Provider Update
Volume 13, Number 3
May/June 1996
Special Message for Physicians: Advances
in Pregnancy Care
By Harvey A. Gabert, MD
FACOG, FRCS (c)
Professor and Acting Chairman
Louisiana State Medical School
Obstetrics and Gynecology
New Orleans, Louisiana 70112
Note from the
Medical Director: This Provider Update inaugurates our new idea of having guest writers
share their expertise with other providers.
Harvey Gabert, MD has kindly written an update on pregnancy care.
DHH and Unisys will be inviting other provider representatives to share
their knowledge in future editions.
DHH continues to
confront budgetary realities with the input of all interested citizens, while
seeking to emphasize cost-effective, appropriate, quality medical care.
The DHH announcement on "Ventilator Assist Devices" follows a
cooperative quality initiative to practicing Louisiana physicians to assist DHH
in developing appropriate criteria in this area.
I will update you on other initiatives as they successfully conclude.
Sincerely,
Charles Lucey, MD,
MPH
Unisys Medical Director
Advances in the field of obstetrics have progressed steadily over the past 20
years. The maternal morality has
dropped to about 9/100,000, along with a dramatic improvement in perinatal
mortality. Some advances are due to
improved availability of patient care during the pregnancy, while others relate
to specific diagnoses along with testing procedures that were not available
several decades ago.
One notable advance is prenatal care in the form of
appropriate visits. In general,
interval visits scheduled should total 12 over the 6-40 week period.
Some recent information indicates that perhaps 9 visits are sufficient,
based on outcomes similar to the 12 visit regimen.
My own thought would be that patients would need to be categorized into
normal and at risk pregnancies. The
normal population in all probability will have a similar outcome with 9 visits,
while risk patients may potentially need double that figure.
The risk patients would include those with insulin dependent diabetes and
chronic systemic diseases (such as lupus, bowel inflammation, and chronic
respiratory compromise). In
addition, patients with a history of premature rupture of membranes, premature
delivery, multiple gestation, and any process causing uncommon uterine
distention will need closer follow-up.
It is apparent to the medical and, I believe, the general
populations that Rh disease has almost disappeared from our high risk category.
The initial management with titers of the antibody followed by
amniocentesis and intrauterine transfusion markedly decreased the prenatal
complication and death rate. The
advent of Rhogam given at 28 weeks, postpartum, and after procedures such as
amniocentesis, dilatation and curettage, and tubal pregnancies, has dropped the
incidence of sensitization to about 0.1%. However,
recent information appears to indicate the Rhogam at 28 weeks may not impact
greatly on Rh sensitization. If
this fact is true, then the administration at 28 weeks might well be excluded.
Prenatal diagnosis for previous anomalies due to genetic
abnormalities, prior dysmorphic offspring, and a history of other general
abnormalities is available. The
diagnostic procedures do not, however, create a decrease in the prenatal
mortality; rather, they create intrauterine and after-delivery management issues
that may produce positive effects for the newborn.
These procedures include amniocentesis, chorionic villus sampling, and
umbilical cord blood aspiration. The
testing is by sex determination or karyotype for specific abnormalities, such as
cystic fibrosis. These tests are
used only when indicated necessary by history.
Maternal serum alpha-fetroprotein, at high levels, is a
screening test for open spine defects, abdominal defects, kidney abnormalities,
and fetal growth. On the other
hand, low levels relate to Down Syndrome and other chromosome abnormalities.
The triple test using three hormones is specific for Down Syndrome and,
if used as a screening test, can decrease the number of amniocenteses for
karyotype studies. The latter test
is performed at 15-17 weeks.
Ultrasound has been one of the major advances in pregnancy.
It is useful in confirming and dating a pregnancy.
An anatomic study at about 18 weeks is very accurate in diagnosing fetal
structural defects and, in addition, pregnancy can be dated within about 10 days
at that time. Ultrasound has
advanced to the point where Doppler and color Doppler can be used to assess
fetal welfare and growth. Fetal
growth can be predicted within 5-10% and may be of help in early and late
pregnancies. Fetal echocardiography
studies can be performed that allow appropriate management and site of delivery
to be determined. Fetal
echocardiography would be indicated if a positive maternal and/or sibling
history is present. In addition,
dysrhythmias found on auscultation and ultrasound would need follow-up.
Other fetal assessment tests include the contraction stress
test, fetal activity determination test (non-stress test), and the biophysical
profile. The contraction stress
test is not used routinely at this time, except to assess a fetus' ability to
withstand labor. The non-stress
test is used as a screening tool for fetal welfare and as one component of the
biophysical profile. The
biophysical profile also includes ultrasound study to determine fetal tone,
breathing, movement, and amniotic fluid volume.
These tests, along with fetal growth assessment, are useful in managing a
pregnancy with a resultant decrease in newborn morbidity and morality. These tests would be indicated if fetal growth or maternal
problems occur.
Premature deliveries occur in 10% of pregnancies.
Most result in fetal lung immaturity.
Fetal lung maturity determinations have resulted in a decrease in
respiratory distress syndrome and hyaline membrane disease.
The addition of steroids, if premature delivery is imminent, administered
to the mother at 26-32 weeks has shown a marked improvement in fetal lung
maturation, thereby decreasing respiratory distress, the need for intubation,
and the number of days spent in the neonatal intensive care unit.
The recent development of surfactant that can be injected into the
newborn lung field has helped to manage the premature infant. The use of surfactant, together with pre-delivery steroids,
has had a positive influence on neonatal management.
One final aspect to consider in pregnancy care is the
length of stay for a normal vaginal delivery and an abdominal (Caesarean)
delivery. There is a great deal of
controversy that has arisen because of managed care. The managed systems feel early discharge is paramount in
order to decrease costs. On the
other hand, many problems can arise in the first 48-96 hours concerning the
newborn and mother after delivery. Early
discharge has, in some cases, resulted in serious morbidity.
I feel that 48 hours for a vaginal delivery and 96 hours for an abdominal
delivery may be justifiable. This
would be a good compromise and decrease newborn and maternal morbidity.
On the other hand, there are some patients that can be discharged safely
earlier. If home care is available, earlier discharge could be
justified. To date, it is not clear
if early discharge reduces the overall cost.
In summary, the technical, diagnostic, and management
advances have had a most positive influence on pregnancy outcome.
We must, however, take care to realize that a certain level of care must
be continued for good outcome. All
newborns should have the prospect of long and fruitful lives.
Louisiana Drug Utilization Review (LADUR) Education
Issues
�
NSAIDs are among the most frequently prescribed medications.
�
Certain patient populations may be at increased risk for adverse
effects.
�
NSAIDs have the potential to interact with other medications.
�
Newer NSAIDs have long half-lives that affect duration of adverse
effects.
�
H2-receptor antagonists prophylaxis does not protect
against NSAID-induced GI mucosal injury.
Non-Steroidal Anti-Inflammatory Drugs
Edwin H. Adams, R.Ph.
Specialist in Poison Information
Louisiana Drug and Poison Information Center
Northeast Louisiana University
School of Pharmacy
Non-steroidal anti-inflammatory drugs (NSAIDs) are one of
the most frequently prescribed class of drugs.
These drugs are used in such chronic conditions as rheumatoid arthritis,
osteoarthritis, ankylosing spondylitis, gout, and headaches.
In addition, NSAIDs are helpful in treating pain associated with
dysmenorrhea, dental procedures, and musculoskeletal disorders.
Current marketing strategies make it difficult for patients to decide
which products are safe and effective for use.
Important considerations in choosing a drug include age, concomitant
medications, risk factors, and medical history.
Table 1
|
Prescription
Drug
|
Over-the-Counter
Product
|
|
Ketoprofen
Orudis�
25 mg, 50 mg, 75 mg
Oruvail�
150 mg, 200 mg
|
Orudis KT�
12.5 mg
|
|
Naproxen
Naprosyn�
250 mg,
375 mg, 500 mg
Naproxen Sodium
Anaprox�
250 mg, 500 mg
|
Aleve�
200 mg (220mg Naproxen Sodium)
|
NSAIDs have anti-inflammatory, antipyretic,
and analgesic effects. Inflammation,
fever, and pain are medicated through the production of prostaglandins via the
arachidonic acid cascade, and NSAID activity is aimed at inhibiting the
production of these prostaglandins. These
drugs do not arrest or alter the progression of the disease.
Most of the side effects associated with NSAID
therapy are mild and abate upon discontinuation of therapy. However, several side effects warrant further consideration.
The most common side effects of NSAIDs involve the gastrointestinal
tract. Up to 20% of users are
affected by GI symptoms. The damage
to the GI tract occurs via two mechanisms.
One is by direct mucosal injury. Aspirin,
for example, can cause minor mucosal erosions or hemorrhages, and can be locally
irritating. The other mechanism is
more serious and involves the inhibition of endogenous gastric prostaglandin
production. These compounds are
important in the production of gastric bicarbonate, gastric mucous, and in the
maintenance of submucosal blood flow. Inhibition
of prostaglandins by NSAIDs increases the likelihood of mucosal injury.
In 1992, there were an estimated 13 million people taking
NSAIDs chronically. An FDA study
estimated 10,000 to 20,000 deaths per year associated with serious NSAID-induced
gastric ulcers and their complications. Patients
at risk for developing NSAID-induced gastric ulcers are listing in Table 2.
Table 2
|
NSAID-Induced
Gastric Ulcer Risk Factors
|
|
Increased age
History of
Peptic Ulcer Disease
Previous
intolerance to NSAIDs
Cigarette
smoking
History of
alcoholism
Concomitant
serious illness
|
The danger associated with these gastric ulcers is that
most patients remain asymptomatic until complications arise.
Although perforation can occur within days following initiation of
therapy, most complications occur with chronic use of NSAIDs.
In addition, there appears to be a dose-response relationship relative to
the extent of gastric injury. Taking
NSAIDs with food does not appear to affect the risk of ulceration.
Prophylactic treatment with H2-receptor antagonists, antacids,
and sucralfate is not effective in reducing NSAID-induced GI injury.
Misoprostol (Cytotec), a prostaglandin E1 analog, is the only drug that
is FDA approved for prophylactic use in the prevention of NSAID-induced gastric
and duodenal mucosal injury in patients who are using NSAIDs chronically.
The NSAIDs exhibit anti-platelet activity by inhibiting
platelet cyclooxygenase. The
resulting thrombocytopenia may contribute to bleeding associated with GI mucosal
damage. There are two factors which
determine the amount of time required for normal platelet function to return.
The first is the extent of drug binding to cyclooxygenase.
For example, aspirin irreversibly binds to cyclooxygenase, thus
inhibiting platelet function for the life of the platelet.
Platelet activity is then dependent upon the production of new platelets,
which takes 7 to 12 days. Ibuprofen
reversibly binds to cyclooxygenase, allowing normal platelet function to return
once the drug is eliminated. The
half-life of the drug which reversibly binds to the platelet ultimately
determines how long it will take for normal platelet function to return. [Table
3.]
Table 3
|
NSAID
|
Half-Life
(Hrs.)
|
|
Ibuprofen (Motrin�)
Ketoprofen (Orudis�)
Flurbiprofen (Ansaid�)
Etodolac (Lodine�)
Naproxen Sodium (Anaprox�)
Nabumetone (Relafen�)
Piroxicam (Feldene�)
Oxaprozin (Daypro�)
* Normal Population Values |
1.8-2.5
2-4
5.7
7.3
12-15
22.5-30
50
42-50
|
Although adverse effects in the kidneys are rare, there are
certain patient populations that are at an increased risk of developing adverse
renal effects. These include
patients with congestive heart failure, cirrhosis, hypovolemia, or a
pre-existing renal condition. Signs
or potential renal toxicity are listed in Table 4.
Table 4
|
Signs
of NSAID-Induced Renal Toxicity
|
|
Decreased
urine output
Rapid rise
in serum creatinine
Rapid rise
in blood urea nitrogen
Gain in body
weight despite diuretic therapy
|
There are two mechanisms by which the kidneys are affected.
The first mechanism is an indirect effect on renal perfusion.
Prostaglandins which enhance the vasodilation of renal vasculature are
inhibited by NSAIDs, leading to a decrease in renal perfusion, which can cause
an ischemic injury. For those
patients at risk, acute renal failure can occur soon after NSAID therapy is
begun. It is the loss of renal
perfusion, not basal prostaglandin production, which is responsible for the
injury. The second mechanism is an
idiosyncratic reaction causing interstitial nephritis.
It can occur within days to months after the initiation of therapy and
appeals to be immunologically medicated. Renal
function will generally recover after discontinuation of the suspected causal
agent.
There are a few clinically significant drug-drug
interactions associated with NSAID therapy.
Most of these interactions involve the NSAID's effect on platelets and
the GI mucosa. [Table 5.]
Table 5
|
Drug
Interactions
|
|
Corticosteroids:
Increased incidence and severity of GI ulceration.
|
|
Methotresate:
Increased serum concentrations secondary to decreased excretion
and/or displacement from plasma proteins (especially salicylates and
ketoprofen.
|
|
Coumarin-Type
Anticoagulants: Cautious
use because of NSAID antiplatelet effects and induction of GI injury
(especially with aspirin and phenylbutazone.
|
|
Lithium: Increased lithium plasma concentrations (EXCEPT aspirin and
sulindac).
|
|
Antihypertensive
Agents: Antihypertensive
effects may be attenuated by concurrent use of NSAIDs.
|
Conclusion
NSAIDs are excellent agents in alleviating mild to moderate
pain secondary to an inflammatory process.
They are among the most prescribed drugs on the market today.
However, careful consideration must be applied to their use because of
the possible risks associated with NSAID therapy.
NSAID-induced gastric ulcers and ulcer complications occur in 15-20% of
patients in chronic therapy. These
adverse GI effects are compounded by their asymptomatic nature.
Misoprostol (Cytotec) is the only drug FDA-approved for use in preventing
NSAID-induced gastric ulcers in patients undergoing chronic NSAID therapy.
Though many effects are milder, some require immediate attention.
Signs of renal toxicity warrant the immediate discontinuation of therapy.
Due to the extensive use of NSAIDs, it is vital that health professionals
under their potential for adverse effects.
References
Clinical Pharmacology
(An Electronic Drug Reference and Teaching Guide), v.1.5, Gold Standard
Multimedia Inc.
Drug Facts and
Comparisons. Updated Monthly:
251-252f.
Insel, P.A. "Analgesic-Antipyretic and Anti-inflammatory
Agents; Drugs Employed in the Treatment of Rheumatoid
Arthritis," Goodmand and Gilman's The
Pharmacological Basics of Therapeutics, 8 (New York: Pergamon, 1990):
638-681.
Knodel, L.C. "NSAID Adverse Effects and Interactions:
Who Is At Risk?," American Pharmacy,
NS32, No. 3 (1992): 39-47.
Policy Notes: Providers
SOBRA/CHAMP Program
Effective January 1, 1989, the Department of Health and
Hospitals implemented SOBRA (Sixth Omnibus Budget Reconciliation Act)/CHAMP
(Child Health and Maternity Program) as policy in the Medicaid Program, which
created a new group of eligibles. Under
this policy, indigent pregnant women and indigent children born after September
20, 1983 are eligible for Medicaid.
Pregnant women may have "Presumptive Eligibility (PE),
"established by a "qualified provider" such as a state hospital
or public health unit for a period of up
to forty-five (45) days. Application
must also be made for full SOBRA eligibility, but during this period the
"presumptive eligible" pregnant women will be eligible for ambulatory
(outpatient) prenatal care including non-emergency transportation.
Once fully certified as a SOBRA eligible, she will be given a new
identification number and can receive any pregnancy-related services, including
hospital and delivery until 60 days after delivery.
Pregnancy-related services cover any medical conditions which can impact
the pregnancy by affecting the mother's health.
The eligibility card for these "Presumptive Eligibles" is
different and specifies those services for which the recipients are eligible. The 45-day period of presumptive eligibility expires
automatically if eligibility has been established. Verification should
be made at the parish office. The
new identification number is to be used for billing services provided after the
45-day time period has elapsed.
9PC
LOUISIANA MEDICAL ELIGIBILITY CARD
PAD16
PRESUMPTIVE ELIGIBILITY
P.O. BOX 2343
BATON ROUGE, LA
70896
ERMA SMITH
555 BROWN STREET
ANYTOWN, LA 70000
ID NUMBER
NAME
BIRTHDATE
17-16-0-012350-20
ERMA SMITH
10-30-73
PRESUMPTIVE ELIGIBILITY PERIOD BEGINS
***01-02-95***
SERVICES LIMITED TO AMBULATORY PRENTAL
CARE ONLY
HOSPITALIZATION, LONG TERM CARE SERVICES
NOT AUTHORIZED
**MAY NOT EXCEED 45 DAYS AND MAY BE
SHORTENED IF RECIPIENT IS
INELIGIBLE OR FAILS TO COMPLY WITH
ELIGIBILITY REQUIREMENTS
SAMPLE PRESUMPTIVE ELIGIBILITY CARD
NOTE: Authorized for
outpatient services only. Card has
a 45-day limit maximum.
Notice to Certified Nurse Practitioners
The Bureau of Health Services is pleased to inform
you of the following codes which will become payable at 80% of the full service
fee to Certified Nurse Practitioners, effective with the date of service May 1,
1996. The fees stated below reflect 80% of the full service fee.
Z9001 - Prenatal lab panel (1-3 tests), fee $9.29
Z9002 - Prenatal lab panel (4-5 tests), fee $13.46
Z9003 - Prenatal lab panel (6 or more tests), fee $16.78
Z9004 - Initial prenatal visit, new or established patient,
fee $36.00
Z9005 - Follow-up prenatal visit, fee $19.44
Z9006 - Postpartum visit, fee $19.44
31500 - Intubation, endotracheal, emergency procedure, fee
$44.37
Notice to RHC and FQHC Providers
In reference to questions about the way in which RHC
and FQHC visits are counted, please be advised all providers were notified in
the September/October 1995 issue of the Provider
Update that the count of physician, RHC, and FQHC visits was changed in
July, 1995 from calendar year to state fiscal year.
Additionally, visits with dates of service July 1, 1995 and
thereafter which had been denied with error edit 907 after July 1, 1995, were
recycled and paid in the September 5, 1995 checkwrite.
Notice to CRNAs
Effective with date of service May 1, 1996, CPT code 31500
- Intubation, endotracheal, emergency procedure - will become payable to CRNAs
at a flat fee of $55.46. It should
not be billed with modifiers or minutes.
Phone Number Correction
Please note that the correct telephone number for the
Recipient Eligibility Verification System, the Unisys automated eligibility
line, is (800) 776-6323. The
telephone number was incorrectly listed in the last Provider
Update.
Policy Notes: Pharmacists
Recipient Eligibility Cards and Metric Decimal Quantities
Recipient
Eligibility Cards
Pharmacy providers are reminded to review monthly recipient
eligibility cards prior to submission of pharmacy claims through POS.
This will prevent unnecessary delays in adjudication when invalid
recipient ID numbers are submitted.
Metric Decimal
Quantity
NCPDP data element number 442, Metric Decimal Quantity, is
being utilized with POS for the submission of quantities dispensed with each
pharmacy claim. Providers now have
the ability to enter five (5) numbers to the left of the decimal and three (3)
numbers to the right of the decimal (Example:
99999.999). This new format
will accommodate exact quantity billings on those drugs which are packaged in
fractional units. Pharmacists are
to indicate on the pharmacy claim the exact quantity dispensed and their usual
and customary charge associated with that quantity. Stadol NS and DDAVP are examples of commonly dispensed
medications which can now be billed in the decimal quantity dispensed.
The pharmacy program has identified providers billing 2 packages of
Stadol NS (2.5 ml package) with a quantity of "6".
These pharmacies rounded the 2.5 ml package to 3 ml and overcharged the
pharmacy program when multiple packages were dispensed.
In previous audits, recoupments were made for the overpayments.
Pharmacists should carefully review all packages being
dispensed, especially those billed in milliliters and grams, to assume proper
quantities are charged to the program.
Drug and Supply Coverage Under Medicare Part B
Immunosuppressant
Drugs
Effective January 1, 1987, Medicare Part B began paying
FDA-approved immunosuppressant drugs. This
benefit is subject to Part B deductible and coinsurance provisions and until
recently was limited to one year after a covered organ transplant.
Effective February 19, 1996, the Bureau will revise the
reimbursement policy on immunosuppressant drugs to be in compliance with OBRA
1993. According to the June 1995
DMERC Medicare Advisory, a phased-in extension of immunosuppressive drug therapy
occurs based on the month of discharge following a Medicare covered transplant.
The accompanying table identifies the month of discharge from a covered
organ transplant with the total number of months of Medicare coverage.
Month of
Discharge
Total Months of Coverage
08/93
13
09/93
14
10/93
15
11/93
16
12/93
17
01/94
18
02/94
19
03/94
20
04/94
21
05/94
22
06/94
23
07/94
24
08/94
25
09/94
26
10/94
27
11/94
28
12/94
29
01/95
30
02/95
31
03/95
32
04/95
33
05/95
34
06/95
35
07/95
36
Claims for
immunosuppressant drugs for a recipient of a Medicare covered transplant whose
discharge date was prior to April 1, 1994 can be filed with the Bureau's fiscal
intermediary January 1, 1996. Claims
billed for those recipients whose discharge occurred after April 1, 1994, must be
filed first with Medicare and then straight Medicaid coverage will begin on the
date of discharge for the year identified in the following table.
Month of
Discharge
Total Months of Coverage
04/94
01/96
05/94
03/96
06/94
05/96
07/94
07/96
08/94
09/96
09/94
11/96
10/94
01/97
11/94 03/97
12/94 05/97
01/95
07/97
02/95
09/97
03/95
11/97
04/95
01/98
05/95
03/98
06/95
05/98
07/95 07/98
Beginning with dates of
discharge after July, 1995, Medicare coverage for immunosuppressant drug therapy
will extend for a period of 36 months. During
this 36 month period, all immunosuppressant drug claims are to be submitted to
the Medicare carrier prior to billing Medicaid.
As new immunosuppressants
are approved by the FDA, the Bureau will add them to the drug file.
Billing for these new immunosuppressants will follow the established
claim filing procedures and timetable.
Presently, the following
immunosuppressant drugs are being added to the drug file.
The corresponding HCPCS codes are identified for your convenience.
K0412 - Mycophenolate
Mofetil, oral 250 mg
K0121 - Neoral (Cyclosporine
for microemulsion)
J7507 - Tacrolimus, oral,
per 1 mg (Prograf)
J7508 - Tacrolimus, oral,
per 5 mg (Prograf)
Codes J7500 - J7506,
previously listed on pages 5-7 and 5-8 of the Pharmacy Provider Manual (February
1993), are no longer valid for claims submitted to the DMERC; the following
codes should be used instead.
K0119 - Azathioprine -
oral, tab, 50 mg
K0120 - Azathioprine -
parenteral, 100 mg
K0121 - Cyclosporine -
oral, 25 mg
K0122 - Cyclosporine -
parenteral, 250 mg
K0123 - Lymphocyte immune
globulin, antihymocyte globulin - parenteral, 5 mg
K0124 - Monoclonal
Antibodies - parenteral, 5 mg
K0125 - Prednisone - oral,
5 mg
J7509 - Methylprednisolone
- oral, 4 mg
J7510 - Prednisolone -
oral, 5 mg
After the carrier
processes the claim, the information will automatically crossover from the
carrier to the fiscal intermediary for payment of the coinsurance and deductible
amounts, where applicable.
The Bureau is redesigning
the processing of claims for immunosuppressant drug therapy to accommodate the
electronic billing of these claims. Recipients on immunosuppressant drug therapy
are being identified with their date of discharge from a Medicare-covered
transplant or other diagnosis necessitating the utilization of this type of drug
therapy. This date of discharge or diagnosis will be carried on the recipient
file for the system to calculate Medicaid drug coverage according to the new
Medicare schedule above. Appropriate documentation will be needed in order to
have the date of discharge or diagnosis entered into the recipient file. If
providers choose, faxing the recipient's discharge date or other diagnosis
information will be accepted by the Bureau at (504) 342-3893, with a fax cover
sheet addressed to the Pharmacy Program. Please include the recipient ID number
on all correspondence. All subsequent immunosuppressant drug claims can be filed
in the manner the provider is accustomed to billing all other pharmacy claims.
As a result, immunosuppressant drug therapy claims will be less cumbersome to
file and process.
Oral Anticancer Drugs
Effective January 1, 1994,
Medicare Part B coverage was extended to include oral anticancer drugs approved
by the FDA. OBRA 93 provides for
coverage of oral, self-administered, anticancer chemotherapeutic agents.
Currently, the following drugs meet the requirements for coverage under
OBRA 93. Use
the NDCs to bill the oral anticancer drugs.
(Unlike other drugs billable to the DMERC, these oral anticancer drugs
are not submitted with HCPCS codes.)
Cyclophosphamide - 25
mg/oral and 50 mg/oral
Etoposide - 50 mg/oral
Methotrexate - 2.5 mg/oral
Melphalan - 2 mg/oral
Pharmacy providers should
submit claims to the Medicare carrier prior to billing Medicaid for those
individuals eligible for the Medicare Part B coverage.
After the carrier
processes the claim, the information will automatically crossover from the
carrier to the fiscal intermediary for payment of the coinsurance and
deductible, where applicable.
Drug Used with Nebulizers
Medicare Part B eligible
recipients requiring nebulizer medications are to have those pharmaceuticals
billed first to the Medicare carrier. Palmetto
Government Benefits Administrators (GBA) will automatically crossover the claim
information to the Louisiana fiscal intermediary for payment of the coinsurance
and deductible amounts where applicable.
According to the July,
1995 Medicare Region C DMERC Supplier Manual, the following HCPCS codes are to
be used when billing for nebulizer medications:
J2545 - Pentamidine
isethionate, inhalation solution, per 300 mg, administered through a DME
J7610 -Acetylcysteine, 10%
per ml, inhalation solution, administered/DME
J7615 - Acetylcysteine,
20% ml
J7620 - Albuterol sulfate,
0.083% per ml
J7625 - Albuterol sulfate,
0.5% per ml
J7627 - Bitolterol
Mesylate, 0.2% per 10 ml
J7630 - Cromolyn sodium,
per 20 mg
J7640- Epinephrine, 2.25%
per ml
J7650 - Isoetharine
hydrochloride, 0.1% per ml
J7651 -Isoetharine
hydrochloride, 0.125% per ml
J7652 - Isoetharine
hydrochloride, 0.167% per ml
J7653 - Isoetharine
hydrochloride, 0.2% per ml
J7654 - Isoetharine
hydrochloride, 0.25% per ml
J7655 - Isoetharine
hydrochloride, 1.0% per ml
J7660 - Isoproterenol
hydrochloride, 0.5% per ml
J7665 - Isoproterenol
hydrochloride, 1.0% per ml
J7670 - Metaproterenol
sulfate, 0.4% per 2.5 ml
J7672 - Metaproterenol
sulfate, 0.6% per 2.5 ml
J7675 - Metaproterenol
sulfate, 5.0% per ml
J7699 - Unlisted or
compounded inhalant drugs
J7051 - Sterile saline or
water, up to 5 ml
Q0132 -
Dispensing fee for covered drug administered through DME nebulizer
XX001 - Sterile saline,
unit dose, up to 5 ml each
Diabetic Supplies
Effective since February
19, 1996, the following services given to insulin-treatment Medicare Part B
eligible recipients are first to be billed to the Medicare carrier.
If claims are first billed to Medicaid, the claim will deny and the
provider will receive the following explanation of benefit codes:
#275 - Recipient is
Medicare Eligible
#988 - Item covered by
Medicare
Following Medicare claim
submission, Palmetto GBA will automatically crossover the claim information to
the Louisiana fiscal intermediary for payment of the coinsurance and deductible
amounts, where applicable.
A4253 - Blood glucose test
or reagent strips for home blood glucose monitor, per 50 strips
A4259 - Lancets, per box
of 100
The ZX modifier is
required on every claim for diabetic supplies when the patient is an
insulin-treated diabetic. The order
for diabetic supplies must be signed and dated by the ordering physician and
maintained in the provider's file. Medicare
allows prospective billing of these supplies only for a 90-day period.
Medicare Infusion Pump Policy
An external infusion pump
is covered for the administration of parenteral medication in the home setting
when both of the following criteria are met:
1.
Parenteral administration of the medication in the home is reasonable and
necessary, and
2.
An infusion pump is necessary to safely administer the medication.
When an infusion pump is
covered, the medication used in the pump is also covered.
Medication used in an
external infusion pump should be coded using the appropriate J series HCPCS
code. If the medication does not
have a distinct J code, then use the unclassified drug code J7799. For your convenience, the following HCPCS codes are listed:
J0895 - Injection,
deferoxamine mesylate, 500 mg per 5 cc
J1570 - Injection,
ganciclovir sodium, 500 mg
J1170 - Injection,
dobutamine hydrochloride, per 250 mg
J1250 - Injection,
dobutamine hydrochloride, per 100 mg
J2175 - Injection,
meperdine hydrochloride, per 100 mg
J2260 - Injection,
milrinone lactate, per 5 ml
J2270 - Injection,
morphine sulfate, up to 10 mg
J2275 - Injection,
morphine sulfate, preservative-free sterile solution, per 10 mg
J3010 - Injection,
fentanyl citrate, up to 2 ml
J3370 - Injection,
vancomycin HC1, up to 500 mg
J7799 - NOC drugs, other
than inhalation drugs, administered through DME
J9000 - Doxorubicin HC1,
10 mg
J9040 - Bleomycin sulfate,
15 units
J9100 - Cytarabine, 100 mg
J9190 - Fluorouracile, 500
mg
J9200 - Floxuridine, 500
mg
J9360 -Vinblastine
sulfate, 1 mg
J9370 - Vincristine
sulfate, 1 mg
XX009 - Dobutamine, 250 mg
Pharmacy providers should
submit claims to the Medicare carrier prior to billing Medicaid for those
individuals eligible for the Medicare Part B coverage.
Miscellaneous Information
Pharmacies billing for
Medicare services must have a Medicare supplier billing number which can be
obtained by writing or calling the National Supplier Clearinghouse at:
Palmetto GBA
National Supplier Clearinghouse
P. O. Box 100142
Columbia, SC 29202-3142
803/754-3951
Claims for Medicare
covered pharmacy services are to be billed on the HCFA-1500 claim form.
A copy of the HCFA-1500 claim form and instructions for completing the
form are provided in the section of the Pharmacy Provider Manual entitled
HCFA-1500 Instructions.
HCFA-1500 claim forms can
be ordered using the following:
Mail:
U.S. Government
Printing Office
Superintendent of Documents
P. O. Box 371954
Pittsburgh, PA 15250-7954
Phone:
202/512-1800
FAX:
202/512-2250
When ordering
claim forms by mail, checks or money orders are to be made out to the
Superintendent of Documents. Phone
or FAX orders can be charged to VISA or MasterCharge.
Orders take approximately three (3) weeks to process.
National claim
form vendors (Moore Business, Standard Register, Wallace, etc.) stock HCFA-1500
forms as well.
Medicare claims
should be sent to the following address:
Palmetto
GBA-M
Medicare DMERC Operation
P. O. Box 100233
Columbia, SC 29202-3233
After the carrier
processes the claim, the information will automatically crossover from the
carrier to the fiscal intermediary for payment of the coinsurance and deductible
amounts, where applicable, only if DHH has the provider's DMERC billing number
on file.
Palmetto GBA's
ombudsman for Louisiana is Bobby Smith. He
can be reached by contacting:
Bobby
Smith
P. O. Box 9225
Jackson, MS 39286
601/898-0067
Telephone numbers
which may assist you with your Medicare claims and/or billing problems:
Dedicated
Work Teams and DMERC General Information
- 803/691-4300
Professional
Relations General Information Number
- 803/735-1034
HCPCS
Help-Line
- 803/736-6809
Electronic
Data Interchange
- 803/788-9751
Anti-Fraud
Hotline
- 803/788-5414
The recipient's
monthly eligibility card will identify Medicare Part B coverage on the TPL File. The key to the TPL codes
is located in the bottom shaded message area of the recipient's monthly eligibility
card.
The HCFA 1500
claim form requires diagnosis codes in field #21.
Use of ICD-9-CM coding is mandatory.
The following codes are taken from the 1996 edition of the reference.
250.0 - Diabetes
mellitus
V42.0 - Kidney
transplant
V42.1 -
Heart transplant
V42.6 - Lung
transplant
V42.7 - Liver
transplant
V42.8 - Bone
Marrow transplant
Policy
Notes: Pharmacists and Providers
HCPCS Codes Added to Pharmacy Crossover Claims
The following
HCPCS codes have been added for pharmacy crossover claims. The Medicare carrier should be billed first when Medicare
Part B eligible recipients receive prescription services for these
pharmaceuticals.
Cancer
Drug Therapy
Code
Description
Effective Date
K0415 Prescription antiemetic drug, oral,
per 1 mg, for use in onjunction with oral 04/01/96
anti-cancer drug, NOS
K0416
Prescription antiemetic drug, rectal,
per 1 mg, for use in
04/01/96
conjunction with oral anti-cancer drug, NOS
Infusion Drug Therapy
Code
Description
Effective Date
J1455
Injection, foscarnet sodium, per 1000 mg
04/01/96
J9010
Doxorubicin HC1 50 mg
04/01/96
J9065
Injection, cladribine per 1 mg
04/01/96
J9110
Cytarabine 500 mg
04/01/96
J9375
Vincristine sulfate, 2 mg
04/01/96
J9380
Vincristine sulfate, 5 mg
04/01/96
Nebulizer Drug Therapy
J7645
Ipratropium bromide, 0.02% per ml
01/01/96
Updating
Information on Nursing Home Residency
If prescription
copays are being taken incorrectly on nursing homer residents, pharmacists have
the option of faxing a copy of the recipient's 148 form (the Medicaid Program
Notification of Admission or Change) directly to DHH at 504/342-3893, to the
attention of Kay Gaudet. Upon
receipt, DHH will research and update the recipient record if necessary.
Please be sure to include a valid recipient MID number on all
correspondence.
Change
in Billing Procedure for Waiver Providers
Effective immediately, providers billing waiver services hardcopy on the HCFA
1500 claim form should being writing WAIVER in bold black letters across the TOP
of the claim forms. This will
assist Unisys in processing these claims.
Questions concerning
this new procedure should be directed to Unisys Provider Relations at (800)
473-2783 or (504) 924-5040.
Reimbursement
for CPT Code 36522
Effective with date of
service April 1, 1996, CPT code 36522 (Photopheresis, extracorporeal) will be
covered at a fee of $132.50. This
procedure will be reimbursed only when used in the palliative treatment of the
skin manifestations of cutaneous T-cell lymphoma (CTCL) that has not responded
to other therapy. The only
diagnoses for which this CPT code will be reimbursed will be ICD-9-CM codes in
the range of 173.0 through 173.9 and 202.0 through 202.9.
Claims for code 36522 with a diagnosis other than these will deny.
Policy
Notes: DME Providers
New Guidelines for Ventilator Assist Devices
New policy guidelines have
been adopted for the prior authorization of all Ventilator Assist Devices in the
DME Program. Please note that the
new policy will be listed under the heading of Ventilator Assist Devices in
future editions of the Medicaid eligibility Manual and includes revised criteria
for CPAP devices as well as criteria for "Intermittent Bi-level Assist
Devices" which have been added to the DME Program.
Also note that separate criteria for adult and pediatric requests have
been developed under both the subheadings of Continuous Positive Airway Pressure
Devices (CPAP) and Intermittent Bi-level Assist Devices (Codes E0452 and E0453).
Codes E0452 (Intermittent
Assist Device with CPAP) and E0453 (Therapeutic Ventilator:
Suitable for Use 12 Hours or Less Per Day) have been made payable for
Intermittent Bi-level Assist Devices with an effective date of 02/01/96.
Both will be paid at the rate of 80% of the Medicare fee schedule
amounts. The description for code
E0452 correlates with the commonly prescribed BIPAP-S Airway Management System
and code E0453 correlates with the BIPAP S/T Ventilatory Support System.
The following new policy
guidelines are for all Ventilator Assist Devices:
1.
All equipment needs, including emergency equipment, must be prior
authorized. The Unisys Prior
Authorization Unit will act on emergency requests and give decisions within two
working days. For written,
non-emergency request, the Unisys Prior Authorization Unit will give decisions
within 25 days.
2.
Unless the physician can clearly justify an equipment purchase, a rental
period of up to three months can be requested in order for the physician to have
an adequate trial period to document appropriateness.
3.
Other equipment, such as low pressure alarms, must be separately
documented to show medical necessity. Low pressure alarms will be approved for patients who are
ventilator dependent or at risk for a life threatening event.
Pulse oximetry, due to its technological limitations, is not reimbursable
for home use.
4.
These guidelines exist to assist the physician and the fiscal
intermediary to efficiently approve most applications, but also allow physicians
to request consideration for patients who, for unique reasons, fall outside
criteria. All medical providers are
expected to preserve pertinent information which may periodically be surveyed to
evaluate these criteria in the future.
5.
Non-disposable, reusable supplies should be prescribed, if appropriate,
for medical care and economical reasons. Where the possibility exists for an increase in supply needs,
an extra prescription should be written at that time and not as a p.r.n. (as
necessary) usable at any time over several months.
6.
The use of oxygen must be considered for those patients where these
devices fail to adequately improve the patient's condition.
These must be documentation to satisfactory clinical improvement such
that mechanical ventilation through a tracheostomy tube is justifiably avoided.
Continuous Positive Airway Pressure Devices (CPAP)
CPAP is a non-invasive
procedure of taking air pressure through the nostrils, via a nose mask and a
flow generator system, that prevents collapse of the oropharyngeal walls during
sleep. CPAP can be considered for
coverage for recipients with a diagnosis of
severe obstructive sleep apnea (OSA). Prices
for CPAP include the costs of all necessary accessories, i.e., mask or cannula.
Separate charges for tubing, masks, or respiratory services are not
payable since they are included in the payment for the equipment.
Adult Criteria (Age 21 and over)
The following information
should accompany the request to document medical necessity:
1.
Diagnosis of severe obstructive sleep apnea as documented by sleep study
and other studies from a registered or approved sleep laboratory.
2.
Documentation of clinical severity, such as recurrent hospitalization and
complication, and frequent clinic and emergency room visits.
3.
Evidence that surgery is the only likely alternative to CPAP.
4.
Sleep studies should document at least 30 episodes of apnea, each lasting
a minimum of 10 seconds, during six to seven hours of recorded sleep.
Copies of the patient's sleep lab evaluation and oxygen saturations must
accompany the request.
5.
If the purchase of a CPAP device is requested, documentation should
support the long term nature of the condition.
Pediatric Criteria (Under age 21)
The following information
should accompany the request to document medical necessity:
1.
Documentation of physical exam (including airway) and of any other
medical condition which may be correctable (e.g., tonsillectomy and/or
adenoidectomy) prior to assisted ventilation.
2.
Documentation of how sleep disturbance reduces the quality of life and
affects the activities of daily living.
3.
Prescription should be made by a physician with training and expertise in
pediatric respiratory sleep disorders.
4.
Documentation of the medical diagnosis, which is known to cause
respiratory/sleep disorders.
5.
Sleep or respiratory study documenting two or more of the following:
a.
Oxygen saturation of less than 90% pulse oximetry or partial pressure of
transcutaneous or arterial oxygen of less than 60 mm.
Hg.;
b.
Carbon dioxide greater than 55 mm. Hg. by end tidal, transcutaneous,
arterial, or capillary blood measurement;
c.
Apnea of 10 to 20 seconds duration on the average of one per hour.
6.
A follow-up plan should be submitted identifying the responsible
physician or facility, giving data collected to demonstrate the success or
failure of intervention, and showing a visit within the first month of use and a
second assessment within the first three months of use.
7.
Indication of a responsible, committed home environment and of caregivers
properly trained in appropriate respiratory care.
8.
A written plan for home health follow-up care.
Intermittent Bi-level Assist Devices (Codes E0452 and E0453)
An intermittent bi-level
assist device may be indicated for patients with severe obstructive sleep apnea
with documented patient non-response to other less complex respiratory therapy,
including an adequate CPAP trial. Prices
include costs for the provision of all necessary accessories.
Separate charges for accessories or respiratory services are not payable
since they are included in the payment for the equipment.
Adult Criteria (Age 21 and over)
Requests for intermittent
assist devices with CPAP (E0452) and therapeutic ventilators (E0453) must
include availability of records showing that the recipient has not responded to
other pulmonary respiratory therapy (including CPAP) and that these therapies
have failed to stop the progression of disease.
Pediatric Criteria (Under age 21)
Requests for approval must
meet the CPAP pediatric criteria as outlined below. Intermittent bi-level assist devices (E0452 andE0453) may be
appropriate for certain documented reasons:
1.
Failure of CPAP to improve or reverse respiratory abnormalities due to
obstructive sleep apnea, airway instability (demonstrated by sleep study, see
CPAP criteria number 5); or
2.
The presence of the following: airway
instability which includes hypopharyngeal collapse; tracheal or bronchial
malacia; central alveolar hypoventilation; central apnea; severe respiratory
muscle weakness; chronic respiratory failure secondary to progressive
respiratory disease (cystic fibrosis, bronchopulmonary dysplasia); and
respiratory failure secondary to chest wall deformity.
Reminder
to Providers: Eligibility
Verification Information
Provider Relations Field
Analysts are available to visit providers on-site and to provide training to new
providers and their office staffs. Providers
are encouraged to request Analyst assistance in training staff in billing
Medicaid claims and in resolving complicated billing issues.
However, calls regarding eligibility or calls to request Unisys claim
forms, manuals, or other policy documentation should not be directed to the
Field Analysts.
Eligibility verification
may be obtained by calling the Unisys Recipient Eligibility Verification System,
or REVS line, at (800) 776-6326. If
further eligibility clarification is needed, providers should contact the Unisys
Provider Relations Telephone Inquiry Unit at (800) 473-2783 or at (504) 924-5040
in Baton Rouge. The Telephone
Inquiry Unit should also be contacted with requests for Unisys claim forms,
manuals, provider newsletter copies, and other policy documentation.
Criteria
Revisions for Enteral Nutritional Therapy
The criteria for enteral
nutritional therapy has been revised. The
most important feature of the new policy is its removal of the requirement for
tube feeding for consideration of Medicaid approval of enteral therapy.
The new criteria is effective for prior authorization requests with dates
of service retroactive to 12/19/95. The
following is the revised criteria for the prior authorization of enteral
nutrition therapy in the DME program.
Enteral Nutrition Therapy
Enteral therapy may be
provided safely and effectively in the home by nonprofessional persons who have
undergone special training. Medicaid
will not pay for any services furnished by non-physician professionals.
Enteral nutritional therapy
is considered reasonable and necessary for a recipient when medical
documentation, such as hospital records and clinical findings, support the
conclusion that the recipient has a
permanently inoperative internal body organ or function which does not allow
absorption of sufficient nutrients to maintain weight and strength commensurate
with his or her general condition. For
purposes of this policy, permanent means an indefinite period of at least
months.
Prescriptions for enteral
feedings must be for an average of at least 750 calories per day over the
prescribed period and must constitute at least 70% of the daily caloric intake
to be considered for coverage by Medicaid.
Coverage of prescribed feedings of less than an average of 750 calories
per day may only be considered with additional physician documentation and
justification of the reason for prescribing less than an average of 750 calories
per day. Baby food and other
regular grocery products that can be processed in a blender and used with an
enteral system are not covered.
All requests must include
the following:
1.
The name of the nutrient product or nutrient category;
2.
The number of calories prescribed by enteral feeding per day (100
calories = 1 unit) and whether the prescribed amount constitutes 70% or more of
the daily caloric intake;
3.
The frequency of administration per day;
4.
The method of administration (oral or, if tube, whether syringe, gravity,
or pump fed);
5.
The route of administration, if tube fed (i.e., nasogastric, jejunostomy,
gastrostomy, percutaneous enteral gastrostomy, or naso-intestinal tube; and
6.
The reason for the use of a pump, if prescribed.
Enteral nutritional therapy
will not be approved for temporary impairments or for convenience feeding via
gastrostomy.
Enteral feeding can only be
provided for the most economic package equivalent in calories and ingredient
content to the needs of the patient as established by medical documentation.
The physician must document the reason for prescribing a formula higher
than category I-A (HCPCS procedure code B4150 - semi-synthetic intact
protein/protein isolates) or category II (code B4152 - intact protein/protein
isolates, calorically dense). This
includes any formula in category I-B (code B4151 - natural intact
protein/protein isolates) or categories III through VI (codes B4153 through
B4156).
Approved requests shall be
reviewed at periodic intervals not to exceed six months.
Approval may be granted for
up to six months at a time. Medicaid,
however, will pay for no more than one month's supply of enteral nutrients at
any one time.
Enteral Infusion Pump
A standard enteral infusion
pump will be approved only with documented evidence that the pump is medically
necessary and that syringe or gravity feedings are not satisfactory due to
complications such as aspiration, diarrhea, dumping syndrome, etc.
Medicaid can pay for the
lease/rental, as well as the delivery and set up, of a standard enteral infusion
pump and accessories. Medicaid can
pay for repairs not covered by the warranty or lease agreement.
Nutritional Supplementation
Nutritional supplements
given between meals to boost daily protein-caloric intake or as the mainstay of
a daily nutritional plan may be covered for recipients under age 21 where
medical necessity is established. Nutritional
supplements will not be covered, however, for recipients age 21 years or older.
Policy Notes: Providers
Unisys Provider Relations Correspondence Unit
Many providers submit
"clean" claims to the Provider Relations Department hoping to expedite
processing of these claims. However,
this actually delays claim processing, as the claims must pass through
additional hands before reaching the appropriate processing area.
In addition, it diverts productivity that would otherwise be devoted to
researching and responding to provider requests for assistance with legitimate
claim problems.
Providers are asked to send "clean" claims directly to the
appropriate post office box as listed below:
Type of Claim
Post Office Box
Pharmacy
91019
Professional, Independent Labs, Substance Abuse, and Mental
91020
Health, Hemodialysis, Chiropractor, Durable Medical Equipment
Mental Health Rehab Health Services, Case Management, FQHC,
Rural Health Clinics (Providers billing on HCFA-1500)
Inpatient and Outpatient Hospitals, Long Term Care, Hospice,
91021
Hemodialysis, Free-Standing Psychiatric Hospitals
Dental, Transportation (Ambulance and Non-Ambulance),
91022
Rehabilitation, Home Health
Crossovers and Adjustments
91023
EMC, Unisys Business, and Miscellaneous Correspondence
91025
The zip code for all Unisys
post office boxes in Baton Rouge, Louisiana, is 70821.
Providers who wish to
submit problem claims for research and a written response are encouraged to
submit them to the Unisys Provider
Relations Correspondence Unit, P. O. Box 91024.
THE
PROBLEM CLAIMS MUST BE ACCOMPANIED BY A COVER LETTER INDICATING THE PROBLEM AND
THE PROVIDER'S REQUEST FOR ACTION. CLAIMS
RECEIVED WITHOUT A COVER LETTER WILL BE CONSIDERED "CLEAN" CLAIMS AND
WILL NOT BE RESEARCHED.
Requests to update
recipient files with correct eligibility and third party liability information
should also be directed to the Correspondence Unit.
Such requests must include a cover
letter stating what the provider is requesting and a copy of documentation
verifying the eligibility or TPL information (e.g., a copy of the recipient's
Medicaid card showing eligibility for the date of service in question or a
letter from the recipient's other insurance indicating coverage has been
terminated).
ALL
RESUBMISSIONS MUST BE ACCOMPANIED BY A COPY OF THE CLAIM FORM WITH CORRECTIONS
WHERE APPLICABLE.