PROVIDER UPDATE

VOLUME 12, NUMBER 5

NOVEMBER/DECEMBER 1995


Message from the LMMIS Project Manager Act 648: Informed Consent Necessary Prior to Abortion
Vaccines for Children Funding of CPT Code 26591
LADUR Education Article Funding for CPT Codes 51795 and 51797
CPT Code 99429 in Non-Pay Status > Revised Checkwrite Dates
Funding for Chemotherapy Injections  Reimbursement for Salaried Hospital Personnel
Attention: Case Management Providers and PCA Providers Changes in Anatomical Lab Codes and Fees
Addition of Home Health Supplies to the DME Program Adjustments in Fees for J Codes
DME Reimbursement Changes A Note Regarding the Mental Health Rehabilitation Program
Attention Providers of Lab Services Service Reduction and Terminations in the Chiropractic Program

Classification and Reimbursement for Hearing Aids

Message from the LMMIS Project Manager

In 1995, the Medicaid program went through some difficult cutbacks.  The amount of state funding available to match federal funds in the program was approximately $750 million below the Medicaid program's level of need.  The Governor and his executive agencies (DHH, LHCA, DOI) worked with the Legislature on several alternatives and solutions for the Medicaid program to deal with the fiscal shortfall.  In fact, the Department of Health and Hospitals submitted the 1115 waiver to HCFA on December 31, 1994, which addressed the issue of recipient choice.  The intent of this waiver request was to enable the Louisiana Department of Health and Hospitals to design a managed care program that would overcome the financial shortfalls posed by the Medicaid cutbacks.

The managed care plans designed by the DHH would have included services which would have continued to provide comprehensive health care to the Medicaid recipient, a high level of care which has always been a part of the Louisiana Medicaid program.

Unfortunately, we could not find a way to meet the needs of all interested parties and HCFA.  The reasons are many and complex.  Financial constraints were certainly important, as were the issues of designing a health delivery system that met not only the recipients' service needs, but also met the providers' expectations as to how they were to deliver those services.  Each of these elements required thoughtful consideration, time to develop, and agreement among healthcare providers that the new service delivery mechanisms would work in everyone's best interest.

Although the 1115 Waiver is still pending approval from HCFA, the Department of Health and Hospitals is now carrying out its legislative mandates to cut program costs.  DHH recognizes that this is a difficult time for all providers, and is very carefully cutting back on services so that provider and recipient hardships are shared fairly and with a minimum of disruption in critical services.

With the advent of a new Governor and Legislature, there will be new challenges to face.  The DHH is continuing to work on new approaches for a managed health care delivery program in order to present them to the new Administration.  In the meantime, we continue to ask for your patience and for your continued medical support of those eligible recipients who need services.  With your support, and also with direction from the new Governor and Legislature, we believe that we can provide a responsible and responsive Medicaid program for the citizens of Louisiana.

Gary Hulshoff, Ph.D.
LMMIS Project Manager


Act 648:  Informed Consent Necessary Prior to Abortion

During the 1995 Regular Legislative Session, the Louisiana Legislature passed Act 648, a law which requires the informed consent of a pregnant woman prior to an abortion being performed.  This Act became effective September 25, 1995.

Effective with date of service September 25, 1995, in order for Medicaid reimbursement to be made for abortion, providers must attach a copy of the initialed certification form (Certification of Informed Consent - Abortion) to their claim form for an abortion.  This requirement is in addition to previously stated requirements for reimbursement of abortions as explained in the November/December 1994 issue of the Provider Update and page 17-15 of the February 1, 1993 issue of the Physician Services Manual.

The above mentioned certification form, in addition to other abortion materials, was sent by the Department of Health and Hospitals in a packet to all health care professionals on August 11, 1995.


Vaccines for Children

The Vaccines for Children (VFC) Program provides free vaccines to enrolled physicians/clinics/KIDMED clinics via the Centers for Disease Control (CDC).  Providers must enroll in the VFC Program via the Immunization Division at the Office of Public Health (504/483-1900).  If the provider is VFC enrolled, he/she cannot be reimbursed for the full component of the service (vaccine plus administration).  He/She shall be limited to professional component reimbursement for that CPT-4 procedure code which is reimbursed at a rate of $9.45 for administration only.  Charges for administration of VFC vaccines to non-Medicaid VFC eligibles (uninsured, etc.) must be the same as charges for administration to Medicaid eligibles.

If a VFC enrolled provider is utilizing vaccines he/she has previously purchased, the appropriate CPT-4 procedure code would be billed with a modifier of "15" to indicate that the immunization should include both the administration and the vaccine.

The system changes to implement this will not be in place until mid-November at the earliest.  The modifier of "15" cannot be used until then and is effective for dates of service 10/1/94 and after.  Please hold billings for VFC vaccine administration until after late November.

A new error code will be implemented to advise providers that a "cut-back was made for VFC administration only" when payment is for professional component.  If only the administration fee is paid when the claim should have been paid for full service (due to the provider using previously self-purchased vaccines), then submit an adjustment with the "15" modifier and the difference will be paid.

The following immunization codes are subject to the above payment logic:

90700 DTaP (Diphtheria, Tetanus, Acellular Pertussis)*

90701 DTP (Diphtheria, Tetanus, Pertussis)*

90702 DT (Diphtheria, Tetanus)*

90707 MMR (Measles, Mumps, Rubella)

90712 OPV (Polio virus vaccine (live))

90713 Polio Injection

9072 DTP/Hib

90731 HBV (Hepatitis B vaccine)

90737 Hib (Haemophilus type B conjugate)


Funding of CPT Code 26591

The Bureau of Health Services Financing is pleased to inform you of the funding of CPT code 26591 - repair, intrinsic muscles of the hand (specify), effective with date of service November 1, 1995 at a fee of $202.23.  This code will also be placed in pay status on the anesthesia file with three base units.


Louisiana Drug Utilization Review (LADUR) Education    

Methylphenidate (Ritalin) for Treatment of Narcolepsy and ADHD

Robert L. Judd, Ph.D.  
Asst. Professor of Pharmacology
Northeast Louisiana University  
School of Pharmacy  

Issues

  • Methylphenidate (Ritalin) is a CNS stimulant similar to amphetamine.

  • Methylphenidate's sympathomimetic stimulation of the brain produces an increase in motor activity and mental alertness.

  • Because of the increased brain and motor activity it produces, methylphenidate is extremely useful in the treatment of narcolepsy and attention-deficit hyperactivity disorder (ADHD).

Methylphenidate (Ritalin) is an orally administered central nervous system (CNS) stimulant that is chemically and pharmacologically similar to amphetamines.  Methylphenidate's CNS actions are milder than those of amphetamines and have more noticeable effects on mental activities than on motor activities.  The drug also shares the abuse potential of the amphetamines and is also a DEA schedule II controlled substance.  It is clinically used in the treatment of narcolepsy and as adjunctive treatment in children with attention-deficit hyperactivity disorder (ADHD).  Methylphenidate was approved by the FDA in 1955.

Methylphenidate exhibits pharmacological activity similar to that of amphetamines.  The drug's exact mechanism of action in the CNS is not fully understood, but the primary sites of activity appear to be in the cerebral cortex and the subcortical structures including the thalamus.  Methylphenidate blocks the reuptake mechanism present in dopaminergic neurons.  As a result, sympathomimetic activity in the central nervous system and in the periphery increases.  Methylphenidate-induced CNS stimulation produces a decreased sense of fatigue, an increase in motor activity and a mental alertness, mild euphoria, and brighter spirits.  In the periphery, the actions of methylphenidate are minimal at therapeutic doses.

Methylphenidate hydrochloride is orally administered and is well absorbed from the GI tract.  Peak serum concentrations are achieved in about 1.9 hours and 4.7 hours for the regular and extended-release forms, respectively.  The duration of action ranges from 3-6 hours with regular tablets and about 8 hours with the extended-release tablets.  The distribution in humans is unknown.  Metabolism of methylphenidate occurs in the liver via hydroxylation to ritalinic acid.  Methylphenidate is almost completely eliminated in the urine, with approximately 95% of a dose being recovered as metabolites in urine within 90 hours.

Drug interactions are not uncommon with methylphenidate.  The CNS stimulant effects of  methylphenidate can be addictive when used concurrently with other CNS stimulants.  In addition to drugs with CNS stimulating effects, caffeine may also cause excessive CNS stimulation if used by patients receiving the drug.  Methylphenidate can potentiate the actions of both exogenous (such as dopamine and epinephrine) and endogenous (such as norepinephrine) vasopressors.  Because methylphenidate and monoamine oxidase inhibitors both potentiate the effects of catecholamine neurotransmittors, concomitant use of these agents should be avoided.  A hypertensive crisis may occur, although data supporting this hypothesis is limited.  In general, methylphenidate should not be given to any patient within 14 days of receiving an MAO inhibitor.  Other interactions have been noted with anticholinergic, anticonvulsant, and tricyclic antidepressant drugs.

As mentioned, methylphenidate is commonly used in the treatment of ADHD, which is associated with excessive motor activity, difficulty in sustaining attention, and impulsiveness.  Onset of symptoms occurs between 3 and 7 years of age, and must be present for 6 months to make a diagnosis.  Children with this disorder are frequently troubled by academic difficulties, impaired interpersonal relationships and excitability.  In treating children with ADHD, methylphenidate produces a calming effect.  This action of methylphenidate results in a decrease in hyperactivity and an increase in the child's attention span.

Tests of cognitive function (memory, reading, arithmetic) often improve significantly.  These effects appear paradoxical and the mechanism of action responsible for them is unclear, but is thought to involve catecholamines, which have been linked to the control of attention at the level of the cerebral cortex.

Treatment with methylphenidate usually begins with a dose of 5 mg of methylphenidate in the morning and at lunch.  The dose is gradually increased over a period of weeks depending upon the response as judged by parents, teachers and the physician.  The total daily dose generally should not exceed 60 mg.  Because of its short duration, most children require two or three doses each day.  The timing of doses is adjusted individually in accordance with rapidity of onset of effect and duration of action.  If the child does not respond after 1 month of therapy, the drug should be discontinued. Methylphenidate and dextroamphetamine appear to have similar efficacy in the treatment of ADHD, while pemoline, even though it can be used once a day, seems to be somewhat less effective.  In addition to drug therapy, treatment should involve behavior modification for the child and counseling for parents and teachers.

The decisions to commence and continue drug therapy are difficult to make and depend in part on cultural expectations.  Drugs are not indicated if symptoms are mild.  Furthermore, when drugs are employed, they should be interrupted periodically to assess the need for their continuation.  Many children can reduce or eliminate drug use on weekends and holidays, and in no case should treatment continue for more than one school year without interruption.  The summer school break is often a good opportunity for a prolonged drug holiday, with treatment resuming, if indicated, after school recommences.

The principal adverse effects of methylphenidate treatment are insomnia, nervousness and suppression of growth.  Insomnia and nervousness result from CNS stimulation and can be minimized by taking the last dose of the day no later than 6 hours before bedtime.  Growth suppression occurs secondary to appetite suppression.  Growth rate should be monitored.  Once treatment ceases, a rebound increase in growth usually takes place.  Other adverse effects include headache and abdominal pain, which occur in 10% of those treated, and lethargy and listlessness, which can occur when dosage is excessive.

In summary, methylphenidate is a CNS stimulant similar to amphetamine. Methylphenidate produces a sympathomimetic stimulation of the brain, which produces an increase in motor activity and mental alertness.  This increase in activity makes it extremely useful in the treatment of narcolepsy and ADHD.

References

Clinical Pharmacology (An Electronic Drug Reference and Teaching Guide). v. 14, Gold Standard Multimedia Inc.

Goodman and Gilman, 1990, "Catecholamines and Sympathomimetic Drugs" The Pharmacological Basis of Therapeutics, 8th Edition. Pergamon Press: New York, Pp. 187-220.

Klein, D.F., Gittlemen, R., Quitkin, F., and A. Rifkin, 1980, "A Diagnosis and Drug Treatment of Childhood Disorders" in Diagnosis and Treatment of Psychiatric Disorders:  Adult and Children, 2nd Edition. The Williams & Wilkins Co.: Baltimore, Pp. 590-775.

Munson, Paul L., ed. 1995, "CNS Stimulants" in Principals of Pharmacology, Basic Concepts and Clinical Applications. Chapman and Hall: New York, Pp. 495-528.

Rang, H.P., Dale, M.M., Ritter, J.M., and P. Gardner, 1995, "Central Nervous System Stimulants and Psychotomimetic Drugs" in Pharmacology, 4th Edition. Churchill Livingstone: New York, Pp. 634-645.

Tatro, David S., ed. 1995, Drug Interaction Facts (Facts and Comparisons), J.B. Lippincott Co.: St. Louis.


Funding for CPT Codes 51795 and 51797

The Bureau of Health Services Financing is pleased to announce the funding of the following CPT codes effective with date of service November 1, 1995:

51795 - Voiding pressure studies (VP); bladder voiding pressure, any technique; and

51797 - Intra-abdominal voiding pressure (AP) (rectal, gastric, intraperitoneal).

The fees for these codes are $16.00 and $50.00, respectively, for the full service and $6.40 and $20.00, respectively for the professional component.  When billing for the professional component only, a 26 modifier is to be attached to the code.  Each of these codes will be restricted to a maximum of one unit per day.


CPT Code 99420 in Nonpay Status

Effective with date of service November 1, 1995, CPT code 99420 - Administration and interpretation of health risk assessment instrument (e.g., health hazard appraisal) - was placed in nonpay status.


Revised Checkwrite Dates

Please note that, due to the holidays and the inaugural date for Louisiana's Governor, scheduled check release dates have been changed:

Christmas Week:  Checks will be released on 12/28/95.

New Year's Week:  Checks will be released on 1/4/96.

Governor's Inaugural Week:  Checks will be released on 1/10/96 for regular and LTC checkwrites.


Funding for Chemotherapy Injections

The Bureau of Health Services Financing is pleased to inform you of the funding of the following chemotherapy injections through the Physicians Program effective with date of service December 1, 1995.

Code                 Description                                                                    Fee

J9203                Ifosfamide/Mesna (Ifex/Mesnex) injection,

                        Combo Package, 1g/200 mg                                              $740.07

J9204                Ifosfamide/Mesna (Ifex/Mesnex) injection,

                        Combo Package, 3g/400mg                                               $888.10

J9205                Ifosfamide/Mesna (Ifex/Mesnex) injection,

                        Combo Package, 1gm                                                          $1788.30

J9206                Navelbine (Vinorelbine Tartrate) injection

                        10mg/ml, 1ml vial                                                                    $45.00

J9207                Navelbine (Vinorelbine Tartrate) injection

                        10mg/ml, 5ml vial                                                                    $225.00

J9265                Paclitaxel (Taxol) injection, 30mg/5ml                               $173.35


Reimbursement for Salaried Hospital Personnel

The professional services of salaried employees of a hospital are not to be billed to Medicaid of Louisiana under any circumstances or scenario.  Reimbursement for the services of salaried personnel are included in a hospital's prospective per diem rate.

The above statement does not apply to the professional services of doctors and certified registered nurse anesthetists even though they may be salaried.  Reimbursement for the administrative duties which a doctor or CRNA may perform for a hospital is included in the prospective per diem rate, but no reimbursement is included in the rate for the professional services of either of these groups.  Therefore, these services may continue to be billed to Medicaid.

Questions about other professional salaried providers should be directed via letter to Kandis V. McDaniel, Physicians Program Manager, at P. O. Box 91030, Baton Rouge, Louisiana 70821-9030.


Attention:  Case Management Providers and PCA Providers

EPSDT Personal Care Services

The Department of Health and Hospitals, Bureau of Health Services Financing, has implemented a new program for EPSDT eligibles (recipients up to 21 years of age) which may provide personal care services to those meeting medical necessity criteria for these services.  As an enrolled Medicaid provider of the MR/DD Waiver Personal Care Attendant Services, you are eligible to participate in this program.  Noted below is information about the program which will assist you in making a decision regarding participation in the program.

A.    The scope of care to be provided by EPSDT Personal Care Services providers is defined, in part, as follows:

1.       Assisting the recipient in daily living activities such as eating, bathing, dressing, personal grooming, oral hygiene and transfer to wheelchair, etc.  Limited household duties related specifically to the care of the recipient may be included in the Plan of Care, but are not to be provided for the entire household.

2.       EPSDT Personal Care Services may be provided only to Medicaid recipients who are EPSDT eligible (i.e., birth to 21 years of age).  However, EPSDT PCS may not be approved for childcare purposes.  Documentation that there will be a caregiver in the home (parent/relative or paid childcare) must be submitted in the Plan of Care.

3.       EPSDT Personal Care Services, by definition, may not include any medical tasks such as medication administration, tracheostomy care, feeding tubes, catheters, etc.  If such medical tasks are necessary, they must be requested under either the MR/DD Waiver PCA Program or the Home Health Program.  BHSF will not accept the physician's delegation for EPSDT PCS providers to perform such medical tasks.

If Personal Care Services are being provided under the MR/DD waiver, EPSDT Personal Care Services will not be approved until the waiver PCA limit is exhausted.

B.  EPSDT Personal Care Services may be provided by currently enrolled providers of MR/DD Waiver Personal Care Attendant Services, as such providers must be licensed by Department of Social Services.  Personal Care Services may not be provided by a member of the recipient's immediate family.  Immediate family is defined as:  mother, father, brother/sister, aunt/uncle, grandparent, or any individual acting as parent or guardian of recipient who resides with recipient.

C.  EPSDT Personal Care Services must be prior authorized by the Bureau of Health Services Financing in accordance with medical necessity criteria established by the Bureau.  Medical necessity criteria requires that the recipient be impaired in at least two daily living skills and whose needs meet a level of care equivalent to an Intermediate Care Facility I (ICF-I).

D.  EPSDT Personal Care Services are limited to four hours per day with provisions for extension if more care is medically necessary.

E.   EPSDT Personal Care Services are billed in half-hour increments and paid at a rate of $3.34 per unit of service (or $6.68/hour).

F.   Pending finalization of program-specific forms, requests for EPSDT Personal Care Services must be in increments of up to six months duration and must be accompanied by the following documents:

  1. Copy of the recipient's Medicaid Eligibility Card;

  2.    Physician referral for PCS and physician approval of Plan of Care prepared by a PCS agency.

  3. Form 90-L completed by physician (within last 90 days) to document the recipient requires/would require institutional level of care equal to an Intermediate Care Facility I; and

  4. Treatment Plan approved by the recipient's referring physician which provides the following information:  

    a.         Recipient name, Medicaid ID number, date of birth, and address;

    b.         Date EPSDT PCS services required to start;

    c.         Provider name and Medicaid provider number and address of PCS agency;

    d.       Name and phone number of someone from your agency who may be contacted, if necessary, for additional information;

    e.         Medical reasons supporting the need for PCS (must be accompanied by appropriate medical record documentation for recipient and parent/caregiver, if disabled);

    f.          Goals of each activity;

    g.         Specific activities (bathing, dressing, eating, etc.) that the PCS provider is to assist the recipient with; number of days services are required each week; number of hours required for each activity for each day; times that services will be needed (i.e., 8 - 10 a.m. and 4 - 5 p.m.);

    h.         Other in-home services utilized or requested for recipient (i.e., MR/DD Personal Care Attendant or Respite services, Home Health services - specify whether nurse, aide, or physical therapy services, OCDD sponsored care, home teacher, etc.); and

    i.          Childcare arrangements (parent/relative/paid caregiver) for child under 14 years of age and activities for which parent or other care giver require the assistance of the Personal Care Services provider.

Requests for Personal Care Services should be submitted to the following address:

Bureau of Health Services Financing  
Program Operations Section
P. O. Box 91030  
Baton Rouge, LA  70821-9030

The request shall be reviewed by BHSF's physician consultant and a decision rendered as to the approval of the service.  A letter will be sent advising of the agency's decision.

G.    If the EPSDT Personal Care Services are approved, an EPSDT PCS provider should bill using a HCFA 1500 and "Procedure Code Z0200 - EPSDT Pers Care Service."  The approval letter must be attached to the claim when submitting to Unisys for payment.


Changes in Anatomical Lab Codes and Fees

The following changes were made to a number of anatomical lab codes and/or their fees effective with date of service August 15, 1995.

1)     The fees for the 17 codes listed below were adjusted on both the full service and the professional component files.  Reduce the listed fees by 40% to obtain the fees for the professional components.

Code                 Fee                               Code                 Fee

80500                $21.68                           88314                $34.85

84182                $18.69                           88349                $75.48

86320                $18.69                           88371                $18.69

86325                $18.69                           88372                $18.69

86327                $18.69                           89100                $32.85

86334                $18.69                           89105                $29.33

88125                $12.01                           89132                $12.66

88302                $22.33                           89136                $14.23

88304                $32.02

2)     The fees for the codes listed below were reduced on the professional component file to 40% of the full service fees.  Prior to August 15, 1995 the fees for these codes were the same on both files.  This was incorrect.  The former fees for these codes should never have been more than 40% of the full service fees.

Codes               Fee                               Code                 Fee

88172                $6.76                            88313                $2.08

88173                $13.52                           88321                $20.64

88300                $3.84                            88323                $25.81

88305                $18.06                           88331                $15.50

88307                $25.81                           88332                $5.17

88309                $25.81                           88346                $7.62

88311                $2.08                            88348                $40.80

88312                $4.39

3)     Codes 80500, 80502, 85095, 85097 and 85102, which were on both the full service and the professional component files, were placed in nonpay status on the professional component files as they should not have been on that file.  These codes never need a modifier.  They remain payable on the full service file.

4)     Codes 88108, 88180, and 88182 were placed in pay status on the professional component file.  The fees for these codes are $9.16, $4.53, and $15.22, respectively.


Addition of Home Health Supplies to the DME Program

Effective immediately and retroactively for dates of service beginning August 18, 1995, medical supplies provided by home health agencies, which were previously reimbursed through the Home Health Program, will be authorized and paid for through the DME Program.

Home health providers may continue to provide these supplies, if they choose, by sending a written request to our Provider Enrollment section to have the status of DME provider added to their Home Health Provider Number.  This will enable them to continue to provider supplies approved through the DME Program prior authorization process, once the change is made to the provider files.

Some home health agencies, however, may decide to request these supplies through an already enrolled DME provider.  In these instances, the DME provider must submit Form PA01 to Unisys, in the usual manner.  In addition to an M.D. prescription for the supplies, a statement from the DME provider should accompany the Form PA01 to notify the Prior Authorization Unit that supplies are being requested by a home health agency for their use in the recipient's home.  The name of the home health agency making the request should also be indicated on the statement.  Upon approval by the Prior Authorization Unit, the DME provider may then provide the supplies to the home health agency to use for that recipient and may then bill Unisys for payment in the usual manner. 

Many of the aforementioned supplies that home health agencies may request for recipients are already listed as covered items in the DME Program.  Requests for payment of these supplies may be submitted using the same procedure codes already established.  Other items which are presently not listed as covered items in the DME Program may be requested by using code E1399, with the specific description on the PA01, for each item.  Additional codes will be created at a later time for some of these items.

Please note, however, that diapers and blue pads, which were previously supplied through some home health agencies, are not covered in the DME Program and will not be authorized for purchase.

Please note, also, that coverage for home IV pain management administration equipment or supplies cannot be authorized for recipients age 21 and older.  We understand that some home health agencies have been providing pain management IV supplies in the past to recipients of their services of all ages.  This was done, however, in contradiction to Home Health Program policy.  The DME Program, therefore, is not required to authorize IV pain management equipment or supplies as part of the transfer of home health supplies coverage from the Home Health Program.  IV pain management equipment and supplies must be covered for recipients under age 21, however, because of federal EPSDT requirements.  The medications, also, may continue to be authorized through the Pharmacy Program for enrolled pharmacy providers.


Adjustment in Fees for "J" Codes

Effective with date of service December 1, 1995 adjustments in fees will be made to the following codes:

Code                 Description                                                                    Fee

J3250                Hemodialysis, Tigan, Phenergan Inj.                                  $2.23

J3410                Injection Vistaril, 25mg., restricted to Mental

                        Health Clinics on crossover claims                                      $1.00

J9130                Injection, DTIC-DOME, 100mg/10ml.                             $13.83

J9140                Injection, DTIC-DOME, 200mg/20ml.                             $22.23


DME Reimbursement Changes

Effective for dates of service of July 7, 1995 and after, the Department of Health and Hospitals revised the flat fee reimbursement methodology for DME items by establishing flat fees reimbursement at a rate of 80% of the Medicare DME fee schedule or at 80% of flat fee amounts which have been established by determining the lowest cost at which a needed item is widely available (state established fee schedule).

The flat fee reimbursement methodology for DME was recently changed again, however.  Effective, retroactively, for dates of service beginning July 7, 1995, and afterwards, flat fees are established at 80% of the Medicare DME fee schedule or at the lowest cost at which the needed items are widely available.

If an item is not available at 80% of the Medicare DME fee schedule, the flat fee to be utilized will be 100% of the Medicare DME fee schedule or the lowest cost at which the item is determined to be widely available.

DME claims for recipients with both Medicaid and Medicare Part B coverage will continue to cross over to Medicaid from Medicare for payment of the coinsurance and deductible up to 100% of the Medicare fee schedule allowable charge.

Please note also that customized or individually priced items, such as customized wheelchairs (code E1220) and other miscellaneous items (E1399), for which we have no flat fees established, are not affected.


A Note Regarding the Mental Health Rehabilitation Program

Effective December 1, 1995, the Mental Health Rehabilitation (MHR) Program will be subject to the Emergency Rules which were published in the November 20, 1995, issue of the Louisiana Register.

Here are a few of the changes.

1)     A recipient cannot receive services from both a MHR provider and a Case Management provider.

2)     Existing MHR providers must be approved for and receive a Transitional Certification in order to continue providing MHR services.

3)     The criteria for the target population now includes a Level of Need screening.  In order for an individual to meet medical necessity for the target population, that individual must have a High Level of Need in addition to the previously established criteria.

4)     Services will be reimbursed at a flat rate per month based on the Level of Need.

The changes are far more inclusive than mentioned here.  Please review the Emergency Rules for the entirety of the changes.  If you have any questions, please call your Regional Office of Mental Health Prior Authorization Coordinator.


Attention Providers of Lab Services

The edits which regulate reimbursement for lab services for automated multichannel tests, hematology, prenatal lab panels and urinalysis have been revised.  Listed below are revisions to old policy and the declaration of new policy regarding reimbursement for these and other lab services.

Automated Multichannel Tests and Panels
1)     Effective with dates of pay in December, 1995, billings for procedure code 84478 (Triglycerides) will be denied with the error message "Included in the automated multichannel test panel codes" as code 84478 is being included in the list of automated multichannel tests enumerated under the heading "Automated Multichannel Tests" on page 264 in the 1995 issuance of the Physicians' Current Procedural Terminology.

2)     Effective with dates of pay in December, 1995, providers must bill a panel code (80002 - 80019) after the performance of the first, rather than the second, automated multichannel test.

3)     If more than one of the codes listed below is billed by the same billing provider for the same recipient for the same date of service, the system will pay the first billing and deny the second with the message "Multiblood tests billed; to be combined to panel."

82040                82250                82251                82310                82315          82320
82325                82330                82375                82435                82465          82565
82947                83615                83620                84060                84075          84100
84132                84155                84295                84450                84455          84460
84465                84520                84525                84550                83624          83610
82555                84478                82550                84160

Hepatic Function Panel and General Health Panel

4)     If individual tests and panel codes are billed for the same recipient for the same date of service by the same billing provider, the system will pay the first and deny the second with the message "Blood component billed with panel code."

Hematology

5)     Incorrect billings of hematology components, indices, and profiles will be denied with the message "Hematology Components/Indices/Profiles billed incorrectly."

Only one of the codes 85021 through 85027 shall be paid to the same billing provider for the same recipient for the same date of service.  A second billing of any of these codes on the same date of service for the same recipient by the same billing provider will be denied.  Code 85021 should be billed by itself OR one of 85022, 85023, 85024, 85025, or 85027 should be billed.

The billing of more than two of the hematology component codes (85007, 85014, 85018, 85041, 85048, 85595) by the same billing provider for the same recipient for the same date of service will result in denial of the third code in this group, as a profile code should be billed if more than 2 tests in this group are performed.

The billing of one of the above profile codes (85021 - 85027) and one or more of the component codes 85014, 85018, 85041, or 85048 by the same billing provider for the same recipient for the same date of service will result in payment of the first billing and denial of the second, as the component codes are included in the profile codes.

The billing of code 85007 and one or more of codes 85022 or 85023 on the same date of service for the same recipient by the same billing provider will result in payment of the first claim and denial of the second because 85007 is included in codes 85022 and  85023.

A billing of code 85595 and one or more of codes 85023, 85024, 85025 or 85027 by the same billing provider for the same recipient for the same date of service will result in payment of the first claim and denial of the second because code 85595 is included in codes 85023, 85024, 85025, and 85027.

Panel Codes

6)     A billing of more than one panel code (80002 - 80019, 80050 and 80058) on the same date of service for the same recipient by the same billing provider will result in denial of the second billing with the message "Max allowed.  One panel per day per billing provider."

Prenatal Lab Panels

7)     A billing of more than one prenatal lab panel code (Z9001, Z9002, Z9003) on the same date of service for the same recipient by the same billing provider will result in denial of the second billing with the message "One prenatal panel per pregnancy payable."

Only one prenatal lab panel code is to be paid per pregnancy.  Therefore, a second billing of Z9001, Z9002, or Z9003 within a 270 day period by the same billing provider for the same recipient will be denied with the message "Max reached.  Only one payable per pregnancy."

Procedure code 80055 (Obstetric panel) will be placed in nonpay status as the Louisiana Medicaid Program has locally-assigned codes for prenatal lab panels.

Providers who have been reimbursed for a Z9001, Z9002, or Z9003 on a recipient will not be reimbursed for codes 85018, 85022, 85025, 86592, 86762, 86900, 86901, or 86850 on the same recipient.

Only one of code 81000 OR 81001 (a new urinalysis code making its debut in the '96 issuance of CPT) will be payable per pregnancy pre recipient per billing provider UNLESS the primary diagnosis code for subsequent billings of 81000 or 81001 is within the 590 - 599 range.  This takes into account recurrent urinary tract infections, which are common among pregnant recipients.

Urinalysis

8)     A billing code of 81000 and one or more of 81002, 81003, or 81015 by the same billing provider for the same recipient for the same date of service will result in denial of the second billing with the message "Urinalysis billed incorrectly" because 81002, 81003, and 81015 are inappropriate with 81000.

A billing of code 81002 and 81003 on the same date of service for the same recipient by the same billing provider will result in denial of the second claim with the same message because the descriptions of the two codes are contradictory.

A billing code of 81001 and 81002, 81003 or 81015 on the same date of service for the same recipient by the same billing provider will result in denial of the second claim as the descriptions of the letter three codes are contradictory to that of code 81001.

A billing of code 81000 and 81001 on the same date of service for the same recipient by the same billing provider will result in denial of the second claim as the two codes have contradictory descriptions.

Panels and Component Codes Within Panels

9)     A billing of panel code 80050 and component codes 80012 - 80019, 85022, 85025, and/or 84443 by the same billing provider on the same date of service for the same recipient will result in denial of the second claim with the message "Billed panel and individual code within panel."

A billing panel code 80058 and component codes 82040, 82250, 84075, 84450, and/or 84460 by the same billing provider on the same date of service for the same recipient will result in denial of the second billing with the same message.

If panel code 80059 is paid, component codes 86287, 86291, 86289, 86296, and 86302 will not be paid on the same date of service for the same recipient to the same billing provider.

The above rule also applies to panel codes 80061, 80072, 80090, 80091, 80092, and their components.


Service Reductions and Terminations in the Chiropractic Program

Because of a lack of funding, services by chiropractors to recipients 21 years of age and older will be suspended by the Louisiana Medicaid Program effective with the date of service December 1, 1995.

The only services payable for recipients to the age of 21 effective with date of service December 1, 1995, and thereafter will be medically necessary spinal manipulations (CPT codes 97260 and 97261) provided as the result of a referral from an EPSDT medical screening provider.

Claims for these two codes (97260 and/or 97261) must be submitted hardcopy with documentation justifying medical necessity attached.  Also attached must be a copy of the EPSDT medical screening referral.  Electronic submissions of these two codes will deny with the message "Resubmit with EPSDT referral and documentation attached.

An emergency rule under the authority of Louisiana Constitution Article 7, Section 10, Louisiana Revised Statutes 39:73. 39:77, 46:153, 49:950, and 42 U.S.C.A. Section 1396 is the state law which requires this automatic change.  The emergency rule was published in the November 20, 1995, issue of the Louisiana Register with an effective date of December 1, 1995.  Public hearings will be held when the final rule process is initiated.  Claims for dates of service prior to December 1, 1995, will be reimbursed to the extent that funds are authorized by legislative appropriation for said services.

Questions may be directed to telephone numbers 504/342-9490, 504/342-8223, or 504/342-3932.


Classification and Reimbursement for Hearing Aids

Hearing aids are currently covered for recipients, under age 21 only, as an EPSDT service and a DME service.  While we will continue to list hearing aids and their medical criteria for coverage in the DME manual, they will be classified and budgeted as an EPSDT service.  Therefore, hearing aids are subjected to the 15% budgetary reduction effected by the EPSDT Program for EPSDT covered services for dates of service, retroactively, to July 7, 1995 and afterwards.