500 Cummings Center • Suite 6500 • Beverly, MA 01915(P) 978-236-1744 (F) 978-236-1777 website: www.nepho.org

SAVE THE DATESAVE THE DATESAVE THE DATE

October/November 2016

PHYSICIAN UPDATESPHYSICIAN UPDATESPHYSICIAN UPDATES

MD Orienta� on Date: December 8, 2016 @7:30 A.M.

500 Cummings Center—Suite 6500

Good Harbor Room—Beverly, MA

RSVP: Judy O’Leary at jmoleary@nhs-healthlink.org

or (P) 978-236-1739

OFFICE MANAGER Mee� ng Date: December 7, 2016 @12:00 P.M.

500 Cummings Center—Suite 6500

Good Harbor Room—Beverly, MA

RSVP: Judy O’Leary at jmoleary@nhs-healthlink.org

or (P) 978-236-1739

New Physicians• Lilit Garibyan, MD has joined Massachuse� s Dermatology Associates, P.C. located at 900 Cummings

Center, Suite 311 T, Beverly, MA 01915 (P) 978-225-3376 (F) 978-560-1245

• Deborah Zucker, MD has joined North Shore Primary Care, 5 Federal Street, Danvers, MA 01923

(P) 978-777-6544 (F) 978-774-2091

Physician and Prac� ce Changes

• As of November 1, 2016, Hugh O’Flynn, MD is affiliated with Sports Medicine North, 1 Orthopedics

Drive, Peabody, MA 01960 (P) 978-818-6350 (F) 978-818-6355

• As of November 1, 2016, Anthony Lomonaco, MD is affiliated with North Shore Pain Management, 900

900 Cummings Center, Suite 221U, Beverly, MA 01915 (P) 978-927-7246 (F) 978-927-7249

OPTUM Newsle� er: October is Breast Cancer Awareness monthNovember is American Diabetes monthSee pages 11 & 12 of this newsle� er

The NEPHO Office will be closed on: November 24 and 25 for the Thanksgiving holiday, andDecember 23 and 26 for the Christmas holiday.

2016 CUSTOMER SURVEY RAFFLE WINNERS2016 CUSTOMER SURVEY RAFFLE WINNERS2016 CUSTOMER SURVEY RAFFLE WINNERS

Zaven Jouhourian, MD whose prac� ce is located at Addison Gilbert Hospital

298 Washington Street, Gloucester, MA and Ma� sha Chao, Office Manager at

Dr. Leonard Horowitz’s office located at 7 Federal Street, Suite 11, Danvers,

MA. Both Ma� sha and Dr. Jouhourian are the recipients of a $50.00 VISA gi� card. NEPHO wishes to

thank everyone who par� cipated in our Customer Survey. We con� nue to strive to improve our services

to our providers and their staff, and your answers and comments help us achieve this goal. Survey results

will be published in a later edi� on of this newsle� er.

1

OPEN MEETING II SUMMARYOPEN MEETING II SUMMARYOPEN MEETING II SUMMARY

President’s Report

• PHO Updates - Dr. Ezzi began the 2016 Open Mee� ng Presenta� on II by sharing overviews on Network

Growth, Performance, MACRA and MassHealth ACOs.

• NECoMG Membership Updates – The list of 16 physicians who joined NECoMG in the last year was re-

viewed; there were 2 new PCPs and 14 new Specialists. Dr. Ezzi noted the 304 providers in NEPHO,

comprised of 58 PCPs and 246 Specialists. Twenty-four percent (24%) of the 304 providers are em-

ployed while the remaining 76% are in private prac� ces.

• Health Plan Membership Updates — Payor enrollment changes from 2015 to 2016 were presented,

with a noted net increase of 3% in covered lives over the prior year.

• Quality Score Updates— Dr. Ezzi informed the a� endees that a combined gate score of 2.8 was pro-

jected for the 2015 BCBS AQC. This would result in $8.2M in earned funds for LCPN. He then de-

scribed how those funds would be distributed among the three risk units. For 2016, the gate score is

currently at 1.6 but is projected to be 3.0 by the end of the year. Should that target be met, it would

result in $5.3M in earned funds for 2016.

• ACO Performance— Dr. Ezzi then reviewed Lahey Clinical Performance Accountable Care Organiza-

� on’s (LCP-ACO’s) performance for 2013-2015. In 2015, LCP-ACO demonstrated nearly $9.8M in sav-

ings and earned a Quality score of 96.5%. These results equated to $4.6M in earned funds for LCP-

ACO. The ACO is in the process of calcula� ng the distribu� on of those funds.

Contrac� ng Update

Dianne Dobbins, NEPHO Director of Contrac� ng & Opera� ons, highlighted some of the key findings from

the September 2016 report from the Center for Health Informa� on and Analysis (CHIA) which included

data on 2015 healthcare trends in Massachuse� s. She provided updates on changes to Lahey Clinical Per-

formance Network (LCPN) and NEPHO payor contracts for 2017. She also reviewed the 2016 top 10

health care trends as reported by PwC (Pricewaterhouse Coopers).

Pharmacy Update

Carol Freedman, NEPHO Clinical Pharmacist, gave an overview of NEPHO pharmacy performance and re-

lated trends. Pharmacy costs have grown significantly from 2012 to 2016, and Carol discussed a variety of

poten� al ways to reduce those costs. Carol also shared informa� on on the biosimilar market. She noted

that while there will likely be hurdles to acceptance of biosimilars, RAND Pharmaceu� cals projects that

their use could result in more than $44 billion in savings over the next 10 years.

Quality Update

Liz Isaac, NEPHO Director of Ambulatory Performance Improvement, concluded the Presenta� on with in-

forma� on about Quality Improvement ini� a� ves and challenges. She also gave an overview of MACRA

(Medicare Access and Children’s Health Insurance Program (CHIP) Reauthoriza� on Act” with a focus on the

Quality and Clinical Prac� ce Improvement measures.

2

POD MEETING SUMMARYPOD MEETING SUMMARYPOD MEETING SUMMARY——— OCTOBER 2016OCTOBER 2016OCTOBER 2016

In the month of October, a� endees at the PCP POD mee� ngs were introduced to NEPHO’s newest Rheu-

matologist, Michael Indelicato, MD, who shared his background and made his contact informa� on availa-

ble. Dr. Di Lillo shared insights gained from reviewing Q2 2016 year-to-date OOPHO referrals. He wel-

comed feedback and a hearty discussion transpired. The Quality team con� nues the year-end push for

AQC performance. The group reviewed quick � ps for acute bronchi� s (as we enter the season) as well as

informa� on learned from chart review of low back pain measure outliers. Also discussed were year-end

ac� on steps for the hypertension measure. Refreshed PCP scorecards and pa� ent lists were distributed.

It was evident from the discussion and ques� ons that much work con� nues at the prac� ces to address

gaps in care for these pa� ents by year end. The PCP Report Cards through Q2 2016 were reviewed and

the details of the 2016 PCP Incen� ve program were re-distributed.

POD MEETING SUMMARYPOD MEETING SUMMARYPOD MEETING SUMMARY——— NOVEMBER 2016NOVEMBER 2016NOVEMBER 2016

Introduc� on - Ken King, Director of Transi� onal & Ambulatory Care Management

Ken shared the ini� a� ves ahead for the Case Management department. One priority project is the imple-menta� on of a new case management data warehouse (Optum), beginning in January 2017.

Mammograms - Guest, Dr. Jean O’Brien

Dr. O’Brien presented to all PODs in November, focusing on ques� ons such as how early & o� en to screen, dense breast considera� ons, new tomo technology which offers improved sensi� vity and specifici-ty rates, and internal data collected to date.

Quality AQC Push

PCP scorecards and pa� ents lists were refreshed and shared at POD mee� ngs. Hypertension was ad-dressed again, given its weight and end-of-year importance. Issues around documen� ng 2nd blood pres-sure (BP) in EPIC, feasibility of re-checking near-compliant BPs, avoiding scheduling appointments in 2017,holiday availability, no-copay nurse BP checks, workflow issues that prevent recheck (e.g., char� ng a� er pa� ent has le� the room) were discussed. The depression measure was also reviewed – there is an op-portunity to “keep it simple” and u� lize depression-related codes other than Major Depression when ap-plicable; e.g., situa� onal, dysthymia, adjustment reac� on, and grief. U� lizing these as appropriate when selec� ng a diagnoses will avoid erroneous coding and inclusion of these pa� ents in this measure, which is targe� ng long-term medica� on compliance in Major Depression.

Contrac� ng Update

Dianne Dobbins provided a contrac� ng update to all POD, the same informa� on presented to a� endees at the Open Mee� ng II presenta� ons in October. The current reimbursement landscape and industry trends, as well as PHO and LCPN contracts, were also reviewed.

MANJU SHETH, MDMANJU SHETH, MDMANJU SHETH, MD

The Indian Medical Associa� on of New England, one of

the oldest organiza� ons of physicians of Indian origin in

the United States, will honor Dr. Manju Sheth with the

Dis� nguished Physician Award at its 38th annual mee� ng

on November 19th. Please join us in congratula� ng her!

3

Congratulations NEPHO Staff

HOSPITALS HONOREDHOSPITALS HONOREDHOSPITALS HONORED

The 2016 Colleague Service Awards Celebra� on held on Sep-

tember 28th at the Danversport Yacht Club honored col-

leagues celebra� ng significant achievements and milestones

in their careers.

NEPHO is happy to congratulate our colleagues who received

service awards: Front row: Stacey Keough, NEPHO Execu� ve

Director—20 years; Lisa Enderle, Creden� aling Coordinator—

10 years; Ann Cabral, Provider Rela� ons Manager—20 years.

Back row: Cheryl Clocher, Care Management Coordinator—10 years;

Carol Freedman, RPh, Clinical Pharmacist—30 years; Alison Gustafson, NP, Popula� on Health Nurse Prac� -

� oner—30 years and Liz Isaac, Director Ambulatory Performance Improvement—5 years.

And congratula� ons to the following NEPHO Physicians for their years of service:

COLLEAGUE SERVICE AWARDS CEREMONYCOLLEAGUE SERVICE AWARDS CEREMONYCOLLEAGUE SERVICE AWARDS CEREMONY

25 YearsBruce Barlam, MD, Curtis Ersing, MD, Henry Frissora, MD, John Gurley, MD,

Neil Kobrosky, MD, Louis Laz, MD, Robert Rokowski, MD,Beverly Shafer, MD, Jeffrey Stockman, MD, Philip Thomason, MD

20 YearsAmy Esdale, MD

15 YearsDaniel McCullough, MD, Angus McIntyre, MD

10 YearsKevin Ennis, MD, Neil Mann, MD

Beverly, Addison Gilbert and BayRidge Hospitals were recently honored by Nurses Improving Care for

Healthsystem Elders (NICHE) for once again achieving Exemplar status for our nurse-driven NICHE pro-

grams that greatly increase quality of care for older adult pa� ents. Our hospitals are the only organiza-

� ons in Massachuse� s to achieve this designa� on and are among only three in New England. There are

680 NICHE sites throughout the United States, Canada, Bermuda and Singapore; only 88 of them

achieved Exemplar status.

Exemplar status designa� on indicates a hospital has demonstrated ongoing, high-level dedica� on to geri-

atric care and preeminence in the implementa� on and quality of system-wide interven� ons and ini� a-

� ves. There are 15 designated NICHE sites in Massachuse� s, including Winchester Hospital and Lahey

Hospital & Medical Center. This is the third consecu� ve Exemplar designa� on for Addison Gilbert, Bever-

ly and BayRidge Hospitals. Click here to learn more.[nicheprogram.org]

4

CARE MANAGEMENTCARE MANAGEMENTCARE MANAGEMENT

Upcoming Changes

A Nobel Prize for literature was just awarded to Bob Dylan—Boomers may remember his song “Times They

are A-changing” from 1964. A por� on of that song reads:

“And the present now will soon be the past; the order is rapidly fading

The first one now will later be last; for the � mes, they are a-changing”

Case Management (CM) � mes are changing, and we will be facing new workflows, expecta� ons and goals.

We are working in a landscape that references the Triple Aim, and CM needs to contribute to that model

with an emphasis on Popula� on Health Management.

Lahey is providing us with a tool to do so with Optum, which will recognize the top 5% of our high risk pa-

� ents and gives CM a pla� orm to address and engage with these pa� ents. As a unit we need to dedicate

our efforts to carrying out this task and with that comes poten� al changes in how we address other tasks

and pa� ent issues. To date, our caseloads have been directed by inpa� ent admissions; we now will be di-

rec� ng our resources on capturing pa� ents primarily from the ambulatory se� ng.

Three issues to consider ini� ally:

1. The CM’s will start to work with their respec� ve prac� ces to develop strategies for engaging with pa-

� ents that may need some services that do not necessarily require a licensed nurse to carry out. We

are also doing this internally in our group discussing use of the PHO Social Worker and Pa� ent Engage-

ment Coordinator.

2. We are working on a resource guide for all of our prac� ces, sharing the informa� on and resources we

use when needed.

3. The goal is to have the CM be able to provide advice and guidance when Ad-Hoc referrals come in so

we can collaborate effec� vely to address pa� ents’ needs. (There is also work being done to have Ad-

Hoc referrals “ordered” through EPIC with specific requests and goals.)

The focus of the CM’s rounds at the offices should be on: i) the pa� ents that are in our high risk registry; ii)

using the provider’s input to priori� ze pa� ents in need; iii) review of care plans developed for ac� ve pa-

� ents and iv) outcomes. There may be prac� ce assignment changes as we prepare for Optum to “go live”,

some� me a� er the first of the year, and we will prepare for any changes as � mely as possible. Any ques-

� ons or concerns can be directed to Ken King, Director of Transi� onal & Ambulatory Care Management at

kmking@nhs-healthlink.org, (P) 978-236-1766, or via EPIC messaging.

New Geriatric Social Worker

Ken King and Dr. Louis Di Lillo, Medical Director of NEPHO, are happy to announce that Deirdre Putnam

LICSW has joined NEPHO. Deirdre will be joining the Care Management team star� ng November 15th.

Deidre earned her BA in Sociology at UMass, Harbor Campus and her Masters from Salem State College

with a concentra� on on Aging. She has extensive experience working with the geriatric popula� on, having

worked in se� ngs such as SeniorCare, PACE and most recently at Brooksby Village. There is no doubt her

experience will be a valuable asset to the Care Management Team.

5

Congratula� ons — Jean St. Peter, RN, CMM

The NEPHO Care Management Team extended their celebra� on of Case Management Week by congratu-

la� ng Jean St Peter, RN for passing her Case Management Cer� fica� on Exam. A� er months of prepara-

� on Jean took the exam in August and was recently no� fied that she has received the designa� on of CCM.

Jean has been a valuable member of the NEPHO Care Management team and now joins the ranks of those

who are recognized as CCM's! Please join us in congratula� ng Jean on this on this well-earned achieve-

ment.

CARE MANAGEMENT, cont.CARE MANAGEMENT, cont.CARE MANAGEMENT, cont.

Update

As of October 15, 2016, state law (Massachusetts General Laws Chapter 94C Section 24A

[malegislature.gov]) now requires that a prescriber must check the new prescrip� on monitoring program—

Massachuse� s Prescrip� on Awareness Tool (MassPAT), any� me that they are issuing a prescrip� on:

• for any Schedules II and III[dea.gov] narco� c drug;

• the first � me for a benzodiazepine (Lahey is recommending that as a best prac� ce the database be

accessed each � me a benzodiazepine is prescribed given their poten� al for abuse); and

• for a controlled substance that is a Scheduled IV or V drug—as designated by DPH (please note that

DPH has NOT issued a list of drugs that have received this designa� on at this � me).

Clarifica� ons

• Providers are not required to check MassPAT when they are giving a prescrip� on to a pa� ent as part

of the discharge planning process from an inpa� ent facility if the prescrip� on is issued prior to dis-

charge (even though it will be filled at an outpa� ent pharmacy off the premises of the hospital). 105

CMR 700.0012(H)(3)(e) exempts a registered prac� � oner from consul� ng MassPAT if he/she is

“providing medical, dental, podiatric, pharmaceu� cal or nursing care to hospital inpa� ents”. This ex-

emp� on would apply to a prescrip� on to a pa� ent that hasn’t been discharged yet. Observa� on is

not considered inpa� ent, so if the pa� ent is admi� ed overnight for observa� on and sent home with

pain meds, MassPAT needs to be checked.

• For an ED physician, you are now required to check MassPAT if you are issuing a prescrip� on for one

of the three criteria outlined above. Please note that there used to be an excep� on for ED providers

that would exempt you from checking PMP if the prescrip� on is for a less than 5 day supply; that ex-

cep� on is no longer valid under current law and the planned changes in the regula� on.

PHARMACYPHARMACYPHARMACY———MassPATMassPATMassPAT

6

QUALITYQUALITYQUALITY

A Little Hypertension R & RAs we head into the final weeks of the 2016 BCBS Quality Measurement Period, we as a PHO need to get36 more compliant diabetic BPs and 83 more compliant hypertensive BPs to reach the maximumthresholds in both measures. The target values for each measure are:

To help us achieve these goals, we need a little R & R: Retake and Reschedule.

• Retake an over target BP at some point during the encounter.

o 43% of our above target BP readings are right at or just above the 140/90 threshold. Repeating a

BP slightly over target will often bring it into the compliant range.

o Blue Cross will accept a composite BP that is compliant – see the example below

Patient’s 1st BP reading: 150/89

Patient’s 2nd reading: 139/90

Equals compliant BP = 139/89

Blood pressure measuring gurus: Please do NOT round up!

• Reschedule the patient for a follow-up visit before the end of 2016.o If after 2 or 3 tries the blood pressure is still elevated, reschedule the patient for another

appointment before 12/31/16.

o There does not need to be a claim for an office visit for the BP to count, so consider a BP check

with an MA or RN and record the BP in the chart.

The LAST blood pressure of the year taken by a provider managing the patient’s diabetes or hypertension

is the one that is submitted to BCBS. This can be taken by the PCP, an Endocrinologist, Cardiologist or

Nephrologist if they are involved in managing the patient’s hypertension. Our PHO staff also emails and

flags these specialists to alert them to upcoming appointments and remind them to pay attention to

blood pressure readings.

Have questions? Need your updated patient list? Please see contact a member of the PHO Quality Team:

Liz Isaac at eisaac@nhs-healthlink.org or (P) 978-236-1767; Alison Gustafson, NP at agustafs@nhs-

healthlink.org or (P) 978-236-1709; Lucia Kmiec at lucia.kmiec@nhs-healthlink.org7 or (P) 978-236-1719;

Jennifer Andersen at email:jandersen@nhs-healthlink.orgor (P) 978-236-1747; and Laureen Viel at

email:lviel@nhs-healthlink.org or (P) 978-236-1746.

Target BP: General Hypertension

Age under 60: Less than or equal to 139/89

Age 60 and above (nondiabetics only): Less

than or equal to 149/89

Target BP: Diabetes

Less than or equal to 139/89

7

CODING CORNERCODING CORNERCODING CORNER

ICD-10-CM and ICD-10-PCS Update

The ICD-10-CM diagnosis and ICD-10-PCS procedure codes have been updated for FY17 effec� ve October

1, 2016. For a list of new and invalid codes effec� ve for dates of service on or a� er October 1, 2016, click

on this link: h� ps://www.cms.gov/Medicare/Coding/ICD10

Obesity in ICD 10 (Courtesy of Fallon Health Plan)

Obesity is a major problem in the United States and can be a very sensi� ve subject to address in the phy-

sician's office. Overweight is defined as a Body Mass Index (BMI) of 25-29.9 kg/m2. Obesity is defined as

BMI greater than 30 kg/m2 while morbid obesity is defined as a BMI of greater than 40 kg/m2. Obesity

increases the risks of certain diseases such as diabetes, heart disease, stroke, arthri� s, sleep apnea and

some cancers.

BMI documenta� on can be from clinicians who are not the pa� ent's provider; however an associated

diagnosis such as morbid obesity verbiage must be documented in the pa� ent's record by a physician

to assign the morbid obesity code. For example, a morbidly obese pa� ent with a BMI of 50 kg/m2,

should be coded with both the BMI code and the corresponding Obesity code: Z68.43 and E66.01.

Documenta� on � ps:

• Key words for your documenta� on should include: "obese" or "BMI out of range". Consider using bill-

ing diagnoses and problem list entries, incorpora� ng the pa� ent's BMI range.

• A follow-up plan should be documented and must be connected to the diagnosis in your docu-

menta� on. Some examples that can be used in a follow-up plan include:

° Exercise or nutri� onal counseling

° Provision of weight management educa� onal literature

° A referral to a nutri� onist, die� cian, physical therapist, exercise physiologist, bariatric center for

surgery, mental health provider for behavioral changes. May also include a referral to an occupa-

� onal therapist. Prescribing FDA approved weight-loss medica� on or dietary supplements

° Discussion of lifestyle changes, addressing barriers to changes and self-monitoring.

BMI: Obesity:

Z68.30—39 BMI 30.0-39.9 adult E66.9—Obesity unspecified, NOS

Z68.41—BMI 40.0-44.9 adult E66.3—Overweight

Z68.42—BMI 45.0-49.9 adult E66.01—Morbid (severe) obesity due to excess calories

Z68.44—BMI 60.0-69.9 adult

Z68.45—BMI 70+, adult

Z68.43—BMI 50.0-59.9 adult

8

PAYOR UPDATESPAYOR UPDATESPAYOR UPDATES

BCBSMA— 9/1/16 Fee Schedule Update

The BCBS fee schedule update effec� ve September 1, 2106 has been loaded onto the NEPHO website for

your reference.

HPHC—Advance Care Planning

Advance care planning is a crucial step to ensure that pa� ents get the medical care they want when they

are unable to speak for themselves due to illness or injury. Recognizing the importance of advance care

planning, Harvard Pilgrim made a determina� on in July to cover the following services for dates of service

beginning January 1, 2016: 1) 99497 — Advance care planning including the explana� on and discussion of

advance direc� ves such as standard forms (with comple� on of such forms, when performed), by the phy-

sician or other qualified health care professional; first 30 minutes, face-to-face with the pa� ent, family

member(s), and/or surrogate. 2) 99498 — Advance care planning including the explana� on and discus-

sion of advance direc� ves such as standard forms (with comple� on of such forms, when performed), by

the physician or other qualified health care professional; each addi� onal 30 minutes (list separately in ad-

di� on to code for primary procedure). To view the complete no� fica� on, click on this link: h� ps://

www.harvardpilgrim.org/portal/page?_pageid=253,9525993&_dad=portal&_schema=PORTAL

[harvardpilgrim.org]

HPHC— CPT 99050

HPHC has updated their Evalua� on and Management reimbursement policy to clarify that CPT 99050 is

only reimbursed for Sundays and holidays. Based on the CPT®/AMA guidelines, you may report 99050 —

Services provided in the office at � me other than regularly scheduled office hours, or days when the office

is closed (e.g., holidays, Saturday or Sunday), in addi� on to basic service — for any service provided in the

office at a � me when the prac� ce would normally be closed (e.g., weekends or evenings). Code 99050 is

reported in addi� on to the code for the basic service.

If your prac� ce already maintains regular hours on evenings, weekends, or holidays, and you provide a

service during those � mes, you should skip 99050 and use 99051 — Service(s) provided in the office dur-

ing regularly scheduled evening, weekend, or holiday office hours, in addi� on to basic service.

To view the complete policy, click on this link: h� ps://www.harvardpilgrim.org/pls/portal/docs/PAGE/

PROVIDERS/MANUALS/PAYMENT%20POLICIES/H-2%20EVALUATION-MANAGEMENT_101516.PDF

[harvardpilgrim.org]

HPHC— Preven� ve Services Billing

Harvard Pilgrim requires that most in-network preven� ve services be covered for members without cost

sharing. Harvard Pilgrim would like to remind providers in network that all diagnosis codes for preven� ve,

screening, counseling, or wellness services should be billed in the primary posi� on when indicated. Billing

the appropriate diagnosis code in the primary posi� on helps ensure that the claim will be accurately pro-

cessed. For addi� onal informa� on and to view the no� fica� on, click on the link below.

h� ps://www.harvardpilgrim.org/portal/page?_pageid=253,9539993&_dad=portal&_schema=PORTAL

[harvardpilgrim.org]

9

PAYOR UPDATES, cont.PAYOR UPDATES, cont.PAYOR UPDATES, cont.

Addison Gilbert Primary Care – Overall Assessment

My visit was informa� ve and helpful. Dr. Damico was pleasant and knowledgeable about my health. She

took the � me to listen and discuss op� ons etc. I very much appreciated her exper� se and manner.

Dr. Carabba took the � me to explain how my health may be effected by family history. No physician has

ever done that in a visit. He was extremely thorough, professional and kind. Dr. Carabba also was pa� ent

explaining a new medica� on and what to expect from a new diagnosis.

Center for Health Aging – Overall AssessmentVery courteous, always helpful!

Danvers Family Doctors, PC – Overall AssessmentExcellent experience. Kim Neskey is through, kind, very informa� ve. She's a pleasure.

Family Medicine Associates, PC – Overall AssessmentAll personnel are professional, kind/caring/friendly and proficient.

Family Medicine Associates —Manchester —Overall AssessmentSue is very knowledgeable; genuinely interested in who you are; helpful, AND she called me before a trip I

was taking to make sure I was feeling be� er. She's the only person to do this. Excellent customer ser-

vice!!

Family Medicine Associates, South Hamilton – Overall AssessmentGreat confidence in Dr. Taylor and staff. I appreciate that when Eve isn't sure of an answer to one of my

ques� ons about complicated issues, she takes � me to look up possible solu� ons & then follows up with

phone/mail. I have the utmost confidence in my care team. Autumn M. Smith is knowledgeable, up to

date on new meds and a very caring provider. She has NEVER not been able to help me.

Garden City Pediatrics – Overall AssessmentI feel comfortable speaking to Dr. Goldstein about my granddaughters. I started using Garden City Pediat-

rics 40 years ago when my daughter was born and have been with them since for all my foster children

and now my grandchildren who I am raising. I wouldn't go anywhere else!

Internal Medicine of the North Shore —Overall AssessmentI am so GRATEFUL to be under Dr. Cohen's care. I am always treated with respect.

Tu� s—SA Modifier Update

You likely recall that effec� ve 7/1/16, Tu� s changed their billing policy to require that physicians sub-

mi� ng claims for noncontracted Nurse Prac� � oners (NPs) had to include the SA modifier for “incident to”

services; reimbursement would be 85% of the applicable MD fee schedule. As of 1/1/17, Tu� s will re-

verse this policy so that claims for “incident services” provided by a noncontracted NP can again be billed

under the supervising provider without the SA modifier and reimbursement will be at 100% of the appli-

cable MD fee schedule. See page 13 of this newsle� er for a copy of the updated policy. Please contact

Dianne Dobbins, NEPHO Director of Contrac� ng & Opera� ons at 978-236-1704 or Dianne.Dobbins@nhs-

healthlink.org if you have any ques� ons.

PATIENT EXPERIENCE COMMENTSPATIENT EXPERIENCE COMMENTSPATIENT EXPERIENCE COMMENTS ––– OCTOBER / NOVEMBER 2016OCTOBER / NOVEMBER 2016OCTOBER / NOVEMBER 2016

10

Optum360 ICD-10-CM: Professional for Physicians 2016. Salt Lake City: 2015. 1. American Cancer Society. Breast Cancer Facts & Figures 2013-2014. Atlanta: American Cancer Society, Inc. 2013.2. Mandelblatt JS, Cronin KA, Bailey S, et al. Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Annals of Internal Medicine 2009;151(10):738-7473. “Medicare Claims Processing Manual: Chapter 18 - Preventive and Screening Services.” Centers for Medicare & Medicaid Services (CMS). N.p., n.d. Web. 3 Sept. 2014. <http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/

clm104c18.pdf>.4. AHA Coding Clinic, 4th Quarter 2008, pg 156 5. The Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). “ICD-10-CM Official Guidelines for Coding and Reporting.” Department of Health and Human Services. DHHS. 2015. September. Web. 1 September

2015 <http://www.cdc. gov/nchs/data/icd/10cmguidelines_2016_Final.pdf>

Focus on: BREAST CANCER

InsiderInformative and educational coding information for providers

Always remember ... y Patients taking anti-neoplastic medications (i.e., Tamoxifen,

Femara) for breast cancer are coded to the active code for malignant neoplasm for as long they are taking the medications4

y Use additional code to identify estrogen receptor status (Z17.0, Z17.1), and for Long term (current) use of anti-neoplastic medications (Z79.810, Z79.818)

Documentation and coding tipsDocumentation should include the specific site of tumor and laterality (e.g., right, left, bilateral).

C50 Malignant neoplasm of breast5 y 4th character identifies site: nipple/areola (0); quadrants

(2-5); overlapping boundaries (8); unspecified (9) y 5th character identifies sex: female (1); male (2) y 6th character identifies laterality: right side (1);

left side (2); unspecified (9)

Example of coding female breast cancerC50.411 Malignant neoplasm of RUOQ of female breast C50.919 Malignant neoplasm unspecified site unspecified breast

Example of coding male breast cancerC50.029 Malignant neoplasm of nipple/areola, unspecified male breastC50.829 Malignant neoplasm of overlapping sites of unspecified male breast

History of breast cancerZ80.3 Family history of malignant neoplasm of breast Z85.3 Personal history of malignant neoplasm of breast

Breast cancer screeningZ12.31 Encounter for screening mammogram for malignant neoplasm of breast

Coding example: A 68-year-old female seeing hematology-oncology for Stage IIA, ER+ breast cancer, RUOQ, previously removed by ultrasound-guided biopsy. Radiation therapy completed, currently on Femara

C50.411 Malignant neoplasm of upper-outer quadrant of right female breast

Z17.0 Estrogen receptor positive status [ER+]

Z79.818 Long term (current) use of other agents affecting estrogen receptors and estrogen levels

October is Breast Cancer Awareness MonthOctober 2016

Facts about breast cancerOne in eight women will develop breast cancer.1 Although breast cancer usually can be treated successfully when detected early, it nevertheless is the second-leading cause of cancer-related deaths among women. Every woman is at risk, and the risk increases with age. Mammography is an excellent screening tool for breast cancer.2 Accordingly, screening mammography is a healthcare quality mandate from the Centers for Medicare & Medicaid Services (CMS) quality measures, including Healthcare Effectiveness Data and Information Set (HEDIS).3

Current cancer vs. History of cancerTo correctly report a diagnosis of cancer, determine whether the patient’s cancer has been eradicated or is currently being treated. The neoplasm table in the ICD-10-CM code book establishes three categories of malignancy: primary, secondary and in situ. Malignantneoplasms should be coded as categorized; unknown sites (primary or secondary) must also be coded.

Current cancerPatients with cancer who are receiving active treatment for the condition should be reported with the malignant neoplasm code corresponding to the affected site. This applies even when a patient has had cancer surgery, but is still receiving active treatment for the disease.

History of cancerPatients with a history of cancer, with no evidence of current cancer, and not currently under treatment for cancer should be reported as “Personal history of malignant neoplasm.” These Z85 codes require additional characters to identify the site of the cancer and should be reported only when there is no evidence of current cancer. If a patient’s presenting problem, signs, or symptoms may be related to the cancer history or if the cancer history (personal or family) impacts the plan of care, then report the appropriate Z code and not the code for the active cancer.

Per the ICD-10-CM Official Guidelines for Coding and Reporting FY 2016: “A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included at the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required.” Thus the bolding of ICD-10-CM codes represents only those fully reportable codes, not categories or subcategories, that map to the 2017 CMS-HCC risk adjustment model for Payment Year 2017.

• Please refer to ICD-10-CM Mappings for all codes that map to risk in this model: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html• Please refer to 2017 Announcement for risk scores, disease interactions and hierarchy (pp 78-87): https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/

Announcements-and-Documents.html

This guidance is to be used for easy reference; however, the ICD-10-CM code book and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. The information presented herein is for general informational purposes only. Neither Optum nor its affiliates warrant or represent that the information contained herein is complete, accurate or free from defects. Specific documentation is reflective of the “thought process” of the provider when treating patients. All conditions affecting the care, treatment or management of the patient should be documented with their status and treatment, and coded to the highest level of specificity. Enhanced precision and accuracy in the codes selected is the ultimate goal. Lastly, on April 4, 2016, CMS announced the CMS-HCC Risk Adjustment model for payment year 2017 driven by 2016 dates of service. For more information see: http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2017.pdf, http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2017.pdf, https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/index.html. OptumTM and its respective marks are trademarks of Optum, Inc. This document is proprietary and confidential; rebranding, public posting, digital downloading is not permitted without the express consent of Optum. All other brand or product names may be registered marks of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer. ©2016 Optum, Inc. All rights reserved.

For more information on Optum and the products and services we offer, contact us at 1-877-751-9207 or email providersupport@optum.com. If you have questions or wish to be removed from this email, please contact your local Optum Healthcare Advocate.

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Optum360 ICD-10-CM: Professional for Physicians 2017. Salt Lake City: 2016. 1. “Statistics About Diabetes.” American Diabetes Association. N.p., 10 Sept. 2014. Web. 1 Oct. 2014. <http://www.diabetes.org/diabetes-basics/statistics/>.2. Kalyani RR, Margolis S. 2015 Diabetes: Your annual guide to prevention, diagnosis and treatment. The Johns Hopkins White Papers.:64-79.

Focus on: DIABETES

InsiderInformative and educational coding information for providers

November is American Diabetes MonthNovember 2016

The prevalence rate of diabetes mellitus (DM) in American seniors is 25.9% or 11.8 million seniors (diagnosed & undiagnosed). Diabetes contributes to heart disease and stroke and is the leading cause of kidney failure, blindness and non-traumatic lower limb amputations. Diabetes is the seventh leading cause of death in the U.S.1 Early detection and treatment of diabetic complications can prevent progression, so monitoring with dilated eye exams, urine tests and foot exams is essential. Because the risk of cardiovascular disease is increased in those with diabetes and prediabetes, blood pressure and lipid management, along with smoking cessation, are especially important.

Screening diabetesBecause diabetic nephropathy can occur in up to 40% of diabetics, annual screening for micro-albuminuria and calculation of the glomerular filtration rate (GFR) should be performed.2 Diabetic retinopathy is the leading cause of preventable blindness in people 25-74 years of age. Up to 80% of all diabetics will eventually develop some evidence of retinopathy, most without vision loss. A dilated and comprehensive eye examination by an ophthalmologist or optometrists should be performed annually.2

According to the American Diabetes Association (ADA), “diabetic adults have heart disease-related death rates of two to four times the rate of non-diabetics.” If an adult also has Peripheral Arterial Disease (PAD), they have an increased risk for heart attack and stroke. An estimated 1 out of every 3 people with diabetes over the age of 50 have PAD. Screening for PAD is best achieved by obtaining a history of claudication and performing an ankle brachial index (ABI) on DM patients.2

70%-100% of diabetics may develop at least mild neuropathy over the course of their lifetime. Of these, 48% of type 2 diabetics present with neuropathy at time of their DM diagnosis, but up to 50% are asymptomatic. DM can cause three types of nerve damage: mononeuropathy, peripheral and autonomic neuropathy. Annual screening for neuropathies should include a comprehensive foot exam, including testing for loss of protective sensation.

This guidance is to be used for easy reference; however, the ICD-10-CM code book and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. The information presented herein is for general informational purposes only. Neither Optum nor its affiliates warrant or represent that the information contained herein is complete, accurate or free from defects. Specific documentation is reflective of the “thought process” of the provider when treating patients. All conditions affecting the care, treatment or management of the patient should be documented with their status and treatment, and coded to the highest level of specificity. Enhanced precision and accuracy in the codes selected is the ultimate goal. Lastly, on April 4, 2016, CMS announced the CMS-HCC Risk Adjustment model for payment year 2017 driven by 2016 dates of service. For more information see: http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2017.pdf, http://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Announcement2017.pdf, https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/index.html. OptumTM and its respective marks are trademarks of Optum, Inc. This document is proprietary and confidential; rebranding, public posting, digital downloading is not permitted without the express consent of Optum. All other brand or product names may be registered marks of their respective owners. Because we are continuously improving our products and services, Optum reserves the right to change specifications without prior notice. Optum is an equal opportunity employer. ©2016 Optum, Inc. All rights reserved.

For more information on Optum and the products and services we offer, contact us at 1-877-751-9207 or email providersupport@optum.com. If you have questions or wish to be removed from this email, please contact your local Optum Healthcare Advocate.

Per the ICD-10-CM Official Guidelines for Coding and Reporting FY 2016: “A dash (-) at the end of an Alphabetic Index entry indicates that additional characters are required. Even if a dash is not included at the Alphabetic Index entry, it is necessary to refer to the Tabular List to verify that no 7th character is required.” Thus the bolding of ICD-10-CM codes represents only those fully reportable codes, not categories or subcategories, that map to the 2017 CMS-HCC risk adjustment model for Payment Year 2017.

• Please refer to ICD-10-CM Mappings for all codes that map to risk in this model: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Risk-Adjustors.html• Please refer to 2017 Announcement for risk scores, disease interactions and hierarchy (pp 78-87): https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/

Announcements-and-Documents.html

Always remember ... y When documenting diabetes, it is important to document

the type of diabetes, the control status, and the complications/manifestations associated with diabetes mellitus (e.g., “with”, “due to,” “secondary to” or “diabetic”)

y If the type of diabetes is not documented, it defaults to type 2 according to the guidelines

y Type 2 diabetes: Use additional code to identify control using insulin (Z79.4), oral antidiabetic drugs (Z79.84) and/or oral hypoglycemic drugs (Z79.84)

Documentation and coding tipsICD-10-CM diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected and complications affecting that body system.

Coding type 2 diabetes mellitus (to code type 1 diabetes, change the 3rd character to a zero): E11.21-E11.29 Type 2 diabetes mellitus with kidney complicationsE11.311-E11.39 Type 2 diabetes mellitus with ophthalmic complicationsE11.40-E11.49 Type 2 diabetes mellitus with neurological complicationsE11.51-E11.59 Type 2 diabetes mellitus with circulatory complicationsE11.610-E11.69 Type 2 diabetes mellitus with other specified complications

What’s new in ICD-10-CM for 2017 diabetes coding?• A 7th character is now required for many of the diabetes

with opthalmic complications codes. For type 2 diabetes, subcategories E11.32, E11.33, E11.34, E11.35 and E11.37 all require a 7th character to report laterality.

• Subcategories E11.352-E11.354 contain new type 2 diabetic retinopathy codes that reflect traction retinal detachment. A 7th character is required to reflect the laterality.

• Subcategory E11.355 is a new code that indicates type 2 diabetes with stable proliferative diabetic retinopathy. A 7th character is required to reflect laterality.

Note: The CMS-HCC model which includes the new diabetic retinopathy ICD-10-CM codes effective October 2016, has not been released as of the date this Insider was written. Therefore, the new ICD-10-CM codes effective 10/1/16 do not apply to the bolding legend.

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