Provider Update
Volume 20, Issue 2
April/May 2003
Expansion of CommunityCARE In Regions 7 and 8
Effective June 1, 2003, Louisiana Medicaid will expand the CommunityCARE Program to include Bossier, Caddo, Caldwell, Franklin, Lincoln, Ouachita, and Tensas Parishes. Medicaid recipients in these parishes will receive a brochure and a letter advising then that CommunityCARE is coming to their parish. During the first week of May a second letter will be mailed to recipients asking them to chose a CommunityCARE doctor from an enclosed list of enrolled CommunityCARE providers in the recipient�s parish of residence. Both letters provide an �800� number to call if they have questions. Recipients who do not select a provider by May 23 rd will be assigned to a doctor. Recipients will receive a third letter either confirming their choice or informing them of the provider assigned to them. If the recipient is not satisfied with their doctor, they have ninety (90) days to change to a different CommunityCARE doctor.
Beginning June 1, 2003, providers in these parishes who are not enrolled as CommunityCARE PCPs (primary care providers) must obtain a referral from the CommunityCARE PCP in order for Medicaid to pay for most services provided to CommunityCARE enrollees. Medicaid primary care providers (Family Practice, General Practice, Internal Medicine, OB, Pediatricians), physician groups, Rural Health Clinics (RHCs), and Federally Qualified Health Centers (FQHCs) may enroll as CommunityCARE providers. Medicaid providers who have not completed their enrollment as a CommunityCARE providers by April 15, 2003 will not be included in the June 1, 2003 assignment rotation and will not be listed as an available choice on the list included in the recipient letters. However, providers may continue to enroll as CommunityCARE providers at any time. Enrollment packets for CommunityCARE may be obtained by contacting Unisys Provider Relations at 800-473-2783. Questions may be directed to Provider Relations at that number, or to the CommunityCARE program office at 225-342-1304.
For your information, the CommunityCARE expansion schedule for the year 2003 is as follows:
June 2003 - Bossier, Caddo, Caldwell, Franklin, Lincoln, Ouachita, and Tensas.
September 2003 - Orleans
December 2003 - Plaquemine, St. Bernard, Jefferson - East Bank, and Jefferson - West Bank
New State Plan Personal Care Services Program
The Department of Health and Hospitals, Bureau of Health Services Financing is developing a new optional State Plan Program to provide personal care services. The Long Term-Personal care Services program, slated to begin in July of this year, will enhance the lives of elderly and disabled individuals by enabling them to remain in their own homes. This program is designed to supplement the family and/or community supports that are available to maintain the individual in the community, but it is not a substitute for these supports. Long-term care is a general term used to describe an array of medical and supportive services to help individuals perform basic life activities. Within this very broad framework of long-term care, there is a set of services referred to as �personal care.� Medical care - whether skilled or unskilled - is typically not considered personal care.
Personal care services are those services that provide assistance with activities of daily living (ADL) and the instrumental activities of daily living (IADL). Assistance may be either the actual performance of the task or supervision and prompting so the individual can perform the task by him/herself. ADLs are personal, functional activities required by an individual for his/her well being and safety. ADLs include such tasks as:
� eating
� bathing
� grooming
� transferring
� reminding the individual to take their medicine
� ambulation
� toileting
IADLs are activities that are essential for sustaining the individual�s health and safety, but may not require performance on a daily basis. IADLs include such tasks as:
� light housekeeping
� food preparation
� grocery shopping
� laundry
� assisting with scheduling medical appointments
� assisting the recipient to access transportation
Most long-term personal care is provided informally by family members and friends, but many people pay out-of-pocket for these services through a home care agency or by independently hiring someone to provide assistance. The primary source of public payment for these services is Medicaid. Personal care services are currently being provided through home and community-based services (HCBS) waivers. These services will now be available as an optional Medicaid State Plan service.
A Medicaid recipient qualifying for the program must be 65 years of age or older, or 21 years of age or older and disabled. Disability is defines as meeting the Social Security Administration�s criteria for disability benefits. The services for the program must be prescribed by the recipient�s primary care physician. The recipient must also meet a nursing facility level of care as defined in the Standards for Payment for Nursing Facility Services and be able to participate in his/her care and direct the activities of the personal care worker independently or through a responsible representative.
Individuals who qualify for the program may receive up to 56 hours of personal care services per week based on need demonstrated by an individual assessment performed by an independent contractor.
Providers who wish to participate in the PCS Program must comply with the following:
� Possess a current, valid license for the Client Services Provides, Personal Care Attendant Services issued by the Bureau of Licensing;
� Comply with state licensing regulations;
� Meet Medicaid provider enrollment requirements;
� Meet standards of care set forth by the Louisiana Board of Nursing;
� Comply with the policy and procedures contained in the personal care services provider manual; and
� Demonstrate experience in successfully providing direct care services to the target population or demonstrate the ability to provide these services to the target population.
Providers who wish to provide PCS to the target population need to contact Provider Enrollment at (225)237-3370 to obtain a PE-50.
Recipients who are currently receiving personal care attendant services through the PCA or EDA (elderly and disabled adult) waivers will be transitioned into the State Plan PCS program. Providers who currently provide PCA services under these waivers and wish to continue will need a new provider number. Providers should contact Provider Enrollment at (225)237-3370 to obtain a PE-50 for the new State Plan PCS Program.
Personal Assistant Services Program to be Implemented
In response to the federal Ticket-to-Work and
Self-Sufficiency Program, the Department of Health and Hospitals, Bureau of Health Services Financing is developing a personal assistant services program. The Ticket-to-Work Program is a nationwide initiative designed to bring major positive change to the lives of individuals with disabilities. Under the Ticket Program, disabled individuals who receive Social Security and Supplemental Security Income may receive employment services, vocational services, or other support services to help them go to work and earn more money.
The Personal Assistant Services (PAS) Program, slated to begin in July 2003, will support the employment efforts of these individuals and enable them to obtain, regain, and/or maintain employment. The mission of the Medicaid funded personal assistant services is to enhance the individual�s independence and thereby reduce their dependency on cash assistance. The program is designed to supplement the family and/or community supports available to the individual and is not intended to be a substitute for available family and/or community supports. These services must be prescribed by a physician or psychiatrist and be coordinated with other Medicaid services being provided to the individual. Personal assistant services will provide help with activities of daily living (ADL) and instrumental activities of daily living (IADL). Assistance may be either the actual performance of the task or supervision and prompting so the individual can perform the task by him/herself. ADLs are personal, functional activities required by an individual for his/her well being and safety. ADLs include such tasks as:
� eating
� bathing
� dressing
� grooming
� transferring
� reminding the individual to take their medicine
� ambulation and
� toileting
IADLS are activities that are essential for sustaining the individual�s health and safety, but may not require performance on a daily basis. IADLs include such tasks as:
� light housekeeping
� food preparation and storage
� grocery shopping
� laundry
� assisting with scheduling medical appointments
� Providing transportation when necessary
� to seek employment
� to go to and from recipient�s place of employment or
� to access other necessary activities
� providing assistance in the completion of employment related or other necessary correspondence
To qualify for the PAS program, a Medicaid recipient must be 18 through 64 years of age and disabled as defined by the Social Security Administration�s criteria for disability benefits. They must also be employed, seeking employment, or participating in employment related training; require assistance with at least two activities of daily living, and be able to participate in his/her care and self direct the services provided by the personal care assistant independently or through a responsible representative.
Individuals who qualify for the program can receive up to 56 hours of personal care services per week based in need as demonstrated by an individual assessment performed by an independent contractor.
Providers who wish to participate in the PCS program must:
� possess a current, valid license for the Client Services Providers, Personal Care Attendant Services from the Bureau of Licensing;
� comply with state licensing regulations;
� medicaid provider enrollment requirements, the standards of care set forth by the Louisiana Board of Nursing, and
� the policy and procedures contained in the personal care provider manual
� demonstrate experience in successfully providing direct care services to the target population or
� demonstrate the ability to provide these services to the target population successfully.
Providers wishing to enroll may call Provider Enrollment at (225)237-3370 to obtain a PE-50 packet.
HIPAA
ARE YOU READY?
� Are you preparing to be HIPAA ready?
� Do you plan to bill electronically? If so do you have a vendor, billing service or clearinghouse (VBC)?
� Has your VBC signed up with our testing service?
� Are you making plans to attend the training seminars?
� Have you visited our lamedicaid.com web site for current HIPAA information?
If you answered NO to any of these questions, continue reading below to find out what you need to do to become HIPAA ready.
� Becoming "HIPAA Ready" for EDI Transactions with Louisiana Medicaid
What providers and submitters need to do to become HIPAA ready
� Medicaid Provider Training Seminars
Provider training schedule information update
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,
instructions will also be provided.
Note: If you currently submit claims electronically to 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. For ease of review, from this point on, a "Software Vendor," "Billing Agent", or "Clearinghouse" will be referred to collectively as a 'VBC'.
1. The first step toward your HIPAA readiness is to have your VBC contact Medicaid and enroll in our testing service. As a provider who bills electronically, your VBC will be tasked with making your claims HIPAA Ready. Therefore to ensure success, the VBC must contact the Medicaid HIPAA EDI Group.
The HIPAA EDI group will support all VBCs through the enrollment, testing, and production approval processes.
VBCs must contact the HIPAA EDI group to enroll in Medicaid's testing service by
e-mailing 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 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 for free from
www.wpc-edi.com.
The implementation guides at this site ARE the specifications for the new HIPAA transactions.
Our testing service is available 24-hours-a-day, 7-days-a-week.
2. If you are a Medicaid provider AND
a. VBC Or b. Your VBC does not plan to become HIPAA ready
YOU SHOULD:
Subscribe to the weekly VBC list and HIPAA updates by e-mailing 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 Medicaid HIPAA testing service and are pursuing HIPAA readiness.
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," "Parallel," or "Approved." The final "Approved" status means the submitter has successfully submitted HIPAA compliant EDI claims to Medicaid. However it does not insure that all future transactions received on behalf of a provider from that VBC will be HIPAA compliant, since other factors may affect successful transmission. This list will be dynamic and updated weekly as VBCs enroll and progress through the testing process. The weekly VBC list will be e-mailed to those providers who have sent 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 email list for the most up-to-date information on HIPAA and a status on all enrolled VBCs as they pursue HIPAA readiness with Medicaid.
Providers are encouraged 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 has contacted Medicaid for enrollment in the Medicaid HIPAA testing service, the process toward HIPAA readiness can begin. Please have your vendor enroll early, even if they are not ready to send a test file. This will let Medicaid know the VBC intends to become HIPAA ready and can be included in the list of VBCs. In addition, Medicaid 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 will have everything a VBC needs to test for HIPAA readiness. 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 Medicaid).
5. VBCs that have successfully completed our testing program will be "Approved" for HIPAA electronic claim submission. Providers can use any "Approved" VBC as their electronic means of claims
submission to us.
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 table below 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 7/11/03 are tentative, therefore an exact date is not indicated.
More specific information regarding the training seminars (including dates, time and specific locations), plus additional implementation information will be included in future Provider Updates as well as RA messages.
*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.
If you are unable to attend a training seminar, please contact provider relations at 800/473-2783 to obtain a copy of the training materials or go to the lamedicaid.com web site to download a copy of the training material.
HIPAA Privacy
Medicaid is taking all the necessary steps to comply with the HIPAA Privacy regulations prior to the April 14, 2003 deadline for compliance. All current Medicaid households are being mailed a copy of the new Department of Health and Hospitals' "Notice of Privacy Practices." Newly certified Medicaid eligibles will be provided with a "Notice of Privacy Practices" at the time they are enrolled in the program. You can access a copy of the notice through the DHH Website
www.dhh.state.la.us .
New Online MEVS Feature Coming Soon
A new Medicaid Eligibility Verification System (MEVS) application will be available on the Louisiana Medicaid website effective 6/28/03. Providers will be able to verify recipient eligibility for a single recipient at a time. This will be particularly useful to small provider offices that don't need to verify large numbers of recipients, or when there is urgent need for verification and the current MEVS application is unavailable. The provider can initiate a single transaction inquiry by going to the http://www.lamedicaid.com website, and then entering his/her 7-digit Louisiana Medicaid Provider ID in the Provider Login field. At the secure website area, the provider can choose the type of search, e.g., recipient name and date of birth, and enter all required fields for that selection on the input screen. Verification information will be returned on a response screen. Once the response has been received, the provider may request verification for another individual recipient. A user's guide will be available on the website for further help in using this new application.
The first time a provider without access attempts to log on, the input screen will prompt the provider to enter relevant information on an Agreement page, which is then automatically processed for approval. Access will be granted within 24 hours of the request.
Attention All Outpatient, Hemodialysis, Dental, and RHC/FQHC Providers
LA Medicaid has mandated the use of standards code sets effective May 1, 2003 for your programs. Local Codes for Outpatient, Hemodialysis, Dental and RHC/FQHC can no longer be submitted for Dates of Service on or after May 1, 2003. If you have not begun using the new codes for dates of service May 1, 2003 and later, your claims will deny. In order to ensure that your claims are not denied and are paid timely, please ensure that:
� The Standard Code Sets are being used for dates-of-service 5/1/2003 and after
� Your billing system will allow the entry of the new standard code sets.
If your billing system does not accept the new standard code sets then you should contact your vendor/billing agent/clearing house (VBC) immediately.
Any providers who did not attend the Provider Training seminars for these programs may download a copy of the training packets at
www.lamedicaid.com.
Changes in Prior Authorization Process
BHSF is pleased to announce minor changes in the Prior Authorization process for the above listed services. The Prior Authorization staff will begin designating some recipients as Chronic Needs Cases. These are recipients for whom prior authorized services are continuous and expected to remain at current levels based on their medical condition. Once a recipient is deemed to be a Chronic Needs Case, providers must only submit a PA request form accompanied by a statement from a physician that the recipient's condition has not improved and the services currently approved must be continued at the approved level. This determination only applies to the services in the affected Prior Authorization Number and only if services are to remain at the currently approved level. Request for an increase in these services will be treated as a traditional PA request and is subject to full review.
The staff and Unisys will identify these cases when reviewing requests for services and will notify both the provider and the recipient on the approval letter. The approval letter will give directions for future requests involving those services.
For information about receiving your listing electronically or for any other questions, please call Randy Davidson at (225) 342-3935.
CPT Codes To Be Added
Effective with date of service January 01, 2003, the following CPT codes will be added to the list of codes payable to CNPs and CNSs.
95805 MSLT, record, analysis, interpret
95810 Polysomnography, 4 or more
95811 Polysomnography w/cpap
Written Authorizations From the PCP Required
Audiologists are reminded that for recipients in the CommunityCARE program, there must be a written authorization from the recipient's PCP for the audiologist's services. This includes recipients that are referred by the Head Start program.
Home and Community Based Waiver Services
DHH recently launched a new �Waiver Program� for persons with developmental disabilities. The NOW (New Opportunities) allows greater flexibility for patients. Go to the Waiver Website at
www.dhh.state.la.us/bcss .
For information about Home and Community-Based Waiver Services as an alternative long term care option, please call 1-800-660-0488.
CPT Code Z9921
Effective with the date of service August 01, 2002, CPT code Z9921 ( Lunelle Monthly Contraceptive Injection) was replaced by CPT code J1056 (Lunelle Monthly Contraceptive Injection). CPT code Z9921 was placed in non pay status effective with date of service August 1, 2002.
CPT Code 53850
The fee for CPT code 53850 (Transurethral destruction of prostate tissue by microwave thermo therapy) was increased to $1,522.20 effective with date of service March 1, 2003.
CPT Code 99239
Prior to January 1, 2003, CPT code 99239 was payable for Medicare/Medicaid recipients only. Effective date of service 01/01/2003, this code was made payable for straight Medicaid recipients, at a fee of $66.42.
CPT Code 51736
CPT Code 51736 (Simple Uroflowmetry) was made payable effective with date of service March 1, 2003 at a fee of $31.06. The professional component fee is $15.53.
HCPCS Code G0181
Effective with the date of service January 1, 2003, HCPCS code G0181 for Home Health Care Supervision was made payable at a fee at $107.10. This code is restricted to crossover claims.
Fee for Mirena
Since HIPAA regulations no longer allow the bundling of services; we have changed the billing policy for the Mirena Implantation.
The remittance advices of January 14, 2003 and January 21, 2003 stated that the fee for the Mirena Implant (J7302-billing c ode) would increase effective for date of services on or after January 1, 2003. Due to an error the fee increase was not entered into claims processing until March 14, 2003.
You can now bill for the implantation of Mirena by using CPT code 11981. The fee is $107.06.
If you bill for the implant itself, use the code J7302. The fee is $384.39. Adjustments may be submitted for the difference between the old and new rates. We apologize for any inconvenience this
oversight may have caused.
26 Modifier To Be Added
Effective with the publication of this notice, providers who perform the professional component of the following codes shall modify the code with - 26 when the equipment used to provide the services is not owned, rented, or leased by the physician.
91000, 91055, 91060, 91122, 93501, 93505, 93510, 93511, 93514, 93524, 93526, 93527, 93528, 93529, 93561, 93562, 93600, 93609, 93615, 93620, 93621, 93622, 93623, 93624, 93631, 93640, 95958, 95961 and 95962.
Dental Program Changes Effective May 1, 2003
Claim Form Changes:
Effective May 1, 2003, the 2002 American Dental Association (ADA) Claim Form is required for use when filing for Medicaid reimbursement of services provided under the EPSDT Dental Program and Adult Denture Program, regardless of date of service.
Any other revisions of this claim form will be rejected if submitted for payment. The 2002 ADA Claim Forms must be obtained from the ADA, your normal ADA form supplier, or a business forms supplier. Unisys does not supply ADA claim forms.
The 2002 ADA Claim Form is also used for Prior Authorization requests.
Adjustment/Void Form Changes:
Effective May 1, 2003, dental providers must use the newly revised EPSDT Dental Services 209 Adjustment/Void Form (revision 01/03) and the newly revised Adult Dental Services 210 Adjustment/Void Form (revision 01/03) to adjust/void claims payment, regardless of date of service. These revised forms may be obtained by calling Unisys Provider Relations at (800) 473-2783 or (225) 924-5040, or request the forms in writing at:
Unisys - Provider Relations
Attn: Forms Distribution
P.O. Box 91024
Baton Rouge, LA 70821
Procedure Code Changes:
All existing dental codes for dental claims are being changed to comply with the HIPAA standard code set guidelines. Effective May 1, 2003, all current dental procedure codes used on the ADA Dental Claim Form will be changed from a "0" to a "D" in the leading position. For dates of service prior to May 1, 2003, claims must contain the old procedure codes with a "D" in the leading position. Any claim submission for dates of service May 1, 2003 and after must use the new HIPAA standard codes. (Refer to the Medicaid Dental Fee Schedule for specific LA Medicaid approved codes and requirements regarding tooth number/letter or oral cavity designator.)
New Error Codes:
Effective May 1, 2003, two new error codes will be added for claim denials.
Code 598: PA Tooth/Oral Cavity Code Not Same as Claim - The tooth number or letter on the claim does not match the tooth number or oral cavity designator prior authorized.
Code 677: Restorative/Surgical Procedure Required - Nitrous Oxide (D9230) or behavior management (D9920) is only reimbursable for dates of service on which restorative and/or surgical services (codes D2140 - D4999 and D7140 - D7999) are performed. If one of the allowable restorative/surgical procedures is not billed for the same date of service, the claim for nitrous oxide or behavior management will deny with error code 677.
Electronic Billing:
If dental providers are currently submitting claims electronically to LA Medicaid, the current method will not be HIPAA compliant without modifications by the Software Vendor, Billing Agent or Clearinghouse (VBC). Providers should instruct VBCs to contact the Unisys HIPAA EDI group to enroll in Medicaid's testing service by e-mailing a request to *hipaaedi@unisys.com (NOTE: * is part of the e-mail address) or by calling (225) 237-3318.
Dental providers who are currently billing paper claims but are interested in billing electronically should subscribe to the weekly Vendor, Billing Agent or Clearinghouse (VBC) list by e-mailing the Unisys HIPAA EDI group at paaedi@unisys.com. Put "subscribe to VBC list" in the subject line. VBCs identified in the list are those that have enrolled with the HIPAA testing service and are pursuing HIPAA readiness.
Training Packet Requests:
The information above was discussed in detail at the 2003 Dental Provider Training held March 31 - April 4, 2003. Since providers are responsible for the information contained in the training packets, providers who were unable to attend should request a copy of the training packet by calling Unisys Provider Relations at (800) 473-2783 or (225) 924-5040. This packet will also be available on the Medicaid web site, lamedicaid.com, within the coming weeks.
Additional Hemodialysis Center Code Changes Made for HIPAA
The 2003 Hemodialysis Center provider training workshops were recently held to inform providers of upcoming changes from locally assigned Medicaid procedure codes to HIPAA standard codes, effective May 1, 2003. Two code changes are being made that were not correctly indicated in the training materials distributed at those workshops. Procedure code Z6138 (Calcitriol, 2 MCG) should be crosswalked to code J0636 (Calcitriol, .1MCG). (Please note the difference in drug strength.) The training packet material crosswalked this code to a deleted code. Procedure code J0960 (Delatestryl injection) should be crosswalked to code J3120 (Testosterone Enanthate injection - up to 100 mg). This code was inadvertently left off the training packet material. If you were unable to attend the 2003 training workshops, please contact Provider Relations at (800) 473-2783 or (225) 924-5040 to obtain a training packet.
Louisiana Drug Utilization Review (LADUR) Education
Attention Deficit Hyperactivity Disorder (ADHD) in the Louisiana Medicaid Population: Prevalence, Demographic, and Clinical Characteristics
By: Larry J. Humble, R.Ph., Gina C. Biglane, Pharm. D., Sandra G. Blake, Ph. D.
Issues:
� ADHD is the most frequently diagnosed neurobehavioral disorder of childhood.
� Actual prevalence of ADHD has been difficult to determine.
� Pharmacotherapeutic options for children with ADHD are usually focused on one of several classes of drugs...
Introduction
Attention deficit hyperactivity disorder (ADHD) is a chronic condition characterized by varying degrees of inattention, hyperactivity, and impulsivity. ADHD is the most frequently diagnosed neurobehavioral disorder of childhood.[1] Actual prevalence of ADHD has been difficult to determine. At least 13 different epidemiologic studies have been conducted since 1980, with prevalence rates ranging from 2% to 14.4%.[2] Difficulties in determining prevalence may be due to many factors, one of which is the lack of a definitive diagnostic test. The diagnosis must rely on reported information from the child, parents, and teachers. The method of reconciling inconsistent data from multiple sources can have an impact on the prevalence. Difficulty in placing the child on a spectrum of symptoms may also contribute to difference in prevalence rates. The exact threshold or point at which the symptom is attributed to the child may be difficult to determine. Another difficulty involves determining the level of impairment the child is experiencing. A strict symptom count usually results in a higher prevalence than a symptom count with impairment.
Criteria for diagnosis of ADHD are published in The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).[3] These criteria require the presence of symptoms of inattention, hyperactivity, or impulsivity for six or more months, with clear evidence of impairment of functioning. Additionally, some of the symptoms should be present prior to 7 years of age, and the impairment should be present in two or more settings (i.e., school and home).
Pharmacotherapeutic options for children with ADHD are usually focused on one of several classes of drugs, which include stimulants, antidepressants, monoamine oxidase inhibitors, and clonidine. In a recent study, Zito et al grouped these medication classes into three categories: standard stimulant therapy, psychotherapeutic agents other than stimulants, and a combination of the two.[4] They reported that 82.8% of medication visits involved stimulant therapy alone, 7.6% involved psychotherapeutic agents other than stimulants, and 9.6% involved both stimulants and other psychotherapeutic agents. Zito et al. also reported that 61% of ADHD visits were to a pediatrician or family practice physician. Psychiatrists conducted 25% of visits.[4]
Purpose of the Study
The purpose of this analysis was to examine ADHD within the Louisiana Medicaid population under 18 years of age and to analyze their pharmacy utilization between July 1, 2001, and June 30, 2002. Specific objectives included:
� To determine the prevalence of ADHD among Medicaid recipients under the age of 18 for the
study period;
� To demographically describe this population;
� To examine pharmacotherapies by drug class;
� To determine the presence of related comorbidities (by ICD-9-CM diagnosis); and
� To examine the use of psychotherapy as primary therapy and/or adjunct to pharmacotherapy.
Methods
Data Source
The data source for this analysis was the Louisiana Medicaid Medical and Pharmacy Claims Data stored in the Louisiana Medicaid MARS Data Warehouse maintained by Unisys Corporation, fiscal intermediary for the Louisiana Medicaid program.
Inclusion Criteria
To be included in this study, a recipient must have met all of the following inclusion criteria:
� Have a birth date after June 30, 1984 (to ensure that recipients in the study group were less than 18 years of age for the entire study period);
� Have at least one claim with a primary or secondary diagnosis of ADHD defined as ICD-9-CM codes 314.0, 314.01, or 314.9; [5]
� No diagnosis of narcolepsy as defined by ICD-9-CM code 347.xx;[5]
� Have continuous eligibility for Medicaid during the study period as determined by eligibility records in the MARS Data Warehouse; and
� Have complete demographic information available.
All analyses were performed using SAS Version 8.2� and SAS Enterprise Guide�.
Results
A total of 22,481 recipients met the inclusion criteria and comprised the study group. The demographic information for each recipient was obtained from the recipient's first paid Medicaid claim in the study period. Figure 1 describes the distribution of the study group by gender, race, age and region of residence. The percentage of recipients in each category is provided.
Figure 1. Demographics of Study Group (Recipients under age
18, diagnosed with ADHD)
n = 22,481 continuously eligible recipients under age 18
*Parishes included in each of the regions available upon request from (318)410-4385 or mmasssey@ulm.edu
As seen in Table 1, the overall unadjusted period prevalence of ADHD in the Louisiana Medicaid population for the period of July 1, 2001 - June 30, 2002 was 5.74%. The male (8.33%) to female (3.04%) prevalence ratio was 2.74. In the study sample, the highest prevalence was noted among White males (12.87%). The lowest prevalence was noted among Black or African American females (2.07%). The highest prevalence among the age groups was the 9 - 12 year-old group (10.31%).
Table 1. ADHD Prevalence, Unadjusted*
* Unadjusted Prevalence = Number diagnosed within the strata/Total number in the strata
The classes of pharmacotherapeutics tracked for this study were: 1) stimulants, 2) antidepressants, 3) antipsychotics, and 4) antihypertensives. During the study period, 20,575 (91.5%) of 22,481 recipients comprising the study group received a pharmacotherapeutic agent. Of those 20,575 recipients who received a pharmacotherapeutic agent, 60.23% were treated with an agent from a single class; 27.30%, agents from two classes; and 12.47%, agents from three or more classes. For further analysis, the classes were categorized as follows: stimulant only, other psychotherapeutic agent (antidepressants, antipsychotics, and antihypertensives) only, and stimulant plus other psychotherapeutic agent. According to Figure 2, 57% of the 20,575 on drug therapy (20,575) received only a stimulant during the study period. An additional 38% of the recipients on drug therapy received a stimulant in combination with some other psychotherapeutic agent, and the remaining 5% were treated with other psychotherapeutic agents only. A stimulant, either alone or in combination with some other psychotherapeutic agent, was prescribed to 19,461 (86.6%) recipients of the 22,481 in the study group.
ADHD related comorbidities were defined as anxiety, conduct disorder, depression, learning difficulty, and tic. ICD-9-CM codes were used to identify the diagnosis of a comorbidity in the claims database and are listed in Table 2.[5] At least one of the selected comorbidities was observed in 2,873 (12.78%) study recipients. As seen in Figure 3, the predominant ADHD comorbidity in this study sample was a conduct disorder (58% of those recipients with a comorbidity); with the majority of these (70%) between the ages of 5 and 12.
Figure 2. ADHD Pharmacologic Treatment (n = 20, 575)
According to the paid Medicaid claims, psychotherapy was provided to 104 (0.46%) of the recipients in the study group. Ninety-six percent of the recipients receiving psychotherapy were receiving pharmacologic treatment also. Of the1,670 recipients with an additional diagnosis of conduct disorder, 21 were receiving psychotherapy. It is important to note that counseling may have been provided to other recipients diagnosed with ADHD during the study period. Counseling directed toward behavior modification may have been provided to recipients at school counseling centers, churches, or other community centers. Provision of counseling at these locations is not billed to Medicaid.
Conclusion
The overall prevalence rate of ADHD in children with Medicaid in Louisiana (5.74%) is well within the ranges established by other studies (2-14.4%).[2] Ninety one and one-half percent (91.5%) of children with ADHD received medication therapy, which is consistent with the medication rate of 97%established by Wilens, et al [6]. Interestingly, stimulant therapy alone was prescribed for 82.8% of the recipients in the study by Zito, et al, as compared to 57% of the children in our study group. However, 38% of the ADHD recipients in our study received combination therapy consisting of a stimulant plus another psychotherapeutic agent, while only 9.6% received combination therapy in the study conducted by Zito et al.[4] Future analysis is needed to determine if the patients on combination therapy had reached maximal doses of one product before a second was added.
Table 2. ADHD-related Comorbidities
It would seem that Louisiana has room to improve on the use of other interventions, such as psychotherapy, for ADHD. Only 0.46% of children in our study group had a claim for psychotherapy, while 25% of the visits were conducted by psychiatrists in another study.[4]
It is also interesting to note that claims were found for ADHD treatment for modafinil (Provigil�), which is not indicated for ADHD treatment (recipients with diagnosis of narcolepsy were eliminated prior to this analysis). Additionally, claims for pemoline (Cylert�), which is no longer recommended due to the risk of hepatic failure, were identified.[7]
Figure 3. Comorbidities of ADHD (n=2, 873)
This study examined drug therapies for the 22,481 recipients who met the study criteria of diagnosis, age 1-17, and continuous eligibility. There are other children enrolled in the Medicaid program with a diagnosis of ADHD who may not have met the eligibility criterion so the total population affected by this disorder is greater than 22,481.
Perhaps the newest product on the market for treating ADHD will offer some promise for patients with ADHD. Lilly has recently released atomoxetine (Strattera�), which is the only non-stimulant therapy indicated for treatment of ADHD in children, adolescents, and adults. Atomoxetine is a selective norepinephrine reuptake inhibitor; it is similar in structure to fluoxetine. Doses can be given once daily in the morning, or split between morning and afternoon. Atomoxetine has not been shown to exacerbate co-morbid conditions such as tics, which has been noted with stimulant medication. Because it is not a controlled substance, access to the medication will be much easier for the parents of children with ADHD.