Provider Update
Volume 16, Issue 3
June/July 1999
Changes to Medicaid
Identification Numbers
For the last several months, the Department of
Health and Hospitals and Unisys have been working diligently to ensure that all
Louisiana Medicaid systems are Year 2000 ready. In conjunction with the Y2K
readiness efforts, we would like to emphasize strongly to you that the current
13-digit recipient identifying number will be changing as well. This 13-digit
number is and always has been an important identifying number for Medicaid
recipients and the providers who serve Medicaid recipients.
PERMANENT 13 DIGIT IDENTIFICATION
NUMBER
The Medicaid recipient identification number
presently assigned to recipients is a 13-digit number that includes as a part of
the number a two- digit parish code as the first and second digits of the
number, and a two-digit eligibility category code as the third and fourth digits
of the number. If your billing service, clearinghouse, or accounting system
depends on the current 13-digit recipient ID numbers to identify parish codes,
please take the necessary steps to account for this change and make arrangements
to collect this information from another source. Additionally, the 12th and 13th
digits represent the household member. The use of an "intelligent"
number that houses pieces of information in this manner has caused billing
difficulty for the provider community. Whenever a recipient moves or changes
category of eligibility, a new number is issued. Thus, providers are continually
changing numbers for their recipient patients. In spite of the best efforts by
DHH to systematically link multiple ID numbers to a single recipient, problems
have continued. Many claims have denied for name, number, or eligibility issues,
and the provider has had the burden of locating another ID number with which to
re-bill claims.
In an effort to resolve these issues,
beginning July 6, 1999, a permanent 13-digit person number will be assigned to
each Medicaid recipient. The most current 13-digit recipient ID number will be
frozen and will become the permanent person number for all individuals on the
Unisys recipient file on June 30, 1999. Please remember, however, that although
the numbers may "look" the same, the numbers will not denote any
pieces of information as in the past.
Recipients added to the file as of July 1,
1999 and after will be assigned a new permanent 13-digit number. These newly
assigned 13-digit numbers may look somewhat unusual to you (i.e.,
#0000000000001, 8888888888888, 0000000000025, 0000000486100, 0000761147692).
USE OF PREVIOUSLY ISSUED RECIPIENT
IDENTIFICATION NUMBERS
This does not mean that other identification
numbers previously issued to recipients may not be used to bill claims for
services rendered. Any 13-digit number that was a valid recipient number and is
still on the recipient file may be used to bill claims. In fact, in asituation
where services were pre-certified or prior authorized using a certain number
other than the new, permanent 13-digit person number, it will be necessary to
bill using the number under which the pre-certification or prior authorization
was issued.
Beginning in July, 1999, we encourage
providers to make note of the identification number confirmed or obtained from
Unisys REVS or MEVS eligibility inquiries as this number will be the PERMANENT
number. For dates of service and pre-certification and prior authorization after
July 1, 1999, the permanently assigned 13-digit person number will be used by
all DHH and Unisys systems.
PARISH AND ELIGIBILITY INFORMATION
Information previously obtained from the
"intelligent" number is currently available and will be supplied as a
part of the response given when making eligibility inquiries through MEVS or
REVS. Although a parish name or number will not be provided, the response
message returned to the provider will supply all information required to serve
the recipient. The following is some of the information received from MEVS or
REVS:
�Recipient resides in Community CARE
parish and is Community CARE recipient.
Response will include a message indicating that the recipient is Community CARE,
the name of the recipient's PCP, and the PCP�s phone number to allow the
inquiring provider to contact the PCP for a referral before providing services.
�Recipient is eligible through category
of service that limits coverage of certain services or by certain providers.
Information provided as part of eligibility response. Ex., If the recipient is
covered through the Medically Needy Program, which does not cover certain
services, and the provider calling is a provider of non-covered services, the
response will include a message indicating that the recipient is Medically Needy
and the services provided by the calling provider would not be covered.
�Recipient is QMB eligible.
Response will indicate recipient is QMB eligible. In cases where the
recipient is Pure QMB, the response will state, "This recipient is only
eligible for Medicaid payment of deductible and co-insurance of services covered
by Medicare. This recipient is not eligible for other types of Medicaid
assistance."
�Recipient is Presumably Eligible.
Response will indicate that the recipient may be eligible for outpatient
ambulatory service only. You must call 1-800-834-3333 to verify current
eligibility.
�Recipient is a child.
Response will indicate recipient is EPSDT eligible, meaning the recipient is
under 21 years of age and eligible for all services and service limits allowed
for children. All eligibility and service limit information is related to the
inquiring provider in this same manner. However, the provider still must know
and understand policy limitations.
Providers must access and verify eligibility through REVS or MEVS. This
will provide the eligibility information formerly provided by the 13-digit
recipient number and the paper cards that were replaced by permanent, plastic
identification cards
.ELIGIBILITY ACCESS
The Medicaid Eligibility Verification System (MEVS),
an automated eligibility verification system using a swipe device or PC
software, and the Recipient Eligibility Verification System (REVS), an automated
telephonic eligibility verification system must be used to verify Medicaid
recipient eligibility prior to providing services. Both MEVS and REVS are Y2K
ready and require that 8-digit date (service dates, dates of birth, etc.) must
be entered when making eligibility inquiries through these systems. Entry of
anything other than 8-digit dates will prevent a valid eligibility response. The
provider will receive a prompt to enter an 8-digit dates accompanied by an
example, to allow continuation of the inquiry. Please be sure to use 8-digit
dates for all dates required when using MEVS or REVS. It is imperative that
the most current 13-digit recipient ID number or the newly assigned person
number be used to prevent any difficulty in obtaining eligibility information
through MEVS or REVS.
Parties interested in MEVS may obtain a list
of participating telecommunications vendors and fees by contacting Unisys
Provider Relations at (800) 473-2783 or (225)924-5040. REVS may be accessed with
a touchtone phone by dialing 800-776-6323 or (225) 216-7387.
*Pharmacy POS
providers may continue to use the 16 digit CCN number for POS processing.
Effective January 1, 1998 HCFA mandated that the Medicaid Program begin
applying Clinical Laboratory Improvement Amendments (CLIA) claims processing
editing to all laboratories submitting claims for services and denying those
that did not meet the required criteria.
Claims are to be edited to insure payment is
not being made to:
- Labs which do not have a CLIA certificate
- Labs submitting claims for services
rendered outside the effective dates of the CLIA certificate and
- Labs submitting claims for services not
covered by their CLIA certificate.
Louisiana Medicaid maintains a provider CLIA
file with the required information on that file. Therefore, providers do not
have to include their CLIA certification number on claim forms.
Notices were included on several remittance
advices, provider training manuals and newsletter articles in late 1997 to let
providers know about the required change. From January 1998 to November 1998
explanation of benefits (EOB) message codes were given on providers' remittance
advices as a means of letting the providers know this needs to be
corrected/updated. In November 1998 claims began denying if they did not meet
the required criteria established by HCFA.
Below are the three CLIA editing codes that
Medicaid is applying to claims. You will find the code, a description of the
code, why the code is applied and what actions are needed to clear the denial.
Code: 387
- No CLIA number on our file
Action: Medicaid checks the provider's CLIA file for the presence of a
CLIA number; if there is no CLIA number, claims will deny with code 387.
To clear this edit code the provider needs to
fax a copy of his/her CLIA certificate to Provider Enrollment at 225-342-3893.
Providers should allow 2 weeks before submitting any new lab claims or
resubmitting the previously denied claims.
Code:
329 - CLIA number does not cover date of service
Action: Medicaid checks to see if the date of service on the claim
falls within the provider's CLIA certificate effective thru expiration dates; if
the date is outside the range, claims will deny with code 329.
To clear this edit code providers should fax a
current copy of their CLIA certificate showing the new effective/expiration
dates to Provider Enrollment at 225-342-3893 or call Provider Relations at
1-800-473-2783 or 225-924-5040 for information on where to obtain an updated
certificate.
Code: 386
- Not payable with CLIA cert. type
Action: Medicaid checks to see if the procedure code
billed is payable under the provider's certification type; if the procedure code
is not listed as payable, the clams will deny with code 386.
To clear this edit code providers should bill
the appropriate codes allowed under their CLIA certification type. Providers
with regular accreditation, partial accredited or registration certificate types
are allowed by CLIA to bill for all lab codes. Providers with waiver or
provider-performed microscopy (ppm) certificate types can only be paid for those
waiver and/or provider-performed microscopy codes approved for billing by HCFA.
Below is a listing of payable codes for each restricted CLIA certificate type.
Providers with waiver or provider-performed
microscopy (ppm) certificates wishing to bill for codes outside their restricted
certificate types should call Provider Relations at 1-800-473-2783 or
225-924-5040 for information on where to obtain the appropriate certificate.
(Please note: If your certificate type is upgraded, claims can only be paid for
dates of service that fall within the upgraded cert dates.)
CLIA Waiver Certificate (type 2) Payable
Codes
| G0054 thru G0057 |
Q0116 |
| 80061 |
80101 |
| 81002 |
81003 |
| 81025 |
82044 |
| 82270 |
82273 |
| 82465 |
82947 |
| 82962 |
82985 |
| 83026 |
83036 |
| 83718 |
83986 |
| 84478 |
84830 |
| 84999 |
85013 |
| 85014 |
85018 |
| 85610 |
85651 |
| 86308 |
86318 |
| 86588 |
87072 |
CLIA Provider-Performed Microscopy (type 4)
Payable Codes
| G0026 |
G0027 |
| Q0111 thru Q0115 |
81000 |
| 81001 |
81015 |
| 81020 |
89190 |
| G0054 thru G0057 |
Q0116 |
| 80061 |
80101 |
| 81002 |
81003 |
| 81025 |
82044 |
| 82270 |
82273 |
| 82465 |
82947 |
| 82950 thru 82952 |
82962 |
| 82985 |
83026 |
| 83036 |
83718 |
| 83986 |
84478 |
| 84830 |
84999 |
| 85013 |
85014 |
| 85018 |
85610 |
| 85651 |
86308 |
| 86318 |
86588 |
| 87072 |
|
Note: Listing does not include those codes
exempted from CLIA editing.
We have received several questions regarding billing for outpatient wound
care. Regarding wound care, hospitals
may only bill for the use of the treatment/observation room and the medical
supplies. Wound care is not considered a rehabilitation service and will not be
prior authorized as a rehabilitation service. If wound care services are
provided by a physical therapist, the therapist's time is not to be billed.
Effective with date of service April 8, 1999, CPT code 95145 was removed
from the Global Surgery Periods edits. This action allows the providers to bill
physician visits with the code during the GSP time frame.
We have been receiving inquiries regarding the billing of recipients if a
request for pre-certification of an inpatient hospital stay is denied OR if an
extension is denied following approval of the initial precert.
If a request for precertification is denied
because medical necessity is not met, the recipient cannot be billed. If the
case had met medical necessity, it would have been precerted; thus, if it was
not medically necessary for the recipient to be in the hospital, the provider
should never have admitted the patient. This same logic applies to the
extensions - if it is not medically necessary for the patient to be in the
hospital, then discharge would be in order.
Providers also should not bill recipients
simply because they were late in submitting their precertification information.
One situation where a provider could bill the
recipient is when the recipient presents himself to the hospital as a
private-pay patient, not informing the hospital of his Medicaid coverage.
When a hospital's precertification request
(initial request or extension request) is denied due to timely submittal, the
physician may have payment services considered paid only if the claims, along
with an admit and discharge summary and a letter requesting a precertification
override, are submitted to Unisys Provider Relations Correspondence Unit, P O.
Box 91024, Baton Rouge, La., 70821. These claims will be reviewed for medical
necessity and special-handled for processing. The same procedure is to be
followed by the physician if a hospital fails to request initial
precertification.
If additional assistance is needed regarding
billing of recipients, please contact Unisys Provider Relations at (225)
924-5040 or (800)473-2783.
This notice is a reminder to physicians who employ or contract with
certified nurse practitioners and/or chiropractors to provide services to
Medicaid recipients must notify Provider Enrollment at 225-342-9454 of such
employments or contract(s) so that the provider number of the CNP and/or
chiropractor can be linked to the physician�s group number on our files.
This means that all certified nurse
practitioners and chiropractors who provide services to Medicaid recipients must
have individual provider numbers. This also means that physicians who do not
have group numbers are required to apply for a group billing number if/when they
contract with or employ a CNP or chiropractor.
In billing for services, the individual
provider number of the CNP or chiropractor who provided the service must be
declared in Item 24K on the HCFA 1500(Field 21, Data Element 29 for EMC billers),
and the physician�s group number must be listed in Item 33 (Field 9, Data
Element 14 for EMC billers).
Hyperbaric Oxygen Diagnosis
Code Correction
In the April 1999 edition of the Provider
Update, there was a mistake in the list of diagnosis codes for hyperbaric oxygen
therapy. The list included the code 40.0. The correct code is 040.0.
CPT procedure code 54660 (Insertion of testicular prosthesis) was made
payable on the procedure file effective with date of service February 1, 1999 at
a fee of $290.60 for the surgeon and a fee of $58.12 for the assistant surgeon.
The anesthesia base unit figure = 3.
This message will serve as a reminder of Registered Nurse qualifications
for psychiatric home health visits. The following is taken from the Minimum
Standards for Licensing Home Health Agencies (LAC 48:1. Chapter 91).
Only RNs who have met the following
credentials shall make psychiatric nurse visits. Experience must have been
within the last five years. If not, documentation must support psychiatric
retraining, or classes, or CEUs to update psychiatric knowledge.
I. RN with master�s degree in psychiatric
or mental health nursing.
II. RN with a bachelor�s degree in nursing and one year experience in
an active treatment unit, a psychiatric or mental health hospital or
outpatient clinic.
II. RN with a diploma or associate degree with two years experience in
an active treatment unit, a
psychiatric or mental health hospital or outpatient clinic.
For
additional information, please refer to the Minimum Standards for Licensing Home
Health Agencies (LAC 48:1. Chapter 91).
Additionally,
the services must be prior authorized as medically necessary and provided only
to recipients who meet Medicaid�s homebound criteria.
Effective with date of service May 1, 1999, it is mandatory that the
referring physician�s name and/or provider number be included in Item 10 on
the Unisys 101 Home Health claim form. If this item is left blank, the claim
will deny. For electronic billing, the attendingphysician portion must be
completed.
If the referring physician is an enrolled
Medicaid provider, you must enter his name and/or Medicaid provider number. If
the referring physician is not an enrolled Medicaid provider, his name is to be
entered.
EPSDT Personal Care Services (PCS) is a program for Medicaid recipients
under the age of 21 who meet medical necessity criteria. The recipient's
physician must give a referral or order for the services, complete a 90-L form,
and approve a plan of care. Services are provided by a Personal Care Services
worker through a Medicaid enrolled Personal Care Attendant agency. Generally,
tasks are limited to those dealing with:
1. Personal hygiene
2. Meal preparation and eating
3. Household services for the recipient
4. Accompanying the recipient to and from medical appointments
These
services are not intended to provide respite. In addition, a recipient receiving
Waiver PCA services is not eligible for EPSDT PCS. Prior authorization of
services is necessary. Requests from the PCA agency for prior authorization of
EPSDT Personal Care Services must be sent to Unisys. The KIDMED office may be
called at 1-800-259-4444 to obtain the names of PCA agencies. For questions
regarding the prior authorization of PCS, contact the Unisys Prior Authorization
Unit at 1-800-807-1320.
Effective with date of service, April 1, 1999, VALSTAR (valrubicin)
Sterile Solution for Intravesical Instillation will be covered by Medicaid for
the treatment of cancer of the bladder. Listed below are the fees to be paid by
Louisiana Medicaid for this drug.
Strength - 200 mg/5 mL
Description - 5 mL Single-Use Vial
Code - J9193
Projected Fee - $349.05 per vial
Effective with date of service March 15, 1999, a Global Surgery Period (GSP)
of 10 will be assigned to codes 11975 (insertion, implantable contraceptive
capsules) and 11977 (removal with reinsertion, implantable contraceptive
capsules). A GSP of 0 will be assigned to code 11976 (removal, implantable
contraceptive capsules).
Pharmacy Questions
Q: Does the plastic ID card show
lock-in status?
A:
Lock-in status is not indicated on the card itself. A POS electronic
response message will identify lock-in information for the pharmacy provider.
Q: How
may a pharmacy claim be paid if the recipient is locked-in to another pharmacy?
A:
Only in emergency situations, when life-sustaining medicines are
required, or in cases when the lock-in pharmacy cannot supply medications (such
as intravenous medications) may a pharmacy be paid for prescription drug
services rendered to a recipient locked-in to another pharmacy provider.
Specific billing instructions for this situation are on p. 22 of the 1998
Pharmacy Training packet and p. 4-9 of the Prescription Drug Services provider
manual.
Q:
Does Medicaid pay for diabetic supplies for straight Medicaid,
non-insulin dependent recipients?
A: Yes,
excluding long term care residents.
Q:
Can pharmacy providers be paid by Medicaid for diabetic supplies for a
recipient who is Medicare eligible and in a long term care facility?
A: No.
Q:
Have the physicians been made aware of the diagnosis codes necessary for
payment of prescriptions for H2 antagonists?
A:
Yes.
Q:
Must Medicare be billed prior to billing Medicaid for nebulizers for long
term care residents?
A:
No. Medicare pays for nebulizers for only Medicare/Medicaid eligibles who
do not reside in long term care facilities. Providers must bill Medicare first
for any Medicare/Medicaid eligible who does not reside in a long term care
facility.
Q:
If a prescription for a long term care resident isn't covered by
Medicaid, is it the recipient's responsibility to pay, or should the
prescription be provided by the long term care facility?
A: Non-routine medications or
supplies may be billed to the recipient. Routine medications or supplies are
included in the per diem paid to the nursing home and should not be billed to
the recipient.
Long Term Care Questions
Q:
Should Medicaid cards for long term care recipients be returned to the
State if the recipient dies?
A:
No, long term care facilities should destroy the Medicaid cards in such
instances.
Q:
How would the following scenario be reported on the TAD: a recipient
leaves for home and is gone for 16 hours, returns to the facility, and then
leaves again for more than 24 hours?
A: The absence of 16 hours is not reported.
An absence must be reported once it exceeds 24 hours; therefore, the second
absence must be reported on the TAD.
Q:
If a recipient has several absences within a month, should the sets of
leave days be listed by leave type (i.e., home leave days together and then
hospital leave days together) or in chronological order?
A:
Leave days should be listed in the order in which they occur regardless
of leave type.
Q:
Where do long term care providers obtain the initial 148 form?
A: This form should be obtained from
the parish Medicaid office.
Q:
Should the nursing facility in which the recipient resides keep the
recipient's plastic Medicaid ID card, or should the card be kept by the
recipient's family?
A:
The plastic ID card should be kept by the nursing facility, as the
facility is responsible for the patient's care. If an emergency should occur or
if other care should be needed, the nursing facility should give a copy of the
card to providers rendering services to the recipient. This will allow the
providers to verify eligibility and access recipient information necessary for
reimbursement of their services.
Q:
Are all providers required to purchase a "swipe" device?
A:
Obtaining a swipe device is optional, not mandatory. REVS will always be
available at no charge to verify eligibility. However, the swipe device will
provide printed verification of eligibility, whereas the REVS line will not.
Q: How
should claim denials for error code 290 be rectified?
A: Error
code 290 indicates that the recipient has other insurance coverage. A claim for
services must be submitted to the other insurance company. Once the other
insurance processes the claim and produces an explanation of benefits (EOB),
services are to be billed to Medicaid on the TAD with the EOB attached. The
six-digit TPL carrier code and any amount paid by the other insurance should be
entered on the TAD in the appropriate shaded portion.
Q:
In the above scenario, what should be done if the other insurance is no
longer in effect?
A:
If coverage is no longer effective, the provider should submit the TAD
and the EOB or other documentation verifying that the coverage was not in effect
for the date of service to the Provider Relations Correspondence Unit as
indicated on p. 100 of the 1998 Long Term Care/Hospice Training packet.
Q: When
billing on the TAD, should providers report the first day of hospital or home
leave?
A: Providers do not
need to report an absence if it is less than 24 hours.
Q: When a
resident leaves for the hospital in one month, and the leave goes over into the
next month, how is this reported on the TAD.
A:
The first month's absence is reported through the last day of the month.
The second month's absence is reported beginning with the first of the month
(entering "01" in the "from" date of the home and hospital
leave days section of the TAD). Our computer will automatically calculate the
correct number of absence days based on the provider's reporting of absent days
in both months.
Q:
How can it be assured that the name of a new resident added to the TAD
will be pre-printed in the future?
A: If the entry adding a recipient to
the TAD indicates a status code of "6," the recipient's name should
begin to appear on the pre-printed TAD produced each month. Depending upon when
Unisys receives the TAD adding the recipient, it may take up to a month for the
recipient's name to appear on the pre-printed TAD.
Q: Can the TAD be billed electronically?
A: The TAD has not been approved by DHH to be billed
electronically.
Q: A
recipient must be discharged from the long term care facility once his hospital
leave exceeds 30 consecutive days. Does this 30-day rule apply to home leave
days also?
A: Yes. Once an absence
exceeds 30 consecutive days, the resident must be discharged. If the recipient
subsequently returns to the facility, he must be added to the TAD, and the 51-NH
certifying re-admission must be attached to the TAD.
Q:
Sometimes when a resident comes in and several months are being
back-billed, Unisys does not pay for one of the months. Why does this happen?
A:
In general in such a situation, all months should be paid. When billing
for a new admission, remember to indicate the admit code from the 51NH for the
month of entry. All subsequent months must indicate "6" for the admit
code. The 51NH must be attached to the TAD, and the comment section should
indicate that the recipient is a new admission and the 51NH is attached.
Q: Is the
cost of physical therapy included in the long term care facility per diem?
A: All therapy for
a skilled level patient is included in the long term care per diem. For patients
who are at a non-skilled level of care, these services can be provided by a home
health agency. The home health agency must apply for prior authorization of
these services and should bill the Medicaid program directly.
Q:
Who is the program director at DHH over the long term care program?
A:
John Marchand is the Section Chief for Institutional Reimbursement and
Lisa Deaton is the Section Chief for Health Standards.
Q:
If a resident exceeds his resources for only one month, should he be
deleted from the TAD?
A:
Yes.
Q:
Where on the 212 adjustment/void form should a level of care change be
noted?
A: Item 10
should be used to indicate the correct level of care. In addition, a new 51-NH
indicating the new level of care should be attached to the completed 212 form.
Hospital Questions
Q:
When a patient comes to the hospital emergency room and is then admitted
as an inpatient, should the precertification be requested to begin at the time
the patient was admitted to the emergency room for observation or the time he
became inpatient?
A: The
precertification should begin at the time the patient came into the emergency
room, and the emergency room charges should be included in the bill for the
inpatient stay.
Q: If
the last day approved under a precertification falls on the weekend and the
patient continues to be a patient, when would an extension request be submitted
to precertify additional days?
A:
If the expected discharge day is on Saturday or Sunday, the extension
request may be submitted to Unisys on Monday.
Q: If
the physician intends to send the patient home but then changes his mind about
the discharge, how should this be handled with regard to precertification?
A:
An extension request should be submitted to Unisys for any days in
addition to those already precertified.
Q:
In what situations may a hospital bill for its hospital-based ambulance?
A: The hospital must be approved by
DHH to provide hospital-based ambulance services. A hospital-based ambulance can
be used to pick up a patient for transport to the hospital. A hospital-based
ambulance cannot be used to transfer a patient to another facility or to take a
stretcher-bound patient home or to a nursing home. Such services must be
provided by a Medicaid non-emergency ambulance service.
Q:
For hospitals with a special care unit that is not an NICU, is there any
special coding for precertification for sick infants?
A:
No. Precertification only applies when a newborn goes to NICU or remains
in the hosital when the mother is discharged from the hospital. Then
precertification must be obtained for the baby.
Q:
If a newborn is started in NICU and then improves enough to be moved to
Level 2?
A:
If the initial request was submitted with the baby in NICU and criteria
were met, the baby was approved for a length of stay. If additional days are
needed and the level of care has changed, then the change in level of care
should be indicated when an extension request is submitted.
Q:
In situations in which a recipient is suicidal or homicidal, should it be
documented why staff did a certificate of need?
A:
Recipients under 21 or over 65 years of age must have a certificate of
need signed by a team not associated with the hospital. Providers should include
this documentation with their precertification requests. This is also true for
an ordinary admit of a recipient under 21 to a free-standing psychiatric
facility. If this is documented as an emergency admission and criteria are met,
then the certificate of need can be signed by admitting hospital team.
Q: How
can hospital personnel be authorized to discuss specific precertification cases
with Unisys?
A: For confidentiality
reasons, Unisys staff will only discuss precertification details with persons
authorized by the hospital. In order for the hospital to have a name added to
the list of authorized hospital personnel, that person's name should be shown as
the contact person on a PCF01 submitted by the hospital. When the hospital's
utilization review department submits a PCF01 with a name as the contact person,
that name is added to the list of authorized hospital personnel.
Q:
What is the time limit for appeals submitted to DHH?
A: Appeals should be submitted within 30 days of the denial letter being
sent to the facility from the Unisys Precertification department.
Q:
Why doesn't Unisys keep a PCF01 on file when the case is rejected?
A: Unisys keeps a copy on file,
but providers must resubmit everything (including the PCF01) when pursuing a
rejected precertification. The amount of documentation Unisys receives is
tremendous, and it is not feasible to attempt to retrieve a PCF01 when providers
submit additional information on a case.
Q:
Do nurses read the information sent by the hospitals?
A:
Yes. It is not necessary for providers to send Unisys a copy of the
patient's entire chart. Providers should send a day-to-day current (last 48
hours) summary. The most recent information should be submitted, including the
chart documentation that supports the criteria related to the diagnosis being
submitted. Submitted documentation should support the dates for which
precertification is requested.
Q:
For emergency room admissions, Unisys considers the admission to have
begun at the start of the ER visit. Is this when the 24-hour count (to determine
deemed inpatient status) begins?
A:
Yes. Medicaid policy requires that admissions greater than 24 hours are
considered inpatient, regardless of whether the patient was actually admitted as
inpatient by the facility.
Q:
If consent (documented on OFS Form 96) is obtained by a physician who
subsequently leaves the hospital staff and is unavailable, can a new physician
sign the physician statement on the form in Section IV and perform the tubal
ligation?
A:
Yes. All of the form must be completed according to the published
instructions.
Q:
Must procedures be added to the precertification file if they are done
later in the stay after the precertification has been obtained?
A: Outpatient
surgical procedures performed within 48 hours of admission must be added to the
precertification file. If the outpatient surgical procedure is performed later
in the stay (after the first 48 hours), that procedure need not be added to the
precertification file.
Q: Sometimes
patients are admitted and then the physician wants to perform an outpatient
procedure on the second day of the stay. What must the hospital do in these
cases?
A:
If an outpatient procedure is to be performed on the day of admit or the
day after, the hospital's utilization review department should submit this
information to Unisys as soon as they are aware of it. This should be submitted
as an update on a PCF01 with accompanying documentation showing the medical
necessity for the patient to be admitted as an inpatient for what is established
as an outpatient procedure.
Q:
When an outpatient procedure is being performed on an inpatient basis and
we are trying to add it to the precertification file, what must we submit? Often
we don't have access to an operative report.
A: The outpatient procedure is added
by submitting an updated PCF01 to request an update to the existing
precertification. An operative report does not have to be submitted if other
submitted documentation can show medical necessity.
Q:
If a patient is admitted for a regular vaginal delivery with a tubal
ligation done the next day, can this all be documented on the PCF01?
A:
Yes. The patient's stay will be determined by the admitting diagnosis for
the delivery, not the tubal ligation.
Q:
If a patient is admitted and the hospital finds out five days later that
the recipient has Medicaid, should the hospital wait until the patient is
discharged to try to precertify?
A: No. A patient who has
Medicaid must be precertified within 24 hours of admission or on the next
business day after admission in order to meet DHH timely submitted regulations.
Q:
If a PCF01 is unintentionally filed with a wrong recipient number, is
there any recourse?
A:
Yes. An updated PCF01 should be submitted to Unisys with the correct
Medicaid number circled.
Q: How should precertification be obtained if the patient was initially
seen as an outpatient and then admitted after an outpatient procedure was
performed, and it is after closing time for Unisys?
A: The facility has 24 hours or until the
next business day to submit an initial request for inpatient admission. If this
admission is a roll-over from an outpatient stay, the facility will use the
outpatient day as the admit date and note on the PCF01 that the admit date is
the outpatient day. Specific questions on this process should be directed to the
Unisys Precertification department.
Q:
If a patient comes in through the emergency room one evening, kept
overnight for observation, and then admitted the next day, how is this handled
for precertification purposes?
A:
The date of admit to ER becomes the admit date on the initial PCF01. The
facility will note on the PCF01 that the admit date is the ER admit date and
will also note that this patient was admitted inpatient after observation in the
ER.
Q:
What should a provider do if the patient, upon admission, claims to be
self-pay and then produces a Medicaid card once he receives a bill?
A:
The provider should submit a request for precertification when notified
of the patient's Medicaid number. The Unisys Precertification department will
clarify the patient's Medicaid status at the time of admit. If the recipient had
Medicaid at the time of admission, the request for precertification will be
denied for timely submittal. Ultimately, the provider may appeal the timely
submittal denial through the DHH appeal process.
Q: Can the
patient be billed directly for services rendered if the patient claims to be
private pay upon admission?
A:
Yes.
Q: When a sick newborn transfers to our hospital,
should our staff initiate the 152-N process?
A:
The 152-N should be filled out by the transferring hospital where the
baby was born, but the receiving hospital may do this as well. It may be more
difficult for the receiving hospital to ensure that the mother signs the form.
Q:
Can you please clarify the "admission process." For example, if
the physician writes orders to admit a patient for a procedure or for
observation, should the hospital automatically begin the request for
precertification?
A: Not
necessarily. If the doctor writes orders to admit patient for observation or for
a procedure, the patient is not being admitted to the hospital as an inpatient.
If, however, the doctor writes orders for an inpatient admission, the patient is
considered an inpatient and is subject to all the rules governing inpatient
admission.
Q:
What is the P.O. Box for Medicare Part B crossovers which didn't
automatically crossover?
A: The address is Unisys, P.O. Box
91023,Baton Rouge, Louisiana 70821.
Q:
We have several instances where the OB schedules a sterilization
procedure but, because they don't accept Medicaid, they have never requested the
patient to sign the OFS 96 form. Can we get paid for these claims?
A:
No. In order to receive payment from Medicaid, the recipient must have
signed the OFS 96 form according to policy guidelines (no other form is
acceptable). The only exception to this rule is if the sterilization is done
during the same stay as a delivery. In that case, providers may be paid for the
delivery stay less the charges related to the sterilization. Instructions for
billing claims for this are included in the hospital provider manual.
Q:
Are prior authorization and precertification the same thing?
A:
No, they are two different processes. Prior authorization pertains to
prior approval that must be obtained for certain surgical procedures or to
durable medical equipment and supplies. Precertification refers to registering
and obtaining approval for inpatient hospital stays.
Q:
Once a hospital has a contact person added to the Unisys list of
authorized persons, how long does the contact person's name remain on the list?
A:
Contact persons authorized by the hospital remain on the list until the
hospital requests that the name be removed.
Q:
How does Unisys know the fax number to use to send precertification
information?
A:
The hospital's authorized fax number is taken from the PCF01. If the
hospital needs to change the fax number, the new fax number should be entered on
the PCF01 and circled prominently(so Unisys staff will notice it).
Q:
There have been occasions where Unisys Precertification staff have told
me that I am faxing too many pages (and if I mail them I don't make timely
filing). What do I do?
A: You should not need to send that many
pages. All we are looking for is the most pertinent information, which means
that you should only fax documents from the day before precertification has
ended and the day that precertification is ending. This should not result in
that many pages. If you need specific help on a case and what to fax or mail,
call Unisys Precertification for guidance.
Q:
When is the best time to request additional days?
A: The best time to
request additional days is on the expected discharge day. This way you are
submitting the most current information (and giving Unisys the best information
on which to base a decision) and are complying with timely submittal
requirements.
Q:
If a recipient receives therapy visits in excess of those authorized, may
he be billed for visits in excess of those approved?
A:
Yes. The extra visits are considered non-covered by Medicaid and may be
billed to recipient.
Q:
In regard to electronic claim filing, must a submitter contact the Unisys
EMC department if submitting two different files with two different provider
numbers within a 24-hour period?
A:
Yes. Submitters should notify EMC if submitting more than one file within
a 24-hour period.
Q:
What should a provider do if an attorney sends him a payment for an
accident-related claim that has already been filed to Medicaid?
A:
The provider should direct the attorney to DHH in order to make
reimbursement arrangements with the State. Call Third Party Liability at
342-3888.
Q: Is
Medicaid considering expanding the 24 hour outpatient rule?
A:
Not at this time.
Q:
What should a provider do if a date of birth is incorrect on the state
file and the recipient or parish office is not cooperating with updating the
file?
A:
Providers can use the social security number, rather than the date of
birth, to retrieve eligibility information on REVS/MEVS. Ultimately it is the
patient's responsibility to have the file corrected through the parish office.
Finally, providers may send a letter and supporting documentation to the Unisys
Provider Relations Correspondence Unit requesting the correction.
Q:
As a free standing psychiatric unit, we do not need the Community Care
referral number for our claims, but other providers performing services for our
patients (such as the radiologist) will need it. How can they get information on
the PCP and obtain a referral?
A:
This information can be retrieved on the REVS and MEVS system. The
provider will need to contact the PCP to obtain a referral.
Q:
Several months ago Medicaid changed the diagnoses required for
reimbursement of hyperbaric oxygen services. We have certain patients that are
still receiving HBO services, but their diagnoses are no longer among those
acceptable for HBO. Will we still get paid?
A: If the diagnosis is not on
the most recent approved list for hyperbaric oxygen services, Medicaid will not
reimburse charges for the services.
Q:
Is it acceptable to change the diagnosis on these claims in order for
them to be paid?
A: As long as
documentation supports the diagnosis billed on the claim, it may be used. If the
primary diagnosis is on the list of diagnoses required for hyperbaric oxygen
services, the claim should pay.
Q:
Are there any plans to expand the Community Care program?
A:
Unisys is not aware of any such plans. However, such inquiries may be
directed to the Community Care unit at DHH.
Q:
If hospital staff believe they have submitted a PCF01 to Unisys, and
Unisys does not show that is has been received, what is the hospital's recourse?
A:
If the hospital staff have a transmittal number, Unisys will trace it.
For specific information on a case needing to be traced, call Unisys
Precertification.
Q: Several months ago, we offered a
transmittal number in order to trace certain faxes for cases that were denied
due to untimely submittal, but were told that the tracing could not be done.
Why?
A: Our fax system has
the capacity to reproduce fax transmissions for seven days. If the request to
trace a transmission is submitted more than seven days from the fax date, Unisys
cannot reproduce that transmittal document. Therefore we cannot override a
denial for timely submission based on that transmittal report.
Q:
How many pages can the Unisys faxes accept?
A:
Our faxes can accept an unlimited number of pages. The fax receiving
system operates 24 hours a day
Q:
Is there any recourse if we have to appeal a precertification case from
last month or any time over a week ago?
A: Appeals are handled through
the DHH appeal process. Providers have 30 days from the denial in order to
appeal.
Q:
At what point must a hospital obtain precertification?
A:
Precertification must be obtained at the point that the recipient is
admitted to the hospital or after the recipient has been in the emergency room
or observation for greater than 23 hours, 60 minutes.
Q: If the
last authorized day of a precertification falls on a Monday, may the
precertification extensions be submitted on Friday?
A: The extension may be submitted on
Friday. However, the data submitted with the request will be outdated by Monday
and the review nurse may not be able to approve days. Remember that the data
submitted for extension of stay must be current. The best solution for a case
with the last authorized day on Monday is to submit the extension request on
Monday with current data.
Q: In
the past we have submitted the PCF02 on Monday morning when the last authorized
day was the previous Friday. Is this acceptable?
A:
If the last authorized day is Friday, the extension request may be
submitted on the following Monday without penalty for timely submittal.
Q: What
can the hospital do if the additional information that Unisys is requesting is
not available?
A:
The hospital should resubmit the data available and submit documentation
that the requested data is not available and why. It is possible that your days
may not be approved if the requested data is not available for review.
Q:
What is the time limit on precertification for retroactively eligible
recipients?
A: The facility has up to one year
from the date that the recipient was added to the Medicaid files in order to
request precertification.
Q:
Does this one-year timely filing limit for precertification also apply to
those patients who have exhausted their Medicare Part A during a
hospitalization?
A: No. When a facility
bills Medicare and receives their notification from the Medicare fiscal agent
that the recipient has exhausted Medicare Part A benefits, the facility should
submit the precertification request at that time.
Q:
When was the Unisys turnaround time on precertifications changed from
four hours to 24 hours?
A:
This change was made approximately three years ago.
Q:
Once a hospital has submitted a precertification request with a primary
diagnosis on the PCF01, may the hospital then submit an update in order to
change the primary diagnosis on the precertification file?
A: No. The initial
length of stay was approved based on the primary diagnosis. Therefore, changing
the diagnosis after approval invalidates the initial days approved.
Q: If the
patient comes in for a vaginal delivery and then has a C-section, should this
patient be precertified at the time of admission, or should the hospital wait
until the delivery in order to make sure that the correct diagnosis/procedure is
on the precertification file?
A: The hospital should
precertify for a vaginal delivery upon admission and then submit an update or an
extension request noting the C-section delivery date in order to receive the
correct number of days for the C-section delivery.
Q:
Since it seems simple enough that a vaginal delivery has a two-day stay
and a C-section has a four-day stay, why do hospitals need to go through
precertification in order to get paid for these days?
A:
If all vaginal deliveries were approved for two days, what would happen
to the patient who was admitted in labor for two days and then delivered? What
about the C-section patient who labored for one day and then delivered? In both
cases there are more days needed than two or four. That is why all deliveries
require precertification.
Q:
When is it necessary to precertify a patient who has exhausted his
Medicare Part A benefits?
A: Once
the Medicare benefits have been exhausted, from date on which Part A benefits
are exhausted the hospital stay becomes Medicaid only and must be approved by
Unisys Precertification. The initial submittal must have proof that Medicare
Part A is exhausted attached. The precertification initial request should be
submitted as soon as the hospital receives notification that Medicare Part A
benefits are exhausted.
Q:
As a free-standing psychiatric facility, we often send our patients to
the acute care hospital which is located next door. Who should bill Medicaid?
A: The facility in which the patient
is admitted should bill Medicaid. If the patient must be sent to a second
facility without being discharged from the first facility, the first facility
should bill Medicaid for all days of admission and should reimburse the second
facility for any services performed there.
Q:
If a patient, admitted with both Medicare and Medicaid, just had a baby
and the baby is sick, should the newborn be precertified, since the baby will
most likely have both Medicare and Medicaid as well?
A:
The newborn will be Medicaid eligible and not necessarily Medicare
eligible. Therefore, Medicaid precertification will be necessary once the
newborn is admitted to NICU or if the newborn remains hospitalized after the
mother has been discharged.
Q:
If a patient is a pure QMB and Part A benefits have exhausted, can the
patient be billed for the hospital charges?
A: Yes.
Medicaid will only consider charges which Medicare pays for pure QMB recipients.
Because the recipient does not have Part A coverage, Medicaid will not consider
the hospital inpatient charges.
Q:
If a patient with HMO coverage opts to utilize an out-of-network provider
and the HMO denies resulting claims, can that provider bill the patient?
A:
Yes. Medicaid will not consider charges that are denied by an HMO because
the recipient used an out-of-network provider or because the recipient did not
follow HMO-required protocol.
Q:
A patient has both Medicaid and TPL (other insurance). The other
insurance has denied claims due to injury caused by an accident. Liability
insurance has paid and reimbursed the patient, who reimbursed the hospital. Is
this acceptable?
A:
This is acceptable as long as the provider never filed any of those
claims with Medicaid. Once a provider is paid by Medicaid, he may not
subsequently void his claims in order to accept reimbursement from a settlement
or similar liability payment.
Q:
How are claims filed for recipients in the LACHIP program?
A: This program refers to
lowered eligibility threshholds for children under age 19. It does not affect
Medicaid billing. Once a child is deemed eligible through LACHIP, he is
considered Medicaid eligible and is subject to all usual policies and conditions
of the Medicaid program.
Q:
We are having a great deal of problems with our electronic adjustments
and voids. What do we do?
A: You should contact your software
vendor to ensure that you are using your billing software correctly and that the
software is set up to file adjustments and voids properly. If that does not
rectify the problem, you may contact Unisys EMC or have your software vendor
contact EMC.
Q:
If an initial precertification is denied for timely submittal, will the
whole stay be denied?
A: Yes. There is no
mechanism to resubmit a denied initial request. The entire stay can be appealed
through the DHH appeal process. The hospital should file its appeal with the DHH
Bureau of Appeals as soon as it receives the denial for timely submittal.
Q:
If a patient comes in at 11:45 p.m., when do we have to request
precertification?
A:
It must be submitted the next business day.
Q: What
is the clarification of a "business day"?
A: The
business day is Monday through Friday during regular working hours (8 a.m. until
5 p.m.), not including Unisys holidays.
Q:
What can I do when a precertification is denied for timely submittal,
when I faxed it timely but Unisys just did not receive it timely?
A:
Call the Unisys Precertification department with your fax transmission
report for that specific case. The Precertification staff will ask you for
information from that transmittal. Using this information, the Precertification
staff will attempt to trace the fax. If Precertification staff are unable to
locate your fax, they will ask you to fax to them the transmittal report for
definitive resolution of the fax issue of that case.
Q:
Is a letter from a physician necessary in order to request a
reconsideration?
A:
No. Progress notes or other documentation which supports interval
criteria for the denied days may be submitted. A letter from the physician sent
with the data often can help to identify his medical reasons for keeping the
patient in the facility. A reconsideration must be submitted within 24 hours of
the denial being sent by Unisys.
Q:
Unisys used to send a letter cancelling duplicate precertification
numbers. Why was this stopped?
A:
The number of duplicate precertification numbers became so large that
Unisys could no longer cancel each duplicate. The precertification number sent
on the provider letter should be used. All other numbers should be disregarded.
Q:
What is the procedure for precertifying a healthy newborn to a mother
that has insurance other than Medicaid?
A: The
PCF01 submitted to request the precertification must show the newborn
information and must state "Mother is not Medicaid eligible." This
PCF01 should be submitted to the attention of Sandy or Janeen.
Q:
How does Unisys precertify a healthy newborn who must remain in the
hospital after the mother's discharge because the baby is going to be adopted
(state law requires that the newborn be hospitalized for five days)?
A:
Unisys cannot precertify a healthy newborn in this situation, as the
Medicaid program will only precertify stays which are medically necessary. Days
that the newborn must remain in the hospital but which do not require
hospitalization as medically necessary will not be precertified or reimbursed.
Q: How
should a hospital precertify a woman who is admitted to the hospital in labor
and labors for two days before giving birth?
A:
The hospital must file for precertification the first business day
following admission. If the initial approved lentgh of stay (LOS) is not
sufficient because the mother labored longer than anticipated, the hospital
should then file the PCF02 for an extension and document the labor days, the
delivery date, and whether the delivery is a vaginal birth or a C-section
delivery.
Q:
May our facility use our old PCF01 forms or must we use the PCF01 version
in this packet (the 1998 hospital training packet)?
A: You
may use the old ones, but the one in this packet should be copied from now on.
This updated PCF01 form has the specific areas to check update and retrospective
review.
Q:
If a Medicaid patient has been precertified, but eligibility expires
during the hospital stay, what should the hospital do?
A: The
precertification only determines medical necessity. If the patient loses
eligibility for Medicaid during the stay, the hospital should bill the portion
of the stay that is covered as a split bill. If the recipient's eligibility is
updated to include the remainder of the hospital stay, the hospital may then
resubmit an extension request using the previously assigned precertification
case number. If a break in coverage has occurred, the precertification
department staff can assist the hospital with the steps to take to file a new
precertification number to cover the eligible days.KIDMED
Q.
If we receive our RS-0-07 each month, do we still need to check
eligibility on each recipient each month?
A. The RS-0-07 is
run at the end of each month to show KIDMED linkages for the following month. It
is not a guarantee of eligibility, as eligibility could possibly end after the
printing of the report. Eligibility should still be checked each month using
REVS or MEVS.
Q.
Can a claims history be used for timely filing?
A.
Yes. Submit the claim hardcopy with documentation showing the date of the
denial to the Provider Relations Correspondence Unit with a cover letter
requesting override for proof of timely filing.
Q. How
long may the resubmittal turnaround document (RTD) be submitted?
A.
Each RTD indicates a date by which it should be resubmitted in order to
be considered for processing.
Q.
May an interperiodic screening be requested by a family member? Would the
family member be considered "outside of the formal health care
system?"
A. Yes to
both questions.
Q.
We are apparently mixed up with another provider, since they are getting
our RS-0-07s. How do we correct that?
A. Call
Provider Relations so Unisys can check the address that the RS-0-07s are being
sent to. If the address is correct on file, Unisys can address this internally
to their mailing staff.
Q.
We normally send out PKUs to a lab. Can we bill for those lab codes?
A. No.
You may not bill for the performance of a lab test that you do not perform at
your office.
Q.
When we bill for a newborn under the mother's name and number, the claim
is denied. Does Medicaid tell these mothers to apply for a number? How does that
happen?
A.
Form 152-N is used to initiate assignment of a Medicaid number for a
newborn. Normally the hospital gets the mother to sign this form while she is in
the hospital after delivering, and then the hospital sends the form in to have
the baby entered in the Medicaid system and assigned a number. Any physician
whose name and address is listed on the 152-N should receive notification when
the baby has been assigned a number.
Q.
How long does it take for newborns in the hospital to receive a new
Medicaid ID number?
A. That
depends on the office actually processing the paperwork. Usually the numbers are
issued within a couple of months.
Q.
If a newborn does not have a Medicaid number yet, and his screening claim
is getting close to 60 days old, what can I do?
A.
The KIDMED timely filing edit allows six months for newborns, not the
usual 60 days. The edits program adds six months to the date of birth to
calculate the date for timely filing. For example, if a child is born on January
1, 1999, the provider has until June 30, 1999 to file any screening claim. A
Medicaid number will normally be assigned in this time.
Q:
If a name/number mismatch denial is received after filing the baby's
screening claim with the Medicaid number transmitted via the 152-N form, can the
152-N be used with the KIDMED screening to get our claim paid?
A: In such a
situation, the provider should send the screening claim, a copy of the denial
received from Unisys, a copy of the 152-N showing the baby was assigned a
Medicaid number, and a cover letter requesting that the baby's recipient file be
updated to the Provider Relations Correspondence Unit. They will forward the
information to the State to have the recipient file corrected and the claim
processed.
Q:
If a KIDMED screening and sick visit are performed on the same day for
the same patient, must I use an established patient code for the sick visit,
even though the patient is new to the clinic?
A: No. We will pay both the
KIDMED screening and a new patient visit code for the same patient, same date of
service, and same attending provider if the visit is low level.
Q: If a
person is not eligible and then is made eligible retroactively, how can proof of
timely filing requirements be met?
A: On the
retroactive eligibility form, Form 18-SSI, there is an issue or certification
date in the upper right hand corner of the form. This date is when "the
clock starts ticking" for timely filing purposes. For services other than
screenings, providers would have one year from the issue or certification date
on the 18-SSI in order to file claims timely. If the claim is within that one
year window, but the date of service is over a year old, the claim should be
filed hardcopy with a copy of the Form 18-SSI and a cover letter explaining the
situation to the Provider Relations Correspondence Unit for handling.
Q:
May a stamped signature be used on the KM-3 form where a signature is
required?
A:
Medicaid will allow a stamped signature as long as there are handwritten
initials along with the stamped name.
Q:
Who signs the KM-3 form?
A:
Normally the person performing the screening signs the KM-3.
Q: When
filing KM-3s electronically, are there fields to enter the next appointment day
and time?
A:
Unisys specifications provide fields for next screening appointment date
and time. Providers should check with their electronic billing software vendors
if unsure how to enter this information into the claim.
:
If a CP-0-51 shows a denial indicating that the claim is a duplicate of a
previously paid claim, how can the previously paid claim be found?
A:
If the claim denied as a duplicate of a previously paid claim, one must
check his past remittance advices to find the first claim that already paid
(same recipient, same provider number, same date of service, same procedure). If
the claim denied as a duplicate of a previously approved claim that did not
appear on a remittance advice yet, check future remittance advices to find the
first claim once it pays.
Q: If
more than three referrals are required as a result of KIDMED screening, should
two KM-3s be submitted, since the KM-3 only has space for three referrals?
A:
Providers should submit one KM-3 with three referrals only and record the
additional referrals in the patient's chart.
Q:
If a recipient is under care for a treatment with another provider's
office (not in-house), should item 32 on the KM-3 indicate that the recipient is
under care?
A: Yes.
Q:
If a child is seen for a KIDMED screening, can the child be referred to
the clinic's physician on the same day?
A: Yes, but the physician
cannot charge for any higher office visit that 99212.
Q:
In the above situation, if the child has a screening done by the nurse
and is then seen for an office visit by the physician, is the office visit code
still limited to 99212 or lower?
A: Yes.
Q:
What should be done if a child comes in to the KIDMED clinic with a
grandparent or other relative who does not have any necessary information to
complete the KM-3 regarding immunization status?
A: Items 29 and 30 of the
KM-3 regarding immunization status should be completed based on whatever
information is available regarding the patient's history. If it is determined
that an immunization is appropriate, it may be performed and billed on the
HCFA-1500.
Q:
It appears there are times when the recipient's next screening date
according to the RS-0-07 does not coincide with the periodicity schedule and
screenings that have been paid. What can we do about this?
A:
This has been reported and Unisys is looking into the problem. Providers
should continue to screen according to the periodicity schedule in the manual
and should clearly document that they are doing so.
Q: A child's parent has called and
requested that the child's linkage be changed from one provider to another, but
the new linkage has not become effective yet. If the new provider performs a
screening, how should it be billed?
A:
This situation should be very infrequent. Normally a provider would wait
to perform the screening until after the recipient appears on his RS-0-07. If
there is some reason the screening must be performed immediately, the former
provider (to whom the child is still linked) may refer in writing the child to
the new provider in order for the screening to be performed. In this situation,
the former provider's Medicaid number must be entered in block 9 of the KM-3
form. Provider linkage questions should be directed to the KIDMED Hotline at
1-800-259-8000.Q: In the situation above, does a copy of the referral need to be
sent with the KM-3?A:
No, but it should be kept in the patient's chart or medical records so
that it can be retrieved if necessary for an audit or monitoring visit.
Q:
I screened a child, incorrectly billed the claim with his sibling's name
and ID number, and received payment. I voided the paid claim to correct the
record, but now the correct claim for the correct child is denying for timely
filing. Is there any way to be paid for the correct claim?
A:
If Unisys did not receieve the correct claim until after the 60-day
filing limit, there is no mechanism for paying the claim.
Q:
When exactly is a recipient's KIDMED eligibility terminated upon turning
21? At what point will a recipient no longer be eligible for KIDMED services?
A:
If a recipient's twenty-first birthday is on the first day of the month,
his eligibility ceases with the first day of the month. If his birthday is any
other date during the month, his eligibility ceases at the end of the month.
Q:
As an FQHC, we perform a KIDMED screening and determine that the patient
needs to see the physician on staff for an identified condition. How would we
bill the physician visit - under our X9928 encounter code?
A: No. Medicaid will not pay for both an encounter code and a
KIDMED screening to the same provider for the same recipient on the same date of
service. A low level visit could be billed under the physician provider number.
Q:
If a mental health condition is noted during a screening, and the child
is seen by the KIDMED clinic's BCSW on a different day, may the BCSW visit be
billed using a KIDMED counseling/consultation codes? If the BCSW visits are to
be one time a week for several weeks, may these visits also be billed with the
same code?
A: The answer to
the first part of the question is "yes." The answer to the second part
of the question is "no." EPSDT Consult Codes are short-term codes not
designed with episodic or continuous therapy in mind. EPSDT BCSW Consult Codes
(X0189) is not for treatment for mental illness or emotional disturbances. That
type of ongoing therapy is payable by Louisiana Medicaid under the Mental Health
Rehabilitation Program or through the EPSDT Health Services Program where
psychiological counseling can be performed by a licensed therapist. Appropriate
referrals should be made.
Q:
What constitutes "short-term?"
A: Short term is considered to
be less than six weeks.
Q: Is
there a limit of nurse consults that can be billed per month?
A:
Such visits are subject to post-pay review for appropriateness,
particularly if numerous visits are being billed consistently. Documentation
must justify the need for a nurse consult. Recoupment of payments can be made on
those consults billed inappropriately.
Q:
Clarify the appropriate use of the interperiodic screening code.
A:
An example of use of the interperiodic screening code would be when there
is a referral from the school indicating a child needs to be checked for a
problem observed at school. The five components of the medical screening must
all be documented in order to bill the interperiodic screening. The
interperiodic screening is a result of a perceived problem, so a well diagnosis
would not be appropriate.
Q:
A KIDMED provider referred one of his KIDMED recipients for EPSDT dental
services. The recipient missed the appointment and the dental office charged a
missed appointment fee. The same situation happened again. Now the dental office
is refusing to see the recipient unless they pay the missed appointment fees.
Can the dental provider do this? How should this be resolved?
A:
Once a Medicaid provider has agreed to accept an individual as a Medicaid
patient, he can only charge for services rendered. Therefore, a provider should
not charge a missed appointment or late fee to a Medicaid recipient. Providers
do have the option of picking and choosing from which patients they will accept
Medicaid. Providers are not required to accept every Medicaid recipient
requiring treatment. However, the provider must discuss the
acceptance/non-acceptance decision with the Medicaid recipient.
Q:
A KIDMED provider referred a recipient to his family physician as a
result of a KIDMED screening. However, the family physician refuses to provide
services until the family pays a previous outstanding balance. Can the provider
do this? How should this be resolved?
A: As in the
previous question, providers do have the option of picking and choosing from
which patients they will accept Medicaid. Providers are not required to accept
every Medicaid recipient requiring treatment, but they must discuss the
acceptance/non-acceptance decision with the Medicaid recipient.
Home Health/Rehab Questions
Q:
Do providers ever obtain "instant" prior authorization (PA)?
A:
Sometimes the Unisys Prior Authorization department will give an
immediate emergency authorization, such as when a patient is coming home from
the hospital. They will often give such authorization for a day or two and then
follow the usual PA procedures.
Q:
If a patient has a Medicare HMO which denies services saying
"services not covered", then how will Medicaid pay the claim?
A: If the claim is for a service that the
HMO simply does not cover and Medicaid does cover it, Medicaid will consider the
claim as a straight Medicaid claim. If the claim is denied because the services
were "not medically necessary," Medicaid will not pay.
Q:
How is the 13-digit Medicaid number obtained, since it is not on the
plastic ID card?
A:
REVS and MEVS give that information to providers checking eligibility.
Q: Are multiple home
health visits authorized for recipients under age 21 only?
A: Yes.
Extended and multiple visits require prior authorization and are only covered
for recipients through age 21.
Q:
How may extended home care and physical therapy be requested on a child
under three years of age?
A: Normally
physical therapy for children under three years of age is provided through the
EPSDT program.
Q:
Will recipients still receive a paper card?
A: No. Recipients
received a paper card and a plastic card the first month of plastic card
implementation in their parishes. Thereafter, the recipients will receive
nothing else and will use their plastic ID cards.
Q: Can
rehabilitation services be provided to nursing home residents even if the
nursing home has therapists on staff?
A:
Yes, if the recipient is in an ICF I or ICF II facility and in need of
therapeutic services. Services must be prior authorized and medically necessary.
Q:
How may a home health provider bill for rehabilitation services if opting
to perform those services?
A:
A provider is automatically able to bill as a rehabilitation provider
when enrolled as a home health provider.
Q:
If we provide services to a medically needy recipient, and those services
are not covered for medically needy recipients, may we bill the recipient?
A:
Yes. Services not covered under the medically needy program may be billed
to the medically needy patient. Providers may bill the patient for non-covered
services or those which exceed a service limitation.
Q: Must we notify the patient up front that we will bill them for the
non-covered charges?
A:
This is not required, but it is to your benefit (and to the recipient's
benefit) to tell the patient he will be responsible for payment.
Q:
How often is the Unisys eligibility system updated?
A:
The Unisys eligibility files are updated daily.
Q:
Since when did providers have to prior authorize home health services?
A: Prior Authorization only
applies to multiple visits/disciplines for those recipients under 21 years of
age. This requirement has been in effect for some years now.
Q:
Do we have to do OASIS on every recipient?
A:
No. This is only done at timepoint assessment. Questions regarding OASIS
can be directed to Cecole Castello, RN, DHH Coordinator of OASIS at
(225)342-2449.
Q:
According to federal guidelines, a registered nurse must have two years
of psychiatric experience in order to perform a psychiatric evaluation. Does
Medicaid require the same standard?
A:
Yes. For specific personal qualifications information, refer to the
Minimum Standards for Home Health Agencies (Chapter 91).
Q:
How can we identify which recipients have another insurance?
A:
Both the REVS and MEVS systems will indicate this with eligibility
verification if the State has been made aware of other insurance. If the other
insurance has not been reported by the recipient, it likely will not be on file
and will not be indicated by REVS or MEVS. That is why it is very important that
you ask the patient when he comes in if he has other insurance.
Q:
Under freedom of choice, shouldn't the recipient be allowed to utilize
any agency he wants, whether or not it is within their network?
A: The
recipients are free to see anybody they want, but the Louisiana Medicaid program
will not pay for services denied by the HMO because the recipient utilized an
out-of-network provider. It will be the recipient's responsibility to pay for
those services.
Q:
If a claim is paid and then found to have been billed with an incorrect
date of service, should an adjustment or a void be filed to correct the wrong
date of service?
A: An adjustment should be
submitted indicating the services performed and the correct date of service.
Voids are filed when claims are paid with an incorrect provider number or
recipient number.
Q:
We know about many children under three years of age who need more
aggressive therapy that Early Intervention Center can provide. How can we help
those children?
A:
Write to the Medicaid EPSDT program manager at DHH to voice your
concerns, including specific instances and any documentation you may have.
Q:
Are social worker visits with recipients over age 21 covered?
A:
This is not a covered service under either the home health or
rehabilitation programs.
Q:
What should we do with those patients who have applied for Medicaid, but
no determination has been made yet?
A:
Since they have not been deemed eligible yet, they would be considered as
private pay patients.
Mental Health Rehabilitation Questions
Q:
May service logs be kept on computer diskette instead of storing the hard
copies?
A:
The information may be on disk for frequent
use. However, the hard copies must be kept for a period of five years. Q:
May billing be done once the prior authorization has been received?
A: Once 80% of the services
have been provided and entered, the prior authorization is released to Unisys
and the services may be billed.
Q:
Does the agency bill for the psychiatric director's services when he
completes a clinical evaluation?
A:
Those services may be billed through the physician's program, as
completing a clinical evaluation is not a billable mental health rehabilitation
service.
Q:
How would Medicaid be billed when a third-party carrier denies a claim
for preventive services because the other insurance does not cover prevention?
A: Medicaid
will pay the claim if it is a covered service, the recipient is fully eligible
for all Medicaid benefits, and prior authorization is obtained. On the HCFA
1500, the six digit carrier code must be entered in block 9A, any payment
received must be entered in block 29, and the EOB from the other insurance must
be attached.
Q: On many occasions we have not
received a Medicare payment because it conflicts with Medicaid policy (and we
were following Medicaid policy). Has this conflict been resolved?
A: A recent clarification from HCFA now
allows Medicaid to be billed in full for mental health rehabilitation services
rendered to Medicaid/Medicare recipients. This policy was issued by provider
notice dated 1-15-99.
Q: We
have received notices from the Office of Mental Health (OMH) that nursing home
residents do not qualify for mental health services because they are not high
need, even though they meet qualifications for PASARR. Is this correct?
A:
Nursing home residents must qualify through both PASARR and prior
authorization criteria at OMH in order to be eligible for mental health
rehabilitation services.
Q:
We have six different service fees. Which charge do we list on the claim?
A: The prior authorization you
received from OMH should indicate the procedure code approved. Reimbursement is
based on the procedure code billed and varies according to the recipient's age
(child or adult) and level of need.
Q:
If the psychiatric director sees a mental health rehabilitation patient
in the hospital, are those charges covered in the single fee for that prior
authorization period?
A: No. Those
charges are billed by the physician through the physician program.
Q: If
our mailing address does not change, but the physical address does, do I need to
notify BHSF?
A: Yes.
You should notify BHSF of any changes in your provider information.
Q:
When a recipient has a new Medicaid number, do I bill under the old
number or under the new number?
A: It is best to
bill with the new Medicaid number. If the new Medicaid number is different from
the Medicaid number on the prior authorization record, you should contact OMH to
request an update of the PA to reflect the new Medicaid number.
Q:
If MHRSIS accepts a recipient name or number, but Unisys denies the claim
for wrong recipient name or number, how can this be corrected?
A:
The information at the parish office, OMH, and Unisys must all be correct
and match. If the recipient number on the PA record is different from the
recipient's current Medicaid ID number, contact OMH to have the PA record
updated.
Q:
Is the Family Support License not required anymore?
A:
This license is not required by the mental health rehabilitation program.
Federally Qualified Health Center/Rural
Health Clinic Questions
Q:
Can immunizations be billed on the same day as a core visit or in the
cost report at the end of the year?
A:
At this time, immunizations must be billed using an individual physician
or group provider number.
Q:
Can influenza injections be billed out separately from a core visit?
A: The flu shot is an injection and
may not be billed out separately as all injections are "incidental to"
core visits.
Q:
What will the eligibility verification system show if a patient sees and
has his card swiped by two different doctors on the same day?
A: The
verification system shows physician visits remaining based on the number of
visits paid. Claims for visits are paid in the order they are received. In this
specific case, both physicians will receive the same information regarding
visits remaining, because the number of visits paid will not change within a
single day.
Q:
How long does it take to update the date of birth?
A: It depends on the parish office handling the
update. It could be anywhere from two to six weeks.
Q:
May a provider accept money from a recipient if the provider is not part
of the recipient's HMO?
A: Yes.
However, the provider should make sure the recipient understands his financial
responsibility and the reason for it. Medicaid will not pay for claims denied by
an HMO because the recipient used a provider outside the HMO's approved network.
Q:
Will Medicaid pay the deductible on Medicare patients?
A: If
the recipient is a dual QMB, Medicaid pays the coinsurance and deductible on
Medicare-covered services AND the full range of Medicaid benefits. If the
recipient is a pure QMB, Medicaid will pay the coinsurance and deductible only
for Medicare-covered services.
Q:
How are Medicare/Medicaid crossover claims filed if they do not
"cross over" automatically?
A:
Medicare/Medicaid crossover claims which do not electronically cross over
to Medicaid must be filed hard copy. A copy of the UB92 that was filed to
Medicare should be filed to Medicaid, along with a copy of the Medicare EOB. Of
course, the Medicaid provider number should be entered in form locator 51.
Q: If a recipient comes in for a
non-covered service, should we bill the recipient our core charges or a
fee-for-service charge?
A:
If a Medicaid recipient receives a non-covered service, he is considered
a private pay patient for those services and is subject to whatever standards
your office sets for private pay patients.
Q:
When the REVS system indicates that a recipient has other insurance,
should that insurance be billed prior to Medicaid?
A:
Yes.
Q:
What can we do when we lose a remittance advice?
A: Providers may order individual
remittance advices for specific dates, or they may order a provider history if a
several weeks' or months' worth of remittance advices are required. This
documentation must be kept for five years.
Q:
What type of recipient information can be used for eligibility
verification through REVS?
A:
Eligibility may be verified using a Medicaid ID number that has been on
file within the past 12 months or using the card control number and either the
date of birth or the Social Security number.
Q:
While a nurse practitioner is waiting for his Medicaid provider number to
be issued, may his services be billed under the physician's provider number?
A: The nurse
practitioner should wait to bill for services until after he receives a Medicaid
provider number. At that point, his claims may be billed with the physician's
billing number (block 33 of the HCFA) and the nurse practitioner's attending
number (block 24k of the HCFA). Enrollment can be made retroactive if so
requested to allow providers to bill for services rendered while waiting to
receive a provider number.
Q:
How long have electronic adjustments and voids been available?
A:
They have been available for some time. Providers should check with their
vendors to see if their software has adjustment/void capability. Specifications
for adjustments and voids are available from the Unisys EMC department.
Q:
Are charge slips used by the physician's office sufficient documentation
of services rendered?
A: That
depends on what services are being billed. If the provider has an extensive
charge slip that lists taking blood pressure and temperature, and all the
provider is billing is a low-level office visit, then the charge slip may be
enough. However, it will not be sufficient for a more comprehensive visit.
Patient chart notes should be as complete as possible to document services
rendered.
Q:
What if a lock-in recipient has an emergency and goes to a rural health
clinic physician who is not his lock-in physician?
A: That treating physician must enter
"EMERGENCY" in the diagnosis section of the claim form in order to be
paid for the visit.
Q:
May a lock-in recipient see any physician in the clinic?
A: If the
recipient is locked-in to a particular physician within the clinic, then he may
only see that lock-in physician .
Q:
Will a physician assistant ever be able to get his own provider number?
(Medicare has agreed to issue physician assistant provider numbers.)
A:
As of right now, DHH is not giving physician assistants their own
provider number.
Q:
In order to bill Medicaid, does the overseeing physician have to be in
the office with the physician assistant? A:
The supervising physician need not be in the office with the physician
assistant, but both must comply with the Physician Assistant Practice Act (LRS
1360:22).
Q:
If a patient comes in with an HMO and has Medicaid secondary, can we
accept the HMO copayment from the recipient?
A: If
you accept Medicaid for this patient, you may not accept any copayments.
Q:
In block 33 of the HCFA 1500, may we just stamp the physician's signature
on the claim form?
A:
Yes, but there must be handwriting in that block (either a signature must
be handwritten, or someone must initial a stamped signature or printed name).
Community Care Questions
Q:
Do the new plastic ID cards give an indication of the recipient's
Community Care Physician?
A:
The card itself does not list the PCP. However, the PCP name and phone
number are given when eligibility is verified through the REVS or MEVS systems.
Q:
Will the Community Care program be expanded statewide?
A: There is no plan at this time to expand Community
Care to include all of Louisiana.
Q:
What if a Community Care recipient comes to our office saying he has no
way to get back to his own parish to his PCP?
A:
In order for the visit to be covered, you must have a referral from the
recipient's PCP.
Q:
If a Community Care recipient moves to a non-Community Care parish, how
long does it take for the recipient to be unlinked from the PCP?
A:
The linkage should be ended on the first of the month following when the
change is reported to the parish office. Linkages normally are not ended in the
middle of the month.
Q:
What if a recipient is now living in a non-Community Care parish but is
still linked to a PCP? How long do we go about seeing the recipient?
A: You
still need to obtain a referral from the PCP while the linkage is in place.
Q:
What if the PCP refuses to give us a referral, even though he says this
is no longer his patient?
A:
You should contact the Provider Relations Representative for your region
who will assist in the resolution of this matter.
Ambulance Transportation
Q:
What should we do if we find there is Medicaid coverage for a person who
has paid a membership fee to a transportation company?
A: No
action is necessary.
Q: At
a particular hospital, the medical director refuses to sign the MT3 form if he,
the attending physician, and the recipient are not in the same room at the same
time. How can we handle this situation?
A:
You should report this with specific information so we can call upon the
hospital to remind them of their responsibilities.
Q:
What option is available if the physician refuses to sign the MT3, saying
the situation was not a true emergency and that the recipient should never have
come to the hospital?
A:
In such situations, providers should bill code A0226 for a non-emergency
reimbursement. Prior authorization is not required. The cost of the trip should
not be billed to the patient since the service is covered.
Q: Our
ambulance claims were denied by Medicare with the reason that the
"recipient could have used other means of transportation." Can we get
paid by Medicaid?
A: You should bill code A0226 for a non-emergency
reimbursement. No prior authorization is required.
Q:
If we take a recipient to a medical provider who then refuses to sign the
MT3 form, do we still get paid?
A: You can be paid if you document
the reason why the provider refused to sign the form. If this is occurring
routinely, please report it.
Q: How do I get
assistance with electronic billing?
A: You
may contact Unisys EMC at (225) 237-3303.
Q:
When Medicare clams fail to crossover automatically, do timely filing
rules still apply?
A:
Yes. Manually file these claims if they have not crossed automatically
within six weeks from your Medicare payment date. These claims must be billed to
Medicare within one year from the date of service, or to Medicaid within six
months from the Medicare EOB date, whichever is longer.
Q:
May we solicit a Medicare/Medicaid eligible recipient for an ambulance
membership?
A: Yes.
However, the recipient must know the membership enrollment is voluntary.
Q:
We provided an emergency transportation service on the same day that
another ambulance provider had also provided services. Can we still get paid, or
does this exceed limitations?
A:
State approval would be required for payment of the second service on the
same day. You should send these claims hardcopy with the 105 certification form
and a letter requesting payment for additional emergency services.
Q:
To what hospital should we take the recipient?
A:
The recipient should be transported to the closest facility that can
provide the level of care required.
Non-Emergency Medical Transportation
Q: May a non-emergency medical
transportation provider refuse a recipient due to continual dry-runs or abusive
behavior?
A:
Yes. The provider should send a letter to the dispatch office indicating
the grounds for refusal. The Dispatch office should no longer request that
provider to transport that recipient.
Q:
Where may I get statistics of needy regions within the state so that I
can provide transportation needs where it is needed?
A:
That information can be obtained by calling the transportation program
manager at BHSF at (225)342-0127.
Q:
Since the new plastic ID cards only have a card control number, how is
the recipient ID number obtained?
A: The
authorization letter faxed from Dispatch will contain the recipient ID number.
In addition, the 13-digit ID number may be obtained through REVS or MEVS using
the card control number and other recipient information.
Q: Why would Dispatch request us to
transport a person who is no longer eligible?
A:
The dispatch office will not request you to transport anyone who is not
eligible for Medicaid. You may verify recipient eligibility through the MEVS or
REVS systems if you think a recipient is not eligible.
Q:
Why is mileage not reimbursed for non-emergency, non-ambulance services?
A: Non-emergency, non-ambulance
medical transportation includes reimbursement of average mileage, but no
separate billing is allowed.
Q:
I am a non-profit, non-emergency medical transportation provider.
Dispatch is denying me those trips for recipients who need non-emergency
transportation on a regular basis for services such as dialysis or chemotherapy.
How do I go about providing transportation for those recipients?
A: Non-profit transportation
agencies cannot be reimbursed at capitated rates. Refer to page 6-5 of the
Medical Transportation Provider Manula, issued June, 1998.
Q: Is
part of the nursing home per diem allotted for transportation?
A: Yes. The
nursing home per diem is meant to include the cost of non-emergency,
non-ambulance transportation.
Q: How many children are
allowed to accompany each recipient?
A: A
provider may allow as many as he wishes, but transporting the accompanying
children is not payable, nor do we require that they be transported.
Q:
Is there any possibility of raising the reimbursement rates for
non-profit providers?
A:
DHH has no plans to increase rates at this time.
Dental
Q.
If a recipient has his twenty-first birthday in the middle of the month,
is he covered for EPSDT dental services for the whole month?
A. If a recipient's twenty-first birthday is on the first day of the
month, his eligibility ceases with the first day of the month. If his birthday
is any other date during the month, his eligibility ceases at the end of the
month.
Q.
How often should bitewing radiographs be taken for EPSDT patients?
A.
Bitewing radiographs are required at the initial dental screening on all
recipients. After that appointment, providers are limited to one set per year
per recipient. If on the subsequent checkup appointment no authorized services
are necessary, then the program does not require the provider to take
radiographs.
Q.
Will nitrous oxide be covered with the procedure sealants?
A. Currently
the program will pay for nitrous oxide with sealants.
Q.
Does Medicaid pay for orthodontics for recipients under 21 years?
A.
Full orthodontic services and maintenance of appliance are provided only
in those instances in which treatment is considered medically necessary (i.e.
for children with cleft lips and/or palates, hemi-facial hypertrophy, and other
craniofacial deformities resulting in a physically handicapping malocclusion.)
The program does provide for interceptive orthodontics (minor tooth movement).
Reimbursement for interceptive orthodontics will be limited to no more than
$200.00, which includes all visits and adjustments/maintenance.
Q. Is
orthodontic treatment payable for treatment of a severe crossbite?
A. No, treatment is not covered for
patients having only crowded dentition or having overjet/overbite discrepancies.
Q.
If a minor crossbite service costs $500.00, can the patient be billed for
the $300.00 not paid by Medicaid?
A. No. If the
Medicaid eligible individual has been accepted by the provider as a Medicaid
patient, the provider has agreed to accept as payment in full the amounts
established by BHSF.
Q.
Why aren't pulputomies on 6-year-olds payable?
A. Endodontic
specialists avoid pulputomies on permanent molars because in some cases it makes
the future root canal much more difficult.
Q.
In our practice, our dentist had a stroke and we have a temporary
dentist. Does he need a Medicaid provider number?
A.
Yes. To receive reimbursement for services provided under the Medicaid
dental program a provider must be an enrolled provider.
Q.
A dentist in Bossier City will be on a 3-month leave. Can our dentist
bill under his own number if he goes there one day a week?
A.
Yes. He will be doing the work and should bill as the attending provider.
Q.
Does Medicaid pay for a panorex?
A.
Medicaid will pay for a panorex if the procedure anticipated or the
diagnostic necessity justifies the panorex. A full mouth series or panoramic
radiograph for screening purposes is not reimbursable in the program (i.e.; a
reason for taking the panorex must exist before taking the panorex).
Q.
Will Medicaid ever pay for extractions on recipients who are 21 years old
or older?
A.
Currently there is no funding for any expansion of the Adult Dental
Program.
Q. How long after a recipient gets his denture must he
wait to have a reline done?
A. Relines
are payable in the adult denture program if a full year has passed since the
original denture was delivered or if one year has passed since a reline has been
done. Only two major services (one denture and one reline or two relines) are
allowed in a seven-year period.
Q.
If a patient dies before the dentures are delivered, how can the provider
be paid?
A.
In these situations, partial reimbursement is provided by Medicaid. The
provider must contact the prior authorization unit at LSU to get partial
reimbursement. The partial reimbursement will be based on the steps completed
prior to the death of the patient. The fee for these services will be authorized
with the code 05999 (non-specific prosthetics).
Q.
Is it true that providers may file claims with only 4-digit diagnosis
codes?
A.
The EPSDT dental and the adult denture programs do not use diagnosis
codes. The oral and maxillofacial surgery program uses diagnosis codes which are
listed in the ICD-9-CM diagnosis codebook. Claims may be filed with whatever
diagnosis code is appropriate; however, some diagnosis codes that are specific
to the fifth digit are not on file with Unisys. If there are any questions
regarding these codes, providers may contact Provider Relations telephone
inquiry unit.
Q.
What is the youngest age at which a recipient may receive dental
services?
A.
As long as they are Medicaid eligible, recipients may receive dental
services from age 0 on up. The EPSDT program covers recipients until the
twenty-first birthday with general dental services, and after that the adult
denture program provides for dentures.
Q.
What is the code for non-specific orthodontic work?
A.
The code for all orthodontic services is 08999. All orthodontic services
must be prior authorized. Each prior authorization request for orthodontic
services must be accompanied by complete documentation, including radiographs,
study models, photographs, daignosis, and prognosis.
Q.
Should providers bill their usual and customary fee when filing claims?
A.
Yes.
Q. Can the REVS line be used to check eligibility for
future dates of service?
A.
At this time, recipients eligible on the first day of the month are
generally eligible through the entire month. Therefore, if eligibility is
verified at some point during the month, generally the recipient will be
eligible for the entire month. However, DHH intends to make eligibility valid on
a day-to-day basis. At that point, recipient eligibility must be verified each
time the recipient is seen.
Q.
What procedure code should be billed for maintenance of orthodontic
appliance?
A. The
maintenance fees for Medicaid-covered orthodontic appliances are included in the
payment for the appliance. In an instance where the provider must assume care
mid-treatment of a full orthodontic case, for a recipient who meets the
medically necessary criteria, that provider should contact the dental
authorization unit to obtain prior authorization for his services.
Q.
Must patients be over 65 years of age to qualify for adult denture
services?
A. No.
Recipients are eligible for the adult denture program once they reach 21 years
of age.
Q. Must we engrave the recipient's name on all
dental prosthetic devices?
A.
This requirement has not been made effective yet.
Q.
What is the turnaround time for electronic filing?
A. Normally claims
that are filed electronically are processed in 10 days or less.
Q.
What is the date on which it will be mandatory to use the 1994 ADA form?
A. That
date has not yet been determined.
Q.
What can a provider do about a Medicaid recipient who is a habitual
"no-show"?
A.
Providers may discontinue offering services to that recipient after
completing their current course of treatment.
Q.
If a procedure is not covered by the Medicaid program, may charges for
that procedure be billed to the recipient?
A.
Yes.
Q.
If a recipient insists on a 6 month visit, and Medicaid only provides
annual visits, may the recipient be billed for visits that Medicaid does not
cover?
A.
Yes, as these are considered non-covered services.
Q.
Can recipients lose eligibility within the month?
A If
recipients� 21st birthday is the first day of the month they will lose EPSDT
eligibility on that day. Recipient�s whose 21st birthday is not the first day
of the month will maintain eligibility for the remainder of that month.
Q.
May a Medicaid dental provider fileclaims for another dental provider
that is not enrolled with Medicaid?
A.
No. Each dentist must be enrolled as a Louisiana Medicaid provider in
order to be reimbursed for services provided to Medicaid recipients.
Q. Where
can I get more information on electronic filing?
A.
Contact the EMC department at (225) 237-3239.
Q. We
have two individual dentists in our practice. Dentist #1 is incorporating and
Dentist #2 is part of the group. How do we handle this with Medicaid, since both
dentists now only have individual numbers?
A. Dentist #1 may
request that his individual number become a group number. The individual number
for dentist #2 must then be linked to provider #1's group number in order for
provider #1 to bill for provider #2. Dentist #1 could also apply for a separate
group number and then have his individual number and dentist #2's individual
number linked to the new group number.
Q.
Is there anything I can do so that my computer generated claim forms
don't print out the license number where the provider number goes? Currently, I
have to manually change it every time.
A. That
issue sould be discussed with your software vendor.
Q.
What is a spend-down recipient?
A. A spend down recipient is someone who is
not normally eligible for Medicaid but, because of catastrophic illness or other
circumstances, becomes eligible for Medicaid. Such recipients must "spend
down" from their own financial resources an amount of money before Medicaid
begins to reimburse providers for services.
Q. If
prior authorization is obtained for a root canal and the patient cancels the
service, must eligibility be re-verified when the patient returns at a later
date to have the procedure done?
A.
Recipient Medicaid eligibility should be re-verified. However, the prior
authorization decision is valid for the length of time specified on the prior
authorization letter. Prior authorization does not verify eligibility
Q.
If a provider plans to change banks soon, should he contact (225)
342-9454 to update his direct deposit agreement?
A. Yes.
Q.
Is it permitted to bill a Medicaid patient when he does not appear for
his scheduled appointment?
A. Once a Medicaid provider has agreed to
accept an individual as a Medicaid patient, he can only charge for services
rendered. Therefore, a provider should not charge a missed appointment or late
fee to a Medicaid recipient. Providers do have the option of picking and
choosing from which Medicaid patients they will accept. However, the provider
must discuss the acceptance/non-acceptance decision with the Medicaid recipient.
Q. What
happens if the name or the spelling of the name on the card is wrong?
A.
In such a case, any claims for the recipient should be submitted with the
recipient's name as it appears on the card. The recipient should contact his
parish office to correct his name.
Q.
Where should the prior authorization number be indicated on the dental
claim form?
A.
It should be shown in block 38 of the 1994 ADA form.
Q.
How long does it take to order a Remittance Advice?
A. Remittance
advices are usually produced within two or three weeks from the date ordered.
Q.
Do recipients get a new card every year?
A.
No. Recipients only receive a new card if theirs is lost, damaged, or
stolen or if the recipient's name changes.
Q.
Do REVS and MEVS give eligibility status?
A.
Yes.
Q.
Does Unisys supply the 1994 ADA forms?
A.
No. These claim forms must be purchased from a national claim form vendor
or a business printing firm.
Q.
How important is it to indicate the address in block 9 of the dental
claim form? It is not on the new card.
A.
The address is not required.
Q.
Would a CommunityCare referral be required for routine dental procedures?
A. No. Only
if the patient is admitted to a hospital for dental services or if the services
are provided by an oral surgeon would a CommunityCare referral be required.
Q.
Why is an original signature required on a paper claim but not for an
electronically filed claim?
A.
When submitters file claims electronically, they must submit to Unisys a
signed certification sheet for each transmission. In a way that is the
equivalent of the signature on each paper claim.
Q.
Must dental providers have a different Medicaid number to provide
services through the adult denture program?
A.
No. The same provider number may be used to file claims for EPSDT and
adult denture services.
Q.
Is electronic filing mandatory?
A. No,
electronic filing is not mandatory. However, providers who choose to file their
claims electronically usually have a shorter claim turnaround time
(approximately a seven-day claim turnaround). Also, the possibility for errors
related to handwritten paper claims is greatly reduced.
Q. What
forms are used to file adjustments?
A.
Unisys forms 209 and 210, supplied by Unisys at no charge, are used to
file adjustments. Adjustments can also be filed electronically.
Q.
When billing for a root canal, where is the tooth number indicated on the
claim form?
A. The tooth
number is shown in the first column under block 37 on the 1994 ADA form.
Q.
How long should copies of the old paper cards be kept?
A.
They should be kept until claims for services rendered during the month
of issue are paid.
Q.
On the claim form, should the last name be shown first, or should the
first name be shown first?
A.
The 1994 ADA form requires the first name first and the last name last.
Physician Questions
Q: Does the swipe
card device automatically verify eligibility?
A: The swipe card device will
verify eligibility as well as additional information regarding Community Care,
service limits, and third party liability.
Q:
Where is the 13-digit Medicaid number on the plastic ID card?
A: The plastic ID card does
not show the recipient's Medicaid ID number. The card control number (CCN) on
the card is used with either REVS or MEVS to obtain the 13-digit Medicaid ID
number.
Q:
Does the REVS system give TPL information?
A:
REVS gives the name of the recipient's other insurance and the TPL
carrier code.
Q:
What is the correct procedure for filing a claim for removing keloids
performed for non-cosmetic purposes?
A: The
provider should submit the claim plus documentation explaining why the procedure
is not cosmetic to Provider Relations Correspondence Unit. The diagnosis code
must be 701.4.Q: Should this be done the first time the claim is
filed?
A: Yes.
Q:
What can a provider do if the cost of providing a particular service
exceeds the Medicaid reimbursement?
A:
The provider should write to his program manager at BHSF, including
invoices or other documentation substantiating the cost of the service.
Q:
Where does Medicaid stand on pain management?
A: In general, Medicaid does not
cover pain management except on days of delivery and surgery for that day only.
Oral and patch narcotics are provided for pain management through the Pharmacy
Program if prescribed by a doctor.
Q:
Pain management is not covered in conjunction with office visits?
A: Only
the initial diagnostic visit can be billed. No succeeding services can be
billed.
Q: Does Medicaid pay for
post-operative pain management after surgery on the same day?
A: Yes, but not on
successive days.
Q: May
anesthesia claims be billed using bilateral modifiers?
A: No. If
multiple surgical procedures are performed within the same surgical session, the
claim should be billed with the total number of minutes for which anesthesia was
administered.
Q:
Our office runs into timely filing problems when recipients do not
identify themselves as having Medicaid until after one year from the date of
service. May we bill the recipient for these claims?
A: You may bill the recipient for such
services.
Q:
If the recipient is out of office visits, may we ask them for payment for
visits exceeding their allowed 12 and then request an extension for the extra
visits?
A: Yes. However, if the
provider obtains an extension of visits using the 158-A form, the fee paid by
the recipient must be returned in its entirety.
Q:
Is there a list of diagnoses for which we can request extension of
visits?
A:
There is no such list. Extensions are granted in cases of emergencies
(e.g., trauma and life-threatening conditions) and life- sustaining treatments
(e.g., chemotherapy for malignant diseases or radiation therapy).
Q:
Is it acceptable to bill the recipient for physician hospital visits when
the precertification is denied? What about if the hospital fails to request
precertification altogether?
A: The recipient may not be billed if the hospital precertification is denied as
not meeting criteria for medical necessity. If the hospital fails to request
precertification altogether, or if an admission or extension is denied because
the request for precertification was not submitted timely by the hospital, the
physician may submit his claims, the admit and discharge summaries, and a cover
letter requesting override of the precertification edit to the Provider
Relations Correspondence Unit.
Q: If
I render a service in the office and cannot charge for it, should I include it
on the HCFA-1500 with a $0.00 charge?
A: No--there is no need
to bill for the charge.
Q: How
should a physician employing a nurse practitioner and physician assistant bill
for their services?
A: Claims for
physician assistant services are billed with the employing physician's provider
number as the billing provider number. (Physician assistants are not assigned
provider numbers by Medicaid.) Nurse practitioner services are billed using the
nurse practitioner's number as the attending provider number (block 24K on the
HCFA-1500) and the employing physician's number as the billing provider number
(block 31 of the HCFA-1500). CNPs can also bill on their own by placing their
individual number in Item 24k and 30 and the name of their directing physician
in Item�s 17 and 17A.
Q:
Is precertification required for recipients who have Medicare and
Medicaid?
A:
Precertification is required if the recipient has Medicare Part B only or
if Part A benefits are exhausted.
Q:
How is the HMO copayment handled?
A:
If a provider accepts Medicaid for a recipient who is a member of an HMO,
the provider may not collect the copayment from the recipient.
Q: What
is the time limit between visits on outpatient consultations for recipients
under age 21?
A:
Three outpatient consultations within 180 days are payable without
review. It is possible that more consultations would be payable if circumstances
warrant.
Q:
How does the diagnosis code affect the consultation limits?
A: Consultations are not payable for
simple , non-complex diagnoses.
Q:
If a physician provides an outpatient consultation and determines that he
needs to perform surgery on the patient, can he still bill for the consult?
A:
No. The consultant became the treating physician at the moment he made
the decision to operate. Consequently, the fee for the consultation is included
in the reimbursement paid to the physician for the surgery.
Q:
If a patient goes to a general practitioner who refers him to an
orthopedist, can both providers see the patient on the same day?
A: If the recipient is under 21 years of
age, he may see more than one provider on the same day per concurrent care
guidelines. If the recipient is 21 years of age or older, Medicaid will only pay
one office visit per date of service. If the recipient is 21 or older the range
of codes used is different (99201-99215 by GP and 99241-99245 by orthopedist),
both will pay.
Q:
With regard to EMC billing, why shouldn't we file claims on Friday after
the Unisys office closes?
A:
Because of our processing schedule, files sent to Unisys at this time may
be overwritten by subsequent file transmissions.
Q:
Who do providers contact if wanting to perform electronic adjustments or
voids?
A:
The vendor of the provider's electronic billing software should be
contacted to ensure that the software is set up to allow for electronic
adjustments and voids.
Q: Who do vendors contact if they have questions about electronic
adjustments or voids?
A:
Vendors should contact the Unisys EMC department at (504) 237-3303.
Q: Can
any software vendors set up electronic crossovers?
A: No.
Only Medicare fiscal intermediaries can electronically cross Medicare claims to
Medicaid.
Q:
What should we do if several weeks pass and we don't receive our R.A.?
A: If you call Unisys Provider Relations within three weeks of the missing R.A.
date and indicate that you did not receive your R.A., one will be mailed to you
at no cost. If you do not notify Provider Relations until after three weeks, a
copy can be provided at a cost of $.25 per page.
Q:
Does ambulatory surgery require precertification?
A: No. There are some
procedures, however, that require prior authorization regardless of the place of
service. These procedures are listed in the 1998 Professional Services training
packet.
Q:
If a patient has several procedures performed on the same day at an
ambulatory surgical center, how should the facility fees be billed?
A:
Medicaid will reimburse the ambulatory surgical center a facility fee for
only one procedure per recipient per day. Only one procedure code should be
billed by the ambulatory surgical center.
Q:
If a patient requires several procedures at an ambulatory surgery center,
is it acceptable to bring the patient in on different dates of service?
A: This
would be acceptable if there were a medical reason why the patient could not
have all procedures performed at once and had to be brought in on different
days.
Q:
As a nurse practitioner, my claims are filed with the physician's
provider number as the billing number and my provider number as the attending
provider number. Will my claims be paid at 80% of the fee schedule or at 100% of
the fee schedule?
A:
The claims will be reimbursed at 80% of the fee schedule amount (except
for immunizations, which pay at 100% of the fee schedule amount).
Q:
How can claims be paid when the TPL code on the DHH file and the
recipient's correct insurance carrier are not the same?
A:
The provider should send the claim, any required attachments, any EOBs
from other insurance carriers, and a cover letter explaining the situation to
Unisys Provider Relations Correspondence Unit. The Correspondence Unit will
forward the documentation to DHH to have the recipient TPL file corrected and
the claim paid.
Q:
We have had physician visits to a recipient in a nursing home deny
because the recipient has exceeded their 12 visits per State fiscal year. Can we
request an extension for these visits?
A:
Yes. These would be requested using Form 158-A, which would be completed
and mailed to the Unisys Prior Authorization department. The request will be
reviewed and returned to you. If your request is approved, mail your claims, the
approved 158-A form, and a cover note to Unisys Provider Relations
Correspondence Unit.
Q: If
the physician sees a patient for an office visit within the global surgery
period (GSP), can he bill the office visit with a diagnosis different from that
of the procedure to get the claim paid?
A:
The physician should use whatever diagnosis is correct for the visit. If
this diagnosis is unrelated to the diagnosis of the procedure with the global
surgery period, then the office visit claim should not deny for the GSP edit.
Q:
May a circumcision claim be billed under the baby's name and mother's
Medicaid number?
A:
Billing a claim for circumcision in this manner will result in a denial
for a name and number mismatch.
Q: When
filing a claim for circumcision, is it acceptable to place the newborn's name in
blocks 1 and 4 of the HCFA-1500?
A:
Yes. The circumcision claim must have the newborn's name in block 1 and
the newborn's Medicaid ID number in block 3 in order to be paid.
Q:
How do we know which lines of the OFS Form 96 (sterilization consent) can
be corrected?
A:
Policy in both the Physician Services Medicaid provider manual and the
1998 Professional Services provider training packet details the policy for the
completion and correction of OFS Form 96.
Q:
When sending in a corrected claim form, should I send it to the Provider
Relations Correspondence Unit?
A:
Not necessarily. If the claim required a simple correction, and the
correction has been made, the claim should be submitted to the appropriate
claims post office box. Sending it to Correspondence will only delay processing.
Claims with attachments that require special handling, such as proof of timely
filing or a 158-A extension of visits approval should be sent to Correspondence
with a cover letter indicating what attachments are included.
Q: Will Medicaid pay for both the visit and the casting
materials when the physician puts a cast on a recipient?
A: The cost of the casting materials is included in
the reimbursement for the office visit, and no separate reimbursement will be
made.
Q:
How will we know when our check is deposited in our account, now that we
have direct deposit?
A:
The remittance advice will indicate that direct deposit has been made.
The actual time that funds are deposited in your account will depend in part on
your bank.
Q: Are procedure codes 00096 and 00097 payable to everyone?
A: Effective with dates of service 8/2/98,
these codes are payable with review to anesthesiologists,
non-anesthesiologist-directed CRNAs, and physicians.
Both DHH and Unisys have recently received
calls from physician providers who are requesting that Unisys Provider Relations
or DHH Program Operations staff determine or confirm that a procedure to be
performed is medically justified. The policy of DHH which has been required of
Unisys is that coverage of a procedure code can be verified and the amount of
payment for the code given. Consultations regarding medical necessity or
justification are not available by phone. Should a treating physician have a
dilemma regarding the provision of a treatment course, a written request from
the provider to DHH, Program Operations Section, P.O. Box 91030, Baton Rouge, LA
70821, is necessary.
A part of the responsibility of any Medicaid
provider is to keep all provider information current and accurate. In recent
months, the Post Office has returned excessive amounts of provider mail,
including remittance advices, due to invalid or old addresses. In many cases,
when attempts are made to contact these providers, the telephone numbers on file
are also invalid or no longer in service.If your address and telephone number
are not current and accurate, please send a letter updating this information to:
Louisiana Department of Health and Hospitals
Medicaid Provider Enrollment Unit
P.O. Box 91030
Baton Rouge, LA 70821
The letter should contain your request that
your provider file be updated with current information and should include your
7-digit provider number, the old address which is on the Medicaid file and the
new address and current telephone number.
DHH is aware of a recent increase in the number of physician clinics
being acquired by hospitals as extensions of the hospitals' outpatient
departments. Because of different cost reimbursement systems, billing under
Medicaid and Medicare is handled differently. Unlike Medicare, whose policy of
acquiring physician practices is outlined in regional Carrier Letter No: 98-01
and Regional Intermediary Letter No. 98-01, which reduces the physician payment
to offset for the facility expense, Medicaid does not. Under Medicaid, the
physician payment is all-inclusive, meaning that all room, supply and incidental
costs are included within the physician�s payment.
The duplication occurs when the hospital bills
Medicaid on the UB-92 for things such as, but not limited to, revenue code 250
(pharmacy-vaccines provided through the VFC Program), 270 (supplies), and 760
(observation room), and the physician also bills Medicaid for his professional
services. These duplicate payments are subject to recoupment.
Should
you have any questions regarding this, please contact Provider
Relations at 1-800-473-2783.
This notice is to remind all EMC providers that at this time Louisiana
Medicaid does not accept printouts of MEDICAID electronic remittance advice
screens as proof of timely filing. The only proof of timely filing currently
acceptable by Medicaid is:(1) a copy of the hard copy Medicaid remittance advice
page indicating that the claim was processed within the specified time frame;
(2) a copy of a hard copy page from a Medicaid provider claims history
indicating that the claim was processed within the specified time frame; or (3)
correspondence from either the Medicaid Program or local Medicaid eligibility
staff concerning the claim and/or the eligibility of the recipient.
Documentation MUST reference the individual
recipient and date of service. Postal "certified" receipts and such
are not acceptable proof of timely filing.
Optimal Use of Angiotensin-Converting
Enzyme Inhibitors
Roy C. Parish, Pharm.D.Associate Professor of
Clinical Pharmacy PracticeCollege of Pharmacy, Northeast Louisiana
UniversityMonroe, LAGratis Faculty, Department of Pharmacology and
TherapeuticsSchool of Medicine, Louisiana State University LSU Medical Center
Shreveport
Issues...
- Beliefs and practices with
regard to the use of ACE inhibitors in heart failure and diabetic nephropathy.
- Recent findings in heart
failure and diabetes.
- Suggestions to maximize
the benefits of ACE inhibitors in these diseases.
The introduction of the angiotensin-converting enzyme (ACE) inhibitor
captopril in the early 1980s was the result of an exponential growth of
knowledge of the biochemical basis of blood pressure regulation that occurred
during the 1970s and made possible considerable improvement in the specificity
of drug therapy for this and other cardiovascular diseases. Initially
FDA-approved for the treatment of essential hypertension, the drug soon gained
approval for congestive heart failure. Enalapril and other ACE inhibitors were
later marketed and there is now a proliferation of these agents. Despite
manufacturer�s claims, there are few practical differences among this growing
class of drugs other than their duration of action. Except for the effect of
this difference on dosing and possibly on the development of functional renal
insufficiency, they will be discussed as a class.
The ACE inhibitors continue to be the subject
of basic and clinical research, and beneficial effects and potential uses of
this class are yet emerging. Although an impressive record of benefits in heart
failure and diabetic nephropathy is established, there is evidence that these
drugs are underutilized in these conditions. Beliefs and practices with regard
to the use of ACE inhibitors in these two conditions differ considerably; this
article will discuss recent findings in heart failure and diabetes and offer
suggestions to maximize the benefits of ACE inhibitors in these diseases.
Chronic Heart Failure (CHF)
The use of the term Achronic, in place of
Acongestive, underscores the growing awareness that the progression of CHF is
driven by maladaptive humoral compensatory changes that, in the acute
hypovolemic/ hypotensive situation would be beneficial, but in the chronic
setting give rise to myocardial remodeling, increased afterload and sympathetic
tone, and other alterations that are either directly cardiotoxic or
hemodynamically deleterious. The renin-angiotensin-aldosterone system has a
central role in these changes. Specifically, angiotensin-II (A-II) may function
as a myocardial growth factor that promotes remodeling. Blockade of the
conversion of A-I to A-II interrupts this element of the cycle, while lower
circulating concentrations of A-II result in decreased afterload and decreased
myocardial work. In the CONSENSUS study, enalapril was the first drug to be
shown unequivocally to decrease mortality in CHF. Later studies have extended
this finding to most of the ACE inhibitors.
Greater benefit from ACE inhibitors in CHF
appears to accrue when therapy is initiated early and when doses are advanced to
the upper part of the range recommended by the manufacturer. Clinical practice
guidelines recommend ACE inhibitors (if tolerated) in all patients with
significantly reduced leftventricular ejection fraction; consideration of these
drugs is recommended even in asymptomatic patients and those in New York Heart
Association (NYHA) functional class I (minimal disability). These guidelines
recommend titrating doses of captopril upward to 50 mg three times a day, or
enalapril to 10 mg twice a day. Titration of enalapril and isosorbide dinitrate
doses to a mean of 40 mg and 153 mg, respectively, was shown in one study to
result in a mean functional improvement of one NYHA class and a clinically
significant increase in ejection fraction in 72 of 99 patients (both
statistically significant).
Readmission due to heart failure has been
shown to be reduced by enalapril doses of 20 mg/day or more, but not by doses of
5 mg/day or less, or by digoxin or diuretics. Improved readmission-free survival
has also been shown to occur in inpatients discharged on ACE inhibitors at these
high doses compared with those discharged on lower doses.
"Triple therapy" withdigoxin,
diuretic, and ACE inhibitor was evaluated by meta-analysis, using data from the
RADIANCE and PROVED studies: worsening heart failure occurred in only 4.7% of
patients continuing ACE inhibitor, diuretic, and digoxin, compared with 19.0% of
patients who discontinued ACE inhibitors and 39.0% of patients discontinuing
both ACE inhibitors and digoxin.
A widespread tendency to underdose ACE
inhibitors in heart failure is well documented. For example, McDermott and
associates found that only 18% of patients discharged on captopril or enalapril
were receiving doses recommended by the clinical practice guidelines; Luzier�s
group reported that 67% of heart failure patients were receiving ACE inhibitors;
of those, 22% were dosed at recommended doses, while 41% received 5 mg/day of
enalapril or less. This tendency to underdosing is more pronounced in elderly
patients. In a small study of patient records combined with telephone
interviews, 21.4% of elderly patients were found to have been prescribed target
doses, whereas 68.8% of younger patients were receiving target doses. One study
of 819 nursing home patients, 119 of whom met strict criteria for heart failure,
found that only 41% of the patients with heart failure and no contraindications
to ACE inhibitors were receiving these drugs; most of these patients were
receiving doses of 5 mg/day or less of enalapril or 50 mg/day or less of
captopril. Other sources generally reflect these findings.
Studies with various designs have established
that both older and newer ACE inhibitors are cost-effective in chronic heart
failure; these pharmacoeconomic studies have been reviewed by Szucs.
The reluctance to introduce ACE inhibitors and
advance doses aggressively may be due, in part, to the drugs� reputation for
causing functional renal insufficiency. It is now widely accepted that ACE
inhibitors are generally not directly nephrotoxic; any agent that acutely lowers
blood pressure lowers renal perfusion and results in a transient increase in
serum creatinine, which usually returns to baseline after a few days if therapy
is continued. Sodium and water deficits are risk factors for renal insufficiency
following ACE inhibitor therapy, and care is advised in correcting water and
salt replacement before beginning therapy. This can often be accomplished by
simply withholding diuretics for one or two days. The use of long-acting ACE
inhibitors is a smaller risk factor, perhaps because with the short-acting
agents, drug effects are minimal in the latter hours of the dosing interval.
Although ACE inhibitors have a low index of renal toxicity, it would seem
prudent to withhold therapy with these agents for a few days before and after
nephrotoxic drugs or procedures such as radiopaque contrast media are given.
Diabetes Mellitus
DIABETIC NEPHROPATHY
In both insulin-dependent and
non-insulin-dependent diabetes mellitus (IDDM and NIDDM), damage to the
glomerulus progresses in parallel fashion with damage to other microvascular
structures. In the United States, diabetic nephropathy is the most frequent
cause of end-stage renal disease and replacement (dialysis or transplantation);
the point prevalence of end-stage renal disease in IDDM is approximately 40%. In
IDDM, nephropathy follows an unrelenting (if not treated) course from
hyperfunction through incipient, overt, and finally, end-stage disease; in NIDDM,
fewer patients progress to the end stage and the course is more highly variable
compared to that of patients with IDDM. Several factors are known to drive
disease progression, but A-II and glomerular hypertension are central to the
process, and it is inviting to make comparisons with the role of A-II in the
progression of chronic heart failure.
Control of blood pressure is widely believed
to be the most important and effective means to prevent or attenuate the
development of diabetic nephropathy, both in NIDDM and IDDM. The pharmacologic
effects of ACE inhibitors at the afferent and efferent glomerular arterioles, as
well as their interference with the putative growth hormone effects of A-II,
suggest that ACE inhibitors should be effective renal-protective agents in
diabetes. This is, indeed, clearly established. In NIDDM, these drugs have been
shown to slow the progression of proteinuria and the decline in renal function
in both hypertensive and normotensive patients. In IDDM, ACE inhibitors protect
against deterioration in renal function in patients with established nephropathy
as well as those with only microalbuminuria.
The American Diabetic Association currently
recommends ACE inhibitors in the following situations:
1: Diabetes, hypertension, and
microalbuminuria or overt nephropathy;
2: IDDM and microalbuminuria, even in patients with normal blood pressure;
3: NIDDM and hypertension or progressive albuminuria.
The cost-effectiveness of ACE inhibitors in
both NIDDM and IDDM are well shown. For example, Rodby and associates showed
lifetime direct and indirect cost savings of $55,630 per patient with NIDDM and
$116,940 per patient with IDDM.
Some studies suggest that combined therapy
with ACE inhibitors and non-dihydropyridine calcium channel blockers may produce
additional reductions in blood pressure and proteinuria, with a more favorable
adverse effect profile than that of either drug alone.(Bakris & Williams,
1995) This combination may be useful in patients with diabetes and refractory
hypertension, but further clinical and pharmacoeconomic studies are needed
before firm recommendations can be formulated.
DIABETIC AUTONOMIC NEUROPATHY
Symptoms of diabetic autonomic neuropathy
(impotence, postural hypotension, diarrhea) occur commonly in diabetes, and over
half the patients with symptoms have autonomic dysfunction demonstrable by
objective testing, such as reduced postural hemodynamic reflexes, loss of
resting heart rate variability (electrocardiographic R-R interval variability),
and sluggish pupillary reflexes; the five-year mortality rate in patients with
abnormal autonomic function on presentation is more than three times that in
patients with initially normal autonomic testing. Diabetes and autonomic
dysfunction are associated with increased risk of myocardial infarction and
sudden death.
In a retrospective analysis of the GISSI-3
study, Zuanetti and associates found that information on diabetic status was
available for 18,131 patients suffering acute myocardial infarction, of whom
2,790 had a history of diabetes. Mortality in the diabetic patients at 6 weeks
post-infarction was 8.7% in the group treated with the study drug (lisinopril)
versus 12.4% in the untreated group, an effect that was significantly larger
than that in non-diabetic patients. Treatment with lisinopril effected a saving
of 37 lives per 1,000 patients treated. Similar findings have been reported from
other studies.
Recommendations and Precautions
The improved survival and quality of life
resulting from therapy of heart failure with ACE inhibitors are now well
established, as is the cost-effectiveness of these drugs. There seems little
reason to deny patients these benefits if the drugs are tolerated. Most
practitioners believe ACE inhibitors to be first-line agents in heart failure,
and practice guidelines now recommend their use in all patients with left
ventricular systolic dysfunction as tolerated. The last decade has seen a shift
toward earlier use of ACE inhibitors in CHF and initiation of ACE-inhibitor
therapy in patients with milder disease as characterized by NYHA functional
class.
ACE inhibitors have been shown unequivocally
to have a renal protective effect in IDDM and NIDDM. Although practice
guidelines suggest their use in low-risk patients only after signs of renal
disease progression appear, it seems likely that these recommendations will be
expanded to include use of these protective agents before overt damage is
evident.
The adverse effects of ACE inhibitors have
been reviewed elsewhere. A few adverse effects bear emphasis because of their
seriousness. These drugs are contraindicated in pregnancy because of reports of
fetal oligohydramnios and anencephaly. The anti-aldosterone effects of ACE
inhibition and A-II reduction facilitate potassium retention, and careful
attention to serum potassium concentration is required when ACE inhibitors are
used concurrently with potassium-sparing diuretics or potassium supplementation.
Lastly, angioedema of the oral cavity is a potentially life-threatening
condition that may occur more commonly than is suggested from Phase III and
post-marketing studies, and appears to be more common in African-Americans and
in patients with collagen-vascular disease. This is a class effect, and patients
experiencing angioedema should probably never receive any ACE inhibitor
thereafter. Functional renal insufficiency is largely preventable by correction
of fluid and sodium deficits before ACE-inhibitor therapy begins and concerns
over its possibility should not deter judicious administration of these drugs.
Bibliography
ACC/AHA Task Force. (1995). Guidelines
for the evaluation and management of heart failure. Report of the American
College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Committee on Evaluation and
Management of Heart Failure). Journal of the American College of Cardiology, 26,
1376-1398.
American Diabetic Association. (1998).
Diabetic nephropathy (Position Statement). Diabetes Care, 21(Suppl 1), S50-S53.
Anderson, A., Christiansen, J., Andersen, J.,
Kreiner, S. & Deckert, T. (1983). Diabetic nephropathy in type 1 (insulin
dependent) diabetes: An epidemiological study. Diabetologia, 25, 496-501.
Bakris, G. & Williams, B. (1995).
Angiotensin converting enzyme inhibitors and calcium antagonists alone or
combined: Does the progression of diabetic
renal disease differ? Journal of Hypertension, 13, S95-S101.
CONSENSUS Trial Study Group. (1987). Effects
of enalapril on mortality in severe congestive heart failure. New England
Journal of Medicine, 316, 1429-1435.
Ewing, D., Campbell, I. & Clarke, B.
(1980). The natural history of diabetic autonomic neuropathy. Quarterly Journal
of Medicine, 49, 95-108.
Forman, D., Chander, R., Lapane, K., Shah, P.
& Stoukides, J. (1998). Evaluating the use of angiotensin-converting enzyme
inhibitors for older nursing home residents with chronic heart failure. Journal
of the American Geriatrics Society, 46, 1550-1554.
Gattis, W., Larsen, R., Hasselblad, V., Bart,
B. & O'Connor, C. (1998). Is optimal angiotensin-converting enzyme inhibitor
dosing neglected in elderly patients with heart failure? American Heart Journal,
136, 43-48.GISSI-3 Investigators. (1994).
GISSI-3: Effects of lisinopril and transdermal
glyceryl trinitrate singly and together on 6-week mortality and ventricular
function after acute myocardial infarction. Lancet, 343, 1115-1122.
Levine, T., Levine, A., Keteyian, S., Narihs,
B. & Lesch, M. (1997). Reverse remodeling in heart failure with
intensification of vasodilator therapy. Clinical Cardiology, 20, 697-702.
Lewis, E., Hunsicker, L., Bain, R. &
Rohde, R. (1993). The effect of angiotensin-converting-enzyme inhibition on
diabetic nephropathy. New England Journal of Medicine, 329, 1456-1462.
Linn, W. (1996). Angiotensin-converting enzyme
inhibitors in left ventricular dysfunction. Pharmacotherapy, 16 (2 Pt 2),
50S-58S.
Luzier, A., Forrest, A., Adelman, M., Hawari,
F., Schentag, J. & Izzo, L. (1998). Impact of angiotensin-converting enzyme
inhibitor underdosing on rehospitalization
rates in congestive heart failure. American Journal of Cardiology, 82, 465-469.
McDermott, M., Lee, P., Mehta, S. &
Gheorghiade, M. (1998). Patterns of angiotensin-converting enzyme inhibitor
prescriptions, educational interventions, and outcomes among hospitalized
patients with heart failure. Clinical Cardiology, 21, 261-268.
Mogensen, C. (1997). How to protect the kidney
in diabetic patients: With special reference to IDDM. Diabetes, 46(Suppl 2),
S104-S111.
M�lgaard, H., Christensen, P., S�rensen, K.,
Christensen, C. & Mogensen, C. (1994). Early recognition of autonomic
dysfunction in microalbu minuria:
Significance for cardiovascular mortality in diabetes mellitus? Diabetologia,
37, 788-796.
Packer, M., Gheorghiade, M., Young, J.,
Constantini, P., Adams, K., Cody, R., Smith, L., Voorhees, L.V., Gourley, L.
& Jolly, M. (1993). Withdrawal of
digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme
inhibitors. RADIANCE study. New England Journal of Medicine, 329, 1-7.
Parish, R. & Miller, L. (1992). Adverse
reactions to angiotensin converting enzyme inhibitors: An update. Drug Safety,
7, 5-18
Ravid, M., Savin, H., Jutrin, I., bental, T.,
Katz, B. & Lishner, M. (1993). Long-term stabilizing effect of angiotensin-converting
enzyme inhibition on plasma creatinine and on proteinuria in normotensive type
II diabetic patients. Annals of Internal Medicine, 118, 577-581.
Rodby, R., Firth, L. & Lewis, E. (1996).
An economic analysis of captopril in the treatment of diabetic nephropathy. The
Collaborative Study Group. Diabetes Care, 19, 1051-1061.
Szucs, T. (1997). Pharmacoeconomics of
angiotensin converting enzyme inhibitors in heart failure. American Journal of
Hypertension, 10(Pt 2), 272S-279S.
The Microalbuminuria Captopril Study Group.
(1996). Captopril reduces the risk of nephropathy in IDDM patients with
microalbuminuria.
Diabetologia, 39, 587-593.
Uretsky, B., Young, J., Shahidi, F., Yellen,
L., Harrison, M. & Jolly, M. (1993). Randomized study assessing the effect
of digoxin withdrawal in patients with
mild to moderate chronic congestive heart failure: Results of the PROVED trial.
Journal of the American College of Cardiology,
22, 955-962.
Yokoyama, H., Tomonaga, O., Hirayama, M.,
Ishii, A., Takeda, M., Babazono, T., Ujihara, U., Takahashi, C. & Omori, Y.
(1997). Predictors of the progression of diabetic nephropathy and the beneficial
effect of angiotensin-converting enzyme inhibitors in NIDDM patients.
Diabetologia, 40, 405-411.
Young, J., Gheorghiade, M., Uretsky, B.,
Patterson, J. & Adams, K. (1998). Superiority of "triple" drug
therapy in heart failure: Insights from the
PROVED and RADIANCE trials. Journal of the American College of
Cardiology, 32, 686-692.
Ziyadeh, F. (1993). Renal tubular basement
membrane and collagen type IV in diabetes mellitus. Kidney International, 43,
114-120.
Zuanetti, G., Latini, R., Maggioni, A.,
Franzosi, M., Santoro, L. & Tognoni, G. (1997). Effect of the ACE inhibitor
lisinopril on mortality in diabetic patients
with acute myocardial infarction: Data from the GISSI-3 study. Circulation, 96,
4239-4245.