PROVIDER
UPDATE
VOLUME
14, NUMBER 1
FEBRUARY
1997
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.
Summary
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.
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
Issues�
-
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.
Corticosteroids
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
TRIGGERS
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.
Allergens
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.
Exercise
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
CONCLUSION
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.
References
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.
EPSDT HEALTH SERVICES � CODING CHANGES*
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.
SPEECH
THERAPY
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)
OCCUPATIONAL
THERAPY
97535 - Deleted effective 1/1/97
97537 - Deleted effective 1/1/97
PHYSICAL
THERAPY
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.