Volume 15, Issue 5
HCFA CIVIL RIGHTS COMPLIANCE STATEMENT
The Health Care Financing Administration�s vision in the current Strategic Plan guarantees that all our beneficiaries have equal access to the best health care. Pivotal to guaranteeing equal access is the integration of compliance with civil rights laws into the fabric of all HCFA program operations and activities. I want to emphasize my personal commitment to and responsibility for ensuring compliance with civil rights laws by recipients of HCFA funds.
These laws include: Title VI of the Civil Rights Act, as amended; Section 504 of the Rehabilitation Act, as amended; the Age Discrimination Act of 1975, as amended; the Americans with Disabilities Act of 1990, as amended; and Title IX of the Education Amendments of 1972, as well as other related laws.
The responsibility for ensuring compliance with these laws is shared by all HCFA operating components. Promoting attention to and ensuring HCFA program compliance with civil rights laws are among our highest priorities for HCFA, its employees, contractors, State agencies, health care providers, and all other partners directly involved in the administration of HCFA programs. HCFA, as the agency legislatively charged with administering the Medicare, Medicaid and Children�s Health Insurance Programs, is thereby charged with ensuring these programs do not engage in discriminatory actions on the basis of race, color, national origin, age, sex or disability.
HCFA will, with your help, continue to ensure that persons are not excluded from participation in or denied the benefits of its programs because of prohibited discrimination. To achieve its civil rights goals, HCFA will continue to incorporate civil rights concerns into the culture of our agency and its programs, and we ask that all our partners do the same.
We will include civil rights concerns in the regular program review and audit activities including: collecting data on access to, and the participation of, minority and disabled persons in our programs; furnishing information to recipients and contractors about civil rights compliance; reviewing HCFA publications, program regulations, and instructions to assure support for civil rights; and working closely with the Department of Health and Human Services (DHHS), Office of Civil Rights, to initiate orientation and training programs on civil rights.
HCFA will also allocate financial resources to the extent feasible to: ensure equal access; prevent discrimination; and assist in the remedy of past acts adversely affecting persons on the basis of race, color, national origin, age, sex, or disability. DHHS will seek voluntary compliance to resolve issues of discrimination whenever possible. If necessary, HCFA will refer matters to the Office for Civil Rights for appropriate handling. In order to enforce civil rights laws, the Office for Civil Rights may:
1) refer matters for an administrative hearing which could lead to suspending, terminating, or refusing to grant or continue federal financial assistance; or
2) refer the matter to the Department of Justice for legal action. HCFA�s mission is assure health security for the diverse population that constitutes our nation�s Medicare and Medicaid beneficiaries; i.e., our customers.
We will enhance our communication with constituents, partners, and stake holders. We will seek input from health care providers, states, contractors, and DHHS Office for Civil Rights, professional organizations, community advocates, and program beneficiaries. We will continue to vigorously assure that all Medicare and Medicaid beneficiaries have equal access to and receive the best health care possible regardless of race, color, national origin, age, sex, or
Nancy-Ann Min DeParle
Health Care Financing Administration
BCG Live Price Increase
The Bureau of Health Services Financing is pleased to inform you of a price increase for code J9031 - BCG Live (Intravesical), per vial, effective with date of service September 1, 1998. The increased fee is $100.00 per
Increased Fees for Cochlear Implant Devices
Recently you were notified of the funding, effective with date of service August 1, 1998 for the cochlear implant device for recipients with profound-to-total bilateral hearing loss. Please be informed the fees for the cochlear implant device, the speech processor repair, the headset replacement, and the microphone repair listed in the recent publication have been increased. The increased fees, effective with date of service August 1, 1998, are stated
L8614 Cochlear Implant Device $18,350.00
L8700 Speech Processor Repair $395.00
L8701 Headset Replacement $400.00
L8702 Microphone Repair $288.00
Fee Increase for Code 87536
The Bureau of Health Services Financing is pleased to inform you of a fee increase for procedure code 87536 - (HIV-1, quantification) to $80.00, effective with date of service
Rhogam Injection Claims
Recently you were notified of a fee increase for the Rhogam injection (code 90742) to $72.72, effective with date of service June 1, 1998. We recently learned the fee on file was not updated to reflect the increased fee. As a result, claims with dates of service 6-1-98 forward have been paying incorrectly. Please be informed a recycle of these claims will be completed shortly.
Breast Reconstruction Fees and Policy
The Bureau of Health Services Financing is pleased to announce the funding of breast reconstruction codes 19364 and 19366 effective with date of service October 1, 1998, at a fee of $1288.33 and $1067.34, respectively. The assistant surgeon fees are $257.67 and $213.47, respectively. These two procedures will each be allowed six base units of anesthesia.
Also effective October 1, 1998, procedure codes 19350 and 19357 will no longer require prior authorization. Claims within the range of 19350 through 19369 will pend for medical review; therefore, they must be submitted hardcopy with the patient�s history and operative report attached. Claims submitted electronically or with no attachments will
Procedure Codes 00096, 00097, and 00099Now Payable to All
Please be informed effective with date of service August 28, 1998, reimbursement for anesthesia procedure codes 00096, 00097, 00099 is payable to all physicians, not only anesthesiologists. Also, effective September 22, 1998, all three codes will pend for medical review. Proof of medical necessity and an anesthesia report are required when billing any of these three procedure codes. Claims submitted without documentation will be denied. Claims for these procedure codes cannot be billed electronically. The descriptions and fees for these codes are stated
00096 Anesthesia - pediatric - up to one hour $45.00
00097 Anesthesia - pediatric - over one hour $67.00
00099 Anesthesia - arterios, CC, CT, MRI, Angios $90.00
Ventilation Assist and Management Procedure Codes
CPT codes 94656 and 94657 (ventilation assist and management procedures) are being removed from the global surgery edits. Therefore, office visits may be billed in conjunction with these procedures. Codes 94656 and 94657 are included in Medicare�s global surgery policy; therefore, all crossover claims for these procedures will continue to be guided by Medicare policy.
New Codes Now Payable to Assistant Surgeons
The Bureau of Health Services Financing is pleased to inform you that CPT codes 32440 (removal of lung, total pneumonectomy) and 33820 (repair of patent ductus arteriosus; by ligation) are now payable to assistant surgeons effective with date of service October 1, 1998. The fees for assistant surgeons are as follows.
CPT Codes 54324 and 59350
CPT codes 54324 and 59350 are also now payable to assistant surgeons with date of service September 1, 1998. The fees are as follows:
Cochlear Device Implantation Policy
The Bureau of Health Services Financing is pleased to announce funding, effective with date of service August 1, 1998, for the cochlear implant device for recipients with profound-to-total bilateral hearing loss.
Only recipients two years of age through twenty years of age who meet the medical and social criteria printed at the end of this document shall qualify for implantation.
Only one device per lifetime per eligible recipient shall be reimbursed unless the device fails or is damaged beyond repair, in which case reimbursement for another device and reimplantation will be considered.
All aspects of this procedure (preoperative speech and language evaluation, implantation, device, repairs, supplies, therapy) must be prior authorized. The request to perform surgery shall come from the multidisciplinary team which assessed the recipient�s disability and determined him/her to be a possible candidate for implantation.
The multidisciplinary team shall consist of a surgeon/otologist; an audiologist; a speech/language pathologist; a psychiatrist and an educator of the deaf with experience in oral/auditory instruction.
The team�s written decision regarding the recipient�s candidacy for the implant and the results of all pre-operative testing (audiogram, tympanogram, speech and language evaluation, social evaluation, etc.) shall be submitted in a single packet labeled Unisys Prior Authorization Unit - Request for Cochlear Implant to the Prior Authorization Unit for review. PA�s address is Box 14919, Baton Rouge, LA
BILLING FOR THE DEVICE
Reimbursement will be made to the hospital for both the device and the per diem. The device must be prior authorized. A Form PA-01 must be completed for the device and submitted to the Prior Authorization Unit as part of the multidisciplinary team�s packet. After approval has been granted, the hospital shall bill for the device by submitting HCPCS code L8614 (Cochlear Device System) on a HCFA 1500 claim form to Unisys Corp. The letters DME must be written in red on the top of the form, and the PA number must be written in Item 23. The device will be reimbursed at a fee of $18,350.
Note: Reimbursement for the device will not be authorized until the surgical procedure has been
BILLING FOR THE IMPLANTATION
The implantation of the device (CPT procedure code 69930 (Cochlear device implantation, with or without mastoidectomy)) must also be prior authorized.
A PA-01 form requesting approval to perform the surgery must be submitted to Prior Authorization by the surgeon as part of the multidisciplinary team�s packet. After approval and implantation, code 69930 and code 69930-80 shall be billed on HCFA 1500 claim forms by the surgeon and the assistant surgeon, respectively. This procedure shall not be billed as either team surgery or co-surgery (modifiers 62 and 66). The surgeon�s claim form must have the PA number written in Item 23, but the assistant surgeon�s claim form can be submitted without a PA number.
The surgeon�s fee for CPT code 69930 will be $1319.24, and the assistant surgeon�s fee will be $263.85. The anesthesiologist�s fee will be eight base units of anesthesia plus the actual number of time units (1 = 15 minutes) multiplied by the co-efficient of $13.50. The anesthesiologist�s claim form does not need a PA # . It and the assistant surgeon�s claim form will pend to the Medical Review Unit for review and will be paid only if the surgeon�s request for implantation has been approved.
BILLING FOR THE PRE-OPERATIVE SPEECH AND LANGUAGE EVALUATION
This service must be prior authorized, as well. The audiologist shall submit a PA-01 form requesting approval to Prior Authorization as part of the multidisciplinary team�s packet. After approval has been given, the audiologist shall bill CPT procedure code 92506 (Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status) on a HCFA 1500 to receive reimbursement for the evaluation. This service will be paid for ALL cochlear implant candidates even though the candidate may not subsequently receive an implant.
Code 92506, payable at $300, shall be payable only once per candidate per lifetime and is restricted to the specialty of Audiology. The PA number must be printed on the claim form in Item 23 in order for payment to be
BILLING FOR THE POST-OPERATIVE REHABILITATIVE COSTS
Only the audiologist will be reimbursed for the aural rehabilitation of the cochlear implant recipient after implantation of the device. Procedure code 92510, payable at $94.90, shall be billed on the HCFA 1500 for this service. This code does not have to be prior authorized.
BILLING FOR SUBSEQUENT SPEECH, LANGUAGE AND HEARING THERAPY SERVICES
Subsequent speech, language and hearing therapy services for cochlear implant recipients must be prior authorized like all other rehabilitation services. The request for PA should be submitted to the Prior Authorization Unit on Forms PA 01 and PA 02 at the address previously given.
The following expenses are to be the responsibility of the recipient or the recipient�s family or caregivers:
1) All costs for service contracts and/or extended warranties;
2) All costs for insurance to protect against loss and
BILLING FOR SPEECH PROCESSOR REPAIRS, BATTERIES, HEADSET CORDS, ETC.
Requests for reimbursement for speech processor and/or microphone repairs, headset cords, headset replacements and batteries must be prior authorized and may be made on Form PA01 to the Prior Authorization Unit at the address previously given.
The locally-assigned codes to use to request approval and reimbursement for these items and their fees are as follows:
L8700 - Speech Processor Repair - $395
L8701 - Headset Replacement - $400
L8702 - Microphone Repair - $288
L8703 - Speech Processor Battery - $6
L8704 - Headset Cord - $12.
Statistics show that, on the average, processors need repairing every 2.5 years and that headset cords need to be replaced from 2-4 times per year. Batteries require replacement every 10-12 months.
Requests for reimbursement for the above items should be made conservatively. The Prior Authorization Unit reserves the right to refuse reimbursement for these maintenace costs when/if it feels requests are being made too frequently due to patient negligence.
The procedure for obtaining reimbursement for the items above is the same as that for obtaining reimbursement for the device, i.e. the provider should submit the applicable HCPCS code on a HCFA 1500 claim form with the letters DME written in red on the top of the form. The PA number must be written in Item
REPLACEMENT OF THE EXTERNAL SPEECH PROCESSOR
The Louisiana Medicaid Program will consider replacing the external speech processor only if one of the following occurs:
1) The recipient loses his processor
2) The processor is stolen OR
3) The processor is irreparably damaged.
An upgrade to the speech processor because of cosmetic or technological advances in the hardware shall not qualify as a reason for replacement.
Prior authorization for replacement of the external speech processor (HCPCS code L8619) must be obtained when/if replacement becomes necessary.
The multidisciplinary team shall initiate a new request for approval and shall submit the following information with its request for replacement:
1) A copy of Prior Authorization�s initial approval letter for the implant
2) Documentation explaining the reason a new processor is needed
BILLING FOR REPLACEMENT OF THE EXTERNAL SPEECH PROCESSOR
Hospitals or professional services billers shall bill for this component by submitting HCPCS code L8619 on a HCFA 1500 claim form with the letters DME written in red on the top. The PA number must be written in Item 23.
Replacement of the external speech processor shall be reimbursed at a fee of $4,936.
BILLING FOR RE-PERFORMANCE OF THEIMPLANTATION SURGERY
Re-performance of the implantation surgery (CPT code 69930) because of infection, extrusion or other reasons must be prior authorized.
Documentation explaining the reason the initial implant surgery has to be repeated and the request for re-performance should be submitted simultaneously to the Prior Authorization Unit for review.
The PA number approving the re-performance must be on the claim form for reimbursement to be
Hyperbaric Oxygen Policy Revised
As you know, coverage for hyperbaric oxygen therapy, CPT Code 99183, is restricted to certain diagnoses. Effective with date of service August 1, 1998, Louisiana Medicaid has revised its policy to reflect Medicare�s policy on acceptable diagnoses. The approved diagnoses are listed
Hyperbaric Oxygen Therapy Diagnosis Codes
1) Acute Carbon Monoxide Intoxication (986)
2) Decompression illness (993.3)
3) Gas Embolism (993.9, 996.7_, 999.1, or 958.0)
4) Gas gangrene (040.0)
5) Acute Traumatic Peripheral Ischemia (925-929 or 900-904)
6) Crush injuries and suturing of severed limbs (925.0- 929.9 or
7) Progressive necrotizing infections (necrotizing fasci- ties (728.86), meleney ulcers
8) Acute Peripheral Arterial Insufficiency: Diabetic patient (250.7 (primary) and 443.81 (secondary)) Non Diabetic patient (362.30, 362.31, or
9) Preparation and preservation of compromised skin graft
10) Chronic Refractory Osteomyelitis, unresponsive to medical and surgical management (730.1_ (fifth digit 0-9 for
11) Osteoradionecrosis as an adjunct to conventional treatment (526.89 or
12) Cyanide poisoning (989.0 or 987.7)
13) Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment
14) Soft tissue radionecrosis (990)
Debridements are not considered medically necessary on a daily basis, but could be considered reasonable approximately once per week, if the medical necessity is clearly evident from the
Covered ICD-9 Codes:
039._, 040.0, 250.7, 362.30-.31, 443.81, 444._,526.89, 686.0, 728.86 (8/11/97), 730.1_, 900-904, 925-929._958.0, 986, 989.0, 987.7, 990, 993.3, 993.9, 996.52, 996.7_,996.9,
All other ICD-9 codes not mentioned above will be denied.
Fee Increase for Depo-Provera
The Bureau of Health Services Financing is pleased to announce a fee increase for Depo-Provera effective with date of service August 1, 1998.
The increased fee for code J1055 (for contraceptive use) is $39.85. The increased fee for code J9162 (chemotherapy treatment) is $49.39.
Price Increase for Code J9031
The Bureau of Health Services Financing is pleased to inform you of a price increase for code J9031 - (BCG Live (Intravesical)) pervial, effective with date of service September 1, 1998. The increased fee is $100.00 per injection.
New Local Phone Number for REVS
Effective 9/28/98, a new local telephone number has been added to the Recipient Eligibility Verification System (REVS) for local provider use (Baton Rouge and local dialing area). The new number is 225/216-REVS (7387). If you are located in the Baton Rouge local area, please begin using this number rather than (800) 776-6323. This will allow more long distance providers accessing REVS to use the toll free number for eligibility verification. We hope this new number will be a positive and effective addition for your staff.
REVS Reminders: Please remember to use eight-digit numbers (dates of birth, dates of service, etc.) when accessing information using REVS. Also, please remember if you are using a 13-digit recipient ID number to access REVS, only recipient identification numbers which are current within the last 12 months will allow you to access REVS eligibility information. If you are using a number which is not valid within the last 12 months, the system will respond stating the recipient is not on file.
Prior Authorization and Billing Changes for DME
BHSF has made the following HCPC procedure code changes for prior authorization and billing for DME items:
1. Code A4627 has been established as a payable code, effective 09/01/98, for the prior authorization and billing of aerochambers. The code is currently described on the systems file as a spacer, bag or reservoir. It may be authorized only for recipients under age 21. The maximum price allowable is $32.00.
2. Code E0416 has been established as a payable code for portable oxygen refills, effective 09/01/98. This code also can only be authorized for recipients under age 21. The price maximum is $10.00 per refill.
3. Code Z1399 has been established for the authorization of supplies which do not have a more specific applicable code. The description on the systems file is �Supplies, not elsewhere classified�. The code�s effective date is 09/01/98. Pricing will be done for individual products by the Prior Authorization Unit.
Effective immediately, all providers should begin using Z1399, instead of E1399, for prior authorization requests for miscellaneous supplies with beginning dates of service of 09/01/98 or later. This code must be used for all requests for home health supplies and other DME related supplies for which no more specific code exists. Code E1399 must now be used only for prior authorization requests for medical equipment items with no more specific code (although Medicare crossover claims will still process for both equipment and supply items with this code).
4. Several duplicate codes have been changed on our system files to non-payable status. These codes are Z4913, Z9575, Z9580, and Z9585.
Providers should discontinue using these codes immediately for prior authorization requests and should use, instead, other applicable codes on file for these same items. The effective date of this change in our system files has been delayed until 12/01/98, however, to allow sufficient time for processing of any claims that may already be in the system with these codes.
Please note that BHSF is discontinuing coverage of a number of codes established for individual enteral formulas effective 10/01/98. The discontinued codes include XX030 through XX084. These formulas will now be covered under two broader categories already listed for enteral formulas. These two categories are codes B4154 and B4155. Effective immediately, providers should begin using the appropriate B4154 or B4155 code for all prior authorization requests for formulas for which one of the XX030 through XX084 codes were previously used.
BHSF is establishing two separate procedure codes to be used for prior authorization requests for protective helmets in the DME Program. Currently, a single code (Z9100) exists for protective helmets. Since there are two basic types of helmets, soft and hard types, with different pricing for each of the types, BHSF is changing the description of the existing code for a protective helmet and adding an additional code. Code Z9100, already on file with the description of �Protective Helmet� and price per unit of $85, will now have a description of �Protective Helmet, Soft Type� with the same price. Additionally, code Z9101 has been created with the description of �Protective Helmet, Hard Type� and a price maximum of $170 per unit. Both codes will have a PAC of 880 and will be priced manually by the Prior Authorization Unit of Unisys. Both codes are also restricted to under age 21 recipients only. The effective date for these changes is 08/01/98.
Correct Taxpayer ID Information for All Providers
As we approach the end of another year, the Bureau is reminding all providers once again of their responsibility to report any changes in Taxpayer Identification Number (TIN), also known as Employer Identification Number (EIN), to the Provider Enrollment Unit. If you submitted a Form SS-4 to the Internal Revenue Service for a new number in 1998 and obtained a new number, please mail 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.
Bureau of Health Services Financing
P. O. Box 91030
Baton Rouge, LA 70821-9030
Attention: Provider Enrollment Unit
FAX Number: (225) 342-3893
We are asking that you act upon this immediately in order for the forms 1099 which will be issued the latter part of January 1999 to include the correct identification number.
Please refer to the June 1998 Louisiana Medicaid Provider Update regarding electronic fund transfer or direct deposit, as it is more commonly known. At that time we reported that approval for EFT was at 69% for long term care facilities and 56% for all other providers.
We are pleased to announce that the percentages have increased to 92% for long term care and 89% for all other providers. We have initiated a �second� sweep of providers who are still not approved for EFT. Providers who have not returned the previously mailed EFT agreements should complete the blank direct deposit agreement, attach a voided check and mail both items to DHH Bureau of Health Services Financing, P. O. Box 91030, Baton Rouge, LA 70821-9030 Attn: Provider Enrollment/Direct Deposit.
If the EFT packet has been misplaced, you may call the Direct Deposit Unit at (225) 342-2703 and request another packet. As previously advised in the letter mailed to all providers and in the June 1998 article, participation in EFT is mandatory.
Official notification of approval of direct deposit funds will not be furnished. Providers should review the financial page of their remittance advice which indicates direct deposit has been established and the date of deposit of funds.
Electronic Claims Submission
Electronic media claim submission is an alternate method of submitting Medicaid claims to Unisys. With electronic media, a provider or a third party contractor (billing agent) submits Medicaid claims to Unisys on a computer encoded magnetic tape, diskette or via
Each claim undergoes the editing common to all claims, e.g., verification of dates and balancing. Each type of claim has unique edits consistent with the requirements outlined in the provider manuals. All claims received via electronic media must satisfy the criteria listed in the manual for that type of
Electronic media claims submission significantly reduces the time for payment, because claims with errors are automatically denied and returned to the provider immediately for
Advantages of submitting claims electronically include increased cash flow, improved claim control, decrease in time for receipt of payment, automation of receivables information, improved claim reporting by observation of errors and reduction of errors through pre-editing claims
Each reel of tape, diskette or telecommunicated file submitted for processing must be accompanied by a submission certification form signed by the authorized Medicaid provider or billing agent for each provider whose claims are billed using electronic media. The certification must be included in each tape or diskette submitted. Providers submitting by telecommunications must submit this certification within 48
If you are not in possession of the certification forms, you should call the EMC Department at Unisys and request an EMC packet. The packet includes all the different types of certification forms required. Third-party billers are also required to submit a certification form. You should select the certification form in the packet that applies to your particular provider type and make copies as necessary for submission to Unisys. Contact the EMC Department at Unisys at (225) 237-3303. The mailing address for the EMC Department at Unisys is P.O. Box 91025, Baton Rouge, LA 70821.
Policy Questions and Answers
The Bureau of Health Services Financing met with an ambulance provider recently to clarify some Medicaid policies. In an effort to clarify our policy to all ambulance providers, we are sharing these questions and our responses with all enrolled ambulance providers.
1. If Medicare pays an ambulance claim, does Medicaid require that the medical certification form (Unisys 105 Attachment 1, 2, or 3) be completed in order to process the claim?
No. If Medicare pays, Medicaid will pay the co-insurance and deductible without the medical certification
2. If a private insurance company pays on a claim, does Medicaid still require that the medical certification form be completed in order to process the claim?
Yes. Medicaid will not pay these claims unless the medical certification form is
3. Is it true that only the physician may complete the information in the physician section of the certification form?
4. May someone else complete the form and have the physician sign the form?
No. All information concerning the certification of medical necessity MUST be completed by the physician. This includes sections 1, 2, and 3 of the medical certification form.
5. Does the doctor signing the certification form have to be the physician who treats the patient? If a resident sees the patient, may the attending physician or staff physician sign the form? May a D.P.M. or a D.O. sign the form, or must it be an M.D.? May the recipient�s regular Primary Care Physician (PCP) complete the form, even if he or she was not in attendance during the episode, since he or she knows the patient�s history and could certify the necessity of ambulance transportation?
The doctor signing the certification form must be the physician treating the patient or the medical director of the facility. In the case of teaching hospitals, the physician completing the form may be a resident, attending physician, or staff physician. The recipient�s PCP may not complete the form if he or she was not
Medicaid will recognize the signatures from an M.D., D.O. , or Nurse Practitioner. Chiropractors and D.P.M.s, however, are not allowed to complete medical certification
6. If the ambulance makes a trip that seems to require ambulance transportation, but the physician later will not certify that an ambulance was needed, may the ambulance provider bill the patient?
No. Medicaid policy does not allow providers to bill recipients for covered services. Code A0226 is a code ambulance providers may use to bill for such services and they will be reimbursed at the non-emergency, non-ambulance rate. Therefore, this remains a covered service by Medicaid and billing the recipient would not be
7. May a physician go back later and sign a new certification form changing the previous determination?
Medicaid will accept the medical certification form that most accurately attests to the needs of the patient on the day of
8. For nursing home residents, may ambulance providers use the Non-Nursing Facility Certification Form (Attachment 2) rather than the Nursing Facility Certification Form(Attachment 1)?
Yes. In emergency situations at nursing homes, the Other Than Nursing Facility Form should be used and completed by the physician at the hospital. The Nursing Facility Form is for non-emergency transportation such as transport to the nursing home upon discharge from a hospital or transport to the hospital for previously planned
9. If the Director of Nursing (DON) is not available to sign the appropriate section of the nursing facility certification form (the section �to be completed by nursing facility personnel�), may the charge nurse complete and sign that section?
The nursing facility�s Director of Nursing (DON) or person designated to act as DON in his/her absence shall sign and date the form. This may include charge nurses, as long as they are designated by the DON to assume the responsibilities of the position.
Attention Pharmacy Providers
The PBM Help Desk telephone number is 1-800-648-0790. Hours are 8am to 5pm Monday through Friday.
Please be informed that effective immediately the UVS (Daily Units Allowed) for CPT code 87230, Toxin/Antitoxin Assay, Tissue Culture has been increased to �003.�
Reimbursement Allowed for Both 80054 and 82250
As you know, current edits prevent the reimbursement of both laboratory panels and component codes within a particular panel when billed on the same recipient for the same date of service. These claims are denied with error edit 619.
We have received a policy clearance from HCFA stating it is appropriate to reimburse for both 80054 (Comprehensive metabolic panel) and 82250 (Bilirubin; total OR direct) on the same recipient with the same date of service. For instance, when the panel code 80054 is performed, the total bilirubin test may be performed. The bilirubin direct may then be performed individually, if necessary.
System programming is being corrected to allow the reimbursement of both codes. A recycle of claim denials will be completed within the near future. There is no need to resubmit such denials.
Providers of Audiology Services
This notice will serve as a reminder of billing procedures for audiologists. Audiologists who are salaried employees of hospitals cannot bill Medicaid for their professional services rendered at that hospital because their services are included in the hospital�s cost report.
Audiologists can enroll and bill Medicaid if they are providing services at a hospital which does not have an audiologist on staff.
Notice to All Providers
The State-Funded Medically Needy Program was terminated effective July 1, 1997 when the Federally-funded Medically Needy Program was reinstated. In accordance with Medicaid policy, providers had one year from the date of service to file a claim for payment and another year from the date of service to resolve any billing problems. Any State-Funded Medically Needy claims not adjudicated by September 30, 1998 will not be reimbursed by the Medicaid Program.
Notice to Certified Nurse Practitioners
The Bureau of Health Services Financing is pleased to inform you that CPT codes 99347, 99348, and 99349 are now payable to Certified Nurse Practitioners effective with date of service 1-1-98. These three codes replace CPT codes 99351, 99352, and 99353, which were deleted in 1998.
LADUR Eucation Article
Congestive Heart Failure: A Review of Drug Therapy
By Robert L. Judd, Roy Parish, and Philip J. Medon Northeast Louisiana University School of Pharmacy
ISSUES . . .
- There are nearly a half-million newly diagnosed cases of CHF each year.
- The rate of mortality in severe disease is nearly 50% per year.
- Early diagnosis and treatment management are the hallmarks of patient care and effective cost management.
Congestive heart failure (CHF) is a common condition whose incidence continues to increase and remains a major cause of morbidity and mortality in the United States. There are nearly 500,000 newly diagnosed cases of CHF each year in the U.S. with four times that number of Americans suffering from various stages of that disease. These patients are associated with an extraordinarily high cost ($12 billion annually) as the National Heart, Lung and Blood Institute estimates CHF results in nearly 1 million hospitalizations each year.
Most of the expense of heart failure is related to hospitalizations and not other costs. In addition, the rate of mortality in severe disease is nearly 50% per year, increasing from 10,000 in 1968 to more than 40,000 in 1993. Future growth in the number of elderly patients is expected to result in more patients diagnosed and treated for CHF.
Early diagnosis and appropriate management of patients with CHF are the hallmarks of patient care and effective cost management. Cost-reduction efforts in CHF are accomplished by reducing the number and length of hospitalizations. Although CHF cannot be cured, it can be treated if diagnosed early. Treatment options should
� Patient education about CHF;
� Appropriate diet and exer- cise;
� Abstinence from tobacco and the value of smoking
� Life-style modifications and expectations;.
The role of drug therapy and other treatment options.
Education. Following a diagnosis of CHF an appropriate patient education program should be initiated. It is estimated that upwards of 50% of patients with heart failure fail to follow treatment recommendations resulting in hospitalizations (or rehospitalizations). Health care providers can play an active role in enhancing the patients� (and the patients� families�) understanding and compliance with suggested treatment modalities.
Patient education programs generally focus on what heart failure is, its symptoms and prognosis. The patients� and their families� understanding of the basic cause of their symptoms is essential to successful management. Key educational components should
Dietary education and management. Although beyond the scope of this review, appropriate dietary control is absolutely essential to the management of CHF. Generally advice should include restricting salt (to as close to two grams a day as possible), cholesterol, fat and alcohol intake. In-depth counseling by a dietician is
Exercise. If the patient�s condition is stable, regular exercise such as walking or cycling appropriate to the patient�s condition is recommended. Although not always necessary, patients may be anxious about exercising on their own and may be dyspneic with low levels of exercise and may benefit from rehabilitation
Smoking and Alcohol Cessation. Patients who smoke should be strongly encouraged to participate in smoking cessation programs and limit alcohol consumption.Living Within Expectations. As the disease progresses, patients must be aware that symptoms of dyspnea and fatigue will interfere with certain strenuous activities. Patients should also recognize that cessation of symptoms with management does not signal a reduction in management
Monitoring. Monitoring should include self-monitoring diet and weight reduction or stabilization. Daily weighing by the patient might assist the patient in monitoring their own success. However, patients often need assistance in monitoring the success of drug therapy, particularly when asymptomatic. Health care providers should monitor compliance with medication on a regular basis, along with continual
Drug Therapy of CHF. Careful selection of drug therapy appropriate to the stage of CHF. The focus of this review is the pharmacology of drugs commonly used in the management of CHF. These are summarized
Pharmacologic Management of CHF: Goals of Therapy
Treatment of congestive heart failure consists primarily of the prevention or treatment of identifiable causes of myocardial injury, including anti-ischemic and antihypertensive therapy, correction of abnormal hemodynamic variables, and prevention of disease progression. Specifically, this involves decreasing preload and afterload and, in some patients, augmenting myocardial contractility. Newer approaches are directed at interrupting the neurohumoral response mechanisms of heart failure, which are thought to be responsible for disease progression.
It is now recognized that hemodynamic compensatory mechanisms in the majority of patients with established heart failure result in high sympathetic tone, elevated circulating catecholamine levels, and activation of the renin-angiotensin system. Patients with primarily systolic dysfunction generally benefit from inotropic agents, diuretics, and ACE inhibitors, whereas patients with diastolic dysfunction may derive greater benefit from calcium channel blockers.
The American College of Cardiology and the American Heart Association have jointly released guidelines for treatment (ACC/AHA Guidelines). The complete Evaluation and Management of Heart Failure Clinical Guidelines recommended by the American Heart Association may be viewed at:
A. Diuretics. These agents are utilized in CHF to decrease sodium and water retention caused by decreased perfusion of the renal beds. The selection of a diuretic is based on the degree of fluid overload present and the response to therapy.
Early in CHF, a thiazide or thiazide-like diuretic may provide sufficient fluid mobilization. Thiazides also have the advantage of producing direct antihypertensive effects. As failure progresses, increased diuresis is needed. Loop diuretics such as furosemide and bumetanide are the mainstays of fluid mobilization in this stage of heart failure. They act principally by inhibiting chloride resorption in the thick ascending limb of the loop of Henle, which results in decreased sodium resorption. Select patients can monitor their weight with a home scale and adjust their own diuretic therapy. Large doses of loop diuretics are commonly required. Even with loop diuretics, resistance to diuretic effect may occur.
Fluid accumulation can occur rapidly in response to numerous changes in the clinical status of the patient. Increases in dietary sodium, for example, can increase the amount of fluid retention and exacerbate heart failure. Unfortunately, patients may be unaware of these changes until their symptoms worsen, and they may be unaware that certain nonprescription drugs either contain large sodium loads or promote sodium retention.
Adverse effects reported with thiazide therapy include hypokalemia, hyperuricemia, and impaired glucose tolerance. A hemodynamically complicating effect of diuretic therapy in early CHF is the activation of the renin-angiotensin system, resulting in further vasoconstriction. The effects may increase with higher doses of diuretics.
Diuretics are recommended in the ACC/AHA Guidelines for all patients with diastolic dysfunction and patients with systolic dysfunction who have fluid overload.
B. Angiotensin-converting Enzyme (ACE) Inhibitors. As cardiac output decreases, the renin-angiotensin system increases its activity in response to reduced perfusion pressure. While not direct vasodilators, ACE inhibitors prevent the conversion of angiotensin-I to angiotensin-II, a potent vasoconstrictor, and reduce the degradation of bradykinin, a vasodilatory peptide. The beneficial effects of ACE inhibitors appear to be related to a class effect. Enalapril and captopril are the most widely investigated agents in CHF, although several other ACE inhibitors have been studied as well. The major therapeutic difference among ACE inhibitors is the greater incidence of hypotension reported with certain members of the family, especially enalapril.
Hypotension remains a troubling complication of afterload reduction in CHF. Symptomatic hypotension is more frequent in patients with volume deficits or sodium deficits. To minimize the risk of hypotension, these deficits should be corrected before beginning ACE inhibitor therapy; often, it is sufficient to withhold diuretics for 1 or 2 days before starting the ACE inhibitor.
Additionally, captopril (because of its shorter half-life) may be used as a test dose to evaluate the patient�s hemodynamic response, occasionally at adult doses as low as 1 mg. The main risks of hypotension are syncope and hypoperfusion of organ systems, particularly the kidney, and the potential for reflex tachycardia. Adverse effects reported with ACE inhibitors include cough and decreased renal perfusion. These can sometimes be difficult to interpret in CHF, since they can occur as a result of CHF as well as ACE inhibitor therapy.
An increase in serum creatinine following the initiation of ACE inhibitor therapy is not unexpected, since these drugs acutely lower blood pressure and renal perfusion. In most cases, serum creatinine returns to baseline within 3 or 4 days as intrarenal autoregulation re-establishes creatinine clearance. ACE inhibitors tend to have a potassium-sparing effect, which can be beneficial in patients also undergoing thiazide therapy. Hyperkalemia can be induced in patients who are receiving potassium supplementation or undergoing treatment with potassium-sparing diuretics. It is widely accepted that these drugs decrease mortality in CHF patients, and they are now recognized as first-line agents; some clinicians recommend their use even before the patient develops significant symptoms.An uncommon, but serious, adverse effect is angioedema. This is life-threatening when the oropharynx is involved, and patients should be advised to report promptly any swelling within the oral cavity or difficulty in swallowing. As this appears to be a class effect, patients should avoid all ACE inhibitors after experiencing this effect.
The ACC/AHA Guidelines recommend ACE inhibitors for all patients with systolic dysfunction and significantly reduced left ventricular ejection fraction unless a contraindication exists; for patients with diastolic dysfunction, ACE inhibitors are considered acceptable, but of uncertain efficacy.
C: Positive Inotropes. The cardiac glycosides (digoxin, digitoxin) have been used for the treatment of CHF for over 200 years. They are thought to exert a positive inotropic effect by inhibiting the sodium-potassium ATPase exchange mechanism. This results in increased availability of calcium, which is thought to increase contractile force. Cardiac glycosides also appear to enhance the entry of calcium into the cell through the slow calcium channels and to increase norepinephrine levels within the myocardium. Cardiac glycosides also have electrophysiologic properties, including a vagally-mediated slowing of AV nodal conduction, enhanced conduction in myocardial contractile fibers, and slowing in other conduction tissue. Finally, cardiac glycosides have been shown to decrease circulating norepinephrine levels and plasma renin activity, to increase levels of atrial natriuretic factor, and to normalize baroreceptor sensitivity.
Digoxin (Lanoxin) is the prototypical cardiac glycoside used in CHF. It significantly improves ejection fraction and reduces decompensation of heart function. However, it remains a difficult drug to use because of its narrow therapeutic index and its propensity for interaction with other drugs. For example, antacids, cholestyramine, and sucralfate decrease digoxin levels, while amiodarone, cyclosporine, ver-apamil, several antibiotics, and quinidine increase serum digoxin levels.
While most significant interactions with digoxin involve reduction in renal clearance, a few atypical interactions have been reported. One of the most interesting is the effect of antimicrobial therapy on digoxin levels in some patients. Approximately 10% of patients have gut flora that metabolize digoxin. Treatment with antimicrobials, particularly erythromycin, can increase the available digoxin by decreasing bacterial metabolism.
The therapeutic serum range of digoxin is typically accepted as 0.5 to 2.0 ng/mL, although up to 2.5 ng/mL has been reported to be therapeutically necessary. The use of these higher levels appears to have emerged from efforts to elicit a direct effect of digoxin on AV nodal conduction, an approach that has fallen into disuse. This therapeutic range is poorly defined, and dosing is best regulated according to the patient�s clinical condition. Recent studies have shown that high doses of inotropic agents sufficient to produce hemodynamic improvement are associated with increased mortality, whereas low doses that produce only subjective improvement are associated with decreased mortality.
The ACC/AHA Guidelines do not recommend digoxin for all patients; this drug is not recommended in the Guidelines for patients with diastolic dysfunction alone unless the patient also has supraventricular arrhythmias. For patients with systolic dysfunction, the Guidelines consider digoxin as of unproven efficacy.
D: Calcium Channel Blockers. Calcium channel blockers (CCBs) are potent vasodilators, both in the periphery and in coronary vessels. In many respects, this would appear to make them ideal agents in the treatment of CHF. In spite of this potent vasodilatory effect, however, not all patients with CHF can tolerate CCBs; the mechanism for producing vasodilation�the blockade of voltage-dependent calcium channels�produces a negative inotropic effect and limits the usefulness of these drugs in CHF. With verapamil and diltiazem, for instance, the negative inotropic effects are seldom offset by sufficient
The current use of CCBs is in the therapy of CHF patients with diastolic dysfunction. Systolic dysfunction is nearly always accompanied by diastolic dysfunction, but diastolic dysfunction frequently occurs alone. The two can be distinguished on the basis of ventricular ejection fraction. In diastolic dysfunction, a major defect is incomplete ventricular relaxation during diastole, which limits diastolic inflow and, consequently, cardiac output. CCBs facilitate diastolic relaxation and can improve the clinical status of carefully selected patients.
Peripheral edema, a symptom of worsening CHF, has been observed during the course of therapy with many CCBs, particularly those with the most potent vasodilatory effects. Although the edema seen during therapy with these drugs results from their vasodilatory effects and typically does not represent worsening heart failure, its presence can make it more difficult to recognize a true exacerbation of CHF.New CCBs (primarily of the dihydropyridine family) have been developed based, in part, on their relative lack of myocardial depressant activity. Trials evaluating the effect of these drugs on the outcome of CHF have increased our understanding of this disease and demonstrated that CCBs (especially those that are more vascularly selective) can have a profound impact on the therapeutic outcome of CHF.
CCBs are not recommended by the ACC/AHA Guidelines for patients with systolic dysfunction; for patients with diastolic dysfunction alone, the Guidelines consider CCBs to be of uncertain
E. Beta Blockers. Many patients with systolic dysfunction exhibit insufficient cardiac response to exercise, probably due to down-regulation of myocardial beta-adrenergic receptors. Although traditionally avoided in patients with heart failure, beta-blockers are being increasingly used in selected patients. Initially, clinical conditions worsen after therapy with these drugs begins, but after a period of several weeks, cardiac output and exercise tolerance paradoxically improve. This is believed to be due to up-regulation of myocardial beta-adrenergic receptors as a result of partial blockade. Carvedilol, a relatively new agent producing both non-selective beta blockade and alpha-adrenergic blockade, has recently been approved by the Food and Drug Administration for adjunctive use with digitalis, diuretics, and ACE inhibitors in the treatment of mild to moderate heart failure.
Beta blockers are recommended in the ACC/AHA Guidelines for all patients who have suffered myocardial infarction and are at high risk for reinfarction. For both systolic and diastolic dysfunction, beta blockers are classified as of unproven efficacy; however, the public information articles in the AHA web site indicate that carvedilol is used for mild to moderate heart failure and gives advice to patients regarding self-monitoring for adverse effects. Clinical investigation is under way to define more clearly the place in therapy for carvedilol and other beta-blockers.
The application of a disease management approach to heart failure has been shown to be effective. Consensus guidelines from the ACC/AHA and AHCPR are continuously being updated and revised, requiring continual practitioner education. Suitable monitoring of the guidelines and the patient�s adherence to them is necessary to assess compliance with therapy and detect early signs of a worsening of the disease. Drug regimens can be complicated and drug therapy can produce unwanted side effects. A careful coordination of health care through providers with CHF patients can be beneficial.
American Society of Health-System Pharmacists. ASHP Therapeutic Guidelines on Angiotensin-Converting-Enzyme Inhibitors in Patients with Left Ventricular Dysfunction. Am J. Health-Syst. Pharm. 1997;
Guidelines for the Evaluation and Management of Heart Failure: Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Committee on Evaluation and Management of Health Failure). Circulation. 1995;
Heart Failure: Evaluation and Care of Patients with Left-Ventricular Systolic Dysfunction, Clinical Practice Guideline No. 1 (AHCPR Publication No.
Clinical Practice Guideline, Quick Reference Guide for Clinicians (AHCPR Publication No. 94-0613).Treatment of Heart Failure: A Managed Care Perspective. The Am. J. Managed Care. 1998;
Special Supplement to Pharmacotherapy. Pharmacotherapy. 1996; 12 (Part
Congestive Heart Failure. E.M. Bednarczyk. Pharm/Alert Continuing Education. 1993; 1:1-8.
Provider Instructions for Lock-In Claims
This article offers instructions to pharmacies and physicians for submitting claims for processing through the DHH Program Integrity Lock-In
Lock-In Program Objective
The goal of the DHH Lock-In Program is to educate Medicaid recipients in the proper utilization of physician and pharmacy
Medicaid recipients are placed in the Lock-In Program upon recommendation of a professional panel of physicians and pharmacists. This panel reviews profiles of individual Medicaid recipients with a history demonstrating a consistent pattern of misuse of pharmacy
A review by the Lock-In Unit may be initiated when there is a medical history indication or health care provider report of an individual�s possible misuse of
Often, restrictions are necessary to assure that each of the Medicaid providers involved in the individual�s treatment is aware of all of the services and medication being received by the
Claims Which Must Be Processed through the Lock-In Unit
Listed below are the five specific types of claims which require manual processing through the Lock-In
Information Required forManual Processing
To assist our Medicaid providers in assuring that their claims are processed as quickly and efficiently as possible, we are issuing the following instructions regarding Lock-In recipients� claims which must be submitted to the Program Integrity Lock-In Unit for manual
1. Emergency Prescription Drugs - Claims submitted from a pharmacy other than the Medicaid recipient�s Lock-In pharmacy for emergency circumstances. The physician should notate �Emergency RX� at the top of the prescription. In cases of an obvious emergency room prescription, an explanation is unnecessary other than the �Emergency RX� notation. However, if the prescription comes from a facility other than an evident emergency room, additional documentation is required explaining the emergency. **This is the only type of claim which should have the notation �Emergency RX.�
2. IV Drugs Unavailable Through a Conventional Pharmacy (the Lock-In Pharmacy) - Note on the claim �IV drug not available through Lock-In pharmacy.� To assure proof of timely filing, claims should be submitted through Point of Sale. If Point of Sale is unavailable, claims should be submitted directly to Unisys for
3. Prescription Drugs Unavailable Through the Lock-In Pharmacy - Please submit the Drug Rejection Notice or, if unavailable, the Unisys 111R with an explanation of why the Medicaid recipient was unable to obtain the medication through the designated Lock-In pharmacy. Before the claim is processed, the Lock-In Unit will contact the Lock-In pharmacy for verification that the drug was not available. If the prescription drug was available through the Lock-In pharmacy, the claim cannot be approved for
4. Prescriptions from a Physician Other than the Lock-In Physician - Such prescriptions cannot be processed through the normal procedures because the prescription originates from a physician other than the Medicaid recipient�s Lock-In physician. Documentation must be provided to substantiate that the proper referral was obtained from the Lock-In
5. Prescription Drug Claims for Lock-In Recipients Who Have Been Placed in a Long Term Care Facility - Such claims must be accompanied by verification from the Nursing Home documenting the Medicaid recipient�s Admit Date and Discharge Date (if applicable) from the
Common Errors Which Result In Processing Delays
The Lock-In Unit frequently receives claims with incomplete items or improper documentation, which delay the processing of the claims. Listed below are the most common errors which result in claim processing
1. Claims submitted without a �Signature of Vendor or Authorized Representative.� Claims submitted with this item incomplete on the Form 111R or the Drug Claim Rejection Notice must be returned for
2. Claims forwarded to the Program Integrity Lock-In Unit for processing which are not Medicaid Lock-In recipients. Only claims for recipients included in the Lock-In Program may be processed thorugh the Lock-In
3. Claims with a service date over one year from date of service with no proof of timely filing. Such claims should be submitted with evidence of proof of timely filing within a year, as required by Medicaid regulations (Examples: DTA Form or Remittance Advice page). Claims without the proper timely filing verification may not be
4. Drug claims with incorrect NDC numbers.
5. Duplicate submission of claims.
6. Claims submitted which have already been reimbursed by
7. Claims from a pharmacy other than the Medicaid recipient�s designated Lock-In pharmacy, which are submitted without the required
8. Multiple claims on a particular individual with RX�s, NDCs, Fill and Refill dates which do not
9. Form 111R submitted with refill code incorrectly listed as �1.5.� The proper refill code options are 1, 2, 3, 4, or 5.
10. Prescriptions which do not legitimate Emergency Prescriptions, but which have �Emergency RX�
11. Receipt of HCFA 1500s for physician claims which have an erroneous identification number (such as the DEA number) of the referring physician in item
12. HCFA 1500s for Durable Medical Equipment. �DME� claims requiring overrides should be submitted to: DME Program Manager Bureau of Health Services Financing Box 91030 Baton Rouge, LA
Tips for Avoiding Processing Delays
1. Review claims for completeness and correctness of all items.
2. In cases where many claims are submitted at one time for a particular individual (such as Long Term Care claims submitted in bulk), claims should be submitted in order according to NDC Numbers, Fill/Refills and Dates of Service. Having the claims in order will assist the provider in assuring that all items on the claims are correct and that no duplicates are submitted. Please check claims to make sure that refills and dates of service
3. Prescriptions resulting from actual emergency circumstances should be the only prescriptions with an �Emergency RX�
4. Item 17A on the HCFA 1500 for physician services claims should correctly list the Medicaid Identification Number (Not the Universal Provider Identification Number) of the referring
5. If possible, providers should submit the �Drug Claim Rejection Notice� in lieu of the 111R for prescription drug claims of Lock-In recipients. The Drug Claim Rejection Notice may provide timely filing verification, and will specify the reason the claim denied
The Program Integrity Lock-In Unit hopes that this information will be beneficial to our Medicaid providers. Our staff is always available if there are any problems, questions, or comments regarding Medicaid claims on Lock-In
Medicaid Lock-In Program Staff
Melwyn Wendt, Pharmaceutical Consultant-Supervisor
Gale Nadler-Policy Analyst 2(Contact for Lock-In Recipient Claim