Message from the Medical Director  Code 91033 Funded
Code 93016 Funded Code 90700 Funded
Increase in UVS for Code 99183 Placement of Deleted Codes in Non-Pay Status
Monthly Medical Card Changes Revised Limits for MHR Option
Notice to NEMT Providers Clarifications and Revised Limits for MHR Option: Effective July 1, 1994
Target Population for Mental Health Rehabilitation Services LADUR Education Article
Billing for Professional Services Under Pre-Admission Certification/LOS Independent Labs - Medicare Crossover Claims
Supervised Independent Living Providers: Consultation Information Authorization of Services for the Chronically Mentally Ill Which Exceeds the Maximum Units Per Year
New Dispensing Costs for Pharmacists HCPC DME Code Changes and Additons 
Changes in Case Management Program Case Management for Persons With Serious Mental Illness

Message from the Medical Director

Louisiana Drug Utilization Review Program Update (LADUR)

LADUR is a drug review program required by OBRA 90, the goal of which is to enhance and improve the quality of pharmaceutical care and Medicaid patient outcomes by ensuring that prescriptions are appropriate, medically necessary, and not likely to result in adverse medical effects.  LADUR is important because it helps achieve quality and cost containment without compromising access to medically necessary therapy.

LADUR focuses on interventions that convey to physicians individual Medicaid recipients drug utilization patterns as it impacts therapeutic exception criteria.  Program activities include developing new therapeutic exception criteria, developing educational articles, surveying the provider population, coordinating a drug utilization review board, and communicating with providers via regional committees.  1993 activity focused on over-utilization or drug-to-drug problems in either high cost or particularly risky therapeutic drug classes.

In 1993, nearly 5,000 LADUR provider letters were mailed to physicians, hospitals, and pharmacists.  The high 65% provider response rate and numerous positive comments suggest program acceptance and approval by the provider community.  Data indicates that significant changes and reductions uniformly occur in prescribing and utilization patterns within six months of LADUR intervention.  Utilization reduction varied from 9% to 65% among the therapeutic classes reviewed.  These annualized reductions for LADUR-reviewed recipients projected into a direct $3.6 million 1993 cost avoidance.

Future program plans include strengthening the educational emphasis on direct provider correspondence and additional drug education articles, focusing on duration of therapy issues, and developing new therapeutic drug criteria.

Hospital Pre-Admission/Length of Stay Review Program Update

This program will conduct pre-admission and length-of-stay (LOS) review for distinct part psychiatric facilities and long-term care hospitals.  Acute care and rehab hospitals will participate only in the LOS review program.  The InterQual review criteria will be used to review admissions and customized criteria will be used for long-term care.  LOS will be assigned based on HCIA Southern Regional data and appropriate specialty customization based on a DHH Advisory Committee's deliberations.

Admissions and LOS reviews will be conducted by specialized review nurses with physician consultant oversight.  Complete program information is included in the new Hospital Manual that will soon be mailed to affected providers.

The program will be phased in slowly over several months beginning in late July with the initial hospitals selected by DHH.  Program orientation will be provided once a hospital has been requested to participate.  No action is necessary on the part of a hospital until they have been contacted by DHH.

Dr. Gregg Paine

Code 91033 Funded

CPT procedure code 91033 - Esophagus, acid reflux test, with intraluminal pH electrode for detection of gastroespohageal reflux; prolonged recording - has been funded at $52.44 effective with date of service June 15, 1994.  The professional component fee for this service has been set at $20.98 effective the same date.

Code 93016 Funded

Procedure code 93016 - Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report - has been funded at $59.27 effective with date of service July 1, 1994.

Code 90700 Funded

CPT procedure code 90700 - Immunization, active; diptheria, tetanus toxoids, and acellular pertussis vaccine (DTaP) - has been funded at $20.00 per injection effective with date of service July 1, 1994, for recipients to the age of 21.

This fee is for the vaccine only; the costs of administration are included in the attendant office visit fee.

Increase in UVS for Code 99183

The UVS (number of units that can be billed daily) for CPT code 99183 - Physician attendance and supervision of hyperbaric oxygen therapy, per session - was increased from one to three effective with date of service July 1, 1994.

One unit equals one session.  Therefore, if you are billing for two or three dives or sessions administered on a given day, place a "2" or "3" in the units column on the claim form as appropriate.  However, if billing for one session on a given day, do not place any number in the units column.

Code 99183 should never be modified.  Claims billed with a 26 modifier attached to 99183 will deny as this code does not have a professional component.  The reimbursement for code 99183 is $127.72 per session.

Placement of Deleted Codes in Non-Pay Status

The CPT codes deleted in the 1994 issuance of the Physician's Current Procedural Terminology were placed in non-pay status effective with dates of service August 1, 1994.  Please program your billing systems immediately to bill current codes if you have not already done so.  A list of the codes added and deleted for 1994 begins on page 7 of this issue of the Provider Update.

Notice to NEMT Providers

Listed below are procedure codes effective beginning July 1, 1994.  There is no reimbursement for dry runs, wait time, or any mileage.  Negotiated fees will be provided by the Dispatch Office beginning July 1, 1994.

Profit Providers:
Flat Rate $15.00 Z5177
Negotiated Rate To be given by Dispatch Office  Z5178
Capitated Urban Rate $150.00 Z5179
Capitated Rural Rate $200.00 Z5180
Non-Profit Providers:
Flat Rate $12.00 Z9498
Negotiated Rate To be given by Dispatch Office Z5176

Monthly Medical Card Changes

The appearance of the monthly medical card produced by Unisys will be changing effective with the November 1994 card.

The new card will be printed on an 8 1/2 x 11 sheet, folded in half, and sealed into a one-piece mailer.  The card's edges will be perforated for easy removal.

The top half of the card will contain recipient eligibility information and the bottom half will contain messages, notices, and other pertinent Medicaid information.

Refer to your March/April 1994 Provider Update for a sample of the new card.  Please note that the final printed version of the medical card may be slightly different in format than the example.

Revised Limits for MHR Options

As of August 15, 1994, the following are the maximum limits.

Counseling and Therapy limits are for any combination of therapy types under the MHR Option.  Calendar year remains the same at 208 30-minute units; monthly is 50 units; and daily is 4 units.

Psychosocial Skills Training limits for calendar year are 780 one-hour units; monthly is 100 units; and daily is 6 units.  Psychosocial Skills Training must be limited to eight individuals per skills trainer.

 Treatment Integration limits for calendar year are 1040 30-minute units; monthly is 90 units; daily is 6 units.

Clarifications and Revised Limits for MHR Option:  Effective July 1, 1994

1.     The target population criteria have been redefined as explained later in the article titled "Target Population for Mental Health Rehabilitation Services" found on the lower portion of this page.  Mental Health Rehabilitation Services must cease for any recipients who do not meet these guidelines as of July 1, 1994.

2.     Mental Health Rehabilitation Management evaluations and assessments must be completed as needed to determine medical necessity of services within the previously established parameters.  Not all evaluations and assessments are necessary for each client.  Evaluations and assessments completed more than once per year require written justification that must be placed in the recipient's record.  Evaluations and assessments should not be completed routinely.

3.     The revisions for counseling and therapy follow.

Family Therapy

Family therapy is billed per unit of time, not for the number of individuals participating in therapy.  If more than one family member is receiving MHR services, then only one recipient's number can be billed for that time.

Group Therapy

Eight individuals is the maximum number of individuals that can be served in one group for adults.  Six individuals is the maximum number of individuals that can be served in one group for children/youth.

4.     Treatment Integration must be limited to one recipient per treatment integration worker.  Treatment Integration cannot be billed at the same time as another service by the same staff person.  It cannot stand alone as a service; it must be provided as a supplement to another service.

5.     Collateral Consultation must be provided by a QMHP or someone with a master's degree in psychology, counseling, or social work.
Collateral Consultations can be billed only if someone outside of the billing agency is consulted regarding the recipient's care.  Any contacts between employees of an agency are considered agency staffings and are not billable.  Only the agency initiating the collateral consultation may bill for the contact when two Mental Health Rehabilitation agencies are involved.

6.     All claims submitted for recipients under the age of six will be subject to pre-pay review.  Substantial documentation will be required before payment is allowed included a psychosocial or psychiatric evaluation, a recent psychosocial evaluation, and documentation from sources which led to professional consultation.  All claims must be submitted hard copy on the HCFA 1500 with all pertinent history attached.  If the claim is not submitted in such a fashion, the claim will be denied.

Target Population for Mental Health Rehabilitation Services

(Also Applies to Case Management for the Mentally Ill)

Medicaid assistance is designed to assist eligible Medicaid recipients in obtaining medical care.  Reimbursement may be made for Mental Health Rehabilitation Services when performed by qualified providers for Medicaid recipients who meet the definitions of disability defined in this section or reside in nursing facilities and have been determined through the pre-admission screening and annual resident review (PASARR) process to require active treatment services.

The Medicaid Program will not reimburse for Mental Health Rehabilitation Services provided to residents of ICF/MR group homes. 

The disability definitions for adults and children who qualify to participate in this program are defined below.

Adults with Severe and Persistent Mental Illness

Adults must meet all of the following criteria (A, B, C, and D) for serious mental illness (SMI).

A.  Age:  18 years or older, AND

B.  Diagnosis:  Severe non-organic mental illness including but not limited to schizophrenia; schizo-affective disorders; mood disorders; and severe personality disorders that substantially interfere with a person's ability to carry out such primary aspects of daily living as self-care, household management, interpersonal relationships, and work or school; AND

C.  Disability:  Impaired role functioning caused by at least two of the following functional areas.

1.   Unemployed or has markedly limited skills and a poor work history or, if retired, is unable to engage in normal activities to manage income; OR

2.   Employed in a sheltered setting; OR

3.   Requires public financial assistance for out-of-hospital maintenance (e.g., SSI), and/or is unable to procure such without help (does not apply to regular retirement benefits); OR

4.   Severely lacks social support systems in the natural environment (e.g., no close friends or group affiliations, lives alone, or is highly transient); OR

5.   Requires assistance in basic life skills due to mental illness (e.g., must be reminded to take medicine, must have transportation arranged for them, needs assistance in household management tasks); OR

6.   Exhibits social behavior which results in a demand for intervention by the mental and/or judicial/legal system.

D.  Duration:  Must meet at least one of the following indicators of duration.

1.   Psychiatric hospitalizations of at least six months in the last five years (cumulative total); OR

2.   Two or more hospitalizations for mental disorders in the last 12-month period; OR

3.   A single episode of continuous structural supportive residential care other than hospitalization for a duration of at least six months; OR

4.   A previous psychiatric evaluation indicating a history of severe psychiatric disability of at least six months duration.

Children/Youth with Severe Emotional/Behavioral Disorder

Behavioral or emotional responses so different from appropriate age, cultural, or ethnic norms that they adversely affect performance (including academic, social, vocational, or personal skills); a disability that is more than a temporary, expected response to stressful events in the environment and is consistently exhibited in two different settings and persists despite individualized intervention within general education and other settings.  Emotional and behavioral disorders can co-exist with other disabilities.

Children/youth must meet all of the following criteria (A, B, C, D, and E) for emotional/behavioral disorder.

A.  Age:  Under age 18; AND

B.  Diagnosis:  has a DSM-III-R (or successor) diagnosis indicating a severe mental disorder such as, but not limited to psychosis, schizophrenia, major affective disorders, reactive attachment disorder of infancy or early childhood (non-organic failure to thrive) or severe conduct disorder.
This category does not include children/youth who are socially maladjusted unless it is determined that they also meet the criteria for emotional/behavioral disorders; AND

C.  Meets one of the following three criteria which operationalize the above definitions.

1.   Exhibits seriously impaired contact with reality and severely impaired social, academic, and self-care functioning; thinking is frequently confused; behavior may be grossly inappropriate and bizarre; emotional reactions are frequently inappropriate to the situation; OR

2.   Manifests long-term patterns of inappropriate behaviors, which may include but are not limited to aggressiveness, anti-social acts, refusal to accept adult requests or rules, suicidal behavior, developmentally inappropriate inattention, hyperactivity, or impulsiveness; OR

3.   Experiences serious discomfort from anxiety, depression, or irrational fears and concerns whose symptoms may include but are not limited to serious eating and/or sleeping disturbances, extreme sadness, suicidal ideation, persistent refusal to attend school or excessive avoidance of unfamiliar people, maladaptive dependence on parents, or non-organic failure to thrive.

D.  Disability:  There is evidence of severe, disruptive, and/or incapacitating functional limitations of behavior characterized by at least two of the following criteria.

1.   Inability to routinely exhibit appropriate behavior under normal circumstances; OR

2.   Tendency to develop physical symptoms of fears associated with personal or school problems; OR

3.   Inability to learn or work that cannot be explained by intellectual, sensory, or health factors; OR

4.   Inability to build or maintain satisfactory interpersonal relationships with peers and adults; OR

5.   A general pervasive mood of unhappiness of depression; OR

6.   Conduct characterized by a lack of behavioral control or adherence to social norms which is secondary to an emotional disorder.  (Note:  If all other criteria are met, then "conduct disorders" are eligible.)

E.  Duration:  The impairment or pattern of inappropriate behavior(s) has persisted for at least three months and the impairment of pattern of inappropriate behavior(s) will persist for at least one year.

Note:  Circumstance, behaviors, and interventions leading up to the referral for professional consultation must be documented and included in the recipient's record.

Note:  A diagnosis of substance abuse or developmental disabilities/mental retardation prevents participation in the Mental Health Rehabilitation (and Case Management for Mental Illness) Programs unless accompanied by a primary diagnosis of mental illness.

LA Drug Utilization Review (LADUR) Education

Therapeutic Class

NSAIDs and Antidiabetic Drug-Drug Interaction


       The primary categories of NSAIDs include the salicylates (aspirin) and the propionic acid derivatives (ibuprofen).

       Sulfonylureas (glyburide) are useful in reducing hyperglycemia in the diabetic primarily by increasing pancreatic insulin secretin.

       When salicylates are coadministered with sulfonylureas, the hypoglycemic effect of the sulfonylureas may be potential resulting in hypoglycemia.

       Propionic acid derivatives should be cautiously combined with sulfonylureas and insulin as they may displace the sulfonylureas from binding sites on protein.

The Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are widely prescribed, orally effective agents.  These agents are mainstays in the treatment of inflammatory disorders (e.g., rheumatoid arthritis) and are used to relieve mild-to-moderate pain, suppress fever, and relieve symptoms of primary dysmenorrhea.  All NSAIDs pose a risk of gastric ulceration, acute renal failure, and suppression of platelet aggregation.  The primary categories of these agents include the salicylates (aspirin) and the propionic acid derivatives (ibuprofen).  They are classified as NSAIDs to distinguish them from cortisone and other steroids used to treat inflammatory disorders.

The sulfonylureas (glyburide) are commonly used in the treatment of non-insulin-dependent (Type II) diabetes mellitus.  These agents are useful in reducing hyperglycemia in the diabetic primarily by increasing pancreatic insulin secretion.  Many studies show salicylates (aspirin) reduce basal plasma glucose levels, increase glucose tolerance, and augment insulin response.  Thus, when salicylates are coadministered with sulfonylureas, the hypoglycemic effect of the sulfonylureas may be potentiated.  This has resulted in several reported instances of hypoglycemia and accompanying problems.  Therefore, blood glucose levels should be monitored when these agents are coadministered.  If hypoglycemia develops, consideration should be given to dosage adjustments and/or switching to another analgesic agent.  Additionally, blood glucose levels should be closely monitored during withdrawal of NSAIDs from patients also receiving a sulfonylurea agent.  The mechanism for this effect is not completely understood.  An additive effect with two hypoglycemic agents is a possibility.  In addition, inhibition of prostaglandin synthesis may inhibit acute insulin response to glucose.  Protein binding displacement of the sulfonylurea has been suggested.

The administration of insulin (e.g., Iletin, Humulin) in combination with the salicylates should also be evaluated and used with caution since the salicylates significantly increase basal insulin secretion and enhance the acute response to a glucose load and the secondary insulin-secretion response.  As with sulfonylurea coadministration, blood glucose levels should be monitored and the insulin dose tailored as needed to prevent hypoglycemia.

Caution should also be used when other NSAIDs (e.g., propionic acid derivatives) are used in combination with the sulfonylureas and insulin.  They may displace the sulfonylureas from binding sites on protein molecules.  This is particularly true with phenyl-butazone which may decrease sulfonylurea excretion, interfere with protein binding, and/or interfere with the metabolism of hypoglycemic agents (depending on the specific sulfonylurea).

The Louisiana Department of Health and Hospitals has used LADUR to evaluate patterns of NSAID and antidiabetic use within the Medicaid Drug Program.  This evaluation has included concomitant use of the antidiabetic agents and NSAIDs.  These combinations often resulted from the patient's use of multiple physicians and/or pharmacies.

The concurrent use NSAIDs and antidiabetic agents such as insulin and the sulfonylureas should proceed cautiously to decrease the risk of potentiating hypoglycemic effects.  Physicians should monitor patients for possible signs of hypoglycemia.


AMA Drug Evaluations, Annual 1991. Agents Used to Regulate Blood Glucose. Milwaukee, pp. 869-989.

AHFS Drug Information, 1994. "Insulin." pp. 2046-2056. "Sulfonylureas." pp. 2056-2075. Bethesda, MA.

Goodman and Gilman, 1990. The Pharmacological Basis of Therapeutics. 8th edition. "Insulin, Oral Hypoglycemic Agents, and the Pharmacology of the Endocrine Pancreas." Elmsford, NY pp. 1463-1495.

Kafflu, M., Ramiriz. L.C., and P. Raski, 1989. Diabetes Nutrition and Metabolism. "The Effect of Many Commonly Used Drugs on Diabetic Control." 2:75-93.

USPDI, 1994. Anti-Inflammatory Analgesics, Nonsteroidal (Systemic). 14th edition. Rockville, MD, pp. 355-406.

Billing for Professional Services Under Pre-Admission Certification/LOS

Effective July 1, 1994, the Bureau of Health Services Financing began phasing in the implementation of a Hospital Pre-Admission/Length of Stay (LOS) review program.  Beginning January 1, 1995, BHSF will implement this review program for all hospitals excluding state-operated and out-of-state facilities.  Distinct part psychiatric facilities and long-term hospitals will undergo pre-admission review and LOS assignment.  Acute care and rehabilitation hospitals will participate only in the LOS review process.

All physician hospital visits (procedure codes 99221 through 99223, 99231 through 99238, 99251 through 99255, 99431, and 99433) excluding inpatient visits to a state-operated or out-of-state hospital will be subjected to pre-certification requirements editing.  Follow the instructions below to obtain reimbursement for inpatient professional services effective with date of service January 1,1995.

1.     Physician claims will not be paid without a certification on file for the hospital stay unless appropriate documentation is attached to the claim identifying the hospital stay (see #3 below).  If the service was performed in a state-operated hospital and the physician is not based at that facility, then the physician will have to identify this service by putting a "Y" in item #19 on the HCFA 1500 or on record type # in charity indicator field for EMC submissions.  For those physicians who are based at a state-operated facility, there is not need to identify your claims with a "Y' in this field.

2.     The physician should indicate the hospital pre-certification number on the HCFA 1500 item #23 or on EMC record type E in the prior authorization field if the physician has access to that number.  To ensure accurate, timely processing of your claim, we recommend that you place the pre-certification number on the claim.  However, if you do not have access to the pre-certification number, you can bill your claim without it and the claim recipient ID and dates of service will be used to find the hospital pre-certification on file.

The pre-certification number will be stored on the claim record and will be printed on the remittance advice.  The physician visit days will be paid according to the LOS approved dates for the hospital stay.  Before your claim can be paid, there must be an approved pre-certification record for the hospital stay on file at Unisys.

3.     In those cases when the hospital chooses not to bill Medicaid, the physicians may bill their claims with appropriate documentation (admit/discharge summary) so that medical necessity and LOS can be determined.  These claims will pend to the Unisys Pre-Certification Department for review and decision, and will be assigned a prior authorization number.  The physician will receive a notice letter indicating approval/denial status, days approved, and the PA number.  Inquires about approval/denial or assigned length of stay should be directed to the Unisys Pre-Certification Department.  Your claim will be processed with the assigned PA number.

These new procedures will not negate or affect any of the policies and procedures currently in effect for hysterectomies, sterilizations, and outpatient surgeries performed in an inpatient setting.

Effective with dates of service July 1, 1994, you will no longer be required to attach documentation to claims for inpatient visits exceeding 15 days per year since this limitation has been eliminated.

Independent Labs - Medicare Crossover Claims

BHSF is currently in the process of updating the Medicare/Medicaid conversion file for automatic crossovers for independent laboratories.  We are asking that all currently enrolled independent laboratories assist the Provider Enrollment Unit in updating the conversion file by supplying your current Medicare number.

Please mail or fax your Medicare number(s) and the Medicaid provider number to which crossover claims should be matched.  Your assistance will enable us to process the crossover claims quickly and correctly.

FAX Number:

Mailing Address:
Bureau of Health Services Financing
P.O. Box 91030
Baton Rouge, LA 70821-9030
Attn: Provider Enrollment

Supervised Independent Living Providers:  Consultation Information

Recent reviews of claims for consultations revealed that some inappropriate claims have been submitted.  Agencies receiving payment for claims that are not valid consultations must repay the full sum received.  Repayment may be accomplished voluntarily by the agency submitting adjustment/void forms or repaying by check, or involuntarily by recoupment.  Consultations are appropriate only in the following circumstances.

1.     The purpose of the consultation is to train SIL staff to work with the client (i.e., to "train the trainer").

2.     The consultation is not a direct service provided to the client.

3.     Staff training is not otherwise available.  For example, consultation reimbursement is not available when staff is trained in appropriate techniques as part of the recipient's therapy visits.

4.     The consultant is not a member of the staff of the provider agency either by direct employment or by contract.

5.     Necessity and frequency of consultations is determined by the case management ID team based on appropriate documentation.  Consultations are entered on both the Comprehensive and Service Plans of Care as separate items.

6.     Consultations take place on a reasonable schedule (i.e., sufficiently often to determine that staff is following instructions).  Consultations are typically necessary no more often than monthly or quarterly.

7.     Consultations are available for persons living in an Independent Supervised Living arrangement for whom base rate is applicable.

8.     Consultants shall furnish a written report of each consultation including date and duration of contact, persons involved, pertinent findings and recommendations, and, if appropriate, progress since a previous consultation.  The report shall be filed in the recipient's case record maintained by the provider and shall be available for review by staff as necessary.

Please report suspected instances of incorrect consultation code use to Louise Dubroc at (504) 342-5457.

Authorization of Services for the Chronically Mentally Ill Which Exceed the Maximum Units Per Year

All requests for additional units of service (for dates of service prior to August 1, 1994) which exceed the maximum specified in the DHH Medicaid Case Management Services manual must be submitted in writing to OMH regional coordinator for continuation of services.

The request should document the circumstances which led to the high need for services, the necessity for additional services, and the number of additional units requested.  All service logs and progress notes should also be submitted with the request for additional services.

New Dispensing Costs for Pharmacists

The maximum allowable overhead cost (dispensing fee) for Medicaid prescription services was increased to $5.77 effective for services beginning July 1, 1994.

This fee includes the provider fee mandated under state law for every prescription filled by a pharmacy or dispensing physician.  Also, please be reminded that providers are required to bill their usual and customary charges.

HCPC DME Code Changes and Additions

The following changes have been made recently for these DME procedure codes.

1.     Code V5014 has been added as a payable code to replace V5299 for hearing aid repairs.

2.     Three additional codes have been added to the automatic pricing file (PAC = 850):
E0244 = $65.00 (Raised Toilet Seat)
E0243 = $60.00 (Toilet Rail, Each)
E0246 = $60.00 (Transfer Tub Rail Attachment)

3.     Code L3907 (EHFO, Wrist Gauntlet with Thumb Spica, Molded to Patient Model) has been added as a payable code to be automatically priced (PAC = 850) at $323.92.

Also, the following new procedure codes have been created by HCFA and will be entered on the DME file as payable codes.

1.     Codes K0001-K0117 have been created for wheelchairs and accessories.  These codes will be made payable retroactive to 1/1/94 (see the list beginning on page y of this Provider Update).  All will be automatically priced except for K0108, K0109, and K0177.

2.     Codes K0126-K0165 are new codes created for already covered items including orthotic devices, urinary catheters, and ostomy supplies.
These are also being added retroactive to 1/1/94 (see list on page 7).

3.     Codes XX030-XX072 have been created for category IV and V enteral formula products for which Medicare has descriptive and pricing information on file.  They will replace codes B4154 and B4155 for these products.  Codes B4154 and B4155 may still be used, however, for other formulas in these categories for which no "XX" code has been assigned (see list on page 7).

4.     Codes L0984-L8490 on attached list have also been added by HCFA as payable codes for additional orthotic and prosthetic items (see list on page 7).  The items will be automatically priced.

Changes in Case Management Program

As part of DHH's efforts to maintain quality and enhance administrative oversight of all case management services.  BHSF has published an emergency rule in the Louisiana Register effective July 22, 1994.  This rule makes changes in the requirements for provider enrollment, staff coverage, qualifications for case managers and their supervisors, and required staff training.  It clarifies medical necessity criteria for recipients, the mandated components of case management services and expectations for documentation.  Copies of this rule are being sent to each case management agency.  Questions regarding these changes should be directed to Suzanne Danilson (504) 342-3965 or Delphine Jackson (504) 342-0940.

Case Management with Persons With Serious Mental Illness

Beginning August 1, all case mgt. services to persons with serious mental illness must be authorized by the regional OMH in advance of service delivery.  The authorization is a two-step process as outlined below.

1.     The provider must submit medical evidence that individuals meet the target population definition for adult with serious mental illness or child with emotional/behavioral disorder.  If the individual meets the definition, an initial service assessment and planning period will be authorized.  During this period, the case management will complete the strengths assessment, a comprehensive service plan, and the CAMIS initial assessment form.  Upon completing this information, the agency may bill for services.  The information must be submitted to the regional office for authorization of services.

2.     Upon review of the strengths assessment, service plan, and CAMIS assessment, the regional office will authorize the continuation of services if they are determined necessary.  The agency will be issued an authorization number, a number of service units, and a time period for delivery of these services not to exceed six months.

Upon expiration of the service units or time period, the agency may apply for additional units of service based on the resubmission of updated information contained in the documents outlined in number 2 above.

There will be two new procedure codes for case management services.  Code X0028 will be used to bill for the initial assessment and service planning period.  Code X0029 will be used to bill for ongoing case management services.  These ongoing services will not be differentiated into three types of case management contacts as has been the case previously.  This change in coding will be effective August 1, 1994.