April Newsletter

Coming Soon: New iCES Facility Claims Editor

We will begin using the new iCES Facility Claims Editor on May 1. It will work very similar to the existing Professional Claims Editor in detecting appropriate coding and billing. Here are some things you should know about the new claims editor:

• Venipunctures will be disallowed as incidental to labs.
• We will be following Medicare guidelines (OPPS Edits) for all products.
• Use of modifiers are necessary. Specifically:
  • Modifier 27 required for multiple E/M visits on same date of service.
  • Modifier L1– Outpatient laboratory tests that are generally packaged as ancillary services should have Modifier L1 attached if the hospital provides an outpatient lab test on the same date of service as other hospital outpatient services that are clinically unrelated and should be paid separately.
  • Therapy modifiers.
• Modifier reductions
• Unbundling/rebundling of services (i.e. lab panels).
• Therapy functional reporting HCPCS codes are required.
• We will be following Medicare’s MUE guidelines.
• When billing revenue code 637, a HCPCS code must be submitted—the line cannot be blank.
• When reporting CPT 90999 for Dialysis, a modifier for URR (G1-G6 Modifier) must be attached.
• The patient discharge status code must be 30 (still patient) when the frequency digit is the type of bill 2 (Interim – First Claim) or the frequency digit is the type of bill 3 (Interim – Continuing Claim).

Pharmacy Updates

All Plans

Formulary Additions

• Esbriet (pirfenidone) – A pyridone analog for Idiopathic Pulmonary Fibrosis (IPF).
  • Commercial – Tier 6 with PA
  • Medicare and Duals – Non-Formulary
  • Medicaid – Covered with PA
• Ofev (nintedanib esylate) – A systemic enzyme inhibitor for Idiopathic Pulmonary Fibrosis (IPF).
  • Commercial – Tier 6 with PA
  • Medicare – Tier 5 with PA
  • Duals – Tier 2 with PA
  • Medicaid – Covered with PA
• Akynzeo (netupitant/palonosetron hcl)—A combination neurokinin 1 (nk1) receptor antagonist/5-ht3 receptor antagonist for nausea and vomiting associated with cancer chemotherapy.
  • Commercial – Tier 3 with Quantity Limit of 3 capsules per 28 days
  • Medicare, Duals, and Medicaid – Non-Formulary
• Savaysa (edoxaban) – A novel oral anticoagulant for stroke risk reduction in patients with NVAF and prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE).
  • Commercial – Added to Tier 3 with Step Therapy through warfarin and Xarelto;
  • Medicare, Duals, and Medicaid – Non-Formulary
• Mircera (methoxy polyethylene glycol-epoetin beta) – An erythropoiesis stimulating agent (ESA) for anemia associated with chronic kidney disease (CKD).
  • Commercial – Tier 3 with no restrictions
  • Medicare – Tier 3 with B versus D Determination
  • Duals – Tier 2 with B versus D Determination
  • Medicaid – Covered without PA

Medicaid

New Policies

• Medicaid Drug Policy for ADHD Medications – Establishes PA criteria for brand name ADHD medications
• Medicaid Drug Policy for High Risk Drugs – Establishes PA criteria for medications that have been classified by the AGS Beers Criteria as high risk

Criteria Change

• Medicaid Drug Policy for Anticoagulant, Novel, Pradaxa and Xarelto Step-Edit – Added Step Therapy through Xarelto for Pradaxa, and removed language excluding cardiologists from Step Therapy

Medicaid & Commercial

New Policies

• Thiola (tiopronin)  – Now requires a prescription from a urologist and the diagnosis of severe homozygous cystinuria with urinary cysteine > 500mg/day as part of new PA
• High Dollar Medication Override – Establishes procedure for overriding a claim whose billed dollar amount is above a set threshold
• Idiopathic Pulmonary Fibrosis (IPF)  – Criteria for Esbriet and Ofev require prescription from a specialist, baseline LFTs and a confirmed diagnosis of IPF as defined by the American Thoracic Society. Added quantity limits

Criteria Changes

• Diabetes Drug Therapies – Added quantity limits to GLP-1 medications
• Excluded Drug List – Added medical marijuana and the V-Go Insulin Delivery Device
• Cyramza – Added criteria for non-small cell lung cancer (NSCLC)
• Kalydeco – Added criteria for R117H mutation in the CFTR gene
• Statin, Brand Name – Removed language excluding cardiologist from PA on branded products

Commercial

Criteria Changes

• Anemia SGM – PA removed from drugs on Anemia SGM policy (Aranesp, Epogen, Procrit, and Omontys)
• Hemophilia SGM – PA removed from drugs on Hemophilia SGM policy (Advate, Helixate FS, Kogenate FS, Recombinate, Xyntha, Hemofil M, Monoclate-P, Koate-DVI, Alphanate, Humate-P, Wilate, BeneFIX, AlphaNine SD, Mononine, Bebulin VH, Profilnine SD, Feiba NF, NovoSeven RT, and Stimate)
• Anticoagulant, Novel, Eliquis, Pradaxa, and Savaysa Step-Edit – Added Savaysa. Added Step Therapy through both warfarin and Xarelto for Non-Preferred products Eliquis, Pradaxa and Savaysa. Removed language excluding cardiologists from Step Therapy.
  • Note: Xarelto will be covered at Preferred Brand tier, without restrictions.

Helpful ICD-10 FAQ

We know you and your team might have questions about the transition to ICD-10, which goes into effect October 1, 2015. Our coding and CPS teams put together an FAQ to help. Below is a preview. You can see the whole FAQ on the Forms & Resources page of Your Health Alliance.

If you have other ICD-10 questions, email us at PSC@healthalliance.org.

• What has Health Alliance done to prepare for ICD-10?

Our design, development, testing, and deployment are aligned for the October 1, 2015, ICD-10 compliance date. We have completed all analyses, including gap and system impact inventory, and system remediation. We have engaged the impacted areas of our company in our business assessments.  We will be ready for the move from ICD-9 codes to ICD-10 codes.

• How will reimbursement methodology be impacted by ICD-10?

The ICD-10 conversion was not intended to transform payment or reimbursement. However, it may result in reimbursement methodologies that more accurately show patient status and care. We have engaged the impacted areas of our company in business assessments and planning for the move from ICD-9 codes to ICD-10 codes. As a result of this assessment, we will be updating all impacted policies, processes and systems to be compliant with the ICD-10 code set.

• Will you accept both ICD-9 and ICD-10 code formats after October 1, 2015?

No. Beginning with dates of service/discharge on or after October 1, 2015, ICD-10 codes will need to be submitted. ICD-9 codes should be submitted for dates of service/discharge before October 1, 2015.

New Clear Coverage Function

Clear Coverage has enhanced its help section to include short FAQ demos that answer questions on how to perform certain tasks in the Clear Coverage Outpatient application. They include:

• What should I do if a medical review results in Criteria Not Met?
• How do I add a preferred service facility?
• How do I add a preferred provider to the Requesting Clinician drop-down list?
• How do I fax information to an authorization request?

Log in to Your Health Alliance and open Clear Coverage. You’ll find the demos in the Help Contents section. Choose Video Tutorials, and then a topic.

Diagnosis Codes and Risk Adjustment

All Risk Adjustment models are dependent on diagnosis codes received through claims submission. It is imperative that all claims and associated diagnosis codes are submitted to Health Alliance. Recently, we have identified 2 areas of opportunity related to provider business processes.

• Code truncation (limiting the number of diagnosis codes per claim submission)
• Claims that are not submitted at all (e.g. capitated, custodial care, etc.)

These scenarios result in inaccurate reporting of the overall risk of our population. Please assess your billing practices at an organizational and provider level to ensure these situations don’t apply to you. If you have identified these issues in your provider system, email CodingCounts@healthalliance.org so we can help with a solution.

Health & Wellness Info on Our Website

If your patients/our members are looking for health resources, please direct them to the recently updated Health & Wellness section of HealthAlliance.org. It includes resources and info like:

• Health record cards
• Immunization schedules
• BMI charts
• How to manage diabetes, high blood pressure, and other conditions
• Asthma videos on how to use an inhaler and flow meter
• Links to healthy extras like Assist America and Anytime Nurse Line

Check out Coding Counts

The Risk Adjustment coding consultant team has informative info on Coding Counts, for providers, billing staff, and coding professionals. It includes quarterly blog posts on a variety of risk adjustment topics, commonly asked questions, links to helpful resources, details on upcoming events, videos of past coding workshops, and all of the emails we’ve sent. Visit Coding Counts today.