News from NEPHO – FEBRUARY 2021 Edition

NEW PROVIDERS

Alireza Sepehr, MD
Massachusetts Dermatology Associates
900 Cummings Center Suite 311T
Beverly, MA 01915
978-225-3376 (F) 978-560-1245

SAVE THE DATE

CODING AND BILLING WEBINARS

Date: Wednesday, March 17, 2021 @10:30–11:30am
Coding and Billing Annual Wellness Visits
Location: GoogleMeet Conference Call
RSVP: margaret.m.doyon@lahey.org

Date: Wednesday, March 31, 2021 @10:30–11:30am
Evaluation and Management (E/M) Documentation Best Practice
Location: GoogleMeet Conference Call
RSVP: margaret.m.doyon@lahey.org

NEW PHYSICIAN ORIENTATION
Date: Thursday, March 11, 2021 @7:30–8:30am
Location: GoogleMeet Conference Call
RSVP: alycia.messelaar@lahey.org or 978-236-1784

NP PA MEETING
Date – Rescheduled to: Wednesday, March 31, 2021 @12:00-1:00pm
Location: GoogleMeet Conference Call
RSVP: alycia.messelaar@lahey.org or 978-236-1784

NEW OFFICE MANAGER ORIENTATION
Date: Tuesday, March 30, 2021 @11:00am-12:00pm
Location: GoogleMeet Conference Call
RSVP: alycia.messelaar@lahey.org or 978-236-1784

OPEN MEETING I SESSIONS

Thursday, March 25, 2021 @12:30pm  │   Wednesday, March 31, 2021 @7:00am   │   Wednesday, April 7, 2021 @5:30pm

Please note: the same presentation will be repeated at each of the three Open Meeting I sessions. Attendance at more than one Open Meeting I session will NOT provide additional attendance credit.

Primary Care Physicians and Specialty Physicians will receive credit for March 2021 meetings by attending an Open Meeting I session.

Open Meeting I in March/April 2021 will not replace March pod meetings. We will be having March pod meetings.

We will NOT have October pod meetings, as we will encourage everyone to participate in Open Meeting II.

Please check the meeting calendar on our website to get the latest meeting status, notification of the Coding and Billing webinars, Specialty Specific meetings, and IPA/POD meetings.

IPA/POD SUMMARIES

QUALITY 

• Quality performance trending for 2019 and 2020 was shared, along with 2021 projection gate scores showing the impact of a reduced measure slate and expanded patient populations.
• Reducing the measure slate dramatically decreases NEPHO gate score if performance stays the same as 2019.
• The gate score projection with an expanded population impact is barely on the dashboard (0.07) and is a considerable departure from the 2019 gate score of 3.5.
• Given the importance of outcome measures, a multi-pronged performance improvement plan was proposed for HTN, DM HTN, A1c measures.
• A performance improvement plan was also proposed for HPV Vaccination and Cancer Screening Measures, as HPV is a new measure and the Cancer Screening Measures involve large numbers of patients.

POPULATION HEALTH

• An HPV case presentation was shared at February Pediatric and Family Practice pods and IPAs.
• Given considerable positive feedback on its usefulness, an aggressive timeline for the Diabetes Care Collaborative Pilot expansion is planned for February and March months. The quality team analysts will help with the continued rollout, due to Lucia Kmiec’s transition.
• NEPHO Commercial Care Managers, Amy Gibbs and Jean St. Peter attended pod and IPA meetings to discuss their role on their care team and capabilities to manage and support NEPHO providers in care of their patients.

INFORMATIONAL

• Stacey Keough presented contract updates for BCBS, Tufts and HPHC including overviews on fee schedule changes and quality and efficiency funding.
• Dr. Peppe shared highlights of the final PCP and Specialist risk share methodology for 2021.
• Detail was shared on three new quality measures: HPV Vaccination, Risk of Continued Opioid Use, and Depression Screening and Follow Up plan.
• A high level quality plan was shared for discussion and input by attendees.

PAYOR UPDATES

Centers for Medicare/Medicaid Services – Medicare

Effective January 1, for Physician Fee Schedule (PFS) payment of office and outpatient Evaluation and Management (E/M) visits (CPT codes 99201 through 99215), Medicare generally adopted the new AMA coding, language, and interpretive guidance framework. See the fact sheet (PDF) for more information, including: 1) PFS payment of Medicare’s add-on codes for prolonged office and outpatient visits (G2212) and visit complexity (G2211) and 2) Medical review when time is used to select visit level. To view the fact sheet, click here. Posted to the website 2/12/2021.

2021 Special Enrollment Period in response to the COVID-19 Emergency

Starting on February 15, 2021 and continuing through May 15, 2021, Marketplaces using the HealthCare.gov platform will operationalize functionality to make a SEP available to all Marketplace-eligible consumers who are submitting a new application or updating an existing application. These consumers will newly be able to access the SEP through a variety of channels: through HealthCare.gov directly, the Marketplace call center, or direct enrollment channels. Additionally, consumers can work with a network of over 50,000 agents and brokers who are registered with the Marketplace, along with over 8,000 trained assisters, ready to assist consumers with their application for coverage. For additional information, click here.

Fallon Health

Reminder for Submission of Corrected Claims

Specify the correction to be made on the Request for Claim Review Form fchp.org/en/providers/forms.aspx in the comments field (e.g. units, procedure, diagnosis, modifier etc.) along with any other pertinent information for review. Be sure to include all lines on the claim that should be processed in totality, not just claim line(s) to be corrected. For additional information and to view the notification, click here and scroll to related title. Posted to the Fallon Connection January 2021 Newsletter, which can be viewed here.

Harvard Pilgrim Health Care

Claims Editing Enhancements and Correct Coding Reminders

Harvard Pilgrim is enhancing existing claims editing for commercial plans to improve the overall accuracy of claims processing, effective for dates of service beginning March 1, 2021. Enhancements will include, but are not limited to, prepayment review of modifiers based on the claim details and the patient’s claim history. In advance of these claims editing enhancements, Harvard Pilgrim would like to offer the attached reminders related to correct coding and appropriate reporting of modifiers. For additional information, click here. Posted to the February 2021 issue of Network Matters.

2021 Fee Schedule Updates
On April 1, 2021, Harvard Pilgrim will update its: 1) Standard professional fee schedule, incorporating recently released Medicare relative value units (RVUs) and laboratory rates for 2021 and 2) Durable medical equipment (DME) fees, which may also include changes resulting from Harvard Pilgrim’s annual review of purchase (NU), maintenance (MS), and rental (RR) terms, and item limits. Beginning in mid-February, providers may request 2021 sample fee schedules by calling the Provider Service Center at 800-708-4414. To view the notification, click here. Posted to the February 2021 issue of Network Matters.

MassHealth

All Provider Bulletin 310: Transportation for Members to Vaccination Sites for Coronavirus Disease 2019 (COVID-19) Vaccine Administration

Effective for dates of service on or after February 17, 2021, selected MassHealth members may receive certain transportation services listed on the web page www.mass.gov/info-details/covid-19-vaccinationlocations. To be eligible for these transportation services, such individuals must have an appointment for the administration of COVID-19 vaccine. MassHealth’s Eligibility Verification System (EVS) will be updated to reflect the availability of these transportation services to these individuals. To view the complete bulletin, click here.

Tufts Health Plans

Modifier Reimbursement Changes

As previously communicated, and effective for dates of service on or after February 25, 2021, Tufts Health Plan will implement changes to modifier reimbursement processing. When a modifier has been appropriately applied, as determined through the coding validation process, providers will be reimbursed at 100% of the allowed amount for that service, unless otherwise specified in the provider’s Tufts Health Plan contract. For additional information and to view the entire notification, click here. Posted to the Provider Update, Feb. 2021 Newsletter.

Tufts Medicare Preferred HMO Enrollment

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 allows a special election period where patients 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
• This also means for our members that you’re not locked in to whatever plan you choose.  If life changes and you need new/different coverage, our 5-star rating gives you one additional opportunity 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.

A few more updates and reminders:

• February virtual meeting registration information can be found here www.thpmp.org/meetings and dates & times are as follows. CMS permits you to distribute this information to patients via email and in office material. If interested, please reach out to me for more details.
• 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 refer to: https://tuftshealthplan.com/covid-19/provider/coronavirus-updates-for-providers

• 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
Office: 617-972-9400 Ext: 48010

PROVIDER RELATIONS

Interested in being Featured?

Please reach out to Alycia Messelaar at 978-236-1784 or Alycia.Messelaar@lahey.org 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.

Please take a moment to review your practice information and reach out to Alycia Messelaar, Alycia.Messelaar@lahey.org with update requests.

Click here to find the most recent links to COVID-19 specific health plan materials and updates. Please note, we have included health plans that NEPHO does not contract with in an effort to help keep you well informed of current COVID-19 updates we have been made aware of.  If you have questions or concerns, please reach out to Alycia Messelaar, Alycia.Messelaar@lahey.org.

The Northeast PHO is here to ensure you are not alone and that we are in this together. We are doing our best to keep your practice as updated as possible with all things COVID-19. Please take a moment to visit the COVID-19 tab by clicking here.

PHARMACY

Diabetes Evidence Based Medicine (EBM) Prescribing Initiative

NEPHO will be implementing a Diabetes EBM Prescribing initiative over the next several months in collaboration with the BILHPN System wide TME Reduction initiative: A1c Control and appropriate utilization of SGLT-2 diabetes agents. The purpose of this program is to improve care of patients with Diabetes who have CAD, HF or progressing renal dysfunction. In addition, there is evidence Total Medical Expenses (TME) can be positively impacted as a result of reducing inpatient, outpatient and emergency expenses.

By prescribing SGLT- inhibitor diabetes agents (canagliflozin, Invokana; empagliflozin, Jardiance; or dapagliflozin, Farziga) to appropriate patients with diabetes, evidence has shown reductions in MACE (major adverse cardiovascular events) in patients with and without CAD, a decrease in progression of CKD and a reduction in HHF (hospitalizations for heart failure). Conversely, pharmacy costs may increase somewhat.

Providers will be oriented to the process for this initiative during March pod meetings. Please see BILPHN Pharmacy Newsletter below for more details. If you have any questions in the meantime, please contact Carol Freedman at carol.freedman@lahey.org

Practical Prescribing Pearls – Top 10 take-home points for treatment of T2DM

Please click here for BILHPN Pharmacy Practical Prescribing Pearls.

BILHPN Pharmacy Newsletter – BILHPN Collaborative TME Goal: Use of Evidence-Based Medicine in T2DM

For more information or questions, please contact Carol Freedman, NEPHO Pharmacy Manager at carol.freedman@lahey.org

POPULATION HEALTH

March is Colorectal Cancer Awareness Month

Statistics and risk factors

Among cancers that affect both men and women, colorectal cancer is the second leading cause of cancer deaths in the United States. Risk increases with age. More than 90% of colorectal cancers occur in people who are 50 years old or older. Precancerous polyps and colorectal cancer don’t always cause symptoms, especially at first. Symptoms may include blood in the stool, stomach pain that does not resolve, or unexplained weight loss.

Every year, about 140,000 people in the United States get colorectal cancer, and more than 50,000 people die of it. The American Cancer Society estimates 104,610 new cases of colon cancer and 43,340 new cases of rectal cancer in 2020. Only about two-thirds of adults in the United States are up-to-date with colorectal cancer screening. On average, the lifetime risk of developing colon cancer is about 1 in 23 (4.4%) for men and 1 in 25 for women (4.1%).

The ACS recommends that people at average risk* of colorectal cancer start regular screening at age 45. The USPSTF recommends that adults begin screening at age 50 and continuing until age 75. This can be done either with a sensitive test that looks for signs of cancer in a person’s stool (a stool-based test), or with an exam that looks at the colon and rectum (a visual exam).

People who are in good health and with a life expectancy of more than 10 years should continue regular colorectal cancer screening through the age of 75.

For people ages 76 through 85, the decision to be screened should be based on a person’s preferences, life expectancy, overall health, and prior screening history.

People over 85 should no longer get colorectal cancer screening.

*For screening, people are considered to be at average risk if they do not have:

• A personal history of colorectal cancer or certain types of polyps
• A family history of colorectal cancer
• A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease)
• A confirmed or suspected hereditary colorectal cancer syndrome, such as familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer or HNPCC)
• A personal history of getting radiation to the abdomen (belly) or pelvic area to treat a prior cancer

Sources:
“Colorectal Cancer Screening Saves Lives”
cdc.gov/cancer/colorectal/index.htm, March 2021
“American Cancer Society Guideline for Colorectal Cancer Screening”
cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-rexommendations.html

QUALITY

This month, HPHC announced that NEPHO has been named to the 2021 Harvard Pilgrim Health Care Physician Group Honor Roll with Distinction. Congratulations!

Harvard Pilgrim’s Honor Roll Methodology evaluated our performance on 14 HEDIS measures in acute, chronic, and preventative care domains. Physician groups with performance in the Top 10th percentile of physicians measured nationally on these measures are named to the Honor Roll with Distinction. Harvard Pilgrim issued a press release announcing the Honor Roll and details about the 2021 Honor Roll can be found on the HPHC website by clicking here. NEPHO is one of 16 organizations who achieved the “With Distinction” status, which is designated by an asterisk on the HPHC Honor Roll webpage.

CODING TIP OF THE MONTH

NEPHO Coding Audit Results Quarter 4 2020

The NEPHO Coding Team completed an audit at the end of January 2021. The scope of the audit focused on the Risk Adjustment Coding capture during Quarter 4 2020. NEPHO will be working to help educate providers on Risk Adjustment coding capture to ensure patient health status is accurately presented to the payers. This recent audit showed that many high risk patient conditions are not being captured to their highest specificity. Patients that are being managed with a higher level of risk need resources to support potential relapse, medications, treatment planning to better support their chronic condition management such as: diabetes, COPD, and Vascular Disease. The areas of missed coding opportunities from the Northeast PHO patients and providers include the following:

Missed COPD coding capture during sick visit:

• Example: Patient has a sick visit for flu like symptoms and does have COPD that is being managed by the PCP and Pulmonary. The provider diagnosis capture is:

Muscle pain (M79.1), Fatigue (R53.83), Cough (R05), Shortness of breath (R06.02), Sneezing (R06.7), Loss of appetite (R63.0), Headache (R51), Nasal congestion (R09.81). The provider does not capture the chronic condition COPD (J44.9) – this is a lung condition and the flu like symptoms such as cough, shortness of breath, and fatigue can be linked to the COPD.

CKD Stage 3 coding updates effective 10/1/2020

• Example: Patient has CKD Stage 3 and the current coding is CKD 3 (N18.3). This code was broken down to 3 sub-stages effective 10/1/2020.
  • N18.30 (CKD, stage 3 unspecified)
  • N18.31 (CKD, stage 3a)
  • N18.32 (CKD, stage 3b)

Diabetes with Complications captured to the highest specificity:

• Example: Patient has a 3 month follow-up visit and has the following chronic conditions: Diabetes II (E11.9), CKD 3 stage 3a (N18.31), Morbid Obesity (E66.01) with BMI >40 (Z68.41), hyperthyroidism (E03.9).
  • Accurate coding: Diabetes with CKD stage 3a: E11.22, N18.31, Diabetes with complications: E11.69, E66.01, E03.9.

Morbid Obesity and BMI accurate coding capture:

• Example: Patient has Morbid Obesity (E66.01) and BMI is >40 (Z68.41). The provider captures the Morbid Obesity (E66.01) but does not capture the BMI (Z68.41) this will not risk adjust as both the E66.01 and Z68.41 must be documented and coded together to accurately capture the risk adjustment coding. Both the E and Z code needs to be captured.

Capturing chronic conditions during Telehealth visits:

• Example: Patient is having 3 month check in call with provider. Could not have face-to-face visit due to flu like symptoms. Patient is being managed by provider for depression (F33.8), Anxiety (F41.1), Hypertension (I10), and Rheumatoid Arthritis (RA) (M06.9).
• The provider has a check in call with the patient via Video/Audio and captures/documents Depression & Anxiety only. Accurate coding and documentation should have included:
  • Depression
  • Anxiety
  • Hypertension
  • RA

Updating Problem List to help support accurate coding capture:

• Example: Patient has diabetes II (E11.9) and morbid obesity with BMI >40 (E66.01, Z68.41). The patient has been focused on weight loss and diet changes. Their blood sugar level has been normal and their BMI is below <32.
  • The provider should update the problem list as Diabetes – Resolved and BMI should be updated to <32 (Z68.32).

Missing High Risk conditions on an annual basis:

• Example: Patient is having their annual visit with their PCP. The patient has been seeing Oncology for prostate cancer and is still on medication after radiation treatment. The PCP captured the prostate cancer (C61) as history of prostate cancer (Z85.46).
  • The patient is still on medication for prostate cancer so the cancer should be captured as prostate cancer (C61) not history of prostate cancer (Z85.46).

Missing chronic condition capture during annual visits – Annual Exam Encounter (Z00.00):

• Example: Patient comes in for their Annual Exam and has the following chronic conditions: Asthma (J45.909), Diabetes II (E11.9), CKD 3 stage 3b (N18.32), Hypertension with Heart Failure (I11.0), Congestive Heart Failure (I50.82). The provider only codes the Annual Exam Encounter (Z00.00) and misses all chronic conditions. Accurate coding would include the following:
  • Z00.00, J45.909, E11.22, N18.32, I10, I50.32, I13.0 (Hypertensive Heart Disease with HF and CKD 3)

Missing HCCs Rx coding capture when provider is prescribing medication to manage condition:

• Example: Patient has not been seen since October 2020 and PCP is prescribing medication for the following chronic conditions: Anxiety (Zoloft), Hypertension (Acebutolol), Hyperlipidemia (Lipitor). The provider is also managing the patient’s diabetes II – The patient visit was in February 2021 and the provider only codes the diabetes (E11.9). The patient might not come back for a visit in 2021 and the following codes that risk adjust with medication updates are missed Anxiety (F41.1), Hypertension (I10), and Hyperlipidemia (E78.5). To capture this patient accurately for 2021 the following coding should be captured:
  • E11.9, F41.1, I10, E78.5 and highest specificity if the hyperlipidemia was linked to the diabetes would be: Diabetes with complications E11.69, E78.5

High Level Results: Area of Coding Capture Opportunity – Quarter 4

• COPD was missed during sick visits.
• CKD Stage 3 was missed in early October – this condition was updated on October 1, 2020 to include 3 sub stages (ICD-10 Updates). November and December showed better capture.
• Diabetes with complications is missing specificity and missing accuracy when capturing complications.
• Missing complete Morbid Obesity coding – must capture E and Z code for Morbid Obesity to Risk Adjust.
• Weight on Telehealth visits and Chronic Conditions are not being captured during Video/Audio Telehealth visits.
• Missing updates to the problem list – this is across the NEPHO organization – maintain an accurate problem list is necessary to keep diagnosis coding accurate – updating resolved conditions, in remission updates and condition progression updates must be maintained.
• Missing high risk conditions annually are being missed such as: Multiple Sclerosis (MS) G35, Cancer – prostate cancer C61 when patient is still on medication.
• Physical Exams (Annual) Coding Z00.00, the provider is not updating chronic conditions during these visits and are only coding Z00.00 (Annual Exam Encounter).
• HCCs that risk adjust when provider is prescribing medication are being missed – example: Hypertension I10, Hyperlipidemia E78.5, and Asthma J45.909.

These examples highlight the areas that are being missed on an annual basis. Complete diagnosis risk capture must be updated annually to ensure the patient’s Risk Adjustment Factor (RAF) score is calculated accurately to have the funds available to support patient care management.

Please reach out to Shawn Bromley at shawn.m.bromley@lahey.org or 978-236-1704 if you would like more information regarding risk adjustment coding capture for your practice or providers.

PATIENT EXPERIENCE COMMENTS

Blackburn Primary Care, Gloucester – 1 Blackburn Drive

• Dr. Jay Isaac is the most conscientious physician I have had. He listens well and uses his scientific knowledge to diagnose as necessary. He looks at me, and sees me as a whole person.

Lahey Primary Care, Beverly – 100 Cummings Center

• Dr. Khalil Shahin This provider has been extremely easy to talk with about all of my health concerns.

Lahey Primary Care, Danvers – 5 Federal Street

• Dr. Brent Fryling is one of the most competent doctors I have had. He is thorough and caring.
• Dr. Margaret Legner Everyone was polite, friendly & very helpful.

Lahey Primary Care, Danvers – 480 Maple Street

• Dr. Kristina Jackson is always thorough, kind, informative!

Lahey Primary Care, Hamilton (LPCO) – 15 Railroad Avenue

• Dr. William Medwid is a terrific PCP – knowledgeable, empathetic, and very helpful. Staff is very friendly!

Lahey Primary Care, Manchester (LPCO) – 192 School Street

• Dr. Matthew Plosker Exceptional care, great skills. I’m very happy to have Dr. Plosker as my provider!

Dr. Brian Orr Pediatrics Gloucester – 1 Blackburn Drive

• Dr. Brian Orr’s office is wonderful. They are always quick & respond, love everyone at the office.

PRACTICE RECOGNITION

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!

NEW COPAYMENT ASSISTANCE FUND
FOR FRONTLINE HEALTH CARE WORKERS

The HealthWell Foundation^®, an independent non-profit, has launched a new fund to provide copayment assistance for behavioral health treatments for frontline health care workers who have been impacted by the COVID-19 health crisis. Through the COVID-19 Frontline Health Care Workers Behavioral Health Fund, HealthWell will provide up to $2,000 in financial assistance for a 12-month grant period to eligible health care workers who have annual household incomes up to 500 percent of the federal poverty level. For a family of four living in New England, this translates to up to $132,500. New Behavioral Health Fund to Assist Frontline Health Care Workers.

The HealthWell Foundation recognizes the importance of mental health in frontline health care workers’ ability to cope with the impact of the COVID-19 pandemic. Through this fund, HealthWell will assist frontline health care workers in covering their out-of-pocket treatment-related copayments for prescription drugs, counseling services, psychotherapy and transportation needed to manage COVID-19 related behavioral health issues.

To learn more, visit HealthWell’s COVID-19 Frontline Health Care Workers Behavioral Health Fund page.