Message from the Medical Director Increase in Fee for 21248
Funding of Code 95807 Clarification of Code 99183
Restrictions on Echography During Pregnancy Funding for CPT Code Z9918
Increase in Fee for 69450 Funding for Code 95810
J9383 in Non-Pay Status Funding for Code Q0134
NICU Revenue Codes Expanded Abortion Coverage
Flat-Fee Anesthesia Code List Expanded Correct Taxpayer ID Information for All Providers
Addition of Payable Code for Chiropractors Medical Card Changes
LADUR Education Article Diabetic Supplies for Adults
Case Management for Head Injury Notice to Case Management Providers
Extension of Units for Targeted Case Management Reminder to Providers of Waiver Services
Flat-Fee for Service Reminders Personal Emergency Response System
Echocardiography Code Fee Adjustments Mental Health Rehabilitation Reminders
Filing for Professional Services Reimbursement Under Pre-Certification/Length of Stay DME Code Changes

Providers/Enrollment Centers

Message from the Medical Director  

I'd like to update you on the Hospital Preadmission/Length of Stay (LOS) Review Program.  This does not apply to state operated or out-of-state hospitals.

This program was designed to be implemented in conjunction with the new hospital per diem rate reimbursement structure that went into effect July 1, 1994.  The hospital pre-admission/LOS program began on August 1, 1994, and all hospitals will be phased in by January 1, 1995.  No action is necessary on the part of hospitals until they are contacted by DHH or Unisys regarding their participation.  A series of training sessions will be held around the state for groups of hospitals prior to their participation in the program.  Complete details about the program will be included in the new Medicaid Hospital Manual which will be mailed to providers during the month of September.

All program policies for the pre-cert/LOS program were developed by a DHH Advisory Committee composed mostly of Louisiana Hospital Association representatives along with representatives from DHH and Unisys.  The program will conduct both preadmission and length of stay reviews for distinct part psychiatric facilities and long term hospitals using customized criteria developed by this group.  This comprises approximately 10% of all Medicaid hospital admissions.  Acute care and rehab hospitals, which together comprise the remaining 90% of all Medicaid admissions, participate only in the LOS review program.  The InterQual review criteria will be used to review acute care extension requests while customized criteria developed by the Advisory Committee will be used for long term admissions.  Length of stay will be assigned based on the HCIA Southern Regional 1994 data with appropriate specialty customization where designated by the DHH Advisory Committee.

The InterQual criteria can be purchased by calling InterQual at (603) 964-7255.  The HCIA Southern Regional Length of Stay criteria can be purchased from HCIA by calling (800) 568-3282.

Admissions and LOS reviews will be conducted by review nurses with physician consultant oversight.  Most communications can be conducted between Unisys and hospitals via fax by submitting the appropriate forms and criteria sheets with the relevant boxes checked and standard medical documentation included.  Numerous 1-800 fax and phone lines have been installed to facilitate communication and data submission.  Every attempt has been made by the DHH Advisory Group and by Unisys staff to make procedures as clear and simple as possible.  In addition, we will fine tune our policies and procedures to make the program work even better based on comments and interactions with hospitals already being phased in

Dr. Gregg Pane

Increase in Fee for 21248

BHSF is pleased to inform you of an increase in fee for CPT code 21248-Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); partial.  The fee has been increased to $1,025.27 effective with date of service October 1, 1993.

If you have performed this service since October 1, 1993, and wish to receive the additional fee, you must submit an adjustment form to Unisys.  The instructions can be found in the Physician Service Manual, page 35-1.

Funding of Code 95807

CPT code 95807-sleep study, three or more parameters of sleep other than sleep staging, attended by a technologist-has been funded effective with date of service August 1, 1994, at a full service fee of $266.00.  The professional component fee for this service will be $106.40.

A limit of two tests per calendar year per recipient has been placed on codes 95807 and 95808 effective with publication of this notice.  For example, either two billings of code 95807 or two billings of code 95808 in a year's time will be payable for a single recipient.  Or one billing of code 95807 and one billing of code 95808 will be payable for a single recipient.  A third billing of either of these codes will be denied.

Clarification of Code 99183

The question has been asked whether or not physicians must be present during the entire hyperbaric oxygen therapy session to bill CPT code 99183 - Physician attendance and supervision of hyperbaric oxygen therapy.  The answer to this question is "YES."

CPT code 99183 is to be used per dive per patient.  The physician must be physically present on the unit during the entire dive to bill and receive reimbursement for this service.  Documentation in the dive record must reflect the provider's participation in and presence on the unit during the dive.

Evaluation and management (E&M) services may be billed on the same date of service as 99183 if 1) a separate, identifiable service unrelated to hyperbaric oxygen therapy (HBO) or the condition necessitating HBO is rendered, and 2) the service could not be rendered at the time of HBO (e.g., dysuria with a urinalysis office visit for cystitis).

Restrictions on Echography During Pregnancy

Effective August 1, 1994, the number of echographies (CPT codes 76805, 76810, 76815, and 76816) during pregnancy will be limited to three per recipient per pregnancy without review.  A total of three claims with any combination of these codes will be paid per recipient per pregnancy.  A fourth and succeeding echographies will pend to Medical Review and will be paid only if they meet the criteria listed below.

1.     Complications related to pregnancy requiring ongoing diagnosis and/or therapy which necessitates additional echographies.  Documentation supporting medical necessity should be attached.

2.     Abnormal findings on previous echographies which require additional echographies to further monitor, evaluate, and treat.  Documentation supporting medical necessity should be attached.

The first three claims can be billed electronically.  A fourth and succeeding claim must be billed hard copy.

Funding for CPT Code Z9918

Anesthesia for the removal of leaking breast implants (code Z9918) has been funded with three base units effective with date of service October 1, 1993.

This is the date of service on which the removal itself was funded, but, through error, no mention was made in the original announcement about the funding of anesthesia for this service.  Claims are to be submitted with appropriate modifiers and minutes.

Increase in Fee for 69450

CPT code 69450 - Tympanolysis transcanal - was increased from $84.50 to $316.79 effective with date of service September 1, 1994.

Funding of Code 95810

CPT code 95810 (Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist) has been funded effective with date of service September 1, 1994 at a full service fee of $300.12.  The professional component fee for this service will be $120.05.

A limit of two tests per calendar year per recipient has been placed on this code as was placed on codes 95807 and 95808.  Therefore, these three codes are restricted to a maximum of two per year per recipient (any combination).  A third billing within the calendar year of any of these codes will be denied.

J9383 in Non-Pay Status

Effective with date of service October 1,1994, we will place code J9383 (Zoladex-goserelin acetate implant, 3.6 mg) into non-pay status.  The code to bill in its place is J9202 (the code Medicare uses for Zoladex).  The fee for code J9202 is $344.76 for 3.6 mg.

Funding for Code Q0134

BHSF announces the funding of HCPCS code Q0134 (Collagen implant, urinary tract, per 2.5 cc syringe) effective with date of service 10/1/94 at $217.00, including shipping and necessary supplies.

Medicaid is adopting Medicare's guidelines for the use of this treatment modality for Type III stress urinary incontinence secondary to intrinsic sphincter deficiency (ISD), and will restrict the reimbursement for this code to five treatment sessions per recipient.  Please refer to the 9/1/94 issue to Medicare's Provider News for additional comments, information, and policy regarding the use of Contigen implants.

NICU Revenue Codes

  Effective with dates of service July 1, 1994 and after, non-LHCA or non-state operated in-state hospitals approved for NICU Level II, NICU Level III, and NICU Level III Regional Units should bill all NICU days under the baby's name and Medicaid ID number from the day the baby is placed in this unit.  Use Revenue Code 175.  It does not matter that the mother is still a patient in the hospital.

Regular nursery days and NICU Level I should continue to be included on the mother's bill as long as the mother is a patient.  Use Revenue Codes 170, 171, or 172 to indicate these types of stays.  On the mother's bill, only the mother's accommodation days will be paid, which is the same way such claims were paid prior to July 1, 1994.  Bill with the baby's name and number only after the mother has been discharged or if she was never admitted to the hospital.

Expanded Abortion Coverage

The State Plan under Title XIX has been amended effective August 24, 1994, to provide the payment to the attending physician for abortions terminating pregnancies resulting from rape or incest in accordance with provisions of State Law (La. R.S. 40:1299-:34.5 and La. R.S. 40:1299:35.7 as amended and enacted by Act 1 of the Fourth Extraordinary Session of the 1994 Legislature).

Flat-Fee Anesthesia Code List Expanded

The Bureau of Health Services Financing is pleased to inform you of the following CPT codes that will be included in the list of anesthesia codes which pay a flat fee.  We are also adjusting our fees for codes 36488, 36489, and 64510 as listed below.  These changes are effective with date of service September 1, 1994.

Code 36488 is the placement of central venous catheter (subclavian, jugular, or other vein) for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy; percutaneous, age 2 years or under.  It will be paid at $91.17.

Code 36489 is the same as above, percutaneous, over age 2.  It will be paid at $80.77.

Code 64510 is the injection of anesthetic agent, stellate ganglion (cervical sympathetic).  It will be paid at $162.50.

Code 93313 is echocardiography, real time with image documentation (two dimensional) with or without M-Mode recording, transesophageal; placement of transesophageal probe only.  The fee for 93313 has not changed; it remains at $49.98.

These codes should be billed without modifiers or minutes.

Correct Taxpayer ID Information for All Providers

The Internal Revenue Services considers a taxpayer identification number (TIN) as incorrect if either the name or number shown on an account does not match a name and number combination in their files or the files of the Social Security Administration (SSA).  If you do not take appropriate action to help BHSF correct this problem, the law requires us to withhold 31% of the interest, dividends, and certain other payments that we make to your account.  This is called backup withholding.

In addition to backup withholding, you may be subject to a $50 penalty by the IRS for failing to give us your correct name/TIN combination.

An individual's TIN is his or her social security number (SSN).  However, sometimes an account or transaction may not contain the actual owner's correct SSN.  An account should be in the name and SSN of the actual owner.

A corporation's TIN is the IRS number assigned to the business entity by the IRS.  The name and number in the Medicaid records must match what is in the IRS files.

Please send any necessary information changes to the address below or FAX to Provider Enrollment Section at (504) 342-3893.

Bureau of Health Services Financing
P. O. Box 91030
Baton Rouge, LA  70821-9030
Attention:  Provider Enrollment Unit

Addition of Payable Code for Chiropractors

Effective with dates of service September 1, 1994, CPT Code 97250 (Myofascial release/soft tissue mobilization, one or more regions) is being added to the list of codes payable to chiropractors.  The fee for this code is $25.61.

Medical Card Changes

The appearance of the monthly medical card produced by Unisys will be changing effective with the November 1994 card.

The new card will be printed on an 8 1/2 x 11 sheet, folded in half, and sealed into a one-piece mailer.  The card's edges will be perforated for easy removal.

The top half of the card will contain recipient eligibility information and the bottom half will contain messages, notices, and other pertinent Medicaid information.

You will find a sample of the new card provided on the following page.  Please note that only the inside portion of the card is shown.  The outside contains mailing information.

Sample of Card

LA Drug Utilization Review (LADUR) Education  

Antimicrobial Therapy in Acute Otitis Media

Otitis Media Treatment in Children
Antimicrobial therapy can shorten the duration of symptoms of otitis media and prevent complications such as mastoiditis and meningitis.  Some studies show that Streptococcus pneumonia accounts for approximately 35% of acute otitis media, non-typable strains of Hemophilus influenza accounts for approximately 25% of cases, Moraxella catarrhalis accounts for about 15% of cases and about 5% of cases is secondary to Streptococcus pyogenes.  Important to note is that about 70-90% of M. catarrhalis and about 30-40% of H. influenza otitis media produce beta-lactamase and are resistant to amoxicillin in vitro1.  Interestingly, about 15% of cultured middle ear fluid aspirate were sterile in some studies2.

Amoxicillin has been considered the drug of choice for initial treatment of acute otitis media.  Other agents have been used as alternatives3.  Antimicrobial resistance in acute otitis media is not clear.  Persistent symptoms may be secondary to a concurrent viral infection.  Recurrent infections may be secondary to a new bacterial strain 4 , 5.

The State of Louisiana has a drug formulary that allows the practitioner latitude in the selection of drug therapies.  The drug program thus provides for optimal drug coverage and flexibility for both the patient and practitioner.  The Department of Health and Hospitals believes that the nature of the drug program improves the health of recipients and reduces overall health costs to the state.  However, it is incumbent upon the prescribing practitioner to select drug therapy on the basis of both appropriateness of drug therapy for the clinical diagnosis and cost containment.

The Provider Update illustrates the potential of the prescribing physician as a sentinel for the patient's health care decisions while following guidelines necessary for a complete drug program.


Drug                                                                 Daily Dosage

Amoxicillin - Amoxil                                        40 mg/kg in 3 doses

Trimethoprim-sulfamethoxazole --                     8 mg/kg in 2 doses

Erythromycin-sulfamethaxazole --                      50 mg/kg erythromycin - 150 mg/kg
                                                                          sulfisoxazole in 4 doses

Amoxicillin-clavulanic acid -- Augmentin          40- mg/kg amoxicillin - 10 mg/kg
                                                                     clavulanic acid in 3 doses

Cefaclor -- Ceclor                                                       40 mg/kg in 2 or 3 doses

Cefixime -- Suprax�                                        8 mg/kg in 1 or 2 doses

Cefprozil -- Cefzil                                          30 mg/kg in 2 doses

Cefpodoxime -- Vantin                                  10 mg/kg in 2 doses

Cefuroxime axetil -- Ceftin�                             500 mg in 2 doses

Loracarbef -- Lorabid�                                    30 mg/kg in 2 doses

Guidelines for Otitis Media Treatment6

1.   Amoxicillin is the most rational choice for the initial treatment of acute otitis media when there is not a high incidence of ampicillin-resistant H. influenza and B. catarrhalis.

2.   If these resistant organisms are commonly observed, then one of the beta-lactamase resistant antibacterials should be used (i.e., Pediazole or Augmentin).

3.   If these treatments fail, the more expensive cephalosporins may be used such as Suprax, Ceftin, or Ceclor.  It is unnecessary and costly to use cephalosporins as a first line of treatment for otitis media.

Choice of Initial Therapy in Otitis Media7
Pediatric literature suggests that most children with acute otitis media are treated without a specific bacteriological diagnosis, and may have infections resolve during treatment with less than optimal drugs8.

Comparative clinical trails have generally shown that most of the drugs used to treat acute otitis media are about equally effective7.  Medical Letter consultants consider amoxicillin a suitable first choice for most patients.  For those who have recently taken amoxicillin or live in areas with a high pattern of betalactamase resistance, the use of alternative drugs may be warranted.

Despite the increasing prevalence of resistant pathogens, the Medical Letter consultants still consider amoxicillin the drug of choice for initial treatment of most children with acute otitis media7.


1. ME Pichichero, Pediatr Infec Dis J, 13:527, Jan 1994

2. CD Bluestone et al, Pediatr Infec Dis J, 11:57, 1992

3. Trimethoprim-sulfamethoxazole, erythromycin with a sulfonamide, amoxicillin/clavulanic acid, and various oral cephalosporins

4. M. Arola et al, J. Pediatr, 116:697. 1990

5. MA Del Beccar et al, J. Pediatr, 120:81, 1992

6. Clinical Formulary:Prescribing Guidelines, PCS Health Systems, Inc, Clinical Pharmacy Advantage 1994-95

7. The Medical Letter, vol 36 (issue 917) p. 20, March 4, 1994

8. JO Klein, Pediatric Infec Dis J, 12:973, Dec 1993


Guidelines for Urinary Tract Infection Treatment1

1.     Patients should take sulfonamides and antimicrobial agents with a full 8-ounce glass of water.  Several additional glasses of water should be taken every day.  When using sulfonamide derivatives, additional water intake is recommended to prevent crystalluria.

2.     Some sulfonamides may make some people more sensitive to sunlight.

3.     Sulfa drugs have been associated with the development of agranulocytosis, aplastic anemia, and other blood dyscrasias.  Periodic CBC monitoring in patients on long-term therapy is recommended.

4.     For uncomplicated UTI, use sulfamethoxazole/trimethoprim or ampicillin or amoxicillin as single dose or short course therapy.

5.     Consider chronic antimicrobial prophylactic therapy for patients with recurrent UTIs.  Effective treatments include 50-100 mg nitrofurantoin daily (assess renal function for appropriate dosing) and 1/2 tablet regular strength sulfamethoxazole/trimethoprim daily.  Monitor efficacy on a regular basis.

6.     More expensive fluoroquinolones are not recommended as first line treatment for an uncomplicated UTI.


Brand                                                 Generic            Dosage

Acute, Uncomplicated UTI

Bactrim/Septra                               TMP/SMX        2DS tabs x1 or 1 DS tab BID x 3 days

Vibra-Tabs                                      doxycyline         100 mg BID x 7days

Trimpex                                           trimethoprim      200 mg QB x 10 days

Complicated UTI (not for initial treatment)

Noroxin                                           norfloxacin         400 mg BID x 10 days

Floxin                                                  ofloxacin             200 mg BID x 10 days

Cipro                                              ciprofloxacin       500 mg BID x 10 days

Maxaquin                                        lomefloxacin       400 mg QD x 14 days

Guidelines for Fluroquinolone Use1

1.     All quinolones except for lomefloxacin can interact with theophylline, increasing the theophylline levels.  Use care when changing the doses of either drug.

2.     Concomitant administration of sucralfate, iron salts, zinc salts, or antacids with fluoroquinolones is not recommended.  Serum level of quinolone is decreased due to interference with absorption.

3.     Fluoroquinolones should not be used in children younger than eighteen years of age unless skeletal growth is complete.  For children 9-18 years of age with serious infections (e.g., CF) the benefits may outweigh the possible risks.

4.     Patients should be advised to drink fluids liberally when taking fluoroquinolones.

5.     Fluoroquinolones should be reserved for infections not likely to be responsive to other antibiotics or as a second line of defense after traditional therapy has been tried.  They are not first-line agents in treating most UTIs because of high cost of potential resistance.  Inappropriate use of these drugs will increase the rate of bacterial resistance.


1ME Pichichero, Pediatr Infect Dis J., 13:527, Jan 1994.

Diabetic Supplies for Adults

There has been some confusion in the pharmacy provider community regarding Medicaid coverage for disposable insulin syringes.

Adult Medicaid eligibles who are not QMBs (recipients having a one and seven in the third and fourth digits of their identification numbers) and who are NOT residents of nursing homes are eligible to receive diabetic supplies through the Medicaid Pharmacy Program.

For disposable insulin syringes, the prescriptions must contain the prescribing physician's written statement that the recipient is INSULIN DEPENDENT or INSULIN REQUIRING.

Disposable insulin syringes, blood glucose monitoring strips, and lancets are to be dispensed in the amount of 100 unit doses or a month's supply, whichever is greater.

Providers are to bill their usual and customary charges for these supplies.  The maximum payment allowed for these supplies will be the prevailing wholesale cost plus 50%.

Please be advised we have an extensive pharmacy audit program and observe for compliance with state and federal regulations in this area.  Any advertised prices are considered general public prices and may be utilized for audit purposes.

Case Management for Head Injury

In preparation for implementation of the Head Injury Maintenance waiver, case management agencies interested in enrolling as providers of case management services for that waiver population are hereby notified that applications for enrollment are being considered.

Providers will be subject to new regulations on case management implemented through emergency rulemaking effective July 22, 1994, and any subsequent department of bureau regulations issued.  Please note that reimbursement for case management persons with head injuries is available only for waiver participants.  Payment for claims for other Medicaid-eligible persons with head injuries is not available.  A maximum of 100 persons will be eligible for waiver services.

Employees providing case management under this service shall meet a least one of the following criteria.

  • A master's degreed social worker certified as required by state law with a minimum of one year experience as a social worker in a public or private social service agency.

  • A registered nurse currently licensed as a registered nurse in Louisiana and having a minimum of one year experience as a nurse in working with persons with head injuries.

  • A master's degreed rehabilitation therapist with a minimum of one year experience working with persons with head injuries.

In addition, case managers shall be required to participate in training approved by the Head Injury Foundation prior to providing services.

Requirements for agency enrollment are completion of PE-50, Disclosure of Ownership form and Board Resolution form.  Agencies may be subject to pre-enrollment inspection.

Enrollment packets may be requested by telephone or in writing from the following address:

Unisys/Louisiana Medicaid
8591 United Plaza Blvd., Ste. 100
Baton Rouge, LA  70809
Attn:  Provider Relations
(800) 473-2783
(504) 924-7051

Completed forms and appropriate attachments are submitted to

Bureau of Health Services Financing
Provider Enrollment Section
P. O. Box 91030
Baton Rouge, Louisiana  78021-9030

Providers requiring assistance in completing enrollment forms should contact Provider Enrollment section at (504) 342-9454.

Notice to Case Management Providers

Do not put any data in the prior authorization field for case management services with a date of service prior to August 1, 1994.  Doing so unnecessarily delays processing as your claims pend for review, code 190.  Services for dates of services prior to 8/1/94 do not require prior authorization and this item should be left blank when billing.

Extension of Units for Targeted Case Management

Extensions of case management units will require the following information prior to review.

  • The 13-digit Medicaid Identification Number

  • The recipient's social security number

  • A current Plan of Care/Service Plan (signed)

  • Service logs for the current calendar year

  • Progress notes for the current calendar year

  • A cover letter indicating why the request is being made and the anticipated number of units for the remainder of the year.

Reminder to Providers of Waiver Services

Home and Community Based Services (HCBS) waivers provide reimbursement for services necessary to maintain participants, in the community rather than an institution.  Currently, the HCBS waivers are Adult Day Health Care Waiver, MR/DD Waiver, Personal Care Attendant Waiver, and Home Care for the Elderly Waiver.  The Head Injury Maintenance Waiver will be implemented shortly.

Participants must meet all financial and medical criteria required for Medicaid payment for the alternative institutional care to qualify for waiver participation.  The number of persons who may participate is limited, and there are waiting lists for eligibility.

Only persons who have been determined eligible for a HCBS waiver slot may receive waiver services.  Possession of a valid Medicaid card is not justification for providing these services.  Reimbursement is available only for authorized services.

In waivers with more than one service, the case manager notifies the service provider chosen by the participant using the Form MR/DD 14, which specifies the service to be provided, number of authorized units of service, and special conditions such as scheduling.

Services are not authorized and are not to be provided without Form MR/DD 14.  Reimbursement for all services provided without a supporting Form MR/DD 14 must be repaid, and appropriate sanctions may be imposed on the offending provider, including disenrollment as a provider.  The following services are to be provided only when Form MR/DD 14 has been received from the case manager:

  • Respite

  • Personal Care Attendant

  • Substitute Family Care

  • Residential Habilitation (Supervised Independent Living)

  • Pre-Vocational Habilitation

  • Supported Employment

  • Day Habilitation

  • Environmental Modifications

  • Personal Emergency Response Systems

  • Assistive Devices

Case Management for the Elderly may be provided only for persons who have been determined eligible for Home Care for the Elderly Waiver.

Flat Fee-for-Service Reminders

We would like to remind physicians, optometrists, nurse-midwives , and dentists about their flat fee-for-service billing and payment methodology in effect since 1987.

Payment for surgery is made as a surgical package and payment to anesthesiologists for general anesthesia is paid based on actual time plus base units assigned to the surgical procedure.  Please keep in mind that Louisiana Medicaid does not pay for all procedures listed in the CPT Code Book, not do they pay for all procedures covered by Medicare.  Louisiana Medicaid does not pay for some procedures not covered by Medicare.  Consult your program's Provider Manual for specific information.

If you would like Louisiana Medicaid to consider a procedure for coverage, you must write to the agency and give the CPT (or HCPC) code, definition, and full description of the service and the benefits realized from that procedure.  It is helpful to the reviewing physicians is you can also send published material regarding the procedure.

All procedures described in CPT as "unlisted" must be accompanied by an operative report or other substantiation of medical necessity.  Always review your CPT and Provider Manual to determine if there is a HCPC code describing the procedure before billing an "unlisted" procedure.

Personal Emergency Response System

There has been some misunderstanding regarding documentation required for enrollment as a provider of Personal Emergency Response Systems.

Medicaid enrolled providers must be authorized by the manufacturer to distribute the systems.  A letter from a distributor does not constitute appropriate documentation for enrollment as a Medicaid provider for this service.

Echocardiography Code Fee Adjustments

Effective with date of service September 1, 1994, the Bureau of Health Services Financing is adjusting its fees for the following CPT codes.  The new fees are listed below.

Code                             Fee

93307                            $187.12

93308                            $92.06

93312                            $114.35

93320                            $103.98

93325                            $90.96

Mental Health Rehabilitation Reminders

1.     All clients must meet the target population criteria which became effective on July 1, 1994.  Be certain that the client records contain documentation supporting every component of that criteria.

2.     Every service provided must be record in the client record.  A record must be maintained indicating 1) start time, 2) end time, 3) total time/units billed, 4) type of service provided (i.e., treatment integration, individual therapy, etc.), 5) service provider, and 6) a detailed note describing the service provided.

3.     All staff must be qualified for the service(s) they are providing.  The personnel record must contain copies of degrees and verification of experience.  Remember, QMHPs experience must be in the delivery of mental health services!

4.     Clients must be given a freedom of choice form to sign for each component of service that they receive.  This must be signed and kept in the client's chart.

5.     Crisis Services are to be given only to clients with established Mental Health Rehabilitation Plans.  A person cannot be brought into the program via the Crisis Services.

6.     Medication Administration must be provided by a licensed nurse or physician or someone who has legal approval to administer medication.  Medication is not to be administered to recipients with other available access to their medication, this includes children at school.  Schools have a nurse who can administer medication.

7.     Schools cannot provide lists of Medicaid recipients.  Providers must not ask them to do so.

8.     A component of the Mental Health Rehabilitation Option must be offered in full by the provider.  No other provider can bill for any piece of that component.  (Ex., if you are the Rehab Manager, you are responsible for all necessary evaluations.  If a recipient needs a psychological evaluation, another Rehab Management Agency cannot provide that piece for you.)  Two different agencies cannot bill for any one component.

9.     All official regulations must come in writing from the Bureau of Health Services Financing (BHSF), better known as Medicaid of Louisiana.  If you hear or read something that does not come from BHSF, it is not an official regulation or policy.  If what you are told or read contradicts the manual, please call Kelly Coreil for clarification at (504) 342-9319.

Filing for Professional Services Reimbursement Under Pre-Certification/Length of Stay

Effective July 1, 1994, the Bureau of Health Services Financing began phasing in the implementation of a Hospital Pre-Admission/Length of Stay (LOS) review program.  Beginning January 1, 1995, BHSF will implement this review program for all hospitals excluding state-operated and out-of-state facilities.  Distinct part psychiatric facilities and long term hospitals will undergo pre-admission review and LOS assignment.  Acute care and rehabilitation hospitals will participate only in the LOS review process.

All physician hospital visits (procedure codes 99221 through 99223, 99231 through 99238, 99251 through 99255, 99431, and 99433) excluding inpatient visits to a state-operated or out-of-state hospital will be subjected to pre-certification requirements editing.  Follow the instructions below to obtain reimbursement for inpatient professional services effective with date of service January 1, 1995.

1.     Physician claims will not be paid without a certification on file for the hospital stay unless appropriate documentation is attached to the claim identifying the hospital stay (see #3 below).  If the service was performed in a state-operated hospital and the physician is not based as that facility, then the physician will have to identify this service by putting a "Y" in item #19 on the HCFA 1500 or on record type E in charity indicator field for EMC submissions.  For those physicians who are based as the state-operated facility, there is not need to identify your claims with a "Y" in this field.

2.     The physician should indicate the hospital pre-certification number on the HCFA 1500 item #23 or on EMC record type E in the prior authorization field if the physician has access to that number.  To ensure accurate, timely processing of your claim, we recommend that you place the pre-certification number on the claim.  However, if you do not have access to the pre-certification number, you can bill your claim without it and the claim recipient ID and dates of service will be used to find the hospital pre-certification on file.

The pre-certification number will be stored on the claim record and will be printed on the remittance advice.  The physician visit days will be paid according to the LOS approved dates for the hospital stay.  Before your claim can be paid, there must be an approved pre-certification record for the hospital stay on file at Unisys.

3.     In those cases when the hospital chooses not to bill Medicaid, the physicians may bill their claims with appropriate documentation (admit/discharge summary) so that medical necessity and LOS can be determined.  These claims will pend to the Unisys Pre-Certification Department for review and decision, and will be assigned a prior authorization number.  The physician will receive a notice letter indicating approval/denial status, days approved, and the PA number.  Inquiries about approval/denial or assigned length of stay should be directed to the Unisys Pre-Certification Department.  Your claim will be processed with the assigned PA number.

These new procedures will not negate of affect any of the policies and procedures currently in effect for hysterectomies, sterilizations, and outpatient surgeries performed in an inpatient setting.

Effective with dates of service July 1, 1994, you will no longer be required to attach documentation to claims for inpatient visits exceeding 15 days per year since this limitation has been eliminated.

DME Code Changes

The following changes have been made recently in DME procedure codes:

A      Code K0195 has been added as a payable code for "Elevating Leg Rests, Pair."

A price of $84.00 per pair has been added to the file for automatic pricing.

B      Code Z0100 has been added as a payable code for "Measuring/Fitting Fee, Stockings."  The Prior Authorization Unit will manually price this item.

Providers/Enrollment Centers

Providers who wish to assist their patients/clients in establishing Medicaid eligibility may become an Enrollment Center authorized to take Medicaid applications.  Enrollment Centers are provided training, forms, and updated eligibility information, and are reimbursed for the time involved.

Providers are reminded that Enrollment Centers receive a pre-application fee and shall not bill time involved in financial application activities as a Medicaid service such as case management.