DOH Medicaid Update September 2002 Vol. 17, No. 9

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Governor George Pataki has signed into law legislation extending the statutory authority of the Portable X-ray Demonstration Program. The demonstration will be in effect for services provided through June 30, 2003 and permits Medicaid payment to companies enrolled in the demonstration.

These companies provide portable x-ray services to residents of nursing homes and intermediate care facilities for the developmentally disabled when Medicare does not cover these services.

Medicare-certified portable x-ray companies that are not already participating in the demonstration program may contact the Department of Health at (518) 474-8161 for information about the enrollment process.

If you have questions about the extension of the Portable X-ray Demonstration Program, please contact Mary Horsman in the Medicaid Bureau of Policy Development and Agency Relations at (518) 473-4055.

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This article clarifies Medicaid policy as it relates to personal assistance provided to Medicaid recipients by ambulette staff. The Medicaid program does not limit the number of stairs or floors in a building that a provider must climb in order to provide personal assistance to a Medicaid recipient.

The ambulette service is required by Medicaid rules to provide personal assistance and door- to-door service. This means the staff must transport the recipient from his or her front door (including apartment door, room in nursing home, etc.), no matter where it is located, to the door of the medical practitioner from whom the recipient is receiving medical services.

Personal assistance is defined in Title 18, Section 505.10 of the New York State Codes Rules and Regulations as follows:

Questions about this article may be directed to Provider Resources Unit at (518) 474-9219.

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In the United States, about 22 million adult women and at least 1.5 million adolescent girls currently smoke cigarettes. Among women, use of tobacco has been shown to increase the risk of cancer, heart and respiratory diseases, and reproductive disorders. More than 140,000 women die each year from smoking-related diseases-the most preventable cause of premature death in this country.

An open letter from Commissioner Novello to the 9.8 million Women and Girls of New York was recently published and is printed below. Please discuss the use of tobacco with your patients and feel free to make copies of this letter.

In addition, the Smoker's Quitline 1-866-NYQUITS (1-866-697-8487) is available free of charge to all New Yorkers, including Medicaid recipients. For more information on Medicaid's smoking cessation coverage and policy, contact the Pharmacy Policy and Operations staff at 518-486-3209.

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Foot ulcers and amputations are a major cause of morbidity and disability, as well as emotional and physical costs for people with diabetes. Diabetes is the leading cause of lower extremity amputations in the United States. Each year approximately 100,000 amputations are performed on people with diabetes. After an amputation, the chance of another amputation within three-five years is as high as 50 percent. The five-year mortality rate after amputation ranges from 39 to 68 percent.

The U.S. Department of Health and Human Service, Health Research and Services Administrations (HRSA) has developed LEAP, Lower Extremity Amputation Prevention program. The LEAP program is designed to educate primary care providers and their patients about the importance of frequent and through foot inspections. A number of materials are available free of charge for both providers and patients.

The LEAP materials include:

• Performing Foot Exams to Prevent Lower Extremity Amputations in Patients with Diabetes, a video for primary care providers which demonstrates how to use the LEAP Filament in screening patients at risk for diabetes, or who have diabetes, for loss of protective sensation of the foot. The video also describes steps to help prevent and detect loss of protective sensation in the foot, and emphasizes the importance of ongoing self-assessment by the patient.

• LEAP Foot Test Instruction, a booklet for patients available in English, Spanish, and in large print, instructs patients on how to do a Diabetes Foot Screen, and how to record their findings to report to their provider.

• LEAP Filaments are available in a singular pack or in packs of 50.

To order LEAP Materials:

Publications Code	Title
PC495	Foot Assessment of the Adult Diabetic Patient (video)
PC548	LEAP Filament
PC561	LEAP Filaments (50 pack)
PC544	LEAP Foot Test Instructions
PC560	LEAP Foot Test Instructions (large print)
PC00053	LEAP Foot Test Instructions (Spanish)

Write:	Or Call:
HRSA Information Center 8280 Greensboro Drive, Suite 300 McLean, VA 22102	Phone: 1-888-Ask HRSA TTY: 1-877-4TY-HRSA Fax: 703-821-2098 E-mail:ask@hrsa.gov Web: www.hrsa.gov/orderpublications/index.html Se Habla Espanol

The Medicaid Program reimburses for medically necessary care, services and supplies for the diagnosis and treatment of diabetes. For information regarding Medicaid coverage of services related to diabetes, contact the Bureau of Program Guidance at (518) 474-9219, or go to http://www.health.ny.gov/health_care/medicaid/program/2000/oct2000.htm.

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In June 2000 the New York State Department of Health awarded seven coalitions funding to fight childhood asthma across the State. These asthma coalitions are made up of leaders of community organizations and volunteers who are combining their efforts to improve the quality of life of children and families with asthma. Each coalition provides asthma education, to improve care coordination and to develop data systems necessary to track disease and measure program effectiveness. The major objectives of the asthma coalitions are to decrease asthma-related emergency visits and school days lost from asthma-related illness.

Specific coalition activities to accomplish the objectives are:

Name	Contact Information	Counties Served
Erie County Dept. of Health Western NY Public Health Coalition	Phone: (716) 691-5864 Fax: (716) 691-5012 E-mail: Iness@lawny.org	Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming
Finger Lakes Asthma Coalition	Phone: (716) 442-8189 Fax: (716) 442-9882 E-mail: alajl@rochester.rr.com http://www.rcanasthma.net	Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne, Yates
Central New York Asthma Coalition	Phone: (315) 422-6142 Fax: (315) 422-9710 E-mail: masmith@aloofcny.org	Cortland, Herkimer, Jefferson, Lewis, Madison, Oswego, Oneida, Onondaga, St. Lawrence, Tompkins
Greater Capital District Asthma Coalition	Phone: (518) 459-4197 Fax: (518) 489-5864 E-mail: jcolon@alaneny.org	Albany, Columbia, Fulton, Hamilton, Greene, Montgomery, Schnectady, Schoharie, Rensselaer
Hudson Valley Asthma Coalition	Phone: (914) 949-2150 Fax: (914) 949-4765 E-mail: jgallagher@alahv.org	Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester
Nassau Suffolk Asthma Coalition	Phone: (631) 231-5864 Fax: (631) 231-5118 E-mail: alittle@alans.org	Nassau, Suffolk
St. John Riverside Hospital - Yonkers	Phone: (914) 964-4673 Fax: (914) 964-4718 E-mail: jbyrne@riversidehealth.org	Yonkers
New York City Childhood Asthma Initiative	Asthma Action Line 1-877-ASTHMA-0 1-877-278-4620 http://www.nyc.gov/html/asthma.html	New York City

The NYS Medicaid Program reimburses for medically necessary care, services, and supplies for the diagnosis and treatment of asthma. For more information, please contact the Bureau of Program Guidance at (518) 474-9219. For more information on asthma, please go the NYS Department of Health website, http://www.health.state.ny.us/diseases/asthma/.

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The start date of the new Medicaid Mandatory Generic requirements will be November 17, 2002. In order to avoid having providers make two sets of system changes, this program will be implemented at the same time as the new eMedNY Point of Sale (POS) system.

As of November 17, 2002, all new prescriptions for brand-name drugs, where an A-rated generic equivalent is available, will be subject to prior authorization. Refills on prescriptions, which were already written and dispensed prior to November 17th, will not require prior authorization. When the current prescription expires, however, a prior authorization will be required for that patient to continue to receive the brand name drug.

The Commissioner of Health has exempted specific brand-name drugs from prior authorization. The following brand-name drugs, which have a generic available, may be prescribed without prior authorization:

These exemptions are not meant to discourage generic prescribing. These drugs have been exempted from new prior authorization requirements based on specific characteristics of the drug and/or disease state generally treated. Their exemption should not be considered an opinion on the bioequivalency of the generic versions.

For more information on the Mandatory Generic Program visit the following website:

Additional information on this program, with instructions on how to use the prior authorization system, will be provided in a special issue of the Medicaid Update to be released in Mid-September. If you would like more information, please e-mail your questions to ppno@health.state.ny.us, or contact the Pharmacy Policy and Operations staff at (518) 486-3209.

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According to the National Institute for Health Care Management, from 2000 to 2005, drugs with combined annual sales of approximately $20 billion are scheduled to come off patent. The use of generic drugs has a potential to play an important part in containing drug costs.

Diuretics and beta-blockers have proven to be very effective in the treatment of hypertension. It is important to assure that patients with hypertension are provided the most clinically appropriate and cost effective therapy. The cost of several common diuretics and beta-blockers to the Medicaid program is outlined below.

	Estimated Medicaid Cost/Month (as of 6/12/02)
Drug	Brand	Generic	Savings
Bumex, 1mg qd (bumetanide)	$13.98	$5.63	59.7%
Lasix, 40mg qd (furosemide)	$7.98	$1.79	77.6%
Lopressor, 50mg bid (metoprolol)	$43.44	$4.22	90.3%
Lozol, 2.5mg qd (indapamide)	$33.12	$3.38	89.3%
Maxzide, 75/50mg qd (triamterene/hctz)	$30.80	$1.46	95.3%
Moduretic, 5/50mg qd (amiloride/hctz)	$17.96	$1.98	88.8%
Tenormin, 50mg qd (atenolol)	$31.95	$1.39	95.6%
Trandate, 200mg bid (labetalol)	$45.63	$26.62	41.7%

Please refer to product literature for a complete list of indications, dosing regimens and administration requirements.

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However, adherence rates have been low for many years, especially in the elderly. There are many new drugs with fewer side effects and greater efficacy, but these medications are ineffective when patients do not take them, or take them inappropriately. Not surprisingly, hospitalizations are reduced when patients adhere to appropriate medication regimens.

Why do most patients not take their medication?

• Dislike side effects
• Feel better (although the underlying condition remains)
• Do not understand or misinterpret directions
• Interferes with daily activities
• Instructions are too complex
• Lack understanding of importance of medication and/or goals of therapy
• Believe medication will not work or unnecessary
• Forgetting to take their medication, or the dose at the proper time

What steps can clinicians follow to improve patient's medication compliance?

• Talk to your patients, discuss diagnosis and treatment plan
• Discuss importance of compliance, even though the patient may not feel "sick"
• Simplify medication regimen by reducing the number of medications and frequency of doses
• Address side effects through dosage adjustments or change in therapy when necessary
• Involve family members, when appropriate
• Arrange follow-up appointments and ask patient if they are taking their medications and how they are taking them
• Recommend pill containers and prepare medications

Patients who feel actively involved in their treatment plan are more likely to comply with their treatments. Clinicians can facilitate adherence by discussing the importance of compliance when prescribing and by following up with questions about compliance on subsequent visits with their patients.

Pharmacists, prescribers, and patients working together can greatly enhance healthcare outcomes while reducing costs.

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Practitioner Designation of Authority to Sign Orders for Laboratory Tests

Medicaid regulations previously required practitioners to personally sign the laboratory test order form.

Revised regulations allow practitioners to designate to personnel/staff the authority to sign laboratory test order form(s) on their behalf.

• Practitioners and designated staff may use electronic or computer-generated means of authentication.
• The practitioner must still select the appropriate laboratory tests based on his/her assessment of medical necessity.
• Practitioners choosing this option remain financially responsible for laboratory tests ordered on their behalf.

Practitioner Electronic Laboratory Test Ordering and Signature

Medicaid did not previously accept electronic laboratory test ordering.

Revised regulations permit qualified ordering practitioners to use electronic signatures for laboratory test ordering.

Practitioners and laboratories that use electronic means to order laboratory tests must employ safeguards to ensure the security and confidentiality of all information. These measures shall include but not be limited to:

• The assignment, as appropriate, of a unique identifier assigned in a confidential manner.
• Certification in writing by the practitioner and the practitioner's authorized user that each identifier assigned is confidential and is available and accessible only to the person authorized to use the electronic or computer authentication system.
• Implementation of policies and procedures to ensure the security of electronic or computer equipment from unwarranted access.
• Implementation of policies and procedures that restrict access to information and data to those individuals who have need and permission for such access.
• Develop a means to track access by users.

Again, the ordering practitioner remains responsible for ordered tests.

Standing Orders

Medicaid did not previously recognize "standing orders."

Under the revised regulations, qualified practitioners may authorize certain laboratory tests to be performed at defined intervals over a period of six months with one "standing order" in certain clinical situations as follows:

• CBC and platelet count for cancer treatment recipients;
• Blood glucose testing for diabetics;
• Prothrombin and digoxin levels for cardiac recipients; and
• Monitoring therapeutic levels of prescribed drugs.

For all other tests and clinical situations a separate order is required for each date that testing is requested.

The full text of the regulation is available at the Department's website www.nyhealth.gov/regulations/nycrr/title_18/ (search title 18, and type in 505.7 where required) or by request to the Bureau of Policy Development and Agency Relations at (518) 473-2160. Bureau staff is also available to respond to specific questions about the rule at that number.

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Department of Health routine audits have found that laboratories are billing molecular diagnostic procedure codes inappropriately.

Molecular diagnostic procedure codes 83890-83912:

Reimbursement for laboratory testing is limited to those procedures listed in the procedure code section of the Medicaid Management Information System (MMIS) Provider Manual for Laboratories.

It is unacceptable to bill Medicaid for procedures or categories of procedures that are not included on your laboratory permit. (See the MMIS Provider Manual for Laboratories, page 2-46).

Laboratory providers should refer to the procedure code section of the MMIS Manual for Laboratories, rule number 14, for instructions on the proper use of procedure codes 83890-83912.

Questions on this article can be directed to the Bureau of Policy Development and Agency Relations at (518) 473-2160.

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Effective October 1, 2002, HIV genotypic and phenotypic resistance tests will no longer be included in the benefit package provided by managed care plans.

• HIV resistance tests performed on or after October 1, 2002 should be billed to MMIS, rather than the managed care plan.
• Medicaid managed care enrollees will obtain these services through the Medicaid fee-for-service program when ordered by an HIV specialist. As required for other Medicaid covered services excluded from the Medicaid managed care benefit package, enrollees will use their Medicaid card to obtain services from qualified Medicaid providers.

Laboratories, designated AIDS centers, residential health care facilities, and ordering practitioners are reminded of the following payment policies applicable to all laboratory testing, including HIV resistance testing:

• Laboratories should use MMIS procedure code 87901 when billing for the HIV genotypic assay. The maximum reimbursable amount for code 87901 is $350. Laboratories should use MMIS procedure code 87903 when billing for HIV phenotypic assay. The maximum reimbursement amount for code 87903 is $675.29.
• HIV resistance testing is a covered service when clinically indicated, up to a maximum of 3 tests(any combination of genotypic and phenotypic) per recipient per patient treatment year.
• Laboratories may not bill on a fee-for-service basis for a test performed while a patient is in hospital inpatient status. Medicaid payment to the hospital includes all necessary laboratory services.
• All ordered HIV resistance tests are reimbursable fee-for-service directly to the testing laboratory. This includes tests ordered for:
  • Outpatients and inpatients of Article 28 residential health care facilities;
  • Patients of Designated AIDS Centers operating under the Tier AIDS payment structure; and,
  • Patients of Article 28 certified outpatient clinics.
• Medicaid regulation requires that:
  • Payment be made to the provider actually performing the test; and,
  • Medicaid-enrolled clinical laboratories with Department of Health approval to perform HIV genotypic and phenotypic resistance assays are entitled to reimbursement.

If you have questions about the Medicaid managed care benefit package, please contact Elizabeth Macfarlane at (518) 473-0122.

If you have questions on coverage for HIV resistance tests, please contact the Bureau of Policy Development and Agency Relations at (518) 473-5873.

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Effective for dates of service on or after October 1, 2002, note the following fee changes in your MMIS Durable Medical Equipment Provider Manual(Rev. 4/02):

THREE-PRONG/QUAD CANES and FOREARM CRUTCHES

Prior approval requests from DME and Pharmacy providers will be considered using code A4649 Surgical supply miscellaneous for these items under the following conditions:

• Three-prong/quad cane: 31" or lower height and/or rotation option. (An EMEVS DVS authorization must be obtained for all other three-prong/quad canes using code E0105.)
• Forearm crutches: 23" or lower height and/or rotation option. (All other forearm crutches should be direct billed using either code E0110 or E0111.)

Documentation of medical necessity for the specific height ranges and/or rotation option must be submitted with the prior approval request.

Questions may be referred to the Bureau of Medical Review and Payment at (518) 474-8161.

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Coming to you later this month

A supplemental Issue of the Medicaid Update

Devoted to the new Medicaid Law on Mandatory Generics

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To avoid delayed claim submissions, you should not mail your tape or diskette claim submission in the same package with other correspondence, especially if the package is addressed differently from the address given above. For example, if you are on tape remittance and are returning your processed remittance tapes to CSC, do not mail your claim submissions in the same package with your returned tape remittances. Returned tape remittances must be sent to the attention of the Tape Library at the above address. Or, if you also submit paper claims, do not mail your tape or diskette claim submission in the same package as your paper claims, which are addressed to a PO box.

You must always include a signed NYS DSS Transmittal form with each tape or diskette submission. As always, the Transmittal form must have an original signature. Signature stamps or photocopied signatures are not acceptable. If you are resubmitting a previously rejected tape or diskette you must send a new, signed Transmittal form with the resubmission. A missing Transmittal form, or non-original signature, will cause a delay in the processing of your media or, possibly, the return of the media.

As a reminder, CSC accepts the electronic transmission of all claim types, as well as Medicaid Encounter Data (MEDS), through the NYS MMIS Electronic Gateway (NYS-MMIS-EG). Electronic claim transmission offers several benefits including:

• The elimination of manual handling of claim media and related documents.
• The accelerated return of submission information - information regarding the general acceptance of claims is generally available for retrieval (downloading) within two hours of file transmission.
• Invoice level rejection - individual claims within an electronic transmission may reject without causing the entire transmission to reject.

Switching to electronic claim submission is easy! If you currently submit on tape or diskette media you already have a Transmission Supplier Number (TSN), which is required for electronic transmission. As a tape or diskette submitter you may already have a Certification Statement on file with CSC, which is also required for electronic transmission. With the required paperwork in place, you may request a User ID and initial password, which, once assigned, can be issued to you over the phone.

For more information on the requirements and benefits of electronic transmission, please call the Electronic Media Claims (EMC) Control unit at (518) 447-9256. At the same time, you may want to request an Electronic Claim Submission System (ECSS) User Manual. This manual contains all of the necessary information for electronic claiming, including the required hardware and software configurations for your PC.

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Effective November 1, 2002, the Onondaga County Long Term Care Resource Center will no longer review or process prior approval requests for Private Duty Nursing services. All administrative functions related to prior approval requests for Onondaga County Medicaid private duty nursing recipients will be transferred to the State Medicaid Bureau of Medical Review and Payment in Albany.

Starting on November 1, 2002, please submit prior approval requests and required documentation to the following address:

Questions should be directed to the Onondaga County Long Term Care Resource Center at (315) 435-5600 or to the State Medicaid Bureau of Medical Review and Payment at (518) 474-8161.

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The following discharge status codes can now be used on your inpatient Medicaid claims

Code Definition

61 Discharged/transferred within this institution to hospital-based Medicare approved swing bed Approved for use as of 4/1/01

62 Discharged/Transferred to another rehab facility including rehab distinct parts/units of a hospital Approved for use as of 1/1/02

63 Discharged/Transferred to a long-term care hospital Approved for use as of 5/9/02

71 Discharged/Transferred/referred to another institution for outpatient services as specified by the discharge plan of care
Approved for use as of 4/1/01

72 Discharged/Transferred/referred to this institution for outpatient services as specified by the discharge plan of careApproved for use as of 4/1/01

If you have any questions regarding use of these codes, please contact Computer Sciences Corporation at (800) 522-1892 or (518) 447-9810.

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The State Department of Health welcomes your comments or suggestions regarding the Medicaid Update.

Please send suggestions to the editor, Timothy Perry-Coon:

NYS Department of Health
Office of Medicaid Management
Bureau of Program Guidance
99 Washington Ave., Suite 720
Albany, NY 12210
(e-mail MedicaidUpdate@health.state.ny.us )

The Medicaid Update, along with past issues of the Medicaid Update, can be accessed online at the New York State Department of Health web site: http://www.health.ny.gov/health_care/medicaid/program/main.htm