Welcome to the November Wesgram. This edition contains important updates from CMS, Palmetto and other payers. You'll also find information about upcoming educational opportunities. There are also some fun ICD-10 codes to celebrate the Thanksgiving season.

The WVSMA staff wishes you a wonderful Thanksgiving!
ICD-10 Latest News
You asked and the WVSMA has listened!  In order to help you ensure that you are billing and coding correctly, we have scheduled two special classes for January.

On Wednesday, January 24 th , 2018, we will host 2 training sessions and invite you to register and attend. You may choose either session or stay all day. Three CEUs are available for each class. Register here for one or both classes.
8:30 AM – 11:30 AM 2018 Coding and Reimbursement Updat e --This class covers the most current reimbursement information available specifically for medical office coding and billing professionals, providers, office managers, consultants, and compliance officers.

1:00 PM—4:00 PM Bridging the Gap--Clinical Documentation and Coding -- This class will help coders and billers work with providers to assess and gather the information needed in documentation to support appropriate code assignments. Participants must bring a current ICD-10-CM code set manual to class.

For more information, contact Barbara Good, WVSMA Physician Practice Advocate.

Speaking of coding, here are some Thanksgiving ICD-10 codes--

Y93.G3- Activity, Cooking and Baking
W29.0 – Contact with powered kitchen appliance
K21.9 – Gastroesophageal reflux disease without esophagitis
Z63.1 – Problems in relationship with in-laws
W61.42XA (struck by turkey, initial encounter)
W61.42XD- Struck by turkey, subsequent encounter
W21.01XA: struck by football, initial encounter
Y93.61 activity, American tackle football
Y93.62: activity, American touch football
Z72.4- Inappropriate diet and eating habits
(information from Palmetto GBA)

The ERAs for QMB claims no longer contain patient co-insurance and/or deductible data. For situations when claims are crossing over to the state systems, the local Medicaid agency has requested that the provider send them a duplicate Standard Paper Remittance (SPR). However, the SPRs for these claims also do not show any coinsurance/deductible values. Palmetto GBA has contacted the CMS System Maintainers and they are currently researching this issue. Updates will be provided on the Claims Payment Issues Log (CPIL) as soon as they are received.

Lack of Documentation Affects Your Reimbursement!

‘Remember the Golden Rules:

  • All information about services performed must be documented
  • If it isn’t documented, then it wasn’t performed. Reviewers do not know the services provided if there is no documentation.
  • You are paid for what you document, not what you did
  • Document, Document, Document
  • More is always better when it comes to documentation

The Targeted Probe & Educate (TPE) process was implemented effective October 1, 2017. Based on data analysis of claims payment, Palmetto GBA will identify areas with the greatest risk of inappropriate program payment based on claims reviewed.

The TPE review and education process includes a review of 20-40 claims followed by one-on-one, provider-specific, education to address any errors with in the provider’s reviewed claims.

Providers/suppliers with moderate and high error rates in the first round of reviews, will continue on to a second round of 20-40 reviews, followed by additional, provider specific, one-on-one education. Providers/suppliers with high error rates after round two will continue to a third and final round of probe reviews and education. In addition to education at the conclusion of each 20-40 claim probe review, MACs also educate providers throughout the probe review process, when easily resolved errors are identified, helping the provider to avoid additional similar errors later in the process.

Providers/suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100% prepay review, extrapolation, referral to a Recovery Auditor, or other action. Providers/supplier may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS. 

It is imperative when responding to the TPE Additional Documentation Request (ADR) that you include the name and number of your designated contact person. The Palmetto GBA medical reviewer will contact your designated person prior to the conclusion of each TPE round to discuss the review summary.
Physician Compare Website

The Centers for Medicare and Medicaid Services (CMS) created the Physician Compare website as required by the Patient Protection and Affordable Care Act (ACA) of 2010. The site was launched on December 30, 2010. Initially, Physician Compare used the existing Healthcare Provider Directory on Medicare.gov. Since that time, CMS has continually worked to make the site function better, improve the information available, and provide useful information about physicians and other health care professionals who take part in Medicare. This ongoing effort, along with the addition of quality measures on the site, helps Physician Compare serve its two-fold purpose:

  • Provide information to help consumers make informed decisions about their health care
  • Create clear incentives for physicians to perform well

On October 18, CMS opened the 30-Day Preview Period for the 2016 performance information targeted to be publicly reported on  Physician Compare  starting in December 2017. The preview was scheduled to end on November 17, but. due to a technical issue preventing the data from properly displaying in the preview portal, all data were not viewable for the first week of preview. This display issue has now been resolved and CMS is extending preview through  Friday, December 1  at 8pm EST to provide more time for clinicians and groups to preview their performance data as a result of this technical issue. 

 If more assistance is needed, you email PhysicianCompare@westat.com or call QualityNet’s Help Desk (866) 288 8912.  

As a reminder, this data will soon be available to the public.
Payer News

Highmark WV Update

Highmark Foundation is pleased to announce a Lunch and Learn on HPV (human papillomavirus). Please join us on December 4, 2017 to learn about HPV, reducing barriers to immunization, eliminating myths, and how to reduce risk of developing this disease.

Dr. Pamela Murray will provide information and answer your questions about HPV, treatment options, and prevention efforts. The forum is open to those who want to learn the facts about HPV including business and healthcare professionals, school nurses, teachers, parents, and the community. There is no cost to attend and lunch will be provided

Time: 11:30 a.m–1:30 p.m.
Registration begins at 11:30 a.m. Lunch served at noon
Location: Grand Pointe Conference Center 1500 Grand Central Avenue Vienna, WV 26105

RSVP by November 28, 2017, to Tracey Pollard by email: info@highmarkfoundation.org or phone (toll-free): 1-866-594-1730

Highmark’s peer-to-peer review process for prior authorization requests for Medicare Advantage members is no longer available as of Sept. 12, 2017

The peer-to-peer conversation offered providers the opportunity to discuss a pending adverse determination of an authorization request for medications or medical services with another peer designee from Highmark before Highmark made a final decision. Elimination of the Medicare Advantage peer-to-peer review process benefits the member and the provider by resulting in a more timely and efficient processing of authorization requests.

With notification of a denial decision, providers and members continue to be informed of their appeal rights and procedures. The denial letter includes instructions on how a provider or member can request a Medicare Advantage appeal. The appeal will provide an opportunity for review of the initial determination and any additional documentation provided to support the request.

To ensure a thorough initial review of your authorization requests for medications or medical services for your Medicare Advantage patients, please be sure to:

  • Submit all relevant medical records and pertinent information to support the request with the initial authorization request to Highmark.
  • Respond promptly to any requests for additional information so a comprehensive review and decision can be made efficiently.

Note : Highmark’s NCQA-accredited vendors (Tivity Health [formerly Healthways], National Imaging Associates, Inc., eviCore healthcare, and naviHealth) will continue to offer the peer-to-peer review process for prior authorization requests for Medicare Advantage members. These vendors must offer the peer-to-peer review process to meet NCQA accreditation requirements. Additionally, the peer-to-peer review process for prior authorization requests continues to be available for Highmark’s commercial product members.

Highmark has also announced that the plan will be making formulary changes as of January 2018. If you are a prescribing physician in our network, effective Jan. 1, 2018, Highmark will be making changes to specific drugs included in the formularies and Pharmacy benefit programs for Medicare Advantage plans. Letters outlining this update,are being mailed to prescribing providers in the near future. We encourage you to be looking for the letters that will arrive shortly.

WV Medicaid Update

Please be aware that as of December 31, 2017, all current MCO providers must be enrolled with WV Medicaid or the MCO will terminate your contract. This means that if you are currently seeing MCO patients and are not seeing fee for service Medicaid, you MUST enroll with WV Medicaid in order to continue participating with the MCOs.
As of January 1, 2018, Molina will begin screening new MCO network providers who must have a participation agreement in effect with the State Medicaid agency, even if they do not plan to participate in the Medicaid FFS program.  The Managed Care Federal Rule (March 2016) stated that Medicaid has the ultimate responsibility for screening, enrolling, and periodically revalidating all Medicaid MCO network providers. These MCO providers will also be subject to revalidation.

As of June 1, 2018, Cycle 2 of Provider Revalidations will begin for WV Medicaid providers, which will include MCO providers, as applicable.  As a reminder, provider revalidation is require at least every 5 years for provider screening and enrollment. Revalidation date is based on the most recent effective data.

UniCare Update

The WV State Medical Association has been made aware that CAMC Health System has communicated they will continue to accept Unicare in 2018 and continue to treat Unicare MCO beneficiaries.
Educational Opportunities 
2018 CMOM Class Scheduled!

The WVSMA will host the 2018 Certified Medical Office Manager (CMOM) beginning on Thursday/Friday, February 22 nd and 23 rd and Thursday/Friday, 1 st and 2 nd .  Participants should plan to attend all four days and take the national certification exam on Friday, March 2 nd

Registration information is available on the WVSMA website, www.wvsma.org

March Conference
The WVSMA and the WVMGMA will again combine forces this year to host a conference for physicians, management and staff. Mark your calendars now for  Friday, March 23th at the Embassy Suites in Charleston.  The groups are preparing a wide variety of programming to keep you apprised of all that is happening in the healthcare arena. Plan now to attend and watch both association websites for updates!