PROVIDER
UPDATE
VOLUME 14,
NUMBER 4
AUGUST 1997
Precertification
Clarification
The Department of Health and Hospitals has seen great
success with the inpatient hospital precertification process which was
implemented in late 1994. There
still seem to be some areas of confusion and lack of communication between the
hospitals and physicians involved in the cases which must be precertified.
Since physicians can not precertify cases, it is extremely important that
the lines of communication between hospital staff responsible for
precertification and physicians remain open.
Some situations involving physician billing which have caused confusion
follow.
1
For a precertified case, only dates of service which are precertified are
payable by Louisiana Medicaid. Many physicians seem to be under the impression that their
services are payable even if the dates of service are outside the precertified
dates. This is incorrect.
Neither the hospital nor the physician services are payable if they fall
outside the precertified dates of service.
2
In cases where a hospital submits a precertification request which is
denied because it does not meet precertification criteria for medical necessity,
neither the hospital nor the physician services are payable.
3
In cases where a hospital chooses not to precertify a case, the physician
can get services paid only if the claims, along with an admit and discharge
summary and a letter requesting a precertification override, are submitted to
Unisys Provider Relations Correspondence Unit, P. O. Box 91024, Baton Rouge, LA
70821. These claims must
be reviewed for medical necessity and special handled for processing
4
Precertification of newborns needs clarification.
Initially only the mother is precertified for the delivery.
An initial precert of 2 days is given for a vaginal delivery and 3 days
for a C-Section. If the mother and
baby are well and both go home together within the 2 or 3 day timeframe,
respectively, it is not necessary to obtain a precert for the baby.
The hospital bills mother and baby charges under the mother's Medicaid
recipient ID number with the mother's precert case number.
The physician should bill newborn procedure codes and a discharge and
will be paid accordingly without a precert for the baby.
If the mother is sick and must stay in the hospital beyond the initial 2 or 3
days precertified, the hospital should submit an extension request under the
mother's precert case number for the mother's stay. If the baby is well, the baby will not meet precert criteria,
and Medicaid will not pay for any services (hospital or physician) if the baby
is kept in the hospital with the mother. (The
baby is only covered under the mother's precert for the first 2 or 3 days,
respectively.) Charges for the baby
should not be rolled into the mother's hospital charges for any days over the
initial 2 or 3 days approved.
If the baby is transferred to NICU at any time during the stay (from birth
forward), the hospital should request a precert in the baby's name and Medicaid
number. The admit date is the date
of birth or the day on which the baby was transferred to NICU.
The baby must meet the NICU criteria established in order for a precert
to be approved. Physicians should bill appropriate inpatient codes for
services as well as hospital discharge codes to the baby, and claims should pay
under the baby's precert number. If
the baby does not meet the NICU criteria, AND the "admit" date is
within the 2 or 3 days approved for the mother, AND the mother has not been
discharged, no precert is approved and the baby's stay continues to be covered
with the mother through the 2 or 3 days initially approved.
Whether the hospital has an NICU or only a general nursery, if the mother is
discharged before or after the respective 2 or 3 day period, and the baby is sick
and stays in the hospital longer than the mother, the hospital must get a
precert in the baby's name and number. The
baby's admit date is the mother's discharge date.
Again, physicians should bill appropriate inpatient codes as well as the
hospital discharge code, which should pay under the baby's precert number.
Whether the hospital has an NICU or only a general nursery, if the mother is
sick AND the baby is sick AND both must stay longer than the 2 or 3 days
approved for vaginal or C-Section, respectively, the hospital must request an
extension under the mother's precert for the mother's stay AND must also get a
precert in the baby's name and number. The
baby's admit date is the day he becomes sick following the 2 or 3 days initially
approved.
In some cases while the mother is still inpatient and within the initial 2 or 3
days approved, the baby is not admitted to NICU but requires services over and
above newborn care. In these cases,
no precert is required for the baby; however, for the physician to bill and be
paid for inpatient services other than newborn care, the claims, along with
appropriate documentation substantiating the medical necessity for these
services and a letter requesting a precert override, must be submitted to the
Unisys Provider Relations Correspondence Unit. The documentation will be reviewed for medical necessity and
the claims special handled for processing. Services over and above newborn care should not be billed
unless medically necessary.
5
Finally, physicians and hospitals must be aware of whether a patient is
inpatient or outpatient. We have
encountered numerous cases where physicians are billing for inpatient services
where no precertification was obtained. A review of the case reveals that the hospital has billed an
outpatient claim for the date(s) of service in question.
Obviously, this is a problem which must be corrected, and all parties
must agree on the patient's status PRIOR TO BILLING MEDICAID for services
rendered. Requests for further
clarification of these policies may be directed to Unisys Precertification at
(800) 877-0666 or Provider Relations at (800) 473-2783.
Louisiana Drug
Utilization Review (LADUR) Education
A Review of
Current Antiretroviral Therapy for Treatment of Human Immunodeficiency Virus
(HIV) Infection:
Part 1
By Nancy M. Toedter, Pharm.D. Assistant
Professor of Clinical Pharmacy Northeast Louisiana University School of Pharmacy
Issues . . .
-
Several
antiretroviral agents with different mechanisms of action are available for
treatment of HIV infection.
-
Since combination
therapy is more effective than monotherapy in delaying disease progression or
death, patients are taking multiple antiretroviral medications.
-
There is a great potential for serious
drug interactions, overlapping toxicities, and difficult dosing schedules
associated with those antiretroviral agents.
Acquired immunodeficiency syndrome (AIDS) was first
described in the United States in 1981. Now
it is the leading cause of death among males aged 25 to 44 years.
As of December 1996, more than 562,000 cumulative AIDS cases have been
reported in the United States and this number continues to increase.
Louisiana is not immune to AIDS. As
of April 1997, 9,471 cumulative AIDS cases and 5,179 cumulative HIV (non-AIDS)
cases have been reported in Louisiana.1
In 1987, the first antiretroviral agent for treating HIV
infection was approved by the Food and Drug Administration (FDA).
Over the past ten years, several more antiretroviral agents have emerged,
and now eleven drugs are approved for treating HIV infection.
Important advances have recently been made in understanding
drug therapy for the clinical management of HIV infection.
Most notable has been zidovudine monotherapy, which was considered the
standard of care several years ago and is now considered suboptimal because
combination therapy with two or more drugs is proven to be more effective in
reducing mortality and disease progression.
However, combination regimens pose a challenge to both patients and
health professionals as the potential exists for additive toxicities, drug
interactions, and difficult dosing schedules.
This article review currently approved agents for treating HIV infection
because a better understanding of current antiretroviral therapy will allow more
optimal patient care.
HIV Replication Cycle
The complex replication cycle of HIV will be reviewed because understanding
this life cycle will reveal unique points of drug attack, which result in
selective inhibition of HIV replication. There
are several potential targets which may interrupt viral replication, but
currently available drugs are targeting only two stages of the cycle -
inhibition of reverse transcriptase and inhibition of protease enzymes.
There are basically four stages in the life cycle of HIV.
1
Binding and Entry: HIV
binds to CD4 receptors located on T-lymphocytes and is then internalized by
fusion into the host cell.
2
Reverse Transcription: After internalization, the HIV virion is uncoated, yielding
viral genomic RNA. Reverse
transcriptase (RT), an enzyme located in the core of the virion, then uses the
viral RNA to form a single-stranded DNA. RT
is specific to retroviruses and is thus a primary target for antiretroviral
agents, such as zidovudine and didanosine.
Single-stranded DNA is duplicated, forming double-stranded DNA (proviral
DNA), which then migrates into the nucleus and becomes integrated with the
host-cell genome.
3
Transcription and Translation: The
proviral DNA is transcribed into messenger RNA and then translated into viral
proteins. Following translation,
HIV protese further modifies the large precursor polyproteins into smaller
functional proteins. The protease
enzyme is another target for antiretroviral drugs, such as indinavir and
ritonavir. Inhibition of HIV
protease leads to the production of non-infectious immature HIV particles.
4
Assembly and Release: After
the viral proteins are assembled in the cytoplasm, the virus buds from the cell
surface and infects other CD4+ cells.2-4
Nucleoside Reverse Transcriptinase Inhibitors (NRTIs)
NRTIs were the first class of agents approved for treating HIV infection.
They work early in the replication cycle of the virus by inhibiting the
reverse transcriptase enzyme. By
blocking the initial phase of viral replication, these agents prevent infection
of new cells but do not affect chronically infected cells (cells where the HIV
genomes are already integrated into the host genome).4, 5
These agents are nucleoside analogues and require
conversion to their active triphosphate forms by cellular kinases in order to
exert their effect. As
triphosphates, they compete in binding to HIV reverse transcriptase with the
natural substrates required for viral DNA synthesis.
They also act as chain terminators when incorporated into a growing viral
DNA strand.4,6
Currently, there are five NRTIs approved for treating HIV
infection. Although they have
similar mechanisms of action, they differ in their dosing instructions and
toxicity profiles. Retail prices
for these NRTIs usually average approximately $200-$300 per month. A brief review of these NRTSs follows.
Zidovudine
Zidovudine was the first drug approved by the FDA to treat HIV infection.
Although zidovuine can be used as monotherapy, combination regimens have
been shown to be superior in delaying disease progression or death, and
zidovudine monotherapy is thus no longer recommended.6,7
Most initial antiretroviral combination regimens contain zidovudine,
partly because of its possible role in preventing AIDS dementia complex.3
Patients usually stay on this drug until resistance develops, resulting
in disease progression, or until toxicities occur, and they can no longer
tolerate the drug.
The current recommended dose of zidovudine for treating HIV
infection is 600 mg per day in divided doses.
Zidovudine is usually dosed as 200 mg three times daily (using 100 mg
capsules) or as 300 mg twice daily (using 300 mg tablets).
The latter dose can help simplify medication regimens and improve patient
compliance. The effect of food on
zidovudine absorption has not been fully determined, so if possible, the drug
should be taken on an empty stomach.9
Although zidovudine can cause adverse reactions such as
headache, insomnia, nausea, vomiting, abdominal discomfort, and malaise, the
dose-limiting toxicities include anemia and neutropenia.
The use of epoetin alfa or granulocyte colonystimulating factor may help
control the zidovudine-induced bone marrow suppression.
Complete blood counts with differentials should be monitored regularly.
Avoid concurrent use of zidovudine with ganciclovir, a drug used for
treating cytomegalovirus disease, as this combination frequently results in
severe nuetropenia.4, 6
Studies have shown the zidovudine has a limited duration of
effectiveness. Resistance to its
antiviral action usually develops after 18-24 months of treatment. Zidovudine
resistance tends to develop more rapidly in patients with advanced HIV infection
than in those with early infection. Switching
to another antiretroviral agent, such as didanosine, zalcitabine, or combination
therapy may be warranted when HIV disease progresses.5, 10
Didanosine
Didanosine was the second drug approved for treatment of HIV infection.
It may be used as monotherapy or in combination regimens with other
antiretroviral agents. Didanosine
is rapidly degraded by gastrid acid, so all oral formulations contain buffering
agents (antacids). Administration
with food can decrease absorption, so the drug should be taken on an empty
stomach. Because of the buffering
component, didanosine may interfere with the absorption of other drugs,
including dapsone, ketoconazole, itraconazole, tetracycline, or quinolones.
Separate the administration of these agents from didanosine by at least
two hours.4, 6
Didanosine is available as chewable/dispersible buffered
tablets and as a buffered powder for oral solution. Since the tablets are used more frequently, dosing and
administration for this formulation will only be discussed.
Dosing is based on patient weight. For
patients weighing 60 kg or more, the didanosine dose is 200 mg every 12 hours;
for those weighing less than 60 kg, it is dosed at 125 mg every 12 hours.
The tablets should be thoroughly chewed or dispersed in water before
swallowing. Patients should not
swallow the tablets whole.11 Didanosine
tablets have been recently reformulated such that they are smaller and easier to
chew and also disperse in water more rapidly.
In contract to zidovudine, didanosine does not cause
significant hematologic effects. The
major dose-limited toxicities of didanosine are peripheral neuropathy and
pancreatitis. Serum amylase and
lipase levels should be monitored.4, 6
Because of the nonoverlapping toxicities, didanosine is frequently used
in combination with zidovudine.
Zalcitabine
Zalcitabine is most frequently used in combination regimens with zidovudine
and/or protease inhibitors. It may
also be used as monotherapy; however, this practice is generally associated with
poorer outcomes and is not recommended as initial antiretroviral therapy in
patients who have not received and previous drugs for treatment of HIV infection
(treatment-na�ve patients). Thus,
zalcitabine monotherapy is generally only indicated in patients who are
intolerant to or who have had disease progression while receiving alternative
anti-retroviral agents.7, 11
Zalcitabine is dosed as 0.75 mg every 8 hours.
Food may affect absorption of zalcitabine, so if possible, it should be
taken on an empty stomach. The
major dose-limiting toxicity of zalcitabine is peripheral neuropathy involving
predominantly the lower extremities. Other
less severe reactions include fever, rash, and aphthous oral ulcerations, and
these adverse effects often subside with continued therapy.
Rare cases of pancreatitis have been associated with zalcitabine.2,
4, 6 Because of overlapping
toxicities, including peripheral neuropathy and pancreatitis, it is not
recommended that zalcitabine be given concurrently with didanosine.
Stavudine
Stavudine is currently approved for management of HIV infection in patients
who are intolerant of other anti-retroviral drugs or who have had disease
progression while taking these drugs. It
may be used as monotherapy or in combination with didanosine or lamivudine.
These combination regimens (stavudine + didanosine and stavudine +
limivudine) are being evaluated as alternative initial antiretroviral therapies
in treatment-na�ve patients.6, 7, 11 The combination of stavudine and zidovudine may be
antagonistic and may result in a decrease in CD4+ cell counts, possibly due to
overlapping intracellular phosphorylation pathways.8
Stavudine is dosed based on patient weight.
For patients weighing 60kg or more, the recommended starting dose is 40
mg every 12 hours; for those weighing less than 60 kg, it is dosed 30 mg every
12 hours. Stavudine may be taken
without regard to meals.
Similar to didanosine and zalcitabine, the principal
dose-limited toxicity of stavudine is peripheral neuropathy.
When stavudine is used in combination with didanosine, one should monitor
for neurotoxicity, especially in patients with more advanced disease.
Other adverse effects of stavudine include elevation of hepatic
transaminases, headache, nausea and vomiting, and in rare cases, pacreatitis.
2, 4
Lamivudine
Lamivudine is the most recent nucleoside reverse transciptase inhibitor to
be approved. It is currently
indicated in combination with zidovudine for the treatment of HIV infection.
This combination of lamivudine and zidovudine is particularly potent and
may even be more effective than combinations of zidovudine with other nucleoside
analogues in reducing the risk of progression to AIDS or death. Furthermore, the addition of lamivudine to a zidovudine
regimen appears to delay the onset of zidovudine-resistant virus and may even
restore zidovudine sensitivity to viruses that are resistant to zidovudine.
Lamivudine monotherapy is not recommended because of the rapid
development of resistance. Lamivudine has also been used in combination with stavudine
as initial therapy in antiretroviral-na�ve patients. Triple combinations including lamivudine, zidovudine, and a
protease inhibitor may be even more powerful in delaying disease progression and
increasing survival than double combination therapy. 6, 12, 13
Lamivudine is available as an oral solution and as
film-coated tablets. Dosing is
based on patient weight and age. For
adults and adolescents (12-16 years) weighing 50 kg or more the dose is 150 mg
every 12 hours administered in combination with zidovudine. For those weighing less than 50 kg, the dose is 2 mg/kg every
12 hours, and for pediatric patients, it is dosed 4 mg/kg every 12 hours.
Lamivudine may be taken without regard to meals. 11
Lamivudine is well-tolerated when administered alone or in
combination with zidovudine. Adverse
effects of lamivudine include gastrointestinal irritation, headache, fatigue and
skin rash. 6
It should be noted that although some of the
antiretroviral agents are approved for use as monotherapy, combination regimes
that usually include two NRTIs and a protease inhibitor are more effective and
should be used. In fact,
monotherapy with any of the currently available antiretroviral agents is
generally not recommended.
See the October 1997 issue of the Provider Update
for Part II of the LADUR article. Non-Nucleoside
Reverse Transcriptinase Inhibitors and protease inhibitors will be discussed.
References
1.
State of Louisiana Office of Public Health HIV/AIDS Services.
2.
Fletcher CV, Collier AC. Principles and management of human
immunodeficiency virus infection. Pharmacotherapy: A Pathophysiolic Approach. 3rd Edition.
Stamford, CT: Appleton and Lange; 1997: 2353-2386
3.
Acosta EP, Fletcher CV. Agents for treating human immuno deficiency virus
infection. Am. J. Hosp. Pharm. 1994; 51: 2251-67.
4.
Sande MA, Volberding PA, eds. The Medical Management of AIDS. 4th
Edition. Philadelphia, PA: W.B. Saunders Company, 1995.
5.
Hirsch MS, D'Aquila RT. Therapy for human immunodeficiency virus
infection. New England Journal of Medicine. 1993: 328 (23): 1686-1695.
6.
Threlkeld SC, Hirsch MS. Antiretroviral therapy. Med. Clin. North Am.
1996: 80 (6): 1263-1282.
7.
Carpenter CCJ, Fischl MA, Hammer SM, et. Al. Antiretroviral therapy for
HIV infection in 1996. JAMA. 1996: 276 (2): 146-54.
8.
BHIVA Guidelines Co-ordinating Committee. British HIV association
guidelines for antiretroviral treatment of HIV seropositive individuals. Lancet.
1997: 349: 1086-92.
9.
Glaxo Wellcome. Package Literature for Retrovir. September 1996.
10.
Graham NMH, Hoover DR, Park LP, et al. Survival in HIV-infected patients
who has received zidovudine: comparison of combination therapy with sequential
monotherapy and continued zidovudine monotherapy. Am. Intern. Med. 1996-:
124: 1031-38.
11.
McEvoy GK, ed. AHFS Drug Information '97. Bethesda, MD: American
Society of Health-System Pharmacists, Inc. 1997.
12.
CAESAR Coordinating Committee. Randomised trial of addition of lamivudine
or lamivudine plus loviride to zidovudine-containing regimens for patients with
HIV-1 infection: the CAESAR trial. Lancet. 1997: 349: 1413-21.
13.
Glaxo Wellcome. Package Literature for Epivir. September 1996.
14.
Rozane Laboratories. Package Literature for Viramune. June 1996.
15.
Pharmacia & Upjohn. Package Literature for Rescriptor. April 1997.
16.
Sperling J., Jennings TS. Formulary considerations for selection of
protease inhibitors. P & T. 1997: 22 (5): 145-53.
17.
Deeks SG, Smith M. Holodiniy, et. al. HIV-1 protease inhibitors: a review
for clinicians. JAMA, 1997: 277 (2): 145-53.
18.
Roche Laboratories. Package Literature for Invirase. January 1997.
19.
Merch & Co. Package Literature for Crixivan. March 1996.
20.
Agouron Pharmaceuticals. Package Literature for Viracept. March 1997.
21.
More new drugs for HIV and associated infections. The Medical Letter
on Drugs and Therapeutics. 1997: 39 (issue 994): 14-16.
Policy Notes:
Physician Providers
Notice to Physicians Billing for Newborn Care and Discharge
Physician providers billing for newborn care should use
code 99431 (History and examination of normal newborn infant, initiation of
diagnostic and treatment programs, and preparation of hospital records) for the
examination rendered on the date of birth.
This code should also be used to bill for birthing room deliveries.
Code 99431 is limited to one per lifetime.
Procedure code 99433 (Subsequent hospital care, each day;
newborn services) should be billed for each day of normal newborn care
subsequent to the date of birth. Code
99433 is limited to 3 per lifetime.
If discharge services are provided on the date of
discharge, code 99238 (Hospital discharge day management) should be billed, not
code 99433. Please be sure you are
billing appropriately for these services.
Notice to
Physician Providers: New Error Edit
#110
Some physicians are using code 58120 (nonobstetrical
dilation and curettage) to bill for a D&C after a miscarriage or an
abortion. The use of code 58120 in
either of these two situations is inappropriate. Use one of the following codes instead: 59160, 59812, 59820, or 59821.
A new error edit has been implemented to advise providers
they are billing incorrectly. New
error edit 110 reads, "Rebill OB or abortion D&C code with
reports."
Policy Notes:
DME Providers
Attention All Nursing Homes (ICF, I, II, and SNF) and All DME Providers:
Coverage of Nebulizers, Suction Machines, and Suction Catheters for
Nursing Home Residents
Nebulizers and suction machines are standard nursing care
equipment that nursing facilities are expected to provide for their Medicaid
recipients under the Long Term Care Standards For Payments for nursing homes (ICF,
I & II and SNF). The Medicaid
DME Program will provide these only for technology dependent recipients
(ventilator and tracheostomy patients) who reside in a nursing facility.
Accessories and supplies for use with these machines are
expected to be furnished by the nursing facility, since we do not furnish the
machines to their residents unless they are technology dependent.
Medicaid DME can only consider covered accessories and supplies for the
technology dependent recipients in these facilities.
Suction catheters should also be considered for prior
authorization only for tracheostomy or ventilator dependent recipients in
nursing facilities. The nursing
homes are responsible for all other catheters, except indwelling catheters and
catheter trays, for their residents under the Standards For Payment.
In response to a question received from a nursing facility
about Medicaid coverage of accessories and supplies for a nebulizer or suction
machine that had previously been provided by Medicaid, in error, for a recipient
in their facility (a non-technology dependent recipient), Medicaid is under no
obligation to continue to furnish any accessories or supplies for use with these
machines for these recipients. We
can only cover accessories and supplies for use with equipment for which a
Medicaid recipient would qualify under Medicaid DME criteria.
Policy Notes:
DME Providers
Notice to DME Providers
All DME providers need to note that BHSF has changed the
effective date of discontinuance for the discontinued codes listed in the
memorandum mailed to all DME providers in April of this year, and in the June
Provider Update newsletter. The
effective date of 07/01/97 is being changed to an effective date of 12/01/97.
This will allow additional time for the claims processing of previous
prior authorizations given for these codes with dates of services beyond
07/01/97.
It will not be necessary for providers to submit
corrections to prior authorizations received with any of the discontinued codes
so long as the prior authorization dates of service do not go beyond 12/01/97.
This will only be necessary if the dates of service on the existing prior
authorizations extend beyond 12/01/97. Any
future prior authorization requests must be submitted using the new replacement
codes which are now payable on the system with an effective date of 01/01/97.
Policy Notes:
Providers
Notice to Providers Concerning Medicare HMO Claims
Providers should continue to hold crossover claims for
Medicare HMO recipients until a payment mechanism is put in place.
However, we would like to remind providers that recipients must use the
services of the HMO which they freely choose to join.
If you are not a member of the Medicare HMO provider network and the
Medicare HMO denies the services because the recipient sought medical care
outside of the HMO network and without the HMO's authorization, these claims are
not payable by Medicaid. Please do
not hold these claims to submit to Medicaid for consideration as they will be
denied.
Criteria for
CPT Codes 96115 and 96117
Recently you were notified that the number of
neurobehavioral and neuropsychological testing procedures (CPT codes 6115 and
96117) a recipient can have without review are limited to one per recipient per
year. The 2nd and
subsequent billings must have supporting documentation attached. Listed below is the documentation required.
96115 - An interpretive report signed by a medical doctor
(M.D.), a doctor of Neuropsychology (Ph.D.), or a doctor of Clinical Psychology
(Ph.D.).
96117 - An interpretive report signed by a doctor of
Neuropsychology (Ph.D.).
A report signed by someone other than the M.D. or the Ph.D.
or failure to submit documentation will result in denial of the claim.
Notice to
Providers of Lab Services
Effective with date of service July 1, 1997, fees for
certain laboratory codes have been reduced in order to bring Medicaid
reimbursement amounts for those codes in line with those being paid to Medicare.
Notice to All
Providers
Please do NOT refer recipients to the Provider Relations
Inquiry Unit telephones. If
recipients have questions, please refer them to their parish case workers.
Thank you.
Codes Payable
to Certified Nurse Midwives
Effective with dates of service July 1, 1997, additional
codes have been added to the list of codes reimbursable to Certified Nurse
Midwives.
The following is a list of all codes reimbursable to
Certified Nurse Midwives. This list
includes the codes payable prior to 07/01/97 as well as those made payable as of
07/01/97.
The codes that were made payable effective July 1, 1997,
are indicated with an asterisk (*).
Certified Nurse
Midwife Codes
*J1005
Z9004
Z9005
Z9006
11975
11976
11977
*53670
*56501
57061
57170
*57452
57454
*57505
*57511
*58100
58300
58301
*58999
59020
59025
59050
59300
59410
59414
*59610
*59612
*59614
76805
76810
76815
76816
76818
80002
80003
80004
80005
80006
80007
80008
80009
|
80010
80011
80012
80016
80018
80019
*80050
*80055
*80058
*80059
*80061
*80091
*80092
80439
80440
81000
81002
81005
81007
81015
81025
*82105
*82270
82465
*82670
82947
82962
83001
83002
83020
83718
83719
83721
*84144
*84146
*84403
84443
84702
84703
85013
85014
|
85018
*85022
85023
85024
85025
85031
*85590
*85660
*86287
86302
86311
86317
86403
86430
86431
86580
*86585
*86588
86592
86663
86664
86665
86674
86687
86688
86689
86694
86695
86701
86702
86762
86777
86778
86781
86787
86850
86900
86901
87070
87072
*87081
|
*87082
87086
87087
87088
87110
87164
87178
*87206
87210
87211
*87353
90718
*90742
*90782
99201
99202
99203
99205
99211
99212
99213
99214
99215
99218
99219
99220
*99221
99231
*99232
99238
*99239
*99241
*99242
*99243
*99251
*99252
*99253
*99261
*99262
99281
99282
|
99283
99341
99342
99343
99351
99352
99353
*99381
*99384
*99385
*99391
*99394
*99395
99431
99432
99433
99440
|
�
codes added effective 7-1-97.
Notice to Rural
Health Clinics and FQHCs
Due to numerous questions that Program Operations has
received regarding billing for Rural Health Clinics (RHC) and FQHCs, DHH is
issuing the following clarifications to providers. (All the following references to RHCs pertain to FQHCs as
well.)
1.
Diagnostic procedure codes should not be billed as an encounter since
they are "incident to" services.
2.
A Physician Assistant (PA) must have direct supervision at all times by
an on-site RHC employed physician regardless of where service occurs (i.e., if
the P.A. goes to a nursing home, the RHC physician must be with him/her at the
time the service is performed. If
services are provided at the RHC, the doctor must be on-site at the times of all
services performed by the P.A.).
3.
Do not bill an encounter and any type of evaluation and management office
visit on the same date.
4.
KIDMED screenings should not be billed as an encounter.
5.
All surgical procedures should be billed fee for services under
individual (non-RHC) provider numbers using CPT procedure codes.
Do not bill an encounter for these services.
6.
You may bill for global (technical and professional) x-ray services only
if the RHC owns the equipment that is located on-site at the clinic.
An encounter code cannot be billed to read an x-ray (professional
component). Medicaid does not cover the technical component as a separate
service.
7.
Allergy testing may be billed fee for service, but allergy injections are
"incident to" services and no encounter shall be billed for either
service.
8.
"Incident to" services include the following:
EKGs, Peek Flow, Spirometry Respiratory Flow Volume Loop, and injections.
9.
You may not share RHC space with other entities.
For further classification of licensure issues, please contact Health
Standards at 504/342-0148.
10.
Each RHC location must be certified and have its own provider number.
11.
You may not charge any person/entity (private pay patients, HMOs) less
than you charge Medicare for the same services.
Questions may be submitted in writing to DHH Program
Operations, ATTN: Janith Miller, P.
O. Box 91030, Baton Rouge, LA 70821-9030
Outpatient
Hospital Services Clinic Services
Physician services provided in a clinical setting on an
outpatient hospital basis are covered as outpatient physician visits and should
be billed as physician services on the physician claim form (HCFA - 1500), not
as outpatient hospital services. The
facility fee for clinic services may not be billed as a separate charge by the
hospital. Hospital clinic visits
are counted as part of the 12 annual physician office visits allowed.
Refer to page 5-3 of the Hospital Services Manual.
Revenue codes 511, 512, 519, and 520, which are associated with revenue
code 510, are being placed in the non-payable status effective DOS 5-1-95 since
we notified providers of the non-payment status of the group of revenue codes
starting with 510.
Prior
Authorization Request for Transplant Procedure(s)
In 1996, the Louisiana Department of Health and Hospitals (DHH)
Medicaid Transplant Ad Hoc Committee was formed to review Medicaid policy and
guidelines for transplant procedures. The
Prior Authorization Request for Transplant Procedure(s) form was designed by the
committee to assist Unisys Prior Authorization Department and the physicians
consulting on these procedures in their review process.
The transplant form is to be used by all Transplant
Coordinators when requesting approval for transplant procedures.
After receiving the new form, please complete each item and attach
supporting documentation to warrant medical necessity; then, please mail the
form to the Prior Authorization Department at Unisys.
Thank you, in advance, for your cooperation.
Notice to
Orthopedic Surgeons
The Bureau of Health Services Financing is pleased to
announce a fee increase for the following arthroscopy procedures, effective with
date of service July 1, 1997.
Code
Fee
29875
$452.12
29877
$516.80
29880
$611.36
29881
$543.58
29888
$966.35
Changes in
Medically Needy Program
Effective August 1, 1997, the Department of Health and
Hospitals will no longer pay for the following services through its
Medically Needy Program: dental
services or dentures, chiropractic, optometry, podiatry, alcohol and substance
abuse clinic, mental health clinic, home and community based waiver services (HCBS),
home health (nurse aide and physical therapy), case management, mental health
rehabilitation, psychiatric inpatient hospital for persons under age 22,
audiology, sexually transmitted disease (STD) and tuberculosis clinics.
Other covered Medicaid services are not affected.
Medically Needy Recipients are identified by the
notation of Type Case 20, 21, 25, or 34 on the Medicaid Eligibility card.
RECIPIENTS ELIGIBLE THROUGH PROGRAMS OTHER THAN THE MEDICALLY NEEDY
PROGRAM ARE NOT AFFECTED. Recipients
with questions should be advised to direct inquiries to BHSF Eligibility
Operations Section at 1-888-342-6207. Providers
with inquiries should call Unisys Provider Relations at 1-800-473-2783 or (504)
924-5040.
Notice to
Physician-Owned Laboratories
Effective 01/01/98, claims on Medicaid-only recipients with
procedure codes for laboratory services covered by a CLIA certificate (all
laboratories including physician-owned) will be denied if their CLIA certificate
numbers are not on file. Current
CLIA certificates with current CLIA period of eligibility may be FAXED to the
Provider Enrollment Unit at (504) 342-3893.
The FAX cover sheet must include the provider number(s) to which the
certificate(s) applies.
1997 Unisys
Provider Workshops Schedule
Location
|
Day 1
|
Day 2
|
Day 3
|
|
|
|
|
Alexandria
Holiday Inn
Convention Center
Alexandria, LA
318/442-9000
|
October 15
8:30 - 9:45 -
Dental
10:00 - 11:00
- Case Mgmt.
11:15 - 12:15
- RHC/FQHC
1:45 - 2:45 -
MH Rehab
3:00 - 4:15 -
LTC
4:30 - 5:30 -
EPSDT
6:00 - 7:00 -
Pharmacy
|
October 16
8:00 - 12:00
- Professional
1:30 - 4:45 -
Hospital
5:00 - 6:00 -
Transportation
|
October 17
8:30 - 9:30 -
HH/Rehab
9:45 - 11:00
- DME
|
|
|
|
|
Baton Rouge
Stage One
13465 S. Harrells Ferry
Rd.
Baton Rouge, LA
504/951-2417
|
September
30
8:00 - 12:00
- Professional
1:30 - 4:45 -
Hospital
5:00 - 6:00 -
Transportation
6:15 - 7:15 -
Pharmacy
|
October 1
8:30 - 9:30 -
HH/Rehab
9:45 - 11:00
- DME
11;15 - 12:30
- LTC
1:45 - 3:00 -
Dental
3:15 - 4:15 -
Mental Health Rehab
4:30 - 5:30 -
EPSDT
|
|
|
|
|
|
Covington
Holiday Inn
501 N. Highway 190
Covington, LA
504/893-3580
|
October 2
8:30 - 12:30
- Professional
|
|
|
|
|
|
|
Lafayette
Hotel Acadiana
1801 W. Pinhook
Lafayette, LA
318/233-8120
|
October 6
8:00 - 12:00
- Professional
1:30 - 4:45 -
Hospital
5:00 - 6:00 -
Transportation
|
October 7
8:30 - 9:45 -
LTC
10:00 - 11:15
- Dental
11:30 - 12:30
- RHC/FQHC
1:45 - 2:45 -
HH/Rehab
3:00 - 4:15 -
DME
|
|
|
|
|
|
Lake Charles
Holiday Inn
505 N. Lakeshore Drive
Lake Charles, LA
318/433-1645
|
October 13
8:00 - 12:00
- Professional
1:30 - 4:45 -
Hospital
5:00 - 6:00 -
Transportation
|
October 14
8:30 - 9:30 -
HH/Rehab
9:45 - 11:00
- DME
11;15 - 12:30
- LTC
1:45 - 3:00 -
Dental
|
|
|
|
|
|
Monroe
Holiday Inn Holidome
Monroe, LA
318/387-5100
|
October 28
8:30 - 9:45 -
LTC
10:00 - 11:15
- Dental
11:30 - 12:30
- RHC/FQHC
1:45 - 2:45 -
HH/Rehab
3:00 - 4:15 -
DME
5:00 - 6:00 -
Transportation
|
October 29
8:00 - 12:00
- Professional
1:30 - 4:45 -
Hospital
|
|
|
|
|
|
New Orleans
Ponchartrain Center
New Orleans, LA
504/465-9985
|
November 5
8:00 - 12:00
- Professional
1:30 - 4:45 -
Hospital
5:00 - 6:00 -
Transportation
|
November 6
8:30 - 9:30 -
HH/Rehab
9:45 - 11:00
- DME
11:15 - 12:30
- LTC
1:45 - 3:00 -
Dental
|
|
|
|
|
|
Shreveport
Holiday Inn
Financial Center
5555 Financial Plaza
Shreveport, LA
318/688-1877
|
October 22
8:00 - 12:00
- Professional
1:30 - 4:45 -
Hospital
5:00 - 6:00 -
Transportation
|
October 23
8:30 - 9:45 -
LTC
10:00 - 11:00
- RHC/FQHC
12:30 - 1:30
- HH/Rehab
1:45 - 3:00 -
DME
3:15 - 4:30 -
Dental
|
|
1997 Unisys
Provider Workshops
This is the schedule for the 1997 Unisys Provider
Workshops. These workshops are
designed to be an overview of the different Medicaid Programs with an emphasis
on billing policies and procedures, as well as any recently related changes.
Due to space limitations, only personnel involved in billing should be in
attendance with the exception of the Hospital Workshop.
For the Hospital Workshop ONLY, personnel from the Utilization Review
Department and those involved in precertification for inpatient admissions
should attend. Portions of this
workshop will be specifically for precertification information. Please limit the number of personnel to attend to three (3)
per provider. Also, be sure to have
your Medicaid Provider I.D. number and Name with you for registration.
You are required to have a valid Medicaid Provider I.D. number for the
workshop you plan to attend. Please
arrive 15-20 minutes early to register.
Medicaid Programs for discussion at the workshop include:
1.
Professional: Physicians,
Labs, Optometrists, Chiropractors, ASC, Optical Suppliers, Nurse Practitioners,
Audiologists, Nurse Midwives, CRNAs, Hemodialysis (supervision ONLY), Mental
Health Clinics, and Substance Abuse Clinics.
2.
Hospital: Acute, Rehab,
Long Term, Free-standing Psych, Distinct Part Psych, and Hemodialysis (facility
billing). Please have staff from
billing (at least one manager/supervisor) and Utilization Review attend.
3.
Long Term Care: Nursing
and ICF/MR Facilities and Hospice Services.
4.
Case Management Agencies: (does not include Hospital Case Managers).
5.
Mental Health Rehabilitation Agencies.
Held in Alexandria and Baton Rouge ONLY.
6.
Home Health Agencies/Rehab Centers (Home Health providers who are
also DME providers should attend both the Home Health and DME Sessions).
7.
DME Suppliers.
8.
Dental: EPSDT and Adult
and Oral Surgery.
9.
Transportation: Ambulance
and Non-ambulance.
10.
EPSDT: PCS and Health
Services (school boards, Early Intervention Centers, and PCA providers should
attend). Held in Alexandria and
Baton Rouge ONLY.
11.
Pharmacy. Held in Alexandria
and Baton Rouge ONLY.
12.
FQHC and Rural Health Centers. Held
in Alexandria, Lafayette, Monroe, and Shreveport ONLY.
Due to the ongoing changes in the Waiver Program,
training will not be offered for this program at this time.
Please refer to the following list for dates (Day 1 and Day
2) and times at each workshop location. There
is no pre-registration required. Please
direct any questions concerning the workshops to Unisys Provider Relations at
800/473-2783 or 504/924/5040. Meeting sites should be contacted for directions or sleeping
accommodations ONLY!