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Medical Coverage Policies update III

Kaiser Permanente named 2015 ‘Official Health Care + Coverage Provider’ of the Baltimore Orioles

Pharmaceutical management Information and updates

Provider access to health education materials

Documentation of coordination of care with primary care physicians (PCPs)

Documenting and coding the diagnosis: why it is important

Clinical practice guideline updates

National Coverage Analysis (NCA) for screening for lung cancer with low dose computed tomography (LDCT)

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FOR PRACTITIONERS & PROVIDERS OF KAISER PERMANENTE

Produced by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., with the Mid-Atlantic Permanente Medical Group, P.C. Website: providers.kaiserpermanente.org/mas

JUNE 2015

Provider demographic changesEffective April 13, 2015, consistent with the articles of our contract, Kaiser Permanente will now review all provider demographic changes for locations and relocations within Provider Contracting and Network Management for approval in a timely manner. Services should not be rendered to our members at your new location or relocation until your requested change has been approved by Kaiser Permanente.

When initiating a provider demographic request for a new location or relocation, all requests must come from the provider on company letterhead. For additional information on Demographic Changes, you may also view our provider website at providers.kp.org/mas. This request should be faxed to (301) 388-1700 or emailed to: provider.relations@kp.org.

The demographic requests will be reviewed by a member of our Provider Contracting team. The review process will be completed within thirty (30) business days from date of receipt and a decision will be communicated via letter, unless credentialing is required for the demographic request. Please refer to section 10.5 Credentialing and Re-credentialing Process.

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The Kaiser Permanente Participating Provider Manual, Section 10.13: Quality and Health Management is updated to reflect the change in provider demographic changes for locations and relocations requirements. You may download

an updated version of Section 10.13 from our community provider website at providers.kp.org/mas, or request a hard-copy by contacting Provider Relations at 1-877-806-7470.

Medical Coverage Policy Updates I 2015Medical Coverage Policies (MCPs) are developed in collaboration with specialty service chiefs and clinical subject matter experts. MCPs specify clinical criteria supported by current peer reviewed literature and are intended to guide use of health care services such as devices, drugs, and procedures. The policies are reviewed and updated annually, reviewed for approval by the Regional Utilization Management Committee (RUMC), and filed with the Maryland Insurance Administration. These MCPs are usually applicable only to commercial members, except where noted.

• New wide bore MRI and open MRI: New MCP which indicates that Wide Bore MRIs currently have superior resolution with 1.5 Tesla magnets; the majority of Open MRIs currently have 1.2 Tesla magnets, which have inferior resolution. As a quality of care standard, all members, regardless of health plan type, including those with network and point of service benefits, should be considered, and referred when possible, for initial MRI with a 1.5 Tesla magnet, prior to referral to less powerful units.

• Acupuncture: Treatments are considered medically necessary for nausea, vomiting and chronic pain conditions after failure of 4 weeks or more of medical therapy. Patient must have an acupuncture benefit. Smoking, asthma, stroke, IBS, dysmenorrhea, and carpal tunnel syndrome are not covered indications for treatment. No significant changes to previous criteria.

• Autologous stem cell cardiomyoplasty: The existing evidence is of insufficient quality and quantity to establish its safety and effectiveness. No significant changes to previous criteria.

• Cardiac rehabilitation: Cardiac rehabilitation is covered with a referral from cardiology after Acute MI, CABG, heart/heart-lung transplant, and for other conditions where monitoring and rehabilitation to achieve an improvement in function is needed and no contraindications are present. No significant changes to previous criteria.

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• Cranial remodeling bands and helmets: Cranial remodeling DME devices are covered for Synostotic plagiocephaly following surgical correction and for moderate to severe positional head deformities associated with premature birth, restrictive intrauterine positioning, cervical abnormalities, birth trauma, torticollis (shortening of the sternocleidomastoid muscle) and sleeping positions in infants when banding is initiated at 4 to 12 months of age and the following conditions are met. No significant changes to previous criteria.

• Foot and ankle orthotics: Limited coverage for foot orthotics for post-operative patients and those with diabetes who have a foot orthotic benefit. AFOs may be covered if prefabricated or in certain instances for custom made AFOs. Coverage may be for ambulatory and non-ambulatory patients.

• Genetic testing: A patient must have clinical features or be at risk of having a disease, the diagnosis will impact treatment or management,

a definitive diagnosis remains uncertain and there must be a validated test available supported by peer reviewed literature. List of diseases removed and Milliman criteria will be followed for specific genetic tests.

• Habilitative services (ONLY FOR SPECIAL DC PLANS small group/individual: Services covered may include PT,OT,SLP and ABA therapy for maintaining , learning, or improving skills for daily living. No significant changes to previous criteria.

• Infertility: The definition of infertility includes women planning on using donor sperm, women with known tubal disease, and couples with known male-factor infertility as well as couples who are unable to conceive after a specified time period. All patients will require a workup as listed (estradiol, LH, FSH, TSH, and prolactin within one year, semen analysis within one year and a HSG). Benefits for advanced reproductive therapies have not changed and the benefit array determines what is covered for the patient/couple.

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• Virtual colonoscopy, Maryland: Indicated for patients with a known partial colonic obstruction, failure to achieve optical colonoscopy due to technical reasons or stenosing lesions, or if an optical colonoscopy is medically contraindicated. For members whose insurance is regulated by state of Maryland screening for average risk asymptomatic patient’s age 50 years and older is covered without meeting the above criteria that is required for diagnostic colonoscopies.

• Virtual colonoscopy, Virginia, DC, federal employees: Indicated for patients with a known partial colonic obstruction, failure to achieve optical colonoscopy due to technical reasons or stenosing lesions, if an optical colonoscopy is medically contraindicated.

• For network physicians: access to MCPs is only two clicks away in Health Connect Affiliate Link Provider Portal located at providers.kp.org/mas. Contracted physicians with access to our provider portal can view our MCPs, and their patients’ benefits and medical record. To obtain access, go to the same web address and click

the Forms tab. After completing the enrollment packet, fax to 301.388.1695. Access usually takes 5-7 days after enrollment forms are received.

After access to Health Connect Affiliate Link has been obtained, click on the Clinical Library section on the right side of the KPHC Home page and then type in medical coverage policies in the search box. All medical coverage policies will be displayed. If you would like to receive a hard copy of the Medical Coverage Policy, please contact the Utilization Management Operations Center (UMOC) at 1-800-810-4766 and follow the prompts

If you have questions please feel free to contact Dr. Claudia Donovan or Robin Boltz.

* Claudia Donovan M.D. Physician Referral Manager Claudia.K.Donovan@kp.org

* Robin S. Boltz R.N. Compliance & Program Manager robin.s.boltz@kp.org (301) 816-5656

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Kaiser Permanente named 2015 ‘Official Health Care + Coverage Provider’ of the Baltimore OriolesKaiser Permanente of the Mid-Atlantic States has signed on as the ‘Official Health Care + Coverage Provider’ of the Baltimore Orioles. The multi-year partnership began just in time for Opening Day.

“Baltimore is a city on the move and the Orioles are a team on the rise,” shares Kim Horn, President of Kaiser Permanente of the Mid-Atlantic States. “As the Official Health Care + Coverage Provider, we are proud to partner with the Orioles to address the needs of Baltimore.”

This partnership follows Kaiser Permanente’s recent announcement to expand access to its high-quality, efficient, affordable care at the new Kaiser Permanente Baltimore Harbor Medical Center. Set to open this fall, this center will be the largest full service medical center in the Inner Harbor.

Today, Kaiser Permanente is serving more than 70,000 Baltimore residents with its unique integrated model which brings care and coverage together. As the region’s top ranked health plan and a leader in innovation, members benefit from features like the telemedicine program, which allows patients to access care from anywhere, at any time.

In addition to expanding care in the city, Kaiser Permanente has invested in the wellness of local residents for more than 30 years, working with the City of Baltimore, nonprofit partners and local schools to improve community health.

As the Official Health Care + Coverage Provider for the Baltimore Orioles, Kaiser Permanente will participate in several promotional events this season and combine efforts with the Orioles to support the health of Baltimore residents.

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Pharmaceutical management information and updatesThe KPMAS Regional Pharmacy & Therapeutics (P&T) Committee approves drug formularies for all lines of business. The Regional P&T Committee, with expert guidance from various medical specialties, evaluates, appraises, and selects from available medications those considered to be the most appropriate for patient care and general use within the region. The purpose of the formulary is to promote rational, safe, and cost-effective drug use and the formulary is updated monthly

with additions and/or deletions approved by the Regional P&T Committee. For the most recent information on drug formulary updates or changes, please reference the broadcast email distributed by the Regional P&T Committee co-chairs, the quarterly “Tips on Scripts” Newsletter (MAPMG practitioners) and/or the online Community Provider Portal (CPP for affiliated practitioners) available at providers.kaiserpermanente.org/html/cpp_mas/formulary.html.

Provider access to health education materials Kaiser Permanente physicians and network providers have access to health education information to include in patient’s After Visit Summary or to help supplement discussion from a patient visit. The centralized internal “clinical library” contains an electronic inventory of health education materials that physicians can use for all visit types. All providers can print the content from the library at the end of a patient visit. Additionally Kaiser Permanente physicians can include smart text containing health education content in the printed visit summary.

• KP providers are able to refer or direct book members into some health education

programs through eConsult system, and can provide members with information on how to self-register for programs via the After Visit Summary or hard copy flyers.

• Network providers can access and direct members to the available health education programs through kp.org.

Additional information on health education programs, tools, and resources is available by:• Visiting kp.org/healthyliving• Contacting the Health Education automated line

(301) 816-6565 or 1-800-444-6696 (toll free)

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Documentation of coordination of care with primary care physicians (PCPs)Kaiser Permanente continues to be a leader in promoting the integration of behavioral and medical health care and views care coordination between Behavioral Health and Primary Care to be a critical aspect of treatment.

Behavioral Health providers are asked to obtain the member’s consent to communicate the following to the patient’s PCP within seven (7) days of the beginning of treatment:• Date of initial service• Patient’s diagnosis and brief assessment of their

findings

• Treatment plan and recommendations• Medications prescribed

If you are not sure how to contact the member’s PCP, you may mail or fax treatment information to the following address and we will make sure the PCP gets your report:

Kaiser PermanenteRegional HIMS6526 Belcrest Road, Suite 207Hyattsville, Maryland 20782Fax: (301) 209-6065

ICD-10 UpdateInternational Classification of Diseases (ICD) is a coding system used for inpatient and outpatient diagnoses and inpatient procedures. ICD-9 is the current version used in the United States when billing for health care services.

On January 16, 2009, the Department of Health and Human Services released the Final HIPAA Administrative Mandate to Adopt Version 10 (ICD-

10.) The compliance date for implementation of the ICD-10 Coding System has now been set for October 1, 2015.

For more information, visit our website at providers.kp.org/mas for the latest information and links to resources for providers to prepare for the ICD-10 implementation

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Documenting and coding the diagnosis: why it is importantThe diagnosis code supports the medical necessity for a medical service, and informs the payer why the service was performed. Providers must comply with general diagnosis coding guidelines from ICD-9CM (and ICD-10CM on and after 10/01/2015).

Code to highest level of specificityThe guidelines support using the diagnosis code that describes the patient’s diagnosis, symptom, condition, or complaint. If the diagnosis is not known, use a sign or symptom rather than “rule out” or “possible” for outpatient services. Code to the highest level of specificity. Using unspecified diagnosis codes when a more specific code is accurate is not appropriate. The “more specific” diagnosis should be used to support a more serious level of acuity in in the patient.

Code for chronic conditionsThe CMS and ICD-9 (and ICD-10CM on and after 10/01/2015) guidelines also say, “Code a chronic condition as often as applicable to the patient’s treatment.” If a patient is seen multiple times for the same condition, code the service on multiple

visits. The last guideline, “Code all documented conditions which coexist at the time of the visit that require or affect patient care or treatment. (Do not code conditions which no longer exist; it may be accurate to select a “history of” code.) If a condition is mentioned in the past medical history but is not addressed at this visit, don’t report it. If the condition is considered — even if that physician isn’t treating it — do document and code the diagnosis.

Coding and Documentation Example:• Provider Documentation: Pt seen in the office

with Diabetic Dyslipidemia, Severe Obesity with a BMI of 40 and HTN. Labs assessed and medication adjusted.

• Assessment: Diabetic Dyslipidemia- meds adjusted, Severe Obesity BMI 40- diet and exercise discussed, HTN controlled continue medication.

• Provider Codes: DM 2 W Diabetic Dyslipidemia (250.80, 272.4), Severe Obesity (278.01) BMI 40.0-44.9 (V85.41) HTN (401.9).

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Clinical practice guideline updatesClinical practice guidelines are systematically designed tools to assist participating practitioners and patient decisions regarding specific medical conditions and preventive care. Guidelines are informational and are not intended or designed as a substitute for the reasonable exercise of independent clinical judgment by participating practitioners in any particular set of circumstances for each patient.

KPMAS has adopted and implemented the evidence-based Clinical Practice Guidelines developed by the Care Management Institute in conjunction with Permanente physician-experts from across the KP program. These guidelines cover preventive, acute, and chronic care.

Preventive care guidelines include, but not limited to, breast, cervical, and colorectal cancer screening, immunizations, and obesity. Clinical practice guidelines address the primary care management of common diagnoses, such as adult and pediatric asthma, diabetes mellitus, hypertension, attention deficit hyperactivity disorder, coronary artery disease, and adult depression.

The following clinical practice guidelines have been approved throughout this year and are available on the MAPMG online Web site. These guidelines apply to members in our commercial, Medicare, Maryland Medicaid, Virginia Medicaid, and Marketplace products.

Adult diabetes (October 2014)

Revisions:• A1c test is now a recommended test to screen

for diabetes and pre-diabetes, in addition to a fasting plasma glucose test. Previously, A1c was an acceptable option, but not a recommended option.

• Removed recommendation for screening for Type 2 diabetes that focused solely on sustained elevated blood pressure; other risk factors for screening were not revised.

• Removed recommendation for beta-blocker therapy for secondary prevention of cardiovascular disease in patients with diabetes.

• Removed recommendation for multifactorial Interventions for preventing CVD in patients with type 2 diabetes.

Coronary artery disease secondary prevention (October 2014)

No changes from the prior guideline.

To read the guidelines, login at mapmgonline.com/portal. Select ‘Guidelines’ under the “Group Navigation” drop down list and locate the appropriate topic and Clinical Practice Guideline. If you need assistance with your site registration, please e-mail Lee.S.Milliner@kp.org or call Lee at (301) 816-6309.

Several other clinical practice guidelines may be found at the above Web site. If you would like to receive a hard copy of these or any other Clinical Practice Guideline, please contact the Provider Relations Department at 1-877-806-7470.

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Coordinated, tracked, managedGreat care management goes far beyond diabetes to scores of other conditions. Our integrated, coordinated care model, combined with system-wide collaboration and communication across disciplines, is good for the full range of medical conditions requiring long-term management. Maintaining a large number of registries of members with chronic health conditions gives every Permanente Physician the information needed to proactively manage care and quickly identify concerns that need attention. It helps reduce health care disparities between races and

ethnicities and keep patients living full, productive, and healthy lives.

From hypertension, coronary artery disease, diabetes, asthma, HIV, sickle cell disease, and depression to Parkinson’s, multiple sclerosis, cystic fibrosis, rheumatoid arthritis, and virtually any other health condition, Permanente Medicine provides an unrivaled level of care. Permanente patients know they are in good hands. After all, they have a whole team of experts on their side.

Provider referral requestsThe Kaiser Permanente Utilization Management Operations Center reviews each referral request and determines the number of visits that are medically necessary. When requesting referrals, please only request one visit or the exact number of visits that will be needed for a three (3) month period. If additional visits are requested beyond those that are outlined within the submitted

clinical information, the member will receive a partial approval/denial letter. This creates confusion for members as they believe their referral has been denied. To help avoid this, please only request one visit or the exact number of visits necessary per your plan of care. Additional visits can be requested and added, as medically necessary, after our initial approval.

Utilization Management Affirmation StatementKaiser Permanente practitioners and health care professionals make decisions about which care and services are provided based on the member’s clinical needs, the appropriateness of care and service, and existence of health plan coverage. Kaiser Permanente does not make decisions regarding hiring, promoting, or terminating its practitioners or other individuals based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits. The health plan does not specifically reward, hire, promote, or terminate practitioners or other individuals for issuing denials of coverage or benefits or care. No financial incentives exist that encourage decisions that specifically result in denials or create barriers to care and services or result in underutilization. In order to maintain and improve the health of our members, all practitioners and health professionals should be especially diligent in identifying any potential underutilization of care or service.

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National Coverage Analysis (NCA) for screening for lung cancer with low dose computed tomography (LDCT)The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to add a lung cancer screening counseling and shared decision making visit, and for appropriate beneficiaries, annual screening for lung cancer with low dose computed tomography (LDCT), as an additional preventive service benefit under the Medicare program.

For additional information, please visit cms.gov and add CAG-00439N in the search box. Read the article titled “Decision Memo for Screening for Lung Cancer with Low Dose Low Dose Computed Tomography.”

Innovation in practice: The 21st century housecallCovering Maryland, the District of Columbia, and Virginia, the Mid-Atlantic Permanente Medical Group cares for Kaiser Permanente members who live and work across a large area. It is a region perfectly suited for growth and innovation in telemedicine.

One Permanente telemedicine initiative provides 24/7 video chat communication between members and board-certified physicians covering

a wide range of health issues, such as minor eye complaints, urinary tract infections, and skin conditions. With complete patient information at their fingertips, physicians can often eliminate the need for unnecessary trips to the doctor by resolving problems right then and there. Just as easily, they can seamlessly link the patient to necessary face-to-face care. They will even check for and schedule unrelated preventive care.

Prevention is everyone’s businessKaiser Permanente’s HealthConnect® provides real-time updates on every patient to every physician, including alerts about upcoming tests, screenings, and appointments. Physicians have time and resources to educate patients about preventive measures in person and by telephone, email, and videoconference.

The Mid-Atlantic Permanente Medical Group, P.C.2101 E. Jefferson StreetRockville, MD 20852

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