Reid August Newsletter
August 8, 2017Submitting Therapy Preauthorization Requests on eviCore
Recently, there’s been some confusion around therapy preauthorization (PA) requests on eviCore. This chart can help make sense of who you need to make preauthorization requests for and the timeframes for those requests:
Physical, Occupational, Massage, Acupuncture, and Chiropractic Therapies
| Patient Type | When Is PA Through eviCore Required? |
|---|---|
| Patients currently in treatment plans that began before August 1, 2017 |
PA is not required through eviCore through 2017 unless there is a change in diagnosis. PA must be obtained for continuing treatment before January 1, 2018.* |
| Patients who will begin treatment on August 1, 2017 or after |
PA is required for all dates of service of August 1, 2017 and after.* |
*Note: eviCore will accept PA requests for these therapy programs no more than 14 days before the date of service if requested online through Your Health Alliance for providers. If requested via phone or fax, they will not accept them more than 7 days before the date of service.
Radiation Therapy
| Patient Type | When Is PA Through eviCore Required? |
|---|---|
| Patients currently in treatment plans that began before August 1, 2017 | PA is not required through eviCore through 2017 unless there is a change in diagnosis. PA must be obtained for continuing treatment before January 1, 2018. |
| Patients who will begin treatment on August 1, 2017 or after | PA is required for all dates of service August 1, 2017 and after. |
If you have any questions, contact your provider relations specialist.
New Numbers & Medicare Cards Coming in April 2018
Medicare is taking steps to remove Social Security numbers from Medicare cards. People with Medicare will begin receiving new Medicare cards in April 2018, until all cards are replaced by April 2019. These cards will have a Medicare Beneficiary Identifier (MBI) number that is randomly generated.
Medication Reconciliation Post-Discharge Measure
Medication reconciliation after a hospital, skilled nursing facility (SNF), or extended care facility (ECF) stay is an important part of continuity of care and improves the safety of patients. In one study, more than 80% of patients had an error related to or a misunderstanding of their discharge medications, more commonly with the medications that were unrelated to their primary diagnosis.
The measure evaluates if a provider completed a medication reconciliation for Medicare Advantage patients within 30 days of discharge from acute and non-acute settings.
A prescribing provider, registered nurse, or pharmacist can complete medication reconciliation. It can be done at the time of discharge or within 30 days, but it must be clear that any medications the patient had before their admission were compared with their medications at the time of their discharge. Phone call and home visit documentation of a medication review can also be used if the notes are included in the outpatient record.
The National Committee of Quality Assurance (NCQA) recognizes this evidence as meeting compliance for this measure:
- Billing codes 99495, 99496, and 1111F
- Discharge summary with documentation that discharge medications were reconciled with the most recent medication list in the outpatient record, which must be filed in the outpatient record within 30 days of discharge
- Post-discharge hospital follow-up visit with documentation of medication reconciliation or review
- Documentation of the current medications and a notation that:
- Discharge medications were reviewed
- References the discharge medications (e.g., no changes in medications since discharge, same medications at discharge, or discontinue all discharge medications)
- The provider reconciled the current and the discharge medications
- Documentation of both current and discharge medication lists and a notation that both were reviewed on the same date of service
- Notation that no medications were prescribed or ordered upon discharge
Note: If a patient discharges from a hospital to an SNF or ECF, medication reconciliation must be documented in their outpatient record within 30 days of being discharged from the SNF or ECF.
Thank you for your efforts in helping patients understand their medication and how to take them safely.
Statin Use and Adherence HEDIS Measures
Statin Therapy for Patients with Cardiovascular Disease and Statin Therapy for Patients with Diabetes are 2 measures the NCQA included in the 2017 HEDIS audit.
Both of these measures are administrative measures, which means data is collected from claims submitted to us. To get accurate results, claims information must be complete, reflecting the appropriate diagnosis, as well as any conditions or medications that may exclude the member from the denominator.
Statin Therapy for Patients with Cardiovascular Disease
Reflects the percentage of members, males 21 to 75 years and females 40 to 75 years, who have had a diagnosis of clinical atherosclerotic cardiovascular disease and were dispensed at least one high or moderate-intensity statin medication during the measurement year.
The adherence rate is also measured to show the percentage of members who achieved a proportion of days covered (PDC) of at least 80%, beginning with the first prescription fill to the end of the measurement year.
Statin Therapy for Patients with Diabetes
Reflects the percentage of members with diabetes between the ages of 40 to 75 who were dispensed a prescription for a statin during the measurement year.
The adherence rate is also measured to show the percentage of members who achieved a PDC of at least 80%, beginning with the first prescription fill to the end of the measurement year.
Members with the following conditions are allowed to be excluded from both measures:
- Pregnancy
- Having in vitro fertilization procedure
- Current prescription for clomiphene
- End stage renal disease
- Cirrhosis
- Myalgia
- Myositis
- Myopathy
- Rhabdomyolysis
Most of the allowed exclusions can be coded during the measurement year or the year before the measurement year; however, myalgia, myositis, myopathy, or rhabdomyolysis need to be coded annually if that’s the reason the patient can’t tolerate the statin.
See the list of conditions and codes accepted as exclusions by the NCQA for muscle pain and muscle disease below. Providers can receive other diagnosis codes accepted as exclusion by contacting the Quality Management department at 1-800-851-3379, ext. 8112.
| Code | Definition | Code System |
|---|---|---|
| G72.0 | Drug-induced myopathy | ICD10CM |
| G72.2 | Myopathy due to other toxic agents | ICD10CM |
| G72.9 | Myopathy, unspecified | ICD10CM |
| M62.82 | Rhabdomyolysis | ICD10CM |
| M79.1 | Myalgia | ICD10CM |
HEDIS 2017 (Measurement Year 2016) and HEDIS 2016 (Measurement Year 2015) Results
National benchmarks are not available at this time.
Statin Therapy for Patients with Cardiovascular Disease
Commercial HMO/POS
| HEDIS 2017 | HEDIS 2016 | |
|---|---|---|
| Received Statin Therapy – Males | 81.87% | 79.33% |
| Statin Adherence 80% – Males | 72.56% | 75.09% |
| Received Statin Therapy – Female | 73.40% | 71.46% |
| Statin Adherence 80% – Females | 66.44% | 68.79% |
| Received Statin Therapy – Total | 79.49% | 77.16% |
| Statin Adherence 80% – Total | 70.97% | 73.48% |
Medicare HMO
| HEDIS 2017 | HEDIS 2016 | |
|---|---|---|
| Received Statin Therapy – Males | 75.00% | 76.22% |
| Statin Adherence 80% – Males | 82.81% | 84.40% |
| Received Statin Therapy – Female | 70.59% | 59.04% |
| Statin Adherence 80% – Females | 66.67% | 83.67% |
| Received Statin Therapy – Total | 73.60% | 69.91% |
| Statin Adherence 80% – Total | 77.90% | 84.18% |
Northwest Medicare HMO
| HEDIS 2017 | HEDIS 2016 | |
|---|---|---|
| Received Statin Therapy – Males | 86.11% | 82.29% |
| Statin Adherence 80% – Males | 79.57% | 81.01% |
| Received Statin Therapy – Female | 80.85% | 77.50% |
| Statin Adherence 80% – Females | 78.95% | 80.65% |
| Received Statin Therapy – Total | 84.52% | 80.88% |
| Statin Adherence 80% – Total | 79.39% | 80.91% |
Statin Therapy for Patients with Diabetes
Commercial HMO/POS
| HEDIS 2017 | HEDIS 2016 | |
|---|---|---|
| Received Statin Therapy | 61.18% | 60.56% |
| Statin Adherence 80% | 74.62% | 73.33% |
Medicare HMO
| HEDIS 2017 | HEDIS 2016 | |
|---|---|---|
| Received Statin Therapy | 69.15% | 69.16% |
| Statin Adherence 80% | 82.05% | 82.43% |
Northwest Medicare HMO
| HEDIS 2017 | HEDIS 2016 | |
|---|---|---|
| Received Statin Therapy | 74.16% | 70.80% |
| Statin Adherence 80% | 72.95% | 74.58% |
Please discuss the benefits of statin use with your patients and, if you have patients who cannot tolerate one of the statins, be sure and code the reason.
NCQA is a nonprofit organization dedicated to improving our nation’s health care system. Since its founding in 1990, NCQA has been a central figure in health care improvement, and its seal is a widely recognized symbol of quality and service.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
Meet with a Coding Specialist
The risk adjustment coding consultants are continuing to request meetings with participating, high-volume provider offices. These meetings are designed to share member-specific examples of coding and quality measure needs and to update providers on the latest efforts to educate on risk adjustment. Along with member specific examples, there is information on yearly risk adjustment data validation (RADV) audits and how provider practice participation is essential in this process.
A member of the coding consultant team is willing to meet with you to discuss any coding or quality questions you may have, or to provide member-specific examples from your panel of members. If interested, contact us at CodingCounts@healthalliance.org.
Pharmacy Updates
All Plans
eviCore Preauthorizations – Effective August 1, 2017
- All oncology regimens will require PA through eviCore
- This includes many new medications that did not previously require PA through us
- Refer to our formulary for more details
Review of P&T Committee Minutes – From April 5, 2017
- Diabetes Drug Therapies – Added non-preferred insulin step therapy (ST)
- Novolog and Novolin products require step through Humalog/Humulin
Formulary Additions
- Rhofade (oxymetazoline hydrochloride) – Indicated for the persistent facial erythema associated with rosacea in adults.
- Medicare – Non-formulary
- Eucrisa (crisaborole) – Indicated for the treatment of mild to moderate atopic dermatitis in patients 2 years of age and older.
- Medicare – Non-formulary
- Dupixent (dupilumab) – Indicated for the treatment of moderate to severe atopic dermatitis in adults whose disease is not adequately controlled with topical prescription therapies, or when those therapies are not advisable.
- Medicare – Non-formulary
Medicare
Tier Changes
- Fluticasone propionate/salmeterol – Moved from Non-Formulary to Tier 2
- Authorized generic for AirDuo RespiClick
- Generic version $113 per month versus Advair $435 per month
- Available strengths include 55/14, 113/14, and 232/14
- Nitrofurantoin (Macrobid) – Moved from Non-Formulary to Tier 2
- The American Geriatrics Society 2015 Beers Criteria Update Expert Panel has revised its recommendation to avoid use of nitrofurantoin in renal impairment from patients with a CrCl <60mL/min to those with a CrCl <30mL/min, based on 2 retrospective studies that identified the safety and efficacy of nitrofurantoin in this population
- Additionally, the increasing resistance to both sulfamethoxazole/trimethoprim and fluoroquinolones gives an advantage to the use of nitrofurantoin
Tier Changes – Effective January 1, 2018
- Olmesartan Products – Moving from Tier 2 to Non-Formulary
- Dr. Farasat provided feedback that this would be reasonable given there are several covered alternatives
- Esomeprazole – Moving from Tier 2 to Non-Formulary
- Dr. Moy provided feedback that this would be reasonable given there are several covered alternatives