Welcome to the WESGRAM. This edition contains important updates from CMS, Palmetto and other payers, as well as important information about the WV Rx Card. You'll also find information about important upcoming educational opportunities.
ICD-10 Latest News
Here are some fun ICD-10 codes for the winter season:
W00.0XXA: Fall due to slipping on ice
Y93.H1XA: Shoveling snow
Y92.014: Place of occurrence, driveway
F34.8: Seasonal Affective Disorder
R45.1   Cabin Fever
E55.9: Vitamin D deficiency
X15.XXXA:  Burned by electric blanket
(information from Palmetto GBA)

Medicare Outpatient Observation Notice (MOON) Instructions

Change Request (CR) 9935 updates Chapter 30 of the "Medicare Claims Processing Manual" to include the Medicare Outpatient Observation Notice (MOON), and related instructions. Providers should use the MOON to inform Medicare beneficiaries when they are an outpatient receiving observation services, and are not an inpatient of the hospital or a Critical Access Hospital (CAH). 

New Function Available

Electronic Audit (eAudit) is a new function available in the eServices online portal, which allows providers the ability to access personal reports of audit results for claims which have been chosen for Complex Medical Review by various Medicare review contractors. eAudit gives providers the opportunity to see what claims may be pending Complex Medical Review currently and the results of any recent review decisions. This information can be used for self-assessment of provider performance on Medicare audits utilizing a dashboard which contains the most common denial reasons. The eAudit tool currently features CERT contractor claim review data with JM Medicare Administrative Contractor (MAC) Medical Review and JM Appeal review data coming soon!

New Influenza Virus Code Rejecting Incorrectly

Claim detail lines for CPT code 90674 (influenza vaccine Flucelvax) rejected incorrectly on claims processed between January 1, 2017 through January 23, 2017. Affected detail lines rejected with Claim Adjustment Reason Code 181 (Procedure code was invalid on the date of service) and Remittance Advice Remark Code M20 (Missing/incomplete/invalid HCPCS).

There is no provider action required. The claims processing system has been updated to correct the issue. Affected claims will be identified and adjusted.

Add-On Procedure Code Denials

Some Add-On Codes are denying even though the Primary Code was submitted on the same claim, for same DOS, same provider. It has been noted that some claims in this situation are processing correctly and an investigation request has been submitted for further research. If the Primary Code claim is submitted first and a separate claim is submitted with the Add-On Code there does not appear to be an issue at this time.

Respond to ADRs via eServices

As a provider, you 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 Palmetto’s free eServices. This will eliminate mailing time and costs.  You will also receive a confirmation receipt letting you know when the records are received.

Gain Insight Into Your Billing Patterns and Utilization Services: Use Electronic Comparative Billing Reports (eCBRs)

Palmetto GBA uses electronic Comparative Billing Reports (eCBRs) as an educational tool for providers to use in order to provide insight into your billing patterns and utilization of services in comparison to your peers. eCBR will provide you with the ability to view and download your individual CBR online.

E/M  Tip: Counseling and/or Coordination of Care

An evaluation and management (E/M) service is only based on time when counseling and/or coordination of care dominates (more than 50 percent) of the physician/patient and/or family encounter.

eUtilization: See Who Has Been Using Your NPI

Electronic Utilization (eUtilization) reports are now available in the eServices portal. eUtilization reports provide rendering providers and ordering and referring providers access to their personal data. This data can be reviewed to ensure providers are aware of when and by whom their NPI is being used for billing Medicare services and when their NPI is entered on a Medicare claim as the ordering referring physician.

CMS awards approximately $100 million to help small practices succeed in the Quality Payment Program

On Friday, February 17, the Centers for Medicare & Medicaid Services (CMS) awarded approximately $20 million to 11 organizations for the first year of a five-year program to provide on-the-ground training and education about the Quality Payment Program for clinicians in individual or small group practices of 15 clinicians or fewer. CMS intends to invest up to an additional $80 million over the remaining four years.

These local, experienced, community-based organizations will provide hands-on training to help thousands of small practices, especially those that practice in historically under-resourced areas including rural areas, health professional shortage areas, and medically underserved areas. The training and education resources will be available immediately, nationwide, and will be provided at no cost to eligible clinicians and practices.

“Clinicians in small and rural practices are critical to serving the millions of Americans across the nation who rely on Medicare for their health care,” said Dr. Kate Goodrich, CMS Chief Medical Officer and Director of the Center for Clinical Standards and Quality. “Congress, through the bipartisan Medicare Access and CHIP Reauthorization Act, recognized the importance of small practices and rural practices and provided the funding for this assistance, so clinicians in these practices can navigate the new program, while being able to focus on what matters most -- the needs of their patients.”

The selected organizations will provide customized technical assistance to clinicians and practices to help them be successful in the Quality Payment Program. For example, clinicians will receive help choosing and reporting on quality measures, as well as guidance with all aspects of the program, including supporting change management and strategic planning and assessing and optimizing health information technology.

This funding is one part of a multi-level outreach effort to help clinicians understand and provide feedback about the new Quality Payment Program. Through webinars and in-person presentations, thousands have received free training and education from CMS staff since the Quality Payment Program Final Rule was released last October. In addition, through the established Quality Innovation Networks, the Transforming Clinical Practice Initiatives, and the Alternative Payment Model Learning Systems, every clinician in the Quality Payment Program can receive in-person training, including information about the Merit-based Incentive Payment System, as well as the Alternative Payment Model track.

As part of that outreach effort, CMS also launched a new telephone helpline for clinicians seeking assistance with the Quality Payment Program. Clinicians may contact the Quality Payment Program by calling 1-866-288-8292 from 8AM – 8PM EST or emailing qpp@cms.hhs.gov.

For more information on the Quality Payment Program, please visit: qpp.cms.gov.

One of the recipients of the CMS contracts is Quality Insights (West Virginia Medical Institute).  The WVSMA will be working with Quality Insights to provide “on –the-ground” training and education to small practices. 
Payor News
Come meet the West Virginia government and commercial payors at the WVSMA/WVMGMA Conference on Friday, March 24, 2017, at the Charleston Embassy Suites.  For more information, click here.
Other News

New Insurance Commissioner Announced

West Virginia Gov. Jim Justice has appointed Allan L. McVey as the state’s insurance commissioner, effective April 1.

Mr. McVey currently serves as vice president and agency manager for BB&T-Carson Insurance Services in Charleston, West Virginia, the state Department of Revenue said Wednesday in a statement.

The West Virginia Offices of the Insurance Commissioner’s general counsel, Andrew Pauley, is serving as acting commissioner until Mr. McVey begins his tenure, according to the statement issued on February 16, 2017.  

News From the AMA

In a landmark win on January 23, 2017, for organized medicine and the nation’s patients, federal judge John D. Bates blocked the proposed Aetna-Humana merger. The judge found that the merger would have substantially lessened competition in Medicare Advantage and commercial health insurance markets. This is an extraordinarily well documented, comprehensive, fact-based ruling by U.S. District Judge John D. Bates, which acknowledges that meaningful action was needed to preserve competition and protect high-quality medical care from unprecedented market power that Aetna would acquire from the merger deal. The decision is a historic, stunning affirmation of the position urged by the American Medical Association (AMA) and the 17-state medical association antitrust coalition members. The court’s ruling sets a notable legal precedent by recognizing Medicare Advantage as a separate and distinct market that does not compete with traditional Medicare. This was a view advocated by the AMA, as well as leading economists.

The AMA and its coalition partners worked tirelessly to oppose this merger: sending comprehensive, evidence-based advocacy letters to the US Department of Justice (DOJ) and state regulators after the merger was announced in July 2015; engaging like-minded stakeholders like the American Hospital Association and various patient coalitions, as well as the National Association of Attorneys General; conducting extensive physician surveys to gauge physician concern about the merger and presenting the DOJ and state regulators with compelling survey results; testifying in or submitting memoranda in various state insurance department hearings and/or attorney general investigations, and making that, and other evidence and testimony, available to the DOJ and state regulators; securing outside experts to buttress our arguments and strip down those of the insurers.

MACRA “Lunch and Learn”

The WVSMA is hosting  MACRA Lunch and Learn events on the Wednesday, March 1, 2017, and Wednesday, March 8, 2017.   You are invited to register for one of these educational sessions.  Register today at www.wvsma.org.

 Huntington Area Medical Practice Consortium Plans Meeting

The Huntington Area Medical Practice Consortium will meet on Wednesday, March 1, 2017 at 5:00 PM at the St. Mary’s Center for Education Rahall Room.   The meeting is sponsored by St. Mary’s Medical Center.  All practice administrators/managers are invited to attend!

Hors D’oeuvres will begin at 5:00 PM, with Breakout Sessions on HR/Personnel Issues/IT/Payer Issues/Clinic Operations beginning at 5:30 PM.   

WVSMA/WVMGMA Physician Practice 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 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.  Speakers include nationally known healthcare attorney Robert Liles,  MGMA national speaker/author Dave Gans, along with Palmetto GBA’s Shannon Chase and Jezreel Harrison RN.

The conference will also include concurrent break out sessions on various topics, so you may want to send several people from your practice in order to not miss out on any updates.  

Plan now to attend!   Register at www.wvsma.org 

Save the Date!

The WVMGMA will be holding regional meetings during May.  Below are the days and locations.  Watch for more details coming soon!

Tues, May 16 – Parkersburg

Wed, May 17 – Morgantown

Wed, May 17-- Teays Valley (Huntington and Charleston attendees)

Fri, May 19 – Beckley