March 23, 2016

Welcome to the Wesgram Online!  


Welcome to the March 2016 Wesgram. This edition contains important information about Medicare and Medicaid changes. You'll also find updates from insurers  as well as some upcoming educational events.  


story1ICD-10 Latest News
Clinical Documentation of Underdosing

ICD-10 now provides codes to utilize when your patient is noncompliant with his/her medications. Underdosing is an important new concept and term in ICD-10. It allows physicians to identify when a patient is taking less of a medication than is prescribed. This "underdosing" concept can often be coded along with the patient's reason for not taking the prescribed medications. You should document if there is a medical condition linked to the underdosing that is relevant to the encounter and ensure the connection is clearly made. The ICD-10-CM terms provide new detail.

When documenting underdosing, include the following:

1. Intentional, Unintentional,Non-compliance--  
     Is the underdosing deliberate? (e.g., patient refusal)
2. Reason --Why is the patient not taking the medication?
            ( hardship, age-related debility)

You will find the underdosing codes in the "Table of Drugs and Chemicals" in your ICD-10-CM Manual.

Palmetto GBA News
(information from Palmetto GBA)

E/M Comparative Billing Reports: Peer Code Comparison
The Evaluation and Management (E/M) Comparative Billing Reports: Peer Code Comparison are complete for South Carolina (SC), North Carolina (NC), Virginia (VA), and West Virginia (WV). The reports are based only on the Part B Extract Summary System (BESS) data between January 1, 2015 - June 30, 2015.
Understanding eCheck in eServices
eCheck allows providers to submit either solicited or voluntary payments electronically. The electronic payment is treated like an immediate debit card transaction. The amount and necessary bank information from the check is captured and routed using PHT A-Claim Technology to make the payment directly from the provider's financial institution.
E/M Tip: Medical Decision Making - Complexity
The levels of evaluation and management (E/M) services recognize four types of medical decision making (straightforward, low complexity, moderate complexity and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option
E/M Tip: 1995 Examination-Constitutional
The measurement of at least three vital signs (sitting or standing blood pressure, supine blood pressure, pulse rate and regularity, respiration, temperature, height and weight) or the patient's general appearance must be documented in order to receive 'credit' for 'constitutional,' under the 1995 'organ systems.'
E/M Tip: History of Present Illness (HPI) - Multiple Complaints
A patient may present with more than one complaint, sign or symptom. They may use the most descriptive under the History of Present Illness (HPI) and additional information may be used under review of systems (ROS).
Authentication Matters!
Medicare requires that services provided/ordered be authenticated by the author. The method used must be a hand written or an electronic signature.
Stamped signatures are not acceptable. Stamped signatures are only permitted in the case of an author with a physical disability who can provide proof to CMS or a CMS contractor of an inability to sign due to a disability.
Signatures, Credentials and Dates: They Are Important
Each entry in the patient's medical record requires the acceptable signature of the person writing the note along with the date. Palmetto GBA also recommends the inclusion of the applicable credentials (e.g. P.A., D.O. or M.D.), especially when the services being billed are only coverable when performed by certain credentialed professionals

The Centers for Medicare & Medicaid Services (CMS) recently announced a proposed rule to test new models to improve how Medicare Part B pays for prescription drugs and supports physicians and other clinicians in delivering higher quality care. CMS says that it values public input and comments as part of the rulemaking process, and looks forward to continuing to work with stakeholders through the rulemaking process to maximize the value and learning from the proposed tests.

Medicare Part B covers prescription drugs that are administered in a physician's office or hospital outpatient department, such as cancer medications, injectables like antibiotics, or eye care treatments. The proposed Medicare Part B Model would test new ways to support physicians and other clinicians as they choose the drug that is right for their patients.

The proposed rule is designed to test different physician and patient incentives to do two things: drive the prescribing of the most effective drugs, and test new payment approaches to reward positive patient outcomes. Among the approaches to be tested are the elimination of certain incentives that work against the selection of high performing drugs, as well as the creation of positive incentives for the selection high performing drugs, including reducing or eliminating patient cost sharing to improve patients' access and appropriate use of effective drugs.

Prescription drug spending in the U.S. was about $457 billion in 2015, or 16.7 percent of overall health spending, according to a report also released today. In 2015, Medicare Part B spent $20 billion on outpatient drugs administered by physicians and hospital outpatient departments.

The proposed rule will be open to a 60-day comment period. CMS is accepting comments on the proposed rule through May 9, 2016.

The proposed rule is available for viewing at:

 The proposed rule seeks comments on testing six different alternative approaches for Part B drugs to improve outcomes and align incentives to improve quality of care and spend dollars wisely.  To read more about the proposed rule:

The WVSMA urges you to express your comments and concerns during the 60 day comment period. 
Payor News and Other News 

WV CHIP Update -Important Information
(information from BMS)
As of January 1, 2016, the West Virginia Children's Health Insurance Program (WVCHIP) is using Molina to process claims.

All WVCHIP providers are required to enroll and provide credentialing. If you have not done so, or if you have submitted incomplete information, BMS is unable to process your claims.
There are issues with some provider files which are expected to be resolved in the next 30 days. If you are having difficulty with claims payment, please let BMS know by emailing
NOTE: Prior Authorization requests are still to be submitted to HealthSmart.
Although WVCHIP is now a division of the West Virginia Department of Health and Human Resources, it still operates as the same program, with the same benefits and payment rates.
WVCHIP is not part of Medicaid or its managed care programs.
Providers can confirm eligibility for a patient without a member card through the provider tab on Membership may also be verified by the patient, who can print a temporary card through this website. Contact the WVCHIP Helpline at 1-877-982-2447 or Molina at 1-800-479-3310, if assistance is needed.
Highmark West Virginia News
Physicians were recently sent a communication from Highmark regarding a change in reimbursement for their ACA product. Highmark West Virginia has taken a measured approach to managing ACA fees with an aggregate adjustment (reduction) of 0.6 percent for ACA direct-pay products.
Effective May 1, 2016, Highmark will adjust the provider fee schedule to implement new fees for their ACA individual (direct-pay) products.

Current fees are available in NaviNetĀ®, and the ACA fees will be viewable in the system on or before May 1, 2016. (For more information on accessing current fees in NaviNet, please see "Fees Available via NaviNet" below. If you don't yet have NaviNet, visit to get access to the system.)
The Highmark mailing also included an addendum to memorialize the fee changes and other agreements relevant to Highmark West Virginia's ACA network and products. Physicians should retain this document with their contract records.
On or before May 1, 2016, practices will be able to access all applicable payment information online. Visit the Provider Resource Center (via NaviNet) and select Administrative Reference Materials, and then Fee Schedule Information. Please note that fees are not published on the public Provider Resource Center.
Questions regarding the new fees should be addressed to Highmark's Provider Resource Center.
Highmark West Virginia has also announced that the plan is doing business differently in 2016. You will no longer have an assigned Provider Relations representative, but are instead encouraged to utilize the plan's self-service options. Highmark encourages you to take advantage of the online and telephonic tools that the plan offers.
NaviNet should be utilized as the primary resource for inquiries related to West Virginia Family Health members. Questions that cannot be resolved through NaviNet functionality for these members should be directed to West Virginia Family Health Provider Services at 1-855-412-8002.

WVMGMA Regional Meetings
The West Virginia Medical Group Management Association (WVMGMA) has planned a series of statewide regional meetings in May. Ken T. Hertz, Principal Consultant with MGMA will be speaking on the topics of Trends in Practice Management and Setting a Vision for Your Practice. The meetings are free but registration is necessary.
Below are the dates and locations for the regional meetings. Please register with the contact person at least ten (10) days prior to the meeting you would like to attend.
Monday, May 23rd---Morgantown
Holiday Inn Morgantown - University Area
9:00am - 11:15am
Tuesday, May 24th---Parkersburg
Camden Clark Hospital      
10:30am - 2:00pm
Wednesday, May 25th----Beckley
Mountain State Co-op                
10:00am - 2:00pm
Thursday, May 26th----Teays Valley
Sleepy Hollow                      
9:00am - 11:15am
Charleston Chapter OMA Educational Meeting
The Charleston OMA Chapter will meet on Tuesday, April 12, 2016 at 11:00 AM for a luncheon presentation on  "ICD-10 Taming the Beast"by Jenny Pauley, CMC, CMOM, Billing Director with MediSys Practice Solutions.
The meeting will be held at Thomas Hospital's Education Center. Members may attend free with a $20.00 charge for non-members.
Please RSVP to Carole Parkins by Thursday, April 7th.   RSVP to: or call 304-342-7186.

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