PROVIDER
UPDATE
VOLUME 9, NUMBER 3
JUNE 1992
All Providers
Unisys Name Change
Unisys/LA. Medicaid is now operating under the name Paramax Systems
Corporation, a Unisys company. Paramax
Systems Corporation, headquartered in McLean, Virginia, is a $2 billion
information systems company with 17,000 employees.
A subsidiary of Unisys Corporation, Blue Bell, Pennsylvania, Paramax is
an experienced leader in complex systems integration, custom electronic
products, and related professional services for civil and defense agencies of
the U.S. Government, Canada, and nations on five continents.
Our recent name change, however, need not concern the Medicaid provider
community in Louisiana. Now, more
than ever, we are dedicated to meeting our customer's needs and expectations.
Paramax has a long history of proven performance and a long list of
satisfied customers.
Paramax is market-driven and technology-enabled.
Simply put, we develop and apply leading-edge technologies to meet our
customer's needs and requirements. We
blend our technical substance with a corporate style that stresses quality,
cost-effectiveness, program performance, and partnership with out customers.
Ultimately, what makes Paramax special is the proud reputation we've achieved
among our customers for being a responsible contractor, for keeping promises,
for getting the job done.
Our promise to the provider community of Louisiana is to build on our core
strengths and to forge new partnerships in the years to come.
Recipient Eligibility Verification System
We would like to encourage providers to use our new computerized Recipient
Eligibility Verification System. To
access the system, providers must telephone (800)
776-6323 and have their seven-digit Provider I.D. number, as well as
the appropriate thirteen-digit recipient number and date of service, available.
Procedural instructions will be given via voice response prompt messages.
Those providers who are familiar with the procedures for entering information
need not wait for the voice response prompt messages; instead, they may begin
entering information as soon as they have accessed the system.
To discontinue the service, providers must press *9
on their touch-tone telephones. Otherwise,
the service will be continued for another 90 seconds, even if the provider has
already hung up the telephone.
Provider Relations
The Provider Relations inquiry staff strives to respond to provider inquiries
quickly and efficiently. However,
due to the number of incoming calls for other departments that must be
transferred out of Provider Relations, the inquiry staff is having difficulty
responding to Provider Relations related inquiries in a timely manner.
Thus, to help us serve the provider community better, we are requesting
that providers telephone Provider Relations only when they have questions
concerning printed policy, claims processing problems, or the status of
particular claims.
NOTE:
We request that providers review and reconcile their Remittance Advices
before they call Provider Relations for the status of a claim.
Providers who have questions concerning EMC may telephone (504)
924-7051.
Providers who have questions concerning Prior Authorization may telephone (504)
928-5263 or 1-800-488-6334.
NOTE:
PA claims billing problems, however, should be addressed to Provider
Relations.
Providers requesting check amounts, eligibility information, and the number
of remaining recipient days or visits may call our VIPS line at 1-800-776-6323.
NOTE:
Effective immediately, we are no longer able to transfer providers out of
Provider Relations to other departments.
Recipient Telephone Inquiries
The Provider Relations telephone unit is set up to receive telephone
inquiries from providers, not recipients. We do not have access to any information that could benefit
recipients. Therefore, we ask that
providers not issue our telephone number to their Medicaid patients.
Recipient inquiries tie up our lines disproportionately so that we are
unable to process provider inquiries in an efficient and timely manner.
If recipients have problems with eligibility, it is appropriate to refer them
to their eligibility worker at the parish office.
If providers have difficulties with filing claims, they should call
Provider Relations for assistance.
Claims Resolution Procedures
Providers should note that hospital claims only may be sent to the attention of Sandra Victor
for consideration of an override of the two-year timely filing limitations.
All other claims should be sent to the attention of their respective
programs, such as Pharmacy, Physician, or Transportation Programs.
It should be noted that a two-year override will only be considered for cases
involving retrospective eligibility
or an administrative error.
Claims not adjudicated within the two-year time frame as a result of
provider error will not be considered for an override.
If a claim involves retroactive eligibility or a provider feels that an
administrative error has occurred, the provider must submit documentation to
substantiate the claim and attach documentation of timely filing in order to be
considered for an override of the two-year timely filing limitations.
Refunds & Voids
Instead of simply refunding payments when errors in billing occur, e.g.,
duplicate payments, providers should initiate claim adjustments or voids.
However, should providers find it necessary to refund a payment, they
should make checks payable to the Department of Health and Hospitals, Bureau of
Health Services Financing, and they should mail the refunds to the following
address:
Division of Fiscal Management
Financial Management Section
P. O. Box 91117
Baton Rouge, LA 70821-9117
NOTE:
Checks should not be made payable to Paramax.
To ensure that accounts are reconciled appropriately, providers must attach a
copy of the Remittance Advice to their return check.
To determine the amount of a refund, providers should consider the following
rules:
�
Whenever a duplicate payment is made, the full amount of the second
payment must be refunded.
�
If another insurance company pays after Medicaid has made its payment,
and the TPL payment is greater than the Medicaid payment, the full amount of the
Medicaid payment should be refunded.
NOTE:
Providers should never submit a void and a refund for the same payment
amount.
Physicians
Only
1992
CPT Procedure Codes
The 1992 CPT procedure codes have been priced and
placed on the procedure/formulary file effective with date of service January 1,
1992. You may begin billing these
codes immediately. The fees for
these codes are provided in the Attachments
section of this issue of the Provider
Update. Please remove this
attachment and add it to your 1992
Professional Services Fee Schedule.
Antibiotic
Injections
Currently, the only antibiotic injections payable by
the Physicians Program are injections of procaine penicillin or bicillin for
recipients under the age of 21. These
two injections are billed by use of procedure code 90782.
Effective with date of service May 1, 1992, all
other antibiotic injections will become payable as well, but only for
recipients to the age of 21.
Providers should continue to bill for these injections
by using procedure code 90782. The reimbursement rate for all antibiotic injections will be
$8.27.
These injectables have no limitations.
Allergen
Immunotherapy
Effective immediately, the submittal of documentation
on claims for procedure codes 95150 and 95155 (Professional service for the
supervision and provision of antigens for allergen immunotherapy; single or
multiple antigens, one multiple dose vial or two or more multiple dose vials) is
no longer necessary because the computer has been programmed to accept and pay
claims for these two codes without their pending to the MRT for review.
Even though these claims will no longer pend, Medicaid
policy in regards to these two codes remains the same.
Only one claim line per provider, per recipient, per every 90 days, will
be payable. A second claim line in the same 90-day period will deny with
error edit 733. If a provider fails
to bill for a 3-month supply on the first claim, the provider will have to file
an adjustment to get correct payment.
Physicians,
Speech Pathologists, Audiologists, School Boards, & Rehab Centers
Hearing
& Speech Testing
The following policy has been adopted by the Bureau of
Health Services Financing regarding the provision of certain hearing and speech
testing services.
Now, we will require that speech pathologists and
audiologists meet state licensure as follows:
�
By having obtained a certificate of clinical competence from the American
Speech and Hearing Association;
�
By having completed the equivalent educational and work experience
requirements for the certificate; and/or
�
By having completed the academic programs by acquiring supervised
experience to qualify for the certificate.
The following procedures and reimbursement requirements will be effective
July 1, 1992.
Codes 92252 through 92585 will be limited to reimbursement once in 180 days.
The following codes are subject to the restrictions indicated and will now
reimburse in accordance with the maximum fee amount shown.
Audiologic Function Tests with Medical Diagnostic Evaluation
|
CODE
|
DESCRIPTION
|
MAXIMUM
REIMBURSEMENT
AMOUNT($)
|
RESTRICTION
|
|
|
|
|
|
| 92551
|
Screening
test, pure tone, air only
|
4.00
|
Must
be performed by RN, physician, audiologists or speech pathologist.
|
| 92552
|
Pure
tone audiometry (threshold), air only
|
25.00
|
Audiometer,
not handheld device, must be used.
|
| NOTE:
The following codes except for codes 92567, 92568, and 92569, must
be performed in a sound proof booth, by only an ASHA-certified audiologist
or a physician otologist. Audiometers
must be calibrated once per year.
|
|
CODE
|
DESCRIPTION
|
MAXIMUM
REIMBURSEMENT
AMOUNT($)
|
RESTRICTION
|
|
|
|
|
|
| 92553
|
Pure
tone audiometry (threshold), air and tone
|
50.00
|
Bill
either 92552 or 92553; do not bill both
|
| 92555
|
Speech
audiometry; threshold only
|
10.00
|
|
| 92556
|
Speech
audiometry; threshold and discrimination
|
25.00
|
Bill
either 92555 or 92556; do not bill both
|
| 92557
|
Basic
comprehensive audiometry
|
60.00
|
Bill
this code only if both 92553 and 92556 are performed.
This code cannot be performed by a nurse.
|
| 92559
|
Audiometric
testing of groups Bekesy audiometry; screening Bekesy audiometry;
diagnostic Loudness balance test
|
Not
payable
|
|
| 92563
|
Tone
decay test
|
10.00
|
|
| 92564
|
Short
increment sensitivity index
|
20.00
|
|
| 92565
|
Stenger
test, pure tone
|
15.00
|
|
| 92566
|
Impedance
testing
|
Not
payable
|
Deleted
in 1991 CPT-4
|
| 92567
|
Tympanometry
(Impedance testing)
|
25.00
|
|
| 92568
|
Acoustic
reflex testing
|
25.00
|
|
| 92569
|
Acoustic
reflex decay test
|
36.00
|
|
| NOTE:
The following codes may be performed by physicians and ASHA-certified
practitioners:
|
|
CODE
|
DESCRIPTION
|
MAXIMUM
REIMBURSEMENT
AMOUNT($)
|
RESTRICTION
|
|
|
|
|
|
| 92571
|
Filtered
speech test
|
25.00
|
This
code is not a preliminary test code.
|
| 92572
|
Staggered
spondaic word test
|
75.00
|
|
| 92573
|
Lombard
test
|
Not
payable
|
|
| 92574
|
Swinging
story test
|
Not
payable
|
|
| 92575
|
Sensorineural
acuity level test
|
20.00
|
|
| 92576
|
Synthetic
sentence identification test
|
25.00
|
|
| 92577
|
Stenger
test, speech
|
15.00
|
|
| 92578
|
Delayed
auditory feedback test
|
Not
payable
|
|
| 92580
|
Electrodermal
audiometry
|
Not
payable
|
|
| 92581
|
Evoked
response audiometry
|
|
Deleted
in 1991 CPT-4
|
| 92582
|
Conditioning
play audiometry
|
50.00
|
|
| 92583
|
Select
picture audiometry
|
25.00
|
This
code is the same as 92256. Do
not bill both codes.
|
| 92584
|
Electrocochleography
|
200.00
|
|
| 92585
|
Brainstem
evoked response recording
|
200.00
|
|
| 92589
|
Central
auditory function tests
|
Not
payable
|
|
| 92590
|
Hearing
aid exam and selection; monaural
|
65.00
|
|
| 92591
|
Hearing
aid exam and selection; binaural
|
65.00
|
|
| 92592
|
Hearing
aid check; monaural
|
25.00
|
|
| 92593
|
Hearing
aid check; binaural
|
50.00
|
|
| 92594
|
Electroacoustic
evaluation for hearing aid; monaural
|
25.00
|
|
| 92595
|
Electroacoustic
evaluation for hearing aid; binaural
|
50.00
|
|
| 92596
|
Ear
protector attenuation measurements
|
Not
payable
|
|
| X0401
|
Objective
speech and language screening;
|
Not
payable
|
|
| NOTE
ON SURGERIES: We are pleased
to announce that we are increasing fees for the following surgeries:
|
|
CODE
|
DESCRIPTION
|
MAXIMUM
REIMBURSEMENT
AMOUNT($)
|
RESTRICTION
|
|
|
|
|
|
| 42820
|
Tonsillectomy
and adenoidectomy; under age 12
|
630.00
|
|
| 42821
|
Tonsillectomy
and adenoidectomy; age 12 or over
|
630.00
|
|
| 42825
|
Tonsillectomy,
under age 12
|
600.00
|
|
| 42826
|
Tonsillectomy,
over age 12
|
650.00
|
|
| 42830
|
Adenoidectomy,
under age 12
|
605.00
|
|
| 42831
|
Adenoidectomy,
over age 12
|
575.00
|
|
| 69436
|
Tympanomastoid
(requiring insertion of ventilating tube), general anesthesia
|
420.00
(for 2)
|
|
Pharmacists and Prescribers
Federal Upper Limits Suspended
The Federal Upper Limits on the following drugs have been suspended:
Generic Name:
Gentamicin Sulfate Opth. Ointment
3 mg/gm
Eff. 3/5/92
Primidone
250 mg tablet
Eff. 3/5/92
Trihexyphenidyl Hydrochloride
2 mg tablet and 5 mg tablet
Eff. 3/5/92
Methenamine Hippurate
1 gm tablet
Eff. 4/29/92
Lithium: Educational
Article
Lithium is a monovalent cation possessing antimanic, antidepressant and
antipsychotic activities. This
agent has been shown to be effective for the treatment and prophylaxis of
recurrent episodes of acute mania. It has demonstrated particular benefits in the treatment of
bipolar disorder (previously referred to as Manic-Depressive Illness).
The onset of lithium's antimanic action may be slow.
Several days (3 to 14) may be required for lithium to exert its maximum
antimania effect. Initial therapy
for symptomatic relief and behavioral control might warrant the use of a
phenothiazine derivative or haloperidol, depending on the clinical situation.
It is recommended that serum levels be determined twice weekly during the
first month of therapy and then weekly or when suspicion of toxicity or
noncompliance is present. To treat
acute mania, lithium levels should be in the range of 1.0 to 1.5 mEq/L.
For prophylaxis and maintenance therapy, however, levels of 0.6 to 1.2
mEq/L are recommended.
Lithium should be avoided in patients with severe renal dysfunction and in
lactating females. Caution should
be exercised in patients with significant cardiovascular disease, those
presenting with dehydration or sodium depletion, and those requiring diuretic
therapy.
Lithium toxicity may be categorized according to symptomatology and plasma
lithium levels. Mild
toxic manifestations (LiCp <1.5 mEq/L) include:
fine hand tremor, GI upset, mild polyuria, polydipsia, and muscle
weakness. Moderate
toxicity (LiCp 1.5 - 2.5 mEq/L) includes:
coarse tremor, twitching; recurrence of GI upset, slurred speech,
vertigo, sedation, lethargy, and hyperreflexia. Severe toxicity (LiCp
> 2.5 mEq/L) includes: seizures,
stupor, coma, cardiovascular collapse, and death.
NOTE:
Levels should be drawn at least 10 to 12 hours after the last dose.
The narrow therapeutic range of lithium, together with the severity of
lithium toxicity, makes it difficult to manage patients receiving other drugs
capable of altering lithium blood levels. Patients require frequent monitoring of lithium levels with
resultant changes in dosages to maintain blood levels within the desired
therapeutic ranges without concomitant toxicities. Lithium levels are know to be affected by therapeutic agents
which increase or decrease lithium elimination.
The chronic use of thiazide diuretics in combination with lithium may result
in a decreased lithium clearance and a clinically significant increase in
lithium levels and toxicity. However, lithium and thiazide diuretics can be
co-administered safely provided lithium levels are monitored and the patient is
observed for signs and symptoms of toxicity.
Dosage adjustments may be necessary to maintain proper therapy in these
patients.
Increases in serum lithium levels have also been reported following chronic
administration of diclofenac, ibuprofen, indomethacin, naproxen, and piroxicam,
possibly due to NSAID interference with prostaglandin production and decreased
lithium excretion. Monitoring and
adjustments of lithium dosage may similarly be necessary when adding or changing
NSAID therapy.
Dose Adjustment Suggestions:
In compliant patients, dosage adjustments to compensate for hydrochlorothiazide's
effect on lithium clearance can be calculated as follows:
Formula One
DLiCl=
(LiCp1 - LiCp2) (100%)
LiCp1
Where:
DLiCl=change
in lithium clearance
LiCp1=lithium level before HCTZ added
LiCp2=lithium level after HCTZ added
The adjusted lithium dose (in mEq/day)
can be calculated by:
Formula Two
LiD2= (LiD1)
(1 + DLiCl)
Where:
300 mg lithium carbonate equals approximately 8mEq of lithium
LiD1=original dose of lithium (in mEq/day)
LiD2=adjusted dose of lithium (in mEq/day)
Example:
A patient on 1200 mg/day lithium carbonate (32 mEq/day) is started on
standard HCTZ therapy.
Using Formula One:
LiCp1=0.9
LiCp2=1.3
DLiCl=-44%
Using Formula Two:
LiD2=(32 mEq/day)(1 + (-.44)
LiD2=17.92 mEq/day(where 300 mg lithium carbonate = 8mEq)
Therefore, an adjusted dose of lithium to compensate for HCTZ effects on
lithium clearance would be approximately 600 mg/day (300 mg bid) of lithium
carbonate.
Other lithium drug-drug interactions, however, may be unrelated to changes in
lithium blood levels. The
combination of lithium with either haloperidol or carbamazepine represents two
such interactions of clinical significance.
Patients receiving these combinations of drugs require close supervision.
Several reports suggest that the combination of lithium/carbamazepine is
responsible for a variety of neurotoxic effects including lethargy, muscular
weakness, ataxia, tremor, and hyperreflexia, while blood levels of both agents
may remain unchanged. On the other
hand, combination therapy is claimed to have a synergistic effect in controlling
mania.
Combinations of lithium with haloperidol is also known to produce a toxic
syndrome, consisting of weakness, lethargy, tremors, confusion, stupor, fever,
extrapyramidal symptoms and dystonias, leukocytosis, elevated serum enzymes, and
blood urea nitrogen, although numerous others have demonstrated that the
combination can be used safely with adequate monitoring.
Management of reported drug-drug interactions involves a combination of
awareness and appropriate monitoring. With a knowledge of the complete drug regime and lithium
levels, the physician may determine an appropriate course of action (or
inaction). These drug-drug
interactions require management similar to that employed for lithium therapy in
general. The physician needs to be
aware of medications which may have been prescribed by other physicians.
Monitoring programs consistent with good medical practice, including
blood lithium determinations and assessment of patient symptoms, may ameliorate
potential harmful effects of combination therapies.
Hemodialysis Centers
CAPD Services
Medicaid of Louisiana recently approved payment of Continuous Ambulatory
Peritoneal Services (CAPD) provided by Hemodialysis Centers, effective
retroactive to July 1, 1991. More recently, Medicaid of Louisiana approved payment to
Hemodialysis centers at the same rate as Medicare for the hemodialysis and CAPD
services. The effective date for
this change was April 1,1992.
Hemodialysis centers were notified of the approval for payment for CAPD
services and of the requirements to participate in a memorandum dated February
13, 1992. They were notified of the
new payment methodology in a memorandum dated March 16, 1992.
DME Suppliers
Recipient Concerns
Recently, we have received a number of calls from recipients, indicating that
the quantity of an item or a supply dispensed is less than the quantity
authorized by the Paramax Prior Authorization Unit.
Further research indicates that the amounts billed by the providers for
these claims are equal to the prior authorized amounts.
Thus, providers should review their billing practices to ensure that
claims reflect actual services provided and that providers are not billing for
services which may not have been provided.
158-C Requests
Requests formerly made on the 158-C form are now made on the PA01 form.
Providers should ensure that these PA01 forms are sent to Paramax at the
following address:
Paramax Systems Corporation
Prior Authorization Unit
P. O. Box 14919
Baton Rouge, LA 70898-4919
Providers should no longer send completed 158-C forms or PA01 forms to the
Bureau of Health Services Financing.
Wheelchairs
In an effort to clarify bidding procedures on wheelchairs, we are publishing
the following statement.
The physical therapist, the social worker, the recipient, or the Prior
Authorization Unit must obtain three bids on any special type of wheelchair
costing more than $1000.00. The
provider of service is not allowed to obtain these bids.
The expedite the bidding process, providers should attach the seating
evaluation to the prior authorization request, and, if that is not available,
the provider should attach the following specifications:
the patient's weight, the specific equipment required, and the
measurements of the chair.
The Augmentative Communication Device
Effective May 1, 1992, program coverage was expanded to include Augmentative
Communication Devices (ACDs) for recipients to the age of 21 only.
The procedure code for the basic unit is Z0629, and the procedure code
for the accessories is Z0619.
Rehabilitation Services Provider
Prior Authorization No Longer Necessary
Effective May 1, 1992, Medicaid of Louisiana will no longer require prior
authorization of evaluations for
outpatient physical, occupational, and speech therapy services.
Payment will be limited, however, to no more than one evaluation, per
recipient, every 180 days to the same provider.
NOTE:
Therapy treatment plans will continue to require prior authorization.
Oral Surgeons
Billing CPT-4 Codes
Effective July 1, 1992, oral surgeons will be allowed to bill CPT-4 codes
appropriate to their specialty. Providers should consult their CPT-4 for appropriate codes.
The list of codes in the Dental
Services Provider Manual will be obsoleted.
Also, we will allow oral surgeons to use any appropriate ICD-9-CM codes
available. The list in the manual
will no longer be limited to the 11 diagnoses listed.
Scan Attachments 4 pages