PROVIDER
UPDATE
VOLUME 13, NUMBER 6
DECEMBER 1996
Beyond 2000: The Unveiling
of DHH's Plan for the 21st Century
Department of Health and Hospitals Secretary Bobby Jindal recently introduced
a far-reaching, innovative health care reform plan for the state of Louisiana.
This plan is designed to produce healthier citizens, to give the elderly
and disabled more choices for community living, to help the uninsured buy health
insurance, and to convert charity hospitals into "centers of
excellence." Secretary
Jindal's plan, unveiled this fall, is aptly titled "Beyond 2000."
Governor Mike Foster commented at a recent news conference, "I am
impressed with this plan. It deals
with the issue of health care comprehensively, it considers all citizens and
their needs, and it sets an ambitious course for us to fundamentally restructure
the state's role in health care as we move into the 21st
Century."
According to Secretary Jindal, Louisiana must explore new ways to better care
for nearly 800,000 citizens who are served by Medicaid over the course of each
year. Louisiana Medicaid recipients
receive expensive health care services, but they suffer from higher incidences
of preventable diseases. Secretary Jindal's new reform plan addresses these concerns.
"Beyond 2000" has three general themes that set the course for
Louisiana Medicaid for the coming years. They
are: fiscal restraint and control;
service quality; and accountability. Secretary
Jindal says the state is already trying new ways of restructuring our health
care system, improving health outcomes, and moving decision-making closer to
communities. For example, the
Capital Area Healthcare District is governed by a local citizens board, to which
about $25 million annually will be redirected from the state to provide
outpatient services for public sector clients in the Greater Baton Rouge area.
Two other options - managed care and vouchers - will also be explored for
citizens on Medicaid. In fact, by
the time this Provider Update has been
published, a managed care pilot program will be announced.
"Beyond 2000" sets three main goals for Louisiana's public health
care system:
The strategic plan of "Beyond 2000"
translates the above three goals into four primary objectives:
-
Promoting healthier citizens;
-
Strengthening the safety net for the uninsured;
-
Providing consumer choice for the elderly and the disabled;
-
Reforming charity hospitals.
Some of the specific action item steps recommended by
Secretary Jindal to accomplish the goals and objectives noted above are on the
following page.
The Department's goals are attainable with the same
high level of patient care and provider support is has always received from the
medical community. We thank you
again for making our Medicaid programs serve the citizens of Louisiana.
Tom Collins
Director, BHSF
Secretary
Jindal recommends the following action steps to achieve the goals and objectives
of "Beyond 2000."
PROMOTING
HEALTHIER CITIZENS
"Providing the Medicaid
population with appropriate clinical care at reasonable costs"
-
Place
Medicaid recipients in direct and lasting relationships with primary care
doctors to ensure continuity and quality of care.
-
Set
goals for health outcomes (i.e., immunizations, screenings), coordinate
health services among providers, and measure the progress of meeting those
goals.
-
Implement point-of-sale and lock-in pharmacy programs to reduce
misuse.
-
Pilot
managed care / voucher program for a maximum of 50,000 Medicaid recipients
and expand these programs to cover 240,000.
-
Enroll 80 percent of the non-elderly and non-disabled Medicaid
population in private insurance plans.
REFORMING
CHARITY HOSPITALS
"The charity hospital system must be
a national model of excellence medical education"
-
Protect the interests of Tulane, Ochsner, and LSU.
-
Focus specialty education for students at regional centers.
-
Offer high quality and effective services to the uninsured.
-
Operate on predictable and reasonable budgets.
-
DOA approval or expended or new services.
-
Coordinate services with primary care providers to avoid
duplication and improve quality of care.
-
Enlist private partners to share financial responsibility and
improve purchasing, staffing, and billing.
-
Let charity hospitals earn and keep revenues from fees, third
party recoveries, and cost-savings.
-
Integrate
with local communities, sharing patients and resources with local hospitals
to take advantage of local capacity and to minimize transportation costs and
inconvenience.
STRENGTHENING THE SAFETY NET
"Providing more comprehensive and
planned coverage for the uninsured"
-
Modify
and activate the Department of Insurance's LA Health plan to provide basic
health insurance coverage to low-income workers.
-
Expand the state catastrophic insurance plan to help families
facing overwhelming expenses and illnesses.
-
Encourage insurance companies to offer basic health plans for
small businesses.
-
Offer tax credits to employers where they purchase insurance
and health care.
-
Allow the uninsured to pay sliding premiums for access to
Medicaid managed care or voucher systems.
-
Convert part of disproportionate share dollars to help pay
health insurance premiums for the uninsured.
-
Offer access to health care plans for the uninsured, focusing
on those up to 200 percent above the poverty level.
PROVIDING CONSUMER CHOICE
"Serving more disabled and elderly
citizens; offering them consumer choice"
-
Expand the number of elderly and disabled who are offered
waivers to live in the community.
-
Inform clients about the full range of services available for
community living.
-
Offer
100 highest-functioning citizens with developmental disabilities in public
facilities the option to move to less restrictive environments.
-
Freeze growth at public facilities while improving staff ratios
and quality of care for residents.
-
Enhance quality assurance monitoring and enforcement.
-
Pilot multi-parish management of outpatient services.
Louisiana Drug Utilization Review (LADUR) Education
Advances in the Management of a Peptic Ulcer Disease
Issues
-Helicobacter
pylori (H. pylori) has been implicated as a causative factor in cases of
duodenal ulcer, gastric ulcer, and chronic active gastritis.
-The
effective management of peptic ulcer disease involves the prevention of
recurrent episodes through the eradication of H. pylori.
-There are multiple accepted therapies in the
eradication of H. pylori in peptic ulcer disease.
"Disease Management" (DM) may be defined as "a comprehensive
approach to improving patient outcomes and lowering costs in key disease
categories" (Andjuar 1996). As such, disease management in Louisiana's Medicaid Drug
Program includes a number of interrelated components including:
a) an understanding of each disease state along with associated
diagnostic and therapy costs; b) treatments focusing on these diseases and their
sequelae; and c) comprehensive patient and provider educational methods.
These and other DM components are the hallmarks of integrated programs
focusing on managing diseases instead of simply treating underlying symptoms (Saltiel
1996). Louisiana's Department of
Health and Hospitals has instituted a disease management component of a broader
pharmacy benefits management system that will focus on several disease states,
including peptic ulcer disease. Peptic
ulcer disease includes gastroesophageal reflux disease (GERD) and gastric and
duodenal ulcer. Gastric and
duodenal ulcer disease together are referred to as peptic ulcer disease.
This article focuses on the following components of the disease management
effort for peptic ulcer disease and antisecretory medications.
-
The impact of Helicobacter pylori
(H. pylori) as a causative agent in peptic ulcer disease, and the role of
detection and eradication of this microorganism in the management of these
diseases;
-
The contribution of side effects of nonsteroidal anti-inflammatory (NSAIDs)
therapy as a causative factor in peptic ulcer disease; and,
-
The pharmacoeconomic impact of the chronic use of antisecretory agents in
situations where alternate therapies may be more appropriate.
The potential impact on therapies and economic outcomes of appropriate
therapeutic alternatives in the treatment of peptic ulcer and related disorders
is clear. Four of the top ten
drugs (in terms of both number of prescriptions and in dollars spent) in
Louisiana in 1995 were in the antisecretory drug category, and these agents were
primarily used for the treatment of peptic ulcers and related diseases.
These drug categories represent nearly 10% of the Medicaid Drug Program
budget and include the widely prescribed histamine2 receptor
antagonists (cimetidine, famotidine, nizatidine, and ranitidine) and proton pump
inhibitors (lansoprazole and omeprazole). The
effectiveness of these agents as palliative treatments for these related
disorders is amply demonstrated by the wide usage of these antisecretory agents
in patients exhibiting a variety of symptoms.
These antisecretory drugs increase the gastric pH (reducing its acidity)
thereby allowing ulcers to heal through the body's physiological repair
mechanisms.
Causes of Peptic Ulcer Disease
Our understanding of the role of H. pylori as a causative factor in peptic ulcer disease has grown in
recent years. Recent
recommendations from the National Institutes of Health have focused on
antibiotic therapy to manage patients suffering with peptic ulcer disease. These advances in our knowledge regarding causative factors
have dramatically altered our focus regarding both diagnostic testing and
treatment choices. The evidence is
substantial, and the pharmacoeconomic implications are obvious:
-
H. pylori has been implicated
as the causative factor in more than 95% of cases of duodenal ulcer, 70% of
cases of gastric ulcer, and 70% to 100% of the cases of chronic active
gastritis.
-
Simple eradication of H. pylori
infections in affected patient populations could result in substantially lower
rates of recurrence of peptic ulcer disease, and thus a resultant marked
reduction in treatment costs.
-
Antibiotic treatment regimens are relatively short in duration (one to
two weeks) and provide a cure rather than simply symptomatic treatment.
-
Less than 1% of the cases are due to hypersecretory conditions such as
the Zollinger-Ellison Syndrome.
Complications (side effects) from NSAID therapy represent a second leading
cause of gastrointestinal tract disorders and related problems. These
problems are largely avoidable with simple monitoring of the patients and their
therapeutic regimen. This is
especially true in certain vulnerable populations (patients with renal
insufficiency, geriatric patients, and those patients with underlying
gastrointestinal tract disorders).
Recurrence of Peptic Ulcer Disease
Another major factor that increases costs associated with antisecretory
therapy (both histamine2 receptor antagonists and proton pump
inhibitors) is related to the failures of these agents to affect H.
pylori. While these drugs provider symptomatic relief during extended
therapy, cessation of treatment usually results in a recurrence of the H.
pylori infection and associated symptoms.
The costs associated with recurrences are avoided when patients are
treated with appropriate antibiotics. Table
1 reflects current antibiotic therapies in use today to eradicate H. pylori. When these
regimens are adequately employed, the need for additional antiulcer therapies
can be avoided.
Combating Helicobacter Pylori
Infection
There has been a plethora of discussion in the medical literature about the best
regimen to use in order to eradicate the H.
pylori bacteria, and additional alternatives continue to emerge.
The National Institutes of Health Consensus Statement recognizes the
value in eliminating H. pylori as a
causative agent as appropriate in the treatment of ulcers. In their statement, the NIH also acknowledged a variety of
regimens as effective in this treatment.
Table 1 presents a synopsis of recommended regimens and the efficacy of each
in the eradication of H. pylori.
Please note that the agents and doses within each regimen are not
necessarily interchangeable. There
is NO single correct therapy and there may be different versions of the listed
therapies as well. Consideration of
H. pylori as a potential cause for symptoms of peptic ulcer disease
may be the most appropriate choice at this time. Testing for H. pylori
includes gastroscopy with biopsies, serologic testing, and potentially breath
tests. The choice of tests and the
conditions of testing will be the subject of later educational interventions.
However, an appropriate determination of H.
pylori as the potential cause of symptoms should lead to the most
appropriate treatment.
TABLE 1. REGIMENS USED TO TREAT HELICOBACTER PYLORI PROBLEMS
|
NAME
|
BISMUTH2
|
ANTIBIOTIC
1
|
ANTIBOTIC
2
|
PPI/H2RA
|
DURATION
|
EFFICACY
|
| Quadruple
Therapy
|
Bismuth
2 tabs 4x day
|
Metronidazole
250mg 2-3x day
|
Tetracycline3
500 mg 4x day
|
Omeprazole
20mg 2x day
|
1 to 2
Weeks
|
94 - 98%
|
| Bismuth
Triple
Therapy
|
Bismuth
2 tabs 4x day
|
Metronidazole
250mg 2-3x day
|
Tetracycline3
500 mg 4x day
|
(H2RA)4
|
1
to 2 Weeks
|
86
- 90%
88 - 96%
|
|
|
Bismuth
2 tabs 4x day
|
Metronidazole
250mg 2-3x day
|
Amoxicillin
500mg 3-4x day
|
|
1
to 2 Weeks
|
75
- 81%
80 - 94%
|
|
|
Bismuth
2 tabs 4x day
|
Clarithromycin
500mg 3x day
|
Tetracycline3
500 mg 4x day
|
|
1
to 2 Weeks
|
>90%
|
|
|
Bismuth
2 tabs 4x day
|
Clarithromycin
500mg 3x day
|
Amoxicillin
500mg 3-4x day
|
|
1
to 2 Weeks
|
>90%
|
|
|
Bismuth
2 tabs 4x day
|
Clarithromycin
500mg 3x day
|
|
Omeprazole
20mg 2x day
|
8
days1
|
80%
|
|
|
RBC5
400mg
2x day
|
Clarithromycin
500mg 3x day
|
|
|
2 Weeks
|
82 - 94%
|
| PPI
Triple
Therapy
|
Metronidazole
500mg 2-3x day
|
Clarithromycin
250mg 2x day
|
|
Omeprazole
20mg 2x day
|
1
to 2 Weeks
|
85
- 91%
|
|
|
Clarithromycin
500mg 2x day
|
Amoxicillin
1 gm 2 x day
|
|
Omeprazole
20mg 2x day
|
1
to 2 Weeks
|
80
- 95%
|
|
|
Metronidazole
500mg 2-3x day
|
Amoxicillan
1 gm 2x day
|
|
Omeprazole
20mg 2x day
|
1 to 2
Weeks
|
77 - 86%
|
| PPI
Dual
Therapy
|
|
Amoxicillan
500mg 3x day
|
|
Omeprazole
40mg daily
|
2
Weeks
|
54
- 79%
|
|
|
Clarithromycin
500mg 3x day
|
|
|
Omeprazole
40mg daily
|
2 Weeks
|
83%
|
| Antibiotic
Dual
Therapy
|
Metronidazole
500mg 2-3x day
|
Amoxicillan
750mg 3x day
|
|
|
2
Weeks
|
>85%
|
|
|
Clarithromycin
500mg 3x day
|
Amoxicillan
500mg 2x day
|
|
|
2
Weeks
|
>90%
|
NOTES:
1.
This regimen includes bismuth and clarithromycin for 1 week, plus
omeprazole for 8 days.
2.
Bismuth subsalicylate (such as Pepto-Bismol�).
3.
Separate bismuth and tetracycline dosages by at least two hours.
4.
Helidac� therapy (Proctor & Gamble) in which bismuth and
tetracycline are taken together plus H2RA.
5.
Ranitidine bismuth citrate (Tritec� - Glaxco Wellcome).
Adapted
from table appearing in the Pharmacists
Letter by Veronica Moriarty, Pharm.D.
If diagnostic testing indicates H. pylori eradication as a desired therapeutic alternative, the use
of combination antibiotics with or without bismuth, plus the inclusion of an
antisecretory agent represents best current therapy. The optimal therapeutic regimen is not year clear, though
bismuth plus metronidazole (or clarithromycin) and tetracycline (or amoxicillin)
with or without an antisecretory agent have become accepted therapy.
The recent release of Helidac� and Tritec� may provide the appropriate
combinations of therapy required for H.
pylori eradication.
Although recent studies seem to indicate that the empiric treatment of H.
pylori infected patients with antibiotics may make pharmacoeconomic sense (Fendrick
1995), the increase resistance that may result and the potential for side
effects associated with such as approach should be carefully considered.
It also should be pointed out that non-ulcer dyspepsia does not respond
to antibiotic therapies (Kozol 1996).
Decreasing Problems with NSAID Therapy
Many GI problems in patients taking NSAIDs can be prevented by closely
monitoring patients who are vulnerable. This group includes those who have a diagnosis related to
renal insufficiency, who are older than 60, or who have had a previous history
of gastric ulcer disease of GI bleeding. This
situation occurs commonly and causes increased (and many times unnecessary)
medical and pharmaceutical costs to the Louisiana Medicaid Drug Program as well
as increased health risks to the patients.
Appropriate monitoring of patients on NSAIDs can significantly reduce
associated side effects and decrease medical costs.
In certain circumstances, it may even be prudent (both medically and
economically) to consider prescribing prophylactic therapy (such as micoprostol
or concurrent use of an antisecretory drug) in combination with NSAIDs in
"at-risk" patients who absolutely need an anti-inflammatory agent.
Chronic Therapy With Antisecretory
Agents
Additional cost savings and enhanced therapy may be seen when patients
receive chronic therapy only for periods of time associated with proven
beneficial results. This is
generally no more than eight weeks of
therapy except in certain specific
indications, e.g., GERD and certain hypersecretory conditions (Zollinger-Ellison
Syndrome) and gastrointestinal tract disorders (Barrett's Esophagitis).
The use of the most cost effective prescription alternatives, or the
recommendations for nonprescription dosages of existing agents are also suitable
cost saving alternatives when appropriate.
It is difficult to rationalize the benefits of use of prolonged
antisecretory therapy except with specific therapeutic indications.
Summary
The effective management of peptic ulcer disease involves the prevention of
recurrent episodes through the eradication of H.
pylori. This infection is generally curable in patients where NSAID
therapy is not contributing to the gastrointestinal tract problems.
Only a small number of patients, who are not cured by one of the
recommended H. pylori regimens, are
candidates for long term therapy. Whenever patients present symptoms of peptic ulcer disease
for a second (or more frequent) time within a 12-month time period, therapy with
antibiotics aimed at eradication of H.
pylori should be instituted in combination with an appropriate antisecretory
drug. The cost effectiveness of
such a treatment protocol should be balanced with the potential for drug
resistance or possible drug-related side effects.
In patients on multiple or chronic NSAID therapy, a key to effective
management may be careful monitoring and the use of lower doses of
shorter-acting agents.
References Available Upon Request
Policy Notes: Physician
Providers
Warning to Physicians
Louisiana Medicaid's Surveillance and Utilization Review (SURS) Unit has
uncovered a disturbing billing practice in which entities not enrolled as
Medicaid providers are using physicians' Medicaid numbers in order to submit
billing for their services. SURS
has found that some physicians have unknowingly become involved in this
fraudulent billing practice, and wants to raise physician awareness of this
practice so that physicians may not become liable for this billing.
This scam is put into motion when a non-Medicaid enrolled entity hires an
enrolled physician provider, and then uses that physician's Medicaid number for
billing. These fraudulent billings
are detected by SURS audits, which find unusual, aberrant billing patterns; for
example, inappropriate testing maybe detected.
Physicians risk being drawn into a long, complicated fraud investigation
and the unenrolled entities risk criminal prosecution.
Please be careful with your Medicaid number.
If you are aware of a suspicious practice, please call our fraud line at
1-800-488-2917.
Charles Lucey, MD, JD, MPH, and Bob
Patience, DHH SURS Manager
Notice to Anesthesiologists: Delivery
Codes
In 1996 CPT, there are new "delivery after previous Caesarean
delivery" codes (codes 59610 through 59622).
This notice is to serve as clarification of the codes and modifiers to be
used when billing anesthesia for these procedures.
If billing for an epidural performed for a vaginal delivery (59610, 59612, or
59614), bill code 62279 with modifiers AA, AI, AE, 24, or 25 (the same code and
modifiers that are used to bill for epidural anesthesia for vaginal delivery
code 59410). If billing for
maternity related anesthesia for Caesarean Section, bill code 59618,
59620, 59622 with modifiers AA, AI, AE, 24, or 25 (the same modifiers
that are used with code 595150.
In addition to the correct modifier, any provider who uses procedure code
62279 must also use the correct diagnosis code to ensure payment.
Providers should use diagnosis code 650-659, 669.5, or 669.6.
No other digits in the 5th place should be accepted.
On diagnoses 669.5 and 669.6, only digits 0 and 1 should be in the 5th
place.
Notice to Physicians and KIDMED Clinics
We recently learned that on September 9, 1996 the Office of Public Health
distributed the flu vaccine (CPT code 90724) to all Vaccines for Children (VFC)
enrolled providers who requested it. Therefore, since September 9, 1996, CPT code 90724 has been
reimbursed at a fee of $9.45 for the administration-related costs only, the same
as other vaccinations provided through the VFC Program.
If you received a payment greater than $9.45 for this vaccine for date of
service September 9, 1996, or thereafter, the difference in payment will be
recouped in the near future.
Notice to Physicians: Duplicate
Claims
We have found duplicate claims payments where two different billing providers
were paid for the same services rendered by one attending physician.
Where payment was made to the attending and to a group, the payment to
the attending was voided. Where
payment was made to two groups, the second claim paid was voided.
These claims received EOB message 849 which stated "Already paid
same attending different billing provider."
Five Prescription Limit Rescinded
The Department of Health and Hospitals, Bureau of Health Services Financing,
published an emergency rule establishing a limit of five prescriptions per month
in the Pharmacy Program effective for dates of service beginning January 1,
1997.
Please be advised that the Department has determined that it is necessary to
rescind this emergency rule. Therefore,
this emergency rule will not be implemented effective January 1, 1997.
The Medicaid Dental Program
By Dr. Robert Barsley
Dentistry is a small but important part of the health care system in general
and also in Medicaid of Louisiana. The EPSDT Dental Program provides comprehensive coverage of
basic dental needs to recipients under the age of 21. The Adult Denture Program provides complete denture services
to recipient older than 21 who no longer have any teeth. Together, these programs treated over 160,000 recipients in
the last fiscal year at a cost of $26,000,000.00.
Two-thirds of Louisiana's dentists are enrolled as providers and some 65%
of these were active in the program within the last 12 months.
In fiscal year 1992-93, the budget for EPSDT and adult dental services
slightly exceeded $29,000,000.00, and has decreased annually since that time.
Virtually all Adult Denture Program services require prior authorization
as do many of the non-emergency EPSDT Dental Program services.
Dental consultants at the LSU School of Dentistry in New Orleans handle
more than 50,000 prior authorizations issued each year.
The state, through the Office of Maternal and Child Health, has once again
funded Dr. Jim Sutherland as State Dental Officer.
He is a commissioned officer of the National Public Health Service.
Along with input from several sources (including Medicaid), his office is
conducting a reassessment of the oral health needs in Louisiana.
One of his first findings has been the less than optimal state of the
community water fluoridation program in this state.
Today, less than 50% of Louisiana citizens receive the well-documented
benefits of community water fluoridation. Monroe,
Alexandria, Baton Rouge, and Lafayette are some of the areas without
fluoridation. If you have questions about fluoridation in your area, Dr.
Sutherland can be reached at (504) 568-7706.
The Medicaid Dental Program is also attempting to address the difficulties
encountered by older recipients who require dental treatment as a medically
necessity adjunct to medical treatments such as organ transplants.
Dental disease can be a complicating factor in such cases.
We are attempting to identify a methodology to ensure that such
recipients are cared for in a timely manner and that the dental provider is
reimbursed.
Please feel free to call the dental consultants at (504) 619-8589 if you have
questions about these or other facets of the Dental Program operated by Medicaid
of Louisiana.
Dr. Robert Barsley is a graduate of LSU School of Dentistry and has been
a member of the facility since 1982. He
has worked with the Medicaid Dental Program since 1991 and was appointed
Director in 1994 upon the retirement of Dr. Harry Leveque.
Multiple Surgical Procedures: Expediting
Correct Payment
When more than one surgical procedure is submitted for a recipient on the
same date of service, the claim is always evaluated by the Unisys Medical Review
Unit, regardless of the method or timing of claim submittal.
Listed below are suggestions for facilitating correct payment:
1.
All attachments should be clear, easy-to-read copies.
2.
Correctly date all operative reports.
3.
Use specific, appropriate diagnostic codes.
4.
Submit requested documentation at your earliest convenience so that
correct payment can be quickly determined.
5.
Refrain from submitting two or more identical HCFA 1500 forms at the same
time. Bill all procedures performed
under the same anesthesia session on the same HCFA 1500 form.
Use correct modifiers and attach operative report and any other pertinent
documents with the claim. Failure
to do this may slow payment and/or result in time consuming voids or
adjustments.
6.
Assistant surgeons should always append an 80 modifier on each claim
line. Assistant surgeons are not
required to use the 51 modifier for secondary procedures.
Professional Services Training:
Medicaid Issues for 1996 offers the following concise guidelines.
Billing Multiple and Bilateral
Procedures
When billing multiple surgical procedures while under the same anesthesia
session, the correct procedure is to bill the major procedure with no modifier
and to put a 51 modifier on any or all additional procedures.
When billing bilateral procedures, the correct procedure is to bill the CPT
code for the procedure done with a 50 modifier on one line with total charges on
that line.
Billing the CPT code on one line with no modifier and on a second line with a
50 modifier is incorrect. If billed
on two lines as stated above, the line with the unmodified CPT code will pay and
the line with the 50 modifier on the CPT code will be denied 987 - rebill on
adjustment. The provider will then
have to submit an adjustment using the CPT code with a 50 modifier.
The paid line is the line which would need to be adjusted (page 56).
Unlisted Procedures
Providers should not bill unlisted procedure codes when there are listed
codes that describe the service.
An example is the use of code 37799 to bill for insertion of catheters.
Code 36800 - 36820 and other procedure codes cover cannula/catheter
insertion.
Claims submitted under unlisted procedure codes are subject to manual review.
If a CPT code exists that describes the service that was billed as an
unlisted procedure code, the claim will deny.
Providers are required to attach operative reports each time an unlisted
procedure code is billed.
If you have any questions concerning coding, please contact the American
Medical Association at (312) 464-4737 or 1-800-262-3211 (page 61).
We want to expedite your claims; please help us to help you.
Unisys Medical Review Unit
Policy Notes: Pharmacy
Program
APRNs Granted Limited Prescription Authority
Effective November 15, 1996, Advanced Practice Registered Nurses (APRN) were
granted limited prescriptive authority and the right to distribute free samples
in a limited demonstration project in accordance with Act 629 of the 1995
Legislature.
The Board of Nursing promulgated the necessary rule in the October 20, 1996
issue of the Louisiana Register. Approximately thirty-three APRNs have been certified to have
limited prescriptive authority. In
accordance with the Louisiana laws and regulations, the Board of Nursing has
issued APRN certificate numbers to nurses certified to participate in the
demonstration project and have prescriptive authority.
Prescriptions written by an APRN must contain the following information:
1) the name, office address, telephone number, "RN"
designation, and clinical specialty area of the APRN; 2) the collaborating
physician's name shall be preprinted, stamped, or handwritten on the
prescription form and shall be clearly distinguishable; 3) the date the
prescription is written; 4) the name, home address, and telephone number of the
patient; 5) the full brand name of the drug and directions for its use; 6) each
prescription written by an APRN pursuant to authority granted under these rules
shall bear the legend "DEMONSTRATION PROJECT (per R. S. 37:
1031-1035"; 7) an APRN with limited prescriptive authority shall retain a
duplicate or copy of each prescription written and issued to patients; and 8)
prescriptions written by an authorized APRN with the abbreviation for the
applicable category of advanced nursing practice, and the identification number
assigned by the Board of Nursing.
The Bureau of Health Services Financing will reimburse for prescriptions
written by APRNs in accordance to their rules and regulations.
We require that pharmacists use the APRN's Medicaid provider number when
billing on a pharmacy claim form. In
the event that an APRN does not have a Medicaid provider number, the pharmacist
should contact the Bureau's Provider Enrollment Unit (504-342-9454) for the
provider number of the APRN or for the issuance of a prescriber only number for
use on the claim form's prescribing provider information.
Medicaid will require the APRN's number rather than the collaborating
physician's Medicaid provider number.
Attention Pharmacy Providers: Miscoded
NDC Numbers
We have been notified by Bayer Laboratories through the submission of drug
utilization rebate data that pharmacies are billing and getting reimbursed for
NDC numbers which are miscoded or not on the manufacturer's master file.
Please be advised that these Bayer Laboratories drug products have been coded
to non-payable status:
192-2502-45
192-2501-07
Please ensure when billing drug products that you use the NDC from the
package from which you are dispensing. We will continue to inform you of drug products which are
considered obsolete.
Reimbursement for Amphetamines
Effective for services beginning October 18, 1996, the Bureau of Health
Services Financing will begin reimbursing for the following amphetamines for
medically approved indications other than when prescribed as an anorexiant for
weight reduction. When amphetamines
are prescribed as an anorexiant, they will continue to be non-reimbursable.
In order for amphetamines to be reimbursed by the Medicaid Program, a
hard copy claim form must be completed with an attachment to the hard copy
claim. The prescription must be
hand-written with the prescribing physician's written statement of the medically
accepted indication for the drug which appears in peer-reviewed medical
literature or which is accepted by one or more of the following compendia:
the American Hospital Formulary Service-Drug Information, the American
Medical Association Drug Evaluations and the United States Pharmacopoeia-Drug
Information.
For claim acceptance, the prescriber must include a copy of the prescription
with the prescribing physician's statement of the medical indication, a
statement written and signed by the prescribing physician, or a typed statement
that must be signed by the prescribing physician.
The indication must not be used as an anorexiant or as an adjunct in a
weight reduction program. Non-amphetamine
anorexiants remain non-covered items. When
amphetamines are prescribed for attention-deficit disorder or narcolepsy, they
will only be reimbursed for recipients from ages 3 to 21.
Louisiana Maximum Allowable Costs will be established for the following
drugs:
Generic Description
LMAC
Effective Date
Dextroamphetamine sulfate tablet 10mg 0.33600
11-1-96
Dextroamphetamine sulfate tablet 5 mg 0.18815
11-1-96
Only those drugs manufactured by companies participating in the rebate
agreement are payable.
Policy Notes: All Providers
Notice to Providers: Code
J3988 in Non-Pay Status
Effective with date of service November 1, 1996, code J9388 - Etoposide,
20mg/ml - was placed in non-pay status. The codes to bill in its place are as follows:
J9181, Etoposide, up to 10 mg, fee $11.23
J9182, Etoposide, up to 100 mg, fee $112.35
Notice to Certified Nurse Practitioners: Vaccine Codes
The following codes for the Hepatitis B vaccine have been added to the list
of codes payable to nurse practitioners, effective with date of service 1-1-96.
Remember, immunizations are reimbursed to nurse practitioners at 100% of
the fee on file.
90744 (Hepatitis B Vaccine - under 11 years), fee $9.45
90745 (Hepatitis B Vaccine - 11-19 years), fee $9.45
90746 (Hepatitis B Vaccine - 20-21 years), fee $9.45
Requirements for Receiving Glucose Monitors
Glucose monitors are provided to Medicaid eligible recipients who are
insulin-dependent, insulin-requiring, or gestational diabetics.
The prescription or letter for the blood glucose monitor must state that:
1.
The recipient is an insulin-dependent or insulin-requiring diabetic, or
the recipient's diagnosis is gestational diabetes;
2.
The recipient or someone on his/her behalf can be trained to use the
monitor correctly; and
3.
The monitor is for home use.
Diabetic supplies for insulin-dependent, insulin-requiring, or gestational
diabetes are available through the Pharmacy Program.
All insulin-dependent, insulin-requiring, or gestational diabetic
Medicaid recipients must present a physician's prescription and current Medicaid
card to pharmacies which accept Medicaid for the following diabetic supplies:
disposable insulin syringes, blood glucose monitoring strips, urine
ketone monitoring strips, auto-lancet devices, and auto-lancets.
The prescription for disposable syringes must contain the prescribing
physician's written statement that the recipient is insulin-dependent or
insulin-requiring.