News from NEPHO – JULY 2021 Edition


Dan Arnett, MD
Lahey Cardiology, Beverly
75 Herrick Street, Suite 206
Beverly, MA 01915
Phone: 978-927-8400
Fax: 978-922-1452

Adam Ludvigson, MD
Lahey Institute of Urology
75 Herrick Street, Suite 219
Beverly, MA 01915
Phone: 978-927-0714
Fax: 978-927-9135

William Mayers, MD
North Shore Pain Management
900 Cummings Center, Suite 221U
Beverly, MA 01915
Phone: 978-927-7246
Fax: 978-927-7249

Brendan Sheehy, MD
Beverly Anesthesia Associates
480 Maple Street, Suite C233A
Danvers, MA 01923
Phone: 978-304-8690
Fax: 978-304-8697


  • Jana Oettinger, MD of Family Medicine Associates, A Member of Lahey Health has closed her patient panel to existing patients only.


Did you know you can use our website to search for a NEPHO Provider? Go to You can search by name, specialty, or location.


Coding and Billing Webinar
Wednesday, August 11, 2021 @11:30am–12:30pm
ICD-11 Overview
GoogleMeet Conference Call

New Physician Orientation
Thursday, August 25 @ 8:30 am
Location: GoogleMeet Conference Call
RSVP: or 978-236-1784

Date: Wednesday, September 8th @ Noon
Location: GoogleMeet Conference Call
or 978-236-1753

Office Manager Meeting
Wednesday, September 15, 2021 @ Noon
Location: GoogleMeet Conference Call
RSVP: or 978-236-1784

Coding and Billing Webinar
Wednesday, September 22, 2021 @11:00am–12:00pm
Title: ICD-10 CM Updates 2022 By Chapter
Location: GoogleMeet Conference Call




  • Data on NEPHO 2021 performance on BCBS HMO, HPHC, and Tufts Quality measures was shared, as well as updated performance data on the BILH System Diabetes Composite.
    • The diabetes composite includes annual eye exam, A1c < 9, and BP<140/<90.
    • The measurement period for the BILH System DM Composite goal is January 1, 2021 through August 31, 2021.
    • The goal is to have all 3 in control by August 31.


  • Information on the upcoming patient experience refresher webinar sessions was shared.
  • Recordings and the slide deck are available on request (Please email
  • Risk management credit is available for those who attend the live sessions only (not for viewing the recordings).


  • Information on collaborations with GI and Endocrine was shared.


  • A case based discussion on routine labs was offered.
    • Please do not order labs unless there is an indication and the lab is associated with the indication.
  • Follow up from previous month’s meetings was offered regarding BILH Behavioral Health walk-ins. Currently walk-ins are paused due to staffing. Patients can call for an appointment but there is a waitlist.
  • Follow up was offered for entering BPs taken at home during a telephone or virtual encounter. EPIC users can use Ctrl+Shift+V to open vitals flowsheet and enter BPs.
  • Discussion was invited on initiative by the ED to schedule post ED follow up visit when it is needed.
  • Considerations for future pod and IPA meetings were shared. Attendees were asked to complete survey inviting feedback on format, time of day, days preferred, etc. The survey was emailed immediately following each meeting.


Individual Claims Consultation Days, virtual appointments now available

The Individual Claims Consultation (ICC) Days held annually by the Massachusetts Medical Society are designed to provide an opportunity for practices to meet with Massachusetts health plan representatives to troubleshoot problem claims. The ICC Days will take place virtually this year (via Zoom or phone). Appointments begin July 21.
Use links below to register for your 30-minute appointments with specific health plans.

Blue Cross Blue Shield of Massachusetts

Authorization Requirements by Products

BCBSMA has posted an updated Authorization Requirements by Products. To view the complete list, click here.

CMS – Medicare

Inhalant Drugs: Bill Correctly

An Office of Inspector General (OIG) report found that CMS improperly paid suppliers for inhalation drugs. Review the Provider Compliance Tips for Nebulizers and Related Drugs (PDF) fact sheet to help providers bill correctly. For additional information, click here.

Harvard Pilgrim Health Care

Payment Policy Update: Diabetic Care

Harvard Pilgrim Health Care has updated the payment policy as follows: 1) Updated provider billing guidelines; 2) Removed version 5010 from billing guidelines. For additional information and to view the notification, click here.

Bariatric Surgeries Medicare Advantage Prior Authorization Request Form

Harvard Pilgrim Health Care has posted an updated Prior Authorization Request Form for Bariatric Surgery to the website. For additional information and to view the form, click here.

Medicare Advantage Prior Authorization Request Form

Harvard Pilgrim Health Care has updated the Medicare Advantage Prior Authorization Request Form, updated July 2021. For additional information and to view the form, click here.

Medicare Advantage Prior Authorization Request Form: Reconstructive & Restorative Skin Services

Harvard Pilgrim Health Care has updated the Medicare Advantage Prior Authorization Request Form for Reconstructive & Restorative Skin Services. For additional information and to view the form, click here.

Medicare Advantage Prior Authorization Request Form: Sinus Surgeries

Harvard Pilgrim Health Care has updated the Medicare Advantage Prior Authorization Request Form for Sinus Surgeries. For additional information and to view the form, click here.

Optum Behavioral Health Continuing Education Series

Harvard Pilgrim’s behavioral health partner, Optum/United Behavioral Health, is offering a three-part series of free continuing education sessions focused on the integration of behavioral health services into the clinical primary care setting and the successful management of population health for improved outcomes. The sessions are designed to meet the educational needs of primary care physicians, physician assistants, nurses, and nurse practitioners who are interested in learning about pertinent topics in behavioral health, including the screening, referral, diagnosis, and treatment for depression, along with the related aspects of Healthcare Effectiveness Data and Information Set (HEDIS) measures. For additional information, click here.

Tufts Health Plans

Temporary COVID-19 Telehealth Payment Policy Update

Added reference to telehealth responsibilities in the Commercial and Tufts Health Public Plans Provider Manuals. Click here to view the Payment Policies.

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.

A few more updates and reminders:

August virtual meeting registration information can be found here and dates & times are as follows. CMS permits you to distribute this information to patients via email and in office material including flyers which are attached.

  • Tuesday, August 10, 2021 – 10:00am (Virtual Medicare Meeting – Enrollment)
  • Thursday, August 12, 2021 – 10:00am (Virtual Medicare 101 – Educational)
  • Tuesday, August 17, 2021 – 10:00am (Virtual Medicare Meeting – Enrollment)
  • Wednesday, August 18, 2021 – 10:00am (Virtual Medicare Meeting – Enrollment)
  • Wednesday, August 18, 2021 – 4:00pm (Virtual Medicare 101 – Educational)
  • Thursday, August 19, 2021 – 10:00am (Virtual Medicare Meeting – Enrollment)
  • Monday, August 23, 2021 – 4:00pm (Virtual Medicare Meeting – Enrollment)
  • Tuesday, August 24, 2021 – 10:00am (Virtual Medicare Meeting – Enrollment)
  • Wednesday, August 25, 2021 – 10:00am (Virtual Medicare 101 – Educational)
  • Thursday, August 26, 2021 – 10:00am (Virtual Medicare 101 – Educational)

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 at or 617-417-2587.


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 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 view the Provider Spotlights!

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

Virtual Networking videos from NEPHO providers can be found at

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


Diabetes Evidence Based Medicine Initiative (DM EBM)

Pharmacists are making recommendations to initiate SGLT2 inhibitors and GLP1 agonists for your patients with DM when CAD, CHF and CKD when appropriate (e.g. eGFR > 30*). This initiative is to improve patient DM control, provide CV protection, reduce HF progression, and minimize TME (Total Medical Expenses) etc.

Please see the “considerations” charts below for SGLT2 inhibitor and GLP1 agonist medication classes, which provide guidelines for initiation and follow up management. For more information on this program, please see both the February 2021 and March 2021 BILHPN Pharmacy Newsletter editions.

*eGFR cut off dependent on particular agent

Medication Suspension: CHANTIX (varenicline) 0.5mg and 1 mg tablets

Chantix is indicated for use as an aid to smoking cessation treatment.

Recently Pfizer suspended distribution of Chantix and announced a warehouse level recall of nine lots due to the discovery of nitrosamine impurities that were found in some of the tablets during product testing. Currently there is a “pause” on distribution and a warehouse recall.

For more information or questions, please contact Carol Freedman, NEPHO Pharmacy Manager at or 978-380-4089.


Thank you for all of your efforts to document patient reported blood pressures obtained during telehealth visits. Below are some of the questions and answers that have come up recently.

  • Question: Do patient reported blood pressure readings have to be blood pressures taken on the day of the visit?

Answer: Patient reported blood pressure readings do not have to be from the day of the visit. Blood pressure readings obtained from previous days can be recorded. Documentation in the EMR must include the specific date the BP was taken and that the patient used a digital blood pressure monitor.

  • Question: Which blood pressure reading is submitted for quality contract measures?

Answer: The last blood pressure reading of the year is submitted for quality contracts. If a blood pressure is taken on an earlier date and the patient has a blood pressure taken at the visit, it is the blood pressure from the most recent date that would be submitted. (For this reason, when feasible, please obtain a BP taken from the day of the visit).

  • Question: Is there a way to document blood pressures in EPIC while in a telephone note encounter?

Answer: Use Ctrl+Shift+V to pull up the Vitals flowsheet and record the blood pressures. Please continue to document a 2nd blood pressure if the 1st reading is >139 systolic or >89 diastolic.


Concierge Scheduling for Mammograms

The concierge scheduling program for patients who are in need of mammograms has resumed as of July 2021.

  • Each patient’s chart is reviewed to insure that the patient is due for a mammogram.
  • The patient is then scheduled based on the time and location of their last scheduled mammogram.
  • A letter is sent to the patient listing the day, time and location of their appointment, along with the contact information for Laureen Viel, NEPHO Lead Population Health Specialist.
  • As of the first two weeks of July, 20 appointments have been scheduled. 3 patients have reached out to Laureen to reschedule (not cancel!) their appointments.
  • Please see below for a copy of the letter that is sent to patients

In addition to the concierge scheduling program, the NEPHO Quality Team collaborated with the Beth Israel Lahey Health Performance Network on a texting campaign for patients ages 50 to 74. For NEPHO patients, 500 text messages were sent every Tuesday during the months of June and July.

How you (practice-wide) can help:

  • Please encourage your patients to schedule their mammograms and extract a commitment. Example: “It is important for you to get this screening done. Will you be able to call this week to schedule it?”
  • If patients refer to the letter or texting campaigns, let them know you are aware of these campaigns and support getting this screening completed.

If you have any questions regarding the concierge scheduling program, please contact Laureen Viel at 978-236-1746 or


OPTUM Newsletter – July 2021 | Arthritis (Rheumatoid, Osteo and Psoriatic)

  • 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 COPD (J44.9) could have been included to capture the chronic condition– this is a lung condition and the flu like symptoms such as cough, shortness of breath, and fatigue can be linked to the COPD.
  • 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, Z68.41, 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.
  • 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 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

NEPHO Education Plan 2021

Monthly Coding & Billing Webinars
Risk Adjustment Coding Capture Education
1×1 Provider Education Sessions – 44 Providers
New NEPHO Physician Coding On-Boarding Sessions – 23 Providers
2022 Coding Updates – ICD-10 CM & CPT
Telehealth Focused Education
Diabetes Coding with Complications

NEPHO Education Plan 2022 – Quarter 1

Smoking Cessation, TCM, CCM
NEPHO Coding & Billing Webinars
Depression & Anxiety HCC Capture Education
Provider 1×1 Sessions
New Physician Coding Onboarding
Welcome to 2022 Coding and Billing

Please reach out to Shawn Bromley if you are interested in reviewing more about Risk Adjustment Coding capture. Contact or 978-236-1704.


Press Ganey Online

The old on-line platform will be retired on July 31, 2021. The new Press Ganey Online, or PGO, provides a unified platform with powerful, market-leading insights, analytics and comparative benchmarks to engage stakeholders, drive improvement and sustain results.

The new portal will allow users to review key performance indicators such as provider ratings, likelihood to recommend at provider or practice level, survey detail, performance measures by month, quarter, etc., as well as site scorecards, provider dashboards including patient comments and CAHPS summary data and much more!

If you have any questions or would like access to your practice’s primary care data, please contact Stephanie Cunningham at or 978-236-1753.


Cape Ann Medical Center – 1 Blackburn Drive

  • I have been very pleased with Dr. James Maguire and his staff. I am always treated with respect, honesty, and I feel welcome, not a number. The timing for appointments are always on time.
  • Dr. Janet Doran is knowledgeable, empathetic, and respectful in all her patient interactions. Personnel at the Cape Ann Medical Center are unfailingly courteous and supportive.

Cape Ann Pediatrics – 298 Washington Street

  • Dr. Jeffrey Stockman has always been a great pediatrician for my son. Wonderful bed side manner, connection with child, great clinical skills, very compassionate.

Lahey Primary Care, Beverly – 30 Tozer Road

  • Dr. Tina Waugh is amazing. She listens and is very thorough. She explains everything. I love that she is my doctor!
  • Dr. Gail Ellis always takes the time to find out how I’m doing and is always respectful and makes me feel comfortable.

Lahey Primary Care, Beverly – 100 Cummings Center

  • I’ve always felt comfortable and confident under the care of Dr. Pierre Ezzi and staff. He/they are both professional and personable. I feel he genuinely cares about my well-being as a patient.
  • Dr. Khalil Shahin is one of the best doctors I have ever seen!

Lahey Primary Care, Beverly– 900 Cummings Center

  • I have gone to this office for many years and have always had a good relationship with Dr. Andrew Lenhardt with no problems!
  • I had the best experience ever with Dr. Daniel McCullough. He was honest, down to earth and listened intently. I’ve never had a better experience!

Lahey Primary Care, Danvers – 480 Maple Street

  • Dr. Galina Feldman is the best PCP I have ever had. I have family members who have changed to go to her practice.
  • Dr. Kristina Jackson is a great doctor. She is just a nice person and very caring. She is always very thorough and I’m grateful to have her as my primary care doctor. Also, she is down to earth and easy to talk to. Overall I’m very pleased with the care she provides.

Lahey Primary Care, Danvers – 5 Federal Street

  • I have been a patient of Dr. Margaret Legner for a few years. She is very thorough. If she thinks I need to see a specialist she will recommend one. She has a very pleasant bedside manner. I have a great deal of faith in her. She’s a wonderful doctor!
  • Dr. Brent Fryling is an excellent addition to the staff here. I get professional, compassionate care with whomever is assigned to me when I visit.
  • Dr. Mauri Cohen is an outstanding physician with excellent patient communication skills. I find him to be a very caring competent physician with excellent listening skills. He always addresses whatever major or minor concerns I may have. I feel extremely comfortable with his style and approach and it’s a pleasure to deal with such an effective physician.

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

  • Dr. Victor Carabba and staff are always caring and professional, my medical questions and Dr. Carabba’s concerns are answered thoroughly without that being “rushed” feeling.
  • Dr. Yuliya Mandel is fabulous! I recently changed from my doctor of 30 years or so, and it’s one of the best decisions I’ve ever made! Thank you, Dr. Mandel!

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

  • Dr. Amy Esdale I am always happy to go see and her staff, they are the best.
  • I have a lot of health issues and Dr. Kathryn Hollett always listens, provides knowledgeable feedback and information. She is compassionate and thoughtful, and never ever makes me feel rushed, or that what I’m sharing isn’t important. We have a great doctor patient relationship, and I hope she’ll remain my PCP for a very long time. I have great respect for Dr. Hollett and feel lucky with my choice of PCP.

Lahey Primary Care, Hamilton – 15 Railroad Avenue

  • I think Dr. Laurence Gordon is fabulous, and the more I see him the more I like him.
  • Dr. William Medwid always listens, hears me, addresses any concerns I may have. He is wise and comforting and always compassionate. He keeps up to date on any tests needed and advises me well. I feel very confident in his opinions and is considerate of mine. His job is busy and difficult, but, always gives me the time I need for my appointment. Anyone would be blessed to be his patient and listen to his wisdom and knowledge. I trust him completely. Thank you so much!

Lahey Primary Care, Manchester192 School Street

  • Dr. Jana Oettinger is the most caring and compassionate provider I have ever had. She listens to my concerns and never makes me feel rushed. She is truly an asset to your practice!!
  • I had a good experience! I am happy I switched Primary to Dr. Matthew Plosker.


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:

Bridget Ernest, Cape Ann Eye Specialists, was recognized for her efforts to keep specialty care in the Northeast PHO network.

June Figurido, Lahey Health Primary Care, Beverly, was recognized for her patient experience comment “I spoke with June, Dr. Lenhardt’s nurse, and even though it wasn’t her job, she got it done right away & has gone above & beyond to help me since then!”

Tammy Sload, Beverly and Addison Gilbert Hospitals, was recognized for providing training in support of NEPHO concierge mammogram scheduling initiative.

Bridget Ernest and Dr. Matthew Weinstein-Zanger, Cape Ann Eye Specialists


June Figurido (in the purple) with Sarah Tsouvalas, NP

Tammy Sload, Beverly and Addison Gilbert Hospitals, shown here with Eva Favalora in pink, Manager, Patient Access Call Center and Makala Moutsoulas in white

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!