Skip Navigation

April Newsletter

April 9, 2014

ICD-10 Transition Delayed to 2015

On April 1, President Obama signed bill H.R. 4302, enacting into law the Protecting Access to Medicare Act of 2014. The act was introduced as a temporary solution to the Medicare sustainable growth rate, but it also delays implementation of ICD-10 until October 1, 2015, at the earliest.

It’s unclear how delaying ICD-10 became part of the act, and this came as a complete surprise to most in the health care industry. In fact, the U.S. Department of Health and Human Services has not released an official statement on the change.

Although this delays the transition to ICD-10, it does not change the training and preparation needed to transition to the new code set. Please continue to assess if you are ready for ICD-10. If you are not ready, please talk to your administrators and ask them, what your plan for ICD-10 is. You can view the official industry resources for the ICD-10 transition on CMS’s website.

Watch your email for the next ICD-10 Sneak Peek from Coding Counts, brought to you by our Risk Management coding consultant team. If you would like to be added to our distribution list, email us at CodingCounts@healthalliance.org.

Risk Adjustment – Coding Consultant Team

The coding consultant team works with high-volume providers on risk mitigation, coding accuracy, and best practices in documentation. We regularly post coding updates on Coding Counts. You can also contact us at CodingCounts@healthalliance.org to sign up for monthly emails which highlight information related to risk adjustment and ICD-10.

Feel free to contact us for any risk adjustment coding needs.

Use New 1500 Claim Form

As of January 2014, providers can use the 1500 version 02-12 paper claim form. Providers could still use the old version of the form (CMS 1500 v. 08-05) or the new version (1500 v. 02-12) until the March 31, 2014 compliance date.

Since we are now past that date, you must only use the new 02-12 version.  Any paper claims that we receive from providers submitted on the CMS 1500 (08-05) form after March 31, 2014 will be rejected to the provider with a request to resubmit on the 1500 (02-12) claim form.

For more information on the 1500 (02-12) claim form, visit the National Uniform Claim Committee website or contact your provider relations specialist.

2014 Provider Manuals Available

The 2014 Provider Manuals are available on the Forms and Resources page of Your Health Alliance for providers and office personnel. Contact your provider relations specialist with any questions or if you would like to order a CD copy.

Pharmacy Updates

Medicare

New and Revised Policies

New Medicare Policies

Med D Tier Changes

  • Vimpat – Moved from Tier 4 to Tier 3 on all formularies
  • Neupro – Moved from Tier 4 to Tier 3 on all formularies
  • Pataday – Added to all formularies at Tier 4
  • Patanol – Added to all formularies at Tier 4
  • Saphris – Step removed and available at Tier 3 on all formularies

Medicaid

Formulary Additions

  • Ampyra (dalfampridine)
    • MMAI – Tier 2 with preauthorization (PA)
    • SPD – Covered with PA
  • Fetzima (levomilnacipran extended release)
    • MMAI – Tier 2 with step through generic SSRI
    • SPD – Not covered
  • Fycompa (perampanel)
    • MMAI – Tier 2 with no restrictions
    • SPD: Covered with no restrictions
  • Gazyva (obinutuzumab)
  • MMAI – Tier 2 with PA
  • SPD – Covered with PA
  • Granix (TBO-filgrastim)
    • MMAI – Tier 2 with PA
    • SPD – Covered with PA
  • Imbruvica (ibrutinib)
    • MMAI – Tier 2 with PA
    • SPD – Covered with PA
  • Olysio (simeprevir)
    • MMAI – Tier 2 with PA
    • SPD – Covered with PA
  • Sovaldi (sofosbuvir)
    • MMAI – Tier 2 with PA
    • SPD – Covered with PA

Revised Policies

  • Excluded Drug Policy Additions
    • Compounded products containing one or more ingredients that are bulk powders which are commercially available drugs
    • Compounded products of 2 or more commercially available drugs that offer no additional clinical benefit compared to taking the individual components
  • Neupogen Policy (SPD only)
    • Step through Granix for all indications

Commercial


Formulary Additions

  • Brintellix (vortioxetine) – Tier 3 with PA
  • Fetzima (levomilnacipran extended release) – Tier 3 with PA
  • Adempas (riociguat) – Tier 5 with PA
  • Opsumit (macitentan – Tier 5 with PA
  • Mekinist (trametinib dimethyl sulfoxide) – Tier 5 with PA
  • Tafinlar (dabrafenib mesylate) – Tier 5 with PA
  • Gilotrif (afatinib dimaleate) -Tier 5 with PA
  • Imbruvica (ibrutinib) – Tier 5 with PA
  • Gazyva (obinutuzumab) – Tier 5 with PA
  • Valchlor (mechlorethamine HCl) – Tier 5 with PA
  • Granix (TBO-filgrastim) – Tier 4 with PA
  • Mirvaso (brimonidine tartrate) – Tier 3 with Step Therapy through generic topical metronidazole
  • Olysio (simeprevir) – Tier 4 with PA
  • Sovaldi (sofosbuvir) – Tier 5 with PA
  • Fycompa (perampanel) – Tier 3
  • Tivicay (dolutegravir – Tier 5
  • Trokendi (topiramate extended release) – Tier 3 with Step Therapy through generic topirimate

Revised Policies

  • Excluded Drug Policy
    • Compounded products containing one or more ingredients that are bulk powders which are commercially available drugs
    • Compounded products of 2 or more commercially available drugs that offer no additional clinical benefit compared to taking the individual components
  • Isotretinoin Oral
    • Coverage of Absorica requires trial and failure with Amnesteem, Claravis, Myorisan, Or Zenatane
  • Savella
    • Added trial and failure of or contraindication to duloxetine to criteria
  • Advair 500/50
    • Preauthorization requiring a diagnosis of Asthma has been removed
    • All strengths of Advair will now be available without preauthorization
  • Behavioral Health Policy
    • Applies to Viibryd, Fetzima, and Brintellix
    • Requires trial and failure of 2 Tier 1 SSRIs and 2 Tier 1 SNRIs (venlafaxine, venlafaxine XR, or desvenlafaxine and duloxetine)

HEDIS® Measure – Disease-Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis

This HEDIS measure assesses whether patients with rheumatoid arthritis (RA) receive a Disease Modifying Anti-Rheumatic Drug (DMARD) to slow the disease’s progression and help them maintain functional capacity longer.

Historically, the Health Alliance HEDIS rate for Commercial members with RA who take a DMARD has been above or near the 90th percentile, as reported in Quality Compass. However, as the table below shows, the percentage of Medicare Advantage members with RA who take a DMARD decreased from HEDIS 2012 to HEDIS 2013, with the HEDIS 2013 Medicare PPO result falling between the Quality Compass National Average and 75th percentile.

This HEDIS measure is a Medicare Star Rating. The Health Alliance Medicare HMO plan remained at 5 stars for this specific measure, but the Medicare PPO plan dropped to 4 stars for this measure. The Health Alliance Medicare HMO overall 2014 Star Rating is 4.5, and the Medicare PPO plan dropped to an overall rating of 4 stars.

Please consider prescribing a DMARD medication for your patients with rheumatoid arthritis.

Disease Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Quality Compass® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Colonoscopy Coding Reminders

We now cover colonoscopy codes 45378-PT and 45380-PT for members 50 and over once every 10 years under the wellness benefit. The PT modifier is required for coverage under the wellness benefit.

The 45383-PT, 45384-PT, and 45385-PT colonoscopy codes continue to be covered under the wellness benefit once every 10 years for members 50 and over.

Encourage Seniors to Get Active with SilverSneakers®

We know you want the best for your senior patients’ health and continued mobility. One way you can encourage your patients on our Medicare Advantage plans to stay active is by reminding them that their coverage includes free access to the SilverSneakers program.

SilverSneakers members can:

    • Use all basic amenities and take classes at any of the 11,000 SilverSneakers locations
    • Get guidance and help from a Program AdvisorSM
    • Enjoy fun social activities
    • Go online for nutrition and fitness tracking tools, exercise videos, and expert advice
    • Order a fitness kit to get moving at home

Medicare Advantage members can visit SilverSneakers.com or HealthAllianceMedicare.org to learn more, and if you have questions, give us a call at 1-800-965-4022.

Save