016.06.13 Ark. Code R. 022
Summary for
State Plan Amendment #2013-024 and
Prosthetics 5-13
Effective for claims with dates of service March 1, 2014 and after, the Arkansas Department of Human Services is implementing coverage of the MIC-KEY Percutaneous Cecostomy Tube for all ages. In addition, the MIC-KEY Skin Level Gastrostomy Tube will be expanded to coverage for all ages. Arkansas Medicaid has estimated an annual budget impact of $31,000.
The Arkansas Medicaid Program reimburses for the MIC-KEY Skin Level Gastrostomy Tube (MIC-KEY button) and supplies for Medicaid-eligible beneficiaries of all ages. Prior authorization (PA) from AFMC is required.
When requesting prior authorization, form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be completed and sent, along with sufficient medical documentation, to AFMC.
The MIC-KEY Kit is benefit-limited to 2 per state fiscal year (SFY). The accessories, extension sets and adapters are covered under the $250 medical supply benefit limit.
Benefit extensions will be considered on a case-by-case basis if proven to be medically necessary. Prior authorization must be obtained from AFMC for any extensions using form DMS-679A. View or print AFMC contact information. View or print form DMS-679A and instructions for completion.
The Arkansas Medicaid Program reimburses for the MIC-KEY Percutaneous Cecostomy Tube (MIC-KEY button) for Medicaid-eligible beneficiaries of all ages. Arkansas Medicaid will reimburse the MIC-KEY Skin Level Gastrostomy Tube for all ages, when used for the management of severe fecal incontinence (see diagnosis codes below) requiring percutaneous cecostomy tube placement for bowel evacuation. Prior authorization (PA) from AFMC is required.
When requesting prior authorization, form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs and Wheelchair Components, must be completed and sent, along with sufficient medical documentation, to AFMC. View or print AFMC contact information. View or print form DMS-679A and instructions for completion.
The MIC-KEY button is benefit-limited to 2 per state fiscal year (SFY).
The MIC-KEY button for a Percutaneous Cecostomy Tube requires use of the following diagnosis codes:
Diagnosis Code | Description |
564.00-564.09 | Constipation |
787.60 | Fecal Incontinence |
787.61 | Incomplete Defecation |
787.62 | Fecal Soiling |
The MIC-KEY button for a Percutaneous Cecostomy Tube requires use of the following CPT codes:
44300 | 49442 | 49450 |
and MIC-KEY Percutaneous Cecostomy Tube and Supplies for Beneficiaries of All Ages
NOTE: When billing for the MIC-KEY Percutaneous Cecostomy Tube and/or supplies, an additional third modifier UA will be required.
Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.
Procedure Code | M1 | M2 | PA | Description | Payment Method |
B9998 | Y | MIC-KEY Kit | Purchase | ||
B9998 | NU | U1 | Y | SECUR-LOK Extension Set with 2 Port 'Y' and Clamp 12" Length | Purchase |
B9998 | NU | U2 | Y | SECUR-LOK Extension Set with 2 Port 'Y' and Clamp 24" Length | Purchase |
B9998 | NU | U3 | Y | Bolus Extension Set with Single Port Clamp 12" Length | Purchase |
B9998 | NU | U4 | Y | Bolus Extension Set with Single Port Clamp 24" Length | Purchase |
B9998 | NU | U5 | Y | Bolus SECUR-LOK Extension Set Single Portw/Clamp 12" Length | Purchase |
B9998 | NU | U6 | Y | Bolus SECUR-LOK Extension Set Single Port w/Clamp 24" Length | Purchase |
B9998 | NU | U7 | Y | Microvasive Adapter | Purchase |
B9998 | NU | U8 | Y | Microvasive Decompression Tube | Purchase |
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
ATTACHMENT 3.1-A
* Effective April 1,2002, these services require prior authorization for eligible Medicaid recipients under age 21 to determine and verify the patient's need for services.
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
ATTACHMENT 3.1-B
* Effective April 1,2002, these services require prior authorization for eligible Medicaid recipients under age 21 to determine and verify the patient's need for services.
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES -OTHER TYPES OF CARE
ATTACHMENT 4.19-B
Reimbursement is based on the lesser of the amount billed or the Title XIX (Medicaid) Maximum charge allowed. The Title XIX Maximum is 80% of the psychologist fee schedule.
Reimbursement is based on the lesser of the amount billed or the Title XIX (Medicaid) Maximum charge allowed. The Title XIX Maximum is 80% of the psychologist fee schedule.
Reimbursement is based on the lesser of the amount billed or the Title XIX (Medicaid) Maximum charge allowed. The Title XIX Maximum is 80% of the psychologist fee schedule.
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES -OTHER TYPES OF CARE
ATTACHMENT 4.19-B
Effective for dates of service on or after March 1,2014, coverage of the MIC-KEY for Percutaneous Cecostomy Tube will be reimbursed based on the above-mentioned methodology.
016.06.13 Ark. Code R. 022