June 22, 2005

 

 

TO:                 Physicians, Mid-level Practitioners, and Hospitals

 

FROM:           Leslie M. Clement, Deputy Administrator

 

SUBJECT:     CHANGE IN MEDICAID COVERAGE FOR MALE CIRCUMCISION

 

Effective with dates of service on or after 8/1/2005, Medicaid will only cover male circumcisions which are medically necessary. Circumcisions performed for religious or cultural preferences will not be covered.

 

·        How to bill Medicaid for medically necessary circumcisions:

Claims billed with CPT (Current Procedural Terminology) circumcision codes 54150, 54152, 54160 and 54161, and related charges such as medications, supplies, equipment, and treatment rooms will require the provider to include documentation of medical necessity. Documentation may be a note in the comments field of the claim, or an attachment to the claim.

 

·        Medically necessary circumcisions do not require Prior Authorization:

Valid diagnoses indicating medical necessity for a circumcision include recurrent balanoposthitis, recurrent urinary tract or localized infections, recurrent lesions, trauma, or malignancy.  

 

If a client has a different diagnosis than those listed above and the provider wants approval from Medicaid prior to performing the circumcision, the provider may submit a Request for Prior Authorization following the procedures in the Medicaid Provider Handbook, General Billing Section 2.3, that is available online at: http://www.healthandwelfare.idaho.gov/Portals/_Rainbow/Documents/medical/s2_gen_billing.pdf

The Prior Authorization form is available online at: http://www.healthandwelfare.idaho.gov/Portals/_Rainbow/Documents/medical/s6d_forms.pdf

Requests for Prior Authorization should be sent to:

 

Division of Medicaid

EPSDT Coordinator

Bureau of Care Management

P.O. Box 83720

Boise, ID 83720-0036

FAX: (208) 364-1864  Phone: (208) 364-1842

 

·        Billing the parent(s) or responsible party for circumcisions performed on or after August 1, 2005: 

A provider may bill the parent(s) or responsible party directly for the charges related to the circumcision if the provider informs the parent(s) or responsible party, before the procedure is performed, that Medicaid will not cover routine circumcisions. For additional information about Medicaid Non-Covered Services please refer to General Section 1.3.3.1 of the Medicaid Provider Handbook, which is available on line at:

 

It is not necessary to obtain a denial from Medicaid before billing the parent(s) or responsible party for routine circumcisions. Billing Medicaid for non-covered routine circumcisions will cause your entire claim to pend for manual review, causing an unnecessary delay in processing.

 

If you have questions concerning this Information Release, please contact Ms. Arla Farmer, Bureau of Medicaid Policy, at (208) 364-1958 or by FAX at (208) 334-2465.

 

Thank you for your participation in the Medicaid program.

 

This Information Release changes information in the Physician/Osteopath Section 3.2.5 of the Idaho Medicaid Provider Handbook, available online at: http://www.healthandwelfare.idaho.gov/_Rainbow/Documents/medical/s3_004_005_physician.pdf

and the Hospital Section 3.6.2 of the Idaho Medicaid Provider Handbook, available online at:

 

LC/af