May Informed Newsletter

May 20, 2025

Always Grateful

With spring in full bloom and summer around the corner, we know it’s a particularly busy time of year for you. Please know how deeply grateful we are for all you do for our members and for us. Your hard work, dedication and skills never go unnoticed. Thank you for your incredible partnership.

Weight Loss Medication Coverage for State of Illinois Employees

If your patients are State of Illinois employees (or their eligible covered dependents) who are members of our health plan, they’re currently eligible for weight loss medication coverage if they’ve met prior authorization criteria (including enrollment and participation in a lifestyle management program). Please note, however, that Health Alliance™ will no longer be offering State of Illinois employee health plans after June 30, 2025, and that these patients will be enrolling with a new carrier for their coverage effective July 1, 2025. When their new coverage with a new carrier begins on July 1, these patients who are currently on medications for weight loss may have new prior authorization requirements and may need to enroll in the new carrier’s lifestyle management program. You and your patients may want to verify any new prior authorization requirements proactively, to help prevent or minimize any disruptions in coverage.

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Help us move the needle.

Together we can help people live their healthiest lives. Find reminders, tips and more in this section, to guide improvements in patient outcomes. Help us move the needle.

Help reduce readmissions.

You can help reduce hospital readmissions. Here are some strategies:

Set up and use care transition programs. These help your patients transition smoothly from inpatient to outpatient care. These programs include giving your patients a written care plan personalized to them, coordinating their follow-up visits, and educating them about their conditions and self-management.
Perform medication reconciliation. Do this before patients are discharged, and make sure they understand their medications, their dosages and how to take their drugs effectively.
Schedule postdischarge follow-up visits. These help monitor your patients’ progress and address any issues.
Provide comprehensive patient education. Make sure your patients understand their conditions, care plans, self-management and the importance of adhering to your recommendations.
Practice care coordination with your patients’ other healthcare providers. Share information and keep each other in the loop.
Work with social workers and community resources to address your patients’ social determinants of health. Connect your patients to transportation, food and housing assistance as needed.
Implement quality improvement initiatives to specifically address readmissions. Analyze your data and create specific approaches to the pitfalls you’re noticing.
Actively engage your patients and their families in the care plan.

Source: Jasninder S. Dhaliwal and Ashujot Kaur Dang, “Reducing Hospital Readmissions,” StatPearls, 7 June 2024.

School Physical Reminder

As May becomes June and the start of summer, don’t forget to schedule your child and teen patients’ school and sports physicals for the upcoming school year. Summer is a busy time for all, so we recommend you schedule as early as possible.

Physical exams are a great way to help make sure any health problems are detected in their earliest stages when they are easiest to treat. These exams also give you a chance to talk to your young patients about body mass index (BMI) and the importance of nutrition and maintaining a healthy weight.
It’s also important to ask if your patients are up to date on needed vaccines, including Gardasil, which helps prevent HPV (an infection that can lead to cancer).
If your patient takes medication, make sure prescriptions are up to date and they have a supply for the beginning of the school year.
Remember, for children who participate in sports, sports physicals are often required by schools, and without one, they may not be allowed to participate.

Virta – For Your Patients with Diabetes

Help your patients transform their lives: If they have diabetes and are a member of our health plan, encourage them to use the Virta benefit.

Virta is made up of physicians, nurse practitioners and health coaches who deliver medically supervised, individualized carbohydrate restriction via the Virta app. Care is available seven days a week, enabling patients to lose weight, normalize blood sugar and require fewer medications.

Virta can help patients lower their blood sugar, stopping progressive diabetes in its tracks. Provider-led and coach-supported care keeps patients on track without counting calories.

Patients who use Virta experience results quickly, often in a matter of weeks. And the results last.

Average Weight Loss: 12% experience weight loss similar to that delivered by current weight loss drugs
Medicaton Reduction: 63% fewer diabetes medications.
HbA1c Reduction: 3% reduction occurs simultaneously with blood sugar improvement.

Virta is a trusted extension of your practice that helps patients safely and sustainably lower HbA1c, reduce medications and lose weight, while making it easier for you to do the work you love. Virta’s continuous monitoring tracks patient health and appropriately deprescribes medications when needed. Importantly, Virta stays in touch on relevant patient milestones and health changes.

Virta providers act as diabetes and obesity specialists, additive to your role as the patient’s primary care provider. Virta providers work closely with your patients to ensure they can achieve their best health, by monitoring their biomarkers, counseling them on their metabolic health and deprescribing diabetes medications when it’s safe and appropriate to do so. Virta keeps you informed of changes to your patient’s medication regimens and they’re there to answer any questions you may have.

Not all patients on our health plans are eligible for Virta. For information on eligibility or questions regarding this diabetes reversal program, please have your patients (or you) call the number on their health plan ID card. Virta is available to members and eligible dependents 18 years or older who are enrolled in the health plan. This benefit is currently being offered to those with type 2 diabetes. There are some medical conditions that would exclude members from the diabetes reversal program. Participation in the program is not a guarantee that the member’s diabetes will be reversed and it requires active participation/adherence by the member.

CDC Asthma Action Plan

The CDC has created an Asthma Action Plan template for your patients with asthma. Print and fill these out with your patients, and advise them to keep it on their fridge, in their purse or somewhere else close at hand.

Find the template here: CDC Asthma Action Plan.

HEDIS Measure: Asthma Medication Ratio (AMR)

By meeting HEDIS^®* quality measures, we together improve care for your patients. Here’s information about the Asthma Medication Ratio (AMR) HEDIS measure.

What Is Measured

The percentage of adults and children (age 5 to 64) with persistent asthma who have a ratio of controller medications to total asthma medications of 0.50 or greater.

Why it Matters

Asthma, which affects over 25 million Americans, is treatable and manageable with the appropriate medications. It’s important that your patients use a higher proportion of controller medications (which are key to long-term asthma management) vs. reliever medications (which are used for quick relief of symptoms). Appropriate use of medications not only helps your patients’ health, but it also saves costs and can prevent emergency department visits, hospitalizations, and missed days of school or work.

*The Healthcare Effectiveness Data and Information Set (HEDIS^®) is a set of quality standards that helps us together measure and assess the care and treatments patients receive. HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

HEDIS Measure: Medical Assistance with Smoking and Tobacco Use Cessation (MSC)

By meeting HEDIS^®* quality measures, we together improve care for your patients. Here’s information about the HEDIS measure for Medical Assistance with Smoking and Tobacco Use Cessation (MSC).

What Is Measured

The measure checks whether doctors provide medical assistance to help their patients quit smoking/tobacco use. It checks whether doctors:

Advise smokers and tobacco users (18 years of age and older) to quit, by giving cessation advice.
Discuss cessation medications with these patients.
Discuss cessation strategies and methods with these patients.

Why It Matters

Smoking and tobacco use are the largest cause of preventable death (and disease) in the U.S. Quitting can save lives and improve overall health. And patients turn to their doctors for trusted, expert advice, giving doctors a unique opportunity to move the needle. Comprehensive cessation interventions from trusted doctors can help patients quit. *The Healthcare Effectiveness Data and Information Set (HEDIS^®) is a set of quality standards that helps us together measure and assess the care and treatments patients receive. HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Please note: For your patients who are members of our health plans, remind them that many of our plans offer access to Quit For Life^® at no additional cost. It’s a built-in part of their plan – just waiting for them to use – where they can get personalized help to quit smoking/tobacco. They should visit hally.com/care for more information, and call the number on their health plan ID card to see if their plan includes Quit For Life.

HEDIS Measure: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

By meeting HEDIS^®* quality measures, we together improve care for your patients. Here’s information about the HEDIS measure for Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC).

What Is Measured

The measure looks at outpatient visits to primary care providers or OB-GYN providers, for children and adolescents age 3 to 17, making sure their doctors:

Documented their body mass index (BMI).
Gave them counseling for nutrition.
Gave them counseling for physical activity.

Note: Because BMI goals for youth vary with age and gender, the HEDIS measure evaluates whether BMI percentile is documented, rather than an absolute BMI value.

Why It Matters

Childhood and adolescent obesity have rapidly increased in the past few decades, leading to many health concerns. Early obesity has both immediate and long-term health effects and can become a lifelong issue. It’s key for doctors to monitor weight issues in children and adolescents – and provide continued guidance on how to eat nutritionally, stay active and maintain a healthy weight.

Tips to Help Keep Your Young Patients Healthy

When parents and guardians need expert advice for their children’s health, they turn to you. Here are some tips you can pass along, from the CDC.

Healthy, nutritional eating and regular physical activity:
- Are key for growth and development during the childhood, adolescent and teenage years.
- Help prevent obesity and related conditions, like diabetes, asthma, anxiety and depression.
- Boost immunity.
- Can help raise academic performance.
For healthy eating, limit saturated fat, added sugar and salt.
For physical activity, help kids find something they enjoy – it’ll help them stick with it!
Kids need plenty of sleep, for both their physical and mental well-being.
Parents and guardians should limit children’s screen time.
Finally – but quite importantly – parents and guardians should realize that they are role models to their children. They themselves should model healthy lifestyle behaviors, because their kids often watch and follow.

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Coding Counts:
Specificity matters for depression.

Accurate coding and supporting documentation are key to making sure your patients receive the care they need. Here’s some important information about ICD-10 coding for depression.

There are several different, specific ICD-10 codes used for depression – depending on the type, severity and duration of the condition.

Coding Considerations:

Specificity: It’s crucial to document the specific type and severity of depression. The severity of depression (mild, moderate, severe) and whether it’s a single episode or recurrent episode must be clearly documented.
Duration: For recurrent major depressive disorder (F33), it’s important to note how many episodes of depression the patient has had.
Comorbidities: When the patient has comorbid conditions, such as anxiety disorders or substance use, these should be coded as well. For example, if the patient has major depressive disorder with comorbid anxiety, both F32.1 and F41.9 may be applicable.

Common ICD-10 Codes for Depression:

F32.A – Depression, unspecified.
F32.0 – Major depressive disorder, single episode, mild.
F32.1 – Major depressive disorder, single episode, moderate.
F32.2 – Major depressive disorder, single episode, severe without psychotic features.
F32.3 – Major depressive disorder, single episode, severe with psychotic features.
F32.4 – Major depressive disorder, single episode, in partial remission.
F32.5 – Major depressive disorder, single episode, in full remission.
F32.9 – Major depressive disorder, single episode, unspecified.
F33.0 – Major depressive disorder, recurrent, mild.
F33.1 – Major depressive disorder, recurrent, moderate.
F33.2 – Major depressive disorder, recurrent, severe without psychotic features.
F33.3 – Major depressive disorder, recurrent, severe with psychotic features.
F41.0 – Panic disorder [episodic paroxysmal anxiety].
F41.9 – Anxiety disorder, unspecified (used in cases where depression is associated with anxiety).

We thank you for your attention to detail and professionalism, and we’re always here to help. To find more coding resources and information, visit our Coding Counts page. Thank you for your continued care and dedication to our members’ health.

Questions?

Please contact us at CodingCounts@HealthAlliance.org.

References Used for this Article:

EncoderProFP.com/epro4payers/index.jsp

CodingClarified.com

Contact Us

(800) 851-3379, option 3

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