CurrentAlliance HealthPolicy 1D-2

Sexually Transmitted Disease Treatment Provided in Health Departments

Defines coverage, eligibility, and limitations for STD treatment services provided in local health department settings to North Carolina Medicaid beneficiaries, including EPSDT considerations for beneficiaries under 21.

Policy Summary

PayerAlliance Health

PolicySexually Transmitted Disease Treatment Provided in Health Departments

Policy CodePolicy 1D-2

Change TypeNo material change

Effective DateAugust 15, 2023

Next Review DateN/A

Key ActionDocument EPSDT medical necessity for beneficiaries under 21 when requesting coverage beyond policy limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NCapplicable state

History/diagnostics/treatmentservices included

4/daybilling units limit

T1002HCPCS code

Coverage Criteria and Limitations

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General medical necessity: The procedure, product, or service is individualized, specific, and consistent with symptoms or a confirmed diagnosis and not in excess of the beneficiary's needs.

[3.1.a]

Safety and alternatives: The procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide.

[3.1.b]

Not for convenience: The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

[3.1.c]

General coverage conditions

Covered when delivered in local health departments by eligible providers and within billing limits:

Core coverage conditions: Service is delivered in a health department; provider meets Medicaid participation and applicable DHHS administrative agreements; when provided by a public health nurse, HCPCS code T1002 is billable only when all service components are provided; billing does not exceed the maximum of 4 units per day (units may be split across two days if delayed test results require a return visit, but all service components must be provided across the days).4 units/day

Prior approval is not required for STD treatment provided in health departments; T1002 billing rules and unit limits apply; T1002 cannot be billed with preventive, prenatal, or treatment codes.

Medicaid shall not cover the procedure, product, or service related to this policy when any of the following apply: the beneficiary does not meet the eligibility requirements listed in Section 2.0; the beneficiary does not meet the criteria listed in Section 3.0; the procedure, product, or service duplicates another provider’s procedure, product, or service; or the procedure, product, or service is experimental, investigational, or part of a clinical trial.

When STD treatment services are provided in health departments, billing depends on the provider and the service rendered. The health department may bill the appropriate E/M code when there is a separately identifiable medical condition and the diagnosis on the claim must reflect that condition. Laboratory tests performed on site should be billed using laboratory codes. All other providers delivering services in health departments must bill using the appropriate E/M codes.

Coding, Codes, and Billing Limits

Codes and Modifiers (refer to attachment)mixed

No codes listed

Covered HCPCS CodesHCPCSCovered

T1002

Public health nurse STD procedure code; billable when all service components are provided; maximum of 4 units per day; if split between days due to delayed test results, all components must be provided across the days.

Billing and coding requirementsmixed

Professional (CMS-1500/837P)	Required claim type for professional billing
ICD-10-CM / PCS (current edition)	Report diagnosis and procedural codes to highest level of specificity
CPT (current edition)	Report most specific CPT code that accurately describes the service
HCPCS (current edition)	Report most specific HCPCS code that accurately describes the service
UB-04 revenue codes	Use UB-04 Data Specifications Manual for institutional revenue codes
Unlisted CPT/HCPCS with Special Report	Use unlisted procedure code and submit Special Report when no specific code exists

Maximum billable units per day

Maximum billable units per day4 units per day

Split across days when test delays occurUp to 4 units may be split between two separate days if delayed test results require return; all service components must be provided across the days

Applies to T1002Maximum applies to HCPCS code T1002 as billed by public health nurses

Billing units per day

Billing units per day (limit)Maximum 4 units per day may be billed

Provider billing noteIf T1002 is billed on separate days due to delayed test results, all service components must be provided across the days

Claiming guidanceFollow Attachment A claim type and coding requirements when billing units (Professional CMS-1500/837P for professional services)

Provider Actions, Documentation, and Prior Authorization

Prior Authorization

Prior Authorization Required / EPSDT Exception

Prior approval is required when specified by policy. For beneficiaries under 21 (EPSDT), the requirement for prior approval remains in place — document medical necessity to support any service that would exceed usual policy limits. Note: Medicaid does not require prior approval for sexually transmitted disease (STD) treatment provided in health departments.

EPSDT beneficiaries: prior approval requirement remains; document medical necessity when requesting services that exceed policy limits.
STD treatment in health departments: no prior approval required.

Denial Risk

Denial and Adjustment Process for Additional Units

Reimbursement for units beyond standard limits will be considered only when medical necessity is documented. If additional units are denied, do not submit a corrected claim; instead submit a Claim Adjustment Request form and include the medical indication and supporting documentation.

Include medical indication(s): allergic reaction to treatment, STD and TB visit same date, history of false positive complicating treatment, co-morbid conditions, multiple STDs.
Use the Claim Adjustment Request form; NC Medicaid's fiscal agent will perform the adjustment using the original claim.

Documentation Required

Documentation Required for Adjustment Requests

Documentation supporting adjustment requests must clearly state the medical indication and include pertinent clinical records to justify additional units or services. For EPSDT (beneficiaries under 21), explicitly document how the service is medically necessary to correct or ameliorate a condition identified through screening.

Attach clinical notes, lab results, or other supporting records demonstrating medical necessity.
For adjustments, list the specific medical reason(s) on the Claim Adjustment Request form as instructed.
Do not submit a corrected claim when requesting an adjustment.

Billing Rule

Potential Denial Triggers for Coding and Claim Submission

Claims must be submitted on the correct claim type and follow NCTracks, national billing and coding guidelines. Use Professional (CMS-1500/837P) unless directed otherwise; institutional billing must follow National Uniform Billing Guidelines. All claims must comply with NCTracks submission rules and the NCTracks Provider Claims and Billing Assistance Guide.

Required claim type: Professional (CMS-1500/837P) unless otherwise directed.
Institutional claims: follow National Uniform Billing Guidelines.
Follow NCTracks Provider Claims and Billing Assistance Guide for submission specifics.

Documentation Required

Coding and Claims Documentation Standards

Report diagnosis and procedure codes to the highest level of specificity that supports medical necessity. Use the current ICD-10-CM/PCS, CPT, HCPCS, and UB-04/Revenue code manuals in effect at the time of service. When no specific CPT/HCPCS code exists, report the appropriate unlisted code and follow the CPT/HCPCS instructions for a special report.

ICD-10-CM/PCS: report to highest specificity and use the current edition.
CPT/HCPCS/UB-04: report the most specific code that accurately describes the service.
Unlisted codes: follow current CPT/HCPCS instructions and include required special report.

Note

Conservative Treatment Preference

Use the most conservative, equally effective, and less costly statewide treatment when available. Coverage is contingent on there being no equally effective and more conservative or less costly option available statewide.

Document why a more conservative or less costly statewide option is not appropriate when applicable.

Step Therapy

No general or specific step therapy requirements apply to this policy.

Step therapy: None apply.

Billing Rule

Coding and Documentation Requirements

Providers must report ICD-10 and procedure codes at the highest specificity, use current code editions, and follow CPT/HCPCS/UB-04 instructions. Bill laboratory codes for tests performed on site. If another health department provider sees the recipient the same date of service for a separately identifiable medical condition, bill the appropriate E/M code and include the diagnosis that supports the separately identifiable condition. T1002 cannot be billed with preventive medicine, prenatal, or treatment codes.

Report ICD-10-CM/PCS to highest specificity and use current edition.
Report most specific CPT/HCPCS/Revenue codes; follow unlisted code reporting rules if necessary.
Bill lab codes for on-site tests.
T1002 billing restrictions: cannot be billed with preventive medicine, prenatal, or treatment codes.
When separately identifiable condition is present on same date, bill appropriate E/M with supporting diagnosis.

Background and Scope

This policy applies to the treatment of sexually transmitted diseases delivered in local health department settings. Covered services include obtaining a medical history, conducting diagnostic examinations, ordering and performing indicated laboratory testing, providing treatment, and arranging referrals as appropriate. EPSDT provisions allow exceptions to policy limitations for Medicaid beneficiaries under 21 when services are medically necessary to correct or ameliorate a condition; services must be individualized and consistent with symptoms or a confirmed diagnosis.

Definitions and Key Terms

Definitions

Definitions present in policyNone Apply

ImplicationNo specific policy-level definitions are provided in Section 1.1

Reference locationSection 1.1 of the policy document (Definitions) states 'None Apply.'

T1002 (HCPCS)

HCPCS code T1002Used by public health nurses when all service components for STD-related service are provided; billable when all components are provided

Unit limit tied to T1002A maximum of 4 units per day may be billed for T1002

Split-billing rule for T1002If delayed test results require return, the 4 units may be split between two days provided all service components are completed across the days

EPSDT (Exception for beneficiaries under 21)

EPSDT exceptionException to policy limitations for Medicaid beneficiaries under 21 (EPSDT) allows medically necessary services that correct or ameliorate a condition to exceed policy limits

Prior approval and EPSDTIf a service requires prior approval, EPSDT status does not remove the prior approval requirement; providers must follow NCTracks and EPSDT guidance

Policy referencesEPSDT special provision and historical revisions are documented in the policy's revision history and Section 2.2.1