PROVIDER UPDATE
VOLUME 12, NUMBER
2
MARCH/APRIL 1995
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.
Obesity
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.
Infertility
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
Unisys
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.
Reminders
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
Issues
-
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
INR=
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
|
Thromboplastin
|
Patient's
PT*
|
Mean
Normal*
|
PT
Ratio
|
|
A
|
17
|
12.0
|
1.4
|
|
B
|
18
|
12.0
|
1.5
|
|
C
|
21
|
13.0
|
1.6
|
|
D
|
24
|
11.0
|
2.2
|
|
E
|
38
|
14.5
|
2.6
|
*seconds
�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.
|
Thromboplastin
|
Patient's
PT*
|
Mean
Normal*
|
PT
Ratio
|
ISI
|
INR
|
|
A
|
17
|
12.0
|
1.4
|
2.8
|
2.6
|
|
B
|
18
|
12.0
|
1.5
|
2.4
|
2.6
|
|
C
|
21
|
13.0
|
1.6
|
2.
|
2.6
|
|
D
|
24
|
11.0
|
2.2
|
1.2
|
2.6
|
|
E
|
38
|
14.5
|
2.6
|
1.
|
2.6
|
*seconds
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.
Complications
Some co-morbid conditions preclude the use of warfarin
because of increased risk of bleeding.
-
Recent trauma
-
Active peptic ulcer
-
Coagulopathies
-
Uncontrolled hypertension
-
History of intracranial hemorrhage
-
Conditions that predispose patients to falls (drugs, Parkinson's disease,
frequent syncope, seizure disorders)
-
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
-
Be aware of the laboratory's method of reporting PT results (patient PT
ratio vs. INR).
- Maintain INR within suggested clinical guidelines for specific disorder
addressed.
- The incidence of warfarin-associated bleeding may be reduced by careful
attention to the INR.
- 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.
References
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.