Provider Update
Volume 14, Issue 6
December 1997
Advantages of New Medicaid Technology
The cover story of the October, 1997 Provider Update profiled a new enhancement to the Louisiana Medicaid Program: the introduction of plastic ID cards for recipients and the implementation of the new, automated Medicaid Eligibility Verification System (MEVS).Plastic ID card implementation will begin March 1, 1998. Both enhancements are expected to be fully implemented in
1998.
The October article highlighted basic introductory information on the ID card, MEVS system, and the upgrade of the existing Recipient Eligibility Voice Response System (REVS).We have received inquiries from the provider community questioning the advantages of having access to the MEVS system. Some of these advantages are as
follows:
1. The plastic ID cards will be permanent cards and will no longer have information concerning eligibility periods, restricted eligibility information (Lock-In, CommunityCARE, etc.), and such on the card face. Providers who utilize MEVS will receive printed confirmation of eligibility, including restricted eligibility information, Medicare, and other insurance
coverage.
2. MEVS will supply this printed response within approximately 15 seconds of entry. An average REVS telephone inquiry takes approximately two
minutes.
3. It will no longer be necessary for providers� staff members to be on the telephone for eligibility
information.
4. Providers will have access to more extensive eligibility information through the automated systems, thus freeing provider inquiry phone lines for claims and policy
questions.
We anticipate that at least four or five telecommunications vendors will be contracted to market and provide the telecommunications link from the providers� offices to Unisys for the MEVS system. When contracts are finalized, a list of these vendors will be made available to providers for reference. It is anticipated that these vendors will be calling on the provider community beginning in late January to market their services. We ask providers to please ensure that any vendor considered for contracting on this project is on the Unisys list of approved vendors. Unisys will not charge providers for this service. Any charges will be between the telecommunications vendor and the provider.Plastic ID cards will be implemented by region throughout the state. The anticipated schedule for this implementation is as
follows:
Region V: Lake Charles,
March 1, 1998
Region III: Houma/Thibodeaux,
May 1, 1998
Region II: Baton Rouge,
June 1, 1998
Region IV: Lafayette,
July 1, 1998
Region VI: Alexandria,
August 1, 1998
Region VIII: Monroe,
September 1, 1998
Region VII: Shreveport,
October 1, 1998
Region IX: St. Tammany/Mandeville,
November 1, 1998
Region I: New Orleans,
January 1, 1999
The first month both permanent, plastic ID cards and current, paper ID cards will be mailed to recipients as a safety net. For at least two months prior to the mailing of plastic cards, recipients will receive information on the paper cards informing them of the transition to plastic cards. When the plastic cards are initially mailed in each region, recipients will receive an informational booklet letting them know about the card and how to use
it.
Although the plastic cards will be implemented by region, the MEVS system will be available across the state for any provider who chooses to contract with a vendor to have access to the system. This will allow providers outside of the regions implemented to use MEVS should a recipient with a plastic ID card go outside the region of residence for
services.
Finally, provider workshops will be held in each region prior to implementation of this project. The Provider Update will continue to be used to transmit information on the project for the next several months. Please continue to watch your newsletters and Remittance Advice messages for further updates.
Louisiana Drug Utilization Review (LADUR) Education
New Criteria for Type 2 Diabetes: Diagnosis, Screening, and Nomenclature
Tracy S. Hunter, Ph.D., R.Ph., Director, Clinical Pharmacy Practice Division, Northeast Louisiana University, and Sandra Blake, Ph.D., Fellow, Pharmacoeconomics and Outcomes Research, Northeast Louisiana University
ISSUES . . .
- Diabetes Mellitus is a group of chronic metabolic disorders common in the United States.
- In June 1997, an international Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (sponsored by the American Diabetes Association) suggested lowering the numerical value by which diabetes is diagnosed by the Fasting Plasma Glucose (FPG) Test from > 140 to < 126 mg/dL.
- The Expert Committee also made recommendations for earlier universal screening and labeled a FPG > 110 bu < 126 mg/dL as �Impaired Fasting Glucose.�
Due in part to a recent national report, diabetes is again in the national spotlight. Diabetes Mellitus is a group of chronic metabolic disorders common in the United States, and a serious health threat to thousands of Medicaid patients in Louisiana. The national statistics regarding the morbidity and mortality of diabetes are staggering, and quite pertinent to Louisiana health care
professionals.
Presently, more than 16 million Americans are reported to have diabetes and the figure is growing by 800,000 annually. Another 6 million have diabetes that remains unrecognized. It is thought that up to half are not diagnosed because Type 2 diabetes is generally asymptomatic until complications emerge. It is estimated that in Louisiana alone, there are 265,000 individuals with diabetes, and 132,000 who are undiagnosed
Table 1. Diabetes Statistics for LouisianaSource: American Diabetes Association
| Diabetes Statistics |
Method A |
Method B (Race/Ethnic Group) |
| # Diagnosed |
132,067 |
Caucasian - 138,765
Afr.-Amer. - 112,015
Nat. Amer. - 2,966
Asian Amer. - 3,465 |
| # Undiagnosed |
132,067 |
|
| Total Number |
264,134 |
257,211 |
| # of Children |
2,160 |
|
| # of Deaths Caused |
2,971 |
|
| # of Amputations/Yr |
891 |
|
| # of New Blindness Cases |
198 - 396 |
|
In June 1997, an international Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (sponsored by the American Diabetes Association) updated the guidelines for the diagnosis and classification of diabetes mellitus, and added new classification nomenclature. In addition, the Committee made recommendations for earlier universal screening and created a �gray zone� between diabetic and
normal.
DIABETES MELLITUS
Diabetes Mellitus is a series of complex chronic metabolic disorders characterized by glucose intolerance and hyperglycemia. Diabetic hyperglycemia is the elevation in measured blood glucose that is the result of a deficiency, either relative or absolute, in insulin performance. This deficiency is due to either inadequate insulin secretion by the beta cells of the pancreas or a decrease in the responsiveness of insulin-sensitive
tissues.
Not only is diabetes a leading causes of death by disease in the nation, it is the leading cause of adult blindness, end-stage renal disease requiring dialysis or transplantation, and non-traumatic lower extremity amputations (approximately 55,000 foot amputations each year nationally, almost 900
in Louisiana). The incidence of coronary artery disease (which leads to angina, heart attacks, need for coronary bypass surgery, angioplasty, and sudden death) is increased 3 to 4 times in Type 2 patients. Strokes are twice as likely in such patients. In terms of health economics, the annual cost of diabetes care is estimated to be over $100 billion a year for both direct and indirect costs, accounting for 13% of the total of U.S. health care expenditures. Direct health care costs are $46.7 billion. This translates to approximately $2.27 billion in terms of Louisiana health care dollars, according to American Diabetes Association statistics.
Table 2. Annual Economic Cost of Diabetes in LouisianaSource: Louisiana Affiliate of ADA
| Total Costs: |
$2,271,552,400 |
| Direct Cost(Medical): |
$1,521,940,108 |
| Indirect Cost(Lost Productivity): |
$749,612,292 |
Long term complications of diabetes include abnormalities of insulin secretion and vascular and neurologic problems such as retinopathy, nephropathy, neuropathy, and coronary artery disease (Table 3).
Table 3: Chronic Complications
| Atherosclerosis |
| Nephropathy |
| Retinopathy |
| Diabetic Neuropathy |
The relationship of diabetes to coronary artery disease is not as generally well known to the public as the association with other complications. It is therefore incumbent upon Louisiana health care professionals to increase public awareness to the dangers and the importance of early detection of Diabetes Mellitus and its
complications.
The prevelance of diabetes is rising for three reasons:
-Extended aging of our population;
- Growth in minority populations most susceptible to Type 2 diabetes; and
- Increased prevalence of obesity.
Diabetes is especially troublesome in minority populations and should be of special interest to Louisiana with its high percentage of ethnic minorities and a recent influx of immigration. For example, diabetes is over twice (60%) as prevalent in African Americans, twice as prevalent in Hispanics, and approximately 10 times greater in American Indians than in other population groups. (The numbers of Louisiana are listed in Table 1.) Additionally, the disease seems to appear earlier in these populations. This increases the socioeconomic burden of long-term complications on the individual patient, family, and
society.
NEW CRITERIA FOR DIAGNOSIS
The 1997 Expert Committee on the Diagnosis and Classification of Diabetes Mellitus changed the guidelines for the diagnosis and classification of disease. The Committee added new nomenclature for classifications and recommended earlier universal screening. A newly created �gray zone� category between diabetic and normal was
proposed.
In these revised guidelines, the criteria to diagnose diabetes were redefined to bring the diagnosis into closer alignment with the known risk of complications. It recommended lowering the number value at which diabetes is diagnosed by the Fasting Plasma Glucose (FPG) test. This new lowering of the criteria could lead to the identification of 2 million Americans not previously diagnosed with diabetes and a significant number of new diabetic patients in our
state.
The three criteria to diagnose diabetes mellitus are:
1. A Fasting Plasma Glucose (FPG) level of > 126 mg/dL (after no caloric intake for at least 8 hours). The old level criteria was > 140
mg/dL.
2. Symptoms of diabetes mellitus plus a casual plasma glucose (a reading taken anytime without regard to time of last meal) concentration of > 200
mg/dL.
3. A 2-hour plasma glucose level of > 200 mg/dL during an oral glucose tolerance test (OGTT).
An abnormal test result must be confirmed by repeating the test on a subsequent day. As mentioned above, the OGTT and FPG are both suitable tests for diagnosis. However, the FPG is the recommended procedure because it is easier to perform, more reproducible, and less expensive. This change does not alter the criteria for diagnosing gestational diabetes mellitus but note that a recommendation was made as to which women to
screen.
At this time, the Committee does not recommend the hemoglobin A1c (Hba1c or glycosylated hemoglobin) test for diagnostic purposes, but the ADA emphasized its usage as a monitoring tool. It is important to remember that the finger-stick blood glucose test (used by patients to monitor their glucose levels and sometimes used at health fairs as diabetes risk assessment) is considered a screening test and not a diagnostic
procedure.
NEW STATE DEFINED BETWEEN �NORMAL� AND �DIABETES�
It was the consensus of the Committee that the new upper limit of normal blood glucose on the FPG be defined as a value of 110 mg/dL. It also recognized two categories of impaired glucose metabolism that are considered risk factors for developing diabetes and cardiovascular disease. These categories include:
- Impaired Fasting Glucose, a new category, in which fasting glucose is
greater than 110 mg/dL but less than 126 mg/dL.
- Impaired Glucose Tolerance, an already existing category, in which results of the more complicated OGTT are greater than 140 mg/dL but less than 200 mg/dL in the two-hour
sample.
The new category, Impaired Fasting Glucose, was initiated because research showed that complications occur at lower blood glucose levels than previously considered. People in this range should be alerted that their impaired glucose homeostasis puts them at greater risk for developing diabetes and macrovascular complications such as heart attack and strokes. In this range they should closely monitor their condition and pay careful attention to their diet, weight control, and exercise in order to prolong or delay the onset of Type 2
diabetes.
NEW CLASSIFICATION TERMINOLOGY
Traditionally, diabetes was classified by age of onset of the disease, treatment, or method of control. Early criteria labeled diabetes as juvenile onset, adult onset, insulin dependent (IDDM), non-insulin dependent (NIDDM), brittle, chemical, overt, or latent. These labels were confusing to patients and to practitioners alike. Until now, the accepted treatment classifications were the result of a 1979 recommendation of the National Diabetes Data Group. This classification -- Insulin Dependent Diabetes Mellitus (or Type I) and Non-Insulin Dependent Diabetes Mellitus (or Type II) -- was the accepted terminology. The confusion inherent with this nomenclature occurred when patients developed Type I Diabetes after childhood, or when Type II Diabetes required insulin for glucose
control.
This terminology was replaced in the summer of 1997 by the recommendations of the Expert Committee. They reclassifed and differentiated insulin-sensitive and insulin-resistant Type 2 disease. In addition, they recommend that the label Type 1 Diabetes replace the term insulin dependent diabetes (IDDM) and the term non-insulin depended diabetes (NIDDM) be labeled as Type 2 diabetes. (The Arabic numerals are preferred in order to prevent Type II from being confused with the number
eleven.)
Screening
Symptoms associated with diabetes are polyuria, polydipsia, polyphagia, weight loss, blurred vision, numbness or tingling in the feet, recurrent infections, itching, and unexplained fatigue. More than half of patients with Type 2 diabetes will not have symptoms or do not recognize the symptoms for many years. Therefore, prolonged hyperglycemia leads to the development and progression of vascular and neurologic complications. Thus, screening should be considered for individuals with one or more of the risk factors listed in �Who to Screen For
Diabetes.�
Who Needs To Be Screened?
In addition to the routine diabetes testing of all adults aged 45 and older with repeated testing every three years, the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus recommended earlier or more frequent testing for the individuals listed
below.
Who to Screen For Diabetes
- All first-degree relatives over age 30 or 40 of a diabetic patient -- especially in affected minority populations. - Members of high-risk groups, such as African-American, Hispanic, Native American, and Asian.
- Women with a history of gestational diabetes or those who delivered a baby weighing over 9 pounds.
- Individuals with obesity (>120%) of ideal body weight. Particular attention should be paid to those with upper body obesity because they are at greater risk.
- Individuals with a history of high blood pressure (BP > 140/90).
- Individuals with history of coronary heart disease, stroke, or claudication.
- Individuals with a history of gout.
DISTINGUISHING TYPE 1 AND TYPE 2 DIABETES
Although the Expert Committee addressed their recommendations to Type 2 diabetes, health care practitioners should be able to distinguish between to two major types of diabetes and explain the difference to patients, especially newly diagnosed patients. Of particular concern to patients is the strong genetic component of Type 2 diabetes and the role of lifestyle. Strong genetic factors can be mitigated by weight control, diet, and exercise. Table 4 (on page 12) summarizes the major differences between the types.
Diabetes knowledge, treatment, and prevention strategies advance daily from research. Scientists are searching for ways to predict who will go on to develop diabetes from the impaired fasting glucose category and how to prevent such progression. The take home message is that all adults, especially those with a family history of diabetes, should try to maintain ideal body weight and a regular exercise program in order to delay or prevent the onset of Type 2 diabetes. As practitioners, it is up to us to remain aware of these developments.
Proactive treatment is aimed at keeping blood glucose near normal levels at all times. Training in self-management is integral to the treatment of diabetes and its related disorders. Treatments must be individualized and should address medical, psychosocial, and lifestyle issues. It is our task as Louisiana health care professionals to provide the most up-to-date information available in order to be better care givers to those Medicaid patients in our
trust.
Table 4: Distinguishing Criteria for Type 1 and Type 2 Diabetes
| Characteristics |
Type 1 |
Type 2 |
| Onset |
Under age 30 |
Over age 40 |
| Rapidness of Onset |
Abrupt |
Gradual |
| Family History |
Little genetic component |
Strong genetic component |
| Insulin in blood |
Deficiency or absence in secretion |
Some usually present. May be low, normal, or high (insulin
resistance) |
| Body weight |
Undernourished, thin |
Often obsese |
| Symptoms |
Polyuria, polydipsia, polyphagia, weight loss |
Often asymptomatic, polyuria or polydipsia may be present |
| Distribution |
10% |
90% |
Medical Eligibility Determination Requirements for Vendor Payment in Nursing
Facilities
The Department of Health and Hospitals, Bureau of Health Services Financing, published a final rule in the October 20, 1997 edition of the Louisiana Register establishing medical eligibility determination requirements for vendor payment in nursing facilities. The adoption of these requirements was necessary in order to assure timely and appropriate determinations of medical necessity and to establish that the department is in compliance with federal requirements pertaining to all admission screenings. The rule will establish time frames necessary for the submission of evaluative data, as well as identify the forms which are needed for medical certification for nursing facility services and hospice services in nursing
facilities.
The DHH Health Standards Section will begin enforcing these requirements effective January 1, 1998. A copy of this rule will be mailed to all facilities. Administrators will be held accountable for assuring that the information is disseminated to all facility staff who will be responsible for submitting admissions paperwork to the regional Health Standards offices. After January 1st, no exceptions will be made for late submissions. Questions regarding this rule may be directed to Terry Cooper, RN Program Manager, at (504) 342-0118, or to regional Health Standards offices.
Additional Codes Payable to Certified Nurse Practitioners
Effective with date of service November 1,1997 the following codes were added to the list of codes reimbursable to Certified Nurse Practitioners.
| 11975 |
57454 |
| 11976 |
57505 |
| 11977 |
57511 |
| 56501 |
58100 |
| 56605 |
58300 |
| 57061 |
58301 |
| 57160 |
81000 |
| 57170 |
81025 |
| 57452 |
85025 |
| |
86403 |
Certified Nurse Practitioner Services are reimbursed at 80% of the current fee on file, with the exception of immunizations, which are reimbursed at 100% of the fee on file.
Stadol Placed on Schedule IV
Effective with date of service October 31, 1997, Stadol (butorphanol) has been placed on Schedule IV of the Federal Schedule of Controlled Dangerous Substances.
Billing for Clinical Laboratory Tests: Organ and Disease
Panels
The February 15, 1997 issue of Medicare Providers� News contains an article entitled, �Clinical Laboratory Tests: Organ and Disease Panels.� CPT codes 80058, 80061, and 80072 each contain one or more of these tests, which are usually performed on multichannel analyzers. These tests are also on the list of Automated Multichannel Tests appearing at the beginning of the lab code section in the CPT book and/or in current Medicare regulations. The tests on the list are always to be billed using the appropriate multichannel code if two or more are done, regardless of how they are
performed.
When these panels are performed with other multichannel tests and codes, the organ and disease panel code should not be billed. The multichannel tests included in the panel should be combined with the other multichannel tests and the appropriate multichannel code should be billed. The other tests in the organ and disease panel should be billed separately. Any claims received that are billed improperly will be
denied.
Examples
All five tests (82040, 82250, 84075, 84450, and 84460) in 80058 are multichannel tests. If these tests are performed with, for example, five other multichannel tests on the same day, multichannel code 80010 should be billed, NOT 80058 and
80005.
80061 contains two multichannel tests, 82465 and 84478, and CPT code 83718 (HDL cholesterol). If, for example, the two tests are perfomed with five other multichannel tests on the same day, multichannel code
80007 and code 83718 should be billed, NOT 80061 and 80005.
80072 contains one multichannel test and CPT codes 85651 (sedimentation rate, erythrocyte, non-automated) 86255 (fluorescent antibody, screen, each antibody) and 86430 (rheumatoid factor, qualitative). If this multichannel test is performed with, for example, five other multichannel tests on the same day, multichannel code
80006 and codes 85651, 86255, and 86430 should be billed, NOT 80072 and 80005.
Electronic Funds Transfer Implementation
In the October, 1997 edition of the Provider Update, providers were informed of the upcoming implementation of Electronic Funds Transfer, or �Direct Deposit.� Direct Deposit will be very beneficial to providers, as they will no longer have to wait for Medicaid payment checks to arrive in the mail. Funds will be deposited directly to providers� checking or savings
accounts.
The Bureau of Health Services Financing (BHSF) will implement this project in phases by provider type, beginning in January, 1998. All providers will be registered in this program and receiving their Medicaid payments through Direct Deposit by July 1, 1998. Participation in this program is
mandatory.
Provider notices of registration, with authorization agreements attached, will be mailed to providers by type as they are phased into the program, beginning in early January, 1998. Providers will have five days from receipt for signing and returning the completed form to
BHSF.
This project is currently in the testing phase to ensure that all systems are working properly. Please continue to watch your newsletters, RA messages, and provider notices for further information on this program.
New Orthopaedic Program
The American Academy of Orthopaedic Surgeons has launched a national public education program that focuses on major consequences of falls of the elderly and prevention strategies to avoid falls. The program is called �Don�t Let a Fall Be Your Last
Trip.�
The Academy has published a brochure by the same name. It calls attention to the medical and personal risk factors for falls and the causes of falls in the home. The key message of the brochure is that falls are not natural occurrences and can be
prevented.
Providers are encouraged to obtain this free brochure, �Don�t Let a Fall Be Your Last Trip,� by calling (800) 824-BONES.
Changes in Insulin Prescriptions
Effective with date of service December 1, 1997, prescriptions for disposable insulin syringes need not contain the prescribing physician�s written statement that the recipient is insulin requiring. In lieu of the physician�s statement, the recipient�s paid pharmacy claim history will be searched at the point-of-sale to identify a paid insulin claim in the 120 days prior to the date of service for the insulin syringe claim. If there is no insulin claim in the preceding 120 days of the recipient history, the claim will deny with our edit #668, �No patient history of insulin requirements,� which is lined to NCPDP rejection code #80, Drug Diagnose
Mismatch.
In the case of a recipient beginning initial insulin therapy, the provider should submit the insulin claim first to establish the insulin requirements on the patient history. Subsequently, the insulin syringe claim can be submitted for
payment.
In addition, effective since November 1, 1997, a recipient�s pharmacy claim history will be searched for a paid insulin claim when diabetic supplies for recipients with Medicare Part B coverage are submitted. The following circumstances will apply:
- If there is a paid insulin claim in the 120 days preceding the diabetic supply claim, the claim will continue to deny advising that Medicare is to be billed with our edits 275, �Recipient is Medicare eligible� and 988, �Item covered by Medicare.� These edits are linked to NCPDP edit #41 (�Submit to Other Processor or Primary
Payor�).
- If there is no paid insulin claim in the preceding 120 days, the pharmacist should enter a diagnosis in NCPDP field #424. Acceptable diagnoses include 250.00 - diabetes mellitus, type II (non-insulin dependent type), or unspecified type, uncontrolled. If no diagnosis is entered in the NCPDP field #424, the claim will continue to deny with our edits 275 and 988 (NCPDP code #41). If an invalid diagnosis is entered, the claim will deny with NCPDP code #39 - Missing or invalid diagnosis which is our edit 020. We recommend dialogue with the patient and/or physician as to the use of insulin syringes when insulin has not been dispensed in the previous four
months.
The Bureau of Health Services Financing also advises pharmacy providers that effective January 1, 1998, Medicare Part B will extend the coverage of diabetic supplies to all diabetics regardless of insulin requirements. At that time, all diabetic supply claims from pharmacy providers for a Medicare Part B eligible recipient will deny. The pharmacy will be advised through point-of-sale to submit the claim to the Medicare carrier. As more information of the expanded Medicare diabetic service coverage becomes available, the Bureau will inform providers of impacts to Medicaid pharmacy billing
procedures.
In order to bill for a Medicare service, pharmacies must have a Medicare supplier billing number. Many pharmacy providers have failed to apply for their Medicare supplier billing number or have not notified Medicaid of their assigned Medicare number. An application for a Medicare supplier billing number can be obtained by contacting the National Supplier Clearinghouse
at
Palmetto GBA
National Supplier Clearinghouse
P.O. Box 100142
Columbia, SC 29202-3142
(803) 754-3951
The National Clearinghouse has indicated a 45 day turnaround time in the assignment of Medicare supplier billing
numbers.
The Medicaid Provider Enrollment Unit must be notified of all Medicare supplier billing numbers. When contacting the Provider Enrollment Unit, please identify the provider name, address, telephone number, and Medicaid and Medicare provider numbers. The provider should request the Medicare and Medicaid provider numbers to be lined to ensure proper cross-over processing. The Provider Enrollment Unit can be contacted
at:
LA Department of Health and Hospitals/Provider Enrollment
P.O. Box 91030
Baton Rouge, LA 70821-9030
FAX: (504) 342-3893
After the Medicare carrier processes the claim, the information will automatically crossover to the fiscal intermediary for payment of the coinsurance and deductible amounts, where applicable. Failure to notify Medicaid Provider Enrollment of a Medicare billing number will result in the Medicare crossover claim being dropped from processing and no Medicaid payment made on the coinsurance or
deductible.
Medicare policy requires all providers of Medicare Part B services, whether assigned or non-assigned, to submit claims to Medicare carriers on behalf of Medicare beneficiaries. There are penalties associated with failure to comply with this policy. Questions concerning Medicare billing can be directed to Medicare Team Services at (803)
691-4300.
Should a provider need assistance with Medicaid pharmacy billing, the Point-of-Sale Help Desk can be reached toll free at 1-800-648-0790. Thank you for your continued cooperation.
Revision of Criteria for CPAP Devices
A revision of Ventilator Assist Devices criteria, which expands the coverage criteria for therapeutic ventilators, has been approved and is now awaiting Rule publishing. This new policy also includes a minor revision of wording in the CPAP criteria published previously in the Medicaid Eligibility Manual (Section 0-204.17) and in the policy for Ventilator Assist Devices under �Adult Criteria (Age 21 and Over), Item
#4.�
The sentence to be revised states, �Sleep studies should document at least 30 episodes of apnea, each lasting a minimum of 10 seconds, during 6 to 7 hours of recorded sleep.� The revised sentence reads, �Sleep studies should document at least 30 episodes of apnea, each lasting a minimum of 10 seconds, during a 6 to 7 hour study.� This change is being made to allow for situations where the patient slept less than 6 to 7 hours during a sleep study, but still met the criteria of having at least 30 episodes of apnea, each lasting a minimum of 10 seconds. It will also allow for the split night sleep studies, which are being more frequently utilized by physicians and sleep study clinics. In a split night study, a study is done in one night instead of two. The first half is recorded without the CPAP device and the second half is done with the CPAP device in
use.
Effective immediately, the Unisys Prior Authorization Unit will implement this change in wording from requiring the listed number and duration of apnea spells during 6 to 7 hours of recorded sleep, to requiring the same number and duration of apnea spells during a 6 to 7 hour study. Please note, though, that the same number and length of apnea episodes are still required to document medical necessity. The only change is that the Prior Authorization Unit will accept the same standards when they are met in a shorter period of recorded sleep.
Attention Hospital Providers: Billing Ectopic Pregnancy
When billing an inpatient claim or an outpatient claim for removal of an ectopic (tubal) pregnancy, the correct ICD-9-CM Procedure Code to use is 6662. The correct ICD-9-CM Diagnosis Code would be 633 through 6339.
Notice to Providers Who Deliver Babies
Senate Bill No. 1309 (Act 1138) mandates the length of the hospital stay for cesarean delivery to be no less than 96 hours. In accordance with this legislation, the global surgery period for cesarean delivery codes 59515 and 59618 - 59622 has been changed from 4 days to 5
days.
There is no change in the number of global surgery period days for vaginal delivery codes (59410 and 59610 - 59614), which remains at 3 days.