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A publication of Texas Children’s Health Plan
PROVIDER NEWS
FALL 2 01 4
IN THIS ISSUE
2 Medical Director
Corner
3
Synagis season
2014 to 2015
5 OB Provider
Incentive Program
8
Prepare for cold and
flu season
4
Lab provider changes
6 ECI Services
10 Short acting BETA
agonists
11
CONNECT Program
12 CMS NCCI and
MUE guidelines
ND-1014-210
P.O. Box 301011, NB 8301
Houston, Texas 77230
NONPROFIT ORG.
U.S. POSTAGE
PAID
PERMIT NO. 4
HOUSTON, TX
MEDICAL DIRECTOR CORNER
Vice President and Chief Medical Officer
Angelo P. Giardino, MD, PhD
of their patients diagnosed with sinusitis, 60
percent with pharyngitis, and 70 percent with
bronchitis in children ages 6 and under. The total
number of prescriptions for amoxicillin being
given to children 6 and under is 65 percent of all
amoxicillin claims.
Choose Wisely:
An initiative of the
ABIM Foundation
A
s we enter into the fall respiratory season,
the American Academy of Pediatrics
(AAP) and Texas Children’s Health
Plan are requesting for our providers to “choose
wisely” when considering antibiotics and cough
and cold medicines. Texas Children’s Health Plan
has analyzed data from our providers as it relates
to the top two recommendations focusing on
(1) antibiotics should not be used for apparent
viral respiratory illnesses, and (2) cough and
cold medicines should not be prescribed or
recommended for respiratory illnesses in children
under 6 years of age.
In the first recommendation from AAP,
antibiotics should not be used for apparent
viral respiratory illnesses including sinusitis,
pharyngitis, and bronchitis. Although overall
antibiotic prescription rates for children have
fallen, they still remain alarmingly high. Data
from September 2013 through March 2014 on
the most prescribed antibiotic shows that our
providers are prescribing amoxicillin to 50 percent
2
TexasChildrensHealthPlan.org
Unnecessary medication use for viral respiratory
illnesses can lead to antibiotic resistance and
contributes to higher health care costs and the risks
of adverse events. Antibiotics are effective against
bacterial infections, certain fungal infections, and
some kinds of parasites. Antibiotics don’t work
against viruses. Symptom relief might be the best
treatment option for infections caused by viruses
like colds, most sore throats, bronchitis, and some
ear infections. Other consequences of antibiotic
resistance are the increased costs associated
with prolonged illnesses, including expenses for
additional tests, treatments and hospitalization,
and indirect costs, such as lost income.
The CDC has a Get Smart campaign on the
principles for appropriate antibiotic use for
pediatric upper respiratory tract infections. These
guidelines were developed in collaboration with
the American Academy of Pediatrics and members
of the American Academy of Family Physicians.
The CDC then collaborated with members of
the American Academy of Family Physicians,
American College of Physicians, Infectious
Diseases Society of America, and the American
College of Emergency Physicians. The pediatric
guidelines provide a definition of appropriate
832-828-1008
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prescribing and include the following practical
tips when parents ask for antibiotics to treat
viral infections:
Explain that unnecessary
antibiotics can be harmful.
Tell parents that based on the latest evidence,
unnecessary antibiotics CAN be harmful, by
promoting resistant organisms in their child and
the community. Please see Dr. Peacock’s article on
page 9 as well.
Share the facts.
• Explain that bacterial infections can be cured
by antibiotics, but viral infections never are.
• Explain that treating viral infections with
antibiotics to prevent bacterial infections does
not work.
Build cooperation
and trust.
• Convey a sense of partnership and don’t
dismiss the illness as “only a viral infection.”
• Encourage active management of the illness.
• Explicitly plan treatment of symptoms with
parents. Describe the expected normal time
course of the illness and tell parents to come
back if the symptoms persist or worsen.
Be confident with the
recommendation to use
alternative treatments.
• Prescribe analgesics and decongestants,
if appropriate.
• Emphasize the importance of adequate
nutrition and hydration.
• Consider providing “care packages” with
non-antibiotic therapies.
• Create an office environment to promote
the reduction of antibiotic use.
Talk about antibiotic use
at 4- and 12-month wellchild visits.
By sharing these tips not only are you “choosing
wisely,” you will strengthen your relationship with
your patients and avoid antibiotic resistance.
In the second recommendation from AAP, cough
and cold medicines should not be prescribed or
recommended for respiratory illnesses in children
under 6 years of age. No one likes getting a cold,
but a child’s cold can be hard on the child as
well as their parents. Children get 6 to 8 colds
per year that typically last 3 to 14 days. Wellmeaning parents who want to help their sick child
will often ask a provider for prescription cold
or cough medicine. Cough and cold medicines
are the best way to help a child who has a cold
feel better—right? Think again. Cough and
cold medicines aren’t recommended for children
younger than age 2, and the jury is still out on
whether cough and cold medicines are appropriate
for older kids.
So how can you treat a child’s cold? Cough
and cold medicines don’t effectively treat the
underlying cause of a child’s cold, and they
won’t cure a child’s cold or make it go away any
sooner. These medications also have potentially
serious side effects, including rapid heart rate and
convulsions. The Food and Drug Administration
(FDA) discourages the use of cough and cold
medicines for children younger than age 2. Many
cough and cold products for children have more
than one ingredient, increasing the chance of
accidental overdose if combined with another
product. Using claims and pharmacy data from
September 2013 through March 2014, the results
show that our providers are prescribing cough
medicine at a high rate to children who are 6 and
under. In fact, in this time period the health plan
reports that Bromfed DM was the most prescribed
cough medicine. Furthermore, in the graph below,
there is an alarming prescription rate of 63 percent
for Bromfed DM for children ages 6 and under.
The highest diagnosis for this prescription is otitis
media and the second most prescribed diagnosis is
strep throat. Bromfed DM has not been shown to
cure otitis media nor strep throat. Likewise, cough
and cold products have not been shown to be safe
or effective in children younger than 6 years of age.
Bromfed DM has significant side effects including
headaches, dizziness, and nausea. Moreover, it
costs the health plan millions of dollars.
Providers are encouraged to talk to patients and
their caregivers about non-prescriptive alternatives
that will relieve the symptoms of these diagnoses.
We hope that you implement the Choosing
Wisely® recommendations into your practice.
Synagis season
2014 to 2015
Texas Children’s Health Plan will authorize
the usage of Synagis for those infants requiring
the vaccine beginning with dates of service
October 1, 2014 to February 28, 2015. Texas
Children’s Health Plan will again require a prior
authorization for this drug that providers can
obtain by using the form available at navitus.
com/texas-medicaid-star-chip/priorauthorization-forms.aspx. This form will include
the most current guidelines for use and include
the specialty pharmacies from which the drug can
be ordered and shipped. And like last year, this
medication is available only from select specialty
pharmacies Maxor Pharmacy and Avella Pharmacy.
Providers can fax their authorization form to either
of these pharmacies and they will work to obtain
the needed authorization.
PLEASE CHECK
with your Provider Relations Manager
for more information as the season for
vaccinating our population nears.
1-800-731-8527
832-828-1008
TexasChildrensHealthPlan.org
3
Laboratory provider changes effective January 1
T
exas Children’s Health Plan
has entered into an agreement
with Quest Diagnostics to
serve as our exclusive reference lab
provider effective January 1, 2015.
In the interim, Quest will serve as
our Preferred Reference Lab and
we request that you begin utilizing
Quest Diagnostics as much as
possible for your reference lab needs.
Per state regulations, laboratory
specimens that are required to be sent
to state laboratories for processing
will continue to follow guidelines
provided in the Texas Medicaid
Provider Procedures Manual
(TMPPM).
If you do not currently have a
relationship with Quest Diagnostics,
you will be contacted by a Texas
Children’s Health Plan or Quest
Diagnostics representative to discuss
how to establish a relationship with
Quest. Providers currently have
two options for accessing reference
laboratory services. These options
will continue and, after January 1,
2015, should be directed to Quest
Diagnostics as indicated below:
1. Provider can collect specimens
in office and Quest will pick up
specimens for testing.
2. Texas Children’s Health Plan
members can be sent to Quest
Patient Service Centers for
specimen collection and testing.
Providers may continue to perform
specific lab tests in their office and
receive reimbursement fromTexas
Children’s Health Plan. Effective
January 1, 2015, the attached list
of Physician Office Lab Tests are
reimbursable by Texas Children’s
Health Plan. All other lab tests must
be referred to Quest Diagnostics
or State of Texas Laboratories as
required in TMPPM.
We sincerely appreciate the care and
service you provide to our members.
For questions, please contact
Provider Relations at 832-828-1008
or toll-free at 1-800-731-8527.
Physician Office Lab Test List
80061
81000
81001
81002
81003
81005
81007
81025
82009
82044
82120
82247
82270
82465
82731
82947
82948
82950
82962
83036
83037
83655
84112
84450
84460
4
Lipid Panel (80061)
Urinls Dip Stick/Tablet Reagnt Non-Auto Micrscpy (81000)
Urinalysis with Microscopy, Automated
Urnls Dip Stick/Tablet Rgnt Non-Auto W/O Micrscp (81002)
Urinalysis w/o Microscopy, Automated.
Urinalysis, Qualitative
Urine Screen for Bacteria
Urine Pregnancy Test Visual Color Cmprsn Meths (81025)
Acetone or Other Ketone Bodies
Urine Dipstick For Micro-Albumin
Amines Vaginal Fluid Qualitative (82120)
Bilirubin Total (82247)
Blood Occult Peroxidase Actv Qual Feces 1 Deter (82270)
Cholesterol Serum/Whole Blood Total (82465)
Ftl Fibronectin Cervicovag Secretions Semi-Quan (82731)
Glucose Quantitative Blood Xcpt Reagent Strip (82947)
Glucose, Blood Reagent Strip
Glucose Post Glucose Dose (82950)
Glucose Blood Test
Hemoglobin A1C
Hemoglobin A1C
Lead Screening
Aminsure
Transferase Aspartate Amino Ast Sgot (84450)
Transferase Alanine Amino Alt Sgpt (84460)
TexasChildrensHealthPlan.org
832-828-1008
84703
85007
85013
85014
85018
85025
85027
85048
85610
85651
86308
86403
86580
87081
87210
87220
87420
87430
87800
87804
87807
87880
88720
89060
1-800-731-8527
Chorionic Gonadotropin Assay
Blood Count Smear Mcrscp w/Mnl Difrntl WBC Count (85007)
Spun Hematocrit
Blood Count Hematocrit (85014)
Blood Count Hemoglobin (85018)
Blood Count Complete Auto&Auto Difrntl WBC Count (85025)
Blood Count Complete Automated (85027)
WBC
Prothrombin Time
Sedimentation Rate
Heterophile Antibodies Screen (86308)
Particle Agglutination (Rapid Strep)
TB (Intradermal & Tine)
Cul Prsmptv Pthgnc Organism Scrn W/Colony Estimj (87081)
Smr Prim Src Wet Mount Nfct Agt (87210)
Koh—Tissue Exam For Fungi
Iaad Eia Respiratory Synctial Virus (87420)
Strep Screen
Iadna Multiple Organisms Direct Probe Tq (87800)
Iaadiadoo Influenza (87804)
Iaadiadoo Respiratory Synctial Virus (87807)
Iaadiadoo Streptococcus Group A (87880)
Bilirubin Total Transcutaneous (88720)
Crystal Id Light Microscopy Alys Tiss/Any Fluid (89060)
OB Provider Incentive Program
Texas Children’s Health Plan offers an OB
Provider Incentive Program to reward your
group for providing quality care to our members
during their pregnancy, from early prenatal care
to delivery and postpartum care. The first payout
was August 2014 for the look back period from
November to April 2014.
Qualifying
measure #1
Qualifying
measure #2
Retention Measures
Retention is defined as the number of pregnant
women who stay enrolled in Texas Children’s
Health Plan through their delivery. Your retention
rate is represented as a percentage of the total
pregnant women who are assigned to your
OB Group.
You meet the retention threshold if your
retention rate is 70 percent or greater.
(i.e., At least 70 percent of potential deliveries are
still Texas Children’s Health Plan members at the
time of delivery.)
*Maternal Fetal Medicine Specialists (MFM) are
exempt from the volume measure.
Performance
measure #1
Performance
measure #2
How the program works:
The OB Incentive Program has 4 parts: 2
qualifying measures and 2 performance measures.
All payouts are biannual. To be eligible to receive
the biannual payments, you must meet the 2
qualifying measures, which focus on volume and
member retention.
The program’s primary goal is to encourage you
to provide quality care to Texas Children’s Health
Plan pregnant members. In order to receive the
biannual payments, you must meet at least one of
the performance measures, which emphasize early
prenatal and postpartum care. You will be paid for
each goal that you exceed.
How to qualify:
You qualify for the OB Incentive Program by
meeting both of the qualifying measures below.
Volume Measure*
Volume is the number of deliveries where the
obstetrician’s group is the primary care provider
of obstetrical care.
You meet the volume threshold if you serve as
the primary obstetrical provider for a minimum
of 50 deliveries for Texas Children’s Health Plan
members per group, per year.
Payout schedule
We calculate qualifying measures once a year
based on the calendar year. After meeting both
qualifying measures, you are then eligible to
receive payment for one or both of the following
performance measures.
1. Prenatal Care
Prenatal visits performed within 42 days of
a member’s enrollment in Texas Children’s
Health Plan.
2. Postpartum Care
Postpartum visits performed between 21 to
56 days after delivery.
3. Payout Schedule
See chart below.
Payment administration
• Payment will be made to the Vendor and
Vendor Tax ID number to which the practice
(and the Practice’s providers) is affiliated for
claims payment. We will not pay individual
physicians if their claims payments are affiliated
with a group.
• Provider groups must be actively contracted with
CHIP and STAR (not retired or terminated) at
the time of payout to be eligible for payment.
• Explanation of Payment (EOP) statements will
be prepared on a biannual basis to distribute
to each practice. Payments are consolidated for
multiple practices and providers who practice
within the same vendor and tax ID number.
We cannot direct how the Vendor distributes
money within its practice.
• We will communicate the performance and
payout results to the practice. The individual
OB scores will be attached to the EOP.
Program changes
and continuation
• Texas Children’s Health Plan reserves the right
to continue and/or modify the program but
attempts to provide advance notice of any
changes that would be significant to a provider.
• Providers or practices under Texas Children’s
Health Plan payment review at the time of
payout will not be eligible for OB Incentive
payout and will remain ineligible until removed
from payment review.
Payment frequency
Measurement period
for payment #1
Payout #1
Measurement period
for payment #2
Payment
#2
Biannual payments with
qualifying measures
calculated once a year
November 2013
to April 2014
August
2014
May 2014 to
October 2014
February
2015
Note: Provider group must be actively contracted with Texas Children’s Health Plan for CHIP and STAR at
the time of payment to be eligible.
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5
Early Childhood Intervention
services and referrals
7 calendar days from the day the provider
identifies the member. Claims for all physical,
occupational, speech and language therapy must
be submitted to Texas Children’s Health Plan
from the ECI Provider.
To find a program in your area and make
a referral:
E
arly Childhood Intervention (ECI) is
a statewide program combining case
management and service coordination for
children from birth to age 3 who have disabilities
or developmental delays. ECI teaches families
how to help children reach their maximum
potential through education and therapy services.
Federal law requires that providers refer children
to ECI within 2 working days of identifying a
developmental disability or delay. Providers can
call the ECI Referral Line at 1-800-628-5115 to
identify an ECI program in the member’s area.
Brochures and posters are available for provider
offices by calling Texas Children’s Health Plan
Provider and Care Coordination.
Members can self-refer to local ECI service
providers without a referral from the member’s
PCP. A diagnosis is not required prior to referring
a member to ECI. Infants and toddlers from birth
to age 3 may be referred if:
• Services are personalized for each child
and family.
• Involves families in services that incorporate
therapeutic intervention strategies in their
child’s daily routine.
• An interdisciplinary team of licensed or
credentialed professionals are available for
the treatment of each child.
• Call DARS Inquiries Line at 1-800-628-5115.
• Visit dars.state.tx.us/ecis/searchprogram.asp
to find a local program in your area.
• Contact your local ECI program with
information on the child in need.
• Provide the contact information to the family
so they can contact ECI directly.
• Incorporates measurable outcomes.
Texas Children’s Health Plan has only qualified
ECI providers in network for members under the
age of 3. Visit TexasChildrensHealthPlan.org to
search for ECI providers in your area.
• Offers services in the home and
community setting.
(Source: Department of Assistive and Rehabilitative
• Every family received case management.
Services Division for Early Childhood Intervention
Services, dars.state.tx.us/ecis.)
• Guides families in transitioning to different
services after the child is 3 years old.
• Developmental delay
• The family suspects delays in one or
more areas of development.
• Medically diagnosed condition
• Auditory or visual impairment
• The child exhibits atypical
developmental delay.
Steps for determining ECI services:
Local programs conduct free developmental
screenings and assess the child for developmental
delay and eligibility. Once a child is accepted
and enrolled, an Individual Family Service Plan
(IFSP) is developed and services are initiated.
Texas Children’s Health Plan will accept and
coordinate services indicated in an IFSP, including
claims payment for PT/OT/ST. If the child is not
accepted in the program, ECI staff will refer the
family to other resources.
ECI has provided specialized services for more
than 30 years at no cost to the family. These
services range from therapy to nutrition
counseling for Texas families with children
who have developmental delays and disabilities.
This makes ECI a great resource for members
who qualify needing speech therapy services.
These services are provided by a Licensed
Speech Language Pathologist.
TexasChildrensHealthPlan.org
• Specialize in infants and toddlers.
The following categories are evaluated to
determine eligibility:
• They have medical conditions known
to result in delays in development.
6
Benefits of ECI services:
1
Referral.
2
Evaluation with interdisciplinary team to
determine child’s eligibility.
3
Once it is determined the child is eligible
for services, the interdisciplinary team
and parents work together to develop an
Individualized Family Service Plan (IFSP).
4
The IFSP is shared with the child’s
physician with parental consent.
Texas Children’s Health Plan ensures network
providers are knowledgeable about the federal laws
on the referral procedures with ECI. Network
providers are required to identify and provide
referral information to the LAR of any member
under the age of 3 who is suspected of having
a developmental delay or otherwise meeting
eligibility criteria for ECI services within
832-828-1008
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Reimbursement
code for sports
and camp
physicals
As a value added service to our CHIP and
STAR members, Texas Children’s Health Plan
will reimburse code 97005 – Athletic Training
Evaluation and Management. This code is only
reimbursed for sports and camp physicals.
Payment for this service will be a flat rate of $30
for participating providers only. Texas Children’s
Health Plan will pay for 97005 – Athletic Training
Evaluation and Management on the same date
of service a Texas Health Steps (THSteps) visit
occurs. If you need further clarification, please
contact your Provider Relations Manager at
832-828-1008 or 1-800-731-8527.
Medical record documentation
Correct
Texas Health Steps requirements
billing with
rendering
provider
A
s the patient’s medical home, primary care physicians are required to maintain comprehensive
and accurate medical records to ensure quality and continuity of care. The record must support
medical necessity based on the clinical condition and needs of the patient as well as the specific
elements required to satisfy the level or type of service described in the Current Procedural Terminology
(CPT) edition.
Providers billing for
Texas Health Steps:
Please include the attested NPI number of the
rendering individual provider in box 24J on
paper claims or loop 2310B on EDI claims
when using a group NPI number as the
billing NPI.
Providers who render a service and bill with
an individual provider NPI number do not
need to add the information in the rendering
provider field.
Please follow this guide
for Texas Health
Steps claims:
Billing NPI
Rendering NPI
Individual provider
Not needed if same
individual
Group NPI
Must be NPI of individual
rendering service
Using an attested NPI number as required by the
State of Texas allows Texas Children’s Health Plan
to submit the claim to the State of Texas encounter
system, which allows the State to track member
usage and provides data on provider utilization.
If you have questions, please call your Texas
Children’s Health Plan Provider Relations team at
832-828-1008 or toll-free 1-800-731-8527.
Retrospective reviews are routinely performed by state agencies and Texas Children’s Health Plan
to ensure the medical record documentation supports the services that were billed. In the event the
documentation does not support the services billed, the claims are subject to recoupment. With the
implementation of ICD-10 approaching rapidly, it is very important for each provider practice to
perform a self-evaluation to ensure services rendered are being documented appropriately in the medical
record. It is important to provide complete diagnosis coding that includes the underlying conditions
so that acuity can be appropriately measured. The medical record documentation should include the
specificity needed to support payment of the ICD-10 codes.
Following is a list of items that should be documented in the medical record for all providers:
• Patient identification information (full name,
address, phone number).
• Patient’s history (history of present illness, past
history, family history, social history).
• Present physiological condition (drug or allergy
sensitivities, current medications).
• Progress notes:
˚ P
atient’s complaint or reason for visit
˚ R
esults of physical examinations
˚ T ests, procedures, and medications ordered
by physician
˚ Diagnosis and problems identified
˚ H
ealth education/preventative
services performed
˚ L aboratory, referral, and consultation
notes/reports
˚ C
opies of reports concerning hospital
admissions (including authorizations, surgical
reports, and discharge summaries)
• Centralized vaccine tracking log:
˚ Vaccine given
˚ Vaccination date (month, day, year)
˚ Vaccine lot number
˚ Name of vaccine manufacturer
˚ Signature and title of the health-care provider
administering the vaccine
˚ Organization name and address of the clinic
location (where the records are kept)
˚ Date on Vaccine Information Statement issued
to patient, parent, or guardian
• Documentation that supports that the member
was notified of all abnormal laboratory and/or
diagnostic results.
• Documentation of instructions and education
provided to the member for interventions that
occurred during office visits.
• Documentation of provider-to-provider
communications.
Additional Mandatory Requirements
(2013 Texas Medicaid Provider Procedures Manual – Section 1: Provider Enrollment, Section 1.6.10)
• All entries must be legible, dated, and signed by
the performing provider.
• Each page of the medical record should include
the patient’s name and Texas Medicaid number.
• Prior authorizations should be included,
if applicable.
• Medically necessary diagnostic lab and X-ray
results are included in the record, and abnormal
findings should have an explicit notation of the
follow-up plans.
• Prior authorizations should be included, if applicable.
• Unresolved problems should be noted in the record.
•A
llergies and adverse reactions (including immunization reactions) must be prominently noted in record.
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7
Prepare your patients for cold and
flu season
Harold J. Farber, MD, MSPH, FAAP, FCCP
Associate Professor of Pediatrics, Pulmonary Section
Baylor College of Medicine, Texas Children’s Hospital
Associate Medical Director, Texas Children’s Health Plan
> WHAT SORT OF FLU SEASON IS
EXPECTED THIS YEAR?
Getting through the high demand of cold and flu season can be challenging. Here are a few things
to think about to help parents manage a mild illness at home.
• Give them a prescription for a pain and fever reliever to have on hand at home. Acetaminophen
is on the Texas Medicaid Preferred Drug list and can be covered with a physician’s prescription.
Be sure to include a weight-based dose (concentration of pediatric acetaminophen is 160mg/ml)
and encourage parents to use a measured dosing device.
• Give parents of infants a bulb syringe and prescription for saline nose drops to keep their child’s
nose clean and make their breathing easier. Nasal irrigation with saline can help alleviate a sore
throat, thin nasal secretions, and improve nasal breathing in older children as well, reducing the
need for further medication. Saline nose drops are on the Preferred Drug List and can be covered
with a physician’s prescription.
• Honey has been shown to help a cough from a cold. Recommend that parents administer ½ to
1 tsp. of undiluted honey just before bedtime. Honey should not be given to children younger
than 1 year of age because of concerns about infant botulism. Cough medicines are of no more
benefit than a placebo. The American Academy of Pediatrics Red Book discourages the use of
cough and cold medicine for children under 6 years of age because of lack of efficacy and
concerns regarding safety.
• Before parents ask for antibiotics, explain
that unnecessary antibiotics can be harmful
and colds are not cured by antibiotics. Be
sure to provide an active treatment plan to
parents that includes the treatment strategies
already mentioned.
• Smoke exposure makes colds worse. Help your
tobacco dependent caregivers by giving them
a referral to the National Smoker’s Helpline at
1-800-QUIT NOW (1-800-784-8669).
• Be sure that your patients over 6 months of age get the influenza vaccine. Although we can’t
prevent all respiratory viral infections, this is one very important one that we can help to prevent.
Inactivated and live attenuated influenza vaccine can be given simultaneously with other live and
inactivated vaccines.
• Inactivated influenza vaccine is well tolerated by nearly all egg allergic patients. The AAP Red Book
advises that children with a history of mild reactions to egg (such as hives alone) can receive inactive
influenza vaccine in the physician’s office. Watch the patient in the office for 30 minutes after
immunization. Children with a history of severe reaction to eggs should consult with an allergist
prior to influenza vaccination.
Patient Information sheets on cough and cold care are available from your Texas Children’s Health Plan
Provider Relations representative.
8
TexasChildrensHealthPlan.org
832-828-1008
CDC update
on this year’s
influenza season
1-800-731-8527
It’s not possible to predict what this flu season will
be like. Flu seasons are unpredictable. While flu
spreads every year, the timing, severity, and length
of the season varies from one year to another.
> WILL NEW FLU VIRUSES CIRCULATE
THIS SEASON?
Flu viruses are constantly changing so it’s not
unusual for new flu viruses to appear each year.
For more information about how flu viruses
change, visit cdc.gov/flu.
> WHEN WILL FLU ACTIVITY BEGIN?
The timing of flu is very unpredictable and can
vary from season to season. Flu activity most
commonly peaks in the U.S. in January or
February. Seasonal flu activity can begin as
early as October and continue as late as May.
> WHAT SHOULD YOU DO TO PREPARE
PATIENTS FOR THIS FLU SEASON?
CDC recommends a yearly flu vaccine for
everyone 6 months of age and older as the first
and most important step in protecting against this
serious disease. While there are many different
flu viruses, the seasonal flu vaccine is designed
to protect against the top 3 or 4 flu viruses that
research indicates will cause the most illness during
the flu season.
> WHEN SHOULD PATIENTS
GET VACCINATED?
Doctors and nurses are encouraged to begin
vaccinating their patients soon after the vaccine
becomes available. Those children ages 6 months
through 8 years who need two doses of vaccine
should receive the first dose as soon as possible to
allow time to get the second dose before the start
of flu season. The two doses should be given at
least 4 weeks apart. It takes about 2 weeks after
vaccination for antibodies to develop in the body
and provide protection against the flu.
Summary of the AAP Clinical 2013 Report:
Principles of Judicious Antibiotic Use
Cynthia Peacock, MD
Associate Medical Director, Texas Children’s Health Plan
S
imilar to the CDC recommended use of antibiotics for viral infections,
the AAP clinical report addresses the three most common bacterial
URIs—acute otitis media, acute bacterial sinusitis, and group A
streptococcal (GAS) pharyngitis—and guides treatment.
Acute Otitis Media is defined as middle ear effusion with signs of
inflammation (e.g., bulging). Watchful waiting without antibiotics should be
considered for children older than 2 years of age who have unilateral disease
without severe symptoms. Amoxicillin remains the first-line therapy and
the use of amoxicillin with clavulanate if amoxicillin was used in the prior
6 weeks or if a high local prevalence of amoxicillin-resistant Haemophilus
influenza is confirmed.
Acute Bacterial Sinusitis antibiotic treatment should be reserved for severe
disease with high fever and purulent rhinorrhea or persistent rhinorrhea and
cough without improvement 10 days into the course and situations where
clinical worsening follows initial improvement in URI symptoms.
Practitioners should not consider azithromycin for treatment of acute otitis
media or acute bacterial sinusitis because of the high rates of resistance for
pneumococcus, the most common etiologic agent.
The GAS Pharyngitis recommendation includes always testing and
confirming before prescribing an antibiotic and testing only when 2
of the following are present: fever, tonsillar exudates/swelling, swollen/
tender anterior cervical nodes, and absence of cough. Testing generally is
not recommended for those younger than 3 years of age and in patients
with symptoms suggestive of viral illness, e.g., cough, nasal congestion,
conjunctivitis, hoarseness, diarrhea, or oropharyngeal lesions (ulcers,
vesicles). One daily dose of amoxicillin for 10 days is recommended
as the appropriate approach to therapy.
With reassurance and educational materials from their health care provider,
parents are usually agreeable to not using antibiotics, especially when
presented with the information that the risks of antibiotics outweigh the
benefits. Educational materials for families can be ordered from the
CDC website at cdc.gov/getsmart/campaign-materials/posters.html.
Texas Children’s Health Plan has CDC educational materials available for
your practice and can be requested by contacting your Provider Relations
representative or calling 832-828-1008 or toll-free at 1-800-731-8527.
(Source: AAP Clinical 2013 Report: Principles of Judicious Antibiotic Prescribing for
Upper Respiratory Tract Infections in Pediatrics (Pediatrics 2013; 132:1146-1154)
Enterovirus 68: What providers need to know
D
r. Jeffrey Starke, infection control officer
at Texas Children’s Hospital, has provided
some helpful information to update you
about the growing concern of Enterovirus 68.
This is very useful information that you can also
share with your patients and their families.
The enterovirus is part of a larger family of viruses
and is not new. What is new is the sudden outbreak
that has occurred. It’s likely that the virus changed a
little bit. As a result, kids have not been immune to
it and are getting more serious symptoms than they
were in the past.
We aren’t sure why the outbreak has occurred, but
it is not surprising that it has happened as kids went
back to school. This is similar to the winter months
when there is an increase in influenza cases when
children return from winter break.
All viruses are transmitted person-to-person and
the most common way is on the hands. Good hand
hygiene and proper hand washing are the most
important things one can do to prevent the spread of
the virus. It’s not completely clear whether this virus
is spread through the air or not, but it could be the
reason why it is spreading so quickly.
For this virus, there is no vaccine and no particular
treatment. The only way to prevent it from being
transmitted to you is by practicing good hand
hygiene and covering your cough.
There is no reason for Houstonians to worry at this
point. Normal cold and flu symptoms occur all the
time. If a child has a normal cold, it is not necessary
to take them to the emergency room or rush to the
pediatrician’s office. If a child has a high fever for
more than a couple of days, is having a difficult time
keeping down fluids, and particularly if the child is
having difficulty breathing, that often indicates that
the child has pneumonia and parents should place a
call to their child’s doctor to see if they need to come
in for evaluation.
T he enterovirus has been confirmed in about 10
states with a surge in respiratory infections. There
have been no cases at Texas Children’s Hospital.
Every day, the hospital is monitoring the number of
children with respiratory infections in its pediatrics
practices, emergency center, and critical care units,
and there has not been an increase in patients with
these symptoms. If there is an increase in the number
of cases, Texas Children’s Hospital will immediately
go into action to figure out what is going on and
respond accordingly.
1-800-731-8527
Even though the number of children who have been
infected with this virus appears to be high, the actual
percentage of children infected is extremely low.
832-828-1008
TexasChildrensHealthPlan.org
9
Top
over-the-counter
medications
prescribed
in 2014
T
exas Children’s Health Plan STAR members
are able to obtain over-the-counter (OTC)
medications at the local pharmacy in the
same way they can obtain any other prescription.
Providers only need to write the prescription,
and the member can then obtain the OTC at
their local Texas Children’s Health Plan
contracted pharmacy.
In 2014, the following OTC medications are
the top OTC medications prescribed for our
STAR members.
Ibuprofen
Vanacof
Q-Pap
Dr. Smith’s Diaper
Loratadine
Cetirizine Hcl Children’s
Sea Soft Nasal Mist
Q-Pap Children’s
Loratadine Children’s
Children’s Silapap
Lohist-DM
Oralyte
Hydrocortisone
Pain and Fever Children’s
Lortuss DM
Ibuprofen Children’s
Mapap
Alahist DM
Infants Silapap
Pediatric Electrolyte
Children’s Ibuprofen
Baby Ayr Saline
Cetirizine Hcl
Cetirizine Hcl
Allergy Children’s
Q-Dryl
Gnp Pediatric Electrolyte
Children’s Loratadine
Clotrimazole
Deep Sea Nasal Spray
10
TexasChildrensHealthPlan.org
Getting the most value from short
acting BETA agonists
Harold J. Farber, MD, MSPH
Associate Professor of Pediatrics, Pulmonary Section
Baylor College of Medicine, Texas Children’s Hospital
Associate Medical Director, Texas Children’s Health Plan
M
etered dose inhalers (MDIs) can feel the same and still deliver puffs long after it is no longer
able to deliver a full dose of the medicine. When it “feels empty” or no longer gives a puff
of medicine the inhaler has probably been empty or near empty for a while. Dose counters
help the patient to know when their inhaler is empty. Of the short acting beta agonists inhalers on the
Preferred Drug List (PDL), only ProAir HFA (red inhaler) has a built in dose counter. Proventil HFA
(yellow inhaler) does not.
Brand Name
Generic Name
PDL status
Built in Dose Counter
ProAir HFA
Albuterol
On PDL
YES
Proventil HFA
Albuterol
On PDL
NO
Xopenex HFA
Levalbuterol
NOT on PDL
NO
Ventolin HFA
Albuterol
NOT on PDL
YES
Watch for overuse.
Short acting beta agonists are crisis care medicines. Frequent need for asthma symptom relief from short
acting beta agonist medication is associated with an increased risk for asthma emergency department
visits, hospitalizations, and death from asthma. A child whose asthma is in good control should not need
more than 2 short acting beta agonist inhalers (total of 400 puffs) a year. A warning sign that asthma
may be very poorly controlled is a child who is going through 4 or more short acting beta agonist
inhalers (800 puffs) a year.
The Center for Children and Women
set to open new location
The Center for Children and Women, a patient and family-centered medical home for Texas Children’s
Health Plan members, is set to open its second location in Southwest Houston in November. The
facility is designed to address the shortage of primary care medical needs for the Medicaid and CHIP
(Children’s Health Insurance Program) populations. In-house services include behavioral health,
optometry, radiology, speech therapy, and dentistry. Open 7 days a week with extended hours, patients
and families can have all their medical needs met on the same day and in the same location, eliminating
the need for multiple appointments. The Center for Children and Women has been recognized as a
Level 3 Patient-Centered Specialty Practice for Obstetrics and a Level 3 Patient-Centered Medical Home
by the National Committee for Quality Assurance (NCQA). The first Center for Children and Women
facility opened in August 2013 and is located in the Greenspoint area.
832-828-1008
1-800-731-8527
New program CONNECTS
members to health information
T
exas Children’s Health Plan has a new, comprehensive disease management program
called CONNECT. The goal is to reduce the number of potentially preventable admissions,
readmissions, and emergency room visits among members with select chronic diagnoses
and/or co-morbid state. The program connects members to health management information through
a home health nurse at a face-to-face hospital and/or home visit. Visits are followed by telephonic
health coaching with the member to discuss appropriate service and resource use, disease management,
and preventive care for their condition and/or co-morbidities.
During these points of contact, a home visit assessment will be conducted, health education tools
distributed, follow-up doctor appointments scheduled, and an individualized plan of care created.
Members are encouraged to take the plan of care to their doctor upon follow-up. If, after the 4-week
program, the home health nurse thinks that the member grasps how to manage their health, the
program will conclude for that member. If, however, the home health nurse deems the member needs
more health coaching, they will be referred to a Texas Children’s Health Plan Case Manager.
Members qualifying for the CONNECT program must have 1 or more long-term diagnoses
on this list:
Asthma
Migraine headache
Attention Deficit Hyperactivity Disorder (ADHD)
Seizure (epileptic)
Cellulitis
Sickle cell
Barrier
Busters offers
comprehensive
case review for
patients
A
n important component of CONNECT
program that is available to Primary
Care Providers is called Barrier Busters.
The Barrier Buster collaborative approach is a
comprehensive case review for individuals who
have excessive utilization patterns. The case review
is held at the office of the Primary Care Provider,
with all other providers (such as behavioral health,
home health, therapy, and specialty providers)
invited to join in person or by phone. The case
managers are present as well as a Texas Children’s
Health Plan associate medical director.
The Ishikawa approach to identifying barriers is
used to detail barriers as well as an assignment of
action steps made for attending representatives.
A follow-up meeting is established 4 months
following the Barrier Buster to give time for use
changes to occur. The health plan is responsible for
sharing a comprehensive overview of use at each
meeting. To refer a patient for the Barrier Buster
component of the CONNECT Program, contact
Deb Boggs, RN, CPHQ, Care Manager at
832-828-1284 or [email protected].
Diabetes
AND have 1 of the following:
2 or more emergency room (ER) visits in 6 months
2 or more inpatient admissions in 6 months, OR
1 admission and 1 ER visit in 6 months
Members are identified monthly based on medical and pharmacy claims, but can also be referred
to CONNECT by:
a) Practitioner referral (with a faxed order for a home health visit)
b) Health Risk Assessment (completed upon enrollment to Texas Children’s Health Plan)
c) Member (Self ) referral (through phone, fax, or face-to-face event)
d) Utilization Management (referral from authorization activity)
You will receive a fax request for home health if you have a qualifying patient.
Medical home practitioners will be notified of members who qualify for the CONNECT program
through a posted registry on the Texas Children’s Health Plan Provider Portal. For practitioners who
do not use the online portal, a phone and/or fax connection will be made available.
1-800-731-8527
832-828-1008
TexasChildrensHealthPlan.org
11
New Texas
provider
marketing
guidelines
Further reading:
You can go to our website and log-in to Provider TouCHPoint to learn more on topics like:
New provider marketing rules, required by Senate
Bill 8, 83rd Legislature, Regular Session, 2013,
have been adopted and are in effect as of July
6, 2014. The new rules give Medicaid providers
guidance about what is allowed and what is
prohibited when they are marketing their services.
Providers must adhere to all of the marketing
guidelines. Providers are encouraged to read the
guidelines carefully before marketing their services.
Texas Medicaid has published the Texas Provider
Marketing Guidelines at tmhp.com/Pages/
Topics/Marketing.aspx.
Pharmaceutical management procedures
Disease Management Programs
Formulary
How practitioners can access
authorization criteria
Limits/quotas
Availability of staff to discuss
authorization process
Supporting an exception process
Availability of TDD/TTY services
Member rights and responsibilities
Availability of language assistance for members
Generic substitution, therapeutic interchange,
and steptherapy protocol
Prohibiting financial incentives for utilization
management decision makers
Clinical practice guidelines and preventive
health guidelines
The guidelines are updated on a quarterly basis
and providers need to ensure they are monitoring
for updates and changes. Texas Children’s Health
Plan continues to implement and enforce correct
coding initiatives.
for all claims
In compliance with Texas Medicaid Healthcare
Partnership (TMHP) and Centers for Medicare
& Medicaid Services (CMS) guidelines, Texas
Children’s Health Plan implemented the CMS
National Correct Coding Initiative (NCCI)
and Mutually Exclusive Edit (MUE) guidelines
effective April 1, 2011 for dates of service on or
after October 1, 2010. All claims must be filed
in accordance with these guidelines, including
services that have been prior authorized with
medical necessity documentation.
The CMS NCCI and MUE guidelines can be
found in the NCCI Policy and Medicare Claims
Processing manuals, which are available at the
CMS website at http://www.cms.gov/Medicare/
Coding/NationalCorrectCodInitEd/index.
html?redirect=/National CorrectCodinitEd. Edit
files are available to the public on the Medicaid
TexasChildrensHealthPlan.org
Referrals to case management
NCCI webpage on the Medicaid.gov website.
Typically, CMS posts the edit files for the public
on the Medicaid NCCI webpage on the first day
of the calendar quarter.
CMS NCCI and
MUE guidelines
12
Quality program goals, processes, and outcomes
Note: Providers are required to comply with
NCCI and MUE guidelines as well as the
guidelines that are published in the Texas Medicaid
Provider Procedures Manual and Children with
Special Health Care Needs (CSHCN) Services
Program Provider Manual.
condition for reimbursement, it is not a guarantee
of payment.
If a provider appeals a previously processed claim,
then the NCCI edit rules will apply and claims
will be subject to the guidelines.
Providers with questions or comments on the
NCCI and MUE guidelines are encouraged to
contact their professional societies for clarification.
For additional information, providers are
encouraged to refer to the TMHP NCCI
Compliance web page at:
http://www.tmhp.com/Pages/CodeUpdates/
NCCI.aspx.
In instances where the Texas Medicaid medical
policy is more restrictive than the NCCI or MUE
guidance, Texas Medicaid or CSHCN Services
Program medical policy prevails.
If a rendered service does not comply with a
guideline as defined by NCCI, medical necessity
documentation may be submitted with the claim
for service to be considered for reimbursement.
However, medical necessity documentation does
not guarantee payment for these services.
Important: Prior authorization and authorization
based on documentation of medical necessity is a
832-828-1008
1-800-731-8527
PROVIDER NEWS
Provider News is published quarterly by
Texas Children’s Health Plan.
© 2014 Texas Children’s Health Plan
All rights reserved. P.O. Box 301011, NB 8301
Fall 2014