Provider Update

December 2000/January 2001

Volume 17, Issue 6 

HIPPA Two-Year Countdown Begins Reimbursement for the Use of an Operating Microscope
Acoustic Reflex Testing and Tympanometry Billing CPT Code 56441
Louisiana Children's Choice - New Waiver Program for Children CPT Code 96450
Include Cover Letter with Problem Claims CPT Code 47136
Computing Recoupment for Physicians Services Policy Change for Thyroxine 
Reimbursement for Speech, Occupational, and Physical Therapy Through the Home Health Program Fee Increases
Procedure for Obtaining Prior Authorization of Extended Home Health Services at the Time of Hospital Discharge Auditory System Procedures to be Included in Tympanostomy
CPT Code 33140 LADUR Education Article
Billing of Spirometry

HIPAA Two-Year Countdown Begins

The August 2000 Provider Update introduced you to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Under the terms of the HIPAA/EDI Administrative Simplification Provisions Act, these mandatory regulations apply to health plans, healthcare clearing houses, and healthcare providers who transmit any health information in electronic form. Currently, Unisys accepts 85 % of data from providers in electronic form. At the 2000 Annual Statewide Provider Workshops in September and October, we provided additional information on this Act through distribution of a fact sheet to providers attending the workshops. At these workshops we learned that most providers are unaware of HIPAA. Since this new regulation will significantly impact practically everyone in the healthcare industry in one way or another - including all providers - we want to continue our informational and educational efforts on an ongoing basis through articles in the Provider Update. 

At the time of our article in August, we reported that the Department of Health and Human Services had not officially released the final rule for HIPAA. However, the final rule concerning standards for electronic transactions was officially published in the Federal Register dated August 17, 2000. The rule will become effective on October 16, 2002. All healthcare entities impacted must comply by that date. We are reprinting the fact sheet distributed at the provider workshops here, and we encourage all providers to obtain a copy of the Federal Register, Vol. 65, No. 160, dated Thursday, August 17, 2000, Part III, 45 CFR Parts 160 and 162. 

� Also known as the Kennedy-Kassenbaum Bill
� Effective October 16, 2002 (small providers effective October 16, 2003)
� Reduces costs & administrative burdens of health care by standardizing electronic transmission of administrative & financial transactions currently handled manually 
    -Reduces human intervention 
    -Reduces errors 
    -Reduces processing time
� Reduces fraud
� Makes EDI transmissions viable & preferable to manual processing
� Implements security standards
� Implements privacy standards
� Ultimately plans to implement national provider & recipient numbers
� All health plans, all payers, and all clearinghouses that process health data must comply
� All healthcare providers who conduct specific transactions electronically must conduct them according to standards
� Standardization will impact both electronic and hardcopy billers
� All current claims formats will be converted to the following standardized transaction types: 
    Professional (HCFA 1500) 
    Institutional (UB-92) 
    Dental (ADA Standard Format) 
    Pharmacy (NCPDP Format)
� Standard code sets include, but are not limited to: 
    Procedure Codes (CPT, HCPCS, etc.) 
    Claim EOB/Error Codes 
    NDC Drug Codes 
    Diagnosis Codes 
    Types of Service
� Other areas impacted by HIPAA: 
    Eligibility Inquiries (REVS/MEVS) 
    Payment Registers (RAs) 
    Claims Status Checks 
    Authorization Requests/Approvals

Acoustic Reflex Testing and Tympanometry Billing

Louisiana Medicaid is now paying separately for code 92567 (tympanometry) and code 92568 (acoustic reflex testing), as distinct and separate procedures, if done on the same day for the same recipient.

If questions arise, please call Kandis V. Whittington, Physicians Program Manager, at 225-342-9490.

Louisiana Children�s Choice - New Waiver Program For Children 

Effective January 15, 2001, the Department of Health and Hospitals (DHH) will implement Louisiana Children�s Choice, a new waiver for children on the MR/DD Waiver waiting list. Children�s Choice is a capped waiver which means all recipients will have a monetary limit on their yearly cost of waiver services. The direct waiver services are family support, center-based respite care, case management, crisis support, and environmental and general adaptations. Case management is a required service for this waiver.

Children�s Choice waiver services providers will be required to be licensed as a personal care attendant (PCA) agency and to either provide all of the waiver services or have an agreement with an agent approved by DHH to provide the services. Notices were mailed to Medicaid PCA agencies, and statewide informational meetings were held in November and December, advising those interested of the special enrollment requirements for providers participating in this new waiver.

For more information concerning the requirements for enrollment as a provider in Louisiana Children�s Choice, please contact the Bureau of Community Supports and Services (BCSS), Quality Management section at: 

DHH/BCSS/Quality Management 
Office of the Secretary 
4615 Government Street, Bldg. B 
Baton Rouge, LA 70806-4949 
PH: (225) 922-0785 
FAX: (225) 922-0791 

Include Cover Letter with Problem Claims

Providers who submit problem claims for research to the DHH TPL Unit must submit the following:

� A cover letter explaining the problem or question
� A copy of the claim(s), and 
� All pertinent documentation. 

Claims received without a cover letter will be sent directly to claims processing without review of any kind.

Computing Recoupment For Physicians Services

Inaccurate information was given to some providers regarding the formula for computation of recoupment monies. You may have been told that 7% less an offset amount of $1.48 would be recouped on each claim. The true amount being recouped is 7% minus .0534 or 6.9466 %. This formula applies only to recoupments on straight Medicaid claims. 

Recoupments on professional cross-over claims may total more or less than 7%. No offset amount such as .0534 is being applied to these claims.

Please adjust your records accordingly.

If questions arise, please call Kandis Whittington at 342-9490 or Tracey Zimmerman at 342-9319.

Reimbursement for Speech, Occupational, and Physical Therapy Through The Home Health Program

Effective with date of service September 21, 2000, in addition to physical therapy services, speech and occupational therapy services will be covered through the Home Health Program.

These services will require prior authorization. Rehabilitation services are excluded from the service limit of fifty (50) home health visits per calendar year for Medicaid recipients twenty-one (21) years of age and older. 

Procedure codes and reimbursement rates for these home health rehabilitation services are the same as those for outpatient hospital rehabilitation services. 

To request prior authorization for home health rehabilitation services, providers must complete the PA-01 and PA-02 prior authorization request forms. All initial requests must have a copy of the physician's referral and the results of the evaluation of the patient that document the need for therapy attached. All extension requests must have attached a copy of the physician's referral and progress notes that document the need for the continuation of therapy. The procedure codes used to request prior authorization of these services are the same "Y" codes as those used for outpatient hospital rehabilitation services.Completed requests should be mailed to the following address: 

P. O. Box 14919 
Baton Rouge, LA 70821-4919 
Attention: Prior Authorization 

When a decision has been made, the home health agency and the recipient will receive written notification of the decision. Upon receipt of the approval, the provider may render the service.

Providers may bill hard copy claims using the Unisys 101 Home Health claim form. The service codes used in billing as well as the corresponding procedure codes and their fees are listed below. The nine-digit prior authorization number assigned should be entered in Item 15 under the section labeled "Supplies." Reimbursement will be made at a flat fee for service.

 Please note that the service codes are now alpha/numeric. When entering the alpha codes, it is necessary to use capital letters. 

Please remember to contact your software vendor to make any necessary updates for billing electronically.

The following procedure codes are being placed in non-pay status effective with this policy. 

X9926 - Home Health Physical Therapy 
X9936 - Home Health Physical Therapy - PT Assistant 
X9905 - Home Health Physical Therapy Visit after Initial Visit 
X9915 - Home Health Physical Therapy Visit after Initial Visit - PT Assistant

NOTE: Billing procedures and reimbursement rates for home health services other than rehabilitation services have not changed.


Physical therapy, evaluation  Y7702  $59.40
Occupational therapy evaluation  Y7812  $56.10
Speech evaluation  Y2602  $49.50
Hearing evaluation  Y2612  $49.50
Wheelchair seating evaluation  Y7902  $56.10
Physical therapy, one modality  Y7000  $22.00
Physical therapy, 2 or more modalities  Y7050  $33.00
P.T. - 1 or more procedure, and/or mod., 15 min.  Y7106  $11.00
P.T. - with procedures, 20 minutes  Y7105  $14.85
P.T. - with procedures, 30 minutes Y7100  $22.00
P.T. - with procedures, 45 minutes  Y7101  $33.00
P.T. - with procedures, 60 minutes  Y7102  $44.00
P.T. - with procedures and mod., 60 minutes  Y7202  $44.00
P.T. - with procedures, 75 minutes  Y7103  $55.00
P.T. - with procedures, 90 minutes  Y7104  $66.00
Occupational therapy, 15 minutes  Y7810  $ 8.80
Occupational therapy, 20 minutes  Y7811  $12.10
Occupational therapy, 30 minutes  Y7813  $17.60
Occupational therapy, 45 minutes  Y7814  $26.40
Occupational therapy, 60 minutes  Y7815  $35.20
Speech and hearing therapy, 15 minutes  Y2609  $ 8.25
Speech and hearing therapy, 20 minutes  Y2611  $11.00
Speech and hearing therapy, 30 minutes  Y2613  $16.50
Speech and hearing therapy, 45 minutes  Y2614  $24.75
Speech and hearing therapy, 60 minutes 0 Y2615  $33.0

All services must be approved in advance by the Prior Authorization Unit except initial evaluations and wheelchair seating evaluations, which are restricted to one evaluation per recipient every 180 days. For wheelchair seating evaluations, providers must have M.D. prescriptions.

NOTE: Cardiac and Pulmonary/Respiratory therapy are not covered under Louisiana Medicaid. These services should not be prior authorized or billed using covered rehabilitation codes.

Billing procedures and reimbursement rates for home health services other than rehabilitation services have not changed. Listed below are these service codes and corresponding procedure codes. 

A=X9900         Initial Skilled Nursing Visit 
B=X9902         Skilled Nurse Visit (Hourly Rate) 
C=X9903         Nurse Visit(s) After Initial Visit (Limit 3 Per Day) 
D=X9904         Aide Visits After Initial Visit (Limit 1 Per Day) 
F=X9901         Initial Aide Visit 
G=X9910         Initial Skilled Nursing Visit (LPN) 
H=X9907         Skilled Nurse (Hourly Rate) for Multiple Recipients 
I=X9913           Skilled Nursing Visit After Initial Visit 
K=X9916         Skilled Nursing Visit for Multiple Recipients (LPN) 
M=X9906         Skilled Nurse Visit for Multiple Recipients (RN) 

If additional assistance is required, you may call Unisys Provider Relations at 1-800-473-2783 or (225) 924-5040. 

Procedure for Obtaining Prior Authorization of Extended 
Home Health Services at the Time of Hospital Discharge 

At times there has been a gap in services between hospital discharge and the start of extended home health services due to the time it takes to gather the necessary information and have it signed by the physician. This delays the Prior Authorization (PA) process and sometimes leaves a gap of one to three weeks before services are started. In order to provide continuity of care for recipients, the following procedure will be used for recipients requiring extended home health care immediately after discharge from the hospital.

Prior to hospital discharge the PA process can begin. The following information must be sent to the PA Unit: 

� A letter of medical necessity from the primary physician; 
� A signed prescription indicating the number of hours of extended home health that are being requested; 
� A copy of the admission assessment (history and physical); 
� Progress notes; 
� Discharge orders; 
� A copy of the discharge summary if available; and, 
� A copy of the unsigned Plan of Care (POC). The unsigned POC will be accepted only if the recipient is being discharged from the hospital and is included with the above information. The POC must be done from an at home assessment. The assessment cannot be done in the hospital.

If the recipient meets the criteria for extended home health services, then he/she will be approved for services.

The home health agency must forward the signed POC to the PA Unit as soon as the signed copy is received from the physician. 

The extended home health request will be issued a PA number if the service has been approved. A letter of acceptance or denial will be sent to the agency. The agency can call the PA Unit to check the status of the request and to get the PA number in order to immediately start approved services.

The recipient will be prior authorized for only six (6) weeks of extended home health services. This is to ensure the signed POC is on file with Unisys. Prior to the end of the six (6) week prior authorized period, all of the requested information must be resubmitted to the PA Unit at Unisys including the signed POC. The same information can be resubmitted unless there has been a change in the recipient�s condition.

CPT Code 33140

CPT Code 33140 (Transmyocardial Revascularization - TMR) will pend for medical review and will be paid only if the criteria printed in the 11-99 issue of the Medicare Provider News are met.

CPT Code 56441

Two (2) base units of anesthesia were funded for CPT code 56441 (Lysis of Labial Adhesions) effective with date of service November 1, 2000.

Billing of Spirometry 

Referencing page 24-15 of the Physician�s Services manual, Spirometry (CPT Code 94010) is a comprehensive code that includes respiratory flow volume loop (CPT Code 94375). When spirometry is billed, respiratory flow volume loop may not be billed on the same date of service by the same provider or group for the same recipient. Bronchospasm evaluation (CPT Code 94060) is a comprehensive code that includes spirometry and respiratory flow volume loop (CPT Code 94010 and 94375). Therefore, when bronchospasm evaluation is billed, neither spirometry nor respiratory flow volume loop may be billed on the same date of service by the same provider or group for the same recipient. 

Reimbursement for the Use of an Operating Microscope

The Louisiana Medicaid Program will reimburse surgeons for the use of an operating microscope (CPT Code 69990) only in situations which justify its use. Some claims have been received from providers billing for code 69990 in addition to code 69436 (Tympanostomy, general anesthesia). If a procedure is considered routine by the physician - consultants, code 69990 will be denied with error edit 774 - Included in related procedure.

CPT Code 96450

The fee for CPT code 96450 (Chemotherapy administration, into CNS, requiring and including lumbar puncture) was increased from $32.90 to $64.63 effective with date of service November 1, 2000.

CPT Code 47136

The fee for CPT code 47136 (Liver allotransplantation; heterotopic, partial or whole, from cadaver or living donor, any age) was changed to $2,122.12 effective with date of service November 1, 2000.

Policy Change for Thyroxine

With the publication of this notice, Louisiana Medicaid is changing its policy on thyroxine (CPT code 84436) and thyroid hormone (CPT code 84479) to allow for the payment of both tests on the same date of service for the same recipient.

Fee Increases

The following increase in fees was made effective with date of service November 1, 2000:

CPT code 69400 (Eustachian tube inflation, transnasal; with catheterization) - $59.78
CPT code 69401 (Eustachian tube inflation, transnasal; without catheterization) - $46.82
CPT code 69405 (Eustachian tube inflation catheterization, transtympanic) - $151.07

Auditory System Procedures to be Included in Tympanostomy

Effective with date of service November 1, 2000, the following auditory system procedures were included in the performance of tympanostomy (CPT code 69436).

Code 69200 - removal foreign body from external canal; without general anesthesia 
Code 69205 - removal foreign body from external auditory canal; with general anesthesia
Code 69210 - removal impacted cerumen separate procedure; one or both ears
Code 69401 - eustachian tube inflation, transnasal; without catheterization

This means you will receive payment for code 69436 only for a particular recipient even though the other four procedures may have been performed on that recipient as well on the same date. Conversely, a payment for code 69200 for a particular recipient on a particular date of service will result in denials of claims for codes 69205, 69210, 69401, and 69436.

LADUR Education Article

Appropriate Use of Prescription Antisecretory Agents in Acid-Related Diseases

By Shanna Thibodeaux, Pharm.D. Assistant Professor 
Clinical Pharmacy College of Pharmacy
University of Louisiana-Monroe

� The use of gastric acid secretion inhibitors has increased over the past 20 years.
� A key factor in the development of GERD is the reflux of gastric acid or other noxious 
substances from the stomach into the esophagus.
� Decreasing acid production minimizes acid-induced damage, alleviates symptoms, 
promotes healing, and prevents recurrence and complications.

Pharmacologic gastric acid suppression is a major component in the treatment of patients with acid-related disorders including gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), and Zollinger-Ellison syndrome (ZES) (1). As a result, the use of gastric acid secretion inhibitors, such as proton pump inhibitors (PPIs) and histamine H2 receptor antagonists (H2RAs), has increased tremendously over the last 20 years (1,2). The purpose of this article is to briefly review the pathophysiology of normal digestion, PUD, GERD, and ZES, as well as review the mechanisms of action and indications for use of the H2RAs and PPIs. 

Digestion of nutrients in the upper gastrointestinal (GI) tract involves acid and peptic enzymes that function best at a pH < 3.0. The pH of the stomach results mainly from secretion of hydrochloric acid by parietal cells in the body and fundus of the stomach. Secretion of hydrochloric acid by the parietal cells involves the exchange of hydrogen and potassium ions, which is catalyzed by hydrogen-potassium adenosine triphosphatase (H+/K+ ATPase). This enzyme is known as the gastric proton pump, and it releases the energy required for ion exchange from adenosine triphosphate (ATP). Gastrin, acetylcholine, and histamine can activate the proton pump, which is the final common pathway for acid secretion (3).

Gastroesophageal Reflux Disease 
A key factor in the development of GERD is the reflux of gastric acid or other noxious substances from the stomach into the esophagus (3,4). This reflux is responsible for the symptoms, as well as the mucosal damage, that are seen in some patients with GERD (1). Factors that are thought to cause reflux and contribute to development of GERD include decreased lower esophageal sphincter (LES) pressure, anatomic factors (e.g. hiatal hernia), prolonged esophageal clearance, and delayed gastric emptying. Acid, pepsin, and bile, which make up the refluxate, can cause erosive esophagitis when they overcome mucosal defenses (3,4), so one of the goals of treatment is to decrease the acidity of the refluxate.

Peptic Ulcer Disease 
PUD is an acid-related disease of the upper gastrointestinal (GI) tract that occurs in the presence of acid and pepsin when factors such as Helicobacter pylori and nonsteroidal anti-inflammatory drugs (NSAIDs) disrupt or alter the normal mucosal defense and healing mechanisms (4). The two most common causes of PUD include H. pylori and use of NSAIDs (3,4).

Zollinger-Ellison Syndrome 
Zollinger-Ellison Syndrome is a pathological GI hypersecretory condition that is characterized by hypersecretion of gastric acid and recurrent peptic ulcers that result from gastrin-producing tumors (i.e. gastrinomas). ZES accounts for about 0.1% of patients with duodenal ulcers in the United States. Treatment is based on the presence or absence of peptic ulcers, esophagitis, diarrhea, and a gastrinoma (4).

Acid suppression is very important in the treatment of GERD, PUD, and ZES because gastric acid plays an important role in the pathogenesis of these conditions (3,5). Decreasing acid production minimizes acid-induced damage, alleviates symptoms, promotes healing, and prevents recurrence and complications (3). 

About 10% of Americans suffer from heartburn daily and about one-third have periodic symptoms (4). Heartburn is the most common symptom in the 20 to 40% of adults who experience recurrent symptoms of GERD (3). Lifestyle modifications (e.g. weight loss, smoking cessation, alcohol avoidance), dietary modifications, and medications which increase LES pressure, along with antisecretory agents, are used in the treatment of GERD (3). Most patients with mild, occasional heartburn can be treated with antacids, over-the-counter H2RAs, or 4 weeks of standard H2RA therapy. H2RAs are the mainstay of therapy(1), while PPIs have traditionally been reserved for use in GERD patients who have failed H2RA therapy, patients who present initially with moderate to severe symptoms, or patients with esophagitis (5).

Histamine H2-Receptor Antagonists 
Histamine H2-Receptor Antagonists inhibit gastric acid secretion by reversibly and competitively inhibiting histamine at the H2 receptors in the gastric parietal cells. The H2RAs are highly selective and do not affect the H1 receptors. They inhibit fasting and nocturnal secretions as well as secretions stimulated by food (6). 

Histamine H2-Receptor Antagonists relieve heartburn and promote healing in patients with GERD. Treatment response is better in patients with mild esophagitis than in patients with more severe disease with healing occurring in only about 50% of patients with severe esophagitis. Use of H2RAs in mild disease after healing may reduce the risk of disease recurrence which is common without maintenance therapy. 

In PUD, H2RAs promote healing of gastric and duodenal ulcers, and they help prevent recurrence of duodenal ulcers. All four H2RAs are equally effective in healing ulcers, and ulcers generally heal with 8 weeks of therapy in most patients. (See Table) 

In patients with ZES, H2RAs relieve symptoms and may promote healing, but these drugs fail to heal ulcers in 25% of patients, possibly because of inadequate dosing. Larger, more frequent doses are needed for ZES than for GERD and PUD. (See Table) 

H2RAs are generally well-tolerated. The most commonly reported side effects include headache and diarrhea. H2RAs may interact with other medications by increasing gastric pH (e.g. ketaconazole). Cimetidine is a potent inhibitor of the cytochrome P-450 enzyme system and may interact with drugs metabolized by the cytochrome P-450 enzymes (3). 

Proton Pump Inhibitors 
Proton Pump Inhibitors are the most potent antisecretory agents. They suppress gastric acid secretion by specific inhibition of the H+/K+ ATPase enzyme system at the secretory surface of the gastric parietal cell. Because this enzyme system is the "acid (proton) pump" within the gastric mucosa, these agents have been characterized as gastric acid pump inhibitors. This effect is thought to inhibit both basal and stimulated acid secretion regardless of the stimulus (6). The PPIs bind to the gastric proton pump and inhibit hydrogen ion secretion regardless of whether it is stimulated by histamine, acetylcholine, or gastrin (3,5). They block the final step of acid production (6). Proton pump inhibitors have a greater and more prolonged acid-suppressing potency than the H2RAs because acid secretion does not resume until additional H+/K+ ATPase can be synthesized (3). 

Though it is stated that PPIs inhibit both daytime and nocturnal acid secretion (5), nocturnal breakthrough gastric acid secretion can occur during PPI therapy even when the drugs are given as two divided daily doses instead of as a single daily dose in the morning. The absence of food's buffering effect at night may explain acid breakthrough, but the net effect of food on gastric acidity is difficult to assess. The pattern of gastric acid secretion may help explain increased acidity at night. Gastric acid secretion follows a circadian profile which is characterized by an increase in gastric acid secretion in the evening, with a peak around midnight. The stimulus for nighttime gastric acid secretion is unclear, but the absence of cephalic, gastric, and intestinal stimuli of nighttime acid secretion suggests that histamine may play a role in nocturnal acid secretion (7). With this in mind, H2RAs may be useful for blocking nocturnal breakthrough acid secretion that may occur during PPI therapy (3). Use of H2RAs as adjunct therapy to PPIs is still under investigation, but concurrent use of a PPI with an evening dose of an H2RA may serve as a more cost-effective method of acid-suppression in those patients requiring a higher degree of acid suppression than that produced by single daily doses of PPIs. Concurrent H2RA and PPI is not recommended as general therapy. 

Proton pump inhibitors provide more prompt relief of heartburn, higher healing rates for erosive esophagitis and ulcerative lesions, and lower recurrence rates than H2RAs in patients with GERD. Proton pump inhibitors are often reserved for use in patients with moderate to severe symptoms of GERD, esophagitis, an inadequate response to H2RAs, or in patients with complicated symptoms of GERD, while H2RAs are used to manage most mild cases. 

In PUD, symptom relief and peptic ulcer healing occur faster with proton pump inhibitors than with H2RAs. Thus, proton pump inhibitors are now well-accepted as first-line therapy for healing peptic ulcers with all proton pump inhibitors being similar in efficacy (3,5). 

Duodenal and gastric ulcers have a high recurrence rate when antisecretory agents are discontinued. Most studies have shown that ulcer recurrence rates after treatment with PPIs are comparable to those seen with H2RA therapy. Maintenance healing rates are similar with H2RAs and PPIs with a decrease in recurrence to about 20% per year. 

In H. pylori-positive patients, the long-term treatment of choice is eradication of the organism (5). Antisecretory agents alone are not an acceptable treatment for H. Pylori-positive patients (8). Combinations of antimicrobial agents with prescription acid antisecretory agents are used to eradicate H. pylori infections (3). All H. Pylori-infected ulcers should be treated, whether the ulcer is active or not. Suggested treatment regimens should have an eradication rate of about 90% or greater. No regimen has a 100% cure rate. Eradication of H. Pylori infection heals ulcers, alters the natural history of H. Pylori-positive PUD, and reduces the risk of recurrence to <10% in 1 year. 

Most uncomplicated NSAID-induced ulcers will heal with standard regimens of either an H2RA or PPI if the NSAID is discontinued. In patients whom NSAIDs cannot be discontinued, or if there is a large ulcer, PPIs are the drugs of choice because they accelerate ulcer healing (4). 

Proton pump inhibitors reduce acid-related symptoms in patients with ZES. They are the agents of choice for patients with ZES (4,5,6) who cannot be treated surgically (3). Though oral H2RAs are no longer agents of choice in ZES, intravenous H2RAs are still used in hospitalized patients who cannot take oral medications because there is no intravenous PPI dosage form currently available (5). 

Proton pump inhibitors are generally well tolerated with a side effect profile similar to that of the H2RAs. Headache and diarrhea are the most common side effects (3). Because hypergastrinemia secondary to prolonged acid suppression has been associated with enterochromaffin-like (ECL) cell hyperplasia and gastric carcinoid tumors have developed in rats after long-term treatment with some PPIs, concerns have surfaced about the risk of gastric malignancy from long-term acid suppression with proton pump inhibitors. Evidence to date does not link long-term use of proton pump inhibitors with gastric cancer in humans (3,5,9).

In acid-related disorders, complete control of symptoms is a reasonable therapeutic goal and arresting the disease is often possible. Many patients get complete symptom relief with antacids and H2RAs, but for those patients who remain symptomatic despite therapy with H2RAs, continuing therapy at the same or higher doses may not be efficacious. For those patients, PPIs are a reasonable alternative. In general, concurrent use of PPIs and H2RAs is not recommended. Whether there is some benfit to adding an evening dose of an H2RA to PPI therapy to control nocturnal breakthrough acid secretion is currently being studied. As has been presented in this article, chronic use of H2RAs and PPIs at full therapeutic dosages is generally not indicated and claims exceeding 90 days of acute therapy will be denied by the Louisiana Pharmacy Benefits Management System (NCPDP rejection code #88 and EOB #656). However, if in the professional judgment of the prescriber, a determination is made to continue acute therapy beyond 90 days, the prescriber must indicate in writing on the prescription or an attachment a diagnosis necessitating the continuation of acute therapy. The pharmacy provider must then supply this information with POS submission of the claim and have the information recorded on the hard copy. The following diagnoses will allow reimbursement for more than 90 days of acute therapy: 

202.6        Systemic Mastocyctosis 
237.4        Multiple Endocrine Adenomas 
251.5.1     Zollinger-Ellison Syndrome 
530.1        Esophagitis 
530.11      GERD 
530.81      GERD 
530.2        Barrett's Esophagitis 
531.9        Gastric ulcer 
532.9        Duodenal ulcer 
533.9        Peptic ulcer
535.5        Gastritis
535.5        Gastroduodenitis
536.6        Duodenitis
536.8        Dyspepsia
536.8        Gastric hypersecretion
537.9        Unspecified disorder of stomach and duodenum
555.9        Crohn's Disease
569.9        Unspecified disorder of the intestines
577.1        Chronic pancreatitis
578.9        Gastrointestinal bleeding


1. Kahrilas PJ. Fennerty MB. Joelsson B. High- versus Standard-Dose Ranitidine for Contol of Heartburn in Poorly Responsive Acid Reflux Disease: A Prospective, Controlled Trial. Am J Gastroenterol. 94(1): 92-7, 1999 Jan.

2. Qvidstad G. Arnestad JS. Brenna E. Waldum HL. Treatment with Proton Pump Inhibitors Induces Tolerances to Histamine-2 Receptor Antagonists in Helicobacter pylori-negative Patients. Scand J Gastroenterol. 33(12):1244-8, 1998 Dec. 

3. American Pharmaceutical Association. New Product Bulletin on AciphexTM (Rabeprazole Sodium).

4. DiPiro JT. Talbert RL. Yee G, et al. Gastroesophageal Reflux Disease. Ulcer Disease. Pharmacotherapy: A Pathophysiologic Approach. 4th edition. 532-70.

5. Berardi RS. Welage LS. Proton Pump Inhibitors in Acid-related Diseases. Am J Health-Syst Pharm. 55: 2289-98, 1998 Nov 1.

6. Drug Facts and Comparisons Staff. Histamine H2-Receptor Antagonists. Proton Pump Inhibitors. Drug Facts and Comparisons. 1128-38b.

7. Peghini PL. Katz PO. Bracy NA. Castell DO. Nocturnal Recovery of Gastric Acid Secretion with Twice-Daily Dosing of Proton Pump Inhibitors. Am J Gastroenterol. 93(5): 763-7, 1998 May.

8. Williams MP. Sercombe J. Hamilton MI. Pounder RE. A placebo-controlled trial to assess the effects of 8 days of dosing with rabeprazole versus omeprazole on 24-hour intragastric acidity and plasma gastrin concentrations in young healthy male subjects. Aliment Pharmacol Ther. 12: 1079-89, 1998.

9. Cloud ML. Enas N. Humphries TJ. Bassion S. et al. Rabeprazole in Treatment of Acid Peptic Diseases. Results of Three Placebo-controlled Dose-Response Clinical Trials in Duodenal Ulcer, Gastric Ulcer, and Gastroesophageal Reflux Disease. Dig Dis Sci. 43(5): 993-1000, 1998 May.

10. Axid (Nizatidine) package insert. Revised 1996, Aug. 22.