Advances in the Treatment of Stroke LADUR Education Article
Attention All EPSDT Health Services Providers Changes in the Home and Community Based Services Waiver for the Elderly
New CLIA Waived Tests Unisys Hospital Precertification Department Update
Precertification: What Providers Can Do to Help the Process Tracing Lost Faxes: Unisys Precertification Department
Hospital Precertification Error Message 147 Notice to Certified Nurse Midwives 
Notice to Physicians: Changes in Physical Medicine Codes  Changes in Second Norplant Implantation

Notice to Physicians and KIDMED Clinics

Advances in the Treatment of Stroke

As part of our efforts to invite Louisiana health experts to share their knowledge with Medicaid providers, I am proud to introduce this issue�s guest columnist, Tulane University School of Medicine�s Leon Weisberg, M.D., Vice Chairman of the Department of Psychiatry and Neurology.  Dr. Weisberg, along with other Louisiana colleagues, recently gave a comprehensive update in the November 1996 Journal of the Louisiana State Medical Society for the prevention, treatment, and rehabilitation of the number three cause of death in the United States, stroke from cerebrovascular disease.  A December 18, 1996 JAMA article found that treating isolated systolic hypertension, which more commonly affects our elderly, lowered major cardiovascular disease occurrence by one third, with greater absolute rate reduction of diabetics.  Primary prevention with regular exercise, nutritionally balanced diet, and avoidance of tobacco could dramatically improve the health of all Louisiana citizens.  Regular and continuing reinforcement of these positive messages by all health care providers can help install these values in our patients.

Charles Lucey, M.D., M.P.H.

Stroke due to cerebrovascular disease is the third leading cause of death and the major cause of disability.  Cerebrovascular disease is usually due to arterial or arteriolar disease but may rarely be due to venous thrombosis.  The majority of stroke is ischemic (80%) and the minority of cases are hemorrhage (20%).  Of hemorrhagic stroke, intracerebral hemorrhagic comprise 15% and subarachnoid hemorrhagic comprise 5%.  Hypertension and cardiac disease (cardiogenic cerebral embolism) are the major risk factors for stroke.  There has been a decline in stroke mortality, probably due to improved risk factor control.  For example, with improved hypertension management, there has been a dramatic decrease in the incidence of intracerebral hemorrhage

In patients with nonvalvular atrial fibrillation (AF) (prevalence of 2.5 million cases), stroke represents the major embolic complication, causing 75,000 strokes per year. Utilizing oral anticoagulation with coumadin, the stroke risk is markedly reduced.  By maintaining an INR (International Normalized Ratio) between 2.0 and 3.0, the benefit of stroke prevention outweighs the potential risk of brain hemorrhage.  Despite the beneficial role of coumadin, less than 30% of the AF patients receive coumadin.

Cerebrovascular disease is frequently due to deposition of lipids with the arterial wall to cause narrowing of the vessel lumen.  This may cause blood flow to become turbulent rather than laminar.  Carotid bruits (murmurs) may be heard when the clinician ausculates the carotid artery in the neck region.  Bruits indicate that flow is turbulent and indicate that the clinician should perform noninvasive Doppler duplex ultrasound to determine if carotid stenosis is present.  One recent study demonstrated that certain patients with asymptomatic carotid stenosis of at least 60% should undergo prophylactic carotid endarterectomy to reduce stroke occurrence.

Certain patients with cerebrovascular disease develop transient focal deficits which are referred to as transient ischemic attacks (TIA).  It is important to exclude other paroxysmal transient events such as epilepsy, migraine, and syncope.  Brain (CT, MRI) and vascular imaging (ultrasound, angiography) procedures should be performed to determine if permanent brain injury (infarction, hemorrhage) has occurred and to determine the underlying vascular abnormality.  Of TIA patients, 35% subsequently develop complete stroke and the critical time period for stroke occurrence is 24 months after TIA incident.  Dependent upon the results of brain and vascular imaging procedures, the following management options are available.

1.   CEA should be performed if there is greater than 70% carotid stenosis.  For less than 30% stenosis, CEA is not indicated and for 30 to 69% stenosis, the role of CEA is being evaluated in clinical trials.

2.   If the TIA is due to cardiogenic cerebral embolism, anticoagulation with coumadin (INR adjusted to 2.0 to 3.0 for nonvalvular atrial fibrillation and high intensity anticoagulation for valvular heart disease) should be carried out.

3.   If TIA is due to high-grade stenosis of large intracranial artery (carotid, basilar, middle cerebral) which is not surgically accessible, the risk of stroke is high and anticoagulation is utilized by many clinicians; however, there is no evidence to support this strategy.

4.   If TIA is due to small vessel (arteriolar) or lesser degree of arterial stenosis, antiplatelet agents include aspirin and ticlopidine are utilized for stroke prevention.  Although many clinicians utilize 325 mg. of aspirin (appropriate dose for prevention of cardiovascular disease), there is evidence that 900 to 1300 mg. is necessary for cerebrovascular protection.  Ticlopidine is utilized at a dose of 250 mg. twice daily.  It appears more effective than aspirin in women and African-American patients.  The major side effect of aspirin is gastrointestinal ulcer and bleeding; the major side effect of Ticlopidine is leukopenia (usually reversible and occurs within the initial 3 months).

If stroke syndrome persists, this represents a medical emergency and attempts to reverse the deficit must be initiated immediately.  These include:

1.   Blood pressure (BP) management.  Rapid lowering of BP is warranted in acute hypertensive crisis and neurological improvement follows rapid lowering of BP with nitroprusside or labetalol.  In hypertensive patients with ischemic stroke, elevated BP may worsen arterial edema; however, rapid lowering of BP may reduce cerebral perfusion pressure and worsen neurological deficit.  In acute ischemic stroke, the use of sublingual Procardia should be avoided.  BP should be lowered if three BP readings obtained within initial 30 minutes indicate BP exceeding 220/120mm Hg.

2.   Thrombolytic therapy utilizing IV tissue plasminogen activator (tPA) is effective if utilized within 3 hours of stroke onset.  This narrow time frame excludes almost 85% of all ischemic stroke patients unless educational efforts are initiated to make patients aware of the initial and early stroke signs.  The potential risk is intracranial hemorrhage and this risk increases as treatment is initiated later than 6 hours after stroke onset.

3.   In patients with deteriorating stroke, the use of anticoagulation to prevent distal clot propagation should be initiated and efforts to reduce cerebral edema (hyperventilation, mannitol, glycerol, corticosteriods) may be initiated.  Their efficacy is not established.  Efforts to control hyperglycemia, hypoxia, and hyperthermia should be initiated.

4.   Neuroprotective agents are being developed which reverse the �ischemic cascade� which leads to neuronal cell death.  Ischemia results when the artery is blocked.  If neuroprotective agents can prevent cell death while thrombolytic agents are being administered to restore arterial circulation, permanent neurological deficit may be prevented.  Although no neuroprotective agents have been FDA approved, several have shown extreme promised with minimal toxicity.  Clinical trials continue.

5.   The risk of current stroke following initial stroke is 30-35%, and this may be reduced with CEA, anticoagulant, or antiplatelet medication.

Recent advances in cerebrovascular management have lifted the pessimistic approach to the stroke patient and exciting new treatment strategies promise to reduce the mortality and morbidity associated with this disorder.  Several studies have demonstrated improved outcome when neurologists manage stroke patients compared with other health care providers, e.g. primary care physicians and internists.  This improved outcome comes at a higher cost for the initial hospitalization but this is well worth the cost if the patient can become independent in activities of daily living.

Louisiana Drug Utilization Review (LADUR) Education Article

Managing Asthma

By William Ross, BS Pharm , Clinical Coordinator of Drug Information
Northeast Louisiana University
College of Pharmacy and
Barry Bleidt, PhD, PharmD
, Medical Information Scientist
Health Resources Consulting


  • Asthma constitutes a serious health problem, with many factors contributing to airflow restriction, and each is related to an inflammatory progression.

  • Many different kinds of mediators play a role in the etiology of asthma, including mast cells, T-lymphocytes, alveolar macrophages, and eosinophils.

  • Asthma cannot be cured, but it can be managed.  There have been recent advances in this disorder that greatly help with its management.


Asthma is a chronic inflammatory disorder characterized by episodes of dypsnea with difficulty in breathing; it also constitutes a serious health problem.  There are many factors that contribute to the airflow restriction in asthma, each related to an inflammatory process.  In patients with asthma, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough particularly at night and/or in the early morning.  Many different kinds of mediators play a role in the etiology of asthma, including mast cells, T-lymphocytes, alveolar macrophages, and eosinophils.

The medical, economic, and social burdens of asthma can be alleviated through well-developed prevention and control strategies.  Asthma cannot be cured, but it can be managed.  Recent advances in this disorder include an understanding of the role of airway inflammation in its pathogenesis, a new focus on control through treatment and a new emphasis on identifying risk factors that may act as triggers or casual factors and identifying appropriate prevention programs.1

Classification of Asthma Severity
In order to classify the severity of a patient�s asthma it is useful to combine observations of symptoms and measurements of lung function.  The clinical features before treatment of this classification scheme from worst to least severe are as follows:

Step 4:  Severe Persistent Asthma
Continuous symptoms; frequent exacerbations; frequent nighttime asthma symptoms; physical activities limited by asthma symptoms.
Lung Function; PEF or FEV1 is less than or equal to 60% predicted and variability is greater than 30%.

Step 3: Moderate Persistent Asthma
Symptoms daily; exacerbations affect activity and sleep; nighttime asthma less than 1 time a week; daily use of inhaled short-acting B2-agonist.
Lung Function; PEF or FEV1 is 60% to 80% predicted and variability is greater than 30%.

Step 2:  Mild Persistent Asthma
Symptoms appear less than or equal to 1 time per week, but less than 1 time per day; exacerbations may affect activity and sleep; nighttime asthma symptoms are greater than 2 times per month.  
Lung Function; PEF or FEV1 is greater than or equal to 80% predicted and variability is less than 20% to 30%.

Step 1:  Intermittent Asthma
Intermittent symptoms 1 time per week; brief exacerbations (from a few hours to a few days); nighttime asthma symptoms are less than or equal to 2 times per month; asymptomatic and normal lung functions between exacerbations.
Lung Function; PEF or FEV1 is greater than or equal to 80% predicted and variability is less than 20%.

The understanding that inflammation plays a primary role in increased chronic bronchial hypersensitivity as well as the development of severe exacerbations in asthma, has altered therapeutic focus from the symptomatic relief of bronchospasms to prevention and suppression of the underlying inflammatory processes.

Managing Asthma
Alleviating exacerbations and managing their occurrence involves the use of different classes of drugs.  Anti-inflammatory agents (corticosteroids), B-agonists, and anti-leukotrienes are all used to control or prevent asthma exacerbations as well as other agents.

There are several characteristics of the corticosteroids which make them useful therapeutic tools for treating asthma.  These drugs increase the number of B-adrenergic receptors and improve receptor responsiveness to B-adrenergic stimulation.  This effect is enhanced by the ability to restore receptor sensitivity and to prevent tolerance induced by chronic administration of B-agonists.  Glucocorticoids also reduce mucus production and hypersecretion, and inhibit the inflammatory response by interfering with the synthesis and function of various immune response reactants.  Additional therapeutic benefits relate to inhibiting histamine synthesis (but not release) and constricting microvasculature to reduce fluid and protein influx.2,3,4

Inhaled Corticosteroid Therapy
As the contribution of inflammation in the pathogenesis of asthma becomes better understood, inhaled glucocorticoids are being used more often as the drugs of choice for chronic asthma.  Agents currently available in the U.S. for inhaled use include beclomethasone diproprionate (Beconase�), triamcinolone acetonide (Azmacort�), Flunisolide (Aerobid�), budesonide (Rhinocort�), and fluticasone diproprionate (Flovent�).

 There is no well-established dose equivalency among the inhaled glucocorticoids because of the paucity of clinical trials designed to establish the relative efficacy of these drugs in asthma.  Current guidelines of the chronic management of asthma, however, assume the same relative potency for all the available products.  The dose-dependent suppression of the adrenal cortex caused by inhaled glucocorticoids is less than that which results from oral administration.  Definitive comparative studies among the inhaled analogs are limited; however, initial investigations suggest that both budesonide and fluticasone produce less cortisol suppression.  Inhaled steroids produce local effects that include dysphonia and oropharyngeal candidasis, both of which are dose related.  The former, evidently associated with drug induced myopathy, can be minimized by use of a spacer device in the inhaler to decrease oropharyngeal deposition.  The candidiasis is due to local immunosuppression and can be reduced with less frequent administration along with rinsing of the oropharnyx and use of a spacer device.  Spacer device use further enhances desposition of the steroid within the airways so as to improve drug efficacy.

It is generally recommended that regardless of the type of glucocorticoid therapy employed, bronchodilator co-administration should be considered to allow a decrease in the steroid dose required to control signs and symptoms.  The glucocorticoids may interact with other drugs such as enzyme inducers (phenytoin), estrogens, non-steroidal anti-inflammatory agents, potassium-depleting drugs (furosemide), cyclosporin, vaccines, and toxoids with results that vary in clinical significance.2,3,4

Beta-Adrenergic Receptor Agonists
Short-acting inhaled selective B2-agonists are used for the treatment of intermittent episodes of bronchospasm and are the first treatment of choice as the bronchodilator for acute severe asthma and the prevention of exercise-induced asthma.  These agents include albuterol (Ventolin�), isoetharine (Bronkometer�), isoproterenol (Isuprel�), metaproterenol (Alupent�), and terbutaline (Brethine�).  The pharmacological effect of these drugs is elicited via a decrease in intracellular calcium to produce smooth muscle relaxation, mast cell membrane stabilization, and skeletal muscle stimulation.  The B2-agonists, when administered in equipotent doses, will produce the same intensity of response; the only distinguishing features among them are duration of action and cardiac toxicity potential.

Administration of inhalation not only enhances bronchoselectivity but also provides a more rapid response and a greater degree of protection against asthma triggers such as exercise and allergens.  The only significant drawback of the aerosol route is that many patients have difficulty in using the inhalers correctly.2,3,4  This disadvantage can be overcome through patient education programs designed to train the consumers in how to use the inhalers and spacer bars.

The exact role that long-acting inhaled B2-agonists will play in chronic asthma therapy has yet to reach a consensus among members of the asthma treatment community.  The only long-acting B2-agonists currently approved for marketing in the United States is salmeterol (Serevent�).  Another long-acting B2-agonists, fomoterol, is under-going clinical trials.  The FDA-approved indication for salmeterol is chronic asthma maintenance therapy.  Its efficacy has been demonstrated whether or not it is administered concomitantly with inhaled corticosteroids.  Patients must understand, however, that salmeterol is ineffective in acute severe asthma exacerbations because its onset of action is 20 minutes and it takes 1 to 4 hours to achieve maximum bronchodilation following inhalation.2,3

Anti-Leukotriene Drugs
A new category of drugs, the anti-leukotrienes, is currently undergoing clinical testing in asthma treatment.  Leukotrienes play a crucial role in asthma and are produced from arachidonic acid found on the membranes of reactive cells, such as macrophages and mast cells.  These substances contribute to airway smooth muscle spasm, increased vascular permeability, edema, enhanced mucus production, reduced mucociliary transport, and leukocyte chemotaxis.

Recently, the FDA approved the first of these agents, zafirlukast (Accolate�).  Another product, zileuton (Zyflo�), should be available in early 1997.  These two drugs belong to different classes of the anti-leukotrienes.  Zafirlukast blocks the leukotriene receptor and zileuton reduces leukotriene production by inhibiting 5-lipoxy-genase.  Early data indicates that zafirlukast is moderately effective, comparable to inhaled cromolyn therapy and is relatively safe.  On the other hand, zieluton has demonstrated better benefit, but causes more adverse effects.  Liver toxicity is the most serious of these problems.  It is recommended that patients on zileuton get liver function tests once a month for the first three months, then every two to three months for a year.  Some of the more significant drug interactions of these two drugs include increased theophylline, warfarin, and propranol effects.  The metabolism of cyclosporine, cisapride, terfenadine, and astemizole may also be diminished.5

There are environmental influences, collectively called triggers, which can exacerbate asthma.  These triggers can be categorized into the following groups:  allergens, occupational exposure, exercise, respiratory infections, psychological factors, and miscellaneous stimuli.  It is important to note that an item which causes a significant problem in one patient may pose no threat to other patients.  Discovering which specific factors affect an individual is one of the keys to managing successfully a patient with asthma.  Once these triggers are known, steps can be taken to minimize exposure to them.

Allergies are the most common cause of asthma.  This category of triggers is not only the most difficult to determine, but it is also the most important one to track.  Discovering and eliminating which portions of a patient�s environment cause problems helps the patient have more control over his or her condition and to do things that prevent exacerbations.

Epidemiological investigations indicate that 70% to 90% of all patients with asthma experience exercise-induced asthma (EIA).  Pulmonary function in these individuals, as measured by forced expiratory volume (FEV) procedures, increases during the first few minutes but begins to decrease after 6 to 8 minutes of vigorous exercise.  EIA is defined as a drop in FEV of greater than 15% to 20% of the baseline pre-exercise value.  Heat and/or water loss from the central airways appear to be primary pathogenic factors, although the exact mechanism is unknown.  These patients are at greater risk of EIA in cold, drug air than in warm, humid air.3,6

As with the general population, it is essential that patients who have asthma maintain themselves in good physical condition.  In order to prevent exercise-induced exacerbations, an extended warm-up period is needed before any strenuous activity is initiated.

Psychological Factors
Psychological factors rarely precipitate asthma attacks, but can intensify or worsen an exacerbation in progress.  Evidence indicates that excess parasympathetic activity is the primary mechanism in psychologically-mediated bronchoconstriction.  Although asthma is not an �emotional disease,� calming influences and relaxation techniques may be therapeutic for the patient who becomes emotionally distraught during an asthma attack.3,6

Respiratory Infections
Asthma may be worsened by the presence of an upper respiratory infection.  Current research shows that exacerbations result primarily from viral rather than bacterial etiologies.  Respiratory syncytial virus, parainfluenza virus, coronavirus, rhinovirus, and influenza virus infections are major precipitants in 20% to 40% of the acute exacerbations of asthma in children.  As many as 40% to 50% of patients with asthma have abnormal sinus radiographs; sinusitis and rhinitis are both considered asthma trigger factors.  These two factors may aggravate asthma via transport of mucous chemotactic factors and inflammatory mediators from nasal passages into the lung, which produces an increase in bronchial hyperresponsiveness.  It is important that patients with asthma contact their physician at the first signs of an upper respiratory infection or the flu.3,6

Occupational Exposure
Occupational asthma is thought to account for 2% of all patients with asthma.  Certain chemical agents found in the workplace are documented asthma triggers.  Although the specific mechanism involved is unknown, it is thought that the process begins with damage to the lung epithelium and inflammation of the airway mucosa.  These individuals exhibit the typical symptoms of cough, dyspnea, and wheezing during times of work and show significant signs of improvement during periods away from the employment environment.  In most of these cases, pretreatment with cromolyn sodium blocks pollutant obstruction of the bronchioles, suggesting mast cell or irritant receptor involvement.3,7

Miscellaneous Stimuli
There are other stimuli in the environment that are known to exacerbate asthma.  Among these miscellaneous factors are high air pollutant levels, steam from showers or cooking, very cold or humid weather, and smoking.  Patients with asthma should avoid exposure to any of these possible irritants.  Other factors associated with worsening of asthma that have been identified are gastroesophageal reflux and premenstrual hormonal fluctuations.3,6,8

In summary, asthma, though serious and potentially deadly, can be managed through understanding its causes and exacerbations.  Understanding the inflammatory nature of this disorder has led to a new emphasis on using certain therapies.  Working to reduce the inflammatory impact of daily activities through the use of inhaled corticosteroids is a major advance in controlling moderate and severe persistent asthma conditions.  Complete control of a patient�s environment is rarely achievable or realistic, but it is essential to do as much as possible to remove and/or avoid identified asthma triggers.  Some of the simplest effective steps include:

  • Avoid contact with warm-blooded pets;
  • Ban smoking in the home and workplace; and  

  • Control dust mites through weekly washing of linens in hot water, airing out all living spaces regularly, and vacuuming often.


1.              National Heart, Lung, and Blood Institute, Global Strategy for Asthma Management and Prevention.  Washington, D.C.: Government Printing Office (Pub. No. 95-3659), 1995.

2.              C.R. Gelman and A.J. Hess (eds), Drugex� System. Englewood, Colorado:  Micromedex, Inc. (edition expired 11/30/96).

3.              H.W. Kelly and A.K. Kamada, Asthma. J.T. Dipiro, R.L. Talbert, G.C. Yee, et al, (eds.), Pharmacotherapy:  A Pathophysiologic Approach.  Stamford, Connecticut:  Appleton and Lang, 1996: 553-588.

4.              G.K. McElvoy (ed.), Drug Information.  Bethesda, Maryland: American Society of Health-System Pharmacists, 1996.

5.              Asthma.  Pharmacist�s Letter.  1997: 13:1:6.

6.              G. Hamilton. Asthma (Disease and Trauma for Acute Care).  In B. Honigman, B. H. Rumack, S. Silverstein (eds.), Emergidex� System.  Englewood, Colorado: Micromedex, Inc. (edition expired 11/30/96).

7.              S.C. Lazarus, P. W. Lofholm (eds.), Asthma Management: Optimizing the Health.  Laguna Niguel, California: Institute for Medical Studies. 1996: 1-39.

8.              H.S. Nelson, �Is gastroesophageal reflux worsening your patient�s asthma?�  Journal of Respiratory Disorders, 1990: 9: 872-844.

Attention All EPSDT Health Services Providers

The 1996 EPSDT Health Services/EPSDT PCS Training Packet included several procedure code changes for EPSDT Health Services which were effective June 1, 1995 and January 1, 1996.  Some errors were identified in this information after printing.  Below are corrections to these errors.

Effective June 1, 1995 or January 1, 1996, the CPT-4 (Physicians� Current Procedure Terminology) codes used as the basis for billing some EPSDT Health Services were modified as follows:

*If 1/1/96 is not specified, changes were effective 6/1/95.

Occupational Therapy (OT)
(Refer to pages IV-9 and IV-10 of the Provider Manual.)

97530 � Therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance � each 15 minutes)
Limit: Four 15-minute units per day
Reimbursement: $7.20 per 15-minute unit

97531 � Deleted � use 97530

97535 � Placed in non-pay status effective 1/1/97

97540 � Deleted effective 1/1/96

97541 � Deleted effective 1/1/96

97720 � Deleted � use 97750

97721 � Deleted � use 97750

97750 � New Code � Physician performance test or measurement (e.g., musculoskeletal, functional capacity), with written report � each 15 minutes.
Limit:  Four 15-minute units per day
Reimbursement: $7.20 per 15-minute unit

97752 � Deleted effective 6/1/95 � use 97750 after

Physical Therapy (PT)
(Refer to pages IV-12 and IV-13 of Provider Manual)

For all physical therapy codes, a therapist is required to have direct (one on one) patient contact.

97110 � Therapeutic procedure, one or more areas, each 15 minutes.  Therapeutic exercises to develop strength and endurance, range of motion and flexibility.
Limit:  Four 15-minute units per day
Reimbursement: $7.20 per 15-minute unit

97112 � Neuromuscular reduction of movement, balance, coordination, kinesthetic sense, posture and proprioception, each 15 minutes.
Limit: Four 15-minute units per day
Reimbursement: $7.20 per 15-minute unit

97114 � Deleted � use Y7200

97118 � Deleted � use 97032

97032 � New Code � Application of modality to one or more areas; electrical stimulation (manual), each 15 minutes.
Limit: Four 15-minute units per day
Reimbursement: $7.20 per 15-minute unit

97124 � Massage, including effeurages, patrissage, and/or tapotement (stroking, compression, etc.), each 15 minutes.
Limit:  Four 15-minute units per day
Reimbursement:  $7.20 per 15-minute unit

97145 � Deleted � use 97110-97139

Place of Service codes on the claim form must utilize one of the following codes:

�12�   =       Home
�99�   =       Unlisted Facility (School/Early Intervention Center)

NOTE: The following codes were loaded incorrectly for the 7/10/96 change and are being corrected.  Claims paid at the incorrect rate were recycled.

Code           Incorrect Rate              Correct Rate

Y2615          $30.00                            $27.00

Y2611          $10.00                            $9.00

Y2512          $16.00                            $14.40

Y2509          $8.00                              $7.20

Y2510          $5.00                              $4.50

Y2511          $4.00                              $3.60

97032**        $8.00                             $7.20

X0421          $25.00                            $22.50

**Typo on notice � listed as 90732 but should have been 97032.

EPSDT Health Services Rates Effective July 10, 1996 and After

Corrections to the Table
Effective with date of service July 10, 1996 and after, the Bureau of Health Services Financing reduced by ten percent (10%) reimbursement rates for rehabilitation services included in an Individual Education Plan or Individual and Family Service Plan and provided under the EPSDT Health Services Program for recipients under 21 years of age.  These rehabilitation services include evaluation and treatment for services for speech, occupational, physical, and psychological therapies as well as audiological services.  Below are corrections to the codes and rates previously listed.

Y2615 - Individual Speech Therapy - 60 minutes Rate Prior to 7/10/96:  $30.00 7/10/96 Rate:  $27.00 (Previously indicated as $27.00 and $24.30).
X0424 - Individual Speech Therapy - Additional 15 minutes Rate Prior to 7/10/96:  $8.00 7/10/96 Rate:  $7.20 (Previously listed at Y0424)

97535 - Deleted effective 1/1/97
97537 - Deleted effective 1/1/97

97114 - PT Functional Activity - 30 Minutes (Deleted 6/1/95 - use Y7200)
97032 - Application of modality to one or more areas - 15 Minutes - Rate Prior to 7/10/96:  $8.00 7/10/96 Rate:  $7.20 (Previously printed as 90732 in error)
97145 - PT One Area - each additional 15 minutes
(Deleted 6/1/95 - use 97110 - 97139)  

Changes in the Home and Community Based Services Waiver for the Elderly

Due to the increasing cost incurred by participants in the Services for the Elderly Waiver there is a danger that the program will lose cost effectiveness.  Therefore, the following changes are being made effective April 1, 1997.  Individual service limits will cease to exist.  Instead, case managers will begin to calculate the costs of services for each participant in the waiver.  Costs must not exceed $35.00 per day for any participant.  Costs over that amount must be medically necessary and approved by Health Standards State Office staff.  Applicants or participants whose needs cannot be met in a cost-effective manner may not be approved or continue to be eligible to participate in this waiver program.

Effective April 1, 1997, providers of Personal Care Attendant services will be able to offer these additional services as follows:

  • Household Supports (homemaker, chore services)
  • Personal Supervision (day)
  • Personal Supervision (night)

These services are in additional to Personal Care services, which will be limited to providing actual physical care to the participant.  An additional 500 spaces are being added to this waiver and the target population is being broadened to include disabled adults as well as the frail elderly.  Each applicant must be eligible for admission to a nursing facility, as well as be able to have his or her medical needs met within the limits of the services and budget available in the waiver in order to be approved for waiver participation.  Applications will continue to be made through the local Councils on Aging.  Case management and PCA providers are being contacted about training which will cover these changes.

Notice to Providers:  New CLIA Waiver Tests

We were recently informed by HCFA of seven new CLIA waived tests.  All new waived tests were assigned CPT codes and a new modifier, QW.

With the establishment of the modifier to be used with the CPT codes, HCFA temporary national codes Q0116, G0054, G0056, and G0057 will be discontinued.

Upon receipt of this notification, these codes with the new QW modifier are to be used by laboratories billing for the newly created waived tests for services rendered on January 23, 1996 forward.  These codes may be used by any laboratory that holds a CLIA certificate.

The replacement codes for the G and Q codes are to be used for dates of service 1-23-96 forward.

Below is a list of the seven new waived tests as well as a list of the previous G and Q codes assigned to waived tests with their CPT code modifier.

87072QW - Culture or direct bacterial identification method, each organism, by commercial kit, any source except urine
86588QW - Streptococcus, screen direct
82465QW - Cholesterol, serum, total
83718QW - Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
84478QW - Triglycerides (noncovered service) 
82947QW - Glucose; quantitative
82044QW - Microalbumin, urine, semiquantitative (e.g., reagent strip assay)
Discontinued G and Q codes with new CPT codes plus modifier are as follows:
82465QW (G0054) - Cholesterol, serum, total
82950QW (G0055) - Post Glucose dose (includes glucose)
82951QW (G0056) - Tolerance test (GTT), three specimens (includes glucose)
82952QW (G0057) - Tolerance test, each additional beyond three

The fees for the preceding codes are as follows:

*New code 87072QW is priced at the same rate as code 87072 ($7.86).
*New code 86588QW is priced at the same rate as code 86588 ($11.10).
*New code 83718QW is priced at the same rate as code 83718 ($9.51)
*New code 82947QW is priced at the same rate as code 82947 ($4.62)
*New code 82044QW is priced at the same rate as code 82044 ($3.38)
*New code 85018QW is priced at the same rate as code 83026 ($2.77)
*New code 82465QW is priced at the same rate as discontinued code G0054 ($3.88)
*New code 82950QW is priced at the same rate as discontinued code G0055 ($4.42)
*New code 82951QW is priced at the same rate as discontinued code G0056 ($12.54)
*New code 82952QW is priced at the same rate as discontinued code G0057 ($3.71)  

Unisys Hospital Precertification Department Update

We are proud to announce the addition of three child psychiatrists to our case review process.  The physicians bring to this process a wealth of specialization in their reviews of pediatric cases.

We have also implemented a change in the handling of reconsiderations.  In the past, DHH policy required that the same physician who denied the initial review on any case was to perform subsequent reviews.  DHH is now allowing different physicians to perform the various levels of review in cases, expediting the reconsideration process.  We anticipate that this will lead to a reduction in requests for doctor-to-doctor telephone conferences.

Another change in DHH policy now allows the Precertification Department 24-hours to respond to all precertification requests for admissions and extensions.

Unisys Precertification Department is excited about these changes and looks forward to being able to better help providers and recipients with their hospital precertification needs.

Precertification:  What Providers Can Do To Help The Process

The following are things providers can do to help the Unisys Precertification Department expedite the review and processing of your precertification requests.

1.     The notification letter to the provider will contain the status of the request and, using 3-digit codes, will inform the provider of any additional information needed.  Providers need to respond by sending the requested information or by writing an explanation of why the information is not available.

2.     Rejection letters (not denial letters) indicate that the provider should resubmit all the information sent with the rejected request in addition to the requested information.  This will expedite the re-review of the request.

3.     Read over what is to be sent to Unisys.  Often providers send conflicting documentation among disciplines.  These cases are reviewed based on the preponderance of information.

4.     Often information is difficult to read.  This may be the result of copier quality or writing legibility.  Please be as clear as possible.

5.     Psychiatric cases are evaluated using scientific/medical criteria established by the Department of Health and Hospitals.  This criteria requires that documentation show the patient to be homicidal, suicidal, or gravely disabled.  Unisys PreCert staff are reading for descriptions of this behavior which are contained in the submitted documentation.  Judgmental or speculative comments regarding a patient's behavior are not usually supportive of the criteria.

6.     Unisys PreCert staff always require current, up-to-date information on medications and therapies supporting the criteria.  Lack of current or time-sensitive information usually results in an unfavorable decision.

Thank you, in advance, for helping the Unisys Hospital Precertification Department serve the provider community.

Tracing Lost Faxes:  Unisys Precertification Department

Unisys Precertification Department relies heavily on its fax machines to provide prompt service to providers.  Sometimes, however, faxes get lost on their way from provider to PreCert.  That is why the Unisys fax server system has a mechanism to track or trace lost faxes.

This system works in a two-fold manner to retrieve faxes that are important in Unisys business dealings.  For incoming faxes, the system can actually "visualize" faxes as they are received by the fax/computer.  The benefit of this feature is that Unisys is able to track a fax from the time it enters the system until the time it is printed in PreCert.  If a provider has an ongoing problem with faxes sent, Unisys can utilize this tracking system.  The limitation of this mechanism is that Unisys can track faxes for only 5 days after they've been sent and only if the provider has his CSID number on each faxed page.

The second unique feature of the PreCert fax service is its written reports, generated each hour, documenting failed faxes.  (These are faxes PreCert is sending to providers).  This allows PreCert staff to refax information listed as having failed.  If groups of faxes sent to the same facility continue to fail in transmission, the PreCert staff contacts the facility to alert its staff to potential problems with the provider's fax machine.  Every 24 hours, PreCert receives a written log of all faxes sent, those received by the providers as well as those which failed and were re-sent.

If, despite these features, providers have an ongoing fax problem with either sending data to or receiving data from PreCert providers are encouraged to contact Unisys Precertification Department at 504/237-3205.  Please ask to speak with Janeen or Sandy, who will assist in identifying the problem and in advising of its solution.

Hospital Precertification Error Message 147

(Only a portion of the days needed is approved.  The remaining days on this request are denied�Submit Reconsideration)

As a provider, you have seen this message on your Pre-Cert notification letters.

Error message 147 is used when a Unisys physician has reviewed all data submitted by the provider for this request.  The physician has determined that only part of the days being requested meets criteria; therefore, a portion of the days requested is approved but the remaining days being requested are denied.  The provider should then submit a reconsideration request and appropriate data for the remaining days needed for the hospitalization.  This offers the provider the opportunity to send to Unisys PreCert additional information which documents the patient's severity of illness and intensity of hospital service needed.

Notice to Certified Nurse Midwives

Effective with date of service 1-1-96, CPT codes 59610, 59612, and 59614, vaginal delivery after previous Caesarean delivery codes, have been added to the list of codes reimbursable to Certified Nurse Midwives.

Changes in Second Norplant Implementation

Currently, claims for a second Norplant implantation and/or removal with a five year period pend for review.

Effective with the publication of this notice, these claims will no longer pend.  Consequently, said claims may be billed electronically.  

Notice to Physicians:  Changes in Physical Medicine Codes

Effective with date of service January 20, 1997, the Professional Services Program will no longer reimburse physicians for certain physical medicine codes as listed below.  Medicaid provides reimbursement for similar services under different procedure codes in the benefit categories of Home Health Services, Rehabilitation Services, and Early Periodic Screening, Diagnosis and Treatment Services.

97010   97020   97026   97035   97122  
97012   97022  97028   97036   97250  
97014   97024   97034   97039   97265  

Notice to Physicians and KIDMED Clinics

The Bureau of Health Services Financing is pleased to announce the funding of the administration fee for Varicella (Chicken Pox) Vaccine, CPT code 90716, effective with date of service December 17, 1996 for recipients 12 to 24 months of age.  The Varicella vaccine is provided free through the Vaccines for Children (VFC) Program to all VFC enrolled providers upon request from the Office of Public Health.  Code 90716 will be reimbursed at a fee of $9.45, as are other vaccinations provided through the VFC Program.