Newsletter. Provider. National Correct Coding Initiative and Outpatient Coding Edits

Transcription

1 Fourth Quarter 2013 Provider Newsletter D.C. Healthy Families/D.C. Healthcare Alliance National Correct Coding Initiative and Outpatient Coding Edits The National Correct Coding Initiative (NCCI) is a program developed by the Center for Medicare and Medicaid Services (CMS) that consists of coding policies and edits. NCCI edits address correct coding combinations submitted by a provider for multiple services in regards to the same patient, on the same anatomic site, on the same date of service. There are two types of edits: procedure to procedure edits and medically unlikely edits (MUEs). Procedure to procedure edits make certain that CPT and/or HCPCS codes billed together are eligible for separate reimbursement and medically unlikely edits (MUEs) ensure that the appropriate number of units for a particular service were billed. MedStar Family Choice claims processing center utilizes CCI edit software from Ingenix so that providers are reimbursed for services in accordance with the NCCI procedure to procedure edits. We also expanded our existing NCCI edits to include the MUEs for professional claims and some types of outpatient facility claims. This logic includes a maximum number of units of service for each HCPCS/CPT code. Claims that do not meet criteria set in the CCI edit software are denied. Instances when a claim is denied because of NCCI procedure to procedure edits include, but are not limited to: Mutually exclusive codes that cannot be reported together were billed Unbundling of codes when a single comprehensive CPT code is available Please keep in mind that many procedure codes have CCI edits associated with them. Providers should use applicable modifiers when services are in fact separate and independent from each other in order for claims to be processed and paid as separate procedures. Since modifiers can be used to bypass CCI edits, MedStar Family Choice monitors their use. Therefore, if a modifier is to be used to bypass CCI edits, it is imperative that providers clearly document and explain the circumstances of the services that were provided in the member s chart. The documentation must clearly show that the procedure code and modifier met the conditions for separate billing. At this time, coding edits affect professional and outpatient claims submitted on CMS-1500 forms, as well as outpatient facility claims submitted on UB-04 (CMS-1450) forms. It was determined by (continued on page 2)

2 (National Correct Coding continued from page 1) the Department of Health Care Finance (DHCF) (in conjunction with CMS) that procedure to procedure edits for outpatient hospital claims regulated by the Health Services Cost Review Commission are not permissible. The DHCF clarified that the only outpatient coding edits that must be implemented for regulated outpatient hospital claims are a subset of edits identified under the CMS Integrated outpatient Coding Edits (I/OCE). Visit CMS.gov/OutpatientCodeEdit/Downloads/ Attachment_A_IOCE_Specifications_ Document_V113.pdf for a detailed listing of permissible edits. Pages 12 to 13 of that document include a listing of OCEs. Those marked with a Y in the Non-OPPS Hosp column are permissible and are used as edits in the MedStar Family Choice claims system. If you need more information regarding NCCI methodologies and the appropriate usage of modifiers, visit CMS.gov/MedicaidNCCICoding for the National Correct Coding Initiative Policy Manual for Medicaid Services. Important Member Appeal Reminder In order for a provider to appeal a denied service on a member s behalf, the provider must obtain written permission from the member. A member appeal cannot be processed without the member s permission. Therefore, MedStar Family Choice has developed a Provider Permission Form for member appeals for the provider s use. Visit the Reference Tools section of MedStarFamilyChoice.com to access and print the Provider Permission Form. This does not apply to provider claims appeals. Obtaining Prior Authorizations A limited number of services require authorization from the MedStar Family Choice Care Management department before the patient receives care. To obtain prior authorization, the rendering/ordering provider must send us the following information: Requesting provider s name Rendering provider name and location Exact diagnosis code(s) Exact procedure (CPT) code(s) Please note: The diagnosis and CPT code attached to the authorization must match the diagnosis and CPT code that will be billed to ensure proper claims processing. In addition to sending the requested information, the rendering/ordering provider must attach all pertinent clinical information supporting the request for medical review. Failure to provide clinical information within 14 days of your original request will result in denial of services. Upon gathering all of the necessary information listed above, please fax your request to the MedStar Family Choice Care Management department at or call , option 2. Some authorizations may take up to 14 days to process, depending on the completeness of the clinical received. To avoid unnecessary cancellations, please send elective authorization requests at least 14 days in advance of the procedure. 2

3 Coordination of Care MedStar Family Choice members often need follow-up care by the primary care provider after an inpatient admission when care was provided by specialists and when laboratory or diagnostic testing was performed. It is important that there is a process for ensuring that care is delivered seamlessly across a multitude of delivery sites by different providers. There should be mechanisms in place to ensure that members and clinicians have access to and take into consideration all required information on the member s conditions and treatments to ensure that the member receives appropriate healthcare services. Therefore, it is important for the specialist to list on the referrals the name of the member s primary care physician (PCP). This is particularly important for Ob/Gyns, who refer members for a Pap smear or mammogram. In most cases, the PCP is not aware that the member had a Pap smear or mammogram. Specialists, PCPs, ambulatory facilities, and hospitals are to share reports and other documentation with each other in order to provide the quality of care our members need. At the same time, members are to assume responsibility by informing their PCPs and specialists of their current health status, as well as ensure that their doctors are aware of hospitalizations or recent tests that have been ordered. They need to inform the appropriate practitioner so that the results can be obtained. The Quality, Outreach and Provider Relations departments at MedStar Family Choice will be working with the providers and members to try to improve this process. Please contact Provider Relations at , option 5, with suggestions, comments and questions. Find a Provider Online Finding a participating MedStar Family Choice provider couldn t be easier! Visit MedstarFamilyChoice.com to look up participating PCPs and specialists by logging on to our online provider directory. Providers can be found by: Specialty Last name/ facility name First name Group name Languages Hospital affiliations New patients Gender City Radius/ZIP Just complete one or more of the search fields and you will get updated information instantly. If your office does not have access to the web, please contact Provider Relations at , option 5. 3

4 Alcohol Prevention During Pregnancy Smoking Cessation Member Benefits In an effort to assist our members who are interested in or are trying to live a smoke-free life, MedStar Family Choice offers a variety of smoking cessation classes and over-the-counter smoking cessation drugs that are free of charge to our members. If you have a patient that can benefit from a smoking cessation class and/or support group, you can find dates and times for these classes at MedStarFamilyChoice.com in our Health Education Schedule of Classes. MedStar Family Choice members who need the assistance of nicotine replacement medications are eligible for a 90-day supply, per calendar year, of nicotine patches, nicotine gum and lozenges. These over-the-counter medications are free of charge to MedStar Family Choice members, but providers must write a script for the medication and give it to the member to present to the pharmacy. If you would like additional information on MedStar Family Choice educational classes and MedStar Family Choice benefit information, as well as hard copies of educational materials, please contact MedStar Family Choice Provider Relations at , option 5. MedStar Family Choice and ValueOptions are collaborating on an initiative to increase screening of pregnant women for alcohol use during pregnancy. The incidence of alcohol use among pregnant women is unchanged since 1991 based on research published by the U.S. Centers for Disease Control and Prevention (CDC) when comparing rates between 1991 and The National Institute on Drug Abuse in 1996 released data showing an incidence rate in 1992 of 18 percent for alcohol use while pregnant. A brochure from the CDC titled, Think Before You Drink, will be enclosed in mailings to pregnant women along with other prenatal materials. The pamphlet provides education regarding the effects of alcohol on the baby and provides information should the woman need assistance to stop drinking. The pamphlet is available in English and Spanish. ValueOptions recommends that practitioners consider using the T-ACE (T = tolerance, A = annoyed, C = cut down, E = eye opener) screening tool developed by R. J. Sokol, MD. This four-item questionnaire is based on the CAGE, but was developed specifically for prenatal use. It takes about one minute to ask and provides validated screening for risk-drinking. In addition, for high risk women, a urine test for ethylglucuronide (EtG) is now widely available. This test, if positive, indicates exposure to alcohol up to five days prior to the test. Verify interpretation of results with your laboratory. (continued on page 9) 4

5 Promoting Early Detection of Substance Use Disorders in Youth Substance use disorders are a major problem in adolescents and a leading cause of mortality and injury. Although still a major health issue, adolescent substance use of all drugs and alcohol except for prescription opiates has decreased over the past five years. The use of prescription opiates continues to rise. Surprisingly, some studies show more than 80 percent of high school graduates have tried alcohol, making the use of alcohol almost normative in teens. The major clinical challenge is identifying youth who need treatment and to identify those who are at risk of developing chronic substance use disorders in adulthood. SAMHSA, through The National Survey on Drug Use and Health in 2006, reported that approximately five percent of youth between the ages of 12 and 17 need substance use treatment. Adolescence is marked by neurological development in areas of motivation and impulsivity, which contributes greatly to substance use. Causes of use are multifactorial and complex. Thankfully for most adolescents, problematic use usually extinguishes in the early 20s. Programs teaching life skills and strategies to resist drug use can be helpful, and early intervention is the major prevention strategy. As a first step, it is vital to assess for problematic use in the teen population. The CRAFFT questionnaire has high reliability in 14- to 18-year olds and can be easily administered. Copies may be downloaded from the ValueOptions website at ValueOptions.com/Providers/ Network/NCSC_State_Local_Government.htm. This version of the CRAFFT was developed by the Center for Adolescent Substance Abuse Research (CeASAR) at Children s Hospital and is used with permission from CeASAR and the Massachusetts Partnership. It is designed for self-administration by the adolescent while in the waiting room. A score of two or more yes answers suggests a significant problem, abuse or dependence, but is not sufficient to make a diagnosis. A clinical evaluation is indicated. ValueOptions has a toll-free PCP Consultation Line for pediatricians and family practice staffed by board-certified psychiatrists. Call from 9 a.m. to 5 p.m. This service includes consultation regarding substance abuse assessment and treatment. Early Intervention Providers There is a law that mandates that children with disabilities, as well as their families, receive specialized services as early as possible. This is the Federal Individuals with Disabilities Education Act (IDEA), Part C, along with the District of Columbia Public Law To help with identifying eligible children, ages birth to 3 years, there are both parent-completed and provider-administered screening tools available to assist with developmental surveillance. Resources are available on the D.C. intervention program OSSE website at OSSE.DC.gov/Service/ DC-Early-Intervention-Program. To assist with referrals to early intervention providers, MedStar Family Choice contracts with several EIPs. For a listing of these providers, please go to our website at MedStarFamilyChoice.com and using the find-a-doc feature. Please contact Provider Relations at to request a hard copy listing of participating early intervention providers. 5

6 You Can Find It On the Web The MedStar Family Choice website is updated regularly. Users can log on to MedStarFamilyChoice.com and view: Appeal process Availability of UM criteria Case management and disease management services Claims information (including a link to the online claims status check) Clinical practice guidelines Contact information for MedStar Family Choice Credentialing process False claims act/fraud and abuse Find-A-Provider (searchable provider directory) Formulary Hours of operation and after-hours instructions Interpreter services Medical record documentation guidelines Member rights and responsibilities Notice of privacy practices Outreach program Pharmacy protocols and procedures Pre-authorization requirements Provider alerts Provider manual Provider newsletters Quality improvement programs Quick reference guide Schedule of health education classes Topic of the month articles Transportation guidelines Utilization management decision making If your office does not have access to the Internet, all of these materials are available in print by contacting our Provider Relations department, Monday through Friday, 8 a.m. to 5:30 p.m., at , option 5. Eye Exams Under the Early Periodic Screening and Development program, children up to five years of age are assessed for vision impairments through: health history, physical examination and gross subjective assessment. Objective vision tests are recommended at age four through six years of age, 12 years, 15 years, and 18 years of age. CPT codes 92002, 92004, 92012, classified as General Ophthalmological Services, and Determination of Refractive State, are not recommended objective vision screening test(s) in the EPSDT recommendations or federal mandates and are not intended as screening test(s). Claims submitted with these codes by providers other than optometrists or ophthalmologists will be denied by MedStar Family Choice. Appropriate claims for the CPT codes listed in this communication, rendered by optometrists or ophthalmologists, are processed by Advantica. Please contact Advantica at regarding participation and claims processing questions. 6

7 Fluoride Varnish Treatments The American Association of Pediatrics and the American Association of Pediatric Dentistry recommend infants have their first dental visit no later than one year of age. By incorporating oral health screenings, caries risk assessments, parental guidance, and fluoride varnish applications into well-baby visits as a routine standard of care, child health providers will be helping their young patients achieve optimal oral health and preventing or minimizing the serious health consequences of rampant decay. As of Oct. 1, 2013, primary care physicians in the District of Columbia will be able to use CDT code D1206 for billing and reimbursement of fluoride varnish up to four times a year for children up to age three for MedStar D.C. Healthy Families members. Only physicians who completed their EPSDT/HealthCheck Training and fluoride varnish application training will be eligible for reimbursement. Web-based provider training is available on DCHealthCheck.net. Mandatory EPSDT Web-Based Training Early and Periodic Screening, Diagnostic, and Treatment (EPDST) training and certification is required for providers who serve children under the age of 21 and includes pediatricians, family practitioners, general practitioners, nurse practitioners, internists, and gynecologists. The EPSDT program focuses on preventative care and screening services in order to identify and treat health problems early on. The training will cover the EPSDT periodicity schedules, compliance requirement, the Salazar Order/ Consent Decree and subsequent court orders. All new providers to MedStar Family Choice D.C. Healthy Families must be EPSDT certified within one month (30 days) of entering the MedStar Family Choice network. Once the initial training is completed, providers must recertify every two years. Providers who do not recertify every two years will be terminated for the MedStar Family Choice D.C. Healthy Families product because it is a requirement for re-credentialing with MedStar Family Choice. EPSDT training is completed online at DCHealthcheck.net. Once the training is complete, providers will receive five free continuing medical education (CME) credits. 7

8 MedStar Family Choice Physician Satisfaction Survey DC 2013 Summary On Nov. 12, 2012, MedStar Family Choice began servicing the Medicaid programs in the District of Columbia. These programs that are operated by the District of Columbia Health Care Finance (DHCF) include D.C. Healthy Families and D.C. Healthcare Alliance. In July of 2013, not quite a year later, MedStar Family Choice sent out a satisfaction survey to all participating providers to gather responses and satisfaction data. The satisfaction tool identifies areas that may need improvement to maintain open communication and a high level of satisfaction within the provider network. With this goal in mind, providers were asked to rate their knowledge of how to contact MedStar Family Choice for prior authorization, claims questions, eligibility issues, guidelines/policies, or referral questions, as well as their satisfaction with the three main divisions of MedStar Family Choice operations: Provider Relations, Care Management and the MedStar Family Choice Claims Processing Center. Only a handful of PCP offices responded that they do not know how to contact MedStar Family Choice for prior authorization, claims questions, eligibility issues, guidelines/policies, or referral questions. Specialist responses reflected that they were less likely to know how to contact MedStar Family Choice in these areas. When providers were asked to rate provider relations and care management regarding the ability to reach the department, being able to obtain information, receiving a return call within 48 hours, and speaking to a courteous representative, PCPs were more satisfied than specialists. According to the responses, specialists were least satisfied when trying to reach MedStar Family Choice promptly by telephone but once they were connected to the department, they were able to obtain the information that was needed in their most recent call to resolve a problem. When they were asked to rate the claims department with the same questions, both PCPs and specialists gave high ratings. PCPs and specialists were then asked to rate their general satisfaction levels as they pertain to prior authorization, claims processing, eligibility issues, guidelines and/or policies, referral questions and pharmacy authorizations. Specialists were more satisfied than PCPs in all of these areas with satisfaction levels as excellent, very good or good. Most PCPs rated their satisfaction with guidelines and/or policies and eligibility issues as good to excellent. PCPs were less likely to be satisfied with prior authorization and claims processing. referral questions and pharmacy authorizations received moderate satisfaction scores, indicating that improvement is needed. In order to improve areas of dissatisfaction, provider relations will work more closely with care management and the claims department to resolve claims issues and identify denial trends in order to educate the internal MedStar Family (continued on page 12) 8

9 Provider Manual Updates in 2013 During the year 2013, we made a few updates to MedStar Family Choice District of Columbia Healthy Families and D.C. Healthcare Alliance Provider Manual. A summary of the changes included: Section 1 D. Member Rights and Responsibilities Two bullets were updated to include additional protected categories: Be treated with respect and dignity no matter race, color, creed, national origin, ancestry, marital status, age, sexual orientation, religion, gender, political beliefs, personal appearance, physical or mental disability, or type of illness or condition. Have access to care no matter your race, color, creed, national origin, ancestry, marital status, age, sexual orientation, religion, gender, political beliefs, personal appearance, physical or mental disability, or type of illness or condition. Section 1 H. Becoming a MedStar Family Choice Practitioner or Provider This section now references our participation with CAQH that became effective earlier this year. In addition, there is additional information about how the health plan can use provider performance data. This language is a requirement under NCQA. (Alcohol Prevention continued from page 4) Early screening can contribute to better risk identification, secondary prevention efforts and improved pregnancy outcomes for offspring at risk from heavy prenatal alcohol exposure. (Sokol RJ, Martier SS, Ager JW: American Journal of Obstetrics/Gynecology 1989 Apr, 160(4): 863-8). Research by Grace Chang, MD, concludes that consistent screening followed, when indicated, by brief interventions with women and their partners can result in reduced drinking levels even with high levels of use. (2005) Section 1 I. Provider Training This section now includes the District of Columbia Department of Health Care Finance requirement for all HealthCheck providers to complete the EPSDT online provider training within 30 days of joining the MCO network and every two years thereafter. It is also a requirement of recredentialing. An update to our new address was made in the following sections: Section 3 H. Referral and Utilization Management Process Section 3 I. Claims Appeal Process Section 5 B. Fraud, Waste and Abuse Section 5 C. Grievances and Appeals Reporting A copy of this manual may be reviewed and downloaded from the D.C. Healthy Families and D.C. Healthcare Alliance portion of our website at MedStarFamilyChoice.com. For those without Internet access, a copy of the changes to the Provider Manual can be mailed to you. If you are in need additional copies, please contact provider relations at A copy of the T-ACE may be downloaded from the ValueOptions website at ValueOptions.com/ Providers/Network/NCSC_State_Local_ Government.htm. Please call for a copy if you do not have Internet access. 9

10 Update to the Medstar Family Choice Formulary District of Columbia Healthy Families Synagis Updates New Vendor The MedStar Family Choice vendor for the Synagis product for the 2013/2014 season has changed to CVS CareMark. Synagis continues to require prior authorization for each member. Providers do not need to request an authorization number for each order of the vaccine (up to five doses) as long as the ordered vaccines are follow-up injections for the same MedStar Family Choice Healthy Families member. To obtain an authorization, providers must complete and fax the MedStar Family Choice Synagis form to our Care Management department at , Attn: District of Columbia Healthy Families Program. Once the request is approved, MedStar Family Choice will notify your office and provide an authorization number. The requesting provider will also receive a follow-up call or fax from CVS CareMark to confirm the delivery date. A copy of the MedStar Family Choice Synagis form is available at MedStarFamilyChoice.com. Please contact Provider Relations at , option 5, with questions or to request a hard copy of this form. General Observations About Prescribing Due to the higher cost, MedStar Family Choice limits the use of insulin pens to members who cannot physically or mentally use a syringe and vial. MedStar Family Choice covers OTC PPIs rather than the generic PPIs on the market. You may prescribe an OTC with a prescription like any other medication along with refills. Update to the Glucometer Information in the Third Quarter Provider Newsletter MedStar Family Choice uses AccuChek brand glucometers and strips. If you have a member with another meter, they may obtain a new AccuChek meter for free, as long as the provider writes a script and has the member take it to a pharmacy. Therefore, provider offices should write a script instead of calling AccuChek. Please transition members now to the appropriate formulary medication or supply. Updates to the MedStar Family Choice formulary are available quarterly at MedStarFamilyChoice.com and more frequently on eprocates. Paper booklets of the 2013 formulary have been mailed. If you have not received a copy or would like additional copies, please contact your provider relations representative. Details of the prior authorization criteria are available on the MedStar Family Choice website with the other pharmacy protocols. Contact provider relations at if your office does not have access to the Internet and you would like copies of this information. At the September 2013 Pharmacy and Therapeutics Committee meeting, the following changes were made: Additions that have or will go into effect in the next few weeks: Ketostix 10

11 Additions with prior authorization effective on or around Oct. 1, 2013: Mekinist (trametinib) is indicated for the treatment of patients with unresectable or metastatic melanoma with BRAF V600E or V600K mutations, as detected by an FDAapproved test. Mekinist (trametinib) is not indicated for treatment of patients who have received prior BRAF-inhibitor therapy. Tafinlar (dabrafenib) is indicated for the treatment of patients with unresectable or metastatic melanomawith BRAF V600E mutation, as detected by an FDA-approved test. Tafinlar (dabrafenib) is not indicated for treatment of patients with wild-type BRAF melanoma. Managed drug limitations and step therapy Fluconazole 150 milligram tabs increased to 3/23 days Details of the prior authorization criteria are on this website with the other pharmacy protocols. Other changes to pharmacy services in the District of Columbia for ALLIANCE MEMBERS only D.C. Healthcare Alliance members have used the Unity Pharmacies to obtain their medications. The Unity Pharmacies were to close by Sept. 21, Starting on Oct. 1, 2013, Alliance members will need to obtain their medications at one of the expanded network of ADAP pharmacies. A list of the pharmacies has been sent to members, is posted on the DHCF website and is also posted on the Alliance part of the MedStar Family Choice website. In-network Labs As a reminder, both primary care and specialty care providers may refer a member to a participating laboratory with a lab requisition or a script. Participating laboratories for the MedStar Family Choice D.C. Healthy Families and Alliance program includes: Quest Diagnostics (effective Oct. 1, 2013) LabCorp Visit QuestDiagnostics.com or call 866-MYQUEST ( ) for more information about Quest Diagnostics, including account set up, supplies, forms, courier pick-up, or a list of Quest Diagnostics Patient Service Center locations. Visit LabCorp.com or call or for more information about LabCorp, including account set up, supplies, forms, courier pick-up, or a list of Quest Diabnostics Patient Service Center locations. Changes to Our Notice of Privacy Practices On Sept. 23, 2013, the MedStar Family Choice Notice of Privacy Practices was updated. The full document that includes all changes can be found on our website at MedstarFamilyChoice.com. Provider offices without access to the web can contact provider relations at , option 5, to request a hard copy. 11

12 PCP Auto Assignment Members who fail to designate a primary care provider (PCP) after enrolling in the MedStar Family Choice will be called by our Member Services team and assisted in selecting a PCP. If we are unable to contact the member, we will assign a PCP that is geographically close to the member s residence. Members under the age of 21 are automatically assigned to EPSDT providers as appropriate. Members can change PCPs at any time by calling Member Services at If your name is not listed on the member s card on the date of service, you are permitted to see the member as long as you are participating with MedStar Family Choice and the member is eligible. When possible, we ask that your office assist the member in having his/her member card changed to reflect the correct primary care provider by calling Member Services at We continue to mail member rosters to PCPs on a monthly basis, but this information changes daily and should not be used to determine member eligibility. Therefore, provider offices should be utilizing the states IVR line to verify benefits on the date of service. If you have questions regarding eligibility, our Outreach department is available by calling , option 1. (MedStar Family Choice Physician Satisfaction Survey continued from page 6) Choice departments and/or the provider office. MedStar Family Choice provider relations will also continue to conduct large provider orientations, as well as individual education sessions. All provider offices should either attend a yearly orientation or schedule a private education session with their provider relations representative. At this time, all departments continue to monitor monthly phone calls to ensure that provider calls are answered in a timely manner and that departments are easily accessible. This method is proven to be effective, but the department s focus in 2014 will be to ensure providers receive a return phone call within 48 hours. All in all, the results of the satisfaction survey is shared with staff members who work in the surveyed departments and all team members will continue to work together to improve satisfaction scores for next year. Providers can contact Provider Relations at , option 5, with comments, questions and to schedule a provider orientation. EPSDT Online Training EPDST/HealthCheck training is required for family practitioners, pediatricians, nurse practitioners, and/or all providers serving children under the age of 21 who are licensed by the state. Once the initial training is completed, providers must recertify every two years. EPSDT training is completed online at DCHealthcheck.net. Once the training is complete, providers will receive five free continuing medical education (CME) credits. 901 D St., SW Suite 1050 Washington, D.C PHONE The MedStar Family Choice Newsletter is a publication of MedStar Family Choice. Submit new items for the next issue to Melanie Bodencak, MedStar Family Choice, melanie.bodencak@medstar.net Kenneth A. Samet, FACHE President and CEO, MedStar Health Eric Wagner President, MedStar Family Choice Melanie Bodencak Editor MedStarFamilyChoice.com 13-MFC