Message from the Medical Director Reimbursement for Hernia Repair Codes
Rate Increase for Pediatric Surgery Services New Billing Policy and Procedures for Substitute Physicians
DME Providers Dually Enrolled as Environmental Modification Providers Criteria for Bilirubin Lamps
Authorization for Environmental Modification Claims LADUR Education Article
Notice to All Providers: NEMT Advertising Rules Community Care Program Information
MHR Option Policy Unisys Provider Relations
DME and Supplies - Medicare Crossover Claims Adjustment in Fee for DTP Vaccine
EPSDT Dental Program - Payment Denial EPSDT Dental Program  - Error Code Updates

Rate Increase For Pediatric Surgery Services


Medicaid Facts
Did you know that Louisiana Medicaid is one of the larger Medicaid programs in the U.S. with total expenditures of over $4 billion?  The program serves over 600,000 beneficiaries each year with 50,000 of these being served by the Community Care Primary Care Case Management program in 20 rural parishes.  Unisys processes 40 million claims annually.  About 98% of these paper claims are paid within 21 days and most EMC submissions are paid within 7 days.  Louisiana has one of the lowest administrative expenditures in the country with only 2% of costs going toward administrative expenses.  This is in contrast to the national Medicaid average of 4% for administrative costs.  Only two states spend less on administrative costs than Louisiana.

Hospital Pre-Admission/Length of Stay Review Program Update
This program will conduct pre-admission and LOS review for distinct part psychiatric facilities and long term care hospitals.  Acute care and rehab hospitals will participate only in the LOS review program.  An Advisory Group of hospital association representatives, DHH and Unisys staff has been meeting to formulate review criteria.  The Interqual Severity of Illness/Intensity of Service criteria will be used to review acute care hospital admissions.  Customized criteria for LTC, psych, and rehab patients have been developed and almost final.  LOS will be assigned based on nationally recognized criteria for acute hospitals with appropriate customization for specialty areas based on the committee's deliberations.  

Admissions and LOS reviews will be conducted by specialized review nurses.  Physician consultants will review all denials and reconsiderations.  There was a final public hearing on May 20, 1994.  A phased-in program is planned for July 1 before full program implementation later in 1994.

Deferred Compensation Update
The Louisiana Medicaid Deferred Compensation Plan allows individual providers to invest their Medicaid compensation on a before-tax basis avoiding current federal or state income taxes.  Interest accumulates tax deferred until withdrawal of funds.  Providers can contribute up to a maximum of 25% of their adjusted gross Medicaid income, not to exceed $7,500 per calendar year.  Great West, the plan administrator, can be reached at (504) 926-8082.  The initial response to the January/February Provider Update publicizing the program has been outstanding with nearly 300 inquiries about the plan.  Of those callers, 20% qualify for program participation.  All qualifying callers enrolled or are currently enrolling.  A Medicaid provider must bill the program with his/her individual Medicaid provider number and have Medicaid payments reported using his/her Social Security number.  You may not exceed the IRS 415 limits of $30,000 per year into an IRA.  There are several considerations concerning which type of plan a provider might already have such as a KEOGH, 403B, or 401K.  Details can be discussed with Great West.

Dr. Gregg Pane

Reimbursement for Hernia Repair Codes

In 1991, the Louisiana Medicaid Program began to reimburse a number of hernia repair codes at 100% per unit billed when performed bilaterally.  Four of these codes were deleted in the 1994 edition of the Physicians' Current Procedural Terminology and five new codes were added.

The programming has been completed for reimbursing these five new codes at 100% per unit billed effective with date of service January 1, 1994.

The five new codes are 49495, 49496, 49501, 49507, and 49521.  When billing these codes, do not modify them with a -50 modifier.  To denote that the procedure was performed bilaterally, place a "2" in the units column and bill the procedure on one claim line.

If performed secondarily, the above codes must be billed hard copy with the -51 modifier attached.  Otherwise, they may be billed electronically.

Rate Increase for Pediatric Surgery Services

The Bureau of Health Services Financing is pleased to announce an increase in the reimbursement for pediatric surgery services effective with date of service July 1, 1994.

Fees have been set as follows.

                  22842                 $1311.38

                  54336                   1283.75

                  47701                   1230.66

                  49605                   1077.38

                  61140                   1029.76

                  54332                    983.45

                  54324                    909.13

                  54328                    882.83

                  54326                    870.59

                  62230                    696.42

                  54322                    686.14

                  67332                    658.10

                  76332                    658.10

                  67331                    592.22

                  61120                    539.40

                  54340                    502.95

                  27003                    508.90

                  52340                    444.84

                  67030                    430.27

                  27001                    355.55

                  52332                    207.56

                  52281                    175.77

                  52005                    157.07

                  52000                    112.18

                  36625                    111.30

                  53020                      85.00

                  51750                      41.91

New Billing Policy and Procedures for Substitute Physicians

Currently, physicians who hire substitute physicians to manage their patient caseloads while on vacation, ill, or unable to provide services cannot bill Medicaid for the services rendered by the substitutes.  The substitutes must obtain Medicaid billing numbers and bill with their own numbers for the services they provided while employed.

The Bureau of Health Services Financing is changing this policy and the procedures related to it with the publication of this notice.

Medicaid allows two substitute physician billing arrangements:  1) the informal reciprocal arrangement (a period not to exceed 14 continuous days), and 2) the locum tenens or temporary arrangement (90 continuous days or longer period if allowed) in the case of a per diem or other fee-for-time compensation.

For both arrangements, the primary physician may bill and receive payment for the substitute's services.  Physicians should bill for a substitute physician's services as follows.

If billing under a reciprocal arrangement, append the modifier Q5 to the procedure codes of the services rendered by the substitute (item 24D on the HCFA 1500).

If billing under a locum tenens arrangement, append the modifier Q6 to the procedure codes of the services rendered by the substitute (item 24D on the HCFA 1500).

For both of the above billing arrangements, the regular (billing) physician or medical group must, in lieu of entering the UPIN of the substitute physician on the claim form, keep on file for three years a record of each service provided by the substitute.

This record would include the date and place of the service, procedure code, charge, recipient name, and the substitute physician's name.  This procedure is to be used for both crossover and straight claims.  Claims with these modifiers may be billed electronically.

DME Providers Dually Enrolled as Environmental Modification Providers

It is possible for some durable medical equipment (DME) providers to dually enroll in the Louisiana Medicaid Program as environmental modification providers.

Environmental modifications are available for persons have a slot in the MR/DD Waiver, Home Care for the Elderly Waiver, or Head Injury Waiver.

Environmental modification is an existing service that previously required enrolling providers to be licensed in an appropriate building trade.  It is appropriate that some DME providers be allowed to provide this service also.

The modifications these providers would perform include such items as prefabricated wheelchair ramps for the home and installation of handicapped shower facilities in the home.

Current DME providers who dually enroll will receive a separate provider number to bill for environmental modification services.  Submission of these claims is to be done with the Environmental Modifications provider number on the HCFA 1500 form.  Providers must not use their DME provider number for these services.

Any DME provider submitting a request for prior authorization of a home modification as a DME provider rather than as an environmental modification provider will be denied, even if the request is for a recipient under age 21.

The DME Program does not have any provisions for coverage of any home modifications.

Any DME providers wishing to enroll as a environmental modification providers should call the Provider Enrollment Section at 342-9454.

Criteria for Bilirubin Lamps

The Bureau of Health Services Financing would like to notify DME providers that the medical criteria for infants qualifying for the rental of bilirubin lamps for home photo therapy have been revised.  Please note that the following seven criteria must be met for this service.

1.              Term infants

2.              Greater than 48 hours of age and Coombs negative

3.              Otherwise healthy

4.              Showing a total bilirubin of 12 or greater but less than 18

5.              Indirect bilirubin can be 1.0 to 1.5 units less than the total but not more than this

6.              Normal CBC with differential documented before discharge if Coombs positive .

7.              Home photo therapy is to be monitored by home health nurses who are able to check the bilirubin levels every 12 hours for he first 24 hours, then every 24 hours after that.  The nurse must also check with the physician if they exceed his or her predetermined upper limits or rate of rise.

Authorization for Environmental Modification Claims

Payment for home modifications necessary to accommodate disability may be provided for some Home and Community Based Services waiver participants.

All such services are authorized by form MR/DD-14 from the case manager, and may not be provided without such authorization.

DME providers who are currently enrolled with Medicaid may enroll as providers of Environmental Modifications.

Enrollment as an Environmental Modifications provider requires completion of form PE-50, Disclosure of Ownership, and either a building trades license (such as contractor or plumber) or current Medicaid enrollment as a DME provider.



Benzodiazepines (Use in the Elderly)


       The prevalence of anxiety and sleep disorders in the elderly leads to common usage of benzodiazepines in the geriatric population.

       Usage should be guided by the clinician's evaluation of the patient's age, CNS status, and functional capacity of vital metabolic systems.

       Benzodiazepine use has been linked to an increase in adverse reactions such as cognitive impairment, falls, and hip fractures.

       Normal and pathologic changes in the elderly may alter the effects of the antianxiety agents.

       The need for tapering benzodiazepine withdrawal may be particularly problematic in the elderly patient.

Benzodiasepines are the most commonly used anxiolytics and hypnotics in all medical settings, including the elderly.  Studies of the prevalence of anxiety and sleep disorders in the general population consistently show that elderly individuals are equally or disproportionately represented, thus explaining why the benzodiazepines are widely used in the elderly population.

Clinicians should be guided in the choice of anti-anxiety drugs by the patient's age, experience with the benzodiazepines, current central nervous system status, and functional capacity of the organs involved in metabolism of the medication (liver).  Besides the benzodiazepines, there are older (meprobamate) and newer agents (buspirone) in common use.

Although all the benzodiazepines are thought to act through similar mechanism(s) of action, slight differences in these agents may justify the selection of a unique agent for a particular indication.

The benefits of using benzodiazepines in the elderly are numerous in relieving suffering and improving the quality of life.  However, as with most drug groups, benzodiazepines can cause some adverse reactions.

The incidence of drug reactions with the benzodiazepines clearly increases the patient's age.  Numerous epidemiological studies have demonstrated potential hazards associated with benzodiazepine use in the elderly.

There is a statistically significant association between the use of the benzodiazepines and various adverse reactions such as cognitive impairment, falls, and hip fractures.

Within the benzodiazepine class, the risk of hip fracture appears to be greater with long half-life agents than with short half-life agents due to drug accumulation.  Increased drowsiness has also been reported as an adverse reaction among elderly patients as compared to the general population.  This association was found to be especially prevalent with the anxiolytic drugs chlordiazepoxide and diazepam.

Pharmacodynamic changes associated with old age play a large role in the incidence of adverse reactions observed upon administration of benzodiazepines in the elderly.  Important changes in hepatic enzyme function occur with age--conjugation changes to a small degree while oxidation becomes less efficient.  Thus, specific agents metabolized primarily by oxidation *diazepam and flurazepam) accumulate with the potential to produce exacerbated therapeutic effects.  Certain other medications (cimetidine, disulfiram, etc.) can also compete for metabolizing enzymes, thus promoting longer functional half-lives of benzodiazepines and their active metabolites.

Various disease states, such as liver and respiratory disease, may also impact the effects normally observed with benzodiazepines.  In addition, many aspects of brain function are more vulnerable to the adverse effects of the benzodiazepines because of the advanced age.

The results may be depressed mood or dysregulation and lability, disturbed memory, disorientation, dulled awareness, excessive or ill-timed drowsiness, and impaired gait and balance, leading to ataxia with possible falls.  This is especially a problem with long half-life benzodiazepines because their side effects may not develop until steady state is reached (often weeks after beginning the medication).

Tapering of benzodiazepine dosages in patients addicted/tolerant to the benzodiazepines has become accepted therapy.  Without an adequate period of tapering, the patient may be subject to a variety of usually stressful but potentially serious adverse reactions.

Therefore, the clinical literature is strongly supportive of the need for tapering benzodiazepine withdrawal, or at least monitoring the risks associated with benzodiazepine withdrawal.

Currently, accepted protocols include but are not limited to a 10%reduction in dosage at weekly intervals.  Generally, a period of 6 to 12 weeks is required in such tapering programs.  An evaluation of patient profiles usually shows some evidence of the tapering of dosages.  The need for tapering withdrawal may be particularly problematic in the elderly patient.

New uses of benzodiazepines in the treatment of panic disorders often result in higher than usual doses of antianxiety agents.  This may result in situations when patients become dependent upon even higher dosages of these agents.

Caution should be exercised during the implementation of withdrawal programs in these patients because of the increased potential for serious withdrawal symptoms.  A longer tapering schedule may need to be employed.


Caranasos, G.J., "Drugs in the Elderly."  Hospital Formulary.  123-130, January 1982.

Greenblatt, D.J., Harmatz, J.S., and Shader, R.I., "Clinical Pharmacokinetics of Anxiolytics and Hypnotics in the Elderly (Part I).  Clinical Pharmacokinetics. 21(3):  165-177, 1991.

Greenblatt, D.J., Harmatz, J.S., and Shader, R.I., "Clinical Pharmacokinetics of Anxiolytics and Hypnotics in the Elderly (Part II)."  Clinical Pharmacokinetics.  21(4):  262-273, 1991.

Stoudemire, A., and Moran, J.G., "Psychopharmacologic Treatment of Anxiety in the Medically Ill Elderly Patient:  Special Considerations."  Journal of Clinical Psychiatry.  54(5-Supp): 27-33, 1993.

Notice to All Providers:  NEMT Advertising Rules

Medicaid providers may advertise only via television, radio, and newspapers.  Advertisements must not include the terms "free," "free ride," "at no cost to you," or any reference to indicate that the ride is "free" because Medicaid is a paying program.

Under no circumstances may the toll-free scheduling service numbers be included in any advertisement.

Providers must not solicit door-to-door or pass out or post handbills.  Telephone solicitation is prohibited.  Providers may give business cards to beneficiaries riding with them, but only one card per beneficiary.  Beneficiaries may not give out or pass out business cards for providers.

Transportation providers may not solicit business for medical providers and medical providers may not solicit business for transportation providers.

Orleans, Jefferson, St. Bernard, St. Charles, and Plaquemines parishes are under a federally approved transportation Freedom of Choice Waiver.  In all other parishes, the beneficiary is entitled to freedom of choice.

A medical provider cannot decide which transportation provider a beneficiary will use in the non-waiver parishes.  A medical provider, therefore, cannot use or make arrangements to use one transportation company exclusively.

Providers are prohibited from offering inducements to beneficiaries to obtain or solicit business or continue business.  Examples of prohibited inducements include

       Sending birthday, sympathy, Christmas, greeting cards, etc.

       Offering raffle tickets

       Providing "free refreshments" 

       Provider "free" breakfasts, lunch, dinner, or snacks

       Transporting (even in a provider's personal vehicle) beneficiaries to the cleaners, grocery store, or other destinations that are not Medicaid-covered services

       Providing a monetary payment for using the provider's service.

All Medicaid providers must be aware of and adhere to these guidelines.  A provider who offers inducements or incentive in an attempt to capture business is subject to sanctions that may include, but are not limited to, suspension and/or termination from the Medicaid Program.

Community Care Program Information

Community Care is a managed care program administered by Louisiana Medicaid.  It is a system of comprehensive health care adopted because of its advantages in rural communities.

The program links Medicaid recipients in designated parishes with a physician, Federally Qualified Health Center, or rural health clinic that serves as the recipient's primary care physician (PCP).

The goals of Community Care are to improve the accessibility, continuity, and quality of care to recipients, while reducing the overall cost of care by strengthening the patient/physician relationship and discouraging inappropriate or unnecessary use of medical care services. 

The Community Care Program current services 50,000 recipients in the following 20 parishes:

East Carroll
Jefferson Davis
Red River
St. Charles
West Carroll.

Recipients have the opportunity to select a participating provider, generally within their parish.  If the recipient does not select a provider, one is assigned.

The PCP has total responsibility for managing all facets of the recipient's health care, including education, prevention, maintenance and acute care, and referral to specialists when necessary.

The PCP must provide KIDMED preventive health care and immunizations, coordinate all inpatient care, maintain an integrated medical record of all care the patient receives, as well as provider 24-hour, 7-day a week availability by telephone.

The Community Care recipient's monthly Medicaid eligibility card has the name and telephone number (24-hour access) of the selected/assigned PCP in the lower right-hand corner of the card.

Most medical services provided by anyone other than the PCP require authorization from the PCP.  Claims for services other than those outlined below will be denied if they are not rendered by the PCP or if they are not authorized by the PCP.  The PCP will provide the specialty provider with a seven-digit authorization number on the written referral form.

When the PCP refers a patient to a hospital or to a specialist who admits the patient, it is the responsibility of the hospital/specialist to make the referral form from the PCP available to any group providing services related to the patient's admission (anesthesiology, radiology, pathology, etc.).

The following Medicaid-covered services do not require PCP authorization or referral from the PCP:  skilled nursing facility care, pharmacy services, ICF/MR services, OCDD, PCA, elderly, ADHC, or any other home and community-based waiver services, EPSDT health services for special needs children, in-office dental services, family planning services, transportation services, in-office ophthalmology and optometry services and eyeglasses, targeted case management, psychiatric hospital services, mental health rehabilitation services, mental health and substance abuse clinic services, and chiropractic services.

Emergency room screening exams, immediate stabilization, and resuscitation of life threatening emergencies do not require prior authorization.  However, after the emergency condition has been stabilized, the PCP must be contacted at the 24-hour access telephone number listed on the recipient's Medicaid card.

MHR Option Policy

Any Mental Health Rehabilitation services billed to Medicaid by a Mental Health Rehabilitation provider must be delivered by employees of the provider.

The provider may not subcontract with another provider or individual to provide any service or portion of a service for which the provider will bill the Medicaid Program.

Unisys Provider Relations

The Unisys Provider Relations unit is ready to assist providers with any questions they may have.  This unit's primary responsibility is to respond to telephone inquiries at the following numbers:  Baton Rouge Providers (504-924-5040); Louisiana Provider Outside of Baton Rouge (800-473-2783).  Telephone service is available Monday through Friday from 8:00 am to 5:00 pm.  In addition, providers can mail written inquiries to the following address:

Attention:  Provider Relations
Unisys P. O. Box 91024
Baton Rouge, LA  70821

Provider Relations also has a staff of Field Analysts are available to help providers with billing problems and to help train new provider staff members.  To request a visit with a Field Analyst, call or write the Provider Relations staff.  Written inquiries should contain a note or letter explaining the nature of the problem.  Inquiries submitted without explanations could be processed without additional consideration.  Also, providers who are calling Unisys Provider Relations should telephone that unit directly rather than call the main Unisys switchboard.

The following lists explain which Field Analysts are assigned to each Louisiana parish.

Kim Gassie/Kim Barnett:  Acadia, Allen, Ascension, Assumption, Beauregard, Calcasieu, Cameron, E. Baton Rouge, E. Feliciana, Evangeline, Iberia, Iberville, Jefferson Davis, Lafayette, Livingston, Pointe Coupee, St. Helena, St. Landry, St. Martin, St. Mary, Vermillion, W. Baton Rouge, W. Feliciana.

Cora Burks:  St. Charles, St. James, St. John the Baptist, St. Tammany, Tangipahoa, Washington.

Michelle Fulton:  Jefferson, Lafourche, Orleans, Plaquemines, St. Bernard, Terrebonne.

Pat Boudreaux:  Bienville, Bossier, Caddo, Claiborne, DeSoto, Grant, Jackson, Natchitoches, Red River, Sabine, Vernon, Webster, Winn.

Karen Simms:  Avoyelles, Caldwell, Catahoula, Concordia, E. Carroll, Franklin, LaSalle, Lincoln, Madison, Morehouse, Ouachita, Richland, Tensas, Union, W. Carroll.

Pat Boudreaux/Karen Simms:  Rapides.

DME and Supplies - Medicare Crossover Claims

Palmetto Government Benefits Administrators recently began processing DME claims for the Medicare program for Louisiana providers.

A new Medicare provider number was assigned to each provider.  This new number was to have been sent to the Medicaid agency via magnetic tape and we were to match these new numbers to the Medicaid provider numbers on our file to process the crossover claims sent by Palmetto.

We received this tape but have had great difficulty in producing a provider match in which we have confidence.  We need your assistance in giving our provider enrollment unit your new Medicare DMERC provider billing number.

Please mail or fax us your Medicare number(s) and the one Medicaid provider number to which the crossover claims should be matched.  Your assistance will enable us to process the crossover claims quickly and correctly.

  FAX Number: 
(504) 342-3893

Mailing Address:
Bureau of Health Services Financing
P. O. Box 91030
Baton Rouge, LA 
Attn:  Provider Enrollment

If you have been recently contacted by the provider enrollment staff about this matter or have already faxed information, you need not respond.

If you experience any processing problems with your Medicare crossover claims, please advise by calling (504) 342-3855 or writing to the address in column two.


In September 1993, the Bureau increased the fee for the DTP vaccine (CPT code 90701) by $4.56 to compensate providers for the federal excise tax which had been reinstated in August 1993 on seven childhood vaccines by the United States Budget Reconciliation Act of 1993.  This increase brought the reimbursement level for this vaccine to $22.56. 

It was recently brought to our attention, however, that we are currently reimbursing providers twice, rather than once, for the federal excise tax because we did not decrease the fee for DTP in January 1993 when the tax was discontinued.  Therefore, effective with date of service June15, 1994, the fee for procedure code 90701 will be adjusted to $18.00.

Payment Denial

The Medicaid program will deny payment for codes D2330, D2331, and D2332 (resins) on the following teeth:  #2, 3, 4, 13, 14, 15, 18, 19, 20, 29, 30, and 31.  Please refer to page 7-12 of the EPSDT Dental Program Provider Manual.

Error Code Updates

Procedure D2951 (pin in tooth) will deny with error code 612 if billed on a deciduous tooth.  Procedure D3220 (pulpotomy) will deny with error code 611 when billed on a permanent tooth.  Procedure D3110 (pulp cap) will deny with error code 611 when billed on a permanent tooth.  Procedure D3110 (pulp cap) and will deny with error code 610 if billed on a deciduous tooth.