PROVIDER
UPDATE
VOLUME 11,
NUMBER 4
JULY/AUGUST
1994
Message from the Medical Director
Louisiana
Drug Utilization Review Program Update (LADUR)
LADUR is a drug review program required by OBRA 90, the
goal of which is to enhance and improve the quality of pharmaceutical care and
Medicaid patient outcomes by ensuring that prescriptions are appropriate,
medically necessary, and not likely to result in adverse medical effects.
LADUR is important because it helps achieve quality and cost containment
without compromising access to medically necessary therapy.
LADUR focuses on interventions that convey to physicians
individual Medicaid recipients drug utilization patterns as it impacts
therapeutic exception criteria. Program
activities include developing new therapeutic exception criteria, developing
educational articles, surveying the provider population, coordinating a drug
utilization review board, and communicating with providers via regional
committees. 1993 activity focused
on over-utilization or drug-to-drug problems in either high cost or particularly
risky therapeutic drug classes.
In 1993, nearly 5,000 LADUR provider letters were mailed to
physicians, hospitals, and pharmacists. The
high 65% provider response rate and numerous positive comments suggest program
acceptance and approval by the provider community.
Data indicates that significant changes and reductions uniformly occur in
prescribing and utilization patterns within six months of LADUR intervention.
Utilization reduction varied from 9% to 65% among the therapeutic classes
reviewed. These annualized
reductions for LADUR-reviewed recipients projected into a direct $3.6 million
1993 cost avoidance.
Future program plans include strengthening the educational
emphasis on direct provider correspondence and additional drug education
articles, focusing on duration of therapy issues, and developing new therapeutic
drug criteria.
Hospital
Pre-Admission/Length of Stay Review Program Update
This program will conduct pre-admission and length-of-stay
(LOS) review for distinct part psychiatric facilities and long-term care
hospitals. Acute care and rehab
hospitals will participate only in the LOS review program.
The InterQual review criteria will be used to review admissions and
customized criteria will be used for long-term care.
LOS will be assigned based on HCIA Southern Regional data and appropriate
specialty customization based on a DHH Advisory Committee's deliberations.
Admissions and LOS reviews will be conducted by specialized
review nurses with physician consultant oversight. Complete program information is included in the new Hospital
Manual that will soon be mailed to affected providers.
The program will be phased in slowly over several months
beginning in late July with the initial hospitals selected by DHH.
Program orientation will be provided once a hospital has been requested to
participate. No action is necessary
on the part of a hospital until they have been contacted by DHH.
Dr. Gregg Paine
Code 91033 Funded
CPT procedure code 91033 - Esophagus, acid reflux test,
with intraluminal pH electrode for detection of gastroespohageal reflux;
prolonged recording - has been funded at $52.44 effective with date of service
June 15, 1994. The professional
component fee for this service has been set at $20.98 effective the same date.
Code 93016 Funded
Procedure code 93016 - Cardiovascular stress test using
maximal or submaximal treadmill or bicycle exercise, continuous
electrocardiographic monitoring, and/or pharmacological stress; physician
supervision only, without interpretation and report - has been funded at $59.27
effective with date of service July 1, 1994.
Code 90700 Funded
CPT procedure code 90700 - Immunization, active; diptheria,
tetanus toxoids, and acellular pertussis vaccine (DTaP) - has been funded at
$20.00 per injection effective with date of service July 1, 1994, for recipients
to the age of 21.
This fee is for the vaccine only; the costs of
administration are included in the attendant office visit fee.
Increase in UVS for Code 99183
The UVS (number of units that can be billed daily) for CPT
code 99183 - Physician attendance and supervision of hyperbaric oxygen therapy,
per session - was increased from one to three effective with date of service
July 1, 1994.
One unit equals one session. Therefore, if you are billing for two or three dives or
sessions administered on a given day, place a "2" or "3" in
the units column on the claim form as appropriate.
However, if billing for one session on a given day, do not place any
number in the units column.
Code 99183 should never be modified.
Claims billed with a 26 modifier attached to 99183 will deny as this code
does not have a professional component. The
reimbursement for code 99183 is $127.72 per session.
Placement of Deleted Codes in Non-Pay Status
The CPT codes deleted in the 1994 issuance of the Physician's
Current Procedural Terminology were placed in non-pay status effective with
dates of service August 1, 1994. Please
program your billing systems immediately to bill current codes if you have not
already done so. A list of the
codes added and deleted for 1994 begins on page 7 of this issue of the Provider
Update.
Notice to NEMT Providers
Listed below are procedure codes effective beginning July
1, 1994. There is no reimbursement
for dry runs, wait time, or any mileage. Negotiated
fees will be provided by the Dispatch Office beginning July 1, 1994.
| Profit
Providers: |
| Flat Rate |
$15.00 |
Z5177 |
| Negotiated Rate |
To be given by Dispatch Office
|
Z5178 |
| Capitated Urban Rate |
$150.00 |
Z5179 |
| Capitated Rural Rate |
$200.00 |
Z5180 |
| Non-Profit
Providers: |
| Flat Rate |
$12.00 |
Z9498 |
| Negotiated Rate |
To be given by Dispatch Office |
Z5176 |
Monthly Medical Card Changes
The appearance of the monthly medical card produced by
Unisys will be changing effective with the November 1994 card.
The new card will be printed on an 8 1/2 x 11 sheet, folded
in half, and sealed into a one-piece mailer.
The card's edges will be perforated for easy removal.
The top half of the card will contain recipient eligibility
information and the bottom half will contain messages, notices, and other
pertinent Medicaid information.
Refer to your March/April 1994 Provider Update for a sample of the new card.
Please note that the final printed version of the medical card may be
slightly different in format than the example.
Revised Limits for MHR Options
As of August 15, 1994, the following are the maximum
limits.
Counseling and Therapy limits are for any
combination of therapy types under the MHR Option.
Calendar year remains the same at 208 30-minute units; monthly is 50
units; and daily is 4 units.
Psychosocial Skills Training limits for calendar
year are 780 one-hour units; monthly is 100 units; and daily is 6 units.
Psychosocial Skills Training must be limited to eight individuals per
skills trainer.
Treatment Integration limits for calendar year
are 1040 30-minute units; monthly is 90 units; daily is 6 units.
Clarifications and Revised Limits for MHR Option:
Effective July 1, 1994
1.
The target population criteria have been redefined as explained later in
the article titled "Target Population for Mental Health Rehabilitation
Services" found on the lower portion of this page.
Mental Health Rehabilitation Services must cease for any recipients who
do not meet these guidelines as of July 1, 1994.
2.
Mental Health Rehabilitation Management evaluations and assessments must
be completed as needed to determine medical necessity of services within the
previously established parameters. Not
all evaluations and assessments are necessary for each client.
Evaluations and assessments completed more than once per year require
written justification that must be placed in the recipient's record.
Evaluations and assessments should not be completed routinely.
3.
The revisions for counseling and therapy follow.
Family Therapy
Family therapy is billed per unit of time, not for the
number of individuals participating in therapy. If more than one family member is receiving MHR services,
then only one recipient's number can be billed for that time.
Group Therapy
Eight individuals is the maximum number of individuals that
can be served in one group for adults. Six
individuals is the maximum number of individuals that can be served in one group
for children/youth.
4.
Treatment Integration must be limited to one recipient per treatment
integration worker. Treatment
Integration cannot be billed at the same time as another service by the same
staff person. It cannot stand alone
as a service; it must be provided as a supplement to another service.
5.
Collateral Consultation must be provided by a QMHP or someone with a
master's degree in psychology, counseling, or social work.
Collateral Consultations can be billed only if someone outside of the billing
agency is consulted regarding the recipient's care. Any contacts between employees of an agency are considered
agency staffings and are not billable. Only
the agency initiating the collateral consultation may bill for the contact when
two Mental Health Rehabilitation agencies are involved.
6.
All claims submitted for recipients under the age of six will be subject
to pre-pay review. Substantial
documentation will be required before payment is allowed included a psychosocial
or psychiatric evaluation, a recent psychosocial evaluation, and documentation
from sources which led to professional consultation.
All claims must be submitted hard copy on the HCFA 1500 with all
pertinent history attached. If the
claim is not submitted in such a fashion, the claim will be denied.
Target Population for Mental Health Rehabilitation Services
(Also Applies to Case Management for the Mentally Ill)
Medicaid assistance is designed to assist eligible Medicaid
recipients in obtaining medical care. Reimbursement
may be made for Mental Health Rehabilitation Services when performed by
qualified providers for Medicaid recipients who meet the definitions of
disability defined in this section or reside in nursing facilities and have been
determined through the pre-admission screening and annual resident review (PASARR)
process to require active treatment services.
The Medicaid Program will not reimburse for Mental Health
Rehabilitation Services provided to residents of ICF/MR group homes.
The disability definitions for adults and children who
qualify to participate in this program are defined below.
Adults with Severe
and Persistent Mental Illness
Adults must meet all
of the following criteria (A, B, C, and
D) for serious mental illness (SMI).
A.
Age: 18 years or older, AND
B.
Diagnosis: Severe
non-organic mental illness including but not limited to schizophrenia; schizo-affective
disorders; mood disorders; and severe personality disorders that substantially
interfere with a person's ability to carry out such primary aspects of daily
living as self-care, household management, interpersonal relationships, and work
or school; AND
C.
Disability: Impaired role
functioning caused by at least two of
the following functional areas.
1.
Unemployed or has markedly limited skills and a poor work history or, if
retired, is unable to engage in normal activities to manage income; OR
2.
Employed in a sheltered setting; OR
3.
Requires public financial assistance for out-of-hospital maintenance
(e.g., SSI), and/or is unable to procure such without help (does not apply to
regular retirement benefits); OR
4.
Severely lacks social support systems in the natural environment (e.g.,
no close friends or group affiliations, lives alone, or is highly transient); OR
5.
Requires assistance in basic life skills due to mental illness (e.g.,
must be reminded to take medicine, must have transportation arranged for them,
needs assistance in household management tasks); OR
6.
Exhibits social behavior which results in a demand for intervention by
the mental and/or judicial/legal system.
D.
Duration: Must meet at
least one of the following indicators of duration.
1.
Psychiatric hospitalizations of at least six months in the last five
years (cumulative total); OR
2.
Two or more hospitalizations for mental disorders in the last 12-month
period; OR
3.
A single episode of continuous structural supportive residential care
other than hospitalization for a duration of at least six months; OR
4.
A previous psychiatric evaluation indicating a history of severe
psychiatric disability of at least six months duration.
Children/Youth with
Severe Emotional/Behavioral Disorder
Behavioral or emotional responses so different from
appropriate age, cultural, or ethnic norms that they adversely affect
performance (including academic, social, vocational, or personal skills); a
disability that is more than a temporary, expected response to stressful events
in the environment and is consistently exhibited in two different settings and
persists despite individualized intervention within general education and other
settings. Emotional and behavioral
disorders can co-exist with other disabilities.
Children/youth must meet all of the following criteria (A, B, C, D, and E) for emotional/behavioral disorder.
A.
Age: Under age 18; AND
B.
Diagnosis: has a DSM-III-R
(or successor) diagnosis indicating a severe mental disorder such as, but not
limited to psychosis, schizophrenia, major affective disorders, reactive
attachment disorder of infancy or early childhood (non-organic failure to
thrive) or severe conduct disorder.
This category does not include children/youth who are socially maladjusted
unless it is determined that they also meet the criteria for
emotional/behavioral disorders; AND
C.
Meets one of the following
three criteria which operationalize the above definitions.
1.
Exhibits seriously impaired contact with reality and severely impaired
social, academic, and self-care functioning; thinking is frequently confused;
behavior may be grossly inappropriate and bizarre; emotional reactions are
frequently inappropriate to the situation; OR
2.
Manifests long-term patterns of inappropriate behaviors, which may
include but are not limited to aggressiveness, anti-social acts, refusal to
accept adult requests or rules, suicidal behavior, developmentally inappropriate
inattention, hyperactivity, or impulsiveness; OR
3.
Experiences serious discomfort from anxiety, depression, or irrational
fears and concerns whose symptoms may include but are not limited to serious
eating and/or sleeping disturbances, extreme sadness, suicidal ideation,
persistent refusal to attend school or excessive avoidance of unfamiliar people,
maladaptive dependence on parents, or non-organic failure to thrive.
D.
Disability: There is
evidence of severe, disruptive, and/or incapacitating functional limitations of
behavior characterized by at least two of the following criteria.
1.
Inability to routinely exhibit appropriate behavior under normal
circumstances; OR
2.
Tendency to develop physical symptoms of fears associated with personal
or school problems; OR
3.
Inability to learn or work that cannot be explained by intellectual,
sensory, or health factors; OR
4.
Inability to build or maintain satisfactory interpersonal relationships
with peers and adults; OR
5.
A general pervasive mood of unhappiness of depression; OR
6.
Conduct characterized by a lack of behavioral control or adherence to
social norms which is secondary to an emotional disorder.
(Note: If all other criteria
are met, then "conduct disorders" are eligible.)
E.
Duration: The impairment or
pattern of inappropriate behavior(s) has persisted for at least three months and
the impairment of pattern of inappropriate behavior(s) will persist for at least
one year.
Note:
Circumstance, behaviors, and interventions leading up to the referral for
professional consultation must be documented and included in the recipient's
record.
Note:
A diagnosis of substance abuse or developmental disabilities/mental
retardation prevents participation in the Mental Health Rehabilitation (and Case
Management for Mental Illness) Programs unless accompanied by a primary
diagnosis of mental illness.
LA Drug Utilization Review (LADUR) Education
Therapeutic
Class
NSAIDs
and Antidiabetic Drug-Drug Interaction
Issues
�
The primary categories of NSAIDs include the salicylates (aspirin)
and the propionic acid derivatives (ibuprofen).
�
Sulfonylureas (glyburide) are useful in reducing hyperglycemia in
the diabetic primarily by increasing pancreatic insulin secretin.
�
When salicylates are coadministered with sulfonylureas, the
hypoglycemic effect of the sulfonylureas may be potential resulting in
hypoglycemia.
�
Propionic acid derivatives should be cautiously combined with
sulfonylureas and insulin as they may displace the sulfonylureas from binding
sites on protein.
Background
The Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are widely prescribed,
orally effective agents. These
agents are mainstays in the treatment of inflammatory disorders (e.g.,
rheumatoid arthritis) and are used to relieve mild-to-moderate pain, suppress
fever, and relieve symptoms of primary dysmenorrhea.
All NSAIDs pose a risk of gastric ulceration, acute renal failure, and
suppression of platelet aggregation. The
primary categories of these agents include the salicylates (aspirin) and the
propionic acid derivatives (ibuprofen). They
are classified as NSAIDs to distinguish them from cortisone and other steroids
used to treat inflammatory disorders.
The sulfonylureas (glyburide) are commonly used in the
treatment of non-insulin-dependent (Type II) diabetes mellitus.
These agents are useful in reducing hyperglycemia in the diabetic
primarily by increasing pancreatic insulin secretion.
Many studies show salicylates (aspirin) reduce basal plasma glucose
levels, increase glucose tolerance, and augment insulin response.
Thus, when salicylates are coadministered with sulfonylureas, the
hypoglycemic effect of the sulfonylureas may be potentiated.
This has resulted in several reported instances of hypoglycemia and
accompanying problems. Therefore, blood glucose levels should be monitored when
these agents are coadministered. If
hypoglycemia develops, consideration should be given to dosage adjustments
and/or switching to another analgesic agent.
Additionally, blood glucose levels should be closely monitored during
withdrawal of NSAIDs from patients also receiving a sulfonylurea agent.
The mechanism for this effect is not completely understood.
An additive effect with two hypoglycemic agents is a possibility. In addition, inhibition of prostaglandin synthesis may
inhibit acute insulin response to glucose.
Protein binding displacement of the sulfonylurea has been suggested.
The administration of insulin (e.g., Iletin, Humulin) in
combination with the salicylates should also be evaluated and used with caution
since the salicylates significantly increase basal insulin secretion and enhance
the acute response to a glucose load and the secondary insulin-secretion
response. As with sulfonylurea
coadministration, blood glucose levels should be monitored and the insulin dose
tailored as needed to prevent hypoglycemia.
Caution should also be used when other NSAIDs (e.g.,
propionic acid derivatives) are used in combination with the sulfonylureas and
insulin. They may displace the
sulfonylureas from binding sites on protein molecules.
This is particularly true with phenyl-butazone which may decrease
sulfonylurea excretion, interfere with protein binding, and/or interfere with
the metabolism of hypoglycemic agents (depending on the specific sulfonylurea).
The Louisiana Department of Health and Hospitals has used
LADUR to evaluate patterns of NSAID and antidiabetic use within the Medicaid
Drug Program. This evaluation has
included concomitant use of the antidiabetic agents and NSAIDs.
These combinations often resulted from the patient's use of multiple
physicians and/or pharmacies.
The concurrent use NSAIDs and antidiabetic agents such as
insulin and the sulfonylureas should proceed cautiously to decrease the risk of
potentiating hypoglycemic effects. Physicians
should monitor patients for possible signs of hypoglycemia.
References
AMA Drug Evaluations, Annual 1991. Agents Used to Regulate Blood Glucose. Milwaukee, pp. 869-989.
AHFS Drug Information, 1994. "Insulin." pp.
2046-2056. "Sulfonylureas." pp. 2056-2075. Bethesda, MA.
Goodman and Gilman, 1990. The Pharmacological Basis of Therapeutics. 8th edition.
"Insulin, Oral Hypoglycemic Agents, and the Pharmacology of the Endocrine
Pancreas." Elmsford, NY pp. 1463-1495.
Kafflu, M., Ramiriz. L.C., and P. Raski, 1989. Diabetes
Nutrition and Metabolism. "The Effect of Many Commonly Used Drugs on
Diabetic Control." 2:75-93.
USPDI, 1994. Anti-Inflammatory
Analgesics, Nonsteroidal (Systemic). 14th edition. Rockville, MD,
pp. 355-406.
Billing for Professional Services Under Pre-Admission Certification/LOS
Effective July 1, 1994, the Bureau of Health Services
Financing began phasing in the implementation of a Hospital Pre-Admission/Length
of Stay (LOS) review program. Beginning January 1, 1995, BHSF will implement this review
program for all hospitals excluding state-operated and out-of-state facilities.
Distinct part psychiatric facilities and long-term hospitals will undergo
pre-admission review and LOS assignment. Acute
care and rehabilitation hospitals will participate only in the LOS review
process.
All physician hospital visits (procedure codes 99221
through 99223, 99231 through 99238, 99251 through 99255, 99431, and 99433)
excluding inpatient visits to a state-operated or out-of-state hospital will be
subjected to pre-certification requirements editing.
Follow the instructions below to obtain reimbursement for inpatient
professional services effective with date of service January 1,1995.
1.
Physician claims will not be paid without a certification on file for the
hospital stay unless appropriate documentation is attached to the claim
identifying the hospital stay (see #3 below). If the service was performed in a state-operated hospital and
the physician is not based at that facility, then the physician will have to
identify this service by putting a "Y" in item #19 on the HCFA 1500 or
on record type # in charity indicator field for EMC submissions.
For those physicians who are based at a state-operated facility, there is
not need to identify your claims with a "Y' in this field.
2.
The physician should indicate the hospital pre-certification number on
the HCFA 1500 item #23 or on EMC record type E in the prior authorization field
if the physician has access to that number.
To ensure accurate, timely processing of your claim, we recommend that
you place the pre-certification number on the claim.
However, if you do not have access to the pre-certification number, you
can bill your claim without it and the claim recipient ID and dates of service
will be used to find the hospital pre-certification on file.
The pre-certification number will be stored on the claim record and will be
printed on the remittance advice. The
physician visit days will be paid according to the LOS approved dates for the
hospital stay. Before your claim
can be paid, there must be an approved
pre-certification record for the hospital stay on file at Unisys.
3.
In those cases when the hospital chooses not to bill Medicaid, the
physicians may bill their claims with appropriate documentation (admit/discharge
summary) so that medical necessity and LOS can be determined.
These claims will pend to the Unisys Pre-Certification Department for
review and decision, and will be assigned a prior authorization number.
The physician will receive a notice letter indicating approval/denial
status, days approved, and the PA number. Inquires
about approval/denial or assigned length of stay should be directed to the
Unisys Pre-Certification Department. Your claim will be processed with the assigned PA number.
These new procedures will not negate or affect any of the
policies and procedures currently in effect for hysterectomies, sterilizations,
and outpatient surgeries performed in an inpatient setting.
Effective with dates of service July 1, 1994, you will no
longer be required to attach documentation to claims for inpatient visits
exceeding 15 days per year since this limitation has been eliminated.
Independent
Labs - Medicare Crossover Claims
BHSF is currently in the process of updating
the Medicare/Medicaid conversion file for automatic crossovers for independent
laboratories. We are asking that all currently enrolled independent
laboratories assist the Provider Enrollment Unit in updating the conversion file
by supplying your current Medicare number.
Please mail or fax your Medicare number(s) and
the Medicaid provider number to which crossover claims should be matched.
Your assistance will enable us to process the crossover claims quickly and
correctly.
FAX Number:
(504)342-3893
Mailing Address:
Bureau of Health Services Financing
P.O. Box 91030
Baton Rouge, LA 70821-9030
Attn: Provider Enrollment
Supervised Independent Living Providers: Consultation Information
Recent reviews of claims for consultations revealed that
some inappropriate claims have been submitted.
Agencies receiving payment for claims that are not valid consultations
must repay the full sum received. Repayment
may be accomplished voluntarily by the agency submitting adjustment/void forms
or repaying by check, or involuntarily by recoupment.
Consultations are appropriate only in the following circumstances.
1.
The purpose of the consultation is to train SIL staff to work with the
client (i.e., to "train the trainer").
2.
The consultation is not a direct service provided to the client.
3.
Staff training is not otherwise available.
For example, consultation reimbursement is not available when staff is
trained in appropriate techniques as part of the recipient's therapy visits.
4.
The consultant is not a member of the staff of the provider agency either
by direct employment or by contract.
5.
Necessity and frequency of consultations is determined by the case
management ID team based on appropriate documentation.
Consultations are entered on both the Comprehensive and Service Plans of
Care as separate items.
6.
Consultations take place on a reasonable schedule (i.e., sufficiently
often to determine that staff is following instructions).
Consultations are typically necessary no more often than monthly or
quarterly.
7.
Consultations are available for persons living in an Independent
Supervised Living arrangement for whom base rate is applicable.
8.
Consultants shall furnish a written report of each consultation including
date and duration of contact, persons involved, pertinent findings and
recommendations, and, if appropriate, progress since a previous consultation.
The report shall be filed in the recipient's case record maintained by
the provider and shall be available for review by staff as necessary.
Please report suspected instances of incorrect consultation
code use to Louise Dubroc at (504) 342-5457.
Authorization of Services for the Chronically Mentally Ill Which Exceed
the Maximum Units Per Year
All requests for additional units of service (for dates of
service prior to August 1, 1994) which exceed the maximum specified in the DHH
Medicaid Case Management Services manual must be submitted in writing to OMH
regional coordinator for continuation of services.
The request should document the circumstances which led to
the high need for services, the necessity for additional services, and the
number of additional units requested. All
service logs and progress notes should also be submitted with the request for
additional services.
New Dispensing Costs for Pharmacists
The maximum allowable overhead cost (dispensing fee) for
Medicaid prescription services was increased to $5.77 effective for services
beginning July 1, 1994.
This fee includes the provider fee mandated under state law
for every prescription filled by a pharmacy or dispensing physician.
Also, please be reminded that providers are required to bill their usual
and customary charges.
HCPC DME Code Changes and Additions
The following changes have been made recently for these DME
procedure codes.
1.
Code V5014 has been added as a payable code to replace V5299 for hearing
aid repairs.
2.
Three additional codes have been added to the automatic pricing file (PAC
= 850):
E0244 = $65.00 (Raised Toilet Seat)
E0243 = $60.00 (Toilet Rail, Each)
E0246 = $60.00 (Transfer Tub Rail Attachment)
3.
Code L3907 (EHFO, Wrist Gauntlet with Thumb Spica, Molded to Patient
Model) has been added as a payable code to be automatically priced (PAC = 850)
at $323.92.
Also, the following new procedure codes have been created
by HCFA and will be entered on the DME file as payable codes.
1.
Codes K0001-K0117 have been created for wheelchairs and accessories.
These codes will be made payable retroactive to 1/1/94 (see the list
beginning on page y of this Provider
Update). All will be
automatically priced except for K0108, K0109, and K0177.
2.
Codes K0126-K0165 are new codes created for already covered items
including orthotic devices, urinary catheters, and ostomy supplies.
These are also being added retroactive to 1/1/94 (see list on page 7).
3.
Codes XX030-XX072 have been created for category IV and V enteral formula
products for which Medicare has descriptive and pricing information on file.
They will replace codes B4154 and B4155 for these products.
Codes B4154 and B4155 may still be used, however, for other formulas in
these categories for which no "XX" code has been assigned (see list on
page 7).
4.
Codes L0984-L8490 on attached list have also been added by HCFA as
payable codes for additional orthotic and prosthetic items (see list on page 7).
The items will be automatically priced.
Changes in Case Management Program
As part of DHH's efforts to maintain quality and enhance
administrative oversight of all case management services.
BHSF has published an emergency rule in the Louisiana Register effective
July 22, 1994. This rule makes
changes in the requirements for provider enrollment, staff coverage,
qualifications for case managers and their supervisors, and required staff
training. It clarifies medical
necessity criteria for recipients, the mandated components of case management
services and expectations for documentation.
Copies of this rule are being sent to each case management agency.
Questions regarding these changes should be directed to Suzanne Danilson
(504) 342-3965 or Delphine Jackson (504) 342-0940.
Case Management with Persons With Serious Mental Illness
Beginning August 1, all case mgt. services to persons with
serious mental illness must be authorized by the regional OMH in advance of
service delivery. The authorization
is a two-step process as outlined below.
1.
The provider must submit medical evidence that individuals meet the
target population definition for adult with serious mental illness or child with
emotional/behavioral disorder. If
the individual meets the definition, an initial service assessment and planning
period will be authorized. During
this period, the case management will complete the strengths assessment, a
comprehensive service plan, and the CAMIS initial assessment form.
Upon completing this information, the agency may bill for services.
The information must be submitted to the regional office for
authorization of services.
2.
Upon review of the strengths assessment, service plan, and CAMIS
assessment, the regional office will authorize the continuation of services if
they are determined necessary. The
agency will be issued an authorization number, a number of service units, and a
time period for delivery of these services not to exceed six months.
Upon expiration of the service units or time period, the agency may apply for
additional units of service based on the resubmission of updated information
contained in the documents outlined in number 2 above.
There will be two new procedure codes for case management services.
Code X0028 will be used to bill for the initial assessment and service
planning period. Code X0029 will be used to bill for ongoing case management
services. These ongoing services
will not be differentiated into three types of case management contacts as has
been the case previously. This
change in coding will be effective August 1, 1994.