Month: July 2021

Posted in HEDIS Measures, Training, Updates

HEDIS Measure: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

Posted on by KR2Medical Billing

HEDIS is always a hot topic of discussion. In this blog post we will discuss the HEDIS measure WCC or Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents.

Background/Research Data:

The research analyzed doctor visits pre-pandemic then during the pandemic period and the increases were dramatic. Overall obesity increased from 13.7% to 15.4%. Increases observed ranged from 1% in children aged 13 to 17 years to 2.6% for those aged 5 to 9 years.

The purpose of this HEDIS Measure:

This HEDIS measure looks at the percentage of patients between the 3-17 years of age, who had an outpatient visit with a PCP or OB/GYN and have documented evidence for all the following during the measurement year:

  • Body mass index (BMI) percentile (percentage, not value)
  • Counseling for nutrition
  • Counseling for physical activity

This HEDIS Measure (WCC) requires the following documentation:

  • When counseling for nutrition, document current nutritional behavior, such as meal patterns, eating and diet habits, and weight counseling.
  • When counseling for physical activity, document current physical activity behavior, such as exercise routine, participation in sports activities, bike riding and play groups.
  • Handouts about nutrition and physical activity also count toward meeting this HEDIS measure when documented in the member’s health record.

Telehealth, virtual check-in, and telephone visits all meet the criteria for nutrition and physical activity counseling. Counseling does not need to take place only during a well-visit, WCC can also be completed during sick visits. Documenting guidance in your patient’s records is key.

Source: Progress on Childhood Obesity | VitalSigns | CDC

Proper Coding and Billing:

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Posted in BCBS Empire NY, Training, Updates

BCBS (NY): Proper coding for INR In-home patient monitoring

Posted on by KR2Medical Billing

This following policy is part of BCBS (NY) administrative policy guidelines (07/01/2021)

This blog post is for providers that need to meet the INR (in-home) monitoring quality measure.

What you will learn?

  1. What is INR monitoring Quality measure?
  2. Proper coding for in-home INR monitoring
  3. Documentation requirements to meet the INR in home monitoring measure

What is INR (International normalized ratio)?:

International normalized ratio (INR) is blood-clotting test. It is a test used to measure how quickly your blood forms a clot, compared with normal clotting time.

Background:

International normalized ratio is part of the 2021 Quality Measure Set (Pharmacy Quality Alliance (PQA) measures.

The QRS measure set is comprised of clinical quality measures, including the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) measures and Pharmacy Quality Alliance (PQA) measures.

Previously, patients taking warfarin (brand name Coumadin) were heading off to the lab or clinic every few weeks for an international normalized ratio (INR) blood test. However, currently there is a small, portable device that patients on warfarin, can now self-test with a finger prick drop of blood.

Is there a provider type restriction for this quality Measure?

No, there is not provider type restriction.

As a provider, which proper codes should I use for INR in-home patient monitoring?

Below please see the proper codes that providers should use for INR in-home patient monitoring.

Meeting INR monitoring Quality Measure:

Definition: The percentage of members 18 years of age and older who had at least one 56-day interval of warfarin therapy and who received at least one international normalized ratio (INR) monitoring test during each 56-day interval with active warfarin therapy.

INR quality measure requirements.

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Posted in Oscar Insurance, Training, Updates

Oscar Insurance: New Physical and Occupational Therapy Prior Authorization Process

Posted on by KR2Medical Billing

I am getting a lot of request from PT/OT providers, regarding the new Oscar Insurance “medical necessity” review process. So, I decided to write a FAQ blog post on this subject.

Are you a PT or OT provider? Do you accept patients with Oscar Insurance? Then this blog post is for you!

What you will learn in this blog post?

1. Know who to contact to get your authorization on the first submission.

2. Avoid unnecessary denials!

3. Keep yourself and your staff current on the most updated medical billing/authorizations guidelines.

Let’s begin.

Recently Oscar Insurance announced that effective 07/15/2021, the “medical necessity for Physical and Occupational Therapy”, will be handled by the American Specialty Health Group, Inc. (ASH Group).

For the purposes of this blog “medical necessity” is interchangeable with “prior authorization”

Below are the most frequently asked questions and their answers:

  1. I am a participating OT/PT provider; how do I submit an authorization?

As a participating provider, you have several ways to submit medical notes for prior auth.

  1. Provider portal: www.ASHLink.com
  2. Fax: 877-248-2746
  3. Mail: American Specialty Health (ASH) PO Box 509077, San Diego, CA 92150-9077

2. Where can I find information regarding clinical documentation?

The clinical information guidelines are available on the website : www.ASHLink.com . On the website you need to click Resources then Providers then Physical , Occupational and Athletic Training and then click on Practitioner Claims Packet-Oscar.

3. Do I need to register with ASH in order to view the necessary information?

Yes, in order to access any information regarding the prior authorization criteria and documentation requirements, you have to register with ASH and/or activate your account.

4. I am a participating Provider (with Oscar), where should I go to verify patient’s eligibility?

A participating provider should go to hioscar.com/provider or call 1855-oscar-55 to verify the member eligibility, before requesting a PT/OT medical necessity review.

5. Will my claim will be denied if I do not obtain a prior authorization (PT/OT) before sending the claim for processing?

Yes, it will be. As a participating provider it is the responsibility to obtain a “medical necessity review” prior to submitting claims for payment.

6. Where do I submit PT/OT claims to?

As a participating PT/OT provider you will submit the claims directly to Oscar at:

Oscar Insurance Corporation

PO Box 52146

Phoenix, AZ 85072-2146

7. How do I file an appeal?

If the PT/OT services are denied, as a participating provider you have the right to file an appeal. That information is going to be included in the determination documentation.

8. If I am a participating provider who can I contact for more information?

Please contact Oscar Provider Services at 1-855-OSCAR-55

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