PROVIDER
UPDATE
VOLUME 8,
NUMBER 1
FEBRUARY 1991
All Providers
Help Us Help You
It is our desire at Unisys to respond to all provider
telephone inquires about the Louisiana Medicaid Program in an accurate and
timely manner. We realize that our
telephone representatives must respond to requests for information concerning
claim settlements and the eligibility status of particular Medicaid recipients
as quickly as possible. Therefore,
we have installed additional lines in our Provider Relations telephone inquiry
section to enable us to respond to more calls in a more efficient manner.
In addition, we are furnishing a schedule of our peak
workload period so that providers will be able to reschedule their telephone
inquiries accordingly. The
following is a record of the day-to-day percentage of incoming calls for a
typical Monday through Friday workweek:
Workday
Percentage of Calls
Monday
25%
Tuesday 23%
Wednesday 23%
Thursday
16%
Friday
13%
We would also like to request providers to call either
before or after our lunch period (11:30
A.M. to 1:30 P.M.) because we are working with a reduced staff during the
two-hour lunch period. In fact, to
ensure that you receive an expeditious response to your inquiries, the best time
to schedule your telephone calls is between 8:00 A.M. and 9:00 A.M. and 4:00
P.M. and 5:00 P.M. Monday through Friday.
Finally, we would like to remind providers to telephone the
Provider Relations switchboard, not the main Unisys switchboard.
Providers outside of Baton Rouge should telephone 1-800-473-2783.
Baton Rouge providers should
telephone 924-5040.
Documentation of Medical Services
The Surveillance and Utilization Review Subsystem (SURS)
would like to remind providers that they are required to keep complete and
accurate medical records and/or documentation for all services that are billed
to the Louisiana Medicaid Program. Such
records of documentation of the rendition of particular services may be
requested for review by the Medicaid Program.
Therefore, it is very important to providers to keep all files updated
for a period of at least three years. Medical
records that may be requested include the following:
1) Patient
office charts,
2) Billing
statements and/or ledger cards,
3) Laboratory
test results,
4) Hospital
charts (inpatient, outpatient, and emergency),
5) Doctors'
and nurses' notes,
6) Operative
reports,
7) Information
regarding payments for services rendered, and
8) Any
other pertinent medical or billing information.
If requested, these records must be furnished to the Bureau
of Health Services Financing, its authorized representative(s), representatives
of the United States Department of Health and Human Services, or the State
Attorney General's Medicaid Fraud Control Unit.
Proper documentation, which may be requested for review,
includes all objective and subjective findings, any laboratory forms or charts
that list the specific or total results of the diagnostic procedures being
billed, and a statement of any treatment that was rendered to the recipient.
However, providers should note that such documentation,
including office and hospital progress and operative notes, are considered valid
only if they are signed or initialed by the physician who provided the services.
Medical records and/or documentation may be requested for
many reasons. Often, the Louisiana
Medicaid Program will request additional information about claims to determine
whether or not reimbursement for services rendered is due to the provider.
In some circumstances, if a provider does not submit
additional information for review, incorrect payments may be issued, and the
following actions may be taken:
1)
A provider's billing practice may be investigated;
2) The
Louisiana Medicaid Program may decide to recoup money that has already been paid
to a provider; and/or
3) The
provider may face disciplinary action.
Recipient Fraud
It has come to our attention that individuals who are not
eligible for Medicaid services and who do not possess a Medicaid I.D. card of
their own are using the Medicaid I.D. cards of other individuals who are
Medicaid recipients in order to obtain medical services from the Louisiana
Medicaid Program. Providers,
therefore, should be made aware of the fact that any unauthorized use of a
Medicaid I.D. card constitutes recipient fraud.
In fact, for such cases of recipient fraud, the Louisiana Medicaid
Program could take action against the unauthorized user of the card, the owner
of the card, and/or any provider who knowingly render services to such
ineligible individuals.
Consequently, we would like to caution all providers to use
whatever means are available to establish the correct identify of the recipient
prior to rendering Medicaid services. For
instance, providers could request to see the recipient's driver's license,
Social Security card, or check cashing card. If a recipient is attempting to falsify his/her identity, the
provider should contact the proper local legal authorities, e.g., the local
police or sheriff, or the Recipient Fraud Hotline Number, 1-800-256-3150, to
report the recipient for attempted theft by Medicaid fraud.
Segmenting Diagnostic Procedures
The Louisiana Medicaid Program has always expressed the
intent to pay for the most inclusive procedure code available which describes
the procedure(s) performed and/or the result(s) obtained.
Thus, the individual component codes should be used only when individual
components are being performed. In
addition, the Physicians' Current Procedural Terminology, Fourth Edition (CPT-4)
states that the terminology and coding selected should be that which most
accurately identifies the service performed (page XVI).
Consequently, providers who bill segmented diagnostic
procedure codes will be subject to review and subsequent disciplinary action,
the minimum of which is recoupment of payments. Other sanctions will be administered as is deemed necessary
and appropriate by the Department of Health and Hospitals.
Provider I.D. Numbers
Claim forms arrive daily without correct seven-digit
Provider I.D. Numbers entered in the applicable blocks.
In addition, Providers are also submitting claims with Provider I.D.
Numbers that are fewer than seven digits. However,
claims that do not have the Provider I.D. Number entered or those that do not
have the Provider I.D. Number entered correctly cannot
be processed. Consequently, we urge
providers to check their claim forms before submitting them for processing
because all incorrect or incomplete claim forms will be rejected before they can
be processed, and the provider will not be reimbursed.
All HCFA 1500 Billers
Block 24-H
All providers, especially those who are physicians in a
group practice, who use the HCFA 1500 form to bill for Medicaid services should
note that block 24-H on the form should be used to indicate the attending
physician's Provider I.D. Number. Many
providers are entering their attending physician's Provider I.D. Number in the
block for the Prior Authorization Number; and, therefore, many claims are being
delayed in processing and returned to the provider so corrections can be made.
Transportation Providers
Emergency Ambulance Transportation Rates
The Medicaid Program has increased its reimbursement rates
for emergency ambulance transportation effective February 1,1991.
Our new rates for emergency ambulance transportation are now the same as
the rates paid by Medicare. In
addition, providers should no longer bill with procedure code A0225 [Base rate
neonatal (ALS or BLS)]. Instead,
providers should use procedure codes A0010 [Base rate (BLS) neonatal transport]
and A0220 [Base rate (ALS) neonatal transport].
Also, Z5100 should be used to bill ALS transfers.
The procedure codes used to bill for emergency ambulance transport, as
well as a brief description and the new reimbursement rates for each of the
codes, are listed as follows:
A0010
Base rate, basic life support
$148.69
A0020
Vehicle miles, basic life support
$3.43
A0220
Base rate, advanced life support
$275.36
A0221
Vehicle miles, advanced life support
$3.43
Z5100
Transfer rate, basic life support
$148.69
Z5101
Transfer rate, advanced life support
$275.36
A0223
Base rate, advanced life support, where
nonreusable ALS supplies are billed separately (this code
used only on Medicare crossovers) The payment amount equals the
Medicare
and Medicaid payments combined.
$143.18
Nonprofit Non Emergency Transportation Rate Increases
The transportation reimbursement rate for the Nonprofit Non
Emergency Transportation providers has been increased from $.21 per mile to $.24
per mile effective August 1, 1990. Providers
may begin billing the new rate immediately.
Also, because this increase is retroactive, providers may obtain the
additional money to which they are entitled by submitting claim adjustments for
any claims already submitted to Unisys with the date of service on or later than
August 1, 1990.
Dental Providers
Prior Authorization
The CPT-4 Procedure Code D7971, Pericoronal Excision, does
require prior authorization. Also,
the Dental Services Manual Transmittal #90-1 dated August 9, 1990, did
not list this code with an asterisk as it should have.
Therefore, we ask that providers make the appropriate corrections on page
9-18 of their manuals
DME Providers
Criteria Required for Prior Authorization
When requesting approval for the use of a nebulizer or an
oxygen concentrator, providers must confirm that the recipient meets certain
criteria that make the use of the nebulizer or oxygen concentrator medically
necessary. Listed below are two
checklists of questions that outline the criteria. The answers to these questions should be attached to the PA01
form whenever a provider is requesting approval by mail for a nebulizer or an
oxygen concentrator.
Nebulizer Checklist
1)
Diagnosis?
2)
Age of recipient?
3)
Medicaid I.D. Number?
4)
What medications is the client on?
5)
Number of emergency visits and dates?
6)
Hospitalizations in the last 6 months?
7)
Is the patient's ability to breathe impaired?
8)
Does the patient require aerosol medication regularly or frequently?
List medication.
9)
Does the patient require regular or frequent medication with
bronchodilator and/or antihistamine-decongestants?
10) Does
the patient require hyposensitization extract versus aero-allergens?
11) Any
supportive pulmonary function studies (adults only)?
Oxygen Concentrator
1)
Prior and recent arterial blood gases at room air?
At rest?
2)
Medical diagnosis and age of client?
3)
Length of time required?
4)
Po2
Pco2-pH
O2sat.
Anesthesiologist & CNRAs
Anesthesia Policy Clarification
The Louisiana Medicaid Program has received several
inquiries from providers about its new anesthesia policy.
This article, therefore, should serve as the Bureau of Health Services
Financing's official clarification on the questions raised.
In regards to the use of modifiers, anesthesiologists and
CRNAs must use the appropriate modifier when billing CPT-4 procedure codes
62276, 62278, and 62279 for maternity-related anesthesia.
The term anesthesia,
in reference to Cesarean delivery, is defined as and includes the following
types: Epidural, epidural and
subsequent general anesthesia, or general anesthesia. For Cesarean delivery, the reimbursement fee is the same no
matter what type of anesthesia, or combination of types, is used.
If the anesthesiologist or CRNA inserts the epidural
catheter and subsequently reinjects it, he should bill CPT-4 procedure code
59515 plus the applicable modifier (AA, AI, AB, AC, AD, or AH).
If general anesthesia is administered from the beginning or subsequently
administered after an epidural has been inserted, the provider should bill in
the same way, that is, CPT-4 procedure code 59515 in addition to the appropriate
modifier. Reimbursement will be
$330.00 for AAs and AIs and $198.00 for AHs.
Anesthesiologist who personally medical direct (ABs, ACs, and ADs) will
receive $132.00.
Physicians
Pulmonary Care Policy Clarification
Effective with date of service March 1, 1991, procedure
codes 94656 (Ventilation assist and management; initial) and 94657 (Ventilation
assist and management; subsequent) should not be billed on the same date of
service as procedure codes 99160 (Critical care, initial; each hour) and 99162
(Critical care, initial; additional 30 minutes). However, codes 94656 and 94657 may be billed on the same day
as codes 99171 (Critical care; subsequent), 99172 (Critical care; limited),
99173 (Critical care, intermediate), and 99174 (Critical care; extended).
Physicians & Pharmacists
Revised LMAC Limits
The Louisiana Department of Health and Hospitals has
revised the Louisiana Maximum Allowable Costs (LMAC) limits for the drugs listed
below:
Meclofenamate Sodium caps 100mg
PAC: 7KO
LMAC: 0.44750
Effective Date: 11-20-90
Meclofenamate Sodium caps 50mg
PAC: 7KO
LMAC: 0.32510
Effective Date: 11-20-90
Megestrol acetate tabs 20mg
PAC: 7KO
LMAC: 0.45650
Effective Date: 12-1-90
Megestrol acetate tabs 40mg
PAC: 7KO
LMAC: 0.77970
Effective Date: 12-1-90
Oxtriphylline tablet 200mg
PAC: 7KO
LMAC: 0.11190
Effective Date: 12-18-90
Rifampin caps 300mg
PAC: 7KO
LMAC: 1.56440
Effective Date: 12-1-90
In addition, the Federal Upper Limits for Meclofenamate
Sodium EQ 50mg and 100mg capsules have been suspended effective November 19,
1990. Also, Megestrol 20mg and 40mg
tablets were removed from the Federal Upper Limit listing in the July 1990
Transmittal #18.
Pharmacy Audits
Peat Marwick Main, our contractual agent for conducting
Pharmacy audits, has completed the second year of audits.
In July 1990, they began performing their third year of audits for fiscal
year 1990-91. Some of the most
frequently reported discrepancies include the following:
1)
"Prescription Over Ten Days
Old When Filled"
The Pharmacy Provider Manual states
that prescriptions must be filled within ten days of the date they are issued.
This regulation is designed to prevent expenditures for prescriptions
filled too late to do the patient any good and to prevent the patient from
receiving drugs the physician would not want him to have at the late date.
To avoid this discrepancy, pharmacists may contact the prescribing
practitioner and obtain permission to dispense the outdated prescription.
We also suggest that you change the date of the prescription to the date
the permission is obtained, thereby,
treating the date of the permission as the date of the original prescription.
Pharmacists must also make some notation on the prescription that the
physician authorized the date change.
2)
�No Refills Authorized and
Unauthorized Refill"
Program policy regarding refills of prescriptions states that refills shall be
provided if authorized by the prescribing practitioner up to the Medicaid
Program's limit of no more than five times or no more than six months from the
date the prescription was issued. However,
in complying with the Board of Pharmacy regulations and the Durham-Humphrey Act
which states that a prescription or refill authorization may be transmitted by
telephone, the pharmacist must reduce the prescription and/authorization to
writing promptly and file it accordingly. It
is necessary that refills be documented properly in order for the prescription
not to be discrepant in these areas. We
would advise that all pharmacy providers review the Board of Pharmacy
regulations regarding refill instructions.
3)
"Early Refills"
This discrepancy means that, within the timeframe cited in the audit, the
amount of the medication dispensed (the day's supply) lasted the recipient a
certain number of days which exceeded the directions on the prescription.
It is the Medicaid Program's position that the pharmacist has the
responsibility of monitoring the recipient's medications to ensure that they are
taken correctly. We do realize,
however, that there will be circumstances when prescriptions need to be refilled
prematurely, and we suggest that the pharmacist note on the prescription any
reason for these early refills. The
note would help the pharmacist to continue to provide the quality medical care
desired by the Medicaid Program and would still allow the prescription to be
within program regulations.
4)
"Unauthorized MAC
Overrides"
This discrepancy is reported when a pharmacist indicates a MAC override on the
claim, but when reviewing the actual prescription, the auditor finds that there
is no certification which indicates that the physician required a specific brand
of medication be dispensed.
Both state and federal regulations state that the MAC limits for drugs do not
apply if, "a physician certifies, in his own handwriting, in his medical
judgment, that a specific brand is medically necessary for a particular
recipient." The wording of the
certification should testify to the medical necessity of the brand name drug by
stating either "brand medically necessary" or "brand
necessary." The phrases
"dispense as written" or "do not substitute" are not
acceptable for overriding MAC limitations.
Again, the certification must be in the physician's handwriting.
Also, Act 450 of the 1989 Louisiana Legislature states that a
practitioner must write "Brand Necessary" in his own handwriting on
the face of the prescription to prevent a valid interchange on a Medicaid or
Medicare prescription.
Recent audit findings regarding MAC override claims for some providers who tape
bill revealed that, in some instances, a large percentage of the provider's
claims were MAC overrides but that the audit findings did not reveal the
"brand necessary" wording on the prescription.
Thus, to ensure the accuracy of legitimate MAC overrides, we are
requesting pharmacists to review their internal procedures for allowing a MAC
override through their tape billing system.
We are also advising pharmacists to verify that their internal procedures
for allowing MAC overrides are justified so chargebacks on audits would not be
necessary.
5)
"Usual and Customary
Charges"
Federal regulations governing the Medicaid Program require that participating
providers agree to charge no more for services to eligible recipients than they
charge for similar services to non-recipients (general public).
In implementing this regulation, the Medicaid Program states that
providers in the Pharmacy Program may not charge a higher dispensing fee, on the
average, for recipients' prescriptions than is charged for non-recipients'
prescriptions (third party and insurance prescriptions are components of the
non-recipient group).
In performing the pricing portion of the audit, there are certain criteria
utilized to estimate whether a pharmacy is overcharging the Medicaid Program.
Some of these criteria include the following:
making sure the prescription is not for catheters, catheterization trays,
insulin, or diabetic supplies. There are audited separately.
Thus, we would like to remind pharmacists that if generic prescriptions are to
be included in the general public sample of the pricing audit then the
manufacturer or labeler of the drug must be identified on the hard copy
prescription or the computerized prescription file. Also, pharmacists should indicate their USUAL AND CUSTOMARY
CHARGES on their claim forms when billing for prescription services even
if this charge exceeds our maximum payment.
6)
"National Drug Code (NDC)
Shown On Claim Differs From Either The Drug Shown On The Prescription And/Or
From The Drug Dispensed"
Medicaid Program regulations require that the manufacturer number, product
number, and package number for the claim form be taken from the actual package
from which the drug was dispensed. Thus,
the Medicaid Program aggressively audits for compliance with this program
regulation, and audits have shown that this discrepancy is the most common
Pharmacy Program abuse problem.
Unfortunately, because the pattern of abuse indicates the intent to file false
claims, many pharmacy providers have been subject to prosecution for Medicaid
fraud. Consequently, the majority
of the pharmacy provider Medicaid fraud convictions result from pharmacies
dispensing one drug and billing for another.
Dispensing Cost Survey
The Bureau of Health Services Financing has a State Plan
Agreement with the federal government which requires the periodic surveying of
pharmacy costs to determine the appropriate dispensing cost.
The Bureau of Health Services Financing has contracted with the firm of
Postlethwaite and Netterville, Certified Public Accountants, to perform the 1991
Dispensing Cost Survey.
All pharmacists who
are enrolled in the Louisiana Medicaid Program are required to participate in
the survey process.
The survey is designed to measure all costs associated with
filling a prescription and to determine usual and customary charges.
In addition, this information will be used in supporting the Bureau of
Health Services Financing's waiver of cost avoidance requirements and will allow
further analysis of the impact of discounts on drug purchases in regard to the
prescription reimbursement methodology.
For the Medicaid Program to be able to determine the
dispensing cost and provider enrollment in the Medicaid Program and to be able
to make the necessary appropriate request for the next fiscal year, we request
that providers respond promptly and completely to the survey.
Long Term Care Providers
Nursing Facility Discharge Procedures
The procedures for discharging a resident from a nursing
facility, as outlined in the Standards for Payment, include providing sufficient
preparation and orientation to the resident to ensure his/he safe and orderly
transfer or discharge from the facility. The procedures also include making medical arrangements to
alleviate any adverse effects of the discharge.
In addition, the Bureau of Health Services Financing
recently received complaints from the New Orleans Legal Assistance Corporation
that residents being discharged from nursing facilities are not being given
their current Medicaid eligibility cards. Thus,
recipients' access to medical care is jeopardized.
Providers, therefore, should ensure that residents being discharged from
nursing facilities leave with their current Medicaid eligibility cards and that
any eligibility cards received thereafter are forwarded to the Medicaid
recipients.
CPT-4 Procedure Codes
New CPT-4 Cardiovascular Procedure Codes and Prices
Provided on the following page is a listing of the 1990
CPT-4 cardiovascular procedure codes and prices that the Medicaid Program placed
on the procedure/formulary file effective with date of service December 15,
1990.
|
1990
CPT-4 PROCEDURE CODES
|
|
CODE
|
DESCRIPTION
|
MAX
FEE ($s)
|
|
93321
|
Doppler
echocardiography, pulsed waive and/or continuous
|
50.00
|
|
93325
|
Doppler color flow
velocity mapping to code for echocardio
|
125.00
|
|
93350
|
Echocardiography,
real-time w/image documentation
|
125.00
|
|
93609
|
Intraventricular
and/or intra-atrial mapping of tachycardia
|
465.00
|
|
93615
|
Esophageal recording
of atrial electrogram wow ventricular
|
56.00
|
|
93620
|
Comprehensive
electrophysiologic evaluation w right atrial
|
750.00
|
|
93621
|
Comprehensive
electrophysiologic evaluation w left atrial
|
850.00
|
|
93622
|
Comprehensive
electrophysiologic evaluation w left ventri
|
850.00
|
|
93623
|
Programmed stimulation
& pacing after intravenous drug
|
500.00
|
|
93624
|
Electrophysiologic
follow-up study w/pacing & recording
|
500.00
|
|
93631
|
Intra-operative
cardiac pacing & mapping
|
465.00
|
|
93640
|
Electrophysiologic
evaluation of cardioverter defibrillator
|
1250.00
|
|
93650
|
Intracardiac catheter
ablation of arrhythmogenic focus
|
926.00
|
|
93797
|
Physician services for
outpatient cardiac rehabilitation
|
50.00
|
|
93798
|
Physician services for
outpatient cardiac rehab w/ecg mon
|
65.00
|
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