PROVIDER
UPDATE
VOLUME 11, NUMBER 3
MAY/JUNE 1994
MESSAGE FROM THE MEDICAL
DIRECTOR
Medicaid
Facts
Did you know that Louisiana Medicaid is one of the larger Medicaid programs in
the U.S. with total expenditures of over $4 billion?
The program serves over 600,000 beneficiaries each year with 50,000 of
these being served by the Community Care Primary Care Case Management program in
20 rural parishes. Unisys processes
40 million claims annually. About
98% of these paper claims are paid within 21 days and most EMC submissions are
paid within 7 days. Louisiana has
one of the lowest administrative expenditures in the country with only 2% of
costs going toward administrative expenses.
This is in contrast to the national Medicaid average of 4% for
administrative costs. Only two
states spend less on administrative costs than Louisiana.
Hospital
Pre-Admission/Length of Stay Review Program Update
This program will conduct
pre-admission and LOS review for distinct part psychiatric facilities and long
term care hospitals. Acute care and
rehab hospitals will participate only in the LOS review program.
An Advisory Group of hospital association representatives, DHH and Unisys
staff has been meeting to formulate review criteria.
The Interqual Severity of Illness/Intensity of Service criteria will be
used to review acute care hospital admissions.
Customized criteria for LTC, psych, and rehab patients have been
developed and almost final. LOS will be assigned based on nationally recognized criteria
for acute hospitals with appropriate customization for specialty areas based on
the committee's deliberations.
Admissions
and LOS reviews will be conducted by specialized review nurses.
Physician consultants will review all denials and reconsiderations.
There was a final public hearing on May 20, 1994.
A phased-in program is planned for July 1 before full program
implementation later in 1994.
Deferred
Compensation Update
The Louisiana Medicaid Deferred Compensation Plan allows individual providers to
invest their Medicaid compensation on a before-tax basis avoiding current
federal or state income taxes. Interest
accumulates tax deferred until withdrawal of funds.
Providers can contribute up to a maximum of 25% of their adjusted gross
Medicaid income, not to exceed $7,500 per calendar year.
Great West, the plan administrator, can be reached at (504) 926-8082.
The initial response to the January/February Provider
Update publicizing the program has been outstanding with nearly 300
inquiries about the plan. Of those
callers, 20% qualify for program participation.
All qualifying callers enrolled or are currently enrolling.
A Medicaid provider must bill the program with his/her individual
Medicaid provider number and have Medicaid payments reported using his/her
Social Security number. You may not
exceed the IRS 415 limits of $30,000 per year into an IRA.
There are several considerations concerning which type of plan a provider
might already have such as a KEOGH, 403B, or 401K.
Details can be discussed with Great West.
Dr.
Gregg Pane
Reimbursement for Hernia Repair
Codes
In 1991, the Louisiana Medicaid
Program began to reimburse a number of hernia repair codes at 100% per unit
billed when performed bilaterally. Four
of these codes were deleted in the 1994 edition of the Physicians' Current Procedural Terminology and five new codes were
added.
The programming has been completed
for reimbursing these five new codes at 100% per unit billed effective with date
of service January 1, 1994.
The five new codes are 49495, 49496,
49501, 49507, and 49521. When
billing these codes, do not modify them with a -50 modifier.
To denote that the procedure was performed bilaterally, place a
"2" in the units column and bill the procedure on one claim line.
If performed secondarily, the above
codes must be billed hard copy with the -51 modifier attached. Otherwise, they may be billed electronically.
Rate Increase for Pediatric
Surgery Services
The Bureau of Health Services
Financing is pleased to announce an increase in the reimbursement for pediatric
surgery services effective with date of service July 1, 1994.
Fees have been set as follows.
22842
$1311.38
54336
1283.75
47701
1230.66
49605
1077.38
61140
1029.76
54332
983.45
54324
909.13
54328
882.83
54326
870.59
62230
696.42
54322
686.14
67332
658.10
76332
658.10
67331
592.22
61120
539.40
54340
502.95
27003
508.90
52340
444.84
67030
430.27
27001
355.55
52332
207.56
52281
175.77
52005
157.07
52000
112.18
36625
111.30
53020
85.00
51750
41.91
New Billing Policy and
Procedures for Substitute Physicians
Currently, physicians who hire
substitute physicians to manage their patient caseloads while on vacation, ill,
or unable to provide services cannot bill Medicaid for the services rendered by
the substitutes. The substitutes
must obtain Medicaid billing numbers and bill with their own numbers for the
services they provided while employed.
The Bureau of Health Services
Financing is changing this policy and the procedures related to it with the
publication of this notice.
Medicaid allows two substitute
physician billing arrangements: 1)
the informal reciprocal arrangement (a period not to exceed 14 continuous days),
and 2) the locum tenens or temporary arrangement (90 continuous days or longer
period if allowed) in the case of a per diem or other fee-for-time compensation.
For both arrangements, the primary
physician may bill and receive payment for the substitute's services.
Physicians should bill for a substitute physician's services as follows.
If billing under a reciprocal
arrangement, append the modifier Q5 to the procedure codes of the services
rendered by the substitute (item 24D on the HCFA 1500).
If billing under a locum tenens
arrangement, append the modifier Q6 to the procedure codes of the services
rendered by the substitute (item 24D on the HCFA 1500).
For both of the above billing
arrangements, the regular (billing) physician or medical group must, in lieu of
entering the UPIN of the substitute physician on the claim form, keep on file
for three years a record of each service provided by the substitute.
This record would include the date
and place of the service, procedure code, charge, recipient name, and the
substitute physician's name. This
procedure is to be used for both crossover and straight claims. Claims with these modifiers may be billed electronically.
DME Providers Dually Enrolled
as Environmental Modification Providers
It is possible for some durable
medical equipment (DME) providers to dually enroll in the Louisiana Medicaid
Program as environmental modification providers.
Environmental modifications are
available for persons have a slot in the MR/DD Waiver, Home Care for the Elderly
Waiver, or Head Injury Waiver.
Environmental modification is an
existing service that previously required enrolling providers to be licensed in
an appropriate building trade. It
is appropriate that some DME providers be allowed to provide this service also.
The modifications these providers
would perform include such items as prefabricated wheelchair ramps for the home
and installation of handicapped shower facilities in the home.
Current DME providers who dually
enroll will receive a separate provider number to bill for environmental
modification services. Submission
of these claims is to be done with the Environmental Modifications provider
number on the HCFA 1500 form. Providers
must not use their DME provider number for these services.
Any DME provider submitting a
request for prior authorization of a home modification as a DME provider rather
than as an environmental modification provider will be denied, even if the
request is for a recipient under age 21.
The DME Program does not have any
provisions for coverage of any home modifications.
Any DME providers wishing to enroll
as a environmental modification providers should call the Provider Enrollment
Section at 342-9454.
Criteria for Bilirubin Lamps
The Bureau of Health Services
Financing would like to notify DME providers that the medical criteria for
infants qualifying for the rental of bilirubin lamps for home photo therapy have
been revised. Please note that the
following seven criteria must be met for this service.
1.
Term infants
2.
Greater than 48 hours of age and Coombs negative
3.
Otherwise healthy
4.
Showing a total bilirubin of 12 or greater but less than 18
5.
Indirect bilirubin can be 1.0 to 1.5 units less than the total but not
more than this
6.
Normal CBC with differential documented before discharge if Coombs
positive
.
7.
Home photo therapy is to be monitored by home health nurses who are able
to check the bilirubin levels every 12 hours for he first 24 hours, then every
24 hours after that. The nurse must also check with the physician if they exceed
his or her predetermined upper limits or rate of rise.
Authorization for Environmental
Modification Claims
Payment for home modifications
necessary to accommodate disability may be provided for some Home and Community
Based Services waiver participants.
All such services are authorized by
form MR/DD-14 from the case manager, and may
not be provided without such authorization.
DME providers who are currently
enrolled with Medicaid may enroll as providers of Environmental Modifications.
Enrollment as an Environmental
Modifications provider requires completion of form PE-50, Disclosure of
Ownership, and either a building
trades license (such as contractor or plumber) or
current Medicaid enrollment as a DME provider.
LA DRUG UTILIZATION REVIEW (LADUR)
EDUCATION
THERAPEUTIC CLASS
Benzodiazepines (Use in the
Elderly)
Issues
�
The prevalence of anxiety and sleep disorders in the elderly leads to
common usage of benzodiazepines in the geriatric population.
�
Usage should be guided by the clinician's evaluation of the patient's age,
CNS status, and functional capacity of vital metabolic systems.
�
Benzodiazepine use has been linked to an increase in adverse reactions
such as cognitive impairment, falls, and hip fractures.
�
Normal and pathologic changes in the elderly may alter the effects of the
antianxiety agents.
�
The need for tapering benzodiazepine withdrawal may be particularly
problematic in the elderly patient.
BACKGROUND
Benzodiasepines are the most commonly used anxiolytics and hypnotics in all
medical settings, including the elderly. Studies
of the prevalence of anxiety and sleep disorders in the general population
consistently show that elderly individuals are equally or disproportionately
represented, thus explaining why the benzodiazepines are widely used in the
elderly population.
Clinicians should be guided in the
choice of anti-anxiety drugs by the patient's age, experience with the
benzodiazepines, current central nervous system status, and functional capacity
of the organs involved in metabolism of the medication (liver). Besides the benzodiazepines, there are older (meprobamate)
and newer agents (buspirone) in common use.
Although all the benzodiazepines are
thought to act through similar mechanism(s) of action, slight differences in
these agents may justify the selection of a unique agent for a particular
indication.
The benefits of using
benzodiazepines in the elderly are numerous in relieving suffering and improving
the quality of life. However, as
with most drug groups, benzodiazepines can cause some adverse reactions.
The incidence of drug reactions with
the benzodiazepines clearly increases the patient's age. Numerous epidemiological studies have demonstrated potential
hazards associated with benzodiazepine use in the elderly.
There is a statistically significant
association between the use of the benzodiazepines and various adverse reactions
such as cognitive impairment, falls, and hip fractures.
Within the benzodiazepine class, the
risk of hip fracture appears to be greater with long half-life agents than with
short half-life agents due to drug accumulation.
Increased drowsiness has also been reported as an adverse reaction among
elderly patients as compared to the general population.
This association was found to be especially prevalent with the anxiolytic
drugs chlordiazepoxide and diazepam.
Pharmacodynamic changes associated
with old age play a large role in the incidence of adverse reactions observed
upon administration of benzodiazepines in the elderly. Important changes in hepatic enzyme function occur with
age--conjugation changes to a small degree while oxidation becomes less
efficient. Thus, specific agents
metabolized primarily by oxidation *diazepam and flurazepam) accumulate with the
potential to produce exacerbated therapeutic effects.
Certain other medications (cimetidine, disulfiram, etc.) can also compete
for metabolizing enzymes, thus promoting longer functional half-lives of
benzodiazepines and their active metabolites.
Various disease states, such as
liver and respiratory disease, may also impact the effects normally observed
with benzodiazepines. In addition,
many aspects of brain function are more vulnerable to the adverse effects of the
benzodiazepines because of the advanced age.
The results may be depressed mood or
dysregulation and lability, disturbed memory, disorientation, dulled awareness,
excessive or ill-timed drowsiness, and impaired gait and balance, leading to
ataxia with possible falls. This is
especially a problem with long half-life benzodiazepines because their side
effects may not develop until steady state is reached (often weeks after
beginning the medication).
TAPERING
SCHEDULES
Tapering of benzodiazepine dosages in patients addicted/tolerant to the
benzodiazepines has become accepted therapy.
Without an adequate period of tapering, the patient may be subject to a
variety of usually stressful but potentially serious adverse reactions.
Therefore, the clinical literature
is strongly supportive of the need for tapering benzodiazepine withdrawal, or at
least monitoring the risks associated with benzodiazepine withdrawal.
Currently, accepted protocols
include but are not limited to a
10%reduction in dosage at weekly intervals.
Generally, a period of 6 to 12 weeks is required in such tapering
programs. An evaluation of patient
profiles usually shows some evidence of the tapering of dosages. The need for tapering
withdrawal may be particularly problematic in the elderly patient.
New uses of benzodiazepines in the
treatment of panic disorders often result in higher than usual doses of
antianxiety agents. This may result
in situations when patients become dependent upon even higher dosages of these
agents.
Caution should be exercised during
the implementation of withdrawal programs in these patients because of the
increased potential for serious withdrawal symptoms. A longer tapering schedule may need to be employed.
REFERENCES
Caranasos, G.J., "Drugs in the
Elderly." Hospital Formulary. 123-130,
January 1982.
Greenblatt, D.J., Harmatz, J.S., and
Shader, R.I., "Clinical Pharmacokinetics of Anxiolytics and Hypnotics in
the Elderly (Part I). Clinical Pharmacokinetics. 21(3):
165-177, 1991.
Greenblatt, D.J., Harmatz, J.S., and
Shader, R.I., "Clinical Pharmacokinetics of Anxiolytics and Hypnotics in
the Elderly (Part II)." Clinical
Pharmacokinetics. 21(4):
262-273, 1991.
Stoudemire, A., and Moran, J.G.,
"Psychopharmacologic Treatment of Anxiety in the Medically Ill Elderly
Patient: Special
Considerations." Journal
of Clinical Psychiatry. 54(5-Supp):
27-33, 1993.
Notice to All Providers:
NEMT Advertising Rules
Medicaid providers may advertise
only via television, radio, and newspapers.
Advertisements must not include
the terms "free," "free ride," "at no cost to
you," or any reference to indicate that the ride is "free"
because Medicaid is a paying program.
Under
no circumstances may the toll-free scheduling service numbers be included in any
advertisement.
Providers must not solicit
door-to-door or pass out or post handbills.
Telephone solicitation is prohibited.
Providers may give business cards to beneficiaries riding with them, but
only one card per beneficiary. Beneficiaries
may not give out or pass out business cards for providers.
Transportation providers may not
solicit business for medical providers and medical providers may not solicit
business for transportation providers.
Orleans, Jefferson, St. Bernard, St.
Charles, and Plaquemines parishes are under a federally approved transportation
Freedom of Choice Waiver. In all
other parishes, the beneficiary is entitled to freedom of choice.
A medical provider cannot decide
which transportation provider a beneficiary will use in the non-waiver parishes.
A medical provider, therefore, cannot
use or make arrangements to use one transportation company exclusively.
Providers are prohibited from
offering inducements to beneficiaries to obtain or solicit business or continue
business. Examples of prohibited
inducements include
�
Sending birthday, sympathy, Christmas, greeting cards, etc.
�
Offering raffle tickets
�
Providing "free refreshments"
�
Provider "free" breakfasts, lunch, dinner, or snacks
�
Transporting (even in a provider's personal vehicle) beneficiaries to the
cleaners, grocery store, or other destinations that are not Medicaid-covered
services
�
Providing a monetary payment for using the provider's service.
All Medicaid providers must be aware
of and adhere to these guidelines. A
provider who offers inducements or incentive in an attempt to capture business
is subject to sanctions that may include, but are not limited to, suspension
and/or termination from the Medicaid Program.
Community
Care Program Information
Community Care is a managed care
program administered by Louisiana Medicaid.
It is a system of comprehensive health care adopted because of its
advantages in rural communities.
The program links Medicaid
recipients in designated parishes with a physician, Federally Qualified Health
Center, or rural health clinic that serves as the recipient's primary care
physician (PCP).
The goals of Community Care are to
improve the accessibility, continuity, and quality of care to recipients, while
reducing the overall cost of care by strengthening the patient/physician
relationship and discouraging inappropriate or unnecessary use of medical care
services.
The Community Care Program current
services 50,000 recipients in the following 20 parishes:
Allen
Beauregard
Bienville
Cameron
Claiborne
DeSoto
East Carroll
Jackson
Jefferson Davis
Madison
Morehouse
Natchitoches
Red River
Richland
Sabine
St. Charles
Union
Vernon
Webster
West Carroll.
Recipients have the opportunity to
select a participating provider, generally within their parish.
If the recipient does not select a provider, one is assigned.
The PCP has total responsibility for
managing all facets of the recipient's health care, including education,
prevention, maintenance and acute care, and referral to specialists when
necessary.
The PCP must provide KIDMED
preventive health care and immunizations, coordinate all inpatient care,
maintain an integrated medical record of all care the patient receives, as well
as provider 24-hour, 7-day a week availability by telephone.
The Community Care recipient's
monthly Medicaid eligibility card has the name and telephone number (24-hour
access) of the selected/assigned PCP in the lower right-hand corner of the card.
Most medical services provided by
anyone other than the PCP require authorization from the PCP. Claims for services other than those outlined below will be
denied if they are not rendered by the PCP or if they are not authorized by the
PCP. The PCP will provide the
specialty provider with a seven-digit authorization number on the written
referral form.
When the PCP refers a patient to a
hospital or to a specialist who admits the patient, it is the responsibility of
the hospital/specialist to make the referral form from the PCP available to any
group providing services related to the patient's admission (anesthesiology,
radiology, pathology, etc.).
The following Medicaid-covered
services do not require PCP authorization
or referral from the PCP: skilled
nursing facility care, pharmacy services, ICF/MR services, OCDD, PCA, elderly,
ADHC, or any other home and community-based waiver services, EPSDT health
services for special needs children, in-office dental services, family planning
services, transportation services, in-office ophthalmology and optometry
services and eyeglasses, targeted case management, psychiatric hospital
services, mental health rehabilitation services, mental health and substance
abuse clinic services, and chiropractic services.
Emergency room screening exams,
immediate stabilization, and resuscitation of life threatening emergencies do
not require prior authorization. However,
after the emergency condition has been stabilized, the PCP must be contacted at
the 24-hour access telephone number listed on the recipient's Medicaid card.
MHR Option Policy
Any Mental Health Rehabilitation
services billed to Medicaid by a Mental Health Rehabilitation provider must be
delivered by employees of the provider.
The provider may not subcontract
with another provider or individual to provide any service or portion of a
service for which the provider will bill the Medicaid Program.
Unisys Provider Relations
The Unisys Provider Relations unit
is ready to assist providers with any questions they may have. This unit's primary responsibility is to respond to telephone
inquiries at the following numbers: Baton
Rouge Providers (504-924-5040); Louisiana Provider Outside of Baton Rouge
(800-473-2783). Telephone
service is available Monday through Friday from 8:00 am to 5:00 pm.
In addition, providers can mail written inquiries to the following
address:
Attention:
Provider Relations
Unisys
P. O. Box 91024
Baton Rouge, LA 70821
Provider Relations also has a staff
of Field Analysts are available to help providers with billing problems and to
help train new provider staff members. To
request a visit with a Field Analyst, call or write the Provider Relations
staff. Written inquiries should
contain a note or letter explaining the nature of the problem.
Inquiries submitted without explanations could be processed without
additional consideration. Also, providers who are calling Unisys Provider Relations
should telephone that unit directly rather than call the main Unisys
switchboard.
The following lists explain which
Field Analysts are assigned to each Louisiana parish.
Kim
Gassie/Kim Barnett:
Acadia, Allen, Ascension, Assumption, Beauregard, Calcasieu, Cameron, E.
Baton Rouge, E. Feliciana, Evangeline, Iberia, Iberville, Jefferson Davis,
Lafayette, Livingston, Pointe Coupee, St. Helena, St. Landry, St. Martin, St.
Mary, Vermillion, W. Baton Rouge, W. Feliciana.
Cora
Burks:
St. Charles, St. James, St. John the Baptist, St. Tammany, Tangipahoa,
Washington.
Michelle
Fulton:
Jefferson, Lafourche, Orleans, Plaquemines, St. Bernard, Terrebonne.
Pat
Boudreaux:
Bienville, Bossier, Caddo, Claiborne, DeSoto, Grant, Jackson,
Natchitoches, Red River, Sabine, Vernon, Webster, Winn.
Karen
Simms:
Avoyelles, Caldwell, Catahoula, Concordia, E. Carroll, Franklin, LaSalle,
Lincoln, Madison, Morehouse, Ouachita, Richland, Tensas, Union, W. Carroll.
Pat
Boudreaux/Karen Simms:
Rapides.
DME and Supplies - Medicare
Crossover Claims
Palmetto Government Benefits
Administrators recently began processing DME claims for the Medicare program for
Louisiana providers.
A new Medicare provider number was
assigned to each provider. This new
number was to have been sent to the Medicaid agency via magnetic tape and we
were to match these new numbers to the Medicaid provider numbers on our file to
process the crossover claims sent by Palmetto.
We received this tape but have had
great difficulty in producing a provider match in which we have confidence.
We need your assistance in giving our provider enrollment unit your new
Medicare DMERC provider billing number.
Please mail or fax us your Medicare
number(s) and the one Medicaid provider number to which the crossover claims
should be matched. Your assistance
will enable us to process the crossover claims quickly and correctly.
FAX Number:
(504) 342-3893
Mailing Address:
Bureau of Health Services Financing
P. O. Box 91030
Baton Rouge, LA
70821-9030
Attn: Provider Enrollment
If you have been recently contacted
by the provider enrollment staff about this matter or have already faxed
information, you need not respond.
If you experience any processing
problems with your Medicare crossover claims, please advise by calling (504)
342-3855 or writing to the address in column two.
ADJUSTMENT IN FEE FOR DTP
VACCINE
In September 1993, the Bureau
increased the fee for the DTP vaccine (CPT code 90701) by $4.56 to compensate
providers for the federal excise tax which had been reinstated in August 1993 on
seven childhood vaccines by the United States Budget Reconciliation Act of 1993.
This increase brought the reimbursement level for this vaccine to $22.56.
It was recently brought to our
attention, however, that we are currently reimbursing providers twice, rather
than once, for the federal excise tax because we did not decrease the fee for
DTP in January 1993 when the tax was discontinued.
Therefore, effective with date of service June15, 1994, the fee for
procedure code 90701 will be adjusted to $18.00.
Payment Denial
The Medicaid program will deny
payment for codes D2330, D2331, and D2332 (resins) on the following teeth:
#2, 3, 4, 13, 14, 15, 18, 19, 20, 29, 30, and 31.
Please refer to page 7-12 of the EPSDT Dental Program Provider Manual.
Error Code Updates
Procedure D2951 (pin in tooth) will
deny with error code 612 if billed on a deciduous tooth.
Procedure D3220 (pulpotomy) will deny with error code 611 when billed on
a permanent tooth. Procedure D3110
(pulp cap) will deny with error code 611 when billed on a permanent tooth.
Procedure D3110 (pulp cap) and will deny with error code 610 if billed on
a deciduous tooth.