NEWS FROM NEPHO – November 2019


Mary Dipirro, MD
Salem Peabody Oral Surgery
6 Essex Center Drive Suite 112A
Peabody, MA 01960
(P) 978-531-1450 (F) 978-531-9984

Yuliya Mandel, MD
Lahey Health Primary Care, Gloucester
298 Washington Street, (4th Floor)
Gloucester, MA  01930
(P) 978-283-7580  (F) 978-283-0456

Sheaumei Tsai, MD
Urology Consultants of the North Shore
400 Highland Avenue – Suite 6
Salem, MA 01970
(P) 978-741-4133  (F) 978-741-7742


  • Jeffrey Melamed, MD of Beverly Radiological Associates retired as of 7/15/2019.
  • Effective 9/30/2019, Jennifer Schwartz, MD of Lahey Cardiology, Beverly has terminated her affiliation with the Northeast PHO.


Date: December 11, 2019 @ 12:00 p.m. (Noon)
Place: 500 Cummings Center, Suite 6500 – Good Harbor Room – Beverly, MA 01915
RSVP: Judith.O’

Date: December 16, 2019 @5:30 p.m.
Place: 500 Cummings Center – Suite 6500
Good Harbor Conference Room – Beverly, MA 01915
RSVP: or 978-236-1784


Northeast Dermatology Associates (NEDA)
went live with TeleHealth services on  November 14th.
NEPHO has been working directly with NEDA to ensure a successful program implementation funded by the Harvard Pilgrim Health Care grant. The TeleHealth grant has helped purchase equipment, marketing materials, and a TeleHealth platform of the practices choice.

Presently, Dr. David Greenstein and Alison Carpenter, PA will be offering TeleHealth services to patients on:

  •  Wednesdays from 8am-10am and
  • Thursdays from 2pm-4pm.

Services will continue to expand through patient interest and need.  Currently services are being reimbursed by covered insurance and patient self-pay.

Contact Shawn Bromley at or 978-236-1704 if you would like to learn more about TeleHealth.

NEPHO NP PA Meeting Summary

Dr. Justin Fernandes spoke about breast cancer treatments including surgical options. He also reviewed criteria for breast reduction. A very important point discussed was that in the US Stage 1 breast cancer has a 99% survival rate. This really highlights our mission of screening mammograms.

Lucia Kmiec, NEPHO Population Health Coach, also spoke of outreach initiatives she is working on and encouraged providers to talk to their patients about the importance of screening mammograms. You can contact Lucia at or 978-236- 1719.

A note from Alison Gustafson, NP

Hope you can come to the upcoming NP/PA meetings. We have timely topics, updates and great networking opportunities. The presentations are CME approved and we provide lunch!  Stay tuned for next meeting dates and topics.

If you have any special interests please contact me at  or call / text me
at  978-882-2454.

Thank you,
Alison Gustafson, FNP
NP/PA meeting coordinator for NEPHO
Click flyer to be directed to the presentation
Dr. Justin Fernandes, Beverly Shafer, MD presenting at the November 21st. NP PA Meeting



  • Ann Cabral distributed Q2 referral reports by provider. Referral reports have been updated to include: denial, yes or no and if the patient was redirected to an in-PHO specialist. The reports are used as an informational tool to allow providers to see where their patients are going for care.


  • Updated attendance through October meetings was shared.


  • Carol Freedman provided the updated timeline for an education program that has been developed for management of diabetes consistent with current ADA guidelines.
  • Carol provided a detailed review of newer diabetes agents with cardiovascular and renal benefits and a one page “Key Takeaways” reference sheet.


  • The updated 2019 AQC Quality Scorecard was reviewed with focus on areas of opportunity.
  • Currently there are more measures with better performance in 2018, same period.
  • The PHO Quality team’s one to one meetings with providers to review opportunities were completed in October.
  • Updated Quality AQC Provider Specific Action Lists and Scorecards were distributed.

Patient Experience

  • NEPHO results from the 2019 MA Health Quality Partners statewide primary care patient experience survey were reviewed.
  • Both adult and pedi performance improved year over year in all but one measure (adult, access).
  • Minimum and maximum threshold increases in 2019 impacted overall performance despite improvement.
  • NEPHO performance is statistically better than the state in Adult Behavioral Health.
  • In December, MHQP will recognize FMA Hamilton with the 2019 Award for “Most Improved in Assessment of Patient Behavioral Issues”
  • The following practices were notable for performing better than the state, by domain:
    • Patton Park Medical Associates: Knowledge of Patient, Access, Office Staff
    • FMA Beverly, Tozer Road: Self-Management Support
    • Beacon Family Medicine: Office Staff
    • North Shore Pediatrics: Knowledge of Patient
  • Updated Press Ganey star ratings for timeframe January 2018 through August 2019 will be distributed at pod meetings along with patient feedback.
  • Updated star ratings for timeframe January 2018 through July 2019 were distributed at pod meetings along with patient feedback.


  • BILHPN representation, quality data and information regarding VNA payment changes was shared.
  • POD and IPA attendees were asked to complete a Rapid Meeting Assessment as time allowed.


Blue Cross Blue Shield

BCBS AIM High Tech Radiology (HTR) Program

Effective 01/01/2020, prior authorizations for High Tech Radiology (HTR) will not be required from either AIM or BCBS for Commercial HMO and POS members that have an LCPN PCP (Lahey, Congenial, NEPHO and WinPHO). Patients with PCPs who participate in AIM HTR and are affiliated with other networks outside of the Legacy LCPN entities will still require an AIM Prior Authorization. As a reminder; effective 10/01/2019 Prior Auth is required for Medicare Advantage HMO and PPO patients.

Please refer to the following summary grid below as a reference:

*Effective 01/01/2020

Patients are responsible for providing the registration staff with the most current insurance information at, or prior to check-in. Ordering clinicians should confirm benefits and eligibility prior to all services being rendered.

Online registration is required for access to AIM’s Provider Portal. Providers who are already registered on the online portal will not have to re-register.

To access AIM’s Provider Portal, log onto unless otherwise required by your health plan. Some health plans require their user’s to logon via the health plan’s website. See attached documentation for AIM process.

If you have any questions or issues, please contact AIM’s Web Customer Service at 1-800-252-2021.

Harvard Pilgrim Health Care

New Beth Israel Lahey Health Products

Harvard Pilgrim is introducing three new commercial products for Beth Israel Lahey Health (BILH) employees, effective Oct. 1, 2019 for Anna Jaques Hospital employees and Jan. 1, 2020 for the remainder of the BILH member population.

The new products will be called Domestic and Community HMO, HMO Plus, and Tiered POS. The BILH Tiered POS and HMO Plus plans will be tiered, full-network products, with cost sharing varying by tier. The BILH Domestic and Community HMO will be a tiered, limited-network product. Members of this plan will have access to network benefits when services are rendered by providers who are participating in the network, and cost sharing will vary by tier.

Please refer to the HPHC online provider directory for information on participating providers and tier, when applicable, for these new products and benefits. You can recognize members with these products and benefits by their ID cards.

Fallong Health 

Product Reference Guide: Fallon Health Member ID Cards 

Fallon Health posted an updated Product Reference Guide Member ID Cards. Note: The November 2018 guide displays ID cards and details for plans that are effective through December 31, 2019. The October 2019 guide includes essentially the same plans with changes, such as Medicare plans for 2020. For additional information and to view the notification,
click here.

Tufts Health Plan

Choose us as your Medicare plan
and see why 97% of our members
stay year after year.

Click 5 Reasons to Choose 5 Stars to read more.






Blue Cross 2019 Quality Measures – December To-Do List

With only 1 month remaining in the 2019 AQC measurement period, The Northeast PHO gate score sits at 1.89 out of 5 maximum weighted points. We have not yet met the minimum threshold in 9 measures:

  • Diabetes A1c 2x Testing, Diabetes Eye Exams & Diabetes Adherence to Statins
  • Well-Child Visit measures for ages 12-21 and 3-6
  • Breast Cancer Screening & Cervical Cancer Screening
  • Chlamydia Screening Ages 16-20 & 21-24

Here is a brief list of things to think about as we head into the final month of the 2019 Quality measurement period:

  • Schedule Well-Child Visits and Chlamydia Screens. Blue Cross covers physical exams based on the calendar year not 365 days, so please schedule patients even if it has been less than a year since their last physical. Physicals performed in 2020 will not count towards compliance for this AQC cycle so reschedule them to another date this year if possible.
  • Schedule follow up visits or BP checks for patients in the blook pressure measures who’s most recent blood pressure is above target.
    • The target is 139/89 or less for all patients in both the Diabetes & Hypertension Blood Pressure Control measures
    • If a reading is above 139/89, please take a second blood pressure before the end of the visit.  Schedule follow up visits or BP checks for patients in the blood pressure measures who’s most recent blood pressure is above target.
    • Blood pressures taken at home are acceptable only when downloaded electronically from a monitoring device to the medical record
  • There is still time for patients to get mammograms before year end. The PHO’s Health Coach, Lucia Kmiec, has been working all year assisting patients with scheduling their mammograms.  AGH, Lahey at Danvers and Beverly Hospital offer walk in mammograms too.
  • Offer FIT tests or Cologuard to patients on the Colon Cancer Screening measure patient list if they are reluctant or unable to schedule a colonoscopy.

Please let us know how else we may help and support you and your staff. Contact the PHO Quality/Population Health teams:  Liz Isaac, /978-236-1767, Lucia Kmiec, /978-236-1719, Jennifer Andersen,, 978-236-1747, Laureen Viel /978-236-1746.


Harvard Pilgrim New Pharmacy Benefit Manager in 2020

Harvard Pilgrim has selected OptumRx to offer pharmacy benefit management services for commercial and Medicare Advantage plans as of Jan. 1, 2020. Providers will need to obtain prior authorizations through OptumRx and submit mail service prescriptions to OptumRx Home Delivery.

Key points to be aware of during the transition

  • Active prior authorizations and open refills will automatically be transferred to OptumRx.
  • Harvard Pilgrim will continue to manage the pharmacy program, including drug formularies, the development of utilization management criteria, and the appeals function.
  • Requesting new prior authorizations and ordering mail service prescriptions will need to be done using OptumRx.
  • Harvard Pilgrim’s specialty pharmacy and fertility pharmacy vendors are not changing.

Process for requesting prior authorization

Phone and fax:

  • Commercial members: Phone – 855-258-1561; Fax – 844-403-1029
  • Medicare Advantage members: Phone – 855-524-0380; Fax – 844-403-1028

Mail (all lines of business):

Prior Authorization Department
P.O. Box 25183
Santa Ana, CA 92799

Please note: OptumRx offers a tool that integrates with many electronic medical record systems to enable providers to check current prescription coverage and price based on the member’s benefit plan; find alternative medications; and request prior authorization.

Options for ordering mail service prescriptions

Patients can continue to have maintenance medications mailed to their home through OptumRx Home Delivery. Patients can sign up for this service directly or can be requested by:

P.O. Box 2975
Mission, KS 66201

For questions or more information contact Carol Freedman, NEPHO Pharmacy Manager at 978-236-1744 or e-mail


November is Diabetes Awareness Month

As a Health Coach I can help your patients with diabetes through coaching on nutrition, physical activity, and medication adherence, etc.

Managing diabetes is a challenge nationally.  Here’s the current diabetes landscape according to the American Diabetes Association*:

  • Based on recent studies, there is a significant gap in what patients say they are willing to do to reduce A1C and what physicians believe patients are willing to do to reduce A1C.
  • In the last 20 years despite more technology, more education and more drug therapies the average A1C for a person with diabetes has not changed. The number of patients with an A1C over 9% has actually increased.
  • Treatment intensification is significantly behind recommendations in the ADA Standards of Care.
  • Only 5% of recently diagnosed patients with diabetes on Medicare are using Diabetes Self Management Education and Support.
  • Real time patient data indicates that within one year of a diabetes diagnosis, less than 50% of patients are still taking the prescribed medication.
  • In 2017 $327 billion was spent on treatment of people with diagnosed diabetes ($237 direct medical costs and $90 billion reduced productivity)

Please let me know if you have a patient that could benefit from Health Coaching.  I’m here to help.

Lucia Kmiec
NEPHO Health Coach – Population Health
T: 978-880-2318

 For more information on Standards of Medical Care in Diabetes:

*Reference: American Diabetes Association


OPTUM Newsletter – November Focus: Diabetes

CPT Coding Updates Effective January 1, 2020

Effective on January 1, 2020 are the new CPT code updates.  There are 394 changes, including 248 new codes, 71 deletions and 75 revisions. It is important to be aware of these changes as they impact correct coding and reimbursement for provided services. NEPHO is in the process of researching guidelines to ensure accurate education rollout of these new updates. Please contact Shawn Bromley at or 978-236-1704 if you would like to have an education session at your practice and/or have questions related to these 2020 updates. There are many new updates to the Surgery Section of CPT and having a solid understanding of the changes is necessary for accurate coding and billing.

Updates include the following:  Click here to print this information

  • 6 new CPT codes to report online digital E/M service: These codes are for use when Evaluation and Management (E/M) services are performed, types that would be done face-to-face, are performed through a HIPAA compliant secure platform. These are for patient-initiated communications, and may be billed by providers who bill E/M services. 99421, 99422 and 99423 describe patient-initiated digital communications with a physician or other qualified health professional and 98970, 98971 and 98972 represent patient-initiated digital communications with a nonphysician health professional.
  • Additional requirements for 99421, 99422 and 99423:
    •  The interaction must be documented in the permanent record.
    •  If within seven days of the initiation of the online service a face-to-face E/M service occurs, then the time of the online service or decision-making complexity may be used to select the E/M service, but this service may not be billed.
    • If the patient initiates this online service within seven days after an E/M service for the same problem, these codes may not be billed.
    • If the patient inquiry is within seven days of an E/M service for a new problem, the online service may be reported.
    • This is for established patients, per CPT.
    • This may not be billed by surgeons during the global period.
    • The digital service must be provided via a HIPAA compliant platform, such as an electronic health record portal, secure email or other digital applications.
  • 2 new codes for home blood-pressure monitoring: Also spurred by the popularity of digital health tools, new codes 99473 and 99474 will allow reporting self-measured blood pressure monitoring. Tracking blood pressure at home helps patients take an active role in the process and enables physicians to better diagnose and treat hypertension.
  • Updates for health and behavior assessment and intervention services: New codes 96156, 96158, 96164, 96167, and 96170, and add-on codes 96159, 96165, 96168, and 96171 for health and behavior assessment and intervention services will replace six older codes. This update is
    intended to more accurately reflect current clinical practice that increasingly emphasizes interdisciplinary care coordination and teamwork with physicians in primary care and specialty settings.
  • Significant enhancements for reporting long-term electroencephalographic (EEG) monitoring services (95700-95726): Monitoring the electrical activity of the brain is critical to diagnose epilepsy. Four older codes have been deleted to make way for 23 new codes for long-term electroencephalographic (EEG) monitoring services.
  • Surgical Section Updates:
    • Grafting: Watch for four new codes for grafting of autologous fat harvested by liposuction, 15771-15774. The codes vary based on the amount of injectate and the grafting site. The 2020 code set deleted 20926 for other tissue grafts, but added 15769 (Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)).
    • Needle insertions: Dry needling will have two new codes with 20560 (1-2 muscles) and 20561 (3 or more muscles) representing needle insertion without injection.
    • Drugdelivery devices: There will be six new add-on codes, +20700-+20705, related to drug-delivery devices. Three codes are for manual preparation and insertion, varying based on deep, intramedullary, or intra-articular placement. There will be three additional codes for removal based on those same locations. Report these codes along with the appropriate primary surgical procedure.
    • Chest wall tumor excision: New codes for chest tumor excision are 21601-21603 and deleted are 19260, 19271 and 19272.
    • Nasal/sinus endoscopy: Several nasal/sinus endoscopy codes will carry the triangle symbol that indicates a revision for 2020. The AMA reworked the descriptors so the codes can be arranged into more specific families. 31295-31298 will no longer have just “Nasal/sinus endoscopy, surgical” before the semicolon in the descriptor. All will start with the phrase “Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation)” before the semicolon.
    • Pericardial services: The 2020 code set will replace pericardiocentesis codes 33010 and 33011 with 33016, which includes any imaging guidance. Code 33015 for tube pericardiostomy is deleted. Pericardial drainage codes include 33017-33019.
    • Pacemaker removal: A revision to 33275 brings the existing guideline that the code includes imaging guidance into the descriptor for this leadless pacemaker removal code.
  • Surgical Section Update (cont.)
    • Aortic arch grafts: Ascending aorta graft code 33860 will be replaced by 33858 (for aortic dissection) and 33859 (not for dissection). In place of 33870, watch for more detailed code 33871 (Transverse aortic arch graft, with cardiopulmonary bypass, with profound hypothermia, total circulatory arrest and isolated cerebral perfusion with reimplantation of arch vessel(s) (eg, island pedicle or individual arch vessel reimplantation)).
    • Endovascular repair: Deleted 0254T for iliac artery bifurcation endovascular repair. CPT 2020 will have +34717 and 34718 for deployment of an iliac branched endograft. You’ll use +34717 as an add-on code with iliac endovascular repair codes 34703-34706. Code 34718 will be a standalone code for iliac repair “not associated with placement of an aorto-iliac artery endograft at the same session.”
    • Artery exploration: Artery exploration without surgical repair has updated but there is still 35701, but it will change from carotid only to cover any neck artery, with carotid and subclavian. 35702 for the upper extremity and 35703 for lower extremity services. Codes 35721 (femoral), 35741 (popliteal), and 35761 (other) will be deleted.
    • Hemorrhoidectomy: Internal hemorrhoidectomy coding has changes for 2020 that include; Ligation codes 46945 and 46946 will have the phrase “without imaging guidance” added to the descriptors. A new code, 46948, provides a specific option for transanal dearterialization of two or more hemorrhoid columns or groups, including ultrasound guidance.
    • Pelvic packing: New codes for preperitoneal pelvic packing with exploration are 49013 and re-exploration of the wound with packing removal and any repacking 49014.
    • Orchiopexy: Code 54640 has been updated in 2020. Before 2020, the descriptor referred to inguinal orchiopexy with or without hernia repair, suggesting the code included hernia repair. But CPT guidelines instructed you to report the services separately: “For inguinal hernia repair performed in conjunction with inguinal orchiopexy, see 49495-49525.” The 2020 code set keeps that guideline to report the services separately and clarifies the descriptor by removing the hernia reference: “Orchiopexy, inguinal or scrotal approach.”
  • Spinal puncture: There will be an imaging guidance update for spinal puncture. Continued codes are 62270 (lumbar diagnostic) and 62272 (therapeutic), but you’ll also have new options 62328 and 62329 for when those services respectively use fluoroscopic or CT guidance.
  • Nerve injection: The update is that the descriptor wording before the semicolon changes from “Injection, anesthetic agent” to “Injection(s), anesthetic agent(s) and/or steroid.” This change affects every code in the code family. Some of the codes within the code family will see individual updates, such as deletion of 64402 (facial nerve), 64410 (phrenic nerve), and 64413 (cervical plexus).             
  • Additional revisions include:
    • Code 64400 will change from “trigeminal nerve, any division or branch” to “trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular)”
    • Codes 64415 (brachial plexus), 64445 (sciatic nerve), and 64447 (femoral nerve) will remove “single” from their descriptors
    • Code 64420 will add “level” to become “intercostal nerve, single level”
    • Code 64421 will become an add-on code for 64420 and change from “multiple, regional block” to represent “each additional level”
    • There will be two new codes, 64451 for “nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography)” and 64454 for “genicular nerve branches, including imaging guidance, when performed.”
  • Nerve destruction: The sacroiliac (SI) joint and genicular nerves mentioned above get additional attention in two more new codes: 64624 for genicular nerve branch destruction by neurolytic agent, including imaging guidance if used and 64625 for radiofrequency ablation of nerves innervating the SI joint, with imaging guidance.
  • Ciliary body destruction: Code 66711 will add “without concomitant removal of crystalline lens” to the end of the current descriptor, “Ciliary body destruction; cyclophotocoagulation, endoscopic.” When there is lens removal, guidelines will direct to new codes 66987 and 66988.
  • Cataract removal: Code 66984 and complex removal code 66982 will each have “without endoscopic cyclophotocoagulation” added to the ends of their descriptors. This change makes room for the addition of 66987 (complex) and 66988 for the removal procedures with endoscopic cyclophotocoagulation.


Danvers Family Doctors – 140 Commonwealth Avenue
• Dr. Subroto Bhattacharya − Excellent doctor and staff!

Lahey Health Primary Care, Beverly – 30 Tozer Road
I have been with Dr. Susan DeLuca for years – she’s the best!
I have been a patient of Dr. Tina Waugh for over 10 years and she has always showed concern for me.

Lahey Health Primary Care, Beverly – 100 Cummings Center, Suite 126Q
Dr. Pierre Ezzi provides excellent medical care. I have been his patient for several years.
I highly recommend Dr. Ezzi without reservation.

Lahey Health Primary Care, Danvers – 480 Maple Street
Dr. Manju Sheth has been my doctor for 7 years. She’s always available and respectful.

Lahey Health Primary Care, Danvers5 Federal Street
Never had a bad experience with Dr. Mauri CohenDr. Cohen and his staff are the most caring people!

Lahey Health Primary Care, Gloucester – 298 Washington Street, 4th Floor
Dr. Karen Damico and all staff members were professional, courteous and respectful as always.

Lahey Health Primary Care, South Hamilton – 15 Railroad Avenue
Dr. Hugh Taylor has been my primary care physician for about 25 years. He is among the BEST!
Dr. Laurence Gordon is the best doctor I’ve had in my 91 years.

North Shore Pediatrics – 480 Maple Street, Danvers, MA
Dr. Shannon Dufresne is exceptional!  We love this practice.

North Shore Preventive HC, PC75 Herrick Street, Beverly, MA
Five star treatment! Only the best of care from Dr. Roy Ruff and his staff.

Candace Thompson, MD 9 E Dr. Osman Babson Road., Gloucester, MA
Can’t say enough about this compassionate doctorDr. Candace Thompson truly is one of a kind!
She is the ultimate professional demonstrating knowledge, kindness and concern for my well being.


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:

Please let us know if you have any office staff you would like to nominate for the recognition program.

Theresa Horgan, Lahey Health Primary Care, Gloucester, was recognized for her patient comment “Staff is very friendly especially Theresa Margaret”.

Tracy Pelletier, Lahey Health Primary Care, Danvers, was recognized for excellent patient outreach efforts scheduling needed appointments.

We appreciate their efforts in supporting the PHO goal to provide high quality, community health care.   We will deliver gift cards to the winners each month, and they will be announced here in the newsletter.

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

Theresa Horgan and Andrea Budrow
Tracey Pelletier and Dr. Steven Keenholtz