News from NEPHO – DECEMBER 2021 Edition


No new providers at this time.


  • Syed Quadri, MD of Lahey Clinic Inc., Thoracic Surgery Department has resigned effective 10/1/2021
  • Effective 1/26/2022, Gary Rogers, MD of University Skin Oncologists will be relocating from the Oncology Building, 85 Herrick Street, Beverly, MA 01915 to the Women’s Health Building, 83 Herrick Street, Suite 2003, Beverly, MA 01915 Phone: 978-524-7933 Fax: 978-524-7954


Coding and Billing Webinar
Continuing a Successful Telehealth Program in 2022

Date: Wednesday, January 12th @ Noon
Location: Teams Meet

Speaker: Dr. Gross,
Title: Pre- and Post-Exposure Prophylaxis for HIV
Wednesday, January 19th @ Noon
Location: Teams Meet

Coding and Billing Webinar
Social Determinants of Health (SDOH) Coding Capture Overview

Date: Wednesday, January 26th @ Noon
Location: Teams Meet

Coding and Billing Webinar
Risk Adjustment Coding Capture 2022
Wednesday, February 9th @ Noon
Location: Teams Meet


AllWays Health Partners

Telehealth Policy

Last month, we announced that we would return to pre-pandemic payment policies for certain telehealth services on 1/1/2022. This decision was based on state law (Chapter 260) and related guidance. However, in response to changing needs of members and providers during the COVID-19 pandemic, we will not be reverting to pre-pandemic telehealth policies in January. We will continue to monitor the situation and provide updates over the coming months. 


2022 National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services

CMS has posted the 2022 policy manual to the website. Updates to the manual are shown in red print. To view the notification including links to each chapter of the manual, click here.

CARES Act Provider Relief Fund Frequently Asked Questions

An updated document has been posted to the website. To view the information, click here.

Blue Cross Blue Shield of Massachusetts

December 2021 Medical Policy Announcements

BCBSMA posted a list of policies which include the following: 1) New and revised policies; 2) Clarified policies; 3) Retired policies. A full draft version of each policy is available only by request, to ordering participating clinician providers, one month prior to the effective date of the policy. To request draft policies, contact Medical Policy Administration at To view the list, click here.

Authorization Requirements and Credentialing Procedures Relaxed

To address health facility staffing and capacity constraints, effective as of November 18, 2021, BCBSMA is waiving authorization requirements and expediting credentialing applications through February 15, 2022. To view the complete notification, click here.

Harvard Pilgrim Health Care

COVID-19 Updates

Harvard has posted the following COVID-19 policies and procedures in mind: 1) Prior Authorization Update for MA Commercial Products; 2) Medicare Advantage Plans Coverage of COVID-19 Vaccine; 3) COVID-19 Vaccine for Children Ages 5-11. For complete details on the policies and procedures, click here.

Tufts Health Plans

Working with CareLink

The administrative services for CareLink accounts are shared between Tufts Health Plan and Cigna; however, one is selected to serve as the primary administrator for each particular CareLink account. To view the complete notification, click here.

Imaging Services Payment Policy Update (Commercial products and Tufts Health Public Plans Products)

As previously communicated, Tufts Health Plan and Harvard Pilgrim Health Care are reviewing existing payment policies and assessing opportunities for consistency, in addition to standard periodic reviews. Based on a review of the Imaging Services Payment Policy, effective for dates of service on or after January 1, 2022, Tufts Health Plan will be updating the compensation amounts for imaging services that are subject to multiple procedures reduction logic. For additional information and to view the entire notification, click here.

2022 Benefit Changes (Tufts Medicare Preferred HMO)

The attached benefit changes apply to Tufts Medicare Preferred HMO members and are effective for dates of service on or after January 1, 2022, upon the plan’s effective or renewal date. For additional information and to view the entire notification, click here.

2022 Benefit Changes (Tufts Health Plan SCO)

The attached benefit changes apply to Tufts Health Plan Senior Care Options (SCO) members and are effective for dates of service on or after January 1, 2022, upon the plan’s effective or renewal date. For additional information and to view the entire notification, click here.

Tufts Health Plan SCO Annual Training

Tufts Health Plan SCO is required to provide annual training to participating providers. To facilitate your completion of this required training, Tufts Health Plan has developed the following online educational materials:
Tufts Health Plan asks that you complete the online training and attestation by January 15, 2022. If you have any questions about the training or how to access it, please contact Tufts Provider Services at 800.279.9022. Thank you in advance for your participation.

Billing for Vaccines and Immunizations (All Products)

As a reminder, providers must submit both the administration procedure code(s) and the vaccine/toxoid procedure code(s) on the same claim. If an administration procedure code is billed without a corresponding vaccine/toxoid procedure code, the administration line will deny, and Tufts Health Plan will deny the claim and request that it be resubmitted. For additional information and to view the entire notification, click here.

Tufts Health Public Plans Member ID Cards to Be Updated

As previously communicated, and as part of the Consolidated Appropriations Act: No Surprises Act, Tufts Health Plan will be updating member ID cards.

Below you will find a mockup of the new ID cards that will be used for Tufts Health Public Direct members, per the below update. Please note that subsidized vs non subsidized will not be listed on the cards.


Things are constantly changing within NEPHO practices – it truly is inevitable. As a reminder, please reach out to the Provider Relations Department periodically to request updates or assistance in creating provider lists. Examples of frequent outreach we receive include and are not limited to:

  • Primary Care Providers with open panels for patients transitioning out of Pediatric care.
  • Primary Care Providers with open panels for Special Needs patients transitioning out of Pediatric care.
  • NEPHO PCP practice rosters used to update EMR mapping tied to billing/ referral network identification.

Please do not hesitate to reach out to Alycia Messelaar at for such requests. We are here to help bring ease to both the practices and the patients you serve.

Please click here to take a moment to read the Provider Spotlight.

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

Virtual Networking videos from NEPHO providers can be found at

Please reach out to Alycia Messelaar at if you are interested in being featured in a Provider Spotlight or Virtual Networking video.

Please reach out to Alycia Messelaar,  to keep NEPHO informed of changes in practice schedules due to the current resurge of 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 for the PDF version of the updated PHO Directory as of December 2021. For your convenience, click here for the separate Specialists Only PDF directory to refer to as needed.

Please share this directory with your office by printing or showing them how to visit us online for an easy to use directory search tool!

Note: Primary care providers (PCPs) in the BILH Performance Network no longer need to submit an administrative referral to refer Blue Cross Blue Shield of MA, Harvard Pilgrim Health Care, or Tufts Health Plan members to a specialist in the BILH Performance Network. Please reach out to Alycia Messelaar at, regarding questions pertaining to providers within the BILHPN Network. 

As a reminder, it is important to use the NEPHO Physician Directory when referring to a specialty physician. 



  • LMI has hired a full time dietician. Appointments needed within 48 hours can be made by contacting Pat Ferreira at
  • Nutrition and Diabetes Counseling services are also offered in Peabody and Burlington, booking in December. Medical weight loss is booking into end of February.
  • New England Baptist Orthopedics Program criteria for elective surgery was shared. Please refer to the meeting packet for details and a copy of the pre-procedure letter that is being sent out listing the criteria.

Follow-up November PODs

  • Non-nutritive sweeteners are not shown to help with body weight or glycemic control in patients with diabetes (limited high quality data on this topic).
  • Obesity coding (GO447) can be utilized for obesity counseling given for at least 8 minutes.


  • Results of a BILHPN pharmacy initiative to improve evidence based prescribing in patients with diabetes show improvement with NEPHO patients.
  • Threshold is set at 39.7% for 2022, based on improvement seen across the performance network (FY2022 baseline is 37.7%).


  • Compliance with screening mammograms scheduled through the concierge program is around 80% through November.
  • Patients with outstanding Cologuard tests were sent reminder letters to complete the tests. Phone outreach is planned for those who have unread MyLaheyChart messages, and for patients with soon to expire orders/kits.
  • Updated commercial quality data (claims processed through August) was shared for BCBS HMO, PPO, HPHC, and Tufts. Final DM Composite data for 2021 Performance Period was shared. Please refer to the meeting packet for details.

Population Health

  • Case based questions for Medication Over Prescribing were shared, along with reference sheets for common medication classes to consider deprescribing (and methods specific to those classes).
  • To minimize medication overload:
    • Inventory all prescription and OTC medications taken by the patient.
    • Ask about patient values, preferences and goals.
    • Create a plan of action for deprescribing.
    • Communicate the plan to other prescribers, the patient and family.


The NEPHO Quality team has been following up with patients with high blood pressure readings that were documented at recent outpatient visits. Patients were grateful for the outreach; here are some of their comments:

“I’m so glad you called me. My blood pressure was so high at my last appointment and I have been worrying about it ever since. I really appreciate the outreach.” 

“Oh that’s how you are supposed to take a home blood pressure?! I haven’t been doing it right!” (BP at goal after following how to obtain accurate BP directions). 

“Thanks for checking in on me, I appreciate the call.” 

Please continue to take and record a 2nd BP when the 1st reading is >139/>89. When adding a 2nd blood pressure in EPIC, it is important to change the date/time to reflect when the BP was actually taken. See the steps below to update date/time on 1st and subsequent BP readings in EPIC.


  1. Open Vitals
  2. Change ”taken on:” click calendar icon (select date), click clock icon (select time)
  3. Insert BP

**When adding a 2nd BP: 

  1. Click + New– located above VS fields
  2. Change ”Taken on”: change time of second BP
  3. Insert BP

Please also continue to enter BPs obtained during a telephone or virtual encounter. Use Ctrl+Shift+V to open the vitals flowsheet in EPIC.

Thank you to everyone who has collaborated with us over the past year on quality initiatives. We are aware of the many challenges that practices have faced and continue to face every day and are grateful for the work that you do.

We wish you all a Happy and Healthy New Year! 


OPTUM Newsletter – December 2021 | Focus on Chronic obstructive pulmonary disease (COPD)

Coding Tip of the Month December

NEPHO is working to close down 2021 and preparing for 2022. There are a few keys areas to make sure practices and providers are focusing on to the start of January 2022. The two priority areas include the following:
  • Hierarchical condition categories (HCCs) Coding Capture: All chronic conditions captured in 2021 will reset as of January 1, 2022.
    • Chronic conditions should be coded and captured on an ongoing basis to support quality patient care.
      • Example: A patient with Diastolic congestive heart failure and hypertension should be coded as follows annually: Chronic CHF: I50.32 and hypertension with CHF: I11.0.
    • Treatment and care for the condition needs to be supported by documentation and diagnosis capture.
      • Example: Mr. Jones is taking lisinopril and following up with Cardiology to manage his CHF I150.32.
    • All diagnoses that receive care and management during a patient encounter should be captured.
      • Example: Mr. Jones depression has been stable taking Celexa and seeing his counselor monthly. Recurrent depression would be coded as patient still on medication treatment: F33.81.
    • Conditions that are no longer active and/or not being treated should not be captured/reported. This should include problem list diagnoses that have be resolved.
      • Example: Mr. Jones Type II diabetes has resolved as he has been following a low salt diet and exercise routine. Diabetes Type II E11.9 should be updated on the problem list as “resolved” as it is no longer an active problem.
    • Capture “history of” and “status” of conditions when there is an impact on patient current care or treatment.
      • Example: Mr. Jones has history of prostate cancer. He has been cancer free for 12 years. History of prostate cancer will be captured as: Z85.46.
    • Diagnoses captured need to be supported by documentation. A diagnosis does not have to be in the assessment portion of the note. Providing a status update is sufficient to capture the diagnosis.
      • Example: Mr. Jones Type I diabetes is stable and is managed by Endocrinology. Type I diabetes E10.9 can be coded as documentation supports diagnosis capture.
  • NEPHO 2021 Risk Adjustment Workflow Most Improved Awards – NEPHO will be announcing the 3 most improved NEPHO providers in 2021 in the upcoming coming January 2022 newsletter. Areas of improvement include the following: Risk Adjustment coding workflow, Risk Adjustment coding capture, Diabetes with complication coding capture, Depression/Substance Abuse coding capture, Coding to the highest specificity, Daily pre-visit planning improvement. We are excited in recognizing our providers who worked to make adjustment in their daily workflow to improve Risk Adjustment coding capture in 2021.
  • No Surprise Billing Act: Effective January 1, 2022
    • Protects patients from receiving surprise medical bills resulting from gaps in coverage for emergency services and certain services provided by out-of-network facilities.
    • Holds patients liable only for their in-network cost-sharing amounts, and requires that the patient’s share cannot exceed in-network rates without patient consent.
    • Provides guidance for how providers and insurers can negotiate fair reimbursement for out-of-network services.
    • Includes the requirements that providers submit Good Faith Estimates to payers and that payers utilize those estimates to create and provide Advance Explanation of Benefits to members.
    • Providers can do the following to meet regulatory requirements:
      • Give patients clear and accurate estimates of authorized services before, or at, the point-of-service, so they feel more in control of their financial obligations.
      • Working with payers rather than patients for payment will be a new practice for providers.
      • The rule will require all providers to reach out to patients prior to a scheduled appointment to solicit the patient’s insurance information and then issue a “Good Faith Estimate” to the patient’s insurance plan. The estimate should include the following:
        • A description of services to be provided, whether the provider is in or out of network.
        • The contracted rate for services (if the provider is in network).
        • A description of how to access in network care (if the provider is out of network).
        • The provider’s estimate of charges and the patient’s responsibility total.
        • The patient’s status regarding deductible and out-of-pocket maximum.
      • Included in the documents released by CMS is a template for providers and healthcare facilities to use to deliver good faith estimates under the No Surprises Act. CMS says one of the documents (CMS-10791 – 11. 2. Good Faith Estimate Template) that providers can “fill in the blanks” with their own information and HHS will consider the use of the template to be in compliance with the No Surprises Act.
      • Click here for more information.

    NEPHO will be providing updated information in these two areas as we move forward into 2022. There will be Coding and Billing Webinars scheduled in mid-January 2022 to help provide guidance and answer questions related to Risk Adjustment Coding and the Surprise Billing Act. Please reach out to Shawn Bromley at if you have questions or would like to have additional education provided to your practice and/or providers.


Beverly Medical Associates, Beverly – 30 Tozer Road

  • Dr. Deborah Shih is an excellent physician and I travel from NH to see her.
  • Dr. Alyssa Handler and her team are the best I ever had. Very happy with her care. She listens and I’m doing much better after I started with her. Everybody is friendly and cordial. Helpful anytime I had a question. Could not be more satisfied!

Blackburn Primary Care, Gloucester – 1 Blackburn Drive

  • Dr. Jay Isaac and his staff are always responsive to my needs. I love using his practice. My health has improved so much due to the joint effort of Dr. Isaac and myself!

Cape Ann Medical Center, Gloucester – 1 Blackburn Drive

  • A visit to Dr. Janet Doran is always good, thoughtful & respectful. Dr. Doran has been my primary doctor for ten + years. Thanks to her!
  • Dr. Shawn Pawson is an excellent healthcare provider!

Garden City Pediatrics, Beverly – 83 Herrick Street

  • Dr. John Dean is the best ever and we always recommend him. Our daughter actually looks forward to visiting him and trusts his advice.
  • We love Dr. Erica Goldstein. She is always calm, easy to talk to and explains everything. Would recommend her!
  • Dr. Suzanne Graves is the most amazing provider, I can’t say enough about how wonderful she has been for me and my family over the last 6 years. She is so knowledgeable, very caring and very personable. Dr. Graves is just the best!

Leonard Horowitz, MD, Danvers – 7 Federal Street

  • I can’t say enough about Dr. Leonard Horowitz and his staff are incredible simply the best!

Danvers Family Doctors, Danvers – 140 Commonwealth Avenue

  • Dr. Subroto Bhattacharya – I have been with the practice for over 15 years. Office staff has always been amazing. They are so personal and always try to get an appointment for you as soon as it is available. All NP’s and Dr. Bhattacharya have always been caring, thorough and always listen to your concerns. You don’t feel rushed at your visit like other offices where your concerns aren’t heard. Great office!

Lahey Primary Care, Beverly – 900 Cummings Center

  • I feel so lucky to have Dr. Andrew Lenhardt as my GP. He is a brilliant doctor/diagnostician and really takes time to listen to what’s going on with you and explain the treatment/recommendations.

Lahey Primary Care, Beverly – 40 Tozer Road

  • Dr. Tina Waugh is an exceptional doctor. Best doctor I have ever seen. She is VERY caring and kind. She makes me feel I am the most important patient during my visit. Do not feel rushed and she is attuned to my feelings and is very informative and makes me feel so comfortable in her care. I am so lucky and blessed to be a patient in her practice.

Lahey Primary Care, Beverly – 100 Cummings Center

  • I’ve recommended Dr. Pierre Ezzi office to multiple people, all of whom have continued to go to this office. All the staff is considerate, enthusiastic and professional.
  • Dr. Khalil Shahin is AMAZING! I would definitely recommend Dr. Shahin!

Lahey Primary Care, Danvers – 5 Federal Street

  • Dr. Mauri Cohen has always provided exceptional service. Excellent primary care doctor!
  • Dr. Brent Fryling is terrific. His manner is warm and attentive, his knowledge extensive, and his listening skills excellent. He is a pleasure to meet with. The staff at BILH Primary Care is always friendly, responsive, and helpful.

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

  • Dr. Victor Carabba is a doctor’s doctor. I have recommended him to several friends/acquaintances who have incorporated him as part of their health.

Lahey Health Primary Care, Gloucester – 298 Washington Street 1st Floor

  • Dr. Karen Damico is a wonderful, caring person and Doctor. I have recommended her to others!

Lahey Primary Care, Hamilton – 15 Railroad Avenue

  • Dr. William Medwid – I always have good experiences very respectful receptionists, nurses and doctors I’m very happy with FMA!!!
  • I have always had a very good experience at FMH. Dr. Hugh Taylor is amazing, as are the nurses & everyone else!

Lahey Primary Care, Manchester – 192 School Street

  • Dr. Jana Oettinger This experience is always thorough, sensitive, caring, and I am completely confident in the care I am receiving!
  • Dr. Matthew Plosker is very personable and knowledgeable and takes the time to explain and listen to my health concerns and well being. 

North Shore Pediatrics, Danvers – 480 Maple Street

  • Dr. David Danis is a great pediatrician who has taken good care of our daughter since her birth. We would recommend him and North Shore Pediatrics to any parents in the area in need of a pediatrician.

Brian Orr Pediatrics, Gloucester – 1 Blackburn Drive

  • Dr. Brian Orr – I can’t say enough good things about this practice! Providers are always empathetic, compassionate and easy to talk to.


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:

Pat Ferreira, Lahey Outpatient Center Danvers, was recognized for collaborating with NEPHO Quality Team to improve care for patients.

Alex Kadim, Blackburn Primary Care, was recognized for his patient experience comment “Alex is amazing & friendly & goes above & beyond what regular medical assistants do.”

Pat Ferreira

Dr. Jay Isaac and Alex Kadim

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!