Form Dma 3137 - Personal Care Services (Pcs) Icd-10 Transition Form - North Carolina Department Of Health And Human Services
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North Carolina Department of Health and Human Services – Division of Medical Assistance
Personal Care Services (PCS) ICD-10 Transition Form
PCS is a Medicaid benefit based on an unmet need for assistance with Activities of Daily Living (ADLs), which means bathing,
dressing, toileting, eating, and mobility in the setting of care.
All Health Insurance Portability and Accountability Act (HIPAA) covered entities are required to use ICD-10 diagnosis and procedure codes for dates of
service on or after October 1, 2015. ICD-9 diagnosis and procedure codes can no longer be used for health care services provided on or after this date.
Completed form should be faxed to Liberty Healthcare Corporation-NC at 919-573-9694 or 866-728-8039 (toll free) or uploaded by PCS
Provider into QiReport as a supporting document. For questions, call 855-740-1400 or 919-322-5944 or send an email to
NC-
. This is a required form for current PCS beneficiaries
SECTION A. BENEFICIARY DEMOGRAPHICS
Beneficiary’s Name: First:_____________________ MI:___ Last:______________________ DOB: ____/____/________
Medicaid ID#: __________________ Gender: M F
Language: English Spanish Other_______________
Address:
_____ City: __________________________
County:
Zip:
Phone: _______________________
Alternate Contact (Non-PCS Provider)/Parent/Guardian
: Name: ____________________________
(required if beneficiary < 18)
Relationship to Beneficiary:
_____
Phone: _______________________________
Current PCS Provider Name: _________________________________ NPI:_______________ Phone: ______________
Beneficiary currently resides: At home Adult Care Home Special Care Unit (SCU) Group Home
Other _______________________________
SECTION B. BENEFICIARY’S CONDITIONS THAT RESULT IN NEED FOR ASSISTANCE WITH ADLS
Identify the current medical diagnoses related to the beneficiary’s need for assistance with qualifying Activities of Daily
Living (bathing, dressing, mobility, toileting, and eating). List both the diagnosis and the ICD-10 code for each.
ICD-10 Code
Medical Diagnosis
(4 or 5 digits required)
_ _ _ . _ _ _
_
_ _ _ . _ _ _
_
_ _ _ . _ _ _
_
_ _ _ . _ _ _
_
_ _ _ . _ _ _
_
_ _ _ . _ _ _
_
_ _ _ . _ _ _
_
_ _ _ . _ _ _
_
SECTION C. PRACTITIONER INFORMATION/Referral
Your signature below confirms that you recommend the beneficiary receive an annual assessment to determine the level of need for
hands on assistance with ADLs.
Practitioner’s Name: _____________________________________ Practitioner NPI#:___________________
Select one: Beneficiary’s Primary Care Practitioner Outpatient Specialty Practitioner Inpatient Practitioner
Practice Stamp:
Practice Name: _________________________________________________
Practice Contact Name: ___________________________________________
Address:_______________________________________________________
Phone (______) _______________ Fax (______) _________________
Practitioner Signature AND Credentials:
Date:
__________________________________________ Date: ____/____/____
“I hereby attest that the information contained herein is current, complete, and accurate to the best of my knowledge and belief. I
understand that my attestation may result in the provision of services which are paid for by state and federal funds and I also understand that
whoever knowingly and willfully makes or causes to be made a false statement or representation may be prosecuted under the applicable
federal and state laws.”
DMA 3137: ICD-10 Transition Form
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