Provider Update

Volume 15, Issue 1

February 1998

Implementation of the Medicaid Eligibility Verification System (MEVS)

Implementation of the Medicaid Eligibility Verification System (MEVS) and usage of plastic identification cards for recipients is upon us. By the time you read this article, approved telecommunications vendors will be marketing their eligibility products in the provider community.

Plastic ID cards will be implemented by region throughout the state. The anticipated schedule for phasing in this project is as follows: 

This schedule may fluctuate based on implementation needs.

Although the plastic cards will be phased in by region, please remember that MEVS will be available beginning in March for use across the state by any providers who choose to contract with a vendor to access the system. The enhanced Recipient Eligibility Verification System (REVS) will continue to be available to all providers statewide.

Provider awareness seminars will be held in each region approximately a month prior to the implementation date for the region. Please continue to watch the Provider Update and provider notices for the date and location for your region.

Revision of Policy for Repairs to Electric Wheelchairs

The following policy revision has been adopted by BHSF for the prior authorization for repairs to electric wheelchairs.

Repairs to electric wheelchairs may be considered if the recipient remains in an education or training program or remains employed. Repairs to electric wheelchairs may also be considered for recipients who already own an electric wheelchair even if they are not currently enrolled in an education or training program, or are not employed, if the following conditions are met: 

1) The electric wheelchair is the recipient�s only wheelchair; 

2) The only alternative to the repairs is replacement by a new manual type chair; 

3) The repairs do not cost more than the estimated replacement cost of a new, appropriate manual type chair; and 

4) Only basic repairs, not major modifications or reconstruction of the chair, are being requested.

MDS Automation for Long Term Care Facilities

The MDS (Minimum Data Set) Automation Regulation was published in December. To obtain a copy of the regulation, contact the U.S. government Printing Office at (202) 512-1800. Ask for Part III of the Federal Register published on 12/23/97 (pages 67174-67213). The fee is $8.00. You may also download the regulation from the Internet. Call 1-888-293-6498 for Internet assistance.

There will be a four-hour satellite broadcast produced by HCFA on 2/19/98. The purpose of this broadcast is to provide nursing homes and SNF units with an understanding of the requirements for submission of the MDS data to states from a policy and systems perspective. Please contact LNHA at (504) 927-5642, or LAHSA at (504) 767-2900 for information on sites, fees, and registration.

HCFA has sponsored development of free software for LTC facilities to use for MDS electronic data submission. This software is available from the HCFA MDS technical web site on the Internet at www.hcfa.gov/medicare/hsqb/mds20/. You must have a 486 computer or faster to run this program.

If you have any questions about LTC MDS electronic submission, please contact Cathy Brunson, RN, MDS Coordinator, at (504) 342-2482 or the MDS Help Line at 1-800-261-1318.

Louisiana Drug Utilization Review (LADUR) Education

Polypharmacy in the Elderly

Tracy S. Hunter, Ph.D., R.Ph., Director, Division of Clinical Pharmacy Practice, Northeast Louisiana University, and Sandra Blake, Ph.D., Fellow, Pharmacoeconomics and Outcomes Research, Northeast Louisiana University

ISSUES . . . 

• The elderly now make up over 12% of the U.S. population, but take more than 25% of all medications and 70% of all over-the-counter medications (OTCs).
  
  

•  �Polypharmacy� is the use of multiple prescriptions and OTCs simultaneously. The elderly are at greater risk for polypharmcy than the rest of the population, and thus at greater risk for negative side effects, noncompliance with drug regimens, adverse drug reactions (ADRs), and drug-drug interactions due to polypharmacy.

Polypharmacy refers to the use of multiple prescription and over-the-counter drugs simultaneously. This occurs frequently in individuals with multiple chronic conditions in the care of one or more physicians who are unaware of medicines prescribed by other physicians, or patient over-the-counter drug consumption. Polypharmacy is not an absolute number of prescription drugs per month (although a regimen of 5-6 medications is a common delimiter), nor does it imply that the prescribing of multiple medications by different specialists is absolutely wrong and to be avoided. For some elderly patients suffering from multiple chronic diseases, complex drug regimens may be necessary and therapeutic. However, multiple prescribing increases the probability of adverse drug outcomes. 

This article addresses factors often associated with polypharmacy and offers suggestions that may assist the health care professional in controlling polypharmacy and maximizing drug therapy treatments.

Why Be Concerned About Polypharmacy in the Elderly?
The elderly now make up over 12% of the U. S. population but take more than 25% of all medicines and 70% of all over-the-counter medications (OTCs). It is estimated that individuals over 65 take an average of 3 prescription medicines and 4 OTCs each day. An early 1990s study of medication use among noninstitutionalized residents over age 62 at the Christopher Homes in New Orleans showed that, on average, these elderly consumed 3.24 prescription and 1.53 nonprescription medicines during a 2-week period. (Barbre, Smith, Sharpe, 1992)

On the percentages alone, taking this number of medications increases the potential for negative side effects, noncompliance with drug regimens, adverse drug reactions (ADRs), and drug-drug interactions. These, in turn, can lead to confusion, weakness, sedation, falls, hospitalization, injury, and even death. However, the symptoms of polypharmacy�disorientation and altered mental states, urinary incontinence, malnutrition and failure to thrive�can be confused with symptoms of disease and treated with more medication, compounding the problem.

Physiological Changes Associated with Aging
Several unique characteristics make elderly patients vulnerable to drug misadventures and drug-induced iatrogenesis. In addition to the functional impairments often associated with aging�loss of vision and hearing and possible cognitive dysfunction�the way that the body manages drugs may be substantially altered. These physiologic changes due to aging alter the pharmacokinetic and pharmacodynamic responses to medications and must be considered in the drug selection process.

Pharmacokinetics � how the body processes drugs � specifically refers to the absorption, distribution, and elimination of medication by the body. In the elderly, these functions are different than in the young subjects of clinical trials. Not only are elderly patients consuming more drugs, their bodies are handling them differently. Of particular concern are medication absorption and distribution in tissue compartments, hepatic metabolism, and renal elimination. These factors, discussed below, add to the dangers of polypharmacy in the elderly patient.

1. Absorption. Initial absorption of pharmaceutical agents is naturally altered in elderly patients by three primary factors. The first factor is a reduction in the stomach�s production of gastric acid and the frequent use of antihistamine antagonists or antacids. The second factor is the ratio of lean body mass to adipose tissue changes with muscle loss. The third factor is the elderly have lower levels of circulating serum albumin. Depending on the solubility and binding mechanisms of particular agents, these factors affect drug concentrations in the elderly body, either making them higher and increasing the potential of toxicity, or lower, leading to decreased activity. 

2. Metabolism. In most elderly patients, there is a reduction in hepatic blood flow, thus reducing the rate of hepatic drug metabolism. For drugs that are dosed with an expectation of a high rate of excretion during the first pass through the liver, this lower hepatic metabolism results in higher drug concentrations and may result in toxicity.

3. Excretion. Perhaps the most significant and well-known pharmacokinetic change associated with aging is the decline in ability of the kidney to excrete drugs. Many medicines with a narrow therapeutic range between effectiveness and toxicity are renally eliminated. Dosages calculated without consideration of this altered kidney function may allow drugs to reach dangerously high concentrations especially in thin or frail patients. 

Factors Contributing to Polypharmacy
Due to the effects of aging, elderly patients tend to have a proportionally high number of medical maladies and symptoms. They are more likely to see multiple specialists and their primary care physician�s medical record may not accurately list all current medications. 

Psychosocial studies have shown that older patients tend to value drug therapy more than education and expect that a visit to the physician will result in a prescription. Older patients may be unaware of the dangers of interactions between prescriptions prescribed to them but often expect aggressive medicine-based treatment for their ailments because they perceive that medicines are appropriate for relief of symptoms. Research has shown that physicians are more likely to prescribe for the elderly than for any other group, and older patients are less likely to freely contribute additional information or ask for clarification of the physician�s decisions. 

Elders are more likely to hoard old drugs, attempt self-treatment with OTCs, and borrow medicines. This problem is compounded considering that many prescriptions have automatic refills. Elders who change physicians and receive new prescriptions often continue to take their old prescriptions while adding the new.

Controlling/Reducing Polypharmacy in the Elderly
Numerous clinicians have offered suggestions for practical methods of reducing polypharmacy in the elderly. The following list was condensed from the literature:

1. Identify for special consideration those patients that are particularly vulnerable, generally those with multiple chronic diseases or metabolic disorders. 

2. Encourage the use of a single pharmacy for all of a patient�s medications (prescription and over-the-counter) and where possible, do not change the manufacturer of the product. 

3. Communication among all providers, especially physicians, pharmacists, and home health care nurses who have direct patient contact, increases in importance when the patient is taking multiple medications. 

4. When prescribing, adjust doses to account for physiologic changes due to aging. Review all medicines for efficacy, action, adverse effect or interactions, and build a �gray list� (See Table 1) of drugs poorly suited for use in geriatric patients and monitor accordingly. 

5. Each drug administered should be linked to clinical indication. Eliminate drugs with no effective indication. Drugs are sometimes prescribed when not necessary as prevention or to treat symptoms when no disease is present. Try to avoid medicine for minor symptoms. 

6. Sometimes non-pharmacologic care measures like massage, backrubs, and relaxation offer comfort or relief of minor discomforts. 

7. Substitute with less toxic varieties when possible. Start at the lowest therapeutic dose and increase slowly until desired effect is achieved. 

8. Attempt the �one disease, one cure, once-a-day� compliance scheme to reduce drug regimen complexity. When possible substitute single for multiple doses, taken around mealtimes (considering gastro-intestinal health). Try to find a single medicine to treat two unrelated illnesses (such as a calcium antagonist for hypertension and angina). When a new drug must be added to the regimen, try to remove another.

9. Avoid what is known as �double dipping�, using drugs to treat adverse drug reactions. Rather than starting new medicine to treat the side effect, make an effort to remove the initial offending drug. When any additional palliative medicines are administered during courses of toxic therapy, make sure they are withdrawn once therapy is completed. Try to find alternatives when maintenance medicines cause side effects rather than increasing total drug consumption. 

10. Practice patient education. Refer to drugs by their generic name and class to emphasize formulation over manufacturer. Nonprescription drug terminology is sometimes confusing to patients. (For example, Mylanta� a product previously known to consumers as an antacid, now has a form that contains cimetidine). Remind the patient that drugs with similar names are not equivalent (for example, norpramin and nortriptyline). 

11. It is sometimes best to avoid dosage forms that are similar in size, shape and color to other medications that the patient is taking. 

12. When necessary, provide an audiotape if patient is not able to read because of illiteracy, cataracts, or color blindness. 

13. One effective technique often used by pharmacists is the �Brown Bag Test.� Ask the patient to fill a bag with all of their medicines and bring it to you to review. From the contents of the bag, construct a comprehensive medication profile and make sure that the patient understands all aspects of the medications they are taking. Show the patients the medicines that are therapeutic duplicates and discard out of date products or the ones not currently prescribed. Formulate a clear written medical time schedule for dosage and carefully review it with the patient, family members, or care givers.

Conclusion
The need for specialized care for the elderly will continue to grow well into the 21st century. As baby boomers age, our elderly population will increase and continue to be the most rapidly growing segment of society. Today�s longer life expectancy means that more people will be looking to Louisiana health care professionals for medicine-based solutions for the cure to chronic illness and the diseases of age. An organized therapeutic plan and a critical evaluation of the list of drugs an elderly patient is taking will help in establishing a safe and effective drug regimen.

Table 1. 

REFERENCES

Barbre, Ann R., Mickey C. Smith and Thomas R. Sharpe. �Medication Use Patterns Among a Noninstitutionalized Urban Elderly Population.� Journal of Pharmaceutical Marketing & Management. 7 (Spring 1992 ):65-75.

Carlson, John E. �Perils of polypharmacy: 10 steps to prudent prescribing.� Geriatrics. 51 (July 1996): 26-30, 35.

Colley, Colleen A., and Linda M. Lucas. �Polypharmacy: The Cure Becomes the Disease.� Journal of General Internal Medicine. 8 (May 1993): 278-283.

Davant, Charles, III. �Taking the confusion - and - danger out of polypharmacy.� Medical Economics. 70 (Dec 13, 1993): 125-126.

Drake, Audrey C., and Evelyn Romano. �How to Protect Your Older Patient from the Hazards of Polypharmacy.� Nursing. 25 (June 1995): 34-39.

Duxbury, Andrew S. �Geriatrics: Unmasking �Polypharmacy� Problems and Adverse Drug Effects.� Consultant (April 1996): 762-764, 770, 771, 775, 776, 783.

Lilley, Linda L., and Robert Guanci. �Polypharmacy in Elders.� American Journal of Nursing. 96 (November 1996): 12-14.

Ostrom, F. E., E. R. Hammarlund, D. B. Christensen, et al. �Medication Usage in Elderly population.� Medical Care. 23 (February 1985): 157-164.

Regan, Timothy S. �The Multipill Challenge.� Vibrant Life. 10 (November-December 1994): 22.

Stewart, Ronald B., and James W. Cooper. �Polypharmacy in the Aged. Practical Solutions.� Drugs & Aging 4 (June 1994): 449-461.

Bureau of Census

Notice to Rural Health Clinics and Federally Qualified Health Centers

The Bureau of Health Services Financing (BHSF) is submitting the following answers to questions that were asked during the recent Unisys Provider Training.

1. Question: Must a nurse practitioner be �supervised� by a physician? The law has changed whereby a nurse practitioner and physician may have a �collaborative� arrangement. 
Answer: Medicaid requires that each nurse practitioner have a protocol established by a directing physician and functions according to that protocol, or at the direction of that physician, or finally, with the approval of a directing physician. Each nurse practitioner must have written documentation of formal affiliation with a licensed physician (protocol[s]) available for review upon request. These protocols shall be renewed annually by the physician and kept on file at the RHC/FQHC.

2. Question: Should RHC/FQHCs enroll all appropriate providers of service (specifically nurse practitioners) and use their provider numbers as the individual provider of service on the claim? 
Answer: Medicaid requires that certified nurse practitioners and/or chiropractors who are employed or contract with physician groups to provide services to Medicaid recipients must have individual provider numbers and must notify Provider Enrollment at (504) 342-9454 of such employment or contracts so that provider numbers can be linked to the physician�s group number, or in this case, the RHC/FQHC. When billing for services, the provider number of the individual who provided the service must be entered in Item 24K on the HCFA 1500 form (Field 21, Data Element 29 for EMC billers). 

3. Question: If a recipient is seen at the RHC/FQHC and then later is admitted to the hospital, is the visit a payable encounter? 
Answer: Yes.

4. Question: If a recipient goes to the Emergency Room at the hospital of a provider-based RHC and the services are not available at the RHC/FQHC, is the RHC visit a payable encounter? 
Answer: Yes.

Electronic Fund Transfer

The mailout of direct deposit agreements was initiated by the Department of Health and Hospitals beginning with Long Term Care facilities on January 15, 1998. Separate mailouts are being forwarded to other provider types at different intervals. Providers should be anticipating receipt of the direct deposit agreements within the next 8 to 10 weeks. The agreement should be returned to the Provider Enrollment Unit within five (5) days.

The process for direct deposit involves submission of the completed direct deposit agreements to Unisys. This information is then shared with City National Bank, the automated clearinghouse, and subsequently with the provider�s bank of choice. Each provider will then be placed in a pre-note �test� status for a period of approximately two weeks to ensure proper transmission and deposit of funds. Once a provider is approved, i.e., passed the pre-note �test process� for direct deposit, the Unisys system is updated to indicate approval of direct deposit funds.

Official notification of approval of direct deposit funds will not be furnished. Providers should review the financial page of their remittance advice which indicates direct deposit has been established and the date of deposit of funds.

Attention Physicians: Changes in CPT Code 59020

Formerly, CPT code 59020 - Fetal Oxytocin Stress Test - was payable to obstetricians and gynecologists who certified in writing to the state that they had the equipment in their office to perform this test. This notice is to advise that perinatologists (specialists in the practice of Maternal and Fetal Medicine) may now be reimbursed for this procedure when they meet the same criteria. Changes must be made to the provider file in order for payment to be made for this code.

Perinatologists requesting reimbursement for code 59020 must complete Form 24 and submit it to:

Provider Enrollment Section, 
P.O. Box 91030,
Baton Rouge, LA 70821-9030

To request Form 24, please call the Provider Enrollment Unit at (504) 342-9454.The �professional component only� of this code (billed 59020-26) is payable to obstetricians, gynecologists, and perinatologists when the place of service is inpatient, outpatient, or office setting.

The fee for the full service (59020 without modifier - 26 appended) is not payable to any physician when the place of service is inpatient or outpatient hospital.

Seating Evaluation Requirements for Customized Wheelchairs

Medicaid policy requires that all requests for prior authorization of customized wheelchairs include an evaluation by a rehabilitation therapist.

The requirement for an evaluation by a rehabilitation therapist implies that a rehabilitation therapist (licensed physical or occupation therapist) must see the recipient and personally evaluate the recipient�s limitations and disabilities as they pertain to the recipient�s specialized wheelchair needs. It is not acceptable, for example, for a therapist to simply sign an evaluation already performed by a wheelchair provider to indicate that they agree with the provider�s recommendations. The evaluation submitted with a customized wheelchair request must be the therapist�s own observations and recommendations.

In order to confirm that a therapist has actually performed the seating evaluation, the Prior Authorization Unit at Unisys will now accept only the following two types of therapist evaluations for customized wheelchair requests:

1. Detailed, handwritten notes, or individualized and detailed typewritten notes, composed by the therapist, with the therapist�s signature and date.


2. A pre-designed, typewritten evaluation form with standardized questions, fill-in-the-blank, and/or check-off type information for the therapist to complete. The therapist must sign and date a statement at the bottom of the form to certify that he/she has participated in a seating clinic or performed a wheelchair seating evaluation for the recipient and that the comments on this form are his/her personal observations and recommendations.

Please note that the signature on the therapist�s evaluation should be handwritten, and not stamped.