In this issue

  • Close quality gaps through claims

  • Observation billing

  • Summit Health referral removal

  • Medicare Annual Wellness Visits

  • Statin therapy and muscle symptoms

  • RPM updates

  • Medical criteria updates
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Close quality gaps through claims

Did you know you can close quality gaps through claims and help reduce the burden of providing charts during the HEDIS season? Below are some informational CPT II’s that can be billed on claims to help you close quality gaps on specific HEDIS measures, including:
 
Controlling Blood Pressure (CBP) and Blood Pressure Control for Patients with Diabetes (BPD)
  • 3074F: Most recent systolic blood pressure less than 130
  • 3075F: Most recent systolic blood pressure 130-139
  • 3077F: Most recent systolic blood pressure greater than or equal to 140
  • 3078F: Most recent diastolic blood pressure less than 80
  • 3079F: Most recent diastolic blood pressure 80-89
  • 3080F: Most recent diastolic blood pressure greater than or equal to 90
 
Hemoglobin A1c control for patients with diabetes
  • 3044F: Most recent hemoglobin A1c (HbA1c) level less than 7.0%
  • 3046F: Most recent hemoglobin A1c level greater than 9.0%
  • 3051F: Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0%
  • 3052F: Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0%
 
Eye exam for patients with diabetes
  • 3072F: Low risk for retinopathy (no evidence of retinopathy in the prior year)
  • 2022F: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; with evidence of retinopathy
  • 2023F: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed; without evidence of retinopathy
 
Prenatal and postpartum care
  • 0500F: Initial prenatal visit
  • 0502F: Subsequent prenatal visits
  • 0503F: Postpartum care visit
Correct billing for hospital Observation or Inpatient Care Services

To make sure you are correctly billing for reporting professional services of Observation or Inpatient Care Services, procedure codes 99234 – 99236 are for the evaluation and management of a patient including admission and discharge on the same date. The patient must be admitted to observation status for a minimum of eight (8) hours, but less than 24 hours, and discharged on the same calendar date for the provider to report 99234 – 99236.
 
Procedure codes 99234 – 99236 should not be reported by hospitals for observation facility fees. Instead, G0378 Hospital observation service, per hour is to be used by the hospital for this purpose.
 
For more information, please see:
Summit Health specialist referrals no longer required in 2023

Starting Jan. 1, 2023, Summit Health Medicare Advantage plan will no longer require a referral for Medicare patients to see a specialist. Removing this requirement means primary care providers (PCPs) do not need to submit a referral to Summit Health before your patients see a specialist. 
 
Summit Health patient claims will no longer deny or pay at the out-of-network rate due to not having a referral on file. Patients can see any in-network provider without a referral on file at the in-network benefit.
 
Please note that some specialists prefer that a PCP refer patients to them, so you may still need to submit a referral to the specialist. But starting in 2023, the Summit Health plan will no longer require one.

Medicare Annual Wellness Visits

Throughout the year, Moda Health and Summit Health have been advocating for our Medicare members to complete their annual preventive visits in hopes of improving and maintaining their overall health. 
 
As we near the end of the year, we ask that you encourage your patients to complete their Medicare Annual Wellness Visits (AWV) and/or Annual Physical Exams. Closing these care gaps can lead to better health outcomes for them, as well as impact your financial incentives in our Medicare Advantage Primary Care Incentive Program (MAPCIP) for 2022. 
 
Moda Health Medicare Advantage and Summit Health cover an AWV (once every calendar year) and an Annual Physical Exam (once every calendar year) at no cost to your patients. Both can be completed at the same visit and can also be combined with a problem visit. However, a cost-share would apply if combined with a problem visit. Please be sure to code services accurately, for both your own reimbursement and quality measure reporting.
The benefits statin therapy, and their connection with muscle symptoms

While statin medications are a highly utilized and effective therapy for the prevention of atherosclerotic cardiovascular disease, they are also associated with a risk of muscle pain or weakness and rhabdomyolysis.
 
Although myopathy associated with substantial muscle damage is rare (approximately 1 case per 10,000 person years), myalgias and arthralgias are frequently reported as side effects of statins. Patients commonly discontinue statins due to their perceived intolerance to statin medications, with myalgias and arthralgias often being the cause of this intolerance. 
 
But new evidence has emerged supporting the belief of healthcare professionals that statins may not be the cause of the majority of myalgias reported by patients. 
 
A meta-analysis reviewed 23 double-blind trials (19 statin vs. placebo trials and four higher-intensity vs. lower-intensity statin trials) and found that there is a 7% increased risk for muscle symptoms with statin use versus placebo in this first year of use, with a decline of risk during following years of use. Additionally, the risk of muscle symptoms increases slightly with higher intensity statins but is no higher than 10%.
 
While this analysis does indicate low rates of statin-induced myopathy, it should be noted that creatine kinase concentration was available in few patients who reported muscle pain or weakness (6.2%). Therefore, rates of statin-associated muscle damage cannot be accurately estimated.1  
 
Although further scientific evaluation is needed to understand the differences in incidence of statin-induced myalgias reported in real-world evidence compared to double-blind trials, the cardiovascular benefit of statins remains well understood. In cases where patients complained of myalgia after starting statin therapy, additional testing may rule out other causes of muscle pain or weakness when continuing their statin therapy. In all cases, providers should continue to evaluate risk versus benefit based on their Medicare patient’s specific characteristics before discontinuing their stain therapy.
 
Questions?
We’re here to help. For questions, please call:
  • Moda Health Medicare Advantage Pharmacy Customer Service at 503-265-4709
  • Summit Health Pharmacy Customer Service at 541-663-2721 
 
As always, we appreciate your support in helping our members to better health and wellness.
 
1Cholesterol Treatment Trialists' Collaboration. Effect of statin therapy on muscle symptoms: an individual participant data meta-analysis of large-scale, randomised, double-blind trials. Lancet. 2022 Sep 10;400(10355):832-845. doi: 10.1016/S0140-6736(22)01545-8. Epub 2022 Aug 29. Erratum in: Lancet. 2022 Oct 8;400(10359):1194. PMID: 36049498; PMCID: PMC7613583.
Reimbursement Policy Updates

The following table includes RPM updates for October and November 2022.
Policy
Summary of update
Reviewed in October 2022
Clarification, no policy changes:
RPM005, “Records Fees, Copying Fees”
  • Change to new header; includes Idaho.
  • Acronym table: 2 entries added.
  • Definition of Terms table: Added. Definitions adapted/paraphrased from references cited.
  • References & Resources: 1 entry added.
  • Policy History section: Added.
RPM012, “Routine Venipuncture and/or Collection of Specimens”
  • Change to new header. Includes Idaho.
  • Section A: Added information re: 36400 – 36410.
  • Definition of Terms table added.
  • Modifier table: Added.
  • References & Resources: 3 entries removed (no longer available on the Noridian website). Remaining listings renumbered & 1 entry added.
  • Policy History section: Added.
RPM014, “Intra-joint and Surgical Site Postoperative Pain Relief Drug Delivery System (Pain Pump)”
  • Change to new header; includes Idaho.
  • 3rd paragraph, item # 3: Added “(peri-incisional)” from the CMS footnoted reference.
  • Coding Guidelines: Added 6 quotes.
  • References & Resources: Verified current numbering & updated CMS NCCI references. Added Texas MAC for # 8 & 9. Added item # 10.
  • Policy History section: Added.
RPM020, “Maternity Care”
  • Change to new header; includes Idaho.
  • Section H.7 added for clarification.
  • Acronym table: 5 entries added.
  • Modifier table: Added.
  • Improved or added Bookmark Links at various locations.
  • Policy History section: Added.
RPM023, “Procedure Codes Assigned to Surgical Benefit Categories”
  • Change to new header; includes Idaho.
  • Section F: Added wording re: CMS global surgery package days values.
  • Cross References: 2 entries added.
  • Policy History section: Added.
RPM039, “Medical Records Documentation Standards”
  • Document Title: “& Outlier Review” added.
  • Scope, States: Idaho added.
  • Section A: Revised & reworded to include outlier reviews.
  • Section D DRG outlier reviews: Added. These have been occurring, but now specifically discussed for clarity; thus not subject to 28 TAC.
  • Cross References: 4 entries added. Hyperlinks added.
Annual review (includes formatting changes):
RPM003, “Modifier 52 - Reduced Services”
  • Change to new header; includes Idaho.
  • Acronym table: 5 entries added.
Policy
Summary of update
RPM006, “Robotic Assisted Surgery”
  • Change to new header. Includes Idaho.
  • Converted to outline format.
  • Modifier table added.
  • Policy History section: Added.
RPM010, “Modifiers 58, 78, and 79 – Staged, Related, and Unrelated Procedures”
  • Change to new header. Includes Idaho.
  • Acronym table: 7 entries added.
  • Cross References: 1 entry added.
  • Policy History section: Added.
RPM011, “Global Surgery Package for Professional Claims”
  • Policy name: “Professional Claims” changed to “Professional Providers.”
  • Change to new header. Includes Idaho.
  • Moved from Administrative to Surgery section.
  • Cross References: 1 entry added.
  • Policy History section: Added.
RPM018, “Modifier 53 – Discontinued Procedure”
  • Change to new header; includes Idaho.
  • Acronym table: 1 entry added.
RPM019, “Valid Modifier to Procedure Code Combinations”
  • Change to new header. Includes Idaho.
  • Policy History section: Added.
RPM023, “Procedure Codes Assigned to Surgical Benefit Categories”
  • Change to new header. Includes Idaho.
  • Cross References: 2 entries added.
  • Policy History section: Added.
RPM045, “Reference (Outside) Laboratory -- Modifier 90”
  • Change to new header. Includes Idaho.
  • Converted to outline format.
  • Policy History section: Added.
RPM046, “Colorectal Cancer Screening and Related Ancillary Services”
  • Change to new header. Includes Idaho.
  • Policy History section: Added.
RPM057, “Modifier 50 – Bilateral Procedure”
  • Change to new header. Includes Idaho.
  • Acronym table: 1 entry added.
  • Policy History section: Added.
RPM058, “Behavioral Health Case Management & Care Coordination”
  • Scope: Added Idaho; not subject to 28 TAC.
  • Acronym table: 1 entry added.
RPM063, “340B Drug Discount Program-Acquired Drugs and Biologicals (Modifiers JG & TB)”
  • Change to new header. Includes Idaho.
  • Policy History section: Added.
RPM074, “Additional Practice Expense Items During a Public Health Emergency (PHE) – CPT 99072”
  • Change to new header. Includes Idaho.
  • Acronym table: 5 entries added.
  • Policy History section: Added.
RPM077, “Therapy Assistant Modifiers CO & CQ”
  • Change to new header. Includes Idaho.
  • Policy History section: Added.
Reviewed in November 2022
Clarification, no policy changes:
Policy
Summary of update
RPM020, “Maternity Care”
  • Section H.3.c clarification of diagnosis coding for high-risk pregnancy or complications of pregnancy additional antepartum visits.
  • Section J.1 expanded for clarification of midwife coverage by type of business.
  • Acronym table: 1 entry added.
  • Cross References: Hyperlinks added.
  • References & Resources: 2 entries added.
RPM022, “Modifier 51 - Multiple Procedure Fee Reductions”
  • Change to new header. Includes Idaho. Subsection designation changed.
  • Section A: Clarification of ranking method added & rephrasing of percent discount calculations, per inquiry. Sections B, C, D, & E linked back to section A for same information.
  • Section D.2: Minor rephrasing and bookmark link added back to section B.3-B.5.
  • Acronym table: 4 added.
  • Definition of Terms table added.
  • Cross References: Hyperlinks added.
  • References & Resources: 5 entries added.
  • Policy History section: Added.
RPM026, “Operating Microscope (CPT Code 69990)”
  • Change to new header; includes Idaho.
  • Converted to Outline format.
  • Clarification of how eligibility for separate reimbursement by provider type is determined.
  • Clarification of denial rationale if 69990 is billed for other magnifying devices.
  • Cross References: Hyperlinks added.
  • Policy History section: Added.
RPM055, “E0486 Oral Sleep Apnea Device/Appliance Documentation & Bundled Services”
  • Document Title: “Bundled Services” added.
  • Section A: New wording added about E/M services & bundled services, for clarification per discussion with Provider Networking.
RPM065, “Facility Guidelines, General Overview”
  • Change to new header; includes Idaho.
  • Section I: Clarification of DRG outlier line item reviews added.
  • Cross References: Hyperlinks added.
RPM069, “Facility DRG Validation & Outlier Review”
  • Document Title: “& Outlier Review” added.
  • Scope, States: Idaho added.
  • Section A: Revised & reworded to include outlier reviews.
  • Section D DRG outlier reviews: Added. These have been occurring, but now specifically discussed for clarity; thus not subject to 28 TAC.
  • Cross References: 4 entries added. Hyperlinks added.
Annual review (includes formatting changes):
Policy
Summary of update
RPM021, “Medical, Surgical, and Routine Supplies (including but not limited to 99070)”
  • Change to new header; includes Idaho.
  • Section A. General Policy Statement: Hyperlinks added.
  • Acronym Table added.
  • Cross References: Hyperlinks added.
  • Policy History section: Added.
RPM024, “Modifier SL - State Supplied Vaccine”
  • Change to new header; includes Idaho.
  • Cross References: Hyperlinks added.
  • Policy History section: Added.
RPM025, “Add-on Codes”
  • Change to new header.
  • Acronym table added.
  • Definition of Terms table added.
  • Policy History section: Added.
RPM048, “Moderate (Conscious) Sedation”
  • Change to new header; includes Idaho.
  • Acronym table: 2 entries added.
  • Cross References: Hyperlinks added.
  • Policy History section: Added.
RPM049, “Modifiers 73 & 74 - Discontinued Procedures for Facilities”
  • Change to new header; includes Idaho.
  • Changed Section from Modifiers to Facility-Specific & added Subsection of Modifiers.
  • Section A: General Policy Statement minor rephrasing.
  • Section B: Items moved out of General Policy Statement into a separate section to simplify Section A. B.3 added.
  • Modifier Table: Modifier 53 added, since it is mentioned in Section G.
  • Cross References: Hyperlinks added.
  • Policy History: Original Effective Date corrected from 11/16/2017 to 1/1/2018.
RPM061, “Clinic Services in the Hospital Outpatient Setting - Commercial”
  • Change to new header; includes Idaho.
  • Acronym Table: 6 entries added.
  • Coding Guidelines & Sources: 4 entries added.
  • Cross References: Hyperlink added.
  • References & Resources: 5 added, 1 removed.
  • Background Information: Minor rewording and additions.
  • Policy History section: Added.
RPM067, “Level of Care Review”
  • Change to new header; includes Idaho.
  • Section F: Minor rephrasing/re-ordering. No content changes.
  • Cross References: Hyperlinks added.
  • References & Resources: 13 entries added as additional resources for section G Noridian footnote & references.
Medical Necessity Criteria updates

The following table includes medical criteria updates for September and October 2022.
Criteria
September
Medical Criteria Summary
Pharmacy/medical
Clinical trials 
Introduction: This is an annual review
Criteria changes: No changes
Medical
Electron beam computed tomography
Introduction: This is annual review.
Criteria changes: Policy to be archived
Medical
Hydrogen breath testing
Introduction: This is an annual review
Criteria changes: No changes
Medical
Intraocular lens implant
Introduction: This is an annual review
Criteria changes: No changes
Medical
Intrathecal opioid therapy
Introduction: This is an annual review
Criteria changes: No changes
Medical
Nitric oxide therapy
Introduction: This is an annual review
Criteria changes: No changes
Medical
Non-invasive testing for liver fibrosis
Introduction: This is an annual review
Criteria changes: No changes
Medical
Pulmonary rehabilitation
Introduction: This is an annual review
Criteria changes: No changes
Medical
Salivary hormone testing
Introduction: This is an annual review
Criteria changes: No changes
Medical
October medical criteria summary
Breast reconstruction
Introduction: This is annual review
 
Criteria changes:
Added requirements for coverage of breast reconstruction when a medically necessary surgery of the affected breast results in asymmetrical change/ deformity in breast shape during one of the following procedures:
  • Mastectomy or lumpectomy as a treatment for breast cancer or as prophylactic treatment for the prevention of breast cancer
  • Lumpectomy due to chronic, severe fibrocystic breast disease (cystic mastitis) unresponsive to medical therapy
Medical
Custom compression garments
Introduction: This is annual review.
 
Criteria changes: Clarified language to state ‘a maximum of 2 pairs of pressure gradient support stockings’
Medical
Standers/Standing frames
Introduction: This is an annual review
Criteria changes: No changes
Medical
Hospital beds and accessories for home use
Introduction: This is annual review.
 
Criteria changes: Updated the language ‘fixed height hospital bed’ for clarity and consistency within the medical necessity requirements
Medical
Prolotherapy
Introduction: This is an annual review
Criteria changes: No changes
Medical
Contact us
Moda Health Medical Customer Service
For claims review, adjustment requests and/or billing policies, please call 888-217-2363 or email medical@modahealth.com.
 
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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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