Volume 14, Issue 

October 1997

New Technology to Enhance Louisiana Medicaid Publication Clarification
LADUR Article Changes/Adjustments in Dates of Service for Prior Authorization of DME Supplies and Equipment
Discontinued Codes Physician-Owned Laboratories
Clarification of Critical Care Policy Clarification of Professional Consultations Policy
Correct Taxpayer ID Information for All Providers New License Fees
Electronic Fund Transfer Notice to Providers: Noncoverage of CPT Codes
MDS Automation for LTC Facilities (NFs and SNFs) Global Surgery Period for Vaginal and Caesarean  Deliveries
Medicare Part B Crossover Claims Billing for Newborn Care and Discharge
Certified Nurse Midwives Non-Payable NDC Numbers

Criteria and Procedures for Approval of Customized Wheelchairs and Standard Construction Wheelchairs

New Technology to Enhance Louisiana Medicaid

Plastic ID Cards
Beginning in March 1998, Louisiana�s Medicaid Program will begin issuing plastic ID cards to its recipients. These new permanent identification cards will replace the monthly paper cards currently being issued as evidence of Medicaid eligibility. Use of these cards will require provider verification through the Recipient Eligibility Verification System (REVS) or the Medicaid Eligibility Verification System (MEVS) of recipients� current eligibility prior to provision of services. It is anticipated that the plastic ID cards will be piloted in DHH Region 5 and then phased in statewide.

Recipient Eligibility Verification System 
The Recipient Eligibility Verification System (REVS) is a telephonic system used to verify Medicaid eligibility. Enhancements are planned for the existing system.

With its enhancements, REVS will provide verbal confirmation, but no printed verification, of: 
- Recipient eligibility; 
- Third Party (Insurance) Resources; 
- Service limits and restrictions; 
- Community Care; 
- Lock-In; and 
- Managed Care.

REVS will continue to be accessed through touch-tone telephone equipment using the current Unisys toll-free telephone number, 1-800-776-6323, at no additional cost to enrolled providers.

Medicaid Eligibility Verification System 
The Medicaid Eligibility Verification System (MEVS) will be an electronic system used to verify Medicaid eligibility. It is anticipated that this verification process will expedite reimbursement, reduce claim denials, and help to eliminate fraud. Except for a short time needed each day for maintenance, MEVS will be available 24 hours a day, 7 days per week to allow providers easy and immediate retrieval of current recipient eligibility information.

MEVS will allow providers to retrieve printed verification of:
 - Recipient eligibility; 
- Third Party (Insurance) Resources; 
- Service limits and restrictions; 
- Community Care; 
- Lock-In; and 
- Managed Care.

MEVS can be accessed by any of three methods: 
- Point of sale technology, using �swipe card devices� similar to retail credit cards; 
- Personal computer (PC) software tailored to fit the individual provider�s specific needs; or 
- Computer terminal.

NOTE: MEVS access will be provided through contracts with �Switch Vendors� who will be responsible for provision of the magnetic card reader, PC software, or computer terminal necessary to access this system. Fees will be dependent on the types of services selected. All fees are the responsibility of the provider of service.

Multiple Eligibility Inquiry Access Capability
The Department of Health and Hospitals (DHH) is enhancing REVS and implementing MEVS to: 

- Assist providers by offering multiple mechanisms to provide necessary eligibility and third party liability information in a more efficient and expedient manner; 

- Allow constant access to eligibility and third party liability information by providers; and 

- Give providers ready access to provider inquiry telephone lines for billing and policy inquiries.

By this effort, DHH will allow each provider to select the verification method(s) most beneficial to his/her own needs. Providers are free to chose any one or more options. The REVS telephone option is available to all providers regardless of any MEVS option selected. 

Also, the REVS and MEVS systems will now allow access to recipient information using pieces of recipient information rather than only the recipient�s Medicaid ID number. Providers will now be able to access either system without a recipient ID number.

The responses providers will now receive from REVS and MEVS will include information not previously accessible through an automated system, such as PCP information, TPL information, managed care information, and lock-in information. 

Publication Clarification

We wish to make a clarification to the recently published booklet, �Nursing Home Care in Louisiana.� Following the publication, an error was noted on page 34 in the last paragraph of the page in the �Note� section. The first sentence, �While the nursing home is responsible for arranging for many services, such as transportation, therapy and dental work, the nursing home is not required to assume financial responsibility for these services,� is incorrect. Transportation to medical appointments within reasonable proximity to the facility and therapy if the resident is certified at the Medicaid skilled level of care are considered to be included in the facility�s per diem paid by Medicaid. This sentence will be deleted from future printings of the booklet.

A Review of Current Antiretroviral Therapy for Treatment of 
Human Immunodeficiency Virus (HIV) Infection: Part II

By Nancy M. Toedter, Pharm.D.Assistant Professor of Clinical Pharmacy Northeast Louisiana University School of Pharmacy By Nancy M. Toedter, Pharm.D.Assistant Professor of Clinical Pharmacy Northeast Louisiana UniversitySchool of PharmacyNancy M. Toedter, Pharm.D.Assistant Professor of Clinical Pharmacy Northeast Louisiana University School of Pharmacy

ISSUES . . . 
- Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs) are the newest class of antiretroviral agents, and they should always be administered in combination regimens to prevent development of resistance. 
- Protease inhibitors act at a later stage in the HIV replication cycle than other antiretroviral agents and are therefore recommended as part of combination regimens for greater potency. 
- Combination regimens with various antiretroviral agents present a challenge to patients and physicians, as various toxicities, potential drug interactions, and difficult dosing schedules are associated with their use.

This is the continuation of the discussion on current antiretroviral therapy for treating HIV infection. Part I discussed the HIV replication cycle and the nucleoside reverse transcriptase inhibitors (NRTIs), which work early in the replication cycle and prevent infection of new cells. Currently available NRTIs include zidovudine (Retrovir�), didanosine (Videx�), zalcitabine (Hivid�), stavudine (Zerit�), and lamivudine (Epivir�). These agents have similar mechanisms of action but differ in their dosing instructions and toxicity profiles. Part II of this article discusses non-nucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors. Again, it should be emphasized that three-drug combination regimens, such as two NRTIs + a protease inhibitor, are recommended because of their potency and ability to reduce plasma viral loads to below the level of detection.

Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs)

NNRTIs are the newest class of antiretroviral agents, and similar to the nucleoside analogues (e.g., zidovudine, didanosine, lamivudine, etc.), these drugs work early in the HIV replication cycle and prevent infection of new cells. The mechanism of action of NNRTIs differs from that of the nucleoside reverse transcriptase inhibitors (NRTIs). The nucleoside analogues require intracellular conversion to their active triphosphate form and then compete with naturally occurring substrates for binding to HIV reverse transcriptase; they also cause viral DNA chain termination when incorporated into a growing viral strand. NNRTIs, on the other hand, bind directly to the reverse transcriptase enzyme and prevent the conversion of RNA to DNA by disrupting the enzyme�s catalytic site. NNRTIs do not compete with natural substrates or nucleoside triphosphates, and they do not require conversion to an active form. Additionally, NNRTIs should always be administered in combination with other antiretroviral agents as resistance rapidly develops when administered as monotherapy. Rash is the most common adverse effect associated with these drugs. Currently, there are two NNRTIs which are available: nevirapine (Viramune�) and delaviradine (Rescriptor�). 6, 11, 14, 15

Nevirapine (Viramune�)
Nevirapine was the first NNRTI to be approved and is indicated for use in combination with nucleoside analogues for treatment of HIV infection. It should never be used as monotherapy because resistance rapidly emerges. 14

The most frequently reported adverse effects include rash, fever, nausea, headache, and abnormal liver function tests. The major clinical toxicity of nevirapine is rash. Rashes are usually mild to moderate, although severe and life-threatening rashes (including Stevens-Johnson syndrome) have occurred. Abnormal liver function tests, including cases of hepatitis, have also been reported. 14Drug interactions with nevirapine are due to its induction of hepatic cytochrome P450 CYP3A metabolic enzymes, which result in lower plasma concentrations of drugs extensively metabolized by these isoenzymes. The protease inhibitors are metabolized via this pathway, so concurrent administration with nevirapine may decrease plasma concentrations of protease inhibitors. Until further data are available evaluating the need for dosage adjustments, concomitant use of nevirapine with protease inhibitors should be avoided. Nevirapine should also not be administered concomitantly with oral contraceptives. 14

Nevirapine is dosed using a lead-in period to reduce the frequency of rash. Dosing should be initiated at 200mg daily for the first 14 days, followed by 200mg twice daily thereafter. If any rash occurs during the two week lead-in period, then the dose should not be increased until the rash resolves. Nevirapine may be taken without regard to meals.14

Delaviradine (Rescriptor�)
Delaviradine is one of the newest antiretroviral drugs currently on the market. Like nevirapine, delaviradine should always be given in combination with other antiretroviral agents to prevent rapid emergence of resistance. Rash is also the predominant toxicity associated with delaviradine and usually occurs within one to three weeks after starting treatment. In most cases, the rash is transient and does not require drug discontinuation. Unlike nevirapine which is dosed using a lead-in period to reduce the frequency of rash, dose titration with delaviradine does not significantly reduce the incidence of rash. Delaviradine is primarily metabolized by the cytochrome P450 isoenzyme CYP3A, and it also has an inhibitory effect on this same isoenzyme. Various drug interactions have been documented or could potentially occur, and may even result in potentially serious and/or life-threatening adverse events. 15

Delaviradine is dosed 400mg (4 x 100mg tablets) three times daily. Taking twelve delaviradine tablets per day in addition to all of their other medications can be difficult for many patients. It may be easier to allow the tablets to disperse in water and then consume the dispersion. Delaviradine may be administered with or without food, but it should be spaced apart from antacids by at least one hour. 15

Protease inhibitors have had a major impact on the treatment of HIV infection. They have been shown to significantly reduce viral loads and increase CD4+ cell counts in patients with HIV infection. Unlike nucleoside analogues and NNRTIs which work early in the HIV replication cycle and prevent infection of new cells, protease inhibitors act in the later stages of the cycle and inhibit replication in chronically infected cells (cells in which the HIV genetic material is integrated into the host-cell genome) and prevent spread of the virus to other cells. 6, 16 These drugs work by inhibiting the viral protease enzyme, which is responsible for cleaving precursor polyproteins into smaller functional proteins, and thus prevent the formation of mature, infectious viral particles. Instead, an immature virus that is incapable of infecting new cells is formed. Since protease inhibitors target a different enzyme in the viral replication process, synergism occurs when these drugs are combined with reverse transcriptase inhibitors. 16

Protease inhibitors have been well tolerated in clinical trials. Gastrointestinal symptoms including nausea, vomiting, diarrhea, and abdominal discomfort are the more common adverse effects reported. Hematologic toxicities, peripheral neuropathies, and pancreatitis associated with certain reverse transcriptase inhibitors have not been reported with protease inhibitors. These agents can be used in combination regimens without sharing overlapping toxicities. 16, 17 Please note that the FDA has recently warned that protease inhibitors may increase blood sugar and thus may lead to new or worsening diabetes. Glucose levels should be monitored in patients taking protease inhibitors.

There are special considerations with protease inhibitors regarding administration, drug interactions, and resistance problems. Depending on the specific protease inhibitor, it may be dosed two or three times per day, administered with or without food, and may require anywhere from six to twelve tablets/capsules per day. The dosing schedule and large pill burden may be difficult for some patients.

There is a potential for many drug interactions with protease inhibitors, and this can be quite problematic. These drugs are primarily metabolized via the cytochrome P450 3A4 (CYP3A4) enzymes. Therefore, drugs that induce the activity of these isoenzymes (e.g., rifampin, phenobarbital, and carbamazepine) can produce subtherapeutic concentrations of protease inhibitors, resulting in the development of resistance. Additionally, protease inhibitors themselves inhibit the CYP3A4 isoenzyme, which can result in serious or life-threatening adverse effects when they are administered concurrently with certain nonsedating antihistamines, sedative hypnotics, and antiarrhythmics. 16

 Resistance has been seen with all currently available protease inhibitors. Cross-resistance among certain protease inhibitors, particularly between ritonavir and indinavir, has also been reported. Administering protease inhibitors in combination with reverse transcriptase inhibitors rather than as monotherapy may help minimize development of resistance. Furthermore, it is essential that protease inhibitors be administered without interruption and at full therapeutic doses to prevent resistance. 6, 16

Protease inhibitors are quite expensive. Retail prices for these drugs range from approximately $500 - 675 per month at recommended doses, although prices among pharmacies may vary. Since protease inhibitors are almost always used in combination with other antiretroviral agents, monthly costs to patients can be staggering. Laboratory costs are also necessary to monitor for clinical efficacy and for potential adverse effects. 16, 17 A brief review of currently available protease inhibitors follows.

Saquinavir (Invirase�)
Saquinavir was the first protease inhibitor approved in the United States. It is currently indicated only in combination with nucleoside analogues and should not be used as monotherapy. The current formulation has limited efficacy, most likely due to its high first-pass metabolism and low oral bioavailability (4%). A new soft-gel formulation with improved bioavailability and thus greater antiviral activity should be approved soon. 7, 17

Saquinavir is dosed 600mg (3 x 200mg capsules) three times daily and should be taken with a high-fat meal to improve absorption. Escalated doses (up to 7200mg/day) are being studied and have revealed higher drug plasma levels and thus improved efficacy with only a slight increase in side effects. 6, 16, 18

Saquinavir appears to be the best tolerated protease inhibitor. Adverse effects are generally mild with gastrointestinal disturbances (diarrhea, nausea, abdominal pain) and headache occurring most commonly. Specific laboratory monitoring is not necessary for saquinavir therapy. 16, 17

Ritonavir (Norvir�)
Ritonavir was the second protease inhibitor to be approved and may be used in combination with nucleoside analogues or as monotherapy. It is very potent and has demonstrated dramatic effects on plasma viral load and CD4+ cell counts. In contrast to saquinavir, ritonavir has greatly improved oral bioavailability. 6, 17 Ritonavir has also just been recently approved for use in children.

Ritonavir is dosed 600mg (6 x 100mg capsules) twice daily and should be taken with food. Some patients may not initially tolerate full doses, so ritonavir may be given via dose escalation. It may be initiated at 300mg twice daily and gradually increased over 1-2 weeks as tolerated to 600mg twice daily. Ritonavir should be stored in the refrigerator. 16, 17

Ritonavir is associated with more adverse effects than the other protease inhibitors, especially during the first few weeks of therapy. Adverse effects commonly reported with ritonavir include nausea, vomiting, diarrhea, taste disturbances, asthenia, paresthesias, abdominal pain, and headache. Tolerance to these adverse effects should improve with time. Laboratory abnormalities associated with ritonavir therapy include elevated triglycerides and liver transaminases; thus, periodic monitoring is indicated. 16, 17

Ritonavir is a particularly potent inhibitor of the hepatic cytochrome P450 enzyme system. Therefore, certain drugs metabolized by this pathway should not be administered concurrently with ritonavir. Since this includes many drugs, careful attention is necessary to avoid adverse drug interactions. 6, 7, 16 Please refer to the package insert for a complete list of contraindicated concurrent medications.Indinavir (Crixivan�)Indinavir was the third protease inhibitor to be approved. It is comparable in potency to ritonavir and has improved bioavailability over the current formulation of saquinavir. It is approved for use as monotherapy or preferably in combination with nucleoside analogues. 6, 16 

Indinavir is generally well tolerated. The most common adverse effects include abdominal pain, nausea, vomiting, diarrhea, and headache. An indirect hyperbilirubinemia has also been noted in patients, but it is not associated with hepatitis or liver damage and usually resolves with continued therapy. Another important adverse effect is nephrolithiasis, which occurs in approximately 4% of patients. Indinavir can precipitate in the renal collecting system, eventually leading to stone formation. Discontinuing therapy is not necessary. To prevent this complication, patients should drink at least 1.5 liters of fluid per day. 6, 16, 17

Indinavir is dosed 800mg (2 x 400mg capsules) every 8 hours. It should be taken at intervals of 8 hours, and not simply three times per day, in order to maintain constant therapeutic levels. Indinavir should also be taken on an empty stomach, one hour before or two hours after a meal. If necessary, it can be taken with a light, low-fat meal (e.g., toast, juice, and coffee, or cornflakes and milk). Such dosing restrictions may reduce patient compliance. Because of its sensitivity to moisture, indinavir should be stored in the original container. 16, 17, 19

Similar to the other protease inhibitors, indinavir should not be administered concurrently with agents that interact with cytochrome P450 3A4 enzymes (including terfenadine, astemizole, cisapride, triazolam, and midazolam) because potentially serious adverse events may result. Also, didanosine�s buffering agent can affect indinavir absorption, so the two drugs should be spaced apart by at least one hour. 17, 19

Nelfinavir (Viracept�)
Nelfinavir is the newest protease inhibitor to be approved. It may be used as monotherapy or in combination with nucleoside analogues. Since antiviral activity is enhanced when nelfinavir is administered with nucleoside analogues, the manufacturer recommends combination therapy. It is approved for use in both adult and pediatric patients. 20 Its potency is similar to that of ritonavir and indinavir but greater than that of saquinavir. 21

Nelfinavir is well tolerated with the most common adverse effect being mild-to-moderate diarrhea. Similar to the other protease inhibitors, nelfinavir affects hepatic metabolism of other drugs. Its drug interaction profile is similar to that of indinavir and should not be used concurrently with terfenadine, astemizole, cisapride, midazolam, or trizolam. In adults, nelfinavir is dosed 750mg (3 x 250mg tablets) three times daily. It should be taken with food for increased absorption. 17, 20

Many antiretroviral agents are currently available for treatment of HIV infection, and several more will soon come to market. Although some of these medications are approved for use as monotherapy, combinations of drugs with different sites or mechanisms of action and with nonoverlapping toxicities are more effective and should be used. Antiretroviral agents offer patients and practitioners a challenge as various toxicities, potential drug interactions, and difficult dosing schedules are associated with their use. Ensuring patient compliance not only improves patient outcomes but also reduces the potential for the development of resistance.


1. State of Louisiana Office of Public Health HIV/AIDS Services.

2. Fletcher CV, Collier AC. Principles and management of human immunodeficiency virus infection. Pharmacotherapy: A Pathophysiologic Approach. 3rd Edition. Stamford, CT: Appleton and Lange; 1997: 2353-2386.

3. Acosta EP, Fletcher CV. Agents for treating human immuno deficiency virus infection. Am. J. Hosp. Pharm. 1994; 51: 2251-67.

4. Sande MA, Volberding PA, eds. The Medical Management of AIDS. 4th Edition. Philadelphia, PA: W.B. Saunders Company, 1995.

5. Hirsch MS, D�Aquila RT. Therapy for human immunodeficiency virus infection. New England Journal of Medicine. 1993: 328 (23): 1686-1695.

6. Threlkeld SC, Hirsch MS. Antiretroviral therapy. Med. Clin. North Am. 1996: 80 (6): 1263-1282.

7. Carpenter CCJ, Fischl MA, Hammer SM, et al. Antiretroviral therapy for HIV infection in 1996. JAMA. 1996: 276 (2): 146-54.

8. BHIVA Guidelines Co-ordinating Committee. British HIV association guidelines for antiretroviral treatment of HIV seropositive individuals. Lancet. 1997: 349: 1086-92.

9. Glaxo Wellcome. Package Literature for Retrovir. September 1996.

10. Graham NMH, Hoover DR, Park LP, et al. Survival in HIV-infected patients who have received zidovudine: comparison of combination therapy with sequential monotherapy and continued zidovudine monotherapy. Ann. Intern. Med. 1996: 124: 1031-38.

11. McEvoy GK, ed. AHFS Drug Information �97. Bethesda, MD: American Society of Health-System Pharmacists, Inc. 1997.1

2. CAESAR Coordinating Committee. Randomised trial of addition of lamivudine or lamivudine plus loviride to zidovudine-containing regimens for patients with HIV-1 infection: the CAESAR trial. Lancet. 1997: 349: 1413-21.

13. Glaxo Wellcome. Package Literature for Epivir. September 1996.

14. Roxane Laboratories. Package Literature for Viramune. June 1996.

15. Pharmacia & Upjohn. Package Literature for Rescriptor. April 1997.

16. Sperling J, Jennings TS. Formulary considerations for selection of protease inhibitors. P & T. 1997: 22 (5): 145-53.

17. Deeks SG, Smith M, Holodniy, et al. HIV-1 protease inhibitors: a review for clinicians. JAMA. 1997: 277 (2): 145-53.

18. Roche Laboratories. Package Literature for Invirase. January 1997.

19. Merck & Co. Package Literature for Crixivan. March 1996.

0. Agouron Pharmaceuticals. Package Literature for Viracept. March 1997.

21. More new drugs for HIV and associated infections. The Medical Letter on Drugs and Therapeutics. 1997: 39 (issue 994): 14-16. 

Changes/Adjustments in Dates of Service for Prior Authorization of DME Supplies and Equipment

Please note that the date of service on the prior authorization request does not usually correlate to the date of delivery, since the date of service is an anticipated date. It is necessary, though, for the date of service entered on a claim form to match the date of service on the prior authorization file for a claim to process. It is also necessary that the delivery be made prior to, or at the same time as, the submittal of the claim for payment. A provider cannot submit a claim form for payment before delivery. Therefore, when a delivery is made much later than the anticipated date of service on the prior authorization file, a problem can result in the timely processing of claims for payment.

Because of some recent questioning of the appropriateness of changing dates of services in certain situations, the Department of Health and Hospitals (DHH) has issued the following guidelines for the Prior Authorization staff at Unisys to follow when reviewing a request from DME providers to adjust or change the dates of service for DME items after a request has been authorized. Requests to Unisys to adjust the dates of services can be considered only in the four (4) instances described below.

1. A telephone authorization had been obtained for DME services to be provided after a recipient�s discharge from a hospital facility. If the discharge was delayed beyond the anticipated date of discharge and service, a date of service may be adjusted, at the provider�s request, to reflect the actual discharge date as the date of service.

2. A change in providers after prior authorization is given for services may justify a change in the �thru� or end date of service for the old provider�s PA file.

3. When a delay in the delivery of an item, after its prior authorization by Unisys, is justified as unavoidable by the provider. The date of service would then be adjusted to match the delivery date. The provider must document the reason for the delay and the actual day of delivery (documented with a delivery ticket). An adjustment of the date of service may be considered, however, if the date of delivery is within six months of the original, anticipated date of service that was entered onto the prior authorization file when the request was approved. Any delays of delivery longer than six months after the date of service on the PA file cannot be considered for date of service adjustment. Delays by the provider in submissions of a claim for payment, not involving a justified delay in delivery, cannot be considered by the Prior Authorization Unit as a reason for changing the dates of services on the PA file. Any delays by the provider in submitting a claim after delivery, which result in a problem in meeting the timely filing deadlines, can be considered only for resolution through the established procedures for an override of the timely filing limits for claims.

4. If a provider is approved for a service and is able to deliver the approved item at an earlier time than the anticipated date of service that was entered on the Prior Authorization file, the provider may ask that the date of service be adjusted to an earlier date to match his/her earlier delivery date. The provider must send documentation with the request (copy of the delivery ticket).

Please be advised that all requests for adjustments of dates of services must be sent in writing to the Prior Authorization Unit at Unisys. Requests should always include the reason for the adjustment and documentation of the delivery date. Telephone requests cannot be taken.

Please be reminded of the need to allow enough time in the dates of service used on your PA request to allow for PA turnaround time, and any other anticipated delays in service, to attempt to match the date of service as closely as possible to the date of delivery of an item. This is important in order to avoid any potential problems in the timely filing and processing of your claims for payment. 

Please also be reminded that any information on DME claims (not prior authorization requests) for payments cannot be changed after submittal.

Discontinued Codes

Please note that effective 12/31/97, codes A4347 and K0132 will be discontinued, and providers are asked to begin using K0410 and K0411, effective immediately, for all new prior authorization requests for these types of male external catheters. Thank you for your cooperation.

Physician-Owned Laboratories 

Effective January 1, 1998, claims on Medicaid-only recipients with procedure codes for laboratory services covered by a CLIA certificate (all laboratories including physician-owned) will be denied if your CLIA certificate number is not on file. Current CLIA certificates with a current CLIA period of eligibility may be faxed to the Provider Enrollment Unit at (504) 342-3893. The fax cover sheet must include the provider number(s) to which the certificate applies. 

Clarification of Critical Care Policy

For recipients 21 years of age and older, if critical care and a hospital visit are billed for the same recipient for the same date of service by the same or different providers, the critical care claim, if justified by documentation, will be paid and the visit code will be denied or voided. Also, all providers are reminded that Louisiana Medicaid does not cover concurrent care for recipients 21 years of age or older.

Clarification of Professional Consultations Policy

A question has arisen as to whether a provider of professional services must adjust his/her fee for an inpatient consultation on a patient 21 years of age or older to that of a visit if he sees the same patient a month or even later for treatment for the same condition. The answer to this question is that it depends on the provider�s assessment of the patient�s condition at the conclusion of the consultation.

If the professional sees the patient for an initial consultation and feels, by the conclusion of the consultation, that he/she will not need to see the patient again, he/she may keep the consultation fee even if the patient returns at a later date for treatment. The provider should document the record after the consultation with the statement that the patient�s condition does not appear to warrant further treatment.

However, if by the end of the consultation the professional knows or suspects the patient will have to return for treatment, he/she should bill the appropriate level evaluation and management code rather than a consultation code. Again, he should document the record to denote the fact that he/she expects to treat the patient again.

Regarding future reviews by the Surveillance and Utilization Review team, if the provider�s intent regarding future visits is not addressed in the documentation for the consultation, it will be assumed that the provider intended to see the patient again, and the consultation fee will be adjusted to a visit fee.

Correct Taxpayer ID Information For All Providers

The Internal Revenue Service considers a Taxpayer Identification Number (TIN), also known as Employer Identification Number (EIN), as incorrect if either the name or number shown on an account does not match a name or number combination in their files or the files of the Social Security Administration (SSA). Each year at this time we receive a tape from the IRS which shows numerous mismatches from our Medicaid provider files and the IRS files for previous years.

If the appropriate action is not taken to correct the mismatches, the law requires the agency 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 the information in the IRS files.

If you submitted a Form SS-4 to the Internal Revenue Service for a new employer identification number in 1997, and you obtained a new number, please send or fax a copy of your Notice of New Employer Identification Number Assigned to the Provider Enrollment Unit. In a letter or on the fax cover sheet, please list the Medicaid provider numbers affected by any changes. The address is listed below and the fax number is (504) 342-3893.

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

New License Fees

The 1997 Louisiana Legislature enacted Section 1.R.S.40:2006 Fees: licenses; penalties effective July 1, 1997. The DHH/BHSF - Health Standards Section will implement this new state licensing fee of six hundred dollars ($600) effective January 1, 1998 for the following facility types: 

        Adult day health care facility; Substance abuse/addiction treatment facility; Ambulatory Surgery Center; Case
        management provider; Urine drug screening providers; Home health agencies; Hospice; Hospital; Nursing
        Home; Rural health clinic; Intermediate care facility for the mentally retarded (ICF/MR).

An additional fee of five dollars ($5) per unit (room or station) shall be assessed for the following: 

        Hospice; Hospital; Nursing Home; Intermediate care facility for the mentally retarded (ICF/MR); 
        Substance abuse/addiction treatment facility.

Any facility operating a satellite, branch, or off-site office shall be assessed a fee of three hundred dollars ($300) per satellite, branch, or off-site office.

A delinquent fee of one hundred dollars ($100) shall be assessed for failure to timely renew a license and/or any subsidiary license (satellite, branch, or off-site office). The delinquent fee is applicable to all of the above mentioned facility types.

Electronic Fund Transfer

The Bureau of Health Services Financing (BHSF) is currently in the planning stages of implementing electronic fund transfer (EFT), also known as direct deposit, of the weekly Medicaid payments to participating providers. The effective date of EFT transmission is the first check write after the beginning of the next state fiscal year (7/1/98).

A Medicaid Direct Deposit Authorization Agreement form is being developed. Agreements will be forwarded to participating providers in the near future.

he agency will be enrolling providers for this service after the beginning of the next calendar year (1/1/98).

dditional information will be forthcoming in the form of RA messages, letters from the Bureau, and/or letters from various provider associations.

Notice to Providers: Noncoverage of CPT Codes

The February 15, 1997 issue of Medicare Providers� News includes articles regarding noncoverage of the following CPT codes:

95921 and 95922 - RR Interval Calculation procedures

95923 - Quantitative Sudomotor Axon Reflex Test (QSART) - Reiteration

Because these codes are considered by Medicare as not medically necessary or investigational, effective with date of service 10/1/97, these codes were placed in non-pay status.

MDS Automation for LTC Facilities (NFs & SNFs)

HCFA anticipates that by the Spring of 1998 LTC Nursing Facilities (NFs) and Skilled Nursing Facilities (SNFs) will transmit Minimum Data Set (MDS) data via modem to the DHH/Health Standards Section office in Baton Rouge. HCFA has designated �Netscape� as the standard communication software for transmission. All NF and SNF facilities recently received an MDS Automation Survey. According to the survey, most facilities have purchased MDS version 2.0 software. The following are computer hardware requirements for running the MDS and Netscape programs.

- 386 PC, network or stand alone 
- Windows 3.1 or Windows 95 
- 8 megabytes of RAM 
- 20 megabytes of available hard disk space 
- 3.5� floppy disk drive 
- Color VGA monitor 
- 14.4 kbps modem connected to a dedicated (single) phone line 
- Netscape Personal Edition 2.02

- At least 486 PC, network or stand alone 
- Windows 95 or Windows NT 4.0 
- 16 megabytes of RAM 
- 80 megabytes of available hard disk space 
- 3.5� floppy disk drive 
- CD-ROM drive 
- Mouse 
- 28.8 modem connected to a dedicated (single) phone line 
- Netscape Personal Edition 3.0 or Netscape Communicator 4.03

Address inquiries to Cathy Brunson, RN, MDS Coordinator, (504) 342-5438, or contact the HCFA MDS Website at

Global Surgery Period for Vaginal and Caesarean Deliveries

Please be informed that the CPT codes for delivery are now included in the global surgery edits. The Global Surgery Period (GSP) for each code is as follows:

59410 and 59610 - 59614: GSP of 3 days
59515 and 59618 - 59622: GSP of 4 days

The fee for delivery includes inpatient visits made the day prior to delivery, the day of delivery, and for the GSP after delivery. If an outpatient visit is made the day prior to delivery and billed with the proper �Z� code, the outpatient visit will be paid.

Medicare Part B Crossover Claims

Effective with date of service July 1, 1997, the full co-insurance and deductible on Medicare Part B crossover claims for professional and portable x-ray services are being reimbursed on dually-eligible Medicare/Medicaid recipients.

Billing for Newborn Care and Discharge

In the August 1997 issue of the Provider Update, an article concerning billing of newborn and discharge codes appeared on page 7. This article was printed because it has come to the attention of BHSF that providers are billing procedure code 99433 instead of code 99238, for services provided to newborns on the date of discharge in an effort to maximize payment for discharge service. Please be advised that Medicaid policy requires providers to bill discharge code 99238 when discharge services are provided. The newborn care code 99433 should not be billed on the discharge date in lieu of code 99238. It is appropriate to bill code 99433 when billing subsequent hospital care on days other than the discharge date.

Additionally, procedure code 99435 (History and examination of normal newborn infant) should be used only for newborns admitted and discharged from the hospital or birthing room on the same date.

Certified Nurse Midwives

Recently Certified Nurse Midwives were notified of additional payable codes effective with date of service July 1, 1997. Code 87353 was included in error. The correct code is 87253. We are sorry for any inconvenience this may have caused you.

Non-payable NDC Numbers

We have been notified by Zenith Goldline Laboratories (Best Generics) through submission of drug utilization rebate data that pharmacists are billing and getting reimbursed for NDC numbers which have been terminated and are expired. Please be advised that Zenith Goldline Laboratories� (Best Generics) drug products have been coded to non-payable status. Please ensure when billing drug products that you use the NDC from the package from which you are dispensing.

Criteria and Procedures for Approval of Customized Wheelchairs 
and Standard Construction Wheelchairs

Medicaid policy for the prior authorization of customized wheelchairs requires that a seating evaluation be conducted by a rehabilitation therapist for each request submitted for a customized wheelchair. BHSF considers a rehabilitation therapist, in this context, to be a licensed physical or occupational therapist.

The Prior Authorization Unit of Unisys will deny any prior authorization request submitted for a customized wheelchair which does not have a seating evaluation signed by a licensed physical therapist or occupational therapist.