PROVIDER UPDATE

VOLUME 12, NUMBER 4

SEPTEMBER/OCTOBER 1995

Message from the Medical Director

The last two months have been busy as we implement the rule changes issued by the Department of Health and Hospitals, as mandated by the Louisiana Legislature.  DHH has held public meetings to solicit comments and its continuing to monitor the impact of its changes.  As stated in several communications, your patience and assistance in this process of ensuring continuing health care to the citizens of Louisiana speak well of the health care community and are greatly appreciated.

I would like to remind providers that Louisiana Medicaid pays for screening mammograms for women, age 40 and older.  Screenings should be ordered for those women who lack signs or symptoms which could be attributable to breast cancer.  Diagnostic mammography should be reserved to those with abnormal screening mammography, possible breast cancer signs or symptoms, or other special characteristics like breast implants.

All major authorities agree that screening exams should be performed every 1 to 2 years after age 50, with some recommending earlier screening beginning at age 40.  Patient and family history of breast cancer must be taken into account by the treating physician.  While mammography is the most sensitive and specific test currently available, a clinical breast exam should be done concurrently, and the clinician should not allow a negative mammography to cancel his or her concern for a clinically suspicious finding.

These and other helpful tips can be found in the Agency for Health Care Policy and Research, U.S. Public Health Service's High-Quality Mammography:  Information for Referring Providers, Quick Reference Guide for Clinicians No. 13.  To request free copies, call 1-800-358-9295.  A patient information brochure is also available in English and Spanish.  Please take the opportunity to educate women and their families when they are in contact with you on the importance of this life-saving exam.

By following practice innovations such as those described by Morrow, et al., in Archives of Surgery (1994; 129:1091-1096), low risk findings can be safely followed or needle biopsied, helping to ease patients' concerns about surgery.  Good patient follow-up to assure that patients obtain their mammograms and their results can reinforce our educational efforts.  Let us all work together to improve mammography screening rates and help save lives in Louisiana!

Charles Lucey, MD, MPH

Correct Taxpayer ID Information for All Providers

The Internal Revenue Service considers a Taxpayer Identification Number (TIN), also know as Employer Identification Number (EIN), as incorrect if either the name or number shown on an account does not match a name or number combination in their files or the files of the Social Security Administration (SSA).  If you do not take appropriate action to help BHSF correct this problem, the law requires us to withhold 31% of the interest, dividends, and certain other payments that we make to your account.  This is called backup withholding.

In addition to backup withholding, you may be subject to a $50 penalty by the IRS for failing to give us your correct name/TIN combination.

An individual's TIN is his or her social security number (SSN).  However, sometimes an account or transaction may not contain the actual owner's correct SSN.  An account should be in the name and SSN of the actual owner.

A corporation's TIN is the IRS number assigned to the business entity by the IRS.  The name and number in the Medicaid records must match what is in the IRS files.

If you have submitted a Form SS-4 to the Internal Revenue Service for a new employee identification number in 1994 and 1995, and you have obtained a new number, please send or FAX a copy of your Notice of New Employer Identification Number Assigned (IRS Form Number CP-575) to the Provider Enrollment Section.  The address is listed below and the FAX number is (504) 342-3893.

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

Filing Adjustments for a Medicare/Medicaid Claim

When a provider has filed a claim with Medicare, Medicare pays, then the claim becomes a "crossover" to Medicaid for consideration of payment of the Medicare deductible or copayment.

If, at a later date, it is determined that Medicare has overpaid or underpaid, the provider should rebill Medicare for a corrected payment.  These claims may "crossover" from Blue Cross to Medicaid, but cannot be automatically reprocessed by Medicaid as the information appears to be a duplicate claim, and therefore must be denied by Medicaid.

In order for the provider to receive an adjustment, it is necessary for the provider to file a hard copy claim (Form 213) with Medicaid.  These should be sent to Unisys, Attention:  Crossover Adjustments, P. O. Box 91023, Baton Rouge, LA  70821, and should have copies of all Medicare explanations of benefits and previous claims from Medicare and Medicaid attached.

Physicians:  Reimbursement for CPT Code 92992

Effective with date of service July 1, 1995, CPT code 92992 - Atrial septectomy or septostomy; transvenous method, balloon, Rashkind type (includes cardiac catheterization) will be reimbursed at a fee of $684.00.

Fee Adjustments for Codes J0170 and J2910

Effective with date of service July 1, 1995, the fees for codes J0170 (injection, adrenalin/epinep, 1ml) and J2910 (injection, gold therapy - arthritis) will be adjusted to $.69 and $11.41 respectively.

Notice to Providers:  Changes in the Calendar Year for Outpatient Physician/Clinic Visits

Previously, the count of outpatient physician/clinic visits for recipients 21 and older extended from calendar year to calendar year.

Recently, however, the Bureau changed the count to correspond with the state fiscal year which runs from July 1 of each year through June 30 of the following year.  As a result of this change, the count of visits for each Medicaid recipient 21 and older started over on July 1, 1995.  It will end on June 30, 1996.

These visits continue to be limited to 12 per year for each eligible recipient who is 21 years of age or older.

Additionally, effective with date of service July 1,1995, each visit at a rural health clinic, outpatient hospital clinic, or Federally Qualified Health Center will count toward the total of 12 allowable visits per year.

Extensions may be requested via Form 158-A.

All Providers: The PE-50 Form

When completing the Provider Enrollment Form (PE-50), providers should submit a one-page form (front and back).  In other words, providers should not submit the form on two separate pages.

In addition, providers should ensure that the PE-50 has an original signature.  Stamped or copied signatures are not accepted.

Lack of Funding for Chicken Pox Vaccine

Louisiana Medicaid has not received the funding necessary to reimburse for the Chicken Pox vaccination.  Until further notice, Louisiana Medicaid will not be paying for this vaccine.

Louisiana Drug Utilization Review (LADUR) Education

Metformin Approved for Non-Insulin-Dependent Diabetes

Robert L. Judd, Ph.D.
Assistant Professor of Pharmacology
Northeast Louisiana University
School of Pharmacy

  Priya Raman, M. Phar.
Northeast Louisiana University
School of Pharmacy

Issues

• Metformin hydrochloride (Glucophage, Bristol-Myers Squibb Company, NJ) has recently been approved by the FDA as therapy for non-insulin-dependent diabetes.

• Metformin improves glycemic control by improving insulin sensitivity and decreasing intestinal absorption of glucose.

• Adverse reactions to the drug include nausea, loss of appetite, and a metallic taste.  Many patients also experience diarrhea and a reduction in vitamin B12 levels.

• The most serious effect of metformin is that it has been linked to lactic acidosis; metformin labeling contains a warning about his particular risk.

The biguanide drug metformin has been used for 30 years to treat hyperglycemia in non-insulin-dependent diabetes mellitus (NIDDM).  Its history may be traced from the use of Galega Officinalis (Goat's rue or French lilac) as a traditional treatment for diabetes in medieval Europe.  The plant proved rich in guanidine, a toxic hypoglycemic substance unsuitable for clinical purposes.  Several derivatives of guanidine were explored in the 1920s, and the hypoglycemic effect of biguanides was considered until the 1950s.  The two main  biguanides, metformin (dimethylbiguanide) and phenformin (phenethylbiguanide) have been used widely, although metformin was not marketed in the United States.  Phenformin was withdrawn in most European countries at the end of the 1970s, due to an association with lactic acidosis.

Recently, the FDA approved metformin hydrochloride (Glucophage, Bristol-Myers Squibb Company, Princeton, NJ) for marketing as therapy to lower blood glucose in non-insulin-dependent diabetes mellitus (NIDDM).  The drug product was previously approved under a treatment IND.  Metformin is indicated as an adjunct to diet therapy in patients whose diabetes cannot be satisfactorily managed by diet alone.  It may also be used concomitantly with a sulfonylurea when diet and metformin or a sulfonylurea alone do not result in adequate glycemic control.

Metformin, a biguanide-type oral hypoglycemic agent has a different mechanism of action from that of sulfonylureas, currently the only other FDA-approved oral hypoglycemic drug products.  In contrast to the sulfonylureas, which cause insulin to be released from the pancreas, metformin improves glycemic control by improving insulin sensitivity (e.g., increase peripheral glucose uptake and utilization as well as decrease hepatic glucose production) and decreasing intestinal absorption of glucose.  In vitro studies suggest that metformin acts at the level of the insulin receptor binding, glucose transport, and nonoxidative glucose metabolism (glycogen formation).  Additionally, metformin inhibits hepatic glucose production, primarily affecting gluconeogenesis rather than glycogenolysis.  Enhancement of insulin sensitivity is seen more consistently in obese than in lean individuals with NIDDM, perhaps because of loss of appetite and weight loss that accompanies treatment.  Other benefits include improvement in dyslipidemia, with a decrease in HDL cholesterol, a fall in triglycerides, and a fall in LDL cholesterol levels.  Metformin does not stimulate appetite and is consequently useful in the majority of NIDDM patients who are obese and who fail treatment with diet alone.  It can be combined with sulfonylurea drugs.

The pharmacokinetic properties of metformin have been investigated in patients with NIDDM and in healthy volunteers, using the oral and intravenous routes of administration (although metformin is always given orally in the clinical setting).  Doses of 0.5 to 1.5 have an absolute oral bioavailability of 50% to 60%; the discrepancy between the amount of drug absorbed and the amount available may result from presystemic clearance or binding to the intestinal wall.  The rate of oral absorption of the drug is slower than that of elimination.  Metformin is rapidly distributed and accumulates in the esophagus, stomach, duodenum, salivary glands and kidneys.  Binding to plasma proteins is negligible, as is the case when phenformin.  Dosage of the drug is 1-2.55 g per day in divided doses.  Metformin does not undergo extensive metabolism and is excreted unchanged in the urine.  It has a duration of action of 10-12 hours with a half-life of about 1.5-4.9 hours.

The main unwanted disturbance is gastrointestinal discomfort with nausea, loss of appetite, and a metallic taste being common.  Many patients experience diarrhea, particularly upon initiation of treatment, so starting with low dosages is prudent.  Vitamin B₁₂ levels are reduced, especially in long term use, although this is rarely associated with evidence of deficiency states.  Cimetidine and, perhaps, other H₂ antagonists increase metformin levels by competing for renal tubular excretion.  Thus the drug should be used with caution when administered with other agents eliminated by the kidneys, particularly intravenous X-ray contrast media.  IDDM, pregnancy, alcohol abuse, B₁₂ or folate deficiency, and any severe medical illnesses are other contraindications, and the drug should probably be temporarily discontinued in the setting of an acute hospitalization or major surgical procedure.  Biguanide administration has been linked to lactic acidosis.  Metformin labeling contains a boxed warning about the risk of lactic acidosis, which is calculated to occur at a rate of three cases per 100,000 patient-years.  This risk has been carefully reviewed by the FDA and by its Metabolic and Endocrine Advisory Committee, which recommended approval.  FDA's review included re-examination of the experience with phenformin, another biguanide oral hypoglycemic agent which was removed from the market in 1977 because of an unacceptably high incidence of lactic acidosis.  Extensive marketing experience in other countries suggests that the risk of this complication associated with metformin is much less.  Decreased renal function is the most important risk factor for the development of metformin-induced lactic acidosis.  As with all oral hypoglycemic drug products, metformin's labeling will also carry a warning that one study showed an increased risk of cardiovascular mortality associated with sulfonylureas and biguanide therapies.

The drug's sponsor is undertaking a professional and patient education program to encourage appropriate use of metformin.  The program includes a patient package insert explaining, among many other matters, the risks of lactic acidosis, its symptoms, and the conditions that predispose patients to its development.  This information is provided in detail in the approved physician labeling, which also contains information on appropriate monitoring and treatment.

References

Bailey, C.J., 1988, "Metformin Revisited:  Its Actions and Indications for Use," in Diabetic Medicine. 5:313-320.

Bloomgarden, Zachary T., 1995, "Metformin," in Diabetes Care. 18:1078-1080.

Dunn, Christopher, and David Peters, 1995, "Metformin:  A Review of its Pharmacological Properties and Therapeutic Use in Non-Insulin-Dependent Diabetes Mellitus," in Drugs. 49:721:749.

Nightengale. Stuart, 1995, "Metformin Approved for Non-Insulin Dependent Diabetes," in the Journal of the American Medical Association.  Pp. 273:613.

Nightengale, Stuart, 1993, "Metformin under a Treatment IND," in the Journal of the American Medical Association. Pp. 270:2269.

Pre-Certification Program Update

This October marks the one year anniversary for the Pre-Certification Program.  During this past year, with the assistance of the Louisiana Hospital Association, the Department of Health and Hospitals, and providers, we have modified our Pre-Certification process and also the documents providers must send to Unisys.  These modifications have prompted numerous questions and have created some confusion.  In order to solve these problems, we would like to clarify some of the issues raised due to our changes.

One issue consistently raised and identified is the definition of terms used in completing and processed PCF01 forms.  The following is a glossary of our terms.

Approved:  Admission and/or extension is approved.

Denied:  Admission and/or extension is denied because documentation does not meet the criteria to warrant medical necessity after being reviewed by the consulting physician and psychiatrist.

Rejected:  Admission and/or extension is rejected because documentation is insufficient and additional information is needed in order to process the case.

Reconsideration:  Hospitals may request reconsideration of cases denied for lack of medical necessity.

Resubmittal:  Hospitals may send additional documentation/information for requests that have been rejected.

Update:  Hospitals may request the addition of newborn Medicaid ID numbers and/or outpatient procedures performed on an inpatient basis if it is the primary or only procedure performed within the first two days of the hospital stay.  Please indicate what items need to be updated by circling the item.  All update requests should include the Pre-Certification case number.

Retrospective:  Hospitals may request certification for cases where the Medicaid eligibility was not determined during the admission period.

Another issue involving the PCF01 form is the problem of supporting documentation.  In April 1995, an update was sent to each hospital with the new PCF01 forms, abstracts, and instructions for the completing of these forms.  Please note that all requests for certification should be submitted in a timely manner and should follow the guidelines outlined in Chapter 7 of the Hospital manual.

Timeliness is a Unisys goal as well. To help us respond to your request in a timely manner, please do the following:

• For Rejection/Resubmittal:  Please review the three-digit rejection code and its corresponding description on the fax letter, which is sent with all rejected cases.  To resubmit your request, please resubmit a copy of the fax rejection letter, the PCF01 or Abstract (depending on which was used), and any documentation you originally submitted, as well as the additional information requested by the Pre-Certification Program.

• Write the description of the ICD-9 codes submitted.

• Indicate the level of care when using only the abstracts for extensions.

• Include start and stop dates of medication, and date all lab values and vital signs.

• Write legibly and large.

• Transcribe the requested physician progress notes if they are not legible.

• Do not fax copies of photographs since they copy very poorly.  Instead, please submit descriptions or mail pictures or wounds/decubiti.

• Submit documentation which supports intensity of service for the extension diagnoses' body system.

Retrospective Case:  Retrospective cases need pertinent information to assist the review nurse in determining medical necessity.  Suggested pertinent information includes:

PCF01 (all cases)

Discharge summary (all cases)

Admission history and physical (acute/rehab, long-term)

Physician orders (psych only)

Physician psychiatric evaluation (psych only)

Certificate of Need (free-standing psych only)

Nursing assessment (psych only)

Nursing progress notes (psych only)

Multidisciplinary Team Notes (Rehab, Long-Term)

Finally, there are three more issues that need clarification.

1.     Newborns that are either admitted to NICU or that become ill require a pre-cert case number.  If the newborn is admitted to NICU on the day of his/her birth, the admit date is the birth date.  If a newborn becomes ill and his/her mother is discharged, then the mother's discharge date becomes the ill newborn's admit date.

2.     Certificate of Need (CON) must be signed by the independent admit team if the patient is Medicaid certified.  This form can only be signed up to 5 days prior to admit, and is to be used for free-standing psychiatric facilities only.

3.     Explanation of Medicare Benefits (EOMB) from Medicare indicating Medicare Part A benefits are exhausted must accompany requests for Medicaid certification.

The Pre-Certification Department routinely announces changes in the Provider Update sent to all providers, and on remittance advice (RA) messages sent to all hospital billing departments.  We strongly recommend that copies of the Provider Update and RA messages pertaining to Pre-Certification be sent to the Utilization Review Department.

Finally, thank you for your questions.  Please continue to share your thoughts and questions with us.  They help us to continually refine and improve the Pre-Certification Program.

Changes in the Lock-In Program

The Lock-In Program is being changed to a double tier system.  Some recipients are being restricted to a primary care provider and a pharmacy provider, while other recipients are restricted to a pharmacy provider only.  For those restricted to a pharmacy provider only, the Medicaid card will have the message "NO MD RESTRICTIONS" printed beneath the item requesting physician name, and the pharmacy name and identification number printed under the items requesting pharmacy name and identification number.  For recipients restricted to both provider types, the Medicaid card will have both a physician's name and identification number and the pharmacy name and identification number printed under the items requesting them.

However, a recipient restricted to both provider types is informed that he must come to the Parish Office to choose his pharmacy provider and his physician provider.  In this instance the provider should refer the recipient to the Parish Office and be aware of the limitations noted on the card itself.

Due to the increased number of Lock-In recipients, Unisys will begin issuing Lock-In eligibility cards effective October 1, 1995.  The cards resemble a regular eligibility card with "Lock-In" printed on the top and bottom of the card.  Please pay close attention and review all eligibility cards carefully.  The green Lock-In card will still be issued by local offices when a Unisys-issued Lock-In eligibility card has been misplaced or when a recipient changes providers.

Using Correct Prescriber Numbers

We would like to alert providers to the importance of using the correct prescriber numbers when preparing pharmacy claim forms.  In order for the Louisiana Drug Utilization Review (LADUR) to be effective, we need accurate prescriber information.  Information sent to the wrong provider will result in unnecessary administrative expenditures.