In this issue
- HEDIS Medical Record Review
- Prolonged Services reimbursement policy
- Medicare Part B Step Therapy Requirements
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HEDIS Medical Record Review
Moda Health will conduct our annual HEDIS medical record review chart audit starting in early February and ending May 7th. Moda has partnered with Cotiviti and KDJ Consultants to assist with the chart retrievals by EMR and on-site. To minimize Covid-19 exposure during the pandemic and reduce your administrative burden, we would like to encourage remote access. To establish remote access, please contact Adam Taylor at HEDIS@modahealth.com or call 503-412-4001. We appreciate your assistance in helping us fulfill these annual CMS and NCQA requirements.
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Prolonged Services reimbursement policy
Effective January 1, 2021, Moda Health is implementing a new reimbursement policy for 2021 prolonged office/outpatient evaluation and management (E&M) codes. This policy is based on coding principals and current guidance established by the Centers for Medicare and Medicaid Services (CMS) relative to the use of these new prolonged services CPT/HCPCS codes.
In addition to following correct coding guidance for use of prolonged services in addition to the primary procedure, Moda will:
- Only accept CPT code 99417 for submission on Oregon Medicaid claims
- Accept HCPCS code G2212 for submission on all commercial, Medicare Advantage and Oregon Medicaid plans
This policy applies to all claims submitted with dates of service January 1, 2021 and beyond and is intended to ensure time and resources are accurately captured in reported services. For more information on prolonged services requirements, review the Reimbursement Policy found here: https://www.modahealth.com/pdfs/reimburse/RPM076.pdf
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Medicare Part B Step Therapy Requirements
On January 1, 2021 Moda implemented Step Therapy requirements for Medicare outpatient (Part B) medications. Step therapy is required for select medications, provided the following are met for the requested drug:
- Meets the definition of a Medicare Part B medication
- New for the patient, as defined by no use in the last 365 days
- Proposed use of the requested and alternative drug has been determined to be a medically accepted indication under Medicare Rules
- Dose, frequency and duration of use may not exceed the safety and efficacy data supporting the medically accepted indication
Effective April 1, 2021, there will be changes to the preferred products for short-acting granulocyte colony-stimulating factor and trastuzumab products, as outlined below:
Preferred Medication(s) Effective 4/1/2021 [HCPCS]
- Zarxio [Q5101]
- Ogivri [Q5114]
- Trazimera [Q5116]
- Kanjinti [Q5117]
Non-preferred Medication(s) [HCPCS]
- Neupogen [J1442]
- Nivestym [Q5110]
- Granix [J1447]
- Herceptin [J9355]
- Herceptin Hylecta [J9356]
- Ontruzant [Q5112]
- Herzuma [Q5113]
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Reimbursement Policy Updates |
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RPM074: Additional Practice Expense Items During a Public Health Emergency (PHE) - CPT 99072 |
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99072 is not separately reimbursable until as such time CMS publishes additional specific reimbursement information. |
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RPM075: Emergency Department Visit Leveling |
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Level 4 & 5 ED visit charges billed with a Low Acuity Non Emergent (LANE) condition (diagnosis code) will be reimbursed as a Level 3 ED visit. |
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RPM076: Office or Other Outpatient Evaluation and Management (E/M) Visits and Prolonged Services |
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New CPT code 99417 will not be considered a reimbursable code for Commercial and Medicare Advantage lines of business effective 1/1/2021. New HCPCS code G2212 will be accepted for all lines of business. |
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RPM008: Technical Component (TC), Professional Component (PC/26), and Global Service Billing |
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Clarification of Moda following CMS guidelines in the case of the discrepancy between AMA guidelines and CMS guidelines for Molecular Pathology codes and the use of modifier 26.
Added clarification about clinical edit and related invalid modifier EX codes.
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November 2020
January 2021
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RPM032: Anesthesia Physical Status Modifiers (P1-P6) |
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RPM036: Modifiers GA, GX, GY and GZ |
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“Services explicitly excluded by Medicare” has been replaced by “services specifically listed as noncovered in the member’s Evidence of Coverage.”
“…uncertain if services will be covered…” has been replaced by “any services that are not specifically called out as noncovered in the member’s Evidence of Coverage.”
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RPM073: Telehealth and Telemedicine Expanded Services for COVID-19 |
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New CMS documents required updates: 11 new codes added by CMS in 2020-10-15-MLNC-SE “Trump Administration Drives Telehealth Services in Medicaid and Medicare” are added to Commercial list of covered codes. (Any codes that CMS covers, we have been adding to the Commercial list of codes called out in RPM073.)
Clarification of applicability to IOP/PH BH programs.
Added Newborn Nurse Home Visits to Commercial covered telehealth codes effective 1/1/2021.
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November 2020
December 2020
January 2021
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RPM044: Gynecologic or Annual Women's Exam Visit & Use of Q0091 (Pap, Pelvic, & Breast Visit) |
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Updated Code Definitions table with 2021 E/M office visit code changes for 99201 - 99215 and added 99417 prolonged service code. Corrected Pap test and cervical cancer screening lab test codes to correct G and P codes. Added G0476 HPV screening lab code and added additional ICD-10 diagnosis codes to definition table. |
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November 2020
December 2020
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RPM055: E0486 Oral Sleep Apnea Device/Appliance Documentation |
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Added CMS reference for proof of delivery requirements. |
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RPM062: Modifier 63 - Procedure Performed on Infants Less than 4kg |
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Annual review with no content changes. |
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RPM004: After Hours and Other Special Circumstances |
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Added "This policy does not apply to Medicaid plans." |
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RPM027: Modifiers XE, XS, XP, XU and 59 - Distinct Procedural Service |
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Added X{EPSU} examples from MLN SE1418 revised. |
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Added mention of revenue codes, cross-provider unbundling or duplication, laterality inconsistencies to paragraph # 2. |
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RPM006: Robotic Assisted Surgery |
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Annual review with no content changes. |
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RPM010: Modifiers 58, 78, and 79 - Staged, Related, and Unrelated Procedures |
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Added cross reference to RPM027 Distinct Procedural Service. |
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RPM011: Global Surgery Package for Professional Claims |
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Annual review with no content changes. |
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RPM046: Colorectal Cancer Screening And Related Ancillary Services |
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Clarification regarding specialist consultation E/M visits prior to screening colonoscopy and delineated differences between Commercial and Medicare Advantage lines of business. Deleted CPT code 99201 for 2021 and added cross reference to RPM036. |
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RPM057: Modifier 50 - Bilateral Procedure |
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Annual review with no content changes. |
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RPM063: 340B Drug Discount Program-Acquired Drugs and Biologicals (Modifiers JG & TB) |
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Annual review with no content changes. |
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August Medical Criteria Summary
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Introduction: This is annual review
Criteria Changes: No content changes
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Introduction: This is annual review and updates
Criteria Changes: Myriad Inc requested some changes for indications to allow coverage for BRACAnalysis CDx and myChoice CDx genetic tests. With frequent approval on new genetic tests and treatment considerations, this prompts for more updates for genetic testing criteria.
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BRACAnalysis CDx: An update was done to remove ‘women’ and replace with individuals, as this would broaden coverage for breast, ovarian and prostate cancer.
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myChoice CDx: An update included adding an indication for using this test for advanced epithelial ovarian cancer, fallopian tube or primary peritoneal cancer when there is consideration for combination treatment using Lynparza and Bevacimumab.
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Introduction: This is annual review
Criteria Changes: Grammar updates. No content changes.
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Introduction: This is an annual review
Criteria changes: No content changes
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Cochlear Implants and Auditory Systems |
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Introduction: This is an annual review
Criteria changes: No content changes
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Cryoablation of Breast Fibroadenomas |
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Introduction: This is an annual review
Criteria changes: No content changes
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Introduction: This is an annual review
Criteria changes: Added a section for indications where wheelchair accessories and options are considered experimental and investigational. This was prompted by a decision to archive Moda wheelchair criteria and utilize CareWeb guidelines for reviewing wheelchairs-related requests.
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Experimental and Investigational Services |
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Introduction: This is an annual review
Criteria changes: No content changes
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Hearing Assistive Technology |
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Introduction: This is an annual review
Criteria changes: No content changes
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Introduction: This is annual review
Criteria changes: Updates for the policy included review and comments from AllMed and HCS team review. In the description section, information was reviewed and updated to have an introduction that includes explanation of the procedures included in the criteria.
Addition and rewording of requirements for Functional Endoscopy Sinus Surgery (FESS) and Balloon Sinuplasty. This included, addition of missing information, replacing general terms and grammar correction
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Wheelchair accessories and options |
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Balloon Dilation of Eustachian Tube (BDET) |
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Introduction: New criteria
- Balloon dilation of the eustachian tube is a minimally invasive method for treating chronic obstructive eustachian tube dysfunction. The minimally invasive intervention aims to increase the patency of the cartilaginous part of eustachian tube and reduce inflammation
- New policy in place to review requests for BDET
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Effective 4/15/2021
Medical
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Moda 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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