PROVIDER UPDATE
VOLUME 8, NUMBER 6
DECEMBER 1991
All Providers
Reminder
To reduce the cost of postage and additional handling
charges, providers may send more than one claim in an envelope when they submit
claims to Unisys for processing.
Refunds & Voids
Instead of simply refunding payments when errors in billing
occur, e.g., duplicate payments, providers should initiate claim adjustments or
voids. However, should providers
find it necessary to refund a payment, they should make checks payable to the
Department of Health and Hospitals, Bureau of Health Services Financing, and
they should mail the refunds to the following address:
Division of Fiscal
Management
Financial Management
Section
P. O. Box 91117
Baton Rouge, LA
70821-9117
NOTE:
Checks should not be made payable to Unisys.
To ensure that accounts are reconciled appropriately,
providers must attach a copy of the Remittance Advice to their refund or return
check.
Finally, to determine the amount of a refund, providers
should consider the following rules:
Whenever a duplicate payment is
made, the full amount of the second payment must be refunded.
If another insurance company pays
after Medicaid has made its payment and the TPL payment is greater than the
Medicaid payment, the full amount of the Medicaid payment should be refunded.
NOTE:
Providers should never submit a void and a refund for the same payment
amount.
Reproductions of Electronically Submitted Remittance Advices
Providers should disregard the article entitled "EOBs"
on page two of the October 1991 Provider Update.
Effective immediately, those providers who receive
electronic Remittance Advices from Medicare may be submitting reproductions of
their electronically submitted Medicare Remittance Advices on their hardcopy
Medicare/Medicaid crossovers. However,
other providers who do not receive electronic RAs from Medicare may continue to
submit hardcopy Medicare EOBs.
All policy regarding other TPL documentation, i.e., copies
of checks from commercial insurance carriers, EOBs, etc., remains the same.
EMC Submitters
New EMC Staff
We would like to welcome Sue Kendrick and Debbie Perry to
the EMC staff. Providers who have
technical questions or problems with disks may address their questions to Sue or
Debbie at the following address:
Sue Kendrick/Debbie
Perry
Unisys/Louisiana
Medicaid
8591 United Plaza
Blvd.
Baton Rouge, LA
70809
Telephone:
(504) 924-7051
Name/Number Mismatch
To avoid having Medicaid claims deny with error code 217
(Name/Number Mismatch), submitters must enter the recipient's name exactly as it
appears on the recipient's Medicaid identification card.
Specifically, if the recipient's last name is less than
five positions and is accompanied by an abbreviated personal title (Jr., Sr., I,
II, or III), the personal title must be keyed in. However, no punctuation or spaces should be entered with that
title.
One each provider's data file, however, it is possible for
a provider to input the name Tom Lee, Jr. as LEE - JR (or any other equivalent).
The provider's software should compact the name to LEEJR by eliminating
the special characters. It may even
contain special data fields for these titles.
Providers should contact their software vendors to find out how their
software operates under these conditions.
Also, providers should be aware that the various EMC
specifications were written with different requirements for the recipient's name
field.
To ensure proper processing of claim types having more than
five last name characters or more than one first name character, providers must
submit the correct characters in the first five positions.
For audit trail purposes, however, it is necessary to
complete names to the fullest extent of the field. For example, the name Sister Margaret Westinghouse on a HCFA
1500 claim should be entered as WESTINGHOUSE
SISTERMAR.
The following examples illustrate the correct forms of
names that have caused claims processing difficulties in the past.
The name Tom Lee Jr., should be entered as L E E J R T .
The name Burny Age II should be entered as A G E I I B .
The name Tyrone Le, Jr. should be entered as L E J R _ T .
If there are not enough characters in the last name to use
all five spaces provided, and if there is no personal title, the unused spaces
should be left blank. The first
character of the first name should not be put in the unused space.
The first character of the first name should be placed in the field
designated for the first name. Examples are provided below.
The name Sister Rita Carter should be entered as C A R T E
S .
The name Father Michael Edmund should be entered as E D M U
N F.
Also, punctuation and spaces within names, such as the
saint names and French names, should be ignored.
Examples are illustrated below.
The name Paul St. Julien should be entered as S T J U L
P .
The name David D'Hemecourt should be entered as D H E M E
D .
Questions should be addressed to the EMC coordinator,
Jerrold Perry, at (504) 924-7051.
Billing Line Items
Physician EMC submitters, those providers who bill claim
type 04, may now bill more than 16 line items.
To accommodate this change, the maximum number of claim
lines per invoice will be increased to 99.
However, providers may start billing the increase immediately.
In addition, providers should contact their software
vendors and inform them of this change.
Questions regarding these changes may be addressed to Sue
Kendrick or Debbie Perry at (504) 924-7051.
EMC Certification Forms
The Third-Party Certification Form has been updated to
include a list of provider names and identification numbers.
A copy of the new certification is provided in the Attachments
section of this issue of the Provider
Update.
In addition, we would like to remind billing agents and
providers who are billing for other providers to make sure that the provider who
rendered the services furnishes a Professional, Pharmacy, or Hospital Services
Certification From on which the service provider attests to the truth, accuracy,
and completeness of the claim information and agrees to maintain the appropriate
forms for a period of three years in the billing agent's office.
NOTE:
All certification forms sent to Unisys should be mailed to Post Office
Box 91025.
Physicians
Time Restriction for Norplant
Effective with date of service May 1,1991, physicians may
bill for the insertion, only, of the Norplant contraceptive implant by attaching
a -26 modifier to HCPCS code 58302. The
fee for insertion is $100.00.
Physicians who wish to be reimbursed for the kit as well as
the insertion should bill code 58302 with no modifier.
The fee for the kit and insertion is $450.00.
In addition, a restriction of one implant per five years
per recipient has been placed on this contraceptive. Claims for a second implant on the same recipient within the
five-year period will pend for review by the Medical Review Team and will be
paid only if the circumstances under which the client was reimplanted meet the
criteria established by Medicaid of Louisiana.
Procedure Codes 93503, 36620 & 36010
Effective with dates of service November 1,1991,
anesthesiologists will be paid a flat fee for the performance of procedure code
93503 (Insertion and placement of flow directed catheter, e.g., Swan-Ganz, for
monitoring purposes). The fee for
code 93503 will be $195.00
NOTE:
Minutes should not be billed with 93503.
In addition, the fees for codes 36620 [Arterial
catheterization for prolonged infusion therapy (chemotherapy), cutdown] and
36010 (Introduction of catheter; in superior or inferior vena cava, right heart
or pulmonary artery) will be increased to $73.00 and $136.00, respectively,
effective November 1, 1991.
Procedure Code 11770
Effective with date of service June 1, 1991, CPT-4
procedure code 11770 (Excision of pilonidal cyst or sinus, simple) was placed on
the anesthesia (tos 01) file with a base unit figure of 3.
Fee Increase for Vaginal and Cesarean Delivery
The fees for vaginal delivery (CPT-4 procedure code 59410)
and Cesarean delivery (CPT-4 procedure code 59515) will be increased to $860.00
and $1,100.00, respectively, effective with date of service October 15,1991.
Procedure codes 59500 and 59520 will be placed in non-pay
status effective this same date.
Secondary or Multiple Surgical Procedures
Current policy for multiple surgical procedures states that
secondary or multiple procedures must be modifier with modifier -51.
Providers, however, continue to bill secondary or multiple surgical
procedures without modifier -51. This
practice results in inappropriate reimbursement to the provider.
Therefore, effective January 1, 1992, claims for secondary
or multiple surgical procedures will be adjudicated as follows:
For multiple surgical procedures
submitted on the same claim, where the secondary or multiple procedures are not
modified with modifier -51, the first procedure listed on the claim will be paid
in full, and the other procedures will be denied; or
For secondary or multiple
procedures that are submitted on separate claims without the appropriate
modifier, the first claim will be paid, and all others will be denied.
Modifiers 62 & 66
Modifiers -62 (two surgeons, usually of different skills)
and -66 (concomitant services of several physicians, often of different
specialties) should be used only in the cases of two cosurgery or team surgery.
Thus, each surgeon involved must append the -66 or -62
modifier to the specific procedures he/she performed. If one provider fails to use the -62 or -66 modifier, then
all of the providers involved in the procedure will be required to adjust any
claims with this omission that were paid in order for the other surgeon or team
to be paid with same modifier.
Also, when either of these modifiers is used, the operative
reports must document the specific procedure(s) provided by each surgeon or team
member.
In addition, in the case of skin grafting on burn patients,
the size and areas treated by each surgeon or team must be documented.
Physicians and DME Supplies
D-TAD Gastrostomy Tube
The D-TAD gastrostomy tube is covered for eligible
recipients who are under the age of 21, and it is payable with code Z0483
(stomach tube). The UVS is 10
units, and the charge is $38.00 per box. There
are 5 tubes in a box.
Physicians, Pharmacists, and Other Prescribers
Drug Utilization Review Program
The Omnibus Budget Reconciliation Act of 1990 (OBRA 90)
mandates a retrospective drug use review program to, "assure that
prescriptions are (i) appropriate, (ii) medically necessary, and (iii) not
likely to result in adverse medical results . . ."
The Louisiana Drug Utilization Review (LADUR) program
became effective in January of 1991. In
the LADUR process, information from paid claims is compare3d to therapeutic
exception criteria developed for the program.
Computer identification occurs for those patients with potential
drug-related conditions. Regional
committees of physicians and pharmacists review the patient profiles and may
request that recipient drug profile information be sent to attending providers.
Then providers are asked to respond to the correspondence.
LADUR initially focused on drug to drug issues within the
following therapeutic categories:
H2 Antagonists
Cardiovasculars NSAIDS Anticoagulants
The exceptions criteria that have occurred most frequently
within the Medicaid recipient population and the incidence rate per 1,000
eligible recipients are listed as follows:
Exception
Criteria
Incident Rate per 1,000
Digoxin w/Verapamil-may increase Digoxin levels
3.49
Quinidine S04 w/Digoxin-may increase Digoxin level
2.26
Cimetidine w/Theophylline-may increase Theophylline level
2.08
Ibuprofen w/Naproxen NA-no evidence of added combo benefit
1.64
Ibuprofen w/Naproxen-no evidence of added combo benefit
1.61
Cimetidine w/Ranitidine-no evidence of added combo benefit
1.54
Diclofenac NA w/Ibuprofen-no evidence of added combo benefit
1.07
Ketoprofen w/Ibuprofen-no evidence of added combo benefit
1.02
Warfarin NA w/Ranitidine-may increase anticoagulant effect
1.02
Ibuprofen w/Picroxicam-no evidence of added combo benefit
.92
Nizatidine w/Ranitidine-no evidence of added combo benefit
.63
Provider responses to LADUR
correspondence exceed 80%. In many
cases, physicians are aware of the condition and are monitoring the patient.
However, in a number of cases, physicians have responded that they were
not aware that the patient was seeing other physicians who were also prescribing
medication. As a result, follow-up
patient counseling, further monitoring, and/or discontinuance of a medication
has been the indicated plan of action.
November and December
recipient reviews will continue to focus on the Anticoagulant drug to drug
issues.
Revised
LMAC Limits
The Louisiana Department of
Health and Hospitals, Bureau of Health Services Financing, has revised the
Louisiana Maximum Allowable Costs (LMAC) limits or the following drug:
Drug
LMAC
Eff. Date
Dexamethasone
0.75 mg Dosepak
.29583
11/1/91
Package
size 12
Status
on Dipyridamole
Recently, we have published remittance advice message
regarding the reimbursement of Dipyridamole.
Providers should note that there is no Maximum Allowable Cost for
Dipyridamole, and, presently, brands of Dipyridamole manufactured by
Boehringer-Ingelheim, Barr, Lederle, and Purepac have received FDA approval and
are covered in the Pharmacy Program. The
FDA has approved Dipyridamole for the indication stated below
"as an adjunct to coumarin
anticoagulants in the prevention of post-operative thromboembolic complications
of cardiac valve replacement."
Our program staff concurs with the FDS that
physicians/pharmacists are not restricted to prescribing/dispensing drugs for
indications only approved by the FDA. Therefore,
Dipyridamole is presently covered in the Pharmacy Program, and we do not
restrict its coverage to a particular indication.
We have been notified by other manufacturers that they
distribute Dipyridamole for the manufacturers Barr, Purepac, and Lederle.
Providers should note that if we have documentation from a manufacturer
that it is distributing Dipyridamole by one of these companies the NDC will be
made payable.
Also, we would like to take this opportunity to inform
providers that Section 4401 of OBRA 90, which created Section 1902 (a)(54)(A) to
the Social Security Act, requires states to pay only for drugs "�
which are prescribed for a medically accepted indication."
Section 1927 (K)(6) defines "medically accepted indication" as
the following:
"any use for a covered
outpatient drug
which is approved under the Federal Food, Drug, and Cosmetic Act;
which appears in peer-reviewed medical literature; or
which is accepted by one or more of the following compendia;
o
the American Hospital Formulary Service-Drug Information,
o
the American Medical Association Drug Evaluations, and
o
the United States Pharmacopeia-Drug Information."
Reimbursing Proper Units
In reviewing drug unit rebate problems identified with the
Medicaid Drug Rebate, we have noted the billing discrepancies that are listed
below.
Reimbursement is made on a per unit basis (tabs, ml, vials,
kits, suppositories, and packets).
If a providers are unsure about the proper unit for a
particular drug, they should call Unisys, Provider Relations, at 1-800-473-2783
or at (504) 924-5040.
Obtaining the correct information may avoid drug rejection notices or
possible future recoupments of overpayments.
Billing Discrepancies
Drug: Monocid,
1 gram vial
Units Billed: 10
units = 1 vial
Correct
Unit to Bill: 1
vial = 1 vial.
Drug: Ventolin
Rotocaps Kit
Units Billed: 96
capsules = 1 Kit
Correct
Unit to Bill: 1
Kit = 1 Kit
Proctor & Gamble Products
We have received notices from Proctor & Gamble
informing pharmacists that several of their over-the-counter products are
reimbursable under Medicaid since they have signed the rebate agreement with the
federal government. However,
providers should be advised that only those over-the-counter products listed in
Appendix A of the Pharmacy Provider Manual are covered.
Although Proctor & Gamble's labeler code 37000 has been
included for coverage under the Medicaid Rebate Program, providers should not
assume that all of their products are covered.
In Louisiana, over-the-counter products, except for those
listed in Appendix A, are excluded from coverage in the Pharmacy Program.
We regret the confusion these notices have caused, and we
encourage providers who have questions about drug coverage to contact Unisys.
Proper Use of National Drug Codes
In order to capture accurate rebate data and to adhere to
Medicaid regulations we require pharmacists to bill claims with the NDC number
from the actual package from which the drug was dispensed.
Thus, computerized pharmacies, which are dispensing a different NDC for a
drug, such as the same drug from a different generic company, should use the NDC
from the actual package from which the drug is dispensed.
Providers should note that dispensing drugs from a package
that is not accurately represented in the billing information may be considered
as fraudulent billing.
Using Correct Presciber Numbers
We would like to alert providers to the importance of using
the correct prescriber number when preparing pharmacy claim forms.
In order the Louisiana Drug Utilization Review (LADUR) to be effective,
we need accurate prescriber information. Information
sent to the wrong provider may result in unnecessary administrative
expenditures.
LTC Providers
Clarification
The clarify the article on page six of the October 1991 Provider
Update concerning recoupments of vendor overpayment to LTC facilities,
Medicaid of Louisiana is issuing the following statement:
The change in recoupment of vendor
overpayment affects not only nursing homes but all LTC facilities.
Errors that result from WIS system limitations, mass PCN changes, SSA
COLS, VA income changes, and all errors of less than $50.000 will also be
corrected by Form 148-PLI.
Transportation Providers
Rate Increase for Non-Emergency Ambulance Services
The Department of Health and Hospitals, Office of the
Secretary, Bureau of Health Services Financing, has approved a rate increase for
the ambulance transportation providers effective November 1, 1991.
The rate increase is for non-emergency ambulance transportation services,
which include base rate, transfer rate, and mileage.
We have increased the payment for base rate and transfer rates from
$77.50 to $81.84. Mileage
reimbursement has been increased from $2.00 per mile to $2.11 per mile.
No adjustment is being made in the reimbursement for
emergency services because we are already paying the same as Medicare for
Advanced Life Support (ALS) and Basic Life Support (BLS) services and mileage.
According to federal regulations, we cannot exceed Medicare's
reimbursement rate for any service.
Questions concerning this policy change may be addressed to
James Phillips at (504) 342-3935.
The MT-4 Form
Each non-emergency transportation driver is required to use
a current continuous Daily Trip Log (MT-4 Form) each day that he/she provides
services. However, recent reviews
have shown that many providers of non-emergency transportation are using
obsolete MT-4 forms.
Thus, an example of the current MT-4 in the only acceptable
format (effective July 1, 1991) and the appropriate instructions are provided in
the Attachments section of this issue
of the Provider Update.
Providers should use the attached form for copying their inventory.
MT-4 Form
MT-4 Instructions
1.
Record the vehicle identification number as it appears on your vehicle
registration form. Please do not
confuse it with your internal identification.
2.
Record the month, date, and year on which the transport(s) occurred.
3.
Record the complete name of the driver.
4.
Record the vehicle odometer reading at the beginning of the day (from the
base or the point of pickup and then at the end of the day (from the base or the
dropoff point). Calculate the total miles driven and express the total in
whole numbers; please do not use tenths.
5.
Record the complete name of the recipient being transported.
6.
Record the scheduled appointment time.
Note whether it is A.M. or P.M.
7.
Record the following information relating to the point of origin:
Location/address where the trip began
If the recipient was not home or if the recipient refused transport
(Place a check mark in the "cancelled column" if the recipient was not
home or if the recipient refused transport.)
The pickup time (Note whether it is A.M. or P.M.)
8.
Record the following information relating to the destination point:
Location/address where trip ended
The dropoff time (Note whether it is A.M. or P.M.)
9.
Record the trip odometer readings at the beginning and ending of each
trip.
10.
Calculate and record the total miles driven for that particular trip.
Please note that this is a continuous format, so the ending reading on
the first entry becomes the beginning reading for the second trip.
You should also not that for two-way transports, each recipient must have two
separate entries: one for the
pickup and dropoff at the medical provider's location and the other for the
pickup and dropoff at the residence . Both
entries must be recorded in the actual sequence that they occurred.
Thus, the odometer readings will show a continuous flow.
11.
Calculate and record the total miles driven for all trips by the
individual driver for the day. This total must agree with the "total miles
driven" in Item 4 outlined above.
NOTE:
Failure to use the attached MT-4 Form may result in the recoupment of
payments by the SURS Unit.
Third Party Certification Form
