Provider Update

Volume 20, Issue 1 

February/March  2003

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Message from the Secretary

Recently, I have been sharing my thoughts about where Louisiana is headed in regard to health care. I think this perspective is particularly relevant now as the campaign for governor and other elected officials begin.

Politics is all about priorities, and it is my hope that as candidates for governor establish their priorities and their goals, they will be realistic about what can be accomplished. For example, if a candidate puts forward a plan that promises to increase funding for teacher pay, higher education, economic development, highways, corrections and health care, all without increasing taxes, should be examined very closely.

No one has a crystal ball, but I think we all know that revenues for the next few years are likely to be tight. Even a strong economic recovery is not likely to produce enough revenue to bring us up to the southern average in every category. We certainly won't get there without additional taxes, a possibility that is very slim. Federal funds are also likely to be in short supply, particularly for areas such as health care.

So what's on the horizon for health care over the next few years? Without a doubt, we will have to continue to provide health coverage for those who need it the most. In addition to the elderly and those with disabilities, during this administration we have made children our top priority. Over the past four years we have increased by over 80 percent the number of children we provide health coverage for, from 315,000 to over 565,000.

This was possible because child health was adopted as a state priority, by both the Foster Administration and the Legislature. Our philosophy is that a healthy child is much more likely to stay in school, graduate, get a job and be a productive adult, one not dependent on taxpayer supported public programs. Child health care is a good investment.

In addition to providing coverage for children, we are working hard to ensure that they have access to medical care. Our CommunityCARE program is being expanded state wide in order to link our Medicaid recipients with a primary care physician. Providing a medical home for more than 600,000 children and adults is a tremendous undertaking, perhaps the largest health plan change ever in Louisiana. But it will provide better health care and reduce emergency room costs. Our state is number one in emergency room usage in the entire country, a reflection of the poor access to primary care that prevails throughout Louisiana. 

In terms of reducing the number of uninsured children by providing health care coverage and improving access to primary medical care, DHH is getting it done. But, we have many challenges ahead of us if we are to maintain and protect the progress made in health care over the past few years. How can we ensure that improvements will continue? How can we preserve progress if the fiscal climate at both the state and federal levels is bleak? 

There are no easy solutions anymore. That is why now more than ever we must set clear priorities. Without going into great detail, our priorities are primary care, preventive efforts and community-based care. These three concepts form the basis of how we provide medical care, care to our aging citizens, services and support to people with disabilities, services to those who are battling a substance abuse problem, and the care and treatment for people with mental illnesses.

When our state continues to rank at or near the bottom for almost all indicators for quality health and quality of life, something must be done. Louisiana will never realize significant changes in the health outcomes of our citizens if our goal is to maintain the status quo.

Over the next 11 months, I will continue to take every public opportunity to discuss the health care issues that face our state. It is critical that candidates for governor and other elected offices are informed, and understand the health care priorities that are necessary to move our state forward.

David W. Hood

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HIPAA Bulletin

February 2003

This bulletin provides important information to Medicaid providers regarding changes being made by Louisiana Medicaid in order to comply with the Electronic Data Interchange (EDI) requirements of the federally mandated Health Insurance Portability and Accountability Act (HIPAA) by our October 16, 2003 deadline. This bulletin is divided into the five sections: 

� Becoming �HIPAA Ready� for EDI Transactions with Louisiana Medicaid
What providers and submitters need to do to become HIPAA ready.
� HIPAA Systems Implementation Schedule
The HIPAA project multi-phase implementation schedule. 
� Medicaid Provider Training Seminars
The provider training schedule.
� Nursing Facilities/ICF-MR/ADHC/Hospice Update
Information regarding the LTC/ADHC/ICFMR/Hospice Program implementation.
� Dental Alert
Important information on HIPAA dental changes

Becoming HIPAA Ready for Louisiana Medicaid
The following information will assist your software vendor, billing agent or clearinghouse to become HIPAA approved. For those who do not have a software vendor, billing agent or clearinghouse to become HIPAA approved, instructions are also provided. 

Note: If you currently submit claims electronically to LA Medicaid, your current method WILL NOT be HIPAA compliant without modifications by your software vendor, billing agent or clearinghouse. The only exception to this statement is for electronic billing of non-ambulance transportation claims as they are exempt from HIPAA. All other claims are affected. A "Software Vendor," "Billing Agent", or "Clearinghouse" will be referred to collectively as a 'VBC'.

1. The first step toward HIPAA compliance is to have your VBC contact LA Medicaid and enroll in our testing service. As a provider who bills electronically, your VBC will be responsible for with making your claims HIPAA compliant. Therefore to ensure success, the VBC must contact the LA Medicaid HIPAA EDI Group.

The HIPAA EDI group will support all VBCs through the enrollment, testing, and production approval processes. VBCs may contact the HIPAA EDI group to enroll in LA Medicaid's testing service by emailing a request to *hipaaedi@unisys.com (Note: * is part of the e- mail address) or by calling 1-225-237-3318

A HIPAA EDI representative will issue the VBC login information for our testing service. Companion guides contain data elements specific to LA Medicaid and will be available for download from within the testing service. These guides are supplements to the National Electronic Data Interchange Transaction Set Implementation Guides which can be downloaded from www.wpc-edi.com. 

Our testing service is now available 24-hours-a-day, 7-days-a-week.

2. If you are a LA Medicaid provider AND
    a. You do not have a Software Vendor, Billing Agent or Clearinghouse (VBC)
        Or
    b. Your VBC does not plan to become HIPAA ready

YOU SHOULD:

Subscribe to the weekly VBC list and HIPAA updates by emailing the HIPAA EDI group at  *hipaaedi@unisys.com (Note: * is part of the e-mail address). Put "subscribe to VBC list" in the subject line. VBCs identified in the list are those that have enrolled with the LA Medicaid HIPAA testing service and are pursuing HIPAA compliance.

As VBCs enroll in our testing service, we will publish a list of those VBCs. The list will include contact information, the types of X12N HIPAA transactions they support, and a status of "Enrolled", "Testing" or "Approved." The final "Approved" status means the submitter can submit HIPAA EDI claims on behalf of providers to LA Medicaid. This list will be dynamic and updated weekly as VBCs enroll and progress through the testing process. The weekly VBC list will be emailed to those providers who have submitted a subscription request to *hipaaedi@unisys.com (Note: * is part of the e-mail address), and will also be available on
the web at www.lamedicaid.com/hipaa.

Visit the web site often or subscribe to our e-mail list for the most up to date information on HIPAA and a status on all enrolled VBCs as they pursue HIPAA readiness.

We encourages all providers to be good consumers and use the VBC list to shop for a VBC that best suits their needs and their budget. The features, functions, and costs vary significantly between VBCs. Find the one that is right for you.

3. Once your VBC enrolls in the HIPAA testing service, the process toward HIPAA compliance can begin. Please have your vendor enroll early, even if they are not ready to send a test file. This will let us know the VBC intends to become HIPAA compliant and can be included in the list of VBCs. In addition, we primarily will communicate with all the VBCs primarily through the testing service. To ensure success, VBCs should enroll early to access the most up to date testing information.

4. The testing service has everything a VBC needs to test for HIPAA compliance with LA Medicaid.  Companion Guides, Trading Partner Agreements, and other necessary documentation will be available for download from within the testing service. The testing service is comprehensive and evaluates the 7 levels of testing as defined by Wedi-Snip (level 7 is specific to LA Medicaid).

5. VBCs that have successfully completed our testing program, will be "Approved" for HIPAA electronic claim submission to LA Medicaid. Providers can use any "Approved" VBC as their electronic means of claims submission.

HIPAA Systems Implementation Schedule
The Louisiana HIPAA project will be implemented in multiple phases, also called implementations. The impact on the provider community will vary depending on the size and complexity of each implementation. A brief description of each implementation is given to highlight the effect the implementation will have on providers.

A type or a combination of types identifies each implementation: Local Code, EDI or Claim Form. Local Code identifies that the implementation primarily focuses on the transition from Louisiana local codes to HIPAA standard code sets. EDI indicates this implementation is a standard electronic HIPAA transaction. Claim Form indicates changes made to the hardcopy claim form and/or instructions.

Each implementation will have an effective date. The effective date will indicate the specific date of transition to a new process or code set. However, for EDI related implementations, the effective date actually indicates that one submitter has completed the 7 levels of testing. At that point all remaining submitters can begin or finalize their testing process to become "Approved" to submit specific HIPAA electronic transactions. 

The following table that describes each HIPAA implementation. Note that exact dates have been included here only for the implementations occurring up to 5/1/2003. The schedule after that date is considered to be tentative, therefore only a month & year are indicated.

Provider Training Seminars
The Unisys Provider Relations Department will be conducting training seminars in four locations across the state. These will be held concurrently in Baton Rouge, Lafayette, New Orleans and Shreveport.

The following table lists the training schedule and the programs to be presented at each session. The materials presented at the seminars will be mailed, upon request, to those providers unable to attend the training seminars. As with the implementation schedule above, the dates for activities after 5/1/03 are tentative, therefore an exact date is not indicated.

Training Seminar	Programs	Seminar Dates
One	1. Dental 2. Hospital (Inpatient, Outpatient) 3. Hemodialysis 4. Rural Health/FQHC	March 31-April 1, 2003
Two	1. Home Health 2. Professional (Includes: Pre-natal Clinics, TB Clinics, STD Clinics, Ambulatory Surgical Centers, Vision, Physician Services, Lab & X-Ray, Family PLanning, EPSDT Health Services, EPSDT Rehab, Mental Health Clinics, MR Rehab, and Rehab) 3. Pharmacy	TBD
Three	1. LTC/ADHC/ICF-MR/Hospice 2. KIDMED/EPSDT Screening	TBD
Four	1. DME 2. Waiver	TBD

*PHARMACY PROVIDERS-NCPDP 5.1 testing will be done with the switch vendors. Any provider, who is certified by a switch vendor in NCPDP 5.1 does not need to test for POS with LA Medicaid.

*RHC/FQHC PROVIDERS-If you bill for dental services you should also attend the Dental training seminars. (See Dental Alert below)

More specific information regarding the training seminars (including dates, time and specific locations), plus additional implementation information will be included in the Provider Update as well as RA messages.

Nursing Facilities/ICFMR/ADHC/Hospice Update
The implementation of the 837I electronic institutional claim billing and the hardcopy UB92 was previously scheduled for May 2003. Due to the responses received on the recent LTC survey sent out in late December, it has become clear to DHH and Unisys that a large portion of the affected providers will not be ready by May. To ensure the least amount of disruption to the providers, DHH and Unisys have decided to move this implementation to September 2003. At that time we will accept the 837I and the UB92 and continue to accept the TAD until a date for elimination is finalized by the Department. Providers will be notified in advance of this date. We strongly encourage all providers affected by this change to make every effort to attend the training seminar in your area.

Dental Alert
The Medicaid Dental Program will experience many changes with the implementation of HIPAA. These changes will affect both electronic and hardcopy claim submitters. Therefore, we encourage all dental providers, or appropriate office staff, to attend the HIPAA Training Seminar that will be held on March 31 & April 1, 2003. At the Training Seminar, dental providers will be informed of coding and definition changes, fee changes, new claim form and claim form instruction changes and other important information. 

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Services Available to Medicaid Eligible Children Under 21

If you are a Medicaid provider, recipients you serve under the age of 21 may be eligible for the following services:

*Doctor�s Visits	*Residential Institutional Care or Home and Community Based (Waiver) Services
*Hospital (inpatient and outpatient) Services	*Medical, Dental, Vision and Hearing Screenings, both Periodic and Interperiodic
*Lab and X-ray Tests	*Immunizations
*Family Planning	*Eyeglasses
*Home Health Care	*Hearing Aids
*Dental Care	*Psychiatric Hospital Care
*Rehabilitation Services	*Personal Care Services
*Prescription Drugs	*Audiological Services
*Medical Equipment, Appliances and Supplies (DME)	*Necessary Transportation: Ambulance Transportation, Non-ambulance Transportation
*Case Management	*Appointment Scheduling Assistance
*Speech and Language Evaluations and Therapies	*Substance Abuse Clinic Services
*Occupational Therapy	*Chiropractic Services
*Physical Therapy	*Prenatal Care
*Psychological Evaluations and Therapy	*Certified Nurse Midwives
*Psychological and Behavioral Services	*Certified Nurse Practitioners
*Podiatry Services	*Mental Health Rehabilitation
*Optometrist Services	*Mental Health Clinic Services
*Hospice Services	*Extended Skilled Services

and any other medically necessary health care, diagnostic services, treatment, and other measures which are coverable by Medicaid, which includes a wide range of services not covered for recipients over the age of 21.

If Medicaid recipients you serve are under age 21 and are on the MR/DD Request for Services Registry, they may be eligible for case management services. To receive more information on these services, contact the Bureau of Community Supports and Services at 1-800-660-0488.

Both, providers and recipients, may call KIDMED at (toll-free) 1-877-455-9955 to receive information regarding other available services. As a provider, KIDMED can also inform you of which services must be pre-approved. If you service recipients who are deaf or hard of hearing, please instruct them to call the TTY number, (toll-free) 1-877-544-9544. If recipients have a communication disability or are non-English speaking, you may have someone else call KIDMED and the appropriate assistance can be provided.

Whenever health treatment or additional services are needed, recipients may obtain an appointment for a screening visit by contacting KIDMED. Such screening visits also can be recommended by any health, developmental, or educational professional. To schedule a screening visit, contact KIDMED at (toll-free) 1-800-259-4444 (or 928-9683, if the recipient lives in the Baton Rouge area), or by contacting their physician if they already have a KIDMED provider.

Louisiana Medicaid encourages recipients to contact the KIDMED office to obtain a KIDMED provider so that they may be better served.

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Occupational Therapy, Physical Therapy, and Speech 

� Pursuant to order of the federal court, audiologic services, occupational therapy evaluations and treatment services, psychological evaluations and therapy (individual and group) and speech and language evaluations and therapy (individual and group) may be provided by any willing enrolled Medicaid provider even if furnished as part of an IEP or an IFSP, or provided in a school setting.

� If your client is needs occupational therapy, physical therapy, speech pathology and/or audiology services provided for in the home, he or she may receive them in the home. Providers of these services are home health agencies.

� If you don't know of a home health agency that provides these services in the home, contact the Referral Assistance Hotline at ACS.

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DHH to Aid in Arranging Services

As a result of a settlement in the Chisholm v. Hood lawsuit, DHH has agreed to do the following:

In the event that an individual class member or case manager acting on behalf of the class member is unable to locate a willing PCS or extended home health provider who is able to promptly provide the necessary service to the recipient, DHH agrees to take all reasonable steps necessary to locate a provider to submit a request for prior approval for the service requested by the class member (if the service has not already been prior approved) within 10 working days. IF the service has already been prior approved, DHH agrees to take all reasonable steps necessary to locate and arrange for services within 10 working days.

IF you are faced with this situation for either PCS or extended home health services, this is what you do:

� Call the Referral Assistance Hotline at ACS (1-877-455-9955) and tell him/her that you cannot find a willing provider for these types of services. 
� Follow up with ACS (so you will know if ACS is having success). 

If you are dissatisfied or are having difficulty with ACS, call the person(s) listed on your Medicaid Chart for either PCS services or extended home health services.

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All Agencies Must Comply With Minimum Standards

In a recent legislative review of Home Health agency records, it was discovered that not all agencies were complying with a requirement published in the Minimum Standards for Home Health Agencies. These standards were promulgated as a rule in the December 20, 2001 Louisiana Register, volume 27, number 12. The requirement is that the patient or a responsible person must sign the permanent record of visit that is retained by the agency. The responsible person may be a spouse, relative, neighbor or friend, but may not be an employee of the Home Health agency. The person who signs the form should also date it.

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Alternatives To Long Term Care

The Louisiana Department of Health and Hospitals (DHH) Bureau of Community Supports and Services (BCSS) administers Medicaid Home and Community-Based Waiver Services programs throughout the state. 

Home and community-based waiver services offer an alternative to nursing home long-term care by providing supplemental supports and services to eligible elderly, and/or disabled adults in a home and community-based setting. These services supplement natural supports (family, friends, community resources, etc.) by providing assistance with everyday activities of daily living such as bathing, dressing, grooming, eating, toileting and other services to eligible persons who would otherwise require nursing home level of care. Individuals interested in participating in these programs must meet age, disability and nursing facility level of care admission criteria, as well as Medicaid financial eligibility requirements.

In an effort to foster informed choice, and to assure timely dissemination and accessibility of information about home and community-based waiver services, the DHH/BCSS will be conducting several statewide informational training workshops on home and community-based waiver services as an alternative option to nursing home long term care (all workshop participants will be issued a certificate of attendance). Training workshop sessions dates, times and locations are listed below (workshop sessions are on a first-come-first served basis - your registration will be confirmed by BCSS).

Louisiana's Home and Community-Based Services Waivers
Alternatives to Nursing Home Long-Term Care Workshops

Alexandria, Louisiana 

Date: Tuesday, March 11, 2003
Location: Rapides General Medical Center, 211 Fourth St., Alexandria, LA
Time: Session 1: 9:00 a.m. - 10:30 a.m.
Session 2: 11:00 a.m. - 12:30 a.m.
Session 3: 1:30 a.m. - 3:00 p.m. 

Baton Rouge, Louisiana

Date: Friday, April 4, 2003
Location: Louisiana Municipal Association Building, 700 N. 10th Street, Baton Rouge, LA
Time: Session 1: 9:00 a.m. - 10:30 a.m.
Session 2: 11:00 a.m. - 12:30 p.m.
Session 3: 1:30 p.m. - 3:00 p.m. 

If you or your agency would like to register to attend any one of the training workshop sessions listed above, or to request additional information about home and community-based waiver services, please e-mail or fax Janice LaBorde at: JMLaborde@dhh.state.la.us, Fax: (225) 219-0201. Include the following information: 
� Agency Name
� Address (Including city, state & zip code)
� Phone #
� Fax #
� Email address
� Person(s) attending

You may also call the BCSS Statewide Toll Free Help Line at 1-800-660-0488 or visit the DHH/BCSS HOME web site address at: http://www.dhh.state.la.us/BCSS/index.htm for more information on home and community-based waiver services and to access training materials.

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New Provisions to EPSDT Psychological and Behavioral Services

Effective July 2002, the Department adopted new provisions governing Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Psychological and Behavioral Services. Pursuant to a federal court order in the Chisholm lawsuit, a notice was sent to recipients who were identified as Chisholm class members informing them of their potential eligibility for these services. A notice was also sent to all licensed psychologists in Louisiana informing them that they may enroll in the Medicaid Program (if he/she meets the qualifications) to provide these services to Medicaid recipients who: 

� Are under the age of twenty-one (21); and 
� Are currently on the BCSS Request for Services Registry(formerly known as the MR/DD waiver 
waiting list); or
� Were on the registry on or after October 20, 1997 (the Chisholm class).

To obtain these services, the recipient must be a member of the Chisholm class, as defined above, and must meet one of the following criteria. The child:

� Has a diagnosis of Pervasive Developmental Disorder (PDD) according to a clinically appropriate diagnostic screening tool or other assessment; OR
� Has an impaired functional status that can be addressed by psychological treatment, [validated] on an 
instrument or other assessment of individual functioning that is appropriate for individuals with developmental disabilities; OR
� Engages in behaviors so disruptive or dangerous that harm to others is likely (e.g., hurts or tries to hurt others, such as hitting, biting, throwing things at others, using or threatening to use a weapon or dangerous object). Behaviors are recurrent, not a single instance; OR
� Engages in behaviors that have resulted in actual physical harm to the child him/herself, such as bruising, lacerations, or other tissue damage, or would result in same if the child were not physically restrained. Behaviors are recurrent, not a single instance. Behaviors are not the result of clinically suicidal intent.

The psychologist must verify both Medicaid eligibility and that the recipient meets the above criteria in order to be reimbursed for this service. Evaluations and assessments are available for those recipients who are Chisholm class members, but do not know if he/she meets any of the additional criteria.

In order to assist a family in finding an enrolled provider, please tell them to call the Referral Assistance Hotline at 1-877-455-9955.

These services may change in the future. If and when the services do change, you will be notified by DHH. If you have any questions about these services, or need additional help in finding a psychologist, please contact Mary Norris at (225) 342-1247 or Dawn Matte at (225) 342-8223.

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NOTICE TO PHARMACISTS: REGIONAL LADUR COMMITTEE

The Department of Health and Hospitals is accepting nominations for pharmacists to serve on the Region Two Louisiana Drug Utilization Review Committee. The committee consists of three pharmacists and one physician who meet monthly to review profiles of drug usage from a therapeutic perspective and to clarify or send information to the medical community. One pharmacist opening is currently available. The nominees should be Louisiana Medicaid providers and practice in one of the following parishes: 

Ascension	Iberville	St. Helena	St. Mary
Assumption	Lafourche	St. James	Terrebonne
East Baton Rouge	Livingston	St. John	W. Baton Rouge
East Feliciana	Pointe Coupee	St. Landry	West Feliciana
Iberia	St. Charles	St. Martin

Committee members must have time available to meet monthly for one to three hours and must meet the following requirements:

PHARMACISTS
� Pharmacy degree from an accredited U.S. pharmacy school
� Licensed to practice in Louisiana as a pharmacist
� No previous sanctions from the State of Louisiana

Please print or type your nomination on this form in the space provided below (brief resume appreciated) and return the form as soon as possible to:

Unisys: Louisiana Medicaid
8591 United Plaza Blvd., Suite 300
Baton Rouge, LA 70809
ATTN.: S. DELAVILLE

LMMIS REGION TWO DRUG UTILIZATION REVIEW COMMITTEE

NAME:_____________________________________PHONE:_____________________

ADDRESS:______________________________________________________________

______________________________________________________________

PARISH:____________________________EMPLOYER:________________________

I am nominating the above mentioned for consideration as a member in the LMMIS REGION TWO DRUG UTILIZATION REVIEW COMMITTEE.

NAME (PRINT) ____________________________________ TITLE ____________________

SIGNATURE:________________________________________PARISH___________________

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NOTICE TO PHYSICIANS: REGIONAL LADUR COMMITTEE

The Department of Health and Hospitals is accepting nominations for physicians to serve on the Region Three Drug Utilization Review Committee. The committee consists of three pharmacists and one physician who meet monthly to review profiles of drug usage from a therapeutic perspective and to clarify or send information to the medical community. One physician opening is currently available. We are requesting that the nominees be Louisiana Medicaid providers and practice in at least one of the following parishes: 

Acadia	Allen	Avoyelles	Beauregard	Calcasieu	Cameron
Catahoula	Concordia	Evangeline	Grant	Jeff. Davis	Lafayette
LaSalle	Rapides	Vermillion	Vernon

Committee members must have time available to meet monthly for one to three hours and must meet the following requirements:

� Doctor of medicine degree from an accredited U.S. medical school
� Licensed to practice in Louisiana as a medical doctor
� Board certification in their specialty
� No previous sanctions from the State of Louisiana

Please print or type your nomination on this form in the space provided below (brief resume appreciated) and return the form as soon as possible to:

Unisys: Louisiana Medicaid
8591 United Plaza Blvd., Suite 300
Baton Rouge, LA 70809
ATTN.: S. DELAVILLE

_____________________________________________________________________________
LMMIS REGION THREE DRUG UTILIZATION REVIEW COMMITTEE

NAME: ________________________________________ PHONE:_____________________

ADDRESS:______________________________________________________________ ______ 

_____________________________________________________________________

PARISH: ____________________________ EMPLOYER:____________________________

I am nominating the above mentioned for consideration as a member on the LMMIS REGION THREE DRUG UTILIZATION REVIEW COMMITTEE.

NAME (PRINT) ____________________________________ TITLE ____________________

SIGNATURE:_______________________________________ PARISH___________________

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Interperiodic Screens Are Available To Your Clients

Did you know that interperiodic screens are available to Medicaid eligible children under the age of 21? An interperiodic screen is a medical, vision, or hearing screening that is provided outside of and in addition to the regular periodic screen.

Such a screen would be necessary if a new condition is suspected, or if a condition is worsening. Medicaid will pay for this screen even though it is not within the periodicity schedule.

A health, developmental or educational professional, parent, guardian, or you may recommend the screen.

To obtain the screen, do the following:
� Document the circumstances concerning the request
� Contact ACS to schedule the interperiodic screen with the child's KIDMED provider.

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2002 Provider Training Questions and Answers

BASIC 
1. Is it necessary to write �EOB attached� on hardcopy TPL claims when an EOB is attached?
No, it has never been necessary to make such a statement.

2. Can providers adjust more than one line per day when filing electronically?
Yes.

3. Are there any plans to decrease reimbursements?
Unisys is not aware of any pending changes to reimbursement.

4. Does Medicaid pay co-insurance/deductible when Medicare is primary?
Depending on the patient�s QMB status, Medicaid will consider payment of co-insurance and deductible up to Medicaid�s allowable fee.

5. If a claim is over one year old and proof of timely filing is needed, is it necessary to attach all of the denied RA�s, or just one?
If the claim is over one year old, it is necessary to prove that the claim was received timely (within one year from the date of service). Providers only need to attach one RA that proves the claim was submitted timely.

6. Does Medicaid pay for tetanus shots?
Tetanus shots are covered if the recipient is under the age of 21. If the recipient is 21 years or older, this is considered a non-covered service and the patient may be held responsible for the payment.


COMMUNITYCARE
1. Can a physician who is part of a group choose not to participate as a Primary Care Physician?
Yes.

2. Is a referral needed for a sports physical?
If the recipient is linked to a PCP, and the physician performing the service is not the PCP, it will be necessary to obtain a PCP referral form in order to receive reimbursement from Medicaid.

3. If an emergency room visit results in an inpatient stay for a CommunityCARE patient, does the hospital still have to obtain pre-cert?
Yes. The referral requirement does not negate the need for any other protocols currently in place.

4. Is it possible for a recipient to be linked to a Kidmed provider who is not their PCP?
It should not happen.Please contact ACS/Birch & Davis if this occurs, at 1-800-609-3888.

5. Do public health units (without physicians) have to obtain a referral for immunizations?
Yes, a referral is needed if the public health unit is not sub-contracted to provide the Kidmed service for the recipient.

6. If a multi-specialty clinic has both PCPs and specialists, do the specialists need to obtain a referral from the PCP for services rendered?
Yes; any services rendered by the non-PCP require a referral.

7. A) Is a referral needed for sterilization services? B) If a patient presents for birth control, is a referral needed?
A.)No
B.)Family planning services are exempt from the referral process, if the claim is billed with a family planning procedure or diagnosis code.

8. If a patient presents to the emergency room for a foreign body removal, and the situation is considered to be an emergency, is a referral needed?
Emergency services that meet the criteria for the two lowest level emergency visit codes need a post-authorization. Emergency services that meet the CPT criteria for the three highest level emergency codes do not need a referral. 

9. Will a radiologist need a referral for services associated with procedure codes 99283-99285?
Radiology codes 70010 � 7999 when provided in the emergency room and billed with a place of service 23 do not require a CommunityCARE referral.

10. Does a radiologist have to maintain a copy of the referral?
The answer depends on where the records are housed. If the radiologist works out of the hospital and his/her medical records are maintained as a part of the hospital records, then the hospital copy of the actual referral form serves as the radiologist�s referral. If the radiologist maintains records elsewhere, a copy of the referral form must be in the records maintained by the radiologist. 

11. How long must providers maintain the CommunityCARE referral?
According to the Medical Assistance Program Integrity Law (MAPIL), �all providers should maintain and retain all records for a period of five (5) years�.

12. Should providers bill Medicaid using their usual and customary charges or Medicaid�s fee schedule?
Providers are instructed to bill their usual and customary charges; however, how much providers indicate on the claim form is an internal decision. Keep in mind that if there is a rate increase, Medicaid will pay indicated charges up to Medicaid�s fee schedule. Therefore, providers may short-change themselves if they bill according to Medicaid�s fee schedule rather than their usual and customary fees.

13. Do home health aid visits require a referral?
Yes.

14. Is only the hospital face sheet needed in order for the PCP to grant/deny a referral request?
The most used documentation is the face sheet because it usually indicates �presenting symptoms�. However, a PCP may request additional information if the face sheet does not indicate presenting symptoms or does not provide enough detailed information about presenting symptoms for the PCP to make an informed decision.

15. Is a reason required to deny a referral?
Yes, the PCP should indicate why the referral is being denied.

16. If a referral request is not answered by the PCP within 10 days, what recourse is there?
If a particular PCP continues to avoid issuing a response, (either approved or denied) within the 10 day timeframe policy providers may contact Unisys so that the PCP can be educated on their responsibilities.

17. If a surgeon schedules a surgical session at a hospital, who is responsible for obtaining the referral?
The surgeon is responsible for getting the referral if he/she is the entry point for Medicaid services. The surgeon is responsible for sharing the referral with anyone called in on the case, including the hospital.

18. Are patients still limited to 3 emergency room visits per calendar year if they have a Primary Care Physician?
No. If patients have a Primary Care Physician, they have no limit on emergency room visits. The PCP is expected to manage all patient care, and it will be necessary to obtain a referral from the Primary Care Physician if the visit is a low level complexity.

DME
1. If a nursing home recipient needs an oxygen concentrator, does the nursing home bill Medicaid or does the DME provider bill Medicaid?
If the physician writes the script for Oxygen PRN (or as needed), it is the nursing home�s responsibility to provide the oxygen concentrator. If the script is written for continuous oxygen, the DME provider may submit a request for prior authorization and then provide the service after authorization has been granted.

EPSDT/PCS
1. Can a PCS provider pick the child up from school? Is this service billable, and, if so, what procedure should be used?
No. PCS does not reimburse providers for transportation. PCS only allows for accompanying, not transporting, recipients to and from their physician and/or medical facility for necessary medical services. 

HOME HEALTH
1. Why are providers receiving an error code for invalid place of service when they indicate place of service code of 4 (patient�s home) on therapy services provided in the home?
When a Rehab provider bills for home health services, the services need to be billed on the 101 claim form. This claim form only allows two place of service codes: 1 (patients home) and 2 (other facility). All other rehab services should be billed on the 102 claim form, in which place of service 2 (outpatient hospital), 3 (office), and 7 (intermediate care facility) should be used.

2. Do providers need to indicate the Primary Care Physicians name as well as the referral number in block 10?
No. Providers should only indicate the referral number.

3. If a patient has two different conditions, but the referral only indicates one of the conditions, is it necessary to acquire a second referral for the other condition?
Yes; the referrals are date and illness specific. Hopefully, a PCP will indicate both conditions on one referral if he/she is referring the patient for services related to both conditions.

HOSPICE
1. What is the time frame for submitting the certification and election forms?
The election form and the certification form must be submitted within 10 calendar days following the initiation of hospice care. (This is a clarification of information given in the initial hospice provider manual and the training workshops).

2. How can a provider know if a recipient has elected hospice?
Providers can contact Provider Relations Inquiry Unit to check patient status. At present, MEVS and REVS does not indicate hospice election, but this information will be added to these eligibility systems in the near future.

3. Part A: If a patient becomes an inpatient while receiving hospice care, since the hospice provider may not bill for room and board and inpatient care for the same dates of service, should the hospice provider discharge and readmit the patient on their TAD? 
A. No. 
Part B: Is the hospice provider still responsible for paying the LTC facility for those inpatient days for straight Medicaid recipients? 
B. Yes, the Hospice Provider is responsible for the total care of the patient.

4. If the patient is Medicare and Medicaid and residing in the home, can the Medicare election form be used in lieu of the BHSF election form?
No, the BHSF election form must be used.

5. Since providers are allowed to e-mail the BHSF forms to the Hospice Manager, and original signatures cannot be placed on e-mail forms, what type of signature is acceptable when e-mailing?
The provider can scan the BSHF Hospice Form and then email to the Hospice Manager.

6. If the patient is on Medicaid, but pending certification for long term care benefits, must the hospice agency wait until the LTC segment has been approved and certified before billing for room and board?
Yes.

7. Is the physician�s Medicaid provider number a requirement when completing the BHSF forms? It may be very difficult to obtain this number.
The Physician�s Medicaid provider number is a required field to be completed on the BHSF Hospice Form.

8. Is it acceptable to use the card control number (CCN) on the BHSF forms?
The preferred information is either the social security number or the 13-digit recipient identification number.

HOSPITAL
1. How should a hospital bill for inpatient Part B only claims that are multiple pages?
Unisys can only accept a one page claim with a total of 23 lines. Providers will need to lump together appropriate revenue codes so that only one page is submitted.

2. When a claim is sent to the Correspondence Unit and then is forwarded to DHH, how long before the claim is processed?
It should take 30-45 days but can be longer, depending on the extent of the review by DHH.

3. How can a hospital bill for newborn charges when a baby is born to a non-Medicaid mom?
It will be necessary to obtain a precert number (unless it is a state hospital) and then the provider will have to wait until the newborn has a Medicaid number before filing the claim. 

4. Do the well-baby charges have to be billed on the mom�s claim?
Yes; the hospital program policy requires that these charges are billed on the mom�s claim.

KIDMED
1. Can a provider bill a new patient visit (99202) on the same day as an initial screening?
The only Evaluation and Management (E & M) procedure codes that can be billed on the same date as a screening are 99211 and 99212. The initial screening is performed the first time that patient is seen by the provider and this serves as the new patient visit. Thereafter, the patient is considered an established patient and, as such, should be billed as established patient E & M charges.

2. Can a consult code be billed on the same day as an E & M code?
No.

3. Can a provider perform a screening if the patient is not linked to them?
This depends on whether the recipients are CommunityCARE or if they are linked to a Kidmed provider. If they are not CommunityCARE recipients and not linked to a Kidmed provider, then any provider can perform and bill for the screening. If they are CommunityCARE recipients, then a referral will be needed if the person providing the screening is not sub-contracted with the PCP to provide the service. If they are not CommunityCARE but are linked to a Kidmed screening provider, the other provider may not bill for screenings.

4. If the hearing machine is broken, can the recipient be rescheduled for just the hearing screening?
Yes. The hearing screening should be billed only when the service has been performed.

PHARMACY
1. Why did you choose to put any antibiotics (Levaquin specifically mentioned) on the non-preferred list?
Therapeutic classes for review and consideration for prior authorization are recommended by the Medicaid Pharmaceutical and Therapeutics Committee and submitted to the Secretary of the Department for approval. 

2. If the patient is not a CommunityCARE recipient, is the attending information still needed?
Yes. The attending physician�s name needs to be in block 10.

3. If a patient is Medicare/Medicaid, must prior authorization be obtained if a drug is on the non-preferred list?
If the drug is a drug that is covered by Medicare, and the claim is submitted to UNISYS as a crossover claim, Medicaid prior authorization is not required. If the drug is not covered by Medicare, and the recipient is eligible under a Medicare/Medicaid category that would allow Medicaid to pay for the medication, a Medicaid prior authorization is required.

PROFESSIONAL
1. At present there are two different sterilization consent forms. Does it matter which one is used?
No. At this time, either form is acceptable.

2. If a physician performs a consult visit on the date of discharge, and the hospital did obtain precert, will the physician receive payment for services rendered?
Only if he submits a discharge summary from the hospital with his claim. The discharge information and any other information the doctor wishes to submit about the patient will be reviewed by one of the physician-consultants for medical necessity. If the consult is determined to be medically necessary, it will be paid. The date of discharge is not covered by the precertification period.

3. If a facility has a group provider number, does the individual provider number have to be indicated in block 24K of the HCFA1500 claim form? 
Yes. In billing for services, the individual provider number of the person who provided the service must be declared in Item 24K on the HCFA 1500 (Field 21, Data Element 29 if filing electronically), and the physician�s group number must be listed in Item 33 (Field 9, Data Element 14). 

4. If a provider was paid twice by Medicaid for the same service, do they need to submit a void?
Yes.

5. Can procedure code 99435 be used in lieu of procedure code 99238 for discharging a newborn?
If the situation being billed meets the description of code 99435 better than the description of code 99238, then 99435 should be billed.

6. Does Medicaid pay for school physicals?
Yes. School physicals are considered preventative services that are covered for recipients under the age of 21.

7. If a physician is on call and sees a Medicaid patient in the hospital, does the physician have to see that patient (and accept the Medicaid card) in the office?
The physician MUST accept Medicaid if (1) the physician is on-call; (2) the hospital requests services by that physician; and (3) the physician responds to this request because he is the on-call physician. If the hospital accepts Medicaid, it is obligated to provide services to Medicaid recipients and accept Medicaid payment for those services. This includes physician on-call services. Although the physician is required to accept Medicaid for the on-call hospital services, he is not obligated to accept Medicaid in his office or other settings unless he and the patient have a prior financial arrangement which specifies that the doctor will provide office services and accept the patient�s Medicaid card. If the recipient�s course of treatment is not completed before he leaves the hospital, the on-call physician should, at the time of discharge or before, refer the recipient to a doctor who accepts Medicaid for completion of the course of treatment. If the on-call doctor is not an enrolled Medicaid provider, he is not required to accept the Medicaid card for on-call services and can charge teh patient. for services to be provided and Medicaid to be accepted. 

REHAB
1. What procedure codes will Medicaid use when HIPAA is implemented?
Medicaid will use the National Standard Procedure Codes that is mandate by HIPAA.

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Louisiana Drug Utilization Review (LADUR) Education

Guidelines for the Treatment of High Cholesterol: A Review

W. Greg Leader, Pharm.D.
Head and Associate Professor
Department of Clinical and Administrative Sciences
School of Pharmacy
The University of Louisiana at Monroe

Issues...

� CHD is still a significant cause of morbidity and mortality in the United States.

� High cholesterol is a major contributor to CHD.

� The American Heart Association estimates that  CHD costs almost $112 billion annually...

Despite the advances made in the diagnosis, prevention and treatment of coronary heart disease (CHD), CHD is still a significant cause of morbidity and mortality in the United States. Currently, CHD is the leading cause of death in the United States.¹ High cholesterol is a major contributor to CHD, and in the United States, more than 65 million people have high cholesterol with over half being eligible for cholesterol lowering therapy.² In Louisiana, more than one-third of the adults age 35 or older report being told by a health care professional that their blood cholesterol is high.3 In addition, CHD has tremendous economic consequences. The American Heart Association estimates that CHD costs almost $112 billion annually with more than half of the costs coming as direct cost associated with disease treatment.⁴ 

Despite the well known association between high cholesterol and CHD, more than 50% of patients eligible for either lifestyle or pharmacologic therapy have not been prescribed treatment. In addition, when therapy is initiated, less than forty percent of treated patients achieve targeted goals for low-density lipoprotein (LDL-C). Statistics for patients with established CHD are more disturbing with less than 18% of this population reaching their LDL-C goal.

This article is a brief review of the changes in the guidelines for the detection and management of high cholesterol as well as an overview of the treatment of high cholesterol. For complete information on this topic, you may download the National Cholesterol Education Program�s Adult Treatment Panel III report at http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm.⁵

What Is New In the Guidelines?
In May 2001, the National Cholesterol Education Program�s (NCEP) Expert Panel updated its guidelines for cholesterol testing and management. This update was based on a large amount of emerging data on the risk factors and treatment of high cholesterol, and landmark trials demonstrating significant decreases in morbidity and mortality of patients with or without CHD when �statin� agents were used to aggressively lower LDL-C. Despite significant changes, ATP III maintains continuity of ATP-II and shared features are identified in Table 1. The primary difference in ATP-II and ATP-III is that the new guidelines place a heavy emphasis on primary prevention of CHD in patients with multiple risk factors. Specific changes in the guidelines are outlined below:

Focus on Multiple Risk Factors⁵
The ATP-III uses the assessment of 10-year absolute CHD risk using Framingham projections to identify patients with multiple risk factors for more intensive treatment. Patient risk is calculated using the Framingham Point Score (Table 2). The calculation takes into account age and gender as well as other contributing factors (Total cholesterol, HDL cholesterol, smoking status and systolic blood pressure) to predict the 10-year risk of a CHD event. Patients with a 10-year risk > 20% are considered to have a CHD risk equivalent and are treated as if they have CHD. Patients with a 10-year risk of 10-20% are categorized as a moderate risk, and patients with a 10-year risk < 10% are considered a low risk. 

In previous guidelines, diabetes mellitus was considered a risk factor for CHD; however, under the ATP-III, patients with diabetes mellitus without CHD are considered CHD equivalents and should be treated the same as a patient with CHD. Other groups that are considered CHD risk equivalents include those with peripheral artery disease, abdominal aortic aneurysm, thrombotic stroke, transient ischemic attacks, and as previously mentioned, patients with multiple risk factors that result in a 10-year CHD risk > 20%. The guidelines also emphasize the identification of patients with metabolic syndrome (Table 3) who are candidates for intensified lifestyle changes and, if needed, drug therapy.

Table 1. Shared Features of ATP-III and ATP-II⁵

� Continued identification of LDL-C lowering as the primary goal of therapy � Consideration of high LDL-C (>160mg/dL) as a potential target for LDL-lowering drug therapy, specifically as follows: o For patients with multiple risk factors whose LDL-C is high (>160mg/dL) after dietary therapy, consideration of pharmacotherapy is recommended. o For people with 0-1 risk factor whose LDL-C levels are 160-189 after dietary therapy, drug treatment is optional; if LDL-C levels are >190mg/dL after dietary therapy, drug treatment should be considered. � Emphasis on intensive LDL-C lowering therapy in persons with established CHD � Identification of three categories of risk for different LDL-C goals and different intensities of LDL-C lowering therapy o CHD and CHD risk equivalents (other forms of clinical atherosclerotic disease) o Multiple (2+) risk factors o 0-1 risk factor � Identification of population groups, besides middle aged men, for detection of high LDL-C (and other  lipid risk factors) and for clinical intervention o Young adults o Postmenopausal women o Older persons � Emphasis on weight loss and physical activity to enhance risk reduction in persons with elevated LDL-C

Modification of Lipid and Lipoprotein Classification⁵
Primary changes in lipoprotein classification includes the defining of optimal LDL-C as 100mg/dL, increasing the cutoff for low levels of high-density lipoprotein (HDL-C) to < 40mg/dL, and decreasing the triglyceride threshold to emphasized moderate elevations (Table 4). Although the primary target of lifestyle changes and pharmacotherapy is to reach targeted values of LDL-C, non-HDL-C is also identified as a secondary therapeutic target in patients with elevated triglycerides. Non-HDL-C can be calculated by subtracting HDL-C from total cholesterol, and should be within 30mg/dL of LDL-C.

In addition to these major changes, the guidelines recommend a complete fasting lipoprotein profile as the preferred initial test. The report also encourages the use of plant stanols/sterols (e.g. Benecol) and viscous (soluble) fiber as dietary options to enhance therapy as well as treatment beyond lowering of LDL-C for patients with triglycerides > 200mg/dL.

Detection and Treatment of High Cholesterol

Determine a Patient�s Risk Status⁵
Because the first step in prevention is to match the intervention with the risk of the negative outcome, determination of a patient�s risk status is necessary for therapy to be initiated. Risk determination includes an evaluation of LDL-C as well as accompanying risk factors for the development of CHD. A fasting lipoprotein panel (total cholesterol, LDL-C, HDL-C, and triglycerides) should be obtained every five years in patients aged 20 years or older. A fasting lipid panel is defined as being obtained after 9 to 12 hours of fasting. If the patient is not in a fasting state, only the total cholesterol and HDL-C should be evaluated. In this case, the patient will need to have a complete fasting lipid panel reevaluated if the HDL-C is < 40mg/dL or if the triglycerides are > 200mg/dL. ATP-III classifications of lipoprotein classifications are shown in Table 4.

Table 2. Assessment of 10-year CHD Risk (Framingham Point Scale) ^4,5

Age (yrs)			Systolic Blood Pressure								HDL-C Cholesterol
	Points				Points							Points
					Untreated			Treated
yrs	Male	Female	Mm Hg		Male	Female		Male	Female		mg/dL	Male	Female
20-34	-9	-7	<120		0	0		0	0		>60	-1	-1
35-39	-4	-3	120-129		0	1		1	3		50-59	0	0
40-44	0	0	130-139		1	2		2	4		40-49	1	1
45-49	3	3	140-159		1	3		3	5		<40	2	2
50-54	6	6	>160		2	4		4	6
55-59	8	8
60-64	10	10
65-69	11	12
70-74	12	14
75-79	13	16
Total Cholesterol
Age (yrs)	20-39		40-49			50-59			60-69			70-79
mg/dL	Male	Female	Male	Female		Male	Female		Male	Female		Male	Female
<160	0	0	0	0		0	0		0	0		0	0
160-199	4	4	3	3		2	2		1	1		0	1
200-239	7	8	5	6		3	4		1	2		0	1
240-279	9	11	6	8		4	5		2	3		1	2
>280	11	13	8	10		5	7		3	4		1	2
Smoking Status
Age (yrs)	20-39		40-49			50-59			60-69			70-79
	Male	Female	Male	Female		Male	Female		Male	Female		Male	Female
No	0	0	0	0		0	0		0	0		0	0
Yes	8	9	5	7		3	4		1	2		1	1
10-Year CHD Risk (%)
Men							Female
Points	Risk	Points	Risk				Points		Risk	Points		Risk
0	<1	15	20				<9		<1	23		22
0-4	1	16	25				9-12		1	24		27
5-6	2	>17	>30				13-14		2	>25		>30
7	3						15		3
8	4						16		4
9	5						17		5
10	6						18		6
11	8						19		8
12	10						20		11
13	12						21		14
14	16						22		17

Other determinants of risk include the presence or absence of CHD or CHD equivalents, including absolute 10-year risk for CHD, as well as the risk factors identified in Table 5. Absolute 10-year risk for CHD can be calculated using the Framingham Point Score. (Table 1). A program for calculating the Framingham Point Score using the Palm Operating System based Personal Digital Assistant or an Excel� spreadsheet can be obtained at http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm. Based on these risk factors, patients are then stratified into three categories. The category with the highest risk include those patients with CHD, other clinical forms of atherosclerotic disease (peripheral vascular disease, abdominal aortic aneurysm, symptomatic carotid artery disease [thrombotic stroke and transient ischemic attacks]), diabetes mellitus, and patients with a > 20% 10-year absolute risk of CHD. The target LDL-C goal in this population is < 100mg/dL. The intermediate risk group is those patients with two or more risk factors with an absolute 10-year CHD risk < than 20%. Goal LDL-C in this population is <130mg/dL. The final category is patients with < 2 risk factors. These patients generally have a goal LDL<160mg/dL and usually have an absolute 10-year CHD risk < 10%.

The guidelines recognize that the risk of CHD can be influenced by a number of factors not included in the list of major risk factors. Some of these risks termed life-habit risk factors (e.g. obesity, physical inactivity, atherogenic diet) are not used to set lower target LDL-C levels; however, they are considered direct targets for clinical interventions. In some patients, major, life-habit and emerging risk factors occur in a combination that constitutes a condition identified as metabolic syndrome (Table 3). In this situation, aggressive treatment of the metabolic syndrome is a secondary therapeutic target.

Table 3:  Clinical Identification of Metabolic Syndrome5
Risk Factor	Defining Level
Abdominal Obesity Men Women	Waist Circumference >102 cm (>40 inches) >88cm (>35 inches)
Triglycerides	>150mg/dL
HDL-C Men Women	<40mg/dL <50mg/dL
Blood Pressure	>130/>85mm Hg
Fasting Glucose	> 110 mg/dL

 

 

 

 

 

 

The diagnosis of metabolic syndrome is made in patients with three or more of the risk factors listed.

LDL Lowering Therapy in the Three Risk Categories⁵
Goals and thresholds for the initiation of lifestyle or pharmacologic therapy are given in Table 5. LDL-C continues to be the primary target of cholesterol-lowering therapy. The two primary modalities for lowering LDL-C are therapeutic lifestyle changes and drug therapy. 

Table 4: ATP-III Classification of LDL-C, Total Cholesterol, HDL-C, and Triglycerides5
LDL Cholesterol <100 mg/dL 100-129 mg/dL 130-159 mg/dL 160-189 mg/dL >190 mg/dL	Optimal Near optimal/above optimal Borderline high High Very high
Total Cholesterol <200 mg/dL 200-239 mg/dL >240 mg/dL	Desirable Borderline high High
HDL Cholesterol <40 mg/dL >60 mg/dL	Low High
Triglycerides <150 mg/dL 150-199 mg/dL 200-499 mg/dL >500 mg/dL	Normal Borderline High High Very High

For patients with CHD or CHD risk equivalents, intensive lifestyle therapy should be initiated for patients with an LDL-C > 130mg/dL, and because most patients cannot reach their goal LDL-C of 100mg/dL alone, drug therapy may be initiated simultaneously. If LDL-C levels are between 100mg/dL and 129mg/dL lifestyle therapy should be intensified with an emphasis placed on weight reduction and increased physical activity in patients with metabolic syndrome. The use of LDL-C lowering agents may be delayed; however, therapy should be considered for the treatment of elevated triglycerides or low HDL-C.

For patients with 2 or more risk factors and a 10-year absolute CHD risk of 10-20%, intensive lifestyle therapy should be initiated and maintained for a minimum of three months in patients with an LDL-C > 130mg/dL. If after three months of lifestyle changes the patient has not reached their goal LDL-C of < 130mg/dL, pharmacotherapy with LDL-C lowering agents should be considered. For patients with 2 or more risk factors and a 10-year risk < 10%, therapeutic lifestyle changes should be initiated for an LDL-C > 130mg/dL. If lifestyle changes alone maintain LDL-C < 160mg/dL, no further intervention is needed. LDL-lowering drugs are usually not necessary in this subpopulation. LDL-C goal for therapy in this group of patients is < 130mg/dL.

Patients with 1 or less risk factor and a 10-year absolute CHD risk < 10% should initiate therapeutic lifestyle changes for LDL-C > 160mg/dL. Drug therapy is usually reserved for patients with an LDL-C > 190mg/dL; however, if the patients LDL-C falls between 160 and 189 after three months of lifestyle change therapy, LDL-C lowering pharmacothearapy should be considered if the patient has a single severe risk factor (heavy cigarette smoking, poorly controlled blood pressure, strong family history of premature CHD, or low HDL-C), multiple life habit or emerging risk factors, or a 10-year absolute CHD risk approaching 10%.

Therapeutic Interventions⁵
Therapeutic Lifestyle Changes
Lifestyle changes for the primary prevention of CHD include: (1) reduced intake of saturated fat and cholesterol; (2) therapeutic options for enhancing LDL-C lowering such as plant stanols/sterols (e.g. Benecol� 2g/day) and increased viscous (soluble) fiber (10-25 grams/day); (3) increased physical activity, and (4) weight control.

Table 5: LDL Cholesterol Goals and Cut points for Therapeutic Lifestyle Changes (TLC) and Drug Therapy in Different Risk Categories5
Risk Category	LDL Goal	LDL level at which to institute TLC	LDL level at which to consider drug therapy
CHD or CHD Risk Equivalent (10 year risk > 20%)	< 100 mg/dL	> 100 mg/dL	> 130 mg/dL (100-129 mg/dL; drug optional)
2+ Risk Factors (10 Year Risk <20%)	< 130 mg/dL	>130 mg/dL	10-year risk > 20% > 130 mg/dL 10-year risk < 10% >160 mg/dL
0-1 Risk Factors	< 160mg/dL	>160mg/dL	>190 mg/dL (160-189 mg/dL; LDL lowering drug optional)

The overall composition of the therapeutic lifestyle change diet is shown in Table 6. Saturated fat intake should be limited to < 7% of total calories and cholesterol should be limited to < 200mg/day. In addition, total fat content of the diet can be as much as 25-35% of the diet provided that the saturated and trans-fatty acids are kept low. If after 6 weeks of the diet, LDL-C goals have not been achieved; therapeutic options such as the use of plant stanols/sterols and viscous fiber can be added to the diet. After maximal reduction of LDL-C with dietary therapy has been accomplished, the focus turns to the treatment of metabolic syndrome through weight reduction and physical activity. The reduction in LDL-C with appropriate diet, weight loss and these therapeutic options may be as great as 30%. 

Pharmacotherapy
Many people will require the initiation of drug therapy to reach LDL-C goals. It is important to remember that therapeutic lifestyle changes should be maintained and reinforced. If goal LDL-C levels have not been reached after an appropriate trial of therapeutic lifestyle changes (usually 3 months), LDL-C lowering therapy should be initiated. Four classes of lipid modifying drugs are available. Of these, the statins, bile acid sequestrants, and nicotinic acid have significant LDL-lowering capacities and the fibrates primarily exert their effect on triglycerides. Although the statins are usually considered first-line therapy because they have the greatest impact on LDL-C levels, alternatives include a bile acid sequestrant or nicotinic acid.

HMG CoA reductase inhibitors commonly referred to as the �statins� have repeatedly demonstrated benefit in primary and secondary prevention of CHD. The statins work by inhibiting HMG-CoA reductase resulting in a decrease in the synthesis of cholesterol and leading to physiologic changes that result in the increased clearance of LDL-C. Statins also decrease the production of very low-density lipoproteins (VLDL), a precursor to LDL-C. The magnitude of decrease in LDL-C is between 18 and 55%, and these agents also positively impact HDL-C (increase by 5-15%) and triglyceride (decrease by 7-30%) levels. There are relatively few contraindications for the use of these agents, but they should be avoided in patients with acute and chronic liver disease. Major adverse effects of these agents include increased liver transaminases as well as myopathy. Patients that develop elevations of transaminases > 3 times the upper limit of normal that is confirmed on a second test should have therapy discontinued. After transaminases return to normal, patients may be rechallenged with the same or a new statin. Although not absolutely contraindicated, caution and close patient follow-up is advised if these agents are given concomitantly with drugs that inhibit cytochrome P450 3A4 isozyme (e.g., azole antifungals, cyclosporine, and macrolide antibiotics) as these agents increase the risk of statin associated rhabdomyolysis. The risk of rhabdomyolysis is also increased with concomitant use of nicotinic acid and the fibrates. Once daily administration of these agents, usually in the evening or at bedtime, is usually sufficient. Lovastatin should be given with the evening meal because its absorption is decreased when taken on an empty stomach. Pravastatin should be given on an empty stomach because food decreases its absorption. The other statins can be given with or without food. Giving the statin dose in the morning decreases efficacy by approximately 3-6%.

Because adverse effects of the different agents appear to be similar, the selection of a statin should be based on the desired reduction in LDL-C and the cost of the agent. The percentage reduction desired can be calculated by the following method: (Current LDL-C � Desired LDL-C)/ Current LDL-C. In general, the same reduction in LDL-C can be obtained with each of the statins by use of an equipotent dose; however, some differences do exist with fluvastatin (Lescol) being the least potent and atorvastatin (Lipitor) being the most potent. 

Bile acid sequestrants primarily lower LDL-C cholesterol with marginal or no effects on HDL-C and triglycerides. When used in combination, sequestrants add to the LDL-C lowering effects of statins. Because the sequestrants are not absorbed, they have no systemic activity; however, their use may be limited due to a lack of patient convenience as well as their propensity to cause gastrointestinal distress including abdominal pain, bloating fullness, nausea, flatulence and constipation. Gastrointestinal adverse effects appear to occur less often with low doses or with colesevelum. Cholestyramine and colestipol are available as powders that have to be mixed with a fluid to be administered. Colesevelam is available in a tablet form. These drugs are contraindicated as monotherapy in patients with triglycerides >400mg/dL and familial dysbetalipoproteinemia, and should be used cautiously in patients with triglyceride levels >200mg/dL because they may increase triglycerides in some patients. In addition to binding bile acids in the intestine, bile acid sequestrants may bind to and decrease the absorption of many other drugs when administered concomitantly. Other drugs should be taken one hour before or four hours after the administration of a bile acid sequestrant. Colsevelum does not appear to decrease the absorption of drugs given concomitantly.

Nicotinic acid or niacin alters lipid concentrations by inhibiting lipoprotein synthesis and decreasing the production of VLDL by the liver. These changes result in a 5-25% decrease in LDL-C, a 15-35% increase in HDL-C and a 20-50% decrease in triglycerides. Thus, niacin favorably affects all aspects of the lipid profile. Currently, niacin is available as crystalline nicotinic acid (immediate release), sustained-release (or time-time released) nicotinic acid and extended-release nicotinic acid (Niaspan�). Niacin is contraindicated in chronic liver disease and severe gout and should also be used with caution in patients with hyperuricemia. Niacin is not contraindicated in diabetes; however, because high doses (> 3 grams/day) may worsen hyperglycemia in patients with type 2 diabetes, care should be taken to monitor blood sugar levels when high doses are used. Although several formulations of niacin are available as over the counter medications, patients should be cautioned against self-treating for hypercholesterolemia. The primary drawback to niacin therapy is the potential adverse effects. Flushing of the skin often occurs, and it is often intolerable for many patients. Flushing is most commonly associated with the use of immediate release niacin (the crystalline form), and tolerance tends to develop after prolonged use. The incidence of flushing may be decreased by taking the drug during or after meals or by taking aspirin prior to the niacin. Flushing is less often associated with the sustained-release products; however, because of differences in metabolism, the sustained-release products have a higher incidence of hepatotoxicity. The incidence of hepatotoxicity does appear to increase with increasing dose of niacin. Care should be taken in switching a patient from immediate-release niacin to sustained release niacin. The total niacin dose should be decreased to avoid the risk of hepatotoxicity. A new extended release product, Niaspan�, appears to cause less flushing than immediate-release niacin and less hepatotoxicity than sustained-release niacin. Other adverse effects of niacin include nausea, dyspepsia, flatulence, vomiting, and activation of peptic ulcer, as well as the less frequent adverse effects including conjunctivitis, nasal stuffiness, acanthosis nigricans, ichthyosis, and retinal edema. Although niacin is usually administered two to three times a day, the Niaspan� formulation is administered once daily at bedtime. Niaspan� is available by prescription only.

Table 6: Nutrient Composition of the Therapeutic Lifestyle Change Diet5
Nutrient	Recommended Intake
Saturated fata	< 7% of total calories
Polyunsaturated fat	Up to 10% of total calories
Monounsaturated fat	Up to 20% of total calories
Total fat	25-35% of total calories
Carbohydrateb	50-60% of total calories
Fiber	20-30 grams/day
Protein	Approximately 15% of total calories
Cholesterol	< 200mg/day
Total Calories (energy)	Balance energy intake and expenditure to maintain desirable weight and prevent weight gain.
aTrans fatty acids are another LDL-raising fat that should be kept at low intake. bCarbohydrates should be derived primarily from foods rich in complex carbohydrates including grains, especially whole grains, fruits and vegetables.

Treatment of Metabolic Syndrome and High Triglycerides⁵
The guidelines identify metabolic syndrome as a potentially significant contributor to CHD. Metabolic syndrome represents a group of lipid and non-lipid factors that are of metabolic origin (Table 3) that enhance the risk of CHD at any LDL-C level. The management of metabolic syndrome has two major objectives: (1) reduce the underlying causes (obesity and physical inactivity) and (2) treat associated lipid and non-lipid risk factors. The primary targets for reducing the underlying causes are weight reduction through diet and increased physical activity. These activities will enhance LDL-C lowering, increase HDL-C and positively affect non-lipid risk factors such as hypertension and insulin resistance. Treatment specific to lipid and non-lipid risk factors include the treatment of hypertension, the use of aspirin in patients with CHD to reduce the prothrombotic state and treatment of elevated triglycerides and low HDL-C.

Elevated triglycerides increase CHD risk, and elevated triglycerides are most often seen clinically in patients with metabolic syndrome. This finding suggests that some triglyceride-rich lipoproteins (VLDL or remnant lipoproteins) are atherogenic, and the level of these lipoproteins can be predicted by non-HDL-C. Non-HDL-C can be measured by subtracting HDL-C from total cholesterol, and Non-HDL-C is a secondary therapeutic target for therapy for a patient with triglycerides >200mg/dL. The targeted goal for non-HDL-C is 30mg/dL higher than the LDL-C goal. This is based on the understanding that normal VLDL cholesterol is <30mg/dL. 

Treatment for elevated triglycerides depends on the cause of the elevation and its magnitude. In order to prevent pancreatitis, patients with triglycerides levels >500mg/dL should be treated aggressively using a very low fat diet (<15%), weight reduction, increased physical activity and triglyceride lowering drugs (fibrates or niacin). For triglycerides between 200-499mg/dL, non-HDL-C becomes a secondary target of drug therapy. In addition to weight control and increased physical activity, non-HDL-C goals can be achieved by intensifying LDL-C lowering therapy or with an addition of a fibrate or niacin. Keep in mind that the addition of a fibrate or niacin to statin therapy may increase the risk of adverse effects. If triglycerides are borderline high (150-199mg/dL), patients should be placed on weight reduction and increased physical activity.

Conclusion
CHD is a common disorder that contributes significantly to morbidity and mortality in this country. The NCEP ATP-III guidelines provide specific definitions of high cholesterol and its treatment goals based on the patient�s risk of CHD. For some groups, these treatment goals are more aggressive than those in the previous guidelines. Clinicians should use these guidelines as a basis for clinical decision making in the treatment of high cholesterol.

References

1. Anderson KM, Castelli WP, Levy D. Cholesterol and mortality: 30 years of follow-up from the Framingham study. JAMA. 1987; 257:16:2176-80.

2. Pearlman BL. The New Cholesterol Guidelines. Postgrad Med. 2002; 112(2):13-26.

3. Office of Public Health. State Center for health Statistics. 2002 Louisiana health Report Card. Available at: http://oph.dhh.state.la.us/recordsstatistics/statistics.

4. Talbert, RL. New Therapeutic Options in the National Cholesterol Education Program Adult Treatment Panel III. Am J Manag Care. 2002; 8:S301-S307.

5. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. National Cholesterol Education Program: Adult Treatment Panel III Report. Bethesda, Md: National Heart Lung and Blood Institute; 2001. Publication 01-3095.