Welcome to the September Wesgram. This edition contains important updates from CMS, Palmetto and other payers, as well as some updated coding information.
ICD-10 Latest News
Autumn ICD-10 Codes
W19 Unspecified fall
W14 Fall from tree
Y93.6 Sporting Activity (Group)
W60 Contact With Sharp Leaves
ICD-10 Coding Changes for 2018

2018 will bring many coding changes, including the addition of more than 360 new codes, the deletion of 142 existing codes, and the revision of 220 codes.  Are you ready?  Make sure you are using the 2018 ICD-10 codes as of October 1, 2017!

The WVSMA is currently planning Coding Workshops to help you prepare for the 2018 changes in CPT and ICD-10 coding. Watch for a schedule of courses coming soon!
(information from Palmetto GBA)

Influenza Virus Vaccine Code
Effective Date: August 1, 2017
Implementation Date: January 2, 2018
The influenza virus vaccine code set is updated on a quarterly basis. This update will include one new influenza virus vaccine code: 90756.
Effective for claims processed with dates of service (DOS) on or after January 1, 2018,
influenza virus vaccine code 90756 (Influenza virus vaccine, quadrivalent (ccIIV4), derived from cell cultures, subunit, antibiotic free, 0.5mL dosage, for intramuscular use) will be payable by Medicare. This new code will be included on the 2018 Medicare Physician Fee Schedule Database file update and the annual Healthcare Common Procedure Coding System (HCPCS) update.
During the interim period of August 1, 2017, through December 31, 2017, Palmetto will use code Q2039 (Influenza virus vaccine, not otherwise specified) to handle bills for this new influenza virus vaccine product (Influenza virus vaccine, quadrivalent (ccIIV4). Q2039 is already an active code.  
The Medicare Part B payment allowance limits for influenza and pneumococcal vaccines are 95 percent of the Average Wholesale Price (AWP) as reflected in the published compendia except where the vaccine is furnished in a hospital outpatient department, Rural Health Clinic (RHC), or Federally Qualified Health Center (FQHC). Where the vaccine is furnished in the hospital outpatient department, RHC, or FQHC, payment for the vaccine is based on reasonable cost.

The Medicare Part B payment allowances for the following Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes below apply for the effective dates of August 1, 2017-July 31, 2018:

 CPT 90653 Payment allowance is $50.217.
 CPT 90655 Payment allowance is pending.
 CPT 90656 Payment allowance is $19.247.
 CPT 90657 Payment allowance is pending.

The payment allowances for seasonal influenza virus vaccines are updated on August 1 of each year.
Make Sure You Are Using the Correct PO Box Address!
Palmetto GBA has reduced the number of addresses used for submitting provider checks to satisfy Medicare debts. Please immediately begin using the addresses below to submit payment for any Medicare Debts. All other PO Boxes will be closed.

PO Box 100246
Columbia, SC 29202

Please note that the new PO Boxes will be reflected on all forms and letters. This will not affect payments being submitted by eCheck.

Providers are strongly encouraged to submit payment electronically using eCheck via Palmetto GBAs eServices. Providers can electronically submit their payment and PDF attachments online. Once submitted, you will receive a confirmation from Palmetto GBA indicating that the payment has been received. 

Email and Faxed Inquiries

CMS requires all providers to utilize the Provider Contact Center (PCC) (855-696-0705) as their point of contact with their Medicare Administrative Contractors. If you submit an unsolicited fax or email inquiry directly to a specific department or individual your inquiry will be routed to the written correspondence area within the PCC for proper logging, tracking, research and response. An escalation process is used for complex issues. Submitting inquires directly to the PCC will assure CMS compliance and allow for the most timely response.
Additional Guidance on Electronic Signatures Is Available

For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.
Healthcare Provider Taxonomy Codes (HPTCs) October 2017 Code Set Update

Change Request (CR) 10141 instructs MACs to obtain the most recent Healthcare Provider Taxonomy Code (HPTC) set and to update their internal HPTC tables and/or reference files. Make sure your staff is aware.

Implement Operating Rules -Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule -Update from Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE)
Change Request (CR) 10140 instructs MACs and Medicare's Shared System Maintainers (SSMs) to update systems based on the CORE 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule publication. These system updates are based on the CORE Code Combination List to be published on or about October 1, 2017.
Email and Faxed Inquiries  

CMS requires all providers to utilize the Provider Contact Center (PCC) (855-696-0705) as their point of contact with their Medicare Administrative Contractors. If you submit an unsolicited fax or email inquiry directly to a specific department or individual your inquiry will be routed to the written correspondence area within the PCC for proper logging, tracking, research and response. An escalation process is used for complex issues. Submitting inquires directly to the PCC will assure CMS compliance and allow for the most timely response.

Medicare Secondary Payer Inquiry Form  
As a reminder, A Medicare Secondary Payer Inquiry Form is available in the Medicare Secondary Payer forms section of our website. To ensure timely processing of your request, this form should be used for any Medicare Secondary Payer (MSP) request pertaining to Primary or Secondary payment of claims.
Palmetto GBA Medic al R eviews
The following are the current Medicare reviews being performed by Palmetto GBA:
CPT 99233 E&M
CPT 99233 E&M -
CPT 11042-11047 Outpatient Surgical Debridement in POS 22
CPT 99283, 99284, 99285 Emergency Department E&M
CPT 99291-99292 Critical Care, First Hour Plus
CPT 99309-99310 Subsequent Nursing Facility Care
HCPCS A0425, A0428 Ambulance Service, NonEmergent
HCPCS A0429, A0427, A0425 Ambulance Services, Emergent
E/M Tip

E/M Tip: Billing Observation or Inpatient Care Services (Including Admission and Discharge Services)
The physician must satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. In addition to meeting the documentation requirements for history, examination and medical decision making, documentation in the medical record must include:

  • Documentation stating the stay for hospital treatment or observation care status involves
eight hours but less than 24 hours
  • Documentation identifying the billing physician was present and personally performed the services
  • Documentation identifying the admission and discharge notes were written by the billing physician
( Information from CMS)

Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program

Medicare providers may not bill QMB individuals for Medicare cost-sharing, regardless of whether the State reimburses providers for the full Medicare cost-sharing amounts. Further, all original Medicare and MA providers--not only those that accept Medicaid--must refrain from charging QMB individuals for Medicare cost-sharing. Providers who inappropriately bill QMB individuals are subject to sanctions.
RENAL CONSULTANTS in West Virginia is recruiting nephrologists for our physician practice locations in Kanawha and Boone counties. Our practice consists of a busy CKD clinic, ESRD patients, home dialysis and post-transplant care. Applicant must be BC/BE and prepared to be busy immediately. Salary awarded proportionate to productivity. J1 Visas welcomed. Email resume to dmiller@gcdkidney.com .
Payer News

Highmark Discontinues Peer-to-Peer Review Process for Medicare Advantage
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 will continue to be informed of their appeal rights and procedures. The denial letter will continue to include 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: The peer-to-peer review process for prior authorization requests will continue to be available for Commercial members.

UnitedHealthCare Update
Effective for claims with dates of service on or after Oct. 1, 2017, UnitedHealthcare will reimburse the appropriate evaluation and management (E/M) procedure code which describes the office visit, hospital care, nursing facility care, home serviceor domiciliary/rest home care reported in lieu of a consultation services procedure code.
This notification will be the first of several communications to clarify this change in reimbursement strategy supporting our commitment to the Triple Aim of improving health care services, health outcomes and overall cost of care.
UnitedHealthcare will align with the Centers for Medicare & Medicaid Services (CMS) and no longer reimburse consultation services represented by CPT codes 99241-99245 and 99251-99255. At the time of the original CMS decision to no longer recognize these consultation services procedure codes, UnitedHealthcare began pursuit of data analysis and trending to better understand the use of consultation services codes as reported in the treatment of our commercial members. Similar to CMS’s findings, our extensive data analysis has revealed misuse of consultation services codes for this population.
The current Relative Value Unit (RVU) assignments reflect numerous changes made during recent years to both E/M codes and other surgical services creating an overall budget neutral experience supporting this strategy as a more accurate reflection of services rendered.

West Virginia Medicaid News
At the recent Molina trainings, practices were reminded that WV Medicaid is required by CMS to direct all providers to:
Screen employees and contractors for excluded persons to prevent Medicaid payments for items/services furnished or ordered by excluded individuals and entities.
 Search the Office of Inspector General’s (OIG) List of Excluded Inidviduals and Entities (LEIE) monthly to capture new exclusions or reinstatementss that occurred since the last search. Click here for the LEIE’s online searchable database  

( Special note----If you need assistance with your exclusion program, the WVSMA can assist you. We have an arrangement with Exclusion Screenings for our physician practices.)
Also, as of December 31, 2017, all current MCO (Managed Care Organizations) providers must be enrolled with WV Medicaid or the MCO will terminate their contracts. This means that in order to participate with any of the MCOs---Aetna Better Health, The Health Plan, UniCare or WV Family Health---you must have a participation agreement in effect with the State Medicaid agency, even if you don’t plan to participate in the Medicaid fee for service program.
The Managed Care Federal Rule from March 2016 states that Medicaid has the ultimate responsibility for screening, enrolling, and periodically revalidating all Medicaid MCO network providers.    The MCO providers will also be subject to revalidation.
Other News  

 Walking Miracles Plans Fundraiser

Walking Miracles Family Foundation is celebrating five years of helping West Virginia families by hosting a Benefit on Friday, September 29, 2017, from 5:30 -7:30 PM at Berry Hills Country Club in Charleston, WV. The speaker will be Roger Holzberg, Founder and Creator of Reimagine Well Online Community and the Infusionarium Project. Roger is a cancer survivor and a former Disney imagineer.

Tickets are $75.00 per person and may be purchased at the door. Oncologists are invited to attend at no charge. For additional information, please contact Brett Wilson , Founder. Walking Miracles Family Foundation.
Educational Opportunities  
  West Virginia Office Managers Association Conference

The West Virginia OMA conference will be held on Thursday/Friday, October 19/20, 2017 at the Flatwood Conference Center in Sutton, WV. This is the organization's 31st annual conference. For additional information please contact Rita Hope or Pam Shafer.