Provider Update
Volume 20, Issue 3
June/July 2003
Changes in Medicaid Billing Procedures
Louisiana Medicaid understands how important it is that Medicaid providers receive timely payment for services rendered. Claims filed with incorrect information result sin delayed reimbursement. Effective May 1, 2003, Louisiana Medicaid implemented billing changes for the following programs:
� Hospital
� Hemodialysis
� EPSDT Dental & Adult Denture
� Rural Health Clinic (RHC)
� Federally Qualified Health Center (FQHC)
To better serve and educate providers on the billing changes required to comply with HIPAA regulations, we have included important information regarding new billing
procedures for the above mentioned programs. We encourage you to remove the summary page appropriate to your program and post in a convenient area for quick reference. Please be sure to route this information to office managers, billing departments, and all other appropriate personnel.
Attention Hospital Providers
Category
|
|
Old Local
Codes/Processes
|
New
Standard Codes/Processes
|
|
|
|
Prior to 5/1/03
|
Effective 5/1/03
|
Outpatient
Hospital
|
ST, OT, PT
|
Y
Codes
|
Standard
CPT Codes replace Y codes (See page 4 in the 2003 Hospital Provider
Training packet for the local code conversion table)
|
Prenatal Lab
Panels
|
Z
codes
|
Obstetrical
lab panel 80055 replaces Z codes ( Refer to the 2003 CPT-4 code book for
tests included in this panel)
|
Conscious
Sedation
|
00099
|
Standardized
Codes replace code 00099 (See page 5 of the 2003 Hospital Provider
Training packet for the conscious sedation code conversion table)
|
Anesthesia for
Dental Restoration
|
W3340
|
00170
|
Brainstem
Evoked Response Screening
|
Z9916
|
92586
|
Ifex/Mesnex
Inj Com 1gm
|
J9205
|
J9208/J9209
|
Wheelchair
Seating Evaluation
|
Y7902
|
97001
and 97003 with UD modifier
|
Inpatient
Hospital
|
Hospital
Revenue Codes
|
Hospital
Revenue Codes as outlined in the Hospital Manual
|
Hospital
Revenue Codes as outlined in the Hospital Manual (No Change)
|
|
Invalid
96 Form for Sterilization at Time of Delivery
|
Local
Occurrence Code 50
|
Local
Occurrence Code 50 no longer valid � The procedure code for the
sterilization & the diagnosis code associated with the sterilization
should not be reported on the claim form and charges related to the
sterilization should not be reported on the claim form.
|
|
Hardcopy
Claim Form
|
|
UB-92
|
UB-92
(No Change)
|
|
Adjustment
Form
|
|
In
form locator 4 (Type of Bill) use the number 6 as the 3rd digit
|
In
form locator 4 (Type of Bill) use the number 7 as the 3rd digit
regardless of date of service�(Can continue to use the number 6 instead
of the number 7 until further notification) Remainder of form completion
remains the same.
|
|
Electronic
Data Interchange (EDI)
|
|
Unisys
proprietary electronic specifications
|
837I
(In
addition to the 837I, Unisys proprietary electronic specifications can be
used 5/1/03 and after until further notification)
|
|
Prior
Authorization for Outpatient Therapy
|
Billing
for dates of service prior to 5/1/03
|
Use
the Y codes and the existing approved, unused, & unexpired prior
authorization for the Y code(s)
|
Use
the Y codes and the existing approved, unused, & unexpired prior
authorization for the discontinued Y code(s)
|
|
Billing
for dates of service prior authorized prior to 5/1/03 but not rendered
until 5/1/03 & after
|
N/A
|
Use
the new standard code and the existing approved, unused, & unexpired
prior authorization for the discontinued Y code(s)
|
|
Filing
for prior authorization
|
Use
the Y codes in place for the date of service
|
Use
the new standard codes in place for the date of service
|
|
PA
01 Form
|
PA
01
|
Use
revised PA01 Form (regardless of date of service)
|
Precertification
Process for Inpatient Stays
|
|
Use
process as outlined in the Hospital Manual
|
Use
process as outlined in the Hospital Manual (No Change)
|
| |
|
|
|
|
|
Attention RHC/FQHC Providers
RHC/FQHC ENCOUNTERS
|
Dates
of Service Prior to 5/1/03
|
Dates
of Service 5/1/03 and After
|
RHC Encounter Visit
|
X9928
|
T1015
(The new encounter code includes all
services provided to the patient on that date of service.
All services �incident to� an encounter code are not billable.)
|
FQHC Encounter Visit
|
X9927
|
T1015
(The new encounter code includes all
services provided to the patient on that date of service.
All services �incident to� an encounter code are not billable.)
|
|
RHC/FQHC
Obstetrical Visit
|
Z codes (Z9004, Z9005, Z9006)
|
T1015 & modifier TH
|
RHC/FQHC KIDMED
|
Prior
to 5/1/03
|
5/1/03
and After
|
|
Billing
for Screening Services on the KM-3 Form -
|
KM-3 � 03/01/92 version
|
KM-3 � 2/03 version (Includes
Procedure Codes & Modifiers and encounter codes)
(See pages 27-38 in the 2003 RHC/FQHC
Provider Training packet for claims filing instructions)
|
|
Screening
Procedure Codes
|
No procedure codes used for DOS prior
to 5/1/03. Check appropriate screening block,
|
**RHC/FQHC
KIDMED screening services must
be billed on the revised KM-3 form and encounter code T1015 along
with modifier EP must be placed on the appropriate line labeled
�Encounter (RHC/FQHC)�.
**Additionally,
individual procedure codes for each specific screening service rendered must
be place on the appropriate line.
**If
a registered nurse performs the screening, modifier TD must be entered
next to the appropriate screening procedure code)
|
|
Billing
for Immunizations on the CMS-1500 (Formally HCFA-1500)
|
Use CMS-1500 - (HCFA-1500)
|
Use CMS-1500 � (HCFA-1500)
(See pages 8-16 in the 2003 RHC/FQHC
Provider Training packet for claims filing instructions)
|
|
Immunization
Procedure Codes
|
Use immunization procedure codes in
effect for date of service
|
** Immunizations should be given at
the time of the screening. If
a medical condition prevents giving immunizations with the screening, they
must still be billed once rendered even though the claim will deny
as immunizations are not payable separately from the screening.
Encounter code T1015 and
modifier EP must be billed accompanied by the appropriate immunization
codes. All claims billed
using the T1015 and the EP modifier MUST include supporting detail immunization procedures.
Use procedure codes in effect for date
of service. (Please refer to pages 24-26 in the 2003 RHC/FQHC Provider
Training packet for information regarding procedure codes and/or procedure
code changes)
|
|
Reimbursement
for Screenings
|
Paid as separate procedures
|
Payment is included in the encounter
rate. (An encounter must
include a physician or nurse screening in addition to any immunizations,
vision and/or hearing screening.)
|
RHC/FQHC DENTAL
|
Prior to 5/1/03
|
5/1/03 and After
|
All Dental
Procedure Codes
EPSDT and
Adult Denture
|
For Dates of Service prior to 5/1/03:
When filing on the 1994 ADA Claim
Form, use the procedure codes in effect for those dates of service with
the exception of replacing the number 0 (zero) in the leading position of
the procedure code to the letter D.
For
Date of Service 5/1/03 and after:
When filing on the
1994 ADA Claim Form, use the procedure codes in effect for dates of
service 5/1/03 and after. Please refer to Appendix A in the 2003 Dental
Provider Training packet for the new dental fee schedule effective 5/1/03.
For more information on local code conversions, refer to the EPSDT
Dental Program HIPAA Implementation Procedure Code/Coding Definition
Changes tables on pages 4-15 or the Adult Denture Program HIPAA
Implementation Procedure Code/Coding Definition Changes tables on pages
16-18 in the 2003 Dental Provider Training packet.
|
For Dates of Service prior to 5/1/03:
When filing on the 2002 ADA Claim
Form, use the procedure codes in effect for those dates of service with
the exception of replacing the number 0 (zero) in the leading position of
the procedure code to the letter D.
For
Date of Service 5/1/03 and after:
When filing on the 2002 ADA Claim
Form, use the procedure codes in effect for dates of service 5/1/03 and
after. Please refer to Appendix A in the 2003 Dental Provider Training
packet for the new dental fee schedule effective 5/1/03. For more
information on local code conversions, refer to the EPSDT Dental Program
HIPAA Implementation Procedure Code/Coding Definition Changes tables on
pages 4-15 or the Adult Denture Program HIPAA Implementation Procedure
Code/Coding Definition Changes tables on pages 16-18 in the 2003 Dental
Provider Training packet.
|
Oral Cavity Designator (OCD) Codes
|
When filing on the 1994 ADA Claim
Form, use the new OCD, regardless of date of service, in the Tooth
Number column of the 1994 ADA Claim Form (Please refer to page 23 in
the 2003 Dental Provider Training packet for information regarding the new
oral cavity designator code conversions)
|
When filing on the 2002 ADA Claim
Form, use the new OCD, regardless of date of service, in the OCD column
of the 2002 ADA Claim Form (Please refer to page 23 in the 2003 Dental
Provider Training packet for information regarding the new oral cavity
designator code conversions)
|
|
ADJUSTMENT/VOID
FORMS
|
1991
and 1993 Forms
|
2003
Revised Forms
|
EPSDT Dental Services 209 Adjustment/Void Form
|
Unisys 209 � 1993 version is no
longer accepted effective 5/1/03.
|
Unisys 209 � 01/03 version of this
form is the only version accepted effective May 1, 2003.
(This form was updated to include form locator 24H � Oral Cavity
Designator. See page 23-24 in
the 2003 Dental Provider Training packet for more information on the
changes made to the Unisys 209 Form)
|
Adult Dental Services 210 Adjustment/Void Form
|
Unisys 210 � 5/91 version is no
longer accepted effective 5/1/03.
|
Unisys 210 � 01/03 version of this
form is the only version accepted effective 5/1/03.
(This form was updated to include form locator 23F � Oral Cavity
Designator and form locator 23G � Tooth #.
See page 24-25 in the 2003 Dental Provider Training packet for more
information on the changes made to the Unisys 210 Form)
|
|
PRIOR
AUTHORIZATION (PA)
|
Dates
of Service Prior to 5/1/03
|
Dates
of Service 5/1/03 and After
|
|
Automatic
PA Conversions
|
Automatic
PA Conversions: Many prior authorizations which were approved
prior to 5/1/03 which remained unexpired and unused on 5/1/03 were
automatically converted by Medicaid.
See pages 19�21 in the 2003 Dental Provider Training Packet for
more information regarding the automatic conversions of existing prior
authorizations.
|
Automatic PA Conversions:
Many
prior authorizations which were approved prior to 5/1/03 which remained
unexpired and unused on 5/1/03 were automatically converted by Medicaid.
See pages 19�21 in the 2003 Dental Provider Training Packet for more
information regarding the automatic conversions of existing prior
authorizations. See page 20 in the 2003 Dental Provider Training packet
entitled �Non-Specific Service Codes� and �Miscellaneous
Discontinued Codes' for information on the exceptions from automatic
conversions.
|
|
Filing
for Prior Authorization
|
When submitting a new PA request or correcting an existing PA for Dates of Service prior to
5/1/03, use the codes in effect for the specific date of service (with a
�D� in the first position). See
above for automatic PA conversion information.
|
When submitting a new PA request for
Dates of Service 5/1/03 and after, use the new standard procedure code.
See Appendix A in the 2003 Dental Provider Training packet for the
new EPSDT and Adult Denture Fee Schedule which also indicates the codes
requiring PA.
|
|
Billing
for EPSDT and Adult Denture Procedures Previously Authorized Prior to
5/1/03
|
Use the codes in effect prior to
5/1/03 with the existing approved, unused, & unexpired prior
authorization number granted for the code(s)
|
When Billing for Dates of Service
Prior to 5/1/03:
Bill using the discontinued
prior authorized code (with a �D� in the first position) and the PA
number granted for the discontinued code.
When Billing For Dates of Service
5/1/03 and after: Bill
using the new standard PA procedure code and the same PA number as granted
for the discontinued code.
|
Attention Dental Providers
Use the letter �D� in the leading position of the procedure code when submitting all dental claims, regardless of the date of service.
ADA Claim Forms
|
1994
ADA Claim Form
|
2002
ADA Claim Form
|
ADA Claim Form
(Please note that Medicaid will not
accept the 1999 ADA Claim Form)
|
The 1994 ADA Claim Form may be used
until further notice.
|
2002 ADA Form may be used and will
become mandatory for use in the near future.
|
|
Procedure
Codes and Oral Cavity Designators
|
1994
ADA Claim Form
|
2002
ADA Claim Form
|
All Dental
Procedure Codes
EPSDT and Adult Denture
|
For Dates of
Service prior to 5/1/03:
When filing on the 1994 ADA Claim
Form, use the procedure codes in effect for those dates of service with
the exception of replacing the number 0 (zero) in the leading position of
the procedure code to the letter D.
For
Date of Service 5/1/03 and after:
When
filing on the 1994 ADA Claim Form, use the procedure codes in effect for
dates of service 5/1/03 and after. Please refer to Appendix A in the 2003
Dental Provider Training packet for the new dental fee schedule effective
5/1/03. For more information
on local code conversions, refer to the EPSDT Dental Program HIPAA
Implementation Procedure Code/Coding Definition Changes tables on pages
4-15 or the Adult Denture Program HIPAA Implementation Procedure
Code/Coding Definition Changes tables on pages 16-18 in the 2003 Dental
Provider Training packet.
|
For Dates of
Service prior to 5/1/03:
When filing on the 2002 ADA Claim
Form, use the procedure codes in effect for those dates of service with
the exception of replacing the number 0 (zero) in the leading position of
the procedure code to the letter D.
For
Date of Service 5/1/03 and after:
When filing on the 2002 ADA Claim
Form, use the procedure codes in effect for dates of service 5/1/03 and
after. Please refer to Appendix A in the 2003 Dental Provider Training
packet for the new dental fee schedule effective 5/1/03. For more
information on local code conversions, refer to the EPSDT Dental Program
HIPAA Implementation Procedure Code/Coding Definition Changes tables on
pages 4-15 or the Adult Denture Program HIPAA Implementation Procedure
Code/Coding Definition Changes tables on pages 16-18 in the 2003 Dental
Provider Training packet.
|
Oral Cavity Designator (OCD) Codes
|
When filing on the 1994 ADA Claim
Form, use the new OCD, regardless of date of service, in the Tooth
Number column of the 1994 ADA Claim Form (Please refer to page 23 in
the 2003 Dental Provider Training packet for information regarding the new
oral cavity designator code conversions)
|
When filing on the 2002 ADA Claim
Form, use the new OCD, regardless of date of service, in the OCD column
of the 2002 ADA Claim Form (Please refer to page 23 in the 2003 Dental
Provider Training packet for information regarding the new oral cavity
designator code conversions)
|
|
ADJUSTMENT/VOID
FORMS
|
1991
and 1993 Forms
|
2003
Revised Forms
|
EPSDT Dental
Services 209 Adjustment/Void Form
|
Unisys 209 � 1993 version is no
longer accepted effective 5/1/03.
|
Unisys 209 � 01/03 version of this
form is the only version accepted effective May 1, 2003.
(This form was updated to include form locator 24H � Oral Cavity
Designator. See page 23-24 in
the 2003 Dental Provider Training packet for more information on the
changes made to the Unisys 209 Form)
|
Adult Dental
Services 210 Adjustment/Void Form
|
Unisys 210 � 5/91 version is no
longer accepted effective 5/1/03.
|
Unisys 210 � 01/03 version of this
form is the only version accepted effective 5/1/03.
(This form was updated to include form locator 23F � Oral Cavity
Designator and form locator 23G � Tooth #.
See page 24-25 in the 2003 Dental Provider Training packet for more
information on the changes made to the Unisys 210 Form)
|
|
PRIOR
AUTHORIZATION (PA)
|
Dates
of Service Prior to 5/1/03
|
Dates
of Service 5/1/03 and After
|
|
Automatic
PA Conversions
|
Automatic
PA Conversions: Many prior authorizations which were approved
prior to 5/1/03 which remained unexpired and unused on 5/1/03 were
automatically converted by Medicaid.
See pages 19�21 in the 2003 Dental Provider Training Packet for
more information regarding the automatic conversions of existing prior
authorizations.
|
Automatic PA Conversions:
Many
prior authorizations which were approved prior to 5/1/03 which remained
unexpired and unused on 5/1/03 were automatically converted by Medicaid.
See pages 19�21 in the 2003 Dental Provider Training Packet for more
information regarding the automatic conversions of existing prior
authorizations. See page 20 in the 2003 Dental Provider Training packet
entitled �Non-Specific Service Codes� and �Miscellaneous
Discontinued Codes' for information on the exceptions from automatic
conversions.
|
|
Filing
for Prior Authorization
|
When submitting a new PA request or correcting an existing PA for Dates of Service prior to
5/1/03, use the codes in effect for the specific date of service (with a
�D� in the first position). See
above for automatic PA conversion information.
|
When submitting a new PA request for
Dates of Service 5/1/03 and after, use the new standard procedure code.
See Appendix A in the 2003 Dental Provider Training packet for the
new EPSDT and Adult Denture Fee Schedule which also indicates the codes
requiring PA.
|
|
Billing
for EPSDT and Adult Denture Procedures Previously Authorized Prior to
5/1/03
|
Use the codes in effect prior to
5/1/03 with the existing approved, unused, & unexpired prior
authorization number granted for the code(s)
|
When Billing for Dates of Service
Prior to 5/1/03:
Bill using the discontinued
prior authorized code (with a �D� in the first position) and the PA
number granted for the discontinued code.
When Billing For Dates of Service
5/1/03 and after: Bill
using the new standard PA procedure code and the same PA number as granted
for the discontinued code.
|
|
MEVS
|
Responses
Prior to 6/28/03
|
Responses
Effective 6/28/03
|
|
MEVS
(Medicaid Eligibility Verification System) Inquiry Responses
|
DHH approved
inquiry responses given prior to 6/28/03 will no longer be valid effective
6/28/03.
|
Effective 6/28/03, Federally required
standardized inquiry responses will be given (Responses are more general
than the former DHH approved inquiry responses)
|
Attention Hemodialysis Providers
|
|
Prior
to 5/1/03
|
Effective
5/1/03
|
Procedure Codes
|
Old Code
|
New Standard Code/Processes
|
J0960
Delatestryl Injection
|
J3120
Testosterone Enanthate
Injection - up to 100 mg
|
J0940 Deca-Durabolin
|
J2322
Nandrolone Deconate,
Inj. Up To 200MG
|
|
Z1638
Calcijex (Calcitriol)
|
Non-Payable
|
Z6138 Calcijex
(Calcitriol)
|
J0636 Calcitriol
Inj. .1MCG
|
Hardcopy Claim Form
|
UB-92
|
UB-92 ( No Change)
|
|
Electronic
Data Interchange (EDI)
|
Unisys proprietary electronic
specifications
|
837I
(In addition to the 837I, Unisys
proprietary electronic specifications can be used 5/1/03 and after until
further notification)
|
EPOGEN (EPO) Claims Filing Reminders
-
There are limits placed on the number of line items that are allowed when filing claims. ALL claims are limited to 23 total lines, which includes the line for the total charges.
-
Always enter "1" for service units in form locator 46 when billing for Epogen services.
-
Always enter the appropriate value code and hematocrit level in form locator 39 when billing
for Epogen services (value code = 49).
-
Always enter the appropriate value code total Epogen units in form locator 40 (value code = 68).
Reimbursement of Epogen
Effective with date of service July 1, 2001 Medicaid of Louisiana has changed the payment methodology for reimbursement of the drug EPO. Reimbursement will be paid per 1,000 units (rounded to the nearest 100 units) administered, not to exceed the Medicare rate of June 30, 2001.
Incorrect Reimbursement
When claims for EPO services are billed with HR634 or HR635, payment is indicated on the first line and all other lines are paid at zero (0). This payment methodology does not allow provider to submit adjustments if the claims are paid incorrectly. Providers must submit a void and resubmit a corrected claim in order to correct reimbursement. Be sure to submit the void one week prior to submitting the corrected claim. Keep in mind that to void more than one claim line, a separate UB92 form is required for each claim line since each claim line has a different Internal Control Number.
Reading the Remittance Advice for EPOGEN Payments
Payment is based on the total units as indicated in value code 40A. The total payment for is indicated on the first treatment claim line for the first service date, and the remainder of the treatment dates will appear on the RA with zero (0 dollar) payments and edit code 978 (payment adjusted to zero, call help desk).
MEVS Web Application
Beginning June 28, 2003, MEVS moved to the web. Providers will now be able to verify eligibility and service limits for a Medicaid recipient using a web application accessed through www.lamedicaid.com. This application will be implemented to provide eligibility verification capability in addition to MEVS swipe card transactions and REVS. An eligibility request can be entered via the web for a single recipient and the eligibility and service limits data for that individual will be returned on a web page response.
The application is to be used for single individual requests and cannot be used to transmit batch requests.
A User Manual is provided at www.lamedicaid.com. Download your copy and take advantage of this new informational technology.
Pharmacy Point-of-Sale "Moving Up"
Pharmacy Point-of-Sale (POS) claims are "moving up" August 24th from NCPDP version 3.2 to version 5.1. Claims submitted in batch mode will be received in the NCPDP version 1.1 batch format. Specifications for the software change are available at www.lamedicaid.com by selecting the link to HIPAA Billing Instructions and Companion Guides.
Since NCPDP version 1.1 includes the claim format specified by NCPDP version 5.1, the Vendor Specifications for NCPDP 5.1 are your Companion Guide for batch processing as well as POS. Paper claims must be sent on the Universal Prescription Claim Form. Instructions for submitting this form are also posted at the link listed above.
-
Take advantage of the training to be offered July 28th through August
1st!
-
Please contact your software vendor to make sure your POS claims submission software is upgraded to NCPDP 5.1 and your batch submission software upgraded to NCPDP 1.1 prior to August 24th.
-
Verify with your software vendor that your software upgrade has been tested with your
switch vendor. Individual provider testing with Unisys is not required.
Expansion of CommunityCARE in Region I
Effective September 1, 2003, Orleans Parish will be included as part of the statewide expansion of CommunityCARE in Louisiana Medicaid. Medicaid recipients in this parish will receive a brochure and a letter in Mid-July advising them that CommunityCARE is coming to their parish. During the first week of August, a second letter will be mailed to recipients asking them to choose a CommunityCARE doctor from an enclosed list of enrolled providers in the recipient�s parish of residence. Both letters provide the �800� toll-free phone number for recipients to call if they have questions or to choose a primary care provider (PCP). Recipients who do not select a PCP by August 22, 2003 will be assigned a doctor by the state. Recipients will receive a third letter either confirming their choice or informing them of the provider assigned to them by the state. If the recipient is not satisfied with their doctor, they have ninety (90) days to change to a different CommunityCARE doctor.
Beginning September 1, 2003, providers in this parish who are not enrolled as CommunityCARE PCPs must obtain a referral from the CommunityCARE PCp in order for Medicaid to pay for most services provided to Medicaid CommunityCARE enrollees. Medicaid primary care providers (Family Practice, General Practice, Internal Medicine, OB, Pediatricians), physician groups, Rural Health Clinics (RHCs), and Federally Qualified Health Centers (FQHCs) may enroll as CommunityCARE providers. Medicaid providers who have not completed their enrollment as a CommunityCARE provider by July 15, 2003 will not be included in the August 1, 2003 assignment rotation and will not be listed as an available choice on the list sent to recipients. However, providers may continue to enroll as CommunityCARE providers at any time. Enrollees have the option to change to PCPs who were not available during the initial implementation assignments. Enrollments packets for CommunityCARE may be obtained by contacting Unisys Provider Relations at 1-800-473-2783. Questions may be directed to Provider Relations or to the CommunityCARE Program Office at 225-342-1304.
For your information, the final phase of the statewide CommunityCARE expansion schedule is as follows:
December 2003 - Plaquemines, St. Bernard, Jefferson - East Bank and Jefferson - West Bank.
Nursing Facilities, Hospice, Adult Day Health Care, ICF-MR
The Department of Health and Hospitals (DHH) is changing the billing requirements for Nursing Facilities, Adult Day Health Care, Hospice, and ICF-MR services in order to standardize claim processing and conform to the HIPAA mandates. These changes will phase out the current Turnaround Document (TAD).
Unisys will begin accepting the 837I and UB-92 for your claims beginning with September 2003 dates of service. You must submit a separate claim for each recipient for whom you provided services during the previous month using the electronic 837I claim or the paper UB92.
Beginning with December 2003 dates of service, the TAD will be discontinued.
-
Be sure to take advantage of the training being offered August 21st through August 22nd and
August 24th through August 29th. Bring your questions.
-
Contact your software vendor to make sure he receives the billing instructions and 837I Companion Guide from the LA Medicaid Testing Service.
-
If you need a software vendor for electronic billing, check our list of VBC by linking to the HIPAA Information Center located at
www.lamedicaid.com.
Becoming "HIPAA Ready" for Louisiana Medicaid Billing Changes
The following information will assist your Software Vendor, Billing Agent or Clearinghouse to become HIPAA approved. For those who do not have a Software Vendor, Billing Agent or Clearinghouse to become HIPAA approved, instructions are also provided.
Note: If you currently submit claims electronically to LA Medicaid, your current method
WILL NOT be HIPAA compliant without modifications by your Software Vendor, Billing Agent or Clearinghouse. The only exception to this statement is for electronic billing of Non-Ambulance Transportation claims as they are
exempt from HIPAA. All other claims are affected. For ease of review, from this point on, a "Software
Vendor," "Billing Agent", or "Clearinghouse" will be referred to collectively as a 'VBC'.
1. The first step toward your HIPAA readiness is to have your VBC contact LA Medicaid and enroll in our testing service. As a provider who bills electronically, your VBC will be tasked with making your claims HIPAA compliant. Therefore to ensure success, the VBC
must contact the LA Medicaid HIPAA EDI Group.
The HIPAA EDI group will support all VBCs through the enrollment, testing, and production approval processes.
VBCs must contact the HIPAA EDI group to enroll in LA Medicaid's testing service by emailing a request to
*hipaaedi@unisys.com (Note: * is part of the e-mail address) or by calling
1-225-237-3318. Enrollment forms can be downloaded at www.lamedicaid.com/hipaa
A HIPAA EDI representative will issue the VBC login information for our testing service. Companion
guides contain data elements specific to LA Medicaid and will be available for download from within the testing service. These guides are
supplements to the National Electronic Data Interchange Transaction Set Implementation Guides which can be downloaded from
www.wpc-edi.com .
Our testing service is now available 24-hours-a-day, 7-days-a-week.
2. If you are a LA Medicaid provider AND
a. You do not have a Software Vendor, Billing Agent or Clearinghouse (VBC)
Or
b. Your VBC does not plan to become HIPAA ready
YOU SHOULD:
Subscribe to the weekly VBC list and HIPAA updates by e-mailing the HIPAA EDI group at
*hipaaedi@unisys.com (Note: * is part of the e-mail address). Put "subscribe to VBC list"
in the subject line. VBCs identified in the list are those that have enrolled with the LA Medicaid HIPAA testing service and are pursuing HIPAA readiness.
As VBCs enroll in our testing service, we will publish a list of those VBCs. The list will include contact information, the types of X12N HIPAA transactions they support, and a status of "Enrolled", "Testing" or "Approved." The final "Approved" status means the submitter has successfully submitted HIPAA compliant EDI claims to LA Medicaid. However it does not insure that all future transactions received on behalf of a provider from that VBC will be HIPAA compliant, since other factors may affect successful transmission. This list will be dynamic and updated weekly as VBCs enroll and progress through the testing process. The weekly VBC list will be e-mailed to those providers who have sent a subscription request to
*hipaaedi@unisys.com (Note: * is part of the e-mail address), and will also be available on the web at
www.lamedicaid.com/hipaa .
Visit the web site often or subscribe to our email list for the most up to date information on HIPAA and a status on all enrolled VBCs as they pursue HIPAA readiness with LA Medicaid.
LA Medicaid encourages all providers to be good consumers and use the VBC list to shop for a VBC that best suits their needs and their budget. The features, functions, and costs vary significantly between VBCs.
Find the one that is right for you.
3. Once your VBC has contacted LA Medicaid for enrollment in the LA Medicaid HIPAA testing service, the process toward HIPAA readiness can begin. Please have your vendor enroll early, even if they are not ready to send a test file. This will let LA Medicaid know the VBC intends to become HIPAA ready and can be included in the list of VBCs. In addition, LA Medicaid will communicate with all the VBCs primarily through the testing service. To ensure success VBCs should enroll early to access the most up to date testing information.
4. The testing service will have everything a VBC needs to test for HIPAA readiness with LA Medicaid. Companion Guides, Trading Partner Agreements, and other necessary documentation will be available for download from within the testing service. The testing service is comprehensive and evaluates the 7 levels of testing as defined by WEDI-SNIP (Level 7 is specific to LA Medicaid).
5. VBCs that have successfully completed our testing program will be "Approved" for HIPAA electronic claim submission to LA Medicaid. Providers can use any "Approved" VBC as their electronic means of claims submission to us.
Two Digit Place of Service Codes Required
As we convert to the required HIPAA standard code sets, it is necessary that providers who report Place of Service (POS) codes begin using the two digit codes on all claim forms.
Please make immediate plans to have your billing software converted to the two digit codes. After October 16, 2003, the one digit POS codes will no longer be accepted.
All provider who elect to use the HIPAA 837P Professional format are required to use the HIPAA standard two digit POS codes.
For Rehabilitation Centers, one digit POS codes will continue to be accepted until further notice.
If you have questions concerning this transition, please contact Unisys Provider Relations at 800-473-2783 or 225-924-5040.
CP-0-92 and RS-0-07 Now Online
Please note that the CP-0-92 (monthly listing of CommunityCARE enrollees) and the RS-0-07
(monthly listing of KIDMED recipients) are now available online to providers who are enrolled in these programs. Providers may access this information using the same ID and password used to access other online provider information. Instructions for providers to enroll in this online system are
available at the website www.lamedicaid.com. It is recommended that providers begin using this online method as a convenient way to access this information.
Codes Payable to CNPs and CNSs
Effective for dates of service on or after May 1, 2003, the following CPT codes were added to the list of codes payable to Certified Nurse Practitioners and Certified Nurse Specialists:
96115 99232 99244 99252 99261
99221 99233 99245 99253 99262
99223 99243 99251 99254 99263
Discontinuation of Wheelchair Seating Evaluation
Effective October 1, 2003, state assigned procedure codes Y7702 (physical therapy evaluation), Y7712 (occupational therapy evaluation), and Y7902 (wheelchair seating evaluation) will no longer be payable. The physical therapy and occupational therapy evaluation codes will be replaced with HIPAA compliant procedure codes 97001 and 97003 respectively. The wheelchair seating evaluation will be billable using modifier UD with procedure code 97001 or 97003, depending on whether the physical therapist or occupational therapist performed the evaluation. Reimbursement rates will be at the established rates for the occupational and physical therapy evaluation codes. One occupational therapy evaluation, one physical therapy evaluation, and one wheelchair evaluation for a recipient over a period of six months will be allowed, when medically necessary.
Reimbursement for Nebulizers
Effective May 1, 2003, reimbursement for a nebulizer with compressor has been reduced from a maximum of $95.00 to a maximum of $60.00, not to exceed the provider�s usual and customary charges. This reduction was published as a rule in the April 20, 2003 edition of the Louisiana Register.
Identical Submission of the Same Prior Authorization Request
Please do not submit a request to the Prior Authorization Unit more than once. Identical submission of the same prior authorization request cause errors and impede the process. Inquiries regarding pending requests should be directed to the Prior Authorization Unit at 1-800-488-6334 or 225-928-5263.
When submitting requests for authorization of services, equipment, or supplies for a member of the Chisholm Class, please include the case manager�s name and telephone number and the case management agency name and address on the Form PA01 in the comments section. It is the case manager�s responsibility to notify you after an individual has selected you as their service provider. If you have knowledge that an individual has selected you are their service provider and you have not been notified by the case manager, please contact the Bureau of Community Support and Services (BCSS), Case Management Section, at 225-219-0236.
EPSDT Indicator Required
When submitting claims on the 2002 ADA claim form, it is required that the EPSDT indicator in block 1 on the hard copy claim be marked if the claim is for an EPSDT recipient (under 21 years old). If this block is not marked, the claim is automatically processed as an adult claim. Please ensure that you are marking this block when appropriate as many claims are being denied because the block is left blank.
Billing for Emergency Room Services for CommunityCARE Recipients
This is to clarify procedures for hospitals billing for emergency room services provided to CommunityCARE recipients. Claims billed with high level procedure codes (99283, 99284, 99285, 99291, 99292, 99243, 99244, and 99245) are NOT subject to the CommunityCARE referral process. Therefore, it is not necessary to request a referral from the CommunityCARE PCP for these visits. These claims will pay if filed correctly. THE HOSPITAL MAY NOT BILL THE RECIPIENT FOR THESE HIGH LEVEL VISITS, as they are a covered Medicaid service and any claim denial is probably a result of billing error.
Please note that claims billed with low level procedure codes (99281 and 99282) are still subject to the CommunityCARE referral process. Claims with these procedure codes will deny if the authorization number of the CommunityCARE PCP to whom the patient is assigned is not placed in the appropriate block on the claim form. Hospitals are reminded that these referrals should be requested on the next business day from the CommunityCARE PCP. The PCP should respond in writing within ten days, either granting or denying the referral. If it is denied, a reason for the denial must be included in the response. The hospital may NOT bill the recipient for these visits until a written response to the request is received from the CommunityCARE PCP. All CommunityCARE providers are reminded that DECISIONS TO GRANT OR DENY A REFERRAL FOR EMERGENCY ROOM SERVICES MUST BE BASED UPON WHETHER THE PATIENT�S PRESENTING SYMPTOMS MET THE PRUDENT LAYPERSON STANDARD. �HAVING NEVER SEEN THE PATIENT� OR �MY OFFICE WAS OPEN� IS NOT AN ACCEPTABLE REASON FOR DENIAL OF AN AUTHORIZATION FOR EMERGENCY ROOM SERVICES.
Questions regarding this matter may be directed to Unisys Provider Relations at 800 473-2783.
Outpatient Hospital Clinic Services
Effective for dates of service October 21, 2002 and after, revenue codes for outpatient hospital clinic services are in payable status. The payable revenue codes are 510, 514, 515, 517, and 519. These revenue codes must be billed with the appropriate accompanying CPT codes of 99201, 99202, 99203, 99204, 99205, 99211, 99213, 99214, and 99215. Hospitals may now submit claims to Medicaid for payment of these codes.
Reminder
This is a reminder that it is against Medicaid policy to solicit recipients to enroll with your agency for services.
Please refer to Section 12-5, Section A, Item 4 of the July 1, 1999 issue of the Mental Health Rehabilitation manual which states that the solicitation or subsidization of anyone by paying or
presenting any person with money or anything of value for the purpose of securing patients may constitute sufficient grounds for a provider abuse or other incorrect practices referral. If any MHR provider suspects solicitation, please contact Dawn Matte, Program Specialist at (225)342-8223.
Any suspicion of this kind of activity will be reported immediately to the Department�s Program Integrity Section.
Change to EMC Professional Specifications
Effective July 1, 2003, a change has been made to the EMC professional specifications to allow billing an emergency indicator on EMC claims when high level emergency room services are rendered to CommunityCARE recipients. If you need this indicator for your claims and you plan to continue using the Unisys proprietary specifications to bill EMC claims until transition to the HIPAA standardized 837P is required, your vendor should call the Unisys EMC coordinator at 225-237-3239 to obtain a copy of the revised proprietary specifications.
CPT Code 90742
Effective for dates of service on or after May 1, 2003, CPT code 90742 (Injection, Rhogam) was replaced by CPT code J2790 (Rhogam Injection, RHO D Immune Globule). CPT code 90742 has been placed in non-pay status effective with date of service May 1, 2003.
CPT Code J9219
Effective for dates of service on or after February 1, 2003, CPT code J9219 (Leuprolide Acetate Implant 65 mg.) was made payable at a fee of $4,252.91. The fee for implant insertion (CPT code 11981) is $107.06 and the fee for the removal of the implant (CPT code 11982) is $122.51.
Procedure Code Q0111
A claim type restriction was placed in error on procedure code Q0111 in March, 2003. This error has been corrected. Denied claims for this code may be rebilled. We apologize for the inconvenience caused by this oversight.
CPT Codes for Assistant Surgeons
Effective for dates of service on or after May 1, 2003, the following CPT codes will be added to the list of codes payable to assistant surgeons.
58551 Laparoscopy, Remove Myoma
58660 Laparoscopy, Lysis
58661 Laparoscopy, Remove Adnexa
58662 Laparoscopy, Excise Lesions
58673 Laparoscopy, Salpingostomy
�Y� Indicator To No Longer Be Accepted
With HIPAA implementation and the mandated elimination of local codes effective October 16, 2003, the "Y" indicator entered in field 19 of the CMS (HCFA) 1500 claim form and record type E of the Unisys EMC proprietary specifications will no longer be accepted to indicate professional services
provided at a state operated hospital. It has also come to our attention that some providers are using this indicator for
services that are not provided at state hospitals. Inappropriate use of this indicator is considered abusive or fraudulent billing and should be discontinued immediately.
Louisiana Drug Utilization Review (LADUR) Education
Glucocorticosteroids and Osteoporosis
Bill Ross, BS Pharm.
Clinical Coordinator for Drug Information
Louisiana Drug and Poison Information Center
School of Pharmacy University of Louisiana at Monroe
Issues:
� Osteoporosis is a progressive systemic skeletal disorder.
� Primary osteoporosis is found in both sexes at all ages, but frequently follows menopause in women and
occurs later in life in men.
� Adequate intake of calcium and vitamin D is essential to the development of optimal peak bone mass
and to the preservation of bone mass throughout life.
OVERVIEW
The first documented observation of skeletal decalcification resulting from adrenal hyperplasia secondary to ACTH-producing pituitary tumors was reported by Cushing in 1932. (27) Osteoporosis may be defined as a progressive systemic skeletal disorder characterized by low bone mass, microarchitectural deterioration of bone tissue, with resulting compromised bone strength predisposing a person to an increased risk of fracture. (1,19) Two primary factors, bone density and bone quality, constitute bone strength. Bone density is defined as grams of mineral per area or volume and is individually determined by peak bone mass and amount of bone loss. Factors such as architecture, turnover, damage accumulation (e.g., microfractures), and mineralization constitute bone quality. (1) There is no current accurate measure of overall bone strength. A frequently used proxy measure is bone mineral density (BMD) and accounts for approximately 70% of bone strength. The World Health Organization (WHO) defines osteoporosis as bone density 2.5 standard deviations below the mean for young white adult women. How this diagnostic criterion is to be applied to men and children and across ethnic groups is unclear. (1) Primary osteoporosis is found in both sexes at all ages, but frequently follows menopause in women and occurs later in life in men. Secondary osteoporosis, in contrast, results from the effects of medications such as glucocorticoids, conditions such as hypogonadism, or diseases such as celiac disease. An osteoporotic fracture is result of a failure-inducing force such as trauma applied to compromised osteoporotic bone. Such traumatic events range from normal lifting and bending to high-impact falls and can have profound physical, financial, and psychosocial consequences. Approximately one third of patients with hip fractures are discharged to nursing homes within one year following a fracture and only one third of patients regain their prefracture level of function. Within a year after an osteoporotic hip fracture, 20% of affected patients are no longer living. The treatment of osteoporotic fracture in the United States involves an estimated direct expenditure of $10 to $15 billion annually. These figures may severely underestimate the actual costs because they do not include the indirect costs of lost wages or productivity of either the patient or the caregiver. (1) The prevention of osteoporosis is multi-factorial and begins early in life. Adequate intake of calcium and vitamin D is essential to the development of optimal peak bone mass and to the preservation of bone mass throughout life. Additionally gonadal steroids are important determinants of peak and lifetime bone mass. Regular exercise, especially high-impact and resistance activities, are critical to development of high peak bone mass and may reduce risk of falls in the elderly. (1) This paper will review the relationship between corticosteroids (glucocorticoids) and osteoporosis. The adrenal cortex produces both glucocorticoids, primarily hydrocortisone, and mineralocorticoids, primarily aldosterone. (31) Publications relative to adrenal hormones and osteoporosis frequently use the general term "corticosteroids", but there is no credible clinical evidence of a contribution of mineralocorticoids to development of osteoporosis. Consequently this review relates to glucocorticoids, although the term corticosteroid will also be used to designate glucocorticoids.
Pathophysiology
Bone tissue is subject to a constant metabolic turnover and remodeling process throughout adulthood, and this process reflects a fine balance in the bone matrix in terms of the activity of bone-forming (osteoblasts) and bone-breakdown cells (osteoclasts). (22) Glucocorticoids decrease bone formation and increase bone resorption via variable processes. Corticosteroids directly inhibit osteoblast function at the glucocorticoid receptor. This alteration of function causes a decrease in replication, differentiation, proliferation, and life span of osteoblasts. As a result the total amount of bone restored during each remodeling cycle is decreased by 30%, resulting in diminished mean wall thickness. Additionally, glucocorticoids enhance the activity and increase the number of osteoclasts, which results in a greater number of active resorption surfaces. (9)
Dose-dependant calcium malabsorption has also been demonstrated in steroid-treated patients as a result of direct impairment of the intestinal cell calcium transport process. (10) Decreased calcium absorption is evident within the first two weeks of glucocorticoid therapy. (11) A secondary hyperparathyroidism may then occur with urinary calcium excretion double that of non-steroid treated patients. (10) In addition, corticosteroids reduce levels of prostaglandin E2, insulin-like growth factors, phosphate, type 1 collagen, and non-collagens including osteocalcin. (12, 13)
Estrogen in women and both androgen and estrogen in men determine both peak and lifetime bone mass. (1, 3) Bone loss from the total hip was eight times as great in elderly women with estradiol levels below 5 pg per milliliter as in women with levels of 10 pg per milliliter or greater. Glucocorticoid alteration of gonadal hormone levels is multifactorial with effects on the pituitary, gonads, and adrenal glands. Pharmacologic doses affect the pituitary by inhibiting the response of leuteinzing hormone, the gonadotropin-releasing hormone, thereby decreasing gonadal hormone production. Glucocorticoids may also directly inhibit gonadal hormone production. Adrenal hormone production is inhibited through suppression of corticotrophin secretion and the production of androstenedione, a substrate for both testosterone and estrone. (3) Men treated with glucocorticoids were shown to have testosterone concentrations of only 50% of those of a control group. (9)
Risk Factors
Bone loss becomes evident if the bone resorbed is not fully replaced due to over activity of the osteoclast or under activity of the osteoblast. Functional capability of osteoblasts and osteoclasts may be assessed by bone cell markers such as serum bone specific alkaline phosphatase, osteocalcin, type I procollagen peptides (bone formation), and serum or urine pyridinoline crosslinks (bone resorption). (20)
Biochemical determinants of bone formation include levels of alkaline phosphatase, osteocalcin, procollagen type 1 carboxyterminal and aminoterminal propeptide, and procollagen type 3 aminoterminal propeptide; all of which are serum determinations. Markers of bone resorption include levels of urinary hydroxyproline, urinary or serum pyridinium, cross-links, urinary collagen type 1 cross linked N-telopeptide, urinary collagen type 1 cross-linked C-telopeptide (crosslaps), and serum carboxyterminal telopeptide of type 1 collagen. Generally bone formation markers are more sensitive than bone resorption markers for determining the effect of glucocorticoids, with osteocalcin being the marker of choice because of its sensitivity, specificity, and reproducibility. However bone markers cannot be used without reserve as a surrogate for bone density to predict the risk of development of osteoporosis. (22) A small study of adult asthmatic patients, treated with oral and inhaled glucocorticoids, evaluated osteocalcin and procollagen as markers for the risk of osteoporotic fracture. Results indicated that neither of these two markers proved sufficiently accurate to be reliable as indicators for fracture risk in elderly, corticosteroid-treated asthmatic adults. (18)
General risk factors associated with low BMD include age, ethnic origin, gender, diet (primarily inadequate calcium and vitamin D intake), physical activity, thyroid status (history of hyperthyroidism), sex hormone status, low weight and body mass index (being in the lowest quartile in weight ,<=57.8 kg, thinness), family history of osteoporosis, history of smoking, prior fracture history after the age of 40, history of a fracture at the hip, wrist, or vertebra in a first degree relative, and possibly ethanol and caffeine consumption. (1, 19, 22) Both men and women experience an age-related decline in BMD beginning around midlife. In the early years following menopause, women experience more rapid bone loss, which places them at earlier risk of fractures. This group experiences almost three quarters of all hip fractures and has the highest age-adjusted incidence of fracture. In men, hypogonadism is also an important risk factor. Men and perimenopausal women with osteoporosis more commonly have secondary causes for bone loss than do postmenopausal women. The incidence of osteoporosis is highest in Caucasian and Oriental women and lowest in women of African decent. Mexican-American women have BMDs between those of white non-Hispanic women and African American women. Based on limited available data, Native American women have lower BMDs than white non-Hispanic women. (1)
Contribution of Glucocorticoids to Osteoporosis
Osteoporosis is reported to occur in more than 50% of patients who receive long-term glucocorticoid therapy. Risk of bone fracture is two to four times higher in patients taking glucocorticoids than that in glucocorticoid-na�ve patients. The overall estimates of fracture secondary to steroid therapy range from 30 to 50%. (9) Results of cross-sectional studies suggest that minimally one in four long-term corticosteroid users sustain osteoporotic fractures. The prevalence of vertebral fractures is 11% among asthma patients who receive steroid therapy for at least one year. Patients ingesting 7.5 mg per day or more of prednisone for six months or longer risk rapid bone loss from the hip, spine, and forearm. (28) Some evidence exists, however, that these adverse effects of glucocorticoids on bone may be reversible. A study by Laan et al (29) demonstrated that in patients receiving =< 10 prednisone per day for 18 months, there was a significant but incomplete reversal of bone loss once the prednisone was discontinued.
Glucocorticoids exert the greatest effect at skeletal sites with a higher proportion of trabecular bone than cortical bone, probably because trabecular bone has an inherently higher turnover rate than cortical bone. (3) This is not always the case, however, as demonstrated in the study by Israel et al in which glucocorticoids affected the total hip and the trochanter but not the spine. (4)
Oral glucocorticoid alteration of bone mineral density is dose-related and seen early in the course of treatment. (3) Bone reduction is dose-dependent and time-dependent and occurs most rapidly during the first six to 12 months of therapy. On average 5% of bone mass is lost within the first year of therapy; thereafter, the annualized rates of loss range from 0.3% to 3%. It has been demonstrated that daily doses of oral prednisone greater than or equal to 7.5 mg, or cumulative doses greater than 10 grams, cause the most significant detrimental effect, with no risk reduction with alternative-day administration. (9) An oral dose of prednisolone as low as 2.5 mg per day has been associated with an increased risk of vertebral fracture. (3) The relationship of inhaled glucocorticoids with osteoporosis is less clear, but a study by Israel et al documented adverse effects on bone density in women without other apparent risk factors for bone loss (4) These findings are supported by the recent investigation between the use of inhaled corticosteroids and an increased risk of nonvertebral, hip, and vertebral fractures. (3)
A four-year longitudinal study by Masumato et al evaluated the effect of inhaled beclomethasone diproprionate and short-term oral corticosteroid therapy on lumbar bone density. Generally lumber bone density remained unchanged regardless of dose, whereas the Z score (i.e., the percentage of normal value predicted from age and sex) increased significantly. Patients receiving frequent oral doses demonstrated significantly greater loss in BMD and Z score compared with those receiving sporadic courses. (2) A decrease in bone density associated with the daily dose of inhaled corticosteroid and extended years of prednisone use was demonstrated in a cross-sectional study of asthmatic adults. Interestingly, a subgroup analysis of 41 postmenopausal asthmatic women from this study found that increased bone density was associated with the number of years of supplemental estrogen therapy received, suggesting that estrogens may have a protective effect against glyucocorticoid-induced osteoporosis. (23)
A comparison of effects of fluticasone and budesonide in dry powder inhalers in healthy versus asthmatic subjects (5) found that budesonide significantly reduced osteocalcin in both groups relative to fluticasone. These results suggest that fluticasone and budesonide may have differential effects on bone metabolism. In a placebo-controlled study of inhaled triamcinolone in COPD, patients taking triamcinolone had a higher percentage decrease from base line in femoral and lumbar bone density compared to the placebo group. (6) In a small randomized but open parallel study, inhaled fluticasone propionate (500 micrograms twice daily) and budesonide (800 micrograms twice daily) were evaluated in adults with moderate to severe asthma relative to effects on biochemical markers for bone turnover, as well as changes in bone mineral density. Results demonstrated no evidence of a significant difference between the inhaled steroids on bone markers of bone resorption and formation or bone mineral density during the 12-month study with either fluticasone or budesonide. (25) In a small placebo controlled trial, Li et al evaluated the effect of inhaled fluticasone propionate powder on the hypothalamic-pituitary-adrenal axis and bone mineral density over a two year period in adult asthma patients. (21) Study results suggested that this glucocorticosteroid, dosed at 500 micrograms twice daily for up to two years, was efficacious and well tolerated and produced no clinically relevant effects on the
hypothalamic- pituitary-adrenal axis or bone density. In a pharmacoeconomic review, inhaled fluticasone in recommended doses does not appear to reduce bone mineral density in adults or to reduce growth in children between the ages of four and 14 years. (7) An additional finding was that fluticasone produced equivalent or reduced effect on this end point compared to both beclomethasone and budesonide and had similar effects to sodium cromoglycate on bone growth in children. A small multicenter trial involving moderate asthmatic patients evaluated the effect of fluticasone (400 and 750 mcg. per day) and beclomethasone (800 and 1500 mcg per day) on bone density and bone metabolism. The prospective data for this year-long study show that inhaled corticosteroids, within study parameters, had no adverse effects on bone mass and metabolism (16). An investigation of 157 asthmatic children who received inhaled budesonide for three to six years, determined that bone density measurements did not differ significantly compared with those of asthmatic control subjects who had not received steroids. (24) Wong et al (8), in a cross-sectional study, evaluated inhaled corticosteroid use and bone-mineral density in asthma patients. Beclomethasone was used by 80% of the study subjects. Confounding variables were minimized by using young patient subjects with mild asthma and by excluding those who had received more than two courses of oral corticosteroids. A doubling of cumulative dose resulted in a decrease in both lumbar and femoral bone mineral density compared with age-matched reference data.
A number of glucocorticoids are administered intranasally rather than by multidose inhaler devices. In a review of the systemic effects of intranasal steroids (9), Allen notes that harmful effects of intranasal steroids on bone metabolism have not been adequately evaluated but are unlikely.
Treatment
Oral bisphosphonates are generally considered a first-line therapy for glucocorticoid-induced osteoporosis (31). The three bisphosphonates currently marketed in the United States include alendronate (Fosamax), etidronate (Didronel), and pamidronate (Aredia), which is available only in a parenteral form. Currently risedronate (Actonel) is FDA approved for both prevention and treatment and alendronate has approval for treatment of glucocorticord-induced osteoporosis. Various studies suggest that these drugs reduce bone loss in men and women and lower the rate of fracture in patients with osteoporosis. (3) Interpreting study results can be difficult at times because of varying bisphosphonates and regimens, the heterogenicity in study populations, the effect of underlying disease on bone, and concomitant therapeutic interventions. (9) Information on the impact of bisphosphonates on the risk of glucocorticoid-induced fractures is limited and not conclusive, since most of the trials have been of 2 years or less in duration and insufficiently powered to show fracture reduction. It appears that postmenopausal women not taking estrogen supplementation seem to benefit most from taking bisphosphonates for the prevention of bone loss and vertebral fractures in corticosteroid- induced osteoporosis. (9) A recent meta-analysis indicates that in patients at risk for glucocorticoid induced fractures, bisphosphonates have shown some of the best evidence for reducing bone loss, particularly at the lumbar spine. It was concluded that bone density changes correlate with fracture risk in patients with corticosteroid-induced osteoporosis, but there are insufficient data to make conclusions regarding fracture risk reduction and the use of bisphosphonates. (14) In an earlier small placebo controlled study etidronate and calcium supplements were evaluated for impact on bone density in adult asthma patients receiving long-term high-dose inhaled glucocorticoids. Endpoints were bone density and changes in bone cell markers. Study results suggested that inhaled corticosteroids under study parameters induce bone loss that is preventable with calcium supplementation with or without etidronate. (26) A recent multi-arm clinical trial evaluated the cost effectiveness of calcium and vitamin D supplementation, etidronate, and alendronate in the prevention of vertebral fractures in women receiving glucocorticoids. Data analysis indicated that calcium and vitamin D supplements and low cost bisphosponate therapy such as cyclic eitdronate decrease the life-time vertebral fracture risk at acceptable costs and should be considered when beginning glucocorticoid therapy in women. (34)
In a placebo controlled trial alendronate, with concomitant administration of calcium and vitamin D, was evaluated for the prevention and treatment of glucocorticoid-induced osteoporosis. Using endpoints of BMD and bone fractures, the authors concluded that although alendronate does prevent progressive osteopenia in this population, it has not been proved to prevent vertebral compression or hip fractures (17) In a randomized, multicenter, open-label trial with 195 subjects, alendronate, calcitriol, and simple vitamin D were compared in the prevention and treatment of glucocorticoid-induced bone loss. The resulting data do not suggest any difference between vitamin D and calcitriol but demonstrate that alendronate was superior to either treatment for glucocorticoid-induced bone loss. (33)
Raloxifene (Evista) is the only selective estrogen-receptor modulator that has been approved for the prevention and treatment of osteoporosis. This agent has been shown to be effective in the prevention of vertebral (but not non-vertebral) fractures in postmenopausal women. (31) Use in patients with osteoporosis secondary to corticosteroids has not been evaluated.
Calcitonin is a naturally occurring peptide that at pharmacologic doses inhibits osteoclastic activity and thus acts as an anti-resorptive drug. In preventive studies calcitonin reduced bone loss secondary to glucocorticoid therapy, but did not lead to a net gain in bone mineral density. Among osteoporotic patients or those on long-term glucocorticoids, calcitonin produced a net gain in BMD, although no data addresses the incidence of fractures. (30) Currently calcitonins are not FDA approved for this purpose.
Parathyroid hormone was first investigated for the treatment of clinical osteoporosis over 20 years ago, but studies since then have been limited. One investigation of parathyroid hormone (teriparatide or Forteo) for the treatment of glucocorticoid-induced osteoporosis demonstrated a significant increase in BMD in the lumbar spine and an insufficient gain in the femoral neck. (31) A recent review of randomized clinical trials concluded that parathyroid hormone reduces vertebral fractures and increases spinal bone density in glucocorticoid-induced osteoporosis, but at the expense of decreased radius-bone density. (32)
Dietary or supplemental calcium and vitamin D intake is essential for the prevention of osteoporosis, but should not be used as sole therapy. (31) The American College of Rheumatology Task Force Guidelines (15) recommends calcium supplementation of 1500 mg per day in these patients, and patients at risk for vitamin D deficiency may also require supplementation.
Specific Recommendations for Prevention and Management
Assessment of bone mass, identification of fracture risk, and additional risk parameters for patients to be treated are determinants when evaluating patients for glucocorticoid-induced osteoporosis. (1) Pharmacologic prophylaxis should be considered in all patients beginning high-dose (>7.5 mg/day) prednisone (check equivalent doses) long-term (> six months) glucocorticoid therapy. Guideline recommendations suggest a baseline BMD measurement of all patients with dual energy x-ray absorptiometry (DXA) to ascertain the risk of osteoporosis and to monitor the efficacy of preventive measures throughout the course of therapy. BMD measurements may be repeated in six to 12 months depending on initial bone mass. Initial pharmacotherapy should be reevaluated if BMD has decreased by more than 5% from baseline. Prior to considering a dose form change to oral dosing, dose maximization of inhaled and topical corticosteroids is recommended. Preventive lifestyle modifications include smoking cessation, maintenance of healthy body weight, regular weight-bearing exercise, decreased alcohol consumption, sodium restriction, and increased calcium intake. (9)
American College of Rheumatology Task Force Guidelines (15)
Topical or inhaled glucocorticoids should be used instead of oral preparations when possible. Protection does not appear to be afforded by use of alternate-day therapy. Baseline bone mineral densitometry should be performed before long-term steroid therapy or very soon thereafter. Ideally an anteroposterior dual-energy x-ray absorptiometry measurement of both the lumbar spine and femoral neck should be done. If only one site measurement can be obtained, it is recommended that the lumbar spine be measured in men and women less than 60 years old and the femoral neck in men and women older than 60 years because in the older patients the lumbar measurements are not as reliable as those of the femoral neck. Postmenopausal women taking glucocorticoids should take hormone replacement therapy, if no contraindications exist. Premenopausal women who experience oligomenorrhea or amenorrhea while taking corticosteroids should consider oral contraceptives absent contraindications. Testosterone levels should be measured in men who are receiving glucocorticoids. Patients treated with corticosteroids should also take 1500 mg per day of a calcium supplement along with vitamin D supplementation for at risk patients.
(15)
References:
1. McElvoy CE, Niewoehner DE. Adverse Effects of Corticosteroid Therapy: A Critical Review. Chest.
1997; 111(3):732-743
2. Klibanski A, et al. Osteoporosis Prevention, Diagnosis, and Therapy. JAMA 2001;285(6):785-795
3. Fairney A. Bone loss and glucocorticoid therapy in patients with respiratory disease. Thorax. 1999; 54(Supp. 2):S52-S57
4. Schimmer, Parker K. Adrenocorticotropic Hormone. In: Hardman JG, Lee EL, Gilman AG, editors. The Pharmacologic Basis of Therapeutics. 10th
ed. New York: McGraw-Hill;2001. p. 1655
5. Lipworth BJ. Systemic Adverse Effects of Inhaled Corticosteroid Therapy: A Systematic Review and Meta-analysis. Archives of Internal Medicine.
1999;159(9):941-955
6. Blair MM, Carson DS, Barrington R Bisphosphonates in the Prevention and Treatment of
Glucocorticoid-Induced Osteoporosis. Journal of Family Practice. 2000; 49(9):839-848
7. Fleisch H. Bisphosphonates:mechanism of action. Endocr Rev 1998;19:80-100
8. Wolinsky-Friedland M. Drug-induced metabolic bone disease. Endocrinol Metab Clin North Am 1995;24:395-420
9. Reid Ir. Glucocorticoid osteoporosis mechanisms and management. Eur J. Endocrinol
1997;137:209-217
10. Lukert BP, Raisz LG. Glucocorticoid-induced osteoporosis. Rheum Dis Clinic North Am.
1994;20:229-250
11. Dawson-Hughes B. Bone Loss Accompanying Medical Therapies. NEJM. 2001;345(13):989-991
12 .Reid DM. Corticoid induced osteoporosis: guidelines for prevention-are they useful? Br J
Rheumatol. 1997;36:1035-1036
13. Wisniewski AF, Lewis SA, Green, DJ, Maslanka W, et al. Cross section investigation of the effects of inhaled corticosteroids on bone density and bone metabolism in patients with asthma. Thorax.
1997;52:853-860
14. Toogood JH, Hodsman AB, Fraher, LJ, et al. Serum osteocalcin and procollagen as markers for the risk of osteoporotic fracture in
corticosteroid-treated asthmatic adults Journal of Allergy & Clinical Immunology. 1999;104(4):769-774
15. Skolnick A. Rheumatologists Issue Guidelines for Preventing and Treating Corticosteroid-Induced Osteoporosis. JAMA. 1997;277(2):98-100
16. Saag KG. Low-dose Corticosteroid Therapy in Rheumatoid Arthritis:Balancing the Evidence. American Journal of Medicine. 1997;103
(Supp. 6A):31S-39S
17. van Staa TP, Leufkena HGM, Cooper C. Use of inhaled corticosteroids and risk of fractures. J Bone Miner Res 2001;16:581-588
18. Matsumoto H, Ishihara K, Hasegawa T, Umeda B. Effects of Inhaled Corticosteroid and Short Courses of Oral Corticosteroids on Bone Mineral Density in Asthmatic Patients: A 4-Year Longitudinal Study. Chest 2001;120(5):1468-1473
19. Hanania NA, Chapman KR, Sturtridge, WC, Szalii JP, Kesten S. Dose-related decrease in bone density among asthmatic patients treated with
inhaled corticosteroids. J Allergy Clin Immunol. 1995;96:571-579
20. Harrison TW, Wisniewski A, Honour J, Tattersfield AE. Comparison of the systemic effects of fluticasone propionate and budesonide given by dry powder inhaler in healthy and asthmatic subjects. Thorax 2001;56:186-191
21. Wise R, Connett J, Weinmann G, Scanlon P, Skeans M. Effect of Inhaled Triamcinolone on the Decline in Pulmonary Function in Chronic Obstructive Pulmonary Desease. NEJM 2000;343(26):1002-1090
22. Hughes JA, Conry BG, Male SM, Eastell R. One year prospective open study of the effect of high dose inhaled steroids, fluticasone propionate, and budesonide on bone markers and bone mineral density. Thorax 1999;54(3):223-229
23. Li J, Ford L, Chervinski P, Weisberg S, Kellerman D, et al. Fluticasone propionate powder and lack of clinically significant effects of hypothalamic-pituitary-adrenal axis and bone mineral density over 2 years in adults with mild asthma. Journal of Allergy & Clinical Immunology 1999;103(6):1062-1068
24. Lamb HM, Culy CR, Faulds D. Inhaled Fluticasone Propionate. A Pharmacoeconomic Review of its Use in the Management of Asthma. Pharmacoeconomics 2000 18(5):487-510
25. Medici TC, Grebski E, Hacki M, Ruegsegger P, et al. Effect of one year treatment with inhaled fluticasone propionate or beclomethasone dipropionate on bone density and bone metabolism: a
randomized parallel group study in adult asthmatic subjects. Thorax 2000;55(5):375-382
26. Agertoft L, Pedersen S. Bone mineral density on children with asthma receiving long term treatment with inhaled budesonide. Am J Respir Care
Med. 1998;157:178-183
27. Myers K. New evidence of a link between inhaled corticosteroid use and osteoporosis. CMAJ-JAMC 2000; 163(10):1335-1337
28. Brown, JP, Josse RG et al. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ-JAMC 2002;167(10Supplement):1S
29. Homik JE, Cranney A, Shea B, et al. A meta-analysis on the use of bisphosphonates in corticosteroid induced osteoporosis. J Rheumatol 1999;26:1148-57
30. Wang WQ, IP MS, Tsang KW, Lam KS. Antiresorptive therapy in asthmatic patients receiving high-dose inhaled steroids: A prospective study for 18 months. Journal of Allergy and Clinical Immunology 1998;101:445-450
31. Buckley LM, Hillner BE. A cost effectiveness analysis of calcium and vitamin d supplementation, etidronate, and alendronate in the prevention of verteberal fractures in women treated with glucocorticoids. J Rheumatology 2003;30(1):1-3
32. Wernick R, Campbell S. Update in Rheumatology 2000;132(2):125-133
33. Sambrook P, Kootwicz M, Nash P, Styles, CB et al. Prevention and treatment of
glucocorticoid-induced osteoporosis: a comparison of calcitrol, vitamin D plus calcium, and alendronate plus calcium. J Bone Miner Res 2003;18(5):919-924
34. Sambrook P, Birmingham, J, Kelly P, Kempler S, et al. Prevention of Corticosteroid Osteoporosis A Comparison of Calcium, Calcitrol, and
Calcitonin. NEJM 1993;328(24):1747-1752
35. Crandall C. Parathyroid hormone for treatment of osteoporosis. Arch Intern Med
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36. American College of Rheumatology Task Force on Osteoporosis Guidelines. Recommendations for the prevention and treatment of
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INSERT -
2003 Unisys Provider Workshop Schedule for
KidMed, Professional, LTC, Hospice, Home Health, and CommunityCare
The Department of Health and Hospitals and Unisys invite and strongly encourage you to attend the 2003 LA Medicaid Provider Training Workshops scheduled for August 25- September 4, 2003. These workshops will focus on
billing changes that will impact payment to the LA Medicaid provider community as a result of the Federally mandated Health Insurance Portability and Accountability Act (HIPAA) of 1996.
These workshops are for the following provider types:
KidMed - (KidMed Providers - EXCLUDING RHC/FQHC Providers)
Professional - (Physicians, Ambulatory Surgical Centers, Prenatal Clinics,
Independent Labs) **
LTC - (Nursing Homes, ICF/MRs, and ADHCs ONLY)
Hospice - (Hospice Providers ONLY)
Home Health - (Home Health Providers ONLY)
CommunityCARE - (Providers involved in the CommunityCARE Program should attend. CommunityCARE PCPs and hospitals are strongly encouraged to attend.)
** Provider Training for Vision Services (Ophthalmologists, Optometrists, and Vision Providers) will be held at a later date. Providers will be notified of the training date and time.
We recommend that business office management and billing staff, as well as administrative personnel attend these provider workshops.
The billing changes that will be discussed will affect your Medicaid payment.
The workshop schedule can be found on the following page. Please review this schedule for the location and time of your workshop, and mark your calendar to attend.
Bring your LA Medicaid provider number to the workshop, as it is required for registration.
2003 Unisys Provider Workshop Schedule for KidMed, Professional, LTC, Hospice,
Home Health, and CommunityCare
|
CITY
|
DAY, DATE, TIME,
AND SESSION
|
New Orleans
|
Tuesday, August 26
|
|
Room
Name
|
Belle
Grove Plantation Ballroom
|
Rivertown
|
|
Pontchatrain
Center
4545
Williams Blvd
Kenner,
LA 70065
|
KidMed
� 8:00-10:00
Professional
� 10:15-12:45
CommunityCare
� 2:00-3:30
(Due
to the September 1, 2003 implementation date for Orleans parish, the hours
for the CommunityCare session may be extended for this city only)
|
LTC � 8:00-10:30
Hospice � 10:45-12:15
Home Health � 1:15-4:15
|
|
Lafayette
|
Wednesday,
August 27
|
|
Room
Name
|
Festival
|
Mardi
Gras
|
|
Cajun
Dome Convention Center
444
Cajun Dome Blvd
Lafayette,
LA 70503
|
KidMed
� 8:00-10:00
Professional
� 10:15-12:45
CommunityCare
� 2:00-3:30
|
LTC � 8:00-10:30
Hospice � 10:45-12:15
Home Health � 1:15-4:15
|
|
Baton Rouge
|
Friday, August 29
|
|
Room
Name
|
Trademart
|
Banquet
|
|
Lamar
Dixon Expo Center
9039
St. Landry Rd.
Gonzales,
LA 70737
|
KidMed
� 8:00-10:00
Professional
� 10:15-12:45
CommunityCare
� 2:00-3:30
|
LTC � 8:00-10:30
Hospice � 10:45-12:15
Home Health � 1:15-4:15
|
|
Monroe
|
Wednesday,
September 3
|
|
West
Monroe Convention Center
901 Ridge Ave.
West Monroe, LA 71291
|
KidMed
� 8:00-10:00
Professional
� 10:15-12:45
CommunityCare
� 2:00-3:30
|
LTC � 8:00-10:30
Hospice � 10:45-12:15
Home Health � 1:15-4:15
|
|
Bossier City
|
Thursday, September 4
|
|
Bossier
City Civic Center
620
Benton Road
Bossier
City, LA 71111
|
KidMed
� 8:00-10:00
Professional
� 10:15-12:45
CommunityCare
� 2:00-3:30
|
LTC � 8:00-10:30
Hospice � 10:45-12:15
Home Health � 1:15-4:15
|
PLEASE NOTE: Not all provider types are included in this workshop. Only those provider types listed above should attend.
Medicaid Billing Changes/HIPAA Electronic Data Interchange (EDI)
Schedule
Billing changes resulting from HIPAA will be implemented in multiple phases also called "implementations." The impact on the provider community will vary depending on the size and complexity of each implementation.
A type, or a combination of types, identifies each implementation: Local Code, Electronic Data Interchange (EDI), or Claim form.
- Local Codes primarily focus on the transition from Louisiana specific codes to HIPAA
standard codes sets.
- EDI indicates this implementation is a standard electronic HIPAA transaction.
- Claim Form indicates changes made to the hardcopy claim form and /or instructions.
- The effective date will indicate the specific date of transition to a new process or code set.
- The effective date of EDI related implementations actually indicates that one submitter
has completed the 7 levels of testing. After the effective date, all remaining submitters
can begin or finalize their testing process to become "Approved" to submit specific HIPAA
electronic transactions. (See "Becoming HIPAA Ready for LA Medicaid Billing Changes")
|
Implementation
Title
|
Type
|
Date
|
Description
|
|
Pharmacy
|
Local
Codes
|
01/21/03
|
Eliminate
the use of LA specific pharmacy NDC codes for indwelling catheters
|
|
|
EDI
|
04/07/03
|
HIPAA
transaction 835/U277 electronic remittance advice now available to those
providers who request it.
|
|
|
EDI
|
04/07/03
|
Begin
accepting 837I inpatient/outpatient electronic institutional claims
|
|
Privacy
|
NA
|
04/14/03
|
The
Privacy HIPAA Rule becomes effective.
|
|
Dental
|
EDI/Local
Codes/Claim Form
|
05/01/03
|
|
|
|
Local
Codes
|
05/01/03
|
Eliminate
the use of LA specific codes.
|
|
Hemodialysis
|
Local
Codes
|
05/01/03
|
Eliminate
the use of LA specific codes.
|
|
Rural
Health/FQHC
|
Local
Codes/Claim Form
|
05/01/03
|
Eliminate
the use of LA specific codes. Begin
new payment methodology. Begin use of new billing instructions for KIDMED
KM-3 paper claim form.
|
|
MEVS/REVS
270/271
|
EDI
|
06/28/03
|
Begin
receiving recipient status requests and transmitting responses in the
HIPAA standard electronic formats. End use of 3040
version.
|
|
Professional
837P
|
EDI
|
07/26/03
|
Begin
accepting 837P electronic professional claims.
|
|
POS
NCPDP V5.1
|
EDI
|
08/24/03
|
Begin
use of NCPDP 5.1 real-time format for pharmacy Point of Sale claims. RA
response codes for pharmacy claims upgraded to NCPDP version 5.1.
End use of version 3.2.
|
|
Pharmacy
NCPDP V1.1
|
EDI/Claim
Form
|
08/24/03
|
Begin
use of Universal Prescription Claim Form (UCF). Begin use of NCPDP 1.1
batch electronic format for pharmacy claims. End use of proprietary
electronic format.
|
|
Transportation
|
Local
Codes
|
10/01/03
|
Eliminate
the use of LA specific codes for emergency transportation providers and
begin use of standard code
|
|
Home
Health
|
EDI/Local
Codes/ Claim Form
|
10/01/03
|
Begin
use of UB92 paper claim form and 837I electronic claims for this program.
Eliminate use of LA specific codes and begin use of standard codes. End
use of proprietary 101 paper forms.
|
|
Professional
- Physicians
(Including: Pre-natal Clinics,
Ambulatory Surgical Centers, , Physician Services, Lab & X-ray,
Transportation, Immunizations, Family Planning Clinics, Anesthesia, EPSDT
Screening Clinics)
|
Local
Codes
|
10/01/03
|
|
KIDMED Local Code
(EPSDT
Screening Service)
|
Local
Codes/Claim Form
|
10/01/03
|
|
LTC/ICFMR/ADHC/Hospice
837I
|
EDI/Claim
Form
|
10/01/03
|
Begin
accepting UB92 paper claim form and 837I electronic institutional claims
with standard codes.
|
|
Claims
Status Inquiry (CSI) 276/277
|
EDI
|
10/13/03
|
Begin
online provider Claim Status Inquiry (CSI)
|
|
Professional
� Non-Physicians
(Including: TB Clinics, STD Clinics,
EPSDT Health Services, Mental Health Clinics, MH Rehab, Vision(eyeglasses),
Rehab Centers
|
Local
Codes
|
TBD
|
|
|
Prior
Authorization 278
|
EDI
|
TBD
|
Begin
to accept prior authorization requests in the electronic 278 format.
|
|
DME/DME
Pharmacy
|
Local
Codes
|
TBD
|
|
|
Waiver
|
Local
Codes
|
TBD
|
|