Provider Update

Volume 13, Number 3 

May/June 1996


Special Message for Physicians:  Advances in Pregnancy Care

By Harvey A. Gabert, MD
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.


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


         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


Orudis 25 mg, 50 mg, 75 mg

Oruvail 150 mg, 200 mg

Orudis KT 12.5 mg


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


Half-Life (Hrs.)

Ibuprofen (Motrin)

Ketoprofen (Orudis)

Flurbiprofen (Ansaid)

Etodolac (Lodine)

Naproxen Sodium (Anaprox)

Nabumetone (Relafen)

Piroxicam (Feldene)

Oxaprozin (Daypro)

 * Normal Population Values









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.



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.


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


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  


                                                                 ERMA SMITH

                                                                555 BROWN STREET

                                                                ANYTOWN, LA  70000


ID NUMBER                                            NAME                                                                                BIRTHDATE

17-16-0-012350-20                              ERMA SMITH                                                                   10-30-73








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

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

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. 


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).