Notice Update in Anesthesia Billing Coding Corner: Proper Uses of the 25 Modifier... 4 New Fax Scam Involving Fraudulent Prescriptions...

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Melissa Stephens
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..... 5 CLINICAL UPDATES Notice of Vaccine Reminder Mailer to Members........ 6 Environmental Lead Investigation.

1 May 2018 An Update for Gateway Health Providers and Clinicians PROGRAM AND BENEFIT NEWS Notice Update in Anesthesia Billing Coding Corner: Proper Uses of the 25 Modifier New Fax Scam Involving Fraudulent Prescriptions CLINICAL UPDATES Notice of Vaccine Reminder Mailer to Members Environmental Lead Investigation Learning and Earning With Gateway Health Webinars...8 The Five A s of Tobacco Cessation POLICY NEWS Notice of Practice/Practitioner Changes Important Phone Numbers Important Phone Numbers

2 2 Anesthesia Billing Guidelines Anesthesia Services Providers are reminded of the anesthesia billing guidelines below. Gateway Health requires that all anesthesia services must be submitted with one of the following pricing modifiers in the first modifier position. Required Anesthesia Modifiers AA Modifier Description Anesthesia Services performed personally by an 100% anesthesiologist AD* Medical supervision by a physician for more than four 100% concurrent anesthesia procedures QK Medical direction of two, three, or four concurrent 50% anesthesia procedures involving qualified individuals QX Qualified non-physician anesthetist with medical 50% direction by a physician QY Medical direction of one qualified non-physician 50% anesthetist by an anesthesiologist QZ CRNA service without medical direction by a physician 100% Reimbursement Percentage *Not accepted for PA Medicaid Anesthesia claims must be billed with appropriate modifiers. o AA Modifier denotes the Anesthesiologist did the actual procedure. o QY/QX modifiers denotes the CRNA rendered the service alone or under the Anesthesiologist guidance.

3 3 Anesthesia Billing Guidelines cont. Additional anesthesia billing guidelines to consider:: Gateway processes anesthesia services based on anesthesia procedure codes only. All services must be billed in minutes. Fractions of a minute should be rounded to whole minutes (30 seconds or greater: round up; less than 30 seconds: round down). Physical status modifiers, P1-P6, will not allow any additional payment. These are informational modifiers only and should be submitted after the pricing modifier. The claim should include ONLY the primary anesthesia code except when there is an addon code that should be reported along with the primary anesthesia service. If you provide pain management services, continue to bill with surgical codes. If you provide medical procedures such as Swan Ganz, Laryngoscopy Indirect with Biopsy, Venipuncture Cutdown, Placement of Catheter or Central Vein, then continue to bill with the medical procedure code. When billing OB anesthesia codes 01960, 01961, 01962, 01963, and you do not need to add an additional hour for patient consultation. The Department of Human Services has already added 4 to the relative value unit for these codes. When billing anesthesia for all obstetrical procedures, use the anesthesia procedure codes as defined in the Anesthesia section of the CPT4 manual. Should you have any questions about this communication please contact your Provider Relations Representative or Gateway s Customer Service Department. Customer Service is available 8:30 am to 4:30 pm Monday through Friday by calling for Medicaid or for Medicare Assured.

4 4 Proper Uses of Modifier 25 Preventative Medicine and Sick Visits As per AMA CPT Guidelines, Gateway shall allow reimbursement for a medically necessary sick visit Evaluation and Management (E/M) Service at the same visit as a Preventative Medicine Service (CPT ) when it is clinically appropriate. Providers shall use CPT codes to report a sick visit E/M with CPT modifier 25 to indicate that the E/M is a significant, separately identifiable service from the Preventative Medicine code reported. If modifier 25 is not appended, the sick visit will deny. Please verify with the Medicaid Fee Schedule for reimbursable Preventative Medicine Service codes. Modifier 25 vs Modifier 57 As per AMA CPT Guidelines, Gateway will reimburse E/M Services on the same day as a global surgical procedure for the following circumstances: Modifier 25 Significant evaluation and management service by same physician on date of global procedure E/M Service that is significant and separate on the day of a procedure with a 0 or 10-day global surgical period Modifier 57 Decision for surgery made within global surgical period E/M Service that is the decision for surgery on the day of or on the day before a procedure with a 90-day global surgical procedure The modifiers should be appended to the E/M Service. Absence of the modifiers will cause the E/M Service will deny as global to the procedure. References American Medical Association, Current Procedural Terminology (CPT) CMS, Medicare Claims Processing Manual, Chapter 12 Physicians/Non physician Practitioners, CMS, Medicare Claims Processing Manual, Chapter 18 Preventative and Screening Services

5 5 Warning to Providers About Fraudulent Prescription Scam Gateway Health s Payment Integrity department has been made aware of a new scam involving fraudulent prescriptions being faxed to physicians for their signature. We've received complaints from Gateway Health s members who have received unrequested large quantities of medications and supplies. These complaints prompted us to conduct numerous investigations into these suspected fraudulent prescriptions. We've learned that telemarketing companies are contacting members and obtaining their primary care physician's contact information. Then, the companies fax prescriptions to the physician's office to obtain his or her authorization. HOW TO AVOID THE FAXED PRESCRIPTION SCHEME Gateway urges you to pay attention to any prescriptions or certificates of medical necessity (CMN) faxed from pharmacies or suppliers indicating that the patient has requested the medication or supplies. Be on the alert especially for the following types of requests: Acid reflux or GERD medication (omeprazole sodium bicarbonate) Braces knee, neck, back, or wrist Compound creams Diabetic supplies: blood glucose meters, alcohol pads, test strips, lancet devices, control solutions, and lancets Non-steroidal anti-inflammatory drugs such as mefenamic acid or fenoprofen calcium Scar and skin creams (Urevaz or fluocinonide) TENS units and associated supplies, such as electrodes, leads, and batteries Topical pain creams (lidocaine, diclofenac sodium, Vanatol LQ, and combination packs) Vitamins RED FLAGS The prescription or CMN typically will be completed with the medication or supplies and SIG (label or directions) already filled in, including the number of refills. The quantity of the medication may be unusually high. Most ointments, gels, and creams are dispensed in grams. Most tubes and jars come in sizes of 35.4, 50, or 100 gram sizes. The questionable prescriptions may request a quantity of 250 grams and up. The requesting pharmacy will usually be out of state. The prescription could list multiple diagnoses as checked off, or multiple options in the following categories: topical pain therapy; wellness; scar or dermatitis; eczema; general or diabetic neuropathy; inflammatory pain; arthritis; acid reflux; or GERD. The list of medications can change. Please review any prescription carefully that your office did not initiate. If you are not sure that the patient actually requested and needs the medication, please do not approve the request. If you believe your office has received questionable prescriptions, you may contact the Gateway Health Fraud Hotline at

6 6 New Pediatric Vaccine Reminder Recall Program Launching Gateway Health has partnered with Pfizer to introduce a reminder recall program for patient outreach! By way of print postcards, this reminder recall program will prompt appropriate patients or their guardians to schedule an appointment with your office for recommended immunizations or wellness visits. We have provided samples of the two mailers below. Through this program, executed by a third-party vendor, West (previously known as TeleVox), your patients may be contactedregarding: Pediatric immunizations Pediatric well visits As part of this program, households will receive a notice that explains our records show their child missed a vaccine. Gateway Health members may receive these postcards at 6, 8, 10, and 16 months of age. All communications target members who have already received at least one dose of their recommended childhood vaccines. Your office may experience an increased call volume from patients as a result of this initiative.

7 IS YOUR CHILD FULLY PROTECTED? 29282

8 29317 Open here for important information. Ensure your child receives their recommended vaccinations Model used for illustrative purposes only.

Model used for illustrative purposes only. Dear Parent or Guardian, Our records show that you may have a child who has a recommended 12-month well visit coming up.

9 Model used for illustrative purposes only. Dear Parent or Guardian, Our records show that you may have a child who has a recommended 12-month well visit coming up. At this visit, your doctor may give recommended vaccines, track your baby s growth, and talk about developmental milestones. If your child does not have a well visit appointment scheduled, please contact your child s doctor or health clinic as soon as possible. Vaccines Baby May Receive at 12-Month Well Visit HepB vaccine Hepatitis B Hib vaccine Haemophilus influenzae type b Pneumococcal vaccine Invasive pneumococcal disease Inactivated polio vaccine (IPV) Polio Flu vaccine Influenza MMR vaccine Measles, mumps, and rubella Varicella vaccine Chicken pox HepA vaccine Hepatitis A Source: Centers for Disease Control and Prevention. This postcard is being sent by your child s health plan, health clinic, or health department. Financial support for this communication has been provided by Pfizer Inc. No patientspecific information has been or will be provided to Pfizer. Gateway Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex gender, gender identity or expression, or sexual orientation. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call: (TTY/PA RELAY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY/PA RELAY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп/pa RELAY: 711). PP-PNP-USA Pfizer Inc. All rights reserved. Printed in USA /March 2018

Dear Parent/Guardian: Records show that you may have a child who may have missed a vaccine shot. Please contact your child s doctor or health clinic to find out if you need to schedule an appointment.

10 Dear Parent/Guardian: Records show that you may have a child who may have missed a vaccine shot. Please contact your child s doctor or health clinic to find out if you need to schedule an appointment. This postcard is being sent by your child s health plan, health clinic, or health department. Financial support for this communication has been provided by Pfizer Inc. No patient-specific information has been or will be provided to Pfizer. Gateway Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, creed, religious affiliation, ancestry, sex gender, gender identity or expression, or sexual orientation. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call: (TTY/PA RELAY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY/PA RELAY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп/pa RELAY: 711). PP-PNP-USA Pfizer Inc. All rights reserved. Printed in USA/March 2018

11 7 Gateway Health Environmental Lead (ELI) Investigation Services Gateway Health has contracted with a state-wide provider, Accredited Environmental Technologies (AET), to provide free Environmental Lead Investigation Services to Gateway Health members. Medicaid members are required to be tested for Lead Levels by their 12 month appointment and again at their 24 month appointment, as well as other ages based on history and risk assessment. Members with a venous lead draw showing an Elevated Blood Lead Level of 5 μl/dl, are eligible for an Environmental Lead Investigation. You can refer a patient for an Environmental Lead Investigation. The process to refer for an Environmental Lead Investigation is quick and easy: Complete the form at the link provided below Fax to AET at You can obtain the referral form here: %20Provider%20Page%20Files/ELI%20Process%20Update%20For%20Website.pdf?ver= Services are limited to one ELI per household. Should you have questions about the AET form or the AET Investigation process, please contact Eric Sutherland at AET at AET. Questions regarding Gateway s EPSDT program can be direct to Rebecca Vidak, EPSDT Coordinator at rvidak@gatewayhealthplan.com. Thank you for partnering with Gateway Health.

12 8 Learning and Earning with Gateway Professional Education CME/CEU Webinar Series Gateway Health, in conjunction with Allegheny Health Network, is pleased to present the Learning and Earning with Gateway professional development series. Health care professionals that are part of the Gateway network are invited to participate in a monthly webinar and earn free CME and CEU credits. The series will feature guest speakers who will cover a range of topics relevant to your clinical practice, including: Pediatric Dental Care Wednesday, June 6, 2018 (12-1 p.m.) Cultural Competency Wednesday, July 3, 2018 (12-1 p.m.) *Stay tuned for future webinar topics later in the year. In order to receive CME/CEU credit and webinar dial-in information, healthcare providers MUST ENROLL prior to their first webinar using the following link: Questions? Please contact your dedicated Provider Engagement representative or us at: ProviderEngagementTeam@Gatewayhealthplan.com. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Allegheny General Hospital and Gateway Health Plan. Allegheny General Hospital is accredited by the ACCME to provide continuing medical education for physicians. Allegheny General Hospital designates this live webinar activity for a maximum of 1.0 AMA PRA Category 1 Credit TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

13 9 Begin the Conversation: Help Your Patients Quit Smoking For Good Did you know that 7 out of every 10 smokers want to quit, but only 20% of them will do it on their own, or ask for help? With your help, your patients can begin to live tobacco-free. Starting that conversation can be difficult, but it s crucial to be consistent and talk to your patients about cessation during every encounter. To help you start the conversation, we d like to remind you of the 5As, a proven effective strategy to help you and your patient work toward a tobacco-free life. It allows you to assess your patient s willingness to quit and provide them with the most effective tools to help them quit for good. The 5As are: Ask about and document tobacco use status at EVERY visit Advise in a clear, direct, personalized manner that tobacco users stop smoking Assess willingness to quit at this time. For former tobacco users, ask how recently they stopped and what challenges they may still have trouble dealing with. Assist by prescribing NRT, unless medically contraindicated. Arrange follow up, including counseling. For more information on how you can help your patients quit smoking, go to Black, J Evidence base and strategies for successful smoking cessation. Journal of Vascular Surgery. Volume 51 Number 6. Pg

14 10 Notice of Practice/Practitioner Changes One of the many benefits to the Gateway Health member is improved access to medical care through Gateway s contracted provider network. To ensure our members have up to date and accurate information on availability it is imperative that providers submit written 60 days advance notice of the following: Address changes; Phone & fax number changes; Changes to hours of operation; Primary Care Practice (PCP) panel status changes (Open, Closed & Existing Only); Practitioner participation status (additions & terminations) and; Mergers and acquisitions The Gateway Practice/Provider Change Request Form can be completed for conveying practice/practitioner changes or notice on your practice letterhead is acceptable. If you are a FQHC or RHC please utilize the Roster Template available within the FQHC/RHC Resource Center: to submit practice changes. The regular Provider form is available on --select Provider, and then click on Forms & Reference Materials. As a reminder, the PA Department of Human Services (DHS) requires all providers to have current MPI information. It is critical that providers revalidate their information on a regular basis. If providers do not enroll/revalidate their information with DHS, no payments will be made. Please submit your change request via fax or mail. Fax to: Mail to: Gateway Health Provider Information Management Four Gateway Center 444 Liberty Avenue, Suite 2100 Pittsburgh, PA If you have questions about this Provider Update please contact your Provider Relations Representative directly. Provider Relations Department. Gateway Health

15 11 IMPORTANT PHONE NUMBERS MEDICARE ASSURED IMPORTANT PHONE NUMBERS MEDICAID IMPORTANT PHONE NUMBERS CALL TO INQUIRE ABOUT: FOR INQUIRIES, PLEASE CALL PROVIDER SERVICES MONDAY FRIDAY, 8 A.M. 4:30 P.M (KY) (NC) (OH) (PA) TTY/TDD (FOR ALL DEPARTMENTS) 24 HOURS A DAY, 7 DAYS A WEEK 711 or (KY) (NC) (OH) (PA) MTM (Transportation Services) MONDAY FRIDAY, 8 A.M. 5 P.M.SATURDAY 9 A.M. 1 P.M (KY, NC and OH) (PA) TTY is VOIANCE LANGUAGE SERVICES 24 HOURS A DAY, 7 DAYS A WEEK (Offers bilingual interpreters at a special Gateway rate) , ext.1 MEMBER PROGRAMS MONDAY - FRIDAY, 8:30 A.M.- 4:30 P.M Care Management, select option 1 Maternity/MOM Matters, select option 2 Asthma/ Cardiac/ COPD/ Diabetes, select option 3 Preventive Health Services/ EPSDT/Outreach, select option 4 FRAUD AND ABUSE AND COMPLIANCE HOTLINE 24 HOURS A DAY, 7 DAYS A WEEK (Voic during off hours:the call will be returned the next business day.) Please do not leave multiple voic messages or call for the same authorization request on the same day. TTY/TDD (FOR ALL DEPARTMENTS) MONDAY - FRIDAY, 8 A.M.- 5 P.M. 711 or

CLINICAL UPDATES The Five A s of Tobacco Cessation... 6 Chronic Obstructive Pulmonary Disease...7 Asthma Awareness... 8

CLINICAL UPDATES The Five A s of Tobacco Cessation... 6 Chronic Obstructive Pulmonary Disease...7 Asthma Awareness... 8 May 2018 An An Update Update for for Highmark Highmark Health Health Options Options Providers Providers and and Clinicians Clinicians PROGRAM AND BENEFIT NEWS Anesthesia Billing Guidelines..............2-3