In this issue
- Place of Service (POS) 19 update
- New timeframe and coverage for engineered skin and tissue substitutes
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Annual Wellness Visit
Please join us in encouraging your patients to complete their Annual Wellness Visits (AWV). Moda and Summit Health have contracted with, Carenet Health, to educate and assist members to get their annual checkup. AWVs are fully covered and come at no cost to your patients.
Carenet will be placing welcome calls to our Medicare Advantage (MA) membership. They will ensure patients have health plan information that helps them schedule their annual visit. In the coming months, your office can expect to receive calls from Carenet and your patients to schedule annual wellness visits.
While an AWV is not a Medicare Star Measure, it is an opportunity to impact many quality measures and improve better health outcomes for your patients. A key aspect of these visits is the Health Risk Assessment, which is required by Medicare in every AWV. During an AWV, you can assess your patient’s physical health status, psychosocial and behavioral risks, cognitive and functional status, biometric health indicators, and establishing risk factors and personalized plan for preventive care. This enables you and your patients to stay current on preventive screenings and vaccines, effectively manage chronic conditions, and be proactive in addressing any care gaps.
It is important to code the wellness visit accurately, for both your own reimbursement and quality measure reporting. Learn more about how to code an AWV at the Medicare Wellness Visit website.
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Place of Service (POS) 19 update
We’ve recently identified an error in our configuration of Place of Service (POS) code 19. POS codes specify the location where the item was used or the service was performed.
POS 19 Outpatient Hospital — Off Campus is defined as a portion of an off-campus hospital, provider-based department that provides diagnostic, therapeutic (both surgical and non-surgical) and rehabilitation services to sick or injured people who do not require hospitalization or institutionalization. CMS states that POS 19 should have a facility-based payment rate.
Effective with processing dates of June 1, 2021 and after (regardless of the date of service), Moda Health will be reimbursing POS 19 at the facility rate.
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Reimbursement Policy Updates
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RPM001: Moda Health Reimbursement Policy Overview
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In conjunction with update of Important Statement wording:
- Collaboration between Provider Networking and Claims Support to refine and simplify language.
- Member contract language change to member’s benefit plan.
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RPM004: After Hours and Other Special Circumstances
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- Added "This policy does not apply to Medicaid plans."
- Converted to outline format.
- Updated Important Statement section to new wording.
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RPM027: Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service.
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- Converted to outline format.
- Added –X{EPSU} examples from MLN SE1418 Revised.
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Updated Important Statement section to new wording.
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RPM044: Gynecologic or Annual Women’s Exam Visit & Use of Q0091 (Pap, Pelvic, & Breast Visit).
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- Updated Code Definitions table with 2021 E/M office visit code changes for 99201 - 99215.
- Added 99417 prolonged service code.
- Corrected Pap test and cervical cancer screening lab test codes to correct CMS G codes and P codes.
- Added G0476 HPV screening lab code.
- Added additional ICD-10 diagnosis codes listed in the Medicare Preventive Services Quick Reference Chart for these screening services to the diagnosis code definition table.
- Updated Important Statement section to new wording.
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RPM073: Telehealth and Telemedicine Expanded Services for COVID-19.
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Provider request for clarification:
- Clarification added about billing telehealth for behavioral health intensive outpatient programs and partial hospitalization programs.
- Important Statement section updated to newly approved wording.
- Scope section updated for duration of Medicaid and Commercial “…until the voluntary agreement with the State of Oregon expires.”
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RPM076: Office or Other Outpatient Evaluation and Management (E/M) Visits and Prolonged Services.
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New policy in response to discrepancy between 99417 & G2212:
- Section A: Summary of the 2021 coding changes for Office or other outpatient evaluation and management (E/M) visits (99202 – 99215). Records do not need to be submitted with the claim, only if Moda sends a records request. Please note time rules for split or shared visits.
- Section B: Prolonged Services for 99202 – 99215. Commercial & Medicare Advantage: 99417 not accepted and will be denied; use G2212.
- Moda Health will accept 99417 for processing for Medicaid plans.
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December 2020
January 2021
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- Added mention of revenue codes, cross-provider unbundling or duplication, laterality inconsistencies to paragraph # 2.
- Updated Important Statement section with revised wording approved 12/9/2020.
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RPM006: Robotic Assisted Surgery
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- Updated Important Statement section with revised wording approved 12/9/2020.
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RPM008: Technical Component (TC), Professional Component (PC/26), and Global Service Billing.
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- Added section B.4.a with detail and clarification on Physician Services Only – PC/TC Indicator “0.”
- Updated sections B.5 and C.3 with additional EX code and increased detail of other EX codes.
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RPM010: Modifiers 58, 78, and 79 – Staged, Related, and Unrelated Procedures
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- Converted to Outline Format.
- Added cross reference to RPM027 Distinct Procedural Service.
- Updated Important Statement section wording.
- Fixed font sizing inconsistencies.
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RPM011: Global Surgery Package for Professional Claims
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- Relocated Background section.
- Updated Important Statement section wording.
- Minor formatting and spacing improvements.
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RPM046: Colorectal Cancer Screening And Related Ancillary Services.
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Regulatory & Benefit updates for Medicare Advantage.
- Effective 1/1/2020 Moda Medicare Advantage plans do not cover a specialist consultation visit prior to the screening colonoscopy procedure.
- Section E.2 split & E.3 added for Medicare Advantage.
- Section F was split into two separate sections by LOB, as there are differences for Medicare Advantage related to 1) specialist consultation prior to the screening colonoscopy procedure and 2) use of modifier 33 versus PT with anesthesia services.
- The previous section G now is renumbered to section H and divided by LOB.
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RPM057: Modifier 50 – Bilateral Procedure.
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- Updated Important Statement section wording.
- Updated Acronym Table listing for MPFSD.
- Minor format changes.
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RPM063: 340B Drug Discount Program-Acquired Drugs and Biologicals (Modifiers JG & TB)
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- Updated Important Statement section wording.
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RPM073: Telehealth and Telemedicine Expanded Services for COVID-19.
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Update for OAR 333-006-0170:
- Added information re: OAR 333-006-0170 as item # D.8. Changes effective 1/1/2021.
- Added OHA to Acronym table.
- Added Newborn Nurse Home Visits to list of Commercial covered telehealth codes. Changes effective 1/1/2021.
- Added items # 24 & 25 to bibliography.
- Fixed numbering typo in section D.
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RPM012: Routine Venipuncture and/or Collection of Specimens.
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- Converted to outline format.
- Added explanation code z39 to section A.5.c.
- Updated Important Statement section wording.
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RPM045: Reference (Outside) Laboratory -Modifier 90.
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- Updated Important Statement section wording.
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RPM058: Behavioral Health Case Management & Care Coordination.
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- Added adaptive behavior services codes and new HCPCS codes. Noted deleted codes.
- Sections B.1.c.ii and B.2.c.ii updated CPT guidelines quote.
- Added item #7 to References & Resources list from CPT book guidelines.
- Updated Important Statement section wording.
- Minor format/grammar corrections.
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RPM060: Transportation of Portable X-ray Equipment, Multiple Portable X-rays – Modifiers UN, UP, UQ, UR, US.
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- Updated listing for MPFSD in the Acronym Table to include variations.
- Updated Important Statement section wording.
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RPM003: Modifier 52 - Reduced Services
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- Updated Scope section.
- Converted to outline format.
- Updated explanation codes.
- Added section H "Selecting Between Modifier 52 and Modifier 53."
- Added Acronym Table.
- Added # 11 to References & Resources.
- Updated Important Statement section wording.
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RPM005: Records Fees, Copying Fees
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- Updated Important Statement section wording.
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RPM014: Intra-joint and Surgical Site Postoperative Pain Relief Drug Delivery System (Pain Pump)
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- Updated Scope section.
- Added information for disposable drug delivery system, supplies, and drugs for pain pumps.
- Added items # 8 & 9 to References & Resources.
- Added Acronym Table.
- Updated Important Statement section wording.
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RPM015: Drugs and Biologicals, Wastage and/or Discarded Amounts (Modifier JW).
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- Converted to outline format.
- Updated Important Statement section wording.
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RPM016: Clinical Drug Screening and/or Drug Testing
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- Updated Important Statement section wording.
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RPM018: Modifier 53 – Discontinued Procedure
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- Converted to outline format.
- Updated Important Statement section wording.
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RPM048: Moderate (Conscious) Sedation.
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- Converted to outline format.
- Added section A.3.c clarification of practice expense only rules for 99153.
- Updated Important Statement section wording.
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RPM073: Telehealth and Telemedicine Expanded Services for COVID-19.
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Provider inquiry via Medicaid team:
- Added D.8 “The list of telehealth services covered under Medicaid includes:” and section D.8.b “Any procedure code with modifier GT listed as an allowed modifier on the OHA Behavioral Health fee schedule in any Service Type category.” Notation and link also added to Codes and Definitions section.
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New timeframe and coverage for engineered skin and tissue substitutes
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For engineered skin and tissue substitutes, the duration for full thickness neuropathic diabetic foot ulcer is to be greater than six (6) weeks. This update allows the provider time to determine if the wound is suitable for grafting. This requirement went into effect in February 2021.
As of February 2021, Epifix is now covered for chronic venous stasis ulcers management.
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Skin and tissue substitutes – Engineered
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- This is annual review, updated requirement for full thickness neuropathic diabetic foot ulcer duration to be greater than 6 weeks. Duration time allows to determine wound suitability for grafting.
- Added coverage for Epifix for chronic venous stasis ulcers management
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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
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Provider Updates
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