October 2016

Welcome to the Wesgram Online!  


This edition of the Wesgram contains information about upcoming classes and events, as well as payor news.   You'll also get the latest MACRA and Palmetto GBA updates.    

story1ICD-10 Latest News
Practices were to begin using the 2017 ICD-10 codes as of October 1, 2017 With all the coding changes that have occurred,  you should ensure that you have your 2017 coding books and EHR systems ready with the new codes. Failure to use the updated codes, or using deleted codes will affect your reimbursement.

Here are some ICD-10 "fun" codes:

S60.420A - Blister (nonthermal) of right index finger, initial encounter

S60.422A - Blister (nonthermal) of right middle finger, initial encounter

S60.424A - Blister (nonthermal) of right ring finger, initial encounter

W27.1XXA - Contact with garden tool, initial encounter

Y93.H1 - Activity, digging, shoveling and raking

Y92.017 - Garden or yard in single-family (private) house as the place of occurrence of the external cause
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Palmetto GBA News

(information from Palmetto GBA)

Managing Multiple eService Accounts Just Got Easier with Account Linking!

Palmetto GBA is excited to announce the highly anticipated eService enhancement- Account Linking!

No longer will you need a separate login for each PTAN and NPI combination. Palmetto GBA now gives users the ability to link their previously assigned eServices user IDs under one default ID. Users should log into eServices with the user ID that they wish to designate as their default login ID. This is the user ID that will be used to access the linked accounts. Once the user has successfully logged into eServices, they will select the My Account Tab and then access the Account Linking sub-tab. This will allow you to choose the accounts they wish to link.


New CERT Documentation Contractor Effective October 14, 2016

AdvanceMed, the current Comprehensive Error Rate Testing (CERT) Review Contactor are also operating the CERT Documentation Center, effective October 14, 2016. Beginning October 7, 2016, all CERT inquires and medical records were to be sent to AdvanceMed.

Signatures Are Important

CMS mandates the presence of signatures for medical review purposes. Signature requirements are applicable to all Medical claims and medical records submitted for medical review purposes.

Documenting Is Critical

To ensure your medical record is documented correctly be sure to include the following: patients name and date of service; reason for the encounter or service; history, physical exam findings and relevant health risks; reasons and results of all diagnostic tests and ancillary services; and assessment, treatment and discharge plans.

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.

Respond to ADRs via eServices

Medicare providers may be spending time, effort and money to ensure medical records are sent to Palmetto GBA in a timely fashion. If you are an eServices user, you have the advantage or submitting medical records via our free eServices. This will eliminate mailing time and costs. You will also receive a confirmation receipt letting you know when the records are received.

Clarification of Certain Policies in Pub. 100-08, Chapter 15 Regarding the Processing of Form CMS-855R Applications

Change Request (CR) 9552 clarifies policies in Chapter 15 (Medicare Enrollment) of the "Medicare Program Integrity Manual" concerning the processing of Form CMS-855R (Reassignment of Medicare Benefits) applications and adds a supplementary guide to this chapter that provides education on the preparation and submission of reassignment applications. A Form CMS-855R application must be completed for any individual who will: (1) reassign his/her benefits to an eligible entity, (2) terminate an existing reassignment, or (3) update the primary practice location listed on the Form CMS-855R. Separate Form CMS-855Rs must be completed for each transaction.

Providers May Request Offsets via eServices

eOffset allows providers to request an immediate offset if they have received an overpayment letter. Providers also have the option to select a permanent offset request for all future demanded overpayments.

Voluntary Refunds Job Aid

A voluntary refund should be returned to Medicare anytime an overpayment has been identified by the provider. Overpayments are Medicare funds that a provider, physician/supplier or beneficiary has received in excess of amounts due and payable by Medicare. Once a determination of overpayment has been made, the amount is a debt owed to the United States Government.

Influenza, Pneumococcal and Hepatitis B Vaccines and Administration Reimbursement

These immunizations are paid at 100 percent of the established fee schedule amount. Coinsurance and the annual deductible do not apply.

E/M Tip: Drug Therapy Requiring Intensive Monitoring (Table of Risk)

In order to receive 'credit' for 'drug therapy requiring intensive monitoring for toxicity,' you must manage/monitor the drug.

E/M Tip: An E/M on the Same Day as Psychotherapy

The documentation must clearly reflect both services (E/M and psychotherapy) were rendered. The E/M service is selected based on the documentation requirements (history, examination, and/or medical decision making). The time spent performing the E/M service is not included in the psychotherapy time.

E/M Tip: Signatures (Ancillary Staff - Incident to)

A 'nurse visit' is considered an 'incident to service' if the requirements are met; therefore the physician/non-physician practitioner who is supervising must sign the documentation.

E/M Tip: Denials or Down codes
If you receive a denial or down code based on medical necessity, it is important to review the documentation submitted along with the E/M guidelines to determine the reason/cause for the denial. You may use the online E/M Checklist and Scoresheet Form to assist with auditing/selecting the E/M level.
MACRA Update
CMS announced recently that the final MACRA regulation will exempt physicians from any risk of penalties if they choose one of multiple MIPS reporting options in 2017, in addition to the option of participating in an advanced APM.   These options and other supporting details will be described fully in the final rule.
As previously reported in the Wesgram, CMS and the DHHS released the 2400 page final MACRA rule on October 14, 2016. The final rule is scheduled to be published in the Federal Register next Friday, November 4, 2016.  

MACRA changes the way that physicians will be reimbursed for Medicare services. By tying payments to outcomes and quality care, MACRA becomes more than just reimbursement.
For the most up to date information about MACRA and how your practice can assess its readiness, the AMA is providing the following website 

 The WVSMA will keep you updated on educational events and MACRA training.   One such opportunity is next week when you may join this Centers for Medicare & Medicaid Services (CMS) National Provider Call to learn how to report quality measures during the 2016 program year to maximize your participation in Medicare quality programs, including the Physician Quality Reporting System (PQRS), Medicare Electronic Health Record (EHR) Incentive Program, Value-Based Payment Modifier (Value Modifier), and the Medicare Shared Savings Program. 
Satisfactory reporters will avoid the 2018 PQRS negative payment adjustment, satisfy the clinical quality measure component of the EHR Incentive Program, and satisfy requirements for the Value Modifier to avoid the downward payment adjustment. A question and answer session will follow the presentation. 
Register for the call here.

Medicare Advantage Plans Update
According to the Centers for Medicare and Medicaid (CMS), the Average Medicare Advantage monthly premiums will actually decrease from $32.59 in last year to $31.40 in 2017.   Meanwhile, enrollment is expected to increase to 18.5 million and cover nearly one-third of all Medicare beneficiaries, building on a surge of new members over the past five years.
Changes to the MA program prompted by the Affordable Care Act drove the enrollment boost, according to CMS. In 2017, the program will cover 60 percent more beneficiaries than it did in 2010, with premiums that are 13% lower on average.
Similarly, premiums for Medicare Part D will remain stable at $34 a month in 2017. Since 2010, the program has saved each enrollee an average of more than $2,100 in drug costs.
CMS also announced new updates to the Medicare Advantage Star Rating system that will "strengthen the accuracy of the evaluation system" by accounting for low income, dual-eligible and disabled individuals. The agency has also finalized new payment adjustments that will pay more for beneficiaries in those high risk categories.
Payor News and Other News 
Molina Update

Molina recently held Provider Workshops statewide. The agenda included a wide variety of speakers and topics. Several items of special importance include:

            Effective in October, 2016, Medicaid will be placing provider payholds and/or terminating providers who are not currently in communication with and working with Molina to complete their revalidation.

            Effective November 1, 2016, any prescriptions (new or refill) written by providers who are not enrolled with West Virginia Medicaid will be denied. This edit applies to anyone who prescribes, including newly eligible to enroll as part of their revalidation, (i.e. Residents and Physician Assistants).

            As of January 1, 2017, the physician's effective date of enrollment will be based on the date that Molina receives a complete provider enrollment application.

The Molina Spring Provider Trainings will be held in April, 2017.

CIGNA Update
Cigna providers who are enrolled in electronic funds transfer (EFT) receive their payments three times a week, instead of once a week. Payment calendars may be found on the website, www.cigna.com.
Cigna also has a new app "Coach by Cigna" that is available for all patients, even those without Cigna insurance. The app helps patients manage key factors that contribute to health issues. To learn more go to http://www.cigna.com/about-us/coach-by-cigna/coach
Highmark News

West Virginia Family Health Has New Toll-free Phone Number-----Six Provider Telephone Numbers Retired from Service
Effective Aug. 8, 2016, the telephone numbers listed in the chart have been retired. Practices should be using the new centralized number, 1-855-412-8001.
Retired Department Numbers
Rx Pharmacy Services
IVR (Eligibility Verification)
Provider Services
Utilization Management
Care Management
Behavioral Health Utilization
Management and Care Management

Effective Aug. 8, 2016, a new toll-free telephone number for West Virginia Family Health (WVFH) network providers was launched. The new number - 1-855-412-8001 - was created to replace six numbers and consolidate those provider service functions behind one convenient, centralized number.

When dialing the new number, you must select either Option 1 and enter your 10-digit national provider identifier (NPI) number or Option 2 and enter your nine-digit tax identification number. (Without your NPI or tax ID number, you cannot proceed and use the subsequent touchtone options.)

Once you've entered your NPI or tax ID number, you can select from the following touchtone options to obtain information about your WVFH patients across the following key categories:
  • Option 1 - Retail or specialty pharmacy questions (Rx Pharmacy Services)
  • Option 2 - Eligibility verification (WVFH's 24/7 interactive voice response system [IVR])
  • Option 3 - Claims questions, benefits verification or to check authorizations on file (Provider Services)
  • Option 4 - Authorization requests (Utilization Management)
  • Option 5 - Care coordination (Care Management)
  • Option 6 - Behavioral health authorization requests, or to speak with a Behavioral Health case manager (Behavioral Health Utilization Management and Care Management)
True Performance Program Launching 1/1/17

Primary Care Physicians are reminded that Highmark will launch the Highmark True Performance value-based reimbursement program beginning Jan. 1, 2017. True Performance will replace the existing PCP programs across all markets and member populations as a single, unified, simplified program.

Through the years, Highmark's PCP incentive programs have helped to improve health care on many fronts. The company firmly believes that True Performance is the next step in the evolution of value-based reimbursement and represents the future of efficient, quality health care delivery. True Performance will benefit Highmark members - your patients.

True Performance will allow Highmark to continue to focus on lasting transformation of the health care delivery system and align with the Blue Distinction® Total Care initiative of the national Blue Cross Blue Shield Association. They will work closely with providers and communicate frequently in the months ahead to support the transition to this new value-based model.

For more information on True Performance, providers currently in a Highmark pay-for-value program should continue to watch for news and alerts on the provider portal, which is accessible via NaviNet®. Also, to learn more, contact your Provider Relations Representative.
story6Other News
Compliance Update

Remember that OSHA training, like HIPAA training, must be done annually in your office. If you've not yet had your the required training, you should arrange to do so before the end of the year.  Be sure to document that employees received this training. 

There is a change in the OSHA training requirement this year. As a part of the training program, practices must have a live person to conduct an OSHA question and answer training. Make sure you are compliant and schedule your OSHA training!

Also, remember that under the federal government's mandatory exclusion authority (as written in the Social Security Act) any individual or entity convicted of certain offenses must be excluded from participation in federal health care programs. The Office of the Inspector General (OIG) maintains the List of Excluded Individuals and Entities (LEIE) on its website.   Although there is no statutory or regulatory requirement to check the LEIE, since February of 2011, the OIG has recommended that physician practices screen all employees and contractors prior to hire and monthly afterward.

Huntington Area Medical Practice Consortium

Huntington Area Medical Practice Consortium will meet on Thursday, November 10th, 5:00 PM at the HIMG Regional Medical Center (The Dr. Charles "Skip" Turner Memorial Education Center). 

The topic for the meeting is "Opiod Epidemic:  How Physicians Can Help" and will feature both physicians and City of Huntington management. 

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WESGRAM is solely intended for members of the West Virginia State Medical Association (WVSMA) and PMI certified professionals.To join WVSMA, go to our website.