Volume 13, Number 2
Message From The LMMIS Deputy Director:
As shared with the provider community,
a segment of the Louisiana Medicaid Pharmacy Benefits Management (LMPBM)
Program's primary components, consisting of the Point-of-Sale/Prospective Drug
Utilization Review (POS/ProDUR) system, is slated to commence operations in
April 1996. This is an exciting
addition to the Louisiana Medicaid Program, and we are proud to be part of this
program, one of the only Medicaid PBM programs of its kind.
The Department of Health and Hospitals
has structured the PBM to contain the major components of a private PBM;
however, there are unique features of this program.
For example, clinical aspects relative to quality outcomes, disease
management, and case management will be conceived through Louisiana schools of
pharmacy and medicine.
Essential features of the Louisiana PBM
include the emphasis on quality clinical outcomes, access by recipients to the
PBM, and conservation of Medicaid funds. As
education is also an important component of the PBM, a special Louisiana
Medicaid Interdisciplinary Medicine and Pharmacy Task Force has been meeting
over the past few months as an adjunct to the Managed Pharmacy Advisory Work
Group. This task force is comprised
of representatives from Louisiana schools of medicine and pharmacy, the medical
societies, the pharmacy associations, LHCA, and the Legislature.
The goals of the Task Force, with
respect to the PBM, are as follows:
Coordination of the educational
interventions of the LMPBM, schools of medicine and pharmacy, and the
Foundation for the data exchange for
outcome disease management research/studies/
Forum for Medicaid managed care
Consultation for PBM activities.
The Louisiana Medicaid
Interdisciplinary Medicine and Pharmacy Task Force is being chaired by the
Department's Medical Director, Dr. Larry Hebert.
This committee serves as a fine example of the seats of education,
provider community, private industry, and the Department working in concert for
the quality of health of the citizens of Louisiana.
In the succeeding months, we will
continue to keep you advised as to the Pharmacy Benefits Management Program.
Thank you for your continued support and participation in the Louisiana
Code J9381 Placed in Nonpay Status
Effective with date of service
February 15, 1996, code J9381 - BCG Intravesical - was placed in nonpay status.
The code to bill in its place is J9031 (which is the code Medicare uses
for BCG Intravesical, per vial). The
fee for J9031 is $72.42.
Notice to Anesthesiologists: Changes in CPT Codes
In 1996 CPT, there are new
"delivery after previous Caesarean delivery" codes (codes 59610
through 59622). Effective with date
of service January 1, 1996, anesthesiologists are to bill these new delivery CPT
codes using the same modifiers as are used with CPT codes 59410 and 59515.
Notice to Physicians:
CPT Codes in Nonpay Status
The CPT codes which were deleted in the
1996 issuance of the Physician's Current
Procedural Terminology will be placed in nonpay status effective with date
of service April 1, 1996. Please
program your billing systems immediately to bill current codes if you have not
already done so.
Changes in CPT Code 31276
Effective with date of service January
1, 1996, CPT code 31276 (nasal/sinus endoscopy, surgical with frontal sinus
exploration, with or without removal of tissue from frontal sinus) was placed on
the list of bilateral surgeries which pay 200% of the fee on file.
When this procedure is performed bilaterally, providers should place a
"2" in the units column and bill the procedure on one claim line.
Do not append the 50 modifier to this code. For further information on bilateral surgeries that pay 200%
of the fee on file, refer to the February 1, 1993 edition of the Physician
Services manual, Chapter 15, page 28-3.
Changes in Codes J9390 and J9396
Effective with date of service
January 1, 1996, oncology providers should use code J9390 to bill for the 10mg
dosage of Vinorelbine Tartrate (Navelbine) and code J9396 for BCG Tice Vaccine.
The fees are $47.21 and $147.50,
Codes J9206 and J9207 were placed
in nonpay status effective with date of service January 1, 1996.
CPT Codes Placed in Pay Status
The following CPT codes, which
are pancreas transplantation procedures, have been placed in pay status on the
anesthesia file and the assistant surgeon file effective with date of service
||Base Units of Anesthesia
The assistant surgeon fees are
Louisiana Drug Utilization Review (LADUR) Education
Pharmacological Treatment of NIDDM
Dr. Robert L. Judd
Asst. Professor of Pharmacology
Northeast Louisiana University
School of Pharmacy
NIDDM is a chronic metabolic disorder,
with complications ranging from peripheral neuropathy to peripheral nephropathy
and congestive heart failure.
The major group of pharmacological
agents utilized are the sulfonylureas.
Other agents, such as metformin or
insulin, may also be used, as well as possible new treatments for NIDDM.
Diabetes mellitus is a chronic
disease of carbohydrate, fat, and protein metabolism that affects approximately
14 million Americans. Almost 50% of
these cases are undiagnosed. Nearly
95% of patients with diabetes in this country have Type II, or
non-insulin-dependent diabetes mellitus (NIDDM).
Diabetes mellitus is the fourth leading cause of death from disease in
the United States. Among
working-age adults, diabetes is the principal cause of new blindness and primary
cause of nontraumatic lower extremity amputations and end-stage renal disease. Diabetes is a well-know risk factor for cerebrovascular
disease, peripheral vascular disease, and ischemic heart disease.
Uncontrolled diabetes and its resultant complications take enormous
personal, emotional, social, and financial tolls.
The direct and indirect costs of diabetes in the United States are
estimated to be more than $100 billion per year.
Pathophysiology of NIDDM
The pathophysiology of NIDDM is
multifactorial. It is well known
that NIDDM is an inherited disorder, but the specific genetic defects leading to
its clinical expression have yet to be elucidated.
The two fundamental defects associated with NIDDM are impaired or faulty
insulin secretion and insulin resistance. Additionally,
basal hepatic glucose production is increased in patients with NIDDM.
These three factors contribute to the glucose intolerance associated with
NIDDM. Whether one factor assumes
principal responsibility for the evolution of NIDDM remains unclear.
Management of NIDDM involves an
appropriate diet plan, exercise, oral sulfonylureas (with or without metformin),
and/or insulin. Because most
patients with NIDDM are overweight, a calorie-restricted diet is usually
necessary to effect weight loss and improve metabolic control.
The diet should offer the patient a range of food choices, and meals
should be evenly spaced throughout the day.
Because many patients with NIDDM have hyperlipidemia, fat consumption
(especially saturated fat) should also be reduced.
Patients who fail to achieve improved
metabolic control following an adequate trial of diet and exercise (including
weight loss) are candidates for pharmacological intervention. Options include oral sulfonylureas (along or in combination
with insulin), metformin (alone or in a combination with oral sulfonylureas),
and insulin alone. The optimal
approach depends on many factors, including the degree of hyperglycemia, patient
and provider preference, cost, patient age, glycemic goals, and self-monitoring
Six oral hypoglycemic agents are
marketed in the United States for Management of NIDDM.
They include four first-generation sulfonylureas (Acetohexamide [Dymelor],
Chlorpropamide [Diabinese], Tolazamide [Tolinase], Tolbutamide [Orinase]), and
two second-generation sulfonylureas (Glipizide [Glucotrol], Glyburide [Glynase
Pres Tab, Micronase, Diabetal]). Although the second-generation agents are more potent than
their predecessors, both agents have similar mechanisms of action, and they are
The primary effect of sulfonylureas is
to increase the secretion of insulin from pancreatic beta cells located in the
islets of Langerhans. The binding
of the drug to a plasma-membrane receptor on the beta cell results in insulin
mechanisms may also be involved, but this has not been demonstrated
significantly in a clinical situation. All
of the sulfonylureas undergo extensive hepatic metabolism to mostly inactive or
weakly active metabolites. The
hypoglycemic activity of the sulfonylureas may be prolonged by liver disease,
and caution should be exercised if sulfonylureas are used in patients with
impaired liver function. Sulfonylureas
and their metabolites are excreted mainly by the kidneys. They are extensively protein bound (more than 90%), making
them prone to displacement by other drugs.
Drug interactions are not uncommon with sulfonylureas, especially with
regard to first-generation agents. Interactions
which increase the hypoglycemic effects are cimetidine, fluconazole, salicylates,
and tricyclic antidepressants. Interactions
which decrease the hypoglycemic effects include beta-blockers, phenytoin, and
Sulfonylureas are generally well
tolerated. Adverse reactions which
are uncommon and usually mild, have resulted in a patient discontinuation rate
of only 2%. Gastrointestinal
complaints include nausea, vomiting, heartburn, and abdominal pain.
These problems can be reduced when the drug is taken with small amounts
of food. Although the sulfonylureas
are well absorbed, they should be administered 30 minutes before a meal.
Hypoglycemic reactions probably pose the greatest risk associated with
the use of sulfonylureas. Insufficient
food intake, missed meals, and alcohol consumption are major contributing
factors to hypoglycemic episodes.
"Secondary failure" is the
term used to describe initial glycemic control followed by gradual loss of
efficacy over months to years. Approximately
5-10% of patients taking sulfonylureas experience secondary failure.
In many cases, the cause is unknown.
Identifiable causes include hyperglycemic drugs, nonadherence to dietary
requirements, nonadherence to drug regimen, stressors (e.g., infection,
surgery), and/or weight gain. Available
evidence supports a trial of combination therapy for patients requiring large
doses of insulin (more than 100 units/day) and those with persistent fasting
hyperglycemia despite maximum doses of a sulfonylurea.
The biguanides (phenformin,
metformin, and buformin) are classified as antihyperglycemic agents used in the
management of NIDDM. In 1995, the
FDA approved metformin hydrochloride (Glucophage) for use as monotherapy or in
combination with a sulfonylurea treatment of NIDDM.
Metformin improves glycemic control by increasing glucose use in the
muscle and intestinal wall and decreasing insulin resistance.
Hepatic glucose production may also be affected.
As monotherapy, metformin can reduce fasting plasma glucose
concentrations by approximately 20%. When
combined with a sulfonylurea, the drug exhibits additive effects on glycemic
control. Combination therapy has
been shown to reduce basal plasma glucose concentrations by 20-40%.
Recent evidence suggests that insulin is required for the metabolic
action of metformin to occur.
Metformin is generally well
tolerated; however, its use is associated with a 20% incidence of
gastrointestinal distress (anorexia, nausea, diarrhea, and metallic taste). These effects are transient and dose-related, and can be
reduced with food. Hypoglycemia,
the major detrimental side-effect of the sulfonylureas, rarely occurs in
patients receiving metformin; exceptions occur when the drug is concomitantly
administered with oral sulfonylurea or alcohol. Lactic acidosis, which was a problem with phenformin, is also
uncommon in patients taking metformin. Contraindications
include renal disease or dysfunction, acute or chronic metabolic acidosis,
dehydration, and hypoxemia.
Recent Therapeutic Trends
Because many patients with NIDDM
ultimately require insulin therapy, various insulin agonists or insulin
replacements are currently under investigation.
Glucagon antagonists are also currently under development for use in
management of NIDDM. Their specific
roles, if any, await the results of prospective clinical trials. Acarbose (Precose) is an oral alpha-glucosidase inhibitor
that reduces the intestinal absorption of carbohydrates. Its primary effect is to lower postprandial blood glucose
levels. The FDA recently approved
its use for treatment of patients with NIDDM whose condition cannot be managed
by diet alone. Other agents include
the thiazolidinediones (e.g., troglitazone, pioglitazone), which sensitize
skeletal muscle, adipose tissue, and the liver to the actions of insulin.
One or more of these new agents may become accepted as therapeutic
alternatives for the management of NIDDM.
NIDDM is a chronic disorder, with
complications ranging from peripheral neuropathy to congestive heart failure. The major
group of pharmacological agents utilized are the sulfonylureas.
If they are ineffective, other agents such as metformin or insulin are
utilized. Several new
pharmacological treatments may be on the horizon.
Bressler, R., and D. Johnson,
"New Pharmacological Approaches to Therapy of NIDDM," Diabetes Care, 15 (1992): 792-805
Pharmacology (An Electronic Drug Reference and Teaching Guide),
v.1.5, Gold Standard Multimedia Inc.
and Gilman's The Pharmacological Basis of Therapeutics,
9 (New York: McGraw-Hill, 1995):
Mathews, S.J., "Focus on
Metformin: A New Biguanide
Antihyperglycemic Agent," Formulary,
30 (1995): 383-387.
Ponte, Charles D.,
"Non-Insulin Dependent Diabetes Mellitus - Current Practice and Future
Trends," Journal of the American
Pharmaceutical Association, NS36 (1996):
"Usual and Customary Charges"
Federal regulations governing the
Medicaid Program require that participating providers agree to charge no more
for services to eligible recipients than they charge for similar services to
non-recipients (general public). In
implementing this regulation, the Medicaid Program states that providers in the
Pharmacy Program may not charge a higher dispensing fee, on the average, for
recipients' prescriptions than is charged for non-recipients' prescriptions
(Third party and insurance prescriptions are components of the non-recipient
In performing the pricing portion
of the audit, there are certain criteria utilized to estimate whether a pharmacy
is overcharging the Medicaid Program. Some
of these criteria include making sure the prescription is for a top Medicaid
drug and making sure the prescription is not for catheters, catheterization
trays, insulin, or diabetic supplies (these are audited separately).
Thus, we would like to remind
pharmacists that if generic prescriptions are to be included in the general
public sample of the pricing audit, then the manufacturer or labeler of the drug
must be identified on the hard copy prescription or the computerized
prescription file. Also,
pharmacists should indicate their USUAL AND CUSTOMARY CHARGE on their claim
forms when billing for prescription services even if this charge exceeds our
Days Supply-Early and Late Refills
With Point-of-Sale, patient drug
compliance monitoring (early and late refills) will be conducted on-line through
the prospective drug utilization monitoring modules. Pharmacists must report an accurate days supply for all
If the days supply is not apparent, an
estimate must be made based on the pharmacist's professional judgment of the
quantity dispensed versus the dosing schedule.
This will result in a valid patient utilization record and fewer
prospective drug utilization edits for patient compliance.
Update on the Lock-In Program
Lock-In is an educational program
designed to inform recipients about their health status and appropriate use of
medications. Currently, we have a
two-tier Lock-In Program.
recipient can be monitored by a primary care physician, a specialist (if
needed), and pharmacist.
In these instances, the physicians who
are writing the prescriptions must be the physician providers listed on the
Medicaid ID card. In situations
when a referral was given by one of the Lock-In physicians listed on the
card, proof of the referral should be submitted along with the DTA (denied
turnaround agreement) to: DHH,
BHSF, Program Integrity-Pharmacy Unit, P. O. Box 65271, Baton Rouge, LA
A recipient can be monitored only by a
In these instances, the pharmacies
filing the prescriptions must be the pharmacy provider listed on the Lock-In
card. In a pharmacy-only Lock-In,
there are no restrictions on physician providers.
It is the responsibility of the pharmacist to monitor the recipient's
medications and contact physician prescribers when appropriate.
Effective April 1, 1996, a recipient
can be monitored by a Community Care physician provider and a pharmacy provider
(see the following article).
In these instances, the recipient must
see the Community Care physician provider for physician services, but this has no
impact on the adjudication of pharmacy claims.
When a Community Care physician is listed on an eligibility card which
also has a pharmacy Lock-In indicator, the only restrictions the pharmacist
needs to consider is the pharmacy segment.
Notice for Community
Care PCPs, Physicians, and
Effective with the issuance of the
April 1996 medical eligibility cards, some Community Care recipients will remain
linked to their Community Care Primary Care Physician (PCP) as well as being
linked to a pharmacy-only Lock-In provider simultaneously.
As a Community Care PCP, or as a
physician to whom a Community Care recipient has been referred, your obligation
to the treatment of the Community Care recipient does not change.
In the case of a Community Care recipient who has a
Community Care PCP and a pharmacy-only Lock-In provider, the
recipient must see his/her Community Care PCP for all medical care including
referral for specialty care. The
fact that there is a pharmacy-only Lock-In provider listed on the medical card
does not impose additional restrictions on the PCP or on the physician to whom
the PCP referred the recipient. The
additional restrictions hold only for the recipient, who must fill all pharmacy
prescriptions at the pharmacy provider listed on the medical card.
The same applies to the pharmacy-only
Lock-In provider. There are no
physician provider restrictions, and the only restriction the pharmacy provider
is to consider is pharmacy-only Lock-In criteria.
New TPL Code for Medical Eligibility Card
HCFA regulations require that
recipients having private insurance coverage through an HMO carrier must use the
services of the HMO provider (for HMO-covered services) when the health
insurance premium for their carrier coverage is paid by the Medicaid-funded
Group Health Insurance Premium Payment Program (GHIPP).
A new TPL code H has been added to the Medical Eligibility Card (MEC) to
identify these recipients. Recipients
having a TPL indicator code H on the MEC must use providers approved through
their HMO plan for HMO-covered services. The
carrier code on the Medicaid billing claim must match the HMO carrier code on
the Medicaid TPL Resource File or the claim will deny.
Providers must determine, prior to
providing a service, which HMO the recipient belongs to and if the provider
himself is approved through that particular HMO.
(If the provider is not HMO approved, the recipient should be advised
that he/she will be responsible for the bill and given the option of seeking
treatment elsewhere.) Pharmacy
claims will still be handled through the "pay and chase" process;
however, claims denied by an HMO because the billing pharmacist was not HMO
approved will be voided back to the billing pharmacy.
Therefore, pharmacists must also determine which HMO the recipient
belongs to, and whether the pharmacist himself/herself is HMO approved.
GHIPP Program is a Medicaid program
that pays for the cost of premiums for group health insurance for
Medicaid-eligible persons when it is determined by DHH to be cost-effective to
do so. If the cost of the insurance
is less than what DHH would spend in Medicaid payments for services covered
under the policy, the insurance policy is considered to be cost-effective.
Medicaid recipients who are enrolled or eligible to enroll in a group
health insurance plan are eligible for participation in the GHIPP Program.
Providers wishing to refer a recipient
for this program or anyone with questions should contact the DHH Third
Party/Medicaid Recovery Unit, GHIPP Program at (504) 342-9250. The fax number is (504) 342-3893.
Hospital Pre-Certification Reconsideration/Appeal
All types of inpatient hospital stays
must be approved through the Pre-Certification Department at Unisys.
In the event that an admission or extension is denied and the facility
feels that there is a valid need for the admission or extension, the following
procedure should be followed.
Once the facility has received the
denial from the Pre-Certification Department, the facility may request a
reconsideration must be submitted in writing to the Pre-Certification
Department. The reconsideration
process will involve a physician-to-physician conference.
That means that the treating physician of the facility will have a
telephone conference with the Unisys physician on the clinical aspects of the
Do not send this reconsideration to the
Bureau of Appeals in DHH. It is too
early in this process to file a formal appeal.
If the Unisys physician upholds the
denial and the facility still feels that a valid need exists to admit or extend
the stay of a patient, then a formal appeal may be initiated through the Bureau
of Appeals in DHH.
When initiating a formal appeal, please
include the following information in the letter to the Bureau of Appeals:
The recipient's full name and Medicaid
The first date which was not reimbursed
through the date of discharge.
The total number of days under appeal
(please remember that discharge date is not reimbursable).
The official name and address of the
facility and the provider number.
The name and telephone number of a
The name, address, and telephone number
of your attorney when one will be representing the facility.
In addition, please send the last
denial from the Unisys Pre-Certification Department.
This information must be sent to:
N. Torry, Director
O. Box 4183
Rouge, LA 70821-4183
Fed Regs Forbid Accident-Related Claims for Profit
Void to Avoid
A provider who accepts Medicaid payment
for an accident-related service or illness may not later void the Medicaid claim
in order to pursue repayment from an award or settlement with a liable third
party. Federal regulations prohibit
All providers enrolled in Louisiana's
Medicaid Program are required to accept Medicaid payment as payment in full and
not to seek additional payment for any unpaid portion of the bill.
Stamp Medical Info
Providers who furnish medical
information to attorneys, insurers, or anyone else must obtain an ANNOTATION
STAMP and must assure that all outgoing medical information bears the stamp,
which notifies the receiver that services have been provided under Louisiana's
Medicaid Program (see example below).
MEDICAID PROVIDER NO. (7-digits)
(Optional Control Number)
Under Louisiana's Medicaid
Services have been provided
Program and are payable under
R.S. 46:446:1 to:
P. O. Box 91030
DHH Bureau of Health Services Financing
Baton Rouge, LA 70821-9030
Attention: Third Party
Be obtained from DHH/BHSF's TPL Unit-
Any additional authorization needed may
telephone number (504) 342-9250).
Providers are reminded to include the
appropriate trauma diagnosis code when billing for accident-related injuries or
Provider cooperation is vital as trauma
codes are used to help uncover instances of unreported third party liability.
To Find Us
Providers with questions about medical
services to Medicaid recipients involved in accidents with liable third parties,
and providers wishing to refer information about Medicaid recipients involved in
accidents with liable third parties may contact the DHH Third Party
Liability/Medicaid Recovery Unit at (504) 342-9250 or fax information to (504)
Vaccines for Children:
Changes in Reimbursement
The Vaccines for Children
initially implemented by an emergency rule published in the January 20, 1995
issue of the Louisiana Register. This
emergency rule noted that when the distribution system for the VFC immunizations
was fully implemented, Medicaid would begin only reimbursing the $9.45 for the
administration-related cost of vaccines. The
Office of Public Health has been distributing vaccines to all VFC enrolled
provider (both public and private) since October, 1995.
Therefore, effective for dates of service April 1, 1996, Medicaid will no
longer reimburse for the cost of vaccines and will only pay the administration
fee of $9.45 for all vaccines available through VFC, including the following:
MMR - Measles, Mumps, and Rubella;
A. DtaP - Diphtheria, Tetanus, and
B. DPT - Diphtheria, Tetanus, and
E. Hep B - Hepatitis B;
F. HIB - Hemophilus Influenza B;
G. Td - Tetanus and Diphtheria;
DTP-HIB combination vaccine.
Medicaid enrolled providers not already
enrolled in Vaccines for Children should immediately contact the Office of
Public Health's Immunization Section to enroll in VFC if they provide vaccines
to Medicaid eligibles.
Unisys Reminders to Providers
As providers know, the Unisys Provider
Relations inquiry staff strives to respond to provider inquiries quickly and
efficiently. However, there are a
number of ways in which the provider community itself can assist the staff in
responding to inquiries in an even more timely and efficient manner.
The Unisys Provider Relations telephone
unit is set up to receive telephone inquiries from providers, NOT recipients.
We do not have access to any information that could benefit recipients.
Therefore, PLEASE do not issue the Unisys Provider Relations telephone
number to Medicaid recipients. Recipient
inquiries tie up the phone lines disproportionately, reducing the number of
incoming provider calls that can be answered.
If recipients have problems with eligibility, it is appropriate to refer
them to their eligibility worker at the parish office.
Please review and reconcile the
provider Remittance Advice that you have questions on before calling the Unisys
Provider Relations Department for the status of claims.
Some providers call Provider Relations frequently to ask questions that
could be answered if they reviewed their RAs thoroughly.
However, Unisys encourages providers to call Provider Relations with
questions concerning printed policy, procedures, and billing problems
Questions regarding claims problems
should be directed to the Unisys Provider Relations inquiry staff.
Inquiries regarding other issues may be directed as follows:
Unisys Prior Authorization:
(504) 928-5263 or (800) 488-6334
Unisys Pre-Certification: (800)
Unisys Electronic Claims: (504)
Unisys Recipient Eligibility Verification System (REVS):
Providers inadvertently reaching the
wrong department may be asked to terminate the call and redial, as it is not
always possible to transfer calls between departments.
Providers should have the following
information ready when contacting the Unisys Provider Relations Department
regarding claim inquiries:
The correct Medicaid provider number;
The recipient's Medicaid recipient number;
The date of service;
other information, which might help to identify the specific claim in
Providers calling regarding difficult
claim problems requiring extensive research may be asked to submit their
requests in writing, along with any attendant documentation, to the Unisys
Provider Relations Correspondence Unit. This
unit has the capability to research claim questions in more detail and to
provide written responses regarding provider inquiries.
Finally, Provider Relations Field
Analysts are available to assist providers on-site and to provide training to
new problems and their office staff. Providers
are encouraged to request their assistance in resolving complicated billing
The Unisys Provider Relations
Department thanks you, in advance, for your cooperation with these requests.
Notice to Providers:
CPT Codes 80500 and 80502
Effective with date of service April 1,
1996, CPT codes 80500 and 80502, which are pathological consultations, will pend
for medical review. These
consultations are covered services when they are reasonable and medically
necessary for the diagnosis or treatment of an illness or injury. Claims for these procedures must have documentation of such.
The criteria to be met for payment can be found on page 38 of the
November 30, 1995 issue of the Medicare Providers' News.
Claims submitted without this documentation will deny.
Notice to Ambulatory Surgical Centers
It has come to our attention that some
Ambulatory Surgical Centers may be billing for supplies used in the treatment of
pain management. This is to inform
you that billings for the supplies and/or facility fees for the treatment of
pain management are against policy and any reimbursements received for such will
Notice to Professional Service Providers
Effective with date of service February
1, 1996, CPT codes 93010, 93016, and 93227, which are cardiography codes, become
payable on the professional component file (TOS 05) for crossover claims only.
These codes will remain payable on the full service file (TOS 03) for
straight Medicaid recipients.