Network Management

DME Fee Schedule Update

As noted in the October 2017 Provider Bulletin, the DME fee schedule update will take place April 1, 2018. The Medicare (CMS) DMEPOS fee schedule is based on the CMS DMEPOS Competitive Bidding Program that was mandated by Congress through the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). The statute requires that Medicare replace the current fee schedule payment methodology for selected Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) items with a competitive bid process. The intent is to improve the effectiveness of the Medicare methodology for setting DMEPOS payment amounts. Under the program, a competition among suppliers who operate in a particular competitive bidding area was conducted. Suppliers are required to submit a bid for selected products. Not all products or items are subject to competitive bidding. Bids are submitted electronically through a web-based application process. Bids are evaluated based on the supplier’s eligibility, its financial stability and the bid price. Contract suppliers must agree to accept assignment on all claims for bid items and will be paid the single payment amount. The amount is derived from the median of all winning bids for an item.

Prior to the DMEPOS Competitive Bidding Program, Medicare paid for these DMEPOS items using a fee schedule that is generally based on historic supplier charges from the 1980s. Numerous studies from the Department of Health and Human Services Office of Inspector General and the Government Accountability Office have shown these fee schedule prices to be excessive, and taxpayers and Medicare beneficiaries bear the burden of these excessive payments. Round 1 2017 was implemented on January 1, 2017. In addition, Section 16007 of the 21st Century Cures Act extends the transition period for the 50/50 blend of unadjusted and adjusted fees for competitive bid items in non-competitive bid areas.  Section 16007 of the Cures Act extends this transition period from June 30, 2016 to December 31,2016 with the full implementation of the 100 percent adjusted fee schedule amounts applying on or after January 1, 2017. There were also additional concerns raised by the public regarding the possible impact on access to services in rural areas so additional adjustments were made for rural areas sometime in 2016. The rural area is defined by CMS. Because the competitive bidding resulted in several corrections and adjustments over a few years to the DMEPOS fee schedules, PreferredOne limited the impact and changes until the fee schedule was more stable. Therefore in 2018, PreferredOne will begin moving toward the CMS DMEPOS competitive bid fee schedule rates with full implementation in 2019. For more information on the CMS DMEPOS competitive bid process, please see https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSCompetitiveBid/index.html.

Fee schedules will be made available upon request to your provider relations representative and/or contract manager. For questions please contact your contract manager.

Medical Records Reimbursement Policy Update

Please be advised that effective 2/12/2018 the PreferredOne Medical Records Reimbursement policy (P-24), located in our online Office Procedures Manual, has been updated to provide additional clarity around instances where medical records requests are non-reimbursable. The updated policy has been included below for reference.

P-24 Medical Records Reimbursement(Effective Date: 2/1/0)5 (Updated 2/12/2018)

PURPOSE: The purpose of this policy is to define the circumstance under which the Provider, the PPO Payer and PreferredOne are each responsible for bearing the cost of providing a copy of the medical record.

POLICY: Guidelines regarding the reimbursement of medical record requests.

PROCEDURE:

I. Regular Review Purposes

The Provider shall bear the cost of copying and submitting medical records to PreferredOne in the following instances:

1. A. The Provider elects to submit medical records in substantiation of an appeal.
2. B. PreferredOne or payer requests medical records to determine medical necessity on retrospective claims that were not prior authorized.
3. C. The Provider submits a claim adjustment or a new claim with changes in which case medical records are required to support the changes.
4. D. PreferredOne or payer requests operative reports or medical records to substantiate billing.
5. E. HEDIS medical record review.
6. F. Risk adjustment validation audits.

II. Quality/Complaint Issues

1. A. If PreferredOne requests the medical record based on a complaint/quality issue, then PreferredOne will bear the cost of copying and obtaining such record. PreferredOne will indicate which portions of the medical record it requires and will not accept responsibility for copying or sending any other portions of the record beyond that which is requested.
2. B. Should Payer request medical records, then the payer is responsible for the copying and sending costs of the portion of the medical record which it requests.

III. Reimbursable Cost

1. A. Reimbursement for all records shall be at the local community standard and according to State Law, should any apply.

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Quality Management

Blood Pressure Readings for Controlling High Blood Pressure

In 2018 PreferredOne will once again be focusing on an initiative to control high blood pressure among our members diagnosed with hypertension. Controlling blood pressure is a HEDIS measurement specified by NCQA and is also reported by Minnesota Community Measurement. We value this project and deem it as important to our members because hypertension is the most treatable form of cardiovascular disease and medication compliance is a significant factor that contributes to the overall success of treatment. As part of this initiative in 2018 we are asking for provider’s assistance by conducting a secondary reading of your patient’s blood pressure if it is high following the initial reading and ensuring that the patient’s medical records reflects both of the measurements taken.

2018 HEDIS Medical Record Review

As a reminder, PreferredOne’s HEDIS Medical Record Review Vendor (Guardian Angel) will be contacting clinics in the coming weeks to coordinate medical record review for PreferredOne members seen at your clinics. As a contracted provider you are obligated to allow PreferredOne and its vendor to conduct this review. HEDIS measures are nationally used by all accredited health plans and PreferredOne also has an obligation to the Minnesota Department of Health to collect HEDIS data on an annual basis. Medical record review is an important component of the HEDIS compliance audit. It ensures that medical record reviews performed by our vendor meet audit standards for sound processes and that abstracted medical data are accurate. We would appreciate your cooperation with collecting medical record review information at your clinic site(s). We appreciate your clinic’s assistance in making this a smooth process.

Medical Record Documentation Policy

Please see our Medical Record Documentation Policy.

Serving a Culturally and Linguistically Diverse Membership

Cultural and linguistic competence is the ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by their patients/consumers to the health care encounter. Cultural and linguistically appropriate services lead to improved outcomes, efficiency, and satisfaction.

Culture Care Connection is an online learning and resource center, developed by Stratis Health, aimed at supporting health care providers, staff, and administrators in their ongoing efforts to provide culturally-competent care in Minnesota.

For more information regarding Stratis Health’s resource center, click on the following link, http://www.culturecareconnection.org/.

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Medical Management

Affirmative Statement About Incentives

PreferredOne does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for utilization management decision-makers do not encourage decisions that result in under-utilization. Utilization management decision making is based only on appropriateness of care and service and existence of coverage.

Member’s Rights and Responsibilities

PreferredOne presents this Member Rights & Responsibilities with the expectation that observance of these rights will contribute to high quality patient care and appropriate utilization for the patient, the providers, and PreferredOne. PreferredOne further presents these rights in the expectation that they will be supported by our providers on behalf of our members and an integral part of the health care process. It is believed that PreferredOne has a responsibility to our members. It is in recognition of these beliefs that the following rights are affirmed and presented to PreferredOne members. (See the 2017 member newsletters – PCHP Member Newsletter and PIC Member Newsletter)

Adverse Determination – To Speak to a Physician Reviewer

PreferredOne Integrated Healthcare Services Department attempts to process all reviews in the most efficient manner. We look to our participating practitioners to supply us with the information required to complete a review in a timely fashion. We then hold ourselves to the timeframes and processes dictated by the circumstances of the case and our regulatory bodies.

Practitioners may, at any time, request to speak with a peer reviewer at PreferredOne regarding the outcome of a review by calling 763-847-4488, option 2 and the Intake Department will facilitate this request. You or your staff may also make this request of the nurse reviewer with whom you have been communicating about the case and she/he will facilitate this call. If, at any time, we do not meet your expectations and you would like to issue a formal complaint regarding the review process, criteria or any other component of the review, you may do so by calling or writing to our Customer Service Department.

Phone number: (763) 847-4488, Option 3.
(800) 379-7727, Option 3

Address: PreferredOne, Grievance Department
6105 Golden Hills Dr.
Golden Valley, MN 55416

Medical Policy Updates

The Integrated Health and Pharmacy and Therapeutics Quality Management Subcommittees approve new criteria sets for use in their respective areas of Integrated Healthcare Services. Quality Management Subcommittee approval is not required when there has been a decision to retire a PreferredOne criteria document or when medical polices are created or revised; approval by the Chief Medical Officer is required. The Quality Management Subcommittees are informed of these decisions.

For the most current versions of the Medical Policy documents, please access the Medical Policy section on the PreferredOne website (PreferredOne.com). (Click on Coverage & Benefits then choose Medical Policy). Medical Policy documents are available on the PreferredOne website to members and to providers without prior registration.

Since the last newsletter, the following are the new, revised, or retired Medical Policy documents. Some of the more extensive Medical Policy updates are detailed for a few of the items below. If you wish to have paper copies of these documents, or you have questions, please contact the Medical Policy Department telephonically at (763) 847-3386 or online at Heather.Hartwig-Caulley@PreferredOne.com

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List

There have been no updates since the October 2017 Provider Newsletter.

Medical Criteria

• MC/H003 Bariatric Surgery – “Vertical Gastric Banding (VGB) / Vertical Banded Gastroplasty” has been deleted from the list of bariatric surgical procedures because it is no longer considered a routine bariatric surgery procedure.
• MC/T001 Bone Marrow/ Stem Cell Transplantation – Added osteoporosis as an additional proven effective indication for allogenic BMT/SCT.
• In all of the following transplantation criteria, the list of contraindications has been revised for clarity and also, due to variability within the published literature, we have eliminated the age thresholds for transplantation. Additionally, the exclusion of xenotransplantation has been revised to exclude all forms of xenotransplantation.
• MC/T001 Bone Marrow/ Stem Cell Transplantation
• MC/T002 Kidney Transplantation, Simultaneous Pancreas-Kidney Transplantation, Simultaneous Cadaver-Donor Pancreas and Living-Donor Kidney Transplantation
• MC/T003 Heart Transplantation
• MC/T004 Liver Transplantation
• MC/T005 Lung and Lobar Transplantation
• MC/T007 Pancreas Transplantation, Pancreas After Kidney (PAK) Transplantation, Autologous Islet Cell Transplantation

Medical Policy

• MP/R002 Reconstructive Surgery –revisions were made to capture the Minnesota state statute coverage requirements for reconstructive surgery on congenital anomalies.
• The following policy has been extensively updated to reflect the current proven effective molecular/biomarker/tumor marker tests, their clinical indications, and where applicable, their specific CPT codes.
• MP/M001 Molecular Testing: Tumor/Neoplasm Biomarkers

Investigative List – Additions:

• Cardiac Devices and procedures for occlusion of left atrial appendage (eg, Amplatzer cardiac plug/the Amulet, the AtriClip device, the Lariat snare device, the PLAATO device, and the Watchman device)
• Chelation therapy for all indications, except the following.
• Aceruloplasminemia (hereditary ceruloplasmin deficiency)
• Aluminum overload in persons with end-stage renal failure
• Biliary cirrhosis
• Cooley's anemia (thalassemia major)
• Cystinuria
• Diamond-Blackfan anemia
• Heavy metal poisoning (eg, arsenic, cadmium, copper, gold, iron, lead, mercury)
• Secondary hemochromatosis (ie, due to iron overload from multiple transfusions including persons with IPSS Low- or Intermediate-1-risk myelodysplastic syndrome)
• Sickle cell anemia
• Wilson's disease
• Circulating tumor cells/markers or cell-free tumor DNA testing (eg, CellSearch® System) for the management of all cancers, specifically breast, colorectal, melanoma, and prostate)

Pharmacy

Pharmacy criteria documents for coverage of drug requests under the Pharmacy benefit are available at PreferredOne.com by clicking on Coverage and Benefits, choosing Pharmacy Information, then choosing Formulary. Pharmacy criteria documents developed for drug requests under the Medical benefit are found in the Medical Policy section on PreferredOne.com.

• Pharmacy Criteria for provider administered drugs – revisions have been made to the following Biologics criteria. To view the currently posted criteria, please visit the Pharmacy criteria documents in the Medical Policy section on PreferredOne.com.
• PC/B004 Biologics for Rheumatoid Arthritis: Actemra, infliximab, Orencia, Rituxan, and Simponi Aria
• PC/B005 Biologics for Plaque Psoriasis: infliximab
• PC/B006 Biologics for Crohn’s Disease: Entyvio, Stelara, infliximab, and Tysabri
• PC/B010 Biologics for Juvenile Idiopathic Arthritis and Juvenile Rheumatoid Arthritis: Actemra, infliximab, and Orencia
• PC/B011 Biologics for Psoriatic Arthritis: infliximab, Orencia, and Simponi Aria
• PC/B012 Biologics for Ankylosing Spondylitis: infliximab and Simponi Aria
• PC/B013 Biologics for Ulcerative Colitis: Entyvio and infliximab
• Pharmacy Policy – No revisions were made to Pharmacy policies.

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Coding

2018 CPT^® and HCPCS Codes Highlights
CPT^® Codes

The information contained in this article is not inclusive of all the new, revised, and deleted CPT^® and HCPCS codes for 1st quarter 2018. Please refer to your coding manuals or encoders for the complete set of code changes.

The following two codes replace expired HCPCS codes G0505 and G0507. Exact same documentation criteria applies to the new CPT codes that applied to the HCPCS codes.

• 99483 – Assessment of and care planning for a patient with cognitive impairment,…..(please see CPT manual for complete description which includes the required 10 elements to be rendered in order to submit).
• 99484 – Care management services for behavioral health conditions,…..(please see CPT manual for complete description which includes the required 4 elements to be rendered in order to submit).

Three new codes were created for psychiatric collaborative care management (CoCM). Details for these codes can be found in Medicare Learning Network (MLN) ICN 909432 dated January 2018.

• 99492 – Initial psychiatric collaborative care management, first 70 minutes in the first calendar month of behavioral helath care manager activities,…..(please see CPT manual for complete description which includes the required 5 elements to be rendered in order to submit).
• 99493 – Subsequent psychiatric collaborative care management, first 60 minutes in a subsequent month of behavioral health care manager activities,…..(please see CPT manual for complete description which includes the required 7 elements to be rendered in order to submit).
• 99494 (add-on code) – Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities,…..(please see CPT manual for complete description and information).

• 00731 - Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified – use with non-ERCP services
• 00731 - Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified – use with ERCP services only

Additional information for the following anesthesia codes can be found in MLN MM10181, related CR Transmittal# R3844CP

• 00811 - Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified – use when a screening colonoscopy converts to a diagnostic colonoscopy.
• 00812 - Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy.
• 00813 - Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum.
• REMINDER: Anesthesia modifiers are required to be submitted on the above codes, when reported.

20939 - Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List separately in addition to code for primary procedure)

31298- Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (eg, balloon dilation) – is diagnosis specific for PreferredOne^®.

The following three new codes are investigative;

• 33927 – Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy
• 33928 - Removal and replacement of total replacement heart system (artificial heart)
• 33929 (add-on code) - Removal of a total replacement heart system (artificial heart) for heart transplantation (List separately in addition to code for primary procedure)

The following two new codes for vein surgery require prior authorization. These codes now include all supplies, equipment, sclerosant, compression stockings/bandages;

• 36465 – Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein)
• 36466 - Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg

The following two new codes for vein surgery are investigative.

• 36482 – Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated
• 36483 (add-on code) - Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

The following surgical code requires prior authorization;

• 55874 - Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed. This is for the SpaceOAR® System. This new code replaces expired Category III code 0438T.

Chest xray codes 71010 – 71035 have been expired and replaced with the following new codes, which are designated by views;

• 71045 – Radiologic examination, chest; single view
• 71046 – Radiologic examination, chest; 2 views
• 71047 – Radiologic examination, chest; 3 views
• 71048 – Radiologic examination, chest; 4 or more views

Abdominal xray codes 7400 – 74020 have been expired and replaced with the following new codes, which are designated by views;

• 74018 – Radiologic examination, abdomen; 1 view
• 74019 – Radiologic examination, abdomen; 2 views
• 74021 – Radiologic examination, abdomen; 3 or more views

Genetic Testing

Most genetic tests and molecular pathology tests require prior authorization. It is the ordering provider’s responsibility to obtain any required prior authorization for genetic testing prior to sending the specimen to the reference lab (caveat will be for pathology tissue specimens). The prior authorization number is to be noted on the lab order, which allows the lab to perform the testing. PreferredOne® has several medical policies addressing genetic tests and molecular pathology tests. These are accessible online at PreferredOne.com.

There were multiple new genetic testing and molecular pathology codes added. The following codes have been designated as investigative.

• 81230 – CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22)
• 81231 - CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7)
• 81520- Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score (Prosigna® Breast Cancer Assay, NanoString Technologies, Inc)
• 81521 - Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis (MammaPrint®, Agendia, Inc)

A new code for the Shingrix was released. This vaccine is approved for ages 50 years and older, even if the Zostavax had been previously administered. Shingrix is a 2-dose vaccine, with each vaccine being administered two months apart.

• 90750 - Zoster (shingles) vaccine (HZV), recombinant, sub-unit, adjuvanted, for intramuscular use

The following modifiers will be required to be appended to all services rendered for habilitative and rehabilitative services. Failure to report these modifiers will result in claim denial.

• 96 - Habilitative Services: When a service or procedure that may either be habilitative in nature or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified healthcare professional may add modifier 96- to the service or procedure code to indicate that the service or procedure provided was habilitative. Such services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep or improve those learned skills. Habilitative services also help an individual keep, learn, or improve skills and functioning for daily living.
• 97 - Rehabilitative Services: When a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified healthcare professional may add modifier 97- to the service or procedure code to indicate that the service or procedure provided was rehabilitative. Rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled.

HCPCS Codes

Many new “C” codes have been created for injectable or infusion drugs. Most of these require prior authorization if the “C” code has been granted pass-through status. Please refer to the HCPCS Manual for identification of these drugs.

The majority of the HCPCS code changes were in the “Quality Measures” section, G8935 – G9977 range. This includes newly created, revised, and deleted codes.

Codes G0202, G0204 and G0206 were expired in favor of the CPT codes 77065, 77066, and 77067 as the CPT codes already include the computer-aided detection (CAD).

The following new codes will be processed as provider liability since they are mostly for reporting on Medicare services and for a limited number of codes. Please see Transmittal 3844, CR 10181, dated Aug 18, 2017 for additional information.

• G0513 - Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service)
• G0514- Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code G0513 for additional 30 minutes of preventive service)

Many new “J” codes have been created, several of them replacing deleted “C” codes. Please refer to the HCPCS Manual for those. Many of these drugs require prior authorization.

FY - X-ray taken using computed radiography technology/cassette-based imaging - providers are encouraged to work with the PreferredOne^® Contract Manager on the implementation of this modifier for any reimbursement impact. It will be required to be submitted as defined by Consolidated Appropriations Act of 2016.

General Coding

Claims for Chemotherapy Infusions - It is important to follow the official ICD-10-CM guidelines for correct sequencing of diagnosis(ses) when the encounter is for chemotherapy infusion treatment. Chapter 2:Neoplasms (C00 – D49), states, “….if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or external beam radiation therapy, assign the appropriate Z51.--, code as the first-listed or principal diagnosis, and the diagnosis or problem for which the service is being performed as a secondary diagnosis.” PreferredOne® is following this guidance and will be returning claims for incorrect diagnosis reporting, if this is not followed. This is applicable to all claim form types.

90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered))

90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure))

90471(Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid))

90472(Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure))

90460 and 90461 are reported only when the physician or qualified health care professional (includes registered nurse practitioners (eg,NP, CNP, FNP, PNP) and physician assistants (PA)) provide face-to‐face counseling to the patient and/or the patient’s family during the administration of a vaccine. These codes may not be reported when other types of office clinical staff (eg, RNs, LPNs, CMAs) provide the counseling and immunization administration. For immunization administrations performed by an office nurse who is allowed by applicable statute or regulation to explain the risks and benefits of vaccines, codes 90471--‐90474 should be reported.

Note: 90460-90461 for patients through age 18. For immunization administration of any vaccine that is not accompanied by face-to-face physician or qualified health care professional counseling to the patient/family or for administration of vaccines to patients over 18 years of age, report codes 90471-90474.

(Article source: AMA, CPT^® Assistant, July 2012)

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