Volume 10, Number 1
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
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.
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.
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
Overdose, including single terfenadine
doses as low as 360 mg and astemizole doses as low as 20 to 30 mg/day;
Significant hepatic dysfunction; and
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.
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.
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.
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
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:
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.
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.
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
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
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
of Soma, Dilaudid, and Percodan
(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, 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
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
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
The three pools are as follows:
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.
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.
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.
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.
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
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.
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
Evaluation and management office visit
or other outpatient service codes;
Specified CPT diagnostic radiology
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.
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
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.
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.
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
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
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
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,
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.
Care Policy Clarifications
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
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.
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
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
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.
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.
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
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.
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:
(Urine pregnancy tests, visual color comparison test, $11.37)
(Ovulation test kits, visual color comparison test for human luteinizing hormone
(Hemoglobin; by copper sulfate method, non-automated, $3.59)
(Glucose, blood; by glucose monitoring device cleared by he FDA specifically for
home use, $4.80)
(Blood, feces, $6.61)
(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)
(Microhematocrit, spun, $3.59)
(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 &
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.
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
For more information, call (504)
924-7051, and ask for our EMC department.