Oregon | September/October 2016  
An update on preparation for the flu season
As published in the Aug. 26, 2016, Morbidity and Mortality Weekly Report, the Advisory Committee on Immunization Practices (ACIP), released recommendations on the effectiveness and use of live attenuated influenza vaccines.

"In light of concerns regarding low effectiveness against influenza A(H1N1)pdm09 in the United States during the 2013-14 and 2015-16 seasons, for the 2016-17 season, ACIP makes the interim recommendation that live attenuated influenza vaccine (LAIV4) should not be used."

Based on this recommendation, Moda will not cover the live attenuated influenza vaccine, known as the "nasal spray" flu vaccine, under the pharmacy or medical benefit. The injectable inactivated influenza vaccine is the recommended alternative per ACIP for all those siz months of age and older, and is covered under both the pharmacy and medical benefit at select network providers and pharmacies for zero out-of-pocket expenses (for most Moda plans).

Learn more about the committee's influenza vaccine recommendation at www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6505.pdf  

Risk adjustment and status conditions
Providers play an important role in risk adjustment, a process that identifies patients who require more resources and disease intervention through diagnosis coding (ICD-10-CM). Appropriate diagnosis documentation explains the decision-making thought process and supports the potential risk adjustment of a patient, ultimately affecting the financial stability of the health system.

Chronic conditions require long-term attention and management. Due to high familiarity with the patient, documentation of diagnoses during face-to-face visits can dwindle. This affects the assignment of diagnosis codes, as well as the risk adjustment of a patient. All conditions affecting the treatment of management of a patient's health should be documented at least once a year, as it applies to medical decision-making.

Few conditions are as frequently under-documented as status conditions. Documenting a patient's status of amputation, stoma or history of transplant makes a dramatic impact on documentation and the risk adjustment of the patient. According to CMS, providers "should code for all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management."  (CMS, et al ) This includes any conditions that affect current care of influence the patient's treatment. Status codes may be captured, but first they must be documented.
Amputation status
Be sure to document the consideration you are applying to the patient, as amputations (and artificial limbs) likely contribute to a higher level of medical decision-making.

Best Practice: 
Because this condition is incurable, site and laterality of the amputation may be minimally noted in past medical history to be captured as a current condition.
  • Z89.611 Acquired absence of right leg above knee (HCC)
  • Z89.412 Acquired absence of left great toe (HCC)
  • Z44.122 Encounter for fitting and adjustment of partial artificial left leg (HCC)

Artificial opening status

Artificial opening status is an important condition to capture every time the patient is seen. Even if the patient is not adversely affected during the visit, they require a higher level of provider attention and treatment and that care is indicated with thorough documentation.


Best Practice:

The Exam (Objective) is a great place to note the presence of any opening of stoma. Any complications can be further addressed in the HPI (Subjective) or Assessment/Plan.

  • Z93.0 Tracheostomy status (HCC)
  • Z93.3 Colostomy status (HCC)
  • Z43.5 Encounter for attention to cystostomy (HCC)

1. CMS, NCHS, AHA, & AHIMA. ICD-10-CM Official Guidelines. Section 4J. 

You can make a difference in HEDIS scores
What is HEDIS?
HEDIS (Healthcare Effectiveness Data and Information Set) is one of the most widely used sets of healthcare performance measurement tools. HEDIS was developed and is maintained by the National Committee for Quality Assurance (NCQA), whose vision is to transform healthcare quality through measurement, transparency and accountability.

The importance of HEDIS - and your role
At Moda, HEDIS plays an integral part of our commitment to provide access to high-quality care for our members. HEDIS measures focus on prevention, screening and access to care. Results from HEDIS reflect both clinical quality and member experience and serve as measurements for quality improvement process, identify quality initiatives and provide opportunities for improvement.

HEDIS data is collected through claims data, and some of the HEDIS measures are rated through medical chart review. If services are not documented properly on the medical record, they are considered non-compliant whether services have been provided to the patient.

You play a critical role in promoting better health for our members and using appropriate coding on all claims, since every HEDIS measure is linked to specific coding criteria. You and your staff can help facilitate the HEDIS process by applying these general rules of medical record documentation.

All progress notes should have:
  • Patient demographics (full name, date of birth, etc.)
  • Provider name, signature and credential
  • Date of service (DOS)
  • Encounter with multiple pages, patient demographic and provider information should be on every page.

Two measures specifications and examples:


Adult BMI Assessment (ABA)

This measure looks at the percentage of members ages 18 to 74 who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year (2016) or the year before the measurement year (2015).


For memberse age 21 and older, documentation in the medical record must include:

  • Date of the Body Mass Index (BMI)
  • Weight
  • BMI Value

For members 18 to 20, documentation of BMI percentile is required:

  • BMI documented as a percentage
  • BMI percentile plotted on an age-growth chart

Notation of only height and weight does not meed criteria.


Weight assessment and counseling for nutrition and physical activity for children/adolescents (WCC)


This measure looks at the percentage of members ages three to 17 who had an outpatient visit with PCP and had evidence of BMI percentile that was documented, had documentation of counseling for nutrition and documentation of counseling for physical activity during the measurement year.


Guidelines for the three components for this measure should be documented at least once during the measurement year (2016):

  • Height and weight in the measurement year
  • BMI percentile (ages 3-15) or BMI value (Ages 16-17)
  • Counseling for nutrition
  • Counseling for physical activity

Quick tip: Moda members coming in for sports or school checkups? Turn these into complete child checkups. This benefits the member, and unclogs your schedules from overlapping visits.


Want to learn more? Explore our site for quality improvement tools and tips. We are here to help and if you have any comments about ways we can improve or are interested in learning more about the HEDIS process and results from our review, we would love to hear from you. Email us at HEDIS@ModaHealth.com with your comments or questions.

Magellan Rx web portal makes prior authorizations easy
Moda has partnered with MagellanRx to assist you in medical pharmacy management through the provider administered injectable medication program. In an effort to save your practice time, Magellan Rx Management's HIPAA-compliant online portal allows prior authorization request to be submitted electronically. By requesting prior authorizations through Magellan's provider portal, you may track authorization status, view current and pending authorization requests and create authorization reports specific to your practice.

Additional benefits to utilizing the Magellan Rx online portal include:
  • 24-hour access to accommodate scheduling
  • Administrative efficiency
  • Education and guidance
  • Real-time approval for most cases
  • Online reporting capabilities
  • Increase to quality of care

Get started today!

To begin requesting prior authorizations through the Magellan Rx self-service portal, visit ih.magellanrx.com/ and select "New Access request-Provider" on the right side of the home page. Find out which medications require prior authorization through Magellan Rx at modahealth.com/medical/injectables

Injectable medication program expansion
Effective  Jan. 1, 2017 , 12 new medications will be added to the  prior authorization list
 of medications currently in the Magellan Rx program. Magellan Rx will review your prior authorization requests for these specialty injectable medications, along with other specialty medications that are already part of the program when administered in:
  • An outpatient facility
  • A patient's home
  • A physician's office
Brand name Generic name HCPCS code
Aldurazyme laronidase J1931
Aralast NP Alpha-1 proteinase inhibitor J0256
Cuvitru subcutaneous immunoglobulin J3590
Gazyva obinutuzumab J9301
Glassia Alpha-1 proteinase inhibitor J0257
Lumizyme alglucosidase alfa J0221
Naglazyme galsulfase J1458
Prolastin Alpha-1 proteinase inhibitor J0256
Prolastin-C Alpha-1 proteinase inhibitor J0256
Sustol granisetron extended-release J3490
VPRIV velaglucerase alfa J3385
Zemaira Alpha-1 proteinase inhibitor J0256

To view a complete list of injectable medications, visit  modahealth.com/medical/injectables/.

New diagnosis code requirements for commercial claims
In response to Healthcare Effectiveness Data and Information Set (HEDIS) and federal government reporting requirements, in 2017 Moda Health is expanding the scope of two major diagnosis code requirements for Medicare Advantage and Medicaid claims to include commercial claims. Effective for service dates Jan. 1, 2017 and after, all commercial claims submitted with one or more incomplete diagnosis codes or using inappropriate diagnosis codes in the primary diagnosis position will be denied.

Incomplete diagnosis codes
Diagnosis codes must be complete, valid and include all required digits and characters. These requirements apply to all diagnosis codes billed in any position, on all claims, and is applicable in all settings from all provider types.

If a claim is billed with at least one incomplete diagnosis code, the claim will deny with explanation code 85M (One of more diagnosis codes on this claim requires more digits to be complete. Please resubmit the claim with a more specific diagnosis). Invalid and incomplete diagnosis codes denials apply to all claims (all providers and all settings).

Inappropriate diagnosis codes in the primary diagnosis position
Certain diagnosis codes are not eligible to be reported in the principle diagnosis field.
  • Coding rules require that manifestation diagnosis codes, external causes of morbidity/injury codes and certain other diagnosis codes with specific sequencing instructions must always be reported as secondary to another diagnosis code.
  • CMS also identifies specific diagnosis codes that are unacceptable as a principle diagnosis on facility claims. This CMS list will be applied to commercial claims for 2017 dates of service.

Any claim billed with primary diagnosis code that does not meet these requirements will deny with explanation code 992 (Primary diagnosis is invalid for this setting. Please resubmit with valid primary diagnosis).


To see Moda's Diagnosis Code Requirement reimbursement policies RPM053 and RPM054, visit


Guidelines for prescribing ADHD medications to pediatric patients
Patients 6 to 12 years old who are newly prescribed ADHD medications need timely follow-up with their prescribing provider to check for medication adherence, tolerance and appropriate dosing. The National Committee for Quality Assurance (NCQA) has two guidelines for patients on ADHD medications:
  • One face-to-face visit with the prescribing provider within 30 days of medication initiation (even after a 'medication vacation' over summer months).
  • Two additional visits with the prescribing provider over the next nine months, one of which can be a telephone visit.

A Moda Health advocate regularly reaches out to eligible patients and providers to facilitate appointment scheduling and answer any questions about the guidelines. If you have questions about Moda's care programs or if you would like to speak to an advocate, contact our care team at 855-718-1769.


NCQA's guidelines for follow-up care for children prescribed ADHD medication can be found here.

Emerging clinical evidence: SGLT2 inhibitor cardiovascular (CV) outcomes and kidney warnings
The following are preliminary CV Outcomes in the EMPA_REG trial:

CV morbidity and mortality for Jardiance vs. placebo in addition to standard of care for secondary prevention in patients with type 2 diabetes.
  • Significant reduction in the primary composite outcome of death from CV causes, nonfatal myocardial infarction (MI; excluding silent MI), and nonfatal stroke vs. placebo (10.5% vs. 12.1%).
    • Results driven by death from CV causes (nonfatal MI and stroke not statistically significant)
    • Numerically higher incidence of nonfatal stroke with Jardiance than placebo (3.2% vs. 2.6%)
  • Significant decrease in rates of death from CV causes (3.7% vs. 5.9%), death from any cause (5.7% vs. 8.3%) and hospitalization from heart failure (2.7% vs. 4.1%) with Jardiance vs. placebo, respectively.
Kidney warnings from the FDA (June 2016)2:
  • Strengthened warnings about acute kidney injury risk for Invokana and Farxiga:
    • 101 post-marketing cases were reported from March 2013 to October 2015
    • ~50% occurred within one month of initiating treatment, and most improved upon discontinuation
  • FDA recommendations:
    • Consider predisposing factors to acute kidney injury prior to prescribing
    • Evaluate renal function prior to initiation as well as occasionally during therapy
    • Educate patients on signs and symptoms of acute kidney injury
    • If acute kidney injury occurs, discontinue the medication and treat kidney impairment promptly

Clinical pharmacist interpretation: While the CV outcomes data is promising, further evidence is needed to make a strong recommendation for SGLT2 inhibitors over other second-line diabetes treatment options. The new kidney warnings make individualizing therapy based on patient-specific factors even more critical.



1. Zinman B, Wanner, C, Lachin J, et al. "Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes." N Engl J Med. 2015; 373: 2117-28.

2. FDA Strengthens Kidney Warnings for Diabetes Medicines Canagliflozin (Invokana, Invokamet) and Dapagliflozin (Farxiga, Xigduo XR)." FDA Drug Safety Communication. U.S. Food and Drug Administration, 14 June 2016. Web. 27 July 2016.

Generic medication updates
The table below (Table 1) includes some commonly used medications that have recently become generically available, or are anticipates to become generically available in the near future.

Table 1: Generic pipeline update
Generic Name Brand Name Patent Expiration/Release Date*
rosuvastatin calcium Crestor 5/2/2016
armodafinil Nuvigil 6/1/2016
olmesartan/olmesartan HCTZ Benicar/Benicar HCT Q4 2016
salmeterol/fluticasone propionate Advair Q1 2017
ezetimibe Zetia Q2 2017
quetiapine extended release tablet Seroquel XR Q2 2017
*Expected release dates subject to change due to patent protections, litigations or other exclusivities, and delays in generic launch

High-cost medications with lower-cost alternatives
The table below (Table 2) includes some commonly used, high-cost medications with lower cost alternatives to consider when clinically appropriate.

Table 2: High-cost medications with lower cost alternatives

High-Cost Medications Average AWP* Lower-Cost Alternative Average AWP*
armodafinil, modafinil $26.95
Immediate-release stimulants (e.g. amphetamine salt combo tablet, dextroamphetamine tablet) $6.84/tablet
doxycycline hyclate capsule, tablet, DR tablets doxycycline monohydrate capsule (75mg, 150mg) tablet (100, 150mg) IR/DR tablet $5.53 - 22.67/unit (depends on formulation and strength) doxycycline monohydrate capsule
(50mg and 100mg) tablet
(50mg and 75mg)
$1.55 - 3.36/unit (depends on formulation and strength)
metformin ER (generic Glumetza) $120.22
metformin ER (generic Fortamet or Glucophage) $24.33/tablet
rosuvastatin $8.94
atorvastatin $4.81/tablet

Medical necessity updates
We've recently made a number of updates to our medical necessity criteria. You can find a complete list of medical necessity criteria changes below, or online at modahealth.com/medical/medical_criteria.sthml.

In This Issue
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To ensure that we provide high-quality service to our members, Moda's "Find a Provider" online search tool helps members connect with out extensive network of contracted providers. To meet the CMS requirement to have the most up-to-date information about your practice or facility available to our members, please email our provider updates team at
when any of the following changes occur, including the effective date:
  • New street address, phone number or office hours
  • Changes in the "When you are accepting new patients" status for all contracted Moda lines of business
  • Changes that affect the availability of providers in you practice

This will help ensure that our members can locate providers that are available and best suit their needs. 

Go digital today!
If you would like to start exchanging information electronically with Moda, please contact the Moda Electronic Data Interchange team at edigroup@modahealth.com
Moda Contact Information
Moda Medical Customer Service
For claims review, adjustment requests and/or billing policies, call (888) 217-2363 or email medical@modahealth.com.

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