Provider Update

Volume 10, Number 4 

November/December 1993

Message from the Medical Director: Expansion of Community Care

DHH Seeks Input on Hospital Pre-Admission Certification

Breast Cancer Screenings

Dental Program Update

Rehab Services for Home Health

NICU Policy

Maternity Anesthesia Fee

Facilities Which Can Bill NICU Codes

Survey of Pharmacy Costs

NICU Policy Changes

Certified Nurse Practitioner Information

Removal of Breast Implants

Pharmacy Provider Numbers

UB92 Specifications for EMC

LADUR Education: Antipsychotics and Antidepressants

Androscopy, Anorectal Manometry, and Lupron Depot Powder for Injection

Case Management Policy Clarification

Allergy Patch Testing Policy

24-hour EEG Monitoring Tympanostomy (CPT Code 69436) Billing
Ventricular Septal Defect Fee Fee Adjustments
Fee Increases for Vaccines Diagnostic Radionuclide Billing Tips
Antigen Immunizations Anesthesiologists/CRNAs Billing Instructions
Audiologist Claims to be Recycled Prosthetic Eye Codes
Verify Tax Identification Numbers Fee Increase for H or F Reflex Studies
Notice to Pharmacists: Clarification of Edit 453 (Schedule II narcotic analgesics) Deferred Compensation Plan Available to Louisiana Medicaid Providers
Physician Documentation Reminder HCFA 1500 Reminders

Message from the Medical Director

This 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.

There 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.

Two 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 sleep apena.

Unisys 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.

Unisys 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.

Unisys 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 5 days.

Unisys is currently working with the Medicaid Dental Advisory Committee to streamline and improve their prior authorization procedures.

As 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.

Lastly, 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 proposal.

Again, we genuinely appreciate your participation and cooperation in all our initiatives.

Dr. Gregg Pane

Breast Cancer Screenings

The 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.

Claims for screening mammography (CPT code 76092) with well diagnoses are now accepted by BHSF effective with date of service August 1, 1993.

One 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.

Maternity Anesthesia Fees

Diagnosis 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.

Removal of Breast Implants

The Bureau of Health Services Financing announces funding for the removal of leaking breast implants, effective with date of service October 1, 1993. Claims for removal of leaking breast implants are to be billed using local procedure code Z9918.  The fee for removal is $168.55

24-Hour EEG Monitoring

  The fee for 24-hour EEG monitoring (CPT Procedure Code 95950) has been increased to $204.83, effective with date of service October 1, 1993.

Tympanostomy (CPT Code 69436) Billing Instructions

When 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 was unilateral.

The 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.

If 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.

Example:  69436 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.

Ventricular Septal Defect Fee

The 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.

Fee Adjustments

The following fee adjustments became effective with date of service October 1, 1993:

CPT code 33250                $839

CPT code 32251                $1118

CPT code 33260                $802

CPT code 33261                $1039

Androscopy, Anorectal Manometry, and Lupron Depot Powder for Injection

The 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.

Providers 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.

Anorectal manometry (CPT code 91122) may be billed effective with date of service October 1, 1993.  The fee for anorectal manometry is $85.80.

Lupron Depot Powder for Injection will be payable only once monthly at a rate of $451.25 effective with date of service September 1, 1993.

Allergy Patch Tests Policy

Allergy 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.

Fee Increases for Vaccines

The 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. These increases were made to compensate providers for the federal excise taxes they must now pay on these vaccines.  Adjustments may be requested.

Diagnostic Radionuclide Billing Tips

Providers billed for CPT procedure 78990, Provision of Diagnostic Radionuclide(s), must submit the following information with the HCFA claim form.

  1. Name of specific nuclide used for individual recipient.

  2. Amount (dosage) of this specific nuclide used for this individual recipient.

  3. Amount paid to the supplier for this individual dose of this specific nuclide used for this individual recipient.

  4. Copy of invoice from supplier for this specific nuclide used for this individual recipient.

Antigen Immunizations

Public 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 appropriate.

The 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 MMR vaccine.

Effective November 9, 1993, BHSF prohibits the use of a single-antigen vaccine if an approved, medically appropriate combined-antigen can be given.

The 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.

These codes will funded at a later date.

Rehabilitation Services and the Home Health Provider

Home Health providers are asked to note pages 15 through 26 in the Home Health Services Provider Manual, which were revised January 19, 1993.

Home 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).

Physical 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.

Unlike the Home Health Program, services covered under the Rehabilitation Services Program are not reimbursable when provided in the recipient's home, under any circumstances.  Rehabilitation 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.

Under 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.

While 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.

In 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.

Anesthesiologists/CNRAs Billing Instructions

The 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.

Claims 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.

Audiologist Claims to be Recycled

A 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.

Prosthetic Eye Codes

In 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."

Verify Tax Identification Numbers (TINs)

The 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.

All 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:

Bureau of Health Services Financing
Attn:  Provider Enrollment Unit/Form 1099
P. O. Box 91030
Baton Rouge, LA  70821-9030.

The forms can also be forwarded via FAX to (504) 342-3893.

Please forward this information as soon as possible so this year's 1099 form can be issued with the correct information.

Survey of Pharmacy Costs

The 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.

All 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.

In 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.

Based on the number of requests from the pharmacists, we extended the effective date to December 1, 1993. Several pharmacies have still not returned their survey form.  As a result, their pharmacy number has been closed on the Provider File.

If 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:

Department of Health and Hospitals
P. O. Box 91030
Baton Rouge, LA  70821
Attn:  M. J. Terrebonne

Certified Nurse Practitioners Eligible for Direct Reimbursement

Effective 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.

Medicaid reimbursement for nurse practitioner services may be made to an individual who

  • is a licensed registered nurse;  

  • is certified by the Louisiana State Board of Nursing as a Primary Nurse Associate (also known as nurse practitioner); and  

  • has filed credentials with the Louisiana State Board of Nursing indicating an area of specialization in pediatrics, neonatology, maternal and child health, or general practice.

Certified 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.

Each 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.

Each 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.

Services 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.

Certified 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."

A 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 treatment.

Reimbursement 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.

Pharmacies: Entering Incorrect Prescribing Provider Numbers

Some pharmacies continue to enter invalid or incorrect prescribing provider numbers on pharmacy claim forms.  Two main types of errors have been identified.

  • Computerized stores have entered numbers incorrectly in the M.D. record of the prescribing provider file in the pharmacy computer.  

  • Institution ID numbers are being used without a pharmacy identifying the individual prescribing provider within the institution.

For the Louisiana Drug Utilization Review (LADUR) program to work efficiently, it is imperative that pharmacy claims have the correct prescriber number.

In 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.

Please assist BHSF by reviewing billing procedures to ensure accurate prescribing provider numbers.

If 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 assigned.

A 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.



  • Use of antipsychotic and antidepressants at appropriate dosages and for recommended durations of therapy provides maximal therapeutic responses.  

  • Use of 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.  

  • Antipsychotic and antidepressants may be selected to minimize drug-drug interactions or, in the case of antidepressants, to take advantage of certain opposing therapeutic responses.  


Antipsychotics and Antidepressants


The 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.

The 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.

Pharmacology 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.

The 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 Therapy.  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 these effects.

Adequate Monitoring of Therapeutic Effectiveness.  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 evaluated.


AMA Drug Evaluations, Annual 1991.  Drugs Used in Mood Disorders, p. 257-283, Antipsychotic Drugs, p. 233-255, Milwaukee (1991).

AHFS Drug Information 91, Psychotherapeutic Agents, Antidepressants, p. 1232-1264, Tranquilizers, p. 1269-1300, Bethesda, MA (1991).

USPDI, 13th Edition, Phenothiazines (systemic), p. 2218-2243, Antidepressants, tricyclic (systemic), p. 278-291, Rockville, MD (1993).

Facts and Comparisons, Psychotherapeutic Drugs, p. 262j-268a, St. Louis, MO (1993).

Goodman and Gilman's The Pharmacological Basis of Therapeutics, 8th Edition, Drugs and the Treatment of Psychiatric Disorders, p. 383-435, Elmsford, New York, (1990).

Policy Clarifications for Case Management Providers

Providers, please be certain that all employees involved in your case management program receive a copy of this update.

We 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:

  1. The 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.  

  2. Under the 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.  

  3. If the 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.)

  4. Payment 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.

We hope these clarifications will assist you in operating your case management programs and making proper determinations of Medicaid billable targeted case management services.

These 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.

Dental Program Update

Providers of the Dental Medicaid Program should be aware that "modular dentures" are not accepted for use in the program. Each step, as outlined in the provider manual for the construction of complete dentures must be carried out as indicated. Any 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.

DHH Needs Input Into Hospital Pre-Admission Certification

The Department of Health and Hospitals recently published a Notice of Intent regarding a proposed rule to institute a pre-admission certification process for hospital admissions.

The 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.

The 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.

Reviews will also be conducted for approval for continued stays.

In 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 Rouge, Louisiana. At 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 address:

Thomas D. Collins
Bureau of Health Services Financing
P. O. Box 91030
Baton Rouge, LA  70821-9030

Neonatal Intensive Care Policy

The 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.

The 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).

Not included in these codes are code 99440 (newborn resuscitation) and extraordinary surgical procedures which may have to be rendered.

Considered to be "extraordinary" are the following surgical procedures:

Code 32000                Code 32020

Code 33010                Code 36450

Code 49080                Code 61070.

Babies 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.

The 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.

If the patient has left the NICU but still requires critical care services, the critical care codes 99291 and 99292 should be used.

Regarding 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 99295-99297.

The 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.

Fees have been established as follows:

Code 99295 - $725
Code 99296 - $350
Code 99296 - $200

The 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 electronically.

For more information about the correct usage of the NICU codes, please refer to the page from Pediatric Coding News on the next page.

Facilities Whose Physicians May Bill the NICU Codes

Baton Rouge General Medical Center                            Baton Rouge, Louisiana
Earl K. Long                                                                 Baton Rouge, Louisiana
Woman's Hospital                                                         Baton Rouge, Louisiana
Lafayette General                                                          Lafayette, Louisiana
St. Jude Medical Center                                                Kenner, Louisiana
Lakeside Hospital                                                         Metairie, Louisiana
St. Francis Hospital                                                       Monroe, Louisiana
Ochsner Foundation Hospital                                         New Orleans, Louisiana
LSU Medical Center                                                     Shreveport, Louisiana
Tulane Medical Center                                                   New Orleans, Louisiana
St. Francis Cabrini Hospital                                           Alexandria, Louisiana
Women's and Children's                                                 Lafayette, Louisiana
Lake Charles Memorial                                                  Lake Charles, Louisiana
Lake Area Medical Center                                             Lake Charles, Louisiana
Slidell Memorial                                                             Slidell, Louisiana
Highland Park                                                                Covington, Louisiana
East Jefferson Hospital                                                    Metairie, Louisiana
University Medical Center                                               Lafayette, Louisiana
E.A. Conway                                                                  Monroe, Louisiana
Pendleton Memorial                                                        New Orleans, Louisiana
Medical Center of Baton Rouge                                      Baton Rouge, Louisiana
Schumpert Medical Center                                             Shreveport, Louisiana
Seventh Ward General Hospital                                      Hammond, Louisiana
St. Tammany Parish Hospital                                          Covington, Louisiana
Touro Infirmary                                                               New Orleans, Louisiana
Willis Knighton-South Hospital                                        Shreveport, Louisiana
Medical Center of Louisiana                                            New Orleans, Louisiana
Children's Hospital                                                           New Orleans, Louisiana

BHSF Announces NICU Policy Changes

 Paragraph six of the first page of the neonatal intensive care policy states,

 "If resuscitation (code 99440) is not required, prolonged physician attendance (codes 99150 and 99151) is not to be billed."

The Bureau of Health Services Financing is hereby deleting this sentence from the NICU policy effective with date of service May 1, 1993.

This means that the pediatrician or neonatologist who provides the standby services may bill for these services whether or not resuscitation is required.

Neonatal Intensive Care Codes For 1993 from Pediatric Coding News

  Scan page

TPL Carrier File Listing

 Scan 12 pages

Appendix B Amendment

  Notice to Pharmacists:  Please include these pages in your Appendix B.

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Notice to Pharmacists: Clarification of Edit 453 (Schedule II Narcotic Analgesics)

Providers 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.

Deferred Compensation Plan Available to Louisiana Medicaid Providers

The 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 individuals.

The 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.

Any 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.

When 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.

The 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.

Great West is the plan administrator that provides communication, recordkeeping of the accounts, and investment of the plan assets.

For more information, please call or visit the Great West office at 2237 South Acadian Thruway, Suite 702, Baton Rouge, LA  70808.

Telephone:  (504) 926-8082 or LINC 925-3700 or 1-800-345-4699
The 24-hour rate line is 1-800-443-7331.

Physician Documentation Reminder

The 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.

Proper 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 initials.

Remember, a service not documented is a service not rendered.  For this reason, your documentation must be complete.

HCFA 1500 Reminders

 Provided below are some general reminders for providers billing on the HCFA 1500 claim form:

Providers may submit more than one claim per envelope to reduce provider postage costs and to aid Unisys in handling mail.

Providers 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 expired.

Don't forget to sign and date your claim form.  We will accept stamped or computer-generated signatures, but they must be initialed.

UB92 Specifications Developed for EMC Submitters

UB92 specifications are now available from the Unisys EMC Department.  These specifications are replacing the current UB82 specifications.

Louisiana 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.

The 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.

Changes 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.

The 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).

Complete code tables are included in the data dictionary part of the specifications.

The 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. Questions or comments about the specifications may be directed to Unisys, EMC Coordinator Sue Kendrick at (504) 924-7051, extension 2239.

Fee Increases for H or F Reflex Studies

The 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.

BHSF will pay for 2 units per day with no documentation or review. Claims billed with more than 2 units per day should include documentation which substantiates the medical necessity of the additional units. All claims billed with more than 2 units per day will pend for medical review.