Provider Update

Volume 19, Issue 5 

October/November 2002

Louisiana Expands Medicaid Coverage for Pregnant Women 

Progress has been made in recent years through expansions in the Louisiana Medicaid Program to improve the long term health care of all Louisiana citizens and especially children. However, as numerous studies have shown, health coverage for children starting at birth isn't quite enough. In order to avoid many health problems for children later in life, expectant mothers need to receive proper pre-natal care. In an effort to make proper pre-natal care available to more pregnant women, effective January 1, 2003, Louisiana Medicaid will expand coverage to pregnant women with family incomes up to 200% of the Federal Poverty Level using income disregards. 

"If those of us involved in Louisiana's health system are going to improve the historically poor health outcomes of our state's citizens we need to take smart steps," said DHH Secretary David W. Hood. "Making sure that expectant mothers get proper pre-natal care is just one of those steps."

Hood notes that preliminary research here in Louisiana has shown that fewer low birth weight babies are born to teen moms who have Medicaid or LaCHIP coverage than to teen moms who lack any type of health insurance.

Louisiana Medicaid is seeking the assistance of Medicaid providers in conducting an aggressive outreach campaign to assure that pregnant women are aware of the need for proper pre-natal care and the availability of care through the Medicaid program. Be on the lookout for more information over the next couple of months, as this program is set to begin at the start of the New Year!

HIPAA Update

In a joint effort, Louisiana Medicaid and Unisys are developing plans for meeting the Health Insurance Portability and Accountability Act (HIPAA) requirements for standard electronic transactions and code sets for all program types.

The Louisiana Department of Health and Hospitals (DHH) will be changing the requirements for Long Term Care/Adult Day Health Care Services in order to standardize claim processes and conform to the HIPAA mandates. These changes will eliminate the current Turnaround Document (TAD) and require Long Term Care/Adult Day Health Care providers to utilize either the X12 837 Institutional electronic format for billing each recipient monthly, or submit a monthly hard copy (paper) claim for each recipient, using the Universal Billing - 92 (UB-92) claim form. 

A tentative date is scheduled for the summer of 2003 for implementation of both the 837 Institutional for electronic claims submission and the UB-92 for hard copy claims. The date by which DHH must be totally compliant is October 16, 2003.

In general, only procedural changes will directly impact Long Term Care/Adult Day Health Care Providers:

� Unisys will no longer produce and mail the pre-printed monthly Turnaround Document (TAD). Each 
facility will be responsible for submitting a monthly claim for each recipient on the 837I electronically 
or the UB-92 monthly claim form.

� The implementation of Case Mix will not change or disrupt the new 837I or UB-92 claim formats.

The monthly payment cycle process will remain the same, with payments issued on or about the 10th of each month. The monthly billing and Patient Liability rules will also continue to apply; claims must be submitted on or after the first day of the month for the previous month's billing.

There are various methods of electronic claims submission. Many providers choose to submit electronically with a vendor's software program, while others submit electronically through a billing agent or clearinghouse. Providers will need to evaluate their electronic submission options and determine which best suits their needs. Upon request, Unisys will provide a list of electronic submitters as they become approved during testing.

Submitting claims electronically has many advantages, including:

� Faster claim adjudication
� Increased cash flow
� Reduced key errors
� Reduced cost of preparing and mailing paper claims

In preparation for the transition to the 837I transaction for electronic claims, a secured access into the Unisys testing environment will be required. The Unisys HIPAA QA Department is available to assist the providers with the testing process and with any 837I electronic claims testing questions. The 837 I implementation guide is available for download at: http://www.wpc-edi.com/hipaa

For access to Unisys' test environment or if you have any questions pertaining to testing, email the Unisys QA Department: randall.fillmore@unisys.com or melinda.napier@unisys.com 

As we move forward with the HIPAA Administrative Simplification compliance, Unisys will communicate the actual dates for implementation of the 837I electronic claims submission and the hard copy UB-92 through Provider Seminars, Special Provider Notices, Provider Updates, Association Articles, and Remittance Advice Messages. All publications will be posted on the Louisiana Medicaid website: www.lamedicaid.com.

CPT Code X0516 Placed in Non Pay Status
RA Message 9/21/02 and 10/1/02
FIMS # 6651

Effective with date of service October 1, 2002, CPT code X0516 (Paragard Intrauterine Copper Contraceptive was replaced by CPT code J7300 (Paragard Intrauterine Copper Contraceptive) CPT code X0516 was placed in non pay status effective with date of service October 1, 2002.

CPT Codes Payable to Optometrists
Ra Message 10/22/02 and 10/29/02
FIMS # 6662

Effective with date of service 02-01-2002, the following CPT codes were added to the list of codes payable to Optometrists.

99218, 99219, 99291, 99292, 99316, 99360, 99374, 99377, 99379, 99380,
99381, 99382, 99383, 99384, 99385, 99392, 99393, 99394, 99395, 99396
99429, 99499, 92135, 92499, 68040, 68761, 82945, 86021, 99090, 99172, 
99173, 99374, 99377, 99379, 99380, 95930, 95933, 95999, 97530, 97532,
97533, 96100, 96110, 96115 and 96117.

Modifications to the Preferred Drug List

Following is a listing of drugs to be added to the Medicaid Prior Authorization (PA) Process' Preferred Drug List (PDL). The listing includes preferred drugs and those drugs requiring prior authorization with effective implementation dates shown. Please add this list to the ones previously sent.

The PA process, in accordance with the program's "Continuity of Care" policy, does not impact original prescriptions (or refills) issued by a prescribing practitioner prior to effective PA dates of drugs as they are added to the PA process as long as they are within the 5 refills and 6-month program limits. An educational alert will notify the pharmacist that prescriptions (and their refills) will require a new prescription and prior authorization if the prescription life exceeds six months or the refill exceeds the 5 refill limit. The educational alert will state, "NEW RX WILL REQUIRE PA AFTER (DATE)."

The Medicaid Pharmacy Benefits Management Program utilizes a numbering system to assist providers in maintaining the lists disseminated. You will note the list included with this correspondence is "02-03." Please be advised this attachment contains updates to the previously issued Prior Authorization PDL Implementation Schedules issued May 24, 2002 (Issuance 02-01) and July 16, 2002 (Issuance 02-02). These updates are noted on the attachment in bold and italics and include the following therapeutic classes: Proton Pump Inhibitors, Inhaled Steroids, and Beta Adrenergic Agents. Some drugs in these therapeutic classes which previously required prior authorization have been moved to the PDL while others will now require prior authorization. The effective dates of these changes are also shown on the chart. It is recommended that you make notations with effective dates on transmittals whenever changes occur in therapeutic classes to ensure you are referencing the most current status of a drug. For example, a note on the "Proton Pump Inhibitor" class on Transmittal 02-01 such as "Obsolete effective October 14, 2002 by Transmittal 02-03" might be helpful. Additionally, the last page of the attachment contains drug products are to be removed from the listings as a result of the drug being discontinued or obsolete.

Information on the Prior Authorization process, including the PDL and Prior Authorization Request Form, is also available on the Louisiana Medicaid website (www.lamedicaid.com). This website will be updated when changes (additions or deletions) are made to the PDL. The program may also utilize the provider remittance advices to notify providers of PDL changes that must be implemented in short time frames.

The Department has received inquiries that drug products requiring PA are not reimbursable by Medicaid. Medicaid does reimburse for drug products requiring prior authorization when the prior authorization process is followed.

Thank you for your continued cooperation. We appreciate your participation in the Medicaid program.

 

Notification to Providers of Wheelchairs Operating Under the DME Program 

The Bureau has amended its� policy governing recipient qualification for motorized/power wheelchairs. Formerly a recipient had to be either employed or in an education training program in order to qualify for a motorized/power wheelchair. These provisions are no longer applicable.

Under our current rule, a recipient must be non-ambulatory and have severe weakness of the upper extremities due to a neurological or muscular disease or condition. The recipient�s condition must be such that without the use of a wheelchair the patient would otherwise be bed or chair confined. The recipient�s condition must be such that a wheelchair is medically necessary and he/she is unable to operate a wheelchair manually. The recipient must be capable of safely operating the controls for a motorized/power wheelchair.

Prior Authorization for motorized/power wheelchairs is a requirement. All requests for a motorized/power wheelchair must include a completed PA-01 form, a physician�s prescription, and a written evaluation by a physical therapist or occupational therapist. The evaluation must include documentation of the appropriateness of the specific wheelchair requested and all modifications and/or attachments to the specific wheelchair and its ability to meet the recipient�s long-term medical needs.

Options that are beneficial primarily in allowing the patient to perform leisure or recreational activities are not covered. Documentation must also support that the recipient can safely operate the wheelchair and that he/she does not have the upper extremity function necessary to operate the manual chair. 

Documentation must also support that the patient�s condition is such that the requirement for a motorized/power wheelchair is long term (at least six months).

Authorization for payment of a motorized/power wheelchair will be made for only one wheelchair at a time. Backup chairs, either motorized/power or manual, will be denied as not medically necessary.

Payment for motorized/power wheelchairs will be authorized in accordance with specific criteria related to the condition of the patient. The wheelchairs covered are the standard weight frame motorized/power wheelchairs (procedure code K0010), standard weight frame motorized/power wheelchairs with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking (procedure code K0011), and lightweight, portable motorized/power wheelchairs (procedure code K0012).

Wheelchairs with individualized features required to meet the needs of a particular patient will be approved under the correct code for the wheelchair base and the appropriate codes for wheelchair options and accessories. All such features and modifications are subject to prior authorizations along with the wheelchair.

Skilled Nursing Services Provided to MR/DD Waiver Recipients

Effective November 1, 2002, the MR/DD Waiver has a new service of skilled nursing services available to MR/DD Waiver recipients who meet the specific criteria. The service is designed to provide skilled nursing services to MR/DD individuals. The skilled nursing service must be provided by a licensed nurse, either RN or LPN through a home health agency and must be ordered by a physician and meet medical necessity. You may contact Claudette Hill, MR/DD Waiver manager at 225-219-0211, regarding any questions.

LADUR Education Article

Vitamin Use in Adults

Prepared by Charles W. Jastram, Jr., Pharm.D., B.C.N.S.P.Associate Professor and Clinical Coordinator University of Louisiana at Monroe, College of Pharmacy

Issues...

� Adequate nutritional intake plays a pivotal role in the maintenance of good health 
and the prevention of disease.

� High-risk patient populations for development of vitamin deficiencies include the very 
young, the elderly, and the immuno-suppressed (i.e. cancer, AIDS, transplant patients).

Introduction
Adequate nutritional intake plays a pivotal role in the maintenance of good health and the prevention of disease. It has been postulated that 85% of chronic diseases observed in the elderly could be eliminated or ameliorated if more attention was given to the nutritional status of this select group of patients. Unfortunately, the recognition and treatment of nutrient deficiencies is an area where considerable controversies and knowledge deficits exist in healthcare. The reasons for these controversies and knowledge deficits are numerous and complicated, but include inadequate attention given to the area of nutrition in most U.S. healthcare professional training programs, poor funding for nutrition research and therapy, inadequate regulation of the nutritional product industry, and false or misleading consumer marketing of nutritional products. This article will focus only on the known functions, signs of deficiency, requirements, toxicities, and interactions of the 14 vitamins known to be essential to humans.

Pathophysiology and Deficiency States
Vitamin deficiencies are well described in the literature, but seldom observed in well-nourished individuals. High-risk patient populations for development of vitamin deficiencies include the very young, the elderly, and the immuno-suppressed (i.e. cancer, AIDS, transplant patients). The onset of vitamin deficiency is dependent upon the rate of loss of the individual vitamin along with the individual�s vitamin stores. Table 1 describes the pathophysiology of several vitamin deficiencies.

Table 1 � Pathophysiology of Vitamin Deficiencies



Clinical manifestation of vitamin deficiency is usually a late development, and can take several months to years to manifest. Blood levels fall much earlier than clinical manifestations and are clinically useful, but due to the great expense of obtaining most vitamin blood levels, their use is limited. In several instances, single vitamin deficiencies may be present such as pernicious anemia (vitamin B12) and folic acid deficiency. Patients with malabsorption syndrome usually present with multiple vitamin deficiencies such as vitamins A, D, E, and K. Therapeutic supplementation will be discussed later in this article. Table 2 summarizes vitamin functions, deficiency states, and foods high in individual vitamins.

Table 2 � Vitamin Functions, Deficiency States, and Major Food Sources



Requirements 
Intake of vitamins is assessed in two ways: (1) the amount needed to prevent vitamin deficiency state, which is termed daily requirement, and (2) the average daily amount an entire population group should consume in a period of time to prevent deficiency, which is referred to as the recommended daily allowance or RDA. Statistically, the RDA is set two (2) standard deviations above the average requirement, and has been established for the U.S. population by the National Research Council. The RDA takes into account the dietary form of the vitamin, the efficiency of vitamin absorption, and several other factors. The RDAs were developed as estimates for normal intake, and were designed to provide guidelines for therapy. These estimates were established for normal, healthy individuals and have been criticized as being too low for special situations such as patients with critical illness or malabsorption states. RDAs have not been established for intravenous vitamin therapy for patients unable to absorb oral vitamins and other nutrients. The National Advisory Group of the Department of Foods and Nutrition-American Medical Association (NAG-AMA) has established guidelines for parenteral vitamins. The Food and Drug Administration (FDA) has modified the requirements recently to increase amounts of ascorbic acid, thiamine, pyridoxine, and folic acid along with inclusion of vitamin K. Table 3 summarizes the RDAs, NAG-AMA, and FDA guidelines for vitamins. RDAs for biotin and pantothenic acid have not been established due to incomplete data on content in many food sources and the lack of the degree of absorption from the gastrointestinal tract. The data for biotin and pantothenic acid is derived from the estimated safe and adequate daily intake data from the National Academy of Sciences.

Table 3 � Recommended Dietary Allowances (RDA), NAG-AMA and FDA Guidelines for Parenteral Vitamin Supplementation


* - Represent safe and adequate daily dietary intakes


Vitamin Supplementation 
Vitamin supplementation in healthy adults is seldom necessary when individuals consume a balanced daily diet. Supplementation should be considered in high�risk patients such as the patient with malabsorption syndrome or other chronic gastrointestinal diseases, alcoholics, cancer, and multiple trauma patients. This does not represent a complete list, but only a few classic examples of patients requiring multivitamin supplementation. Pregnant and lactating females represent another group requiring multivitamin supplementation, especially folic acid. Folic acid supplementation during pregnancy has been well established to reduce the incidence of infant neural tube defects. Dieting has become a very common phenomenon in the U.S., and when these diets restrict caloric intake to 1200 calories or less, multivitamin supplementation should be considered. 

Drug-Vitamin and Vitamin-Drug Interactions 
Interactions between vitamins and drugs must be divided into 2 categories: (1) drug effects on vitamin absorption and metabolism, and (2) vitamin effects on drug effect or toxicity. Drug-vitamin interactions are seldom clinically significant and are usually the result of megavitamin supplementation, which should be discouraged by all healthcare practitioners due to a lack of data supporting the practice and the increased risk of vitamin toxicity. Tables 4 and 5 summarize known interactions between vitamins and drugs. Since these tables do not represent all potential interactions, consumers and healthcare practitioners are encouraged to consult with a registered pharmacist regarding potential drug interactions.

Table 4 - Drug Effects on Vitamin Absorption and Metabolism

Table 5 � Vitamin Effects on Drugs

Dieting has become a very common phenomenon in the U.S., and when these diets restrict caloric intake to 1200 calories or less, multivitamin supplementation should be considered. 

Drug-Vitamin and Vitamin-Drug Interactions 
Interactions between vitamins and drugs must be divided into 2 categories: (1) drug effects on vitamin absorption and metabolism, and (2) vitamin effects on drug effect or toxicity. Drug-vitamin interactions are seldom clinically significant and are usually the result of megavitamin supplementation, which should be discouraged by all healthcare practitioners due to a lack of data supporting the practice and the increased risk of vitamin toxicity. Tables 4 and 5 summarize known interactions between vitamins and drugs. Since these tables do not represent all potential interactions, consumers and healthcare practitioners are encouraged to consult with a registered pharmacist regarding potential drug interactions.

References

1. Alpers DH, Stenson WF, Bier DM. The Manual of Nutritional Therapeutics. 3rd edition. Little, Brown and 
Co., 1995.

2. Parenteral multivitamins products; drugs for human use; drug efficacy study implementation; amendment 
(21 CFR 5.70). Federal Register. April 20, 2000; 65:21200-21201.

3. Gottschlich MM et al. The Science and Practice of Nutrition Support: A Case-Based Core Curriculum.
American Society for Parenteral and Enteral Nutrition. Kendall/Hunt Publishing Co., 2001.

4. Food and Nutrition Board, National Research Council, Recommended Dietary Allowances. 10th ed. Washington, DC: National Academy of Sciences, 1989.

5. American Medical Association Department of Foods and Nutrition. Multivitamin preparation for parenteral use:a statement by the Nutrition Advisory Group. J Parenter Enteral Nutr, 1979;3:258-262.