PROVIDER UPDATE -OCTOBER 1991

PROVIDER UPDATE

VOLUME 8, NUMBER 5

OCTOBER 1991

Medicaid Recipient Identification Cards	Unisys Field Analysts
EOBS	Retroactive Services For Zebley SSI Eligibles
CPT-4 & ICD-9-CM Code Books	EMC Reminders
CRNA - Billing Instructions	Procedure Code A455
Ventilation Equipment and Accessories	Prescriptions
Covered Supplies	New Code for Benadryl Injection
Reactivation of Code J0940	Recoupment of Vendor Overpayment to Nursing Homes
Norplant Contraceptive Implant Kit	Third-Party Insurance Payment
Distinct Part Psychiatric Billing Practices	Medicare Part B Immunosuppressant Claims
Outpatient Services	Pharmacy Audits
Dispensing Fee Increases	Drug Rebate Agreement
Coding for Emergency Room Services	Lab and X-Ray Equipment
Pulmonary Function Tests	Bilateral Procedures
Secondary and Multiple Surgical Procedures	Need for Physicians Sub-Specialty
Billing Instructions for CPT-4 Codes 77420, 77425, & 77430.	Funding of CPT-4 Code 77417
Fee Increase for CPT-4 Code 31000	Critical Care
New Regulations	Corrections
Code Y2511	Eligibility Card
Medicaid Drug Rebate Participating Pharmaceutical Companies	DME Procedure Codes for Ventilator Equipment and Accessories

ALL PROVIDERS

MEDICAID RECIPIENT IDENTIFICATION CARDS

Medicaid of Louisiana is planning to make some changes to the appearance of the recipient Medicaid identification card that is issued by Unisys.

Effective January of 1992, the TPL code descriptions will begin appearing on the back of the identification card rather than in the upper right hand corner on the front of the card, where they have been located in the past. The actual TPL codes, however, will continue to appear under the heading "TPL" on the front of the card.

In addition, the effective month of the card, as well as any special messages that pertain to the recipient's Medicaid coverage, will begin appearing in the upper right hand corner of the card.

Samples of these new cards are provided in the Attachments section of this issue of the Provider Update.

UNISYS FIELD ANALYSTS

Provider Relations has a staff of provider analysts who are available to help providers with billing problems and with training new staff members. To request a visit from one of our field analysts, providers may telephone Provider Relations at the following numbers:

Baton Rouge Providers:
(504) 924-5040

Providers Outside of Baton Rouge
(Louisiana Providers Only):
1-800-473-2783

NOTE: Telephone service is available Monday through Friday from 8:00 A.M. to 5:00 P.M.

Each of the field analysts is assigned to a specific territory. Provided below is a list of the field analysts and their assigned territories:

Contact Person(s): Phyllis Broussard, Medicaid Field Operations Supervisor, and Debbie Talbot, Field Analyst.
Parishes: Jefferson, Orleans, Plaquemines, Lafourche, St. Bernard, St. Tammany, St. John the Baptist, Terrebonne, St. James, Tangipahoa, Washington, and St. Charles.

Contact Person(s): Kim Gassie, Field Analyst, and Seneca Snell, Field Analyst
Parishes: Acadia, Allen, Beauregard, Calcasieu, Cameron, Evangeline, Jefferson Davis, Iberia, Lafayette, St. Landry, St. Martin, St. Mary, Vermillion, Assumption, Livingston, Ascension, East Baton Rouge, West Baton Rouge, Pointe Coupee, West Feliciana, East Feliciana, St. Helena, and Iberville

Contact Person(s): Gwen Davis, Analyst
Parishes: Avoyelles, Catahoula, Concordia, LaSalle, Rapides, Lincoln, Union, West Carroll, East Carroll, Franklin, Madison, Morehouse, Ouachita, Richland, Tensas, and Caldwell

Contact Person(s): Michelle Shaw, Analyst
Parishes: Grant, Rapides, Vernon, Sabine, Winn, Jackson, Webster, Bienville, Bossier, DeSota, Caddo, Claiborne, Natchitoches, and Red River

NOTE: Rapides parish is assigned to both Gwen Davis and Michelle Shaw

EOBS

We have received numerous claims with attached EOBs, Explanations of Benefits, that are generated by the provider. However, we can only accept EOBs from Medicare. Thus, we request that providers submit EOBs from Medicare only.

RETROACTIVE SERVICES FOR ZEBLEY SSI ELIGIBLES

Due to the February 20, 1990, U.S. Supreme Court decision in favor of class members in the Sullivan vs. Zebley lawsuit, SSI is currently reviewing applications for children that were rejected previously because they did not meet the criteria of disability.

SSI reports that they have reviewed and certified some applications that were denied between February of 1990 and February of 1991. As soon as those certifications are matched with System Data Exchange to let Medicaid of Louisiana know the eligibility dates these Zebley recipients will receive their retroactive Medicaid eligibility cards.

Medicaid eligibility cards for these Zebley class members will be no different from the Medicaid cards of any other Medicaid recipient. However, the Medicaid eligibility dates may go back to February of 1990, thus allowing those Zebley SSI recipients to be reimbursed the entire amount for any covered Medicaid services provided to them back to that month should the provider of the service agree to reimburse all of the money to the Zebley class member and to bill Unisys.

Medicaid providers who receive requests for reimbursement for services provided to these Zebley SSI recipients and who agree to the reimbursement should submit their claims to Unisys for payment.

CPT-4 & ICD-9-CM CODE BOOKS

Providers who code their services from the CPT-4 code book or the ICD-9-CM code book are advised to purchase the current edition as soon as possible.

The current edition of the CPT-4 code book may be ordered from the following address:

American Medical Association
P. O. 341/7
P. O. Box 10946
Chicago, IL 60610

ICD-9-CM code books are used to obtain diagnosis codes. Volume I is a numeric listing of diagnosis codes, and Volume II is an alphabetical listing (Volume III is a listing of ICD-9-CM procedure codes that are used by hospitals only.). These books may be ordered from the following address:

ICD-9-CM
P. O. Box 971
Ann Arbor, MI 48106

Current prices for CPT-4 or ICD-9-CM code books may be obtained by phoning the American Medical Association at (312) 464-5000.

In addition, providers are advised to review their remittance advice messages on an ongoing basis. Medicaid of Louisiana is Mandated by HCFA to update the claims processing procedure code file to agree with current CPT-4 coding. Therefore, new procedures are reviewed and placed on the processing file on an ongoing basis, and provider notification is sent via the Remittance Advice

NOTE: Providers should remember that not all CPT-4 codes are payable by Medicaid of Louisiana.

In addition, providers should note that the ICD-9-CM "E" and "M" services diagnosis codes are not a part of the current diagnosis file and that they should not be used on claims submitted to Medicaid of Louisiana. Claims with these codes will be denied with error code 252 (Diagnosis not on file.). Claims denied with error code 252 may be resubmitted with the appropriate numeric or alpha/numeric codes, i.e., codes that are not part of the "E" or "M" services.

EMC SUBMITTERS

REMINDERS

EMC submitters should use padded envelopes when submitting tapes/diskettes for processing. Otherwise, their tapes/diskettes may be damaged in the mail.

Providers have been mailing/submitting claims directly to the EMC unit rather than mailing them to the EMC Post Office Box. Using the EMC label with the appropriate box number will decrease the processing turnaround time.

Telecom certifications must be received within 48 hours of transmission. Tapes/diskettes must be submitted before the next processing period, or claims may be subjected to delayed processing.

CRNAS

BILLING INSTRUCTIONS

CRNAs and their billing agents must remember to place the name of the CRNA's supervising doctor in Item 19 of the HCFA 1500 claim form, or the claim will deny with edit 400 (Referring physician required in block #19.). This rule applies to non-anesthesiologist-directed CRNAs as well as to anesthesiologist-directed CRNAs.

DME PROVIDERS

PROCEDURE CODE A4555

HCFA has notified Medicaid of Louisiana procedure code A4555 (Primary surgery dressing kit), which is billed by DME suppliers, is not to be paid for anyone who is in a nursing facility and whose level of care is 20, 21, 22, 25, 26, 28, and 30.

Consequently, effective immediately, claims for claim types 09 and 15 with code A4555 will be denied with a new error code and the message, "not covered for nursing home resident."

VENTILATION EQUIPMENT AND ACCESSORIES

Effective immediately, recommended DME procedure codes for ventilator equipment and accessories have been approved. These codes, their descriptions, and their fees are provided in the Attachments section of this issue of the Provider Update.

DME & REHABILITATION PROVIDERS

PRESCRIPTIONS

It is not acceptable for the provider to type a prescription and submit it to the physician for his signature only. Medicaid of Louisiana must receive a prescription on a physician's pad that is written and signed by the prescribing physician. Any requests received without the doctor's handwritten prescription will be returned to the provider.

DME SUPPLIERS, PHYSICIANS, AND HOSPITALS

COVERED SUPPLIES

For recipients under the age of 21, insulin, non-disposable glass syringes, glucometers, and blood testing strips are covered by Medicaid of Louisiana, according to established medical criteria. However, disposable syringes, lancets, and alcohol swabs are not covered, but this policy is currently under consideration.

Blood Glucose Monitors and Test Strips

Home blood glucose monitors and the blood glucose strips used with such monitors are covered for eligible recipients under the age of 21, only when the following conditions are met:

1) The client must be a Type I dependent insulin - diabetic (injection dependent);

2) There must be documentation by a physician of poor diabetic control, i.e., poorly controlled blood sugars and frequent episodes of insulin reactions;

3) The client's physician states that the patient or a responsible family member or caretaker can be trained to use the particular device in an appropriate manner and to monitor the patient to assure that the intended effect is achieved; and

4) The device is designed for home use rather than for clinical use.

HEMODIALYSIS PROVIDERS

NEW CODE FOR BENADRYL INJECTION

Effective with date of service September 1, 1991, hemodialysis providers are to use HCPCS code J1200, instead of code J0490, to bill for Benadryl injections. The fee for code J1200 will be $3.75 per unit (1 unit = 50mg), with a maximum of 8 units allowed to be billed per day.

Code J0490 will be placed in non-pay status effective with date of service September 1, 1991.

REACTIVATION OF CODE J0940

Injection code J3490 (Decadurabolin, 200mgs) will be placed in non-pay status effective with date of service October 1, 1991. Providers should bill code J0940 for Decadurabolin, 200mgs, administered on October 1, 1991, and thereafter. The fee for code J0940 will be $16.70.

NURSING HOMES

RECOUPMENT OF VENDOR OVERPAYMENT TO NURSING HOMES

Administrative errors by nursing facility staff will continue to be reported to the parish office via Form 148-PLI. The nursing facility should attach, to the form, any income and/or medical insurance premium verification information related to the report change to allow the expedited review and signing off of the budgets in question.

OFS administrative errors and errors caused by unreported recipient changes will be handled by overpayment summary reports to the OFS Fraud and Recovery Section. Nursing facilities will no longer be required to make adjustments for these over payments via Form 148-PLI and to seen reimbursement from the nursing home resident.

HOSPITALS

NORPLANT CONTRACEPTIVE IMPLANT KIT

Billing for the Norplant contraceptive implant kit by use of a pharmacy revenue code is prohibited by Medicaid of Louisiana. Thus, such billing practices should be discontinued immediately.

Additionally, all funds received by providers who have billed for this service in this manner should be returned to the fiscal intermediary by check as soon as possible. Funds not returned will be recouped.

Only physicians may bill Medicaid for this service under HCPCS code 58302.

THIRD-PARTY INSURANCE PAYMENTS

Medicaid of Louisiana has received inquiries concerning the proper handling of claims with third-party insurance payments in relation to cost reporting requirements. Medicaid generally tracks Medicare cost reimbursement principles. That is, in regard to third-party insurance payments, if the third-party payment is greater than the Medicaid payment, the total charges are included in the cost report, but the charges/costs and the discharge are not included as program (Medicaid) charges/costs and discharges.

The following clarification should assist hospitals in the correct handling of these types of claims on the cost report:

Medicaid days times the per diem should be used as the basis for comparison to the insurance payment. For the period of time when PAS/LOS cutbacks are applied, the billed days should be used for the per diem amount rather than the payment reflected on the remittance advice.

1) In instances where the insurance payment exceeds the amount of the interim per diem payment, the claim is considered a "no pay" or "zero pay" claim, and all statistical data and costs are removed from the cost report. The days and charges should not be reflected as covered services for Title XIX reimbursement, nor should they be used for the purpose of determining disproportionate share qualification. The private insurance payment is not used to reduce the provider's Title XIX reimbursement. Because Medicaid is billed, the hospital may not bill the recipient for any difference in charges and payment, or the hospital will be in violation of Medicaid regulations.

Hospitals will be audited for credit balances to determine instances when third-party payments or billing of recipients for differences is not reported.

2) In instances where the insurance payment is less than the interim per diem amount, the claim is considered "partial pay," and all statistical data and costs are included in the cost report. For cost reporting purposes, the days and charges are reflected as covered services for the purpose of determining Title XIX reimbursement. The days are recognized as Medicaid days for the purpose of determining disproportionate share qualification. The total amount of private insurance received by the provider is reflected in the cost report as a recovery of cost.

Requests for re-openings for prior cost reporting periods to incorporate adjustments related to this clarification of policy must be submitted to Medicaid of Louisiana, Attention: Program Operations, for approval. These requests will be subject to the three-year limitation on re-openings. Once approved, requests for re-openings will be forwarded to Blue Cross for appropriate action.

DISTINCT PART PSYCHIATRIC BILLING PRACTICES

Hospitals with distinct part psychiatric units should review billing practices to ensure compliance with Medicaid policy. Some providers are billing incorrectly for routine medical care and/or diagnostic tests. Specifically, these services are being billed as outpatient services under the hospital's acute care provider number.

However, charges/costs for routine medical care, such as treatment of minor illness, e.g., a cold or a cut, which do not require transfer to the acute care portion of the hospital may not be billed separately. These charges/costs should be included in the distinct part psychiatric unit's billing for services.

Corrective action should be taken immediately if such incorrect billings have occurred. Such charges/costs related to the distinct part psychiatric unit which are billed separately as outpatient services will be disallowed at audit and cost settlement.

HOSPITALS, PHARMACISTS, AND PHYSICIANS

MEDICARE PART B IMMUNOSUPPRESSANT CLAIMS

The address for submitting Medicare Part B immunosuppressant claims is as follows:

Transamerica Occidental Insurance Company
Medicare Immuno Drug Claims
P. O. Box 50065
Upland, CA 91785-5065

HOSPITALS AND PHYSICIANS

OUTPATIENT SERVICES

Medicaid's adoption of Medicare's definition for outpatient hospital services necessitates a policy clarification. Therefore, the following guidelines regarding the definition of outpatient services are being provided to ensure providers' compliance with Medicaid's policy, as specified by state and federal regulations.

1) If a patient is admitted as an inpatient, the services provided cannot be billed as outpatient, even if the stay is less than 24 hours. Federal regulations are specific in regard to the definition of both inpatient and outpatient services, and billing for a patient who is admitted as inpatient as an outpatient constitutes fraud.

2) If a patient has outpatient surgery and needs to observed for several hours after the surgery in an observation room, the services may be billed as outpatient provided that the duration of the treatment from beginning to end is less than 24 hours and that the patient is not admitted as inpatient.

3) If a patient is treated in the emergency room and requires surgery which cannot be performed for several hours because arrangements need to be made, the services may be billed as outpatient provided that the patient is not admitted as inpatient and that the duration of the services from entry into the emergency room until release is less than 24 hours.

4) If an outpatient's duration of service exceeds 24 hours, the services are "deemed" inpatient, even if the patient is admitted as outpatient, and the services are billed as inpatient services.

Claims processing changes have been completed that permit hospitals to bill for treatment or observation room charges with revenue codes 760-769. For surgery listed as outpatient surgery that is reimbursed on a flat-fee basis, all charges, including treatment or observation room charges, are covered by a flat-fee payment.

For these claims, Admission Hour and Discharge Hour (Items 16 and 20) are required on the outpatient hospital claim form.

NOTE: Physicians must adhere to the above guidelines when determining and indicating the place of service on the HCFA 1500 for any services provided to Medicaid recipients.

In addition, physicians cannot bill for observation room charges; they can bill only for the actual services provided.

Questions related to the definition of outpatient services should be addressed to the Hospital Program Manager, Ron Jesse, at (504) 342-5774.

Questions related to physician services should be directed to the Physician's Program Manager, Kandis McDaniel, at (504) 342-9490.

PHARMACISTS

PHARMACY AUDITS

Effective August 1, 1991, Postlethwaite and Netterville were contracted to perform the pharmacy audits.

DISPENSING FEE INCREASE

Effective for services beginning October 1, 1991, the dispensing fee for prescription services has been increased to $5.00.

PHARMACISTS, DENTISTS, & PHYSICIANS

DRUG REBATE AGREEMENT

In accordance with Section 4401 of the Omnibus Budget Reconciliation Act of 1990 (OBRA 90), Medicaid of Louisiana will reimburse only for those drug products for which the pharmaceutical company has entered into a rebate agreement with the Department of Health and Human Services.

Provided in the Attachments section of this issue of the Provider Update is an Appendix C which identifies the pharmaceutical companies which have entered into an agreement with the federal government. Providers should take note of the effective date of the labeler codes and should attach Appendix C to their provider manuals.

NOTE: This listing includes additional labeler codes for manufacturers.

Medicaid of Louisiana will provide coverage for only those drug products labeled by the pharmaceutical companies that are identified in Appendix C for the respective effective dates. The therapeutic categories, e.g., cough and cold preparations, anorexics, and cosmetic drugs will remain non-payable. The over-the-counter items which were covered previously by Medicaid will remain reimbursable only if the manufacturer for the drug is listed in Appendix C.

As new pharmaceutical companies enter into rebate agreements, labeler codes will be added, and the updated information will be mailed to providers via remittance advices.

PHYSICIANS

CODING FOR EMERGENCY ROOM SERVICES

Revenue codes 450 and 459 must be used to bill for outpatient emergency room services, except for when the patient is admitted as inpatient.

In instances where patients are admitted from the emergency room, the emergency room charges should be billed with inpatient services and revenue code 500.

Questions relating to this policy should be directed to the Hospital Program Manager, Ron Jesse, at (504) 342-5774.

LAB AND X-RAY EQUIPMENT

Physicians should notify the Bureau of Health Services Financing when they purchase or lease new lab and x-ray equipment. Otherwise, they may not be certified to perform certain lab and x-ray examinations.

The provider must complete a BHSF Form 24 and list the new equipment. The completed form is to be mailed to the following address:

BHSF
P. O. Box 91030
Baton Rouge, LA 70821-9030
Attention: Provider Enrollment

Providers may obtain a copy of this form by writing to the same address or by telephoning the BHSF at (504) 342-9454.

PULMONARY FUNCTION TESTS

Provided below is a list of the pulmonary function test codes that are grouped according to how they are paid by Medicaid of Louisiana:

94060 includes 94010
94010 and 94060 include 94150, 94160, and 94200

The definitions for these codes are as follows:

94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), and/or maximal voluntary ventilation

94060 Bronchospasm evaluation: spirometry as in 94010, before and after brochodilator (aerosol or parenteral) or exercise

94150 Vital capacity, total (separate procedure)

94160 Vital capacity screening tests: total capacity, with timed forced expiratory volume (state duration) and peak flow rate)

94200 Maximum breathing capacity, maximal voluntary ventilation

Billing any of these procedures with procedure code 94060 constitutes duplicate billing because 94060 includes procedure codes 94010, 94150, 94160, and 94200. In addition, procedure code 94010 may not be billed with procedure codes 94150, 94160, or 94200 because 94010 includes these codes as well.

Any provider who continues these billing practices may have his Medicaid payments recouped by the SURS Unit.

BILATERAL PROCEDURES

Effective the first week in October, reimbursement for the procedures listed below will be made at 100% per unit when the procedures are performed bilaterally and primarily:

            CPT-4 codes 49500-49535
            CPT-4 codes 69420-69436
            CPT-4 code 30903
            CPT-4 codes 31250-31277

Providers are not to modify the codes listed above with the modifier -50 after publication of this notice. To denote the fact that the procedure is performed bilaterally, providers should place a 2 in the units column and should bill the procedure on one claim line.

If performed secondarily, the above codes must be billed hard-copy with the -51 modifier attached. Payment will be reduced according to current payment methodology. Otherwise, the procedures may be billed electronically.

SECONDARY AND MULTIPLE SURGICAL PROCEDURES

Policy concerning billing procedures for secondary and multiple surgical procedures has been issued on page 4-6 of the Professional Services Provider Manual. However, Unisys continues to receive claims for these procedures that are billed incorrectly, and providers continue to be reimbursed incorrectly. Consequently, we are issuing the following policy clarification for secondary and multiple surgical procedures.

When billing for secondary or multiple surgical procedures, providers must bill the primary surgical procedure with its usual and customary fee and no additional modifier. However, secondary or multiple procedures must be billed with their usual and customary fee and and modifier. When modifier 51 is used with the secondary or multiple surgical procedures, the modifier will automatically cut the payment or fee for the secondary or multiple procedures back to one half of the current fee amount.

Failure to adhere to this policy will result in erroneous reimbursement or the denial of services.

NEED FOR PHYSICIANS' SUB-SPECIALTY

The Bureau of Health Services Financing plans to implement a concurrent care policy for recipients under the age of 21 effective with date of service December 1, 1991. However, before implementation can begin some preliminary groundwork must be accomplished.

Within the near future, all physicians currently enrolled as Medicaid providers will receive a letter from Medicaid of Louisiana requesting information about each physician's sub-specialty. Physicians should complete it and return it to the BHSF as soon as possible. Failure to return this letter may impact providers' reimbursement upon implementation of the concurrent care policy.

If questions, arise providers call Kandis V. McDaniel, Physician's Program Manager, at (504) 342-9490.

BILLING INSTRUCTIONS FOR CPT-4 CODES 77420, 77425, & 77430

To bill for weekly radiation therapy management when the complete course of therapy consists of a number of fractions not evenly divisible by 5, such as 3, 4, 6, 7, 8, 9, 11, 12, 13,14, 16, 17, 18, 19, 21, 22, 23, 24, etc., one should bill the appropriate level code -- either 77420, 77425, 77430 -- modified with a -52 (to denote reduced service) and place the number of fractions for which payment is being requested in the description column.

For example, to bill for a complete course of therapy in which three fractions were administered, one should bill 77420-52 (assuming the simple level of treatment is given) once and should place the words "three fractions" in the description column and "one" in the units column. To bill for a complete course in which 21 fractions of the intermediate level were given, one should bill code 77425 once (place "four" in the units column) and code 77425-52 once (place "one" in the units column) and write "one fraction" in the description column. To bill for a complete course in which 32 complex treatments were rendered, one should place code 77430 on the claim form once (and place "six" in the units column) and place code 77430-52 on the claim form once (and place "one" in the units column). In addition, one should write "two fractions" in the description column.

Also, span dates should be used. Claim lines that include modifier -52 must be billed hardcopy so they may be reviewed manually and priced by the Medical Review Team. Thus, one should not bill these claim lines electronically.

To bill for a complete course of therapy in which a number of fractions evenly divisible by five are administered, one should place code 77420, 77425, or 77430 on the claim form once and the number of weeks for which one is billing in the units column. If one is billing for one week consisting of five fractions, one should place "one" in the units column. If one is billing for two weeks of five fractions each or en fractions total, one should place "two" in the units column. If payment is being requested for thirty fractions or six weeks of treatment, one should bill the appropriate level code once with "six" in the units column. The description column should be completed in the usual manner.

Again, span dates should be used, and claim lines without modifiers may be billed electronically.

These instructions apply to billing for straight Medicaid recipients only.

The daily treatment management codes 77400, 77405, and 77410 will be placed in non-pay status effective with date of service October 1, 1991.

FUNDING OF CPT-4 CODE 77417

Procedure code 77417 (Therapeutic radiology port film(s)) has been placed in pay status effective with date of service October 1, 1991. The full service fee is $30.00, and the professional component fee is $12.00. The number of units billable per day is 004.

This code replaces procedure code 77415, which was placed in non-pay status effective with date of service October 1, 1991.

FEE INCREASE FOR CPT-4 CODE 31000

The Bureau of Health Services Financing is pleased to announce a fee increase for CPT-4 code 31000 (Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium)) effective with date of service July 30, 1990. The new fee for code 31000 will be $120.00.

Adjustments may be submitted by providers who performed this procedure on or after July 30, 1990.

CRITICAL CARE

Providers should disregard the critical care article on page seven of the August 1991 edition of the Provider Update. Instead of following the billing procedures discussed in that article, providers may continue to bill for critical care services according to the 1990 definition of code 99160 until January 1, 1992.

PHYSICIANS AND INDEPENDENT LABS

NEW REGULATIONS

The Federal Register, dated March 14, 1990, contains a change in rules and regulations regarding independent laboratories and physicians who maintain a laboratory in their offices. The previous policy allowed physicians not registered as an independent lab to perform a certain number of diagnostic tests on referrals from other physicians.

Part 493, Laboratory Requirements, on pages 9576-9578 states, in part, that an independent laboratory performing diagnostic tests is one which is independent of both the attending or consulting physician's office and the hospital which meets at least the requirements specified in section 1861(e) of the Act to quality for payment for emergency hospital services under section 1814 (d) of the Act. In addition, it states that services furnished by out-of-hospital laboratories under the direction of a physician, such as a pathologist, are considered to be subject to the conditions of the facility where the physician holds himself and the facilities of his office out to other physicians as being available for the performance of diagnostic tests.

However, a laboratory maintained by a physician for performing diagnostic tests for his own patients is exempt from the conditions unless such a laboratory accepts laboratory tests on referral. Thus, if a physician accepts any diagnostic tests on referral, his laboratory must be registered as an independent laboratory.

PHYSICIANS AND HEALTH SERVICES PROVIDERS

CORRECTION

The word "group" was inadvertently left out of the description of code Y2512 which became payable at $16.00 effective with date of service May 1, 1991. The correct description of code Y2512 is as follows: Group speech, language, and hearing therapy -- one hour.

CODE Y2511

Effective with date of service December 1, 1991, the number of units per line one may bill for code Y2511 (Group speech therapy -- additional 15 minutes) will be 001.

LOUISIANA MEDICAID ELIGIBILITY CARD