Clinical Support

Pre-diabetes coverage
Priority Health covers pre-diabetes education classes, which are focused on healthy eating and daily activity. Glucose monitors are covered for this diagnosis under the DME benefit, or commercial members may obtain them for free from Accu-Chek or OneTouch. The test strips are covered under the DME benefit (any brand) and pharmacy benefit (Accu-Chek and One Touch brands only). Under the pharmacy benefit, Accu-Chek and OneTouch strips are available with a generic copay, which is more often less costly than using the DME benefit. NOTE: this does not apply to PriorityMedicare members. Contact the Provider Helpline at 800 942-4765 for coverage information on plans other than commercial and Medicare.

Flu season: Plan and prepare
Plan for the Novel H1N1 Influenza
The CDC is urging medical offices to develop a business continuity plan, so you can manage an increased demand for services in the midst of an H1N1 outbreak. Visit the CDC’s Resources for Clinicians at cdc.gov/h1n1flu/clinicians to find 10 Steps You Can Take: Actions for Novel H1N1 Influenza Planning and Response for Medical Offices and Outpatient Facilities and the most up-to-date guidance on vaccines and treatment.

The CDC has announced five priority target groups to receive the H1N1 flu vaccine, when it becomes available:

• Pregnant women
• Household contacts of children who are younger than six months of age
• Health care workers and emergency medical services personnel
• Children and young people between the ages of six months and 24 years of age
• Nonelderly adults with chronic medical conditions

Because the issues surrounding the H1N1 virus are rapidly developing and changing, please visit the Clinical Resources section of the Provider Center at priorityhealth.com for our health plan coverage, vaccination guidelines, anti-viral treatment options and additional helpful information.

Seasonal Influenza
We encourage our members to get their seasonal flu vaccines from participating providers and pharmacies. Most of our members (99.92%) have vaccine coverage, however a small group of selffunded plans don't have vaccine coverage and aren't eligible for this benefit.

Here’s what you can do for seasonal influenza:

• Utilize the Influenza Vaccine Exchange Network (IVEN). Share information on your vaccine inventory with IVEN, which facilitates vaccine redistribution and can be used by licensed staff. You must be registered with MCIR to use it. For more information, visit michigan.gov/flu.
• Follow Priority Health’s Preventive Health Care Guidelines for seasonal influenza vaccines.
• Include a pneumonia shot with the flu shot for all patients age 65 and older. If a patient received a dose prior to age 65, give a single vaccination at age 65 or older, if at least five years have elapsed. Vaccinate patients ages 2 – 64 if they have a chronic health condition or are immunocompromised.
• Refer to influenza vaccine codes and coverage available in the online Provider Manual.
• Download Michigan-specific versions of the Vaccine Information Statements (VIS).

Antibiotic use and URIs
Although research has consistently shown that antibiotics have no benefits for the management of viral URIs, inappropriate use of antibiotics continues to be widespread. Overuse or inappropriate use of antibiotics can lead to the development of antibiotic-resistant microbial strains. Steps your office can take to ensure appropriate use include:

• Remember that antibiotics are not a prescription for patient satisfaction. Studies have found that receiving an antibiotic prescription is not associated with patient satisfaction. Instead, research shows that patient satisfaction with URI-related visits depends on whether patients leave the visit understanding their illness and feel that their physician spent enough time with them.
• Steer patients toward appropriate symptomatic relief. Over-the-counter and home therapies targeted towards the worst symptoms can help a patient through the natural course of the illness. You can save time and send a consistent message by keeping prescription pads or patient handouts on hand containing a preprinted checklist of medications and tips (e.g., decongestants, antihistamines, antitussives, vaporizers and gargling with warm saline) for symptomatic relief.
• Put a “wait” on that Rx. Research shows that giving a patient an antibiotic prescription — but specifying that it should only be filled if symptoms fail to improve or worsen within several days — is a compromise that also helps to reduce antibiotic use.

For more information on antibiotic drug resistance and informative handouts to give your patients on antibiotics and URIs, check out cdc.gov/drugresistance/.

Reference: "Guidelines for the Use of Antibiotics in Acute Respiratory Tract Infections," American Family Physician, September 15, 2006.

Physical exam reminder calls to your Priority Health Medicare patients
If your office has received phone calls from your Priority Health Medicare patients asking for a comprehensive physical exam, it’s most likely a result of reminder phone calls from Priority Health’s Medicare health improvement nurse. The courtesy calls are a proactive approach to assist you in encouraging patients to not only schedule a physical exam, but to verify current health conditions in their medical records. This is part of our “stimulus package” of $25 per patient, Priority Health’s Medicare Complexity of Care pilot program for 2009.

Next steps for members will include:

• “I missed you“ letters to your patients we’re unable to contact by phone.
• Follow-up letters to patients we contact, which includes a “Condition List” showing the diagnosis we currently have on file. We’ll encourage your patients to bring this form with them at the time of their physical to encourage discussion of their health conditions with their physician. (This form doesn’t replace the Physician Diagnosis Validation Report required in the pilot program.)

Tips for physicians:

• Please use one of the following codes when you complete your patient’s physical exam:
  • Preventive medicine new patient: 99385, 99386 and 99387
  • Preventive medicine established patient: 99395, 99396 and 99397
• At the time of the physical exam, be sure to complete a condition assessment utilizing the Physician Diagnosis Validation Report.
• Priority Health Medicare members are covered for one comprehensive physical exam each year. For more information on our plan and benefits, go to priorityhealth.com/ medicare09/medical-plans/compare-prioritymedicare-plans.
• The Centers for Medicare & Medicaid Services are using a risk adjustment model for Medicare reimbursement, which is based on documentation and ICD-9 codes reported. Utilize Priority Health’s Physician Diagnosis Validation Report when you see your patient for a comprehensive physical exam. If a health condition has resolved, indicate it’s no longer active. If a health condition isn’t listed, please supply us with the additional information.

Colorectal cancer screening: Use correct coding to ensure preventive coverage
If the purpose of a colonoscopy or sigmoidoscopy is preventive (i.e., for colorectal cancer screening), then the procedure is paid under the preventive benefit provisions of the member’s coverage. The table below shows common colorectal cancer screening procedures and the corresponding CPT and ICD-9 codes that are considered preventive.

Description	CPT codes	ICD-9 codes for preventive test**
Sigmoidosopy, flexible; diagnostic	45330, 45331, 45333, 45334, 45338, 45339, G0104*, G0106*	V10.0, V10.01, V10.02, V10.03, V10.04, V10.05, V10.06, V16.0, V76.41, V76.51
Colonoscopy, flexible, proximal to splenic flexure; diagnostic	45378, 45380, 45382, 45385, G0105*, G0120*, G0121*
Fecal occult blood test	82270, 82274, G0328*

*G-Codes are for Medicare members only.
** Tests for purposes other than preventive colorectal cancer screening require different diagnostic coding.

This is true even when polyps are removed during the screening colonoscopy or sigmoidoscopy procedure. However, the pathology tests on any polyps found are considered diagnostic and will be subject to a deductible. Explaining the follow-up testing procedures and costs to members will help them understand charges they may be responsible for.

If you believe that a deductible has been incorrectly applied to the screening, please send us the medical record indicating the purpose of the test, and the claim will be reviewed and adjusted if appropriate. Print our Provider Dispute Resolution form.

Sedation choices
The preventive health benefit for colonoscopies assumes conscious (moderate) sedation as the standard of care. If general anesthesia is used as part of the procedure, it is considered to be an additional service beyond the “preventive” component of care and is subject to the deductible. If a patient has a condition which indicates that general anesthesia is required for a successful procedure, then it’s important to include documentation in the medical records supporting that need and to ensure the patient understands the associated out-of-pocket costs.

Lead testing

Elevated blood lead levels can lead to serious health consequences and developmental delays. Protect your young patients by screening children at ages 12 and 24 months who fall into any of these high-risk categories:

Risk criterion	Description
Medicaid coverage	All children covered by Medicaid are required without exception to have a blood lead test at 12 and 24 months.
WIC enrollment	All children enrolled in the WIC program are required without exception to have a blood lead test at 12 and 24 months.
Geography	These areas have been identified as high risk by MDCH. Screening is strongly recommended for children residing in these areas: Battle Creek Benton Harbor Dearborn Detroit Flint Grand Rapids Hamtramck Highland Park Jackson Kalamazoo Lansing Muskegon/Muskegon Heights Pontiac Saginaw
Environmental risk	If none of the other risk criteria apply, then order a blood test IF a parent/ guardian responds “Yes” or “Don’t Know” to any of the following risk questionnaire items: Does the child live in or often visit a house, daycare, preschool, home of a relative, etc., built before 1950? Does the child live in or often visit a house built before 1978 that has been remodeled within the last year? Does the child have a brother, sister or playmate with lead poisoning? Does the child live with an adult whose job or hobby involves lead? Does the child’s family use any home remedies or cultural practices that may contain or use lead? Is the child included in a special population group, i.e., foreign adoptee, refugee, immigrant, foster care child?

Clinical practice guidelines for testing and treatment of lead poisoning are available at: priorityhealth.com/provider/clinical/lead-poisoning/.

Priority Health makes it easier to stay on top of the lead testing status of your patients by reconciling member claims data on lead testing with additional data from MCIR. We notify members who are due or overdue for a lead test and request that they schedule a test with their PCP.

In addition, we prepare reports for each practice listing screening rates and the members who are due for a test. As of October 2009, MDCH will require that at least 80% of Medicaid-enrolled children be current on their lead test by age 2. We are adjusting our reports to make it easier to see how your practice is performing against this benchmark. For additional information, please contact your PAE.