Provider Update

Volume 19, Issue 6 

December 2002/January 2003

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Expansion Of CommunityCARE In Region 4

Effective March 1, 2003, Louisiana Medicaid will expand the CommunityCARE Program to include Acadia, Evangeline, Iberia, Lafayette, St. Landry, St. Martin, and Vermilion parishes. During the initial enrollment period, all Medicaid recipients in these parishes will receive a letter and brochure in mid-January. The letter states that CommunityCARE is coming to their parish and that they will receive another letter in a couple of weeks assigning them to a CommunityCARE doctor. The letter will also provide an "800" phone number to call if they have questions. During the first week of February a second letter will be mailed to recipients telling them the name and phone number of the doctor assigned to them. This letter will inform recipients that they may change to a different CommunityCARE doctor if they are not satisfied with the assigned physician. This letter will again provide the recipients with the toll free number along with a list of CommunityCARE enrolled physicians in the recipients' parish of residence. All enrollees will have ninety (90) days to request a change to a different provider. Recipients who make change requests before February 23, 2003, will be able to see the new PCP beginning March 1, 2003. 

After March 1, 2003, providers not enrolled in CommunityCARE in the above parishes must obtain a referral from the CommunityCARE PCP in order to bill for services provided to most Medicaid 
recipients.

Medicaid primary care providers (Family Practice, General Practice, Internal Medicine, OB, Pediatrician), physician groups, Rural Health Clinics(RHCs), and Federally Qualified Health Centers(FQHCs) may enroll as CommunityCARE providers, and that enrollment process must begin now to insure completion by January 15, 2003. Medicaid providers who have not completed their enrollment as a CommunityCARE provider by January 15, 2003 will not be included in the assignment rotation and will not be listed as an available choice for recipients. Enrollment packets for CommunityCARE may be obtained by contacting Unisys Provider Relations at 800 473-2783. Questions may be directed to Provider Relations at that number, or to the CommunityCARE program office at 225 342-1304.

For your information, the CommunityCARE expansion schedule for the year 2003 will also include the following parishes:

March 2003- Acadia, Evangeline, Iberia, Lafayette, St. Landry, St. Martin, and Vermilion

June 2003-Bossier, Caddo, Caldwell, Franklin, Lincoln, Ouachita, and Tensas

September 2003-Orleans

December 2003-Plaquemine, St. Bernard, Jefferson-East Bank, and Jefferson-West Bank

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2002 ADA Claim Form to Become Mandatory

When HIPAA is implemented, the 2002 American Dental Association (ADA) claim form will become mandatory when billing hardcopy for the EPSDT Dental and Adult Denture Programs. Dental providers should obtain a supply of these claim forms from their supplier and use them when this requirement is effective. The Medicaid Program will provide instructions for completion of this claim form. Providers who use software to print their claim forms for hardcopy billing should contact their software vendors to ensure that their software is compatible with the 2002 ADA claim form.

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Additional Dental Procedures Available for Reimbursement

Effective immediately, the following two dental procedures are available for Medicaid reimbursement for recipients under the age of 21: 02161 (Amalgam Restoration - four or more surfaces, permanent) and 02335 (Resin-based Composite Restoration - four or more surfaces, anterior). Each procedure will be reimbursed at a rate of $75.00. Prior authorization is required for procedure 02335 (Resin-based Composite Restoration - four or more surfaces, anterior). At this time, prior authorization is not required for procedure 02161 (Amalgam Restoration - four or more surfaces, permanent). Should you have any questions regarding this matter, you may contact the dental consultants at the LSUHSC, School of Dentistry, Medicaid Dental Unit by calling 504-619-8589.

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HIPAA

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). It will 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 the 837I (Institution electronic format) 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 according to the "LTC Monthly Processing Schedule" for each year. The schedule(s) for each year will be mailed to the LTC facilities in November & December of the current year for the next year.

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 837I 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 and 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.

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2003 NATIONAL MEDICAID HIPAA & MMIS SUMMIT

The Centers for Medicare & Medicaid Services and the Louisiana Department of Health and Hospitals are sponsoring the 2003 National Medicaid HIPAA & MMIS Summit in New Orleans, Louisiana. The conference will be held on February 9-13, 2003 at the Hyatt Regency Hotel. This annual conference is a leading national forum on issues related to the Health Insurance Portability and Accountability Act (HIPAA) and Medicaid Management Information Systems (MMIS). This conference is divided into tracks focusing on HIPAA and on ways to take advantage of the MMIS to improve program performance while reducing costs. The theme of this year's conference is "Parading Toward Compliance." 

HIPAA deadlines for Privacy and Transactions and Codes Sets will occur in 2003 while the final Security Rule is scheduled for issuance in early 2003. The HIPAA Track will cover practical suggestions and solutions in the areas of HIPAA Privacy readiness and compliance, Transactions and Codes implementation, and Security planning through the presentation of "Best Practices" and cutting edge technologies in these areas. The faculty for this Track include federal and state health care officials from across the country whose job it will be to see that HIPAA happens, and health care industry executives who are directly involved in HIPAA implementation. They will not only be presenting their views but will be available to answer questions on HIPAA Privacy, Security and Electronic Data Interchange (EDI).

Medicaid Management Information Systems (MMIS) are responsible for managing each state's largest investment in health care programs, the Medicaid and S-CHIP programs. The MMIS Track will cover issues directly related to the use of current and future technologies for the management of health care information. The faculty for this Track include federal and state health care officials from across the country whose job it is to manage the largest health care information system, and health care industry executives who are directly involved in assisting them. In addition, the Conference will showcase CMS' new national cross-cutting initiative, the Medicaid Information Technology Architecture (MITA). Presenters will not only share their views but be available to answer questions on health care information management.

This conference will also afford you an opportunity to review, first hand, the latest in services and technology for meeting the challenge of HIPAA and health care information management in the vendor area. 

Those who would benefit from attending this health care summit are any and all federal, state or local officials and employees involved in health care as either a provider or payer of health care services, private health care providers, health care lawyers, health information management officers, privacy officers, security officers, health care planners and policy makers, direct health care providers, health care administrators and health care educators.

The Hyatt Regency Hotel is located in downtown New Orleans next to the Superdome and within a mile of the historic French Quarter. The summit is scheduled in the middle of the Mardi Gras season in the city which is know worldwide for its Mardi Gras celebration, cultural uniqueness and delightful cuisine. 
For more information on the agenda and registration please go the DHH Home page http:\www.dhh.state.la.us

Ya'll come down and learn and then, "Laissez les bons temps rouler" (let the good times roll).

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Documentation Reminders

The Surveillance and Utilization Review Subsystem (SURS) is required to review billing practices and is often required to make decisions based on the documentation presented. The members of the SURS team would like to remind you that an undocumented service is considered a service not rendered. Providers should ensure their documentation is accurate and complete. All undocumented services are subject to recoupment.

Proper documentation should include:

All records should be clearly legible and documented at a time in close proximity to the actual patient encounter. All progress notes in the patient record should include a thorough and adequate narrative description of the foregoing items. Standard forms with check boxes are usually in and of themselves not adequate for complete documentation. 

The Surveillance and Utilization Review unit will continue to conduct unannounced site visits to compare medical records against provider billing histories. Claims paid without proper documentation will be considered overpaid and the money will be recouped. In some cases it has been noted that the overbilling is so consistent as to be purposeful or intentional; these will continue to be referred to the Medicaid Fraud Control Unit of the Attorney General's Office.

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Stereotactic Procedures

Stereotactic procedures will not be paid with sinus surgery procedures by Louisiana Medicaid.

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Internet State License Renewal Procedure for Nursing Homes

In September 2002 the DHH Health Standards Section launched a pilot project for license renewal via the Internet. The project is ready for statewide implementation effective January 1, 2003, at which time all nursing homes will have the option to renew their license via the Internet. Renewal letters will be sent out approximately 60 days prior to the expiration of the current license. This letter will include information on the Internet renewal process. 

The Nursing Home Internet License Renewal Provider Manual (16 pages) is available on the Health Standards Section Long Term Care Publications web page at http://www.dhh.state.la.us/hss/ltc_publications.htm. Please read the manual prior to renewing your license online. You will need a computer that is connected to the Internet, State ID number, and Clerk or authorization password. The password will be sent out with the renewal letter. If you do not have access to the Internet, please call 225-342-0114 and request an application. The DHH licensing fee should still be sent to P.O. Box 1666, Baton Rouge, LA 70821.

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Ambulance 105 Attachment Revised

Medicaid has revised the current Unisys 105 (Medical Certification Form) currently being used to establish medical necessity. Use of this shall be effective with date of service November 1, 2002. Providers may discontinue using the current Unisys 105 attachments immediately. Unisys will supply this revised form; however, providers are asked to make copies of this double-sided document until notification of availability through Unisys is announced. 

The new Medical Certification Form shall allow for additional signatures other than the physician to establish medical necessity. Medicaid will accept the signatures of the professional who furnished the medical care to include the physician assistants (PA), nurse practitioners (NP), or clinical nurse specialists (CNSs) or Director of Nursing/Nursing Facility (DON) (all applicable State licensure or certification requirements must be met) based on the patient's condition at the time that ambulance services were ordered to substantiate the need for ambulance transportation services. 

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2002 Provider Training Questions and Answers

AMBULANCE
1. Does Unisys accept electronic adjustments and voids?
Yes. If your software is not set up to allow electronic transmissions, adjustments/voids, contact your software vendor for assistance.

2. Is it necessary to include the 105 attachments when submitting adjustments and voids?
No.

3. If a claim has more than one line, is it necessary to complete an adjustment or void for each line?
Yes, you must adjust each line. Complete instructions relating to filing adjustments/voids can be found in the provider manual.

4. Has there been any education for emergency room physicians and their personnel regarding the revised 105 form?
No. This form was revised just prior to initiation of provider workshops. 

5. How should a provider bill if an Advanced Life Support (ALS) team is dispatched but no ALS services are performed?
Providers may bill the service as Basic Life Support (BLS).

6. Does the 205 adjustment form require the EMT's signature?
No.

BASIC
1. If a recipient has other insurance, but Unisys does not reflect this information in their system, how should a physician's office bill?
The provider needs to notify Unisys that the patient has other insurance. They should send a copy of the EOB to Unisys Provider Relations so that this information is forwarded to DHH. The provider needs to send the claim along with a cover letter indicating the problem. It is also important that the claim has the carrier code in the appropriate block for that claim form, and that the EOB is attached.

2. 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 investigated and removed from the recipient's file.

3. Is UNISYS going to update their modifiers?
Once HIPAA is implemented all coding will be standardized.

4. How should a provider notify UNISYS that their bank account information has changed?
The provider would need to submit another EFT form to Provider Enrollment indicating that a change has occurred.

5. Is there a comprehensive list of error codes?
No. Providers are encouraged to compile their own list by using those error codes included on the last page of their Remittance Advice.

6. How long does it take to update third party liability on the recipient file?
The exact time frame may vary. DHH must investigate the new insurance company and verify the information prior to assigning a 6-digit carrier code.

7. Does a provider have to accept Medicaid when the patient has Medicare HMO primary?
Yes.

8. Electronic Remittance Advices (ERAs) do not print out the message page of the Remittance Advice. How can this information be obtained?
Providers can either use the Internet and access the website for this information, or they can review the hardcopy Remittance Advice that they receive (even if a provider receives an ERA, they will still receive a hardcopy RA).

9. When a provider submits a Medicare primary claim to Medicaid, their computer system automatically indicates Medicare's payment in block 29 of the HCFA 1500 Form. Do they need to white out that information prior to sending the claims?
Yes. The provider should not indicate anything in block 29 of the HCFA 1500 if the patient has Medicare primary to Medicaid. All they need to do is attach the Medicare EOB to the claim.

10. When Medicaid initiates a Medicare recoupment, how far back can they go?
The six (6) month filing limitation for Medicare/Medicaid corssover claims willbe determined using the Medicare payment register date as the date of receipt by Medicaid. Claims filed after the six (6) month timely filing limitation will be denied unless sometimes recipients qualify for Medicaid eligibility after six (6) month filing limit for Medicare crossover calims. If you are filing a claim for dates of services more than six (6) months old, for a recipient�s letter/notification to the claim form. 

11. How often does a provider need to submit a "Certification Letter for Electronic Submission" form?
Providers need to send one each time they send electronic claims, either by modem or tape/diskette.

COMMUNITYCARE
1. What should the provider do if an incorrect PCP number is indicated on the referral form?
The provider should contact the PCP and obtain a corrected referral.

2. Does a provider need to obtain a referral if a pregnant patient has an abnormal PAP Smear?
If the date of service occurred on September 1, 2001 or later, and it is a result of a pregnancy-related diagnosis, the provider does not need a referral.

3. How do providers obtain a list of Primary Care Physicians in their area?
Providers may obtain this information by logging onto the Community CARE website at www.LACommunityCARE.com.

4. Are providers able to limit the number of referrals they issue?
Providers may limit the number of referrals/authorizations they issue by assuring referrals/authorizations are issued for an appropriate length of time and/or number of visits to meet the needs of the enrollee. PCP�s must issue referral/authorizations for any medically necessary service the PCP does not provide or if the PCP cannot provide the service in a timely manner appropriate to the medical needs of the enrollee.

5. If a specialist receives an incomplete referral, can they refuse to provide services to the patient?
The PCP's office should never release an incomplete referral form. If a provider receives a referral form with incomplete information, they should return it to the PCP's office and request it to be completed. Once the referral form is corrected, the specialist may proceed with the appointment. 

6. What should a provider do if the patient indicates an address different than that of the Medicaid records?
The provider may contact the Parish office and report this information; they may also contact the Fraud and Abuse Hotline at 1-800- 488-2917 if they suspect that the patient is using another person's identification card.

7. If a provider receives a referral for a surgery, but the date of surgery changes and it is not within the dates indicated on the referral, does that provider need to obtain another referral?
Yes.

8. How do providers resolve 106 denials when the patient has Medicare coverage?
Although recipients with Medicare coverage should not have a PCP linkage, there are occasions when linkage occurs. In these situations, the first step is to contact Provider Relations at 1-800-473-2783 and make Unisys aware of the problem. The staff at Provider Relations will print the recipient file and forward it to DHH. The staff at DHH will review the documentation and correct the recipient file, making sure that the linkage is terminated effective the first day of the following month; however, the existing linkage cannot be altered. The service provider should also contact the PCP and request that a referral is forwarded to them for the service performed. You should also contact Provider Relations for assistance, if teh PCP denies the referral/authorization for a Medicare recipient.

9. Who is authorized to sign the referral form?
The Primary Care Physician or his/her authorized representative.

10. Can the referral form be faxed, or must it be an original form?
The PCP will have an original form (with ink signature), but facsimiles for all other providers are acceptable.

11. Does the PCP need to issue a referral when writing a prescription?
No. Pharmacy services are exempt from CommunityCARE.

12. Does the PCP need to issue a referral when writing a script for rehab or DME services?
Yes; however, the script may serve as the referral if the PCP indicates all the same information as required on the referral form. If not, the PCP must issue a referral form along with the script for rehab or DME services. 

13. If a patient arrives at the hospital with Physician Orders but does not have a referral, what can the hospital do?
For routine admission it is the hospital�s responsibility to obtain a referral. The facility may delay the admission, until the ordering physician can be contacted for a copy of the referral. For urgent or emergent situations (hospital or hospital transfers) the facility should first and foremost make sure the patient is stable and then set about obtaining a referral from the appropriate source.

14. Is it possible for consultations that result from a high-level emergency room visit to be exempt from CommunityCARE?
Effective July 1, 2002, emergency department physician visits of moderate to high complexity (CPT 99283, 99284, 99291, 99292, 99243, 99244, 99245) were exempt from the CommunityCARE referral/authorization process.

15. Can the same referral given to the hospital be used for a provider seeing the patient after discharge?
If the date range given on referral form includes the date that the provider is seeing the patient, and it is for the same diagnosis, the referral form can be shared.

16. Is DHH recruiting new physicians?
Recruitment is the responsibility of ACS/Birch & Davis. They may be contacted at 1-877-455-9955 if assistance is needed in locating a Medicaid provider.

17. What is the procedure when a patient is being referred to a provider out of state?
The referral needs to accompany the patient to the out-of-state provider's office, or it needs to be forwarded to the provider (via facsimile or mail).

18. Are the patients required to sign a waiver?
No. Participation in CommunityCARE is mandatory for most Medicaid recipients.

19. Is a referral needed when lab specimens are being sent to outside labs?
If the lab specimen is for a pregnancy-related diagnosis, no referral is needed. The lab will need a referral for any other diagnosis. The lab requisition may be used as the referral if all of the information that is normally found on the referral is written on the lab slip. If not, a separate referral should be attached to the requisition slip.

20. If the Primary Care Physician writes a referral for a specific date, and the specialist sends the patient to the lab the next day, can the lab use that same referral for their services?
No. The date of service must be indicated on the referral. For this reason, the Primary Care Physicians are encouraged to indicate a range of dates on the referral, appropriate to the diagnosis or problem indicated on the referral form.

21. Can the recipient be billed if the PCP denies a referral request?
The recipient may be billed if the PCP refuses to issue a referral for non-emergency services. Prior to providing services, the recipient should be informed that they are linked to a PCP and without a referral from that doctor their Medicaid Card will not cover their visit and they will be responsible for payment of the bill.

22. Is there a limit to the number of visits allowed in an office setting?
Those persons age 21 and over are limited to 12 visits per year.

23. If the PCP decides that lab work needs to be performed, should they give the recipient the referral or give them a copy of the referral for the lab?
The PCP should never give out the original referral. The original should be kept in the patient's chart. The PCP can give the recipient a copy of the referral for the lab, or they may use the lab request form as the referral. If the PCP uses the lab request form, he/she must ensure that the referral number is on it, as well as all the other information contained on the referral form.

24. If the purpose of the referral is to "evaluate and treat," can the non-PCP physician use that referral to perform surgery?
As long as the date range on the referral covers the date of surgery, that referral allows surgery to be performed.

25. If a recipient contacts the PCP to schedule an office visit, but the PCP cannot see the recipient, can the PCP refer the recipient to another PCP?
It is the responsibility of the PCP to provide medical care to his/her patients appropriate to the medical needs of the enrollee. If the PCP cannot, or will not, provide the service appropriate to the medical needs of the enrollee, it is acceptable to refer the recipient to a physician that can provide the service.

26. There are occasions when the hospital refuses to send medical records. What can be done about this situation?
Providers can contact DHH or their UNISYS field analyst to contact the hospital to provide education on CommunityCARE responsibilities.

27. Will Nurse Practitioners be allowed to function as PCPs?
At the present time nurse practitioners cannot serve as PCPs. Rural Health Clinics (RHC) staffed primarily by a Nurse Practitioner with a physician Medical Director may enroll as a PCP. You may contact the program manager at DHH for further assistance.

28. Should the PCP give a referral to the recipient for admission to the hospital?
Yes.

29. How can a PCP retain linkages if he/she has more than 2500 patients?
DHH can approve special cases in which the PCP has more than the state maximum of 2500 recipients. In these situations, DHH will make appropriate arrangements so that the linkages can occur.

30. Who is responsible for educating the recipient?
Patient education is a community effort-it is the responsibility of DHH and the provider community to educate the recipient. DHH has created a tri-fold pamphlet that addresses CommunityCARE policy from the patient's standpoint. Providers may contact ACS/Birch and Davis if they wish to have these pamphlets mailed to them.

31. Can a patient be billed for an emergency room visit that does not meet "prudent layperson standard"?
Yes. The hospital staff must inform the recipient that Medicaid does not cover routine care in the emergency room and that he/she will be liable if the primary care physician does not approve the referral and the service was truly not an emergency.

32. How long must the referral be kept, and does DHH mandate where the provider keeps the referral?
According to MAPIL, all records must be maintained and retained for a period of five years - including referrals. DHH requires that field staff from ACS monitor the providers. When the nurse comes to the provider's office, the provider must be able to locate the referral to prove that the service was approved by the PCP. DHH does not dictate where the referral is kept, as long as it is accessible.

33. If a hospital provides psychiatric services, but does not have a distinct part psychiatric unit in their facility, do they still need to obtain a referral for services?
Yes. CommunityCARE policy exempts inpatient psychiatric service in a distinct part psychiatric unit and psychiatrists services; services billed as a acute care hospital service are not exempt. DHH is currently reviewing this issue..

34. If a referral is denied, does the PCP have to indicate the reason for denying it?
The PCP should indicate the reason for denying the request.

35. Can the recipient request a PCP that is more than two parishes away from his/her residence?
Yes, but only on a case-by-case basis. CommunityCARE allows the recipient to select a PCP that is within the parish of residence, in a contiguous parish, or 30 miles from the parish of residence. Recipients requesting linkage to a PCP that is not the closest available PCP should be reminded that Medicaid will only provide transportation to the nearest appropriate physician.

36. Who do you contact if a PCP is not complying with CommunityCARE policy?
Providers should contact UNISYS if they are experiencing problems with other providers.

37. If a PCP has more than one site, is the site number required on the claim form?
No. The only information that should appear in the block designated for the referral is the PCP referral number. 

DME
1. Is the comment "prior authorization is not a guarantee of payment" on all PA letters?
Yes.

2. Why does the prior authorization letter indicate dollar amount only for supply requests?
All DME services are paid according to automatic pricing or manual pricing. If the DME item being requested is an automatic priced item, the PA letter will only indicate units, not dollar amount. If the DME item being requested is a manually priced item, the PA letter will only indicate dollar amount, not units. The system can only recognize dollar amount or units, not both.

3. What is the turnaround time on adjustment forms?
Hardcopy adjustments/voids have the same processing time as initial hardcopy claims-30 days from the date received. Providers filing claims electronically have the ability to file electronic adjustments/voids. If your software is not set up to handle electronic adjustments, you will need to contact your vendor to discuss this option. Electronic adjustments process in one week.

4. Is the referral number the same as the doctor's UPIN number?
No. It is a unique 7-digit number assigned by the state.

5. Is there a list of Prior Authorization denials?
No. Providers can compile their own list by referring to those denials indicated on the PA letter.

6. We received an approved PA but we submitted the request with the wrong amount. How do we correct it?
You need to submit a Reconsideration explaining that the incorrect amount was listed. Make sure that you attach the PA01, all documentation from the initial PA, and a copy of the PA letter with the letters "RECON" written on the top of the letter. The Prior Authorization Unit will send another PA letter with the corrected amount (if approved).

7. We received an approved PA but the amount was mis-keyed causing an incorrect payment amount. How do we correct it?
Since this situation involves a keying error, the Prior Authorization Unit will correct it. Be sure to contact them and explain the situation to them. They will pull the original request and verify that the information was correct. As long as there is no discrepancy, the Prior Authorization Unit will correct it.

EPSDT/PCS
1. Does a child have to be homebound to receive Personal Care Services?
No.

2. Who is able to provide the Personal Care Services?
Those providers who are able to perform PCA/PCS services must meet specific requirements to obtain a Personal Care Attendant License from the Department of Social Services. That license is required to enroll in Medicaid to provide these services. Contact DSS for information on specific requirements.

3. Is it acceptable to provide both Personal Care Services and Children's Choice services on the same day?
Yes. However, those two services cannot be performed at the same time.

4. Can the respite worker provide Personal Care Services?
Yes, but the respite and PCA services cannot be performed at the same time.

5. Is it acceptable for a physician's partner to sign the 90-L form, even though the recipient is linked to him/her as the primary care physician?
It is acceptable for a physician out of the group to sign the 90-L form, even if they are not the actual primary care physician.

HOME HEALTH
1. How can providers obtain an extension on the 50-visit limit?
At the present time, Medicaid policy allows recipients 21 and older to have 50 visits per calendar year. There is no mechanism for extensions. Providers can write to the program manager at DHH if they wish to have a policy change considered.

2. Does the website provide a comprehensive error code list?
No.

3. According to Medicaid policy, Home Health Aides require RN supervision every 14 days. Is this policy changing to every 60 days?
This policy is actually issued by the Health Standards Section in the Standards for Payment for Home Health document. Much of the policy contained within are taken from existing state and federal regulations, such as Code of Federal Regulations (CFR) 42 published by the Centers of Medicare and Medicaid Services (CMS). Questions related to the Standards for Payment publication for Home Health Agencies should be addressed to Marian Tate in the Health Standards Section.

4. If a recipient has extended home health care and the physical therapist arrives while the skilled nurse is present, does the skilled nurse have to leave according to Medicaid policy?
No, but Medicaid may not be billed for both services during the same time period. Obviously both cannot be providing services at the same time, and we would not authorize payment for the time a nurse is in the home when a physical therapist is in the home performing a service during this time.

5. If a patient is evaluated every 3 months, but Medicaid only pays for an evaluation once every 6 months, can the provider bill the patient for the unpaid evaluation?
Yes, but the evaluation should be justified and the recipient must be told that it is not covered by Medicaid.

HOSPICE
1. How are evacuations reported on the TAD?
If the evacuation is a mandated evacuation (mandated by the Office of Emergency Preparedness or local government/law enforcement), the facility may bill for a service day; if the family chooses to take the recipient out of the facility, a leave day may be billed; if the facility decides to evacuate recipients and asks family/friends to take the recipient (not an evacuation mandated by the appropriate authorities), the facility must discharge and readmit them when they return to the facility. In this specific case, a new 142A and 18LTC are not required upon readmission. The facility should state in the comments section of the TAD the reason for the discharge and readmit (ex: 'readmitted following discharge due to hurricane').

2. Will Hospice providers always bill long term care (LTC) room and board on the Turn Around Document (TAD)?
No. Once HIPAA is implemented, Hospice providers will bill LTC room and board on the UB-92 form.

3. Will Hospice providers be assigned a new revenue code with the implementation of HIPAA?
All code sets will be standardized for health care billing. The federal list of codes will be approved by CMS and published to providers by DHH prior to HIPAA implementation.

4. Will the diagnosis field on the UB-92 need to be completed?
Yes. The patient's diagnosis is a required field.

5. If the 81B form is sent, how does Medicaid know whether the patient was discharged or expired? There is no place on the form to state a reason for cancellation.
The parish office is notified of a recipient's death. The parish office updates the file by indicating that "file is closed due to death". If the file does not indicate a death, the DHH Hospice Unit assumes that the recipient was discharged.

6. Will a new Hospice agency have to obtain prior authorization before accepting a patient from an old Hospice agency?
As of January 1, 2003 the new hospice provider will have to obtain authorization if the certification period requires PA.

7. Who is qualified to provide critical care services to a patient in the home?
At the present time, providers should follow Medicare's guidelines.

8. Is the reimbursement rate listed in the 2002 Training Packet correct? As of October 1, 2002, the Medicare rate was increased to a higher rate?
Effective October 1, 2002, the Medicare rate increased. However, these rates have not been approved by DHH for payment by Medicaid. Providers should bill with the higher rate. If the higher rate is approved by DHH, DHH will instruct UNISYS to recycle those claims once the files have been updated, and providers will receive the higher amount at that time.

9. What is the mailing address for Hospice claims?
Those claims should be sent to UNISYS P.O. Box 91021 Baton Rouge, LA 70821.

10. What should a Hospice agency provide to Medicaid to let them know that a patient presently in a nursing home has elected Hospice?
The Hospice provider should send the BHSF form Hospice Recipient Election/Cancellation/Discharge Notice.

11. If patient is at home upon Hospice enrollment, and then admitted to a long term care facility, what paperwork should be submitted to Medicaid?
The long term care facility sends the 142 form.

12. Does the election form need to be sent to an address other than the BHSF address?
No, not at this time.

13. Should all subsequent certification forms be sent to BHSF?
Yes - the address/fax/e-mail is on page 3-8 of the Hospice Provider Manual.

HOSPITAL
1. Does Medicaid accept electronic EOB print-outs as proof of timely filing?
No.

2. How should a hospital bill for the services of a transport team (a nurse or team of nurses accompanying the patient) when the hospital ambulance transports a recipient from one facility to another?
If a patient is transported to a hospital by a hospital-based ambulance (ground or air) and is admitted, the ambulance charges and the transport team charges must be billed on the UB-92 as part of the inpatient services using revenue code 540.

3. How often are therapy evaluations paid?
Medicaid policy allows and pays for one evaluation every six months. 

KIDMED
1. Has policy for Kidmed changed since the expansion of CommunityCARE? What procedure code should school board nurses use to bill for the medical screening?
There have been some changes in Kidmed policy since the expansion of CommunityCARE. Please refer to the provider updates and RA messages as well as letter to providers outlining the changes. 
The fields for a medical screening by a nurse on the KM-3 form should be completed. School nurses in CommunityCARE parishes can bill for a medical screening oinly if they have a referral from the PCP or Contract with the PCP to perform the medical screening for the PCP.

2. In the process of completing a Kidmed screening, a patient requires an in-house referral. Can the provider charge a new patient consult code for this service?
No. If the referral is in house, the recipient is not a new patient. 

3. Can ACS/Birch and Davis still remind patients of their screenings since the expansion of CommunityCARE?
Yes. That service has not changed.

4. What is the timely filing guidelines when billing a well child visit on the HCFA-1500 form?
All services on the HCFA-1500 form have 1 year timely filing guidelines.

5. Can providers adjust and/or void the KM3 form electronically?
No. Electronic adjustments/voids are not available at this time for KM-3 forms.

6. Is there a manual that accompanies the Keymaster software?
Yes. Providers should receive it when they obtain the software. An extra copy can be provided by contacting the UNISYS EMC Department at 225-237-3303.

7. Do the optional tests offered in lieu of the Denver testing require the same training?
Any questions related to the optional testing forms should be directed to the ACS Kidmed nurse for that provider area. To contact the ACS KIDMED nurse, call 1-800-259-8000.

LONG TERM CARE 
1. When will long term care providers have to use the UB-92 form?
The exact date has not been set. This transition will occur with HIPAA implementation. UNISYS will notify the providers once a formalized schedule has been determined.

2. If a provider is submitting claims for old dates of services, what Level Of Care (LOC) code should be used?
The new Level of Care code (88) is not effective until January 1, 2003. Any dates of service prior to 1/1/2003 should be submitted with the Level of Care code applicable to that time period.

NON-EMERGENCY MEDICAL TRANSPORTATION
1. Is DHH considering increasing reimbursement rates for this program?
Currently, there has been no mention of an increase in reimbursement. Providers may voice their concerns, in writing, by sending a letter to DHH-NEMT Program Manager, P.O. Box 91030, Baton Rouge, LA 70821.

2. How can a provider receive payment for a claim that denied with error code 272 (claim over one year old)?
The answer depends on whether the claim was submitted within a year of the date of service. As long as there is proof of timely filing proving that the claim was received within one year from the date of service, the provider has until two years from the date of service to receive payment for that claim. To reconcile the denial, the provider can submit documentation as proof of timely filing along with the hardcopy claim. If proof is attached, Unisys staff will override the timely filing edit and allow the claim to process. If the claim was not submitted within the first year, the provider will not receive payment for that claim, and may not bill the recipient. Complete information on timely filing guidelines can be found in your provider manual. 

3. How long does a provider have to void a claim?
Providers should void their claims as soon as they realize that an error was made. In order to submit a 206 void form, the provider has two years from the date of payment of the claim. If the claim needs to be voided later than two years from this date, the provider must submit a check to DHH for the total amount along with a copy of RA highlighting the claim(s) to be voided. Be sure the check total and the total claims payment equal. Complete instructions on submitting voids/adjustments or refund checks can be found in the provider manual and Basic Training Packet.

PHARMACY
1. Is there a limit on emergency room prescriptions?
General Medicaid policy states that an emergency prescription should not be written for more than a 30-day supply. 

2. If there are large numbers of requests for a particular drug, will it be placed on the Preferred Drug Listing (PDL)?
DHH does review such data. This information may assist in the determination of which drugs are placed on the preferred list. The Medicaid Pharmaceutical Therapeutic Committee makes recommendations to the Department based on clinical and economic reviews of therapeutic classes of drugs.

PROFESSIONAL
1. When a physician bills for an inpatient visit, but another doctor has already received payment for that same date of service, the claim is denied. Can Unisys inform the biller of the doctor who has already received payment?
No. DHH has instructed Unisys to not release that information.

2. How are patients made aware of Medicaid limitations, such as only twelve visits per year? Is a pamphlet sent to the patients?
No pamphlet is sent to the recipients. Their education is the responsibility of the DHH parish office and the providers of service.

3. Who reviews outpatient visit extension requests?
Unisys retains physicians as consultants who are responsible for reviewing the extension requests.

4. Can a dietician enroll as a Medicaid provider?
No. A dietician cannot enroll as a direct services provider. 

5. Under what circumstances is it acceptable to apply for an office visit extension?
Office visit extensions are granted for life threatening and/or emergency situations.

6. If a surgeon is consulting on a patient's case and decides that surgery needs to be done, how should the office visit be coded?
The office visit should be billed as an evaluation and management code, not a consult. Also, if the surgery falls within the global surgery policy (GSP), the office visit may not be billable as a separate procedure. Consult the GSP policy for details.

7. If a physician employs a nurse practitioner, does a group provider number need to be obtained, and both provider numbers linked to that group number?
Yes. A group number must be obtained and both numbers linked to the group number.

8. How often can a new patient evaluation and management code be billed?
According to Medicaid policy, providers may bill a new patient code as long as they have not provided services to that recipient in the past two years.

9. How can nurse practitioners receive payment for a procedure code that is not on the nurse practitioner list, but is within the scope of their practice?
Providers can write a letter to DHH requesting that a procedure code be reviewed and added.

10. Will Medicaid reimburse a certified nurse practitioner as an assistant surgeon during a surgery?
At this time, Medicaid does not reimburse nurse practitioners for assistant surgery services. An assistant surgeon must be a licensed physician. It is also against Medicaid policy to bill the recipient for this service.

11. If Medicaid is billed secondary to Medicare with the -GA modifier, will the claim process?
Yes, as long as Medicare is the primary payer.

12. Will Medicaid consider paying for glasses to a person over the age of 21?
At the present time, Medicaid will not reimburse for glasses if the recipient is 21 or older.

13. If a provider is performing a bilateral procedure that happens to be secondary in a multiple procedure setting, which modifier should be used first?
It does not matter which modifier is first, as long as they are both indicated on the claim.

REHABILITATION
1. A claim that was paid as Medicaid primary should have been paid as secondary to Medicare. How should this be corrected?
The provider needs to submit a void. Medicaid will take back the payment. It is up to the provider to resubmit the claim with the EOMB attached so that co-insurance/deductible is paid. It may also be wise to 
forward this information to Provider Relations Correspondence Unit so that the Medicare coverage can be included on the recipient's file.

2. Is a power wheelchair considered an emergency request?
No.

---

Louisiana Drug Utilization Review (LADUR) Education

New Oral Pharmacologic Options in the Treatment of Overactive Bladder: 
Focus On the Antimuscarinic Agents

By: Nicole Robin Krohn, Pharm.D.
Clinical Assistant Professor of Pharmacy at ULM School of Pharmacy and Pharmacy Clinical Coordinator at Lafayette General Medical Center

Issues...

� The term overactive bladder encompasses a wide range of symptoms.

� In the last several years advances have been made in the treatment of OAB.

� The most commonly used medications to treat OAB are the antimuscarinics.

The term overactive bladder (OAB) has been popularized over the past 5 years as a condition that encompasses a wide range of symptoms including urinary frequency, urgency, and urge incontinence, singly or in combination.1 It is estimated that about 17 million people in the United States suffer from overactive bladder, thus making OAB more prevalent than asthma, osteoporosis, and diabetes.2 Urinary incontinence not only causes considerable medical and psychosocial morbidity, but also results in enormous cost to the patient and the health care system. Conservative projections for costs related to diagnosis and treatment of urinary incontinence exceed $26 billion annually, which is more than what is expended by Medicare on dialysis and coronary bypass grafting combined. Moreover, these costs apply only to individuals 65 years and older, who constitute less than half of those with urinary incontinence.3

Fortunately, in the last several years, several advances (new drug delivery routes, long acting oxybutnin and tolterodine etc.) have been made in the treatment of OAB and are still in the research phases. The goal of this article is to review three new oral antimuscarinics: oxybutynin XL, tolterodine, and tolterodine LA and to take a look at darifenacin, an antimuscarinic that is still currently in clinical trials. 

New Oral Pharmacologic Options for the Treatment of OAB (See Table 1)
The most commonly used medications to treat OAB are the antimuscarinics. Anticholinergics are competitive inhibitors of acetylcholine at muscarinic receptors (mainly M3 receptor subtype); they, thereby, inhibit involuntary bladder contractions.4, 5 The effective dose is found by titration of the medication until the symptoms of incontinence are reduced or relieved. Often times adverse effects will halt dose titration or interfere with patient compliance. The major dose limiting side effects of anticholinergic medications include dry mouth, constipation, dry eyes, drowsiness, and tachycardia. Antimuscarinic agents are contraindicated in patients with closed-angle glaucoma, obstructive uropathy, urinary retention, GI obstruction or ileus, toxic megacolon, and severe ulcerative colitis.13

Oxybutynin
Oxybutynin was originally identified in the 1960s as a potential treatment for GI hypermotility. Further investigation showed that it was effective in inhibiting uncontrolled bladder contractions. In 1975 oxybutynin was approved by the FDA.13 Subsequently, oxybutynin has been the gold standard and most widely used pharmacologic agent for the treatment of overactive bladder for over 20 years.6

Oxybutynin is a potent anticholinergic agent with a strong independent musculotropic relaxant activity, as well as local anesthetic activity. Oxybutynin acts mainly on the muscarin-3 (M3) subtype receptors.6 In human tissue, oxybutynin has higher affinity for muscarinic receptors in the parotid gland than in the bladder.5 This accounts for the drug�s major side effect of dry mouth. Other adverse effects that can be attributed to oxybutynin�s anticholinergic properties include: drowsiness, constipation, decreased diaphoresis, and tachycardia. Dosing of oxybutynin is usually initiated in the elderly at 2.5mg bid-tid and younger adults at 5mg bid-tid and titrated to effect or tolerability of side effects. The maximum dose of oxybutynin is 5mg qid or 20 mg/day.5, 13

Efficacy and Safety
The clinical efficacy of oxybutynin for the treatment of OAB has been well established.6 Most of the studies showed that oxybutynin was more effective than placebo. Moreover, comparative studies show that oxybutynin is at least as effective as propantheline, propiverine, penthienate, and trospium.6

In the largest of these studies, Madersbacher et al.6 treated 366 overactive bladder patients randomized to treatment with 5mg oxybutynin three times a day (n=145), 15mg popiverine three times a day (n = 149), or placebo (n=72) for 28 days. Results showed that about 80% of patients in each drug group reported global symptomatic improvement.6 However, despite clinical efficacy, oxybutynin does cause significant dose related adverse effects of dry mouth, constipation, drowsiness, and blurred vision. In fact, proof of this was shown in a short follow-up study of 231 patients receiving antimuscarinic therapy of OAB (84% taking oxybutynin). At 6 months, the study showed that only a minority of patients were still being treated. Most patients that withdrew from the study had withdrawn secondary to intolerability of adverse effects.6

Oxybutynin XL
To increase patient convenience, compliance, and to reduce the concentration-dependent antimuscarinic adverse events, the formulation of a 24hr extended release oxybutynin was developed. Oxybutynin XL (Ditropan�XL) was approved by the FDA and released for general use in the United States in 1999.14 One of Oxybutynin XL formulations is based on the OROS osmotic drug delivery system (ALZA CORP., Palo Alto, CA), which delivers the drug at a steady rate over 24hrs. Drug absorption begins to occur in the large intestines, rather than in the stomach like traditional oxybutynin, causing less oxybutynin metabolite formation. In some patients this may reduce oxybutynin�s adverse effect profile since oxybutynin�s metabolite, rather than oxybutynin itself, appears to be responsible for most of the side effects.5, 6 Oxybutynin XL is available as 5mg, 10mg and 15mg tablets. It is initiated at 5mg once daily in both young adults and elderly and can be titrated weekly to a maximum of 30mg/day. Tablets should not be crushed.13

Efficacy and Safety
A 13 center, randomized, double-blind, parallel group, dose titration study was done by Anderson et al7 (The Oros Oxybutynin Study Group) to compare the efficacy and safety of controlled and immediate release oxybutynin.7 The mean number of weekly urge incontinence episodes decreased from 27.4 to 4.8 in the controlled release oxybutynin and from 23.4 to 3.1 in the immediate release group (p = 0.6). As far as safety issues found, the most common anticholinergic event in both groups was dry mouth (68% of the controlled and 87% of the immediate release group p=0.04).7 Except for dry mouth, the 2 treatments produced comparable anticholinergic events.7 This trial concluded that controlled and immediate release oxybutynin produced similar reductions in urge and total incontinence but exhibited lower rates of dry mouth in the controlled release formulation .7

However in contrast to the trial above, another much smaller study failed to demonstrate improved tolerability for the extended-release formulation. Nilsson et al., recorded a similar frequency of dry mouth between both traditional oxybutynin and extended release oxybutynin.6

Tolterodine
In 1998 the FDA approved the first drug specifically developed for the treatment of patients with overactive bladder.6, 14 Tolterodine (Detrol�) was designed to be bladder specific and its actions on the bladder include inhibition of bladder contraction. Because of this specificity for the bladder, the antimuscarinic effects on the salivary gland are much less pronounced than the effects on the bladder. Also as a benefit, tolterodine and its active metabolite have a lipophilicity of 30 and >350 times lower (respectively) than oxybutynin, making tolterodine less likely to cross the CNS.13

Tolterodine is available in 1mg and 2mg tablets. The recommended starting dosage is 2mg twice daily, which can be lowered to 1mg twice daily in some patients. For patients with reduced hepatic function or for those taking erythromycin or ketoconazole (inhibitors of CYP3A4), it is recommended that dosing start at 1mg bid.9,14 Maximum dose for tolterodine is 4mg daily. Adverse effects are similar to oxybutynin but less severe.4,5,6,8,9

Efficacy and Safety
The efficacy and safety of tolterodine was evaluated in a randomized, placebo controlled, parallel group study by Millard, R et.al.10 Patients were randomized to receive 1 or 2mg of tolterodine or placebo.10 Results demonstrated that after 12 weeks of treatment there was a significant decrease in the number of voids per 24 hrs and change in urine volume per void for each tolterodine dose. Nonsignificant findings were in the episodes of urge incontinence per 24 hrs, but each dose was more effective than placebo. After 12 weeks of treatment, incontinence episodes were decreased from baseline values by 43 and 50% in the 1 and 2 mg tolterodine groups, respectively. However, patient perceived improvement was 38%, 41%, and 59% with placebo, 1mg and 2mg tolterodine doses, respectively.10 As for safety, only minor noncholinergic and cholinergic adverse events were reported by the majority of the patients treated in each group. The number of adverse events per patient was comparable among the groups. Dry mouth was the most frequently reported adverse event in each tolterodine group, as notice by 13% of the patients on placebo, and 24 and 39% of those on 1 and 2 mg, respectively.10

Tolterodine LA
A long acting formula of tolterodine was approved by the FDA and released in the early part of 2001.14 The sustained release capsule of tolterodine LA (Detrol� La) was designed to provide sustained release of the drug for 24 hrs, producing a flatter serum concentration-time profile versus the immediate release tablet formulation.11 This was expected to increase patient compliance, convenience, and to reduce the adverse effect profile seen with the IR Tolterodine along with keeping comparative efficacy. Tolterodine LA is available as 2 and 4mg tablets given once daily. The maximum dose is 4mg/daily.14

Efficacy and Safety
Tolterodine LA has fewer side effects and similar or modestly better efficacy than the twice daily tolterodine formulation.5 Van Kerrebroeck et al11 compared the efficacy and safety of tolterodine long acting 4mg once daily to tolterodine immediate release 2 mg bid and placebo. The trial was a double-blind, multicenter, randomized placebo controlled trial of 1529 patients treated for 12 weeks. Both Tolterodine ER and IR showed significant reductions in the number of incontinence episodes compared with placebo. Because of the skewed nature of the data, the median reductions of the percentage change from baseline were calculated (placebo 33%, tolterodine IR 60% and tolterodine ER 71%). This data revealed that the ER formulation was significantly (18%) more effective than the IR formulation.11 Dry mouth, constipation and headache were the most common adverse events. Aside from dry mouth (patients taking the ER formulation had 23% less dry mouth than those taking the IR formulation, p<0.02) all other side effects were seen with similar frequency in the treatment groups vs. placebo.5, 11

Oxybutynin XL vs Tolterodine
To date there have been no trials comparing oxybutynin XL to Tolterodine LA but there was a large prospective, randomized, double-blind, parallel-group study done at 37 US study sites done by Appell et al.12comparing oxybutynin XL and tolterodine IR. The OBJECT study evaluated the efficacy and tolerability of extended release oxybutynin 10 mg/day and tolterodine 2mg bid over 12 weeks in 332 patients with OAB.12 At the end of 12 wks, the study showed that oxybutynin XL was significantly more effective than tolterodine at reducing the mean number of weekly urge incontinence episodes (oxybutynin XL from 25.6 to 6.1 and tolterodine from 24.1 to 7.8) (p=0.03), total incontinence episodes/wk (oxybutynin XL from 28.6 to 7.1 and tolterodine from 27.0 to 9.3) (p=0.02) and micturation frequency/wk (oxybutynin XL from 91.8 to 67.1 and tolterodine from 91.6 to 71.5) (p=0.02). Both drugs significantly improved the symptoms of overactive bladder compared to baseline. As for adverse effects, the incidence of dry mouth was similar in the oxybutynin XL group (28.1%) compared to the tolterodine group (33.2) (p=0.32). All other adverse effects such as asthenia, blurred vision, dizziness, insomnia, nervousness, and somnolence occurred at low rates and there was no difference between the two treatment groups.12

Oral Antimuscarinic Agents on the Horizon

Darifenacin
Darifenacin is a new antimuscarinic agent still in clinical trials. Darifenacin was developed to have specificity for the M3 receptor subtype which has major involvement in bladder contraction. It is hoped that darifenacin�s subtype selectivity will prove very effective in treatment and almost negate the systemic adverse effects.6, 9 Darifenacin has been tested in a small placebo controlled study that showed improvement in urodynamic parameters following single oral doses of 10 mg. However, at this dose there was an effect on the salivary glands. Clinical trials are still ongoing.9

Conclusion
Antimuscarinic agents have remained the cornerstone for the treatment of overactive bladder since the approval of oxybutnin in 1972. The main motivations for developing new products to compete with oxybutynin have been to improve compliance, convenience, and to reduce the major adverse effects of dry mouth, constipation, drowsiness, and blurred vision. In the last five years with the addition of tolterodine, oxybutynin XL, and tolterodine LA, there are now 3 medications that are better tolerated than traditional oxybutynin. It is expected that in the near future a new oral antimuscarinic, darifenacin, may be yet another more bladder specific agent added to the arsenal of drugs for the chronic condition of overactive bladder.

References 

1.     Davila, GW, Neimark M. The Overactive Bladder: Prevalence and Effects on Quality of Life. Clin Obstet            Gynecol. 2002; 45(1):173-181.

2.     Urinary Incontinence. In: Appell RA. Rakel: Conn�s Current Therapy. 2002:678-679.

3.     Resnick NM. Improving Treatment of Urinary Incontinence (editorial). JAMA 1998; 280(23):2034-2035.

4.     Franks M, Chartier-Kastier E, Chancellor MB. New Pharmacologic and Minimally Invasive Therapies for            the Overactive Bladder. Drug Benefit Trends. 2000; 12(5):49-57.

5.     Washington Cannon T, Chancellor MB. Pharmacotherapy of the Overactive Bladder and Advances in             Drug Delivery. Clin Obstet Gynecol. 2002; 45(1):205-217.

6.     Chapple CR. Muscarinic Receptor Antagonists in the Treatment of Overactive Bladder. Urology. 2000;             55(Suppl 5A):33-46.

7.     Rodney UA, Mobley D, Blank B, et al. Once Daily Controlled Versus Immediate Release Oxybutynin            Chloride For Urge Urinary Incontinence. J Urol. 1999; 161:1809-1812.

8.     Elliot DS. Medical Management of Overactive Bladder (editorial). Mayo Clin Proc. 2001; 76:353-355.

9.     http://www.powerpak.com Overactive Bladder Treatment Update. 2001:1-26.

10.     Millard R, Tuttle J, Moore K, et al. Clinical Efficacy and Safety of Tolterodine Compared to Placebo in              Detrusor Overactivity. J Urol. 1999; 161:1551-1555.

11.     Van Kerrebroeck P, Kreder K, Jonas U, et al. Tolterodine Once-Daily: Superior Efficacy and Tolerability  
           in the Treatment of the Overactive Bladder. Urology. 2001; 57:414-421.

12.     Appell R, Sand P, Dmochowski R et al. Prospective Randomized Controlled Trial of Extended-Release  
           Oxybutynin Chloride and Tolterodine Tartrate in the Treatment of Overactive Bladder: Results of the 
           OBJECT Study. Mayo Clin Proc. 2001; 76(4):358-363

13.     Oybutynin drug information. Clinical pharmacology 2000 Online. www.cp.gsm.com version 2.05 (3rd 
           Quarter, 2002)

14.     Tolterodine drug information. Clinical pharmacology 2000 Online. www.cp.gsm.com version 2.05 (3rd 
           Quarter, 2002)