Summary
Michigan Medicaid bulletin MSA 19-27, issued August 30, 2019, clarifies prior authorization and documentation requirements for genetic testing. Prior authorization is required for most genetic laboratory tests and must be obtained before the test is performed, using form MSA-6544-B. The bulletin also sets standards of coverage, documentation and billing rules for continuous glucose monitoring systems (CGMS) and their supplies, changes the Maternal Infant Health Program fee schedule to a 10% increase for services on or after October 1, 2019 (contingent on CMS approval of a State Plan Amendment), and lists existing codes whose coverage was made retroactive effective May 1, 2019 and June 1, 2019.
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What to do
Action · 12 steps
01Check current applicability of these 2019 requirements before acting on them.
02Genetic testing: Billing team should get prior authorization before the test is performed, using form MSA-6544-B, and check the CHAMPS Code Rate and Reference tool for which tests need it.
03Medical documentation must be submitted by the beneficiary's attending provider (MD, DO, PA or NP) along with the form, including the indication for the test, clinical notes on signs and symptoms, relevant family history, other related testing or clinical findings, documentation that the results will significantly alter management or treatment, and the name and NPI of the performing laboratory.
04Medical necessity letters or genetic testing request forms from the performing laboratory will not be accepted as clinical documentation.
05CGMS: Documentation must be less than 90 days old and include a written order from the treating physician or non-physician practitioner.
06Prior authorization is not required for infants and toddlers age 5 and under if standards of coverage and documentation requirements are met, and is required for all other ages and conditions.
07Sensors, transmitters and receivers are purchase-only items except K0554.
08The HCPCS codes A4233, A4234, A4236, A4244, A4245, A4246, A4247, A4250, A4253, A4255, A4256, A4257, A4258, A4259, E0607, E2100 and E2101 are included in the allowance for K0553 and may not be billed separately.
09Providers must use the most appropriate HCPCS code for each brand, make and model by reviewing FDA product approvals and the PDAC contractor website; upcoding is incorrect billing and could result in post-payment recovery of funds or provider audit.
10Rendering providers: claims requiring a rendering provider must include that field, and the rendering provider must be enrolled with the program for payment; claims without rendering provider information cannot be paid.
11Claims for services rendered by nonphysician practitioners (such as physician assistants and nurse practitioners) must be billed under the practitioner's NPI and include the NPI of the supervising physician as applicable.
12Nurse practitioners and clinical nurse specialists: professional claims must include the practitioner's NPI in the Rendering Provider field and the supervising or collaborating physician in the Supervising Provider field as applicable.
Codes mentioned
87481874918759187801G0396G0397G2011K0553K0554A4233A4234A4236A4244A4245A4246A4247A4250A4253A4255A4256A4257A4258A4259E0607E2100E2101
Original notice
MSA 19-27
michigan.gov · Always check the source before changing claims.
Related changes
See all Michigan Medicaid - MDHHS changes →MSA 19-04MediumEffective Apr 1, 2019 · Provider BulletinMMP 23-31: Revisions to Continuous Glucose Monitoring Systems (CGMS) PolicyMediumEffective Jun 1, 2023 · Medical PolicyMMP 23-52: Updates to the MDHHS Medicaid Provider ManualMediumEffective Oct 1, 2023 · Medical PolicyMMP 23-27: End of the Federal Public Health Emergency and Unwinding of COVID-19 Response PoliciesMediumEffective May 11, 2023 · Provider BulletinBrowse every Michigan Medicaid - MDHHS change in the policy list
Related policy hubs
Michigan Medicaid - MDHHS policiesMI policy changesGeneticsEndocrinologyGeriatricsPediatricsOB-GYNPsychiatryCode 87481Code 87491Code 87591Code 87801Code G0396Code G0397Code G2011Code K0553Code K0554Code A4233Code A4234Code A4236Code A4244Code A4245Code A4246Code A4247Code A4250Code A4253Code A4255Code A4256Code A4257Code A4258Code A4259Code E0607Code E2100Code E2101