- New Diabetes Care Guidelines Issued by Professional Associations Emphasize Tailored Treatment
- Diagnosis and Documentation of Major Depression
- Montefiore HMO Is Now Montefiore Diamond Care
- Fee Schedule Increase
- Coding Corner: Tips for Correct HCC Coding
- Claims Corner: Distinct Procedural Modifiers
- Statement Regarding Appropriate Services and Coverage for Health Plan Delegated Members
- Meet Your Provider Relations Liaison
New recommendations for the treatment and care of people with diabetes have been issued since the start of the year by the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE).
While the recommendations differ somewhat in their focus, they are consistent on one significant point for primary care practitioners: the need to balance individual patient factors, such as age and comorbidities, with efforts to achieve blood sugar control and comprehensive risk factor management.
According to an ADA press release, “The Association is recommending a less stringent diastolic blood pressure target for people with diabetes and that all people with diabetes take either moderate or high doses of statins, in keeping with recent changes to guidelines for cardiovascular risk management enacted by the American College of Cardiology (ACC) and American Heart Association (AHA).”
The new standards represent the ADA’s response to recommendations by the ACC and AHA for cardiovascular risk management. People with diabetes are two to four times as likely as people without diabetes to have a heart attack or stroke, and cardiovascular disease is the number one killer of people with diabetes, the ADA release notes.
The ADA guidelines also include recommendations about new BMI cut offs when screening for diabetes, changes to recommendations for exercise and lifestyle modification, and the organization’s lack of support for e-cigarettes as a smoking alternative. Immunization guidelines have also been updated to reflect CDC vaccination recommendations.
The AACE/ACE guidelines also cover the spectrum of management of the patient with type 2 diabetes. The published guidelines and algorithms include significant changes related to choosing antihyperglycemic agents and managing hypertension, nephropathy and hypoglycemia in patients with type 2 diabetes. The new guidelines also cover vaccinations, cancer risk, obesity, sleep disorders and depression and how to manage patients with occupations where hypoglycemia is particularly dangerous The updated information also briefly addresses the use of insulin in type 1 diabetes..
In a statement issued by the AACE, Dr. Yehuda Handelsman, President of the American College of Endocrinology and cochair of the guideline writing committee, said that “although there are different nuances (such as recommendations for statin and metformin use and for blood-pressure goals and HbA1c targets) between the AACE/ACE guidelines and the 2015 ADA update, ‘the core messages are very similar.’"
The ADA Guidelines and additional material can be found at http://professional.diabetes.org/ResourcesForProfessionals.aspx?cid=84160&loc=rp-slabnav
The AACE/ACE Clinical Practice Guidelines For Developing A Diabetes Mellitus Comprehensive Care Plan – 2015 and the AACE/ACE Comprehensive Diabetes Management Algorithm are published in the April issue of Endocrine Practice.
Depression is a general term that can mean a temporary mood change or a specific clinical diagnosis that is characterized by loss of interest in normal daily activities and relationships every day for a two-week period with a decrease in day to day function. Transient, or temporary, depression should be followed and, if not improved over a 1-2 month period, may need to be assessed for a clinical or major depression. Clinical, or major depression, is a diagnosis that may require treatment with an antidepressant medication and psychotherapy.
Major Depressive Disorder can be seen in patients who have suffered a depressive episode lasting at least two weeks and with at least five of the following symptoms:
- Depressed mood
- Loss of interest or pleasure in most or all activities
- Insomnia or hypersomnia
- Change in appetite or weight; psychomotor retardation or agitation
- Low energy
- Poor concentration
- Thoughts of worthlessness or guilt
- Recurrent thoughts about death or suicidal ideation.
Refer to the DSM-5 diagnostic criteria to determine if the diagnosis of major depression is appropriate for your patient. If you are using the PHQ9 measure for depression, a score of 10 or greater has a sensitivity and specificity of 88% for major depression. However, diagnostic confirmation using the DSM 5 criteria is still recommended.
Major Depression is highly recurrent, with recurrent episodes occurring in 50 percent or more of patients.1
A depressive episode persisting for at least two years is seen as Chronic Major Depression.
Documentation for depression should reflect severity of illness and support the burden of care for the ill patient. In ICD-9-CM, there is an option to code for depression or major depression, and the choice makes a significant difference in the risk adjustment value for the Medicare Advantage population.
When documenting major depressive disorder, it is important to document the episode (single or recurrent), the severity (mild, moderate, severe without psychotic features or severe with psychotic features) and the clinical status of the current episode (in partial/full remission).
 Burcusa, Stephanie L, & Iacono, W.G. Risk for recurrence in depression. Clinical Psychology Review 27 (2007) 959-985.
MLTC Plan Exceeds Growth Projections for First Year of Operations
Montefiore Diamond Care is the new name for Montefiore’s Managed Long Term Care (MLTC) Plan. Launched in November 2013 as Montefiore HMO, Montefiore Diamond Care is now providing services to more than 500 Bronx and Westchester Medicaid beneficiaries who live independently at home or in a nursing home.
Montefiore Diamond Care covers all Medicaid home care and other long term care services, including:
- Home health aides
- Adult day and social day care
- Nursing home care
- Dental and vision services
- Physical therapy
- Transportation to medical appointments
Montefiore Diamond Care enrollees have personalized care plans and their own care management team to coordinate their needs. Enrollees are also able to keep seeing their regular doctors for services not covered by the MLTC program. The Montefiore Diamond Care team coordinates both MLTC and medical services.
To be eligible, individuals must:
- Be at least 21 years old
- Live in the Bronx or Westchester
- Be Medicaid eligible
- Be able to safely live at home, or in a nursing home
- Require at least 120 days of long-term care services
To refer a patient to Montefiore Diamond Care, call 1-855-55-MONTE (1-855-556-6683) and select option 2.
The MIPA Board of Directors approved a 3% increase in aggregate to the 2014 provider fee schedule effective January 1, 2015. Capitation rates for Primary Care Providers were also increased by a similar percentage. As in previous years, the MIPA Board of Directors will continue to evaluate the fee schedule and MIPA’s financial position, and make modifications as conditions require. If you have any questions regarding the enhanced fee schedule, please contact Laura DeMaria, Director of Provider Relations, at 914-721-8592.
Tips for Correct HCC Coding
Cause and effect relationship between disease and manifestation must be established when assigning the code. Coders cannot assume the relationship (e.g. Diabetic Neuropathy)
Assess all chronic conditions yearly so Medicare has the information about the severity of each patient’s disease
Document acute disease, not “history of,“ if the condition is currently being treated
It is not appropriate to code a condition represented only by an up or down arrow combination (such as [↑] chol or [↓] hypercholesterolemia) to suggest a change in diagnosis
Presentations designed to give you a full understanding of the HCC coding are available at http://www.cmocares.com/body.cfm?id=82.
Contact the HCC team with any questions:
Modifier 59 and Subset Modifiers XE, XP, XS, XU for Distinct Procedural Services
Effective January 1, 2015, CMS established four new HCPCS modifiers—XE, XP, XS and XU—to define specific subsets of the 59 modifier used to define a “Distinct Procedural Service.”
The new modifiers have been created to reduce the erroneous use of modifier 59 to bypass edits under the National Correct Coding Initiative. Misuse of modifier 59 to identify distinct services has been estimated to cost Medicare $77 million a year in overpayments.
Modifier 59 is defined as Distinct Procedural Service
Modifier 59 is used to identify procedures and services other than E&M that are not normally reported together on the same day by the same provider, but that may be appropriate under the circumstances. Documentation in the medical record must support:
- A different session, different procedure or surgery, different site or organ system, or
- A separate incision/excision, separate lesion or separate injury (or area of Injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
When another already established modifier is appropriate, however, it should be used rather than modifier 59: for example, Anatomic modifiers: RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, RI; Other modifiers: 2 4, 25, 27, 57 [for E&M], 58, 76, 77, and 91.
Only when a more descriptive modifier is not available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.
Modifier 59 should never be appended to an E&M service. To report a separate and distinct E&M service with a non-E&M service performed on the same day, see modifier 25.
The new modifiers are defined as follows:
- XE – Separate encounter. A service that is distinct because it occurred during a separate encounter.
- XS – Separate Structure. A service that is distinct because it was performed on a separate organ/structure.
- XP – Separate Practitioner. A service that is distinct because it was performed by a different practitioner.
- XU – Unusual non-overlapping service. A service that is distinct because it does not overlap usual components of the main service.
These new modifiers may be used in place of modifier 59 under the same circumstances for which modifier 59 is correctly used. CMS and CMO systems and McKesson ClaimsXten edit rules will perform the same for the new “X” modifiers as they do now for modifier 59. Modifier 59 may also continue to be used when there is no other more appropriate modifier available to describe the distinct procedural situation.
In the future, CMS may identify coding situations in which a specific “X” modifier will be required in order to override certain CCI code pairs. CMS will publish educational articles and guidance before any modifier-specific edits or audits are implemented. CMO will apply these edits as they are defined by CMS.
Additional information on modifier 59 and the new “X” modifiers, can be found at the following links:
- http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8863.pdf; http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1503.pdf
CMO, Montefiore Care Management (CMO) is dedicated to ensuring the delivery of appropriate care to health plan- delegated members.
This statement affirms CMO’s policy regarding Utilization Management (UM) decisions made by Clinical Peer Reviewers and CMO Network Care Management and University Behavioral Associates (UBA) staff:
- All UM decisions are based only on the appropriateness of care and services and the existence of coverage.
- CMO does not specifically reward practitioners or other individuals for issuing denials of coverage.
- Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
Bronx: 3584 Jerome Ave. (off 213th St.). 2700 sq. ft., modern, 4 exam rooms, reception area and a consultation office. Metered parking available. Flexible hours. Call Meir Salama, MD, at 718-231-4443.
Riverdale: Share office space 1-3 times per week at a medical office located at 3220 Fairfield Ave. (one block east of Henry Hudson Parkway). 800 sq. ft., fully furnished. Includes separate ground floor entrance from the street, reception room, waiting area, consultation room, two exam rooms and a small office. Call Norman Sas, MD, at 917-807-9828.
Riverdale: Share a large medical office conveniently located near public transportation and major highways. Rent includes two examining rooms, furnishings and office assistance. Flexible hours are available. Call Robin Schiff, MD, at 718-549-6229.
Riverdale: Riverdale Ave., corner of 235th St. Three exam rooms for specialist in primary care office. Each room is 110 sq. ft. and furnished. Shares a beautiful, spacious waiting room. Call Liliya Lotsvin, MD, at 718-432-5500.
Riverdale: 5750 Mosholu Avenue—Four rooms available for rent for any medical specialties. Call 718-601-0627 or 718-601-0628.
Dobbs Ferry: 18 Ashford Avenue. Fully furnished space in medical office building. Includes two treatment rooms and a consultation room. Available for three-to four-day practice schedule. Specialist welcomed. Call Sanford Proner, MD, at 914-772-7595.