Volume 7 |  July 2018
CMS Takes Action to Modernize Medicare Home Health

On July 2, CMS proposed significant changes to the Home Health Prospective Payment System (PPS) to strengthen and modernize Medicare, drive value, and focus on individual patient needs rather than volume of care. Specifically, CMS is proposing changes to improve access to solutions via remote patient monitoring technology, and to update the payment model for home health care.   READ MORE
CMS Proposes Rule Change to Protect Medicaid Provider Payments
Today, the Centers for Medicare & Medicaid Services (CMS) proposed changes to the Medicaid Provider Reassignment regulation that would eliminate state’s ability to divert Medicaid payments away from providers, with the exception of payment arrangements explicitly authorized by statute. This proposed regulatory change is designed to ensure that taxpayer dollars dedicated to providing healthcare services for low-income vulnerable Americans are not siphoned away for other purposes.  READ MORE
HCPCS Drug/Biological Code Changes: July 2018 Quarterly Update MLN Matters Article — Revised
A revised MLN Matters Article on  Quarterly Healthcare Common Procedure Coding System (HCPCS) Drug/Biological Code Changes – July 2018 Update  is available. Learn about six new HCPCS codes effective for claims with dates of service on or after July 1, 2018.
Quality Payment Program: Obtaining Your EIDM Credentials
To access the  Quality Payment Program Portal , you will need your Enterprise Identification Management (EIDM) User ID and Password. Log in to:
  • Submit your Merit-based Incentive Payment System (MIPS) performance data
  • Access your 2017 MIPS final score
  • View your 2017 MIPS performance feedback
  • Request a targeted review for your 2017 MIPS final score and 2019 payment adjustment
For More Information:
Prohibition Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program 
Note: This article was revised on June 26, 2018, to clarify the description of the QMB program. It also adds that starting July 2018 the Medicare Summary Notice (MSN) is another way for providers to verify the QMB status of beneficiaries for Medicare Fee-For-Service (FFS) claims. All other information remains the same. READ MORE
Be the first to earn your certification!
Exclusive, first-time course offering
Charleston, WV | July 26 & 27
West Virginia State Medical Association is committed to bringing you the educational opportunities you've asked for. The Certified Medical Chart Auditor course answers the call for all of you who have shown an interest in certification. This course will take place in Charleston, WV at the WVSMA headquarters at 2018 Kanawha Blvd., E.

July 25: Webinar: EHRs—Usability and optimization
Electronic health records have transformed health care over the last decade. While they have improved some aspects of clinical practice, they are still often associated with physician burnout and patient safety concerns. This webinar, noon–1 p.m. CDT—will provide an overview of the AMA's initiatives focused on improving the usability of EHRs through research, guiding principles and collaboration. It will also cover resources and best practices available to physicians and practices to support optimization.  Register .
New Part B Edit for Duplication of Diagnosis Codes on Hard Copy Claims
Medicare is implementing systems changes to ensure that all Part B 837 coordination of benefits/Medicare crossover claims do not include duplicate diagnosis codes. Part B providers: Effective July 2, 2018, CMS-1500 hard copy claims should not list the same diagnosis code twice within item 21, or your Medicare Administrative Contractor will return these claims as unprocessable with Claim Adjustment Reason Code 16, Remittance Advice Remark Code (RARC) M76, and alert RARC N211.
CMS Releases Proposed 2019 Medicare Physician Fee Schedule
On July 12, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2019 Medicare Physician Fee Schedule (PFS) addressing Medicare payment and quality provisions for the coming year. READ MORE
Do you have patients who haven't received their new Medicare card?
Please share this link with your patients.
Comprehensive Error Rate Testing: Arthroscopic Rotator Cuff Repair
As reported in the  Medicare Quarterly Compliance Newsletter (October 2017) , the Comprehensive Error Rate Testing (CERT) review contractor conducted a study of claims for arthroscopic rotator cuff repairs billed with HCPCS code 29827 submitted from January through March 2016. Most improper payments were due to insufficient documentation.
Avoid documentation errors and payment recoveries:
WV Pain Care Meetings

2018 Healthcare Summit & Annual Business
at the Greenbrier! August 24-25, 2018. REGISTRA T ION IS OPEN
The discounted room rate (WVSMA Room Block) has been extended to JULY 24! RESERVE YOUR ROOM HERE

Appalachian Addiction & Prescription Drug Abuse Conference
October 18-20, 2018 at the Embassy Suites, Charleston, WV
Additional Ambulatory Sensitive Conditions Will Require Enhanced Utilization Review, Effective Aug. 17, 2018
Highmark is adding more codes to our list of ambulatory sensitive conditions that pend for full clinical review when a patient has an urgent unplanned hospitalization. The majority of the new codes pertain to the 35 existing conditions that pend today.
Revisions are noted in red font below.
JUNE 12, 2018 SEPT. 11, 2018
The extension to Sept. 11, 2018 is provided so that all health plans can notify their prescribers. Effective June 12, 2018 Sept. 11, 2018, Express Scripts®, the company that processes Highmark drug claims, will implement state prescriptive authority logic within their pharmacy claim processing system. This implementation is phase one of the three-phased initiative that will ensure all applicable Highmark regions, as well as all states, are in compliance with Federal law and applying specific prescriptive state authority.  READ MORE
Updates to Notification/Prior Authorization Requirements for Specialty Medications for UnitedHealthcare Commercial and Community Plan Members
New procedure codes will become effective July 1, 2018 due to updates from the Centers
for Medicare & Medicaid Services (CMS). Correct coding rules dictate that assigned and
permanent codes should be used when available. The following injectable medications
that may be subject to prior authorization and/or Administrative Guide Protocols will have
new codes for UnitedHealthcare commercial plans, UnitedHealthcare Community Plan and
UnitedHealthcare Medicare Advantage Plans:

UnitedHealthcare Medicare Advantage Prior Authorization Reduction Pilot Concludes
On Oct. 1, 2018, the UnitedHealthcare Medicare Prior Authorization Reduction Pilot will
conclude, resulting in re-implementation of prior authorization for services previously
removed from this requirement. The pilot was implemented Jan 1, 2017, impacting: READ MORE
Network National Laboratory Services Care Providers for 2019
In 2019, UnitedHealthcare is growing its national network of participating laboratory
providers to better support our members and the care providers who order
laboratory services:
• LabCorp will remain in-network and until Jan. 1, 2019 will serve as UnitedHealthcare’s exclusive national laboratory care provider.*
•Beginning Jan. 1, 2019, Quest Diagnostics will be an in-network laboratory care provider for all
UnitedHealthcare members.*
*Excluding existing lab capitation agreements
Need to get the word out? Have content suggestions? Please contact angie@wvsma.org.