Provider Update

Volume 15, Issue 4

August 1998

Clarification of ID Card/MEVS Issues 1998 CPT Codes and Fees
Funding for CPT 54322 Error Edit 619
New Policies on Cochlear Implants System Changes for 1998 Lab Panels
Removal of Codes New CPT Codes: Antigen Testing
Reimbursement of Cesarean Assistance New Fees for Lab Codes
Reminder to Providers of Maternity-Related Anesthesia Notice to Providers of Corneal Transplants and Tissue
Hospital Admission Process Hospital Providers: Reminder Billing for Organ Transplants
Funding of Paragard Funding of CPT 76870
Fee Increase for Rhogam Investigational Codes Placed in Nonpay Status
Dates of Service for CustomWheelchairs Payment Rate for Orthopedic Shoes and Corrections
Urological Supplies for Nursing Home Residents Office/Outpatient  CPT Codes
New Codes for Mickey Gastronomy Tube LADUR Education Article
Adjustment of Reimbursement Rate for Forearm Crutches  


Clarification of ID Card/MEVS Issues

New, permanent plastic ID cards have now been issued for Regions V (Lake Charles), III (Thibodaux), II (Baton Rouge), IV (Lafayette), and Region VI (Alexandria). As we continue the implementation of this new project, as well as the implementation of the Medicaid Eligibility Verification System (MEVS), several issues that require clarification have come to our attention:

1. All providers must continue to submit Medicaid claims using the 13-digit recipient ID number for the patient. The new 16-digit card control number (CCN) found on the plastic ID cards may not be used to submit claims, except for pharmacies submitting drug claims through the Pharmacy POS system. All other claims submitted with the 16-digit CCN will be returned to you for correction and resubmission, which will slow the processing of your claim.

2. Eligibility inquiries made through either the MEVS or REVS systems must be made using either the new CCN accompanied by an 8-digit DOB (MM/DD/YYYY) or a recipient ID number which was valid during the 12 months prior to the date of service. If an invalid DOB or a 6-digit DOB is used, eligibility information will not be returned. If a recipient ID number older than the 12-month required timeframe is used, eligibility information will not be returned. Please be sure you use correct and valid recipient information for eligibility inquiries.

3. All required dates entered into either the MEVS or REVS systems must be 8-digit dates (MM/DD/YYYY).The statewide provider seminars concerning the implementation of these projects are complete. If you failed to attend one of the seminars and would like a copy of the information presented, or more information on these projects, please contact Unisys Provider Relations Department at 800/473-2783 or 504/924-5040.

The three approved telecommunications vendors for the MEVS project are:

1. MediFAX: Contact Randy Bertrand, 800/444-4336, ext. 4545, or visit their web site at

2. Envoy: Contact Envoy Target Marketing Group, 800/366-5716, or visit their web site at

3. HealthNet Data Link: Contact Gary Stafford,800/486-7352, or visit their web site at

If you plan to install MEVS in your office/facility, please be sure you contact an approved vendor. Please continue to watch the Provider Update and RA messages for additional information on these important projects.

Funding for CPT 54322

The Bureau of Health Services Financing is pleased to announce that effective with date of service June 1, 1998, CPT code 54322 - One stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal advancement (e.g., Magpi, V-flap) - was made payable to assistant surgeons. The fee for the assistant surgeon is $123.51.

Removal of Codes from Global Surgery Edits

CPT codes 33518 - 33523 (coronary artery bypass procedures), 95115, 95117, and 95165 (allergen immunotherapy procedures) are being removed from the global surgery edits. Therefore, office visits may be billed in conjunction with these procedures. Codes 95115, 95117, and 95165 are included in Medicare�s global surgery policy; therefore, all crossover claims for these procedures will continue to be reimbursed according to Medicare policy.

New Policies on Cochlear Implants and Intrathecal Baclofen Therapy

The Bureau of Health Services Financing is planning to implement policies on Cochlear Implants and Intrathecal Baclofen Therapy in the near future. For the first time, hospitals which have multidisciplinary teams of professionals who are currently performing or plan to perform these procedures will be reimbursed directly by the Medicaid Program for the devices (cochlear implant device and ITB pump).

As special computer hardcoding must be accomplished before claims can be paid, we request hospitals notify the Physicians Program by September 15, 1998 of their intent to perform these procedures by calling Kandis McDaniel at 504-342-9490 or Celia Gascon at 504-342-8223. Notification of intent can also be FAXED to Kandis or Celia at 504-342-3893.

Reimbursement for Caesarean Assistance

The Bureau of Health Services Financing is pleased to announce reimbursement to certified nurse midwives (CNMs) for assisting at Caesarean deliveries effective with date of service July 1, 1998, provided the certified nurse midwife has been credentialed by her hospital, institution, or facility to serve in this capacity. Documentation of said competency must be available for review upon request. When billing for assisting at a Caesarean delivery, the modifier 80 should be attached to the appropriate CPT code. Therefore, procedure codes 59515-80 and 59620-80 were made payable to CNMs effective with date of service July 1, 1998.

A Reminder to Providers of Maternity-Related Anesthesia

1. If billing for maternity related anesthesia for Caesarean section, regardless of the type of anesthesia administered, bill code 59515, 59618, 59620, or 59622 with modifiers AA, AI, AE, 24, or 25. This anesthesia is paid on a flat fee basis, so no minutes are required. The appropriate diagnosis code is 799.9.

2. If billing for general anesthesia for a vaginal delivery, bill the delivery code 59410, 59610, 59612, or 59614 with the correct modifier (AA, AE, AI, 24, or 25) and with the minutes listed in the units column on the claim form. The appropriate diagnosis code is 799.9.

3. If billing for an epidural performed for a vaginal delivery (CPT code 59410, 59610, 50612, or 59614), bill procedure code 62279 with modifiers AA, AI, AE, 24, or 25. In addition to the correct modifier, any provider who uses procedure code 62279 for anesthesia for a vaginal delivery must also use the correct diagnosis code to ensure payment. Providers must use diagnosis code 650-659, 669.5, or 669.6. For diagnosis codes 669.5 or 669.6, only digits �0� and �1� should be in the fifth place. This procedure is paid on a flat fee basis, so no minutes are required.

4. If billing 00098 for reinjection of the epidural for tubal ligation during a hospital stay for vaginal delivery, providers are to use the same modifiers and diagnosis codes as are used for the epidural for vaginal delivery. As listed above, the modifiers are AA, AI, AE, 24, and 25. The diagnosis codes are 650-659, 669.5, or 669.6. For diagnosis codes 669.5 or 669.6, only digits �0� and �1� should be in the fifth place. The sterilization consent form 96 must be attached to the claim form. If the form 96 is not attached to the claim form, the claim will be denied. All claims must be submitted hard copy. Code 00098 is restricted to one per recipient per lifetime. This procedure is paid on a flat fee basis, so no minutes are required.

Hospital Admission Review Process (HARP)

This is a follow-up confirmation that the Hospital Admission Review Process (HARP) implemented by the Department of Health and Hospitals went into effect on July 1, 1998 for the New Orleans and Shreveport Regions. Trainings for providers were held in New Orleans on June 5, 1998, and in Shreveport on June 9, 1998.

As discussed in the trainings, this is an outreach program designed to enhance access to appropriate psychiatric services for Medicaid recipients under the age of 22. Admitting physicians are required to contact the Regional Office of Mental Health to provide notification of psychiatric hospital admission of children under the age of 22. The procedure consists of the following:

1. On-site visits will be made to review recipients� medical charts.

2. A face-to-face interview will be conducted with recipient, family and/or treating physicians.

3. Level of need and the availability of community resources will be evaluated and findings shared with the treating physician.The toll-free phone numbers for the Regional Offices of Mental Health are: New Orleans Region: 877-744-0442 Shreveport Region: 877-744-0441.

Funding of Paragard

The Bureau of Health Services Financing is pleased to announce the funding of Paragard (intrauterine copper contraceptive), effective with date of service June 1, 1998. The code to bill for Paragard is X0516. The fee is $262.60, which includes a $35.00 insertion fee. Paragard is restricted to one every 7 years for females between the ages of 10 and 60.

Fee Increase for Rhogam

The Bureau of Health Services Financing is pleased to announce a fee increase for Rhogam Injections, CPT code 90742. The increased fee is $72.72 per injection, effective with date of service June 1, 1998.

Dates of Service for Custom Wheelchairs and Other DME

Many requests for prior authorization of customized wheelchairs are being submitted to Unisys Prior Authorization Unit with past dates entered on the Form PA01 as the dates of service.

Often providers are using the date of evaluation or the date of prescription as the date of service for these requests. Please note, that this is not correct. Using these past dates as the dates of service is often causing claims for payment to exceed the timely filing limits when they are later submitted to Unisys.

DME providers should note that when requesting prior authorization of wheelchairs and other DME items, a future date of service should always be entered unless the item has already been provided to the recipient. The date of service on a prior authorization request should be the nearest estimated date that the wheelchair, or other DME item, can be expected to be furnished to the recipient. The calculation of an anticipated date that a service can be provided should always allow an estimated time for prior authorization, ordering the chair and components or other DME item, and provision of the item to the recipient.

Please note also that an adjustment in the date of service on the prior authorization file can be made, if requested, after prior authorization is given and delivery made, to match the actual date of delivery (if the delivery date is within six months of the date of service on the PA file). Please see the article published on page three of the October 1997 issue of the Provider Update newsletter for more detailed instructions for date of service adjustments.

Urological Supplies for Nursing Home Residents

DME providers and nursing facilities should note that the Long Term Care Standards for Payments requires that all catheters and supplies needed to perform intermittent catheterization are the responsibility of the nursing facility.

Nursing facilities are not required to provide indwelling catheters and related supplies, nor are they responsible for providing external catheters and supplies. Indwelling catheters and indwelling catheter insertion trays are covered by the Medicaid Pharmacy Program and may be obtained from any pharmacy provider.

Medically necessary supply items for the irrigation and maintenance of indwelling catheters, after their initial insertion, are available through the DME Program. All external catheters and supplies for nursing home recipients are also available through the DME Program.DME providers should also note that procedure code E1399 will not be accepted by the Prior Authorization Unit for any urological supply items. Only the appropriate, specific code that is applicable should be listed on requests.

New Codes for Mickey Gastrostomy Tube

This is to notify providers of the addition of the following two state assigned procedure codes in the DME Program for Mickey gastrostomy tubes:

Z4100 � Mickey Gastrostomy Insertion Kit

Z4101 � Mickey Gastrostomy Tube Replacement

These codes were added to the file with an effective date of 7/1/98. A price of $152.00 has been established for Z4100 and a price of $105.00 has been established for Z4101.These codes should be used on all future requests for prior authorization of these supplies.

Adjustment of Reimbursement Rate for Forearm Crutches

This is to notify providers that the two procedure codes for forearm crutches, codes E0110 and E0111, have been adjusted to pay at 100% of the Medicare fee allowable for these codes. This change is being made because of the increasing difficulty in obtaining these items statewide at 80% of the Medicare fee allowable rate.

1998 CPT Codes and Fees

We recently learned the wrong fees were loaded on the files for the 1998 radiology codes. Fees have been corrected and adjustments of paid claims will be completed in the near future. The 1998 radiology CPT codes and fees are stated below.

Code Fee
76076 $60.94
76078 $35.37
76390 $437.54
76831 $85.70
76885 $86.36
76886 $76.91
78708 $201.62
78709 $208.14

The professional component fees are 40% of the above stated full service fees.

Error Edit 619

As you know, current edits prevent the reimbursement of both laboratory panels and component codes within a particular panel when billed on the same recipient, same date of service. These claims are denied with error edit 619.

We recently received a policy clearance from HCFA stating it is appropriate to reimburse for both 80054 (Comprehensive metabolic panel) and 82250 (Bilirubin; total OR direct) on the same recipient, same date of service. For instance, when the panel code 80054 is performed, the total bilirubin test may be performed. The bilirubin direct may then be performed individually, if necessary.

System programming has been corrected to allow for reimbursement. A recycle of both 80054 and 82250 claim denials has been completed.

System Changes for 1998 Laboratory Panels

As you know, 1998 CPT included new and/or revised organ or disease oriented laboratory panels (codes in the 80000 series). We have learned the system programming that was implemented for these new lab panels has not allowed reimbursement of some of the individual codes within a panel. The error edits on these claim denials include 614, 619, 713, and 714. Claims for code 84478 were also denied with error edit 399.

System changes have been implemented to correct these problems. Claim denials for dates of service 1-1-98 forward for the new 1998 laboratory panels and their component codes with error edits stated above have been recycled.

New CPT Codes: Antigen Testing

CPT created a number of new 1998 codes in the series 87470-87799 to identify microbiology laboratory tests for specific antigens. Each single antigen has three separate codes. For each antigen listed, the lowest code in the range of three codes is for the �direct probe technique,� the middle code is for the �amplified probe technique,� and the highest code in the range is for �quantification.� These codes are intended to replace the previously used CPT codes which described steps in the laboratory process without identifying a specific antigen. Previous coding practices for these laboratory tests resulted in a number of codes being submitted by a provider for a single laboratory test performed for antigens which could not be identified or tracked.

Only one code in the triad of each antigen is to be billed for a recipient for the same date of service, for each test performed (i.e., for each test result obtained). For example, even though amplification is a step used in the HIV viral load test, the code 87536 assumes that this step/technique is included and code 87535 should not be billed in addition to 87536.

Effective July 1,1998, if more than one code in a triad is billed for the same recipient, same date of service, the highest code in the triad will be paid. The other code(s) will deny.

New Fees for Laboratory Codes

Effective with date of service July 1, 1998, fees for certain laboratory codes were reduced in order to bring Medicaid reimbursement amounts for these codes in line with those being paid by Medicare. Listed below are the codes whose fees were reduced and their new fees.

Code 60% Fee 62% Fee
80197 $18.97 $19.60
82523 25.83 26.69
83902 19.61 20.26
84484 13.60 14.05
87477 22.76 23.52
87482 22.76 23.52
87492 22.76 23.52
87512 22.76 23.52
87527 22.76 23.52
87533 22.76 23.52
87539 22.76 23.52
87542 22.76 23.52
87582 22.76 23.52
87592 22.76 23.52
87622 22.76 23.52
87652 22.76 23.52
88142 14.50 14.98

Notice to Providers of Corneal Transplants and Tissue

The Bureau of Health Services Financing is pleased to announce the funding of corneal tissue code V2785, effective with date of service of July 1, 1998. The fee for code V2785 is $920.00.

Also effective with date of service July 1, 1998, fees for the following corneal transplant procedures were adjusted as follows:

Code Description Fee
65730 Keratoplasty; penetrating (except in aphakia) $797.69
65750 Keratoplasty; penetrating (in aphakia) $843.07
65755 Keratoplasty; penetrating (in pseudophakia) $841.91

Hospital Providers Reminder: Billing for Organ Transplants

When a Louisiana Medicaid recipient receives an organ transplant, all charges incurred in the transplant are to be included in the recipient�s inpatient hospital charges. This includes all procedures involved in the harvest of the organ from the donor.

Donor search costs are also included in the recipient�s inpatient bill and will not be paid on an outpatient basis.

Medicaid does not pay for harvesting of organs when a Louisiana Medicaid recipient is the donor of an organ to a non-Medicaid recipient.

Remember that all organ transplants must be authorized by the Prior Authorization Unit prior to the performance of the surgery. If the transplant is approved by the Prior Authorization Unit, the authorization must be attached to all transplant-related claims submitted to Unisys for processing.

Notice to All Providers: Change of Address

The offices of Institutional Reimbursement have moved to 1201 Capitol Access Road, DOTD East Annex Building, 2nd Floor, Baton Rouge, LA 70821. Please note that the mailing address (P.O. Box 546, Baton Rouge, LA 70821) has not changed.

Funding of CPT 76870

The Bureau of Health Services Financing is pleased to announce the funding of CPT code 76870 � echography, scrotum and contents � effective with date of service July 1, 1998. The full service fee for code 76870 is $65.42. The professional component fee is $26.17.

Investigational Codes Placed in Nonpay Status

Effective with date of service July 1, 1998, the following CPT codes were placed in nonpay status. These codes are considered by Medicare to be investigational.

53852 - Transurethral destruction of prostate tissue; by radiofrequency thermotherapy.

83019 - Helicobacter pylori, breath test (including drug and breath sample collection kit).

Payment Rate for Orthopedic Shoes and Corrections

BHSF has adjusted the payment rates for orthopedic shoes and corrections (procedure codes L3000 through L3649) to reimburse providers at the rate of 100% of the fees on file for these codes. The fees for these codes are state assigned amounts and not based on Medicare fee amounts. Since these fees were assigned a number of years ago, and since it is becoming increasingly difficult for recipients to obtain these shoes and corrections at the reduced payment rate (80% of the fees on file), BHSF has adjusted the payment rate to pay at the full amount of the previously established fee amounts.

Please note that procedure codes L3000 through L3640 are paid automatically by the system. Code L3649, however, is priced manually by the Prior Authorization Unit.

Office/Outpatient CPT Codes

The Bureau of Health Services Financing is pleased to announce an increase in fees, effective with date of service July 1, 1998, for the following office or other outpatient visit CPT codes.

Code Fee
99212 $21.00
99213 $27.00
99214 $32,00

Louisiana Drug Utilization Review (LADUR) Education

Osteoporosis:Prevention and Treatment

Edited by Tracy S. Hunter, Ph.D., R.Ph.Director of Division of Clinical Pharmacy Practice Northeast Louisiana University School of Pharmacy

ISSUES . . .

- Osteoporosis affects 12% of Louisiana�s population.

- 50% of all Osteoporosis is preventable through lifestyle, diet, exercise, and therapeutic approaches.

- Early testing and detection can help prevent many of the negative effects of Osteoporosis

Osteoporosis is a disease of porous bones that can be described as an orthopedic condition or metabolic disorder that is the result of a hormone imbalance. Decreased bone mass and structural deterioration of bone tissue result in bone fragility and an increased susceptibility to fractures of the hip, spine, and wrist. Osteoporosis is one of the main causes for admission to a nursing home in the State of Louisiana, affecting men as well as women.

Approximately 50% of Osteoporosis cases are preventable with a combination of lifestyle, diet, exercise and therapeutic approaches. This Provider Update reviews the diagnosis and classification of Osteoporosis, analyzes the risk factors, and explains the role of diet, exercise, and drug therapy in preventing and treating this disease.

Porosity of bone is a consequence of a metabolic process that breaks down bone faster than it is rebuilt. There are two principal types of Osteoporosis �Type I and Type II. Type I is associated with the accelerated bone loss (2 to 3 % annually) related to estrogen deficiency. It begins at the time of menopause, and while the loss may continue for up to 20 years, is most rapid during the first 3 to 6 years following the onset of menopause. Type I Osteoporosis increases the risk of vertebral compression and distal forearm fractures.

Type II Osteoporosis is a slow constant bone loss (0.3% to 0.5% annually) progressing over many years. This type is sometimes called senile Osteoporosis and results in hip and vertebral fractures in both men and women over the age of seventy.

National and Louisiana Osteoporosis Statistics

  • Osteoporosis is the most common bone disease in North America and a public health threat for 25 million Americans, 80% of whom are women. In Louisiana, 12% of the population � about 157,000 women and 50, 000 men � are reported to have Osteoporosis. Almost 500,000 women in the state are thought to have Osteoporosis and low bone mass.

  • After age 50, 1 in every 4 women and 1 in 8 men are affected; after age 70, 1 in 2 women are affected. For men over 70, 1 in 5 are affected.

  • More than 2 million American men suffer from Osteoporosis and millions more are at risk. Each year 80,000 men suffer hip fractures and one-third of these men die within a year. Over 82,000 men in Louisiana are reported to have Osteoporosis or low bone mass.

  • Direct expenditures in American hospitals and nursing homes for Osteoporosis and related fractures are estimated to be $14 billion annually.

Identifiable Risk Factors for Osteoporosis

Many factors influence the likelihood of developing Osteoporosis. Women are more vulnerable than men and comprise 80% of those affected. Small, thin-boned women and Caucasian and Asian women are at greatest risk. African-American and Hispanic women have a lower, but significant risk. Bone loss is universal with advancing age; thus, the incidence increases with age. Susceptibility to fracture may be, in part, hereditary. People whose parents have a history of fractures may have reduced bone mass and may be at greater risk for fractures.

In addition to a diet low in calcium, other lifestyle factors that contribute to Type I Osteoporosis include smoking, alcohol consumption and lack of proper exercise.

Cigarette smoking lowers blood levels of estrogen. Women who smoke frequently go through menopause earlier and have lower levels of estrogen compared to nonsmokers. Postmenopausal women who smoke often require higher doses of hormone replacement therapy and may experience more side effects. Smokers may absorb less calcium from their diets.

Excessive alcohol consumption inhibits calcium absorption and may be associated with inadequate diet. Consumption of 2 to 3 ounces of alcohol on a regular basis may damage the skeleton, even in young women and men. Because of poor nutrition and a greater risk of falling, heavy drinkers are more prone to bone loss and fractures.

Bone is living tissue that responds to exercise by becoming stronger. A sedentary lifestyle or extended bed rest decreases bone mass. The best activities for bone health are weight bearing exercises that work against gravity such as walking, hiking, jogging, stair-climbing, weight training, tennis, and dancing. Swimming does not strengthen bones.

Osteoporosis can be induced by extended use of certain medications. Two that lead to loss of bone density and fractures are glucocorticoids and some anticonvulsants. Glucocorticoid-induced Osteoporosis is dose and duration-dependent; alternate day dosing does not prevent it. These drugs decrease bone formation and increase bone resorption. Inhaled steroids used long-term to control asthma do not appear to contribute to the development of Osteoporosis.

Antiseizure drugs such as phenytoin (Dilantin�), barbiturates and valproate (Depakote�) increase Vitamin D metabolism and produce osteomalacia which can lead to osteoporosis and fractures. Other long term drug therapy treatments that can cause bone loss include treatment with gonadotropin releasing hormone (GnRH) analogs used to treat endometriosis, excessive use of aluminum-containing antacids, certain cancer treatments and excessive thyroid hormone (>2 grains).

Clinical Presentation

Because bone loss progresses over a long period of time without symptoms, Osteoporosis was called the �silent disease�. Before bone mass testing, it was diagnosed when a sudden strain, bump, or fall caused a hip fracture or a vertebra to collapse. The first physical symptoms of a collapsed vertebra may be severe back pain, loss of height, or spinal deformities such as kyphosis or severely stooped posture.

Early Detection

Early detection is critical in controlling Osteoporosis. Bone Mineral Density (BMD) Tests measure bone density in the spine, wrist, and/or hip (the most common sites of fractures due to Osteoporosis), while other tests measure bone in the heel or hand. These tests are painless, noninvasive, safe and available around the state. Bone Density Tests can diagnosis Osteoporosis after a fracture or fall, detect low bone density before a fracture occurs, and monitor the effectiveness of treatment (if the test is conducted frequently). To find the location of bone density-testing centers telephone the National Osteoporosis Foundation at 800-464-6700.

Falling Injuries

Preventing injurious falls is critical for patients with Osteoporosis. Falling increases the likelihood of fracturing a bone in the hip, wrist, spine or other part of the skeleton. In addition to environmental factors, falls can be caused by diminished vision and/or balance or by medications (e.g. sedatives and antidepressants) that impair mental or physical function. It is important that individuals with Osteoporosis be aware of any physical changes they may be experiencing that affect their balance or gait, and that they discuss these changes with their health care provider.

Prevention and Treatment

To reach optimal peak bone mass and continue building new bone tissue, several factors should be considered. Studies correlate low calcium intake over a lifetime to low bone mass, rapid bone loss, and high fracture rates. National nutrition surveys report that most people consume less than half the amount of calcium recommended for building and maintaining healthy bones.

Calcium: Observational studies indicate that calcium is most effective when consumed in the diet. Research indicates that dietary calcium, but not supplemental calcium, reduces the risk of high blood pressure and of kidney stones. Low fat dairy products (such as milk, yogurt, cheese, and ice cream) are concentrated sources of calcium and are often fortified with Vitamin D. Dark green, leafy vegetables (such as broccoli, collard greens, bok choy and spinach) are calcium-rich. Sardines and salmon with bones, tofu, and almonds are also good dietary sources. Many foods (such as orange juice, cereals and breads) are now fortified with calcium.

Individuals may need to take a calcium supplement depending upon daily calcium intake, age, gender and hormonal status. Calcium compounds contain varying amounts of pure (elemental) calcium and also vary in bioavailability. Calcium citrate has advantages over other salts in that it is more readily absorbed, can be taken on an empty stomach and is less likely to cause constipation or gas. Other calcium compounds should be taken with meals to improve absorption. The amounts of elemental calcium in common supplements are listed in Table 1 below.

An individual�s need for calcium shifts over a lifetime. The requirement for calcium is greatest when the skeleton is growing rapidly and during pregnancy or breastfeeding. Older people of both genders and postmenopausal women should consume more elemental calcium daily because of inadequate amounts of Vitamin D, or because they have become less efficient at absorbing nutrients. Calcium absorption is impaired by chronic medical problems and medications that reduce gastric acidity.

Optimal Calcium Intake for Adult Women


Age (Years) Daily Intake of Elemental Calcium
11-24 1200-1500 mg
25-50 women 1000 mg
51-64 (women on ERT )* 1000 mg
51+ (women not on ERT) 1500 mg
65 or older 1500 mg
Pregnant or lactating 1200-1500 mg

* and Men

Vitamin D: Vitamin D is necessary for healthy bones. It stimulates an active calcium transport system that facilitates calcium absorption from the small intestines and acts on bone mineralization. Although most people are able to obtain enough Vitamin D in their diet and through exposure to sunlight, Vitamin D production decreases in the elderly and in nursing home patients unable to get natural sources. These individuals may require Vitamin D supplementation to ensure a daily intake of between 400 to 800 IU.


Medications that inhibit or stop bone loss, increase bone density and reduce fracture risk are available. Currently, the U. S. Food and Drug Administration (FDA) approves estrogen, calcitonin, and alendronate for the treatment of postmenopausal Osteoporosis.

Estrogen, raloxifene and alendronate are approved for the prevention of the disease. However, a comprehensive Osteoporosis treatment program should also focus on proper nutrition, exercise, and safety issues to prevent falls that may result in fractures.Estrogen: Estrogen replacement therapy (ERT) in the dosage range of 0.625 to 1.25 mg daily reduces bone loss, increases bone density in both the spine and hip, and reduces the risk of hip and spinal fractures in postmenopausal women. It works by slowing bone resorption. ERT is advocated for women whose ovaries were removed before age 50. For those women with an intact uterus, progestin is added to the regimen (hence, hormone replacement therapy or HRT). HRT relieves menopausal symptoms and has been shown to have beneficial effects on both the skeleton and heart. Currently, HRT is approved for women at high risk for Osteoporosis for both the prevention and treatment of Osteoporosis. It is most effective for the first 5 to 10 years after menopause but can slow bone loss even when started after age 70. Women who have experienced natural menopause and have multiple Osteoporosis risk factors (such as early menopause, family history of Osteoporosis, or below normal bone mass for their age) should consider HRT.

Alendronate: Alendronate (Fosamax�) is a bisphosphonate approved for both the prevention and treatment of Osteoporosis. It works by slowing resorption. It increases bone density in both the spine and hip and reduces the risk of fractures. Side effects from bisphosphonates may include GI upset (e.g. nausea or diarrhea, or esophagitis) or musculoskeletal pain. It is dosed 10 mg daily for treatment and 5 mg daily for prevention. Although proven clinically effective, dosing instructions for this drug are difficult for most patients to follow. It should be taken on an empty stomach and with a full glass (6 to 8 ounces) of plain water first thing in the morning. Even dosing with orange juice or coffee has been shown to markedly reduce the absorption of Fosamax�. After taking this drug it is important to wait in an upright position for at least one-half hour, or preferably one hour, before taking the first food, beverage, or other medications of the day.

Calcitonin: Calcitonins are naturally occurring polypeptide hormones that have a role in calcium regulation and bone metabolism. Although their actions are not fully understood, they appear to slow bone resorption. Calcitonin-salmon is indicated for the treatment of postmenopausal Osteoporosis in women who are at least 5 years beyond menopause and have lower bone mass than normal. It reduces the risk of spinal fractures and may reduce hip fracture risk as well. It is reserved for women who refuse or cannot tolerate HRT. Adequate calcium and Vitamin D intake should be maintained during therapy. Calcitonin-salmon prevents progressive bone loss, increases spinal bone density, and according to anecdotal reports, relieves the pain associated with bone fractures. It is available as an injection (take 50 to 100 IU daily or every other day) or in a nasal spray as Calcitonin-salmon (Miacalcina� ). While it does not affect other organs or systems in the body, injectable calcitonin may cause an allergic reaction and unpleasant side effects including flushing of the face and hands, urinary frequency, nausea, and skin rash. The recommended dosage of the nasal spray is one 200 IU spray to one nostril daily. Nostrils should be alternated daily. The dose may be administered at any time during the day. The only side effects reported with nasal administration include rhinitis and other nasal symptoms such as crusts, dryness, redness, sores, itching, or tenderness.

Raloxifene: Raloxifene (Evista�) was recently approved for the prevention of Osteoporosis. It is from a new class of drugs called Selective Estrogen Receptor Modulators (SERMs) that prevent bone loss at the spine, hip, and total body. Raloxifene�s effect on the spine does not appear to be as powerful as either estrogen replacement therapy or alendronate, but its effect on the hip and total body is comparable. While side-effects are not common with raloxifene, those reported include hot flashes and deep vein thrombosis, the latter of which is also associated with estrogen therapy.

Psychological Reactions

As with other chronic disease, patients with Osteoporosis experience many psychological consequences such as anxiety, depression or feelings of hopelessness. These feelings may originate after the diagnosis of Osteoporosis or when a fall results in a fracture. After this initial event a patient may then develop anticipatory anxiety or become fearful that even regular movements will bring about pain or another fall. A cascade of events may follow in which they limit their activities, reducing their physical conditioning and rendering them more vulnerable to subsequent falls. Symptoms consistent with depression � sleep problems, diminished appetite, apathy, as well as thoughts of death and dying� are common. Self-image and self-esteem may be damaged by the disfigurement of multiple vertebral fractures. These fractures cause stooped posture, loss of stature, and protruding abdomen making it difficult to purchase clothing that fits properly. This only exacerbates the patient�s self-image as deformed.


Fractures associated with Osteoporosis produce a great deal of pain and may challenge a patient�s coping skills. Acute pain due to fractures is initially severe but can be treated on a short-term basis. Chronic pain from spinal deformity poses an ongoing problem. Functional limitation results when muscle tone is lost. Pain may also limit activity because of decreased ability and desire to move. Pain management can be enhanced or accomplished in a variety of ways other than medications, including: heat and ice, physical therapy, transcutaneous electrical nerve stimulation, acupuncture, biofeedback, behavior modification, support braces, and hypnosis.


Early testing and detection is the best plan of attack in the battle against Osteoporosis. In the treatment phase, a multi-disciplinary team approach including physician, physical therapist, nutritionist, pharmacist and psychiatric social worker addresses the medical and psychosocial aspects of the disease. Although it may be difficult for some patients to have access to programs that include all of these health care professionals, it is essential that the psychosocial as well as medical consequences of Osteoporosis be acknowledged and treated.

Table 1 - Elemental Calcium in Common Supplements

Calcium compound Percent elemental CA Tablet size Elemental CA
CA Carbonate 40 500 mg 200 mg
CA Gluconate 9 500 mg 45 mg
CA Citrate 21-23 950 mg 200 mg
CA Lactate 13 650 mg 85 mg


The National Osteoporosis Foundation Osteoporosis and Related Bone Diseases National Resource Center (NCR). 1150 17th St., NW, Suite 500, Washington DC their 20036(202) 223-0344 or 800-624-BONE

Supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, this nonprofit organization seeks to support research on and an awareness of Osteoporosis, Paget�s disease, and osteogenesis imperfecta. It offers many educational materials and programs (many in Spanish and some in large-type print).

National Institute on Aging

Information Center

PO Box 8057

Gaithersburg, MD 20898-8057


This branch of the NIH provides material for health care professionals and for patients. It is reliable and free of charge.