Precertification Clarification LADUR Education Article
Notice to Physicians Billing for Newborn Care and Discharge New Error Edit #110
Coverage of Nebulizers, Suction Machines, and Suction Catheters for Nursing Home Residents Notice to DME Providers
Notice to Providers Concerning Medicare HMO Claims Criteria for CPT Codes 96115 and 96117
Notice to Providers of Lab Services Notice to All Providers
Codes Payable to Certified Nurse Midwives Notice to Rural Health Clinics and FQHCs
Outpatient Hospital Services Clinic Services  1997 Unisys Provider Workshops Schedule
Prior Authorization Request for Transplant Procedure(s) Notice to Orthopedic Surgeons
Changes in Medically Needy Program Notice to Physician Owned Laboratories

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 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 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 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 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 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.


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






















































































































































































                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



Day 1

Day 2

Day 3






Holiday Inn

Convention Center

Alexandria, LA


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


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








Holiday Inn

501 N. Highway 190

Covington, LA


October 2

8:30 - 12:30 - Professional








Hotel Acadiana

1801 W. Pinhook

Lafayette, LA


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


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







Holiday Inn Holidome

Monroe, LA


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


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







Holiday Inn

Financial Center

5555 Financial Plaza

Shreveport, LA


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!