PROVIDER UPDATE

VOLUME 8, NUMBER 1

FEBRUARY 1991


 

Help Us Help You Documentation of Medical Services
Recipient Fraud Segmenting Diagnostic Procedures
Provider ID Numbers Block 24-H
Emergency Ambulance Transportation Rates Nonprofit Non-Emergency Transportation Rate Increases
Prior Authorization Criteria Required for Prior Authorization
Anesthesia Policy Clairification Revised LMAC Limits
Pharmacy Audits Dispensing Cost Survey
Nursing Facility Discharge Procedures New CPT-4 Cardiovascular Procedure Codes and Prices
1990 CPT-4 Procedure Codes TPL Carrier Listing

All Providers

Help Us Help You

It is our desire at Unisys to respond to all provider telephone inquires about the Louisiana Medicaid Program in an accurate and timely manner.  We realize that our telephone representatives must respond to requests for information concerning claim settlements and the eligibility status of particular Medicaid recipients as quickly as possible.  Therefore, we have installed additional lines in our Provider Relations telephone inquiry section to enable us to respond to more calls in a more efficient manner.

In addition, we are furnishing a schedule of our peak workload period so that providers will be able to reschedule their telephone inquiries accordingly.  The following is a record of the day-to-day percentage of incoming calls for a typical Monday through Friday workweek:

Workday      Percentage of Calls 

Monday                 25%
Tuesday                23%
Wednesday          23%
Thursday               16%
Friday                    13%

We would also like to request providers to call either before or after our lunch period (11:30 A.M. to 1:30 P.M.) because we are working with a reduced staff during the two-hour lunch period.  In fact, to ensure that you receive an expeditious response to your inquiries, the best time to schedule your telephone calls is between 8:00 A.M. and 9:00 A.M. and 4:00 P.M. and 5:00 P.M. Monday through Friday.

Finally, we would like to remind providers to telephone the Provider Relations switchboard, not the main Unisys switchboard.  Providers outside of Baton Rouge should telephone 1-800-473-2783.  Baton Rouge providers should telephone 924-5040.


Documentation of Medical Services

The Surveillance and Utilization Review Subsystem (SURS) would like to remind providers that they are required to keep complete and accurate medical records and/or documentation for all services that are billed to the Louisiana Medicaid Program.  Such records of documentation of the rendition of particular services may be requested for review by the Medicaid Program.  Therefore, it is very important to providers to keep all files updated for a period of at least three years.  Medical records that may be requested include the following:

1)    Patient office charts,
2)    Billing statements and/or ledger cards,
3)    Laboratory test results,
4)    Hospital charts (inpatient, outpatient, and emergency),
5)    Doctors' and nurses' notes,
6)    Operative reports,
7)    Information regarding payments for services rendered, and
8)    Any other pertinent medical or billing information.

If requested, these records must be furnished to the Bureau of Health Services Financing, its authorized representative(s), representatives of the United States Department of Health and Human Services, or the State Attorney General's Medicaid Fraud Control Unit.

Proper documentation, which may be requested for review, includes all objective and subjective findings, any laboratory forms or charts that list the specific or total results of the diagnostic procedures being billed, and a statement of any treatment that was rendered to the recipient.

However, providers should note that such documentation, including office and hospital progress and operative notes, are considered valid only if they are signed or initialed by the physician who provided the services.

Medical records and/or documentation may be requested for many reasons.  Often, the Louisiana Medicaid Program will request additional information about claims to determine whether or not reimbursement for services rendered is due to the provider.

In some circumstances, if a provider does not submit additional information for review, incorrect payments may be issued, and the following actions may be taken:

1)    A provider's billing practice may be investigated;
2)    The Louisiana Medicaid Program may decide to recoup money that has already been paid to a provider; and/or
3)    The provider may face disciplinary action.


Recipient Fraud

It has come to our attention that individuals who are not eligible for Medicaid services and who do not possess a Medicaid I.D. card of their own are using the Medicaid I.D. cards of other individuals who are Medicaid recipients in order to obtain medical services from the Louisiana Medicaid Program.  Providers, therefore, should be made aware of the fact that any unauthorized use of a Medicaid I.D. card constitutes recipient fraud.  In fact, for such cases of recipient fraud, the Louisiana Medicaid Program could take action against the unauthorized user of the card, the owner of the card, and/or any provider who knowingly render services to such ineligible individuals.

Consequently, we would like to caution all providers to use whatever means are available to establish the correct identify of the recipient prior to rendering Medicaid services.  For instance, providers could request to see the recipient's driver's license, Social Security card, or check cashing card.  If a recipient is attempting to falsify his/her identity, the provider should contact the proper local legal authorities, e.g., the local police or sheriff, or the Recipient Fraud Hotline Number, 1-800-256-3150, to report the recipient for attempted theft by Medicaid fraud.


Segmenting Diagnostic Procedures

The Louisiana Medicaid Program has always expressed the intent to pay for the most inclusive procedure code available which describes the procedure(s) performed and/or the result(s) obtained.  Thus, the individual component codes should be used only when individual components are being performed.  In addition, the Physicians' Current Procedural Terminology, Fourth Edition (CPT-4) states that the terminology and coding selected should be that which most accurately identifies the service performed (page XVI).

Consequently, providers who bill segmented diagnostic procedure codes will be subject to review and subsequent disciplinary action, the minimum of which is recoupment of payments.  Other sanctions will be administered as is deemed necessary and appropriate by the Department of Health and Hospitals.


Provider I.D. Numbers

Claim forms arrive daily without correct seven-digit Provider I.D. Numbers entered in the applicable blocks.  In addition, Providers are also submitting claims with Provider I.D. Numbers that are fewer than seven digits.  However, claims that do not have the Provider I.D. Number entered or those that do not have the Provider I.D. Number entered correctly cannot be processed.  Consequently, we urge providers to check their claim forms before submitting them for processing because all incorrect or incomplete claim forms will be rejected before they can be processed, and the provider will not be reimbursed.


All HCFA 1500 Billers

Block 24-H

All providers, especially those who are physicians in a group practice, who use the HCFA 1500 form to bill for Medicaid services should note that block 24-H on the form should be used to indicate the attending physician's Provider I.D. Number.  Many providers are entering their attending physician's Provider I.D. Number in the block for the Prior Authorization Number; and, therefore, many claims are being delayed in processing and returned to the provider so corrections can be made.


Transportation Provider

Emergency Ambulance Transportation Rates

The Medicaid Program has increased its reimbursement rates for emergency ambulance transportation effective February 1,1991.  Our new rates for emergency ambulance transportation are now the same as the rates paid by Medicare.  In addition, providers should no longer bill with procedure code A0225 [Base rate neonatal (ALS or BLS)].  Instead, providers should use procedure codes A0010 [Base rate (BLS) neonatal transport] and A0220 [Base rate (ALS) neonatal transport].  Also, Z5100 should be used to bill ALS transfers.  The procedure codes used to bill for emergency ambulance transport, as well as a brief description and the new reimbursement rates for each of the codes, are listed as follows:

 

A0010          Base rate, basic life support
                    $148.69

A0020          Vehicle miles, basic life support
                     $3.43

A0220          Base rate, advanced life support
                    $275.36

A0221          Vehicle miles, advanced life support
                    $3.43

Z5100          Transfer rate, basic life support
                    $148.69

Z5101          Transfer rate, advanced life support
                    $275.36

A0223          Base rate, advanced life support, where 
                      nonreusable ALS supplies are billed separately (this code
                      used only on  Medicare crossovers) The payment amount equals the 
                      Medicare and Medicaid payments combined.
                      $143.18


Nonprofit Non Emergency Transportation Rate Increases

The transportation reimbursement rate for the Nonprofit Non Emergency Transportation providers has been increased from $.21 per mile to $.24 per mile effective August 1, 1990.  Providers may begin billing the new rate immediately.  Also, because this increase is retroactive, providers may obtain the additional money to which they are entitled by submitting claim adjustments for any claims already submitted to Unisys with the date of service on or later than August 1, 1990.


Dental Providers

Prior Authorization

The CPT-4 Procedure Code D7971, Pericoronal Excision, does require prior authorization.  Also, the Dental Services Manual Transmittal #90-1 dated August 9, 1990, did not list this code with an asterisk as it should have.  Therefore, we ask that providers make the appropriate corrections on page 9-18 of their manuals


DME Providers

Criteria Required for Prior Authorization

When requesting approval for the use of a nebulizer or an oxygen concentrator, providers must confirm that the recipient meets certain criteria that make the use of the nebulizer or oxygen concentrator medically necessary.  Listed below are two checklists of questions that outline the criteria.  The answers to these questions should be attached to the PA01 form whenever a provider is requesting approval by mail for a nebulizer or an oxygen concentrator.

         Nebulizer Checklist

1)    Diagnosis?

2)    Age of recipient?

3)    Medicaid I.D. Number?

4)    What medications is the client on?

5)    Number of emergency visits and dates?

6)    Hospitalizations in the last 6 months?

7)    Is the patient's ability to breathe impaired?

8)    Does the patient require aerosol medication regularly or frequently?  List medication.

9)    Does the patient require regular or frequent medication with bronchodilator and/or antihistamine-decongestants?

10) Does the patient require hyposensitization extract versus aero-allergens?

11) Any supportive pulmonary function studies (adults only)?

Oxygen Concentrator

1)    Prior and recent arterial blood gases at room air?  At rest?

2)    Medical diagnosis and age of client?

3)    Length of time required?

4)    Po2                                   
Pco2-pH                             
O2sat.                                


Anesthesiologist & CNRAs

Anesthesia Policy Clarification

The Louisiana Medicaid Program has received several inquiries from providers about its new anesthesia policy.  This article, therefore, should serve as the Bureau of Health Services Financing's official clarification on the questions raised.

In regards to the use of modifiers, anesthesiologists and CRNAs must use the appropriate modifier when billing CPT-4 procedure codes 62276, 62278, and 62279 for maternity-related anesthesia.

The term anesthesia, in reference to Cesarean delivery, is defined as and includes the following types:  Epidural, epidural and subsequent general anesthesia, or general anesthesia.  For Cesarean delivery, the reimbursement fee is the same no matter what type of anesthesia, or combination of types, is used.

If the anesthesiologist or CRNA inserts the epidural catheter and subsequently reinjects it, he should bill CPT-4 procedure code 59515 plus the applicable modifier (AA, AI, AB, AC, AD, or AH).  If general anesthesia is administered from the beginning or subsequently administered after an epidural has been inserted, the provider should bill in the same way, that is, CPT-4 procedure code 59515 in addition to the appropriate modifier.  Reimbursement will be $330.00 for AAs and AIs and $198.00 for AHs.  Anesthesiologist who personally medical direct (ABs, ACs, and ADs) will receive $132.00.


Physicians

Pulmonary Care Policy Clarification

Effective with date of service March 1, 1991, procedure codes 94656 (Ventilation assist and management; initial) and 94657 (Ventilation assist and management; subsequent) should not be billed on the same date of service as procedure codes 99160 (Critical care, initial; each hour) and 99162 (Critical care, initial; additional 30 minutes).  However, codes 94656 and 94657 may be billed on the same day as codes 99171 (Critical care; subsequent), 99172 (Critical care; limited), 99173 (Critical care, intermediate), and 99174 (Critical care; extended).


Physicians & Pharmacists

Revised LMAC Limits

The Louisiana Department of Health and Hospitals has revised the Louisiana Maximum Allowable Costs (LMAC) limits for the drugs listed below: 

Meclofenamate Sodium caps 100mg
PAC:  7KO             LMAC:  0.44750
Effective Date:  11-20-90 

Meclofenamate Sodium caps 50mg
PAC:  7KO             LMAC:  0.32510
Effective Date:  11-20-90 

Megestrol acetate tabs 20mg
PAC:  7KO             LMAC:  0.45650
Effective Date:  12-1-90 

Megestrol acetate tabs 40mg
PAC:  7KO             LMAC:  0.77970
Effective Date:  12-1-90 

Oxtriphylline tablet 200mg
PAC:  7KO             LMAC:  0.11190
Effective Date:  12-18-90 

Rifampin caps 300mg
PAC:  7KO             LMAC:  1.56440
Effective Date:  12-1-90

In addition, the Federal Upper Limits for Meclofenamate Sodium EQ 50mg and 100mg capsules have been suspended effective November 19, 1990.  Also, Megestrol 20mg and 40mg tablets were removed from the Federal Upper Limit listing in the July 1990 Transmittal #18.


Pharmacy Audits

Peat Marwick Main, our contractual agent for conducting Pharmacy audits, has completed the second year of audits.  In July 1990, they began performing their third year of audits for fiscal year 1990-91.  Some of the most frequently reported discrepancies include the following:

1)    "Prescription Over Ten Days Old When Filled"

The Pharmacy Provider Manual states that prescriptions must be filled within ten days of the date they are issued.  This regulation is designed to prevent expenditures for prescriptions filled too late to do the patient any good and to prevent the patient from receiving drugs the physician would not want him to have at the late date.  To avoid this discrepancy, pharmacists may contact the prescribing practitioner and obtain permission to dispense the outdated prescription.  We also suggest that you change the date of the prescription to the date the permission is obtained, thereby, treating the date of the permission as the date of the original prescription.  Pharmacists must also make some notation on the prescription that the physician authorized the date change.

2)    ´┐ŻNo Refills Authorized and Unauthorized Refill"

Program policy regarding refills of prescriptions states that refills shall be provided if authorized by the prescribing practitioner up to the Medicaid Program's limit of no more than five times or no more than six months from the date the prescription was issued.  However, in complying with the Board of Pharmacy regulations and the Durham-Humphrey Act which states that a prescription or refill authorization may be transmitted by telephone, the pharmacist must reduce the prescription and/authorization to writing promptly and file it accordingly.  It is necessary that refills be documented properly in order for the prescription not to be discrepant in these areas.  We would advise that all pharmacy providers review the Board of Pharmacy regulations regarding refill instructions.

3)    "Early Refills"

This discrepancy means that, within the timeframe cited in the audit, the amount of the medication dispensed (the day's supply) lasted the recipient a certain number of days which exceeded the directions on the prescription.  It is the Medicaid Program's position that the pharmacist has the responsibility of monitoring the recipient's medications to ensure that they are taken correctly.  We do realize, however, that there will be circumstances when prescriptions need to be refilled prematurely, and we suggest that the pharmacist note on the prescription any reason for these early refills.  The note would help the pharmacist to continue to provide the quality medical care desired by the Medicaid Program and would still allow the prescription to be within program regulations.

4)    "Unauthorized MAC Overrides"

This discrepancy is reported when a pharmacist indicates a MAC override on the claim, but when reviewing the actual prescription, the auditor finds that there is no certification which indicates that the physician required a specific brand of medication be dispensed.

Both state and federal regulations state that the MAC limits for drugs do not apply if, "a physician certifies, in his own handwriting, in his medical judgment, that a specific brand is medically necessary for a particular recipient."  The wording of the certification should testify to the medical necessity of the brand name drug by stating either "brand medically necessary" or "brand necessary."  The phrases "dispense as written" or "do not substitute" are not acceptable for overriding MAC limitations.  Again, the certification must be in the physician's handwriting.  Also, Act 450 of the 1989 Louisiana Legislature states that a practitioner must write "Brand Necessary" in his own handwriting on the face of the prescription to prevent a valid interchange on a Medicaid or Medicare prescription.

Recent audit findings regarding MAC override claims for some providers who tape bill revealed that, in some instances, a large percentage of the provider's claims were MAC overrides but that the audit findings did not reveal the "brand necessary" wording on the prescription.  Thus, to ensure the accuracy of legitimate MAC overrides, we are requesting pharmacists to review their internal procedures for allowing a MAC override through their tape billing system.  We are also advising pharmacists to verify that their internal procedures for allowing MAC overrides are justified so chargebacks on audits would not be necessary.

5)    "Usual and Customary Charges"

Federal regulations governing the Medicaid Program require that participating providers agree to charge no more for services to eligible recipients than they charge for similar services to non-recipients (general public).  In implementing this regulation, the Medicaid Program states that providers in the Pharmacy Program may not charge a higher dispensing fee, on the average, for recipients' prescriptions than is charged for non-recipients' prescriptions (third party and insurance prescriptions are components of the non-recipient group).

In performing the pricing portion of the audit, there are certain criteria utilized to estimate whether a pharmacy is overcharging the Medicaid Program.  Some of these criteria include the following:  making sure the prescription is not for catheters, catheterization trays, insulin, or diabetic supplies. There are audited separately.

Thus, we would like to remind pharmacists that if generic prescriptions are to be included in the general public sample of the pricing audit then the manufacturer or labeler of the drug must be identified on the hard copy prescription or the computerized prescription file.  Also, pharmacists should indicate their USUAL AND CUSTOMARY CHARGES on their claim forms when billing for prescription services even if this charge exceeds our maximum payment.

6)    "National Drug Code (NDC) Shown On Claim Differs From Either The Drug Shown On The Prescription And/Or From The Drug Dispensed"

Medicaid Program regulations require that the manufacturer number, product number, and package number for the claim form be taken from the actual package from which the drug was dispensed.  Thus, the Medicaid Program aggressively audits for compliance with this program regulation, and audits have shown that this discrepancy is the most common Pharmacy Program abuse problem.

Unfortunately, because the pattern of abuse indicates the intent to file false claims, many pharmacy providers have been subject to prosecution for Medicaid fraud.  Consequently, the majority of the pharmacy provider Medicaid fraud convictions result from pharmacies dispensing one drug and billing for another.


Dispensing Cost Survey

The Bureau of Health Services Financing has a State Plan Agreement with the federal government which requires the periodic surveying of pharmacy costs to determine the appropriate dispensing cost.  The Bureau of Health Services Financing has contracted with the firm of Postlethwaite and Netterville, Certified Public Accountants, to perform the 1991 Dispensing Cost Survey.

All pharmacists who are enrolled in the Louisiana Medicaid Program are required to participate in the survey process.

The survey is designed to measure all costs associated with filling a prescription and to determine usual and customary charges.  In addition, this information will be used in supporting the Bureau of Health Services Financing's waiver of cost avoidance requirements and will allow further analysis of the impact of discounts on drug purchases in regard to the prescription reimbursement methodology.

For the Medicaid Program to be able to determine the dispensing cost and provider enrollment in the Medicaid Program and to be able to make the necessary appropriate request for the next fiscal year, we request that providers respond promptly and completely to the survey.


Long Term Care Providers

Nursing Facility Discharge Procedures

The procedures for discharging a resident from a nursing facility, as outlined in the Standards for Payment, include providing sufficient preparation and orientation to the resident to ensure his/he safe and orderly transfer or discharge from the facility.  The procedures also include making medical arrangements to alleviate any adverse effects of the discharge.

In addition, the Bureau of Health Services Financing recently received complaints from the New Orleans Legal Assistance Corporation that residents being discharged from nursing facilities are not being given their current Medicaid eligibility cards.  Thus, recipients' access to medical care is jeopardized.  Providers, therefore, should ensure that residents being discharged from nursing facilities leave with their current Medicaid eligibility cards and that any eligibility cards received thereafter are forwarded to the Medicaid recipients.


CPT-4 Procedure Codes

New CPT-4 Cardiovascular Procedure Codes and Prices

Provided on the following page is a listing of the 1990 CPT-4 cardiovascular procedure codes and prices that the Medicaid Program placed on the procedure/formulary file effective with date of service December 15, 1990.

1990 CPT-4 PROCEDURE CODES

CODE

DESCRIPTION

MAX FEE ($s)

93321

Doppler echocardiography, pulsed waive and/or continuous

50.00

93325

Doppler color flow velocity mapping to code for echocardio

125.00

93350

Echocardiography, real-time w/image documentation

125.00

93609

Intraventricular and/or intra-atrial mapping of tachycardia

465.00

93615

Esophageal recording of atrial electrogram wow ventricular

56.00

93620

Comprehensive electrophysiologic evaluation w right atrial

750.00

93621

Comprehensive electrophysiologic evaluation w left atrial

850.00

93622

Comprehensive electrophysiologic evaluation w left ventri

850.00

93623

Programmed stimulation & pacing after intravenous drug

500.00

93624

Electrophysiologic follow-up study w/pacing & recording

500.00

93631

Intra-operative cardiac pacing & mapping

465.00

93640

Electrophysiologic evaluation of cardioverter defibrillator

1250.00

93650

Intracardiac catheter ablation of arrhythmogenic focus

926.00

93797

Physician services for outpatient cardiac rehabilitation

50.00

93798

Physician services for outpatient cardiac rehab w/ecg mon

65.00


TPL Carrier Listing