85 Herrick Street
Beverly, MA 01915
(P) 978-922-3000 (F) 978-927-3534

77 Herrick Street Suite 203
Beverly, MA 01915
(P) 978-998-4601 (F) 978-998-4973

480 Maple Street Suite C233 A
Danvers, MA 01923
(P) 978-304-8690 (F) 978-304-8697

1 Wallace Bashaw Jr. Way
Newburyport, MA 01950
(P) 978-691-5690 (F) 978-216-6895

480 Maple Street Suite C233 A
Danvers, MA 01923
(P) 978-304-8690 (F) 978-304-8697


Kyle Lacy, MD of Coastal Orthopedics has relocated to Sports Medicine North 1 Orthopedic Drive Peabody, MA 01960 effective 4/16/2019

Kevin Ennis, MD and Neil Mann, MD of The Center for Healthy Aging will no longer provide primary care services effective 4/6/2019

Sports Medicine North 1 Orthopedic Drive Peabody, MA 01960 now offers same day urgent care visits for orthopedic trauma

Dan Dolan, MD of Northeast Emergency Associates has resigned

Zaven Jouhourian, MD will be practicing (Saturdays) at Cape Ann Medical Center 1 Blackburn Drive Gloucester, MA 01930
978-281-1500 (F) 978-281-3611


SAVE THE DATE                                                     ATTENDANCE REMINDER


Date:  May 13,  2019 @5:30 P.M. (CANCELLED)
Place: 500 Cummings Center, Ste. 6500
Good Harbor Room Conference Room
Beverly, MA  01915
RSVP: or 978-236-1784

NP/PA MEETING – CME approved

Date: May 22, 2019 @12:00 P.M. (lunch provided)
Place: Addison Gilbert Hospital
Women’s Health Conference Room
Gloucester, MA  01930
Guest Speaker: Carol Freedman, RPh
“What Providers Should Know About Patients Using Cannabis”
RSVP: Judith.O’Leary@Lahey. org or 978-236-1739

The NEPHO website is easy to navigate and can
be used to quickly check  meeting attendance.
Attendance is routinely updated by the last week
of the month. You can find the Attendance
link under any of the following website tabs:

Quick Links button
>  Provider Information
>  Meetings Calendar

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The Northeast PHO is pleased to announce that Harvard Pilgrim Health Care has awarded NEPHO the Quality Grant funding for a Pilot Telehealth Program. This pilot program will support the implementation of telehealth services to 3 NEPHO physicians. These practices include; Shawn Pawson, MD, Cape Ann Medical Center, Robert Tufts, MD, Sleep Medicine and David Greenstein, MD, Northeast Dermatology Associates.

Total funding requested and awarded is $33,500.00. These funds will help to purchase service equipment, organize practice coding and billing workflow, update practice website with telehealth service information, IT support, as well as provide resources focused on the implementation of telehealth services within each practice.

This pilot program spans over one year and offers NEPHO the opportunity to help build a telehealth program model. We will build an unique scope of services for each practice to ensure success in revenue capture, improved management of care, patient convenience, and additional access to healthcare services.

We will provide progress updates as the Telehealth Committee moves forward with implementation of this pilot program. Please contact me directly if you have questions on this exciting new program. or 978-236-1704.

Come learn more about this exciting opportunity at the 2019 NECoMG Annual Meeting



Dr. Di Lillo has retired from his Medical Director role at the Northeast PHO

Dr. Di Lillo became the Northeast PHO Medical Director in November of 2015.  He was a long-standing board member on the New England Community Medical Group and Northeast PHO boards participating as a representative on many committees and task forces.

In his years at the PHO, Dr. Di Lillo has focused on improving our contract performance related to efficiency, quality, and patient experience.  We appreciate how he has encouraged the PHO team to work more closely together to support the patients.  He will be remembered for being visible, dedicated and friendly.

Please join us in wishing Dr. Di Lillo well in his retirement.  We would like to thank him for his commitment and contributions to the PHO and hospital colleagues, providers and practices.


Performance Update
  • Stacey Keough provided an updated on LCPN Q3 Commercial contract performance, which looks better than the same time period, 2017.
Risk Share 2019
  • Stacey Keough reviewed the highlights and updates to the Physician Risk Share for 2019.
  • Carol Freedman provided a comprehensive review of cannabis, including:
    • overview of products
    • availability and access
    • drug interactions
    • information on efficacy/inefficacy
    • patient certification
    • talking points for patients using products
Patient Experience
  • Liz Isaac presented updated provider patient experience star ratings and patient comments, for timeframe January 2018 through January 2019.
  • The majority of physicians improved their star ratings with this refresh.
  • Liz provided an update that the paper process may continue beyond the initial 6 months as Lahey marketing is working on obtaining a project quote from their web vendor (Digital Artisans) and determine which website to pull the information to, as the original site (Lahey/Beverly) is planned to be sunsetted.


Boston Medical Center Health Net Plan

Policy and Prior Authorization Program Changes
Effective June 3, 2019, Boston Medical Center will institute an administrative denial process to address those circumstances in which there is insufficient clinical information to render a medical necessity decision. If the Plan outreach attempts to obtain the necessary clinical information are unsuccessful, Boston Medical Center will issue an administrative denial to the requestor. It will specify the required clinical information that the Plan will need to make an appropriate clinical decision. To view the complete notification, click here.

Fallon Health

Revised Payment Policy: Evaluation and Management
The Payment Policy has been updated. The Plan clarified policy section regarding CMS documentation requirements. To view the updated Policy, click here.

Harvard Pilgrim HealthCare

HPHC Emergency Department Overuse Program
Harvard Pilgrim is committed to improving the quality and value of care for our members, and the physicians in our network are key partners in the pursuit of that goal. In 2019, Harvard Pilgrim has made it a priority to reduce avoidable emergency department (ED) use among our members. Our approach focuses on addressing issues of access to care, offering support and information to our provider network, and educating Harvard Pilgrim members on the medically appropriate use of EDs (the Emergency Care Payment Policy in Harvard Pilgrim’s commercial Provider Manual offers information on the ED services we do and do not cover).

According to data from the Massachusetts Health Policy Commission (HPC), over half of the respondents to the 2014 Massachusetts Health Insurance Survey who had been to the ED in the past year said they had done so because they could not get a timely appointment with their usual source of care. Some potential solutions that could improve access to timely primary care include expanding provider office hours, connecting patients with retail clinics and urgent care centers, and increasing the availability of nurse hotlines and telehealth (which Harvard Pilgrim offers through our telemedicine vendor, Doctor On Demand), and granting nurse practitioners full practice authority.

Print poster link below

In the 2016 Cost Trends Report, the HPC reported that 42% of all ED visits in Massachusetts in 2015 were avoidable. As HPHC detailed in this article from the May 2018 issue of Network Matters, this sort of overuse can be combated through methods like identifying the critical characteristics of over-utilizers in this space, developing action plans with ED staff, and supporting primary care provider practices.

At the Massachusetts Medical Directors’ Meeting last spring, Harvard Pilgrim medical directors, the medical leaders of participating hospitals and provider organizations, and other local industry leaders discussed the importance of decreasing avoidable ED visits and addressed potential strategies. You can find the agenda from that meeting and a copy of the presentation on our MA Medical Director Meetings page. Additionally, the Massachusetts Employer Health Coalition has some helpful materials on appropriate ED use that you can share with your patients or hang up in your office, like this poster on when to go to an urgent care center and when to go to the emergency room.

Submitting Claims for Fidelity, Sedgwick and Nielsen
Please keep the following information in mind regarding the correct process for submitting claims for Fidelity Investments, Sedgwick Claims Management Services, and Nielsen members. As a result of the partnership Health Plans, Inc. (HPI), a Harvard Pilgrim company, has with UnitedHealthcare and UMR, HPI manages claims from Massachusetts, New Hampshire and Maine providers for Fidelity, Sedgwick, and Nielsen members, whereas UMR manages claims from Connecticut, Rhode Island, and Vermont providers for these members. This took effect on Jan. 1, 2019.

MA, NH, and ME providers
If you are a provider based in Massachusetts, New Hampshire, or Maine, please submit claims for Fidelity, Sedgwick, or Nielsen members to Harvard Pilgrim via our usual e-channels (HPHConnect, NEHEN, or NEHENNet), and we will transfer the claim to HPI for processing.

Alternatively, you can send the claim to WebMD/Change Healthcare using HPI’s EDI number (44273), or submit on paper by mailing to:
Health Plans, Inc.
P.O. Box 5199
Westborough, MA 01581

If you submitted a claim for these members to an incorrect address and received a rejection message, you must resubmit the claim to the appropriate address noted above to ensure receipt of claim and appropriate processing.

Recognizing members
You can recognize members of the Fidelity, Sedgwick, and Nielsen plans by their ID cards, which display the Harvard Pilgrim logo on the front of the card and the HPI logo on the back (see the sample below). Please note that while HPI members typically are assigned member ID numbers beginning with HH, this is not the case for the Fidelity, Sedgwick and Nielsen members.

For your reference, the group numbers for these accounts is as follows:

  • Fidelity Group # 76-413512
  • Nielson Group # 76-413554
  • Sedgwick Group # 76-413489
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2019 Payment Adjustments
CMS shared resources about payment adjustments related to Merit-based Incentive Payment System (MIPS).  Medicare Part B claims will have a positive, neutral or negative MIPS payment adjustments for dates of service in calendar year 2019 based on clinicians’ 2017 MIPS final scores.  Medicare applies a payment adjustment rather than adjusting the fee schedule.  The payment adjustment is applied to the Medicare paid amount only and not the patient portion.

Please see the linked “Merit-based Incentive Payment System (MIPS) Payment Adjustment Remittance Advice FAQ ” for an overview of the code types used to explain the MIPS payment adjustments on remittance advices, including examples. For more information about the MIPS program, please refer to the “Fact Sheet: 2019 Merit-based Incentive Payment System (MIPS) Payment Adjustments based on 2017 MIPS Scores”

If you have any questions, feel free to contact Stacey Keough at or 978-816-2010.


The Northeast PHO website has been updated with the new fee schedules for AllWays Health Partners (AHP), BCBS, Cigna, Fallon, HPHC, Tufts HMO/PPO and Tufts Health Public Plans (THPP).  Please note that the THPP fees apply to their subsidized Connector plans.  The THPP MassHealth plans and BMCHP MassHealth plans are paid at 100% of the Medicaid rates.  The Medicare and Medicaid fee schedules were also updated.

Please take a moment to review the updated fee schedules on the PHO website and adjust your charges accordingly.  Please forward this information to your billing department.

Click here to access the PHO website.  Access to the fee schedules requires a login with your username and password.  Once logged into the website, the fee schedules are located under the “Provider Information” tab.

If you have any questions about the fee schedule or accessing the website, please contact Alycia Messelaar at or 978-236-1784 or Shawn Bromley at or 978-236-1704.


Prevalence of Mental Illness

  • Approximately 1 in 5 adults in the U.S.—43.8 million, or 18.5%—experiences mental illness in a given year.
  • Approximately 1 in 25 adults in the U.S.—9.8 million, or 4.0%—experiences a serious mental illness in a given year that substantially interferes with or limits one or more major life activities.
  • Approximately 1 in 5 youth aged 13–18 (21.4%) experiences a severe mental disorder at some point during their life. For children aged 8–15, the estimate is 13%.
  • 1.1% of adults in the U.S. live with schizophrenia.
  • 2.6% of adults in the U.S. live with bipolar disorder.
  • 6.9% of adults in the U.S.—16 million—had at least one major depressive episode in the past year.
  • 18.1% of adults in the U.S. experienced an anxiety disorder such as posttraumatic stress disorder, obsessive-compulsive disorder and specific phobias.
  • Among the 20.2 million adults in the U.S. who experienced a substance use disorder, 50.5%—10.2 million adults—had a co-occurring mental illness.


Consequences Of Lack Of Treatment

  • Serious mental illness costs America $193.2 billion in lost earnings per year.
  • Mood disorders, including major depression, dysthymic disorder and bipolar disorder, are the third most common cause of hospitalization in the U.S. for both youth and adults aged 18–44.
  • Individuals living with serious mental illness face an increased risk of having chronic medical conditions. Adults in the U.S. living with serious mental illness die on average 25 years earlier than others, largely due to treatable medical conditions.
  • Over one-third (37%) of students with a mental health condition age 14­–21 and older who are served by special education drop out—the highest dropout rate of any disability group.
  • Suicide is the 10th leading cause of death in the U.S., and the 2nd leading cause of death for people aged 10–34.
  • More than 90% of people who die by suicide show symptoms of a mental health condition.
  • Each day an estimated 18-22 veterans die by suicide.
  • For local Behavioral Health Resources click here



Effective April 25: New Epic Best Practice Advisories (BPA)

  • There are two new BPAs that will alert primary care and behavioral health providers and support staff of patients age 12 and older who score positive (score is greater than 9) on PHQ-9 depression screening.
  • The BPAs are designed to prompt a follow up screening of these patients in 3-12 months.
  • If a patient scores greater than 9 during a current encounter, a BPA will fire prompting the provider to schedule a follow-up appointment for a repeat PHQ-9 screening in 3-12 months.
  • If the patient has had a PHQ-9 greater than 9 in the previous 3-12 months, a BPA will fire to staff and providers prompting a follow-up PHQ-9 screening during the current visit.
  • These BPAs are important tools to help support depression screening and timely follow-up, and is a process that is measured as a quality care indicator by many health plans.
  • Click on this link to see screenshots of the new BPAs:


Reconciliation, deprescribing and 2019 Updated Beers Criteria for Potential Inappropriate Medications (PIM) in Older Adults

Reconciliation of patients’ medication lists should be completed at each office / telehealth visit and at all transitions of cares points such as ER visits, hospital / SNF admission and discharges. During medication reconciliation, it is important to identify medications that may be potentially inappropriate medications (PIM) for older adults.  Recently, the American Geriatrics Society updated the Beers Criteria to assist in addressing some of these medication issues.  In addition, consider deprescribing medications that have no indication and/or may need dosing adjustments for older adults.

Measles FAQs
The U.S. has seen more cases of measles (465) in the first 3 months of 2019 than all of 2018, according to the Centers for Disease Control and Prevention (CDC).  This is the second-greatest number of cases reported in the U.S. since measles was eliminated in 2000. Although Massachusetts is one of the states with reported cases, it is not considered a “measles outbreak” (defined as 3 or more cases). Outbreaks have been linked to travelers who brought measles back from other countries such as Israel, Ukraine, and the Philippines, where large measles outbreaks are occurring.  Click here for FAQs.

Angiotensin II receptor blocker (ARB) Update

The FDA has recalled and/ or removed ARB drug products from the market over several months with impurity levels of nitrosamine above acceptable limits. See the recent  FDA’s Assessment of Currently Marketed ARB drug products  which have been tested and reveal overall nitrosamine as “not present”. In addition, products that have incomplete assessment or impurity levels above acceptable limits are denoted “TBD”.

Please contact Carol Freedman, Pharmacy Manager, at or 978 236 1774 for questions.


OPTUM Newsletter – April is Alcohol Awareness Month

Evaluation and Management Coding Best Practices

The evaluation and management (E/M) patient visit is the core of all physician practices.  Physicians and other qualified providers can maximize payment and reduce stress associated with audits by understanding how to properly document and code E/M patient visits.

Evaluation and management services are a category of CPT codes and are used for billing purposes. The majority of patient visits require an E/M code. There are different levels of E/M codes, which, among other things, are determined by the visit complexity and documentation requirements.

Effective January 1, 2019 Medicare allows physicians to document review and verification of any history entered into the medical record by ancillary staff or the beneficiary in lieu of re-entering that information. For established patients only, history and examination already contained in the medical record need not be re-entered. Rather, the physician may document what has changed and pertinent items that have not changed since the last visit.

The basic principles for E/M documentation are as follows:

  • The medical record should be complete and legible
  • Documentation should include reason for the encounter, relevant history, physical examination, findings, prior diagnostic test results, assessment, and clinical impression, or diagnosis, plan for care, date and legible identity of the observer.
  • If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred
  • Past and present diagnosis should be accessible to the treating and/or consulting physician
  • Appropriate health risk factors should be identified
  • The patient’s progress, response to and changes in treatment, and revision for diagnosis should be documented
  • The CPT and ICD-10 codes reported on the claim should be supported by the documentation in the medical record

E/M Coding and the Documentation Guidelines: Putting It All Together:

Key components that make up an established patient visit are History (HPI), Exam and Medical Decision Making (MDM). An established patient visit will need to have 2 of 3 key components and must meet medical necessity.

The underlying problem for wrong billing of these services includes the following:

  • Lack of understanding on how the coding system for E/M works
  • Inaccurate and incomplete documentation to support the code billed
  • Supporting medical necessity
  • Downcoding (documentation supports a higher level service code)
  • Upcoding (documentation supports a lower level service code)c

Comparison coding and billing for level 99213 and 99214:

Click to enlarge/print

Many providers are consistently undercoding for their services because they have a limited understanding of the rules.  A working knowledge of the E/M coding is the best way to ensure optimal compliance and avoid inadvertent undercoding. Providers who understand the process of E/M documentation can optimize a higher rate of return for their services. If you know how to accurately bill for your services, there is a better chance you will get paid for what you really do.

Changes Coming in 2021

  • New rules for coding based on time
  • Code based on MDM alone
  • New blended payment structure for new and established office patients
  • New minimum documentation threshold for new and established office patients
  • New G code for increased reimbursement for primary care physicians
  • New G code for increased reimbursement for non-procedural specialty care services
  • New outpatient prolonged services code with decreased time threshold
  • A great resource for E/M coding guidance is:

Please contact Shawn Bromley at or 978-236-1704 if you have questions regarding E/M coding and billing.



Brian Orr Pediatrician – 1 Blackburn Drive, Gloucester
Dr. Brian Orr and his staff truly care about my children! I feel lucky to have Dr. Orr and his staff taking
 care of my children!

Family Medicine Associates, Hamilton – 15 Railroad Avenue
Dr. William Medwid
is a compassionate and highly skilled physician!
Dr. Hugh Taylor is like visiting an old friend that knows everything about me.  A great man and MD!

Garden City Pediatric Associates – 83 Herrick Street, Beverly
Dr. Ian Sklaver
is just what you want your doctor to be – knowledgeable, kind and caring!

Lahey Health Primary Care, Beverly – 100 Cummings Center
Dr. Pierre Ezzi
has been my PCP for more than a decade and I am totally satisfied with my level of care.
I am very pleased with the practice and staff.

Lahey Health Primary Care, Beverly – 30 Tozer Road
I have been going to Dr. Susan Deluca since she opened her practice. She is very caring and provides
the best possible answers.  She is an excellent doctor!

Lahey Health Primary Care, Danvers – 480 Maple Street
Dr. Kristina Jackson
and her staff are very professional.
Dr. Manju Sheth is the best doctor I have ever had in my sixty years of age.  She is amazing, kind,
caring and very bright!

Lahey Health Primary Care, Danvers – 5 Federal Street
Dr. Mauri Cohen is an outstanding physician, caring, compassionate and thorough.

Lahey Health Primary Care, Gloucester – 298 Washington Street
Dr. Victor Carabba is an excellent communicator (eye contact, listening and clear speaking)  He is always
encouraging – I recommend Dr. Carabba to my family, friends, and even my mother-in-law.
I am completely satisfied with Dr. Amy Esdale and her entire staff.

Mindful Medicine, Beverly – 900 Cummings Center, Ste. 218
Dr. Spencer Amesbury shows respect and courtesy to their patients in need.

North Shore Pediatrics  – 480 Maple Street, Danvers 
Dr. Shannon Dufresne never rushes us and is always helpful.

North Shore Preventive Health Care – 75 Herrick Street, Beverly 
Dr. Roy Ruff is extremely compassionate, knowledgeable and skilled.

Thomas Pearce, MD – 279 E. Main Street, Gloucester 
Dr. Pearce always takes his time to listen to concerns.


The Northeast PHO recognizes colleagues who provide a positive experience to our patients, help keep care local, and meet our quality targets. We appreciate their efforts in supporting the PHO goal to provide high quality, community health care. We will deliver gift cards to the winners each month, and they will be announced here in the newsletter.

This month’s winners are:

Jenn Lavy, Cape Ann Medical Center, was recognized for
her patient experience comment “Always greets me with a smile!”

Traci Cushman, Garden City Pediatrics Associates, was recognized for assisting with a project to collect data for quality measures.

Sue Henry, North Shore GI, was recognized for excellent patient outreach efforts scheduling needed colonoscopy procedures.

Be sure to look for the new winners in next month’s issue!