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Florida | 2016 | Issue III
Diabetes ICD–10 Coding Guidelines ...Page 1 Q3 Provider Formulary Update ...Page 2 Benefits of Providing Services in
an ASC Setting ...Page 2 RAPS Provider Education ... Page 3 Updated Clinical Practice
Guidelines ... Page 3 Healthy Rewards Program ... Page 3 Utilization Management Ensures
the Right Care ...Page 4 How to Improve Patient Satisfaction and CAHPS® Scores ...Page 4 Member Rights and Responsibilties ...Page 5 Updating Provider Directory
Information ...Page 5 Medical Record Requests for Risk
Adjustment Review ...Page 6 Coding Corner ...Page 7 SUNCAP Helps Ensure Proper
Payment ...Page 7 2016–2017 Influenza Season...Page 8 Provider Resources...Page 8 We’re Just A Phone Call or a
Click Away ...Page 8
DIABETES ICD-10 CODING GUIDELINES
Diabetes mellitus (DM) is a group of metabolic diseases characterized by high blood sugar levels over a prolonged period.
If the documentation in a medical record does not indicate the type of DM, but indicates that the patient uses insulin, code E11.-, type 2 DM should be assigned. Code Z79.4-long-term use of insulin should also be assigned to indicate that the patient uses insulin. Code Z79.4 should not be assigned if the insulin is given temporarily to get a type 2 patient’s blood sugar under control during an encounter.
Secondary DM codes under categories E08, DM due to underlying condition; E09, drug- or chemical-induced DM; and E13, other specified DM, identify complications/manifestations associated with secondary DM.
Diabetes with high blood sugar (hyperglycemia) – High blood sugar, or hyperglycemia, occurs when a person’s blood sugar stays too high for too long. High blood sugar is an indication that the body doesn’t have enough insulin. In ICD-10, for type 1 DM patient, use code E10.65; for type 2 DM patient, use code E11.65.
Diabetes with low blood sugar (hypoglycemia) –This condition occurs when a patient’s blood sugar level drops too low to provide enough energy for the body’s activities. In ICD-10, for type 1 DM patient, use code E10.649; for type 2 DM patient, use code E11.649.
Diabetic hyperlipidemia is a major factor involved in a cardiovascular disease. Diabetic hyperlipidemia occurs when a patient has high cholesterol and diabetes. In ICD-10, for type 1 DM patient, use code E10.69; for type 2 DM patient, use code E11.69.
Q3 2016 PROVIDER FORMULARY UPDATE
MEDICAID:
The Staywell Preferred Drug List (PDL) has been updated. Visit ahca.myflorida.com/Medicaid/Prescribed_Drug/
pharm_thera/fmpdl.shtml to view the current Staywell PDL and pharmacy updates.
Visit www.wellcare.com/Florida/Providers/Medicaid/Pharmacy for the Staywell Kids PDL and pharmacy updates.
You can also refer to the Provider Manual available at www.wellcare.com/Florida/Providers/Medicaid to view more information regarding WellCare’s pharmacy Utilization Management (UM) policies and procedures.
MEDICARE:
There have been updates to the Medicare formulary. Find the most up-to-date complete formulary at www.
wellcare.com/Florida/Providers/Medicare/Pharmacy.
You can also refer to the Provider Manual available at www.wellcare.com/Florida/Providers/Medicare to view more information regarding WellCare’s pharmacy UM policies and procedures.
BENEFITS OF PROVIDING SERVICES IN AN ASC SETTING
Operating in an ambulatory surgery center (ASC) setting (Place of Service 24), rather than an outpatient hospital setting (Place of Service 22), may be beneficial to patients, providers and payers. The benefits of providing services in an ASC setting may include:
• A more relaxed, less stressful and lower cost environment
• Provider autonomy over work environment and quality of care
• Increased provider control over surgical practices
• Provider specialties tailored to the specific needs of patients
• Raised standards in patient satisfaction, safety, quality and cost management
• Additional hospital operating room time reserved for more complex procedures
• Comparable patient satisfaction
• Quality of care as the hallmark of the ASC model
Providers are encouraged to provide services in an ASC setting (Place of Service 24) when appropriate.
Please contact your Provider Relations
representative for more information on ASCs in your area.
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RAPS PROVIDER EDUCATION
Have you ever wanted to learn more about risk adjustment?
Are you struggling with ICD-10? If you are, then Risk Adjustment Processing System (RAPS) Provider Education is for you!
• Education on MRA and HEDIS® to achieve a Five-Star Quality Rating for each IPA/provider:
– Setting expectations for the IPA/providers
• Providing necessary education for areas needing improvement – Understanding MRA
– Understanding HEDIS coding – Documentation training – ICD-10 coding training
• Providing a TEAM effort to ensure all MRA & HEDIS criteria are being met. TEAM includes:
– Auditor Educator – IPA/PR Rep – Quality Nurse – Medical Director
• Regular and ongoing outreach and training – on-site, webinar, phone, email
• Regular and ongoing chart auditing for retrospective review and prospective education Please contact the RAPS Medical Coding Auditing department at [email protected].
HEALTHY REWARDS PROGRAM
The Healthy Rewards Program rewards members for taking small steps to help them live healthy lives.
When they complete primary care provider (PCP) visits, prenatal visits, and certain health checkups, members earn rewards that are placed on reloadable Visa® cards.
Members can use these cards at a variety of locations to purchase items including milk, bread, diapers and over-the-counter (OTC) items from a pharmacy. The
Providers can encourage their patients to take part in this program by signing and including their provider ID on applicable activity reports.
For more information on the Healthy Rewards Program, please contact your Provider Relations representative or call one of the Provider Services phone numbers at the end of this newsletter.
UPDATED CLINICAL PRACTICE GUIDELINES
Clinical Practice Guidelines (CPGs) on the following topics have been updated and published to the provider website: ADHD, Asthma, Cancer, Coronary Artery Disease, Diabetes in Adults, Diabetes in Children, HIV Antiretroviral Treatment, Smoking Cessation, and Substance Use Disorders. A Clinical Practice Guideline
Hierarchy has also been developed and published.
This provides a summary of all CPGs and the national/
professional organization that WellCare aligns with. To access other CPGs related to Behavioral, Chronic, and Preventive Health, visit www.wellcare.com/Florida/
Providers/Clinical-Guidelines/CPGs.
MEDICAID
HOW TO IMPROVE PATIENT SATISFACTION AND CAHPS
®SCORES, PART 2 OF 3
GOOD COMMUNICATION CAN IMPROVE HEALTH OUTCOMES AND MEMBER EXPERIENCES
1) ENCOURAGE YOUR PATIENTS TO SPEAK
This will help you to understand what patients know and what they need to learn about their care. Try these strategies to encourage patients to become engaged in their care:
• Listen to the patient’s point of view. Focus on the value of what the patient is saying. Validate something a patient has said. This will encourage a patient to speak up.
• Sit in the room with the patient. This improves the patient’s perception of the time you have spent with him or her.
• Ask your patient, “How would you like to participate in your care?”
• Tell your patient, “I want you to feel free to ask me any question, even difficult questions. I welcome that.”
(Don’t make your patient think you are rushed.)
2) COMMUNICATION TIPS AND POSITIVE SCRIPTING WORKS!
You and your medical staff can help patients gain positive perceptions about you and your staff and the care they are getting. Here are examples of ways you and your staff can sound positive and promote your assets while helping the patient prepare for the visit:
The reception staff, office managers, medical assistants, care managers, nurses, and/or physicians can use the examples below to greet patients in your office:
• “Dr. Smith will be with you soon. She’s really great with kids. She’s a good listener. Be sure to talk to her and ask her those questions you had about your little girl.”
• “Dr. Patel will be right here. You’ll find him to be very sensitive about properly addressing any pain you may experience during the procedure.”
• “Oh, I see Dr. Weinstein is your doctor. We have many patients who request him. Once you get to know him, you will understand why his patients love him. He is an excellent doctor.”
• “Be sure to check out with Maria. She’s nice and helpful. She’ll get you a follow-up appointment and answer any questions you have.”
References:
The CAHPS Ambulatory Care Improvement Guide: Practical Strategies for Improving the Patient Care Experience. Agency for Healthcare Research and Quality (AHRQ), 2015. www.ahrq.gov/cahps/quality-improvement/improvement-guide/improvement-guide.html.
UTILIZATION MANAGEMENT ENSURES THE RIGHT CARE
WellCare’s Utilization Management Program includes components of prior authorization and prospective, concurrent and retrospective review activities. Each component is designed to provide for the evaluation of health care and services based on WellCare members’
coverage, and the appropriateness of such care and services, and to determine the extent of coverage and payment to providers of care.
WellCare does not reward practitioners, providers or associates who perform utilization reviews, including those of the delegated entities, for denials. No one is compensated or otherwise given incentives to encourage denials that result in underutilization. Utilization reviews are based on appropriateness of care and existence of coverage. Utilization denials (adverse determinations) are based on lack of medical necessity or lack of covered benefits.
If you have questions about this program, please refer to your Quick Reference Guide at www.wellcare.com/Florida/Providers/Medicaid for contact information.
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UPDATING PROVIDER DIRECTORY INFORMATION
We rely on our provider network to advise us of demographic changes so we can keep our information current.
To ensure our members and Provider Relations staff have up-to-date provider information, please give us advance notice of changes you make to your office phone number, office address or panel status (open/
closed). Thirty-day advance notice is recommended.
New Phone Number, Office Address or Change in Panel Status:
Send a letter on your letterhead with the updated information. Please include contact information if we need to follow up on the update with you.
Please update your information or send the letter by any of these methods:
• Call: 1-407-551-3200, Option 2
• Email: [email protected]
• Fax: 1-813-865-6764
This contact information is only for the updates mentioned above in bold. Any other correspondence sent through these channels will not be reviewed or
MEMBER RIGHTS AND RESPONSIBILITIES
As a WellCare provider, it’s important for you to know what our members’ rights and responsibilities are.
OUR MEMBERS HAVE THE RIGHT TO:
• Participate with practitioners in making decisions about their health care
• Receive information about our organization, services, practitioners and providers, and member rights and responsibilities
• Be treated with respect and dignity
• Have their privacy protected
• Have a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost and benefit coverage
• Voice complaints or appeals about WellCare or the care we provide*
• Make recommendations regarding WellCare’s member rights and responsibilities policy
*Under WellCare’s grievance process and
administrative review process, members may file a grievance/complaint and may appeal medical or administrative decisions.
IN ADDITION, OUR MEMBERS HAVE THE RESPONSIBILITY TO:
• Supply information that WellCare, our practitioners and providers need to provide care
• Follow plans and instructions for care that they have agreed on with their practitioners
• Understand their health problems
• Help set treatment goals that they agree to with their practitioners
Members may have additional rights and responsibilities. A complete listing can be found in the Provider Manual and Member Handbook.
MEDICAL RECORD REQUESTS FOR RISK ADJUSTMENT REVIEW
The Centers for Medicare & Medicaid Services (CMS) has implemented a system for paying managed care plans based on the health status of their members. All Medicare Advantage plans obtain health status documentation from diagnoses contained in claims and from information in the member’s medical record. On January 1 of each year, members’ chronic conditions are resolved in the CMS model. CMS requires that we report the presence of chronic persistent conditions each year for each member.
By providing medical record documentation for risk adjustment review, WellCare can avoid unnecessary and costly administrative revisions and premium changes. And we can provide your patients, who are our members, with quality customer service. Coding accuracy also helps us identify patients who may benefit from disease and medical management programs.
WHAT WE’RE REQUESTING
Records for all dates of service from Jan. 1, 2015 through Dec. 31, 2015 to include the following:
• History and physical, progress notes, consultations
• Discharge, consults, diagnostic results, pathology summaries and reports
• Subjective and objective assessments and plan notes
• Surgical procedures, operating room summaries
• Must state patient’s name and dates of service on chart for each date of service
• CMS requires all signatures contain provider name, credentials and date signed
WHO WILL BE REQUESTING RECORDS?
WellCare has business agreements with CIOX Health, Altegra Health™ and Centauri Health Solutions to retrieve charts on our behalf. Compliance with these requests is not a HIPAA violation. Providers may disclose protected health information (PHI) under the Health Insurance Portability and Accountability Act Privacy Rule, allowing them to release PHI to health plans and their agents for health care operations and risk management (www.cms.gov).
HOW TO SUBMIT RECORDS
Please refer to the instruction on the medical record request you’ve received. For questions or concerns, please contact the Risk Adjustment Department at [email protected].
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CODING CORNER
INITIAL ANNUAL WELLNESS VISIT (AWV) LIFETIME LIMIT Description of Service:
The Centers for Medicare & Medicaid Services (CMS) Medicare Claim Processing Manual, Chapter 12, Section 30.6.1.1, says the Initial Annual Wellness Visit (AWV) providing a personalized prevention plan of service (PPPS) (HCPCS G0438) is a one-time allowed benefit. HCPCS code Initial Annual Wellness Visit (AWV) includes a PPPS.
The PPPS may include a written patient screening schedule, a list of risk factors, and furnishing personalized health services and referrals, as needed.
The determination of whether the AWV is an initial or subsequent visit is based on the patient and not the provider. It is subject to editing if billed more than once by different providers.
WellCare applies a once-in-a-lifetime limit to HCPCS code G0438 for a single member by any number of providers. When HCPCS code G0438 is submitted for a member who has already had a paid G0438 claim, the later G0438 will be denied.
For more information, refer to CMS MLN Matters® Number: MM7079 at: www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7079.pdf.
URINE VALIDITY TESTING Description of Service:
According to the CMS National Correct Coding Initiative Policy Manual, providers performing validity testing on urine specimens used for drug testing should not separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed. Testing to confirm that a urine specimen is unadulterated is an internal control process.
Per WellCare Claims Edit Guideline (Drug Testing: HS-247) published Dec. 16, 2015, specimen validity testing, including, but not limited to, pH, specific gravity, oxidants, and creatinine, is not separately reportable and will not be reimbursed.
Please refer to the WellCare secure provider portal for the specific edit start date.
SUNCAP HELPS ENSURE PROPER PAYMENT
SUNCAP is an electronic version of capitation payments made to our vendors and providers who have a
capitated arrangement with WellCare.
The data is sent in a pipe-delimited text format
and includes member-level detail to allow our providers an electronic means to reconcile their monthly
payments. The files are sent by the 20th of each month to a Secure File Transfer Protocol (SFTP) site.
SUNCAP does not replace the existing documents that are available through PaySpan Health®. It simply offers another means for our providers to ensure proper payments are received.
Please contact your Provider Relations representative for additional information on enrolling to receive this
WE’RE JUST A PHONE CALL OR CLICK AWAY!
Medicare:
1-855-538-0454
Staywell 1-866-334-7927
Staywell Kids
1-866-698-5437 www.wellcare.com/Florida
PROVIDER RESOURCES
WEB RESOURCES
Visit www.wellcare.com/Florida to access our Preventive and Clinical Practice Guidelines, Clinical Coverage Guidelines, Pharmacy Guidelines, key forms and other helpful resources. You may also request hard copies of any of the above documents by contacting your Provider Relations representative. For additional information, please refer to your Quick Reference Guide at www.wellcare.com/Florida/Providers/Medicaid or www.wellcare.com/
Florida/Providers/Medicare.
PROVIDER NEWS
Remember to check messages regularly to receive new and updated information. Visit the secure area of www.wellcare.com/Florida to find copies of the latest correspondence. Access the secure portal using the Provider Secure Login area in the provider drop-down menu on the top of the page. You will see Messages from WellCare located in the column on the right.
ADDITIONAL CRITERIA AVAILABLE
Please remember that all Clinical Coverage Guidelines detailing medical necessity criteria for several medical procedures, devices and tests are available on our website at www.wellcare.com/Florida/Providers/Clinical- Guidelines.
FL034292_PRO_NEW_ENG Internal Approved 07112016
©WellCare 2016 NA_06_16 FL6PRONEW76100E_0616
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2016–2017 INFLUENZA SEASON
By now, your practice should be prepared for the 2016–2017 flu season. It’s important to develop an influenza vaccine purchasing plan that allows you to meet the needs of your patients. Flu seasons are unpredictable and can begin earlier or last longer than expected, so plan ahead to protect your patients and employees. You should regularly review your influenza vaccine purchasing options and reassess the needs of your organization. For assistance, please call one of the Provider Services phone numbers at the end of this newsletter.
FOR THE IMMUNIZATION-RESISTANT
Misinformation about vaccine safety has existed since the dawn of vaccines, and its dissemination is permitted by the freedom to express opinions, no matter how incorrect. Nurses, physician assistants and other office staff play a key role in establishing and maintaining a practice-wide commitment to communicating effectively about vaccines and maintaining high vaccination rates – from providing educational materials, to being available to answer questions, to ensuring that families who may opt for extra visits for vaccines schedule and keep vaccine appointments.
Confused parents may delay or refuse immunizations for their child due to misperceptions of disease risk and vaccine safety. A successful discussion about vaccines involves a two-way conversation, with both parties sharing information and asking questions. These communication principles can help you connect with patients and their caretakers by encouraging open, honest and productive dialogue.
