June 2024

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The Payor Issue Database is found in the Members section of the KHF Intranet under the Financial menu. If you need access to the KHF Intranet, please email PayorConcerns@khfirst.com.

 

The Payor Issue Database contains a current list of payor and claim issues KHF is tracking on behalf of the practices. The issues were identified by your KHF network peers and escalated to KHF for research. In the Payor Issue Database, you will find:

  • key dates (issue identified, most recent update, resolution date)
  • claim issue descriptions
  • current action
  • resolution (when received)
  • practices impacted


When you identify a claim issue during your EOB review, check the Payor Issue Database for known issues and their status. This may decrease your research time and offer next steps. Please encourage all billing staff to reference this helpful resource!

 

Is your issue not found on the Payor Issue Database? Let us know! You can add your practice to an existing issue or submit a new issue for research by emailing PayorConcerns@khfirst.com


Reminder! Please submit your PHI and claims examples securely. KHF can provide a secure email for you if needed.

CURRENT TRENDS

KHF 2024 Top Codes Tip Sheet



Click here to access!


CareSource Recoupments


CareSource, contracted through TCCN, completed a recoupment project in March/April 2024 resulting in recoupment letters sent to practices. The recoupments impacted 2023 claims recouping approximately 2% on payments. CareSource confirmed recoupments were processed in error.


  • Practices can disregard recoupment letters​.
  • CareSource will not recoup money from future payments. ​
  • Practices do not need to send in recoupment checks. ​
  • A retraction letter is being drafted by CareSource for distribution to practices. 
  • If your practice sent a recoupment check to CareSource, please notify your PR rep.

PAYOR UPDATES

Anthem


Wellstar Health Plan’s Employee Plan: Preventative Care Deductible Error

Anthem updated Wellstar Health Plan’s claim pricing to process preventative care at 100% on April 12, 2024 and claims were reprocessed. 

  • If your practice has fallout claims, contact Wellstar Health Plans to initiate reprocessing or contact your TCCN PR rep for assistance.

Cigna


Modifier 25

Supporting documentation requirements are only on selected code edits when modifier 25 or 59 is billed. It is not an across-the-board requirement for all uses of these modifiers. A specific list of combinations that require documentation is available on CignaforHCP.cigna.com. To view, click on Resources Claim Editing Procedures.


Diagnosis Coding Guidelines:

Cigna will administratively deny claims submitted with an unspecified laterality diagnosis code when it is the only code billed on the claim. Topics found on page 2: Office or Other Outpatient E&M and Preventative E&M with ‘Z’ Diagnosis and ’Z’ Diagnosis Codes Not Covered.

Diagnosis Coding Guidelines (cigna.com)

Humana


New Effective 7/1/2024 Commercial Preauthorization and Notification List


Revised 6/4/2024 Commercial Medication Preauthorization List

Multiplan/PHCS


Kaiser Permanente Dual Choice PPO accessing the PHCS network

Peach State Health Plans


Sports Physical and Well Visit


PSHP Pediatric Pocket Guide (2024 Measurement Year)

Coding for HEDIS measures.

United Healthcare


Reimbursement Policy Update: June 2024

UHC’s bundling policy changes effective 9/1/2024 to bundle G2211 with E&M’s billed. The code will no longer be payable.

6/1/2024 – UnitedHealthcare Commercial Reimbursement Policy Update Bulletin: June 2024 (uhcprovider.com)

BEST PRACTICES & QUICK TIPS

Check the KHF Intranet for fee schedules updated in 2024.

Updated W-9 Form


A revised W9 was recently released. Please update your W9’s to the new form.

Discard any W9 that does not have Rev. 2024 in the top left corner.

See attachment.


BILLING FOR HEDIS COMPLIANCE

What is HEDIS? 


The Healthcare Effectiveness Data and Information Set (HEDIS) is a widely used set of performance measures in the managed care industry, developed and maintained by the National Committee for Quality Assurance (NCQA). HEDIS was designed to allow consumers to compare health plan performance to other plans and to national or regional benchmarks.

 

Billers and coders play a vital role in ensuring a practice meets their HEDIS quality measures. This newsletter section will offer billing insight into HEDIS guidelines. If you identify a code or process change that can improve your practice, please discuss them with your Practice Administrator and/or Quality Champion.

 

When a patient completes a service and a provider documents the visit, it is important that all associated CPT and diagnosis codes are billed on the claim. If codes are left off or not billed with the correct specificity, a patient may be identified as non-compliant for the care they received. 

Lead Screening in Children

See Attachment


To be HEDIS compliant for the Lead Screening in Children measure, children must receive a lead screening by their second birthday. 

 

CPT 83655 (Lead Test) must be billed on a HCFA and processed by the payor for the member to be identified as compliant.

  • If the claim is denied, payors will still acknowledge the procedure for HEDIS compliance.
  • If a claim receives a front-end rejection, the member will remain on non-compliant lists.

 

Per the Bright Futures Periodicity Schedule:

How Billing Analysis May Improve HEDIS Compliance


Pull a report for instances of CPT 83655, Lead Test, billed by your practice for a set time period (example: January 1st - June 30th).



  • Analyze the instances of CPT 83655 billed before and after the patient’s 2nd birthday.
  • What is the percentage of lead tests done before versus after the second birthday?
  • Remove patients from the data set where lead tests were billed before the second birthday from further analysis.
  • If billed after the second birthday, was there a lead test done previously that made them compliant? 
  • If yes, remove these from further analysis.
  • You should be left with only patients receiving lead tests after the second birthday. 
  • Identify a subset of patients and identify the reason(s) or barriers of why the lead screening was given after the second birthday.
  • You can look at all patients if your data set is manageable in size.
  • Create a breakout of the reasons/barriers.
  • Did patients have a visit during the lead screening assessment time periods (see above) where a lead screening could have been performed?  
  • Did they decline a lead test?
  • Were they not seen in the office?
  • Other reasons?
  • Collaborate with your practices Quality Champion and/or Practice Administrator to identify if a process change should be considered for this code.
  • Highlight other barriers not billing related that could be topics to address.
  • Utilize the TCCN Quality Team and/or Provider Relations Representative if additional advice or resources may be needed. We are here to help!


We Want To Hear From You!


Do you have billing topics, best practices, claim questions, or good news to share? Email KHF at PayorConcerns@khfirst.com.

RESOURCES

Kids Health First Intranet Page