansas Medicaid Program. Roy Jeffus, Director If you need this material in an alternative format, such as large print, please contact our Americans with Disabilities Act Coordinator at (501) 682-6789 and 1-877-708 -8191. Both telephone numbers are voice and TDD.

If you have questions regarding this notice, please contact the EDS Provider Assistance Center at In-State WATS 1-800-457 -4454, or locally and Out-of-State at (501) 376-2211.

Arkansas Medicaid provider manuals, official notices and remittance advice (RA) messages are available for downloading from the Arkansas Medicaid website: www.medicaid.state.ar.us.

016.06.04 Ark. Code R. 087

5/9/2005