NEPHO CONTACT LIST
Need to contact us, but not sure how?
Click here to view the NEPHO Colleague Contact List
No New Providers this month. Check back next month.
PRACTICE CHANGES / UPDATES
Evan Rochman, MD of Beverly Radiological Associates has retired effective 3/18/2021
DR. MANJU SHETH’S INTERVIEW WITH ABC/CITYLINE
Click here to view Dr. Sheth’s interview with ABC and CityLine.
NEWS FROM NEPHO
MARCH 2021 EDITION
IN THIS ISSUE:
SAVE THE DATE
Date: Wednesday, April 14, 2021 @10:30–11:30am
Evaluation and Management Documentation Examples
Location: GoogleMeet Conference Call
Date: Wednesday, April 28, 2021 @10:30–11:30am
Coding and Billing Opportunity 2021
Location: GoogleMeet Conference Call
Date: Wednesday, May 12, 2021 @10:30–11:30am
Services Supported by Telehealth
Location: GoogleMeet Conference Call
Date: Wednesday, May 26, 2021 @10:30–11:30am
Risk Adjustment Coding Capture Review
Location: GoogleMeet Conference Call
PHIL CORMIER PRESENTED LANE AWARD
The William L. Lane Hospital Advocate Award
Philip Cormier, president of Beverly and Addison Gilbert Hospitals, part of Beth Israel Lahey Health, received the prestigious 2021 William L. Lane Hospital Advocate Award from MHA last week. The annual award acknowledges a senior hospital or health system executive’s outstanding efforts on behalf of their organization, and their innovative and positive leadership and advocacy to further healthcare access and high-quality, safe care for all.
“Phil is a tireless advocate for the patients, staff, and entire community that Beverly and Addison Gilbert Hospitals serve,” said Steve Walsh, president & CEO of MHA. “While the COVID-19 pandemic has challenged every Massachusetts healthcare organization like never before, it hasn’t deterred Phil’s efforts to continually improve the care, services, and workplace experience for everyone who calls Beverly and Addison Gilbert their hospital.”
The William L. Lane Hospital Advocate Award was established to embody the spirit of William Lane, who led Holy Family Hospital in Methuen, Mass., for many years.
Cormier’s outstanding work, including investing in new services and programs for underserved patient populations, has increased access to high-quality healthcare across all North Shore communities. He oversaw the development of the hospitals’ High Risk Intervention Team, with the goal of addressing gaps in the care of patients with complex social, behavioral, and medical needs. He also expanded programs and local access to specialists and to behavioral health services, among other initiatives.
“Phil is a dedicated, visionary leader who put his heart and soul into ensuring the hospitals’ success,” said Nancy Palmer, chair of Beverly & Addison Gilbert Hospitals Board of Trustees.
ULTRASOUND ELASTROGRAPHY CAPABILITIES
We are pleased to inform you that we are now able to perform Elastography Ultrasound at Beverly Hospital and Lahey Outpatient Center, Danvers.
This is a useful technology for grading and following hepatic fibrosis and diffuse liver disease. It can be performed as an isolated study or in conjunction with abdominal Ultrasound.
This new program will begin on March 22nd, 2021. To start, we will offer patient appointments on Monday’s, at Lahey Outpatient Center, Danvers (LOCD).
To schedule your patient for Elastography, please enter the order in Epic and call central scheduling at 866-479-3208. Elastography should always be ordered with Abdomen unless the patient had a recent Abdomen Ultrasound.
Use these codes to enter the order into Epic:
- IMG14257 – US Abdomen Complete with Elastrography
- IMG14258 – US Abdomen Limited with Elastrography
- IMG14254 – US Elastrography
If you have any questions, please contact Mary Jane O’Neill, MD, President, Beverly Radiology Associates at 978-816-2380 or maryjane.o’firstname.lastname@example.org; or Denielle Palm, MBA, RTR(M), Manager, Radiology at 978-304-8002 or email@example.com.
IPA AND POD MEETINGS KEY TAKEAWAYS
- There is opportunity to improve with diabetic eye exams
- There are new quality performance reports that we will be sharing over time
- Hypertension: BP can be recorded for all payers (MassHealth TBD) by phone or video
- Record the date and time of the reading
- Record the reading
- Record that a digital BP cuff was used
- Record who took the BP and who documented BP
- Efficiency data was shared but is not yet risk-adjusted making it difficult to interpret
- There is an Evidence Based Medicine (EBM) prescribing program to reduce TME
- The goal is to review patients with CAD and HF for evidence based prescribing opportunities
- PCP Risk Share Dashboards (previously called Report Cards) were included for review
- A case based review on Alcohol Use Disorder was discussed
- Alcohol consumption guidelines change for patients who are ages 65 and older
AllWays Health Care Partners
Three tips to improve virtual healthcare visits
During the COVID-19 pandemic, many providers have turned to telemedicine to care for their patients safely. In a survey about COVID-19 impact collected through our Provider Roundtable, respondents shared that telehealth can be especially challenging both to learn as well as getting patients used to the change. So, if you’re new to virtual care, or if you’d like to enhance your experience, here are three tips for an excellent telehealth experience. Click here to read more.
Blue Cross Blue Shield of Massachusetts
Medicare Advantage Telehealth Cost Share & COVID-19 Vaccine Billing
This is a reminder that effective January 1, 2021, BCBSMA is waiving cost share (copayment or co-insurance) for Medicare Advantage members who receive telehealth services for the following types of services: primary care visits; specialist visits when treatment is related to COVID-19; urgent care visits; outpatient mental health visits. Cost share will apply for all other telehealth visits, such as physical therapy visits. For additional information and to view the notification, click here.
New Medical Policy on Coverage for Lab Tests
BCBSMA recently announced a new medical policy for specific lab tests that will be effective April 1, 2021 for commercial (HMO and PPO), Indemnity, and Medicare Advantage members. This policy will help to ensure coverage for necessary lab tests, while adhering to current best practices, and reducing medical spending waste. Click here for more details.
COVID-19 Interim Billing Guidance for Providers for Commercial Customers
Cigna has updated the interim coverage accommodations for commercial Cigna medical services and the Interim Billing Guidelines for Coronavirus (COVID-19). For additional highlighted updates and to view the information, click here and expand options.
Harvard Pilgrim Health Care
Sign Up for Our Virtual Provider Meetings
Join us in April for the next stop in our network engagement series: a virtual Provider Engagement Meeting! Sign up today to attend and hear the latest news and updates from Harvard Pilgrim on topics including: COVID-19, product and policy information, online tools and resources, and more. As your feedback is important to us, the meetings also include a Q&A session.
Click on one of the following dates to register:
COVID-19 Information and Resources (COVID-19/Telemedicine/Telehealth)
Harvard Pilgrim Health Plan has updated the Latest Updates as follows: 1) Updated COVID-19 testing information to note that cost-sharing is waived as noted until further notice. For additional information and to view the notification, click here.
Payment Policy Update: Certified Nurse Midwives, Certified Professional Midwives, Nurse Practitioners and Physician Assistants
Harvard Pilgrim has updated the Payment Policy for Certified Nurse Midwives, Certified Professional Midwives, Nurse Practitioners and Physician Assistants as follows: Administrative edits. For additional information and to view the notification, click here.
Tufts Health Plans
Tufts Health Plan is experiencing several issues related to authorizations for Tufts Health Public Plans products (e.g. issues with the MHK and eviCore systems). Tufts Health Plan is currently researching these issues and is committed to remediating them systemically. Until further notice, please send all questions regarding valid authorizations to Alycia Messelaar, firstname.lastname@example.org and Natalie Ohiri, email@example.com
Newborn Payment Policy Update
Clarified notification process for Tufts Health Together and Tufts Health Unify products, effective for dates of service on or after January 1, 2021. To view the complete policy, click here.
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, firstname.lastname@example.org, in order to begin the marketing process.
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)
- Ages treated
- 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 email@example.com 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, firstname.lastname@example.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, email@example.com.
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.
Virtual Visit Safety Information
The Academic Medical Center Patient Safety Organization formed the Virtual Care Task Force. This task force developed a document called “Patient Safety Guidance for the Virtual Visit” to outline best practices for virtual care in the ambulatory setting. Please click here to view information on how to keep your patients safe during a virtual visit.
Northshore magazine has named a number of Northeast PHO physicians and specialists to its annual ‘Top Doctors’ list. See below for a list of NEPHO members listed. Congratulations to everyone included in the issue!
- Gregory R. Blaha, MD, PhD of Lahey Medical Center Ophthalmology and Gurley Eye Care Associates
- Daniel S. Blander, MD of Lahey Institute of Urology, Beverly
- Beth A. Bouthot, MD of Beverly Hospital and Addison Gilbert Hospital Nephrology
- Caitlin K. Carney, MD of Northeast Dermatology Associates
- Jeffrey Chang, MD of Lahey Medical Center Ophthalmology
- Mauri R. Cohen, MD of Lahey Health Primary Care, Danvers
- Deborah Cummins, MD of Massachusetts Dermatology Associates
- James L. Demetroulakos, MD of North Shore ENT Associates
- Poonam N. Doshi, MD of Specialized Pediatric Eye Care
- Eric C. Fu, MD of Sports Medicine North
- Ioannis P. Glavas, MD of Ioannis P. Glavas, M.D.
- John M. Gurley, MD of Gurley Eye Care Associates
- Anoush Hadaegh, MD of Aesthetic Plastic Surgery of the North Shore P.C.
- John Karbassi, MD of Sports Medicine North
- Michael Kearny, MD of Northshore Physicians Group, Urology
- Timothy R. Kelliher, MD of Northshore Neurology and EMG
- Danielle Ledoux, MD of Specialized Pediatric Eye Care
- Tamar Lipof, MD of Essex Surgical Associates
- Edward Loughery, MD of Lahey Cardiology, Danvers
- Emma Massicotte, MD of Gurley Eye Associates
- Steven Mattheos, MD of Sports Medicine North
- Cristina Palumbo, MD of Asthma and Allergy Affiliates
- Michael A. Piacentini, MD of Gurley Eye Associates
- Gary S. Rogers, MD of University Skin Oncologists
- Sheryl R. Silva, MD, MPH of Garden City Pediatrics
- Jonathan S. Silver, MD of Lahey Cardiology, Beverly
- Bojan B. Zoric, MD of Sports Medicine North
Diabetes Evidence Based Medicine (EBM) Prescribing Initiative
Last month we introduced the Diabetes EBM Prescribing project that is a collaborative effort with the BILHPN System-wide TME (Total Medical Expense) Reduction initiative: A1c Control and appropriate utilization of SGLT-2 diabetes agents.
As you may recall, the purpose of this program is to improve care of patients with Diabetes who have CAD, HF or progressing renal dysfunction while potentially reducing TME by avoiding IP, OP and/or ED visits. Recently several studies have been published supporting utilization of SGLT- inhibitor diabetes agents (canagliflozin, Invokana; empagliflozin, Jardiance; or dapagliflozin, Farziga) to appropriate patients with diabetes with evidence showing the following:
- Reductions in MACE (major adverse cardiovascular events) in patients with and without CAD
- Reduction in progression of CKD
- Reduction in HHF (hospitalizations for heart failure)
Please click on the following links for recent BILHPN Newsletters:
For more information or questions, please contact Carol Freedman, NEPHO Pharmacy Manager at
Every April the National Council for Alcoholism and Drug Dependence (NCADD) sponsors Alcohol Awareness Month to increase awareness and understanding of the causes and treatment of the nation’s #1 public health problem: alcoholism. Part of this awareness is aimed at educating people about the treatment and prevention of alcoholism, particularly among our youth, and the important role that parents can play in giving kids a better understanding of the impact that alcohol can have on their lives. Approximately 5,000 youth under the age of 21 die each year because of drinking.
Alcohol use disorder can be mild, moderate or severe, based on the number of symptoms experienced. Signs and symptoms may include:
- Being unable to limit the amount of alcohol you drink
- Wanting to cut down on how much you drink or making unsuccessful attempts to do so
- Spending a lot of time drinking, getting alcohol or recovering from alcohol use
- Feeling a strong craving or urge to drink alcohol
- Failing to fulfill major obligations at work, school or home due to repeated alcohol use
- Continuing to drink alcohol even though you know it’s causing physical, social or interpersonal problems
- Giving up or reducing social and work activities and hobbies
- Using alcohol in situations where it’s not safe, such as when driving or swimming
- Developing a tolerance to alcohol so you need more to feel its effect or you have a reduced effect from the same amount
- Experiencing withdrawal symptoms — such as nausea, sweating and shaking — when you don’t drink, or drinking to avoid these symptoms
- Alcohol use disorder can include periods of alcohol intoxication and symptoms of withdrawal.
Alcohol intoxication results as the amount of alcohol in the bloodstream increases. The higher the blood alcohol concentration is, the more impaired one becomes. Alcohol intoxication causes behavior problems and mental changes. These may include inappropriate behavior, unstable moods, impaired judgment, slurred speech, impaired attention or memory, and poor coordination. One can also have periods called “blackouts,” where they do not remember events. Very high blood alcohol levels can lead to coma or even death.
Alcohol withdrawal can occur when alcohol use has been heavy and prolonged and is then stopped or greatly reduced. It can occur within several hours to four or five days later. Signs and symptoms include sweating, rapid heartbeat, hand tremors, problems sleeping, nausea and vomiting, hallucinations, restlessness and agitation, anxiety, and occasionally seizures. Symptoms can be severe enough to impair the ability to function at work or in social situations.
If someone feels that they sometimes drink too much alcohol, or their drinking is causing problems, or their family is concerned about their drinking, they should talk with your doctor. Other ways to get help include talking with a mental health professional or seeking help from a support group such as Alcoholics Anonymous or a similar type of self-help group.
Well Child Visits
Since the COVID-19 pandemic began, the American Academy of Pediatrics (AAP) has noted a significant drop in well-child visits which has resulted in delays of vaccinations, screenings, referrals and parental guidance needed to assure optimal health. A recent white paper released by FAIRHEALTH found that in March and April of 2020, mental health claims for patients aged 13-18 approximately doubled compared to the same months in the previous year. A similar pattern was observed for patients ages 19-22, though the changes were smaller. The study noted that young people have been especially vulnerable to mental health issues related to COVID-19, and a review of international literature identified high rates of anxiety, depression and post-traumatic symptoms.
The AAP has also noted that while outpatient visits to Adult PCPs have resumed to near pre-pandemic levels, pediatric visits and immunization rates have been slower to rebound. The AAP has issued the following guidance:
Consistent with previous guidance, all well-child care should occur in person whenever possible and within the child’s medical home where continuity of care may be established and maintained. For practices who have successfully implemented telehealth to provide appropriate elements of the well exam virtually, these telehealth visits should continue to be supported, followed by a timely in-person visit.
Pediatricians should identify children who have missed well-child visits and/or recommended vaccinations and contact them to schedule appointments inclusive of newborns, infants, children, and adolescents. Pediatricians should work with families to bring children up to date as quickly as possible, particularly given reported decreases in childhood and adolescent immunization rates and the potential for other vaccine preventable disease outbreaks. State-based immunization information systems and electronic health records may be able to support any catch-up immunizations.
CODING TIP OF THE MONTH
OPTUM Newsletter – March 2021 | Morbid Obesity and Malnutrition
Modifiers Utilized To Ensure Accurate Reimbursement
Modifiers 24, 25, and 57 are often misunderstood. Each modifier has specific circumstances for use. Proper application of these modifiers will help ensure proper reimbursement.
- Unrelated evaluation and management service by the same physician or other qualified health care professional during a post-operative period
- Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service
- Decision for surgery
These specific modifiers are appended to evaluation and management (E/M) codes only. Use them in accordance to global surgery guidelines, set forth by the Centers for Medicare & Medicaid Services (CMS) in the National Correct Coding Initiative (NCCI) edits.
When an E/M service is billed in the global period of a procedure without a modifier, the E/M service is denied as incidental to the procedure. Medicare advises there is an E/M component of every procedure in the CPT. CMS also designated every procedure with a 0-, 10-, or 90-day global period. Necessary components of every procedure include:
- The decision to perform a procedure
- Ensuring the patient is healthy enough to receive the procedure
- Informing the patient about the procedure
E/M services within these global periods that meet these criteria are not separately payable and should not be reported; however, when providers render E/M services within these global periods that do not meet the above criteria, append the appropriate modifier to ensure separate reimbursement.
Modifier 24 is used if the E/M service is within the 10- or 90-day global period but is unrelated to the procedure. It is not used for an E/M service on the same day as a procedure. For example: A patient has a fractured wrist. The patient comes into the office during the 90-day global period of the fractured wrist to discuss knee pain. The knee pain is completely unrelated to the wrist fracture treatment, so the provider should get separate reimbursement for the E/M service rendered that day. To communicate this to the payer, append modifier 24 to the appropriate E/M code.
Unexpected complications of a procedure can also result in an E/M service that goes above the routine care included in the global period of a procedure. If a new history, exam, and medical decision-making (MDM) are rendered, you may bill an E/M service with modifier 24 appended, even if those services are provided to the same body part that is already in a global period.
Appropriate Use of Modifier 24
A 4-year-old patient is seen in the physician’s office with a 2.5-cm laceration to the right anterior side of the wrist, on which an intermediate layered closure was performed five days ago (CPT code 12031). The patient presents to the physician’s office today complaining of bilateral ear pain. The patient’s mother states he was up all night crying. The physician performs an expanded problem-focused history and examination. The final diagnosis is bilateral otitis media. The provider prescribes amoxicillin and instructs the mother to bring the patient back in seven days to recheck his ears.
Inappropriate Use of Modifier 24
A 4-year-old patient was seen in the physician’s office five days ago with a 2.5-cm laceration to the right anterior side of the wrist, on which an intermediate layered closure was performed (CPT code 12031). The same patient now presents with redness, swelling, and drainage to the sutured area. The final diagnosis was infected laceration.
Modifier 25 is used if the E/M service is rendered the same day as a procedure with a 0- or 10-day global period. The debate over appropriate use of modifier 25 has been ongoing for years. The Office of Inspector General (OIG) routinely finds this modifier misused. The decision to perform a procedure cannot be the sole justification for coding a separate E/M with modifier 25. Similarly, being a new patient is not justification alone for billing a separate E/M. If an E/M service is unrelated to the procedure, or if the E/M service goes above and beyond the decision-making required for the procedure, the provider should get separate reimbursement for that work, and modifier 25 should be appended to the E/M code.
Appropriate Use of Modifier 25
A 4-year-old established patient presents to his family practice physician’s office with a 2.5-cm laceration to the right anterior side of the wrist. The laceration is closed by the physician with 2-0 Vicryl. During the visit, the patient’s mother asks the physician about her child’s asthma. The physician decides to adjust the patient’s asthmatic medication and performs an expanded problem-focused physical.
The coding assigned would be:
- 12001 Simple Repair, Superficial Wounds, Scalp/Neck/Axillae/Genitalia/Trunk/Extremities; 2.5 cm.
- 99213-25 Office Outpatient Visit, established patient, expanded problem focused history; expanded problem focused physical; medical decision making of low complexity.
Modifier 57 is applied to E/Ms that result in major procedures. Surgical procedures are not the only procedures where modifier 57 should be applied. The CPT manual states modifier 57 can be used on any E/M during which the physician decides a “major” procedure/surgery is necessary.
Appropriate Use of Modifier 57
A patient presents to the emergency department (ED) with abdominal pain and fever. The consulting surgeon documents a level 3 outpatient consult and decides at that visit to perform an emergency appendectomy. The appropriate coding for payment of the preceding E/M is 99243-57; 44950.
Click here to be directed to a Training Forum for Mass Health Claims.
Please contact Shawn Bromley at firstname.lastname@example.org or 978-236-1704 if you have questions regarding coding and billing.
PATIENT EXPERIENCE COMMENTS
Blackburn Primary Care – 1 Blackburn Drive
Dr. Jay Isaac always listens and helps me with every single concern I have. He is an amazing doctor who cares about his patients.
Cape Ann Medical Center – 1 Blackburn Drive
Dr. Shawn Pawson was very clear in his explanations, and also empathetic and helpful about a stressful situation.
Lahey Primary Care, Beverly – 30 Tozer Road
Dr. Susan Deluca is fantastic with kids!
Lahey Primary Care, Beverly – 100 Cummings Center
Dr. Khalil Shahin I have gone to this office for many years and have always had a good relationship & with no problems!
Lahey Primary Care, Danvers – 5 Federal Street
Dr. Margaret Legner Excellent experience with Margaret A. Legner, MD. She was very helpful and followed thru with me and listened to my concerns about my condition/illness.
Dr. Brent Fryling I believe Dr. Fryling to be exceptional good listener & communicator.
Dr. Mauri Cohen and his nurse are excellent.
Lahey Health Primary Care, Gloucester – 298 Washington Street 4th Floor
Dr. Karen Damico All was excellent!
Lahey Health Primary Care, Gloucester – 298 Washington Street 1st Floor
Dr. Kathryn Hollett is an excellent doctor and I would recommend her to others.
Lahey Primary Care, Hamilton – 15 Railroad Avenue
Dr. William Medwid He’s the best! We love Dr. Medwid.
Lahey Primary Care, Manchester – 192 School Street
Dr. Jana Oettinger is a smart, caring, kind physician who demonstrates her interest in me as her patient.
North Shore Pediatrics – 480 Maple Street
Dr. Thomas Seman All staff are friendly, kind, helpful, and knowledgeable.
Dr. Lance Goodman Always a pleasant experience. Dr. Goodman always answers any questions/concerns.
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:
Gail Hendrickson, Family Medical Associates – Manchester, was recognized for supporting quality improvement efforts.
Christina Medeiros, Blackburn Primary Care, was recognized for her collaboration with the PHO Referral Team. Christina is energetic and excited to learn about the NEPHO. She trained our supporting referral staff in their Athena EMR.
Dr. Jay Isaac, Christina Medeiros, Office Manager and Beth Shanks, PA
Gail Hendrickson, Practice Manager and Dr. Jana Oettinger
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.