PROVIDER
UPDATE
VOLUME 11, NUMBER 1
JANUARY/FEBRUARY 1994
Message from the Medical Director
I would like to highlight an attractive financial program offered by
Louisiana Medicaid to its medical providers.
The Deferred Compensation Plan allows individual
participants to invest money on a before-tax basis, using payroll deduction. Because the participant's taxable income is reduced with each
contribution, the participant can save money rather than pay it in taxes.
The before-tax aspect is what makes the Deferred Compensation Plan so
helpful. Participants pay no
federal or state income tax on their contributions.
In addition, interest on their account earnings accumulates tax-deferred. No taxes are paid on the account until the participant begins
withdrawing funds.
Any amount excluded from gross income under a 403(b) annuity, a 401 (K), a
profit sharing plan, or a simplified employee pension is to be treated as an
amount deferred under the 457 plan. Participants
can enter the plan with as little as $20.00 per month and contribute up to a
maximum of 25% of their adjusted gross income, not to exceed $7,500 per
calendar year. A special
"catch up" provision may be used to save up to $15,000 per year for
the three years prior to retirement.
When a participant joins the plan, he/she may choose the amount to save and
the type of fund(s) in which to invest. The
participant may transfer monies to other available funds and increase, decrease,
or stop deferrals at any time.
The plan offers both guaranteed and variable investment options from which
participants may select a fund, or a combination of funds, to satisfy their
personal investment objectives. Upon deciding on the amount to save, a trained account
executive will provide information on the available investment options:
-
Lump-sum payment
-
Payments over your lifetime
-
Payments for a specified amount or time
-
Joint and survivor benefits.
Due to federal government regulations, you may withdraw
funds only at the following times:
Great-West, the plan administrator, provides
communication, record-keeping of the accounts, and investment of the plan assets.
For more information, providers may call or visit the
Great-West office at 2237 South Acadian
Thruway, Suite 702, Baton Rouge, LA 70808. Great-West
can be reached by phone at (504) 926-8082
or Linc 925-3700.
The 24-hour rate line is 1-800-443-7331.
Dr. Gregg Payne
Increase
in Lab Fees
In November, BHSF announced a 2% increase in clinical
and hospital lab fees effective with date of service July 1, 1993.
Adjustments may be requested.
Funding
of Transurethral Balloon Dilation of the Prostatic Urethra (CPT Code 52510)
The Bureau of Health Services Financing is pleased to
announce the funding of transurethral balloon dilation of the prostatic urethra
(CPT code 52510), effective with date of service December 1, 1993.
The fee for this service is $433.00.
Placement
of Adjustable Sutures During Strabismus Surgery (CPT Code 67335)
BHSF began funding placement of adjustable sutures
during strabismus surgery (CPT code 67335), effective with date of service
December 1, 1993. The fee for this
service is $225.00.
Anesthesia
Units of CPT Code 68825 (Explore Tear Duct System)
The base units on procedure code 68825, type of service
01, was increased to 6, effective with date of service December 1, 1993.
Placement
in Non-Pay Status of Deleted 1993 Pathology and Laboratory Codes
The pathology and laboratory codes that were deleted in
the 1993 issue of the CPT were placed in non-pay status on January 1, 1994.
Funding of Anesthesia for
Bone Marrow Biopsy, Needle, or Trocar (CPT Code 85102)
BHSF is pleased to announce the funding of anesthesia
for bone marrow biopsy, needle, or trocar (CPT Code 85102), effective with date
of service December 1,1 993. Claims
should be billed with appropriate modifiers and minutes.
A relative value of four (base units) has been assigned to CPT code
85102.
Thermograms
in Non-Pay Status
CPT codes 93760 (thermogram; cephalic) and 93762 (thermogram;
peripheral) were placed in non-pay status effective with date of service January
1, 1994. HCFA has determined
thermography is ineffective as a diagnostic technique.
Placement
of Hysteroscopy on Assistant Surgery File (CPT Codes 56354 and 56356)
Hysteroscopy with removal of leiomyomata (56354) and
hysteroscopy with endometrial ablation (56356) have been funded for assistant
surgeons effective with date of service November 1, 1993.
Code 56354 is payable at a fee of $65.85 and 56356 is payable at $68.23.
Assistant surgeons bill these codes with a modifier of 80.
Correction
of Allowable Prices for Enteral/Parenteral Products
BHSF was recently informed that for enteral/parenteral
products, Medicare is now applying the lowest of the charge level screens to
payments instead of the 75th percentile of the prevailing charge.
Therefore, the correct charges to be used by the Prior Authorization Unit
should be based on the lowest charge screen amounts to be consistent with
Medicare pricing methodology.
Brain
Stem Evoked Response Screening (Z9916) and Recording (CPT 92585)
To dispel confusion about specific definitions and
requirements for billing brain stem evoked response screening (Z9916) and brain
stem evoked response recording (92585), BHSF has gathered data from key
physicians and audiologists concerning these procedures.
Their conclusions follow.
Screening:
The use of standardized tests in the mass examination of a designated population
to detect the existence of one or more particular diseases or health deviations
or to identify for more definitive studies individuals suspected of having
certain diseases (Medicaid Provider Manual 1992).
Proposed
Screening Definition:
Brain stem evoked response screening (Z9916) is
considered to be the use of a 100 microsecond click stimulus at one or more
predetermined intensity levels, which must include 35dBnHL, to determine the
presence or absence of a normal response in each ear.
**If more than one level is employed, it should be
recorded in tests results for review.
Diagnostic
Procedure:
Determination of the range, nature, and degree of hearing loss (Medicaid
Provider Manual 1992).
Proposed
Recording Definition:
Brain stem evoked response recording (92585) when done
for the purpose of determining hearing sensitivity is considered to be, at a
minimum, the use of a 100 microsecond click stimulus at varying intensity levels
to determine response thresholds in each ear (a latency-intensity function).
If a hearing loss is detected or suspected, response thresholds to bone
conducted clicks must also be obtained, as well as response thresholds utilizing
low frequency tone bursts.
**For this testing (92585) to be comprehensive in a
pediatric population and for valid interpretation of brain stem evoked response
tests results, it should be accompanied by tympanometry (92567) and acoustic
reflex testing (92568) for concomitant middle ear assessment and/or, as an
additional option, otoacoustic emissions testing (Z9917).
Claim
Denied: Recipient Not Eligible
The Unisys Provider Relations Unit would like to
suggest providers copy each recipient's eligibility card every month, not just
on a recipient's initial appointment.
If a claim is ever denied because the recipient is not
eligible, you should call REVS at 1-800-776-6323 to see if the recipient's file
has been updated. If not, you must
have a copy of the recipient's eligibility card from the month corresponding to
the date of service on the claim. The copy of the card is the proof of eligibility necessary to
resolve the claim.
Send a copy of the recipient's eligibility card and the
claim to Provider Relations, P. O. Box 91024, Baton Rouge, Louisiana 70821.
Please make sure to attach a note to the claim stating the problem,
explaining what materials are enclosed, and requesting that the recipient's file
be updated. If you do not attach
this explanatory note, the claim will go directly to processing and will deny
for the same reason.
Submitting
Claims
When initially submitting claims, please attach all
pertinent documentation, if any is necessary.
This will expedite payment of denied turnaround documents, adjustments,
unlisted procedures, and claims with modifiers 50, 51, 52, 62, 66, and 22.
When claims are denied for additional documentation, please resubmit all
previous documentation and claim forms and attach all additionally requested
information.
When submitting a claim for a bilateral procedures that
will require a 50 modifier or a claim for multiple units of the same procedure
that has multiple units available (e.g., removal of skin lesions), list the
procedure only one time on one line of the claim form, lump the charges, and use
the appropriate modifier, or appropriate number of units in the unit block on
the form.
Reduction
Mammaplasty
For a reduction mammaplasty to be considered medically
necessary, the client must suffer from severe, intractable, debilitating
symptoms not amenable to other therapeutic efforts to relieve distress such as
proper supportive appliances, weight reduction, and/or general physical
conditioning. Also, the client must
have exceeding large breasts in relation to body size posing a threat to her
health.
If a request is approved, a copy of the approval letter
must be attached to the claim form when submitted to Unisys for payment.
The fee for procedure code 19318 is determined by the
reviewing physician based on past guidelines established by BHSF.
Currently, these guidelines state that reimbursement is to be made at 70%
of the reasonable or billed charge, whichever is lower.
Notice
to DME Providers
New
Codes for Diabetic Shoes
The following HCPC procedure codes have been added by
Medicaid for use in requests and claims for extra-depth or custom-molded shoes
for diabetics, as wells as inserts and modifications for them.
These codes are now payable through the Medicaid Program and require
prior authorization.
Q0117 - For
diabetics only: fitting, custom preparation, and supply of an off-the-shelf,
depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe.
Q0188 - For
diabetics only: fitting, custom preparation, and supply of shoes molded from
cast(s) of patient's foot (custom-molded shoe), per shoe.
Q0119 - For
diabetics only: multiple density insert(s), per shoe.
Q0120 - For
diabetics only: modification of depth-inlay or custom-molded shoe with roller or
rigid rocker bottom, per shoe.
Q0121 - For
diabetics only: modification of depth-inlay or custom-molded shoe with wedge(s),
per shoe.
Q0122 - For
diabetics only: modification of depth-inlay shoe or custom-molded shoe with
metatarsal bar, per shoe.
Q0123 - For
diabetics only: modification of depth-inlay shoe or custom-molded shoe with
off-set heel(s), per shoe.
Approval of extra-depth or custom-molded shoes as well
as inserts or modifications can be given for a recipient whose physician 1)
documents that the recipient has diabetes, 2) documents that the recipient has
at least one of the following:
-
Previous amputation of the foot or part of the foot,
-
History of previous foot ulceration,
-
Pre-ulcerated callus formation or peripheral neuropathy with a
history of callus formation,
-
Foot deformity, and
3) certifies that the recipient is being treated under a comprehensive plan
of care for his/her diabetes and that he/she needs therapeutic shoes.
Code for Artificial
Larynx
Please note that the procedure code for artificial larynx has been changed
from Z9690 to L8500 to match the Medicare codes for this item.
Policy for Wheelchairs
and Other DME
Billing should not be submitted for payment for wheelchairs or any other DME
items prior to delivery of the item. It has come to our attention that some providers have been
billing for payment after they receive a Prior Authorization approval number but
before they provide the service.
Billing for a service not rendered to a Medicaid recipient can be considered
grounds for a provider fraud referral under Medicaid policy (chapter 7, Medical
Services Manual, page 12-2). The service (delivery or repair of purchased or rented
equipment) should always be rendered prior to billing for payment.
Continuous Positive
Airway Pressure System (CPAP)
CPAP (HCPC code E0601) can be considered for coverage for patients with a
diagnosis of severe obstructive sleep apnea (OSA).
Prices for CPAP include the costs of all necessary accessories.
The current rental price is $103.91, while the purchase price is $995.00.
To document medical necessity, the following information should accompany
the request.
1.
Diagnosis of severe obstructive sleep apnea as documented by sleep study
and other studies from a registered or approved sleep laboratory.
2.
Documentation of clinical severity such as recurrent hospitalization and
complications and frequent clinic and emergency room visits.
3.
Evidence that surgery is the only likely alternative to CPAP.
4.
Sleep studies should document at least 30 episodes of apnea each lasting
a minimum of 10 seconds during 6 to 7 hours of recorded sleep. Copies
of the patient's sleep lab evaluation and oxygen saturations must accompany the
request.
5.
If purchase of CPAP device is requested, documentation should support the
long-term nature of the condition.
Notice to Non-Emergency, Non-Ambulance Transportation Providers
Recently, Unisys has been asked numerous questions about mileage
calculations. Please be advised
that all mileage begins either at the base, suboffice, recipient's residence, or
point of pick-up.
Trips Originating Within Service Area
When a provider picks up a recipient in the service area and transports that
recipient outside the service area, Medicaid will pay for return mileage only if
there is another trip waiting back at the base or suboffice.
If the provider does not have another trip waiting, the driver is expected to
stay with the recipient until the medical appointment is completed.
If the driver chooses to return to the base or suboffice without another
trip waiting, Medicaid will not pay for that mileage.
Trips Originating Outside Service Area
When a provider picks up a recipient in a parish in which there is no base or
suboffice, mileage is charged on the round trip from the recipient's pick-up
point back to that pick-up point. Providers may not charge mileage from the main base or
nearest suboffice to the pick-up point, nor may they charge from the recipient's
drop-off point back to the base or suboffice.
At no time does mileage begin or end at any parish line.
Transporting Vehicles from One Parish
to Another
If an additional vehicle is needed in another parish to transport a
recipient, the provider may not bill for the mileage used to transport that
vehicle to the other parish. In
these situations, mileage always begins at the base, suboffice, or pick-up
point.
Telephone Inquiries
The Provider Relations Unit strives to respond to provider inquiries quickly
and efficiently. However, because
of the increase in the number of incoming calls and in provider participation in
Louisiana Medicaid, Provider Relations may have difficulty responding to
inquiries in a timely manner. Some
provider inquiries require lengthy policy discussions or file research;
therefore, providers who only want to ask simple questions are having to hold
until an inquiry representative is available.
However, there is a simple solution to this problem.
Providers who wish to ask the following questions, may use our Recipient
Eligibility Verification System (REVS) telephone service.
-
Is a particular recipient eligible for services?
-
What are the service limits for a particular recipient?
-
What other payment source does a particular recipient have?
-
What is my current check amount?
This system is operational 24 hours a day, 7 days a week, except for a short
period on Sunday when the system is being updated.
To access the system, you just have to dial (800) 776-6323 on a touch-tone
telephone and have your provider identification number, the appropriate
recipient identification number, and date of service ready.
Once you are connected to the system, you will receive procedural
instructions via voice response prompt messages.
If you are familiar with the procedures for entering information, you do
not have to wait for the prompt.
We understand that there will be times when you will need to speak to one of
our inquiry representatives. When
you have questions concerning printed policy, claims processing problems, or
when you need to determine the status of a particular claim, we encourage you to
call the Unisys Provider Relations Unit. To
expedite your inquiry, please have all of the necessary information when you
call. The Provider Relations Unit
phone numbers are 1-800-473-2783 or 504-924-5040.
When you do not have time to speak to one of our representatives, use REVS.
It is a quick and easy system designed to aid all providers.
Fees for Critical Care and Chemotherapy Administration
The fees for critical care and chemotherapy administration will be adjusted
to the following amounts effective with date of service March 1, 1994.
Code
Fee
99291
$167.00
99292
96.00
96400
6.11
96408
12.22
96410
12.22
96412
12.22
96414
12.22
96420
36.56
96422
36.56
96423
36.56
96425
36.56
96440
36.56
96445
36.56
96450
36.56
New codes 96405 and 96406 will be funded effective with date of service
January 1, 1994, at $16.59 and $25.04, respectively.
If you have been billing for chemotherapy administration with the
"W" codes, please switch to the CPT codes listed above effective with
date of service March 1, 1994, as the "W" codes will be placed in
non-pay status effective that date.
Coming Soon . . .
The 1994 Medicaid Training Seminars are scheduled for April 6 - May 26, 1994.
Please check the cover of Remittance Advices and watch for the formal
invitation. Once the training dates
and locations have been received by your office, please make plans to attend.
Home Health Notice
Medicaid will make payment for home health services only when the services
are ordered by a licensed physician who certifies that the recipient is
homebound. In addition, the patient
must meet the Medicaid definition of homebound to be considered homebound by
Medicaid.
Essentially, a patient is considered to be homebound if the patient
experiences a normal inability to leave home, is unable to leave home without
expending a considerable and taxing effort, and absences from the home are
infrequent, of short duration, or to receive medical care.
Chiropractic Documentation
The Louisiana Medicaid Program is often required to make payment and review
decisions based on information contained in the patient record.
All services billed to the program should have proper documentation.
Proper documentation should include
-
Diagnosis and chief complaint
-
Relevant history
-
Examination findings
-
Response to therapy
-
Progress notes and patient disposition
-
Procedures performed and results
-
X-ray, lab, and diagnostic tests ordered along with results.
All records should be clearly legible and documented at a time in close
proximity to the actual patient visit. All progress notes in the patient record should include a
thorough and adequate narrative description of the foregoing items.
Standard forms with check boxes are usually in and of themselves not
adequate for complete documentation.
Extension Procedures for Case Management Units
The Bureau of Health Services Financing is introducing a procedure to process
case management claims when an extension of units is approved.
Currently, the case management monitoring section reviews these requests
for necessity and appropriateness.
Please note that extensions of units of service are processed for the current
calendar year only. Extensions
for calendar year 1993 must be submitted prior to March 11, 1994.
BHSF will now begin writing letters to the provider stating the number of
units approved and effective dates for billing purposes.
These claims must be billed hard copy and pend for manual review of
compliance as per BHSF letter.
Switch from UB-82 to UB-92
Please remember that after March 31, 1994, you must begin billing with the
UB-92. All
claims received after March 31, 1994, must be submitted on the UB-92 regardless
of the date of service.
Beginning on page 7 of this newsletter is a cross reference list for the two
forms. We have included the data
element, the form locator number from the UB-82, and corresponding form locator
number for the UB-92.
Please make note of this change. Any claims submitted after March using a UB-82 will be
denied.
UB-82/UB-92 Cross Reference List
|
DATA
ELEMENT
|
UB-82
Field #
|
UB-92
Field #
|
| PROVIDER
NAME, ADDRESS/TELEPHONE # |
1
|
1
|
| UNLABELED
FIELD (STATE) |
N/A
|
2
|
| PATIENT
CONTROL NUMBER |
3
|
3
|
| TYPE
OF BILL (INPATIENT/OUTPATIENT) |
4
|
4
|
| FEDERAL
TAX NUMBER |
6
|
5
|
| STATEMENT
COVERS PERIOD (FROM AND THRU DATES) |
22
|
6
|
| COVERED
DAYS |
23
|
7
|
| NON-COVERED
DAYS |
24
|
8
|
| COINSURANCE
DAYS |
25
|
9
|
| LIFETIME
RESERVE DAYS |
26
|
10
|
| BENEFICIARY
PHONE # |
N/A
|
11
|
| PATIENT'S
NAME |
10
|
12
|
| PATIENT'S
ADDRESS (CITY, STATE, ZIP CODE) |
11
|
13
|
| PATIENT'S
BIRTHDATE |
12
|
14
|
| SEX |
13
|
15
|
| MARITAL
STATUS |
14
|
16
|
| ADMISSION
DATE |
15
|
17
|
| ADMISSION
HOUR |
16
|
18
|
| TYPE
OF ADMISSION |
17
|
19
|
| SOURCE
OF ADMISSION |
18
|
20
|
| DISCHARGE
HOUR |
20
|
21
|
| PATIENT
STATUS |
21
|
22
|
| MEDICAL/HEALTH
RECORD NUMBER |
45
|
23
|
| CONDITION
CODES |
35-39
|
24-30
|
|
Special Program Indicators
|
44
|
24-30
|
|
PRO Approval
|
87
|
24-30
|
| UNLABELED
FIELD (NATIONAL) |
N/A
|
31
|
| OCCURRENCE
CODES AND DATES |
28-32
|
32-35
|
| OCCURRENCE
SPAN CODE AND DATES |
33
|
36
|
|
State Assigned
|
88-89
|
N/A
|
| A,
B, C, ICN/DCN # ORIGINAL BILL |
94
|
37
|
| RESPONSIBLE
PARTY NAME AND ADDRESS |
34
|
38
|
| VALUE
CODE AND AMOUNTS |
46-49
|
39-41
|
| REVENUE
CODE |
51
|
42
|
| REVENUE
DESCRIPTION |
50
|
43
|
| HCPCS/RATES |
50
|
44
|
| HCPC/CPT-4
CODE (OUTPATIENT DX LAB) |
50
|
N/A
|
| DATE
OF SERVICE (OUTPATIENT ONLY) |
50
|
45
|
| UNITS
OF SERVICE |
52
|
46
|
| TOTAL
CHARGES |
53
|
47
|
| NON-COVERED
CHARGES |
54
|
48
|
| UNLABELED
FIELD (NATIONAL) |
N/A
|
49
|
| PAYER
IDENTIFICATION |
57
|
50
|
| PROVIDER
NUMBER |
8
|
51
|
| RELEASE
OF INFORMATION |
28
|
52
|
| ASSIGNMENT
OF BENEFITS CERTIFICATION INDICATOR |
59
|
53
|
| PRIOR
PAYMENTS |
63
|
54
|
| ESTIMATED
AMOUNT DUE |
64
|
55
|
| UNLABELED
FIELDS (56 STATE/57 NATIONAL) |
N/A
|
56 & 57
|
| INSURED'S
NAME |
65
|
58
|
| PATIENT'S
RELATIONSHIP TO INSURED |
67
|
59
|
| INSURED'S
IDENTIFICATION NUMBER |
68
|
60
|
| INSURED'S
GROUP NAME (MEDICAID NOT PRIMARY) |
69
|
61
|
| INSURED
GROUP NUMBER (MEDICAID NOT PRIMARY) |
70
|
62
|
| TREATMENT
AUTHORIZATION CODE |
91
|
63
|
| EMPLOYMENT
STATUS CODE |
72
|
64
|
| EMPLOYER
NAME |
73
|
65
|
| EMPLOYER
LOCATION |
75
|
66
|
| PRINCIPAL
DIAGNOSIS |
77
|
67
|
| OTHER
DIAGNOSIS CODES |
78-81
|
68-75
|
| ADMIT
DIAGNOSIS |
N/A
|
76
|
| EXTERNAL
CAUSE INJURY CODE |
N/A
|
77
|
| UNLABELED
FIELD (STATE) |
N/A
|
78
|
| PROCEDURE
CODING METHOD USED |
82
|
79
|
| PRINCIPAL
PROCEDURE CODE AND DATE |
84
|
80
|
| OTHER
PROCEDURE CODES AND DATES |
85-86
|
81
|
| ATTENDING
PHYSICIAN ID |
92
|
82
|
| OTHER
PHYSICIAN ID |
93
|
83
|
| REMARKS |
94
|
84
|
| PROVIDER
REPRESENTATIVE SIGNATURE |
95
|
85
|
| DATE
BILL SUBMITTED |
96
|
86
|
N/A = Not applicabl
Sign Your Claims
Please remember to sign your claim forms.
If you use a computer-generated or a stamped signature, please remember
to initial your claim forms. If you
do not sign or initial your claims, they will be denied for processing.
Post Office Box Pointers
Mailing your claims to the correct post office box will enable Unisys to
decrease the turnaround time on paying your claims.
Provided below are the correct post office boxes for each claim type.
When you mail your claims to Unisys, always double check the P. O. box.
The zip code for all of our post office boxes in Baton Rouge, Louisiana,
is 70821.
Pharmacy:
P. O. Box 91019
Inpatient Hospital, Outpatient
Hospital, and Long Term Care: P.
O. Box 91021
Professional (HCFA-1500):
P. O. Box 91020
Dental, Transportation, Rehabilitation,
and Home Health: P. O. Box 91022
Crossovers and Adjustments:
P. O. Box 91023
Provider Relations and Other Written
Correspondence: P. O. Box 91024
EMC:
P. O. Box 91025
If you have any questions about these post offices boxes, contact Provider
Relations at (800) 473-2783. Our
staff will be pleased to assist you.