September 2015
General News
Annual notice:
Medica encourages members to get flu shots
Each year, Medica encourages its members to get seasonal influenza shots, and will do so again by promoting them through member newsletters, worksite flu-shot clinics, and targeted member mailings this fall. In addition to providing protection against H1N1 ("swine flu"), this year's vaccine is available in both trivalent and quadrivalent variations that protect against other strains of the influenza virus. Health care professionals should talk to their patients about which vaccine is appropriate for them.
Vaccine priorities
The U.S. Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) recommend that everyone 6 months of age and older get a flu vaccine each year. It is especially important for the following individuals to receive a flu vaccine, either because they are at higher risk for infections or complications from the flu, or they live with or care for those at higher risk:
- Pregnant women
- Household contacts and out-of-home caregivers of children younger than 5 years of age
- People 50 years of age and older
- People of any age with certain chronic medical conditions
- People who live in nursing homes and other long-term-care facilities
- People who live with or care for those at high risk for complications from flu, including health care workers
- Household contacts of persons at high risk for complications from the flu
Pharmacist-administered vaccination
Medica members may be able to receive their flu vaccination through a Medica network pharmacy. Inquiries can be directed to a member's local pharmacy.
Billing for shots
Clinics should use their regular billing methods for flu shots. To ensure full coverage, Medica members must receive shots from a Medica network provider.
When submitting claims for flu shots, providers should use applicable codes of the International Classification of Diseases, Clinical Modification (ICD-9-CM or ICD-10-CM, when applicable), Common Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS). Medica will accept codes for reimbursement as outlined by CDC.
More information
More details on seasonal flu vaccine are available online:
Providers who have questions or comments about Medica flu and pneumonia prevention programs may call the Medica Provider Service Center at 1-800-458-5512. In the event of a vaccine shortage, providers are encouraged to refer to the Minnesota Department of Health (MDH) website »
Effective August 1, 2015:
Member ID cards to no longer include issue date on back
Beginning August 1, 2015, Medica is making changes to some members’ ID cards. Members of large employer groups that have no plan changes from year to year will no longer receive new member ID cards upon renewal. This change should help eliminate member confusion over receiving duplicate cards every year. This change does not apply to groups that have My Plan by MedicaSM or groups with six-digit policy numbers.
To allow cards to have a longer “life” beyond a single calendar year, the issue date on the back of these ID cards will no longer be included. The issue date is the date the card was printed. This date often gets confused with the member’s effective date of coverage, too.
In addition, ID cards that are shaded (often in gray or blue) will be changed to only be printed with a white background, which should make copying cards easier for provider offices. This change is scheduled to occur as groups renew in 2016.
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Clinical News
Effective July 15, 2015:
Medica makes coverage policy change
The following benefit determination was effective beginning with July 15, 2015, dates of service. This change applies to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Endoscopic balloon sinuplasty for treatment of chronic sinusitis
Medica has reviewed endoscopic balloon sinuplasty for treatment of chronic sinusitis and has determined that this technology is no longer investigative and therefore is covered either as a stand-alone procedure or as part of functional endoscopic sinus surgery for treatment of chronic rhinosinusitis in individuals 18 years of age or older. For all other indications, endoscopic balloon sinuplasty remains investigative and therefore not covered. For further information, refer to Medica’s coverage policy titled “Endoscopic Balloon Sinuplasty for Treatment of Chronic Sinusitis.”
Balloon sinuplasty, a minimally invasive dilation procedure intended to widen sinus passages and restore normal sinus drainage and function, is suggested for treatment of chronic sinusitis (i.e., rhinosinusitis lasting longer than 12 weeks) associated with inflammatory obstruction of the sinus passages in individuals who are refractory to conservative medical treatments. The procedure is typically performed by an otolaryngologist using guidewires and either fluoroscopic or fiberoptic guidance. After insertion of an initial placement guidewire and catheter into the affected sinus, the balloon catheter is inserted and gradually inflated to dilate the sinus passage. After balloon removal, sinus irrigation may be performed. Additional sinus passage dilation may be performed to achieve desired results. Several sinus cavities can be treated during one session.
The complete text of the policy that applies to the determination above is available online or on hard copy:
- See Medica’s coverage policies; or
- Call the Medica Provider Literature Request Line for printed copies of documents, toll-free at 1-800-458-5512, option 1, then option 5, ext. 2-2355
Effective October 1, 2015:
Medica to make coverage policy change
The following benefit determination will be effective beginning with October 1, 2015, dates of service. This change will apply to all Medica products including government products unless a particular health plan (whether commercial, Medicare or Medicaid) requires different coverage.
Minimally invasive access techniques for lumbar interbody fusion
Medica has reviewed minimally invasive access techniques for lumbar interbody fusion (LIF) and has expanded coverage to address other access routes in addition to lateral approaches. The related coverage policy title was changed to reflect this change of scope. Medica has determined that the following access approaches are no longer investigative and therefore are covered:
- Minimally invasive anterior lumbar interbody fusion
- Minimally invasive posterior lumbar interbody fusion
All other minimally invasive access approaches are investigative and therefore will not be covered. These include:
- Laparoscopic anterior lumbar interbody fusion
- Lateral lumbar interbody fusion (eXtreme lateral interbody fusion, or XLIF®; direct lateral interbody fusion)
- Oblique lumbar interbody fusion
- Para-axial/presacral lumbar interbody fusion (e.g., AxiaLIF®)
- Transforaminal lumbar interbody fusion
Lumbar interbody fusions are surgical procedures that attempt to eliminate instability in the back by fusing two or more vertebrae. Minimally invasive approaches have been developed to access the surgical site through a short incision, thereby reducing damage to the muscles surrounding the spine. Specially designed incision and access tools, implant devices, and accessories are used to minimize incision size and tissue or muscle disruption. Minimally invasive access techniques are purported to reduce post-surgical pain and aid in faster recovery with minimal post-surgical complications. Minimally invasive access techniques are defined by entry location: from the front of the body (anterior), from the back of the body (posterior), from the side of the body (lateral), and at the lumbar/sacral junction (para-axial/presacral).
The complete text of the policy that applies to the determination above will be available online or on hard copy:
Effective October 1, 2015:
Medical policies and clinical guidelines to be updated
Medica will soon update one or more utilization management (UM) policies, coverage policies, Institute for Clinical Systems Improvement (ICSI) guidelines, and Medica clinical guidelines, as indicated below. These policies will be effective October 1, 2015, unless otherwise noted.
UM policies — Revised
These versions replace all previous versions.
| Name |
Policy number |
| Inpatient (Hospital) Level of Care (update to MCG 19th edition, August 2015) |
III-INP.01 |
Coverage policies — Revised
These versions replace all previous versions.
| Name |
| Antigen Leukocyte Cellular Antibody Test (ALCAT Test) for Food & Chemical Allergies |
| Cytoxic Testing for Allergy Diagnosis |
| Digital Breast Tomosynthesis |
| Endoscopic Balloon Sinuplasty for Treatment of Chronic Sinusitis (effective 7/15/15) |
| Intracellular Micronutrient Analysis: MicroNutrient Testing Intracellular Mineral Electrolyte Analysis |
| Keratoprosthesis for Corneal Opacity (Kpro); |
| KRAS Mutation Analysis for Predicting Response to Drug Therapy |
| Minimally Invasive Access Techniques for Lumbar Interbody Fusion (formerly Minimally Invasive Lumbar Spinal Fusion Surgery Using Axial Lumbar Interbody Fusion (AxiaLIF) or Lateral Interbody Fusion) |
| OncoSorb Therapy (UltraPheresis) for Non- Hematologic Cancer |
| Repair of Pierced Body Part |
| Serial Dilution Endpoint Titration for Diagnosis and Treatment of Airborne Allergy |
Coverage policies — Inactivated
| Name |
| Non-Contact Normothermic Wound Therapy |
These documents will be available online or on hard copy:
Advance directives: A valuable part of patient consultations
In recent years, medical technologies have made great advancements in extending life, while making dying a longer process. Life-extending technologies include dialysis, feeding tubes, ventilators, defibrillator, pacemakers, and on and on.
Providers today play an important role in initiating and guiding their patients to articulate their wishes for end of life and to create a formal document about their wishes. This is often not an easy conversation with a patient due to the patient’s fear or discomfort with dying, or their cultural or religious beliefs.
Having the conversation
David Casarett, MD, associate professor of medicine at the University of Pennsylvania and director of Penn’s hospice and palliative care program, suggests that the conversation regarding advance directives should be thought about as a way to help families come together and do the right thing for themselves and their family member. Families wouldn’t want to wait to have such a conversation when a family member has been diagnosed with a terminal illness — Life can change quickly, and having a discussion well in advance of a crisis gives an opportunity for clarification and mutual understanding.
Many providers start these discussions with patients who are about 50 years of age. In some cases, depending on the health history of the patient and family, providers may wish to begin the conversation even earlier. It is important to support advance care-planning decisions with formal documents, such as an advance directive, that could be provided to the patient in the provider’s office. With changes in delivery of medical care, often the provider that best knows the patient and his or her wishes is not at the hospital caring for the patient in a time of crisis, so having the document can help in making appropriate decisions about ongoing care.
An important part of the patient medical record
The Centers for Medicare and Medicaid Services (CMS) encourages providers to have end-of-life discussions with Medicare patients. The Minnesota Department of Human Services (DHS) also encourages them for adult Minnesota Health Care Programs (MHCP) enrollees.
Often providers include an advance directive in the patient’s medical record. Medica actually verifies to make sure providers have an advance directive for Medicare and MHCP members during its nurse reviews of medical records on behalf of CMS and DHS, due to its contract with both. See more about medical record reviews by Medica (under “Provider Responsibility Policy”).
Advance directives also come in many languages. Patients can learn more and get a copy from:
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Pharmacy News
Effective October 1, 2015:
Medica to update commercial, Marketplace, MHCP drug lists
Medica has reviewed the following products, with their respective coverage status to be effective October 1, 2015. As indicated in the table below, these changes will apply to the Medica Commercial Preferred Drug List; the new Marketplace Preferred Drug List for individual and family business (IFB) members and small group plan members who purchase health plans on state exchanges; and the Medica List of Preferred Drugs for Minnesota Health Care Programs (MHCP). The Medica MHCP formulary applies to the following products: Medica Choice CareSM (including Minnesota Senior Care Plus program, or MSC+), Medica MinnesotaCare, Medica AccessAbility Solution® (Special Needs Basic Care program, or SNBC), and Medica DUAL Solution® (Minnesota Senior Health Options program, or MSHO), for non-Part D drugs. These changes will not apply to the Medica Medicare Part D formulary.
| Generic name (brand name) |
Commercial and Marketplace formulary status |
Medica MHCP formulary status |
Current preferred alternatives |
Restrictions and comments |
Approved therapeutic indications |
| exenatide extended-release (Bydureon®) |
Commercial tier 3; Marketplace tier 3 |
Non-formulary |
Trulicity, Victoza |
Step therapy required |
Adjunctive treatment to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus |
| exenatide (Byetta®) |
Commercial tier 3; Marketplace tier 3 |
Non-formulary |
Trulicity, Victoza |
Step therapy required |
Adjunctive treatment to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus |
| albiglutide (Tanzeum®) |
Commercial tier 3; Marketplace tier 3 |
Non-formulary |
Trulicity, Victoza |
Step therapy required |
Adjunctive treatment to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus |
| dulaglutide (Trulicity®) |
Commercial tier 2; Marketplace tier 2 |
Formulary |
|
|
Adjunctive treatment to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus |
| liraglutide (Victoza®) |
Commercial tier 2; Marketplace tier 2 |
Formulary |
|
|
Adjunctive treatment to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus |
Medica drug formularies are available online or on paper:
Medication request forms
A uniform formulary exception request form should be used when requesting a formulary exception. It is important to fill out the form as completely as possible and to cite which medications have been tried and failed. This includes the dosages used and the identified reason for failure (e.g., side effects or lack of efficacy). The more complete the information provided, the quicker the review, with less likelihood of Medica needing to request more information. To request formulary exceptions, providers can:
Effective October 1, 2015:
Changes to Medica Part D drug formularies
Medica posts changes to its Part D drug formularies on medica.com 60 days prior to the effective date of change. The latest lists notify Medicare enrollees of drugs that will either be removed from the Medica Part D formulary or be subject to a change in preferred or tiered cost-sharing status effective October 1, 2015. Medica also notifies affected Medica members in their Medicare Part D Explanation of Benefits (EOB) statements mailed out monthly. View the latest Medicare Part D drug formulary changes »
Medica periodically makes changes to its Medicare Part D formularies: the Part D open formulary (4-tier + specialty tier) and the Part D closed formulary. The Medica Medicare Part D drug formularies are available online or on paper:
Medication request forms
A medication request form should be used when requesting a formulary exception. It is important to fill out the form as completely as possible and to cite which medications have been tried and failed. This includes the dosages used and the identified reason for failure (e.g., side effects or lack of efficacy). The more complete the information provided, the quicker the review, with less likelihood of Medica needing to request more information. To request formulary exceptions, providers can:
- Download a Medica coverage determination form »
- Call MedImpact at 1-800-788-2949.
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Network News
Effective July 1, 2015:
Medica updates Medicare physician fee schedule
Beginning with July 1, 2015, dates of service, Medica implemented the quarterly drug and immunization rate updates to its Medicare physician fee schedule for applicable Medica products. In addition, as a follow-up to the previously published notice about this update, the July 2015 update also included changes to the overall Medicare physician conversion factor and 2015 relative value units (RVUs).
These changes are being implemented in conjunction with the Medicare Access and CHIP Reauthorization Act of 2015, which allowed a zero percent update that would have ended on March 31, 2015, to continue through June 30, 2015, and allows for an increase in payment for RVU-based services from July 1, 2015, to December 31, 2015. See details on Medicare fees from CMS »
Medica previously notified providers about this with a Provider Alert in July 2015. No claims resubmission or adjustments were necessary.
(Update to "Medica to update Medicare physician fee schedule" article in the June 2015 edition of Medica Connections.)
Effective October 1, 2015:
Medica to update Medicare physician fee schedule
Beginning with October 1, 2015, dates of service, Medica will implement the quarterly update to its Medicare physician fee schedule for applicable Medica products. This fee schedule change will reflect the October 2015 Centers for Medicare and Medicaid Services (CMS) update applicable to reimbursement for injectable drugs and immunizations. The reimbursement impact of this quarterly update will vary based on specialty and mix of services provided. Updates for durable medical equipment (DME) and orthotics and prosthetics (O&P) will not be implemented at this time.
Details on Medicare changes to drug fees are available online from CMS.
Providers who have further questions may contact their Medica contract manager.
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Administrative News
Key takeaways from ICD-10 code testing with providers
49 days until go-live date arrives!
Medica recently completed ICD-10 code testing with its provider partners. Key findings underscore how correct coding is so important to properly process claims (just as it is today!). Testing takeaways include:
- On facility claims, for rehabilitation services in an inpatient setting, it is important to code the rehabilitation procedures to receive the rehabilitation diagnosis-related group (DRG) payment rates for ICD-10 diagnosis codes. This is a change because with ICD-9 codes, rehabilitation procedures such as physical, speech or occupational therapy were not required to be coded on inpatient claims.
- Coders need to follow the Official Guidelines for Coding and Reporting. While true for ICD-9 coding, it is even more the case for ICD-10, as there have been some changes. One area of particular note is Chapter 16, “Certain Conditions Originating in the Perinatal Period.” When both birth weight and gestational age are available for a premature infant, both should be coded on the claim. Failing to include these codes may result in the assignment of a DRG with a lesser weight.
The bottom line: Coders should continue to code correctly and follow best practices for using diagnosis codes once the ICD-10 implementation date arrives on October 1, 2015.
Here are other resources that may help providers prepare for the ICD-10 transition:
Effective October 1, 2015:
Credentialing to add new provider specialty designation
Effective October 1, 2015, Medica will add a new practitioner specialty to identify practitioners as part of their provider demographics (for instance, available in provider directories for Medica members to use). The new specialty is Electrophysiology. Practitioners with the appropriate training or education who would like to request Electrophysiology as their specialty can do one of the following:
Effective October 1, 2015:
Medica to revise reimbursement policies
Medica will soon update the reimbursement policies indicated below, effective with October 1, 2015, dates of processing. Such policies define when specific services are reimbursable based on the reported codes.
Reimbursement policies — Revised
These versions replace all previous versions.
| Name |
| Obstetrical (updated code list) |
| Self-Administered Drugs (updated policy summary and code list) |
| Wrong Surgical or Other Invasive Procedures (updated policy statement) |
These revised policies will be available online or on hard copy:
Reminder:
Correct coding, documentation related to reimbursement policy
The following reminder is about correct coding as reflected in the Split Surgical Package reimbursement policy. Such policies define when specific services are reimbursable based on the reported codes.
Split surgical package
A surgical package consists of the pre-operative management, surgical care and post-operative management services associated with a surgical procedure. When more than one physician not within the same group practice is involved in providing the surgical package, a split surgical package occurs.
Medica reimburses separately for each of the components of the split surgical package when the appropriate modifier is appended to the surgical procedure code. The following table lists the applicable modifiers and the description for each.
| Modifier |
Description |
| 54 |
Surgical care only |
| 55 |
Post-operative management only |
| 56 |
Pre-operative management only |
One example of a split surgical package is for co-managed vision services. This occurs when physicians agree on the transfer of care during the global period of an eye surgery. The surgeon (ophthalmologist) appends the eye surgery code with modifier 54 and a provider (optometrist) not in the same group practice but performing the post-operative care bills the same eye surgery code appended with modifier 55. Both the bill for the surgical care only and the bill for the post-operative management only will include:
- The same date of service
- The same surgical procedure code
- Required modifiers:
- The procedure code for the surgical procedure only, billed by the ophthalmologist, is appended with the 54 modifier (“Surgical care only”).
- The same surgical code billed by the ophthalmologist is billed by the optometrist for the post-operative management only and must be appended with the 55 modifier (“Post-operative management only”). Note: On the claim form, the physician billing for the post-operative care must include the date care was assumed and the date care was relinquished. These dates must be indicated in the remarks field or free text segment on the claim form. Without these dates on the claim form for the post-operative care, the claim will be denied with reason code 577 ("Re-submit records with date of service").
Refer to policies, such as this one on split surgical packages, either online or on hard copy:
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PPO News
Latest UHC provider bulletin available online
UnitedHealthcare (UHC) has published the latest edition of its Network Bulletin (July 2015). Highlights that may be of interest to LaborCare® network providers include:
- ICD-10 codes have been added to commercial reimbursement policies
- Certain outpatient surgical procedures to require prior authorization — scheduled for October 2015
- Infertility treatment to require prior authorization — scheduled for October 2015
View the July 2015 UHC provider bulletin.
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