Provider Update

Volume 22, Issue 3 

Summer 2005

National Provider Identifier Anesthesia Provider
Changes in the Hospice Program Routine Circumcisions no Longer Payable
Health Standards to E-mail Statements of Deficiencies Inhibin A (CPT Code 86336)
Staffing Data Changes on CMS Website Conscious Sedation Billing Issues
Claims Reconciliation and Resubmittal Third Party Liability - Newborn Notification
Implementation of e-PA LADUR Education Article
Reimbursement of Multiple Units for Surgical Procedures Insert - 2005 Provider Training Workshop Schedule

National Provider Identifier

The Centers for Medicare and Medicaid Services (CMS) has announced the adoption of a national provider identifier (NPI) for health care providers to use in the filing and processing of electronic health care claims and other transactions. This standard unique identifier is a mandate of the HIPAA legislation.

What will the NPI do?
� A 10-digit all numeric identifier will replace the use of all legacy provider identifiers. 
� It will reduce costs and improve efficiency of claims processing and reporting.

Who must apply for an NPI?
� All covered health care providers (i.e. those that transmit data in HIPAA standard electronic transactions) 
must obtain an NPI. All covered Louisiana Medicaid providers who transmit data in electronic form are 
encouraged to apply for a NPI.
� Health care providers who are non-covered entities may also apply for and be assigned an NPI.
� Providers who provide atypical or non-medical services that are indirectly health care related are not considered health care providers under HIPAA and are not eligible to receive an NPI. Examples include non-emergency transportation, carpenters, etc. 

Compliance Date:
� Covered providers may begin applying for NPIs now.
� All covered entities doing business with Medicaid must be using the NPI in standard transactions by May 23, 2007.

The national system that will handle the assignment of NPIs is ready to accept applications. CMS will provide the health care industry with information relating to the NPI, including the application process and the availability of the NPI application forms (see the CMS website for the sample applications at

The Final Rule for the HIPAA Administrative Simplification Standard Unique Health Identifier for Health Care Providers may be accessed through the CMS website at:

The Provider Update will continue to provide updates to this Rule.

Changes In The Hospice Program

Hospice providers and nursing facilities will notice a difference in the way hospice cases are handled. Medicaid field staff will no longer be responsible for entering hospice segments into the Medicaid Information System. This will be handled by Hospice Program staff the State Office. The BHSF Form 148 generated by the nursing facility, which reflects a recipient's hospice status must be faxed to the Hospice Unit at 225-342-1411

Nursing facilities will continue to send the Form 148 to the Medicaid analysts in the Parish Offices. The Hospice Unit will send hospice certification notices to the nursing facilities and hospice providers. Please pay close attention to the recipient's certification date. 

Hospice providers will need to contact the nursing facility for patient liability (PLI) amounts. Nursing facilities that have been paid for days after the date in which hospice was certified must either void or adjust those claims to ensure that they are not paid for days which the hospice provider is responsible for that patient. Federal regulations require that payments for hospice services be made to the hospice providers, including the room and board. The hospice provider is responsible for paying the nursing facility. Nursing facilities that do not correct claims are subject to administrative sanctions by DHH and/or the Centers for Medicare and Medicaid Services (CMS). We are requesting that hospice providers work closely with nursing facilities to ensure that payments are handled appropriately and within the federal guidelines. 

Health Standards Section to E-mail Statements of Deficiencies

On May 2, 2005, the Health Standards Section (HSS) began e-mailing the Level 2 and Statements of Deficiencies (SoDs) to nursing facilities. Only those nursing facilities with a current e-mail address on file with HSS will receive the electronic forms. The Enforcement Letter, Plan of Correction (PoC) Components and Informal Dispute Resolution (IDR) Request form will also be sent as attachments. The HSS email system will generate a "notification of receipt" when the facility opens the e-mail. Unfortunately, HSS is unable to receive the completed plan of correction via e-mail at this time. 

If you would like to verify your e-mail address or learn more about this new procedure please contact Kay Morris, Nursing Home Desk, at 225-342-0114 or e-mail

You may also verify your e-mail address by visiting the Nursing Home Online License Renewal website:

Staffing Data Changes On the CMS Nursing Home Website

The Centers for Medicare and Medicaid Services (CMS) continues to make improvements in the accuracy and comprehensiveness of staffing information available on the Nursing Home Compare (NHC) website. This information is essential in helping consumers make informed choices about nursing facilities. CMS is implementing a number of changes to the display of staffing information on NHC which will improve the accuracy of the information. The immediate consequence will be that some facilities� staffing information will be temporarily excluded from NHC or reported staffing ratios will be somewhat altered. Most facilities' staffing information will remain unchanged. 

As of April 2005, state agencies should have received a list of facilities whose staffing data has been excluded by CMS edits. Health Standards will be responsible for assuring that there have been no data entry errors. If it can be verified that data entry was accurate, the provider will be asked to confirm the data. CMS is only interested in staffing for certified beds. 

Claims Reconciliation and Resubmittal

It has come to our attention through claims review that many providers are not reconciling their remittance advices or working their claim denials in a timely manner. In order to be reimbursed for services rendered to Medicaid recipients, all providers must comply with the required claims filing limitations set by Medicaid. These requirements may also be found in all provider manuals and training packets.

It is the provider's responsibility to establish and maintain a system of tracking claim submissions, payments, and denials. This includes thoroughly reviewing the weekly remittance advice (RA), correcting claim errors as indicated by error edit codes and timely resubmitting corrected claims. Providers should also resubmit any claims which do not appear on an RA within 30-40 days of submission for hard copy claims and within three weeks of transmission for EMC claims.

Provider Relations will only respond to inquiries concerning particular claims when the provider has reconciled the RA and determined that the claim has been denied, pended, paid or rejected prior to entry into the system. Provider Relations does not reconcile provider accounts or work old accounts for providers. To assist with reconciling claims, providers may also use the web application e-CSI.

In situations where providers choose to contract with outside billing or collection agencies to bill claims and reconcile accounts, it is the provider's responsibility to provide the contracted agency with copies of the RAs, access to e-CSI, or other billing related information.

We encourage all providers to ensure that remittance advices are worked and claims resubmitted in a timely manner to avoid any potential problems with non-payment of claims due to filing limitations.

Implementation of Electronic Prior Authorization (e-PA)  

1. What is e-PA? 
e-PA is an abbreviation for electronic Prior Authorization. 
It is a Web-based application designed for the Louisiana Department of Health and Hospitals that can be used by providers to submit prior authorization requests to Unisys. e-PA allows for the completion and transmission of an electronic PA request form by providers via the web. It allows the provider to view an electronic response of the PA status after it is established by the Unisys Prior Authorization Department. 

2. Who can use e-PA?
e-PA is available to all currently enrolled providers participating in Louisiana's Medicaid Program who are required to submit prior authorization requests for services through Unisys, and who have registered on the Louisiana Medicaid website:
Note: At this time e-PA is not available for Dental PA requests, including Adult Dental, EPSDT Dental, and EDSPW Dental services. The Dental e-PA application will be enabled in the summer of 2005. 

3. Where is e-PA located?
It is located in the Restricted Provider Applications area on the website:

4. When will e-PA be available?
Below is the planned roll-out schedule for e-PA. The plan is subject to change by DHH.

5. How can I get training/additional information on e-PA and is there a user guide available?
If you want to schedule a training session or you want additional information, please contact your Unisys Provider Relations field representative. There is a user guide available for download on the LAMEDICAID.COM website in the NEW MEDICAID INFORMATION link on the left-hand side of the home page.

6. Who do I contact if I need technical support on e-PA?
Contact the Unisys Technical Support help-desk at 1-877-598-8753 (toll-free) or via e-mail at

Reimbursement of Multiple Units for Surgical Procedures

The Medicaid policy for reimbursement of multiple surgical procedures also applies to multiple units of CPT surgical procedure codes 10000-69990. When more than one unit is billed, the first unit is paid at 100% and all subsequent units are paid at 50%. This reimbursement logic was unintentionally overlooked when the enhanced reimbursement for recipients age 0-10 years was originally implemented. We recently became aware of this oversight and have corrected the logic and adjusted of claims retroactive to date of service, January 1, 2003. The adjustments appeared on the remittance advice of May 3, 2005.

Questions regarding these claims may be directed to Provider Relations at 1-800-473-2783 or 225-924-504.

Anesthesia Providers

We have corrected the system logic that prevented payment of anesthesia administered for a tubal 
sterilization following a vaginal delivery on the same date of service. Claims that were incorrectly denied for error edit 617 were recycled on the RA of April 26, 2005.

Questions regarding these claims may directed to Renee Haines, RN Coordinator at 225-342-6254.

Routine Circumcisions Are No Longer Payable

Effective April 21, 2005, routine circumcisions are no longer a covered Medicaid service in either inpatient or outpatient settings. However all medically necessary circumcisions will continue to be a covered 
service. Charges associated with routine (non-medically necessary) circumcisions must be identified as non-covered charges. 

Inhibin A (CPT Code 86336)

Effective for date of service July 1, 2005, Louisiana Medicaid has put CPT code 86336 for Inhibin A testing in �pay� status. This test is used for screening fetal abnormalities and coverage is not intended for use in fertility testing. 

Conscious Sedation Billing Issues

It has come to our attention that claims for conscious sedation (CPT codes 99141 and 99142) billed with surgical procedure codes have been incorrectly denied for error edit 791. Providers will be notified when the system logic has been corrected.

Louisiana Medicaid has adopted the 2005 CPT Guidelines which lists procedures that include conscious sedation as an inherent part of providing the procedure. Claims paid inappropriately are subject to recoupment. 

Third Party Liability-Newborn Notification

Beginning May 20, 2005, the Department of Health and Hospitals, Bureau of Health Services Financing adopted the provisions under the Third Party Liability Program governing newborn notification requirement for hospitals. The hospital shall report the birth and health insurance status of a qualifying newborn on a Newborn Notification Form. The form must be completed and submitted to any and all applicable health insurance issuers within seven days of the date of birth. It may be submitted via U.S.Mail, fax or e-mail. 

The form shall be sent to the Department of Health and Hospitals, Bureau of Health Services financing, Third Party Liability/Medicaid Recovery within seven (7) days of the birth of the child/children.

A copy of the Newborn Notification Form is available for download on the website.

Louisiana Drug Utilization Review (LADUR) Education

Polypharmacy: Consequences and Management

By: Corbin Turpin, M.D., Melissa L. Dear, R.Ph., and Pam Walters, R.Ph.


� Polypharmacy is the use of multiple prescriptions and/or over-the-counter medications simultaneously.

� order to identify polypharmacy, it is necessary to evaluate a patient�s medication profile for �excessive� or �unnecessary� medications.

� At times, polypharmacy may be necessary in order to treat patients with multiple chronic diseases...

Polypharmacy has been defined in a number of ways, one of which is the use of multiple prescriptions and/or over-the-counter medications simultaneously. Although "polypharmacy" may have a negative connotation, in certain situations, using multiple prescriptions may be appropriate, such as when treating several chronic disease states concurrently. Another definition states that polypharmacy is the excessive or unnecessary use of prescription or nonprescription medications. In this instance, in order to identify polypharmacy, it is necessary to evaluate a patient's medication profile for "excessive" or "unnecessary" medications. It is estimated that approximately 34% of prescriptions written in the United States are unnecessary. These could be medications without an appropriate indication, duplicate therapy to treat a specific condition, interacting medications, inappropriate dosages, or the use of drug therapy to treat adverse drug reactions.

Potential Causes and Risk Factors
At times, polypharmacy may be necessary in order to treat patients with multiple chronic diseases and should be done with careful monitoring and patient follow-up. However, the use of multiple medications is inappropriate when the risks outweigh the benefits. Inappropriate use may be due to varying factors. The patients contribute to the problem by:

� Taking over-the-counter medications, herbal remedies, vitamins, or other supplements without notifying the physician
� Seeing multiple physicians without providing each of them an accurate medication list
� Using multiple pharmacies
� Demanding medications to address every complaint or symptom. It is estimated that 75% of physician visits results in a written prescription.

Physicians also contribute to the problem when they have excessive or inappropriate prescribing practices, such as continuing the use of a medication that should have been discontinued because it has lost its effect, or using medication to alleviate adverse reactions to other medications. 

Advanced age is the greatest risk factor for polypharmacy because many elderly patients suffer from multiple chronic disease states. Fifty percent of patients over the age of 65 have more than one chronic condition. Another contributing factor for the elderly population is that one-fourth of these patients are under the care of four or more physicians. Other risk factors include:

� Number of drugs taken daily 
� Socioeconomic factors (such as living arrangements)
� Female gender
� Factors related to the patient's health care provider.

Adverse Consequences of Polypharmacy
There are numerous consequences to the patient from the practice of polypharmacy. These consequences include decreased social activity, decreased cognition, increased risk of depression, and increased morbidity. Also, the risk is multiplied in the elderly because of reduced renal or hepatic function and altered functional status. Polypharmacy has also been shown to be an independent risk factor for eventual nursing home placement. 

Another result of polypharmacy is increased medical costs. Increased costs cause financial strain for many, often leading to a decrease in patient compliance when patients may not be able to afford all the drugs they have been prescribed. Poor compliance rates are also compounded by complex drug regimens from multiple prescriptions. 

Adverse Drug Reactions
The most dangerous outcome of polypharmacy is the increased risk of adverse drug reactions (ADRs) which includes drug-drug interactions. Each drug has potential adverse side effects; thus the greater the number of drugs being used, the greater the likelihood of an adverse reaction. 
The potential for ADRs has been estimated at:

� 6% when patients take two medications
� 50% when patients take five different medications, and
� 100% when patients take eight or more medications.

Over 2 million serious drug reactions and 100,000 deaths occur yearly due to adverse drug reactions. Adverse drug reactions are the fourth leading cause of death, ahead of pulmonary disease, diabetes, AIDS, pneumonia, accidents and automobile deaths.

ADRs in the Elderly
Seventeen percent (17%) of hospitalizations in elderly patients are due to adverse drug reactions(ADRs). These ADRs cause significant problems in the elderly since these adverse effects often mimic the aging process and/or diseases such as anxiety, depression, Parkinson's disease, CHF with fluid retention, gastroenteritis, and many others. 

These reactions occur more frequently in the elderly due to the fact that age-related factors alter drug metabolism in several ways, including: 

� Altered absorption. Drug absorption is affected by alterations in gastric pH and gastrointestinal motility, which may delay the absorption of drugs.

� Altered distribution. Distribution is affected by the alterations in protein binding that occur when drugs compete for the same protein-binding sites, particularly in the elderly, who have decreased protein-rich lean body mass or low serum albumin levels.

� Decreased hepatic metabolism. Many commonly prescribed drugs are metabolized by the liver, specifically cytochrome P450 enzymes. Since hepatic metabolizing capability slows with age, elderly individuals may be particularly vulnerable to toxicity from drugs that induce or inhibit the P450 isoenzymes used during drug metabolism. 

� Decreased renal elimination. The majority of the elderly experience a decline in renal function (i.e.decreased renal blood flow, renal mass, glomerular and tubular function). Therefore, drugs eliminated through the kidneys require monitoring of renal function to determine if downward dosage adjustment is necessary to prevent potentially toxic accumulation of active compounds. 

The categories of medications most commonly associated with adverse reactions in elderly patients are 
listed below.

� Psychotropic medications (particularly the benzodiazepines)
� Antihypertensives (including diuretics)
� Nonsteroidal anti-inflammatory medications
� Systemic steroids
� Theophylline
� Warfarin
� Cimetidine
� Digoxin.

Drug-Drug Interactions
When discussing ADRs, it is important to remember that ADRs include drug-drug interactions. Drug interactions represent 3-5% of preventable in-hospital ADRs and play a large part in many emergency room visits. Drug interactions can occur by several mechanisms.

� Interactions could occur even before drugs enter the body due to formulation incompatibility. For example, when phenytoin is added to dextrose, a precipitate forms turning phenytoin into an insoluble salt which makes it unavailable to control seizures.

� Drug binding could take place in the GI tract which would prevent absorption and reduce systemic availability. An example would be the ability of aluminum-containing medicines, such as sucralfate and antacids, to reduce the absorption of antibiotics like ciprofloxacin and azithromycin.

� An interaction could occur in the liver or GI tract due to changes in the rates of drug metabolism caused by other medicines that are inducers or inhibitors of drug metabolism. The interaction between fluoxetine and amitriptyline is an example of this. The combination of these two drugs results in increased plasma levels of amitriptyline with an increased potential for side effects due to the fact that fluoxetine is a potent inhibitor of the CYP2D6 enzyme. 

� An interaction could also happen at the level of drug action, such as the combination of verapamil, a calcium channel blocker, and a beta-blocker. Both slow the heart rate by different mechanisms which could result in heart block.

The table (TABLE 1.Overview of Selected Serious Drug Interactions) on the following page represents an overview of selected serious drug interactions that should be monitored closely in patients with multiple medications.

Management of Polypharmacy
Due to the extensive number of problems that can arise from the practice of polypharmacy, it is crucial for prescribers to manage it aggressively. This can be done by carefully analyzing all aspects of drug therapy, including the prevention of drug interactions.

The following is a stepwise approach that can be used by prescribing providers to prevent drug interactions:

� Take a good medication history. 
� The "AVOID Mistakes" mnemonic can help with this process. 
o Allergies?
o Vitamins and herbs?
o Old drugs and OTC? (as well as current medications)
o Interactions?
o Dependence? Contract? Consider the possibility of needing a behavioral contract between the provider and the patient in an effort to help the patient reach the therapeutic goal, either in the case of drug dependence or adherence to a therapeutic regimen.
o Mendel: Family History? A family history of benefits or problems with drugs will 
help determine whether pharmacogenetics should play in role in the selection of drug 

� Identify high risk patients, such as those taking a high number of medications.
� Check pocket references for possible interactions.
� Consult pharmacists/drug information specialists.
� Check one of the up-to-date computerized drug information databases.

In order to analyze an entire drug regimen, another method was developed to ensure appropriate prescribing. This method, known as the "SAIL" protocol, is summarized below. Although this method has not been tested in clinical practice, its application could help physicians and other 
prescribers minimize polypharmacy in their practices. 

Table 2. The SAIL Protocol for Appropriate Prescribing

Lee RD. Polypharmacy: A Case Report and New Protocol for Management. The Journal of the American Board of Family Practice 1998; 11: 140-44

Although polypharmacy is appropriate in certain situations, regimens of multiple medications should be reviewed routinely to ensure that the patient is receiving maximum benefit with the least amount of risk. By carefully reviewing drug regimens and being aware of the risks, physicians can provide the highest level of care for their patients. 

References available upon request.

Insert - 2005 Fall Provider Training Workshop Schedule

Following is the schedule for the 2005 Fall Unisys Provider Workshops. Please carefully review the schedule to see which programs are included at each location as program offerings vary by city.

The annual Unisys/Louisiana Medicaid Provider Workshops focus on presenting vital policy and billing information and addressing questions relating to recent policy and procedure changes. Our training format separates basic information from specific program information.

All Basic workshop sessions will be identical in content and will only be presented once in each location and will not be repeated in specific program workshops. The Basic Medicaid information workshops will cover general Medicaid policy such as standards for participation, recipient eligibility/ID cards, third party liability, how to obtain assistance from Unisys, general Unisys website information, etc. (A separate session will be held to present all web applications.)

NOTE: We encourage all providers who have never attended a Basic workshop, and are new to billing Louisiana Medicaid OR those providers who have questions concerning basic Medicaid policy to attend this workshop.

New this year is the LA Medicaid Web Applications workshop. With the exception of e-RA, all LA Medicaid Web Applications will be covered in this separate workshop. DHH and Unisys encourage providers to begin using these available web applications as we move toward providing LA Medicaid data electronically.

CommunityCARE will be covered in separate CommunityCARE workshops. These workshops will cover all aspects of the CommunityCARE Program, including e-RA. These workshops are not restricted to Primary Care Providers and all Medicaid Providers are encouraged to attend. CommunityCARE will not be discussed in detail in any other workshops.

Workshop Registration: 

� Due to space limitations in all workshops, please limit attendees to two (2) persons per provider.
� Attendees should arrive 15 - 20 minutes early to register
� Each attendee must register individually supplying their provider name and Medicaid ID number or the provider name and Medicaid ID number of the provider they are representing
� Providers are required to have a valid Medicaid provider ID number for each specific program workshop attended

Medicaid Programs to be Presented at the Workshops

1. Basic Medicaid Information: All providers may attend. Basic Medicaid information will be presented as previously detailed.

2. CommunityCARE: All providers may attend. CommunityCARE information and e-RA will be presented as previously detailed.

3. Dental: For EPSDT Dental, Adult Denture, Expanded Dental Services for Pregnant Women (EDSPW), and Oral Surgeons for dental services.

4. DME: All Durable Medical Equipment providers including Pharmacies functioning as DME providers.

5. Eligibility: All providers may attend. Includes information on the Medicare Prescription Drug Plan and the Medicaid Services Chart.

6. EPSDT Health Services: For School Boards, Early Intervention Centers, and EarlySteps providers. EPSDT PCS services will be discussed in the PCS workshop.

7. Home Health: For Home Health Providers. 

8. Hospice: For Hospice providers. 

9. Hospital: For Acute, Rehabilitation, Long Term, Free-Standing Psychiatric and Distinct Part Psychiatric Hospitals.

10. KIDMED: For all KidMed providers.

11. LA Medicaid Web Applications: For all providers. All LA Medicaid Web Applications (e-MEVS, 
e-CSI, e-CDI and e-PA) excluding e-RA. 

12. Long Term Care: For ICF/MR, Nursing Home, and ADHC providers.

13. Mental Health Rehabilitation: For Mental Health Rehabilitation providers. 

14. PCS (EPSDT and Long Term): For EPSDT PCS and Long Term PCS providers.

15. Professional: Professional services include physicians, APRNs, physician assistants, optometrists, ophthalmologists, audiologists, podiatrists, chiropractors, laboratories, ambulatory surgery centers, school-based health centers, and oral surgeons for medical services.

16. RHC/FQHC: For Rural Health Clinic and Federally Qualified Health Center providers.

17. Waiver/Case Management: For all Waiver and Case Management providers. PCS services will be presented in the PCS workshop.

Workshops will not be held at this time for the following programs: Pharmacy, Ambulance, Free Standing Rehabilitation Centers, Hemodialysis, Mental Health Clinics, and Vision (Eyewear). 

Please refer to the workshop schedule for dates (Day 1, Day 2, or Day 3) and times for each workshop location. Note that there may be more than one session held at the same time. There is no pre-
registration required. Please direct any questions concerning the workshops to Unisys Provider Relations at 800/473-2783 or 225/924-5040. Meeting sites should be contacted for directions or sleeping 
accommodations ONLY. DO NOT contact the meeting sites with questions related to the workshops.