Provider Update

April 1999

Volume 16, Issue 2

Year 2000 Update Identification of Quantities Dispensed Is Necessary
BHSF Clarifies Physician Supervisory Responsibilities DHH Designates New Division of Bureau of Health Services Financing
Changes to Technical Component Codes Direct Deposit of Medicaid Claims
Enrollment in Vaccines for Children Program Clarifications for DME Claims and Waivers
Hyperbaric Oxygen Therapy Diagnosis Code List Updated New Dispatch Service Appointed
Selective Billing of Medicaid Covered Services Cost Report Audits Provided for in Louisiana Medicaid State Plan
Outpatient Services Included in Inpatient Bill Claims Filing
Mistake in Code J9265 LADUR Education Article

Year 2000 Update

Year 2000 Readiness Disclosure

As press coverage of the new millennium increases, the Department of Health and Hospitals (DHH) and Unisys want to assure you that work is continuing to prepare the Medicaid Management Information System (MMIS) for Y2K readiness. As work progresses, you, the providers, will see changes in the following areas:

Remittance Advices (RAs)

Beginning with the 4/6/1999 RA, you will see several minor changes on the hardcopy RAs. The RA date in the upper right section of each page will appear as an 8-digit date with appropriate divisions between the month, day, and 4-digit year (MM/DD/CCYY). The �From� and �Through� date will remain 6 digits (MM DD YY). All other dates (financial page dates, duplicate claim dates, etc.) will appear as 8-digit dates without divisions (MMDDCCYY or CCYYMMDD). Electronic RAs and Remittance Tapes will not change and will continue to contain 6-digit dates.

Hardcopy Checks

Hardcopy checks will be modified, beginning 4/6/1999, to show an 8-digit date (MM DD CCYY).

Electronic Funds Transfer (EFT)

DHH and Unisys have worked closely with Bank One and determined that no changes will be made to the EFT process.. Bank One will use standard windowing techniques to convert 6-digit dates to 8-digit dates as needed.

Electronic Media Claims (EMC)

As stated in the December 1998 Provider Update article, no changes will be made to the EMC submission process at this time. Once thenational standardized submission formats are finalized (probably in Fall 2001), EMC processes will be modified to handle the new standards. Until then, DHH has decided to maintain current submission standards and employ standard windowing techniques for date conversions to handle year 2000 dates.

Hardcopy Claims

Hardcopy claims will continue to be accepted with 6-digit dates. Unisys will employ standard windowing techniques to expand to 8-digit dates for internal processing.

Pharmacy Point of Sale (POS)

There will be no changes necessary for providers using the Pharmacy POS system. Watch for updates to the Year 2000 conversion process of the MMIS system in future Provider Update articles. Unisys and DHH personnel continue to work diligently to see that the MMIS is Y2K ready and that all claims will be processed correctly after December 31, 1999.

Bureau of Health Services Financing Clarifies Physician Supervisory Responsibilities

The Bureau of Health Services Financing has been asked to clarify the supervisory responsibilities of the physician who supervises one or more physician assistants.

Louisiana Revised Statute 1360:22 states a "supervising physician" is a physician who has been approved by the Louisiana State Board of Medical Examiners to supervise a physician assistant. "Supervision" means responsible direction and control, with the supervising physician assuming legal liability for the services rendered by the physician assistant in the course and scope of the physician assistant's employment. Such supervision shall not be construed in every case to require the physical presence of the supervising physician. However, the supervising physician and the physician assistant must have the capability of being in contact with each other by either telephone or another telecommunication device.

Additionally, the supervising physician must register with the Board the name of each physician assistant under his control.

In other words, a physician assistant can be supervised electronically or telephonically within a reasonable distance by the supervising physician. He or she CANNOT be supervised by a physician who is out of the country, however. The physician assistant whose supervising physician is away for a given period of time may be supervised by a qualified supervising physician on a locum tenens basis until the return of his or her supervising physician.

No physician shall act as a supervising physician for more than four physician assistants at any one time.

Supervision shall exist when the supervising physician responsible for the patient gives informed concurrence of the action of a physician assistant, whether given prior to or after the action, and when a medical treatment plan or action is made in accordance with written clinical practice guidelines or protocols set forth by the supervising physician.

Physician assistants will not be enrolled as Medicaid providers. The supervising physician or rural health clinic may submit claims for Medicaid reimbursement for their physician assistant services provided the physician assistant's supervising physician executes an affidavit attesting that the services were performed within the scope of the supervising physician's authority under LA.R.S.37:1360.21 - 1360.38.

Changes to Technical Component Codes for Cardiology Procedures Announced

Effective with date of service April 1, 1999, technical component codes 93231, 93232 and 93236 will be made payable for crossover claims only.

Effective the same date codes 93005, 93041, 93270 and 93271 will be placed in non-pay status for straight claims and will be made payable for only crossover claims.

The pay status for four other technical component codes, 93012, 93017, 93225 and 93226, will also be changed effective with date of service April 1, 1999. Rather than paying for QMB claims, only, these codes will be made payable for ALL crossovers.

Enrollment in Vaccines for Children Program

The Vaccines for Children (VFC) program provides public purchased vaccine, for eligible children, at no charge to public and private providers. The Office of Public Health has been distributing vaccines to all VFC enrolled providers since October, 1995.

VFC covers vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and approved by the Centers for Disease Control and Prevention (CDC). Medicaid will pay the $9.45 administration fee for the vaccines available through VFC for Medicaid eligible children.

Medicaid providers not already enrolled in Vaccines for Children should contact the Office of Public Health's Immunization Section at 504-483-1900 for more information or to enroll in VFC if they provide vaccines to Medicaid eligibles.

Hyperbaric Oxygen Therapy Diagnosis Code List Updated

In keeping with Medicare policy, we are updating the list of Hyperbaric Oxygen Therapy diagnosis codes for which we reimburse Medicaid providers. Effective with date of service April 1, 1999, Medicaid will cover the following ICD-9 Diagnosis Codes for CPT Code 99183.

039.0-039.9 927.20-927.21
40.0 928.8-928.9
444.21-444.22 928.00-928.01
526.89 928.10-928.11
686.01 928.20-928.21
686.09 958.0
728.86 986
730.00-730.19 987.7
733.41-733.49 989.0
903.01 990
904.0 993.3
904.41 993.9
909.2 996.52
927.8-927.9 996.90-996.99
927.00-927.11 999.1

Effective with date of service April 1, 1999, the following Hyperbaric Oxygen ICD - diagnosis codes will not be covered:

250.7 730.7-730.9
362.30-362.31 900-904
443.81 925-927
444.0-444.2 928.0-928.3
444.8 929.0-929.9
686.0 996.7
730.1-730.3 996.9

All diagnosis codes that are deemed not medically reasonable or necessary will be denied.

Selective Billing of Medicaid Covered Services

Please refer to the rule entitled "Provider Billing for Covered Services" published in the March 20, 1991 issue of the Louisiana Register and the article entitled "Picking and Choosing Services" subsequently published in the June 1991 issue of the Provider Update. The rule states that "practitioners who participate as providers of medical services shall bill Medicaid for all covered services performed on behalf of an eligible individual who has been accepted by the provider as a Medicaid patient."

The Health Care Financing Administration (HCFA) has recently advised us that there continues to be instances of providers (physicians) inappropriately requiring Medicaid patients to make cash payments to them for Medicaid covered services. To illustrate the seriousness of this problem, HCFA provided the example of an anesthesiologist who refused to administer an epidural if the Medicaid patient did not make an up-front payment for the anesthesia service.

HCFA has recommended that we advise HOSPITALS of their responsibility under the Medicaid Program when a physician demands cash payment for a covered service as in the situation described above. When a hospital accepts a Medicaid patient for treatment, it also accepts the responsibility for ensuring that the patient receives all medically necessary services ordered by the attending physician. The conditions of participation that govern hospital care provided to Medicaid and Medicare patients require that the governing body of the hospital assures the accountability of the medical staff for the quality of care provided to patients.

HCFA further states that if the physician does not accept a particular patient for treatment, the hospital has the responsibility of assuring the delivery of these medically necessary services without imposition of deductibles, cost sharing, or similar charges.

To quote HCFA, "Each physician determines whether or not to accept an individual patient for treatment. A physician who participates in a State's Medicaid Program, and agrees to treat a Medicaid patient for service covered by the state plan, may not require a co-payment for his or her services, but must accept payment by the State's Medicaid agency as payment in full. Under federal Medicaid law, deductibles, cost sharing or similar charges are not permitted for Medicaid services furnished to pregnant women. Thus, a participating physician's demand for these additional payments would be a violation of the law. However if a physician accepts an individual for treatment not as a Medicaid patient, but as a private patient, and the Medicaid beneficiary accepts the arrangement as a condition of treatment for pregnancy and delivery; the arrangement is not governed by Medicaid regulations."

Further questions regarding this policy may be referred to Kandis McDaniel, Physician Program Manager, or Derek Stafford, Hospital Program Manager.

Outpatient Services Included in Inpatient Bill

Louisiana Medicaid policy states that outpatient services performed during an inpatient stay are to be included in the hospital's inpatient bill. Please refer to page 5-2 of the Hospital Services Manual.

Until now, there have been no edits in place to deny outpatient claims that occur during the inpatient hospital stay.

Effective for date of service 2/15/99, new error edits are in place to prohibit payment of outpatient claims billed for dates when the patient was an inpatient. Two error messages will be used to deny these claims.

Error code 172 - same provider, outpatient during an inpatient stay.

Error code 173 - different provider, outpatient during an inpatient stay.

Any questions concerning these error edits can be directed to Celia Gascon at (225) 342-8223.

Mistake in Code J9265 Corrected

When code J9265 (Paclitaxel, 30 mg) was funded, a mistake was made in the number of units payable per day to providers. Only one unit was payable per day, rather than the number actually administered, until September 9, 1998, at which time this error was corrected.

Adjustments for dates of service not yet two years old may be filed if you were inaccurately paid for a date of service prior to 9-9-1998.

We regret any inconvenience this incident may cause you.

Identification of Quantities Dispensed is Necessary

You are reminded that when submitting POS claims with fractional quantities, you are required to identify the actual quantity dispensed.

Examples: Stadol NS� (one bottle) has a quantity of 2.5 ml. The quantity submitted for payment of one bottle should be 2.5, not 3. If 2 bottles are dispensed, the quantity should be 5, not 6.

Xalatan� ophthalmalic drops (one bottle) has a quantity of 2.5 ml. The quantity submitted for payment of one bottle should be 2.5, not 3. If 2 bottles are dispensed, the quantity should be 5, not 6.

DHH Designates New Division of Bureau of Health Services Financing

In August 1998, the Administration of the Department of Health and Hospitals designated a separate division within the Bureau of Health Services Financing solely devoted to developing, managing, and overseeing the operations and monitoring of the home and community-based service waivers.

Bureau staff has been designated in each DHH region to address these programs, and an agreement between BHSF and the Office for Citizens with Developmental Disabilities allows the two offices to work jointly in precertification visits and monitoring visits. This joint effort is expected to provide valuable, needed services to each participant in a home and community-based waiver in Louisiana.

In addition, the Division of Home and Community-Based Waivers has established a complaint process that provides a system for reporting, investigating, and insuring health and safety for individuals who receive waiver services. To facilitate the reporting of complaints, a toll free telephone number has been installed. The number is 1-800-660-0488.

Direct Deposit of Medicaid Payments

The Department of Health and Hospitals initiated the direct deposit of weekly (monthly for Long-Term Care) payments for Medicaid services effective January 1998. We are proud to declare that the agency is at approximately 95% of its goal in having all payments deposited directly into the financial accounts of our participating providers.

We have learned over the last few months that there are several problems associated with the direct deposit arrangement. Provider file updates and/or changes should include the direct deposit agreement if appropriate. For example, if an individual physician is currently employed by a hospital or clinic, payments for his services are being deposited into the bank account for that facility. If the physician chooses to open his own private practice, he must complete the direct deposit agreement in order to have payments made to his own bank account. Also, when changing bank accounts, you must notify the Provider Enrollment Unit in a timely manner in order for payments to be made to the appropriate account.

The monthly bank statement should be reviewed in order to determine the date and amount of the payment made by the Department of Health and Hospitals. The deposit account number on your bank statement consists of the middle five digits of your Medicaid provider number with two leading zeros plus the remittance advice number. The amount of the deposit for a particular date is the same as the total payment shown on the financial page of the remittance advice of the corresponding date.

All areas of clearance should be attempted before contacting the Department. We would like to stress that providers try to resolve the problems with their accounting departments or their banking institution before contacting the Department of Health and Hospitals. If satisfaction cannot be obtained, then call the Provider Enrollment Unit at (225) 342-9454.

Clarifications for DME Claims and Waivers

DME providers should always enter DME in large, bold letters at the top of each claim form. DME claims should be mailed to P.O. Box 91020. We are finding that many DME providers are mailing claims incorrectly to the P.O. Box designated for submission of prior authorization requests, thus causing a delay in the processing of their claims. Please insure that you are submitting your DME claims to the proper P.O. Box and that they are marked appropriately with DME at the top of the form.

Waiver providers should always enter WAIVER in large, bold letters at the top of each claim form. Waiver claims should also be submitted to P.O. Box 91020. Please insure that your claims are marked appropriately with WAIVER at the top of the form and mailed to the correct P.O. Box.

New Dispatch Service Appointed

Effective 2/1/99, Medical Dispatch Inc. replaced LaVergne�s Telemessaging as the contractor for Non-Emergency Medical Transportation dispatch services in the Alexandria region and the Shreveport/Monroe region. In the transition process, they are experiencing problems with scheduling both capitated and regular trips at this time. We are aware of the problems and are attempting to resolve them in a timely manner or as soon as possible.

Providers who have transported recipients for capitated trips which were not authorized in this transition period will be paid for the trips. Medical Dispatch will work with the NEMT providers to rectify the situation. We regret the inconvenience and we thank you for your patience.

Cost Report Audits Provided for in Louisiana Medicaid State Plan

The State of Louisiana performs audits of cost reports for a representative sample of providers in each per diem reimbursed program in order to assure that reimbursements to providers are reasonably related to costs.

In accordance with CFR42CUR, �431.107 and the Louisiana Medicaid State Plan, providers participating in the Louisiana Medicaid program agree to keep any records necessary to disclose the extent of services the provider furnishes to recipients, and, on request, furnish to the Medicaid agency, the Secretary, or the State Medicaid fraud control unit any information regarding payments claimed by the provider for furnishing services under the plan, and comply with the disclosure requirements specified in CFR42CUR, Chapter IV, Part 455, Subpart B.

In addition, The Code of Federal Regulations, as stated in CFR42CUR 420.302, has, since the early 1980s, required that "when a provider enters into a contract with a subcontractor, e.g., management company, pharmacy, doctor, hospital, etc., for service, the cost or value of which is $10,000 or more over a 12-month period, including contracts for both goods and services in which the service component is worth $10,000 or more over a 12 month period, the contract must include a clause giving state or federal health agencies or their agents, access to the subcontractor's books until expiration of four years after the services are furnished under the contract or subcontract." Access shall also be allowed for any subcontract between the subcontractor and any subsequent subcontractors and any organization related to any subcontractor.

If a contract subject to the requirements of this section does not contain the clause as required, the Louisiana Medicaid program, in accordance with CFR42CUR 420.302, "will not reimburse the provider for the cost of the services furnished under the contract and will recoup any payments previously made for services under the contract."

Claims Filing

To expedite payment, providers should send �clean� claims directly to the appropriate post office box as listed below. All post office boxes are for Unisys Corporation, Baton Rouge, LA, 70821.

Type of Claim      P.O.Box
Pharmacy      91019
Providers billing on HCFA-1500:          Professional, Independent Labs,Substance Abuse and Mental Health Clinics, Hemodialysis Professional Services; Chiropractor,Durable Medical Equipment, Mental  Health Rehab; EPSDT Health Services,Case Management, FQHC, Rural HealthClinics  91020
Inpatient and Outpatient Hospitals,Long Term Care, Hospice,Hemodialysis Facility, Free- standing Psychiatric Hospitals    91021
Dental, Transportation (Ambulance and Non-Ambulance), Rehabilitation,Home Health   91022
Crossovers and Adjustments 91023
Provider Relations    91024
EMC, Unisys Business, andMiscellaneous Correspondence    91025
Prior Authorization          14919
KIDMED 14849

Normal Processing Time for Paper Claims

Normal, clean claims that go to the Claims P.O. Box should take no more than 30 calendar days from the date Unisys receives the claims. Providers should allow a few days for Unisys to receive the mailed claims.Of course, claims that must pend will take longer. Nonetheless, these will appear in the provider�s �claims in process� section of the remittance advice within the 30-day timeframe.

Louisiana Drug Utilization Review (LADUR) Education

Erectile Dysfunction: Part 2Prescription Drug Utilization for the Treatment of Erectile Dysfunctionin the Louisiana Medicaid Program

By: Sandra Blake,Ph.D, Philip Medon, Ph.D, and Edwin Adams, Pharm.D


� The demographics of the Erectile Dysfunction population.

� The utilization of drug treatments for erectile dysfunction in the Louisiana Medicaid Program.

� Cost and impact of the 6-unit limit.

In the last issue of the Louisiana Medicaid Provider Update, the etiology and pathology of erectile dysfunction (ED) were discussed along with a brief review of drug treatment options. Part 2 of this series on ED used claims data to demographically describe the ED population and to examine utilization of drug treatments for ED in the Louisiana Medicaid program. Associated costs and the impact of the 6-unit limit were examined. The Northeast Louisiana University School of Pharmacy (NLU) conducted several studies of prescription drug utilization in the treatment of ED over the past eight months. This article presents results of the most recent study, through December 31, 1998. 

Unisys Corporation extracted the data from the Medicaid claims history file, reformatted it and delivered it to NLU for analysis. Twelve of the 15 claim types were extracted, covering medical, pharmacy and allied health claims, such as durable medical equipment and home health. To be identified and included in this study, a recipient must have met at least one of the following criteria within the study period (July 1, 1997 through December 31, 1998): 

1. Had one or more claims with a primary or secondary diagnosis of erectile dysfunction of inorganic (ICD-9-CM 302.72) or organic (ICD-9-CM 607.84) origin; or 
2. Had one or more pharmacy claims for Caverject, Muse, Edex or Viagra. 

Two thousand four hundred seventy-five recipients met the criteria and were included in this study. Only three recipients were found to have had a diagnosis of ED in a medical claim but did not have a paid pharmacy claim for one of the above-mentioned drugs. Demographic data on the study group was obtained from the most recent claim for each recipient. Table 1 presents an overview of the demographics of the study group. In Table 1, the majority of Medicaid recipients receiving treatment for ED was disabled (74.06%). Over half (55.96%) could be considered middle-aged, between the ages of 43 and 62 (Age 43-52, 22.71% and Age 53-62, 33.25%). Also, the majority of the study group was black (58.14%), followed by white (26.51%) and Asian American (15.35%). Most resided in the New Orleans area (39.39%) However, each of the four areas of the state was well represented, as can be seen by the table. Charts 1-4 present pharmacy utilization and costs for the four drugs studied: Caverject, Edex, Muse and Viagra. As the charts readily show, in April 1998, when Viagra became available, pharmacy costs and utilization for treatment of ED increased substantially. However, the dollar cost increases were not due to an increased cost per prescription. As Chart 1 shows, the number of recipients receiving drug therapy for ED each month increased from the approximately 40-50 per month (using Caverject, Edex or Muse) to over 800 per month. There are currently about 18-22 recipients per month receiving a prescription for one of these drugs and about 850 per month receiving a Viagra prescription. The data analysis showed that during the study period 266 recipients had at least 1 prescription for Caverject, Edex or Muse. Also during the study period, 2,365 recipients had at least 1 prescription for Viagra. These numbers indicate that not all recipients who received a Viagra prescription received a refill each month. The analysis further showed that new prescriptions for Viagra (of any strength) continue to decline. In May 1998, there were 745 recipients receiving their first prescriptions for Viagra. In August, only 190 received a first prescription. And, in December 1998, only 94 received a first prescription. Chart 2 provides a brief look at total payments for drug treatment of ED. The chart clearly shows the costs for this class of drug rose substantially after Viagra became available. Chart 3 shows the average quantity per prescription of Caverject, Muse or Edex and Viagra. The impact of the 6-unit limit for Viagra prescriptions is seen quite clearly in the abrupt reduction in average quantity per Viagra prescription. Chart 4 compares the average cost per prescription. As can be seen, a prescription of Caverject, Muse or Edex costs between $100 and $120, depending on quantity. The cost of a prescription of Viagra currently costs slightly less than $50. This chart also shows the impact of the 6-unit limit. It appears from Charts 1-3 that the costs associated with Viagra result from the increased numbers using ED drug therapies rather than an increased cost per treatment. There are a number of drugs associated with ED. Table 2 presents several of the more common and the number of recipients receiving both ED drug treatment and at least 1 prescription of one of these other drugs. A review of patients' drug profiles may indicate a possible therapeutic substitution for one of the listed drugs and negate the need for Caverject, Edex, Muse or Viagra.