Provider Update
Volume 20, Issue 4
August-October 2003
Expansion of CommunityCARE in Region 1
Effective December 1, 2003, Louisiana Medicaid will complete the statewide expansion of the CommunityCARE Program by including Jefferson, Plaquemines, and St. Bernard Parishes in the program. Medicaid recipients in these parishes will receive a letter and brochure in mid-October. The letter advises recipients that CommunityCARE is coming to their parish and that they will receive another letter in a couple of weeks asking them to choose a CommunityCARE doctor. The letter also provides an �800� phone number to call if they have questions. During the first week of November, a second letter will be mailed to recipients asking them to choose a doctor or clinic from a list of providers in their parish. This letter will again provide the recipients with the toll free number along with the list of CommunityCARE enrolled physicians. All enrollees will have ninety (90) days after linkage to a physician to request a change to a different provider.
After December 1, 2003, providers not enrolled in CommunityCARE in these parishes must obtain a referral from the CommunityCARE PCP in order for Medicaid to pay for most services provided to CommunityCARE enrollees. Primary Care Providers (Family Practice, General Practice, Internal Medicine, OB, Pediatrician), physician groups, Rural Health Clinics (RHCs), and Federally Qualified Health Centers (FQHCs) may enroll as CommunityCARE providers.
Medicaid providers who did not complete their enrollment by October 15, 2003, will not be included in the assignment rotation and will not be listed as an available choice on the list included in the recipient letters.
Enrollment packets for CommunityCARE may be obtained by contacting Unisys Provider Relations at (800) 473-2783. Questions may be directed to Provider Relations at that number, or to the CommunityCARE program office at (225)342-1304.
Policy Clarification on Emergency Requests for Unisys Prior Authorized Services
In the past, there has been some confusion within the provider community concerning the Louisiana Medicaid policy related to
emergency requests for Unisys prior authorized services. Below is the policy. Please contact the Unisys Prior Authorization Unit (PAU) at (800) 488-6334 with questions concerning this policy.
Emergency Requests for Unisys Prior Authorization
A request is considered an emergency if a delay in obtaining the medical service equipment, appliance, or supplies would be life-threatening to the recipient. In addition, emergency requests may be taken for services needed for a hospital discharge. Emergency requests can be made for any of the Medicaid services that require prior authorization through the
Unisys PA Unit.
The providers of emergency items must contact the Unisys PAU immediately by telephone and provide the following information:
� The beneficiary�s name, age, and 13-digit Medicaid identification number;
� The treating physicians�s name;
� The diagnosis;
� The time period of need for the item or service;
� A complete description of the item(s) or service(s) requested;
� The reason that the request is a medical emergency; and
� The cost of the item (only applies to Durable Medical Equipment).
The decision will be made by the Unisys PAU within two working days of the date the completed request is received. The Unisys PAU will contact the provider by telephone and will follow up with written confirmation of the decision.
Emergency Requests for Unisys Prior Authorized Services that are not truly emergencies will be denied, and the provider must resubmit as a routine request.
For non-emergency requests and for requests not made through the Unisys Prior Authorization Unit, please continue to use your current prior authorization process.
Increase in Fees
The Louisiana Medicaid Program is pleased to announce an increase in fees retroactive to date of service January 1, 2003 for the following services:
� Surgical Services. Fees were increased to 100% of the Medicare Region 99 allowables for Year 2002 for the primary servicing physician, only, for children from birth through age 10 (codes in the range of 10021 - 69990 except for non-payable codes restricted to crossovers, codes whose fees were already at 100% of the Medicare Region 99 allowables for Year 2002 and codes for newborn circumcisions [codes 54150 and 54160]).
� Musculoskeletal System Services. Fees were increased to 80% of the Medicare Region 99 allowables for Year 2002 for recipients 11 years of age and older (codes in the range of 10000 - 29999) except for non-payable codes and codes whose fees were already at 80% of the Medicare Region 99 allowables for Year 2002.
� Selected Specialty Services. Fees were increased to 84% of the Medicare Region 99 allowables for Year 2002 for codes 36460, 59000, and 59015 for recipients 11 years of age or older. Fees for codes 76825, 76828, 93531, 93533, 99231, and 99232 were increased to 84% of the Medicare Region 99 allowables for Year 2002 for all recipients regardless of age.
Adjustments appeared on the remittance advices of August 26 and September 3, 2003.
If you wish to submit a second adjustment to a claim because your billed charge was less than the increased rate, the ICN of the first adjustment must be submitted on the second adjustment form instead of the ICN of the original payment.
CPT Code 90782
The fee for CPT code 90782 was increased to $22.00 effective with date of service July 1, 2003, retroactively to date of service January 1, 2003. Claims were recycled. Payment adjustments appear on this RA. If it is necessary for providers to submit an adjustment because their billed charges were less than the increased rate, the new adjustment ICN on this RA should be used.
Fee for Intrauterine Copper Contraceptive
The fee for the intrauterine copper contraceptive is being
unbundled with an effective date of service 10/1/03. Currently, a portion of the fee is for inserting the device, a portion is for handling and shipping and the remainder is for the device.
Effective with date of service 10/1/03, code J7300 shall be billed for the device ($344.00) and the most appropriate CPT code shall be billed for the insertion. No fee will be paid for handling and shipping.
CPT Code 20936
CPT code 20936 (Spinal Bone Auto graft) will be made payable effective with date of service August 1, 2003 at a fee of $174.78. The assistant surgeon�s fee will be $43.70.
Procedure Code 77418
The units for procedure code 77418 (Radiation Tx Delivery, IMRT) were increased from 1 to 2 effective with date of service August 1, 2003.
Elimination of �Y� Indicator
With HIPAA implementation and the mandated elimination of local codes, effective October 16, 2003, the �Y� indicators entered in field 19 of the CMS (HCFA) 1500 claim form and record type E of the Unisys EMC proprietary specs will no longer be accepted to indicate professional services provided at a state operated (charity) hospital. Additionally, it has become apparent that some providers are using this indicator for services that are not provided at charity hospitals. Inappropriate use of this indicator is unacceptable, will be monitored, and can result in payment recoupments. If providers are using this indicator and are not providing services at a charity hospital, they should discontinue this practice immediately.
Billing Encounter Codes on the New KM-3 Form
Please remember when billing the encounter code, T1015, for KIDMED screenings on the new KM-3 form and for immunizations billed on the CMS 1500 form, modifier EP is required. All claims billed using T1015 plus the EP modifier must include supporting detail procedures. Please refer to the 2003 RHC/FQHC Training Packet for complete billing instructions. This packet can be found on the website, www.lamedicaid.com. If you have additional questions or do not have web access and need the 2003 training packet, please contact Provider Relations at (800) 473-2783 or (225) 924-5040.
Policy Revision for Acrylic Interim Partial Dentures
Medicaid may provide an acrylic interim partial denture (D5820/D5821) in the mixed dentition or beyond the mixed dentition stages in the following cases: 1) Missing one or two maxillary permanent anterior tooth/teeth; or 2) Missing two mandibular permanent anterior teeth; or 3) Missing three or more permanent teeth in the same arch (of which at least one must be anterior). The Dental Services Manual will be revised to reflect this information. This revision will be sent to all dental providers. Should you have any questions, you may contact the LSU Dental Medicaid Unit by calling (504) 619-8589.
Procedure Codes E1399 and Z1399
We would like to remind you that procedure codes E1399 and Z1399 should only be used when there is not another applicable code available. It may never be used in place of a procedure code that is loaded in non-pay status or to obtain a higher rate than approved for the procedure. We have instructed Unisys Prior Authorization Unit (PAU) to deny any requests for authorization of equipment and supplies with procedure codes E1399 and Z1399 when there is an assigned code for the equipment or supply item.
Programming the Vagus Nerve Stimulator (VNS)
Effective with date of service July 29, 2003 and after, procedure code C95974, programming of the Vagus Nerve Stimulator (VNS) will not require authorization for the first three events. After the third service you must submit hardcopy claims to the Provider Relations Unit with documentation attached supporting the medical necessity for the procedure. Payment will not be made on claims billed electronically or claims lacking the required documentation. This documentation must include the
following:
1. Patient response; the status of seizure control, i.e., frequency and severity of seizures;
2. Current VNS program settings, i.e., current output, pulse width, duty cycle, and signal frequency;
3. Frequency of medications and dose schedule;
4. Documentation of adverse effects such as swallowing problems, hoarseness, coughing, and
neck tightness;
5. Magnet setting; and
6. Reason for reprogramming.
DME Procedure Codes
The Bureau of Health Services Financing has loaded the following codes to be used for dates of services on or after April 1, 2003. Codes being replaced will not be accepted after October 1, 2003. Procedure codes with a Price Action Code (PAC) of 880 will be manually priced. Procedure codes with a PAC of 850 will be paid at an established fee, priced at 80 percent of the Medicare rate. Procedure codes with a PAC of 820 are only covered for Qualified Medicare Beneficiaries (QMB) when a Medicare payment is made and the claim is crossed over to Medicaid for payment of deductibles and co-insurance. Medicaid only pays co-insurance up to the amount of the Medicaid allowable fee.
Codes appear on Page 6.
|
CODE
|
DESCRIPTION
|
PAC
|
REASON
|
|
A4405
|
NONPECTIN
BASED OSTOMY PASTE
|
880
|
REPLACED
K0561
|
|
A4406
|
PECTIN
BASED OSTOMY PASTE
|
880
|
REPLACED
K0562
|
|
A4407
|
EXT
WEAR OST SKN BARR <=4SQ"
|
880
|
REPLACED
K0563
|
|
A4408
|
EXT
WEAR OST SKN BARR >4SQ"
|
880
|
REPLACED
K0564
|
|
A4409
|
OST
SKN BARR W FLNG <=4 SQ"
|
880
|
REPLACED
K0565
|
|
A4410
|
OST
SKN BARR W FLNG >4SQ"
|
880
|
NEW
|
|
A4413
|
2 PC
DRAINABLE OST POUCH
|
880
|
REPLACED
K0569
|
|
A4414
|
OSTOMY
SKNBARR W FLNG <=4SQ"
|
880
|
REPLACED
K0570
|
|
A4415
|
OSTOMY
SKN BARR W FLNG >4SQ"
|
880
|
REPLACED
K0571
|
|
A4422
|
OST
POUCH ABSORBENT MATERIAL
|
880
|
NEW
|
|
A4452
|
WATERPROOF
TAPE
|
880
|
NEW
|
|
A4558
|
CONDUCTIVE
PASTE OR GEL
|
820
|
QMB ONLY
|
|
A4606
|
OXYG
PROBE F USE W OXIMETER DEVICE, REP
|
820
|
QMB ONLY
|
|
A4609
|
TRACH
SUCTION CATH CLSED SYS
|
820
|
QMB ONLY
|
|
A4632
|
INFUSION
PUMP REPLACEMENT BATTERY
|
820
|
QMB ONLY
|
|
A4633
|
UVL
REPLACEMENT BULB
|
820
|
QMB ONLY
|
|
A4634
|
REPLACEMENT
BULB FOR THERAPEUTIC LIGHT
|
820
|
QMB ONLY
|
|
A4639
|
INFRARED
HEAT SYSTEM REPLACEMENT BULB
|
820
|
QMB ONLY
|
|
A4653
|
PERITONEAL
DIAL CATH ANCHOR DEV BELT, EACH
|
820
|
QMB ONLY
|
|
A4930
|
GLOVES,
STERILE, PER PAIR
|
820
|
QMB ONLY
|
|
A4931
|
ORAL
THERMOMETER, REUSABLE, ANY TYPE, EACH
|
820
|
QMB ONLY
|
|
A6011
|
COLLAGEN
GEL/PASTE WOUND FILLER
|
820
|
QMB ONLY
|
|
A6410
|
STERILE
EYE PAD
|
820
|
QMB ONLY
|
|
A6411
|
NON-STERILE
EYE PAD
|
820
|
QMB ONLY
|
|
A6421
|
PAD
BANDAGE >=3 <5IN W /ROLL
|
820
|
QMB ONLY
|
|
A6422
|
CONF
BANDAGE NS >=3<5"W/ROLL
|
820
|
QMB ONLY
|
|
A6424
|
CONF
BANDAGE NS >=5"W /ROLL
|
820
|
QMB ONLY
|
|
A6426
|
CONF
BANDAGE S >=3<5" W/ROLL
|
820
|
QMB ONLY
|
|
A6428
|
CONF
BANDAGE S >=5" W /ROLL
|
820
|
QMB ONLY
|
|
A6430
|
LT
COMPRES BDG >=3<5"W /ROLL
|
880
|
REPLACED
A4460
|
|
A6432
|
LT
COMPRES BDG >=5"W /ROLL
|
880
|
REPLACED
A4460
|
|
A6434
|
MO
COMPRES BDG >=3<5"W /ROLL
|
880
|
REPLACED
A4460
|
|
A6436
|
HI
COMPRES BDG >=3<5"W /ROLL
|
880
|
REPLACED
A4460
|
|
A6438
|
SELF-ADHER
BDG >=3<5�W /ROLL
|
820
|
QMB ONLY
|
|
A6440
|
ZINC
PASTE BDG >=3<5"W /ROLL
|
820
|
QMB ONLY
|
|
A6501
|
COMPRES
BURNGARMENT BODYSUIT
|
820
|
QMB ONLY
|
|
A6502
|
COMPRES
BURNGARMENT CHINSTRAP
|
820
|
QMB ONLY
|
|
A6503
|
COMPRES
BURNGARMENT FACEHOOD
|
820
|
QMB ONLY
|
|
A6504
|
CMPRSBURNGARMENT
GLOVE-WRIST
|
820
|
QMB ONLY
|
|
A6505
|
CMPRSBURNGARMENT
GLOVE-ELBOW
|
820
|
QMB ONLY
|
|
A6506
|
CMPRSBURNGRMNT
GLOVE-AXILIA
|
820
|
QMB ONLY
|
|
A6507
|
CMPRS
BURNGARMENT FOOT-KNEE
|
820
|
QMB ONLY
|
|
A6508
|
CMPRS
BURNGARMENT FOOT-THIGH
|
820
|
QMB ONLY
|
|
A6509
|
COMPRES
BURN GARMENT JACKET
|
820
|
QMB ONLY
|
|
A6510
|
COMPRES
BURN GARMENT LEOTARD
|
820
|
QMB ONLY
|
|
A6511
|
COMPRES
BURN GARMENT PANTY
|
820
|
QMB ONLY
|
|
A6512
|
COMPRESSION
BURN GARM, NOT OTHERWISE CL
|
820
|
QMB ONLY
|
|
A7025
|
REPLACE
CHEST COMPRESS VEST
|
820
|
QMB ONLY
|
|
A7026
|
REPLACE
CHST CMPRSS SYS HOSE
|
820
|
QMB ONLY
|
|
A7030
|
CPAP
FULL FACE MASK
|
820
|
QMB ONLY
|
|
A7031
|
REPLACEMENT
FACEMASK INTERFA
|
820
|
QMB ONLY
|
|
A7032
|
REPLACEMENT
NASAL CUSHION
|
850
|
REPLACED
K0184
|
|
A7033
|
REPLACEMENT
NASAL PILLOWS
|
850
|
REPLACED
K0184
|
|
A7034
|
NASAL
APPLICATION DEVICE
|
850
|
REPLACED
K0183
|
|
A7035
|
POS
AIRWAY PRESS HEADGEAR
|
850
|
REPLACED
K0185
|
|
A7036
|
POS
AIRWAY PRESS CHINSTRAP
|
850
|
REPLACED
K0186
|
|
A7037
|
POS
AIRWAY PRESSURE TUBING
|
850
|
REPLACED
K0187, E1352
|
|
A7038
|
POS
AIRWAY PRESSURE FILTER
|
850
|
REPLACED
K0188
|
|
A7039
|
CPAP
FILTER
|
850
|
REPLACED
K0189
|
|
A7042
|
IMPLANTED
PLEURAL CATHETER
|
820
|
QMB ONLY
|
|
A7043
|
VACUUM
DRAINAGEBOTTLE/TUBING
|
820
|
QMB
ONLY
|
|
A7044
|
PAP
ORAL INTERFACE
|
820
|
QMB ONLY
|
|
E0117
|
UNDERARM
SPRINGASSIST CRUTCH
|
820
|
QMB ONLY
|
|
E0203
|
THERAPEUTIC
LIGHTBOX, MINIMUM 10,000 LUM
|
820
|
QMB ONLY
|
|
E0445
|
OXIMETER
DEVICE FOR MEASURING BLOOD OXY
|
820
|
QMB ONLY
|
|
E0454
|
PRESSURE
VENTILATOR
|
820
|
QMB ONLY
|
|
E0483
|
CHEST
COMPRESSION GEN SYSTEM
|
820
|
QMB ONLY
|
|
E0484
|
NON-ELEC
OSCILIATORY PEP DVC
|
820
|
QMB ONLY
|
|
E0618
|
APNEA
MONITOR
|
880
|
REPLACED
E0608
|
|
E0619
|
APNEA
MONITOR W RECORDER
|
820
|
QMB ONLY
|
|
E0636
|
PT
SUPPORT & POSITIONING SYS
|
820
|
QMB ONLY
|
|
E0691
|
UVL
PNL 2 SQ FT OR LESS
|
820
|
QMB ONLY
|
|
E0692
|
UVL
SYS PANEL 4 FT
|
820
|
QMB ONLY
|
|
E0693
|
UVL
SYS PANEL 6 FT
|
820
|
QMB ONLY
|
|
E0694
|
UVL
MD CABINET SYS 6 FT
|
820
|
QMB ONLY
|
|
E0701
|
HELMET
W FACE GUARD PREFAB
|
820
|
QMB ONLY
|
|
E1011
|
PED
WC MODIFY WIDTH ADJUSTM
|
820
|
QMB ONLY
|
|
E1012
|
INT
SEAT SYS PIANAR PED WC
|
820
|
QMB ONLY
|
|
E1013
|
INT
SEAT SYS CONTOUR PED WC
|
820
|
QMB ONLY
|
|
E1014
|
RECLINING
BACK ADD PED WC
|
820
|
QMB ONLY
|
|
E1015
|
SHOCK
ABSORBER FOR MAN WC
|
820
|
QMB ONLY
|
|
E1016
|
SHOCK
ABSORBER FOR POWER WC
|
820
|
QMB ONLY
|
|
E1017
|
HD
SHOCK ABSRBR FOR HD MAN WC
|
820
|
QMB ONLY
|
|
E1018
|
HD
SHOCK ABSRBER FOR HD POW WC
|
820
|
QMB ONLY
|
|
E1020
|
RESIDUAL
LIMB SUPPORT SYSTEM
|
820
|
QMB ONLY
|
|
E1025
|
PEDWC
LAT/THOR SUP NOCONTOUR
|
820
|
QMB ONLY
|
|
E1026
|
PEDWC
CONTOURED LAT/THOR SUP
|
820
|
QMB ONLY
|
|
E1027
|
PED
WC LAT/ANT SUPPORT
|
820
|
QMB ONLY
|
|
E1037
|
TRANSPORT
CHAIR
|
820
|
QMB ONLY
|
|
E1038
|
TRANSPORT
CHAIR
|
820
|
QMB ONLY
|
|
E1161
|
MANUAL
ADULT WC W TILT-IN-SPACE
|
820
|
QMB ONLY
|
|
E1231
|
RIGID
PED WC TILT-IN-SPACE
|
820
|
QMB ONLY
|
|
E1232
|
FOLDING
PED WC TILT-IN-SPACE
|
820
|
QMB ONLY
|
|
E1233
|
RIG
PED WC TLTNSPC W/O SEAT
|
820
|
QMB ONLY
|
|
E1234
|
FID
PED WC TLTNSPC W/O SEAT
|
820
|
QMB ONLY
|
|
E1235
|
RIGID
PED WC ADJUSTABLE
|
820
|
QMB ONLY
|
|
E1236
|
FOLDING
PED WC ADJUSTABLE
|
820
|
QMB ONLY
|
|
E1237
|
RGD
PED WC ADJSTABI W/O SEAT
|
820
|
QMB ONLY
|
|
E1238
|
FLD
PED WC ADJSTABL W/O SEAT
|
820
|
QMB ONLY
|
|
E1700
|
JAW
MOTION REHAB SYSTEM
|
820
|
QMB ONLY
|
|
E1701
|
REPL
CUSHIONS FOR JAW MOTION
|
820
|
QMB ONLY
|
|
E1702
|
REPL
MEASR SCALES JAW MOTION
|
820
|
QMB ONLY
|
|
E1802
|
ADJST
FOREARM PRO/SUP DEVICE
|
820
|
QMB ONLY
|
|
K0550
|
HOSPITAL
BEDXTRA HVY DTY X WIDE
|
820
|
QMB ONLY
|
|
K0576
|
OSTOMY
POUCH COMFORT PANEI
|
820
|
QMB ONLY
|
|
K0577
|
OSTOMY
POUCH ODOR BARRIER
|
820
|
QMB ONLY
|
|
K0578
|
URINARY
POUCH FAUCET/DRAIN
|
820
|
QMB ONLY
|
|
K0580
|
OST
POUCH LOCKING FLANGE
|
820
|
QMB ONLY
|
|
K0581
|
OST
PCH CLSD W BARRIER/FILTER
|
820
|
QMB ONLY
|
|
K0582
|
OST
PCH W BAR/BITINCONV/FILTER
|
820
|
QMB ONLY
|
|
K0583
|
OST
PCH CLSD W/O BAR W FILTER
|
820
|
QMB ONLY
|
|
K0584
|
OST
PCH FOR BAR W FLANGE/FIT
|
820
|
QMB ONLY
|
|
K0585
|
OST
PCH CSLD FOR BAR W LK FI
|
820
|
QMB ONLY
|
|
K0586
|
OST
PCH FOR BAR W LK FI/FILTER
|
820
|
QMB ONLY
|
|
K0587
|
OST
PCH DRAIN W BAR & FILTER
|
820
|
QMB ONLY
|
|
K0588
|
OST
PCH DRAIN FOR BARRIER FI
|
820
|
QMB ONLY
|
|
K0589
|
OST
PCH DRAIN 2 PIECE SYSTEM
|
820
|
QMB ONLY
|
|
K0590
|
OST
PCH DRAIN/BARR IK FLNG/F
|
820
|
QMB ONLY
|
|
K0591
|
URINE
OST POUCH W FAUCET/TAP
|
820
|
QMB ONLY
|
|
K0592
|
URINE
OST POUCH W BITINCONV
|
820
|
QMB ONLY
|
|
K0593
|
OST
URINE PCH W B/BITIN CONV
|
820
|
QMB ONLY
|
|
K0594
|
OST
PCH URINE W BARRIER/TAPV
|
820
|
QMB ONLY
|
|
K0595
|
OS
PCH URINE W BAR/FANGE/TAP
|
820
|
QMB ONLY
|
|
K0596
|
URINE
OST PCH BAR W LOCK FIN
|
820
|
QMB ONLY
|
|
K0597
|
OST
PCH URINE W LOCK FLNG/FT
|
820
|
QMB ONLY
|
|
K0600
|
FUNCTIONAI
NEUROMUSCULARSTIM
|
820
|
QMB ONLY
|
|
L0210
|
THORACIC,
RIB BELT, CUSTOM FITTED
|
850
|
REPLACED
A4572
|
|
L0450
|
TLSO
FLEX PREFAB THORACIC
|
820
|
QMB ONLY
|
|
L0452
|
TLSO
FLEX CUSTOM FAB THORACI
|
820
|
QMB ONLY
|
|
L0454
|
TLSO
FLEX PREFAB SACROCOC-T9
|
820
|
QMB ONLY
|
|
L0456
|
TLSO
FLEX PREFAB
|
820
|
QMB ONLY
|
|
L0458
|
TLSO
2MOD SYMPHIS-XIPHO PRE
|
820
|
QMB ONLY
|
|
L0460
|
TLSO2MOD
SYMPHYSIS-STERN PRE
|
820
|
QMB ONLY
|
|
L0462
|
TLSO
3MOD SACRO-SCAP PRE
|
820
|
QMB ONLY
|
|
L0464
|
TLSO
4MOD SACRO-SCAP PRE
|
820
|
QMB ONLY
|
|
L0466
|
TLSO
RIGID FRAME PRE SOFT AP
|
820
|
QMB ONLY
|
|
L0468
|
TLSO
RIGID FRAME PREFAB PELV
|
820
|
QMB ONLY
|
|
L0470
|
TLSO
RIGID FRAME PRE SUBCIAV
|
820
|
QMB ONLY
|
|
L0472
|
TLSO
RIGID FRAME HYPEREX PRE
|
820
|
QMB ONLY
|
|
L0476
|
TLSO
FLEXION COMPRES JAC PRE
|
820
|
QMB ONLY
|
|
L0478
|
TLSO
FLEXION COMPRES JAC CUS
|
820
|
QMB ONLY
|
|
L0480
|
TLSO
RIGID PLASTIC CUSTOM FA
|
820
|
QMB ONLY
|
|
L0482
|
TLSO
RIGID ILNED CUSTOM FAB
|
820
|
QMB ONLY
|
|
L0484
|
TLSO
RIGID PLASTIC CUST FAB
|
820
|
QMB ONLY
|
|
L0486
|
TLSO
RIGIDILNED CUST FAB TWO
|
820
|
QMB ONLY
|
|
L0488
|
TLSO
RIGID ILNED PRE ONE PIE
|
820
|
QMB ONLY
|
|
L0490
|
TLSO
RIGID PLASTIC PRE ONE
|
820
|
QMB ONLY
|
|
L0500
|
LUMBAR-SACRAL-ORTHOSES (LSO), FLEXIB
|
850
|
REPLACED
L0900, L0920, L0940
|
|
L0510
|
LSO, FLEXIBLE (LUMBO-SACRAL SURGICAL
|
850
|
REPLACED
L0910, L0930, L0950
|
|
L1652
|
HO
BL THIGHCUFFS W SPRDR BAR
|
820
|
QMB
ONLY
|
|
L1836
|
RIGID
KO WITHOUT JOINTS
|
820
|
QMB ONLY
|
|
L1901
|
PREFAB
ANKIE ORTHOSIS
|
820
|
QMB ONLY
|
|
L3651
|
PREFAB
SHOUIDER ORTHOSIS
|
820
|
QMB ONLY
|
|
L3652
|
PREFAB
DOUBIE SHOUIDER ORTHOSIS
|
820
|
QMB ONLY
|
|
L3701
|
PREFAB
ELBOW ORTHOSIS
|
820
|
QMB ONLY
|
|
L3762
|
RIGID
EO WO JOINTS
|
820
|
QMB ONLY
|
|
L3909
|
PREFAB
WRIST ORTHOSIS
|
820
|
QMB ONLY
|
|
L3911
|
PREFAB
HAND FLNGER ORTHSIS
|
820
|
QMB ONLY
|
|
L4386
|
NON-PNEUMATIC
WALKING SPLINT
|
820
|
QMB ONLY
|
|
L5781
|
LOWER
LIMB PROS VACUUM PUMP
|
820
|
QMB ONLY
|
|
L5782
|
HD
LOWER LIMB PROS VACUUM PUMP
|
820
|
QMB ONLY
|
|
L5848
|
KNEE-SHIN
SYS HYDRAUI STANCE
|
820
|
QMB ONLY
|
|
L5995
|
LOWER
EXT PROS HEAVYDUTY FEA
|
820
|
QMB ONLY
|
|
L6025
|
PART
HAND DISART MYOELECTRIC
|
820
|
QMB ONLY
|
|
L6638
|
ELEC
LOCK ON MANUAL PW ELBOW
|
820
|
QMB ONLY
|
|
L6646
|
MULTIPO
LOCKING SHOULDER JNT
|
820
|
QMB ONLY
|
|
L6647
|
SHOULDER
LOCK ACTUATOR
|
820
|
QMB ONLY
|
|
L6648
|
EXT
PWRD SHIDER LOCK/UNLOCK
|
820
|
QMB ONLY
|
|
L6812
|
AQMB
ONLYUEOUS SHUNT PROSTHESIS
|
820
|
QMB ONLY
|
|
L7367
|
REPLACEMNT
LITHIUM IONBATTER
|
820
|
QMB ONLY
|
|
L7368
|
LITHIUM
ION BATTERY CHARGER
|
820
|
QMB ONLY
|
|
L8600
|
IMPLANT
BREAST SILICONE/EQ
|
820
|
QMB ONLY
|
|
L8610
|
OCULAR
IMPLANT
|
820
|
QMB ONLY
|
|
L8612
|
AQUEOUS
SHUNT PROSTHESIS
|
820
|
QMB ONLY
|
|
L8613
|
OSSICULAR
IMPLANT
|
820
|
QMB ONLY
|
|
L8630
|
METACARPOPHALANGEAL
IMPLANT
|
820
|
QMB ONLY
|
|
L8641
|
METATARSAL
JOINT IMPLANT
|
820
|
QMB ONLY
|
|
L8642
|
HALLUX
IMPLANT
|
820
|
QMB ONLY
|
|
L8658
|
INTERPHALANGEAL
JOINT IMPLNT
|
820
|
QMB ONLY
|
|
L8670
|
VASCULAR
GRAFT
|
820
|
QMB ONLY
|
|
V2531
|
CONTACT
LENS GAS PERMEABLE
|
820
|
QMB ONLY
|
|
V2627
|
SCLERAL
COVER SHELL
|
820
|
QMB ONLY
|
|
V2780
|
OVERSIZE
LENS/ES
|
820
|
QMB ONLY
|
Billing Clarification
Home Health agencies are not to bill Medicaid for rehabilitation in nursing homes. As per the Code of Federal Regulations, section 440.70, � A recipient�s place of residence, for home health services, does not include a hospital, nursing facility, or intermediate care facility for the mentally retarded.�
Billing Codes
All providers are responsible for filing the correct billing codes on a claim. If a LPN provided services, the provider must submit the appropriate LPN service code for payment. Likewise, if an RN delivers service, the claim must identify the codes associated with the appropriate service. Home health providers should perform a self-audit to identify claims paid incorrectly and report any overpayments to Program Integrity.
All providers are responsible in assuring that your professional employees (ex., RNs, LPNs, Aides, etc.) are only practicing within the limitation established by their licensing boards.
Locating Personal Care Service
As a result of a settlement in the Chisholm v. Hood lawsuit, DHH has agreed to do the following:
In the event that an individual class member, or case manager acting on behalf of the class member, is unable to locate a willing Personal Care Service (PCS) or extended home health provider who is able to promptly provide the necessary service to the recipient, DHH agrees to take all reasonable steps necessary to locate a provider to submit a request for prior approval for the service requested within10 working days of receiving notice of the inability to find a provider. If the service has already been prior approved, DHH agrees to take all reasonable steps necessary to find a provider and arrange for services within10 working days of receiving notice that a provider cannot be located.
IF you are faced with this situation for either PCS or extended home health services you can:
� Call the ACS Referral Assistance Hotline at (1-877-455-9955) and tell the operator that you cannot find a willing provider for these types of services.
� Tell the Referral Assistance operator what service you are seeking and where you are located.
� The operator will give you a list of available providers in your area. The operator will give you the name(s) and phone number(s) of the available provider(s), along with any other important information about the provider(s).
� If, after calling all providers, you are unable to locate one willing to provide the requested service(s), call the ACS Referral Assistance Hotline at (1-877-455-9955) again.
� The operator will give you additional names and telephone numbers of providers in surrounding areas. You need to call these providers, tell them the service you are seeking, and where you are located to see if they are willing to provide the service.
In the event that ACS is unable to find a provider, ACS will report the situation to DHH. DHH has 10 working days to take reasonable steps necessary to locate a provider to submit a prior approval request or arrange for services.
NOTE: If you reach an answering machine when calling the ACS Referral Assistance Hotline, leave your name, telephone number with the area code, and the name of the recipient so that your call can be returned by a Referral Assistance operator.
If you are dissatisfied or are having difficulty with ACS, call your case manager. Your case manager will contact the appropriate PCS or extended home health services Medicaid staff.
Clarification of HIPAA Regulations and Requests for Recipient Medical Information
We have recently received several inquiries concerning HIPAA regulations regarding the release of Medicaid recipients� medical information to the Department of Health and Hospitals (DHH) and its fiscal intermediary, Unisys Corporation.
Federal and State law require that DHH, as the state Medicaid agency, maintain the integrity of the Medicaid Assistance Program, both programmatically and fiscally:
42 U.S.C. �� 1396a(a)(37)(B), 1396a(a)(42), and 1396a(a)(61); LSA-R.S. 36:254; 46437.1 et seq. This function is performed through the Department of Health and Hospitals (DHH), Division of Program Integrity, SUR, and its fiscal intermediary, Unisys Corporation.
The DHH is a covered entity under HIPAA. Therefore, DHH and Unisys, acting on behalf of DHH are exempt from the HIPAA privacy regulations regarding records for any claims for which Medicaid reimbursement is sought.
Section 164.506(a) of the HIPAA privacy regulations provides that covered entities are permitted to use or disclose Protected Health Information (PHI) for treatment, payment, or health care operations. In addition, a �HIPAA Authorization� or �Opportunity to Agree or Object� by the individual is not required for uses and disclosures required by law.
We appreciate your prompt cooperation when copies of medical records for Medical recipients are requested by DHH or Unisys.
Claims Submitted with Invalid Denial Reasons from Other Insurance
Providers have been submitting claims for Medicaid payment with an attached Explanation of Benefits (EOB) from Medicare or a private insurance payer which indicates payment was denied by Medicare or the private insurance payer only because the claim was improperly filed. Upon review of the EOB, the Provider Relations staff has had reason to suspect that in some cases the Medicare or other insurance denial is due to a technical issue rather than non-coverage of the procedure. It appears the claim may have been intentionally filed incorrectly in order to receive a denial from Medicare or the private insurance payer in order to obtain the full amount of payment from Medicaid.
When the provider intentionally bills incorrectly in order to obtain the full amount of the payment from Medicaid, this is a violation of federal and state laws which make Medicaid the payer of last resort. We have instructed Unisys Provider Relations to deny these claims and in some cases, refer claims to our Program Integrity SURS Unit for investigation. These violations subject the provider to possible sanctions including recoupment of payments and other legal actions as deemed appropriate.
We realize a claim may be filed incorrectly due to human error, causing the claim to deny. We ask that you review your Medicare or private insurance denial carefully before submitting them for Medicaid payment. In some cases, you may find a claim can be technically corrected and resubmitted to Medicare or the private insurance payer for payment.
If you have any questions regarding this matter, you should contact a staff person in the Unisys Provider Relations Unit at (800) 473-2783 or (225) 924-5040. Thank you for your cooperation in this matter.
Standards of Participation
The Bureau of Community Supports and Services, BCSS with input from stakeholders and providers, has developed and promulgated the Standards for Participation for Home and Community-Based Waiver service providers. The final rule can be viewed in the Louisiana Register published on September 20, 2003. All providers that request to enroll to provide these Medicaid services in one of the DHH regions where they are not currently providing services must meet these requirements prior to enrollment. This includes participation in a required provider enrollment orientation training session. The final rule that reference enrollment orientation can be viewed in the Louisiana Register published on December 20, 2003. Currently enrolled providers with existing, established services in DHH regions will be required to meet these standards through BCSS compliance monitoring within the next two years. Additional information on the requirements for existing providers will be submitted to each enrolled provider.
Louisiana Medicaid HIPAA Implementation Schedule
|
Implementation
Title
|
Type
|
Date
|
Description
|
|
Pharmacy
|
Local Codes
|
01/21/03
|
Eliminate the use of LA specific pharmacy NDC codes for
indwelling catheters
|
|
|
EDI
|
04/07/03
|
HIPAA transaction 835/U277 electronic remittance advice now
available to those providers who request it.
|
|
|
EDI
|
04/07/03
|
Begin accepting 837I inpatient/outpatient electronic
institutional claims
|
|
Privacy
|
NA
|
04/14/03
|
The Privacy HIPAA Rule becomes effective.
|
|
Dental
|
EDI/Local Codes/Claim Form
|
05/01/03
|
|
|
|
Local Codes
|
05/01/03
|
Eliminate the use of LA specific codes.
|
|
Hemodialysis
|
Local Codes
|
05/01/03
|
Eliminate the use of LA specific codes.
|
|
Rural Health/FQHC
|
Local Codes/Claim Form
|
05/01/03
|
Eliminate the use of LA specific codes.
Begin new payment methodology. Begin use of new billing
instructions for KIDMED KM-3 paper claim form.
|
|
MEVS/REVS 270/271
|
EDI
|
06/28/03
|
Begin receiving recipient status requests and
transmitting responses in the HIPAA standard electronic formats. End use
of 3040
version.
|
|
Professional 837P
|
EDI
|
07/26/03
|
Begin accepting 837P electronic professional claims.
|
|
POS NCPDP V5.1
|
EDI
|
08/24/03
|
Begin use of NCPDP 5.1 real-time format for
pharmacy Point of Sale claims. RA response codes for pharmacy claims
upgraded to NCPDP version 5.1. End use of version 3.2.
|
|
Pharmacy NCPDP V1.1
|
EDI/Claim Form
|
08/24/03
|
Begin use of Universal Prescription Claim Form
(UCF). Begin use of NCPDP 1.1 batch electronic format for pharmacy claims.
End use of proprietary electronic format.
|
|
Ambulance Transportation
|
Local Codes
|
10/01/03
|
Eliminate the use of LA specific codes for emergency
transportation providers and begin use of standard code
|
|
Professional � Including Physician Services (Pre-natal
Clinics, Ambulatory Surgical Centers, Lab & X-ray,
Immunizations, Family Planning Clinics, Anesthesia)
|
Local Codes
|
10/01/03
|
|
KIDMED Local Code
(EPSDT
Screening Services and Clinics)
|
Local Codes/Claim Form
|
10/01/03
|
Begin using the revised KM-3 paper claim form with new
billing instructions. Eliminate the use of LA specific codes and
begin use of standard codes.
|
LTC/ICFMR/ADHC/Hospice 837I
|
EDI/Claim Form
|
10/01/03
|
Begin accepting UB92 paper claim form and 837I electronic
institutional claims with standard codes.
|
|
Claims Status Inquiry (CSI) 276/277
|
EDI
|
10/15/03
|
Begin online provider Claim Status Inquiry (CSI)
|
|
Home Health
|
EDI/Local Codes/ Claim Form
|
12/08/03
|
Begin use of UB92 paper claim form and 837I
electronic claims for this program. Eliminate use of LA specific codes and
begin use of standard codes. End use of proprietary 101 paper forms.
|
|
Professional � (Including:
TB Clinics, STD Clinics, EPSDT Health Services, Mental Health Clinics, MH
Rehab, and Rehab Centers, Vision (eyeglasses)
|
Local Codes
|
12/31/03
|
|
|
Prior Authorization 278
|
EDI
|
12/31/03
Tentative
|
Begin to accept prior authorization requests in the
electronic 278 format.
|
|
DME/DME Pharmacy
|
Local Codes
|
12/31/03
|
Eliminate the use of LA specific codes and
begin use of standard codes.
|
|
Waiver
|
Local Codes
|
12/31/03
|
Eliminate the use of LA specific codes and
begin use of standard codes.
|
Louisiana Medicaid Contingency Plan
Attention all electronic submitters. In order to minimize disruption of provider payments, Unisys will continue to accept claims and send remittance advices in the current proprietary electronic format after October 16, 2003 and until further notice. This is applicable to all programs except Home Health and current TAD billers.
Home Health Providers will have until December 4, 2003 and TAD billers until December 18, 2003 to use the current proprietary formats.
If you have been approved by the LA HIPAA Testing Center for production and submission of the Professional (837P), Institutional (837I), Dental (837D) or Pharmacy (NCPDP 5.1) formats, you are HIPAA compliant and should continue to submit your claims in these formats.
Trading partners who are not HIPAA compliant on October 16, 2003, must make arrangements to test and move into production with the HIPAA required formats as soon as possible.
Contact the Medicaid HIPAA EDI testing group by emailing a request to *hipaaedi@unisys.com (note * is part of the address) or by calling 1-225-237-3318.
Attention Home Health Providers
Effective December 8, 2003, Home Health providers must begin using the new UB-92 paper claim form or the 837I electronic transaction for submitting claims regardless of the date of service. If the date of service is prior to December 8, providers must use the state assigned procedure codes in effect on that date of service. The same applies to voids and adjustments. If billing for dates of service on or after December 8, 2003, the provider will use the standard procedure codes and revenue codes as listed in the 2003 Home Health Provider Training packet.
There will be no "grace" period for transition from the proprietary claim format to the new standard format for Home Health. The last day for acceptance of the current proprietary electronic format will be Thursday, December 4, 2003 at 12:00 noon. The last day for acceptance of the current Unisys 101 paper claim form is close of business November 28, 2003. Unisys will return to providers any proprietary paper claims or proprietary electronic claims received after these dates. The providers will be expected to resend these claims using the UB 92 paper claim form or the 837I electronic transaction.
This billing information will be distributed and presented to providers in training seminars scheduled November 3 through November 7, 2003. Invitations to the training have been mailed to providers and are available on www.lamedicaid.com and included in this edition of the Provider Update. The training seminars will focus on these billing changes that will impact payment to Home Health Providers.
2003 Home Health Provider Training Workshops
The Department of Health and Hospitals and Unisys invite and strongly encourage you to attend the 2003 LA Medicaid Provider Training Workshops scheduled for November 3-7, 2003.
These
workshops will focus on billing changes that will impact payment to the LA Medicaid Home Health provider community as a result of the federally mandated Health Insurance Portability and Accountability Act (HIPAA) of 1996.
The effective date of LA Medicaid billing changes for home health services is December 8, 2003. We strongly encourage administrative and billing staff to attend this most important workshop, as
information presented in the workshop will affect your Medicaid claims
payment. The workshop schedule follows. Please review this schedule for the location and time of the workshop nearest you, and mark your calendar to attend.
Please bring your LA Medicaid provider number to the workshop, as it is required for registration.
| DATE |
CITY |
LOCATION |
TIME |
| November 3, 2003 |
New Orleans |
Ponchartrain Center
4545 Williams Blvd
Kenner, LA |
12:00 - 3:00p.m |
| November 4, 2003 |
Lafayette |
Holiday Inn Holidome
2032 N.E. Evangeline Thruway
Lafayette, LA |
12 00 - 3 00p.m |
| November 5, 2003 |
Baton Rouge |
LA State Police Academy
7901 Independence Blvd
Baton Rouge, LA |
12:00 - 3:00p.m |
| November 6, 2003 |
Monroe |
Holiday Inn Holidome
I-20 @ Hwy 165 North
Monroe, LA |
2:00 - 5:00pm |
| November 7, 2003 |
Bossier City |
Bossier City Civic Center
620 Benton Road
Bossier City, LA |
9:00 - 12:00am |
Louisiana Drug Utilization Review (LADUR) Education
Low Molecular Weight Heparin in the Treatment of Deep Vein Thrombosis:
Bridging the Gap to Better Outcomes
By: Martin B. Steffenson, Pharm. D. Associate Professor of Clinical Pharmacy Practice,
The University of Louisiana at Monroe, School of Pharmacy,
Glenwood Anticoagulation Management Clinic
Summer C. Helo (Pharm. D. cand.) Monroe, School of Pharmacy
September E. Lee (Pharm. D.cand.) Monroe, School of Pharmacy
Michael S. D. Huynh (Pharm. D. cand.) Monroe, School of Pharmacy
LMWH Bridging
� Use LMWH as a transitional agent to help patients reach therapeutic intensities of desired oral anticoagulation goals safely.
� Reduce the time period during which patient experiences a hypercoagulable state when warfarin is started, stopped, or restarted
Provide a means for patients to leave a healthcare facility prior to reaching a therapeutic intensity on warfarin, and thereby reduce length of stay and associated costs
Introduction
Acute deep vein thrombosis (DVT) affects as many as 800,000 patients annually. Although causation of DVT may be due to a number of factors, most etiologic factors are related to one of Virchow�s triad, those being blood stasis, vascular injury particularly to the endothelial tissue of the vessel wall, and inherent states of hypercoagulability.
Stasis is often tied to immobility. In the infirm, it may be related to health problems that require an extended convalescence or paralysis. The immobility may also be environmentally driven. A common example would be sitting that one might experience on a transcontinental airplane flight or occupationally, it might be found with repetitive tasks such as a sewing machine operator where the foot must continually stay in place to operate a pedal. When extended periods of venous stasis occur, platelets are apt to aggregate on the endothelial vessel wall. A thrombus may then form with the advancement of the coagulation cascade. In typical thrombophlebitis, this thrombus will attach to the lumen wall. The adherent thrombus is then invaded by fibroblasts and scarring of the venous wall may result in the destruction of the nearby venous valve. Even though circulation is usually restored by a process of revascularization, destruction of the valves chronic venous insufficiency often ensues. In a majority of cases, venous thrombotic lesions begin in the deep veins of the calf, and hence the term deep vein thrombosis (DVT) is applied to these conditions.
Trauma to the vein may be typically seen in patients undergoing major surgical procedures that will induce clinical manifestations of thrombus formation. Long and invasive operations such as hip replacements are often associated with higher incidences of thromboembolic occurrence, especially when immobility occurs following vascular wall injury from the surgery.
A sizeable number of patients suffer inherently from hypercoagulable states arising out of inherited Protein C and Protein S deficiencies, antithrombin III, factor V Leiden mutation, cold agglutination disorder, malignancies, and nephrotic syndrome. Other risk factors for deep vein thrombosis include oral contraceptive use among women who smoke, advanced age, previous thrombosis, systemic lupus, and inflammatory bowel disease. (1)
Clinical Signs/Symptoms and Diagnostic Techniques
Nearly half of patients with thrombophlebitis have no physical symptoms or signs with the affected limb. Patients with thrombophlebitis may complain of aching, tightness, or pain in the leg, especially when ambulating. Upon examination of the upper calf, many may have slight edema, and patients may have a low-grade fever accompanied with tachycardia. Homan�s sign (passive dorsiflexion pain with the ankle) is positive in approximately half of the cases.
A definitive diagnosis is made possible by use of Duplex ultrasonography, ascending contrast venography, or by a gadolinium enhanced magnetic resonance venography. Duplex ultrasonography is the most widely used test in the initial laboratory assessment of patients with suspected DVT. The examination has two modes, a Doppler Flow Analysis and a B Mode image. Doppler findings that would indicate acute thrombosis include spontaneous flow absence, a lack of flow variation with respiration, and a failure to see increased flow velocity with distal augmentation. B Mode imaging is capable of differentiating between chronic and active thrombi based on echogenic features of the lesions.
Ascending contrast venography is seldom used because of its invasive nature, potential risks from ionizing radiation, and contrast induced nephropathy. The use of the contrast media in the vein places the patient at risk for inducing phlebitis. Gadolinium-enhanced magnetic resonance venography is now available for use in patients who have suspected deep vein thrombosis but have conflicting results from the Duplex ultrasonography examination. (1)
Traditional In-patient Treatment for DVT
In the latter half of this past century, the standard treatment for deep vein thrombosis was the intravenous infusion or subcutaneous injection of unfractionated heparin adjusted to achieve an activated partial thromboplastin time (aPTT) greater than 1.5. Typically the target range has been 1.5 to 2.5 times normal aPTT. The purpose of this approach is to reduce the rate of thrombophlebitis recurrence. The heparin does not lyse existing thrombi, but instead stops their continued development and allows the body time to naturally break down thrombi through fibrinolysis.
Failing to achieve adequate anticoagulation during the first few days of heparin therapy increases the long term risk of DVT recurrence. One should check baseline aPTT and full blood count. The patient should have no contraindications to heparin therapy. It is recommended that patients receive an initial bolus dose of 5,000 IU or approximately 100 units/kg followed by continuous infusion anywhere from 10 to 18 IU/kg/hr. Check aPTT every six hours for the first 24 hours; then check daily thereafter. Goal aPTT should be 1.5 to 2.5 times normal aPTT. Heparin infusion should be continued for five to seven days. Oral warfarin therapy should be started on day one of heparin therapy and heparin may be stopped when INR is greater than 2 for more than 48 hours. (2)
Unfractionated heparin (UFH) is a highly charged polyanion consisting of chains having anywhere from 18 to 50 saccharide units. The heparin molecule therefore can weigh anywhere from 5,000 d to 30,000 d, but has a mean of approximately 15,000 d. Approximately one third of the chains have a pentasaccharide sequence that uniquely binds to antihrombin, while the larger chains bind thrombin. These features greatly enhance the molecule�s ability to inactivate thrombin.
Heparin has a strong binding affinity to many cells such as macrophages and platelets, and it is also binds to plasma proteins including fibrinogen, vitronectin, fibronectin, and von Willebrand factor. Heparin with its high binding affinity and various cellular interactions significantly affects subcutaneous absorption resulting in highly variable plasma levels. Practitioners must therefore titrate doses by monitoring its intrinsic pathway effects using the activated partial thromboplastin time (aPTT) as a marker. It is important to note that its binding platelet factor 4 may stimulate antibody formation, believed to be responsible for the development of heparin induced thrombocytopenia. (3)
|
Summary Checklist for
Initial Therapy for DVT with Unfractionated Heparin (UFH) (2) |
|
1. Check baseline aPTT, INR/PT, CBC
2. Confirm that patient has no known contraindications to heparin therapy
3. Administer bolus 5,000 IU (or 100 IU/kg) of heparin
4. Choice of either IV or SQ administration:
Continuous UFH infusion - start infusion between 10-18 IU/kg/hr
Check aPTT q 6h for first 24 hours, then once daily thereafter
Target aPTT goal for 1.5 to 2.5 times normal
Recheck aPTT at q 6h after each adjustment
Continue UFH infusion for five to seven days
5. Check platelet count daily for any occurrence of thrombocytopenia
6. Begin oral warfarin therapy on day one on a regimen determined by local protocol
7. Continue heparin for at least four to five days after starting UFH
8. Stop UFH infusion when INR greater than 2.0 for more than 48 hours
9. Continue warfarin therapy for three to six months with INR between 2.0 - 3.0
Extended (after 3-6 months) Low intensity anticoagulation (1.5 -2.0) may supplant
the 2.0 - 3.0 range due to results of new study. (4)
10. Be certain that management process is in place to monitor INR and warfarin regimen closely during oral anticoagulation |
Use of Low Molecular Weight Heparin in Treatment of DVT
Low molecular weight heparins began to be available in the U.S. pharmaceutical market beginning in the early middle 1990s. The low molecular weight heparins (LMWH) are prepared by chemical cleaving of porcine heparin through depolymerization. Their molecular weight ranges from roughly 4,000 d to 6,500 d. Not only do these heparins have a lower molecular weight, but in LMWHs the number of saccharide units is reduced to between 13 and 22 in number compared to UFH which runs from 18 to 50 saccharide units. The LMWHs have about one third the number of pentasaccharide binding sites compared to UFH, therefore the antithrombin complex is significantly weaker when compared to the much larger and longer chained UFH. Because of this weak effect on thrombin, LMWHs have only slight effect on aPTT unless present in very high blood plasma concentrations. Part of LMWHs effectiveness as anticoagulants lies in their characteristic to stimulate the release of tissue factor pathway inhibitor (TFPI) from the endothelial tissue of the vessel wall. TFPI binds factor Xa which then inhibits tissue factor/factor VIIa complex. The LMWH when bound to antithrombin also exerts its anticoagulant effect by inactivating Xa bound to platelets. (3)
Agent
|
Average molecular weight
(Da)
|
Intravenous
half-life
(minutes) |
Ardeparin
(Normiflo) |
6,000 |
200 |
Dalteparin
(Fragmin) |
5,000 |
119 to 139 |
Enoxaparin
(Lovenox) |
4,500 |
129 to 180 |
Danapariod
(Orgaran) |
5,500 |
24 hours |
LMWHs with their smaller saccharide chain lengths have minimal binding of cell and plasma proteins when compared to heparin. This results in an anticoagulation agent that has higher and more consistent bioavailability when administered by the subcutaneous route. The effect of LMWH on factor Xa is directly and linearly related to the dosage amount delivered. Given that the subcutaneous absorption is nearly 90%, drug binding is not a significant problem. Dosage amount is directly related to the plasma amount and anticoagulation effect, thus monitoring of Xa plasma level is not a necessity. In fact, Xa plasma levels do not correlate that closely to clinical efficacy. Specific patients out of the general population that might benefit from Xa monitoring would be those patients either of low weight or with severe obesity. This group would include children less than 50 kg and patients greater than 120 kg. Pregnant patients and patients with renal failure should also be monitored for Xa levels. Pregnancy may cause significant weight gain as the pregnancy progresses necessitating dosage increases, while renal disease will impact the LMWHs as excretion is via the kidneys. (3)
Other advantages to the use of a LMWH as an anticoagulant include its lower incidence of heparin induced thrombocytopenia (HIT). Less frequently seen is skin necrosis at the site of injection in comparison to UFH. Bleeding is still a major adverse effect of LMWH, especially if a patient has an epidural catheter inserted for surgical anesthesia. Factors that increase the risk of bleeding include low body weight, age greater than 70 years, recent surgery or injury, and concurrent use of drugs that are anticoagulants of a fibrinolytic or antiplatelet function. (3).
|
Advantages of LMWH over UFH (2) |
- More reliable relationship of dose and response
- Reduced need for laboratory monitoring
- Reduced need for dose adjustment
- Lower incidence of thrombocytopenia
- Allows for home administration by patient or care giver
- Significant potential for decreasing hospital length of stay
|
Use of LMWH as a Bridging Agent for Hospital to Home Therapy
As indicated in the prior section, LMWH offers many advantages to both the patient and the clinician in treatment of DVT over traditional acute care setting treatment of patients with UFH. Clinical trial data have been demonstrating both the efficacy and safety in treating deep vein thrombosis on an outpatient basis. (5,6,7,8) The major challenges in assisting patients bridge from a LMWH to oral warfarin in the outpatient setting lies in establishing and utilizing appropriate criteria in patient selection and risk stratification. Success depends on assisting those qualified patients with the appropriate health team members able to insure that out-patient care results in desired healthcare outcomes.
Once qualified patients are selected for outpatient LMWH therapy, there must be in place ancillary healthcare personnel able to teach LMWH administration. Personnel must also be able to arrange for a capable home healthcare or an anticoagulation management service to work with the patient and caregivers to ensure safe and efficacious care under the supervision of the primary care provider who has expertise in anticoagulation management.
Drug selection, which would include a variety of pharmaceutical factors, may be affected by ease and frequency of dosage administration, cost, clinical trial evaluation of safety and efficacy. The low molecular weight heparins are each prepared with a different method of depolymerization and result in differing molecular weight and chain sizes. With differing weights and chain structure, the LMWHs have unique effect on factor Xa and thrombin. For this reason the LMWH are distinct in structure; however, their pharmacologic and clinical characteristics are similar with the exception of danaparoid. Danaparoid is a mixture of heparan, dermatan, and chondroitin sulfates and is indicated for use in heparin-induced thrombocytopenia. At this juncture it does not appear that any one LMWH is more effective or safer than any other. Protocol development for home treatment of DVT should include information on anticoagulation therapy, laboratory monitoring procedures, limits on patient activities, non-pharmacologic management of DVT, and patient education. (5)
Exclusionary Risk Factors for Outpatient
Treatment of DVT (5)
Absolute Exclusionary Risk Factors:
- Platlet count <100K
- Active hemorrhage
- GI bleed within 6 months
- Heparin sensitivity (allergy to heparin or pork products)
- Underlying liver disorder
- Familial bleeding disorder
- Hypertensive: SBP>220 and DBP> 120mmHg
- Catheter-associated DVT
- Recent surgery
- Morbid obesity >30% ideal body weight
- Congenital/acquired hypercoagulable state
- Iliofemoral thrombosis
- Comorbid illness requiring inpatient treatment
|
Relative Exclusionary Risk Factors:
- Age > 75 years
- Pregnancy
- PE (clinically unstable or massive PE is absolute exclusionary
criterion)
- Renal insufficiency (CrCl ,30 cc/min or dialysis-dependent patient
is absolute exclusionary criterion)
- Other factors increasing risk of home treatment (eg, comorbidity,
insurance compliance)
- History of noncompliance with medicines
- History of substance abuse
- Language barrier
- Inability to pay for LMWH
- Inaccessibility to clinic or telephone
- Unstable home environment
- Incompetence to assume responsibility of self-care or inability of
family/friend/nurse to administer care
- Elevated PT or aPTT
|
This brief article does not intend to be a pharmacoeconomic analysis of healthcare savings capable under outpatient care of DVT utilizing LMWH. Studies have shown savings from anywhere from $547 per patient to $2,500 per patient (6,7,8,9,10). Decreasing length of stay �LOS� has become a buzz phrase in healthcare case management. Low molecular weight heparins by themselves will not miraculously decrease health care expenditures for the treatment of DVT. Health care providers with expertise in anticoagulation management under a primary care physician with the ability to manage antithrombotic therapy on an outpatient basis can make significant improvement in the healthcare outcomes of patients with DVT. At the same time, these healthcare professionals can make substantial cuts in healthcare costs by reducing length of stays in acute care facilities for patients who qualify for outpatient care of DVTs.
References:
1. Tierney LM, McPhee S J, and Papadakis M A. Current medical diagnosis and treatment, 42nd edition. New York: Lange Medical Books/McGraw -Hill. 2003.
2. Turpie AG, Chin BS, and Lip GT. ABC of antithrombotic therapy; venous thromboembolism: treatment strategies. BMJ 2002; 325: 948-950.
3. Becker RC, Fintel DJ, and Green DG. Antithrombotic therapy, 2nd edition. Caddo, OK. Professional Communications, Inc. 2002.
4. Ridker PM. Et al. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism. N. Engl. J. Med. April 10, 2003; paging to be announced.
5. Yeager BF and Matheny C. Low -molecular-weight heparin in outpatient treatment of DVT. American Family Physician. April 1999. Found at http://www.aafp.org/afp/990215ap/945.html.
6. Spyropoulos AC. Outpatient-based treatment protocols in the management of venous thromboembolic disease. The American Journal of Managed Care. 2000; 6: (20 supp): s1034-44.
7. Dedden P, Chang B, and Nagel D. Pharmacy-managed program for home treatment of deep vein thrombosis. Am. J. Health-System Pharm. 1997,V 54; 196: 72.
8. Dunn A S. et al. Outpatient treatment of deep vein thrombosis in diverse inner-city patients. The American Journal of Medicine. Volume 110. P.458-462. April, 2003.
9. Lissovoy G D, et al. Cost for inpatient care of venous thrombosis: A trail of enoxaparin vs standard heparin. Arch. Int. Med. Vol. 160. P.3160-3165.
10. Groce J B, III. Patient outcomes and cost analysis associated with an outpatient deep venous thrombosis treatment program. Pharmacotherapy. Vol 18. NO. 16. P.175-180. 1998.