In this issue Network name change Modifier 25/59 best practices Care Gaps RPM updates Medical necessity criteria updates Join our email list Join our email list in order to begin receiving bi-monthly newsletters, as well as occasional electronic communications.

Network name change With the 2022 plan year almost here, we want to let you know about an upcoming network name change. Effective Jan. 1, 2022, the OHSU Tuality Health & Associates Network will be rebranded and named OHSU Health HMC Network. This network is available exclusively to OHSU Health Hillsboro Medical Center (formerly Tuality Healthcare) employees. This name change will not impact your current participation in any other networks, your reimbursement rates or the administrative requirements. Please note that this network panel is currently closed except for behavioral health and alternative care providers located in the Portland metro area.

Best practices for using modifiers 25 and 59 To help reduce healthcare waste and billing errors, we strongly encourage the following best practices for using modifier 25 and modifier 59. Per CMS, modifiers may be appended to HCPCS/CPT codes only if clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI edit if clinical circumstances do not justify the use of it.   Please note the following: 1. Modifier 25 (RPM028): Significant, separately identifiable E&M service on the same day as a procedure or other service: The submission of modifier 25 appended to a procedure code indicates that documentation is available in the patient’s records that supports the distinct, significant, separately identifiable nature of the evaluation and management service submitted with modifier 25 The additional E&M service must be able to stand alone as a billable service with no overlapping of key E&M components (e.g., medical history, medical examination and medical decision making performed) 2. Modifier 59 (RPM027): Distinct, independent non-E&M procedures and services that are not normally reported together, but are appropriate under the circumstances: Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual Modifier 59 should only be reported if a more descriptive modifier (e.g., modifier XE, XP, XS, or XU) is unavailable, and it is the most accurate modifier to describe the circumstances   Our reimbursement policies follow CMS/Medicare coding guidelines, along with other industry standard guidelines, including AMA, CPT and HCPCS for the appropriate adjudication of claims. To learn more, please see the following: RPM027, Modifiers XE, XS, XP, XU and 59 – Distinct procedural service RPM028, Modifier 25 – Significant, separately identifiable E&M service

Closing gaps of care for your Medicare patients To support your patients in their health journey, our staff of highly trained health advocates at Moda Health and Summit Health are reaching out to your Medicare Advantage patients to help schedule their recommended preventive services before the end of the year.   We ask that you work with your patients to complete any care gaps that are appropriate to manage their overall health. In doing so, please be sure to code services accurately for both your own reimbursement and quality measure reporting.   Our goal is to help reduce any gaps of care for your Medicare patients. We recognize that many providers are overwhelmed with competing priorities, we appreciate your support in caring for our members.   Learn more about Medicare Preventive Services at the Medicare Learning Network.

Reimbursement Policy Updates

Policy

Reason for review

Summary of update

Reviewed in October 2021

RPM008, “Technical Component (TC), Professional Component (PC/26), and Global Service Billing.”

Annual review

Scope – Added Summit Health Section N.3 – Changed “chemical dependency” to “substance use disorder” to be consistent with terminology changes in Oregon statute & soon Oregon administrative rules per email from Dan Thoma Acronym & abbreviation table – Removed EOCCO. Added 3 missing acronyms. Minor formatting adjustments.

RPM034, “Modifiers AA, AD, GC, QK, QX, QY, QZ – Anesthesia Payment Modifiers.”

Annual review

Scope – Added Summit Health. Removed EOCCO. Converted to outline format Section B.2 – Updated Physician Fee Schedule status indicator information Section C – C.2 & C.3 added Section D – Rephrased, content unchanged Acronym table – Added 3 acronyms References & resources – Added #6 & 7 Important statement wording updated Minor font adjustments

RPM037, “Preventive Services versus Diagnostic and/or Medical Services.”

Annual review

Scope – Added Summit Health. Removed EOCCO. Replaced “should” with “must” in all locations except direct quotes from AMA CPT Assistant articles. Section D – Added link to section H Section E.2 – Added notation on management of labor with link to section J. Section J – Added link to section E.2 Definition of terms table – Added Precipitous Delivery Important statement wording updated Minor grammar & formatting adjustments

RPM046, “Colorectal Cancer Screening and Related Ancillary Services.”

Annual review

Scope – Added Summit Health. Removed EOCCO. Section C – Added another example for XS for separate lesion Section D.1 – Clarifying statement added Acronym table – Added Modifier definitions – Minor phrasing change for 2015 establishment of modifiers -X{EPSU} Coding guidelines – Added quote from CCI chapter 1, C.5. References & resources – Added #8 Minor punctuation & font size adjustments

RPM053, “Diagnosis Code Requirements – Level of Detail, Number of Characters, and Laterality.”

Annual review

Scope – Added Summit Health. Removed EOCCO. Changed “should not be used” to “may not be used” Acronym table – Added Definition of terms table – Added References & resources – Added #3 Important statement wording updated Minor formatting adjustments

Policy

Reason for review

Summary of update

RPM065, “Facility Guidelines, General Overview.”

Oregon statute terminology changes

Scope – Added Summit Health Section N.3 – Changed “chemical dependency” to “substance use disorder” to be consistent with terminology changes in Oregon statute & soon Oregon administrative rules per email from Dan Thoma Acronym & abbreviation table – Removed EOCCO. Added 3 missing acronyms. Minor formatting adjustments.

RPM074, “Additional Practice Expense Items During a Public Health Emergency (PHE) – CPT 99072.”

Annual review

Scope – Added Summit Health. Removed EOCCO. Converted to outline format Section B.2 – Updated Physician Fee Schedule status indicator information Section C – C.2 & C.3 added Section D – Rephrased, content unchanged Acronym table – Added 3 acronyms References & resources – Added #6 & 7 Important statement wording updated Minor font adjustments

Reviewed in November 2021

RPM020, “Maternity Care”

Annual review

Scope – Added Summit Health. Removed EOCCO. Replaced “should” with “must” in all locations except direct quotes from AMA CPT Assistant articles. Section D – Added link to section H Section E.2 – Added notation on management of labor with link to section J. Section J – Added link to section E.2 Definition of terms table – Added Precipitous Delivery Important statement wording updated Minor grammar & formatting adjustments

RPM027, “Modifiers XE, XS, XP, XU, and 59 – Distinct Procedural Service.”

Annual review

Scope – Added Summit Health. Removed EOCCO. Replaced “should” with “must” in all locations except direct quotes from AMA CPT Assistant articles. Section D – Added link to section H Section E.2 – Added notation on management of labor with link to section J. Section J – Added link to section E.2 Definition of terms table – Added Precipitous Delivery Important statement wording updated Minor grammar & formatting adjustments

RPM029, “Modifier 57 – Decision for Surgery.”

Annual review

Scope – Added Summit Health. Removed EOCCO. Changed “should not be used” to “may not be used” Acronym table – Added Definition of terms table – Added References & resources – Added #3 Important statement wording updated Minor formatting adjustments

Policy

Reason for review

Summary of update

RPM032, “Anesthesia Physical Status Modifiers (P1 - P6).”

Annual review

Scope – Added Summit Health. Removed EOCCO. Acronym table – Added Important Statement wording updated Minor formatting adjustments

RPM040, “Incident-To Services.”

Annual review

Scope – Added Summit Health. Removed EOCCO. Converted to Outline format Acronym table – Added Important statement wording updated Minor formatting adjustments

RPM041, “Critical Care, Evaluation and Management Services (99291, 99292).”

Annual review

Scope – Added Summit Health Reimbursement Guidelines – “should be submitted” changed to “is to be submitted” Acronym table – Added Important Statement wording updated Minor formatting adjustments

RPM046, “Colorectal Cancer Screening and Related Ancillary Services.”

External request for clarification

Section A.1.b – Changed wording to reference and link to the preventive services for adults document on Moda's external website under Provider Resources, Preventive Services

RPM051, “Procedures Designated as "Separate Procedure".”

Annual review

Scope – Added Summit Health Acronym table – Added Definition of terms – Converted to table and moved location to above the Modifier table Important Statement wording updated Minor formatting adjustments

RPM054, “Diagnosis Code Requirements - Invalid As Primary Diagnosis.”

Annual review

Scope – Added Summit Health. Minor changes for clarity. Converted to outline format Sections A.3, B.3, & C.3 financial responsibility – minor phrasing changes for clarity Section C, Medicaid Removed “EOCCO” from section title Reversed order of information to match pattern in other LOB, all claims listed first, Inpatient claims listed second Added mention of financial responsibility, even though this is consistently understood for Medicaid claims/rules Acronym table – Added 10 acronyms Important statement wording updated Minor formatting adjustments

RPM062, “Modifier 63 - Procedure Performed on Infants Less Than 4 kg.”

Annual review

Scope – Added Summit Health. Removed EOCCO. Removed statement that policy does not apply to Facility claims, as it conflicted with section D.1. Acronym table – Removed EOCCO. Added 7 acronyms. Definition of terms – Updated definition of “infant” for clarity Important statement wording updated Minor formatting adjustments

Medical Necessity Criteria updates

Criteria

September Medical necessity criteria

Pharmacy/medical

Anesthesia for routine gastrointestinal endoscopic procedures

Introduction: This is annual review  Criteria changes: No changes

Medical

Breast pumps

Introduction: This is annual review   Criteria changes: No changes

Medical

Computer assisted navigation for musculoskeletal procedures

Introduction: This is an annual review   Criteria changes: No changes

Medical

Cooling devices

Introduction: This is an annual review   Criteria changes: No changes

Medical

Electron-beam computed tomography (EBCT)

Introduction: This is an annual review   Criteria changes: No changes

Medical

Gender confirming surgery

Introduction: This is an annual review   Criteria changes: No changes

Medical

Interferential stimulation devices

Introduction: This is an annual review   Criteria changes: No changes

Medical

Obstructive sleep apnea: Surgical treatment

Introduction: This is an update   Criteria changes: Added coverage guidelines for hypoglossal nerve stimulation

Medical

Patient lifts

Introduction: This is an annual review   Criteria changes: No changes

Medical

Post-op sinus endoscopy debridement

Introduction: This is an annual review   Criteria changes: No changes

Medical

Reduction mammoplasty

Introduction: This is an annual review   Criteria changes: No changes

Medical

Criteria

October Medical necessity criteria

Pharmacy/medical

Anesthesia for routine gastrointestinal endoscopic procedures

Introduction: This is an update   Criteria changes: Replaced wording “frequently/intermittently” with “occasional” marijuana use

Medical

Clinical trials

Introduction: This is annual review   Criteria changes: Added guidelines for clinical trials that apply to Texas members as per the Texas statute requirements

Medical

Intraocular lens implant

Introduction: This is annual review.   Criteria changes: Removed ‘cost alternative’ wording. Medical necessity requirements are guided by evidence -based research

Medical

Intrathecal opioid therapy

Introduction: This is an annual review   Criteria changes: added ‘infusion pump’ wording to title

Medical

Nitric oxide therapy

Introduction: This is an annual review   Criteria changes: No content changes

Medical

Nitric oxide therapy Non-invasive testing for liver fibrosis

Introduction: This is an annual review   Criteria changes: No content changes

Medical

Pulmonary rehabilitation

Introduction: This is an annual review   Criteria changes: added “Emphysema” to list of diagnosis

Medical

Hydrogen breath testing

Introduction: This is an annual review   Criteria changes: No content changes

Medical

Salivary hormone testing

Introduction: This is annual review   Criteria changes: No content changes

Medical

Experimental & investigational services

Introduction: This is an annual review   Criteria changes: Updated references

Medical

Salivary hormone testing

Introduction: This is an annual review   Criteria changes: No content changes

Medical

Contact us

Moda Medical Customer Service For claims review, adjustment requests and/or billing policies, please call 888-217-2363 or email [email protected].   Moda Provider Relations For escalated claim inquiries, contract interpretation, educational opportunities or onsite visit requests please email [email protected]

Provider Updates For provider demographic and address updates, please email [email protected]. Credentialing Department For credentialing questions and requests, please email [email protected].

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