Provider Update

Volume 19, Issue 2 

April/May 2002

Compliance Date Extended for HIPAA Transactions and Code Sets

Overview of the Extension
On December 27, 2001, President Bush signed Bill H.R. 3323 now Public Law 107-105, extending the compliance date for one year until October 16, 2003 for the electronic transactions and code sets standards under HIPAA. Small health plans received no extension. ALL covered entities that bill electronically are affected. This change does not affect the Privacy compliance date of April 14, 2003. 

Covered entities that are prepared to begin HIPAA electronic transactions by the original October 16, 2002 compliance date may still do so as planned. The new law requires those seeking the delay to submit a "compliance plan" detailing why the delay is needed and how they will come into compliance by October 16, 2003.

The Department of Health and Human Services (HHS) published HIPAA Model Compliance Extension Form on March 29, 2002, which can be used by covered entities to request a one-year extension to the October 16, 2002 compliance date for standard transactions and code sets. The form (and a soon to be available electronic submission option) can be accessed at CMS' HIPAA site: .

HHS shall furnish all compliance plans to the National Committee on Vital and Health Statistics (NCVHS). Taking measures to protect all confidential information, the NCVHS shall select and analyze a representative sample of the compliance plans to determine the most common or challenging problems encountered by entities who submitted the plans. To assist all entities in becoming HIPAA compliant, the NCVHS will disseminate written reports to the public containing effective solutions to the selected compliance problems.

An entity who fails to submit a plan, and is not compliant with the applicable requirements by October 16, 2002, is subject to penalties and/or exclusion from participation in Medicare. An entity may also be excluded if it fails to begin testing by April 16, 2003. 

What must be in the plan for extension?
The compliance plan per DHHS' published form includes the following conditions:
� The extent to which the covered entity is not in compliance; and the reason for non-compliance.
� A budget, work-plan, schedule and implementation strategies for accomplishing compliance.
� Whether the entity plans to use a contractor or other vendor to assist the entity in achieving compliance. 
� Testing timetables which are to begin no later than April 16, 2003 (only six months past the original compliance date).

What is the position of Louisiana Medicaid regarding the extension? 
Louisiana Medicaid has opted to file for the extension. This complex task has proven that the additional time will be beneficial in meeting the meticulous demands necessary in properly making the needed policy, procedural and system changes to reach full compliance. 

Should providers request the extension?
When considering the option to request an extension for the electronic transactions and code sets standards, a covered entity should conduct a careful analysis to determine its status in the HIPAA process, as well as the status of its trading partners. Many covered entities have developed an implementation strategy based on their trading partner's prior commitments. 

If compliance by the original deadline date of October 16, 2002 is not certain, we strongly recommend you submit the extension plan while continuing to progress towards the earlier implementation date. Any break in activities may hinder timely success and increase overall costs.

Our goal is to keep the provider community informed of the required changes to our system and business processes. More information will be disseminated as it is developed. 

Important Points
� Covered entities that will be compliant by the original compliance date of October 16, 2002, should not submit a compliance plan.
� Covered entities opting to file a compliance plan may do so anytime before October 15, 2002 using the model plan published by DHHS.
� Entities that are not compliant and have not submitted a compliance plan by October 16, 2002, are subject to exclusion from participation in Medicare. 
� HHS could impose monetary penalties as a result of non-compliance.
� The Privacy Standards compliance date of April 14, 2003 is unaffected by this extension.

* Text of H.R. 3323 is available on the congressional web site:*

Where can I find out more? -- Administrative Simplification - Institute for Health Care Research & Policy, Georgetown University - American Health Information Management Association (AHIMA) 
www.hl7 -- Health Level 7 for the exchange of key sets of clinical and administrative data. -- Responsible for developing retail drug standards. -- Implementation guides for proposed standards - American Medical Association -- Supports the Accredited Standards Committee responsible for developing transaction and code set standards. -- National Uniform Claims Committee -- National Uniform Billing Committee - National Committee on Vital and Health Statistics - HIPAA Advisory - Centers for Medicare and Medicaid Services (formerly HCFA)

Question Corner

PCS Providers

1. What is the difference between PCA and PCS?

PCA services through the MR/DD Waiver provide assistance to the individual with eating, bathing, dressing, personal hygiene, and activities of daily living and must be identified on their comprehensive plan of care.

EPSDT Personal Care Services (PCS) are defined as tasks that are medically necessary as they pertain to an EPSDT eligible�s physical requirements when physical limitations due to illness or injury necessitate assistance with eating, bathing, dressing, personal hygiene, bladder or bowel requirements.

EPSDT PCS are not provided to meet child care needs nor as a substitute for the parent in the absence of the parent.

A parent or other care giver must be in the home with an EPSDT eligible 
fourteen years of age or younger.

EPSDT PCS are not allowable for the purpose of providing respite care for the primary care giver.

EPSDT does not include medical tasks.

2. What is the reimbursement rate for PCS?

The reimbursement rate for PCS providers is $4.05 per unit (thirty minutes), $8.10 an hour.

3. Who is eligible for PCS?

The person must be a categorically eligible Medicaid recipient, birth to twenty-one years of age (EPSDT eligible), and have been prescribed EPSDT PCS as medically necessary by a physician. The physician shall specify the health/medical condition which necessitates EPSDT Personal Care Services (PCS).

Note: All PCS services require Prior Authorization. 

Policy for Exchanging Identifying Information Over the Internet
FIMS # 6482 - RA Message 1/15/02, 1/29/02, 2/5/02, and 2/12/02 

It has come to the Department�s attention that some providers are sending identifying Medicaid patient information over the Internet that may or may not be encrypted. Do not send any identifying information (e.g., name, social security number, Medicaid numbers, etc.) over the Internet unless the information is encrypted. 

Recipients With TPL Coverage
RA Message 5/7/02

The Unisys Provider Correspondence Unit is receiving numerous requests to update TPL information as well as assign a six-digit TPL carrier code for certain companies. In many of these cases, the information is and has been on file for some time. Please remember that providers should check recipient eligibility, which includes the recipient�s TPL segment, through MEVS and/or REVS to obtain or verify the name of the third-party insurance carrier and the associated TPL code. (Providers are mailed a TPL listing at the beginning of the year. The listing is updated mid-year.) The carrier code and TPL payment should be placed in the appropriate box of your claim form. For questions or concerns, please contact Provider Relations at 1-800-473-2783. 

Louisiana Medicaid Paper Claim Form Submission Procedures

Unisys Louisiana Medicaid has implemented new and improved claims data capture technology to 
better serve the Louisiana Medicaid Provider Community. All Louisiana Medicaid paper claims are now scanned and stored on-line.

This process allows the Unisys Provider Relations Department to respond more efficiently to claim inquiries by facilitating the retrieval and research of submitted claims.

If you cannot submit claims electronically, prepare your paper claim forms according to the following instructions to ensure appropriate and timely processing.

� Submit an original claim form whenever possible. Do not submit carbon copies under any 
circumstance. If you must submit a photocopy, ensure that it is legible, and not too light or too dark.
� Enter information within the appropriate boxes and align forms in your printer to ensure the correct 
horizontal and vertical placement of data elements within the appropriate boxes.
� Use high quality printer ribbons or cartridges-black ink only.
� Use 10-12 point font sizes. We recommend font styles Courier 12, Arial 11 and Times New Roman 11. 
Do not use italic, bold, or underline features.
� Do not use a marking pen to omit claim line entries. Use a black ballpoint pen (medium point).

Note 1. We currently return illegible claims. The criteria for legible claims are that all information is readable for the normal eye and that essential information not be blocked out. 

Note 2. Electronic submission of claims is the most efficient and gives the provider a quicker 
turnaround on payment.

Objective Hearing and Vision Screenings
FIMS # 6908 - RA Message 3/11/02, 3/19/02, and 3/26/02

Effective immediately, the KIDMED objective hearing and vision screenings (codes 92551 and X9007) may be performed by trained office staff under the supervision of a LICENSED Medicaid physician, physician assistant, registered nurse, optometrist (for vision screening), or audiologist or speech pathologist (for hearing screenings). Please make these changes to your KIDMED policy manual. The interpretive conference to discuss findings from the screenings must still be performed by a licensed physician, physician assistant, or registered nurse as is currently the stated policy in the KIDMED manual. 

Nursing Facilities

The 42 CFR at 483.156 (b) (3) Registry of Nurse Aids mandates that the State must determine which individuals have successfully completed a nurse aide training and competency evaluation program or nurse aide competency evaluation program; have been deemed as meeting these requirements; or have had these requirements waived by the State but do not qualify to remain on the registry because they have performed no nursing or nursing related services for a period of 24 consecutive months. 

The Standards for Payment for nursing facilities states that biennially, the registry will verify that an individual has continued employment (performing nurse aide related duties) without a break in 
services for two years or more. Upon this verification, the certification will be renewed. 

The forms that must be used for the Louisiana Nurse Aide Registry are identified in the August 20, 1991 rule (Louisiana Register, Volume 17, Number 8). Form NAT-7 must be used by the nursing facility to notify the Registry of employment or termination (employment ceased) of Certified Nurse Aides.

Failure to submit these documents to the Louisiana Nurse Aide Registry upon employment/termination of a nursing assistant will be viewed as a deficient practice by the facility. Repeated offenses will result in adverse action for non-compliance. 

Professional Employees Limitations
FIMS # 6496 - RA Message 1/29/02, 2/5/02, 2/12/02, and 2/19/02

All providers are responsible for ensuring that their professional employees (ex. RNs, LPNs, CNPs, etc.) are practicing within the limitations established by their licensing boards.

Second Sonogram Allowed
FIMS # 6511 - RA Message 2/19/02, 2/26/02

Effective with date of pay 2-18-02, payment for a second complete sonogram per recipient will be allowed within a 270 day period when performed by a different provider.

A claim must have a diagnosis other than V22, V22.0, V22.1, or V22.2, be billed hardcopy, and have attachments justifying medical necessity in order to pend for medical review.

No changes were made to the remaining parts of this policy.

Clarification for Newborn Hearing Screening

Newborn hearing screening is required in all birthing hospitals in Louisiana by LA Revised Statute 46:2261. Administrative rules accompanying that statute (Louisiana Administrative Code-LAC 48:V. Chapter 22) specify that only certain types of personnel are allowed to provide hearing screening as described in the procedures cited below:

2209. Hearing Screening Procedures
A. Personnel. Hearing screening will only be performed by:
1. Board eligible or board certified physicians with special training in auditory 
brainstem response testing and/or otoacoustic emission testing and in infant hearing 
2. Audiologists licensed by the Louisiana Board of Examiners for Speech Pathology and 
Audiology with special training in auditory brain stem response testing and/or otoacoustic 
emissions testing and in infant hearing testing.
3. Persons trained and supervised by personnel meeting requirements for 2209.A.1 or 2. 

While the above individuals are allowed to perform the screening, to obtain Medicaid reimbursement for newborn hearing screening the following is required:

Medicaid providers (Physicians or Audiologists) are entitled to bill for newborn hearing screening if they own, rent, or lease the equipment used to conduct the test and they perform the professional 
component of the service. If the screening device used to perform this screening does not require the interpretation services of a doctor or audiologist, no claim for the professional component (modifier - 26) should be submitted. Additionally, no claim for the professional component should be submitted if a trained and salaried employee of the hospital performs the screening.

If a technician or nurse employed by the hospital performs the testing and the hospital owns, rents, or leases the equipment, the hospital may only bill the Medicaid per diem rate established for that 
hospital. If the hospital finds that the costs of the screening exceed the Medicaid reimbursement, at the end of each year they may either request an increase in the per diem rate or an additional cost 
settlement for salaries of those personnel.

Technicians under the supervision of an audiologist cannot bill Medicaid for newborn hearing 

So, while technicians cannot bill Medicaid for newborn hearing screening, in many settings they 
continue to perform the screening and are allowed to do so under appropriate supervision according to RS:46:2261.

Notice To Physicians and Pharmacists: Regional LADUR Committee

The Department of Health and Hospitals is currently accepting physician and pharmacist nominations for the Region 3 Drug Utilization Review Committee. The committee consists of three pharmacists and one physician who meet monthly to review profiles of drug usage from a therapeutic perspective and to clarify or send information to the medical community. Currently one physician opening and one pharmacist opening are available. We are requesting that the nominees be Louisiana Medicaid providers and practice in at least one of the following parishes: 

Acadia Allen Avoyelles Beauregard Calcasieu Cameron
Catahoula Concordia  Evangeline Grant Jeff. Davis Lafayette
LaSalle Rapides  Vermillion  Vernon      

Prospective committee members must have time available to meet monthly for one to three hours and must meet the following requirements:

� Doctor of medicine degree from an accredited U.S. medical school
� Licensed to practice in Louisiana as a medical doctor
� Board certification in their specialty
� No previous sanctions from the State of Louisiana

� Pharmacy degree from an accredited U.S. pharmacy school
� Licensed to practice in Louisiana as a pharmacist
� No previous sanctions from the State of Louisiana

Please print or type your nomination on this form in the space provided below and return the form as soon as possible to:

Unisys: Louisiana Medicaid
8591 United Plaza Blvd., Suite 300
Baton Rouge, LA 70809

(Brief resume appreciated)






I am nominating the above mentioned for consideration as a member in the LMMIS REGION THREE DRUG UTILIZATION REVIEW COMMITTEE.


Louisiana Drug Utilization Review (LADUR) Education

Who Defines �Quality of Life�?

By: Lesa W. Lawrence, PhD, Pharmacy Administration 
Assistant Professor - College of Pharmacy
The University of Louisiana at Monroe


� The health care industry has deemed it necessary to measure health-related quality of life in order to 
make economic decisions.

� Two components of quality of life are duration of life and physical, social, and psychological functional 

From the health care perspective, �quality of life� is one of those phrases that has become somewhat perplexing during the past decade. For its face value, �quality� means something that is of perceived value to someone and that can be described but not measured or quantified. However, in health care we have deemed it necessary to measure health-related quality of life in order to make economic decisions. So, who defines �quality of life�? Let�s first consider how it is defined in the ISPOR Lexicon that is published by the International Society for Pharmacoeconomics and Outcomes Research.

We have defined �quality of life� as �the value assigned to duration of life as modified by the impairments, physical, social, and psychological functional states, perceptions, and opportunities that are influenced by disease, injury, treatment, or policy�. (1) It is also known as health-related quality of life. Therefore, the answer to �Who defines quality of life?� is determined by who assigns the �value� to life as described in this definition. It is a multidimensional evaluation, by both intrapersonal and social-normative criteria, of the person-environment system of the individual. (2) 

In order to better understand this definition, let�s dissect it into two components. First, there is �duration of life as modified by impairments� that indicates a quantitative measure of how long someone can be expected to live given his or her disease state. This relies on research and statistical analysis of a sample of the impaired population. In order to do this, standard forms of measurement are developed, tested for validity and reliability, and administered to a sample of individuals fitting a specific operational definition. From this, duration of life is quantified and applied to an economic model to compare various forms of therapeutic interventions.

Next, there are the �physical, social, and psychological functional states, perceptions, and opportunities that are influenced by disease, injury, treatment, or policy�. Functional states are defined as �the extent to which individuals can perform normal or usual behaviors and activities, given their limitations due to health problems�. From this definition comes the challenge of defining �normal or usual behaviors�. The methodology employed here is a survey instrument such as a questionnaire administered to a �normal� segment of the population and then to an �impaired� segment of the population to determine the influence of disease, injury, treatment, or policy. From this, quality adjusted life years are determined based on one�s ability to perform activities of daily living such as bathing, dressing, toileting, transferring, and eating.

A measure of health related quality of life that is designed to be broadly applicable across diseases and health conditions, populations, and healthcare interventions and that summarizes an individual�s health across the various aspects of health-related quality of life is the generic quality of life (QOL) instrument. Examples include the SF-36 Health Status Questionnaire, the Functional Independence Measure, the Sickness Impact Profile, the Quality of Well-Being Questionnaire, and the Katz Activities of Daily Living. In addition to these health status instruments are condition-specific quality of life instruments such as the Migraine Specific Quality of Life, HRQOL for Parkinson�s Disease, and Quality of Life in Glaucoma Research. These measures are applicable to a single disease or health condition and summarize an individual�s health in the various areas most important to that clinical condition.

In cost analysis, a measure of the desirability of, or preference for, a particular health outcome or state is a utility. Utility measurement is an assessment of a patient�s preference for specific outcomes in relation to each therapy. Utilities are quantitative and are measured on a scale of 1.0 (perfect health) to 0 (dead), where the maximum and minimum levels are known as anchors. The most commonly used unit to express the results of cost-utility analyses is the quality-adjusted life year (QALY). One year at perfect health equals 1 QALY. One year at a health state that is rated by the patient as 40 percent of perfect health equals 0.4 QALY. (3) This is how the patient plays a significant role in the determination of �quality of life� as it relates to outcomes. 

Other determinants to outcomes include patient, provider/practitioner, community, and health system factors. Patient factors are biological variation, sociodemographic, and lifestyle/behavior. Biological factors are the patient�s genetic health-related factors and are generally beyond the control of providers. They include familial predispositions to heart disease, cancer, or other diseases. Sociodemographic factors are patient characteristics such as age, sex, and race that are associated with increased or decreased prevalence of different diseases. Lifestyle/behavior are patient health-related influences such as smoking, diet, and sexual behavior that are typically beyond the control of providers but which may be influenced by providers. Provider/practitioner determinants of outcomes are hospital or physician factors which may contribute to a variation in patient outcomes. Hospital factors include availability of certain services or products, experience with specific patient diagnoses, size, teaching status, and location. Physician factors include specialty type, experience with specific patient diagnoses, board certification, and year or era of initial medical training. Community outcome determinants are local, geographic-specific factors typically beyond an individual provider�s control. Health system factors are national or regional in nature and influence access to care as well as its cost and quality. (4)

Closely aligned with quality of life are patient centered outcomes that are measures focusing on the effectiveness perceived by the patient of the care offered by practitioners. Patient satisfaction emphasizes the collection of data in several domains such as care of physical needs, pain management, communication, education, respect for patient preferences, emotional support, family involvement, and preparation for hospital discharge. Quality of care is the evaluation of medical providers according to the degree to which the process of care increases the probability of outcomes desired by patients and reduces the probability of undesired outcomes. Which elements of patient outcomes predominate depends on the patient condition. Expressing a provider�s pattern of practice as a rate, some measure of use or outcome aggregated over time for a defined population of patients under the provider�s care, results in a practice profile. This profile relates back to the initial concept of who defines quality of life (QOL).

As defined, QOL is a health outcome measure that focuses on how the patient experiences an illness (i.e. discomfort, decreased function). QALY expresses the number of life years gained as a result of a health-care intervention, weighted by the quality of life (utility) experienced during those added years. Included in both of these definitions is the subjective measure of how a patient experiences life and illness. While not all pharmacoeconomic measures depend on QOL or QALY, they remain an ingredient in many cost analyses either directly or through some form of indirect or intangible cost inclusion. Grief, family problems, changes in social function, apprehension or anxiety, pain, and suffering are considered intangible costs. 
One of the most widely used QOL scales is the SF-36. It was constructed to satisfy minimum psychometric standards necessary for group comparisons involving generic health concepts. The underlying model for the SF-36 has three levels which are items, eight scales that aggregate 2-10 items each, and two summary measures that aggregate scales. The eight scales are hypothesized to form two higher-ordered clusters. Factor analytic studies have been used to demonstrate that the scales account for 80-85% of the physical and mental health variance in the US population. The SF-36 has also been shown to operate with about 80-90% empirical validity. (5) The eight dimensions measured are:

� Physical functioning
� Role limitations due to physical problems
� Social functioning
� Bodily pain
� General mental health
� Role limitations due to emotional problems
� Vitality
� General health perceptions

An even shorter version of the SF-36, the SF-12, has been shown to capture about 85% of the reliable variance for QOL measurement. It is used whenever a one-page scannable survey form is most practical. 

Even with its reliability and validity clearly in tact, quality of life scales have been criticized by some researchers as not allowing patients to comment on how they feel instead of just answering questions. A review of the literature showed that six out of 75 research articles included patients� assessment as to the importance of the items assessed.(6) Researchers asked about what symptoms were present and not about how these symptoms bothered patients. This is seen as a limitation of QOL measurement tools by some researchers. 

Because of a lack of clear understanding among researchers as to what quality of life is, a meta-search of literature showed that fewer than 5 percent of all randomized controlled trials included a quality of life measure. For studies involving cancer, this was below 10 percent. Even though quality of life measurement is increasing, 0.63 percent in 1980 to 4.2 percent in 1997, it is still a challenge for research design. (7) This is expected to continue to improve as more data on the reliability and validity of QOL scales are accepted as a critical part of medical research. The trade-off here is to replace more subjective scales with more objective scales. 

One of the objectives of providers/practitioners is to improve quality adjusted life years. In order to make the best decisions for patients, research on quality of life provides data or evidence that a therapeutic intervention will have a positive outcome on a patient�s quality of life. Therefore, a quality of life outcome or endpoint is defined as �a consequence of the use of a health care intervention that affects the patient�s physical functioning (including extent and severity of symptoms and physical capacity), social functioning (including role function or employment), and/or psychological or emotional functioning or functional status, as well as the patient�s perceptions of these�. (8) From this definition, it becomes evident that quality of life still lies very much in the perceived values assigned to life as defined by patients themselves. Therefore, from the basis of patients� quantitative assignment of value to quality of life will come more pharmacoeconomic models that incorporate the patient�s quality of life as a significant endpoint. 


1. Pashos, Chris; Klein, Eric; Wanke, Lee. ISPOR LEXICON, First Edition, 1998.

2. Lawton, M. P., �A Multidimensional View of Quality of Life in Frail Elders.� In J. E. Biren et al, eds., The Concept and Measurement of Quality of Life. New York: Academic Press.

3. ISPOR LEXICON, First Edition, 1998.

4. ISPOR LEXICON, First Edition, 1998

5. Ware, JE, Sherbourne CD. �The MOS 36-Item Short-Form Health Survey. Conceptual Framework and Item Selection.� Med Care 1992;30:473-83.

6. Gill TM, Feinstein AR. �A Critical Appraisal of the Quality of Quality-of-Life Measurements.� JAMA 1994;272:619-26.

7. Sanders, C et al. �Reporting on Quality of Life in Randomized Controlled Trials: Bibliographic Study.� British Medical Journal, Oct 31, 1998, p1191.

8. ISPOR LEXICON, First Edition, 1998.