Spring 2013 Leading the way A Newsletter for Providers of Medical Associates Health Plans New Chief Medical Officer at Medical Associates Clinic & Health Plans Dale Dreiling, M.D., has joined Medical Associates Clinic & Health Plans in the role of Chief Medical Officer. Dr. Dreiling provides leadership in all areas of clinical quality including continuous assessment and improvement of patient care practices. He works closely with our physicians and professional staff to promote the delivery of excellent healthcare to all patients. Dr. Dreiling’s background includes executive management experience as Senior Vice President of Tanner Medical Group in Carrollton, Georgia, as Chief Executive Officer of Staten Island Physician Practice in Staten Island, New York, and leadership experience with Geisinger Health System in Danville, Pennsylvania. In addition, Dr. Dreiling was President and co-founder of Eagle Physicians and Associates in Greensboro, North Carolina, where he practiced Family Medicine for 18 years. Dale Dreiling, M.D. Dr. Dreiling received his Bachelor of Science degree in Business from Virginia Tech, his Doctor of Medicine degree from the Medical College of Virginia, and a Masters of Medical Management from Carnegie Mellon University in Pittsburgh. Dr. Dreiling is married to Dr. Karen Dreiling, a practicing pediatrician. They are the parents of two children. Medical Record Documentation medical record for your documentation Complete medical records are the cornerstones of quality healthcare. Wellorganized, legible medical records allow for a clear picture of the patient’s complaint, symptoms, procedures, medical treatments, status, and the outcome of care. In compliance with both the National Committee for Quality Assurance and Medicare, we offer the following recommendations: •Patient medical information is kept confidential and well organized. •Each page in the chart has patient name and ID number. •Medical history includes current and past diagnoses, surgeries, allergies, adverse reactions, and immunizations. Family history of parents, grandparents, and siblings. •Documentation of each patient visit including subjective, objective, lab, x-ray, action, treatment, medications, therapies, all consistent with diagnosis. •Evidence of continuity and coordination of care between primary and specialty physicians; evidence of preventive health screenings/services offered. information Communication All practitioners participating with Medical Associates Health Plans may freely communicate with patients regarding treatment options available. This may include medical care, risks, benefits, consequences of treatment or nontreatment, the opportunity to refuse treatment, and to express preferences about future treatment. CODING TIPS Positive Air way Pressure (PAP) and Respiratory Assist Device (RAD) Accessories Positive Airway Pressure (PAP) and Respiratory Assist Device (RAD) Accessories The key to correctly billing for PAP and RAD accessories is to be aware of the allowable quantity. A supplier must not dispense more than a certain quantity of PAP/RAD accessories at a time. Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not reasonable and necessary. HCPCS DESCRIPTION USUAL MAXIMUM AMOUNT A4604 TUBING WITH INTEGRATED HEATING ELEMENT FOR USE WITH POSITIVE AIRWAY PRESSURE DEVICE 1 per 3 months A7027 COMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE, EACH 1 per 3 months A7028 ORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, EACH 2 per 1 month A7029 NASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, PAIR 2 per 1 month A7030 FULL FACE MASK USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH A7031 1 per 1 month A7032 CUSHION FOR USE ON NASAL MASK INTERFACE, REPLACEMENT ONLY, EA. 2 per 1 month A7033 PILLOW FOR USE ON NASAL CANNULA TYPE INTERFACE, REPLACEMENT ONLY, PAIR 2 per 1 month FACE MASK INTERFACE, REPLACEMENT FOR FULL FACE MASK, EACH 1 per 3 months A7034 NASAL INTERFACE (MASK OR CANNULA 1 per 3 months TYPE) USED WITH POSITIVE AIRWAY PRESSURE DEVICE, WITH OR WITHOUT HEAD STRAP A7035 HEADGEAR USED WITH POSITIVE AIRWAY PRESSURE DEVICE 1 per 6 months A7036 CHINSTRAP USED WITH POSITIVE AIRWAY PRESSURE DEVICE 1 per 6 months A7037 1 per 3 months A7038 FILTER, DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE 2 per 1 month A7039 FILTER, NON DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE 1 per 6 months A7046 WATER CHAMBER FOR HUMIDIFIER, USED WITH POSITIVE AIRWAY PRESSURE DEVICE, REPLACEMENT, EA. 1 per 6 months TUBING USED WITH POSITIVE AIRWAY PRESSURE DEVICE Source: https://www.noridianmedicare.com/dme/coverage/docs/lcds/current_lcds/positive_airway_pressure_pap_devices_for_the_treatment_of_obstructive_sleep_apnea.htm%3f HEALTH CARE SERVICES AVAILABLE 24/7 health care Our nurse case managers in the Health Care Services Department are available to help coordinate a variety of needs for your Medical Associates Health Plan patients, from out-of-plan referrals, to hospital pre-authorizations and benefits determination. Normal business hours are Monday through Friday, 8:00 a.m. to 5:00 p.m. Members and practitioners may communicate with the Health Care Services staff in these ways: • Telephone: 563-584-3275 or toll-free within U.S. 800-325-7442 • Fax: 563-585-1545 • E-mail: healthcareservices@mahealthcare.com • Personal visit: 1605 Associates Drive, Suite 101, Dubuque Iowa After-hours and on holidays, the local and toll-free numbers are forwarded to our 24-hour Patient Services Help Nurse line. Information is collected by the Patient Services staff and sent to our Health Care Services nurses the next working day via fax. If an immediate care decision is required, the Patient Services staff will contact a member of the Health Care Services nursing staff at a designated afterhours telephone number. Department, 584-3275 or toll free 800-325-7442. UTILIZATION MANAGEMENT utilization Criteria. If you wish to have a copy of our utilization management criteria, feel free to call the Health Care Services Department at 584-3275 or toll free 800-325-7442. External Review. We comply with state regulations regarding external appeal. Some denials (after they exhaust internal appeal) may be eligible for review by an Independent Review Organization. For most of our plans, the denial of coverage must be based on medical necessity to be eligible. If you would like more information, please contact our Member Services Manager at 563-584-4857. Physician Reviewer Availability. If you wish to speak with a physician reviewer regarding a utilization decision (including behavioral health), please call our Health Care Services Department, 584-3275 or toll free 800-325-7442.