PROVIDER
UPDATE
VOLUME 11, NUMBER 2
MARCH/APRIL 1994
MESSAGE FROM THE MEDICAL
DIRECTOR
Medicaid Hospital
Pre-Admission/Length of Stay Review Program
Last fall, DHH
issued a Notice of Intent to develop a hospital pre-admission/length of stay
(LOS) review program for Medicaid admissions.
Hearings were held in December and January.
As a result of public comments, an advisory group representing the
provider community and a smaller work group task force were established to help
DHH develop an effective and easy to use program.
DHH chose
pre-admission/LOS review to monitor length of stays for Medicaid hospital
admissions in conjunction with the new per diem prospective payment system.
This method is generally favored by providers because receiving payments
will be faster, simpler, and more predictable.
Based on public
comments, DHH limited pre-admission certification to distinct part psychiatric
facilities and long term care hospitals. They
will also participate in the LOS review program.
Acute care hospitals (excluding LHCA facilities) compose over 90% of all
Medicaid admissions and will participate only in the LOS review.
Thus, most hospital admissions will require only notification to DHH/Unisys,
not pre-approval.
The program will
use nationally recognized medical review criteria, the various options of which
are still under discussion. These
criteria will be shared with
providers. Also, a nationally
accepted diagnosis-based LOS system will be used which is specific to Medicaid
and to patient age.
Most admissions
and LOS reviews will be conducted by review nurses specializing in either acute
care medical-surgical admissions, psychiatric, or long term care.
Before any denial is made, a physician consultant will review the case.
Providers may request an informal reconsideration of any denial before it
is finalized. Medicaid also has a formal appeals process for denial
decisions.
The advisory
committee is setting timely turnarounds for each program aspect.
There will be a simplified on-page pre-admission certification and LOS
assignment form to send in for review together with direct phone lines between
provider representatives and review nurses.
The telephones should transmit a busy signal less than 2% of the time and
callers will have instant voice mail contact if desired for timely review nurse
follow-up. Providers and patients
will be notified of decisions by mail, or by phone or fax when appropriate.
There is now a
15-day annual Medicaid limit on hospitalizations.
For extension requests, hospitals must submit paperwork.
It is difficult for physicians to bill for services during extensions
because they must get the approval form from the hospital to send in with their
claim. This entire process will be
replaced by the new program. It
will be easier and faster to request LOS extensions, and physician billing will
be simplified because the system will automatically link the physician provider
number with the approved stay for a given patient.
DHH and Unisys are
committed to working with providers to develop an efficient, simple program to
successfully monitor hospital admissions that will be responsive to all health
care providers. The next public
hearing will be on April 20 at DHH. There
are plans to conduct a pilot prior to full implementation.
New Rules for Reporting
Critical Care Placement
Effective with
date of service March 1, 1994, critical care services providers will bill the
Medicaid Program for said services according to the guidelines printed on pages
49 and 50 of the 1994 edition of the Physician's
Current Procedural Terminology.
For example, if
you spend less than 30 minutes providing constant attention to a critically ill
or injured patient, you will bill procedure code 99232 or 99233 for the services
rendered rather than codes 99291 or 99292.
One unit of code 99291 and 3 units of code 99292 will be billed for
135-164 minutes of constant attention.
Services not
included in codes 99291 and 99292 may be reported separately.
Placement in Non-Pay Status of
Code J9394
The
locally-assigned code for the DTP-HIB immunization injection, J9394, will be
placed in non-pay status effective with date of service March 1, 1994, as new
code 90720 has replaced it.
Code 90720 has
been funded at $29.56 effective with date of service January 1, 1994.
You will be notified when other new immunization codes are funded.
Reinstatement of Payment for
EKG Interpretations
Effective with
date of service January 1, 1994, payment for interpreting electrocardiograms
(codes 93000, 93010, 93040, and 934042) has been reinstated for
Medicare/Medicaid recipients.
Placement in Pay Status of 1994
CPT Codes
The majority of
the 1994 CPT codes have been funded effective with date of service January 1,
1994. You may begin billing these
codes immediately.
End Stage Renal Disease
Services
The end stage
renal disease services codes 90918 and 90919 have been funded effective with
date of service January 1, 1993, at a fee of $159.
Increase in Allowable Units for
CPT Code 28308
The allowable
units for procedure code 28308 (osteotomy, metatarsal, base or shaft, single,
with or without lengthening, for shortening or angular correction--other than
first metatarsal) will be increased to nine effective with date of service April
1, 1994.
Increase in Zoladex Fee
BHSF is pleased to
announce an increase in the fee for Zoladex (goserelin acetate impact, 3.6 mg). The procedure code for Zoladex is J9383 and we are increasing
the rate from$331.50 to $344.76 effective with date of service April 1, 1994.
Notice to Anesthesiologists and
CRNAs: Anesthesia Funding
The Bureau of
Health Services Financing is pleased to announce the funding of anesthesia for
arteriograms, cardiac catheterizations, angioplasties, CT scans, and MRIs. Anesthesia funding is effective with date of service January
1, 1993, under locally assigned procedure code 00099.
The Bureau should
not be billed for anesthesia for these services unless its provision was medically necessary.
Examples of
medical necessity include, but are not limited to, the patient's inability to
remain completely immobile, the patient's being in extreme pain, or there being
any other problem(s) which would compromise the accuracy of the procedure.
Claims for
anesthesia for these services are to be billed without
minutes or modifiers under procedure code 00099.
This code will be payable only to anesthesiologists and CRNAs at a flat
fee of $100. Claims for this service
may be electronically filed.
Case Management Clarification
In the
November/December Provider Update, an article was published on page seven entitled,
"Policy Clarifications for Case Managers." At the request of the providers, we are expanding on the
clarifications of the policies in numbered sections 2 and 4 of that article.
Number 2 stated,
"Under the federal statute, case management service must 'assist a Medicaid
eligible individual in gaining access to needed medical, social education, and
other services.'
The term 'gaining
access' may include necessary assistance
and monitoring or follow-up of an individual's progress or status.
This could include observing the beneficiary in various settings.
These case management services must be furnished in amounts which are
reasonable given the needs and condition of the particular beneficiary."
Number 4 stated,
"Payment for case management is dictated by the nature of the activity and
the purpose for which the activity is performed.
It
is necessary for case managers to have various discussions to make assessments
and reassessments of the need for services.
Case management may include discussions with beneficiaries regarding such
topics as personal behavior, financial budget, or medication and side effects.
The necessity for, and amount of,
these discussions must be determined on an individual basis."
We have had
inquiries regarding the bold portions of the above statements.
Please be aware that each of the activities which are mentioned as being
allowable has restrictions that must be noted.
The
amounts of time must be reasonable in length and the activities must be
necessary.
In number 2,
"assistance and monitoring or follow-up of an individual's progress"
has been defined as making certain that the client is satisfied with the
services he/she is receiving. It
may also include communicating with the service providers for ongoing progress
updates with the client's permission, until the service is firmly established.
The latter part of number 2 states, "This could include observing
the beneficiary in various settings."
When a client is observed, it must be for a specific purpose.
It should not be an ongoing type of case management activity and it also
should not be lengthy in nature.
The case manager's
role is not to observe the client's job performance/training, but rather to make
certain that the client is satisfied and being treated properly.
Observing the client may come into play when there is dispute between the
client and service provider. This
type of observation would be for the purpose of advocating on the client's
behalf.
The instances
cannot be defined in a paragraph as to what would or would not be acceptable.
What is important is that providers realize that the activity must
be necessary. The reasons for
necessity must be documented and the length of time must be reasonable.
In number 4, the
bold portion discusses determining service needs that may include assessments
and discussions with the client. The
point to be emphasized here is that these activities must be for the purpose of
determining services. The
activities cannot be an end in themselves.
Discussions cannot be of a counseling nature, except for a specific
situation, and working toward a goal.
Remember, the case
management should emphasize the work in meeting the goals, not just in
determining the goals. Again, the
activities must be necessary and the amount of time reasonable.
Please call
Program Integrity with any questions at (504) 922-2239.
Prescriptions by Certified
Optometrists Reimbursed
The Bureau of
Health Services Financing will reimburse for prescriptions prescribed by a
certified optometrist. The
Louisiana Board of Pharmacy has stated the following in their January 1994
newsletter.
"Act Number
202 of the 1993 Louisiana Legislature expands the scope of optometry and allows
board-certified optometrists to prescribe diagnostic and therapeutic
pharmaceutical agents, which means any chemical in solution, suspension,
emulsion, or ointment base, other than a narcotic, when applied topically that
has the property of assisting in the diagnosis, prevention, treatment or
mitigation of abnormal conditions and pathology of the human eye or its adnexa,
or those which may be used for such purposes, or oral antibiotics, and oral
antihistamines only when used in the treatment of disorders or diseases of the
eye or its adnexa.
The Optometry
Board promulgated the necessary rule in the December 20, 1993 issue of the Louisiana
Register, and at a subsequent meeting certified approximately 200
optometrists for prescribing. The
optometrists will be given a certification number which will be placed on the
prescription. The Optometry Board
will provide each certified optometrist with a certificate bearing their
original optometry number plus a three-digit number followed by a "T"
to designate therapeutic pharmaceutical agent (e.g., 111-506T, or TPA may be
used instead of the T).
The Board of
Pharmacy will be furnished with a list of certified optometrists.
May 1994 Medicaid Billing
Seminars
Unisys, Fiscal
Agent for Louisiana Medicaid, wishes to invite you to attend the 1994 Medicaid
Billing Seminars, which actually began in April.
All are welcome to attend; however, the seminars are structured for
billing personnel. Please review
the schedule for your provider type at the location nearest your office.
Due to limited seating, only two members of the billing staff per office
will be allowed to attend.
The Professional
Services** seminars held on day three in Lafayette and New Orleans will be
exactly the same as day one. It is
not necessary to attend both sessions.
**Professional
Services include the following provider types:
Ambulatory
Surgical Centers
Anesthesiology
Audiology
Certified Nurse
Practitioner
Federally
Qualified Health Centers
Hemodialysis (HCFA
1500 billing)
Independent
Laboratory
Nurse Midwife
Optometry
Physician (all
specialties)
Podiatry
Portable X-Ray
Rural Health
Clinics
May
3-4, 1994
- Lake
Charles
Holiday Inn
505 Lakeshore
Drive
Lake Charles, LA 70601
(318) 433-1645
Day
One (May 3, 1994)
9:00-12:00
Professional Services** (Registration at 8:30 am)
1:30-3:30
Hospital/Dialysis Centers (UB-92 billing only)/Distinct Part Psych Unit
3:45-5:00 Home
Health/Rehab
7:00-8:30 Pharmacy/DME
Day
Two (May 4, 1994)
8:30-10:00 Long
Term Care/Hospice/Freestanding Psych Hospitals
10:15-11:30 Dental
1:00-2:00 MRDD Waiver/PCA/Respite
2:15-3:45 Mental
Health & Substance Abuse/Mental Health Rehab
4:00-5:00 Case
Management
5:15-6:15 EPSDT
Health Service
7:00-8:30
Transportation
May
10-12, 1994
- Lafayette
Ramada Inn Airport
2501 S.E.
Evangeline Thruway
Lafayette, LA
70508
(318) 234-8521
Day
One (May 10, 1994)
9:00-12:00
Professional Services** (Registration at 8:30 am)
1:30-3:30
Hospital/Dialysis Centers (UB-92 billing only)/Distinct Part Psych Unit
3:45-5:00 Home
Health/Rehab
7:00-8:30 Pharmacy/DME
Day
Two (May 11, 1994)
8:30-10:00 Long
Term Care/Hospice/Freestanding Psych Hospitals
10:15-11:30 Dental
1:00-2:00 MRDD Waiver/PCA/Respite
2:15-3:45 Mental
Health & Substance Abuse/Mental Health Rehab
4:00-5:00 Case
Management
5:15-6:15 EPSDT
Health Service
7:00-8:30
Transportation
Day
Three (May 12, 1994)
9:00-12:00
Professional Services** (Registration at 8:30 am)
May
17-18, 1994
- Houma
Holiday Inn
210 S. Hollywood
Road
Houma, LA
70360
(504) 868-5851)
Day
One (May 17, 1994)
9:00-12:00
Professional Services** (Registration at 8:30 am)
1:30-3:30
Hospital/Dialysis Centers (UB-92 billing only)/Distinct Part Psych Unit
3:45-5:00 Home Health/Rehab
7:00-8:30 Pharmacy/DME
Day
Two (May 18, 1994)
8:30-10:00 Long
Term Care/Hospice/Freestanding Psych Hospitals
10:15-11:30 Dental
1:00-2:00 MRDD Waiver/PCA/Respite
2:15-3:45 Mental
Health & Substance Abuse/Mental Health Rehab
4:00-5:00 Case
Management
7:00-8:30
Transportation
May
24-26, 1994
- New
Orleans (Kenner)
Radisson Inn
New Orleans
Airport
2150 Veterans
Memorial Blvd.
}
Kenner, LA
70062
}
(504) 467-3111
Day
One (May 24, 1994)
9:00-12:00
Professional Services** (Registration at 8:30 am)
1:30-3:30
Hospital/Dialysis Centers (UB-92 billing only)/Distinct Part Psych Unit
3:45-5:00 Home
Health/Rehab
7:00-8:30 Pharmacy/DME
Day
Two (May 25, 1994)
8:30-10:00 Long
Term Care/Hospice/Freestanding Psych Hospitals
10:15-11:30 Dental
1:00-2:00 MRDD Waiver/PCA/Respite
2:15-3:45 Mental
Health & Substance Abuse/Mental Health Rehab
4:00-5:00 Case
Management
7:00-8:30
Transportation
Day
Three (May 26, 1994)
9:00-12:00
Professional Services ** (Registration at 8:30 am)
Rate Increase for Emergency
Ambulance Services
The Department of
Health and Hospitals, Office of the Secretary, Bureau of Health Services
Financing has approved a rate increase for the ambulance transportation
providers effective January 1, 1994. The
rate increase is for emergency advanced life support (ALS) and basic life
support (BLS) transportation services and mileage.
We have increased
our payment for emergency ALS services from $297.24 to $306.16.
We have increased our payment for emergency BLS services from $160.51 to
$165.33. Mileage reimbursement
rates for ALS and BLS miles have been increased from $3.70 per mile to $3.81 per
mile.
The combined
Medicare and Medicaid payment for crossover code A0223 has been increased from
$154.57 to $159.21. These rate
adjustments will keep Medicaid's rates at the same amount as Medicare's rates.
Change in Chiropractic Program
Policy
The Health Care
Financing Administration has mandated a change in the number of outpatient
chiropractic visits Medicaid recipients 21 years and older can have per calendar
year. This change will be effective
with calendar year 1994.
Effective
immediately, Medicaid recipients 21 years of age or older will be allowed 12
physician/clinic visits, 4 chiropractic outpatient visits (procedure codes 99201
through 99215), and 25 chiropractic encounters per calendar year among all
providers.
The fifth claim
for an outpatient visit (as represented by the evaluation and management codes
listed above) in a calendar year by a chiropractor for Ms. A will deny with the
message "Chiropractic e & m visit max reached," provided Ms. A has
already had four outpatient chiropractic visits.
If/when you
receive this denial, you may request an extension of outpatient visits by
completing and submitting Form 158-A to the Unisys Prior Authorization Unit for
review. If the consultants approve the visit, you will be reimbursed
for the service provided.
Please follow the
instructions on pages 7-2 through 7-5 of the Physician
Services Manual for requesting extensions.
If questions arise, please call Kandis V. McDaniel, Physicians Program
Manager, at (504) 342-9490.
Physicians, Chiropractors,
Clinics, Dentists, Hospitals:
Controlling Transportation
Costs
The Bureau of
Health Services Financing is requesting your assistance in helping to control
costs in the Medicaid Transportation Program.
The expenditures in this program have risen to $71 million for state
fiscal year 1993-1994. You can
assist by scheduling appointments for family members so that all members can
ride together rather than scheduling multiple trips in one day.
For example, if
there are three children in a family, schedule visits/services consecutively
instead of one appointment in the morning and two in the afternoon.
Any help that you can provide in this area is appreciated and can help
considerably in controlling the mounting costs of the transportation program.
If you have any further suggestions, we would appreciate hearing from
you. Please address any concerns to the Transportation Program
Manager at P. O. Box 91030, Baton Rouge, LA
70821-9030.
Clarification for Nursing
Facility Administrators
Please be advised
that when a resident must be transferred to a psychiatric hospital for
treatment, the resident must be discharged from the nursing facility.
The 10-day bed hold policy is not applicable in these cases.
This requirement applies only to free-standing psychiatric hospitals
enrolled in the Long Term Care Program; it does not apply to distinct part units
located within an acute care hospital. Medicaid
reimbursement cannot be made to two long term care facilities at the same time.
DME Electronic Billing
We are pleased to
announce that durable medical equipment (DME) providers may now submit their
claims electronically. If you have
any questions about the billing procedures or if you would like billing
specifications for the electronic media claims unit (EMC), please call Sue
Kendrick at (504) 924-7051, ext. 2239.
Provider Manual Mailings
When you request
provider manuals or other Medicaid materials from the Unisys Provider Relations
Unit, please give the telephone representative your physical location address.
With a physical
location, your materials will be sent via UPS.
However, if we only have a post office box for your address, the
materials will be sent by regular mail.
Recipients' Monthly Medical
Card Changes
The appearance of
the monthly medical card produced by Unisys will be changing in approximately
two to three months.
Unisys has
purchased a Moore Pressure Sealer Mailing system.
This system will print all necessary information on the inside and
mailing address on the outside of an 81/2 by 11 sheet, then fold it in half, and
seal the card into a one-piece mailer.
The edges of the
card will be perforated for easy removal. The
top half of the card will contain recipient eligibility information and the
bottom half will contain messages, notices, and other pertinent Medicaid program
information.
Program Integrity Address
Attention case
management providers, non-emergency medical transportation providers, and all
Medicaid providers needing to reach the Surveillance and Utilization Review
Unit. These persons and their staff
can be reached at the following address.
Don Gregory,
Program Integrity Manager
Barbara Barenis,
Case Management Supervisor
Shirley Smith,
supervisor of NEMT Inspectors
Bob Patience, SURS
Supervisor
Department of
Health and Hospitals
Bureau of Health
Services Financing
P. O. Box 91030
Baton Rouge, LA
70821-9030
Phone:
(504) 922-2239
DME and Supplies-Medicare
Crossover Claims
Palmetto
Government Benefits Administrators recently began processing DME claims for the
Medicare program for Louisiana providers. A
new Medicare provider number was assigned to each provider.
This new number was to have been sent to the Medicaid agency via magnetic
tape and we were to match these new numbers to the Medicaid provider numbers on
our files to process the crossover claims sent by Palmetto.
We received this
tape but have had great difficulty in producing a provider match in which we
have confidence. We need your
assistance in giving our provider enrollment unit your new Medicare DMERC
provider billing number. Please
mail or fax us your Medicare number(s) and the one Medicaid provider number to
which crossover claims should be matched. Your
assistance will enable us to process the crossover claims quickly and correctly.
FAX Number:
(504) 342-3893
Mailing Address:
Bureau of Health
Services Financing
P. O. Box 91030
Baton Rouge, LA
70821-9030
Attn:
Provider Enrollment
If you have been
recently contacted by the provider enrollment staff about this matter, you need
not respond.