PROVIDER UPDATE
Vol. 17; Issue 1
February 2000
DHH Takes Action to Reduce Medicaid Spending
In late January, the Department of Health and Hospitals notified the Legislature of steps being taken to address a projected shortfall in the Medicaid budget. This spending reduction plan amounts to a total of $180 million (including $54 million in state funds), or about five percent of the total Medicaid budget of $3.365 billion.
DHH Secretary David Hood said the plan was developed with a goal of minimizing its impact upon recipients of Medicaid programs and services.
"We were faced with the agonizing choice of either eliminating services and placing restrictions on eligibility or lowering reimbursement that we pay to providers," Hood said. "Although we recognize that these cuts might prove difficult for our providers, we believe we have avoided cuts that are drastic and devastating to our recipients."
The plan is currently being implemented through rule-making and administrative action. It reduces provider reimbursement rates, halts implementation of several new programs and eliminates three small optional services. In addition, the plan calls for the Legislature to give approval for the department to tap funds in the Medical Assistance Trust Fund to allow DHH to meet it budget obligations.
"If we had to rely solely on spending reduction measures to meet our target, we would be faced with a catastrophic cut in our pharmacy program," Hood explained. "Instead, we are proposing the use of non-recurring revenues in the trust fund to avoid eliminating optional pharmacy benefits that thousands of Medicaid recipients rely upon."
Hood acknowledges that the plan includes many difficult and painful choices, but manages to avoid onerous reductions in services.
"I have cautioned members of the Legislature against altering this plan for fear it would possibly result in deeper reductions to other vital programs and services," Hood added.
Secretary Hood has begun meeting with representatives of many of the provider groups affected by the reductions. He has promised to work with providers to consider other solutions and options that address the current situation.
"We are committed to listening to each and every idea that might help us generate funds or otherwise solve this problem. I know that many providers have ideas that might help resolve this situation, and it is incumbent upon this department to give consideration to possible solutions," Hood said.
New Codes for Oral Enteral Formulas
FIMS #5864 and 5871
(RA Message 11/30/1999, 12/7/1999, 12/14/1999)
The following procedure codes have been established in the DME Program for the authorization of enteral formulas that are administered
orally:
Z4150 -- Enteral formula; Category I; semi-synthetic intact protein/protein isolates, oral-fed, 100 calories = 1
unit
Z4151 -- Enteral formula; Category I; natural intact protein/protein isolates, oral-fed, 100 calories = 1 unit
Z4152 -- Enteral formula; Category II; intact protein/protein isolates, oral-fed, 100 calories = 1 unit
Z4153 -- Enteral formula; Category III; hydrolized protein/amino acid, oral-fed, 100 calories = 1 unit
Z4154 -- Enteral formula; Category IV; defined formula for special metabolic need, oral-fed, 100 calories = 1 unit Z4155 -- Enteral formula; Category V; modular components (protein, carbohydrates, fat), oral-fed, 100 calories = 1 unit
Z4156 -- Enteral formula; Category VI; standardized nutrients, oral-fed, 100 calories = 1 unit
These codes have been established effective 01/01/2000 with a PAC of 880 for manual pricing.
Please note also that these codes track the descriptions and pricing of codes B4150 through B4156 for enteral formulas with the exception that they are to be used for oral-fed formulas only.
Effective immediately, DME providers should begin using these new "Z" codes for prior authorization requests for oral-fed formulas submitted with begin dates of service of 01/01/2000 and after. The Prior Authorization Unit will also begin to substitute the appropriate "Z" code for oral-fed enteral formula requests submitted to them with begin dates of service of 01/01/2000 and after. By using these new "Z" codes for oral-fed formulas, it will no longer be necessary to submit claims to BHSF for an override of the Medicare edit.
The B4150 through B4156 codes should continue to be used for tube-fed formulas. The "B" codes will, however, continue to process for any prior authorization requests already approved for oral-fed formulas using these codes. Medicare crossover claims will also continue to process with the "B" codes.
DME Providers and ICF-MR Facilities
Effective for dates of service on March 1, 2000 and after, Medicaid will deny DME claims for the purchase or rental of any medical equipment and/or supplies that the ICF-MR facility is responsible for providing to its residents. The Unisys Prior Authorization Unit will also discontinue the authorization of these DME requests with dates of service on or after March 1, 2000 for services rendered to ICF-MR residents. The ICF-MR facility shall be responsible for furnishing all the medical equipment and supplies listed in section 0-500 of the DME Program Provider Manual, with the exception of certain disposable supply items that will continue to be covered by the DME Program. Additionally, other non-listed medical equipment items that would normally be considered by the DME Program for EPSDT eligible recipients must be furnished by the ICF-MR facility when the interdisciplinary team identifies the recipient's need for the item.
Therefore, claims for medical equipment and supplies provided to ICF-MR residents should be billed directly to the ICF-MR facility. Please note that the ICF-MR facility is responsible for the payment of the coinsurance and deductible amounts for any medical equipment and supplies provided to Medicare/Medicaid recipients that has been approved and reimbursed by Medicare and for which the facility is required by Medicaid to furnish.
The following supplies will continue to be reimbursed through the DME Program: Urinary catheters (except indwelling types that are covered through the Pharmacy Program) and disposable urological supply items; enteral and parenteral formulas or solutions and administrative supplies (the ICF-MR facility is responsible for providing infusion pumps and stands); administrative supplies for IV therapy (the ICF-MR facility is responsible for providing IV pumps and stands; the IV medications and fluids are only available through the Pharmacy Program); ostomy supplies; surgical dressings and bandages for wound care ( including gauze, tape, sponges, cement, and disposable gloves); disposable tracheostomy supplies (such as trach tubes, trach care kits, and cannulas); suction catheters; and batteries for hearing aids, pacemakers, and artificial larynxes.
The facility is expected to provide all accessories (disposable and non-disposable) necessary for the use of the equipment furnished to residents. In addition, the facility is responsible for the repair and replacement of all parts and components of the equipment when necessary.
Any questions regarding DME Program coverage of specific DME items should be directed to Mr. Gene King of BHSF at (225)-342-3930.
New Codes For Cervical, Craniostenosis Helmets
The following procedure codes are now payable with prior authorization in the DME Program for special type helmets for children with certain cranial
deformities:
L0100 --- Cervical, craniostenosis, helmet, molded to patient model
L0110 --- Cervical, craniostenosis, helmet, non-molded
Both codes were made active for payment effective with date of service 09/01/99 and after for recipients under age 21.
Please note that Z9100 (protective helmet, soft type) and Z9101 (protective helmet, hard type) remain active codes for use in requests for helmets for the protection of the head for recipients under age 21 with other medical needs for them. They should not be used for children with cranial deformities.
EPSDT Health Services Training Corrections
(RA Message on 1/25/2000, 2/1/2000, and 2/8/2000)
Please note the following corrections to the EPSDT Health Services Training, Medicaid Issues for
1999:
1) On p. 2, procedure code 92251 should be procedure code 92551. The reimbursement is
$3.60.
2) On p. 3, procedure code 92585 is reimbursed at $180.00, not $65.00.
3) On p. 3, procedure code X0412 is reimbursed at $45.00, not $48.60.
Please make these corrections to your 1999 EPSDT Health Services Training packet. If you wish to request a new, corrected training packet, please contact Unisys Provider Relations at (800) 473-2783 or (225) 924-5040. EPSDT Health Services providers who have billed and been paid for procedure code 92585 at a rate less than $180.00 for 1999 dates of service may file adjustments for such claims.
LADUR Education Article
Urinary Tract Infections
Nancy M. Toedter, Pharm.D.Assistant Professor of Clinical Pharmacy
Practice
University of Louisiana at Monroe College of Pharmacy
ISSUES:
� UTIs are one of the most common infectious diseases encountered
today, contributing significantly to healthcare costs.
� UTIs are most prevalent in women, and causative organisms
usually originate from the fecal flora of the host.
� The antimicrobial choice for treatment of UTIs must take into consideration the
spectrum of activity, potential toxicities, and current resistance patterns.
Urinary tract infections (UTIs) are one of the most commonly occurring medical problems, causing considerable morbidity and healthcare costs. In the United States, UTIs account for approximately seven million office visits to physicians each year, and over one million hospitalizations annually are attributed to or complicated by UTIs. Overall annual healthcare costs due to UTIs are estimated to exceed $1
billion.1 Although UTIs can occur in persons of all ages, sexually active young women are more commonly affected. It is estimated that 40% of women will develop UTI sometime during their lifetime, and 20% of women reporting UTI will have multiple
recurrences.2,3 As these figures demonstrate, UTIs are a major health problem, and appropriate management can help minimize morbidity and costs associated with
them.
Definitions
The general term "urinary tract infection" refers to the presence of microorganisms in the urinary tract, which includes the bladder, kidneys, collecting systems, or prostate. Most UTIs are caused by bacteria, although fungi and viruses may occasionally be
involved.4 UTIs may be classified by anatomic site of involvement or may be categorized as uncomplicated versus complicated. Regarding anatomic designations, UTIs are divided into lower tract infections (cystitis, urethritis, prostatitis, and epididymitis) and upper tract infections (acute or chronic pyelonephritis).1 The other method of classification divides UTIs into uncomplicated versus complicated infections. Uncomplicated UTIs generally occur in sexually active, nonpregnant adult women who do not have structural or functional abnormalities of the urinary tract. This is the more common type of UTI and is most responsive to
antibiotics.1,5 Complicated UTIs, on the other hand, are harder to treat and occur in patients with structurally or functionally abnormal urinary tracts. This includes patients with renal stones, indwelling urinary catheters, prostatic hypertrophy, obstruction, or diabetes. Infections occurring in elderly, children, men, or pregnant women as well as hospital-acquired UTIs are also considered
complicated.1,5,6
Bacteriuria refers to the presence of bacteria in the urine. The term "significant bacteriuria" has been used to differentiate true infection from contamination, and historically, bacterial counts greater than or equal to 100,000 organisms/ml indicated a true infection while counts less than 100,000 organisms/ml represented
contamination.7 This traditional threshold of greater than or equal to 100,000 bacteria/ml has been challenged because 30-50% of women with acute cystitis have less than 100,000 bacteria/ml. In those symptomatic women with low bacterial colony counts, the infection may be in an early phase and may not yet be established in the bladder; this is often termed "urethral syndrome." Additionally, the infection may be subsiding, or the patient may have recently urinated or may be taking a
diuretic.3,5,6 Therefore, significant bacteriuria may be better defined based on patient population and method of urine collection, and this definition may be expanded to include the following
criteria:8
� >102 CFU coliforms/ml or > 105 CFU noncoliforms/ml in a symptomatic female
� >103 CFU bacteria/ml in a symptomatic male
� >105 CFU bacteria/ml in asymptomatic patients on two consecutive specimens
� >Any growth of bacteria on suprapubic catheterization in a symptomatic patient
� >102 CFU bacteria/ml in a catheterized patient (CFU = colony-forming
units)
Pathophysiology
Bacteria can invade the urinary tract through three possible routes: the ascending, hematogenous, and lymphatic pathways. Most infections occur via the ascending pathway, with bacteria moving from the urethra to the bladder (cystitis) and continuing up the ureter to the kidney (pyelonephritis). The short length of the female urethra along with its close proximity to the perirectal area promote urethral colonization, and sexual intercourse may then force bacteria into the bladder. Hematogenous spread of organisms rarely occurs, accounting for less than 5% of documented UTIs. Infection of the kidneys by this route usually results from bacteremia with invasive pathogens, such as
Staphylococcus aureus. Finally, the lymphatic pathway appears to have an insignificant role in the pathogenesis of UTIs. Although lymphatic communications exist between the bowel/kidney and bladder/kidney, there is no evidence that organisms enter the kidney via this
route.1,4,7,9
Once bacteria do reach the urinary tract, various factors can influence the development of infection. The normal urinary tract possesses several defense mechanisms to prevent infection. For example, the urine possesses antibacterial activity; a low pH, high urea and organic acid concentrations, and a high osmolality are all factors that can inhibit microorganisms. Additionally, micturition involves removal of contaminated urine, and certain antiadherence mechanisms present in the bladder, such as urinary mucus, prevent bacteria from colonizing and infecting the urinary tract. On the other hand, bacteria can possess certain virulence factors that increase their likelihood of causing an infection. An example is the presence of fimbriae, or rigid hair-like appendages, that allow bacteria to adhere to uroepithelial
cells.4,7
Predisposing Factors
Certain risk factors have been identified which increase the chances of developing UTIs. Age and gender are two such factors. Elderly patients are at increased risk due to impaired bladder emptying, obstruction secondary to prostatic disease, bladder catheterization, and increased perineal soiling. Regarding gender, adult women are thirty times more likely than men to develop UTI. Sexual intercourse is another risk factor, as this may facilitate migration of pathogens into the bladder. The use of a diaphragm and spermicide for contraception also present an increased risk; not only can the diaphragm cause urinary obstruction, but the spermicide can also cause a change in vaginal flora. Delayed postcoital micturition and pregnancy are other risk factors. Postmenopausal women may also be predisposed to infection due to an increase in vaginal pH, which alters endogenous flora. Hospitalized patients, those with urinary catheters, and those with neurologic disorders as well as patients with diabetes mellitus are also at increased risk for development of
UTIs.1,4,9,10
Etiology
Most UTIs are caused by a single pathogen, usually enteric gram-negative bacteria originating from the fecal flora of the host. The most common cause of uncomplicated, community-acquired UTIs is
Escherichia coli, accounting for more than 80% of infections. Staphylococcus saprophyticus is the second most common pathogen, particularly among young, sexually active females, accounting for 5-15% of community-acquired episodes. This pathogen is generally considered more aggressive than
E. coli because about 50% of the women present with upper tract involvement, and
infections due to this organism are more likely to be recurrent, relapsing, and persistent. Occasionally, other Enterobacteriaceae, such as
Proteus mirabilis or Klebsiella spp. are isolated in uncomplicated
UTIs.1,3,7,11
Complicated UTIs, including nosocomial infections, are caused by more varied organisms and are generally more resistant than those causing uncomplicated infections. Although
E. coli is still frequently isolated, it causes less than 50% of infections. Other organisms that are frequently isolated include
Proteus spp., Klebsiella pneumoniae, Enterobacter spp., Pseudomonas aeruginosa, staphylococci, and enterococci.
Enterococcus faecalis is now the second-most frequently isolated bacteria in hospitalized patients. This may be due to indwelling urinary catheter use or overuse of third-generation cephalosporins, which have no activity against enterococci.
Candida spp. also cause UTIs, particularly in the critically ill and chronically catheterized patient as well as those patients receiving broad-spectrum
antibiotics.1,6,7,9
Clinical Presentation
The clinical presentation of UTI can be separated into those symptoms associated with lower tract and upper tract infections. Lower tract symptoms have an abrupt onset and result from bacteria irritating the urethral and bladder mucosa, causing dysuria, urgency, and frequency. Patients sometimes report suprapubic pain or heaviness, and occasionally, hematuria is present. The urine may be cloudy and foul smelling. Systemic symptoms, such as fever and leukocytosis, are generally absent with acute
cystitis.7,9,12
Clinical findings of upper tract infections typically involve systemic symptoms, including fever, chills, nausea, vomiting, flank pain, costovertebral angle tenderness, and malaise. Leukocytosis and hematuria are also usually present. Lower tract symptoms (urgency, frequency, and dysuria) are often present and may even precede fever and upper tract symptoms by one to two
days.7,9,12
Not all patients with UTIs present with these classic symptoms. Elderly patients, for example, may present with altered mental status, loss of appetite, lethargy, nausea, vomiting, or abdominal pain. Infants may also present with nonspecific symptoms, including poor feeding, vomiting, and fever. Additionally, both upper and lower tract infections can be asymptomatic. Asymptomatic UTIs occur most commonly in elderly patients, children, pregnant patients, and those with indwelling
catheters.6,7,9,12
Diagnosis
In addition to symptoms, diagnosis of UTIs depends on examination of the urine, specifically performing a urinalysis and, if indicated, a urine culture. In order for laboratory evaluation to be useful, proper collection of urine is necessary. There are three methods of urine collection: midstream clean-catch method, urinary catheterization, and suprapubic bladder aspiration. The midstream clean catch is the preferred method for routine urine collection and is the most practical for outpatient use because it utilizes voided urine. When patients are uncooperative or are unable to void, catheterization or suprapubic bladder aspiration may be indicated. These alternative methods utilize catheterized urine or urine aspirated directly from the
bladder.7,9,10
A definitive diagnosis of UTI depends on the presence of pyuria and bacteriuria, which can be determined from a urinalysis. A macroscopic examination of the urine is initially performed, followed by a microscopic analysis. A macroscopic analysis involves describing the urine color, measuring its specific gravity, and estimating pH, glucose, protein, ketone, blood, and bilirubin content. Cloudy or turbid urine often suggests UTI, and hematuria as well as proteinuria may be present with UTIs. The urinary pH may increase because of by-products produced by urea-splitting bacteria, such as
Proteus spp. A microscopic examination of the urine sediment, on the other hand, describes the presence and quantity of erythrocytes, leukocytes, epithelial cells, crystals, casts, and bacteria. Pyuria (greater than 10 WBCs/mm3
of urine) is often seen in symptomatic patients, and WBC casts often suggest
pyelonephritis.3,6,7,13,14
Urine dipstick tests are also available which can rapidly screen urine for the presence of pyuria and bacteriuria by detecting leukocyte esterase and nitrite, respectively. The leukocyte esterase test detects the enzyme leukocyte esterase, which is unique to granulocytic cells, such as leukocytes, and indicates the presence of WBCs (pyuria). The nitrite dipstick test detects the presence of nitrite, which is formed when gram-negative bacteria reduce nitrate that is normally present in the urine. It should be noted that not all bacteria reduce nitrates to nitrites. This includes gram-positive organisms and
Pseudomonas aeruginosa, which may thus give false-negative results with this
test.3,7,9 These urine dipstick tests are now available for home testing of UTIs. The UTI Urine Nitrite Test Strips screen for the presence of nitrites only, while the Azo Test Strips detect both leukocytes and nitrites. Patients should be cautioned that false-negative results could occur with these tests if they are taking tetracycline or large doses of vitamin C. Additionally, phenazopyridine can stain the test strip and make it harder to
read.15,16
Consequently, the urine culture is the most reliable method for diagnosing UTIs. This quantifies the number of bacteria present and allows identification of the infecting pathogen and subsequent susceptibility testing. Urine cultures may not be necessary in women with acute, uncomplicated cystitis but should be performed when a complicated infection or pyelonephritis is
suggested.7,14
Treatment
When selecting an antimicrobial agent for treatment of UTI, various factors should be considered. These include spectrum of activity, pharmacokinetics favoring decreased dosing frequency, underlying disease states or complicating host factors, patient allergies, ability to achieve adequate urinary concentrations (including adequate tissue levels in the kidney if pyelonephritis is being treated), potential for adverse effects or drug interactions, prevalence of antimicrobial resistance patterns among common UTI pathogens, and
cost.5,14 Practitioners should become aware of current patterns of antimicrobial resistance among organisms causing uncomplicated UTIs since resistance among these uropathogens is growing. Reports that 25-35% (or higher) of
E. coli isolates may be resistant to ampicillin, amoxicillin, or sulfonamides have resulted in decreased usage of these antibiotics as empiric
therapy.9,11 Of greater concern is that a recent study among women with uncomplicated cystitis showed an increasing prevalence of
E. coli resistance (up to 18%) to trimethoprim and trimethoprim-sulfamethoxazole (TMP-SMX), commonly used agents for treating acute cystitis; resistance to nitrofurantoin and ciprofloxacin remained extremely
low.17
Several nonspecific therapies have been used in preventing UTIs and as an adjunct to antibiotics in treating UTIs. Increased fluid intake is one such strategy, as this may result in removal of uropathogens by frequent voiding. Postcoital micturition may also flush bacteria from the bladder and urethra. Ascorbic acid may acidify the urine, thus increasing the antibacterial activity of urine. More commonly, cranberry juice has been used to acidify the urine and has also been shown to prevent
E. coli from adhering to the uroepithelium, thereby preventing infection. Additionally, urinary tract analgesics, such as phenazopyridine, may be used to relieve dysuria. It has no antibacterial activity and is generally only used for one or two days. Patients should be warned that phenazopyridine may discolor the urine to a red-orange-brown color, which can stain clothing. Finally, estrogen therapy may prove useful in postmenopausal women with frequent UTIs, as estrogens may decrease vaginal pH, thus increasing vaginal colonization with lactobacilli and suppressing vaginal growth of
Enterobacteriaceae.5,9,18,19,20
Acute Cystitis
Treatment options for acute, uncomplicated cystitis include single-dose therapy and three- or seven-day antibiotic regimens. In the past, it was considered standard therapy to treat cystitis with 7-10 days of antibiotics. However, it is now apparent that acute cystitis is a superficial mucosal infection that can be treated with much shorter courses of therapy, such as single-dose and three-day regimens. These short-course regimens offer the advantages of fewer side effects, improved compliance, and lower
cost.9,14
Single-dose therapy results in high urinary concentrations that persist for at least 12-24 hours and eliminate bacteria when confined to the bladder. This regimen should only be used in young women of childbearing age who have no complicating factors present; it should not be used in treating upper tract infections or in pregnant women, elderly women, diabetics, or males. Single-dose therapy is often associated with lower cure rates and a higher risk of recurrence, most likely due to the inability of single-dose antibiotics to eradicate
E. coli from the fecal and vaginal reservoir, which is the source for the ascending route of infection. Of single-dose therapies, the most effective results have been achieved with TMP-SMX (2 double-strength tablets), various fluoroquinolones, or fosfomycin (Monurol 3g). Lower cure rates have been reported with single doses of beta-lactams, primarily due to the high incidence of ampicillin- and amoxicillin-resistant organisms and faster elimination rates associated with beta-lactams. It is also noteworthy that with single-dose regimens,
E. coli seems to be eliminated more effectively than S. saprophyticus. Another drawback to single-dose regimens is the patients' perception about the adequacy of their therapy, since symptoms of UTI often persist beyond the day of
treatment.2,5,9,10,11,12,18
Three-day regimens are more effective than single-dose therapy and offer comparable efficacy to seven-day regimens but with fewer side effects and lower cost. Unlike single-dose therapy, three or more days of antibiotic therapy generally eradicate
E. coli from the fecal and vaginal reservoir. Greater cure rates have been associated with trimethoprim, TMP-SMX, and various fluoroquinolones, including ciprofloxacin, ofloxacin, norfloxacin, and levofloxacin. The new quinolone, gatifloxacin (Tequin), also is effective in complicated and uncomplicated
UTIs.21 Amoxicillin and first-generation cephalosporins are generally not good choices for empiric therapy due to the high prevalence of organisms resistant to these agents. Additionally, three-day regimens of nitrofurantoin have resulted in higher treatment failures due to its short plasma half-life; therefore, it should be given for at least seven days for treatment of acute cystitis. Based on cost and efficacy, a three-day regimen of TMP-SMX should be considered first-line for empiric therapy in uncomplicated cystitis. The fluoroquinolones, although highly effective and well tolerated, should primarily be used in patients who are allergic to sulfonamides, who are suspected of having antimicrobial-resistant pathogens, or who reside in an area with a high prevalence of TMP-SMX
resistance.2,3,5,11,22
Seven-day antibiotic regimens, once considered the standard of therapy, are now generally reserved for infections in patients with complicating factors. These include male sex, a history of a previous UTI caused by resistant bacteria, diabetes, symptoms present for more than seven days, pregnancy, age over 65 years, urinary tract abnormality, or immunosuppression. Short-course therapy is not recommended in these patients, as these complicating factors may compromise three-day cure
rates.5,9,11,18
Recurrent Cystitis
Recurrent UTIs are common among young, otherwise healthy females, occurring in more than 20% of women. Although such recurrences may occasionally be due to a relapse (persistent infection with the same organism), most recurrences represent episodes of reinfection (infection with different organisms). In cases of relapse, a urine culture and susceptibility testing should be done, and the patient should be placed on an antibiotic for a longer treatment course, such as 2-6 weeks. For reinfections, three management strategies have been used: continuous low-dose antimicrobial prophylaxis, postcoital prophylaxis, or patient-initiated therapy. Women should be questioned about their method of contraception since diaphragm-spermicide use may contribute to recurrent infections. If UTIs are associated with sexual activity, voiding after intercourse may prove beneficial. Finally, in postmenopausal women with recurrent infections, intravaginal estrogen cream may decrease the incidence of
UTI.2,9,11,19,22
Acute Uncomplicated Pyelonephritis
Women with acute uncomplicated pyelonephritis may be categorized into those who are sick enough to require hospitalization for parenteral therapy and those who can be safely managed as an outpatient with oral therapy. Urine cultures are indicated in all patients with suspected pyelonephritis, and blood cultures should also be obtained in hospitalized patients. When selecting antimicrobial therapy, consideration must be given that the antibiotic achieve adequate concentrations in both urine and kidney tissue. Therefore, drugs such as nitrofurantoin should not be used in treating pyelonephritis because it does not achieve reliable tissue concentrations. The usual duration of therapy for pyelonephritis is fourteen
days.2,5,6,11,18
Empiric therapy should include an agent with a broad spectrum of coverage. For patients with mild to moderate infections (no nausea or vomiting), oral agents such as TMP-SMX, the fluoroquinolones, or extended-spectrum cephalosporins may be used. However, patients who are more severely ill and are experiencing nausea/vomiting or dehydration may require parenteral therapy. Intravenous agents often used for initial treatment include third-generation cephalosporins, fluoroquinolones, extended-spectrum penicillins, or aminoglycosides. As the patient improves clinically, therapy may be converted to an oral regimen to complete the fourteen-day
course.2,5,6,11,18
Conclusion
UTIs are one of the most common infectious diseases and are seen in both the inpatient and outpatient settings. An understanding of the pathogenesis, diagnosis, clinical course, and treatment regimens are essential in managing this disease state. Knowledge of antimicrobial spectrum of activity along with current resistance patterns, drug cost, and potential medication side effects may help guide antimicrobial selection. Nonpharmacologic modalities should also be used in treatment. Gaining a better understanding of this disease state can result in more optimal patient outcomes.
References
1. Bacheller CD, Bernstein JM. Urinary tract infections. Med Clin North
Am. 1997;81(3):719-30.
2. Orenstein R, Wong ES. Urinary tract infections in adults. Am Fam
Physician. 1999;59(5):1225-34.
3. Faro S, Fenner DE. Urinary tract infections. Clin Obstet Gynecol.
1998;41(3):744-54.
4. Wisinger DB. Urinary tract infection: current management strategies.
Postgrad Med. 1996;100(5):229-36, 239.
5. Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated urinary tract infection.
Infect Dis Clin North Am. 1997;11(3):551- 81.
6. Barnett BJ, Stephens DS. Urinary tract infection: an overview.
Am J Med Sci. 1997;314(4):245-9.
7. Mullenix TA, Prince RA. Urinary tract infections and prostatitis. In: DiPiro JT, Talbert RL, Yee GC, et al., eds.
Pharmacotherapy: A Pathophysiologic Approach. 4th ed. Stamford, Connecticut; Appleton & Lange,
1999:1779-94.
8. Johnson CC. Definitions, classification, and clinical presentation of urinary tract infections.
Med Clin North Am. 1991:75(2):241-52.
9. Sobel JD, Kaye D. Urinary tract infections. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases. 4th ed. New York; Churchill Livingstone,
1995:662-90.
10. Hatton J, Hughes M, Raymond CH. Management of bacterial urinary tract infections in adults.
Ann Pharmacother. 1994;28:1264-72.
11. Stamm WE, Hooton TM. Management of urinary tract infections in adults.
N Engl J Med. 1993;329(18):1328-34.
12. Romac DR. Urinary tract infections. In: Herfindal ET, Gourley DR, eds.
Textbook of Therapeutics: Drug and Disease Management. 6th ed. Baltimore; Williams & Wilkins,
1996:1307-25.
13. Sahai JV, Fendler KJ. Urinary tract infections. In: Koda-Kimble MA, Young LY, eds.
Applied Therapeutics: The Clinical Use of Drugs. 5th ed. Vancouver, Washington; Applied Therapeutics, Inc.
1992:43.1-43.23.
14. Tice AD. Short-course therapy of acute cystitis: a brief review of therapeutic strategies.
J Antimicrob Chemother. 1999;43(Suppl A):85-93.
15. UTI Urine Nitrite Test Strips. Consumers Choice Systems, Inc. Bellevue, Washington: 1996. Product
information.
16. Azo Test Strips. PolyMedica Corporation. Woburn, MA: 1997. Product
information.
17. Gupta K, Scholes D, Stamm WE. Increasing prevalence of antimicrobial resistance among uropathogens causing acute uncomplicated cystitis in women.
JAMA. 1999;281(8):736-38.
18. Perdue BE, Plaisance KI. Treatment of community-acquired urinary tract infections.
Am Pharm. 1995;NS35(12):37-45.
19. Stapleton A, Stamm WE. Prevention of urinary tract infection.
Infect Dis Clin North Am. 1997;11(3):719-33.
20. Avorn J, Monane M, Gurwitz JH, et al. Reduction of bacteriuria and pyuria after ingestion of cranberry juice.
JAMA. 1994;271(10):751-54.
21. Tequin (gatifloxacin). Bristol-Myers Squibb Company. Princeton, NJ: 1999. Product
information.
22. Hooton TM, Stamm WE. Management of acute uncomplicated urinary tract infection in adults.
Med Clin North Am. 1991;75(2):339- 57.
Untimely Crossover Claims Recovery Project
(UCC)
(Ra Message on 1/25/2000)
As a result of Legistative Audit findings, Medicare crossover claims files to Medicaid untimely were recovered on March 2, 1999 and August 10, 1999. If any of your claims appeared in the Untimely Crossover Claims Recovery Project and you want the claim(s) to be reconsidered because you do have proof of timely filing, you have until March 31, 2000 to resubmit the claim(s) to Unisys. Be sure to attach proof of timely filing, along with all other necessary attachments. Remember that you must attach a copy of the original Claim Detail Listing, which you have received in February 1999, so that your resubmitted claim(s) can be identified as being part of the UCC Recovery Project. Should you have any questions, contact Judy Cain at (225)342-9463.
Blephroplasty Codes
When billing for blephroplasty procedures 15820, 15821, 15822, 15823, 67916, 67917, 67923, and 67924, the visual field test results as well as the patient history and operative reports are needed by the medical review staff for proper review and payment of the claim.
Please submit this necessary documentation with your claim form for timely and correct payment.
Use of 1999 American Dental Association Claim Form
FIMS #5845
(RA Message on 11/16/1999, 11/23/1999, and 11/30/1999)
Until further notice, please do not submit the new 1999 American Dental Association (ADA) dental claim form for payment of Medicaid dental claims or for Medicaid dental prior authorization determinations. The Medicaid claims processing and prior authorization systems are currently not capable of processing these forms; therefore, they will be returned to you without being processed. When these systems are adjusted to accept the 1999 version of the ADA dental claim form, you will be notified.
At a future date, use of the 1999 version of the ADA dental claim form will be mandatory and it will be the only dental claim form accepted for Medicaid claims processing and/or prior authorization determinations. You will be notified when this claim form becomes mandatory and will be allowed a transition period in order to adhere to this new requirement.
This requirement should be considered when purchasing new dental claim forms or obtaining new software. If you are an electronic submitter, adjustments to your current software may be necessary to adapt to the 1999 version of the claim form. However, please note that until the system is able to accept the new 1999 claim form, you must continue to use the previous ADA claim forms. If you have any questions, you may contact Unisys Provider Relations by calling 1-800-473-2783 or (225) 924-5040.
Pre-Cert Changes Announced
Effective February 7, 2000, The Bureau has updated the version of HCIA LOS criteria utilized by Unisys in determining initial length of stays for hospitals subject to Pre-Admission Certification and Length of Stay Criteria.
The 1999 version of HCIA LOS will replace the 1993 version. In the future, the LOS criteria will be updated annually beginning February 1st with the latest version of HCIA available.
DHH Announces Emergency Rules
The following is a list of the emergency rules implemented by the Department of Health and Hospitals to address the shortfall in the Medicaid
budget.
Effective February 1, 2000:
1. Early Periodic Screening Diagnosis and Treatment (EPSDT) KidMed Services: reduces the reimbursement fees for the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) KidMed services by seven percent
(7%).
2. Early Periodic Screening Diagnosis and Treatment (EPSDT) Rehabilitation Services: reduces the reimbursement rates for the Early Periodic Screening Diagnosis and Treatment (EPSDT)Rehabilitation services by seven percent
(7%).
3. Emergency Ambulance Transportation Services: reduces the base rate for emergency ambulance transportation services by seven percent
(7%).
4. Laboratory and Portable X-Ray Services: reduces the reimbursement for laboratory and portable x-ray services by seven percent
(7%).
5. Rehabilitation Centers Services: reduces the reimbursement rates for services provided in rehabilitation centers by seven percent
(7%).
6. Physician Services: reduces the reimbursement fees for surgery codes, medicine codes, evaluation and management codes, and selected locally-assigned Health Care Financing Administration (HCFA) Common Procedure Codes (HCPC) by seven percent
(7%).
7. Early Periodic Screening Diagnosis and Treatment (EPSDT) Dental Services: reduces the reimbursement fees for the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Dental services by seven percent
(7%).
8. Mental Health Rehabilitation Services: reduces the reimbursement rates for the Mental Health Rehabilitation Program by seven percent
(7%).
9. Crossovers-Professional Services Program: Medicare and Medicaid payments will be compared and if the Medicaid payment is greater than the Medicare payment, either the lesser of the co-insurance and deductible or up to the Medicaid maximum payment will be paid. If the Medicare payment exceeds the Medicaid payment, the claim will be adjudicated as a paid claim with a zero
payment.
10. Crossovers- Inpatient Hospitals: Medicare and Medicaid payments will be compared and if the Medicaid payment is greater than the Medicare payment, either the lesser of the co-insurance and deductible or up to the Medicaid maximum payment will be paid. If the Medicare payment exceeds the Medicaid payment, the claim will be adjudicated as a paid claim with a zero
payment.
11. Crossovers-Laboratory and Portable X-Ray Services: Medicare and Medicaid payments will be compared and if the Medicaid payment is greater than the Medicare payment, either the lesser of the co-insurance and deductible or up to the Medicaid maximum payment will be paid. If the Medicare payment exceeds the Medicaid payment, the claim will be adjudicated as a paid claim with a zero
payment.
12. Crossover-Substance Abuse Clinics : Medicare and Medicaid payments will be compared and if the Medicaid payment is greater than the Medicare payment, either the lesser of the co-insurance and deductible or up to the Medicaid maximum payment will be paid. If the Medicare payment exceeds the Medicaid payment, the claim will be adjudicated as a paid claim with a zero
payment.
13. Pharmacy Program Average Wholesale Price (AWP): limits payments for prescription drugs to the lower of AWP minus 15 percent for independent pharmacies and 16.5 percent for chain pharmacies and changes the definition of chain drug stores from 5 or more stores to more than 15 stores under common
ownership.
14. Extended Home Health - 1st hr: reduces the reimbursement for Home Health skilled nursing services to $20 for the 1st hour of extended skilled nursing services provided to medically fragile recipients under the age of
21.
15. Home Health Skilled Nursing & Physical Therapy: reduces Home Health payments for skilled nursing and physical therapy services when performed by a LPN and PT
assistant.
16. T & A Procedure Codes: reduces the reimbursement for tonsillectomy & adenoidectomy procedure codes by twenty-five percent
(25%).
17. Professional Services Program Neonatal Care: reduces the professional fees for performance of neonatal services for CPT codes 99295 and 99298 to $496.85 and $100.10,
respectively.
18. Non-emergency Ambulance Transportation Services: reduces the base rate for non-emergency ambulance transportation services to the rate that was in effect prior to July 1, 1999.
Effective February 8, 2000:
1. Crossovers-Outpatient Hospitals: Medicare and Medicaid payments will be compared and if the Medicaid payment is greater than the Medicare payment, either the lesser of the co-insurance and deductible or up to the Medicaid maximum payment will be paid. If the Medicare payment exceeds the Medicaid payment, the claim will be adjudicated as a paid claim with a zero
payment.
2. Crossovers-Inpatient Psychiatric Services: Medicare and Medicaid payments will be compared and if the Medicaid payment is greater than the Medicare payment, either the lesser of the co-insurance and deductible or up to the Medicaid maximum payment will be paid. If the Medicare payment exceeds the Medicaid payment, the claim will be adjudicated as a paid claim with a zero
payment.
3. Crossovers-Rehabilitation Services: Medicare and Medicaid payments will be compared and if the Medicaid payment is greater than the Medicare payment, either the lesser of the co-insurance and deductible or up to the Medicaid maximum payment will be paid. If the Medicare payment exceeds the Medicaid payment, the claim will be adjudicated as a paid claim with a zero
payment.
4. Crossovers-Hemodialysis: Medicare and Medicaid payments will be compared and if the Medicaid payment is greater than the Medicare payment, either the lesser of the co-insurance and deductible or up to the Medicaid maximum payment will be paid. If the Medicare payment exceeds the Medicaid payment, the claim will be adjudicated as a paid claim with a zero
payment.
5. Crossovers-DME: Medicare and Medicaid payments will be compared and if the Medicaid payment is greater than the Medicare payment, either the lesser of the co-insurance and deductible or up to the Medicaid maximum payment will be paid. If the Medicare payment exceeds the Medicaid payment, the claim will be adjudicated as a paid claim with a zero
payment.
6. Case Management: reduces the reimbursement rates for Infants and Toddlers, Elderly and Disabled Adult Waiver, HIV, and High Risk Pregnant Women Case Management services by seven percent
(7%).
7. Durable Medical Equipment (DME) Flat Fee Amounts: changes the reimbursement for these items from 80% of the Medicare Fee Schedule to an established flat
fee.
8. Durable Medical Equipment(DME) Equipment and Supplies Delivery: reduces the reimbursement rate to be the lesser of billed charges or five percent (5%) of the total prior authorized shipment amount for medical equipment and supplies up to a maximum of fifty dollars
($50).
9. Durable Medical Equipment(DME) Ostomy and Urological Supplies: reduces the reimbursement rate for these items by ten percent
(10%).
10. Durable Medical Equipment(DME) Orthotics and Prosthetics: reduces the reimbursement for orthotic and prosthetic items by ten percent
(10%).
11. Durable Medical Equipment(DME) Oxygen Concentrators and Glucometers: reduces the reimbursement fees for oxygen concentrators to $1250 for purchase and $150 per month for rental and for glucometers to $30 for
purchase.
12. Durable Medical Equipment(DME) Enteral Formulas: reduces the reimbursement for enteral formulas by twenty percent
(20%).
13. Durable Medical Equipment(DME) Z and E Procedure Codes: reduces the reimbursement for medical equipment and home health supply items in the Durable Medical Equipment Program that are identified by a HCPC code beginning with the letter "Z" or HCPC code E1399 or Z1399 by thirty percent
(30%).
14. Durable Medical Equipment(DME) Parenteral and Enteral Supplies: reduces the reimbursement rate for these items by ten percent
(10%).
15. Durable Medical Equipment(DME) Customized Wheelchairs: reduces the reimbursement for manual type customized wheelchairs and their components from MSRP minus fifteen percent (15%) to MSRP minus twenty percent (20%) and reduce the reimbursement for motorized type customized wheelchairs from MSRP minus twelve percent (12%) to MSRP minus seventeen percent
(17%).
16. Durable Medical Equipment(DME) E and K Procedure Codes: reduces reimbursement for specified HCPC procedure codes by ten percent (10%) for the following
items:
� Wheelchairs with special features;
� Breast prosthesis;
� Prosthetic sheaths and socks;
� Elastic support stockings;
� Nebulizer administrative supplies;
� Traction equipment;
� External ambulatory infusion pumps;
� Patient lift slings;
� Percussors;
� Humidifiers; and
� Compressors.
17. Family Planning Clinics: reduces reimbursement rate by seven percent
(7%).
Effective February 21, 2000:
1. Adult Denture Program: terminates coverage of denture services for recipients aged twenty-one (21) and
older.
2. Substance Abuse Clinics: terminates coverage for recipients aged twenty-one and
older.
3. Chiropractic Services: terminates coverage for recipients aged twenty-one and
older.
Effective March 1, 2000:
1. Inpatient Psychiatric Services: reduces the reimbursement rates for inpatient psychiatric services by seven percent
(7%).
2. Long Term Hospitals: reduces the reimbursement rates for Long Term Hospital services by seven percent
(7%).
3. Private ICFs/MR: reduces the reimbursement rates for private ICF/MR services by seven percent
(7%).
4. Private Nursing Facilities: reduces the reimbursement rates for private nursing facility services by seven percent
(7%).
5. Crossovers-Emergency Ambulance Transportation Services : Medicare and Medicaid payments will be compared and if the Medicaid payment is greater than the Medicare payment, either the lesser of the co-insurance and deductible or up to the Medicaid maximum payment will be paid. If the Medicare payment exceeds the Medicaid payment, the claim will be adjudicated as a paid claim with a zero payment.
Effective March 8, 2000:
1. Outpatient Hospital Rehabilitation Services: reduces the reimbursement for outpatient hospital rehabilitation services by seven percent
(7%).
2. Out of State Hospitals: reduces reimbursement for out-of-state trade area hospitals to the lower of the current Medicaid per diem on file or the actual cost per day for latest filed cost
report.
3. Outpatient Hospitals: reduces the interim reimbursement rates for outpatient hospital services from 60% to a hospital�s specific cost to change ratio of billed
charges.
4. Private Hospitals: reduces the reimbursement rates for inpatient hospital services by seven percent
(7%).
5. Outpatient Laboratory: reduces the reimbursement rates for outpatient hospital laboratory services by seven percent (7%).
6. NF - Hospital Leave Days: reduces the per diem rate payment to the facility for hospital leave days by
25%.
7. ICF-MR - Hospital Leave Days: reduces the per diem rate payment to the facility for hospital leave days by
25%.
8. Outpatient Surgery Services: changes the reimbursement for ambulatory surgical procedures not included in the four established payment groups from a percentage of billed charges to a flat fee.
QW Modifier Required For Billing
Previously, the Bureau did not require providers who have CLIA waivered or provider-performed microscopy (PPM) certificates to use the QW modifier when billing for certain laboratory procedures.
Effective for dates of service on or after February 1, 2000, waived (certification type 2) or PPM (certification type 4) providers will be required to use the QW modifier when billing certain CPT laboratory procedure codes. The QW is a modifier which has been assigned by HCFA as a mandated addition to the CLIA waived codes.
For your information the periodically updated list of tests granted waiver status under CLIA may be found online at the following Internet address:
http://www.hcfa.gov/medicaid/clia/waivetbl.htm