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Select News: February / March 2017

HEDIS® Spotlight: Get credit for body mass index (BMI) screenings

Careful monitoring of BMI helps health care providers identify at-risk members and provide focused advice and services to members so they can reach and maintain a healthier weight. Check with your IT electronic medical records vendor to make sure the BMI diagnosis codes are placed on your claims.

HEDIS-acceptable diagnosis codes for adult BMI assessment:

Adult BMI assessment 

The percentage of members 18–74 years of age who had an outpatient visit and whose BMI was documented during the measurement year or the year prior to the measurement year.

BMI value (ages ≥ 20) last 2 digits is BMI value

Z68.1, Z68.20, Z68.21, Z68.22, Z68.23, Z68.24, Z68.25, Z68.26, Z68.27, Z68.28, Z68.29, Z68.30, Z68.31, Z68.32, Z68.33, Z68.34, Z68.35, Z68.36, Z68.37, Z68.38,Z68.39, Z68.41, Z68.42, Z68.43, Z68.44, Z68.45

BMI percentile (ages < 20)

Z68.51 — under 10th percentile
Z68.52 — 5th to 85th percentile
Z68.53 — 85th to 95th percentile
Z68.54 — above 95th percentile


Reminder: Immunization Registry regulation

If you are an immunization provider in South Carolina, you are required to register with the South Carolina Department of Health and Environmental Control (SCDHEC). As of January 1, 2017, all immunizations administered in South Carolina must be reported to the statewide immunization registry. For more information, visit the SCDHEC website.

Prescribing opioids

If you are prescribing opioids for chronic pain:

  1. Make sure the benefits of prescribing opioids outweigh the risks associated with opioid use. Opioids are not the first-line treatment for chronic pain.
  2. Establish treatment goals, including an appropriate time to discontinue opioid use based on improvement in pain or when benefits no longer outweigh risks.
  3. During opioid therapy, talk with patients about the known risks and realistic benefits.
  4. Prescribe immediate-release or short-acting (IR/SA) opioids at the onset of treatment for chronic pain in place of extended-release or long-acting (ER/LA) opioids.
  5. When initiating immediate-release opioids, begin at the lowest dose (less than 50 morphine milligram equivalents (MME)/day). Avoid increasing the dose to 90 MME or more per day. Carefully justify the need for doses at or above 90 MME/day.
  6. Opioids initiated for acute pain may lead to chronic opioid use. Limit treatment to three to seven days — no longer.
  7. For chronic pain, one to four weeks of treatment time is sufficient to evaluate the risks and benefits of opioid use. Thereafter, evaluate every three months.
  8. Assess patients periodically during opioid treatment. If there is a history of opioid overdose, substance use disorder, or concurrent benzodiazepine use, consider also prescribing naloxone.
  9. As a reminder, please check patient profiles in the South Carolina Reporting & Identification Prescription Tracking System (SCRIPTS) to monitor controlled substance history before initiating an opioid. Continue to check SCRIPTS for proper prescribing and dispensing.
  10. Consider urine drug screenings annually or more often to assess the use of prescribed opioids and other controlled prescription or illicit drugs.
  11. Whenever possible, avoid prescribing opioids and benzodiazepines concomitantly.
  12. Refer to behavioral health specialists for treatment if patients have or develop an opioid use disorder.

For more information, visit the Centers for Disease Control and Prevention.

Drug updates

Please visit our website for up to-date pharmacy information, including changes approved by the Pharmacy and Therapeutics Committee, as well as:

  • Preferred drug list updates.
  • Drug recalls.
  • Updated pharmaceutical management procedures.
  • New prior authorization criteria and procedures for submitting a prior authorization.
  • Pharmacy benefit restrictions or limitations.

Behavioral health access guidelines

Behavioral health providers must adhere to the following access standards for First Choice members, as prescribed by the National Committee for Quality Assurance (NCQA):

Appointment type  Standard of care 
Non-life threatening emergency: required immediate attention but absence of care would not result in death Within six hours
Urgent care: severe enough that care is required to prevent deterioration of member’s condition Within (48) hours
Routine care: non-emergency, non-urgent, and no post-discharge follow-up appointment Within 10 business days
Post-discharge follow-up: An outpatient visit following hospitalization for a mental health disorder Within seven calendar days.


We encourage our providers to help prevent fraud, waste, and abuse in the Medicaid system.

We reimburse for long-acting, reversible contraception devices

Select Health covers long-acting, reversible contraception methods, or LARCs, including intrauterine devices and Nexplanon® implants, for our First Choice members. In accordance with South Carolina Department of Health and Human Services’ requirements, we reimburse providers for devices and insertion of devices when performed in a private practice, clinic, or inpatient setting, if completed at the time of delivery. Choosing LARCs may result in fewer unplanned pregnancies for First Choice members. The South Carolina postpartum LARC toolkit is available online.

Pediatric research in office settings (PROS) — Research that matters for kids

The PROS network is the office-based research network of the American Academy of Pediatrics and includes practices, academic centers, and federally funded clinics all over the United States. Currently 11 South Carolina practices participate in PROS and we need more. Please join us! When more South Carolina practices participate, results are more relevant for our children. The network conducts research ranging from fever in young infants to smoking cessation in adolescents, asthma, precocious puberty, attention-deficit/hyperactivity disorder, and child abuse. Many studies dovetail with the Quality Transformation in Practice Learning Collaborative quality improvement (QI) projects. Participation in each study is optional.

Some offer Part 4 MOC credit for the American Board of Pediatrics.
Current studies include:

  • The dialogue around respiratory illness treatment study, evaluating the effect of a distance-learning QI intervention on antibiotic prescribing rates for acute pediatric respiratory tract infections.
  • A multisite study assessing a text messaging intervention for the second dose of influenza vaccine (Flu-2-Text).
  • Population effects of motivational interviewing on pediatric obesity in primary care (BMI-3).
  • Interventions to decrease marijuana use in adolescents.

To learn more or join the network, contact Debbie Greenhouse, M.D., F.A.A.P., or Greg Barabell, M.D., F.A.A.P.

Reminder: Access standards for primary care and specialty providers

Primary care providers must adhere to these access standards:

  • Routine visits: within four weeks. Wait times must be 45 minutes or less for scheduled appointment of a routine nature.
  • Urgent, non-emergency visits: within 48 hours.
  • Emergency visits: immediate upon presentation at a service delivery site.
  • Walk-in patients with urgent needs should be seen, if possible, or scheduled for an appointment consistent with written scheduling procedures.

After hours: Primary care services must be accessible to members when medical conditions require medical attention before the next day of scheduled office hours. After-hour access information may be provided:

  • Personally or through coverage arrangements with a designated contracted primary care physician.
  • Provide twenty-four hour coverage by direct access or through arrangement with a triage system.

Specialty providers must adhere to the following access standards:

  • Emergent visits: immediate upon referral.
  • Urgent medical condition: within 48 hours of referral or notification by the primary care physician.
  • Routine care (non-symptomatic) visits: within four weeks; for unique specialists, no more than 12 weeks.

After hours: Specialists must be available 24 hours a day, seven days a week through:

  • On-call arrangements.
  • Emergency department call rotations.

Providers must monitor the adequacy of appointment processes.

Save time, reduce paperwork with online prior authorization

When you submit a pharmacy Prior Authorization (PA) Form online, your requests are instantly submitted to PerformRxSM, with a 24-hour turnaround time. Even better, if the requested medication is a part of the E-Tool, you receive immediate approval and your patient, our member, may go directly to the pharmacy for pick up. The online process also allows one provider to enter multiple PAs at once.

Follow best practice guidelines when prescribing antibiotics to children

In accordance with the Centers for Disease Control and Prevention’s pediatric treatment recommendations, antibiotic prescribing guidelines establish standards of care, focus quality improvement efforts, and improve patient outcomes. Please use proper coding to ensure the medical necessity for antibiotics is reflected in your claims.