TENNESSEE July The following entries apply to all Tennessee Amerigroup Community Care Providers.

Transcription

1 TENNESSEE July 2015 The following entries apply to all Tennessee Amerigroup Community Care Providers. Medical policies update On [February 5, 2015], the Medical Policy and Technology Assessment Committee (MPTAC) approved and adopted the following medical policies applicable to Amerigroup Community Care health plans. These medical policies were developed or revised to support clinical coding edits. These medical policies were made publicly available on the Amerigroup Medical Policy and Clinical UM Guideline website. Visit to find specific policies. Existing precertification requirements have not changed. Medical policy Medical policy Medical policy Medical policy effective date number new/revised April 7, 2015 DRUG Alpha-1 proteinase inhibitor therapy NEW April 7, 2015 DRUG Rilonacept (Arcalyst ) NEW April 7, 2015 DRUG Alemtuzumab (Lemtrada ) NEW April 7, 2015 GENE Genetic testing of an individual s genome for inherited diseases NEW April 7, 2015 MED Outpatient cardiac hemodynamic monitoring using a wireless sensor for heart failure management April 7, 2015 MED Near-infrared spectroscopy brain screening for hematoma detection NEW February 9, 2015 DRUG Enteral carbidopa and levodopa intestinal gel suspension February 9, 2015 GENE Genetic testing for hereditary pancreatitis February 9, 2015 SURG Intraocular telescope April 7, 2015 ADMIN Medical policy formation April 7, 2015 GENE Genotype testing for genetic polymorphisms to determine drugmetabolizer status NEW April 7, 2015 GENE Cell-free fetal DNA-based prenatal screening for fetal aneuploidy April 7, 2015 DRUG Omalizumab (Xolair ) April 7, 2015 DRUG Belimumab (Benlysta ) April 7, 2015 MED Diaphragmatic/phrenic nerve stimulation and diaphragm pacing systems April 7, 2015 MED Autologous cell therapy for the treatment of damaged myocardium April 7, 2015 SURG Treatments for urinary incontinence April 7, 2015 SURG Percutaneous vertebroplasty, kyphoplasty and sacroplasty April 7, 2015 SURG Sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS) for urinary and fecal incontinence; urinary retention April 7, 2015 SURG Interspinous process fixation devices Pending GENE Analysis of fecal DNA for colorectal cancer screening and surveillance Pending Pending SURG Allogeneic, xenographic, synthetic and composite products for wound healing and soft tissue grafting TNPEC B Pending

2 Clinical Utilization Management Guidelines update On [February 5, 2015], MPTAC approved the following Clinical Utilization Management (UM) Guidelines. These clinical guidelines were developed or revised to support clinical coding edits. This list represents the guidelines approved and adopted by the Medical Operations Committee on [February 23, 2015]. Clinical UM Guidelines are publicly available on the Amerigroup Medical Policies and Clinical UM Guidelines website. Visit to search for specific policies. Existing precertification requirements have not changed. Effective date Clinical UM guideline number Clinical UM guideline title Guideline new/revised April 7, 2015 CG-DRUG-43 Natalizumab (Tysabri ) NEW April 7, 2015 CG-DRUG-44 Pegloticase (Krystexxa ) NEW April 7, 2015 CG-SURG-46 Myringotomy and Tympanostomy tube insertion NEW February 9, 2015 CG-ANC-04 Ambulance services: air and water February 9, 2015 CG-DME-21 External infusion pumps for the administration of drugs in the home or residential care settings February 9, 2015 CG-OR-PR-04 Cranial remodeling bands and helmets (cranial orthotics) April 7, 2015 CG-BEH-07 Psychological testing April 7, 2015 CG-DME-19 Therapeutic shoes, inserts or modifications for individuals with diabetes April 7, 2015 CG-DME-24 Wheeled mobility devices: manual wheelchairs standard, heavy duty, lightweight April 7, 2015 CG-DME-31 Wheeled mobility devices: wheelchairs powered, motorized, with or without power seating systems and Power Operated Vehicles (POVs) April 7, 2015 CG-DME-33 Wheeled mobility devices: manual wheelchairs ultra lightweight April 7, 2015 CG-DRUG-07 Hepatitis C pegylated interferon antiviral therapy April 7, 2015 CG-DRUG-14 Dihydroergotamine mesylate (DHE) injection for the treatment of migraine or cluster headaches in adults April 7, 2015 CG-DRUG-21 Naltrexone (Vivitrol ) injections for the treatment of alcohol and opioid dependence April 7, 2015 CG-LAB-09 Drug testing or screening in the context of substance abuse and chronic pain April 7, 2015 CG-MED-22 Neuropsychological testing April 7, 2015 CG-MED-32 Ancillary services for pregnancy complications April 7, 2015 CG-MED-46 Ambulatory and inpatient video Electroencephalography April 7, 2015 CG-SURG-33 Lumbar fusion and lumbar artificial intervertebral disc (LAID) April 7, 2015 CG-SURG-39 Pain management: epidural steroid injections April 7, 2015 CG-SURG-41 Surgical strabismus correction April 7, 2015 CG-SURG-44 Coronary angiography and cardiac catheterization in the outpatient setting

3 The following medical policies and Clinical UM guidelines have been archived on the date listed below. Effective date Clinical UM guideline number Clinical UM guideline title Guideline April 7, 2015 GENE Diagnostic genetic testing of a potentially affected individual (adult or child) Archived April 7, 2015 GENE Predictive genetic testing for non-malignant diseases Archived April 7, 2015 CG-DRUG-32 HCV and HIV-AIDS anti-viral drug treatment regimens Archived TNPEC Reimbursement Policy Update These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement if the service is covered by a member s Amerigroup Community Care benefit plan. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis as well as to the member s state of residence. Proper billing and submission guidelines are required along with the use of industry-standard, compliant codes on all claim submissions. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, we strive to minimize these variations. For more information on these and other Amerigroup Reimbursement Policies, visit our website at and click on Quick Tools. Policy Update Allergy Treatment: Immunotherapy (Policy , effective 08/01/2015) Reimbursement is allowed for allergy immunotherapy. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate for the injection, antigen dosage/preparation when meeting the below criteria. The injection service component code and the antigen dosage/preparation component code (per dose) should be billed separately. Additionally: Claims submitted with a procedure code representing the complete service (collectively including the injection service, antigen dose and the antigen preparation) will be denied If the antigen is prepared other than in the physician s office, the physician may bill only for the injection services Physicians using treatment boards must bill with the component codes even though they prepare no vials If multiple antigen doses are prepared in the same setting, either: o The injection service and the antigen dosage/preparation service indicating the number of dosages for the injection administered during the first visit must be billed o The injection service only for remaining injections administered during subsequent visits must be billed [Note: Amerigroup allows reimbursement of up to 20 doses billed for preparation of single or multiple antigen doses for a 30-day period. Claims billed for more than 60 doses during a 90-day period will be denied.] Providers may not bill for Evaluation and Management (E&M) visits for established patients on the same day as allergy injection services unless the E&M visit represents a significant, separately identifiable service and is appended with Modifier 25. Claims submitted for an E&M visit in conjunction with allergy injection services

4 without the Modifier 25 will be denied. Claims submitted for E&M visits for new patients on the same day as allergy injection services may be reviewed for medical necessity. For additional information, refer to the reimbursement policies at providers.amerigroup.com and click on Quick Tools. TNPEC OrthoNet to conduct professional service coding reviews for musculoskeletal providers Summary of Update: Effective August 1, 2015, Amerigroup Community Care will collaborate with OrthoNet, LLC to conduct a focused claim review program for musculoskeletal providers. What does this mean for you? Effective August 1, 2015, OrthoNet will conduct post-service, prepayment coding review of professional services for all musculoskeletal provider specialties included in the Focused Claim Review Program, including but not limited to the specialties below: Cardiology Dermatology Ear, nose and throat General surgery Hand surgery Pain management Pediatric orthopedics Pediatric neurosurgery Pediatric neurology Pediatric sports medicine Physiatry/physical medicine and rehabilitation Plastic surgery Podiatry Neurosurgery Neurology Orthopedic surgery Sports medicine Urology These services may be selected for post-service, prepayment coding review of professional services. Living Wills Change to Advanced Directives Background: Tennessee law will no longer use the term living will. Effective July 1, 2015, living wills are referred to as advance directives. TNPEC What does this mean to you? Members have the right to make their own health care decisions. Advance directives can help people communicate their treatment choices when they would otherwise be unable to make such decisions. Living will is the term formerly used in Tennessee law. In 2004, Tennessee law changed the form name of living will to advance care plan. An advance care plan is a document that tells physicians how patients want to be treated if they become terminally ill or permanently unconscious. Medical power of attorney is a term used in the state s law prior to In the new law, this is referred to as an appointment of health care agent. An appointment of health care agent is another type of advance directive that allows a patient to name a person to make health care decisions for them if they are unable to make them for themselves. Additional forms can be found on and the Provider Portal, availity.com.

5 What resources are available to me? You may contact Provider Services at or send a fax to for precertification and services. Please refer to your Amerigroup Community Care quick reference card for additional information and be sure to visit us online at providers.amerigroup.com/tn for the latest reference materials. TNPEC The key to great health care communication Background or summary: Every year, Amerigroup Community Care sends a survey to members to review the care they ve received within the last six months the CAHPS* survey. The results of the survey help Amerigroup to better serve our members and providers. We use the information to develop new processes and education or improve skills and services already in place. Amerigroup wants to partner with providers to ensure our members your patients are receiving the best care possible. Proper communication is essential to the care we give. *CAHPS is a registered trademark of the Agency for Healthcare Research and Quality. What this means to you: Effective communication about diseases, medications and treatment plans is the number-one key to improving patient care. (Based on the 2014 member survey results.) Why is this change necessary? Survey results from the 2014 member survey show our membership ranked communication in the 10th percentile. If your patients don t understand important information about subjects such as their medical conditions or how to take their medications, it can cause breakdowns in medical care and compliance. We, at Amerigroup, know your time is valuable, so let s make it count. Keys to enhance communication with patients: Listen attentively when your patient is speaking Spend time with your patient Explain care and treatment in a way your patient can understand Show respect for questions your patient asks Share decision making with your patient Make sure all questions are answered before the visit is over Discuss medications and answer all questions about them TNPEC Flu prevention and treatment saves lives Flu season is upon us, and patients with certain chronic conditions, including asthma, diabetes and chronic heart disease, are at increased risk for illnesses and hospitalizations caused by seasonal flu. The Centers for Disease Control and Prevention (CDC) estimates more than 200,000 people are hospitalized from flu complications annually, and between 3,000 and 49,000 die each year from flu-related causes.

6 An ounce of prevention While the CDC recommends everyone 6 months of age and older receive the vaccine, flu shots are especially important for your high-risk patients. Encourage them to be vaccinated as soon as possible a flu shot is still the best prevention method. Those at highest risk include: Children younger than 5, but especially younger than 2 years old Children between the ages of 6 months and 8 years of age who are receiving a flu vaccine for the first time will need to have two doses with at least four weeks between doses Adults 65 and older Residents of nursing homes and other long-term care facilities Pregnant women (and women up to two weeks postpartum) Patients with certain chronic diseases Native Americans and Alaska Natives Encourage your patients to get a flu vaccine. Please educate your patients about the risks of the flu and provide flu vaccines as appropriate. Remember, adult members with Amerigroup* pharmacy benefits can get a free flu shot. They just need to show their member ID card at a participating pharmacy during flu shot clinic hours. Coverage for children s vaccines varies, so contact your local Provider Relations representative to learn more. Antiviral drugs If patients do get sick, antiviral drugs not only lessen flu duration and symptoms but decrease the risk for flurelated complications. Antiviral drugs, as well as many cough and cold products, are on our formulary posted at providers.amerigroup.com. Restrictions apply. Stay informed Find the latest flu updates, health care recommendations and printable patient education materials at Remember to protect yourself and your patients by getting your vaccine, too. Source: Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, August 15, 2014, Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices United States, Influenza Season. (Page last updated: January 8, Accessed April 29, 2015) PEC-ALL Now available: Send claims medical attachments through Availity Summary: Amerigroup Community Care partners with Availity to offer providers the ability to check patients eligibility and claims status, as well as submit claims and access multiple payer information with a single, secure Availity Web Portal login. The Medical Attachments feature is now available to providers. You can now use your billing National Provider Identifier (NPI) number to register and submit attachments, with or without a claim, through the Availity Web Portal. This service enables you to submit attachments (e.g., medical records, itemized bills, etc.) prior to claims submissions, with claims submission or as requested by Amerigroup.

7 What does this mean to you? To access this new feature, primary access administrators (PAAs) should register today by logging in at Click on the Amerigroup medical attachments registration link under your PAA dashboard, and you can then assign access to appropriate office staff. Additional information As an Amerigroup provider, you can now send up to 10 unsolicited attachments through the web portal. You may submit up to 10 attachments for each claim, with a maximum file size of 10MB per attachment. This service includes attachments for secondary claims, or even attachments that are not related to a claim at all. Availity rejects any individual files larger than 10MB and requests that you split larger files into smaller files. Files can be submitted as TIFFs (.tif), JPEGs (.jpg), and PDFs (.pdf). This new feature allows your team to submit supporting medical documentation for claims without prompting by Amerigroup. Unsolicited attachments streamline the claims process and can improve your revenue cycle by capturing required documentation needed to adjudicate a claim up front. Plus, the Web Portal captures, transmits, stores, and retrieves your medical attachments, providing an electronic history that s easily accessible, now or in the future. To access additional training about this new Availity feature: 1. Log in to the Availity Web Portal at To do this: a. Go to b. Click the Web Portal Users Login link in the upper right corner. c. On the Availity portal login page, enter your Availity user ID and password. d. Click Log in. 2. At the top of any Availity portal page, click Help Get Trained. (Make sure you do not have a pop-up blocker turned on or the next page may not open.) 3. In the new window a list of available topics will open. Locate and click Medical Attachments. 4. Under the Recordings section, click View Recording (next to Amerigroup Medical Attachments). TNPEC Hypertensive diseases: Navigating the ups and downs of documentation and coding Blood pressure is the force of blood against the walls of the arteries. Abnormally high pressure or hypertension damages blood vessels causing them to become scarred, hardened and brittle. The damaged vessels are no longer able to adequately supply blood to the organs and tissues of the body. Hypertension can lead to strokes, organ failure, or heart attacks when not properly controlled. Treating hypertension Hypertension is a chronic condition that requires lifelong treatment for most people. Treatment is aimed at controlling blood pressure and treating underlying or secondary conditions. The American Heart Association recommends blood pressure levels below 120/80 and screenings starting at 20 years of age. Hypertension is typically treated with medications, exercise and diet, managing stress, and not smoking.

8 Documentation and coding The medical record documentation for patients with hypertension should include each of the following: Type of hypertension benign (mildly elevated arterial pressure) or malignant (severe elevation that results in complications) Complications body system such as heart or kidney that are affected by hypertension Specific conditions details on the conditions that result from hypertension (i.e., heart failure, nephritis, cardiomegaly) Assessment/treatment all measures aimed at controlling the hypertension or treating symptoms of complication(s) Diagnosis code assignment is based on provider documentation and the medical record must support the codes submitted on the claim. Essential (primary) hypertension 401 Code assignment is based on the type of hypertension documented (benign, malignant or unspecified). Statements such as high blood pressure, hypertension and hypertensive vascular disease are all coded with category 401 essential hypertension. When only an elevated blood pressure is noted without a diagnosis of hypertension, assign code elevated blood pressure reading without diagnosis of hypertension. Terms such as controlled and uncontrolled indicate the status of the condition and do not have a bearing on code assignment for hypertension. Hypertensive heart disease 402 Assign category 402 hypertensive heart disease when a cardiac condition is stated (due to hypertension) or implied (hypertensive).the physician must document cause and effect between the two conditions. Category 402 is further specified based on the presence of heart failure. Use additional codes from ( ) to specify type of heart failure if known. Hypertensive chronic kidney disease 403 ICD-9 coding guidelines assume a cause and effect relationship when both hypertension and chronic kidney disease are documented. Assign codes from category 403 hypertensive chronic kidney disease along with additional codes for the stage of CKD from category 585 chronic kidney disease. Hypertensive heart and chronic kidney disease 404 When documentation supports heart and kidney complications with hypertension, the rules of cause and effect are as follows: Assumed cause and effect for hypertension and chronic kidney disease Requires documented cause and effect for hypertension and heart disease Instructional notes state to use additional codes from to to specify the type of heart failure (if known) and the stage of CKD from category 585 chronic kidney disease. ICD-10 equivalent code category: I1 hypertensive heart and chronic kidney disease. Secondary hypertension 405 Hypertension caused by underlying conditions such as adrenal gland disorders, kidney disease and drugs is called secondary hypertension. Assign codes for the underlying conditions in addition to codes from category 405 for secondary hypertension when documentation supports a cause and effect relationship.

9 AHA Coding Clinic advice When the provider establishes a linkage or relationship between two conditions, they should be coded as such. The entire record for the date of service should be reviewed to determine whether a relationship between the two conditions exists. The fact that a patient has two conditions that commonly occur together does not necessarily mean that they are related. A different cause may be documented by the provider. If it is not clear whether or not two conditions are related, coders should query the provider (AHA Coding Clinic Q3, 2012). Hypertensive Diseases in ICD-10 An important change for hypertension is that ICD-10 does not require documentation of the type of hypertension for correct code assignment. Providers will need to document the effects of hypertension along with any underlying conditions and treatment given. The table below shows code categories for hypertensive diseases in ICD-10. ICD10 I10 I11 I12 I13 I15 Essential (primary) Hypertension Description Hypertensive Heart Disease (with or without heart failure) Use an additional code from I50 to specify type of heart failure (if present) Hypertensive Chronic Kidney Disease Use an additional code from N18 to identify stage of chronic kidney disease Hypertensive Heart and Chronic Kidney Disease Use an additional code from I50 to specify type of heart failure (if present) and an additional code from N18 to identify stage of chronic kidney disease Secondary Hypertension Requires two codes, one for underlying cause and on from category I15 to identify secondary hypertension. Sequencing is based on circumstances of visit and documentation The following entry applies to Tennessee Medicare Advantage Providers. Recovery look-back period to align with CMS excerpt from TNPEC To align with Centers for Medicare & Medicaid Services guidelines, Amerigroup Community Care will begin recovering Medicare Advantage claim overpayments within four years of the claim payment date. Currently, Amerigroup recovers overpayments within three years of the claim payment date. What this means to you As of May 1, 2015, providers have been notified in writing of any Medicare Advantage claim overpayments identified with good cause within four years of the claim payment date consistent with the CMS guidance below unless a different time frame is specifically noted for Medicare Advantage plans in the provider s contract.

10 CMS guidance 42 CFR gives guidance to Payors that overpayment recoveries can occur: (1) Within one year from the date of the initial determination or redetermination for any reason. (2) Within four years from the date of the initial determination or redetermination for good cause as defined in (3) At any time if there exists reliable evidence as defined in that the initial determination was procured by fraud or similar fault as defined in (4) At any time if the initial determination is unfavorable, in whole or in part, to the party thereto, but only for the purpose of correcting a clerical error on which that determination was based. (5) At any time to effectuate a decision issued under the coverage appeals process. In addition, CMS Medicare Integrity Program employs Recovery Audit Contractors (RAC) to identify and correct improper Medicare payments. The RAC program allows for a look-back period of up to five years. Overpayment examples: Billing errors, such as deviation from National Correct Coding Initiative guidelines and improper use of billing modifiers. Payment errors, such as an incorrect fee schedule applied to the claim or identification of a member s other health insurance that would be primary. The appeals process remains unchanged. If you have any questions, please call the Provider Services Unit at or contact your Provider Relations representative. We appreciate your care for our Medicare Advantage members. Amerivantage is an HMO plan with a Medicare contract and a contract with the Tennessee Medicaid program. Enrollment in Amerivantage depends on contract renewal. excerpt from TNPEC Do you need free language help? Habla español y necesita ayuda con esta carta? Llámenos gratis al (TennCare) o al (CHOICES). (Arabic); (Bosnian); (Kurdish-Badinani); (Kurdish- Sorani); (Somali); (Vietnamese) call (TennCare), (CHOICES) or For TDD/TTY help call Federal and State laws protect your rights. They do not allow anyone to be treated in a different way because of: race, language, sex, age, color, religion, national origin, or disability. Need help due to a disability or to report a different treatment claim? Call the Office of Non- Discrimination Compliance for free at or (CHOICES). For TTY dial 711 and ask for