In this issue
- Cervical cancer screening
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HEDIS medical records review is underway
From now through the end of April, our medical chart retrieval partners, Cotiviti and KDJ Consultants, are reaching out to providers to collect charts for the current HEDIS® season.
If you received a request from either of these vendors, we ask that you provide the medical charts requested. These charts are essential to the yearly HEDIS project, and are protected through HIPAA as an operational function between the health plan and the provider.
The charts can be provided through EHR remote access, onsite retrieval or by fax or mail. We highly encourage using remote access through EHRs for ease and efficiency.
Questions?
If you have any questions about this process or would like to set up remote access, please email us at HEDIS@modahealth.com.
We appreciate for your time and effort this HEDIS season!
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New clinical edits address CMS guidelines and billing errors
We recently identified billing errors related to key CMS guidelines. To address these issues, we’ve developed the following clinical edits that will be effective for dates of service starting May 1, 2023, and after. These new clinical edits include:
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DMEPOS Single Date of Service — A single date of service equal to the delivery date (or discharge date, when appropriate) must be billed for items on the DMEPOS per the Medicare Claims Processing Manual (Chapter 20, Section 110.3.2), the Medicare Program Integrity Manual (Chapter 5, Section 5.2.4, 5.15 and 5.13) and Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) (cms.gov). We are implementing a clinical edit to deny all non-rental DMEPOS codes when the ‘from’ date of service is not equal to the ‘to’ date of service. This edit will not impact Diabetic supply codes or rented DME items (billed with modifier RR).
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Correct Type of Bill (TOB) for Critical Access Hospital (CAH), Rural Health Center (RHC) and Federally Qualified Health Center (FQHC) facility claims — When CAH, RHC or FQHC claims are billed with a TOB that’s not approved by CMS per the Medicare Claims Processing Manual (Chapter 1, Section 80.3.2.2), the claim will be denied.
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Duplicate billing of professional services — When we identify that professional services have been submitted on a CMS-1500 and on a CMS-1450 under revenue codes 096X-098X, the duplicate services on the second processed claim will be denied.
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Help close cervical cancer screening gaps
April is both National Cancer Control Month and STD Awareness Month. This month, we’re raising awareness about cervical cancer and what we can do to help our members lower their risk.
Around 13,000 new cervical cancer cases are diagnosed in the U.S. every year. Unfortunately, about 4,000 women who are diagnosed with this disease die each year. Anyone with a cervix is at risk for cervical cancer, and Human Papillomavirus (HPV) greatly increases the risk of being diagnosed with this disease.
We encourage you to offer cervical cancer screenings to all of our members who have a cervix. These screenings include both cervical cytology and high-risk HPV testing.
The NCQA recognizes the following tests to close cervical cancer screening gaps, including:
- Women ages 21-64 who had cervical cytology performed within the last 3 years
- Women ages 30-64 who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last 5 years
- Women ages of 30-64 who had cervical cytology/high-risk human papillomavirus (hrHPV) co-testing within the last 5 years
Thank you for all that you do to keep our members safe and healthy!
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It’s now easier to capture HCCs and close care gaps
- View and close care gaps
- Capture Hierarchical Condition Codes (HCC’s) throughout the year
- Manage your patient roster
- View your incentive program progress
Our goal with CGMA is to help you easily capture HCCs and close care gaps. The onboarding process does not require any lift on your part. You simply have to set up login access and the tool is ready to use.
Questions?
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Reimbursement Policy Updates
The following table includes RPM updates for February to March 2023.
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Reviewed in February 2023 |
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RPM078, “Preventive Medicine & Problem-Oriented E/M Visits, Same Day” |
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- New policy effective for dates of service May 1, 2023, and following. Effective only for member plans issued in the states of Oregon & Alaska (at this time).
- When a preventive medicine visit and a problem-oriented Evaluation and Management (E/M) visit are reported on the same day for the same patient by the same provider:
- The preventive medicine service will be reimbursed at 100% of the allowance.
- The problem-oriented E/M service (with modifier 25 appended) will be reimbursed at 50% of the allowance.
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Rationale: The fee reduction on the problem-oriented visit is due to the shared resources of the overlapping services (e.g., practice expense) already being considered in the reimbursement of the preventive service.
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RPM065, “Facility Guidelines, General Overview” |
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- C.2.e & C.3.b: Clarifies Method II CAH exception for revenue codes 0960 – 0989 and how duplicate professional charges on CMS1500 claims will be handled.
- Section P: Added for correct TOB for Critical Access Hospital (CAH), Rural Health Center (RHC) and Federally Qualified Health Centers (FQHC).
- Definition of Terms: 4 entries added.
- References & Resources: 4 entries added.
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Clarification, no policy changes: |
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RPM028, “Modifier 25 – Significant, Separately Identifiable E/M Service” |
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- Section E.1 – Add mention and link to new payment policy RPM078 for reducing allowance for problem-oriented E/M with preventive visit.
- Cross References: Added entry for new policy RPM078. Hyperlinks added for all entries.
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RPM044, “Gynecologic or Annual Women’s Exam Visit & Use of Q0091 (Pap, Pelvic, & Breast Visit)” |
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- Types of Business: Corrected to remove Medicaid.
- Section B.1: Added “Do not report using S0610-S0613.”
- Procedure Code Table: Updated prolonged services codes.
- Cross References: One entry for new RPM078 added.
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RPM055, “E0486 Oral Sleep Apnea Device/Appliance Documentation & Bundled Services” |
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- Section B.5 & Background Information: “…impressions or molds…” updated to “…impressions, scans, or molds…” for clarity per provider suggestion.
- Formatting fix of section B numbering.
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RPM075, “Emergency Department Visit Leveling” |
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- Section F.2: Added “…by Healthcare Services…” for clarity.
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Reviewed in March 2023: No updates |
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Medical Necessity Criteria updates
The following table includes medical criteria updates for February to March 2023.
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February 2023
Medical Criteria Summary
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Introduction: This is an annual review
Criteria changes: No changes
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Cardiac disease screening lipid profile |
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Introduction: This is an annual review
Criteria changes: Removed lipoprotein and Homocysteine lipid profile tests requirements as prior authorization is no longer required.
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External infusion insulin pumps |
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Introduction: This is an annual review
Criteria changes: No changes
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Extracorporeal shock wave therapy (ESWT) |
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Introduction: This is an annual review
Criteria changes: Grammar updates. No changes
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Kyphoplasty and vertebroplasty |
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Introduction: This is an annual review
Criteria changes: No changes
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Introduction: This is an annual review
Criteria changes: No changes
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Skin & tissue substitutes |
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Introduction: This is an annual review
Criteria changes: Grammar updates, E/I codes added, no content changes
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Minimal residue Disease testing |
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Introduction: This is a NEW policy created as a breakout from general genetic testing criteria. The policy will be used to review requests related to minimal residue disease testing for hematological cancers. Testing for minimal residual disease allows members and providers to determine the course of treatment for individuals undergoing cancer treatment.
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March 2023
Medical Criteria Summary
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Bone growth stimulators – Electric |
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Introduction: This is an annual review
Criteria changes: Updated the requirements for Invasive or non-invasive electrical bone growth stimulators for skeletally mature individuals as an adjunct to spinal fusion surgery.
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Herniated disc-noncovered procedure |
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Introduction: This is an annual review
Criteria changes: No changes
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High-frequency chest wall oscillation devices (HFCWO) |
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Introduction: This is an annual review
Criteria changes: No changes
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Obstructive sleep apnea surgical management |
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Introduction: This is an annual review
Criteria changes: Updated Age requirement for hypoglossal nerve stimulation as 18 years and older
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Introduction: This is an annual review
Criteria changes: No changes
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Treatment or removal of benign Skin Lesions |
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Introduction: This is an annual review
Criteria changes: No changes
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Upper hand/wrist/ elbow/shoulder extremity prostheses |
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Introduction: This is an annual review
Criteria changes: No changes
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Moda Health 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
Credentialing Department
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