RA Messages for June 12, 2001

PHARMACY PROVIDERS, PLEASE NOTE!!!

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

PLEASE MAKE THE FOLLOWING CHANGES TO THE 12/9/00 VERSION OF APPENDIX A:

PLEASE FILE ADJUSTMENTS FOR CLAIMS WHICH MAY HAVE BEEN INCORRECTLY PAID

NOTICE TO PROVIDERS OF PROFESSIONAL SERVICES

THIS YEAR'S ISSUANCE OF THE CPT CONTAINS THREE CODES WHICH ARE TO BE  USED BY PROVIDERS TO BILL FOR RESISTANCE TESTING IN HIV-INFECTED PATIENTS. THESE THREE CODES ARE 87901(INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID {DNA OR RNA}, HIV 1, REVERSE TRANSCRIPTASE AND PROTEASE) 87903(INFECTIOUS AGENT PHENOTYPE ANLAYSIS BY NUCLEIC ACID{DNA OR RNA}  WITH DRUG RESISTANCE TISSUE CULTURE ANALYSIS, HIV 1; UP TO 10 DRUGS);  AND 87904(......; EACH ADDITIONAL DRUG, UP TO 5 DRUGS {LIST SEPARATELY  IN ADDITION TO CODE FOR PRIMARY PROCEDURE}). 

RECENTLY, THE AMA ISSUED CODES 0023T (PREDICTIVE PHENOTYPE) TO BE USED  IN CONJUNCTION WITH CODE 87901. THESE FOUR CODES ARE DESIGNED TO  FACILITATE BILLING IN PAIRS. FOR EXAMPLE: FOR JUST THE PHENOTYPE TEST,  BILL CODE 87901 BY ITSELF. THE VIRTUAL PHENOTYPE TEST SHOULD BE BILLED AS 87901 AND 0023T. THE COMPLETE PHENOTYPE TEST IN WHICH 15 DRUGS ARE TESTED MUST BE BILLED WITH BOTH 87903 AND 87904. 

THESE FOUR CODES WILL PEND FOR REVIEW AS THE CRITERIA FOR TESTING MUST  BE MET BEFORE THE CLAIM CAN BE PAID. CONSEQUENTLY, THESE CLAIMS CANNOT BE BILLED ELECTRONICALLY, AS THEY MUST BE ACCOMPANIED BY THE RESULTS OF  LAB TESTS, HISTORY AND OTHER APPLICABLE DOCUMENTATION. 

INTERNATIONAL AIDS SOCIETY AND KAISER FOUNDATION CRITERIA FOR RESISTANCE TESTING WILL BE USED IN DETERMINING IF A CLAIM CAN BE PAID. IF THESE CRITERIA ARE MET, THE LOUISIANA MEDICAID PROGRAM WILL PAY FOR ONE BILLING OF CODE 87901 BY ITSELF, ONE BILLING OF CODES 87901 AND 0023T  AND ONE BILLING OF CODES 87903 AND 87904 PER CALENDAR YEAR PER RECIPIENT.

AS STATED EARLIER, CODES 87901 AND 0023T BILLED TOGETHER REPRESENT THE  VIRTUAL PHENOTYPE AND CODES 87903 AND 87904 BILLED TOGETHER EQUAL THE  COMPLETE PHENOTYPE. THE GENOTYPE TEST IS CODE 87901 BY ITSELF. 

LISTED BELOW IS THE NUMBER OF TIMES EACH CODE WILL BE REIMBURSED IN A CALENDAR YEAR PER PATIENT (PROVIDED HE/SHE MEETS THE CRITERIA) AND ITS  FEE. THIS POLICY IS EFFECTIVE WITH DATE OF SERVICE 1-1-01: 

87901-TWICE-$284.63      0023T-ONCE-$165.37      87903-ONCE-$540.24 
87904-ONCE-$144.10 

ELECTRONIC CLAIMS AND HARD COPY CLAIMS BILLED WITHOUT THE APPROPRIATE ATTACHMENTS WILL BE DENIED WITH ERROR EDIT 481-SEND DOCUMENTATION TO JUSTIFY SPECIFIC LAB TEST. 

IF QUESTIONS ARISE, PLEASE CALL KANDIS WHITTINGTON AT 225-342-9490 OR TRACEY ZIMMERMAN AT 225-342-9319.    

NOTICE TO PROVIDERS OF PROFESSIONAL SERVICES

EFFECTIVE WITH DATE OF SERVICE FEBRUARY 1, 2001, CPT CODE 88358 (MORPHOMETRIC ANALYSIS:TUMOR) WAS MADE PAYABLE AT A RATE OF $139.19 FOR  THE FULL SERVICE AND $199.83 FOR THE PRFESSIONAL SERVICE. 

NOTICE TO PROVIDERS OF PROFESSIONAL SERVICES

PAGE 93 OF THE 1998 PROVIDER TRAINING PACKET STATES THAT PROVIDERS WILL NOT BE REIMBURSED FOR THE REMOVAL OF KELOIDS IF REMOVAL IS/WAS FOR COSMETIC REASONS. THE INITAL DIAGNOSTIC VISIT IS EXCLUDED FROM THIS  POLICY; HOWEVER. REIMBURSEMENT FOR THE INITIAL DIAGNOSTIC VISIT WILL BE MADE. 

NOTICE TO CERTIFIED NURSE PRACTITIONERS

 EFFECTIVE WITH DATE OF SERVICE APRIL 1, 2001, LOCALLY ASSIGNED CODE  X9921 (LUNELL MONTHLY CONTRACEPTIVE INJECTION) HAS BEEN ADDED TO THE  LIST OF CODES PAYABLE TO CERTIFIED NURSE PRACTITIONERS. IF YOU HAVE BILLED FOR LUNELL SINCE APRIL 1, 2001 AND HAD BEEN DENIED, PLEASE RESUBMIT YOUR CLAIM.