Provider Update

Volume 10, Number 1 

April/May 1993

Medical Director's Message: New Formats and Implementation of Community Care

LADUR Education: Terfenadine and Astemizole Drug-Drug Interactions

Metered Dose Inhalers and Diabetic Supplies

Changes in Hospital Disproportionate Share Methodologies

Reimbursable CPT Codes for Chiropractors

Abuse of Soma, Dilaudid, Percodan

Required Qualifications for MHR Counselors and Therapists

Reminder: Review RAs for Amendments to Appendices

Depo-Provera C Billing for Diagnostic Radiology Services
Organ or Disease Panels Urinalysis During Obstetrical Care
Epilepsy Evaluation and Surgery Level of Care Definitions
Community Care Policy Clarifications Keeping Records
Rate and Rule Changes for Emergency and Non-Emergency Transportation Providers CLIA Number Required on Claims
HCFA-1500 Claim Forms Advantages to Billing EMC


Message from the Medical Director

This issue of the Louisiana Medicaid Provider Update debuts our newly designed and updated format, which we hope will be more readable and informative.  As always, we welcome your comments and suggestions.

Also newly updated are many of the Medicaid provider manuals which outline program policies and procedures.  The Provider Relations Unit at Paramax has just completed a series of provider training sessions around the state, at which time the new manuals were presented and distributed.  The Louisiana Medicaid Provider Update is the vehicle for keeping you current with new information and policy as it evolves, and thus, should be retained for reference along with your provider manuals.

The claim volume processed by Paramax for the Medicaid program is projected to reach an all time record 35 million during this fiscal year.  Approximately 84% of all claims processed are approved and paid.  EMC claims account for 77.5% and are usually adjudicated within three days.  All paper claims are processed within 30 days.  Overall, 99.6% of all Medicaid claims are resolved in less than 30 days.

For claims requiring prior authorization, processing always occurs in less than 10 days, with certain types of requests requiring just a day or two.  The staff accepts emergency requests via fax, and has initiated a program of calling providers to obtain necessary information over the phone in order to resolve claims on the spot.  Also, the staff and consultants in the Prior Authorization Unit strive to be flexible in interpreting program guidelines and considering the special needs of patients and providers.

Claims which the system pends for medical review are also processed in under 10 days.  Less than 1% of all claims require medical review.  The staff has increased automation so claims can be adjudicated as soon as possible.  In the area of utilization review, Paramax, in consultation with the Department of Health and Hospitals, is making proactive efforts to continuously evaluate our guidelines and reimbursement policies, to ensure they are of maximal benefit to patients.  In the future, we hope to make available utilization date to providers as an educational service.

There have been a number of exciting program policy additions recently which should be of great interest to clinicians, some of which are detailed in this update.  Pharmacy program coverage is being expanded to include diabetic supplies for insulin dependent or insulin requiring adult Medicaid recipients.  In addition, blood glucose monitors will now be covered in the DME program for the same group of recipients.  Community Care, a primary case management program for Medicaid recipients in rural areas, has been implemented in a number of parishes.  The program links Medicaid recipients with a primary care physician who receives a monthly care management fee in addition to the regular fee for service.  The Department of Health and Hospitals has been frequently meeting with physicians in the Community Care parishes in order to ease implementation and to make the program guidelines as flexible as possible.

We are always willing to consider your ideas concerning program improvements, and we will try to expeditiously resolve any problems you may be encountering.  Our goal is to show you just how responsive and innovative Medicaid can be.

 --Dr. Gregg Pane

LADUR Education

 Terfenadine and Astemizole Drug-Drug Interactions

Terfenadene (Seldane) and astemizole (Hismanal) are widely prescribed, orally effective antihistamines which are considered to be non-sedating when used at normal dosages.  When used appropriately they are effective in the symptomatic management of allergic rhinitis and symptoms such as sneezing, rhinorrhea, pruritus, and lacrimation.  These agents have been shown to produce significantly less sedation and motor impairment than other antihistamines when used at recommended doses.

However, rate instances of serious cardiovascular dysrhythmia have been reported following (a) the use of excessive dosages of the medications, (b) their use in patients with hepatic dysfunction, and (c) the use of terfenadine or astemizole in combination with erythromycin, ketoconazole, or itraconazole.  This has resulted in several reported instances of toxicity and the issuance of several warnings regarding the use of these two antihistamines.  These warnings are detailed in the Warning box in the next column.

Warning:  Astemizole and terfenadine:  QT interval prolongation/ventricular arrhythmias - Rare cases of serious cardiovascular adverse events, including death, cardiac arrest, torsade de pointes, and other ventricular arrhythmias, have been observed in the following clinical settings, frequently in association with increased terfenadine and astemizole (including metabolite) levels which lead to electrocardiographic QT prolongation:

1.                  Overdose, including single terfenadine doses as low as 360 mg and astemizole doses as low as 20 to 30 mg/day;

2.                  Significant hepatic dysfunction; and

3.                  Concomitant administration of erythromycin, ketoconazole or itraconazole.

Terfenadine and astemizole are contraindicated in patients taking ketoconazole, itraconazole, or erythromycin and in patients with significant hepatic dysfunction.

Do not exceed recommended dose.

In some cases, severe arrhythmias have been preceded by episodes of syncope.  Syncope in patients receiving astemizole or terfenadine should lead to discontinuation of treatment and full evaluation of potential arrhythmias, including ECG testing (looking for QT prolongation and ventricular arrhythmias).

The Louisiana Department of Health and Hospitals has utilized LADUR to evaluate the patterns of terfenadine and astemizole use within the Medicaid Drug Program.  This evaluation included an examination of the use of higher than recommended doses of the non-sedating antihistamines, and the prescribed combination of terfenadine with either erythromycin, ketoconazole, or itraconazole.  Two percent of recipients were shown to have been receiving higher than the recommended dosage of terfenadine (greater than 120 mg/day), while only 25% of astemizole patients received the higher than recommended dosage (greater than 20 mg/day).  However, nearly 6% of terfenadine recipients also received either erythromycin, ketoconazole, itraconazole in combination with the antihistamine.  These combinations often were the result of the patient's use of multiple physicians and/or multiple pharmacies, but also resulted from prescriptions written by a single physician and filled by a single pharmacy.

Although the potential for cardiovascular toxicity related to the use of terfenadine and astemizole is low, these combinations are not recommended.

LADUR Education and Additional Drug Program Information

Metered Dose Inhalers

The appropriate use of albuterol and other beta agonists by oral inhalation is a mainstay of therapy in the management of asthma and other obstructive airway diseases.  The use of metered dose inhalers (MDIs) for the administration of bronchodilators and anti-inflammatory agents is a remarkably effective treatment modality for these patients.  Recently, the use of MDIs (particular beta agonists) has increased.

Therefore, the Louisiana Drug Utilization Review (LADUR) program is evaluating the use of such MDIs for potential misuse.  LADUR believes that either patients are using MDIs incorrectly (It has been estimated that 75% of patients may be using MDIs incorrectly.) or that misuse may be the result of a change in the patient's condition, which may require a complete evaluation of the patient's therapy.  Both physicians and pharmacists need to be aware of LADUR's findings.  So they may assist in monitoring the adequacy of therapy and patient compliance.

LADUR exception criteria have been established for patients receiving more than the normal number of bronchodilator MDIs per month.  Limits were established based on the recommended maximum dosages per day for these products.  In general, the normal patient's usage maximum should be approximately 16.6 days per inhaler.

The Department of Health and Hospitals is aware that some patients will require more than the recommended maximums, and, indeed, additional usage may be prescribed for these patients by the physician.  It is not the intention of LADUR to remove the physician's prerogative to prescribe the inhalers in a manner required for the individual patient, but that decision can only be made if the physician is aware of the patient's usage patterns.

In particular, LADUR has focused on certain common situations seen in the Louisiana Medicaid Drug Program.

        Patients receiving MDI prescriptions from more than one physician or pharmacy.  Since many prescriptions may be written by the physician to be refilled on a "p.r.n." basis, the potential misuse of the medication may be without the knowledge of the physician or pharmacist.

        A patient's condition may be worsening, either due to normal fluctuations or progression of the disease or by alterations in other drug therapy.  The physician should be made aware of any changes in other medications or in changes in the level of usage of MDIs which are not prescribed by the physician.

        The patient may be using the MDIs incorrectly.  If MDIs are misused, the patient may not be receiving the required and prescribed dosage of the medication, thus requiring intervention by the physician or pharmacist or both.

Some overutilization patterns, however, may not represent therapeutic misuse.  These patterns include the following:

        Situations where the use of MDIs is clearly intended by the prescribing physician.  Such instances may be indicated by the number of MDIs prescribed by a single physician or even very consistent patterns of MDI usage as prescribed by a single physician.

        Situations where the same physician is involved in changes in prescribed drug therapy.  Such situations may be indicated by the addition of other therapeutic agents to the patient's drug regimen as an attempt to manage the asthmatic patient.  On the other hand, the omission of a drug from the patient's normal regimen may require notification of the physician; the patient may not be taking drugs prescribed by the physician.

        Frequent occurrences of exceptions triggered by incorrect information being placed on Medicaid claim forms.  The most common exception seen appears to be the result of an inappropriate day's supply being indicated on the claim form by the pharmacist.

LADUR hopes to provide information which may reflect a need to adjust drug therapy and/or provide instruction to the patient.  The reported high prevalence of poor inhalation technique indicates a need for initial instructions, observation of technique, and frequent follow up to ensure optimal therapy.

Patients should not discontinue therapy without medical advice and should seek care if symptoms cause them to exceed the recommended maximum of 12 inhalations of the prescribed beta agonist in one day.

Diabetic Supplies for Adults

Effective for prescription services beginning April 1, 1993, diabetic supplies will be covered for adult Medicaid eligibles who are not QMBs (recipients have a one and a seven in the third and fourth digits of their identification numbers) or who are not residents of nursing homes.

The covered supplies include disposable insulin syringes, blood glucose monitoring strips, urine ketone monitoring strips, and lancets.

For disposable insulin syringes, the prescription must contain the prescribing physician's written statement that the recipient is insulin dependent or insulin requiring.

These supplies are covered for these individuals even if the manufacturer is not participating in the program.  These supplies do not include glucose monitors.  Glucose monitors are covered under the DME program and require approval by the Prior Authorization Unit at Paramax.

Disposable insulin syringes, blood glucose monitoring strips, and lancets are to be dispensed in the amount of 100 or a month's supply, whichever is greater.

Providers are to bill their usual and customary charges for these supplies.  The maximum payment for these supplies will be the prevailing wholesale cost plus 50%.

Abuse of Soma, Dilaudid, and Percodan

Soma (carisoprodol), a non-controlled substance, is being abused and sells for $4.00 to $8.00 per tablet on the street.  Dilaudid (hydromorphone), a Schedule II drug, sells for $50.00 $75.00 per tablet and Percodan (oxycodone), also Schedule II, sells for $15.00 to $25.00.

Reprinted from the Louisiana State Board of Medical Examiners Newsletter, December 1992, Vol. 6, No. 1.

Depo-Provera C

Depo-Provera C, the contraceptive injection, is covered under the Pharmacy Program rather than the Physicians Program.  Therefore, recipients wishing to use Depo-Provera C must be given a prescription to be filled at a participating pharmacy.

The fee for the administration of the injection is included in the fee for the office visit during which the prescription is written.  If the recipient returns to the office a the end of three, six, or nine months for another injection which is given by the nurse without the physician seeing the recipient, no higher level evaluation and management code than 99211 should be billed.

Reminder: Review RAs for Appendices Amendments

Pharmacists and physicians should review their weekly remittance advice messages to note amendments to Appendices A, B, and C.  In addition, they should remember to make notes in their manuals regarding these changes.

Changes in Disproportionate Share Adjustment Payment Methodologies for Hospitals

Restructuring to a prospective disproportionate share payment methodology is necessary to ensure compliance with the cap (limit) established under P.L. 102-234 and federal regulations published November 24, 1992 (Federal Register, Vol. 57, No. 227, pages 55118-55265).

Therefore, the rules published effective 1/1/93 are rescinded and superseded by the following methodology, subject to review and approval by HCFA.  If federal approval is not received, the rules (effective January 1, 1993) which were published in the January 20, 1993, Louisiana Register (pages 19-20) shall remain in effect.  This action is necessary to reduce the projected disproportionate share payments to a level that will remain under the cap and will ensure that other services for healthcare to the need of the state would remain available.  Otherwise reductions in these services may result if the cap is exceeded.

Methodology for Disproportionate Share Adjustment

Effective for dates of service March 1, 1993, and after, qualification for and calculation of disproportionate share payments shall be based on the latest filed fiscal year-end cost report as of March 31st of each year.  Hospitals which meet the qualification criteria outlined in the State Plan in Item 1, D.1.a-d, based on the latest filed fiscal year-end cost report as of March 31st of each year, shall be included in one of the three following pools for calculation of disproportionate share adjustment payments.  A one-time provision for transition to the new methodology for disproportionate share payments shall provide that hospitals filing a minimum of a three month interim cost report and which meet all qualification criteria shall be "grandfathered" into the pools.  Qualifying hospitals with cost reports which do not reflect a full year shall have days annualized for purposes of the pools.

Qualifying disproportionate share hospitals with Medicaid utilization rate percentages equal to the Medicaid utilization's qualifying threshold (the mean plus one standard deviation of the Medicaid utilization for all such hospitals in the state participating in Medicaid) plus twenty-five percent shall be recognized as "Medicaid dependent hospitals."  Medicaid dependent hospitals shall have days in the pool weighted by applying a factor of up to 1.25 to the actual days in the pool.  In determining pool payments, days for Medicaid dependent hospitals shall be increased by the factor noted above.  Disproportionate share payments for each pool shall be calculated based on the product of the ratio of each qualifying hospital's total Medicaid inpatient days for the applicable cost report as adjusted for annualization and Medicaid dependent status, divided by the total Medicaid inpatient days provided by all such hospitals in the state qualifying as disproportionate share hospitals in their respective pools, multiplied by an amount of funds for each respective pool to be determined by the Director of the Bureau of Health Services Financing.  Disproportionate share payments cumulative for all payments shall not exceed the federal disproportionate share cap for each federal fiscal year.  Notice of the actual pool amounts shall be published prior to the issuance of the first payment each year.  The total disproportionate share payment amount for each qualifying hospital shall be calculated after March 31st of each year and payments shall be issued via at least three payments throughout the year for services in the immediately preceding months.  Monthly payments may be issued for a transition period from April through October of 1993 to allow hospitals to adjust to cash flow changes in disproportionate share payments.

The three pools are as follows:

Teaching hospitals - acute care general hospitals (exclusive of distinct part psychiatric units) recognized as approved teaching hospitals under Medicare principles for the latest filed fiscal year-end cost report as of March 31st of each year.

Non-teaching hospitals - acute care general hospitals (exclusive of distinct part psychiatric units) not recognized as approved teaching hospitals under Medicare principles for the latest filed fiscal year-end cost report as of March 31st of each year.

Distinct part psychiatric units/freestanding psychiatric hospitals - distinct part psychiatric units of acute care general hospitals meeting the Medicare criteria for PPS exempt psychiatric units and enrolled under a separate Medicaid provider and freestanding hospitals recognized for the latest filed fiscal year-end cost report as of March 31st of each year.

If at audit or final settlement of the pool base(s) cost report the above qualifying criteria are not met, or the number of Medicaid inpatient days are reduced from those originally reported or annualized, appropriate action shall be taken to recover such overpayments.  No additional payments shall be made if an increase in days is determined.  No redistribution of the "pool" shall occur because of changes resulting from adjustments at audit/settlement or subsequent amending of cost reports.

Additional Disproportionate Share Payments for Indigent Days

A fourth pool was created via emergency rulemaking effective January 1, 1993, for disproportionate share payments based on a qualifying hospital's indigent days (under an indigent/free-care plan approved by the Department of Health and Hospitals) as a ratio of total indigent days in a pool of all hospitals qualifying for disproportionate share payments.  Qualification for this pool must also meet the criteria specified on page 4 for disproportionate share adjustment.  The payments for this pool are in addition to those for the above pools based on Medicaid days.  Providers shall be required to submit data annually for indigent care days provided in the previous state fiscal year.  Forms requesting this data will be issued to all qualifying disproportionate share providers in the near future to collect information regarding indigent days in state fiscal year 1992 in order to calculate payments via this pool.  Total disproportionate share payments under all four pools and the previous methodology may not exceed the federal cap on disproportionate share payments in any federal fiscal year.

Questions regarding these changes should be submitted to the Institutional Reimbursements Section, P. O. Box 91030, Baton Rouge, Louisiana 70821-9030, or telephone (504) 342-6116.

Increase in Inpatient Psychiatric Prospective Per Diem Rate

Effective for dates of service January 1, 1993, and after, the Medicaid statewide inpatient psychiatric per diem was increased to $292.65.  The new per diem was calculated based on 1991 allowable costs in accordance with Medicare principles of reimbursement.  These rates will be updated annually effective January 1 of each year by increasing the previous year's per diem rate by the Health Care Financing Administration's (HCFA) target rate percentage increase factor for the applicable year.  The rule detailing this proposed change was published in the January 20, 1993, Federal Register (page 19).  The provision in this rule mandating separate enrollment for psychiatric units was rescinded in revised rules which were published February 26, 1993, and are effective March 1, 1993.  Implementation of this change by HCFA will automatically cancel the provisions of this proposed rule and current policy will remain in effect.

Effective March 1, 1993, the per diem for inpatient psychiatric services provided by both free-standing psychiatric hospitals and acute care general hospital's distinct part psychiatric units will be adjusted to $292.65.  Additional amounts for January 1, 1993, through February 28, 1993, dates of service due to providers affected by this change will be reimbursed in the annual cost report settlement process.

Questions regarding this change should be submitted to Medicaid of Louisiana, Institutional Reimbursement Unit, P. O. Box 91030, Baton Rouge, Louisiana 70821-9030, or telephone (504) 342-6116.

Reimbursable CPT Codes for Chiropractors

Effective with date of service January 1, 1993, the Bureau of Health Services Financing began reimbursing chiropractors for selected services rendered to Louisiana Medicaid recipients.

Three groups of CPT codes will be reimbursed:

        Evaluation and management office visit or other outpatient service codes;

        Specified CPT diagnostic radiology codes;

        Selected CPT treatment codes.

Limitations, however, do apply.  These limitations, as well as a more comprehensive explanation of the Medicaid policy that applies to chiropractors is published in the new Physician Services provider manual available at Paramax.

Updates to that policy, however, have been made.  Those updates follow.

Billing Clarification

Claims for chiropractic encounters #26 through #36 should be submitted hardcopy to Paramax with office notes attached.  These claims will then be reviewed for medical necessity by the Medical Review Unit, and payment will be made if the criteria governing extensions are met.

 If the 26th and following encounters are billed without the office notes, the claim will be denied with instructions to rebill with office notes attached.  Claims for encounters after the 25th, therefore, should not be billed on tape.

Because the maximum number of chiropractic extensions a recipient is allowed is 10, the 36th claim will be denied because the maximum will have been reached.  Providers should not rebill this denied service as an office visit as doing so will constitute a breach of Medicaid policy.

Form 158-A should be used to request an extension of outpatient visits, but it should not be used to request an extension of chiropractic encounters.

Lock-In Recipients

Chiropractors may render chiropractic services to Lock-in recipients.  However, chiropractors cannot be listed on the recipient's Lock-in card as one of the client's two Lock-in physicians because chiropractors cannot prescribe drugs.

Community Care

Chiropractors can provide services to recipients in Community Care parishes without a referral.  Since no referral is needed, Item 17 on the claim form does not have to be completed.

 Billing for Diagnostic Radiology Services

When billing for radiology procedures (70000 CPT range) and laboratory procedures (80000 CPT range), physicians should not bill for both the full service and the professional component only for the same patient, for the same service.

For example, a treating physician who takes and interprets an X-ray in his office should bill for the full service, and, if the treating physician sends the X-ray to a radiologist for a consultative interpretation, the radiologist should be informed that he/she may not bill for the professional component only.  Instead, the treating and the consultant physician must establish an arrangement between themselves to ensure that the radiologist is paid for his services.

Providers should not bill Medicaid of Louisiana for radiological/laboratory services they do not perform in their own offices.  Tests which are sent to other facilities for processing should not be billed to Medicaid of Louisiana.

To bill appropriately for either the full service or the professional component only, providers should follow the procedures delineated below:

To denote full service, providers should bill the procedure code without a modifier.  Billing for a full service implies that the physician owns or leases (and has on the premises) the equipment necessary to perform the "technical" aspect of the service.  Payment for full service encompasses both the use of the equipment and the physician's professional services.

To denote professional component only, providers should bill the procedure code with the modifier -26.  Use of this modifier implies that the physician does not own or lease the equipment needed to perform the service, but that he does have he expertise to interpret the results of test performed.

This policy is further clarified on pages 24-4 and 24-5 of the Physicians Services provider manual.

Organ or Disease Panels

Medicaid of Louisiana would like to call to your attention the changes in the definitions and criteria necessary to substantiate the billing of procedure codes 80050-80092 as redefined in the 1993 edition of the Physicians' Current Procedural Terminology.  The section entitled Organ and Disease Oriented Panels on pages 469-472 lists specific tests which must be substantiated in the medical records.

Providers, however, should not confuse the use of the organ panel codes with the multichannel test codes on pages 467-468.  As stated on page 467, providers should use codes 80002-80019 for the billing of any combination of the tests listed on pages 467 and 468.  This distinction has remained constant from previous year's CPT manuals.  This policy is further clarified on pages 24-4 through 24-12 of the Physician Services provider manual reissued in February of 1993.

In addition, we would like to remind providers that Medicaid of Louisiana has always expressed the intent to pay for the most inclusive procedure code available which describes the procedure(s) performed and/or the result(s) obtained.  Thus, the individual component codes should be used only when individual components are being performed.

Urinalysis During Obstetrical Care

Page 11-4 of the 1993 Physicians Services provider manual specifies that routine 'dip-stick' urinalysis is included in the prenatal office visit code.  Therefore, providers should not routinely bill procedure code 81002 with codes Z9004, Z9005, and Z9006.

Non-routine lab work billed with prenatal visits (Z9005) should be substantiated by appropriate diagnosis code(s).

Epilepsy Evaluation and Surgery

Medicaid of Louisiana is pleased to announce funding for the evaluation of epileptic patients who may benefit from epilepsy surgery and an increase in the fee for epilepsy surgery effective with date of service November 1, 1992.

The valid procedure codes providers may use to bill for these services are 95829 ($62), 95950 ($128), 95951 ($173), 95952 ($142), 95953 ($268), 95956 ($405), and 95958 ($286).

The effective date of payment for codes 95953 and 95956 is January 1, 1993, as these two codes did not appear in the CPT until 1993.

Before providers render these services, they should obtain permission to evaluate a patient for possible epilepsy surgery from the Prior Authorization Unit at Paramax via a PA01 form with diagnosis(es) and documentation of medical necessity.

However, prior authorization for the performance of these codes must be obtained only if the diagnosis is epilepsy or epilepsy-related, and the codes will be performed as a workup for possible surgery.  These codes do not have to be prior authorized if performed for patients with other diagnoses.

The fee for epilepsy surgery (code 61536) has been increased to $1673 effective with date of service November 1, 1992.

 Level of Care Definitionsevel of Care Definitions

All providers are requested to review the level of care definitions in the 1993 edition of the Physicians' Current Procedural Terminology manual before billing for office and hospital visits.  In the 1993 edition, the definitions for office or other outpatient service codes are listed on pages 14-22, with definitions of key components in the Evaluation and Management (E/M) Services section on pages 1-13.

Community Care Policy Clarifications

Continuous Referral.  You may refer pregnant recipients for the term of pregnancy and a postpartum visit.  All other referrals should be limited to six months and should be for treatment of a specific illness or disease that you do not treat.  The continuous referral is not to be used to refer whole practices.

When the PCP refers a recipient to a specialist for treatment of an illness, for example a neurologist, it is permissible for the neurologist to pass along that PCP's authorization number for additional specialty services which may be required in the course of treating that illness.  For example, the neurologist would pass the authorization number to a radiologist who reads an X-ray.

A physician who uses the emergency room doctors employed by the hospital as back-up must have a written agreement with the hospital administrator.

When Community Care providers have questions about program policies or procedures, they should call the Community Care program staff; Sondra Burns, Program Manager; Bobbie Heard; or Leah Schwartzman, at (504) 342-1304.

Transportation Notes�

  Rate Increase for Emergency Ambulance Services

A rate increase for emergency ambulance advanced life support (ALS) and basic life support (BLS) transportation services and mileage has been approved effective January 1, 1993.  We have increased our payment for emergency BLS services from $155.68 to $160.51, ALS services from $288.30 to $297.24, and mileage reimbursement rates for ALS and BLS miles from$3.59 per mile to $3.70 per mile.  The combined Medicare and Medicaid payment for crossover code A0223 has been increased from $149.92 to $154.57.  These rate adjustments will keep Medicaid's rates at the same amount as Medicare's rates.

Non-Emergency Transportation Emergency Rule Changes

Medicaid has implemented new policies in the Non-Emergency Medical Transportation (NEMT) Program for both the profit and the non-profit NEMT providers.

As part of these changes, effective February 15, 1993, non-profit providers may bill for a pick-up charge, as well as for mileage.  The pick-up fee has been set at $5.00 per recipient, regardless of whether the trip is a one-way trip or a round trip.  The mileage reimbursement rate has been increased to $0.36 per mile.

Prior to February 15, 1993, providers were allowed to bill mileage for each recipient; they may now bill only for the actual miles logged on each trip, starting when they leave to pick up a Medicaid recipient and ending when they return to their base.  Only miles used for Medicaid recipients may be billed. Miles used for non-Medicaid individuals must be "backed out" when calculating mileage.

New procedure codes have been entered into the system to allow providers to bill according to the new procedures.  Procedure code A0110 should be used to bill for the pick-up fee for the first trip, same-day transport of a recipient, and procedure code A0115 should be used to bill for the pick-up fee for the second trip, same-day transport of a recipient.  Procedure code A0120 should be used to bill for mileage for the first trip, same-day transport of a recipient, and procedure code A0125 should be used to bill for mileage for the second trip, same-day transport of a recipient.  Procedure codes A0080, A0090, and Z9490 are no longer valid on claims with dates of service of February 15, 1993, or later.

Advertising Reminder

Medicaid of Louisiana would like to remind transportation providers that certain rules apply to advertisements for transportation services.  Specifically, providers should not use the terms free, no cost, or at no cost to you.

Keeping Records

Medicaid of Louisiana is often required to make payment decisions based on information contained in medical records.  Therefore, we request that providers maintain all records which are necessary to document and support the delivery of services rendered for a period of three years after the date of service.

Offices that may request to review the records include the Office of Family Support, its authorized representatives, representatives of the Department of Health and Human Services, or the State Attorney General's Medicaid Fraud Control Unit.

Records which may be requested include patient office charts, billing statements and/or ledger cards, laboratory test results, hospital charts (inpatient, outpatient, and emergency room), doctors' and nurses' notes, operative reports, and any other pertinent medical and/or billing information, including information regarding payments claimed for services rendered.

HCFA-1500 Forms

Effective April 1, 1993, Medicaid of Louisiana will discontinue accepting the 01/84 version of the HCFA-1500 claim form.  Providers, therefore should begin submitting the 12/90 version instead.

CLIA Number Required on Claims

The Clinical Laboratory Improvement Amendments (CLIA) require all providers of laboratory services to obtain a CLIA certificate and CLIA number.  Medicaid of Louisiana mailed letters requesting the necessary CLIA certification data in August of 1992.  The CLIA data providers returned as a result of that mailing was loaded onto the Provider File for claims processing purposes.

Therefore effective April 1, 1993, all claims for clinical laboratory services will be paid only if the provider's CLIA number is on the Medicaid Provider File. Any provider who bills for clinical laboratory services and who does not have a CLIA number on file, will be denied payment for the laboratory services.  Those providers who have a CLIA certificate of waiver are reminded that they may bill for the eight designated waiver procedures only.  These procedures are listed as follows:

Q0095 (Urine pregnancy tests, visual color comparison test, $11.37)

Q0096 (Ovulation test kits, visual color comparison test for human luteinizing hormone $18.48)

Q0097 (Hemoglobin; by copper sulfate method, non-automated, $3.59)

Q0098 (Glucose, blood; by glucose monitoring device cleared by he FDA specifically for home use, $4.80)

82270 (Blood, feces, $6.61)

Q0100 (Urinalysis by dip stick or tablet for bilirubin glucose, hemoglobin, ketone, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of constituents; non-automated, without urobilinogen, any number of constituents; non-automated, without microscopy, $3.88)

Q0101 (Microhematocrit, spun, $3.59)

Q0102 (Sedimentation rate, erythrocyte; non-automated, $5.38)

Medicaid of Louisiana will not require providers to indicate their CLIA number on the claim form because the CLIA number will be recorded on the provider's file.  Therefore, no changes in billing procedures are necessary.

Providers who have questions may contact Paramax Provider Relations at 1-800-473-2783 or (504) 924-5040.

Required Qualifications for MHR Counselors & Therapists

We would like to clarify who may provider services as a MHR counselor or therapist for individual, group, or family counseling.  All counseling or therapy services must be provided under the supervision of a Qualified Mental Health Professional (QMHP) who is a licensed professional.  This group includes physicians, psychologists, social workers, counselors, and nurses.  Other QMHPs (those who are not licensed) and those practitioners with masters degrees in psychology, counseling, or social work who do not have the years of service delivery experience to qualify as a QMHP may provide these services if they are practicing under the supervision of a QMHP who is licensed.

Advantages to Billing EMC

-Increased cash flow

-Improved claim control

-Decreased time for receipt of payments

-Improved claim reporting by observation of errors

-Reduction of errors through pre-editing

For more information, call (504) 924-7051, and ask for our EMC department.