Provider Update
Volume 21, Issue 2
March/April 2004
Louisiana Medicaid Pharmacy Benefits Management System
and Disease Management
Note: This is the first in a series of articles on Louisiana�s state operated Medicaid Pharmacy Benefits Management (PBM) System.
Introduction
Over the past year the Medicaid Pharmacy Benefits Management section has implemented mechanisms to enhance and expand the Medicaid Program�s disease management initiatives and to improve the program�s integrity through expanded prescription verification functions. This is the first in a series of articles on the Louisiana Medicaid Pharmacy Benefits Management System.
Louisiana Medicaid Pharmacy Benefits Management (LMPBM) System Overview
DHH administers its own Medicaid Pharmacy Benefits Management (PBM) System. Unlike insurance companies and Health Maintenance Organizations, who contract with private entities to provide PBM
services, the State operates its PBM System utilizing its state owned, federally certified Medicaid Management Information System (MMIS). Pharmaceutical technical support and disease management
program services for the system are provided through contracts with the University of Louisiana at Monroe (ULM) School of Pharmacy, the only state operated pharmacy school, and Unisys, the Medicaid program�s fiscal intermediary.
The LMPBM System began in 1966 with a very basic system that utilized a few controls, such as claims processing audits/edits and provider audits, and has evolved into today�s sophisticated system which includes the 1990 and 1991 federal Omnibus Budget Reconciliation Act mandates and other features, such as a point-of-sale electronic claims management system, prospective and retrospective drug utilization reviews, recipient lock-in, disease state management, and comprehensive provider audits. Thus, the current LMPBM System has many features of a typical private PBM, but also has many additional features.
The LMPBM System also has the unique nonprofit characteristic of returning monies resulting from cost containment measures to the State of Louisiana.
With its MMIS, Drug Utilization Review (DUR) Program, and pharmacy school contract, the Department is able to operate a disease state management program for its entire Medicaid population which focuses on diseases such as asthma, diabetes, arthritis, hyperlipidemia, etc. Outcomes studies are conducted by university staff. A report issued on a study of the Asthma Disease State Management Program disclosed
that as a result of the disease management program, asthma-related physician office visits declined in all areas of the state; there was a decline in asthma-related inpatient utilization in all areas of the state; emergency room visits declined in three of the four regions of the state; there was an increase in the use of long-term control medications rather than quick-relief medications; and while pharmacy expenditures increased, the increases were accompanied by decreases in spending on other health services resulting in a decline in total asthma-related expenditures.
Omnibus Budget Reconciliation Act (OBRA) of 1990
In 1990 the federal OBRA amended the Social Security Act and placed into law specific requirements for payment of covered outpatient drugs in the Medicaid program. One of the mandates is that states must administer a Drug Utilization Review (DUR) Program with a DUR Board. In accordance with the Act and federal regulations, states are mandated to have a Medicaid DUR program with the goal, �. . . to ensure appropriate drug therapy, while permitting sufficient professional prerogatives to allow for individualized drug therapy.� The DUR program�s required components are:
1. Prospective drug review,
2. Retrospective drug use review,
3. An educational program, and
4. A state Drug Utilization Review Board.
In addition, the DUR program is mandated to assess drug use information against predetermined standards.
The OBRA retrospective DUR requirements recognize the functions of MMIS Surveillance and Utilization Review (SUR) subsystems which were in effect prior to OBRA 1990. The regulations, therefore, permit states to
limit retrospective DUR review activities to those that focus on appropriate and medically necessary care to avoid duplication of activities relating to fraud and abuse under the SUR program.
The Louisiana Medicaid Program had a retrospective drug utilization review program with Peer Utilization Review committees, a federally approved SUR program and a recipient prescription �lock-in� program for many years prior to OBRA 1990. In 1996 the Department promulgated implementing regulations for the additional OBRA 1990 drug use review, disease state management and the point-of-sale electronic claims management system mandates which enhanced the effectiveness of the pharmacy program.
Prescribing Practitioner and Pharmacy Peer-based Profiling State Legislation (Act 795 of 1999 and Act 395 of 2001)
During the 1999 Regular Session of the Legislature, LA R.S. 46:153.3 was amended to authorize the Department of Health and Hospitals to develop peer-based prescribing and dispensing practice patterns for health care providers participating in Medicaid and to promote these practice patterns. LA R.S. 46:153.3 was further amended during the 2001 Regular Session of the Legislature (Act 395) to mandate these peer-based functions. This state legislation supports the federal mandates placed on Medicaid pharmacy programs.
Prescription Utilization and Disease Management Opportunities for the Medicaid Pharmacy Benefits Management System
DHH is in a unique position to utilize features of its PBM system to:
1. Improve prescription drug utilization by its recipients and
2. Expand and enhance its current disease state management program.
The following are key components of Louisiana�s successful Medicaid Pharmacy Benefits Management System which are employed to enhance prescription utilization and operate its disease state management program:
1. DUR Programs (prospective and retrospective)
2. DUR Committees - four regional committees
3. DUR Board
4. Pharmacy Lock-in Program
5 Disease State Management Program
6. Prescribing Practitioner and Pharmacy Peer-based Profiling Program
7. SUR Program
8. MMIS Reporting Systems
9. Interdisciplinary Medicine and Pharmacy Council
10. Pharmacy Advisory Committee.
Watch for future articles that will focus on the above listed components as well as other features of the PBM system�s administration.
Pharmaceutical Care and Patient Outcomes � LaDUR
Note: This is the second in a series of articles on Louisiana�s state operated Medicaid Pharmacy Benefits Management (PBM) System.
The Louisiana Medicaid Program with Unisys, its fiscal intermediary, has implemented an enhanced Retrospective Utilization Review (LaDUR) component in its Drug Utilization Review (DUR) system. The enhancement includes features to help prescribers and pharmacists provide improved
pharmaceutical care and patient outcomes. It also interfaces well with the other existing Pharmacy Benefits Management (PBM) components. The following is an explanation of the retrospective review component of the DUR system, the purpose of DUR and an explanation of this enhancement. It is hoped that the new LaDUR system will be beneficial to you in the treatment of your Medicaid patients.
Purpose
The purpose of the Medicaid Drug Utilization Review system is to provide assistance in the care of Medicaid patients by alerting their medical caretakers to possible problems with a patient�s drug
regimen. Appropriate pharmaceutical care remains a significant component of managing any disease state.
The federal Omnibus Budget Reconciliation Act of 1990 (OBRA �90) specifically states that the
purpose of a drug use review program for outpatient prescriptions is to assure that prescriptions are: (1)Appropriate, (2) Medically necessary, and (3) Not likely to result in adverse medical results.
Background
The Louisiana Medicaid program has conducted retrospective Drug Utilization Reviews since the 1970�s. Since the beginning of these reviews, four regional committees, each comprised of three pharmacist providers and one physician provider, have conducted monthly reviews of Medicaid patients� prescription profiles. These reviews assess the possibility of underutilization, overutilization, or contraindications of prescription therapy by querying a recipient�s disease history and drug utilization. The committees correspond with patients� prescribers and pharmacists regarding their observations in an effort to correct aberrant prescription therapies and utilization.
Omnibus Budget Reconciliation Act of 1990 (OBRA �90)
In accordance with OBRA �90, all Medicaid agencies are required to operate a DUR program. The law requires the program to provide for retrospective review, prospective review and cognitive services.
In 1991, the Louisiana Medicaid Program partnered with pharmacy faculty at Northeast Louisiana University to develop therapeutic criteria (predetermined standards) for assessing appropriate prescription utilization. The Medicaid program then added the prospective review and cognitive services requirements to its drug utilization review program in 1993 in compliance with the law.
Enhanced Retrospective Drug Utilization Review
How did Louisiana Medicaid enhance its federally mandated Retrospective Drug Utilization Review component (LaDUR) to improve the quality of pharmaceutical care and patient outcomes?
The retrospective review process in the DUR program has been enhanced by shifting its focus from a fundamental review of therapeutic drug criteria based on a patient�s prescription utilization to examination of patients� disease states using nationally recognized clinical practice guidelines.
Until recently, when a recipient�s prescription utilization pattern correlated with developed criteria, a prescription profile was generated for review. The profiles were examined by Drug Utilization Review committee members, and when appropriate, contact was made with prescribers and pharmacists. Retrospectively, the LaDUR process has reviewed prescription utilization patterns for signs of polypharmacy, physician shopping, overutilization or possible inappropriate use of narcotic analgesics, anxiolytics, muscle relaxants, histamine receptor antagonists, proton pump inhibitors, nonsteroidal anti-inflammatory drugs, beta-adrenergic agonists and many other therapeutic classes of drugs.
The focus has now been broadened, through enhanced computer programming, to identify prescription use or absence within a disease state. This approach shifts our sights from examining issues of overutilization and duplication of prescriptions to a global approach concentrating on a disease state. In April and May 2004, the DUR committees will review aspects of diabetes. For example, DUR committees will examine profiles of diabetic patients who have hypertension and are not utilizing an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB). American Diabetes Association clinical practice recommendations were considered and approved by the DUR Board in developing standards for review. Cardiovascular disorders will be highlighted in August and September 2004 with emphasis on congestive heart failure and hypertension.
Drug Utilization Review demands constant re-evaluation of established parameters as new drug therapies become available and clinical guidelines and prescribing algorithms are refined. The success of the program has created the need to look not only at drug utilization, but the existing diseases as well.
A Message to Prescribers and Pharmacists
The provider community has been very receptive to correspondence and other contacts received from the Drug Utilization Review committees regarding patients with identified potential drug therapy problems. Response rates from pharmacy and physician providers have escalated to nearly 40% with this recent enhancement. The Medicaid program staff hopes these enhancements will provide new valuable information on your patients� therapies that will improve pharmaceutical care and patient outcomes. We invite your comments regarding the information provided and any interventions resulting from this information. Please fax your comments to the LMPBM staff - Attn: M J. Terrebonne, Pharmacy Director or Melwyn Wendt, Pharm D. at 225-342-1980.
Other LMPBM Initiatives
Audit
The Department of Health and Hospitals, Medicaid Pharmacy Benefits Program, is enhancing its Pharmacy Information Management System to perform a Pharmacy Compliance Review/Audit function in-house. This function will be performed by the Pharmacy Benefits Management Section and the University of New Orleans (UNO) audit staff. This enhanced system will allow our auditors to review both submitted and paid claims for program compliance and billing.
You will be contacted by our audit staff to validate claims if your submissions meet the criteria for exception. In some instances, you may be required to pull original documentation including, but not limited to, wholesaler invoices and/or physician prescriptions in support of your submission. The release of this information is authorized in the Title XIX Manual for Prescription Drug Services on page 3-3, which addresses Standards of Participation in the Medicaid program.
Please note that the Department of Health and Hospitals is a covered entity under HIPAA. Therefore, DHH, and UNO acting on behalf of DHH are exempt from the HIPAA privacy regulations regarding records for any claims for which Medicaid reimbursement is sought. Section 164.506(a) of the HIPAA privacy regulations provides that covered entities are permitted to use or disclose Protected Health Information (PHI) for treatment, payment, or health care operations. In addition, a �HIPAA Authorization� or �Opportunity to Agree or Object� by the individual is not required for uses and disclosures required by law.
Coordination of Benefits
Effective July 1, 2004, Louisiana Medicaid will begin to deny pharmacy claims when other insurance is noted on the recipients� resource file.
Federal law mandates that Medicaid is the payer of last resort. The NCPDP 5.1 transaction set allows for pharmacies to coordinate benefits with third party payers. This feature allows pharmacy providers to bill a Medicaid recipient�s primary insurance company, then bill Medicaid last.
It has been brought to the attention of the Department, that not all providers are capable of coordinating benefits or
�split-billing.� Prior to implementation, pharmacies may need to contact their software vendors or corporate offices if their current layouts do not include the coordination of benefits segment. NCPDP override conditions will be supported. Provider training will be provided. Detailed information packets will be sent to pharmacy providers in May.
Please contact the POS helpdesk at 1-800-648-0790 with any questions.
HIPAA Rule � National Provider Identifier
Centers for Medicare and Medicaid Services (CMS) has announced the adoption of a National Provider Identifier for health care providers to use in the filing and processing of electronic health care claims and other transactions. This standard unique identifier is a mandate of the HIPAA legislation.
What will it do?
� A 10-digit all numeric identifier, it will replace the use of all legacy provider identifiers.
� It will reduce costs and improve efficiency of claims processing and reporting.
Who must/may/may not apply for an NPI?
� All covered health care providers (those who transmit data in electronic form, i.e. standard transactions) must obtain an NPI.
� Providers who provide atypical or non-traditional services that are indirectly health care
related are not considered health care providers under HIPAA and are not eligible to receive an NPI.
� Non-covered providers may apply for an NPI. NPIs can be used on paper transactions.
� All health care providers, whether or not they are covered entities under HIPAA, are eligible to apply for, and be assigned, an NPI.
Compliance Dates:
� Covered providers may begin applying for NPIs after May 23, 2005.
� All covered entities doing business with Medicaid must have, and begin using, the NPI in standard transactions by May 23, 2007.
Health care providers do not need to take any action to apply for NPIs at this time. The national system that will handle the assignment of NPIs will be ready to accept applications after May 23, 2005. CMS will provide the health care industry with information relating to the NPI, including the application process and the availability of the NPI application forms, closer to the effective date for filing applications. This Provider Update will also continue to provide updates to this rule.
The Final Rule for the HIPAA Administrative Simplification Standard Unique Health Identifier for Health Care Providers may be accessed through the CMS website at
www.cms.hhs.gov/hipaa/hipaa2 .
HIPAA Update & Common Provider Billing Errors
Following more than two years of planning, development, and hard work, the Department of Health and Hospitals (DHH) and Unisys are in the process of completing implementation of the HIPAA Transaction & Code Set Rule for Louisiana Medicaid. As this project moves from an implementation phase to "standard operating procedure", we need your assistance with some areas of the final transition.
1. Contingency Plan:
In October 2003 DHH implemented a Contingency Plan to provide Vendors, Billing Agents, and Clearinghouses (VBCs) additional time to develop HIPAA compliant specifications and allow providers to continue to submit claims using DHH proprietary electronic specifications until their VBCs are compliant. This move was initiated to prevent any unnecessary hardship on providers and vendors as they worked to become compliant. This Contingency Plan is ongoing but will ultimately come to an end.
Currently, more and more VBCs are HIPAA approved and submitting claims using HIPAA compliant specifications. Providers who are continuing to submit electronic claims with proprietary specifications should pursue locating a HIPAA compliant vendor and transition to HIPAA specifications as quickly as possible to avoid potential problems when the option to bill using proprietary specifications via the Contingency Plan is eliminated.
2. TAD Billing:
DHH extended the February 2004 deadline for Long Term Care (LTC) providers to transition from the TAD to the 837I HIPAA complaint specifications. Ultimately, the TAD will become obsolete, and LTC providers will bill using the UB-92 for hard copy claims and the HIPAA compliant 837I for electronic claims.
There are currently 13 VBCs approved to submit LTC claims via the 837I specifications. LTC providers planning to submit claims electronically are strongly encouraged to pursue a HIPAA compliant VBC at this time to allow time for their office transition and avoid potential problems when TADs will no longer be used for submitting claims.
3. Claim Denials:
With the implementation of each Medicaid program, claim denials attributed to the transition and related systems changes have been identified, corrected, and affected claims recycled. During these implementation periods and thereafter, we have also identified provider billing errors that have caused claim denials. In an effort to assist you with resubmitting denials and ensuring that future claims submittals are accurate,
some of the more prevalent denials are listed below by program:
| Code |
Description |
Program |
Comments |
| 092 |
Invalid/Missing Modifier |
Home Health
Ambulance
|
Newly required modifiers are missing from the claim
Billing without required modifiers. Which was effective 03/15/03 |
| 136 |
No Eligible Service Paid |
RHC/FQHC |
Not including supporting detail codes on
KIDMED Svcs subsequent lines of claim - KIDMED encounters must be accompanied by detail medical screening procedure codes on the claim |
| 232 |
Procedure Code Not on File |
Dental |
EPSDT procedures are billed and EPSDT is not indicated at the top of
the ADA 2002 claim form OR when "0" instead of "D" is used for the first digit of the procedure code. |
| 234 |
Procedure Age Restriction |
Dental |
EPSDT procedures are billed and EPSDT is not indicated at the top of the claim form |
| 232 |
Procedure Code not on File |
All |
Billing codes that have been deleted
with HIPAA implementation |
| 269 |
Anesthesia CPT Not Covered |
Physician |
Billing ASA CPT procedure codes rather
than surgery CPT procedure codes prior to 10/01/03 |
| 248 |
Deleted, Bill Current Code |
All |
Using old local procedure codes instead of
using new HIPAA codes after implementation date |
| 298 |
Invalid Procedure Code for Date |
All |
Using old local procedure codes instead of
using new HIPAA codes after implementation date |
| 603 |
Tooth Code/Oral Cavity
Designator Required |
Dental |
Not using OCD field properly |
| 613 |
Invalid Tooth Code/Oral
Designator |
Dental |
Using Tooth Code field and OCD field
Incorrectly |
| 615 |
Rebill with Primary Code |
Physician |
Billing "add on" procedure codes without
the primary code required for billing the "add on" code |
| 702 |
New Patient/Established
Patient Code Conflict |
KIDMED |
Not using established patient procedure
codes with billing for established patients - codes are divided into new patient and established patient codes and should be used appropriately |
| 813 |
Exact Duplicate Error |
Physician |
When billing for anesthesia services for a
delivery, 59410 is billed on one line and 59410-47 is billed on a second line. Code 59410-47 should be billed for the delivery and the anesthesia. |
Please use this information to resubmit any of these denials at this time to avoid potential timely filing issues.
NOTE: Questions concerning these or other claim denials may be directed to Unisys Provider Relations at (800) 473-2783 or (225) 924-5040.
CPT Code 92065
CPT code 92065 (orthoptic and/or pleoptic training, with continuing medical direction and evaluation) can only be billed if the place of service (POS=11) is the physician�s/optometrist�s office and performed 1 on 1 with the patient.
CPT Code G0202
Effective with the date of service July 1, 2003, CPT code G0202 for Screening Mammography was made payable on the professional component file at a fee of $48.69. This code is restricted to crossover claims.
Ultrasound Policy Change
The policy limiting the number of ultrasounds during pregnancy was changed effective with date of services 10-01-2003. Claims that inappropriately denied were recycled and appeared on the RA of 02-17-2004.
Facility Self Report
Health Standards (HSS) has recently completed the development of a web-based program which will allow Nursing Home and ICF/MR providers to submit via the Internet required reports of alleged neglect, abuse, injuries of unknown source and/or misappropriation of resident property. Injuries of unknown origin, which are required to be reported to HSS, are defined as those injuries which meet the following two conditions:
The source of the injury was not observed by any person or the source of the injury could not be explained by the resident;
AND the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma).
All injuries of unknown origin not meeting the two conditions noted above are required to be
investigated by the facility and documentation of their investigation is maintained in the facility.
There are two pilot groups currently testing the program. Please stay tuned for more information and directions once the pilots have been completed.
As a result of the development of the web-based program the ABO1 and ABO2 have been revised. The newly revised form has been placed on the following website
http://www.dhh.state.la.us/hss/ltc_publications.htm
.
DME Rental Equipment to Require Prior Authorization
Effective immediately, all durable medical equipment (DME) approved as rental equipment will be approved by the Prior Authorization Unit (PAU), and must be billed by the provider, using the appropriate procedure code and the RR modifier which designates it as rental equipment.
Because of this change, the Prior Authorization Unit will no longer require an anticipated delivery date from the DME provider. Instead, a span date will be given by PAU. The provider must deliver the equipment prior to the end of this span date or the authorization will no longer be valid. The actual date of delivery must be indicated on the claim as the date of service.
If the equipment has already been delivered by the provider prior to the request, the actual date of delivery should be indicated on the prior authorization request form.
Providers should never delay delivery of equipment or supplies until after payment is received, but should make delivery as soon as possible after receiving notification of approval for payment from PAU. Providers may deliver the equipment or supplies, at the provider�s own risk, prior to receiving authorization from
PAU.�
DME Procedure Code Clarification
Payment for both open and closed system suction catheters are currently being authorized by the Prior Authorization Unit (PAU) and billed by providers using procedure code A4624. Payment for facial prosthetics are being authorized and billed using procedure code L8499.
We have identified valid, HIPAA compliant procedure codes that are more appropriate. We have placed these codes in pay status, effective January 1, 2004. Providers should begin using these codes immediately, as appropriate.
Procedure code A4609 should be used for a tracheal suction catheter for less than 72 hours use in a closed system. The reimbursement fee is $10.01 per catheter. Procedure code A4610 should be used for a tracheal suction catheter for 72 hours or more of use. The reimbursement fee is $15.64 per catheter. Procedure code A4624 should be used for a tracheal suction catheter, any type other than a closed system. The reimbursement rate is $1.76 per catheter.
Procedure code L8040 should be used for a nasal prosthesis. The reimbursement rate is $1,352.99 for the initial fitting, $1,285.34 for a replacement including new impression/moulage, and $541.18 for a replacement using a previous master model. Procedure code L8041 should be used for a midfacial prosthesis. The reimbursement rate is $1,630.81 for the initial fitting, $1,549.26 for a replacement including new impression/moulage, and $541.18 for a replacement using a previous master model.
Procedure code L8042 should be used for an orbital prosthesis. The reimbursement rate is $1,832.37 for the initial fitting, $1,740.75 for a replacement including new impression/moulage, and $732.95 for a replacement using a previous master model.
When considering authorization request for these procedures, PAU will use the current criteria for catheters and prosthetics when making a determination of medical necessity.
Maintaining Primary Care Physician Referrals
Our Program Integrity staff has been conducting field audits on Durable Medical Equipment providers and has found in some cases, the provider is not maintaining a copy of the primary care physician�s referral. This is a requirement under the CommunityCare Program. Failure to maintain a copy of a referral is grounds for recoupment of money paid for services, equipment and supplies, as well as imposition of other sanctions as a result of the provider not adhering to Medicaid Policy.
It is not necessary to have a referral from the primary care physician prior to submitting a request for authorization of payment to the Prior Authorization Unit (PAU). However, a referral must be obtained and maintained on file prior to billing, since all conditions required for payment must be met prior to billing.
CommunityCARE Clarification for All Providers
A. High Level Emergency Room Visits
It has come to our attention that some hospitals are requesting post-authorization for high level emergency room visits (99283, 99284, 99285). High level emergency room visits and associated services
do not require post authorization by the PCP. Claims that are associated with a high level emergency room visit should be identified by the presence of a �3� indicator in locator 11 of the UB 92 or by �3� in 24I on the CMS 1500. PATIENTS MAY NOT BE BILLED FOR THESE VISITS.
B. After the Fact Referral/Authorizations for Regular Office Visit
The PCP is the �enrollees� medical home.Sspecialty services should typically be ordered by the PCP once the PCP has seen the patient for their complaints and determined that specialty care is needed. Providers who deliver non-emergent services to CommunityCARE enrollees without proper referral/authorization from the PCP before providing the services are at risk for non-payment. PCPs are not expected to routinely provide after-the-fact referral/authorizations for these types of visits. PCPs are responsible for requesting medical documentation supporting the need for an after-the-fact referral/authorization. Patients who present for or request appointments with a provider who is not their PCP (and that provider does not have an appropriate referral/authorization) should be redirected to their CommunityCARE PCP.
C. Verbal (phone) Authorizations
CommunityCARE policy requires referral/authorizations to be written. PCPs should not give phone authorization unless there is some extenuating situation. A written referral/authorization must follow the verbal approval in those situations. Both CommunityCARE and non-CommunityCARE providers are subject to post-payment review to ensure that written authorization is obtained/given for services that are not provided by the PCP.
D. Who is Enrolled in CommunityCARE
As of December 1, 2003, the CommunityCARE program has been implemented statewide.
Approximately 80% of all Medicaid eligibles are enrolled in CommunityCARE and are linked to a CommunityCARE Primary Care Physician
(PCP). Therefore, the CommunityCARE program impacts the reimbursement and practice of all Medicaid providers in every area of the state, not just CommunityCARE-enrolled PCPs.
All Medicaid providers should become familiar with the program, and read all remittance messages and Provider Update articles concerning CommunityCARE.
E. How do I know which PCP a recipient is linked to?
Providers can find out which PCP a patient is linked to when they check the patient�s Medicaid eligibility using any of the Medicaid eligibility verification systems, ie; REVS, MEVS and the web application, eMEVS. This information should always be checked prior to providing services to any Medicaid recipient. If there is not a PCP listed, then the patient is not in CommunityCARE, and a PCP referral is not needed.
CP-0-92 and RS-0-07 Available Online
In January and February, notices were sent out to all CommunityCARE providers advising that the monthly CP-0-92 and RS-0-07 reports would no longer be available on hard copy. These reports are now available online and will no longer be sent to providers who have web access. To access these reports online, go to the Louisiana Medicaid website at
www.lamedicaid.com and register for a log-in and password. If you already have a log-in and password for the site, it is not necessary to re-register. If you have difficulty accessing or utilizing the site, you may call 877-598-8753 for technical assistance. Please note that each month you will need to download a copy of your report to keep for your files, as only the current and previous month�s reports will be available. There will be no access to reports more than one month previous. All Medicaid payment records must be kept for a minimum of five years. We are encouraging all PCPs to begin utilizing this convenient tool for accessing their CP-0-92 and RS-0-07 reports.
As we have moved from hard copy reports to electronic on-line reports, we have received a number of provider calls informing us that the Unisys watermark on each page is causing difficulty in two areas: (1)ectended printing time and (2) information on the page is un-readable beacuse the watermark prints too darkly. As a result of your concerns, the watermark is being removed from the report pages. This change will take place for the May 2004 reports.
As we move toward on-line access to information, we want to encourage all providers to review the on-line capabilities accessible to your staff and consider making changes if appropriate. It will be advantageous for your staff needing Medicaid information to have the ability to have on-line access, including search capabilities, to obtain needed recipient information for the current month.
Clarification of Telephone Number Appearing on the Recipient Medicaid ID Card
During the initiation of Medicaid plastic ID cards in 1998, some initial ID cards were printed with an incorrect, transposed telephone number for recipient use when inquiring about the Medicaid card or the Medicaid program. This number is found on the back of the card.
The error was caught quickly, corrected, and those cards printed with the error were reissued with a notice to the recipients to destroy the original card and begin using the corrected card.
Recently, we were notified that apparently some individuals kept the erroneous phone number and have begun using it again as calls are being placed to that phone number.
The correct telephone number for these calls is 1-800-834-3333. If you are attempting to assist your Medicaid patients by providing them with contact phone numbers, please ensure that you provide them with this correct number for any issues concerning the Medicaid card or the Medicaid program, and discard any other telephone number you may have for this contact point.
Safe Haven Relinquishments - Summary of Information
What is a safe haven?
A safe haven refers to a designated emergency care facility where a parent may anonymously leave his or her infant child. Louisiana is one of 41 states that have passed safe haven laws between 1999 and August 2002 in response to the apparent growing national trend of young mothers discarding their newborn babies in dumpsters and alleyways. The Louisiana law, which initially passed in April 2000 and was revised in the 2003 legislative session, is entitled �Safe Haven Relinquishments.�
This law gives parents a mechanism to safely and anonymously relinquish the care of their newborn to the state without fear of prosecution. Ordinarily a parent could be charged with criminal abandonment for leaving an infant with no intent to return. However, this law provides the relinquishing parent an affirmative defense against criminal abandonment if the circumstances meet the criteria for �Safe Haven Relinquishments� as spelled out in Chapter 13, Articles 1149-1160 of the Louisiana Children�s Code. By placing the infant in the hands of an employee at a safe haven, the parent is in essence voluntarily relinquishing his or her parental rights to the child for the ultimate purpose of adoption.
What are the requirements for a Safe Haven Relinquishment?
In order to qualify for a Safe Haven Relinquishment, the infant must be unharmed and less than 30 days old with no signs of abuse or neglect. It is important to note that the infant must be left in the care of an individual at a designated emergency care facility without a statement of an intention that someone will return for the child.
If the baby is left unattended, for instance on a doorstep or in a bathroom, it will not meet the criteria for a safe haven relinquishment.
What is a �designated emergency care facility?�
A designated emergency care facility includes any hospital licensed in Louisiana, public health unit, emergency medical service provider, medical clinic, fire station, police station, pregnancy crisis center, and child advocacy center.
Does the parent have to provide any information?
As prescribed by law, a parent, when bringing the baby to a safe haven, will be able to leave the child with an employee without having to give any information. At that moment, the employee receiving the child will give the relinquishing parent a card prepared by the Department of Social Services, Office of Community Services. This card will contain a toll-free number, 1-800-CHILDREN, (1-800-244-5373) for parents to call for more information. The parent can call to get answers to any questions or concerns regarding legal rights, including how to reclaim the child if they change their mind, or about how to initiate future contact with the child. They will also be given information on how to access confidential counseling, should they so desire. There will be a section on the card by which the designated emergency care facility can provide its name and phone number. The relinquishing parent, who chooses to provide any genetic or medical history, information on prenatal care, or the name of the father, will be able to do so anonymously by calling either the toll free number or the facility where the child was relinquished. Under the state�s law, this information can never be used against the parent in any way. Instead, these facts will be used to help provide better care for the baby as well as notify the birth father of his parental rights, if he is named.
What happens to the child?
If a child is relinquished to any designated emergency care facility other than a hospital, the child is to be transported immediately to a hospital for medical assessment and treatment. After a child is received, the representative of the designated emergency care facility shall immediately notify the Department of Social Services, Office of Community Services, of the relinquishment.
Upon notification, the Department will initiate legal proceedings to obtain custody of the child. Upon discharge, plans will be implemented to place the child with an adoptive family.
What are the responsibilities of designated emergency care facilities?
A designated staff person needs to be available during regular hours with knowledge about safe haven responsibilities, requirements and protocol for the facility. During non-business hours, designated staff will be available by phone. They also need to make sure that all staff persons are familiar with the safe haven contact person and emergency procedures.
They are responsible for providing the parent the �Safe Haven Card� provided by the Department of Social Services, including the name and phone number of their facility.
They are also to have medical/genetic forms available (provided by the Department of Social Services) for parents to complete should they chose to provide this information.
Finally, they are to notify their local Department of Social Services when the child is received, and ensure that confidentiality of the parent and the child are maintained.
What are a hospital�s responsibilities?
In addition to their responsibilities as a designated emergency care facility, hospitals receiving relinquished infants are responsible for the completion of a comprehensive medical examination including but not limited to HIV, hepatitis, fetal alcohol, and drug testing, if suspected. They are responsible for the assessment of abuse or neglect (and if suspected, are to make a report to their local parish Office of Community Services as per established mandatory child abuse reporting laws).
Finally, they are required to notify the Bureau of Vital Statistics for issuance of a birth certificate, unless it is known that one has already been issued. Unless otherwise known, the infant shall be presumed to have been born in Louisiana.
Where can I find more information?
For more information about safe haven relinquishments, call the Prevent Child Abuse Louisiana crisis line at 1-800-CHILDREN (1-800-244-5373) or your local parish Office of Community Services. Furthermore, the Department of Social Services and its community stakeholders have developed a written protocol for the implementation of this law, which we plan to make available via the internet at
www.dss.state.la.us in the near future. You will soon find this information near the bottom of the DSS home page under �Departments, - Office of Community Services�. Safe havens will be one of the services that will be listed. This site will provide training material and a facsimile contact information card for designated emergency care facility staff. Please note that additional contact cards for designated emergency care facility staff can be obtained from the local Regional Offices of Community Services in the near future as well.
You may contact the Prevent Child Abuse Louisiana crisis line at 1- 800-CHILDREN (1-800-244-5373) to obtain the phone number or address of the appropriate regional OCS office.
Long-Term Personal Care Services Program
The Louisiana Medicaid Program has implemented a new optional service program called Long Term- Personal Care Services (LT-PCS) Program. The LT-PCS Program is designed to provide assistance with personal care tasks to qualified Medicaid recipients so that they may continue to live at home or return home from a nursing facility.
In order to determine whether the recipient meets the qualifications for services, a 90-PCS form must be completed by the recipient�s primary care physician. If the recipient has a diagnosis of mental illness or mental retardation, a Level 1 Screen for Preadmission Screening and Annual Resident Review (PASARR) forms must also be completed by the primary care physician. The 90-PCS form is similar to the 90-L form that is currently used to determine the level of care for a home and community based waiver slot or admission to a nursing facility. The Level 1 Screen for PASARR is used to determine if a nursing facility is an appropriate placement for an individual with a diagnosis of mental illnes or mental retardation. It is at the descretion of the physician to decide is an office visit is necessary to complete the 90-PCS forms and the Level 1 Screen for PASARR.
On the 90-PCS form, the physician will be asked to provide a medical history, identify the recipient�s functional limitations, and give his/her medical opinion on whether the recipient meets the admission requirements for a nursing facility and whether the services offered by the LT-PCS Program are adequate to meet the recipient�s needs. Since level of care is a determining factor in establishing the recipient�s qualifications for personal care services, it is imperative that you complete Section III on the 90-PCS form in its entirety.
The 90-PCS form and a fact sheet describing the LT-PCS Program will be mailed directly to your office by Affiliated Computer Services (ACS), the independent agency contracted to assist the Medicaid Program in the management of the LT-PCS Program. We are requesting that you promptly complete and return the 90-PCS form and the Level 1 Screen for PASARR, if applicable, to ACS in the stamped, self-addressed envelope that will be included for your convenience
Your cooperation and participation is vital to the success of the LT-PCS Program. If you have any questions regarding the 90-PCS and/or the Level 1 Screen for PASARR forms, you may contact the ACS representative at the telephone number indicated on the 90-PCS cover letter or contact the Program Operations Section at (225) 342-9485.
Louisiana Drug Utilization Review (LADUR) Education
Age-Related Macular Degeneration: Past, Present and Future
By Lisa Digioia-Ross, Pharm.D. Assistant Professor of Pharmacy Practice at University of Louisiana Monroe
and Robert D. Ross M.D., F.A.C.S. Physician and surgeon of the retina, macula and vitreous
Issues...
� Macular degeneration is a condition that can cause permanent loss of central (detail) vision.
� A test that is frequently used to detect even the smallest changes in vision is the amsler grid.
� Researchers theorize that ARMD may end up being treated with an array of drugs and/or approaches much like cardiologists treat heart disease.
Age related macular degeneration (ARMD) is the most common cause of severe visual disability in patients over 65 years old in developed countries, surpassing diabetic retinopathy and glaucoma combined. Macular degeneration is defined as a condition that can cause permanent loss of central (detail) vision. There are approximately13.5 million people in the U.S. who have ARMD and 200,000 new cases of the "wet type" are diagnosed each year. The pathophysiology is multi-factorial and, in addition to age, includes previous diagnosis in the fellow eye, diet, UV and blue light exposure, associated systemic vascular disease, compromised choroidal circulation, female sex, light fundus pigmentation, fair hair and skin, smoking, and genetic factors. In some cases, ARMD advances slowly causing little noticeable effect on vision; although in other cases, it advances quickly producing vision loss in one or both eyes. Macular degeneration alone does not result in total blindness. To better understand this disease, the anatomic and physiologic function of the retina should be reviewed briefly.
The retina has two parts, the peripheral retina and the macula. The choroid is the blood vessel layer under the retina that helps to supply it with oxygen and nutrition. The macula, located centrally and posteriorly, is histologically defined as having a multilayer ganglion cell zone. The center of the macula is called the fovea. This is an area devoid of retinal blood vessels which enhances visual resolution. The fovea is located near the optic nerve and makes up a very small area of the retina. In order to see fine detail, one would look straight ahead using the fovea area for central vision. The fovea is 100 times more sensitive to detail than the peripheral retina and is the only way to see small detail clearly. Activities that require fine detail or central vision include reading, threading needles, recognizing people's faces and driving. Macular degeneration is a condition that can cause permanent loss of fine detail vision, either slowly or very quickly, with pronounced vision deficits, unilaterally or bilaterally.
ARMD may be detected by viewing the macula with an ophthalmoscope and observing the characteristic fundus findings. Fluorescein angiography is also used to diagnose ARMD. It involves a dye injection into an arm vein that travels through the body to the eye. A special camera is then used to take photographs of the retina and provides the physician with a map of the eye vessels, including the vascular changes indicative of ARMD. Another test that is frequently used to detect even the smallest changes in vision is the amsler grid. If an area of the grid appears distorted or a dark gray spot is seen, this may be indicative of macular degeneration. Amsler grids are usually given to ARMD patients to help them self-monitor the progression of their disease.
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How to Use
the Amsler Grid
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|
1.
You should look at your amsler grid each morning and check both eyes.
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| 2.
Use the same lighting and put on your regular reading glasses each time.
If you wearbifocals, use the bottom portion (the reading portion of the
glass)
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| 3.
Cover your right eye.
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| 4.
Hold the grid at your usual reading distance about 12 to 14 inches
from your face.
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| 5.
Look only at the black dot in the center of the grid.
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| 6.
All the lines on the grid should be straight and unbroken. If any lines
around the dot are wavy, choppy,
blurred or distorted or if a dark spot appears on the grid, tell yourophthalmologist
promptly.
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| 7.
Cover your left eye and repeat the same steps above .
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Table adapted from reference #1, 9 and 14
Macular degeneration commonly occurs in two different forms, atrophic or non-neovascular ("dry") and exudative or neovascular ("wet"). The dry or non-neovascular form of macular degeneration occurs when there is a progressive buildup of light oxidized indigestible waste products of photoreceptor metabolism called drusen. Macular degeneration often starts with the appearance of drusen in the macula, although drusen itself usually does not significantly affect vision. Approximately 90% of ARMD constitutes the dry type, although atrophic ARMD produces significant vision loss in only 10 % of patients. There are currently no treatments available to reverse this degenerative process. However, a landmark clinical trial, The Age Related Disease Study, demonstrated that intake of a high dose combination of vitamins A, C, E, zinc and copper decreased the progression of ARMD over a 10 year period by about 25%. The dry type can ultimately progress to the wet form. True wet ARMD involves development of new blood vessels under the retina (choroidal neovascularization) which leads to breakdown of the blood ocular barrier, analogous to tree roots growing underneath concrete. This breakdown subsequently leads to a large exudative response associated with sub retinal blood, fluid and lipid. These elements, not normally present in the sub retinal space, lead to disruption of overlying retinal function with eventual scarification and loss of central vision.
Symptoms of the wet type ARMD include straight lines or edges appearing crooked and/or blurred, and may be followed by a central blind spot (scotoma). About 15% of people with sight loss experience visual hallucinations probably as a result of the brain trying to normalize the scotoma. Vision loss may occur in one or both eyes and can be either subtle or dramatic. Color vision is also adversely affected. There are a variety of low vision aids available commercially to help patients afflicted by vision loss secondary to
ARMD.
For many years, laser photocoagulation was the only clinically established effective treatment modality for choroidal neovascularization (CNV) in wet ARMD located outside the central foveal zone. Traditional thermal laser photocoagulation destroys CNV and, nonselectively, the overlying retina, thus attenuating the exudative phenomenon thereby improving central retinal function. Unfortunately, the retina overlying the CNV is thermally damaged leading to a scotoma located to the side of central vision. Fluorescein retinal angiography is used to guide laser treatment in wet ARMD by helping to identify the location of the CNV. Most cases of CNV, however, are not well delineated angiographically (occult or non classic CNV) and despite adequate laser treatment, a 50% recurrence rate is observed. Additionally, the majority of CNV will eventually grow into the fovea and, in this situation, destructive laser photocoagulation is not indicated, as immediate loss of central vision will occur secondary to laser induced retinal thermal damage. In reality, less than 10% of all CNV patients will benefit from laser photocoagulation.
Photodynamic therapy, or PDT, is another form of laser therapy and it involves the drug Visudyne�(verteprofin) by Novartis. Studies have demonstrated that photodynamic therapy with Visudyne� decreased the likelihood of moderate levels of vision loss compared to placebo treatments in patients with greater than 50% classic subfoveal CNV and thus was approved for use by the FDA in April 2000. More recent data analysis suggests efficacy in occult choroidal neovascular disease as well. The therapy works by attempting to selectively close the abnormal blood vessels and leave the normal retinal tissues relatively intact. It accomplishes this through a two-step process in which the drug Visudyne� is given by intravenous infusion and then activated by nonthermal or "cold" laser light which is directed toward the choroidal neovascularization through a contact lens placed on the cornea. Visudyne� (verteprofin), a light sensitizing medication, is a second-generation benzoporphryn photoactive molecule and selectively localizes to LDL receptors in CNV. Photo activation by a non thermal 689nm laser results in a photochemical reaction generating reactive oxygen species to cause local cellular and tissue damage, such as free radical formation, lipid peroxidation, endothelial damage and capillary closure, while sparing the overlying subfoveal retina. Some of the disadvantages of PDT are that vision improves only in a minority of patients and it may cause some ocular ischemic non-perfusion, re-growth of blood vessels, and other potential problems. Moreover, not all patients are candidates for this treatment. Studies are currently underway which examine ARMD patients who underwent PDT for choroidal neovascularization related to ARMD looking for internal limiting membrane changes (ILM). ILM changes may occur due to run off of free radical oxygen species causing a remote effect on the inner retina (where the ILM is located), farthest from the choroidal neovascularization. Post PDT ILM changes could suggest a lack of specificity of Visudyne� for choroidal neovascular membranes with potential associated remote inner retinal insult and visual morbidity.
Other experimental treatments for wet ARMD include: feeder vessel photocoagulation, thermotherapy, and various other antiangiogenic drug agents including Macugen� , rhu Fab� and intravitreal or retrobulbar Kenalog�.
Feeder vessel photocoagulation is performed with a diode laser set on a small spot size with a high repetitive rate focally directed to the afferent choroidal vessel supplying the neovascular membrane resulting in tissue edema and feeder vascular closure with minimal insult to the overlying retina. Feeder vessels can be identified using real time confocal and high speed-scanning laser ICG video angiography. Thermotherapy, more formally known as transpupillary thermotherapy or TTT, is for patients with occult choroidal neovascularization related to ARMD. TTT is primarily indicated for occult CNV in patients who do not fit the criteria for photodynamic therapy. This process involves use of a diode laser set on low power and a wide spot, which is directed at the CNV. Thermotherapy delivers attenuated infared heat energy to the CNV resulting in minimal damage to the overlying retina, and has been shown to decrease the sub retinal exudative response.
The latest approach to treating ARMD involves using drugs which strike at the molecular level. Researchers believe they have found some of the molecular switches that cause neovascularization in the eye and they hope to find a drug to turn off this process. Angiogenesis research dates back to the 1960's when cancer investigators hoped to find a way to go after molecules which create unwanted vessels, stop them from acting, and ultimately starve tumors of their blood supply. Today more than 80 diseases are believed to have angiogenic pathology including ARMD. In ophthalmology, VEGF (vascular endothelial growth factor) has been identified as a significant player in the angiogenic cascade that leads to the growth of blood vessels. Vascular endothelial growth factor, or VEGF, is a heparin binding glycoprotein discovered in 1983 which induces or stimulates angiogenesis and endothelial cell proliferation. Currently, three human trials involving antiangiogenic drugs are underway. Eyetech is developing a VEGF (vascular endothelial growth factor) aptamer (Macugen�), which is a chemically synthesized short strand of an RNA molecule, which binds to the VEGF protein preventing it from binding to its receptor. This drug is between phase 2 and 3 trials at the present time. Genentech is developing a VEGF antibody that is injected into the vitreous cavity of the eye. The antibody is called rhu Fab� and is a customized fragment of humanized anti-VEGF monoclonal antibody. "Rhu" stands for recombinant humanized fragment and "fab" is the antigen-binding portion of the monoclonal antibody. This drug is presently between phase 1 and 2 trials. Alcon is testing anecortave acetate, an angiostatic steroid which is a small molecule for sub-Tenon's periocular injection. It is currently in phase 2 trials. The drug is devoid of glucocorticoid activity but retains its anti-inflammatory properties. Its exact mechanism of action is unknown but one theory is that it inhibits the enzymes that blood vessels use to invade tissues. Intravitreal Kenalog� (triamcinolone) is a steroid injection into the vitreous cavity, while retrobulbar Kenalog�(triamcinolone) is an injection of steroid around the globe. Intravitreal and retrobulbar Kenalog�(triamcinolone) injections exhibit anti-angiogenic properties which can augment photodynamic therapy. Celebrex�, an anti-inflammatory drug, has prevented the growth of abnormal blood vessels associated with tumors. This agent may reduce swelling and reduce vessel re-growth in AMD, thereby enhancing the effectiveness of PDT. Studies have demonstrated the existence of an inflammatory response in the retina of patients with CNV as well as in the patients receiving PDT. Patients undergoing PDT therapy have vascular remodeling and a continued neovascular process; therefore, it is postulated that use of Celebrex� may be beneficial to these patients. Finally, surgical removal of the CNV and retinal translocation procedures have been developed which have demonstrated some efficacy. Pneumatic displacement, with or without intravitreal tissue plasminogen activator (t-PA),of CNV related sub-retinal hemorrhage has also been evaluated.
ARMD has become a major health issue over the last decade due to its increasing commonality, heightened public awareness, and its ability to cause severe visual disability. There is significant research time and money being directed at learning about and treating ARMD and new vision sparing treatment options have been discovered. Several of the newer treatment modalities involve experimental drugs and combinations of therapeutic modalities. Researchers theorize that ARMD may end up being treated with an array of drugs and/or approaches much like cardiologists treat heart disease. It is not likely that just one single drug alone will fix the entire problem. It is important for physicians and other health care providers to be aware of this disease and the drug treatment options which are presently approved and those on the horizon in order to help direct their patients accordingly.
References:
1. For my Patient: Macular Degeneration Booklet. The Retina Research Fund. San Francisco, California .1999.
2. Age Related Macular Degeneration. www.shreyas.freeserve.co.uk/amd.htm. 6/16/01.
3. Toth CA. Macular Translocation Surgery at Duke University Eye Center (12/20/00);
www.dukeeye.org/amd/handout.html. 6/16/01.
4. Harold V. Age Related Macular Degeneration: Status of Research (3/1997) at Department of Health and Human Services; www.nei.nih.gov/news/varmus.htm. 6/16/01.
5. Macular Degeneration at John Hopkins Medicine (May 2000). http://www.hopkinsmedicine.org/maculardeneration.html. 6/6/2001.
6. Visudyne�-Macular Degeneration: Drug Therapy treatment (12/13/00).
www.visudyne.com/about/index.html 6/16/01.
7. Ross RD, et al. Presumed Macular Watershed Vascular Filling in Patients with Age Related Macular Degeneration. American Journal of Ophthalmology.1998; 125:71-80.
8. Karmel M. Age Related Macular Degeneration (AMD) Under The Scope. Eyenet. May 2002: 29-34.
9. Mogk LG, Mogk M. Macular Degeneration, The Complete Guide to Saving and Maximizing Your Sight.1st. Revised Edition, New York, NY, Ballantine Publishing Group, 2003(1999).
10. Magdalena G, et al. Preventive of Experimental Choroidal Neovascularization with
Intravitreal Anti-vascular Endothelial Growth Factor Antibody Fragment. Archives of Ophthalmology.2002; 120(3): 338-346.
11. Mittra, RA. And Singerman, LJ. "Recent Advances in the Management of Age- Related Macular Degeneration". Optometry and Vision Science 2002; 79:218-224.
12. "Celecoxib to Treat Macular Degeneration in Patients Receiving Photodynamic Therapy."
www.clinicaltrials.gov..National Eye Institute: trial currently recruiting patients, 11/2003.
13. Transpupillary Thermotherapy for Exudative Age-Related Macular Degeneration. Iridex
Corporation document September 2001:1-15.
14. Macular Degeneration leaflet. American Academy of Ophthalmology. San Francisco, California. February 2002.