PROVIDER UPDATE
VOLUME 12, NUMBER 3
SUMMER 1995
MESSAGE TO ALL ENROLLED MEDICAID PROVIDERS
As a result of reductions in the budget
appropriation for the Medicaid Program mandated by the Legislature, the Bureau
of Health Services Financing has issued thirty-eight (38) emergency rules which
make changes in the policy and reimbursement methodology governing the provision
of Medicaid services in order to assure the continued operation of the Medicaid
Program.
We regret the necessity of having to
implement these budget reduction measures at this time.
However, this action is being taken in order to comply with the 1995-96
General Appropriation Act, which states that the Secretary shall implement
reductions in the Medicaid program as necessary to control expenditures to the
level approved in this schedule, and that the Secretary is directed to utilize
various costs containment measures to accomplish these reductions.
The following Provider Update articles summarize the program changes enacted by
the emergency rules. We know that
there will be difficult times ahead for all service providers as these program
changes are implemented. However,
we hope that we can continue to rely on your cooperation and patience as the
continued well-being of Medicaid recipients is the primary concern shared by
both service providers and the Bureau. Further
clarifications and updates will be forthcoming.
Thomas D. Collins
Director
EMERGENCY RULES
Editor's Note:
Because of the importance of these thirty-eight (38) Emergency Rules, we
felt it necessary to deviate from the traditional format of the Provider Update;
we apologize, in advance, for any confusion the new order may cause.
The following Emergency Rules are
ordered by effective dates; please read through the entire section in order to
find all of the rules that pertain to your program.
Acute Hospital Services - Reimbursement-Median
Effective for date of service July 1,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing will no longer reimburse acute hospitals for inpatient
services above the peer group weighted median per diem rate for inpatient acute
hospital services. The Department
will establish a weighted average per diem rate based on estimated payments
under a capped weighted median per diem rate and will reimburse no inpatient
acute hospital above the weighted average per diem rate.
Medicaid per diem rates for inpatient acute hospitals with per diem rates
above the peer group weighted average per diem rate will be reimbursed at the
peer group weighted average per diem rate.
Specialty hospitals will be reimbursed at the lowest blended per diem
rate for each specialty hospital category.
For the purpose of this emergency rule, specialty hospitals are designed
as long term hospitals, rehabilitation hospitals, and Children's Hospital in New
Orleans.
Acute Hospital Services - Reimbursement-Inflation
Effective for date of service July 1,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing will trend payment rates to the midpoint of the payment year
using the lowest of the DRI Type Hospital Marketbasket Index, the Consumer Price
Index - All Urban Consumers or the Medicare PPS Marketbasket Index.
Acute Inpatient Hospital Services -
Reimbursement-Outlier
Effective for discharges on or after
July 1, 1995, the Department of Health and Hospitals, Office of the Secretary,
Bureau of Health Services Financing amends its reimbursement methodology for
qualification and calculation of outlier payments for catastrophic costs
associated with medically necessary services provided to children under six in
disproportionate share hospitals and for services to infants one year or under
in all general acute care hospitals. To
qualify for an outlier payment the covered charges for the case must exceed both
$150,000 and 200 percent of the prospective payment.
Outlier cases qualifying under the above criteria will be reimbursed the
marginal cost associated with the excess cost above the prospective payment
amount. Marginal cost is considered
to be 55% of cost.
Outpatient Hospital Services
Effective with date of service July 1,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing reimburses outpatient hospital services the interim rate of
60% of billed charges except those services subject to the fee schedule for
laboratory services which will be reduced 10% and outpatient surgeries on the
Medicaid Outpatient Surgery list. Final
reimbursement for outpatient services shall be adjusted to 85% of allowable cost
through the cost report settlement process, except those services subject to the
Medicare fee schedule for laboratory services and outpatient surgeries.
Out-of-State Hospital Services
Effective with date of service July 1,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing reimburses out-of-state outpatient hospital services 50% of
billed charges and reimburses out-of-state inpatient hospital services the lower
of 50% of billed charges or the Medicaid per diem rate of the state wherein the
services are provided. If the state
wherein the inpatient services are provided does not use a per diem rate payment
methodology, the Bureau will reimburse the out-of-state hospital 50% of the
billed charges.
Private ICF/MR Facility Services
Effective for dates of service
beginning July 1, 1995 and after, the Department of Health and Hospitals, Bureau
of Health Services Financing revises the Private ICF/MR reimbursement rates by
limiting Management Fees and Central Office costs to a combined total of 6% of
allowable costs.
Nursing Facility Services Reimbursement
Effective for dates of service
beginning July 1, 1995 and after, the Department of Health and Hospitals, Bureau
of Health Services Financing reimburses private nursing facilities under the
methodology established effective January 1, 1995 utilizing all specific direct
resident care cost and indirect resident care cost categories at the 60th
percentile to base the per diem rates.
Pharmacy: Maximum
Allowable Overhead Cost
The Department of Health and Hospitals
will maintain the Maximum Allowable Overhead Costs (dispensing fee) for Medicaid
prescription services for fiscal year 1995-96 at the same level established for
fiscal year 1994-95.
The maximum allowable overhead cost
(established by applying the 1993 indices to appropriate cost categories for a
one-year period) will remain at $5.77. This
fee includes the provider fee mandated under state law for every prescription
filled by a pharmacy or dispensing physician.
No inflation indices or any interim adjustments will be applied to the
Maximum Allowable Overhead Costs for the time period July 1, 1995 through June
30, 1996.
Also, please be reminded that providers
are required to bill their usual and customary charges. Pharmacy compliance audits will be conducted to determine
that providers are billing in accordance with Medicaid regulations.
EPSDT Screening Fees
Effective for dates of service
beginning July 7, 1995 and after, the Department of Health and Hospitals, Bureau
of Health Services Financing reimburses KIDMED providers $51.00 under the Early
Periodic Screening Diagnosis and Treatment Program for medical screenings of
Medicaid recipients under 21 years of age, which are performed by or under the
supervision of a licensed physician, or by a certified physician assistant or
registered nurse within their scope of practice permitted by state law.
New Limits on EPSDT Eyeglasses and Hearing Aids
Effective for dates of service
beginning July 7, 1995 and after, the Department of Health and Hospitals, Bureau
of Health Services Financing limits EPSDT eyeglasses to three per year with
provision for extending if medically necessary and reduces reimbursement fees
for eyeglasses and hearing aids by fifteen percent for providers of the
following Early Periodic Screening Diagnosis and Treatment services.
EPSDT Eyeglasses: Procedure Codes - X6366-X6368; X6370-X6376; X9066-X9068; and
X0089.
EPSDT Hearing Aids: Procedure Codes -X0192; V5030; V5040; V5050; V5060; V5070;
V5080; B5100; V5120; V5130; V5140; V5150; V5170; V5180; V5190; V5210; V5220;
V5230; and V5299.
Air Ambulance Reimbursement Methodology
Medicaid will pay a base rate plus
mileage according to the rates in effect for Medicare as of January 1, 1995.
Separate reimbursement for oxygen and disposable supplies will be made
when the provider incurs these costs. Reimbursement
for these services will be made in accordance with the rates previously
established by Medicare and approved by Medicaid effective April 1, 1995.
Reimbursement for helicopter transports
will be at Medicare's current rate of $1,200.00 for the base rate plus $12.00
per mile.
Reimbursement for fixed wing transports
will be at Medicare's current rate of $1,000.00 for the base rate plus $10.00
per mile.
Standards for Payment
1.
Helicopters and fixed winged aircraft must be certified by the Department
of Health and Hospitals, Bureau of Health Services Financing in order to receive
Medicaid reimbursement, and all air ambulance services must be provided in
accordance with the state law and regulations governing the administration of
these services. All air ambulance services must comply with the state law and
regulations governing the personnel certifications of the emergency medical
technicians administered by the Department of Health and Hospital's Bureau of
Emergency Medical Services.
2.
The Prior Authorization Unit of the fiscal intermediary must approve the
medical necessity for all air ambulances.
3.
The Prior Authorization Unit of the fiscal intermediary must review air
ambulance claims and either approve or disapprove these services based on the
following requirements:
a.
Air ambulance services are covered only
if speedy admission of the patient is essential and the point of pick-up of the
patient is inaccessible by land vehicle, or great distances or other obstacles
are involved in getting the patient to the nearest hospital with appropriate
facilities.
b.
Payment for air mileage will be limited
to actual air mileage from the point of pick-up to the point of delivery of the
patient.
c.
Payment for a round trip transport on
the same day between two hospitals is the base rate plus the round trip mileage.
d.
If a land ambulance must be used for
part of the transport, the land ambulance provider will be reimbursed separately
according to rules and regulations for ground ambulance services.
Non-Emergency Ambulance Transportation Services
Effective for dates of service
beginning July 7, 1995 and after, the Department of Health and Hospitals, Bureau
of Health Services Financing reduces by 20% the established provider rate for
non-emergency ambulance transportation services. The new rates will be $65.47 for the transport of the
recipient and $1.69 per mile.
Reduction of Fees for Professional Services
Effective with date of service July 7,
1995, the fees for Surgery (CPT procedure codes 10040-69979), Medicine (CPT
codes 90700, 96999, 97265-99199), and Evaluation and Management (CPT codes
99201-99499) will be reduced by 10%. Additionally,
fees for the following locally assigned codes and HPCS codes will also be
reduced by 10%:
Z9001-Z9006-Prenatal
labs, prenatal visits, postpartum visit; Z9916-Brainstem
evoked response screening; Z9919-Z9920-Androscopy
with and without biopsy; 00099-Anesthesia
for arteriograms, cardiac caths, CT scans, angioplasties, and MRIs; Z9918-Removal
of leaking breast implants; J0170-Adrenalin
injections; J7190-Factor VIII
injections for hemophilia; J2910-Gold
therapy injections; J1055-Depo-Provera
C injections; L8603-Collagen implant.
Exception:
The fees being paid to anesthesiologists and CRNAs for procedure codes
62279 and 59515, as the fees for these codes were reduced effective with date of
service 6/1/95, and the neonatal per diem codes 99295, 99296, and 99297, as
these codes are included in another emergency rule.
Effective with date of service July 7,
1995, the fees for Radiology (CPT codes 70010-79999) and Pathology and
Laboratory (CPT codes 80002-89399) will be reduced by 15%.
Additionally, the fees for the
following locally assigned codes will also be reduced by 15%:
Z0053-Fructosamine;
Z0054-Zinc Protoporphin; Z0055-Free
Erythrocyte Protoporphin.
Fee Reductions for Neonatology Services
Effective with date of service July 7,
1995, the per diem fees for CPT codes 99295, 99296, and 99297 will be reduced to
$323.90, $190.20, and $150.10, respectively.
The per diem fee for "step-down
babies (CPT procedure code 99297-52) will be reduced to $60.04, also, effective
with date of service July 7, 1995.
DME Reimbursement Changes
BHSF has determined that it is
necessary to revise the reimbursement methodology (for Medicaid only recipients)
for all DME items for which flat fees are used to determine reimbursement rates.
Effective with dates of service July 7,
1995 and after, the Department of Health and Hospitals is revising the flat fee
component of the reimbursement methodology.
DHH is establishing the flat fee at a rate of 80% of the Medicare durable
medical equipment fee schedule and is
instituting the flat fee schedule for certain durable medical equipment items at a rate
of 80% of the lowest cost at which the needed item is widely available.
However, DME claims for recipients with
both Medicaid and Medicare Part B coverage will continue to crossover to
Medicaid from Medicare for payment of the co-insurance and deductible up to 100%
of the Medicare Fee Schedule allowable charge.
Maximum Rates for Home Health Agencies
Effective July 7, 1995 and after, the
BHSF is revising the reimbursement to home health agencies by establishing
maximum rates for interim and cost settlement payment amounts.
The maximum interim and cost settlement payment amounts for reimbursable
services shall not exceed the following limits:
1) skilled nursing visits (procedure code X9900) - $64.54; 2) health aid
visits (procedure code X9901) - $22.81; and 3) physical therapy (procedure code
X9926) - $70.46. The Bureau shall
reimburse the home health agency at an interim rate of 80% of allowable billed
charges for covered non-routine supplies (procedure code X9925).
Final reimbursement for covered non-routine supplies shall be adjusted to
80% of allowable costs through the cost settlement process except for diapers
which are not reimbursable items under the supply cost category for home health
services.
Case Management Flat Fees
Effective for dates of service July 7,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing is reducing the reimbursement for case management services by
lowering both the flat fee amount and the $13.26 unit rate by 20%.
Lab and X-ray Services Not Provided by a Hospital
Effective for dates of service July 7,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing, reduces reimbursement by 15% for lab and x-ray services.
Habilitation Services MR/DD Waiver
Effective for dates of service July 7,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing reduces reimbursement rates by ten percent for the following
services: 1) Habilitation/Supported
Employment Follow-along and Enclave/Mobile Crew, 2) Prevocational Habilitation,
and 3) Day Habilitation.
Rehabilitation Clinic Services
Effective for dates of service of July
7, 1995 and after, reimbursement to rehabilitation clinics which are not part of
a hospital, but are organized to provide a variety of outpatient rehabilitative
services (including physical, occupational, speech, hearing, and language
therapies), will be reduced by ten percent.
Attention Pharmacists and Physicians:
Co-payments for Prescription Services
Effective for services beginning July
13, 1995, the Louisiana Department of Health and Hospitals is implementing a
co-payment on prescription services.
The co-payment will be paid by the
recipient and collected by the provider at the time the service is rendered.
Medicaid reimbursement to the provider shall be adjusted to reflect the
co-payment amount for which the recipient is liable.
Providers shall continue billing their usual and customary charges for
prescription services. Unisys will
calculate and deduct the co-payment amount from the amount billed on the claim
form.
In accordance with 42 CFR 447.15, the
provider may not deny services to any eligible individual on account of the
individual's inability to pay the co-payment amount.
Under 42 CFR 447.15, this service statement does not apply to any
individual who is able to pay, nor does an individual's inability to pay
eliminate his or her liability for the co-payment.
The co-payments to be imposed shall be
based on the following schedule.
Calculated
State Payment Co-Pay
$10.00 or less
$0.50
$10.01 to $25.00
$1.00
$25.01 to $50.00
$2.00
$50.01 or more
$3.00
The pharmacy provider shall collect a
co-payment for each drug dispensed by the provider and covered by Medicaid.
This co-payment is NOT taxable. Providers
should not collect tax on the co-payment.
Quantities dispensed by pharmacists shall
not be adjusted to reflect the co-payment amounts paid by the recipient.
By your participation in the pharmacy program, providers have agreed to
accept, as payment in full, the amounts paid by the agency plus any deductible,
co-insurance or co-payment.
The following pharmacy services are
exempt from the co-payment requirement:
�
Services furnished to individuals under
21 years of age. (DATE OF BIRTH IS
ON THE RECIPIENT'S ELIGIBILITY CARD.)
�
Services furnished to pregnant women if
such services are related to the pregnancy, or any other medical conditions that
complicate the pregnancy.
�
Services furnished to any individual
who is an inpatient in a hospital, long term care facility, or other medical
institution. These include type
cases 04, 05, 10, 16, 17, 62, 64, 65, 90, 92, 98 and 99. Type case is printed on the recipient's eligibility card.
Individuals in group homes are classified in this category.
�
Emergency services provided in a
hospital, clinic, physician office, or other facility equipped to furnish
emergency care.
�
Family planning services and supplies.
(Prescriptions for family planning
services may be prescribed by any prescribing physician).
These drugs and supplies include contraceptives, spermicides, and
condoms, and require a prescription.
When a physician issues a prescription
to a pregnant woman, he or she shall indicate on the prescription that the
recipient is pregnant. In the case
of a telephoned prescription, the information that the recipient is pregnant
shall be communicated to the pharmacist and the pharmacist must document on the
prescription that the recipient is pregnant.
When a physician issues a prescription to a recipient for an emergency,
he or she shall certify on the prescription in his or her own handwriting,
"EMERGENCY PRESCRIPTION" or "EMERGENCY Rx."
When a physician authorizes a
prescription for a pregnant recipient, the pharmacist shall maintain the proper
documentation on the prescription indicating for audit purposes that the
individual is pregnant. The
pharmacist will then enter a "P" in the block "MAC OVERRIDE"
located on the claim form prior to submitting the claim to Unisys for
reimbursement. The pharmacist shall
continue to enter a "C" in the "MAC OVERRIDE" block when the
physician indicates that a brand name drug is medically necessary for a
particular recipient and a "Q" when the physician indicates that the
prescription is for a pregnant recipient and the brand is medically necessary.
When a physician certifies the
prescription is an "Emergency Prescription," the pharmacist shall
enter an "E" in the block "MAC OVERRIDE" located on the
claim form prior to submitting the claim to Unisys for reimbursement.
When a physician certifies the prescription is an "Emergency
Prescription" and a brand name drug is medically necessary, the pharmacist
shall enter a "F" in the block "MAC OVERRIDE" located on the
claim form prior to submitting a claim.
Family planning services and supplies
furnished to individuals of child bearing age are exempt from copayment
liability. Drugs and supplies
include contraceptives, spermicides, and condoms.
The following table providers a quick
reference summary of applicable override codes for MAC versus Non-MAC drugs.
MAC
Non-MAC
Drugs
Drugs
Pregnancy
Q
P
Emergency
F
E
Long-Term
Care Facility (LTC) M
L
Family
Planning T
S
All
Others
C
Table
1: Summary of applicable override
codes for MAC and Non-MAC codes.
For providers who bill electronically
and are unable to use the "MAC OVERRIDE" field to enter a
"P," "Q," "E," or "F" for the
circumstances cited above, we recommend that you bill via a hard copy claim
until the provider's electronic format is modified to accomplish this task.
Otherwise, the claim will process with the co-payment amount deducted
from your payment as an adjustment will have to be completed.
In order to accommodate some tape
billers who requested codes for institutionalized individuals and for family
planning services and supplies, the Department has made allowances for software
programming. For institutionalized
individuals, providers may enter an "L" in the block "MAC
OVERRIDE" located on the claim form prior to submitting the claim to Unisys.
If the recipient is institutionalized and the brand name drug is
medically necessary, the pharmacist may enter a "M" in the block
"MAC OVERRIDE."
For family planning services, the
provider may enter a "S" when a family planning drug is dispensed in
the "MAC OVERRIDE" field and a "T" when a family planning
drug is dispensed and the brand name is medically necessary in the block
"MAC OVERRIDE" located on the claim form.
Codes (L, M, S, T) are not required on
the claim form. The Department will
determine from the recipient file which recipients are institutionalized based
on the type cases listed above and from the drug file which drugs are family
planning drugs.
Should you have any instances when a
recipient is in a nursing facility but has not received approval for nursing
home certification and the claim has received a co-pay deduction, an adjustment
form will need to be completed along with a copy of BHSF Form 148 (Medicaid
Program Notification of Admission or Change) to collect any co-payments which
should not have been deducted.
|
MAC
Refill Invoice No.
|
Billed
Charge
|
Calculated
Payment
|
TPL
|
Amount
Paid
|
|
0 8888
|
5161
|
5161
|
00
|
5161
|
|
5 8888
|
7180
|
7180
|
00
|
7180
|
|
5 8888
|
887
|
887
|
00
|
887
|
|
5 8888
|
3045
|
3045
|
00
|
3045
|
|
4 8888
|
742
|
707
|
00
|
707
|
Table
2. Co-payment is shown in the TPL
field on the RA.
Providers should note that the
remittance advice has been modified to reflect the co-payment deducted. The advice will continue to include the Billed Charge,
Calculated Payment, Third Party Liability Payment and Amount Paid.
Co-payment will be shown in the field which now carries Third Party
Liability Payments. It is possible, in some instances, that this field will also
include TPL Payment and/or co-payment deductibles.
In accordance with 42 CFR 447.15, the
provider may not deny services to any eligible individual on account of the
individual's inability to pay the co-payment amount.
Under 42 CFR 447.15, this service statement does not apply to an
individual who is able to pay, nor does an individual's inability to pay
eliminate his or her liability for the co-payment.
Provider shall not waive the recipient
co-payment liability. Department
monitoring and auditing will be conducted to determine provider compliance.
Violators of this policy will be subject to penalty such as suspension of
the program for one year. In
signing the claim form statement, providers are certifying that they are
complying with the rules and regulations of the program.
Inpatient Psychiatric Services
Effective for date of service July 13,
1995 and after, the Department of Health and Hospitals, Office of the Secretary,
Bureau of Health Service Financing, limits inpatient psychiatric services to a
maximum of 30 days per calendar year per recipient.
This limitation applies to Medicaid recipients who are under 21 years of
age and over 65 years of age for inpatient psychiatric services provided other
than in a distinct part psychiatric unit. The
fiscal intermediary shall continue to review each inpatient's psychiatric
admission to determine the recipient's eligibility for these services in
accordance with established regulations for inpatient psychiatric services.
Mental Health Clinics
Effective for date of service July 13,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing reimburses Mental Health Clinics for only one procedure per
day per recipient.
Occupational therapy, recreational
therapy, music therapy, and art therapy are not reimbursable services under the
Medicaid Program.
Mental Health Rehabilitation Services/Nursing
Facility Residents
Effective for date of service July 13,
1995, a nursing facility resident must be identified as needing specialized
mental health services through the Pre-Admission Screening and Annual Resident
Review process in order to receive services under the Mental Health
Rehabilitation Program.
Substance Abuse Clinics
Effective for date of service July 13,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing reimburses Substance Abuse Clinics for only one procedure per
day per recipient.
Occupational therapy, recreational
therapy, music therapy, and art therapy are not reimbursable services under the
Medicaid Program.
Service Limits in the Mental Health Rehabilitation
Program
Effective for dates of service July 13,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing eliminates procedure code X0103, "Other
Evaluations." Also, effective
from July 13, 1995 through October 31, 1995, the Department of Health and
Hospitals, Bureau of Health Services Financing adopts the following service
limits in the Mental Health Rehabilitation Program for Adults with Serious
Mental Illness and Children with Emotional/Behavioral Disorders:
Procedure
Code
Service
Monthly Limit
X0107, X0108 Individual
2 units total**
X0109
Family and Group Counseling
And Therapy
X0110
Treatment Integration 22 units for children
26 units for adults
X0111
Psychosocial Skills Training
20 units for children
55 units for adults
X0112
Medication Administration 1 unit
X0113
Medication Monitoring
3 units
X0114
Crisis Intervention 8 units
X0115
Crisis Support 72 units
**Codes X0107, X0108, and X0109 will
pay 0 units of service for dates of service July 13, 1995 through July 31, 1995.
In addition, the following procedure
codes are limited to a maximum of 1 unit of service for the period from July 13,
1995 through October 31, 1995:
Procedure
Code
Service
Limit
X0100
Medical Assessment
1 unit
X0101
Psychological Evaluation 1 unit
X0102
Psychosocial Evaluation 1 unit
X0104
Rehabilitation Plan Development 1 unit
X0105
Rehabilitation Plan Update 1 unit
ICF Leave Days
Effective for dates of service
beginning July 13, 1995 and after, the Department of Health and Hospitals,
Bureau of Health Services Financing reduces payments to ICF/MR facilities by
limiting the number of payable leave of absence days as follows:
Beds are reserved for up to five (5)
days per hospitalization for treatment of an acute condition; beds are also
reserved for up to twenty-two (22) days per State fiscal year for other leave
days with a fourteen (14) day interval limit per temporary absence per
recipient. Leave days for the
following purposes will be limited to fourteen (14) days per occurrence and
shall be excluded from the annual twenty-two (22) day limitation:
1.
Special Olympics
2.
Roadrunner sponsored events
3.
Louisiana planned conferences
4.
Trial discharge leaves.
Nursing Facility Program-Leave Days
Due to budget constraints, the
Department of Health and Hospitals is reducing payments to nursing facilities
effective July 13, 1995, by limiting the number of payable leave of absence days
as follows.
�
Payable hospital leave days are reduced
to five days per hospitalization for treatment of an acute condition.
�
Other leave days are reduced to 4 days
per calendar year.
Changes for Federally Qualified Health Center
Providers
Effective with date of service July 13,
1995, rural health clinic visits (encounter code X9928) will be counted as 1 of
the 12 allowable visits per calendar year for recipients who are 21 years of age
or older.
Changes for Rural Health Clinic-Providers
Effective with date of service July 13, 1995, rural health
clinic visits (encounter code X9928) will be counted as 1 of the 12 allowable
visits per calendar year for recipients who are 21 years of age or older.
Adult Dental Program
Effective for date of service July 13,
1995 and after, the Department of Health and Hospitals Bureau of Health Services
Financing will require in the Adult Dental Program that new dentures are only
allowable seven years after the original dentures are provided.
In addition, the Adult Dental Program shall no longer reimburse for cast
partial dentures (Procedure Codes 05213 and 05214).
Any of the above services previously authorized but not completed prior
to July 13, 1995 shall not be reimbursed.
Chiropractic Services
Effective for date of service July 13,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing repeals the January 1, 1993 rule on chiropractic care and
establishes the following provisions to govern Chiropractic Services under the
Professional Services Program.
A.
GENERAL PROVISIONS
1.
Chiropractors' services consist of
diagnostic and treatment services, which are within the scope of practice for
chiropractors under state law and regulations.
2.
An encounter is defined as any visit in
which any of the services listed in the Professional
Services Program Manual are rendered, which are included under the selected
CPT treatment codes.
3.
All chiropractic treatment services for
recipients under the age of twenty-one shall be prior authorized.
B.
SERVICE LIMITS
1.
One diagnostic evaluation per 180 days
per recipient not to exceed two diagnostic evaluations per calendar year per
recipient will be allowed.
2.
Radiology services are limited to $50
per recipient per 180 days not to exceed $100 per calendar year per recipient.
3.
Recipients twenty-one years of age and
older are allowed eighteen (18) chiropractic encounters or treatment services
per calendar year. No extension of
this number shall be granted.
C.
REIMBURSEMENT
1.
Reimbursement is provided to
chiropractors who are licensed by the state to provide chiropractic care and
services and who are enrolled in the Medicaid Program as an enrolled provider.
2.
Reimbursement is made in accordance
with the following designated CPT codes under a maximum fee schedule for
billable codes established by the Professional Services Program for each
chiropractic service rendered to a Medicaid eligible individual.
Procedure Code
Proposed Rate
97010
$7.41
97012
$5.31
97014
$7.41
97020
$4.88
97022
$6.65
97024
$4.88
97026
$4.88
97028
$1.66
97039
$6.65
97110
$8.08
97112
$8.08
97032
$8.08
97122
$3.85
97124
$5.05
97034
$6.65
97035
$3.85
97139
$6.65
97036
$11.09
97250
$12.94
97260
$8.00
97261
$3.54
PCA Services
Effective for date of service July 13,
1995 and after, the following changes will be implemented for Personal Care
Attendant Services provided through Home and Community Based Services waivers:
1.
Reimbursement shall be in half-hour
units. A full half-hour of service
shall be provided in order to bill for the service.
Minutes from different occasions of service provision shall not be rolled
to accumulate half-hour units.
2.
The reimbursement rate for PCA provided
as a waiver service shall be $5.00 per half-hour unit, except as provided below
for care given to multiple participants by the same attendant or care given to
one participant by two attendants.
3.
PCA services provided in the Supervised
Independent Living (SIL) setting shall not be reimbursed separately, but shall
be included in the daily rate paid to the SIL provider.
4.
PCA services shall not be available for
children under the age of 5.
5.
Reimbursement for PCA services shall be
limited to 200 hours (400 half-hour units) per calendar month.
6.
Annual service limit shall be 1,825
hours (3,650 half-hour units) per calendar year, with no exceptions.
7.
The reimbursement rate for PCA services
provided to multiple waiver participants in the same home by a single attendant
shall be 75% of the reimbursement rate for PCA services provided to one waiver
participant.
8.
The reimbursement rate for PCA services
provided to one or more waiver participants by two attendants shall be 75% of
the reimbursement rate for PCA services provided to one waiver participant by
one attendant.
Supervised Independent
Living-MR/DD Waiver
Effective for date of service July 13,
1995, the Department of Health and Hospitals, Bureau of Health Services
Financing will implement the following changes in Residential
Habilitation/Supervised Independent Living.
1.
Reimbursement shall consist of flat
daily rates for participants in single-participant households, 2-participant
households, and 3-participant households who require less than three hours daily
of direct-care staff time, 3 to 10 hours daily of direct-care staff time, and 10
or more hours daily of direct-care staff time.
2.
Each Residential
Habilitation/Supervised Independent Living provider shall be licensed as both a
Supervised Independent Living agency and a Personal Care Attendant agency.
3.
Services may be billed only for days
when the waiver participant is present in the residential habilitation setting.
The participant will be considered absent from the home when the
participant is away from the residential habilitation setting for a continuous
24 hour period.
Individual Job/Intense
Training-MR/DD Waiver
Effective on July 13, 1995, the
Department of Health and Hospitals, Bureau of Health Services Financing shall
not provide reimbursement for Individual Job/Intense Training (levels 1-4) under
Habilitation/Supported Employment for participants in the MR/DD Home and
Community Based Services Waiver.
Vacated Slots in the
MR/DD Waiver
Effective for date of service July 13,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing will not fill vacated slots in the MR/DD waiver, except that
the eligibility determination process shall be completed in the following
circumstances: (1) For those
persons whose applications for waiver services were filed in the parish BHSF
office prior to July 13, 1995; and (2) for those foster children who have been
designated by court order and who are in the custody of the Office of Community
Services for whom that agency will provide state funds required to match federal
financial participation for the waiver.
Case Management/Elderly Waivers
Effective for date of service July 13,
1995, the Department of Health and Hospitals, Bureau of Health Services
Financing reduces the reimbursement for the initial assessment and planning
period for case management services for the elderly by 20%.
Reimbursement for ongoing case management for the elderly is changed from
a service unit rate to a flat monthly rate to be billed for the second and
subsequent months in which actual service coordination and/or service provider
monitoring occurs. Ongoing case
management services shall consist of a minimum of two (2) hours of documented
service coordination per month and/or quarterly monitoring of service providers.
Respite
Services-MR/DD Waiver
Effective for date of service July 13,
1995 and after, the Department of Health and Hospitals, Bureau of Health
Services Financing will implement the following changes for respite services
provided through the MR/DD waiver:
1.
Reimbursement shall be in half-hour
units. A full half-hour of service
shall be provided in order to bill for the service.
Minutes from different occasions of service provision shall not be rolled
to accumulate half-hour units.
2.
The reimbursement rate for in-home
respite shall be $5.00 per half-hour unit, except as provided below for care
given to multiple participants by the same respite worker.
3.
The reimbursement rate for center-based
respite shall be $3.75 per half-hour for respite services provided to multiple
waiver participants by one respite worker and $5.00 per half-hour for respite
services provided to one waiver participant by one respite worker.
Medical necessity must be documented in the plan of care when the needs
of the waiver participant require the full-time attention of a respite worker.
4.
Annual service limit shall be 720 hours
(1,440 half-hour units) per calendar year, with no exceptions.
5.
The reimbursement rate for in-home
respite provided to multiple waiver participants in the same home by a single
respite worker shall be 75% of the reimbursement rate for respite services
provided to one waiver participant.
6.
The reimbursement rate for in-home
respite provided to one or more waiver participants in the same home by two
respite workers shall be 75% of the reimbursement rate for respite services
provided to one waiver participant by one respite worker.
Louisiana Drug Utilization Review (LADUR) Education
Calcium Channel Blockers:
Antihypertensive Agents
Robert L. Judd
Assistant Professor of Pharmacology
Northeast Louisiana University
School of Pharmacology
Issues�
�
Calcium channel blockers are clinically
approved for angina, hypertension, subarachnoid hemorrhage, and various
arrythmias.
�
Calcium channel blockers essentially
lower blood pressure by reducing calcium entering into specific channels of the
vascular smooth muscle and myocardial cells.
�
Adverse effects associated with these
drugs include headache, dizziness, peripheral edema, and gingival hyperplasia.
�
Demographic characteristics affect the
treatment responses with various classes of hypertensive drugs including calcium
channel blockers.
Hypertension is a serious systemic
disorder affecting approximately 50 million people in the United States.
If not treated, it may lead to the development of stroke, coronary artery
disease, renal disease, and other systemic complications.
It is especially dangerous because it may be totally asymptomatic.
Hypertension is clinically defined as an arterial pressure greater than
140 mm Hg systolic and 90 mm Hg diastolic.
It is becoming increasingly well
documented that changes in health practices may lower blood pressure and offer
hope for prevention of the disease. Such
changes include decreased cigarette smoking, weight reduction, modification of
alcohol intake, increased physical activity, stress modification techniques, and
dietary modifications. When
incorporated into an antihypertensive regimen, such nonpharmacological measures
may be useful as definitive intervention or as adjuncts to pharmacological
therapy.
If pharmacological intervention is
necessary, multiple agents are currently available, including diuretics,
adrenergic inhibitors, angiotensin converting enzyme (ACE) inhibitors, and
calcium antagonists or calcium channel blockers.
The Fifth Report of the Joint National Committee on Detection, Evaluation
and Treatment of High Blood Pressure (JNC V) recommends the use of diuretics and
beta blockers for initial monotherapy in the treatment of hypertension based on
their reported effects on morbidity and mortality.
The Committee also recommended that calcium channel blockers,
angiotensin-converting enzyme inhibitors, alpha-receptor blockers, and the
alpha-beta blockers as effective agents for initial monotherapy when diuretics
and beta blockers are unacceptable, contraindicated, or ineffective.
The calcium channel blockers are a
large and continually expanding group of pharmacological agents.
They may be grouped into three chemical classes:
the dihydropyridine, benzothiazepine, and phenylalkylamine derivatives of
which nifedipine, diltiazem, and verapamil are representative, respectively.
Calcium channel blockers are clinically approved for a variety of
indications including angina, hypertension, subarachnoid hemorrhage, and various
arrhythmias. With regard to
hypertension, specific calcium antagonists include the following agents.
| Chemical Class
|
Agent
|
| Phenylalkylamine
|
Verapamil
|
|
Benzothiazepine
|
Diltiazem
|
Dihydropyridine
|
Nifedipine
Amlodipine
Felodipine
Isradipine
Nicardipine |
Although the chemical structure and
tissue-specific affinity differ, all calcium channel blockers essentially lower
blood pressure by reducing calcium entry into specific channels of the vascular
smooth muscle and myocardial cells. Lower
levels of intracellular calcium result in reduced vascular tone and
contractility. Consequently, both
peripheral resistance and blood pressure fall.
In addition to the dilation of arterial
resistance vessels, the vasoselective agent nifedipine may cause a reflex
stimulation and tachycardia consistent with a higher circulating level of serum
catecholamines. The "second
generation" dihydropyridines include amlodipine, felodipine, isradipine,
nicardipine, and nitrendipine. These
agents appear to have fewer negative inotropic effects and greater vascular
selectivity than nifedipine.
After chronic treatment, blood pressure
is further reduced, while heart rate, cardiac index, and plasma norepinephrine
return to pretreatment values. Additional
effects of calcium antagonists include maintenance of renal blood flow and a
reduction in left ventricular hypertrophy, commonly associated with
hypertension.
In normal subjects, calcium antagonists
do not greatly modify blood pressure unless high doses are used.
A 10% to 15% decrease in mean blood pressure is obtained after oral
administration of 20 mg of nifedipine, 160 mg of verapamil, or 120 mg of
diltiazem. Hypertensive patients
with mild to moderate hypertension, however, appear to be much more sensitive to
calcium antagonists.
Using regional arterial infusions, it
has been demonstrated that verapamil produces a greater increase in forearm
blood flow in hypertensive patients than in normotensive subjects.
Smooth muscle relaxation of large arteries by calcium antagonists
improves arterial compliance, which prevents deterioration of elastic properties
of large arteries.
Adverse effects associated with the use
of calcium channel blockers include headache, dizziness, peripheral edema, and
gingival hyperplasia. Tachycardia
has been observed with the dihydropyridines, and atrioventricular block and
bradycardia with the phenylalkylamines and benzothiazepines.
Such cardiovascular effects make the use of verapamil and diltiazem in
individuals with myocardial dysfunction problematic.
Drug-drug interactions should also be
considered when using these agents, especially because hypertension is sometimes
treated with two or more agents. Carbemazepine,
rifampin, and phenobarbital may decrease serum concentrations of calcium channel
blockers, while cimetidine may increase serum levels.
Serum levels of prazosin, quinidine, theophylline, and cyclosporine may
be increased by specific calcium antagonists.
Calcium channel blocks are used in
monotherapy and in combination therapy with other antihypertensive agents in the
treatment of hypertension. The
maximal doze for verapamil is 320 mg, for nifedipine 80 mg, and for diltiazem
300 mg. In combination therapy, the
step care approach is based on the precept that the addition of second and third
drugs in smaller doses is preferable to larger doses of single agents.
Calcium channel blockers are often used in combination with ACE
inhibitors, adrenergic inhibitors, and diuretics.
Different demographic characteristics
have been identified in response to treatment with various classes of
antihypertensive drugs. With regard
to calcium channel blockers, they have found that blacks may be more responsive
to them than to beta blockers or ACE inhibitors.
Gender has not been reported to affect drug responsiveness, but the
elderly may be more responsive to all classes of antihypertensive agents,
especially calcium channel blockers. For
this reason, these drugs may be especially useful as initial antihypertensive
agents.
In conclusion, calcium channel blockers
are a very effective group of pharmacological agents used commonly in the
treatment of both angina and hypertension.
They are used both as a monotherapy and in combined therapy form in the
treatment of hypertension. Various
factors should be considered before using this category of drugs, including
specific adverse effects, drug-drug interactions, and demographic
characteristics and age.
References
Antonaccio, Michael J., ed., 1990.
"Antiarrhythmic Drugs" in Cardiovascular
Pharmacology, 3rd Edition. Raven
Press: New York. Pp.
369-485.
"The Fifth Report of the Joint
National Committee (JNC V) on Detection, Evaluation, and Treatment of High Blood
Pressure," 1993, in Archives of
Internal Medicine. 153:
154-183.
Goodman and Gilman, 1990.
"Antiarrhythmic Drugs" in The
Pharmacological Basis of Therapeutics, 8th Edition.
Elmsford, NY. Pp. 840-874.
Khan, M. Gabriel, ed., 1992.
Cardiac Drug Therapy, 3rd
Edition. W. B. Saunders:
London.
Munson, Paul L., ed., 1995.
"Antiarrhythmic Drugs" in Principles
of Pharmacology, Basic Concepts and Clinical Applications.
Chapman & Hall: New
York. Pp. 495-528.
Tatro, David S., ed., 1994 Drug Interaction Facts (Facts and Comparisons).
J. B. Lippincott Co.: St.
Louis.
Weinberger, M. H., 1992.
"Hypertension in the Elderly" in Hospital
Practice. 25:103-120.
Deleted 1995 HCPCS Codes in Non-Pay Status
The CPT codes deleted in the 1995
issuance of the Physician's Current
Procedural Terminology were placed in non-pay status during the month of May
1995. Please program your billing
systems immediately to bill current codes if you have not already done so.
Increase in Fee for J9202
BHSF is pleased to inform you of an
increase in fee for Zoladex, code J9202, to $358.55, effective for claims with
date of service May 1, 1995.
Policy Update on CPT Codes 11975 and 11976
In 1992 providers were notified that if
they check their Norplant patients a week after implantation to be sure
everything was satisfactory, they could bill the Medicaid Program for no higher
level visit than a problem-focused exam with straightforward medical decision-making (code 99201) if the patient was new, or a minimal visit (code 99211) if
the patient was established.
Effective with the publication of this
notice, the Bureau is rescinding this policy.
(Note that this first appeared on the 4/4/95 RA messages.)
Code 11975 is considered to be a surgical procedure; therefore, it falls
within the surgical package policy guidelines (i.e., pre- and post-operative
visits are included in the global fee for the procedure).
Current policy restricts code 11975--Insertion implantable contraceptives
capsules--to one implant per recipient per five years.
Second and subsequent billings for an implant per recipient within a
five-year period pend to the Medical Review Unit for review and are paid if the
criteria for medical necessity are met. Effective
May 1, 1995, this same restriction was placed on CPT Code 11976--Removal,
implantable contraceptive capsules.
The question has been asked if we will
pay for a follow-up visit(s) if all six capsules are not removed at the original
removal of the Norplant. The answer
is NO. Only one removal fee will be paid for each Norplant
Insertion. Code 11976 is also
considered to be a surgical procedure; therefore, it also falls within the same
surgical package policy guidelines as code 11975.
C-Section Information For MDs & Nurses
The question has been asked, "Can
a doctor charge a recipient for a nurse to assist during a C-Section?"
The answer is NO. The Medicaid
Program reimburses a medical doctor to assist at a C-Section.
If a doctor chooses to bring a nurse to assist during a C-Section, it is
against Medicaid policy to charge the recipient for this service.
Home Health Reminder
If you have been approved by the state
to bill either multiple visits of the same level service on the same date of
service or multiple levels of service on the same date of service, you must
submit these claims hard copy. You
must also submit the state approval letter and note of explanation to the
following address for special handling.
Unisys Provider Relations Dept.
Correspondence Unit
P. O. Box 91024
Baton Rouge, LA 70809
You may
not submit these claims without special handling! This notice is to
reinforce policy that has been in place since this approval process was
implemented. Attempts to bypass
this process will result in claims payment cutbacks or denials.
If a cutback occurs, you must file an adjustment of the paid claim along
with a copy of the approval letter and explanation note.
Do not submit new claims for
the additional visits. Should you have questions, please contact Unisys Provider
Relations at (800) 473-2783 or (504) 924-5040.
Correct Billing of CPT Codes 90918-90921
We have noticed that some providers are
billing incorrectly for codes 90918-90921 (End Stage Renal Disease Services).
The July/August 1993 issue of the Provider
Update contains the instructions for the correct billing of these codes. The fee for each of these codes is $159.00 per month,
not per day. A month is considered
to be 30 days even if a month has 28, 29, or 31 days.
These codes may be span-billed, but if they are, a "1" (and no
other number) is to be placed in the units column on the claim form.
Any payments in excess of $159.00 per month for these codes are subject
to recoupment.
Corrections to the Hospital Services Manual
The Hospital Program recently made
revisions to the Hospital Services Manual
with issue date June 1, 1995. The
revised pages to the manual were distributed via memorandum dated May 19, 1995
to all hospital providers. These
revisions include corrections to the original issue and some policy revisions
for clarity. There are three issues
included in the policy clarifications that need to be noted.
1)
The statement on page 5-3 of the Hospital
Services Manual regarding the billing of a facility fee for hospital clinic
services is incorrect. It is being
revised as follows. "The
facility fee for the hospital's charges may not be billed as a separate charge
by the hospital."
2)
The statement on page 5-3 regarding the
annual service limits for outpatient clinic visits is unclear and has been
revised as follows. "Hospital clinic visits are counted as part of the 12 annual
physician office visits allowed."
3)
The statement on page 5-6 of the manual
regarding the billing for Norplant contraceptive implant kits by the hospital is
also incorrect. This page has been
revised as follows. "Billing
for the Norplant contraceptive implant kit by use of a pharmacy revenue code is
prohibited by the Medicaid Program in Louisiana.
Only physicians may bill Medicaid for this service."
Prior Authorization of Mental Health Rehabilitation
Effective July 15, 1995 the Bureau of
Health Services Financing adopts the following regulations governing the
provider participation and Medicaid reimbursement of all mental health
rehabilitation services delivered under the State Plan.
In order to be reimbursed by the Bureau of Health Services Financing
under the Medicaid Program, the providers of mental health rehabilitation
services must:
A.
Obtain prior authorization from the
Medicaid agency or its designee certifying candidates for mental health
rehabilitation services who are Medicaid eligible and are members of the
population of adults with serious mental illness or children with
emotional/behavioral disorders as defined by the Office of Mental Health.
B.
Obtain prior authorization of the
mental health rehabilitation plan by the Medicaid agency or its designee.
C.
Participate in provider training and
technical assistance as required by the Medicaid agency or its designee.
D.
Participate in the mental health
rehabilitation information system and provide up-to-date data including client
data, service delivery information and assessment information to the Medicaid
program or its designee on a weekly basis via electronic mail.
Mental Health Rehabilitation Procedure Code X0106
Collateral consultations, procedure
code X0106, will not be paid by the Medicaid Program in Louisiana if provided on
or after May 1, 1995, in accordance with a finding from HCFA on a recent review.
Prior Authorization of Case Management
Effective June 1, 1995 the Bureau of
Health Services Financing adopts the following regulations governing the
provider participation and Medicaid reimbursement of all case management
services for the populations of mentally retarded/developmentally disabled or
infants and toddlers with special needs.
These regulations are in addition to
current requirements for case management services and are applicable to case
management services delivered under the State Plan or under an approved waiver
from the Health Care Financing Administration.
OPTIONAL TARGETED CASE MANAGEMENT
SERVICES FOR THE MENTALLY RETARDED/DEVELOPMENTALLY DISABLED OR INFANTS AND
TODDLERS WITH SPECIAL NEEDS POPULATIONS.
A.
Candidates for case management services
must be Medicaid eligible.
B.
Medicaid eligibles must be certified as
a member of the targeted populations by the Medicaid agency or its designee.
C.
The case management service plan is
subject to prior authorization by the Medicaid agency or its designee.
D.
Providers of case management services
are required to participate in provider training and technical assistance as
required by the Medicaid agency or its designee.
Coverage of Wound Care Supplies in Nursing
Facilities
Due to the numerous inquiries received
from both nursing facilities and Medicare suppliers, DHH requested clarification
from HCFA regarding the appropriateness of billing the Medicare program for
wound care supplies for residents who are eligible for both Medicare and
Medicaid benefits. The response
received was that states are responsible for establishing NF per diem
reimbursement rates that cover the nursing facility services furnished to
residents. If medical supplies are
considered by the State to be pat of the NF benefit package and, therefore,
included in the reimbursement rate paid to the NF (as in Louisiana's case), any
Medicaid payment to a supplier for medical supplies would create a duplication
of payment. The State Medicaid
agency is not required, under these circumstances, to make a separate payment
for the co-insurance for these supplies. The
supplier would have to look to the NF for collection of this amount.
Any claims for wound care supplies crossing over to Medicaid for payment
of co-insurance will automatically deny if the recipient is a resident in a
nursing facility.
Medicare Crossover Claims
Two Medicare crossover problems have
recently been brought to the attention of BHSF.
Blue Cross of Arkansas has recently
advised that there are approximately 1500 Medicare provider numbers that are not
crossing over to the Louisiana Medicaid provider numbers. These Medicare numbers consist of 5 digits and are numeric
with possibly some alpha characters.
Palmetto Government Benefits
Administrators processes DME claims for the Medicare program for Louisiana
providers. New 10-digit Medicaid
DMERC provider numbers were assigned when this company took over the processing
of DME claims. The new numbers were
forwarded to the Medicaid agency via magnetic tape to be matched to the Medicaid
provider numbers. We are still
having
difficulty in producing a provider match in which we have confidence.
If your Medicare number, either
assigned by Blue Cross of Arkansas or Palmetto Government Benefits, is not being
automatically converted to your Medicaid number, we need your assistance in
giving our Provider Enrollment Unit the necessary information to update the
automatic conversion file.
Please mail or fax us your Medicare
number(s) and the Medicaid provider number to which the crossover claims should
be matched. Your assistance will
enable us to process the crossover claims quickly and correctly.
The correct FAX Number is (504) 342-3893.
Our mailing address is as follows:
Bureau of Health Services Financing
P. O. Box 91030
Baton Rouge, LA
70821-9030
Attn: Provider
Enrollment
If you have been recently contacted by
the provider enrollment staff about this matter, you need not respond.
NDC Code Not on File
If you have claims denied for "NDC
not on file," please send copies of the label and your invoice showing its
AWP to the following address:
Unisys
Files Maintenance Dept.
P. O. Box 3396
Baton Rouge, LA
70821
Claim Preparation - Estimated Day Supply (EDS)
Pharmacists are advised to enter an
"estimated day supply" consistent with the prescribing physician's
directions and/or your professional judgment.
Currently, some providers are incorrectly enter a "30-day
supply" on all prescriptions
despite a "Sig," which would indicate a smaller EDS.
Claim Submission - Non-Payable NDCs
Pharmacists are strongly encouraged to
update NDC records in their store computers based on deny claim information
found on the remittance advices. Currently,
some pharmacies have many denials for the exact NDC claim. This should not be occurring if the remittance advice
information is used to prevent future submission of non-payable NDC claims.
Wheelchair Seating Evaluations
In the 10/4/93 memo to all
rehabilitation coordinators of customized wheelchair seating evaluations from
Tom Collins, Director of the Bureau of Health Services Financing, the procedure
of inviting three DME providers to participate in wheelchair seating clinics was
established. The rehabilitation
provider conducting the seating clinic must, in consultation with the recipient,
invite three DME providers to participate in any scheduled seating clinic.
Please note, however, that if a DME
provider who has not been invited to a scheduled seating clinic contacts the
rehabilitation coordinator about a specific scheduled seating clinic for a
particular recipient and expresses a desire to participate in that clinic, the
rehabilitation coordinator should then invite that DME provider to participate.
The coordinator should always, however, consult the recipient first about
the additional invitation. If the
recipient does not want to exclude the additional DME provider, an invitation
should be extended.
If there are any questions concerning
these procedures, you may contact Mr. Gene King of BHSF at (504) 342-3930.
Case Management Policies
The September/October 1993 Provider Update contained an article on non-billable case management
activities. We are reiterating
Medicaid policy regarding transportation being billed as a case management
service. Any form of direct service
is not a billable activity. This
includes (but is not limited to) visiting, transporting, waiting for
appointments, shopping, accompanying on recreational activities, picking up
medication, etc. Case management
services do not consist of the provision of needed services, but are used as a
vehicle to help the individual gain access to them.
Leaving messages for someone, faxing or
mailing information, reviewing recipient records, and writing progress notes or
the Plan of Care without being in the presence of the client are not billable
services. A good "rule of
thumb" to remember is that if there is no interaction in person, by
telephone, or by correspondence on behalf of the recipient, the activity is most
likely not billable.
Message from the Medical Director
This issue of the Provider Update has been delayed by our desire to include
information on the new Louisiana Medicaid regulations which DHH is implementing
to achieve the necessary fiscal savings. These
new rules challenge all of us who are providing good health care to Louisiana's
citizens to continue to do our best to achieve this important goal.
DHH and Unisys are working together to revise the computer and other
processing functions to ensure a smooth transition to the new rules, some of
which are undergoing final revision as this issue goes to press.
We appreciate your efforts and your cooperation as we work together to
provide necessary Medicaid medical services to our recipients.
I would like to give you my perspective
on the efforts to revise Medicaid to meet changing federal funding rules.
Since the first public hearing on the proposed Medicaid Managed Care
Waiver in December, there have been countless planning sessions and many
Louisianians attempting to do all they humanly can to achieve the best health
care possible for their fellow citizens.
On the Quality and Benefits committees,
representatives from many different organizations ranging from the medical
community to the school nurses to ordinary private citizens unselfishly gave
their time to the effort.
I also appreciate your individual
efforts to help us save money for the state.
One physician recently made a suggestion on how we could save money
without impacting on care. We are
currently analyzing this suggestion to determine possible cost savings.
Other physicians and hospitals are helping us develop better criteria for
approving durable medical equipment, which we can then follow in a prospective
study to demonstrate appropriateness. Together,
we can all continue to improve the health and care given to all Louisiana
residents.
Charles
Lucey, MD, MPH
Notice to Providers
The Unisys Provider Relations telephone
numbers are for provider use only. Please
do not refer recipients to Unisys Provider Relations. Recipients should be referred to their parish offices for
assistance. Your cooperation in
this matter will assist us in handling a greater number of provider calls.