News from NEPHO – APRIL 2021 Edition


Peter Dresens, MD
Beverly Anesthesia Associates
480 Maple Street Suite C233 A
Danvers, MA 01923
978-304-8690 (F) 978-304-8697


  • Thomas Pearce, MD will be transitioning to MDVIP only effective June 30, 2021.
  • Roy Ruff, MD of North Shore Preventative Health, PC, will be retiring effective May 14, 2021.
  • Kevin Ollington, MD of Northshore GI will be leaving the practice effective September 25, 2021.
  • Poonam Doshi, MD of Specialized Pediatric Eye Care, will be leaving the practice effective June 30, 2021.

The Northeast PHO Podiatrists are included in the Referral Simplification process for BCBS, HPHC and Tufts Health Plan. Practices included are as follows:

  • Beverly Podiatry
  • Coastal Orthopedic Associates
  • Foot and Ankle Clinic of Danvers
  • Jewett Podiatry Center
  • Matthew P. Butler, DPM
  • NPA Cape Ann Foot & Ankle
  • Peabody Podiatry 
  • Podiatry Health Care, PC

If you have any questions or concerns regarding this update, please contact Ann Cabral at or 978-236-1758.


A Message to Medicare ACO Practices from the Northeast PHO Care Management Team:

Recently the performance network made communication changes to better cover the PHO primary care practices including a change in telephone numbers.

Effective April 1,2021 the PHO Medicare ACO care management team assigned to your practice can be contacted as follows:

Diane Hannify-Broughton RN
978-307-6307 ext. 1771

Sandra Pajarillaga LICSW
978-307-6307 ext. 1731

Deirdre Putnam LICSW
978-307-6307 ext. 1763

As always, we are here to assist you with the care management of your Medicare ACO population. We can be reached via telephone, email or Epic inbasket. Please don’t hesitate to reach out with any questions or concerns.

Thank you,

The PHO Care Management Team


Date: Wednesday, May 12, 2021 @10:30–11:30am
Optimize Reimbursement with Telehealth
GoogleMeet Conference Call

Date: Wednesday, May 26, 2021 @10:30–11:30am
Risk Adjustment Coding Capture Review
GoogleMeet Conference Call

Date: Wednesday, June 16, 2021 @11:30am–12:30pm
Coding Diabetes With Complications Overview
GoogleMeet Conference Call

Date: Wednesday, July 14, 2021 @11:30am–12:30pm
Coding and Billing – Sneak Peek at 2022
Location: GoogleMeet Conference Call

Date: Wednesday, May 12, 2021 @5:30pm
GoogleMeet Conference Call
RSVP: or 978-236-1784






  • PCPs will receive combined quality performance data at the practice level (periodically) and provider level (monthly) by measure.
  • Telehealth visits with diabetes patients present good opportunity to close care gaps.
  • Virtual blood pressure trainings for MAs were completed. A recording will be sent out to be shared with folks who could not attend.


  • Dr. Peppe invited discussion on ways the PHO can support practices.


  • BCBS PPO Attribution Methodology was shared.
  • Encourage regular well visits to ensure that patients are attributed to the correct PCP.


  • There is a pilot program for patients being discharged from the hospital, starting with total hip and total knee replacements.


Blue Cross Blue Shield of Massachusetts

Authorization Requirements by Products

BCBSMA has posted an updated Authorization Requirements by Products. Click here to view the complete list.

Harvard Pilgrim Health Care

Revised Payment Policy: Evaluation and Management

The Payment Policy has been revised. Added requirements for time-based coding, removed reference to total time for prolonged codes. To view the complete policy, click here.

Revised Payment Policy: Pain Management for Non-Anesthesiologists

The Payment Policy has been revised. Updated Provider Billing Guidelines and Documentation section; removed the Biofeedback Medical Policy from the Related Policies section. To view the complete policy, click here.


New Provider Enrollment Administrative Action Authorities

This article gives providers important information about recently issued regulatory authorities. These authorities affect currently enrolled Medicare providers and suppliers, or prospective providers and suppliers. Providers and staff should be aware of these new authorities. To view the MLN Matters article, click here.

Repayment of COVID-19 Accelerated and Advance Payments Began on March 30, 2021

CMS issued information about repayment of COVID-19 accelerated and advance payments. If you requested these payments, learn how and when we’ll recoup them:

  • Identify payments we recovered
  • Prepare your billing staff

More Information:

Tufts Health Public Plan

Online Claim Submission Function

Providers contracted with Tufts Health Together –MassHealth MCO Plan and Accountable Care Partnership Plans (ACPPs) and Tufts Health RITogether now have the ability to submit online claim adjustments (corrections, disputes and return of funds) in the secure Provider portal currently utilized by all other Tufts Health Plan lines of business (Commercial products [including Tufts Health Freedom Plan] and Senior Products).

For additional information, updates and instructions, refer to the frequently asked questions (FAQs), the Tufts Health Plan Secure Provider Portal User Guide, and the Online Claim Adjustments user guide.

Reminder of Recent Changes 

As a reminder, effective for dates of service on or after April 1, 2021, the following changes were implemented:

Notification: Notification is required within 2 business days of the admission for the following:

  • Urgent/emergent inpatient admissions and post-acute admissions
  • Diagnoses and treatment related to COVID-19 or suspected of having COVID-19 contraction

Prior Authorization:

  • Prior authorization is not required, for diagnoses and treatment related to COVID-19 or suspected of having COVID-19 contraction, including for transfers to post-acute non-hospital facilities and home health care.
  • The following prior authorization requirements are reinstated and apply to all diagnoses, except for a COVID-19 diagnosis:
    • Prior authorization is required for non-hospital locations for post-acute care (i.e. inpatient rehab, LTAC, skilled nursing facilities and home care), including following an inpatient hospital admission.
    • Prior authorization requirements will be reinstated for hospice services.
  • For Massachusetts Commercial Products and Tufts Health Direct, prior authorization requirements will be reinstated for any inpatient treatment or outpatient scheduled surgeries or admissions to acute care hospitals or mental health hospitals.
  • Refer to the benefit-specific payment policies located in the Provider Resource Center for additional information.

Concurrent Review:

  • Concurrent review requirements will be reinstated for Massachusetts Commercial Products and Tufts Health Direct for all inpatient treatment (including inpatient hospice services) and outpatient scheduled surgeries at acute care hospitals or mental health hospitals. Pre-COVID processes should be followed.

Tufts Medicare Preferred

As a result of the 5-Star rating* given to the Tufts Medicare Preferred HMO plans by Medicare, your eligible patients can enroll in these plans all year long. Tufts Health Plan achieved a 5-Star CMS Quality rating for 2021 — now for six years in a row! Tufts Health Plan is one of only two plans in the country to achieve 5 Stars for six consecutive years. What does this mean for your patients and our members?

Our 5-Star rating gives patients the freedom of a special election period where they can enroll into one of our plans outside of Medicare’s Annual Election Period. Tufts Medicare Preferred HMO and Senior Care Options plans received 5 stars in several measures including:

  • Staying Healthy: Screenings, Tests and Vaccines
  • Member Experience with Health Plan
  • Health Plan Customer Service

What this means for members is they are not obligated to remain in whatever plan chosen. If life changes and a member needs new/different coverage, our 5-star rating gives the freedom to use one additional opportunity (outside of the annual enrollment period) to move to one of our other plans.

We have the largest Medicare Advantage membership in Massachusetts, with 97% of our members staying with us year after year. In these uncertain times, Tufts Health Plan Medicare Preferred HMO is a 5-Star rated plan you can trust.

For the most up-to-date information about Tufts Health Plan’s policies and coverage pertaining to COVID-19 including testing and treatment, telehealth, billing guidelines, etc., please click here.

We also offer Tufts Medicare Preferred Supplement plans and, for participating providers, Tufts Health Plan Senior Care Options (SCO). Tufts Health Plan SCO (which also has a 5-Star rating) may be a great option for patients who are 65+ and on MassHealth Standard and continues to offer monthly enrollment. With SCO, members get more benefits than MassHealth and Original Medicare, plus free extras, all at no cost. If you have questions or need digital or physical marketing materials for your practices, please contact Marcel Philippe, Manager of Business Development, Senior Products Division, Tufts Health Plan, Cell: 617-417-2587.

*Medicare evaluates plans based on a 5-Star rating system. Star ratings are calculated each year and may change from one year to the next. Visit for more information.


Please take a moment to look at our Provider Spotlight on the website by clicking here.

If you would like to be featured on the PHO website, please reach out to Alycia Messelaar or 978-236-1784.

Interested in being Featured?

The Northeast PHO Provider Relations Department is excited to have you as part of our network of physicians!

In an effort to spread the word about the services you currently or will be providing, we would like to obtain information to be used to host virtual introductions, virtual drop-in sessions, a video to be posted on the NEPHO website, along with a provider spotlight bio to share with the NEPHO Primary Care Providers. Click here to be directed to our Virtual Networking page.

Please send requested marketing materials to Alycia Messelaar,, in order to begin the marketing process.

Thank you,
The NEPHO Provider Relations Department

Please provide the following to create a 1-3 minute video about yourself.  This can be done right from your smartphone!  Please see Tips for Shooting better video on your smartphone.

Short bio (In paragraph format that includes the following information – please do not send a copy of your CV)

  • Name
  • Practice
  • Specialty
  • Ages treated
  • Education/Training
  • Past professional experience
  • Special interests
  • Whether you offer telehealth services
  • Personal hobbies
  • Professional photograph
  • Best hours and days to set up brief virtual meetings with PCP practices that are interested in speaking with you directly
  • Best ways to reach out directly regarding patient specific care questions

Please reach out to Alycia Messelaar, 978-236-1784 or to keep NEPHO informed of changes in practice schedules due to COVID-19 (office closures, limited office hours, scope of appointment, telehealth use, phone line to reach staff, etc.) or if you have questions about other practice schedules.

Click here to access a list of practices who are scheduling in office visits and/or TeleHealth visits at this time. The PHO has discontinued sending the bi-weekly emails outlining this information. Please review your practice information and reach out to Alycia Messelaar, with update requests.  The updates will be included in this section in the next newsletter.


Janelle Jensen, NEPHO Provider Relations and Enrollment Coordinator, will be going on leave May 2021. Please direct all questions and enrollment needs to Alycia Messelaar, 978-236-1784 or



A Few Mental Health Facts 

* 1 in 5 adults in America experiences a mental illness.
* Nearly 1 in 25 (10 million) adults in America face the reality of living with serious mental illness.
* One-half of all chronic mental illness begins by the age of 14; three-quarters by the age of 24.
* Approximately 10.2 million adults have co-occurring mental health and addiction disorders.

Unlike many diseases and disorders, mental health can be difficult or uncomfortable to discuss. Sometimes we don’t know a loved one or friend has a mental health issue until something drastic happens. Most mental health issues live in silence. The more we continue to talk about them, the more we can end the stigma.

How the Coronavirus and Social Distancing Has Contributed to More Mental Health Problems:

We all had problems and issues before the pandemic hit. It wasn’t as if the old normal was perfect. When the pandemic hit, many of us were forced to deal with our own thoughts. With extra time, thoughts we suppressed by being busy were now in the open.

Which is why we should and need to prioritize mental health for ourselves and loved ones.

What Affects Our Mental Health?

Suppression: The stigma of mental health can lead to fear and judgment, which leads to suppressing feelings. We all have problems and it’s important to work through them.

Stress: Stress is stress. It can come from anywhere from personal life, work, running, or anything.

Social Isolation: Most people don’t want “social isolation” forever. The feeling of loneliness is challenging for anyone.

Trauma: Trauma can come in many different forms: being a victim of a crime, neglect, military experience, or any serious incident.

Physical Health: Lack of exercise, proper nutrition, and even sleep play a role in our mental health. Sleep is one of the most overlooked factors!

Social Media Overload: Most of us have found ourselves on screens more. Take breaks from social media and allow yourself to be disconnected. Social media makes it easy to compare ourselves to others, but it also can cause you to be bogged down by bad news.

Here Are a Few Ways You Can Help Your Mental Health:

Physical Health: Finding a routine that gets you out the door to get some movement is essential for mental health. The key is finding something you like. If walking with your family is enjoyable, do that! If you like running or lifting weights, do that.

Nutrition: Nutrition plays a role both mentally and physically. It’s important to eat well, but it’s also important not to be strict. You don’t want to deprive yourself, but you do want to have a well-balanced diet to provide nutrition.

Sleep: Sleep is the most underrated physical and mental aspect. Throw out social norms and if getting to bed at 8 pm works for you and your family, do so. If you take anything from this, it’s getting more sleep. Try to turn off social media by 8 pm. Don’t answer texts or scroll through social media…just relax.

Get Outside: Fresh air and Vitamin D can help mental health in a big way. If the weather allows, make sure to spend some time outdoors each day. Even just 30 minutes a day can help your mental and physical health.

Reach Out: Even if you aren’t able to see relatives and friends in person, make sure to reach out. Staying connected digitally is easier than ever. Know the signs and reach out if you or a loved one needs help.

With many people social distancing alone, it’s more important than ever to maintain contact with loved ones. You never know who is living with a mental illness. No one should suffer alone. If you find yourself uncomfortable talking about your mental health, find someone who makes you feel comfortable.

Remember, no one’s life is perfect and we all have things we are dealing with. Many therapists are doing virtual meetings. It’s okay to seek help.

Ask for Help: Finding the right therapist for you can be tricky. Like a running shoe or coach, there is no best therapist for everyone. Finding someone that meshes well with your personality can take time, but having an unbiased person to help work through your feelings and emotions is one of the best things you can do for yourself.

If you don’t know where to start, here are a few places to start:

NAMI or National Alliance on Mental Health

National Institute of Mental Health

National Institute of Health


New Quality Measure for 2021 – HPV Immunizations for Adolescents

Blue Cross has retired the 3 Well Child visit measures for 2021. Instead, there is a new measure for the adolescent population: HPV Immunization for Adolescents. The details are as follows:

  • The HPV Immunizations for Adolescents measure calculates the percentage of adolescents, both girls and boys, who had HPV vaccines at least 146 days apart between their 9th and 13th birthdays.
  • The denominator includes patients who turn 13 in 2021.
  • Exclusions include patients who are in hospice or who have not had the first vaccine due to an allergic reaction to the components of the vaccine. 
  • Minimum threshold is 16.8%. Maximum threshold is 48%. Current 2020 performance is 12.1%. 

The Quality Team will provide each practice with a list of their patients in the measure who are due for immunization. Please contact Laureen Viel 978-236-1746, or Jennifer Andersen 978-236-1747, with questions.


OPTUM Newsletter – April 2021 | Endocrine and Metabolic Disorders

Medicare recently announced a second quarter update to the HCPCS Level II code set used for reporting products, supplies, and services. 23 codes are added to these categories and additionally, six codes are revised and 12 are discontinued, effective April 1, 2021. The 2021 Official HCPCS Level II Codes are an essential key to quality measures, durable medical goods, injectable drugs, outpatient surgery, and other areas related to coding and billing.

The Quarter 2 HCPCS Level II Code Updates Include the following:

New Codes:

  • A9592 Copper cu-64, dotatate, diagnostic, 1 millicurie
  • C9074 Injection, lumasiran, 0.5 mg
  • C9777 Esophageal mucosal integrity testing by electrical impedance, transoral (list separately in addition to code for primary procedure)
  • G2020 Services for high intensity clinical services associated with the initial engagement and outreach of beneficiaries assigned to the sip component of the pcf model (do not bill with chronic care management codes). CMS recommends that the G2020 service must be provided and billed at least one day before any other services subject to the flat visit fee may be reimbursed accordingly.
  • G2172 All-inclusive payment for services related to highly coordinated and integrated opioid use disorder (oud) treatment services furnished for the demonstration project
  • J1427 Injection, viltolarsen, 10 mg
  • J1554 Injection, immune globulin (asceniv), 500 mg
  • J7402 Mometasone furoate sinus implant, (sinuva), 10 micrograms
  • J9037 Injection, belantamab mafodontin-blmf, 0.5 mg
  • J9349 Injection, tafasitamab-cxix, 2 mg
  • K1013 Enema tube, any type, replacement only, each
  • K1014 Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control
  • K1015 Foot, adductus positioning device, adjustable
  • K1016 Transcutaneous electrical nerve stimulator for electrical stimulation of the trigeminal nerve
  • K1017 Monthly supplies for use of device coded at k1016
  • K1018 External upper limb tremor stimulator of the peripheral nerves of the wrist
  • K1019 Monthly supplies for use of device coded at k1018
  • K1020 Non-invasive vagus nerve stimulator
  • M0245 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring
  • Q0245 Injection, bamlanivimab and etesevimab, 2100 mg
  • Q2053 Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose
  • S1091 Stent, non-coronary, temporary, with delivery system (propel)

Revised Codes:

  • C9761 Cystourethroscopy, with ureteroscopy and/or pyeloscopy, with litotripsy, and ureteral catheterization for steerable vacuum aspiration of the kidney, collecting system, ureter, bladder, and urethra if applicable
  • G9868 Receipt and analysis of remote, asynchronous images for dermatologic and/or ophthalmologic evaluation, for use only in a Medicare-approved cmmi model, less than 10 minutes
  • G9869 Receipt and analysis of remote, asynchronous images for dermatologic and/or ophthalmologic evaluation, for use only in a Medicare-approved cmmi model, 10-20 minutes
  • G9870 Receipt and analysis of remote, asynchronous images for dermatologic and/or ophthalmologic evaluation, for use only in a Medicare-approved cmmi model, more than 20 minutes
  • J7321 Hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose

Deleted HCPCS Level II Codes

  • C9068 Copper cu-64, dotatate, diagnostic, 1 millicurie
  • C9069 Injection, belantamab mafodontin-blmf, 0.5 mg
  • C9070 Injection, tafasitamab-cxix, 2 mg
  • C9071 Injection, viltolarsen, 10 mg
  • C9072 Injection, immune globulin (asceniv), 500 mg
  • C9073 Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose
  • C9122 Mometasone furoate sinus implant, 10 micrograms (sinuva)
  • J7333 Hyaluronan or derivative, visco-3, for intra-articular injection, per dose
  • J7401 Mometasone furoate sinus implant, 10 micrograms
  • K1010 Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each
  • K1011 Activation device for intraurethral drainage device with valve, replacement only, each
  • K1012 Charger and base station for intraurethral activation device, replacement only

Please review the new, revised, and deleted codes to ensure your chargemaster is updated with current billing and coding to ensure accuracy in reimbursement. Reach out to Shawn Bromley at or 978-236-1704 if you have questions related to coding and billing.


Blackburn Primary Care – 1 Blackburn Drive

  • I love Dr. Jay Isaac. He is always kind, patient, takes the time I need during all appointments.

Lahey Primary Care, Beverly – 30 Tozer Road

  • I am very happy to have Dr. Neeraj Mahajan as my PCP – thank you!

Lahey Primary Care, Beverly – 100 Cummings Center

  • Dr. Khalil Shahin is the man! Love this guy. Well educated, knowledgeable and willing to listen and talk to me.

Lahey Primary Care, Danvers – 5 Federal Street

  • Dr. Margaret Legner and her office staff, PA and assistants have been offering excellent professional services whenever I been in for  help at any time. So I am grateful!

Lahey Health Primary Care, Gloucester 298 Washington Street 4th Floor

  • Dr. Victor Carabba and his staff provided me with an appointment immediately and assumed responsibility for my life. I feel confident I am in good hands!

Lahey Primary Care, Manchester 192 School Street

  • Dr. Nicholas Avgerinos is great – the staff is efficient & courteous.

North Shore Pediatrics – 480 Maple Street

  • Dr. Maureen Mathews is fantastic! And always is! She is realistic, truthful and personable. She always cares for us as if we’re her only patients! We love her!

Candace Thompson, MD9 E Dr Osman Babson Road

  • Dr. Candace Thompson is a wonderful health care provider. Her staff is A++. Thank you.


The Northeast PHO recognizes colleagues who provide a positive experience for our patients, help us keep care local and meet our quality targets.

This month’s winners are:

Amanda Budrow Lahey Health Primary Care, Gloucester, was recognized for the patient experience comment “Everyone at Dr. Hollett’s was super nice to me each time I have gone to see her.”

Cynthia Sonia, Lahey Health Primary Care, Beverly, was recognized for collaborating with the NEPHO Quality Team to create virtual MA Blood Pressure Training and implement Diabetes Pre Visit Planning.

Amanda Budrow and Kathryn Hollett, MD

Cynthia Sonia and Daniel McCullough, MD

Please let us know if you would like to nominate a team member in your practice or another practice for the recognition program. We will deliver gift cards to the winners each month, and they will be announced here and in our website “Hot Topics” section.

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