Volume 10, Number 3
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
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
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.
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.
Three additional codes have been made payable:
A5119 - Skin
Barrier; wipes, box of 50
Adhesive; dish or foam pad
Incontinence/ostomy supply; miscellaneous
Please note the addition of the following codes as payable:
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
Intermittent urinary catheter, straight tip
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
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
concentrator, flow rate does not exceed 2 liters per min, at 85% or greater
E1401 - Oxygen
concentrator, flow rate greater than 2 liters per min, but less than 3 liters
per min. at 85% or greater concentration
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
Enlargement of ocular prosthesis
Reduction of ocular prosthesis
Fabrication and fitting of ocular conformer
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
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.
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
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.
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:
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.
Every time period billed must have a corresponding "paper
trail" to validate it.
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.
Case managers must meet the qualifications as defined in Section 4-7 of
the provider manual when they are hired.
The choice of service providers, including case management, must be
documented. See page 4-9-1 of the
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.
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.
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.
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.
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.
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.
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.
recipient records for any reason is not a billable activity.
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.
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
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.
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.
Enter the recipient's 13-digit Medicaid identification number exactly as
it appears on the recipient's Medicaid identification card.
Enter the recipient's last name and first name as they appear on his/her
Medicaid identification card.
Number: Enter the dentist's
individual 7-digit Medicaid identification number.
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.
Services: Only procedures that
require prior approval should submitted on the PA03 form.
Enter the appropriate 5-digit code and its corresponding
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.
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.
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.
Always attach a copy of the Unisys
claim form, with all services listed, so the entire treatment plan may be
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.
You must have your 9-digit prior authorization number in
the appropriate block when submitting for payment of services requiring prior
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
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
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:
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