CMA - California Medical Association

CMA Practice Resources (CPR) is a free monthly e-bulletin from the California Medical Association’s practice management experts that focuses on critical payor and health care industry changes and how they directly impact the business of a physician practice. Each issue includes tips on reimbursement and contracting related issues along with information on the latest practice management news.

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In this issue:

• File by Dec. 16 to avoid Medicare PQRS and value-based modifier penalties 
• United Healthcare issues amendment to physicians participating in Core network
• New law requiring accurate provider directories includes provider obligation to update information
• Physicians urged to preemptively file for meaningful use hardship exemptions
• Anthem asking physicians to affirm participation in workers’ comp MPNs by Dec. 31 
• Why it’s important to verify your patients’ eligibility and benefits for 2016
• United Healthcare to delay implementation of multiple procedure payment reductions until March 1 
• DMHC fines Blue Shield and Anthem for provider directory inaccuracies
• DWC reinstates requirement to pay lien activation fees for Workers' Compensation claims
• CMS changes enrollment requirements for Part D prescribers
• United Healthcare to delay Premium Designation assessment until January 2017
• CMA to relaunch webinar program; first program on meaningful use scheduled for Jan. 13
• The Coding Corner: “Initial” vs. “subsequent” vs. “sequela” in ICD-10-CM coding

Regular features:

• Payor updates
• Problems getting paid?
• Health plan provider newsletters

 

File by Dec. 16 to avoid Medicare PQRS and value-based modifier penalties

Problems with how the Centers for Medicare and Medicaid Services (CMS) has been collecting and analyzing data related to the Physician Quality Reporting System (PQRS) and the value-based payment modifier (VM) may lead to inappropriate penalties of 2-4 percent of Medicare payments for thousands of physicians.

Despite making good faith efforts to participate in Medicare quality reporting programs, many physicians will face payment penalties in 2016 due to CMS’ failure to provide transparent, clear and timely information on the various data problems and system glitches that have impeded accurate calculation of 2016 adjustments. These problems have led to mass confusion among physicians, with many still unaware that they are facing significant Medicare payment reductions that they could, and should, contest.

Although CMS has already twice pushed back the deadline for physicians to request an informal review, many physicians are still unclear whether they should or should not file a request, or what exactly they need to address in such a review. (An informal review is the process that allows physicians and physician groups to request a CMS review of their incentive eligibility or payment penalty determination.)

The American Medical Association (AMA) is urging ALL physicians who received a payment reduction notice to file an informal review request by December 16, 2015, to avoid any possible inappropriate penalties. Additionally, practices that didn’t receive a payment adjustment notice are encouraged to review their CMS Physician Feedback Program Quality and Resource Use Report (QRUR) through the CMS Enterprise Portal and, if they do not satisfy the requirements, file an informal review request. All physicians who file an informal review request with CMS before midnight Eastern time on December 16 will have their payment adjustment determinations verified by CMS.

AMA is also urging CMS to apply a broad “hold harmless” policy that would automatically exempt all physicians who attempted to comply with the 2014 PQRS requirements from any PQRS or VM penalties in 2016. Alternatively, at the very least, AMA is urging CMS to extend the informal review request deadline into the next calendar year.

Additional information about the process and contact information for questions are available in CMS' informal review fact sheet.

CMS has advised that the informal review system will be down December 3-7 and unable to accept requests during that time.

Contact: Cheryl Bradley, (213) 226-0338 or cbradley@cmanet.org. 

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United Healthcare issues amendment to physicians participating in Core network

United Healthcare (UHC) recently issued a contract amendment to practices participating in the California health benefit exchange through its UHC Core network. The new contract language amends (or replaces) the prior Appendix 2 of the UHC participating physician agreements.

UHC also advised the California Medical Association (CMA) that the only option for physicians who wish to opt out of the Core product network is to terminate the underlying UHC commercial agreement. There is no option to opt out of just the Core network.

The Core network, introduced earlier this year, is a network being marketed to employer groups seeking lower premiums and used for its 2016 exchange product. This narrowed network will include approximately 45 percent of UHC’s PPO provider network.

In April, UHC notified 19,000 practices included in its commercially contracted provider network, advising of their inclusion in the UHC Core network.

UHC has been approved to offer exchange coverage in the five regions of California where fewer than three exchange health plans offered for 2016 including:

• Region 1: Northern counties (Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne and Yuba counties)
• Region 9: Central Coast (Santa Cruz, San Benito and Monterey counties)
• Region 11: Central Valley (Fresno, Kings and Madera counties)
• Region 12: Central Coast (San Luis Obispo, Santa Barbara and Ventura counties)
• Region 13: Eastern region (Imperial, Inyo and Mono counties)

UHC Core exchange patients from these counties will be allowed to visit any participating Core provider throughout California.

Regarding Section 7 of the amendment, CMA expressed concern to UHC that arranging for services 24/7 for solo or small group practices would not be feasible. In response, UHC clarified that a voicemail message or answering service directing patients with an emergency to the nearest emergency room or to call 911 would satisfy this requirement. For non-emergent situations, the requirement can be met by directing callers to an in-network urgent care center or giving them the ability to speak with a physician or qualified health care professional within a specified time frame.

CMA has also asked UHC to clarify the requirements under Section 19 of the contract amendment, which includes language about conditions under which UHC will pay for services provided when a prior authorization is obtained, and whether it is consistent with Health & Safety Code §1371.8, which prohibits plans from rescinding or modifying authorizations after the provider renders the service in good faith pursuant to the authorization for any reason, including situations where the plan later determines the patient wasn’t eligible.

UHC will be sending a welcome packet to Core participating physicians this month. The payor is also offering a number of one-hour webinars to provide more information about the United Healthcare Core product. Topics included are health plan overview, eligibility and benefits details, how to verify participation status and prior authorization requirements.

To register for one of the webinars, visit www.UnitedHealthcareOnline.com > Tools & Resources > Products & Services > 2016 Health Plans Training.

Physicians who are unsure about their participation in the Core plan network can contact UHC Network Management at (866) 574-6088. 

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New law requiring accurate provider directories includes provider obligation to update information

On July 1, 2016, a new law will take effect that requires plans and insurers to comply with uniform standards, and provide timely updates, for their provider directories. The law (SB 137) includes multiple components aimed at providing patients with more accurate and complete information to identify which providers are in their payor’s network.

Specifically, the law requires:

• Plans/insurers must offer an online provider directory available to the public, including physicians, without any restrictions or limitations.

• The directory must be searchable electronically by, at a minimum, name, practice address, city, zip code, license number, NPI, admitting privileges to an identified hospital, product, tier, provider language, provider group, hospital name, facility name, or clinic name, as appropriate. This provision takes effect July 31, 2017, or 12 months after the date provider directory standards are developed, whichever occurs later.

• The directory must use a consistent method of network naming, product naming, or other classification method to ensure easy identification of which providers participate in which networks for which products. This provision is effective July 31, 2017, or 12 months after the date provider directory standards are developed, whichever occurs later.

• The directory must state whether a provider is accepting new patients.

• The directory must include an email address and telephone number for providers and members of the public to report directory inaccuracies.

• The directory must not include providers who do not have a current contract with the plan/insurer. If a provider is listed as participating in error and an enrollee reasonably relied upon that information, the plan/insurer may be required to pay for covered services and to reimburse the enrollee for any amount beyond in-network cost sharing.

• Plans/insurers must promptly investigate, and, if necessary, correct any issues within 30 business days if they receive a report of a possible inaccuracy in the directory.

• Plans/insurers must update paper directories at least quarterly and online directories at least weekly.

• Plans/insurers must file an amendment with the regulator if there is a 10 percent change in the network size for a product in a region.

• Plans/insurers must include a contractual requirement that providers inform the plan within five business days if they are not accepting new patients or if they were previously not accepting new patients but are now open to new patients.

• Plans/insurers must have a process to ensure accuracy, and must at least once per year conduct a thorough review and update of the directory. This process must include notification to contracting providers to advise them of the information the plan has about them in the directory. Group providers will be noticed annually and other providers will be noticed every six months. The notice must include information about how providers can update their directory information using an online interface, which must generate an acknowledgment of receipt by the plan. The notice must also include a statement that the failure to respond may result in a delay of payment.
  
  
  • If the payor does not receive updates to any information or confirmation from the provider that the information is accurate, the plan is required to verify the provider’s information by contacting the provider in writing, electronically and by telephone. The plan must document the outcome and each attempt to verify the information. If the payor is unable to verify the provider’s information, the payor may remove the provider from the directory and delay payment, after providing at least 10 business days advance notice.

• The directory must inform enrollees of their rights to language interpreter services and access to covered services under the ADA.

SB 137 Effect on Physicians

The new law also establishes certain requirements for physicians. The requirements underscore the importance of ensuring that practice demographic information, including whether or not the practice is accepting new patients, is up-to-date with contracted payors and any changes to practice demographics are communicated to the plan/insurer in a timely manner. Specifically, the law requires:

• Providers will be required to notify plans and insurers within five business days if they are no longer accepting new patients or, alternatively, if they were previously not accepting new patients and are now open to new patients.

• If a provider is not accepting new patients and is contacted by a new patient, the provider must direct the patient to the plan/insurer to find a provider or to the regulator to report a directory inaccuracy.

• Providers will be required to respond to plan and insurer notifications regarding the accuracy of information in the provider directory by either confirming the information is correct or updating demographic information as appropriate. Failure to do so may result in a delay in payment and removal from the provider directory. Additionally, a provider group may terminate a contract with a provider for a pattern or repeated failure to update the required information in the directories.

• For providers that have capitated payor contracts, the plan can delay up to 50 percent of the next scheduled capitated payment for up to one calendar month if they fail to update their provider demographics or fail to confirm the accuracy of the current information. Payments to providers who have fee-for-service contracts can be delayed for up to one calendar month, beginning on the first day of the following month.

To help physicians understanding how to update their provider demographic information, until the electronic online option is required, the California Medical Association (CMA) queried the major payors on their processes. Their responses have been compiled into a members-only resource for physicians, “Updating Provider Demographic Information with Payors,” which is available free to CMA members at www.cmanet.org/ces. 

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Physicians urged to preemptively file for meaningful use hardship exemptions

Because of a delay in the publication of regulations governing the Medicare meaningful use program, physicians are being urged to preemptively file for a 2015 hardship exemption to avoid penalties in 2016.

Physicians should apply for an exemption under the “extreme and uncontrollable circumstances” category, even if they are uncertain whether they will meet the program requirements this year. Doing so will not preclude physicians from receiving an incentive if they do meet meaningful use requirements, but applying can serve as a safety net in staving off a penalty.

In order to avoid a penalty under the meaningful use program, eligible professionals must attest that they met the requirements for meaningful use stage 2 for a period of 90 consecutive days during calendar year 2015. Unfortunately, however, the Centers for Medicare and Medicaid Services (CMS) did not publish the updated regulations for stage 2 meaningful use until October 16, 2015. As a result, eligible professionals were not informed of the revised program requirements until fewer than the 90 required days remained in the calendar year.

CMS has stated that it will grant hardship exemptions for 2015 if eligible providers are unable to attest due to the late publishing of the rule. However, under current law, CMS can only grant such exemptions on a case-by-case basis. This means that many eligible professions will be required to apply for exemptions and that CMS will have to act on each application individually. CMS has approved over 85 percent of hardship exemptions in the past.

Hardship applications will be available in early 2016 at www.cms.gov/EHRIncentivePrograms.

The California Medical Association (CMA) and the American Medical Association are also supporting new legislation in Congress to streamline the hardship exemption process. The legislation, H.R. 3940 – the Meaningful Use Hardship Relief Act of 2015 – would grant CMS the authority to grant blanket hardship exceptions to physicians, hospitals and other affected providers for 2015, alleviating burdensome administrative issues for both providers and the agency.

CMA will continue to monitor this situation.

For more information on the electronic health record (EHR) incentive program, see the CMS tipsheet, "EHR Incentive Programs for Eligible Professionals: What You Need to Know for 2015." 

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Anthem asking physicians to affirm participation in workers’ comp MPNs by Dec. 31

Anthem Blue Cross recently sent a request to physicians who participate in various workers’ compensation medical provider networks (MPN) through their Prudent Buyer agreements, asking them to affirm their continued participation in each of these networks.

This request is required as part of the reforms instituted under SB 863, which mandates that MPNs obtain written acknowledgement from each participating physician that the provider elects to be a member of the network.

Under the resulting regulations, physicians who have entered into contracts with workers’ compensation payors prior to August 27, 2014, and who have contracts that automatically renew without the need for physician signature, must affirmatively acknowledge their participation in the MPN no later than January 1, 2016. Providers that do not respond to acknowledge their MPN participation will be removed from the MPNs listed in the Anthem Provider Affirmation Portal.

Through the affirmation process, physicians have the right to either opt in or opt out of each MPN offered by a payor (8 C.C.R §9767.5.1).

Physicians wishing to continue their participation in the Anthem MPNs may fax their acknowledgement to (888) 205-6065, visit the Provider Affirmation Portal located under Provider Access on the Anthem.com website, or contact Anthem Blue Cross Workers Compensation at (866) 700-2168. Instructions for accessing the Provider Affirmation Portal are available here. 

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Why it’s important to verify your patients’ eligibility and benefits for 2016

With the new year soon upon us, physicians are urged to be diligent in verifying patients' eligibility and benefits to ensure they will be paid for services rendered. The beginning of a new year means calendar year deductibles and visit frequency limitations reset. With open enrollment there may also be changes to patients’ benefit plans, or patients may even be covered by a new payor.

The new year also brings a host of other challenges that could affect your ability to be paid:

• Medicare patients can modify their enrollment choices from October 15 through December 7, allowing them to switch between Medicare fee-for-service and Medicare Advantage, or switch from one Advantage plan to another.

• The Covered California open enrollment period began November 1 and runs through January 31, 2016. Covered California estimates it may enroll more than 300,000 new enrollees during the 2016 open enrollment period. However, existing enrollees also have the option to change plans and/or products.

Along with the 10 existing plans, two new plans are offering coverage on the exchange in 2016. United Healthcare and Oscar are entering the exchange marketplace for 2016 in select regions.

It’s important that physicians and their staff understand their participation status in the various exchange products offered in their areas in order to advise patients before scheduling as to whether they are participating in the patients' plans. For detailed instructions on how to check physician participation status, see CMA’s toolkit, Covered California: Know Your Participation Status, free to CMA members in our exchange resource center at www.cmanet.org/exchange. Contact information for each exchange plan is also included in the toolkit, should practices have additional questions about participation status.

Don’t get stuck with unnecessary denials or an upset patient. Do your homework before the patient arrives by obtaining updated insurance information at the time of scheduling, if possible, and making copies of the insurance card at the time of the visit.

And don't forget that deductibles are typically based on the calendar year and will reset on January 1. Many of the exchange/mirror plans have high deductibles (e.g., $5,000 deductible on the Bronze plan), as do some employer-based plans. This reinforces the importance of verifying patient eligibility – particularly for exchange patients – each time they are seen. Best practice is to communicate with patients upon scheduling to remind them that their plan has a deductible that may be resetting on January 1 and, if that is the case, payment will be due at the time of service. If you offer an appointment reminder service, remind the patient if payment is expected at the time of service. Failure to collect deductibles, copays and coinsurance at the time of service can be very costly for a practice as your ability to collect can decrease significantly after the patient leaves the office.

Taking these proactive steps to protect your practice by preventing denials, delays in payment and disgruntled patients goes a long way toward ultimately saving time and money. 

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United Healthcare to delay implementation of multiple procedure payment reductions until March 1

In its December 2015 Network Bulletin, United Healthcare (UHC) announced that the multiple procedure payment reductions scheduled to begin with November 15, 2015, dates of service have been delayed until March 1, 2016.

UHC previously announced in August that it would begin applying multiple procedure payment reductions to the following services:

• Technical component of diagnostic cardiovascular and ophthalmology procedures
• Professional component of diagnostic imaging services
• Some endoscopy procedures

According to UHC, the new claim edits will apply for UHC commercial claims and that it is implementing the reductions to better align with the Centers for Medicare and Medicaid Services.

Questions about any of the claims editing rules or payment policies can be directed to UHC at (877) 842-3210. 

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DMHC fines Blue Shield and Anthem for provider directory inaccuracies

On November 3, the California Department of Managed Health Care (DMHC) announced it had fined two of the state's largest health plans for inaccurate Covered California provider directories. Blue Shield of California was fined $350,000, while Anthem Blue Cross was fined $250,000. 

These two insurers account for almost 60 percent of patient enrollment in Covered California. Both insurers are also utilizing networks for their exchange/mirror products that are significantly narrower than their regular PPO networks. These narrowed networks, combined with inaccurate provider directories, have led to significant confusion and frustration for both physicians and patients.

DMHC has directed both plans to improve the accuracy of their provider directories and to also reimburse enrollees who may have been negatively impacted. Blue Shield has already reimbursed more than $38 million to enrollees who incurred out-of-network costs.
The fines were the result of a five-month investigation of the Anthem and Blue Shield Covered California networks, which found that more than 25 percent of physicians listed as participating in the plans’ directories were not taking these patients or they were no longer at the location listed by the companies.

The audit also found that in both cases, auditors were unable to confirm Covered California participation status for more than 40 percent of physicians listed as participating in the plans’ directories – after three separate attempts to contact them using information in the directory. This hindrance to accessibility for such a substantial portion of listed physicians is a violation of state law, DMHC said in its report.

According to the DMHC audit, only 58.7 percent of the physicians listed in Anthem's Covered California directory could be verified as accepting Covered California patients, which is consistent with previous California Medical Association surveys of physicians listed as participating in Covered California. DMHC found that 12.8 percent of physicians listed by Anthem were not accepting Covered California patients, while 12.5 percent were not in practice at the location listed in Anthem’s directory.

DMHC has initiated a follow-up survey to determine if the plans have corrected the deficiencies identified in the initial survey reports.

You can read the Blue Shield agreement here, and the Anthem agreement here. 

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DWC reinstates requirement to pay lien activation fees for Workers' Compensation claims

The Division of Workers’ Compensation (DWC) recently announced that beginning November 9, 2015, the lien activation fees mandated under the Senate Bill 863 workers' compensation reforms will be reinstituted.

This announcement comes in the wake of the Ninth Circuit United States Court of Appeals decision to uphold the constitutionality of the lien activation fees and subsequent dismissal of the preliminary injunction imposed as part of the Angelotti Chiropractic, Inc., et al. v. Baker, et al. case.

Under this order, any affected lien claimant who files a Declaration of Readiness or appears at a lien conference from November 9 to December 31, 2015, will be required to pay the activation fee if it has not previously been paid. Additionally, the order stipulates that the lien activation fees must be paid prior to midnight on December 31, 2015, or the affected lien will be dismissed (Labor Code § 4903.06(a)(5)).

The fee for filing liens remains in effect and was not affected by the ruling.

DWC began collecting lien filing and activation fees in 2013 as authorized by SB 863, which made wide-ranging changes to the California workers' compensation system. The fees were intended to clear up a large backlog of hundreds of thousands of liens and to discourage the filing and pursuit of low-dollar-value liens by rendering them valueless. Under the law, holders of liens filed before the law took effect on January 1, 2013, were required to pay a $100 activation fee by January 1, 2014, or have their liens dismissed.

The preliminary injunction that went into effect November 19, 2013, prohibited DWC from collecting the $100 activation fee for the pre-2013 liens and from enforcing a provision in SB 863 that dismissed any liens for which the activation fee was not paid by December 31, 2013.

Providers seeking to pay the electronic lien activation fee or seeking additional information on the lien filing fees are directed to the Lien Filing Fees section of the DWC website. 

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CMS changes enrollment requirements for Part D prescribers

Beginning on June 1, 2016, all physicians and other providers who prescribe Medicare Part D drugs must be enrolled in Medicare or have a valid record of opting out. Failure to do so will result in a denial of the pharmacy claim or the beneficiary’s request for reimbursement.

The Centers for Medicare and Medicaid Services (CMS) had originally intended to begin enforcing this regulation last June, but the agency delayed implementation to allow sufficient time for beneficiaries and Medicare Part D plans to prepare.

All physicians and other prescribers who are not currently in compliance are encouraged to complete their Medicare enrollment or submit an opt-out affidavit no later than January 1, 2016. This will ensure sufficient processing time so that their Part D patients will continue to have access to necessary medication without interruption.

If you are unsure if you are compliant with this requirement, please review the CMS prescriber enrollment file.

Enrollment applications can be submitted on paper or online via PECOS. To enroll offline using a paper enrollment form, complete the CMS-855O application and mail to Noridian, California's Medicare contractor. Providers should be aware, however, that this form only allows you to enroll in Medicare for the purpose of ordering and certifying services and items, and to prescribe Part D drugs. It will not allow you to bill or be paid for Medicare services. To apply as a Medicare provider with full billing privileges, you will need to complete the appropriate CMS-855 form(s).

For more information, see the CMS Part D Prescriber Enrollment webpage and MLN Matters number SE1434. CMS has also put together a Part D Provider Enrollment FAQ.

For more information on opting out, see the Noridian website. 

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United Healthcare to delay Premium Designation assessment until January 2017

United Healthcare (UHC) has announced it will delay the next version of its Premium Designation physician quality and cost assessment program until January 2017. The program uses clinical information from health care claims to evaluate physicians against various quality and cost-efficiency benchmarks.

Originally scheduled to publish its latest results in January 2016, UHC has stated it is delaying in order to allow for improvements to the quality measures and cost-efficiency metrics in response to feedback provided by physicians. This means that the currently posted ratings will remain in place through the end of 2016. Although the California Medical Association (CMA) recognizes that this additional delay may frustrate some physicians, UHC reports it is a necessary delay in order to allow it to make system changes to benefit physicians going forward.

The most recent results were released publicly via UHC's online physician directory on January 1, 2015, and were based on claims data from January 1, 2011, through February 28, 2014.

CMA had previously voiced concerns about the UHC Premium Designation program citing reliance on data that was more than a year old to determine current physician cost and quality designations and for failing to adequately account for the performance of physicians who have modified their practice patterns since their last Premium Designation assessment.

Premium Designation assessment results are accessible online on the United Healthcare website at www.unitedhealthcareonline.com. Physicians wishing to still dispute their 2015 Premium Designations may do so by submitting an online reconsideration request via the UHC website through July 2016. Physicians who encounter problems with their physician assessment reports or who have concerns regarding their Premium Designation can contact United Healthcare at (866) 270-5588. Practices that are unable to obtain answers to their questions or resolve their issues with United Healthcare directly should contact CMA. 

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CMA to relaunch webinar program; first program on meaningful use scheduled for Jan. 13

Beginning in January, the California Medical Association (CMA) will relaunch its full webinar program, featuring two to three subjects each month. Geared toward both physicians and their staff, the topics will range from everyday practice management—including contracting with payors, claims and reimbursement, and customer service—to timely issues such as MACRA, meaningful use, CMA governance and HIPAA compliance, among many others. The webinars will take place during the lunch hour, from 12 to 1 p.m.

Kicking off the new year and start of the 2016 webinar program will be "Patient Engagement vs. Patient Education – What’s the Difference?" This webinar will be presented on Wednesday, January 13, by Jamie Verkamp, a popular breakout speaker from the 2015 Western Health Care Leadership Academy who specializes in practice management education and techniques.

This webinar will examine meaningful use stage 2 and how to meet the requirements in measures related to patient engagement. It will also cover how to educate patients in order to keep them informed without burdening them with too much information.

Click here for more information or to register.

Contact: Juli Reavis, (916) 551-2046 or jreavis@cmanet.org. 

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The Coding Corner: “Initial” vs. “subsequent” vs. “sequela” in ICD-10-CM coding

CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.   

Many codes in Chapter 19 of ICD-10-CM (Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88)) require a 7th character to identify the episode of care. With the exception of the fracture codes, most Chapter 19 codes have three 7th character values.

Example 1: An initial encounter (character “A”) describes an episode of care during which the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.

Although it’s counter-intuitive, “initial encounter” does not necessarily mean “initial visit.” A patient may receive active treatment for a condition beyond the initial visit. The ICD-10-CM Chapter 19 Guidelines confirm: “While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time” (emphasis added).

Assuming the provider is providing active care, a seventh character of “A” is appropriate, regardless of how many times the provider saw the patient previously.

Example 2: A subsequent encounter (character “D”) describes an episode of care during which the patient receives routine care for her or his condition during the healing or recovery phase. Examples include cast change or removal, medication adjustment, and other follow-up visits following treatment of the injury or condition.

Note that ICD-10-CM guidelines do not definitively establish when “active treatment” becomes “routine care.” This is a clinical decision based on the individual’s course of treatment. As Rhonda Buckholtz, AAPC Vice President of Strategic Development, explains, “When the doctor sees the patient and develops his plan of care—that is active treatment. When the patient is following the plan—that is subsequent. If the doctor needs to adjust the plan of care—for example, if the patient has a setback or must returns to the OR—the care becomes active, again.”

A seventh character “D” is appropriate during the recovery phase, no matter how many times he has seen the provider for this problem previously.

Example 3: A sequela character (“S”) is applied for complications or conditions that arise as a direct result of a condition or injury (in ICD-9, these were known as “late effects”). Examples may include joint contracture after a tendon injury, hemiplegia after a stroke or scar formation following a burn.

A late effect can occur only after the acute phase of the injury or illness has passed; therefore, you cannot report a code for the acute illness and a code for the late effect at the same encounter, for the same patient. The only exception occurs if both conditions exist (for example, the patient has a current cerebrovascular condition and deficits from an old cerebrovascular condition).

When reporting sequela(e), you usually will need to report two codes. The first describes the condition or nature of the sequela(e) and the second describes the sequela(e) or “late effect.” For example, you may report M81.8 Other osteoporosis without current pathological fracture with E64.8 Sequelae of other nutritional deficiencies (calcium deficiency).

If a late effect code describes all of the relevant details, you should report that one code, only (e.g., I69.191 Dysphagia following nontraumatic intracerebral hemorrhage). 

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Payor updates

CIGNA: Effective January 1, 2016, Cigna will implement a precertification program for musculoskeletal services including major joint surgery services related to the hip, knee and shoulder, as well as interventional pain management services. Physicians will need to request precertification for these services through eviCore healthcare (formerly CareCore/MedSolutions). Physicians may request precertification through eviCore’s website at myportal.medsolutions.com. A full list of affected services and CPT® codes, as well as additional information about the program, including a program Quick Reference Guide, can be found at medsolutions.com/implementation/Cigna.

UNITED HEALTHCARE: United Healthcare has announced updates to its medical policy, drug policy, coverage determination and utilization review guidelines effective January 1, 2016. Physicians can view all United Healthcare medical policies in their entirety online by visiting the United Healthcare website at www.UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines >Medical Policy Update Bulletin.

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Problems getting paid?

The California Medical Association’s Center for Economic Services provides direct reimbursement assistance to CMA physician members and their office staff.

Reimbursement Help Line (888/401-5911)

• One-on-one educational and reimbursement assistance to physician members and their staff

Practice Empowerment

• Tools and resources to empower physician practices
• Seminars and toolkits for physicians and their staff

Experienced Staff

• Staffed by practice management experts with a combined experience of over 125 years in medical practice operations

Need help? Contact CMA’s reimbursement experts at (888) 401-5911 or economicservices@cmanet.org.

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Health plan provider newsletters

To make sure that you are aware of important news from your contracting health plans, we encourage you to regularly read plans' provider newsletters and bulletins. Follow the links below to access the current issues.

AETNA: www.aetna.com. Click on "Health Care Professionals" in the main menu, then on "News for Providers" in the left sidebar.

CIGNA: www.cigna.com. Click on "Health Professionals" under "Customer Care" in the main menu. Then, scroll down and click on "Newsletters."

ANTHEM BLUE CROSS: www.anthem.com/ca. Click on "Providers" in the main menu, then on "Professional Network Update" under "Spotlight."

BLUE SHIELD: www.blueshieldca.com. Click on "I'm a Provider," then on "Announcements" under "News and Features."

HEALTH NET: www.healthnet.com. Click on "I'm a Provider" and then "California." Enter username and password, and then click "Online News."

MEDI-CAL: www.medi-cal.ca.gov. Click on "Publications" in the main menu, then on "Provider Bulletins."

MEDICARE/NORIDIAN: https://med.noridianmedicare.com/web/jeb/fees-news. Noridian publishes individual articles through the Latest Updates section in the left sidebar. The articles are condensed approximately every six-to-eight weeks into a Bulletin.

UNITED HEALTHCARE: www.unitedhealthcareonline.com. Click on "Tools & Resources" in the main menu, then on "Network Bulletin."

CMA RESOURCE: Find up-to-date profiles on each of the major payors in California.

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Got questions?

If you have questions related to any of the articles in this issue, please contact CMA's reimbursement help line, (888) 401-5911 or economicservices@cmanet.org. Questions about membership, including technical website issues, should be directed to CMA's member help center, (800) 786-4CMA or memberservice@cmanet.org.

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Tell us what you think

Let us know which topics you would like to see addressed in future issues. Contact CMA's Center for Economic Services at (916) 551-2061 or economicservices@cmanet.org.

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