Provider Update

Volume 13, Number 4 

Summer 1996

Message from the LMMIS Project Manager

In 1995, the Medicaid Program underwent some very difficult budget reductions.  At that time, the Bureau of Health Services Financing issued thirty-eight (38) Emergency Rules, which initiated changes in policy and reimbursement methodology for the provision of Medicaid services in Louisiana.

It appeared that this year, Louisiana would have again faced an extension round of Medicaid budget reductions; however, through the efforts of our Senators and Representatives in Washington, the Governor and his Executive Agencies, and the Secretary of DHH and his staff, those potentially massive Medicaid program reductions were thankfully avoided.  The total avoidance of Medicaid program budget reductions was not possible.  However, Medicaid has been able to fund all mandatory services as appropriate levels as well as institutional and home and community based services to the handicapped.  In addition, plans are in place to generate a state-funded program closely resembling the discontinued Medically Needy program.  Even though some difficult reductions have been made, Louisiana Medicaid will provide in excess of $3.1 billion in medical services to the citizens of the state.

  Norm Nichols

Policy Notes

  Notice to Physicians, CNPs, and Chiropractors

Effective with the publication of this notice, physicians who employ or contract with certified nurse practitioners and/or chiropractors to provide services to Medicaid recipients must notify Provider Enrollment at 504-342-9454 of such employment or contract(s) so that the provider number of the CNP and/or chiropractor can be linked to the physician's group number on our files.

This means that all certified nurse practitioners and chiropractors who provide services to Medicaid recipients must have individual provider numbers.  This also means that physicians who do not have group numbers are required to apply for a group billing number if/when they contract with or employ a certified nurse practitioner or chiropractor.

In billing for services, the individual provider number of the certified nurse practitioner or chiropractor who provided the service must be declared in Item 24K on the HCFA 1500 (Field 21, Data Element 29 for EMC billers), and the physician's group number must be listed in Item 33 (Field 9, Data Element 14).

Changes in CPT Codes 99261, 99262, & 99263

Effective with dates of service July 1, 1996, CPT codes 99261, 99262, and 99263, which are follow-up inpatient consults payable for recipients to the age of 21, are now subjected to the preadmission/length of stay requirements.  The exception to this precertification requirement will be for inpatient visits in state-operated or out-of-state hospitals or nursing facilities.

Only inpatient visits in state-operated or out-of-state hospitals and nursing facilities are excepted from this precertification requirement.

Attention Home Health Providers

The memo sent to Home Health providers from Tom Collins (dated 02/08/96) concerning new procedures for extended nursing care and multiple visits contained claim form examples.  These examples indicated a place of service of 12 (home) in error.  Please be aware that your actual claims should always indicate a place of service 1 (home).

Pharmacy and Physician Providers:  Notice from Barr Laboratories

We have been notified by Barr Laboratories through the submission of drug utilization rebate data that pharmacists are billing and getting reimbursed for NDC numbers which are obsolete, discontinued, or their shelf-life has expired.  Please be advised that many of Barr Laboratories' drug products have been coded to non-payable status.

Please ensure when billing drug products that you use the NDC of the package from which you are dispensing.  We will continue to inform you of drug products which are considered obsolete.

If you have any questions or require and additional information, please contact Wanda Perraultat (504) 342-0427.

Notice to Rehabilitation Centers

This will serve as notice to Rehabilitation Centers that CPT code 97535 - self care/home management training (e.g., activities or daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in the use of adaptive equipment), direct one on one contact by provider, each 15 minutes - was placed in pay status effective with date of service January 1, 1996.  The fee is $7.20, with a UVS of 4.  This procedure must be prior authorized.

Rehabilitation centers that have received denials for this procedure with dates of service of January 1, 1996 and thereafter may resubmit claims for reprocessing after authorization is received.

Changes in Lupron Depot Therapy

Lupron Depot, the chemotherapeutic agent used in the treatment of prostate cancer (code J9217), is now available in a new three month injection developed to deliver three months of therapy rather than just one.  To bill for the three month injection, submit code J9217 with a "3" in the units column.  Reimbursement will be three times the single injection fee of $451.25 or $1,353.75.

Louisiana Drug Utilization Review (LADUR) Education


  • Alendronate (Fosamax) is the first approved nonhormonal treatment for osteoporosis in postmenopausal women.

  • Alendronate inhibits the activity of osteoclasts, the cells that resorb (break down) bone tissue.

  • It has also been approved for the treatment of Paget's disease of bone.

Alendronate (Fosamax):  A New Agent for the Treatment of Osteoporosis


By Robert L. Judd, PhD.
Assistant Professor of Pharmacology
Northeast Louisiana University

Osteoporosis is a progressive disease that is characterized by a reduction in bone mass, which results in bones that are prone to fracture.  It affects more than 25 million Americans, 80% of them women.  Each year, osteoporosis is attributed with more than 1.5 million fractures, primarily spinal, hip, and wrist fractures, as well as numerous deaths that result from complications of the fractures.  Osteoporosis occurs most commonly in postmenopausal women.  After menopause, bone turnover increases, and the rate of bone formation because of a drop in the amount of estrogen.  Bone loss occurs and, in the first five years after menopause, women may lose as much as 75% of their bone mass, increasing the possibility of fractures, height loss, curvature of the spine, restricted movement, and disability.  Osteoporosis may be confirmed by the finding of low bone mass or by the presence or history of osteoporic fracture.

Alendronate sodium (Fosamax-Merck) is an aminobisphonate derivative with properties that are most similar to those of etidronate (Didronel) and pamidronate (Aredia).  It is the first nonhormonal therapy for the treatment of postmenopausal osteoporosis (the safety and effectiveness in men with osteoporosis has not been established).  Prior to its approval, treatment options were limited to estrogen replacement therapy (e.g., conjugated estrogens [Premarin]), which has been used in the treatment of osteoporosis, and calcitonin (Miacalcin).  However, some women do not tolerate estrogen treatment well, and until recently, when a nasal spray formulation was approved, calcitonin was only administered parenterally.

Alendronate binds to bone hydroxyapatite crystals and specifically inhibits the activity of osteoclasts, the cells that resorb (break down) bone tissue.  It therefore reduces the elevated rate of bone turnover observed in postmenopausal women to approximate more closely that of premenopausal women.  In clinical studies, alendronate produced a progressive increase in bone mineral density (a measure of bone strength), a reduction in the number of new spinal fractures, and less height loss when compared to women who received placebo.

The effectiveness of alendronate in the prevention of osteoporosis has not yet been demonstrated, and this is not a labeled indication at the present time.  The manufacturer is conducting a study comparing the efficacy of conjugated estrogens and the combined use of the two agents.

Alendronate has also been approved for the treatment of Paget's disease of bone in patients having alkaline phosphatase at least two times to upper limit a normal.  Paget's disease of bone is a chronic bone disorder that may result in fragile, enlarged, and deformed bones that are more likely to fracture.  It is the second most prevalent bone disease after osteoporosis, affecting about 1.3 million Americans.  Alendronate joins etidronate, pamidronate, and calcitonin as the treatment options for this disorder, and, in a comparative study, the response with alendronate was greater than with etidronate.

Use of alendronate is contraindicated in patients with hypocalcemia or hypersensitivity to any component of the product.  Hypocalcemia must be corrected before initiating therapy with the new agent, as should any other disturbances of mineral metabolism (such as vitamin D deficiency).  The action of alendronate to increase bone mineral may be associated with small, asymptomatic decreases in serum calcium and phosphate, especially in patients with Paget's disease.  Adequate calcium and vitamin D intake should be ensured to provide for these enhanced needs.

Alendronate was generally well tolerated in clinical studies, and the rate of discontinuation of therapy because of adverse events was actually lower with alendronate in the 10mg/day regimen used for osteoporosis (4%) than in the group receiving placebo (6%).  Adverse reactions most commonly associated with the use of alendronate (and reported at an incidence greater than with placebo) include abdominal pain (7%), musculoskeletal pain (4%), esophageal ulcer (2%), flatulence (3%), and headache (3%).  For patients with Paget's disease, who are treated with a higher dosage alendronate (40 mg/day), the frequency of adverse reaction is higher, especially upper gastrointestinal effects (18%).  As with etidronate and pamidronate, alendronate should be used with caution in patients with active upper GI problems.  The incidence of upper GI effects increased in patients taking alendronate (in a dosage greater 10mg/day) as well as an aspirin-containing product.  The concurrent use of alendronate with aspirin or a nonsteriodal anti-inflammatory drug should be closely monitored.

Because the primary indication for alendronate is in post-menopausal women, its use during pregnancy or in nursing mothers has not been studied, and such use should be avoided.  Alendronate is classified in Pregnancy Category C.  Alendronate is not metabolized and is primarily excreted in the urine.  It is not necessary to reduce the dosage in patients with mild-to-moderate renal insufficiency.  However, use of alendronate is not recommended for patients whose creatinine clearance is less than 35 ml/minute, because of lack of experience.

The recommended dosage of alendronate is 10 mg once a day for treating osteoporosis in postmenopausal women, 40 mg once a day, for six months, for treating Paget's disease of bone.  Relative to an IV reference dose, the mean oral bioavailability of alendronate in women was 0.7% when administered after an overnight fast and two hours before a standardized breakfast.  Bioavailability was negligible whether alendronate was administered with a standardized breakfast of up to two hours afterwards.  Even orange juice, coffee, and mineral water may markedly reduce the absorption of alendronate.  Patients should be informed that alendronate must be taken with plain water only (a full 6 or 8 oz glass) at least one-half hour before the first food, beverage, or medication of the day.  After taking, the patient must wait 30 minutes before eating, in order to improve absorption to the drug.  To facilitate the delivery of the drug to the stomach and to reduce the potential for esophageal irritation, patients should avoid lying down for at least 30 minutes thereafter.  Alendronate is available as white, uncoated tablets in two strengths and shapes:  10 mg, which are round, and 40 mg, which are triangular.


Chestnut, C.H. III, McClung, M.R., Ensrud, K.E., et al. "Alendronate Treatment of the Postmenopausal Osteoporotic Woman; Effect of Multiple Dosages on Bone mass and Bone Remodeling." American Journal of Medicine, 99 (1995): 144-152.

Hussar, D.A. "New Drugs of 1995." Journal of the American Pharmaceutical Association, NS36(3) (1996): 158-186.

Alendronate (Fosamax). New Product Bulletin (1996).

 Papapoulos, S.E. "The Role of Disphosphonates in the Prevention and Treatment of Osteoporosis. "American Journal of Medicine, 95 (supp. 5A) (1993): 48S-52S.

Watts, N.B. "Treatment of Osteoporosis with Bisphosphonates." Theum. Dist. Clin. North Am., 20 (1994): 717-734.

Policy Notes

To All Providers:  Duplicate Claims Payments

We have found duplicate claims payments where two different billing providers were paid for the same service rendered by one attending physician.  Where payment was made to the attending and to a group, the payment to the attending was voided.  Where payment was made to two groups, the second claim paid was voided.  These claims will generate EOB message 849 which states, "Already paid same attending different billing provider."

CPT Code 92568 with 92567

It has been the policy of the Louisiana Medicaid Program not to pay for duplicate or inclusive procedures.  We would like to remind providers that 92567 (Tympanometry) includes 92568 (Acoustic Reflex Testing).  Therefore, these codes should not be billed on the same recipient on the same date of service.  Billing on these codes together is contrary to Medicaid policy, and claims will be subject to recoupment.

Notice to Providers of Lab Services

Effective with date of service July 1, 1996, fees for certain laboratory codes (CPT codes in the 80,000 series) were reduced in order to bring Medicaid reimbursement amounts for these codes in line with those being paid to Medicare.

Questions about this matter may be directed to Kandis V. McDaniel, Physicians Program Manager, at 504-342-9490.

Attention Pharmacy Providers:  NDCs Removal from the Drug File

Effective July 1, 1996, the following Rugby Laboratories' NDCs which are classified as food supplements were made non-payable.  Please be advised that several of Rugby Laboratories' drug products have been coded to non-payable status:  536-0082-90, 536-3954-10, 536-4082-01, 536-4341-01, 536-4379-01, 536-4606-10, 536-4634-01, and 536-4820-25.

Notice to Pharmacy Providers:  Lancets and Glucose Strips

Lancets and blood glucose or reagent strips for a home blood glucose monitor are Medicare covered only if the patient is insulin treated.  Medicare is to be billed first for insulin treated Medicare Part B eligible recipients obtaining those diabetic supplies.  If the recipient is not insulin treated, hard copy billing and pharmacy or physician documentation to that fact must be mailed to P. O. Box 91024.

Notice to Physician Providers:  Indigent Patient Drug Programs

As some physician providers may be aware, there are pharmaceutical manufacturers that have established programs to make some drugs available free of charge to indigent patients.  These programs are not government-sponsored; in fact, Medicare and Medicaid patients may be disqualified by certain companies.

However, if a Medicare/Medicaid physician provider believes that he/she has an indigent patient that could possibly benefit from such indigent patient drug programs (for example, aging patients on fixed incomes whose medication is costly), that physician may want to discuss this possibility with that patient.  If they choose to proceed, the manufacturer of the drug must be found (drug companies are listed in the Physician's Desk Reference (PDR)) and the physician is generally required by most companies to make the initial contact.  If a patient is determined to be eligible for the program, the manufacturer will send the medication t the physician's office for distribution.

Again, these are not government-funded programs:  Medicare/Medicaid physician providers are not obligated to provide this service, and these is no guarantee that Medicare/Medicaid patients will be eligible for indigent patient drug programs.

Reimbursement Rates for Apnea Monitors, Oxygen Concentrators, and Nebulizers

The Bureau, as of July 1, 1996, has revised the rates of reimbursement for the following items:

Apnea monitor [code E0608] = $1900 [purchase] & $160 [rental]

Oxygen concentrator [codes E1400, E1401, E1402, E1403, & E1404] = $1500 purchase & $175 [rental]

Nebulizer, with compressor [code E0570] = $95 [purchase] & $175 [rental]

Facilities Whose Physicians May Bill the NICU Codes:  New Listing

Baton Rouge General Health Center - Baton Rouge, LA
Children's Hospital - New Orleans, LA
E. A. Conway Medical Center - Monroe, LA 
East Jefferson General Hospital - Metairie, LA
Earl K. Long Medical Center - Baton Rouge, LA
Kenner Regional Medical Center - Kenner, LA
Lafayette General Medical Center - Lafayette, LA
Lake Area Medical Center - Lake Charles, LA
Lake Charles Memorial Hospital - Lake Charles, LA
Lakeland Medical Center - New Orleans, LA
Lakeside Hospital - Metairie, LA
Lakeview Regional Medical Center - Covington, LA
Lane Memorial Hospital - Zachary, LA
Leonard J. Chabert Medical Center - Houma, LA
LSU Medical Center - Shreveport, LA
Meadowcrest Hospital - Gretna, LA
Medical Center of Baton Rouge - Baton Rouge, LA
Medical Center of Louisiana - New Orleans, LA
Mercy Baptist Medical Center - New Orleans, LA
Minden Medical Center - Minden, LA
North Oaks Medical Center - Hammond, LA
Northshore Regional Medical Center - Slidell, LA
Ochsner Foundation Hospital - New Orleans, LA
Pendleton Memorial Methodist Hospital - New Orleans, LA
St. Francis Cabrini Hospital - Alexandria, LA
St. Francis Medical Center - Monroe, LA
St. Tammany Parish Hospital - Covington, LA
Schumpert Medical Center - Shreveport, LA
Slidell Memorial Hospital & Medical Center - Slidell, LA
Terrebonne General Medical Center - Houma, LA
Touro Infirmary - New Orleans, LA
Tulane University Hospital - New Orleans, LA
University Medical Center - Lafayette, LA
West Jefferson Medical Center - Marrero, LA
Willis Knighton Medical Center - Shreveport, LA
Woman's Hospital - Baton Rouge, LA
Women's and Children's Hospital - Lafayette, LA

Claims Denied Through the Duplicate Drug ProDUR Module

Effective July 15, 1996 and after, the Bureau will deny claims identified through the Duplicate Drug ProDUR module.  The Duplicate Drug ProDUR module detects duplicate prescriptions for the same drug (form and strength).  A claim denial will occur as a patient attempts to obtain the same drug from a different pharmacy sooner than is anticipated based on the estimated days supply.  The drug conflict code for duplicate therapy is ID in the NCPDP field 439.  Our explanation of benefits edit is 445-Duplicate Drug Therapy.

If a claim is denied for duplicate drug therapy, the provider may telephone the POS Help Desk for more detailed information of direction.  After consultation with the physician, patient and/or the POS Help Desk, the provider must determine whether there are extenuating circumstances which substantiate the dispensing of a duplicate claim.  If extenuating circumstances exist, the provider must use the following procedures to initiate an override of the denial for duplicate therapy:

1.      The provider must document on the prescription hard copy the circumstances for the override and signify a duplicate drug therapy occurrence by entering "ID" in NCPDP field 439.
Specific contacts and circumstances must be documented.

2.      The provider must indicate on the denial claim resubmission one of the following intervention code indicators in NCPDP field 440:

M� - Prescriber was consulted and authorized the dispensing of the duplicate

P� - Patient consulted and had an explanation as to the necessity of dispensing the duplicate, or

R� - Pharmacist consulted another source and determined the duplicate is a false positive

3.      The provider must indicate on the denied claim resubmission one of the following outcome code indicators in NCPDP field 441:

1A-Filled as is, false positive

1B-Filled prescription as is

1C-Filled, w/different dose

1D-Filled, w/different directions

1E-Filled, w/different drug

1F-Filled, w/different quantity

1G-Filled, w/prescriber approval

Providers having any questions should contact the POS Help Desk at 1-800-648-0790 or (504) 237-3381.

Notice to Providers:  Changes in Reduction Mammoplasty Services

Effective with date of service July 20, 1996, the Bureau of Health Services Financing adopted the following criteria to govern the provision of reduction mammoplasty services under the Medicaid Program.  Prior to requested prior authorization for a reduction mammoplasty, recipients must meet the following criteria:

I.                   Approval Requirements

A.    Qualifying Condition

The recipient must meet the following weight and height criteria before the  provider is to submit a request for evaluation and consideration for reduction mammoplasty services.  The recipient's total weight shall not exceed the weight limit established by the following formula by more than twenty percent.

Height                                                            Pounds

5 feet                                                                100

Each additional inch over 5 feet                            5

For example:  A request for reduction mammoplasty services shall not be submitted for consideration for a recipient who is 5 feet tall who weighs more than 120 pound (100 pounds plus 20%).  A person who is 5 feet one inch tall shall weight no more than 126 pounds (105 pounds plus 20%) to be considered.  A recipient who is 5 feet, 5 inches tall shall weigh no more than 150 (pounds) 125 pounds plus 20%) to be considered.

B.                  Prior Authorization

  1. If the qualifying condition stated above is met, providers may then submit a request for prior authorization of reduction mammoplasty upon which the determination of medical necessity will be made.

  2. The following documentation must accompany the request for prior authorization of reduction mammoplasty services:

  • Posterior photo view of the shoulder straps area

  • Frontal phone view of chest with face blocked;

  • Lateral photo of chest; and

  • Number of grams of breast tissue to be removed from each breast.


II.                   Payment Requirements

The pathology report and the PA01 or the PA approval letter must be attached to the claim submitted for payment to the fiscal intermediary.  The HCFA 1500 claim form cannot be electronically transmitted.  The claim will be denied payment if the above documentation is not attached to the claim.

Emergency Rules

  Notices for All Medicaid Providers

The Department of Health and Hospitals, Bureau of Health Services Financing, has adopted the following Emergency Rules in the Medical Assistance Program as authorized by R.S. 46:153 and pursuant to Title XIX of the Social Security Act and as directed by the 1996-1997 General Appropriation Act, which states: "The Secretary shall implement reductions in the Medicaid program as necessary to control expenditures to the level approved in this schedule.  The Secretary is hereby directed to utilize various cost containment measures to accomplish these reductions, including but limited to pre-certification, pre-admission screening, and utilization review, and other measures as allowed by federal law."  These Emergency Rules are adopted in accordance with the Administrative Procedure Act, R.S. 49:950 et seq. and shall be in effect for the maximum period allowed under the Administrative Procedure Act or until adoption of the rules, whichever occurs first.

Termination of the Medically Needy Program

Effective for dates of service July 1, 1996 and after, coverage for all individuals certified for the Medically Needy Program, including those individuals with an approved period of coverage which extended beyond June 30, 1996, has been terminated.

The Department of Health and Hospitals will no longer approve any applications, taken on July 1, 1996 or afterwards, for the Medically Needy Program categories of assistance.  The Department, however, has decided to continue to provide medical benefits, from specially allotted state funds, for all Medically Needy Program recipients who are currently certified and remain eligible continuously or who apply for MNP before July 1, 1996 and are then found eligible and remain eligible continuously.  The following provisions shall govern the administration of this State-Funded Medically Needy Program.

I.                   General Provisions

The State-Funded Medically Needy Program shall be administered in accordance with requirements of Title XIX of the Social Security Act for Medically Needy Program under the Act except as described below.

  1. Coverage under this Program shall be limited to individuals who are certified for the Title XIX Medically Needy Program or have a pending application for participation under the Title XIX Medicaid Program and are subsequently found eligible for Title XIX Medically Needy for June 1996.

  1. Recipients must continually meet all the federal eligibility criteria under the Title XIX Medically Needy Program in order to maintain their eligibility status under the State-Funded Medically Needy Program.

  1. Recipients who are determined to be potentially eligible under any Title XIX eligibility category or any other benefit must take all appropriate steps to pursue that eligibility including:  applying for coverage and providing the necessary information to determine eligibility for the Title XIX category or other benefit.

  1. Eligibility for the State-Funded Medically Needy Program will be terminated under the following circumstances:  a) The recipient is determined eligible under a Title XIX category or other benefit; or b) the recipient refuses to apply for coverage or cooperate in the eligibility determination process.

  2. The State-Funded Medically Needy Program shall not provide for a process to determine the eligibility of any new eligible beginning July 1, 1996.

A)    Services

The scope of services and reimbursement for the covered services shall be provided in accordance with the federal and state regulations that governed the Medically Needy Program under the Title XIX as previously administered by the Bureau of Health Services Financing.

B)    Appeal Rights

Recipients who lose their eligibility under the State-Funded Medically Needy Program shall be afforded the opportunity to appeal the agency's decision in accordance with the Administrative Procedure Act.  There shall be no continuation of benefits pending appeal.  Recipients can call 1-800-256-8032 for information.

All Providers

  Program Termination of AFCD-M and SSI-M Eligibles

  Effective July 1, 1996, benefits for these two groups of eligibles were terminated.  AFDC-M eligibles are identified by both the number "13" in the third and fourth digits of the Medicaid identification number and a Type Case of 01 or 09 printed on the card.  SSI-M eligibles are identified by Type Case 68 printed on the card.  In order to help prevent denial of claims for eligibility reasons, please be sure your staff is asking to see a CURRENT valid card for the month of service.  Eligibility verification is also available to providers by calling 1-800-776-6323.  Recipients can call 1-800-256-8032 for information.

Physician Providers

  Notice to Physicians and Independent Labs

Effective with date of service July 1, 1996, adjustments were made in the fees for the procedures listed below which are billed by physicians and independent labs.

Code                Description                                                                                                                              Fee

36415                Routine venipuncture or finger/heel/ear stick for collection of specimen(s)                $2.65

99211                Office or other outpatient visit, established patient (may not required                         $9.25
                   physician's presence)

99212                Office of other outpatient visit, straightforward medical decision-making                   $18.91

99233                Subsequent hospital care, medical decision-making of high complexity                      $42.60

Bilateral Procedures

Currently, there are a number of bilateral procedures which are reimbursed at a rate of 200% of the fee on Physicians Formulary file or the billed charge, whichever is lower.  Effective with dates of service July 10, 1996 and after, the Bureau of Health Services Financing has reduced reimbursement for these procedures to 150% of the fee on file, or the billed charge, whichever is lower.

The CPT procedure codes which are being reimbursed at 150% of the fee on the Physician Formulary file are listed below:

30903              49505              31254              49507

31255              49520              31256              49521

31267              49525              31276              69420

49495              69421              49496              69424

49500              69433              49501              69436

These procedure codes must be billed with the -50 modifier if performed bilaterally (just like all other bilateral procedures) and the number "1" must be placed in the form locator 24G (Days or Units column) on the HCFA 1500 claim form.

Effective with dates of service July 10, 1996 and after, these claims must be billed hardcopy with documentation attached, rather than electronically.

Anesthesia Services

The following policy governing the provision of anesthesia services under the Professional Services Program was adopted effective with date of service July 10, 1996:

1.      Anesthesia services are reimbursed for the day of surgery or delivery.

2.      Because tubal ligations are not always performed immediately after the delivery (but usually within twenty-four hours), a locally-assigned code, 00098, has been devised and placed on the file to reimburse providers for the reinjection of the epidrual catheter for the tubal ligation.  Therefore, effective with date of service July 10, 1996, code 00098, whose description is "Reinjection of the epidural catheter for tubal ligation," is to be used to bill for this service rather than code 62279.  The fee for code 00098 is $50.00.

3.      Payment for CPT codes 62274 through 62282, code 62289, and codes 64400 through 64450 will be restricted.  The first claim submitted for any of the codes listed above will be paid.  Subsequent billings within the 180 day period of the same code or of a different code within a range of codes listed will deny with error edit 950 (Operative and History Reports Required), if the claim is billed electronically or if it is submitted hardcopy without attachments.

If submitted with attachments (Operative and History Reports), the claim will pend for review for medical necessity.  If it is determined the service was medically necessary, the claim will be paid.  Otherwise, the claim will be denied with error edit 664 (Only One Payable Per 180 Days).

Global Surgery Periods

Effective with date of service July 10, 1996, payment for pre- and post-operative visits made during global surgery periods is included in the fee for the surgery.  Three different global surgery periods (GSP) will be utilized for the reimbursement of surgeries.  One period shall consist of 0 days, the second period shall consist of 10 days, and the third period shall consist of 90 days.  Each CPT surgery code shall be assigned to one of the global surgery periods (GSP):

If a code's GSP is 0, no outpatient or inpatient visits on the day before or the day of surgery will be allowed unless the diagnosis for the visit is different from that of the surgery.

If a code's GSP is 10, no outpatient or inpatient visits will be allowed on the day before surgery, the day of surgery, or for 10 days after the day of surgery unless the diagnosis for the visit is different from that of the surgery.

If a code's GSP is 90, no outpatient or inpatient visits will be allowed on the day before surgery, the day of surgery, or for 90 days after the day of surgery unless the diagnosis for the visit is different from that of the surgery.

The Medicaid global surgery listing of procedures is the same as Medicare's 1992 global surgery listing.  All providers should have a copy of the Medicare list in their offices.

Community Care Program

  Physician Management Fee

Effective for dates of service July 1, 1996 and after, physician management fees have been reduced in the Community Care Waiver Program to $2.00 per enrolled recipient per month.

Federally Qualified Health Centers

  Reimbursement Methodology

Effective for dates of services July 1, 1996 and after, the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, will limit reimbursements to federally qualified health centers by applying the Medicare payment limit to core services.  Thus, core services/encounter rates will not be paid nor cost settled at a higher rate than the Medicare payment limit.  This rule applies to core services only and not to other ambulatory services provided.  A core service is defined as a face-to-face encounter with a physician, physician assistant, nurse practitioner, clinical psychologist, or clinical social worker.

Early Periodic Screening Diagnosis and Treatment (EPSDT) Program

  Follow-up Screening Services

Effective for dates of service July 1, 1996 and after, the Department has reduced reimbursement fees for providers of medical screening services for the following codes included under the Early Periodic Screening Diagnostic and Treatment Program:

Procedure Code

Old Rate New Rate
X0180 Consult
EPSDT - New Dx by Nurse
$15.71 $13.71
X0181 Consult
EPSDT-New Dx by Nutrition
$15.71 $13.71
X0182 Consult
EPSDT - New Dx by Social Worker
$15.71 $13.71
X0187 Consult
EPSDT - Scrn Dx by Nurse
$15.71 $13.71
X0188 Consult
EPSDT - Scrn Dx by Nutrition
$15.71 $13.71
X0189 Consult
EPSDT- Scrn Dx by Social WOrker
$15.71 $13.71

Health Services:  Rehabilitation

Effective for dates of service July 10,1996 and after, the Department has reduced reimbursement fees by TEN PERCENT (10%) for rehabilitation services included in an Individual Education Plan or Individual/Family Service Plan and provided by school boards and early intervention centers under the Early Periodic Screening, Diagnosis and Treatment (EPSDT) Health Services Program for Medicaid recipients under twenty-one years of age.  These rehabilitation services include evaluations and treatment services for speech, occupational, physical, and psychological therapies as well as audiological services.

Home Health

Reimbursement for Psychiatric Services

Please disregard our July 23, 1996 memorandum in which you were notified that reimbursement would no longer be covered for home health services provided to recipients whose primary diagnosis is a psychiatric diagnosis.  We are rescinding the Emergency Rule implementing this policy change that was published in the July20, 1996 edition of the Louisiana Register.

However, these services must be provided in accordance with state requirements as published in the Minimum Standards for Home Health Agencies.  One requirement is the stipulation that "only registered nurses (RNs) who have at least three full time years of verified direct psychiatric care experience shall make psychiatric nurse visits.  Master's preparation in psychiatric nursing may be substituted for experience."

Additionally, the services must be medically necessary and provided only to recipients who meet Medicaid's homebound criteria as published in the March 20, 1996 edition of the Louisiana Register.

Case Management

  Termination of the Case Management for the Seriously Mentally Ill Program (Formerly Chronically Mentally Ill)

Effective for dates of service July 1, 1996 and after, the Medicaid Program shall no longer cover or reimburse for Case Management services to the Seriously Mentally Ill.  Claims for services prior to July 1, 1996 will be reimbursed for these services to the extent that funds are authorized by legislative appropriation for these services.

Services for the Mentally Retarded/Developmentally Disabled - Non-Waiver

Effective July 1, 1996, a change in service coverage to terminate the case management program for the mentally retarded/developmentally disabled (MR/DD) WHO ARE NOT participants in the MR/DD Home and Community-Based Services waiver was adopted.

Thus, effective for dates of service July 1, 1996 and after, the Medicaid Program shall no longer cover or reimburse for Case Management services to the Mentally Retarded/Developmentally Disabled individuals who do not also participate in the MR/DD Home and Community-Based Services waiver.  Claims for services prior to July 1, 1996 will be reimbursed to the extent that funds are authorized by legislative appropriation for these services.

The case management services for the Mentally Retarded/Developmentally Disabled population under the Home and Community-Based Waiver Services are retained.


  Outpatient Laboratory Services

The Bureau has determined it is necessary to reduce the reimbursement for outpatient hospital lab services subject to the Medicare fee schedule in order to achieve a uniform reimbursement methodology for all laboratory services subject to the Medicare fee schedule regardless of the setting in which the services are performed.  Therefore, the following Emergency Rule has been adopted to reduce the payment for outpatient hospital laboratory services subject to the Medicare fee schedule.

Effective for dates of service August 1, 1996 and thereafter, the Bureau has reduced the reimbursement rate for outpatient hospital laboratory services to the same reimbursement rate for laboratory services provided in a non-hospital setting.

Outpatient Rehabilitation Services

Effective for dates of service August 1,1996 and thereafter, the Department is reimbursing hospitals for outpatient rehabilitation services including speech, occupational and physical therapies at a flat fee for service based on payments made to rehabilitation clinics for these services.  These services shall no longer be settled in the cost report.  Hospitals are required to bill for these services using the same state-assigned HCPCS procedure codes payable to rehabilitation clinics, in addition to the hospital revenue code.

When the revenue code listed at Form Locator 24 of UB-92 is 420, 421, 422, 424, 430, 431, 432, 434, 440, 441, 442, 443, 444, or 454, the correct procedure code corresponding to the revenue code shown below must be entered at Form Locator 44.  If this procedure is not followed, the claim will deny.

Revenue Code File Description Code
424 Physical Therapy Evaluation Y7702
434 Occupational Therapy Evaluation Y7812
444 Speech Evaluation Y2602
444 Hearing Evaluation Y2612
454 Wheelchair Seating Evaluation Y7902
420, 421 Physical Therapy, one modality Y7000
420, 421 Physical Therapy, 2 or more modalities Y7050
420, 421 PT, 1 or more procedures and/or mods., 15 min. Y7106
420, 421 PT with procedures, 20 min. Y7105
420, 421 PT with procedures, 30 min. Y7100
420, 421 PT with procedures, 45 min. Y7101
420, 421, 422 PT with procedures, 60 min. Y7102
420, 421 PT with procs and mods, 60 min. Y7202
420, 421 PT with procedures, 75 min. Y7103
420, 421 PT with procedures, 90 min. Y7104
430, 431 Occupational Therapy, 15 min. Y7810
430, 431 Occupational Therapy, 20 min. Y7811
430, 431  Occupational Therapy, 30 min. Y7813
430, 431 Occupational Therapy, 45 min. Y7814
430, 431 Occupational Therapy, 60 min. Y7815
440, 441 Speech and Hearing Therapy, 15 min.  Y2609
440, 441 Speech and Hearing Therapy, 20 min. Y2611
440, 441 Speech Therapy, 30 min. Y2613
440, 441 Speech Therapy, 45 min. Y2614
440, 441, 442 Speech Therapy, 60 min. Y2615
443 Group Speech Therapy, 20 min. Y2510
443 Group Speech, Language, Hearing, Therapy, 30 min. Y2509
443 Group Speech Therapy, additional 15 min. Y2511
443 Group Speech, Language, Hearing Therapy, 1 hour Y2512

Rehabilitation Clinics

  Changes in Medicaid Reimbursement Rates

Effective for dates of service July 10, 1996 and after, the Department will reduce the reimbursement for services provided by rehabilitation clinics by ten percent (10%).  Rehabilitation clinics are not part of a hospital but are organized to provide a variety of outpatient rehabilitative services including physical, occupational, and speech/hearing and language therapies.  This action is necessary to avoid a budget deficit in the medical assistance programs due to the lack of sufficient state funds required to match federal financial participation mandated under Title XIX of the Social Security Act.  Beginning with date of service July 10, 1996 and after, payment of these services will be made in accordance with the rates noted in the table below.  Prior authorization procedures will remain the same.

Description Procedure Code Rate
Evaluation Procedures
Wheelchair seating evaluation Y7902 $41.31
Physical therapy evaluation Y7702 $43.74
Occupational therapy evaluation Y7812 $41.31
Speech evaluation Y2602 $36.45
Hearing evaluation Y2612 $36.45
Physical Therapy Procedures
Physical therapy, one modality Y7000 $12.96
Physical therapy, 2 or more modalities Y7050 $19.44
Physical therapy, 1 or more

Procedures and/or modalities, 15 min.

Y7106 $6.48
P.T. - with procedures, 20 min. Y7105 $10.80
P.T. - with procedures, 30 min. Y7100 $12.96
P.T. - with procedures, 45 min. Y7101 $19.44
P.T. - with procedures, 60 min. Y7102 $25.92
P.T. - with proc. and mod., 60 min. Y702 $28.80
P.T. - with procedures, 75 min. Y7103 $36.00
P.T. - with procedures, 90 min. Y7104 $43.20
Occupational Therapy Procedures
Occupational Therapy, 15 min. Y7810 $4.14
Occupational Therapy, 20 min. Y7811 $5.51
Occupational Therapy, 30 min. Y7813 $8.27
Occupational Therapy, 45 min. Y7814 $11.18
Occupational Therapy, 60 min. Y7815 $14.10
Speech Therapy Procedures
Speech and Hearing Therapy, 15 min. Y2609 $6.48
Speech and Hearing Therapy, 20 min. Y2611 $8.10
Speech Therapy, 30 minutes Y2613 $12.15
Speech Therapy, 45 minutes Y2614 $18.63
Speech Therapy, 60 minutes Y2615 $24.30
Group Speech Therapy Procedures
Group Speech Therapy, 20 min. Y2510 $4.05
Group Speech Therapy, 30 min. Y2509 $6.48
Group Speech Therapy, add. 15 min. Y2511 $3.24
Group Speech Therapy, 1 hour Y2512 $12.96


DME Providers

  Revision of Procedures for Seating Evaluations, Prior Authorization and Reimbursement for Customized Wheelchairs

Effective for requests received on or after July 1, 1996, the Bureau of Health Services Financing will no longer reimburse DME providers for customized wheelchairs based on the lowest bid from the DME providers participating in a wheelchair seating evaluation.  Instead, the Bureau will be using a reimbursement formula that applies a discount of 18% to the manufacturers' suggested retail price, for the model of wheelchair and its accessories.

Effective since July 1, 1996, all rehabilitation providers, who receive an M.D. prescription for a wheelchair which is specially designed or constructed for the individual (HCPC procedure code E1220), should provide the recipient an opportunity to make an informed choice of a DME provider to participate in the seating evaluation.  It will no longer be necessary to invite three (3) DME providers to participate in customized wheelchair seating evaluations.  Only one DME provider will be invited to participate in the seating evaluation, in accordance with the recipient's choice.

Upon completion of the seating evaluation, the rehabilitation provider will send a copy of the evaluation including the recommended specifications, to the DME provider who participated in the evaluation.  The rehabilitation provider will no longer be completing the Form PA01 and submitting it to Unisys.  Instead, the DME provider will complete the Form PA01 to request prior authorization for the wheelchair and submit it to the Prior Authorization Unit at Unisys Corporation.

Upon the receipt of the request for prior authorization, the Prior Authorization Unit will review the request for medical necessity.  If approved, the Prior Authorization Unit will determine the allowable reimbursement amount by applying a discount of 18% to the manufacturer's suggested retail prices for the wheelchair model requested and its accessories.

When completing the Form PA01, the DME provider should give a complete description of the wheelchair and accessories, giving the model and product number for each component.  Procedure code E1220 should be used for these customized chairs.  Specific HCPC codes assigned for individual wheelchair components should not be used in the description.  These codes are intended for use only when requesting parts or accessories for replacements, repairs, or additions, but not for customized wheelchair descriptions and breakdown of components.  Delivery fees can be listed with a separate procedure code when there is a charge for delivery from a store or a dealer representative to a recipient in another parish.  Labor charges may also be listed with a separate procedure code.

Requests for wheelchairs for recipients with other third party insurance coverage should be submitted in the same manner, with a copy of the EOB from the other insurance carrier.  The same reimbursement formula will then be applied to determine the total allowable price for the chair.  Unisys claims processing will then pay the difference between that price and the amount paid by the insurance carrier, when billing is submitted.

Policy Notes

  Restrictions of Out-of-State Care

The Louisiana Medicaid Program covers out-of-state hospital services on an emergency basis only.  The exception to this policy is when an out-of-state facility has been approved through the Unisys Prior Authorization process to provide medically necessary services not available in the state of Louisiana.  Louisiana Medicaid also covers non-emergency services other than psychiatric and substance abuse services when those services are provided by hospitals in the bordering states of Texas, Arkansas, and Mississippi that are routinely used by Louisiana residents.

In July of 1995, severe budget problems forced a reduction in payments to out-of-state hospitals to the lower amount of 50% of billed charges or the hospital's per diem rate.  All hospitals, in-state or out-of-state, are reimbursed at a flat fee per service for ambulatory surgical procedures and laboratory and x-ray services provided on an outpatient basis.

Hospital psychiatric or substance abuse services are not covered on an outpatient basis.  Inpatient stays for psychiatric or substance abuse treatment are only covered in out-of-state hospitals in the event of a medical emergency, for a maximum of two days to allow time for the patient to be stabilized and transferred to a Louisiana psychiatric hospital, when appropriate.

Attention Ambulance Providers:  Rate Increase for Emergency ALS Codes and Crossovers

The Medicaid Program has approved a rate increase for two emergency medical transportation advance life support (ALS) services in order to reimburse these services at the Medicare rate.  Additionally, Medicaid has approved payment of the full co-insurance and deductible amounts on Medicare crossover claims for non-emergency ambulance transports provided to all Medicare/Medicaid eligible recipients.  Previously, approval was given to pay the full co-insurance and deductible amounts only for those recipients who were Qualified Medicare Beneficiaries (QMB).  These rate increases are approved retroactively to January 1, 1996.  We will re-process claims for the adjusted payment amounts.

Please refer to the following list of procedure codes and keep it as a quick reference to use when billing for services.  A brief description and the Medicaid rate of reimbursement is given for each non-emergency ambulance procedure code.  The procedure codes are grouped according to the non-emergency ambulance services and the emergency ambulance services.  The emergency ambulance services are payable in accordance with the rates established by Medicare for each of the Medicare regions.


Code               Description of Service                                                                        Rate

A0360             Base Rate, BLS non-emergency, 1st trip                                             $65.47
A0364             Base rate, non-emergency, no specialized ALS services, 1st trip          $65.47
A0366             Base rate, non-emergency, specialized, ALS services, 1st trip              $65.47
A0380             Non-emergency loaded miles, BLS, 1st trip                                         $2.11
A0390             Non-emergency loaded miles, ALS, 1st trip                                         $2.11
Z5100              Transfer, non-emergency, ALS or BLS, 1st trip                                  $65.47
Z5101              Transfer, non-emergency, ALS or BLS, 2nd trip                                 $65.47
Z5102              Non-emergency loaded miles, ALS or BLS, 2nd trip                          $2.11
Z9497              Base rate, non-emergency, ALS or BLS, 2nd trip                              $65.47


Code               Description of Service

A0362             Emergency transport; BLS
A0368             Emergency transport; no specialized ALS services rendered
A0370             Emergency transport; specialized ALS services rendered
A0380             Emergency "loaded" miles, BLS
A0382             Routine disposable supplies, BLS
A0390             Emergency "loaded" miles, ALS
A0398             Disposable supplies, ALS
A0422             Oxygen and oxygen supplies, ALS or BLS
Z5100              Emergency transfer from hospital to hospital, BLS
Z5101              Emergency transfer from hospital to hospital, ALS


Code REG 01 REG 02 REG 03 REG 04 REG 05 REG 06 REG 07 REG 08
A0362 $169.46 $164.00 $169.46 $169.46 $169.46 $169.46 $169.46 $169.46
A0368 $308.71 $309.08 $308.03 $309.13 $308.99 $308.99 $308.24 $309.32
A0370 $308.71 $309.08 $308.03 $309.13 $308.99 $308.90 $308.24 $309.32
A0380 $3.91 $3.91 $3.91 $3.91 $3.91 $3.91 $3.91 $3.91
A0382 $7.50 $17.00 $17.00 $17.00 $17.00 $17.00 $17.00 $15.00
A0390 $3.91 $3.91 $3.91 $3.91 $3.91 $3.91 $3.91 $3.91
A0398 $7.50 $17.00 $17.00 $17.00 $17.00 $17.00 $17.00 $15.00
A0422 $34.51 $34.51 $34.51 $34.51 $34.51 $34.51 $34.51 $34.51
Z5100 $169.46 $169.46 $169.46 $169.46 $169.46 $169.46 $169.46 $169.46
Z5101 $308.71 $309.08 $308.03 $309.13 $308.99 $308.99 $308.24 $309.32

Services Provided Involving both HMO and Medicaid Coverage

HCFA has recently clarified several issues concerning services provided to recipients who are covered by both an HMO and Medicaid.  Effective with dates of service September 1, 1996, Louisiana Medicaid will adopt the following policy concerning HMO/Medicaid coverage.  This policy is based on HCFA clarification.

The recipient must use the services of the HMO which they freely choose to join.  These claims must be submitted hardcopy with a copy of the HMO EOB from the carrier which is on file with the State.

1.      If the HMO denies the service because the service is not a covered service offered under the plan, the claim will be handled as a Medicaid claim and processed based on Medicaid policy and pricing.

2.      If the HMO denies the claim because the recipient sought medical care outside of the HMO network and without the HMO's authorization, Medicaid will deny the claim with a message that HMO services must be utilized.

3.      If the recipient uses out of network providers for emergency services and the HMO does not approve the claim, Medicaid will deny the claim with a similar edit.

If the provider of the service plans to file a claim with Medicaid, copayments or any other payment cannot be accepted from the Medicaid recipient.

Please make this information available to all staff who may need it.