Volume 10, Number 4
from the Medical Director
issue of the Provider Update contains a number of important items that
should be of interest to many providers. The
Community Care Program, a primary care case management program in rural parishes,
will expand on December 1, 1993 to five additional parishes:
Allen, Beauregard, Cameron, Jefferson Davis and Vernon.
Community Care will now be present in 20 rural parishes around the state.
have been several program coverage additions often as a result of provider
input. This issue details broadened
coverage for maternity-related anesthesia, anorectal manometry, androscopy, and
removal of leaking breast implants.
important new coverage decisions were recently announced by the Bureau of Health
Services Financing (BHSF). BHSF is
funding breast cancer screenings as a preventive service for female Medicaid
beneficiaries 40 years old or older and prior authorized coverage of continuous
positive airway pressure devices (CPAP) for the diagnosis of severe obstructive
has been working with BHSF to conduct research studies of the Medicaid database
in order to improve patient care. A
statewide utilization review study of Cesarean section was recently completed,
and now, a task force of provider and public representatives is being assembled
to study the issue and implement recommendations.
has also been participating on the Committee for Louisiana Health Care Reform, a
committee of governmental agency representatives convened to develop a strategy
to enhance the delivery of public health services to Louisiana residents.
The committee is an advisory body to DHH Secretary Rose Forrest and is
chaired by Carolyn Maggio. The
committee is in the early process of developing reform principles with plans to
complete its objectives by early 1994. Various
healthcare associations and representatives of the private sector will be
joining and contributing to this committee in December 1993.
has made important strides in improving claims processing and customer service.
Turnaround times in October for prior authorization were 7 days for
durable medical equipment, 5 days for rehab, and 3 days for dental.
Medical Review resolved pended hospital and physician claims in less than
is currently working with the Medicaid Dental Advisory Committee to streamline
and improve their prior authorization procedures.
a reminder, Paramax is now known as Unisys once again due to a corporate
reorganization. This change will be
evident to you through our correspondence and when phoning Unisys.
All of our other operating procedures should remain the same.
In addition, Medicaid of Louisiana is now officially known as the
Louisiana Medicaid Program.
this issue contains a brief summary of a Notice of Intent sent out by BHSF
concerning implementation of a pre-admission certification program for Medicaid
inpatient admissions. BHSF wants
very much to obtain provider participation in the design and development of this
we genuinely appreciate your participation and cooperation in all our
Bureau of Health Services Financing is pleased to announce the funding of breast
cancer screenings as a preventive health service for Medicaid females 40 years
old or older.
for screening mammography (CPT code 76092) with well diagnoses are now accepted
by BHSF effective with date of service August 1, 1993.
bilateral screening mammography per year will be allowed.
The fee for procedure code 76092 is $43.00.
This code can be billed without a modifier only if the provider rents,
owns, or leases the equipment used to perform the test and also renders the
professional interpretation. Otherwise,
it is to be billed with modifier -26. BHSF
does not reimburse providers for technical-only services.
codes 650-659 allow providers of maternity-related anesthesia to receive flat
fees for procedure codes 62276, 62278, and 62279. Diagnosis codes 669.5 and 669.6 were added to this range of
diagnoses effective with date of service July 1, 1993.
Adjustments may be requested.
of Breast Implants
Bureau of Health Services Financing announces funding for the removal of leaking
breast implants, effective with date of service October 1, 1993.
for removal of leaking breast implants are to be billed using local procedure
code Z9918. The fee for removal is
fee for 24-hour EEG monitoring (CPT Procedure Code 95950) has been increased to
$204.83, effective with date of service October 1, 1993.
(CPT Code 69436) Billing Instructions
billing for CPT procedure 69436 on the HCFA 1500 form, providers are reminded to
use 2 in the Units box on the form, if the procedure was performed bilateral.
A 1 or no number would be appropriate in the Units block if the procedure
use of the 50 modifier for this particular procedure is inappropriate to denote
bilateral procedures. If, however,
multiple surgeries were performed, such as a tonsillectomy and adenoidectomy in
addition to the tympanostomy, a 51 modifier should be appended to the procedure
considered by the surgeon to be secondary.
the surgeon fails to append the 51 modifier to either procedure, the Medical
Review Unit will determine and price the secondary procedure based on billed
charge--the procedure with the highest billed charge will be considered the
major and will be paid the full flat fee or the full charge, whichever is lower.
The procedure with the lesser charge will be considered the secondary and
will be paid 50% of flat fee or 50% of billed charge, whichever is lower.
billed with 2 units and a charge of $800; 42820 billed with a 51 modifier and
charge of $700.
This claim would be worked as follows:
69436 would be paid $420--the flat fee of 2 full units (flat fee for 1
unit being $210). CPT procedure
code 42820-51 would be paid $315--50 percent of the flat fee, which is $630.
The above information does not apply to free-standing
surgical centers. These
outpatient surgical centers are paid one procedure per day per recipient and
should bill only one procedure per day per recipient on the HCFA 1500 form.
Septal Defect Fee
fee for closure of ventricular septal defect, with or without patch (code
33681), was reduced to $1420.00 effective with date of service October 1, 1993.
following fee adjustments became effective with date of service October 1, 1993:
Anorectal Manometry, and Lupron Depot Powder for Injection
Bureau of Health Services Financing is pleased to announce funding of
androscopy, anorectal manometry, and the chemotherapy drug Lupron Depot Powder
for Injection (single dose, 7 1/2 mg vial, with diluent and syringe) for
treatment of prostate cancer.
may bill for androscopy with or without biopsy effective with date of service
October 1, 1993. Androscopy with
biopsy should be billed under locally assigned procedure code Z9919 and
androscopy without biopsy should be billed under locally assigned procedure code
Z9920. Code Z9919 is payable at a
fee of $43.42 and code Z9920 is payable at a fee of $28.95.
One unit per day of each code is payable.
manometry (CPT code 91122) may be billed effective with date of service October
1, 1993. The fee for anorectal
manometry is $85.80.
Depot Powder for Injection will be payable only once monthly at a rate of
$451.25 effective with date of service September 1, 1993.
patch tests are generally read within 48, 72, or 96 hours after administration.
When the recipient comes into the office for the reading, and that is the
only service rendered to the recipient on that day, no higher level evaluation
and management code than 99211 should be billed.
Increases for Vaccines
fees for childhood vaccines ORIMUNE (code 90712), TETRAMUNE (code K9394), and
DTP (code 90701) have been increased to $18.29, $29.56, and $22.56 respectively,
effective with date of service September 1, 1993.
increases were made to compensate providers for the federal excise taxes they
must now pay on these vaccines. Adjustments
may be requested.
Radionuclide Billing Tips
billed for CPT procedure 78990, Provision of Diagnostic Radionuclide(s), must
submit the following information with the HCFA claim form.
Name of specific nuclide used for individual recipient.
Amount (dosage) of this specific nuclide used for this individual recipient.
Amount paid to the supplier for this individual dose of this specific nuclide
used for this individual recipient.
Copy of invoice from supplier
for this specific nuclide used for this individual
Law 103-66 (OBRA 93) was signed into law by President Clinton in August 1993.
Section 13631 of the law containing the Medicaid Pediatric Immunization
provisions provides that Medicaid can no longer cover and reimburse providers
for a single-antigen vaccine if a combined-antigen vaccine is medically
law further stipulates that combined antigen vaccines must be approved by the
Secretary of the Department of Health and Human Services (DHHS).
The only combined antigen currently approved by Secretary Shalala is the
November 9, 1993, BHSF prohibits the use of a single-antigen vaccine if an
approved, medically appropriate combined-antigen can be given.
1994 issue of the Physician's Current Procedural Terminology has seven new
immunization codes. They include
codes 90700 - DT and Acellular Pertussis (DTAP), 90170- MMR and Varicella, 90711
- DTP and Injectable Poliomyelitis, 90716 - Varicella, 90720 - DTP and HIB,
90730 - Hepatitis A, and 90735 - Encephalitis Virus.
codes will funded at a later date.
Services and the Home Health Provider
Health providers are asked to note pages 15 through 26 in the Home Health
Services Provider Manual, which were revised January 19, 1993.
health services covered under Medicaid include services of a skilled nurse, an
aide, or a physical therapist. As
stated on page 15 of the manual, home health services are payable only
if the service is provided in the patient's home or place of residence (not
hospital or nursing home).
therapy is covered under both the Home Health and the Rehabilitation Services
programs. Speech and occupational
therapy are covered under the Rehabilitation Services Program, but are not
covered under the Home Health Program. Home
Health providers must bill for physical therapy provided in the home by
placing the letter P (which coverts to procedure code X9926) under service code
when billing on the Home Health Services Form 101.
Prior authorization is not required.
the Home Health Program, services covered under the Rehabilitation Services
Program are not reimbursable when provided in the recipient's home, under any
Program providers must use the Y codes when billing for physical therapy,
occupational therapy, or speech services. These
services are payable at a fixed rate per procedure. Billing must be made on the Rehabilitation Services Form
Unisys-102. Requests for
Rehabilitation Program services must be made using forms PA01 and PA02, and the
services must be approved by the Prior Authorization Unit at Unisys before
payment can be made.
certain conditions, Home Health providers may provide rehabilitation services
that are normally provided by Rehabilitation providers to a Medicaid recipient
residing in an Intermediate Care Facility I or II. When these conditions are met, the Home Health provider is
considered by Medicaid as a Rehabilitation Services provider.
rehabilitation services provided to Medicaid recipients in their homes by
rehabilitation agencies are not presently reimbursable by Medicaid, BHSF is
considering changing this policy to allow payment under certain conditions.
BHSF is seeking a policy clearance regarding this issue from the Health
Care Financing Administration (HCFA) before implementing the policy change.
the meantime, rehabilitation services providers are asked to refrain from
submitting requests for authorization to provide rehabilitation services in a
recipient's home to the Unisys Prior Authorization Unit.
Providers will be notified when such requests may be submitted.
Bureau of Health Services Financing is pleased to announce the funding of
general anesthesia for tubal ligations performed several hours after, but on the
same day as, vaginal deliveries effective with date of service October 1, 1993.
billed with CPT code 58605 are payable to anesthesiologists and
non-anesthesiologist-directed CRNAs, regardless of whether an epidural (CPT code
62279) was administered on the same date of service.
The appropriate modifier (either AA or AI) should be used and the number
of minutes general anesthesia was provided should be designated.
Claims to be Recycled
number of newly enrolled audiologists have experienced some problems in getting
their claims paid. These problems
have been corrected and these claims will be recycled without the need for
resubmittal by the provider. Thank
you for your cooperation and patience in this matter.
the last Provider Update, V2632 was incorrectly identified as an eye
code. The correct code should be
V2623. Also, the description for
code V2624 should read "Polishing prosthesis."
Tax Identification Numbers (TINs)
Internal Revenue Services has notified BHSF that for tax year 1992 there were
many Louisiana Medicaid providers whose TINs were either missing or did not
match their records.
providers should review their form 1099 forwarded in January 1, 1993 for tax
year 1992. If the provider name and
the TIN reported on the form 1099 do not match, it is imperative that you report
the correct name and TIN to the Provider Enrollment Unit at BHSF.
Please forward a copy of the 1992 form 1099 and the correct W-0 to:
of Health Services Financing
Provider Enrollment Unit/Form 1099
O. Box 91030
Rouge, LA 70821-9030.
forms can also be forwarded via FAX to (504) 342-3893.
forward this information as soon as possible so this year's 1099 form can be
issued with the correct information.
of Pharmacy Costs
Bureau of Health Services Financing's State Plan Agreement with the federal
government requires periodic survey of pharmacy costs to determine an
appropriate dispensing cost. BHSF
contracted with the firm of Postlethwaite and Netterville, Certified Public
Accountants, to perform the 1993 Dispensing Cost Survey.
pharmacists which are enrolled in the Louisiana Medicaid Program are required
to participate in the survey process. Should a provider fail to participate, BHSF is required to
terminate the provider from the program.
August 1993, all pharmacies were sent a survey form for completion.
In September 1993, a second form was sent to those pharmacies which had
not submitted their completed form. In
October 1993, a notice was submitted to all pharmacies which had not completed
the survey stating their pharmacy provider number was going to be terminated
from the Medicaid program effective November 1, 1993.
on the number of requests from the pharmacists, we extended the effective date
to December 1, 1993.
pharmacies have still not returned their survey form. As a result, their pharmacy number has been closed on the
your pharmacy is a terminated provider and you desire to re-enroll in the
Medicaid program, please complete your survey form and return it to:
of Health and Hospitals
O. Box 91030
Rouge, LA 70821
M. J. Terrebonne
Eligible for Direct Reimbursement
July 1, 1993, Certified Pediatric Nurse Practitioners and Certified Family Nurse
Practitioners are eligible for direct Medicaid reimbursement.
There professionals are known as Primary Nurse Associates in Louisiana.
The Louisiana Board of Nursing, under the authority of the Louisiana
Nurse Practice Act, certifies Primary Nurse Associates in the areas of
pediatrics, neonatology, maternal and child health, and general practice which
meet the definition of the federal law.
reimbursement for nurse practitioner services may be made to an individual who
licensed registered nurse;
certified by the Louisiana State Board of Nursing as a Primary Nurse Associate
(also known as nurse practitioner); and
credentials with the Louisiana State Board of Nursing indicating an area of
specialization in pediatrics, neonatology, maternal and child health, or general
Pediatric Nurse Practitioner or Certified Family Nurse Practitioner services are
those services performed within the scope of practice for the appropriate
certification as defined by state law and regulations.
They are beyond the scope of services provided by Registered Nurses and
include some services usually provided by physicians.
Current Louisiana state law does not allow Nurse Practitioners to write
prescriptions or make diagnoses.
Nurse Practitioner functions according to protocols established by a directing
physician, or at the direction of that physician, or with the approval of a
directing physician, or under the protocols jointly established by a directing
physician and Primary Nurse Associate.
Nurse Practitioner must have written documentation of formal affiliation with a
licensed physician [protocol(s)] available for review upon request.
These protocol(s) must be renewed annually.
Any medical situation or condition that is not addressed by a protocol or
other physician direction must be referred immediately to a physician.
The physician retains ultimate responsibility for directing the specific
course of medical treatment.
provided by a Certified Pediatric or Family Nurse Practitioner must be counted
toward the applicable limits specified for physicians services.
Beneficiaries under age 21 are excluded from these limits as are
beneficiaries receiving services of a Nurse Practitioner at a Rural Health
Clinic of Federally Qualified Health Center.
Pediatric or Family Nurse Practitioners may bill Medicaid for certain approved
procedures as listed in the revised Physician Services Provider Manual.
A diagnosis code must be included on each billing form.
This diagnosis may come from the protocol when the Nurse Practitioner has
made the medical decision that the patient meets the condition describing in
that protocol. The directing
physician's provider number or name must be entered on the billing form (HCFA
1500) in the space labeled "name or referring physician."
Certified Pediatric Nurse Practitioner or Family Nurse Practitioner who is
employed by or under contract to any physician, clinic, hospital, or nursing
facility cannot bill for any service for which reimbursement is made to the
physician, clinic, hospital, or nursing facility where the patient is receiving
for services is based on the same methodology used for establishing physician
fees for state, federal, and CPT assigned procedure codes.
Certified Pediatric Nurse Practitioner and Family Nurse Practitioner
services are payable at 80% of the amount currently established for type service
03. Immunizations are payable at 100%
up to Medicaid's file maximum.
Prescribing Provider Numbers
pharmacies continue to enter invalid or incorrect prescribing provider numbers
on pharmacy claim forms. Two main
types of errors have been identified.
stores have entered numbers incorrectly in the M.D. record of the prescribing
provider file in the pharmacy computer.
ID numbers are being used without a pharmacy identifying the individual
prescribing provider within the institution.
the Louisiana Drug Utilization Review (LADUR) program to work efficiently, it is
imperative that pharmacy claims have the correct prescriber number.
reviewing pharmacy audit findings, we identified prescriptions from incorrect
prescribers who are receiving LADUR correspondence. This results in increased paperwork and review by physicians
and LADUR staff and incorrectly reported data.
assist BHSF by reviewing billing procedures to ensure accurate prescribing
you do not know that physician's provider number, contact the Unisys Provider
Relations Unit at 1-800-473-2783. If
that unit has no record of a provider number for the physician, contact the
Provider Enrollment Unit at (504) 342-9454 and a prescribing number will be
listing of physician provider numbers can be obtained from the Louisiana
Pharmacists Association. The
telephone number is (504) 926-2666 and the FAX number is (504) 926-1020.
antipsychotic and antidepressants at appropriate dosages and for recommended
durations of therapy provides maximal therapeutic responses.
multiple psychotherapeutic agents in individual patients is usually
unnecessary and is most often the result of the patient's use of
multiple pharmacies and/or physicians.
and antidepressants may be selected to minimize drug-drug interactions or, in
the case of antidepressants, to take advantage of certain opposing therapeutic
tricyclic (TCA) and atypical antidepressants represent the most currently used
therapeutic agents in the treatment of major depression.
The monoamine oxidase (MAO) inhibitors have also been used to treat
depression in the past, but currently are only used when the TCA antidepressants
produce unsatisfactory results and when electroconvulsive therapy is
inappropriate or refused.
antipsychotics are classified primarily on the basis of their chemical structure
and include the phenothiazines, thioxanthenes, butyrophenones, and the
indolones. They are used to treat
schizophrenia, organic psychoses, and other serious psychiatric illnesses.
and Therapeutics: the tricyclic (TCA) and
atypical antidepressants potentiate the action of biogenic amines by blocking
their reuptake into presynaptic nerve terminals, thus increasing their
synaptical concentrations. This
makes the TCAs particularly effective in relieving the symptoms of major
depressive episodes; bipolar disorder, depressed type; dysthymia; and atypical
depressions; some depression associated illnesses including alcoholism, stroke,
and Parkinson's disease.
antipsychotic drugs interfere with dopamine's action as a neurotransmitter.
They are particularly effective in treating disorders in which psychotic
symptoms or agitation are evidenced.
Reduction of Overuse and/or Duplicative
Although the concomitant use of antipsychotics and/or antidepressants
or high dosages of these agents may be beneficial to some patients, using
single pharmacologic agents at recommended periods of time is considered the
desired therapeutic regimen. Patients
often receive such combinations or excessive dosages by using multiple
physicians and/or pharmacies without informing the health care providers.
Elimination of Drug-Drug Interactions. Using psychotropic agents may precipitate drug interactions
related to both known pharmacologic effects of the agents and effects on
disposition processes. This may
cause additive or inhibitory toxic effects.
These can often be eliminated by using single agents or, in the case of
antidepressants, by using agents without opposing actions.
Careful selection of antipsychotics and/or antidepressants can minimize
Adequate Monitoring of Therapeutic
The extended use of the antipsychotics and/or antidepressants at full
therapeutic dosages should be evaluated.
For maximal care, providers should periodically attempt to reduce
therapy to the minimum required dosage to control patient symptoms.
Reduced Dosages in Pediatric, Geriatric, or
Debilitated Patients. The extended use of
antipsychotics and/or antidepressants at full therapeutic dosages should be
Drug Evaluations, Annual 1991. Drugs
Used in Mood Disorders, p. 257-283, Antipsychotic Drugs, p. 233-255,
Drug Information 91, Psychotherapeutic Agents, Antidepressants, p.
1232-1264, Tranquilizers, p. 1269-1300, Bethesda, MA (1991).
13th Edition, Phenothiazines (systemic), p. 2218-2243, Antidepressants,
tricyclic (systemic), p. 278-291, Rockville, MD (1993).
and Comparisons, Psychotherapeutic Drugs, p. 262j-268a, St. Louis, MO
and Gilman's The Pharmacological Basis of Therapeutics, 8th
Edition, Drugs and the Treatment of Psychiatric Disorders, p. 383-435,
Elmsford, New York, (1990).
Clarifications for Case Management Providers
please be certain that all employees involved in your case management program
receive a copy of this update.
recently received the following policy clarifications from the Health Care
Financing Administration (HCFA) regarding a number of activities which meet the
statutory definition of optional targeted case management activities under
Medicaid and some activities which fail to meet this definition:
statutory definition of case management found at Section 1915(g)(2) of the
Social Security Act does not include physically escorting a beneficiary to
scheduled appointments or staying with the beneficiary.
However, it is permissible for a case manager to refer a beneficiary to
an escort and/or transportation service.
federal statute, case management services must "assist a Medicaid eligible
individual in gaining access to needed medical, social, education, and other
services." The term
"gaining access" may include necessary assistance and monitoring or
follow-up of an individual's progress or status. This could include observing the beneficiary in various
settings. These case management
services must be furnished in amounts which are reasonable given the needs and
condition of the particular beneficiary.
assistance means providing the specific service, such as shopping or bill
paying, this would not be acceptable under the statutory definition of case
management. Activities such as
delivering bus tickets, food stamps, or money to a beneficiary also go beyond
the Medicaid definition of case management. Targeted case management does not include payment for the cost of the specific
service needed by the beneficiary, nor does it include payment for the cost of
the administration of other services to which a beneficiary is referred (e.g.,
education services, juvenile services.)
for case management is dictated by the nature of the activity and the purpose
for which the activity is performed. It
is necessary for case managers to have various discussions to make assessments
and reassessments of the need for services.
Case management may include discussions with beneficiaries regarding such
topics as personal behavior, financial budget or medication and side effects.
The necessity for, and amount of, these discussions must be determined on
an individual basis.
hope these clarifications will assist you in operating your case management
programs and making proper determinations of Medicaid billable targeted case
clarifications will be included in the revised Case Management Provider
Manual to be issued to all enrolled case management providers in December
1993. You are encouraged to contact
the Medicaid Policy Section at (504) 342-9493 or the Case Management Monitoring
Unit at (504) 342-2022 if you have any policy questions.
of the Dental Medicaid Program should be aware that "modular dentures"
are not accepted for use in the program.
step, as outlined in the provider manual for the construction of complete
dentures must be carried out as indicated.
deviation from the "minimum procedural requirements for the construction of
complete denture protheses" as outlined on page 8-8 of the Dental
Provider Manual, will be considered as noncompliance with program guidelines
and may result in sanctions against the provider.
Needs Input Into Hospital Pre-Admission Certification
Department of Health and Hospitals recently published a Notice of Intent
regarding a proposed rule to institute a pre-admission certification process for
proposed rule would be effective for dates of service March 1, 1994 and
thereafter, and would amend the methodology for Medicaid reimbursement of
inpatient hospital services to eliminate the service limit of 15 inpatient
hospital days per recipient and implement a pre-admission certification for all
Medicaid inpatient admissions in acute care general hospitals including distinct
part psychiatric/substance abuse units.
non-emergency inpatient admissions will be reviewed and approved as medically
necessary prior to admission while emergency admissions to be reviewed and
approved concurrent with the admission.
will also be conducted for approval for continued stays.
order to solicit public and provider input in developing the pre-admission
certification process, a public hearing will be held at 9:30 a.m., Tuesday,
December 29, 1993, in the DOTD Auditorium, 1201 Capitol Access Road, Baton
that time, all interested parties are welcomed and encouraged to submit data and
opinions orally or in writing. In
addition, interested persons may submit written comments to the following
of Health Services Financing
O. Box 91030
Rouge, LA 70821-9030
Intensive Care Policy
1993 CPT procedure codes 99295, 99296, and 99297 are to be used to bill for
neonatal intensive care services effective with date of service May 1, 1993.
Only pediatricians or neonataologists rendering services in a recognized
neonatal intensive care unit may bill these codes.
A list of the hospitals in Louisiana which have recognized NICUs is
presented in this newsletter.
NICU codes shall include 1) all procedures described in the CPT on pages 52 and
53, 2) neonatal intensive care services provided in the emergency room or
department, and 3) code 99223 (Initial hospital care, per day).
included in these codes are code 99440 (newborn resuscitation) and extraordinary
surgical procedures which may have to be rendered.
to be "extraordinary" are the following surgical procedures:
do not have to be "still NPO" in order for code 99297 to be billed.
The other conditions listed in the description must be met, however.
Subsequent Hospital Care codes (99231 - 99233) should be used to bill for
services to an infant whose condition no longer meets the criteria listed in
code 99297. Also, the Subsequent
Hospital Care codes should be used to bill for services to a baby who, for some
reason, is housed in NICU but is not critically ill.
the patient has left the NICU but still requires critical care services, the
critical care codes 99291 and 99292 should be used.
transfers, the physician at the sending facility should bill codes 99291 and
99292 if the facility has a PICU rather than a recognized NICU.
IF the facility has a recognized NICU, the physician must bill codes
physician at the receiving facility which must have a recognized NICU must bill
codes 99295-99297. If the transfer
is from one neonatologist to another, both should bill the per diem NICU codes
provided both facilities have recognized NICUs.
have been established as follows:
99295 - $725
99296 - $350
99296 - $200
per diem rate for "step-down" babies has been set at $80.
"Step-down" babies are those neonates who no longer meet the
criteria listed for code 99297, but who still require more care than that
described by Hospital Subsequent Care code 99233.
Providers in recognized NICUs should bill CPT code 99297 with modifier
-52 to receive this fee. As this
code will be priced manually, until further notice, it cannot be billed
more information about the correct usage of the NICU codes, please refer to the
page from Pediatric Coding News on the next page.
Whose Physicians May Bill the NICU Codes
Rouge General Medical Center
Baton Rouge, Louisiana
Baton Rouge, Louisiana
Jude Medical Center
New Orleans, Louisiana
New Orleans, Louisiana
Francis Cabrini Hospital
Lake Charles, Louisiana
Area Medical Center
Lake Charles, Louisiana
New Orleans, Louisiana
Center of Baton Rouge
Baton Rouge, Louisiana
Ward General Hospital
Tammany Parish Hospital
New Orleans, Louisiana
Willis Knighton-South Hospital
Center of Louisiana New Orleans, Louisiana
New Orleans, Louisiana
Announces NICU Policy Changes
six of the first page of the neonatal intensive care policy states,
resuscitation (code 99440) is not required, prolonged physician attendance
(codes 99150 and 99151) is not to be billed."
Bureau of Health Services Financing is hereby deleting this sentence from the
NICU policy effective with date of service May 1, 1993.
means that the pediatrician or neonatologist who provides the standby services
may bill for these services whether or not resuscitation is required.
Intensive Care Codes For 1993 from Pediatric Coding News
Carrier File Listing
to Pharmacists: Please include
these pages in your Appendix B.
to Pharmacists: Clarification of Edit 453 (Schedule II
should be advised that edit number 453 (Schedule II narcotics must be dispensed
within five days of the date the physician wrote the prescription), has been
modified to include only Schedule II narcotic analgesics.
In some cases in the past, other Schedule II drugs, which are not
narcotic analgesics, may have been included in this edit.
Therefore, if a prescription is covered by the state Medicaid program and
is a Schedule II narcotic analgesic, the prescription must be filled within five
days of the date the physician wrote it to receive Medicaid reimbursement.
Schedule II prescription drugs, which are not narcotic analgesics, must
be dispensed by the pharmacists within six months of the date written by the
physician in order for Medicaid to reimburse for them and must comply with the
Board of Pharmacy regulations.
Compensation Plan Available to Louisiana Medicaid Providers
Louisiana Medicaid Program continues to offer providers the opportunity to
invest Medicaid payments in a deferred compensation plan.
The Louisiana Deferred Compensation Plan allows individuals who
are medical providers the opportunity to invest money on a before-tax basis,
using payroll deduction. Because your taxable income is reduced with each
contribution, you can save money rather than pay it in taxes. This plan is not available for corporations, only
before-tax aspect is what makes the Deferred Compensation Plan very attractive.
Participants pay no federal or state income tax on their contributions.
In addition, interest or earnings on your account accumulate
tax-deferred. No taxes are paid on
the account until you being withdrawing funds.
amount excluded from gross income under a 403(b) annuity, a 401(K), a profit
sharing plan, or a simplified employee pension is to be treated as an amount
deferred under the plan. You can
enter the plan with as little as $20.00 per month and contribute up to a maximum
of 25% of your adjusted gross income, not to exceed $7,500 per calendar year. A
special "catch up" provision may be used to save up to $15,000 per
year for the three years prior to retirement.
you join the plan, you choose the amount to save and the type of fund(s) in
which to invest. You may revise
your choice at any time; transfer monies to other available funds; and increase,
decrease or stop deferrals any time.
plan offers both guaranteed and variable investment options from which you may
select a fund, or combination of funds, to satisfy your personal investment
objectives. Upon deciding on the
amount you would like to save, a trained account executive will provide
information on investment options.
West is the plan administrator that provides communication, recordkeeping of the
accounts, and investment of the plan assets.
more information, please call or visit the Great West office at 2237 South
Acadian Thruway, Suite 702, Baton Rouge, LA
(504) 926-8082 or
24-hour rate line is 1-800-443-7331.
Louisiana Medicaid Program is often required to make payment decisions based on
information contained in medical records. If
these records are not properly documented, incorrect payments may be made, and
overpayment collections may result. In
some cases, providers may be investigated for false billing.
documentation should include all objective and subjective findings and a
statement of treatment rendered. In
addition, all documentation, including office progress notes, operative reports,
and hospital progress notes should contain the physician's signature or
a service not documented is a service not rendered. For this reason, your documentation must be complete.
below are some general reminders for providers billing on the HCFA 1500 claim
may submit more than one claim per envelope to reduce provider postage costs and
to aid Unisys in handling mail.
should always notify the Bureau of Health Services Financing (BHSF) when a
mailing address change occurs to allow rejected claims to be returned more
quickly to providers. Many claims
are returned to Unisys because forwarding orders at the post office have
forget to sign and date your claim form. We
will accept stamped or computer-generated signatures, but they must be initialed.
Specifications Developed for EMC Submitters
specifications are now available from the Unisys EMC Department.
These specifications are replacing the current UB82 specifications.
Medicaid will begin accepting claims submitted on the UB92 specifications
immediately, but UB82 specifications will be acceptable until March 31, 1994.
After that date, only UB92 specifications will be accepted.
UB92 specifications are based on the Medicare flat file specifications version
4. Changes have been made to
reflect the specific requirements of the Louisiana Medicaid Program.
to the original Medicare specifications include elimination of several record
types. Many fields required by
Medicaid have been eliminated. All
field placements and field types have been preserved.
Louisiana Medicaid Program relies primarily on the submitted ID and the Medicaid
Provider number instead of Employer Identification Number (EIN) or Taxpayer
Identification Number (TIN).
code tables are included in the data dictionary part of the specifications.
EMC Department requires that all new UB92 submissions must be tested and
approved prior to making regular production submissions.
All testing must be arranged and coordinated with the EMC Department.
or comments about the specifications may be directed to Unisys, EMC Coordinator
Sue Kendrick at (504) 924-7051, extension 2239.
Increases for H or F Reflex Studies
allowable units on H or F reflex studies (CPT code 95935) will be increased to a
total of 10 per day effective with date of service December 1, 1993.
will pay for 2 units per day with no documentation or review.
billed with more than 2 units per day should include documentation which
substantiates the medical necessity of the additional units.
claims billed with more than 2 units per day will pend for medical review.