Network Management

“On the last weekend of May 2022, PreferredOne loaded the April 2022 Medicare APC grouper into production so that new diagnoses codes would group and price. The weight and rate files did not change, so there should be no impact to reimbursement”

Medical Management

Medical Policy

Medical Policy documents are available on the PreferredOne website to members and to providers without prior registration. The most current version of Medical Policy documents are accessible under the Medical Policy section on the PreferredOne website (PreferredOne.com). (Click on Coverage & Benefits then choose Medical Policy).

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.Thompson@PreferredOne.com.

Prior Authorization List

  • Cardiovascular: Left Atrial Appendage – added CPT codes 33267, 33268, 33269

  • Gender Reassignment – added CPTs 14000, 14001, 14041, 1534, 15738, 15750, 15757, 15758, 15769, 15771, 15772, 15773,15774, 53410, 58180, 58554, 58720, 58940, 64856, 64892, 64896 and deleted CPTs 56810, 57106, 57107, 57291, 57292, 58263, 58275

  • Laboratory Testing: Comparative Genomic Hybridization - added CPTs 81349, 0209U, S3870

  • Molecular Testing, Gene Expression – added CPTs 81523, 0287U, 0288U – deleted 0208U

  • Pharmacogenetic/Pharmacogenomic testing added CPTs 0029U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0175U

  • Neurology: Hypoglossal nerve stimulation – added CPTs 64582, 64586 and deleted CPTs 0466T, 0467T

  • Radiofrequency ablation – added CPTs 64627, 64659 – deleted HCPCS C9752, C9753

  • Obstructive Sleep Apnea Surgery, Adult: replaced Uvulopalatopharyngoplasty with Palatopharyngoplasty (same CPT Code).

Prior Authorization Form

  • Clinical Trial Notification – new

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies List

  • Revisions:

    • Compression burn garments – revised quantity limit verbiage

      • A6501, A6502, A6503, A6509, A6510, A6511, A6512, A6513 – 12 per year changed to 1 per month
      • A6504, A1505, A6506, A6507, A6508 - 24 per year changed to 2 per month

    • Positioning cushion/pillow/wedge

      • Added HCPCS E0190 as non-covered
      • Deleted the entry that it would be allowed for infants with severe GERD

  • Deletions: Intermittent limb compression device, NOS (HCPCS E0676)

    • Back to Top ↑

Medical Clinical Policies

New: None

  • Gender Reassignment, Surgical Treatment for Gender Dysphoria (MC/G019)

  • Pharmacogenetic Testing, CYP2C19 and CYP2D6 (MC/L027)

Revisions (substantive clinical revisions)

  • Dental Services, Pediatric Orthodontic Coverage Under Medical Benefit (MC/B003) –Roman numeral I. revised statement related to cleft lip/cleft palate

  •  DMEPOS, Continuous Glucose Monitoring Systems for Long-term Use (MC/L008) and DMEPOS, Insulin Infusion Pump (MC/L011) - revised age range for the TSlim X2 with Control-IQ technology

  • Intervertebral Disc Prosthesis, Cervical and Lumbar (MC/F022) – Revised Contraindications I.E.3 statement related to lordosis of the cervical spine

  •  Molecular Testing, Gene Expression (MC/L012) – Revised Roman numeral II.C. Prostate, deleted indications regarding life expectancy and revised Decipher’s medical necessity requirements
  • Pharmacogenetic/Pharmacogenomic Testing (MP/P013)
    • FoundationOne CDx is now approved as a companion diagnostic test for melanoma and non-small cell lung cancer (NSCLC)
    • Oncomine DX is now approved as a companion diagnostic test for the use of Rybrevant (amivantamab-vmjw) for NSCLC

  • Preventive Coverage for Colorectal Cancer Screening (MP/P014)

    • Addition of new Coverage Statement
    • The age to allow any of the Colorectal Cancer Screening preventive/no cost-sharing services is lowered to age 45. The coverage goes through age 75; ends on 76th birthday
    • Deleted Barium enema as a test for colorectal cancer screening
    • Revised various diagnosis to procedure code requirements

  • Preventive Coverage for Osteoporosis Screening (MP/P016) - Covered procedures has been revised; Removed the limitation to allow once per lifetime, only; cost-sharing versus no cost-sharing is driven by the diagnosis code submitted on the claim

  • Preventive Coverage for Prenatal Services (MP/P015)

    • Revision of the last paragraph, under Background, to align with the COC and SPD coverage language
    • Addition of the new coverage for provision on Counseling for Healthy Weight and Weight Gain During Pregnancy (Released May 2021; Effective June 2022 and upon group renewal, thereafter)
    • Expansion of coverage for ultrasounds, by the addition of CPT codes 76811, 76812, 76816 and 76817 for groups subject to Minnesota state statutes

  • Radiofrequency Ablation (MC/F024) - addition of the statement under the Site of Care indications Roman numeral I.D.

  • Special Coverage for the COVID-19 Pandemic (MP/C015) – revised included services

  • Speech Therapy, Outpatient Setting (MC/N004) - Combined the previous A and C statements, into one new statement (A) and added language and hearing as other areas where a functional defect/physical impairment may occur (beyond speech or swallowing), and for which speech therapy may be allowed

Retired

  • Gender Reassignment, Non-Surgical Treatment for Gender Dysphoria (MC/G014)

  • Hospice Services (MP/H007)

    • Back to Top ↑

Medical Investigative List

Addition: Skin and soft tissue substitutes; does not include the products under Comments

Revisions

  • Acellular and cellular dermal replacement products from human placental membrane and umbilical tissue for wound care has been revised to allow Epifix® or Grafix® (GrafixPL, GrafixPL PRIME) for treatment of diabetic foot and chronic venous ulcers, only; all other uses are investigative

  • Cerebral perfusion analysis using computed tomography – is now proven effective for acute cerebral ischemia (acute stroke, only); all other uses remain investigative

  • Extensive code revisions made throughout the Investigative List

  • Implantable subcutaneous target stimulator / peripheral subcutaneous field stimulation (PSFS)/ peripheral nerve field stimulation (PNFS); Comments/definitions revised to include the name of a device, the Sprint PNS System and to also include chronic migraine prevention or treatment as examples of investigative uses

Deletions

  • Computed tomography scan for purpose of biomechanical computed tomography analysis CPT 0558T

  • Pharmacogenetic/pharmacogenomic testing, GeneSight Psychotropic panel

  • Prosthesis, lower limb - powered microprocessor components – deleted HCPCS code L5859

Please visit PreferredOne.com for the most current version.

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 underutilization. Utilization management decision making is based only on the appropriateness of care and service and existence of coverage.

Back to Top ↑

Quality Management

Exchange of Information
Coordination of care among providers is a vital aspect of good treatment planning to ensure appropriate diagnosis, treatment and referral. PreferredOne would like to take this opportunity to stress the importance of communicating with your patient’s other health care practitioners. This includes primary care physicians and medical specialists, as well as behavioral health practitioners. While we realize in this age of electronic medical records, many records are available to other practitioners in the same care system, currently across systems there is not this coordination of information about your patients.

Coordination of care is especially important for patients with high utilization of general medical services and those referred to a behavioral health specialist by another health care practitioner. PreferredOne urges all its practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other health care practitioners at the time treatment begins.

We encourage all health care practitioners to:

1. Discuss with the patient the importance of communicating with other treating practitioners.

2. Obtain a signed release from the patient and file a copy in the medical record.

3. Document in the medical record if the patient refuses to sign a release.

4. Document in the medical record if you request a consultation.

5. If you make a referral, transmit necessary information; and if you are furnishing a referral, report appropriate information back to the referring practitioner.

6. Document evidence of clinical feedback (i.e., consultation report) that includes, but is not limited to:

  • Diagnosis

  • Treatment plan

  • Referrals

  • Psychopharmacological medication (as applicable)

We appreciate your efforts to provide coordinated care among our membership population and ensuring your patients and their entire medical team is informed about patients’ medical treatment plans and outcomes.

Minnesota Community Measurement - Release of the 2021 Health Care Quality Report
Minnesota Community Measurement (MNCM) is a collaboration among health plans and provider groups designed to improve the quality of medical care in Minnesota. MNCM’s mission is to accelerate the improvement of health by publicly reporting health care information. MNCM has three goals:

  • Reporting the results of health care quality improvement efforts in a fair and reliable way to medical groups, regulators, purchasers, and consumers.

  • Providing resources to providers and consumers to improve care.

  • Increasing the efficiencies of health care reporting in order to use our health care dollars wisely.

PreferredOne is one of seven founding health plan members of MNCM. The state medical association, medical groups, consumers, businesses, and health plans are all represented on the organization's board of directors. Data is supplied by participating health plans on an annual basis for use in developing their annual Health Care Quality Report.

MNCM released their 2021 Health Care Quality Report on their website during the first quarter of 2022. The 2021 Health Care Quality report features comparative provider group performance on depression care, preventive health screening, and chronic disease care. One of the primary objectives of this report is to provide information to support provider group quality improvement. Provider groups will find this report useful to improve health care systems for better patient care. Sharing results with the public provides recognition for provider groups that are doing a good job now and motivates other groups to work harder. The report will allow provider groups to track their progress from year-to-year and to set and measure goals for future health care initiatives. The MNCM website also provides consumers with information regarding their role as active participants in their own care. Visit the MNCM website site to view the 2021 Minnesota Health Care Quality Report at www.mncm.org.

HEDIS Measurement and Specification
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. The measures listed below are hybrid measures; this means the data can be collected both from administrative data and chart information. What you may not realize is that the difficulty of collecting this information from clinic records could be lessened if practitioners were to use appropriate codes when submitting their billing statements. These measures have appropriate codes that would assist PreferredOne in collecting this information administratively through claims data.

  • Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents:

    This measure examines the percentage of members 3-17 years of age who had an outpatient office visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition, and counseling for physical activity.

    Please ensure that for adolescents that a BMI is both calculated, and a percentile is coded and documented accordingly.

    Description CPT ICD-10-CM Diagnosis HCPCS
    BMI Percentile Z68.51-Z68.54 3008F
    Counseling for nutrition 97802-97804 Z71.3 S9470, S9452, S9449, G0270-G0271, G0447
    Counseling for physical activity Z02.5, Z71.82 S9451, G0447

 

  • Controlling High Blood Pressure

    This measure examines the percentage of members 18-85 years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90 mm Hg) during the measurement year.

    Systolic Blood Pressure CPT ICD-10-CM Diagnosis HCPCS

    Systolic Blood Pressure

     

    3074F(systolic < 130mmHg), 3075F(systolic 130-139mmHg), 3077F(> or = 140 mmHg)

    		 I10  

    Diastolic Blood Pressure

     

    3079F(diastolic 80-89mmHg), 3078F(diastolic <80mmHg), 3079F(diastolic 80-89 mmHg), 3080F(diastolic > or = 90 mmHg)

    I10

     

We encourage practitioners to use the above coding specifications to reduce the burden of chart review that will need to be performed at your clinic in the following year.  If you have questions about these measures, you may visit NCQA’s website at www.ncqa.org or contact us at quality@preferredone.com.

HEDIS Data
We would like to thank all of our provider groups for their cooperation and collaboration during our recent HEDIS medical record review process.  We realize that this process is burdensome to clinics and staff and appreciate your willingness in working with our vendor to ensure our HEDIS results for measurement year 2021 are accurate.  Thank you!

Reminding Patients of Yearly Physical Exam
As the end of 2022 rapidly approaches, we want to encourage all our practitioners to remind their patients to make an appointment for their annual physical exam. In the wake of the COVID-19 pandemic annual screenings, especially for older adults and those with chronic or pre-existing conditions, decreased. Now with robust vaccination programs and effective safety protocols in place patients can feel safe to visit their primary care practitioner and have their annual screenings performed.

Back to Top ↑

CODING

ICD-10-CM Coding Reminders

Z79.01 - Z79.899Long-term (current) drug therapy
PreferredOne receives claims with diagnosis Z79.899 (Other long term (current) drug therapy) on claims for drug testing (CPT® codes 80305 – 80307, 80320 – 80377, HCPCS codes G0480 – G0484 and G0659). This is incorrect and will result in the claim being denied for incorrect diagnosis. Resource for this determination is the ICD-10-CM Official Guidelines for Coding and Reporting, Chapter 21: Factors influencing health status and contact with health services (Z00 – Z99).

Subcategory Z79); Codes from this category indicate a patient’s continuous use of a prescribed drug (including such things as aspirin therapy) for the long-term treatment of a condition or for prophylactic use. It is not for use for patients who have addictions to drugs. This subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence). Assign the appropriate code for the drug dependence instead.

Back to Top ↑