Provider Update

Volume 18, Issue 5 

October/November 2001

WHAT IS HIPAA?

The Health Insurance Portability & Accountability Act (HIPAA) was passed by Congress in 1996. The two major legislative actions, Health Insurance Reform and Administrative Simplification, direct the adoption of national standards for electronic data interchange (EDI). The objectives of Administrative Simplification are as follows: 

� Reduce administrative costs and burdens by standardizing electronic transactions
� Reduce fraud and abuse
� Encourage electronic transactions in the health care industry and simplify the process
� Mandate standards for the security and privacy of health information

The Administrative Simplification provision is composed of several components and each has its own �rules� and �implementation guides (IG)�. There are several components of Administrative Simplification and only two (Electronic Transactions & Code Sets and Privacy Standards) have become �final�. The others are in the �proposed� stage. When final, all components will have different compliance deadline dates.

The components of Administrative Simplification are:

� ELECTRONIC TRANSACTIONS & CODE SETS STANDARDS � Compliance date is 10/16/02
� UNIQUE HEALTH IDENTIFIERS
� PRIVACY & CONFIDENTIALITY STANDARDS � Compliance date is 04/13/03
� SECURITY STANDARDS
� ELECTRONIC SIGNATURES

All current claim formats will be converted to the following standardized transaction types:

� Professional Claim (HCFA 1500)� 837(P) 
� Institutional Claim (UB-92)� 837(I)
� Dental Claim (ADA Standard Format)� 837(D) 
� Pharmacy � (NCPDP Format)
� Payment & remittance advice � 835
� Health claim status request & response� 276/277
� Enrollment � 834
� Eligibility request & response� 270/271
� Plan premium payments � 820
� Referral certification - 278 

Once the standards are implemented, health care providers will be able to submit the same transaction in the same format to any health plan. This will benefit the entire health care industry.

After the implementation date of October 16, 2002, any transaction submitted electronically will have to be in the HIPAA compliant format. It is the provider�s responsibility to develop the 837 or the provider can choose to use a clearinghouse or translator to convert their transactions into the HIPAA compliant format.

A copy of the 837 implementation guide is located on the Washington Publishing website located at 
www.wpc-edi.com/hipaa

WHO IS AFFECTED?

You are affected. Health plans, public health authorities, employers, life insurers, clearinghouses, billing agencies, information system vendors, universities and others are also affected. In other words all healthcare organizations are affected.

WHY COMPLY?

Significant financial penalties have been outlined for failure to comply:

� $100 per violation
� Maximum of $25,000 per year
� Up to $250,000 AND/OR up to 10 years imprisonment for violation of the Privacy Standard

WHAT IS LOUISIANA MEDICAID DOING?

The Department of Health and Hospitals is actively working towards the elimination of local codes due to the mandate. Compliance date is October 16, 2002. Over 1200 local codes have been identified and are currently being reviewed and mapped to standard procedure codes such as CPT and HCPCS which will affect provider billing practices. These changes may affect policy, reimbursement rates, and state regulations. Other activities include but are not limited to the following: 

�Mapping EOB/Error message codes; 
�Development of electronic claim attachments; 
�Simplifying prior authorizations; and,
�Development of HIPAA provider outreach efforts, and more.

Testing will be done prior to the HIPAA implemention. You will be notified of the testing either by the Provider Update, bulletins and newsletters, RA messages or our www.lamedicaid.com web site. Additional HIPAA related information will also be provided in billing manuals, training packets, and provider workshops. 

WHAT SHOULD HEALTHCARE PROVIDERS BE DOING?

Your organization must begin NOW to analyze how your systems and business processes are impacted by HIPAA. Listed below are some steps to take for successful HIPAA implementation:

� Education is the key - First, get educated. Read the rule at www.aspe.os.dhhs.gov/admnsimp.
Attend seminars and conferences. Build organizational HIPAA awareness.
� Assess your organization�s information systems � You must determine the impacts associated 
with your systems. Evaluate how your facility conducts business today and how you will need to
conduct business under HIPAA.
� Talk with your vendors � Check with your technical programming and system vendors to see 
what their plans are regarding HIPAA and determine when and if they will become HIPAA
compliant. 
� Talk with your business associates � Determine what their HIPAA compliance plans are and 
review contracts with your legal counsel for possible revisions due to the mandate. 
� Plan compliance strategies � As an organization, discuss and plan business strategies. 
� Implementation � Determine what system changes and/or process changes your organization 
needs for HIPAA compliance and how you will implement these changes. Networking with 
other providers and associations could prove to be beneficial. 

HIPAA RELATED WEB SITES

www.hcfa.gov/medicare/edi/hipaadoc.htm

http://aspe.os.dhhs.gov/admnsimp

www.wpc-edi.com/hipaa 

www.wedi.org

www.aha.org/hipaa/hipaa_home.asp

www.hcfa.gov/medicaid/hipaapls.htm

Clarification of Information Processed into New Dental Prosthetics


The original identification requirements which were required to be processed into new removable dental prosthetics for both the EPSDT Dental and Adult Denture Program have been shortened. The new criteria that must be processed into the acrylic base of each new removable dental prosthesis are as follows:

� The first four letters of the recipient�s last name and their first initial,

� The month and year; and, 

� The last five digits of the Medicaid provider number. 

The possible increase in expense associated with this requirement was calculated into the January 21, 2001, rate increase. Should you have further questions, please contact the LSU Dental School, Dental Medicaid Unit, by calling 504-619-8589.

Adult Denture Program Service Location Policy

On May 20, 2001, the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing established requirements for Adult Denture Program providers reimbursed under the Medicaid Program and conducting business at locations other than their principle place of practice. 

Adult Denture Program providers shall provide the physical address and business telephone number of their principle place of practice to the Medicaid Provider Enrollment Unit and to the DHH dental consultants at the LSU School of Dentistry, Dental Medicaid Unit. This address must be on file with the Louisiana Board of Dentistry. Records documenting the services provided shall be maintained at this location. 

For reimbursement, the service must be performed in either the parish where the provider�s principle place of practice is located, any surrounding parish with a contiguous border of at least one mile, or any parish with a land border of at least one mile contiguous with those parishes. Should you have any further questions regarding this matter, you may contact the LSU School of Dentistry, Dental Medicaid Unit by calling 504-619-8589.

Clarification of OB Sonogram Policy

Please note that, one complete sonogram (either 76805 or 76810) and two follow-up sonograms (either two 76815�s, two 76816�s or a combination of 76815 and 76816) will be reimbursed per recipient per 270 days among all providers.

Changes in Home Health Services

The Home Health Program is now being managed by Kandis V. Whittington. Please direct your phone calls about Home Health to Dawn Matte at 225-342-8223.

CPT Codes for Critical Care Services

Page 25-2 of the Physician Services Manual indicates that CPT codes 93000, 93010, 93040, and 93042 are included in Codes 99291 and 99292. Therefore, at this time, they cannot be billed separately. This policy was made before the descriptors in CPT listed the codes included in 99291 and 99292 and 99295 - 99298.

Effective with date of service September 1, 2001, providers will be allowed to bill CPT codes 93000, 93010, 93040, and 93042 in addition to 99291 and 99292 and/or 99295 - 99298 on the same date of service for the same recipient.

CPT codes 99291, 99292, 99295, 99296, 99297, and 99298 are global codes which contain component codes. The component codes are not to be paid on the same date of service as the global code to the same provider for the same recipient. As soon as programming can be completed, payment for the component codes will be recouped if paid to the same provider for the same recipient on the same day as the global code. Excluded from this programming will be procedure codes 71010, 71015, and 71020. 

The components codes for each of the global CPT codes can be found on pages 19, 20, and 21 of the 2001 Current Procedural Terminology.

Upcoming CommunityCARE Policy Changes

The CommunityCARE program will begin to exempt all Obstetrical and Dialysis services from the CommunityCARE referral process by January 1, 2002. More information on this program change will be provided to you via the RA Messages and the Provider Update as soon as it becomes 
available. Please direct your phone call about this to the Provider Realtions Unit at 1-800-473-2783. 

Code 46924 and Anesthesia

Effective with date of service on or after August 1, 2001, CPT code 46924 (Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum, contagiosum, herpetic vesicle, extensive, any method) will be funded with 5 base units of anesthesia.

Additional codes for CNPs

Effective with date of service on or after July 1, 2001, the following CPT codes were added to the list of codes payable to Certified Nurse Practitioners. 

11721 - Debridement of nails by any method; six or more
11055 - Paring or cutting of benign hyperkeratotic lesion; single lesion
11056 - Paring or cutting of benign hyperkeratotic lesion; two to four lesions
97601 - Removal of devitalized tissue from wound; selective debridement
97602 - Removal of devitalized tissue from wound; non-selective debridement

Two New Locations for BCSS

The Department of Health and Hospitals Bureau of Community Supports and Services (BCSS) has a new physical and website address. 

Correspondence to BCSS State Office should be sent to:

Bureau of Community Supports and Services
446 North 12th Street
Baton Rouge, LA 70802-4613
PH: (225) 219-0200 
FAX: (225) 219-0202

The BCSS website has been designed to answer many questions for both recipients and providers. It can be accessed at the following web address:

http://www.dhh.state.la.us/bcss/

To expedite answers to your questions and concerns, we encourage you to use this website to research issues and/or questions you may have regarding BCSS�s services. 

Clarification of �Claim in Process�

When the ICN of a claim appears on a remittance advice (RA), with a message of �Claim In Process,� the claim is in the process of being reviewed. The claim has not been approved for payment yet, and the claim has not had payment denied. During the next week, the claim will be reviewed and will appear as a �paid� or �denied� claim on the next RA unless additional review is required. The �Claim In Process� listing on the RA appears immediately following the �Denied Claims� listing and is often confused with �Denied Claims.�

Pended claims are those claims held for in-house review by Unisys. After the review is completed, the claim will be denied if a correction by the provider is required. The claim will be paid if the correction can be made by Unisys during the review.

Claims can pend for many reasons. The following are a few examples:

� Errors were made in entering data from the claim into the processing system.
� Errors were made in submitting the claim. These errors can be corrected only by the provider who
submitted the claim.
� The claim must receive Medical Review.
� Critical information is missing or incomplete. 

EPSDT Code Clarification

The description of EPSDT consultation codes X0180-X0182 and X0187-X0189 found in the KIDMED manual are for one (1) face to face contact. Multiple units may not be billed for the same contact.

Clarification of Repair and Preventive 
Maintenance for Breathing Equipment 

The reference to repair and preventive maintenance for breathing equipment in the April/May 2001 Provider Update relates specifically to oxygen concentrators and nebulizers.

That April/May Provider Update article does not impact the Department�s policy related to ventilators.

Clarification of Repair and Preventive Maintenance for Breathing Equipment 

The reference to repair and preventive maintenance for breathing equipment in the April/May 2001 Provider Update relates specifically to oxygen concentrators and nebulizers.

That April/May Provider Update article does not impact the Department�s policy related to ventilators.

Question Corner

Professional Services

1. What is HIPAA and how will it effect providers?

HIPAA is the acronym for the Health Insurance Portability and Accountability Act of 1996, an act created by Congress to address a wide range of health related issues. HIPAA requires the use of standardized record formats, code sets, and of health care processing. It simplifies the administration of systems to enable efficient electronic transmission of certain health information. HIPAA will allow the entire health care industry to be able to communicate through electronic data using a single set of standards. Thus, nonstandard formats and state-assigned codes will be eliminated. Providers will be required to bill only nationally recognized CPT and HCPCS codes.

In keeping with these requirements, our staff is currently devoting a large segment of its time to converting state-assigned codes, like Z9004 and Y2509, to nationally recognized CPT and HCPCS codes.

Training sessions with providers will be necessary so that provider systems can be converted and tested prior to the October 2, 2002 deadline for state-wide HIPAA compliance.

Questions about HIPAA and its impact on the Physicians Program can be directed to Kandis Whittington at 225-342-9490.

2. How does the service limit file work for recipients to age 21 and recipients 21 and older?

Outpatient visits are limited to 12 per state fiscal year for each eligible recipient who is 21 years of age or older. Visits for recipients younger than 21 are unlimited. Since there are no service limit restrictions on visits for children to age 21, the service limits file always gives a �00� response to a provider�s inquiry via MEVS.

Outpatient visits for recipients age 21 and older are limited. Each July, recipients age 21 and older are given 12 outpatient visits to be used through the following June. The service limit file keeps track of the number of visits paid for each recipient per state fiscal year. 

There is one thing about which providers should be aware when using this file. If a provider makes an inquiry in July or August of the new year about the number of visits remaining in that year, he may receive information indicating the recipient has no visits left. This response may lead one to believe the file information is erroneous. It is not, because the service limits file doesn�t �roll over� to show new year statistics until the first visit in the new year has been paid. In other words, the payment of the first visit prompts the file to �roll over�. So, don�t let yourself be misled by this occurrence. If, after making an inquiry, you still are not sure if the recipient has visits remaining, call Ida Duncan of the Physicians Program at 225-343-3932. She will be happy to help you.

2001 Provider Training Questions

The following information is the first half of the questions asked during the 2001 Provider Training sessions. A second series of questions will be included in the December 2001/January 2002 Provider Update.

Basic 

1. Is there a statewide schedule for the �roll out� of the CommunityCARE program?
Effective March 1, 2002, Louisiana Medicaid will expand the CommunityCARE program to include Livingston, St. Helena, St. Tammany, Tangipahoa, and Washington parishes. Please watch the Provider Update and RA Messages for more information concerning the schedule for the remaining parishes.

2. Who is responsible for getting the CommunityCARE referral, the recipient or the provider?
The recipient should have the referral when arriving for an appointment, or the PCP can FAX/mail the referral prior to the appointment. If the recipient does not have the referral and it has not been FAXED/mailed, the provider may either contact the PCP for a paper referral or send the recipient back to the PCP. It is the provider�s responsibility to have the referral on file when billing for the visit.

3. What management fee does the PCP receive for enrolling in the CommunityCARE program?
The PCP receives a $3 monthly management fee for each CommunityCARE recipient linked to him/her as the PCP in addition to the regular fee for service reimbursment.

4. Will the recipient�s Medicaid card display that the recipient is in CommunityCARE?
The card will not indicate that the recipient is CommunityCARE. It is the provider�s responsibility to check eligibility using the REVS or MEVS systems each time the recipient requests services. REVS/MEVS will tell you if the recipient is in CommunityCARE and the PCP�s name and phone number.

5. Should a lab provider who obtains referral forms for patients participating in the CommunityCare Program be keeping this form on file?
Yes, labs must keep referral forms and other Medicaid documentation on file for a period of five years.

6. When a new CommunityCARE PCP is inundated with Medicaid patients who have been auto-assigned to his/her practice, what can be done?
There is a cap of 2000 recipients for a full time physician and 500 additional recipients for a full time nurse practitioner working in the practice. The doctor can request to limit his/her practice to current patients only. Please contact Birch and Davis to discuss the process to make this arrangement.

7. A CommunityCARE patient comes into a specialist�s office without a referral form in hand and the specialist contacts the PCP who tells the specialist to render services and a referral will be forwarded. If the PCP doesn�t send the referral, what recourse does the specialist have?
You should call your Unisys field analyst or the DHH CommunityCARE Program for assistance in resolving the problem.

8. What are timely filing limits for claims for CommunityCARE patients?
CommunityCARE does not change the timely filing limits for claims; you have one year from the date of service to submit your claim in to Unisys or 60 days from date of service for KIDMED claims.

9. How are accident related claims handled?
You must make an initial decision whether you will bill Medicaid for your services or pursue payment from another party that may have liability. If you accept the patient�s Medicaid card for payment, you must accept the Medicaid payment as payment in full. All documents related to the case and requested by other parties must be stamped with an annotation stamp to indicate to other parties that Medicaid has paid your services, and any payment should be made to the Medicaid Program. Other parties should be directed to the DHH TPL Unit concerning the case. You may not void the Medicaid claim to obtain monies from another source. 

10. Regarding the question above, in a situation where a provider doesn�t know that the accident may result in payment from another liable party and receives payment in full from Medicaid, it does not seem fair that the Medicaid payment cannot be returned since the provider did not have the knowledge that other payment could be forthcoming.
This is an issue that will have to be handled internally. A procedure should be implemented to question the patient upon registering them as to whether or not the injury was accident related. Also, remember that a provider has the option of waiting to bill Medicaid until the claim is nearing the one year timely filing limit which should allow ample time to clarify the situation.

11. Can co-pays be collected from recipients?
The pharmacy program has state approved Medicaid co-payments that may be collected from the recipient; managed care co-payments may NOT be collected.

12. What is the process for having a private insurance or Medicare removed from a recipient�s file because it is no longer effective?
The claim and insurance EOB or denial letter should be sent hard copy with a cover letter of explanation to Unisys Provider Relations. The claim will be processed and the insurance/Medicare information will be forwarded to the DHH TPL Unit to have this information removed from the recipient�s file.

If you know that an insurance/Medicare should be removed or added to a recipient�s file but do not have any documentation from the carrier, you may write a letter to the DHH TPL Unit giving the information you have for the carrier, and the TPL Unit will contact the carrier and correct the file if appropriate.

If DHH learns of a situation where a private insurer goes out of business (i.e., Gulf South) or another type of mass change takes place that affects large numbers of recipients, a systems change may be initiated to change all recipient files involved.

If you have received payment from Medicaid and a private insurance because a recipient�s file is incorrect, you should adjust the Medicaid claim to indicate the payment from the private insurance. 

13. If a Medicare carrier does not automatically cross claims to Medicaid, what documentation should be attached to the claim filed with Medicaid?
The claim should be identical to the one filed to Medicare and a copy of the EOMB from Medicare should be attached.

14. If a claim is older than two years old and must be reviewed by the state, where should the claim be sent?
A letter of request, accompanied by the claim and supporting documentation, may be mailed either to the Unisys Correspondence Unit who will forward it to the state, or this request may be sent directly to DHH to the attention of the appropriate program manager.

15. What is the time span to receive a referral from the PCP?
There is no specific time frame to request a referral. The primary concern is that a paper referral must be obtained for services provided. We encourage providers to either approve or deny a referral within 10 working days of receiving the request.

16. Is it necessary to verify eligibility through REVS or MEVS to determine if a recipient is a CommunityCARE recipient?
Yes, eligibility should always be verified prior to rendering service to Medicaid recipients. CommunityCARE information will be provided with the eligibility response.

17. Can we obtain a complete list of denial error codes?
No, the denial error code listing continually changes. In addition, on your weekly remittance advice the denial error code (numbers and description) specific to your situation is defined. We are working toward having that information available on the Internet.

18. Can a patient be held responsible for payment when a PCP refuses to give a referral, specifically when the patient comes into the ER for a non-emergency?
If the patient�s presenting symptoms do not meet the �prudent layperson standard�, this is considered routine care (non-emergent care) which is a non-covered service by Medicaid, and the patient can be billed.

19. What should we do when we are having trouble with a Medicare HMO?
Call the State TPL Department at (225) 342-9454.

20. Are recipients getting letters about CommunityCARE?
Yes, they receive an initial letter about 2 months before their region rolls into CommunityCARE. A second letter asking that they choose a PCP is sent approximately 1 month prior to the date their region rolls into CommunityCARE. After CommunityCARE is implemented in a parish, notices go out once a month to new recipients.

21. How does CommunityCARE affect the hospital specialty consults?
The hospital should be sharing the referral with all other providers who are rendering services during the hospital stay.

22. If the patient is QMB what will Medicaid pay for deductible?
Medicaid will pay up to the allowed Medicaid fee.

23. How do you receive the ERA?
Contact the EMC department at 225/237-3200 for details.

24. Is a referral from the PCP only used for the date or dates indicated on the referral?
Yes, for other dates of service another referral must be obtained. Except when a referral is written to a specialist for a certain time frame and that specialist requests lab or x-rays which cannot be scheduled in that time frame. The lab or radiologist may use that same referral because it is associated with the initial referral.

25. What happens if the current PCP refuses to give an administrative referral when a recipient changes PCP?
The current PCP has that right to refuse an administrative referral, but then he/she must either provide services to that patient or give individual referrals for that patient�s care.

26. We have one example where the PCP faxed a referral form containing only the referral number. Can this referral be used for the recipients for which we requested a referral?
No, it must be completed. See question 32.

27. Is a standardized form for hospital outpatient services acceptable as a referral form if the PCP indicates his authorization number and signs it? 
Yes, if it contains all the information contained on the DHH CommunityCARE referral form.

28. If a recipient is admitted to the hospital and the diagnosis changes during the hospital stay, who should contact the PCP and obtain another referral?
For inpatient only, the initial referral is applicable for the whole stay - no matter how often the diagnosis may change.

29. We are an ENT specialist and see recipients who are pregnant. Should we request the referral from the obstetrician or the PCP?
If the PCP assigns all care to the OB during the pregnancy, then the referral given to the OB is acceptable. If the PCP wants to provide routine care, you will need to request the referral from the PCP.

30. Can a PCP refer out of the parish/contiguous parish to a specialist?
Yes.

31. How do school based health services fit into CommunityCARE?
Most services will require a referral except for the services that fall under the EPSDT exempt services.

32. Does the PCP need to complete the referral form or can the service provider fill it out and send it to the PCP for a signature?
The PCP�s office should complete the form.

33. Will the CommunityCARE PCP receive a management fee for all Medicaid patients he sees or only those recipients linked to him on the CP092 management report?
The management fee is paid for each recipient linked to the PCP on the CP092 report.

34. If a patient receives service from a mental health clinic (which is a CommunityCARE exempt service) and the clinic sends the patient to the hospital for lab work (that does require a referral), who is responsible for obtaining the referral form?
The mental health clinic should contact the PCP for a referral form and forward it to the hospital. Responsibility for obtaining the referral lies with the provider that is the point of entry.

CASE MANAGEMENT

1. Are we now required to document stop times?
No, stop time is not required at this time.

2. At what point will the CPOC format be available on disk?
The BCSS Case Management Program Manager will notify Case Management agencies when it is available.

DME

1. Define �gainful employment�.
An individual is considered gainfully employed if he/she receives $100 or more per month for work related issues.

2. Do we need a CommunityCARE referral for PA?
No, referral is required for the PA process per se. A physician�s prescription is required for the PA process. However, a CommunityCARE referral is required for provision and payment for services.

ELIGIBILITY

1. Is the three month retroactive policy the same as spend down?
No, spend down is a different program. Eligibility may begin up to 3 months prior to the month the application is filed provided all eligibility factors are met. Spend down Medically Needy Program (MNP) Eligibility is determined for 3 month quarters.

2. How do you determine which Medicare/Medicaid patients you pay prescription drugs for?
The QMB categories determine this coverage, and parish office certifies patient for eligibility categories.

3. How many outpatient visits does a patient 21 years of age and older have per year?
Twelve per state fiscal year (July through June).

4. Are patients who have LaCHIP exempt from CommunityCARE?
No, LaCHIP is not an exemption category for CommunityCARE.

FQHC/RHC

1. Our Rural Health Clinic sees patients from many different parishes. Will we still be able to service these recipients once they become enrolled in CommunityCARE?
Rural Health Clinics may become CommunityCARE PCPs. (1) If you choose to participate as a CommunityCARE PCP; (2) are located in the recipients� parish of residence or a contiguous parish (a parish touching the parish of residence), and (3) are the recipients� assigned PCP, you may continue to see the recipients as their PCP (without a referral). Otherwise, a referral is required to be paid for services.

2. When billing private insurance we bill CPT procedure codes such as 99212. How should we bill Medicaid secondary?
Complete the HCFA 1500 claim form according to Medicaid policy and file your claim with an EOB attached and a cover letter stating the reason for the difference in the procedure code.

These claims must be filed hard copy since it is necessary to attach a copy of the private insurance EOB. Electronic submissions will deny.

3. A verification of recipient eligibility through REVS/MEVS indicated that the recipient had one office visit remaining. The claim denied indicating that all the visits were used. How can this happen?
The system counts paid office visits based on claims history. If another provider�s claim processed and paid after the eligibility check and before the claim processed, this would cause the claim to deny for visits exhausted. If the visit was an emergent or life-threatening situation, you should file for an extension of visits. If not, you may bill the patient since all visits were used, and this becomes a non-covered visit.

4. Our Rural Health Clinic physician sees patients at the nursing home. We have been using the RHC provider number to bill this service. Is this correct?
If the doctor is seeing the patient outside of the clinic, he should be filing these services using his individual or group provider number. If these claims have been billed using the RHC provider number, they should be corrected. An adjustment may not be filed to correct provider numbers. The original claim payment must be voided; then a new, original claim must be filed using the correct provider number (in this case it would be the doctors individual or group provider number).

HOSPITAL/PRECERTIFICATION

1. If a patient undergoes a transplant, then must have another one, do both transplants require PA and will a second letter be required for the second transplant?
Yes, each transplant requires a separate authorization.

2. If the mother has HMO coverage but the baby has not been added to the plan, how should this be handled?
Send the bill with documentation (EOB from mom�s HMO), and a letter of explanation to the Provider Relations Correspondence Unit for special handling.

3. If a patient presents to the ER with a broken leg and eight hours later returns and is admitted inpatient do the ER charges roll into the inpatient stay or are the two visits combined?
In this case, the charges should be combined.

4. In regard to the above question, does the same rule apply if the second time that the patient presented to the hospital it was at a different facility?
No, each facility would bill their charges.

5. What is the turn around time for receiving a PA from Unisys?
The Unisys contract requires 25 working days or less, but the average turnaround time is 10-15 working days.

6. How many months of PA can be applied for at a time?
Six months.

7. In regard to the above, is this a new policy?
No, this is not a new policy. Keep in mind that a provider may request only what a doctor prescribes. If the prescription is written for one month of service and the facility/provider requests six months of service, only one month will be authorized if approved.

8. When submitting hard copy claims for outpatient services, is the line item Date of Service required?
Yes, you need to indicate a date of service for each line.

9. Because of pending Medicaid numbers sometimes it is a year or more before we get the information needed to bill. What should we do?
A copy of the DHH retroactive eligibility letter from Parish office should be sent, along with your hard copy claim, to Provider Relations for processing. Don�t forget to get precert for those dates of service. According to policy you have one year from the certification date on the retroactive eligibility letter to submit the claim.

10. Should an ICD-9 procedure code beginning with �99� be billed using revenue code 490?
ICD-9 surgical procedure codes falling within the range of �01-86� should be billed using the 490 revenue code. If the ICD-9 procedure does not fall within this range, and is not included in the four established groupings, bill revenue codes indicating the services that have been provided.

11. Can we bill for two 490 revenue codes for the same date of service?
Two can be billed. Only one per day will be paid.

12. Can a claim be filed to Medicaid for per diem before Medicare pays on the Part B charges?
No, the claim submitted to Medicaid must have the Medicare Part B EOMB attached when filing for per diem.

13. Is it necessary to have a precert number on Medicare Part B claims?
Yes, the only Medicare crossover claims that do not have to be pre-certified are Medicare Part A unless Medicare Part A benefits have been exhausted.

14. Is a patient who is under 40 years of age required to have a personal history or a family history of cancer to reimburse for a mammogram?
Yes, in order for the claim to be reimbursed by Medicaid.

15. Do UB92s have to be submitted hard copy?
No, they may be billed electronically.

16. What is the maximum number of lines that can be submitted on inpatient and outpatient claims?
Outpatient claims may have 23 lines, including the total charges, and inpatient claims may have 26 lines.

17. Do all procedures done during physical therapy have to be prior authorized?
Yes, you must prior authorize every procedure.

18. If after a patient is triaged it is determined that the patient should be seen by the PCP, will the PCP give a referral for the triage charges?
If the presenting symptoms prove it was warranted (i.e., meet the prudent layperson standard), the PCP should issue a referral.

19. What should be done if the hospital is having problems obtaining referral forms from the PCP?
Contact your Unisys field analyst or the DHH CommunityCARE Program who will call the PCP to discuss program policy and procedure.

20. When requesting a reconsideration on a denied case, what documentation should be sent to Precert?
Documentation that supports and substantiates why the patient needs to stay in the hospital.

21. If MEVS transmits incorrect eligibility information, can we get precert?
Yes, if MEVS information is incorrect, the provider may submit the MEVS swipe strip or printout to precert, and he/she is not held responsible for submitting incorrect information (with receipt proof only). ***Please remember that as of July 1, 2001, DHH has clarified that a provider only has 60 days from the date on the EOB to file the retrospective request for precertification of a Medicare Part A exhaust. This clarification was published in the July-August 2001 Provider Update Manual.

22. Can precert be obtained if an EOMB stating that Part A coverage is exhausted is submitted with a PCF01?
Yes, if the common working file demonstrates Medicare Part A is exhausted even if the Medicaid system shows otherwise. (Please remember that as of July 1, 2001, DHH has clarified that a provider only has 60 days from the date on the EOMB to file the retrospective request for precertification when Medicare Part A is exhausted.)

23. What happens when a patient becomes certified for Medicaid after being admitted to the hospital?
The case should be precertified as soon as this information is obtained.

24. When the doctor writes orders to admit the patient, when should the admission time begin? Does it begin when the patient comes into the hospital or when the doctors� orders are written and signed?
Submit documentation of when the patient enters the hospital; the reason for admission should be stated in the documentation.

25. Please explain the denial for alternative care. In some instances, an alternative place can not be found for this care. What should we do when there is not an alternative level of care facility available for wound care and other cases?
In the appeal process, please document to DHH your attempts to find an appropriate place to send the recipient to receive the care needed. The appeals judge will review the criteria as well as the documentation of the inability to find a place to send the recipient.

26. If a fax is transmitted to Unisys and it disappears (is not received), how can the provider prove that the fax was sent?
Send a copy of the transmittal sheet which contains the date, time, and number of pages to be transmitted. The transmittal sheet must have a federal CSID number on it. This information should be sent to the attention of Sandy or Janeen in pre-cert.

27. If projected date of discharge is on Saturday or Sunday when must information be submitted to meet timely submission for precert?
The following Monday for extension of stays.

28. If someone comes through the ER unconcious and is registered as �John Doe� how do we handle this situation?
As soon as the hospital obtains the correct identifying information they should submit the precertification information to Unisys with documentation of the unusual situation.

29. Do babies being admitted to NICU have to be precerted even if the days fall within the mom�s stay?
Yes, any time a baby is admitted to NICU he or she should be precerted.

30. What is the time limit on regular precertification for new cases?
The time limit is no later than one business day after admission.

31. When a patient is discharged and the EOMB shows that Medicare Part A has been exhausted, what process should be followed?
Submit the precert as a retrospective review, and attach the EOMB to show that Medicare Part A was exhausted while the patient was in the hospital.

32. If a baby goes into NICU for injections while mom is in the hospital but baby is not sick and does not meet NICU criteria, should we precert the baby?
No, if mom is still in the hospital and the baby does not meet NICU criteria, you cannot precert the baby.

33. If the patient stays 26 hours and was admitted as outpatient do we have to roll this into an inpatient stay?
Yes, any stay over 24 hours automatically becomes inpatient and must be precerted. If the medical criteria does not meet LOS criteria and precert is denied, you cannot go back and bill this as outpatient. 

34. Is a case number necessary to file precert updates?
Yes, you need a precert case established before you can request an update.

35. When sending a summary of progress notes because of illegible writing, do the actual progress notes need to be sent, also?
Yes, you must submit the physicians� progress notes along with your summary of the notes. Also, remember to sign your summary as this is what makes the document legal.

36. For fax transmittals, if the transmittal slip from the fax machine states only 13 of 15 pages were transmitted, do we need to send all 15 pages again?
Yes.

37. If we send documentation after hours to Unisys and something goes wrong with the fax machine do we need to keep the transmittal slip showing there was a problem?
Yes, keep the transmittal slip, but you should try to fax again the very next day.

38. A patient is using their lifetime days with Medicare and is also pursuing Medicaid eligibility. What process do we follow since the Medicare days are going to end?
As soon as you receive the Medicaid eligibility notification, you should submit the precert from the day Part A was exhausted.

KIDMED

1. If following a KIDMED screening, the patient must be referred, can the KM-3 still be filed electronically?
Yes.

2. Can a CommunityCARE doctor sub-contract his entire KIDMED practice?
No, he must provide services in his office for at least one age group, he must have all equipment on his premises that he would need to provide KIDMED services and he must be KIDMED certified.

3. When will the PCP show on REVS?
Once the patient has been linked the information will be listed. Please make sure to follow all prompts to insure that you obtain all information.

4. If we do not provide KIDMED services, we can not be a PCP. About 50% of our practice is Medicaid. Will we lose all those patients?
Yes, if you do not enroll as a CommunityCARE provider. Medicaid recipients are required to choose a CommunityCARE doctor. We encourage providers to discuss the various arrangements available through which the KIDMED standard can be met before they decide to not enroll in CommunityCARE solely because of the KIDMED component.

5. Four hundred patients have been auto-assigned to our practice, and we cannot possibly see all of these new patients at one time. May we issue referrals for services since we have not seen these patients?
Yes, this is called an �administrative referral� and you should note on the referral that the office is over booked. Whether or not a PCP issues a referral for a patient thay have not seen is a professional decision made by the PCP based on the situation and the patient�s medical needs. However, referrals should not be withheld solely because the PCP has not seen the patient. CommunityCARE PCPs are responsible for writing a referral if they are unable to provide medically necessary care to a recipient in a timely manner. 

6. Is the 90-day time limit going to be in effect for recipients who didn�t receive their letters instructing them on how to choose a PCP?
All enrollees have 90 days to change their PCP after a new enrollment period. The 90 days begins the effective date of a linkage to a specific PCP.

7. Has the schedule for the CommunityCARE roll out changed?
Yes, no one will roll out for the remainder of the year. Please watch your remittance advices and provider newsletters for future roll out dates.

8. Can a provider get a listing of participating PCPs in his/her parish?
No lists will be mailed or faxed. Information is available at the Birch and Davis Provider Help Line.

9. Can a CommunityCARE recipient go to any dentist?
Yes, dental services are exempt from the CommunityCARE program.

10. Can a physician in a contiguous parish become a PCP?
Yes.

11. If a patient has been seeing a specialist for care and is now enrolled in ComunityCARE and linked to a PCP, does the specialist now need a referral to continue care?
Yes, a referral is needed in order to continue treatment.

12. If a PCP wants the school board to perform a screening will the school board need a referral?
Yes, any service performed by a provider other than the PCP must obtain a referral and retain the referral form for a period of five years.

13. What is Childnet?
Childnet is the state�s Early Intervention Program for children 0 through 2 years of age with developmental delays. The lead agency for this program is the Department of Education. KIDMED providers are required to refer children who fail developmental screenings and may meet Childnet eligibility criteria to the Childnet program. Further information may be found on page II-8 and Appendix 15 of the KIDMED Manual.

14. Are there plans to make any exceptions in the CommunityCARE policy/procedures for school boards � particularly related to KIDMED linkages and services?
No exceptions are planned at this time.

15. From time to time, patients state they are not linked to us for screenings; however, they appear on our RS-0-07 report. What should we do?
If a patient appears on your RS-0-07 report, he is linked to you for the entire month reflected in the report date. Linkages only change on the first of each month.

16. What do we do if we cannot get parents to bring their children in for a screening within the allotted timeframes?
Document your efforts at outreaching these recipients.

17. Can an EPSDT consult be done on the same day as a medical screening?
The medical screening fee includes basic preventive counseling, health education, and anticipatory guidance. A consult (codes X0180-X0182, X0187-X0189) can be billed on the same day or at any time if;
� The intervention is beyond the basic health education and anticipatory guidance components of the medical screening,
� There is documentation of the specific need for the consult for that recipient,
� There is documentation of the outcome of the consult, and
� There is documentation of the referrals if further treatment is needed.
The consult is a one-to-one, face to face contact. Multiple units may not be billed for the same contact. Consults are not to be used for ongoing therapy. 

18. When is a site number not required?
If the provider only has one site a site number is not needed.

19. Do RTDs come to the �pay to� address?
Yes.

20. What happens when a newborn does not receive a Medicaid number until sixty days after a screening is performed? We cannot meet the 60-day claims filing limit.
Bill the claim without the Medicaid ID number to get a denial within the sixty-day filing limit. This provides proof of timely filing to bill correctly once the number is obtained.

LONG TERM CARE

1. When a 148 PLI is completed, is it necessary to have a copy of the 18 LTC to convert the liability?
No, when the 148 PLI is in place the 18 LTC is not needed to convert patient liability.

2. Does the long term care provider bill for room and board for a hospice recipient?
No, hospice bills for room and board, then reimburses the long term care facility.

3. How do you handle correcting an adjustment claim?
You would have to adjust the adjustment.

4. Is the old 90-L form still acceptable?
Health Standards is rejecting old 90-L forms. Physicians should be told that the old 90-L is not acceptable any longer. New versions of Form 90-L can be downloaded from the Health Standards Publications page on the Internet at http://www.dhh.state.la.us./hss/ltc_publications.htm The 90-L is still required for HCBS waiver. HCBS is an alternative to LTC.

PROFESSIONAL SERVICES

1. Do regular eye exams require prior authorization?
No.

2. Does it matter which order modifiers are placed on the claim form?
No, two modifiers are acceptable per claim line and the order does not matter.

3. What block does the supervising physician name go in for a CNP claim?
Block 17 of the HCFA 1500 claim form.

4. How long has CommunityCARE been in effect?
The pilot program began in 1992-93 in primarily rural parishes.

5. As a specialty provider, will I need a referral for each Medicaid patient?
PCP referrals are required if the recipient is a CommunityCARE recipient linked to a PCP.

6. In some instances, the patient medical record number is missing on a remittance advice. What happened to it?
If your claim is filed electronically it could be something related to your software. If your claim was filed hard copy this field should be keyed. Please keep in mind that this information does not cross over for Medicare/Medicaid claims and isn�t keyed on hardcopy crossover claims.

7. Can a physician choose to participate in CommunityCARE or not?
Yes, this is a voluntary program, however physicians who are not enrolled in CommunityCARE must have a referral for services provided to CommunityCARE recipients in order for Medicaid to reimburse them.

8. Do the same rules apply to RHC for CommunityCARE as they do for physicians?
Yes.

9. If a patient is already scheduuled for 6 months of care when CommunityCARE is initiated in the parish, do I have to get a referral?
Yes, if the patient is enrolled in CommunityCARE, you will need a referral form prior to rendering services.

10. Will patients know if they will be CommunityCARE?
Yes, they receive information regarding the program prior to being linked to a PCP.

11. For a physician�s group practice, if the recipient sees a particular provider within the practice can whoever is available see them?
Yes, the recipients are linked to the group if the provider is enrolled as a group.

12. Will the fee schedule and visit limits stay the same?
Yes. CommunityCARE does not override other Medicaid policies and procedures such as fees, visit limits, prior authorization, precertification, etc.

13. Does Unisys provide the referral forms?
No, providers may make copies of the one provided in the training packet or create their own form as long as it contains the same information as the DHH referral form.

14. We are a radiology group and we already have problems getting information from a hospital. What can we do?
If you need assistance please contact your Unisys field analyst.

15. How can we be paid for specimen collection (blood, etc.)?
Specimen collection is a part of the office visit and is covered under the office visit reimbursement.

16. If a certain CPT code always requires attached documentation, should the claim with the documentation be sent to the correspondence post office box or the regular claims post office box?
Unless special handling is required or problems exist on the claims, they should be sent to the regular post office box.

17. If a claim is billed without the appropriate modifier, should it be adjusted or voided?
In this case, an adjustment should be made. 

18. Should we attach the original remittance advice to the 213 adjustment/void claim?
No.

19. If a CommunityCARE referral comes from a provider in a group should the group number or the individual number be on the form?
The referral should come from whoever is the recipient�s PCP. In most cases, if providers are practicing under a group number, the group is enrolled as the PCP, therefore the group number should be on the form.

20. We are a mental health rehabilitation provider. One of our patients needs lab work, and we sent them to the lab. Since our services are exempt from CommunityCARE, are we responsible for obtaining the referral?
Yes, even though your mental health services are exempt the lab services are not. Since you are ordering the lab services and the lab needs a referral it is your responsibility to obtain the referral and pass it on to the lab.

21. Can the referral be faxed?
Yes, original hard copy or faxed referrals are acceptable. Verbal referrals are not.

22. Please define family planning services under the CommunityCARE - what is included in a family planning visit? Pap smear, birth control dispensing?
�Family Planning Services� as it relates to services exempt from the CommunityCARE referral process are Family Planning Clinic services.


23. Is block 21E required on the HCFA 1500 claim form?
No.

24. Is the precert number required in block 23 on the HCFA 1500?
No. Our system automatically searches for the precert number for professional claims.

25. Is an eight digit format required for the dates of service on claims?
No, six digits are acceptable.

26. Has there been an update to the TPL listing since 1998?
Yes, please contact Provider Relations at 1-800-473-2783 for an updated list.

27. Can we download this from the Internet?
No, not at this time.

28. With CommunityCARE referral forms, is it necessary to have the address of the doctor to which you are referring the patient?
No, this is not required.

29. Is a date or span of dates required on the CommunityCARE referral form or may we simply write �6 months�?
You should be specific as to the dates of the referral.

30. How long does the recipient have to choose a PCP once they receive their letter?
Ten working days.

WAIVER

1. Why was the payment rate increased for only some of the waiver procedure codes?
The legislature allocated funding for those procedures with provider input.

2. How far in advance should we receive the authorization?
Prior to the billing cycle and prior to the beginning of the delivery of services.

3. If a provider billed claims using the old payment rate and now wants to bill these services with the new rate, can the adjustment be filed electronically or must a hard copy adjustment form be submitted?
Unisys accepts electronic adjustments/voids. Contact your software vendor if you do not have the capability to file these electronically. Please keep in mind that you must file an adjustment for each line item whether filed electronically or hard copy.

4. Should the criminal check be completed before the staff member actually starts working?
Yes.

5. Will the patient be without service during the reconsideration process?
If �reconsideration� is an appeal - If the recipient chooses to appeal and the appeal is filed by the recipient within 10 working days from the advance notice of adverse action (which is 10 days prior to the effective date of the 18LTC), the services will continue at the amount approved for the previous month. If no like services were approved or the appeal request is received after the effective date of the 18LTC, then these services shall not continue while appeal is being heard.

If �reconsideration� is a redetermination - The Case Manager must submit the annual Comprehensive Plan of Care (CPOC) to BCSS no later than 35 days prior to the expiration of the CPOC. If not received, the case manager must submit a revision request to continue current services for 30 days. 

6. In the Children�s Choice program, who decides what �good cause� would justify a change of provider? 
Refer to the Children�s Choice Manual - Section 5 - Procedures for Changing Providers.

LADUR Education Article

Selection of Antipsychotics in the Elderly: A Focus on the Atypical Antipsychotics

By: J. Lance Nickelson, Pharm.D., Assistant Professor, 
Department of Clinical and Administrative Sciences, 
The University of Louisiana at Monroe College of Pharmacy

Issues...

� The use of atypical antipsychotics has become preferred for use in elderly patients

� More information regarding proper dosing is needed to optimize use.

� These agents differ in regard to the incidence or risk of extrapyramidal side effects. 

Introduction:
Over the past 2-3 years, the atypical antipsychotics (risperidone, quetiapine, olanzapine, and ziprasidone) have become the most widely prescribed class of antipsychotics, representing a shift from the use of conventional neuroleptics (haloperidol, chlorpromazine, fluphenazine, etc.). Since the introduction of the atypical antipsychotics, they have been preferred for use in elderly patients due to their improved adverse effect profile. The following paragraphs outline the efficacy, indications, proper dosing, and adverse effect profiles of the atypical antipsychotics: risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and the newest agent ziprasidone (Geodon). The comparison which follows takes into account the unique characteristics of the elderly patient. While the discussion that follows will not cover the appropriate time to use antipsychotics in the elderly, it will focus on the proper selection of an agent once the decision to initiate neuroleptic therapy is made.

Efficacy:
There are a substantial number of pre-marketing trials supporting the efficacy of the atypical antipsychotics when compared to placebo. Post-marketing comparator trials have demonstrated equal efficacy of atypical antipsychotics versus conventional agents in the treatment of positive psychotic symptoms. Efficacy in the treatment of negative symptoms favor atypical agents, but this improvement is usually only seen in long-term studies. For initial selection of an atypical antipsychotic, any of the available agents would be expected to have the same response rate and therefore one atypical is not favored versus another.

Indications:
It is interesting to note that none of the atypical agents is approved for use in geriatric patients. Risperidone is indicated for the treatment of psychotic disorder. Quetiapine and ziprasidone are indicated for the treatment of schizophrenia. Olanzapine has indications for the treatment of schizophrenia and the short-term treatment of acute manic episodes associated with Bipolar I disorder. According to the prescribing information for each of the atypicals, only a small percentage of patients in the pre-marketing trials were over the age of sixty-five. A Medline search does reveal published articles which demonstrate safety and efficacy in geriatric patients for olanzapine, quetiapine, and risperidone. Ziprasidone, being newly released, has little published data on safety or efficacy in elderly patients.

Dosing Issues:
Due to the relatively recent development of the atypical agents, proper dosing is one area where more information is needed for optimizing their use. The dose required to optimize efficacy and maintain a favorable adverse effect profile is still being researched. Theories on dopamine binding may lead to a better understanding of how to best dose the atypical neuroleptics. While none of these agents are approved for use in the elderly, it is recommended that olanzapine, quetiapine, and risperidone be initiated at lower doses. The following chart outlines initial doses, dosing ranges, and recommended starting doses for elderly patients for the four atypical antipsychotics that have been discussed.
It is generally accepted that elderly patients may respond to lower doses of antipsychotic agents than those recommended for younger patients. With their improved adverse effect profile, the ability to titrate doses upward without worsening of unwanted effects is possible. Medical providers may abandon these agents too quickly when a reluctance to titrate doses upward results in a lack of efficacy.


Prescribing olanzapine may be easier due to its less complicated titration schedule, once daily dosing, and favorable adverse effect profile within its dosing range. Quetiapine has the most difficult titration schedule, is dosed two to three times daily, and has a wide therapeutic range. Risperidone tends to show a poor adverse effect profile within the therapeutic range. Ziprasidone requires no dosage adjustment in the elderly, but remains the least studied in this population.

Adverse Effect Profile:
Aspects of the adverse effect profile to be discussed include extrapyramidal side effects (EPS), tardive dyskinesia, weight gain, drowsiness/sedation, orthostasis, prolactin elevation, and QTc prolongation.

Extrapyramidal Side Effects:
As the use of atypical antipsychotics has become more widespread, it has been found that these agents differ in regards to the incidence or risk of EPS, such as parkinsonism, akathisia, and restlessness. Risperidone has been shown to have a strong dose-related risk of EPS. As doses reach or exceed the maximum recommended daily dose of 6mg per day, the incidence of EPS increases. This is of particular concern in the elderly population because of their tendency to be more sensitive to these adverse effects. Elderly patients may experience EPS and restlessness at doses less than 6mg per day while still receiving doses within the recommended therapeutic range. While EPS is also dose related with olanzapine, it is generally not a great risk until doses reach 20mg per day. Geriatric patients that can be maintained on daily doses of 10mg or less would have an acceptable risk of EPS. Quetiapine has shown EPS risk which is comparable to placebo throughout its dosing range. For patients who are sensitive to dopamine blockade, such as Parkinson patients, quetiapine has been shown to be effective in treating psychosis without worsening the symptoms of Parkinson�s Disease. Quetiapine appears to be the least likely to induce EPS, while still being effective at managing psychosis. At this time, it is not possible to predict the dose-related risk of EPS for ziprasidone.

Tardive Dyskinesia
It is well known that elderly patients have a greater risk of developing tardive dyskinesia than younger populations. It does appear that the newer atypical antipsychotics carry up to a 10-
fold decrease in the risk of development of tardive dyskinesia. The risk of tardive dyskinesia is, therefore, minimized but not eliminated. At this early stage it would be difficult to try to compare the rates of tardive dyskinesia in elderly patients for these agents. It is assumed that all carry a decreased risk of tardive dyskinesia in the elderly and this author will make no distinction.

Prolactin Elevation
The significance of prolactin elevation on tolerability and adverse effects is somewhat debatable. Effects such a galactorrhea and amenorrhea are linked to elevation in prolaction. Risperidone shows the greatest effect on prolactin when compared to the other atypical agents. Olanzapine may cause minimal elevation, while quetiapine and ziprasidone appear to cause no prolactin elevation.

Sedation/Drowsiness
Each practitioner may have his own opinion as to which atypical agent is the most sedating. Direct comparison is difficult, especially when using Prescribing Information (PI) provided by the manufacturers. PI data provides dose-related rates of sedation in some instances and in other cases contains rates of sedation pooled from all doses. The prescribing information for each of the agents reveals that higher rates of sedation are reported for olanzapine and quetiapine than for risperidone and ziprasidone. This effect may be pronounced as doses increase, especially in the case of olanzapine and quetiapine. Over sedation may be problematic in geriatric patients; therefore, lower doses and slower titration schedules become important.

Orthostasis
For a comparison of the rates of orthostasis, the prescribing information for each of the atypical antipsychotics was again referred to. Quetiapine carried a reported rate of 7%, olanzapine 3-5%, ziprasidone 1%, and risperidone listed orthostasis as infrequent, revealing no percentage. Orthostasis should be monitored in elderly patients taking these drugs. Whether an effect of atypical antipsychotics or aging itself, the rates of orthostasis may be more likely to increase in elderly patients.

QTc Prolongation
The effect of drugs on QTc intervals has become the object of much scrutiny. Particularly since the introduction of ziprasidone, the effect of antipsychotics on the QTc interval has been studied in detail. The exact risk of serious and/or fatal effects due to QTc prolongation is not fully understood. Most refer to a QTc interval of greater than 500 milliseconds as being the predictor for serious risk. The risk is also increased in states of dehydration, electrolyte disturbance, and in patients taking concomitant medications which increase the QTc interval. Studies indicate that ziprasidone does prolong the QTc interval. The clinical significance of this is debated heavily. Quetiapine prolongs this interval to a lesser degree (PI states not a statistically significant elevation). Olanzapine and risperidone, in general, do not prolong the QTc interval. The situation in elderly patients is often complicated further by their increased risk for prolonged QTc at baseline, and their increased likelihood of being on other medications that place them at risk. The PI for ziprasidone does list contraindications to its use: patients with a known history of QTc prolongation, recent myocardial infarction, or uncompensated heart failure, and with drugs known to prolong the QT interval (quinidine, amitriptyline, etc.). It is advised that practitioners review prescribing information for ziprasidone before using it in geriatric patients. Little information is currently known about ziprasidone�s safety and efficacy in geriatric populations, especially in high-risk elderly patients.

Weight Gain
Weight gain has also become an issue when comparing atypical agents. In general, the criteria set for weight gain is a greater than 7% increase in body weight. A comparison of the percentages of patients that meet this criterion, by package insert data, reveals that olanzapine is associated with the greatest percentage of patients that gain greater than 7% of body weight. Quetiapine shows the second highest incidence of weight gain, followed by risperidone, and then ziprasidone. As it pertains to geriatric patients, the addition of body weight may be positive or negative. In some instances, a malnourished patient with a poor appetite may benefit from weight gain. In other cases, a diabetic patient with dyslipidemia would not benefit from an increase in body weight. Again, the practitioner should base selection on the potential risk or benefit of weight gain on an individual patient.


Conclusion
The selection of atypical antipsychotic agents in the elderly requires particular attention to the adverse effects profile of each drug, and the patient-dependent tolerability to each. Since efficacy of all atypicals appear to be equal, and none of these drugs are FDA approved for use in the elderly, the selection of an agent should primarily be based upon individual patient susceptibility to potential adverse effects. In cases where EPS is the area of significant concern, quetiapine would be the most reasonable choice, whereas risperidone may be avoided. Non-compliant patients may benefit more from olanzapine than quetiapine, due to easier dosing and titration. If sedation is desired, olanzapine or quetiapine may be used; however, if drowsiness becomes bothersome, risperidone or ziprasidone may be preferred. Weight gain whether beneficial or not, is most likely to occur with olanzapine, and least likely to be seen with ziprasidone. QTc prolongation is possible with all antipsychotics but ziprasidone is associated with the greatest risk and should be used cautiously in high risk patients. When deciding on the most appropriate agent, it is important to consider the degree of adverse effects associated with each drug, and choose the atypical antipsychotic that each individual patient tolerates and adheres to most successfully.

References 

Jeste DV. Tardive dyskinesia in older patients: J of Clin Psychiatry 2000;61 Suppl 4:27-32. 

Czedella J, Beasley CM Jr, Dellva MA, Berg PH, Grundy S. Analysis of the QTc interval during olanzapine treatment of patients with schizophrenia and related psychosis: J Clin Psychiatry 2001 Mar;62(3):191-8.

Daniel DG. Antipsychotic treatment of psychosis and agitation in the elderly. J Clin Psychiatry 2000;61 Suppl 14:49-52.

Madhusoodanan S, Brenner R., Alcantra A. Clinical experience with quetiapine in elderly patients with psychotic disorders. J Geriatr Psychiatry Neurol 2000 Spring;13(1):28-32.

Olanzapine (Zyprexa�), Prescribing Information, Eli Lilly and Company, 2001. Available at: http://pi.lilly.com/us/zyprexa-pi.pdf.

Petty RG. Prolactin and antipsychotic medications: mechanism of action: Schizophr Res 1999 March 1;35 Suppl:S67-73.

Quetiapine (Seroquel�), Prescribing Information, AstraZeneca Pharmaceuticals, 2001. Available at: http://www.seroquel.com/pro/index.html.

Rhana N, Spencer CM. Risperidone: a review of its use in the management of the behavioural and psychological symptoms of dementia. Drugs Aging. 2000 Jun;16(6):451-71.

Risperidone (Risperdal�), Prescribing Information, Janssen Pharmaceutica Inc., 1999. Available at: http://www.risperdal.com/professional/home_professional.htm.

Street JS, Clark WS, Gannon KS, et al. Olanzapine treatment of psychotic and behavioral symptoms in patients with Alzheimer disease in nursing care facilities: a double-blind,
randomized, placebo-controlled trial. The HGEU Study Group. Arch Gen Psychiatry 2000 Oct;57(10):968-76.

Targum SD, Abbott JL. Efficacy of quetiapine in Parkinson�s patients with psychosis: Clin Psychopharmacol 2000 Feb;20 (1):54-60.

Tariot PN, Salzman C, Yeung PP, Pultz J, Rak IW. Long-Term use of quetiapine in elderly patients with psychotic disorders.: Clin Ther 2000 Sep;22(9):1068-84.

Williams R. Optimal dosing with risperidone: updated recommendations.: J Clin Psychiatry. 2001 Apr;62(4):282-9.

Ziprasidone (Geodon�), Prescribing Information, Pfizer, 2001. Available at: http://www.pfizer.com/hml/pi�s/geodonpi.pdf.