PHARMACY PROVIDERS, PLEASE NOTE!!! 

PLEASE MAKE THE FOLLOWING CHANGES TO APPENDIX A:  

IF YOU ARE UNSURE ABOUT THE COVERAGE OF A DRUG PRODUCT, PLEASE CONTACT THE PBM HELP DESK AT 1-800-648-0790  

PLEASE FILE ADJUSTMENTS FOR CLAIMS THAT MAY HAVE BEEN INCORRECTLY PAID.

ONLY THOSE PRODUCTS OF THE MANUFACTURERS WHICH PARTICIPATE IN THE  FEDERAL REBATE PROGRAM WILL BE COVERED BY THE MEDICAID PROGRAM. PARTICIPATION MAY BE VERIFIED IN APPENDIX C, AVAILABLE AT WWW.LAMEDICAID.COM

ATTENTION PROVIDERS

LA MEDICAID RECENTLY INFORMED PROVIDERS THAT THE 2006 ICD-9-CM DISEASE AND PROCEDURE CLASSIFICATION UPDATE WAS COMPLETE AND THAT VALID CODES MUST BE USED ON CLAIM SUBMISSIONS WITH DOS 10-1-05 FORWARD. DELETED OR INVALID CODES WERE PLACED IN NON-PAY STATUS, RESULTING IN DENIAL ERROR 433. TO ALLOW PROVIDERS TO MAKE NECESSARY CHANGES IN THEIR CLAIM SYSTEMS, EFFECTIVE IMMEDIATELY UNTIL MARCH 1, 2006, ERROR 433 WILL BE 'EDUCATIONAL ONLY' FOR CLAIMS WITH INVALID CODES. FOLLOWING THE GRACE PERIOD AND PROVIDER NOTIFICATION, CLAIMS WILL AGAIN DENY WITH ERROR 433. CLAIMS RECENTLY DENIED FOR THIS REASON WILL BE RECYCLED. FOR INFORMATION REGARDING ICD-9-CM OFFICIAL GUIDELINES FOR CODING AND REPORTING, PROVIDERS MAY ACCESS THE CMS WEBSITE AT HTTP://WWW.CMS.HHS.GOV/PAYMENTSYSTEMS/ICD9/

ATTENTION ANESTHESIA PROVIDERS

LOUISIANA MEDICAID IDENTIFIED A PROGRAMMING PROBLEM WITH CPT CODE 01961 
(ANESTHESIA FOR CESAREAN DELIVERY ONLY) WHICH BEGAN IN MAY 2005. THE 
PROGRAMMING HAS BEEN UPDATED AND CLAIMS SUBMITTED AFTER SEPTEMBER 14, 
2005, HAVE PROCESSED CORRECTLY. THE CLAIMS THAT ORIGINALLY PROCESSED 
INCORRECTLY PRIOR TO SEPTEMBER HAVE BEEN RECYCLED ON THE 10/25/2005 RA. 

ATTENTION PROFESSIONAL SERVICES PROVIDERS

EFFECTIVE WITH DATE OF SERVICE DECEMBER 1, 2005, LOUISIANA MEDICAID WILL
ADOPT CPT GUIDELINES AS THESE GUIDELINES RELATE TO MODIFIER 51.PROVIDERS
WILL NO LONGER BE REQUIRED TO APPEND A 51 MODIFIER TO AN ADD-ON CODE OR 
A MODIFIER 51 EXEMPT CODE. ALL SURGICAL PROCEDURES THAT ARE NOT 
IDENTIFIED AS MODIFIER 51 EXEMPT WILL BE REIMBURSED BASED ON MULTIPLE 
SURGERY POLICY. 

IF A 51 MODIFIER IS APPENDED INCORRECTLY, THE CLAIM LINE WILL DENY.  FEE SCHEDULE ADJUSTMENTS WILL BE MADE TO SOME PROCEDURE CODES TO ACCOMMODATE THESE CHANGES IN REIMBURSEMENT METHODOLOGY.

FIRST ASSISTANT IN SURGERY - POLICY CHANGE

LOUISIANA MEDICAID WILL REIMBURSE FOR ONLY ONE FIRST ASSISTANT IN 
SURGERY. IDEALLY, THE FIRST ASSISTANT TO THE SURGEON SHOULD BE A 
QUALIFIED PHYSICIAN. HOWEVER, IN THOSE SITUATIONS WHEN A PHYSICIAN DOES 
NOT SERVE AS THE FIRST ASSISTANT; QUALIFIED, ENROLLED, ADVANCED PRACTICE
REGISTERED NURSES (EFFECTIVE AUGUST 1, 2005) AND PHYSICIAN ASSISTANTS 
(EFFECTIVE JULY 1, 2005) MAY FUNCTION IN THAT ROLE, AND SUBMIT CLAIMS 
FOR THEIR SERVICES UNDER THEIR MEDICAID PROVIDER NUMBER. THE 
REIMBURSEMENT OF CLAIMS FOR MORE THAN ONE FIRST ASSISTANT IS SUBJECT TO 
RECOUPMENT. QUALIFIED CERTIFIED NURSE PRACTITIONERS, CLINICAL NURSE 
SPECIALISTS, AND PHYSICIAN ASSISTANTS WHO PERFORM AS THE FIRST ASSISTANT
IN SURGERY SHOULD USE THE HCPCS MODIFIER "AS" TO IDENTIFY THESE SERVICES. 

ATTENTION PROVIDERS

PLEASE BE REMINDED THAT ROUTINE CIRCUMCISION CEASED TO BE A MEDICAID 
COVERED SERVICE EFFECTIVE APRIL 21, 2005. ANY MEDICAID PROVIDER 
RECEIVING PAYMENT FOR A ROUTINE CIRCUMCISION WITH A DATE OF SERVICE 
APRIL 21, 2005 FORWARD WILL BE SUBJECT TO RECOUPMENT.

AMBULATORY SURGERY GROUPS

EFFECTIVE FOR DATES OF SERVICE ON OR AFTER MARCH 1, 2005, THE LOUISIANA MEDICAID PROGRAM REQUIRED THE USE OF CPT/HCPC CODES FOR BILLING OUTPATIENT CLAIMS FOR AMBULATORY SURGICAL PROCEDURES. THE MEDICARE APPROVED AMBULATORY SURGICAL LIST OF PROCEDURES WAS UTILIZED. APPROXIMATELY 25,000 OUTPATIENT CLAIMS HAVE DENIED AS A RESULT OF THIS CHANGE. THE MAJORITY OF CLAIMS WHICH DENIED WERE BILLED WITH NO CPT/HCPC CODE. DHH HAS EVALUATED THOSE CODES REPORTED BY PROVIDERS THAT WERE NOT ON THE ORIGINAL LIST. A TOTAL OF 195 ADDITIONAL CODES HAVE BEEN ASSIGNED TO A GROUP, AND FOR THOSE PROVIDERS WHICH BILLED THESE CODES, YOU MUST RESUBMIT NEW CLAIMS FOR REIMBURSEMENT. WE WILL NOT REPROCESS THESE CLAIMS. 

AS WE TRANSITION THOSE CODES WHICH ARE NOT CONSIDERED AMBULATORY 
SURGERY, AND THEREFORE SHOULD NOT BE BILLED UNDER REVENUE CODE 490, MORE
SPECIFIC INSTRUCTION WILL BE PROVIDED AS TO THE APPROPRIATE METHOD OF 
BILLING. CPT/HCPC CODES BETWEEN THE RANGES OF 10021-69990, WILL CONTINUE TO BE EVALUATED AND PROVIDERS WILL BE MADE AWARE OF CHANGES AS THEY OCCUR. IT IS NO LONGER NECESSARY TO SUBMIT FOR REVIEW THOSE CODES WHICH ARE DENYING UNDER REVENUE CODE 490 WHICH FALL WITHIN THIS RANGE.

A COPY OF THE CODES WHICH HAVE BEEN EVALUATED WILL BE PUBLISHED ON THE 
DHH WEBSITE LOCATED AT WWW.DHH.LOUISIANA.GOV UNDER OFFICES, MEDICAID 
(HEALTH SERVICES FINANCING), RATE AND AUDIT REVIEW SECTION.