BY THE NUMBERS In April, HMSA welcomed The Medical Corner as a new PCMH physician organization. In addition, six new providers have progressed to Population Health Management Level 2, while one provider attained Level 3. This monthly report will now include the number of providers in each population health management level.

Pay-for-QualityMarch 2012 April 2012

Number of providers. 1,022 1,031Number of providers who logged in to HBIOnline™. 234 182Number of providers who have submitted supplemental data claims.

83 71

Number of supplemental data submissions. 5,166 2,105PCMHNumber of physician organizations. 13 14Total number of providers. 388 403Level 1 387 395Level 2 1 7Level 3 0 1

To learn more about the PCMH program and how to participate, access the 2012 Primary Care PCMH Program Guide at www.hmsa.com/providers/assets/HMSA_PCMHProgramGuide.pdf.

PLANS AND PROGRAMS

BCBSA Schedules Quarterly AuditsAuditors contracted by the Blue Cross and Blue Shield Association will be contacting HMSA participating providers for quarterly audits. Providers can expect to hear from the auditors July 7-20 to verify their location, telephone numbers, and other demographic information for the BlueWeb Doctor Finder System. Audits will also occur in October. Thank you in advance for your cooperation with these audits.

For Participating Medical Practitioners June 2012

What’s Inside

Procedures 3

Policy News 6

TriCare 8

1100-0195

HM

SA’s

Hawai‘i Medical Service Association

818 Keeaumoku St.

P.O. Box 860

Honolulu, HI 96808-0860

Phone: (808) 948-5110

Branch offices

located on

Hawaii Island, Kauai, and Maui

Internet address:

hmsa.com

Provider Resource Center:

hhin.hmsa.com

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PLANS AND PROGRAMS

Survey Results — Patient Access to Medical Care AppointmentsResults from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) annual member survey indicate that members in HMSA’s Preferred Provider Plan (PPP) and Health Plan Hawaii (HPH) felt that appointments were not available as quickly as they preferred.

The CAHPS® Clinical & Group survey, which was administered for the first time in the fourth quarter of 2011, asked members to rate their experience with a specific physician and their practice. There were 4,391 surveys collected from PPO, HMO, and Medicare patients of 50 primary care physicians.

Here are two questions from the survey and the results, which were assessed against the 2011 Quality Compass National All Lines of Business benchmarks:

In the last 12 months, when you phoned this doctor’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you thought you needed?

• 52 percent (26/50) of the physicians scored in the 90th percentile.

• 42 percent (21/50) of the physicians scored in the 50th percentile and below.

In the last 12 months, when you made an appointment for a checkup or routine care with this doctor, how often did you get an appointment as soon as you thought you needed?

• 74 percent (37/50) of the physicians scored in the 90th percentile.

• 26 percent (13/50) of the physicians scored in the 50th percentile and below.

Survey results reflected better performance for physicians compared to health plan results, as members responded more favorably when answering questions about a specific physician. (The annual CAHPS survey does not identify specific physicians.)

Survey Results — Behavioral Health Appointment AccessHMSA conducts annual assessments of the behavioral health network to verify that appointment access standards are met, in accordance with standards set by the National Committee for Quality Assurance. Providers are encouraged to ensure members receive the care they need in a timely manner. Survey results are assessed in each appointment category with a goal of 85 percent.

Non-emergency behavioral health standards are:

• A member with a non-life threatening emergency should be seen within six hours.

• A member with an urgent need should be seen within 48 hours.

• A member should be seen for a routine office visit within 10 business days.

Results from 238 provider offices representing adult and child psychiatrists and psychologists indicate that none of the behavioral health appointment categories met the goal of 85 percent. Appointments for non-life threatening emergencies reflected the poorest compliance at 28.1 percent.

Behavioral Health Appointment Category Standard Results

Care for a non-life- threatening emergency

Within six hours 28.1%

Urgent care Within 48 hours 79.2%

Appointment for routine office visit

Within 10 business days 78.7%

The Myers Group, our survey vendor, collected data during the fourth quarter of 2011 through phone interviews with behavioral health offices. This is the first year data was collected by surveying provider offices. Previously, data was collected through member surveys.

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Reminder: Billing for the Administration of Injectable Drugs To ensure accurate payment for injectable drugs dispensed as multi-dose vials, it is important to only bill for units dispensed and not for the entire vial. The administration fee is payable only if the drug is a benefit.

For billing on form UB-04, please enter the units dispensed in block 40. For billing on form CMS 1500, please enter this information in block 46G.

Examples of how to bill for these injectable drugs are shown in this table:

Sample Dose Billable Units100 mg nandrolone decanoate

One unit of J2321.

1.5 g streptomycin When a fraction of a unit is administered, bill for the next higher whole unit. In this case, bill two units of J3000.

200 mg cyclophosphamide (Cytoxan, Neosar)

One unit of J9080.

1.5 g cyclophosphamide Since a unit fraction is administered, bill for the next higher whole unit. In this case, bill one unit of J9092.

90 mg pamidronate disodium (Aredia)

Three units of J2430 (injection, pamidronate disodium, per 30 mg).

Trastuzumab (Herceptin) The maintenance dose of trastuzumab is based on the weight of the patient at a ratio of 2 mg per 1 kg. A patient weighing 50 kg would therefore be given 100 mg and the provider should bill 10 units of J9355 (trastuzumab, 10 mg).

Billing for Screening for Fetal AnomaliesAlthough there is no requirement for screening for fetal anomalies, screening is standard practice in our community and is endorsed by the American Congress of Obstetricians and Gynecologists. To ensure coverage of these services, which are covered once per pregnancy, please use the appropriate V codes.

Code DescriptionV28.89 Other specific antenatal screening (Nuchal Translucency testing).V28.81 Encounter for fetal anatomic survey.

PROCEDURES

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PROCEDURES

MAC Fee ChangesThe maximum allowable charges (MAC) for the following codes are effective June 1, 2012.

Procedure Modifier Description MAC Specialty Hospital Outpatient92585 Auditory evoke potent compre $147.40 $148.2492585 TC Auditory evoke potent compre 113.75 113.75 $117.1695812 Eeg 41-60 minutes 432.25 434.0495812 TC Eeg 41-60 minutes 360.50 360.50 371.3295813 Eeg over 1 hour 504.20 507.0595813 TC Eeg over 1 hour 390.20 390.20 401.9195816 Eeg awake and drowsy 397.80 399.6195816 TC Eeg awake and drowsy 325.55 325.55 335.3295819 Eeg awake and asleep 450.85 452.6695819 TC Eeg awake and asleep 378.60 378.60 389.9695822 Eeg coma or sleep only 411.95 413.7695822 TC Eeg coma or sleep only 339.70 339.70 349.8995861 Muscle test 2 limbs 174.40 177.0195861 TC Muscle test 2 limbs 70.15 70.15 72.2595863 Muscle test 3 limbs 210.70 213.8495863 TC Muscle test 3 limbs 85.10 85.10 87.6595867 Muscle test cran nerv unilat 113.25 114.5995867 TC Muscle test cran nerv unilat 59.55 59.55 61.3495868 Muscle test cran nerve bilat 152.55 154.5495868 TC Muscle test cran nerve bilat 72.90 72.90 75.0995869 Muscle test thor paraspinal 82.25 82.8895869 TC Muscle test thor paraspinal 57.20 57.20 58.9295870 Muscle test nonparaspinal 78.20 78.8195870 TC Muscle test nonparaspinal 53.65 53.65 55.26

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Procedure Modifier Description MAC Specialty Hospital Outpatient95873 Guide nerv destr elec stim 78.60 79.2195873 TC Guide nerv destr elec stim 54.05 54.05 55.6795874 Guide nerv destr needle emg 75.90 76.5395874 TC Guide nerv destr needle emg 50.90 50.90 52.4395925 Somatosensory testing 196.80 197.7095925 TC Somatosensory testing 160.90 160.90 165.7395926 Somatosensory testing 191.00 191.9195926 TC Somatosensory testing 154.60 154.60 159.2495930 Visual evoked potential test 177.00 177.5895930 TC Visual evoked potential test 153.80 153.80 158.4195933 Blink reflex test 97.85 98.8395933 TC Blink reflex test 58.75 58.7595934 H-reflex test 76.05 76.91 60.5195934 TC H-reflex test 41.50 41.5095937 Neuromuscular junction test 84.55 85.62 42.7595937 TC Neuromuscular junction test 41.85 41.8595957 EEG digital analysis 463.75 467.07 43.1195957 TC EEG digital analysis 330.95 330.9595970 Analyze neurostim no prog 70.50 72.26 340.8895971 Analyze neurostim simple 61.20 62.7395972 Analyze neurostim complex 114.90 117.7795973 Analyze neurostim complex 65.45 67.0995990 Spin/brain pump refil & main 98.50 100.9695991 Spin/brain pump refil & main 129.55 132.7999183 Hyperbaric oxygen therapy 233.14 238.97

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Provider Input Solicited for Annual Policy Review HMSA’s medical directors welcome comments and suggestions from participating physicians regarding medical policies that are undergoing annual review.

HMSA does not guarantee any specific proposed change will be included in the final policy. HMSA’s policies rely on the use of evidence-based medicine, typically from peer-reviewed literature. Physicians submitting comments should include supportive citation source material to help HMSA’s medical directors evaluate the comment or proposed change.

HMSA is currently soliciting input for the following policies:• Ambulatory Blood Pressure Monitoring.• Artificial Disc Replacement – Cervical.• Bone Mineral Density Studies.• Bortezomib (Velcade).• Brachytherapy, Intravascular.• Brachytherapy, Non-Coronary.• Carotid Artery Stenting.• Clinical Trials.• Cognitive Rehabilitation and Sensory Integration Therapy.• Colonoscopy.• Colorectal Cancer Screening.• Cytochrome P450.• Erythropoeisis Stimulating Agents.• Genetic Testing – Oncology.• Genetic Testing for Non-Cancerous Inherited Diseases.• Growth Hormone Therapy.• Hepatitis C Treatments.• Insulin Pumps, External.• Kyphoplasty and Vertebroplasty.• Low Molecular Weight Heparin.• Observation Services.• Occupational Therapy.• Off-Label Drug Use.• Palivizumab (Synagis).• Panitumumab (Vectibix).• Physical Therapy.• Polysomnography – Sleep Studies.• Preventive Health Guidelines – Men.• Preventive Health Guidelines – Newborns and Children.• Prophylactic Mastectomy.

Physicians may comment by fax to 944-5611 on Oahu or by email to medical_policy@hmsa.com. Comments are due by June 30, 2012.

New Policy Drafts Online for Review Drafts of new medical policies are posted online for your review. Please visit www.hmsa.com/portal/provider/zav_mm.000.003.htm in the Provider E-Library for drafts of policies that may affect your practice.

Comments should be sent before the due date indicated online and may be emailed to medical_policy@hmsa.com or faxed to 944-5611 on Oahu. Questions? Call Provider Services at 948-6330 on Oahu or 1 (800) 790-4672 toll-free on the Neighbor Islands.

Annual Review of Medical PoliciesThe following policies have been reviewed and updated and are in the Provider E-Library at IN.MM00_Medical_Policies_Current_INDEX.htm; copies are available on request.• FDA-Approved Drugs Requiring Precertification.• Never Events and Hospital-Acquired Conditions.• Transcutaneous Electrical Nerve Stimulation (TENS).• Allogeneic Pancreas Transplant.• Hematopoietic Stem-Cell Transplantation for

Chronic Lymphocytic Leukemia and Small Lymphocytic Lymphoma.

• Hematopoietic Stem-Cell Transplantation for Breast Cancer.

• Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia.

• Hematopoietic Stem-Cell Transplantation for Acute Lymphoblastic Leukemia.

• Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphomas.

• Hematopoietic Stem-Cell Transplantation for Non-Hodgkin Lymphomas.

• Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis.

• Hematopoietic Stem-Cell Transplantation for Waldenstrom Macroglobulinemia.

POLICY NEWS

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Coding UpdatesThe following HCPCS codes have been discontinued and should not be billed for service dates on or after April 1, 2012. A number of these codes are found in the genetic testing policies. Please refer to the specific policies for appropriate diagnosis and procedure coding.

HCPCS DescriptionS3711 Circulating tumor cell test S3713 Kras mutation analysis testingS3818 Complete gene sequence analysis; BRCA1 geneS3819 Complete gene sequence analysis; BRCA2 geneS3820 Complete BRCA1 and BRCA2 gene sequence analysis for susceptibility to breast and ovarian cancerS3822 Single mutation analysis (in individual with a known BRCA1 or BRCA2 mutation in the family)

for susceptibility to breast and ovarian cancerS3823 Three-mutation BRCA1 and BRCA2 analysis for susceptibility to breast and ovarian cancer in

Ashkenazi individuals S3828 Complete gene sequence analysis; MLH1 geneS3829 Complete gene sequence analysis; MSH2 geneS3830 Complete MLH1 and MSH2 gene sequence analysis for hereditary nonpolyposis colorectal cancer

(HNPCC) genetic testing S3831 Single-mutation analysis (in individual with a known MLH1 and MSH2 mutation in the family)

for hereditary nonpolyposis colorectal cancer (HNPCC) genetic testing S3835 Complete gene sequence analysis for cystic fibrosis genetic testingS3837 Complete gene sequence analysis for hemochromatosis genetic testingS3843 DNA analysis of the F5 gene for susceptibility to factor V Leiden thrombophiliaS3847 Genetic testing for Tay-Sachs diseaseS3848 Genetic testing for Gaucher diseaseS3851 Genetic testing for Canavan diseaseS3860 Genetic testing, comprehensive cardiac ion channel analysis, for variants in 5 major cardiac ion

channel genes for individuals with high index of suspicion for familial long QT syndrome (LQTS) or related syndromes

S3862 Genetic testing, family-specific ion channel analysis, for blood-relatives of individuals (index case) who have previously tested positive for a genetic variant of a cardiac ion channel syndrome using either one of the above test configurations or confirmed results from another laboratory

S8049 Intraoperative radiation therapy (single administration)

90-Day Notice for Policy Changes Effective Sept. 1, 2012• Cetuximab (Erbitux): The Criteria/Guidelines section

includes revisions.

• Oxygen and Oxygen Equipment: The Criteria/Guidelines, Limitations/Exclusions, and Administrative Guidelines sections include revisions.

FDA-Approved Drugs Requiring Precertification The following drugs will require precertification:

Effective Date Code DescriptionSept. 1, 2012 J2507 Pegloticase (Krystexxa)Sept. 1, 2012 J0800 Corticotropin (Acthar Gel)

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“TRICARE” is a registered trademark of the TRICARE Management Activity. All rights reserved.

Corrected Claims Functionality Now Available Registered providers can now submit corrected or replacement claims on the secure provider portal at www.triwest.com/provider. The functionality, which is available for both professional and institutional claims, is a simple, paperless way to submit and track your corrected claims.

Providers may use this functionality regardless of the original submission method. Below are examples of how to submit corrected or replacement claims.

Professional

Providers submitting professional claims on CMS-1500 should select the “Corrected” button. You have the option to enter the Original Claim number.

Institutional — Outpatient

Providers submitting Institutional-Outpatient claims on UB-04 should select the appropriate bill type for a Replacement or Void claim. You have the option to enter the Original Claim number.

Institutional — Inpatient

Providers submitting Institutional-Inpatient claims on UB-04 should select the appropriate bill type for a Replacement or Void claim. You have the option to enter the Original Claim number.

View Claims

Please be aware that when viewing corrected claims in the View Claims application, they will be identified with a “Removed” status and a subsequent claim number is generated for the corrected or replacement claim.

For information about the TRICARE program, Hawaii providers may call 948-5213 on Oahu.

TRICARE®