14, NUMBER 3
Community Care is a managed care
program administered by Medicaid of Louisiana.
As Community Care continues to grow across Louisiana, it becomes
increasingly important that all providers understand how this program
operates; which services require Primary Care Physician (PCP) approval and
referral; what to look for to identify the Community Care Medicaid card; and
how to bill using the PCP authorization number appropriately on the claim
form. Over the last few months
more and more claims have denied because the claim does not indicate that a
referral was received from the PCP for the services rendered. We hope the following information concerning this program
will assist providers in preventing denial of claims.
Twenty (20) parishes are currently
participating in the Community Care program:
Bienville; Claiborne; DeSoto; Natchitoches; Red River; Sabine; St.
Charles; Webster; East Carroll; Jackson; Madison; Morehouse; Richland; Union;
West Carroll; Allen; Beauregard; Cameron; Jefferson Davis; and Vernon.
Approximately 43,000 recipients are currently enrolled in this program.
The number of parishes participating and the number of recipients
enrolled are expected to increase over the next several months.
The program links Medicaid recipients
in these participating parishes with a physician, clinic, Federally Qualified
Health Center (FQHC), or Rural Health Clinic (RHC) that serves as the PCP for
that recipient. The PCP bears
total responsibility for managing all facets of the recipient�s health care.
Recipients have the opportunity to
select a participating doctor, FQHC, or RHC to be their primary care provider.
Usually, the PCP is located in the recipient�s parish of residence
or, occasionally, in a contiguous parish.
If the recipient does not select a PCP by the deadline date, the
recipient will be assigned a CommunityCARE PCP in their parish of residence.
Each Medicaid eligible recipient in a family chooses a PCP; thus the
provider of services may see more than one PCP on a Medicaid ID card.
Community Care recipients receive a
monthly Medicaid eligibility care showing the name and telephone number of the
selected/assigned PCP(s). This
appears in the lower right corner of the card.
One Medicaid card is issued for each certified household.
Each eligible recipient�s name is listed on the card, and all
applicable PCPs are listed on the card. A
number (1, 2, 3, etc.) in front of the recipient�s name will indicate a
corresponding PCP�s name. This
indicates the PCP for that family member.
As indicated earlier, the PCP is
totally responsible for managing the health care of his or her Community Care
patients. The PCP must refer a
recipient to a specialist or medical facility for treatment which he does not
provider but is medically indicated. Written
referrals for specialty care should be issued as soon as the PCP determines
that the referral is required.
The referral must be for treatment of a
specific illness or disease. When
the PCP refers a recipient to a specialist for treatment of an illness, the specialist should provide a copy of the PCP�s written referral for
additional specialty services that may be required in the course of treating
that illness. However, if the
specialist discovers a new condition that would require another medical
specialty, the PCP must be advised.
providers should be aware that even providers outside the Community
parishes must have a PCP referral for all services which require PCP
If a recipient accesses emergency
services directly, without going through the PCP, the PCP should be notified
of the situation by the emergency physician after the medical examination and
appropriate stabilizing measures have been undertaken.
If the PCP cannot be reached at that time to give authorization for
services, the emergency physician must obtain post authorization for
services and should contact the PCP within 24 hours.
In billing for services to a Community
Care recipient which require a PCP referral, the seven-digit referral number
must be on the claim form in the appropriate field as indicated below:
UB-92 � Block 83A for inpatient and
HCFA 1500 � Block 17A
Unisys 102 Claim Form (Rehabilitation Centers) � Block 12
Unisys 101 Claim Form (Home Health) � Block 10
If the authorization number is not indicated in the designated field on the
claim form, the claim will deny even if
a copy of the referral is attached to the claim form (in fact, it is never
necessary to attach a copy of the written referral to the claim form; the
written referral should be kept for your records and for audit purposes).
The denial, error code 106, will indicate "�Provider not PCP or
service not authorized by PCP"� Please
be sure to complete the claim form correctly prior to submission.
Further information concerning the
Community Care program, as well as information on exempt services, may be
obtained from the Unisys Provider Relations Department at (800) 473-2783 or
In the April issue of the Provider
Update, the article entitled �Unisys Provider Relations Reminders to
Providers,� contained an error in the section �Claim Special Handling
Reminders.� The section
incorrectly stated that overrides of the yearly outpatient visit maximum need
to be accompanied with a 158-C form. The
correct form number is 158-A. We
apologize for the inconvenience.
A brief review of a small sample of
records has revealed that some KIDMED providers are billing for screenings
without having completed all the required components of the screening.
Do not bill Medicaid for
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): A Review
Edwin H. Adams,
Northeast Louisiana University School
are one of the most commonly prescribed medications for a variety of
conditions such as osteoarthritis, rheumatoid arthritis, ankylosing
spondylitis, and mild to moderate pain.
ibuprofen and aspirin have been �over the counter� products for some time,
other NSAIDs, such as naproxen sodium and ketoprofen, are now available in
�over the counter� strengths.
effects associated with NSAID therapy can cause profound morbidity and
mortality, especially in those patients with certain risk factors.
Each day, approximately three million
Americans take an NSAID for a variety of reasons, making these drugs one of
the most commonly used and prescribed.1
Approximately 70 million prescriptions were written for NSAIDs in 1986
alone. The use of over the
counter NSAIDs is estimated to be five to seven times greater.2
Although these medications are efficacious in alleviating the pain and
inflammation associated with certain joint conditions, dysmenorrhea, and
headaches, they do have adverse effects associated with both short and
long-term therapy. Exacerbating potential problems is the fact that the primary
users of NSAIDs are members of the geriatric population.
These patients in particular are at a substantially higher risk for
developing complications from NSAID therapy. This
and other risk factors, in addition to the volume of usage, make NSAID usage a
potential public health hazard.
Although there are five chemical
classifications of NSAIDs, it is controversial as to whether there are indeed
differences in the efficacy, mechanism of action, and safety profile between
the drugs in each class and between the classes themselves.
Table 1 lists the various classifications of NSAIDs.
|Table 1. The
Classification of NSAIDs4
magnesium salicylate (Trilisate�)
(Anaprox�, Naprelan�, and Naprosyn�)
The therapeutic efficacy of an NSAID in a particular patient is based
on clinical response and usually cannot be predicted prior to initiation of
therapy. Patient responses are
variable and highly individual. Thus,
NSAIDs should be prescribed for a trial period of six weeks.
Patient response should be re-evaluated at that time before an
alternate therapy is chosen. Dose
maximization should be considered at this time.
However, it is not unusual for two or more NSAIDs to be tried before an
effective agent is found. Certain
NSAIDs should be selected initially because they have been found to be more
effective than other NSAIDs in specific conditions.
Indomethacin has demonstrated efficacy in ankylosing spondylitis, acute
gout, and osteoarthritis. Ibuprofen
causes a lysosomal membrane stabilizing effect and preserves myocardial
integrity in mycardial ischemia, whereas indomethacin and meclogenamic acid do
not. Postpartum pain is more
effectively treated with naproxen sodium than free naproxen.
The efficacy of an agent may be dose dependent.
Small doses of an NSAID may be sufficient to produce analgesia, whereas
larger doses may be required to produce anti-inflammatory activity.
The dose of such drugs as ibuprofen and fenoprofen should be maximized
before an alternate agent is chosen. However,
the difference in dose and activity is very small for piroxicam and sulindac
as compared to other NSAIDs.3
Over the counter NSAIDS are approved only for analgesic use, not
anti-inflammatory use. (See Table
Table 2. Over the Counter
(Advil�, Motrin�, others)
The major component of NSAID activity
is believed to be related to a reduction of prostaglandin biosynthesis (PGHS-1
& PGHS-2) by cyclooxygenase inhibition.
(See Figure 1.)
1. Inhibition of Cyclooxygenase
PGHS-1 can be found in vascular endothelial cells,
platelets, and kidney collecting tubules, and the levels of PGHS-1 in the body
remain relatively steady. PGHS-2
concentrations are relatively low but are increasing during an inflammatory
response. Research is now
focusing on selective inhibition of PGHS-2 to circumvent the adverse effects
associated with PGHS-1 inhibition.
Most of the side effects associated
with NSAID therapy are mild and abate upon discontinuing therapy.
There are, however, more serious adverse reactions that warrant further
discussion. The most serious of
these problems involve the gastrointestinal (GI) tract.
It has been estimated that up to 20% of patients on NSAIDs are affected
by GI problems.5 The
FDA has estimated that 2%-4% of chronic NSAID users will develop upper GI
bleeding, a symptomatic ulcer, or an intestinal perforation each year.
In addition, as many as 20,000 deaths occur annually as a result of
NSAID-induced gastric injury. Ulcer
complications account for approximately 7,600 deaths and 76,000
hospitalizations each year.6 These
ulcer complications are insidious in onset, especially in the elderly.
After three months of using NSAIDs, approximately 12% of patients have
endoscopic evidence of a gastric ulcer and about 5% have evidence of a
duodenal ulcer.7 Patients
often remain asymptomatic until the GI events have reached a critical stage.
Although perforation can occur within a few days following initiation
of therapy, most complications occur during chronic NSAID use.8
NSAIDs elicit these adverse events either by direct mucosal irritation
or, more importantly, by inhibiting the protective components of the GI mucosa,
the endogenous prostaglandins. A
common misconception is that one can avoid the adverse GI evens by
administering the NSAID parenterally. It
is true that the direct mucosal irritation is avoided, but the protective
prostaglandins in the gastric mucosa are still inhibited by the NSAID.
Some of the newer NSAIDs, including nabumetone and oxaprozin, have
demonstrated a lower overall incidence of GI bleeding.
The new NSAIDs do not appear to inhibit gastric prostaglandin;
therefore they do not interrupt the cytoprotective prostaglandin activity.9
Prophylaxis with misoprostal (Cytotec �) has been effective in the
prevention of gastric and duodenal ulcers.
This prostaglandin analogue can reduce the incidence of serious NSAID-induced
GI complications by up to 40%.10
NSAIDs exhibit varying degrees of
anti-platelet activity by inhibition of platelet cyclooxygenase. The resulting thrombocytopenia may contribute to the bleeding
associated with GI mucosal damage. There
are several parameters which determine the amount of time required for normal
platelet function to return. One
such factor is the extent to which a drug binds cyclooxygenase.
Aspirin, for example, irreversibly binds to the enzyme, thus inhibiting
function the entire life of the thrombocyte.
Platelet activity is then dependent upon the production of new cells
which takes seven to twelve days. Ibuprofen
and other NSAIDs reversibly bind to cyclooxygenase, thereby allowing normal
platelet function to return once the drug has been eliminated.
For these products, the half-life of the drug ultimately determines how
long it will take for the normal platelet function to return.11
(See Table 3.)
Table 3. NSAID Half-Lives
(8 � 24 Hours)
salicylate (dose dependent
One product in particular, piroxicam, is one of the longest
acting NSAIDs available. Its use
in the elderly has been controversial and potentially dangerous.
It has even been proposed by certain patient activist groups that this
product be removed from use in the elderly population.
Although NSAID therapy rarely causes
significant adverse effects on the kidneys, there are certain patient
populations at increased risk of developing untoward renal effects. These include patient with congestive heart failure,
cirrhosis, hypovolemia, or a pre-existing renal condition. Prostaglandins control of the vasodilation of the renal
vasculature. NSAIDs cause a
decrease in renal perfusion secondary to drug-induced vasoconstriction.
It is this reduction in perfusion, not the basal prostaglandin
inhibition, which is responsible for the renal injury.
Renal function generally recovers soon after discontinuation of
Because NSAIDs are one of the most
widely used medications in the United States, promoting their safe and
effective use is important and represents a logical approach to practicing
cost-effective medicine. (Relative
Costs, see Table 4.)
Table 4. Relative
Costs of NSAIDs12
magnesium salicylate (Trilisate�)
diclofenac (Voltaren�, generic available)
etodolac (Lodine�, generic available)
ketoprofen (Orudis�, Oruvail�, generic available)
naproxen (Anaprox�, Naprelan�, Naprosyn�, generic available)
piroxican (Feldene�, generic available)
indomethacin (Indocin�, generic available)
patients, the benefits of NSAID therapy, outweigh the risks.
However, there are patients who should be monitored closely for adverse
drug events. These populations
include: the elderly; patients
with a history of peptic ulcer disease or GI hemorrhage; patients on long-term
NSAID therapy; patients on concomitant anticoagulant therapy or concomitant
corticosteroid therapy; or patients with a history of heavy over the counter
analgesic use. The best means of
preventing the complications of NSAID therapy is by careful consideration of
each patient�s risk. Patient
education is another means of preventing complications.
Healthcare providers should discuss with the patient the proper dose,
side effect, and expected outcomes from NSAID therapy.
Proper counseling in administration techniques, such as taking an NSAID
with food, could help reduce GI discomfort and increase patient compliance.
Insufficient counseling in these areas could contribute to treatment
failure. Patients should be
encouraged to contact their pharmacist or physician if symptoms worsen, recur,
or fail to improve.
Cooke. �Disease Management:
Prevention of NSAID-induced gastropathy.�
MedscapeR Continuing Medical Education. May 25, 1996. (http://www.medscape.com)
Anti-Inflammatory Drugs and the Gut.�
Southern Medical Journal, 1996. Vol. 89, No. 3. Pages 256-263.
Drug Monograph Service, v. 1.5. Gold
Standard Multimedia Inc.
Pathophysiologic Approach. 3rd Edition.
JT Dipiro, Appleton, and Lange (eds.); 1997.
Chapter 85, pages 1735-1753.
Knodel. �NSAID adverse effects
and interactions. Who is at
Pharmacy, 1992. NS 32:39-37.
Conaway. �Using NSAIDs safely
in the Elderly.� Hospital Medicine, May 1995.
Kantor. �NSAID-induced Risk
Factors in ArthritisTherapy.� A
symposium review of the 1997 American Society of Consultant Pharmacists Annual
Knodel. �NSAID adverse effects
and interactions. Who is at
Pharmacy, 1992. NS 32:39-37
Pharmacology, Drug Monograph Service, v. 1.5.
Gold Standard Mulimedia Inc. (http://www.geohealthweb.com/GWH/private/cliphrm/docs/content/overview/v00055.html#3)
Kantor. �NSAID-induced Risk
Factors in Arthritis Therapy.� A
symposium review from the 1997 American Society of Consultant Pharmacists
Knodel. �NSAID adverse effects
and interactions. Who is at
Pharmacy, 1992. NS 32:39-37.
Drug Monograph Service, v.1.5. Gold Standard Multimedia Inc.
Notice to Providers:
Changes in CPT Codes 96115 and 96117)
Effective with date of service May 1,
1997, the number of neurobehavioral and neuropsychological testing procedures
(CPT codes 96115 and 96117) a recipient can have will be limited to one per
recipient per year.
If additional testing within the year
is required, providers may submit hardcopy claims with documentation attached
to support medical necessity. These
claims will be reviewed by the Medical Review Unit at Unisys.
Claims for the second and subsequent testings billed without supporting
documentation will be denied.
If you are contacted by any of the
following individuals, please immediately contact Bob Patience at (504)
922-2239, or write to him at Program Integrity, P. O. Box 65271, Baton Rouge,
Medical necessity for home health
services and supplies must be certified by the ordering physician, who must
complete HCFA Form 485. (See HCFA
Pub. 11, Section 240.1.)
In signing these documents the
physician services that:
the patient is under his/her care;
these home health services are required
and medically necessary;
the patient is confined to his/her home
as defined by the Bureau�s Homebound Criteria;
there is a written plan for treatment;
the plan will be reviewed periodically
(at least once every 62 days) by him/her;
the patient needs intermittent skilled
nursing care and/or physical or speech therapy; or
the patient needs occupational
Penalties which may be imposed on physicians for
inappropriate certification (false attestation), which constitutes fraud, can
referral to the Office of the Inspector
criminal penalties in U.S. District
Court, resulting in fines and/or a jail sentence;
civil prosecution in a U.S. District
Court, resulting in fines and/or settlements;
civil monetary penalties with an
administrative law judge resulting in fines ($2,000 per line item;
if fraud is proven under the False
Claims Act, tripling of damages and fines;
simple sanction (barred from the
Medicare and Medicaid programs) by the Washington Office of the Inspector
Effective with date of service May 1,
1997, adjustments in fees were made to the following codes:
||Tetanus Toxoid for trauma
||Injection, gold therapy, arthritis
||Injection, Methotrexate Sod. 50 mg
||Velban Injection, 10mg/10cc
Tartrate, 10mg, Navelbine
submitted with new patient preventive medicine codes in the range of 99381
through 99385 will be denied for any recipient who has received
problem-oriented services from the same billing provider in the two years
prior to the date of the preventive medicine visit.
Providers are to bill an established preventive medicine code if the
recipient is asymptomatic.
stated in the Winter-94 CPT Assistant, the initial new patient preventive
codes are to be used to report services to a patient who has moved to a
particular geographic area and is establishing himself/herself with a new
physician without any representing illness.
1922, Shrine hospitals have treated more than 500,000 children in their
facilities through donations, wills, bequests, and membership dues.
The group'� commitment to excellent hospital care and research is
unsurpassed in North America. The Shriners actively engage in providing medical help to
children at no cost.
Shrine of North America operates orthopedic hospitals and three burn
institutes free of charge to all children aged 1 through 18 years of age,
regardless of race, creed, or religious affiliation.
It does not accept any governmental assistance or insurance payments.
further information about the Shrine program, please contact Mr. Sumrall at
Bureau of Health Services Financing is pleased to inform you of an increase in
fee for Depo-Provera for birth control, code J1055 to $37.59 effective with
date of service May 1, 1997.
has been some question as to whether code 99211 can be billed when performed
by a nurse if the doctor is out of the office.
This code should NOT be billed if the doctor is out of the office.
Nurses must be under the personal supervision of the doctor.
�Personal� is defined as if �in the same location.�
following HCPC procedure codes for DME items have been changed from a payable
status to a non-payable status to match changes made by Medicare.
The effective date for the
will be 7/1/97, to allow for the processing of claims already in the system
with the current codes. Please
discontinue the use of these codes immediately for the following DME items.
the following HCPC procedure codes have been added to the DME Program as
payable codes to match Medicare changes.
This change is being made with a retroactive effective date (1/1/97) to
allow for processing by Medicaid of any crossover claims previously submitted
to Medicare using these codes. Please
begin using these codes for all prior authorization requests for DME items.
Supplies: Maint of Drg Infsn Catheter
Supplies: Ext Drg Infsn Pump, cassette/bag
Intermit Urin Catheter, w/Insertion Pipes
Ostomy Adhesive Remover Wipes, 50/box
Ostomy Filter, Any Type, each
Silicone Gel Sheet, each
Wound Pouch each
Alignate Dressing <=16 sq. in.
Alignate Dressing > 16 <=48 sq in.
Alignate Dressing > 48 sq. in.
Alignate Dressing Wound Filler
Composite Drsg. <-16 sq. in.
Composite Drsg. > 16 <=48 sq. in.
Composite Drsg. > 48 sq. in.
Contact Layer <= 16 sq. in.
Contact Layer > 16 <=48 sq in.
Contact Layer > 48 sq. in.
Foam Drsg. <= 16 sq in. w/o border
Foam Drsg. > 16 <= 48 sq. in. w/o border
Foam Drsg. > 48 sq. in. w/o border
Foam Drsg. <=16 sq. in. w/border
Foam Drsg. > 16 <=48 sq. in. w/border
Foam Drsg. > 48 sq. in. w/border
Foam Dressing Wound Filler
Non-Sterile Gauze <= 16 sq. in.
Non-Sterile Gauze > 16 <= 48 sq. in.
Non-Sterile Gauze > 48 sq in.
Gauze <= 16 sq. in. w/o border
Gauze > 16 <= 48 sq. in. w/o border
Gauze > 48 sq. in. w/o border
Gauze <= 16 in NO w/Sal w/o B
Gauze > 16 <= 48 in. NO w/Sal w/o B
Gauze > 48 in NO w/Sal w/o B
Gauze <= 16 sq. inWater/Sal
Gauze > 16 <=48 sq. in. Water/Sal
Gauze > 48 sq. in. Water/Sal
Hydrocolld Drg <= 16 w/o Border
Hydroccolld Drg > 16 <= 48 w/o Border
Hydrocolld Drg > 16 <= 48 w/Border
Hydrocolld Drg Filler Paste
Hydrocolld Drg Filler Dry
Hydrogel Drg <= 16 in. w/o Border
Hydrogel Drg > 16 <= 48 w/o Border
Hydrogel Drg > 48 in. w/o Border
Hydrogel Drg <= 16 in. w/Border
Hydrogel Drg > 16 <= 48 sq. inc. w/Border
Hydrogel Drg > 48 sq. in. w/Border
Hydrogel Drsg Gel Filler
Skin Seal Protect Moisturizer
Absorpt Drg <= 16 sq. in. w/o Border
Absorpt Drg > 16 <= 48 sq. in. w/o Border
Absorpt Drg > 48 sq. in. w/o Border
Absorpt Drg <= 16 sq. in. w/Border
Absorpt Drg > 16 <= 48 sq. in. w/Border
Absorpt Drg > 48 sq. in. w/Border
Transparent Film <= 16 sq. in.
Transparent Film > 16 <= 48 sq. in.
Transparent Film > 48 sq. in.
Wound Cleanser Any Type/Size
Wound Filler Gel/Paste/oz
Wound Filler Dry Foam/gram
Non-Sterile Elastic Gauze/yd
Non-Sterile No Elastic Gauze
Tape per 18 sq. in.
Impreg. Gauze No H2O/Sal/Yard
Sterile Gauze <= 16 sq. in.
Sterile Gauze > 16 <= 48 sq. in.
Sterile Gauze > 48 sq. in.
Sterile Non-Elastic Gauze/yd
Brake for Wheeled Walker
Air Pad Elevator for Heel
Repair for DME, per 15 min.
Mech. Infus. Pump Sht. Trm Drug
Drainable Plastic Pch w/Fcplt
Drainable Rubber Pch w/Fcplt
Drainable Plastic Pch w/o Fcplt
Drainable Rubbe Pch w/o Fcplt
Urinary Plastic Pch w/Fcplt
Urinary Rubber Pch w/Fcplt
Urinary Plastic Pch w/o Fp
Urinary Hvy Plastic Pch w/o Fp
Urinary Ruber Pouch w/o Fp
Ostomy Faceplt/Silicone Ring
Skin Barrier Solig Ext Wear
Skin Barrier w/Flang Ex Wear
Closed Pouch w/St Wear Bar
Drainable Pch w/Ex Wear Bar
Drainable Pch w/St Wear Bar
Drainable Pch Ex Wear Convex
Urinary Pouch w/Ex Wear Bar
Urinary Pouch w/St Wear Bar
Urine Pch w/Ex Wear Bar Conv
KAFO, Plastic, Medlat Rotat Con
Long Leg Braces for Hemophiliacs, BI
Carbon Graphite Lamination
Add Joint Upper Ext Orthosis
Ortho VC Repair per 15 min
Replace Multi-Podus Splint
Replace Ankle Contrc Splint
Replace Foot Drop Splint
Ankle Contracture Splint
Foot Drop Splint Recumbent
Add Endoskel Knee-Shin Single Axis
Shank Ft. w/Vert Load Pylon
Repair Prosthesis per 15 min.
appreciate your cooperation and assistance in implementing these changes.
If you have any questions concerning these changes, you may contact the
Unisys Prior Authorization Unit at 1-800-488-6334.
has been brought to our attention that there is some confusion regarding the
Global Surgery Period policy and when visits may be billed separately from the
should be billed separately ONLY IF THE DIAGNOSIS FOR THE VISIT IS TOTALLY
UNRELATED TO THE DIAGNOSIS OF THE GSP PROCEDURE. If the diagnosis/reason for the visit is in any way related
to the GSP procedure, a visit should not be billed separately.
be sure you are following this policy when billing for procedures reimbursed
under the Global Surgery Period.
has been brought to our attention that some physicians are billing for admit and
discharge services in conjunction with delivery codes 59410 and 59515.
note that this practice is contrary to Louisiana Medicaid policy as stated on
page 21-2 of the Physician Services Manual
and that payments shall be recouped.
fee for delivery (59410 or 59515) includes inpatient hospital visits occurring
both before and after delivery.
policy is applicable to all other payable delivery codes.
has always been Louisiana Medicaid policy that Unisys staff is not allowed to
change any information on a provider�s claim form. We want to remind providers of this policy and use this
avenue to again inform you that if changes are required on a claim before it can
be resubmitted, you must make those changes and resubmit the claim.
Please do not ask Unisys staff to make any changes on your behalf.