Message from the Medical Director
As many of you know, Dr. Gregg Pane has been promoted to
the Unisys headquarters where he will work on new projects and oversee our work
in Louisiana. I would like to
introduce myself to you as the new Unisys Medical Director. I am looking forward to working with all of you to continue
providing excellent health care for Louisiana residents.
I will always attempt to keep the provider community informed about any
issues that may affect it.
I would like to address some of the progress and problems
we have all experienced with the Pre-Certification Program.
The program has now been implemented for 183 facilities.
We have had some difficulties with phone lines and the holidays but we
have purchased new equipment and are using new technology to handle the volume
of admission and extension requests. I
appreciate your patience with some of the temporary measures we have had to take
while working out the start-up kinks.
We realize that delays in pre-certification are frustrating
to providers, so we would like to enlist your help in speeding up the process.
Please make an attempt to concisely organize information and
documentation so that you fax Unisys only the pertinent information required by
Medicaid. The Pre-Certification Program does not require the same
information that Utilization Review might require.
Unisys is now requesting that a patient stay abstract be
submitted to concisely organize information and documentation.
As a guideline for acute care hospital extension, Unisys is issuing a
one-page form for summarizing medical information.
This new form is the "Request for Acute Care Extension, Physician
Reconsideration Review, or Hospitalization for Outpatient Procedures." This form can be used in three ways: 1) as an extension request, 2) as a physician request for
physician review of a pre-certification denial, and 3) for hospital
documentation of outpatient procedures performed as inpatient for cases in
which the outpatient procedure code is the primary or only code.
In the future this form may replace the prior authorization form that
physicians currently submit for these outpatient procedures to streamline all
Unisys requests psychiatric/substance abuse,
rehabilitation, and long term hospitals to submit the physician's history,
physical exam, evaluation (e.g., comprehensive psych assessment), and treatment
plan pertinent to hospitalization with the admission.
If these notes are not available, then please submit them at the first
extension request. In the absence
of these notes, the physician's admit note and admitting orders may be
submitted. Subsequent extension
requests should summarize pertinent clinical information, response to treatment,
and reason for continuing need for hospitalization.
I understand and empathize with the process adjustment you
are going through. Please help us
by reading and undertaking these suggestions so that we will not have large
volumes of unnecessary information. Thank
you for your understanding and your assistance in speeding up the pre-cert
Charles Lucy, MD, MPH
CPT Codes 95165 and 95144
CPT codes 95150 and 95155 were deleted in CPT '94 with
instructions to use code 95165 - professional services for the supervision and
provision of antigens for allergen immunotherapy ; single or multiple antigens,
multiple dose vial(s), (specify number of doses). Codes 95150 and 95155 were restricted to one per recipient
per 90-day period. This same
restriction also applies to code 95165.
CPT code 95144 - professional services for the supervision
and provision of antigens for allergen immunotherapy, single or multiple
antigens, single dose vials (specify number of vials) - is a new code in CPT '94
and replaces codes 95135 and 95140. Code
95144 has a UVS of 10. Reimbursement
is for 10 vials/month rather than 10 vials/day.
Increase in Fee for 21453
BHSF is pleased to inform you of an increase in fee for CPT
code 21543 - closed treatment of mandibular fracture with interdental fixation -
to $402.89 effective date of service March 30, 1994.
If you have performed this service since March 30, 1994 and
wish to receive the additional fee, you must submit an adjustment form to
Unisys. The instructions for this
can be found in the Physicians Services
Manual, page 35-1.
Code 68761 Payable for Optometrists
Effective with date of service February 1, 1995, CPT code
68761 - closure of the lacrimal punctum; by thermocauterization, ligation, or
laser surgery plug, each - is being added to the list of codes payable to
optometrists. The fee for this code
Code J9395 in Non-Pay Status
Effective with date of service February 1, 1995, BHSF will
place code J9395-Lupron Injectable 3.5 mg-into non-pay status.
The code to bill in its place is J9217 (which is the code Medicare uses
from Lupron). The fee for code
J9217 is $451.25. This code will be
restricted to one injection monthly.
Diagnosis Code V06.4
Effective with date of service December 1, 1994, the age
restriction on the diagnosis code V06.4-Vaccination for measles, mumps, and
rubella-is being changed to zero to 21. It
previously had an age restriction of 1 to 21.
Professional Component of Code 79030
Effective with date of service January 1, 1995, BHSF will
pay the professional component of CPT code 79030-radionuclide ablation of gland
for thyroid carcinoma.
The professional fee for this code is $69.31.
To receive reimbursement for the professional component of 79030, attach
the 26 modifier to the code.
Anesthesia Funding for Code 32854
Due to an oversight, the anesthesia for CPT code 32854-lung
transplant, double (bilateral sequential or en bloc) with cardiopulmonary
bypass-was never funded. Anesthesia
for CPT code 32854 is now being funded effective with date of service January 1,
1994, with 25 base units of anesthesia. To
receive reimbursement for anesthesia code 32854, bill the code with modifiers
Increase in Fee for Code 95120
BHSF is pleased to inform you of an increase in fee for CPT
code 95120-professional services for allergen immunotherapy in prescribing
physician's office or institution, including the provision of allergenic
extract; single injection-to $9.10 effective with date of service February 1,
Notice to All Chiropractors
DHH is interested in obtaining information regarding the
billing practices of chiropractors linked with the Behrman Chiropractic Clinics.
All chiropractors associated with these clinics should contact the
Surveillance and Utilization Review Unit at Unisys immediately at (504)
Louisiana Drug Utilization Review (LADUR) Education
Drugs: Drug-Drug Interactions
Antiarrhythmic drugs are classified according to their site of
action, electrophysiologic action, and their ability to increase ventricular
These drugs have a high incidence of drug-drug interactions.
Side effects and interactions vary by class and each class is
discussed in this article.
Arrhythmias are generally defined as alterations or
abnormalities in normal cardiac rhythm. Most
arrhythmias are caused by either alterations in impulse generation leading to
enhanced or abnormal automaticity, or by an abnormality in impulse conduction
resulting in the re-entry phenomenon. Depending on the etiology of the specific arrhythmia, various
lines of drug intervention are used.
Certain agents suppress automaticity primarily by
decreasing diastolic depolarization and/or raising the threshold of discharge to
a less negative voltage. Other
agents prevent re-entry either by improving conduction in the abnormal pathway
or by slowing conduction and/or increasing the refractory period to convert a
unidirectional block into a bidirectional block.
Antiarrhythmic drugs can be classified from three distinct
points of view: 1) according to
their site of action, 2) according to their electrophysiologic action, or 3)
according to their ability to increase ventricular fibrillation threshold.
The most common classification scheme is based on their
electrophysiologic action, focusing on their direct, predominant effects on the
cardiac action potential.
Classification of Antiarrhythmic Drugs
phase 0 depression and slow conduction (2+)
B.Minimal phase 0 depression and slow conduction
C.Minimal phase 0 depression and slow conduction (3-4+)
|Calcium Channel Blockade
Antiarrhythmic agents as a group have a high incidence of
drug-drug interactions. Certain
classes are known to create more than others.
Used therapeutically to treat a wide variety of arrhythmias including
atrial, AV junctional, and ventricular tachyarrhythmias.
Side effects are common with this drug group including cinchonism with
quinidine and a reversible lupus erythematosus-like syndrome that develops in
25-30% of patients taking procainamide. Drug-drug
interaction are also commonplace with quinidine having the most.
Phenytoin, rifampin, and barbiturates stimulate the metabolism of
quinidine, disopyramide, and procainamide, while cimetidine inhibits their
metabolism and increases the blood concentrations.
Quinidine can also increase the steady-state concentration of digoxin by
displacing it from tissue bonding sites. Occasionally,
patients who are receiving warfarin or other anticoagulants will have an
increase in prothrombin time after quinidine therapy is begun. Amiodarone increases the plasma concentrations of quinidine
and procainamide and, therefore, combination therapy with these agents is not
recommended. Co-administration with
lidocaine may give rise to a 25% increase in the unbound form of this drug.
Used therapeutically to treat ventricular arrhythmias arising during
myocardial ischemia, such as that experienced during a myocardial infarction.
In addition, lidocaine is effective in the treatment of digitalis-induced
arrhythmia. These drugs do not slow
conduction and have little effect on atrial or AV junction arrhythmias. Antiarrhythmic agents in Class IB have fewer adverse cardiac
effects than those in either class IA or Class IC. Main adverse side effects are in the CNS.
Adverse effects occur in more than 50% of patients receiving Tocainide,
the most alarming being agranulocytosis, and deaths have been reported.
Few drug-drug interactions have been reported with lidocaine.
Cimetidine can increase the serum concentrations of all Class IB agents.
Lidocaine can potentiate the effects of succinylcholine.
Hepatic metabolism of mexiletine can be accelerated by concurrent
administration of phenytoin or rifampin. A
large number of drug interactions have been reported for phenytoin, including
chloramphenicol, dicumarol, disulfiram, isoniazid, cimetidine, or certain
sulfonamides, which can increase the concentration of phenytoin in plasma by
decreasing its rate of metabolism. Carbamazepine,
which may enhance the metabolism of phenytoin, causes a well-documented decrease
in phenytoin concentration. Conversely,
phenytoin may reduce the concentration of carbamazepine.
Useful in treating refractory ventricular arrhythmias.
Particularly useful in suppressing premature ventricular contraction.
Propafenone may potentiate the effect of warfarin.
Digoxin levels are increased from 35% at 450 mg/l of propafenone daily to
855 at 900 mg daily. The negative inotropic effect of beta blockers or calcium
antagonist is additive. The drug
must be used under strict supervision in combination with these agents.
The drug has been combined with quinidine, procainamide, and amiodarone
at reduced doses.
These agents are useful in treating tachyarrhythmia caused by increased
sympathetic activity. They are also
used for atrial flutter and fibrillation, and for AV nodal re-entrant
pharmacokinetic and pharacodynamic interactions have been noted between beta
blockers and other drugs. Cholestyramine
and colestipol may decrease the absorption of beta blockers.
Drugs such as phenytoin, rifampin, and phenobarbital may induce hepatic
biotransformation enzymes and may decrease plasma concentration of beta blockers
that are metabolized extensively. Cimetidine
and hydralazine may increase the bioavailability of agents such as propranolol
and metoprolol by affecting hepatic blood flow.
Beta blockers can impair the clearance of lidocaine.
Beta blocker and calcium channel blockers have additive effects on the
cardiac conducting system.
Bretylium is useful for life-threatening ventricular arrhythmias,
especially recurrent ventricular fibrillation or tachycardia.
Amiodarone is effective in the treatment of severe refractory
supraventricular and ventricular tachyrhythmia.
Amiodarone increases the plasma concentrations and effects of digoxin,
warfarin, quinidine, procainamide, phenytoin, encainide, flecainide, and
diltiazem. Amiodarone increases the
likelihood of bradycardia, sinus arrest, and AV block when beta blockers or
calcium channel blockers are administered correctly.
Useful as the drug of choice for abolishing acute episodes of paroxysmal
supraventricular tachycardia due to AV nodal re-entry or due to anomalous AV
connections. Also useful in
reducing ventricular rate in atrial flutter and fibrillation.
Concurrent use of verapamil and beta blockers or digitalis can lead to
significant bradycardia or AV block. The
main reason for this is the additive effects of these drugs on the sinus or AV
nodes. In addition, verapamil interacts with digoxin in a manner
similar to the quinidine-digoxin interaction.
Concomitant use of verapamil or diltiazem with antihypertensive drugs
that depress the sinus node (reserpine and methyldopa) can intensify bradycardia.
In summary, a wide variety of agents is useful in the
treatment of numerous types of arrhythmias.
Side effects and drug-drug interactions are common with this group of
pharmacological agents and should be administered with these considerations in
Antonaccio, Michael J., ed. 1990 "Antiarrhythmic
Drugs" in Cardiovascular
Pharmacology, 3rd Edition. Raven Press, New York. pp. 369-485.
Goodman and Gilman, 1990. "Antiarrhythmic Drugs"
in The Pharmacological Basis of
Therapeutics, 8th Edition. Elmsford, New York, pp. 870-874.
Munson, Paul L., ed. 1995. "Antiarrhythmic Drugs"
in Principles of Pharmacology, Basic
Concepts and Clinical Applications, 1st Edition. Chapman and
Hall, New York. pp. 495-528.
Tatro, David S., ed. 1994. Drug Interaction Facts (Fact and Comparisons). J.B. Lippincott Co.,
Status of Application for 1115 Waiver
As most providers are aware, the Louisiana Department of
Health and Hospitals is currently applying for a Section 1115 Medicaid Waiver
from the Health Care Financing Administration.
This waiver would allow Louisiana to restructure its Medicaid system from
the current fee-for-service to include more managed care.
Below is a chronological summary of DHH's activities in November and
December 1994 concerning the proposed Managed Health Care Delivery System.
During the month of November 1994, nine regional public
forums were held in various parts of the state. These meetings drew a total of about 2,000-2,500 attendants.
The nine meetings were scheduled as follows:
11/7 in Lake Charles, 11/9 in Lafayette, 11/10 in Thibodaux, 11/14 in
Alexandria, 11/16 in Baton Rouge, 11/18 in Hammond, 11/21 in New Orleans, 11/29
in Monroe, and 11/29 in Shreveport. At
these public forums, all verbal comments were recorded and all written comments
were collected so that they could be compiled and reconsidered.
DHH reviewed and analyzed all public comments and recommendations
concerning the 1115 waiver proposal.
As the public forums were continuing, technical staff
workgroups met and developed the specific details of the waiver proposal.
These workgroups tried to discuss and outline all facets of a proposed
Managed Care Plan (MCP). Their
working agendas included many of the following topics:
Governance and organization of MCP
Benefit package for MCP
Specialized services (special handling of beneficiaries under
Office of Mental Health, Substance Abuse, and Developmental Disabilities)
Systems and administration (management information systems)
Public and governmental relations/marketing (planned regional
public forums; specialized Medicaid Recipient Mailouts; publicized plan through
meetings, production of introductory video, and various PSAs)
Finance (met with actuarial consultants to strategize financial
aspect of MCP)
On November 29, 1994, the U.S. Department of Health and
Human Services (Bureau of Health Services Financing) approved the media plan for
public input of the 1115 Waiver Proposal. On
December 7, 1994, DHH Secretary and staff met with the HCFA Project Staff in
Washington, D.C. to present the 1115 Waiver Proposal.
As these events transpired, DHH continued to work with managed care
consultants-Covington and Burling, Mercer (actuaries), and Pelrine (et.al) to
develop the waiver document.
DHH met with the Committee on Louisiana Health Care Reform
on December 8 in Baton Rouge to provide the current proposal development.
They then met with the governor and legislative leadership on December 12
to again discuss the waiver proposal. On
the same day, DHH held a focus meeting with consumers and beneficiaries to
provide an update on the status of the 1115 waiver and to solicit input.
After all of this preparation, the 1115 Waiver document was
put on public display for final review before submission at noon on December 15.
The document was disseminated through all regional managers of DHH
(Office of Public Health, Office of Mental Health, Office for Citizens with
Developmental Disabilities, Office and Alcohol and Drug Abuse, Medicaid, and DSS
Office of Family Support and Community Service).
The next day was the final Public Hearing to receive input before
submission to Washington. The
public could continue adding input until December 23, 1994.
Finally, the Waiver Proposal was submitted to HCFA in
Washington, D.C. on December 31, 1994.
There was a day-long planning retreat on January 24, 1995,
to prepare for the next phase of the managed care project.
The retreat was held at the Bluffs, St. Francisville, and focused on two
main areas: internal administration
and personnel features of the project, and the implementation plan.
Although Louisiana will not receive a response to the waiver proposal for
several months, DHH is presently working to create a development and
implementation plan in order to be prepared if the waiver is approved.
Unisys Telephone Number Changes
To better serve all Medicaid providers, Unisys is in the
process of updating and expanding its phone system. Please note that the general operator telephone number has
changed to (504) 237-3200.
Each Unisys employee can now be reached by direct dial
rather than through an automated menu system.
Most employees can be reached by dialing (504) 237-3 plus the same last
three digits of their old extensions. For
example, EMC is not (504) 237-3303 (it was 2303).
This change will not affect our provider information lines.
Please continue dialing into the following departments just as you always
Relations is (504) 924-5040 or (800) 473-2783.
Prior Authorization is (504)
928-5263 or (800) 488-6334. Pre-Certification is (800) 877-0666. The REVS line is
Claims for Non-Physician Laboratories
HCFA has advised that Non-Physician Laboratories holding a
certificate type 4 or 5 are to have claims submitted to Medicaid edited for
compliance with billing only the codes allowed by their certificate type.
Louisiana Medicaid began editing claims submitted in Non-Physician
Laboratories in February 1995. Non-Physician
Laboratories should also contact Medicaid Provider Enrollment if the most
current CLIA number and certificate type have not been previously reported.
Please remember that a service not documented is a service
not rendered. Therefore, your
documentation must always be complete!
Oxygen Concentrator Policy Change
Physicians should note the following changes to pp. 7-23
and 7-24 of the Medical Services Manual and p. 11-12 of the Medicaid Eligibility
Manual (Durable Medical Equipment Manual).
The arterial oxygen saturation level requirements of "at or below
85%" referenced under Group I should be changed to "at or below
88%." The reference to
arterial oxygen saturation level requirement of "at or above 86%" in
the last paragraph under Group I should be changed to "at or above
The reference under Group II to arterial blood oxygen saturation of
86%-89% should be changed to 89%.
Group III should be changed to read as follows.
"Medicaid reimbursement will not be made for patients with arterial PO2
levels at or above 60 mm Hg., or arterial blood saturation at or above