Fall 2012 - Intermountain Physician

Transcription

provider i n s i g h t
inside this issue
CLINICS HONORED FOR CARE. . . . . . . 2
PATIENT PERCEPTION
OF QUALITY SCORES. . . . . . . . . . . . . . . 4
NEW STAFF . . . . . . . . . . . . . . . . . . . . . . . 5
M-TECH . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
HCPC CODES. . . . . . . . . . . . . . . . . . . . . . 7
If you have questions, suggestions, or
success stories you would like to share,
e-mail [email protected].
TM
fall
2012
Clinics Honored For Care
SelectHealth® and Intermountain Healthcare® are presenting the Excellence in Healthcare
Award to 122 healthcare clinics for their work in 2011.
This annual award recognizes independent physician offices as well as those within the
Intermountain system for demonstrating exemplary care in managing chronic illnesses.
These clinics have achieved high service marks from patients in preventive programs.
Honored clinics have rates in the top 10 percent of the scored offices.
The award notes achievement in the following areas: asthma care, diabetes care, breast cancer
screenings, cervical cancer screenings, colon cancer screenings, childhood immunizations,
adolescent immunizations, and customer service.
Many clinics received more than one award for outstanding work in multiple areas.
“Congratulations to the clinics recognized this year,” said Stephen Barlow, MD, SelectHealth
chief medical officer. “Our physicians consistently provide excellent care for their patients,
but these awards represent outcomes that exceed local and national standards.”
Measurements include how well patients control chronic illnesses, test results meeting
recommended levels, percentage of patients who received screenings, and percentage of
patients who received immunizations.
CLINIC SPOTLIGHT
Clinics
Honored
For Care
Intermountain Bountiful Clinic
Front Row: Dr. David Horsley, IM; Dr. Douglas Nielsen, Ped; Sun Yong
Kim, MA; Dr. Celia Blackburn, FP; Cindy Kaufusi, MA;
Terrie Luk, MA; Dr. Tyler Williams, IM
Back Row: Dr. Randy Reese, Ped; Dr. Douglas Kasteler, FP; Julie
Christensen, MA; Dr. Nedda Hendler, IM; Kris Ericksen,
MA; Dr. Scott Beckstead, FP
Alpine Medical Group
Adolescent Immunization
Park City Healthcare
Asthma Management
Ogden Clinic Skyline
Breast Cancer Screening
Sandy Family Practice
Cervical Cancer Screening
Coombs Private Practice
Tri City Medical Clinic Pleasant Grove
Asthma Management
Ogden Women’s Clinic, PC
Taylor Family Practice
Cottonwood Pediatrics
Alta Internal Medicine
River View Medical Clinic
Wade Family Medicine
Grow Up Great Pediatrics
Central Utah Clinic - Provo
Salisbury Internal Medicine
Cottonwood Pediatrics
Childhood Immunization
Intermountain Holladay Pediatrics
City Creek Internal Medicine
Tod L. Berg, MD
Intermountain Memorial Clinic
Cope Family Medicine
Grandview Family Medicine
Granger Medical Clinic
Intermountain North Valley Pediatrics
Intermountain
Avenues Internal Medicine
Grandview Family Medicine
Granger Medical Clinic - Riverton
Intermountain Southridge Pediatrics
Pediatric Care of Ogden
Southpoint Pediatrics
Granger Medical Clinic
Pediatric Asthma Mangement
Intermountain
Asthma Management
Asthma Management
Intermountain
Medical Tower Family Practice
Asthma Management
Intermountain
South Ogden Clinic
Asthma Management
2
Intermountain Budge Clinic
Intermountain Gorang Family Practice
Intermountain Obstetrics &
Gynecology Specialists
Herriman Family Practice
Intermountain
Canyon View Family Practice
Intermountain Bryner Clinic
Intermountain Layton Clinic
Intermountain Syracuse Clinic
Intermountain Sandy Clinic
Jordan Family Health
Intermountain Southridge Pediatrics
Jordan River Family Medicine
Ogden Clinic Canyon View
Ogden Clinic Mountain View
Ogden Clinic Harrison Blvd.
Pediatric Care of Provo
McKay-Dee Porter Family Practice
Olympus Clinic
Southpoint Pediatrics
Intermountain
River Road Internal Medicine
Intermountain Salt Lake Clinic OB
Intermountain
Utah Valley Internal Medicine Clinic
provider INSIGHT
FA L L 2 0 1 2
Southwest Children’s Clinic
Mountain Utah Family Medicine
Customer Service Family Practice
Treehouse Pediatrics and Family Care
Utah Valley Pediatrics American Fork
Wade Family Medicine
Intermountain
Central Orem Clinic OB
Chlamydia Screening
Dixie Primary Care
Customer Service Internal Medicine
Intermountain
Wasatch OB/GYN - McKay-Dee
Chlamydia Screening
Intermountain
Wasatch OB/GYN - North Ogden
Chlamydia Screening
Valley OB/GYN - Provo
Chlamydia Screening
Alta Internal Medicine
Colon Cancer Screening
Christian Private Practice
Intermountain
Intermountain Bryner Clinic
Intermountain
Canyon View Family Practice
Intermountain
Cottonwood Internal Medicine
Intermountain
Gorang Family Practice
Intermountain
McKay-Dee Internal Medicine Clinic
Intermountain
American Fork Internal Medicine
Intermountain
Bountiful Clinic - Internal Medicine
Intermountain
Women’s Health Specialists
Customer Service OB/GYN
Robert W. Later, MD
Russell A. Smith, MD
Intermountain
Holladay Pediatrics North
Customer Service Pediatrics
John Shakula Pediatrics
Kelly Pediatrics
Lofgren Pediatrics
Parkway Pediatrics
Pediatric Care of Ogden
Rose Pediatrics
Central Utah Clinic - Provo
Diabetes Management
Intermountain
Utah Valley Internal Medicine Clinic
Intermountain
Diabetes Management
Diabetes Management
Diabetes Management
Olympus Clinic
Intermountain Central Orem Clinic
Diabetes Management
Intermountain
Cottonwood Family Practice
Diabetes Management
Valley Family Medicine
Alpine Family Medicine
Intermountain
Cottonwood Internal Medicine
Diabetes Management
Coalville Health Clinic
Intermountain Holladay Clinic
Diabetes Management
Intermountain Bear River Clinic
Intermountain
North Canyon Family Practice
Diabetes Management
Intermountain
Gorang Family Practice
SelectHealth has formed a unique strategic
alliance with St. Luke’s Health System, Idaho’s
largest and only locally governed healthcare
system, to offer a new approach to health
insurance benefits to residents of Idaho.
This new alliance is committed to exceptional health care and
exceptional health insurance for Idahoans. The alliance will be
supported by BrightPath, an extensive network of physicians
and healthcare facilities that has been developed over a number
of years by St. Luke’s and other leading providers to provide a
comprehensive healthcare delivery system in Idaho.
Like SelectHealth, St. Luke’s is a nonprofit organization that gives
back to the community. Both organizations share a community
pledge for improving healthcare, providing superior service, and
actively supporting health and wellness education initiatives.
To provide local service to members, providers, and the
community, SelectHealth will establish a local office in Boise.
Intermountain North Ogden Clinic
Diabetes Management
Intermountain Springville Clinic
Intermountain South Ogden Clinic
Diabetes Management
Intermountain Syracuse Clinic
Diabetes Management
Isaacson Family Practice
Olympus Clinic
Diabetes Management
s e le c th ealt h .org
SelectHealth
Announces New
Affiliation with
Idaho-based St. Luke’s
Health SyStem
3
Patient Perception
of Quality Scores
The annual Patient Perception of
Quality was completed in 2011.
SelectHealth attempted to collect
surveys on more than 250 primary
care, OB/GYN, and endocrinology
clinics. Questions on the survey
focused on the patient’s experience
with physicians, nursing staff,
reception staff, cleanliness,
waiting time, and availability of
appointments.
Results for clinics with a sufficient number of completed surveys are
available at selecthealthphysician.org. Copies were delivered to clinc
managers as well. Log in to selecthealthphysician.org to review your clinc’s
results. Click on “Clinical Reports,” “SelectHealth,” “Primary Care” or
“Women and Newborn,” and “SelectHealth Satisfaction and Performance
Rating Reports.” After choosing your clinic and a reporting period in 2011,
click on “satisfaction” at the top of the page to access the results of these
surveys.
Members can review results for primary care and OB/GYN clinics with
more than 30 completed surveys on selecthealth.org.
Scores for primary care physicians have generally improved over the past
three years. Overall, internal medicine practices have shown improvement
for patient interaction and nursing staff for the past four years. Scores
for family practice clinics have increased in the categories “waiting time”
and “experience calling the clinc.” Pediatric clinics have improved in all
categories. Patient scores for OB/GYN clinics were slightly lower in 2010,
but improvements were made in all categories in 2011.
We hope that these positive trends continue and recognize that it takes
effort. SelectHealth offers a one-day class called “Science of Superior
Service.” If you are interested in learning more or enrolling, call Staci
Dearden at 801-442-7158. There is a $30.00 fee for each attendee. We
appreciate all that you do at your clinics to ensure an excellent experience
for our members.
National Drug Codes
As of June 1, 2012, claims submitted without a valid National Drug Code (NDC) are rejected by
our claims processing system.
The NDC is useful because it is a universal identifier for human drugs and biologics. The Healthcare Common Procedure Coding
System (HCPCS) only specifies the chemical name of a drug and can be used to represent multiple NDCs for several drug therapies.
Many healthcare providers have already made changes to their procedures to collect and submit NDC data to meet billing requirements
of some federal and/or state-funded programs. This data helps manage injectable and specialty drug benefits for SelectHealth. This
requirement does not apply to immunizations or services provided as part of an inpatient stay.
In 2007, we asked providers to begin submitting NDCs for injectable and specialty medications (in addition to the HCPCS code).
We appreciate your efforts to provide this information. Currently, approximately 70 percent of all claims submitted for injectable and
specialty medications include an NDC number.
If you need assistance to meet these requirements, please call the SelectHealth EDI department at 801-442-5442.
If you have general questions related to this requirement, contact your Provider Relations representative.
4
provider INSIGHT
FA L L 2 0 1 2
Tom Wahlen has recently joined SelectHealth
as the director of Provider Relations.
Previously, Tom served as senior manager and
negotiation lead in the Payer Contracting
department at Intermountain Healthcare. Tom
holds a Master of Business Administration
degree from Westminster College and earned a
Bachelor’s degree in Business/Public Relations
from the University of Utah.
Health Services Management Team
The update to the 5010 versions of
EDI transactions is now complete. If
your office is having any difficulties
with this transition, please contact
our EDI Team at (801) 442-5442 or
[email protected].
Get Involved!
There are many standards being created
at a national and state level that may have
an impact to your office. The Utah Health
Information Network (UHIN) provides a
way for these community-based standards
to be created and maintained. We share
feedback to UHIN to share with national
organizations that create standards. For
Christine Lake, Chris Chytraus, Lynanne Gibbons, Robbie Morris
more information, visit UHIN.org.
Christine Lake has held clinical positions in hospital and outpatient
surgery. She has worked as a region nurse consultant within the
Intermountain Medical Group and most recently headed up the
implementation of the SelectHealth physician/clinic public reporting
and the Primary Care Physician Incentive program.
Chris Chytraus joined SelectHealth in 2011 to oversee care
management for the Medicaid program. Chris was a manager for the
Utah Department of Health Fostering Healthy Children Program,
where she oversaw administrative care management for children in
Utah’s foster care system. Chris received her nursing degree from
Westminster College and her Certified Public Manager certification
from the state of Utah.
Lynanne Gibbons held nursing positions with Intermountain
Healthcare for 24 years and has been at SelectHealth for seven years.
Lynanne graduated from Brigham Young University with a bachelors
degree in nursing.
Robbie Morris has held positions at SelectHealth for 11 years. She
currently oversees the coordination of care management services for
new product lines. Robbie received a bachelors degree in nursing
from Brigham Young University. She has over 38 years of nursing and
management experience.
5
EDI UPDATES
New Staff at
SelectHealth
m -t E C H
medical technology assessment (M-Tech)
M-Tech is SelectHealth’s formal process for reviewing emerging healthcare technologies (procedures, devices, tests, and biologics)
for the purpose of establishing covered benefits. Existing technologies are, at times, also examined through this process.
Following is a list of recently reviewed technologies and committee recommendations:
Technology
Date
Reviewed*
Committee Recommendations
Continuous Glucose Monitoring Systems
(CGMS)
01/24/12
Continue to cover in limited circumstances. Criteria for coverage have been modified. See Medical
Policy #223.
Intraoperative Stereotactic Image
Guidance for Lumbar Spinal Arthrodesis
01/24/12
Cover. Current evidence, though limited, supports that stereotactic intraoperative image guidance in lumbar
spine surgery improves health outcomes. See Medical Policy #502.
Percutaneous and Endobronchial
Brachytherapy for Lung Tumors
01/24/12
Cover in limited circumstances. Current evidence supports percutaneous endobronchial brachytherapy for
the treatment of lung cancer to be safe and effective. See Medical Policy #501.
Bicompartmental Partial Knee
Replacement/Resurfacing
01/24/12
Deny as unproven and not medically necessary. Current evidence remains limited as to the efficacy, safety,
and durability related to bicompartmental knee replacement/resurfacing. See Medical Policy #431.
Total Hip Resurfacing Age
Limit Restriction
01/24/12
Raise upper age limit to 60 in men, continue age limit of 55 for women. Current evidence supports
total hip resurfacing for men up to age 60 to have equivalent health outcomes to standard total hip
arthroplasty. Evidence beyond age 60 in men is insufficient to draw conclusions. Evidence in women older
than age 55 demonstrates inferior outcomes to total hip arthroplasty. See Medical Policy #254.
Heart Transplant Age Limit Restrictions
01/24/12
Cover in limited circumstances. Current evidence demonstrates no statistically significant difference in
survival or complications for patients undergoing heart transplantation between age 60 and 70. Beyond age
70 the current evidence is insufficient to reach any firm conclusions as to the equivalence of outcomes in
this population. See Medical Policy #125.
Transcutaneous Electrical Modulation
Pain Reprocessing (Calmare®/Calmar™)
03/13/12
Deny as investigational. Current evidence is inadequate to determine the efficacy, safety, durability, or
appropriate therapeutic protocols for transcutaneous electrical modulation pain reprocessing therapy. See
Medical Policy #503.
John Cunningham Virus (JCV) Testing for
The Assessment of Progressive Multifocal
Leukoencephalopathy (PML) Risk
03/13/12
Cover in limited circumstances. Current literature supports use of the STRATIFY JCV Assay in patients
receiving immunosuppressive therapies to stratify risk of PML. See Medical Policy #504.
Shoulder Resurfacing
03/13/12
Deny as investigational. Current evidence suggests shoulder resurfacing has a greater number of
complications and higher revision rate than the current standard of total shoulder arthroplasty for the same
indications. See Medical Policy #505.1.
Axial Lumbar Interbody
Fusion (AxiaLIF®)
04/24/12
Deny as experimental/investigational. Evidence on the safety, efficacy, and durability beyond two years has
not been published for review. See Medical Policy #450.
Endometrial Cryoablation
for Menorrhagia
04/24/12
Cover. Current evidence, though limited, demonstrates endometrial cryoablation to be a safe and effective
technique in the treatment of menorrhagia equal to alternative therapies. See Medical Policy #329.
Intravascular Ultrasound (IVUS) for
Peripheral Vascular Disease (PVD)
04/24/12
Cover. Current literature demonstrates improved stent placement and fewer restenoses with IVUS in PVD.
See Medical Policy #447.
Magnetic Resonance (MR) Neurography
04/24/12
Deny as investigational. Current evidence is limited and has not yet proven clinical validity for many
conditions, and the clinical utility has not been defined. See Medical Policy #491.
MAKOplasty® Hip Replacement
for Osteoarthritis
06/12/12
Deny as investigational and not medically necessary. Current evidence has not demonstrated clinical
utility of this method of total hip arthroplasty as it compares to standard hip arthroplasty. See Medical
Policy #236.
Cooling Garments for the Management
of Multiple Sclerosis (MS)
06/12/12
Deny as investigational. Current evidence has not demonstrated significant impact of these garments on
the health outcomes in individuals with MS compared to nonmedical items. See Medical Policy #345.
Transcatheter Aortic Valve
Replacement (TAVR)/Implant
(TAVI) for Aortic Stenosis
06/12/12
Cover in limited circumstances consistent with FDA-approved indications and at designated facilities
only. See Medical Policy #444.
*“Date reviewed” does not necessarily reflect the policy implementation date. See Medical Policies for details.
If you have questions regarding coverage of these or any other technologies or procedures, or if you would like SelectHealth to
consider coverage for an emerging technology, please e-mail [email protected] or call Ken Schaecher, MD, FACP, M-Tech
committee chairman, at 801-442-7927.
All SelectHealth medical policies and technology assessments can be viewed on selecthealth.org. Click on the “Provider” tab (upper
right corner), enter your login information, and then click on “Policies and Procedures” (left side of page).
6
provider INSIGHT
FA L L 2 0 1 2
The HCPC level I and II codes
became effective January 1, 2012.
Please refer to the latest edition of your coding reference books
or software updates for current information regarding these code
changes. If you have purchased books, be aware that there are
already corrections being made. Please refer to the following
websites to get the lastest information and corrections*:
ama-assn.org/ama/pub/category/3896.html
cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_
summarytables.asp#TopOfPage
cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.
asp#TopOfPage
Preventive Care Tips
As a result of the Affordable Care Act (ACA), the majority
of plans offered by SelectHealth offer preventive care services
covered at 100 percent. SelectHealth defines preventive care
as routine healthcare that includes screenings, checkups, and
patient counseling to prevent illness, disease, or other health
problems not currently known to exist in the person, or in the
case of immunizations, to prevent the development of disease. As
members continue to use this benefit, there are a few points that
can make claims submission easier.
2.365 Days. Prior to January 1, 2011, preventive
services were covered once per calendar year. However,
effective the beginning of this year, members are only
eligible for preventive services every 365 days.
3. Lab Work. Laboratory work billed in conjunction
with a routine exam may be billed as preventive if
the patient has not been diagnosed with a related
condition in the past. In these situations, it is important
that the correct diagnosis is sent to the lab. If the lab
work is not billed with a preventive diagnosis, it will
apply to a different benefit and may be subject to a
copay, deductible, and/or coinsurance. For example, it
is common to see CPT 80050 billed with an existing
diagnosis, which triggers the outpatient minor diagnostic
testing benefit instead of the preventive benefit.
For additional information regarding preventive coding polices
and services, please visit selecthealthphysician.org.
1.Existing Conditions. If the purpose of the
patient’s visit is to evaluate and manage an existing
condition (i.e., treating high blood pressure to prevent a
heart attack or stroke), it is not considered a preventive
service. However, if a member has an existing condition,
they are still eligible for a preventive visit for their general
well-being. In these situations, it is appropriate to bill
using a preventive diagnosis code instead of a code for an
existing diagnosis.
*SelectHealth may link to other websites for your convenience. SelectHealth does not expressly or implicitly recommend or endorse the views, opinions, specific services, or products
referenced at other websites linked to the SelectHealth site, unless explicitly stated. SelectHealth disclaims any responsibility for the content, information or the privacy and security
policies contained on other websites, and does not exert any editorial or other control over those sites.
7
Coding Corner
2012 Code Changes
P.O. Box 30192 • Salt Lake City, Utah 84130
Nonprofit Org.
U.S. Postage
PAID
Salt Lake City, UT
Permit No. 4547
The information that is contained in this
newsletter does indicate whether a treatment is
subject to insurance benefits. If a member has
questions about benefit coverage, please refer
him or her to Member Services at 801-442-5038
(Salt Lake area) or 800-538-5038.
© 2009-2012 SelectHealth. All rights reserved. 1844 09/12
Provider Insight is a trademark of SelectHealth.
Tamara Sheffield, MD, MPA, MPH, and
Shannon Seymour, RN will present current
information about immunizations and
influenza. The summit is free, but seating is
limited. Visit selecthealthphysician.org to
register today!
Immunization Summits

Fall 2012 - Intermountain Physician

Transcription

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