Page 2
Amended medical records HMO providers also participate with
The Children’s Plan Converted to new CMS 1500 yet?
Page 3
MAC fee changes Place of treatment code changes New code and billing instructions for
ranibizumab (Lucentis) More codes that do not meet payment determination criteria
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Annual review of medical policies New policy: Panitumumab (Vectibix)
New policy: 3D reconstruction
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New policy: Spinal cord stimulators New: High-dose chemotherapy
policies
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65C Plus approved CMS notices 65C Plus: Expedited review of
hospital discharge
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PBS Second Opinion season two
For all CPT codes used in this Provider Update: CPT only © 2007, American Medical
Association. All rights reserved.
If you have a question about information in this Provider Update, please call a Provider Teleservice Representative at 948-6330 on Oahu or 1 (800) 790-4672
from the Neighbor Islands.
For Participating Medical Practitioners
Februrary PS08-006
HMSA
Hawaii Medical Service Association
818 Keeaumoku St. P.O. Box 860
Honolulu, HI 96808-0860
Phone: (808) 948-5110 Branch offi ces located on
Hawaii, Kauai and Maui
Internet address: www.HMSA.com Provider Resource Center: hhin.hmsa.com
HMSA conducts post-payment reviews of claims on a regular basis. To verify whether a claim is paid correctly, a request for medical record documentation is sent to the provider who was paid for the service.
Receipt of these documents is essential for claims payment to be properly evaluated. HMSA reviews claims based on the supporting documentation that is initially received. Subsequent documentation will be reviewed as an amendment of the medical record and will not be accepted as part of the supporting documentation.
Complete medical record documentation is essential to quality patient care. Before submitting copies of medical record documentation, review the record to confi rm whether it meets commonly acceptable standards and guidelines.
If the requested documentation is not received, the service is considered not substantiated and the provider will be required to reimburse HMSA for its overpayment. If the documentation received is determined to be insuffi cient to support the level of payment made, HMSA will require the provider to return the amount that was overpaid for the service he or she rendered.
Medical Record Documentation Guidelines
Th e following information should be included as part of the medical record. Th ese guidelines apply to all lines of business.
Each page of the record must contain the patient’s name or ID number.
All medical record entries must have the author’s identifi cation (handwritten signature, unique electronic identifi er or author’s initials).
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Complete documentation needed for
audit compliance
Avoid even the appearance of record
falsifi cation!
Ensure the original record is legible. Original entries that are incorrect must be legible; use a single strikethrough when making a correction. Changes should be initialed by the author making the change.
Strive to complete patient notes in a timely manner and make amendments as soon as possible.
Refrain from. . .
Creating new records when records are requested Backdating entries
Postdating entries Predating entries Writing over entries
Adding to existing documentation outside the prescribed method of amending medical records All entries must be dated.
Th e record should be legible to someone other than the author.
Signifi cant illnesses and medical conditions should be indicated on the problem list. Medication allergies and adverse reactions should be noted in the record. Patients who have no known allergies or adverse reactions should have that noted.
Patient’s past medical history should be identifi ed and include serious accidents, operations and illnesses. For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations and childhood illnesses.
Working diagnoses must be consistent with fi ndings.
Treatment plans must be consistent with diagnoses.
Medical Record Documentation Guidelines
(continued from previous page)Amended medical records
It is not uncommon for patient medical records to be amended by late entries, addenda or corrections. An amendment must:Be entered separately,
State the reason for the amendment, Bear the current date of that entry, and
Be signed by the author of the amendment.
When a paper copy of the original entry has been made prior to the amendment, both the electronic record and the paper copy must have the same amendment information.
HMSA’s Th e Children’s Plan is one of the plans covered under HMSA’s Health Center agreements. Th erefore, HMO providers are participating providers in Th e Children’s Plan network.
HMO providers are The
Children’s Plan providers
Converted to the new
CMS 1500 yet?
Eff ective July 1, 2008, all claims must be submitted using the CMS 1500 (08-05) version. Any claims submitted on the old CMS 1500 claim form on or after July 1, 2008, will be returned.
Billing and Coding
Th e Maximum Allowable Charge (MAC) for the following CPT code has increased, eff ective January 1, 2008.
CPT
Code Description
New MAC
90669 Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use
$ 88.25
Th e MAC for the following CPT codes will increase eff ective February 1, 2008.
CPT
Code Description
New MAC
90691 Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use $51.25
90717 Yellow fever vaccine, live, for subcutaneous use $81.22
90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or
immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use
$32.27
90733 Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use $107.47 90734 Meningococcal conjugate vaccine, serogroups A, C, Y and W-135
(tetravalent), for intramuscular use
$105.44
90735 Japanese encephalitis virus vaccine, for subcutaneous use $108.34
Th e MAC for the new HCPCS code for ranibizumab (Lucentis) is eff ective January 1, 2008.
HCPCS
Code Description
New MAC
J2778 Injection, ranibizumab, 0.1 mg (Use this code for Lucentis) $462.71
MAC fee changes
Eff ective April 1, 2008, the following changes will be made to HMSA’s Place of Treatment lists, which will be aligned with an updated Procedure-Related Group (PRG) list, also eff ective on that date.
CPT codes 43269 and 43271 will be removed from the outpatientlist.
CPT code 43760 will be added to the offi celist. CPT codes 58558 and 58565 will be added to the outpatient list.
Place of treatment changes
Th e following codes that are new for 2008 were added to the Codes Th at Do Not Meet Payment Determination Criteria table.
CPT codes: 27416, 28446, 83993, 95980 to 95982, and 99174.
HCPCS codes: A9277 and A9278.
More codes that do
not meet payment
determination criteria
Panitumumab (Vectibix) is approved for the treatment of patients with metastatic colorectal cancer. It may be considered medically necessary when:
Th e drug is recommended by an oncologist, and
Th e disease continues to progress on or following chemotherapy.
Precertifi cation is required. Precertifi cation requests for continuing therapy may be approved
if the patient shows no progression of the disease. Panitumumab is not considered medically
necessary if the patient has had progression of the disease while being treated with cetuximab (Erbitux). Documentation requirements are included in this policy.
Th is policy will be eff ective April 1, 2008. For a complete version of this new policy, refer to the Provider E-Library.
Panitumumab (Vectibix) – new policy eff ective April 1
3D renderings may be considered medically necessary for specifi c clinical situations. Th is technology is used in radiology settings such as CT, MRI, ultrasound or echocardiography. CPT codes 76376 and 76377 should be billed for these services. Physician supervision is considered part of the 3D services and should not be billed separately. Specifi c exclusions may apply. CPT
guidelines indicate 76376 and 76377 should not be reported in association with specifi c codes listed in the CPT code book and in HMSA’s medical policy.
Th is policy is eff ective April 1, 2008. For a complete version of this new policy, refer to the Provider E-Library.
3D Reconstruction – new policy eff ective April 1
Th e following policies have undergone annualreview and have been updated.
Bone (Mineral) Density Studies eff ective April 1, 2008
Durable Medical Equipment, Prosthetics and Orthotics
Erythropoiesis Stimulating Agents (ESA)
eff ective April 1, 2008
Home Apnea Monitors for Infants Home Health Care
Home Pulse Oximeter
In Vitro Fertilization Off -Label Drug Use
Oscillatory Device for Bronchial Drainage (Th e Vest)
Transcutaneous Electrical Nerve Stimulation (TENS)
Vacuum-Assisted Closure of Chronic Wound Please refer to the Provider E-Library and click on the individual policies to view the changes. Copies of policies are available upon request.
Annual review of medical policies
HMSA has developed policies for high-dose chemotherapy and stem-cell transplants that will be eff ective April 1, 2008. Th ese policies are based on the Blue Cross and Blue Shield Association’s high-dose chemotherapy policies.
High-Dose Chemotherapy and Allogeneic Stem-Cell Support for Genetic Diseases and Acquired Anemias
High-Dose Chemotherapy and Allogeneic Stem-Cell Support for Myelodysplastic Diseases
High-Dose Chemotherapy and Autologous Stem-Cell Support for Autoimmune Diseases, Including Multiple Sclerosis
High-Dose Chemotherapy and Autologous Stem-Cell Support for Malignant Astrocytomas and Gliomas High-Dose Chemotherapy and Hemopoietic Stem-Cell Support as a Treatment of Germ-Cell Tumors
High-Dose Chemotherapy and Hematopoietic Stem-Cell Support for Epithelial Ovarian Cancer
High-Dose Chemotherapy and Hematopoietic Stem-Cell Support for Hodgkin’s Disease
High-Dose Chemotherapy and Hematopoietic
Stem-Cell Support for Miscellaneous Solid Tumors in Adults
High-Dose Chemotherapy and Hematopoietic Stem-Cell Support for Non-Hodgkin’s Lymphomas High-Dose Chemotherapy and Hematopoietic Stem-Cell Support for the Treatment of Chronic Myelogenous Leukemia High-Dose Chemotherapy Plus Hematopoietic Stem-Cell Support to Treat Primary Amyloidosis or Waldenstom’s Macroglobulinemia
High-Dose Chemotherapy with Hepatopoietic Stem-Cell Support as a Treatment of Acute Lymphocytic Leukemia
High-Dose Chemotherapy with Hematopoietic Stem-Cell Support for Acute Myelogenous Leukemia High-Dose Chemotherapy with Hematopoietic
Stem-Cell Support for Breast Cancer
High-Dose Chemotherapy with Hematopoietic Stem-Cell Support for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma
High-Dose Chemotherapy with Hematopoietic Stem-Cell Support for Primitive Neuroectodermal Tumors (PNET) for the CNS and Ependymona
High-Dose Chemotherapy with Hematopoietic Stem-Cell Support for Solid Tumors of Childhood Nonmyeloablative Allogeneic Transplants of Hematopoietic Stem Cells for Treatment of Malignancy
Single or Tandem Courses of High-Dose Chemotherapy plus Hematopoietic Stem-Cell Support for Multiple Myeloma
Please refer to the Provider E-Library and click on the individual policies. Copies of policies are available upon request.
High-dose chemotherapy policies – eff ective April 1
Spinal cord stimulators deliver low voltage electrical
stimulation to the dorsal columns of the spinal cord to block pain. Precertifi cation is required. Th is policy will be eff ective April 1, 2008. Th e complete version of this policy is available in the E-Library.
Spinal cord
stimulators for pain
management – new
policy eff ective April 1
Th e Centers for Medicare & Medicaid Services (CMS) has updated the following forms that facilities must use for HMSA’s 65C Plus members.
Notice of Medicare Noncoverage (NOMNC)
Th e NOMNC form (CMS 10095-A) is issued by the facility when the decision is made to
terminate skilled nursing facility (SNF), home health agency (HHA) or Comprehensive Outpatient Rehabilitation Facility (CORF) services even if the member agrees that services should end.
Detailed Explanation of Noncoverage (DENC)
Th e DENC form (CMS 10095-B) is issued by the facility when members appeal directly to the Qual-ity Improvement Organization (QIO) about the reduction or discontinuation of their SNF, HHA or CORF services.
Notice of Denial of Medical Coverage (NDMC)
Th e NDMC (CMS 10003) is issued by the facility when the decision is made to deny, reduce or discontinue SNF, HHA or CORF services. More specifi cally, the NDMC is issued when:
Medicare benefi ts are exhausted, Medicare admission is denied,
Non-Medicare covered services are denied, or Th ere is a reduction or termination of a Medicare service that does not conclude the skilled
Medicare stay, and the member disagrees with the determination.
CMS requires that facilities use the updated forms eff ective February 12, 2008 (within 90 days of the release of its November 14, 2007, Medicare Advantage Appeals Notice). All prior versions should not be used after February 12, 2008.
Forms are available for immediate use in the Provider E-Library (Forms Index) in PDF format. Th ese forms are also available as MS Word documents, so that facilities can insert their logo in the appropriate space indicated.
Complete information on the above changes, includ-ing the instructions for each of these forms, can be accessed at www.cms.hhs.gov/mmcag.
Updated 65C Plus member notices go into eff ect
February 12, 2008
HMSA’s 65C Plus
HMSA’s 65C Plus members have the right to request an expedited review by a Quality Improvement Organization (QIO) when the facility, with physician concurrence, determines that skilled care is no longer necessary and the member disagrees with that determination. Timely submission of the request for an expedited review is required by the member.
Requests should be submitted to the QIO within the following timetable:
Inpatient hospital denial –no later than midnight of the day of discharge.
Skilled nursing facility (SNF) and home health agency (HHA)
denials – no later than noon of the day after the day the member receives the NOMNC, or if the member receives the NOMNC more than two days prior to the date that coverage ends, the request for expedited review must be received by the QIO no later than noon of the day before the coverage ends.
Expediting appeal of
facility discharge
Second Opinion: Taking Charge of Your Healthcare, began its second season on January 13, on PBS and will continue to air other episodes weekly at 6:30 p.m., Sundays.
Here is a list of the new episodes, beginning with the month of February:
Vision Correction – February 4
Advertising has become standard practice for providers who perform vision correction services. Providers spend nearly $200 million in advertising and Americans spend nearly $2 billion on vision correction. Second Opinion looks into the ethics of advertising in healthcare and the rise of corrective vision surgeries nationwide. Th is episode also presents information that helps people become informed medical consumers.
Stroke – February 10
Also called “brain attack,” the term illustrates the seriousness of the disease and its relationship to heart attack. Second Opinion explores the latest about how a stroke is diagnosed and treated, and ways to prevent it.
Eating Disorders – February 17
Th is disease aff ects several million people, 90 percent of whom are female. Although the general perception is that eating disorders most likely occur in younger women, some research suggests approximately 79 percent of deaths from anorexia occur in women over age 45. Second Opinion
panelists discuss the biological, psychological and cultural factors of this complex problem.
Joint Replacement – February 24
Americans are living longer and leading more active lives. Over time, major joints – hip, knee, shoulder – wear out, become painful, or cease to function properly. Th is episode of Second Opinion
brings together a panel of orthopaedic experts and healthcare providers to discuss the causes and symptoms of joint deterioration and the wide range of treatments available, including joint replacement.
Metabolic Syndrome – March 2
People whose lifestyle lacks physical activity combined with other common health problems are likely candidates for a potentially life-threatening health condition called metabolic syndrome. Th e causes and consequences of this condition and the steps people can take to protect themselves from this life-threatening medical problem will be presented.
Women’s Cardiac Health – March 9
Women develop heart problems later in life than men, and their risk increases more than men when they reach about age 65. Th is edition of Second Opinion explores ways to prevent, assess risk and diagnose heart disease in women.
Back Pain – March 16
In the United States, seven out of ten people will suff er from back pain some time in their lives. Watch this episode for a common-sense discussion about this all-too-common ailment.
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Colon Cancer – March 23
Th is is the third most common type of cancer among Americans and is the third leading cause of cancer-related deaths. Learn how to catch it at the earliest, most curable stage.
Skin Cancer – March 30
Medical experts and skin cancer victims explore the signs, symptoms and outcomes of skin cancer and recommend simple measures everyone can take to signifi cantly reduce the risk.
Asthma – April 6
Between 15 and 20 million Americans (5 million are children) suff er from asthma. Having an asthma attack is frightening and even fatal, but it is treatable and people can take precautions to prevent future episodes. Second Opinion examines the symptoms and causes of asthma and how modern drug therapy can alleviate its eff ects.
