Provider Update
Volume 23, Issue 1
january/February
2006
Louisiana Medicaid Restores Cuts in Provider Payments
Louisiana Medicaid has restored the cuts made to reimbursement rates for certain services as a result of reductions in the appropriations for the Department of Health and Hospitals after Hurricanes Katrina and Rita. These reimbursement cuts were effective for dates of service on or after January 1, 2006.
The Legislature directed the Department to restore the cuts to Medicaid reimbursement if federal funding to the Louisiana Medicaid Program was increased for part of fiscal year 2005-06. On February 8, 2006, President Bush approved legislation that increased federal funding for Louisiana Medicaid through the end of the fiscal year. The Bureau of Health Services Financing repealed the January 1, 2006 emergency rules in the March 20, 2006 issue of the
Louisiana Register.
The reimbursement for the following services was restored to the payment rate on file on December 31, 2005.
� Adult dentures services,
� Anesthesia services performed by certified registered nurse anesthetists,
� Durable medical equipment and supplies,
� Dental services for children,
� Expanded dental services for pregnant women,
� Home health services,
� Hemodialysis services,
� Hospice services,
� Inpatient hospital services,
� Inpatient psychiatric services,
� Intermediate care facility services for the mentally retarded,
� Laboratory and x-ray services,
� Mental health rehabilitation services,
� Non-emergency ambulance services,
� Nursing facility services,
� Outpatient hospital services,
� Physician services,
� Targeted case management services.
Unisys, the Medicaid fiscal intermediary, has started the process to adjust claims for the above services with dates of service on or after January 1, 2006. This will allow providers to be paid for the difference between the old reimbursement rate and the reduced rate without having to resubmit the claims.
Providers may contact Unisys Provider Relations at (225) 924-5040 or (800) 473-2783 if they have any questions regarding their adjusted claims.
Nursing Home Admission Review
As a result of Hurricanes Katrina and Rita, many rules and regulations regarding nursing home admission review were modified through January 31, 2006. This was necessary, in part, to expedite the admission approval time lines and to reduce documentation.
These guidelines were interim measures. They were intended to be in effect only as long as the Department deemed necessary to ensure the safety and care of those Medicaid recipients/eligibles impacted by the storms.
The Department hereby notifies each nursing facility that as of February 1, 2006, all prior rules and regulations (Guidelines for Admissions/Readmissions, Status Changes, Conversions, Deaths, Notices for Nursing Home and ICF/MR Facilities - Effective June 1, 2005) will be followed as written. The interim "storm" rules
will no longer be effective after January 31, 2006.
The following is a listing of all the Regional Nursing Home Admission Review staff and their addresses. Region I will continue to receive mail at the State Office for the Division of Long Term Supports and Services. In addition, we now have Admission Review staff in Regions III and V. Please begin using these addresses immediately for all correspondence related to Nursing Home Admission Review.
Long-Term Supports and Services Nursing Home Admissions Field Offices
|
Region
1 � New Orleans
East Jefferson
West Jefferson
Orleans
Plaquemine
St. Bernard
|
1010 Common St.
Suite 505
New Orleans, LA 70113
Rose Allon
(504) 599-0148
Fax: (504) 599-0293
|
|
Region
6 � Alexandria
Avoyelles
Catahoula
Concordia
Grant
LaSalle
Rapides
Vernon
Winn |
1517
B Washington St
Alexandria, LA 71301
Mary
Holligan
(318) 767-6051
Sarah Wells
� clerical
(318) 767-6053
FAX: (318) 487-5968 |
|
Region
2 � Baton Rouge
Ascension
East Baton Rouge
East Feliciana
Iberville
Pointe Coupee
West Baton Rouge
West Feliciana
|
6554 Florida Blvd.
Suite 250
Baton Rouge, LA 70806
Sharon Meaulance
(225) 925-6350
Bert Christina
(225) 925-6414
FAX: (225) 925-6298
|
Region
7 � Shreveport
Bienville
Bossier
Caddo
Claiborne
Desoto
Natchitoches
Red river
Sabine
Webster |
3018
Old Minden Road
Suite 1109
Bossier City, LA 71111
D�Juan
Alexander
(225) 765-0144
FAX: (225) 765-0140
|
|
Region
3 � Thibodeaux
Assumption
Lafourche
St. Charles
St. James
St. John
St. Mary
Terrebonne
|
1148 Tiger Drive
Thibodeaux, LA 70301
Ginger Tabor
(985) 449-4750
FAX: (985) 449-4706
|
Region
8 � Monroe
Caldwell
East Carroll
Franklin
Jackson
Lincoln
Madison
Morehouse
Quachita
Richland
Tensas
Union
West Carroll |
1401
Hudson Lane
Suite 231 A
Monroe, LA 71201
Marsha
Bayles
(318) 362-4615
Joyce Pauley
(318) 362-4624
Donna Hays
� clerical
(318) 362-5070
FAX: (318) 362-4611
|
|
Region
4 � Lafayette
Acadia
Evangeline
Iberia
Lafayette
St. Landry
St. Martin
Vermillion
|
|
128 Demanade Dr.
Suite 104
Lafayette, LA 70503
Dee Lafleur
(337) 262-1279
Norma LeBlanc
(337) 262-1579
FAX: (337) 262-1300
|
Region
9 � Mandeville
Livingston
St. Helena
St. Tammany
Tangipahoa
Washington
|
21454
Koop Dr
Suite 2B
Mandeville, LA 70471
Edith
Durand
(985) 871-8343
FAX:
(985) 871-8346
Diana
Risher
(985) 871-8328 |
|
Region
5 � Lake Charles
Allen
Beauregard
Calcasieu
Cameron
Jefferson Davis
|
|
2300 Broad St
Lake Charles, LA 70601
Jean Primeaux
(337) 491-2246
FAX: (337) 491-2005
|
|
State
Office
6110 Bluebonnet Blvd
2nd Floor
Baton Rouge, LA 70810
Marguerite Adams,
Program Manager
(225) 765-0141
FAX: (225) 765-0140 |
Emergency Prior Authorization Requests
Emergency prior authorization (PA) requests will be considered under the following circumstances:
� If delay in obtaining the medical equipment, appliance or supplies would be life-threatening to the recipient;
� If you need help to facilitate a discharge from an inpatient hospital stay; or
� If the item is required as part of the treatment plan after an inpatient or outpatient procedure (e.g. special shoes or orthotics braces that are needed to help protect gains from surgery).
Other requests may be approved on a case-by-case basis if medical necessity is established.
To request an emergency PA the provider should contact the prior authorization unit (PAU) by calling (225) 928-5263 or 1-800-488-6334. You may also fax your request to (225) 929-6803.
Currently there is no toll free fax line. You should not use the Electronic PA (e-PA) process to request an emergency authorization. Be sure to tell the nurse it is an emergency request when calling, or to write the words "Emergency Request" in large letters on the cover sheet and on the PA Form when submitting the request via fax.
All requests should include the following information:
� The recipient's name, age, and 13-digit identification number;
� The treating physician's name;
� The diagnosis;
� The time period of need for the item;
� A complete description of the item(s) requested;
� The reason the request is a medical emergency; and
� The cost of the item (in some cases you may need to attach a copy of your invoice or the manufacturer's suggested retail price).
Examples of Emergency Items
The following items are examples of medical appliances and supplies that will be considered for an emergency PA.
� Apnea monitors,
� Breathing equipment,
� Enteral formula,
� Suction machines,
� Temporary rental of wheelchairs due to post-operative need,
� Orthopedic shoes upon removal of casting after corrective surgery, or
� Other equipment or supplies requested during hospitalization of a recipient that is medically necessary for the discharge and is for home use.
Approvals
A decision will be made by the PAU within two working days of the date that the completed emergency request is received by the PAU. The provider will be contacted by telephone and will receive written confirmation of the decision. The recipient will also receive written notification of the decision.
For approved PAs, a letter will be sent indicating the PA number; the approved items; and the time period the approval is valid. If additional supplies are required during this period, a new request and plan of care must be submitted. If approved, these supplies will be added to the supplies covered with the existing PA number.
Supply Limits
A thirty (30) day increment of supplies can be authorized by telephone for a recipient pending discharge from a hospital or on an emergency basis. However, additional supplies must be submitted through the normal PA process. Subsequent requests should be submitted in writing as a routine request. Write "Continuation of Services" on the PA01.
Denials
If the request is denied, the provider and the recipient will be mailed a letter explaining the reason for the denial. The denial notice will inform the recipient of the right to a fair hearing within thirty (30) days of the decision.
Reconsiderations
A provider may submit a request for reconsideration of a denial by following these instructions:
� Write the word Reconsideration across the top of the denial letter and the reason for reconsideration at the bottom of the letter.
� Attach all of the original documentation, as well as any additional information supporting the medical necessity to the letter.
� Mail the letter and all documentation to the PAU at Unisys
If the reconsideration is approved, a letter will be sent to the provider and the recipient.
Appeals
Appeal requests are to be mailed to the Bureau of Health Services Financing, Program Operations Section. This section is responsible for preparing the summary of evidence and representing the agency at the fair hearing.
In the event you experience problems or unnecessary delays contacting PAU using any of the telephone numbers listed above, please contact Mr. James Phillips, the DME Program Manager, at telephone number (225) 342-3935, fax number (225) 376-4704, or by email at:
jphilli3@dhh.la.gov.
Changes in Outpatient Service Limits Policy
Currently, medically necessary outpatient visits for Louisiana Medicaid recipients 21 years of age and over are limited to 12 visits per state fiscal year (July through June).
Effective January 1, 2006, it is the intent of the Department of Health and Hospitals to change the outpatient visit limitation from 12 visits per state fiscal year to 12 visits per calendar year (January through December).
The Department has submitted a Medicaid State Plan amendment regarding this policy change to the Centers for Medicare and Medicaid Services (CMS) for approval. CMS approval is pending. You will be notified through remittance advice messages and via the Louisiana Medicaid website, www.lamedicaid.com, when the amendment is approved.
As always, when providing services for Louisiana Medicaid recipients, eligibility inquiries should be made through REVS, MEVS, or e-MEVS.
System changes will be made to allow 2006 service dates to process on a calendar year basis. Pending the systems update, MEVS/REVS/e-MEVS will provide visit limitation information based on the 2006 state fiscal year timeframe. Providers should monitor RA messages for ongoing updates to the policy and system changes.
Prior to rendering services, providers must fully inform recipients of the recipient's potential financial responsibility for payment of the services beyond the current state fiscal year limit, should CMS deny this request.
Physician Supplied and Administered Injectable Antibiotics
Effective for dates of service on or after December 1, 2005, CPT code 90788 (IM injection of antibiotic) has been placed in non-pay status.
For injectable antibiotics supplied and administered by the physician, physicians must use the specific HCPCS code with the appropriate number of units. Louisiana Medicaid's reimbursement for these HCPCS codes is based on available 2005 Louisiana Medicare Average Sales Price (ASP) amounts.
Providers should refer to the Physician Fee Schedule at: http://www.lamedicaid.com for updated reimbursement information. For assistance regarding a HCPCS code not included on the fee schedule, call Unisys Provider Relations at 800-473-2783.
Guidelines for Claims Resolution
To effectively assist providers with billing and claim processing issues, it is necessary for all providers to follow the procedures in place for handling these problems as shown below:
� Providers should direct all billing and claim processing questions to the Unisys Provider Relations inquiry unit at (800) 473-2783 or (225) 924-5040.
� If inquiry unit personnel are unable to resolve the issue, the inquiry unit staff will forward a request for provider contact to the appropriate Unisys regional field analyst. The field analyst will contact the provider to discuss the issue and resolve it via telephone or schedule a field visit to pursue additional information to reach a satisfactory conclusion.
� If the field analyst is unable to resolve a provider's billing issues, the field analyst will forward the issue to the Bureau of Health Services Financing (BHSF) state office for consultation. The BHSF state office will respond to the field analyst who will in turn notify the provider.
Professional Staff Linkage to a Group
In order to ensure proper reimbursement by Medicaid, providers who add additional physicians, nurse practitioners or physician assistants to their practices must contact Unisys Provider Enrollment at (225) 216-6370 and request the appropriate paperwork to link the new staff member to the practice. Medicaid providers who are enrolled in the CommunityCARE program should also contact Affiliated Computer Services (ACS), the State's
CommunityCARE/KIDMED contractor, at (800) 609-3888 to make sure that the new staff member is added to the group's CommunityCARE enrollment.
This is particularly relevant to CommunityCARE providers who were displaced due to the recent hurricanes and may be practicing in other areas of the state. Providers from the affected areas who have relocated must re-enroll in the CommunityCARE program. CommunityCARE participation is not transferable outside the area of original CommunityCARE certification.
All questions regarding professional staff linkage to a group should be directed to Unisys Provider Enrollment or ACS at the numbers indicated above.
RA Message Corner
Valid Codes on Claim Submissions
Louisiana Medicaid recently informed providers that the 2006 ICD-9-CM Disease and Procedure Classification was complete and that valid codes must be used on claim submissions with dates of services on or after October 1, 2005.
Deleted or invalid codes were placed in non-pay status, resulting in denial error 433 (Missing/Invalid Diagnosis code). In order to allow providers to make necessary changes in their claim systems, error edit 433 will be 'educational only' for claims with invalid codes until March 1, 2006.
Following this grace period and provider notification, claims will again deny with error edit 433. For information regarding ICD-9-CM official guidelines for coding and reporting, providers may access the CMS website at
http://www.cms.hhs.gov/icd9providerdiagnosticcodes/
2006 HCPCS Codes Update
Louisiana Medicaid is in the process of completing the programming for the 2006 HCPCS code updates which includes new and deleted codes. Please monitor remittance advice messages for notification of the implementation date for use of the 2006 HCPCS codes by Louisiana Medicaid.
CommunityCARE Information
The CommunityCARE program office has received calls from providers who have received 106 (billing provider not PCP or service not authorized by PCP) denials for recipients who presented as hurricane evacuees from parishes where the PCP referral is currently waived. However, if a recipient has relocated and changed his/her address with Medicaid, they are no longer considered a resident of the parish where the referral requirement has been waived. Medicaid has closed the recipient linkages of all PCPs who are no longer available to provide referrals. Therefore, if MEVS indicates that a recipient is still linked to a PCP, the only way to ensure payment is to obtain a referral from that PCP. Recipients who have relocated should be advised to change to a PCP in their new parish of residence. The telephone number to call to change PCPs is 800-259-4444. If the recipient needs medical care prior to the PCP change becoming effective, the new PCP may request a transitional authorization from the previous PCP.
Effective April 1, 2006, the waiver of CommunityCARE referral, KIDMED linkage, and KIDMED
timely filing requirements will end across the state.
Louisiana Drug Utilization Review (LADUR) Education
Risks Associated With Inhaled Corticosteroid Therapy
By: Bill Ross
Clinical Coordinator for Drug Information Louisiana Drug and Poison Control Center
College of Pharmacy University of Louisiana at Monroe
and
The Role of the Peak Flow Meter in the Management of Asthma
By: Charles N. Bell, Jr., RPh, AE-C
College of Pharmacy University of Louisiana at Monroe
Note: This is a two-part article
Issues in �Risks Associated With Inhaled Corticosteroid Therapy�
� ...ICS are considered a standard of care in asthma therapy...
� Generally, ICS provide a high topical potency to reduce lung inflammation with relatively low systemic toxicity.
Issues in �The Role of the Peak Flow Meter in the Management of Asthma�
� ...a peak flow meter has been shown to achieve significant improvements in health outcomes for asthmatics...
Risks Associated With Inhaled Corticosteroid Therapy
All pharmacotherapy is a composite of benefits versus risks. This review primarily evaluates risks associated with the use of inhaled cortico steroids (ICS) in the treatment of asthma. Before beginning this analysis, however, one should remember that ICS are considered a standard of care in asthma therapy and are used routinely for patients with chronic obstructive pulmonary disease (COPD). The 2002 NAEPP Expert Panel Report documents strong evidence that ICS improve long-term outcomes for asthmatic children. In the 2002 review, evidence from randomized clinical trials demonstrated that ICS are associated with fewer hospitalizations, fewer urgent care visits, better symptom scores, fewer oral steroid bursts, and better forced expiratory volume in the first second (FEV1) before and after treatment and that none of the other asthma medications reviewed were as effective in improving reviewed outcomes. Furthermore, ICS are considered first line treatment for mild persistent, moderate persistent, and severe persistent asthma. Generally, ICS provide a high topical potency to reduce lung inflammation with relatively low systemic toxicity. The benefits of pharmacotherapy, however, are always countered by associated risks.
Adverse effects associated with chronic ICS therapy generally are classified into the following areas of concern:
| Systemic Effects |
Local Effects |
| � Adrenal Suppression |
� Candidiasis |
| � Bruising |
� Dysphonia |
| � Cataracts |
|
| � Glaucoma |
|
| � Growth Suppression in Children |
|
| � Osteoporosis and Fractures |
|
| � Thinning of the Skin |
|
Systemic Effects
Systemic absorption of ICS can be secondary either to oral or pulmonary mechanisms. Generally, the amount absorbed depends on the type of inhaler device, particle size, disposition site, kinetic and physiochemical properties (lipophilicity), and technique of use. Some analogs (fluticasone) are absorbed to a greater extent in patients with severe asthma and reduced lung function compared to budesonide, which is not affected by patient medical status. Most currently available ICS, however, have limited systemic bioavailability due to high rates of first pass metabolism. As a comparison, fluticasone has a first-pass rate of 99% versus oral prednisolone with a rate of 20%. Systemic effects secondary to ICS are influenced by several factors including dosage, type of device employed, patient technique, and characteristics of the individual drug.
Adrenal Suppression
Early dose-response investigations suggested that ICS causes the potential for adrenal suppression. A later observational study of 33 patients linked adrenal crises to patients receiving ICS therapy. This later study indicated that patients seemed to recover after the drug either was reduced or discontinued. Thirty of the 33 patients in this study were taking fluticasone (Flixotide, Flovent), typically for a one to two year duration. More recently, case reports of 17 patients implicate ICS with adrenal crisis. Of this group, 14 patients were receiving fulticasone.
An early systematic review with meta-analysis identified suppression of the hypothalamic axis with ICS. The clinical significance of this effect, however, was questioned.
Growth Suppression in Children
In assessing the clinical effects of ICS, it is helpful to remember that metered-dose inhalers (MDIs) and dry powdered inhalers originally were developed for use in adults. Changing pharmacokinetic-as well as pharmacodynamic-effect as children mature and varying adherence to inhaler device therapy can cloud both benefits and risks associated with ICS.
Several mechanisms related to glucocorticoid growth suppression in children are postulated. These include inhibition of pastille growth hormone (GH) secretion, GH receptor expression, insulin-like growth factor-1 (IGF-1) bioactivity, collagen synthesis, and adrenal and androgen production.
A recent retrospective review of 21 asthma patients less than 5 years old analyzed the impact of ICS on growth. Results demonstrated a 3.4% reduction in height percentile in treated children, but this difference did not reach statistical significance.
In a review of randomized, blinded clinical trials, Leone, et al., found that ICS are associated with a slower short-term vertical growth rate in children, but that this effect is small and that adult height attained by asthmatic children treated with ICS is not different from non-asthmatics. Further conclusions indicate that ICS use did not correlate with lower bone density in children. Among adult patients, however, those who take high doses of corticosteroids for many years may experience adverse effects on bone density.
An earlier clinical trial of 241 children comparing beclomethasone and salmeterol found that linear growth in subjects receiving beclomethasone (Beclovent, Ovar, Vanceril) in one arm was significantly reduced when compared to the salmeterol (Serevent) arm. A reduction of ~1.5 cm/year in growth of prepubertal children treated with 400 mcg/day of beclomethasone has been demonstrated in additional studies.
A randomized, parallel group trial of 100 prepubretal children with perennial allergic rhinitis treated with intranasal beclomethasone noted a significance difference in mean standing height between the test subjects (5.0 cm) and the placebo group (5.9 cm). Differences in growth were evident as early as one month after beginning therapy.
Another recent placebo-controlled trial examined the effect of ICS on 654 infants born to women with asthma. Measured endpoints were mean birth size and size for gestational age, and no adverse significant difference was demonstrated in the ICS group versus the placebo group.
Osteoporosis and Fractures
A recent case-controlled analysis of 273,456 asthmatic children aged 5 to 17 years led to the conclusion that ICS use does not materially increase the risk of fracture compared with non-exposed subjects. Evidence suggested, however, that longer term use of ICS in patients with comitant or past oral steroid exposure may slightly increase fracture risk.
A recent one year review of 124,655 Danish patients with documented fractures (hip, spine, forearm) failed to show an association between ICS (except prednisolone) and type of fracture.
A case-controlled review of 16,341 hip fracture patients found a risk of hip fracture associated with ICS use, with an odds ratio of 1.19 to 1.87 compared to controls. Additional case-control investigations found a general dose-response relationship between ICS use and hip fracture and an increase in hip fracture among subjects receiving doses of 700 mcg/day or greater.
Another case-controlled study of nearly 90,000 subjects with asthma or COPD evaluated the risk of nonvertebral fracture associated with ICS exposure. For ICS exposure as a class, or with fluticasone alone, no increased fracture risk was observed and no dose-response effect was noted.
A meta-analysis of 11 trials evaluated the effects of ICS on bone in patients with asthma and COPD. A significant deleterious effect was caused by ICS on bone mineral density of the lumbar spine, and at the hip or femoral neck. The impact of ICS on hip fracture demonstrated an odds-ratio of 1.6 compared to controls. No significance was shown relative to lumbar fracture rates.
The least deleterious bone effect was seen with budesonide (Pulmicort), followed by beclomethasone dipropionate, then triamcinolone
(Azmacort, Nasocort).
Skin Thinning/Easy Bruising
The Lung Health Study II--a randomized, multicenter, placebo-controlled trial--evaluated the occurrence of bruising, rashes, slow healing, or other skins lesions in 1,086 COPD patients receiving ICS. An increased risk of bruising and slow healing was demonstrated in those receiving ICS. Rash incidence was less in the ICS cohort versus those receiving placebo. Cutaneous effects were more prominent in older patients in general, with greater risk specifically in elderly females.
Cataracts
A recent case-controlled observational study of 15,479 patients with cataract evaluated whether low doses of ICS are associated with an enhanced risk for cataract formation. Results suggested a significant causal association between cataracts and higher ICS dose, as well as longer duration.
Most data relative to ICS and cataract formation comes from earlier studies. A multicenter, randomized trial of 384 subjects receiving beclomethasone for one year found no increased risk of cataracts. Two similar observational studies of 333 and 485 subjects, respectively, came to similar conclusions.
Garbe's case-controlled analysis of 3,677 subjects found an increased risk of cataract extraction in patients 65 years of age and older. The CAMP Research Group monitored the development of posterior subcapsular cataracts in 311 children receiving BUD over a period of six years and found only one child who developed cataracts. A more recent evaluation of 95 children receiving ICS over 2 +/1 years found that none of the subjects developed cataracts.
Glaucoma
An earlier case series demonstrated a small risk of glaucoma associated with ICS therapy. A later case control study of approximately 50,000 patients found that prolonged, continuous use of ICS was the only significant risk factor for glaucoma. A recent, small (n=95) cohort study of children demonstrated no glaucoma (or ocular hypertension) associated with ICS over a two year period.
Special Populations--Pregnancy
In a case-controlled investigation, 467 cases were reviewed to determine if an association exists between ICS and risk of pregnancy-induced hypertension or pre-eclampsia. No significant risk increase was determined among those who used ICS during pregnancy.
A significant increase in both end points was noted in those subjects with markers for uncontrolled and severe asthma.
Local Effects
An earlier cohort study evaluated local side-effects of ICS in 639 asthmatic children receiving beclomethasone dipropionate or budesonide. Overall, 63.3% of children less than six years of age and 59.5% of those older than six reported one local adverse effect. Cough (39.7%) was dependent on young age, use of BDP, and primarily use of a spacer device. Dysphonia (11.1%) was favored by high doses of both drugs and by spacer use. Thirst (21.9%) and hoarseness (14.1%) were reported with both BDP and BUD. The occurrence of oral candidiasis (10.7%) could not be associated with any given predisposing factor. ICS appear to cause dysphonia by inducing myopathy of the vocal cords.
Oropharyngeal effects of ICS can be reduced by rinsing the mouth and spitting after use and by using spacer devices. If ICS are delivered through a face mask (as with infants), then the nasal-perioral area should be cleaned with a damp cloth after each treatment.
Risk Reduction - Reduction of Dosing Frequency and Amount
Once-daily dosing frequently maintains control for patients with milder asthma and may reduce average effects. Most cases of moderate asthma can be controlled with twice daily dosing of most of the inhaled corticosteroids. NAEPP guidelines recommend initial higher and more frequent dosing, followed by dose tapering once control has been reached.
Dosing Schedule
The NAEPP Guidelines address chronobiological ICS dosing to reduce adverse effects and enhance efficacy. For once-daily dosing, administration between 1,500 and 1,700 appears to improve both outcomes.
New Drugs
A new generation ICS, ciclesonide, with unique pharmacokinetic properties, has been developed with the intent of reducing both systemic and local adverse effects. Added advantages include once-daily dosing and increased patient adherence. Ciclesonide is inactive until it reaches the lung and demonstrates high protein binding, low oral bioavailability, and rapid clearance. Additionally, short duration placebo-controlled studies have demonstrated minimal local and systemic effects with this ICS.
Conclusion
The weight of clinical evidence currently favors a conclusion that the benefits derived from careful and evidential use of ICS in asthma therapy significantly exceed potential risks. Routine inhaled corticosteroid use is recommended in the most recent national asthma guidelines. As those guidelines are applied to increasingly larger numbers of asthma patients, evidence-based clinical data also will increase to better assess inherent risks and benefits of ICS therapy.
The Role of the Peak Flow Meter in the Management of Asthma
Present State of Asthma
Currently, the control of asthma is an obtainable goal. Treatment has changed with the growing understanding of the pathophysiology of asthma, and control is possible with the use of inhaled steroids and established guidelines. Maintaining control is done through:
� A stepwise approach to pharmacotherapy,
� Patient education about their medications,
� Patient education on environment control,
� A partnership with the patient to control their disease through self-management.
The clinician should employ any tool or device that aids in this control. In randomized controlled trials, a peak flow meter has been shown to achieve significant improvements in health outcomes for asthmatics when incorporated into a written action plan.
Current Recommendations
Long-term daily peak flow monitoring is recommended for managing moderate-to-severe persistent asthmatics or those with a history of severe exacerbations. It is suggested that asthmatics with poor symptom perception can benefit from a peak flow meter. Mild intermittent or mild persistent asthmatics may use a peak flow meter if the family/patient and/or clinician feel it will have benefit, but this is not a strong recommendation. All recommendations assume that peak flow monitoring is part of a written action plan.
Differing opinions exist about which method is more efficacious- the use of a peak flow meter or a symptom monitoring approach. Regardless of the method used, it is strongly recommended that either approach should be part of a written patient action plan. For those clinicians who want to incorporate the use of a peak flow meter in an action plan, the following information will be helpful.
What is a peak flow meter and how is it used?
A peak flow meter is an inexpensive, simple device that measures how well air moves out of the large airways of the lungs. The least complicated device should be used. It is used to establish the patient's best Peak Expiratory Flow (PEF).
Instructing the Patient to Use a Peak Flow Meter
The peak flow meter is simple to use. Instruct the patient to do the following:
1. Stand up straight*, and place the pointer on the peak flow meter to zero.
2. Hold the peak flow meter so that the vent is not obstructed, and take in a deep breath.
3. Place the mouthpiece in the mouth, and seal with the lips (keeping the tongue away from the vent).
4. Blow air as hard and as fast as possible thru the mouthpiece, and write down the number obtained.
5. Wait 15 to 30 seconds, repeat the above steps, and take the highest number as the personal best.
* Note: For those patients who are disabled and cannot stand, it is acceptable to be seated in an upright position for a peak flow meter reading.
Establishing a Personal Best with the Peak Flow Meter
The personal best is a number that can be used by both the physician and patient to assess their current disease and adjust therapy. Ideally, your patient's personal best PEF should be estimated after a 2 to 3 week period in which the patient records PEF two to four times a day. This is usually achieved in the early afternoon after maximal bronchodilator therapy. This 'best' should be marked on the peak flow meter. A short course of oral steroids may be needed to establish this.
The personal best should be reevaluated and checked periodically. A personal best should be done every 6 months for moderate-to-severe persistent asthmatics and children. Progression of the disease and patient growth will affect the personal best value.
Tips for Instructing the Patient
Inform the patient that this device will help them understand and control their asthma. Keep all explanations simple, and check frequently to find out if they understand what you have explained. Use the following outline:
1. Explain peak flow meter use in words.
2. Demonstrate how to use it.
3. Allow the patient to explain how to use it to you.
4. Allow the patient to demonstrate the technique to you.
If you choose to use a peak flow meter in the action plan, encourage the patient to use it on a regular basis and record the results in a daily diary. Current recommendations call for a peak flow reading in the morning when the patient awakens and
before using their medication. Action plans should be based on percentages of their personal best PEF.
The usual break points for action are: 80% of their personal best and above signals good control; 50% to 80% indicates caution and a need for medication; 50% and less indicates medical alert and patient needs to seek immediate medical help.
Review and repetition of peak flow meter instructions for use are important. Patients should not interchange brands of peak flow meters, and when buying a new one, a new 'best' should be established.
Recent Study Results regarding Peak Flow Meters
A review of the literature indicates that education in asthma self-management, which involves self-monitoring by either peak expiratory flow or symptoms coupled with
regular medical review and a written action plan, improves health outcomes for asthmatic adults. Individualized written action plans based on PEF are equivalent to action plans based on symptoms. Reducing the intensity of self-management education or level of medical review may reduce the effectiveness.
Conclusion and Summary
A peak flow meter when coupled with medical review and an action plan can have positive health benefits in asthmatics diagnosed as moderate persistent to severe persistent and in those who have severe exacerbations.
2006 Provider Training Workshop Schedule
**************************Announcing************************
2006 Unisys/Louisiana Medicaid Provider Workshops
*****************************************************************
Following is the schedule for the 2006 Spring Unisys Provider Workshops.
Please carefully review the schedule to see which programs are included at each location as program offerings vary by city.
The annual Unisys/Louisiana Medicaid Provider Workshops focus on presenting vital policy and billing information and addressing questions relating to recent policy and procedure changes. Our training format separates basic information from specific program information.
All Basic workshop sessions will be identical in content and will only be presented once in each location and will not be repeated in specific program workshops. The
Basic Medicaid information workshops will cover general Medicaid policy such as standards for participation, recipient eligibility/ID cards, third party liability, how to obtain assistance from Unisys, general Unisys website information, etc. (A separate session will be held to present all web applications.)
NOTE: We encourage all providers who have never attended a Basic workshop,
and are new to billing Louisiana Medicaid OR those providers who have questions
concerning basic Medicaid policy to attend this workshop.
New this year is the LA Medicaid Web Applications workshop. With the exception of e-RA, all LA Medicaid Web Applications will be covered in this separate workshop. DHH and Unisys encourage providers to begin using these available web applications as we move toward providing LA Medicaid data electronically.
CommunityCARE will be covered in separate CommunityCARE workshops. These workshops will cover all aspects of the CommunityCARE Program. These workshops are not restricted to Primary Care Providers and all Medicaid Providers are encouraged to attend.
CommunityCARE will not be discussed in detail in any other workshops.
Workshop Registration:
� Due to space limitations in all workshops, please limit attendees to two (2) persons per provider.
� Attendees should arrive 15 - 20 minutes early to register
� Each attendee must register individually supplying their provider name and Medicaid ID number or the
provider name and Medicaid ID number of the provider they are representing
� Providers are required to have a valid Medicaid provider ID number for each specific program workshop
attended
Medicaid Programs to be Presented at the Workshops
1. Basic Medicaid Information: All providers may attend. Basic Medicaid information will be presented as previously detailed.
2. CommunityCARE: All providers may attend. CommunityCARE information will be presented.
3. Dental: For EPSDT Dental, Adult Denture, Expanded Dental Services for Pregnant Women (EDSPW), and Oral
Surgeons for dental services.
4. DME: All Durable Medical Equipment providers including Pharmacies functioning as DME providers.
5. Program Integrity: All providers may attend. Includes current fraud and abuse information and the Medicaid
Services Chart.
6. EPSDT Health Services: For School Boards, Early Intervention Centers, and EarlySteps providers. EPSDT PCS services will be discussed in the PCS workshop.
7. Home Health: For Home Health Providers.
8. Hospice: For Hospice providers.
9. Hospital: For Acute, Rehabilitation, Long Term, Free-Standing Psychiatric and Distinct Part Psychiatric Hospitals.
10. KIDMED: For all KidMed providers (excluding RHC/FQHC providers).
11. LA Medicaid Web Applications: For all providers. All LA Medicaid Web Applications (e-MEVS, e-CSI, e-CDI and e-PA)
excluding e-RA.
12. Long Term Care: For ICF/MR, Nursing Home, and ADHC providers.
13. Mental Health Rehabilitation: For Mental Health Rehabilitation providers.
14. PCS (EPSDT and Long Term): For EPSDT PCS and Long Term PCS providers.
15. Professional: Professional services include physicians, APRNs, physician assistants, optometrists,
ophthalmologists, audiologists, podiatrists, chiropractors, laboratories, ambulatory surgery centers, school-based
health centers, and oral surgeons for medical services.
16. RHC/FQHC: For Rural Health Clinic and Federally Qualified Health Center Providers
(includes encounter,
KIDMED, and Dental services).
17. Waiver/Waiver Case Management : For all Waiver and Waiver Case Management (Support Coordination)
providers. PCS services will be presented in the PCS workshop.
18. Pharmacy: All pharmacy providers
Workshops will not be held at this time for the following programs: Ambulance, Free Standing Rehabilitation Centers, Hemodialysis, Mental Health Clinics, and Vision (Eyewear).
Please refer to the workshop schedule for dates (Day 1, Day 2, or Day 3) and times for each workshop location.
Note that there may be more than one session held at the same time. There is no pre-registration required. Please direct any questions concerning the workshops to Unisys Provider Relations at 800/473-2783 or 225/924-5040. Meeting sites should be contacted for directions or sleeping accommodations ONLY.
DO NOT contact the meeting sites with questions related to the workshops.