News from NEPHO – SEPTEMBER 2022 Edition


  • Richard Birkett, MD of Essex Surgical Associates, 100 Cummings Center Suite 112 D, Beverly, MA 01915 Phone: 978-922-9226. Fax: 978-922-9203. Anticipated start date: 10/1/2022
  • O’Ine McCabe, MD of Specialized Pediatric Eye Care, 77 Herrick Street, Suite 102, Beverly, MA 01915 Phone: 978-338-4321. Fax: 978-232-1010. Start date: 9/1/2022


  • Jonathan Jaques, MD of Beverly Anesthesia Associates, 480 Maple Street, Danvers, MA 01923 has termed effective 12/31/2021


BCBSMA Online Services will no longer be in service after September 30, 2022. BCBSMA created a reference table to show which technologies to use for referrals and authorizations. To view the reference table and complete notification, click here.


NP/PA Meeting
Date: Wednesday, October 26th, Noon
Speaker: Kimberly Willis, NP-C, Nurse Patient Navigator
Title: Breast Health: How do we treat, guide and educate our patients?
Location: Teams Meeting

Beverly Hospital Provider Networking Event
Date: Wednesday, November 9th, 5:30pm-7:30pm
Location: Tupper Manor at the Wylie Inn & Conference Center
295 Hale Street, Beverly, MA
For more information, contact


The 2022 Attendance Policy was changed from previous years.


  • The October POD meetings were canceled to provide an opportunity for you to attend one of the three Open Meeting II Meetings. If you attend one, you will receive a meeting credit.


  • Open Meeting II is a requirement to meet your attendance goal. If you already attended 1 or 2 meetings (Open Meeting I, Annual Meeting or Specialty Specific Meeting), attendance at an Open Meeting II session is still required.


The same presentation will be conducted at all sessions. Please note: attending more than one session will not earn additional meeting credit.

Date: Wednesday, October 12, 2022, 5:30 pm
Location: Zoom (NOT Teams Meeting)

Date: Tuesday, October 18, 2022, 12:30 pm
Location: Zoom (NOT Teams Meeting)

You may check your attendance on the NEPHO website here. 

If you have forgotten your password, please contact Nick Catino at If you need initial access, please click here to complete a confidentiality agreement and send to Alycia Messelaar at Lisa Driscoll ( may also be able to check your attendance status.


Please join NEPHO and Beverly Hospital on Wednesday, October 5th at 6 pm via Teams to hear Dr. Catherine Caldicott speak on Fostering a Culture of Civility. She has great suggestions on how to successfully deal with difficult behavior.

Click here to join the meeting

We encourage all providers, office managers and leadership roles within the practices to join the session, as we have found the information to be extremely beneficial both professionally and personally.

Hope to see you there!

Click here to view and download the brochure for CME and meeting details.


In 2020, Beth Israel Lahey Health Performance Network (BILHPN) partnered with Harvard Pilgrim Health Care, Blue Cross Blue Shield of MA, and Tufts Health Plan to eliminate the need for an administrative referral for specialty office visits referred within BILHPN. This process is referred to as Referral Simplification.

Tufts identified an issue with their Referral Simplification logic once the Public Health Emergency waivers were lifted. A limited number of claims have been denied for no referral. 

Below is a summary of the current logic for Tufts Commercial plans:


  • Referrals are not required if your primary affiliation is NEPHO and the PCP is within any BILHPN group
  • Referrals are not required from NEPHO PCPs if your secondary affiliation is NEPHO and your primary is with another risk unit
  • Referrals are required from other BILHPN PCPs (Lahey, WinPHO) if your secondary affiliation is NEPHO and your primary is with a non BILHPN risk unit (for example, MGB)


  • Referrals are required from NEPHO PCPs to other BILHPN specialists (WinPHO) if they are primary with a non BILHPN risk unit (for example, NEQCA)

BILHPN and Tufts are working on the issue to address the bullets in red. We will provide an update as soon as possible. If you have any questions about a Tufts referral, please contact Ann Cabral at or Alycia Messelaar at

Thank you,

The NEPHO Referral Management Team

Click here to view examples.


Click here for more information on The Resource Connection. 


Payor Medical Policy Update
Blue Cross Blue Shield of Massachusetts Attention Billing Agencies!
BCBSMA recently created a detailed Brainshark presentation that highlights what resources are available on the Provider Central website for billing agencies and providers who use billing agencies; Where to find self-service resources to get the information providers need; How to sign-up for Provider Central, obtain claim status, and more. To view the complete notification, click here.
Blue Cross Blue Shield of Massachusetts September 2022 Medical Policy Announcements
This document announces new medical policy changes that take effect December 1, 2022. To view the list, click here.
Blue Cross Blue Shield of Massachusetts Medical Policy Update: Surgical and Non-CPAP Treatment of Snoring and Obstructive Sleep Apnea Syndrome
Hypoglossal nerve stimulation for obstructive sleep apnea (OSA) retired from policy 130. Effective 9/11/2022. For coverage information, see AIM Specialty Health Clinical Appropriateness Guidelines for Sleep Disorder Management. Clarified coding information. To view the complete notification, click here.
Blue Cross Blue Shield of Massachusetts Monkeypox Vaccine Billing Guidelines
In response to the monkeypox public health emergency, BCBSMA would like to provide guidelines on how to bill for the administration of the monkeypox vaccine. To view the complete notification, click here.
BMC HealthNet Plan BMCHP Radiology will be changing from Evicore to AIM
Please click here to view and download the information brochure.
Medicare COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (Telehealth/Telemedicine)
Updates have been provided throughout the document. Red font indicates change. To view the updated document, click here.
Medicare Correction: Monkeypox & Smallpox Vaccines: Include Product Code on Claims
The August 11 edition told to only bill for vaccine administration when providers got the vaccine at no cost from the government. The correct instructions are to include these 3 elements on the claim, even if providers get the vaccine from the government for free: 1) Product code (90611 or 90622); 2) Applicable ICD-10-CM diagnosis code; 3) Administration code. For additional information, click here.
Medicare MLN Connects News: Updated COVID-19 Vaccines Providing Protection Against Omicron Variant Available at No Cost
The FDA has authorized the Moderna and Pfizer-BioNTech updated vaccines that target the original COVID-19 viral strain and two Omicron variants (BA.4/BA.5) that are currently the most prevalent in the U.S. Individuals are eligible for their updated vaccine shot at least two months after completing at least their primary vaccination series (two doses of Pfizer-BioNTech, Moderna, or Novavax, or one dose of Johnson & Johnson)—regardless of how many monovalent COVID-19 boosters they have received to date. CMS issued 4 new CPT codes effective August 31, 2022: 91312 for Pfizer-BioNTech, 91313 for Moderna, 0124A for Pfizer-BioNTech administration, 0134A for Moderna administration. For additional information, click here.
Medicare COVID-19 Vaccines and Monoclonal Antibodies (Updated 8/22/22)
The document has been updated with Novavax COVID-19 Vaccine, Adjuvanted emergency use authorization to authorize the use for all patients 12 years and older. To view the document, click here.
Medicare Influenza Vaccine Payment Allowances – Annual Update for 2022-2023
The purpose of this recurring update notification Change Request (CR) is to provide the availability of payment allowances for the seasonal influenza virus vaccines as updated on an annual basis, effective August 1 of each year. The update applies to publication 100-04, chapter 17, section 20.5.9. To view the transmittal, click here.
Medicare 2022-2023 Seasonal Influenza Vaccine Pricing
Annual Influenza Vaccine season starts on August 1 and ends on July 31 of the following year. To view the list of payment allowances for the 2022-2023 flu season, click here.
Harvard Pilgrim Health Care Update on Pediatric Infant Formula
Harvard Pilgrim members may continue to obtain coverage for prescription infant formula, under their medical benefit, at a pharmacy without prior authorization through Oct. 31, 2022. For additional information, click here.
Harvard Pilgrim Health Care Transforming Kidney Health Management
Harvard Pilgrim announced that Point32Health, the parent company of Harvard Pilgrim Health Care and Tufts Health Plan, is collaborating with Monogram Health for in-home chronic kidney disease (CKD stages 3b-5) and end-stage renal disease (ESRD) care management services for commercial fully insured members, effective Sept. 1, 2022. Monogram Health is a leading value-based provider of in-home nephrology, primary care, and benefit management services for individuals with CKD and ESRD. For additional information, click here.
Harvard Pilgrim Health Care COVID-19 Testing, Treatment & Vaccine Coding (COVID-19)
Harvard Pilgrim Health Care has updated the COVID-19 Testing, Treatment & Vaccine Coding guide. For additional information and to view the notification, click here.
Harvard Pilgrim Health Care Payment Policy Update: Telehealth/Telemedicine
Harvard Pilgrim Health Care has updated the policy for dates of service on or after September 1, 2022. For additional information and to view the notification, click here.
Harvard Pilgrim Health Care
NIA Code Coverage and Prior Authorization Update
Harvard Pilgrim will now provide coverage, with prior authorization, for the medically necessary use of magnetic resonance spectroscopy (CPT code 76390) for members of the Commercial plans. To view the complete notification, click here.
Tufts Health Plan
Coronavirus (COVID-19) Updates for Providers (Telehealth/Telemedicine)
Last updated 09/16/22: Added clarifying information regarding Bivalent boosters To view the complete notification, click here.
Tufts Health Plan
Payment Policy Update: Preventive Services
Tufts Health Plan has updated HIV PrEP section. To view the complete policy, click here.
Tufts Health Plan
Update on Pediatric Infant Formula
Tufts Health Plans will continue to waive prior authorization for prescription infant formula through a contracted DME provider through Oct. 31, 2022. For additional information and to view the entire notification, click here.
Tufts Health Plan Prior Authorization Updates Related to Glucose Monitors (Tufts Medicare Preferred HMO, Tufts Health Plan SCO)
Tufts Health Plan updated the Prior Authorization/Prior Authorization and Inpatient Notification Lists for Tufts Medicare Preferred HMO and Tufts Health Plan Senior Care Options for Glucose Monitors, effective for dates of service beginning Nov. 1, 2022. For additional information and to view the entire notification, click here.
Tufts Health Plan Working with CareLink
The administrative services for CareLink accounts are shared between Tufts Health Plan and Cigna; however, one is selected to serve as the primary administrator for each particular CareLink account. To view the complete notification, click here.



Please click here to take a moment to read the Provider Spotlights!

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

Virtual Networking videos from NEPHO providers can be found at

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

Click here for the PDF version of the updated PHO Directory as of September 2022. For your convenience click here for the separate Specialists Only PDF directory to refer to as needed.

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

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

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

Here at the PHO, we completely understand how overwhelming it can be to stay on top of all the email communications that are being sent on a day-to-day basis. In an effort to keep you well informed, below you will find a highlight of key memos that have been sent out over the last month – Just in case you missed it!

  • Monthly BILH Pharmacy Newsletters
  • FREE WEBINAR: Recharge from Pandemic Exhaustion
  • Open Meeting II Reminders
  • BILHPN | Health Plan Orientation – Provider Office Staff Zoom Webinar | Commonwealth Care Alliance – One Care
  • SSRIs and Beyond – CME opportunity for Pediatric and Family Medicine providers (MD/DO/NP/PA/LICSW)
  • BILHPN Participation in MassHealth ACO “Drop-in” Q&A Sessions

Please reach out to Alycia Messelaar at for a specific communication that you are unable to find.


October – Breast Cancer Awareness Month

As most people are aware October is Breast Cancer Awareness Month. During this month, a concerted effort is made to increase awareness of breast cancer and encourage women to get mammograms.

It is not unusual for women to put off their screenings because of anxiety about getting mammograms. Women may be concerned that the procedure will hurt or be uncomfortable. Others fear that they will have cancer. Some patients have concerns about radiation and false positives.

Often times providing information and statistics can help women overcome their anxiety.

  • Of all the mammograms performed only about 10% are called back for further testing and less than 1% will actually be diagnosed with breast cancer1.
  • Current mammography involves a tiny amount of radiation exposure.
  • The radiation dose used for a mammogram is about the same amount of radiation a woman would get from her natural surroundings in approximately seven weeks2.

The chart below shows the breast cancer biopsy results from 2020 to 2021 for Beverly Hospital and Addison Gilbert Hospital. Due to the pandemic there was a delay in screenings. The data showed an increase in cancers diagnosed and a 2% increase in Stage IV cancers.

If providers have a patient who is extremely anxious about getting a mammogram, Denielle Palm, Associate Director of Radiology and the Breast Health Center is happy to talk to patients about any fears or concerns they may have. Her direct line is 978-304-8002.

If a patient has indicated that she is willing to have a mammogram, providers can reach out to Laureen Viel, Lead Population Health Specialist for concierge scheduling. EPIC providers can send an in-basket message to Laureen or she can also be reached by phone at 978-236-1746. To schedule a mammogram through Access Services patients can call 1-866-479-3208.



OPTUM NEWSLETTERSeptember- Focusing on Vascular disease and coagulation defects

ICD -10 CM 2023 Coding Update Highlights

It is important to be ready for the new ICD-10 CM 2023 updates effective 10/1/2022. There are 1,176 new billable codes for 2023 compared to 2022’s 153 new billable codes. The highlights for code updates include the following areas: Dementia, endometriosis, maternal care for fetal disorders, head injuries, and motorcycles/electric bike accidents. There have been 251 codes deleted, and several terms and inclusion terms have been modified. New social determinants of health codes have been introduced in Chapter 21: Factors influencing health status and contact with health services (Z00-Z99) adding several new codes including Z59.82 Transportation insecurity, and Z59.87 Marital hardship. Many of the changes pertain to common home health conditions, including 69 code additions to further identify the stage of severity as well as behavioral and psychological symptoms of dementia. Additional areas with numerous code updates were found in Chapter 14 & 15. 

Chapter 14: Diseases of Genitourinary System (N00-N99) added 168 new endometriosis codes, which provide higher specificity to include anatomic locations, depth, and laterality.

Update examples for Diseases of the Genitourinary System: 

N80.00 Endometriosis of the uterus, unspecified
N80.01 Superficial endometriosis of the uterus
N80.02 Deep endometriosis of the uterus
N80.03 Adenomyosis of the uterus
N80.10 Endometriosis of ovary, unspecified depth
N80.11 Superficial endometriosis of the ovary
N80.129 Deep endometriosis of ovary, unspecified ovary
N80.20 Endometriosis of fallopian tube, unspecified depth

Chapter 15: Pregnancy, Childbirth and the Puerperium (O00-O9A) added 200 new codes needed to more accurately represent a large number of specific fetal conditions that were not represented adequately in prior versions of ICD-10-CM.

Update examples for Pregnancy, Childbirth and Puerperium:

O35.03×5 Maternal care for (suspected) central nervous system malformation or damage in fetus, choroid plexus cysts, fetus 5
O35.04×0 Maternal care for (suspected) central nervous system malformation or damage in fetus, encephalocele, not applicable or unspecified
O35.05×2 Maternal care for (suspected) central nervous system malformation or damage in fetus, holoprosencephaly, fetus 2
O35.06×1 Maternal care for (suspected) central nervous system malformation or damage in fetus, hydrocephaly, fetus 1

Update examples for Behavioral Health, Mood & Neurodevelopment Disorders:

F01.A3 Vascular dementia, mild, with mood disturbance
F01.A4 Vascular dementia, mild, with anxiety
F01.B Vascular dementia, moderate
F01.B0  Vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety
F03.911 Unspecified dementia, unspecified severity, with agitation
F03.918 Unspecified dementia, unspecified severity, with other behavioral disturbance

Additional Coding updates examples for 2023:

D81.82 Activated Phosphoinositide 3-kinase Delta Syndrome [APDS]
E34.30 Short stature due to endocrine disorder, unspecified
G93.39 Other post infection and related fatigue syndromes
I20.2 Refractory angina pectoris
J95.87 Transfusion-associated dyspnea (TAD)
K76.82 Hepatic encephalopathy
M51.A5 Intervertebral annulus fibrosus defect, large, lumbosacral region
M62.5A Muscle wasting and atrophy, not elsewhere classified, back

Social Determinants of Health (SDOH)

There will be updates to SDOH that have been driven by our current environment socially and economically. These codes will be very important in helping to identify areas of need within our communities. Coding these areas for patients will help payers collect data to review immediate needs within our area communities. The 2023 ICD-10 updates include the following areas to help improve patient care:

  • Z55.0 Illiteracy and low-level literacy
  • Z56.0 Unemployment, unspecified
  • Z57.1 Occupational exposure to radiation
  • Z57.31 Occupational exposure to environmental tobacco smoke
  • Z57.39 Occupational exposure to other air contaminants
  • Z57.4 Occupational exposure to toxic agents in agriculture
  • Z57.5 Occupational exposure to toxic agents in other industries
  • Z57.6 Occupational exposure to extreme temperature
  • Z58.6 Lack of adequate drinking water
  • Z59.0 Homelessness
  • Z59.41 Food insecurity
  • Z59.5 Extreme poverty
  • Z59.7 Insufficient social insurance and welfare support
  • Z59.81 Housing instability
  • Z59.82 Transportation insecurity
  • Z59.86 Financial insecurity
  • Z60.2 Problems related to living alone
  • Z60.4 Social exclusion and rejection
  • Z64.0 Problems related to unwanted pregnancy

CMS has provided a conversion table to help compare new codes against old diagnosis codes. This will help in identifying new codes to use and better understand the sub-categories that have been created for ICD-10.

The following link will bring to the CMS conversion table:

Please reach out to Jessica Bryan at if you have questions regarding the new ICD-10 CM Coding Updates. 


Beth Israel Lahey Health Primary and Specialty Care, Beverly – 30 Tozer Road Suite 203

  • Dr. Alyssa Handler was very informative yet listens to what I had to say, asked all questions about my family!
  • I have been a patient of Dr. Deborah Shih’s for many years. She has always been very caring and compassionate, and knows things about me without looking at my chart. She is an excellent physician and I recommend her often.

Beth Israel Lahey Health Primary Care, Beverly – 100 Cummings Center

  • I feel Dr. Pierre Ezzi listens to me and does not rush the appointment. He Is kind and truly listens to what I am saying.

Beth Israel Lahey Health Primary Care, Beverly – 30 Tozer Road

  • Dr. Tina Waugh has been a Godsend many many times over the years. She is knowledgeable, compassionate and determined to keep me healthy & safe!

Beth Israel Lahey Health Primary Care, Beverly – 900 Cummings Center

  • Dr. Andrew Lenhardt is exceptional in his attentiveness, true caring, knowledge, and open-mindedness. I have never had a doctor who I felt so confident in and completely comfortable with.
  • Dr. Daniel McCullough and his staff have always and consistently given the best care and attention to my needs.

Beth Israel Lahey Health Primary Care, Danvers – 480 Maple Street

  • Dr. Kristina Jackson, is by far, the best doctor I ever had, very kind always listens well, is in no hurry, I would surely recommend her to all my friends, & my family too.

Beth Israel Lahey Health Primary Care, Danvers – 5 Federal Street

  • Dr. Brent Fryling is the best dr. I have ever had. He is very compassionate. He is very thorough and listens to whatever is on your mind. I would highly recommend Dr. Fryling.

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

  • Dr. Victor Carabba provides excellent treatment and excellent professional experience.

Beth Israel Lahey Health Primary Care, Hamilton – 15 Railroad Avenue

  • Dr. William Medwid is and has always been thorough, informative and kind. I could not find a better physician if I tried.

Beth Israel Lahey Health Primary Care, Manchester – 195 School Street

  • Dr. Jana Oettinger is a very good listener. Caring and helpful.

Blackburn Primary Care, Gloucester – 1 Blackburn Drive

  • Dr. Jay Isaac always spends the time that I need him to. Listens carefully.

Cape Ann Medical Center, Gloucester – 1 Blackburn Drive

  • Dr. James Maguire’s care is always prompt, thorough and effective.

EMTAR, South Hamilton – 205 Willow Street

  • Dr. Michael Edwards is an excellent doctor. Excellent staff.

Essex County Primary Care, South Hamilton – 42 Asbury Street

  • From when you get greeted at the front desk to when you see Dr. Nicholas Avgerinos. You know that you are surrounded by people who care about your health & well being.
  • I can’t say enough good things about my experience. The staff and Dr. Nicholas Avgerinos were friendly, efficient and informative. I didn’t have an appointment for a physical I needed for work but Dr. Avgerinos and his staff stayed after hours. They did not rush through the exam and he answered all of my questions thoroughly. I would highly recommend Dr. Avgerinos.

Garden City Pediatrics, Beverly – 83 Herrick Street

  • We absolutely love Dr. John Dean and have recommended him and others/the general overall practice to family members who now go there as well. We have never had a bad experience at Garden City pediatrics.
  • Dr. Suzanne Graves is an excellent, thoughtful pediatrician.

North Shore Pediatrics, Danvers – 480 Maple Street

  • Dr. David Danis provided excellent care to our sick child. He was able to see the big picture and not just do tests that might cause him discomfort and trauma! Can’t recommend him enough.
  • Dr. Shannon Dufresne is compassionate and caring!
  • Dr. Thomas Seman and his staff are phenomenal. We are so lucky to have you all!
  • Always pleased with the care, attention and expertise provided by Dr. Thomas Seman and North Shore Pediatrics!