Complete documentation needed for audit compliance

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1 HMSA s For Participating Medical Practitioners Februrary 2008 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 Page 4 Annual review of medical policies New policy: Panitumumab (Vectibix) New policy: 3D reconstruction Page 5 New policy: Spinal cord stimulators New: High-dose chemotherapy policies Page 6 65C Plus approved CMS notices 65C Plus: Expedited review of hospital discharge Page 7 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 on Oahu or 1 (800) from the Neighbor Islands. Complete documentation needed for audit compliance 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 confirm 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 insufficient 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 The following information should be included as part of the medical record. These 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 identification (handwritten signature, unique electronic identifier or author s initials). (continued on next page) PS Hawaii Medical Service Association 818 Keeaumoku St. P.O. Box 860 Honolulu, HI Phone: (808) Branch offi ces located on Hawaii, Kauai and Maui Internet address: Provider Resource Center: hhin.hmsa.com

2 February 2008 Provider Update - Medical Practitioners 2 Medical Record Documentation Guidelines (continued from previous page) All entries must be dated. The record should be legible to someone other than the author. Significant 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 identified 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 n d i n g s. Treatment plans must be consistent with diagnoses. Avoid even the appearance of record falsification! 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 HMO providers are The Children s Plan providers HMSA s The Children s Plan is one of the plans covered under HMSA s Health Center agreements. Therefore, HMO providers are participating providers in The Children s Plan network. 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. Converted to the new CMS 1500 yet? Effective 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.

3 February 2008 Provider Update - Medical Practitioners 3 Billing and Coding MAC fee changes The Maximum Allowable Charge (MAC) for the following CPT code has increased, effective January 1, CPT Code Description Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use New MAC $ The MAC for the following CPT codes will increase effective February 1, CPT Code Description New MAC Typhoid vaccine, Vi capsular polysaccharide (ViCPs), for intramuscular use $ Yellow fever vaccine, live, for subcutaneous use $ Pneumococcal polysaccharide vaccine, 23-valent, adult or $32.27 immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use $ Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 $ (tetravalent), for intramuscular use Japanese encephalitis virus vaccine, for subcutaneous use $ The MAC for the new HCPCS code for ranibizumab (Lucentis) is effective January 1, HCPCS New Code Description MAC J2778 Injection, ranibizumab, 0.1 mg (Use this code for Lucentis) $ Place of treatment changes Effective 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 effective on that date. CPT codes and will be removed from the outpatient list. CPT code will be added to the office list. CPT codes and will be added to the outpatient list. More codes that do not meet payment determination criteria The following codes that are new for 2008 were added to the Codes That Do Not Meet Payment Determination Criteria table. CPT codes: 27416, 28446, 83993, to 95982, and HCPCS codes: A9277 and A9278.

4 February 2008 Provider Update - Medical Practitioners 4 Policy Changes Annual review of medical policies The following policies have undergone annual review 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 (The 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. Panitumumab (Vectibix) new policy effective April 1 Panitumumab (Vectibix) is approved for the treatment of patients with metastatic colorectal cancer. It may be considered medically necessary when: The drug is recommended by an oncologist, and The disease continues to progress on or following chemotherapy. Precertification is required. Precertification 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. This policy will be effective April 1, For a complete version of this new policy, refer to the Provider E-Library. 3D Reconstruction new policy effective April 1 3D renderings may be considered medically necessary for specific clinical situations. This technology is used in radiology settings such as CT, MRI, ultrasound or echocardiography. guidelines indicate and should not be reported in association with specific codes listed in the CPT code book and in HMSA s medical policy. CPT codes and should be billed for these services. Physician supervision is considered part of the 3D services and should not be billed separately. Specific exclusions may apply. CPT This policy is effective April 1, For a complete version of this new policy, refer to the Provider E-Library.

5 February 2008 Provider Update - Medical Practitioners 5 High-dose chemotherapy policies effective April 1 HMSA has developed policies for high-dose chemotherapy and stem-cell transplants that will be effective April 1, These policies are based on the Blue Cross and Blue Shield Association s high-dose chemotherapy policies. and Allogeneic Stem- Cell Support for Genetic Diseases and Acquired Anemias and Allogeneic Stem-Cell Support for Myelodysplastic Diseases and Autologous Stem-Cell Support for Autoimmune Diseases, Including Multiple Sclerosis and Autologous Stem-Cell Support for Malignant Astrocytomas and Gliomas and Hemopoietic Stem-Cell Support as a Treatment of Germ-Cell Tumors and Hematopoietic Stem- Cell Support for Epithelial Ovarian Cancer and Hematopoietic Stem- Cell Support for Hodgkin s Disease and Hematopoietic Stem-Cell Support for Miscellaneous Solid Tumors in Adults and Hematopoietic Stem- Cell Support for Non- Hodgkin s Lymphomas and Hematopoietic Stem- Cell Support for the Treatment of Chronic Myelogenous Leukemia Plus Hematopoietic Stem- Cell Support to Treat Primary Amyloidosis or Waldenstom s Macroglobulinemia with Hepatopoietic Stem- Cell Support as a Treatment of Acute Lymphocytic Leukemia Cell Support for Acute Myelogenous Leukemia Cell Support for Breast Cancer Cell Support for Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma Cell Support for Primitive Neuroectodermal Tumors (PNET) for the CNS and Ependymona 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. Spinal cord stimulators for pain management new policy effective April 1 Spinal cord stimulators deliver low voltage electrical stimulation to the dorsal columns of the spinal cord to block pain. Precertification is required. This policy will be effective April 1, The complete version of this policy is available in the E-Library.

6 February 2008 Provider Update - Medical Practitioners 6 HMSA s 65C Plus Updated 65C Plus member notices go into effect February 12, 2008 The 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) The NOMNC form (CMS 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) The DENC form (CMS B) is issued by the facility when members appeal directly to the Quality Improvement Organization (QIO) about the reduction or discontinuation of their SNF, HHA or CORF services. Notice of Denial of Medical Coverage (NDMC) The NDMC (CMS 10003) is issued by the facility when the decision is made to deny, reduce or discontinue SNF, HHA or CORF services. More specifically, the NDMC is issued when: Medicare benefits are exhausted, Medicare admission is denied, Non-Medicare covered services are denied, or There 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 effective 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, Forms are available for immediate use in the Provider E-Library (Forms Index) in PDF format. These 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, including the instructions for each of these forms, can be accessed at Expediting appeal of facility discharge 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.

7 February 2008 Provider Update - Medical Practitioners 7 PBS Second Opinion, Season Two, begins January 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. This 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 This disease affects 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. This 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. The causes and consequences of this condition and the steps people can take to protect themselves from this lifethreatening 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. This 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 suffer from back pain some time in their lives. Watch this episode for a common-sense discussion about this all-too-common ailment. (continued on next page)

8 February 2008 Provider Update - Medical Practitioners 8 PBS Second Opinion, Season Two, begins January (continued from previous page) Colon Cancer March 23 This 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 significantly reduce the risk. Asthma April 6 Between 15 and 20 million Americans (5 million are children) suffer 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 effects.