Welcome to the December Wesgram. This edition contains important updates from CMS, Palmetto and other payers, as well as information from the WVHIN, and WV Rx Card. You'll also find information about upcoming educational opportunities.
Here are some fun ICD-10 codes for the holiday season:
R46.2 - Strange and inexplicable behavior
R46.1 - Bizarre personal appearance
F10.921 - Alcohol use, with intoxication delirium
W22.02XA - Walked into lamppost, initial encounter
Y90.7 - Blood alcohol level of 200-239 mg/100 ml or more
(information from Palmetto GBA)
Medicare Secondary Payer Inquiry Form
As a reminder, Palmetto GBA added a Medicare Secondary Payer Inquiry Form in the Finance forms section of our website earlier this year. 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
Medicare Does Not Accept Retroactive Orders
Providers may not add late signatures to medical records. Medicare does not accept retroactive orders. In the event a signature is missing, the record cannot be changed.
E/M Tip: 1995 Comprehensive Examination
Palmetto GBA will accept '8 body areas,' '8 organ systems' or 'complete single organ system examination' for a comprehensive examination.
E/M Tip: Brief and Extended History of Present Illness (HPI)
Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s). A brief HPI includes documentation of one to three HPI elements (for both 1995 and 1997 documentation guidelines). An extended HPI includes documentation for at least four HPI elements or the status of at least three chronic or inactive conditions (for both 1995 and 1997 guidelines).
Create a Signature Log
If a physician does not have a signature log currently in place, he/she may create a signature log at any time. Medicare contractors will accept all submitted signature logs regardless of the date on which they were created.
HCPCS Code Update for Medicare Preventive Services
Physicians and other providers who are submitting claims to Palmetto GBA for preventive services provided to Medicare beneficiaries need to use a new CPT code.
MLN Change Request (CR) 9888, announces that, effective for dates of service on and after
January 1, 2017, CPT code 76706 replaces HCPCS code G0389. MACs will apply all editing that was applied to HCPCS code G0389 to CPT code 76706, including the waiver of deductible and coinsurance.
Change Request (CR) 9905 provides that the Centers for Medicare & Medicaid Services
(CMS) revises Chapter 12, Section 184.108.40.206 of the "Medicare Claims Processing Manual" to indicate that beginning Calendar Year (CY) 2017, Current Procedural Terminology (CPT) codes 99358 and 99359 (prolonged services without face-to-face contact)
are separately payable under the Medicare Physician Fee Schedule.
The Quality Payment Program is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and includes two tracks - Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS).
MIPS will replace three Medicare reporting programs:
- EHR Incentive Program (Meaningful Use)
- Physician Quality Reporting System
- Value-Based Payment Modifier
The Quality Payment Program listserv will provide news and updates on:
- New resources and website updates
- Upcoming milestones and deadlines
- CMS trainings and webinars
The Quality Payment Program's first performance period opens on
January 1, 2017 and closes December 31, 2017. Participation in MIPS can start as early as January 1, 2017 or as late as October 2, 2017.
The first payment adjustments based on performance go into effect on January 1, 2019. Subscribe to the Quality Payment Program listserv to receive reminders for all of these important deadlines.
To subscribe, visit the Quality Payment Program
and select "Subscribe to Email Updates".
For certain measures in the CMS EHR Incentive Programs final rule, CMS changed the reporting requirements over time to increase flexibility. CMS provided alternative reporting options and exceptions for providers who are:
- Scheduled to be in an earlier stage of the programs,
- Affected by a significant hardship, or
- Implementing or upgrading certified EHR technology (CEHRT).
In 2016 there are changes to the following objectives:
Secure Electronic Messaging (Eligible Providers) only - This objective has a phased approach for its measure's threshold. For 2016, an eligible professional (EP) must send a secure message using their CEHRT's electronic messaging function to at least one patient (or the patient-authorized representative) the EP sees during the EHR reporting period, or must respond to a secure message that the patient (or the patient-authorized representative) has sent during the EHR reporting period.
Public Health Reporting - In 2016, all EPs must meet two measures or claim alternate exclusions.
Providers should visit the EHR Incentive Programs
and review the What You Need to Know for 2016 Tipsheets for EPs in preparation for attestation. The attestation system will be open from
January 1, 2017 to February 28, 2017.
As of January 1, 2017, you should bill place of service "2" for Telehealth services. This is defined as "the location where health services and health related services are provided or received, through a telecommunication system."
The code is effective January 1, 2017. Many payors are now covering telehealth codes if the member has a telehealth benefit.
WV Medicaid Update
The SSI (Supplemental Security Income) population will be transitioning to managed care as of January 1, 2017. There are approximately 55,000 eligible enrollees statewide. These individuals will choose between the four MCOs. If they do not enroll in an MCO before February 1, they will be assigned.
The West Virginia Bureau for Medical Services (BMS) has set the dates and locations for the 2017 Spring Provider Workshops. Registration information will be available in the near future.
- Monday, April 3 Martinsburg, WV Holiday Inn
- Tuesday, April 4 Wheeling, WV
- Wednesday, April 5 Morgantown, WV Waterfront Place Hotel
- Thursday, April 6 Parkersburg, WV Grand Point Conference Center
- Monday, April 10 Roanoke, WV Stonewall Resort
- Tuesday, April 11 Charleston, WV Beni Kedem
- Wednesday, April 12 Huntington, WV Saint Marys Conference Center
- Thursday, April 13 Beckley, WV Tamarack
Highmark WV Update
(The information below was provided by Highmark to summarize changes made in 2016).
As you probably are aware, Highmark made changes to its service model for Provider Relations effective March 1, 2016.
Highmark, as an enterprise, continually looks to streamline our processes to ensure efficiency. In 2015, we
made great strides in updating our Provider Service Center telephone lines to offer additional self-service options. We also invested in capabilities that allow providers to handle more inquiries quickly and independently. As a result, we began doing business differently, and most providers no longer have an assigned Provider Relations Liaison/Representative.
While the team still exists, Provider Relations Liaisons/Representatives, our primary focus/functions have shifted from
to working closer with our hospital
physician practice partners on quality programs we make available to them, such as True Performance.
of the change to our servicing model
was made directly to offices via letter (sample letter as well the Self-Service Tools brochure that was included in the mailing.) In addition, information continues to be included in our Provider Newsletters regarding the change to our service model.
We encourage ALL providers, including our hospital
physician practice partners, to take advantage of the online and telephonic tools Highmark West Virginia offers.
(NN) - NaviNet should be used to research eligibility and benefits, as well as the status of claims as their first point of contact.
- Provider Resource Center (PRC) - The Provider Resource Center offers a wealth of resources, including the outpatient prior authorization list, Medical Policy search, Medical Policy Updates and various online provider forms, as well as training.
- Provider Service Center - If after using these tools, providers still need assistance, the Provider Service Center (Provider/Customer Service) is available at: 800.543.7822. Our Provider Service Advocates remain available for inquiries they are not able to resolve utilizing self-service options.
- Provider Service Center Escalation Process - In addition, because we realize there are, on occasion, more complicated claims or issues that come up. The Provider Service Center has an escalation process to address these more complicated issues. Please find below the process providers should use in getting resolution to those types of issues going forward.
- viNet investigation must be completed
- If you are not satisfied with the response on NaviNet, please call Provider Service Center at 800-547-3627
- If you are not satisfied with the response received during your phone conversation at Provider Service Center, please ask to speak to a Supervisor so the issue can be escalated
WVHIN West Virginia's Health Information Exchange is Significantly Improving Services
The only network of its kind in the state, West Virginia Health Information Network (WVHIN) supports West Virginia's healthcare providers by ensuring all hospitals, healthcare facilities and physicians have digital access to critical patient-related information with the click of a button. To improve connectively and quality of care in West Virginia, WVHIN recently partnered with the regional health information exchange for the State of Maryland and the District of Columbia, known by their acronym CRISP.
This partnership provides a number of immediate benefits for both patients and physicians, including improved access to the WVHIN secure network of information and state-of-the-art technologies that support a number of new innovative features.
Registered providers with the WVHIN will soon have access to a new Encounter Notification Service (ENS), which will allow physicians to receive real-time notifications when patients undergo significant health events within the regional network, such as emergency room visits, hospital admissions and discharges from multiple hospitals in one consolidated feed. WVHIN is beginning to roll out the ENS feature and is in the final stages of establishing connections to more than a dozen hospitals across the state, including those in Huntington, Charleston, Morgantown, Clarksburg, Parkersburg, Wheeling, the Eastern Panhandle and Princeton. WVHIN anticipates the ENS to be fully functional by summer of 2017. For questions and more information regarding the ENS or to sign up, contact Ray Frye at email@example.com.
Update on the WV Rx Card
While the Medicaid outpatient prescription drug benefit is not a mandatory benefit, all states provide this benefit in their Medicaid programs. As of 2014, Medicaid spending on outpatient prescription drugs registered at $27 billion, or about six percent of Medicaid spending. As a significant cost center, states continue to struggle with controlling Medicaid prescription drug spending including the high-cost of "specialty" drugs. Emerging issues such as specialty drugs will continue to have broader implications for the administration of the Medicaid Drug Rebate Program (MDRP).
The West Virginia Rx Card is a free resource for you to help lower out-of-pocket prescription costs. If you have a high deductible or take a medication not covered by insurance or do not have prescription coverage, the West Virginia Rx Card can save you up to 75%. Log onto
to print a free card. You can also walk into any CVS/pharmacy and request to use the West Virginia Rx Card program. Contact Charlie Hartung at firstname.lastname@example.org or 1-877-669-6569 for more information.
Federal Court Blocks Implementation of Overtime Rule
On Tuesday, November 22, 2016, a Texas federal judge entered a nationwide injunction blocking the Department of Labor's revisions to the overtime rule -- mainly the increase in the salary basis -- that was set to go into effect on December 1. Judge Amos Mazzant from the Eastern District of Texas, a 2014 Obama appointee, held that the Department of Labor's proposed increase in the salary basis test for white collar exemptions under the Fair Labor Standards Act from $23,660 to $47,476 was such a significant increase that it supplants Congress' original intent in creating white collar exemptions that were to be defined by the duties of the employee.
With the issuance of this injunction, employers across the United States will receive at least a temporary reprieve from the implementation of the Overtime Rule. However, this ruling does not necessarily mean the Overtime Rule has been blocked permanently. As this was only a preliminary injunction, future legal proceedings are expected, which could include an immediate interlocutory appeal to the Fifth Circuit Court of Appeals, who could affirm or overturn the lower court's injunction.
Employers should continue to watch for new developments related to the overtime rule, as some uncertainty remains. Until a final decision is reached in the case, employers can rely on existing overtime exemption rules. Employers that have already made adjustments to comply with the new rule may find it difficult to reverse any changes.
2017 CMOM Class Scheduled!
The WVSMA will hold the annual CMOM (Certified Medical Office Manager) class in February at the WVSMA office in Charleston. The dates for the four day course are
Thursday/Friday, February 16/17 and Thursday/Friday, February 23/24.
If you've wanted to obtain your certification, this is the time to do it. You may download a registration form
, or from our
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 24th 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!