In this issue
  • HEDIS annual chart collection

  • MA annual wellness visits

  • MA care guides

  • Reimbursement Policy updates

  • Medical necessity updates
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HEDIS annual chart collection

From February to May, Moda Health will begin collecting medical records for the HEDIS® MY2021 Project. Our vendors, KDJ Consultants and Cotiviti, will soon be reaching out to you to collect charts for review. They will work with you on the best way to complete the process — via electronic health records, on-site retrieval or by faxing/mailing in records.


Questions?
For questions about this process, please email HEDIS@modahealth.com
Medicare annual wellness visits

Join us in encouraging your patients to complete their Annual Wellness Visits (AWV) in 2022. Moda Health and Summit Health Customer Service teams will be placing welcome calls to our new Medicare Advantage membership to educate about the importance of getting an annual checkup.
 
AWVs are fully covered and come at no cost to your patients. Over the next few months, your office can expect to get calls from the Summit Health Customer Service team and your patients to schedule AWVs.
 
An AWV is not a Medicare Star Measure, but it is an opportunity to impact many quality measures and improve better health outcomes for your patients.
 
A key aspect of these visits is a health assessment, which is required by Medicare in every AWV. During the visit, you can assess your patient’s physical health status, psychosocial and behavioral risks, cognitive and functional status, biometric health indicators, establishing risk factors and personalized care plan. This enables you and your patients to stay current on preventive screenings and vaccines, effectively manage chronic conditions and be proactive in closing any care gaps.
 
Accurately coding wellness visits is important for both your reimbursement and quality measure reporting. Learn more at the Medicare Wellness Visit website.
Medicare patient care guides

Moda Health and Summit Health will soon send our first-quarter care guide to educate and help your Medicare Advantage patients schedule their recommended preventive services. We ask that you please work with these patients on their open gaps in care and complete those that are appropriate for their overall health management.
 
These personalized guides are based on your patients’ medical and pharmacy claims data. They’ll remind your patients about services that may be due, including Annual Wellness Visits, cancer screenings, routine diabetes care and more.
 
Many of these services are directly tied to Star Measures, while others have an indirect opportunity to impact quality measures. Closing these care gaps can lead to better health outcomes for your patients.
 
Accurately coding preventive services for Medicare Advantage patients is important for both your reimbursement and quality measure reporting. Learn more at the Medicare Learning Network website.
Reimbursement Policy Updates

The following tables include RPM policy updates for December 2021
and January 2022.
Policy
Reason for review
Summary of update
Reviewed in December 2021
RPM077, “Therapy Assistant Modifiers CO & C.”
New policy
  • New policy prompted by CMS Transmittal 11129/CR12397
RPM007, “Modifier 22 – Increased Procedural Services”
  • Oregon legislative terminology changes
  • Review process changes
  • Additional clarity in response to internal and external questions
  • Scope section – Added Summit Health plan
  • Multiple locations – “Chemical dependency” changed to “substance use disorder” per Oregon legislative terminology changes
  • Section A – Entire section is new information. Previous information moved to sections B & C
  • Section B – B.3, B.4, B.5, B.6 added. Additional detail & clarity added to other subsections
  • Section C – Revised & divide procedure for review by LOB.
  • Section D – D.1, E.3, F, & G - Added
  • Acronym table – Added 8 acronyms
  • Cross References – Added # C
RPM023, “Procedure Codes Assigned to Surgical Benefit Categories”
Annual review
  • Scope – Added Summit Health. Removed EOCCO.
  • Converted to Outline format
  • Section A – Removed “…by either the American Medical Association (AMA) or…”
  • Sections B & C added
  • Section D – Revised information for global days indicators “000,” “XXX,” “YYY” and “ZZZ.” Reworded information for Maternity procedures “MMM.”
  • Section F.4 – added “and cardiac electrophysiology” procedures
  • Codes, Terms & Definitions section – Changed header. Added Acronym table. Converted Global Days Indicators into table format with header.
  • Important statement wording updated
RPM044, “Gynecologic or Annual Women’s Exam Visit & Use of Q0091 (Pap, Pelvic, & Breast Visit)”
Annual review
  • Scope – Added Summit Health. Removed EOCCO.
  • Procedure code table – Added notation to 99417 to See RPM076
  • Cross Reference section – Added RPM076
RPM051, “Procedures Designated as ‘Separate Procedure"
Annual review
  • Scope section – Rephrased listing of Summit Health plan
  • Converted to outline format
RPM052, “Telehealth & Telemedicine Services”
  • Oregon legislative terminology changes.
  • Changes to telehealth POS codes
  • Scope section – Added Summit Health plan
  • Section A.5 – Added due to provider questions
  • Sections B.7.l & D.2.c.ii.12) – “Chemical dependency” changed to “substance use disorder” to be consistent with Oregon legislative terminology changes
  • Sections D & E – Identification of Medicare Advantage & Medicaid LOB simplified for consistency
  • “POS 02” changed to “POS 02 or 10” in multiple locations
  • Section E.1.h.i.b) updated for Medicaid POS 10 information
  • Acronym table, 9 listings added
  • Modifier table, header wording updated.
  • Place of Service table – POS 02 definition updated with effective date notation. POS 10 added.
  • Coding Guidelines section – Quote from CMS Reference # 27 added
  • References & Resources section – # 16, updated name & URL. Added # 20 - 32.
Annual review
  • Scope – Added Summit Health. Removed EOCCO.
  • Acronym table – Removed EOCCO. Added 7 acronyms.
  • Important Statement wording updated
RPM060, “Transportation of Portable X-ray Equipment, Multiple Portable X-rays - Modifiers UN, UP, UQ, UR, US”
Annual review
  • Scope – Added Summit Health. Removed EOCCO.
  • Reimbursement Guidelines – Reworded Note statement
RPM061, “Clinic Services
in the Hospital Outpatient Setting – Commercial”
Provider appeals & member appeals requesting opposite outcomes from each other
  • Scope – Revised for clarity
  • Section B.3.b – Revised
RPM073, “Telehealth & Telemedicine Expanded Services for COVID-19”
  • Oregon legislative terminology changes
  • Changes to telehealth POS codes
  • Scope – Added Summit Health. Removed EOCCO
  • “POS 02” changed to “POS 02 or 10” in multiple locations
  • Section D.10.a updated for Medicaid POS 10 information
  • Codes, Terms & Definitions section – Changed “chemical dependency” to “substance use disorder” to be consistent with Oregon legislative terminology changes
  • Acronym & Abbreviation table – Added six acronyms
  • Place of Service table – POS 02 definition updated with effective date notation. POS 10 added. Added notation about effective dates by transaction not DOS from CMS MM9726.
RPM075, “Emergency Department Visit Leveling”
Annual review
  • Header – Updated section field to correct section name
  • Scope – Added Summit Health. Removed EOCCO.
  • Acronym & Abbreviation table –Removed EOCCO.
Reviewed in January 2022
RPM002, “Clinical Editing”
Oregon statute terminology changes
  • Scope – Added Summit Health. Removed EOCCO.
  • Added clarification that ASC claims on CMS1500 claims are subject to Professional MUEs but Hospital-based ASC claims on UB/CMS1450 claims are subject to OPPS MUEs
  • Cross Reference – Added # C to RPM056
  • Acronym table – Added 3 listings.
RPM004, “After Hours and Other Special Circumstances”
Annual review
  • Scope – Added Summit Health plan
  • Reimbursement Guidelines, overall - Minor rewording to remove redundant use of “Moda Health” in section headers & beginning of statements
  • Section B.3.c. – Minor rewording
  • Acronym table – Added
  • Procedure Code tables – Minor formatting changes
  • Acronym table – Added 3 listings.
RPM010, “Modifiers 58, 78 & 79 – Staged, Related, and Unrelated Procedures”
Annual review
  • Scope – Added Summit Health plan. Removed EOCCO.
  • Section E.2.a – Minor rewording
  • Minor formatting changes
RPM011, “Global Surgery Package for Professional Claims”
Annual review
  • Scope – Added Summit Health plan. Removed EOCCO.
  • Section B header, B.1, B.2.b & B.3 – Reworded to remove “Moda Health”
  • Section K – Reworded for clarity and to remove some complexity
  • Section M.1 – Reworded
  • Section N.1 – Reworded
  • Acronym table – Added
  • Procedure code table – Added
  • Global Days Indicator list – Converted to table format
  • Minor formatting changes
RPM012, “Routine Venipuncture and/or Collection of Specimens”
Annual review
  • Scope – Added Summit Health. Removed EOCCO.
  • Section C header – Removed “(OPPS)”
  • Codes, Terms & Definitions section – Changed header
  • Acronym table – Added
  • Minor formatting adjustments
RPM014, “Intra-joint and Surgical Site Postoperative Pain Relief Drug Delivery System (Pain Pump)”
Annual review
  • Scope – Added Summit Health plan
  • Acronym table – Added 7 entries
  • Minor formatting changes
Medical Necessity Criteria updates

The following table includes medical criteria updates for
November/December 2021 and January 2022.
Criteria
November
Medical Criteria Summary
Pharmacy/medical
Breast reconstruction
Introduction: This is annual review
Criteria changes: Grammar updates, replaced “reassignment” with “confirming procedure”
Medical
Custom compression garments
Introduction: This is an annual review
Criteria changes: No changes
Medical
Hospital beds for home use
Introduction: This is an annual review
Criteria changes: No changes
Medical
Prolotherapy
Introduction: This is an annual review
Criteria changes: No changes
Medical
Standers (standing frames)
Introduction: This is an annual review
Criteria changes: No changes
Medical
Criteria
December
Medical Criteria Summary
Pharmacy/medical
Hearing assistive technology
Introduction: This is an annual review
Criteria changes: No changes
Medical
Cardiac defibrillators, external
Introduction: This is an annual review
Criteria changes: No changes
Medical
Cryoablation of breast fibroadenomas
Introduction: This is an annual review
Criteria changes: No changes
Medical
Criteria
January 2022
Medical Criteria Summary
Pharmacy/medical
Acupuncture
Introduction: This is an annual review
Criteria changes: No changes
Medical
Balloon dilation of eustachian tube
Introduction: This is an annual review
Criteria changes: No changes
Medical
BRCA testing
(BRACAnalysis, myChoice CDx)
Introduction: This is an annual review
Criteria changes: No changes
Medical
Chiropractic services
Introduction: This is an annual review
Criteria changes: No changes
Medical
Cochlear implants and auditory brainstem implants
Introduction: This is an annual review
Criteria changes: No changes
Medical
DME general policy
Introduction: This is an annual review
Criteria changes: No changes
Medical
Experimental and investigational services
Introduction: This is an annual review
Criteria changes: No changes
Medical
Sinus surgery
Introduction: This is an annual review
Criteria changes: No changes
Medical
Contact us
Moda Medical Customer Service
For claims review, adjustment requests and/or billing policies, please call 888-217-2363 or email medical@modahealth.com.
 
Moda Provider Relations
For escalated claim inquiries, contract interpretation, educational opportunities or onsite visit requests please email providerrelations@modahealth.com
Provider Updates
For provider demographic and address updates, please email providerupdates@modahealth.com.


Credentialing Department
For credentialing questions and requests, please email credentialing@modahealth.com.

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