October Provider Post - Providers - AmeriHealth Caritas

1 ProviderPost News and updates you need to know October 2017. Important billing reminder: Articles in this edition External cause of injury diagnosis codes cannot be primary Important billing reminder: External diagnosis codes cause of injury diagnosis codes cannot We would like to remind you to follow the ICD-10-CM Official Guidelines for Coding and be primary diagnosis codes Reporting when submitting external cause of injury diagnosis codes. These are ICD-10. codes that are used to classify environmental events and circumstances as the cause of Revisions to the Early and Periodic injury, and other adverse effects such as: Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Transport accidents. Schedule and Coding Matrix Poisoning and adverse effects of drugs, medicinal substances, and biologicals.

2 Accidental falls. Flu season billing instructions Accidents caused by fire and flames. Quality Enhancement Program (QEP). Accidents due to natural and environmental factors. Late effects of accidents, assaults, or self- injury. New nine-digit member identification numbers Assaults or purposely inflicted injury. Suicide or self-inflicted injury. Make a Choice campaign The guidelines specifically state that external cause diagnosis codes cannot be submitted as the primary diagnosis on professional or institutional claims whether Formulary changes the claim is submitted electronically or on paper. If you suspect it, report it. Help us We may deny or retract claims that are submitted on a: fight fraud, waste, and abuse. CMS 1500/837P with an external cause diagnosis code billed in box A of field 21 or loop 2300, segment HIXX-2 where XX = 01,02,03,04,05,06,07,08,09,10,11,12.

3 UB-04/837I with an external cause diagnosis code billed as the principal diagnosis If you have questions about in field 67 or loop 2300, segment HIXX-2 where XX = 01,02,03,04,05,06,07,08,09, 10,11,12. this communication, please contact your Provider UB-04/837I with an external cause diagnosis code billed in the admitting diagnosis in field 69 or loop 2300, segment HI01-2. Account Executive or one of the following departments: For complete details, please refer to the Claims Filing Instructions available on the Providers section of our websites: AmeriHealth Caritas AmeriHealth Caritas Pennsylvania Pennsylvania Provider Services or 1-800-521-6007. AmeriHealth Caritas Northeast AmeriHealth Caritas Northeast Provider Services 1-888-208-7370. October 2017 | Page 1 of 7. AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast ProviderPost Revisions to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule and Coding Matrix Per the Pennsylvania Department of Human Services (DHS).

4 Medical Assistance Bulletin 99-17-10, effective August 7, 2017, Providers should use the following additional ICD-10 diagnosis codes in conjunction with EPSDT claims for Medical Assistance beneficiaries ages 15 to 21: (Encounter for general adult medical examination without abnormal findings). (Encounter for general adult medical examination with abnormal findings). Please refer to the CMS Billing Guide for PROMISe Early & Periodic Screening, Diagnosis and Treatment (EPSDT). Services for a complete listing of referral codes, modifiers, and diagnosis codes that apply to the EPSDT program. Additional updates The term assessment was changed to Complete Screen . under the Services header on the periodicity chart and in footnote 1 in the legend. Newborn bilirubin concentration screening was added for the newborn inpatient visit.

5 The Alcohol or Drug Use Assessment was revised to include Tobacco.. Maternal depression screening was added for 1-, 2-, 4-, and Hearing screening was added to the newborn inpatient visit. 6-month visits. If the hearing screening is not performed during the newborn Providers are to use a standardized health risk inpatient visit, the hearing screening should be performed at assessment instrument when screening for maternal the 1-month or 2 3 month visits. depression. DHS does not endorse a specific screening Hearing screening was updated to occur once during the tool to assess maternal depression. Providers may use 11 14, 15 17, and 18 20 year visits. a standardized screening instrument that is the most suitable tool for the Provider 's practice. HIV screening was updated to occur once between the 15- year and 18-year visits.

6 Providers are to use procedure code 96160. (Administration of patient-focused health risk assessment Dyslipidemia screening was added to occur once between instrument [ , health hazard appraisal] with scoring and the 17-year and 20-year visits. documentation, per standardized instrument) when the The revised Pennsylvania EPSDT program periodicity schedule maternal depression screening is performed. and coding matrix is available at: Adolescent depression screening was changed to begin at AmeriHealth Caritas Pennsylvania age 12 to be consistent with the recommendations of the Preventive Services Task Force. Vision screening at the 18-year visit was changed to a risk AmeriHealth Caritas Northeast assessment, consistent with the 2016 Bright Futures AAP recommendations. October 2017 | Page 2 of 7.

7 AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast ProviderPost Flu season billing instructions As we prepare for the 2017 2018 flu season, please review our billing instructions listed below. Participating Providers will be reimbursed for the administration of the seasonal flu vaccine to children and adults for the following procedures: Code Description 90630 Influenza, quadrivalent (IIV4), split virus, preservative free, intradermal 90654 Influenza, trivalent, split virus, 18 64 years, intradermal use, preservative free 90655 Influenza, trivalent, split virus, 6 35 months, preservative free 90656 Influenza, trivalent, split virus, 3 years and older, preservative free 90657 Influenza, trivalent, split virus, 6 35 months 90658 Influenza, trivalent, split virus, 3 years and older 90661 Influenza, derived from cell cultures, subunit, preservative and antibiotic free, intramuscular 90662 Influenza, split virus, 65 years and older, enhanced immunogenicity via increased antigen content, intramuscular use, preservative free 90673 Influenza, quadrivalent, split virus, derived from recombinant DNA (RIV3)

8 , hemagglutinin (HA) protein only, preservative and antibiotic free, intramuscular 90674 Influenza virus vaccine, quadrivalent [ccIIV4], derived from cell cultures, subunit, preservative and antibiotic free, mL. dosage, for intramuscular use 90682 Influenza, quadrivalent (RIV4), derived from recombinant DNA, hemagglutinin protein only, preservative and antibiotic free, intramuscular, 18 and older (payable when deemed medically necessary and billed with the appropriate egg allergy diagnosis code). 90685 Influenza, quadrivalent, split virus, 6 35 months, preservative free, intramuscular 90686 Influenza, quadrivalent, split virus, preservative free, 3 years and older, intramuscular 90687 Influenza virus vaccine, quadrivalent, split virus, 6 35 months of age, intramuscular 90688 Influenza virus vaccine, quadrivalent, split virus, 3 years and older, intramuscular Note: AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast will follow the Centers for Disease Control and Prevention's (CDC's) Advisory Committee on Immunization Practices (ACIP) recommendation that live attenuated influenza vaccine (LAIV), also known as the nasal spray, should not be used during the 2017 2018 flu season.

9 Flu vaccine reimbursement is made as follows: Age Reimbursement Where to obtain toxoid Adults, Total payment is made through the billing of the toxoid code Obtain the vaccine and supplies from regular vaccine over and includes the cost of the administration ( , no separate supplier. 18 years payment will be made for the administration of the vaccine). Children, Total payment is made through the billing of the toxoid code Provided free through the Pennsylvania Department 18 years and includes the cost of the administration ( , no separate of Health's Vaccines for Children Program (VFC). For and under payment will be made for the administration of the vaccine). more information on VFC go to: My Health Immunizations Vaccines for Children Program or call 1-888-646-6864. Reminder: AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast members (ages 9 and older) can also be referred to their local participating pharmacies for the flu vaccination.

10 October 2017 | Page 3 of 7. AmeriHealth Caritas Pennsylvania and AmeriHealth Caritas Northeast ProviderPost Quality Enhancement Program (QEP). The updated 2017 QEP manual is available to be viewed and/or printed from our websites at: AmeriHealth Caritas Pennsylvania AmeriHealth Caritas Northeast The QEP is a reimbursement system we developed for participating primary care practitioners (PCPs). It is intended to be a fair and open system that provides incentives for high-quality and cost-effective care, member service and convenience, and submission of accurate and complete health data. The QEP is also intended to be a program that provides financial incentives over and above a PCP practice's base compensation. Incentive payments are not based on individual performance, but rather the performance of your practice, unless you are a solo practitioner.