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CMS Issues Guidance on WCMSA Self-Administration

By , April 14, 2014 2:07 pm

CMS has added a WCMSA Self-Administration page to the Workers Compensation Medicare Set-Aside Arrangement (WCMSA) section of CMS.gov. The new page contains information for individuals who choose to self-administer their WCMSA accounts. Materials available on the new page include:

  • New Self-Administration Toolkit for WCMSAs
  • Account Expenditure for Lump Sum Account (Attestation Letter)
  • Account Expenditure for Structured Annuity (Attestation Letter)
  • Transaction Record Sample
  • WCMSA Reference Guide

The link may be accessed at: http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Workers-Compensation-Medicare-Set-Aside-Arrangements/WCMSA-Self-Administration.html/

This long awaited guidance and detailed information regarding self-administration should be very useful to individuals who must comply with the CMS requirements pertaining to self-administration of WCMSA funds and annual reporting to CMS. Perhaps the most helpful document that CMS has provided is the Self-Administration Toolkit for WCMSAs. The Toolkit describes the process and guidelines for managing a WCMSA account and walks through the set-up of a WCMSA through its depletion (exhaustion).

Payers should direct claimants who wish to self-administer their WCMSA to this website prior to and upon completion of a settlement agreement so the claimant is aware of the requirements to self-administer their WCMSA. Those claimants who find the task of self-administering their WCMSA too complicated or daunting may wish to have their MSA professionally administered. Professional administration is a helpful alternative for those claimants who need assistance in administering their WCMSA.   In determining whether professional administration may be beneficial or warranted on a case settling parties should evaluate the claimant’s education, level of mental function, as well as the severity of the injury and overall WCMSA costs.

For questions on self or professional administration, please contact asktheexperts@pmsisettlement.com.

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ICD-10 Implementation Delayed until October 1, 2015

By , April 1, 2014 10:16 am

Yesterday, the Senate passed HR 4302, the SGR Doc Fix bill that had previously been passed by the House on Thursday, March 27, 2014.  HR 4302 primarily seeks to provide a one-year patch for physician reimbursement rates under Medicare, pushing the effective date past the end of the current congress. Of interest to our clients is Section 212 of the bill that precludes HHS from implementing ICD-10 coding until October 1, 2015.  The bill can be found here.  Now that the bill has been passed by the Senate, it is expected to be signed by President Obama in the very near future.

The passage of HR 4302 should prompt CMS to issue an alert and an update to the current MMSEA Section 111 User Guide notifying the industry that implementation of ICD-10 coding will be delayed.

PMSI is already equipped to handle the anticipated conversion to ICD-10 in October of 2014 but due to the complex process involved, understands the reasoning for a one year extension as provided in HR 4302.  PMSI’s MedicareConnect for MMSEA Section 111 Reporting is ready to report both ICD-9 and/or ICD-10 coding and we will continue to enhance functionality as necessary to provide an industry leading solution to the industry. For any questions, please contact JustRegister@PMSIonline.com.

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CMS Releases NGHP Alert on ICD-10-CM Coding

By , March 25, 2014 4:28 pm

CMS has released a technical alert for NGHPs dated March 25, 2014 that pertains to the reporting of liability insurance, no-fault insurance, and worker’s compensation claims. This alert provides new and clarified guidance around the usage of ICD-10-CM codes as follows:

  • New Excluded ICD-10-CM Diagnosis Codes
    • ICD-10-CM “Z” diagnosis codes are considered invalid for Section
      111 reporting and must be excluded from use in claim reports.
    • CMS has determined that these ICD-10-CM “Z” codes do not provide enough information related to the cause and nature of an illness, incident, or injury to be adequate for Section 111 reporting usage.
    • ICD-10-CM “Z” codes will not be accepted in either Field 15 (Alleged Cause of Injury, Incident or Illness) or in Fields 18 through 36 (ICD Diagnosis slots 1 through 19) of the Claim Input File Detail Record.
    • The “Z” codes are not listed separately on the exclusion list in the NGHP User Guide, Appendix I.
  • Clarification On The Use of V, W, X and Y Codes
    • ICD-10_CM diagnosis codes beginning with the letters “V,” “W,” “X,” or “Y” may only be used in Field 15, the Alleged Cause of Injury, Incident, or Illness, as long as the code does not appear on the excluded diagnosis code list in the NGHP User Guide – Appendix I.
    • These codes are considered invalid for usage in Fields 18 through 36(ICD Diagnosis slots 1 through 19).

This new alert can be found at the following address:

http://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Mandatory-Insurer-Reporting-For-Non-Group-Health-Plans/Downloads/New-Downloads/Technical-Alert-Liability-Insurance-Including-Self-Insurance-No-Fault-Insurance-and-Workers-Compensation-Excluded-Diagnosis-Codes.pdf

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Zogenix Launches Zohydro ER

By , March 13, 2014 4:28 pm

Late last week, California-based Zogenix launched its recently approved Zohydro® ER into the U.S. market despite ongoing criticism that the long-acting version of hydrocodone does not possess any notable abuse-deterrent properties. Intended for use in the treatment of pain severe enough to require around-the-clock pain relief and for which alternative therapy options have failed, Zohydro ER is the first long-acting hydrocodone product to hit pharmacy shelves. Until the launch of Zohydro ER, hydrocodone was only available in the United States in combination products with non-opioid constituents (e.g. acetaminophen, ibuprofen, chlorpheniramine, etc.) and was classified as a Schedule III controlled substance; however, Zohydro ER is classified as a Schedule II controlled substance due to its single-entity composition. Many patient safety advocacy groups are concerned about the lack of abuse-deterrent properties of this drug, given the FDA’s recent unpredictable actions regarding the approval of long-acting opioid pain relievers. Zogenix indicates that an abuse-deterrent formulation is currently being developed and may be available within the next three years, pending FDA approval.

Zohydro
ER

Available Strengths

National Drug Code
(NDC)

Average Wholesale
Price (AWP) per Unit Amount

10 mg

43376-0210-10

$7.02

15 mg

43376-0215-10

$7.50

20 mg

43376-0220-10

$7.74

30 mg

43376-0230-10

$7.98

40 mg

43376-0240-10

$8.22

50 mg

43376-0250-10

$8.58

At this point in time, there is no action necessary on behalf of workers’ compensation payors regarding the official launch of Zohydro ER. As your workers’ compensation pharmacy benefits partner, PMSI and Progressive Medical strive to provide you with up-to-the-minute information on medication changes that may affect your patient population. Given increasing concerns over the lack of abuse deterrent characteristics, all Zohydro ER transactions adjudicated against PMSI and Progressive Medical’s formularies will require prior authorization unless otherwise specified at the client level. It is not anticipated that the launch of Zohydro ER will lead to an overall increase in the use of long-acting opioid pain relievers. Based on historical data, it is likely that Zohydro ER will take over a percentage of the market share of currently available long acting opioid products.

Our various pharmacy partners including Kroger, Target, Walgreens, Walmart, Albertsons, Rite Aid, and Safeway have indicated that Zohydro ER will not be auto-stocked at their various locations. Most pharmacies will base future inventory decisions on demand, but can obtain Zohydro ER within a reasonable time period (e.g. overnight to 1-2 days) if a prescription is received at a particular location that does not stock this product.

If you have any questions or need further information, please contact our clinical department directly at clinical@pmsionline.com.

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