October 2015 Client Newsletter

ICD-10 - MEDICARE ADVANTAGE PLANS, NJ MEDICAID, HORIZON, ET AL

While Traditional Medicare is offering a small amount of “flexibility” – Medicare Advantage, Medicaid, and other insurers (except MVA & W/C) plans are not offering any.  Nor are they required to.  So, be sure the codes you submit are accurate, coded to the maximum required specificity, and properly documented in your medical record (or Run Report if ambulance). 

ICD-10 - Ambulance

By the time you read this, ICD-10 coding will already have gone into effect.  A few reminders:

Ambulance

ICD-10 specificity is MUCH greater due to many factors, but for ambulance it is generally laterality – location of the injury or pain.  If required documentation of pain/injury is missing, no need to release the chart as it will not be codable – and thus not billable – until all required info is provided. 

Examples:
Left arm/right arm.
Left leg/right leg
If a hand or finger – which surface?
If a laceration – how long & deep?
The mechanism of injury is also needed. 

For the abdomen:
RUQ
LUQ
LLQ
RLQ
Epigastric
Etc.

Physicians
For our physician clients, in addition to the above, an indication of whether it is the initial encounter, subsequent, or sequela.  Initial and subsequent are easy.

Sequela is defined as “any abnormal condition that follows and is the result of a disease, treatment, or injury, such as paralysis after poliomyelitis, deafness after treatment with an ototoxic drug, or scar formation after a laceration.”

HORIZON BLUE SHIELD- OMINA HEALTH PLANS 

Horizon is introducing a new health plan – OMNIA – with an effective date of 12/26/15.  They will no longer offer Horizon Advance EPO plans and certain Horizon “Patient-Centered Advantage EPO” plans effective 1/1/16.  Horizon says all Horizon Managed Care Network physicians and other professionals will be participating with the OMNIA plans, but will be set into different “Tiers” which will directly affect the amount of patient cost-sharing.

Tier 1 will have the lowest cost-share.  Be sure to let CMB know which tier level you were assigned to in the letter sent by Horizon on Sept. 10^th.  A copy of the letter would be great.  Ambulance clients likely will not have received a letter or be assigned to a particular tier.