Provider Update

Volume 17, Issue 5 

October 2000

LaCHIP Information Goes Home With School Children

For the second year, through DHH's Covering Kids Initiative, parents of school-age children throughout the state received LaCHIP information with the free and reduced price lunch information. This enrollment information was distributed to over 835,000 children. 

"Last year we increased LaCHIP applications 300 percent using this approach," said DHH Secretary David Hood. "We know that health and academic performance are integrally linked. The partnership we have with the Department of Education is a natural collaboration." 

According to Ruth Kennedy, DHH's Deputy Medicaid Director in charge of LaCHIP, as of July 31, almost 70,000 additional children are now receiving health care benefits through Medicaid than were prior to LaCHIP's implementation in October of 1998. 

"This includes 34,730 children who have been made eligible due to LaCHIP's higher income limits, and another 34,254 children who qualify at the lower Medicaid limits, but who were enrolled following LaCHIP outreach efforts," Kennedy said. 

According to 1998 census estimates, 18.3 percent of Louisiana children are uninsured, compared to 15.5 percent nationally. 

LaCHIP covers health services for youth under age 19 whose families are at or below 150 percent of the Federal Poverty Level (FPL). LaCHIP offers no-cost medical, dental, vision, prescription drugs and mental health services. Beginning in January 2001, the maximum income levels will increase and families earning up to 200 percent of the Federal Poverty Level will qualify for services. 

Cecil J. Picard, State Superintendent of Education, said studies show that youth with health insurance coverage perform better academically and have fewer days of absence from school. 

"To improve the lives of Louisiana's children, we must answer all of their basic needs. Chief among them is good health. The LaCHIP program is making it possible for thousands of children to arrive at school in good health and ready to learn. It's an extremely valuable investment," he said. 

This year's campaign includes a flyer specifically targeted towards encouraging families with teens to apply. Teenagers are more likely to be uninsured than younger age children. While LaCHIP is known to cover common medical services, many teens and their parents may not know it also covers orthodontic work, acne medication and treatment for sports injuries. 

Families can call toll-free 1-877-252-2447 to request a LaCHIP application or for assistance during expanded hours that will run into evenings and weekends. Families who enrolled their children in LaCHIP last year must re-enroll to continue coverage. Updated information must be submitted using a one-page re-certification form that is mailed to their address. This form can also be requested using the toll-free hotline. Eligibility guidelines are listed below. DHH officials encourage families who are close to exceeding the income guidelines to apply for LaCHIP anyway. Eligibility criteria can be marginally different from what appears here. Medicaid providers are encouraged to share this information with their non-Medicaid patients. 

*In January 2001, eligibility will increase to 200% FPL

Clarification of Discharge Time
RA Message 8/15/2000, 8/22/2000, and 8/29/2000
FIMS #6027

Louisiana Medicaid uses Medicare's definition of discharge time which is applicable to both inpatient and outpatient discharges. A patient is considered discharged from the hospital when they are formally released from the hospital or die in the hospital. 

Non-medically necessary circumstances are not considered to be factors in determining the discharge time. Examples of such circumstances are the patient does not have a ride home or does not want to leave the facility; etc. The hospital will not be reimbursed if a patient remains in the hospital for a non-medically necessary reason.

In the event that a Medicaid recipient does not leave the hospital upon discharge, the hospital may bill the recipient but only after hospital personnel have notified the recipient that Medicaid will not pay for this portion of the stay.

Physician's Responsibilities Regarding the Authorization of Personal Care Services (PCS)

A physician must certify medical necessity for EPSDT Personal Care Services. The following must be completed: a Form 90-L, the Plan of Care, and a prescription signed by the physician certifying the necessity for personal care services, and the number of hours requested.

In signing these documents the physician certifies that:
� The patient is under his/her care;
� The recipient meets the requirements for an institutional level of care equal to Intermediate Care Facility 1;
� A face to face medical assessment was performed on the recipient within the last 90 days;
� These personal care services are medically necessary;
� There is a written plan of care that he/she has approved; and
� He/she will periodically review the plan of care (at least every 180 days).

Penalties which may be imposed on physicians for inappropriate certification include:
� Sanctions imposed by BHSF Program Integrity
� Referral to the Office of the Inspector General
� Criminal penalties in U.S. District Court, resulting in fines and/or a jail sentence;
� Civil prosecution in a U.S. District Court, resulting in fines and/or settlements;
� Civil monetary penalties from an administrative law judge resulting in fines ($2,000 per line item);
� If fraud is proven under the False Claims Act, damages and fines will be tripled;
� Simple sanction (barred from Medicare and Medicaid programs) by the Washington Office of the Inspector General.

Change in Reimbursement Methodology for Automated Laboratory Tests

Medicaid intends to adopt Medicare's current reimbursement methodology for automated multichannel laboratory tests. Therefore, providers will be paid only once per day per recipient for codes found on Medicare's uniform national roster. 

For example, ten tests are billed for date of service August 21, 2000 and nine of the codes billed are on the Medicare national roster. Under the adjusted payment schedule for automated multichannel tests, the fee received for the nine codes will be $12.00 instead of $52.70, the amount you are receiving now. The remaining code would be paid at the rate on the Medicaid fee schedule since it is not on Medicare's national roster. 

Automated Tests on Medicare's Uniform National Roster

Fee Schedule for the Procedure Codes on the Uniform National Roster

1or 2 tests:     $5.19 
3 tests:           $7.30 
4 tests:           $9.54 
5 tests:           $10.81 
6 tests:           $10.84 
7 tests:           $11.29 
8 tests:           $11.70 
9 tests:           $12.00 
10 tests:         $12.00 
11 tests:         $12.21
12 tests:         $12.48
13-16 tests:    $14.61
17-18 tests:    $14.71
19 tests:         $15.28
20 tests:         $15.78
21 tests:         $16.27
22 tests:         $16.77 

Providers will be notified of the effective date of this change via a remittance advice. If questions arise, please call Unisys Provider Relations at 1-800-473-2783 or Kandis Whittington at (225) 342-9490. Your cooperation is appreciated.

Payment of CPT Code 69990 
RA Message 10/10/200 and 10/17/2000
FIMS # 6142

The Medicaid Program will reimburse surgeons for CPT Code 69990 ( the use of operating microscope) if it is medically necessary. This must be listed separately in addition to the primary procedure code. These payments will pend until the Unisys physician-consultants make a decision. If the procedure code is considered routine by the physician-consultants, Code 69990 will be denied with error edit 774, (Included in Related Procedure).

Expansion of Covered Services for Certified Nurse Practitioners 

The Bureau announces that it is expanding the covered services payable to Certified Nurse Practitioners (CNP) to include assisting at surgery. According to the Board of Nursing, a CNP qualifies as an assistant at surgery if he/she worked as a first assistant during his/her clinical rotation in the emergency room.

In order to be reimbursed for assisting at surgery, CNPs must meet all state licensing requirements for education and training and provide the following documentation:

� A signed statement giving the name, dates and location of the program where you worked as a first assistant in the emergency room, OR
� A copy of any certificate, award, or letter from the program that shows the required information, AND
� A copy of your assistant-at-surgery protocol.

If questions arise, please call Kandis Whittington at 225-342-9490 or Tracey Zimmerman at (225) 342-9391.

After the documentation has been reviewed and verified, the CNP provider file will be updated to allow payment for assistant-at-surgery services. These services will be reimbursed at eighty percent (80%) of the fee paid to a physician who assists at surgery. Physicians who assist at surgery are paid twenty percent (20%) of the fee paid to the primary surgeon. The documentation required for a CNP to be reimbursed for assisting at surgery should be submitted to: 

Physicians Program 
Bureau of Health Services Financing 
P.O. Box 91030 
Baton Rouge, LA 70821-9030 
Attn: Kandis V. Whittington, Program Manager

We anticipate that Unisys will be able to accept claims for processing by December 2000. Providers will be notified of the date upon which they may begin to bill.

Enrollment of Clinical Nurse Specialists 

Clinical Nurse Specialists (CNS) wishing to participate in the Medicaid Program must complete a provider enrollment packet which can be obtained from Unisys by contacting Provider Relations at (800) 473-2783. The completed enrollment forms must be submitted to the following address for processing: 

Provider Enrollment Section 
Bureau of Health Services Financing 
P.O. Box 91030 Baton Rouge, LA 70821-9030

Claims may be submitted to Unisys for processing after the CNS has received a notice containing his/her Medicaid provider identification number from the Provider Enrollment section.Reimbursement for services rendered will be the same as that paid to Certified Nurse Practitioners (CNP).

Home Health Extended Care Services

Effective for dates of service on or after July 1, 2000, home health extended care services must be billed using procedure code X9902 which will be paid at an hourly rate of $24.50. The first hour payment will not differ from the additional hours rate. This rate has been adjusted to compensate for the cost of extended care.

Please use the new procedure code, which went into effect February 1, 2000, when requesting prior authorization or submitting a claim for extended care services provided by a licensed practical nurse (LPN).

Please refer to the provider notice dated January 24, 2000 for further billing instructions.

Acute Otitis Media: Management and Prevention of Resistance

By: Cathy Whipple, R.Ph
College of Pharmacy, University of Louisiana at Monroe

Issues
-The high incidence rate and treatment failures in acute otitis media
-Review of current standard practice guidelines
-Methods to reduce occurrence of acute otitis media and reduce the associated development of bacterial resistance

Otitis media is one of the most common pediatric illnesses and is also the most frequent diagnosis in children for which physicians prescribe antimicrobial agents. The Southern California/RAND Evidence-based practice center (EPC) estimates that over 5 million episodes of acute otitis media (AOM) occur annually, resulting in drug costs of approximately $3 billion dollars. These numbers have been increasing steadily over the past decade, raising questions about the current management of otitis media. The EPC states there is a need for standard definitions, diagnosis criteria, and treatment outcomes for acute otitis media. 

Current management of acute otitis media with antibiotics is commonly associated with treatment failure, and recurrence rates are high. There is uncertainty about when antibiotics should be used and which antibiotics are appropriate. We should therefore look closer at identifying risk factors to decrease occurrence, methods of prevention, and antibiotic usage to decrease resistance, which is the cause of most treatment failures.

Diagnosis: 
Otitis media may be divided into 4 separate diagnoses. Acute otitis media (AOM) is defined as the presence of fluid in the middle ear (MEF), inflammation, and signs of local and/or systemic illness. A diagnosis of AOM requires the presence of all 3 conditions. Otitis media with effusion (OME) is defined as fluid in the middle ear without the presence of inflammation or signs of illness. External otitis, also known as "swimmer's ear", is defined as infection of the external ear canal. Finally, chronic suppurative otitis media involves chronic otorrhea through a tympanostomy tube or a perforation of the tympanic membrane. This article will direct discussion to acute otitis media (AOM) because it is the most common of the four diagnoses and the area in which there is the most controversy. 

Diagnosis is a difficult process and may be variable depending on the skill of the physician and the cooperation of an infant or young child. The common physical findings upon otoscopic examination of the middle ear are bulging tympanic membrane, inflammation (redness), opacification of the tympanic membrane, hypomobility of the tympanic membrane, and otalgia. Symptoms of systemic illness must also be present to diagnosis AOM. These include symptoms such as rhinitis, fever, sore throat, restlessness, irritability, and pulling or rubbing of the ear. 

Acute otitis media is commonly the end result of a disease process. The process often begins with a viral upper respiratory tract infection. The upper respiratory tract infection causes mucus production and congestion, which can block passage through the eustachian tube. Pathogens from the nasopharnyx are then trapped here between the blockage and the tympanic membrane allowing for a bacterial infection to develop in the middle ear fluid.

Pathogens: 
In patients diagnosed with AOM, the pathogens most commonly isolated from middle ear fluid are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. S. pneumoniae is the most common of the three, causing approximately 40% of AOM diagnoses. Reports of increasing penicillin-resistant strains of S. pneumoniae are worldwide. The highest incidence of pneumococcal resistance is here in the United States. This is attributed to the overuse and inappropriate use of antibiotics. Incidence of these pathogens and resistance of these pathogens direct the treatment guidelines for AOM.

Treatment: 
For more than 20 years, amoxicillin has been the first-line drug of choice in the treatment of AOM. This is attributed to its limited side effects, high patient acceptability, and low cost. Amoxicillin, when compared to other beta-lactam antibiotics, has the lowest minimum inhibitory concentration (MIC) against penicillin-resistant S. pneumoniae. This agent also exceeds the MIC in the middle ear for fully- and intermediate-resistant strains of S. pneumoniae. For these reasons, amoxicillin is recommended as first-line emperic therapy for AOM. The recommended dose is 40 mg/kg/day in 3 divided doses for 10 days. Additionally, high-dose amoxicillin (80-90 mg/kg/day in 2 divided doses for 10 days) is increasingly being used because it provides higher concentrations of the drug in the middle ear fluid and has better success against intermediate and resistant strains of S. pneumoniae. In cases of penicillin allergy, the first-line agent is trimethoprim/sulfamethoxazole (TMP/SMZ) dosed 8mg TMP/40mg SMZ /kg/day in 2 divided doses for 10 days. This agent may not be as effective against S. pneumoniae as amoxicillin but may be slightly better against H. influenzae and M. catarrhalis. 

Second-line agents used for AOM in amoxicillin-treatment failures are controversial. Currently, there are 16 drugs approved by the FDA to treat AOM; however an expert panel directed by the Center for Disease Control (CDC) has suggested 3 options for treatment failure of amoxicillin. These options are 1) high dose amoxicillin/clavulanate (45 mg/kg/day in 2 divided doses for 10 days), 2) cefuroxime axetil (30mg/kg/day in 2 divided doses not to exceed 1gm/day), or 3) im ceftriaxone (50-75mg/kg as a single dose). For patients with penicillin allergy, the recommended second-line agent is erythromycin sulfisoxazole (40-50 mg/kg/day in 3 or 4 divided doses for 10 days). These second-line agents are not recommended as empiric therapy because they have been linked to increased development of resistant strains. This was proven in Finland where empiric use of these agents led to a 20% development of resistance in streptococci, which was previously sensitive to penicillin. The sensitivity was restored after limitation of the macrolide and broad-spectrum cephalosporin usage.

Preventing Resistance: 
Development of resistant strains to antibiotics is an unavoidable occurrence proven throughout evolution. New drugs and new drug classes have in the past remedied this problem. However, depending on the development of new drugs is not a realistic option. One should focus on methods of preventing or delaying resistance to current therapy. The following are some measures that can be taken to decrease the occurrence of AOM and some steps that can reduce the rate of antibiotic resistance.

1) Identify risk factors. These risk factors can help predict the incidence of AOM. Risk factors, which have been shown to increase rates of AOM, can be classified as either environmental or patient- specific. Environmental risk factors include not receiving breast milk, sleeping on stomach or side, using a pacifier, exposure to cigarette smoke, and day care attendance. Parents should be aware of these and make changes in the child's environment accordingly. Patient-specific risk factors include male gender, eustachian tube dysfunction, patients who are immunocompromised, and family history (especially among siblings). Most patient-specific risk factors cannot be adjusted; therefore, children should be closely monitored, and prevention techniques employed.
2) Improving accuracy of diagnosis. This could be the key to decreasing unnecessary use of antibiotics. Physicians have in the past relied solely on otoscopic evaluation for diagnosis, which can be difficult in infants and children. There are now other affordable devices to aid in diagnosis of AOM such as tympanometry. Tympanometry allows objective measurements of the tympanic membrane to determine the presence/absence of middle ear fluid (MEF). The presence of MEF is not the only requirement for a diagnosis of AOM. The patient must also have signs of inflammation and infection. AOM must be distinguished from otitis media with effusion (OME), which is only the presence of MEF without signs of inflammation or infection. OME does not require antibiotic therapy and will usually resolve over time. OME is almost always present after an episode of AOM or it may indicate the onset of AOM. In either case, OME should be closely monitored for signs of infection and/or hearing loss that can result in impaired language development and cognitive skills. 
3) Judicious antibiotic usage. The report recently released by the EPC on acute otitis media found that over 80% of children with AOM who do not receive antibiotic treatment are free of pain and fever within 24 hours of onset, and the infection resolves within 7 days. This compares to 93% recovery in 7 days with antibiotic treatment. This information would suggest that observation might be an alternative first-line therapy. Observation plus treatment of symptoms such as pain and fever for the first 24 hours have been successful in treating AOM, allowing for reduction in unnecessary antibiotic usage. Recommended analgesics and antipyretics include ibuprofen in children over 6 months (5-10 mg/kg/dose every 6-8 hours) or acetaminophen (10-15 mg/kg/dose every 6 hours). A topical analgesic may also be used in the ear such as olive oil or Auralgan�, which contains antipyrine and benzocaine. For this method to be accepted, parents and caregivers must be informed about AOM as a disease state, appropriate therapy, situations in which an antibiotic may or may not be necessary, and methods to decrease recurrence in children at risk. Without education, parents and caregivers will continue to request or even demand antibiotics to treat their children because they have seen the advertising, they believe antibiotics are the only cure, and they know antibiotics are available. Availability in our country is one of the leading causes of overutilization resulting in resistance. Other countries that have limited availability utilize observation as standard first-line treatment for AOM, and only if symptoms have not improved after 1-2 days are antibiotics prescribed. One example is in the Netherlands where antibiotic usage is limited and reported bacterial resistance is about 1% in contrast to the United States where resistance is about 25%. 

In situations where antibiotics are necessary in treating AOM, the recommended first-line therapy is amoxicillin. Trimethoprim/sulfamethoxazole may be used for those patients with a penicillin allergy. The AOM study by the EPC also reported that amoxicillin had similar treatment outcomes compared to other more expensive antibiotics such as cefaclor, azithromycin, and clarithromycin, which are also indicated in the treatment of AOM. Not only are these agents more expensive, but they also produce no better results than amoxicillin, and their increased use has been shown to increase bacterial resistance. Therefore, they should be avoided as empiric therapy.
4) Conjugate pneumococcal vaccine. This vaccine has shown promise in reducing AOM in children less than 2 years, which is the age group associated with the greatest incidence of AOM. Studies with this vaccine have resulted in significant reductions in office and emergency room visits and a significant reduction in the number of episodes in children with recurrent AOM.
5) Chemoprophylaxis. This should be considered only in children with severe or recurrent AOM, which includes children who have been diagnosed with 3 episodes of AOM in 6 months or 4 episodes in 12 months. The recommended drug for prophylaxis is amoxicillin at low doses (20mg/kg/day at bedtime for 3-6 months), or if penicillin-allergie use sulfisoxazole (75mg/kg/day at bedtime for 3-6 months). There is concern that usage of low-dose antibiotics over extended periods of time may cause resistance, but studies compared to placebo have proven chemoprophylaxis to be effective in decreasing recurrent episodes of AOM.
6) Surgery. This may be necessary for those children with severe or recurrent AOM in which other treatment has failed. These children may benefit from myringotomy, placement of ventilating tubes, or adenoidectomy to prevent or reduce episodes of AOM.

Conclusion: 
Antibiotic resistance is an inevitable problem in the treatment of infectious disease. The high incidence of AOM in children requiring treatment with antibiotics has naturally resulted in increased bacterial resistance. Management of AOM should therefore include methods of prevention and treatment guidelines to standardize care and reduce antibiotic resistance. Strategies to prevent episodes of AOM include identification of risk factors, conjugate pneumococcal vaccine, chemprophylaxis, and surgery. Methods to prevent bacterial resistance include improving diagnostic accuracy of AOM to reduce antibiotic usage and judicious use of antibiotics when indicated. In some situations, use of antibiotics may not be necessary and observation for 24 hours may be considered first-line based upon new studies. Education of parents and caregivers about these new findings is essential, and implementation of these strategies to decrease occurrence and resistance will preserve current antibiotic therapy from increasing bacterial resistance.

References 

Klein JO. Clinical Implications of Antibiotic Resistance for Management of Acute Otitis Media. J Lab Clin Med 2000 Mar; 135 (3): 220-224. 

Pelton SI. Challenges in the Management of Otitis Media. The American Journal of Managed Care 1999 Aug; 5 (11): S662-S669. 

Klein JO. Review of Consensus Reports on Management of Acute Otitis Media. Pediatr Infect Dis J 1999 Dec; 18 (12): 1152-1155. 

Management of Acute Otitis Media. Summary, Evidence Report/Technology Assessment: Number 15, June 2000. Agency for Healthcare quality and Research, Rockville, MD. 

Carlson D, Seay R. Acute Otitis Media Program Focuses on Antibiotic Usage. Drug Benefit Trends 1999 May: 40-47. 

Pichichero ME. Changing the Treatment Paradigm for Acute Otitis Media in Children. JAMA 1998 Jun; 279 (21): 1748-1750. 

Lacy CF, Armstrong LL, et al. Drug Information Handbook 7th Edition. Lexi-Comp Inc., 1999. 

Gilbert DN, Meollering RC, et al. The Sanford Guide to Antimicrobial Therapy 1999. Antimicrobial Therapy Inc., 1999.