Northwest February Newsletter 2021

Happy New Year!

After a year like no other, we’re excited to welcome 2021 and the hope and optimism it brings. We’re gearing up for another great year of partnership with each of you, and we deeply appreciate your continued dedication to the health of our members, especially in these trying times.

As always, your provider relations specialist will be at your side throughout 2021, there for you whenever you have any questions or concerns. They’re your liaison with the health plan and are dedicated to making everything easy, transparent and smooth for you and your fellow providers.

They’re available to meet with you at a time of your convenience for an educational chat about our policies and procedures, our new plans and products, Altruista training and more. If you’d like to set up a meeting, call your provider relations specialist. These meetings can be held virtually through our online system, via email or simply over the phone.

Thank you for all you do for our members, and please know we’re always here to offer you the support you need. We value your partnership, and look forward to a bright 2021 ahead.

Get Your COVID-19 Vaccine

Robert G Good, DO, MACOI

Associate Chief Medical Officer for Carle Population Health

After almost a year of dealing with the COVID-19 pandemic, vaccines against the deadly disease are finally here. Frontline healthcare staff at facilities across the country have been immunized, including receiving the second dose. Very few recipients have had adverse effects, with a small number experiencing fever, fatigue or malaise that lasted less than one day. I received my second dose in January.

Without the vaccine, the pandemic will likely continue with more people falling ill, including the small, but significant, number who don’t survive. About 20% of those infected receive extensive care, including hospitalization and critical care. Of those who survive, we’re finding that some have lingering effects including headaches, fatigue, confusion, muscle pain, heart muscle infections and nerve pain of neuropathy. Many who’ve had COVID-19 are dealing with prolonged recovery times.

The vaccine has been shown to be 94 – 95% effective in preventing COVID-19, with the 5% who still got the disease having only a mild form of it. If you’re part of the 30 – 40% of Americans who are hesitant to receive the vaccine, please be assured that it appears to be both safe and effective.

If enough people aren’t vaccinated, society will likely continue to be plagued by unnecessary mortality and morbidity from COVID-19. From a physician who has personally had family members and patients die from this illness, I would strongly urge everyone to receive the immunization.

As It Relates to You

Have a Heart-to-Heart With Your Patients

February is American Heart Month, the perfect time to chat with your patients about the importance of keeping their hearts healthy.

Heart disease is the leading cause of death in the U.S. for both men and women. According to the Centers for Disease Control and Prevention (CDC), it leads to about 25% of all deaths in the country. This includes deaths from sudden events like heart attacks and more chronic, longer-lasting issues. 

Please talk with your patients about heart health, and remind them of the importance of exercise, healthy eating and watching their blood pressure and cholesterol levels. For those who’ve been prescribed heart medications, remind them to take the drugs regularly and as directed.

Also remember to report all conditions for your patients yearly. Some of the most overlooked conditions are Morbid Obesity, Pulmonary Hypertension and Atrial Fibrillation. It’s extremely valuable to your patients’ health to report any and all vascular conditions, as well as any forms of Chronic Heart Failure. Failure to report all conditions for a patient in the current year could lead to gaps in care. For more help on specific conditions reach out to your coding consultant team.

The American Heart Association has many great resources for both you and your patients. Your guidance can help them keep their hearts beating for years to come.

Provider Satisfaction Survey Coming Soon

We depend on you to take care of our members’ health, and we deeply value your opinion. Each year, we send provider satisfaction surveys to a random sample of our providers. We use the feedback from these surveys to make changes to our processes as part of our effort of constant improvement. If you receive a survey, please take the time to give us your honest feedback. It’s how we’re best able to adapt and meet your current and future needs.

We thank you in advance for your help with the survey and – as always – for the excellent care you give our members.

Help Us Move the Needle

Remind Your Patients to Get Preventive Care

Many people have canceled or delayed their preventive care visits during the COVID-19 pandemic due to concerns about the disease and the assumption, false in many cases, that their physicians weren’t seeing other types of patients. But it’s time to start addressing prevention again. It’s simply too important to ignore, delay or cancel.

One reason is COVID-19 itself. The initial studies on COVID-19 show that patients with chronic conditions like diabetes, high blood pressure and heart disease are at higher risk for more severe outcomes if they get COVID-19. For them, it’s vital that they keep up with their preventive care and other routine doctor visits.

Some preventive services can be provided via telehealth. Blood sugar and blood pressure readings can both be shared and managed over a phone call (low tech), and reporting these values to your office keeps the patient engaged. Patients who need a colorectal cancer screening can also consult via telemedicine (computer or phone) and have a Cologuard^® test ordered and sent to their home.

For preventive services that require in-person visits, acknowledge your patients’ concerns about COVID-19, but inform them of the safety measures in place. Tell them how hospitals and healthcare providers are taking extra steps to ensure the safety of all their patients so that visits and procedures can continue. You can even summarize the new masking, social distancing and cleaning procedures you use.

In addition to easing your patients’ worries, it’s also key to emphasize how important these preventive services are. You can even inform them that pneumonia, flu, Tdap and other vaccines help lower their chances of complications from other respiratory illnesses like COVID-19. However you choose to remind your patients, it’s important you do so. Now’s the time to address the preventive care backlog before it becomes even worse. Thanks for your help in this important endeavor.

Help Reduce Hospital Readmissions

Readmissions are expensive. According to the Healthcare Cost and Utilization Project, each readmission (on average) results in more than $14,000 of costs to the hospital. Reducing readmissions helps everyone – the patient, the healthcare facility and us – and we can all help prevent them.

It may seem obvious, but it’s essential for medical staff to make sure their patients understand post-discharge care instructions. When patients misunderstand or forget parts of their instructions, they’re at a much greater risk of needing readmission for additional care in the near future.

For this reason, many places use the teach-back method, where providers ask patients to explain the care instructions back to them. This allows doctors and nurses to judge whether patients fully understand them. According to a review of five studies, published in the Journal of Patient Safety, using the teach-back method resulted in a remarkable 45% reduction in 30-day readmissions.

Another proven strategy: have patients schedule a seven-day follow up with their primary care provider. A recent study in JAMA found that patients who did so had a 30-day readmission rate of 12.7%, while patients who waited longer or did not follow up with their physician had a readmission rate of 17.5%.

Readmissions cost everyone far too much. Improve your patients’ health, and your organization’s financial footing, by helping us reduce them.

HOS and CAHPS^® Surveys Start with You

As survey season quickly approaches, do your part in improving patient satisfaction:

• Ask your patients if they’ve seen another provider. If you know they received specialty care, mention this and discuss as needed.
• Ask if they’re taking medications prescribed by other providers. Let your patients know you have a record of their complete medical history and always ask if there have been changes since you last saw them.
• Regularly assess your patients’ physical activity levels and discuss any changes they could make to improve their health and well-being.
• Conduct an annual wellness visit and review health assessment results with your patients.
• Encourage your patients to take advantage of wellness perks offered by their health plan, like health coaching, our Be Fit fitness reimbursement and our Wellness Rewards.
• Conduct medication reconciliation with your patients for appropriate usage, and modify their prescriptions as needed.
• Be proactive and help avoid gaps in care by calling your patients months in advance to schedule their needed screenings, tests or physicals.
• Encourage your patients to use MDLIVE^®, Zoom or other telehealth services when appropriate, to keep their care up-to-date in a more convenient manner.

Psychotherapy Codes – and When to Bill What

As we all find ourselves adapting to new methods, trends and practices during the pandemic, we thought it might be a good time to remind you about specific psychotherapy codes and when to bill each one.

Per the American Medical Association 2021 CPT^® code set, psychotherapy is defined as a variety of treatment techniques in which a physician or other qualified healthcare provider helps a patient with a mental illness or behavioral disturbance identify and alleviate any emotional disruptions, maladaptive behavioral patterns and contributing/exacerbating factors. Psychotherapy treatment also involves encouraging personality growth and development through coping techniques and problem-solving skills. Here’s a quick guide to the specific codes:

90832

• Report 90832 for one half-hour of face-to-face time spent with the patient without an additional evaluation and management (E/M) service. If a separate E/M service is performed during the same encounter as the 30 minutes of psychotherapy, report both 90832 and add-on code +90833.

90834

• Report 90834 for 45 minutes of face-to-face time spent with the patient without an additional evaluation and management (E/M) service. If a separate E/M service is performed during the same encounter as the 45 minutes of psychotherapy, report both 90834 and add-on code +90836.

90837

• Report 90837 for one hour of face-to-face time spent with the patient without an additional evaluation and management (E/M) service. If a separate E/M service is performed during the same encounter as the 60 minutes of psychotherapy, report both 90837 and add-on code +90838.
• Code also prolonged service for face-to-face psychotherapy with a patient lasting 90 minutes or longer, without E/M service, 99354-99357.

If the psychotherapy service was rendered via telehealth, append Modifier 95 to the specific code(s) above.

All codes include:

• Face-to-face time with the patient (family and/or other informers may also be present).
• Pharmacologic management in time allocated to psychotherapy service codes.
• Service time no less than 16 minutes.
• Services provided in all settings.
• Therapeutic communication to:
  • Ameliorate the patient’s mental and behavioral symptoms.
  • Modify behavior.
  • Support and encourage personality growth and development.
• Treatment for:
  • Behavior disturbances.
  • Mental illness.

One of the most common mistakes is coding the duration of time incorrectly. Per CPT instructions, you must use the code with the time duration closest to the actual amount of time the visit lasted. Here’s a helpful example from the American Academy of Professional Coders™:

Actual amount of time the visit lasted: 37 minutes

Correct code to use: 90832 (30 minutes of psychotherapy)

Incorrect code: 90834 (45 minutes of psychotherapy)

Why: The actual duration of the visit (37 minutes) was closer to 30 minutes (a seven-minute difference) than to 45 minutes (an eight-minute difference).

As always, if you have any questions please call your provider relations specialist. We know coding can be confusing, and our specialists are always happy to help.

The “Big Six” – Diabetes with Complications

It’s incredibly important for us to receive accurate diagnosis code reporting, along with detailed documentation that supports each diagnosis. With such information, we can together plan the best care for our members. Did you know that Diabetes with Complications is one of the “Big Six” diagnosis categories that’s most frequently unsupported in documentation?

When documenting complicated diabetes, always link the etiology (diabetes) with the manifestation (the condition caused by your patient’s diabetes) using as many codes as needed to identify your patient’s conditions.

Here are some helpful documentation tips for reporting Diabetes with Complications:

• Report the complication using cause and effect language to clearly relate the two conditions.
• Use language such as “due to” or “with” to link conditions.
• Include the following in combination codes:
  • Type of diabetes mellitus.
  • Body system affected.
  • Complications affecting that particular body system.
• Two of the most commonly under-documented diabetes mellitus codes are:
  • Type 2 diabetes mellitus with other circulatory complication (E11.59).
    • Requires circulatory complication to be documented and reported.
  • Type 2 diabetes mellitus with other specified complication (E11.49).
    • Requires other specified complication to be documented and reported.

Remember to use at least one component of M.E.A.T. to support the diagnosis you’re reporting:

• Monitor: disease progression/regression, symptoms and give a status
• Evaluate: review test results, medication and/or treatment effectiveness
• Assess: counsel, order tests, review records
• Treat: medications, therapies, referrals

Thank you for your constant care and dedication to our members’ health.

Pharmacy Updates

All Plans

New for 2021: DME Products Covered on Pharmacy Benefit

We made updates to some Durable Medical Equipment (DME) products, effective January 1, 2021, to cover them on the pharmacy benefit instead of the DME benefit. We made this change because these items are generally dispensed from pharmacies along with other prescriptions. These products have been assigned copays that reflect similar member cost sharing to what was paid under DME coinsurances. The products also continue to be available through the DME benefit if received from a DME provider. Note: Abbott preferred test strips will continue to be covered on the Preferred Brand Tier with a quantity limit of 150 per 30 days.

See below for the products that moved and the Tier level they should be hitting on the pharmacy benefit:

Other DME products, including nebulizer supplies and Dexcom, will continue to only be covered on the DME benefit.

COVID-19 Updates

• Pharmacy Department has been monitoring COVID-19 therapies and news regarding emergency use authorization (EUA).
• Treatments provided by the government under EUA would not be PA’d by us.
• COVID-19 vaccine will most likely be provided by the government with the plan covering administration costs.

New Drug Reviews

• DayVigo (lemborexant)—Treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance in adults.
  • Formulary placement recommendations:
    • WA Individual—Non-Preferred Brand.
    • Medicare—Preferred Brand/Tier 3.
  • Ongentys (opicapone)—Adjunctive treatment to levodopa/carbidopa in patients with Parkinson’s disease experiencing “off” episodes.
    • Formulary placement recommendations:
      • WA Individual—Non-Preferred Brand with PA.
      • Medicare—Non-Preferred Brand with ST entacapone.
    • Vyleesi (bremelanotide)—Treatment of premenopausal women with acquired, generalized hypoactive sexual desire disorder (HSDD), as characterized by low sexual desire that causes marked distress or interpersonal difficulty and is not due to a coexisting medical or psychiatric condition, problems with the relationship or the effects of a medication or drug substance.
      • Formulary placement recommendations:
        • WA Individual—Excluded.
        • Medicare—Non-Formulary.

New Policies

• Synarel (nafarelin)—Treatment of endometriosis or Central Precocious Puberty (CPP).
  • Added specialty pharmacy PA criteria as part of annual review of formularies.
  • Mirrors criteria for other endometriosis therapies such as Lupron.
• Zoladex (goserelin)—Treatment of endometriosis, endometrial thinning or oncology indications.
  • Originally approved for breast or prostate cancer and so hitherto reviewed by eviCore.
  • New criteria mirror existing criteria for other endometriosis therapies such as Lupron.

Criteria Changes

• Oxervate
  • Policy now specifies that approvals will need to state which eye the member has met criteria for treatment.
  • Recent PA request resulted in approval for treatment in only one eye since other eye did not meet criteria.
    • PA request for denied eye is currently still out on appeal.
  • Aimée confirmed that clinical trial only tested for Stage 1 loss of corneal sensation.
  • Brian highlighted criteria requiring coordinated review with a medical director.
  • Brian said that pharmacy team proposes revisiting policy as needed should more PA requests arise.
    • Next review would be in August at the latest (during the annual policy review).
• Nucala
  • Added criteria for Hypereosinophilic Syndrome (HES).
  • Updated re-approval criteria (12 months as long as there is improvement in symptoms or reduction in flares).

WA Individual

Tier Changes – WA Individual

• Pradaxa: Move from Non-Preferred Brand to Preferred Brand.
  • Positive member change with rebate savings.
• Synarel: Move from Preferred Brand to Non-Preferred Specialty.
  • Aligns with coverage of other gonadotropin releasing hormone agonists (Lupron, Triptodur, Supprelin LA, etc.).
  • No member utilization in 2020.

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