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October is Breast Cancer Awareness Month!
Please join us in encouraging your patients who are due for a mammogram to schedule an appointment during Breast Cancer Awareness Month.
As you know, 1 in 8 women in the United States will develop breast cancer in their lifetime. Those who follow the CDC guidelines for mammograms can improve their chance of survival. Breast cancer screenings protect your patients by identifying cancer risk early, when it’s most treatable.
Women between the ages of 45 to 74 should receive a annual mammogram to screen for the disease. We encourage all of our valued provider partners to work with your patients to schedule this potentially lifesaving test.
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Recommended therapies for
your diabetic patients
Our Medication Use Evaluation (MUE) program allows us to continually look for ways to improve prescription-drug use and improve the health outcomes of our members. In Q3, our MUEs are focused on identifying gaps in guideline recommended therapies for type 2 diabetes mellitus.
As you know, statins are the standard of care for primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) and cardiovascular events.1,2 Because cardiovascular disease is the leading cause of death for patients with diabetes, the American Diabetes Association (ADA) and American College of Cardiology/American Heart Association recommend using moderate-to-high intensity statins in all patients with diabetes, including those without established ASCVD.1-3
Additionally, recent evidence shows that select SGLT2s and GLP-1s provide risk reduction for adverse cardiovascular events and renal outcomes (i.e., chronic kidney disease).1,4,5 Furthermore, ADA guidelines recommend treatment with select SGLT2 or GLP-1 for additional risk reduction.1,4
Based on each patient’s specific characteristics, please consider discussing the following recommendations with your diabetic patients to help prevent serious long-term disease complications:
- Advantage of select GLP-1 and SGLT2 therapy to improve glycemic control and minimize renal and cardiovascular complications
- Benefit of statin therapy (i.e., atorvastatin, rosuvastatin, etc.) for primary and secondary prevention of ASCVD
If you care for a Moda member who can benefit from these therapies, you will be receiving a more detailed letter soon.
As always, we appreciate your support in helping our members to better health and wellness.
Sources:
1. American Diabetes Association Professional Practice Committee. 10. Cardiovascular disease and risk management: Standards of Medical Care in Diabetes – 2022. Diabetes Care 2021; 45(Supplement_1):S144-S174. doi:10.2337/dc22-S010
2. Lloyd-Jones DM, Braun LT, Ndumele CE, et al. Use of risk assessment tools to guide decision-making in the primary prevention of atherosclerotic cardiovascular disease: a special report from the American Heart Association and American College of Cardiology. Circulation. 2019;139(25):e1162-e1177.
3. Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation. 2020;141(9):e139-e596.
4. American Diabetes Association Professional Practice Committee. Chronic Kidney Disease and Risk Management: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022;45(Supplement_1):S175-S184. doi:10.2337/dc22-S011
5. Sim R, et al. Comparative effectiveness of cardiovascular, renal and safety outcomes of second-line antidiabetic drugs use in people with type 2 diabetes. Diabet Med. 2022;39(3):e14780. doi:10.1111/dme.14780
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New HEDIS measure for 2022
Advance Care Planning (ACP) is a new HEDIS® measure for Medicare patients for the measurement year 2022. This measure will cover adults between the ages of 60 and 80 with advanced illnesses, frailty, or who are receiving palliative care. It will also cover adults 81 years and older who have had ACP during the year.
As a valued provider partner, we encourage you to discuss ACP with your Medicare patients who meet the above criteria. Please document it in the record and bill the following codes on claims:
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CPT Code 99497: ACP, including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate)
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CPT Code 99483: Assessment of and care planning for patients with cognitive impairment like dementia, including Alzheimer's disease at any stage of impairment.
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1123F: ACP discussed and documented advance care plan or surrogate decision maker documented in the medical record.
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1124F: ACP discussed and documented in the medical record, patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
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1157F: Advance care plan or similar legal document present in the medical record.
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1158F: ACP discussion documented in the medical record.
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Medicare Advantage care guides coming soon
Moda Health and Summit Health are sending our Q4 care guides in October to educate and help your Medicare Advantage patients schedule their recommended preventive services. We ask that you work with your patients on their open gaps in care and complete those that are appropriate for their overall health management.
These guides are personalized for your patients based on their medical and pharmacy claims information. They will remind your patients about services that may be due, such as Annual Wellness Visits, cancer screenings and routine diabetes care.
Many of these are directly tied to Star Measures, whiles others have an indirect opportunity to impact quality measures. Closing these care gaps can lead to better health outcomes.
Be sure to code services accurately, for both your own reimbursement and quality measure reporting. Learn more about Medicare Preventive Services at the Medicare Learning Network.
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Reimbursement Policy Updates
The follow table includes RPM updates for August and September 2022.
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Clarification, no policy changes: |
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RPM002, “Clinical Editing” |
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- Change to new header.
- Converted to outline format.
- Section E: Clarification of longstanding policy on same specialty determination for non-physician practitioners, added per provider inquiry.
- Acronym table: 2 entries added.
- Definition of Terms Table added.
- References & Resources: 5 entries added.
- Policy History section: Added.
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RPM041, “Critical Care, Evaluation and Management Services (99291, 99292)” |
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- Change to new header.
- Outline format added.
- Clarification of same specialty, non-physician practitioners, split/shared critical care added per provider inquiry.
- CMS updated guidelines for 2022 incorporated. CMS changes not subject to Texas 28 TAC notice requirements.
- Acronym table: 2 entries added.
- Definition of Terms Table: Added.
- Coding Guidelines & Sources: Added: 3 new quotes.
- References & Resources: #1 & 2 updated. The previous #3 deleted (no longer exists); former #4 is now #3. # 4-10 added.
- Policy History section: Added.
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Annual review/Formatting, no policy changes: |
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RPM040, “Incident-To Services” |
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- Change to new header.
- Policy History section: Added.
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RPM047, “Facility Reimbursement of Respiratory Therapy Services” |
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- Change to new header.
- Section A.1.c wording copied from E.4 & added here for increased visibility due to frequently needed/used for appeals.
- Acronym table: 9 entries added.
- Coding Guidelines & Sources: 2 entries added.
- References & Resources: Typos fixed - entries # 1, 8, & 9. Entry # 3 updated. Entries # 10-13 added as TX equivalent of Noridian references.
- Policy History section: Added.
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RPM051, “Procedures Designated as ‘Separate Procedure’“ |
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- Change to new header.
- Policy History section: Added.
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RPM062, “Modifier 63 - Procedure Performed on Infants Less Than 4 kg” |
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- Change to new header.
- Policy History section: Added.
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Reviewed in September 2022 |
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Clarification, no policy changes: |
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RPM053, “Diagnosis Code Requirements - Level of Detail, Number of Characters, and Laterality” |
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- Change to new header.
- Section B.6.b – Added clarification re: need to properly amend records with missing information when querying provider to determine laterality for diagnosis code(s).
- Acronym table: 1 entry added.
- Policy History section: Added.
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RPM035, “Modifiers 62 & 66 - Co-surgery (Two Surgeons) and Team Surgery (More Than Two Surgeons)” |
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- Change to new header. Changed Subsection from “None” to “Surgery.”
- Section B.6.a: Expanded to add Medicare Advantage pricing adjustment for out-of-network providers for modifier 62.
- Acronym table: 4 entries added.
- Policy History section: Added.
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Annual review/Formatting update: |
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RPM008, “Technical Component (TC), Professional Component (PC/26), and Global Service Billing” |
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- Change to new header.
- References & Resources: 3 entries added from Novitas.
- Policy History section: Added.
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RPM027, “Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service” |
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Change to new header.
- Policy History section: Added.
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RPM029, “Modifier 57 – Decision for Surgery” |
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- Change to new header.
- Policy History section: Added.
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RPM032, “Anesthesia Physical Status Modifiers (P1 - P6)” |
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- Change to new header.
- Policy History section: Added.
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RPM037, “Preventive Services versus Diagnostic and/or Medical Services” |
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- Change to new header.
- Section A.2: Fix typo.
- Section A.4: Fix typo, fix formatting.
- Cross References: 1 added.
- Policy History section: Added.
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RPM054, “Diagnosis Code Requirements - Invalid as Primary Diagnosis” |
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- Change to new header.
- Effective dates by Type of Business moved to header section, allowing consolidation of Reimbursement Guidelines formatting.
- Policy History section: Added.
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RPM055, “E0486 Oral Sleep Apnea Device/Appliance Documentation” |
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- Change to new header.
- Policy History section: Added.
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Medical Necessity Criteria updates
Medical criteria changes July and August 2022.
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July
Medical Criteria Summary
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Introduction: This is an annual review
Criteria changes: No changes
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Factor V Leiden- F5 gene testing |
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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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Upper extremity custom orthoses |
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Introduction: This is annual review.
Criteria changes: added ‘custom’ language to title and guidelines
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Push rim activated power assist device |
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Introduction: This is an annual review
Criteria changes: No changes
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Knee cartilage transplants |
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Introduction: This is annual review.
Criteria changes: updated requirements to align eviCore
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Therapeutic drug monitoring |
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Introduction: This is an annual review
Criteria changes: Grammar update
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Computer assisted navigation for musculoskeletal procedures |
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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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Introduction: This is an annual review
Criteria changes: No changes
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August
Medical Criteria Summary
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Anesthesia for routine endoscopic procedures |
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Introduction: This is annual review.
Criteria changes: Added a list of diagnosis codes with coverage. No other changes
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Gender confirming surgery |
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Introduction: This is an annual review
Criteria changes: No changes
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Interferential stimulation |
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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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Post-op-sinus endoscopy debridement |
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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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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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