APRIL 1991

Provider Relations' Telephones Provider Training
Recipient Eligibility Verification System Competency Testing
Billing Procedures EMC Submission Schedule
Professional Services Certification Physicians Reminder
Specimen Collection and Handling Injections
Additional CPT-4 Procedure Codes for Optometrists Theophylline
Vasocon A New LMAC Limits
OBRA 1990 VA Benefits
Transportation Claims for Trips Over 400 Miles Requests for Exceptions/Adjustments to Cost Per Discharge Limits

All Providers

Provider Relations' Telephones

We would like to remind providers who are calling Unisys, Provider Relations to telephone Provider Relations' switchboard, not Unisys' main switchboard.  Providers outside of Baton Rouge should telephone 1-800-473-2783.  Baton Rouge providers should telephone (504) 924-5040.

Provider Training

Planning for the Louisiana Medicaid Provider Training sessions has been finalized.  The sessions has been finalized.  The sessions or workshops are designated to furnish claims processing information to those individuals who complete the claim form and reconcile the Remittance Advice.  The sessions are scheduled over a two-day period at specific times.

We request that all providers review the schedules for Day One and Day Two of Provider Training and attend the appropriate session on one of the dates listed in the next column.  It is not necessary, however, to advise either Unisys or the Bureau of Health Services Financing of plans to attend the training sessions.

NOTE:  Providers are encouraged to bring examples of specific billing problems and RAs because provider representatives will be available at the training sessions to give assistance.

Provider Training Schedule

Day One - 8:30 A.M. - 11:00 A.M.
Physicians, Optometrists, Ophthalmologists, Optical Supplies, Ambulatory Surgical Centers, Independent Labs, Portable X-ray, and Hemodialysis. 

11:15 A.M. - 12:15 P.M.
Anesthesiologists and CRNAs 

1:30 P.M. - 3:00 P.M.

3:15 P.M. - 4:15 P.M.
Home Health and Rehabilitation 

7:00 P.M. - 8:00 P.M.
DME and Pharmacy 

Day Two
8:30 A.M. - 9:30 A.M.
Long Term Care 

9:45 A.M. - 10:30 A.M.

10:45 A.M. - 11:30 A.M.

Provider Training Sessions

Dates:  5/9/91 and 5/10/91
Location:       Bellmont Hotel
                     7370 Airline Highway
                     Baton Rouge, Louisiana

Dates:  5/14/91 and 5/15/91
Location:       Sheraton Pierremont
                     1719 East 70th Street
                     Shreveport, Louisiana

Dates:  5/16/91 and 5/17/91
Location:       Holiday Inn (Holidome)
                     1051 By-Pass 165/I-20
                     Monroe, Louisiana

Dates:  5/21/91 and 5/22/91
Location:       Holiday Inn
                     2716 N. MacAurthur Drive
                     Alexandria, Louisiana 

Dates:  5/23/91 and 5/24/91
Location:       Hilton
                     505 N. Lakeshore Drive
                     Lake Charles, Louisiana

Dates:  5/29/91 and 5/30/91
Location:       Holiday Inn (Holidome)
                     2032 N. E. Evangeline Thrwy.
                     Lafayette, Louisiana


Dates:  6/4/91 and 6/5/91
Location:       Holiday Inn (Holidome)
                     210 South Hollywood Rd.
                     Houma, Louisiana

Dates: 6/6/91 and 6/7/91
Location:       Sheraton Inn/Airport
                     2150 Veterans Blvd.
                     Kenner, Louisiana

Recipient Eligibility Verification System

Unisys now has a Computerized Recipient Eligibility Verification System available for providers' immediate use to respond to telephone inquiries and to provide telephone inquiries and to provide information regarding recipient eligibility, service limits, and third-party liability for any date of service in the last 12 months.  In addition, providers will be able to obtain their current check amount.  This system is available 24 hours a day, 7 days a week, except for a short period on Sundays when the system is being updated.  In addition, new information will be available every Monday so providers will be able to verify eligibility on a weekly basis.

To access the system, providers must telephone (800) 776-6323 and have their seven-digit Provider I.D. Number, as well as the appropriate thirteen-digit recipient number and date of service, available.  Procedural instructions will be given to the provider via voice response prompt messages.

Health Standards  

Competency Testing

Providers should note that the Louisiana Vocational Technical School's Department of Education is no longer administering Nurse Aide Competency Testing.  For information about the test, providers can contact Burns and Associates at (504) 785-0279.

EMC Billers  

Billing Procedures

All production tapes or diskettes must be sent to the following address:

Unisys, EMC Department
P. O. Box 3396
Baton Rouge, LA  70821

In addition, each production tape or diskette must be accompanied by a Provider Certification, e.g., Professional Services Certification, Hospital Services Certification, Pharmacy Certification, or Third-Party Biller Certification.

The address for certifications of telecommunications, however, is different from the address for production materials.  All certifications for telecommunications should be sent to the following address, not the address listed above:

Unisys, EMC Department
P. O. Box 91025
Baton Rouge, LA  70821

EMC Submission Schedule

All EMC submitters should have received a letter in January and again in February of this year that served as a reminder of our production schedule.  However, for those providers who did not receive such a letter, the schedule is as follows:

All claims received on Magnetic tape or diskette before 5:00 P.M. on a Wednesday will be processed over the weekend.  Also, telecommunications received before 10:00 A.M. on a Thursday will be processed over the weekend.  However, all other tapes, diskettes, and telecommunications not received by these times will be processed the following week.

NOTE:  This schedule will be strictly enforced.

Professional Services Certification

In January of this year, a revised Professional Services Certification was mailed out to all providers that would need to use the form when submitting production tapes or diskettes.  Effective immediately, these providers should note that the old certification, the Professional Certification (only), is no longer valid and that the new certification must be used.  For those providers who did not receive a copy of the new Professional Services Certification, we have provided a copy in the attachments section of this issue of the Provider Update.  Providers should photocopy this attachment until an original can be obtained from Unisys.

Providers who have questions about the new certification form should contact our EMC Coordinator, Jerrold Perry, at (504) 924-7051 or 1-800-473-2783.



For HCFA 1500 claim forms, physicians must remember to enter the attending physician provider number in Item H next to the list of charges, not in the blank for the prior authorization number.  If the provider number is entered in the wrong item, the claim will be denied.

Specimen Collection and Handling

The SURS (Surveillance and Utilization Review Subsystem) Unit would like to remind providers that, effective 7/1/83, fees associated with the collection, handling, and/or conveyance of specimens to laboratories are not payable.  The codes for these procedures include codes 99000 and 99001.  The only exception to this policy is procedure code 99004, Collection of eye culture specimens, which continues to be payable.  In addition, hospitals and independent laboratories may bill for routine specimen collection under procedure codes 36400, 36405, 36410, and 36415.


Injections covered by the Medicaid Program are limited to those listed in the next column:

Immunizations for recipients under the age of 21 should be billed with the CPT-4 immunization injection codes (For further clarification, providers should review page 5 of the August 1990 Provider Update).

Injections of procaine penicillin or bicillin for recipients under the age of 21 should be billed with CPT-4 code 90782, and the type of drugs should be specified.

NOTE:  There is a limit of no more than one injection of penicillin or bicillin per day.

Adrenalin or adrenalin equivalent injections should be billed with code J0170 (Adrenalin injections; 3 units/day).

Tetanus injections following trauma should be billed with procedure code 90703, and the type of injury/trauma should be specified.

Immuno therapy, Allergy Desensitization, injections should be billed with CPT-4 procedure codes 95120 and 95160.

Injections of Factor VIII (hemophilia) should be billed with procedure code J7190, and the type of Factor VIII should be specified.

Gold therapy for treatment of rheumatoid arthritis should be billed with procedure code J2910, and the type of drug used (gold, Myochrupine, or Solganol) should be specified.

Effective 2/1/87, injections for Rhogam (only) should be billed with CPT-4 procedure code 90742.

NOTE:  The claim must reflect an RH factor diagnosis, or this procedure will deny per "medical review guidelines."  A diagnosis of "pregnancy" is insufficient.

Chemotherapy and hemodialysis injection codes are listed on pages 4-17 and 4-18 of the Professional Services Provider Manual.  These codes are to be used according to the instructions provided in the manual.  In addition, other hemodialysis codes, as well as instructions for the use of these codes, can be found in the Hemodialysis Center Services Provider Manual.

Additional CPT-4 Procedure Codes for Optometrists

Effective with date of service 1/1/91, the Bureau of Health Services Financing will allow optometrists to bill and to be reimbursed for the following services:

Home Medical Services.
CPT-4 procedure codes 90100 through 90170 

Hospital Inpatient Medical Services.
Codes 90200 through 90280, except for code 90225. 

Skilled Nursing, Intermediate Care and Long Term Care Facility Medical Services.
Codes 90300 through 9-370 Rest Home, Domiciliary or Custodial Care Facility Medical Services.  Codes 90400 through 90470. 

Emergency Department Services.
Codes 90500 through 90580. 

Other Visits.
Code 90699 

Special Ophthalmological Services.
Codes 92018, 92019, 92120, and 92130 

Codes 92230 and 92235 

Other Specialized Services.
Codes 92265, 92270, 92286, and 92287 

Other Procedures.
Code 92499

Vestibular Function Tests.
Codes 92531 through 92547, except for 92533 and 92543

Removal of Ocular Foreign Body.
Codes 65205 through 65222

Excision or Removal of Lesion Involving More Than Skin.
Codes 67820 and 67825

Probing and Related Procedures.
Codes 68800 through 68840, except for 68825

Diagnostic Ultrasound, Head and Neck.
Codes 76511, 76512, 76516, 76519, 76529, 76970, 76986, and 76999

Chemistry and Toxicology.
Codes 82948 and 83052

Code 86011

Special Services and Reports (Miscellaneous).
Codes 99070 and 99082

Neurology and Neuromuscular Procedures.
Codes 95881, 95882, and 95999

Physical Medicine Procedures.
Codes 97110 through 97114 and 97139

NOTE:  The code optometrists were allowed to bill prior to 1/1/91 are printed on page 4-22 of the Professional Services Provider Manual.

Pharmacists and Prescribers 


Recently, we have received several inquiries from several pharmacists regarding the Federal Upper Limit for the drug Slo-Phyllin 80mg/15ml syrup (The generic name for the drug is Theophylline anhydrous.).  In researching the Approved Drug Products with Therapeutic Equivalence Evaluations and the July 1990 Federal Upper Limit Listing, we have determined that the upper limit of 0.0045 per ml applies to the Theophylline 80mg/15ml oral elixir, not the syrup.  Thus, effective 10/1/90, an update in the drug file was made to reflect the removal of the Federal Upper limit of the syrup.

Vasocon A

Effective for services 4/30/90, the drug Vasocon A was returned to payable status because the Food and Drug Administration no longer considers the drug to be a less than effective drug.


The following changes should be made to Appendix A of the provider manual:

DRUG:         Labetalol
DOSAGE:     Tablet
MAC:          $0.31250/EA
EFF. DATE:  2/01/91 

DRUG:         Labetalol
DOSAGE:     Tablet
MAC:          $0.31250/EA
EFF. DATE:  2/01/91

DRUG:         Labetalol
DOSAGE:     Tablet
MAC:          $0.60860/EA
EFF. DATE:  2/01/91


OBRA 1990

For states to continue receiving federal matching of their expenditures for outpatient drugs dispensed to Medicaid recipients, Section 4401 of the Omnibus Budget Reconciliation Act of 1990 requires a drug manufacturer to enter into a rebate agreement with the federal government.

In accordance with Section 4401 of OBRA 1990, the Department of Health and Hospitals, Bureau of Health Services Financing, will reimburse for only those drug products in which the pharmaceutical company is participating in a rebate agreement with the Department of Health and Human Services.

On March 19, 1991, a listing of pharmaceutical manufacturers that are participating in the Medicaid drug rebate program was sent to all physicians, dentists, and pharmacists who are providers in the Louisiana Medicaid Program.  The listing is labeled Appendix C and should be included in the provider manuals for dentists, physicians, and pharmacists.

Effective for prescription services beginning April 1, 1991, the Louisiana Medicaid Program will provided coverage for only those drug products labeled by the pharmaceutical companies identified in Appendix C.

Corrections to Appendix C include the following:

1.     Providers should correct the manufacturer code for MD Pharmaceuticals.  The code should be 43567.

2.     Providers should add code 00033 for Syntex Laboratories.

3.     Providers should add code 00173 for Glaxo and Allen and Hanbury.

4.     Providers should correct the code for Alza Corporation.  The code should be 17314.

The Federal Upper Limits (FUL) and Louisiana Maximum Allowable Costs (LMAC) will remain in effect.  Also, the therapeutic categories, cough and cold preparations, anorexics and cosmetic drugs, will remain nonpayable.

We would like to emphasize the importance of the proper use of the National Drug Code (NDC) number.  Accurate records must be maintained by Medicaid-participating pharmacies, and the appropriate NDC codes must be used on all pharmacy claims submitted for payment.  Inaccurate records may result in billing the wrong manufacturer for the rebate.

If a provider is unsure about the coverage of a specific drug, he should call Unisys' Provider Relations Unit at 1-800-473-2783 or (504) 924-5040.

Nursing Home Providers 

VA Benefits

Any contact or verification from Veterans Affairs regarding a decrease in VA benefits or an increase in the income the patients are allowed to retain for their personal use must be reported to the local Office of Family Support to allow for timely readjustment of patient liability and protected income.

Transportation Providers  

Transportation Claims for Trips Over 400 Miles

Effective 5/1/91, the Department of Health and Hospitals discontinued the procedure of prior authorizing transportation claims for trips over 400 miles.  Now, these claims can be mailed directly to Unisys/Louisiana Medicaid for processing.  Thus, providers should submit these claims in accordance with standard filing procedures to the following address:

Unisys/Louisiana Medicaid
P. O. Box 91022
Baton Rouge, LA  70821

In addition, those claims previously authorized by DHH and all transportation providers who submitted claims for trips over 400 miles are being reviewed monthly on a post payment review basis by the SURS Unit at Unisys.  So far, the reviews indicate two areas where numerous violations occur:

Providers Are Not Complying With Documentation Requirements.

Providers must complete the MT-4 (Daily Trip Log) form in its entirety.  Many times providers omit odometer readings, vehicle I.D. numbers, and the driver's name.  In addition, providers must complete two lines on the MT-4 form for each of the recipients who are transported two ways.

The Mileage Billed Does Not Coincide With The Mileage Indicated On The MT-4 Form.

Providers are billing more mileage than can be substantiated by the MT-4 forms.  Before billing the Medicaid Program, providers must check the total mileage of each driver to determine the accuracy of the mileage report.  In addition, providers must bill for the actual miles of each trip, not for an estimate of the mileage.

NOTE:  If billing violations are found in a post payment review, the Medicaid Program could recoup payments.

All Hospitals 

Requests for Exceptions/Adjustments to Cost Per Discharge Limits

The bases for requesting an exception or adjustment to the cost per discharge limits applicable to inpatient services are outlined on pages 9-1 and 9-2 of the Hospital Provider Manual.  The specific methodology used by Medicaid to review requests for adjustments or exceptions for hospital providers who are subject to the TEFRA cost per discharge limitations are further delineated below.  Such adjustments are intended to take into account factors which could result in significant distortions in the operating costs of inpatient hospital services.  Such adjustments may be necessary to ensure comparability of cost reporting periods.  The hospital must provide sufficient documentation in a format specified below and as otherwise requested by the State.

Exceptions/Adjustments:  General Procedures

A hospital's operating costs may be adjusted upward or downward, as appropriate, under the circumstances specified below.  An adjustment shall be made only to the extent that the hospital's operating costs are reasonable, attributable to the circumstances specified, separately identified by the hospital, and verified by audit.  An exception or adjustment shall be granted only when the hospital's operating costs exceed the rate of increase ceiling applicable for the cost reporting period.  An exception/adjustment shall not be granted when increased costs are attributable solely to decreases in utilization.  Requests for adjustments or exceptions must be submitted no later than 180 days from the Medicaid Notice of Provider Reimbursement (NPR).

1.  Extraordinary Circumstances:  The hospital must demonstrate that it incurred unusual costs (in either a cost reporting period subject to the ceiling or the hospital's base period) due to extraordinary circumstances beyond its control.  These circumstances include, but are not limited to, strikes, fire, earthquakes, floods, or similar unusual occurrences with substantial cost effects.  These are generally adjustments applicable only to that specific cost reporting period and are not a "permanent" adjustment which would trend forward to subsequent cost reporting periods.

2.  Change in Case Mix/Increase in Intensity of Services:

a    The hospital has added or discontinued services in a cost reporting period after its base period:

b    The hospital has experienced a change in case mix as a result of the addition or discontinuation of services that results in a distortion in the rate of cost increase; and

c    The hospital submits data/documentation summarizing the case-mix changes and the resulting change in costs.

If increased costs are attributed to the addition of a new unit or service, the costs and discharges for this unit/service should be isolated and these costs shall then be added with the current period target amount for the applicable cost reporting period for which the adjustment is requested.  The direct operating costs related to this unit/service may be limited to only routine operating costs or may include related ancillary costs if these differ significantly from those applicable to discharges in the base period.  This revised total inpatient operating cost shall then be divided by the revised number of discharges (the number of discharges attributable to the new unit/service plus the current period number of discharges without the new unit/service discharges).  The figure derived would be the adjusted target rate.  This would be a "permanent" adjustment which would then flow forward to subsequent cost reporting periods if the new unit/service was in operation for the full twelve months of the cost reporting period.  If the new unit/service has been operating less than twelve months, a one-time adjustment for that cost reporting may be granted, but a "permanent" adjustment will then need to be calculated using the subsequent cost reporting period which includes a full twelve months of operation.  The provider must specifically identify the new inpatient unit or service responsible for the increase in inpatient operating costs; identify the date on which a new unit/service became operational; specify the direct costs of the new unit/service and the portion of those costs included in Total Program Inpatient Operating Costs; and identify indirect costs incurred specifically as a result of the addition of the new unit/service.  The request must identify actual increases in indirect costs specifically attributable to the addition of a new unit or service.  An adjustment is only available for actual increases in these costs, not for the redistribution of existing indirect costs that result from the cost finding process.  Documentation submitted must be as complete and detailed as possible.  In addressing the amount of the distortion that occurs, specify the basis for such distortion.  Costs must be categorized as capital costs, staffing costs, supplies, etc.  Additional information such as the number of new personnel employed, special training of personnel, hours of operation and hourly salary levels of staffing should be submitted as well.  The impact of the new unit/service on the historical cost structure of the hospital should be demonstrated by the documentation submitted.  In such an instance, a cost report for the period impacted by the new unit/service which identifies costs associated with this unit/service by running these as a subprovider would be acceptable as documentation along with the impact on the inpatient utilization levels of the hospital and summary of the patient logs related to the new unit/service.  Such summaries should included the patient name, Medicaid identification number, dates of service, date of payment, total charges by revenue code (routine or ancillary).

If increased costs are attributed to an increase in intensity or utilization of a particular ancillary service/cost center for Medicaid recipients, the cost for this service/cost center for the base period should be componentized by determining the average Medicaid cost per discharge in the base period and then inflating up to the current period for which the adjustment has been requested.  Compare the current period cost per discharge for this service/cost center to the inflated base period cost/discharge.  If current year cost is less than base period inflated, no adjustment is warranted.  If current cost is greater than inflated base period cost, incorporate current period costs to base period ancillary cost to adjust base period target rate, then inflate up to current period to calculate revised cost per discharge limitation.  Documentation regarding the utilization in both periods must be submitted (i.e., number of procedures/units).

Addition of a new service does not necessarily warrant rebasing under Section 6105(a) of Public Law 101-239.  In order to justify rebasing, a permanent, substantial, and significant change in the nature of services provided by the hospital must have occurred.  For example, addition of a substance abuse unit would not warrant rebasing.

3.  Length of Stay Changes:  When there is no significant change in the services provided from those in the base period, but the length of stay has increased due to treatment of more seriously ill patients, a one-time adjustment (not permanent) may be granted for that specific cost reporting period in which the change in length of stay occurred.  The adjustment is calculated using the following steps:

a    Identify the total inpatient operating cost excluding pass-through costs for the cost reporting period for which the adjustment is requested (Worksheet D-1, Part II, Line 54);

b    Identify the number of Medicaid days in the cost reporting period for the base period and the period for which the adjustment is requested (Worksheet D-1, Part 1, Line 9);

c    Convert the target amount for current period to a per diem amount by multiplying the target rate for the cost reporting period by the number of discharges and dividing by the number of Medicaid days;

d    Multiply the per diem amount for the current period by the base period discharges and divide by the base period days to determine a revised target amount;

e    Allowable program inpatient costs for the period for which adjustment is requested shall be the lesser of the revised target amount times the current number of discharges or the actual inpatient operating costs, plus excludable program costs.

If the addition of a new unit also increases the average length of stay, an additional adjustment may be requested if the permanent and/or one-time adjustments are not sufficient to permit reimbursement of reasonably allowable cost-related to the basis for requesting an adjustment.  These procedures and calculations are based on the methodology used by Medicare for the purposes of reviewing and calculating adjustments to the cost per discharge limitations in accordance with 42 CFR 413.40.

Requests for adjustment of target rates must be submitted in writing to Carolyn O. Maggio, P. D., Director, Bureau of Health Services Financing, P. O. Box 91030, Baton Rouge, Louisiana  70821-9030 with the basis for adjustment specifically stated and related documentation submitted for review.  Additional information may be requested by the State to ensure that adjustments are related to actual costs and not redistribution of costs.  If desired an example of the above calculations may be obtained by contacting the Bureau of Health Services Financing, Program Operations Section, Attention:  Ron Jesse.