12, NUMBER 5
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
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
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
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
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,
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
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
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,
90701 DTP (Diphtheria, Tetanus,
90702 DT (Diphtheria, Tetanus)*
90707 MMR (Measles, Mumps, Rubella)
90712 OPV (Polio virus vaccine
90713 Polio Injection
90731 HBV (Hepatitis B vaccine)
90737 Hib (Haemophilus type B
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.
Drug Utilization Review (LADUR) Education
(Ritalin) for Treatment of Narcolepsy and ADHD
Robert L. Judd, Ph.D.
Asst. Professor of Pharmacology
Northeast Louisiana University
School of Pharmacy
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.
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
a result, sympathomimetic activity in the central nervous system and in the
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
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
Methylphenidate is almost completely eliminated in the urine, with
approximately 95% of a dose being recovered as metabolites in urine within 90
Drug interactions are not uncommon
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
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
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
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
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
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
This increase in activity makes it extremely useful in the treatment of
narcolepsy and ADHD.
(An Electronic Drug Reference and Teaching Guide). v. 14, Gold Standard
Goodman and Gilman, 1990,
"Catecholamines and Sympathomimetic Drugs" The Pharmacological
Basis of Therapeutics, 8th Edition. Pergamon Press: New York, Pp.
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.
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.
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
Please note that, due to the
holidays and the inaugural date for Louisiana's Governor, scheduled check
release dates have been changed:
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.
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.
Ifosfamide/Mesna (Ifex/Mesnex) injection,
Combo Package, 1g/200 mg
Ifosfamide/Mesna (Ifex/Mesnex) injection,
Combo Package, 3g/400mg
Ifosfamide/Mesna (Ifex/Mesnex) injection,
Combo Package, 1gm
Navelbine (Vinorelbine Tartrate) injection
10mg/ml, 1ml vial
Navelbine (Vinorelbine Tartrate) injection
10mg/ml, 5ml vial
Paclitaxel (Taxol) injection, 30mg/5ml
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
Case Management Providers and PCA Providers
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
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.
The scope of care to be provided by EPSDT Personal Care Services
providers is defined, in part, as follows:
Assisting the recipient in daily living activities such as eating,
bathing, dressing, personal grooming, oral hygiene and transfer to wheelchair,
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
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.
EPSDT Personal Care Services, by definition, may not include any medical
tasks such as medication administration, tracheostomy care, feeding tubes,
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 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:
Copy of the recipient's Medicaid Eligibility Card;
Physician referral for PCS and physician approval of Plan of Care
prepared by a PCS agency.
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
Treatment Plan approved by the recipient's referring physician which
provides the following information:
Recipient name, Medicaid ID number, date of birth, and address;
Date EPSDT PCS services required to start;
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;
Medical reasons supporting the need for PCS (must be accompanied by
appropriate medical record documentation for recipient and parent/caregiver, if
Goals of each activity;
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.);
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
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
The request shall be reviewed by
BHSF's physician consultant and a decision rendered as to the approval of the
letter will be sent advising of the agency's decision.
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
The approval letter must be attached to the claim when submitting to
Unisys for payment.
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.
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
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
The former fees for these codes should never have been more than 40% of
the full service fees.
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.
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.
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
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.
in Fees for "J" Codes
Effective with date of service
December 1, 1995 adjustments in fees will be made to the following codes:
Hemodialysis, Tigan, Phenergan Inj.
Injection Vistaril, 25mg., restricted to Mental
Health Clinics on crossover claims
Injection, DTIC-DOME, 100mg/10ml.
Injection, DTIC-DOME, 200mg/20ml.
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
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
Here are a few of the changes.
A recipient cannot receive services from both a MHR provider and a Case
Existing MHR providers must be approved for and receive a Transitional
Certification in order to continue providing MHR services.
The criteria for the target population now includes a Level of Need
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
Services will be reimbursed at a flat rate per month based on the Level
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.
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
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.
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.
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."
Hepatic Function Panel and General Health Panel
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
Incorrect billings of hematology components, indices, and profiles will be
denied with the message "Hematology Components/Indices/Profiles billed
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
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
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.
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
panel per day per billing provider."
Prenatal Lab Panels
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.
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
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
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
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.
Reductions and Terminations in the Chiropractic Program
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.
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.
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.
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
may be directed to telephone numbers 504/342-9490, 504/342-8223, or
and Reimbursement for Hearing Aids
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
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.