PROVIDER
UPDATE
VOLUME 11, NUMBER 6
NOVEMBER/DECEMBER 1994
Message from the Medical
Director
This issue of the Provider Update contains a notice on page 2 to all providers
concerning a restructuring of Louisiana Medicaid to include more managed care.
The following is a brief summary of the recent history concerning these
efforts along with the near-term future plans.
In August 1993,
the Department of Health and Hospitals (DHH) was designated the lead agency in
developing the state's plans for responding to national health care reform
initiatives. As a result, DHH
convened the Committee on Louisiana Health Care Reform, a group composed of
nearly 100 public and private health care entities who receive public funds to
serve the Medicaid uninsured and under-insured populations.
The Committee's charge was to develop a strategy that would enhance and
improve the delivery of health services to Louisiana residents and would be
responsive to a consistent with national health reform goals and initiatives.
On October 7 1994,
after numerous meetings, the Committee received a draft of the conceptual design
for a managed care system with emphasis on primary and preventive care under the
coordination of primary care providers. This
conceptual design for the health system was called the Louisiana Public Health
Care Network System.
In order to
implement this framework into Medicaid in Louisiana, federal approval of a
Section 1115 Medicaid Waiver from the Health Care Financing Administration is
necessary. The waiver development
schedule has been accelerated because of the projected Medicaid shortfall of
$750 million in fiscal year 1996, which is due to a loss of disproportionate
share funding that occurred as a result of Medicaid program changes on the
federal level. DHH has met with
Secretary of Health and Human Services Donna Shalala who has pledged her support
in assisting Louisiana in developing this federal waiver to implement a Medicaid
managed care program. DHH has
contracted with the Washington DC-based consulting firm of Covington and Burling
to assist in the technical preparation and approval process for this Section
1115 waiver.
In developing the
waiver, DHH will be providing regular updates on its progress and development
and will continue to receive input from the Committee on Louisiana Health Care
Reform, the health care provider community, the Louisiana Legislature, the
Governor's Office, and the general public.
DHH is under a tight timeline anticipating submission of the waiver
request by December 31, 1994, with hopes of implementing the new system in July
1995.
Dr. Gregg A. Pane
Adjustment in Fees for 95144
and 95165
Effective with
Date of service November 1, 1994, BHSF is adjusting its fees for the following
CPT codes. The new fees are listed
below.
Code
Fee
UVS
95144
$6.58
10
95165
$5.59
36
Recipients with Part B Benefits
When hospitals are
billing for inpatient services for a recipient with Part B only Medicare
Benefits, please bill type 121 on the UB92.
CPT Code 65768
Effective with
date of service December 1, 1994, BHSF will place CPT Code 65760 (Keratomileusis)
in non-pay status.
Depo-Provera C (Code J1055)
BHSF is pleased to
announce that effective with date of service November 1, 1994, physicians will
be reimbursed directly for administering the 150 mg injection Depo-Provera C for
birth control. This injection was
previously covered only through the Pharmacy Program.
The code for
Depo-Provera C is J1055. The fee is
$39.87 which includes the cost of the drug and an administration fee of $3.00.
This code is restricted to females between the ages of 10 and 55.
Louisiana and Managed Care
Louisiana is
contemplating restructuring its current publicly-funded health care delivery
program of fee-for-service to a managed care system.
A managed care system, for Louisiana's purposes, means a health care
delivery arrangement in which a gatekeeper (health professional) provides
Medicaid-qualified persons access to proper health services at the most fitting
time, with incentives to reduce unneeded treatments and their resulting costs.
CPT Code 76948
Effective with
date of service December 1, 1994, BHSF will place CPT Code 76948 (Ultrasonic
guidance for aspiration of ova, radiological supervision and interpretation) in
non-pay status.
Hospice Notice to All Providers
"Hospice"
is a concept that extends a process of care to terminally ill patients.
A Louisiana Nursing Facility (NF) Resident who is dually eligible for
both Medicare and Medicaid can elect hospice services by an enrolled hospice
provider.
Hospice is a
program of palliative (control of pain and symptoms) and supportive services
that provides physical, psychological, social, and spiritual care for dying
persons and their families. Hospice
care concentrates on assuring the quality of the terminal patient's remaining
life rather than on trying to prolong the length of that life.
For
Medicare/Medicaid patients who have elected hospice, services covered in the
patient's plan of care should not be billed to Medicaid.
These services are covered in the hospice reimbursement.
Although the following is an example of drug services, the same procedure
should be used by any enrolled provider supply services to a recipient who has
elected hospice care.
Billing of Drug Services for
Hospice Recipient
To ensure the
correct billing of drug services, it is imperative that the hospice provider
communicate with the pharmacist to verify which drugs are related to the
terminal illness (billed to the hospice) and which drugs are not
related to the terminal illness (billed to Medicaid).
The hospice shall assure that the distinction in billing drugs is
understood by enrolled pharmacists who render services to the Medicaid
recipients who have elected hospice.
The
pharmacy provider shall bill outpatient pharmacy claims only for those drugs unrelated
to the terminal illness.
Recoupment of drug
claims erroneously paid to a pharmacy provider through Medicaid for those
Medicaid recipients who have elected hospice will be performed as they are
identified. Any provider of
services to a hospice recipient needs to clear with the hospice that the billed
services is not included in the recipient's plan of care.
Erroneous payment will be recouped as identified.
Louisiana Drug Utilization
Review (LADUR) Education
Glycosylated Hemoglobin:
A Valuable Tool in the Control of Diabetes
Issues�..
�
Glycosylated Hemoglobin (GHb) is being used to accurately monitor
long-term blood glucose control in diabetes mellitus.
�
The term "glycosylated hemoglobin" refers to a series of minor
hemoglobin components that are adducts formed from hemoglobin and various
sugars.
�
Recent studies indicate that traditional methods of assessing blood
glucose control in diabetes have only limited value for long-term monitoring.
�
Several studies indicate a linear correlation between a particular GHb
concentration and concentrations of plasma glucose.
�
For routine clinical use, testing every three to four months is generally
recommended. If patients are poorly
controlled, it should be done more often.
Glycosylated
hemoglobin (GHb) is being used with increasing frequency to monitor long-term
blood glucose control in diabetes mellitus.
It has allowed the health care provider to accurately monitor the degree
of glycemic control achieved by patients.
Under most
circumstances, the test provides an accurate index of the mean concentration of
blood glucose during the preceding two to three months, complementing more
traditional measures of glucose control such as glucose testing in urine and
blood.
The term "glycosylated
hemoglobin" refers to a series of minor hemoglobin components that are
adducts formed from hemoglobin and various sugars.
The reaction between glucose and hemoglobin A is an example of
nonenzymatic glycations, which are slow, continuous, and irreversible.
The human erythrocyte is freely permeable to glucose and within each
erythrocyte, GHb is formed from hemoglobin A at a rate dependent on the ambient
concentration of glucose.
The minor
hemoglobin components were first recognized because some of them showed
differences in electrical charge. They
were called "fast hemoglobins" because they showed less positive
charge at neutral pH and migrated more rapidly than hemoglobin A when placed in
an electrical field. The most
important of these "fast" hemoglobins in respect to diabetes is
hemoglobin A1c, in which glucose is attached to the NH2-terminus
(a valine residue) of one or both beta chains of hemoglobin A.
Depending on the assays method, the proportion of total hemoglobin that
is HbA1c is approximately 3-6% in nondiabetics and as much as 20% or
more if the diabetes is poorly controlled.
Recent studies
indicate that traditional methods of assessing blood glucose control in
diabetes, such as taking the medical history, physical examinations, and
determinations of urine and blood glucose, have only limited value for
monitoring an individual's blood glucose status over time.
Because measurement of GHb is an accurate index of the individual's mean
blood glucose during the preceding weeks to months, the test provides important
information that is not otherwise obtained in the usual clinical settings.
Measurement of GHb
has demonstrated numerous useful clinical research applications.
The test can greatly facilitate any study that requires accurate and
objective assessment of long-term blood glucose control.
The effect of different treatment methods on concentrations of blood
glucose can be compared and the relationship between blood glucose and the
development of chronic diabetics complications can be studied.
Use of the test by medical practitioners has increased steadily over the
past few years as reliable assay methods have become more readily available.
Studies documenting the clinical information value of the tests have also
contributed to its acceptance by medical practitioners.
Several studies
indicate a linear correlation between a particular GHb concentration and
concentrations of plasma glucose. On
the average, each 1% change in GHb represents a 25-35 mg/dl change in plasma
glucose. Regardless of the assay
method, GHb values greater than 3% above the upper limit of normal for the assay
generally indicate that mean plasma glucose concentrations have been well over
200 mg/dl.
A normal GHb
value, on the other hand, indicates that, on average, the concentration of
plasma glucose during the preceding weeks to months was within normal limits.
The test results do not, however, indicate to what extent the normal
value resulted from alternating periods of hypo- and hyper-glycemia.
If glycosylated
hemoglobin is used as a means of assessing glucose control, it is important to
know the laboratory norms and variations because these will influence the
interpretation of reported values. Commercial
and hospital laboratories often use different techniques with various degrees of
precision. It is also important to
consider certain conditions that cause false elevations of glycosylated
hemoglobin including uremia, aspirin intake, the presence of fetal hemoglobin,
and alcoholism. Other conditions
that may cause falsely low levels of glycosylated hemoglobin include uremia,
anemia, and variant hemoglobins, including HbS, C and D, as well as active
erythropoiesis, as occurs in pregnancy.
Several studies
suggest that the degree of chronic hyperglycemia is an important risk factor for
the development of chronic diabetic complications.
Recent data from the Diabetes Control and Complications Trial (DCCT)
support these contentions while demonstrating that patients who received
intensive therapy have average GHb levels that were lower than those in the
conventional treatment group.
For routine
clinical use, testing every three to four months is generally recommended.
If patients are poorly controlled, it should be done more often.
It should be understood that this test is not useful in judging
day-to-day glucose control, and should not be used to replace daily home testing
of blood.
The measurement of
glycosylated hemoglobin is becoming an invaluable tool in the treatment and
management of diabetes. As
physicians gain more experience with it, its use will continue to increase.
As laboratory methods to measure glycosylated hemoglobin become more
standardized, the test will also increase in frequency.
Pharmacists should understood the role of this laboratory value in the
treatment of diabetes and be able to translate this to their patients.
References
Figge, J. and H.
L. Figge 1994. Update on Diabetes
Management and Treatment. Pharmacy Times. 60:1-12.
Goldstein, D.E.,
R.R. Little, H. Wiedmeyer, J. D. England, and E.M. McKenzie 1986.
Glycated Hemoglobin: Methodologies
and Clinical Applications. Clinical Chemistry.
32:B64-B70.
Latsen, J.L., M.
Hotder, and E.F. Morgensen 1990. Effects
of Long-Term Monitoring of Glycosylated Hemoglobin Levels in Insulin-Dependent
Diabetes Mellitus. New
England Journal of Medicine. 323:1021.
Physicians
Guide to Non-Insulin-Dependent (Type II) Diabetes, Diagnosis and Treatment
1988. 2nd ed.
Svendsen, P.A., T.
Lauritzen, U. Soegaurd, et al. 1982. Glycosylated Hemoglobin and Steady-State Mean Blood Glucose
Concentration in Type I (Insulin-Dependent) Diabetes. Diabetologia.
23:403-405.
CLAIMS FOR ABORTIONS DUE TO
RAPE OR INCEST
All
of the following requirements
must be met prior to performing an abortion to terminate a pregnancy due to rape
or incest in order for Medicaid reimbursement to be made for the abortion.
1.
The Medicaid recipient shall report the act of rape or incest to a law
enforcement official unless the treating physician certifies in writing that in
the physician's professional opinion, the victim was too physically or
psychology incapacitated to report the rape or incest.
2.
The Medicaid recipient shall certify that the pregnancy is the result of
rape or incest and this certification shall be witnessed by the treating
physician.
3.
The report of the rape or incest to a law enforcement official or the
treating physician's statement that the victim was too physically or
psychologically incapacitated to report the rape or incest must be submitted to
the Bureau of Health Services Financing along with the treating physician's
claim for reimbursement for performing an abortion.
In review, when
submitting a claim for reimbursement of an abortion due to rape or incest, the
claim form must have attached a law enforcement report or
the treating physician's statement that the victim was too physically or
psychologically incapacitated to report the rape or incest and a signed statement from the Medicaid recipient certifying
that the pregnancy is the result of a rape or incest.
This certification shall be witnessed by the treating physician.
Prior Authorization of
Customized Wheelchairs
1.
Whenever Unisys receives a prior authorization request for a customized
wheelchair directly from a DME provider where no seating clinic has been done by
a rehabilitation clinic or center, the DME provider may be considered as the
recipient's preferred provider. Since
the recipient had furnished the prescription for the chair to that particular
DME provider and that provider has measured and fitted the recipient for the
prescribed chair, then that DME provider will be given an opportunity to meet
the low bid of the three bids obtained, if submitted by another provider.
2.
When a seating evaluation has been done by a rehabilitation clinic or
center, the Form PA01 is completed by the rehabilitation therapist and is sent
to Unisys. If the chair is approved, Unisys then follows up to obtain
bids from the DME providers who participated in the seating clinic and to select
the winning bid. Participating DME
providers should not complete and send a Form PA01 directly to Unisys when a
seating clinic has been held. Unisys
will deny any prior authorization requests received from a DME provider in these
situations.
3.
When a DME provider is contacted by Unisys for a bid on a customized
wheelchair, the provider must respond with a bid within five days to the Unisys
Prior Authorization (PA) Unit. This
five-day limit is being established to facilitate the approval process since the
PA unit must receive, medically review, solicit bids, and approve a wheelchair
request within 25 days.
Non-Emergency Postpartum Care
for Eligible Aliens
BHSF recently
received a letter from the Health Care Financing Administration (HCFA) regarding
investigations of non-emergency postpartum care provided to aliens eligible
under 1903(v) of the Social Security Act (the Act).
HCFA explained that section 1903(v) of the Act allows states to pay for
services to unlawfully admitted aliens only under two conditions.
First, such care and services must be necessary for the treatment of an
emergency medical condition of the alien. Second,
such alien must otherwise meet the eligibility requirements for medical
assistance under the state plan.
The Office of the
Inspector General (OIG) recently completed a study of the services paid for
under the authority of section 1903(v). As
a result of the study, the OIG notified HCFA that some states may be erroneously
claiming Federal Financial Participation (FFP) for the costs of routine
postpartum care provided to aliens eligible for Medicaid under 1903(v) of the
Act.
Under section
1903(v), routine postpartum services or any other non-emergency services
provided to otherwise eligible unlawfully admitted aliens are not eligible for
FFP under Medicaid. The Medicaid
Program in Louisiana will carefully review any claims for 1903(v) services to
assure compliance with these requirements.
New Procedure Codes for
Surgical Dressings
Below is a listing
of new procedure codes adopted by Medicare for surgical dressings.
These codes, with more specific descriptions, are also being added to our
file for Medicaid DME claims.
Also, please note
that all nursing homes (ICF I, II, and SNFs) will continue to be responsible for
providing surgical trays, dressings, bandages, and gauze for their
Medicaid-eligible residents. The
new procedure codes for surgical dressings and supplies, as well as those
already on file, will not be approved for residents of these facilities.
Valid
for Dates of Service On or After March 30, 1994
|
New
|
Old
|
Description
|
|
K0196
|
K0150KB
|
Alginate
dressing, wound cover, pad size 16 sq. in. or less, each dressing
|
|
K0197
|
K0150KC
|
Alginate
dressing, wound cover, pad size more than 16 but less than or equal to 48
sq. in., each dressing
|
|
K0198
|
K0150KD
|
Alginate
dressing, wound cover, pad size more than 48 sq. in., each dressing
|
|
K0199
|
N/A
|
Alginate
dressing, wound filler, per 6 inches
|
|
K0203
|
N/A
|
Composite
dressing, pad size 16 sq. in. or less, with any size adhesive border, each
dressing
|
|
K0204
|
N/A
|
Composite
dressing, pad size more than 16 but less than or equal to 48 sq. in., with
any size adhesive border, each dressing
|
|
K0205
|
N/A
|
Composite
dressing, pad size more than 48 sq. in., with any size adhesive order,
each dressing
|
|
K0206
|
N/A
|
Contact
layer, 16 sq. in. or less, each dressing
|
|
K0207
|
N/A
|
Contact
layer, more than 16 but less than or equal to 48 sq. in., each dressing
|
|
K0208
|
N/A
|
Contact
layer, more than 48 sq. in., each dressing
|
|
K0209
|
K0151KB
|
Foam
dressing, wound cover, pad size 16 sq. in. or less, without adhesive
border, each dressing
|
|
K0210
|
K0151KC
|
Foam
dressing, wound cover, pad size more than 16 but less than 48 sq. in.,
without adhesive border, each dressing
|
|
K0211
|
K0151KD
|
Foam
dressing, wound cover, pad size more than 48 sq. in., without adhesive
border, each dressing
|
|
K0212
|
N/A
|
Foam
dressing, wound cover, pad size 16 sq. in or less, with any size adhesive
border, each dressing
|
|
K0213
|
N/A
|
Foam
dressing, wound cover, pad size more than 16 but less than 48 sq. in.,
with any size adhesive border, each dressing
|
|
K0214
|
N/A
|
Foam
dressing, wound cover, pad size more than 48 sq. in., with any size
adhesive border, each dressing
|
|
K0215
|
N/A
|
Foam
dressing, wound filler, per gram
|
|
K0216
|
A4200KB
|
Gauze,
non-impregnated, pad size of 16 sq. in. or less, without adhesive border,
each dressing
|
|
K0217
|
A4200KC
|
Gauze,
non-impregnated, pad size of more than 16 but less than or equal to 48 sq.
in., without adhesive border, each dressing
|
|
K0218
|
A4200KD
|
Gauze,
non-impregnated, pad size of more than 48 sq. in., without adhesive
border, each dressing
|
|
K0219
|
N/A
|
Gauze,
non-impregnated, pad size of 16 sq. in. or less, with any size adhesive
order, each dressing
|
|
K0220
|
N/A
|
Gauze,
non-impregnated, pad size of more than 16 but less than or equal to 48 sq.
in., with any size adhesive border, each dressing
|
|
K0222
|
N/A
|
Gauze,
impregnated, other than water or normal saline, pad size 16 sq. in. or
less, without adhesive border, each dressing
|
|
K0223
|
N/A
|
Gauze,
impregnated, other than water or normal saline, pad size more than 16 but
less than or equal to 48 sq. in., without adhesive border, each dressing
|
|
K0224
|
N/A
|
Gauze,
impregnated, other than water or normal saline, pad size more than 48 sq.
in., without adhesive border, each dressing
|
|
K0228
|
N/A
|
Gauze
impregnated, water or normal saline, pad size 16 sq. in. or less, without
adhesive border, each dressing
|
|
K0229
|
N/A
|
Gauze,
impregnated, water or normal saline, pad size more than 16 but less than
or equal to 48 sq. in., without adhesive border, each dressing
|
|
K0230
|
N/A
|
Gauze,
impregnated, water or normal saline, pad size more than 48 sq. in.,
without adhesive border, each dressing
|
|
K0234
|
K0149KB
|
Hydrocolloid
dressing, wound cover, pad size 16 sq. in. or less, without adhesive
border, each dressing
|
|
K0235
|
K0149KC
|
Hydrocolloid
dressing, wound cover, pad size more than 16 sq. in. but less than or
equal to 48 sq. in., without adhesive border, each dressing
|
|
K0236
|
K0149KD
|
Hydrocolloid
dressing, wound cover, pad size more than 48 sq. in., without adhesive
border, each dressing
|
|
K0237
|
N/A
|
Hydrocolloid
dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive
border, each dressing
|
|
K0238
|
N/A
|
Hydrocolloid
dressing, wound cover, pad size more than 16 sq. in. but less than or
equal to 48 sq. in., with any size adhesive border, each dressing
|
|
K0239
|
N/A
|
Hydrocolloid
dressing, wound cover, pad size more than 48 sq. in., with any size
adhesive border, each dressing
|
|
K0240
|
N/A
|
Hydrocolloid
dressing, would filler, paste, per fluid ounce
|
|
K0241
|
N/A
|
Hydrocolloid
dressing, would filler, dry form, per gram
|
|
K0242
|
K0148KB
|
Hydrogel
dressing, wound cover, pad size 16 sq. in. or less, without adhesive
border, each dressing
|
|
K0243
|
K0148KC
|
Hydrogel
dressing, wound cover, pad size more than 16 but less than or equal to 48
sq. in., without adhesive border, each dressing
|
|
K0244
|
K0148KD
|
Hydrogel
dressing, wound cover, pad size more than 48 sq. in., without adhesive
border, each dressing
|
|
K0245
|
N/A
|
Hydrogel
dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive
border, each dressing
|
|
K0246
|
N/A
|
Hydrogel
dressing, wound cover, pad size more than 16 but less than or equal to 48
sq. in., with any size adhesive border, each dressing
|
|
K0247
|
N/A
|
Hydrogel
dressing, wound cover, pad size more than 48 sq. in., with any size
adhesive border, each dressing
|
|
K0248
|
K0148KE
|
Hydrogel
dressing, wound filler, gel, per fluid ounce
|
|
K0249
|
N/A
|
Hydrogel
dressing, wound filler, dry form, per gram
|
|
K0250
|
N/A
|
Skin
sealants, protectants, moisturizers, any type, any size
|
|
K0251
|
N/A
|
Specialty
absorptive dressing, wound cover, pad size 16 sq. in. or less, without
adhesive border, each dressing
|
|
K0252
|
N/A
|
Specialty
absorptive dressing, wound cover, pad size more than 16 but less than or
equal to 48 sq. in., without adhesive border, each dressing
|
|
K0253
|
N/A
|
Specialty
absorptive dressing, wound cover, pad size more than 48 sq. in., without
adhesive border, each dressing
|
|
K0254
|
N/A
|
Specialty
absorptive dressing, wound cover, pad size 16 sq. in. or less, with any
size adhesive border, each dressing
|
|
K0255
|
N/A
|
Specialty
absorptive dressing, wound cover, pad size more than 16 but less than or
equal to 48 sq. in., with any size adhesive border, each dressing
|
|
K0256
|
N/A
|
Specialty
absorptive dressing, wound cover, pad size more than 48 sq. in., with any
size adhesive border, each dressing
|
|
K0257
|
A4190KB
|
Transparent
film, 16 sq. in. or less, each dressing
|
|
K0258
|
A4190KC
|
Transparent
film, more than 16 but less than or equal to 48 sq. in., each dressing
|
|
K0259
|
A4190KD
|
Transparent
film, more than 48 sq. in., each dressing
|
|
K0260
|
N/A
|
Wound
cleansers, any type, any size
|
|
K0261
|
N/A
|
Wound
filler, not elsewhere classified, gel/past, per fluid ounce
|
|
K0262
|
N/A
|
Wound
filler, not elsewhere classified, dry form, per gram
|
|
K0263
|
A4202KF
|
Gauze,
elastic, all types, per linear yard
|
|
K0264
|
A4203KF
|
Gauze,
nonelastic, per linear yard
|
Dental Program Changes
Sweeping changes
in the way dentists must bill for services or receive authorization for some
services will become effective January 1,
1995, because of changes in state law.
Because of the change in the law, providers will be filing claims for one
year using three different types of forms (the old EPSDT Dental and Adult Dental
forms as well as the ADA Dental Claim Form).
State law requires
all dental claims involving third party payors (including Medicaid) be submitted
on an ADA (American Dental Association) approved form.
Claims from the Oral and Maxillofacial Surgery Program will continue to
be submitted on the HCFA 1500. These forms will NOT be provided by either the Louisiana Dental Medicaid
Program or by Unisys. Dentists
can purchase the necessary forms directly from the ADA or from nearly any dental
business supplier. Most dentists
already use this claim form for virtually all of their uninsured patients.
Since the Medicaid
Program in Louisiana requires some information about recipients and the services
they receive that ordinary third party payors do not, some areas of the form
will need to contain information slightly different than that listed for the
line or item. However, these
differences are few and the form will be easy to complete.
Dentists will no longer need to include a PA03 Form (or affix an
authorization sticker) to the Dental Claim Form for authorization.
All dental authorizations will be handled in-house by the dental
consultants at the LSU School of Dentistry.
It is anticipated that most problems that arise with Prior Authorization
should be able to be resolved with a single phone call.
A complete
description of these changes will be covered in the revised Medicaid Dental
Services Provider Manual scheduled for release by the first of January.
A summary of the most important changes is listed below.
1)
All claims for payment with a date
of service after 12/31/94 must be submitted on the ADA form.
2)
All requests for prior
authorization received after 12/20/94 shall be returned to the dentists unprocessed
if not on the ADA form.
In order to
receive prior authorization for a services, AT LEAST TWO COPIES OF THE ADA CLAIM
FORM WITH ACCOMPANYING RADIOGRAPHS must be mailed to the dental consultants. A prior authorization letter will continue to be sent to the
provider detailing the services and dates approved. The dental consultants will line out any non-approved service
requests on the form returned to the provider (along with the radiographs).
An abbreviated explanation of benefits (EOB) will also be attached.
A list of all the EOB codes will be included in the revised provider
manual to assist providers with billing.
3)
Prior authorized adult dental claims with a date of service after
12/31/94 will continue to be accepted for payment through one year from date of
authorization.
4)
The Adult Dental Program will once again be operated with a prior
approval system similar to the EPSDT Dental Program.
Electronic billing should be available for adult claims at some future
date.
A new law REQUIRES
THE USE OF ADA CODES, so all of the "D"s and "Z"s must be
changed to zeros ("0"). SOME
CODES HAVE BEEN CHANGED. For
example, a prophy without fluoride has changed to "01203" (it was
D1201). Codes for immediate
dentures, panographic-type radiographs, and stainless steel crowns for permanent
teeth have been added among others. These
do not represent new services, merely a further breakdown of codes to reflect
more accurate coding for the specific services provided.
In January 1995,
Dr. Harry F. Leveque will retire from the Louisiana Dental Medicaid Program and
from the LSU School of Dentistry. Dentists
and Medicaid recipients throughout the state have benefited tremendously from
Dr. Leveque's dedication to this program. He
plans to fish and follow the NFL New Orleans Saints in his well-earned new
leisure time. Dr. Bob Barsley will
be assuming his responsibilities.
All questions
regarding this notice should be directed to Dr. Bob Barsley, Medicaid Dental
Program (504) 948-8589.
Placement of Assistant Surgeon
Codes in Non-Pay Status
Effective with
date of service January 1, 1995, BHSF will no longer reimburse assistant
surgeons for the CPT codes listed below. Please
note that the codes are listed numerically from left to right below.
|
21015
|
21029
|
21031
|
21032
|
21041
|
21050
|
21070
|
|
21121
|
21122
|
21125
|
21137
|
21145
|
21147
|
21150
|
|
21151
|
21155
|
21160
|
21175
|
21179
|
21184
|
21188
|
|
21194
|
21195
|
21240
|
21230
|
21235
|
21245
|
21246
|
|
21248
|
21249
|
21330
|
21335
|
21340
|
21345
|
21355
|
|
21360
|
21386
|
21387
|
21421
|
21431
|
21432
|
21435
|
|
21495
|
21510
|
21610
|
21616
|
21700
|
21705
|
21720
|
|
21805
|
21810
|
22222
|
23035
|
23156
|
23170
|
23172
|
|
23182
|
23530
|
23532
|
23900
|
24116
|
24120
|
24126
|
|
24134
|
24136
|
24138
|
24140
|
24330
|
24331
|
24356
|
|
23362
|
24363
|
24802
|
24930
|
24931
|
24940
|
25005
|
|
25076
|
25085
|
25126
|
25130
|
25145
|
25332
|
25335
|
|
25365
|
25370
|
25392
|
25393
|
25444
|
25900
|
25905
|
|
25907
|
25909
|
25915
|
25920
|
25924
|
25927
|
25931
|
|
26037
|
26070
|
26075
|
26080
|
26121
|
26123
|
26125
|
|
26350
|
26356
|
26357
|
26358
|
26410
|
26412
|
26418
|
|
26420
|
26434
|
26502
|
26504
|
26530
|
26535
|
26536
|
|
26545
|
26562
|
26596
|
26597
|
26992
|
27067
|
27158
|
|
27175
|
27179
|
27181
|
27259
|
27301
|
27390
|
27394
|
|
27397
|
27479
|
27485
|
27647
|
27703
|
27732
|
27734
|
|
27740
|
27831
|
28102
|
28103
|
28171
|
31030
|
31080
|
|
31086
|
31090
|
31400
|
31502
|
31613
|
31614
|
31775
|
|
31800
|
31820
|
31825
|
32440
|
32810
|
33222
|
33411
|
|
33470
|
33472
|
33696
|
33710
|
33735
|
33775
|
33777
|
|
33781
|
33820
|
33852
|
33935
|
35121
|
36835
|
36840
|
|
36845
|
37145
|
38230
|
38240
|
38305
|
38510
|
38520
|
|
38525
|
38550
|
39547
|
40500
|
40525
|
40527
|
41112
|
|
41113
|
41114
|
41115
|
41116
|
42210
|
42215
|
42235
|
|
42335
|
42340
|
42600
|
42810
|
42842
|
42880
|
42900
|
|
42953
|
42961
|
42962
|
43271
|
43272
|
45500
|
46200
|
|
50065
|
50080
|
50526
|
50590
|
50750
|
52337
|
53520
|
|
54135
|
54304
|
54420
|
54430
|
54435
|
54600
|
54602
|
|
54640
|
54840
|
57700
|
58540
|
58605
|
59136
|
59140
|
|
59150
|
59151
|
59320
|
59350
|
61544
|
61556
|
61557
|
|
61558
|
61708
|
61710
|
61720
|
61795
|
62000
|
62120
|
|
62121
|
62180
|
62201
|
62256
|
62287
|
63078
|
63200
|
|
63273
|
63304
|
63308
|
63746
|
63780
|
64740
|
64742
|
|
764744
|
64766
|
64771
|
64786
|
64890
|
64891
|
64893
|
|
64897
|
64902
|
65101
|
65135
|
65140
|
65150
|
65155
|
|
67101
|
67105
|
67405
|
67413
|
67430
|
69120
|
69530
|
|
69550
|
69552
|
69662
|
69725
|
69740
|
69745
|
69910
|
Extension Procedure for Case
Management Units
The Bureau of
Health Services Financing is introducing a procedure to process case management
claims when an extension of units is approved.
Currently, the case management monitoring section reviews these requests
for necessity and appropriateness. Program
Integrity will be responsible for extensions for MR/DD and Part H only.
Please note that
extensions of units of service are processed for the current calendar year only. Extensions for
calendar year 1994 must be submitted prior to March 10, 1995.
BHSF will now
begin writing letters to the provider stating the number of units approved and
effective dates for billing purposes.
These claims must
be billed hard copy and pend for manual review of compliance as per BHSF letter.
Changes in Case Management
Billing Procedures
Effective November
1, 1994, providers of case management for the mentally retarded/developmentally
disabled, infants and toddlers with special needs (Part H), HIV-infected, and
frail elderly waiver members will bill for an assessment and service plan
development period for each first-time case management recipient.
The date of service listed will be the date the service plan is
completed. Thereafter, case
management is to be billed in 15-minute units with one procedure code for
ongoing services. Case management
for high-risk pregnant women will also have a code for assessment and planning,
and one for ongoing case management each month.
Initial assessment and service plan development may only be billed one
time for each recipient of case management services.
The codes listed
below are for dates of service beginning November 1, 1994.
|
Case
Management
Type
|
|
Initial
Assessment and Planning Period
|
Ongoing
Case
Management
|
|
|
Prov
Type
|
Procedure
Code
|
Payment
|
Procedure
Code
|
Payment
|
|
MR/DD
|
49
|
X0116
|
$175.00
|
X0117
|
$13.26
|
|
MR/DD Waiver
Participants
|
49
|
X0118
|
$235.00
|
X0119
|
$13.20
|
|
Part H
|
07
|
X0120
|
$115.00
|
X0121
|
$13.26
|
|
Part H (MR/DD
Waiver Participants)
|
07
|
X0122
|
$175.00
|
X0123
|
$13.26
|
|
HIV
|
46
|
X0124
|
$95.00
|
X0125
|
$13.26
|
|
High-Risk
Pregnant Women
|
48
|
X0057
|
$195.00
|
X0058
|
$30.00
|
|
Frail
Elderly Waiver
|
08
|
Z0064
|
$150.00
|
Z0065
|
$13.26
|