Routine Radiology Services

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1 FOR NETWORK PROVIDERS OF KAISER PERMANENTE networknews APRIL 2007 Produced by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. with the Mid-Atlantic Permanente Medical Group, P.C. Kenya Neal, Manager, Provider Relations address: Website address: Routine Radiology Services Routine radiology services that are performed at a communitybased Kaiser Permanente Participating Radiology site; do not require processed referrals by the Provider Service Center. Kaiser Permanente Participating Radiology Center can perform the following routine services, and send their claims directly to our Claims Department for processing: Screening Mammography Ultrasounds Doppler Studies Duplex Scans Chest X-rays Extremity X-rays Dexa Scans CAT Scans Non-Routine services that require a pre-authorization by the Provider Service Center are: Cyber Knife Studies PET Scans MRI s MRA s Nuclear Medicine Studies Interventional Radiology Studies Referral Guidelines to be named Medical Coverage Policies (Referral) In order to enhance the distinction between Clinical Practice Guidelines established by the Care Management Institute, and Referral Guidelines utilized by Utilization Management as basis for coverage decisions for medical services, we are transitioning the term Referral Guidelines to the industry standard nomenclature, Medical Coverage Policies (Referral). Look for this change soon on the Kaiser Permanente Provider Website at Specialty Care Referrals Kaiser Permanente has been a longstanding advocate for high quality and coordinated patient care. Communication between all providers caring for a member is essential. Specialist providers providing services to a patient should ensure that the patient s PCP is informed of all aspects of their care. Following an approved initial consult, Specialists may complete and fax a Uniform Referral Form to the Provider Service Center at or enter a referral into the Kaiser Permanente Health Connect Online Affiliate Provider website at for those services requiring pre-authorization.

2 Provider Service Center Hospital Hotline New Hours of Operation Effective May 16, 2007 the new hours of operation for the Telephonic Admission and Concurrent Review Team (TACT)-formerly known as the Provider Service Center Hospital Hotline are as follows: Core Facilities: Please call , and select the appropriate option, during the following hours: 8:30 am to 7pm (Monday through Friday) After Hours Coverage is 7pm to 8:30am (Monday through Friday, weekends and holidays) Notification of Admission can be received via voice mail by calling , select the appropriate option and leave the requested information -or- Providers can enter a referral into the Kaiser Permanente Health Connect Online Affiliate Provider website at -or- Fax information to (301) Requests for Hospital Admissions will be responded to by Kaiser Permanente TACT or Utilization Management staff on the next day. Non-Core Facilities: Please call , and select the appropriate option, which will connect you to the Emergency Care Management team. Should you have any questions about the content of this message, please contact the Provider Relations Department at Level of Detail Coding Diagnosis and procedure codes are to be used at their highest number of digits available. ICD-9-CM diagnosis codes are composed of codes with either 3, 4, or 5 digits. Codes with three digits are included in ICD-9-CM as the heading of a category of codes that Claims General Coding Guidelines Clinical Pearls and Other Trivia may be further subdivided by the use of fourth and/or fifth digits, which provide greater detail. A three-digit code is to be used only if it is not further subdivided. Where fourth-digit subcategories and/or fifth digit sub classifications are provided, they must be assigned. Avoid Medication Errors! Put the reason for the drug in the Sig box. e.g. Cortisporin 2 drops each ear QID for ear infection Patients who have undergone Neck Irradiation are at higher risk for premature cerebrovascular disease Be certain that your female patients have a negative HCG result within the 24 hours before undergoing Xray procedures to any pelvic or abdominal area. Fetal Motion Counts in late pregnancy are the best indicator of a healthy baby. Be certain to ask about and document fetal activity in the third Trimester During an average human lifespan the heart will beat 2.5 Billion Times Brought to you by your friendly neighborhood Quality Department. Compiled by Lauren Cosgrove and Joseph Territo, based on cases reviewed this year and interesting trivia. Please send us YOUR tips and feedback at Management of Health Information Kaiser Permanente of Mid Atlantic States is committed to the management of health information to assure federal, state and local regulatory compliance of medical record documentation standards throughout the Mid-Atlantic States region and network practitioners. The organization s commitment is demonstrated by our continuous monitoring of medical record documentation standards. Chart reviews were conducted on a random selection of provider offices that have more than 50 Kaiser Permanente [2]

3 members. Of those members, five members charts that had a minimum of three office visits with you in the past two years were reviewed. The chart reviews were completed by professional clinical data specialist staff. Overall results of providers surveyed indicated a 70% compliance rate. Five out of 21 network practitioners met 85% performance goal. The most problematic elements for the majority of practitioners were 1) a completed problem list, 2) documentation of sexual behavior, smoking, alcohol and substance use history 3) documentation of medical and surgical history 4) lack of immunization record with supporting documentation and 5) time for next visit. KPMAS staff will conduct a follow-up audit of your records within the next 6-9 months to assure compliance of the medical record documentation standards for those offices that did not meet an overall accuracy rate of 85%. For those that met an overall accuracy rate of 85% or greater, your next audit will occur in We would like to commend the office of Angela Hubbard, for scoring 100% in all applicable categories. KP-MAS Documentation Standards Q1 Entries are legible Q2 Entries are dated Q3 All entries contain author s identification Q4 Allergies and adverse reactions are prominently listed or noted NKA Q5 Information regarding personal habits (i.e. sexual behavior, smoking, alcohol use) are recorded Q6 An updated problem list is maintained Q7 Chronic illnesses and medical conditions which are active are listed on the problem list. Q8 Patient s chief complaint or purpose of visit is clearly documented Q9 Follow-up instructions and time frame for follow-up or next visit are recorded. Q10 Am immunization record is completed for members 18 yrs and under. Q11 Lab and other diagnostic reports reflect practitioner review. Q12 If a consultation is requested, there is a written report/ summary in the record reflecting practitioner review. If you have any questions or want more information, please feel free to contact Debbie Reed at (703) or send an to Debbie.A1,Reed@kp.org. The Administrative Simplification provisions of the Health Portability and Accountability Act of 1996 require the Dept. of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans and employers. The National Provider Identifier (NPI) is a 10 digit numeric identifier that will be used to identify healthcare providers. NPIs will be assigned by a Medicare national entity. This identifier is INTELLIGENCE free. It is a randomly selected number not associated with specialty or unique information about the provider. The purpose of the National Provider Identifier (NPI) is to uniquely identify a health care provider in standard transactions, such as health care claims. The compliance date for mandated use of the NPI in standard transactions is May 23, There are two types of NPIs: National Provider Identifier (NPI) 1. Type 1 will be assigned to practitioners 2. Type 2 will be assigned to Ancillary, facilities, DME providers, labs and radiology. It is vital that you obtain your NPI by May 23, 1007, so please use one of the following three ways to apply as soon as possible: 1. A web-based application process is available at nppes.cms.hhs.gov 2. A paper application may be submitted to an entity that assigns the NPI (the Enumerator). A copy of the application, including the Enumerator s mailing address, is available at http//nppes.cms.hhs.gov. A copy of the paper application may be obtained by calling the Enumerator at (800) or TTY (800) With provider permission, an organization may submit a request for an NPI on behalf of the provider via an electron file. Please call Provider Relations at with any further questions [3]

4 The new form will update the existing CMS-1500 claim form (version 12/90), also called the HCFA The new form will allow you to enter your National Provider The New CMS 1500 Health Insurance Form Identifier (NPI) number in block 24I. Provider s claims should be filed on the revised CMS-1500 starting April 1, Here is an example of the revised CMS [4]

5 SUPARTZ treatment reimbursement in 2007 Effective 2007 there will be changes affecting the HCPCS claims coding for SUPARTZ treatments. SUPARTZ treatment is administered through Arthocentesis (Intra articular injection) and is FDA approved for the treatment of osteoarthritis of the knee in patients who have failed to respond to simple painkillers, exercise or physical therapy. It is a solution of highly purified sodium hyaluronate for use in viscosupplementation. SUPARTZ treatment through Arthrocentesis is administered directly into the knee joint to restore the cushioning and lubricating properties of normal joint fluid. A physician administers an injection of SUPARTZ treatment (25mg/2.5ml) into the knee once a week for three to five weeks. The products affected include: SUPARTZ, Hyalgan, Euflexxa, Synvisc and Orthovisc. In recognition of the clinical and dosing differences among the various products, CMS has decided to move all the IA Sodium hyaluronate products into temporary Q-Codes with differing reimbursement levels. The Medicare reimbursement amounts are based on the average selling price and will change each calendar quarter. The codes are as follows: Q4083 SUPARTZ and Hyalgan Q4084 Synvisc Q4085 Euflexxa Q4086 Orthovisc These new Q codes may be used by Medicare carriers. We urge you to update your claims processing software to include Q4083 and the other codes for hyaluronate injections. This will allow efficient claims processing, avoid delays due to the use of invalid codes. If you have questions, contact Provider Relations at The Mid-Atlantic Permanente Medical Group, P.C E. Jefferson Street Rockville, MD Presorted Standard US Postage PAID Rockville, MD Permit # 4297 [1]