As It Relates to You

Coverage Update for Four Diagnosis Codes

As of May 1, 2019, we will no longer cover services when the dx code is one of the following:

Z02.1—Encounter for pre-employment examination
Z02.3—Encounter for examination for recruitment to armed forces
Z02.4—Encounter for examination for a driving license
Z02.6—Encounter for examination for insurance purposes

If you have questions, please contact your provider relations specialist.

Reimbursement Policy for Treatment Rooms

Treatment room services consist of outpatient services furnished on hospital premises that require the use of a bed and periodic monitoring for a relatively brief period of time in order to carry out certain nonsurgical procedures not performed in a specialized suite that is otherwise billable. Recovery from the effects of such a procedure is an appropriate use of the treatment room. The use of the treatment room is an expected part of a minor procedure, and it replaces the charge for an operating room and recovery room.

We reimburse treatment room services when a specific, identifiable surgical procedure has been performed or a treatment rendered that is unrelated to inpatient or outpatient services provided within the contracted global reimbursement period.

Services are subject to applicable member out-of-pocket costs, such as copayment, coinsurance or deductible to their outpatient surgery benefit.

Code	Description	Comment
0760–0761 0769	Treatment Room	Bill with applicable HCPCS/CPT codes when a specific procedure has been performed or a treatment rendered.

Colorectal Cancer Screening Reminder

Colorectal cancer is the second-leading cause of cancer-related death in the U.S. Colorectal cancer is 90 percent preventable and 90 percent treatable when detected early enough. One in three adults over the age of 50 is not up to date on colorectal cancer screening. Talk with your patients about colorectal cancer screening options.

Available colorectal cancer screenings methods include:

• Fecal occult blood test (gFOBT) annually
• FIT (fecal immunochemical test) annually
• Cologuard every three years
• Flexible sigmoidoscopy every five years
• Colonoscopy every 10 years

Whichever screening method our members choose, most of our plans cover it at 100 percent. If additional testing or related services are needed, a copay or coinsurance may apply. To check for exact coverage, members should call the Customer Service number on the back of their ID cards.

Coding Reminders

Both the Medicare Advantage and commercial Marketplace condition category models are dependent on us receiving accurate diagnosis codes through claims submission. All claims submitted to us must have associated diagnosis codes. There are two areas of opportunity we need your assistance in addressing:

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

These scenarios leave gaps in accurate reflections of the overall risk of the population and may inadvertently omit members from being included in care management programs directed at assisting with health outcomes for their chronic conditions. Please assess your billing practices at an organizational and provider level to ensure these situations don’t apply to you.

If you identify these issues or have concerns that the above applies to your system, contact us at CodingCounts@healthalliance.org, and we’ll reach out to help with a solution.

For useful information on documentation and code reporting, subscribe to our coding e-newsletter.

Frequency of Ophthalmological Comprehensive Established Patient Exam (CPT Code 92014)

We provide coverage for CPT procedure code 92014 (ophthalmological services; comprehensive, established patient, one or more visits) once within six months.

If the patient is being seen for follow-up within six months of the comprehensive ophthalmologic service for the same condition, you should bill using CPT procedure code 92012 (ophthalmological services, medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate established patient).

Initial/Subsequent Ophthalmoscopy (CPT Codes 92225 and 92226)

We provide coverage for CPT procedure code 92225 (ophthalmoscopy, extended, with retinal drawing, with interpretation and report; ophthalmoscopy initial) once per year, per eye.

Subsequent services for the same eye should be billed using CPT procedure code 92226 (ophthalmoscopy, extended, with retinal drawing, with interpretation and report; subsequent).

Blood Pressure Screening Reminders and Tips

Hypertension is the most common reason for a person with any chronic condition to visit a clinician. It is a major risk factor for heart disease, stroke and kidney disease. Even small increases in blood pressure raise the risk for cardiovascular disease and mortality. The risk of death from ischemic heart disease and stroke doubles for every 20 mmHg increase in systolic blood pressure or 10 mmHg increase in diastolic blood pressure.

Hypertension affects almost one-third of American adults ages18 or older (72 million people) and is uncontrolled in nearly half of those (35 million people). This population with uncontrolled hypertension represents a large pool of patients for whom clinicians could consider further clinical intervention.

Provide both initial and ongoing training to staff to ensure that blood pressure readings are taken correctly. Make sure that readings are communicated and that elevated blood pressures are reassessed.

• Encourage staff to assess whether patients have used nicotine or caffeine, have exercised in the last 30 minutes or have a full bladder. Have patient sit in a chair with feet on the floor and arm supported so that the elbow is at about heart level. The inflatable part of the cuff should completely cover at least 80 percent of the upper arm. The cuff should be placed on bare skin, not over a shirt. Remove any tight-sleeved clothing.
• Encourage patients to monitor their blood pressure at home. Remember to ask patients to bring their home blood pressure cuff into your office for calibration. Educate them on their blood pressure goals as well as when to report their readings.
• Consider non-pharmacological treatments in addition to medications. Encourage patients to lead a healthier lifestyle including weight loss, reducing sodium intake and increasing physical activity.
• Stress the importance of medication adherence to your patients. Consider prescribing a statin medication as well.
• Encourage patients to participate in health coaching or care coordination. You may place an order for health coaching by using “Amb health coach.” Our members may also call 1-800-851-3379, extension 28947, weekdays 8 a.m.–5 p.m. CT to sign up for these services.

To learn more, review this information from the CDC’s Division for Heart Disease and Stroke Prevention.

Pharmacy Updates

All Plans

Misc. Updates

• Freestyle Libre
• As of 1/1/19, Freestyle Libre continuous glucose meter will now process in the pharmacy under the DME benefit
• Plans without our pharmacy benefit: Coverage depends on their PBM; if meter doesn’t process at pharmacy, it will process at DME provider
• At the pharmacy, members will pay the DME benefit copay
• Gardasil Vaccination
• Only ages 9–26 are covered under wellness benefit
• Patients starting the series who are ages 27–45 will be charged their non-preferred brand copay

Criteria Changes

• Advair generic—Added ONLY Wixela (Mylan [manufacturer] generic) at the non-preferred generic tier with no preauthorization (PA)
• Prasco (manufacturer) generic is Excluded
• Brand-name Advair
• WA Individual—still covered at non-preferred brand tier with PA
• Medicare—still Non-Formulary

Formulary Additions

Infectious Disease

• Aemcolo (rifamycin)
• Indicated for the treatment of travelers’ diarrhea (TD) caused by noninvasive strains of Escherichia coli in adults
• Formulary placement recommendations
• WA Individual—Non-Preferred Brand with quality limit (QL) of #12/30 days
• Medicare—Preferred Brand with QL of #12/30 days
• Krintafel (tafenoquine)
• Indicated for radical cure (prevention of relapse) of P. vivax malaria in patients 16 years of age or older who are receiving appropriate antimalarial therapy for acute P. vivax infection
• Formulary placement recommendations
• WA Individual—Preferred Brand, QL of #2/30 days
• Medicare—Preferred Brand, QL of #2/30 days
• Nuzyra (omadacycline)
• Indicated for the treatment of adults with community-acquired bacterial pneumonia and acute skin and skin structure infections
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with QL
• Medicare—Specialty/Tier 5 with QL
• Pifeltro (doravirine)
• Indicated for the treatment of HIV-1 infection in combination with other antiretroviral agents in adult patients with no prior antiretroviral treatment history
• Formulary placement recommendations
• WA Individual—Non-Preferred Brand
• Medicare—Specialty/Tier 5
• Xerava (eravacycline)
• Indicated for the treatment of complicated intraabdominal infections
• Formulary placement recommendations
• WA Individual—Preferred Specialty
• Medicare—Specialty/Tier 5
• Xofluza (baloxavir marboxil)
• Indicated for the treatment of acute uncomplicated influenza in patients age 12 years and older who have been symptomatic for no more than 48 hours
• Formulary placement recommendations
• WA Individual—Non-Preferred Brand with QL
• Medicare—Non-Preferred Brand/Tier 4
• Zemdri (plazomicin)
• Indicated for the treatment of complicated urinary tract infections
• Formulary placement recommendations
• WA Individual—Non-Preferred Brand
• Medicare—Specialty/Tier 5

Oncology

• Erleada (apalutamide) 60 mg
• Indicated for the treatment of non-metastatic, castration-resistant prostate cancer (NMCRPC)
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Tier 5 with PA; reviewed by Health Alliance
• Poteligeo (mogamulizumabkpkc) 20 mg/5 mL IV solution
• Indicated for the treatment of adult patients with relapsed or refractory mycosis fungoides (MF) after at least one prior systemic therapy AND treatment of adult patients with relapsed or refractory Sézary syndrome (SS) after at least one prior systemic therapy
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Part B; reviewed by eviCore
• Mektovi (binimetinib) 15 mg oral tablet
• Indicated for the treatment of unresectable or metastatic melanoma with a BRAF V600E or V600K mutation (in combination with encorafenib) as detected by an approved test
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Tier 5 with PA; reviewed by Health Alliance
• Braftovi (encorafenib) 50 mg, 75 mg oral capsule
• Indicated for the treatment of unresectable or metastatic melanoma with a BRAF V600E or V600K mutation (in combination with encorafenib) as detected by an approved test
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Part B; reviewed by eviCore
• Copiktra (duvelisib) 15 mg, 25 mg oral capsule
• Indicated for the treatment of relapsed or refractory chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) in adult patients after at least two prior therapies AND treatment of relapsed or refractory follicular lymphoma (FL) in adult patients after at least two prior systemic therapies
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Tier 5 with PA; reviewed by Health Alliance
• Tibsovo (ivosidenib) 250 mg oral tablet
• Indicated for the treatment of relapsed or refractory acute myeloid leukemia (AML) in adult patients with a susceptible isocitrate dehydrogenase-1 (IDH1) mutation as detected by an approved test
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Tier 5 with PA; reviewed by Health Alliance
• Vizimpro (dacomitinib) 15 mg, 30 mg, 45 mg oral tablet
• Indicated for first-line treatment of metastatic non-small cell lung cancer (NSCLC) in patients with epidermal growth factor receptor (EGFR) exon 19 deletion or exon 21 L858R substitution mutations as detected by an approved test
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Tier 5 with PA; reviewed by Health Alliance
• Libtayo (cemiplimab-rwlc) 350 mg/7 mL IV solution
• Treatment of metastatic cutaneous squamous cell carcinoma (CSCC) or locally advanced CSCC in patients who are not candidates for curative surgery or curative radiation
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Part B; reviewed by eviCore
• Talzenna (talazoparib) 0.25 mg, 1 mg oral capsule
• Treatment of deleterious or suspected deleterious germline breast cancer susceptibility gene (BRCA)-mutated (gBRCAm) human epidermal growth factor receptor 2 (HER2)-negative locally advanced or metastatic breast cancer in adults (as detected by an approved test)
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Tier 5 with PA; reviewed by Health Alliance
• Lorbrena (lorlatinib) 25 mg, 100 mg oral tablet
• Treatment of anaplastic lymphoma kinase (ALK)-positive metastatic nonsmall cell lung cancer (NSCLC) in patients whose disease has progressed on crizotinib and at least one other ALK inhibitor for metastatic disease; or progressed on alectinib as the first ALK inhibitor therapy for metastatic disease; or progressed on ceritinib as the first ALK inhibitor therapy for metastatic disease
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Tier 5 with PA; reviewed by Health Alliance
• Daurismo (glasdegib) 25 mg, 100 mg oral tablet
• Treatment of newly diagnosed acute myeloid leukemia (in combination with low-dose cytarabine) in adult patients who are ≥75 years of age or who have comorbidities that preclude use of intensive induction chemotherapy
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Tier 5 with PA; reviewed by Health Alliance
• Vitrakvi (larotrectinib) 25 mg, 100 mg oral capsule
• Treatment of solid tumors (in adult and pediatric patients) that have a neurotrophic receptor tyrosine kinase (NTRK) gene fusion without a known acquired resistance mutation; are metastatic or where surgical resection is likely to result in severe morbidity; and have no satisfactory alternative treatments or that have progressed following treatment
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Tier 5 with PA; reviewed by Health Alliance
• Khapzory (levoleucovorin) 175 mg, 300 mg IV solution
• Treatment of advanced metastatic colorectal cancer (in combination with fluorouracil)
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Part B; reviewed by eviCore
• Xospata (gilteritinib) 40 mg oral tablet
• Treatment of relapsed or refractory acute myeloid leukemia (AML) in adult patients with an FMS-like tyrosine kinase 3 (FLT3) mutation as detected by an approved test
• Formulary placement recommendations
• WA Individual—Non-Preferred Specialty with PA; reviewed by eviCore when applicable
• Medicare—Tier 5 with PA; reviewed by Health Alliance

Hematology

• Tavalisse (fostamatinib)
• Indicated for the treatment of thrombocytopenia in adults with chronic immune thrombocytopenia (ITP) who have had an insufficient response to a previous treatment
• Formulary placement recommendations
• WA Individual— Non Preferred/Non Formulary Specialty/ Tier 6 with PA
• Medicare—Non-Formulary

Commercial

Criteria Changes

• Review of agents used for management of febrile neutropenia—granulocyte colony stimulating factors
• Removed PA from all agents
• Review of Denosumab (Xgeva/Prolia) coverage
• Removed PA from Xgeva
• Prolia currently does not require PA
• Review of Erythropoiesis-Stimulating Agents (Aranesp, Epogen, Procrit, Retacrit, etc.)
• Removed PA for oncology-related diagnoses
• Non-oncology-related diagnoses currently do not require PA

Medicare

Criteria Changes

• Zolpidem IR 5 mg, 10 mg—Removed PA; covered at Tier 2
• Extended-release zolpidem still Non-Formulary

 

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