Message from the Medical Director Claims for Services Rendered by Physician Assistants
Obesity Placement of CPT Codes 43842 and 43853 in Non-Pay Status
Infertility Dietetic and Other Types of Counseling Services
Billing for Pain Management Correction to UVS on CPT Code 95165
1995 Procedure Codes Requiring PA Unnecessary Documentation Sent with Claims
Documentation Sent Without Claim Form Error/Edit Code 106
EMC Submitters: Name/Number Mismatch Duplicate Denies of Provider-Submitted Professional Crossover Claims
Adult Dental Claims: EMC Billing Now Available Pre-Certification Program Update
All Providers Must Keep Accurate Records Procedure for Authorization of Outpatient Surgery as Inpatient
Professional Services Codes in Non-Pay Status Note to Mental Health Rehabilitation Providers
LADUR Education Article Case Management Training Set
152-N Form Requests Clarifications of Physician Policy
Correct P.O. Boxes for Claim Types Provider Site Visits Available

Message from the Medical Director

I would like to briefly review a topic covered in the Current Concepts section of the 2/16/95 New England Journal of Medicine.   A review article, "Abuse and Neglect of Elderly Persons," brings attention to a problem that is probably underappreciated by most physicians and health care providers.   Are you aware that one estimate puts 1 to 2 million older Americans experiencing mistreatment each year?

One must not only look for signs of physical abuse, but also emotional, financial, or neglective mistreatment. In view of our overall goal to promote wellness, any act of omission or commission that prevents an older adult from thriving in the community constitutes inadequate care or mistreatment.   Any individual who suspects that an older adult is being abused or neglected is required by Louisiana Law R.S. 14:403.2 to report the incident. Nursing home patients and adults younger than 60 who may have suffered mistreatment can be reported, anonymously if desired, to DHH's Bureau of Protective Services at (800) 989-4910.   Adults aged 60 and older residing in the community who are suspected of suffering neglect or abuse can be reported to the Governor's Office of Elderly Affairs at (800) 259-4990.

This six-page Current Concepts article quickly covers epidemiology, risk factors, clinical evaluation, interviewing techniques, physical findings, clinical procedures/items, and management.   Two main points need emphasis:   1)   the presentation is often subtle and 2)   the patient and caregiver need to be interviewed separately and privately.   How many of us ensure that we have a proper opportunity to identify such neglect or abuse?   Spouses and adult children constitute the majority of abusers.

One can apply many of this article's concepts and principals to spousal and child abuse (neglect).   Let us beware of the psychological harm that neglect or abuse can cause.   Let us review our practices for ways that we can improve early detection of this tragic social problem.

I would also like to point out a second article in that same issue of The New England Journal of Medicine, "Management of Occupational Exposure to Blood-Borne Viruses."   Six succinct pages review the assessment of exposure, the role of post-exposure prophylaxis, and post-exposure therapy for hepatitis B and C viruses and human immunodeficiency virus (HIV).   You could use this to update your Blood-Borne Pathogens Protocols.

Please write me at the Unisys mailing address if you have comments or suggestions.

Charles Lucy, MD MPH

Physician's Policy

Claims for Services Rendered by Physician Assistants

Claims for services rendered by physician assistants are to be billed to Louisiana Medicaid only if the location at which the services were provided is the same for both the supervising physician and the physician assistant (PA).   In other words, Louisiana Medicaid is not to be billed for the services rendered by a PA if the PA is in a location that is across town or elsewhere from that of the supervising physician even though the PA and the supervising doctor have electronic or other types of access to each other.   The two providers must be in the same office for said services and reimbursement to be billed and claimed.


Providers should be aware that diagnosis code 278.0 (obesity) will pend for medical review.   Surgical procedures used in the treatment of obesity are not covered by Louisiana Medicaid.   Providers should note, however, that all claims billed with this diagnosis code will be reviewed to determine the medical necessity.   If no other medical problem is noted, the claim will be denied.

Placement of CPT Codes 43842 and 43853 in Non-Pay Status

Effective with date of service March 1, 1995, we will place CPT codes 43842 and 43843 (dealing with morbid obesity) into non-pay status.   As noted below, Louisiana Medicaid does not honor claims for the treatment of obesity (278.0) if it is the primary diagnosis.


Louisiana Medicaid does not pay for services relating to correction of infertility problems, including sterilization reversal procedures.   This policy extends to any surgical, laboratory, or radiological service when the primary purpose of the diagnostic test or treatment is to establish a diagnosis related to infertility or to enhance reproductive capacity.   Claims for these services will be denied.

Dietetic and Other Types of Counseling Claims

The fee for all types of counseling, including dietetic, is included in the fee for the physician's office visit. Providers are not to bill Louisiana Medicaid for visits scheduled for subsequent days at which the only service rendered is a counseling service.   Said visits are subject to recoupment.

Billing for Pain Management

Louisiana Medicaid honors billings for procedure code 62279 (injection of anesthetic substance, lumbar or caudal epidural, continuous) for straight Medicaid recipients and Medicare/Medicaid crossovers, but only for delivery or surgery on the day of delivery or surgery.

Billings of code 62279 on subsequent days for pain management, pain control, or any other reason are contrary to Medicaid policy and funds paid for same will be recouped.

Correction to UVS on CPT Code 95165

Previously you were notified of the restriction placed on CPT Code 95165 (professional services for the supervision and provision of antigens for allergen immunotherapy; single or multiple dose vial(s), specify number of doses).   Through error, the UVS (number of units that can be billed in a 90-day period) was listed as 36 instead of 48.   This has been corrected to a UVS of 48.   This change will not be retroactive.

1995 Procedure Codes Requiring PA

Listed below are the new procedure codes in the 1995 CPT that require prior authorization.

31276 - Nasal sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus

43249 - Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus (less than 30 mm diameter)

51784 - Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique

52647 - Non-contact laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included).

Medicaid Billing Information

Unnecessary Documentation Sent With Claims

Recently, a claims screening clerk brought to our attention a hospital claim with over 1,000 pages of attachments.   Our curiosity as to why the hospital would copy every hospital record and send them in led us to research this particular claim.   A quick review of the claims history showed that the original electronic claim had been denied with a request for hard copy claim with supporting documentation.

We found that during the hospital stay, a certain operative procedure was performed that is most often used along with a female sterilization.   Therefore, operative reports were needed to ascertain that this operation did not involve sterilization.   A search through the documentation found the operative reports needed and the claim was processed and paid using only 5 of the 1,000 sheets of documentation.

This overreaction to the original denial and the copying of hundreds of sheets of reports (i.e., daily hospital logs) could have been prevented with an understanding of what are appropriate versus unnecessary attachments.   The following is a guideline of which attachments are appropriate and which are generally required.

Documentation                                                  Required With                                                 

Sterilization Consent Form                                Hospital & Physician Claims*

Hysterectomy Acknowledgement Form            Hospital & Physician Claims*

Operative Reports                                            Hospital & Physician Claims**

Visit Reports                                                    Physician Claims (Concurrent Care)**

Third Party Ins. Payment or Denials                  All Claims Types*

*Always Required.

**Required only if denied for needing documentation.   Check your provider manual for further information.


Unnecessary Attachments

These following types of attachments are generally not required:   invoices or copies of bills, or copies of recipient ID cards.   If a claim is denied for eligibility and numbers shown on remittance are same as on the ID card, contact the local eligibility worker at DHH.

Documentation Sent Without Claim Form

Unisys Louisiana Medicaid has noticed an increase in documentation sent in for previously denied claims without claim forms.   Louisiana Medicaid policy is that once a claim is denied for needing a report or other supporting documentation, a new claim must be submitted along with the required documentation.   Unisys receives and processes over 85,000 paper claims per week in addition to receiving and processing over 650,000 electronic claims.   Due to line item processing, the paper claims generate an average of two claims lines for each document received.

Thousands of claims are rejected each year because a claim copy does not accompany information being supplied in response to a deny code.   Not only it is against policy to use documentation without a claim form, it is also highly impractical to find, copy, and attach documentation to previously processed claims.   An erroneous match would result in inappropriate payment.   Therefore, this policy will remain in effect and we ask that each provider cooperate so that we may pay your claims quickly and correctly.

Error/Edit Code 106

Questions or problems concerning claims that denied for Error/Edit Code 106 (Billing Provider Not PCP or Services Not Authorized by PCP) should be directed to the Provider Relations Unit at Unisys which handles all other claim inquiries (refer to your Physician, Rural Health Clinic, or FQHC Provider Manual).   Effective immediately, the CommunityCARE staff should no longer be contacted about this error code.   The Provider Relations staff is ready to assist all providers with any questions or problems they may have concerning Error/Edit Code 106.   Provider Relations can be reached at (800) 473-2783 or at (504) 924-5040, Monday through Friday from 8:00 a.m. to 5:00 p.m.

Written inquiries must contain a note or letter explaining the nature of the problem, a copy of the remittance advice showing the Community Care denial code 106, and a copy of the recipient's eligibility card for the month in which the service was denied.

Written inquiries should be mailed to the following address:

Attention:   Provider Relations Unit
P. O. Box 91024
Baton Rouge, LA   70821

EMC Submitters:   Name/Number Mismatch

To avoid having Medicaid claims deny with error code 217 (Name/Number Mismatch), submitters must enter the recipient's name exactly as it appears on the recipient's Medicaid identification card.   Please enter as much of the recipient's name as will fit in the appropriate data filed.   If there is space, this includes entering any abbreviated personal title (Jr., Sr., I, II, or III). However, no punctuation or spaces should be entered with that title.

Even though different claim types have different EMC billing specifications, each provider is responsible for following these rules for matching names.   The fewest characters allowed for a recipient's name for EMC billing are five spaces for the last name and one for the first (adult dental, EPSDT dental, home health, non-emergency transportation, and pharmacy).   Other claim types are allowed more space - double-check your billing specifications and follow those rules.

On each provider's data file, however, it would be possible to input the name Tom Lee, Jr.   When you bill, the claim will deny with error code 217 if the last name and title have spaces or punctuation.   However, please contact your individual software vendor to review the rules for inputting the name on your system.   Your software may allow you to type LEE-JR (or any other equivalent). The software should compact the name to LEEJR.   It may even contain special data fields for these titles.   Again, if you have questions, contact your software vendor.

As stated above, some claim types allow more characters than others and you should complete as much as possible. For example, the name Sister Margaret Westinghouse on a HCFA 1500 claim should be entered as WESTINGHOUSESISTERMAR.

The following types of names have caused claims processing difficulties in the past.   These examples are the correct forms of these names.   Please note that these are only shown for claims with five spaces for last name as these are the most confusing.

            "Burny Age II" will be AGEIIB
            "Tyrone Le, Jr." will be LEJRT

If there are not enough characters in the last name to use all spaces provided, and if there is not personal title, the unused spaces should be left blank.   The first character of the first name should not be put in the unused space.   The first character of the first name should be placed in the field designated for the first name.   Examples are provided below.

            "Sister Rita Carter" will be CARTES
            "Father Michael Edmund" will be EDMUNF

Also, punctuation and spaces within names, such as the saint names and French names, should be ignored.   Examples are illustrated below.

            "Paul St. Julien" will be STJULP
            "David D'Hemecourt" will be DHEMED

For questions call the EMC coordinator, Sue Kendrick, at (504) 237-3239 or Debbie Perry at (504) 924-7051.

Duplicate Denies of Provider-Submitted Professional Crossover Claims

Due to a large number of hard copy provider-submitted crossover claims being submitted to Unisys Louisiana Medicaid, a study was done to determine if providers were waiting an appropriate time for the claims to "cross-over" from Medicare.

Using the last quarter of 1994, we found that 41,724 or 21.48% of all professional crossover claims were denied for duplicate submission.   Of these claims, 32,636 or 78.22% were "hard copy" (provider submitted paper claims) that denied against an already processed electronic claim.

Please allow a minimum of four weeks after you receive your Medicaid remittance for Louisiana Medicaid to process your claim before submitting a hard copy claim.

Louisiana Medicaid will process the electronic claims (sent by tape) in the same payment cycle in which they are received from Medicare.   However, there is a required delay before the Medicare carrier can send us the tape.   Also, while rare, it is possible for a tape to have problems and a second tape would have to be requested.   Therefore, please allow the suggested time before submitting hard copy.   It may save you and us unnecessary work.

Adult Dental Claims:   EMC Billing Now Available

Louisiana Medicaid would like to remind Adult Dental providers that they may now bill their claims electronically rather than hard copy.   The advantage of billing EMC is that claims get paid more quickly and more efficiently than paper claims.

If you have never billed any claims electronically, contact the Unisys EMC Unit for a start-up packet.

If you are already billing other claims electronically, call the EMC Unit for the Adult Dental specifications. The unit may be reached at (504) 237-3303.   If you have further questions, contact Sue Kendrick (504) 237-3239 or Debbie Perry (504) 924-7051 for more information.

Pre-Certification Program Update

The Unisys Pre-Certification Department has taken into consideration ongoing concerns and problems from the provider community.   In working with these considerations, we have redefined our processing flow and have developed resolutions to correct these issues.   For a smooth transition into the new process, we would appreciate your assistance in the identified areas as described below.

Policy Clarification

1.      Please note that effective March 1, 1995, providers will receive only fax letters from the pre-certification department rather than mailed letters.

2.      To receive pre-certification approval for outpatient procedures performed on an inpatient basis within the first 48 hours of admission (which are the only or primary ICD-9-CM codes listed), please remember to attach medical documentation to justify inpatient service.   For these procedures, providers must complete and send in both a P.C.F01 and a P.C.F02.


1.   On your fax cover letters, providers should identify total number of pages submitted in that particular fax.

2.   If the fax transmission is interrupted or aborted, proceed as follows:

A.    Attach the fax cover letter to the page(s) unsuccessfully transmitted.

B.    Label as "Fax #2 Due to Interrupted Transmission."

C.    Please identify the recipient's name on subsequent page(s) of a previously interrupted or aborted transmission.

3.      Check your fax transmittal receipt to verify that all pages were sent successfully.

4.      Please list an extension diagnosis for each extension request.   This extension diagnosis should be the attending physician's diagnosis at the time of the extension request and may or may not be the same as the admitting and/or primary diagnosis.

5.      Reconsideration requests are to be used only for denial cases that do not meet medical criteria on initial, extension, or retrospective requests.

All Providers Must Keep Accurate Records

The Surveillance and Utilization Review Unit reports that as a result of recent post-payment reviews a number of providers have had administrative sanctions applied due to undocumented services.   In addition to the recoupment of overpayments, some providers have been excluded from the program because of the extensive nature of lack of proper documentation.

We want to impress upon ALL PROVIDERS the necessity of keeping accurate records.   The following is a repeat message from the January/February 1994 Provider Update.

"The Louisiana Medicaid Program is often required to make payment and review decisions based on information contained in the patient record.   All services billed to the program should have proper documentation.

Proper documentation should include

  • Diagnosis and chief complaint
  • Relevant history
  • Examination findings
  • Response to therapy
  • Progress notes and patient disposition
  • Procedures performed and results
  • X-ray, lab, and diagnostic tests ordered along with results.

All records should be clearly legible and documented at a time in close proximity to the actual patient visit. All progress notes in the patient record should include a thorough and adequate narrative description of the foregoing items.   Standard forms with check boxes are usually in and of themselves not adequate for complete documentation."

The Surveillance and Utilization Review Unit will continue to conduct unannounced site visits to compare medical records against provider billing histories.   Claims paid without proper documentation will be considered overpaid and the money will be recouped from future claim payments immediately.

In some cases, the overbilling is so consistent as to be purposeful or intentional; these have been referred to the Medicaid Fraud Control Unit of the Attorney General's Office.

Procedure for Authorization of Outpatient Surgery as Inpatient

The following procedure has been implemented for an outpatient surgery performed on an inpatient basis, when the procedure is planned within the first two days of the hospital stay.

1.   The provider performing the surgery will complete a P.C.F02 form (Request for Acute Care Extension, Physician Reconsideration Review, or Hospitalization for Outpatient Procedure) and submit it to the hospital for transmission with the P.C.F.01 (Request for Pre-Cert and LOS Assignment).

2.   The BHSF physician will interpret this information to determine the approval or denial status of the admission.   If approved, LOS is assigned based on the primary diagnosis.   If denied, no LOS is assigned and the hospital and provider performing the surgery are refused authorization.

3.   The claim submitted by the provider performing the surgery may indicate the pre-certification number in Item #23 on the HCFA 1500 or the prior authorization/pre-certification number field on the EMC record.   If the claim is submitted without this number, Unisys will attempt to match pre-certification using the recipient identification number and dates of service.

4.    The claims processing programs will be modified to match the surgical procedure range on the inpatient claim to that on the pre-cert file only when the surgery date is within two days from the admit date.   The physician (surgeon) claim, having CPT code indicating outpatient surgery, will be processed against the pre-cert record and the system will check for the presence of a surgical procedure code when the claim's date of service is within two days of admit date.

Professional Services Codes in Non-Pay Status

The codes listed below were placed in non-pay status on the professional component file (TOS 05) effective with date of service April 1, 1995.   They remain payable on the full service (03) file.   When billing these codes in the future, do not modify them as they do not require a modifier.

58982              85095              85097

85102              86318              86332

86805              86807              88140

88150              88155              88230

88233              88235              88237

88245              88250              88262

88263              88267              88283

88285              88321              88325

88329              93000              93005

93010              93014              93015

93018              93041              93042

Note to Mental Health Rehabilitation Providers

The single largest problem that Medicaid is facing with the Mental Health Rehabilitation Program is that many of the recipients being served do not meet the target population.   It is the provider's responsibility to ensure that the recipients meet the target population in every aspect.   In addition, it is the provider's responsibility to ensure that the records clearly reflect that each and every part of the target population definition is met.

To meet the target population for this program, the client must have a history of serious mental or behavioral problems.   It is essential that the recipient record contain all documentation from the sources that identified these problems in the past.   These sources may include (but are not limited to) the family physician, the school teacher, OCS, the mental health center, mental hospitals, any previous counseling, school records such as the IEP, suspension reports, etc.

The record must give examples of the behaviors that led to the professional consultation and examples of behavior which indicates a disability from the disorder/illness.   Every record must contain documentation from sources other than the serving Mental Health Rehab agency.

If a psychological evaluation has been billed to the Mental Health Rehabilitation program, we expect to see all of the testing, the results of the testing, and the interpretation of the results.

Although the psychological, medical, and psychosocial assessments should draw from each other, it adds nothing to the documentation if they are copied from each other.   Each evaluation should be an independent assessment with personal interviews with the client, family members, and other essential people.

If a recipient has been denied Mental Health Case Management services after going through the Prior Authorization process, he/she does not qualify for the MHR Program.

Mental Health Rehabilitation services may be provided only after a Management Plan has been completed for the individual.   Therapy, psychosocial skills training, medication management, and crisis services can only be given after a Management Plan is in place.   If you are a provider of only one service such as therapy, you must receive your referrals from a provider who is a Mental Health Rehabilitation Management agency.   Any service provided under the Mental Health Rehabilitation Program must be on the Mental Health Rehabilitation Program Management Plan.   The plan must specify the specific quantity of service, the frequency of service, and the name of the agency who is to provide that service.

When you serve a child under the age of 6, you must submit your billing hardcopy on a HCFA 1500 along with all of the documentation to verify that the client meets the target population. The information will then be reviewed individually.   If the information does not indicate that the recipient meets the target population, you will receive a denial code 958.   If the information looks as if the recipient qualifies, but the information is insufficient, then you will receive a denial code 770.   In this case, send more detailed information, get information from other sources, review what you sent and compare it to the criteria to see if you are missing something.   Resubmit with a new total packet including the additional information.

Any claim billed to Medicaid must be for services performed by an employee of the provider agency.   Providers may not contract with individuals to provide services covered under the Mental Health Rehabilitation Program and then bill as though they were employees.

Louisiana Drug Utilization Review (LADUR) Education  

Oral Anticoagulant Therapy: Dosing and Monitoring Considerations


  • Prothrombin Time (PT) is the most common method for monitoring oral anticoagulant therapy.
  • Widely varying sensitivities of thromboplastin reagents can create confusion over interpreting results of the PT test.
  • The INR is recommend by WHO to standardize PT test results.
  • The International Sensitivity Index (ISI) measures thromboplastin sensitivity; the higher the ISI, the less "sensitive" the thromboplastin.
  • Current recommendations generally prescribe an INR between 2.0-3.0.
  • Some patients experience co-morbid conditions precluding warfarin use because of increased risk of bleeding.

Oral Anticoagulants
Warfarin exerts its effect by inhibiting the production of vitamin K-dependent clotting factors, protein C, and protein S.

Monitoring Prothrombin Time
Prothrombin time (PT) assesses the function of the extrinsic and common pathways of the coagulation cascade and is the most common method used for monitoring oral anticoagulant therapy.   PT reflects the time required for fibrin strands to appear after the addition of tissue thromboplastin and calcium to a patient's plasma.

For many years, PT was expressed in seconds, percent activity, or PT ratio.   PT ratio is determined by dividing the patient's measured PT by the mean normal PT for that particular reagent/instrument combination.   The PT ratio does not necessarily take into account differences in the sensitivity of the thromboplastin reagent used to perform the test.

Example of Patient Ratio Determination:   A patient's PT time is measured at 17 seconds and the mean control is 11 seconds.

Patient Ratio =       PT patient
                                   PT mean control

Patient Ratio =         17/11

    Patient Ratio=1.55  


There has been a proliferation of thromboplastin reagents with widely varying sensitivities possibly lending to confusion regarding the interpretation of the results of the PT test.   In response to wide variations in thromboplastin sensitivities, the World Health Organization (WHO) recommends a mathematical correction of the PT results known as the International Normalized Ratio (INR).

The INR relies upon the calibration of commercial thromboplastins against a standard reagent with a known sensitivity to the antithrombotic effect of oral anticoagulants. This in effect standardizes the results of the prothrombin time test.   In other words, the INR is the PT ratio that one would have obtained if the WHO reference thromboplastin had been used to perform the test.   INR is determined by the following formula.

            Patient's PT (seconds)           ISI


            Mean Normal PT (seconds)

Understanding the concept of INR reporting is important to warfarin monitoring.   It can be seen from the hypothetical example shown in Table One that one patient's blood sample sent to five different laboratories, each using a different thromboplastin reagent renders different PT ratios because of differences in thromboplastin sensitivity.

Table One


Patient's PT*

Mean Normal*

PT Ratio






















Extracted from �Information Concerning the Management of Coumadin�" (crystalline warfarin sodium); Product information; DuPont Pharma, DuPont Merck Pharmaceutical Co. 1994.

The above date demonstrates a need for some way of correcting differences in results rendered by a wide variation in thromboplastin sensitivity.   Today, the sensitivity of particular thromboplastin reagents is expressed by the International Sensitivity Index (ISI), a measure of the responsiveness of a given vitamin K-dependent coagulation factor compared to the international reference preparation.   The higher the ISI, the less "sensitive" the thromboplastin.

If confusion exists between the understanding of INR and PT ratio values, decisions regarding warfarin dosing decisions could present problems.   If one interprets an INR of 2.5 (a value within the recommended therapeutic range for oral anticoagulant therapy) as a PT ratio of 2.5 ( a value considered high), a decision to lower warfarin dosing could occur possibly reducing the beneficial effects of anticoagulant therapy.

Conversely, if a PT ratio of 2.5 is misinterpreted as an INR of 2.5, a decision to continue warfarin therapy at a dose capable of increasing the risk of adverse warfarin effects could occur.

When prothrombin time testing incorporates the ISI of the thromboplastin reagent, an extension of the hypothetical example data above is realized as displayed in Table Two.


Patient's PT*

Mean Normal*

PT Ratio


































Current recommendations prescribe maintaining an INR between 2.0-3.0 in patients receiving warfarin for non-rheumatic atrial fibrillation.   The recommended therapeutic ranges for various oral anticoagulant therapies in the prevention and treatment of thromboembolism associated with several other factors are presented below.

An INR of 2.0-3.0 should be maintained when the patient experiences any of the following:

  • Atrial Fibrillation
  • Bioprosthetic Heart Valves
  • Pulmonary Embolism
  • Venous Thrombosis
  • Systemic Embolism Post Myocardial Infarction.

However, an INR of 2.5-3.5 should be maintained in the case of mechanical heart valves.

The American College of Chest Physicians (ACCP) in the Third Consensus Conference on Antithrombotic Therapy has expressed its recommendation on intensity of anticoagulant effect entirely in terms of INR.

Some co-morbid conditions preclude the use of warfarin because of increased risk of bleeding.

  1. Recent trauma

  2. Active peptic ulcer

  3. Coagulopathies

  4. Uncontrolled hypertension

  5. History of intracranial hemorrhage

  6. Conditions that predispose patients to falls (drugs, Parkinson's disease, frequent syncope, seizure disorders)

  7. Some consider advanced age to be a co-morbid condition.   Several studies have failed to show an increased risk of hemorrhage in the older population unless there are co-morbid factors contributing to elevated risk potential.

Clinical Suggestions

  1.  Be aware of the laboratory's method of reporting PT results (patient PT ratio vs. INR).
  2. Maintain INR within suggested clinical guidelines for specific disorder addressed.
  3. The incidence of warfarin-associated bleeding may be reduced by careful attention to the INR.
  4. PT changes usually occur approximately 48-72 hours after beginning or changing warfarin dose.   It is recommended that PT laboratory data be done after this time to more accurately reflect the impact that the does change has on PT activity.

Albers, G. W., D. G. Sherman, D. R. Gress, et al., 1991, "Stroke Prevention in Nonvalvular Atrial Fibrillation:   A Review of Prospective Randomized Trials" in Annals of Neurology. 30:511-518.

Hirsh, J., 1992. "Substandard Monitoring of Warfarin in North America" in Arch Intern Med. 152:257-258.

Hirsh, J, J.E. Dalen, D. Deykin, and L. Poller, 1992. "Oral anticoagulant:   Mechanisms of Action, Clinical Effectiveness, and Optimal Therapeutic Range" in Chest. 102(suppl.):312s-326s.

International Committee for Standardization in Hematology and International Committee on Thrombosis and Hemostasis, 1985. "ICSH/ICTH Recommendations for Reporting Prothrombin Time in Oral Anticoagulant Control" in Journal of Clinical Pathology. 38:133-134.

Case Management Training Set

The next case management training workshop will be held in Lafayette on May 10, 1995.   For more information and to register, please call (504) 924-6774.

152-N Form Requests

For providers requesting 152-N forms, please include a contact telephone number (including the area code) with the request.

Clarifications of Physician Policy

In response to a large volume of provider inquiries regarding outdated policy in the Physician's Services Provider Manual, the Bureau of Health Services Financing hereby amends the policy sections listed below.

Providers should make note of these changes as all claims are now being handled according to this revised policy.

The blocked area in the center of page 7-2 in the Physician Services manual currently contains incorrect information.   Louisiana Medicaid will no longer pay more than one new patient code per two-year period to the same group practice, no matter the specialty.

The last paragraph of page 30-1 in the same manual also contains incorrect information.   We do NOT pay for both a hospital admission and an outpatient office visit to the same attending provider, same recipient, same day.   Any claims denied because of these rules are correct denials.

Finally, physicians should be aware that edits on CPT codes 99301, 99302, and 99303 (comprehensive nursing facility assessment codes for new or established patients) allow these billings by the same attending provider once every 730 days (two years).   In other words, a provider may bill one of these codes one time per patient every two years.   These edits are correct and will remain as is.   Denials for these codes billed more than once in a two-year period by the same provider are correct.

Correct P. O. Boxes for Claim Types

If you are submitting claims that do not require special attention, please submit them to the appropriate P. O. Box number rather than to Provider Relations.   This will expedite your claims processing.

Only claims requiring special overrides and written inquiries concerning claims or policy should be addressed to the Provider Relations post office box number.

Please address written inquiries to the Provider Relations Correspondence Unit rather than to a particular individual.   This will expedite the handling of your inquiry.

The zip codes for all of the following P. O. Box numbers is 70821.

Pharmacy:   P. O. Box 91019

Professional (HCFA 1500):   P. O. Box 91020

Inpatient Hospital, Outpatient Hospital, and Long Term Care:   P. O. Box 91021

Dental, Transportation, Rehabilitation, and Home Health: P. O. Box 91022

Crossovers and Adjustments:   P. O. Box 91023

Provider Relations and Other Written Correspondence:   P. O. Box 91024

EMC:   P. O. Box 91025

If you have any questions about these post office boxes, contact Provider Relations at (800) 473-2783 or (504) 924-5040.

Provider Site Visits Available

We have learned that many providers are not aware that Unisys has five field representatives who are available to visit you at your office to discuss billing problems, clarify state policy, or to train providers when necessary.

The field representatives can be reached by calling our Provider Relations Department at (800) 473-2783 or (504) 924-5040.   An appointment can usually be scheduled within two weeks.   Please be aware of this helpful service for your future needs.