provider insightTM

fall 2012

CLINICS HONORED FOR CARE . . . . . . .2

PATIENT PERCEPTION OF QUALITY SCORES . . . . . . . . . . . . . . .4

NEW STAFF . . . . . . . . . . . . . . . . . . . . . . .5

M-TECH . . . . . . . . . . . . . . . . . . . . . . . . . . .6

HCPC CODES . . . . . . . . . . . . . . . . . . . . . .7

If you have questions, suggestions, or

success stories you would like to share,

e-mail provider.relations@selecthealth.org.

inside this issue Clinics Honored For CareSelectHealth® and Intermountain Healthcare® are presenting the Excellence in Healthcare Award to 122 healthcare clinics for their work in 2011.

This annual award recognizes independent physician offices as well as those within the Intermountain system for demonstrating exemplary care in managing chronic illnesses. These clinics have achieved high service marks from patients in preventive programs. Honored clinics have rates in the top 10 percent of the scored offices.

The award notes achievement in the following areas: asthma care, diabetes care, breast cancer screenings, cervical cancer screenings, colon cancer screenings, childhood immunizations, adolescent immunizations, and customer service.

Many clinics received more than one award for outstanding work in multiple areas. “Congratulations to the clinics recognized this year,” said Stephen Barlow, MD, SelectHealth chief medical officer. “Our physicians consistently provide excellent care for their patients, but these awards represent outcomes that exceed local and national standards.”

Measurements include how well patients control chronic illnesses, test results meeting recommended levels, percentage of patients who received screenings, and percentage of patients who received immunizations.

2 provider insight FALL 2012

Alpine Medical groupAdolescent Immunization

Coombs Private PracticeAdolescent Immunization

Cottonwood PediatricsAdolescent Immunization

grow Up great PediatricsAdolescent Immunization

intermountain holladay PediatricsAdolescent Immunization

intermountain Memorial Clinic Adolescent Immunization

intermountain north Valley PediatricsAdolescent Immunization

intermountain southridge PediatricsAdolescent Immunization

Pediatric Care of OgdenAdolescent Immunization

southpoint PediatricsAdolescent Immunization

granger Medical ClinicPediatric Asthma Mangement

intermountainAvenues internal MedicineAsthma Management

intermountain holladay PediatricsAsthma Management

intermountain Medical tower Family Practice Asthma Management

intermountain south Ogden ClinicAsthma Management

Park City healthcareAsthma Management

tri City Medical Clinic Pleasant groveAsthma Management

Alta internal MedicineBreast Cancer Screening

Central Utah Clinic - ProvoBreast Cancer Screening

City Creek internal MedicineBreast Cancer Screening

Cope Family MedicineBreast Cancer Screening

intermountain Avenues internal MedicineBreast Cancer Screening

intermountain Budge ClinicBreast Cancer Screening

intermountain gorang Family PracticeBreast Cancer Screening

intermountain Obstetrics & gynecology specialists Breast Cancer Screening

intermountainRiver Road internal MedicineBreast Cancer Screening

intermountain salt Lake Clinic OBBreast Cancer Screening

intermountain Utah Valley internal Medicine ClinicBreast Cancer Screening

Jordan Family health Breast Cancer Screening

McKay-Dee Porter Family PracticeBreast Cancer Screening

Ogden Clinic skylineBreast Cancer Screening

Ogden Women’s Clinic, PCBreast Cancer Screening

River View Medical ClinicBreast Cancer Screening

salisbury internal MedicineBreast Cancer Screening

tod L. Berg, MDBreast Cancer Screening

City Creek internal MedicineCervical Cancer Screening

grandview Family MedicineCervical Cancer Screening

herriman Family PracticeCervical Cancer Screening

intermountain Bountiful ClinicCervical Cancer Screening

intermountainCanyon View Family PracticeCervical Cancer Screening

intermountain syracuse ClinicCervical Cancer Screening

Jordan Family health Cervical Cancer Screening

Jordan River Family MedicineCervical Cancer Screening

Ogden Clinic Mountain ViewCervical Cancer Screening

Ogden Clinic skylineCervical Cancer Screening

Olympus ClinicCervical Cancer Screening

sandy Family PracticeCervical Cancer Screening

taylor Family PracticeCervical Cancer Screening

Wade Family MedicineCervical Cancer Screening

Cottonwood PediatricsChildhood Immunization

grandview Family MedicineChildhood Immunization

granger Medical ClinicChildhood Immunization

granger Medical Clinic - RivertonChildhood Immunization

intermountain Bountiful ClinicChildhood Immunization

intermountain Bryner ClinicChildhood Immunization

intermountain Layton ClinicChildhood Immunization

intermountain sandy ClinicChildhood Immunization

intermountain southridge PediatricsChildhood Immunization

Ogden Clinic Canyon ViewChildhood Immunization

Ogden Clinic harrison Blvd.Childhood Immunization

Pediatric Care of ProvoChildhood Immunization

southpoint PediatricsChildhood Immunization

Clinics Honored For Care

Intermountain Bountiful Clinic

Front Row: Dr . David Horsley, IM; Dr . Douglas Nielsen, Ped; Sun Yong

Kim, MA; Dr . Celia Blackburn, FP; Cindy Kaufusi, MA;

Terrie Luk, MA; Dr . Tyler Williams, IM

Back Row: Dr . Randy Reese, Ped; Dr . Douglas Kasteler, FP; Julie

Christensen, MA; Dr . Nedda Hendler, IM; Kris Ericksen,

MA; Dr . Scott Beckstead, FP

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southwest Children’s ClinicChildhood Immunization

treehouse Pediatrics and Family CareChildhood Immunization

Utah Valley Pediatrics American ForkChildhood Immunization

intermountain Central Orem Clinic OBChlamydia Screening

intermountain Wasatch OB/gYn - McKay-DeeChlamydia Screening

intermountain Wasatch OB/gYn - north OgdenChlamydia Screening

Valley OB/gYn - ProvoChlamydia Screening

Alta internal MedicineColon Cancer Screening

Christian Private PracticeColon Cancer Screening

City Creek internal MedicineColon Cancer Screening

intermountain Avenues internal MedicineColon Cancer Screening

intermountain Bryner ClinicColon Cancer Screening

intermountain Budge ClinicColon Cancer Screening

intermountain Canyon View Family PracticeColon Cancer Screening

intermountain Cottonwood internal MedicineColon Cancer Screening

intermountain gorang Family PracticeColon Cancer Screening

intermountain McKay-Dee internal Medicine ClinicColon Cancer Screening

intermountain Utah Valley internal Medicine ClinicColon Cancer Screening

Jordan Family health Colon Cancer Screening

Ogden Clinic skylineColon Cancer Screening

Olympus ClinicColon Cancer Screening

sandy Family PracticeColon Cancer Screening

Valley Family MedicineColon Cancer Screening

Alpine Family Medicine Customer Service Family Practice

Coalville health ClinicCustomer Service Family Practice

intermountain Bear River ClinicCustomer Service Family Practice

intermountain gorang Family PracticeCustomer Service Family Practice

intermountain springville Clinic Customer Service Family Practice

intermountain syracuse ClinicCustomer Service Family Practice

isaacson Family PracticeCustomer Service Family Practice

Mountain Utah Family MedicineCustomer Service Family Practice

sandy Family PracticeCustomer Service Family Practice

Wade Family MedicineCustomer Service Family Practice

Dixie Primary CareCustomer Service Internal Medicine

intermountain American Fork internal MedicineCustomer Service Internal Medicine

intermountain Bountiful Clinic - internal Medicine Customer Service Internal Medicine

intermountain Women’s health specialists Customer Service OB/GYN

Robert W. Later, MDCustomer Service OB/GYN

Russell A. smith, MDCustomer Service OB/GYN

intermountain holladay Pediatrics north Customer Service Pediatrics

intermountain holladay PediatricsCustomer Service Pediatrics

John shakula PediatricsCustomer Service Pediatrics

Kelly PediatricsCustomer Service Pediatrics

Lofgren PediatricsCustomer Service Pediatrics

Parkway PediatricsCustomer Service Pediatrics

Pediatric Care of OgdenCustomer Service Pediatrics

Rose Pediatrics Customer Service Pediatrics

Central Utah Clinic - ProvoDiabetes Management

intermountain Avenues internal MedicineDiabetes Management

intermountain Bountiful ClinicDiabetes Management

intermountain Budge ClinicDiabetes Management

intermountain Central Orem Clinic Diabetes Management

intermountain Cottonwood Family Practice Diabetes Management

intermountain Cottonwood internal MedicineDiabetes Management

intermountain holladay ClinicDiabetes Management

intermountain north Canyon Family PracticeDiabetes Management

intermountain north Ogden ClinicDiabetes Management

intermountain south Ogden ClinicDiabetes Management

Jordan Family health Diabetes Management

Olympus ClinicDiabetes Management

SeleCtHealtH announCeS new aFFIlIatIon wItH IdaHo-BaSed St. luke’S HealtH SyStem

SelectHealth has formed a unique strategic

alliance with St. Luke’s Health System, Idaho’s

largest and only locally governed healthcare

system, to offer a new approach to health

insurance benefits to residents of Idaho.

This new alliance is committed to exceptional health care and exceptional health insurance for Idahoans. The alliance will be supported by BrightPath, an extensive network of physicians and healthcare facilities that has been developed over a number of years by St. Luke’s and other leading providers to provide a comprehensive healthcare delivery system in Idaho.

Like SelectHealth, St. Luke’s is a nonprofit organization that gives back to the community. Both organizations share a community pledge for improving healthcare, providing superior service, and actively supporting health and wellness education initiatives.

To provide local service to members, providers, and the community, SelectHealth will establish a local office in Boise.

4 provider insight FALL 2012

Results for clinics with a sufficient number of completed surveys are available at selecthealthphysician.org. Copies were delivered to clinc managers as well. Log in to selecthealthphysician.org to review your clinc’s results. Click on “Clinical Reports,” “SelectHealth,” “Primary Care” or “Women and Newborn,” and “SelectHealth Satisfaction and Performance Rating Reports.” After choosing your clinic and a reporting period in 2011, click on “satisfaction” at the top of the page to access the results of these surveys.

Members can review results for primary care and OB/GYN clinics with more than 30 completed surveys on selecthealth.org.

Scores for primary care physicians have generally improved over the past three years. Overall, internal medicine practices have shown improvement for patient interaction and nursing staff for the past four years. Scores for family practice clinics have increased in the categories “waiting time” and “experience calling the clinc.” Pediatric clinics have improved in all categories. Patient scores for OB/GYN clinics were slightly lower in 2010, but improvements were made in all categories in 2011.

We hope that these positive trends continue and recognize that it takes effort. SelectHealth offers a one-day class called “Science of Superior Service.” If you are interested in learning more or enrolling, call Staci Dearden at 801-442-7158. There is a $30.00 fee for each attendee. We appreciate all that you do at your clinics to ensure an excellent experience for our members.

PAtient PeRCePtiOn OF QUALitY sCORes

The annual Patient Perception of

Quality was completed in 2011.

SelectHealth attempted to collect

surveys on more than 250 primary

care, OB/GYN, and endocrinology

clinics. Questions on the survey

focused on the patient’s experience

with physicians, nursing staff,

reception staff, cleanliness,

waiting time, and availability of

appointments.

nAtiOnAL DRUg CODes

As of June 1, 2012, claims submitted without a valid National Drug Code (NDC) are rejected by

our claims processing system.

The NDC is useful because it is a universal identifier for human drugs and biologics. The Healthcare Common Procedure Coding System (HCPCS) only specifies the chemical name of a drug and can be used to represent multiple NDCs for several drug therapies.

Many healthcare providers have already made changes to their procedures to collect and submit NDC data to meet billing requirements of some federal and/or state-funded programs. This data helps manage injectable and specialty drug benefits for SelectHealth. This requirement does not apply to immunizations or services provided as part of an inpatient stay.

In 2007, we asked providers to begin submitting NDCs for injectable and specialty medications (in addition to the HCPCS code). We appreciate your efforts to provide this information. Currently, approximately 70 percent of all claims submitted for injectable and specialty medications include an NDC number.

If you need assistance to meet these requirements, please call the SelectHealth edI department at 801-442-5442. If you have general questions related to this requirement, contact your Provider Relations representative.

5selecthealth.org

New Staff at SelectHealth

Tom Wahlen has recently joined SelectHealth as the director of Provider Relations. Previously, Tom served as senior manager and negotiation lead in the Payer Contracting department at Intermountain Healthcare. Tom holds a Master of Business Administration degree from Westminster College and earned a Bachelor’s degree in Business/Public Relations from the University of Utah.

HealtH SeRvICeS management team

Christine Lake has held clinical positions in hospital and outpatient surgery. She has worked as a region nurse consultant within the Intermountain Medical Group and most recently headed up the implementation of the SelectHealth physician/clinic public reporting and the Primary Care Physician Incentive program.

Chris Chytraus joined SelectHealth in 2011 to oversee care management for the Medicaid program. Chris was a manager for the

Utah Department of Health Fostering Healthy Children Program, where she oversaw administrative care management for children in Utah’s foster care system. Chris received her nursing degree from Westminster College and her Certified Public Manager certification from the state of Utah.

Lynanne Gibbons held nursing positions with Intermountain Healthcare for 24 years and has been at SelectHealth for seven years. Lynanne graduated from Brigham Young University with a bachelors degree in nursing.

Robbie Morris has held positions at SelectHealth for 11 years. She currently oversees the coordination of care management services for new product lines. Robbie received a bachelors degree in nursing from Brigham Young University. She has over 38 years of nursing and management experience.

The update to the 5010 versions of

EDI transactions is now complete. If

your office is having any difficulties

with this transition, please contact

our EDI Team at (801) 442-5442 or

edi@selecthealth.org.

get inVOLVeD!

There are many standards being created

at a national and state level that may have

an impact to your office. The Utah Health

Information Network (UHIN) provides a

way for these community-based standards

to be created and maintained. We share

feedback to UHIN to share with national

organizations that create standards. For

more information, visit UHIN.org.

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Christine Lake, Chris Chytraus, Lynanne Gibbons, Robbie Morris

6 provider insight FALL 2012

technologydate

Reviewed*Committee Recommendations

Continuous Glucose Monitoring Systems (CGMS)

01/24/12 Continue to cover in limited circumstances. Criteria for coverage have been modified. See Medical Policy #223.

Intraoperative Stereotactic Image Guidance for Lumbar Spinal Arthrodesis

01/24/12 Cover. Current evidence, though limited, supports that stereotactic intraoperative image guidance in lumbar spine surgery improves health outcomes. See Medical Policy #502.

Percutaneous and Endobronchial Brachytherapy for Lung Tumors

01/24/12 Cover in limited circumstances. Current evidence supports percutaneous endobronchial brachytherapy for the treatment of lung cancer to be safe and effective. See Medical Policy #501.

Bicompartmental Partial Knee Replacement/Resurfacing

01/24/12 Deny as unproven and not medically necessary. Current evidence remains limited as to the efficacy, safety, and durability related to bicompartmental knee replacement/resurfacing. See Medical Policy #431.

Total Hip Resurfacing Age Limit Restriction

01/24/12 Raise upper age limit to 60 in men, continue age limit of 55 for women. Current evidence supports total hip resurfacing for men up to age 60 to have equivalent health outcomes to standard total hip arthroplasty. Evidence beyond age 60 in men is insufficient to draw conclusions. Evidence in women older than age 55 demonstrates inferior outcomes to total hip arthroplasty. See Medical Policy #254.

Heart Transplant Age Limit Restrictions 01/24/12 Cover in limited circumstances. Current evidence demonstrates no statistically significant difference in survival or complications for patients undergoing heart transplantation between age 60 and 70. Beyond age 70 the current evidence is insufficient to reach any firm conclusions as to the equivalence of outcomes in this population. See Medical Policy #125.

Transcutaneous Electrical Modulation Pain Reprocessing (Calmare®/Calmar™)

03/13/12 Deny as investigational. Current evidence is inadequate to determine the efficacy, safety, durability, or appropriate therapeutic protocols for transcutaneous electrical modulation pain reprocessing therapy. See Medical Policy #503.

John Cunningham Virus (JCV) Testing for The Assessment of Progressive Multifocal Leukoencephalopathy (PML) Risk

03/13/12 Cover in limited circumstances. Current literature supports use of the STRATIFY JCV Assay in patients receiving immunosuppressive therapies to stratify risk of PML. See Medical Policy #504.

Shoulder Resurfacing 03/13/12 Deny as investigational. Current evidence suggests shoulder resurfacing has a greater number of complications and higher revision rate than the current standard of total shoulder arthroplasty for the same indications. See Medical Policy #505.1.

Axial Lumbar Interbody Fusion (AxiaLIF®)

04/24/12 Deny as experimental/investigational. Evidence on the safety, efficacy, and durability beyond two years has not been published for review. See Medical Policy #450.

Endometrial Cryoablation for Menorrhagia

04/24/12 Cover. Current evidence, though limited, demonstrates endometrial cryoablation to be a safe and effective technique in the treatment of menorrhagia equal to alternative therapies. See Medical Policy #329.

Intravascular Ultrasound (IVUS) for Peripheral Vascular Disease (PVD)

04/24/12 Cover. Current literature demonstrates improved stent placement and fewer restenoses with IVUS in PVD. See Medical Policy #447.

Magnetic Resonance (MR) Neurography 04/24/12 Deny as investigational. Current evidence is limited and has not yet proven clinical validity for many conditions, and the clinical utility has not been defined. See Medical Policy #491.

MAKOplasty® Hip Replacement for Osteoarthritis

06/12/12 Deny as investigational and not medically necessary. Current evidence has not demonstrated clinical utility of this method of total hip arthroplasty as it compares to standard hip arthroplasty. See Medical Policy #236.

Cooling Garments for the Management of Multiple Sclerosis (MS)

06/12/12 Deny as investigational. Current evidence has not demonstrated significant impact of these garments on the health outcomes in individuals with MS compared to nonmedical items. See Medical Policy #345.

Transcatheter Aortic Valve Replacement (TAVR)/Implant (TAVI) for Aortic Stenosis

06/12/12 Cover in limited circumstances consistent with FDA-approved indications and at designated facilities only. See Medical Policy #444.

M-Tech is SelectHealth’s formal process for reviewing emerging healthcare technologies (procedures, devices, tests, and biologics) for the purpose of establishing covered benefits. Existing technologies are, at times, also examined through this process.

Following is a list of recently reviewed technologies and committee recommendations:

MeDiCAL teChnOLOgY AssessMent (M-teCh)

If you have questions regarding coverage of these or any other technologies or procedures, or if you would like SelectHealth to consider coverage for an emerging technology, please e-mail mtech@selecthealth .org or call Ken Schaecher, MD, FACP, M-Tech committee chairman, at 801-442-7927 .

All SelectHealth medical policies and technology assessments can be viewed on selecthealth.org . Click on the “Provider” tab (upper right corner), enter your login information, and then click on “Policies and Procedures” (left side of page) .

*“date reviewed” does not necessarily reflect the policy implementation date. See medical Policies for details.

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Please refer to the latest edition of your coding reference books or software updates for current information regarding these code changes. If you have purchased books, be aware that there are already corrections being made. Please refer to the following websites to get the lastest information and corrections*:

ama-assn.org/ama/pub/category/3896.html

cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_

summarytables.asp#TopOfPage 

cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.

asp#TopOfPage

PReventIve CaRe tIPS

As a result of the Affordable Care Act (ACA), the majority of plans offered by SelectHealth offer preventive care services covered at 100 percent. SelectHealth defines preventive care as routine healthcare that includes screenings, checkups, and patient counseling to prevent illness, disease, or other health problems not currently known to exist in the person, or in the case of immunizations, to prevent the development of disease. As members continue to use this benefit, there are a few points that can make claims submission easier.

1. exIStIng CondItIonS. If the purpose of the patient’s visit is to evaluate and manage an existing condition (i.e., treating high blood pressure to prevent a heart attack or stroke), it is not considered a preventive service. However, if a member has an existing condition, they are still eligible for a preventive visit for their general well-being. In these situations, it is appropriate to bill using a preventive diagnosis code instead of a code for an existing diagnosis.

2. 365 dayS. Prior to January 1, 2011, preventive services were covered once per calendar year. However, effective the beginning of this year, members are only eligible for preventive services every 365 days.

3. laB woRk. Laboratory work billed in conjunction with a routine exam may be billed as preventive if the patient has not been diagnosed with a related condition in the past. In these situations, it is important that the correct diagnosis is sent to the lab. If the lab work is not billed with a preventive diagnosis, it will apply to a different benefit and may be subject to a copay, deductible, and/or coinsurance. For example, it is common to see CPT 80050 billed with an existing diagnosis, which triggers the outpatient minor diagnostic testing benefit instead of the preventive benefit.

For additional information regarding preventive coding polices and services, please visit selecthealthphysician.org.

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2012 CODe ChAnges

The HCPC level I and II codes became effective January 1, 2012. 

*SelectHealth may link to other websites for your convenience. SelectHealth does not expressly or implicitly recommend or endorse the views, opinions, specific services, or products referenced at other websites linked to the SelectHealth site, unless explicitly stated. SelectHealth disclaims any responsibility for the content, information or the privacy and security policies contained on other websites, and does not exert any editorial or other control over those sites.

The information that is contained in this

newsletter does indicate whether a treatment is

subject to insurance benefits. If a member has

questions about benefit coverage, please refer

him or her to Member Services at 801-442-5038

(Salt Lake area) or 800-538-5038.

P .O . Box 30192 • Salt Lake City, Utah 84130

© 2009-2012 SelectHealth . All rights reserved . 1844 09/12

Provider Insight is a trademark of SelectHealth .

Nonprofit Org .

U .S . Postage

PaIdSalt Lake City, UT

Permit No . 4547Immunization Summits

Tamara Sheffield, MD, MPA, MPH, and Shannon Seymour, RN will present current information about immunizations and influenza. The summit is free, but seating is limited. Visit selecthealthphysician.org to register today!