Provider Update

Volume 10, Number 3 

September/October 1993

Message from the Medical Director

As the result of a corporate reorganization, Paramax will now be known as Unisys again.  Mainly, this change will be evident when we identify ourselves in response to your telephone inquiries and will be forthcoming on our stationery and correspondence to you.  All provider policy and procedures will remain the same under the name of Unisys.

This issue of the Provider Update contains an updated list of HCPC procedure codes to be used by DME providers.  The DME program is pleased to announce an expansion of the indications for orthopedic shoes and corrections to include medical necessity for prevention of clinical deterioration of the foot, such as with diabetic patients and those with severe peripheral vascular disease.  This policy change, as well as a number of others in recent months, was in part due to the input of providers.  The average turnaround time in July for Prior Authorization, including DME, physician and hospital extensions, transplant requests, and rehab requests was less than 10 days, with emergency requests being handled the same day.

In an effort to better serve providers and recipients, Unisys has assisted DHH in meeting with representatives of various groups.  Recent meetings have been held with physicians in Southwest Louisiana where Community Care is being expanded, with DME providers to develop custom wheelchair PA procedures, with members of the Louisiana State Medical Society Physician/Patient Advocacy Committee to overview developments in the program, with representatives of podiatrists to update billable codes, and with our attendance at the recent state pharmacy association meeting.

At DHH, Tom Collins has been appointed the new Acting Medicaid Director, replacing John Futrell, who has been named Deputy Secretary.  Rose Forrest is the new Secretary of DHH.  Unisys has recently hired a new Manager of the Provider Relations Unit, several additional nurses in Medical Review, and a new computer programmer for the System Division.

This update contains some important information concerning the new Medicaid Case Management Monitoring Unit, and the Case Management Services provider manual.  Case Management is defined as services which will assist individuals in getting access to needed medical, social, educational, and other services, and is designed to assist recipients in coordinating the needed services and maintaining community living.

Other noteworthy projects underway include a key revision of the Hospital Services manual, an improved drug utilization education feedback program being developed by the Louisiana Drug Utilization Review Board, and several targeted studies using the claims database designed to improve patient care and clinical program policies.  Also, providers will soon be receiving written material concerning screening mammograms and neonatal intensive care policy.

Throughout DHH and Unisys, efforts are being made at all levels to improve service to Medicaid recipients and providers by being responsive to concerns expressed and innovative in finding ways to improve the program.  We appreciate the ongoing working relationships that have been developed in this regard and look forward to continued collaborative interactions as we move forward.

Dr. Gregg Pane.

 Antibiotic Injections for Children to Age 21

Physicians are reminded not to bill CPT code 90782 for just administering an antibiotic injection to the Medicaid recipient.  The fee for code 90782 is payable for the medication you give; the administration fee is included in the fee for the office visit.

Consequently, code 90782 cannot be billed if the pharmacist fills the prescription for the medication, and you or your office nurse administers the injection.  Only the appropriate level office visit can be billed.

Evoked Otoacoustic Emissions Testing

Louisiana Medicaid is pleased to announce the assignment of local code Z9917 to the description "evoked otoacoustic emissions testing."  This test is used to screen newborns for hearing problems, and it measures a sound or "echo" produced by a normal cochlea in response to a sound stimuli.  Code Z9917 is payable effective with date of service July 1, 1993, at a fee of $25.00.  The professional component fee for this code, which is billed with modifier -26 is $10.00.

Providers are reminded to bill for the full service component only if they rent, lease, or own the equipment used to conduct the test and they perform the professional component of the service.

Brainstem Evoked Response Screening

Louisiana Medicaid is pleased to announce the assignment of local code Z9916 to the description "brainstem evoked response screening."  Medicaid providers should use this code to bill for a brainstem evoked response screening, not a brainstem evoked response according, which is billed with CPT code 92585.  Code Z9916 is payable effective with date of service July 1, 1993.  The professional component fee for this code is $20.00 and should be billed with modifier -26.  The full service fee is $50.00.

Providers are reminded that they should bill full service only if they own, rent, or lease the equipment used to conduct the test and they perform the professional component of the service.  If the screening device used to perform the screening does not require the interpretive services of a doctor or audiologist, no claim for the professional component (billed with modifier -26) should be submitted.  Additionally, no claim for the professional component should be submitted if a trained and salaried employee of the hospital performs the screening.

As a final note, providers should never bill for a recording if only a screening was performed.

Calcijex and Infed Approved for Reimbursement

Effective with date of service July 1, 1993, Louisiana Medicaid approved reimbursement for the provision of the drugs Calcijex and Infed to hemodialysis centers for Medicaid eligible dialysis patients.

To bill for Calcijex, hemodialysis centers should use code J0635 for a one microgram ampule of Calcijex, payable at $11.34; code Z6138 for a two microgram ampule, payable at $19.40; and code J1760 for two milliliters of Infed, payable at $34.96.

Orthopedic Shoes and Corrections

Orthopedic shoes and corrections may be approved only when they are attached to braces, are needed to protect gains from surgery or casting, or are medically necessary to prevent clinical deterioration of the foot; i.e., diabetic, severe peripheral vascular disease.  Cables are not considered braces.  Orthopedic shoes and corrections are not provided for minor orthopedic problems, i.e., pes planus, metatarsus adductus, and internal tibial torsion.  Shoe lifts are approved when orthopedic correction is greater than one-half inch.

DME Code Changes

Provided below is a list of procedure code changes for DME providers.  These codes are grouped by equipment/supply category.  We begin with code changes for tracheostomy tubes.

Tracheostomy Tube Code Changes

Code A4622 has been made payable with the description of "Tracheostomy or Laryngectomy Tube" to match the Medicare coding.

Codes Z0466, Z0467, and Z0468 for trach tubes have been changed to non-payable status to eliminate duplication.

Additional Ostomy Supply Codes

Three additional codes have been made payable:

A5119 - Skin Barrier; wipes, box of 50

A5126 - Adhesive; dish or foam pad

A5149 - Incontinence/ostomy supply; miscellaneous

Additional Incontinence Supplies

Please note the addition of the following codes as payable:

A4322 - Irrigation syringe, bulb or piston

A4326 - Male external catheter specialty type, e.g., inflatable, faceplate, etc. each

A4327 - Female external urinary collection device; metal cup, each

A4328 - Female external urinary collection device; pouch each

A4329 - External catheter starter set, male/female, includes catheters/urinary collection devices, bag/pouch and accessories (tubing, clamps, etc.), 7-day supply

A4350 - Catheter care kit

A4351 - Intermittent urinary catheter, straight tip

A4352 - Intermittent urinary catheter, coude (curved) tip

A5112 - Urinary leg bag; latex

A5113 - Leg strap; latex, per set

A5114 - Leg strap; foam or fabric, per set

A4397 - Irrigation supply; sleeve

Oxygen Concentrator Code Changes

The following codes listed in the manual have been deleted by Medicare and are now non-payable:  E1388, E1389, E1391, E1392, E1393, E1394, E1395, E1396, AND Q0036.

The following codes should not be used instead of the above eliminated codes:

E1400 -Oxygen concentrator, flow rate does not exceed 2 liters per min, at 85% or greater concentration

E1401 - Oxygen concentrator, flow rate greater than 2 liters per min, but less than 3 liters per min. at 85% or greater concentration

E1402 -Oxygen concentrator, flow rate greater than 3 liters but less than 4 liters per min., at 85% or greater concentration

E1403 - Oxygen concentrator, flow rate greater than 4 liters but less than 5 liters per min., at 85% or greater concentration

E1404 - Oxygen concentrator, flow rate greater than 5 liters but less than 5 liters per min., at 85% or greater concentration

E1377 - Oxygen concentrator, high humidity system equivalent to 244 cu. ft.

E1378 - Oxygen concentrator, high humidity system equivalent to 488 cu. ft.

E1379 - Oxygen concentrator, high humidity system equivalent to 732 cu. ft.

E1380 - Oxygen concentrator, high humidity system equivalent to 976 cu. ft.

E1381 - Oxygen concentrator, high humidity system equivalent to 1220 cu. ft.

E1382 - Oxygen concentrator, high humidity system equivalent to 1464 cu. ft.

E1383 - Oxygen concentrator, high humidity system equivalent to 1708 cu. ft.

E1384 - Oxygen concentrator, high humidity system equivalent to 1952 cu. ft.

E1385 - Oxygen concentrator, high humidity system equivalent to over 1952 cu. ft.

Ventilator Code Changes

The description in the provider manual for code E0450 should read as follows:  Volume Ventilator and Equipment Package.

Also, code E0451 is now non-payable.  Code E0450 should be used for both stationary and portable ventilators.

Wheelchair Transfer Board

Code E0972 is now payable and should be used for this item instead of the miscellaneous DME code E1399.

Prosthetic Eye Code Changes

The following prosthetic eye codes have been deleted by Medicare and are non-payable:  V2620, V2621, and V2622.  However, code V2632 remains active, and code V2629 has been added as payable, with a description of Prosthetic Eye, other type.

The following codes have also been added as payable codes:

V2624 - Gauze, elastic, all types, per roll

V2625 - Enlargement of ocular prosthesis

V2626 - Reduction of ocular prosthesis

V2628 - Fabrication and fitting of ocular conformer

Description Changes

The description of the following codes have been changed:

A4202 - Gauze, elastic, all types, per roll

A4203 - Gauze, non-elastic, per roll

A4460 - Elastic bandage, per roll (e.g., compression bandage)

E0184 - Eggcrate type mattress

E0199 - Eggcrate type pad for mattress

Case Management Update

This newsletter is being issued to all providers of case management.  Please be certain that all employees involved in your case management program receive a copy.

As many of you know, the Case Management Monitoring Unit is up and running.  We look forward to meeting you and answering questions in person, but we hope that this update will answer many questions that you may have.  As we have monitored, we have run across many similar questions and errors.  This update will mention many of them in hopes that you can utilize this information to improve your programs now, rather than wait until we monitor you.

Procedure Changes

Please refer to page 4-16-4 of the Case Management Services provider manual, where billing multiple activities in the same day is discussed.  According to the manual, you can choose between billing for each time period separately or accruing time throughout the day per procedure code.  We have revised this policy.  You may bill only by accruing time throughout the day, per procedure code.  On any given day, a maximum of one line of billing per day should be submitted per procedure code.  This policy, however, does not apply to case management services for high-risk pregnant women.

For those of you who wonder if this policy clarification means that you should record time in only one cell block for the whole day, the answer to your question is that you should continue to record activities as they occur, but at the end of the day, you should combine the minutes and divide by 15, which will give you the number of units which you may bill for that day.  In addition, you should continue to round the amount as defined on page 4-16-4 of the manual.  If you are using CAMIS, the software will be updated to comply with these changes.  If you are using a software system other than CAMIS, you will need to talk to your programmer to get your system updated to handle these changes.  Again, none of these changes apply to case management policy for high risk pregnant women.

Commonly Noted Errors

This section has been included to assist you in improving your programs based on errors and questions which have been encountered by the Case Management Monitoring Unit.  Please note that the Case Management Services provider manual is intended to set boundaries and give guidelines.  The manual tells you what you can bill for; it will not tell you everything for which you cannot bill.  If you have questions about what is or is not billable, please call the Medicaid Case Management Monitoring Unit at 342-2022 before you assume a service is billable.  Calling before you bill for something you are not sure about could save you valuable time and money.

A list of some of the errors the monitoring unit has noted recently is provided below:

1.      The case note which corresponds to each recorded time of case management activity must be clear as to who was contacted and what case management activity took place.  If should not be a narrative with every detail of the circumstance.  It should be clear to a monitor why that time period was billable.

2.      Every time period billed must have a corresponding "paper trail" to validate it.

3.      Progress notes must be completed at least monthly and signed by the case manager.  The progress notes should indicate how the goals in the Plan of Care/Service Plan are progressing.  Please see page 4-11-9 of the provider manual for details.

4.      Case managers must meet the qualifications as defined in Section 4-7 of the provider manual when they are hired.

5.      The choice of service providers, including case management, must be documented.  See page 4-9-1 of the provider manual.

6.      The record must contain documentation to validate that the recipient is eligible for the targeted case management service.  See pages 4-11-10 and 4-11-11 of the provider manual.  Section 4-6 of the manual lists the qualifications necessary to be eligible for case management services.

7.      The Plan of Care/Service Plan (these words are used synonymously) is defined on pages 4-11-7 and 4-11-8 of the provider manual.  Listed here are some specific problems we have noted:  a) Goals must be specific and measurable; b) Dates for targeted completion and actual completion should be included; c) The individual or provider who will carry out the intervention should be noted; d) Planned frequency of contact with the recipient should be noted, e) A Plan of Care must be completed initially regardless of waiver status.

8.      Case Management providers must cease billing for case management 10 days after a recipient is admitted to an institution or hospital.  Any billing done during those 10 days must not be for services which are included in the reimbursement to the institution or hospital.  Please see pages 4-7-3 and 4-7-4 of the provider manual.  Section 4-10 indicates when closure must occur.

9.      All documents must be labeled clearly with the recipient's name and signed by the individual who produces the document, including, but not limited to, progress notes, service logs or other billing documents, intake forms, etc.

Non-Billable Activities

The following is a list of activities identified through monitoring which are not billable, but have been billed or questioned by a number of providers.  This list is not all inclusive as to what is not billable.  It reflects particular issues that have been identified by the Case Management Monitoring Unit.  A good "rule of thumb" to remember is that if there is no interaction in person, by telephone or by correspondence, on behalf of the recipient, the activity is most likely not billable.

  1. Progress notes are not billable unless they are completed at the time of the visit with the recipient.  If you return to your office or do the notes at the end of the month, the time spent is not billable.

  2. The Plan of Care, including updates, must be completed with the recipient and/or the Interdisciplinary Team.  If you take the Plan of Care back to your office and write it, the time spent is not billable.

  3. Reviewing recipient records for any reason is not a billable activity.

  4. Any form of direct services is not a billable activity.  This includes, but is not limited to, visiting, transportation, waiting for appointments, shopping, accompanying on recreational activities, picking up medication, etc.  If you question whether or not a service is billable, call 342-2022 to find out.  Case management services do not consist of the provision of needed services, but are used as a vehicle to help the individual gain access to them.

  5. Leaving messages for someone, faxing information, and mailing out information are not billable services.


Section 1915 of the Social Security Act defines case management services as services which will assist individuals, eligible under the plan, is gaining access to needed medical, social, educational, and other services.  Case management is designated to assist recipients in coordinating the needed services and maintaining community living.

Please understand that this update is not complete.  It is to be used as a guide to some common problems and misunderstandings.  The provider manual is currently under revision.  The updated manual will reflect all of the changes listed above.  Any other changes which are not included here will be explained in the new manual.

This update is designed to answer questions; it is the most efficient way to reach all the providers at one time.  If you have questions, please contact our Case Management Monitoring Unit at 342-2022.

Mental Health Rehab Providers and Services in ICF-MR Facilities

Providers should note that the per diem rate for ICF-MR facilities includes reimbursement for room and board, as well as reimbursement for all services ordered in the resident's care plan, which include the provision of mental health rehabilitation (MHR) services.

The facility has the option of either providing the MHR services with their own staff or contracting with another agency to provide the services.  However, an ICF-MR facility may not enroll in Medicaid as a MHR provider and submit claims for MHR services rendered to its own residents.

In addition, if a facility enters into a contractual agreement with another agency to provide these services to its residents, then that agency must submit the bill for services rendered directly to the facility.  Claims for MHR services rendered to residents of ICF-MR facilities should never be submitted to Unisys for reimbursement.

Pharmacy Dispensing Fee

The maximum allowable overhead cost (dispensing fee) for Medicaid prescription services has been increased to $5.54, effective for services beginning July 1, 1993.  The new fee reflects the inclusion of the $0.10 provider fee mandated under state law for every prescription filled by a pharmacy or dispensing physician.  Unisys has automatically adjusted any pharmacy claims which were paid previously to allow for additional monies that were due to the provider because of the fee increase.  Providers should be reminded that they are required to continue billing their usual and customary charges.

Dentists: Prior Authorization Requests

Effective July 1, 1993, Louisiana Medicaid began requiring providers to submit all prior authorization requests to the Medicaid Dental Program at the LSU School of Dentistry on form PA03, in addition to submitting these requests on the usual claim forms.  The purpose of the changed procedure is to maintain automated audit trails for all Medicaid services that require prior authorization.

Dental claim forms being returned from LSU School of Dentistry will no longer have an authorization signature and ate.  Instead, providers will receive authorization, as well as their prior authorization number, in a Prior Authorization Notification Letter.  Providers should note, however, that they still must obtain prior authorization only for those procedure codes in the Dental Services manual that are marked with an asterisk.

Providers who have questions regarding these procedures or the PA03 form should contact Peggy Misner at the Unisys Prior Authorization Unit at (504) 924-7051, ext. 2259, or at the toll-free number, 1-800-488-6334.

A sample PA03 is provided on the following page.  It has been completed as an example.  The instructions for completing the form follow.

PA03 Instructions

Note:  On the PA03 form in the Attending Provider Number field, enter your 7-digit individual provider number.

If you are affiliated with a group or clinic, write their 7-digit Medicaid provider number at the bottom of the PA03 form and circle it.

Both numbers will be input onto the Prior Authorization File and a letter of notification will be sent to both the individual and group or clinic providers.

Recipient Number:  Enter the recipient's 13-digit Medicaid identification number exactly as it appears on the recipient's Medicaid identification card.

Recipient Name:  Enter the recipient's last name and first name as they appear on his/her Medicaid identification card.

Attending Provider Number:  Enter the dentist's individual 7-digit Medicaid identification number.

Treatment Plan:  For the beginning date of treatment, enter the date you anticipate providing the first authorized service.  The ending date you enter should be exactly one year later from the beginning date.

Description of Services:  Only procedures that require prior approval should submitted on the PA03 form.

Enter the appropriate 5-digit code and its corresponding description.

List the 5-digit code one time only, the enter the number of times that the procedure will be provided in the requested Units column.

Provider Name, Address, Telephone Number:  Enter the name and address of the provider.  If the provider is affiliated with a group, enter the name and address of the group and highlight this block.

Provider Signature:  Ensure that the form is signed by the provider of service or another authorized representative.  If a stamped signature is used, the request must be initialed.

Note:  Always attach a copy of the Unisys claim form, with all services listed, so the entire treatment plan may be reviewed.

Mailing Information

Mail the PA0-3 form, with the attachments, to the following address:  LSU School of Dentistry, Medicaid Dental Program, 1100 Florida Ave., Box 8301, New Orleans, LA  70119.  To obtain additional PA03 forms, contact the Prior Authorization Unit at Unisys or copy a blank form.

Providers who have problems with payment of dental claims should contact the Provider Relations Unit at (504) 924-5040 or 1-800-473-2783.

Billing Reminders

You must have your 9-digit prior authorization number in the appropriate block when submitting for payment of services requiring prior authorization.

When completing the Unisys EPSDT 109 form, continue to record your pay-to-dentist or group provider number in block #9 and your individual attending provider number in block #19.

On the Unisys Adult Dental 110 form, continue to record your pay-to-dentist or group provider number in block #9 and your individual attending provider number in block #18.

Thank you for your patience during the transition period for these new prior authorization procedures.

"Provider Relations, May I Help You?"

Unisys is proud to announce that the final reconfiguration of the Provider Relations telephone system is complete.  Thanks are in order to all the providers who waited patiently on hold over the past several months.

The upgrades to the telephone system were accomplished over a period of several months.  The final link was the installation of new software to enable easier access to the toll-free line on July 31, 1993.  In the interim period, additional representatives were employed and trained.

Monday, August 4, 1993, was a day that held great promise to the entire Provider Relations Department.  The new system had been installed over the weekend, and all involved were anticipating the start of the business day.  However, Provider Relations quickly realized that quite a few more kinks had to be worked out of the system before the telephones could be classified as "problem-free."

Nevertheless, representatives continued to take calls, and we called the experts in to fix the telephones once and for all.

Off and on for the next two weeks, the telephone company was called to correct and further refine the system.  Finally, there was true progress noticed on the week of August 23.  The provider holding time was at a minimum, and there were actual periods during the day when there were no callers holding.

Now, we can truly say that the new telephone system is operational.

Currently, the toll-free telephone line for Provider Relations is available from 8:00 a.m. to 5:00 p.m. Monday through Friday, excluding holidays.  The new telephone system is computerized and allows a supervisor to know exactly how many callers are holding, and the length of time on hold.  These numbers are watched carefully to ensure that all providers are assisted with a minimum delay.  There are still "peak" times during the day, such as from 10:00 a.m. to 2:00 p.m., when the holding time is longer.  Unisys is encouraging providers to call before or after the peak hours to minimize the excessive delays.

Continuous improvement is the goal for the toll-free line.  Your comments are welcomed and will be used to better assist you.  Please drop a line to us and let us know how we are doing.

The address is provided below:

Provider Relations
P. O. Box 91024
Baton Rouge, LA  70809

Once again, thank you for your patience and understanding during this transition period.  Our provider community's patience has made life easier for all of us during the transition.

 Marion Slaton