Provider Update
Volume 17, Issue 3
June/July 2000
Unisys Field Analysts Here to Help You
The Unisys Provider Relations staff strives to respond to provider needs quickly and efficiently. In addition to the telephone inquiry staff and the correspondence group, Unisys offers the assistance of Field Analysts who are available to visit providers, upon request, on-site and to provide training to new providers and their office staffs. Each analyst is responsible for a particular area of the state. Providers are encouraged to request an analyst visit to assist in training staff on billing Medicaid claims, resolving complicated billing issues, and understanding Medicaid policies and procedures.
If you have not had a recent field visit from your analyst and would like to schedule a visit, please contact Unisys Provider Relations at (800) 473-2783 or (225) 924-5040. The telephone inquiry staff will be happy to refer you to a Field Analyst who will schedule that visit.
The Field Analysts are also the primary presenters at the annual Louisiana Medicaid Provider Workshops held each fall. These workshops are most beneficial to providers and you are encouraged to attend. This year's workshops will include a new informational session covering LaCHIP eligibility and Medicaid services available to EPSDT recipients up to age 21.
The 2000 workshops will begin in mid-September. Please see the next issue of the Provider Update, as well as remittance advice enclosures during the month of August, for the schedule of these workshops. This schedule will also be available in July by calling Unisys Provider Relations at the numbers listed on this page.
Clarification of Aborted Procedures
We have recently received a request for clarification regarding Medicaid payment on claims for aborted procedures. Regardless of the reason the procedure was not performed, Louisiana Medicaid does not provide reimbursement for aborted procedures or for any charges related to the aborted procedure.
Hospitals Must Include Revenue Code
(FIMS # 5983
RA Message 4/4/2000, 4/11/2000, 4/18/2000)
Effective April 15, 2000, it is mandatory that hospitals include the revenue code with the HCPCS code when requesting prior authorization of outpatient hospital rehabilitation services. If the PA request does not include the revenue code, the request will be returned to the provider. If further questions arise, you may call Unisys Provider Relations at 1-800-473-2783 or (225) 924-5040.
Hints for Billing Threatened, Incomplete, or Missed Abortions
For the threatened abortion, please submit patient history, sonogram results, documentation of treatment, and discharge
summary.
For medical treatment of incomplete or missed abortions, please submit patient history, sonogram results, documentation of treatment, pathology report, and discharge
summary.
For surgical treatment of incomplete or missed abortions, please submit patient history, sonogram results, operative report, pathology report, and discharge
summary.
Daily nurses notes, physician order sheets, vital signs graphs, and other hospital records are not necessary.
Home Health Billing and PA Codes
(FIMS # 6019
RA Message 5/9/2000 and 5/16/2000)
When skilled nursing services are provided by a licensed practical nurse (LPN) or when physical therapy services are provided by a physical therapist assistant, the home health agency must use the following codes to request prior authorization and to bill for services. These codes are effective for dates of service on or after February 1, 2000.
| Service Code |
Procedure Code |
Description of Procedure Code |
| G = |
X9910 |
Initial Skilled Nursing Visit (LPN) |
| L = |
X9936 |
Initial Physical Therapy Visit (PT assist) |
| I = |
X9913 |
Skilled Nursing Visit After Initial Visit (LPN) (Limit 3 Per
Day) |
| J = |
X9915 |
Physical Therapy Visit After Initial Visit (PT assist) |
| K = |
X9916 |
Initial Skilled Nursing Visit for Multiple Recipients
(LPN) |
If additional assistance is required, please contact Unisys Provider Relations at (800) 473-2783, or (225) 924-5040.
Questions from 1999 Provider Workshops
DENTAL QUESTIONS
Q:Can the regular dental exam be billed by a different provider?
A:The periodic oral exam (00120) is limited to one per year per recipient. This procedure should not be billed by a provider if he/she has knowledge that the recipient has received this service within the last year from another provider.
Q:An emergency visit has to be billed alone - can the palliative treatment code be billed with the other work
codes?
A:Reimbursement will be made only for radiographs (00220 and 00230) on the same date of service that the palliative treatment (09110) is rendered. No other services will be reimbursed for the same date of
service.
Q:How does one determine if the code to be billed should be a palliative or emergency
visit?
A:Emergency exam (00130) should be billed only when no definitive treatment is rendered that could be billed under another code. Providers cannot bill these exams with any other procedures, except periapical radiographs or other authorized radiographs, on the same date of service. This procedure can only be billed once per year by the same provider. The recipient's complaint and what occurred at the emergency appointment (i.e., referral to a specialist, pain medication or antibiotics prescribed, etc.) must be documented in the patient's record. Palliative treatment (09110) is the treatment of a specific dental complaint. It is to be used when a specific procedure code is not indicated, but when a service is rendered to the patient. Records must document what was done as well as indicate which tooth or area of the mouth was treated. Providers may only be reimbursed for radiographs (00220 and 00230) on the same date of service that the palliative treatment is rendered. No other services will be reimbursed. This appointment requires documentation in the patient's record as to the problem and the
treatment.
Q:I have emergency exams denying when I have billed for periodic exams. Is that
right?
A:Emergency exams (00130) cannot be billed on the same date of service with any other procedures, except periapical radiographs or other authorized radiographs. The emergency exam can only be billed once per year by the same
provider.
Q:On third party coverage, do I have to get prior authorization for root canals when I already have PA from the recipient's
insurance?
A:A prior authorization from the dental consultants at LSU School of Dentistry is always required in order for the provider to receive payment from Medicaid for any services that require prior authorization. Insurance companies may not have the same requirements for authorization as the Medicaid Dental
Program
Q:Can I get a list of pedodontists?
A:Should a pedodontist be required, you may contact KIDMED by calling 1-877-455-9955 for referral assistance. You may also share this number with recipients for their use in obtaining referral
assistance.
Q:How many teeth will Medicaid pay to replace in an appliance per
year?
A:This procedure is not limited by the number of teeth. There is a monetary limit of $125.00 maximum in repair services per arch for the same recipient for a single one year
period.
Q:If a claim for appliance repair denies or exceeds the $125.00 maximum, can we bill the
recipient?
A:If the claim denies because the recipient has already reached the $125.00 maximum, then the recipient may be billed for the service. However, the provider must keep adequate record on repairs and should inform the recipient prior to performing repairs that he has reached the $125.00 maximum.
Q:I was told to put a check mark on the tooth if it was the second time it was replaced. Does the computer deny the claim if we haven't exceeded the $125.00 but we are replacing the same
tooth?
A:No.
Q:Is there a limit on the number of palliative treatments payable per
year?
A:There is no annual service limit for palliative treatments (09110). However, the treatment of a specific dental complaint, which could not be billed as any other procedure code, should be rendered in order to bill for the palliative treatment (09110). Detailed documentation should be kept in the patient's record regarding the problem and the treatment. Overuse of this procedure code may be reviewed by the dental
consultant.
Q:Why are claims for a periapical x-ray and a palliative treatment together sometimes
denied?
A:Questions such as this are difficult to answer without knowing the denial code for the specific situation. If there is a denial for billing for the periapical x-ray and a palliative treatment on the same date of service, the provider should review the denial code for the reason why it denied. Should you have further questions about the particular denial, you may contact Unisys Provider Relations or the Medicaid dental consultants at the LSU School of Dentistry for
assistance.
Q:What do we do to correct a name/number mismatch denial?
A:For a dental claim, the recipient's name should read, first name, then last name. Check your remittance advice and compare it to the claim form. The recipient name should be spelled exactly as it appears on the LA Medicaid Card. Should you need further assistance, contact Unisys Provider
Relations.
Q:Do I bill the third party first?
A:A Medicaid dental provider may bill Medicaid first for EPSDT dental services. Medicaid will process the claim; pay the provider if appropriate; and then pursue reimbursement from the third
party.
Q:Why are there instances when some lines on a multi-line claim are paid and others are
denied?
A:When a claim is submitted to Unisys for processing, each line of the claim is considered independently; therefore each line will either pay, deny or pend for review. Providers should check the remittance advice to account for each claim line. If a line(s) for a particular service is overlooked and not recorded on your remittance advice, that line(s) should be resubmitted for processing. If claim lines are pending, please wait for those lines to either pay or deny before taking action. If you have concerns about specific claims, please contact Unisys Provider Relations for assistance in resolving the
matter.
Q:How do we get paid for extraction of a supernumerary tooth?
A:For supernumerary teeth, a nonspecific oral surgery code (07999) must be used. In order to receive authorization, a request must be submitted to the dental consultants at the LSU School of Dentistry. Please note that if multiple supernumerary teeth must be removed, only one unit of 07999 will be approved. The fee authorized will be the total fee for all nonspecific services provided on that day. You may contact the dental consultants at the LSU School of Dentistry for more assistance with this
matter.
Q:How often may the 00130 code be paid?
A:The emergency or referral exam (00130) can only be paid once per year per recipient per
provider.
Q:What code do you use for an adult denture exam and x/ray?
A:The adult denture exam and x-ray code is 00110.
Q:If resubmitting a claim form on which some line items have been paid, is it better to draw a line through the paid items before resubmitting the
claim?
A:If you line through the items, be sure to do it neatly and change the total amount billed to match the total of all unlined items. To assist in processing, you should make certain it is
legible.
Q:What kinds of partials are provided for EPSDT recipients?
A:For the EPSDT dental program, one-tooth flippers (05820 and 05821) and acrylic partials (codes 05211[upper] and 05212 [lower]) are available for recipients under 21 years of age with prior authorization. Cast partials (05213 and 05214) are available for recipients between the ages of 18 through 20 years old with prior authorization. Please refer to the Medicaid Dental Services Provider Manual for requirements related to these procedures or contact the dental consultants at the LSU School of Dentistry for
assistance.
Q:We requested prior authorization for a root canal. The prior authorization was rejected because it appeared more work was needed, and the dental consultants asked how our doctor was going to treat it. What should we
do?
A:You should resubmit the request as soon as possible, providing the dental prior authorization unit with a complete treatment plan supported by sufficient radiographs, including bitewings to judge the oral health of the recipient. If the radiographs submitted indicate other necessary services have been completed, then a statement from the dentist stating that the services were completed should be sufficient and new radiographs are not
required.
Q:When the dentist cannot verify eligibility because the recipient has a different date of birth than the one on our files, what should be done? The parish office says they've made the change and are waiting for Unisys to correct the date of
birth.
A:You may use the recipient's social security number along with the Card Control Number (CCN) to check eligibility. You should advise the recipient to follow up on correcting the date of birth by calling the toll-free number on the back of his/her Medicaid
card.
Q:Why can providers file a claim electronically without a signature, but they have to put a signature on their paper
claims?
A:The providers who submit their claim forms electronically are required to sign a statement that verifies that the claims that are being submitted electronically contain accurate and true information. When submitting electronically, a copy of this statement must accompany each claims
transmission.
Q:Why are providers only getting paid on one jaw (of a denture), when both jaws are getting prior authorized under the same PA number? One is paying and one is denied as having no
PA.
A:Both the upper and lower denture should be paying if the prior authorization is approved and the claim is filed correctly. You should check the remittance advice. If there is evidence of a billing error, you should correct the error and resubmit the claim. If there is no evidence of a billing error, you may resubmit the claim or you may contact Unisys Provider Relations for assistance.
Q:What is the correct order to list the recipient's name? Why are doctors being penalized when one form has last name first and first name last and another form has first name first and last name
last?
A:Currently both the 1990 and the 1994 versions of the ADA Dental Claim Forms require the first name first and the last name last. The correct order for the recipient's name to be completed on a dental claim form is first name first and last name last. That is the order in which the claims processing system processes the
forms.
Q:If a patient is authorized for services and then loses eligibility during the course of treatment, how can we get paid for our
services?
A:Authorization does not guarantee payment or eligibility. The Louisiana Medicaid Dental Program can only pay for services for Medicaid eligible recipients. Eligibility should be checked by the provider each time a service is rendered to a Medicaid recipient. The Medicaid Eligibility Verification System (MEVS) provides hard copy proof of eligibility that can be used as verification of eligibility for claims payment purposes. The automated telephone Recipient Eligibility Verification System (REVS) may also be used to verify eligibility. In the event that a patient loses eligibility or discontinues treatment during the course of particular procedure (i.e., denture construction), the provider should send a request for review which includes an explanation of why the treatment was interrupted, along with documentation indicating the treatment plan, stage of completion, etc., to the LSU School of Dentistry Medicaid
Consultants.
DME QUESTIONS
Q:What is the delivery fee code?
A: It is Z9210.
Q:Am I correct in my understanding that it is optional to submit a reconsideration request and get a new PA date when the date of delivery is different from the approved PA
date?
A:Yes, but the date of service on the claim form must match the PA date of service for the claim to process. If the provider bills with the date of delivery on the claim and the date of delivery is outside the prior authorized date span or is different than the authorized date, the provider must submit a RECON with the delivery ticket attached. Once the PA date is changed, the provider may resubmit his/her
claim.
Q:How do you find out if a recipient is Community Care and has a PCP if you're not in a Community Care
parish?
A:Use REVS/MEVS to get the PCP name and phone number.
Q:If a recipient has Medicare and the claim crosses over, does the claim still have to have a PA number on
it?
A:No.
Q:I have had crossover claims deny with error code 191. Why would this
happen?
A:If Unisys processed the claim as a straight Medicaid claim rather than a crossover claim, it may have denied for PA. It is possible that the claim was processed as a straight Medicaid claim in error. For assistance with such specific claim issues, please contact Unisys provider
Relations.
Q:Can we get expedited approval for braces for a child that needs them right
away?
A:There are some circumstances in which an emergency request can be considered. See the provider manual for further
information.
Q:Does Medicaid DME cover a breast prosthesis?
A:Yes, but prior authorization must also be obtained for this, as with all DME
items.
Q:How can I, as a DME provider, be paid for glucometer strips and
lancets?
A:These are not payable items under the DME program. In the case of a qualified Medicare beneficiary (QMB), a DME provider may be paid for these items if Medicare pays and then the claim is crossed over to
Medicaid.
Q:If Medicare pays on the lancets and strips but Medicaid denies it as non-covered, can we bill the recipient for the deductible and
co-insurance?
A:Since these items are payable under the pharmacy program, it is best to refer the recipient to a pharmacy for such services. If they still to choose to utilize your DME facility for these supplies, you may charge the recipient for co-insurance/deductible, as long as the recipient is fully aware that they are liable for such costs and that they may avoid these charges by bringing the prescription to a pharmacy.
Q:Can we authorize and bill for delivery fees across state lines?
A:Billing for delivery fees has a direct correlation with the point of origin of the delivery. If the DME item is coming from a warehouse, the warehouse must be located outside of the parish in which the delivery is made. If the DME item is coming from the store, the store must be located outside of the parish in which the delivery is made. Obviously, if the delivery is going across state lines but originates within Louisiana (or vice versa), it meets the criteria to bill for delivery
fees.
Q:Can a physical therapist within a nursing facility be paid for the seating
evaluation?
A:No. The nursing facility should reimburse the therapist.
Q:Medicare does not cover canes for the visually impaired, and the Prior Authorization Unit denies the PA requests for Medicare coverage. How can I get this
approved?
A:Resubmit the PA with the Medicare denial showing non-coverage, along with the appropriate documentation to receive Medicaid approval. PA does not deny requests strictly for Medicare coverage. Please contact the PA unit for assistance in understanding the
denials.
Q:Does a PCP referral cover all services provided by DME?
A:The referral is only valid for a certain date(s) and within a particular diagnosis. If the recipient's needs do not correspond with that referral, another one will have to be obtained from the
PCP.
Q:Does the prescribing physician name need to be in block 17?
A:No.
Q:Is the delivery fee based on 10% of each item or the total delivery?
A:It is based on the total delivery for that date.
Q:Can the date on the claim be any date within the PA span?
A:Yes, in most cases. An exception is as follows: If the PA has been approved using spanning dates (the �from� date if different from the �through� date) AND the provider is billing for the total units or dollar amount approved under the PA AND the date of services on that claim is not a spanning
date.
Q:When we submit our PA, the PA unit is cutting back the units. How can we get more
authorized?
A:The physician must write a letter justifying the need for additional
supplies.
Q:Medicaid does not publish reimbursement rates for 880 PAC items. How are prices for these
determined?
A:There are many factors which affect the pricing of 880 PAC. You will know your reimbursement when you receive the PA
letter.
Q:In regards to those 850 PAC procedure codes which are now payable at 100% of the fee on schedule, when is the 100% rate
applicable?
A:The effective date of the code.
Q:When an item is rented and then Prior Authorization approves a purchase, is this considered new or used
equipment?
A:If the equipment was a brand new item when first rented, the recipient may keep that item. However, if the equipment was used when first rented, it must be traded out with a brand new item once the purchase is
approved.
Q:Do we need to have the recipient sign a waiver when we provide a procedure that is non-payable by
Medicaid?
A:Medicaid does not require a waiver in order to bill the recipient.
Q:What can I do if a patient has a nebulizer rental (which is used), gets approval for a purchase, and we cannot locate the patient in order to exchange the piece of
equipment?
A:You cannot bill Medicaid for the new equipment unless it is actually delivered and the recipient signs the delivery ticket verifying
delivery.
Q:Are Medicaid prescriptions valid for six months or longer?
A:They are generally valid for one (1) year. The Prior Authorization Unit may require that a prescription for a particular DME service be more recent to certify the current medical need. This is especially applicable when the client's condition is subject to change or when the client's utilization of disposable supplies is subject to
change.
Q:Is the name of the nursing facility required on the PA01? I have been receiving PA denials requesting that
information.
A:No, this is not a requirement. The Prior Authorization Unit should not deny any requests for this reason. If you have such denials, you need to contact the supervisor of the PA unit at Unisys (Stephanie Guarino (225)237-3224).
Q:Do you need a new prescription when a patient loses their hearing
aid?
A:Yes; a new prescription must be obtained.
Q:Can a nursing home receive a DME provider number and bill for enteral feedings under the DME
program?
A:Yes.
Q:Can a DME provider provide enteral feedings to a nursing home
patient?
A:Yes.
Q:The procedure codes listed on page 16 of the 1999 DME Training Packet have been changed by Medicare. Does Medicaid intend to change their codes as
well?
A:Oftentimes we will adjust our procedure codes to reflect those used by Medicare. However, the codes on page 16 of the DME Training Packet are currently valid for Medicaid. Please continue using these
codes.
Q:When a patient has dual eligibility, Medicaid is denying the Medicare EOB when procedure code E1399 is submitted. How can I get these claims
paid?
A:There are certain, specific times when the Medicare procedure code and the Medicaid procedure code do not match. In these specific cases, and these cases ONLY, you should send your claim with the Medicare EOB and a cover letter explaining this situation of mismatched procedure codes to the Provider Relations Correspondence Unit requesting special handling of the
claim.
Q:How can I get a listing of all physician Medicaid provider numbers?
A:This information is released to pharmacies only. Contact the Louisiana Pharmacy Association for such
information.
Q:Will REVS/MEVS continue to give PCP information?
A:Yes.
Q:Can you bill for delivery fee if the DME supply is within the same parish as the recipient, but it is being shipped from the warehouse which is not located in the same
parish?
A:Yes. Make sure the delivery ticket supports the delivery is out of
parish.
Q:If I have a 6 month supply, can I bill monthly or for all 6 months?
A:You may bill it monthly or wait until all the service has been performed and bill for the full PA. Please note, however, that supplies should only be provided to the recipient one month at a time during the 6 month certification
period.
Q:In order to update the PA, will it take another 25 days to adjust the date so that we may
bill?
A:You can do a reconsideration (recon) which takes considerably less time than a routine PA
request.
Q:Does the date on the PA01 have to be the delivery date or the date of the
script?
A:The PA01 requests both dates. Where you indicate the prescribing physician there is also a request for the prescription date. The form also asks for the anticipated date of delivery. This date should be as close as possible to the date you intend to deliver the
service.
Q:Is there a limit on the number of times you may submit a claim within that first
year?
A:No; but you should check the RA to determine why the claim is denying and make the necessary corrections to get the claim processed and
paid.
Q:Is Medicaid working toward something better than writing "DME" at the top of the
claim?
A:No, if you file hardcopy you must indicate the letters "DME" at the top of the claim. This is the only way it will process correctly. If you file electronically it is not
required.
Q:When you see a Community Care patient, do you have to get a referral from the
PCP?
A:Yes. Make sure the referral covers the condition and dates for which you are
billing.
Q:Medicare does not cover oral nutritional feedings. Will Medicaid pay for it without
PA?
A:No. You will have to get PA in order to bill it as a straight Medicaid
claim.
Q:If a service is non-covered by Medicare, do we have to submit it to Medicare and obtain a denial before Medicaid will
pay?
A:Refer to the list on pages 17 and 18 of the 1999 training packet. If your item is on this list, it should bypass the 275 error code and pay as a straight Medicaid claim. If the procedure code is not covered by this list, you will have to submit the claim to Medicare and send it to Unisys hardcopy with the EOMB
attached.
Q:When will there be a new manual?
A:DHH is in the process of revising the manual; no date has been set for finalizing this
process.
Q:Why isn't portable oxygen covered?
A:Any concerns about non-coverage of items/services should be addressed in writing to the appropriate DHH Program Manager, BHSF, P.O. Box 91030, Baton Rouge, LA
70821.
EPSDT QUESTIONS
Q:How many pairs of eyeglasses does Medicaid allow per year?
A:Medicaid allows 3 pairs per calendar year, without review. If additional glasses are needed, submit the claim hardcopy with documentation for
review.
Q:Do school boards, through the EPSDT Health Services Program, have to get a referral from a physician for audiologist services?
A:In order to bill for audiology services, you must have a physician referral (it cannot be from a nurse).
Q:Can we bill twice in one year for procedure code 92251?
A:Yes, as long as there are more than 180 days between the visits.
Q:When requesting a history, must we send the fee before we can get the
report?
A:At this time, we have suspended the fees for histories. It takes a week or two to generate the report and then it is mailed to you. However, when fees are charged for histories, it is necessary for the payment to be received before the report is
released.
Q:Can Unisys Field Representatives assist us with software problems?
A:No. Your software vendor should assist you with software problems.
Q:Is there a list of consult codes (�X� codes)?
A:Consult codes are not listed in EPSDT material because they are not EPSDT Health Services codes. Consult codes are payable to KIDMED providers and a list is included in the KIDMED
manual.
Q:What do we use to verify eligibility for REVS?
A:You may use either the 13-digit Medicaid ID number OR the 16-digit Card Control Number AND either the Date of Birth or Social Security number to access and verify eligibility through REVS. However, there is no printed verification of the information provided. Printed documentation of eligibility information may only be obtained by using MEVS.
Q:What is the telephone number for REVS?
A:REVS numbers are (800) 776-6323 and (225) 216-7387. These numbers can be found in the back of the 1999 training packets for each provider type,as well as in the Basic Training Packet. We ask that local Baton Rouge area providers use the local number to allow other provider greater access to the toll-free
number.
Q:Is MEVS a private company?
A:MEVS is an eligibility verification system, the Medicaid Eligibility Verification System. It was developed by Unisys for DHH to provide access to recipient eligibility information for LA Medicaid providers. There are four state approved private vendors who can offer you the hardware and software which will allow you to access the information on this system. You can obtain the names of these approved vendors from the Basic Training Packet or by calling Unisys Provider
Relations.
Q:Will the REVS line tell you if a recipient is a Community Care
recipient?
A:Yes; both REVS and MEVS provide this information and give you the name and phone number of the recipient's
PCP.
Q:Will the REVS line tell you who they are linked to for KIDMED
services?
A:No; in Community Care parishes where the PCP is required to provide KIDMED services, you will get the name and phone number of the PCP, but the KIDMED linkage per se is not given on the MEVS or REVS systems. It is necessary for you to call Birch & Davis/LA KIDMED for linkage
information.
Q:Are the Medicaid ID numbers on the EPSDT eligibility list correct?
A:Yes.
Q:How do we find out if a child is linked to another KIDMED provider when they move to another
parish?
A:Contact Birch & Davis/LA KIDMED for linkage information. If a child is not linked to a KIDMED provider you may bill for screening
services.
Q:What happens when a child moves out of the state?
A:Their eligibility with Louisiana Medicaid ends. You should let the parish office know of their
relocation.
Q:Should children have more than one eligible number now?
A:All recipients should have only one ID number from now on.
Q:Are physical therapy and occupational therapy evaluations allowed to be performed every 180 days? I know that speech evaluations can be performed only every 180
days.
A:No. Only speech evaluations are limited to once every 180 days under the EPSDT Health Services
program.
Q:Can we accept certified nurse practitioner referrals for PT or OT?
A:No. Referrals must be made by a physician.
HOME HEALTH/REHAB QUESTIONS
Q:The QMB identifying number no longer contains "17" in the third and fourth digits. How will we know that a recipient is a pure
QMB?
A:You need to access MEVS or REVS to get this information. The message for pure QMB's indicates eligibility for deductible and co-insurance for Medicare covered services
ONLY.
Q:We have many 191 denials even when we have the PA number on the claim in the remarks section of the claim. Why is
this?
A:Look on the RA and make sure the PA number was keyed correctly. If a PA number is not on the RA, it was either not on the claim or not keyed. If the PA number was keyed and is on the RA, make sure the correct PA was used for the charges you are billing. Refer back to the PA letter you received giving you
authorization.
Q:Can adjustments be sent electronically?
A:Yes, if you have the software capability. Contact your software vendor if you are unsure about your specific
capabilities.
Q:Do adjustments/voids have to have a certification like regular
claims?
A:Yes.
Q:Is there a list of reimbursements for Physical Therapy Rehab
services?
A:Yes, it is documented on page 22 of the 1999 Home Health/Rehab Training
Packet.
Q:Is there a list of physician numbers in the area that we can obtain?
A:This information is released to pharmacies only. Contact the Louisiana Pharmacy Association for such
information.
Q:How do you bill for extended visits?
A:Prior Authorization is required. All hours including the first hour per day are billed with service code �B.�
Q:Does the PA number go in the remarks section?
A:Yes.
Q:What is the maximum length of time for which rehabilitation services will be approved before an extension must be
requested?
A:Normally, six months is the maximum. One year may be prior authorized for chronic conditions/ illnesses for recipients under 21 years of age if documentation is submitted justifying medical
necessity.
Q:Can I use the UPIN in block 10 of the claim form because that is what I have always
used?
A:You must use the referring physician's name. Louisiana Medicaid does not recognize the
UPIN.
Q:Can a copy of home health call-in orders be used to request home health
extensions?
A:No; the request should come in on the physician's letterhead with a
signature.
Q:Can physical therapy be provided in a Medicare approved facility?
A:Yes; however, coverage has to do with the recipient's level of care. We will only approve therapy for recipients who are ICF-I or ICF-II level of
care.
Q:Is the amount billed required on the PA01?
A:No.
Q:If we billed Medicaid and received payment, but should have billed Medicare first, what should we
do?
A:You should void the claim to Medicaid and then bill Medicare.
Q:Can you get an extension for multiple visits for adults?
A:No, this is not a covered service. It is only approvable for patients under the age of
21.
Q:How can we know when eligibility begins? We are a hospital based home health
provider.
A:Only the parish office can tell a provider when a recipient became
eligible.
Q:Can you bill the patient for services when he/she was not Medicaid
eligible?
A:Yes.
Q:When submitting a PA07 for 6 months, do we have to periodically submit signed plans of care as updates during the 6 months that are
approved?
A:No, these should be kept on file and may be needed when applying for an
extension.
Q:Does it matter if a Physical Therapy visit lasts 30 minutes or
longer?
A:It depends on what length visit was authorized. You can only bill for the visit up to what was
authorized.
Q:Do all Medicaid patients require a letter or prescription from the physician every time they are admitted, or only once a
year?
A:Each time they are admitted.
Q:Do we need a prescription each time the patient goes from Medicare to Medicaid, or is this for PCP patients
only?
A:All home health services for Medicaid recipients require a prescription.
HOSPITAL QUESTIONS
Q:Ambulatory surgical centers are reimbursed for services not listed as a grouping at a flat rate of $300.00. Is there any similar flat rate payment? Is there any similar flat rate for outpatient procedures not billed as a 490 revenue
code?
A:Outpatient procedures not billed with revenue code 490 are paid at either a percentage of billed charges or, if billed using revenue codes 300-319, at a flat
rate.
Q:May we bill a mammogram for a recipient under age 40?
A:Yes, if the service is diagnostic. The diagnostic Revenue Code is
required.
Q:Are error codes 172 and 173 in place?
A:Currently, these are educational edits; however, they will be activated in the near
future.
Q:Previously, we were paid for dates of service on an outpatient claim as Medicaid only. Now, our subsequent claims for the same dates of service are being denied for Medicare eligible (error code 275). Why is
this?
A:Our eligibility files are updated daily and the first claim was paid before Medicare was added to the recipient�s eligibility
file.
Q:When we bill speech and audiology evaluations for same date of service, one is denied as a duplicate (error code 813) and the other pays.
Why?
A:This problem has been fixed.
Q:If a recipient doesn't use their HMO and Medicaid denied the claim because the HMO must approve first, can we bill the
recipient?
A:Yes. The hospital�s admissions department should refer the patient to the HMO provider. The policy is the same whether the service provided was outpatient or inpatient. If eligibility is checked prior to providing services, REVS and MEVS give TPL information as a part of the eligibility
response.
Q:We have two physicians employed by the hospital. If they give injections in the hospital-owned clinic, should the injections be billed on the UB-92 or the
HCFA1500?
A:On the HCFA1500. Please note that the type of injections covered by Medicaid is limited. Refer to the Medicaid Physician Services Provider Manual and training packet.
Q:Are you accepting fifth digit diagnosis codes?
A:Yes.
Q:Crossovers on swing beds are being paid at zero. We are a small rural hospital so should we be receiving zero
payments?
A:It is possible that you qualify as a small rural hospital but are not loaded on the system as such. Contact
DHH.
Q:We billed a sterilization that followed a c-section and cannot be paid for this.
Why?
A:A specific claim example is needed in order to answer this question. Please contact Provider Relations or your field analyst for
assistance.
Q:Can we bill the recipient when some of the days are not precertified?
A:No.
Q:How do we get paid for days where Medicare Part A ends during the hospital stay and now the recipient is eligible for Part B
only?
A:You must pro-rate the bill for Part A eligible co-insurance days, and attach a note to the bill explaining that the EOMB does not match your claim form because you have pro-rated your payable co-insurance days. Make sure you send it to the Unisys Provider Relations Correspondence Unit with a cover letter of
explanation.
Q:What happens when a recipient comes into the emergency room and thinks she is pregnant? Should we bill the prenatal panel
codes?
A:No, you should not bill the prenatal panel codes until pregnancy is confirmed. These codes are for lab services when the pregnancy is known and the patient is receiving their initial prenatal
visit.
Q:Should we put all emergency room charges on the UB-92 when the patient is admitted to the
hospital?
A:Yes, all ER charges should be billed under revenue code 500.
Q:Are foster children only allowed three emergency room visits per
year?
A:Yes, three emergency room visits.
Q:Can we bill professional fees on the UB-92?
A:No, all professional fees should be billed on the HCFA-1500.
Q:Who will get paid first, the ER physician or the admitting
physician?
A:For recipients aged 21 or older, the physician whose claim is submitted and processed first will get paid.
Q:Are all Part B charges billed to Medicare before submitting to
Medicaid?
A:Yes.
Q:Why does it take so long to process Medicare Part B claims? We have claims that took up to three months to
process.
A:Medicaid policy states that providers should allow approximately 30 to 45 days from the Medicare payment date for claims to cross over from Medicare electronically. If the crossover claim does not appear on the Medicaid remittance advice within that time, submit the claim hard copy with the Medicare EOMB attached. This hard copy submission will take approximately 30 days to be processed by
Medicaid.
Q:Can we bill a $0.00 charge for EMC voids?
A:No, EMC will not allow a void to process with a $0.00 charge.
Q:Can we adjust third party claims electronically?
A:No, this has to come hardcopy with EOB/attachments.
Q:A patient came into the ER twice in the same day. When do we obtain precert if the patient is
admitted?
A:The precert should begin with the first ER admit time.
Q:Can we use revenue code 174 along with revenue code 171 for UB-92
charges?
A:You can only use revenue code 174 if you are a Medicaid recognized NICU facility. If you are not recognized by Louisiana as a NICU facility, then you should use Revenue Code 171 for those
charges.
Q:When a recipient presents his/her Medicaid card and the control number is given, how do we obtain the correct Medicaid number if the recipient is not found on the eligibility file when checked through MEVS or
REVS?
A:You will need to call 1-800-834-3333. This number can be found on the back of the ID
card.
Q:How long does it take for a pending application to be filed? How can we get the correct policy number when
pending?
A:This information must be obtained by contacting the parish office handling that recipient's
case.
Q:Why can't the blood deductible be paid on a Medicare/Medicaid claim?
A:The blood deductible should be paid until 7/1/99, when Medicare Part A crossover processing
changed.
Q:We have instances where we bill for co-insurance/deductible for crossover claims but the dates cause a conflict due to Medicaid's fiscal year. How should we file these claims so proper reimbursement is
received?
A:You must split bill the claim at the end of the fiscal year. Attach your EOMB indicating how much deductible and co-insurance to apply to both. This must be sent to Provider Relations with a cover letter for special
handling.
Q:If there is an inpatient psychiatric patient that needs surgery during his/her hospital stay, should we bill the outpatient surgery on a separate claim? Would we get denied for outpatient rule? Our psychiatric facility has a different provider number than our acute or outpatient
facility.
A:All charges and services performed for a patient while inpatient at the facility must be included on the inpatient claim. The provider is responsible for paying the other facility for any services performed for a patient while he/she is inpatient at the provider�s
facility.
Q:If there are two applicable procedure codes, should we file revenue code 490 with both codes using $1.00 as the cost of the 2nd procedure
code?
A:Each 490 Revenue Code should be billed. The second 490 code and each additional must have a charge of
$1.00.
Q:If we bill ambulatory surgeries (HR 490) and itemize other charges with other revenue codes, will our claims be
denied?
A:No. DHH has requested that hospitals itemize charges for data collection purposes as they consider moving to APG billing. For ambulatory surgery (HR490) claims, the ambulatory surgery line will pay with a flat group rate, and all other claim lines will deny with error code 266 (�revenue code invlaid for ambulatory
surgery�).
Q:Do electronic billers have to itemize the 490 procedures?
A:No, not at this time.
Q:If the primary procedure is not one that falls within the four flat fee groupings, but a secondary procedure is, will the payment be a grouping flat
fee?
A:Yes.
Q:Why doesn't the revenue code 500 appear on our inpatient bills when keyed
electronically?
A:Check with your software and billing company. Nothing should stop this revenue code from appearing when billed
electronically.
Q:Can we get an updated list of error codes?
A:We are currently reviewing this request.
Q:Should the SNF Medicare provider number be linked to our acute Medicaid provider
number?
A:Yes, for automatic crossover processing.
Q:When submitting a PA07 for six months, do we have to periodically submit the signed plan of care as updates during the six months that are
approved?
A:No, these should be submitted when filing for an extension.
Q:If a patient comes in for ambulatory surgery and stays for 24 hours, and two minutes because he had to wait for a ride and the hospital chooses to bill only for the surgery, will this be
covered?
A:The time element in regard to the 24 hour rule ends at the time in which the hospital discharges the patient. If the patient was in the facility for 24 hours and 2 minutes before the patient is
dishcarged, then you will need to obtain pre-cert for those charges and bill the claim as an inpatient charge. However, if the patient was in the facility for less than 24 hours when
the patient is discharges, but the patient stays on the facility's property while waiting for transportation home, then you would bill the service as an outpatient claim and no precert would be needed.
Q:How do we notify a patient if the services are non-covered and whether or not they are responsible for
payment?
A:Notification should be given prior to the service being rendered.
Q:If a patient is an inpatient in one facility and then is brought to another facility for an outpatient procedure, how does the second facility bill for those
services?
A:The initial facility that had the patient admitted as an inpatient is responsible for reimbursing the second facility for that service. If the patient develops a complication at the second facility and must be admitted, the first facility must discharge the patient in order for the second facility to obtain precert on the admitted
patient.
Q:If a patient is transferred to a nursing home or another facility by the hospital-based ambulance, how can the hospital obtain payment for the ambulance
service?
A:Medicaid will only pay the hospital-based ambulance for emergency runs. The other facility will have to pay the transporting
hospital.
Q:Hospital outpatient rehabilitation units are having difficulty getting their PA letters timely. In many cases, it is necessary to begin rehab services before the authorization is received. When the recipient calls for transportation to the rehab unit for services, the dispatch offices will not schedule the transportation because they have not received a copy of the PA letter either. What are we to do about this problem?
A:DHH will not authorize a transport until the rehab authorization has been
done.
KIDMED QUESTIONS
Q:When the patient come in to have WIC-17 forms completed, we are required to weigh, measure, complete growth chart, copy paperwork, and sometimes have blood work drawn. Can we charge for an RN consult (X0187)?A:If the WIC form is completed within 60 days of a KIDMED screening, it is included in the screening. If the WIC form is completed more than 60 days after the KIDMED screening, you may bill X0187.Q:Why are so many newborn ID numbers not being made effective retroactive to the date of
birth?
A:It is necessary for you to contact the appropriate Medicaid parish office to obtain information concerning this
issue.
Q:When a claim is resubmitted, should it be dated with the date of resubmission next to the physician's
signature?
A:Yes, the date of resubmission should be indicated on the claim form.
Q:Is it possible to get a list of all claim denials for the past few
months?
A:Yes, you may order a claims history from Unisys.
Q:Is there any possibility of KIDMED timely filing being extended past 60
days?
A:No. DHH has stated that this requirement will remain in effect.
Q:Does Unisys have a list of vendors who have KIDMED software (other than the "free data
software")?
A:No. However, you do have two options for electronic submission. First, you may utilize the Keymaster software that Unisys supplies (free of charge) for KIDMED providers; Second, you may request the KIDMED specifications from the Unisys EMC Department and contract with a software vendor to write the program for you. There is no charge from Unisys for these specifications; however, you may incur a cost from the vendor you choose to write the software.
Q:There is a new vaccine that is given to children. It is a comb/vaccine of hepatitis and HBV, with procedure code 90748. I have contacted both Unisys and Vaccines For Children (VFC), as well as reviewing the ICD-9-CM Coding book. No one can give me an ICD-9-CM diagnosis code for this vaccine. Can you help
me?
A:You should use the most appropriate ICD-9-CM diagnosis code.
Q:Are there any charges that can be billed that are not included in the flat rate reimbursement for KIDMED Medical
Screenings?
A:Yes - labs codes that are not included in the flat rate reimbursement; low level in-house referrals; and
immunizations.
Q:If a KIDMED patient is seen for a screening and has an acute problem (such as bronchitis), can this visit be billed through normal
channels?
A:The child may be referred in-house to a qualified practitioner, and the visit may be billed on the HCFA 1500 claim form. Only a low level office visit on the same day as a screening by the same provider will be
reimbursed.
Q:Should flu, pneumonia, and other vaccinations be billed under KIDMED, or can they be billed through normal
channels?
A:Bill on HCFA 1500 claim form using immunization CPT codes covered through
VFC.
Q:I am still confused about who can receive immunizations.
A: Medicaid reimburses for immunizations covered by the VFC program for recipients under age 21. Reimbursement is for administration fee
only.
Q:We have a child that comes to our office that was born in March, 1999. I was told by his worker that his case had been closed and he was no longer Medicaid eligible. Shouldn't his Medicaid number have been good for one year? It was only good for the months of March and
April.
A:You must contact the appropriate Medicaid parish office for assistance with this
issue.
Q:Can a social worker bill for X0182?
A:If the child has received an age appropriate KIDMED screening, the social worker may perform the service; however, it must be billed under the appropriate KIDMED provider
number.
Q:Is it necessary to complete the race block on the KM-3 claim form?
A:No. That block is not a required block for processing the claim.
Q:If a parent calls with concerns about the child, can this be considered a referral for an interperiodic
screening?
A:Yes.
Q:If a child fails his hearing screening because of an ear infection, can an interperiodic screening be
billed?
A:No. Interperiodic screenings are for medical screenings only. An appropriate referral for treatment may be made for diagnosis and
treatment.
Q:What is the difference between an interperiodic screening and a regular evaluation and management
visit?
A:KIDMED providers are required to provide all five components of the periodic screening when billing for an interperiodic. Interperiodic screenings are for medical screenings, whereas evaluation and management visits are for diagnosis and
treatment
Q:The varicella vaccine is payable for those greater than 12 months of age. What are the
limitations?
A:The varicella vaccine can be given to recipients age 1 through age 16.
Q:Since the procedure codes were not loaded until September 1999, can we bill for vaccines given since January 1,
1999.
A:Yes. However, the claims must be received before the one year timely filing limit
lapses.
Q:Does Unisys keep paper claims?
A:Paper claims are microfilmed and then archived.
Q:The ID cards indicate the card control number. Shouldn't the recipient know his/her Medicaid
number?
A:No. The plastic ID cards only have the CCN number. You need to access REVS/MEVS to obtain recipient eligibility information, including the permanent recipient ID
number.
Q:Can the automated lines give out KIDMED linkage?
A:No. It can give you Community Care linkage, but you will need to contact Birch and Davis/LA KIDMED for the KIDMED
linkage.
Q:Can a retroactive eligible case include those instances when newborns are born to Medicaid moms but parish office neglects to give them eligibility effective on the date of
birth?
A:Yes.
Q:Are newborns automatically eligible for Medicaid if the mother is Medicaid
eligible?
A:Yes. The newborn will automatically receive Medicaid eligibility for the first year of
life.
Q:Do we need to wait until the recipient is linked to us to bill for
screenings?
A:No, you do not have to wait until a child is linked to you, but if that child is linked to another KIDMED provider, your screenings will deny. Please call the Birch and Davis/LA KIDMED to check KIDMED linkage before
screening.
Q:Can a recipient be linked to a KIDMED provider and a Community Care
provider?
A:Recipients who reside in Community Care parishes and who are Community Care recipients cannot be linked to separate Community Care and KIDMED providers. The Community Care PCP must provide KIDMED services for these
recipients.
Q:If a Community Care recipient has not chosen a PCP but eventually does choose one, or one is assigned to them, does the date of PCP linkage become effective on the date of
eligibility?
A:No. The linkage to the PCP becomes effective on the date indicated on the Unisys system.
Q:Does the periodic screening require a referral if the screening provider is a school board with a new child entering the
school?
A: If the recipient is Community Care, all services must be either provided by or referred by the PCP. If not Community Care, periodic screenings do not require a referral; however, the screening provider should check with the KIDMED office for linkage.
Q:Can you do an interperiodic screening at the mother's request?
A:Yes.
Q:When would it be appropriate to use a consultation code?
A:This is defined in the KIDMED Provider Manual. Please refer to those
definitions.
Q:What is the time frame for submitting turnaround documents?
A:If you are billing hardcopy (on paper), the turnaround document must be received within 30 days. If you are billing electronically, we suggest that you simply resubmit the claim electronically (with the appropriate corrections) as this will expedite the processing of the
claim.
Q:We have problems with patients that have TPL insurance on your file but the patient no longer has that
coverage.
A:If you cannot get this resolved through the appropriate parish office, send the claim, a letter from the insurance company (indicating that the recipient is no longer covered), and a cover letter of explanation to the Unisys Provider Relations Correspondence Unit. Unisys will forward the information to the DHH TPL Unit. This unit will follow up on the matter with the insurance company and correct the recipient file if appropriate.
Q:Do we have to bill the TPL for KIDMED screenings?
A:No. A KIDMED provider should bill Medicaid first for screenings. Medicaid will process the claim; pay the provider if appropriate; and pursue reimbursement from the third party carrier. (This process is called "pay and
chase".)
Q:If a child has primary insurance that does not cover vaccines, is it necessary to send the child to the health department for
vaccines?
A:If the vaccine is given as a result of a KIDMED referral (�Y� is marked in block 24Hof the HCFA 1500) or if the diagnosis on the claim is a primary preventive pediatric diagnosis (see page 35 of the 1999 Basic training packet), then the provider may bill Medicaid directly without billing the other insurance. Otherwise, you will need to file the claim to the primary carrier(s) in order to receive the denial EOB. Then submit the claim (with the appropriate TPL carrier code in block 9A and the EOB attached) to Unisys. The only exception to this procedure is if the vaccine is given as the result of a KIDMED referral and a Y is marked in block 24H on the HCFA
1500.
Q:We have a child that was on our RS-0-07 but when billed the child was not eligible. How could that
happen?
A:That report is not proof of eligibility. You need to verify eligibility every time a recipient comes into your
office.
Q:Since you can no longer identify the parish on the ID card, do you still have to call that parish
office?
A:Yes.
Q:Can a child who is on the waiver list receive PCS services?
A:Yes. As long as the child is not receiving PCA services, he/she may receive PCS services. If he/she has already been given a waiver slot and are receiving PCA waiver services, he/she cannot receive PCS services since this is considered duplicative
services.
Q:If an individual misses his/her screenings, can he/she be removed from
Medicaid?
A:No, the child cannot be removed from Medicaid. However, if you no longer wish to have this person linked to you as a KIDMED recipient, you should contact Birch and Davis/LA
KIDMED.
Q:Is DHH considering an increase in immunization reimbursement for recipients between the ages of 18 and 21 since VFC does not cover immunizations for individuals who are 18 years of age or
older?
A:DHH is aware of this situation. Should a decision be made to change this reimbursement, providers will be
notified.
Q:Are the 1999 CPT codes retroactive? If so, to what date of service?
A:The 1999 CPT codes are retroactive to January 1, 1999.
Q:If a child comes in with a Medicaid card, how should we verify eligibility and obtain an ID
number?
A:Use REVS or MEVS. The eligibility response includes the permanent recipient ID number. This information is described in the Medicaid Basic Training
packet.
Q:Does timely filing affect the frequency with which the child can be
screened?
A:No.
Q:If we miss getting our screening claim submitted within 60 days for the date of service, can we bring the child in again, screen the child, and bill for the
screening?
A:No. Failure to bill timely does not justify performing unnecessary medical
services.
Q:If another provider sees a patient for a high level visit on the same DOS that we provide a screening, will we be paid if the other visit has already been
paid?
A:Yes. That policy only affects the same provider billing office visits and screenings on the same date of
service.
Q:Is Rocephin payable?
A:The physician may write a prescription for Rocephin and have the recipient obtain the medication
from a pharmacist. (This will be billed through the Medicaid pharmacy services program.) Then the physician may administer the injection to the patient. If the physician only administers the injection, only procedure code 99211 may be billed. If the physician performs the components of a higher level office while giving the injection, he/she may bill for the appropriate level office visit.
Q:One of our new patients is still receiving mail from the provider to which she was formerly linked. That provider is trying to get her business. What can be
done?
A:The patient (or family) may call that provider and ask to be taken off their mailing
list.
LONG TERM CARE QUESTIONS
Q:What adjustment form should be used if we are paid for a patient that is no longer in our
facility?
A:Use the 212 adjustment /void form.
Q:If the patient goes into the hospital at the end of the month and continues into the next month, how should we indicate the hospital leave on the following month's
TAD?
A: Report all hospital leave days for each month. Ex: Recipient went to the hospital on April 28 at 7:00am and returned to the nursing home on May 5 at 3:00pm. On the April TAD you would show hospital leave days as B-29 to 30. On the May TAD you would show hospital leave days as B- 01 to 05. The system would pick it up as a continuous hospital stay.
Q:Why are some claims on the TAD not acknowledged at all? Can I resubmit them
immediately?
A: In the LTC department at Unisys, there are several things that are screened for prior to input by Data Entry. If information and/ or documentation is incomplete or missing, the TAD lines are are not input by Data Entry. Some examples are:
1). Medicaid Vendor No. on the 51NH and the Provider No. on the turnaround document must match.
2). Action Code "A" must always be used anytime you add a recipient on a blank TAD line.
3). When adding a new recipient for the first time, you must:
-attach the 51-NH, and
-block no. 6 (date vendor payment begins) on the 51-NH must be completed with a date that matches the cert date and the from date of service (for the initial month of entry) on that TAD line.
4). When adding a recipient that has been discharged and readmitted back into your facility, you must:
-attach the 51-NH, and
-block no. 6 (date vendor payment begins) on the 51-NH must be completed with a date that matches the cert date and the from date of service (for the initial month of entry) on that TAD line.
5). When rebilling for a recipient that was previously denied:
-If the span of time between the certification date and the date of service on the TAD line is one year or less, send a copy of the 51-NH for the initial certification month.
-If the span of time between the certification date and the date of service on the TAD line is over one year , send a copy of the 51-NH for the initial certification month. You must also give a detailed explanation as to why you are adding
this recipient back onto the Turnaround Document. If you have an RA which shows a denial reason(s), you can submit it instead of the detailed explanation.
6). If the date of service on the TAD line is prior to the cert date (block no. 6 on the 51-NH), the TAD line will not be input.
7). If you are adding a new entry (refer to answers for numbers 3, 4, and 5 of this question) and block no. 6 on the 51-NH is blank, but block no. 7(effective cert/change date) on the 51-NH is completed, or if both block no. 6 & 7 is complete on the 51-NH, we cannot input the TAD line(s) for that individual recipient.
8). If there are two dates in block no. 6 on the 51-NH, we cannot input the TAD line(s) for that individual recipient.
9). If the date of service on the TAD line(s) is over one year old and the date completed on the 51-NH is over one year old, you must have proof of timely filing(RA) in order for Unisys to input the TAD line(s) for that individual recipient.
WE CAN NO LONGER ACCEPT COMMENTS SUCH AS 51- NH IS ON FILE, REBILLING FOR DENIED CLAIMS.
IF YOU SUBMITTED LINES ON THE TURNAROUND DOCUMENT THAT DO NOT APPEAR ON YOUR REMITTANCE ADVICE, PLEASE DO NOT RESUBMIT YOUR BILLING UNTIL YOU HAVE THE CORRECTED INFORMATION NEEDED FOR INPUT. IF YOU SEND THE SAME INFORMATION, YOUR SUPPLEMENTAL BILLING WILL NOT BE INPUT.
Q:How long do I wait for forms 212 and 148-PLI to be paid or denied?
A: Approximately four to six weeks
Q:If a claim is voided in error, how can we resubmit?
A: You must add that claim line back onto the TAD and write a detailed explanation outlining the reason (s) you are rebilling for that individual on the blank TAD line.
Q:I need to know more about the information flow from 142 to 148 to 18-LTC and 51-NHs. It takes three or four months to get the 51-NH and then it isn't filled out properly. I have to send it back to be redone. Sometimes the person has died by
then.
A:This question was forwarded to DHH for review.
Q:Explain the difference between Case ID number and Person ID number.
A:Louisiana Medicaid recipients are identified by two assigned numbers: the 13-digit recipient ID number and the 16-digit card control number. Either number can be used to verify eligibility, but only the recipient ID number can be used for billing purposes. The Case ID number is a number assigned by the parish office to identify the Medicaid case (which normally included all household members). This is not a number used by the Medicaid
system.
Q:Why does a billed claim not appear on the RA if billed correctly?
A:If claims are billed correctly, they should appear on the RA. Some claims are rejected and sent back to the provider before they enter the processing system because of incomplete or missing information. It is necessary to see specific examples in order to answer this
question.
Q:Why do adjustments or voids come back showing no history record on file (error code 799) for adjusted/voided
claims?
A:Usually, this means that the ICN entered on the adjustment/void form by the provider is incorrect or that a data entry error was made when entering that ICN. However, Medicaid claims history is driven by the recipient's original Medicaid Identification Number. There have been times when this original number has been changed or purged by DHH. If that happens, you cannot adjust a claim processed under that original, purged ID number even though the history is in the system. Once this is determined, the only way to adjust a claim is to send the information to the Financial Department at DHH. If you owe DHH money, you should send a refund check with the claims information to DHH Finance. If DHH owes you money, send a letter of explanation and the claims information to the Finance Department and you will be reimbursed. If an adjustment is denied with error code 798 (history record already adjusted), the ICN has already been adjusted. In that case you must use the adjustment control number(ICN) in order to readjust the claim. Do not use the ICN from the original
payment.
Q:We are having problems with 51-NHs being needed for changes in Level of Care. As a hospice provider, we do not receive these forms and have been denied many times this year.
Why?
A:Hospice claims do not require a 51-NH for any of their billing. If you are having claims denied with error code 355 (�no 51-NH attached�), please contact the LTC Department at Unisys and they will research the problem.
Q:We have had problems with incorrect patient liability being withheld from our payment. Is there a way for Unisys to get the correct patient liability amount from the Medicaid
office?
A:For claims processing purposes, patient liability information is taken from the recipient file which is updated by DHH. The only way to correct the payment in Unisys� system is to submit a 148-PLI adjustment for each month where incorrect liability was
deducted.
Q:It is sometimes difficult to get a call back from the Unisys LTC Unit. Sometimes, when callbacks are received, a message must be left, and we must try to call that unit again. This phone number is long distance. Is there a toll-free phone number to reach that
unit?
A:You may contact the Unisys LTC Unit by calling (225) 237-3259. There is no toll free direct line for this unit.
Q:When will we be able to submit the TAD electronically?
A:At present we are unable to accept electronically filed TADs, and there are no definitive plans to accept electronically submitted
TADs.
MENTAL HEALTH REHAB QUESTIONS
Q:If the patient is Medicare/Medicaid, will Medicaid pay for Mental Health Rehab
services?
A:Medicaid will pay unless the patient is a pure QMB recipient.
Q:Would it be wise to keep a hard copy backup if we file
electronically?
A:Yes.
Q:If we check eligibility at the beginning of the month and the recipient is eligible, does that mean that the recipient is eligible for the entire
month?
A:Yes.
Q:If our service dates cover both June and July, and the recipient is eligible for the month of June but not for the month of July, can we bill for the July dates of
service?
A:No, you may only bill for eligible dates of service.
Q:Can we bill on the UB-92 form?
A:No. Mental Health Rehab providers must submit claims on the HCFA 1500
form.
Q:Are recipients who are wards of the state eligible for MHR services?
A:The individual must be Medicaid eligible, have approval from the agency that has guardianship, and the service must be prior
authorized.
Q:When billing for services, how many face-to-face contacts does a clinical manager need with an adult and with a child? Some documentation indicates one for an adult and two for a child. I was under the impression that two face-to-face contacts for adults and four for children are required. Please verify which is
correct.
A:Please refer to page 7-10 of the Mental Health Rehab provider manual or page 6 of the 1999 Mental Health Rehab Training Packet. Clinical managers must have one face-to-face contact every 30 days for adult recipients and two every 30 days for children. The following circumstances will meet the two contacts for children: (1) Two contacts with both child and parent/guardian; (2) One contact with child alone, and one contact with the parent/guardian. These contacts cannot be on the same
day.
NEMT QUESTIONS
Q:What type of licensure does an NEMT driver need?
A:A chauffeurs or commercial license is required.
Q:Can I transport a patient to another city or state?
A:Yes; however, for out -of- state travel you must carry a minimum of a $1.5 million dollar insurance
policy.
Q:Has the number of years for retaining records gone up from three to five
years?
A:Yes; it changed in August 1997. This change was published in the 1998 training
packet.
Q:Does Part 3 of the MT-3 form have to be completed by the physician?
A:No.; it can be authorized by any staff member of the office/clinic.
Q:Is there a possibility of a cost of living increase for NEMT
providers?
A:DHH is responsible for increases in reimbursement. Unisys is not aware of any changes in reimbursement at this
time.
Q:If a recipient name is three characters long and has a title, such as Jr or Sr, we are receiving 217 denials (name/number mismatch). How do I get these claims
paid?
A:Enter the name on the claim exactly as it appears on the recipient's Medicaid ID card, and send the claim with a cover letter of explanation to the Provider Relations Correspondence Unit (P.O Box 91024 Baton Rouge, LA 70821). Be sure to indicate in the cover letter why the claim denied. Unisys will special handle the claim so payment can be
made.
Q:How do I resolve denied claims?
A:At the end of the claims listing on the Remittance Advice (RA) is a page titled "Error Description" which lists each error code received on that RA and what the denial code means. Many times that error code is explicit enough to determine why the claim denied. If the claim denied for a reason that you cannot understand, you may call Unisys Provider Relations at the phone numbers above and request a field
visit.
Q:If a child has a doctor's appointment and the attendant requests other children be allowed to accompany them, are we required to transport the other
children?
A:No.
Q:Recipients often complain when we pick them up one hour before their appointment. Does regulation allow us to do
this?
A:Yes.
Q:How many dry runs is a provider required to make?
A:We do not have any requirements for dry runs. You have the right to refuse transportation to recipients who continuously cause dry runs. Advise the Dispatch Office that you will not offer your services to those recipients.
Q:If the recipient does not return with the provider, does the driver have to sign on the line that says the patient returned
home?
A:Make a notation on the MT-3 that the patient was not returned to the home by the driver with the
reason.
PRE-CERTIFICATION QUESTIONS
Q:If a patient is in observation, do we need to send a PCF01?
A:No; you do not need to send a PCF01 until the patient has been deemed
inpatient.
Q:What time should we use on the PCF01 as the time of admit if the patient comes in through the emergency room and is then
admitted?
A:Use the time the patient came into your facility.
Q:If a patient comes in through the emergency room and is placed in observation, do we fill out a
PCF01?
A:No; only if the patient stays longer than 23 hours 60 minutes and becomes inpatient should you send a PCF01. In those cases, you must go back to the point the patient arrived at the hospital for the precertification request.
Q:Do the fax lines automatically roll to the next available line?
A:Yes.
Q:If a patient comes in to our facility observation room at 6 a.m. and is then admitted at 4 p.m., what admit time do we
indicate?
A:The first point of entry into your facility (which in this example is 6 a.m.) is the admit time, and the patient must be pre-certed back to that
time.
Q:When a patient comes in through the ER and is admitted once the 23 hours 60 minutes has passed, does the patient have to meet InterQual
criteria?
A:A PCF01 should be submitted. The admit time should be backdated to the time the patient came into the ER. You don't need to meet InterQual criteria for the ER. However, documentation for any outpatient procedure must be submitted to justify the
procedure.
Q:After a reconsideration is denied, how quickly can I get a doctor-to-doctor
conference?
A:If the patient is in-house, usually within 2 days. If the patient has already been discharged, there is no time frame. Your only consideration is the timely
filing.
Q:How long does it take to get a doctor-to-doctor review?
A:It depends on the availability of the doctor at your facility.
Q:When a hospital doctor is scheduled for a doctor-to-doctor conference and cannot meet the schedule because of an emergency, why is the doctor-to-doctor rescheduled at the end of the waiting
list?
A:Because there are a number of other providers who have been waiting for a conference as
well.
Q:Does the Unisys physician have to be the same sub-specialty as the hospital physician in the doctor-to-doctor
conference?
A:No; however, a psychiatric request is reviewed by a psychiatrist.
Q:If a patient arrives to the hospital in labor and delivers the following day, can I submit the PCF01 as an
update?
A:You may - or the PCF01 can be submitted with a note saying "see delivery, date of ______". All requests for additional LOS (no matter what type of request) must be submitted
timely.
Q:When a high-risk obstetric patient comes in (with premature ruptured membranes), they are pre-certed for 3 days initially and then we have to apply for extensions. Is there any way to avoid the constant extension
process?
A:Pre-cert is concurrent, so there is no way around being certified only for the days pre-certed, even if you must continue to request extensions have to keep being
requested.
Q:We had to keep a child in our hospital over the weekend to keep him out of harm's way. How can we get paid for this
stay?
A:We cannot pre-cert a patient simply for protection; thus, payment can not be made by
Medicaid.
Q:If a patient becomes retroactively eligible for Medicaid, will it be financially damaging to our hospital if the doctor bills before we obtain pre-cert?
A:No; but you should request pre-cert as soon as possible.
Q:Is there a 4:30 p.m. deadline on submitting pre-cert requests for a particular business
day?
A:No; you can send the PCF01 any time before midnight of the business day in
question.
Q:Should we fax the entire chart with the PCF01 request?
A:No; you only need to fax those parts of the chart that summarize the elements required in InterQual
criteria.
Q:Is there a provision for missing timely submittal for an initial
request?
A:No; you only have the first 24 hours (or first business day) after admit to request pre-cert.
Q:How do I verify eligibility if the recipient cannot provide a Medicaid card and we do not have access to a MEVS
database?
A:You can call either the Medicaid parish office or Unisys Provider
Relations.
Q:If the patient was admitted from the observation room and placed in ICU, do we request pre-cert for the observation
date?
A:Yes; please state on the PCF01 that the date of admit was observation.
Q:On the date of discharge I am putting a lot of work into filing a request for extension just in case the discharge is cancelled. Am I wasting my
time?
A:If you have a written discharge order that is cancelled, we can give an extension. So it is not necessary to request an extension for every approaching
discharge.
Q:How long must we wait for appeals to be heard?
A:You must contact the Appeals Division at DHH for this information.
Q:We have a situation in which the MEVS printout indicated that the patient was not eligible for Medicaid, so we did not obtain pre-cert. At a later date we discovered that the patient did have Medicaid. Now we can't get paid for the hospitalization since pre-cert was not obtained timely. Is there anything we can do in this
case?
A:Yes; if you can provide a copy of the MEVS printout that supports your assertion, we will proceed with the case and determine if medical necessity criteria was met. However, please remember that the provider must enter accurate information (Medicaid ID, CCN, date of birth, etc.) into MEVS in order to receive an accurate response and in order for the MEVS strips to be acceptable documentation for pre-cert review. In other words, if you enter invalid numbers or dates of birth or dates of service, and the "ineligible" or "not on file" response you received is because you did not enter accurate information, this is not a valid reason for a
review.
Q:If Medicaid is any part of the payor source, must we obtain pre-cert?
A:If the patient is Medicare Part A, you do not have to obtain pre-cert (unless Medicare Part A is exhausted). If Medicare Part A is exhausted, and in all other situations, such as those where the recipient has private insurance primary to Medicaid, you must obtain pre-cert.
Q:What happens if the pre-cert does not include an outpatient procedure that was
performed?
A:Although the pre-cert may be approved without an outpatient procedure code, if the claim is submitted with an outpatient procedure within the first two days of admit, the claim will
deny.
Q:Do you have to change the admitting diagnosis when adding an outpatient
procedure?
A:No; the admitting diagnosis is always presumptive.
Q:Is there a special protocol to follow when a patient is admitted from home to a rehab
unit?
A:You will need a physician's order to admit.
Q:Are all pre-cert fax numbers just as effective?
A:Yes. There are three lines you may use: (225) 237-3329, (800) 348-5658, or (800)
717-4329.
Q:We have some old requests that have not been resolved through the Appeals process. Please tell me where we stand with these
requests?
A:The Appeals Division must be contacted to answer this question.
Q:Do I need to submit a PCF-02 form when requesting an extension on NICU
days?
A:The PCF-02 form and the NICU extension request are not the same thing. In order to request an extension on NICU days, you will need to complete the PCF-04 form along with the PCF-01. On page 32 of the 1999 Pre-cert Training Packet is a copy of the form for your
reference.
Q:If we are trying to check on a pre-cert and it cannot be located (Unisys does not have it on file). What can we
do?
A:Contact the Unisys Pre-cert Department. The phone representative in Pre-cert will ask for transmittal information and search for it through imaging and/or the fax number. Keep in mind, however, that tracing potentially lost requests can only be done within seven days of the date faxed.
Q:The following scenario occurs frequently: The last approved day is on a Saturday, with discharge set for Sunday. When I return to work on Monday, the patient is still there. Will I be able to obtain an extension on
Monday?
A:Yes, because it is based on the next business day. If the discharge is due on a weekend or holiday, you have until the next business day to submit extension
request.
Q:Does the provider have to go to Baton Rouge in order to appeal a
case?
A:No; the appeals process is outlined on page 13 of the 1999 Precertification Training
Packet.
Q:If a pre-cert letter indicates an approval, but a code is listed on the bottom of the letter, does this mean that information will be needed for approval of additional
days?
A:Yes.
RHC/FQHC QUESTIONS
Q:What physicals, if any, do you pay for? We received a payment for a sports
physical.
A:Recipients under 21 years of age can receive preventative care billed as
visits.
Q:Is there a list of which physicals we can collect from patients and which Medicaid will pay
for?
A:No.
Q:As a RHC with an optometrist, ophthalmologist, physician assistant, podiatrist, child psychiatrist, adult psychiatrist in house, should claims be submitted under their individual identification numbers or under the RHC clinic number as a group
provider?
A:Core visits should be billed under your RHC number. KIDMED services should be billed under your RHC number as fee-for-service.
Q:Where do we order booklets concerning lead problems to give to KIDMED
patients?
A:As a KIDMED provider, you may call the KIDMED office at 1-800-259-8000. The KIDMED office maintains a resource directory of materials and will assist you in locating needed
information.
Q:How do we bill for a Medicaid patient, over 21 years old, who comes to our office only for a flu shot? Can we submit a claim to Medicaid, should we include it in the cost settlement, or can we bill the
patient?
A:This cannot be billed. Include it in your cost settlement.
Q:We have a dentist who recently moved to Shreveport from Baton Rouge. The dentist is linked to our office but still gets her check mailed to Baton Rouge. What do we need to do to get her checks sent to her new
location?
A:Contact Provider Enrollment to update the provider information and enroll in electronic funds transfer (EFT).
Q:Last year we were told that influenza vaccines could not be billed in addition to an encounter. Is this still the
policy?
A:Last year the influenza vaccine was not available through VFC, therefore the shot was "incident to". Now that it is available through VFC, the administration fee is payable separately from a core visit. However, the vaccine is not payable if given on the same date as a core
visit.
Q:If a patient comes in for just a Depo-Provera shot, can we bill?
A:No, it cannot be billed. It should be included in cost settlement.
Q:Is the PCP's name required on the claim for a Community Care
patient?
A:No. We only require the referral number in block 17A.
Q:How should we submit a claim for a recipient with other insurance when the codes on the EOB and claim do not
match?
A:Send the claim with Medicaid assigned procedure codes, the six-digit carrier code in block 9A, payment amount in block 29, and EOB, along with a cover letter explaining that the codes do not match. All this documentation should be sent to the Provider Relations Correspondence
Unit.
Q:We are not usually very successful at getting recipients to go to parish office to update their TPL information. Can we initiate this
process?
A:Yes. You may send your claim with the EOB and a cover letter explaining the change in TPL coverage to the Provider Relations Correspondence Unit. It takes approximately six to eight weeks to update this information on the recipient file. After that time, check REVS/MEVS to verify that the recipient's file has been
updated.
Q:How do I request an extension of visits?
A:Complete and submit the 158-A form with medical documentation substantiating the need for additional visits. The request is reviewed by a physician for consideration of approval. The form will be returned to you with information concerning the approval or denial. If approved, the visit should be billed with the approved 158-A form attached to the claim. Remember that extensions are approved for emergent or life threatening conditions only. A supply of 158-A forms can be obtained by contacting Unisys Prior
Authorization.
Q:If the nurse practitioner (NP) provides a service that is under protocol, but is not on the list of codes payable for NPs, how do we get that service
paid?
A:Under RHC, the nurse practitioner must provide an encounter in order to bill. Encounters cover all services found in a typical evaluation and management physician
visit.
Q:Is minor surgery a component of the core visit?
A:The surgery may be a part of the core visit.
Q:Can we bill for injections if the recipient is under 21 years?
A:You may bill for VFC immunization codes.
Q:What can we bill if the recipient is 21 years or older?
A:You may bill the core visit. All injections are inclusive in that
reimbursement.
Q:Should we use the same form as Medicare when we adjust a payment (it is the 213 AMA
form)?
A:In order to adjust a Medicare/Medicaid crossover payment, you will need to submit a UB-92 form hardcopy with the Medicare adjustment EOB attached to the claim. The UB-92 form is for Medicare crossover claims only. Straight Medicaid claims are adjusted using the LA Medicaid 213 adjustment
form.
Q:How will we know if we should bill with only one provider number?
A:All RHC's should be transitioning to bill with one provider number.
Q:Does KIDMED billing go on the HCFA1500 form?
A:All services except for screenings are billed on the HCFA 1500. KIDMED screenings are billed on the KM-3
form.
Q:If a recipient is seen in the RHC and then admitted to the hospital, can both the RHC and admitting physician bill for the same date of
service?
A:Provider (hospital) based RHC services performed within 24 hours before the inpatient admission and 24 hours after the discharge are not billable. Such costs are included in the hospital stay. A provider notice was sent to provider based RHCs on December 8, 1999 clarifying this policy. Independent RHCs may provide and bill for an encounter even if a hospital admission or discharge occurs on the same day (assuming, of course, that it is not the same physician who sees the recipient on both
occasions).
Q:Can we do a KIDMED visit and an ill child visit on the same date?
A:Yes. The only restriction is that you may not bill an E&M visit greater than
99212.
Q:If a child comes in for an encounter, are we able to bill for immunizations on the same
date?
A:No; however, an immunization and a low level office visit may be billed on same day of service, if
warranted.
Q:We sent in our Medicare crossovers on HCFA forms. They were returned to us with a letter stating that the claims should be filed on UB92 form. So we sent in the UB92 forms with EOMBs and got the claims returned again requesting the Medicare EOB. We sent in two Medicare EOBs for each UB-92: the UB-92 had two claim lines, and one line was shown on each EOMB. What do I need to
do?
A:Bill each claim line on a separate UB-92 and attach the matching EOMB. We do check to make sure the EOMB matches the
UB-92.
Q:We billed a service at $20.00 and were paid $40.00. Why?
A:Because you billed an encounter code, which is always reimbursed at your encounter rate, regardless of the billed
charge.
Q:Would our dental or optometry services be billed under the single FQHC
number?
A:No. You would bill for those services under the individual provider number which is separate from your FQHC
number.
Q:Will there be a seminar on cost settlement?
A:You should discuss that with DHH.
Q:Why aren't our "Z" codes for obstetric services being paid at our core rate?
A:They should be. Please call the RHC program manager at DHH if there are any
problems.
Q:What do we do if we take an x-ray in our clinic and the physician reads it, then decides to send it out for an
interpretation?
A:If you bill full service for the x-ray, you must reimburse the interpreting physician.
Q:If a patient comes into the RHC for a core visit, we perform several lab tests, and the lab work is sent outside the RHC for processing, how should the lab tests be
billed?
A:If you did not include the labs in your core visit and you send them out, the lab may bill Unisys directly for them. If you include the labs in your core visit and cost settlement, you must pay the lab for their
services.
Q:When I enter code X9928 on my UB-92 computer claim billing screen, it doesn't show up.
Why?
A:The procedure code X9928 is only used to bill straight Medicaid claims on the HCFA-1500 form (not Medicare claims). Each and every clinic has different software. Please contact your software vendor.
LADUR Education Article
Smoking Cessation: Basic Strategies to Foster and Assist Patients to Stop Smoking Tobacco
Martin B. Steffenson, Pharm. D., Asst. Professor of Clinical Pharmacy
Practice and Siddarthan Ilangovan, M. Pharm., Graduate Student, Dept. of Pharmacy
Administration University of Louisiana at Monroe, Monroe, LA 71209
ISSUES:
� If health care providers could influence 10% of their patients who smoke to quit, the impact in terms
of disease prevention would be staggering.
� Certain groups of patients are more likely to respond to smoking cessation counseling than
others.
� Physicians can help patients quit smoking by providing them with a practical plan.
United States health care providers see a large percentage of smokers in their daily practices each year. Approximately 70% of the 50 million Americans who smoke will see a physician during a year.1 This brief Provider Update article reviews the most recent smoking cessation clinical guidelines set forth by the Agency for Health Care Research and Quality (AHRQ). The AHRQ Smoking Cessation Clinical Guideline consists of the five basic steps in Table
1.2
Table 1. The Five Basic Steps in the AHCPR Smoking Cessation Clinical
Guideline.
|
Step 1.
|
Ask and
systematically identify all tobacco users at every visit.
|
|
Step 2.
|
Advise and strongly
urge all smokers to quit.
|
|
Step 3.
|
Identify smokers
willing to make an attempt at quitting.
|
|
Step 4.
|
Assist and aid the
patient in quitting.
|
|
Step 5.
|
Arrange and schedule
a follow-up contact.
|
If primary care providers and other health care professionals could reach and positively influence 10% of their patients who smoke, the impact in terms of disease prevention would be staggering. Many physicians believe that counseling patients about smoking cessation takes too much time. Studies have shown that if physicians spent merely three to five minutes counseling their patients to quit smoking, 5% to 8% would be "tobacco free" at a 12 month
follow-up.3-5 Although 5 - 8 % seems like a small return on time spent, based on the large numbers of smokers, it could equate to millions of individuals with decreased health risk from tobacco products. Certain groups of patients are more likely to respond to smoking cessation counseling, among them are expectant parents who wish to quit smoking for the benefit of not only the fetus, but also to reduce the risk of second hand smoke to newborns and infants. Children are an excellent group to target for the prevention counseling, as more than one-half of smokers had begun to smoke by or before the age of 14
years.6
Physicians can promote their patients' smoking cessation by advising them to do so and by providing them with a practical plan. As part of the chief complaint and completion of the medical history, each patient should be queried regarding their smoking status. Charts can be coded with stickers to readily identify such patients. It is important that the provider understand the underlying reasons for which a patient continues to smoke or is unable to quit smoking. It is helpful to ascertain if the habit is a nicotine dependence situation or if other factors such as psychosocial play a significant role in maintaining the habit. Let patients know that behavioral and pharmacological approaches are available to assist them if they are willing to try to quit
smoking.
Advise the patient to quit smoking after the issue of the chief complaint has been addressed. The advice rendered need not be time consuming; it is sufficient to state that
the most important thing that you can do to improve your health is to quit
smoking.2 If a patient expresses a willingness to quit smoking, be prepared to assist in the process or have staff in your office assist and support the patient in his/her willingness to cease smoking. Encourage the individual in their attempt to quit; let them know that half of all people that have ever smoked have now quit. Express a direct concern and willingness to help. Let the patient talk about the quitting process, especially their worries or fears of difficulties to be faced. Provide basic information on the course of withdrawal, nicotine addiction, and the fact that any smoking at all increases the chance for failure and relapse. Have a ready supply of materials available for patients to assist them in preparing for the next step, setting a quit date. Find out if the patient would prefer more intensive assistance than going the process alone. If such treatment would be appropriate, refer the patient to a tobacco cessation specialist. Patients not willing to commit to a quitting attempt should receive a motivational intervention at a later appointment to foster future attempts at tobacco
cessation.
Patients need to be reminded that they are not to smoke while taking any of the nicotine containing drug products. Be aware that bupropion should not be used in patients with a history or risk of developing seizures.
The Agency for Healthcare Research and Quality (AHRQ) has a small group of publications that would be of great assistance for patients attempting or desiring to quit. Other publications are available that are excellent guides for both primary care clinicians and allied health professionals. These publications are available free of charge and may be ordered either on the internet or by using a toll free telephone number. The internet site is http://www.ahrq.gov and the telephone numbers are 1-800-358-9295 or TDD 1-888-586-6340 (hearing impaired
only).
AHRQ publications of potential interest include:
� You Can Quit Smoking - Smoking Cessation Consumer Guide (Publication Number
AHCPR96-0695)
� Helping Smokers Quit - A Guide for Primary Care Clinicians - Smoking Cessation QRG -Pocket Guide (Publication Number
AHCPR96-0693)
� Smoking Cessation - Information for Specialists - QRG for Smoking Cessation Specialists (Publication Number
AHCPR96-0694)
� Smoking Cessation - Quick Reference Guide - Health Care Systems (Publication Number
AHCPR97-0698)
� The Cost Effectiveness of AHCPR's Smoking Cessation Guideline - Article Reprint
(AHCPR97-R049)
The American Lung Association (ALA) has a Freedom from Smoking Clinic Program. A copy of the program guide may be obtained free of charge by calling 1-800-LUNG-USA. Facilitators for these ALA programs are currently located in Alexandria, Baton Rouge, Covington, Houma, Lafayette, New Orleans, and Shreveport. Smoking cessation materials may also be obtained from the American Cancer Society (ACS) by utilizing their toll-free telephone line at 1-800-ACS-2345 or via the internet at http://www.cancer.org. Included among ACS publications is a Marvel comic book for preteens entitled "Spiderman, Storm, and Cage Battle Smokescreen." The ACS also has a selection of brochures ideal for use in waiting rooms, some specifically targeting pregnant women and young
adults.
Given the broad appeal and ease of consumer access to the World Wide Web (WWW), the following internet sites may provide excellent support to those patients seeking more information about smoking cessation. A brief list of sites useful to patients interested in tobacco cessation programs or in the process of quitting cigarette smoking
includes:
� Smoking Cessation: http://quitsmoking.about.com/health/quitsmoking/mbody.htm
� American Lung Association, Tobacco Control: http://www.lungusa.org/tobacco
� Prenatal Smoking Cessation: http://www.cc.gov/nccdphp/drh/sata_smokcessa.htm
� Quit Smoking for Good!: http://www.quitnet.org/qn_main.jtml?nosession=true
� Smoking Cessation (interactive): http://www.notobacco.com/
Helping the patient develop and implement a plan for quitting smoking is of paramount importance. Contract with patients by helping them set an actual quit date. The quit day should be within 2 weeks of the appointment; it should be at the convenience of the patient. Times of severe stress or depression are not usually conducive to cessation attempts. Have the patient inform family, friends, and co-workers of quitting and ask them for support. The patient should also prepare his or her environment making it as free from temptation as possible. Have the patient remove all cigarettes from living spaces and, in preparing to quit smoking, remind the patient to refrain from smoking in places where a lot of time is spent, e.g. automobile, workshop, kitchen, or den. If the patient has failed in previous smoking cessation attempts, review with the patient factors that might have caused the relapse and focus on other elements that helped up to that point in the past. Try to help the patient and their family members anticipate problems that may occur in the first several weeks. The need to smoke is often linked to triggers: stress, drinking coffee, or social situations involving large numbers of individuals who smoke. Encourage the patient ( and family members to assist patient) to avoid such situations during early stages of
quitting.2
Replacement therapy in the form of nicotine gum or nicotine patch systems should be considered for most patients with the exception of those who are pregnant, breast feeding, individuals with cardiovascular disease specifically those in the immediate post-myocardial infarction period, and those with severe or worsening angina or arrhythmias. Skin reactions to nicotine transdermal systems commonly occur in up to 50% of patients, but are usually mild and self-limiting. Less than 5% of patients experience reactions to such a degree that discontinuation of therapy is required. The AHRQ Panel expressed preference for the patch systems over the gum products because of greater compliance and ease of use. Treatment periods of 8 weeks or less with nicotine replacement products have been no more effective than longer therapeutic regimens. Clinicians should consult individual package inserts for tailoring therapy to patients based on factors such as number of cigarettes smoked daily and degree of nicotine
addiction.2 Patients should be advised that they should refrain from smoking while using these products, and that they are not to be used in a tapering approach.
Bupropion has been shown in initial clinical studies to also result in higher long term smoking cessation rates than the nicotine
patch.7 It was originally released as a non-nicotine containing antidepressant product and is currently being marketed in a 150 mg sustained release formulation as Zyban. It may be used with other replacement therapies; therefore, it offers promise for individuals who have been unable to quit smoking using only nicotine replacement therapies. It also offers the potential of reducing withdrawal symptoms and may reduce weight gain associated with smoking cessation. Bupropion should be used with caution in individuals with a history of seizures or diseases which place them at risk for seizures. Further more, it should be noted there are limited clinical studies as it was released after the 1996 AHRQ Clinical Practice Guidelines were published. Nicotine patch systems and gum are readily available to patients as non-prescription drug products to assist them in reducing the effects of nicotine withdrawal. Medicaid does not pay for these non-prescription products. If you feel that your patient would be more likely to try such an aid as a prescription product, Habitrol and the recently released bupropion (Zyban) are prescription products that would be covered under
Medicaid.
Once a patient has ceased smoking on the designated quit date, it is imperative that complete abstinence is maintained. A single puff or cigarette can quickly lead to relapse. Consumption of alcoholic beverages is highly associated with relapse. Patients should be urged to refrain or greatly limit the intake of alcohol during the smoking cessation process. Another factor that lowers success rate is the presence of other smokers in the household, especially spouses. If household members are not willing to join in the process, they should be advised to smoke elsewhere while the patient attempts to quit. During the quitting stage, healthcare professionals provide access to supplementary material to both inform and support patients during the difficult process of
abstinence.2
References
1. Peter G. Danis, Terry L. Seaton. Patients and Smoking Cessation: The Role of the Primary Care Physician. ResMedica. 1994; 8:
5-10.
2. Michael C. Fiore et al. The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline. JAMA. 1996; 275; 16:
1270-1280.
3. Russel MAH, Wilson C, Taylor C. Effect of general practitioners' advice against smoking. BMJ. 1979; 2:
231-235.
4. Wilson DM, Taylor DW, Gilbert JR, et al. A randomized trial of a family physician intervention for smoking cessation. JAMA. 1988; 260:
1570-1574.
5. Demers RY, Neale AV, Adans R, et al. The impact of physicians' brief smoking cessation counseling: A MIRNET study. J Fam Pract. 1990; 31:
625-629.
6. Johnson LD, O'Malley PM, Bachman JG. National trends in drug use and related factors among American high school students and young adults, 1974-1986. Rockville, MD: National Institute on Drug Abuse, 1987; U.S. Department of Health and Human Services publication (ADM)
87-1535.
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