Provider Update
Volume 10, Number 2
July/August 1993
Message
from the Medical Director
A
number of positive developments have taken place since the last issue of the Provider
Update. In
addition, several important projects are in the final planning stages.
The
Louisiana Drug Utilization Review (LADUR) Board advises the DHH on many aspects
of drug utilization within Medicaid of Louisiana.
One of the major roles of LADUR is to provide educational materials to
physicians and pharmacists.
This issue contains a newly updated and revised format designed to be
concise and readable, and it includes the class of drug studied, key issues,
relevant background, and recommendations.
We welcome your feedback and suggested topics that would be of interest
to clinicians.
Beneficial
changes in clinical policies have occurred.
Hospital observation service codes 99218, 99219, and 99220 can now be
used to bill for evaluation and management services.
The BHSF has also announced funding of the combination vaccine Tetramune.
Specific local codes have now been assigned to three new laboratory
tests, enabling providers to bill electronically, and eliminating the need for
medical review.
The procedure for obtaining prior authorization of transplants has been
streamlined and improved.
In addition, PA for the Dental Program has been implemented.
Medicaid
of Louisiana recently announced coverage for brain stem evoked response
screening and otoacoustic emission testing, which should enhance hearing
screening for infants and children in the state.
Guidelines for chiropractor encounter extension requests were developed
through a collaborative interaction with the Louisiana Union of Chiropractic
Physicians and the Chiropractic Association of Louisiana.
In addition, there are many program policy suggestions under
consideration that were provided by physicians and other providers from across
the state.
The
Community Care program continues to expand and has now been implemented in 15
parishes. A
recent survey found the program to be generally well received by physicians and
patients.
The
Provider Relations Unit at Paramax is implementing a new telephone system, which
should greatly enhance the ability of providers to receive timely and accurate
responses to their questions.
In addition, representatives in the field have been issued
state-of-the-art notebook PCs to improve their services.
The Prior Authorization and Medical Review Units are continuing their
efforts to streamline procedures, increase automation, and improve
communication. Despite
a rapidly increasing claim volume, processing times have decreased in most
areas.
Medicaid
of Louisiana has just developed a new physician concurrent care policy for
recipients to the age of 21.
This new policy should be a tremendous new benefit to patients and
physicians because it allows for the provision of services by more than one
physician to the same patient at the same time in both outpatient and inpatient
settings. Details
of this policy have been mailed to you.
We
greatly appreciate your service to Louisiana's Medicaid recipients, and we are
trying to take proactive steps on a continual basis to simplify processes and to
make program changes to better serve patients.
Dr.
Gregg Pane
LADUR
Education: Histamine H2 Receptor Antagonists
Issues
�
H2As account
for approximately 10% of the total Prescription Drug Program expenditures
($17,941,000).
�
LADUR reviews have
demonstrated a need for practitioners to continually review their prescribing
patterns to assure the appropriate use of acute vs. maintenance dosages of the H2As,
to avoid duplicative therapy, and to reduce the occurrences of drug-drug
interactions.
Therapeutic
Class
Histamine
H2 Receptor Antagonists (H2As)
Background
The
histamine H2 receptor antagonists are used in the management of a
variety of hyper secretory gastrointestinal tract disorders.
The H2As are competitive antagonists of the histamine2
receptors within the gastrointestinal tract, and they reduce the production and
outflow of gastric acid, which makes the H2As particularly effective
in the following:
�
Acute treatment of
duodenal and gastric ulcers,
�
Maintenance therapy of
healed duodenal ulcers,
�
Symptomatic relief of
gastroesophageal reflux disease (GERD), and
�
Treatment of other
gastrointestinal disorders.
Their
wide margin of safety and effectiveness has been responsible for their becoming
the largest single drug category in terms of total expenditures in the Louisiana
Medicaid Drug Program.
The
accompanying dosage guidelines have been prepared using standard compendia
(references available upon request).
In
an effort to improve the education component of LADUR, we changed the format of
our educational articles. Please
detach the LADUR education pages and maintain them in a reference file.
Recommendations
�
Appropriate Use of
Acute vs. Maintenance Dosages. The use of full-dose H2As for extended periods of
time is both unnecessary and expensive. Modest
(and medically appropriate) reductions in the use of the H2As have
the potential to result in significant reductions in drug program expenditures
without reducing the quality of healthcare.
�
Reduction of
Duplicative Therapy.
There is no evidence of any additional therapeutic benefit from the
concomitant use of two or more such agents.
Patients may often receive duplicative therapy as the result of their use
of multiple pharmacies or physicians.
�
Elimination of
Drug-Drug Interactions. H2As
in combination with other therapeutic agents may result in clinically
significant drug-drug interactions ranging from effects on drug-metabolizing
systems in interactions with antacids and foods.
However, not all H2As produce the same type and degree of
drug-drug interactions and careful selection of antagonists by the physician or
pharmacist may help reduce potential interactions.
SUMMARY
OR HISTAMINE H2
ANTAGONISTS
DOSAGE REQUIREMENTS
|
HISTAMINE
H2
|
ACUTE
THERAPY1
(Duration
of Therapy)
|
MAINTENANCE
THERAPY
|
Cimetidine
|
800-1200
mg (4-12 weeks)
|
400
mg
|
Ranitidine
|
300
mg (6-8 weeks)
|
150
mg
|
Famotidine
|
40
mg (6-8 weeks)
|
20
mg
|
Nizatidine
|
300
mg (6-8 weeks)
|
150
mg
|
1
Normal therapeutic dosage range for acute
duodenal or gastric ulcers, or GERD, where appropriate.
Manufacturer's recommended maintenance dosages should be used for therapy
beyond 4-12 weeks (generally 4-8 weeks). Full-dose
therapy beyond recommended periods of time provides no additional therapeutic
benefit. Other gastric disorders
may require other dosage regimens.
Transplants:
PA01 No Longer Required
Effective
July 1, 1993, Medicaid of Louisiana will no longer require the submittal of a
PA01 form for the prior authorization of transplant procedures.
In addition, providers will no longer be required to submit separate
requests for authorization of the same transplant procedure, nor will they be
required to enter an authorization number on the claim form.
The hospital or physician may request authorization by submitting a
written request with supporting medical documentation to the Prior Authorization
(PA) Unit for consideration.
If the transplant is approved, the authorization letter must be attached
to each transplant related claim submitted to Paramax for processing.
If
the transplant request is approved, the PA Unit will issue an authorization
letter to the provider who initiated the request, and the letter may be used by
other providers who participate in the transplant procedure.
Any PA01 forms for transplants currently in house will be reviewed in the
normal manner, and the new authorization letter will be issued (if appropriate)
instead of the computer-generated notice that Paramax used to issue.
If a computer-generated notice has already been issued, any transplant
related claim submitted with the authorization notice attached will be processed
despite the difference in provider numbers on the notice and the claim.
Tetramune
Funded
Medicaid
of Louisiana is pleased to announce the funding of the combination vaccine
Tetramune for immunization against DTP and HIB effective with date of service
May 1, 1993. Providers may bill
locally assigned code J9394 for each 0.5 ml dose of Tetramune given.
The fee for each injection will be $25.00
Allergy
Testing:
New Codes
A
number of allergy/testing codes were deleted in the 1993 issue of the Physician's
Current Procedural Terminology.
However, five new codes replaced these deleted codes.
Providers may begin billing these five new codes effective with date of
service June 1, 1993.
The deleted codes will be placed in non-pay status effective the same
date. The
fees for the new codes are listed below:
Code
95004 - $1.75 per test
Code
95010 - $2.20 per test
Code
95015 - $4.60 per test
Code
95024 - $3.25 per test
Code
95028 - $6.25 per test
The
maximum number of tests a provider can bill per day under code 95004 is 120.
The maximum number under codes 95010 and 95015 is 30, and the maximum
number under code 95024 is 40.
The service limit for code 95028 is 10 per day.
The
number of tests being billed per code should be placed in Item 24G on the HCFA
1500 form. The amount entered in
the "Charges" column should be the total charges.
For example, providers billing code 95004 who rendered five tests should
place a 5 in the "Units" column and $8.75 in the "Charges"
column.
Chemistry
Tests:
Now Billable Electronically
Local
codes have been assigned to the chemistry tests for fructosamine, zinc
protoporphin, and free erythrocyte protoporphin so these tests may be billed
electronically. Effective with date
of service June 1,1993, providers should begin using the following codes:
Z0053
- Fructosamine ($13.00)
Z0054
- Zinc Protoporphin ($8.06)
Z0055
- Free Erythrocyte Protop. ($27.03)
One
unit of each of these is payable daily to a provider.
Codes
to Use for Observation
Services
CPT
codes 99218, 99219, and 99220 should be used to bill for evaluation and
management services rendered to patients who are being observed in the hospital.
Because these codes pertain to initial observation care, per day, they
should not be used to bill for observation services on subsequent days.
The
codes for office or other outpatient services for established patients, CPT
codes 99211-99215, should be used by physicians to bill for services provided on
subsequent days to a patient in an observation area of the hospital.
Care
in another site of service is part of the initial observation care visit when
this care is provided on the same day. In
addition, care in another site of service, including care to a patient in
observation status, is part of the inpatient hospital admission visit when
performed on the same day.
ESRD
Codes 90921 and 90922 Now Funded
Because
of the deletion of codes 90995 and 90998 from the 1993 edition of the Physician's
Current Procedural Terminology, ESRD (End Stage Renal Disease) codes 90921 ($159.00/month) and 90922
($5.30/month) have been funded effective with date of service January 1, 1993.
A month equals 30 days even if a month has 28, 29, 30, or 31 days.
Codes 90918, 90919, and 90920 will be funded later.
Code
90921 may be span billed, but, if it is, a "1" should be placed in the
units column on the claim form. Also,
one claim line per date of service should be billed for code 90922.
Providers
may not bill for both capitation services and dialysis training in the same
month.
DME Repairs
Covered
Medicaid
of Louisiana would like to remind providers that the DME program covers repairs
for oxygen concentrators and electric wheelchairs. Repairs of oxygen concentrators are covered on an as needed
basis after the one-year warranty has expired.
Repairs of electric wheelchairs may be approved for recipients in
education or training programs (with a plan for future self-support and
independence) or for recipients who are gainfully employed.
Chiropractic
Extensions:
Documentation Requirements
Medicaid
of Louisiana requires chiropractors who are requesting extensions for visits 26
through 35 to attach the following documentation to their requests:
-
The diagnosis and chief complaint;
-
The reasons the extra encounters are necessary, noting the
complications that are present;
-
Any progress made in improving the patient's condition;
-
Therapy rendered and the response;
-
Subjective and objective examination findings;
-
Acuity (acute, subacute, chronic, acute exacerbation) and severity
(mild, moderate, severe) of the patient's condition;
-
X-ray, lab, and diagnostic test results; and
The level of care (relief, therapeutic, rehabilitative,
supportive) being rendered.
If
a re-injury or traumatic episode is the rationale for requesting additional
encounters, the chiropractor must submit specific and objective documentation of
the episode. Extensions
will be granted only if the records clearly reflect the emergent medical
necessity of the requested encounters, which might result in the serious
deterioration of the patient's condition, the need for long-term medication, or
the need for surgery.
Claims
for encounters 26 through 35 must be submitted hardcopy.
Pharmacists
and Prescribers: Sorbitol
Solution 70%
Effective
May 1, 1993, Medicaid of Louisiana cancelled coverage for Sorbitol solution 70%
(over the counter). Now, only the
Sorbitol irrigating solution 3% is payable and only if the manufacturer is
participating in the rebate agreement.
Nicotine
Transdermal Patches and Nicotine Polacrilex Gum
Nicotine
transdermal patches and nicotine polacrilex gum are covered only if a
handwritten, original prescription signed by the prescribing practitioner, with
no provisions for refills, is submitted to Medicaid. This coverage provision makes it necessary for the physician
to rewrite the prescription each time the recipient needs a refill.
In
addition, physicians must certify in their own handwriting, either directly on
the prescription or on an attachment to the prescription, that the recipient is
enrolled in a "physician-supervised behavioral program" in order for
Medicaid to provide coverage for the nicotine adhesive patches.
Providers should verify that the required documentation is written on or
attached to the prescription when the prescription is dispensed.
Procedure
Codes for Rehabilitation Providers
Some
procedure codes used to bill for rehabilitation services were omitted from the
revised Rehabilitation Services provider manual.
Rehabilitation providers will receive a replacement page for their
provider manuals that includes these codes, but we have also listed the omitted
codes, their descriptions, and their fees below:
Y7103
- Center visit with procedure(s), 75 minutes ($40.00)
Y7104
- Center visit with procedure(s), 90 minutes ($48.00)
Y7200
- Procedures and modalities, 30 minutes ($16.00)
Y7201
- Procedures and modalities, 45 minutes ($24.00)
Y7202
- Procedures and modalities, 60 minutes ($32.00)
97500
- Orthotics training upper (splinting), 30 minutes ($16.00)
97520
- Prosthetic training, initial 30 minutes, ($21.97)
97530
- Kinetic activities, one area, 30 minutes ($16.00)
97531
- Kinetic activities, additional 15 minutes ($8.00)
97540
- Daily living activities, 30 minutes ($6.00)
97541
- Daily living activities, additional 15 minutes ($8.00)
In
addition, a code was included in the provider manual that is no longer payable.
Coverage for code Y7051 was cancelled effective October 1, 1991.
The manual replacement pages will also reflect this version.
Home
& Community-Based Waiver Programs
Medicaid
of Louisiana has four approved home and community-based services waivers which
furnish special services to a limited number of recipients who have particular
disabling conditions. All
recipients must meet the same medical and financial criteria as required for
placement in the particular institutional setting.
The newest program, Home Care for the Elderly, is scheduled to begin July
1, 1993. The following chart
describes the programs briefly.
Program
|
No.
Served
|
Group
Served
|
Inst.
|
Services
Provided
|
Entry
Point
|
Adult
Day Health
Care
|
300
|
65 or older and Adult
Disabled age > 21
|
NF
|
Adult Day
Health Care
|
ADHC
Facility
|
MR/DD
Waiver
|
1,596
|
Mentally Retarded &
Developmentally Disabled, any age
|
ICF/MR
|
Respite Care, Personal
Care Attendant, Substitute Family Care, Residential Habilitation,
Vocational Habilitation, Day Habilitation, Personal Emerg. Response,
Environmental Modifications, Assistive Devices
|
Regional Offices of
O.C.D.D.
|
PCA
Waiver
|
22
|
Age 18-55 who have lost
motor or sensory capabilities and need only PCA to remain in community.
Must be capable of directing activities of attendant.
|
NF
|
Pers. Care Att.
|
Indep. Living Centers
|
Home
Care
For
the
Elderly
|
222
|
65 or older
|
NF
|
Case Management
Pers. Care Att.
Pers. Emerg. Resp.
Env. Mod.
|
Parish Council on Aging
|
An
additional program for 100 persons with acquired head injuries is being prepared
for implementation. Referrals of
persons who wish to be considered should be made to the Head Injury Foundation
at (504) 455-7199.
Inquiries
about qualifications of providers should be directed to the Provider Enrollment
Section at (504) 342-9454.
Questions
regarding the programs should be directed to Louise Dubroc at (504) 342-0138 or
Virginia Lee at (504) 342-1400.
Transportation
Scheduling Companies
The
following transportation scheduling companies are authorized to inquire on the
behalf of Medicaid of Louisiana to verify whether appointments have been
scheduled or whether scheduled appointments have been kept:
LaVergne's TeleMessaging and Albert Roy Wimberly.
Community Care
Cards
As Community Care
continues to grow across Louisiana, it becomes increasingly important that all
providers look for the Community Care Medicaid card, identify the services which
need PCP approval, and bill using the appropriate claim form block.
The
recipient's PCP name and telephone number are printed on the bottom right corner
of the Medicaid card. If there are
multiple family members n the card, a number (1, 2, 3, etc.) in front of the
recipient's name will indicate a corresponding PCP's name at the bottom right of
the card.
Medicaid
providers of specialty services, such as pathology and radiology, who do not see
the recipient, and who provide services on a referral basis, should obtain the
necessary authorization number from the physician or hospital requesting their
services.
Most
medical services for Community Care recipients, including obstetrical, lab, and
X-ray services, must be provided either by the PCP or authorized by the PCP via
a written referral. Services which
do not require authorization by the PCP are listed as follows:
�
Pharmacy services;
�
ICF/MR services;
�
EPSDT health services for
"special needs" children;
�
Dental services;
�
Transportation services;
�
Optometry, Ophthalmology,
and eyeglass services;
�
Psychiatric hospital
services;
�
Skilled Nursing Facility
Care;
�
Home and community-based
waiver services;
�
Family planning services;
�
Targeted case management;
�
Mental health
rehabilitation services; and
�
Mental health
clinic/substance abuse services.
Claims
for services other than those listed above will be denied if the seven-digit
authorization number is not on the claim form in the fields designated below
(The PCP will provide the authorization number on the written referral.):
�
In block 93 for claim
type 01 and 03 on the UB-82 claim form;
�
In block 17A for the
claim type 04 (Physicians and Durable Medical Equipment);
�
In block 12 for claim
type 05 (Rehabilitation); and
�
In block 10 for claim
type 06 (Home Health).
If
these designated fields do not have the PCP's authorization number, the claim
will be denied with a 106 error code, and the following message:
Billing provider not PCP or service not authorized by PCP.
If
a recipient accesses the emergency room directly, appropriate medical screening
examination and stabilizing measures should be taken. The emergency room physician must obtain post authorization
for the service and should contact the PCP within 24 hours.
TPL
Codes: Check Accuracy
Providers
should check recipient's Medicaid identification cards to verify that the
third-party liability (TPL) codes printed on the cards are accurate according to
the TPL listing and the third-party insurance the recipient has.
If these codes are not correct, providers should instruct recipients to
contact their parish workers to correct their files, especially if the insurance
has been cancelled. Claims
submitted for payment will deny unless the insurance coverage is noted on the
claim with the appropriate TPL code or unless a letter explaining the
cancellation of the insurance from the carrier is attached to the claim.
Americans
with Disabilities Act
Recently,
all providers received correspondence dated June 24, 1993, from Medicaid of
Louisiana concerning the Americans with Disabilities Act.
This correspondence was mailed to providers for informational purposes
only.
As
providers of services for Medicaid of Louisiana, providers are, according to
Title II of the Americans with Disabilities Act (Public Services), public
entities. Therefore, providers are
required to evaluate their current policies and practices to identify and
correct any that are not consistent with the requirements stated in the act.
However, providers do not need to file the self-evaluation with any
federal agency. If the evaluation
is completed, providers should maintain a copy in their offices.
Since there is no standard form available, Medicaid of Louisiana is
unable to furnish providers with a copy.
Title
II of the act is administered by the Department of Justice, Washington, D.C.
20530. All inquires concerning
the act should be directed to the Justice Department at (202) 514-0301.
Hospice
Services in Nursing Facilities
Effective
July 1, 1993, providers of hospice services will be enrolled in Medicaid of
Louisiana to provide hospital care to terminally ill nursing facility residents
who are eligible for Medicare and Medicaid benefits. Hospice providers will contract with nursing facilities to
provide hospice care for these residents. Payment
of the nursing facility per diem will be made to the hospice provider who will
then reimburse the nursing facility for the patient's daily care.
Patient liability will be collected by the nursing facility.
Recipients choosing the option of hospice care for a terminal illness
will be eligible only for hospice and pharmacy coverage from Medicaid.
Audiologists:
Medicaid Provider Enrollment Qualifications
Effective
July 1, 1993, licensed audiologists who meet the provider qualifications and
provide medical services to Medicaid eligible recipients are eligible to be
enrolled as Medicaid provider and to receive direct Medicaid reimbursement for
covered audiology services. Audiologists
providing services to Medicaid recipients must meet the following
qualifications:
Licensure
Requirements
All
Medicaid audiologists must have obtained licensure by the Louisiana Board of
Examiners for Speech Pathology and Audiology.
Certification
Requirements
All
Medicaid audiologists must have done the following:
�
Obtained a
certificate of clinical competence from the American Speech-Language and Hearing
Association (ASHA);
�
Completed the equivalent
educational and work experience requirements for the certificate; or
�
Completed the academic
program and be acquiring supervised work experience to qualify for the
certificate.
Each
Medicaid recipient, except for recipients receiving screening services, should
obtain a written referral by a physician for audiology services at least
annually.
Two
additional procedures have been approved for Medicaid reimbursement.
These codes, their descriptions, and their fees are provided in the table
below.
Audiologist
should note that certain procedures must be performed in a sound treated
enclosure which meets ANSI S 3.1-1977 (R.1986) criteria for permissible ambient
noise during audiometric testing. In
addition, audiometers must be calibrated annually.
When
audiologists submit their applications to Medicaid of Louisiana for enrollment
as providers in the program, they must furnish the serial number of the sound
treated enclosure and the serial and model numbers of the audiometers to the
Provider Enrollment Section.
Physicians
and other enrolled Medicaid providers who bill for audiology services also must
meet the standards outlined previously. Audiologists
may enroll as separate providers or may continue to provide services under
previous policy guidelines if they do not enroll as Medicaid providers.
Code
|
Description |
Reimb.
|
Z9916
|
Brainstem evoked response
screening (Full service fee if the audiologist rents, leases, or owns equipment and reads
the screen. Otherwise bill with
modifier -26
for professional component only payable at $20) |
$50.00
|
Z9917
|
Evoked Otoacoustic Emissions
(EOAE) (Full service fee if the
audiologist rents,
leases, or owns equipment and reads the
screen. Otherwise bill with
modifier -26
for professional component only payable
at $10.00.)
|
$25.00 |
Dentists:
Submit PA Requests to School of Dentistry
Effective
July 1, 1993, it will be necessary for dental providers to submit all prior
authorization requests to the Medicaid Dental Program at the LSU School of
Dentistry on Form PA03, in addition to the usual claim forms.
The purpose of the changed procedure is to be consistent with all other
prior authorization services in Medicaid.
Dental
claim forms being returned from LSU School of Dentistry will no longer have an
authorization signature and date. Instead,
providers will receive authorization, as well as their prior authorization
number, in a Prior Authorization Notification Letter.
Providers should note, however, that they still must obtain prior
authorization only for those procedure codes in the Medicaid manual that are
marked with an asterisk.
Provider
who have questions regarding these procedures or the PA03 form should contact
Peggy Misner in the Paramax Prior Authorization Unit at (504) 924-7051, ext.
259, or at the toll-free number, 1-800-488-6334.
The
instructions for completing the form are provided in the box below.
Instructions
for Completing the PA03 Form
Recipient
Number: Enter
the recipient's 13-digit Medicaid identification number exactly as it appears on
the recipient's Medicaid identification card.
Recipient
Name: Enter
the recipient's last name and first name as they appear on his/her Medicaid
identification card.
Attending
Provider Number:
Enter your 7-digit Medicaid identification number.
Treatment
Plan: For
the beginning date of treatment, enter the date you anticipate providing the
first authorized service.
The ending date you enter should be exactly one year later from the
beginning date.
Description
of Services:
Only procedures that require prior approval should submitted on the PA03
form.
Enter
the appropriate 5-digit code and its corresponding description.
List
the 5-digit code one time only, and enter the number of times that the procedure
will be provided in the requested Units column.
Provider
Name, Address, Telephone Number:
Enter the name and address of the servicing provider.
Provider
Signature:
Ensure that the form is signed by the provider of service or another
authorized representative.
If a stamped signature is used, the request must be initialed.
Always
attach a copy of the Unisys/Paramax claim form, with all services listed, so the
entire treatment plan may be reviewed.
Mail
the PA03 form, with the attachments, to the following address:
LSU School of Dentistry, Medicaid Dental Program, 1100 Florida Ave., Box
510, New Orleans, LA
70119. To
obtain additional PA03 forms, contact the Prior Authorization Unit at Unisys or
copy a blank form.
Post
Office Box Pointers
Mailing
your claims to the correct post office box will enable Paramax to decrease the
turnaround time on your claims.
Provided below are the correct post office boxes for each claim type.
When you mail your claims to Paramax, pick the appropriate post office
box from below.
The zip code for out post office boxes in Baton Rouge, Louisiana, is
70809.
Pharmacy
Claims - P. O. Box 91019
Inpatient
Hospital, Outpatient Hospital, and Long Term Care Claims - P. O. Box 91021
Professional,
Independent Labs, Substance Abuse, Mental Health, Hemodialysis, and DME Claims -
P. O. Box 91020
Dental,
Transportation, Rehabilitation, and Home Health Claims - P. O. Box 91022
Crossover
and Adjustments - P. O. Box 91023
Provider
Relations and Other Written Correspondence - P. O. Box 91024
EMC
- P. O. Box 91025
If
you have any questions about these post office boxes, contact Provider Relations
at 1--800-473-2783.
Our staff will be pleased to assist you.