Produced by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., networkwith the Mid-Atlantic Permanente Medical Group, P.C. Website: providers.kaiserpermanente.org/mas news NOVEMBER 2014 FOR PRACTITIONERS & PROVIDERS OF KAISER PERMANENTE CMS National Coverage Determination update Decision memo for Transcatheter Mitral Valve Repair (TMVR) Transcatheter Mitral Valve Repair (TMVR) The Centers for Medicare & Medicaid Services (CMS) covers transcatheter mitral valve repair (TMVR) under Coverage with Evidence Development (CED) with the following conditions: TMVR is covered for the treatment of significant symptomatic degenerative mitral regurgitation when furnished according to an FDA approved indication and when all of the following conditions are met. • The procedure is furnished with a complete transcatheter mitral valve repair system that has received FDA premarket approval (PMA) for that system’s FDA approved indication. • Both a cardiothoracic surgeon experienced in mitral valve surgery and a cardiologist experienced in mitral valve disease have independently examined the patient face-to-face and evaluated the patient’s suitability for mitral valve surgery and determination of prohibitive risk; and both physicians have documented the rationale for their clinical judgment and the rationale is available to the heart team. • The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care. For additional information, please visit cms.gov/medicare-coverage-database/ details/nca-decision-memo.aspx?NCAId=273 Clinical practice guideline Medical Coverage Policies 2 updates 6 update III 10 New technology Pharmaceutical management Rescheduling of Tramadol and Diagnosis documentation for Information and updates Hydrocodone combination 4 coding heart arrhythmia’s 7 13 products (HCPs) Documentation of Distribution errors can have coordination of care with Provider and practitioner serious consequences primary care physicians (PCPs) satisfaction survey 5 8 — 2 — 14 Decision memo for invalidation of national coverage Administration (FDA) approved/cleared laboratory determination 140.3 - Transsexual surgery tests, used consistent with FDA approved labeling Department of Health and Human Services and in compliance with the Clinical Laboratory Departmental Appeals Board (DAB) has invalidated Improvement Act (CLIA) regulations, when ordered National Coverage Determination (NCD) 140.3 by the beneficiary’s primary care physician or “Transsexual Surgery”. As a consequence of practitioner within the context of a primary care this decision, NCD 140.3 is no longer valid. setting, and performed by an eligible Medicare Implementation of this policy shall be June 29, provider for these services, for beneficiaries who 2014. In the absence of an NCD, MA and Cost meet either of the following conditions. plans such as KP, should consider whether any • A screening test is covered for adults at high Medicare claims for these services are reasonable risk for Hepatitis C Virus infection. “High risk” is and necessary under §1862(a)(1)(A) of the SSA defined as persons with a current or past history consistent with the existing guidance for making of illicit injection drug use; and persons who such decisions when there is no NCD. have a history of receiving a blood transfusion prior to 1992. Repeat screening for high risk For additional information, please visit cms.gov/ persons is covered annually only for persons Regulations-and-Guidance/Guidance/Transmittals/ who have had continued illicit injection drug use Downloads/R169NCD.pdf since the prior negative screening test. • A single screening test is covered for adults who Decision memo for screening for Hepatitis C do not meet the high risk as defined above, but Virus (HCV) in adults who were born from 1945 through 1965. The determination of “high risk for HCV” is identified The Centers for Medicare & Medicaid Services by the primary care physician or practitioner who (CMS) has determined the following: assesses the patient’s history, which is part of The evidence is adequate to conclude that screening any complete medical history, typically part of for Hepatitis C Virus (HCV), consistent with the grade an annual wellness visit and considered in the B recommendations by the U.S. Preventive Services development of a comprehensive prevention Task Force (USPSTF), is reasonable and necessary plan. The medical record should be a reflection for the prevention or early detection of an illness or of the service provided. disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B, as For additional information, please visit cms.gov/ described below. medicare-coverage-database/details/nca-decision- memo.aspx?NCAId=272 Therefore, CMS will cover screening for HCV with the appropriate U.S. Food and Drug — 2 — Clinical practice guideline updates Clinical practice guidelines are systematically Child/adolescent attention-deficit/hyperactivity designed tools to assist participating practitioners disorder (March 2014) and patient decisions regarding specific medical No changes from the prior guideline. conditions and preventive care. Guidelines are informational and are not intended or designed Dyslipidemia treatment (March 2014) as a substitute for the reasonable exercise of independent clinical judgment by participating Guideline was revised to adopt the AHA/ACC practitioners in any particular set of circumstances recommendations for the treatment of blood for each patient. cholesterol. Coronary artery disease secondary prevention KPMAS has adopted and implemented the (May 2014) evidence-based Clinical Practice Guidelines developed by the Care Management Institute in Revisions conjunction with Permanente physician-experts • Incorporation of the JNC 8 Hypertension from across the KP program. These guidelines recommendations. cover preventive, acute, and chronic care. • Incorporation of the AHA/ACC cholesterol Preventive care guidelines include, but not limited treatment recommendations. to, breast, cervical, and colorectal cancer screening, • Incorporation of the USPSTF Aspirin immunizations, and obesity. Clinical practice recommendations. guidelines address the primary care management of common diagnoses, such as adult and pediatric Tobacco cessation (May 2014) asthma, diabetes mellitus, hypertension, attention New guideline to support tobacco screening, deficit hyperactivity disorder, coronary artery counseling, and medication. disease, and adult depression. Diagnosis and treatment of depression in adults The following clinical practice guidelines have been (June 2014) approved throughout this year and are available Revisions on the MAPMG online Web site. These guidelines • PHQ9 or PHQ2 screening tool is recommended apply to members in our commercial, Medicare, for all populations, including pregnant women Maryland Medicaid, Virginia Medicaid, and and older adults and replaces the Edinburgh Marketplace products. Postpartum depression scale and Geriatric Depression Scale, respectively. Adult diabetes (May 2014) • Removed recommendation for St. John’s wort as Revisions a first line treatment. • Incorporation of the JNC 8 Hypertension • Updated language to reflect DSM-5 diagnoses recommendations. related to dysthymia (now persistent depressive • Incorporation of the AHA/ACC cholesterol disorder) as it relates to long-term treatment, treatment recommendations. monitoring, and follow up for patients with • Incorporation of the USPSTF Aspirin double MDD. recommendations. Adult hypertension (August 2014) Heart failure (January 2014) Guideline was revised to adopt the NHLBI JNC 8 No changes from the prior guideline. Hypertension evidence review recommendations. — 3 — Preventive care services for adults and older Guideline. If you need assistance with your site adults (October 2014) registration, please e-mail [email protected] or No changes from the prior guideline. call Lee at (301) 816-6309. To read the guidelines, login at https://www. Several other clinical practice guidelines may be mapmgonline.com/portal. Select ‘Guidelines’ found at the above Web site. If you would like to under the “Group Navigation” drop down list and receive a hard copy of these or any other Clinical locate the appropriate topic and Clinical Practice Practice Guideline, please contact the Provider Relations Department at 1-877-806-7470. Diagnosis documentation for coding heart arrhythmia’s All heart arrhythmias are considered non-systemic 427.1 Paroxysmal Ventricular Tachycardia conditions which require documentation to support A tachyarrhythmia that originates from an ectopic the consideration/evaluation of the condition site in a ventricle and is characterized by sudden in the progress note. Examples of supporting onset and abrupt termination. documentation in the provider’s progress note to support coding the diagnosis: 427.2 Unspecified Paroxysmal Tachycardia 427.31 Atrial Fibrillation Dx: Paroxysmal Irregular rapid atrial contractions exceeding 400 Dx: Atrial Atrial Tachycardia beats per minute. The ventricular response is also Fibrillation Note: patient irregular and variable (“irregularly irregular”). AF is Note: patient given Verapamil 5 the most common sustained arrhythmia in adults. taking Coumadin mg IV over 5 min 427.32 Atrial Flutter” Regular rapid atrial contractions. Cardiac