Related links

Connection supplemental articles and policies - March 2009

Download the print version

Connection - March 2009 (pdf, 82 KB)

Supplemental articles


Policies and forms

The following policy is new:

The following policies have been reviewed and changes are indicated on each policy:


Treating patients with depression

Mental health issues, particularly depression, impact PCPs at an increasing rate. PCPs now prescribe more than half of the antidepressants used in the United States. Additionally, depression is among the chief reasons that patients do not adhere to their chronic care management plan, resulting in increased hospitalizations and ER visits.

Once diagnosed with depression, only about one in five patients receive what recent, evidence-based research would consider minimally adequate treatment. Our goal is to improve the level of care for Fallon Community Health Plan members who are diagnosed with depression.

FCHP’s clinical practice guideline for the diagnosis and treatment of depressive disorders in adults may be accessed at http://www.fchp.org/Providers/Health_care_guidelines.htm.

Measuring quality
One of the ways FCHP measures depression treatment is with the National Committee for Quality Assurance’s HEDIS® measure, “Antidepressant Medication Management.” This measure includes two calculations:

  • The percentage of members who received effective acute-phase treatment by remaining on antidepressant medication continuously in the 12 weeks following a new episode of depression.
  • The percentage of members who received effective continuation-phase treatment by remaining on antidepressant medication continuously in the six months following a new episode of depression.

How to code depression
You can help to ensure that FCHP identifies new episodes of depression by using the correct depression codes when submitting claims for initial and follow-up visits for depression.

Start with the appropriate code below:

  • 296.2X (first episode of depression)
  • 296.3X (recurring depression)
  • 300.4 (chronic mild depression)
  • 311 (depression, not otherwise specified)

Then code the fifth digit for claims purposes:

  • .x1–mild
  • .x2–moderate
  • .x3–severe without psychotic features
  • .x4–severe with psychotic features
  • .x5–partial remission
  • .x6–in full remission
  • .x0–unspecified

Practice ongoing patient monitoring
When you have a patient with depression who is taking antidepressant medication, the goal is to ensure proper patient care by:

  • Making sure your patient is tolerating the medication and taking it as prescribed.
  • Assessing whether your patient is experiencing side effects that could interfere with taking the medication.
  • Reminding your patient that while therapeutic effects may take several weeks, most side effects are temporary. Discussing these side effects with your patient may help ensure that he or she remains on the medication long enough to achieve a therapeutic response.
  • Making adjustments to maintain adequate dosing or changing the medication to enhance adherence.
  • Determining that a full therapeutic response has been achieved.

FCHP is pleased to work with Beacon Health Strategies, which administers the behavioral health benefits for our members and providers. In order to ensure proper care for your FCHP- member patients with depression, please feel free to call Beacon’s clinical department at 1-888-421-8861, Monday through Friday from 9 a.m. to 5 p.m. if you have any questions or concerns, or would like to discuss a patient’s care with a Beacon physician advisor.

Do’s and don’ts of preauthorization

As you know, it’s FCHP’s policy to deny claims for those services that require plan preauthorization if no preauthorization was obtained. The following are important reminders about FCHP’s referral and preauthorization process that will help you avoid denials.

  • PCP coordination of care is the foundation for care delivery.
  • All specialty visits—initial and follow-up—must be coordinated by the PCP. Specialists cannot refer to other specialists.
  • Specialty visits that occur without PCP coordination will not be reimbursed. Any exceptions to this rule—e.g., member self-referrals—are specifically noted in our Provider Manual.
  • FCHP has a designated list of office-based procedure codes that require plan preauthorization by the performing physician. Details are available in the Provider Manual, starting on page 69.
  • PCPs are allowed to refer for specific types of specialty services for eligible health plan members when the member is being referred within their network option.
  • If a PCP refers a member for non-covered benefits or to non-contracted providers, then the PCP’s referral becomes void, as these situations require plan preauthorization. Please note that if these non-covered or out-of-network services are not specifically preauthorized by FCHP, reimbursement to these providers won’t occur, and either the member or the referring physician will be financially liable for the services.


Formulary updates

Fallon Community Health Plan often makes changes to its formularies, including changing prior authorization requirements and adding new medications. Please note the following changes to our commercial plan formulary.

Commercial plan formulary

Additions
Nucort (hydrocortisone) Lotion: Tier 3
Prandimet (repaglinide / metformin) Tab: Tier 2, QLL 90 per 30 days
Sumatriptan (Imitrex® generic): Tier 2, QLL varies

Changes
Renvela (sevelamer carbonate): Changed to Tier 2
Imitrex (sumatriptan): PA removed

New to Market Policy*
Apriso (mesalamine SR 24H)
Banzel (rufinamide)
Mozobil (plerixafor)
Promacta (eltrombopag)
Trilipix (choline fenofibrate)
Xenazine (tetrabenazine)

* FCHP’s New to Market Policy was enacted to ensure patient safety and to allow for adequate time for the development, review and approval of clinical criteria. When a new medication first becomes available, it will fall under this policy and be excluded from coverage. A process is in place that allows for the quick review of provider requests for non-covered pharmaceuticals.

New 2009 CPT/HCPCS codes

As mentioned in the January Connection, all new 2009 codes require preauthorization until a final review is performed by Fallon Community Health Plan. We’ve now reviewed and assigned the appropriate coverage categories and determined preauthorization requirements for all new codes. New CPT/HCPCS codes became effective for claims received on or after January 1, 2009. 

CPT codes
Please note that, effective immediately, the following CPT codes require preauthorization:

41512

Tongue base suspension, permanent suture technique

41530

Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session

61796

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion

61797

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure)

61798

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion

61799

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure)

61800

Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)

63620

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion

63621

Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure)

65756

Keratoplasty (corneal transplant); endothelial

65757

Backbench preparation of corneal endothelial allograft prior to transplantation (List separately in addition to code for primary procedure)

83876

Myeloperoxidase (MPO)

83951

Oncoprotein; des-gamma-carboxy-prothrombin (DCP)

85397

Coagulation and fibrinolysis, functional activity, not otherwise specified (e.g., ADAMTS-13), each analyte

87905

Infectious agent enzymatic activity other than virus (e.g., sialidase activity in vaginal fluid)

88720

Bilirubin, total, transcutaneous

88740

Hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglobin

88741

Hemoglobin, quantitative, transcutaneous, per day; methemoglobin

90951

End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month

90952

End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face physician visits per month

90953

End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month

90954

End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month

90955

End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face physician visits per month

90956

End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month

90957

End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month

90958

End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face physician visits per month

90959

End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month

90960

End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more face-to-face physician visits per month

90961

End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 2-3 face-to-face physician visits per month

90962

End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 1 face-to-face physician visit per month

90963

End-stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

90964

End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

90965

End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

90966

End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older

90967

End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age

90968

End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2-11 years of age

90969

End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 12-19 years of age

90970

End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years of age and older

93228

Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report

93229

Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports

HCPCS codes
Please note that, effective immediately, the following HCPCS codes require preauthorization:

C9245

INJECTION, ROMIPLOSTIM, 10 MCG

C9246

INJECTION, GADOXETATE DISODIUM, PER ML

C9248

INJECTION, CLEVIDIPIEN BUTYRATE, 1 MG

E0487

SPIROMETER, ELECTRONIC, INCLUDES ALL ACCESSORIES

E0656

SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, TRUNK

E0657

SEGMENTAL PNEUMATIC APPLIANCE FOR USE WITH PNEUMATIC COMPRESSOR, CHEST

G0409

SOCIAL WORK AND PSYCHOLOGICAL SERVICES, DIRECTLY RELATING TO AND/OR FURTHERING THE PATIENT'S REHABILITATION GOALS, EACH 15 MINUTES, FACE-TO-FACE; INDIVIDUAL (SERVICES PROVIDED BY A CORF-QUALIFIED SOCIAL WORKER OR PSYCHOLOGIST IN A CORF)

G0410

GROUP PSYCHOTHERAPY OTHER THAN OF A MULTIPLE-FAMILY GROUP, IN A PARTIAL HOSPITALIZATION SETTING, APPROXIMATELY 45 TO 50 MINUTES

G0411

INTERACTIVE GROUP PSYCHOTHERAPY, IN A PARTIAL HOSPITALIZATION SETTING, APPROXIMATELY 45 TO 50 MINUTES

G0412

OPEN TREATMENT OF ILIAC SPINE(S), TUBEROSITY AVULSION, OR ILIAC WING FRACTURE(S), UNILATERAL OR BILATERAL FOR PELVIC BONE FRACTURE PATTERNS WHICH DO NOT DISRUPT THE PELVIC RING INCLUDES INTERNAL FIXATION, WHEN PERFORMED

G0413

PERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION, FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM)

G0414

OPEN TREATMENT OF ANTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, INCLUDES INTERNAL FIXATION WHEN PERFORMED (INCLUDES PUBIC SYMPHYSIS AND/OR SUPERIOR/INFERIOR RAMI)

G0415

OPEN TREATMENT OF POSTERIOR PELVIC BONE FRACTURE AND/OR DISLOCATION, FOR FRACTURE PATTERNS WHICH DISRUPT THE PELVIC RING, UNILATERAL OR BILATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM)

J0641

INJECTION, LEVOLEUCOVORIN CALCIUM, 0.5 MG

J1267

INJECTION, DORIPENEM, 10 MG

J1459

INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), 500 MG

J1750

INJECTION, IRON DEXTRAN, 50 MG

J1930

INJECTION, LANREOTIDE, 1 MG

J1953

INJECTION, LEVETIRACETAM, 10 MG

J2785

INJECTION, REGADENOSON, 0.1 MG

J3101

INJECTION, TENECTEPLASE, 1 MG

J3300

INJECTION, TRIAMCINOLONE ACETONIDE, PRESERVATIVE FREE, 1 MG

J7186

INJECTION, ANTIHEMOPHILIC FACTOR VIII/VON WILLEBRAND FACTOR COMPLEX (HUMAN), PER FACTOR VIII I.U.

J7606

FORMOTEROL FUMARATE, INHALATION SOLUTION, FDA APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, 20 MICROGRAMS

J8705

TOPOTECAN, ORAL, 0.25 MG

J9033

INJECTION, BENDAMUSTINE HCL, 1 MG

J9207

INJECTION, IXABEPILONE, 1 MG

J9330

INJECTION, TEMSIROLIMUS, 1 MG

L6711

TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED, PEDIATRIC

L6712

TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED, PEDIATRIC

L6713

TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, PEDIATRIC

L6714

TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, PEDIATRIC

L6721

TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED

L6722

TERMINAL DEVICE, HOOK OR HAND, HEAVY DUTY, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED

L8604

INJECTABLE BULKING AGENT, DEXTRANOMER/HYALURONIC ACID COPOLYMER IMPLANT, URINARY TRACT, 1 ML, INCLUDES SHIPPING AND NECESSARY SUPPLIES

Q4100

SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED

Q4101

SKIN SUBSTITUTE, APLIGRAF, PER SQUARE CENTIMETER

Q4102

SKIN SUBSTITUTE, OASIS WOUND MATRIX, PER SQUARE CENTIMETER

Q4103

SKIN SUBSTITUTE, OASIS BURN MATRIX, PER SQUARE CENTIMETER

Q4104

SKIN SUBSTITUTE, INTEGRA BILAYER MATRIX WOUND DRESSING (BMWD), PER SQUARE CENTIMETER

Q4105

SKIN SUBSTITUTE, INTEGRA DERMAL REGENERATION TEMPLATE (DRT), PER SQUARE CENTIMETER

Q4106

SKIN SUBSTITUTE, DERMAGRAFT, PER SQUARE CENTIMETER

Q4107

SKIN SUBSTITUTE, GRAFTJACKET, PER SQUARE CENTIMETER

Q4108

SKIN SUBSTITUTE, INTEGRA MATRIX, PER SQUARE CENTIMETER

Q4109

SKIN SUBSTITUTE, TISSUEMEND, PER SQUARE CENTIMETER

Q4110

SKIN SUBSTITUTE, PRIMATRIX, PER SQUARE CENTIMETER

Q4111

SKIN SUBSTITUTE, GAMMAGRAFT, PER SQUARE CENTIMETER

Q4112

ALLOGRAFT, CYMETRA, INJECTABLE, 1 CC

Q4113

ALLOGRAFT, GRAFTJACKET EXPRESS, INJECTABLE, 1CC

Q4114

ALLOGRAFT, INTEGRA FLOWABLE WOUND MATRIX, INJECTABLE, 1 CC