Provider Update

Volume 13, Number 2 

March/April 1996

Message From The LMMIS Deputy Director: LMPBM

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 provider community.

  • Foundation for the data exchange for outcome disease management research/studies/ education;

  • Forum for Medicaid managed care concepts;

  • 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 Medicaid Program.

Norm Nichols

  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, respectively.

 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 1-1-94.  

Code Base Units of Anesthesia  
48550 10
48554  20
48556  20

 The assistant surgeon fees are manually priced.

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 capabilities.


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 clinically equivalent.

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 secretion.  Extrapancreatic 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 thiazide diuretics.

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

 Clinical Pharmacology (An Electronic Drug Reference and Teaching Guide), v.1.5, Gold Standard Multimedia Inc.

 Goodman and Gilman's The Pharmacological Basis of Therapeutics, 9 (New York:  McGraw-Hill, 1995):  733-758.

 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):  50-69.

Pharmacy Program:  "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 group).

 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 maximum payment.

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 prescriptions billed.

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.

  1. A recipient can be monitored by a primary care physician, a specialist (if needed), and pharmacist.  

  2. 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  70896-6271.

  3. A recipient can be monitored only by a pharmacist.  

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 Pharmacies

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.

The 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 Process

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.  The 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 case.

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:

1)      The recipient's full name and Medicaid number.

2)      The first date which was not reimbursed through the date of discharge.

3)      The total number of days under appeal (please remember that discharge date is not reimbursable).

4)      The official name and address of the facility and the provider number.

5)      The name and telephone number of a contact person.

6)      The name, address, and telephone number of your attorney when one will be representing the facility.

7)      In addition, please send the last denial from the Unisys Pre-Certification Department.

This information must be sent to:

Gerard N. Torry, Director
Bureau of Appeals
P. O. Box 4183
Baton Rouge, LA  70821-4183

Fed Regs Forbid Accident-Related Claims for Profit

A 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 this practice.

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.

Must 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).


(Optional Control Number)

                                           Services have been provided
                                             Under Louisiana's Medicaid
                                             Program and are payable under
                                                R.S. 46:446:1 to:

                                          DHH Bureau of Health Services Financing
                                            P. O. Box 91030
                                            Baton Rouge, LA  70821-9030
                                            Attention:  Third Party Liability Unit

                                           Any additional authorization needed may
                                             Be obtained from DHH/BHSF's TPL Unit-
                                             telephone number (504) 342-9250).

  Trauma Diagnosis Codes

Providers are reminded to include the appropriate trauma diagnosis code when billing for accident-related injuries or illnesses. Provider cooperation is vital as trauma codes are used to help uncover instances of unreported third party liability.

How 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) 342-3893.

Vaccines for Children:  Changes in Reimbursement

The Vaccines for Children Program was 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:

                A.          DtaP - Diphtheria, Tetanus, and Acellular Pertussis;
                B.          DPT - Diphtheria, Tetanus, and Pertussis;
             C.          MMR - Measles, Mumps, and Rubella;
             D.          Poliovirus;
                E.           Hep B - Hepatitis B;
             F.           HIB - Hemophilus Influenza B;
             G.          Td - Tetanus and Diphtheria;
             H.           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.

  1. 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.  

  2. 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

  3. 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) 877-0666

              Unisys Electronic Claims:  (504) 237-3200

              Unisys Recipient Eligibility Verification System (REVS):  
                (800) 766-6323.

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.

  1. 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;  

  • Any other information, which might help to identify the specific claim in question; 

  • The Remittance Advice showing disposition of the specific claim in question.

  1. 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.  

  2. 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 issues.

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 be voided.

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.