Volume 18, Issue 6
December 2001/January 2002
Summary of The HIPAA Privacy Regulations
The privacy final rule was published in December 2000 with a compliance date of April 14, 2003. Small health plans will have an additional year to comply. The regulation, which applies to electronic transmissions, paper records and oral communication, requires covered entities to guard the use, disclosure and requests of protected health information (PHI) or individually identifiable healthcare information (IIHI). The rule also establishes administrative and authorization requirements and patient rights. The federal regulations pre-empt all adverse state laws unless the state law is more stringent.
� Health Plan
Private or governmental, individual or group plan that provides or pays for medical services.
� Health care clearinghouse
An entity that processes health care data received from another entity and translates that data to or
from a standard format.
� Health care Provider
Any person or organization who provides health care services and electronically submits claims for
payment for services.
Covered entities must have systems, policies and procedures to safeguard PHI and patient rights. This includes appointing a privacy officer, providing employee training, developing provisions to prevent the misuse of PHI, and developing disciplinary actions for employee violations.
Patient authorization is required for all purposes other than research, public health activities and fraud investigations.
Under the privacy rule, patients have the right to:
� A Notice of Privacy Practices,
� Access, view and copy their protected health information (PHI),
� An accounting of disclosures,
� Request amendment of PHI and,
� Request restrictions on certain uses and disclosures of their PHI.
Business Associations (formerly known as Business Partners)
A covered entity may disclose PHI to its Business Associate (BA) without additional authorizations if the Business Associate agrees to safeguard the information through a written contract. A business associate is a person who on behalf of a covered entity, performs health care services involving the use or disclosure of individually identifiable health information.
Provider �To Do List�
We strongly encourage providers of health related services to read the rule at
http://aspe.hhs.gov/admnsimp/. In addition to reading the privacy final rule, we have listed below a few items to help you get started.
� Appoint a privacy officer
� Develop minimum necessary policies and procedures according to the rule
� Amend business associate agreements and contracts
� Develop verification procedures
� Develop competent accounting of disclosures
� Develop procedures for requests
� Develop procedures for patients to request restrictions of uses and disclosures
� Develop amendment request procedures
� Develop appropriate authorization forms
� Develop procedures for access of information
� Train workforce and develop sanctions for employee violations
� Develop and distribute privacy notice
During this process, it may be helpful to ask yourself the following questions to determine where you are today relative to privacy and where you need to be on April 14, 2003:
� Who needs access to the protected health information?
� How much access is needed?
� What can be done with the data?
� What sub-systems currently exist?
HIPAA WEB SITES
http://aspe.os.dhhs.gov/admnsimp/ � Administrative Simplification
www.healthprivacy.org � Institute for Health Care Research & Policy, Georgetown University
www.ahima.org/privacy � American Health Information Management Association (AHIMA)
www.hl7 � Health Level 7 for the exchange of key sets of clinical and administrative data
www.ncpdp.org � Responsible for developing retail drug standards
www.wpc-edi.com � Implementation guides for proposed standards
www.ama-assn.org � American Medical Association
www.disa.org/x12 � Supports the Accredited Standards Committee responsible for developing transaction and code set standards.
www.nucc.org � National Uniform Claims Committee
www.nubc.org � National Uniform Billing Committee
www.hhs.gov/ocr � Office for Civil Rights (search HIPAA)
We plan to publish our implementation schedule in the next Provider Update.
BENOVA to Begin Taking Long Term Care Applications
Due to procedural changes, a private contractor, BENOVA, will begin taking Long Term Care applications effective January 2, 2002. This will in no way effect the method of determining Medicaid eligibility for Long Term Care applicants.
Effective January 2, 2002, all requests for Long Term Care applications should be referred to BENOVA at 1-877-456-1146 for processing.
Invoices for payment of all applications taken prior to the effective date should be submitted by March 15, 2002. Any request for reimbursement made after this date will not be paid.
We would like to thank you for your participation in the Louisiana Long Term Care application assistance program. We look forward to working with you on other projects in the future.
1. Please explain the correct use of the KIDMED consult codes.
KIDMED consult codes are to be specific to an individual child�s needs.
Documentation should be present justifying the need for the consult for that particular child.
Consult codes are not to be used for ongoing treatment. Outcomes for the consults are to be documented as well as referrals to appropriate resources for those conditions that might require further attention. Consults are to be face-to-face contact in one-on-one sessions.
Group sessions are not allowed. Multiple units may not be billed for the same contact.
2. If a child is in need of services that I do not provide, how can the recipient or I get a list of the providers in the recipient�s parish or area that may provide needed services?
A provider or recipient may call the Referral Assistance Hotline�s toll-free number at 877-455-9955. The caller should give information as to the type of service or provider needed, as well as the place of residence of the recipient. A listing of the providers in the area, along with contact information, will be given.
1. Are braces covered for Medicaid-enrolled children?
Orthodontics require prior authorization and are authorized only when there is a craniofacial deformity, such as cleft palate, cleft lip, or other medical conditions which results in a handicapping malocclusion. Patients having only crowded or crooked teeth, spacing problems or non-debilitating under/overbite discrepancies are not covered for braces. If a Medicaid-enrolled dental provider suspects that a Medicaid patient under age 21 meets the criteria listed above, the provider may refer the patient to a Medicaid-enrolled orthodontist. If referral assistance is needed, the provider should contact the Dental Medicaid Unit by calling 504-619-8589.
2. Why was I denied payment for an authorized service with the denial reason �patient was not
eligible on date of service rendered�?
Prior authorization decisions are given for a one-year time span for the provider�s convenience. Issuance of a prior authorization number does not guarantee eligibility for the dates included in the authorization. The provider must verify eligibility on each date that services are rendered (through MEVS or REVS). Patients can lose eligibility for various reasons after authorization is issued (i.e., they reach their 21st birthday or 19th birthday if certified for LaCHIP, family circumstances may change, program eligibility guidelines may change, etc.). If a patient regains
eligibility, the authorization may be renewable. Should this occur, you may contact the Dental Medicaid Unit for assistance by calling 504-619-8589.
EPSDT-HEALTH SERVICES AND PCS
1. Does a recipient have to be receiving case management or on a waiver waiting list to be eligible to receive EPSDT Personal Care Services (PCS)?
No. All Medicaid recipients under age 21 are eligible for PCS. This is a prior authorized service in which recipients must meet criteria for medical necessity.
2. Do School boards need a physician�s prescription for speech/language therapy billed to Medicaid?
Yes. There must be a physician�s prescription for these services in the Medicaid recipient�s chart.
New Code for Certified Nurse Practitioners
Effective with date of service November 1, 2001, the following CPT code will be added to the list of codes payable to Certified Nurse Practitioners.
31515 - larynogoscopy direct, with or without tracheoscopy; for aspiration.
CNPs Need QW Modifier With Some Codes
Effective with date of service November 1, 2001, the following CPT codes will be added to the list of codes that require a QW modifier:
83001QW - Genua Menopause Monitor Test
82570QW - Creatinine performed by the BayerDiagnostics/MICROALBUSTIX Reagent Strip
84460QW - Cholestech LDX Alanine Aminotransferase (ALT) test
Only Audiologist Allowed to Screen Newborns
The Medicaid Program was asked recently to consider allowing a technician, under the supervision of an audiologist, to perform newborn hearing screenings with payment being made to the audiologist for the supervision of this service. After due consideration, the program hereby announces that its current policy of reimbursing only audiologists for the performance of newborn hearing screenings shall remain in effect.
In other words, only audiologists will be reimbursed for screening newborns for hearing problems. Technicians shall not perform this service on Medicaid recipients nor shall audiologists be reimbursed for the supervision of technicians performing this service on Medicaid recipients.
Clarification of Denials With Error Code 299 and 232
Providers, please be reminded that you cannot always bill the recipient for a service on which you�ve received a 299 or 232 denial.
Some CPT codes are in non-payable status on our files because their services as described in CPT are included in other codes which are covered.
When the denied service is not payable on the file because it is a component of a payable service, it cannot be billed to the recipient.
For example, code 92015 (determination of refractive state) cannot be billed to the recipient because its fee is included in the fee for the office visit. Therefore, code 92015 cannot be billed to the recipient if denied with 299 or 232. Another service which cannot be billed to the recipient is the administration of an injection of a vaccine for which the physician has to pay. Because the fee for administration of the vaccine is included in the fee for the office visit, the recipient cannot be billed when the administration code is denied.
Inclusion of Cardiac Catheterization With Intracoronary Stent Placement
CPT code 93508 (Catheter placement in coronary artery(s), arterial coronary conduit(s), and/or venous coronary bypass graft(s) for coronary angiography without concomitant left heart catheterization) should be included in the performance of CPT code 92980 (Transcatheter placement of intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel). The only time both procedures may justifiably be billed on the same date of service for the same recipient is when the patient experiences chest pain after placement and the possibility exists that the stent has closed. In these cases, the provider must request the claim be reconsidered for payment, as edits will soon be placed in the system to deny code 93508 if there is already a paid claim for code 92982, 92995, or 92980 in history for the same date of service for the same recipient. Likewise, a claim for 92980, 92982, and 92995 will deny if there is a paid 93508 in history.
Medicaid Pharmacy Rebate Claim Verification
Many pharmacies may have noticed an increase in calls from our Pharmacy Rebate auditors seeking to verify specific claims that drug manufacturers are disputing on their quarterly Medicaid Pharmacy Rebate Invoice. We have recently adopted new programs and operating procedures that require us to call dispensing pharmacies in order to verify the accuracy of these claims. We have asked our auditors not to call your stores on Mondays due to the high volume of prescriptions you regularly experience on that day.
Some of the common errors that cause manufacturers to dispute utilization on their rebate invoice are summarized below:
� Generic substitution errors. Billing the brand name NDC, when the generic has been purchased and dispensed. Even if a pharmacy billed and was paid at the generic price due to a MAC or FUL,
the actual NDC that was dispensed must be billed. During our review of 4th quarter 2000, more than 50% of the pharmacies that billed the brand NDC for a specific drug have been stocking and dispensing the generic for an extended period of time.
Please be reminded that when providers bill for services inaccurately, the Medicaid program may impose sanctions on providers.
� Billing of Expired NDC�s. Please verify that the NDC you are dispensing is identical to what you are billing Medicaid. Drug companies will not pay rebates on NDC�s with an expired shelf life. Rebate staff will need you to review your purchasing records and rebill all claims under the actual NDC purchased and dispensed by your pharmacy.
� Unit type errors. Please verify the accuracy of the Medicaid unit type used to determine the quantity you submit to Medicaid. For example, Lovenox (NDC 00075-0624-30) has a Medicaid Unit type of Milliliter. This particular strength has .3 Ml per disposable syringe. A large number of pharmacies are billing in eaches (by the individual injection) rather than multiplying the total number of injections by .3 in order to bill Medicaid the appropriate quantity dispensed in Milliliters. For example, if a pharmacy has billed for 10 syringes with a quantity of 10 rather than 3 (10 times 0.3ml), an overpayment could occur.
� Keypunch errors. For example, 180 pills were dispensed but 1800 pills were billed to Medicaid. Please review your claims for reasonableness and accuracy prior to submission.
� Quantity/Decimal errors. We have found many errors due to rounding. For example, nasal sprays and inhalers may be billed in grams. If they have 16.7 grams in the container, many pharmacies are rounding up and billing Medicaid for 17 grams. In addition, most birth control packs contain 28 pills billable by the pill. However, many of the claims we receive are for a quantity of 30 for a one-month supply, resulting in an overpayment of 2 pills. Pharmacies should contact their software vendor if they do not know how to accurately bill for drugs that are packaged in fractional units.
We are presently reviewing claims on an ongoing basis and will ask you to reverse and rebill incorrect claims that are less than one year old. We are also reviewing all claims back to 1997 for the errors listed above and will recoup money paid to pharmacies for over billed/paid claims.
We would like to emphasize the vital role pharmacist�s play in our Medicaid rebate billing process when billing the proper NDC, quantity and unit type.
It is imperative for the pharmacist to assure that the NDC billed and the NDC dispensed are the same NDC. If you have questions regarding how to bill a particular claim, please contact the Point of Sale Helpdesk at 1-800-648-0790.
Please remember that when a provider bills for services inaccurately, the provider is subject to sanctions by the Medicaid program. The errors covered may constitute misbillings which have or may result in overpayments to the provider. Providers are required by Medicaid to refund any and all overpayments which may have resulted from billing errors committed by the provider or payment error committed by the Department or its fiscal intermediary.
Thank you for taking the time to review the common errors described above that may cause our auditors to call your pharmacy. Please share this information with your staff and stress the importance of accurate Medicaid billing.
Statewide Provider Training Ends
The annual statewide provider training workshops have concluded. If you failed to attend, you should request copies of the training manuals by calling Provider Relations toll free at 1-800-473-2783 or
924-5040 in the Baton Rouge area. All providers must comply with policies contained in the training manuals.
In addition, all of the Provider Updates dating back to February 1991 can be located at the web site at
Please note that providers, their employees, and agents are presumed to know the regulations and policies applicable to the services for which they bill the Medicaid program. All providers are responsible for training their employees and agents on any and all Medicaid regulations and policies applicable to the services billed to the Medicaid program. Ignorance of applicable regulations and policies is not a defense to an administrative sanction.
Expansion of CommunityCARE in Region 9
Effective March 1, 2002, Louisiana Medicaid will expand the CommunityCARE Program to include Livingston, St. Helena, St. Tammany, Tangipahoa, and Washington parishes. Medicaid recipients in these parishes will receive letters early in February advising them to choose a Primary Care Provider in their parish or a contiguous parish. These letters will include a list of CommunityCARE enrolled providers from which to choose. If recipients do not select a provider by the date designated in the letter, auto-assignment by the State will occur. Providers who are not enrolled as a CommunityCARE provider by February 15, 2002 will not be on this list.
Medicaid primary care providers (Family Practice, General Practice, Internal Medicine, OB, Pediatrician) may enroll as CommunityCARE Primary Care Providers, and that enrollment process must begin now. After March 1, 2002, providers not enrolled in CommunityCARE in these parishes must obtain a referral from the CommunityCARE PCP in order to bill for Medicaid services.
The CommunityCARE expansion schedule for the year 2002 will also include the following parishes:
|East Baton Rouge
|West Baton Rouge
Enrollment packets for CommunityCARE may be obtained by contacting Unisys Provider Relations at
1-(800) 473-2783. Questions may be directed to Provider Relations at that number, or to the CommunityCARE program office at (225) 342-1304.
Providers who currently serve patients in the parishes mentioned above should enroll in CommunityCARE in order to continue serving their patients from these parishes.
2001 Provider Training Questions � 2nd Half
1. Can nurse practitioners participate in the CommunityCARE program as the recipient�s PCP?
No, not at this time.
2. Will you provide a listing of diagnosis codes that you deem to be an emergency?
No, your medical professional should be trained to determine if the presenting signs and symptoms meet the Prudent Layperson Standard.
3. If a specialist with a referral sends the patient to a sub-specialist, is this referral sufficient for the sub-specialist also?
Yes, the specialist should note the reason for his referral to the sub-specialist on the form being sent.
4. Must the referral form be signed by a doctor?
No, the form does not have to be signed by a doctor. It can be signed by whoever in the office the doctor has authorized to sign the form.
5. What has been done to educate the recipients on the CommunityCARE Program?
The recipients have been provided with written notices and educational brochures about the program. In addition, the
1-800-354-2122 number is available to discuss CommunityCARE with a trained person who can assist the recipient in understanding CommunityCARE and choosing a PCP.
6. Is there going to be a limited number of PCPs for a certain radius?
No, we will enroll any primary care provider (family practitioner, general practitioner, pediatrician, internist, and OB/Gyn) who is interested in participating.
7. How do we handle the referral if two doctors are taking calls and one physician is CommunityCARE but the other does not participate?
A referral is required for both unless one is a designated backup for the PCP.
8. If the hospital is maintaining the patients� medical records and the patient gets audited, who would be admonished/penalized if the hospital cannot present the paper referral authorizing services?
It depends on the circumstances and pervasiveness of the problem. Each case is considered individually.
9. How far back can we retrieve information from the website on the Provider Updates?
The Provider Updates are archived back to February 1991.
10. When we call the PCP for authorization we are simply given an authorization number. Can we bill with that information or do we have to obtain the paper referral?
You must obtain a paper referral and retain it in the patients� records for a period of five years.
11. How often can a recipient change PCPs?
During the initial assignment the patient has 90 days to choose a new PCP. Each time a change is made a new 90 day period commences. Also, recipients can choose a new PCP (for good cause reason) or the PCP may request the recipient find a new PCP.
12. Does the PCP referral limit the number of visits?
The referral indicates the diagnosis and date(s) of referral not the number of visits.
13. What should be done when the PCP issuing a referral is not the PCP on file for that recipient?
Eligibility should be checked every time a patient comes in for treatment and REVS/MEVS gives the current information. The claim has to reflect the PCP assigned to the recipient on the date of service.
14. What happens when a PCP issues a referral to a specialist for the day of specialist services, and the specialist calls in other servicing providers who see the patient on other dates not covered by this initial referral?
You may make a note to that effect on the referral and pass it along.
15. A patient needs ongoing treatment such as dialysis, and the PCP will only issue a referral for one month at a time. Before the PCP issues another referral, documentation is requested each time from the servicing provider. Is there any recourse to this?
A PCP may manage his/her patients in a manner suitable to his/her own practice. If he/she is closely following such a patient, he/she may want such reports. Providers receiving referrals can discuss with the PCP and an arrangement suitable to both may be worked out.
16. We are getting requests for referrals from providers who have seen our patients but we never have. Do we have to issue a referral if we have never seen them?
It depends on several factors. How long the patient has been assigned to you, their relationship with the provider requesting the referral, and of course the nature of the care being rendered. Also, DHH allows PCPs to issue an administrative referral for the first month of recipient linkage which gives the PCP time to schedule the patient to be seen in his/her office.
17. Is there a list of Medicaid providers available to use for referrals?
Contact Birch & Davis the DHH contract administrator for CommunityCARE at 1-800-609-3888.
18. Will a claim deny for a referral if there is no CommunityCARE information on a patient�s file on MEVS/REVS?
No. If REVS/MEVS does not indicate a PCP, a referral is not needed for that date of service.
19. If a provider is moving out of state, who should be notified concerning his enrollment status with Medicaid?
You should contact Provider Enrollment at (225) 923-8510 to terminate enrollment status. Also, Birch and Davis at 1-800-609-3888. Birch and Davis will work with you to transfer patients.
20. Will claim forms be available on the website to download?
No, not at this time.
21. Is the DME electronic software the same as the POS system?
No, contact the EMC department for electronic software vendor information.
22. Is the patient�s address required on the referral form?
Yes, this information should be on the referral form.
23. How long does it take for a recipient to change PCPs?
It takes approximately 60 days for the entire linkage process to be completed.
24. If a patient goes into the emergency room during the PCP�s regular office hours can a referral be denied because the recipient could have come to the PCP�s office?
No. However, if the presenting signs and symptoms do not meet the Prudent Layperson Standard, a referral may be denied for that reason. The fact that the PCP�s office was open when the recipient presented to the ER is not sufficient reason to deny issuing a referral.
25. We received a CommunityCARE referral form from the hospital that does not cover the date of service (which was the date of discharge). We rendered DME services on the discharge date. Do we need to get another referral?
Yes, the date on the referral must match your date of service.
26. Are there plans at any time in the future to �skip� the MEVS vendor and allow providers to access eligibility through MEVS directly from Unisys?
Not at this time.
27. In order to be in compliance with HMO contracts, a provider must collect a co-pay from the patient. If a co-pay cannot be collected if the recipient is Medicaid, is there a HMO compliance issue?
Medicaid recipients are not responsible for the co-pay for Medicare HMO services. The HMO and DHH are working on a solution for remitting co-pays to the HMOs.
28. Should eligibility be verified every time a patient comes in or only once a month?
It is recommended that eligibility be verified each time a recipient is seen.
29. We have over 1,000 recipients linked to us as their CommunityCARE provider. When the patient goes to the emergency room and is admitted to the hospital, doesn�t the referral that we provided to the hospital cover all other service providers who are called in to treat the condition?
Yes, the referral that you have rendered to the hospital should state that the care by other providers called in on the case is covered by the referral.
30. How do we handle giving a referral for a patient who is changing PCP?
You should issue a transitional referral in this case.
31. We fall into the category of physicians who may enroll as CommunityCARE PCPs. Does this mean that we will be required to enroll?
No, CommunityCARE is a voluntary program. You are not required to enroll. If you choose to, you have options about your enrollment. You may enroll for your current Medicaid patients only, with a stipulation of a limit, or you may open your practice to enrollment. If you do not enroll, you may be limited to the Medicaid patients you see. It is anticipated by the end of 2003 all recipients will be enrolled in the CommunityCARE program. Please see the CommunityCARE article in this edition of the Provider Update.
32. When a newborn is in a Neonatal unit why is there a delay of about two months before the CommunityCARE linkage shows on the file?
The baby first has to obtain a Medicaid identification number and then the parents have some time to choose the PCP. A referral form is not required to bill until the linkage shows up when eligibility is verified.
33. Are we required to send complete medical records in order to obtain a referral form for emergency room services?
Although the PCP must render a decision based on presenting symptoms, the PCP may request medical records to assist in that decision (if the hospital face sheet does not contain sufficient documentation).
Case Management Questions
1. A case management provider closed. Their records were sent to OCDD who in turn forwarded all records to us. As the new provider for the recipients, are we responsible for keeping all the records OCDD sent us for these recipients? The records are about 3 years old.
Contact BCSS Case Management at 219-0200 regarding this issue.
1. How do you know if a patient is no longer LaCHIP eligible once they turn 19 years old?
Call REVS or access MEVS to verify recipient eligibility.
2. Do patients going to State hospital dental clinics for oral care need a CommunityCARE referral for services rendered?
Routine EPSDT dental services do not require a CommunityCARE PCP referral. Services other than routine EPSDT dental services do require a CommunityCARE PCP referral.
3. If the child has a behavior problem how do I document it?
Write a brief description of the problem and the additional services provided to manage the problem in the REMARKS section of the claim form. This information should also be documented in the patient�s record.
4. If I bill Medicaid secondary with EOB of private insurance attached and I get overpaid, what procedure do I follow?
Call Provider Relations and explain your situation. A representative will have your claim pulled for review. Assistance will be provided to file an adjusted claim.
5. Must documentation of TPL be attached when billing Medicaid first?
No, just fill in the OTHER CARRIER box on claim form.
6. Are there any exceptions on the SEVEN YEAR RULE with adult dentures?
No, at the current time, this rule has no exceptions.
7. What is the age limit on billing for flouride treatments?
Flouride treatment is payable up to the 16th birthday.
8. Does the root canal rule of thumb apply for trauma induced services?
No. When requesting a root canal involving a trauma, documentation regarding the need for this treatment should include details about the trauma so that all facts are taken into consideration.
1. I�m getting denials on my PA-01 for not listing the MD�s name but I�m entering the PCP�s number. I thought that either would work.
No, you must enter the MD�s name on the PA-01 not the MD�s number.
2. What procedure should be followed when an emergency situation requires DME equipment and cannot wait 30 days for a PA?
An emergency request for PA can be handled by phone by calling the Unisys PA Unit at 1-800-488-6334.
3. I am an out of state provider. In determining my delivery area, how do I know what the parishes are and what towns fall within a parish? Also, is a parish the same thing as a county?
Yes, a parish is a county. You need to use a map to determine your delivery area so you know what deliveries are billable.
4. Do we put the amount we charge for the purchase or the rental fee on the PA01?
You should just attach proper documentation to support medical neccessity. The prior authorization department will decide if the recipient qualifies for rental or purchase.
5. What amount should we indicate as total charges on our claim form?
You should bill the Medicaid program your usual and customary charges.
6. If after receiving PA for an item, the reimbursement amount is less than it costs to buy the item, do I have to provide the item to the recipient?
Yes, once you have chosen to accept the patient�s Medicaid card you must bill Medicaid for all covered services.
7. Can a reconsideration be done to dispute a reimbursement amount?
No, a reconsideration is for the decision to provide treatment, not for the reimbursement amount allowed for an item. If you have an issue regarding the reimbursement of an item you can discuss it with DME staff.
8. As a home health agency can we bill for delivery?
Yes, if you are functioning as a DME provider and the supply is being delivered from one parish to another.
9. Will the patient�s freedom of choice be taken away when CommunityCARE rolls into a region?
No, the patient should be allowed to tell the PCP or referring doctor which DME company he/she would like to use.
10. Does our company name have to be on the referral form?
If the PCP is referring the patient directly to you, the referral should be made out to you. If a specialist is sending the patient to you, the referral that will be �shared� with you will have the name of the specialist.
12. Is the referral form required when requesting prior authorization?
No, PA is looking at medical necessity. You must have the referral in order to bill for services but it does not play a role in the prior authorization process.
13. Will the time limit for the rental be indicated on the PA?
Yes, the approved PA will include this information.
14. What does it mean when we receive a PA without units?
These are services that are manually priced. Instead of units approved, the PA notice should indicate the dollar amount approved.
15. In order to download the Apnea monitor, we must go out of parish to the patients� home. Can we bill for out of parish delivery for this service?
Medicaid does not pay for this service.
16. If a doctor changes type of care more than three times what course of action do I take with the PA department?
Call the PA department to discuss this.
1. Can a mother apply for LaCHIP before the baby is born?
If the mother is under the age of 19, she could be eligible for LaCHIP for herself and would not need to wait until the baby was born. If the mother is over the age of 19, she can still apply for regular Medicaid as a �Pregnant Woman� and would not need to wait until the baby was born.
2. Should private insurance be dropped before applying for LaCHIP?
A child may not have private insurance in order to qualify for LaCHIP.
3. How will the provider get paid for LaCHIP services rendered?
LaCHIP is simply another category of Medicaid eligibility. The same billing and payment policies apply.
4. Can you go to any Medicaid physician?
The same policies apply as with all other Medicaid recipients.
5. Can I apply for LaCHIP for my son if he is currently 19?
No, you must apply before the recipient turns 19. There is the possibility that the 19 year old could receive Medicaid under a disability related program, if applicable.
6. Do application centers get paid for applications for LaCHIP and are these applications sent to the regional office?
The same reimbursement applies to LaCHIP applications. Application centers submit LaCHIP applications to the LaCHIP Office and not to the regional Medicaid offices. (Note: The simplified application form is used for ALL children under age 19 for both LaCHIP and Title XIX.)
7. How is income of self-employed people calculated?
Computations are taken from the pervious year�s federal tax form with all schedule attachments. If the person has been self-employed for less than a year and does not have IRS forms from the previous year, other proof is required such as records of income, expenses, etc. (Providers can refer self-employed patients to the local Medicaid office for more information on self-employment due to the variables.
1. Will social workers or counselors ever be allowed to provide services under the EPSDT program?
Medicaid has no immedicate plans to reimburse for services provided by these professionals.
2. Can PT assistants provide services for EPSDT program?
Please refer to your EPSDT manual for these qualifications. Medicaid will reimburse if your state�s licensing board allows for these professionals to provide those services.
3. Is the DIAL assistance number and that service being discontinued?
It has not been discontinued, however it is not promoted for use in Medicaid. For assistance in finding a physician or other Medicaid provider, please call the KIDMED and CommunityCARE Referral Assistance Toll-Free Hotline at
4. Page 1 of the 2001 EPSDT training packet states that DHH is now requirung that all EPSDT Health Services providers enrolled in Medicaid give a written statement concerning access to certain medical services to Medicaid-eligible recipients at the time of their IEP or IFSP is developed. Should we be giving this statement to recipients at this time?
You should be currently following this procedure. Please inform your recipients in writing.
5. Can a doctor who is not the child�s CommunityCARE PCP write an order for EPSDT screenings?
Yes, if he has a referral from the child�s PCP.
6. Is there a procedure in place in the EPSDT-PCS manual or other documentation that indicates what to do when a recipient changes providers?
No. However, when a recipient changes providers the new provider must submit a complete prior authorization packet. The old provider must submit a letter discharging the patient so that a new PA can be issued. If the old provider refuses to do this, the recipient�s family can submit a letter stating the old provider is no longer providing services.
7. In the PCS Program, if there are changes in the daily schedule, who at DHH or Unisys should be informed? Can the family constantly request to switch the day and time?
Services should follow an approved plan of care. If constant changes are needed, then a meeting and plan revision is required because the plan in place is not working.
Home Health Questions
1. Can a patient over 21 receive a skilled nursing visit and rehabilitation services on the same date?
Yes, if the 50 visits have not been exhausted and the therapy services have been prior authorized.
2. How should a provider bill for a child covered by Medicare extended care?
You must first bill Medicare and then bill Medicaid with the EOMB attached.
3. A patient was referred by their PCP and presented with the referral, but the patient no longer wishes to see that provider as the PCP. Who should provide the referral?
A referral must come from whomever is indicated on REVS/MEVS as being the patient�s current PCP. Patients may call Birch & Davis to change the PCP if they are dissatisfied with their current PCP.
1. When a patient is transferred from acute care to rehabilitation should we have two precert numbers?
No, one precert is sufficient. If you have two precert numbers you should call our precert department to have the two numbers combined.
2. What should we do with the balance left on our books when a crossover claim pays at zero with a 996 reason code?
You should make a mathematical adjustment to zero out the account. The patient cannot be billed for any remaining balance.
3. On an outpatient claim, if Medicaid is secondary and the private insurance does not pay by line item, how should we file an adjustment?
Pro-rate the payment for each line item adjustment that you have to file.
4. Is precert required for a Medicare recipient who has exhausted their Part A benefits?
Yes, precert is required in this instance (out of state or charity facilities are exempt from precert).
5. Can we bill a patient for a day that is not covered by precert?
In most cases you cannot bill the patient. In cases where continuation of the stay is not medically necessary, but the patient wants to continue the stay, the patient should be told that the remainder of the stay is the patient�s responsibility. You cannot bill the patient for the date of discharge.
6. How should a void/adjustment claim that is two years old be submitted?
If the claim is within two years of the date of payment an adjustment/void claim may be sent to Unisys. If the claim is beyond two years from the date of payment a refund check should be sent to DHH. Please refer to your Hospital Manual for the instructions on sending in a refund.
7. How should surgical procedures in the emergency room be billed?
If the procedure falls on the ICD9 surgical procedure listing or within the range of 01-86, at least one of the line items should be filed using revenue code 490.
8. Can a patient have CommunityCARE and Lock-in?
Yes, if the patient is locked in to a pharmacy then he will need to choose a PCP to manage his overall health care.
9. A CommunityCARE recipient is transferred from one hospital to another facility. Is the referral form that the first hospital received sufficient to cover the services of the second facility?
The second facility must also obtain the referral.
10. In hospital situations, at what point should we tell the patient that they will be responsible for the bill?
If the presenting signs and symptoms do not meet the Prudent Layperson Standard, the patient should be informed immediately that care is routine and is not covered by Medicaid.
11. How does the hospital get paid for the initial emergency room screening and diagnostic testing if it is determined that the patient�s condition is not emergent?
The PCP could issue a post authorization/referral for the screening and diagnostic testing. The hospital should send the face sheet indicating documentation of presenting signs and symptoms to the PCP the day following the ER visit. The PCP will decide based on this information whether to authorize or not.
1. Can an LPN perform a nurse consult or must an RN provide this service?
An LPN cannot perform a nurse consult; an RN must perform this service.
2. To perform services in CommunityCARE, do you have to be an RN or an LPN?
For a KIDMED medical screening, LPNs can obtain patient history, conduct the Denver II test if certified, administer immunizations, perform routine KIDMED lab tests, and conduct health education.
3. If a recipient comes in for a KIDMED screening and is anemic and needs to be treated accordingly, how do I bill for the non-KIDMED services?
To bill for the non-KIDMED services you would bill on the HCFA-1500; to bill for the KIDMED screening services you would use the KM-3. Keep in mind that the highest office level allowed in the same day as screening by the same provider is a 99212.
4. Can I just provide two of the five components in KIDMED or do I have to provide all five?
In order to receive payment for a KIDMED medical screening all five components must be performed. The five components are: 1) comprehensive health and developmental history, 2) comprehensive unclothed physical exam or assessment, 3) appropriate immunization, 4) lab tests, and 5) health education.
5. Will HIPAA increase the KIDMED timely filing guidelines to one year?
6. Can a Rural Health Clinic bill for an in-house referral on the same day as a screening?
7. We are having problems with patients being linked to us for CommunityCARE and not for KIDMED. How do we remedy this situation?
Contact Birch & Davis who handles all linkages for both CommunityCARE and KIDMED.
8. Can we drop a patient off of our RS-0-07 if they do not come in regularly?
Contact Birch & Davis to discuss the process for unlinking a recipient from a provider.
9. Has anyone at the State level been tracking how CommunityCARE has affected school boards so far?
Yes and discussions are occurring regarding the participation of school based health clinics in CommunityCARE.
10. What happens to the patients in a particular area if there are not enough physicians to sign up for participation in the CommunityCARE program?
DHH is actively recruiting PCP�s as all areas roll into CommunityCARE. This will be addressed as it proves to be a problem. Remember, however, that patients can choose a PCP in their own parish or a contiguous parish.
11. Can we bill for a urinalysis and hemoglobin performed at the time of the medical screening?
Anemia and urine screening are included in the reimbursement rate for a medical screening when it is required according to the periodicity schedule and cannot be billed separately.
12. If a child comes in for a medical screening and is referred to a specialist for a problem, can the specialist see the patient on the same day as the screening and bill 99214 for services?
Yes, the referral restriction rule is limited to the physician that performed the screening, not a specialist.
13. If a patient is on my RS-0-07 for a particular month, but has a different doctor as PCP on the MEVS tape what should I do?
Contact Birch & Davis regarding the patient�s linkage. If a child has a PCP, the PCP should also be the child�s KIDMED provider.
14. Must children under 18 have a parent or guardian accompany them to a KIDMED screening?
If a parent, guardian, or other responsible adult is not present when the initial history for a KIDMED medical screening is taken on a child under 12 years of age, you must telephone the parents or guardians or send them a questionnaire to obtain the necessary information. You may obtain the initial history from the child if the child is 12 years of age or older and is capable of providing this information.
15. What should be done if we have knowledge that a patient has moved from our area but still appears on our RS-0-07?
Contact Birch & Davis regarding the linkage or have the patient contact Birch & Davis to have the linkage changed.
1. Should an entire fax be resent if my transmittal sheet does not match the number of pages that I intended to send?
Yes, resubmit the entire fax to insure that we have received all of the information needed to process the precert.
2. If a patient has a TPL without maternity benefits and has only presumptive eligibility what should I do?
You should submit for precert as usual. You will receive a denial but should the patient become eligible for full Medicaid coverage you will have an avenue open to obtain a good precert.
3. Is the PCF01 always required when requesting an extension or reconsideration?
Yes, that is what identifies the case that is being considered for pre-cert approval.
4. What happens if the recipient becomes retroactively eligible for Medicaid after admission? Should we try to pre-cert at that time as a retrospective review or wait until after they are discharged?
If you have determined that the recipient did not show coverage on date of admission but now has coverage and you know that the number is on Unisys� files, it would be to your advantage to obtain pre-cert at this time. If the case is not pre-certifiable (does not meet medical criteria), you would know now instead of days later into the stay. You do not have to pre-cert at this time because the recipient was made Medicaid eligible retroactively, and you have a year from the date of the eligibility determination.
5. Is there a reason why you have updated HCIA LOS criteria to the 2000 version but the INTERQUAL version remains at the 1994 version?
Yes, the state does not feel that hospitals should have to purchase the expensive new INTERQUAL versions.
1. An OB/GYN is on call, delivers a baby, and performs a sterilization on the patient. The physician obtaining the consent is different from the physician signing the 96 form. Can the on call physician receive payment?
Yes, the physician that obtains the signature does not necessarily have to be the physician that performs the sterilization.
2. CPT does not require 51 modifiers on add on procedures. According to the Aug/Sept 2001 Provider Update Medicaid will require the use of a modifier. Please clarify?
Louisiana Medicaid does not always follow CPT guidelines. In order to bill for an add-on procedure a 51 modifier must be used when billing LA Medicaid.
3. Patients in HMOs are exempt from participating in CommunityCARE. What if a patient is participating in a PPO and their PCP for the primary insurance is not the same as their Medicaid PCP - what happens in this case?
Have the recipient call Birch and Davis at 1-800-359-2122 and an exemption can be made after verification of PPO status.
4. Does the person obtaining the patient signature on the 96 form have to be a physician?
No, the physician only has to complete Section 4 of the 96 Form.
5. When Medicare and Medicaid have a different name on file, how is this reconciled?
Submit a letter with a copy of the Medicare card to Provider Relations to have the file updated. Submit the claim under the name on the Medicaid file.
6. Why is modifier 76 not in the list of modifiers recognized by Medicaid?
Modifier 76 is not listed because Medicaid does not require this modifier in order to reimburse any procedure.
7. Is there an age restriction for the pneumococcal vaccine?
Yes, for code 90669 and 90732 it is through age 20.
8. How often does Unisys receive eligibility updates?
We receive updates daily.
9. What should we do if MEVS indicates that the patient is not eligible on the date of service but the patient insists that they are eligible?
You should contact the parish office or 800-834-3333 in these instances.
10. When billing for nurse practitioner services does the physician have to be in the office during the time that the services are being rendered?
No, a nurse practitioner is an independent practitioner and operates with a protocol from the physician. The physician does not have to be physically in the office. If services are provided by an RN, the physician must be physically in the office.
11. If a doctor visits patients that are in a nursing home do they need to obtain a CommunityCARE referral?
No, nursing home recipients are exempt from CommunityCARE.
12. What are the three age groups as determined by Birch & Davis for KIDMED?
0-5 years; 6-13 years; and 14-21 years.
13. Do audiologists have to be a DME provider to bill for hearing aids?
Yes, in order to bill for hearing aids you must be a DME provider.
14. How do we know what cert type we are? It does not show on our CLIA certificate?
Ms. Staci Glueck in Health Standards (225) 342-9324 should be able to help you understand what your cert type is on your CLIA certificate.
15. Medicare has begun to reimburse us for drawing a blood specimen. Will Medicaid begin reimbursing for this service?
At this time this is not a billable service to Louisiana Medicaid and we are not aware of any impending changes.
16. In the J code listing is there an indication of which J codes are only payable for Medicare/Medicaid crossover patients?
17. What documentation is required, if any, to bill for impacted ear wax?
The Bureau will pay for the removal of impacted wax if reflected by the diagnosis.
18. What codes are billable for antibiotic injections for patients under the age of 21?
You should bill using code 90782.
19. When billing for a nurse practitioner when the recipient is covered by a PCP how do we complete block 17 and 17A of the 1500?
The name of the supervising physician should be placed in block 17 and the referral authorization number for the PCP would go in block 17A. (The nurse practitioner�s number goes in block 24K.)
20. When I am filing for an adjustment claim what ICN should I use � the one for the adjustment claim or the original ICN?
You should use the ICN that was assigned to the adjustment claim.
21. When filing an adjustment claim for a recipient who has Medicaid secondary should the EOB be attached to the 213 adjustment claim?
Yes, the EOB must be attached and the payment dollar amount must be indicated on the adjustment form as well.
22. Will Medicaid pay for non-emergency medical transportation for treatment that is not covered by Medicaid?
Medicaid will pay for non-emergency Medicaid transportation to a non-Medicaid provider if the service is a Medicaid covered service and is medically necessary, but Medicaid will not pay for a service not included in the benefit package.
23. How much time must lapse before a regular office visit may be billed after billing for a consult?
This would depend on how the doctor charted the consult in the patients� medical records. If the documentation makes clear that the doctor had no intention of seeing
the patient for a follow up visit and the patient presents for treatment at a later date, then the doctor can bill for a consult for his original contact with the patient. He could bill for an established evaluation and management code when the patient presents to his office. (Keep in mind that this rule applies for recipients over the age of 21.)
24. A 23 year old has a baby which is delivered by a physician in a group. The appropriate prenatal, delivery and postpartum codes are used (Z codes and delivery code). Contraception is discussed at a postpartum visit and the patient is prescribed oral contraceptives. The patient is instructed to return in one year for her preventive care exam and renewal of her oral contraceptive prescription. A preventive care exam includes a comprehensive history and a comprehensive physical. How do we code for this return visit? Will this be covered by Medicaid?
If you are using a diagnosis code indicating that you are providing family planning services we will not limit the way that you code for this visit. As long as you are using a diagnosis that does not indicate preventive care you will be paid. The preventive care codes are not payable for recipients 21 and older.
1. After therapy is completed and the physician wants another evaluation do we need to obtain PA?
No, you do not need PA for the second evaluation but Medicaid only reimburses for one evaluation every six months. The patient may be held responsible for services not covered by Medicaid.
2. Are revenue codes required on the PA01?
No, revenue codes are used for billing claims only.
3. Is PA required with Medicare claims?
Medicare covered claims should cross over from Medicare without Medicaid PA. If the service is a non-Medicare covered service, the procedure should be paid as it becomes a straight Medicaid claim and will require PA.
4. What are timely filing guidelines for crossover claims?
A claim must be filed to Medicare within one year of the date of service to meet Medicaid�s one-year filing limit. Once this has been met you have six months from the date of the Medicare EOB to file your claim to Medicaid.
1. Within the PPS will the KidMed visit be included in reimbursement?
2. Is a critical access hospital based RHC exempt from the 24 hour hospital admit discharge rule?
3. Can RHCs staffed by only nurse practitioners be on the CommunityCARE auto assignment list?
4. In the PCP choice letter that recipients receive, are PCPs located in contiguous parishes on the choice list?
No, only the PCPs whose offices are located in the same parish as the recipients� residence are listed on the letter. However, if recipients wish to choose a PCP in a contiguous parish and that PCP is participating in the CommunityCARE program this request can be made when they are contacting Birch & Davis to make their choice.
5. How do I bill for a flu shot for a patient under 21?
Use a J code for the appropriate injectable.
6. Is the PPS the same for a free standing versus hospital based RHC/FQHC?
7. The training claim example shows an attending provider number in Block 24K on the HCFA1500, as well as the RHC number in Block 33. We have not been filing claims with an attending provider number; we only use the RHC number in Block 33. Are we filing incorrectly?
RHC claims should be filed using an attending provider number if the service is performed by a physician or a nurse practitioner. These providers should have their own Medicaid provider numbers and these would be used as attending provider numbers. In addition, if the attending provider number is that of a nurse practitioner the nurse practitioner�s supervising physician�s name should be shown in Block 17 of the 1500. Remember that the Medicaid provider number of the attending provider must be linked to the RHC provider number. If the service is rendered by someone other than a nurse practitioner or a physician the claim may be filed with only the RHC number in Block 33.
8. If an RHC has a pediatrician on staff, should KIDMED or regular visits be billed for recipients under 21?
You must bill KIDMED for screening. You must bill codes 99381-99397 for preventive care. Regular visits would be billed if the child is referred for a suspected condition or problem.
1. When a recipient exceeds the PCA service limits, we must bill hardcopy (not electronically) to get an override in order to be paid. Are there any plans to change this procedure?
At this time BCSS will continue to require hard copy billing for overrides.
2. We are having problems getting MR/DD 14�s from Case Managers. What can we do?
Report the problem to the BCSS Helpline and it will be referred to Case Management.
Note: EPSDT PCS may not be provided to an EPSDT eligible receiving MR/DD Waiver Personal Care Attendant services until the waiver limit is exhausted.
3. Is a diagnosis required on Elderly Waiver claims? If it is not on the MRDD14 what should be done?
Yes, a diagnosis is required on all claims. Contact the case manager to get the information. If you are unable to get the information from the case manager, contact the BCSS at DHH for assistance.
4. How long does it take to get a new PA number?
For MR/DD it depends on when the PA number request is received by the BCSS Regional Office. It could take up to 8 days to generate after being entered into the PA system.
5. What should we do when we have an incorrect ID# on the MRDD14?
Contact the case manager for the correct ID#. If you are unable to get the information from the case manager, contact the BCSS at DHH for assistance. Have the case manager inform BCSS Regional Office that the number is incorrect.
6. Should I bill Medicaid when I have authorization but I did not provide the service?
No, that would be considered fraudulent billing. You can only bill to Medicaid once services have been rendered.
7. What is the turnaround time for payment of claims?
For claims submitted electronically there is a 1-2 week turn around depending on when the claim was submitted. For hard copy claims the turn around is 30-45 days.
8. What does �claim in process� mean on my remittance advice?
This means that the claim is pending for review of certain information in order to process and pay the claim. The claim will not necessarily pay; there is the possibility it can deny.
9. Who should recipients contact about requesting services for the elderly and disabled adult waiver program?
Contact the Council on Aging or BCSS to inquire about requesting services for the EDA Waiver Program.
10. When should a provider apply for PCS when the recipient is enrolled through MRDD?
The recipient must use all of their PCA hours for the year under MRDD before applying for PCS. Both services may not be provided at the same time.
11. I am requesting four hours per day of PCS services and I am only being authorized for two hours. Are there new doctors reviewing our requests?
Your requests are approved on a case by case basis. You may write to the EPSDT-PCS Program Manager to voice your concerns.
Louisiana Drug Utilization Review (LADUR) Education
Glaucoma 2001: An Overview with Emphasis on Medical Management
By Lisa M. Digioia-Ross, Pharm.D.
� Glaucoma is the second most common cause of blindness overall and the number one cause of blindness
among African Americans.
� Primary management of POAG glaucoma is somewhat controversial.
� The most recent class of glaucoma medications to come onto the market is the prostaglandin analogs.
Glaucoma affects an estimated 2-3 million Americans. Despite advances in treatment it remains a leading cause of blindness. Glaucoma refers to a group of diseases, which are characterized by a relative increase in intraocular pressure (IOP) which results in damage to the optic nerve and subsequent visual field loss.
The most common type of glaucoma is primary open angle glaucoma (POAG), a chronic disease, which results from idiopathic impaired outflow of aqueous humor through the eyes drainage apparatus or trabecular meshwork. Secondary open angle glaucoma results when known entities, such as hemorrhage or pigment, clog the eyes drainage apparatus. Steroids may also cause open angle glaucoma by possibly favoring glycosaminoglycan deposition in the trabecular meshwork, which impairs the eyes� outflow facility. Open angle glaucomas are asymptomatic in the early stages. Another major type of glaucoma is acute angle closure glaucoma (AACG) which occurs secondary to pupillary blockage of aqueous outflow across the lens/iris diaphragm. This type of glaucoma involves an anatomically narrow drainage angle; the iris inserts into the trabecular meshwork at a narrow angle, which can potentially cause pupillary block. This type of glaucoma usually manifests itself as an acute attack involving the following symptoms: pain, blurry vision, nausea, vomiting, sweating, redness of the eye, and presence of halos around lights. In some instances ACG can exist as a chronic condition.
Low-tension glaucoma is an open angle glaucoma involving the typical visual field defects and optic nerve damage. However, the IOP is within the normal range. Ocular hypertension is a condition characterized by an elevated IOP without the associated visual field and optic nerve defects. However, 10% of individuals with this condition do eventually develop glaucoma.
Glaucoma is the 2nd most common cause of blindness overall. However, In African Americans it is the #1 cause of blindness. Glaucoma affects more than 2 million Americans over age 40. In fact, seven percent (7 %) of the population over age 80 carries a diagnosis of glaucoma. Since seventy percent (70%) of all glaucoma cases are POAG, this article will focus on the POAG treatment when pharmacologic interventions are discussed. Certain risk factors are associated with the development of glaucoma and include: advanced age, African American race, cardiovascular disease, thyroid disease, hypertension, diabetes mellitus and myopia (nearsightedness).
The human eye is a complex sensory organ composed of corneal and lens elements for focusing and neurosensory retinal tissue which transmits visual information via the axons of the optic nerve to the brain. Anatomically the eye is composed of the conjunctiva, cornea, sclera, iris, pupil, lens, trabecular meshwork, ciliary body, retina and optic nerve. There are other parts to the ocular anatomy; however, for the purposes of our discussion on glaucoma, this is sufficient. The optic nerve has a central excavation or �cup� with a rim of axonal tissue which is susceptible to damage in glaucoma. If there is damage to the optic nerve from glaucoma then an increased cup to disc ratio is observed; this means that the �cup� area becomes larger in relation to the whole �disc� or optic nerve head. The optic nerve depends on adequate blood perfusion for its health and intraocular pressure (IOP) directly affects the blood supply to the optic nerve. Normal IOP is between 8-21mm Hg. The IOP is a function of ciliary body aqueous humor production and trabecular meshwork outflow plus episcleral venous pressure in mm of Hg.
Aqueous humor production occurs in the non-pigmented ciliary epithelial cells within the ciliary body. Its production is mediated by passive diffusion (high conc. to low conc.), ultrafiltration, active secretion (Na+/k+-ATPase and carbonic anhydrase) and by stimulation or blockade of cholinergic or adrenergic alpha and beta-receptors on the ciliary body. Pharmacologic management of IOP can be directed at any of these variables. After its formation, the aqueous humor travels from the ciliary body to the posterior chamber thru the pupillary margin to the anterior chamber where it then exits the eye via the trabecular meshwork. The trabecular meshwork empties into the canal of schlemm, a lymphatic channel; it then ends up in the ocular venous system and then the body�s main circulatory system. Eighty percent (80%) of all aqueous humor exits the eye this way. However, the remaining twenty percent (20%) of aqueous drains directly across the ciliary body thru the sclera and into the orbit, which is referred to as the uveoscleral pathway.
In glaucoma we see an increased IOP (>21 mm Hg). Typically, there is aqueous humor outflow resistance at the trabecular meshwork which leads to a higher than normal IOP. This in turn leads to optic nerve damage or �cupping� secondary to mechanical and /or vascular factors. Optic nerve damage causes peripheral visual field loss. Eventually total blindness may result.
Clinical goals in the management of glaucoma include achieving an IOP of < 14 mm Hg and a positive clinical response. An individual patient�s clinical response is assessed based on a lack of progression of optic nerve and visual field deterioration.
Lowering of IOP is the only FDA approved medical treatment of glaucoma patients. Neuroprotective drugs are currently being evaluated in glaucoma treatment. Some IOP lowering drugs can however exhibit neuroprotective properties independent of their pressure lowering effects. These drugs include Rescula�, Alphagan� and Betoptic�.
Primary management of POAG glaucoma is somewhat controversial. It may include pharmacologic interventions (medications), Argon laser trabeculoplasty (ALT), or surgery known as a trabeculectomy (� guarded filteration procedure�). Combinations of these are an additional option. Most ocular physicians would try IOP lowering medication(s) first. Then if that was not enough to decrease IOP alone, they would progress to using laser (ALT) and then finally �filteration� surgery. Argon laser trabeculectomy (ALT) works by increasing outflow facility in the trabecular meshwork to create improved routes for aqueous outflow. By improving aqueous outflow the IOP should subsequently decrease. Trabeculectomies or �guarded filteration procedures� are surgeries, which can be performed via various methods/techniques. All have the same goal in mind, which is to create a new pathway for aqueous humor outflow. However, in some highly resistant cases more extreme surgeries such as drainage implant procedure or a ciliary body ablation (cycloablation) can be done. Once again, the improved aqueous outflow from surgical interventions should lead to decreased IOP. Ciliary ablation serves to decrease aqueous production which lowers IOP. There are various classes of medications which can be used to decrease IOP as well. Elaboration of these agents will be the main focus of this discussion on treatment of POAG. These medications will be reviewed by category from the oldest to the newest classes of agents available for treating glaucoma. Most of the medications to treat glaucoma are available as ophthalmic drops and products except for the oral carbonic anhydrase inhibitors and hyperosmotic agents, which are taken systemically. Typically, a single pharmacologic agent would be used initially; then if IOP was not sufficiently controlled, other agents could be added to the regimen.
Historically, the cholinergic or miotic agents were the first drugs available to lower IOP and treat glaucoma. These agents work by causing contraction of the pupil and ciliary muscles which in turn pulls open the trabecular meshwork and causes increased aqueous outflow. The IOP is decreased about 20% using these topical ophthalmic agents. There are three (3) subcategories within this class, including the direct acting cholinergic-miotics, the indirect acting cholinergic-miotics and the mixed acting cholinergic miotic. An example of the mixed acting cholinergic-miotics is Carbachol� (isoptocarbachol). Indirect acting cholinergic-miotics examples include Phospholine Iodide�
(echothiophate) and Humorsol� (demecarium). Pilocar�(pilocarpine) is a direct acting cholinergic-miotic and is the most commonly used medication in this class of agents. Disadvantages of pilocarpine include its qid dosing requirements and poor coverage of early morning IOP increases. All the cholinergic-miotic medications are associated with many unpleasant systemic and local ocular side effects. Systemic side effects include headache, nausea, vomiting, diarrhea, decreased heart rate (bradycardia) and decreased blood pressure (hypotension). Local or ocular side effects include miosis, decreased visual acuity, decreased night vision, myopia, cataracts and retinal detachments. Although quite popular and useful in the past, cholinergic-miotics are not first line agents. The next class of IOP lowering medications for treating glaucoma that came onto the market was non-selective adrenergic ophthalmic agents such as epinephrine and Propine�(dipivefrin), which is an epinephrine prodrug. These agents act by stimulating receptors on the trabecular meshwork, increasing aqueous outflow through it and ultimately decreasing IOP. Side effects of these medications include headache, tachycardia, hypertension and mydriasis (pupil dilation) with a potential risk of acute angle closure glaucoma (AACG) induction. Other ocular side effects include red eyes, severe allergic conjunctivitis, possible drug deposits in ocular anatomy, and cystoid macula edema (CME) in aphakic eyes (after cataract surgery). In the mid-late 70�s, before there were beta-blockers, the non-selective adrenergic agents were the predominant medications used for treatment of POAG. Historically, the next class of IOP lowering medications for treating glaucoma was the systemic hyperosmotic agents including mannitol (a parenteral agent), glycerin and isosorbide, which are given orally. These systemically given agents decrease IOP by increasing blood osmolality causing an osmotic gradient to be created between the vitreous humor and the blood. Fluid is drawn off or out of the vitreous cavity causing it to become dehydrated and IOP is subsequently reduced. Use of hyperosmotic agents can also result in headaches, backaches, nausea, vomiting, diarrhea, diuresis, mental confusion, heart failure, and intracranial bleeding. In addition, oral glycerin use can lead to hyperglycemia and ketoacidosis. These agents have a significant systemic side effect profile as well as a short-lived effect. Therefore, they are usually reserved for use in emergency treatment situations. They are often used to treat AACG.
The next class of agents historically used to treat glaucoma is the beta-blockers, which are the most commonly used group of agents. This extensive class of ophthalmic topical agents is considered the first line pharmacologic treatment for glaucoma and has had that status since the late 1970�s. Timoptic� is the �gold standard� agent against which all other IOP lowering medication is compared to. This group of agents (B-blockers) is very large and it is further sub-divided into selective (i.e. Betoptic� or betaxolol) and nonselective (ie. Timoptic or timolol) beta-blockers. If beta-adrenergic receptors in the ciliary processes are stimulated, aqueous humor is produced. Therefore, beta-adrenergic blockers act to prevent the stimulation of the aforementioned receptor causing a decrease in the amount of aqueous humor produced. Decreasing aqueous humor production is an effective way to lower IOP and treat glaucoma. These agents are typically used twice a day. Efficacy is significant as previously mentioned; however, the side effects of these agents are also significant. Both local ocular side effects, such as visual disturbance, blurring, stinging and ocular allergy, and systemic side effects occur when these agents are used. Systemic side effects include slowing of cardiac conduction, bradycardia, hypotension, increased heart block, lethargy, nausea, lightheadedness, syncope, mood changes, decreased sex drive, decreased HDL �good� cholesterol, wheezing and airway spasms. However, if a technique known as punctual occlusion is performed after the drops are instilled, the systemic side effects from these agents can be reduced. These agents are contraindicated in the following patient populations: asthmatics, severe COPD, cardiac patients with bradycardia or heart block, uncompensated CHF, cardiogenic shock, person hypersensitive to beta-blockers and elderly patients with mental status changes. The other common topical beta- blocker agents for glaucoma which were not previously mentioned are: Ocupress (carteolol), Betaxon (levobetaxolol), Betagan (levobunolol), and Optipranolol (metipranolol). Only Betaxon and Betoptic are cardio-selective beta-blockers. The rest are non selective like Timoptic. Ocupress possesses a property known as intrinsic sympathomimetic activity (ISA), which means its negative cardiac side effects and its ability to decrease HDL cholesterol may be reduced.
The next class of IOP lowering pharmacologic agents is the carbonic anhydrase inhibitors (CAI�s). The agents in this class are sub-categorized into the older systemic (oral and parenteral) agent category which contains Diamox� (acetazolamide) and newer topical ophthalmic agent category, which contains Trusopt� (dorzolamide) and Azopt� (brinzolamide). Acetazolamide has been around for 40 years; however, dorzolamide and brinzolamide have come onto the market only within the last 6 years. Carbonic anhydrase is an enzyme present in the ciliary bodies of the eyes, the lungs and the red blood cells. In the ciliary bodies of the eyes this enzyme is involved in the production of aqueous humor. If the carbonic anhydrase enzyme is inhibited, then aqueous humor production will decrease which ultimately lowers IOP. The CAI�s are sulfa-based agents with no bacteriostatic activity. The agents, especially the systemic agent, should not be used in sulfa allergic patients. The systemic agent acetazolamide decreases IOP by 40%, which makes it highly efficacious. However, it has a significantly negative side effect profile, which limits its use to adjunct (add on) therapy when a patient�s response to topical ophthalmic agents is poor. The adverse effects include bone marrow suppression, blood dyscrasias, severe headache, nausea and vomiting, urolithiasis, diuresis, fatigue and paresthesias. It has never been used as a first line medication for glaucoma. The topical ophthalmic agents dorzolamide and brinzolamide only decrease IOP by 7-27% but rarely cause systemic side effects. These two (2) agents have as their most common side effect local ocular irritation such as redness, stinging and burning. Their introduction was considered a major advance in medical management of glaucoma; however, their tid dosing requirements and inability to decrease IOP as well as topical ophthalmic beta-blockers prevented them from being considered first line agents for glaucoma treatment. Brinzolamide was introduced several years after dorzolamide�s 1995 FDA approval and boasts less local ocular adverse effects (i.e. stinging) and a lower cost than its predecessor. Its dosing is bid. Cosopt�(timolol plus dorzolamide) is a relatively new combination product for glaucoma, which contains both a beta-blocker plus a carbonic anhydrase inhibitor.
Another class of agents for treating glaucoma is the selective alpha-2 adrenergic agonists. Alpha-2 receptors are located presynaptically and when they are stimulated, a decrease in sympathetic output occurs. A decrease in sympathetic output results in a decreased aqueous humor production. There are two agents in this class, Iopidine� (apraclonidine) and Alphagan� (brimonidine). Iopidine� (apraclonidine) came onto the market in 1988 in 1% strength for pre and post surgical use. It was re-released in 1993 as a .5% strength for adjunct short-term therapy of glaucoma in patients unresponsive to other conventional therapies. However, it was never a first line agent for glaucoma treatment because it was associated with a high incidence of tachyphylaxis and a 15-20% incidence of allergic conjunctivitis. In addition, due to its short half-life, it failed to control IOP during the early morning hours when IOP is at its peak and was not an optimal drug from a compliance standpoint with it�s tid dosing requirements. Alphagan�, approved in September 1996, was introduced as an �improved version of Iopidine��. It had the advantages of a dual mechanism of action, longer half-life and an improved side effects profile. It is able to increase uveoscleral aqueous outflow in addition to its aqueous humor production reducing capabilities. Its efficacy is comparable to Timoptic�; it covers early morning IOP peaks and may only require bid dosing. Moreover, Alphagan� lacks Iopidine��s high incidences of tachyphylaxis and allergic conjunctivitis. Alphagan� is such an effective and attractive newer medication that it has the potential to be used as a first line treatment agent for glaucoma management. Side effects common to both Iopidine� and Alphagan� include local allergy, headache, fatigue, dry mouth, mydriasis and lid retraction. These agents should not be used in patients taking monoamine oxidase inhibitors (MAOI).
The most recent class of glaucoma medications to come onto the market is the prostaglandin analogs. Prostaglandins, which mediate inflammation, can be found all over the body. The prostaglandin analog anti-glaucoma agents decrease IOP by increasing uveoscleral outflow of aqueous humor.
Xalatan�(latanoprost), the first agent in this class, was approved in August 1996. It was found to be equal or superior in efficacy to Timoptic�(timolol), the �gold standard� agent, but with the added advantage of once daily dosing at bedtime. Systemic side effects were minimal; however, ocular side effects were unusual and somewhat significant. Xalatan� caused typical ocular side effects such as blurring. Yet it also caused cystoid macular edema, uveitis, increased iris pigmentation, eyelid skin and lash darkening and eyelash growth. Migraine headaches are also possible. It was speculated that this agent could be used as a first line treatment agent. Xalatan� needs to be refrigerated before dispensing and using but patients can keep it at room temperature for six (6) weeks once opened. Lumigan�(bimatoprost), Travatan�(travoprost), and Rescula�(unoprostone) are new ophthalmic prostaglandin analogs. Rescula� was approved first, late last year, and Lumigan� and Travatan� were approved early this year. Rescula� and Travatan� are prostaglandin F-2-alpha or dinoprost analogs, similar to Xalatan�, which act as selective FP prostanoid receptor agonists to reduce IOP by increasing uveoscleral outflow. Lumigan� is a prostamide analog, which mimics the IOP lowering activities of prostamides via the prostamide pathway which ultimately increases the outflow of aqueous humor. At this point in time these three new prostaglandins are used as second line agents after other glaucoma medications fail. Lumigan� and Travatan� appear to be equal in efficacy to Xalatan� and also require only once daily dosing at bedtime. Rescula� seems to be slightly less effective than Xalatan� and it requires twice daily dosing. Rescula� can exhibit neuroproctective properties independent of its IOP lowering effects. Lumigan� and Rescula� can be stored at room temperature. Travatan� can be stored at room temperature or refrigerated but it needs to be discarded six weeks after its sealed pouch is opened. All of these newer prostaglandin analogs have adverse effects similar to Xalatan�; they cause headaches, increased iris pigmentation and eyelid color and possibly eyelash overgrowth. Uveitis and macular are their more significant adverse effects.
An acute attack of ACG is a medical emergency requiring immediate attention. The IOP needs to be reduced quickly by combining and using the aforementioned medications discussed in POAG treatment. In addition to a couple of different varieties of IOP reducing topical agents, systemic CAI and/or hyperosmotic agents will most likely be administered during an AACG attack. After the IOP is brought down to a reasonable level, the patient will usually undergo a procedure known as a peripheral iridotomy (PI) or laser iridotomy. This surgical intervention involves removing a small part of the iris (making a hole) in a peripheral area to create an alternate route for aqueous humor outflow. The primary management of AACG is the PI; however, aggressive pharmacologic intervention is necessary to decrease IOP enough to resolve the initial emergent situation. After a PI is performed the patient may still require IOP lowering medications for a short time or in some cases chronically.
Glaucoma is a spectrum of disease most of which are associated with high IOP and progressive damage to the visual field and optic nerve. If current trends prevail, worldwide prevalence of AACG and POAG will continue to rise. POAG, a chronic disease, is the most common form of glaucoma as well as a leading cause of blindness in the USA.It is usually treated pharmacologically initially. Understanding the anatomy of the eye and pathphysiology of glaucoma is necessary to understand the pharmacologic treatment options. Topical pharmacologic agents are the preferred initial therapy for POAG. The beta-blockers such as Timoptic� have been the first line agents since the late 1970�s. The addition of new highly efficacious IOP lowering medications with novel mechanisms of action and improved side effects profiles challenges beta-blockers exclusive role as 1st. line therapy. It is important to know about the latest treatment options for glaucoma since several new agents such as Azopt�, Travatan�, Lumigan�, and Rescula� have been introduced within the last two (2) years.
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