March 2019 Table of Contents Medicaid: Appointment availability and after-hours access requirements Page 2 Inhaled nitric oxide policy Page 3 Behavioral health nonphysician modifier reimbursement Coding Spotlight: Cancer A provider s guide to properly code cancers Page 4 Page 4 Accessing Patient360 Page 11 Special Section: Long- Term Care and Support Services (LTSS): UM authorization process update Amerigroup Community Care complies with all applicable federal and state civil rights laws, rules and regulations and does not discriminate against members/participants in the provision of services on the basis of race, color, national origin, religion, sex, age or disability. To report a discrimination complaint or to request language, communication or disability assistance for a member/participant, call 1-800-600-4441. Information about civil rights laws can be found on our website and is available from the U.S. Department of Health and Human Services. TN-NB-0140-19-A March 2019
Medicaid: Appointment availability and after-hours access requirements To ensure members receive care in a timely manner, PCPs, specialty providers and behavioral health providers must maintain the following appointment availability standards: Requirements for PCPs and specialists Appointment type Appointment standard Emergency visits all provider types Immediately Urgent visits all provider types Within 48 hours Routine or preventive visits PCPs Within three weeks Routine visits specialists Within 30 days of referral Optometry visits, regular visits Within three weeks Wait time Should not exceed 45 minutes for scheduled appointment OB/prenatal care Within three weeks Requirements for behavioral health providers Outpatient (non-md services) Within 10 business days; urgent within 48 hours Intensive outpatient services Within 10 business days; urgent within 48 hours Substance abuse, outpatient services Within 10 business days; for detoxification: within 24 hours Intensive community based treatment services Within seven calendar days Crisis services (mobile) Face-to-face contact within two hours for emergencies; within four hours for urgent Crisis stabilization Within four hours of referral After-hours access requirements for PCPs: To ensure continuous 24-hour coverage, PCPs must maintain one of the following arrangements for their members to make contact after normal business hours: Have the office telephone answered after hours by an answering service that can contact the PCP or another designated network medical practitioner. All calls answered by an answering service must be returned within 60 minutes. Have the office telephone answered after normal business hours by a recording in the language of each of the major population groups served by the PCP to direct the member to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider s telephone. Another recording is not acceptable. Have the office telephone transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP or a designated Amerigroup Community Care network medical practitioner who can return the call within 60 minutes. Have an automated answering machine that directs the member to the practitioner or appropriate covering practitioner. Page 2 of 11
The following telephone answering procedures are not acceptable: Office telephone that is only answered during office hours. Office telephone that is answered after hours by a recording that directs members to go to an emergency room for any services needed. After-hours calls that are answered outside of 60 minutes. TN-NB-0097-18 Inhaled nitric oxide policy Notification of change regarding inhaled nitric oxide (ino) Effective for dates of service on and after September 1, 2018, the use of ino during an inpatient stay is reviewed for medical necessity using Amerigroup Community Care Medical Policy guidelines for ino (CG-MED-69). ino is a covered service when: The member is eligible. The use of ino meets medical necessity criteria. ino is not used for investigational purposes. You can review the Amerigroup Medical Policy on the use of ino, CG-MED-69, which includes corresponding codes, by going to https://medicalpolicies.amerigroup.com/am_search.html and typing CG-MED-69 in the search bar. This change also requires that the facility notify Amerigroup of ino use during the course of standard inpatient review. If ino is medically necessary, we do not require a prior authorization request before initiating therapy; however, we must review and approve the therapy at some point prior to discharge to avoid exclusion of charges for ino from the claim payment. As noted, the use of ino will be reviewed for medical necessity as part of the inpatient review process. If we are not alerted to the use of ino and, therefore, cannot determine medical necessity or if we determine the use of ino is investigational and/or not medically necessary and charges for ino are included in the claim submission, the charges for ino will not be considered in calculation of reimbursement for the stay. As part of this change, when ino is used, providers must submit an itemized list of charges with the claim for the inpatient stay. Impact on the diagnosis-related group (DRG) payment Since the charges for medically unnecessary ino are not considered, this could impact the DRG outlier threshold, and the stay may not reach outlier status as soon as it would with inclusion of these charges. If the case does reach the outlier threshold, the claim would be adjudicated in alignment with the financial terms of the contract for outliers, without inclusion of charges for ino not medically necessary or use of ino that was not disclosed. Our Utilization Management department, which supports medical necessity reviews for inpatient concurrent reviews, requests that providers fax submission of clinical documentation to 1-877-279-2431. For questions, please call Provider Services at 1-800-454-3730. TN-NB-0131-19 Page 3 of 11
Behavioral health nonphysician modifier reimbursement Summary: Effective October 1, 2017, Amerigroup Community Care reimburses for behavioral health services rendered by licensed behavioral health practitioners as detailed below unless otherwise specified by the Division of TennCare. Using appropriate modifiers Behavioral health practitioners must use the appropriate modifier associated with their licensure for all CPT codes. The correct modifier that identifies who performed the services(s) must be placed in the primary modifier field on the CMS-1500 Claim Form. Claims submitted for behavioral health services without the appropriate modifier are not reimbursable. Licensed behavioral health practitioners will be reimbursed as follows: Practitioner type Modifier Reimbursement Licensed 60 percent of the Amerigroup Tennessee Fee HP psychologist/ph.d. Schedule or at the contracted/negotiated amount Licensed master s clinician HO 50 percent of the Amerigroup Tennessee Fee Schedule or at the contracted/negotiated amount Clinical nurse specialist SA 55 percent of the Amerigroup Tennessee Fee Schedule or at the contracted/negotiated amount If you have any questions, please contact your local Provider Relations representative or call Provider Services at 1-800-454-3730. TN-NL-0115-17 Coding Spotlight: Cancer A provider s guide to properly code cancers Cancer is often coded inaccurately, and there are missed opportunities to show which patients are sicker and are at a higher risk and those that are no longer being treated for this chronic condition. Documentation and coding of neoplasms has proven over time to be a source of many errors, including incorrect assignment of the morphology of the diagnosis and active cancer versus historical cancer. Neoplasms are classified in ICD-10-CM by anatomical location and morphology. It is essential to document the specific site of cancer and laterality. Words like mass, lump and tumor should be avoided if more specific language is available. If known, the behavior of the neoplasm should be documented, such as benign, primary malignant, secondary malignant, in situ or uncertain. History of malignant neoplasm or no evidence of disease should not be documented if the neoplasm is still being actively treated. Instead, the continuation of care should be documented, noting what has been done and what is left to do. Page 4 of 11
History of and no evidence of disease indicate an eradicated condition and a complete cure, according to coding guidelines, and would result in a history of malignant neoplasm code instead of an active malignant neoplasm code. Facts In 2015, 1,633,390 new cases of cancer were reported and 595,919 people died of cancer in the United States. 1 Cancer is the second leading cause of death in the United States. One of every four deaths in the United States is due to cancer. 1 The total global economic cost of cancer in 2010 was estimated at approximately $1.16 trillion. 2 Approximately 70 percent of deaths from cancer occur in low- and middle-income countries. 2 Risk factors Certain risk factors may increase a person s chances of developing cancer. Some risk factors can be avoided and lower the risk of developing certain types of cancer. Age Advancing age is the most important risk factor for cancer overall. Alcohol Drinking alcohol can increase the risk of cancer of the mouth, throat, esophagus, larynx, liver and breast. Cancer-causing substances Exposure to substances such as radiation, pesticides and asbestos can cause cancer. Chronic inflammation Over time, inflammation can cause DNA damage and lead to cancer. For example, people with chronic inflammatory bowel diseases, such as ulcerative colitis and Crohn s disease, have an increased risk of colon cancer. Diet Certain dietary components are associated with a reduced risk of cancer. Hormones Combination menopausal hormone therapy can increase a woman s risk of breast cancer; also, unopposed estrogen can cause endometrial cancer. Immunosuppression Immunosuppressive drugs make the immune system less able to detect and destroy cancer cells and fight off the infections that cause cancer. Infectious agents Viruses, bacteria and parasites can cause cancer or increase the risk. Obesity Obese people have an increased risk of several types of cancer, including breast, colon, rectum, endometrium, esophagus, kidney, pancreas and gallbladder. Radiation X-Rays, gamma rays and other excessive forms of radiation can damage DNA and cause cancer. Sunlight Exposure to UV radiation can lead to skin cancer. 1 Centers for Disease Control and Prevention. Leading Cancer Cases and Deaths, 2014. https://gis.cdc.gov/cancer/uscs/dataviz.html. 2 World Health Organization. Cancer. Key facts. https://www.who.int/en/news-room/factsheets/detail/cancer. Page 5 of 11
Tobacco Tobacco use causes many types of cancer, including cancer of the lung, larynx, mouth, esophagus, throat, bladder, kidney, liver, stomach, pancreas, colon, rectum and cervix. 3 Diagnosis and treatment There are several ways to diagnose cancer, such as lab tests, imaging procedures (including CT scans, nuclear scans, ultrasounds, MRIs, PET scans and X-Rays) and biopsy. Treatment depends on the type of cancer, stage and anatomical location. Most patients receive a combination of treatments. There are many types of cancer treatment: Surgery Targeted therapy Radiation therapy Hormone therapy Chemotherapy Stem cell transplant Immunotherapy Precision medicine 3 HEDIS Quality Measures HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Breast Cancer Screening Breast Cancer Screening measures the percent of women 50 to 74 years of age who had at least one screening mammogram during the current or prior year. Documentation of breast cancer screening includes any of the following: One or more mammograms any time on or between October 1, two years prior to the measurement year and December 31 of the measurement year Mammography results need to be requested and copies of it should be retained with the date of service in the medical record to provide evidence the test was performed Evaluation of primary breast cancer screening tomosynthesis (3-D mammography), biopsies and breast ultrasounds MRIs will not count as primary breast cancer screening Helpful tips: Discuss mammogram screening with all female members between the ages of 50 and 74 (younger if the patient has a family history of breast cancer or other risk factors). Document a history of mastectomy (unilateral or bilateral) on a chart. Conduct outreach calls to patients to remind them of the importance of annual wellness visits and assist with scheduling mammograms. Request and retain copies of mammography results in patient records or ask patients to make sure they request the mammography center to send a copy. Create flags or reminders in the system for members who need mammograms. Arrange one-on-one patient education sessions with health care professionals to discuss the importance of breast cancer screening and mammograms. 3 National Cancer Institute. Risk factors for cancer. https://www.cancer.gov/aboutcancer/causes-prevention/risk. Page 6 of 11
Motivate your office staff to use tools within the office to promote awareness of breast cancer screening, such as member reminder cards, chart or electronic medical record (EMR) flags, and educational brochures. Display posters and educational messages in waiting areas; they help motivate members to initiate discussions regarding screenings. Cervical Cancer Screening Cervical Cancer Screening measures the percent of women who were screened for cervical cancer using either of the following criteria: 21-64 years of age: at least one cervical cytology (Pap) test every three years 30-64 years of age: Pap test/human papillomavirus (HPV) cotesting every five years Documentation should reflect the following: The date and type of test that was performed If the patient had a history of hysterectomy including details if it was a complete, total or radical abdominal or vaginal hysterectomy with no residual cervix History of cervical agenesis or acquired absence of cervix (at a minimum, the year when the surgical procedure was performed should be included) Helpful tips: Discuss the importance of well-woman exams, mammograms, Pap tests and HPV testing with all female members 21-64 years of age. Promote women s health by reminding of the importance of annual wellness visits. Refer patients to another appropriate provider if the office does not perform Pap tests and request copies of Pap test/hpv cotesting results. Use a tracking mechanism (for example, EMR flags and/or manual tracking tool) to identify members due for cervical cancer screening. Display posters and educational messages in waiting areas and treatment rooms to help motivate members to initiate discussions about screening. 4 Colorectal cancer screening Colorectal cancer screening is a measure that focuses on members 50-75 years of age who had an appropriate screening for colorectal cancer. Documentation must indicate date, the result, and one or more of the following screenings: Colonoscopy during measurement year or nine years prior FOBT during measurement year CT colonography during measurement year or four years prior FIT-DNA test during measurement year or two years prior Flexible Sigmoidoscopy during measurement year or four years prior Exclusions: Diagnosis of colorectal cancer and total colectomy 5 4 HEDIS Benchmarks and Coding Guidelines for Quality Care. Amerigroup. https://providers.amerigroup.com. 5 HEDIS Measure 2018 Physician Documentation Guidelines and Administrative Codes. Amerigroup. https://providers.amerigroup.com. Page 7 of 11
Documentation should reflect the following: The date when the screening was performed and a pathology report that indicates the date and type of screening that was performed o The result is not required if the documentation of the test is clearly part of the medical history. Note, only one form of screening is required for the member to be compliant. ICD-10-CM: general coding and documentation Neoplasms are classified primarily by anatomic site and by behavior: Benign (adenoma, fibroma, lipoma) Uncertain behavior Malignant (adenocarcinoma, Unspecified behavior liposarcoma, osteosarcoma) In situ (in original place) In ICD-10-CM, clear and detailed provider documentation of the patient s neoplastic disease is needed for complete and accurate reporting and the documentation should include the following: Anatomical location Treatment Related conditions Metastatic sites Behavior or cell type Complications Conditions related to neoplasms and complications of care must be clearly documented by a provider and linked to the neoplasm. Examples include: Anemia due to adenocarcinoma of colon Diabetes mellitus secondary to pancreatic carcinoma Pathological fracture resulting from metastatic stage 4 ovarian carcinoma. When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85 personal history of malignant neoplasm should be used to indicate the former site of the malignancy. 6 A patient should never be assigned a current, active cancer code if the disease is no longer treated. Documentation must show evidence of current/ongoing treatment of the disease (such as chemotherapy, radiation therapy, suppressive therapy and/or surgical treatment). When a primary malignancy has been excised but further treatment (such as an additional surgery for the malignancy, radiation and/or chemotherapy) is directed to that site, the primary malignancy code should be used until treatment is completed. The statement metastatic to indicates that the site mentioned is secondary. For example, a diagnosis of metastatic carcinoma to the lung is coded as secondary malignant neoplasm of the lung (C78.0-). A code for the primary neoplasm should also be assigned when the primary 6 ICD-10-CM Expert for Physicians: the complete official code set. (2017). Optum 360, LLC. Page 8 of 11
neoplasm is still present. When primary malignancy is not present anymore, assign a history code for the primary malignancy. The statement metastatic from indicates that the site mentioned is the primary site. For example, a diagnosis of metastatic carcinoma from the breast indicates that the breast is the primary site (C50.9-). A code for the metastatic site should also be assigned. A primary malignant neoplasm that overlaps two or more contiguous sites is classified to the subcategory/code.8, signifying overlapping lesion, unless the combination is specifically indexed elsewhere. Code C80.0 disseminated malignant neoplasm, unspecified is for use only in those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified. 7 Code C80.1 malignant (primary) neoplasm, unspecified equates to cancer, unspecified. This code should only be used when no determination can be made as to the primary site of a malignancy. C79.9 secondary malignant neoplasm of unspecified site is assigned when no site is identified for the secondary neoplasm. 7 Malignant neoplasms of the following sites are classified as secondary when not otherwise specified, except for neoplasm of the liver (ICD-10-CM provides code C22.9, malignant neoplasm of liver, not specified as primary or secondary for the use in this situation): Bone Meninges Brain Peritoneum Diaphragm Pleura Heart Retroperitoneum Liver Spinal cord Lymph nodes Sites classifiable to C76.7 Mediastinum Primary neoplasms of lymph nodes or glands are classified in category C81 through C88 with a fourth character providing more specificity about the particular type of neoplasm and a fifth character indicating the nodes involved. 7 Leukemia is classified in categories C91 through C95 with the fourth character indicating either the stage of the disease (acute or chronic) or the type of leukemia (e.g., adult T-cell). TN-NB-0119-18 7 Leon-Chisen N. (2017). ICD-10-CM and ICD-10-PCS Coding Handbook 2018. Chicago, IL: American Hospital Association. Page 9 of 11
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Special section: Long-term care and Support Services (LTSS) Utilization Management authorization process update Page 12 Utilization Management authorization process update The LTSS Utilization Management (UM) team now processes all home health skilled nurse, home health aide, enhanced rate care and specialized consultation and training authorizations. Providers should continue to send any request and authorization issues through the long-term care provider request inbox (ltcprovreq@amerigroup.com) and will still receive notifications via DocuSign. If you have specific questions or need to escalate specific authorizations, please use the UM mailbox (LTSS_UM@amerigroup.com). TN-NB-0125-18 Page 11 of 11