Provider Update

Volume 10, Number 2 

July/August 1993

Transplants: PA01 No Longer Required

Tetramune Funded

LADUR Education: Histamine H2 Receptor Antagonists

Audiologists: Medicaid Provider Enrollment Qualifications

Allergy Testing: New Codes

Dentists: Submit PA Requests to School of Dentistry

Chemistry Testing: Now Billable Electronically

Codes to Use for Observation Services

ESRD Codes 90921 and 90922 Now Funded

DME Repairs Covered

Chiropractic Extensions: Documentation Requirements Pharmacists and Prescribers: Sorbitol Solution 70%
Nicotine Transdermal Patches and Nicotine Polacrilex Gum Procedure Codes for Rehabilitation Providers
Home & Community-Based Waiver Programs Authorized Transportation Scheduling Companies
Community Care Cards TPL Codes: Check Accuracy
Americans with Disabilities Act Hospice Services in Nursing Facilities
Post Office Box Pointers  

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


         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)


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.


         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.




(Duration of Therapy)




800-1200 mg (4-12 weeks)

400 mg


300 mg (6-8 weeks)

150 mg


40 mg (6-8 weeks)

20 mg


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.




Group Served


Services Provided



Adult Day Health



65 or older and Adult Disabled age > 21


Adult Day

Health Care






Mentally Retarded & Developmentally Disabled, any age


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.




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.


Pers. Care Att.

Indep. Living Centers

Home Care

For the



65 or older


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.