Provider Update
Volume 13, Number 4
Summer 1996
Message from the LMMIS Project Manager
In 1995, the Medicaid Program underwent some very difficult
budget reductions. At that time,
the Bureau of Health Services Financing issued thirty-eight (38) Emergency
Rules, which initiated changes in policy and reimbursement methodology for the
provision of Medicaid services in Louisiana.
It appeared that this year, Louisiana would have again
faced an extension round of Medicaid budget reductions; however, through the
efforts of our Senators and Representatives in Washington, the Governor and his
Executive Agencies, and the Secretary of DHH and his staff, those potentially
massive Medicaid program reductions were thankfully avoided.
The total avoidance of Medicaid program budget reductions was not
possible. However, Medicaid has
been able to fund all mandatory services as appropriate levels as well as
institutional and home and community based services to the handicapped.
In addition, plans are in place to generate a state-funded program
closely resembling the discontinued Medically Needy program. Even though some difficult reductions have been made,
Louisiana Medicaid will provide in excess of $3.1 billion in medical services to
the citizens of the state.
Norm Nichols
Policy Notes
Notice to Physicians, CNPs, and Chiropractors
Effective with the publication of this notice, physicians
who employ or contract with certified nurse practitioners and/or chiropractors
to provide services to Medicaid recipients must
notify Provider Enrollment at 504-342-9454 of such employment 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 certified nurse practitioner or chiropractor.
In billing for services, the individual provider number of
the certified nurse practitioner 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).
Changes in CPT Codes 99261, 99262, & 99263
Effective with dates of service July 1, 1996, CPT codes
99261, 99262, and 99263, which are follow-up inpatient consults payable for
recipients to the age of 21, are now subjected to the preadmission/length of
stay requirements. The exception
to this precertification requirement will be for inpatient visits in
state-operated or out-of-state hospitals or nursing facilities.
Only inpatient visits in state-operated or out-of-state
hospitals and nursing facilities are excepted from this precertification
requirement.
Attention Home Health Providers
The memo sent to Home Health providers from Tom Collins
(dated 02/08/96) concerning new procedures for extended nursing care and
multiple visits contained claim form examples.
These examples indicated a place of service of 12 (home) in error.
Please be aware that your actual claims should always indicate a place of
service 1 (home).
Pharmacy and Physician Providers: Notice
from Barr Laboratories
We have been notified by Barr Laboratories through the
submission of drug utilization rebate data that pharmacists are billing and
getting reimbursed for NDC numbers which are obsolete, discontinued, or their
shelf-life has expired. Please be
advised that many of Barr Laboratories' drug products have been coded to
non-payable status.
Please ensure when billing drug products that you use the
NDC of the package from which you are dispensing. We will continue to inform you of drug products which are
considered obsolete.
If you have any questions or require and additional
information, please contact Wanda Perraultat (504) 342-0427.
Notice to Rehabilitation Centers
This will serve as notice to Rehabilitation Centers that
CPT code 97535 - self care/home management training (e.g., activities or daily
living (ADL) and compensatory training, meal preparation, safety procedures, and
instructions in the use of adaptive equipment), direct one on one contact by
provider, each 15 minutes - was placed in pay status effective with date of
service January 1, 1996. The fee is
$7.20, with a UVS of 4. This
procedure must be prior authorized.
Rehabilitation centers that have received denials for this
procedure with dates of service of January 1, 1996 and thereafter may resubmit
claims for reprocessing after authorization is received.
Changes in Lupron Depot Therapy
Lupron Depot, the chemotherapeutic agent used in the
treatment of prostate cancer (code J9217), is now available in a new three month
injection developed to deliver three months of therapy rather than just one.
To bill for the three month injection, submit code J9217 with a
"3" in the units column. Reimbursement
will be three times the single injection fee of $451.25 or $1,353.75.
Louisiana Drug Utilization Review (LADUR) Education
Issues
-
Alendronate (Fosamax) is the first approved nonhormonal treatment
for osteoporosis in postmenopausal women.
-
Alendronate inhibits the activity of osteoclasts, the cells that
resorb (break down) bone tissue.
-
It has also been approved for the treatment of Paget's disease of
bone.
Alendronate (Fosamax): A
New Agent for the Treatment of Osteoporosis
By Robert L. Judd, PhD.
Assistant Professor of Pharmacology
Northeast Louisiana University
Osteoporosis is a progressive disease that is characterized
by a reduction in bone mass, which results in bones that are prone to fracture.
It affects more than 25 million Americans, 80% of them women.
Each year, osteoporosis is attributed with more than 1.5 million
fractures, primarily spinal, hip, and wrist fractures, as well as numerous
deaths that result from complications of the fractures.
Osteoporosis occurs most commonly in postmenopausal women.
After menopause, bone turnover increases, and the rate of bone formation
because of a drop in the amount of estrogen.
Bone loss occurs and, in the first five years after menopause, women may
lose as much as 75% of their bone mass, increasing the possibility of fractures,
height loss, curvature of the spine, restricted movement, and disability.
Osteoporosis may be confirmed by the finding of low bone mass or by the
presence or history of osteoporic fracture.
Alendronate sodium (Fosamax-Merck)
is an aminobisphonate derivative with properties that are most similar to those
of etidronate (Didronel) and pamidronate (Aredia). It is the first nonhormonal therapy for the treatment of
postmenopausal osteoporosis (the safety and effectiveness in men with
osteoporosis has not been established). Prior
to its approval, treatment options were limited to estrogen replacement therapy
(e.g., conjugated estrogens [Premarin]), which has been used in the treatment of
osteoporosis, and calcitonin (Miacalcin). However,
some women do not tolerate estrogen treatment well, and until recently, when a
nasal spray formulation was approved, calcitonin was only administered
parenterally.
Alendronate binds to bone hydroxyapatite crystals and
specifically inhibits the activity of osteoclasts, the cells that resorb (break
down) bone tissue. It therefore
reduces the elevated rate of bone turnover observed in postmenopausal women to
approximate more closely that of premenopausal women. In clinical studies, alendronate produced a progressive
increase in bone mineral density (a measure of bone strength), a reduction in
the number of new spinal fractures, and less height loss when compared to women
who received placebo.
The effectiveness of alendronate in the prevention of osteoporosis has not yet been demonstrated, and this
is not a labeled indication at the present time. The manufacturer is conducting a study comparing the efficacy
of conjugated estrogens and the combined use of the two agents.
Alendronate has also been approved for the treatment of
Paget's disease of bone in patients having alkaline phosphatase at least two
times to upper limit a normal. Paget's
disease of bone is a chronic bone disorder that may result in fragile, enlarged,
and deformed bones that are more likely to fracture.
It is the second most prevalent bone disease after osteoporosis,
affecting about 1.3 million Americans. Alendronate
joins etidronate, pamidronate, and calcitonin as the treatment options for this
disorder, and, in a comparative study, the response with alendronate was greater
than with etidronate.
Use of alendronate is contraindicated in patients with
hypocalcemia or hypersensitivity to any component of the product.
Hypocalcemia must be corrected before initiating therapy with the new
agent, as should any other disturbances of mineral metabolism (such as vitamin D
deficiency). The action of alendronate to increase bone mineral may be
associated with small, asymptomatic decreases in serum calcium and phosphate,
especially in patients with Paget's disease.
Adequate calcium and vitamin D intake should be ensured to provide for
these enhanced needs.
Alendronate was generally well tolerated in clinical
studies, and the rate of discontinuation of therapy because of adverse events
was actually lower with alendronate in the 10mg/day regimen used for
osteoporosis (4%) than in the group receiving placebo (6%).
Adverse reactions most commonly associated with the use of alendronate
(and reported at an incidence greater than with placebo) include abdominal pain
(7%), musculoskeletal pain (4%), esophageal ulcer (2%), flatulence (3%), and
headache (3%). For patients with Paget's disease, who are treated with a
higher dosage alendronate (40 mg/day), the frequency of adverse reaction is
higher, especially upper gastrointestinal effects (18%). As with etidronate and pamidronate, alendronate should be
used with caution in patients with active upper GI problems.
The incidence of upper GI effects increased in patients taking
alendronate (in a dosage greater 10mg/day) as well as an aspirin-containing
product. The concurrent use of
alendronate with aspirin or a nonsteriodal anti-inflammatory drug should be
closely monitored.
Because the primary indication for alendronate is in
post-menopausal women, its use during pregnancy or in nursing mothers has not
been studied, and such use should be avoided.
Alendronate is classified in Pregnancy Category C.
Alendronate is not metabolized and is primarily excreted in the urine.
It is not necessary to reduce the dosage in patients with
mild-to-moderate renal insufficiency. However,
use of alendronate is not recommended for patients whose creatinine clearance is
less than 35 ml/minute, because of lack of experience.
The recommended dosage of alendronate is 10 mg once a day
for treating osteoporosis in postmenopausal women, 40 mg once a day, for six
months, for treating Paget's disease of bone.
Relative to an IV reference dose, the mean oral bioavailability of
alendronate in women was 0.7% when administered after an overnight fast and two
hours before a standardized breakfast. Bioavailability
was negligible whether alendronate was administered with a standardized
breakfast of up to two hours afterwards. Even
orange juice, coffee, and mineral water may markedly reduce the absorption of
alendronate. Patients should be informed that alendronate must be taken
with plain water only (a full 6 or 8 oz glass) at least one-half hour before the
first food, beverage, or medication of the day.
After taking, the patient must wait 30 minutes before eating, in order to
improve absorption to the drug. To
facilitate the delivery of the drug to the stomach and to reduce the potential
for esophageal irritation, patients should avoid lying down for at least 30
minutes thereafter. Alendronate is
available as white, uncoated tablets in two strengths and shapes:
10 mg, which are round, and 40 mg, which are triangular.
References
Chestnut, C.H. III, McClung, M.R., Ensrud, K.E., et al.
"Alendronate Treatment of the Postmenopausal Osteoporotic Woman; Effect of
Multiple Dosages on Bone mass and Bone Remodeling." American Journal of Medicine, 99 (1995): 144-152.
Hussar, D.A. "New Drugs of 1995." Journal
of the American Pharmaceutical Association, NS36(3) (1996): 158-186.
Alendronate (Fosamax).
New Product Bulletin (1996).
Papapoulos, S.E. "The Role of Disphosphonates in the
Prevention and Treatment of Osteoporosis. "American Journal of Medicine, 95 (supp. 5A) (1993): 48S-52S.
Watts, N.B. "Treatment of Osteoporosis with
Bisphosphonates." Theum. Dist. Clin.
North Am., 20 (1994): 717-734.
Policy Notes
To All Providers: Duplicate
Claims Payments
We have found duplicate claims payments where two different
billing providers were paid for the same service rendered by one attending
physician. Where payment was made
to the attending and to a group, the payment to the attending was voided.
Where payment was made to two groups, the second claim paid was voided.
These claims will generate EOB message 849 which states, "Already
paid same attending different billing provider."
CPT Code 92568 with 92567
It has been the policy of the Louisiana Medicaid Program
not to pay for duplicate or inclusive procedures.
We would like to remind providers that 92567 (Tympanometry) includes
92568 (Acoustic Reflex Testing). Therefore,
these codes should not be billed on the same recipient on the same date of
service. Billing on these codes
together is contrary to Medicaid policy, and claims will be subject to
recoupment.
Notice to Providers of Lab Services
Effective with date of service July 1, 1996, fees for
certain laboratory codes (CPT codes in the 80,000 series) were reduced in order
to bring Medicaid reimbursement amounts for these codes in line with those being
paid to Medicare.
Questions about this matter may be directed to Kandis V.
McDaniel, Physicians Program Manager, at 504-342-9490.
Attention Pharmacy Providers: NDCs
Removal from the Drug File
Effective July 1, 1996, the following Rugby Laboratories'
NDCs which are classified as food supplements were made non-payable.
Please be advised that several of Rugby Laboratories' drug products have
been coded to non-payable status: 536-0082-90,
536-3954-10, 536-4082-01, 536-4341-01, 536-4379-01, 536-4606-10, 536-4634-01,
and 536-4820-25.
Notice to Pharmacy Providers: Lancets
and Glucose Strips
Lancets and blood glucose or reagent strips for a home
blood glucose monitor are Medicare covered only if the patient is insulin
treated. Medicare is to be billed
first for insulin treated Medicare Part B eligible recipients obtaining those
diabetic supplies. If the recipient
is not insulin treated, hard copy billing and pharmacy or physician
documentation to that fact must be mailed to P. O. Box 91024.
Notice to Physician Providers: Indigent
Patient Drug Programs
As some physician providers may be aware, there are
pharmaceutical manufacturers that have established programs to make some drugs
available free of charge to indigent patients.
These programs are not government-sponsored; in fact, Medicare and
Medicaid patients may be disqualified by certain companies.
However, if a Medicare/Medicaid physician provider believes
that he/she has an indigent patient that could possibly benefit from such
indigent patient drug programs (for example, aging patients on fixed incomes
whose medication is costly), that physician may want to discuss this possibility
with that patient. If they choose
to proceed, the manufacturer of the drug must be found (drug companies are
listed in the Physician's Desk Reference (PDR)) and the physician is generally
required by most companies to make the initial contact.
If a patient is determined to be eligible for the program, the
manufacturer will send the medication t the physician's office for distribution.
Again, these are not government-funded programs:
Medicare/Medicaid physician providers are not obligated to provide this
service, and these is no guarantee that Medicare/Medicaid patients will be
eligible for indigent patient drug programs.
Reimbursement Rates for Apnea Monitors, Oxygen Concentrators, and
Nebulizers
The Bureau, as of July 1, 1996, has revised the rates of
reimbursement for the following items:
Apnea monitor [code E0608] = $1900 [purchase] & $160
[rental]
Oxygen concentrator [codes E1400, E1401, E1402, E1403,
& E1404] = $1500 purchase & $175 [rental]
Nebulizer, with compressor [code E0570] = $95 [purchase]
& $175 [rental]
Facilities Whose Physicians May Bill the NICU Codes:
New Listing
Baton Rouge General Health Center - Baton Rouge, LA
Children's Hospital - New Orleans, LA
E. A. Conway Medical Center - Monroe, LA
East Jefferson General Hospital - Metairie, LA
Earl K. Long Medical Center - Baton Rouge, LA
Kenner Regional Medical Center - Kenner, LA
Lafayette General Medical Center - Lafayette, LA
Lake Area Medical Center - Lake Charles, LA
Lake Charles Memorial Hospital - Lake Charles, LA
Lakeland Medical Center - New Orleans, LA
Lakeside Hospital - Metairie, LA
Lakeview Regional Medical Center - Covington, LA
Lane Memorial Hospital - Zachary, LA
Leonard J. Chabert Medical Center - Houma, LA
LSU Medical Center - Shreveport, LA
Meadowcrest Hospital - Gretna, LA
Medical Center of Baton Rouge - Baton Rouge, LA
Medical Center of Louisiana - New Orleans, LA
Mercy Baptist Medical Center - New Orleans, LA
Minden Medical Center - Minden, LA
North Oaks Medical Center - Hammond, LA
Northshore Regional Medical Center - Slidell, LA
Ochsner Foundation Hospital - New Orleans, LA
Pendleton Memorial Methodist Hospital - New Orleans, LA
St. Francis Cabrini Hospital - Alexandria, LA
St. Francis Medical Center - Monroe, LA
St. Tammany Parish Hospital - Covington, LA
Schumpert Medical Center - Shreveport, LA
Slidell Memorial Hospital & Medical Center - Slidell,
LA
Terrebonne General Medical Center - Houma, LA
Touro Infirmary - New Orleans, LA
Tulane University Hospital - New Orleans, LA
University Medical Center - Lafayette, LA
West Jefferson Medical Center - Marrero, LA
Willis Knighton Medical Center - Shreveport, LA
Woman's Hospital - Baton Rouge, LA
Women's and Children's Hospital - Lafayette, LA
Claims Denied Through the Duplicate Drug ProDUR Module
Effective July 15, 1996 and after, the Bureau will deny
claims identified through the Duplicate Drug ProDUR module.
The Duplicate Drug ProDUR module detects duplicate prescriptions for the
same drug (form and strength). A
claim denial will occur as a patient attempts to obtain the same drug from a
different pharmacy sooner than is anticipated based on the estimated days
supply. The drug conflict code for duplicate therapy is ID in the
NCPDP field 439. Our explanation of
benefits edit is 445-Duplicate Drug Therapy.
If a claim is denied for duplicate drug therapy, the
provider may telephone the POS Help Desk for more detailed information of
direction. After consultation with
the physician, patient and/or the POS Help Desk, the provider must determine
whether there are extenuating circumstances which substantiate the dispensing of
a duplicate claim. If extenuating
circumstances exist, the provider must use the following procedures to initiate
an override of the denial for duplicate therapy:
1.
The provider must document on the prescription hard copy the
circumstances for the override and signify a duplicate drug therapy occurrence
by entering "ID" in NCPDP field 439.
Specific contacts and circumstances must be documented.
2.
The provider must indicate on the denial claim resubmission one of the
following intervention code indicators in NCPDP field 440:
M� - Prescriber was consulted and authorized the dispensing of the duplicate
P� - Patient consulted and had an explanation as to the necessity of dispensing
the duplicate, or
R� - Pharmacist consulted another source and determined the duplicate is a
false positive
3.
The provider must indicate on the denied claim resubmission one of the
following outcome code indicators in NCPDP field 441:
1A-Filled as is, false positive
1B-Filled prescription as is
1C-Filled, w/different dose
1D-Filled, w/different directions
1E-Filled, w/different drug
1F-Filled, w/different quantity
1G-Filled, w/prescriber approval
Providers having any questions should contact the POS Help
Desk at 1-800-648-0790 or (504) 237-3381.
Notice to Providers: Changes
in Reduction Mammoplasty Services
Effective with date of service July 20, 1996, the Bureau of
Health Services Financing adopted the following criteria to govern the provision
of reduction mammoplasty services under the Medicaid Program.
Prior to requested prior authorization for a reduction mammoplasty,
recipients must meet the following criteria:
I.
Approval Requirements
A. Qualifying Condition
The recipient must
meet the following weight and height criteria before the provider is to submit a
request for evaluation and consideration for reduction mammoplasty services.
The recipient's total weight shall not exceed the weight limit
established by the following formula by more than twenty percent.
Height
Pounds
5 feet
100
Each additional
inch over 5 feet
5
For example:
A request for reduction mammoplasty services shall not be submitted for
consideration for a recipient who is 5 feet tall who weighs more than 120 pound
(100 pounds plus 20%). A person who is 5 feet one inch tall shall weight no more
than 126 pounds (105 pounds plus 20%) to be considered. A recipient who is 5 feet, 5 inches tall shall weigh no more
than 150 (pounds) 125 pounds plus 20%) to be considered.
B. Prior Authorization
-
If the qualifying condition stated above is met, providers may then
submit a request for prior authorization of reduction mammoplasty upon which the
determination of medical necessity will be made.
-
The following documentation must accompany the request for prior
authorization of reduction mammoplasty services:
-
Posterior photo view of the
shoulder straps area
-
Frontal phone view of chest with face blocked;
-
Lateral photo of chest; and
-
Number of grams of breast tissue to be removed from
each breast.
II.
Payment Requirements
The pathology report and the PA01 or the PA approval letter
must be attached to the claim submitted for payment to the fiscal intermediary.
The HCFA 1500 claim form cannot be electronically transmitted.
The claim will be denied payment if the above documentation is not
attached to the claim.
Emergency Rules
Notices for All Medicaid Providers
The Department of Health and Hospitals, Bureau of Health
Services Financing, has adopted the following Emergency Rules in the Medical
Assistance Program as authorized by R.S. 46:153 and pursuant to Title XIX of the
Social Security Act and as directed by the 1996-1997 General Appropriation Act,
which states: "The Secretary shall implement reductions in the Medicaid
program as necessary to control expenditures to the level approved in this
schedule. The Secretary is hereby
directed to utilize various cost containment measures to accomplish these
reductions, including but limited to pre-certification, pre-admission screening,
and utilization review, and other measures as allowed by federal law."
These Emergency Rules are adopted in accordance with the Administrative
Procedure Act, R.S. 49:950 et seq. and shall be in effect for the maximum period
allowed under the Administrative Procedure Act or until adoption of the rules,
whichever occurs first.
Termination of the Medically Needy Program
Effective for dates of service July 1, 1996 and after,
coverage for all individuals certified for the Medically Needy Program,
including those individuals with an approved period of coverage which extended
beyond June 30, 1996, has been terminated.
The Department of Health and Hospitals will no longer
approve any applications, taken on July 1, 1996 or afterwards, for the Medically
Needy Program categories of assistance. The Department, however, has decided to continue to provide
medical benefits, from specially allotted state funds, for all Medically Needy
Program recipients who are currently certified and remain eligible continuously
or who apply for MNP before July 1, 1996 and are then found eligible and remain
eligible continuously. The
following provisions shall govern the administration of this State-Funded
Medically Needy Program.
I.
General Provisions
The State-Funded Medically Needy Program shall be administered in accordance
with requirements of Title XIX of the Social Security Act for Medically Needy
Program under the Act except as described below.
-
Coverage under this Program shall be limited to individuals who are
certified for the Title XIX Medically Needy Program or have a pending
application for participation under the Title XIX Medicaid Program and are
subsequently found eligible for Title XIX Medically Needy for June 1996.
-
Recipients must continually meet all the federal eligibility criteria
under the Title XIX Medically Needy Program in order to maintain their
eligibility status under the State-Funded Medically Needy Program.
-
Recipients who are determined to be potentially eligible under any Title
XIX eligibility category or any other benefit must take all appropriate steps to
pursue that eligibility including: applying
for coverage and providing the necessary information to determine eligibility
for the Title XIX category or other benefit.
-
Eligibility for the State-Funded Medically Needy Program will be
terminated under the following circumstances:
a) The recipient is determined eligible under a Title XIX category or
other benefit; or b) the recipient refuses to apply for coverage or cooperate in
the eligibility determination process.
-
The State-Funded Medically Needy Program shall not provide for a process
to determine the eligibility of any new eligible beginning July 1, 1996.
A)
Services
The scope of services and
reimbursement for the covered services shall be provided in accordance with the
federal and state regulations that governed the Medically Needy Program under
the Title XIX as previously administered by the Bureau of Health Services
Financing.
B)
Appeal Rights
Recipients who lose their eligibility under the
State-Funded Medically Needy Program shall be afforded the opportunity to appeal
the agency's decision in accordance with the Administrative Procedure Act.
There shall be no continuation of benefits pending appeal.
Recipients can call 1-800-256-8032 for information.
All Providers
Program Termination of AFCD-M and SSI-M Eligibles
Effective July 1, 1996, benefits for these two groups of
eligibles were terminated. AFDC-M
eligibles are identified by both the number "13" in the third and
fourth digits of the Medicaid identification number and a Type Case of 01 or 09
printed on the card. SSI-M
eligibles are identified by Type Case 68 printed on the card. In order to help prevent denial of claims for eligibility
reasons, please be sure your staff is asking to see a CURRENT valid card for the
month of service. Eligibility
verification is also available to providers by calling 1-800-776-6323.
Recipients can call 1-800-256-8032 for information.
Physician Providers
Notice to Physicians and Independent Labs
Effective with date of service July 1, 1996, adjustments
were made in the fees for the procedures listed below which are billed by
physicians and independent labs.
Code
Description
Fee
36415
Routine venipuncture or finger/heel/ear stick for collection of
specimen(s)
$2.65
99211
Office or other outpatient visit, established patient (may not required
$9.25
physician's presence)
99212
Office of other outpatient visit, straightforward medical decision-making
$18.91
99233
Subsequent hospital care, medical decision-making of high complexity $42.60
Bilateral Procedures
Currently, there are a number of bilateral procedures which
are reimbursed at a rate of 200% of the fee on Physicians Formulary file or the
billed charge, whichever is lower. Effective
with dates of service July 10, 1996 and after, the Bureau of Health Services
Financing has reduced reimbursement for these procedures to 150% of the fee on
file, or the billed charge, whichever is lower.
The CPT procedure codes which are being reimbursed at 150%
of the fee on the Physician Formulary file are listed below:
30903
49505
31254
49507
31255
49520
31256
49521
31267
49525
31276
69420
49495
69421
49496
69424
49500
69433
49501
69436
These procedure codes must be billed with the -50 modifier
if performed bilaterally (just like all other bilateral procedures) and the
number "1" must be placed in the form locator 24G (Days or Units
column) on the HCFA 1500 claim form.
Effective with dates of service July 10, 1996 and after,
these claims must be billed hardcopy with documentation attached, rather than
electronically.
Anesthesia Services
The following policy governing the provision of anesthesia
services under the Professional Services Program was adopted effective with date
of service July 10, 1996:
1.
Anesthesia services are reimbursed for the day of surgery or delivery.
2.
Because tubal ligations are not always performed immediately after the
delivery (but usually within twenty-four hours), a locally-assigned code, 00098,
has been devised and placed on the file to reimburse providers for the
reinjection of the epidrual catheter for the tubal ligation.
Therefore, effective with date of service July 10, 1996, code 00098,
whose description is "Reinjection of the epidural catheter for tubal
ligation," is to be used to bill for this service rather than code 62279.
The fee for code 00098 is $50.00.
3.
Payment for CPT codes 62274 through 62282, code 62289, and codes 64400
through 64450 will be restricted. The
first claim submitted for any of the codes listed above will be paid.
Subsequent billings within the 180 day period of the same code or of a
different code within a range of codes listed will deny with error edit 950
(Operative and History Reports Required), if the claim is billed electronically
or if it is submitted hardcopy without attachments.
If submitted with attachments (Operative and History
Reports), the claim will pend for review for medical necessity.
If it is determined the service was medically necessary, the claim will
be paid. Otherwise, the claim will
be denied with error edit 664 (Only One Payable Per 180 Days).
Global Surgery Periods
Effective with date of service July 10, 1996, payment for
pre- and post-operative visits made during global surgery periods is included in
the fee for the surgery. Three
different global surgery periods (GSP) will be utilized for the reimbursement of
surgeries. One period shall consist
of 0 days, the second period shall consist of 10 days, and the third period
shall consist of 90 days. Each CPT
surgery code shall be assigned to one of the global surgery periods (GSP):
If a code's GSP is 0, no outpatient or inpatient visits on
the day before or the day of surgery will be allowed unless the diagnosis for
the visit is different from that of the surgery.
If a code's GSP is 10, no outpatient or inpatient visits
will be allowed on the day before surgery, the day of surgery, or for 10 days
after the day of surgery unless the diagnosis for the visit is different from
that of the surgery.
If a code's GSP is 90, no outpatient or inpatient visits
will be allowed on the day before surgery, the day of surgery, or for 90 days
after the day of surgery unless the diagnosis for the visit is different from
that of the surgery.
The Medicaid global surgery listing of procedures is the
same as Medicare's 1992 global surgery listing. All providers should have a copy of the Medicare list in
their offices.
Community Care Program
Physician Management Fee
Effective for dates of service July 1, 1996 and after,
physician management fees have been reduced in the Community Care Waiver Program
to $2.00 per enrolled recipient per month.
Federally Qualified Health Centers
Reimbursement Methodology
Effective for dates of services July 1, 1996 and after, the
Department of Health and Hospitals, Office of the Secretary, Bureau of Health
Services Financing, will limit reimbursements to federally qualified health
centers by applying the Medicare payment limit to core services.
Thus, core services/encounter rates will not be paid nor cost settled at
a higher rate than the Medicare payment limit.
This rule applies to core services only and not to other ambulatory
services provided. A core service
is defined as a face-to-face encounter with a physician, physician assistant,
nurse practitioner, clinical psychologist, or clinical social worker.
Early Periodic Screening Diagnosis and Treatment (EPSDT) Program
Follow-up Screening Services
Effective for dates of service July 1, 1996 and after, the
Department has reduced reimbursement fees for providers of medical screening
services for the following codes included under the Early Periodic Screening
Diagnostic and Treatment Program:
|
Procedure Code |
Old Rate |
New Rate |
X0180 Consult
EPSDT - New Dx by Nurse |
$15.71 |
$13.71 |
X0181 Consult
EPSDT-New Dx by Nutrition |
$15.71 |
$13.71 |
X0182 Consult
EPSDT - New Dx by Social Worker |
$15.71 |
$13.71 |
X0187 Consult
EPSDT - Scrn Dx by Nurse |
$15.71 |
$13.71 |
X0188 Consult
EPSDT - Scrn Dx by Nutrition |
$15.71 |
$13.71 |
X0189 Consult
EPSDT- Scrn Dx by Social WOrker |
$15.71 |
$13.71 |
Health Services: Rehabilitation
Effective for dates of service July 10,1996 and after, the
Department has reduced reimbursement fees by TEN PERCENT (10%) for rehabilitation services included in an
Individual Education Plan or Individual/Family Service Plan and provided by
school boards and early intervention centers under the Early Periodic Screening,
Diagnosis and Treatment (EPSDT) Health Services Program for Medicaid recipients
under twenty-one years of age. These
rehabilitation services include evaluations and treatment services for speech,
occupational, physical, and psychological therapies as well as audiological
services.
Home Health
Reimbursement for Psychiatric Services
Please disregard our July 23, 1996 memorandum in which you
were notified that reimbursement would no longer be covered for home health
services provided to recipients whose primary diagnosis is a psychiatric
diagnosis. We are rescinding the
Emergency Rule implementing this policy change that was published in the July20,
1996 edition of the Louisiana Register.
However, these services must be provided in accordance with
state requirements as published in the Minimum
Standards for Home Health Agencies. One
requirement is the stipulation that "only registered nurses (RNs) who have
at least three full time years of verified direct psychiatric care experience
shall make psychiatric nurse visits. Master's preparation in psychiatric nursing may be
substituted for experience."
Additionally, the services must be medically necessary and
provided only to recipients who meet Medicaid's homebound criteria as published
in the March 20, 1996 edition of the Louisiana
Register.
Case Management
Termination of the Case Management for the Seriously Mentally Ill
Program (Formerly Chronically Mentally Ill)
Effective for dates of service July 1, 1996 and after, the
Medicaid Program shall no longer cover or reimburse for Case Management services
to the Seriously Mentally Ill. Claims
for services prior to July 1, 1996 will be reimbursed for these services to the
extent that funds are authorized by legislative appropriation for these
services.
Services for the Mentally Retarded/Developmentally Disabled - Non-Waiver
Effective July 1, 1996, a change in service coverage to
terminate the case management program for the mentally retarded/developmentally
disabled (MR/DD) WHO ARE NOT participants in the MR/DD Home and Community-Based
Services waiver was adopted.
Thus, effective for dates of service July 1, 1996 and
after, the Medicaid Program shall no longer cover or reimburse for Case
Management services to the Mentally Retarded/Developmentally Disabled
individuals who do not also participate in the MR/DD Home and Community-Based
Services waiver. Claims for
services prior to July 1, 1996 will be reimbursed to the extent that funds are
authorized by legislative appropriation for these services.
The case management services for the Mentally
Retarded/Developmentally Disabled population under the Home and Community-Based
Waiver Services are retained.
Hospitals
Outpatient Laboratory Services
The Bureau has determined it is necessary to reduce the
reimbursement for outpatient hospital lab services subject to the Medicare fee
schedule in order to achieve a uniform reimbursement methodology for all
laboratory services subject to the Medicare fee schedule regardless of the
setting in which the services are performed.
Therefore, the following Emergency Rule has been adopted to reduce the
payment for outpatient hospital laboratory services subject to the Medicare fee
schedule.
Effective for dates of service August 1, 1996 and
thereafter, the Bureau has reduced the reimbursement rate for outpatient
hospital laboratory services to the same reimbursement rate for laboratory
services provided in a non-hospital setting.
Outpatient Rehabilitation Services
Effective for dates of service August 1,1996 and
thereafter, the Department is reimbursing hospitals for outpatient
rehabilitation services including speech, occupational and physical therapies at
a flat fee for service based on payments made to rehabilitation clinics for
these services. These services
shall no longer be settled in the cost report.
Hospitals are required to bill for these services using the same
state-assigned HCPCS procedure codes payable to rehabilitation clinics, in
addition to the hospital revenue code.
When the revenue code listed at Form Locator 24 of UB-92 is
420, 421, 422, 424, 430, 431, 432, 434, 440, 441, 442, 443, 444, or 454, the
correct procedure code corresponding to the revenue code shown below must be
entered at Form Locator 44. If this
procedure is not followed, the claim will deny.
| Revenue Code |
File Description |
Code |
| 424 |
Physical Therapy Evaluation |
Y7702 |
| 434 |
Occupational Therapy Evaluation |
Y7812 |
| 444 |
Speech Evaluation |
Y2602 |
| 444 |
Hearing Evaluation |
Y2612 |
| 454 |
Wheelchair Seating Evaluation |
Y7902 |
| 420, 421 |
Physical Therapy, one modality |
Y7000 |
| 420, 421 |
Physical Therapy, 2 or more modalities |
Y7050 |
| 420, 421 |
PT, 1 or more procedures and/or mods., 15 min. |
Y7106 |
| 420, 421 |
PT with procedures, 20 min. |
Y7105 |
| 420, 421 |
PT with procedures, 30 min. |
Y7100 |
| 420, 421 |
PT with procedures, 45 min. |
Y7101 |
| 420, 421, 422 |
PT with procedures, 60 min. |
Y7102 |
| 420, 421 |
PT with procs and mods, 60 min. |
Y7202 |
| 420, 421 |
PT with procedures, 75 min. |
Y7103 |
| 420, 421 |
PT with procedures, 90 min. |
Y7104 |
| 430, 431 |
Occupational Therapy, 15 min. |
Y7810 |
| 430, 431 |
Occupational Therapy, 20 min. |
Y7811 |
| 430, 431 |
Occupational Therapy, 30 min. |
Y7813 |
| 430, 431 |
Occupational Therapy, 45 min. |
Y7814 |
| 430, 431 |
Occupational Therapy, 60 min. |
Y7815 |
| 440, 441 |
Speech and Hearing Therapy, 15 min. |
Y2609 |
| 440, 441 |
Speech and Hearing Therapy, 20 min. |
Y2611 |
| 440, 441 |
Speech Therapy, 30 min. |
Y2613 |
| 440, 441 |
Speech Therapy, 45 min. |
Y2614 |
| 440, 441, 442 |
Speech Therapy, 60 min. |
Y2615 |
| 443 |
Group Speech Therapy, 20 min. |
Y2510 |
| 443 |
Group Speech, Language, Hearing, Therapy, 30
min. |
Y2509 |
| 443 |
Group Speech Therapy, additional 15 min. |
Y2511 |
| 443 |
Group Speech, Language, Hearing Therapy, 1 hour |
Y2512 |
Rehabilitation Clinics
Changes in Medicaid Reimbursement Rates
Effective for dates of service July 10, 1996 and after, the
Department will reduce the reimbursement for services provided by rehabilitation
clinics by ten percent (10%). Rehabilitation
clinics are not part of a hospital but are organized to provide a variety of
outpatient rehabilitative services including physical, occupational, and
speech/hearing and language therapies. This
action is necessary to avoid a budget deficit in the medical assistance programs
due to the lack of sufficient state funds required to match federal financial
participation mandated under Title XIX of the Social Security Act.
Beginning with date of service July 10, 1996 and after, payment of these
services will be made in accordance with the rates noted in the table below.
Prior authorization procedures will remain the same.
| Description |
Procedure Code |
Rate |
| Evaluation Procedures |
| Wheelchair seating evaluation |
Y7902 |
$41.31 |
| Physical therapy evaluation |
Y7702 |
$43.74 |
| Occupational therapy evaluation |
Y7812 |
$41.31 |
| Speech evaluation |
Y2602 |
$36.45 |
| Hearing evaluation |
Y2612 |
$36.45 |
| Physical Therapy Procedures |
| Physical therapy, one modality |
Y7000 |
$12.96 |
| Physical therapy, 2 or more modalities |
Y7050 |
$19.44 |
| Physical therapy, 1 or more
Procedures and/or modalities, 15 min. |
Y7106 |
$6.48 |
| P.T. - with procedures, 20 min. |
Y7105 |
$10.80 |
| P.T. - with procedures, 30 min. |
Y7100 |
$12.96 |
| P.T. - with procedures, 45 min. |
Y7101 |
$19.44 |
| P.T. - with procedures, 60 min. |
Y7102 |
$25.92 |
| P.T. - with proc. and mod., 60 min. |
Y702 |
$28.80 |
| P.T. - with procedures, 75 min. |
Y7103 |
$36.00 |
| P.T. - with procedures, 90 min. |
Y7104 |
$43.20 |
| Occupational Therapy Procedures |
| Occupational Therapy, 15 min. |
Y7810 |
$4.14 |
| Occupational Therapy, 20 min. |
Y7811 |
$5.51 |
| Occupational Therapy, 30 min. |
Y7813 |
$8.27 |
| Occupational Therapy, 45 min. |
Y7814 |
$11.18 |
| Occupational Therapy, 60 min. |
Y7815 |
$14.10 |
| Speech Therapy Procedures |
| Speech and Hearing Therapy, 15 min. |
Y2609 |
$6.48 |
| Speech and Hearing Therapy, 20 min. |
Y2611 |
$8.10 |
| Speech Therapy, 30 minutes |
Y2613 |
$12.15 |
| Speech Therapy, 45 minutes |
Y2614 |
$18.63 |
| Speech Therapy, 60 minutes |
Y2615 |
$24.30 |
| Group Speech Therapy Procedures |
| Group Speech Therapy, 20 min. |
Y2510 |
$4.05 |
| Group Speech Therapy, 30 min. |
Y2509 |
$6.48 |
| Group Speech Therapy, add. 15 min. |
Y2511 |
$3.24 |
| Group Speech Therapy, 1 hour |
Y2512 |
$12.96 |
DME Providers
Revision of Procedures for Seating Evaluations, Prior Authorization and
Reimbursement for Customized Wheelchairs
Effective for requests received on or after July 1, 1996,
the Bureau of Health Services Financing will no longer reimburse DME providers
for customized wheelchairs based on the lowest bid from the DME providers
participating in a wheelchair seating evaluation. Instead, the Bureau will be using a reimbursement formula
that applies a discount of 18% to the manufacturers' suggested retail price, for
the model of wheelchair and its accessories.
Effective since July 1, 1996, all rehabilitation providers,
who receive an M.D. prescription for a wheelchair which is specially designed or
constructed for the individual (HCPC procedure code E1220), should provide the
recipient an opportunity to make an informed choice of a DME provider to
participate in the seating evaluation. It
will no longer be necessary to invite three (3) DME providers to participate in
customized wheelchair seating evaluations.
Only one DME provider will be invited to participate in the seating
evaluation, in accordance with the recipient's choice.
Upon completion of the seating evaluation, the
rehabilitation provider will send a copy of the evaluation including the
recommended specifications, to the DME provider who participated in the
evaluation. The rehabilitation
provider will no longer be completing the Form PA01 and submitting it to Unisys.
Instead, the DME provider will complete the Form PA01 to request prior
authorization for the wheelchair and submit it to the Prior Authorization Unit
at Unisys Corporation.
Upon the receipt of the request for prior authorization,
the Prior Authorization Unit will review the request for medical necessity.
If approved, the Prior Authorization Unit will determine the allowable
reimbursement amount by applying a discount of 18% to the manufacturer's
suggested retail prices for the wheelchair model requested and its accessories.
When completing the Form PA01, the DME provider should give
a complete description of the wheelchair and accessories, giving the model and
product number for each component. Procedure
code E1220 should be used for these customized chairs.
Specific HCPC codes assigned for individual wheelchair components should
not be used in the description. These
codes are intended for use only when requesting parts or accessories for
replacements, repairs, or additions, but not for customized wheelchair
descriptions and breakdown of components. Delivery
fees can be listed with a separate procedure code when there is a charge for
delivery from a store or a dealer representative to a recipient in another
parish. Labor charges may also be listed with a separate procedure
code.
Requests for wheelchairs for recipients with other third
party insurance coverage should be submitted in the same manner, with a copy of
the EOB from the other insurance carrier. The
same reimbursement formula will then be applied to determine the total allowable
price for the chair. Unisys claims
processing will then pay the difference between that price and the amount paid
by the insurance carrier, when billing is submitted.
Policy Notes
Restrictions of Out-of-State Care
The Louisiana Medicaid Program covers out-of-state hospital
services on an emergency basis only. The
exception to this policy is when an out-of-state facility has been approved
through the Unisys Prior Authorization process to provide medically necessary
services not available in the state of Louisiana.
Louisiana Medicaid also covers non-emergency services other than
psychiatric and substance abuse services when those services are provided by
hospitals in the bordering states of Texas, Arkansas, and Mississippi that are
routinely used by Louisiana residents.
In July of 1995, severe budget problems forced a reduction
in payments to out-of-state hospitals to the lower amount of 50% of billed
charges or the hospital's per diem rate. All
hospitals, in-state or out-of-state, are reimbursed at a flat fee per service
for ambulatory surgical procedures and laboratory and x-ray services provided on
an outpatient basis.
Hospital psychiatric or substance abuse services are not
covered on an outpatient basis. Inpatient
stays for psychiatric or substance abuse treatment are only covered in
out-of-state hospitals in the event of a medical emergency, for a maximum of two
days to allow time for the patient to be stabilized and transferred to a
Louisiana psychiatric hospital, when appropriate.
Attention Ambulance Providers: Rate
Increase for Emergency ALS Codes and Crossovers
The Medicaid Program has approved a rate increase for two
emergency medical transportation advance life support (ALS) services in order to
reimburse these services at the Medicare rate. Additionally, Medicaid has approved payment of the full
co-insurance and deductible amounts on Medicare crossover claims for
non-emergency ambulance transports provided to all Medicare/Medicaid eligible
recipients. Previously, approval
was given to pay the full co-insurance and deductible amounts only for those
recipients who were Qualified Medicare Beneficiaries (QMB). These rate increases are approved retroactively to January 1,
1996. We will re-process claims for
the adjusted payment amounts.
Please refer to the following list of procedure codes and
keep it as a quick reference to use when billing for services.
A brief description and the Medicaid rate of reimbursement is given for
each non-emergency ambulance procedure code.
The procedure codes are grouped according to the non-emergency ambulance
services and the emergency ambulance services.
The emergency ambulance services are payable in accordance with the rates
established by Medicare for each of the Medicare regions.
NON-EMERGENCY
AMBULANCE SERVICES
Code
Description of Service
Rate
A0360
Base
Rate, BLS non-emergency, 1st trip
$65.47
A0364
Base
rate, non-emergency, no specialized ALS services, 1st trip
$65.47
A0366
Base
rate, non-emergency, specialized, ALS services, 1st trip
$65.47
A0380
Non-emergency
loaded miles, BLS, 1st trip
$2.11
A0390
Non-emergency
loaded miles, ALS, 1st trip
$2.11
Z5100
Transfer, non-emergency, ALS or BLS, 1st trip
$65.47
Z5101
Transfer, non-emergency, ALS or BLS, 2nd trip
$65.47
Z5102
Non-emergency loaded miles, ALS or BLS, 2nd trip
$2.11
Z9497
Base rate, non-emergency, ALS or BLS, 2nd trip
$65.47
EMERGENCY
AMBULANCE SERVICES
Code
Description of Service
A0362
Emergency
transport; BLS
A0368
Emergency
transport; no specialized ALS services rendered
A0370
Emergency
transport; specialized ALS services rendered
A0380
Emergency
"loaded" miles, BLS
A0382
Routine
disposable supplies, BLS
A0390
Emergency
"loaded" miles, ALS
A0398
Disposable
supplies, ALS
A0422
Oxygen
and oxygen supplies, ALS or BLS
Z5100
Emergency transfer from hospital to hospital, BLS
Z5101
Emergency transfer from hospital to hospital, ALS
EMERGENCY
SERVICES PROCEDURE CODES AND RATES FOR EACH MEDICARE REGION
| Code |
REG 01 |
REG 02 |
REG 03 |
REG 04 |
REG 05 |
REG 06 |
REG 07 |
REG 08 |
| A0362 |
$169.46 |
$164.00 |
$169.46 |
$169.46 |
$169.46 |
$169.46 |
$169.46 |
$169.46 |
| A0368 |
$308.71 |
$309.08 |
$308.03 |
$309.13 |
$308.99 |
$308.99 |
$308.24 |
$309.32 |
| A0370 |
$308.71 |
$309.08 |
$308.03 |
$309.13 |
$308.99 |
$308.90 |
$308.24 |
$309.32 |
| A0380 |
$3.91 |
$3.91 |
$3.91 |
$3.91 |
$3.91 |
$3.91 |
$3.91 |
$3.91 |
| A0382 |
$7.50 |
$17.00 |
$17.00 |
$17.00 |
$17.00 |
$17.00 |
$17.00 |
$15.00 |
| A0390 |
$3.91 |
$3.91 |
$3.91 |
$3.91 |
$3.91 |
$3.91 |
$3.91 |
$3.91 |
| A0398 |
$7.50 |
$17.00 |
$17.00 |
$17.00 |
$17.00 |
$17.00 |
$17.00 |
$15.00 |
| A0422 |
$34.51 |
$34.51 |
$34.51 |
$34.51 |
$34.51 |
$34.51 |
$34.51 |
$34.51 |
| Z5100 |
$169.46 |
$169.46 |
$169.46 |
$169.46 |
$169.46 |
$169.46 |
$169.46 |
$169.46 |
| Z5101 |
$308.71 |
$309.08 |
$308.03 |
$309.13 |
$308.99 |
$308.99 |
$308.24 |
$309.32 |
Services Provided Involving both HMO and Medicaid Coverage
HCFA has recently clarified several issues concerning
services provided to recipients who are covered by both an HMO and Medicaid.
Effective with dates of service September 1, 1996, Louisiana Medicaid
will adopt the following policy concerning HMO/Medicaid coverage.
This policy is based on HCFA clarification.
The recipient must use the services of the HMO which they
freely choose to join. These claims
must be submitted hardcopy with a copy of the HMO EOB from the carrier which is
on file with the State.
1.
If the HMO denies the service because the service is not a covered
service offered under the plan, the claim will be handled as a Medicaid claim
and processed based on Medicaid policy and pricing.
2.
If the HMO denies the claim because the recipient sought medical care
outside of the HMO network and without the HMO's authorization, Medicaid will
deny the claim with a message that HMO services must be utilized.
3.
If the recipient uses out of network providers for emergency services and
the HMO does not approve the claim, Medicaid will deny the claim with a similar
edit.
If the provider of
the service plans to file a claim with Medicaid, copayments or any other payment
cannot be accepted from the Medicaid recipient.
Please make this information available to all staff who may
need it.